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S. HRG. 110–750 

GENERATION RX: THE ABUSE OF PRESCRIPTION 

AND OVER-THE-COUNTER DRUGS 

HEARING 

BEFORE THE

SUBCOMMITTEE ON THE CONSTITUTION 

OF THE

COMMITTEE ON THE JUDICIARY 

UNITED STATES SENATE 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

MARCH 12, 2008 

Serial No. J–110–80 

Printed for the use of the Committee on the Judiciary 

( 

(II) 

COMMITTEE ON THE JUDICIARY 

PATRICK J. LEAHY, Vermont, Chairman 

EDWARD M. KENNEDY, Massachusetts 

JOSEPH R. BIDEN, JR., Delaware 

HERB KOHL, Wisconsin 

DIANNE FEINSTEIN, California 

RUSSELL D. FEINGOLD, Wisconsin 

CHARLES E. SCHUMER, New York 

RICHARD J. DURBIN, Illinois 

BENJAMIN L. CARDIN, Maryland 

SHELDON WHITEHOUSE, Rhode Island 

ARLEN SPECTER, Pennsylvania 

ORRIN G. HATCH, Utah 

CHARLES E. GRASSLEY, Iowa 

JON KYL, Arizona 

JEFF SESSIONS, Alabama 

LINDSEY O. GRAHAM, South Carolina 

JOHN CORNYN, Texas 

SAM BROWNBACK, Kansas 

TOM COBURN, Oklahoma 

BRUCE A. COHEN, Chief Counsel and Staff Director 

STEPHANIE A. MIDDLETON, Republican Staff Director 

NICHOLAS A. ROSSI, Republican Chief Counsel 

SUBCOMMITTEE ON THE CONSTITUTION

RUSSELL D. FEINGOLD, Wisconsin, Chairman 

EDWARD M. KENNEDY, Massachusetts 

DIANNE FEINSTEIN, California 

RICHARD J. DURBIN, Illinois 

BENJAMIN L. CARDIN, Maryland 

SAM BROWNBACK, Kansas 

ARLEN SPECTER, Pennsylvania 

LINDSEY O. GRAHAM, South Carolina 

JOHN CORNYN, Texas 

ROBERT F. SCHIFF, Chief Counsel 

AJIT PAI, Republican Chief Counsel 

(III) 

C O N T E N T S 

STATEMENTS OF COMMITTEE MEMBERS 

Page 

Biden, Hon. Joseph H., Jr., a U.S. Senator from the State of Delaware ............ 1 

prepared statement .......................................................................................... 44 

Feinstein, Hon. Dianne, a U.S. Senator from the State of California, prepared 

statement .............................................................................................................. 74 

Grassley, Hon. Charles E., a U.S. Senator from the State of Iowa ..................... 1 

prepared statement .......................................................................................... 79 

Leahy, Hon. Patrick J., a U.S. Senator from the State of Vermont, prepared 

statement .............................................................................................................. 88 

WITNESSES 

Clark, Derek, Director, Clinton Substance Abuse Council, Clinton, Iowa .......... 21 

Fetko, Misty, R.N., Patent of Carl Hennon, New Albany, Ohio .......................... 23 

Pasierb, Steve, President and CEO, Patnership for a Drug-Free American, 

New York, New York ........................................................................................... 19 

Paulozzi, Len, M.D., Medical Epidemiologist, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Department of Health and human Services, Atlanta, Georgia .................................... 4 

Volkow, Nora, M.D., Director, National Institute on Drug Abuse, Department 

of Health and Human Services, Washington, D.C. ........................................... 2 

QUESTIONS AND ANSWERS 

Responses of Derek Clark to questions submitted by Senator Biden ................. 31 

Responses of Misty Fetko to questions submitted by Senators Grassley and 

Biden ..................................................................................................................... 34 

Responses of Steve Pasierb to questions submitted by Senators Biden and 

Grassley ................................................................................................................ 37 

Responses of Len Paulozzi to questions submitted by Senators Grassley and 

Biden ..................................................................................................................... 41 

SUBMISSIONS FOR THE RECORD 

Clark, Derek, Director, Clinton Substance Abuse Council, Clinton, Iowa, 

statement and attachment .................................................................................. 47 

Consumer Healthcare Products Association (CHPA), Washington, D.C., statement ...................................................................................................................... 60 

DeLuca, Alexander, Senior Consultant, Pain Relief Newtwork, New York, 

New York, statement ........................................................................................... 66 

Fetko, Misty, R.N., Patent of Carl Hennon, New Albany, Ohio, statement ....... 76 

National Association of Chain Drug Stores (NACDS), Alexandria, Virginia, 

statement .............................................................................................................. 90 

Parsons, Charles, Executive Director, D.A.R.E. America, Los Angeles, California, statement .................................................................................................. 99 

Pasierb, Steve, President and CEO, Patnership for a Drug-Free American, 

New York, New York, statement ........................................................................ 104 

Paulozzi, Len, M.D., Medical Epidemiologist, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Department of Health and Human Services, Atlanta, Georgia, statement and 

attachment ............................................................................................................ 112 

Reynolds, Siobhan, Pain Relief Network, President and Founder, Santa FE, 

New Mexico, statement ....................................................................................... 140 

Page

IV 

Volkow, Nora, M.D., Director, National Institute on Drug Abuse, Department 

of Health and Human Services, Washington, D.C., statement ........................ 131 

Zuppardi, Melissa, President of Helping America Reduce Methadone Deaths 

(HARMD), Branford, Connecticut, statement .................................................... 142 

(1) 

GENERATION RX: THE ABUSE OF PRESCRIPTION AND OVER-THE-COUNTER DRUGS 

WEDNESDAY, MARCH 12, 2008 

U.S. SENATE, SUBCOMMITTEE ON CRIME AND DRUGS, COMMITTEE ON THE JUDICIARY, Washington, DC 

The Committee met, pursuant to notice, at 2:10 p.m., in room 

SD–106, Dirksen Senate Office Building, Hon. Joseph R. Biden, 

Chairman of the Subcommittee, presiding. 

Present: Senator Grassley. 

OPENING STATEMENT OF HON. JOSEPH R. BIDEN, A U.S. 

SENATOR FROM THE STATE OF DELAWARE 

Chairman BIDEN. The hearing will come to order. 

I have an opening statement. My colleague and co-chair here can 

only stay about a half an hour because he has a whole lot of folks 

he has to be meeting with shortly, so I am going to put my opening 

statement in the record in order to save some time. 

Just let me say, though, that I really appreciate all the witnesses 

being here today. This is the Judiciary Subcommittee on Crime and 

Drugs, and the Senate Drug Caucus. We hopefully are going to be 

able to shed some much-needed light on what seems to be a trend 

that has crept into households and communities across the country, 

and that is abuse of prescription drugs and some over-the-counter 

drugs. 

But with that, as I said, I will put my opening statement in the 

record and I will yield to my colleague, if he has any opening statement to make. 

[The prepared statement of Senator Biden appears as a submission for the record.] 

STATEMENT OF HON. CHUCK GRASSLEY, A U.S. SENATOR 

FROM THE STATE OF IOWA 

Senator GRASSLEY. Yes. I have got a long one, so I should put 

it in the record, too. But I would like to summarize a little bit. 

Over here on the right is one of our witnesses, Derek Clark, from 

Clinton, Iowa. 

Chairman BIDEN. I know Clinton. I know Clinton. 

Senator GRASSLEY. Yes. You have been in every county in Iowa. 

Chairman BIDEN. That is true. It did not do a hell of a lot of 

good, but I was there. 

[Laughter.] 

A lot of nice people you have out there. 

2 

Senator GRASSLEY. Now, our witness has served as executive director of the Clinton Substance Abuse Council for the last 10 years. 

As executive director, Mr. Clark works with a wide variety of community members to develop solutions to substance abuse problems 

in and around Clinton, Iowa. So, we thank you for being here. 

In just a way of summarizing, because it is a long statement I 

am going to put in the record, we do have some recent statistics 

of a downturn in the use of illegal drugs. But for the purposes of 

this hearing, we are finding that there is not this downturn, in 

fact, a quick awakening that needs to be done about the use and 

abuse of prescription drugs and over-the-counter drugs. 

So to bring attention to this and to bring attention to a piece of 

legislation that you and I have put in on DXM that we sponsored 

last year, it is very important to have this hearing. But I think one 

of the most important things that can come out of this hearing is 

to alert parents who are very concerned about their young people’s 

use of illegal drugs, that right there in the medicine cabinet could 

be a source of abuse and a major problem, and things that are 

harmful to health that we hope this hearing will bring attention to. 

Thank you. 

[The prepared statement of Senator Grassley appears as a submission for the record.] 

Chairman BIDEN. Thank you very much. As I said, we have a 

very distinguished panel, our first panel. It has not been, as they 

say, a long time between drinks before we had—Doctor, it’s a delight to have you back. Thank you for being here. Is Paulozzi the 

correct pronunciation? 

Dr. PAULOZZI. Paulozzi. 

Chairman BIDEN. Paulozzi. I beg your pardon. Dr. Paulozzi is 

here as well. He is a medical epidemiologist in the Division of Unintentional Injury Prevention at the National Center for Injury 

Prevention and in control of the CDC. He has been working in public health since 1983 and he’s worked 8 years in the State health 

departments as an epidemiologist, focusing on injuries and chronic 

diseases. He returned to the CDC in 1993, and joined its Injury 

Center in 2000. He currently spends most of his time on unintentional poisoning, particularly that involving prescription drugs, as 

I understand it. 

Doctor, I am going to submit again for the record your background. It’s impressive. Again, thank you for coming back. I appreciate it very, very much. It’s an honor to have you here. 

With that, why don’t I begin by yielding the floor and going to 

you, Doctor, first, if you will. 

STATEMENT OF NORA VOLKOW, M.D., DIRECTOR, NATIONAL 

INSTITUTE ON DRUG ABUSE, U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES, WASHINGTON, DC 

Dr. VOLKOW. Yes. Good afternoon. The privilege is mine to be 

here. 

In 2006, it is estimated that 7 million individuals abused prescription medications for non-medical use in the United States. 

Seven million. Last year, actually, the number of new initiates for 

the abuse of prescription pain relievers was greater than the number of new initiates for marijuana. As you mentioned, this is in the 

3 

context of decreases in illicit substance abuse that has occurred in 

the United States over the past 5 years. 

What are the five prescription medications that are abused? 

There are three types: stimulant medications such as Ritalin, and 

Concerta, and Adderall that are used for the treatment of attention 

deficit disorder; pain analgesics that contain opiates that are used 

for the treatment of severe to moderate pain, like Oxycontin and 

Hydrocodone; and sedative hypnotics, which are medications such 

as benzodiazepine, Xanax, Valium, that are used for the treatment 

of sleep disorders and anxiety disorders. 

