[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


                                   
                         [H.A.S.C. No. 115-110]

                     MILITARY HEALTH SYSTEM REFORM:

                        PAIN MANAGEMENT, OPIOIDS

                        PRESCRIPTION MANAGEMENT

                       AND REPORTING TRANSPARENCY

                               __________

                                HEARING

                               BEFORE THE

                   SUBCOMMITTEE ON MILITARY PERSONNEL

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                              HEARING HELD

                             JUNE 20, 2018

                                     
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT] 


                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
33-383                     WASHINGTON : 2019                     
          
--------------------------------------------------------------------------------------



                   SUBCOMMITTEE ON MILITARY PERSONNEL

                    MIKE COFFMAN, Colorado, Chairman

WALTER B. JONES, North Carolina      JACKIE SPEIER, California
STEVE RUSSELL, Oklahoma              ROBERT A. BRADY, Pennsylvania
DON BACON, Nebraska                  NIKI TSONGAS, Massachusetts
MARTHA McSALLY, Arizona              RUBEN GALLEGO, Arizona
RALPH LEE ABRAHAM, Louisiana         CAROL SHEA-PORTER, New Hampshire
TRENT KELLY, Mississippi             JACKY ROSEN, Nevada
(Vacancy)
                 Glen Diehl, Professional Staff Member
                Craig Greene, Professional Staff Member
                         Danielle Steitz, Clerk
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page

              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Coffman, Hon. Mike, a Representative from Colorado, Chairman, 
  Subcommittee on Military Personnel.............................     1
Speier, Hon. Jackie, a Representative from California, Ranking 
  Member, Subcommittee on Military Personnel.....................     2

                               WITNESSES

Bono, VADM Raquel C., M.D., USN, Director, Defense Health Agency; 
  and CAPT Mike Colston, M.D., USN, Director, Mental Health 
  Policy and Oversight, Office of the Assistant Secretary of 
  Defense for Health Affairs.....................................     3

                               
                               APPENDIX

Prepared Statements:

    Bono, VADM Raquel C., joint with CAPT Mike Colston...........    20
    Coffman, Hon. Mike...........................................    19

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    [The information was not available at the time of printing.]

Questions Submitted by Members Post Hearing:

    Ms. Tsongas..................................................    37
                     
                     
                     
                     MILITARY HEALTH SYSTEM REFORM:

    PAIN MANAGEMENT, OPIOIDS PRESCRIPTION MANAGEMENT AND REPORTING 
                              TRANSPARENCY

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                        Subcommittee on Military Personnel,
                          Washington, DC, Wednesday, June 20, 2018.
    The subcommittee met, pursuant to call, at 3:30 p.m., in 
room 2212, Rayburn House Office Building, Hon. Mike Coffman 
(chairman of the subcommittee) presiding.

 OPENING STATEMENT OF HON. MIKE COFFMAN, A REPRESENTATIVE FROM 
     COLORADO, CHAIRMAN, SUBCOMMITTEE ON MILITARY PERSONNEL

    Mr. Coffman. I want to welcome everyone to the Military 
Personnel Subcommittee's hearing on ``Military Health System 
Reform: Pain Management, Opioids Prescription Management and 
Reporting Transparency.'' Our panel includes the Director of 
the Defense Health Agency and the Director of Mental Health 
Policy and Oversight for the Assistant Secretary of Defense for 
Health Affairs.
    They are here to address opioid abuse, an important problem 
that has affected every congressional district in the United 
States. The opioid epidemic in the United States claims roughly 
116 people from drug overdoses every day; 42,249 people died 
from overdosing on opioids in 2016 with an estimated cost of 
over $504 billion. With the military being a vital subset of 
the overall population that may encounter stresses related to 
deployment, training, and family separations, understanding the 
magnitude of opioid abuse and the challenges related to overall 
pain management is a critical part of the Military Personnel 
Subcommittee's congressional oversight efforts. We are here 
today to understand the scope of the opioid abuses, abuse 
issues in the military and with non-Active Duty TRICARE 
beneficiaries. Our panel will also address policy reform on 
opioids from a strategic enterprise perspective and the 
Department of Defense model for pain management.
    The subcommittee is also concerned with the Department of 
Defense's efforts to ensure reporting transparency with State 
prescription drug monitoring programs. We understand there have 
been some challenges with developing a State prescription drug 
monitoring programs, PDMPs, model that balances military 
related cybersecurity and operational concerns with the need 
for data transparency with nonmilitary treatment facility 
clinicians and pharmacists that are serving TRICARE 
beneficiaries accessing multiple points of healthcare services.
    I ask unanimous consent that nonsubcommittee members be 
allowed to participate in today's briefing after all 
subcommittee members have had an opportunity to ask questions. 
Is there objection?
    Without objection, [nonsubcommittee] members will be 
recognized at the appropriate time for 5 minutes.
    Before I introduce our panel, let me offer Congresswoman 
Speier an opportunity to make any opening remarks.
    [The prepared statement of Mr. Coffman can be found in the 
Appendix on page 19.]

