[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
COMBATING THE OPIOID CRISIS
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
NOVEMBER 28, 2017
__________
Serial No. 115-101
__________
Printed for the use of the Committee on Oversight and Government Reform
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
http://oversight.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
31-521 PDF WASHINGTON : 2018
Committee on Oversight and Government Reform
Trey Gowdy, South Carolina, Chairman
John J. Duncan, Jr., Tennessee Elijah E. Cummings, Maryland,
Darrell E. Issa, California Ranking Minority Member
Jim Jordan, Ohio Carolyn B. Maloney, New York
Mark Sanford, South Carolina Eleanor Holmes Norton, District of
Justin Amash, Michigan Columbia
Paul A. Gosar, Arizona Wm. Lacy Clay, Missouri
Scott DesJarlais, Tennessee Stephen F. Lynch, Massachusetts
Virginia Foxx, North Carolina Jim Cooper, Tennessee
Thomas Massie, Kentucky Gerald E. Connolly, Virginia
Mark Meadows, North Carolina Robin L. Kelly, Illinois
Ron DeSantis, Florida Brenda L. Lawrence, Michigan
Dennis A. Ross, Florida Bonnie Watson Coleman, New Jersey
Mark Walker, North Carolina Stacey E. Plaskett, Virgin Islands
Rod Blum, Iowa Val Butler Demings, Florida
Jody B. Hice, Georgia Raja Krishnamoorthi, Illinois
Steve Russell, Oklahoma Jamie Raskin, Maryland
Glenn Grothman, Wisconsin Peter Welch, Vermont
Will Hurd, Texas Matt Cartwright, Pennsylvania
Gary J. Palmer, Alabama Mark DeSaulnier, California
James Comer, Kentucky Jimmy Gomez, Maryland
Paul Mitchell, Michigan
Greg Gianforte, Montana
Sheria Clarke, Staff Director
William McKenna, General Counsel
Sarah Vance, Healthcare, Benefits, and Administrative Rules
Subcommittee Staff Director
Michael Koren, Professional Staff Member
Sharon Casey, Deputy Chief Clerk
David Rapallo, Minority Staff Director
C O N T E N T S
----------
Page
Hearing held on November 28, 2017................................ 1
WITNESSES
Panel I
The Honorable Chris Christie, Governor of New Jersey
Oral Statement............................................... 5
Written Statement............................................ 10
Panel II
Mr. Richard Baum, Acting Director, Office of National Drug
Control Policy
Oral Statement............................................... 43
Written Statement............................................ 46
Dr. Leana Wen, Health Commissioner, Baltimore City Health
Department
Oral Statement............................................... 57
Written Statement............................................ 59
Dr. Caleb Alexander, Co-Director, Center for Drug Safety and
Effectiveness, Johns Hopkins Bloomberg School of Public Health
Oral Statement............................................... 83
Written Statement............................................ 85
APPENDIX
``The Opioid Epidemic From Evidence to Impact'' October 2017
submitted by Dr. Alexander can be accessed here: https://
www.jhsph.edu/events/2017/americas-opioid-epidemic/report/2017-
JohnsHopkins-Opioid-digital.pdf................................ 104
Representative Gerald E. Connolly Statement for the Record....... 105
Letter of November 21, 2017, from Association for Behavioral
Health and Wellness submitted by Mr. Cummings.................. 107
National Healthcare for the Homeless Council Statement for the
Record submitted by Mr. Cummings............................... 110
Response from Mr. Baum, Office of National Drug Control Policy,
to Questions for the Record.................................... 114
Response from Dr. Wen, Baltimore City Health Department, to
Questions for the Record....................................... 115
Response from Dr. Alexander, Johns Hopkins Bloomberg School of
Public Health, to Questions for the Record..................... 117
COMBATING THE OPIOID CRISIS
----------
Tuesday, November 28, 2017
House of Representatives,
Committee on Oversight and Government Reform
Washington, D.C.
The Committee met, pursuant to call, at 12:42 p.m., in the
Chevy Chase Auditorium, Johns Hopkins Hospital, 1800 Orleans
Street, Baltimore, MD, 21287, Hon. Trey Gowdy [Chairman of the
Committee] presiding.
Members present: Representatives Gowdy, Grothman, Palmer,
Comer, Cummings, Norton, Clay, Lawrence, Raskin, and Welch.
Also present: Representatives Sarbanes and Ruppersberger.
Chairman Gowdy. Thank you, Governor, thank you, Mayor Pew,
thank you, Johns Hopkins for pardoning the inconvenience of
having a Committee of Congress come, and appreciating the
seriousness of the issue that brings us here. The Committee
will come to order. Without objection, the Chair is authorized
to declare recesses at any time. I am going to break from
protocol a little bit because we are in Mr. Cummings's
hometown, and because he cares so passionately about this
issue, we are going to recognize you first for your opening
statement.
Mr. Cummings. Thank you very much, Mr. Chairman, and I want
to first of all, take a--just to mention one thing that is so
important to me, Mr. Chairman, and to the members of this
panel.
I cannot come into this hospital without saying thank you
to Hopkins for saving my life, and spent 60 days here this
summer, a lot of it in this building. And so I want to thank--I
see a lot of white coats out there and others, but pass the
word. I thank you for what you have done for me and my family.
I want to begin by thanking Chairman Gowdy for calling
today's very important hearing, and for bringing the Oversight
Committee to Baltimore. I also thank my colleagues for coming
to Baltimore, and certainly my colleagues who represent
Baltimore along with me as Dutch Ruppersberger and John
Sarbanes. I thank you for being here.
I have been in Congress now for 20 years and I have been
through and seen a lot of field hearings. I have never seen as
many members attend any field hearing since I have been in
Congress. I believe today's remarkable turnout reflects the
fact that the opioid crisis is truly a national emergency that
does not discriminate based on politics. It affects the red
states and blue states, and every state in between. So I am
extremely grateful that the Chairman agreed to my request to
bring the Committee to--on the road to investigate the
devastating effects of this very difficult problem.
I also want to thank Dr. Miller and Johns Hopkins for your
warm welcome and your hospitality. The work that you do makes a
huge difference in our community and around the globe. I also
thank our esteemed guests, Governor Hogan and Mayor Pew, for
joining us. We are honored to have you in our presence. And of
course, I thank our witnesses, Governor Chris Christie,
Commissioner Wen, Dr. Alexander, and Mr. Baum. Thank you for
testifying and for all that you are doing to help us combat
opioids and save lives.
A year and a half ago at our Committee's first hearing on
this issue, I warned that so many people were dying in
communities across America and that we could no longer ignore
this emergency. Today, the Centers for Disease Control and
Prevention estimates that more than 64,000 Americans died from
drug overdoses in 2016, an increase of more than 20 percent
over the year before.
To put this in perspective, the death toll from drug
overdoses last year alone was higher than all U.S. military
casualties in Vietnam and Iraq wars combined. Every 20 minutes
someone does from an opioid overdose. If today's hearing lasts
for two hours, half a dozen families will have lost a parent, a
sibling, or a child to opioids. We have the reports. We have
had years of talk. Now it is time for action. The American
people are looking for us to take action. They are looking to
the President and the Congress, and they are asking what are
you going to do?
Governor Christie and the other members of the President's
Commission on Drug Addiction have given us an excellent
blueprint for action with dozens of recommendations. Now it is
up to us, Republicans and Democrats, Federal, State, and local
officials, researchers, policymakers, doctors, drug companies,
health providers on the ground, and families of the faith
communities. We need to work together to end this epidemic.
There are some things that we can do right now to help
prevent addiction and save those who already have this disease.
For example, we can ensure that every single person who needs
naloxone has it. The Commission's report highlights the
importance of equipping first responders with naloxone,
including police officers, fire departments, and public health
officials. But here is a challenge. Drug companies have
continued to hike the price of this 45-year-old drug and
communities have been forced to ration it. In September, I led
50 Members of the House of Representatives in sending a letter
urging President Donald Trump to negotiate lower prices for
naloxone, just as the Commission recommended. Unfortunately, we
never received a response. The President should act now to
ensure that naloxone is available at a reasonable price
wherever and whenever it is needed.
We also need to ensure that every affected person has
access to effective treatment. According to the Commission, and
I quote, ``Today, only 10.6 percent of youth and adults who
need treatment for substance use disorder receive that
treatment.'' Only 10 percent. There is simply no way to end
this crisis if 90 percent of those affected are not being
treated if we do not act now. To do this, we need funding.
Last month, President Trump declared this epidemic a public
health emergency, but he did not propose any additional funding
to combat it. We cannot fight this epidemic without funds equal
to the challenge we face. This is a sad but stark truth.
So finally, we must recognize and acknowledge the many
factors that put people at risk: woefully inadequate support
for our children and our vulnerable residents, worsening
economic inequality, lack of opportunity, and profound
disparities in the criminal justice system. We cannot solve
this crisis until these risk factors are addressed.
With that, Mr. Chairman, again, I thank you for convening
this critical hearing, and I look forward to the testimony and
taking action on it, and I ask, Mr. Chairman, with unanimous
consent, that Representatives Ruppersberger from the State of
Maryland and Representative Sarbanes from the State of Maryland
be permitted to sit in with the Committee and participate in
this hearing today.
And with that, I yield back.
Chairman Gowdy. Without objection, welcome to our
colleagues. I also want to thank the Johns Hopkins community
for taking such great care of our friend and colleague over the
summer. You sent him back stronger than ever, so thank you all
for whoever had a role in that. You didn't send him back quite
that strong, but you sent him back stronger than ever.
Governor Christie, Governor Hogan, recent past and present
governors have witnessed the most devastating drug epidemic in
our Nation's history. Since 1999, more than half a million
Americans have died from a drug overdose, and the epidemic is
escalating. Over the span of nearly 20 years, the death toll
has quadrupled with the emergence of even more potent drugs and
an ever-expanding online marking for illicit distribution.
Today, drug overdoses kill more Americans than gun
homicides and car crashes combined. That is a staggering
reality. Two out of three daily deaths from drug overdoses in
the United States involve an opioid, a class of drugs commonly
prescribed to relieve and manage pain. And actually, over
33,000 Americans died from an opioid-related overdose in 2015,
which is an 11 percent increase from the year before.
In South Carolina where I come from, Greenville and
Spartanburg Counties in particular, suffered more than 100
opioid-related overdoses in 2015, and while the numbers in the
upstate of South Carolina are fewer when compared with cities
like Baltimore, behind every number and every statistic is a
life with loved ones and friends and potential and aspirations.
We have a tendency to use numbers in government and in our line
of work, but the victims aren't numbers. The victims are fellow
human beings ravaged by the consequences of drug addiction,
including the abuse of prescription painkillers.
We are a remarkable country of progress and innovation,
community and charity. We can cure diseases that past
generations lived in fear of. We can put people on the Moon and
we can split atoms. Yet we are struggling with how to respond
to this epidemic. I guess we need to start with how did we get
here? There are more illicit users for these drugs, and there
are illicit users for these drugs and there are licit users for
these drugs. One is unlawful, of course, the other is legal,
but with the potential for abuse and misuse remaining.
Physicians have a role to play for certain. These drugs are
not available legally without a prescription. What are the
pharmaceutical alternatives? Is there overprescribing? Is there
sufficient information shared with patients to avoid misuse and
abuse?
Frequent exposure and easy access to painkillers has led to
dependency and tolerance, which drives those with a substance
abuse disorder to intensify doses or methods with out without
the help of a physician. Addiction to prescription painkillers
is growing exponentially. On the illicit side of the equation,
the level and actors are diverting high potent pills to the
black market to be laced with heroin, resulting in drugs so
lethal they have been called Gray Death, a term used to
describe the high risk associated with every single injection.
Opioid-related overdoses are now deadlier than the HIV-AIDS
epidemic at its peak, more insidious that the cocaine base,
cocaine powder epidemic that predated it.
So there are a plethora of questions to be asked, such as
whether we are being as effective as possible in the diversion
of these highly toxic substances? I actually like doctors. I
happen to be the son of one. But, I also prosecuted doctors.
And I want to make sure the DEA and DOJ are effectively going
to the source of prescriptions issued outside the course of a
professional medical practice. Is HHS monitoring insurers,
placing pricier but less addictive opioids out of reach for
patients with acute pain? Are states regulating so-called sober
homes, which can move vulnerable patients in and out of
treatment, typically for profit? These are the questions our
Committee and the American people want answers to. The health
and safety of our communities all across the Nation are at
risk. Although almost everything seems capable of being reduced
to political exercise in our current environment, I genuinely
hope that this epidemic is above that. I hope it is about
protecting those susceptible to addiction and punishing those
fueling the epidemic. Death, especially among the premature--
especially the premature death of a young life has no political
or ideological bet. Victims are victims. Perpetrators are
perpetrators. Addiction is addiction. Heartache is heartache.
The issue, to me, comes down to those of good conscience
earnestly seeking a solution and those of a malevolent
conscience bent for profit off of other people's addiction and
pain. It is not just the deaths that devastate our families and
communities across the healthcare system; it is also the
disease of addiction that is permeating and threatening in some
places within our country the very fabric of those communities.
At the same time, pain is real. It is real for a
homebuilder in Mr. Cummings' district or mine with immense back
pain who can't otherwise get out of bed in the morning without
his physician-prescribed pain medication.
So how do we solve this epidemic? There is a prevention
aspect, there is a treatment aspect, there is an education
aspect, there is an enforcement aspect, there is a punishment
aspect, and there is an oversight aspect. In March, the
President signed an Executive Order creating a Commission
consisting of governors and attorney general mental health
advocates, and a professor of psychobiology to recommend
policies for the Federal response to this epidemic. Earlier
this month, the Commission finalized recommendations for how
the Federal Government can help states and stakeholders tackle
the evolving crisis and stave off emerging threats. Today, we
will have an opportunity to highlight the report, and in
Baltimore, and appropriately so. We will also examine
Baltimore's state and Federal partners and how they can assist
with and learn from the efforts that are occurring here. The
devastating statistics may leave us feeling like we have just
left the start line, but our country is resilient and we have
resources. We have compassion. I think we have the commitment
to win this battle with opioid and opioid addiction.
Chairman Gowdy. So I want to thank all of our witnesses.
Governor Christie, you are the governor of the great State of
New Jersey. As I mentioned to you in the ante room, you are
also a former United States attorney, so you are uniquely well-
suited and we cannot thank you enough, not just for your
presence today, but for your willingness to undertake this
vitally important responsibility and role, and with that, you
are recognized.
PANEL I
WITNESS STATEMENTS
STATEMENT OF THE HONORABLE CHRIS CHRISTIE, GOVERNOR OF NEW
JERSEY
Governor Christie. Thank you, Mr. Chairman. Ranking Member
Cummings, thank you for your work in this area, and thanks to
all members of the Committee for inviting us today.
As the Chairman mentioned, in March the President asked me
to chair his Commission on Opioid and Drug Addiction in our
country. We worked together to name a bipartisan group of
people to join that Commission. I think that is an important
place to start. I can tell you, as the Chairman referenced in
his remarks and Mr. Cummings in his, I am acutely aware as a
Republican governor in the State of New Jersey that there is
much that divides political dialogue in our country right now
that makes it very difficult for us to get things done. This
cannot be one of them.
I read the obituaries that are happening regularly in our
state, and in none of the obituaries do they designate whether
the person that died was a Republican or a Democrat. They are a
son or a daughter, a husband or a wife, a mother or a father.
And so I hope that what we try to do in the Commission and this
Committee is trying to do today will help to rise--give this
problem the ability to rise above the partisanship that we have
in our country today.
It is true, this is the greatest and broadest public health
epidemic of our lifetime. Everything else pales in comparison
to the breadth of this problem. It is everywhere in America.
One hundred seventy-five people are dying per day, which for
someone who comes from where I come from, the most powerful
analogy is that this means that we have a September 11 every
two and a half weeks. Every two and a half weeks.
Now I want to ask all of you and ask this Committee, if we
had a terrorist organization that was invading our country and
killing 175 of our citizens every day, what would you be
willing to pay to make it stop? We don't ask that question in
this country, and the reason we don't ask this question, in my
view, is because we still believe that this addition is a moral
failing. We are making moral judgments on the people who are
suffering and dying, and we are making moral judgments on their
families.
Every time I go to a drug treatment center in my state and
I ask someone who is in the midst of treatment, tell me your
story. Within the first two minutes, they say to me but
Governor, I am from a good family. And my response to that is
why would you think I would think otherwise? The reason why
they believe that is because the stigma that is attached to
this disease each and every day makes people believe that they
have to defend their very upbringing, their performance as
parents, their role as a child. That somehow we believe that
this is a choice.
I would love to see a show of hands in this audience of who
has not made a bad decision in their life. Usually works. The
fact is, we all have. Many of us in this room are fortunate
that bad decision was not to abuse opioids or heroin, because
if it had been, we might be in a very different judgment
position than some people are today. Addiction is a disease. It
is a chronic disease, and it needs to be treated as such and
viewed as such. That is why I am proud the President declared
this a national public health emergency.
Now, as Mr. Cummings mentioned, we need to fund the Public
Health Emergency Fund, which by my last check was at $66,000. I
don't think that is going to make it, everybody, in combating
this problem. We need to fund the Public Health Emergency Fund
to make sure that the Administration has at their disposal the
resources that they need to implement the recommendations that
the Commission has made.