Why are these drugs or medications specifically abused? They 

are abused because they increase in the brain the concentration of 

a chemical, dopamine, in reward centers, and these are exactly the 

mechanisms by which drugs of abuse produce their rewarding effects and lead to addiction. 

There are two factors that determine whether a drug will be rewarding vis-a-vis just being therapeutic. One of them is the doses 

used. When it is abused, it actually requires much higher doses 

than when it is used therapeutically, and much more frequently. 

The other one is the route of administration. When it is abused, it 

is usually snorted or injected, and that is because this leads to faster concentrations in the brain, and the faster the drug gets into the 

brain, the greater its rewarding effects. 

Now, what are the medical complications? Just as for illicit substances, just as for them, drug addiction. Now, in addition to that 

there are a series of medical complications that are specific for each 

class of drugs. The most problematic vis-a-vis the morbidity and 

mortality relates to opiate analgesics, such as Oxycontin and 

Hydrocodone because opiates decrease, depress the respiratory centers in the brain and can therefore lead to stopped breathing and 

death. 

The same is true for sedative hypnotics such as benzodiazepines, 

except that the therapeutic window between the dose that you give 

for medical purposes and that that will kill you is not as close and 

dangerous as it is for opiates. 

In the case of stimulants, the risks actually involve seizures, they 

involve hyperthermia, and they involve cardiac arrhythmias and 

myocardial infarctions and stroke that can also kill you. These 

drugs can also produce changes in alertness and motor coordination 

that contribute to accidents. The risk of complications is significantly increased when these medications are consumed with other 

medications, with alcohol, or with illicit substances. 

Everyone is at risk for abusing or becoming dependent on prescription medications. It does not matter your gender, it does not 

matter your age, it does not matter your socioeconomic classes. 

Particularly problematic, though, are adolescents, because in adolescents the brain is still developing and these medications may actually interfere with this developmental process. 

A question we ask—is: why are we seeing these dramatic increases now? There are multiple factors, but one of the most important has to do with significant dramatic increases in prescriptions 

for these medications, which lead of course to drug availability. 

How big are these increases? Looking at the numbers, they speak 

for themselves: sevenfold increases in the number of prescriptions 

4 

over the past 16 years for stimulants. Seven-fold. They have gone 

from 4.5 million to 33 million. Opiate analgesics, fourfold increases, 

from more than 40 million to almost 180 million prescriptions per 

year. Think about it: 180 million prescriptions for opiate analgesics 

per year in the United States. 

There are other factors that are likely to contribute, as society 

is increasingly willing to accept medications for the treatment of almost any condition: pervasive advertisement, and very important, 

the sense that because these medications are prescribed by physicians, they are much safer than that of illicit substances, which of 

course is an incorrect statement. 

Now, what is it that science is doing and what is it that NIDA 

is supporting? We are aware that there are two trajectories, one 

that is initiating the abuse with a legitimate prescription that, in 

individuals that are vulnerable, can lead to abuse. The other one 

that is initiating as drug experimentation. Both of them can lead 

to drug addiction. 

So we are developing research that entails both an understanding about the genetic factors that lead to this vulnerability, 

the neurobiological consequences, how do these drugs affect the 

brain and the body, and epidemiological factors, the pattern of 

their abuse. We are also helping to support the development of 

medications that can serve as powerful analgesics or as stimulant 

medications that do not have abuse liability, as well as new delivery systems that minimize the risk of addiction and dependence. 

We are also very aware that these medications, when used properly, can be life-saving. The importance of educating the community, both the medical and the lay public, as well as developing 

standards and evaluating so that we can maximize the therapeutic 

benefits of these medications and minimize their abuse is critical. 

The problem of prescription drug abuse is an urgent one that requires urgent action. I applaud you for your interest in this subject, 

and I would be happy to answer any questions you may have. 

Chairman BIDEN. Thank you. 

Doctor? 

STATEMENT OF LEN PAULOZZI, M.D., MEDICAL EPIDEMIOLOGIST, NATIONAL CENTER FOR INJURY PREVENTION AND 

CONTROL, CENTERS FOR DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 

ATLANTA, GEORGIA 

Dr. PAULOZZI. Good afternoon, Chairman Biden and Senator 

Grassley. My name is Dr. Leonard Paulozzi and I’m a medical epidemiologist with the CDC, which is part of HHS. Thanks for the 

opportunity to appear before you on behalf of CDC to discuss our 

Agency’s research and prevention activities addressing drug overdose deaths. Thanks also for your continued support of CDC as we 

work toward becoming the healthiest Nation. 

I will be talking about unintentional overdose deaths today. Drug 

suicides are not included in the data I’m going to show you. The 

information I share with you will be based primarily on death certificates. I have a set of slides, and I will walk you through them. 

They are numbered in the bottom right-hand corner. 

5 

Slide two. This slide shows the trend in the drug overdose 

deaths, or mortality, in the United States from 1970 through 2005. 

As you can see from this, there has been a steady increase in the 

drug overdose mortality rate. There were increases for epidemics of 

heroin in the mid-1970s and the crack cocaine problems in the late 

1980s and early 1990s. Currently, we are in the midst of what we 

are calling a prescription drug overdose epidemic. Rates now are 

twice the rates obtained during the crack cocaine era, and four to 

five times the rates in the mid-1970s. 

Chairman BIDEN. And we are talking, Doctor, about overdose 

deaths? 

Dr. PAULOZZI. We are talking about drug overdose deaths, exactly. 

Chairman BIDEN. And the chart shows, in the upper righthand 

corner, from 2002 to 2004, prescription drug. That is cumulative, 

right? In other words, are we talking about the same chart? 

Dr. PAULOZZI. Yes, we are. Yes. 

Chairman BIDEN. OK. The prescription drugs. These aren’t totally a consequence of prescription drugs. 

Dr. PAULOZZI. No. 

Chairman BIDEN. This is when prescription drugs became more 

of a problem. 

Dr. PAULOZZI. Right. They are accounting for the increases I will 

show you in just a moment. 

Chairman BIDEN. Got you. Thank you. 

Dr. PAULOZZI. The rate in 2005, which is the last bar in the figure, translates into 22,400 deaths in the United States. To put this 

into context, there were 17,000 homicides that year. Drug overdose 

deaths are second only to motor vehicle crashes. 

Chairman BIDEN. Excuse me again, Doctor. 

Dr. PAULOZZI. Sure. 

Chairman BIDEN. This is not prescribed. This is a combination. 

We’re both asking each other the same question. 

Senator GRASSLEY. About the 22,000 deaths. 

Chairman BIDEN. Twenty-two thousand deaths. 

Dr. PAULOZZI. Yes. 

Chairman BIDEN. They are overdose deaths. But are they overdose deaths that include people who were prescribed the medicine 

and abused it as well as people who were not prescribed the ‘‘legal’’ 

drug, but acquired it and used it, correct? 

Dr. PAULOZZI. Yes. Just to be clear, this is total drug overdose 

deaths, drugs of all types, whether prescribed or not. 

Chairman BIDEN. Got you. 

Dr. PAULOZZI. And in subsequent slides, I will break it down for 

you— 

Chairman BIDEN. OK. Thank you. 

Dr. PAULOZZI.—as to what proportions were accounted for by prescriptions. 

Chairman BIDEN. That’s good. 

Dr. PAULOZZI. So drug overdose deaths are second only to motor 

vehicles as a cause of unintentional injury death. Recently, for the 

45- to 54-year-old age group in the United States, they became the 

leading cause of unintentional injury death, passing motor vehicle 

6 

crashes for the first time in as long as we have been tracking these 

statistics. 

So how do we know that this is prescription drugs? Slide three. 

This shows you the trend in drug overdose rates from 1999 through 

2005. We have broken down the earlier figure we were just talking 

about into the three major components. The red line is ‘‘Deaths 

Due to Narcotics’’, which includes the narcotic painkillers, cocaine, 

and heroin. The yellow line is called ‘‘Other, Specified and Other 

Drugs’’, and then the white line is ‘‘Sedatives and Psychotherapeutic’’. 

You might think from looking at this that the increase in recent 

years has been because of narcotics, which we think of as cocaine 

and heroin. But in fact that is not the case. If you go to the next 

slide, number 4, this slide also looks at 1999 through 2004 data. 

It comes from a study we published in 2006, where we drilled down 

a little bit further into this narcotics category and were able to 

break it down into three main constituents. Those are prescription 

opioids, which is the line in red, cocaine and heroin. 

What this slide shows, is that the increase from 1999 is being 

driven by prescription opioids, which is the prescription painkillers. 

That includes Oxycontin, Vicodin, it also includes methadone, 

which is increasingly being used as a narcotic painkiller. Most of 

the increases, only some of it is due to cocaine, and very little is 

due to heroin-related deaths. 

For the most recent year of data we broke it down even more 

finely, and this is slide five. This shows you the specific drugs that 

are involved, the first listed drug codes among the drug overdose 

deaths in the latest year we have available, 2005. The red bars represent the prescription painkillers. They accounted for 38 percent 

of these drug overdose deaths. 

As you can see, a substantial fraction had methadone listed as 

the first listed painkiller. The white bar is psychotherapeutic 

drugs, like Valium and antidepressants. Together, they account for 

45 percent of these drug deaths. Street drugs—cocaine, heroin, 

methamphetamines—accounted for 39 percent. The other specified 

drugs are mostly prescription drugs as well. So you can see that 

we have moved from an era of illicit drugs to an era where prescription drugs dominate the picture, and they are accounting for 

the increases you see in the first figure. 

With this shift in the type of drugs, we are also seeing a shift 

in the demographics, the people who are dying. It is still men who 

primarily die of drug overdose deaths, as it always has been, but 

now it is people in their 40s and early 50s who have the highest 

rates of drug overdose death in the United States. Rates in whites 

recently passed drug overdose rates in African Americans. It is no 

longer an urban phenomenon, which is what we tend to associate 

with drug overdose deaths. 

If you look at a map of the United States, which is the sixth 

slide, you can see that the States with the highest rates, shown in 

the darkest color, are some of our more rural States. West Virginia, 

for example, has the highest rate. The State of Maine has a high 

rate. So the problem has shifted from an urban to a rural focus. 

Slide seven. What’s causing these deaths? These are not the accidental poisoning deaths of children and these are not elderly people 

7 

mistakenly taking too much medication. These deaths are related 

to the increasing use of certain prescription drugs, particularly the 

painkillers, by people in the middle years of life. In most of these 

deaths, there is evidence that they were related to the misuse or 

abuse of prescription drugs. 

Slide eight shows the same trend. It marks on that a red line 

showing sales of painkillers, indicating since painkiller sales seem 

to be tracking with—we expect an increase in 2006 in the mortality 

rates. Indeed, data from the Drug Abuse Warning Network’s Emergency Department Surveillance System shows an increase in the 

number of emergency department visits associated with opioid 

painkillers in all the years since 2005 through 2007. 

