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COMBATING THE OPIOID ABUSE EPIDEMIC: 

PROFESSIONAL AND ACADEMIC PERSPECTIVES 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

APRIL 23, 2015 

Serial No. 114–34 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

COMMITTEE ON ENERGY AND COMMERCE 

FRED UPTON, Michigan 

Chairman 

JOE BARTON, Texas 

Chairman Emeritus 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOSEPH R. PITTS, Pennsylvania 

GREG WALDEN, Oregon 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

Vice Chairman 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

MIKE POMPEO, Kansas 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

RENEE L. ELLMERS, North Carolina 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

TIM MURPHY, Pennsylvania 

Chairman 

DAVID B. MCKINLEY, West Virginia 

Vice Chairman 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

H. MORGAN GRIFFITH, Virginia 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

JOE BARTON, Texas 

FRED UPTON, Michigan (ex officio) 

DIANA DEGETTE, Colorado 

Ranking Member 

JANICE D. SCHAKOWSKY, Illinois 

KATHY CASTOR, Florida 

PAUL TONKO, New York 

JOHN A. YARMUTH, Kentucky 

YVETTE D. CLARKE, New York 

JOSEPH P. KENNEDY, III, Massachusetts 

GENE GREEN, Texas 

PETER WELCH, Vermont 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(II) 

(III) 

C O N T E N T S 

Page 

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

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

Prepared statement .......................................................................................... 4 

Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 6 

Hon. Marsha Blackburn, a Representative in Congress from the State of 

Tennessee, opening statement ............................................................................ 7 

Hon. Janice D. Schakowsky, a Representative in Congress from the State 

of Illinois, opening statement .............................................................................. 8 

Hon. Paul Tonko, a Representative in Congress from the State of New York, 

opening statement ................................................................................................ 9 

WITNESSES

Robert L. DuPont, M.D., President, Institute for Behavior and Health, Inc. ..... 11 

Prepared statement .......................................................................................... 13 

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

Marvin D. Seppala, M.D., Chief Medical Officer, Hazelden Betty Ford Foundation .................................................................................................................... 22 

Prepared statement .......................................................................................... 25 

Answers to submitted questions ...................................................................... 107 

Laurence M. Westreich, M.D., President, American Academy of Addiction 

Psychiatry ............................................................................................................. 38 

Prepared statement .......................................................................................... 40 

Anna Lembke, M.D., Assistant Professor, Psychiatry and Behavioral Sciences, 

Stanford University School of Medicine ............................................................. 45 

Prepared statement .......................................................................................... 48 

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

Adam Bisaga, M.D., Research Scientist, New York State Psychiatric Institute 54 

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

Patrice A. Harris, M.D., Secretary, Board of Trustees, American Medical 

Association ............................................................................................................ 68 

Prepared statement .......................................................................................... 70 

Answers to submitted questions ...................................................................... 115 

SUBMITTED MATERIAL

Subcommittee memorandum .................................................................................. 98 

(1) 

COMBATING THE OPIOID ABUSE EPIDEMIC: 

PROFESSIONAL AND ACADEMIC PERSPECTIVES 

THURSDAY, APRIL 23, 2015 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:17 a.m., in room 

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

(chairman of the subcommittee) presiding. 

Members present: Representatives Murphy, McKinley, Burgess, 

Blackburn, Bucshon, Brooks, Mullin, Hudson, Collins, Cramer, 

DeGette, Schakowsky, Tonko, Clarke, Kennedy, and Green. 

Staff present: Leighton Brown, Press Assistant; Noelle Clemente, 

Press Secretary; Brittany Havens, Legislative Clerk; Graham Pittman, Staff Assistant; Chris Santini, Policy Coordinator, Oversight 

and Investigations; Alan Slobodin, Deputy Chief Counsel, Oversight; Sam Spector, Counsel, Oversight; Jean Woodrow, Director, 

Information Technology; Jeff Carroll, Democratic Staff Director; 

Ashley Jones, Democratic Director, Outreach and Member Services; 

Christopher Knauer, Democratic Oversight Staff Director; Una Lee, 

Democratic Chief Oversight Counsel; and Elizabeth Letter, Democratic Professional Staff Member. 

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

Mr. MURPHY. All right, good morning. We are here at the Oversight and Investigations Subcommittee hearing on Combating the 

Opioid Abuse Epidemic: Professional and Academic Perspectives. 

Welcome. 

Less than 1 month ago, on March 26, we held the first in a series 

of hearings to examine the growing problems of prescription drugs 

and heroin abuse. During that brief span of time, according to the 

best estimates from the Department of Health and Human Services, at least 3,374 Americans will have died from drug overdoses, 

with opioids being the most common cause. That is 3,374 overdose 

deaths in less than 1 month. Indeed, during the time we spend in 

this hearing, another 10 lives will be lost. 

The headlines out of Pittsburgh last week sent shockwaves 

throughout my district with 10 heroin overdoses in a single 24-hour 

period. Of the two who died, they were found with stamped bags 

2 

marked either ‘‘Chocolate’’ or ‘‘Chicken/Waffle.’’ And this is what 

we are up against. This is what is killing our sons and daughters, 

brothers and sisters, mothers and fathers. 

Let me state clearly so as to leave no room for doubt: Our current strategy just isn’t working, and I am not going to stop until 

we start moving in the direction of success, defined not just as getting individuals off of street drugs and onto a Government-approved opioid, but getting them to the point of drug-free living. 

About 3 weeks ago, on the very same day this committee held 

our first hearing on this issue, the Department of Health and 

Human Services released its long-awaited three-part plan to reverse this epidemic. Elements of the plan made sense; however, I 

am puzzled and amazed to read one particular priority included in 

their press release, and I quote, ‘‘Exploring bipartisan policy 

changes to increase use of buprenorphine and developing the training to assist prescribing.’’ 

We are in desperate need of innovations to reverse the current 

trend and not merely maintain it. Why would we focus only a single opioid replacement program rather than the full range of FDAapproved treatments for opioid addiction? Why the fixation on one 

pharmaceutical product? According to testimony presented to this 

committee last year by the Director of SAMHSA’s Center for Substance Abuse Treatment, nearly 1 million people were prescribed 

buprenorphine in 2011. We know that number is much higher 

today, probably closer to 1.5 million people or more. Think about 

that. Success by Federal Government standards for addiction disorders is 1.5 million people prescribed synthetic opioids. Yet, consider the sad fact that States have not seen their investment in 

prescription clinics reverse this opioid epidemic. States like Maryland, Vermont, Massachusetts and others that have made massive 

investments in buprenorphine maintenance have not seen reductions in overdose deaths. On the contrary, things have gotten much 

much worse. 

According to the DEA, buprenorphine is the third most confiscated drug in law enforcement activities in our country today. 

More than morphine, more than methadone, more than codeine. 

Patients are routinely getting buprenorphine prescribed as ‘‘heroin 

helper’’, meaning they get a month’s supply of buprenorphine to 

use whenever they can’t get heroin. It tides them over, enabling 

them to remain in their active addiction. This should more accurately be called addiction maintenance, not just the euphemistically 

called, opioid maintenance. 

Some addicted to methamphetamines go to local bupe mills and 

get a 30-day supply that they promptly sell to buy their drug of 

choice. In the field of addiction treatment, the enabler is part of the 

problem. Helping intentionally or unintentionally to keep a family 

member as an alcohol or drug addict is enabling. Here, the U.S. 

Government is the biggest enabler of them all. 

Some clinics operate cash-only businesses for writing 30-day supplies of buprenorphine at the highest permissible doses; usually 32 

milligrams, knowing full well patients will sell at least of half of 

the pills in order to pay for their treatment or other illicit drugs. 

At our last hearing, Professor Sarah Melton at East Tennessee 

University noted that that there are methadone clinics operating 

3 

on a cash basis, handing out methadone without any other treatment, or buprenorphine pill mills. It is not acceptable that Federal 

taxpayer money be used to support programs that hand out these 

drugs for cash. Worse, Professor Melton testified that there was a 

dearth of good treatment programs. And what happens after the 

patient leaves the treatment program? What is being done to follow-up with patients to prevent relapses and put them on a path 

of real recovery? I fully recognize the importance of medication-assisted treatment as a transition from street drugs and to prevent 

overdose from heroin, but relying on this as the one and only solution shouldn’t be the strategy. 

As I recently heard Dr. McLellan, the former Deputy Director of 

ONDCP say, while there is an appropriate place for medication-assisted treatment, we should not turn a blind eye to the fact that 

there is also a tremendous amount of medication-assisted addiction. It is not acceptable for Federal taxpayer money to be used to 

support treatment programs that lack evidence of effectiveness, or 

that define success merely as an individual with an addiction disorder using heroin fewer times per week than before treatment. 

I am calling for a patient-centered initiative with a goal of 

matching patients with the most appropriate care, coupled with a 

focus on transition not just off street drugs, but eventual transition 

from opioids altogether. I hope to modernize our existing opioid addiction treatment system to ensure that the right patient gets the 

right treatment at the right time. It simply isn’t true to present 

buprenorphine and methadone as opioid-free treatment. We do a 

tremendous disservice to those living with addiction disorders when 

we advance disingenuous double-talk and not state outright that 

buprenorphine and methadone are highly potent opioids. 

We are not going to end this opioid epidemic by increasing the 

use of opioids. We need an exit strategy that enables Americans to 

become opioid-free altogether. We can do better than addiction 

maintenance. We can and we must. 

I look forward to working with my colleagues and HHS as we explore new innovations for detoxification and treatment models to 

transition individuals off of all opioids and into evidence-based 

counseling with non-addictive, non-narcotic behavioral and medication treatments. We don’t do enough to help those addiction disorders. I believe in recovery. I believe in lives being restored so 

that every individual may live to their full God-given potential and 

do so drug free. I consider opioid maintenance as a bridge to cross 

over in addiction recovery, not a final destination. At this point, the 

Government simply stopped building the bridge. We have not yet 

fully helped move those with addiction disorders beyond opioid 

maintenance, and I seek to lay out a vision for recovery that includes complete withdrawal from opioids as an option. Once we lay 

out those goals, we can then move forward with research and clinical efforts, and boldly declare that we are no longer satisfied with 

the status quo of opioid maintenance only. 

To assist us today, the subcommittee will hear from some of the 

Nation’s foremost professional and academic experts in the field of 

opioid addiction. Among these questions we hope these experts will 

address are, What can be done to incentivize individual compliance 

with prescribed treatment plans and reduce the risk of relapse? 

4 

What should be the aim of treatment for opioid addiction: reduce 

the intake of illicit drugs by these individuals to more moderate 

levels, or should the aim be to place patients on a path to detoxification and ultimately a full recovery, ending all illicit uses and removing the need for lifelong opioid maintenance recovery? To what 

extent is the increased prescribing of methadone for pain contributing to more overdose deaths? Are Medicaid and Medicare payments for the treatment of pain incentivizing doctors to prescribe 

the opioids like candy for the treatment of pain? 

Today we have assembled some of the leading opioid addiction 

experts. We welcome you to get your thoughts on dealing with this 

epidemic. And I thank you for your expertise and look forward to 

hearing your testimony. 

[The prepared statement of Mr. Murphy follows:] 

PREPARED STATEMENT OF HON. TIM MURPHY

Less than one month ago, on March 26, we held the first in a series of hearings 

to ‘‘Examine the Growing Problems of Prescription Drug and Heroin Abuse.’’ During 

that brief span of time, according to the best estimates from the Department of 

Health and Human Services, at least 3,374 Americans will have died from drug 

overdoses, with opioids being the most common cause. That’s 3,374 overdose deaths 

in less than one month. Indeed, during the time we spend in this hearing, another 

10 lives will be lost. 

The headlines out of Pittsburgh last week sent shock waves throughout my district: 10 heroin overdoses in a single 24-hour period. On the 2 who died were found 

stamped bags marked either ‘‘Chocolate’’ or ‘‘Chicken/Waffle.’’ This is what we are 

up against. This is what is killing our sons and daughters; brothers and sisters, fathers and mothers. 

Let me state clearly so as to leave no room for doubt: Our current strategies are 

failing and I am not going to stop until we start moving in the direction of success 

defined not just as getting individuals off of street drugs and onto a Governmentapproved opioid, but getting them to the point of drug free living. 

About three weeks ago, on the very same day this committee held our first hearing on this issue, the Department of Health and Human Services released its longawaited three-part plan to reverse this epidemic. Elements of the plan make sense; 

however, I am puzzled and amazed to read one particular priority included in their 

press release (and I quote): 

• Exploring bipartisan policy changes to increase use of buprenorphine and develop the training to assist prescribing. 

We are in desperate need of innovations to reverse the current trend and not 

merely maintain it. Why would we focus only a single opioid replacement program 

rather than the full range of FDA-approved treatments for opioid addiction? Why 

the fixation on one pharmaceutical product? 

According to testimony presented to this committee last year by the Director of 

SAMHSA’s Center for Substance Abuse Treatment, nearly one million people were 

prescribed buprenorphine in 2011. We know that number is much higher today, 

probably closer to 1.5 million people or more. 

Think about that. Success by Federal Government standards for addiction disorders is 1.5 million people prescribed synthetic opioids. Yet, consider the sad fact 

that States have not seen their investment in prescription clinics reverse the opioid 

epidemic. States like Maryland, Vermont, Massachusetts and others that have made 

massive investments in buprenorphine maintenance have not seen reductions in 

overdose deaths. On the contrary, things have only gotten much much worse: 

• According to the DEA, buprenorphine is the third most confiscated drug in law 

enforcement activities in our country today. More than morphine, more than methadone, more than codeine. 

• ‘‘Patients’’ are routinely getting buprenorphine prescribed as ‘‘heroin helper’’— 

meaning they get a month’s supply of buprenorphine to use whenever they can’t get 

heroin. It tides them over,enabling them to remain in their active addiction. This 

should more accurately be called ‘‘ addiction maintenance’’ not just the euphemistic, 

‘‘opioid maintenance.’’ 