    STATEMENT OF HON. JACKIE SPEIER, A REPRESENTATIVE FROM 
 CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

    Ms. Speier. Mr. Chairman, thank you, and I am delighted 
that after a couple of opportunities to have this hearing that 
had to be postponed, we welcome our individuals who are 
testifying today, and I want to thank the chairman for having 
this hearing because, indeed, it is a crisis in our country. 
When we have over 2 million people over the age of 12 who are 
either dependent on opioids or are abusing them, it is time for 
us to take very seriously the impacts on everyone, none the 
least our service members, their dependents, and retirees. I 
think the military has the opportunity to lead the Nation to 
reduce opioid abuse and develop alternative pain management 
therapies, and today I am eager to hear about your efforts to 
exercise such leadership.
    Several years ago, the military realized it had an opioid 
problem when it became clear that the predominant pain 
treatment for our wounded warriors was prescription medication. 
Changing prescribing practices and increasing the use of 
alternative pain management methods has enabled the military to 
reduce the prescription opioid abuse among Active Duty service 
members to 1 percent.
    However, opioid abuse remains a challenge, especially for 
retirees and dependents. I am interested in hearing how the 
Department's new opioid prescription guidance will be 
implemented to limit the amount of days for each prescription, 
as well as how the DHA [Defense Health Agency] will implement 
it if it becomes law, the NDAA [National Defense Authorization 
Act] requirement to create a Prescription Drug Monitoring 
Program to increase transparency with States as well as reduce 
prescription monitoring.
    I am also interested in hearing about how DHA will lead 
research on and increase the availability of alternative pain 
methods like acupuncture, chiropractic care, and other services 
that are now being utilized by healthcare providers around the 
country.
    So with that, Mr. Chairman, I yield back.
    Mr. Coffman. Thank you Ranking Member Speier. We will give 
each witness the opportunity to present his or her testimony 
and each member an opportunity to question the witnesses for 5 
minutes.
    We would also respectfully remind the witnesses to 
summarize to the greatest extent possible the high points of 
your written testimony in 5 minutes or less. Your written 
comments and statements will be made part of the hearing 
record.
    Let me welcome our panel: Vice Admiral Raquel C. Bono, 
Medical Corps, United States Navy, Director, Defense Health 
Agency; and Captain Mike Colston, Medical Corps, United States 
Navy, Director of Mental Health Policy and Oversight, Office of 
the Assistant Secretary of Defense for Health Affairs.
    Vice Admiral Bono, you are now recognized for 5 minutes.

STATEMENTS OF VADM RAQUEL C. BONO, M.D., USN, DIRECTOR, DEFENSE 
  HEALTH AGENCY; AND CAPT MIKE COLSTON, M.D., USN, DIRECTOR, 
  MENTAL HEALTH POLICY AND OVERSIGHT, OFFICE OF THE ASSISTANT 
            SECRETARY OF DEFENSE FOR HEALTH AFFAIRS