Slide nine. What can we do about this? We need to get the most 

out of State prescription drug monitoring programs to identify doctors and patients who are abusing the system. We need to modify 

patients’ behavior with insurance mechanisms. Hospitals might require screening for substance abuse in their emergency departments before opioids are prescribed. Primary care doctors need 

practice guidelines for when to prescribe and when to take people 

off the drugs. The drug manufacturers can make the prescription 

drugs more tamper-resistant so people do not crush them, dissolve 

them, and inject them. 

Prescription overdoses are a serious public health problem, and 

the CDC will continue to respond with surveillance and epidemiologic studies and evaluation of interventions. 

I would like to thank you for the opportunity to talk about this 

problem, and I appreciate your continued support of the CDC Injury Center. I would be happy to answer any questions. 

[The prepared statement of Dr. Paulozzi appears as a submission 

for the record.] 

Chairman BIDEN. Thank you. You both represent two of the 

greatest assets this country has, NIH and CDC. 

I have a lot of questions, which is very convenient that I am the 

only one here, so I get to ask them. 

[Laughter.] 

My staff is going to be upset because I am not using their questions. 

Folks, let me ask, the NIH is looking at—Doctor, you indicated, 

looking at genetic factors. Going to be looking at, or have begun. 

I was not quite sure I understood your statement. Talk to me a little bit about that. Tell me what you are doing different at NIH recently relative to looking at genetic factors relating to drug abuse. 

Dr. VOLKOW. For many years now, at NIDA we have been studying the genetic factors that makes individuals more vulnerable to 

experimenting with drugs, and when they experiment with drugs, 

as we know, not everybody becomes addicted. So what are the genetic factors that lead to people becoming addicted and those that 

do not? We know that approximately 50 percent of drug vulnerability to the risk of addiction is genetically determined. 

What we are doing now vis-a-vis this new problem of addiction 

to prescription medications, it becomes increasingly urgent to try 

to understand what those vulnerabilities may be, because, for example, for me as a physician, having a patient that may require 

a strong medication against pain, it will be incredibly important to 

8 

know their risk. Why? Because if they do have the genetics and 

vulnerability for addiction, the way that I will prescribe may be affected by it. Thus, from the medical perspective that becomes a 

very urgent need. 

Genetics is also important because, as you identify what genes 

are involved in vulnerability, what we are finding, for example, is 

we are uncovering genes that we have never paid attention to, so 

new molecules that can now be looked into as potential treatments, 

or even prevention strategies for addiction. That is why this area 

of research is so important. 

Chairman BIDEN. One of the areas that I have had the greatest 

interest in for over 30 years, is this area, all the way back to dealing with trying to find—I introduced years and years ago legislation calling for the expenditure of a billion dollars a year, and then 

I went to a billion dollar program to find antigens or antagonists 

for certain drugs. 

The drug companies do not want to become the drug company. 

Drug companies do not want to do this investigation. I understand 

why. Even if they find ‘‘a cure’’ for cocaine addiction, folks who are 

addicted ain’t looking to buy it, don’t have the money to buy it. The 

universe is not that big, they’re not going to make that much on 

it. So we came up with the Orphan Drug Act a long time ago to 

try to promote that. 

One of the things I find startling is the number of doctors who 

do not ask before they prescribe painkillers, even whether or not 

someone is a recovering alcoholic or a recovering drug abuser, 

someone in recovery. Well, they are always in recovery. But let me 

ask you a crazy question. Do they teach that in medical school? I 

mean, I am not being a wise guy, now. I am being deadly earnest. 

I am not being a wise guy and I’m not out looking to pick on the 

medical profession, or anyone else. 

But it astounds me, the number of times—having an uncle who 

is an alcoholic, and a brother who is a recovering alcoholic, the 

number of times that, you know, they have other physical ailments. 

In other words, in one case, broken bones. The prescription is just 

automatic. No one asked any questions. Is that part of the protocol 

that more doctors are learning about or is that even worth the effort? 

Dr. VOLKOW. The answer is, of course it’s worth the effort. I am 

very sensitive to that same issue, and I’m sensitive because I’ve encountered multiple cases where patients have relapsed, that had a 

problem with drug abuse, because they were given a pain opiate 

and the doctor never asked the question. 

I also smile because it has been also very frustrating for me to 

be aware that in the medical system there is very little education 

regarding substance abuse. As a result of that, medical students 

are not taught how to screen and evaluate it. That is a lost opportunity, because by doing an intervention at that point where patients go to seek help, you can have a much greater impact. 

With respect to opiate medications, while we do not have the genetics about what makes you vulnerable, we know that individuals 

that have a past history of drug abuse or dependence in themselves 

or their family members are likely to be at greater risk. I just add 

that that’s not just for illicit substances, it is alcohol, it is nicotine. 

9 

If you have a past history of nicotine dependence, you are very likely to have a higher risk of becoming dependent. Physicians are not 

asking. 

So we put an initiative—that was what I was mentioning, the 

issue of education, to really develop educational guidelines for medical students and specialties to be able to recognize and do interventions in the case of substance abuse. 

Chairman BIDEN. Doctor, do you have any response? 

Dr. PAULOZZI. Yes. I think that most physicians today have gotten some training. But for most, it’s focused on the illicit drugs. 

The widespread use of powerful narcotic painkillers is a relatively 

recent phenomenon in the United States. It is really just since 

1990 and 1992 that these drugs have come into favor. 

Chairman BIDEN. Why? 

Dr. PAULOZZI. Well, there was around the time a sense that pain 

is being under treated in the United States, that people who suffer 

from serious diseases like cancer were not being given narcotics for 

fear of addiction. A lot of that was definitely the case. There were 

some studies that suggested the risk was low for use of opioids. 

The drugs are safe and effective, when used as directed. But the 

key is in that phrase ‘‘as directed’’. 

What’s happened, is physicians today do not have a great deal 

of experience, and certainly not training in medical school, for the 

management of long-term opioid therapy. There are guidelines out 

there, but we don’t think they’re being routinely followed. 

Chairman BIDEN. What I find kind of astounding, is I can understand the increase because some of these drugs are relatively new 

to the market in the last decade, decade and a half. As you said, 

used as prescribed, they’re of great benefit to people. But I didn’t 

realize that there were, respectively, seven and four times—in the 

case of opiates, it as seven times. Is that correct? 

Dr. VOLKOW. Four times. 

Chairman BIDEN. Four times. In the case of stimulants? 

Dr. VOLKOW. Seven times. 

Chairman BIDEN. Seven times the number of prescriptions written. Now, I mean, that surely does not correspond to population increases. I should not say ‘‘surely’’. It doesn’t appear to me to relate 

to that many new and more effective, efficacious stimulants and/or 

opiates that are prescribable now. So has there been any study 

done to suggest that? 

We’re going to hear from a witness on a second panel who’s done 

a lot of good work in the prevention area, and indicated that abuse 

of prescription drugs tends to be for reasons—as I remember reading the testimony last night on my way home on the train—that 

had to do with pressure from grades, classes, studying for a test, 

coming down after a stressful day as opposed to what I would have 

thought back in the old days when I was doing most of this work, 

was just to literally feel the effect, the ‘‘abuse’’ factor just because 

it felt good, dopamine was produced in the case of opiates. 

So are there any studies out there indicating why this incredibly 

exponential increase in the number of prescriptions written? 

Dr. VOLKOW. Well, certainly, epidemiologists have to look at this 

to understand why there are increases. You are pointing out, there 

are multiple factors. That’s going to be dependent also on the age 

10 

of individuals. Among college students, for example, there have 

been studies that actually determine exactly that, that the reason 

why they are abusing—and this relates to stimulant medications— 

is in order to improve their cognitive performance. 

Just today I got an e-mail from a professor at Stony Brook that 

said he was approached by a student because he was concerned 

that his fellow students were taking stimulants for study, and he 

resented it because they could study more, so he wanted my advice. 

So these have been documented as one of the reasons we see an 

increase in the use of stimulant medications in college years. 

With respect to pain medications—that is why I repeated it, 180 

million prescriptions per year in the United States. How many individuals do we have in the United States? There are 3 million people that suffer from severe pain, and still it’s 180 million. I think 

it reflects a greater propensity to give opiate medications by the 

medical community. 

Again, I do respect the tremendous value of opiate medications, 

but I do believe at the same time, while we are under-medicating 

patients that need it, we are also over-medicating individuals that 

we should not. For many years, we still believed in the medical 

community that if you have pain and you get an opiate medication, 

you are not going to become addicted, that pain protects you. The 

epidemiological data show that that’s not the case. Approximately 

5 to 7 percent of those individuals will become dependent. So there 

is, again, the lack of proper understanding about the effects of 

these medications that has led, I think, to increasing the risk of 

seeing these diversions of painkillers. 

Chairman BIDEN. I am going to repeat something you said, because I hear it all the time in the community. Not all the time. I 

hear it in the community. Consuming an opiate to deal with pain, 

if you’re really in pain, you are not going to become addicted. The 

pain somehow is the thing that keeps you from being addicted to 

the very thing you’re taking in order to reduce the pain. That is 

not physiologically correct, is it? 

Dr. VOLKOW. Well, what the epidemiological data are showing, is 

it is not. It’s protective. It’s definitely not a complete protection, because we are seeing people that have pain are becoming dependent 

through their opiate medication. Now we’re actually studying in 

animal models the extent to which we can prevent the dependence, 

or in certain instances accelerate the dependence, by pain. So it depends how severe the pain is, how you properly are scheduling the 

doses. So certainly the answer to, is pain protective so you don’t 

have to worry, the answer is no. Even with pain, you can become 

dependent to opiates. 

Chairman BIDEN. Now, methadone. We’ve gone through cycles 

over the last 75 years dealing with how we view methadone. Back 

in the late 1980s and early 1990s there was sort of a renaissance 

of the notion that in order to treat heroin—or not treat it, but as 

a substitute, basically—became, once again, viewed as a more appropriate avenue. Methadone clinics were kind of shut down, then 

they were opened up and increased. 

What is the reason for the methadone? Are there more methadone clinics? Are these people who are, in your chart, overdosing, 

including the 16 or whatever percent of those who OD’d were beVerDate Nov 24 2008 10:45 Mar 12, 2009 Jkt 047336 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 S:\GPO\HEARINGS\47336.TXT SJUD1 PsN: CMORC
11 

cause of methadone, are they people who are in methadone clinics 

who are trying to beat heroin and then abusing the methadone, or 

is this a prescription written for other reasons than dealing with 

heroin addiction? 

Dr. PAULOZZI. Well, I am glad you asked the question, because 

we do think this is methadone written for pain rather than methadone dispensed by narcotics treatment programs. 

Chairman BIDEN. Right. 

Dr. PAULOZZI. This is methadone in pill form. The clinics use 

methadone in liquid and wafer form. Various reasons tell us that 

this is probably a painkiller problem. Studies that have looked at 

the data from medical examiners have found that only a small fraction of the people dying with methadone in their system were ever 

enrolled in methadone treatment programs in their States. 