• Some addicted to methamphetamines go to local ‘‘bupe mills’’ and get a 30-day 

supply that they promptly sell to buy their drug of choice. 

5 

• In the field of addiction treatment, the ‘‘enabler’’ is part of the problem—helping 

intentionally or unintentionally to keep a family member as an alcoholic or drug addict. Here, the U.S. Government is the biggest enabler of them all. 

• Some clinics operate cash-only businesses for writing 30-day supplies of 

buprenorphine at the highest permissible doses (usually 32 milligrams) knowing full 

well patients will sell at least of half of the pills in order to pay for their ‘‘treatment’’ 

or other illicit drugs. 

At our last hearing, Professor Sarah Melton at East Tennessee University noted 

that that there are methadone clinics operating on a cash basis handing out methadone without any other treatment, or buprenorphine ‘‘pill mills.’’ It is not acceptable 

that Federal taxpayer money be used to support programs that hand out these 

drugs for cash. Worse, Professor Melton testified that there was a dearth of good 

treatment programs. And what happens after the patient leaves the treatment program? What is being done to follow-up with patients to prevent relapses and put 

them on a path of real recovery? 

I fully recognize the importance of medication assisted treatment as a transition 

from street drugs and to prevent overdose from heroin. But relying on this as the 

one and only solution shouldn’t be the strategy. As I recently heard Dr. McLellan, 

the former Deputy Director of ONDCP say, while there is an appropriate place for 

‘‘medication assisted treatment’’ we should not turn a blind eye to the fact that 

there is also a tremendous amount of ‘‘medication assisted addiction.’’ It is not acceptable for Federal taxpayer money to be used to support treatment programs that 

lack evidence of effectiveness, or that define ‘‘success’’ merely as an individual with 

an addiction disorder using heroin fewer times per week than before treatment. 

I am calling for a patient-centered initiative with a goal of matching patients with 

the most appropriate care coupled with a focus on transition not just off of street 

drugs but eventual transition from opioids altogether. I hope to modernize our existing opioid addiction treatment system to ensure that the right patient gets the right 

treatment at the right time. It simply isn’t true to present buprenorphine and methadone as opioid-free treatment. We do a tremendous disservice to those living with 

addiction disorders when we advance disingenuous double-talk and not state outright that buprenorphine and methadone are highly potent opioids. 

We are not going to end this opioid epidemic by increasing the use of opioids. We 

need an exit strategy that enables Americans to become opioid-free altogether. We 

can do better than addiction maintenance. We can and we must. I look forward to 

working with my colleagues and HHS as we explore new innovations for detoxification and treatment models to transition individuals off of all opioids into 

evidencebased counseling with non-addictive, non-narcotic behavioral and medication treatments. 

We don’t do enough to help those addiction disorders. I believe in recovery. I believe in lives being restored so that every individual may live to their full God-given 

potential and do so drug free. I consider opioid maintenance as a bridge to cross 

over in addiction recovery, not a final destination. At this point, we’ve simply 

stopped building the bridge. We’ve not yet fully helped move those with addiction 

disorders beyond opioid maintenance. I seek to lay out a vision for recovery that includes complete withdrawal from opioids as an option. Once we lay out those goals, 

we can then move forward with research and clinical efforts, and boldly declare that 

we are no longer satisfied with the status quo of opioid maintenance only. 

To assist us today, the subcommittee will hear from some of the Nation’s foremost 

professional and academic experts in the field of opioid addiction. Among the questions we hope these experts will address are: What can be done to incentivize individual compliance with prescribed treatment plans and reduce the risk of relapse? 

What should be the aim of treatment for opioid addiction: reduce the intake of illicit 

drugs by these individuals to more moderate levels? Or should the aim be to place 

patients on a path to detoxification and ultimately a full recovery, ending all illicit 

uses and removing the need for lifelong opioid maintenance recovery? To what extent is the increased prescribing of methadone for pain contributing to more overdose deaths? Are Medicaid and Medicare payments for the treatment of pain 

incentivizing doctors to prescribe opioids like candy for the treatment of pain? 

Today we have assembled some of the leading opioid addiction experts to get your 

thoughts about how to reverse this epidemic. We thank you for your expertise and 

look forward to hearing your testimony. 

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

6 

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

Ms. DEGETTE. Thank you so much, Mr. Chairman. Before I make 

my opening statement, I want to announce today is Take Your 

Daughter to Work Day. My daughters tragically have grown up, 

but I have my daughter-for-the-day today, Paula, who is with us. 

Paula is a sixth-grader at Howard Middle School, and she is going 

to be with me today. She just told me she thought it would be really boring to come to the Capitol, but actually, so far she has found 

it to be fascinating. So I think she has a career ahead of her in politics, and we are glad to have her. 

I am also glad, Mr. Chairman, that we are having this hearing 

today. This is our second hearing in the series on this very important issue. 

This is a problem that touches all parts of the country and is 

growing. In 2013, 50 percent of all drug overdoses in this country 

were related to prescription pharmaceuticals. In Colorado, my 

home State, the rate of prescription overdose deaths has quadrupled in the last 10 years. 

I am happy to have this distinguished panel today who I hope 

can actually talk about, Mr. Chairman, what you suggest which is 

science-based treatments, and the best practices for treating this 

disease. All of our panelists have years of experience treating patients struggling with addiction, and I want to hear what all of you 

think is the most effective treatment. 

In our last hearings, we received considerable testimony from experts who told us that medication-assisted treatment, or MAT, can 

play a vital role in treating opioid addiction. Experts tell us that 

a combination of MAT and behavioral treatment, such as counseling and other supportive services, is the best way of treating 

opioid addiction. And, of course, there are several FDA-approved 

medications that have proven effective in treating opioid addiction. 

Now, Mr. Chairman, in your opening, you talked about sciencebased treatments, and I completely support that. You also talked 

about patient-oriented treatments, and I support that too. But in 

doing that, we need to recognize that while it is the goal to get everybody off of these drugs if possible, it is not always the case, and 

we need to look and see at the treatments that should be available 

for every patient. And so in an ideal world, we would have all the 

options available to every patient, and we should strive for that, 

but right now, MAT is not an available option for all patients. Dr. 

Bisaga, for example, will testify today that very few patients with 

opioid addiction receive treatments that have been proven the most 

effective, which includes access to MAT. What many Americans receive instead is a form of rapid detoxification from the drug, followed by an abstinence-only approach. Dr. Bisaga and others have 

called this method outdated and mostly ineffective, and even worse, 

I suppose, it could be dangerous because patients face a significantly elevated risk of dying by overdose if they relapse. So I want 

to ask questions about that today. Is it true that most Americans 

with opioid addictions don’t receive the most effective treatments? 

Do they and their loved ones understand that? Is it true that many 

patients receive treatments that some experts suggest may be inefVerDate Mar 15 2010 11:02 Sep 11, 2015 Jkt 037690 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X34OPIOID PROS\114X34OPIOIDPROSWORKING WAYNE
7 

fective or dangerous? And finally, why is not MAT available as an 

alternative to all patients seeking treatment? 

From the perspective of the Federal Government, it is important 

to have science-based policy so that we are expending our resources 

on efforts that actually have a chance at success. And patients 

seeking treatment for opioid addiction should be apprised of the 

benefits and risks of alternative treatment approaches. 

Now, I understand that we need more study to predict which 

treatment alternatives will be effective for any given patient, and 

that is why I look forward to hearing from Dr. Seppala about the 

work he is doing at the Hazelden Betty Ford to collect data on factors. And by that way, in that vein, I want to recognize our former 

colleague, Mary Bono, who is here with us today, and a former 

member of this wonderful committee. So we are glad to have you 

here, Mary. 

I also recognize that we need more study regarding how to best 

treat opioid-addicted patients for the long-term, particularly people 

who want to taper off of the medications. And I certainly understand and support the desire to move toward medication-free recovery, but we also need to make sure that patients understand the 

risk. 

Finally, Mr. Chairman, much of what is being done to prevent 

and treat the opioid epidemic is happening on the State level. I am 

hoping in one of our future hearings that we can have witnesses 

come from the States to talk about their approaches. In Colorado, 

for example, we have the Colorado Consortium for Prescription 

Drug Abuse Prevention, which is a statewide coalition, and which 

is designing targeted programs. So when we have our hearing, I 

would like to have someone from Colorado. 

I think that this hearing will give us more information, and information and science-based decision making is really what we 

need to make effective use of our resources to combating this very, 

very serious problem of opioid abuse. 

And I yield back. Thank you. 

Mr. MURPHY. Thank you. 

I now recognize the vice chairman of the full committee, Mrs. 

Blackburn, for 5 minutes. 

OPENING STATEMENT OF HON. MARSHA BLACKBURN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF TENNESSEE 

Mrs. BLACKBURN. Thank you, Mr. Chairman. And it is indeed 

Take Your Daughter to Work Day. And after I get to Nashville this 

afternoon, my daughter will go to an event with me. But she is an 

adult and, of course, has two children of her own, and we will not 

take them to that event. 

It is so good to see our former colleague, Mary Bono, here and 

I appreciate the good work that she continues to do on this issue. 

And, Mr. Chairman, I thank you for the hearing because this is 

a critical public health issue, and it does need our attention and 

our best efforts. And we are going to continue to look at this problem of prescription drug and heroin abuse because it has skyrocketed. And since ’97, the number of Americans seeking treatment for addiction to painkillers has increased by 900 percent. 

8 

That should give us all pause. Deaths related to heroin abuse increased 39 percent from 2012 to ’13. That is a 2-year period of 

time. And while heroin use in the general population is still low, 

the number of people beginning to use it has steadily increased 

since 2007. And according to the National Institute on Drug Abuse, 

part of the explanation for the trend is a shift from the abuse of 

prescription pain relievers to heroin as a more potent, readily 

available and cheaper alternative to prescription opioids. 

Addiction and deaths due to overdose are just the tip of the iceberg in terms of medical consequences of this problem. One tragic 

consequence of the problem is neonatal abstinence syndrome. According to Dr. Stephen Patrick at Vanderbilt, in 2013, Tennessee 

became the first State to make NAS a publicly reportable condition 

to the Department of Health. From information reported to our 

Tennessee Department of Health, we know the overall rate is 13 

cases out of 1,000 births in the State of Tennessee. We can and we 

must do better for these babies. Our goal is to improve the Federal 

Government response to this crisis. 

Recently we heard from witnesses who expressed the State and 

local perspectives on this issue. Last year, we heard from a Federal 

panel of witnesses, including CDC, DEA, SAMHSA, NIH, and the 

Office of National Drug Control Policy, and today, we are rounding 

out this focus by hearing from you all who will give us the professional and academic perspectives. And we look forward to your testimony today, and we welcome you. 

And I yield back. 

Mr. MURPHY. And nobody else on this side seeking final 2 minutes, then I will turn towards Ms. Schakowsky for 5 minutes. 

OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS 

Ms. SCHAKOWSKY. Thank you, Chairman Murphy and Ranking 

Member DeGette, for calling this very important hearing on prescription drug and heroin abuse in the United States. Also thanks 

to our witnesses for coming here today to shed more light on this 

issue. 

This hearing could not be timelier. Increasingly, we are hearing 

reports of the toll this crisis is taking in communities across the 

country. And like myself, I am sure that every member of the subcommittee has heard stories from their constituents about the toll 

of prescription drug abuse and heroin abuse, the toll that it has 

taken in their districts. 

I have mentioned previously before this committee that I have a 

constituent, Peter Jackson, who tragically lost his 18-year-old 

daughter, Emily, after she consumed a single Oxycontin tablet that 

she received from her cousin while visiting family. I look forward 

to hearing from our witnesses about the most effective ways to 

combat prescription drug abuse, to learn what additional steps we 

can take together to stop this crisis, and to prevent the further 

tragic loss of life. 

I also want to call attention to the impact that reducing discretionary spending will have on access to treatment and research on 

addiction. Just yesterday, House republicans approved budget alloVerDate Mar 15 2010 11:02 Sep 11, 2015 Jkt 037690 PO 00000 Frm 00012 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X34OPIOID PROS\114X34OPIOIDPROSWORKING WAYNE
9 

cations that will further cut discretionary spending for vital programs like SAMHSA and the National Institutes of Health. We 

have already heard—and we have already seen devastating cuts to 

these same programs. For example, the Substance Abuse Prevention and Treatment Block Grant within SAMHSA when adjusted 

for inflation has actually been cut by 25 percent in the last 10 

years. 

While we are here today to discuss the most effective methods of 

treating addiction, without Federal funding for programs, patients 

will simply not have access to these services, and research on addiction and treatment of addiction will greatly suffer. That is just 

a fact. If we are serious about combating the opioid epidemic, it is 

incumbent that we provide strong Federal funding for the programs that patients and researchers rely on. 

And I want to yield the balance of my time to Representative 

Tonko. 

OPENING STATEMENT OF HON. PAUL TONKO, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW YORK 

Mr. TONKO. I thank the gentlewoman from Illinois for yielding. 

Each and every year, I have spent Super Bowl Sunday in a soup 

kitchen, working alongside and serving individuals of the addiction 

recovery community. Why? Because I choose to land myself in the 

midst of real heroes. The individuals of the addiction recovery community, in my mind, through their courage, determination, and 

conviction are truly heroes. Bearing witness to the joy and rebirth 

that recovery has brought to their lives leaves me no doubt that 

complete recovery to a substance-free life is, and should be, our 

goal for every person who is struggling in the throes of addiction; 

a disease. 

