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[Senate Hearing 114-853]
[From the U.S. Government Publishing Office]

                                                       S. Hrg. 114-853

                       FIGHTING AGAINST A GROWING
                     EPIDEMIC: REDUCING THE MISUSE
                    AND ABUSE OF OPIOIDS IN AMERICA

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED FOURTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        JEFFERSON CITY, MISSOURI

                               __________

                            JANUARY 19, 2016

                               __________

                           Serial No. 114-17

         Printed for the use of the Special Committee on Aging
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         

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

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
48-361 PDF                 WASHINGTON : 2022                     
          
-----------------------------------------------------------------------------------           
       
                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 CLAIRE McCASKILL, Missouri
MARK KIRK, Illinois                  BILL NELSON, Florida
JEFF FLAKE, Arizona                  ROBERT P. CASEY, JR., Pennsylvania
TIM SCOTT, South Carolina            SHELDON WHITEHOUSE, Rhode Island
BOB CORKER, Tennessee                KIRSTEN E. GILLIBRAND, New York
DEAN HELLER, Nevada                  RICHARD BLUMENTHAL, Connecticut
TOM COTTON, Arkansas                 JOE DONNELLY, Indiana
DAVID PERDUE, Georgia                ELIZABETH WARREN, Massachusetts
THOM TILLIS, North Carolina          TIM KAINE, Virginia
BEN SASSE, Nebraska
                              ----------                              
               Priscilla Hanley, Majority Staff Director
                 Derron Parks, Minority Staff Director
                         
                         
                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Claire McCaskill, Ranking Member....     1

                           PANEL OF WITNESSES

Bob Twillman, Ph.D., Executive Director, American Academy of Pain 
  Management, Kansas Missouri....................................     3
Hon. Holly Rehder, Missouri House of Representatives District 
  148, Sikeston, Missouri........................................     5
William Maurice Redden, M.D., Assistant Professor, Department of 
  Neurology and Psychiatry, Division of Geriatric Psychiatry, 
  Saint Louis University School of Medicine, St. Louis, Missouri.     8
Paul Walker, Pharmacy Benefit Manager, Veterans Integrated 
  Service Network 15, Veterans Health Administration, United 
  States Department of Veterans Affairs, Washington, D.C.........    10
Paul E. Tatum, III, M.D., Associate Professor, Department of 
  Family and Community Medicine, University of Missouri-Columbia, 
  and Medical Director, Compassus, Columbia, Missouri............    11

                                APPENDIX
                      Prepared Witness Statements

Bob Twillman, Ph.D., Executive Director, American Academy of Pain 
  Management, Kansas Missouri....................................    29
Hon. Holly Rehder, Missouri House of Representatives District 
  148, Sikeston, Missouri........................................    36
William Maurice Redden, M.D., Assistant Professor, Department of 
  Neurology and Psychiatry, Division of Geriatric Psychiatry, 
  Saint Louis University School of Medicine, St. Louis, Missouri.    39
Paul Walker, Pharmacy Benefit Manager, Veterans Integrated 
  Service Network 15, Veterans Health Administration, United 
  States Department of Veterans Affairs, Washington, D.C. (no 
  written testimony submitted)...................................    --
Paul E. Tatum, III, M.D., Associate Professor, Department of 
  Family and Community Medicine, University of Missouri-Columbia, 
  and Medical Director, Compassus, Columbia, Missouri............    42

 
                       FIGHTING AGAINST A GROWING
                     EPIDEMIC: REDUCING THE MISUSE
                    AND ABUSE OF OPIOIDS IN AMERICA

                              ----------                              

                       TUESDAY, JANUARY 19, 2016

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:45 a.m., in 
65101 Ballroom, Governor's Office Building, 200 Madison Street, 
Jefferson City, Missouri, Hon. Claire McCaskill, Ranking 
Member, presiding.
    Present: Senator McCaskill.

