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96–932 PDF 2015

WHAT ARE THE STATE GOVERNMENTS DOING 

TO COMBAT THE OPIOID ABUSE EPIDEMIC? 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

MAY 21, 2015 

Serial No. 114–46 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

TIM MURPHY, Pennsylvania 

Chairman 

DAVID B. MCKINLEY, West Virginia 

Vice Chairman 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

H. MORGAN GRIFFITH, Virginia 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

DIANA DEGETTE, Colorado 

Ranking Member 

JANICE D. SCHAKOWSKY, Illinois 

KATHY CASTOR, Florida 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

JOSEPH P. KENNEDY, III, Massachusetts 

GENE GREEN, Texas 

PETER WELCH, Vermont 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(II) 

(III) 

C O N T E N T S 

Page 

Hon. Tim Murphy, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 4 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 6 

Prepared statement .......................................................................................... 7 

WITNESSES

Jerome Adams, M.D., M.P.H., Commissioner, Indiana State Department of 

Health ................................................................................................................... 9 

Prepared statement .......................................................................................... 12 

Answers to submitted questions ...................................................................... 91 

Monica Bharel, M.D., M.P.H., Commissioner, Massachusetts Department of 

Public Health ........................................................................................................ 20 

Prepared statement .......................................................................................... 23 

Answers to submitted questions ...................................................................... 96 

Larry Wolk, M.D., M.S.P.H., Executive Director and Chief Medical Officer, 

Colorado Department of Public Health and Environment ............................... 34 

Prepared statement .......................................................................................... 36 

Answers to submitted questions ...................................................................... 105 

Mark Stringer, M.A., L.P.C., N.C.C., Director, Division of Behavioral Health, 

Department of Mental Health, Missouri ............................................................ 40 

Prepared statement .......................................................................................... 42 

Answers to submitted questions ...................................................................... 111 

SUBMITTED MATERIAL

Subcommittee memorandum .................................................................................. 71 

Letter of May 21, 2015, from Don Flattery to Mr. Murphy and Ms. DeGette, 

submitted by Ms. DeGette ................................................................................... 86 

(1) 

WHAT ARE THE STATE GOVERNMENTS DOING 

TO COMBAT THE OPIOID ABUSE EPIDEMIC? 

THURSDAY, MAY 21, 2015 

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC. 

The subcommittee met, pursuant to call, at 10:19 a.m., in room 

2322 of the Rayburn House Office Building, Hon. Tim Murphy 

(chairman of the subcommittee) presiding. 

Members present: Representatives Murphy, McKinley, Burgess, 

Griffith, Bucshon, Flores, Brooks, Mullin, Hudson, Collins, Cramer, 

DeGette, Tonko, Clarke, Kennedy, Green, Welch, and Pallone (ex 

officio). 

Staff present: Will Batson, Legislative Clerk; Andy Duberstein, 

Deputy Press Secretary; Brittany Havens, Oversight Associate, 

Oversight and Investigations; Charles Ingebretson, Chief Counsel, 

Oversight and Investigations; Chris Santini, Policy Coordinator, 

Oversight and Investigations; Alan Slobodin, Deputy Chief Counsel, Oversight; Sam Spector, Counsel, Oversight; Christine Brennan, Democratic Press Secretary; Jeff Carroll, Democratic Staff Director; Christopher Knauer, Democratic Oversight Staff Director; 

Una Lee, Democratic Chief Oversight Counsel; Elizabeth Letter, 

Democratic Professional Staff Member; Adam Lowenstein, Democratic Policy Analyst; and Timothy Robinson, Democratic Chief 

Counsel. 

OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA 

Mr. MURPHY. Good morning. Today we convene the fourth in a 

series of hearings examining prescription drugs and heroin addiction, the growing nightmare of one of America’s biggest public 

health crises. 

Since our opioid hearings earlier this month, approximately 

2,400 Americans have died from drug overdoses, and most of them 

because of opioid abuse. The size of this problem and the need for 

a new paradigm of treatment cannot be understated, and the process of developing legislative solutions has already started. Ranking 

Member DeGette and I have identified 15 areas in need of reform. 

One of those is 42 C.F.R. Part 2, which governs confidentiality protections for all substance use treatment records, both behavioral 

and physical, generated at a substance abuse treatment facility. It 

is well intended, but out dated, and Part 2 compromises medical 

2 

care, increases the risk of dangerous and deadly adverse drug-todrug interactions, and increases risk of relapse to addiction. My 

friend, Congressman Tonko from New York, and I have been working together to stop this medical records discrimination, and I 

thank him for his work. 

At the State level, responses to the epidemic vary. States like Indiana are responding to outbreaks of HIV and hepatitis. States on 

the east coast are confronting the problem of heroin laced with 

fentanyl, another narcotic pain reliever 100 times as powerful as 

morphine. Some States, mostly in the South, are burdened with the 

highest prescribing rates of opioid pain relievers, rates that are 

tenfold the rates in some other States. Also, State efforts share 

many similar challenges. The National Governors Association said 

States need accurate and timely information at their fingertips concerning the incidence and scope of the problem in order to develop 

an effective response. States have no choice but to use incomplete 

and outdated data to identify areas on which to concentrate their 

efforts, given their limited resources. Some States operate Prescription Drug Monitoring Programs, but these systems may not be easy 

to use. In Massachusetts, I believe it takes doctors 11 steps to use 

the program, which makes it difficult to encourage a high degree 

of participation. State systems are not necessarily connected to the 

systems of neighboring States, enabling abusers to doctor-shop 

across borders since their actions are not tracked. Further, the 

data on these systems can sometimes be several weeks old, escalating the risk for errors from inaccurate data. 

Overdose prevention remains a key aim of any meaningful State 

strategy, yet States have adopted different approaches to address 

it. Some provide liability protection for individuals who act in good 

faith to provide medical assistance to others in the event of an 

overdose, or expand access to the lifesaving drug naloxone, or use 

public education on the proper disposal of prescription drugs that 

are vulnerable to misuse. 

States also differ on availability and financing of medication-assisted treatments. Opioid maintenance is a bridge for those with 

addiction disorders to cross over in the recovery process, and we 

support that. Full recovery is complete abstinence. Medication-assisted treatment is valuable, but it must be coupled with proven 

psychosocial therapies and other wraparound services to support 

the person traversing this difficult road and to help with long-term, 

sustained recovery. 

Today we want to hear from the States about best-practice models, problems that they have encountered, and how States have addressed this problem. We also seek absolutely candid and honest 

input from each of our witnesses. Please tell us where there are 

problems, and please tell us where there are successes with any 

Federal programs or policies. We will hear from representatives of 

Indiana, Massachusetts, Missouri, and Colorado State Governments, a sampling of the 50-plus separate efforts being pursued by 

U.S. States and territories to counter opioid abuse. We are honored 

to have our witnesses join us this morning. We thank you for appearing today and look forward to hearing your testimony. 

[The prepared statement of Mr. Murphy follows:] 

3 

PREPARED STATEMENT OF HON. TIM MURPHY

Today we convene the fourth in a series of hearings examining prescription drugs 

and heroin addiction; the growing nightmare of one of America’s biggest public 

health crises. Since our opioid hearing earlier this month approximately 2,400 

Americans have died from drug overdoses, most of them because of opioid use. 

The size of this problem and the need for a new paradigm of treatment can’t be 

understated. And, the process of developing legislative solutions has already started. 

Ranking Member DeGette and I have identified 15 areas in need of reform. One of 

those is 42 CFR Part 2, which governs confidentiality protections for all substance 

use treatment records, both behavioral and physical, generated at a substance abuse 

treatment facility. Well intended, but out dated, Part 2 compromises medical care, 

increases the risk of dangerous and deadly adverse drug-to-drug interactions, and 

increases risk of relapse to addiction. Congressman Tonko from New York and I 

have been working together to stop this medical records discrimination. I thank him 

for his work. 

At the State level, responses to the epidemic vary. States like Indiana are responding to outbreaks of HIV and hepatitis. States on the east coast are confronting 

the problem of heroin laced with fentanyl, another narcotic pain reliever 100 times 

as powerful as morphine. Some States, mostly in the South, are burdened with the 

highest prescribing rates of opioid pain relievers, rates that are 10 fold the rates 

in some States. 

Also, State efforts share many similar challenges. The National Governors Association said States need accurate and timely information at their fingertips concerning the incidence and scope of the problem in order to develop an effective response. States have no choice but to use incomplete and outdated data to identify 

areas on which to concentrate their efforts given their limited resources. 

Some States operate Prescription Drug Monitoring Programs, but these systems 

may not be easy to use. In Massachusetts, it takes doctors 11 steps to use its program, which makes it difficult to encourage a high degree of participation. State systems are not necessarily connected to the systems of neighboring States, enabling 

abusers to doctor-shop across borders since their actions are not tracked. Further, 

the data on these systems can sometimes be several weeks old, escalating the risk 

for errors from inaccurate data. 

Overdose prevention remains a key aim of any meaningful State strategy, yet 

States have adopted different approaches to address it. Some provide liability protection for individuals who act in good faith to provide medical assistance to others 

in the event of an overdose or expand access to the life-saving drug naloxone or use 

public education on the proper disposal of prescription drugs that are vulnerable to 

misuse. States also differ on availability and financing of medication assisted treatments. 

Opioid maintenance is a bridge for those with addiction disorders to cross over 

in the recovery process. Full recovery is complete abstinence. Medication assisted 

treatment must be coupled with proven psycho-social therapies and other wraparound services to support the person traversing this difficult road and to help with 

long-term, sustained recovery. 

Today we want to hear from the States about best-practice models, problems they 

have encountered, and how States have addressed these problems. We also seek absolutely candid and honest input and ideas about where there are problems and successes with any Federal policies. 

We will hear from representatives of the Indiana, Massachusetts, Missouri, and 

Colorado State Governments, a sampling of the 50-plus separate efforts being pursued by U.S. States and territories to counter opioid abuse. 

We are honored to have our witnesses join us this morning. We thank you for appearing today and look forward to hearing your testimony. 

Mr. MURPHY. And I am purposefully cutting this short so we can 

keep this moving. 

Ms. DEGETTE. OK. 

Mr. MURPHY. I recognize Ms. DeGette for 5 minutes. 

4 

OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO 

Ms. DEGETTE. Thank you very much, Mr. Chairman. I have been 

asking you to have a hearing so we can hear from the States, and 

I am glad that the States are here. I think it is important because 

much of the work in this area is happening in the States. 

I am particularly glad that Dr. Wolk is here from my home State 

of Colorado. I am eager to hear about what is happening in Colorado, particularly the positive developments in reducing prescribing 

rates and illicit use of opioid painkillers. It is clear that if we wish 

to reduce the problem of opioid dependency in our communities, we 

also have to address the issue of overprescribing. Last year, the 

CDC released a report on the correlation between opioid prescribing rates and drug overdose rates. CDC Director Tom Frieden 

stated, ‘‘Overdose rates are higher when these drugs are prescribed 

more frequently. States and practices where prescribing rates are 

highest need to take a particularly hard look at ways to reduce the 

inappropriate prescription of these dangerous drugs.’’ 

Colorado has taken a number of important steps to address the 

opioid epidemic at its source. In September 2013, statewide leadership established the Colorado Consortium on Prescription Drug 

Abuse Prevention; its goal is to reduce the misuse of prescription 

drugs through physician training and education, public outreach, 

and safe disposal. The goal of the coalition is also to prevent 92,000 

Coloradans from misusing opioids by 2016, and I am sure we can 

get a good progress report on that from Dr. Wolk. I know that Colorado has seen the rate of non-medical use of opioid painkillers fall 

already as a result of its work, and I am hoping we can hear about 

some of these best practices and lessons learned in this process. 

I am also eager to hear about how the other States here today 

are working to monitor prescribing rates, and reduce the number 

of opioid painkiller prescriptions. Experts tell us that the State 

Prescription Drug Monitoring Programs, or PDMPs, are an integral 

part of the solution to overprescribing. PDMPs can facilitate better 

clinical decision-making by prescribers, reduced doctor-shopping, 

and help physicians refer individuals for addiction treatment. I am 

interested to hear about the efforts that the States are undertaking 

to make PDMPs a more effective tool. For example, again, in Colorado, we were able to double our PDMP utilization rate from 41 

percent to 84 percent in just 1 year. Massachusetts also has high 

provider participation rates. I would like to know how we were able 

to achieve such great results in such a short time. 

Finally, I am interested to know more about the innovative efforts that States are undertaking on the treatment side of the 

equation. For instance, Missouri has made medication-assisted 

treatment available through all its State behavioral health organizations. The State does not contract with organizations that do not 

provide MATs. This is an important step to ensure that patients 

have access to the full evidence-based care that they need. Colorado 

is also taking steps to improve treatment for substance abuse disorders by integrating behavioral and primary care services in the 

State Medicaid Program. This is an ambitious goal of integrating 

80 percent of the primary care practices with behavioral health 

5 

services, including emergency departments, clinics, and private 

practices. I look forward to hearing more about this initiative and 

to similar efforts that are taking place in Massachusetts. 

So the States before us have made some impressive efforts to address this public health concern, but I want to caution that a lot 

more work needs to be done. Even before the opioid epidemic 

began, our infrastructure for treating substance abuse disorders in 

this country was remarkably inadequate to deal with the prevalence of the disease of addiction. Given the history of neglect and 

underinvestment in substance abuse, it is no wonder that the 

opioid epidemic resulted in a public health crisis. 