We had lots of discussion in the opening remarks about the
role of physicians and healthcare providers in all of this. Let
me be very clear. This is a drug epidemic that did not start on
the corners of Baltimore or the corners of my hometown in
Mendham. They started in doctor's offices and in hospitals
across this Nation. And while some of it, as Chairman Gowdy
implied in his remarks, are done by folks who have bad intent,
most of these done by folks who have no intent. Why do
physicians and healthcare providers have no intent on this
issue? Because they are not educated on this issue. Broadly
across our country in medical schools in every state in the
union, we are not educating our future doctors and nurses,
dentists, on the dangers of these drugs.
We grant DEA licenses to write prescriptions for these
drugs without requiring continuing medical education on opioid
addiction and how it can lead to heroin addiction. I, as a
lawyer--a recovering lawyer, but a lawyer nonetheless--I have
to--even as governor today, I have to take continuing legal
education every year to maintain my license. And I'm not
practicing. How is it that physicians can have a DEA license
and not be required to have continuing medical education on
this very problem when 64,000 people died last year? The
Commission recommends that we do that. And if you don't believe
that limits on opioid prescription length as an initial
prescription work, with exceptions, obviously, for people who
are terminal from cancer and in hospice.
Let me tell you what is happening in New Jersey just since
we put a five-day limit on opioid prescriptions beginning on
March 1 of this year. Opioid prescriptions in New Jersey are
down 15 percent from March to October, and the number of pills
are down 20 percent that have been prescribed in just that
seven-month period of time. Those restrictions work, and they
should be instituted in every state across this Nation, and
that is also in the report.
I want to commend the President for granting waivers to
states now for the old-fashioned, antiquated, and ridiculous
IMD restriction, Institutes of Mental Disease. It says that if
there is any hospital healthcare provider that has more than 16
beds, 16, that those folks cannot be reimbursed for the federal
share of Medicaid because they are a state psychiatric
hospital. What that means is there are literally thousands of
beds that could provide the treatment that Chairman--that
Ranking Member Cummings recommended in his remarks that could
begin to take that 10.6 percent number up significantly, but
are not opened because of this antiquated waiver. States have
been asking for this ability to waive this for years. I commend
the President for ordering that to be done, and tomorrow in New
Jersey, the head of CMS will be coming to New Jersey with me to
announce that New Jersey has received a waiver, and that
hundreds of beds will open within the next six months for
people who need drug treatment. And these are folks who are the
neediest in our society, those folks who qualify for Medicaid.
We need to increase physician education across the Nation,
and we need to decrease the influence of the pharmaceutical
industry on that education. See, right now most doctors only
get their education from the very companies that are producing
the pills that they want them to prescribe.
Now as Chairman Gowdy said, I am a former prosecutor, and
that makes me a little bit skeptical, and I am from New Jersey,
which makes me completely cynical. And so what that tells me is
if the only education physicians are getting are from those
people who want them to prescribe these pills, and then in 2015
259 million prescriptions for opioids were written in this
country, enough to give every adult in this country their own
bottle of 30 pills, 259 million. We are four percent of the
world's population, and we consume 85 percent of the world's
opioids. If you don't think that that is where this problem
started, listen to the CDC who says that four of every five new
heroin addicts began with prescription opioids.
We need to have alternatives to opioids, because as the
Chairman said, pain is real for many people in this country.
But that is what pharmaceutical companies should be spending
their money on, not on paying doctors to write more
prescriptions for opioids. And so that is why we as a
Commission brought together Dr. Francis Collins, the head of
NIH, and all of the executives of the major pharma companies in
this country in New Jersey and got them to agree to a
partnership where they will now work with NIH to come up with
two different solutions to this problem. First, more non-opioid
painkillers to be put on the market and be affordable, and
second, more alternatives to medication-assisted treatment for
those who are already addicted. Right now we have three in this
country. There should be more.
Those pharma companies said they have 43 different
compounds among them that could address either or both of these
issues. If they are not moving forward, we need NIH to be the
accelerant for moving them forward, and I would urge this
Committee to look at additional funding for NIH specifically
for that program to make sure that we work in partnership with
the pharma companies to get these things to market, along with
the FDA, as quickly as possible. If people have an alternative
to opioids, both the physicians who prescribe these things for
pain, and the consumer who wants to avoid addiction, to have
non-opioid alternatives, that would be enormously helpful in
stemming the tide here.
The insurance companies play a large role in this as well.
Now as a governor, I get folks all the time saying to me well,
why don't you change the regulation of insurance companies to
make sure that they are covering drug treatment, so that middle
class folks in our country who have employer-provided health
insurance can get treatment, when right now most of them do
not. And I say well, remember this. Only 30 percent in my state
of the health insurance policies, employer-based health
insurance policies, are regulated by the State of New Jersey.
Seventy percent are regulated by the Federal Government under
ERISA. So we say why doesn't the Department of Labor step in?
Well, they don't have the authority to do it. Under the statute
that Congress passed in the Mental Health Parity Act, they do
not allow the Department of Labor to fine an insurance company
or an employer who is not treating mental health and addiction
with parity, and they do not allow the Department of Labor to
investigate individual insurance companies. They must go
employer by employer. How ridiculous is that?
We urge the Congress and the Commission to give the
Secretary of Labor both the authority and the responsibility to
fine insurance companies that are not treating addiction with
parity to all other diseases, and to give the Secretary of
Labor the authority and the responsibility to be able to
investigate insurance companies directly, and not have to go
employer by employer by employer, when we know that we have a
number of very large insurance companies in this Nation that
cover thousands of employers. As a former prosecutor, I can
tell you, one robust investigation is a lot easier to staff
than 2,000 little ones, and much more effective.
Lastly, and then I will leave it for questions, because I
can go on for a long time. Drug court is a very important part
of this. We need alternatives to incarceration. We have put
forward in New Jersey the largest criminal justice reform in
the last two years of any state in America, and one of the
things we have done is institute drug court in every county in
our state.
What does it mean exactly? When you come in, not as a
dealer, not as a violent actor, but as a non-violent possessor,
an addict, you are now in New Jersey required by law to go to
drug court and you are diverted to treatment, not to jail. Now
if you don't take your treatment seriously and the judge
decides that you are not utilizing the opportunity that is
being given to you, they will then send you to jail. But you
are going to get a chance first to go to treatment. We should
have drug court, and the Commission recommends this as well, in
every federal district in this Nation. One judge in every
federal district committed to dealing with the drug problem in
this country, to diverting people into treatment and to giving
those families and those addicts who are suffering from this
disease hope and opportunity to get better. I am a former
prosecutor. I am all for jailing people who profit from this
poison, and I am in favor of putting them in jail whether they
are standing on a street corner in any town or city in this
country, or whether they are standing in a hospital or in a
doctor's office. If you run a pill mill and you have a
physician, you should go to jail just as soon as this drug
dealer on the corner should go to jail, but we will not solve
this problem by incarcerating addicts. And we must get them the
treatment that they need to be able to have the tools to
recover.
In New Jersey, we have now been the first state in the
country to convert a state prison into a drug treatment
facility, and so now, state prisoners who are in their final
year of incarceration who have a demonstrated drug problem
transfer from a standard state prison to the state prison
treatment facility that we have on the property of Fort Dix in
New Jersey run by a certified addiction treatment company that
works in conjunction with our Department of Corrections to give
people the tools to deal with their addiction before they leave
prison, so that when they get back on the street, we lower
their chance for recidivism. All these things are in the report
recommended for states and the rest of this country. We are
proud of Governor Baker, Governor Cooper, Attorney General
Bondi, Congressman Kennedy, and Professor Madras who joins me
on the Commission and worked in a completely nonpartisan manner
to make these recommendations to the President, and I hope that
the members of Congress work with the President and hold the
Administration and each other responsible for getting something
done on this issue.
Thank you, and I am happy to take questions.
[The prepared statement of Governor Christie follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Gowdy. Thank you, Governor Christie. I will now
recognize the gentleman from Maryland for his questions.
Mr. Cummings. Thank you very much, Mr. Chairman, and thank
you, Governor Christie. I want to--and as I said to you before
the hearing and now, an excellent report.
I want to talk about naloxone a little bit. I had a
situation, Governor, where not very long ago I was at an event
for the Maryland Legislative, my caucus, and I walked outside
coming out of the event and somebody just dropped a man right
in front of the hotel. And I said well what's going on? They
said well this happens all the time. We see people who may be
at a party and they don't know--the person has an overdose and
they don't know what to do. And I use that as an introduction
with regards to naloxone, because of course, as you well know,
it has been--it is a drug that has been used to save lives with
regard to overdoses. And in your report, you are saying--this
is what you said. Price increases of the various forms of
naloxone continue to create affordability issues, preventing
state and local governments, as well as community organizations
from stocking naloxone at the levels necessary to rescue more
people from the overdose. Is that correct, Governor?
Governor Christie. That is true, sir, yes, and what we
recommend in the report is that governments, starting with the
Federal Government, should band together to use their
purchasing power to make bulk purchases of naloxone at lower
prices, and then there is no reason why--we do this in many
other areas of bulk purchasing, whether it is through the GSA,
as you know, or through other entities, to be able to do this.
And there is no reason we shouldn't be able to do this with
naloxone.
And one of the things we are doing in New Jersey, which we
are also recommending in the report, is co-prescribing. When
you are a physician, you prescribe an opioid, to prescribe at
the same time naloxone to go to the home, because some of these
overdoses are not intentional. They are accidental. Someone is
in severe pain, thinks well if two pills every four hours is
good, four pills might be better. So it is not just for the
person who is suffering from addiction, it is also for the
person who unintentionally misuses this, to have naloxone
available in the home so that--in an easy form so that the
folks who live with them, if they have an overdose like the one
you mentioned outside the hotel, it is--in its nasal form now
it is very easy. It is two pushes of a button. One in one
nostril, push the button, one in the other nostril, push the
button, and you save a life.
Mr. Cummings. You know, our health commissioner will be
testifying in a few minutes. It is one who has been very
strong, Dr. Wen here in Baltimore. You know, but the thing that
I think bothers me so much about naloxone is that the price was
jacked up, I mean, big time, when--at the very time when first
responders and others were trying to get it because they saw
the effectiveness of it.
Did you have discussions with any of the manufacturers or
drug companies with regard to naloxone?
Governor Christie. We did not in terms of the pricing
issues----
Mr. Cummings. Okay.
Governor Christie. --Congressman. What we did, though, talk
about was the concept of bulk purchasing and their willingness
to consider the idea of bulk purchasing lowering prices. And so
we did talk about that with the manufacturer--with a few of the
manufacturers, and that is why we urged it in the report. We
believe it is something that can be done, and that these
manufacturers recognize. And the Commission emphasized to them
their social responsibility.
Mr. Cummings. And that negotiation recommendation that you
just talked about was in--I noticed it was in the interim
report, but I didn't see it in the final report.
Governor Christie. This is some confusion. The way the
Executive Order was written, Mr. Chairman, was that the
President wanted first an interim report and then a final
report. They should not be read as mutually exclusive, they
should be read together. And so if there is, I think, 56
recommendations in the final report, there is nine in the
interim report. We have made 65 recommendations. So the nine
interim recommendations remain fully enforced and in effect and
should be added to the final report. So----
Mr. Cummings. Good. Well I am glad you clarified that. I
thought you just kind of changed your mind.
Governor Christie. No, sir. I think you know me well enough
to know that changing my mind would be a difficult thing.
Listen, I reminded the White House on a regular basis, and
you need to know this.
Mr. Cummings. My last question----
Governor Christie. This was our report.
Mr. Cummings. My last question is this. Have you discussed
this report at length with the President? In particular, have
you discussed this naloxone recommendation?
Governor Christie. Yes, I have discussed it with----
Mr. Cummings. And which response did you get?
Governor Christie. I did not--let me fully answer this,
sir. I didn't--we have discussed the report at length. I have
not discussed the specific pricing issue of naloxone. My
conversation with the President was more on how important it
was for all law enforcement officers and first responders to
have it, but we did not get into the pricing part of it in my
conversation directly with the President. But I have had that
conversation with other members of the Administration.
Mr. Cummings. Thank you very much, Mr. Chairman.
Governor Christie. Thank you, sir.
Chairman Gowdy. The gentleman from Maryland yields back.
The gentleman from Wisconsin is recognized.
Mr. Grothman. Sure, a couple questions.
This is really a horrible thing, and I think it is a very
publicized problem and it is still underpublicized. Did you
look at other countries who perhaps did not have the opioid
problems we have? I was in Taiwan like 10 years ago and they
had almost no problem. Could--I think England has a big
problem. Could you comment on the criminal justice systems and
how they deal with possession or sale of opioids in other
countries?
Governor Christie. Yeah, we didn't look at it from a
criminal justice perspective. What we looked at it from was an
availability perspective, and the biggest difference we see
between our country and the others is the extraordinary
overprescribing of these drugs. We believe that part of it was
caused by the Federal Government, quite frankly, with this, you
know, pain as a vital sign requirement where everybody who
leaves the hospital has to have the smiley face, you know, on
their lack of pain. And the hospitals were evaluated on this
basis, and so what was going on was hospitals were like heck,
if we are going to be evaluated on this basis, you are going to
leave with no pain, and the best way to leave with no pain is
to give you a whole bottle of Percocet and get you taking it.
And so the difference is the way at the very base of this
problem we are dealing with the availability of this
medication.
Mr. Grothman. Okay. Do you know anywhere where I would even
be able to get access to how they treat possession or sale of
opiates in other countries that don't have this problem?
Governor Christie. Sure. We--and the Commission can be very
helpful in that regard, because we dealt with a lot of other
countries on those issues but not on the particular one you are
talking about. But we would be happy to help. Could you get
your staff in touch with ours? We would be happy to help.
Mr. Grothman. Yeah. Next question I have, what percentage
of people who are arrested for opiates, heroin or whatever, are
addicted and what percentage are just using it?
Governor Christie. I don't know the exact numbers,
Congressman. What I will tell you is that the rate of addiction
in terms of the amount of time that it takes someone to get
addicted to these, according to the CDC, is as little as three
days. So if you have a predisposition to this, within three
days of your use you could become addicted. Which is why the
CDC says their recommendation is to limit prescriptions to no
more than three days on initial prescription, because they
think beyond three days you can become addicted.
Mr. Grothman. Have you talked to anybody who--when you talk
to people who are arrested for heroin, do they say they were
addicted in one or two days?
Governor Christie. I will tell you that this young woman--
yes. The answer is yes, and I have spoken to literally hundreds
of people across my state in treatment centers about this who
say that the time for addiction is very brief. I will tell you
that young--one young woman who is part of our public
advertising campaign on this issue in New Jersey, it is a young
woman who suffered an injury, knee injury. She used her first
bottle of pills. This young woman, who was a college graduate,
cheerleader in college, went out, had her first job, and she
was addicted within the first week that she was on these drugs.
She went from being employed, having her own place to live,
supporting herself, to within 60 days having lost her job,
moved out of her apartment, and was living on the streets of
Atlantic City in New Jersey and prostituting herself to get
heroin.
Mr. Grothman. Okay, I will give you one more question
because I don't see--normally, as you know, on these Committee
hearings have a clock, but I don't--in Vietnam, as I
understand, heroin was somewhat widely used, and something has
been said about how quickly it was not used by the troops once
they got back in the United States, which would be a little bit
inconsistent with the idea that heroin is always addicting. Can
you comment on that?
Governor Christie. Yeah, I don't think anything is always
addictive to anybody. I don't think it is always addictive,
sir. I think there are people, as we know, who use prescription
opioids and some who use heroin who use it and can use it
recreationally and not become addicted. So I think we have to
be very careful about using the phrase always or never in this
context, because you are dealing with human beings who have
different genetic backgrounds and make-ups, different
psychological make-ups, and different physiological make-ups,
and I think any of the physicians who are here at Johns Hopkins
would tell you this is what makes what they do an art, as well
as a science.
And so no, there is no always on this, sir, but what I
would tell you is that when CDC says that four out of every
five heroin addicts start with prescription opioids--and we are
talking about the same compound--this is something that is
lethal in terms of its ability to become addictive.
Mr. Grothman. I will give you one more question.
Governor Christie. Sure.
Chairman Gowdy. The red light--if you are wondering where
the lighting system is, it is right there in front of the
Governor. Although I am in such a charitable mood, if you do
have one more short question, emphasis on short.
Mr. Grothman. Sure. One of the questions--or one of the
things on treatment is, of course, some people feel that
treatment is frequently ineffective. Could you give us your
opinion on what constitutes ineffective treatment or how we can
avoid ineffective treatment?
Governor Christie. Well what constitutes ineffective
treatment is anything that's not evidence-based. And so we
should not be operating theoretically here, and there is no
reason to because there is sufficient information across this
country in the medical community about what works and what
doesn't, and medication-assisted treatment works for most
people who try it. The fact is, though, that the way to make
sure the ineffective treatment isn't happening is through the
state regulatory bodies who regulate the Departments of Health
across this country need to be very vigilant about regulating
what happens in treatment centers. And there are places in this
country where you have a lot of fallacious treatment.