While recovery remains the goal, it is nearly impossible to 

achieve without access to effective treatments. Science tells us that 

the most effective treatment available for opioid addiction is a combination of medication-assisted treatments, commonly known as 

MATs, and behavioral therapy. MATs might not be the preferred 

treatment for everyone, but they constitute a vital tool in our toolbox for treating opiate addiction. Unfortunately, MATs were available in only 9 percent of all substance use facilities nationwide in 

2013, according to SAMHSA. While I will acknowledge the concerns that a reliance on MATs can raise, the immediate tragedy 

here isn’t that some individuals won’t be able to taper off maintenance medications, it is that most won’t even be able to access an 

evidence-based treatment modality that has proven to be their best 

chance of easing the burdens of addiction and saving lives. Across 

my district, there are hundreds on waitlists to access this treatment. Every minute we delay, needed treatment costs lives. In just 

the time that we are having this hearing today, 5 more people will 

die from am opioid overdose, and 4 out of 5 addicted to opioids will 

have no access whatsoever to treatment. This is totally unacceptable. 

No treatment option is perfect, and I strongly support further research that will help us create more effective treatments and cures 

that can rid us of addiction once and for all. For now though, our 

focus has got to be on curbing the epidemic, expanding treatment, 

10 

savings lives, and giving people the stability they truly need to 

achieve recovery. 

I look forward to hearing the perspective of our witnesses on 

these pressing issues. And I yield back, Mr. Chair, the balance of 

my time. 

Mr. MURPHY. Thank you. The gentleman yields back. 

And so we will go right into our witnesses and try and get all 

your testimony done before we have votes, and we will come back 

after votes too. 

We have with us today Dr. Robert DuPont, the President of the 

Institute for Behavior and Health. Additionally, Dr. DuPont was 

the first director of the National Institute on Drug Abuse. Welcome. Dr. Marvin Seppala, the Chief Medical Officer at Hazelden 

Betty Ford Foundation. As acknowledged, Ms. Bono is here with 

you today. Dr. Westreich is the President of the American Academy 

of Addiction Psychiatry. Dr. Anna Lembke is an Assistant Professor of Psychiatry and Behavioral Science at Stanford University 

Medical Center. And Dr. Adam Bisaga is an Associate professor of 

Clinical Psychiatry in the Department of Psychiatry at the College 

of Physicians and Surgeons of Columbia University, and and a research scientist at the New York State Psychiatric Institute. Finally, Dr. Patrice Harris, Elected Member of the American Medical 

Association, Board of Trustees. Dr. Harris has served on the Board 

of the American Psychiatric Association, and was an APA delegate 

to the AMA. I feel like I should get continuing education credits 

today—— 

Ms. DEGETTE. I know. 

Mr. MURPHY [continuing]. For being here. 

I will now swear in the witnesses. 

You are aware that the committee is holding an investigate hearing, and when doing so, has the practice of taking testimony under 

oath. Do you have any objections to taking testimony under oath? 

All the witnesses say they do not object. So the Chair then advises 

you that under the rules of the House and the rules of the committee, you are entitled to be advised by counsel. Do any of you desire to be advised by counsel during testimony today? All the witnesses decline. So in that case, will you all please rise, raise your 

right hand, and I will swear you in. 

[Witnesses sworn.] 

Mr. MURPHY. Thank you. All the witnesses have answered in the 

affirmative. So you are now under oath and subject to the penalties 

set forth in Title XVIII, Section 1001 of the United States Code. I 

will call upon you each to give a 5-minute statement. Just pull the 

microphone close to you, press the button, and make sure the light 

is on. And try and keep your comments under 5 minutes. 

Dr. DuPont, you are recognized first. 

11 

STATEMENTS OF ROBERT L. DUPONT, M.D., PRESIDENT, INSTITUTE FOR BEHAVIOR AND HEALTH, INC.; MARVIN D. 

SEPPALA, M.D., CHIEF MEDICAL OFFICER, HAZELDEN BETTY 

FORD FOUNDATION; LAURENCE M. WESTREICH, M.D., PRESIDENT, AMERICAN ACADEMY OF ADDICTION PSYCHIATRY; 

ANNA LEMBKE, M.D., ASSISTANT PROFESSOR, PSYCHIATRY 

AND BEHAVIORAL SCIENCES, STANFORD UNIVERSITY 

SCHOOL OF MEDICINE; ADAM BISAGA, M.D., RESEARCH SCIENTIST, NEW YORK STATE PSYCHIATRIC INSTITUTE; AND 

PATRICE A. HARRIS, M.D., SECRETARY, BOARD OF TRUSTEES, AMERICAN MEDICAL ASSOCIATION 

STATEMENT OF ROBERT L. DUPONT 

Dr. DUPONT. Thank you, Mr. Chair. It is a privilege for me to 

be with you. 

And let me pick up on some of the things that were presented 

just now. I think one of the most counterproductive approaches to 

the problem is to pick drug-free against medication-assisted treatment, and I think every time we do that we undermine dealing 

with the problem at all. We undermine public confidence, and I 

think it is contrary to what the public interest is and public health. 

And let me be very clear that I believe that full recovery is consistent with continuing to take medications for opiate dependence; 

buprenorphine, methadone, and naltrexone. The issue to recovery, 

to me, is not whether they are taking the medicine, it is are they 

using drugs, are they using alcohol, are they still involved in drugdependent behavior. And that is not compatible with recovery. And 

I am going to talk a little bit more about that issue about drug use 

in medication-assisted treatment, which I don’t think is recovery, 

but I think that concept is very important, just like these patients 

taking psychiatric medicines is fully compatible with recovery. So 

I think that, to me, is a way to bring this together. 

And I also point out what Dr. Marv Seppala is going to talk 

about on the Hazelden Program, which brings together medication 

and the drug-free programs as the way into the future. 

And the last point I want to make before I really get started is 

to think about the elephant in the room when we are talking about 

recovery, and that is the 12-step programs; AA and NA, are an 

enormous part of what we are talking about, about getting well. 

We did a study, the first national study of physicians health programs, and we have now followed up with that 5 years after the 

mandatory monitoring. And 97 percent of those physicians were 

still in recovery 5 years after mandatory—and we asked them what 

part of the program was most helpful to you, and they were in very 

high quality treatment and many other services, by far the biggest 

percentage was participation in 12-step programs. That was what 

was most important to them. So I want to make sure at our hearing we understand the importance of that in terms of recovery. 

Now, my focus is on the users, and I want to make one point 

very clear. Opiate dependence is not like the common cold; it does 

not go away, it is a lifetime problem. A person who has opiate dependence is going to deal with that problem one way or another for 

his or her lifetime. If you don’t understand that then the concept 

of treatment is confusing because you think you are going to be 

12 

confusing because you think you are going to be fixed in treatment. 

People are not fixed in treatment with opiate dependence. Treatment can help them find their path to recovery, but treatment is 

not recovery, and it is really important that people are not fixed 

in any treatment, drug-free or medication treatment. It is a lifetime struggle, and that is a very important perspective on this. 

Now, my concern is that treatment does not match up with the 

disease. The treatment is always short-term. Even medication-assisted treatment, which conceptually goes on for a lifetime, has 

very high drop-out rates, very rapid—patients drop out of the program for medication-assisted treatment. And the other thing is a 

high percentage of people in medication-assisted treatment continue to use opiates and other drugs while they are in the program. 

That is very important to notice that and pay attention to that. But 

even more important, and the thrust of my testimony, all of it is 

accountability for treatment. What are the results during treatment? What percentage of the patients are continuing to use 

drugs? How much retention is there? What is the retention curve 

of the program? How long do they stay in treatment? And when 

they leave, are they any better off than they were when they came 

in? Those questions need to be asked and answered in a systematic 

way. 

The other thing I pick up on the chairman’s statement about the 

standard. What we want is recovery. That means no use of alcohol 

and other drugs, including opiates, not just opiates but all drugs. 

That is what recovery is. It requires that. And what I am proposing 

and encouraging the committee to do is to look long-term, because 

the nature of the disorder is long-term. And I use the 5-year recovery standard. Start with a person who enters treatment. Where is 

that person in 5 years? And you can look at any program; drugfree or maintenance—or medication-assisted, and ask the question 

how good is this program at getting a person into a stable recovery. 

That is one standard for all treatments, and it gets you focused on 

the long-term. And when we do that in this country, including in 

the Federal Government, the whole game changes and we have a 

mechanism to improve treatment. Treatments can all compete on 

a level playing field to achieve that goal. 

So that is my testimony. Thank you very much. 

[The prepared statement of Dr. DuPont follows:] 

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Mr. MURPHY. Thank you. Thank you very much. 

Dr. Seppala, you are recognized for 5 minutes. 

STATEMENT OF MARVIN D. SEPPALA 

Dr. SEPPALA. Chairman Murphy and Ranking Member DeGette, 

thank you very much for inviting me to participate in this important hearing, and for your leadership in addressing the crisis of addiction to opioids in this country. 

My name is Marv Seppala, I am the Chief Medical Officer of the 

Hazelden Betty Ford Foundation. I attended Mayo Medical School, 

and have been practicing in the addiction field for 27 years. On a 

personal note, I have also been in long-term recovery from addiction since age 19. 

The Hazelden Betty Ford Foundation is the Nation’s largest nonprofit addiction treatment provider, and we have been around since 

1949. We have 16 sites in 9 States. We offer prevention and recovery solutions nationwide for youth and adults. At our facilities, we 

have seen a pronounced increase in the number of patients with 

opioid use disorders, paralleling the grim stories you have probably 

been hearing about in your districts for some time now. At our residential youth facility, for example, opioid dependence rates increased from 15 percent of patients in 2011 to 42 percent in 2014. 

That is a dramatic rise, and this is an especially difficult addiction 

to treat. Individuals dependent on prescription pain medications 

and heroin often face unique challenges that can undermine their 

ability to stay in treatment and ultimately achieve long-term recovery. They are hypersensitive to pain and more vulnerable to stress. 

Their anxiety, depression, and intense craving for these drugs can 

continue for months, even years, after getting free from opioid use. 

They experience a strong desire to feel normal again, to escape 

what seems like a permanent state of dysphoria, which puts them 

at high risk for relapse. They are also at higher risk of accidental 

overdose during relapse because they no longer have the tolerance 

to handle the same doses they were taking prior to treatment. In 

other words, with opioids, unlike other drugs, relapse often means 

death. 

In 2012, we launched a new protocol to treat opioid addiction, the 

Comprehensive Opioid Response with 12 Steps, or COR–12 as we 

call it. Our approach is grounded in the traditional 12-step facilitation model and based on abstinence, but it now also utilizes the 

safest live-saving medications that keep patients engaged in recovery long enough to achieve lasting sobriety. 

We don’t see a conflict in utilizing medications and pursuing abstinence, just as Bob described. Even when medications are part of 

our protocol, abstinence is still the objective. In fact, one might call 

it a third way because it strikes a reasonable commonsense balance 

between those who see medication assistance and abstinence as 

diametrically opposed. 

Our COR–12 Program includes changes to traditional group therapy, additional patient education about opioids, and the option now 

of medication assistance. We utilize extended-release naltrexone, 

Vivitrol, as well as buprenorphine/naloxone, or Suboxone, to help 

engage patients long enough to complete treatment, and then become established in solid 12-step recovery. The highest risk period 

23 

for relapse is the first 12 to 18 months after treatment, so we prefer to have our patients involved and on medication in outpatient 

care throughout this extended period. And our goal is to discontinue medication as our patients become established in longterm recovery. 

While our clinicians recommend which medication is appropriate, 

the final decision is up to the patient, and about 1⁄3 of our COR– 

12 patients elect to use no medication. Indeed, medication only addresses the biologic aspect of addiction. Our broader measures treat 

the psychological, social, and spiritual components to improve psychosocial functioning, enrich relationships, and foster a healthier 

lifestyle. And those are the keys to recovery that last. 

Our COR–12 Program has resulted in more patients completing 

residential treatment, and a reduction in overdose deaths after 

treatment. While the research study of COR–12 is ongoing, and we 

do not have full results yet, we do know that COR–12 patients stay 

in treatment longer. Our atypical discharge rate, those who leave 

treatment early, for our general population is 13 1⁄2 percent, and for 

those with opioid dependence who don’t enter this program, it is 

over 22 percent. However, in this program, it is only 7.5 percent. 

Now, based on our early positive results, we plan to continue 

paving the way for others to use both scientific and spiritual solutions to engage more people in treatment, save lives, and ultimately help more people get into long-term recovery. 

I would also like to emphasize the need to educate a wider culture about the dangers of opioid overprescribing. The troubling 

trends began to emerge in the late ’90’s after the FDA approved 

Oxycontin and allowed it to be promoted to primary care physicians 

for treatment of common aches and pains. Education campaigns 

often funded by opioid manufacturers minimized risks, especially 

the risk of addiction, and exaggerated benefits to using these 

opioids long-term for common problems. When prescribing on a 

short-term basis to treat moderate to severe acute pain, opioids can 

be helpful, but when these are highly addictive medications that 

are taken around the clock for weeks, months, and years, they may 

actually produce more harm than healing. An increasing body of research suggests that for many chronic pain patients, opioids are 

neither safe nor effective. Over time, patients often develop tolerance, leading them to require higher and higher doses, which ultimately can lead to quality of life issues and functional decline. 

It should be noted that doctors didn’t start overprescribing out of 

malicious intent, but rather out of a desire to relieve pain more 

compassionately. 

Now, we have a culture that seeks opioid medication for pain relief, not just for physical pain but also to numb psychic pain. Some 

of these patients have a significant risk for the development of addiction in a culture that promotes quick fixes, instant gratification, 

and escapism. Medical professionals need further education about 

the proper use of opioid medications and their risks. The general 

public also needs such education to prove recognition of risk, and 

limitations of these powerful, dangerous medications. It is time 

now to address opioid overprescribing and overuse without stigmatizing pain. This crisis deserves the attention you are providing 

today, and requires a substantial response. 

24 

Thanks again for having me here, and for your leadership. I look 

forward to answering your questions. 

[The prepared statement of Dr. Seppala follows:] 

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Mr. MURPHY. Thank you, Doctor. 