Chairman BIDEN. That’s an important thing to know, because 

urban legend spreads pretty rapidly. So if you give me that last 

statistic, of the people— 

Dr. PAULOZZI. Of the people who die and go to the medical examiner and they find methadone in their bodies— 

Chairman BIDEN. Right. 

Dr. PAULOZZI.—a small percentage—some studies, fewer than 10 

percent—have ever been enrolled in a narcotics treatment program. 

Chairman BIDEN. Got you. OK. 

Now, the other statistic—and every cycle I get back into it. There 

is always something that surprises me. What surprises me, and I’m 

going to be revealing my ignorance here, is the age of those abusing prescription drugs. I would bet you that the vast majority of my 

colleagues, and maybe the public if they were aware this hearing 

was being held, would assume—we’re going to hear witnesses on 

this issue—that we’re talking about teenagers, and sometimes preteens and teenagers, students for whom, as you pointed out, there’s 

more—it’s only exceeded by marijuana in the last year, 2007. Is 

that right? 

Dr. VOLKOW. 2006. 

Chairman BIDEN. 2006. As sort of the gateway drug, the first 

time using or abusing a substance. It is, first marijuana is Number 

one, and prescription drugs are number two. Is that correct? 

Dr. VOLKOW. Well, last year, prescriptions outdid marijuana. 

Chairman BIDEN. OK. 

Dr. VOLKOW. prescription pain relievers outdid marijuana. 

Chairman BIDEN. All right. Thank you. 

Now, again, when we use those kinds of statistics, which are accurate, it leads people to again focus on young people. But one of 

you gave a statistic that is either the bulk of the overdose deaths, 

that people between the ages of 25 and 40, is that what you said? 

Dr. PAULOZZI. Well, no. I think I said that the highest drug overdose mortality rates are with people are in their 40s. 

Chairman BIDEN. Yes. 

Dr. PAULOZZI. The rates basically rise up to 45 and then come 

back down again. It is really the baby boomer generation in their 

40s and early 50s that have the highest death rates. That doesn’t 

necessarily mean that the abuse rates follow that same pattern. 

Chairman BIDEN. That’s what I wanted to clarify. 

12 

Dr. PAULOZZI. Yes. For some reason, the deaths are more concentrated in the middle age group. Maybe they use different drugs, 

maybe they inject them more, maybe they use heavier doses. But 

I think surveys from SAMHSA have indicated that people in their 

20s may be more likely to report having used a drug recreationally 

in the previous month. 

Chairman BIDEN. Got you. 

Now, the other issue was, we talked about at the last hearing we 

had, Doctor, was the means of ingesting this to abuse it. It’s not 

just merely the abuse, it’s the manner in which you abuse. So 

snorting or injecting an opiate, a prescription drug that’s an opiate 

is, in fact, a quicker way to get a bigger bang out of whatever 

you’re seeking. 

Now, both of you said that that there are—are there any discussions, are there any actions being taken on making these drugs 

more tamper-resistant? What are some of those methods? Are there 

any manufacturers who are spending any time on this, as you 

know? 

Dr. VOLKOW. Multiple pharmaceutical companies are spending 

time on this. This is a key component. For many, many years, 

pharmaceutical companies have been working on developing both 

analgesics that do not produce independence. Working with changing the delivery system has already happened. Many medications, 

for example, in terms of stimulants, are already delivered through 

mechanisms that lead to slower uptake into the brain, for example, 

Concerta, with longer-lasting effects. Oxycontin actually started as 

a medication that, in principle, should lead to slower, more stable, 

uptake in the brain. 

The problem with it is, you can extract the substance and then 

inject it. So what the companies are now working with, are new 

polymers where you can actually mix the drug with them, and even 

if you crush it, you cannot inject it. So that’s the issue of tampering. 

Chairman BIDEN. Good. 

Dr. VOLKOW. The other approach that, for example, we’ve been 

working with for the development of medications against heroin 

and for the treatment of addiction to pain analgesics, is to mix 

these medications with an antagonist. When you take it orally, the 

antagonist will not be absorbed. But when you take the same medication and inject it, the antagonist will interfere with its effects. 

So, these are two mechanisms. 

Chairman BIDEN. Is that occurring now? I mean, are pharmaceutical companies doing that now? 

Dr. VOLKOW. Correct. Absolutely. Absolutely. It’s a major area of 

research, both on opiate medications and stimulants. 

Chairman BIDEN. Got you. 

Now, one of the statistics that gets people’s attention, because 

when we use percentages, which we have a tendency to do, there’s 

been an X percent increase, so on, and so forth. It doesn’t calculate. 

But I found the comparison that you used, Doctor, saying that 

those dying from overdose of prescribed and controlled substances 

exceeded the number of, or was second only to, last year, motor vehicle deaths and this year exceeded motor vehicle deaths? 

13 

Dr. PAULOZZI. No, no. I’m sorry. What I said was that unintentional drug poisonings are second to motor vehicle deaths. They are 

still second to motor vehicle crashes. 

Chairman BIDEN. There are roughly 22? 

Dr. PAULOZZI. There are roughly 22,400. Motor vehicles are 

roughly 43,000 per year. I made the comparison to homicide, which 

has 17,000 deaths per year. I mentioned that in the 45 to 54 age 

group. Just in that age group, there are now more overdose deaths 

than there are motor vehicle crashes. 

Chairman BIDEN. OK. That’s what you said. It was only in that 

age group. 

Dr. PAULOZZI. In that age group. 

Chairman BIDEN. OK. 

Going back to what I was sort of stumbling around trying to get 

at, is is there an explanation of why younger people using these 

drugs have a lower mortality rate from overdose than older people? 

Not older, but people in their 40s, for example. 

Dr. PAULOZZI. Well, it’s conjecture, really. It may have something 

to do with the differences in the types of drugs they use. They may 

be less likely to tamper with the drugs and inject them. It may 

have something to do with the pattern and chronicity of their use. 

It could be that people dying in their 40s are people who are longterm drug users who use much larger amounts of drugs. 

Chairman BIDEN. OK. 

And is it true—and I’d ask either one of you, if you know—that 

there is the perception—are there any data that demonstrate this? 

The perception, particularly among young people, that the abuse of 

a prescription drug is less dangerous than the abuse of a controlled 

substance, Schedule I or II substance? 

Dr. VOLKOW. Yes, indeed. There have been epidemiological papers that actually have documented specifically what you are saying, that indeed, young people overall have a sense that these are 

safer drugs, because after all they are being prescribed by physicians. 

Dr. PAULOZZI. And the potency has been established. It’s not like 

they’re dealing with an unknown, in a sense. 

Chairman BIDEN. Yes. 

Dr. PAULOZZI. There’s no risk of HIV from these drugs. It’s because most of the exposure is oral with the prescription opioids. It 

may be a variety of reasons. 

Chairman BIDEN. Now, the recent monitoring figures in the survey, the Monitoring the Future Survey, showed that 7 of the top 

11 drugs most commonly abused by high school seniors are prescription drugs or over-the-counter drugs, not illegal street drugs. 

Now, this figure strikes me as being different than it was a couple 

of decades ago. Have trends always shown that medicine abuse is 

such a large proportion of the problem among teenagers? Did we 

just start asking that question or is this a genuinely new phenomenon? 

Dr. VOLKOW. Well, we have been asking the question in Monitoring the Future about certain prescription medications now for 

many years. Dextromethorphan is a new addition, because we 

started to see increasing numbers of emergency room admissions 

mentioning dextromethorphan. So based on data from both the NaVerDate Nov 24 2008 10:45 Mar 12, 2009 Jkt 047336 PO 00000 Frm 00017 Fmt 6633 Sfmt 6633 S:\GPO\HEARINGS\47336.TXT SJUD1 PsN: CMORC
14 

tional Survey on Drug Use and Health and the Monitoring the Future Survey, there were indications of increased prescription medication abuse, particularly opiates, among youth and young adults 

beginning in the mid-1990s. 

Some of the medications are new. In the past, for example, Monitoring the Future did not differentiate among the opiate medications like Hydrocodone or Oxycontin. However, since 2002, we have 

asked about these medications separately and have seen steady but 

alarmingly high levels of abuse among high school seniors: about 

5% abusing Oxycontin and about 10% abusing Vicodin in the past 

year. Among the stimulant medications, we now also differentiate 

methylphenidate. For the past few years, abuse of stimulants and 

tranquilizers has been more or less stable. However, we did see the 

increases in the abuse of sedatives up until this past year, which 

was the first to show a decline. 

The sustained high levels of Vicodin and Oxycontin abuse among 

adolescents took us by surprise because we did not have a sense 

about how use of opiates affects adolescents, because most of the 

heroin abusers were in their 20s. So all of us in the medical community were faced with very young people abusing opiate medications, with which we had no experience. 

Chairman BIDEN. I see. There does seem, just from a layperson’s 

eyes, a correlation between the number of prescriptions written and 

the increase in these studies. I mean, if you have a seven-times increase in opiate prescriptions that are written since the mid-1990s 

to today and you see this kind of increase, there is some correlation, I guess. I mean, is it that they’re just more available in your 

parents’ medicine cabinet? 

Dr. VOLKOW. It’s both. There are two factors that determine the 

extent to which you will have abuse of a substance. Number one, 

availability, so by increasing this massive number of prescriptions. 

It’s fourfold in opiates, sevenfold in stimulants. So you increase 

prescriptions, you increase production. So in parallel, there is an 

increase in production, so there’s more drug available. 

The second one, which is very important—almost as important— 

is the sense that you have another using the drug. So if you believe 

that others are using, whether it’s true or not, they’re much more 

likely to actually experiment with that drug and use it than you 

have the sense that it’s not. So in stimulant medications, they are 

so widely prescribed among teenagers or children, that kids feel 

that it’s actually a safe thing to do. 

They get it from their friends, actually very frequently. So both 

of those two are contributing. The excess availability, the fact that 

there’s much more medication available, and the other one, the perception that people are taking it and nothing bad is happening to 

them. 

Chairman BIDEN. Now, the last question I have is, tell me if 

there is a correlation between the abuse of stimulants, for example, 

and moving on to controlled substances. In other words, one of the 

things I remember is that you find real serious drug abusers deciding they need just a higher and higher high, so they keep figuring 

out ways to concoct what they’re ingesting in order to get a bigger 

hit from what they’re doing. 

15 

Is that part of the pattern? A kid abuses a drug that his friend 

is taking for attention deficit syndrome that has been prescribed by 

his doctor. Does that kid end up staying in that realm, or is there 

a likelihood that they move into other drugs, street drugs? I mean, 

is there any correlation between prescription drug abuse and what 

people refer to as street drugs? 

Dr. VOLKOW. We know that, for the opiate analgesics, there is 

clear-cut evidence that initiation with an opiate analgesic, in many 

instances, can precede the initiation of heroin. The individual becomes dependent to it and then they shift to heroin, which is less 

expensive. 