I don't want to be the first to shock you and say that
there is fraud in all different areas of our country when there
is money to be made. That does not discount the value of
treatment. What it does is it increases the need for regulatory
bodies and prosecutors to go after those people who are ripping
off people by giving them false hope and fake treatment.
Chairman Gowdy. The gentlelady from the District of
Columbia is recognized.
Ms. Norton. I thank you very much, and I want to thank you,
Mr. Chairman, and the Ranking Member for this very important
hearing, and I want to thank you, Governor Christie, for coming
and for your very forthright report which minces no words.
The last Congress and the last Administration did come
forward with a billion dollars, but we have seen no slowing in
this epidemic. Indeed, my own district, which is not considered
one of the most serious districts, the District of Columbia,
tripled in this opioid crisis in just two years.
This notion of a national emergency versus a public health
emergency has emerged, and I note, Governor Christie, that the
report indicated that this was a national emergency. Is that
not the case?
Governor Christie. Well no, what the report indicates is we
believe it is a national emergency that can be addressed one of
two ways, either through the calling of a public health
emergency under the Public Health Safety Act, which was our
preferred method, or on the declaring of an emergency under the
Stafford Act.
Ms. Norton. Now which--and why did you prefer one to the
other?
Governor Christie. Because of who would administer the
funds. If it is under the Public Health Safety Act, the funds
will be administered by the Department of Health and Human
Services. If it was under the Stafford Act, it would be
administered by FEMA. Having had a little experience with FEMA
during a small storm in New Jersey, I would just tell you that
I don't believe, based on my experience, that FEMA would be
necessarily the best folks to administer these funds, and that
the folks at Health and Human Services would be better. That is
why we made that. We gave the President an alternative because
our--we felt our job was to present alternatives, but I can
tell you that my recommendation to the President was to do it
under the Public Health Safety Act so the funds would be in the
Public Health Emergency Fund; therefore, administered by folks
who I think--no apparent disrespect to FEMA--that would have a
greater sense of expertise on how to deal with this issue at
HHS rather than at FEMA.
Ms. Norton. You know, I can see that bureaucratic
difference may make a difference otherwise.
Governor Christie. Especially if you are a governor who
dealt with FEMA, it makes a big difference.
Ms. Norton. You--the region--this region where we are now,
Maryland, Virginia, the District of Columbia, just had a summit
on this issue. Governor Hogan has declared a national emergency
or a state emergency here. I am trying to find whether the
declaration of a national emergency would encourage Congress
to, in fact, come forward with farther funding that you
indicate that you thought was necessary. I mean, your remarks
were replete with versions of funding one way or the other. You
asked at the beginning of your testimony what would we pay a
terrorist, for example, who invaded our country and making that
analogy to what opioid has done. You have called in your
testimony for funding the Public Health Emergency Fund for
funding, NIH, but we sit here and Congress is, frankly, lost
focus here. In fact, we are not sure whether the government is
going to be kept open and therefore, nobody is thinking about
this issue.
Would declaration of some kind of emergency force this back
to the front burner of the Congress of the United States, which
has not funded anything since last Administration funded $1
billion in additional funding for this emergency?
Governor Christie. Well with all due respect, I think if
Congress needs different wording to focus its attention, then
we need----
Ms. Norton. Then what would you suggest?
Governor Christie. --a new Congress because if you can't
tell from 64,000 Americans dying a day that this is an
emergency because the President did it under the Public Health
Safety Act as opposed to Stafford Act, then I would say to
members of Congress on both sides of the aisle that you need to
reassess from a Governor's perspective what you are doing. And
I recognize the billion dollars that the last Administration,
the last Congress put in. Let me put that into some context of
what is needed.
In New Jersey this year, in New Jersey, we are spending
$500 million.
Ms. Norton. Of their own money?
Governor Christie. Yes, state money, $500 million. And so I
am not, quite frankly, impressed with a billion dollars from
the Federal Government for the Nation, when the State of New
Jersey is dedicating from--in a $34 billion budget, we are
dedicating half a billion dollars just to increasing
availability for opioid treatment, training, naloxone. All of
that is being supplied by the state to localities.
Now we need help from the Federal Government, and I want to
be clear about the public health emergency. It is a national
emergency. It is just two different ways of doing it. Whether
it is under the Public Health Safety Act or the Stafford Act,
and my recommendation was the Public Health Safety Act to keep
this away from people who don't know about this problem. There
is confusion about all this, and you want to see real
confusion? Let's put FEMA in charge of naloxone. As somebody
who was, you know, waiting for blankets and food and water in
Sandy, I don't want to be waiting for FEMA to give me naloxone.
Ms. Norton. Thank you very much.
Governor Christie. Thank you.
Ms. Norton. I see the red light.
Governor Christie. Thank you, ma'am.
Chairman Gowdy. The gentleman from Alabama is recognized.
Mr. Palmer. Thank you, Mr. Chairman.
Is this on?
Chairman Gowdy. There you go. Now we can hear you.
Mr. Palmer. Is the clock started now, or did it----
Mr. Cummings. It just started.
Mr. Palmer. No, or did it start after my colleague turned
on the microphone?
Chairman Gowdy. I would ask me to--yes, I am restarting.
Look into the Iron Bowl and how upset you are.
Mr. Palmer. Don't go there.
Governor Christie. It is worth at least 15 seconds.
Mr. Palmer. All right. I just wanted to go back to
something that was brought up by my colleague from Wisconsin
about heroin, and as an initiator versus the over-prescription
of painkillers. And what we found is that in opioid addiction
as initiated by painkillers like oxycodone and hydrocodone has
actually gone down from 42.4 percent for oxycodone to 27.8--I
mean, to 24.1 and from 42.3 percent for hydrocodone to 27.8,
but in terms of heroin as an initiator, it has gone from 8.7
percent in 2005 to 33.3 percent in 2015. So I think we are on
two tracks here, Governor, that I think that the medical
community has to address, but also the law enforcement
community has to address.
Governor Christie. Oh, no question.
Mr. Palmer. There needs to be a tandem effort.
Governor Christie. Right, the report talks about that.
There is no question that we need to make sure that enforcement
against those--I think I said this in my opening statement,
that as a former prosecutor, enforcement against those who are
profiting from the poison that they are spreading throughout
our communities has to continue, and has to continue
aggressively. And so I don't think there is any--there is no
reason you can't chew gum and walk at the same time. The fact
is that we also need to acknowledge that treatment as a part of
what our overall spend is across the national government and
state governments is a fraction of what we spent on
enforcement.
And so I want the three-legged stool to operate. I want
there to be education prevention, interdiction, and law
enforcement and treatment. But right now, the prevention
education part of the treatment part are shorter legs of that
stool, and as long as that continues, we are going to continue
to have this problem. But you will not find me being opposed to
stricter enforcement. I am against those who are profiting from
this, but we must draw a distinction, in my view, between those
who are profiting from it and committing violent acts in
support of it, and those who are addicted, and without those
other elements. Those people I think, in the criminal justice
system, need to be dealt with differently than those who are
profiting from it.
Mr. Palmer. I also think we need to look at this in a
holistic manner. There is--I don't know anyone who doesn't know
someone, either a friend who has a family member who hasn't
lost someone to an opioid overdose. It crosses every boundary
that you can think of: race, gender, income level, profession.
But one of the interesting things is--that doesn't get talked
about is family structure. When you take a look at that, 68
percent of the population is either married or widowed. Yet
that only represents 28 percent of the overdose deaths. Whereas
the never married and divorced population is about 32 percent,
but they represent 71 percent of the opioid overdoses.
I would like to see us do a deeper dive into that to start
looking at the ages in those categories, but I think that has
got to be part of the discussion is the overall breakdown of
the family and how that has contributed to this.
Governor Christie. You know, I think as a father of four,
married for 31 years, I believe we are doing something right,
at least, we are trying to. But I also want to be very careful
about this as well, because there are plenty of folks who are
in the situation I am who wind up having children who wind up
addicted. And so there is--part of what we said in the report
is there is not one silver bullet to fix this problem. There
just isn't, and whether it is treatment or interdiction, so I
think all of those things have to be considered and looked at
as part of what is leading our country to consume 85 percent of
the world's opioids with four percent of the population. So
something happened all across our country that is encouraging
this. But there is no question that all those things have to be
things that are considered, but I don't want to mislead anyone
that there is one silver bullet to fix this, because there is
not.
Mr. Palmer. Well----
Governor Christie. I am confident of that.
Mr. Palmer. --for my own personal experience, one of my
children's classmates, a tremendously talented young African
American artist died of an overdose, and then one of my board
members of the think tank that I ran, I literally sat in their
living room with them while the local authorities removed the
body of his son in his bedroom who had died.
My last point, Mr. Chairman, if I may, is taking a look at
the drugs prescribed through Tricare and through the VA. I have
gotten information from different people about the tremendous
numbers of drugs and--that are sent out that these people don't
need. This is a huge issue in Alabama. It gets back to where we
started--or where I started with the overprescribing of
medicine. If you would like to address that?
Governor Christie. That is a large part of the diversion
problem, right, so that that is why we have advocated in the
report and it is happening, and it is a good partnership with
the private sector as well. Places like Rite-Aid and Walgreens
and other major national pharmaceutical--pharmacy chains that
are setting up kiosks in all their stores for people to safely
dispose of these unwanted or unused medicines. A lot of times
what happens is that a young man or young woman in their own
home, their parents get a prescription for this. They don't use
the entire prescription and it stays there, and they decide
heck, I might as well try this. Or worse, they take it out and
they go to sell it because there is great value on the streets
for this.
So the over-prescription of this in every way impacts this
crisis in an enormous extent, and that is people who overuse it
themselves, and it is also people who are--don't use it but
don't know how to get rid of it safely, and as a result it
winds up hanging around and is available for diversion to
either other users directly in their home or to be sold outside
of the home.
Mr. Palmer. Thank you, Mr.----
Governor Christie. I do want to mention one other thing, if
I could, on the VA. We took a field visit as a Commission to
the Louis Stokes Veterans Hospital in Cleveland, and they are
doing some extraordinary things in lowering the opioid use by
veterans with alternative therapies and other ways to deal with
this issue with our vets, and we versed in the report that
Secretary Shulkin expand that throughout all the veterans
hospitals for the very reason you talked about. There are a lot
of these vets who know they don't want to take this stuff, but
are in real pain from the war wounds that they have suffered
defending our country, and they are coming up with alternatives
that are really helping the veterans community in Cleveland,
and we think would help the entire country.
Mr. Palmer. Thank you, Mr. Chairman. I yield back.
Chairman Gowdy. The gentleman from Missouri is recognized.
Mr. Clay. Thank you, Governor Christie, for your testimony
today. You know, while we have made critical gains in coverage
as a result of the ACA, we still have work to do. We need to
make sure that they ACA's parity requirement, which requires
that insurance benefits for our mental healthcare be comparable
to those for physical healthcare. I guess that is why you
recommend that the DOL must have authority to investigate
insurance companies.
Let me quote the report. It says ``The Commission found
that there are commercial insurance barriers to Medicaid and
assisted treatment, despite the fact that such treatment is
evidence-based and largely successful.'' Would you agree that
all insurers, both public and private, should work to remove
barriers?
Governor Christie. Sure, and that is the law in the
country. I mean, this is the frustrating thing. Congress passed
the Mental Health and Addiction Parity Act, but for reasons
that are beyond me, gave the Executive Branch no ability to
enforce it. And so we are--I don't want to be, again, New
Jersey cynical, but we are counting on the goodwill of the
insurance industry to cover this treatment that is required,
but there is no penalty for not doing it.
So my view is as a former prosecutor, the law should be
followed, and if Congress's will and the President's will at
that time is to make sure that mental health and addiction is
treated with parity and physical ailments, then the law should
be enforced.
Mr. Clay. So we need to put more teeth in the----
Governor Christie. You got it. And listen, we had Secretary
Costa at a hearing of the Commission, and he asked for this
authority. He said if you give me this authority, I will use
it. And Chairman Gowdy I think knows that Secretary Costa is
also a former U.S. attorney who served with me during the Bush
43 Administration. I know Alex well and I am convinced that
somebody with his background and experience as a prosecutor in
Miami on this issue will be very, very aggressive if the tools
were given to him, and I urge Congress to give him the tools.
Mr. Clay. Thank you for that response. I represent the
State of Missouri and I am proud of a lot of things, but one
issue that I am not that proud of is that we have a patchwork
for a PDMP in Missouri. It may go by county or by city, but it
is not really statewide and it is not effective. Talking to law
enforcement in Missouri, they tell me that it is really
becoming pill mill, and that is an attraction for users as well
as physicians who want to make profit off of that.
Tell me how is Missouri--how do they compare to the rest of
the Nation as far as being a PNA problem for law enforcement?
Governor Christie. It pains me to say this to you, sir, but
it is the worst state in the Nation.
Mr. Clay. Yeah.
Governor Christie. It is the only state in the Nation
without----
Mr. Clay. No, I appreciate----
Governor Christie. --a comprehensive----
Mr. Clay. We need to be critical of our state.
Governor Christie. It is stunning to me that there is a
state in this Nation any longer that doesn't have a
comprehensive prescription drug monitoring program, and that
they are not sharing that information with their neighbors. We
know there are people who go from state to state to be able to
fuel this addiction, and one of the--not only effective law
enforcement tools, but it is also an effective healthcare tool
predominantly for our physicians. They can use the PDMP, be
able to see when someone comes in presenting with symptoms that
might induce them to prescribe, but if they go the PDMP and see
that this patient has had a dozen, two dozen, three dozen from
other doctors prescriptions for this, they can stop adding to
the problem then.
So Missouri is a state that is the sole outlier on this
issue, and one that is damaging the health and the safety and
welfare, in my view, of the people of Missouri.
Mr. Clay. And I appreciate hearing that, and I will make
the effort with our legislature and governor to reinforce it
and tell him how much we need to get our act together.
Governor Christie. Yes, sir.
Mr. Clay. Final question. HHS and CMS now get down to the
tough work of implementing some of your Commission's report,
and I understand that hey are calling for states to apply for
waivers from the IMD exclusion. New Jersey and Utah just got a
waiver approved, but as I understand it, CMS has insisted that
waivers are budget neutral, so CMS is asking for states to
fund--to find cuts elsewhere in underfunded behavioral health
systems to pay for SUD treatment and residential settings. To
me, that doesn't reflect the urgency of this epidemic.
Can you talk to us about how New Jersey dealt with it?
Governor Christie. Yeah, I think that we are finding
areas--and this is part of, I think, each governor's
responsibility, is to find places within the Medicaid program
where spending is not being effective. And so I think it is a
good start. I think once we become convinced at the state level
that we have done what we need to do in terms of cost savings,
that then the Administration is going to have to make the next
decision, which is to lift budget neutrality requirements from
it.
You will notice in our report we do not ask for a waiver of
IMD with budget neutrality, we just ask for a waiver of IMD
exclusions. That is our ultimate recommendation, but I can tell
you in New Jersey that governing is about choosing, and I do
believe that given the level of this crisis, I can make the
choices as governor that are necessary to make those beds
available almost immediately. But there will come a moment when
you are cutting into bone and not fat, and when that happens,
then I think the broader IMD exclusion is something without
budget neutrality that needs to be considered by the
Administration.
Mr. Clay. Thank you for your responses. My time is up.
Chairman Gowdy. The gentleman from Kentucky is recognized.
Mr. Comer. Thank you, Chairman Gowdy, and Governor
Christie, thank you for being here today to discuss the growing
crisis of substance abuse in our country.
The opioid epidemic is a particular challenge for my State
of Kentucky where overdose deaths rose by 12-1/2 percent last
year alone. I appreciate your work as chairman of the
President's Commission on Combating Drug Addiction, and look
forward to working together to make progress on this issue for
all the American people.
My first question is I would like to discuss the issue of
fentanyl, which accounted for nearly half of the overdose
deaths in Kentucky last year. Can you briefly discuss the
Commission's findings and recommendations related to this
especially lethal drug?
Governor Christie. Yes. Fentanyl and carfentanil is what
will take this crisis to its next geometric explosion, because
the strength of fentanyl and carfentanil is so beyond normal
street heroin that the first usage of it can lead to death, and
often does. It is so lethal that law enforcement officers who
come to crime scenes where this is have to be careful in terms
of the way they deal with the crime scene so they don't
contaminate themselves and wind up overdosing. And in the
report, we make it very clear that this is a Chinese problem,
and we have urged the President and the Secretary of State to
make this a priority with the Chinese and the negotiations that
they are undergoing right now. China is where most of the
fentanyl and carfentanil is coming from, sometimes--more times
than not, we found--and this is why we recommend an increase in
border security, not just at the Mexican border, but with the
United States Postal Service. The United States Postal Service
is delinquent in stopping these drugs. These drugs are being
mailed in to the United States, and as are with the other
carriers like FedEx and UPS and others, we are not having the
level of enforcement that we need.
And to your point before, Congressman, you know, this is
one of those areas where I think we need to be able to step up
our efforts at the Postal Service and at DOJ through the DEA to
make sure that we are stopping this stuff from coming into the
country, but we also need to make very clear to the Chinese
that this is an act of war. You are sending this into our
country to kill our people. There is no other purpose for this
drug. This drug will kill people, and any foreign country, in
my view, who is wilfully allowing this to be done is committing
an act of extraordinary aggression on our country and it needs
to be met with the right type of diplomatic response by the
Administration and the Secretary of State, and we have urged
that in the report.