Now, Dr. Westreich, you are recognized for 5 minutes. 

STATEMENT OF LAURENCE M. WESTREICH 

Dr. WESTREICH. Mr. Chairman, members of the committee, 

thank you very much for inviting me to speak to you today about 

treatment for opioid addiction. Dr. Murphy, before I start, I would 

like to say that as a psychiatrist specializing in addiction, I am 

particularly appreciative of the clinical awareness you have imparted to the Helping Families in Crisis Act, which will focus resources on helping our patients. I am Board certified in general 

psychiatry, addiction psychiatry, and forensic psychiatry, and I 

serve as president of the American Academy of Addiction Psychiatry, which is a professional organization for psychiatrists who specialize in the treatment of addiction and other mental illnesses. 

My primary professional focus is on the clinical treatment of addicted people. I trained at Bellevue, where I worked for many years 

and continue to teach, and I treat people addicted to opioids in my 

offices in Manhattan and in New Jersey, where I live. I know this 

committee understands very well the lethal nature of opioid addiction. You don’t need us to tell you about that. My main goal in 

speaking with you today is to underline what you have already 

heard; opioid-addicted people need access to a broad range of treatments for opioid addiction. This must include access to medicationassisted therapy, and treatment for co-occurring psychiatric disorders. I have treated homeless, heroin-injecting senior citizens, 

college students who snort Oxycontin, and practicing attorneys who 

must take an opioid pill every few hours in order to continue seeing 

their clients. The death and destruction I have seen due to opioid 

addiction is profoundly disturbing, but thankfully with appropriate 

treatment, the more common return to health, the workplace, and 

family, is what keeps most of us doing the clinical work which 

helps addicted people in their search for recovery. 

Part of that clinical work includes full treatment for what is ailing the addicted person. Research demonstrates that the opioidusing person often has a co-occurring mental illness, like major depression, bipolar disorder, or PTSD. Sometimes the opioid user is 

self-medicating uncomfortable mood states or anxiety, or just has 

difficulty soothing him or herself. All these circumstances can increase the risk for relapse, and require sophisticated and individualized psychiatric evaluation and treatment. Research makes it 

clear that prescribing the appropriate effective medication to help 

the patient with craving, along with talk therapy and treatment for 

a co-occurring psychiatric disorder, gives the addicted person the 

best possible chance for recovery. 

That sophisticated treatment system must include access to welltrained clinicians who can select between the available psychosocial 

treatments like relapse prevention therapy, cognitive behavioral 

therapy, medications like buprenorphine, methadone, and 

naltrexone, and mutual support groups like Narcotics Anonymous. 

For many, mutual support groups like AA or NA can be extremely 

helpful, but they are not treatment, nor do they claim to be. They 

are support groups which can be lifesaving for some, and not so 

much for others. As you have heard, the available research has not 

39 

provided us with a silver bullet that works for all opioid addiction. 

Rather, the data tell us that some treatment works for some opioid 

addicts some of the time. Others may respond to a very different 

approach. That is one reason we clinicians must have all available 

arrows in our quivers. We must have the skills and training for a 

broad array of approaches to meet the treatment needs of each patient. Quite often, using a treatment—team approach that includes 

psychologists, social workers, nurses and counselors, is critical to 

therapeutic success. 

The wide variety of personal choices addicted people make about 

treatment is yet another reason for supporting the full spectrum of 

treatment possibilities from medication-assisted treatments with 

buprenorphine and methadone, to opioid blockers like naltrexone, 

to relapse prevention therapy. Some patients demand to be treated 

without medications, while others clearly want and need medication to control their craving. And they also require more specific 

psychiatric treatment for any co-occurring disorders. 

Use of buprenorphine and methadone, which are both opioids 

like heroin, can be controversial. When I talk to opioid-addicted 

people and their families, I sometimes, but not always, recommend 

tapering or maintenance with buprenorphine or methadone. The 

question is not whether the medication has side effects; all medications do, but whether the risk is worth the benefit. Patients and 

their families need to know that detoxification treatment and drugfree counseling are associated with a very high risk of relapse. As 

with other medical conditions, the relevant question about whether 

a medication is worth the risk is the following. Compared to what? 

Is taking buprenorphine or methadone better than dying from an 

overdose, better than contracting HIV or Hepatitis, flunking out of 

school, losing a marriage, losing a job? One-size treatment does not 

fit all, and different patients may need different treatments. But 

the very good news in this situation is that people who are able to 

stop their use of illicit drugs, whether through psychotherapeutic 

interventions, medications, and/or help from NA, or most likely 

some combination of the above, can return to vibrant and productive lives. It is that return to physical and emotional health, which 

I find so gratifying; it empowers me to help my patients to keep 

trying. 

Before I stop, let me reiterate my main point, and what I know 

you have heard from many others. Opioid-addicted people need access to a broad range of treatments for addiction. This must include 

medication-assisted treatment, and treatment for co-occurring psychiatric disorders. 

Thank you very much for inviting me today. 

[The prepared statement of Dr. Westreich follows:] 

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Mr. MURPHY. Thank you very much. 

Dr. Lembke, you are recognized for 5 minutes. 

STATEMENT OF ANNA LEMBKE 

Dr. LEMBKE. Thank you for inviting me today to these hearings. 

The main point I would like to make today is simple. We don’t 

just have an opioid abuse epidemic or an opioid overdose epidemic, 

we have an opioid overprescribing epidemic. 

Doctors are a major pipeline of misused and diverted prescription 

opioids, and contrary to what is commonly believed, doctors who 

treat addiction are not the main source of the problem. 

The methadone that accounts for 40 percent of single drug opioid 

pain reliever death is almost entirely in the form of pills prescribed 

for the treatment of pain, rather than coming from methadone 

maintenance clinics that treat heroin-dependent patients. We, thus, 

need to think broadly about the problem with changing the behavior of all physicians and not just those who treat addicted patients. 

I was pleased to see the education of providers was identified as 

one of three priority areas in the report issued last month from the 

Department of Health and Human Services, which called prescribers ‘‘the gatekeepers for preventing inappropriate access.’’ But 

providing educational material on safe opioid prescribing, even if it 

is free and readily available, won’t be enough. To change doctor 

prescribing behavior we need first to acknowledge the enormous incentive to prescribe opioids, and the disincentives to stop prescribing. Many doctors are afraid that a patient will sue them or 

complain about them if they don’t prescribe opioids, even when the 

doctor knows the opioid is harming that patient. Also, no insurer 

questions me when I prescribe Vicodin for pain, but if I want to 

prescribe Suboxone to help an addicted patient stop taking Vicodin, 

I typically have to spend hours fighting an insurance company to 

get the prescription approved. Despite the Mental Health Parity 

and Addiction Equity Act that Congress passed by a huge bipartisan margin in 2008, many insurers still resist reimbursing for addiction treatment. 

The solution to this problem lies in giving doctors tangible incentives to prescribe more judiciously, such that neither pain nor addiction is undertreated. 

Today, I focused on three areas where I believe this Congress can 

make a positive difference. Number one, require revision of 

healthcare quality measures. Number two, incentivize use of prescription drugs monitoring programs. And number three, scrutinize 

accreditation organizations and regulatory agencies. 

First, require revision of healthcare quality measures. The Centers for Medicare and Medicaid Services and the Joint Commission 

exert enormous control over how doctors practice medicine today. 

Their quality measures set the standard of care. In the 1990s, they 

urged doctors to prioritize pain treatment, and that is what we did. 

Prescriptions for opioids skyrocketed, not always to the benefit of 

our patients. 

CMS and the Joint Commission need to link quality measures to 

treatment outcomes for patients with addictions. This will 

incentivize hospitals and clinics to create an infrastructure to 

screen for and treat opioid addiction. 

46 

Quality measures should also limit excessive prescribing of multiple drugs to the same patient, especially of controlled medications. A younger person with no objective evidence of disease 

should not be on 10 different medications, yet I often see this, and 

the medications frequently include an assortment of stimulants, 

sedatives, and opioids. Also, far too many patients are on a prescription of benzodiazepines at the same time as opioids, which 

greatly increases their risk of overdose. 

Finally, CMS and Joint Commission quality measures should not 

be linked to patient satisfactions with opioid prescribing. Illness recovery, not patient satisfaction surveys should be the arbiter of 

quality care. Doctors are not waiters, and opioids are not items on 

a menu. 

Second, incentivize use of prescription drug monitoring programs. Prescription drug monitoring programs allow doctors to see 

all the controlled medications prescribed to a patient beyond just 

the ones that they prescribe. When physicians make use of prescription drug monitoring programs, prescription drug misuse decreases. Monitoring programs don’t merely limit access to opioids 

when they should not be prescribed. They allow for patients who 

really need them to get them. The question is how to get more doctors to use these databases. By some reports, only 35 percent of 

prescribers use these databases. Here are some ways to incentivize 

doctors to use prescription drug monitoring programs. Make it a 

billable medical service. Mandate education on use of PDMPs when 

physicians apply for DEA licensure. Amend privacy laws such as 

42 C.F.R. so that healthcare providers can freely communicate with 

each other around issues related to prescription drug misuse. 

Third, scrutinize accreditation organizations and regulatory 

agencies. The Joint Commission, the accreditation organization 

which sets standards for hospitals, was instrumental in socializing 

doctors to liberally prescribe opioids for pain. The Joint Commission’s campaign on treating pain was funded in part by Purdue 

Pharma, whose main product is Oxycontin. I do not think Congress 

should allow a major healthcare accreditation body like the Joint 

Commission to take money from the pharmaceutical industry. 

In 2012, the Food and Drug Administration wisely rescheduled 

hydrocodone products to Schedule II, but the very same week, the 

FDA approved the use of Zohydro, a longer-acting opioid with high 

abuse potential, similar to Oxycontin. The FDA’s own advisory 

panel recommended not to approve Zohydro, yet it was approved 

anyway. Why? Do we really need one more high-risk opioid medication on the market? It seems to me like trying to empty a bathtub 

with a thimble, while filling it with a firehose. 

Furthermore, the FDA should live up to its commitment to stop 

approving non-abuse deterrent formulations of opioids, which it did 

not do when it approved Zohydro. And doctors and patients need 

to understand that abuse-deterrent formulations make it harder to 

crush and snort and inject an opioid, but they do not prevent ingesting opioids orally at high doses, becoming physiologically dependent on and addicted to them, and overdosing on them. 

To sum up, Congress can push back against the opioid epidemic 

by requiring revision of healthcare quality measures to reduce 

overprescribing, incentivizing use of prescription drug monitoring 

47 

programs, and scrutinizing accreditation organizations and regulatory agencies. All 3 approaches will save lives and improve the 

practice of medicine at the same time. 

Thank you again for this opportunity to testify, and for your 

leadership in addressing this public health epidemic. 

[The prepared statement of Dr. Lembke follows:] 

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Mr. MURPHY. Thank you, Doctor. 

Now, Dr. Bisaga, you are recognized for 5 minutes. 

STATEMENT OF ADAM BISAGA 

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

DeGette, and members of the committee, both for holding this 

hearing and for inviting me to speak to you today. 

My name is Adam Bisaga. I am a scientist, working on developing new medication strategies to treat opioid dependence. I am 

also educating physicians nationally with regards to safe and effective use of these mediations, and I have been practicing addiction 

psychiatry for the past 20 years. 

I would like to speak on the opioid epidemic from the perspective 

of medical management. And I want to point out how our current 

drug treatment system in the United States is outdated; that it 

does not reflect the scientific progress we have made in the past 

50 years. Our current system is built on the model for treating patients with alcoholism, and it is not capable of responding to the 

unfolding opioid epidemic. 

Opioid addiction is manifested by the compulsive use of opioid 

painkillers or heroin. Patients have abnormal activity in several 

brain regions, and experience powerful urges to use that they find 

very difficult to control. This abnormal brain activity can persist for 

months throughout the abstinence, driving high relapse rates. 

Medications can stabilize opioid receptors in the brain; reducing 

craving, eliminating withdrawal, and blunting the patient’s ability 

to feel the effects of heroin. These medications work best in conjunction with psychosocial therapies to produce long-lasting abstinence. This approach has success rates similar to treatments we 

have for many other medical and psychiatric disorders. However, 

in stark contrast, the treatment for most other disorders, very few 

patients with opioid addiction receive evidence-based treatment. 

The traditional approach of a brief detoxification followed by 

therapy-only approaches has no evidence for treating effectively 

opioid addiction. In addition, this approach can be very dangerous. 

Patients that do not receive medications to block the effects of relapse face an elevated risk of dying when they relapse. Certainly, 

all of us have witnessed it on too many occasions. 

So we have three FDA approved medications; methadone, 

buprenorphine, and naltrexone. Methadone activates opioid receptors in the brain and blocks the effects of heroin or painkillers. 

Methadone-treated patients use less heroin, have fewer medical 

complications, and have improved social and work functioning. In 

other words, they are able to lead a normal life. Methadone is the 

most effective medications we have, however, it is a potent medication, and can cause sedation or even death. Therefore, dispensing 

of methadone is highly regulated. 

Buprenorphine works similarly to methadone, but only partially 

activates opioid receptors. It also protects patients from overdose 

risk. Because buprenorphine is safer than methadone, less monitoring is needed and it can be prescribed by the doctors in their offices. 

Naltrexone, the last medication, is available as either a daily tablet or a monthly injection. Naltrexone works differently from methVerDate Mar 15 2010 11:02 Sep 11, 2015 Jkt 037690 PO 00000 Frm 00058 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X34OPIOID PROS\114X34OPIOIDPROSWORKING WAYNE
55 

adone and buprenorphine. It completely blocks opioid receptors, 

and it is used after detoxification to prevent relapse. It has no 

abuse potential, there is no withdrawal when it is stopped. 

