S. Hrg. 115–441 

UNINTENDED CONSEQUENCES: MEDICAID AND THE 

OPIOID EPIDEMIC 

HEARING 

BEFORE THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

JANUARY 17, 2018 

Available via the World Wide Web: http://www.fdsys.gov/ 

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs 

( 
UNINTENDED CONSEQUENCES: MEDICAID AND THE OPIOID EPIDEMIC 
U.S. GOVERNMENT PUBLISHING OFFICE

31–264 PDF WASHINGTON : 2019

S. Hrg. 115–441 

UNINTENDED CONSEQUENCES: MEDICAID AND THE 

OPIOID EPIDEMIC 

HEARING 

BEFORE THE

COMMITTEE ON 

HOMELAND SECURITY AND 

GOVERNMENTAL AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FIFTEENTH CONGRESS 

SECOND SESSION 

JANUARY 17, 2018 

Available via the World Wide Web: http://www.fdsys.gov 

Printed for the use of the 

Committee on Homeland Security and Governmental Affairs 

( 
(II) 

COMMITTEE ON HOMELAND SECURITY AND GOVERNMENTAL AFFAIRS 

RON JOHNSON, Wisconsin, Chairman 

JOHN MCCAIN, Arizona 

ROB PORTMAN, Ohio 

RAND PAUL, Kentucky 

JAMES LANKFORD, Oklahoma 

MICHAEL B. ENZI, Wyoming 

JOHN HOEVEN, North Dakota 

STEVE DAINES, Montana 

CLAIRE MCCASKILL, Missouri 

THOMAS R. CARPER, Delaware 

HEIDI HEITKAMP, North Dakota 

GARY C. PETERS, Michigan 

MAGGIE HASSAN, New Hampshire 

KAMALA D. HARRIS, California 

DOUG JONES, Alabama 

CHRISTOPHER R. HIXON, Staff Director 

GABRIELLE D’ADAMO SINGER, Chief Counsel 

DAVID N. BREWER, Chief Investigative Counsel 

DOUGLAS C. GEHO, Counsel 

JERRY F. MARKON, Senior Policy Advisor 

MARGARET E. DAUM, Minority Staff Director 

STACIA M. CARDILLE, Minority Chief Counsel 

COURTNEY C. CARDIN, Minority Counsel 

LAURA W. KILBRIDE, Chief Clerk 

BONNI E. DINERSTEIN, Hearing Clerk 
(III) 

C O N T E N T S 

Opening statement: Page 

Senator Johnson ............................................................................................... 1 

Senator Peters .................................................................................................. 4 

Senator Paul ..................................................................................................... 19 

Senator Lankford .............................................................................................. 23 

Senator Jones .................................................................................................... 26 

Senator Harris .................................................................................................. 28 

Senator Hoeven ................................................................................................. 30 

Senator Daines ................................................................................................. 33 

Prepared statement: 

Senator Johnson ............................................................................................... 45 

Senator McCaskill ............................................................................................ 47 

Senator Peters .................................................................................................. 52 

WITNESSES 

WEDNESDAY, JANUARY 17, 2018 

Sam Adolphsen, Former Chief Operating Officer, Department of Health and 

Human Services, State of Maine, and Vice President, Rockwood Solutions, 

and Senior Fellow, Foundation for Government Accountability ...................... 6 

Otto Schalk, Prosecuting Attorney, Harrison County, State of Indiana ............. 8 

Emmanuel Tyndall, Inspector General, State of Tennessee ................................ 10 

David A. Hyman, M.D., J.D., Professor of Law, Georgetown University Law 

Center .................................................................................................................... 12 

Andrew Kolodny, M.D., Co-Director, Opioid Policy Research Collaborative, 

Heller School for Social Policy and Management, Brandeis University .......... 14 

ALPHABETICAL LIST OF WITNESSES

Adolphsen, Sam: 

Testimony .......................................................................................................... 6 

Prepared statement .......................................................................................... 56 

Hyman, David A. M.D., J.D.: 

Testimony .......................................................................................................... 12 

Prepared statement .......................................................................................... 69 

Kolodny, Andrew M.D.: 

Testimony .......................................................................................................... 14 

Prepared statement .......................................................................................... 74 

Schalk, Otto: 

Testimony .......................................................................................................... 8 

Prepared statement .......................................................................................... 64 

Tyndall, Emmanuel: 

Testimony .......................................................................................................... 10 

Prepared statement .......................................................................................... 66 

APPENDIX 

Charts submitted by Senator Johnson ................................................................... 83 

Letter to HHS and CMS ......................................................................................... 87 

Majority Staff Report ............................................................................................... 91 

Minority Staff Memo with attachments ................................................................. 255 

Statements submitted for the Record from: 

Center on Budget and Policy Priorities .......................................................... 389 

Andrew Goodman-Bacon, Assistant Professor of Economics, Vanderbilt 

University Emma Sandoe, doctoral candidate, Harvard University ........ 392 
Page

IV 

Statements submitted for the Record from—Continued 

Maine Attorney General Janet Mills .............................................................. 405 

Planned Parenthood ......................................................................................... 407 

Brendan Saloner, Assistant Professor John Hopkins Bloomberg School 

of Public Health ............................................................................................ 409 

Responses to post-hearing questions for the Record from: 

Mr. Kolodny ...................................................................................................... 412 
(1) 

UNINTENDED CONSEQUENCES: MEDICAID 

AND THE OPIOID EPIDEMIC 

WEDNESDAY, JANUARY 17, 2018 

U.S. SENATE, COMMITTEE ON HOMELAND SECURITY

AND GOVERNMENTAL AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 10:03 a.m., in room 

SD–342, Dirksen Senate Office Building, Hon. Ron Johnson, Chairman of the Committee, presiding. 

Present: Senators Johnson, Paul, Lankford, Hoeven, Daines, 

Heitkamp, Peters, Hassan, Harris, and Jones. 

OPENING STATEMENT OF CHAIRMAN JOHNSON 

Chairman JOHNSON. Good morning. This hearing will come to 

order. 

I want to first of all thank all the witnesses for taking the time 

to appear, for taking the time to prepare your testimony, and I look 

forward to your oral testimony and your answers to our questions. 

On its surface, people may be scratching their heads going, ‘‘Why 

is the Homeland Security and Governmental Affairs Committee 

(HSGAC) holding a hearing on potential Medicaid or other Government Federal funding of the opioid crisis? Why are you doing that 

in this Committee?’’ We actually have a pretty long history of delving into this particular epidemic, this particular health care crisis. 

My own involvement started with reports at the Tomah Veterans 

Affair (VA) health care facility where there was overprescription, 

mixed toxicity of drugs resulting in the death of a young Marine 

because of drug toxicity, and finding that within that investigation 

we had, what was it, about a 350-page report, 5,000 pages of supporting documents we also noticed a drug diversion potential within that investigation. This Committee has held three field hearings 

in Wisconsin, a field hearing in Ohio, one in New Hampshire, one 

in Arizona. I proposed the Promoting Responsible Opioid Prescribing (PROP) Act, which the Centers for Medicare and Medicaid 

Services (CMS) actually viewed as so important that they implemented it without us having passed the law, which is kind of nice. 

Senator Portman has been very active on this front, coming from 

Ohio—one of the States really stricken by this epidemic—instrumental in the passage of Comprehensive Addiction and Recovery 

Act (CARA), and in proposing the Synthetics Trafficking and Overdose Prevention (STOP) Act. Both Senator Portman and myself, 

and Senator Hassan, were at the White House last week for the 

signing of the International Narcotics Trafficking Emergency Re-
2 

sponse by Detecting Incoming Contrband with Technology (INTERDICT) Act, which funded and authorized detection devices for 

fentanyl, which is becoming more and more of a problem. And, of 

course, my Ranking Member—I appreciate Senator Peters filling 

in—but Senator McCaskill has been very aggressively pursuing the 

marketing through pharmaceutical companies and seeing how we 

can solve the problem from that aspect. 

So this Committee has been highly involved in this, and I just 

want to kind of lay out specifically why I got involved in this particular issue. It started with a pretty interesting, pretty depressing 

article written in Commentary Magazine by Nick Eberstadt, a demographer who works for the American Enterprise Institute. In 

that article, he was quoting Alan Krueger, the former Chairman of 

President Obama’s Council of Economic Analysis, and Mr. Krueger 

published a report talking about prime, working-age male laborforce dropouts. He said nearly half of all prime-age, working-age 

male labor-force dropouts, an army now totaling roughly 7 million 

men, currently take pain medication on a daily basis. 

He went on to quote the author of ‘‘Dreamland,’’ Sam Quinones. 

This resonated with me, having been a former employer, and I realize that for an awful lot of people, one of the primary motivating 

factors for getting a job is to get health care. And when you combine government programs that provide free health care and then 

on top of that a government program that provides you a prescription card that allows you access to products at a very low price that 

you can sell and divert into illegal drug-trafficking markets and 

supplement your income to the tune of thousands of dollars per 

year, unfortunately some people take advantage of that. 

Mr. Quinones is quoted in that article out of his book ‘‘Dreamland,’’ and I just want to read the quote. He was actually referring 

to Portsmouth, Ohio, when he was talking about this: ‘‘The Medicaid card pays for medicine—whatever pills a doctor deems that 

the insured patient needs. Among those who receive Medicaid cards 

are people on State welfare or on a Federal disability program 

known as Supplemental Security Income (SSI). . . . If you could 

get a prescription from a willing doctor—and Portsmouth had plenty of them—the Medicaid health insurance cards paid for that prescription every month. For a $3 Medicaid co-pay, therefore, addicts 

got pills priced at thousands of dollars, with the difference paid for 

by U.S. and State taxpayers. A user could turn around and sell 

those pills, obtained for that $3 co-pay, for as much as $10,000 on 

the street.’’ 

Later on, Nick Eberstadt just writes, ‘‘Disability checks and 

means-tested benefits cannot support a lavish lifestyle. But they 

can offer a permanent alternative to paid employment, and for 

growing numbers of American men, they do.’’ 

Now, again, that article piqued my interest, and so I asked my 

staff—I said, OK, this is kind of being laid out there, not necessarily as a theory but anecdotally, showing a real problem. And 

so I asked my staff: Can you take a look, do a data search and find 

out and just identify individuals that have been either convicted or 

at least charged with taking their Medicaid card, obtaining those 

pills, and then selling those on the open market? In 4 days they 
3 

1The staff report referenced by Senator Johnson appears in the Appendix on page 91. 

2The letter to HHS referenced by Senator Johnson appears in the Appendix on page 87. 

identified 261 defendants that had either been charged or convicted 

of doing just that. 

OK. We have a problem that needs to be further explored, and 

so we did explore it, and today we are issuing a report1 based on 

our further study in which, again, the staff has uncovered over 

1,000 defendants that have either been charged or convicted of 

using their Medicaid cards and diverting in some way, shape, or 

form. 

Along the road, even though we are focusing on Medicaid, we 

have discovered about 243 defendants in the context of Medicare. 

In November 2017 there were 60 active criminal investigations of 

opioid diversion through the VA health care system. So, again, this 

is a governmentwide program phenomenon where American taxpayers are providing well-intentioned funds into some of these programs, and those funds are being utilized to divert drugs, sell them 

on the open market, and in some cases fuel some pretty interesting 

criminal enterprises or just support a lifestyle of non-work, which 

is not healthy. 

I have as a follow-up today issued a letter2 to the Acting Secretary of Health and Human Services (HHS) asking what controls, 

what can we do, to what extent are they tracking this, to what extent are they aware of how much money we spend on Medicaid and 

Medicare that is being used in this case. 

Now, I do want to point out what I am not saying either in this 

report or in this hearing. I am not making the claim that this 

epidemic is just because of Medicaid expansion. Obviously, there 

are more dollars available through Medicaid expansion. There are 

some indications—HHS had a study that we had to extract from 

them—showing that there may be a difference between Medicaid 

expansion States versus non-expansion States. But this crisis, this 

epidemic, began way before Medicaid expansion. 

I also am not saying that Medicaid does not help an awful lot of 

people and the dollars used for treatment have not helped untold 

numbers of people. I am not saying this is a primary cause. I think 

what we are certainly saying is this is an unintended consequence. 

It is certainly a contributing factor, and it maybe enables something that maybe should not be enabled, and it is a very serious 

problem that has to be looked at. And, again, coming from the 

stand point of the problem-solving process, I think it is kind of 

hard to deny when you take a look at this report, take a look at 

some of these examples—and we have 110 of some of the most 

egregious examples in here involving drug rings, a grocery store 

being used as kind of a central port, pharmacists, and nursing 

homes. Again, it is almost hard to understand the complexity of 

some of these schemes, for example a podiatrist actually injecting 

chemicals to create pain so he can prescribe more opioids and facilitate diversion for profit. 

So the schemes are actually really beyond your imagination, but 

people use their imagination, so it is kind of hard to deny, when 

you take a look at these examples, that this is not a problem that 

needs to be further explored. And I am just saying that we ignore 
4 

1The prepared statement of Senator Peters appears in the Appendix on page 52. 

2The prepared statement of Senator McCaskill appears in the Appendix on page 47. 

3The Memorandum prepared by the Minority Staff appear in the Appendix on page 255. 

this aspect—and it is just an aspect of this overall epidemic—we 

ignore that aspect, this particular phenomenon, this reality, at our 

own peril. 

So, again, I want to thank the witnesses. I look forward to your 

testimony, and I will turn it over to my substitute Ranking Member, Senator Peters, for his opening comments. 

OPENING STATEMENT OF SENATOR PETERS1

Senator PETERS. Well, thank you, Mr. Chairman. Today, as you 

mentioned, I am filling in for Ranking Member McCaskill who 

wanted to be here but due to extenuating circumstances cannot be 

here. But I would like to ask unanimous consent to include her 

opening statement2 and a memorandum prepared by the Committee’s Democratic staff into the hearing record today.3

Chairman JOHNSON. Without objection. 

Senator PETERS. Thank you, Mr. Chairman. 

Before I begin my statement, I would also like to welcome our 

new colleague to the Committee, Senator Doug Jones. Welcome to 

this Committee. Congratulations on your election. You are going to 

find this a very interesting Committee, one doing very important 

work, and we know you are going to do an outstanding job. Thank 

you for joining us. 

Chairman JOHNSON. While you said that, I wanted to wait until 

Senator Jones actually showed up. I also want to welcome you to 

this Committee. I think you will find hopefully in the hearing 

today, we do not do show trials here. This is really a very bipartisan Committee. We conduct ourselves at that level of decorum, 

and it is really about uncovering the truth, laying out realities so 

you can solve problems. Again, I want to congratulate you on your 

election and was really pleased—and we spoke earlier—that you 

joined our Committee. I think you will enjoy your time here as 

well. 

Sorry for interrupting. 

Senator PETERS. No. That is good. Thank you. 