    Admiral Bono. Thank you, sir. Chairman Coffman, Ranking 
Member Speier, and members of the subcommittee, I am honored 
here to be alongside with Captain Colston, who serves as our 
senior clinical policy expert for DOD [Department of Defense] 
on issues related to pain management and opioid abuse issues.
    I want to thank the committee for your continued support 
and investments in pain management research and opioid 
addiction.
    The Military Health System's mission is to ensure the 
medical readiness of our Nation's Armed Forces and to provide 
world-class healthcare for all of our 9.4 million 
beneficiaries.
    The Military Health System is also part of the larger U.S. 
health system, and we have a shared responsibility to take 
action and help address the Nation's public health crisis 
regarding opioid abuse and addiction.
    Today, what I would like to do is outline what we know 
about the current state of opioid issues and addiction among 
DOD beneficiaries, highlight the steps the Department is taking 
to address this crisis, describe the partnerships we have built 
across the public and private sectors, and, finally, to 
describe our efforts to enhance our ability to share our data 
on our beneficiaries with State prescription drug monitoring 
programs.
    The Department has made strides in managing opioid abuse 
within our system and is continuously looking to further 
enhance our programs. Fewer than 1 percent of our Active Duty 
forces either abuse or are addicted to opioids, and our 
overdose death rate among Active Duty is one-quarter the 
national average.
    Chronic opioid use is more common among our patients who 
are 45 years or older, and they are more likely to be retirees 
or family members of retirees, and they receive the majority of 
their care outside of our military hospitals and clinics.
    Just last week, the Department published the Defense Health 
Agency Procedural Instruction for Pain Management and Opioid 
Safety, which establishes the MHS [Military Health System] 
stepped-care model as the comprehensive standardized pain 
management framework for providing consistent, quality, and 
safe care for patients with pain with an emphasis on 
nonpharmacologic therapies.
    With the help of this model, we have reduced opioid 
prescriptions by 15 percent. We plan to further reduce this 
rate through a focus on nonpharmacologic therapies within the 
military treatment facilities and through direct care policy 
changes.
    Working closely with our pharmacy contractor, Express 
Scripts, Incorporated, ESI, we are closely monitoring the 
distribution of opioids across all venues, military pharmacies, 
civilian retail pharmacies, and our mail-order system. We are 
identifying high users of opioids and sharing that information 
with our providers within the military treatment facilities. We 
have also taken measures to minimize complications for patients 
requiring opioids. We are able to monitor the daily morphine 
intake of those patients requiring opioid therapy and easily 
identify those at increased risk for death from opioids. We 
have a patient lookup tool that calculates the risk of overdose 
or serious opioid-induced respiratory depression to assist 
providers in safe opioid prescribing. Naloxone is readily 
available through the pharmacy and the military treatment 
facilities to be dispensed to eligible beneficiaries upon 
beneficiary request or when the pharmacist determines elevated 
risk for life-threatening opiate overdose using the patient 
lookup tool.
    In addition, the new TRICARE managed care contracts require 
our contract partners to act on information provided by DOD on 
a quarterly basis regarding patients with unusually high or 
lengthy opioid use, as well as providers who prescribe high 
amounts of opioids.
    And we have been working with ESI to establish a 
prescription drug monitoring program, PDMP, that will connect 
with the States. This provides a key tool in the opioid fight 
as it will allow DOD providers to access State PDMPs, as well 
as allow civilian providers to access the DOD PDMP.
    Although prescriptions filled for DOD beneficiaries through 
mail or retail venues are readily reported to the States, the 
establishment of the DOD PDMP will provide a full controlled 
substance profile for all providers and pharmacists. Our DOD 
PDMP solution will operate through a commercially available 
portal and hub technology that not only allows us to 
bidirectionally share DOD controlled substance information with 
a State but addresses operational security concerns. I expect 
this new capability to be available by December 2018.
    Mr. Chairman, Madam Ranking Member, this crisis is touching 
the lives of so many of our fellow citizens, and the Department 
is committed to playing its part to help combat the epidemic 
and ensure our patients receive the finest care we can provide. 
DOD is making headway, but there is more to be done educating 
our patients and providers on threats from opioid addiction and 
strategies to reduce abuse.
    Thank you for asking us to be here today. Between myself 
and Captain Colston, who is deeply involved in this issue day 
to day, I look forward to addressing all of your questions. 
Thank you.
    [The joint prepared statement of Admiral Bono and Captain 
Colston can be found in the Appendix on page 20.]
    Mr. Coffman. Thank you, Admiral Bono.
    How is the Department of Defense planning to ensure 
compliance and transparency reporting with the State 
prescription drug monitoring programs, and how do we know this 
is the right model?
    Admiral Bono. Sir, this is a model that has been in use by 
many of the States, and so with what we are doing with making 
our data available to the State PDMPs is by adhering to their 
practices and their requirements for participation. It is 
bidirectional, and so, we have found a way to make sure that 
our data is completely visible to them.
    Mr. Coffman. Okay. Admiral Bono, or Captain Colston, what 
steps or processes are we putting in place to wean service 
members off of opioids, and is this tracked across the Military 
Health System?
    Captain Colston. Yes, sir, it is. So, in fact, opiate use 
is down even over the last year in Active Duty service members 
from 3.2 percent to 2.7 percent. We have introduced a stepped-
care model with regard to the way that we treat pain that puts 
an emphasis on nonpharmacologic therapy and wants to take 
people off of opiates. We want acute pain not to become chronic 
pain, and we want to be able to treat both acute and chronic 
pain without opiates.
    There are several methods to detox someone from opiates 
that we approach clinically, and, of course, for folks who 
struggle with both pain disorders and opiate use disorders, we 
have a full suite of medication-assisted therapy available both 
in network and in MTFs [military treatment facilities].
    Mr. Coffman. Okay. Admiral Bono, anything to add to that?