In the case of stimulant medications, a kid abusing it, not using 

it for prescription reasons, passing to other drugs, illicit drugs, 

there, I do not know that we have sufficient data yet to actually 

determine that answer. 

Chairman BIDEN. Do you have any view on that, Doctor? 

Dr. PAULOZZI. I would agree. I don’t think we have the data. 

Chairman BIDEN. Now, what’s the difference in the treatment regime, if there is any, for addiction to pain relief medicine like 

Vicodin compared to illegal drugs like heroin? 

Dr. VOLKOW. Well, there is a significant difference. Usually what 

happens, it is usually reflected in two aspects of them. A heroin 

abuser usually has histories, much longer histories, of abuse and, 

per potency of the drug, has been exposed for many more years to 

a much more potent drug. They usually have initiated the abuse 

of the substance much younger than for prescription medications. 

As a result of that, that increases their risk and they need much 

higher doses, for example, of methadone to be able to control withdrawal. When you have someone that is initiated in opiate analgesics, they tend to have shorter periods of time. Many of them may 

have been taking drugs that are much less potent, like 

Hydrocodone, so you can manage them with much lower doses of 

methadone, or even better with buperenorphine. In general, their 

outcomes are much better. 

The issue that is problematic, is if you have a patient that has 

genuine pain that requires an opiate medication and it is at the 

same time addictive, that is the challenge because you need to 

treat the pain, while at the same time monitoring that addictive 

component of that individual. That’s where the issue becomes much 

harder to deal with. 

If chronic pain is not an issue, then your outcomes are much, 

much better with someone that is addicted to opiate analgesics for 

these demographic characteristics. 

Chairman BIDEN. I am trying to see. I do not want to keep you 

too long here. 

Is there a different profile—and you may not know this. I mean, 

there may not be any studies done on this—of the kid whose introduction to abuse is through prescription drugs and the profile of a 

kid whose introduction of drugs is through the street with cocaine 

or methamphetamine or speed? Are there different characteristics 

or are they not able to be differentiated? 

Dr. VOLKOW. Well, there is not sufficient data to tell you categorically, but I can tell you what data has emerged from it. The 

differences tend to actually relate more to environmental factors 

16 

than anything else. So if you come from, for example, a rural area 

where methamphetamine—like in Hawaii—is widely available, the 

likelihood that you actually may even initiate with methamphetamine is much higher than if you come from New York, where it 

has actually been shown by these geographical areas, also the likelihood of initiating prescription medication is much lower. But on 

the other hand, if you are in New York in a neighborhood where 

there is a lot of cocaine, you may initiate that way, or marijuana. 

Again, people don’t necessarily consider it, and yet it is very important, that in most instances the first drug of abuse—in most instances—is either nicotine or alcohol, and from there you can go 

into marijuana or you can go into prescription medications. Which 

one you choose may be more of a function of access to that medication than itself the properties of the drug or the unique characteristic of the person. 

Now, having said that, there’s another thing that we need to consider that we also recognize. I told you, people who are in pain are 

basically prescribed medications, but the other side is people that 

may have an underlying psychiatric disorder that is not recognized 

and are at greater risk of ending up using these medications as a 

mechanism of medicating themselves. 

So kids that may have depression, that may have attention deficit disorder may be at higher risk because they do not feel comfortable. They take a drug by experimenting and they feel better, 

and then they learn that, and without really being conscious about 

it they start to take it because they improve, temporarily, their performance. Long term, it actually makes it worse, but short term, 

they may feel better. So that is the other aspect, that a kid having 

a psychiatric disorder that is not properly diagnosed may be at 

greater risk of abusing stimulants because he actually may feel 

better with them. 

Chairman BIDEN. Not directly related, there is a recent piece I 

read about the number of Americans who have been diagnosed 

with depression. The essence of the article was, it’s a staggering 

larger number. If I can make an analogy. When I started doing a 

lot of research about violence against women and statistics started 

coming out from the FBI crime statistics between the late 1970s 

and early 1980s, it rose precipitously, the statistics-reported 

crimes. 

After literally over a thousand hours of hearings we had over 

that whole period, it turned out that some portion of it was the 

feeling of women being more liberated to report. It sounds like an 

oxymoron, liberated to report abuse. But who were more inclined 

to report abuse than their mothers would have reported that abuse, 

or their counterparts 15 years earlier would have. 

Is it that people are a hell of a lot more depressed in America 

or is that it is sort of the diagnosis of choice these days when people used to deal with problems better? Talk to me about that a little bit, about depression and the correlation. 

Dr. VOLKOW. Yes. You are picking up on something else that 

alerted us in the psychiatric community. Now I’m speaking as a 

psychiatrist, because there is a National Institute of Mental Health 

on this issue. There’s been significant increases in the diagnosis of 

17 

depression, and also particularly in young children. The numbers 

are really staggering and it doesn’t seem to be abating. 

Is it because we really are seeing an increase in depression or 

is it because we are recognizing it more, as you say? It’s likely that 

both cases would be the case. It’s evident that more symptomatic 

cases are being diagnosed that in the past would not have met criteria for diagnosis and treatment, and that’s where that same issue 

happens for the case of personality disorders—not just depression, 

but personality disorders or autistic type syndrome disorders, not 

autism. 

So it is possible that we are diagnosing many more and we’re diagnosing people that, per se, don’t meet the criteria of depression 

itself. However, when you see numbers like that, it’s your responsibility to try to understand if indeed there is an increase of the disease itself. 

Based on the data, I do not think that we can say that there is 

such an increase, however, we cannot rule it out. It’s not just for 

depression. If you look at the statistics in psychiatry, there’s a significant increase in cases of attention deficit/hyperactivity disorder; 

obviously the case of autism has attracted a lot of attention. 

Chairman BIDEN. Well, thank you very much. As you can tell, I 

could keep asking you questions all day because this fascinates me, 

and I think it’s a big, big deal. But I’ve trespassed on your time 

too much already. Do either of you have any closing comment you’d 

like to make to the committee as to what you think we should be 

doing most? 

Dr. PAULOZZI. Well, I appreciate the opportunity to speak here. 

I think a lot more work needs to be done to investigate the risk 

factors for these deaths, to look into the wide variation geographically across the country, both in the overdose death rates and in 

the rates of prescribing from one State to another as to the reasons 

for that. We’ll continue to do our work in surveillance and etiologic 

studies and try to evaluate the impact of some interventions at 

CDC. 

Dr. VOLKOW. My perspective is, my ending remark is that this 

is an urgent problem that needs urgent action. It was very categorical, the way that I feel. We’re already seeing significant increases 

in mortality associated from prescription medication. I think that 

slide number two that Dr. Paulozzi showed speaks for itself. 

The other thing is, we are seeing an increasing number of people 

requesting treatment for drug dependence, both for opiate analgesics and stimulants. They are just going way, way up. At the same 

time, we are increasing the number of people being prescribed 

these medications. We need to be aware of what has happened in 

the past. We had an epidemic of stimulant abuse in the United 

States in the 1960s which was very much tied to the increasing 

prescriptions at that time for medications to lose weight. 

We need to learn from those past experiences, because if we do 

not control these we will have a serious problem of dependence, not 

just in terms of abuse and addiction, not just in opiates, but also 

for stimulant medications. This, it has been shown, can have very 

adverse consequences. So I applaud you for your leadership, because this is an area that in my view has not received the level 

of attention that it deserves. 

18 

Chairman BIDEN. Quite frankly, the reason it got my attention, 

is it seems to me that I’ve been doing this long enough to notice 

and to observe that there are sort of early warning signs that a 

new epidemic is on its way. I remember, years ago, writing a report 

saying Ice is on its way, that methamphetamine is going to be a 

giant problem, and no one wanted to pay attention. It was coming 

out of Hawaii at the time. It was like, OK, well, we’ve got an isolated problem. I don’t mean that like I was some kind of oracle. I 

don’t mean that. A lot of experts like you had come before my committee and talked about it. 

One of the things that I am least informed about is what is reasonable to expect of the medical profession, because again they are 

overburdened in a whole lot of ways. I mean, what is reasonable 

to expect of the medical profession in terms of the regimes for prescribing, essentially the sieve they should put their patients 

through before they decide to prescribe, and what to prescribe. I 

mean, it’s a pretty extensive problem. 

So for me, one of the things we’re going to be pursuing, I will 

pursue privately as well with the medical profession, the AMA, and 

others, is what do they think about this? I mean, what are they 

thinking about? What are they recommending? What are the medical schools talking about? What are young doctors being trained to 

do? How high up on the agenda is this? 

The whole issue of drug abuse has so many complicated ramifications for society, economically, politically, criminally, and physically. I mean, I’ve always thought—and I’m no expert on this— 

that the medical profession has almost, in a sense, understandably 

basically said this is not on my watch, this is not really our responsibility, it’s the policymakers’. But it seems to me, we need to look 

to them for some guidance. 

Well, I thank you both very, very much for being here. I do appreciate your time. As I warned the Doctor last time around, we’ll 

call on you again. We’re like poor relatives. When you say you’ll 

show up, we invite you. So, I appreciate the help very, very much. 

Thank you. 

Dr. VOLKOW. Thanks to you. 

Dr. PAULOZZI. Thank you. 

Chairman BIDEN. Thank you, Doctors. 

Our second panel is Steven J. Pasierb, from The Partnership for 

a Drug-Free America. It’s a nonprofit organization, uniting communications professionals, renowned scientists, and parents. Steve 

joined The Partnership in 1993 and became president in 2001. 

Derek Clark has been the executive director for the Clinton Substance Abuse Council in Clinton, Iowa, a town I’ve learned to love. 

Misty Fetko—I hope I’m pronouncing correctly—is a registered 

nurse and the parent of Carl Hennon, who died tragically in 2002 

due to an overdose of a combination of over-the-counter and prescription pain relievers. Since then, she’s dedicated much of her life 

to raising awareness about the risks associated with medicine 

abuse. 

I say to you, Ms. Fetko, I admire you doing this. As someone who 

lost a child in a different circumstance, I never had the nerve to 

face up to it. I just didn’t want to deal with it. The fact that you 

are, in a sense, it’s a bitter irony. Every time you testify, you’re 

19 

brought back and that takes a lot of courage. I want to personally 

thank you for being willing to do it. 

Why don’t you, if you would, deliver your opening statements in 

the order in which you were called, and then I’ll have some questions. Thank you. 

STATEMENT OF STEVE PASIERB, PRESIDENT AND CEO, THE 

PARTNERSHIP FOR A DRUG-FREE AMERICA, NEW YORK, 

NEW YORK 

Mr. PASIERB. Thank you very much, Chairman Biden. And thank 

you for calling this hearing. As you’ve said throughout this, you’ve 

been on this issue for a long time. Those of us in this field appreciate everything you’ve done, most recently with the 

dextromethorphan legislation. We were proud to support that. 