At the start, I think before we start this hearing and hear the 

testimony from the folks before us, I think it is important to reiterate that Medicaid expansion has produced not only historic coverage gains, but it also has very far-reaching positive health effects 

for American families. At its core Medicaid and the Affordable Care 

Act (ACA’s) Medicaid expansion are critical programs that help 

hardworking American families enroll in health care coverage and 

protect our Nation’s vulnerable. 

Nearly 80 percent of Medicaid enrollees come from a working 

family, and over 40 percent of Medicaid enrollees are children. 

Medicaid is a program that literally saves lives. I think we can all 

agree that when you or your family member or friend gets sick or 

hurt, we should be able to access affordable health care coverage. 

Medicaid and Medicaid expansion serves as a bridge to affordable 

health care for millions of working families in our country. And I 

am sure we have all heard stories, but just as a reminder, these 

programs are there to make sure that someone’s parent can have 
5 

that needed surgery or a child’s family can afford the high cost of 

their cancer treatment or that a person who has been injured can 

get care that they need to get back to work. 

Medicaid has also been critical in fighting the opioid epidemic. 

Opioid abuse and its tragic impact continues to be a growing problem in my home State of Michigan, as it is around the Nation. Between 2014 and 2015, the Centers for Disease Control (CDC) report 

that drug overdose deaths in Michigan increased by over 13 percent. In 2015, more than 2 million people across the Nation struggled with prescription pain reliever substance abuse disorder, an 

unfortunate number that continues to trend upward. 

As we work to combat this very serious epidemic, the Affordable 

Care Act has greatly expanded access to treatment in Michigan 

and across the Nation, including for individuals with substance 

abuse disorders. Prior to the passage of the ACA, many individuals 

with substance abuse disorders were unable to get the care that 

they needed. 

Since the passage of the Affordable Care Act, the uninsured rate 

in Michigan has been cut in half, and more than 600,000 individuals are now enrolled in our State’s Healthy Michigan expanded 

Medicaid program. Combined with the private exchanges in our 

State, nearly 900,000 individuals in Michigan have coverage 

through the Affordable Care Act. Many of these individuals are 

now able to access health care insurance for the very first time in 

their lives. 

Since the ACA’s Medicaid expansion went into effect, more than 

1.6 million Americans have gained access to this vital treatment. 

Last year, this Committee, the Homeland Security and Governmental Affairs Committee, the Subcommittee that I am a Member 

of, which is the Permanent Subcommittee on Investigations, had a 

hearing on the opioid epidemic, and we heard from witnesses who, 

like each of you here today, are fighting on the front lines. I spoke 

with Dr. Thomas Gilson, a medical examiner from Cuyahoga County, who told me how Medicaid expansion is literally helping them 

save lives by getting people suffering from addiction into treatment 

programs. 

I also spoke with Thomas Synan, Jr., chief of police for Newtown, 

Ohio, and he largely agreed with Dr. Gilson and went on to tell me, 

and I am going to quote him here, ‘‘To reduce demand and in turn 

reduce supply, we have to get people into treatment, and one of the 

programs our teams are doing out there in the Hamlin County area 

is signing people up for Medicaid to try to get them into that treatment.’’ 

Their overwhelming message to me was that we must preserve 

Medicaid and work to improve the critical health services that the 

program offers because it is literally saving people’s lives each and 

every day. 

And so today I appreciate each of you being here today, and I 

look forward to hearing about how we can work to improve our Nation’s Medicaid program to better serve the families enrolled and 

to continue our efforts to combat the abuse. I have no doubt that 

there are improvements that can be made, and we are going to 

hear about some of those improvements today, and I look forward 

to your suggestions. But I want to end by stressing as we make 
6 

1The prepared statement of Senator Johnson appears in the Appendix on page 45. 

2The prepared statement of Mr. Adolphsen appears in the Appendix on page 56. 

these improvements, we must do it in a way that does not jeopardize the health care for those who so desperately need it. 

Thank you. 

Chairman JOHNSON. Thank you, Senator Peters. 

I would also ask consent that my prepared opening remarks be 

entered into the record.1 Without objection. 

As we are welcoming Senator Jones, we also have to say goodbye to Senator Tester, who has been a very valued Member of this 

Committee. We hate to see him leave, but, again, we are happy to 

have Senator Jones. 

I do need to announce a change in the Subcommittee membership to make it official: Senator Hassan will replace Senator Tester 

on the Permanent Subcommittee on Investigations, and Senator 

Jones will replace Senator Hassan on the Subcommittee on Federal 

Spending Oversight and Emergency Management. So that makes it 

all official. 

Now, it is the tradition of this Committee to swear in witnesses, 

so if you will all stand and raise your right hand. Do you swear 

that the testimony you will give before this Committee will be the 

truth, the whole truth, and nothing but the truth, so help you, 

God? 

Mr. ADOLPHSEN. I do. 

Mr. SCHALK. I do. 

Mr. TYNDALL. I do. 

Dr. HYMAN. I do. 

Dr. KOLODNY. I do. 

Chairman JOHNSON. Please be seated. 

Our first witness is Sam Adolphsen. Mr. Adolphsen is Vice President at Rockwood Solutions and a Senior Fellow at the Foundation 

for Government Accountability (FGA). Mr. Adolphsen previously 

served as the Chief Operating Officer (COO) at the Maine Department of Health and Human Services. He also served as Maine’s 

Deputy Commissioner of finance with oversight over the State’s 

Medicaid budget. Mr. Adolphsen. 

TESTIMONY OF SAM ADOLPHSEN,2 FORMER CHIEF OPERATING OFFICER, DEPARTMENT OF HEALTH AND HUMAN 

SERVICES, STATE OF MAINE, AND VICE PRESIDENT, ROCKWOOD SOLUTIONS, AND SENIOR FELLOW, FOUNDATION FOR 

GOVERNMENT ACCOUNTABILITY 

Mr. ADOLPHSEN. Chairman Johnson, Members of the Committee, 

thank you for the privilege of testifying. 

For 3 years, starting in 2014, I sat in my office in Maine, and 

I watched something terrible unfold right in front of me. I would 

review Medicaid pharmacy spending in one meeting, and then I 

would walk down the hall for my next meeting about the opioid crisis and how to stop it. And the only thing increasing as fast as the 

budget line for opioids was the body count from overdose deaths. 

In the morning I would read a newspaper account of someone 

caught up in a drug arrest, and that afternoon I would see that 
7 

same person again when reviewing welfare enrollment data. It 

happened far too often. 

Our welfare fraud team worked daily with drug enforcement 

agencies to investigate when Medicaid members sold their pills or 

Suboxone strips or traded their welfare cards for heroin. I worked 

with the Medicaid Fraud Control Unit as we reviewed cases of 

caregivers diverting pain pills from desperate and dying Medicaid 

patients. I wish these were isolated incidents, but they are not. The 

paths of dependency on Medicaid and addiction to opioids are often 

intertwined. 

At the same time I was helping to run a Medicaid program that 

was funding record-breaking amounts of opioids, the Nation was 

being told that the solution to the drug problem was to put more 

people on Medicaid. Medicaid expansion was held up as the silver 

bullet solution to the drug crisis. But no one was considering the 

dangerous side effects of Medicaid. And the danger of prescription 

opioids is now better understood. They are the gateway to addiction. Four out of five heroin users started by abusing prescription 

drugs. 

When that free plastic Medicaid card is issued, it does not only 

pay for drug treatment. It also supplies opioids at a staggering 

rate. The numbers are alarming. A quarter of Medicaid members 

get an opioid prescription, and the highest rate is among the Medicaid expansion population of able-bodied adults. A CDC study done 

by the Obama Administration showed that someone on Medicaid 

was six times more likely to die from an opioid overdose. While one 

out of every five people is on Medicaid, the program pays for two 

out of every five emergency room trips for opioid and heroin 

poisonings. Medicaid expansion has not fixed this problem, but it 

might have made the problem worse. 

Rhode Island increased their Medicaid enrollment by 66 percent, 

and their overdose deaths doubled. West Virginia, Ohio, Pennsylvania, all expanded Medicaid, adding a total of a million and a half 

adults to the program. They rank first, second, and third, respectively, in the number of drug overdose deaths. 

Of the 10 States with the highest rate of opioid deaths, nine have 

expanded Medicaid under Obamacare. This correlation is very concerning, and the question of causation begs for more inquiry. 

As millions of adults have been added to the program, prescription drug abuse has multiplied. With no out-of-pocket costs and few 

restrictions on providers, prescription painkillers have flowed unfettered to Medicaid recipients, and this injected a whole new supply of free opioids into the market. 

I also witnessed people on Medicaid withdrawing from the community, not working, living an isolated and idle life that is more 

prone to drug abuse and addiction. Fifty-two percent of able-bodied 

adults on Medicaid, half, do not work. And this is really tragic because we know that for so many, work is the best answer to move 

away from a life of crime or addiction. 

Rather than expanding a broken program that funds pain pills, 

we should focus on breaking the cycle of pain and dependency by 

helping people get back to work. 

This drug problem is bad enough. We have to make sure that 

Medicaid is not throwing fuel on the fire. We need to make sure 
8 

1The prepared statement of Mr. Schalk appears in the Appendix on page 64. 

that Medicaid is not funding the drug problem but instead is structured to promote work and health for our neighbors. 

Thank you. 

Chairman JOHNSON. Thank you, Mr. Adolphsen. 

Our next witness is Otto Schalk. Mr. Schalk is the Prosecuting 

Attorney for Harrison County, Indiana. In addition, Mr. Schalk 

produced the film ‘‘A Hit of Hell,’’ a documentary about the opioid 

epidemic. Mr. Schalk. 

TESTIMONY OF OTTO SCHALK,1 PROSECUTING ATTORNEY, 

HARRISON COUNTY, STATE OF INDIANA 

Mr. SCHALK. Thank you. Good morning. My name is Otto Schalk, 

and I am the prosecuting attorney for Harrison County, Indiana. 

We are a community in southern Indiana that in many ways is representative of much of our Nation. I am honored to serve my county and my State as a prosecutor, and I am humbled to be before 

you this morning. I embrace this opportunity to share with you 

what many of us in law enforcement see and deal with on a daily 

basis. 

Every time a hardworking American pays their taxes, they are 

inadvertently funding drug dealers with a new supply of high-powered opioids that are poisoning our schools and our streets. That 

is a bold claim; however, as a prosecutor, it is something that I see 

routinely. It is no secret that our Medicaid program is ripe for 

fraudulent activity. Prosecutors knows this, doctors know this, and 

the reality is that drug dealers know this as well. An individual 

need not only traffic illegal street drugs to qualify as a drug dealer; 

a Medicaid beneficiary that is selling their prescription pills is no 

different in the eyes of the law. 

It bears mentioning that those who are impoverished are far 

more susceptible to end up in the criminal justice system. Anyone 

who has spent a day in a criminal courtroom across America knows 

this to be true. In my role as prosecuting attorney, I have prosecuted at an extreme disproportionate rate those that are Medicaid 

recipients. I see the disparity each and every time I walk into 

court. For a reference point, just looking at the reported data from 

our county from clients that are on probation that are in an alcohol 

and drug rehabilitation program, more than half of them are making less than $10,000 per year. 

In the simplest of terms, whether it is labeled as Medicaid fraud 

or drug dealing, it exists for the same reason that bank robberies 

occur. There is a pile of cash, and those will ill intentions will let 

greed lead them to commit crimes. Now, common sense dictates 

that when we give someone making less than $10,000 per year, 

that is struggling to keep the lights on, that is struggling to put 

food in the refrigerator, and we give a 90-count bottle of 

hydrocodone each and every month, and some of these pills are 

going for $15 apiece on the street, tax free, they are going to see 

the opportunity for financial gain. If we believe otherwise, we are 

naive. 

Unlike other street drugs such as heroin or meth, a dealer in 

opioids does not need to have someone that is well connected in the 
9 

drug culture to funnel their supply. A dealer in opioids simply 

needs to know a willing doctor and claim to have an ailment. And 

if the opioid dealer is on Medicaid, they receive their supply of 

high-powered narcotics for free or nearly free. Simply polling our 

jail and our probation officers, I found that most of our inmates 

and probation clients that are on probation for drug-related charges 

are taking pursuant to a valid prescription two to four high-powered opioids each and every day. That is 60 to 120 pills they are 

being prescribed each month. 

Now, conservatively, some of these pills are going for $30 apiece 

on the street. The incentive to opt out of Medicaid, to better one’s 

lot in life, is drastically reduced for individuals that are making 

$3,600 a month tax free in selling their prescription pills that they 

are getting at no cost. 

To that extent, the abuse that we see among Medicaid recipients 

as it relates to misuse and/or selling their prescriptions is rampant, 

and that is just based on what we are seeing and what we are filing. And those of us in law enforcement know that we are only 

catching a very small percentage of those committing these crimes. 

A reactive justice system, coupled with a shortage of resources, 

often leads to a small percentage of the bad actors being caught. 

A true number of those that are abusing the system would likely 

be staggering. 

Now, to be clear, I am not here this morning saying that Medicaid is not a tremendous asset for our Nation, but I am speaking 

from my own personal experiences as a prosecutor, a prosecutor in 

the trenches. I see firsthand what is devastating our communities. 

I see day in and day out individuals that are Medicaid recipients 

dealing and abusing their prescription pills that are government 

funded. It is simply a fact. I see individuals getting arrested for 

selling their prescriptions, and yet they test clean for them when 

they are drug-tested during the jail booking process. 

So is the opioid epidemic an unintended consequence of Medicaid? Certainly, with the increased amount of the impoverished 

having access to medical care, there is a greater likelihood that 

those who are impoverished are going to see the opportunity for 

turning a profit, albeit illegal, on the street. Now, one obvious solution would be to create more rigorous checks and balances of the 

medical bills being submitted through Medicaid for payment. Are 

the prescriptions necessary? Is the opiate prescriptions in line with 

the treatment plan? I have never understood why so many of the 

people that I am prosecuting are getting prescription after prescription of high-powered opiates when a simple over-the-counter drug 

would be just as effective. 

The opioid epidemic has brought devastation to our schools and 

our communities. The opioid epidemic is far too complex to narrow 

its causation to one specific issue. And while the issues are complex 

and many, there is one recurring theme, and that is poverty. Until 

we take affirmative steps to create jobs, grow businesses, and slowly diminish the gap between the impoverished and the middle 

class, any changes that are made will be a Band-Aid fix to the underlying problem. 
10 

1The prepared statement of Mr. Tyndall appears in the Appendix on page 66. 

I want to sincerely thank each of you for the opportunity to be 

a part of the solution of this gripping epidemic. I look forward to 

answering any questions that you may have. 

Chairman JOHNSON. Thank you, Mr. Schalk. 

Our next witness is Emmanuel Tyndall. Mr. Tyndall is the Inspector General (IG) for the State of Tennessee. Prior to becoming 

Inspector General, Mr. Tyndall served with the criminal investigation division as a special agent for 10 years investigating TennCare 

cases, TennCare is Tennessee’s Medicaid. He has approximately 35 

years of law enforcement experience and holds master’s degrees in 

health and human performance, management, and criminal justice 

administration. Mr. Tyndall. 