    Admiral Bono. No, sir, this is very comprehensive, and 
Captain Colston described it well.
    Mr. Coffman. Very well.
    Admiral Bono, are we considering healthcare industry best 
practices when it comes to management of opioids? Please 
provide some examples.
    Admiral Bono. Yes, sir. Yes. As a matter of fact, the 
stepped-care model that we are using was done in partnership 
with the VA [Department of Veterans Affairs] and was validated 
with them. We are also working with NIH [National Institutes of 
Health], and we are also working with West Virginia. And part 
of the research that we have been able to do is not only 
collaborate across these institutions but also validate that 
the tools that we are using are effective. The pain scale that 
we use, the Defense Veterans Pain Scale, is something that we 
have done in partnership with the VA. So many of the tools that 
you see in use here have not only been done with best practices 
in civilian and academic centers, but it has been validated by 
them, as well.
    Mr. Coffman. Thank you Admiral Bono.
    Ranking Member Speier.
    Ms. Speier. Thank you, Mr. Chairman.
    Thank you, Admiral and Captain. I would like to spend a 
little time on the CDC [Centers for Disease Control and 
Prevention] guidelines. The CDC guidelines recommend immediate 
release of opioids, not extended. They recommend less than 3 
days' supply and suggest that 7 days will rarely be needed and 
not to allow the use of benzodiazepines at the same time. So 
that is the recommendations by the CDC, and I am wondering why 
your recommendations, your guidelines are, frankly, much more 
liberal than that? In fact, I believe you have 7 days as your 
floor, which to me is more than twice what is being recommended 
by CDC.
    Admiral Bono. So, for minor procedures and acute pain, we 
actually recommend 5, and we also are looking at the morphine 
milligram equivalent to keep that below 90 per day. In that 
case, too, for acute and minor procedures, there can only be 
refill on that prescription for 3 days only if evaluated by a 
provider. For major procedures, we do--we recommend 7 days, 
but, again, refill can only be done after evaluation by a 
provider and with maintaining a morphine milligram equivalent 
below 90.
    Ms. Speier. You are not quite answering my question. Let me 
just read to you one of the other recommendations. It says that 
when considering increasing dosage to more than 50 morphine 
milligram equivalents per day and should avoid increasing 
dosage to 90 milligrams per day or carefully justify a decision 
to titrate dosage to 98 milligrams per day. I guess my point 
is, is that you are exceeding the guidelines in some ways 
significantly from what the CDC is recommending, and I want to 
know why.
    Admiral Bono. While I am familiar with the CDC guidelines, 
I think what I was trying to share is how we stratified it 
between minor procedures and major procedures, and so I would 
probably need to understand it a little bit more, and perhaps I 
might be missing something in the question, if I could----
    Ms. Speier. Ask the Captain?
    Admiral Bono. Yes. One of my lifelines.
    Captain Colston. Ma'am, so most folks get much, much less 
than 50 morphine milligram equivalents per day. For dental 
procedures, it is 1 day with 1-day refill. For short-term pain 
or acute procedures or small procedures, it is 5 days with a 3-
day refill, and again, most people don't get opiates at all for 
these types of procedures. For major procedures, 10 days with 7 
days.
    I can tell you from personal experience, most of the time, 
you don't get opiates. I just broke my foot in four places, and 
I didn't get a shred of opiates. Recovered faster, felt much 
better.
    The overwhelming--there is a consensus both between CDC and 
the VA-DOD guidelines that we don't want to use opiates. We 
would much rather use other modalities for pain, and if we are 
going to use a pharmacological approach, we want to use non-
opiates. When you look at the amount of opiates that we are 
prescribing in the system, that number is down precipitously, 
and I have seen this evolve over the last 5 years.
    Ms. Speier. Okay. I am running out of time. So I think you 
have gotten my point. You might want to go back and look at 
whether you need to reduce it a little bit more. I have a 
subsequent question on--is it gabarbardine or--do you know 
what, Doctor? Gabapentin. And are you using that in lieu of 
opioids, or is that considered an opioid?
    Captain Colston. Yes, ma'am.
    Ms. Speier. All right. Can I just make a point there 
because I was just talking to a doctor because I am about to 
have surgery, and he was saying now the abuse is shifting from 
opioids to this particular drug, so I think we should just be 
on the lookout that if we are just substituting one drug for 
another and it still has addictive qualities, that that is a 
problem as well.
    But I would like to just shift gears for the little time 
that I have left to asking about these alternative pain 
management methods, the use of acupuncture, relaxation therapy, 
chiropractic care. Are there plans to expand these treatments 
to all MTFs, and if they are not currently available in MTFs 
can beneficiary receive treatments in the civilian network?
    Admiral Bono. Yes, ma'am. So 83 percent of our MTFs 
currently offer some kind of complementary modality. I am 
actively looking to see how we can make sure that all 
beneficiaries have availability or access to these 
complementary treatments and have started studying how 
commercial and private plans are including this and what we can 
do to make sure that we have this in our health plan for all 
beneficiaries.
    Ms. Speier. So you are saying, at 80 percent you have at 
least one of these, but you may not have all of them. Is that 
what you are saying?
    Admiral Bono. Yes, ma'am. At least one. There may be a 
combination depending with acupuncture, meditation, and 
alternate pain treatment modalities.
    Ms. Speier. And do you have that chilling system that many 
hospitals are now using in lieu of opioids?
    Admiral Bono. I am sorry?
    Ms. Speier. There is some system where you can put a 
chilling--I am way above my pay grade. I think I will just--I 
will yield back.
    Admiral Bono. I will Google it, if I may.
    Mr. Coffman. Dr. Abraham.
    Dr. Abraham. Thank you, Mr. Chairman.
    If you guys are only got a 1 percent rate, you guys are 
phenomenally doing a great job, I can tell you, because we 
know, compared to the civilian population, that is way below. 
So kudos to what you are doing.
    A couple questions. Admiral, you said there was a 15 
percent reduction. Is that in the young Active troop, or is 
that in the troop that maybe has retired that has comorbid 
conditions, such as arthritis, degenerative disk disease, or 
something like that?
    Admiral Bono. These are primarily with the patients that 
are being treated in our MTFs.