There is just one last thing I want to talk about, Mr. Chairman. 

We had a fellow show up just in the audience at our last hearing, 

Don Flattery, and Don came as a citizen because he lost his son, 

Kevin, to an opioid overdose last Labor Day, and when you hear 

about his son, Kevin, and when you hear about what this family 

went through, it is just heartbreaking. It is heartbreaking. I know 

all of our hearts go out to their family. They dedicated an immense 

amount of time and resources to getting the best treatment for 

Kevin, but they couldn’t find access to the resources and quality 

treatment that they needed. I really want to thank Don for sharing 

his story with us, and for providing the committee with valuable 

insight into the problem. I am hoping we can hear from others like 

Don about the day-to-day challenges they face. Don wrote us a letter which talked about what has happened with his family, and I 

would ask unanimous consent to put that in the record, Mr. Chairman. 

[The letter appears at the conclusion of the hearing.] 

Mr. MURPHY. Well, I agree, because I read the letter, too. It is 

powerful. 

Ms. DEGETTE. Yes. Thank you. And thanks again for holding this 

hearing, and I will yield back. 

Mr. MURPHY. Yes, I just want to note too, I appreciate your request for doing this on a State level. I also want to acknowledge 

that I received a letter from you and Mr. Pallone on other suggestions for the committee. We do a lot of cooperative work together, 

and although that will never make the news that Members of Congress do work together on both sides of the aisle, I wanted to publically acknowledge my gratitude for you on that. 

Now, I don’t know if there are any members on this side who 

want to make an opening statement, but I would like to give an 

opportunity to our colleagues from Indiana to introduce the witness 

from Indiana. Dr. Bucshon, are you going first or is Mrs. Brooks 

going first? 

Dr. Bucshon, you are recognized first. 

Mr. BUCSHON. Thank you, Mr. Chairman. Today, I have the 

pleasure of introducing Indiana State Health Commissioner, Dr. 

Jerome Adams. Through extensive work as a researcher, as well as 

a policy leader, Dr. Adams brings a vast breadth of knowledge and 

experience to both the current opioid abuse epidemic in our State 

and to the witness panel. As we continue to work to curb the opioid 

abuse epidemic occurring through the country, parts of Indiana 

have recently seen HIV outbreaks as a direct result from this epidemic, presenting Dr. Adams with a unique challenge and a unique 

6 

perspective on the current crisis. His expertise will undoubtedly be 

valuable to this committee. 

Dr. Adams, thank you for appearing before us today, and I look 

forward to your testimony. 

And I yield to Congresswoman Brooks from Indiana. 

Mrs. BROOKS. Thank you, Dr. Bucshon. 

I want to thank the chairman for holding, once again, this important hearing, and to hear from witnesses who are battling this in 

our States. I want to extend a special welcome to Dr. Jerome 

Adams, my friend and constituent. It is wonderful for you to be 

here. And, in fact, his first day on the job, we were in an emergency meeting in Indianapolis focused on Ebola. And so here we 

are fast-forward just a few months, and I believe with your background not only as a physician from my medical school, but an anesthesiologist at Ball Memorial Hospital, that you do have the right 

kind of experience and background to help lead the State Health 

Department at this time. And as of May 18, there have been 158 

identified cases of HIV in Scott County, and that number has gone 

up from the time we last had a hearing, and we are asking the 

CDC about Scott County. And so we know that you and your team, 

many of whom are with you today, have done an amazing job of 

curbing the HIV epidemic and slowing its growth, and we look forward to hearing your testimony today. 

Thank you for being here. 

Mr. MURPHY. Gentleman—— 

Mr. BUCSHON. Yield back. 

Mr. MURPHY [continuing]. Yields back? All right, I recognize Mr. 

Pallone for 5 minutes. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. And I want to thank 

you and Ms. DeGette for the hearing, and for your due diligence 

in investigating the opioid abuse epidemic. I am glad the subcommittee is devoting significant attention to this issue because 

like all of the members here today, I am concerned about what is 

happening in my State. 

A New Jersey State official recently reported that more than 

6,000 people in New Jersey have died from overdoses since 2004. 

He also reported that more teens are dying from drug overdoses in 

New Jersey than car accidents. Today, we are hearing from State 

health officials about ongoing efforts within their agencies to combat this epidemic. And I know you all are dealing with many aspects of this issue, from reducing opiate prescribing rates, to increasing access to treatment to programs, and I look forward to 

hearing about the work you are doing, and I hope we can all learn 

from each other. 

I also want to hear from all the witnesses today about how we 

as the Federal Government can help fight this epidemic. We heard 

earlier this month from a number of Federal agencies about their 

work, but I want to make sure we are supporting the States and 

their efforts to address the epidemic. 

7 

We have heard repeatedly throughout this series of hearings that 

significant barriers to treatment for substance use disorders still 

exist. For example, SAMHSA’s 2013 National Survey on Drug 

Abuse and Health found that nearly 40 percent of individuals who 

make an effort to seek treatment were unable to get treatment due 

to lack of health coverage and the prohibitive cost of treatment. Another 8 percent reported that they had health coverage but it did 

not cover the cost of treatment. And with the passage of the Affordable Care Act, approximately 16.4 million Americans have gained 

health insurance coverage, and insurance companies are now required to provide treatment for substance abuse disorders and coverage, just as they would cover treatment for any other chronic disease. But we still need to understand where barriers to treatment 

remain, and we should work on making sure those who want to access treatment are able to do so. 

I also want to hear from all of our witnesses today about how 

Medicaid expansion, or in Missouri’s case of failure to expand Medicaid, has had an impact on treatment for substance abuse disorders. I know Massachusetts and Colorado both signed Medicaid 

expansions into law in 2013, and Indiana expanded Medicaid earlier this year, so I am interested to hear from all three of your 

States about how Medicaid expansion has improved access to behavioral health services, and I want to hear from Missouri how 

Medicaid expansion could help those seeking access to behavioral 

health services and what challenges you face by not expanding the 

program. So thanks again. 

[The prepared statement of Mr. Pallone follows:] 

PREPARED STATEMENT OF HON. FRANK PALLONE, JR. 

Mr. Chairman, thank you for holding today’s hearing and for your due diligence 

in investigating the opioid abuse epidemic. I’m glad this subcommittee is devoting 

significant attention to this issue because like all of the Members here today, I am 

concerned about what is happening in my State. 

A New Jersey State official recently reported that more than 6,000 people in the 

State have died from overdoses since 2004. He also reported that more teens are 

dying from drug overdoses in New Jersey than car accidents. 

Today, we are hearing from State health officials about ongoing efforts within 

their agencies to combat this epidemic. I know you all are dealing with many aspects of this issue, from reducing opioid prescribing rates to increasing access to 

treatment to programs. 

I look forward to hearing about the work you are doing, and I hope you all can 

learn from each other as well. 

I also want to hear from all of the witnesses today how we as the Federal Government can help fight this epidemic. We heard earlier this month from a number of 

Federal agencies about their work, but I want to make sure we are supporting the 

States in their efforts to address the epidemic. 

We have heard repeatedly throughout this series of hearings that significant barriers to treatment for substance use disorders still exist. For example, SAMHSA’s 

2013 National Survey on Drug Use and Health found that nearly 40% of individuals 

who made an effort to seek treatment were unable to get treatment due to lack of 

health coverage and the prohibitive cost of treatment. Another 8% reported that 

they had health coverage, but it did not cover the costs of treatment. 

With the passage of the Affordable Care Act, approximately 16.4 million Americans have gained health insurance coverage. And insurance companies are now required to provide treatment for substance abuse disorders and cover it just as they 

would cover treatment for any other chronic disease. 

But we still need to understand where barriers to treatment remain, and we 

should work on making sure those who want to access treatment are able to do so. 

I also want to hear from all of our witnesses today about how Medicaid expansion—or in Missouri’s case, a failure to expand Medicaid—has had an impact on 

8 

treatment for substance abuse disorders. I know Massachusetts and Colorado both 

signed Medicaid expansion into law in 2013, and Indiana expanded Medicaid earlier 

this year. 

I’m interested to hear from all three of your States about how Medicaid expansion 

has improved access to behavioral health services. And I want to hear from Missouri 

how Medicaid expansion could help those seeking access to behavioral health services and what challenges you face by not expanding the program. 

Thank you again for holding this hearing, and thank you to all our witnesses for 

sharing your insight today. 

I yield my remaining time to Rep. Kennedy. 

Mr. PALLONE. I would like now to yield the rest of my time to 

Representative Kennedy. 

Mr. KENNEDY. Thank you. I would like to thank the ranking 

member. I would also like to thank the chairman of the committee 

for calling this extraordinary series of hearings. They have been, I 

think, extremely enlightening, and shining a light on an incredible 

epidemic our country is facing. 

To the witnesses today, thank you so much for being here to discuss the States’ efforts to combat opioid abuse. In my mind, we are 

here for one reason; to learn from you about what has worked on 

the ground in your States, and how we can try to support those efforts at a Federal level in any way possible. 

Few in my home State have been spared the tragic consequences 

of the ongoing opioid epidemic. Last year, there were more than 

1,000 deaths in our Commonwealth, spanning wealthy and low-income communities alike, areas rural and urban, faces young and 

old. 

Dr. Bharel has been on the frontlines of this battle for long before she was appointed to the Public Health Commission earlier 

this year, but in her new role, she is focused on ensuring treatment 

options are available to all of our citizens, regardless of income. It 

is my honor to welcome her today to Washington, and I look forward to hearing your testimony. 

One issue I hope to hear from all of you today is a little bit about 

one of the issues we have been wrestling with in Massachusetts, 

which is the rising cost of Narcan. At a time when our country 

needs every tool at its disposal in this fight, the price of lifesaving 

treatment continues to skyrocket. Last month in Needham, Massachusetts, the cost per dose rose to $66.89, up from $19.56 last June. 

Now, Narcan is by no means an answer to this epidemic. It is 

a stopgap, not a solution, but it does save lives. It allows us to get 

individuals suffering from crippling addiction into treatment. It 

helps minimize the number of parents, brothers, sisters, and children with loved ones who are taken far too soon. So I would be interested to hear from our witnesses about any price spikes that you 

have seen at home, how those have impacted response efforts, and 

how the Federal Government can help ensure that no one’s life is 

lost because a municipality simply can’t afford a drug. 

Another area that I would like to get some insight on is the effectiveness of Prescription Drug Monitoring Programs. I represent a 

district in Massachusetts that borders Rhode Island, and it has become clear to me that the lack of communication across State lines 

is leaving a gap in how we tackle prescription drugs. To that end, 

I helped to cosponsor the National All Schedules Prescription Electronic Reporting Act with Congressman Whitfield in an effort to 

9 

better support State PDMPs, particularly where interoperability is 

concerned. Drs. Adams, Bharel, Wolk, I hope you will expand a little bit more on the roles PDMPs have played in your States’ efforts 

today. Dr. Stringer, I would love if you would be able to touch a 

little bit about your State’s plans to develop a PDMP. 

Tackling an epidemic of this scope requires partners across local, 

State, and Federal levels. To that end, we are all deeply grateful 

for your presence here today, and look forward to supporting you 

any way we can. 

Thank you, and I yield back. 

Mr. MURPHY. Gentleman yields back. 

I would now like to introduce the witnesses on the panel for today’s hearing. We have already heard about Dr. Jerome Adams, 

the Health Commissioner of the Indiana State Department of 

Health. Welcome. Dr. Monica Bharel, the Commissioner of the 

Massachusetts Department of Health. Dr. Larry Wolk, the Executive Director and Chief Medical Officer at the Colorado Department 

of Public Health and Environment. And Mr. Mark Stringer, the Director of the Division of Behavioral Health at the Missouri Department of Mental Health. 

I would now like to swear in the witnesses. 

You are all aware that the committee is holding an investigative 

hearing, and when doing so, has the practice of taking testimony 

under oath. Do any of you have any objections to testifying under 

oath? All the witnesses answered negative. The Chair then advises 

you that under the rules of the House and the rules of the committee, you are entitled to be advised by counsel. Do any of you desire to be advised by counsel today? All the witnesses indicate no. 

In that case, if you will all please rise and raise your right hand, 

I will swear you in. 

[Witnesses sworn.] 

Mr. MURPHY. You are now under oath and subject to the penalties set forth in Title XVIII, Section 1001 of the United States 

Code. You may now each give a 5-minute summary of your written 

statement, and please try to be under 5 minutes. You will need to 

press the button so the green light is on, and pull the microphone 

fairly close to you. Thank you. 

Dr. Adams, you are recognized for 5 minutes. 

STATEMENTS OF JEROME ADAMS, M.D., M.P.H., COMMISSIONER, INDIANA STATE DEPARTMENT OF HEALTH; MONICA 

BHAREL, M.D., M.P.H., COMMISSIONER, MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH; LARRY WOLK, M.D., M.S.P.H., 

EXECUTIVE DIRECTOR AND CHIEF MEDICAL OFFICER, COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT; AND MARK STRINGER, M.A., L.P.C., N.C.C., DIRECTOR, 

DIVISION OF BEHAVIORAL HEALTH, DEPARTMENT OF MENTAL HEALTH, MISSOURI 

STATEMENT OF JEROME ADAMS 

Dr. ADAMS. Thank you very much. My name is Jerome Adams. 