TESTIMONY OF EMMANUEL TYNDALL,1 INSPECTOR GENERAL, 

STATE OF TENNESSEE 

Mr. TYNDALL. Thank you, Mr. Chairman and Committee Members. As the Chairman said, I am Manny Tyndall. I am the Inspector General for the Office of Inspector General (OIG) in Tennessee. 

In 2004, the Office of Inspector General was created specifically 

to root out fraud and abuse in the TennCare program and criminally prosecute applicants and recipients who game the system. 

And as the Chairman alluded to, TennCare is simply our name for 

the Medicaid program in the State of Tennessee. 

The Office of Inspector General receives and triages more than 

4,000 complaints each year. I think you will find that Tennessee 

is one of a few, if not the only State that criminally prosecutes 

Medicaid applicants and recipients who engage in drug-seeking behavior or prescription drug diversion at the cost of the TennCare 

program. Our research indicates that States bordering Tennessee 

address recipient fraud administratively. I believe that suggests 

that Medicaid fraud is probably underreported nationwide. 

What I would like to share with you today is some examples of 

how the TennCare program is defrauded and how prescription 

drugs paid for by TennCare are diverted for illegal use. 

Approximately 80 percent of all arrests—2,400 of our 

arrests—were prescription drug diversion or doctor-shopping related; the ages ranged between 21 and 78; 1,678 arrests were for 

drug diversion, which includes sale and forgery. 

The courts have ordered approximately $315,000 in restitution to 

be repaid to the Bureau of TennCare for these offenses; 709 arrests 

were for doctor shopping. Our doctor-shopping law became effective 

June 18, 2007. Since that date, the courts have ordered approximately $292,000 in restitution to be repaid to the Bureau of 

TennCare for those offenses. 

Some of the schemes I have been witness to include: 

Recipients receiving valid prescriptions for prescription drugs, 

having it filled and paid for by TennCare, and then selling a portion of the medication on the street. 

Recipients are calling in prescriptions to pharmacies pretending 

to be employees of a medical practice and having TennCare pay for 

that medication. 
11 

Recipients are passing forged or altered prescriptions, written by 

other parties, and then passing those prescriptions at pharmacies 

and having TennCare pay for that medication. 

Recipients are adding medication to a prescription being handcarried between doctor’s office and the pharmacy and having 

TennCare pay for that medication. For example, they may receive 

a prescription for amoxicillin and between the doctor’s office and 

the pharmacy, they will add hydrocodone to that prescription and 

have TennCare pay for that medication. 

Doctor shopping. Doctor shopping is where a recipient fails to advise a provider that within the last 30 days they have already received the same or similar narcotic medication that is being prescribed. There are usually multiple counts of this offense. 

Nurses and medical technicians are selling prescriptions already 

signed by the doctor. Some of those prescriptions have sold for as 

much as $80. 

We work very closely with our drug task forces who make the 

buys. Normally, one, two or three pills are purchased each time 

during a drug transaction, and usually three buys are made before 

we seek an indictment. 

Depending on the type of medication and the milligram, prescrip- tion medication can sell for $5 to $10 per pill or some medications 

as much as $1 per milligram. 

With there being little or no cost/overhead to the Medicaid recipient, if they were to sell an entire prescription of 90 hydrocodone 

5-milligram tablets for $5 per pill, they would make approximately 

$450. If they did this every month it would garner approximately 

$5,400 a year, and that is a very conservative estimate. That is for 

one person for 1 year, and we make approximately 140 or more arrests each year. I am confident that many instances of TennCare 

fraud are not identified. 

The following cases demonstrate the lengths some people will go 

to to obtain pain medication: 

A husband and wife would take turns intentionally burning 

themselves on their lower legs with boiling water and go to a different emergency room to obtain pain medication and have 

TennCare pay for the ER visit and the medication. 

We have charged four individuals for a fourth offense of doctor 

shopping. 

We have charged one individual with 25 counts of prescription 

drug fraud where she forged or altered prescriptions in order to obtain hydrocodone and oxycodone and used her TennCare benefits to 

pay for the medication. She admitted to selling the pills to support 

her lifestyle. 

I personally worked a case where I charged a young woman with 

87 counts of obtaining a controlled substance by fraud, TennCare 

fraud, and identity theft. She was the office manager at a doctor’s 

office and would steal several prescription slips from a prescription 

pad each week. She would forge the doctor’s signature and the 

Drug Enforcement Administration (DEA) number on prescriptions 

in her name, her husband’s name, many of her friends, and even 

her grandmother’s name. Some prescriptions were paid for by 

TennCare, and some she would trade for half of the medication 

that person received. 
12 

1The prepared statement of Dr. Hyman appears in the Appendix on page 69. 

Mr. Chairman, thank you for the opportunity to speak, and I am 

willing to answer any questions the Committee might have. 

Chairman JOHNSON. Thank you, Mr. Tyndall. 

Our next witness is Dr. David Hyman. Dr. Hyman is a physician 

and a professor of law at the Georgetown University Law Center. 

Dr. Hyman focuses his scholarship on the regulation and financing 

of health care. Dr. Hyman. 

TESTIMONY OF DAVID A. HYMAN, M.D., J.D.,1 PROFESSOR OF 

LAW, GEORGETOWN UNIVERSITY LAW CENTER 

Dr. HYMAN. Thank you, Mr. Chairman and Members of the Committee. Much of my testimony is drawn from a book that is going 

to be coming out in April, co-authored with Professor Charles Silver, on the American health care system. The book is titled ‘‘Overcharged: Why Americans Pay Too Much for Health Care, and it explains how the ways in which we have decided to pay for health 

care services have predictable consequences on the cost and quality 

of those services, as well as the rates of waste, fraud, and abuse. 

Our public programs are particularly vulnerable to the latter set of 

problems. 

Today we are here to focus on the opioid epidemic. I commend 

the Committee for holding this hearing. Although a lot of what we 

have heard so far has been about the death rate, it is also important to note the opioid crisis has consequences in terms of destroyed lives, broken families and marriages, medical expenses, 

and lost productivity. 

My testimony flags four distinct issues: the seriousness of the 

problem; the complexity of the causes; the ways in which the design of our public programs make them particularly vulnerable to 

the sorts of abuse and overuse of the sort that you have already 

heard about; and the role that patients have played in this particular problem. In the interest of time, I am going to focus on the 

latter two issues. 

In terms of the role of the causes, it is important to note that 

these are prescription opioids, and apart from outright theft, you 

need a prescription from a physician in order to get them. There 

is a serious problem with overprescription. The causes of that are 

somewhat complex, but there are certainly bad-actor physicians out 

there who are willing to meet their patients in coffee shops and 

restaurants, write them prescriptions in exchange for cash. The 

book talks about one Dr. Yee who was responsible for essentially 

a mini-epidemic of opioid usage. There are particular parts of the 

country that have these problems. South Florida had so many pain 

clinics that the State earned the nickname ‘‘Oxy Express.’’ And so 

that again is an indication of the nature of the reimbursement system that enables these situations to develop. 

Now, both Medicare and Medicaid were designed to mimic Blue 

Cross and Blue Shield programs circa 1965, that is, indemnitybased insurance where the amount that was paid was tightly controlled but the volume of services was really not controlled. If a 

physician said you needed something, the insurance paid for it. 
13 

There was not much in the way of networks or preapprovals or utilization review. 

Over time the private market has evolved, but the public payers 

have remained largely passive bill payers. The results, as we observe in our book, are easy to observe with prescription drug fraud. 

The government has studied prescription drug fraud in public programs repeatedly, and each time it has concluded that fraud is 

rampant. A 2009 Government Accountability Office (GAO) report 

on the Medicaid programs in five large States opened with the observation that investigators ‘‘found tens of thousands of Medicaid 

beneficiaries and providers involved in potential[ly] fraudulent purchases of controlled substances, abusive purchases of controlled 

substances, or both.’’ Sixty-five thousand beneficiaries had engaged 

in ‘‘doctor shopping.’’ Four hundred individuals had gotten prescriptions for controlled substances from between 21 to 112 medical 

practitioners and visited up to 46 different pharmacies to get them 

filled. As long as you have a prescription, it will be filled, and the 

public payers will pay for it. 

Now, we have taken various steps to try and address these problems, including surveillance, prior approval, limitations on the 

number of pills that can be dispensed, disclosure of information to 

physicians about the risks of overprescription, and prescription 

drug monitoring databases. Each of these reforms has the potential 

to help reduce inappropriate prescribing, but design details make 

a big difference, as does implementation. And the fact they are necessary shows how the design features of Medicare and Medicaid 

make them vulnerable to waste, fraud, and abuse. 

Last, the role of patients. The tendency is to focus on providers, 

but patients are often involved in prescription drug fraud. A 2011 

GAO report involving Medicare found that doctor shopping was 

widespread, with more than 170,000 Medicare beneficiaries receiving prescriptions for controlled substances from five or more medical practitioners. Another study found that half a million Medicare 

beneficiaries were prescribed excessive amounts of opioids, including 22,000 who appeared to be doctor shopping. So the problem is 

not limited to Medicaid. It is not limited to public programs. But 

the design features of the public programs make them more vulnerable. 

Thank you very much. 

Chairman JOHNSON. Thank you, Dr. Hyman. 

Our final witness is Dr. Andrew Kolodny. Dr. Kolodny is a physician and the co-director of Opioid Policy Research at the Heller 

School for Social Policy and Management at Brandeis University. 

He previously served as chief medical officer for Phoenix House and 

as chair of psychiatry at Maimonides Medical Center, New York. 

Chairman JOHNSON. Dr. Kolodny. 
14 

1The prepared statement of Dr. Kolodny appears in the Appendix on page 74. 

2The graph referenced by Mr. Kolodny appears in the Appendix on page 78. 

TESTIMONY OF ANDREW KOLODNY, M.D.,1 CO-DIRECTOR, 

OPIOID POLICY RESEARCH COLLABORATIVE, HELLER 

SCHOOL FOR SOCIAL POLICY AND MANAGEMENT, BRANDEIS 

UNIVERSITY 

Dr. KOLODNY. Thank you for the opportunity to appear before 

you today. I would like to also thank Ranking Member McCaskill 

and Members of the Committee for this opportunity. 

The opioid crisis is an epidemic of opioid addiction, meaning that 

the reason the United States is experiencing record-high levels of 

opioid overdoses, the reason we are seeing a soaring increase in infants born opioid-dependent, outbreaks of injection-related infectious diseases, impact on the workforce, the driver behind all of 

these health and social problems has been a sharp increase in the 

number of Americans suffering from opioid addiction. 

The primary driver of the opioid addiction epidemic has been 

made clear by the CDC. This slide is a CDC graph.2 It shows that 

as opioid prescribing began to soar in the 1990s, it led to parallel 

increases in opioid addiction and overdose deaths. This is an epidemic caused by the medical community overprescribing opioids. 

On this graph the green line represents opioid prescribing, the red 

line represents opioid deaths, and the blue line represents opioid 

addiction. As the green line went up, as opioid prescriptions began 

to soar, it led to parallel increases in addiction and overdose 

deaths. 

The reason the green line began rising, the reason the medical 

community began prescribing so aggressively is because we—doctors—were responding to a brilliant, multifaceted marketing campaign that changed the culture of opioid prescribing. Starting in 

the 1990s, we began hearing that patients were suffering because 

we were too stingy with opioids. We began hearing that we should 

stop worrying about getting patients addicted. We began hearing 

that even with long-term use, the risk that a patient would get addicted was much less than 1 percent. 

We would have been less gullible if we were only hearing these 

messages from drug company sales reps. But we were hearing 

these messages from pain specialists, eminent in the field of pain 

medicine; we were hearing it from professional societies, from the 

Joint Commission, which accredits our hospitals; we were hearing 

it from the Federation of State Medical Boards—all of whom had 

financial relationships with opioid manufacturers. 

I would like to thank Ranking Member McCaskill for launching 

an investigation of these relationships. 

It is fair for you to ask about the role played by Medicaid, and 

it is fair to assume that access to medical providers offered by the 

Medicaid program could increase the risk that an individual would 

develop a disease frequently caused by doctors’ prescriptions. I believe that access to prescribers that Medicaid, Medicare, and commercial insurance offers does increase the likelihood that someone 

might develop a disease caused by prescriptions. But I do not believe that Medicaid should be singled out in this regard. Opioid 
15 

1The graph referenced by Mr. Kolodny appears in the Appendix on page 79. 

2The chart referenced by Mr. Kolodny appears in the Appendix on page 82. 

overdoses have been increasing in people with all types of insurance and in people from all economic groups from rich to poor. 

If you look at this graph—it is from a recent Health Affairs 

paper—you will see the orange line at the top of this graph.1 That 

represents people admitted to hospitals being treated for overdose 

insured by Medicare. You can see with all of the colors of the lines 

rising on this graph, they show that we have seen a rise in hospital 

admissions for opioid overdoses for all types of insurance, but what 

we see on this graph is that the fastest-growing share of hospitalizations for opioid overdose has been Medicare, not Medicaid. 

Medicare beneficiaries went from the smallest proportion of these 

hospitalizations in the 1990s to the largest share by the mid-2000s. 

I also do not believe Medicaid expansion is making the epidemic 

worse. Medicaid expansion is not responsible for the very sharp increase we have seen in opioid overdose deaths over the past few 

years. The reason we are seeing a sharp increase in opioid overdose 

deaths, as you know, is because of fentanyl. Medicaid expansion 

has not led to more aggressive opioid prescribing. Since 2012, we 

have seen opioid prescribing trending down, thank heavens. The 

opioid crisis is getting worse, again, most rapidly in the States that 

have the most fentanyl. 

Chairman Johnson, you have made the point that Medicaid is 

not a silver bullet for tackling opioid addiction. I agree with you. 

Medicaid is far from a silver bullet. With regard to improving access to effective addiction treatment, Medicaid is necessary, but it 

is not sufficient. The addiction treatment services that health insurance, including Medicaid, can pay for must also be available. 

The first-line treatment for opioid addiction is buprenorphine, also 

called ‘‘Suboxone.’’ Access to this treatment is not sufficient. For 

opioid-addicted individuals who are fortunate enough to access 

buprenorphine, too often their health insurance, including Medicaid, is only paying for the prescription. Patients with insurance 

must often pay out of their own pocket for the visit to the doctor. 

This is because there are not enough doctors prescribing 

buprenorphine, and the few who do do not accept insurance, including commercial and Medicare. And many State-licensed drug and 

alcohol treatment programs that do accept Medicaid are not offering medication-assisted treatment. 

If you look at the last chart with these horizontal lines,2 that is 

showing you individuals who are receiving medication-assisted 

treatment within the State-licensed system. The fact that these 

lines are pretty much flat shows that, despite our worsening opioid 

addiction epidemic, we have not been increasing access adequately 

to medication-assisted treatment. 