Treatment with medication works best as a maintenance intervention, without a predefined length of treatment. There is no scientific evidence showing benefits to limiting the time someone is 

treated with medication. Opioid addiction is a chronic brain disease, and that responds best to chronic treatment. 

Methadone, buprenorphine, and naltrexone have all different 

mechanism of action. In this era of personalized medicine, patients 

respond best to medication that are tailored to their individual 

needs. All of these medications are needed to adequately address 

the opioid epidemic. Every American should have access to these 

medications, and with the help of a physician, help make an informed decision about their path to recovery. Regulations should be 

put in place to make buprenorphine and naltrexone available at 

every treatment center working with patients addicted to opioids. 

More than 100 of individuals, many of them young adults, die of 

opioid overdoses every day. Medication-assisted treatment is the 

best way to reduce the number of deaths on a large scale. Addiction 

is a treatable disorder, and a joint effort of health professional, 

community advocates, and policymakers is urgently needed to reverse this tragic trend. 

Thank you for the opportunity to testify. 

[The prepared statement of Dr. Bisaga follows:] 

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Mr. MURPHY. Thank you. Appreciate it. 

We are going to try and get Dr. Harris’ testimony in, then we are 

going to run to go vote and come back. 

So you are recognized for 5 minutes. 

STATEMENT OF PATRICE A. HARRIS 

Dr. HARRIS. Thank you. Good morning, Mr. Chairman and Ranking Member, and esteemed members of the subcommittee. I am 

honored to testify today on behalf of the American Medical Association. My name is Dr. Patrice Harris. I am Secretary of the AMA 

Board of Trustees. I am also the Public Health Officer for Fulton 

County, which includes Atlanta, and I am a practicing psychiatrist 

with experience in addiction. 

We are indeed in the midst of an epidemic. Physicians are deeply 

disturbed about the rise in overdoses and fatalities from prescription opioids, as well as the rapid increase in deaths from heroinrelated overdoses. The numbers are sobering and unacceptable. 

The AMA is working on a number of fronts with many other 

groups to develop recommendations and implement specific strategies to confront this public health crisis. Physicians are stepping up 

and taking responsibility to prevent and reduce abuse, misuse, 

overdose, and death from prescription opioids. We also need to 

make sure that our patients who experience pain receive the treatment they need. With opioids, if clinically appropriate, and that patients who have an opioid use disorder have timely access to affordable, comprehensive treatment. 

These are complex problems and there is no one solution. A 

multifaceted, public health strategy is needed. There are key components to this strategy. First, physicians must continue to amplify 

our efforts to train and educate ourselves to ensure that we are 

making informed prescribing decisions, considering all available 

treatment options for our patients, and making appropriate referrals for our patients with substance use disorders. As part of the 

prescriber clinical support system for opioid therapies funded by 

SAMHSA and administered by the American Academy of Addiction 

Psychiatry, the AMA is developing new training materials on responsible opioid prescribing, including a focused educational module on opioid risk management for resident physicians. 

Patients in pain deserve compassionate care, just like any other 

patient we treat. The dialogue must change to reduce the stigma 

that is associated with pain. We need to increase insurance coverage for evidence-based alternative, multidisciplinary, non-drug 

pain management therapies. At the same time, we need to support 

access to opioid-based therapies when clinically appropriate. 

Opioid use disorder is a chronic disease that can be effectively 

treated, but it does require ongoing management. Physicians need 

more resources so that evidence-based treatments such as medication-assistant treatment in conjunction with counseling and other 

behavioral therapies and interventions are more available and accessible to all of our patients. There are not enough programs and 

many are not affordable. 

We strongly support lifting the cap and expanding the number 

of patients that office-based physicians can treat with 

69 

buprenorphine and Suboxone, which are major tools in treating 

opioid use disorder. 

Naloxone has saved thousands of lives across the Nation, and we 

strongly support increasing access to it. We encourage physicians 

to prescribe naloxone to their at-risk patients, but barriers still 

exist to using this effective drug to prevent overdose deaths. 

Now, one way to reduce one of these barriers is passage of Good 

Samaritan laws so that healthcare professionals, first responders, 

friends, family members, and bystanders who see someone who had 

overdosed can help save a life without fear of liability. 

Last, prescription drug monitoring programs can be a helpful 

clinical tool. However, to be most effective and used more often, 

PDMPs need to be real time, interoperable, and available at the 

point of care as part of a physician’s workflow. In order to get to 

this point though, Congress needs to fully fund these programs so 

that States can modernize and fully fund and staff them. 

So in summary, we know that it is up to our profession to provide the leadership necessary to confront this epidemic, and we 

commend this committee’s leadership and look forward to working 

with you and other stakeholders to promote evidence-based solutions. Our patients deserve no less. 

Thank you. 

[The prepared statement of Dr. Harris follows:] 

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Mr. MURPHY. Thank you, Dr. Harris. And thank you to the 

panel. 

We are in the middle of votes, so we are going to break here. It 

is going to take us about half an hour or so for votes. We will come 

back. 

I just wanted to leave one sobering statistic I have here about 

this. In North America, the number of deaths from plane crashes 

between 1975 and today was 42,495. 1975 through today. For the 

United States, the number of drug overdose deaths last year was 

43,000. If we were here having a hearing on plane crashes, we 

would need an arena to handle the media. What a sad day it is 

with 43,000 people died in this country last year. I feel that we 

need to have people understand the severity of that. 

I thank this panel for your testimony. We will come back and ask 

you questions in a few minutes. Thank you. 

[Recess.] 

Mr. MURPHY. All right, we are going to return to our hearing 

here, and as members come in, we will put them in the queue. 

So let me start off here. I want to ask a question here. Dr. 

Seppala, a Federal policy prohibits Medicaid matching funds being 

used at inpatient facilities with more than 16 beds whose patient 

roster is more than 51 percent people with severe mental illness, 

and for individuals between the ages of 22 and 64. Does this affect 

inpatient substance use disorders clinics as well when they have 

those limitations? 

Dr. SEPPALA. It sure would, absolutely. Any population that is restricted in that manner is not going to get adequate treatment. 

Mr. MURPHY. So again, making sure we have options available, 

that is a barrier that we need to eliminate. 

Dr. SEPPALA. Yes, increasing options for addiction treatment is 

really necessary in this country. We don’t have adequate treatment 

to address this problem, but we also have a public health information problem because, if you look at the data from SAMHSA, you 

will see that over 95 percent of the people with addiction don’t even 

know they have it. So that is where the initial problem lies. And 

then of that small group that seeks treatment, the biggest problem 

is access. 

Mr. MURPHY. Now, Dr. DuPont, I want to show you a poster 

here. According to the National Institute on Drug Abuse, for patients treated with opioid addiction with buprenorphine, there is a 

92 percent of relapse with an illicit opiate within 8 weeks after 

stopping treatment. But look at the increases here—this line is 

buprenorphine—from 2003 to 2012, and it has gone up even higher 

now. Methadone rates have remained fairly flat, and heroin rates 

have increased slightly over this time. So I am wondering, given 

these statistics, and given the huge relapse rate with 92 percent, 

relapse with an illicit opiate within 8 weeks after stopping treatment, are we doing enough to hold treatment programs accountable 

to make sure that they are getting people the additional treatments 

to get them on the road to recovery? 

Dr. DUPONT. Well, that is very important information, absolutely, and to me, it shows that buprenorphine or methadone are 

not magic bullets, but they are very attractive to many patients 

and they bring a lot of people into treatment, and that is a good 

80 

thing. I think the question, to me, is what happens to them then? 

And if they just go out and leave the program, nothing very good 

is happening. I am excited about the possibility of having a longerterm perspective on the buprenorphine patients, and helping them 

over a longer period of time. But the answer is, as you show there, 

that most stay a very short time and the outcome when they leave 

is that they relapse to the opiates. 

Mr. MURPHY. And I want to make sure we are all on the same 

page, because what I am pushing for is I want to make sure we 

have a standard here that has hopes of getting people off of substances. And I recognize, like any other field, we can’t reach 100 

percent, but our goals should never be less than 100 percent. But 

there is a big overlap also with people with mental illness. 

Dr. Westreich, so people with mental illness and severe mental 

illness who are actually seeking some substances to numb the effects or self-medicate. I see a lot of these in the military with folks, 

and of course, it makes a bad situation worse. But then when you 

have someone who is now addicted, and we are trying to wean 

them off, I would like to think that this is not just a matter of substituting an opiate with buprenorphine or methadone as a replacement as a road of treatment, but really thinking in terms of should 

they be on another medication, a psychotropic drug, something else 

to treat the underlying mental illness. Is this an appropriate hypothesis? And two, are we doing this, and if not, why not? 

Dr. WESTREICH. First of all, I think it is absolutely an appropriate hypothesis, and I don’t think we are doing it enough. 

I think the point is that people who have addictive disorders as 

well as another mental illness need to have very sophisticated clinicians who are trained in being able to recognize psychiatric symptoms and what they mean. Do they mean that the person is simply 

medicating some uncomfortable symptoms? Do they mean that the 

person has got a freestanding psychiatric illness, which must be 

treated with psychotropic medications, or some combination of the 

above? And so this speaks to the training of psychiatrists, psychologists, social workers, counselors who need to be trained to recognize mental illness symptoms and treat them effectively. 

Mr. MURPHY. And we have heard repeatedly in this committee 

that the huge shortage of psychiatrists, psychologists, especially 

child/adolescent ones, to deal with this issue. But another concern 

we have heard is from States that there are limitations on—they 

have funds for substance abuse, and they have funds for mental illness, and oftentimes they can’t use those together. 

Anybody want to comment on that of what we should be doing 

to make sure that they have maximum flexibility in the States? 

Can anybody comment on that? Dr. Bisaga? 

Dr. BISAGA. I think those very often is more of a norm than an 

exception that they go together. So keeping them separate, in separate pools of money, doesn’t really make sense from a clinical perspective. I think we are much more effective when we are integrating treatment for mental illness and substance abuse by the 

same provider in the same setting. This is the way to have better 

outcomes. 

Mr. MURPHY. Thank you. Anybody else want to comment? Yes, 

Dr. Seppala? 

81 

Dr. SEPPALA. In our residential settings, in our youth settings, so 

it is about age 14 to 24, over 95 percent of our population enters 

treatment with a coexisting diagnosis of a mental illness. In our 

adult populations, again, a residential not outpatient setting, it is 

over 75 percent. So what we are seeing is comorbid psychiatric illness with addiction in our treatment settings. It is the norm. We 

have to treat both. 

Mr. MURPHY. Thank you. 

Ms. Schakowsky, you are recognized for 5 minutes. 

Ms. SCHAKOWSKY. So I have never seen that chart before and, 

you know, you first look at the chart and you think that 

buprenorphine is a bad idea. I mean that is how it looks. So I wondered if anyone—— 

Mr. MURPHY. Yes, I am just saying we are doing more of it, 

but—— 

Ms. SCHAKOWSKY. So maybe Dr. Bisaga can speak to that? 

Dr. BISAGA. Well, you know, obviously, this is a very complex 

problem. You know, we see increasing rates of buprenorphine prescribing because we have an epidemic and we are trying to expand 

the number of people that are treated with this medication. So it 

tells us a lot of things. It is true that not every buprenorphine 

treatment program is to the best standards, but that shouldn’t 

really stop us from trying to expand access. We still have a shortage of providers that are trained to deliver this treatment. But if 

this chart had also a number of people addicted to painkillers, this 

line would probably go down, which I think speaks something 

about at least the beginning of making a—— 

Ms. SCHAKOWSKY. But it does it mean that methadone is better, 

or—— 

Dr. BISAGA. Well, you know, when you compare methadone with 

buprenorphine in a similar situation, methadone is a little bit more 

potent as a medication, but because it is such a, you know, difficult 

medication to use, it cannot be really widely, you know, as easily 

disseminated to the community as buprenorphine, and that is why 

we are pushing for the buprenorphine, again, as a first step of engaging people in treatment, protecting them from overdose, and 

then engaging them in the long-term psychosocial recovery-oriented 

treatment. 

Dr. LEMBKE. Yes, I would just add that this is a really—I just 

would add a really important difference between buprenorphine 

and methadone is that the methadone—the overdose risk with 

methadone is very high, whereas the unique pharmacology of 

buprenorphine makes it very unlikely for people to overdose on it. 

Ms. SCHAKOWSKY. Right. 

Dr. LEMBKE. And so for that reason, there is a huge advantage 

in using buprenorphine, especially since one of the primary things 

we are trying to stop is the number of people who are dying due 

to opioid overdose. 

Ms. SCHAKOWSKY. So also let me understand, on the panel, is 

there anybody who doesn’t think that the combination of meds and 

psychosocial treatment, that one or the other itself is the way to 

go? No, oK. 

So let me ask Dr. Lembke. Unfortunately, there are a number of 

barriers then for people to get medication, assisted treatment, 

82 

MATs, and one of the barriers is insurance coverage. And according 

to the American Society of Addiction Medicine, Medicaid coverage 

for MAT varies greatly from State to State, the chairman was talking about that, with some States not covering all FDA-approved 

medications, imposing prior authorization requirements, and failfirst criteria that require documentation that other therapies were 

ineffective. I wondered, Dr. Lembke, if you have experienced these 

issues in your practice, both of Medicaid and private insurers? 

Dr. LEMBKE. So that is very common with both Medicaid and private insurers that when you try to get coverage for addiction treatment, they give you the huge runaround, you have to talk with 

somebody on the phone for hours regarding medical necessity, 

whereas that is not true if you are prescribing a pharmacologically 

identical medication, or a very similar medication, for the treatment of, for example—— 

Ms. SCHAKOWSKY. So what does that—— 

Dr. LEMBKE [continuing]. Pain. 

Ms. SCHAKOWSKY [continuing]. Really mean for patients? 