I am the Indiana State Health Commissioner, I am a physician anesthesiologist, and I am the brother of an addict. On behalf of GovVerDate Mar 15 2010 08:30 Oct 15, 2015 Jkt 037690 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X46STATEGOVOPIOIDS\114X46STATEGOVOPIOIDSPDFMADE
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ernor Mike Pence and the people of Indiana, it is my honor to be 

here today. 

In rural Scott County, we are dealing with the largest injectiondrug-use-related HIV outbreak in decades, with what CDC Director 

Tom Frieden described as a higher incidence of HIV than any country in sub-Saharan Africa. In an area that had three total cases of 

HIV over the prior 4 years, we, as of today, have 160 positives, 

with 95 percent related to injection drug use, and Hepatitis C coinfection rate of 88 percent. 

At the root of this outbreak is our country’s prescription opioid 

crisis. The crisis is multifactorial, but I think it is helpful to separate it into three distinct problem and solution areas. Number one, 

we need to stop the flow of opioids into communities. Number two, 

we need to deal with the personal and public health consequences 

of communities with overflow of both opioids and people engaging 

in high-risk activities. And number three, we need to create an outlet for those seeking recovery from substance use disorder. 

In terms of stopping the flow, in Indiana we witnessed a 10 percent decrease in prescriptions since we implemented new opioid 

prescribing rules in 2012, but we still have work to do. We need 

an aggressive education and prevention strategy starting in childhood. In addition to promoting the dangers of prescription drug 

misuse, we need better Prescription Drug Monitoring Programs 

with required reporting from the VA and Federal methadone treatment centers, higher thresholds for new FDA approvals of opioids, 

and safety and efficacy reviews of previously approved opioids 

based on recent data. Policies should further promote pharmacy 

and community opioid take-back programs, and require opioid 

manufacturers to facilitate these endeavors. And we should revisit 

both pain as the fifth vital sign, and the pain component of patient 

satisfaction as a consideration for physician and hospital reimbursement. Our focus needs to be on functionality and outcomes, 

and not simply on stopping pain with pills. 

Regarding the consequences of opioid overflow, we have seen not 

just an HIV epidemic, but also regional epidemics of Hepatitis, 

overdose deaths, unsustainable levels of incarceration, and community hopelessness. Our comprehensive approach in Scott County includes increased HIV and Hepatitis testing, and immediate treatment referral, locally based harm reduction strategies, immunizations, healthcare coverage, job training, and an outreach campaign 

targeting drug users and those involved in the commercial sex 

trade. 

On a State level, we have formed a Neonatal Abstinence Syndrome Committee, and recently made Naloxone available for first 

responders and friends or family members of those at risk. As Governor Pence said when he signed our Naloxone Bill, bills like this 

are about saving lives. Thanks to Governor Pence fighting hard to 

receive the only Federal waiver of its kind, and to Representative 

Pallone’s point, we can further address the needs of those with substance use disorder, including healthcare coverage and access, the 

two are not equal, and job training via our Healthy Indiana Plan. 

If people don’t have hope, they will increasingly turn to and stay 

on drugs; a painful lesson we have learned from Scott County. ForVerDate Mar 15 2010 08:30 Oct 15, 2015 Jkt 037690 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X46STATEGOVOPIOIDS\114X46STATEGOVOPIOIDSPDFMADE
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tunately, over 225,000 Hoosiers have more hope now thanks to HIP 

2.0. 

Lastly, in terms of creating an outlet, we must provide options 

for those seeking recovery services. A national campaign could reduce the stigma of substance use disorder and HIV so people aren’t 

ashamed to seek services, and could help reframe addiction from 

that of a moral failure to that of a medical disorder that requires 

a lifetime of attention. Lack of recovery reflects a lack of enlightenment on society’s part, as much of it reflects a lack of earnestness 

on the sufferer’s part. 

Regarding recovery in Scott County, we have found a severe and 

unmet need for access to appropriate substance use disorder treatment, and we have accordingly worked to increase beds in outpatient services. When incarcerated, sufferers also should have access to mental health and addiction treatment, with linkages to 

these services upon release. Such programs exist in Indiana, but 

are often only found in the most well-resourced communities. And 

we must educate communities and the public about medication-assisted treatment as an important component of the recovery safety 

net. Recently enacted legislation in Indiana allows the establishment of additional methadone clinics in our State, and the criminal 

justice system at the county level is increasingly offering Vivitrol 

for inmates upon release, or as an option during drug court diversion programs. 

Our situation in Indiana, in closing, may be unprecedented in 

many ways, but in many others, it illustrates problems faced 

throughout our country. There is much we do, but I am confident 

that we can succeed. If we focus on education, patient-centered 

care, and community and patient empowerment, I am confident we 

can successfully combat the scourge of opioid abuse. 

Mr. Chairman, thank you for your time, and I look forward to 

the opportunity to answer your questions. 

[The prepared statement of Dr. Adams follows:] 

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Mr. MURPHY. Thank you very much, Doctor. 

And now, Dr. Bharel, you are recognized for 5 minutes. 

STATEMENT OF MONICA BHAREL 

Dr. BHAREL. Thank you, Chairman Murphy, Ranking Member 

DeGette, and the members of the committee. Thank you for welcoming us here today, and for the opportunity to provide this testimony on this incredibly pressing issue today. 

My name is Dr. Monica Bharel, and I am proud to have been appointed to serve the Commonwealth of Massachusetts and Governor Baker as its Commissioner of Public Health. I am honored 

to be here representing one of the Nation’s oldest public health departments; one that traces its roots back to Commissioner Paul Revere, and one that has continually led the way in public health 

across the country. Yes, we can talk more about that later. 

As a—— 

Mr. MURPHY. He alerted people with lanterns, I am aware of 

that. So—— 

Dr. BHAREL. He gave out information on cholera throughout the 

Commonwealth. 

As a frontline physician and as a former Chief Medical Officer 

at Boston Healthcare for the Homeless Program, the largest of its 

kind in the Nation, I have seen firsthand the rising tide of an 

opioid epidemic that is overwhelming communities. We have 

watched our family and friends die on our streets, driven by a lethal cocktail of trauma and underlying behavioral health issues. 

This is not something we as a society should accept as the norm. 

This epidemic will be far from easy to tackle, but this challenge 

is precisely what drew me here to work with you and our providers, 

our community leaders. 

To that end, we are already hard at work in Massachusetts and 

throughout the Baker administration, redoubling our efforts to 

identify, triage, address, and treat the opioid epidemic. 

First, to identify the problem. Like so many States across the 

Nation, Massachusetts is facing a growing epidemic of opioid addiction and overdose deaths. In 2013, there were 967 unintentional 

opioid deaths, compared to 371 motor-vehicle-related injury deaths. 

That is 2 1⁄2 times as many people dying from opioid use as for 

motor-vehicle-related injuries. And behind those 967 deaths are 

over 2,000 hospital stays and more than 4,500 emergency room visits, and of course, unquantifiable human suffering. And in 2014, we 

have projected estimations of over 1,000 people dying of an opioidrelated overdose. This is a 51 percent increase from 2012. We will 

fail in our efforts to address this crisis if we do not fully involve 

partners from all sectors. That includes law enforcement, public 

health, healthcare institutions, families, schools, and you, our elected officials. 

Governor Baker prioritized the opioid epidemic early in his new 

administration. In February, Governor Baker appointed 18 individuals to serve on his Opioid Working Group. The group represents 

the many different perspectives that are important to this work, 

and was charged with developing tangible recommendations. The 

working group has held listening sessions across the Commonwealth, hearing from over 1,100 individuals, and receiving hunVerDate Mar 15 2010 08:30 Oct 15, 2015 Jkt 037690 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X46STATEGOVOPIOIDS\114X46STATEGOVOPIOIDSPDFMADE
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dreds of recommendations and emails. No matter which of the lens 

these individuals look at this epidemic, one thing is obvious, that 

opioids are impacting every city and town in the Commonwealth. 

People speak again and again about the wish to have early prevention and increased access to treatment. 

Our success getting to the underlying health issues and social determinants that are driving this epidemic; trauma, and 

undiagnosed behavioral health issues are chief among those, will 

directly correlate with our ability to successfully leverage data and 

to measure results. This data will allow us over time to effectively 

target key populations and hotspot, if you will, to better understand the impact of our collective efforts, and how to use our limited resources better. Utilization of data to combat the opioid crisis 

has a long way to go. For example, currently in our Department 

of Public Health we have more than 300 different internal data 

systems that have developed by individual programs and use a variety of different formats. They are managed by different staff, and 

reside on different servers that don’t talk to each other. However, 

this problem is not unique to Massachusetts, and across the country, public health needs to double down on data and on interoperable secure IT solutions, such as data warehousing, to create better 

linkages between our siloed data sets. 

As a frontline clinician, I have experienced firsthand the real 

roadblocks to helping patients access care. In the area of access, 

particularly with regards to downstream post-detox care, individuals have had a lot of trouble with both residential and outpatient 

medication treatment service availability. In capacity, statewide 

bed capacity, the kinds of bed types available and how to access 

them are not well known. Services for mothers and fathers in recovery who are attempting to reclaim their lives, while trying to 

take care of their children, needs improvement. Individuals suffering from addiction need better access to childcare, stable housing, and employment opportunities, as well as access to timely 

treatment. We need more early interventions in schools, and perhaps most important, this issue of stigma. 

What this hearing alone represents is an important step towards 

societal recovery. We need to talk about this disease. This is a 

chronic disease, and as a community and a nation, we will treat it 

and we will find pathways to recovery together by first speaking 

of it as a chronic disease. From the bedsides to the halls of bureaucracy, addressing this opioid crisis requires taking action 

across the spectrum of prevention, intervention, treatment, and recovery support. At DPH, we are proud of the progress we have 

made in areas such as access to Naloxone kits, with the cities of 

Quincy and Gloucester being some of the first communities in the 

Nation to arm themselves with Naloxone. Beyond saving lives, this 

measure has changed attitudes with police no longer arresting 

their way out of this epidemic, but looking towards solutions. 

Mr. MURPHY. I will need you to wrap up, if you could. 

Dr. BHAREL. Sure. And as a medical community, we know that 

20 percent of pain relievers for nonmedical use are coming directly 

from clinicians, so we as clinicians must shift our expectations of 

practices that opioids are not the first line of defense. However, as 

our national data sets demonstrate, more than 80 percent of lethal 

22 

painkillers come from non-clinicians. And so, again, this highlights 

the element of truth of working across partnerships. 

And I look forward to answering any further questions you have. 

Thank you. 

[The prepared statement of Dr. Bharel follows:] 

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Mr. MURPHY. Thank you very much. 

Dr. Wolk, recognized for 5 minutes. 

STATEMENT OF LARRY WOLK 

Dr. WOLK. Thank you, Chairman Murphy, Ranking Member 

DeGette, and members of the subcommittee for the opportunity to 

provide testimony to you today about our efforts to address the 

opioid epidemic in Colorado. 

In 2012, we had the troubling distinction of ranking second nationally for self-reported, nonmedical use of prescription drugs. 

More than 1⁄4 million Coloradans misused prescription drugs, and 

consequent deaths related to misuse nearly quadrupled between 

2000 and 2011. Drug overdose remains the leading cause of injury 

death in Colorado, and almost 11 percent of Coloradans aged 18 to 

25 still engage in nonmedical use of prescription drugs. In the last 

5 years, the number of heroin users in Colorado has also doubled, 

and we are challenged with concerns that existing treatment capacity is not meeting a rising demand, as treatment admissions for 

heroin and prescription opioid abuse increased 128 percent between 

2007 and 2014. However, recent data suggests that we are heading 

in a better direction. 2013 data released shows that our rate on 

nonmedical use has decreased from 6 percent to nearly 5 percent, 

which represents 39,000 fewer Coloradans who misused prescription drugs. Additionally, the Colorado youth use rate is decreasing 

and is now below the national average. Since 2012, catalyzed by 

Governor Hickenlooper’s leadership as the co-chair of the NGA’s 

Policy Academy for reducing prescription drug abuse, we are currently implementing a coordinated approach, setting as our goal to 

prevent 92,000 Coloradans from engaging in nonmedical use of prescription pain medications through the adoption of our Colorado 

plan to reduce prescription drug abuse. This commitment represents a reduction from 6 percent to 3 1⁄2 percent of Coloradans 

who self-report nonmedical use of prescription drugs, focusing on 

seven key areas: improved surveillance of prescription drug misuse 

data; strengthening the Colorado PDMP; educating prescribers and 

providers; increasing safe disposal; increasing public awareness; 

enhancing access to evidence-based effective treatment; and expanding access to the overdose reversal drug, Naloxone. 