If we want to see opioid overdose deaths start to decline, there 

will need to be a massive Federal investment to build a treatment 

system that does not exist yet. I believe Medicaid is a necessary ingredient to make these programs viable. We must ensure that in 

every county in the United States an opioid-addicted American can 

walk into an outpatient treatment center and on that same day receive effective treatment regardless of their ability to pay for it. 
16 

1The chart referenced by Senator Johnson appears in the Appendix on page 85. 

Until that happens, I believe overdose deaths will remain at 

record-high levels. 

Thank you. 

Chairman JOHNSON. Thank you, Dr. Kolodny. 

I am going to defer my questions except for one, and if you would 

quickly put up the chart with opioid-related hospital stays,1 because you had a similar chart and I just kind of want to get your 

reaction to this. We actually developed this off of the hard numbers 

in terms of the numbers of tens of thousands of people, and we 

plotted this chart with, inpatient stays per 100,000, the difference 

between Medicaid-paid versus private insurance-paid, and it reflects a pretty large difference dating back many years, with a 

slight uptick from about 350 per 100,000 to close to 450 per 

100,000 for Medicaid-paid stays. Can you kind of explain that difference right there? 

Dr. KOLODNY. It would be difficult to explain without reading 

through the full paper. The chart that I showed is from a Health 

Affairs paper that was published a few weeks ago, which has very 

current data in it, and I am more familiar with that data. Those 

were hospital admissions involving opioid overdoses, and what we 

saw in that chart was a very significant rise for all payer types, 

including self-pay. And what we saw in the Health Affairs paper 

is a very substantial increase for Medicaid but an even greater increase for Medicare. 

Chairman JOHNSON. Medicare, OK. Again, these numbers come 

from Health and Human Services, and all we did is just take it and 

put it to number of stays per 100,000 just to make it a little bit 

more relatable. 

With that, I will turn it over to Senator Peters. 

Senator PETERS. Thank you, Mr. Chairman, and thank you to 

each of our witnesses for your testimony today. 

If I could summarize what I heard from everyone—hopefully this 

is accurate—there is a recognition as to how important Medicaid is 

as a health provider for Americans who have the ability to access 

that and that health care should be quality health care that is affordable and accessible to everyone, and that this is not an indictment on that part of Medicaid, that we are going to continue to 

strengthen that if we can and make it work better. But there are 

some issues that we should be talking about, and certainly dealing 

with the opioid addiction, these are important issues that should 

be discussed and we should figure out what is going on. 

Dr. Kolodny, I want to pick up on your comments in particular 

and have you expand. I understand that Medicaid beneficiaries do 

fill more opioid prescriptions. We do know that from some of the 

evidence out there. But I also know that during your time in New 

York City, you worked with Medicaid beneficiaries extensively. You 

served as a Medicaid provider at one point. Could you help this 

Committee understand why Medicaid patients, particularly individuals who qualify through disability and other issues related to that, 

would be prescribed more opioids? Is there something unique about 

the Medicaid population that we should be aware of? 
17 

Dr. KOLODNY. I would really like to see that data. I am not certain that we see far more opioid prescribing in Medicaid populations. One of the populations, for example, where we have seen 

very aggressive prescribing would be workers’ comp. We see very 

aggressive prescribing in Medicare Part D. So we know that people 

with access to doctors and, in particular, people who are prone to 

injuries are going to be—and older people who are going to complain of pain are going to be most likely to be prescribed opioids. 

It is older Americans that are receiving the most opioid prescriptions. 

Senator PETERS. Dr. Hyman, if you could talk a little bit about 

some of the work that you have done in this area and tracking use 

from folks in various medical plans as well. There is certainly a difference, and what we have heard here is that wherever there has 

been Medicaid expansion, there is increased opioid use and addiction. That may very well be a correlation, and correlations do exist, 

but it does not necessarily mean there is causation. 

Do you believe this is merely a correlation or is there also causation that Medicaid expansion has led to increases in opioid addiction? 

Dr. HYMAN. I believe correlation. 

Senator PETERS. Simply correlation. Would you elaborate? 

Dr. HYMAN. Based on the evidence that I have seen, it appears 

to be correlation, not causation—I am sorry. I neglected my thing. 

Based on the evidence I have seen, I would classify it as correlation, not causation. 

Senator PETERS. Could you expand on some of that evidence? 

Dr. HYMAN. So, the first thing that you—this is a general observation that I tell my students. Just because A comes before B does 

not mean that A causes B. Right? You need to look at preexisting 

trends, and if you look at preexisting trends in the States that expanded Medicaid, you see that they had higher opioid usage before 

the Medicaid expansion, which obviously was 2014. And so, you 

need to control for that prior trend in order to infer whether there 

is a sort of bump that is attributable to Medicaid. But even then, 

you need to control for other differences between the States that 

did not expand Medicaid, and you cannot do that just by cherrypicking individual States. 

The other thing you want to do, obviously, is look not just at the 

States that expanded Medicaid but also the States that did not expand Medicaid and see what happened there, and look at the 

States that expanded Medicaid that did not experience finding 

themselves at the top of the distribution of States in terms of their 

death rate. And so, just because A precedes B or seems to go along 

with B does not mean that A causes B. It is sort of Statistics 101. 

Senator PETERS. You also talked in your testimony about some 

of the structural aspects of Medicaid, and I have heard directly 

from physicians in Michigan with concerns that insurers in Federal 

health programs in particular like Medicaid often have policies that 

limit access to less addictive pain medications. I think our goal 

should be to look for alternatives that are not as addictive. You 

mentioned the issue in your testimony briefly and suggested that 

we need to change the ways that we reimburse for certain pain 

management treatments. 
18 

So within our Federal health programs, how can we do more to 

incentivize less addictive pain treatments? 

Dr. HYMAN. So to the extent less addictive pain treatments are 

more expensive, you are going to need to start paying for more expensive pain treatments rather than just the cheapest one, and 

that is an issue that, as my written testimony indicates, has been 

leveled against private payers as well as public payers. 

Second is you basically need to move away from an open-ended 

passive payer of bills to a much more active monitoring role in 

dealing with the, thankfully, relatively small number of true bad 

actors but also creating better incentives for both providers and patients not to overprescribe opioids nor to abuse them. 

Senator PETERS. Dr. Kolodny, in your written testimony, you 

talked about the need to improve access to medication-assisted 

treatments, and I have recently introduced some bipartisan legislation with Senators Capito and Murkowski in the Senate called the 

‘‘YOUTH Act,’’ which aims to increase access to these treatments, 

particularly for young adults and adolescents who, as you know, 

are often precluded from receiving these treatments. 

I would like you to comment on that and whether or not it is necessary for us to expand some of these treatment options for adolescents, who are also very susceptible to these addictions. 

Dr. KOLODNY. It absolutely is necessary, and adolescents are a 

group that may have even less access to some of the most effective 

treatments for opioid addiction because of the bias or stigma 

against treating opioid addiction with medication. Something I 

would just like to add a little more to was my comment about patients not having access to buprenorphine treatment paid for by 

their insurance. What is all too often the problem is that patients 

can access the medication, their Medicaid or their private insurance will pay for the prescription, but there really is not enough 

access to treatment programs that accept the patient’s insurance. 

So with Medicaid expansion, I think there are people who now are 

on buprenorphine for their opioid addiction because they have Medicaid that will pay for that prescription, and that prescription may 

be keeping them alive, but the Medicaid expansion has not helped 

them access the visit. And if we really want to see overdose deaths 

go down, where we want to be is in a place where someone who 

is opioid addicted, when they get up in the morning, and they are 

going to need to use very quickly after they get up, or they are 

going to be feeling very sick. People who continue to use, it is not 

because it is fun. They are using because they have to keep using 

to avoid feeling awful. If for that individual finding a treatment 

center that can treat their opioid addiction with medication is more 

difficult, more expensive, they have to pay that doctor out of their 

own pocket, even if they have the prescription coverage, if all of 

that is more expensive than calling a drug dealer and buying a bag 

of heroin, they are going to buy the bag of heroin. If we want to 

see overdose deaths come down, we have to change that balance. 

Effective treatment for opioid addiction has to be easier and less 

expensive than buying a bag of dope if we want to see deaths come 

down. 

Senator PETERS. Great. Thank you. 
19 

Chairman JOHNSON. Before I turn it over to Senator Paul, I just 

want to chime in one more time. 

Put up the one chart. Again, I think I have been very careful. 

Let me repeat, I agree that correlation does not mean causation, 

but this was an analysis that we got from HHS last year, and what 

they are just trying to show is, anecdotally, they compared States 

with a similar type of demographics, similar type of population, expansion versus non-expansion, and from my standpoint the results 

were somewhat stark: West Virginia, 27 percent increase in 

overdoses; Mississippi, 11 percent; Ohio, 41 percent, versus Wisconsin, 3 percent; Maryland, 44 percent now; Virginia, 22 percent; 

New Hampshire, 108 percent, versus Maine at 55 percent; North 

Dakota, 205 percent, versus South Dakota at 18 percent. Again, expansion versus non-expansion. Again, not saying it is causation, 

but it is this kind of information that would—and I will just ask, 

Dr. Hyman, it at least makes you curious and suggests that something ought to be further explored, don’t you agree? 

Dr. HYMAN. Oh, I certainly agree it should be further explored, 

and you have 10 States. There are obviously 50, right? 

Chairman JOHNSON. Right. Again, this is just an analysis based 

on data, not a scientific study by any means. But you have other 

data that also says once Medicaid has been funding this, you throw 

more money into Medicaid, it might kind of help fuel it as well. 

Dr. HYMAN. I think it is certainly worth study. I would note that 

the four States on the right have relatively low populations, and so 

even a small increase can have a big percentage impact. This is 

part of the process that you have to go through. 

Chairman JOHNSON. Right. Again, all I am saying is it is worth 

dismissing. Let us put it that way. We should not dismiss it. Senator Paul. 

OPENING STATEMENT OF SENATOR PAUL 

Senator PAUL. I think we can argue that the increase in opioids 

that we have seen with Medicaid expansion might be unintended, 

but I do not think we can argue that it is unforeseen. You can 

argue causation and correlation all day long, but if the Medicaid 

population was using opioids at a greater amount than the nonMedicaid population before the expansion, if you give Medicaid 

more money, you are going to see the same thing, and more money 

will simply exacerbate something. So if they were prescribing 

opioids at twice the rate before, maybe they are still doing it at 

twice the rate. So Medicaid expansion did not cause prescribers to 

prescribe it more, but if they are already doing it and you fuel it 

with more money, you are going to get more of a problem. 

So I think it is very predictable, and if you throw more money 

at Medicaid now and you do not have rules on prescribing or you 

do not have significant changes on prescribing, you are going to get 

more of the problem. 

I agree with some of the issues on Suboxone and replacement 

and rehab. All of those things would be good. But if you do not fix 

the rules on prescribing—and normally I would say this is a State 

problem and we should not be involved. But all the money is Federal now, so it is 100 percent Federal in the Medicaid expansion. 
20 

So I guess one question I would have for the Chairman is: 

Do you have any ideas or thoughts—we want to do problem solving—about how we would change the prescribing habits other than 

just suggestions? I think suggestions are not enough here, actually. 

Chairman JOHNSON. Well, again, I am not the witness here, but 

actually, what I want coming out of this hearing is to focus on that 

thought process. One of the reasons I have written a letter to HHS, 

is to let us get the information, let us get the data, and then we 

can work with the experts. What can we do to change the prescribing methodology, those types of procedures so that we stop 

overprescribing and we can actually effectively address this? 

Senator PAUL. Mr. Adolphsen, do you have any ideas on how we 

would change prescribing habits through law? 

Mr. ADOLPHSEN. Thank you, Senator. There are a couple of 

things that are already in law that I think States are not using 

well. I know Maine was not when we arrived there. Prescription 

monitoring in the Medicaid program, there is a program called 

‘‘Lock-In’’ where you restrict a Medicaid member to one pharmacy, 

one doctor, one prescriber. Those programs are not used very effectively or are not used extensively in States. There is somewhat of 

an obsession with access in the Medicaid departments around the 

country, I think, and so it seems that folks are sometimes shy to 

do things that might restrict someone from that access. But I think 

the Lock-In program is good. 

There are other controls, certainly. There is a drug utilization review program that is already in Medicaid, again, but not being 

used well. The bottom line is the money flows through Medicaid, 

and people, I think, view Medicaid as more than it is. It is really, 

as another witness said, a passive payer. And so they are not looking at a person holistically. And, causation, I have seen it line by 

line. I have seen a person access their welfare benefit, and a couple 

days later we see them in the data with an overdose. That is causation, and I think we can find that level of detail if you look at the 

States. But it needs more control. 

Senator PAUL. I think, though, overall we are going to need a 

much more dramatic change in how we prescribe. I mean, Sam 

Quinones in his book talks about that it used to be physicians were 

worried about addiction, and in chronic pain we did not tend to use 

opioids as much. And some of this came from Big Pharma trying 

to change patterns of prescriptions; it came from within the pain 

community. And it came from distorting one study that talked 

about inpatient people on opioids that had really nothing to do with 

outpatient treatment and was misused to say that we could use 

opioids on an outpatient without any consequences. 

So I think it has to be very dramatic, and I think it is going to 

have to actually be in law. As much as I am for freedom of the physician to prescribe stuff, if it is Federal money, we are going to 

have to oversee the Federal money, and we are going to have to 

figure out a way to say maybe other than terminal patients and a 

few other people, it needs to be something else. And you talk about 

expense. I have had a lot of experience with pain myself. Ibuprofen 

I think works in a fabulous way, and it is very cheap. But we have 

convinced patients that it is not good unless it is prescription, unless it is good stuff, unless it is a narcotic it is somehow not a good 
21 

painkiller. But ibuprofen is a very potent painkiller, particularly in 

higher doses. 

But something dramatic is going to have to happen, and I promise you, if we just throw more money at this, the problem will get 

worse. We have one county in Appalachia, and we got rid of the 

really bad doctors. We have done some of the controls that the 

States have tried. And last year, I think it was 20,000 people got 

2.8 million doses of opioids in one county, 150 doses per man, 

woman, and child. And this is after we have spent years in Kentucky really rooting out the bad doctors and doing some good 

things, and yet it is still an enormous problem. 

So I think what we have to look at, Mr. Chairman, I think we 

have to look at the money. We are in charge of the money for the 

Medicaid expansion, and we are in charge of a good chunk of the 

Medicaid program. We need to put in place some rules on this. 

There is going to have to be a dramatic change in this. I am not 

so sure OxyContin should be used for chronic pain at all. So, I 

mean, we really probably need to get away from that, but we cannot have suggestions. What we tend to do up here is we write into 

law suggestions, and they never happen. This is a real epidemic, 

and we are fools to sit up here and say causation versus correlation. People are dying in Medicaid, and we are giving it away for 

$3. If we cannot get over the fact that you give people free medication and then we overprescribe it that there is going to be a problem. We have to have significant rules in place. 

And, Mr. Schalk, you mentioned something about the payment 

with Medicaid, whether or not there could be more rules attached 

to how we pay people for opioids that might lead to improvement. 