Dr. LEMBKE. Well, what that means is that you want to get addiction treatment for patients who are struggling with the disease 

of addiction, and you can’t get insurance companies to pay for it, 

which means that patients don’t access the treatment. All you are 

left with is non—you know, interventions outside of the infrastructure of medical institutions, which is primarily just the 12-step 

movements. So it is a huge problem. 

Ms. SCHAKOWSKY. And so in your opinion, and anybody else can 

weigh-in on this too, would increased coverage of MATs help more 

individuals to remain in recovery? 

Dr. LEMBKE. Well, what happens now is that—what I see with 

private insurers is that they say they cover MATs, but then, basically, they have all kinds of loopholes whereby they can deny that 

coverage, and they just make it so incredibly bureaucratically cumbersome in real time, you know, in the trenches, that you end up 

throwing up your hands. And once you start somebody on 

buprenorphine, you don’t want to just suddenly not have it available to them, but that happens frequently because all of a sudden, 

you have been denied coverage. It is insane. 

Ms. SCHAKOWSKY. Anybody else want to comment on that? 

Dr. SEPPALA. Yes, I could speak to it. 

Ms. SCHAKOWSKY. Yes, Dr. Seppala. 

Dr. SEPPALA. We have had to increase our own infrastructure 

just to have enough people involved to get these medications approved. 

Ms. SCHAKOWSKY. You are talking about people who spend time 

on the phone and—— 

Dr. SEPPALA. Yes. Yes. 

Ms. SCHAKOWSKY. OK. 

Dr. SEPPALA. So trying to limit our doctors’ involvement and 

have other people do that, usually nurses, but it really has required adding FTEs to what we do. So increasing our expenses just 

to get these medications approved by insurance companies. 

Ms. SCHAKOWSKY. And eventually you do get them approved usually? 

83 

Dr. SEPPALA. I would say usually is a good description. Not always. 

Ms. SCHAKOWSKY. Yes. OK. 

Dr. HARRIS. And I also would like to add that it is increasing coverage for MAT, but it is also increasing coverage for the other 

interventions; the behavioral interventions, the therapies, cognitive 

behavioral therapies, the other therapies that we know compliment 

MAT and work well. 

Ms. SCHAKOWSKY. And those are hard to—— 

Dr. HARRIS. It is very difficult to—— 

Ms. SCHAKOWSKY [continuing]. Get approved? 

Dr. HARRIS [continuing]. Get coverage for that, yes. 

Ms. SCHAKOWSKY. Thank you. OK, I don’t know, can Dr.—— 

Dr. BISAGA. Can I—yes, on the other hand, another trend is that 

insurance companies know that this saves them money. Evidencebased treatment saves money. So we also see a trend of them declining to pay for the programs that do not offer evidence-based 

treatment; psychotherapy and the medication and on the 12-step. 

So that is another good trend. So hopefully we, you know, we can 

use the data to inform how we should actually invest in the public 

healthcare. 

Ms. SCHAKOWSKY. Thank you so much. Thanks, Mr. Chairman. 

Mr. MURPHY. Well, I want to follow up on what she is saying. 

It is very important, especially in light of the mental health parity. 

So we want to make sure that evidence-based care is there. Medication-assisted treatment is there as part of a protocol, psychosocial 

therapy is part of a protocol, using the proper things. Just talk 

therapy in a general concept isn’t going to work, it has to be very 

focused with someone who understands addiction. And part of our 

challenge here is, we had previous testimony from some places just 

talking about pill mills where doctors are just cranking out lots of 

medication, and since 90 percent of people we found weren’t in any 

kind of treatment, and of those getting treatment, only 10 percent 

of that were getting the evidence-based treatment. It sounds like 

what you are saying the insurance companies are kind of throwing 

the baby out with the bathwater here, responding to Ms. 

Schakowsky’s questions, making it very difficult to get proper 

treatment. And since most people aren’t getting treatment anyway, 

shouldn’t they be focusing on something else? Dr. DuPont? 

Dr. DUPONT. A point about that—that the evidence of what— 

what is the evidence we are talking about, and the evidence for evidence-based is what happens to the person while they are taking 

the medicine. It is not what happens to them later. Where do they 

go? And what I am encouraging is to have evidence-based assessment of what the consequences are—what the long-term outcome 

is of all of these treatments. Which treatments are getting people 

into stable recovery, which are not. And that is not what we are 

doing now. Our evidence is what happens while they are there, in 

the face of the fact that you have very rapid cycling through these 

programs. If we are talking about dealing with an epidemic, we 

have to deal with those people as individuals for their lifetimes, for 

long periods of time. That is why I say 5 years. So evidence-based 

of while they are in the treatment is good, but it is not what we 

84 

really want. Is it evidence of getting them into stable recovery or 

not—— 

Mr. MURPHY. Thank—— 

Dr. DUPONT [continuing]. That is the question that has to be 

asked. 

Mr. MURPHY. Thank you. 

Ms. DeGette, 5 minutes. 

Ms. DEGETTE. Thank you very much. 

Dr. Lembke, I am listening with interest to this discussion, and 

others might have also input on this, but why is it so difficult to 

get insurance companies and others to pay for these appropriate 

treatments? 

Dr. LEMBKE. My belief is that essentially insurance companies do 

not want people on their panel who have chronic lifetime diseases 

that will need chronic lifetime care, and they essentially view the 

addicted population wrongly as folks who cannot get better and will 

always need lots of medical care. And it is really an untrue bias 

that insurance companies have that mirrors a bias that society has, 

because the truth is when you get addicted persons into quality addiction treatment, they have about 50 percent response recovery 

rates, which is on par with recovery rates for depression and many 

other chronic illnesses—— 

Ms. DEGETTE. So—— 

Dr. LEMBKE [continuing]. With a behavioral component. 

Ms. DEGETTE. So you think that they don’t want to—they are reluctant to get—pay for a treatment plan if they think that it could 

be a chronic long-term plan? 

Dr. LEMBKE. Yes, that those people are going to be—— 

Ms. DEGETTE. Yes. 

Dr. LEMBKE [continuing]. Costly for them. They don’t—— 

Ms. DEGETTE. Right. And—— 

Dr. LEMBKE. They don’t want to—— 

Ms. DEGETTE. And you think one of the solutions might be putting more patients on those boards? 

Dr. LEMBKE. Patients on—— 

Ms. DEGETTE. People who have dealt with recovery and so on, 

is that what I am hearing you saying? 

Dr. LEMBKE. On what boards? 

Ms. DEGETTE. On the insurance review boards. 

Dr. LEMBKE. You know, it is a weird group thing that happens 

even when you have physicians who you have to talk to who are 

representing insurance companies, their mandate is to withhold 

care. Their mandate is to pay for as little as humanly possible. I 

mean I can tell you horror stories about hour-long conversations I 

have had with physicians representing insurance companies who 

then denied care in cases where care was—— 

Ms. DEGETTE. So—— 

Dr. LEMBKE [continuing]. Obviously needed. 

Ms. DEGETTE. So, Dr. Bisaga, I want to follow up with that because in your testimony, you said that very few of the patients with 

opioid addiction receive treatments that have been proven to be effective, and you said the treatment most of them were receiving is 

outdated and mostly ineffective. What kind of treatment is that 

that people are receiving that is just not working? 

85 

Dr. BISAGA. Right, so we just had a wonderful example from Dr. 

Seppala talking about kind of the best possible treatment that marriages very efficiently 12-step with the medications. This is really, 

really exception. This is 1 of the 1 percent. Majority of people, the 

treatment consists of going to the hospital, getting detoxified, and 

then trying to be encouraged to go to the 12-step meetings without 

being told even that there are evidence-based medications. 

Ms. DEGETTE. So what it is, it is kind of a truncated treatment. 

It is like we are—— 

Ms. BISAGA. Again—— 

Ms. DEGETTE [continuing]. We are going to give you some— 

maybe we are going to give you some medication, we are going to 

make—we are going to tell you to go to this treatment, then you 

are on your own. 

Ms. BISAGA. Right. So we only going to detox you, and we expect 

you—that you going to stay abstinent. There is no information 

about the evidence-based medications. After detoxification, opiate 

blocker could be a way to maintain—— 

Ms. DEGETTE. OK. So there is not—there is not even medication 

involved in most of these. 

Ms. BISAGA. No. Many inpatient detoxifications do not put people 

on medication. It—— 

Ms. DEGETTE. They just detox them—— 

Ms. BISAGA. Yes. 

Ms. DEGETTE [continuing]. And then they—— 

Ms. BISAGA. Detox them and sell them to 12-step groups. 

Ms. DEGETTE. OK. 

Ms. BISAGA. It is changing, but slowly. 

Ms. DEGETTE. And do all of the rest of you agree with that, that 

that is what is going on for the most part? Yes? OK. 

Now, Dr. Westreich, you said in your testimony, patients and 

their families need to know that detoxification treatment and drugfree counseling are associated with a very high risk of relapse. So 

it is sort of the same question that I was asking Dr. Bisaga, do you 

think that patients enrolling in programs that employ this approach are being given adequate information to make informed decisions about their treatment? 

Dr. WESTREICH. Well, I think that is exactly the question. At the 

middle and end of that treatment episode, they should be given information about their particular case and what their likelihood for 

relapse is, and what possible treatments are, including medications, including abstinence models, and be able to make an informed decision based on having those treatments available to 

them. And my concern is when they are not available, the person 

cannot make an informed decision. 

Ms. DEGETTE. Right. If you never have MAT offered as an alternative, you can’t have a complete program. 

Ms. WESTREICH. Exactly. 

Ms. DEGETTE. And this is not just your idea or the other esteemed members of this panel, this is like scientifically proven, 

right? 

Dr. WESTREICH. Yes. 

Ms. DEGETTE. Yes. 

Dr. LEMBKE. Can I just add one thing? 

86 

Ms. DEGETTE. Please. 

Dr. LEMBKE. You know, MAT works for some people, it doesn’t 

work for everybody—— 

Ms. DEGETTE. Right. 

Dr. LEMBKE [continuing]. And what some people who are in the 

acute crisis of the disease of addiction need is to be put into a hospital so they can detox, and hopefully then get routed to some kind 

of behavioral or residential treatment. And that is also very hard 

to get insurance companies to pay for. 

Ms. DEGETTE. Right, and if you can find a program to put them 

in. 

Dr. LEMBKE. Even to put them in the hospital—— 

Ms. DEGETTE. Exactly. 

Dr. LEMBKE [continuing]. I mean, even to put them in the hospital for 3 or 4 days is very hard. 

Ms. DEGETTE. And, you know, let me just say, Mr. Chairman, I 

really appreciate this hearing because this is exactly what I have 

been trying to say is, it is not a one-size-fits-all solution for these 

patients, there are different types of solutions, but if you take out 

one of the programs that really works, like MAT, or the MAT plus 

the intensive long-term counseling, not only are you going to have 

a failure rate, but you are also going to have deaths. So thank you. 

Mr. MURPHY. And even that is difficult for them to get. 

Dr. Burgess, recognized for 5 minutes. 

Mr. BURGESS. Thank you, Mr. Chairman. And I do have a number of questions for Dr. Harris. Thank you for being here today. I 

may end up submitting those to you in writing and ask for a written response because I do want to use part of the time that I have 

available to get on my soapbox. That is what we do here. 

This is not quite the appropriate hearing, but this subcommittee 

does have jurisdiction over the Food and Drug Administration, and 

several times we have had the Food and Drug Administration in, 

I have asked the question why we cannot have the availability of 

naloxone or Narcan as an over-the-counter purchase. Why Federal 

law prohibits dispensing without a prescription, but why? No one 

is going to abuse Narcan. Narcan can be a lifesaving measure. 

Sure, I want first responders, police departments, EMTs, I want 

them to have it available in their armament when they arrive on 

the scene of a person who is unconscious. Are there—I don’t think 

we will be inducing anyone to misbehave by having a rescue method at their disposal. 

So, Mr. Chairman, I just wanted to get that out of the way. I do 

think the Food and Drug Administration needs to work on this. I 

think this is one of the things that—I mean you referenced in your 

opening statement the tragedies that occur happen in my suburban 

area as well. The tragedies that occur when we lose a young person 

through what presumably is an unintentional opiate overdose. 

And then the other thing that I just feel obligated to talk about, 

I mean I was in practice for a number of years. Covered for other 

doctors, as we all do, and I know there were times that I was 

burned by a patient who was exhibiting drug-seeking behavior and 

I didn’t immediately recognize it. I tried to guard against that. In 

fact, the latter years that I was in practice, I would not fill a prescription of a patient I did not know over the phone, I would go 

87 

to the office and look up their chart. If I couldn’t find their chart, 

yes, that might be on us because we didn’t have electronic records, 

we had paper charts, I would offer to meet that patient in the 

emergency room and evaluate their signs and symptoms, and if appropriate, prescribe a medication. Suffice it to say, most of the time 

that did not occur and the patient was not willing to come in and 

spend the time required. 

But look, we have prescription drug monitoring programs. And I 

will tell you one time just sticks out in my mind how frustrated I 

was. Called in a prescription for a patient with a very plausible 

story, and the pharmacist said, you know, you are about the fifteenth doc that has called in medicine for that patient this month. 

And I said, what, that is crazy. Well, cancel the prescription. He 

said, you have already called it in, I will fill it for her when she 

shows up, but I just thought you ought to know. And I forget the 

number he gave me, but it was an astounding number of Tylenol 

III that this patient had received during the month. And forget the 

codeine part of the prescription; this was a multiple times lethal 

dose of acetaminophen that, if somebody had actually ingested it, 

their liver was long gone and someone would be paying for a liver 

transplant. We have prescription drug monitoring programs. We 

have one that was passed by this committee, called NASPER, and 

President Bush signed it into law in 2005. There is a competing 

program that was done by the appropriators. That is not your problem, that is our problem. But, Mr. Chairman, it just underscores 

how we need to fix that. And now, we ask the American people 

with the Stimulus Bill to fund this large electronic health records, 

and do we have the interoperability so a doc in practice would 

know what that patient is taking? We don’t really have the availability of getting that because of HIPAA, there are some privacy 

concerns. Somehow we need to bridge that gap, and I really would 

welcome anyone’s comments on the panel about the prescription 

drug monitoring aspect. 