To monitor and coordinate progress, State-level leadership created the Colorado Consortium for Prescription Drug Abuse Prevention. The consortium provides a statewide, interagency, interuniversity framework designed to facilitate the collaboration and 

implementation of the strategic plan, and is comprised of seven 

work groups. For one, the Data and Research Work Group of the 

consortium has worked to map out all sources of data related to 

prescription drug use, misuse, and overdose in the State. Second, 

the PDMP Work Group has worked over the past 2 years to enhance our State’s PDMP as an effective public health tool. As of 

July 2014, our PDMP utilization rate was 41 percent, and in April 

2015, that rate more than doubled, reaching 85 percent. How did 

we accomplish this dramatic improvement? We recently implemented push notices to both prescribers and pharmacists when patients visit a certain number of prescribers and pharmacies to obtain a controlled substance. We require PDMP registration for 

35 

pharmacists and DEA-registered prescribers, but we allow prescribers and pharmacists to assign and register delegates in their 

office, because they are often busy, so that those delegates can 

check the PDMP. We have also enhanced the PDMP interface and 

moved to a daily upload of data so that it is constantly refreshed. 

The Provider Education Work Group focuses on issues related to 

improving the education and training of healthcare professionals 

through a jointly developed policy; a policy that has since been 

adopted by the dental, medical, nursing, pharmacy, optometry, and 

podiatry Boards in Colorado. It is the first joint policy of its type 

adopted by multiple regulatory Boards. As of October 2014, over 

1,300 prescribers had completed the training developed from this 

policy, and 87 percent indicated that they intended to change their 

practice as a result. We were encouraged because the CDC morbidity and mortality report recently ranked Colorado 40th nationally for prescribing rates of opioids, fiftieth being the lowest rate 

of prescribing. 

The Safe Disposal Work Group focuses on issues relating to safe 

storage and disposal of prescription medications, with the potential 

for misuse, abuse, or diversion, knowing that more than 70 percent 

of those who abuse obtain them from the unused supplies of family 

and friends. This work group developed guidelines and outreach efforts, and expanded the number of safe disposal sites throughout 

the State. By next year, we have plans to provide drop boxes in 

every county in the State. 

Public Awareness Group has developed a new statewide advertising and public outreach campaign called Take Meds Seriously. 

Our consortium’s Treatment Work Group has focused on identifying gaps in the need for medication-assisted treatment. And our 

Naloxone Work Group focuses on increasing awareness of and access to Naloxone, making clinical, organizational, and public policy 

recommendations to achieve this goal. 

I thank you for the opportunity. I see that I am out of time, and 

thank you. 

[The prepared statement of Dr. Wolk follows:] 

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Mr. MURPHY. Thank you, Dr. Wolk. 

Mr. Stringer, you are recognized for 5 minutes. 

STATEMENT OF MARK STRINGER 

Mr. STRINGER. Chairman Murphy, Ranking Member DeGette, 

and members of the subcommittee, my name is Mark Stringer and 

I am the Director of the Division of Behavioral Health in the Missouri Department of Mental Health. I also have the privilege of 

serving as President of the Board of the National Association of 

State Alcohol and Drug Abuse Directors, or NASADAD. It is truly 

an honor to offer remarks this morning about what Missouri is 

doing regarding the opioid problem in particular, and addiction in 

general. 

If there is a theme running through our messages this morning, 

I believe one of the most important ones is that access to treatment 

and recovery services is essential to addressing this problem. 

On this very day in Missouri, nearly 3,000 people are on waiting 

lists for substance use disorder treatment services. That equates to 

about 43,000 Missourians waiting for help during the course of a 

year. What is truly sad about this is that often a person seeks 

treatment after some kind of a life-altering event, a run-in with the 

law, a problem at work, some type of illness, an overdose. So every 

name on a waiting list is a potential tragedy for an individual, a 

family, and a community. In order to be successful, services must 

be accessible. They have to be individually tailored, evidence-based, 

and they must include recovery supports. One thing I know with 

certainty after 30 years in this field is that treatment cannot be effective and treatment cannot possibly work if you can’t get access 

to it when you need it. 

So I will give you some just quick information about my State 

of Missouri. We estimate that about 400,000 Missourians have substance use disorders. Last year, 43,000 actually received treatment 

services through the publicly funded system. With regard to 

opioids, Missouri saw 124 percent increase in treatment admissions 

related to prescription drugs from 2007 to 2012, and 125 percent 

increase in admissions related to heroin. We lose about 200 people 

to heroin deaths each year; most of them in eastern Missouri, including St. Louis. 

Here are some steps we are taking to deal with the problem. We 

developed a statewide plan for coordinated treatment and recovery 

services, and we partner with providers to ensure that services are 

high quality and evidence-based. One tool for promoting quality is 

our contracting authority; building in certain requirements that 

providers must follow as a condition of receiving State funds. We 

perform on-site certification reviews to assure that providers are 

adhering to standards of care that are set by the State. As an example, we use these tools to require that all addiction treatment 

providers in Missouri who are, again, contracted with the State 

make medication-assisted treatment available, either directly or by 

referral. This took time, resources, and education, and it is a work 

in progress but it is the right step for Missouri. We have also 

worked hard to leverage SAMHSA’s Access To Recovery program, 

or ATR, to build a statewide system of recovery services. Prevention is critical. Our State has a strategic plan for prevention, with 

41 

a focus on prescription drug abuse. And we have partnered with a 

group, just as an example, in a college setting we have a group 

called Partners in Prevention, that is a coalition of 21 college campuses located throughout Missouri, which is working specifically on 

prescription drug abuse among college students. This effort has 

made a difference. From 2013 to 2014, we have seen a 10 percent 

decrease in the misuse of prescription drugs among college students. 

There are other initiatives in my written testimony, but I will 

now turn to a few recommendations. I recommend that all Federal 

initiatives specifically include involvement of State substance abuse 

agencies, like mine. Given their expertise and authority over the 

addiction prevention, treatment and recovery systems. And I particularly want to recognize the Director of the Office of National 

Drug Control Policy, Michael Botticelli, for his efforts to coordinate 

drug policy across Federal Government, and to keep States informed and engaged. 

Second, I recommend strong support for the Substance Abuse 

Prevention and Treatment Block Grant, a vital part of the public 

safety net for treatment that also provides an average of 70 percent 

of State substance abuse agencies’ funding for primary prevention. 

Third, I support specific initiatives to increase the availability of 

all FDA-approved medications for substance use disorders, and I 

applaud the administration’s proposed $25 million for States to expand opioid treatment services where medication-assisted treatment is an allowable use of funding. 

Fourth, I recommend specific resources to help States and localities purchase Naloxone. This would have an immediate lifesaving 

impact, and I appreciate the administration’s proposal to provide 

$12 million within SAMHSA for overdose reversal and prevention 

activities. I certainly support mandatory prescriber education and 

training on substance use disorders. And finally, I encourage Congress and the administration to continue to work with State-based 

groups heavily involved in this issue, including groups like the National Association of State Alcohol and Drug Abuse Directors, the 

Association of State and Territorial Health Officers, but also our 

parent group, the National Governors Association, which has provided critical leadership in this area. 

Thank you for the opportunity to testify, and I look forward to 

answering questions. 

[The prepared statement of Mr. Stringer follows:] 

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49 

Mr. MURPHY. I thank all the panelists. 

I will now recognize myself for 5 minutes of questions. 

Mr. Stringer, your office sits within Missouri’s Department of 

Mental Health, and in the course of your work, have you found 

that Federal policies, including those affecting the ways in which 

certain treatment options are funded, have hampered any mechanism to treat individuals with co-occurring substance abuse and 

mental health disorders, and if so, what can be done, what do you 

suggest we do to correct that? 

Mr. STRINGER. Mr. Chairman, I am not sure it is a policy issue. 

I am going to try to answer that yes or no. Yes. Yes, there are some 

things that get in the way of treating people with co-occurring disorders. Primarily has to do with funding screens, how funding 

comes to the States, what the limitations are, and how those funds 

are spent. 

We have been successful in Missouri, I think, at braiding funds 

for people with co-occurring disorders, and so we treat some—so 

what we have done is really enhance our substance use disorder 

programs to include some mental health services. We have enhanced our community mental health services to include substance 

use disorder services. So we have been able to do that with the 

flexibility that is already there. 

Mr. MURPHY. I asked that because we have had other witnesses 

say they would like to let the Federal Government merge some of 

those funds so they can treat both. 

I would like to open this question up to all of you. I made some 

comments in my opening statement regarding the 42 C.F.R., and 

some concerns it has with interfering with doctors’ ability to provide safe and effective treatment for patients. I don’t know if any 

of you have reports from the State, but let me elaborate on this. 

A basic quality measure of good healthcare is medication reconciliation, as you are aware, which means assessing and documenting 

all the medications someone may be taking, which would include 

buprenorphine, Vivitrol, or all these other ones, but as a result of 

the 42 C.F.R. Part 2, a doctor’s ability to complete these medication 

reconciliations is very compromised. As I said, Mr. Tonko and I are 

working on this, so a patient may be getting Suboxone from an addiction medication physician, but this person may fail to inform 

their family physician, who may recommend another thing, or you 

can have someone on Vivitrol and—doesn’t tell a physician, and 

next thing you know, they get a pain medication, an opiate, and 

now you have someone who either has a risk of death, or you increase their risk for relapse. And I wonder if any of you can comment. Do you have any suggestions on this? Dr. Wolk, you are nodding your head. You have some comments on that? 

Dr. WOLK. Thank you, Mr. Chair. Prior to assuming this role 2 

years ago, I was the CEO for the State’s Health Information Exchange, CORHIO. And you highlight a very big obstacle when it 

comes to exchanging and making available clinical information to 

all providers involved in a patient’s care. If the health information 

exchange is going to work with regard to reducing duplication, improving quality, and reducing cost, the healthcare provider has to 

have access to all of the patient’s information, whether it is physical, mental health, or substance abuse-related. So—— 

50 

Mr. MURPHY. And we do have barriers that mental health therapy notes don’t get into those things, which is—OK. That is a good 

point. 

I want to follow up with one. Dr. Adams, I want to catch you before my time is out here. The diversion of buprenorphine for illicit 

nonmedical use is a significant problem, and that is just a part of 

the reason why the opioid epidemic is spreading. According to the 

Drug Enforcement Administration, buprenorphine is the third most 

seized prescription opiate by law enforcement. And so is the diversion of buprenorphine a significant problem in your State, and how 

are you handling that? 

Dr. ADAMS. It is a significant problem in parts of our State, and 

that is why we need to have a larger conversation about medication-assisted treatment and what it can and cannot do. Vivitrol, for 

instance, is a wonderful drug for a very small subset of the population. Methadone, we need to separate the discussion between 

methadone for chronic pain versus methadone for substance abuse 

treatment in medication-assisted therapy. And so again, I would 

promote educational campaigns both for the public, for policymakers, and for physicians, quite frankly, in terms of what can and 

can’t be accomplished. And Suboxone is a great drug, again, for a 

certain subset of the population, when done right, but we have 

found when done wrong, diversion can occur, and that is a concern 

that has been brought up by particularly our correctional facilities 

where people say they can easily sneak it in to the correctional facilities. 

Mr. MURPHY. I appreciate that. And my time is almost up, but 

this is the kind of thing we are going to want you to comment on. 

In addition, we made reference before to Don Flattery’s letter to us, 

and he brings up an important point here that opiate pain relievers, or OPRs, can worsen chronic pain over time. And that is another area, it seems to me, as you are recommending we need to 

do much more in education—mandatory education of physicians 

and prescribers on that. So keep that thought in mind, we are 

going to want some input on that too. 

I now recognize—— 

Dr. ADAMS. Mr. Chairman, one thing you can do concretely is you 

can have the VA and you can have Federal methadone programs 

report to Prescription Drug Monitoring Programs. You all can do 

that, and that will help get information out to the physicians. 

Mr. MURPHY. Excellent, thank you. Thank you. 

Ms. DeGette, 5 minutes. 

Ms. DEGETTE. Well, thank you. This sort of follows up on your 

line of questioning, Mr. Chairman. 

Dr. Wolk, I wanted to talk to you about the Prescription Drug 

Monitoring Program a little bit, and what we have done in Colorado, we passed a law in Colorado that now requires medical professionals who prescribe powerful controlled substances to sign up 

for an account. Is that right, Dr. Wolk? 

Dr. WOLK. Thank you, Representative DeGette. That is correct. 

Ms. DEGETTE. And since Colorado implemented that law, the use 

rate of the PDMP has doubled, going from about 40 to 85 percent 

in less than a year. Is that right? 

51 

Dr. WOLK. Thank you, Representative DeGette. That is also correct. 

Ms. DEGETTE. And do you think that mandating the need to 

have an account with the PDMP is the key to Colorado’s higher 

provider utilization rates? Is this something you think other States 

should consider? 

Dr. WOLK. Thank you, Representative DeGette. I do. In addition 

to having the allowance for a delegate in the prescriber’s office, because mandated participation—but then actual participation is enhanced by allowing that delegate to be assigned—— 

Ms. DEGETTE. Um-hum. 

Dr. WOLK [continuing]. To work on behalf of the provider. 

Ms. DEGETTE. OK. And I understand also that key medical 

Boards within the State came together, as we do in Colorado because that is the way we are, to create prescribing guidelines for 

opioid therapies. Can you talk about how this guidance is helping 

to guide Colorado doctors and dentists in their prescribing practices? 

Dr. WOLK. Thank you, Representative DeGette. It is a policy that 

was developed, and then a training from that policy, and because 

of the universal endorsement or adoption by all of those different 

Boards of healthcare professionals that are in a position to prescribe, we really have seen a universal acceptance, high numbers 

of participation, and a very high number 87 percent, who said they 

would change their practice now as a result of that training. 