Do you want to expound on that? 

Mr. SCHALK. Sure. So, in addition to—I said that I ordinarily see 

the impoverished that walk through the courtroom doors, but I 

have also prosecuted a prominent medical doctor in my community 

for committing Medicaid fraud, and what that illustrated to me 

was how susceptible Medicaid patients are to being victims of doctors that are committing Medicaid fraud themselves. And I want to 

say, as a whole, I believe the medical community is well intentioned and is seeking out a healthier community. But as we all 

know, it only takes one bad actor in a community to really exploit 

an already dangerous situation. 

And so what we were seeing was that this doctor’s Medicaid patients, his prescription practices were far different than his prescription practices with non-Medicaid patients. And due to how vulnerable that segment of the community is, whether that is through 

drug addiction or criminal behavior, what we were finding was 

they were being treated differently. And I think if you talk to any 

prosecutor in any part of the country, they are going to tell you all 

their defendants, they always have that one go-to doctor that they 

seek out. We call them ‘‘pill mills’’ in law enforcement because that 

is really how we view them. 

By regulating what the doctors are doing—and just like you, I 

am all for freedom in the medical community. However, I think we 

need to hold doctors more accountable. Are there prescriptions in 

line with the treatment program? As a prosecutor, it is very difficult to go after a medical doctor that is committing Medicaid 
22 

fraud because they are insulated under this treatment of care defense. 

However, what is the difference between a doctor that is prescribing pills that are not necessary and the person who is dealing 

heroin on the street? They are both making a profit by selling 

something that is not needed. 

And so I think that we need to hold our medical community to 

a higher standard as it relates to the egregious prescription practices. I think you are absolutely correct, Senator, that we have to 

regulate prescriptions. 

Chairman JOHNSON. I am going to burn up more of my firstround time here. Your comment begs the question: How are they 

treating the Medicaid patient differently than their normal patients? 

Mr. SCHALK. What we found was that the volume of prescriptions 

that were being prescribed, what was different than the non-Medicaid prescription clients—now, in the case that we had, it was a 

very intricate set of facts, but in terms of—they were coming in 

testing dirty for meth, testing dirty for heroin, and yet they were 

still being given prescription after prescription, and from a medical 

perspective, I do not see how that is a viable or plausible solution. 

Chairman JOHNSON. I want to quickly ask the doctors. We held 

a roundtable in Oshkosh, and I asked the doctors—I did not intend 

to bring this up, but it ties into this—we probably had a couple 

dozen doctors, and I just said, if there is one thing—this is about 

health care in general—if there is one thing that was a problem in 

health care, can you say what it was? And one doctor brought it 

up: Medicaid. And they all shook their head. And it shocked me. 

I said, ‘‘Describe that.’’ And they were talking about the high percentage of no-shows in appointments in Medicaid versus non-Medicaid patients. The reason I bring it up is because I wonder to what 

extent are doctors just giving somebody on Medicaid a month or 2- 

month supply of opioids so they do not have to schedule another 

appointment to have a no-show? Is that part of the kind of realworld reality that occurs? I will just ask the doctors on that. A legitimate question. 

Dr. KOLODNY. So I do not think that the problem you are describing is unique to Medicaid, no-shows, for example. You could see it 

with patients with any type of insurance. I think there are problems that add to overprescribing that have to do with our health 

care system, so that if a doc has 10 or 15 minutes to spend with 

a patient, writing a prescription is usually the quickest way to get 

the patient out of your office. And, it was mentioned earlier about 

paying for alternatives to treating pain with medication. It is not 

so much that payers will not cover physical therapy. But if you are 

a doctor with 10 minutes to spend with a patient, finding an innetwork physical therapist for your patient, then making that referral is going to take a lot more time than writing the prescription. And usually the patient just wants the prescription. 

So, I think we have a health care system that incentivizes treating lots of medical problems with a prescription pad. 

Chairman JOHNSON. Well, again, across the board patients do 

not pay for the products they get, by and large. 
23 

Dr. Hyman, do you want to quickly chime in? Then we will go 

to Senator Lankford. 

Dr. HYMAN. Yes, I certainly agree that writing a prescription is 

often an easy way to bring the clinical interaction to a close. I have 

also heard from many physicians about frustrations of dealing with 

Medicaid. Sometimes that is about the populations covered by Medicaid. Sometimes that is about the Medicaid program itself, which 

has bureaucratic rules and often pays slow and not very much. And 

that is at least the perception among physicians. 

Chairman JOHNSON. Thank you. Senator Lankford. 

OPENING STATEMENT OF SENATOR LANKFORD 

Senator LANKFORD. Thank you, Mr. Chairman. 

Let me bounce several questions and give you a practical example of this, what we have talked about already. In Oklahoma, there 

is currently a physician going through the process right now that 

saw 90 patients a day and was writing narcotics ’scripts to almost 

every one of them as they came through. Ninety a day, on average, 

between 15 to 30 seconds per person that he actually saw them before he was writing a ’script. So it is an issue that we have to resolve, and obviously locating these individuals and then identifying 

them and prosecuting them becomes exceptionally important. 

I have a different angle on this that I want to be able to bring 

up. Mr. Schalk, you brought up in your testimony about Suboxone. 

You brought that up as well. The question I have is: In your testimony you had mentioned that that is being diverted. That is a drug 

designed to be able to help people get off of narcotics. That is now 

being diverted to being on the street as well as a narcotic. Can you 

talk me through what you are seeing there? 

Mr. SCHALK. Yes, well, first, I am not an expert in addiction, but 

from a street-level prosecutor, we see Suboxone being heavily trafficked in our community. 

Now, the flip side of that is we see other forms of opiate treatment, like Vivitrol, for instance, it is an injection, and we see the 

success rates far higher in our community with those having an injection as an opioid blocker as opposed to Suboxone. That is not 

taking away from the benefits of Suboxone, but I can tell you in 

southern Indiana, it is heavily trafficked illegally. 

Senator LANKFORD. OK. Any other comments on that? Go ahead. 

Dr. KOLODNY. I think that the diversion of Suboxone onto the 

black market needs to be understood. Many of the individuals who 

are buying Suboxone on the black market are using it in a somewhat self-therapeutic way, and I think with diversion of opioids 

onto the black market, there are really two things that you have 

to think about and that we would have to be concerned about. 

One is whether or not the diverted opioids onto the black market 

are causing new cases of addiction or more people becoming addicted because of that diversion, which, if that is happening, it 

would be making our opioid addiction epidemic worse. 

And the other thing you would want to be concerned about is 

whether or not the diverted opioid is contributing to overdose 

deaths. In the case of diverted buprenorphine, buprenorphine is a 

very different type of opioid. A young person who is interested or 

curious about experimenting with opioids, if that young person 
24 

makes the mistake of experimenting with buprenorphine, they are 

very likely to have a bad reaction to that drug, and it is not like 

they are going to be feeling lousy for a few hours and then they 

go home at the end of the party. It is a very long-lasting drug. They 

are likely to feel very sick. They are likely to not want to do that 

again. 

Where you can see people get a euphoric effect from diverted 

buprenorphine is if they are an experienced opioid user and they 

have been off of opioids. Then they can feel good about it. 

So I do not think that diverted buprenorphine is becoming a recreational drug causing new cases of addiction. And one of the 

unique properties of buprenorphine is that it is quite hard to overdose on. It has a ceiling on its effect. So even a patient who takes 

an extremely large dose or someone trying to get high by taking 

extra doses is unlikely to overdose, is unlikely to have respiratory 

depression. So I think the existence of this black market for 

buprenorphine has more to do with the fact that we are not making 

that treatment available to the people who need it. 

Senator LANKFORD. OK. Thank you, by the way. 

Senator Paul was mentioning as well that we are trying to figure 

out some way to be able to actually come up with some solutions 

in the process of this. Mr. Adolphsen, you had mentioned about 

pharmacy lock-ins. Oklahoma uses that, my State. Has that been 

successful? Not successful? What have you seen in locations like 

that? 

Mr. ADOLPHSEN. So my impression of it, Senator, is that it is 

being used in a number of States, but not very aggressively. So you 

might find in a State with hundreds of thousands of people on 

Medicaid, a couple hundred people in the lock-in program because 

the parameters of—— 

Senator LANKFORD. They are identifying high risk. 

Mr. ADOLPHSEN. Yes, the parameters are designed, though, 

again, with access in mind. They do not want to—— 

Senator LANKFORD. OK. What about States experimenting with 

limiting dosage for opioids? 

Mr. ADOLPHSEN. I can say in my State of Maine we were very 

aggressive a couple years ago in limiting both the strength and 

length of prescriptions. It was not without controversy, but the 

early data coming back from Maine is that it has been very effective. 

Senator LANKFORD. What about electronic prescriptions rather 

than paper prescriptions for opioids? 

Mr. ADOLPHSEN. In that same law that was passed in Maine, 

they did a required prescription monitoring program requiring docs 

to enter it each time. Again, not without controversy, but it has so 

far early on proven to be helpful. 

Senator LANKFORD. Obviously, there was a question on cost on 

that for physicians. There is a difference in input in personnel time 

to be able to do it as well as the equipment itself to be able to do 

it in the system. What have you seen on that versus what was 

threatened to be what the cost is and what the actual cost is in the 

transition? 

Mr. ADOLPHSEN. I do not have the exact cost, but I know at the 

department level we provided free training. We used the number 
25 

of grants that we had for fighting the opioid crisis in order to help 

educate doctors, go into a hospital, help set it up. I think that is 

probably something that is a good thing to do, help on the cost side. 

But, it is an administrative burden, but I would argue probably one 

that could be worth it in this case. 

Senator LANKFORD. Mr. Tyndall, did you all experiment with any 

of that in Tennessee? 

Mr. TYNDALL. Yes, sir. Senator, thank you for the question. We 

started our monitoring database in 2006. We did not have anything 

before that, and we started it in 2006, and we have had a number 

of enhancements since then. And it is free to all physicians. Any 

medical provider that is enrolled, it is free of charge. And now we 

have had some enhancements where it is mandated that every 

medical professional has to enroll into the system as well as the 

pharmacist. So we monitor any drug prescribed or dispensed in the 

State of Tennessee, two through four. It is somewhat similar to the 

Kentucky All Schedule Prescription Electronic Reporting 

(KASPER) program in Kentucky, and that is the only State we 

kind of communicate with. 

Senator LANKFORD. That was actually my next question. Is there 

cooperation with other States and sharing that information? If you 

live in Memphis, that is very different than a number of States 

that you might have the opportunity to be able to go outside of the 

State to be able to use it. 

Mr. TYNDALL. Right. There are eight States that border Tennessee, and the only one that we really communicate with is Kentucky. We have a reciprocal agreement, I guess, to share the monitoring of prescription drugs two through four. 

Senator LANKFORD. But they could not use, for instance, Medicaid, which is just part of what we are talking about today, but 

the Medicaid portion of it, they could not use in an out-of-State 

pharmacy, or they could? 

Mr. TYNDALL. There are a number of rules, exceptions to all of 

that. Sometimes if it is an emergency and you are out of State, you 

can use your Medicaid benefits to do that. But I am not sure about 

all those exceptions that go with that. 

Senator LANKFORD. One last quick question. If you are buying 

Sudafed in Oklahoma, you have to be able to show a driver’s license to be able to do that, and it is tracked on just the usage of 

Sudafed regardless of where you get that. Is there any system like 

that that has been discussed or is in place on narcotics? 

Mr. TYNDALL. Very similar in Tennessee. You have to sign a log 

and produce a photo ID to get Sudafed. 

Senator LANKFORD. What about for narcotics? 

Mr. TYNDALL. Part of our Controlled Substance Monitoring Database (CSMD) now, you have to present an ID when you pick up 

any kind of narcotic from the pharmacy. You also have to do that 

as well. 

Senator LANKFORD. OK. Thank you. 

Mr. TYNDALL. And one more thing, if I could add. Effective yesterday, with few exceptions TennCare will only pay for a 15-day 

supply of opioid medication within a 6-month period. So we have 

reduced it significantly to get opioids for a 6-month period in Tennessee. 
26 

Senator LANKFORD. OK. Thank you. 

Thank you, Mr. Chairman. 

Chairman JOHNSON. Senator Jones, you are next in line for questioning. 

OPENING STATEMENT OF SENATOR JONES 

Senator JONES. Thank you, Mr. Chairman. 

Having come from a State that did not expand Medicaid and 

probably has one of the most restrictive Medicaid eligibility requirements in the country, we still have an incredible opioid problem. And I appreciate Senator Paul’s comments because what I am 

seeing in Alabama is a prescriber problem more than anything 

else. And I am curious, having been an old prosecutor myself, Mr. 

Schalk, can you give me an idea of—and I know this may be difficult, but how many of those folks that are being prosecuted for 

taking those prescriptions and selling the pills or doctor shopping, 

do you have an idea, a sense of how many of those people actually 

started out addicted to those opioids and they need the money and 

that is driving it, as well as just being generally impoverished? 

Mr. SCHALK. Sure. I think certainly addiction plagues the criminal justice system, and we often throw around the term ‘‘drug dealer’’ very loosely. And we have many kinds of drug dealers in the 

criminal justice system. We have those that deal for profit, and 

then we have those that deal to feed their own addiction. 

Senator JONES. Right. 

Mr. SCHALK. I would say those that deal to feed their own addiction make up the overwhelming majority of those that are in our 

prisons. 

Senator JONES. So if that is the case, do you have a process in 

place when you arrest somebody, do they get treatment? Is there 

a drug court or something like that that you can put these folks 

in to try to keep them out of the system a little bit better but to 

try to deal with that addiction so there is not recidivism? 

Mr. SCHALK. We are blessed in my county to be small enough to 

have a tailor-made program for many of the individuals that are 

coming through the criminal justice system. If you go just a few 

minutes down the road to Louisville, which is, obviously, a much 

larger metropolitan area, it is much more streamlined. They just 

simply do not have the resources or ability. And so, yes, I think 

being able to make a tailor-made treatment program for an individual is a key ultimately to their success, and that includes—and 

a lot of time defendants do not want to hear this—being sober. And 

when you are struggling with opiate withdrawals, in my opinion, 

the best place sometimes to experience those are within a jail 

where we know you are going to be sober, you are not going to go 

out, and you are not going to use again. 

But once we can have 90 days of sobriety, at that point we can 

then start exploring options, treatment programs that are available. 

Senator JONES. I have also noticed in some of the charts that we 

have seen, I guess, there seems to be—the private payers seem to 

be doing a little bit better in terms of the opioid problem. What are 

the private payers doing differently than Medicaid that Medicaid 

can learn from to try to stem the prescriptions to begin with, which 
27 

I think is a big problem? I will just throw that open to anybody 

that might have a proposal or an answer. 

Dr. KOLODNY. The explanation for why in the past few years we 

are seeing, for example, less hospitalizations paid for by a private 

insurance versus Medicare involving opioid overdose is not really 

clear. It is possible, as your question suggests, that there are 

things that the private payers are doing that maybe Medicare or 

Medicaid should replicate. I am not sure that that is the case. In 

the past couple of years, we have seen commercial private insurance companies begin to implement policies to promote more cautious prescribing, but it has been pretty new. 