    Dr. Abraham. So that is a young troop. Good deal. You 
mentioned naloxone, what we call Narcan.
    Admiral Bono. Yes, sir.
    Dr. Abraham. And we know that that can be immediately 
lifesaving, and it seemed like the caregiver is able to access 
that if it is deemed necessary for that particular individual. 
Is that a correct statement?
    Admiral Bono. Yes, sir.
    Dr. Abraham. Do you guys track the amount of Narcan that is 
used?
    Admiral Bono. We have just--I just signed off on the policy 
that allows us to dispense the Narcan from our pharmacies, 
making that available to prescribers as well as pharmacists 
who--so we are just now going to be able to start tracking that 
in real time.
    Dr. Abraham. And you said by April of 2019 or December of 
2018, you will be linking up with some of the States. Have you 
guys got a pilot program already in place?
    Admiral Bono. December of 2018.
    Dr. Abraham. So this year?
    Admiral Bono. Yes, sir. We will be able to communicate with 
all State PDMPs.
    Dr. Abraham. I am from Louisiana, and we have a pretty good 
reporting system there, and it does make a difference as far 
as--I mean, if I can punch up a patient and see that they are 
seeking from another physician, then, you know, we go in and we 
have a little discussion with them, so.
    Admiral Bono. Yes, sir. Our patient lookup tool allows 
providers like Captain Colston to look up day or night into the 
patient's profile, so that has been very helpful.
    Dr. Abraham. Okay. And, you know, again, we understand the 
necessity of getting this right. We certainly understand the 
severity of the problem, not only in the military but across 
the spectrum.
    Kudos to you, Captain, if you had four breaks and did not 
take an opioid.
    Admiral Bono. That is because he did not have many days 
off.
    Dr. Abraham. And we probably rightly and maybe wrongly do 
vilify the opioid drug, but like any particular drug, used in 
the proper setting at the proper dose for the proper amount of 
time, it can be certainly--you don't want your patient to 
suffer. So I think we need to find that little niche, and I 
know it is hard. Individual patients take individual therapy, 
but, you know, we don't need to throw the baby out with the 
bathwater completely. We want to make sure that that troop, 
that retiree does not suffer because we were scared to write a 
prescription. We have got to do the right thing in a lot of 
areas, and so hopefully we will get this right.
    So thanks for what you guys are doing. Maybe we can use 
this as a model for our civilian population.
    So I yield back, Mr. Chairman.
    Admiral Bono. Thank you, sir.
    Mr. Coffman. Thank you, Dr. Abraham.
    Ms. Rosen.
    Ms. Rosen. Thank you, Mr. Chairman.
    And thank you for being here today. I have a couple of 
questions. One of my questions is about your prescribing, and 
so I know--I am from a physician family. My husband is a 
physician. Actually, he just had back surgery, and he has had a 
little bit of experience in some of these prescription issues, 
but are your models separating out inpatient drug use versus 
outpatient drug use because there is major and minor 
procedures. My husband had back surgery; major procedure, 
requires different types of treatment than someone coming in. 
So that is my first part of the question.
    And then also, in regards with that inpatient to 
outpatient, how are you working with emergency rooms, not in 
our VA hospitals or in our treatment facilities but in the 
general population, to be sure that people aren't drug shopping 
by going to some other outpatient center?
    Admiral Bono. Yes, ma'am. I will take the ED [emergency 
department] one, and then I will let Captain Colston talk about 
the difference of inpatient with outpatient because you are 
right, there is a difference there. Part of our participation 
with the PDMP allows us now to have full visibility of people 
going to the ED for prescriptions and even pharmacy being able 
to see these pharmacies that--the pharmacies that they attend 
or go to to get their prescriptions filled. So we have a lot of 
visibility now on what we are doing.
    Our partnership with Express Scripts, since 63 percent of 
our patients receive their care from--or receive their opioids 
from civilian pharmacies or get the prescriptions from our 
civilian partners, they have provided us complete visibility of 
that, as well, and they report to us when we--when one of our 
patients reaches a certain threshold of opioid prescriptions 
or--and how much they are taking.
    Ms. Rosen. And they do that across all types of 
prescriptions because people can get multiple drugs----
    Admiral Bono. Yes, ma'am.
    Ms. Rosen [continuing]. That do the same effects.
    Admiral Bono. Yes, ma'am. And as a matter of fact, part of 
our training has raised the awareness of some of those other 
multiple drugs, particularly benzodiazepines, and that is what 
we have actually seen a slight decrease in our providers 
avoiding prescribing benzodiazepines at the same time. So, yes, 
exactly, we are tracking that very closely, and we have much 
better visibility of that now.
    As far as inpatient and outpatient, since Captain Colston 
is actively taking care of both inpatient and outpatient, I 
will let him--I think you were in outpatient, weren't you?
    Captain Colston. Yes.
    Ms. Rosen. Inpatient monitoring is different, and then you 
have to worry about when they become an outpatient as they 
transition, right?
    Captain Colston. Yes, ma'am. So a few things about 
inpatient care and major procedures. Of course we use opiates. 
We use opiates surgically. We use them with other drugs. We use 
them with ketamine drips. We use them with nerve blocks. We use 
other pharmacological modalities to reduce the amount of opiate 
exposure that someone needs. Now, after a major procedure, say, 
a coronary artery bypass graft or something along those lines, 
you get 10 days of opiates when you leave. That is an extremely 
painful procedure, and you have got your sternum cracked in 
two. And if you need another one, 7 days, but that is really at 
the point where we really need to watch you closely. Because 
the thing that creates addiction is, it is almost always 
iatrogenic. Three-quarters of people who become addicted get it 
from medical intervention. So it is very important for us to 
watch you in those of situations.
    And the two variables that matter most are the dose, the 
amount of opiates that we gave you, and how long we gave them 
to you. And an opiate use disorder is an extremely lethal thing 
to have. The 20-year mortality for that is 40 to 60 percent. So 
you give--you turn an 18-year-old into an opiate addict, that 
person may not reach 40. So we always need to weigh the risks 
and benefits when we start medicine, but opiates are part--
definitely part of the medical care suite and something that, 
of course, we want to deliver humane care, and we want to get 