I’m going to submit to you, obviously it’s been established here 

today that the abuse of prescription and over-the-counter medications, legal substances, of benefit if used appropriately, is the single most troubling phenomenon on today’s drug abuse landscape. 

The Partnership has devoted a good measure of our research over 

the last 4 years, our focus, and our voice to this issue, yet clearly 

much more has to be done. 

The 2007 Partnership Attitude Tracking Study looked at over 

6,500 teenagers in grades 7 through 12. And what that showed, is 

we have 19 percent, or 1 in 5 teens, who are actually reporting that 

they’ve tried a prescription drug without having a prescription, so 

they’ve engaged in this behavior. One in 10 report that they’ve 

used over-the-counter cough medicine to get high. As we’ve established, only alcohol, cigarettes, and marijuana are abused by teenagers at higher rates than prescription drugs, while cocaine, 

Ecstacy, and methamphetamine are each roughly half as prevalent 

as prescription drug abuse in these young people’s lives. 

Now while it is true that the prevalence of medicine abuse has 

not increased in the last 3 years, it is troubling to realize that teen 

use of virtually all other substances of abuse—alcohol, tobacco, 

marijuana, even methamphetamine—has declined over that same 

period of time, and in fact many of these have been in decline 

steadily over the last decade. 

What has this trend really shown us about what we need to do 

as a Nation? We think there are a few areas we need to focus and 

we need to pay attention to. First, these substances are readily 

available to our teenagers across this country. They’re getting it in 

their home medicine cabinets and the medicine cabinets of friends 

for free. Our data is very much in line with the national findings 

from the survey on drug use and health, which shows over 75 percent of teenaged prescription drug abusers say they got those drugs 

from immediate friends or family. 

Second, teens’ perception of the risks of abuse is very low. Our 

past research shows that less than half of teens see great risk in 

experimenting with prescription pain relievers such as Vicodin and 

Oxycontin. Even more alarming on top of that, over one-quarter of 

the teens believe prescription pain relievers are not addictive. 

University of Michigan’s Monitoring the Future survey, going 

back over 30 years, has helped us establish that we need that perception of risk associated with any substance of abuse. When 

20 

they’re there and social disapproval is there, those correlate significantly with actual teen substance abuse rates. 

So, low perception of risk, low disapproval, coupled with the easy 

availability that we’ve been talking about, is a recipe for ongoing 

problems. 

Research conducted by The Partnership in 2007, with support 

from Abbott Pharmaceuticals, gave us really a new light. It cast a 

light on the motivations of teens around prescription drug abuse. 

Traditionally, as you said earlier, we think about this as ‘‘to party, 

to escape, to get a buzz, get high’’, but our 2007 research with Abbott, like the research done among college students by Carol Boyd 

and Sean McCabe, suggests a much wider range of motivations for 

young people’s abuse of prescription drugs beyond getting high, including an emerging set of what we call ‘‘life management’’ or ‘‘regulation’’ objectives. 

Teens appear to be abusing these drugs in a very utilitarian way, 

using stimulants to help them cram for a test or lose weight, pain 

relievers to escape some of the pressure they feel to perform academically or to perform socially, and tranquilizers to wind down at 

the end of a stressful day. 

Once these substances have integrated themselves into teens’ 

regular lives and really have been abused as study aides, as management of life, as relaxation, it’s going to become increasingly 

more difficult to persuade teenagers that these very same drugs 

are unnecessary and unsafe when they’re taken without a prescription. 

Fourth, are parents, who typically are our biggest ally on these 

issues when we deal with them. They’re always right at our side. 

What we find in the research, is parents are generally ill-equipped 

to deal with teens’ abuse of prescription drugs. Parents find it hard 

to understand the scale and the purposefulness of which today’s 

teens are abusing medications, because this is not something that 

went on when they themselves were teenagers. It is not clear to 

them that they may be one of the prime sources of supply to their 

teenagers out of their very own medicine cabinet. 

Further, many parents themselves—we saw this in the Abbott 

study—are engaging in a similar behavior. In our study with Abbott, 28 percent of parents said they had used a prescription drug 

without having a prescription for it, and 8 percent of parents said 

they had given their teenaged child a prescription drug that was 

not prescribed for that teen. 

In our studies, parents tend to underestimate the damage and 

danger of abusing medicines, some actually expressing relief and 

saw less social stigma to hear that kids might be abusing ‘‘safe prescription drugs’’ versus ‘‘dangerous illegal street drugs.’’ 

Finally, the reason I don’t think we’re seeing declines in this behavior in the face of all the other declines, is simply our efforts as 

a United States up to now have not been enough. There simply 

hasn’t been enough public attention, there hasn’t been enough resources devoted to this issue like there has been in recent years on 

other emerging drug threats. Luckily, that’s now beginning to turn. 

ONDCP’s National Youth Anti-Drug Media Campaign should be 

applauded. They just invested $14 million, which will then be doubled by their media match to target parents around the prescripVerDate Nov 24 2008 10:45 Mar 12, 2009 Jkt 047336 PO 00000 Frm 00024 Fmt 6633 Sfmt 6633 S:\GPO\HEARINGS\47336.TXT SJUD1 PsN: CMORC
21 

tion drug abuse issue, provide them with information on how to 

safeguard their homes, and how to keep their kids away from it. 

In some quarters of the pharmaceutical and over-the-counter 

drug industries, there’s been real concern, there’s been action, and 

there’s been active support for prevention and education efforts, 

from associations like PHRMA, the Pharmaceutical Research and 

Manufacturers, from the Consumer Health Care Products Association, as well as select companies that have really stepped forward 

and should be commended for taking what is largely a proactive 

approach. 

As you heard, our Federal agencies, with NIDA at the lead and 

the fore, have done a superb job and have been at the forefront of 

helping us understand this problem. But reducing the actual abuse 

of these products, getting ahead of this and getting it turned in the 

right direction is going to take a heck of a lot more across all of 

our society. 

We had the tragic death of Heath Ledger, and that really cast 

a sudden spotlight on this, much like Len Bias’s death did in 1987, 

which helped America understand cocaine was not a drug without 

harm and without destruction. We’ve got to build on this small bit 

of understanding we have right now and accelerate that, and devote all the necessary resources, education, prevention, addiction 

treatment that it is going to take to drive down the intentional 

abuse of these products. 

So, sir, I thank you for calling this hearing. Mr. Grassley, for all 

he does on a day in, day out basis, and we will stay with you on 

this throughout. 

Chairman BIDEN. Thank you. 

Mr. Clark. 

[The prepared statement of Mr. Pasierb appears as a submission 

for the record.] 

STATEMENT OF DEREK CLARK, DIRECTOR, CLINTON 

SUBSTANCE ABUSE COUNCIL, CLINTON, IOWA 

Mr. CLARK. Chairman Biden, thank you for giving me the opportunity to testify. 

Chairman BIDEN. One important question, first. How much snow 

is on the ground? 

Mr. CLARK. It’s getting better. 

Chairman BIDEN. OK. Good. 

Mr. CLARK. It’s all melting right now. It’s a big mess. 

Well, thank you for letting me testify on behalf of the Clinton 

Substance Abuse Council. I’m going to represent the community 

and the coalition aspect for this issue. 

First, last week a Clinton woman—let’s call her Jane—was 

charged with six counts, felony counts, of fraudulently obtaining 

prescription drugs. Jane was being treated by several doctors over 

the past 3 years. She was receiving prescriptions for Hydrocodone 

and fentanyl—these are powerful drugs—from one doctor, while receiving methadone prescriptions from another doctor, and neither 

doctor knew this woman was seeing the other doctor. 

One of the fastest-growing threats to youth today is the abuse of 

prescription and over-the-counter drugs. This is true at the national level, as well as the local level. As a result of the needs asVerDate Nov 24 2008 10:45 Mar 12, 2009 Jkt 047336 PO 00000 Frm 00025 Fmt 6633 Sfmt 6633 S:\GPO\HEARINGS\47336.TXT SJUD1 PsN: CMORC
22 

sessment that we conduct for our drug-free communities as a 

grantee, we know that 15 percent of the Clinton Community School 

District 11th graders report having used prescription drug medication not prescribed to them at least once in the last 30 days. That’s 

compared to 7 percent of all Iowa 11th grade students. 

Eleven percent of Clinton Community School District 11th grade 

students report having used over-the-counter medications different 

from the directions at least once in the past 30 days, and this is 

compared to 7 percent of Iowa 11th grade students. 

While prescription over-the-counter drug abuse is clearly a problem, because the Clinton Substance Abuse Council is a Drug-Free 

Communities grantee, we have the necessary infrastructure in 

place to effectively deal with this issue and involve all sectors of 

the community. This includes law enforcement, schools, parents, 

youth, and the business and faith communities. 

The Clinton Substance Abuse Council uses the strategic prevention framework when conducting their community planning and decisionmaking process. This is a five-step process: the first one is 

needs assessment; the second one is capacity building; third is 

planning; fourth is implementation; and last, evaluation. This 

framework ensures the focus of CSAC is always current with the 

local trends and we are being as effective as possible with the resources available to us. 

We involve the community in the strategic plan by holding 

monthly meetings to discuss local substance abuse problems, 

emerging drug use trends, designing solutions to address these 

problems, and developing outcomes from programs and projects. 

When needed, task forces and ad hoc workgroups are formed to 

allow individuals to focus on each issue, whether it is addressing 

a specific problem or implementing a project or program. 

In addition to the regular meetings, the Clinton Substance Abuse 

Council also conducts focus groups with local law enforcement, substance abuse treatment providers, mental health providers, human 

service professionals, and community members. When individuals 

are not available, we also do key informant surveys to ensure that 

we are getting the widest amount of information from people and 

ensuring that people have their voice heard. 

CSAC’s prescription drug abuse strategic plan works to develop 

social marketing campaigns to change the perception of risks associated with prescription drug abuse, implement environmental 

strategies to reduce access to prescription drugs—environmental 

strategies are focused on changing the aspects of the environment 

that contribute to the use of drugs—educate the community and 

target segments on the dangers and problems; facilitate participation in the online prescription drug tracking system that is currently being developed by the State of Iowa, and with these actions 

we hope to increase the perception of harm related to prescription 

drug abuse, reduce the number of people reporting illegal use of 

prescription drugs, reduce the number of people arrested for prescription drug abuse, and medical facilities will participate in 

Iowa’s online prescription drug trafficking system. 

Before I leave, let me just leave you with this. A local high school 

student—let’s call him Billy—was caught by his mother stealing 

her heart medication. Billy was crushing this medication and snortVerDate Nov 24 2008 10:45 Mar 12, 2009 Jkt 047336 PO 00000 Frm 00026 Fmt 6633 Sfmt 6633 S:\GPO\HEARINGS\47336.TXT SJUD1 PsN: CMORC
23 

ing it in the hopes of getting high. He didn’t. Billy’s mother became 

suspicious when she noticed her medication was disappearing, and 

confronted him. He admitted his actions. The good news is that 

Billy is currently receiving counseling. 