Ms. DEGETTE. So when were all of these guidances, what year 

were they adopted? 

Dr. WOLK. Thank you, Representative DeGette. It is within the 

past 2 years. 

Ms. DEGETTE. OK, because you had some alarming statistics in 

your testimony about the way opioid use was going up in Colorado, 

and now we seem to be bringing it down. Do you think that these 

new guidelines have helped towards that goal? 

Dr. WOLK. Thank you, Representative DeGette. I do think that 

they have, and we have some preliminary data coming in for 2014 

that shows further stabilization, at least on the prescriptive 

opioids. 

Ms. DEGETTE. And, Dr. Adams, I wanted to ask you, I understand that Indiana has adopted mandatory prescribing guidelines 

for opioid therapies. Can you talk to us about how the guidelines 

work, and what impact that they have had on this overprescribing 

problem? 

Dr. ADAMS. Well, again, we have seen a 10 percent drop in prescribing since we have instituted our opioid prescribing rules. And 

I will tell you, I was on the State Medical Association Board of 

Trustees when these rules were coming through. Education is paramount any time you are trying to prescribe what doctors are and 

are not going to do. 

As far as high points, we have an overall threshold in terms of 

if you go over 60 pills per month or 15 milligrams per day for over 

3 consecutive months, you have to abide by these rules. There is 

a mandatory assessment which includes an H&P, and unfortunately we found people were prescribing pills without actually seeing patients or doing a full exam. 

52 

Ms. DEGETTE. Um-hum. 

Dr. ADAMS. There are regular visits if you are prescribing, there 

is regular checking in with the Prescription Drug Monitoring Program, or our INSPECT program, upfront and then at regular intervals. There is drug testing, and docs have told us over and over 

and over again we need a way to prove whether or not they are 

taking the drugs or diverting the drugs. So drug testing is part of 

that. There is a daily threshold limit that if you go over 60 milligrams per day in the course of therapy, then you have to bring the 

patient back in for a face-to-face and consider referring them. And 

then there are contracts. And docs have told us those have been 

helpful too in terms of establishing the relationship, the expectations, and being able to fire a patient. The best man at my wedding 

got sued by someone who was using because they said he kicked 

them out of care and abandoned them. Contracts protect doctors 

moving forward in terms of being able to say I told you this, these 

will be the expectations, you violated them, and it empowers doctors to be able to participate. But we codified those into our rules 

and regulations, and it has been a tremendous success. 

Ms. DEGETTE. Thank you. I just want to talk for one second 

about treatment because I have heard that there is a shortage of 

doctors who can administer this MAT treatment, particularly in 

rural areas. So I just wanted to ask you, Mr. Stringer, very quickly 

to talk about Missouri. I understand Missouri requires all State behavioral organizations to offer MAT treatment to all patients with 

opioid disorders. Has this helped improve access for the patients? 

Mr. STRINGER. Thank you, ma’am. It absolutely has improved access to evidence-based care. I will tell you that this has not been 

easy for our providers to find physicians. We had one in southwest 

Missouri who has since become one of our leading providers in 

medication-assisted treatment, but in the early days had to go 

through the Yellow Pages physician by physician to try to find one 

who was willing, number one, to work with this population, because many are not—— 

Ms. DEGETTE. Yes. 

Mr. STRINGER [continuing]. And then, secondly, who would work 

for the relatively low reimbursement rates that they could offer. So 

it was a real challenge, but absolutely, it has increased access to 

evidence-based treatment, but we still have these waiting lists. 

Ms. DEGETTE. Thank you. Thank you, Mr. Chairman. 

Mr. MURPHY. Thank you. 

Mr. McKinley, recognized for 5 minutes. 

Mr. MCKINLEY. Thank you, Mr. Chairman. Again, thank you for 

continuing this dialogue that we have now been doing for some 

time. We have had four or five hearings this year. Building off 

what we have learned in the past—a couple of years ago, we had 

a hearing in another committee where the Attorneys General had 

come in and talked about one of the things that they were suggesting on drug overdose and prescription—the pill mills, so to 

speak, whereas having a national registry in real time that was 

available to people across State lines as a way of capturing people 

that are trying to beat the system, is that something—I haven’t 

heard any of you talk about the real-time entry data on that. Dr. 

53 

Wolk, would you—I see you nodding on that, is that one of the 

things we should focus on? 

Dr. WOLK. Thanks, Representative McKinley. Yes, you know, we 

moved from periodic uploading to now daily uploading of the information, so it is real time with regard to our Colorado PDMP registry. 

Mr. MCKINLEY. Yes, that is just in Colorado, but if they go across 

the State line, that is not available as well. 

Dr. WOLK. Right. I think we would be happy to morph our State 

PDMP into a national PDMP so that—especially for neighboring 

States, I think this is a significant challenge. 

Mr. MCKINLEY. Thank you. 

Dr. Adams, your comment about overprescription—I would like 

to get some more—you started rattling off a lot of statistics and 

things that you do within Indiana to see how that works. I would 

like to see how we might be able to apply that in West Virginia 

as well and maybe across the country. So if that is not part of your 

testimony, if you have that separately, if you could send that, because we had this hearing just 3 weeks ago. We had seven panelists, and all of them said this is the number one priority, this is 

the number 1—and all of them were giving us different priorities. 

And I would like to think that Congress can walk and chew gum 

at the same time, but when we hear from professionals giving us 

all seven different directions, all seven agencies, so we asked them 

twhat is the number-one thing, and they talked about prescription. 

Dr. ADAMS. Um-hum. 

Mr. MCKINLEY. They said we are overprescribing. So in the last 

3 weeks, I have talked to a number of doctors at roundtables in 

West Virginia, and they are concerned—they agree, they say, yes, 

we are making addicts with what we do, but we have to have a development of trust with our patients. And do you—I get nervous 

about the fact that we want Congress to try to medicate or try to 

control—try to practice medicine on pain. So they are saying it is 

trust. How have you been able to rectify that or reconcile that in 

Indiana about dealing with that problem? 

Dr. ADAMS. Well, there is no doubt, and it is obvious from our 

outbreak, that we still have a lot of work to do. And I quickly want 

to touch on the point you brought up earlier. We could use a national registry for providers who divert on the job. That is the concern. Indiana was also the first State to have a Prescription Drug 

Monitoring Program talk across State lines. And it is still a problem. Scott County, Indiana, is just 20 minutes north of Louisville, 

but whether it is a national registry or just providing grants and 

funding to facilitate State PDMPs to adopt the best practices that 

talk across State lines, the consistent thing you heard all of us say 

is we need better communication, we need more real time information. 

As far as the trust factor, again, it is an uphill climb, but we 

have worked closely with our State medical association, and we got 

buy-in from doctors in terms of participating and other prescribers. 

And I think an important point my counterpoint brought up from 

Massachusetts was that it is not just docs, a lot of these are delegated prescribers, and the way you get around that problem is you 

have integration with electronic medical records. 

54 

Mr. MCKINLEY. So the more that—if you could get me that information—— 

Dr. ADAMS. I would love to. 

Mr. MCKINLEY. Then I want to open it up to all the panel. I am 

just curious, because you raised this issue last time, 3 weeks ago, 

and that was that the rate of deaths in America from drug overdose is anywhere from 7 to 10 times higher than it is in Europe. 

I raised that question, and I raise it again: What are they doing 

right, or what are we doing wrong? Why from 30,000 feet—what 

is the difference, why do we have such a problem in America compared to Europe? 

Dr. ADAMS. Again, pain as the fifth vital sign, and overflow of 

opioids going into the system, a lack of education for providers, and 

understanding on the part of children in the States. 

Mr. MCKINLEY. So they are doing a better job in Europe, the 

medical community is doing a better job in Europe? 

Dr. ADAMS. I think they are. Less opioids available, in general, 

and I will yield to my counterpart from Massachusetts. 

Mr. MCKINLEY. I am sorry, we are going to run out of time. So 

if you could get back to me, please, I would appreciate that. Thank 

you. 

Mr. MURPHY. We will appreciate also the further elaboration on 

your point about when that becomes part of the hospital satisfaction survey, and then, of course, they get additional funding and 

that cycle, too. 

Now recognize the ranking member, Mr. Pallone, for 5 minutes. 

Mr. PALLONE. Thank you, Mr. Chairman. 

I want to mention, even before the opioid epidemic began, our infrastructure for treating substance abuse disorders in this country 

was shamefully inadequate, including cuts to our healthcare system through sequestration. A combination of long-term neglect, social stigma, and underinvestment by both the State and Federal 

Governments has led to a system in which only 1 in 10 Americans 

with alcohol or drug addiction receive any form of treatment. And 

of those who receive treatment, only 10 percent received evidencebased care. You combine this neglected behavioral health system 

with an epidemic of opioid overprescribing and it is really not surprising that we are currently facing a public health crisis. 

So questions. I would like to ask all the witnesses on the panel 

a question. Is our underinvestment in behavioral health services, 

including the effects of sequestration, hampering our response to 

the opioid epidemic? And let me combine that by saying, have you 

see the effects of sequestration affect what you are doing at the 

State level, and are you able to keep up with the increased demand 

for treatment with the current level of resources dedicated to the 

problem? I guess I will start with Dr. Adams and go down. 

Dr. ADAMS. Thank you for putting me on the spot, Representative. One thing that I have always held as my own personal adage 

is spending more is not the same as spending wisely. And so we 

will all come to you all and say we want more money, but the fact 

is what we are concentrating on, and something you have heard 

continually, is that we need to do a better job of communicating 

with each other to make sure we are making the most efficient and 

effective use of the funds that we have available. We need to make 

55 

sure we are talking with communities, make sure we are talking 

with nonprofits, make sure that, through electronic medical 

records, we are getting the information that we need. 

Policy is always a pie that gets split up. And so do we have 

enough money, again, I would always love more money, but what 

I would love most from you all is help in terms of making sure the 

right partners are at the table so that we can get the most out 

what we are spending. 

Mr. PALLONE. I mean—I appreciate what you are saying, but I 

am saying—my concern obviously is, first, sequestration, but even 

more so, you have more and more people that need treatment, and 

at best we are talking level funding. So, you know, if you could be 

a little more specific about the consequences of that, I would appreciate it. Not that I am taking away from what you said. 

Dr. Bharel? 

Dr. BHAREL. So I want to go back to this point about this chronic 

disease model. So if we look at how we treat other diseases within 

the medical spectrum, when we talk about diabetes, there are multiple places to enter based on the level of severity. So you come into 

the emergency room, you go to an ICU, you go to a hospital, you 

go to outpatient. When you are suffering with the disease of addiction, there are very few routes to enter the system. So when we 

talk about different funding sources, I would like our goal to be to 

look at it as a complete health system. 

Getting back to this concept about Europe. If we think about 

health as a whole entity, and the public health starting at the community and going through the hospital system and out, we have to 

culturally think about not in our fast-paced thinking about pain 

being gone, but pain being relieved to a certain level, thinking culturally about pain not only being relieved with pills but other entities that are available as well, and then in addition to that, having 

PMP. Seventy-nine percent of our physicians in Massachusetts are 

on the PMP, but they say when we can’t then use painkillers, what 

are other opportunities, so there are educational opportunities 

there as well. 

Mr. PALLONE. All right. You guys don’t want to—seem to want 

to talk about money. 

VOICE. I do. 

Mr. PALLONE. Let me add one more thing. Let me add one more 

thing. You know, SAMHSA, we understand that the SAMHSA 

Block Grant, or the Substance Abuse Prevention and Treatment 

Block Grant, you know, has actually been cut by 25 percent in the 

last 10 years. So, you know, maybe we want to talk about that if 

you don’t want to talk about the other things. Go ahead. 

Dr. WOLK. Thank you, Representative Pallone. I will be quick because I know you want to say something about that. 

Absolutely, sequestration has had an impact. We cannot keep up 

with the demand, number one, so any additional resources that we 

can get through block grant money or however else we can do this 

would really be appreciated because even as a State ACA only goes 

so far with regard to coverages that folks can get adequate care. 

We received $65 million from the Federal Government for our innovation model, as Representative DeGette alluded to, so that patients coming to their primary care doctor can get integrated physVerDate Mar 15 2010 08:30 Oct 15, 2015 Jkt 037690 PO 00000 Frm 00059 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X46STATEGOVOPIOIDS\114X46STATEGOVOPIOIDSPDFMADE
56 

ical and behavioral healthcare services, including substance abuse 

screening, treatment services as well, because we are so desperate 

to try and address this access issue and this lack of resource issue 

that maybe there is something there with regard to where they get 

their primary care. 

Mr. PALLONE. Thank you. 

Mr. STRINGER. Mr. Chairman, I know we are out of time. If I 

could—I would like to follow up in writing if I can. That is a great 

question. I very much appreciate that. I was at a women’s prison 

in Missouri in Vandalia just Tuesday of this week, and I have some 

stories to tell from that experience. 

Mr. MURPHY. We would appreciate that. Thank you very much. 

Now recognize Dr. Bucshon for 5 minutes. 

Mr. BUCSHON. Thank you, Mr. Chairman. 

And this has been very insightful, your testimony is very insightful. 