to pain.
    One of the big things that we struggled with as physicians 
in the early 2000s is we just tried to get rid of pain no 
matter what the price, and we really created a number of folks 
who struggled and died.
    Ms. Rosen. Right. Well, thank you.
    I yield back my time. I appreciate your work.
    Mr. Coffman. Ms. Shea-Porter.
    Ms. Shea-Porter. Thank you, and thank you for being here. I 
wanted to show you a picture of Daniel Keegan. Daniel Keegan 
was from my district, and he died from substance use disorder. 
And I wanted to tell you the story and ask you a couple of 
questions about him in honor of him and his mother, who is 
working very hard to let the country know that we have a 
problem and we have to do something about it.
    Daniel Keegan enlisted out of high school at the Dover 
Recruiting Office in my district. All he wanted to do was to 
serve his country. He was the type of recruit that we need many 
more of. Incredibly smart. He scored an 800 on the verbal and 
760 on math. He was well trained by our military. He was an 
impressive soldier. He attended the University of New Hampshire 
to further his military career. We have an All-Volunteer Force. 
We need people like Dan to stand up and answer that call to 
serve, as you well know.
    While serving, Dan developed a substance use disorder. DOD 
diagnosed him, was aware of his problem, but when he separated, 
he did not receive any help getting into the VA system to 
continue treating his substance use disorder. In the time 
period after he separated, he struggled to get his comp and pen 
[compensation and pension] exam, relapsed, and then he died 
waiting for his appointment, which was not scheduled until 
nearly 16 months after he separated.
    His mother Stephanie shared his story with us. When he 
separated, Dan was struggling with this and was not equipped to 
navigate the VA system. Nobody offered him help. The DOD did 
not offer any help at all, even though they knew he had this 
problem. In Dan's words, he was a disposable soldier. We spent 
a fortune training him, but when he got sick, DOD dropped him. 
The VA bears some responsibility here, but it is clear from 
listening to Stephanie that Dan felt that DOD failed him. Dan 
loved the VA and wanted to help other veterans with their 
illness so they could access treatment. He would have been an 
incredible member of our community after separating from the 
DOD, but he wasn't given the chance because DOD dropped the 
ball. He was not connected to DOD or VA service in a way that 
might have saved his life.
    In your testimony, you talk about all of the data that DOD 
has to identify at-risk patients. You have medical records that 
should show when a service member is being treated for 
substance use disorder. You also talk about coordinating care 
with VA, but you do not mention anything about what you will do 
to ensure separating service members get the health care that 
they need. I strongly believe that there has to be a system in 
place that ensures separating service members who are eligible 
for VA care and need VA care have an appointment scheduled 
before they separate from DOD. The command responsible for a 
soldier when he or she is separating should also be held 
responsible for making sure that soldiers are receiving the 
health care that they need when separating. As I said, they 
knew what his problem was.
    Many separating service members are simply left in a 
position to navigate that whole system themselves, and clearly, 
he couldn't. So I would like to ask you to respond to the 
following questions. What is DOD doing to ensure that there is 
no delay in getting care for separating service members? Is 
there any way that they talk to the VA or in some way make sure 
that there is a handoff, that we don't just leave them outside 
the door of the military? Can DOD employ case managers or 
coordinate care and ensure that his appointment is waiting for 
separating service members that are diagnosed either or are at 
risk for substance use disorder? And can we continue offering 
mental health care to separated service members when the 
handoff of the VA does not go smoothly and the service member 
is encountering significant delays in accessing VA care? I 
thank you for listening and would like to hear your response.
    Admiral Bono. Thank you very much for sharing that, and it 
is very sobering to hear something like that when we have 
missed the ball on that, or we have let somebody fall through 
the cracks. We do have quite a few programs, and we recognize 
that we needed to be able to help transitioning service members 
from the DOD to the VA, and actually, we have fairly numerous 
programs. I would like to be able to give you a more complete 
answer, if I could, to give you the list of some of those 
programs because I don't have them readily at my fingertips. So 
I would like to take that for the record if I could.
    But if I may speak from a very broad perspective, DOD and 
VA have done some considerable partnering in recent years 
because we recognize that many of our patients are of the same 
continuum, and part of their care needs to transition from DOD 
to VA. We have recently agreed with the VA to share the same 
electronic health record so that we would be able to retrieve 
that information, the clinical information that is so necessary 
to understand how to make these handoffs happen more smoothly 
so we don't create unnecessary gaps in their care.
    We have also been working at very high levels between the 
DEPSECDEF, Deputy Secretary of Defense, and the Secretary of 
the VA to make sure that we are working on those strategic 
objectives, those strategic imperatives that allow us to be 
more seamless in their delivery of care. And then we also have 
several working groups and subcommittees of the DOD and VA to 
address several transition issues, whether it is health, 
behavioral health, or even in some cases the ability to 
transition from working in the DOD to working in the VA health 
system.
    So, if I could, I would like to take that for the record so 
I can give you a much more comprehensive answer, but at a 
general level, we are working much more closely with the VA.
    [The information referred to was not available at the time 
of printing.]
    Ms. Shea-Porter. I appreciate that. So, if Dan was 
discharged tomorrow, would that system work, the one you just 
described?
    Admiral Bono. Yes, ma'am. I think that what you have 
described and how his process went, I would like to think that 
what we have put in place would not have let that happen.
    Ms. Shea-Porter. Okay. Thank you very much. I yield back.
    Admiral Bono. Thank you, ma'am.
    Mr. Coffman. Thanks. So we are going to do a second round. 
My question is to Active Duty personnel who sustain some type 
of injury or requires surgery where they are given opioids for 
a limited period of time, and let's say that that Active Duty 