Dr. WESTREICH. I would like to comment—— 

Mr. BURGESS. Yes, Doctor. 

Dr. WESTREICH [continuing]. On both. First, I agree 1,000 percent about Narcan, having that available not only to first responders but to families of people who have members who use opioids. 

I agree with you, and I don’t see any reason why that can’t happen. 

Regarding the prescription monitoring programs, we have one in 

New York State where I practice, where I am obligated to look at 

it each time I prescribe an opioid medication. There is one in New 

Jersey which covers Connecticut and Delaware, but there is no national one. So someone can be getting an opioid medication in the 

State next door and I would have no idea from the pharmacy monitoring program. We need to have a fully national program, and it 

would be enormously helpful for treating our patients. 

Mr. BURGESS. Our other problem is we have to—yes, Dr. 

Seppala? I am sorry. 

Dr. SEPPALA. I would like to support both of your recommendations, Congressman. We should have over-the-counter naloxone. It 

is a very innocuous drug, you know that, and there are not many 

side effects or problems you could cause with it. It does one thing; 

it blocks opioid receptors in a very safe manner. 

88 

And as far as the prescription drug monitoring programs, when 

they are not mandatory, as was described earlier, only about 33 

percent of the docs use it, so there is not adequate information on 

them. We need it to be mandatory and across State lines. So I 

agree with both. 

Mr. BURGESS. Yes, Dr. Harris? 

Dr. HARRIS. Yes, PDMPs are a valuable tool. They have valuable 

information, important information for doctors who are prescribing, 

however, they have to be easy to use, available at the point of care. 

Totally agree with interoperability. 

I do want to say that we have some data, we look across the 

States, and where they are readily available at the point of care 

and have real-time information, doctors are using them, but where 

they are more burdensome and don’t have real-time information, 

doctors are not using them as much. And so I think the AMA is 

actually—I chair a task force looking at this issue, and one of the 

things we might come up with is perhaps what should a model 

PDMP look like, to give guidance on that so that doctors increase 

their use of PDMPs. 

Mr. BURGESS. Thank you. 

Mr. Chairman, I will yield back. 

Mr. MURPHY. Yes, just as a follow-up. So what you are describing 

here is just to even know when you are prescribing—you know if 

a patient has already been prescribed opioids by their physician, to 

be able to follow that up. And then in addition to that—but you are 

also treating someone with an addiction disorder. That is the 42 

C.F.R. Part 2 issue. 

Dr. Lembke, can you comment on that about how we need to 

make modifications to that? I am thinking that our former colleague, Patrick Kennedy, is always on me saying we have to fix 

this problem too, that someone has—getting addiction treatment, 

they are not even going doctor shopping, they are actually trying 

to get help, and they go see another doctor, the doctor doesn’t know 

they are getting addiction treatment and he says, here, take this 

Percocet, take this. Can you comment on that, Dr. Lembke? 

Dr. LEMBKE. Yes, so the phenomenon we essentially have today 

is that on one side of the aisle in a medical institution you have 

people prescribing Vicodin, on the other side of the aisle you have 

people trying to get them off of it, and each other doesn’t know 

what the other is doing because, according to 42 C.F.R., we cannot—it is a higher burden of privacy than even HIPAA, if someone 

is getting substance use treatment, we cannot communicate without their expressed consent to another provider that they are getting that treatment. 

This Code of Federal Regulations was implemented more than 2 

decades ago with good reason. What was happening was that police 

were going into methadone maintenance clinics and essentially arresting people who were trying to get treatment for their addiction. 

And so it was a higher burden on privacy so that people wouldn’t 

resist going into treatment because they were afraid of being exposed around their addiction. But in this day and age of electronic 

medical records, and this day and age of prescription drug misuse, 

most importantly, as well as just the fact that we are trying to advocate for addiction being a disease, and we can’t advocate for adVerDate Mar 15 2010 11:02 Sep 11, 2015 Jkt 037690 PO 00000 Frm 00092 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X34OPIOID PROS\114X34OPIOIDPROSWORKING WAYNE
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diction being a disease if we treat it differently from other diseases. 

So I believe we have to amend 42 C.F.R. so that doctors can communicate openly about which patients are possibly misusing the 

drugs that they are prescribing to other providers caring for those 

patients. 

Mr. MURPHY. Other people agree with that? 

OK, Mr. Tonko, you are recognized for 5 minutes. 

Mr. TONKO. Thank you, Mr. Chair. 

All of us on this dais are seeing the toll that addiction can have 

on our communities. However, with that in mind, insufficient data 

are available in the field of opioid addiction treatment. I would like 

to better understand from our panelists just how we should move 

forward with investments in research. How should those efforts be 

utilized to improve recovery outcomes? 

Dr. DuPont, you have been treating opioid addiction for a long 

time. How would you advise us in terms of research dollars—we obviously need to do more in research, I would hope that would be 

an agreement across the board here, but how should those dollars 

be invested, in what ways are they most beneficial? 

Dr. DUPONT. Evaluations of outcomes over a longer period of 

time. But I want to bring up something that I don’t think has been 

clear here, and that is no matter what happens with prescription 

drugs, there is a robust heroin market and it is getting bigger all 

the time, and I think it will be a huge mistake for us to think that 

the only problem we have is prescription drugs. That is contributing to it, that has kicked it off, but now it has taken off in an 

entirely different direction and it is huge, and I think we underestimate the power of heroin distribution in the country that produce 

high quality products at low cost, and that is just going to get 

worse. So I think that is something to keep in mind. 

The other thing is—— 

Mr. TONKO. But that supply and demand equation is something 

we hear about all the time. I hear about it all the time in the district. People are very concerned. 

Dr. DUPONT. Well, it is a very, very serious problem, and it 

drives me nuts that people who want to solve the drug problem by 

legalizing drugs. I say let’s start with heroin. We are going to solve 

that problem by legalizing it? Give me a break. But it is a very serious problem for us to deal with. 

But the other point is, most people who have this problem do not 

see that they have a problem. They do not want treatment. When 

they go to treatment, they drop out of treatment. To get good longterm outcomes the answer is not just in the treatment. You can improve treatment and improve treatment and improve treatment, 

and you are still going to have tremendous frustrations getting people in, and keeping them in and keeping them clean when they 

leave. And that is why I studied the physicians health programs, 

because what those programs do is monitor the people for 5 years. 

And the physicians don’t have a choice of getting out once they are 

diagnosed, and it is interesting how positive they are about that. 

I think one of the things this committee could do is look at the environment in which the choice is made to use and not to use, and 

think about what can be done to change that equation. 

90 

One area of tremendous potential is the criminal justice system, 

where there is the kind of leverage that you have. You have 5 million people on probation and parole in this country, many of whom 

are opiate dependent, but I think also for families to understand 

that they have to be concerned about somebody who has an opiate 

problem, and not—and essentially manage that environment for 

that person, because that person’s judgment is changed by the addiction and they are helpless on their own without somebody intervening. So I would suggest 2 things. One is look long-term, and the 

other is think about the environment in which that is going on, and 

think about ways of using the environment to promote recovery. 

Mr. TONKO. And to our other panelists, are there ways that research can be connected into positive treatment outcomes? 

Dr. SEPPALA. Absolutely. It should be one of the focuses of most 

research to look at positive treatment outcomes, and actually negative treatment outcomes, to define both for the rest of the field so 

we know what we are doing, and we can individualize care in a 

much better way. Right now, there is no research that shows who 

should be on buprenorphine versus who should be on Vivitrol. It 

has not been defined. Our field is limited in regard to the type of 

research to make those decisions. We need a great deal more research in this field. 

Mr. TONKO. Is there anything that has been planted as a seed 

that needs to be grown to a bigger program of research, or is it just 

being avoided in general? 

Dr. SEPPALA. I think research dollars are so limited across medicine right now that it is really hard to get—— 

Mr. TONKO. Well, there is a theme around here at times to cut 

research, which I oppose. I think it is the wrong path, but—— 

Dr. SEPPALA. We have a huge system, we are in 16 States, and 

we don’t even have the infrastructure to gain grants from NIH. We 

can’t do that, we have to partner with people to get research dollars. The research we are doing on this program I described is selffunded. We can’t get the money we need to do the research in our 

setting. 

Mr. TONKO. Anyone else on the panel? Yes, Doctor. 

Dr. BISAGA. Well, I mean, you know, the most of the rest of the 

medicine is moving towards personalized medicine or precision 

medicine, but we are trying to find out which treatments work best 

for which patients so we can avoid wasting time giving ineffective 

treatments. And this is very relevant to this hearing because we 

have four methods of treatment; three medication and maybe some 

people will even respond to no-medication treatment. And we have 

a lot of people affected by the illness. So investing in pursuing, 

again, research, which patients should be treated with which medications, which can be done probably, would be the very smart way 

to use the research dollars to address this, you know, huge problem. 

Mr. TONKO. I, with that, yield back. 

Mr. MURPHY. Thank you. Excellent questions. 

Ms. Brooks, 5 minutes. 

Mrs. BROOKS. Thank you, Mr. Chairman, and thank you so much 

for holding this critical hearing. 

91 

Last year in Indianapolis, an area that I represent, and to the 

north, we saw massive spikes, and I heard from our public safety 

officials, and I a former United States Attorney, about the increased use of heroin in our communities. I met with law enforcement officials first before meeting with treatment providers to see 

what they were seeing, and one of the greatest frustrations some 

of the law enforcement officials in Indianapolis had, who have now 

been trained in the use of Narcan, it is a pilot project being used 

in the city, they would save someone, and about 2 weeks later save 

them again. Same person who they have saved their life, they are 

now getting saved once again by even the same officer. And what 

they were so frustrated about is, where are the treatment providers. You know, we are saving them, you know, they are taken 

to the hospital, where is the system, what are we doing. 

Then when I met with treatment providers, obviously, as we 

have learned, I mean it is very, very difficult, A, to get people to 

stay in treatment, to realize they need the treatment. Drug courts 

sometimes work, and not enough communities have drug courts, although I have recently heard that drug courts—some drug courts 

are not allowing medication-assisted treatment. I am curious what 

your thoughts are about that, because we fund drug courts. Much 

of their funding comes from Federal grants. And so I think that is 

something that we ought to realize that when these patients are 

going in to the drug courts, which can save their lives, there is no 

question about it, would like your comments on that. And then finally, I just would ask all of you, because physicians, whether they 

are in the ER, whether they are part of treatment providers, or 

whether they are treating them for something else, what more 

should we be doing to educate our physicians, because I have also 

prosecuted physicians who became pill mills for communities, this 

was back in the Oxycontin days, but what do we need to do to better educate physicians and psychiatrists about how to treat addictions, because we are not there, we are not even close to being 

there. And I applaud all of you for your work. And I guess I would 

start with the drug treatment courts that we actually may have 

some leverage over. I don’t know who would like to comment about 

drug treatment courts. 

Dr. BISAGA. If I may. You know, I have a lot to say on the issue 

of these topics, but this is very important topic because a lot of people who are under criminal justice system custody really are there 

because they have a disease that affects their functioning and may 

cause them to do criminal things, and the way to help them get out 

of the custody is to treat their medical illness, which is an addiction. However, the drug courts and the judges still, I think, tend 

to think in the old days, thinking that the way to treat them is to 

send them to the medication-free treatment, not medication-assisted treatment. So we are working with the Bureau of Prisons, 

and hopefully you guys can help with that tool, to encourage them 

to use evidence-based treatment when they are making decisions 

about the medical treatments. It can be done in combination with 

the decision about the, you know, criminal justice with ability. 

So—— 

Mrs. BROOKS. Because, you are right, our prisons, which we also 

fund, obviously, as people are coming out of prison, probably one 

92 

of the top reasons they recidivate and are back within a short period of time is they didn’t have their addiction dealt with, and they 

are—anyone else like to comment—— 

Dr. WESTREICH. Yes, as—— 

Mrs. BROOKS [continuing]. Or all of—— 

Dr. WESTREICH. As to drug courts, I mean I would say on both 

of your questions, education is the key. I think drug courts are 

great. I think judges and lawmakers need to be educated about addiction itself and not practice medicine. In the same way, we clinicians need to be educated about law and about the necessity for a 

holding structure of people who are addicted. So I think drug 

courts work well when everyone is educated about what they are 

doing, about therapeutic jurisprudence, which is what that is. 

Secondly, as far as educating doctors, I agree 100 percent. I think 

we need to have much better efforts both through the auspices of 

groups like mine, and organized medicine in general, to educate not 

only psychiatrists but primary care doctors and all physicians 

about prescribing practices, and then about recognizing and treating addiction in an evidence-based manner. So education in both 

spheres, I think. 

Dr. LEMBKE. We give a lot of lip service to addiction being a 

chronic medical illness, but we don’t actually treat it like one, either in the medical system or in the criminal justice system. I cannot imagine a judge working with someone in the criminal justice 

system saying you have to go off your diabetes or your hypertension meds, otherwise you can’t be in this court system. We 

wouldn’t accept that, and yet we accept them saying to these individuals you can’t be on Suboxone. 

So obviously, we don’t regard it as an illness. Even within the 

medical system, doctors do not treat it like a medical illness. So we 

need a huge frame shift. And I think education is really important, 

but unless, again, you incentivize doctors and judges, and whoever 

it is, to really treat it like an illness and create the infrastructure 

to treat it like an illness, you are not going to make any headway. 

Mrs. BROOKS. And while my time is up, Mr. Chairman, I believe 

Dr. Seppala would like to address that question as well, if that is 

oK. Thank you. 