Mr. Comer. And I appreciate the work that you have done,
along with the Administration, on seeing a recent crackdown in
the Chinese manufacturers, and look forward to working with the
Committee to see what more we can do through the Internet and
postal systems to try to prevent that.
My last question, through legislation like the 21st Century
Cures Act, Congress has worked to provide more support and
flexibility to states who are on the frontlines of this battle.
From your experience as governor, as well as your work on the
Commission, what advice do you have for Congress on how best to
support state and local efforts to combat opioid epidemic both
now and over the long term. And I know you mentioned the
billion dollars didn't go very far when you divide it up among
the 50 States, but as you know, we are in a financial crisis as
well in this country so what advice do you have for Congress?
Governor Christie. Well first off, I think if this battle
is going to be won, it is going to be won with the Federal
Government and the state governments acting as partners, but
with the state governments taking the lead. We are the ones who
are on the ground, and as you said, the problem in Kentucky is
different than the problem in New Jersey, and the problem here
in Maryland is different than the problem in Missouri. These
are state circumstances depending upon all the different ways
that you go about enforcement in your state, the ways you go
about treatment in your state and its availability. So our view
is that there is--there should be accountability block grants
that block grants should be sent to the states for dealing with
this crisis, and that Congress should be demanding
accountability in return for the block grant. If I am given a
block grant as a governor, and I say in New Jersey the best way
for me to spend this money is X, and it will show a decrease in
deaths, if I show that decrease in deaths, I should continue to
get my funding. And if I don't, my funding should be reduced.
To force me as a governor to be accountable for what I am
doing.
With all due respect to Congress, you know, it is a very
difficult job to be able to determine individual programs that
are necessary and effective in all 50 states, and so I really
believe we have to trust the governors. And because I don't
believe this is a partisan issue, I don't think there is a
Republican or a Democratic way to combat this. So I think part
of this is going to have to be a leap of faith between Congress
and the governors to be able to sit down, and I really do
believe that if Congress is serious about doing this--and the
President--they need to sit down with the governors. They all
come to Washington in February. I won't be there, but the rest
of them will be. And the fact is that we need to sit down and
say listen to the governors as to what they need and Congress
then needs to make demands on the governors and say okay, if we
are going to be partners in this and we are going to help you
fund this, then what accountability measures are you willing to
give us so that we can be accountable in the financial
situation we are in, that this money is being spent in a way
that is effective to save lives? And that should--in my view
should be the determining factor. If that number, that 64,000
continues to go up, we are failing. When it starts to go down,
we are succeeding.
Mr. Comer. Well thank you, Governor, and I yield back.
Chairman Gowdy. I have not gone yet either, so let me share
this with my colleagues. We want to be a good steward of the
Governor's time. We also want to be a good steward of the next
panel's time, so to the extent we can get it done before the
red light comes on, that would be great for everyone.
And with that, I would recognize my friend from Michigan,
Ms. Lawrence.
Ms. Lawrence. Thank you, Mr. Chairman and Ranking Member
Cummings, and thank you, Governor, for being here.
You know, there is a saying that in government, if you want
to know my priorities, follow my budget. Many of the
organizations receiving funding through the Community Mental
Health Block Grant through the Substance Abuse and Mental
Health Services, and these fundings provide the wraparound
services. We are talking about the access to the drug, but
those of in this room and those who have been on the ground
with this know putting those services to transition and nurture
a person out of addiction back to a healthy life, training,
rehabilitation, case management, comes through the Substance
Abuse and Mental Health Services.
Unfortunately, the House Appropriation bills which we will
vote on this month proposes cutting funding for the Community
Health Mental Health Services Block Grant by $141 million, and
our President's budget proposed cutting it by 116. Now the
Commission--and I read your report. Thank you for it, but you
strongly recommend and urge Congress to do their
constitutionally delegated duty and appropriate sufficient
funds. It is--being in Congress and being a former mayor and
being in local government, sir, being held accountable for my
budgetary decisions, I find I am perplexed how we can have this
Commission have--you being appointed, doing all this work, yet
still what we do in our budget would just cut the legs from
under this program.
I need you to know in your leadership and in your
recommendations to this bipartisan body, this agenda of this
budget that cuts the thing that we are saying that we are so
passionate about--we have statistics. I wanted to say in
Michigan we have enough drugs, like you said, in the United
States to give every person in the State of Michigan 1.8
prescriptions, 1.1 prescriptions, which is 84 opioid pills for
every resident in my state. That is how many prescriptions we
write.
So--but if we really want to make a difference, if they
live, we want to get them off of it. So I need you to comment
on that.
Governor Christie. Well yes, and I think we are very clear
in the report. We believe there needs to be a greater financial
commitment at all levels of government to this problem.
Now, you know, the fact is there are lots of other things
that we can do as well and should be doing that won't cost us
anything, so increased medical education, increased
requirements of continuing medical education for DEA licensees.
There are a lot of good things we can do that don't, but
please, what we said in the report, we mean, which is that we
do not sufficiently fund these programs now and we also
recommend in the report that there needs to be an evaluation of
all the different programs, and you just mentioned one of them,
and there are literally dozens and dozens of programs we looked
at that are being funded. How effective are they? I can tell
you that GAO did two reports during the Obama Administration
that said that these programs were not being effective in
stemming the tide. We know that from the sign that is behind
all of you, the number of deaths.
So I think there are a couple of things that need to be
done. One is to--for us to hold ourselves accountable for all
the good ideas we have had in the past. Some of them were good
and some of them weren't. Let's reevaluate it and reassign that
money to places that we think can be effective, and then there
is going to have to be additional funds given. And I--we made
that very clear. I made it clear to the President in my direct
conversations with him, and every member of Congress who has
asked me about this, I have said there is no avoiding having to
increase funding to deal with this problem. The question is how
and you guys get to make that call.
Ms. Lawrence. Mr. Governor and to the panel, we often hear
the thing of repeal and replace the Affordable Care Act, and I
equate that to you having a Cadillac and you don't change the
oil or you don't rotate the tires, and then when the car
doesn't operate, you say that the car is inefficient and you
just throw it away.
The Affordable Healthcare Act is--provides essential health
benefit services that actually directly go to the mental health
parity part, but all we talk about is repeal and replace, and I
don't know if you are comfortable talking about this, but I am
very comfortable. It is a time for us to have real discussion
on this. We talk about the lives that we are losing, and we are
so compassionate and our hearts break when we read the
obituaries, but we must do the work. And I want to be that
voice in the room while we are talking about this, the action
that needs to be taken needs to happen. It is not good enough
to get a Commission together, write an excellent report, if you
don't fund it. If you don't look at the Affordable Healthcare
Act that had those essential services that we are saying
eliminate, how are we going to get to where we need to go?
Thank you so much. My red light is on.
Governor Christie. One thing I would just quickly in
response to that say to you is we need to remember that no
matter--my position on the Affordable Healthcare Act is pretty
clear over time, but I won't get into all of that. I will just
tell you this. The Affordable Healthcare Act insures a fraction
of the number of people that private health insurance in this
country insures, and yet, Congress is not permitting mental
health and addiction parity to be enforced for them. And so,
you know, the fact is that we have tens of millions of
Americans who work hard every day and are able to obtain health
insurance through their employer and pay for a good part of
that as well, and they are not getting the benefit of the law
and parity either.
And so I don't think it is just in talking about the
Affordable Healthcare Act, we are not enforcing that as the
Affordable Healthcare Act. We are not enforcing that as to
private insurers. You want to talk about a feel good piece of
legislation, okay, the Mental Health and Addiction Parity Act
is a feel good piece of legislation, because when all you do is
ask would you please do this, and if you don't, there is no
penalty, we know what happens in those circumstances.
And so I think we have to have even a broader discussion
about it, because it is not just for those people who are
covered now under ACA, it is also those people who have been
covered under private insurance for a very long time who are
not getting the benefit of that law that is now a decade old.
We have not been enforcing that law since the day we passed it.
So it seems to be we got to have an even broader discussion
that I think includes all of that.
Ms. Lawrence. We have to do the work.
Governor Christie. Right.
Chairman Gowdy. Professor Raskin?
Mr. Raskin. Mr. Chairman, thank you. Governor Christie,
again welcome to Maryland. I want to, first of all, salute you
for the passionate intensity of your leadership of this
Commission and the way that you have clearly absorbed all of
the lessons of it in a powerful way. And I also want to thank
you for the comprehensive nature of the recommendations that
are in the report, which have--which include messages for us in
Congress, and I very much take your point about empowering the
Secretary of Labor to act, and I hope that is one of the things
that will come out very concretely from today's session. But
also, there are a whole series of recommendations across the
Federal Government, the Department of Education, the Department
of Justice, the National Highway Traffic Safety Administration,
HHS, and so on.
So I know you are a big Bruce Springsteen fan. Who is the
boss now? In other words, who is in charge of implementing all
these recommendations across the Federal Government and being
the leader and making sure that these things comes to fruition?
Governor Christie. Well first and foremost, the President
has to be the leader. He is the person who empowered this
Commission, and he is the leader of the Executive Branch of
government and it is his responsibility under the Constitution
to make sure that the laws are duly executed. So the buck stops
with the President of the United States, and I am confident
that the President is serious about this effort and will put
the resources that are necessary to do it.
Mr. Raskin. Can I just follow up on that point? So I was
following your work very closely. You came out with the
Commission report on November the 1st, I think it was. It was
just----
Governor Christie. Yes, it was.
Mr. Raskin. --earlier this month. Did you come down and
have a session with the President and his advisors about
everything that is in this report and talk about what the next
steps are?
Governor Christie. Yes, sir.
Mr. Raskin. Okay, and what came of that meeting? I mean,
has he appointed--is there an opioid crisis czar in the White
House now?
Governor Christie. Not to the best of my knowledge.
Mr. Raskin. Should there be one?
Governor Christie. Listen, I think as a governor, you know,
the czar I think sometimes gets a little overplayed. I think
the fact is the President needs to give direction to his new
HHS Secretary. Because if you look at the recommendations, you
are right that they are all across government. That is why at
every one of the Commission hearings, we had the Deputy
Attorney General, we had the Secretary of HHS until there was a
change there, and then the Acting Secretary. We had Secretary
of Labor. We had the Secretary of Veterans Affairs. All of
those individual cabinet officers I think need to be empowered
to take the section of the report that is theirs and report
back to the President on what they are doing on a regular basis
to implement it.
Mr. Raskin. But you--but as a governor, you also know if
everyone is responsible, no one is responsible.
Governor Christie. The President is responsible.
Mr. Raskin. Okay, well----
Governor Christie. It is----
Mr. Raskin. --with no respect to the President then, I
mean, we have tweets about people kneeling during the playing
of the National Anthem. We have tweets about who got the
Americans out of China from shoplifting charges. I haven't seen
any tweets about the opioid crisis, and I don't see the kind of
passionate intensity of leadership that we need to deal with
what you described as the equivalent of a 9-11 every two weeks
in the United States of America.
Governor Christie. Well let me respectfully say this.
Before this President, you didn't see a national Commission on
this problem. This problem didn't just start on January 20 of
2017. This problem was building for years before this, and
neither President Obama nor President Bush empowered a national
Commission to come up with recommendations, put absolutely no
restrictions on that national Commission on what restrictions--
what recommendations I could make. This President is the
President who has declared a national emergency. This President
is the one who has begun to grant IMD waivers. This President
is the one who is taking the leadership on this.
So listen----
Mr. Raskin. I am just asking about constructively moving
forward----
Governor Christie. But that is----
Mr. Raskin. --how do we make sure that--you know, there are
dozens of recommendations in here. How do we make sure that
they actually get into practice at every level of government?
Governor Christie. Well there are a few ways. First of all,
the President of the United States is the Chief Executive and
he should require of those men and woman who serve in the
Cabinet offices that he has appointed them to that are covered
in this report to report to him on the progress they are making
in implementing the report. I don't think that requires another
person sitting in the office in the executive office building,
you know, sending out emails, with all due respect. I, as a
governor, I hire cabinet people. Those cabinet people are
supposed to run those departments and I think that is what the
President is going to require of them, but more importantly,
what they have seen is that this President is the first
President who has elevated this to this level, and he deserves
great credit for that. And I know it is very fashionable right
now in lots of different corners to be critical of all those
different things, and I have been critical of some of it
myself, but I don't believe it is right at this moment in time
to be critical of the President's efforts in this regard, and
he will be held to account for what he produces.
But I would also say that Congress has to step up as well,
and this is not just the President's responsibility, but every
person sitting up here and every other member of the 535 of you
know about this problem. You didn't need my report. Our report
gives you some good recommendations, but what you know is that
people are dying in your district every day. And so I would say
what are members of Congress doing as well to demand that this
be done? If that happens, then there will be a cacophony in
that city which will force action from both the Executive and
the Legislative branch.
Mr. Raskin. Thank you, Mr. Chairman.
Chairman Gowdy. Gentleman from Vermont, Mr. Welch.
Mr. Welch. I will try to be quick in light of your
admonition.
Number one, Governor Christie, greetings from Governor
Shumlin. He gave the State of the State in 2014 where it was
totally dedicated to opiate crisis, and I remember many of my
colleagues wondered why in the world would you do that, and
then started acknowledging that this is a huge problem in their
states.
Second, we need concrete actions. There is bipartisan
concern about this issue. There is bipartisan conflict about
spending on just about anything. But you outlined some concrete
things we could do. For instance, if we can't appropriate
money, which I would be in favor of, many people here would be,
we can at least deal with the drug company rip-offs, and you
acknowledged that cost increase that is really becoming an
enormous burden on our local communities that are on the
frontlines of trying to address this.
So my--I want to ask you this question and then I will
stop. The ideal outcome here is that Congress would step up and
find the areas where we can act that it would make a
difference, like addressing the cost issue, like the
prescription issue. And my question to you is what would be
your advice to this Committee, knowing that we are divided on
many issues, but we have a common concern about this horrible
scourge in our communities. What are the three things you would
recommend for us to do?
Governor Christie. You know, you are asking me to take 65
recommendations and boil it down to three. I am pretty good,
but I am not that good.
I would just tell you this, that the first thing we need to
make sure we do on the supply side is to nip this fentanyl and
carfentanil problem in the bud. If we don't, 64,000 is going to
look like the good old days. And so our interaction with the
Chinese on this needs to be unequivocal, and our ability to
invest in making sure that we are stopping this as best we can
from coming into our country is going to be enormously
important, because fentanyl and carfentanil is going to make
heroin and prescription opioids look like child's play.
Secondly, I would say that the issue of education of our
medical community, and I include the pharmaceutical companies
in this, about the danger of these drugs and having a real
national conversation on the cost benefit of using these drugs
has to happen. With this many deaths--and I understand pain is
real and the Chairman is right in his recommendation on that,
that we need to deal with those folks who need to get to work
every day and suffer from chronic pain, but I can tell you we
are losing that fight. We are losing that fight because that
homebuilder can't go to work if he is dead. And so, you know,
we need to try to have a conversation about that with our
medical community and get them more tuned to the fact that this
is killing people.
Third, I would say we have to fund greater treatment in
this country. We just have to. And so if you made me come down
to three, I would say fentanyl and carfentanil and the
interaction with the Chinese and our own law enforcement has to
be strengthened, and our communications with the Chinese on
this has to be unequivocal and see it as an attack on our
country and its people. Secondly, we need to work on medical
education because our medical community is not educated enough
at this time on this issue across the country, and that is why
we also recommend things like, you know, distance, you know,
treatment of folks who are in rural areas, can't get to a
physician, being able to do that stuff in different ways is
very important to do. And then lastly, we have underfunded
treatment in this country and we need to make treatment more
available to folks. I think it was as Member Cummings said in
his remarks quoting the report, ``When 10.6 percent of the
people who need treatment are getting treatment, we need to do
better.'' And I think if you maybe boiled down 65 to three, I
would go with those three. And I am sure when I leave, I will
kick myself for not having picked a different one.
Mr. Welch. Thank you very much.
Mr. Cummings. Yield?
Mr. Welch. I yield back. I yield to----
Mr. Cummings. Just one question. I told the Chairman just a
moment ago that this is one of your finest moments, and I
really mean that. And I got to ask this question, because I
think it is critical.
How can you, Governor, with your passion and your full
understanding and embracing of this issue, how can you help us
bridge the gap between Republicans and Democrats so that we can
get something done on this? And I mean--I don't mean to put you
on the spot, but I mean, it is a critical moment. And when you
just said what you said about fentanyl, we got to do something,
and you seem to have pulled it all together and come out with a
very balanced report so that we can be effective and efficient,
and that is all.
Governor Christie. Well I appreciate the opportunity. I
don't feel burdened by it at all, by your question.
The fact is that I will play any role that leaders of both
the Congress and Administration want me to play as a private
citizen in 49 days to be able to continue this fight. Mr.