individual is then returned--they are returned to their duty 
station, whatever it is, so they are not medically discharged, 
but severe enough to be given--to undergo a regimen of opioid 
medications or treatment. So let's say that, because of that, 
they have a problem and that they are seeking out opioids or 
drugs to--that they became addicted at some degree. Through--so 
what tracking programs does the military have now? Do we still 
have--we have periodic urinalysis program, would that pick up 
these--is that programmed to pick up the opioids? And at what 
level does it pick it up at? I mean, if somebody is not--maybe 
tell me what the threshold is, if somebody has done it within 
so many hours, what is the threshold requirement that that test 
could pick it up?
    Admiral Bono. Yes, sir. I think in general terms, and I 
will let Dr. Colston refer to the actual milliequivalents that 
we have set the threshold, not only do we--not only do Active 
Duty undergo routine screening and for those patients that we 
have identified that are long-term opioid users, they are 
actually put on a regular regimen of urine screening so that we 
can monitor that.
    Mr. Coffman. Okay.
    Admiral Bono. The other thing is we have also expanded our 
urine screening, urine drug screening, to include many more 
substances recognizing that that is a risk.
    Mr. Coffman. Okay.
    Admiral Bono. But in terms of what the actual level, I 
don't know if Captain Colston might be more familiar with that.
    Captain Colston. Yes, sir. So there is the readiness 
testing that we do is totally separate from medical testing 
that we do.
    Mr. Coffman. Okay.
    Captain Colston. The readiness testing does have thresholds 
between positive and negative tests. It is extremely accurate. 
We have confirmatory testing, which uses very expensive linear 
chromatography gas mass spectrometry equipment. That is 
something that has nothing to do with health. And what we want 
to do is we want to treat these folks. We want to get these 
folks medication-assisted therapy. We want--if they still have 
a pain disorder, we want to use for medication-assisted therapy 
a drug that also addresses their addiction, like methadone or 
buprenorphine, and we have any number of providers who are 
qualified to give those drugs. In fact, we have a surfeit of 
providers capable of giving those drugs.
    We have a policy on the medical side that we do not want to 
stigmatize any kind of addiction. We want folks to get treated, 
and, in fact, at the partial hospitalization program where I 
work, command is kind of kept away for a little while as we 
focus on these folks because, in fact, relapse is part of 
recovery for addiction, and it is such a dangerous addiction, 
opiates, that we really need folks to almost live in a vacuum 
away from command, and we have been doing that for 7 years 
there, I think, with great success.
    Mr. Coffman. So I think my point is, so if somebody 
undergoes this regimen of treatment due to surgery or due to 
some injury that they have sustained, they then--you have a 
monitoring system for them postelection--postprescription or 
whatever you want to call it, and so nobody is going to fly 
under the radar from your perspective in terms of----
    Captain Colston. Well, the point I was trying to make, sir, 
is the readiness testing is not a way that we find people who 
are addicted. If we identify that you have an opiate use 
disorder, you are going to get regular urinalysis. You are 
going to get pill counts. We are going to check you for 
diversion. We are going to do any number of actions that help 
you get sober.
    Mr. Coffman. But the readiness test would indicate----
    Admiral Bono. Yes, oh, yes.
    Captain Colston. Yes, sir. I just want to add that 
readiness testing, the number of positive opiate screens is 
down 76 percent in the last 5 years. So we know that we are 
headed in the right direction on that problem, sir.
    Mr. Coffman. Okay. And then how long have we been screening 
for opioids and the testing?
    Captain Colston. Since the Nixon administration.
    Mr. Coffman. A long time. Okay.
    Ranking Member Speier.
    Ms. Speier. Thank you.
    Admiral Bono, you are embarking on an $81 million, 6-year 
research collaboration. Can you describe your plans for the 
research, what population you are going to conduct the research 
on, and the extent to which you are going to implement your 
conclusions if they prove--therapies that they prove effective 
before the actual research is completed, or are you going to 
wait the 6 years?
    Admiral Bono. Yes, ma'am. So we have several ongoing 
research collaboratives. One of the most robust ones is with 
West Virginia and also with NIH. So what we do with both of 
these collaboratives is we make sure that, as we see results 
and they get validated--and this is the important part of the 
research, is being able to address certain types of aspects of 
opioid addiction and treatment. And once we get validation and 
we know that it is effective, we try to put those into place 
right away.
    As a matter of fact, Captain Colston and I were just 
remarking that, in the last several years since 2015, because 
we have started seeing the results of some of this research, we 
have been able to put in many of those practices and those 
treatments that we have understood better because of the 
research, and that has been happening in the last few years. So 
I anticipate that as we continue this level of effort, that we 
will be able to implement things much more quickly.
    Ms. Speier. Yield back.
    Mr. Coffman. Dr. Abraham, nothing? Ms. Shea-Porter.
    Ms. Shea-Porter. I am good.
    Ms. Speier. One more question, Mr. Chairman.
    Mr. Coffman. Go ahead.
    Ms. Speier. I read an article that suggests that the use of 
marijuana reduces the amount of opioid usage in those areas 
that have legalized marijuana. I realize the Federal Government 
is not one of them, but I am curious if you have done any 
research on that. It was ``Medicare Patients Use Fewer Opioids 
with Medical Marijuana Laws,'' was the headline on this 
particular article.
    Admiral Bono. Yes, ma'am. We are always monitoring other 
aspects of care and seeing if there is scientific evidence-
based data that would help support that. So we are monitoring 
that. We don't necessarily do that research, but we monitor 
everybody else's research.
    Ms. Speier. And if, in the end, it is found to be helpful, 
what do we do about it?
    Admiral Bono. Well, I think that would be something----
    Ms. Speier. I guess that is our job.
    I yield back.
    Admiral Bono. I was going to ask for help on that one.
    Mr. Coffman. I think you would need it.
    I wish to thank the witnesses for their enlightening 
testimony this afternoon. There being no further business, the 
subcommittee stands adjourned.
    [Whereupon, at 5:32 p.m., the subcommittee was adjourned.]