Thanks for this opportunity to testify. 

Chairman BIDEN. Thank you. 

[The prepared statement of Mr. Clark appears as a submission 

for the record.] 

Chairman BIDEN. Ms. Fetko. 

STATEMENT OF MISTY FETKO, R.N., PARENT OF CARL 

HENNON, NEW ALBANY, OHIO 

Ms. FETKO. Thank you. My name is Misty Fetko and I’m a registered nurse who works in a very busy emergency department in 

central Ohio. But most importantly, I’m a mother of two wonderful 

boys. I am here today to tell you the story of my oldest son, Carl. 

Carl was my beautiful boy, eyes like large dark chocolates, an infectious smile, and an insatiable curiosity. 

I spent years protecting him from harm, but 4 years ago harm 

found a way to sneak in and steal the life of this gifted young man. 

It was the morning of July 16th of 2003. Carl had just graduated 

from high school and was getting ready to leave for Memphis College of Art in 2 days. The college had courted him after he had won 

an award for artwork he created his junior year of high school. 

The night before, Carl and I had sat in his room and talked with 

each other about his day at work and the pending trip to Memphis. 

At the end of the conversation, he smiled and hugged me. He said, 

‘‘Good night, Mom. Love you.’’ The next morning I decided to walk 

the dog before waking Carl. By walking next to his car, I noticed 

an empty bottle of Robitussin in his back seat. Instantly, I knew 

something was wrong. I had been very vigilant for signs of drug 

abuse in the past and hadn’t seen many, but the previous summer 

I’d found two empty bottles of Robitussin in our basement after a 

sleep-over he had had with friends. I knew something was up. 

I rushed to his bedroom door, only to find it locked. After finding 

my way in, I discovered Carl laying peacefully in bed, motionless, 

with legs crossed, but he wasn’t responding to my screams and he 

wasn’t breathing. I quickly transformed from mother to nurse and 

began CPR, desperately trying to breathe life back into my son. 

I could not believe what I had feared most in life had happened, 

but I still did not know what had caused my nightmare. 

We are a very close family and I’m a very involved mother. Carl 

had always assured me that he wasn’t using drugs or alcohol, and 

I, the ever-watchful mom, believed him as there wasn’t any evidence to prove differently. 

During Carl’s junior year of high school, though, I found the first 

evidence of marijuana in his room. After all the talks and reassurances between us, what had changed? I intervened and didn’t see 

anything else suspicious until that summer when I found those two 

empty bottles of Robitussin in our basement. I was determined to 

keep drugs out of our house. But cough medicine? 

I went to search for answers on the Internet and found nothing, 

and then confronted my son. Carl explained that he and his friends 

had heard you could get high off of cough medicine and had tried 

24 

it, but nothing happened. I was reassured once again that he 

wasn’t using hard drugs and not to worry. Finding no further evidence, I believed him. 

During his senior year, we had some incidents with his interest 

that he had developed with marijuana, but I thought we were 

doing what we needed to to address this problem. So why, on that 

dreadful July morning, did I discover that my son had passed away 

during the night? Over the next several months after his death, I 

frantically searched for answers. What signs did I miss? During my 

search, I found two more empty bottles of Robitussin, but it wasn’t 

until after talking to his friends and finding journal entries on his 

computer that I discovered that Carl had been abusing cough medicine intermittently over the past two and a half years. 

He documented his abuse in his computer journal. Through the 

Internet and through his friends, he had researched and educated 

himself on how to use these products to get high. He wrote about, 

and enjoyed, the hallucinations achieved upon intentionally overdosing on cough and cold products. He described the pull that he 

felt toward the disassociative effects of abusing cough medicine and 

seemed to crave these effects. 

According to his journal, he had gradually increased the amount 

of cough medicine he was abusing from 4 ounces to 12 ounces. As 

his abuse increased, many things in his life were changing; graduation, college, his parents’ divorce, and increasing pressures in life. 

I wouldn’t find out until the morning of his death what he and 

many others knew about his abuse of cough medicine. 

The danger that I so desperately had tried to keep out of our 

house had found a way to sneak in, though the signs at the time 

did not indicate what I knew as signs of drug abuse, as there were 

no needles, there were no powders, there were no smells, or large 

amounts of money being spent, none of the typical signs that I associated with drug abuse. 

Carl’s autopsy report revealed that he had died from a lethal mix 

of drugs: fentanyl, a strong prescription narcotic, cannabinoids 

found in marijuana, and dextromethorphan, or DXM, which is the 

active ingredient in cough medicine, were found in his system. To 

this day, I don’t know where he obtained the fentanyl patch. There 

were no journal entries that talked about his use of painkillers. I 

don’t know if this was his first time or why he made the wrong 

choice to abuse prescriptions and over-the-counter drugs. I only 

know parts of his story by the words he left behind in his journal. 

His words are now silent. 

Abuse of over-the-counter and prescription drugs is a very large 

and very concerning problem. We are seeing more teens in our 

emergency departments who are overdosing on these drugs. It is 

becoming more of a norm for us to see than an exception. A couple 

of weeks ago, a young man was brought into our emergency department who was at the home of a friend. They had found him unresponsive and barely breathing. The paramedics rushed him to the 

hospital. He had been chewing on a fentanyl patch. Several unopened patches were found in his pants pockets. 

Just a couple days ago, a young lady was brought in from high 

school, where she had taken 30 Coricidin cough and cold tablets 

that morning at school just to get high. She spent the next several 

25 

days in our intensive care unit. These are just a couple of stories 

of the stories I see daily in our emergency department. 

I want to thank you for inviting me to share Carl’s story. If loving Carl were enough, he would have lived forever. It is now with 

this love that I tell his story so others are aware of the grave dangers of this type of drug abuse. 

Thank you very much. 

[The prepared statement of Ms. Fetko appears as a submission 

for the record.] 

Chairman BIDEN. Thank you. 

Let me start with you, Ms. Fetko. In your attempt to sift through 

the pattern your son got into, did his friends or anything reveal 

how the progression took place from cough medicine to fentanyl? I 

mean, was it sort of part of the culture among his friends? 

Ms. FETKO. What I was able to discover, through the journal entries and through talking to some of the young men that were his 

friends, it seemed like the cough medicine was what they first became attracted to. It sounds like the first experience with it after 

they had heard about it and read about it on the Internet, they had 

actually gone to a local grocery store and stole a four-ounce bottle 

to try it, is what his journal entry talks about. 

Really, the journal entries really focused on his use of the cough 

medicine and the hallucinations that he was achieving from overdosing on it. It seems like the group of friends had discovered this 

and developed an interest in it, but there wasn’t any talk about 

any other drugs at the time, except for the marijuana that I had 

found. 

Chairman BIDEN. Gentlemen, is Ms. Fetko’s story remarkably 

different from what you have become aware of and associated with 

in your work in Clinton and all the work done by the drug council? 

Mr. PASIERB. Unfortunately, we get far too many parents that 

contact us through our web site or call the Partnership and tell 

very similar stories, or not of kids who have died, but kids who are 

in the hospital or kids who are now profoundly addicted and in 

treatment centers. If you just took those alone, those would be 

warning signs that something is going on, let alone the research 

that we have. 

Chairman BIDEN. Mr. Clark. 

Mr. CLARK. We haven’t had any fatalities yet. But the way that 

the numbers are going and what we’re learning now, it may be only 

a matter of time. So, we’re very concerned. 

Chairman BIDEN. The focus of The Partnership for a Drug-Free 

America on this issue is to focus on—you do multiple things, but 

focus on educating parents. Is that right? 

Mr. PASIERB. Primarily we’re going after mom and dad, because 

what we find in the research—or whoever that adult is in a kid’s 

life—is they’re actually behind the kids. We get about 60 percent 

of kids who understand this issue that know that it goes on, have 

heard it’s happening, whereas, when we look at very similar studies around mom or dad or grandma and grandpa, whoever that caring adult is, they don’t understand this. As I said in my testimony, 

we have the most drug-experienced generation of parents in history, is one way to look at it. This behavior did not go on when they 

26 

were in high school in the 1980s or the early 1990s, it was cocaine 

or things like that. 

So what we see, is parents saying, yes, I’m having these conversations with my kid. They tend to overestimate those. But when 

you dig deeper, you find that prescription drug abuse/over-thecounter medicines don’t enter into most of those conversations. So 

mom and dad are well behind their kids. Kids know this is going 

on. They’re finding it on the Internet. They’re seeing it in chat 

rooms. They’re Googling ‘‘cheap way to get high’’ and getting 10,000 

web sites that offer to sell them something. So for teenagers, this 

is pretty omnipresent in their lives. 

As we’ve seen in our research, they’re getting very tactical in 

how they use them. The kids that we saw in some of our qualitative studies would tell you they are not a drug abuser, they are 

not a drug user, they simply get other people’s Ritalins because it 

helps them get better grades, and isn’t that what they’re supposed 

to be doing? So they’re looking at this in a very, very different way. 

So, those kids need to be met by a mom and dad who understand 

this in some way, shape, or form, so we really believe that we have 

got to make some headway with parents and get them engaged in 

this, help them understand they’ve got to safeguard their medication, they’ve got to educate themselves, and then they’ve got to get 

out with their kids and deliver a very strong message that this is 

not a safer way to get high. 

Chairman BIDEN. Mr. Clark. 

Mr. CLARK. Yes. Actually, I sit on the Board of Directors for The 

Partnership for Drug-Free Iowa, so we work closely with the material that they do, because we don’t want to create material that is 

already out there when we can be better using our time. So, like 

I talked about that we do social marketing campaigns, what we try 

to do is work with the youth or with the targeted area we want 

to address. Let’s say we’re working with the youth on this one. 

We’re going to pull in a group of youth to help create a marketing 

campaign, a social marketing campaign, which is pretty much the 

same principles as a marketing campaign, a general one selling a 

product. We’re selling a product, change of social norms, you know 

the risk of use. 

So we’re pulling these youth in to create a campaign to target 

their friends, their peers. And not only are we changing and educating those youth working on the campaign, but then they’re going 

to go out and they’re going to deal with their friends, their social 

network and change the norms, perception of risk related to prescription drug and over-the-counter drug abuse. 

Then not only are we working with youth, their peers, but we’re 

also working towards community-level change by creating this campaign that is then working with the community trying to market 

these youth on changing their social norms, their perception of 

risk. 

Chairman BIDEN. What do these kids talk about? Look, this is, 

in my view, incredibly complicated, but not complicated. I mean, 

there is always a social structure that revolves around the social 

setting in which these kids act, whether it’s their attitude toward 

sex, their attitude toward drug abuse, or their attitude toward 

studying. 