Dr. SEPPALA. I would. We have had a couple of leaders of the 

drug court system come and look at our program, and they have 

held a fairly conservative stance in regard to the use of Suboxone 

and other maintenance medications for opioid dependence over 

time, but I think they are shifting. So I believe that you could play 

a huge role in pushing them along in this direction. They need to 

go there. 

Mrs. BROOKS. And their education. 

Dr. DUPONT. Could I just make one quick comment about this? 

In the physicians health programs, about 1⁄3 of the physicians in 

those programs are opiate addicts, about 1⁄2 are alcoholics, and the 

rest are other drugs. We looked at what happened to the opiate addicts’ physicians, none of them were given Suboxone or methadone, 

and they did as well as the alcoholics in their long-term outcomes. 

They did very, very well without medication. Now, that is a specialized population, I don’t want to generalize it, but I just want to get 

that clear. 

93 

I would suggest in the drug courts that the committee encourage 

the drug courts to actually look at the question, like they are doing 

in Hazelden, and see for themselves, do they get better results 

when they offer that as an option. I think that is a researchable 

question. I think it could go either way. I don’t know what would 

happen, but I think that would be the way to talk about it with 

them, and I think they would be receptive to that. 

Mrs. BROOKS. I want to thank you, Mr. Chairman, for that. And 

I think with respect to educating judges and lawyers, while you are 

focused on physician addicts, there are plenty of judges and lawyers who also could share their knowledge and experience, and 

maybe help better educate our judges and lawyers. 

I yield back. 

Mr. MURPHY. Thank you. 

I now recognize Mr. Kennedy for 5 minutes. 

Mr. KENNEDY. Thank you, Mr. Chairman. I want to thank the 

chairman and the ranking member. I want to also thank an extraordinary group of panelists for your dedication to this issue, 

which is really—it is a preeminent group that we have here. So 

thank you for your testimony today. It has been a big help, I think, 

as we try to think through these issues. 

And, Chairman, I also want to thank your kind comments about 

my cousin, Patrick, as well. This has obviously been an issue that 

has been very close to his professional life’s work, and I appreciate 

your recognition of those efforts. 

A number of you have talked about incentives over the course of 

the testimony today. And, Dr. DuPont, you also mentioned the impact of heroin and the heroin trade. I, like my colleague, Ms. 

Brooks, was a prosecutor—I was a State prosecutor. I ended up 

prosecuting an awful lot of property crimes; breaking and entering 

cases, that were more—it was kids, 18, 20, 22 years old, that were 

breaking into 15 cars in a night to try to feed an Oxycontin addiction. Massachusetts has been struggling with this for years now. I 

met recently with the DEA and, you know, rough numbers, but 

they describe the drug trade with Mexico alone to be in the order 

of $30 billion a year. And a big percentage of that is heroin. So 

until we kind of wrap our minds around the fact that, as the street 

market for Oxycontin is 80—or essentially, a buck a milligram, so 

$80 a pill, but you can get heroin for $3 or $4 a bag, there is a 

very strong economic incentive to push you into heroin. And I think 

I have said this before at these hearings, meeting with local law 

enforcement, meeting with Federal law enforcement back home, a 

widespread recognition, we will not arrest our way out of this problem. So the question becomes, if it is a demand-based epidemic, because people are addicted and that is fueling either because of 

overprescription, because of easy access, and then a migration towards heroin, how do we make sure that we don’t even get there 

in the first place? 

So, one, I wanted to get some thoughts from you, Dr. DuPont and 

Dr. Lembke, as to what we can be doing to make sure that your 

efforts here hopefully one day aren’t necessary, but then two, we 

have touched on this a little bit, in my study of this—people will 

follow incentives, and the Federal Government has systematically 

underinvested in substance abuse treatment and in mental health 

94 

now for decades. I hear from our hospitals, our doctors, our patient 

groups, everybody, our judges, our court system, there are not beds 

for people to get treatment. So if we start reimbursing for—if you 

start to put the economic incentives in for doctors to get compensated adequately for their time for there to be actually treatment facilities, you will see more beds, you will see more treatment 

facilities, you will see more wraparound services. So I was hoping 

to get both of you to comment on that as well, and what—I guess 

bifurcated question to start, what should we be doing to—hopefully 

to make sure we actually one day don’t need all of these services 

you are talking about, and in the meantime, what incentives— 

where should we be really focused on these incentives to build up 

and flush out so that people can get the continuum of care that 

they need? 

Dr. DUPONT. Well, I think one thing to focus on is the drug problem is not just about heroin or opiates; we have a very serious drug 

problem across a very broad spectrum to deal with. But I also want 

to just say it has been my privilege to work with Patrick often, and 

he is a genuine hero of our field and a hero to me. An extraordinary guy who is making a tremendous contribution. 

And I want to go back to those young men you were arresting 

and prosecuting. One of my preoccupations is the use of the criminal justice system in what was described as therapeutic jurisprudence. When that person is arrested, there is an opportunity to 

change his life direction in a very positive way. And one of the 

most striking programs about this is called Hope Probation from 

Hawaii, which uses the leverage of the criminal justice system to 

promote recovery. I visited out there, and let me tell you something, the treatment programs love the people that they get from 

Hope probation because they do stay, they do pay attention, they 

do get better, because they are required to be drug-tested for their 

probation. And so it makes treatment work like that. And I think 

that there is a real opportunity to use that as an engine for recovery that should not be overlooked when a person is out of control. 

But I don’t think we are going to treat our way out of this either. 

We have to deal in an integrated way with a very complex problem, 

and the problem is the drugs really work. People do not understand 

the potential. They think somehow there is—some small percentage of the population is vulnerable to drug addiction. That is not 

correct. It is a human phenomenon, it is a mammalian phenomenon. And when there is access to these drugs, an awful lot of 

people are going to use them, and a lot of the people who use them 

are going to be stuck with that problem for the rest of their lives. 

This is a very big problem, of which this is a very important part. 

Mr. KENNEDY. I am already over time, but if I could ask you to 

just answer as briefly as you can. 

Dr. LEMBKE. Just briefly. I really appreciate your emphasis on 

incentives, particularly in changing doctors’ behavior and creating 

the infrastructure to treat the illness. Even if you don’t believe addiction is a chronic illness, we need to pretend like it is because, 

from a practical perspective, if we don’t, we will just make people 

sicker, we won’t make them well. 

And then what is really driving the recent heroin increase is 

young people, so I absolutely agree that we need to put our reVerDate Mar 15 2010 11:02 Sep 11, 2015 Jkt 037690 PO 00000 Frm 00098 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X34OPIOID PROS\114X34OPIOIDPROSWORKING WAYNE
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sources toward youth, and not just for the short term, but they 

need to learn how to live differently in the world and whatever that 

takes, changing the structure of their lives and their friendship 

groups, giving them jobs, socializing them in a better way to adapt 

to contemporary culture is, I think, you know, where it is, not just 

short-term and long-term. 

Mr. KENNEDY. Thank you. 

Thank you, Mr. Chairman. 

Mr. MURPHY. And, Ms. Clarke, you are recognized for 5 minutes. 

Ms. CLARKE. Thank you, Mr. Chairman. And I want to thank all 

of our witnesses for giving this committee the benefit of your expertise and experience today. 

I would like to focus my questions on the prevention side of the 

equation. I know we have discussed the array of access points to 

heroin and opiates, and I would like to focus us back to the universe of prescribed opiates. 

According to the National Institutes on Drug Abuse, the number 

of prescriptions for opiates in the United States escalated from 76 

million in 1991, to about 207 million in 2013. Between 2000 and 

2010, there was a fourfold increase in the use of prescription opiates for the treatment of pain. The uptake in prescriptions for opiates has been accompanied by a corresponding increase in the 

number of opiate-related overdose deaths. 

So let me start with Dr. Seppala. My question to you is, are opiates being overprescribed, and I want to get to the why if that is 

the case? 

Dr. SEPPALA. Yes, they are being overprescribed, and they are 

being used for purposes that they are not necessarily proven to be 

effective for, and particularly when it comes to chronic pain. 

Opioids are the best, most powerful painkillers on the planet. 

They are necessary for the practice of medicine and for relief of suffering, but primarily, in an acute pain situation. Chronic pain studies are not long-term and don’t show over the long-term the effective relief of chronic pain. Opioids just don’t work that well, and 

yet they are being prescribed readily for that, so people are taking 

them for months and years. 

Ms. CLARKE. So is there a standard of care as to when it is appropriate to prescribe opiates for the management of pain? 

Dr. SEPPALA. Yes, there are standards of care defined for the prescription of opioids for pain, for acute pain and for chronic pain, 

and there has been a shift in how that is viewed, and the standards have shifted over the last 10 years, first to increase the prescribing of opioids for chronic pain, and now to decrease and go 

back to a more conservative approach. So it is being understood in 

medicine but, you know, I am reading the literature right out of 

the pain folks who understand this, and the primary care docs 

don’t necessarily follow suit for years—— 

Ms. CLARKE. Um-hum. 

Dr. SEPPALA [continuing]. They still have to kind of catch up, so 

we do need to educate our physician population. 

Ms. CLARKE. Dr. Lembke, I would like to get your thoughts on 

that as well. 

Dr. LEMBKE. Well, there is a long story to why we overprescribe 

prescription opioids, which we do, and basically, it started in the 

96 

1980s when there was this recognition that we were not doing 

enough to treat pain. It also coincided with the hospice movement. 

And there was a big push to use opioids more liberally for the 

treatment of pain, so doctors did that. What happened was that the 

evidence that showed the use of opioids was indicated for people 

who were dying was then turned over to the use of opioids in those 

who have chronic pain conditions. And Purdue Pharma and others 

aggressively marketed to doctors to use opioids for chronic pain, although there is no evidence to show that they are effective for 

chronic pain. And now reports are coming out that the risks far exceed any benefits that you might have for an individual patient. So 

now there has been a big seat change in that regard. Nonetheless, 

it is hard to get doctors to catch up with that seat change. 

Ms. CLARKE. So are physicians not getting the appropriate level 

of training and education in pain management, and how to identify 

patients who may be at risk for addiction? And I don’t know what 

that universe looks like. It sounds to me, just in hearing the dialogue, that just about everyone can be a candidate for addiction 

under that construct. 

Dr. LEMBKE. They are now getting that education, and there are 

standards. The problem is that a doctor gets paid twice as much 

for a 5-minute medication management visit as they do for 1 hour 

talking to patients, so there is, again, no infrastructure to 

incentivize doctors to not prescribe pills. There is a lot of incentive 

for them to prescribe. 

Ms. CLARKE. Dr. Harris, would the AMA support mandatory 

CME or responsible opioid prescribing practices in addiction tied to 

the DEA registration of controlled substances? 

Dr. HARRIS. So I think the mandatory is the issue, and I think 

the AMA would like to offer an alternative approach because mandatory CME just feels like sort of a one-size-fits-all. You have many 

psychiatrists here on the panel, and the education that we may 

need might be different than the education of our primary care colleagues, and so certainly more education is the key. We are right 

now cataloging best practices. Each of the specialties are looking at 

how should they educate their own colleagues. And so really it is 

about the right education at the right level, for the right specialty. 

So education is key, but certainly not mandatory. Feels like that 

is a one-size-fits-all—— 

Ms. CLARKE. I am over time but, Dr. Lembke, do you agree, 

should we be mandating or do you think that it should be left to 

the field to make—— 

Dr. LEMBKE. Yes, so I respectfully disagree with Dr. Harris. I 

think that when doctors get their DEA license to prescribe controlled and potentially addictive medications, they should mandatory be taught how to use a prescription drug monitoring system, 

that that just simply should be the standard of care, independent 

of their subspecialty. 

Ms. CLARKE. Mr. Chairman, I thank you for your indulgence. I 

yield back. 

Mr. MURPHY. Thank you. This has been quite an enlightening 

panel. I have been writing down some of your recommendations. I 

have a number of things here. Change the 42 C.F.R. program to 

bring us up to 2015 standards of integrating physical and behavVerDate Mar 15 2010 11:02 Sep 11, 2015 Jkt 037690 PO 00000 Frm 00100 Fmt 6633 Sfmt 6633 F:\114THCONGRESS\114X34OPIOID PROS\114X34OPIOIDPROSWORKING WAYNE
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ioral medicine so that we can know who is getting addiction treatments, and help the practices. Improve the intra and interstate 

communication between pharmacies and physicians so they can 

distinguish between patients who truly need a medication, versus 

those who are involved with addiction shopping. Better define recovery. Dr. DuPont, you had said not in terms of just today if they 

are off medication, but recovery as a longer term. And many of you 

have used the word chronic. And we need to be paying attention 

to longer-term data. We need more education to monitor physicians, and more education of monitoring for physicians so they understand prescription drug use here, and what treatment from pain 

is. We also have to make sure we do have insurance parity to truly 

deal with this treatment, something we have been dealing with on 

this committee for 6 or 7 years now. We need more providers who 

are trained and experienced with mental illness, severe mental illness, and addiction. More inpatient beds for treatment for detox, 

for in-depth treatments that meets the needs of the patients. And 

understanding that medication-assisted therapy and psychosocial 

therapy are not enough; we have to make sure that we have this 

spectrum, the pallet of treatments available to people to meet their 

needs. 

I think now as we look at that sobering number of 43,000 overdose deaths, and 1 1⁄2 million on some of these medications as treatments, we have our marching orders. This is not something that 

is simple, but it is something that I think is doable. And the good 

news is this is the committee that can do it, so we will get our 

work together. 

Again, I want to thank this very distinguished panel. Remind 

members that they have a few days to get to us their—what is it? 

VOICE. Ten business days. 

Mr. MURPHY. Ten business days to submit questions for the 

record. And ask all the witnesses if you would respond promptly to 

this. Again, thank you so very much. We have our work cut out for 

us. 

This committee is adjourned. 

[Whereupon, at 1:03 p.m., the subcommittee was adjourned.] 

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