Cummings, this is something that began to be passionate for me
in 1995 when as a local county official, I was brought to a
drug treatment center in my county for adolescents, and I saw
what was going on there. And the priest who started this
treatment facility said to me at the end of my visit, Chris,
this is something you are going to want to be involved in for
the rest of your life. Now in 1995 I was 32 years old. The rest
of my life seemed a lot longer than it does right now, but I
said to him Father, with all due respect, I mean, why am I the
one being involved in this the rest of my life? And he said
because you just walked out of a place where God makes miracles
happen on Earth.
And from that moment on, Mr. Cummings, I have been hooked
on this problem and on saving lives. And so you can see what
happened in New Jersey. I have worked as a Republican governor
every one of my 2,920 days with a Democratic legislature, and
with broad majorities, yet the package that we have done on
this twice has passed overwhelmingly bipartisan majorities. And
I gave my State of the State in 2016 on this with a package of
reforms to insurance, to pharmaceutical companies. All things
that are difficult things to do, they passed within 30 days and
were signed.
I am happy at any time, sir, at the encouragement of the
chairman or of you to come and speak and meet with anyone and
to use my relationship with the President, which goes back 15
years, to encourage people to say this is the new water's edge
in our Nation's conversation. We have to end the politics here.
We have to compromise with each other. There are going to be
some things that people on my side of the aisle are going to
have to vote to fund that they may have some concerns about,
and there is some flexibility and trust that folks on your side
of the aisle may have to give to governors that you are not
normally accustomed to doing. But I think I can speak to that
directly, and you have my word that I will not only speak out
and continue to speak out publicly, but I am cool with every
role you two gentlemen want me to play in helping you to do
this, and the President knows I that I feel exactly the same
way. And I am one of the folks who has known him for 15 years,
so when he needs to hear some truth, he comes to New Jersey not
just to play golf. Let's put it that way.
Chairman Gowdy. Gentleman from Maryland is recognized.
Mr. Sarbanes. Thank you, Mr. Chairman, and thanks for the
opportunity to sit in on the hearing today. Governor, thank you
for your testimony and thank you for the report of the
Commission, which I think is outstanding and has a myriad of
very positive recommendations that we need to--probably need to
prioritize so that we can make forward progress. But I think a
lot of the building blocks are there.
We are very proud of the efforts here in Baltimore that our
health commissioner, Leana Wen, who we will hear from shortly,
has undertaken that healthcare providers, institutions like
Johns Hopkins and others, are undertaking to change the
trajectory on this. It is obviously a heavy lift. But these
recommendations will help.
I want to echo Congressman Cummings' concern about making
sure that naloxone is available in a way that it should be and
there is not price gouging going on around that. I think that
does need a closer look. I was able--and I want to thank you
for the recommendation around co-prescribing of naloxone. We
were able to get included in one of the bills that was passed
last year, the Comprehensive Addiction Recovery Act, a proposal
for demonstration project on co-prescribing of naloxone, to
examine best practices around that, your recommendations, in a
sense, are running along side that in a very positive way, so
we thank you for that.
My question is this. I would imagine that you don't think
yet that the sense of urgency that needs to be in the country
around this issue is there, but it is changing. And as I move
around in my district--and I am sure this is the experience of
others--not only are you hearing about these tragedies that
raise your awareness, but you are also hearing people say
things like, you know, I went to my doctor the other day. I
went to the dentist, and they gave me a prescription for this
Oxycontin or something like that, and all I really needed was
Tylenol. So patients are starting to step back from this, so
something is getting to them. There is beginning to be a level
of public awareness around this.
When will you look at the situation, based on your
experience and being involved with this Commission, and what
will you see? What will be the indications to you that the
level of urgency is where it needs to be among policymakers
that the level of education and awareness out in the public is
where it needs to be? Is it PSAs coming across the airwaves in
a way that matches, you know, election time in a swing election
somewhere? Is it the President getting a briefing every Monday
morning on what the status is with all the steps that are being
taken with respect to addressing this crisis? What are the
indicators that you are looking for to say to yourself we are
starting to get it here?
Governor Christie. That is a really good question,
Congressman. Thank you.
So I have been asked this before. Someone in their remarks,
I forget which member said it, talked about this epidemic being
in greater numbers of deaths now than the AIDS crisis at the
peak of the AIDS crisis in the mid-1980s. I was alive then, and
a young adult, and here is what I think. Were are the marches?
See, I remember the AIDS epidemic and I remember marches in
every major city in this country, and in Washington, D.C., with
people marching to say the government must do something to find
a way to stem the deaths. In this crisis, there are many, many,
many more people impacted than were impacted in the AIDS
crisis, yet we have no marching. And I will tell you that I
think we will have seen that we have begun to remove the stigma
of this disease when the people who are impacted are willing to
show their face and march and demand from their government a
response. And I believe they don't march today because they are
ashamed to march, because they don't want to be identified--I
am not talking about everybody, but I am talking about mass
numbers. They don't want to march. They don't want to be
identified as this having happened in their family to their
loved one. And I think that that is why we recommended a
national advertising campaign beyond PSAs.
I will tell you, in New Jersey in this year, we will spend
$50 million on an advertising campaign in my state to remove
stigma and to let people know how to get treatment, $50 million
of state money. And the reason we are doing it is because I
don't want people to be stigmatized anymore for this and to
avoid treatment and avoid asking for help and avoid demanding
that there be something done about this.
I will tell you one quick story. My mother was an addict.
She was addicted to nicotine. She began smoking when she was 16
years old, and she smoked for 55 years and she tried everything
that she could to quit, and she couldn't. And when she
inevitably, it seemed, was diagnosed with lung cancer at the
age of 71, nobody said to me well, your mother was smoking for
55 years. She has known since 1964 that it could cause cancer.
She is getting what she deserved. No one said that. People said
oh, we are so sorry for your mom. What can we do to help? Let's
recommend doctors or treatments, that she go to this hospital
or that hospital. We are praying for you. They came and visited
her. They consoled her. They encouraged her. And I felt no
shame in telling people that my mother had lung cancer and that
her lung cancer was caused by smoking. I want to ask you, sir,
if my mother was a heroin addict, would I have done the same
thing? And would all those people have come to her aid and
recommended treatments and help? Would my dad have been willing
to ask for that?
I will know that we are at the brink of the urgency to this
when those barriers go away, when people march to demand that
Congress and the President and their government along with our
private sector find treatments to treat people who are addicted
and to find ways for them not to get addicted in the first
place by alternative medicines. I will believe it when people
are marching and showing their faces. And when that happens, we
will know that we are on our way to a solution, and that is why
I firmly believe in my heart and I believe the stigma is
causing death every day, almost as much as the drug is itself.
Mr. Sarbanes. Thank you. I yield back.
Chairman Gowdy. The gentleman from Maryland is recognized.
Mr. Ruppersberger. Yes. Thank you, Chairman Gowdy and
Ranking Member Cummings, thank you for having this hearing in
Baltimore. It is such an important area, and to all our members
on both sides of the aisle, welcome to Baltimore.
Governor--and I want to acknowledge Dr. Wen, who has done a
lot in the Baltimore area.
Governor, I think you are at the right place at the right
time. You were in local government. You were a prosecutor. You
managed a major jurisdiction. That is kind of my life, local
government and managing a jurisdiction, except I am in Congress
and you are a governor. And I really appreciate the fact that
you have made this one of your highest priorities. When you
leave office, probably it will dominate your life for a while.
Now there are a couple suggestions that I do have, though,
and to make sure that we pull all this together. The first
thing when you have a major crisis, you have got to identify
the problem, and I think these hearings--we understand it with
the deaths throughout the country, it is a national issue. It
is not just in urban areas, rural areas, everywhere. But the
part that I am interested in--I am an appropriator, and you
know, one of the issues that we have to deal with is clearly
money, and you know, we have to have that. There has been a lot
of money put into this. There are other areas as far as
treatment and drug--doctors, nurses, treatment centers, all
those types of things. But I know in your report, which is a
good report--I haven't read it, but I have heard and I have
been briefed on it. There are a lot of recommendations, and
when you have that many recommendations, you have to pick
priorities. But I think for us to get to the level--those of us
who are appropriators, we are going to have to find out what
your recommendations are for money, especially from the Federal
Government. We have to have a number, and I would hope that
your Committee or your staff on your Committee to start putting
together a report.
The second thing is there is no question you said that
Congress maintains the power of the purse. But in this
situation, the President who has within his power as President
to free up funding as well. And I am glad the President has
made this a priority, but everything in life you have to have
follow through. And what your relationship--I didn't know you
knew the President for 15 years, that is even better--and with
your tenacity, with your experience in all the areas that I
talked about, I would like to know what your plan would be to
work with his advisors, his Administration, to make sure we
find out where we are as far as the money.
Our governor, and I praise him, has--Governor Hogan has
dedicated $10 million per year for the next five years to fight
this epidemic. I think other governors throughout the country
need to do that too, whether Republican or Democrat. And this
is not a partisan issue. If there is anything that is partisan,
this can't be the case.
So my question to you is, first thing, can you decide what
the recommendations would be as far as funding is concerned?
When we find that number, we will work with you. I will pledge
to work with you as other appropriators, Democrats and
Republicans, to find a way to get Congress to fund this issue
and also to get the President.
You know, Congresswoman Brenda Lawrence made a comment
about certain cuts that are already there, so if the President
has made this such a high priority, we are going to have to
influence it. We are going to have to find a way to get him to
make this a high priority to go forward in what we need to do.
Governor Christie. Sure, a few things. I think when you say
the Commission or my staff, I want to be clear. My staff is
sitting right over there. My chief of staff in the governor's
office was the main staffer. We were not given staff on this.
We had some support from ONDCP, but I will tell you that the
work that you see in that report is the product of the
Commissioners, and so we did not get into an amount of money,
and quite frankly, I didn't think it was our province to do
that. We laid out the priorities that we believe are very
important, and we believe that every one of those are important
priorities.
Now I know from personal experience that governing is
choosing, but the choosing now needs to be done by the
President and the Congress, not by an unelected Commission. We
have laid out all the things that we think need to be done in
both near term and long term. Now I really believe it is up to
the leadership of the Congress and the President, along with
the appropriate Cabinet members, to sit down and to say how do
we implement this plan? How do we want to do that? And I don't
think--listen. I have done this stuff as a governor, but no one
elected me to do this. And I really believe that all of you are
the ones who have both the authority and the responsibility to
do it. I am happy to identify the problem and identify
solutions and bring a practical opinion to it, but I don't
believe it is my realm to talk about how much.
Mr. Ruppersberger. I respect you, what you have done, but
you are the man and if you can't do it, nobody can.
Governor Christie. I am going to have you call my wife and
tell her that.
Mr. Ruppersberger. You have the expertise, you are an
advocate, you have committed. But if you don't have the money,
it is not going to work.
Governor Christie. I agree with you.
Mr. Ruppersberger. So we need you to be not only the
advocate, we need you to be the lobbyist. We will work with
you. We will--I will--Democratic and Republican staff, I
guarantee you on the Appropriations Committee on the House will
come together. But we need your expertise and your advocacy,
especially when it comes to this President.
Governor Christie. Sure. Listen, I--as I said to both Mr.
Cummings and Chairman Gowdy, I am and will continue to be
available to all the folks on this Committee and other members
of Congress who care passionately about this issue to give you
my advice, my counsel, my opinions, and to be an advocate. I am
going to continue to be an advocate no matter who is in the
Congress, no matter who is in the White House. I have been an
advocate on this issue for 22 years. I am going to continue to
be an advocate on this issue because in my heart, I believe
that the most important role of government is to protect the
health, safety, and welfare of its citizens. And this is right
at the core of that, so--I don't know if I like the phrase
lobbyist that you threw in there at the end, but I will
certainly be----
Mr. Ruppersberger. Persuader.
Governor Christie. Yeah, I will be an advocate for this and
I have been an advocate with the President all along, and I
will continue to be.
Mr. Ruppersberger. My time is up, but my staff--I want to
reach out to your staff to find a way how we can start working
on the numbers.
Governor Christie. Excellent.
Mr. Ruppersberger. That is end game.
Governor Christie. I look forward to it, sir.
Chairman Gowdy. Gentleman from Maryland yields back.
Governor, I want to thank you on behalf of everybody for--not
just for being here and sharing your perspective today, but for
the hard work the Commission did.
I go last when it comes to questioning, and I want you to--
while we appreciate the audience that is here, they would be
the upper echelon in terms of engagement and education. I want
you to think of broader audience, broader jury, our fellow
citizens that have heard about the epidemic, perhaps someone
close to their family has been touched by it, but they don't
live and breathe it every day.
As I listened to your opening, you can put physicians, I
guess, in one of three categories. The vast majority of
physicians are incredibly well-intentioned and they are well
trained and they are well educated and they do it the right way
for the right reasons. And then you have a group that is
equally well-intentioned, but they lack the education on it,
and you made reference to continuing legal education,
continuing medical education. There is that group, and I don't
know how big it is. Our perspective is swayed by being
prosecutors. There is that group that is profiting from
people's addiction, and I don't see the diversion cases being
prosecuted like I did in olden days. Am I missing it? Did you
all find it?
Governor Christie. No, I don't think you are missing it. I
do think that there has been over the course of the last decade
or so a de-emphasis on that priority, and I think it is a
mistake. It is--I often think, Mr. Chairman, that folks believe
that to emphasize one issue is to deemphasize another.
So in New Jersey, for instance, we have done broad criminal
justice reform that has lowered our prison population more than
any state in the country. During my time as governor, we have
closed two state prisons. Yet our crime rate is down
significantly in our state. That doesn't mean that I don't want
to see my attorney general continuing--and he has--to
continually aggressively pursue the drug dealers in our state
who are killing our people.
I think that sometimes justice departments, which we have
both been members of, think that if you are in favor of
criminal justice reform, you can't be in favor of aggressive
prosecution of criminals. Or if you are in favor of aggressive
prosecution of criminals, you can't be for criminal justice
reform. I don't believe that, and I think as governor it has
taught me even more than as a prosecutor, the Federal
Government, in my view, over the last decade has dropped the
ball on these cases. And I think that it is contributing--not
causing, but contributing to the problem that we have today.
And that is why I am not in favor of shortening the leg on the
stool of enforcement interdiction. We need to continue to do
that and do it aggressively. I have shared that opinion with
General Sessions, and I believe he understands that piece of
it. But that message has to get out to the U.S. attorneys, and
that can only come from the attorney general and the deputy
attorney general. You and I both know, and when you were a U.S.
attorney, it is kind of like being the captain of a ship out at
sea, you know. Sometime the radio works from the shore, and
sometimes maybe you can't hear it quite as loudly. We need to
make sure the radio is working on this one, and that U.S.
attorneys are not given an option, but are given a directive
from their boss, the Attorney General of the United States,
that these are important cases to do. That doesn't lessen our
commitment to providing more treatment. It doesn't lessen our
commitment to confronting the Chinese on what they are doing
and using our foreign policy tools in addition to law
enforcement in doing that, and it doesn't mean that we don't
believe that education and prevention are really important. We
didn't talk about that today, but let me say in conclusion
here, from my perspective that if we don't start talking to our
children in the middle school about this issue, we will lose
them. And it is frightening to me as a father to think that my
11 and 12-year-old daughter or son needs to be spoken to about
this issue in stark terms, but they do.
And we can't do it anymore. I saw from the Department of
Education they were very proud. They showed me when I first
came to--oh, we have this new pamphlet that we are going to be
giving out in schools on this issue. And I looked at it and I
said so listen, it is a great pamphlet. I read it. There is a
lot of good information. I said if my kids got this pamphlet,
it would go in their backpack. By the end of the school year,
it would be all the way at the bottom of their backpack, and
they would never read it. Because if it is not on here, they
don't read it. We need to modernize the way we are educating
our children. We should be demanding of companies like Google
and Facebook who are such predominant players in communication
today to our young people, that they step up to the plate and
start educating our kids on the things that we need to do.
So what I am saying to you is we have dropped the ball in
my view in the last decade since I have left the Justice
Department in 2008 in doing these cases. We need to do them to
slow the supply, but we also need to make sure that we are
doing those other things as well. And this is the bipartisan
nature of it, and I believe that Mr. Cummings agrees with this
as well. We have got to get rid of our old barriers on this
issue, to think that if you are for one thing, you must be
reflexively against the other, and vice versa. We can do both
and we must do both. And there are people of goodwill and great
experience who are ready to help to do this, and I hope that
they are called upon to do it, and I count myself as one of
them, and I will allow myself to be called upon to do it.
And so I think you make a very good point, Mr. Chairman,
and I think we need to make sure that we don't get caught in
the trap of mutual exclusivity. It is a trap that will lead to
failure, and failure we can't afford.
Chairman Gowdy. Well I want to finish up with drug courts,
because we agree on that. If you want to not only have your own
life change, but see other people's lives change, attend a
graduation for a drug court. That graduation ceremony will be
with you for the rest of your life. And I want to mention one
kind of a niche issue there at the end. I also want you to
address what barriers did you find, if any, for the
pharmaceutical alternatives, non-habitual aiding, non-addictive
pharmaceutical alternative. What are the barriers to either
having them researched, developed, or to market?
Governor Christie. They don't believe they are going to be
profitable. I think that is the single biggest barrier to it,
and that is why I believe bring NIH in as a partner to be a
fair broker of the compounds and say which ones are most
effective, and let's move those most effective ones to the
front of the line and allow them to go to market, and let's see
how it goes.