     
=======================================================================

                            A P P E N D I X

                             June 20, 2018

      
=======================================================================


              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                             June 20, 2018

=======================================================================

      
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
      
=======================================================================


              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                             June 20, 2018

=======================================================================

      

                   QUESTIONS SUBMITTED BY MS. TSONGAS

    Ms. Tsongas. I was pleased to read in your written testimony about 
the Department's work to establish a Prescription Drug Monitoring 
program. How does the DOD plan on requiring military medical treatment 
facilities across the country to utilize and share information through 
this new PDMP--particularly in emergency situations?
    Admiral Bono. The Department has issued a Prescription Drug 
Monitoring Program (PDMP) Contract Modification to Express Scripts Inc. 
to provide visibility to Schedule II-V controlled substances dispensed 
within the Military Health System (MHS) to registered PDMP prescribers, 
pharmacists and law enforcement in all other states. Scheduled 
completion date is 31 Dec 2018. The DOD PDMP program is an adjunct to 
the existing monitoring capabilities that now exist for providers at 
our Military Treatment Facilities (MTF). Prescriptions filled at any of 
the three points of service (mail, retail and MTFs) through TRICARE 
which have been cost shared by TRICARE are collated and available for 
query by MTF providers in real time. The DOD PDMP program will also 
capture controlled substances that were dispensed when the beneficiary 
paid cash. This will ensure a complete history is available to any 
provider, both military and civilian, who is registered to use the PDMP 
program. Once available, DOD will work towards incorporating 
appropriate PDMP review as part of the MHS patient care work flow.
    Ms. Tsongas. Admiral Bono, have you seen any issues or trends 
involving service members seeking opioid pain relievers due to chronic 
musculoskeletal pain caused, in part or in whole, by heavy personal 
protective equipment? If so, how is the Department seeking to manage 
this causal factor?
    Admiral Bono. Musculoskeletal injuries are the number one medical 
threat to readiness. However, the rates of opioid abuse and dependence 
are below 1% among TRICARE beneficiaries, with a 56% decrease since 
2016. Currently, there is no direct evidence of opioid seeking behavior 
related to heavy personal protective equipment. DOD has taken action to 
address pain management and opioid safety through a comprehensive, 
holistic approach by providing intensive training, utilizing external 
partnerships, and implementing policies to discourage opioid overuse. 
The MHS is synchronizing pain care under a stepped care model, which 
equips primary care providers to encourage self-care and provide pain 
management to patients with a focus on non-pharmacologic therapies. Our 
goal is to help patients manage their pain at the lowest care level 
necessary and to teach them the skills necessary to move back down the 
continuum of care with the stepped care model. The MHS has optimized 
opioid safety through specific opioid prescribing guidance for acute 
pain episodes and minor procedures as well as major procedures in the 
uncomplicated patient. The MHS has increased the opioid safety patient 
information availability at the point of care. The Opioid Risk and 
Recommended Clinical Actions (ORRCA) report is a clinical decision 
support tool that providers will use to promote recommendations based 
on clinical practice guidelines into each patient's individualized care 
plan.
    Ms. Tsongas. How does the DOD plan on offering and tracking the 
effectiveness of opioid alternative treatments for chronic pain?
    Admiral Bono. We use a tool called Pain Assessment Screening Tool 
and Outcomes Registry (PASTOR) in specialty clinics to assess the 
efficacy of our complementary and integrative therapies for chronic 
pain. PASTOR is based on the National Institutes of Health investment 
in Patient-Reported Outcomes Measurement Information System (PROMIS) 
and provides advanced analytics for assessing patient reported 
outcomes. PASTOR utilizes evidence-based patient reported outcomes to 
assess effectiveness of clinical and programmatic pain management 
interventions at both the individual and population health levels.
    Ms. Tsongas. Admiral Bono, does the DOD have a plan to address how 
retired service members can obtain alternate forms of pain management 
through TRICARE without these retirees having to pay out of pocket?
    Admiral Bono. We agree that complementary and integrative pain 
therapies, such as mindfulness, massage, yoga, chiropractic care, and 
acupuncture are essential to managing pain in our healthcare system. We 
are actively considering addition of complementary and integrative 
therapies to the TRICARE benefit for provisional coverage. Acupuncture 
and chiropractic care are currently under review. Acupuncturists 
currently are not TRICARE-authorized providers. DHA is proceeding with 
a rule-making to remove the regulatory exclusion of acupuncture and add 
acupuncturists as authorized providers.
    Ms. Tsongas. How is the DOD training its medical professionals on 
the treatment of newborns suffering from opiate exposure? If that 
training is already in place, what does it look like?
    Admiral Bono. There is no formal DOD training in place at this 
time. However, providers caring for neonates should be following and 
delivering care in accordance with the American Academy of Pediatrics 
(AAP) Policy on Neonatal Drug Withdrawal, which utilizes a clinical 
scoring system to determine abstinence and potential need for drug 
therapy. Also, the General Pediatric Content Specifications published 
by the American Board of Pediatrics and utilized in the curricula of 
all the DOD Pediatric Residencies lists neonatal abstinence syndromes 
(i.e., how neonates respond to withdrawal of any substance) among the 
required knowledge for preparation for the certifying examination and 
practice in the care of neonates.
    Ms. Tsongas. What lessons has DOD learned from the Department of 
Veterans Affairs on opioid prescribing practices?
    Admiral Bono. has adopted the MHS Stepped Care Model for Pain, 
modeled on the Department of Veterans Affairs (VA) patient experience, 
as the comprehensive model of pain management focusing on non-
pharmacologic pain treatments. DOD and VA also developed the Defense 
and Veterans Pain Rating Scale as the standard for pain scale. DOD 
continues to execute the Joint Pain Education Project in disseminating 
a standardized DOD and VA pain management curriculum used in education 
and training programs improving pain management competencies in the 
combined federal clinical workforce. DOD is committed to continued 
coordination and collaboration with VA regarding comprehensive pain 
management and opioid safety.

                                  [all]