Dr. Bharel, I was interested in one of the things you said that 

20 percent of the medication that people are abusing have been 

prescribed for medical reasons, and one of the things we have been 

focusing on, of course, is, you know, I am an physician, I was a cardiovascular surgeon before, is prescribing, you know, monitoring 

prescribing habits, but if 80 percent is coming from somewhere 

else, where is it coming from? Seventy, 80 percent, whatever it is— 

I think you said 80 percent. 

Dr. BHAREL. Yes, it is 80 percent of what is—70 percent is coming from family and friends. 

Mr. BUCSHON. OK, that is what I figured, so it is not their particular medical use, but at the end of the day, it has been prescribed for a medical use for someone. OK, and that is where 

maybe, you know, drop boxes and other initially voluntary return 

policies potentially could be helpful because—last year, you probably know, there were enough prescriptions written that every person in the United States of America could have gotten a bottle of 

narcotic pain medicine. And Medicare Part D just came out and 

said recently that the number one prescribed medicine under Medicare Part D—and so this goes across ages, right—was Vicodin. 

Dr. BHAREL. Um-hum. 

Mr. BUCSHON. And so I am very interested in the prescribing 

programs and trying to monitor, you know, physician prescribing, 

and as part of that, education is, of course, important. And that is 

where it is not only for the people using it, but it is the people that 

are being trained to take care of patients as we speak in medical 

schools and other areas. So that is going to be very important. 

Dr. Adams, in your testimony, you say an aggressive educational 

strategy beginning with childhood. Can you kind of expand a little 

bit on that, what your thoughts were on that? 

Dr. ADAMS. Well, thank you for the opportunity. And for those 

of you who don’t know, Congressman Bucshon married up, he married an anesthesiologist. 

But as far as that—— 

Mr. BUCSHON. That is a true statement. 

Dr. ADAMS. The aggressive education campaign—quick story, I 

was in Scott County just a few weeks ago meeting with a 23-yearold individual who had HIV, he was in our clinic. And I said how 

57 

did you get started, and he said, ‘‘I had an injury as a freshman 

in high school, a knee injury playing football. The doc prescribed 

me Vicodin. I kind of liked how it made me feel so I took all the 

Vicodin he gave me, took some more, ran out.’’ He said it was easy 

to get in the community. ‘‘Got more Vicodin. Finally, that wasn’t 

doing the job, switched to Oxycontin until that wasn’t doing the 

job, then I started injecting.’’ And then he switched over to heroin, 

and now he is a 23-year-old HIV addict. 

We have to get to these people earlier. And when you talk about 

an aggressive strategy, it starts with recognition. We need an educational campaign to help students understand that this is a problem. 

I used to sneak to my friend’s house when I was in high school 

and have a beer. They sneak to their friend’s house and pop a pill. 

And unfortunately, 1 out of 15 people who divert a pill will ultimately go onto heroin use. One out of 15 of my friends who popped 

a beer didn’t go on to get HIV. So we need to increase the recognition of the problem. We need resilience in anti-bullying campaigns 

so that kids are OK saying no, I am not going to take a random 

pill out of that bowl. We need appropriate age level education, and 

I was meeting with people from the State just yesterday who 

showed us their data, and the interventions in each age group are 

different. What works for a fifth grader doesn’t work for a sixth 

grader, doesn’t work for an eighth grader. There has to be age-appropriate education and intervention. There has to be adult and 

peer outlets so, hey, if someone is doing something wrong, I know 

who to go to, I know who to tell. And then finally, to your point, 

we need take-back programs. Sixty-two percent of teenagers who 

use say they—number 1 reason they use is because it is easy to get 

the medication, it is from my parents’ cabinet. It is right there. It 

is easier to get a pill than what it was for me to get a beer. And 

you can hide it and you can walk away with it. And so all that 

needs to be part of the campaign, and it needs to start in middle 

school and elementary school. 

Mr. BUCSHON. I have one other question I want to ask about 

Naltrexone, because I have given that to patients in a hospital setting. And, Mr. Stringer, maybe you can comment on that, and I 

think not only the availability but the appropriate training for people, you know, for law enforcement people or EMTs about the fact 

that—like somebody pointed out, it is not a silver bullet here, there 

are also downsides to giving patients Narcan or Naltrexone. Can 

you comment on that, about what type of educational stuff is also— 

I mean—I think, were you one of the ones that were commenting 

on Naltrexone? Yes. Or maybe Dr. Bharel could answer that. 

Mr. STRINGER. Maybe I can just—— 

Mr. BUCSHON. Yes. 

Mr. STRINGER. I can start. And certainly, I will tell you, when I 

went to—— 

Mr. BUCSHON. And I am out of time, so can you—why don’t we 

just do this—— 

Ms. DEGETTE. Let—— 

Mr. BUCSHON [continuing]. Why don’t you just—— 

Ms. DEGETTE [continuing]. Dr. Bharel answer. She has been—— 

Mr. BUCSHON. Why don’t we—— 

58 

Mr. MURPHY. Why don’t we let Dr. Bharel answer? 

Mr. BUCSHON. That will be fine. 

Dr. BHAREL. So as part of our Narcan Program, so we have handed out in Massachusetts since 2007 over 35,000 doses of Narcan, 

and part of that includes to your point about education. So the individuals who are handing out the Narcan to both bystanders and 

law enforcement, there is a training that goes along with it, and 

they are also trained on rescue breaths and the importance of it 

being short-acting and to call 911 at the same time. And we have 

recorded over 5,000 reversals—— 

Mr. BUCSHON. Yes—— 

Dr. BHAREL [continuing]. With that. So the educational component is directly linked when we hand out our—— 

Mr. BUCSHON. Yes, I think that is important because, in my 

opinion, if someone has to give someone Narcan, they should also 

be calling 911, and those people probably should be transported to 

a medical facility. 

Thank you. I yield back. 

Mr. MURPHY. We will want your other thoughts on it, too. We 

have all sorts of people saying that some people have a false sense 

of security thinking, oh, there is Narcan around, I can go ahead 

and take the risk. 

Mr. Tonko, you are recognized for 5 minutes. 

Mr. TONKO. Thank you, Mr. Chair. 

Mr. Stringer, earlier on in the questioning about sequestration 

you had some comments that we didn’t get to. Perhaps you could 

share those right now please. 

Mr. STRINGER. Yes, thank you very much, Representative. In my 

written testimony, there is a two-page thing from NASADAD here 

that describes the block grant and the reduced purchasing power 

of the block grant over time. I will tell you just specifically that I 

think with regard to sequestration. We in the States have really 

counted on the Federal Block Grant to sort of be our—really it is 

our safety net. We have some States have the safety net funds, but 

the block grant has always been stable. It hasn’t grown enough to 

keep pace with inflation, but it has been stable. What we saw with 

the sequestration was that our sense of stability was shaken because we were during tough economic times at the State level, and 

then our block grant funds were reduced temporarily. 

Just this last Tuesday, I was visiting a women’s program in 

Vandalia, Missouri, where we have a unique program going on 

right now where women offenders who leave that institution are 

started on medication-assisted treatment before they leave. So 

when they go home, they return to stable environments. Two of the 

women that I talked to had been on medications before they returned to prison. One was a young lady who was young, attractive, 

smart, had two children, was back in prison for her fourth DWI offense. Before coming to prison, she had been on medication-assisted 

treatment, but because of budget cuts at the State and Federal 

level, her medication-assisted treatment was stopped, and she returned to drinking very quickly after that, got her fourth DWI offense and then wound up back in prison. 

59 

So, you know, the stability of the block grant, and I hope future 

increases in the block grant, will really help to sure-up our safety 

net, and increase access and sustainability of treatment. 

Mr. TONKO. I appreciate that. And for far too long our national 

infrastructure for treating substance use disorders has suffered 

from fragmentation, from neglect, and certain underinvestment. 

Only one in ten Americans with substance use disorders is able to 

access treatment, and of the few who receive treatment, few receive 

anything that approximates evidence-based care. Reimbursement is 

key to modernizing these services, and ensuring that Americans 

struggling with addiction receive timely, appropriate, and evidencebased care. 

The Affordable Care Act, mental health parity efforts go a long 

way toward accomplishing this, but requiring insurers to provide 

coverage for substance abuse treatment, but much more work remains. 

I know the States are experimenting with some innovative ideas. 

Dr. Wolk, can you provide us with an overview of Colorado’s efforts 

to integrate behavioral health services into the primary care setting in the same Medicaid Program? 

Dr. WOLK. Thank you, Representative Tonko. Yes, and it is actually not just for Medicaid, we have a goal that all payers in the 

State will evolve with payment reform models that will allow integrated behavioral and medical care to be provided at the site of primary care. Our goal over the course of the next 4 years is that 80 

percent of all primary care practices in the State, whether they are 

federally qualified health centers, whether they are clinics, whether 

they are private practices, will all have some form of integrated behavioral healthcare as part of the primary care that is being provided as the patient’s medical home. 

Mr. TONKO. And are there any Federal policy changes that you 

would suggest required in order for us to provide—ensure integration is indeed successful? 

Dr. WOLK. Thank you, Representative Tonko. There are along 

the lines, again, of really aligning the incentives to make sure that 

payers, for example, don’t capitate or apportion behavioral health 

services and payment to a provider that is not part of this integrated model. It splits payment and, therefore, splits services. And 

so as a patient, you could come see your primary care provider, and 

that primary care provider would be prohibited from providing you 

mental health or substance abuse treatment services because the 

payer has allocated that money to a behavioral healthcare provider 

or substance abuse provider on a prepayment schedule, and that is 

where we could use some help with regard to reforming how those 

payments are made. 

Mr. TONKO. Um-hum. And, Dr. Bharel, just quickly, what do you 

view as the main barrier to integration of behavioral health and 

physical health? 

Dr. BHAREL. So I think the main barrier is stigma, and that stigma is—penetrates throughout our entire system. My time is up so 

I will stop there. If I can say one more thing is that in Massachusetts, we too are looking towards outcome-based, value-based care 

throughout our system which includes the real cornerstone being 

primary care and behavioral health integration at the office level. 

60 

We have multiple pilots going on including programs of prescribing 

Suboxone in our community health centers. Thank you. 

Mr. TONKO. Thank you. 

I yield back. 

Mr. MURPHY. Thank you. Gentleman yields back. 

It is interesting the way deal with stigma straight on, integration. Good. 

Mr. Flores, you are recognized for 5 minutes. 

Mr. FLORES. My questions have more to do with the education 

elements of that. The background for this is that I have three 

major educational institutions in my district—Baylor, Texas A&M 

University, and University of Texas—that are associated with medical schools. And so I would like to drill into going further upstream, and that is what can we do with the physician community 

and the expert community, professional community, to help them 

to be able to deal with this better? 

So my first question is this, and this is for each of you. Should 

all physicians be required to complete a continuing medical education course on pain treatment, and if so, should they also be 

mandated to complete one on addiction? And I will just start with 

you, Mr. Adams. 

Dr. ADAMS. Should all physicians? I would change that to say all 

prescribers—— 

Mr. FLORES. OK. 

Dr. ADAMS [continuing]. Because it is not just physicians prescribing, and not all physicians prescribe opioids. But we have had 

tremendous success, again, in Indiana. Once we instituted the 

opioid prescribing rules, then that led to an educational campaign 

where we had the opportunity and created the passion for these 

docs, and they had to carve out the time these docs and other providers to learn about the proper ways to prescribe. 

Mr. FLORES. OK. Dr. Bharel, your thoughts? 

Dr. BHAREL. So we also have all physicians required to do pain 

management training, but to your point, I would say that most 

medical schools, PA schools, nurse practitioner schools, et cetera, 

other practitioners who prescribe, do not have acquired training on 

addiction or its variable in school. 

Mr. FLORES. OK. 

Dr. BHAREL. So going further upstream at a Federal level, these 

accreditation bodies could be looked at to require some of that 

training. 

Mr. FLORES. OK. Dr. Wolk? 

Dr. WOLK. Thank you, Representative Flores. In Colorado, some 

of this training is tied to malpractice premium reduction, and so a 

way around us making a requirement is, you can save some money 

on your malpractice insurance if you take this training. And as we 

said, don’t forget about the dentists, the nursing community, the 

optometrists, and the podiatrists because they are all prescribers, 

to the point that was made before. 

Mr. FLORES. OK. Go ahead, Mr. Stringer. 

Mr. STRINGER. And my answer to your question is unequivocally 

yes, there should be mandatory education. 

Mr. FLORES. Right. So the next question would be, and this is 

again for all of you: Does your State think there is any merit to 

61 

linking mandatory physician education for PDMPs to DEA licensure as a way to promote physician use of PDMPs when prescribing a controlled substance? Dr. Adams? 

Dr. ADAMS. I have been longwinded before so I will be very brief. 

Yes. 

Mr. FLORES. OK. Dr. Bharel? 

Dr. BHAREL. We already require, at the time of license renewal, 

for all physicians to sign onto PDMP—— 

Mr. FLORES. I see. 

Dr. BHAREL [continuing]. And that is how we have increased—— 

Mr. FLORES. The question is yes on the merit? 

Dr. BHAREL. Yes. 

Mr. FLORES. OK, great. OK. Perfect. 

Dr. WOLK. Yes, we already require. 

Mr. FLORES. OK. Mr. Stringer? 