One possibility is that for people who become opioid addicted who 

fall out of the workplace because of their opioid addiction and become poor because of their opioid addiction, they may more likely 

wind up insured by Medicaid and fall out of the private system. So 

it is hard to say why we might see a greater problem in people insured by Medicare or Medicaid. 

Senator JONES. All right. Yes? 

Mr. ADOLPHSEN. Senator, I think it is because they are trying. 

Cigna announced that they pledged to lower prescription painkillers by 25 percent in 3 years. So they have acknowledged they 

have a role here that they might be playing in this issue. So I think 

Medicaid has acknowledged that, and it is a little ironic because 

Cigna is using the CDC’s guidelines—the CDC right down the 

street from Medicaid—but they have not seemed to get together on 

it. So I do think there is a level of acknowledgment and effort that 

the private insurers have made. 

Senator JONES. What about the role of the prescription drug companies that are manufacturing these opioids? What role should 

they play? 

Dr. KOLODNY. Well, something that the manufacturers of opioids 

should stop doing and I think something the Food and Drug Administration (FDA) could require them to stop doing if it properly 

enforced the Food, Drug, and Cosmetic Act (FDC), they should immediately cease promoting opioids for chronic pain. As Senator 

Paul mentioned earlier, opioids have not been shown to be safe and 

effective for long-term use for common chronic conditions like low 

back pain, fibromyalgia, chronic headache. These are good medicines to ease suffering at the end of life. They are good medicines 

when you are using them from a couple of days after major surgery. But for daily long-term use, they may be more likely to harm 

the patient than help the patient. Right now we have a law that 

says that drug companies are only allowed to promote products for 

conditions where the benefits are likely to outweigh the risks, and 

those conditions, they become the indication on the label. And if 

the company gets caught promoting use not on the label, they get 

into trouble. The label on opioid analgesics is very broad, which has 

allowed the manufacturers to promote for conditions where we really should not be prescribing opioids. 

Senator JONES. Does anybody else want to take a shot at that? 

Otherwise, Mr. Chairman, that is all I have. Thank you. 

Chairman JOHNSON. I just wanted to quickly follow up. That is 

a problem with FDA approval on that particular drug, right, too expansive an approval? 
28 

Dr. KOLODNY. Yes, I mean, if we could go back in time to the introduction of OxyContin, if FDA had properly enforced the Food, 

Drug, and Cosmetic Act, they would have told Purdue, ‘‘Great, you 

have extended-release oxycodone. That sounds like a good drug for 

cancer patients. We are going to let you send your sales force to 

the hospices and to the oncologists and to palliative care doctors.’’ 

FDA did not do that. And there would not have been that much 

money for Purdue to make if their product had only been prescribed to patients at the end of life. So they promoted broadly, and 

FDA allowed it. But with every manufacturer of opioids, they have 

done the same thing because the big market is chronic pain. Millions of Americans suffer from chronic pain. That is where they are 

going to make their money, and so that is what they have been 

promoting use for. 

Chairman JOHNSON. Well, it is never too late for the FDA to 

change it. 

Dr. KOLODNY. That is correct, and our new FDA Commissioner 

may be finally the FDA Commissioner to do that. He has certainly 

made some statements leading us to believe he may take some of 

the steps necessary. 

Chairman JOHNSON. OK. I will follow up later. 

Dr. HYMAN. If I could just add, I would point out once the FDA 

approves a drug, physicians can use it for off-label indications. 

They do not require the FDA’s permission. And once it has been 

approved, notwithstanding some people’s views on the scope of the 

FDC, there are serious constitutional questions raised by attempts 

to prohibiting pharmaceutical companies unless they are engaging 

in false and misleading speech. 

Chairman JOHNSON. OK. Senator Harris. 

OPENING STATEMENT OF SENATOR HARRIS 

Senator HARRIS. Thank you. 

Dr. Kolodny, I was struck by your fourth slide which showed that 

hospitalizations for opioid overdose are increasing most rapidly, as 

you have mentioned, in Medicare but also increasing for people 

with private insurance and people without insurance and people 

with Medicaid. These facts make it clear, to me at least, that diversion is a risk regardless of the type of insurance coverage a person 

may have. 

To follow up on this conversation, in 1996 Purdue Pharma released OxyContin, an opioid that they falsely claimed would deter 

addiction, as you have mentioned. In the 5 years from 1997 to 

2002, OxyContin prescriptions grew from 670,000 to 6.2 million. 

And overall sales of prescription opioids increased roughly four 

times between the years of 1999 and 2014. 

A number of Senators—Senator Claire McCaskill and myself included—have ongoing investigations of drug companies and distributors who helped cause and exacerbate the opioid epidemic. To 

that end, you have mentioned a bit about what the FDA responsibilities are. Can you talk about what you believe Congress can do 

to hold pharmaceutical companies responsible for its role in causing the opioid epidemic? 

Dr. KOLODNY. That is a really good question. I think one thing 

that Congress could do is hold FDA’s feet to the fire through your 
29 

oversight role of FDA because FDA really has failed to properly enforce the laws and has allowed opioid manufacturers to improperly 

promote opioids. 

I do think that I am very pleased by your investigation and 

Ranking Member McCaskill’s investigation of the role that manufacturers have played. I do want to point out, though, that Senator 

Grassley and former Senator Baucus launched a similar investigation in 2011. The Senate Finance Committee began an investigation, and the Senate Finance Committee has yet to release its findings from that investigation. So I think, making those findings public would be very helpful, I think, for changing the behavior of the 

manufacturers. Many of the organizations or front groups that they 

give money to, they are continuing to fund, and they are front 

groups that are blocking Federal and State efforts to promote more 

cautious prescribing. The Associated Press and the Center for Public Integrity did investigations showing that the opioid lobby, the 

manufacturers, the distributors, have spent more than $880 million 

over the past decade blocking efforts to promote more cautious prescribing, and I think the findings from these investigations may 

make it more difficult for them to continue doing that. 

Senator HARRIS. And you mentioned front organizations. Can you 

talk about who and what they are? 

Dr. KOLODNY. These would be organizations that in some cases 

are pure AstroTurf organizations created by industry—— 

Senator HARRIS. AstroTurf, what do you mean? 

Dr. KOLODNY. AstroTurf is an organization meant to look like a 

grassroots organization, but it has been artificially created by industry. One of the organizations that was very damaging was the 

American Pain Foundation, which was an AstroTurf organization. 

That shut down on the day that the Senate Finance Committee 

launched its investigation. 

There are also medical societies, professional organizations that 

‘‘front group’’ might be a bit strong, but that take very significant 

funding from opioid manufacturers and promote the interests of 

opioid manufacturers rather than the interests of patients. So, for 

example, the American Academy of Pain Medicine and the American Pain Society have promoted very aggressive prescribing of 

opioids and have really come to the defense of manufacturers every 

time efforts are raised that could potentially better regulate them. 

Senator HARRIS. Thank you, and I plan to follow up on your suggestions. Thank you. 

Medicaid is, of course, one of the leading sources of substance 

abuse treatment, covering about one-third of opioid addiction treatment. In June of last year, I toured and met with the patients at 

the Martin Luther King, Jr. Outpatient Center in Los Angeles. I 

will tell you that Medi-Cal pays for 70 percent of the care there. 

The nonpartisan Government Accountability Office found that 

Medicaid expansion increased access to substance abuse treatment, 

and the Urban Institute found much more rapid growth in spending on opioid treatment medications and overdose reversal medications in States that expanded Medicaid, suggesting, of course, that 

more of those who need treatment are getting it thanks to Medicaid expansion. 
30 

1The chart referenced by Senator Hoeven appears in the Appendix on page 86. 

The President’s own opioid commission called for the expansion 

of Medicaid by having the administration grant waivers for all 50 

States to eliminate barriers within the Medicaid program in order 

to help more people have access to treatment. 

My question is: If Medicaid funding is cut, what happens to the 

one in three people who receive treatment under Medicaid for 

opioid addiction? 

Dr. KOLODNY. So I think that there are individuals right now 

who are, thanks to Medicaid expansion, alive, who are having their 

opioid addiction effectively treated. If they were to lose Medicaid 

coverage, for example, I think that there would be a very high likelihood that these individuals would relapse, and if relapsing, a high 

likelihood that they could die from an overdose. 

We have an exceptionally dangerous black market opioid supply. 

We have never had heroin as dangerous as we do today because 

of fentanyl that is in it or fentanyl that is sold as heroin. A relapse 

is not a benign event. One relapse can be fatal. And if patients lose 

health coverage that is paying for their addiction treatment, they 

are at very high risk for relapse and loss of life. 

Senator HARRIS. Thank you. And, Mr. Schalk, I appreciate your 

comments as a fellow prosecutor. I think we both appreciate—and 

certainly your work has pointed this out—that one of the best ways 

that we can be smart on crime is to follow what the public health 

model has taught us, which is if you want to deal with an epidemic, 

be it drug, crime, or health, one of the most effective and smartest 

and efficient ways to deal with it is not reacting after but actually 

preventing before these crimes occur. So I appreciate your comments and the work that you have done highlighting that point. 

Mr. SCHALK. Thank you, Senator. 

Senator HARRIS. It is in the best interest of public safety and also 

taxpayer dollars. 

Mr. SCHALK. Thank you. 

Senator HARRIS. Thank you, Mr. Chairman. 

Chairman JOHNSON. Senator Hoeven. 

OPENING STATEMENT OF SENATOR HOEVEN 

Senator HOEVEN. Thank you, Mr. Chairman. 

I expect that each of you have looked at Chairman Johnson’s 

chart1 on the rise in overdose deaths increasing from 2013 to 2015, 

and also comparing the number of overdose deaths in expansion 

and non-Medicaid expansion States. So I would ask each of you, 

starting with Mr. Adolphsen. Thank you for putting the chart up. 

To what do you attribute it? What is causing it? What should be 

done about it? 

Mr. ADOLPHSEN. Thank you, Senator. I think we have heard 

from a number of folks, not just in this hearing but in previous 

hearings, that we have a real supply side problem on opioids. And 

I think when you are in a hole, you stop digging. And expansion 

has really opened the door to a massive increase in these opioids 

in the market on the supply side. So I think when you look at a 

State that has expanded, that has added hundreds of thousands of 

people who suddenly are not just eligible for the treatment that we 
31 

have heard about but they are also eligible to receive no-cost prescriptions, you are inevitably driving up the supply of this into the 

market. 

Senator HOEVEN. And what should be done? 

Mr. ADOLPHSEN. Well, I think there are some options. One of the 

things that ought to be considered is maybe disconnecting substance abuse treatment from the rest of the benefit. So, for example, there obviously are millions of Americans out there who need 

substance abuse treatment. No one would argue that fact. However, is it best delivered with an entire Medicaid package that includes access to more opioids? And that is really the problem that 

I saw, was we had folks over on one side of the house getting treatment, and those same folks were still getting opioids that caused 

the addiction in the first place. And those two kind of butt heads. 

So I think it does not necessarily have to be one without the 

other. The substance abuse treatment should be very targeted and 

focused and not necessarily come with all of these unintended consequences. 

Senator HOEVEN. Mr. Schalk? 

Mr. SCHALK. Senator, looking at these numbers, what is clear to 

me is when we give more prescriptions, when we give greater access to those that are most susceptible to addiction, that are most 

susceptible to the criminal justice system, at a certain point they 

are going to transition from these opioids that a doctor is prescribing, and they are going to start seeking their high from somewhere else. Perhaps that is because the doctor said, ‘‘I am no 

longer going to write you a prescription. I cannot justify this.’’ At 

a certain point, when they transition from the pills that their doctor is prescribing them, they transition from there to fentanyl and 

heroin laced with fentanyl, that is where these deaths are coming 

from. It is from injecting heroin after—and no one just starts on 

heroin. It is a progression. And almost without fail, before someone 

begins down the path of injecting heroin, they are abusing their 

prescription pills. And I think just looking at the fact when we are 

making these prescription pills more readily available to a greater 

segment of our population, this is what happens. 

Senator HOEVEN. And what should be done? 

Mr. SCHALK. I believe that while this is a multifaceted issue, we 

need to hold the medical community more accountable, would be 

one key aspect, as it relates to their prescription practices. We are 

giving doctors in many ways complete discretion to prescribe synthetic heroin, and that is a lot of power. And so I think we need 

to take a closer look at the prescription practices. Are they in line 

with the treatment plan? Are they improving quality of life? And 

if those answers cannot be met, then we need to hold the doctor 

accountable as to why were they prescribing this unneeded and unnecessary drug to this individual? 

Senator HOEVEN. Mr. Tyndall? 

Mr. TYNDALL. Thank you, Senator. And I do not know that I 

could speak to expansion and non-expansion. That is probably 

above my pay grade in Tennessee, but certainly I think that the 

more people who have access to low-cost and no-cost prescription 

drug medication, the probability of drug-seeking behavior and prescription drug diversion increases. 
32 

Senator HOEVEN. What would you do? 

Mr. TYNDALL. Well, I think there ought to be penalties if you are 

involved in drug-seeking behavior or selling your medications, especially by Medicaid. The penalties need to be more severe for that. 

Senator HOEVEN. Dr. Hyman? 

Dr. HYMAN. So I would echo what has been said about the supply 

side aspects, that, there are physicians who will write prescriptions 

for opioids, and there are patients who will take them and get 

those prescriptions filled. And that is a gateway for some of them 

to more severe drugs once they are cutoff. 

I think on the solution side, so far we have talked a lot about 

the patient and doctor shopping. It is important to recognize, as I 

said at the outset, it takes a physician to write the prescription. 

And so we ought to be looking for outliers in the frequency of prescribing, both relative to the patients that they are seeing and also 

relative to the doses that they are basically writing on the prescription pad. And, you may be an outlier because you are in the pain 

management business and you see a population of patients that 

badly need pain management. Or you may be an outlier because 

you will basically write a ’script for everybody who comes through 

the door. My suggestion would be not necessarily criminal sanctions as your starting point, given the difficulties that Mr. Schalk 

has already talked about, but some combination of financial incentives and licensure sanctions. State medical boards ought to be 

more active in this space. 

Senator HOEVEN. Dr. Kolodny? 

Dr. KOLODNY. So I think this is an interesting association, and 

it is worth investigating to see if this really holds out if you were 

to compare the specific timeframes of Medicaid expansion, were to 

look at States, and it is certainly worth looking at. 

I do believe that we have a good understanding of why the opioid 

addiction epidemic is getting worse and why in States where it has 

gotten much worse, why that happened. 

Something that is important to understand is we have two 

groups of Americans who are opioid addicted: we have a younger 

group and an older group. 