What I say--and listen, you know that New Jersey has more
pharmaceutical companies than any state in the country, and so
I am very sensitive to the importance of the pharmaceutical
industry, the role that they play in our country as an economic
driver, in addition to being a healer. And I am an advocate for
the pharmaceutical industry. But what I reminded my friends in
the pharmaceutical industry is they have a social
responsibility that goes along with that, and that to stand by
and not develop these compounds purely on the basis of concern
about profitability is to, in my view, walk away from part of
your social responsibility as a corporate citizen in this
country.
Now NIH needs, I think, to be a fair broker in all this so
that the right compounds get the right money spent on them to
develop them, but what I heard from them was the biggest
concern was an issue of--with the R&D money that they have
available, is this the best way to spend that money for our
shareholders? And that is an absolutely legitimate fiduciary
concern that they need to have under our laws and our system
of--our economic system, but they also have a social
responsibility as well.
And so what I would say and what we did say to
pharmaceutical companies is would you trust NIH to be a fair
broker on, say, okay, all 43 of these compounds don't need to
be developed, but these five have real potential to be non-
addictive pain relief and/or great medication assisted
treatment to help those who are already addicted. And the
pharmaceutical companies at that meeting in New Jersey agreed
to submit their compounds to NIH. What we need to make sure of
now is that NIH has the funding to make sure that they complete
that job. If they do--I know Dr. Collins is really committed to
this. If they do, we are going to get some of those compounds
onto the market, and that is going to help significantly.
Because I know physicians would much rather prescribe a pain
reliever that is non-addictive but effective, rather than one
that is addictive.
Chairman Gowdy. You mentioned though the phrase social
responsibility--this will be my last point.
In addition to being a colleague, one of my favorite
colleagues in the entire body, Peter Welch, is also a former
public defender, and his clients would have been incredibly
fortunate to have him. In South Carolina, I saw sometimes in
the state system, public defenders would opt for straight
probation as opposed to drug court because it was easier. Now
that is not in their client's best interest. Their client will
remain an addict. But they are right. Straight probation is
easier than drug court. How do we develop around the grant
strategy in sending the defense attorney, the public defender
to encourage their client to go get help as opposed to just
being on probation for the next 12 months and remaining an
addict?
Governor Christie. Well let me tell you, in New Jersey what
we did was we took away the option. You don't have the option
of probation anymore. Your option is this: go to treatment or
go to jail. Now when given that option, it is kind of the
gentle encouragement I am known for, Mr. Chairman. You know, it
is--and where a lot of people absolutely opposed that, said how
dare you do that. If they are not ready, they shouldn't go. I
said I have never met an addict who is ready. I have never met
an addict who is ready. I have done interventions. I have never
seen a--I had a great friend of mine who sat there and argued
with me that I was wrong that he was addicted, he didn't need
treatment. He was fine. Well he is dead now, and the fact is I
have never met an addict who was ready.
So I think one of the things that you could work on from a
grant structure perspective is to say that we want to encourage
those programs that don't give an option, that your option--you
don't have a probation option, because I know. I know exactly
what you are talking about. That was happening in my state
before we passed this law. Now defense attorneys have a really
easy equation to give their clients. You can go to drug court
and go into treatment, or you can go to state prison. And what
we are finding is most people are choosing treatment. And even
when they don't think they are ready and what has happened--you
talked about drug court graduations. The miracle of those drug
court graduations is, in my mind, not the young men and women
and older men and women that I am sitting with on stage, it is
looking out in the audience at their families. Their lives are
hopeful again. Their eyes are lit with joy for the restoration
of a life that they initially brought onto the earth, and which
they had almost given up on.
So from my perspective, the drug court and why I advocate
it for every federal district in this country is because I have
watched it change lives, and so have you. And there is no
reason--even though there are fewer cases on the Federal
Government than would be appropriate than on the state level,
there is no reason that we should have our federal prisons
filled with people who would be better off being treated, for
themselves and for us as a society. Because the recidivism
rate, as you know, for drug court graduates goes down
significantly, and that is what we all want anyway. We would
much rather spend less money on corrections, on BOP, than we
would on other issues that are confronting our country in a
time of limited resources. If we can lower the prison
population like we have done in New Jersey and close two state
prisons in eight years--I defy you to find any other state in
America that is closing state prisons with a decline reduction,
and it is because we are treating folks who have this problem
like they have a disease, not like they have a moral failing.
Chairman Gowdy. Well thank you for your passion and your
expertise, and I know Mr. Cummings would want to thank you also
as we transition from your panel to the next panel. Thank you
on behalf of all of us.
Governor Christie. Mr. Chairman, thank you very much. Mr.
Cummings, thank you for inviting me.
Mr. Cummings. Mr. Governor, thank you very much. Just one
thing being our good colleague from Maryland, Mr. Delaney, has
a phrase that I wish I had invented. He said ``The cost of
doing nothing is never nothing.'' And you have given us a broad
blueprint, and now we have got to act. Thank you very much.
Governor Christie. Thank you, sir. I appreciate that very
much.
[Recess.]
Chairman Gowdy. The Committee would like to welcome our
second panel of witnesses. We have Dr. Richard Baum, Acting
Director of the Office of National Drug Control Policy; Dr.
Leana Wen, the Health Commissioner for the Baltimore City
Health Department; and Dr. Caleb Alexander, Co-Director of the
Center for Drug Safety and Effectiveness at Johns Hopkins
Bloomberg School of Public Health.
Welcome to you all. I am not going to swear you because I
didn't swear the first witness, so I will violate Committee
rules there and hope that nobody knows that I have done it. We
are going to call on you sequentially for your opening
statements. To the extent possible, I will limit those to five
minutes, just understanding that we have the full body of your
opening statement in the record, and then we will--once Dr.
Alexander gives his opening statement, we will then recognize
the members for their questions.
With that, Dr. Baum, you are recognized.
PANEL II
STATEMENT OF RICHARD BAUM
Mr. Baum. Well I thank you, Mr. Chairman, Mr. Cummings.
Thanks so much for inviting me and for the Committee, I am
really honored and pleased to be here in Baltimore for this
important hearing.
You are all familiar with the problem we face because you
see it in your districts. This epidemic knows no geographic,
political, socioeconomic, or racial bounds. We are very mindful
of the fact that your constituents share heartbreaking stories
with you about the loss of too many of our country's sons and
daughters. ONDCP is committed to working with you to turn this
awful crisis around. This truly is the worst epidemic in
American history.
As has been referenced in earlier testimony, we have seen
over 60,000 drug overdoses in 2016, mostly caused by opioids
such as heroin, illicit fentanyl, and prescription pain
medications. Now listen, fentanyl is being added to heroin,
cocaine, and other drugs, increasing their lethality. It is
often being pressed into counterfeit prescription pills,
complete with fraudulent manufacturer logos. We are not getting
enough people with addiction into evidence-based treatment. Our
whole system through response to overdoses and other outreach
efforts has to be faster to go out and find the people that
need help. Once people go through detox or treatment, they need
ongoing recovery support, as well as help with sober housing
and employment so they can fully rebuild their lives and
reintegrate into society. We also need to ensure that law
enforcement agencies have the tools they need to reduce the
drug supply and disrupt and dismantle the drug trafficking
organizations that threaten the safety and health of our
people.
The Administration is working hard on multiple fronts to
address this crisis. As you know, President Trump has been
vocal about the drug crisis, both during the campaign and since
taking office. When the President established the Commission,
he directed it to look at additional actions the government can
take to address this epidemic. ONDCP was tasked with providing
policy and administrative support to the Commission. I had the
honor to serve as the executive director of the Commission, and
ONDCP staff contributed their expertise and time to assist the
Commission with its work, totaling more than 5,500 total staff
hours. On November 1, the Commission released its final report,
which included 56 recommendations, as Governor Christie just
described. The recommendations have now been circulated to all
the agencies in the Administration for careful consideration. I
am glad to say that the Administration is already working on a
number of them.
President Trump declared the opiate crisis a national
public health emergency as the Commission recommended in its
interim report, and he has mobilized the entire Administration
to address the crisis. HHS has announced a proactive policy to
allow states to waive the decades-old ban on Medicaid
reimbursement for patients receiving inpatient treatment at
facilities with 16 or more beds, known as the IMD exclusion.
Utah and New Jersey have already received approvals under the
new policy, and we hope to have many more requests for waivers
in the coming months.
In terms of reducing the availability of these illicit
drugs, the Administration has also taken a number of steps. We
are working with the Chinese government to reduce the flow of
fentanyl and its add-alongs to the United States. This includes
getting additional advanced electronic data from China on
packages mailed into the U.S. This summer, DOJ took down the
dark web marketplace, AlphaBay, and other sustained actions
like this over time will reduce trade over the Internet that
has been threatening the health of our citizens.
The Heroin Response Strategy, which is an initiative of our
ONDCP-run HIDTA program, is bringing law enforcement and public
health together to quickly respond to overdose at the local
level, and to increase law enforcement and--efforts. And the
FDA is working to make prescription opioids safer and lend the
effort to remove the opioid medication Opana extended release
from the market, since it was frequently being diverted and
abused.
The Administration has provided significant resources to
address this crisis. For fiscal year 2018, the President
proposed a $28.7 billion drug budget overall, including $10.8
billion for drug treatment. This year, we have already sent
$800 million out to states for intervention, treatment, first
responders, prescription drug monitoring programs, and recovery
services. The President has requested $500 million additionally
to help states expand access to opioid treatment in the fiscal
year 2018 budget. And at ONDCP, as you know, we are developing
the Trump Administration National Drug Control Strategy, which
will be out early next year. So we are using all the tools in
the toolbox to make headway against this enormous problem which
is affecting every state and many of your constituents in some
way, shape, or form.
I have not yet had the privilege to visit South Carolina as
acting director, but I have visited Anne Arundel and Cecil
Counties in Maryland and I have seen how people in these
communities are coming together to address this crisis at a
local level. This is a critical part of our country's response
to the epidemic.
As I said, this crisis is unlike anything we have seen
before and have been working hard to address it, but we have a
lot more to do. I thank Governor Christie and the Commission
for their recommendations which will help to this end. I also
want to thank the dedicated ONDCP career staff for so
skillfully supporting the Commission's work. And I thank the
Committee for holding today's hearing on this important matter,
and I look forward to more discussion and dialogue. Thank you
very much.
[The prepared statement of Mr. Baum follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Gowdy. Thank you. Dr. Wen?
STATEMENT OF LEANA WEN
Dr. Wen. Chairman Gowdy, Ranking Member Cummings, thank you
for calling this hearing in our city of Baltimore where today,
two residents will die from overdose.
Our aggressive approach to this epidemic has three pillars.
First, we save lives by making the opioid antidote, naloxone,
available to everyone. Not only have we equipped paramedics and
the police, I issued a blanket prescription to all 620,000
residents. Since 2015, everyday individuals have saved the
lives of 1,500 people. But our city is out of funds to purchase
naloxone, as Congressman Cummings mentioned, forcing us to
ration and make decisions about who can receive this antidote.
And at the time of a public health crisis, it is unconscionable
that we are being limited in our ability to save lives.
Second, we aim for on demand addiction treatment, because
the science is clear that addiction is a disease and treatment
works. But nationwide, only 1 in 10 people with addiction get
treatment. Imagine if only 1 in 10 patients with cancer get
chemotherapy?
As an emergency physician, I see patients coming to the ER
all the time asking for help, but I tell them they have to wait
weeks or months. My patients have overdosed and died while they
are waiting, because our system failed them. Here we are
starting a stabilization center, which is the beginning of a
24/7 ER for addiction and mental health. We are expanding
medication assisted treatment, which is the gold standard for
helping people to recover from opioid addiction.
Third, we reduce stigma and prevent addiction. Treating
addiction as a crime is unscientific, inhumane, and
ineffective. That is why our public health and public safety
agencies collaborate closely, including to pilot law
enforcement assisted diversion where individuals caught with
small amounts of drugs are offered treatment instead of
prosecution. Recognizing that it has hurt people who hurt
people. We are working to prevent the next generation of
addiction by addressing trauma and providing mental health
services in our schools.
My written testimony has point-by-point analyses of the
President's Commission's recommendations, and I agree with many
of them, but they do not go nearly far enough in four areas.
First, the Commission did not identify substantial
additional federal funding. We on the frontlines know what
works, and we desperately need new resources, not repurposed
funding that will divert from other critical priorities. These
funds should also be given directly to communities of greatest
need. Cities have been fighting the epidemic for years, and we
shouldn't have to jump through additional hoops. Competing for
grants and having funding passed from the states to cities will
cost time and many more lives.
Second, the Commission failed to advocate for taking on
necessary steps to expand health insurance. One in three
patients with addiction depend on Medicaid. If Medicaid were
gutted and they were to lose coverage, many more would overdose
and die. Other patients on private insurance could find
themselves without treatment if addiction is no longer required
to be part of their health plan. It is estimated that ACA
repeal could result in three million people losing access to
addiction treatment. Block grants should not replace insurance
coverage, because no disease can be treated through grants
alone.
Third, the Commissions' recommendations did not guarantee
access to treatment for addiction. Medication-assisted
treatment reduces the likelihood of death, incidents of other
illness, and criminal behavior. At the very least, medication-
assisted treatment should be the standard of care for all
treatment centers, and we can go further. If doctors can
prescribe opioids that lead to addiction, why shouldn't
hospitals all be required to treat this disease?
Fourth, the Commission ignored evidence-based harm
reduction practices. In Baltimore, needle exchange has resulted
in the percentage of individuals with HIV from injection drug
used decrease from 63 percent in 1994 to seven percent in 2014.
Our programs are staffed by people in recovery themselves who
help patients connect to treatment.
Here in Baltimore, we know what works. We need support from
the Federal Government in three ways: number one, urgently
allocate additional funding to areas hardest hit by the opiate
epidemic; number two, directly negotiate with the manufacturers
of naloxone so that communities no longer have to ration;
number three, protect and expand insurance coverage to get to
on demand treatment for the disease of addiction.
Here in Baltimore, we have done a lot with very little. We
can do so much more if we had more resources, and I urge
Congress to commit these resources so that we can save lives
and reclaim our futures.
I thank you for coming to our city and for calling this
hearing.
[The prepared statement of Dr. Wen follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Gowdy. Thank you, Dr. Wen. Dr. Alexander?
STATEMENT OF CALEB ALEXANDER
Dr. Alexander. Good afternoon, Chairman Gowdy, Ranking
Member Cummings, and members of the Committee. I appreciate the
opportunity to speak today.
I am a practicing primary care physician and co-director of
the Johns Hopkins Center for Drug Safety and Effectiveness at
the Johns Hopkins Bloomberg School of Health. My research
focused on identifying political and policy solutions to the
opioid epidemic, but as a practicing physician, I also know the
power of stories to compel action, and I would like to share
with you a brief one now.
In 2011, Judy Rummler lost her son Steve from an overdose.
I work with Judy on policy reform and I asked her if I could
share his story. She said, I am always happy to share Steve's
story if it helps the cause. Steve's journey began like so many
with a lower back injury that led to chronic opioid use and
subsequent addiction. Years before his death, he wrote
presciently of opioids, ``At first they were a lifeline, and
they became a noose around my neck.'' Steve tried as best he
could to get well and he didn't want to die, but he ultimately
succumbed from an overdose after discharge from a rehab
facility. Now, Judy keeps a picture of Steve along with a note,
``If love could have saved you, you would have lived forever.''
Steve's story, and his family's resolve to ensure that
other families don't have to experience what they have, is a
reminder to me of what is at stake here, and of the loss that
so many have endured.
During the past year, my colleagues at Johns Hopkins and I
have reviewed hundreds of scientific studies and other data
points on the epidemic. Last month, we released this report,
``From Evidence to Impact'', that has been provided with my
written testimony, and that synthesizes the field and provides
recommendations to address the epidemic. Ranking Member
Cummings, we were so honored that you participated in the
release of this report.
In the remainder of my time, I would like to highlight two
points regarding how the Commission's report can best drive
change. First the Commission's findings provide a comprehensive
framework for action. Simply put, the science is the science,
and the Commission's report gets it right. It is based on
evidence and lines up closely with our own appraisal in most
areas. For example, both assessments agree that providers
should be required to use prescription drug monitoring
programs, that the CDC's guidelines should be standard practice
nationwide, and that high quality evidenced-based addiction
treatment should be available on demand.
In my written testimony, I make specific recommendations
regarding steps Congress can take, such as passage of the
Prescription Drug Monitoring Act of 2017, and I also highlight
areas where the Commission might have increased the
comprehensiveness or impact of their review.
Second, as we have already heard urged by some of you this
afternoon, it is now critical for the Administration to develop
a strategy to support the implementation of its
recommendations. It is one thing to say we are going to send a
man to the moon, and it is totally a different thing to have a
plan in place to do so. In my humble opinion, the Commission's
two most important recommendations are that we need to reduce
over-prescribing and provide high quality evidence-based
treatment for addiction upon demand, although I think reducing
the supply of fentanyl in the country is a very close third.