27 

Is there a difference between the kids who are using street drugs 

and—there are still a lot of street drugs out there. It’s down, but 

there’s still an unacceptably large number of kids in high school 

who are using cocaine. There are still a large number of kids who 

are abusing speed, methamphetamine, et cetera. 

Are they a different, in a sense, clique of kids? I mean, do you 

find that kids who abuse prescription drugs or over-the-counter 

medicines, do they think themselves different than the kid, the four 

kids who are getting stoned in the back of the school, or getting 

high on speed, you know, or showing up at parties where it’s open 

and notorious use of these drugs? I mean, what’s the mind-set of 

the kids in the street or the kids in the classroom? 

Mr. PASIERB. All these kids share that common, it’s not going to 

be me, I can handle this, I can do this. I can go out and I can try 

it. When you get back to the research that’s been done, perception 

of risk, social disapproval, whatever you want to call it, one way 

that we’re beginning to think about this is it isn’t that they’re gateway drugs as much as there are gateway attitudes. Young people 

come into society and they say, look, I get great grades, I want better grades, I can use prescription drugs. Or I have nothing to attach to in society, so I’m going to try meth because it’ll make me 

feel perked up. 

It’s these attitudes they bring which are interrelated and complicated, and we’ve only really begun to understand what causes 

them to make that decision the first time when somebody comes in 

and says, here, try this with us, do this. What they bring to them, 

the perception of risk, the social disapproval, the feelings that they 

can get away with it, their own personal feelings of— 

Chairman BIDEN. Talk to me about the social disapproval piece 

of it? 

Mr. PASIERB. Pardon me? 

Chairman BIDEN. Talk to me about the social disapproval piece. 

I remember back in the 1980s, and actually in the 1970s and 1980s 

you could show up certain places. If someone in a high-end neighborhood, young professionals were having lunch on Monday in the 

early 1980s and said, I did a line of coke at so and so’s place, they’d 

say, OK, all right, I don’t do that, but what’s the big deal? Whereas, no one is going to sit down and say that today. 

Mr. PASIERB. Exactly. 

Chairman BIDEN. So that is what I’m trying to get at. What are 

the kind of conversations? Like, your son’s friends are not likely to 

say, you know, I tell you what, man, I’ve got some of the purest 

stuff I ever had before, man, heroin. This stuff I got was really 

pure. They’re not going to sit around your basement and talk about 

that, probably, those kids. 

But would they sit around and say, man, I’ve figured out how to 

mix this stuff, or I’ve figured out how to extract this stuff? I mean, 

is there a social acceptance that is broader in this area than there 

is, and how much of the moral disapprobation of society, their 

peers, their teachers, their parents, is real? I can remember the 

lovely, brilliant woman sitting behind you who used to work for me 

and do all this. I remember her producing the study for me early 

on, where we started off in hearings a decade ago saying, this ain’t 

your mother’s marijuana. The marijuana that my generation used 

28 

in the 1960s ain’t nothing like the marijuana that’s available today. 

And yet, parents back then, the parents of the kids who were teenagers in the 1980s, said, well, thank God they’re only using marijuana. Thank God that’s all it is, because, man, they could really 

be doing something bad. 

Our parents say the same thing now. When you confront a parent—not confront. A parent finds out his kid is abusing cough medicine, is the response, well, thank God it’s cough medicine and not 

whatever? I mean, talk to me about—don’t talk to me like a manager, talk to me like somebody when you deal in the neighborhood, 

when people come in to talk to you. What do they say to you? How 

do they view it? Do they view it with alarm or do they view it as— 

in a sense, Misty, you said—excuse me for using your first name. 

You said, well, you know, it was cough medicine, at least it 

wasn’t—or at least you implied, it wasn’t something really bad. 

Ms. FETKO. Exactly. 

Chairman BIDEN. What was your attitude? 

Ms. FETKO. Exactly. At first, I thought maybe it was possible 

that there was still alcohol in cough medicines, which I thought 

had been removed. Then when I went to the Internet and I didn’t 

find anything, I mean, I was, I was relieved. I was relieved there 

weren’t syringes. I was relieved there wasn’t powder. And, you 

know, here I work in a busy emergency department. I should have 

had my finger on the pulse of the changing environment, and we 

hadn’t even been seeing it or hearing it there. So I did, I felt a sigh 

of relief. But I think the boys also saw it—and these were very intelligent, gifted young men. 

I think the fact that they didn’t have to have a drug dealer to 

get it, it wasn’t shady, they weren’t uncomfortable about doing it. 

Carl wrote about the first time that he had the nerve to walk in 

and purchase it at the drug store. I mean, I don’t think they associate the same feelings that they do with the illegal street drugs. 

Mr. CLARK. Another problem is, it’s readily available. Say a high 

school student can go to high school and they could get some 

Ritalin from their buddy at school because they may have it because it’s prescribed and no one is going to say anything. So another issue to consider is, the schools are also having to address 

this problem. How exactly do they want to handle prescription 

drugs? Do they want, all drugs have to be checked in to the school 

nurse? 

Then that brings up another issue. What if the student runs out 

of medication, they don’t bring it in? There’s a lot of things that 

right now are being discussed and trying to figure out because this 

is such a relatively new problem, and it has a lot of different dynamics to it because these are prescribed. The youth or the user 

does need this medication, but then if the schools don’t regulate it, 

these students have the medication at school and they may be distributing them, selling them, or just sharing. 

Chairman BIDEN. I thought it was pretty instructive, the comment made by NIH. They got a call from a professor saying, it reminded me of the hearings I held on steroids. The hearings I held 

on steroids were, athletes like me resented the hell out of the fact 

that somebody, with one-tenth the work, was getting twice the 

muscle mass and maybe would take my job on the team. I found 

29 

it interesting, the comment made, one student complaining to a 

professor that he was at an intellectual disadvantage in class, and 

his grades, because of the use of—I don’t know which drug she 

said. Whatever. 

Mr. PASIERB. We’re hearing those exact same things, both from 

college kids and high school kids, from a very competitive nature. 

I’m here to compete, I’m here to get better grades, a better job, and 

I resent those people who may be using it, therefore I feel drawn 

to it. We’re stunned when we pull parents together and they begin 

with this disbelief. We’re here to talk about prescription drug 

abuse. Oh, you mean if the label says take two you take two, not 

three? No, about taking six and chasing them down with alcohol. 

No, that doesn’t go on, is the reaction. No, that doesn’t happen. 

They begin to try to disabuse us that such a thing would happen 

in society. 

So you go from this disbelief to almost a relief. Well, it’s prescription drugs. They’re safer. They’re made in sterile labs, the doctor 

prescribes those. That’s much better than cocaine or heroin. Then 

you begin, as Dr. Volkow did, to help us understand: an opioid is 

an opioid is an opioid, and they’re shocked and then they want to 

leave. Then they want to go home and take an inventory of their 

medicine cabinet and talk to their kid right away. We need to kind 

of take that ‘‘in’’ of 15 parents in a focus group and get it out to 

15 million parents, and 150 million, to help them understand that 

they’re in a unique position on this. They can control supply, unlike 

any aspect of the drug issue, control it in their own home and open 

up their radar to it, and they can control demand by engaging their 

kid and helping them understand, this is not only safer, it is extraordinarily dangerous. This is Russian roulette on a scale we 

haven’t seen before. 

Chairman BIDEN. The last question I have. I realize I’m just asking you from your experience base, which is extensive, from the 

early 1990s on. Actually, any one of you can respond. First of all, 

I doubt if there’s any data to sustain the question I’m about to 

ask—the answer, I’m implying. But if, in fact, figuratively speaking, the medicine cabinet is closed, there is no access at the drug 

store over the counter, is the same kid who would be inclined to 

go that route just going to turn around and go to the street? 

The kid who wants to abuse Oxycontin, the kid who wants to 

abuse cough medicine, the kid who wants to abuse whatever the 

over-the-counter prescription drug is, is it just that it’s easier to get 

there and that kid—I’m going to say something really ridiculoussounding: abuse of prescription drug is up among teenagers, other 

drugs are down. Is it because that if you didn’t have this abuse, 

would those other drugs of choice, street choice, would they be back 

up where they are? Do you understand the point I’m trying to 

make? 

Mr. PASIERB. Yes. Yes. We’re not seeing this as a replacement, 

I’m doing this instead of that. None of the data are showing this. 

We’re seeing that for some kids it’s a bridge between the casual alcohol and marijuana user, to then adding these on and then moving on to other drugs. So if from a bridging standpoint on that ladder of drug use, this behavior appears to be there. 

30 

But your earlier question, we believe right now all the studies 

we’re doing is showing only about 1 percent of kids are getting 

these drugs from the Internet. I would wager that if we truly did 

lock down the medicine cabinets and we really did limit that supply, these kids would migrate to the Internet because supply is 

there, at least on some of the lesser opioid products. 

We don’t know if a kid who becomes a dedicated user, who exhausts mom, grandma, dad, and all those other and friends, whether or not he or she, four or five steps down, doesn’t turn to the 

Internet. I believe, as long as there is a demand, supply finds a 

way and we’ve got to go after that demand, otherwise these kids, 

as motivated and as intelligent as they are, will find ways. 

Chairman BIDEN. I appreciate that. 

Does anyone have a closing comment you’d like to make? With 

your permission, I have several questions on behalf of several of my 

colleagues, and myself as well—I’m not going to burden you with 

a whole lot of questions—in writing that I’d like to be able to submit to you, if that’s OK. 

[The questions appear as a submission for the record.] 

Chairman BIDEN. Did anyone have any closing comment? 

Mr. PASIERB. I just want to thank you for forcing this on the national agenda, because it needs to get high up on the agenda. 

Methamphetamine is a huge problem in parts of our country, other 

drugs are huge problems. This seems to be a universal issue from 

Maine to Florida, Hawaii, and every point in between, and we’ve 

really got to help the country understand that this falls into that 

classic, this is a preventable behavior, and where kids end up in 

trouble, this is a treatable addiction, but we’ve got to get this out 

there. 

Chairman BIDEN. Well, I thank you all. I particularly thank you, 

Mrs. Fetko. Like I said, I just think it takes a special kind of person to be able to, in effect—I watched you as you read your statement. It’s always present. 

Ms. FETKO. Thank you. 

Chairman BIDEN. So I thank you for your courage and thank you 

for your willingness to share with us. 

I know you know, Steve, we’ll be back to you for additional help 

here. 

Mr. PASIERB. Yes. 

Chairman BIDEN. This is the beginning of this process, not the 

end of it. I thank you for making the trip in. 

As Senator Grassley says, his office is yours for as long as you 

are here, and maybe I could talk to you about how to vote, OK? 

[Laughter.] 

Thank you all very, very much. 

[The prepared statement of Senator Leahy appears as a submission for the record.] 

[Whereupon, at 3:51 p.m. the Subcommittee was adjourned.] 

[Questions and answers and submission for the record follows.] 

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