The older group are people who are becoming opioid addicted 

mostly through medical treatment. That older group has not been 

turning to the black market. They are getting opioids prescribed to 

them for chronic pain. Up until around 2011, we were seeing most 

of the overdose deaths in older people getting pills prescribed to 

them by doctors. It is possible in that older group, because prescribing has become a bit more cautious, overdose deaths may be 

stabilizing, coming down a bit. 

The younger group are people in their 20s, 30s, and early 40s, 

they are becoming opioid addicted from using prescription opioids, 

either medically or recreationally, or sometimes a combination of 

both. That younger group, when they become opioid addicted, has 

a hard time maintaining their supply visiting doctors. Doctors and 

dentists, as we have been discussing, are too comfortable giving 

young people lots of opioids, but we do not like to give healthy-looking 25-year-olds a large quantity on a monthly basis. So the young 

person who becomes opioid addicted winds up on the black market. 

The pills are very expensive on the black market, and something 
33 

we have seen happening steadily over the past 20 years is a rising 

use of heroin in these young people who wind up on the black market and switch to it because it is much cheaper. 

Beginning in around 2013, overdose deaths in this younger 

group, in the group that has been switching to the black market, 

the group that has been using heroin, overdose deaths are soaring 

because of fentanyl, because the heroin supply is so dangerous 

right now. I think that is really the primary driver. I do not believe 

it is Medicaid expansion. I do not think Medicaid expansion is helping us as much as it could in terms of addiction treatment because 

the services are not there. I think people are getting their prescription paid for. 

So we have to do a lot more if we want to see overdose deaths 

come down, but I do not believe that overdose deaths are rising because of Medicaid expansion. I think it is fentanyl that is causing 

the very sharp rise that we have seen in recent years. 

Senator HOEVEN. Thank you. 

Thank you, Mr. Chairman. 

Chairman JOHNSON. Senator Daines. 

OPENING STATEMENT OF SENATOR DAINES 

Senator DAINES. Mr. Chairman, thank you. And I want to thank 

the Chairman for producing this report. It raises some serious 

questions about whether Medicaid expansion is having a counterproductive impact on the opioid epidemic by proliferating prescription opioid pills. I come from a State that is an expansion State, 

the State of Montana. I am particularly concerned by the report’s 

exposure of how Medicaid expansion dollars have resulted in addiction among some recipients and facilitated illicit distribution of 

these drugs to others struggling with substance dependence. In 

short, the report provides, I would argue, a more complete picture 

on the consequences of Medicaid expansion, and we must not ignore its conclusions. 

The first question is for Mr. Adolphsen. You mentioned in your 

testimony that 52 percent of able-bodied adults on Medicaid do not 

work and that only 16 percent work full-time. Can you share more 

about the positive correlation that you have found between having 

a job and reducing drug dependency among healthy working-age 

Americans? 

Mr. ADOLPHSEN. Thank you, Senator. That is right, that data 

that you referenced is very clear. The number of able-bodied adults 

on Medicaid has quadrupled from 7 million in 2000 to 28 million 

today. Half of those do not work at all. We know from the addiction 

specialists, the recovery community, that work is a pillar of recovery, and certainly in a program that is paying for the amount of 

substance abuse treatment that Medicaid is, we think it makes a 

lot of sense to encourage and assist people getting back to work. 

Unfortunately, that is not what we see. We are seeing the rolls, 

particularly for able-bodied adults, continue to grow, and many of 

those people are not working at all. 

Senator DAINES. Are you aware of what percentage of able-bodied 

Medicaid recipients actually return to full-time gainful employment? 
34 

Mr. ADOLPHSEN. Well, what we are seeing is enrollment continue 

to go up, so if they were moving into full-time employment, if you 

work even at minimum wage full-time, you are out of poverty. So 

if folks were quickly getting back in the work force, working a fulltime job or a couple part-time jobs, they would quickly cycle off of 

Medicaid because they would be earning income above the threshold. That is just not what we are seeing. We are seeing folks come 

on to the program, stay on the program. So, unfortunately, that is 

an indicator that has not been successful at returning people to 

work the way we would like to see. 

Senator DAINES. Why is that? What do you see? It is usually all 

about incentives. What is the incentive to stay on Medicaid versus 

move and become gainfully employed? 

Mr. ADOLPHSEN. Sure, there are probably a lot of things that go 

into that, but I think one thing we probably can all agree on is we 

all need deadlines and a push in our life to accomplish certain 

things, and Medicaid has been free of any requirement for kind of 

community engagement or work activities. That has not been a 

hallmark of the program, which historically might have made more 

sense when there were not able-bodied working-age adults on the 

program. But as I mentioned, that number has grown dramatically 

with the expansion under ACA, and I think that kind of incentive 

structure is needed within the program to help clear that pathway 

and encourage people to get back into the workforce or into training or volunteering and community engagement. 

Senator DAINES. Medicaid has been held up as a cure-all silver 

bullet for opioid treatment, which, by its own right, is critical to 

helping addictions. However, the evidence seems to suggest that 

Medicaid is a two-edged sword by proliferating prescription opioid 

pills due to the ease of access. There is always going to be leakage 

of diverted prescription opioids with or without Medicaid expansion. I think we probably would all agree with that. 

Mr. Adolphsen, what makes those eligible under Medicaid expansion more susceptible to facilitating illicit drug diversion? 

Mr. ADOLPHSEN. Thank you, Senator. I think we have heard a 

lot of great examples of that here in the testimony, the temptation 

to turn a free prescription into several thousand dollars in those 

types of things. I know one of the disconnects I saw in our Medicaid program in Maine was someone would have this access to 

Medicaid, and they might come into substance abuse treatment 

possibly, funded by Medicaid. But the success rate, unfortunately, 

is not very high in some of those programs, typically under 30 percent, sometimes in the teens. It is a difficult addiction to beat, so 

it is tough. 

So what happens, if somebody is in treatment for, say, a week 

or a couple of weeks even, but then they come out of treatment, 

and they still have the rest of their Medicaid benefit, they still 

have their full pharmacy benefit, they still have access to some of 

these other more dangerous drugs that may have led them into the 

addiction in the first place. 

So I think we need to do a better job of connecting those two dots 

within the program. 

Senator DAINES. So when you look at those individuals who are 

getting hooked on diverted drugs—we have kind of been looking at 
35 

the balance here of those coming on, those coming off. Do you believe that more individuals are getting hooked on diverted drugs 

than successfully completing opioid treatment? 

Mr. ADOLPHSEN. Yes, 12.5 million self-reported opioid abuse last 

year, painkiller abuse last year, and I think we heard from another 

witness already that something like a couple million people are trying to get into treatment. So it is pretty clear that on the supply 

side, the number of people misusing or becoming addicted is growing and outpacing the number of folks that are going into treatment and completing it. 

Senator DAINES. Mr. Schalk, in your experience as a prosecutor, 

and, Mr. Tyndall, as the Tennessee IG, you both have indicated the 

extent of Medicaid prescription fraud is unknown due to underreporting and other barriers. How expansive do you think the fraud 

might be? 

Mr. SCHALK. Staggering. Based on the limited numbers that we 

see as opposed to what we know is going on, what we see is going 

on, I believe that if we were to look at the amount of Medicaid 

fraud that was happening just in my own community, Members 

would be outraged. 

Senator DAINES. So ‘‘staggering’’ is a strong word. ‘‘Outraged’’ is 

a strong word. I guess maybe it goes back to my background in 

chemical engineering. I tend to be more of a quantitative guy. I 

know the Chairman is a numbers guy, too. Do you have any sense 

of kind of trying to quantify the size of the bread box here without—‘‘staggering’’ is related—there is something in your mind saying it is large. Can you maybe try to quantify that for us? 

Mr. SCHALK. To sit and quantify with a number I would not be 

able to do. I can only ascertain from my own experiences that I see 

from an investigative side, from a courtroom side. Unfortunately, 

Senator, I am not able to sit and quantify with a particular number. 

Senator DAINES. Mr. Tyndall? 

Mr. TYNDALL. Thank you, Senator. I can only echo what Mr. 

Schalk just said. I have to cover 95 counties in Tennessee. I have 

14 agents. I have not had 100 percent of everybody 100 percent of 

the time, and we stay pretty busy just working the cases that we 

are aware of. 

Senator DAINES. So what steps would you advise Congress—this 

is a great opportunity for you all to put it in the record here and 

instruct this Committee. What would you advise Congress, the 

States, or CMS do to take up, to address this problem? A couple 

things. 

Mr. SCHALK. Well, as has been echoed throughout this hearing, 

I believe that reexamining the prescriptions that are being written 

is an essential element to being a key part of the solution. And, obviously, when doctor bills are being submitted through Medicaid, it 

is no secret that the checks and balances are far less than when 

they are being submitted through a for-profit payer. 

So, with that, I think when we are looking at prescriptions, is 

this prescription being written to pad a Medicaid fraud on behalf 

of the doctor? Again, is this prescription improving quality of life? 

Is it medically necessary? Is it within the scope of the treatment? 

And, frankly, can I go and get an over-the-counter that can be just 
36 

as effective? As Senator Paul said, ibuprofen is very effective. However, an overwhelming majority of the people that come through 

my courtroom, they do not believe ibuprofen is appropriate. They 

believe they need a high-powered painkiller. And I think we need 

to as a society take a step back from that and say ibuprofen sometimes is appropriate. Now, it is not always appropriate, and I recognize that. But I think recognizing that ibuprofen is appropriate 

more often than not is a good step toward reducing this problem. 

Senator DAINES. I am out of time. Mr. Chairman, thank you for 

allowing me additional time. 

Chairman JOHNSON. Well, I will say I want to finish up with my 

questions here. I am going to ask the exact same questions. So 

each one of you, if you had one recommendation in terms of a law 

change that would help solve this crisis, I will give you the opportunity to address that as well. But thank you, Senator Daines, for 

your questions. 

I want to start with the two doctors and just ask a question. Why 

did it take so long for the medical community to just recognize the 

extent of the opioid addiction? Why did you not have the feedback 

loop? You have ongoing education. You have your medical journals. 

I mean, why did it take so long? And why did it take this epidemic 

just bursting onto the scene here before—and I am not even sure 

all doctors are aware of it still. I hope they are, but we—— 

Dr. KOLODNY. Yes, I—— 

Chairman JOHNSON. Well, let me finish up. We held a roundtable 

in Wisconsin, and that is when I was shocked that you had an entire generation of doctors trained that these were not a problem. 

Again, that goes to marketing or whatever. But why wasn’t this 

known really within a couple years? 

Dr. KOLODNY. Yes, that is a great question. I think for many 

years the feeling in the medical community and even the position 

of the American Medical Association (AMA) was that the opioid 

problem was about the bad apples, that there were some doctors 

out there that are really drug dealers running pill mills, and that 

there are some people out there pretending to be patients but they 

are really drug abusers and they want to get their hands on these 

drugs, and that the opioid crisis had nothing to do with well-meaning doctors taking care of their legitimate patients. I think that 

was the thinking for quite a while when the reality is that the 

opioid crisis is really driven by well-meaning doctors who have 

been overprescribing to patients, getting patients addicted, but also 

indirectly causing addiction by stocking homes with a highly addictive drug, creating customers for the drug-dealing doctors, the 

pill mills, for the diversion and the fraud. So the bigger problem 

has been the well-meaning doctors. 

I think part of the problem is it is not just the medical community, but policymakers really for many years failed to look at the 

root of the problem, which was overprescribing. Instead, what they 

accepted was the way industry had been framing the problem and 

the way that the pain organizations funded by industry were framing the problem. What policymakers such as yourself were told was 

that all of this bad stuff that you are hearing about involving 

opioids, that is the drug abusers. There is a subset of our population that wants to get high off of drugs, and maybe because doc-
37 

tors are prescribing more, the drug abusers are getting their hands 

on these drugs. And, yes, we should do something about the drug 

abuse problem and diversion, but let us not forget that tens of millions, a hundred million Americans have chronic pain, they are 

being helped by these medicines, and that your job as a policymaker is to balance these two competing problems. You want to do 

something about the pain problem and do something about the 

drug abuse problem, but do not make the pain problem worse, do 

not punish the pain patients for the bad behavior of the drug abusers. So it was framed as if we had these two distinct groups and 

the harms were limited to so-called drug abusers. Policymakers accepted that. 

If you look at what was coming out of the Federal Government 

even over the past Administration, if you look at what was coming 

out of Substance Abuse and Mental Health Services Administration 

(SAMHSA), National Institute on Drug Abuse (NIDA), Office of National Drug Control Policy (ONDCP), it was almost an exclusive 

focus on the issue of non-medical use, kids getting into Grandma’s 

medicine chest. Nobody was asking why does every Grandma now 

have opioids in her medicine chest. Now we are finally asking that 

question. 

Chairman JOHNSON. The whole point of the PROP Act was to acknowledge the fact that government policy was requiring providers 

to ask the question: ‘‘Are you satisfied with your pain medication?’’ 

And if you got a bad survey result, it affected your reimbursement, 

so, government policy actually fueled that. 

Dr. Hyman, at what point did the medical community all of a 

sudden wake up and say, ‘‘This is a real problem?’’ Has it literally 

just been the last couple years even though this has been around 

for a couple decades? 

Dr. HYMAN. I think it is quite recent that the medical community 

has woken up to it, and you have already alluded to some of the 

incentives that they had to—I do not want to say ‘‘not wake up to 

it,’’ but to focus their attention on other areas. Lots of aspects of 

the health care system more or less run on autopilot. People keep 

doing things the way they were trained to do them. New information may not be available, or if it is available, they may say, oh, 

that is just one study. 

And this is not just about opioids, right? I can tell you story after 

story where there is a surgery or a treatment that gets deployed, 

it sort of spreads like wildfire, subsequent research indicates that 

it is not such a great treatment, and it is very hard to stamp out 

once it is out there because the same sort of passive payer of bills 

creates an incentive for people to keep doing what they are doing. 

Chairman JOHNSON. So a one-number answer out of both of you. 

What percentage of the medical community do you think get it 

now, fully understand it? We will start with Dr. Hyman. 

Dr. KOLODNY. It is age-related. Young doctors get it. They have 

come of age during the opioid crisis. In some cases they have lost 

peers to opioid overdoses. Older doctors, in my experience, doctors 

maybe older than 50, tend to still—many of them tend to be prescribing pretty aggressively. 

Chairman JOHNSON. So what percent? Only half of doctors, 50 

percent are getting—— 
38 

Dr. KOLODNY. It is very difficult to give you an answer. 

Chairman JOHNSON. I realize that. I am not going to hold you 

to it. Would you venture a guess? 

Dr. KOLODNY. I would guess that maybe a third of—it is a wild 

guess, that maybe a third of the prescribers are still very misinformed about opioids and are prescribing very aggressively. 

Chairman JOHNSON. They do not read the news? Dr. Hyman, do 

you agree with that or—— 

Dr. HYMAN. Well, even if they read the news, they may not view 

themselves as part of the problem, right? They may view themselves as treating with compassion and care the patients that 

present in front of them. If you made me give a number, I would 

fall back on my medical school training where an attending told 

me, ‘‘There are only two numbers in medicine—80 percent and 20 

percent.’’ So I would give you the 20 percent number, which is a 

little lower. I think it is higher among younger physicians for the 

reasons that Dr. Kolodny has already alluded to. 