Mr. STRINGER. Sadly, I can only speak theoretically or hypothetically since Missouri is the only State in the country that does 

not have a PDMP yet, although it came very close this session, 

but—— 

Mr. FLORES. OK. 

Mr. STRINGER [continuing]. So I would say yes. Theoretically, 

yes. 

Mr. FLORES. OK. Theoretically. I understand. Again, for each of 

you, and we have just a minute and 45 left. What are the opportunities to—or let me rephrase that. What are the opportunities to 

improve the education of physicians on the appropriate prescribing 

of prescription pain medication? Is it medical school, continuing 

education, all the above, or somewhere else? 

Dr. ADAMS. It is both. I am an assistant professor at the medical 

school, and we don’t get it in medical school, but then there are 

docs out there who are prescribing or want to prescribe who don’t 

have that education. And I am sorry to keep bringing it back, but 

in many cases, the majority of people doing the prescribing of 

opioids are not physicians. So you can do all you want with docs, 

but if you aren’t taking care of everyone who is prescribing opioids, 

you are not going to solve the problem. 

Mr. FLORES. OK. 

Dr. BHAREL. I would say all prescribers at all levels, but also to 

bring back to the point that we all have to be educated. So it is 

a cultural shift also to our expectations of pain relief. 

Mr. FLORES. OK. Dr. Wolk? 

Dr. WOLK. I believe it is ongoing, but again, think about tying 

it to their wallet and then their malpractice premiums. 

Mr. FLORES. Uh-huh, OK. Mr. Stringer? 

Mr. STRINGER. All the above. 

Mr. FLORES. And the last question is this. And I have just a comment. Dr. Bharel, you said something about a cultural shift. Is this 

going to be hard to implement if we began pressing all of the prescribers to have continuing education, and then further upstream, 

to have the medical schools or the professional schools mandate 

this as part of their training? Do you see pushback in this? 

Dr. BHAREL. It is mandated right now in Massachusetts, and I 

believe the prescribers really want to be part of the solution, so 

62 

they are looking to work together. So I think that will be the driving force. They are also fed up with the numbers and the statistics. 

Mr. FLORES. Um-hum. 

Dr. ADAMS. You will see pushback, but it is something that we 

have to do. And again, as Dr. Bharel mentioned, docs want it, but 

we need to facilitate them getting the education, and needing to 

carve out the time either via tying it to the wallet or tying it to 

certification. 

Mr. FLORES. OK, thank you. I yield back the balance of my time. 

Mr. MURPHY. Gentleman yields back. 

Now recognize the gentlelady from New York, Ms. Clarke, for 5 

minutes. 

Ms. CLARKE. I thank you, Mr. Chairman, and I thank our ranking member. I also thank our witnesses for lending your expertise 

through your testimony here today. 

I would like to ask about the impact of Medicaid expansion on 

increasing access to treatment for substance abuse disorders. According to the Centers for Medicare and Medicaid Services, an additional 11.7 million individuals were enrolled in Medicaid and 

CHIP programs since the initial marketplace enrollment began in 

October of 2013, however, 21 States have failed to adopt the Medicaid expansion, leaving large coverage gaps for adults whose incomes are too high to qualify for Medicaid, but too low to qualify 

for premium tax credits through the exchanges. 

Let me start, Dr. Adams, by asking, has Medicaid expansion affected access to behavioral health services in the State of Indiana? 

Dr. ADAMS. Well, the answer is yes, but I want to correct a term 

you used. In Indiana, we didn’t expand Medicaid, we received a 

waiver to reform our Medicaid program via the Medicaid expansion 

funds. And I think that is a key here that we need to allow States 

to come up with—— 

Ms. CLARKE. No, I—— 

Dr. ADAMS [continuing]. The best possible policy. 

Ms. CLARKE. That wasn’t my point. 

Dr. ADAMS. Yes. 

Ms. CLARKE. It was just a question. 

Dr. ADAMS. Yes, ma’am. 

Ms. CLARKE. Has expansion impacted your ability to address the 

HIV outbreak in Scott County? 

Dr. ADAMS. Expansion via the Healthy Indiana Plan has substantially increased our ability. We signed up over 300 people for 

health coverage as part of this outbreak into our Healthy Indiana 

Plan. 

Ms. CLARKE. Well, I thank you for your illuminating response. I 

hope that other States recognize the impact that Medicaid expansion can have on their ability to diagnose and treat substance 

abuse disorders, and comorbidities such as mental illness, HIV, and 

Hepatitis C. 

Mr. Stringer, I would like to turn to you. The current limit for 

nondisabled adults to qualify for Missouri’s existing Medicaid program, MO HealthNet, is 18 percent of the poverty level, or $2,118 

a year. Missouri is a State that has not expanded Medicaid, resulting in a large coverage gap of adults whose incomes are between 

18 and 100 percent of the Federal poverty level. Mr. Stringer, apVerDate Mar 15 2010 08:30 Oct 15, 2015 Jkt 037690 PO 00000 Frm 00066 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X46STATEGOVOPIOIDS\114X46STATEGOVOPIOIDSPDFMADE
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proximately 300,000 working adults would gain access to health 

coverage through Medicaid expansion, is that correct? 

Mr. STRINGER. Yes, that is correct. 

Ms. CLARKE. How would Medicaid expansion affect the population you serve in Missouri? 

Mr. STRINGER. Well, ma’am, of those 300,000, we estimate that 

about 50,000 are people with some type of mental illness or substance use disorder that have no coverage at all right now. 

Ms. CLARKE. Um-hum. 

Mr. STRINGER. And so we are right now, for those that are in our 

system, we are paying for those with 100 percent general funds or 

block grant funds. If and when we expand Medicaid in Missouri, 

those people will receive Medicaid coverage, which does cover substance use disorder treatment in Missouri, and that would, therefore, free-up those funds to treat people who remain uninsured for 

whatever reasons, to provide other kinds of services to help people 

get back to work, things like that. So it would have a tremendous 

impact on Missouri. 

Ms. CLARKE. Wonderful. I thank you for your perspectives. 

And I yield back the balance of my time. Thank you. 

Mr. MURPHY. Gentlelady yields back. 

Now recognize Mrs. Brooks for 5 minutes. 

Mrs. BROOKS. Thank you, Mr. Chairman. 

Dr. Adams, you recently wrote an op-ed, and your quote was that 

building a model for prevention and response should this type of 

outbreak happen in other communities in the U.S. Can you talk to 

us a little bit, and kind of trying to bring it back a bit to the HIV 

outbreak in Scott County, can you explain for us what the model 

looks like? When you talk about the model, what model are you referring to? 

Dr. ADAMS. Thank you for the opportunity. And the Governor 

and I sat down at the beginning of this and said we are going to 

make mistakes, but we want this to be a model moving forward. 

And one important part of that was a comprehensive program. The 

HIV spills over into the opioid epidemic, spills over into Hepatitis, 

et cetera. And at our community outreach center in Scott County, 

we wanted to make sure people were able to access a multitude of 

services that are constant barriers to them getting into the treatment that they need. At our community outreach center, we had 

over 789 visitors, 271 HIV tests, 302 people enrolled in the Healthy 

Indiana Plan, 87 mental health referrals, and 38 job referrals. And 

we also offer birth certificates and identification, which is a barrier 

for people signing up for insurance. And importantly, immunizations for Hepatitis A, Hepatitis B, and the Tdap. When you include 

the needle exchange into that, I would venture to say you won’t 

find another place in our country that offers all those services 

under one small roof. 

Now, what we need to do is look at that as a success, and in 

terms of responding to an epidemic in the future, other places 

should consider providing all those comprehensive services, but for 

the long-term, we need to make sure within communities we are 

not just providing one part, that we are providing the comprehensive services people need because, again, this is a vulnerable population. OK, here is health insurance. Well, I don’t have an ID to 

64 

sign up for it. I can’t prove I am a citizen. Well, here is access to 

HIV care. But I don’t have transportation or it is not available. 

Well, there is an opportunity for you to get into a treatment center. 

But the people aren’t here, they are not close by. So when I say 

a comprehensive response and a model response, it is including all 

those services and thinking about overcoming barriers for the people we are trying to reach. 

Mrs. BROOKS. Thank you very much. And best of luck as you continue to lead the efforts on behalf of the State. 

I want to shift very briefly in the time I have left to discussion 

about the criminal justice system. And in a previous hearing we 

talked about drug treatment courts, and obviously the State also 

has a tremendous responsibility for the corrections system, and the 

corrections systems are administered by the State. And so I would 

be interested in any of your comments with respect to what your 

States are doing with respect to opioid abuse in our corrections systems, and/or the coordination with the drug treatment courts. I 

know that is a big question, but yet I think that is a group of folks 

who are incarcerated or who are on their way to incarceration 

through drug treatment courts, and I am really curious what your 

thoughts have been in your States. 

Dr. ADAMS. Briefly, in our district, we have had much success 

with Vivitrol and drug courts and diversion programs, and we have 

actually connected the prosecutors from Hamilton County, which is 

in our district, with the people from Scott County to share best 

practices. And I think that is going to be a critical, critical aspect 

moving forward to empowering people when they are, quite frankly, a captive audience. 

Mrs. BROOKS. Thank you. Dr. Wolk or Mr. Stringer? 

Mr. STRINGER. Well, I talked earlier about a project we have 

going on in Missouri within our Department of Corrections where 

people are started on medications before they leave prison. That is 

happening in several of our institutions right now, as well as the 

St. Louis City Jail, before people go into drug court. So we are 

starting people on medications before they leave incarceration. We 

also have a growing number of drug courts in Missouri, all of whom 

have embraced medication-assisted treatment. In fact, the drug 

court contracts in Missouri require that drug courts offer medication-assisted treatment for people for whom it is appropriate. 

Mrs. BROOKS. Dr. Wolk, anything with respect to Colorado’s approach? 

Dr. WOLK. Thank you, Representative Brooks. It varies by where 

the population is most dense. So we have a very active program in 

the Denver metropolitan area. A variety of treatment options and 

transition programs from corrections back into the community as 

well. It is not as easy to take advantage of those in the more rural 

parts of our State. 

Mrs. BROOKS. Thank you. Dr. Bharel? 

Dr. BHAREL. And in Massachusetts, we have a strong support for 

drug courts, diversion programs, and starting medication-assisted 

therapy, and part of our working group includes law enforcement 

and multiple segments of the community. And in addition, we have 

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nected to community health centers so that their continuity of care 

can happen in both behavioral and medical illness. 

Mrs. BROOKS. Thank you all for your work. 

I yield back. 

Mr. MURPHY. Mr. Green, you are recognized for 5 minutes. 

Mr. GREEN. Thank you, Mr. Chairman. 

I would like to focus question on the overprescribing of opioid 

pain relievers, and what States are doing to prevent the opioid addiction in the first place. CDC Director Tom Frieden quotes, ‘‘Overdose rates are higher where opioid painkillers are prescribed more 

frequently. States with practices where prescribing rates are highest need to take a particularly hard look at ways to reduce the inappropriate prescription of these dangerous drugs.’’ As this quote 

says, the States where the rubber really meets the road in terms 

of prevention efforts and addressing the overprescribing of opioid. 

Dr. Adams, I know Indiana has been hit hard by the opioid 

abuse epidemic. Can you tell us what the mandatory prescription 

guidelines that the Indiana Medical Licensing Board develops, and 

not just the Medical Licensing Board, if you could talk about all the 

practitioners: the nurses and dentists that have the same—hopefully their prescribing requirements are on all the specialties. 

Dr. ADAMS. Thank you for the opportunity. And we passed those 

rules and the Medical Licensing Board passed them initially for 

physicians, and now the other Boards are adopting their own 

versions of the rules. But again, a critical part of that was the 

mandatory checking in and being a part of the INSPECT, the Prescription Drug Monitoring Program. A mandatory part was assessment and H&P and regular visits. You have to have a face-to-face 

and a relationship with a patient before you prescribe. A mandatory part of that is drug testing so we can know what you are taking, and if you are taking it appropriately. And as many people will 

take more, there are frequently people who are diverting. 

Mr. GREEN. Um-hum. 

Dr. ADAMS. And we found that problem in Scott County. Again, 

a lot of the prescriptions are to little old ladies who really do have 

chronic pain issues, but they can resell their pills for $500, $1,000, 

and quite frankly, put diapers on their grandchildren, versus properly use those opioids. So we need to be able to drug test people 

who we are giving opioids to, and we need to have contracts. Again, 

the docs have told me that they are scared to write, and then the 

docs that are writing are scared not to write because you can get 

sued either way. And so we need to be able to protect docs and 

their ability to do the right thing. 

Mr. GREEN. OK. Do you believe efforts are making an impact on 

inappropriate prescribing of the opioid medications? I know you 

said the other specialties, but at least on the Medical Board that 

you may have some evidence on. 

Dr. ADAMS. Well, exactly. We have seen drops of 10 percent in 

prescribing since we adopted the rules. We have a lot fewer pill 

mills, and that is really what was the impetus for this, but we have 

to do a better job with our Prescription Drug Monitoring Programs. 

Best practices need to be adopted, and the ability to communicate 

across State lines however we facilitate that, because we can’t do 

anything if we don’t know the numbers, and we can’t do anything 

66 

if we know the numbers but we can’t share the data with the appropriate prescribers. 