But I am left asking the questions that some of you may be,
which is what specific steps is the Federal Government going to
take to reduce, for example, opioid over-prescribing? What
resources are required? Which agencies are responsible? What
timeline will be followed? And how will we know when we have
been successful? In short, we urgently need an implementation
plan, and this Committee could support this effort by asking
for and reviewing such a plan for the Commission's most
important recommendations. This Committee can also exercise
oversight capacity to ensure that other federal agencies act on
the Committee's recommendations.
Esteemed representatives, we are missing more than half a
million Americans from overdose that should be with us today,
people like Steve Rummler and so many others. Incredibly, more
deaths from opioids are expected in 2017 than ever before; yet
as we look to 2018, there are reasons for hope. Providers are
increasingly using safer and more effective treatments for
pain. There is growing awareness that addiction is a disease
and treatable, and more Americans are living fulfilling lives
in recovery. Communities are increasingly mobilized, demanding
affordable naloxone, reliable access to addiction treatment,
stronger FDA regulation, and coordinated federal action. This
is a fixable crisis, but not without an implementation plan to
accompany the Commission's recent recommendations.
Thank you again for the opportunity to testify. I look
forward to your questions.
[The prepared statement of Dr. Alexander follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman Gowdy. Thank you, Dr. Alexander. The gentleman
from Maryland is recognized.
Mr. Cummings. Thank you very much, Mr. Chairman.
Dr. Wen, on June 18, 2017, the Baltimore Sun published an
article on naloxone entitled ``Baltimore City Running Low on
Opioid Overdose Remedy.'' The article stated that ``The city
has about 4,000 doses left to last until next May.'' You were
quoted in that same article as stating that, and I quote, ``We
are rationing. We are deciding who is the highest risk and
giving it to them.'' How many doses of naloxone does the city
have left now, and is that number adequate to meet the city's
needs?
Dr. Wen. Thank you, Congressman. We--I have people----
Mr. Cummings. And who are the highest priority people?
Dr. Wen. The highest priority individuals that we allocate
this lifesaving medication to are the individuals who are
clients of our needle exchange plan. These are individuals who
we know are actively using drugs.
Now, I will say that we do not in any way condone drug use,
but we do believe in saving someone's life. If it is a question
of preventing the spread of hepatitis and HIV we need to do
that, and if someone had died today, there is no chance for
them to get into treatment tomorrow. So for 11 unit of naloxone
given out on the needle exchange plan, one unit is used to save
someone's life.
Now I don't know how many medical advances there are out
there that have a number needed to save someone's life as 1 in
11. I have to answer your question. I have about 8,000 units
left between now and July of 2018. Now we are grateful for the
work of our state. Clay Stamp is here from the state. They have
been gracious in providing additional funding for naloxone once
they saw the need in Baltimore City. But if I got 8,000 more
units today, I could distribute them all by this weekend, and
then we can calculate how many more lives are going to be able
to be saved. That is the very definition of rationing. In the
middle of an epidemic, I shouldn't have to be forced to decide
who gets to carry a medication that could save their lives or
their family's lives.
Mr. Cummings. So how many doses do you need? I mean, let
me--to adequately distribute enough to be effective? In other
words, what is your goal?
Dr. Wen. I want----
Mr. Cummings. What would be your goal amount?
Dr. Wen. I would like for everyone in our city to carry
naloxone in their medicine cabinet or their first aid kit.
Imagine if we had the remedy--if Ebola had hit our city or some
other horrible contagious illness were to hit our city, we
would want to make sure that every single person carried the
antidote. I have community members, neighborhood faith leaders
calling me every day asking for naloxone. Why shouldn't it be
available everywhere in every public place in a way that we
have defibrillators available in public places?
Mr. Cummings. Now that Baltimore Sun article in February of
this year said, and I quote, ``The price of a popular
injectable version jumped 500 percent in the past two years,
and the cost of a nasal spray used in Baltimore has increased
nearly 63 percent.'' One auto-injector can now cost about
$4,500 for just two doses, is that correct?
Dr. Wen. That is correct.
Mr. Cummings. So Dr. Wen, what formulation of naloxone is
your office using? I mean, what do you----
Dr. Wen. We use nasal Narcan, which is manufactured by a
company called Adapt Pharma. It is one of the FDA-approved
versions of the medication, and we would hope that in this
epidemic the Federal Government can directly negotiate the
price so that we can get this at a much discounted one.
Mr. Cummings. Some kind of way--we have spent a lot of time
dealing with this issue of drug pricing and over-drug pricing,
and it seems sad--and this is my conclusion--that a lot of
these price hikes are about greed, not about cost of research,
R&D, but greed. And at the same time, we know that we have
something here that works.
Are there other things coming down the pike that you know
of that might be just as effective as naloxone? Have you heard
of any of those things?
Dr. Wen. I have not. There are very few antidotes available
in modern medicine. This is one of them. Naloxone is on the
World Health Organization's list of essential medications. It
is available by the pennies in other countries.
Mr. Cummings. By the pennies?
Dr. Wen. In other countries.
Mr. Cummings. Wow. Thank you very much.
Chairman Gowdy. The gentleman from Wisconsin.
Mr. Grothman. First question for all of you, on the break I
ran into a woman down here--it was very interesting--who had a
relative who had been through treatment dozens of times, which
kind of obviously means that treatment doesn't always work. I
would like you folks to comment on percentage-wise how often in
your experience in programs you deal with treatment works, and
what distinguishes the programs that treat--that are successful
and those programs that are not successful? And also, what
percentage of admissions do you expect to be successful with
regard to treatment?
Dr. Alexander. Well I could begin and say that there is no
question that opioid use disorders are really, really serious,
and the individuals that have opioid addiction remain with a
lifelong vulnerability to the products, and this is one the
reasons that it is so important that we reduce the
overprescribing of prescription opioids in the first place.
Mr. Grothman. They only give me so much time. Can you tell
me percentage-wise in the treatment programs you are familiar
with, percentage-wise how many times people go into treatment,
percentage-wise how often are they successful?
Dr. Alexander. I don't----
Dr. Wen. The data that I have seen are about 40 to 60
percent rate of recovery, recognizing that addiction is a
complex disease and that we need to be ready for people
whenever they want to go into treatment.
Governor Christie had mentioned that he had not met people
who were ready for treatment. I meet them all the time, and the
problem is that we need to be ready for people at that moment,
not have them wait weeks or months, and then recognize that
relapses are part of recovery because that is the nature of the
disease.
Mr. Grothman. So you expect a treatment program to be
successful half the time? Whether it is half the time of a
heroin addict or an opiate addict goes in, they will never do
it again? Is that what your expectation is?
Dr. Wen. They may not be successful that first time, but
they may be successful that second time, and recognizing that
there are forms of treatment that are evidence-based and some
that are not, and so we need to be promoting these evidence-
based treatments which include medication-assisted treatment.
Mr. Grothman. Well just when you get on the Internet, it
implies that, you know, these are wildly unsuccessful, that is
why I am asking.
Mr. Baum. Yeah, I just want to add to that. It is true that
relapse rates are a challenge, but I think that if we move away
from this sort of isolated episodic treatment model to an
ongoing, continuing care, we can drive down relapse rates.
Sometimes we have a detox program that is separate from an
inpatient that is separate from ongoing recovery supports, and
we have to stop doing it that way. The system has to evolve to
have ongoing recovery support so that relapse rates are driven
down.
And just in summary, I would say we shouldn't accept the
level of relapse rates. I think we can drive them lower if we
work harder and work smarter.
Mr. Grothman. Okay. I asked Governor Christie and I will
ask you as well. Some of you made about the fact that heroin
was fairly apparently common in Vietnam. I don't know. And when
people came home, almost all the troops stopped using heroin.
Could you comment on that?
Mr. Baum. Yeah, it is a very interesting point in history.
In Vietnam was when they had the first drug testing program,
and people weren't cleared to go home from Vietnam until they
tested negative for drugs. And so there was--people in Vietnam
were highly motivated to get home. They had to step using
drugs, they had to test negative, and then they went home.
I mean, I do--I don't dispute the point that you changed
the environment and you changed the behavior, but it was also
part of a program to test people and to encourage them to get
off heroin before they came back.
Dr. Wen. Part of it, too, is why it is that people are
using drugs? Part of it may be overprescribing because of
treating physical pain, but people are also treating other
types of pain too. We know that the same communities facing
high rates of overdose are also facing poverty and homelessness
and unemployment, and in order for us to break that cycle of
addiction, we also have to be addressing those underlying
factors and helping those communities thrive too.
Mr. Grothman. Okay, you are touching on something that I
think Governor Christie wanted to stay away from, but do you
find that sometimes family background is a correlation with
abuse?
Mr. Baum. I mean, I think that there is evidence that
people on all walks of life and all type of background, of
every level of wealth and every racial group are affected by
the drug problem.
Mr. Grothman. That goes without saying, but I mean
percentage-wise.
Mr. Baum. No, I think if you look at the percentage
breakdown by socioeconomic group there is a little bit of
variation, but really, everyone is being affected by this
problem. Everyone with the disease of addiction needs and
deserves treatment and ongoing recovery support.
Mr. Grothman. Okay, that is it. On to the next.
Chairman Gowdy. The gentleman yields back. The gentlelady
from the District of Columbia is recognized.
Ms. Norton. I think you can hear me now.
I think it is fair to say that both Democrats and
Republicans underestimated the standing of the Affordable
Healthcare Act until the most recent election where we saw
governor-to-be--governor elect Northam win an election and the
polls say that a lead indicator was the Affordable Healthcare
Act, and they don't even have that in Virginia. People
apparently are very, very afraid for their healthcare, and they
chose that election, which is considered a kind of herald
election for the coming elections to express themselves, even
though they knew that Northam would have a hard time getting
them the Affordable Healthcare Act.
So I--my question is about what role the Affordable
Healthcare Act can play or is playing in this crisis? I know
that Governor Christie indicated that the Affordable Healthcare
Act, unlike, by the way, the plans that many Americans have,
does require that substance abuse be afforded in the same way
as other healthcare. That is an important gain for healthcare
in the United States, at least for those who have the
Affordable Healthcare Act. One of the figures that interested
me was the one on Medicaid expansion and who, in fact, has
benefitted from it? It appears that 3 in 10 non-elderly adults
with substance abuse disorders nationwide get Medicaid
expansion. It says to me it is being used by the very people
that we are discussing here today.
So I need to know from you, perhaps Dr. Wen, Dr. Alexander,
what you think would--what you believe would occur if, in fact,
those states that have Medicaid expansion--this is one of them,
New Jersey, Governor Christie's state, is another--suppose that
was no longer available? What would that do to the crisis under
discussion here this afternoon?
Dr. Wen. More people would die. Because of Medicaid
expansion, 1.6 million people who have substance abuse
disorders are now able to have access to treatment. Prior to
the ACA, one-third of the individual market plans did not cover
substance abuse disorders, and for people who have the disease
of addiction, there is no margin of error. If you are to take
away their treatment today, their only option may be to
overdose and die. And so studies have shown that it will take
$180 billion over a decade to provide healthcare to those who
lose coverage.
So back to the point that Ranking Member Cummings made that
the cost of doing nothing isn't nothing, we are spending that
money anyway. We are spending the money now on medical costs
and cost of incarceration. We can choose to invest it in
treatment instead.
Ms. Norton. Is the Affordable Healthcare Act being used to
prevent opioid addiction and not simply to intervene once it
occurs?
Dr. Wen. We need to do a lot more when it comes to
prevention, including stopping the overprescribing of drugs,
stopping the trafficking of drugs, but also, things like
investing in nutrition, in family literacy, in home visiting.
All those things also help to boost family structure and reduce
poverty, which ultimately also reduces addiction.
Dr. Alexander. I would just add that there are several
provisions--although the ACA wasn't designed for the treatment
of patients with opioid use disorders alone, there are several
provisions within it that have been very important for those
seeking treatment for opioid addiction. And that is not just
the parity provision, but also the requirement that treatments
for addiction be considered an essential health benefit. So
this is something that--the Commission speaks--the Commission's
report speaks to ways that there may be insurance barriers to
accessing, for example, medication-assisted treatment, but is--
does not directly address the role of insurance in the first
place. And as a colleague of mine has, I think, eloquently put
it, until you make it easier for patients to access high
quality addiction treatment than it is to find their next bag
of heroin or their next bottle of Oxycontin, they aren't going
to flock towards treatment. So it is vital that treatment is
expanded.
Ms. Norton. Could you give us some insights on why some
jurisdictions are so much worse off in this crisis than others?
For example, the District of Columbia is a big city. They have
taken--they have used the Affordable Healthcare Act and done a
lot of prevention. The crisis, I think, over the last three
years tripled. Are there characteristics of a jurisdiction that
will predict the opioid crisis that you could speak about, Dr.
Alexander?
Dr. Alexander. Well it is an outstanding question, and
indeed, if you look at maps of the country, county maps, it is
stunning the variation county to county, both in terms of
opioid prescribing as well as injuries and deaths from opioids.
The first point I would make is that these are highly
correlated. That is, if I showed you plots, you don't have to
have a degree in biostatistics to see that there is a very high
correlation between the volume of opioids that is being
prescribed in a given area and injuries and deaths from these
products. We do know that there are a variety of different
state policies and county policies that can make a difference
in the volume of opioids that are prescribed, and in rates of
heroin and illicit fentanyl use.
But I think that there is a lot more that we have to learn,
not only in why it is so bad in some countries, but also why we
have seen counties that have had remarkable gains in terms of
reducing both volume of overprescribing, but also injuries and
deaths from these products. And state policies like
prescription drug monitoring programs ensure policies and state
policies like caps on the volume of prescription opioids that
are prescribed, investments that cities and states are making
and addiction treatment services, all of these can play an
important role.
Ms. Norton. Thank you.
Chairman Gowdy. Gentleman from Alabama, Mr. Palmer, is
recognized.
Mr. Palmer. Thank you, Mr. Chairman.
Mr. Baum, there was a report in the November 2017 Journal
Addictive Behavior that noted that there has been a shift in
drug--opioid abusers first use. According to the report, in
2005 8.7 percent of individuals who began abusing opioids in
2005 began with heroin. By 2015, that had changed to 33
percent. Has your office been able to determine what caused
this shift?
Mr. Baum. You know, thank you for the question. I don't
have a definitive answer, but I would say that the epidemic
continues to evolve rapidly. We know--and I won't repeat what
was discussed what has caused this epidemic, which was the
overprescribing of narcotic painkillers. As more people have
been using heroin, there has been a spread of heroin shared
between family members, boyfriends, girlfriends, and others,
and so I have seen those reports and it is concerning.
And let me just emphasize, we need to get out the message
about the incredible lethality of the drug supply. When someone
consumes heroin, it could contain fentanyl. It might contain
other substances as well. Same with these prescription pills
that people buy. The drug supply is more lethal than ever
before, and really people are taking their lives in their own
hands when they are using these drugs.
Mr. Palmer. Dr. Alexander, it has been reported that there
were 64,000 deaths in 2016. Is that an accurate number?
Dr. Alexander. Yes, correct, from all overdoses.
Mr. Palmer. The information that I have indicates that it
might be reported--underreported by as much as 20 percent, and
each of you have touched on this a little bit because the
reluctance of family members to have that cited as the cause of
death would--is that 20 percent underreporting--does that--is
that real?
Dr. Alexander. Well I don't have a--I am not sure of the
precise degree to which there is underreporting, but there is
no doubt you raise a very good point. And any underreporting
would mean that the epidemic is even more worse than the 64,000
number would suggest.
Mr. Palmer. Well that is my point. The epidemic is at a
point now where it has literally reduced the life expectancy of
Americans. We--for the first time in I forget how many years,
but it has been at least a couple of decades, our life
expectancy in the United States has declined, and there are
some studies indicating it is related to the number of people
dying from drug overdoses, drug poisoning.
Dr. Alexander. Yeah, that is correct, and we see
manifestations in many different sectors of the economy. The
labor force--I think the Commission's report did a good job of
outlining many of the ripple effects. We have heard about
strains on the foster care system, and so there are effects
manifested throughout.
And the other point to make is that the deaths are tragic,
and I know many of you have met with constituents and, you
know, you'll never forget those stories and those days, and yet
the deaths are the tip of the iceberg. For every patient that
has died, there are dozens or more that have opioid addiction.
There are hundreds that are experiencing the effects of going
to emergency departments or having a chaotic household where
someone has an opioid use disorder.
Mr. Palmer. I want to touch on something my colleague from
Wisconsin brought up, and that is about the efficacy of the
treatment using medication assisted treatment. I think the
number--it is not effective for about 40 percent of the
population. We talked a good bit about--but there is another
drug out there, Vivitrol, that does not give the same impact as
opioids. It is not--it is a once a month type pill, but it
literally requires that people go into withdrawal for--I mean,
it takes three to ten days for someone to become clean and use
that. Have you used that, Dr. Wen? I guess that would be more
appropriate to address that to you.
Dr. Wen. Yes, we believe that all three forms of FDA-
approved medications, which are methadone, buprenorphine, and
naltrexone, also called Vivitrol, that all three should be
available in all settings without there being prior
authorization for insurance, without only one form being
available at some places. Because just like for other
illnesses, some patients may do well with one medication, some
may not do well with that medication but may do well with
another one. And so we believe that all three should be
available. And methadone and buprenorphine have had a bag
reputation because they can be abused and misused, but so can
many medications. And we have to follow the signs and evidence
which show that medications as a treatment is the gold standard
and that it reduces illness and death and even criminal
behavior.