Circling back to the question about the frequency of fraud and 

a quantitative figure, the standard figure in the literature is 10 

percent. There is not a great empirical basis for that number, but 

if you add in waste and overuse, you can get much higher numbers. 

And I am happy to share with you some of the research that has 

been done on that. 

Chairman JOHNSON. One of the questions we have submitted to 

CMS is how much are they spending reimbursing for opioids. That 

would be just kind of a nice macro number to know. 

I want to switch over to the prosecutor and inspector general. An 

indicator of the problem we have here is there is actually a 

website—and I am not going to promote it, but there is a website 

you can check to see what the cost is to make sure you are not getting ripped off by your drug dealer in terms of these opioids. So, 

I mean, that is a problem. Can you speak to the relative cost of 

street heroin versus opioids? Any of you three. 

Mr. TYNDALL. I do not know that I can give any specifics, but my 

understanding is that now because of the reformulation of some of 

the narcotics that we receive, they are a bit harder to use, and they 

are becoming more expensive. Heroin is growing cheaper and 

cheaper by the day, so people are now turning to heroin as opposed 

to prescription drugs. 

Mr. SCHALK. What we saw was at the pinnacle of Opana abuse, 

they were going—we had high school kids that were spending $200 

a day on two Opanas, $100 apiece for a simple pill. Once that supply ran up and the formulation changed where it was not as easy 

to abuse, that is when heroin came in, and it devastated our community. And heroin, from our experience, has been easier to get, 

it is cheaper to get, and the effect—once you go down the road of 

heroin, you do not want to go back to pills because the high is not 

as good. 

Chairman JOHNSON. Do people actually buy fentanyl, or do they 

buy it because they think it is heroin? 

Mr. SCHALK. What we see are people buying heroin that is laced 

with fentanyl. 

Chairman JOHNSON. OK. I read something in a magazine article, 

that $800 worth of fentanyl produces about $800,000 of street 
39 

value. So if you have the demand, the profit motivation is so high 

you are going to have the supply. 

When I started this inquiry, again, it was based on that article 

talking about funding a lifestyle of not working, supplying free 

health care, and access to products so beneficiaries can sell opioids 

as an income supplement. In terms of our actual investigation, 

though, we found far more complex and larger schemes. Again, I 

want to ask the prosecutor: is that just because we really do not 

go after the single users, the people who have been using it, and 

we really are focusing what limited investigation and prosecutorial 

resources we have in terms of the larger schemes? 

Mr. SCHALK. I think, like any law enforcement agency, we have 

to focus our resources and our efforts on the most prominent 

issues, and oftentimes that is the bigger players that we are going 

after. If we were to sit and—we would need to expand our police 

agencies tenfold to have a direct—to hold everyone directly accountable in our area. 

Chairman JOHNSON. But with what you were talking about, you 

think this is enormous. So you think it is enormous because individuals literally are accessing, that is, using their Medicaid cards, 

or Medicare or VA benefits, and they are getting the pills, and they 

get a large quantity—by the way, does anybody know what an average quantity is the doctors—I mean, what would be a typical 

monthly supply of one of these opioids? 

Dr. KOLODNY. Well, the vast majority of the prescriptions are 

written for acute pain, so if you are looking at numbers of prescriptions written, most of them are for acute pain, and they are for a 

small quantity. 

Chairman JOHNSON. Or short term. 

Dr. KOLODNY. Yes. 

Chairman JOHNSON. What about chronic? 

Dr. KOLODNY. So when you measure consumption in terms of 

weight of opioid consumed in the United States in terms of a morphine equivalent, the bulk of our consumption is chronic pain, and 

the average patient is given a 1-month prescription with an enormous amount of opioid in it. So it could be about 70 milligram morphine equivalents or more per day. Some patients are on even 

greater quantities that are very dangerous. 

Chairman JOHNSON. How many pills would that be a day or a 

month? I mean, let us say the average size in terms of milligrams. 

Dr. KOLODNY. So for a patient who is receiving opioids for chronic pain, they could be taking one pill in the morning, one pill at 

night. But each of those pills could be the equivalent of 25 or 30 

Vicodin in one pill. So it would be the equivalent of taking 50 pills 

a day, only they are taking it in an extended-release drug. 

Chairman JOHNSON. So you really can, because of the street 

value per milligram, or whatever it is. 

Dr. KOLODNY. It is about $1 a milligram. The most popular 

opioid on the black market is the 30-milligram immediate-release 

oxycodone, which will do what a $10 bag of heroin will do. And the 

effect is actually almost identical. In fact, some people prefer the 

effect of oxycodone. They are using heroin because it is cheaper, not 

because it is a stronger effect. 
40 

Mr. TYNDALL. Mr. Chairman, the prescriptions we are seeing 

sometimes it is 90 to 120 pills per month, depending on the—and 

hydrocodone tends to be kind of the drug of choice in Tennessee. 

You may get 5 milligrams, 7.5 milligrams, or 10 milligrams. So depending on the milligram and the number of pills, if a person 

wants to sell 120 10-milligram pills, that is a pretty good chunk of 

change for a month’s work. 

Chairman JOHNSON. So when you have the difference between 

acute versus chronic, how are you going to control prescriptions 

based on chronic pain? You are not going to require a doctor to 

keep writing that every 3 days. One of the solutions sometimes is 

just limit it to a 3-day supply. But that is just not—that may be 

appropriate for acute pain for a dentist or something like that, but 

not for chronic pain. 

Dr. KOLODNY. So for chronic pain, we should not be putting patients on long-term opioids. We have to prevent new starts. For the 

vast majority of these patients, opioids are not safe or effective. 

And I think that has been one of the main goals of the CDC guideline, is to prevent more people from winding up on long-term 

opioids. We have about 10 million Americans who are on opioids 

chronically, so many Americans on opioids chronically that we are 

seeing ads on television for drugs to treat the side effects of being 

on opioids chronically, like constipation. These 10 million Americans who are on opioids chronically, many of them may not be able 

to come off. Even though the medical community is figuring out we 

should not have started them on opioids, we also do not want them 

to cut them off abruptly. We have to try and help some of these 

patients come off. Some of them can come off. Some of them need 

addiction treatment. Some of them may just need to be maintained 

on safer, lower doses of the medication they are already on. The 

trick is to prevent more people from winding up stuck in their 

shoes. 

Chairman JOHNSON. So Mr. Adolphsen quoted some figures in 

terms of, unfortunately, the ineffectiveness of treatment. Can the 

doctors speak to that? What kind of success rates do we have? And 

also just in terms of Suboxone, does that also give a high? Why 

would that be diverted and be able to be sold? 

Dr. KOLODNY. So if you are an experienced opioid user and let 

us say you are in jail, so you have been off of opioids, and somebody smuggles buprenorphine—Suboxone—into you in jail and you 

take it, you will feel a strong opioid effect as if you have just used 

just about any opioid. If you are taking buprenorphine the way you 

are supposed to on a regular basis, you are not feeling high from 

it. Patients feel normal. They look normal. I have had patients who 

are physicians who I would allow them to operate on me while they 

were on buprenorphine treatment. People can function very well. 

Most patients who are treated with buprenorphine do well. More 

than half of patients have good outcomes. Some younger patients 

with more severe opioid addiction, when you try and treat them 

with buprenorphine, in the first year or so they do not do that 

great. They come on and off. Sometimes they will trade it. But it 

is the first-line treatment, and people who stick with it have good 

outcomes, and it is more effective than the Vivitrol monthly injection. 
41 

Chairman JOHNSON. So successful treatment with Suboxone, how 

long does that take? Months? Years? 

Dr. KOLODNY. What I can say is that short-term use of 

buprenorphine, Suboxone, does not work well. When patients come 

off, they are at very high risk of relapse. So we are talking about 

a longer-term treatment. Some patients, maybe it means for the 

rest of their lives. I would hope not. I think there are people who 

can come off, and maybe we will come up with other treatments for 

opioid addiction so that there are better options available. 

Chairman JOHNSON. How often do they take that? 

Dr. KOLODNY. It is taken every day. Some patients will take it 

in the—— 

Chairman JOHNSON. So just once a day. 

Dr. KOLODNY. Yes, once a day or twice a day. 

Chairman JOHNSON. So we would probably have to make sure 

that we test to make sure they take—— 

Dr. KOLODNY. Yes, you want to make sure you test so that it is 

in their urine so that you know they are not trading it or selling 

it. 

Chairman JOHNSON. Dr. Hyman, do you have anything to add 

about treatment? 

Dr. HYMAN. I agree with everything Dr. Kolodny said, although 

you should count the people who drop out as failures unless they 

re-enroll. 

Dr. KOLODNY. No. I agree. 

Dr. HYMAN. And the second point I would make—and this is sort 

of the incidental consequence of once you start testing people, you 

have suddenly created a Gold Rush for urine testing. So there is 

a huge amount of money that is spent on urine testing as part of 

the treatment. 

Chairman JOHNSON. Buy the stock, huh? Well, again, those are 

my questions, so I will just go starting from my left to right: is 

there one overall suggestion you would have in terms of a change 

in law or something we should do as a Nation to try and solve this 

problem? Mr. Adolphsen. 

Mr. ADOLPHSEN. Thanks, Senator. I think incumbent on us first 

is just to recognize that Medicaid has a large role as a funder of 

opioids, and so we need to recognize that and understand that we 

have to do something about it, admit we are part of the problem, 

so to speak, in the Medicaid program. Slow down the Medicaid 

rush. It is increasing the supply. There is no question about it. 

Even if you go back before expansion, Medicaid enrollment doubled 

from 2000 to 2013. So that is an issue, so I think we need to slow 

that down. 

I would target benefits. I think if somebody is in need of substance abuse treatment, they are low-income, everybody in this 

room, everybody around us wants that person to have the substance abuse treatment. But it does not necessarily have to come 

with all the other potential side effects of having that Medicaid 

card and the free access it provides to other things like opioids. 

Chairman JOHNSON. So put some kind of controls around the 

benefit. Mr. Schalk? 

Mr. SCHALK. Thank you, Senator. From a very broad perspective, 

we need to obviously diminish the gap between the impoverished 
42 

and the middle class. We do that, in my opinion, by creating jobs, 

incentivizing businesses to grow. When we have people that are 

going to work in the morning, their likelihood of walking through 

the courthouse doors as a defendant reduces drastically, especially 

when we are talking about drug abuse. 

From a more narrow perspective, as we have echoed here today, 

I believe that regulating the prescriptions that are being written by 

our medical community would go a long way in curbing the issues 

that we are seeing and discussing today. Thank you. 

Chairman JOHNSON. Mr. Tyndall. 

Mr. TYNDALL. I am going to brag on Tennessee just a little bit, 

Mr. Chairman. Our Controlled Substance Monitoring Database requires every drug, every narcotic that is dispensed, it has to be entered into our Controlled Substance Monitoring Database no later 

than the following business day. So if that is true—and it also requires our physicians to check that CSMD prior to prescribing a 

narcotic. So if that is true, the doctor should see that this person 

has already received that narcotic within 24 or 48 hours and they 

should not, I would hope, be prescribing the same or similar medication for that patient. 

Chairman JOHNSON. Do you know relative to other States, are 

you that much further advanced in terms of that type of monitoring? Is it comparable? 

Mr. TYNDALL. I am not sure, but I think we are much more progressive and aggressive in monitoring and trying to identify people 

who are committing TennCare fraud, Mr. Chairman. 

Chairman JOHNSON. OK. Dr. Hyman? 

Dr. HYMAN. I would change the incentives for physicians to prescribe opioids to Medicare and Medicaid beneficiaries as profligately as they do. 

Chairman JOHNSON. OK. You have to describe that more specifically. What are the incentives right now? And what is the difference between the incentives as they prescribe in Medicaid and 

Medicare versus private insurance? 

Dr. HYMAN. So the incentives for—as I said, Medicare and Medicaid are both sort of passive payers of bills, and so nobody is going 

to look too closely at your prescribing practices unless, many years 

later somebody happens to be paying attention. So, when you couple that with the reality that the way you bring a clinical encounter to a close is by filling out a prescription and handing it to the 

patient, what you want is a system that does not pay providers to 

continue that way of doing things, right? So you could use either 

carrots or sticks to do so, and I would be happy to talk about how 

you would design that. 

Chairman JOHNSON. So it kind of goes back to how you have to 

target the benefits, you have to control them. You have to just 

make it more difficult for doctors to write prescriptions for Medicaid and Medicare versus private insurance. There are more controls in private insurance, is what you are telling me? 

Dr. HYMAN. Because of the limited networks and the sort of forprofit nature of the insurer, there is going to be a tighter feedback 

loop in the private sector than you will see in the public programs. 

Chairman JOHNSON. OK. Dr. Kolodny? 
43 

Dr. KOLODNY. Yes, so to bring our opioid addiction epidemic 

under control and ultimately to an end, First off, you have to frame 

it the right way, and if you understand that it is an addiction epidemic, an epidemic of people with the disease of opioid addiction, 

what we need to do about it is very similar to what you would do 

for any disease outbreak, any disease epidemic. It is similar to 

what you would do for an Ebola outbreak, a measles outbreak, an 

HIV epidemic. What we have to do really are two things: We have 

to prevent more people from becoming opioid addicted. We have to 

see that the people who are opioid addicted have access to effective 

treatment. 

To prevent more people from becoming opioid addicted, more 

than anything else, what you are hearing today and what we know 

is that we are going to need much more cautious prescribing. Even 

though prescribing is trending in the right direction, we are still 

massively overprescribing. Until prescribing becomes more cautious, we are going to keep creating new cases of addiction. 

For the millions that are addicted, they really need access to effective treatment. And when I say ‘‘effective treatment,’’ I am not 

really talking about detox or rehab, which does not work well for 

most people who are opioid addicted. I am talking about long-term 

outpatient treatment. And as you have pointed out, Medicaid is not 

a silver bullet. I believe to really have the right system available 

where someone in every county in the United States can walk into 

a treatment center and be treated that same day, regardless of 

their ability to pay for that treatment, to really get there I think 

requires an investment in the billions, I would estimate $6 billion 

a year to start to build out these systems, and a commitment from 

Congress for 10 years of about $60 billion to get where we need to 

be. And when you consider what this problem is costing us, both 

the human cost and the economic cost, I think that investment is 

very worthwhile. 

Chairman JOHNSON. It will be interesting to see how much we 

actually spend on opioids and how much money we might save by 

spending on Suboxone or something like that. 

Again, thank you all. I enjoyed the hearing. I learned an awful 

lot, and that is because you folks did a great job. So I appreciate 

your time, your testimony, and your answers to our questions. 

The hearing record will remain open for 15 days until February 

1 at 5 p.m. for the submission of statements and questions for the 

record. This hearing is adjourned. 

[Whereupon, at 12:17 p.m., the Committee was adjourned.] 

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Æ