Mr. GREEN. What should we be doing on the Federal level to support your efforts of implementing effective interventions to prevent 

opioid abuse? 

Dr. ADAMS. Well, Senator Donnelly and Senator Ayotte have a 

bipartisan bill that they are promoting right now that has a lot of 

good ideas in it, and I would encourage you all to look at that rather than me spend time going through each of the points. 

Mr. GREEN. Um-hum. 

Dr. ADAMS. The Heroin and Prescription Opioid Abuse Prevention, Education, and Enforcement Act of 2015. I think it has a lot 

of the right ingredients in terms of taskforces and highlighting the 

areas that we need to concentrate on. 

Mr. GREEN. OK. Dr. Wolk, can you tell us about some of the 

same in Colorado, the opioid prescribing guidelines developed by 

the State Boards, again, whether it is medicine, pharmacy, nursing, or dentistry? 

Dr. WOLK. Thank you, Representative Green. Yes, it really just 

keeps coming back from the provider perspective to the two main 

points, or the two number one priorities; one is the mandatory participation in PDMP registration, and the second is some form of requiring or strongly encouraged training with widespread adoption 

across all the disciplines, because we have seen, like I said, 87 percent of those who participate in the training said that they would 

change their practice as a result of it. 

Mr. GREEN. OK. I only have a few seconds. One of the issues is 

doctor-shopping, and is there anything technologically we can do to 

deal with that? 

Dr. WOLK. Yes—— 

Mr. GREEN. And this would be for all of—— 

Dr. WOLK. Sure. We have had a lot of success with the use of 

our health information exchange and having broad participation by 

all of our hospital systems in the State of Colorado, and now well 

over 1,000 providers who have connected their electronic health 

records to each other so that when somebody comes into an office 

or an emergency room, it is relatively easy to now see who they 

have seen and what they have been prescribed or provided for. 

Mr. GREEN. Mr. Chairman, in my last second, Dr. Bharel, you 

talked a lot about Federal qualified health centers and the community centers. In Massachusetts, do they have access to that same 

medical record across the lines of the different centers? 

Dr. BHAREL. Yes, sir, there are many different integrated health 

records that we are looking at. And the PMP is really adding to 

this because it is system-wide, any prescription written within 

Massachusetts, or written out of Massachusetts for somebody residing in Massachusetts. What we really do need though is interoperability that is better between States and also between different 

EHRs, so we can then expand our view. 

Mr. GREEN. OK, thank you. Thank you, Mr. Chairman. 

Mr. MURPHY. Thank you. 

Gentleman from Oklahoma, Mr. Mullin, is recognized for 5 minutes. 

67 

Mr. MULLIN. Thank you, Mr. Chairman, and thank you for being 

persistent on getting down to the roots of the problem. I mean this 

is obviously an epidemic, and I would say most of us know somebody that has abused prescription drugs at one time or the next. 

You know, recently I just went through a surgery on my elbow and 

got prescribed a big old pill of pain medicine, and I wouldn’t even 

take one of them. Fortunately, I have had a lot of surgeries, or unfortunately, and I have built up some type of a pain tolerance, but 

it does become a habit. The pain is still there, it just masks it. And 

when you get used to it, it becomes a dependency. And what we 

are seeing is—in my opinion, it is severely being overprescribed. 

And, Dr. Bharel, you are aware of the severe rise in methadone 

prescriptions, I am assuming, right? The rise in it, how often it is 

being—— 

Dr. BHAREL. The rise in methadone, yes. Yes. 

Mr. MULLIN. Right. Are you aware that methadone accounts for 

30 percent of overdose deaths, while only—— 

Dr. BHAREL. Um-hum. 

Mr. MULLIN [continuing]. Basically covering 2 percent of the prescriptions? 

Dr. BHAREL. Yes. 

Mr. MULLIN. Then I guess the question is why does Massachusetts leave it as a preferred list as a drug to be prescribed when 

CDC is saying it shouldn’t be the first line, it should be considered 

just in a case-by-case situation, rather than being prescribed on a 

regular basis? 

Dr. BHAREL. Thanks for your question. So methadone, you know, 

has become a part of the armamentarium of what can be used as 

pain relievers. In looking at our data within Massachusetts, and 

the data that we collect at the Department of Public Health, when 

we collect preferred drug of choice first and second, methadone is 

actually lower than the average in Massachusetts. It is less than 

15 percent as the preferred drug of choice. But just like with all 

the other medications, there needs to be education around how to 

use methadone if it is going to be used for pain or not. So I agree 

with that point. 

You brought up a point earlier about many people knowing somebody who has used or abused opioids, and I want to bring up a 

point. There was a recent study done through the Harvard School 

of Public Health—— 

Mr. MULLIN. Um-hum. 

Dr. BHAREL [continuing]. Where they looked at the majority of us 

knows somebody who has struggled with addiction, and of those 

who have, 20 percent of us know somebody who has died from it. 

So it is really a profound problem, to your point. And one very interesting thing related to this question that you are asking is that 

36 percent of individuals who were prescribed an opiate were not 

made aware or did not know about the addiction potential. So I 

think that needs to be part of the education. 

Mr. MULLIN. And I agree with that, but then if we know that and 

it is so readily accessible, still yet I am concerned why Massachusetts and Indiana, Dr. Adams, would still leave it on your list of 

prescribed medications, I mean when CDC and American Academy 

of Pain Medicine both have said that methadone should not be conVerDate Mar 15 2010 08:30 Oct 15, 2015 Jkt 037690 PO 00000 Frm 00071 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X46STATEGOVOPIOIDS\114X46STATEGOVOPIOIDSPDFMADE
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sidered a drug of first choice. But when it is listed, we all know 

that doctors refer to this constantly. In fact, that is where Medicaid 

and Medicare a lot of times gets the prescriptions or the drugs that 

they are able to prescribe from. 

Dr. ADAMS. It is cheap. 

Mr. MULLIN. Well, so—I know, but—so a person’s life is cheap? 

Dr. ADAMS. Well, no, a person’s life is not cheap, and I appreciate 

that question. Again, as a person who has been trained in pain 

management, methadone is a great drug when used appropriately. 

Dr. BHAREL. Um-hum. 

Dr. ADAMS. So the problem is that the prescribers aren’t educated and aren’t using it appropriately. So you have a policy situation where you have a cheap drug that the doctors know can be 

used appropriately, but a real world situation where it is not being 

used appropriately. 

Mr. MULLIN. Dr. Adams, I really appreciate your bluntness, but 

cheap shouldn’t matter when we are talking about someone’s life. 

We know it is being abused. History says it is being abused. 

Dr. ADAMS. Um-hum. 

Mr. MULLIN. So why is it still there? 

Dr. ADAMS. Well, because, again, from a policy point of view, 

there are two different directions you can take this. You can either 

say take it off the formulary and what are we going to replace it 

with—— 

Mr. MULLIN. Education isn’t working. We all get those little bottles with the little label on it, and then it even has a folded-up 

package. And I am sure everybody in this room has always read 

that folded-up package. 

Dr. ADAMS. Um-hum. 

Mr. MULLIN. And all of us know what the side-effects are and 

what the consequences are of everything that we have ever taken, 

and in fact, if you are one of those people, I am not—— 

Dr. ADAMS. And as a State health commissioner, I will tell you 

you are right, and again, I will be blunt and say you are right. 

There is a problem and we need to figure out the best way to address the problem, while still providing pain management options 

for the people who are out there. 

Mr. MULLIN. So, Dr. Adams and Dr. Bharel, while we are figuring it out, do you still think it is a good idea to have it on your 

Web site as a preferred medication? 

Dr. ADAMS. That is a great question, and again, the blunt answer 

is, that is a different division than my division. I have spoken with 

Dr. Werner about this problem, and docs feel passionately on both 

sides of the issue, but it is at the top of our radar in terms of making sure we are educating people and considering all options. 

Mr. MULLIN. Dr. Bharel, you want to follow up on that? 

Mr. MURPHY. Gentleman’s time has expired. You can do it real 

quickly. We are about to have votes, so I want to move. 

Dr. BHAREL. I think this issue is going to be a multipronged approach, and one of them is looking carefully at the medications we 

prescribe, and making sure that individuals are educated on how 

to best describe them. Thank you for your question. 

Mr. MULLIN. Mr. Chairman, thank you. 

Mr. MURPHY. Thank you. 

69 

I recognize now Dr. Burgess for 5 minutes. 

Mr. BURGESS. Thank you, Mr. Chairman. And I must say, every 

time I listen to the gentleman from Oklahoma, I learn something. 

And it is a hazard in relying on a medical education that is over 

40 years old, but I remember the morning in medical school hearing the lecture on methadone, and it was repeated over and over 

again; methadone is for maintenance purposes only. I mean I will 

never forget the guy saying that. But is that no longer true; methadone now is being used for things other than maintenance? Dr. 

Adams. 

Dr. ADAMS. In terms of maintenance for medication-assisted 

treatment, or you mean for chronic pain? 

Mr. BURGESS. Well, for someone who has an opiate habituation. 

Dr. ADAMS. Well, the answer is that there are a lot of prescribers 

out there who don’t have the proper education to be prescribing the 

drugs that they are prescribing, and it is a problem. It is—— 

Mr. BURGESS. But again, 40-year-old wisdom, you have somebody 

who has a narcotics habit, they want to rehabilitate themselves, 

they want to get back to taking care of their family, back into society, they can be maintained on methadone and allowed to function 

because it didn’t have the other effects that other opiates do, so 

they can get the high, but they solve the problem of the addiction, 

at least temporarily. But now methadone has uses beyond that? 

Dr. ADAMS. Well, OK, so I am glad you brought that up. Again, 

there is a lot of misunderstanding about methadone. There is 

methadone as used for chronic pain, which the gentleman from 

Oklahoma was talking about, and then there is methadone for 

medication-assisted treatment, which is the person who has substance use disorder who is using it to continue functioning. And 

those are two very different uses of methadone, and confusion has 

led to a lot of policy decisions that I think are underinformed. It 

is important to know that methadone can be a substantial and important part of people’s recovery if they are suffering from substance use disorder, but it is also important, to the point of the 

gentleman from Oklahoma, that we recognize and deal with the 

real problem of methadone being prescribed for chronic pain inappropriately, because it is killing people. I completely agree with 

you, and I thank you for bringing up that point, sir. 

Mr. BURGESS. All right, I am going to switch gears because I had 

a couple of questions about Naloxone. And I have some other questions about NASPER, but then I will probably have to submit for 

written responses because of time. But we have had a number of 

these hearings, and I have expressed support for having compounds like Naloxone or Narcan available over the counter. I mean, 

let’s be honest: People need it, they need it right now, they don’t 

need to be going to get a prescription. So just this week the FDA 

announced a public meeting to discuss increasing the use of 

Naloxone. Now, Dr. Bharel, in Massachusetts, your State has been 

kind of an early adopter in this area. Can you share some of that 

experience with us? 

Dr. BHAREL. Sure. So as I mentioned earlier, we have been using 

Narcan treatments since 2007. We first started by doing outreach 

to high-risk individuals who were using injection drugs as part of 

an, actually, HIV prevention, treatment education program, and 

70 

since then from there moved on to work with so-called bystanders, 

which hare family and friends. And we use our existing community 

coalitions, such as our learn-to-cope, family-run coalitions throughout the State in order to have them provide Narcan. And this is 

done through standing medical orders, so it is still not an over-thecounter, it is through standing medical orders, as well as certain 

pharmacies participate in having it available through standing 

medical orders. And then finally, through the first responders program; both fire and police, in dozens of communities across Massachusetts have adopted the program as well. 

Mr. BURGESS. And, Dr. Adams, can you share with us some of 

your experience in Indiana? 

Dr. ADAMS. Well, we have had great success, some wonderful stories, but I want to second a point that Dr. Bharel made earlier that 

it is important not just to hand out Naloxone, but to provide education as part of that process. There is a big fear—and I think Representative Murphy brought this up earlier, Chairman Murphy— 

that if you are giving people this, they will then use it as an excuse 

to abuse. That has been proven not to be the case when you combine the passing out of Naloxone with education. So when you are 

considering policies moving forward, please don’t forget the educational component because that is what saves lives, along with the 

Naloxone. 

Mr. BURGESS. Yes, of course, that could be said about so many 

other things that we sometimes get involved in, but I appreciate 

your answers. 

Mr. Chairman, I am going to yield back the time because I know 

votes are coming. 

Mr. MURPHY. All right, I want to thank all of the members who 

were here for this, and this panel. This has been a fascinating process. We know what will come out of this. We will get our staffs together. You gave us a great set of recommendations today, thank 

you. 

We do ask you to follow up on some of those other questions, and 

please feel free, if you have other thoughts that come from this, it 

is the kind of things you are thinking about on the plane ride back 

or when you get back to your colleagues. We want to see what we 

need to do in terms of drafting legislation, working with the administration on regulatory changes, working with associations on some 

of these issues. This is critically important. Too many people have 

died, even during the course of this hearing today. I know you all 

care deeply about this. We share that caring, and we want to see 

this change. So thank you very much. 

So I want to thank all the witnesses and members again for 

being here, and remind members that they have 10 business days 

to submit their questions to record. And we ask that you respond 

promptly to that. 

And with this, this committee hearing is adjourned. 

[Whereupon, at 12:05 p.m., the subcommittee was adjourned.] 

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