Mr. Palmer. I see my time is expired. I appreciate your
responses to this.
I just want to point out, though, this is not a political
issue. This is--it is, in my opinion, a public emergency and to
bring the politics into it, I think, is inappropriate. We have
seen a major increase in deaths from drug overdoses since 2010,
so I just want to encourage folks to not look at this as a
political issue. This is a national crisis.
I yield back.
Chairman Gowdy. Gentleman yields back. Gentleman from
Missouri is recognized.
Mr. Clay. Thank you, Mr. Chairman.
If we are to be successful, I am a firm believer that we
must first remove the stigma traditionally associated with drug
use. For far too long, society has deemed drug users criminals
in need of incarceration rather than patients in need of
treatment, as we saw so clearly during the 1980s and '90s.
Dr. Wen, you summarize that change back in January stating,
and I quote, ``Traditionally, it has been seen that if you have
an addiction, it is a moral failing. It is a personal choice.
Now we are calling it a disease.''
Drs. Wen and Alexander, how important is it that we as a
society are finally recognizing addiction for what it is, a
disease?
Dr. Alexander. Well I think it is vital, and I think we
heard this question posed which is can you imagine if we told
people with diabetes that 10 out of 100 will get treatment or
that we told people with kidney cancer we will take 100 of you
and we are going to offer 10 of you the best treatment that we
have. And it is when you look at settings like that where one
realizes the role that stigma has. Another very pervasive and
under-appreciated point is that all too often, we discuss
abuse. And I was heartened by the Commissions' report, the word
addiction is throughout. It is in the first sentence, I
believe. It is in the title and the charge to the Commission.
This is an epidemic of addiction. It is not an epidemic of
abuse. There is non-medical use that takes place, but for far
too long, we have suggested that there are sort of two
populations of individuals. We have the drug abusers that we
need to do everything we can to prevent them from accessing the
medicine, and then, you know, when I was a resident, I was
taught that we need not worry about the addictive potential of
opioids if a patient had ``true or legitimate pain.'' And
nothing could be further from the truth.
So I think that the issue of stigmas is really front and
center, and I think that this will take resources of massive
scale, really, to continue to educate individuals. Who would
choose a life of addiction? It is on anybody who has really
understood and met somebody that has addiction knows that this
isn't a choice that people are making any more than it is a
choice of a 10-year-old to have Type I diabetes.
Dr. Wen. We would never say to somebody with diabetes that
they should go to jail, and if--they should not get treatment
in jail, but once they return, they should be cured. Which is
the type of stigma that we continue to put on people and--who
have the disease of addiction.
I think one of the questions I would ask was about the
communities that are the most heavily affected. Our community
here in Baltimore has been affected for decades. This is not a
new issue, and Congressman Cummings has spoken very eloquently
about this in many talks past that we owe an apology to
generations we have incarcerated. And we owe an apology because
we knew the signs but didn't speak up then.
Mr. Clay. Mr. Baum?
Mr. Baum. Thank you, Congressman, for the question.
Police chiefs and sheriffs, they are doing an incredible
job around this country. They know the difference between
someone who is a drug user who needs treatment and someone who
is a drug trafficker, a major drug dealer who deserves
punishment. It is no question that someone whose criminal
activity is limited to buying and using drugs should be
diverted to treatment. I have been really encouraged with the
police diversion that is happening now around the country pre-
arrest, working very closely with the police assisted addiction
recovery initiative parry. Over 300 precincts and sheriff
offices allow you to walk into a police department or sheriff's
office 24 hours a day and get diverted right to treatment. They
do a quick intake, they put you in the front seat of the police
car, and they drive you to treatment. This program is expanding
rapidly. So we are doing more police pre-arrest diversion than
ever before.
On the other hand, if somebody is selling heroin laced with
fentanyl to our citizens and causing overdoses that are killing
people, that is a serious crime and they deserve prosecution
for that.
So I think we are able to tell the difference between those
who need to be diverted to treatment and those who deserve
prosecution.
Mr. Clay. As well as those physicians who turn their
offices into pill mills.
Mr. Baum. No question there have been some abusive doctors
who have been incredibly reckless and they deserve prosecution
for those crimes as well.
Mr. Clay. Now not to put you on the spot, but is it--is
that the official position of the U.S. Department of Justice,
or can you share with us that----
Mr. Baum. The Department of Justice wants to prosecute
traffickers and criminals and those that are killing our
citizens with these deadly drugs. There is no conflict at all
for diversion for minor, non-violent offenders for treatment.
Mr. Clay. Thank you for your responses, and I yield back,
Mr. Chairman.
Chairman Gowdy. Gentleman from Missouri yields back. The
Chair will now recognize himself.
Dr. Alexander, you mentioned overprescribing as being one
of the--kind of the dual things that you would address first.
What are the causes of over-prescription? Is it a misdiagnosis?
Is it a failure to consider alternatives? What are the root
causes of the over-prescription?
Dr. Alexander. Well thank you for the question, Mr.
Chairman, and the Commission's report discusses these in some
detail. And here again, I think that they hit most of the high
points. Misinformation, as I noted from my own training, when
we were taught in the late 1990s that we had overestimated the
addictive potential of prescription opioids. Labeling that is
inconsistent with the totality of evidence regarding the safety
and effectiveness of these products, and of course, the
labeling, as you know, in turn affects the ways that
pharmaceutical companies can market and promote the products.
The widespread prevalence of pain and a notion that pain needs
to be fully abated and that people should, you know, get to a
zero on a scale of 1 to 10, rather than in many countries,
cultures where pain is something to be managed. I think many
pain experts would say pain is something to be managed and
lived with, not just grin and bear it, but not expect that you
are going to be taking enough opioids that you get down to a
zero.
There are many, many, many causes that have contributed to
the overprescribing.
Chairman Gowdy. Are there certain specialties or
subspecialties where you have identified where the
overprescribing is more prevalent?
Dr. Alexander. Well it is a terrific question. It would be
a privilege to share with the Committee some of our own data
and own analyses in this regard. The point that I would make is
that the prescribing volume of opioids is highly skewed so that
if you look, for example, within primary care physicians, it is
a small subset of primary care physicians that account for the
lion's share of opioids that are prescribed.
With that being said, these are not primarily rogue
prescribers that are down on Main Street seeing 300 patients in
a day and only accepting cash. I think that there is a very
important point here, and in fact, Governor Christie spoke to
it when he said that most prescribers that are contributing to
this epidemic aren't doing so out of ill intent. They are doing
so out of non-intent. So it is important to recognize that
while opioid prescribing is highly skewed, that the prescribers
that are prescribing in such enormous volumes are not
necessarily, you know, just flouting any standard of best
medical practice.
Chairman Gowdy. Now when you say primary care physicians, I
am thinking pediatricians, internists, and GPs. What am I
missing?
Dr. Alexander. Family docs, internists are the big two.
Pediatricians are lower volume only because fortunately, not
many kids are prescribed opioids.
Chairman Gowdy. So we can take pediatricians out of it.
Internists----
Dr. Alexander. Sure.
Chairman Gowdy. --or would you--internists and GP----
Dr. Alexander. Yeah.
Chairman Gowdy. --or what used to be GPs, family doctors.
Dr. Alexander. Um-hum.
Chairman Gowdy. Two questions in this realm. Has there been
any analysis of physicians who write prescriptions for opioids
after a patient has been declined a prescription from another
physician? In other words, doctor shopping?
Dr. Alexander. Yeah, that is a terrific question, and here
again, as with the rogue prescribers, when we look at the data
we reach a very interesting conclusion, which is that opioid
shoppers are exceedingly rare, and almost around the era in
importance relative to other populations of high risk patients.
That is not to suggest that it is not vital that we identify
and intervene upon opioid shoppers, but there are other
populations of chronic opioid users that are much higher risk
when you look at a population level, a public health level than
opioid shoppers. And so I am speaking about individuals that
are on chronic high-dose opioids and also individuals that are
on the combination of prescription opioids and benzodiazepines.
Chairman Gowdy. I have a couple more questions. I am going
to try to fit them in so I don't violate my own rules.
In terms of alternatives--well let me ask you this. We can
test blood pressure, we can test cholesterol, we can check
somebody's temperature. How close are we to having a diagnostic
test for pain?
Dr. Alexander. It is, you know, nowhere in our lifetimes
would be my best guess, and I think it is one of the other
factors that has contributed to the epidemic because it is
really--because pain is so inter-subjective. It varies a lot
person to person, and it is very difficult--there is no
objective test for it.
This is one of the reasons that I think it is so important
that we teach the next generation of professionals and those
currently in practice, there are lots of tools in the toolbox.
We don't need to just wait for the FDA to bring new drugs down
the pipeline 10 or 20 years from now. We already have dozens of
different treatments, both pharmacologic and non-pharmacologic
for pain. And I think one of the things that is happening with
the opioid epidemic is that we are shining such a bright light
on opioids that we are neglecting to consider all of the
alternatives that, in many cases, are safer and more effective.
Chairman Gowdy. The gentlelady from Michigan, Ms. Lawrence.
Ms. Lawrence. Thank you.
I am going to ask this question to Ms. Wen and anyone else
who can answer. You spoke about the Baltimore schools having
addiction screening. We have approximately, as reported, about
430,000 foster children in America. I sit on the Foster Care
Caucus, and it is a high priority for me. Mental health for our
foster children in that alarming rate they suffer five times
more likely from PTSD and from trauma.
With that being said--and we talked about the priority
groups based on the socioeconomics. Is there any focus on
foster children as far as education, screening, and support?
Dr. Wen. That is an excellent question. We know from
studies that children who experience trauma, which losing their
family certainly would be that trauma, or growing up in
families with high rates of addiction would also be traumatic
too, that these children have higher rates of addiction
themselves. And that is this vicious cycle then of poverty,
trauma, and addiction, and addiction begins to beget addiction
too.
So from our standpoint, we absolutely need to provide
services for those children experiencing trauma, but
critically, we also have to provide treatment for their parents
and caregivers, because unless we do that, we are going to have
issues like we have a tripling of the number of children born
with neonatal abstinence syndrome. Some studies show that 40
percent of neonatal ICU days are because of their--the child
being born with and with the opiate addiction themselves. That
is a dangerous cycle, and we can stop it by providing treatment
for the mother, for the parent, for the caregiver.
Ms. Lawrence. I am told by the Department of Human Services
that the fastest growing contributor to foster children growth
in America is from opioid addiction, because children are being
taken away.
The last thing I want to say is that I did enter a bill
that would--the Timely Mental Health for Foster Youth, which
would require all children to be mandated, like they get a
physical health assessment. They need to get a mental health
assessment because we know these children have experienced the
first level of trauma, that is being separated from their
family, and I really hope that as we continue of targeting and
addressing addiction screening, that we keep a focus on our
foster children in America.
Thank you.
Chairman Gowdy. Gentlelady yields back. The Chair would now
recognize the gentleman from Vermont, Mr. Welch.
Mr. Welch. Thank you, Mr. Chairman, and Mr. Gowdy and Mr.
Cummings, I thank you for organizing this hearing. I think all
of us should leave this hearing with some significant amount of
humility. You know, as I see it, the Federal Government
primarily has to be a partner to the local communities that are
doing all the frontline work, and when I look at what you have
done here in Baltimore, just the training of the number of
people who are capable of administering lifesaving medication,
a kind of all-in approach that the city has taken, and also
Johns Hopkins has taken as well. Our role, as I see it, is to
try to get resources back to the communities so that you can
your job, because this appears to me to be fundamentally an
issue that can only be dressed--be addressed at the very local
institutional individual level. I mean, that story, Dr. Wen,
about your 24-year-old patient was--it really says it all. So I
want to thank you--all of you, really, Dr. Alexander and Mr.
Baum. Thank you for your work.
We are going to have a tough time in Congress on money. You
need more and when we don't provide it, our local first
responders are put in a jam, our police officers, the
hospitals. But we can do something about the cost of these
drugs that have gone way up, and it is my hope that this
Committee--there has been a lot of interest by many of our
members in trying to take practical steps to contain the cost.
Both Mr. Gowdy and Mr. Cummings have been leaders in this.
What has the cost of these lifesaving drugs, Dr. Wen, done
to your budget in your health department or in Baltimore?
Dr. Wen. We have redirected--given the scope of the opioid
epidemic, we have redirected funds from other critical programs
in order to fund this. So we--I have to choose all the time, do
we fund asthma programs for children, lead poisoning reduction,
or do we fund the opioid epidemic? And we had to----
Mr. Welch. I will ask all of you. On these drugs like
naloxone and these others, have the changes that have been made
largely, in my view, to extend intellectual property protection
and allow additional price increases, have they made a
significant different in the benefit to the lifesaving
qualities given to the patient, or is it just the higher price?
And you can all address that.
Dr. Wen. Hard to say except that, again, this is available
in other countries for very little, and I would love to see us
get the broad access that this epidemic requires.
Mr. Welch. Mr. Baum, is that an issue?
Mr. Baum. Yeah, I don't know if that is an issue. I have
met with all the manufacturers of these medications and talked
to them about pricing, and they have talked about how if you
have insurance, either public or private, they have a very low
copayment, sometimes----
Mr. Welch. Can I interrupt?
Mr. Baum. Please.
Mr. Welch. I hear that all the time.
Mr. Baum. Yes.
Mr. Welch. It is so corrupt. I mean, what is the problem--
and I am not directing this at you, I am directing it at them.
What is the problem with being able to go on the internet and
finding out what it costs without all the convoluted
obfuscation that occurs in drug pricing? I mean, is that as
frustrating to you as it must be to practitioners?
Mr. Baum. I guess where I am is naloxone saves lives. We
want everyone who needs access to it to get access to it. I was
trained on how to use it. I want it out available----
Mr. Welch. What happens when the drug companies hold
hostage your desire to save lives with a stick up price that
bankrupts your operation?
Mr. Baum. You know, I think that the story is more
complicated than that, and they are getting a lot of this
product out at discounted prices. I think we need to continue
to work with them and need to continue to find resources to
fund naloxone, because I----
Mr. Welch. Explain to me why the price has gone up so much
when it is basically the same product?
Mr. Baum. Well I really--I don't want to speak for the
manufacturers, but my understanding is they had a list price
but the actual price at the retail level that is paid by
consumers is much less.
Mr. Welch. See, that again is gobblygook, because it is a
price--you know, if you went and bought a car and paid $15,000,
and the same car a year later was $25,000, you would be able to
figure out that is a $10,000 difference. You can't figure that
out now.
Mr. Baum. All I can say is, you know, we are committed to
keep working to getting naloxone at a fair price.
Mr. Welch. Well we would love to work with you. You know,
President Trump has said that he wants--he said that the pharma
companies on pricing are getting away with murder.
And by the way, all of us acknowledge that pharma does
fantastic things, life extending and pain relieving drugs. But
if the price kills us, we are not really getting ahead. So we
really need the President and all of us to get involved in
trying to do legitimate things to contain this, in my view,
price gouging.
I yield back.
Chairman Gowdy. Gentleman from Vermont yields back.
I want to thank our panel. We have votes back in Washington
that they expect us to be there for, whether we want to be
there or not. They expect us to be there. So I want to thank
all three of you not just for your time and your expertise
today, but for the dedication of your lives in helping other
people. It has been very instructive. I think we are--all the
members--I want to thank again the good folks at Johns Hopkins
and the mayor and the governor and Governor Christie, and I
want to thank you, Mr. Cummings, for being such a phenomenal
host to all of your colleagues.
Mr. Cummings. Again, I want to thank you, Mr. Chairman. You
didn't have to do this, but you did, and you made a commitment
to me right after you became Chairman that you were going to do
this hearing, and you kept your word. And I really do
appreciate that.
And to all of our witnesses and to Johns Hopkins, we thank
you, and to the members, I want to thank every member. People
in the audience, this is a little bit of a sacrifice for
members to come here. I know it is close to D.C., but they
literally have to come in earlier than they normally would
have, probably catch some earlier flights than they would have
to be with us. And so I want to thank all of our members for
being here.
I just have one quick unanimous consent request, Mr.
Chairman, and that is that the letter dated November 21, 2017,
from the Association for Behavioral Health and Wellness be
entered into the record, and that the testimony of the National
Healthcare for the Homeless Council be admitted into the
record, and it is dated November 28, 2017.
Chairman Gowdy. Without objection.
Chairman Gowdy. The gentleman from Alabama looks like he
seeks recognition.
Mr. Palmer. We will have the opportunity to submit
questions in writing?
Chairman Gowdy. You may. Let me get to that part of it.
The hearing record will remain open for two weeks for any
member to submit a written opening statement or questions for
the record. If there are no further questions, no further
business, we want to thank our second panel again, particularly
for your patience in that the first panel was super important,
but it also maybe went a little bit longer. So we appreciate
your patience and your expertise and your comity, with a t,
with the Committee.
With that, we are adjourned.
[Whereupon, at 3:53 p.m., the Committee was adjourned.]
APPENDIX
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