                 OPENING STATEMENT OF SENATOR 
                CLAIRE McCASKILL, RANKING MEMBER

    Senator McCaskill. This hearing of the United States Senate 
Committee on Aging will come to order.
    We will begin our hearing that is focused on the problem of 
opioid addiction in this country.
    I am really happy to be here in Jefferson City. I spent a 
number of years here, working right down the street. I 
certainly sat through a lot of hearings during those years. 
This is the first time that we have had a field hearing of one 
of my Senate committees here in Jefferson City and I am very 
happy to be here.
    I want to thank you all for coming out for this much needed 
hearing. I am proud to hold another Senate Aging Committee 
hearing in Missouri, this time in Jefferson City.
    First, I want to thank my dear friend and Chairman of this 
Committee, Senator Collins. By the way, she is my dear friend 
and I think it is important to mention that because I think 
that there are a lot of people out in America that do not think 
any of us get along that are of different parties. That is not 
true. Susan is a Republican, I am a Democrat and we work 
closely together, and have throughout my time in the Senate, 
cosponsoring many pieces of legislation and now working closely 
together as the Chairman and Ranking Member on this particular 
committee. [dropped audio.] [continuing]. . . . program to 
prevent doctor shopping, control the. . . [inaudible] 
prescription drug abuse, and outline drug use and abuse trends 
to aid public health initiatives.
    Tackling this complex issue requires a unified effort. I 
look forward to hearing from our panel of witnesses as they 
discuss their work to reverse this epidemic by reducing the 
misuse and abuse of opioids.
    First, we have Dr. Bob Twillman. Dr. Twillman is the 
Executive Director for the American Academy of Pain Management. 
He is responsible for overseeing Federal and State pain policy 
developments and advocating for those supporting an integrated 
approach to managing pain. He also serves as the Chair of the 
Prescription Drug Monitoring Program Advisory Committee for the 
Kansas Board of Pharmacy.
    Today, Dr. Twillman will testify on behalf of the Missouri 
Prescription Drug Monitoring Program NOW Coalition, a 
bipartisan organization composed of individuals, groups and 
associations that support a prescription drug monitoring 
program for Missouri.
    Next is State Representative Holly Rehder. Representative 
Rehder is a Republican member of the Missouri House of 
Representatives, representing District 148, Scott and Frances 
County. She was elected to the State House in 2012. She has 
worked tirelessly to address Missouri's prescription drug abuse 
problem. She is committed to reducing the misuse and abuse of 
prescription drugs in Missouri.
    She will discuss her efforts in the State House to pass 
legislation House Bill 130 that would establish a statewide 
prescription drug monitoring program in Missouri.
    Dr. Paul Tatum is an Associate Professor at the University 
of Missouri--Columbia and the medical director for the 
Compassus Program. He practices in the area of family medicine, 
geriatrics and hospice and palliative medicine.
    Dr. Tatum also serves on the American Academy of Hospice 
and Palliative Medicine Board of Directors. He helped write 
their guidelines for prescription drug monitoring programs.
    Today Dr. Tatum will testify on behalf of the Missouri 
Hospital Association.
    Dr. Maurice Redden is an Assistant Professor in the 
Department of Neurology and Psychiatry for the Division of 
Geriatric Psychiatry for the Saint Louis University School of 
Medicine. Dr. Redden specializes in psychiatric care for 
geriatric patients suffering from delirium, depression, 
dementia or other degenerative diseases, including Alzheimer's.
    In that role, he works with older adults, specifically ages 
65 and older, who are battling with illicit and licit substance 
abuse issues, and finally, Mr. Paul Walker is the Pharmacy 
Benefit Manager for Veterans Integrated Service Network 15 with 
the Veterans Health Administration. Mr. Walker will discuss the 
implement of the Department of Veterans Affairs Opioid Safety 
Initiative, which was developed to reduce the use of opioids 
among Americans veterans. OSI is a comprehensive effort to 
improve quality of life for veterans suffering from chronic 
pain. It emphasizes patient education, intensive monitoring 
with frequent feedback and complementary and alternative 
medicine practices.
    Thank you all for joining us and we will begin with your 
testimony, Dr. Twillman.

               STATEMENT OF BOB TWILLMAN, PH.D.,

            EXECUTIVE DIRECTOR, AMERICAN ACADEMY OF

                PAIN MANAGEMENT, KANSAS MISSOURI

    Dr. Twillman. Thank you. It is a pleasure to be here this 
morning.
    Just by way of background. . . [inaudible] pain management.
    The Academy is a organization in the country for pain 
management clinicians. Half of our 4,200 members are physicians 
while the others represent 30 distinct disciplines and all of 
them treat pain.
    Since it was founded in 1988, the Academy has promoted a 
model of integrated pain management, recognizing phenomenon 
that is best addressed by a care team and a care plan that is 
multidisciplinary, multimodal and comprehensive in its approach 
to caring for each individual person in pain.
    Today, in the United States, we find ourselves wrestling 
with two extraordinarily complex and stubborn public health 
crises. On the one hand, we have about 12.5 million Americans 
who report using prescription pain relievers non-medically each 
year, a costly and persistent problem that results in thousands 
of deaths.
    On the other hand, we have chronic pain. By the Institute 
of Medicine in its 2011 report ``Relieving Pain in America'', 
it can affect more than 100 million American adults. Twenty-
five million of those report suffering from daily pain and 10 
million are disabled by their painful condition.
    This problem costs our economy $560 to $630 billion per 
year, according to the IOM and brings with it a doubling of a 
risk of completing suicide.
    The author H.L. Mencken said ``For every complex problem, 
there is a solution that is neat, simple, and wrong.'' These 
are two complex problems, we may encounter twice as many 
separate solutions that are neat, simple and wrong, complex 
problems often produce negative unintended consequences.
    In the case of these two problems. . . [inaudible] attempt 
to fix one problem makes the other problem worse.
    Fortunately, there is. . . [inaudible].
    I would like to talk very briefly about two of these. . . 
[inaudible].
    Prescription drug monitoring programs, or PDMPs are state-
run electronic data bases that collect, analyze and record 
information on controlled substance prescriptions dispenses to 
patients. This information is then accessible to prescribers 
and dispensers for use in the clinic, and to law enforcement 
and regulatory agencies investigating and adjudicating cases 
involving potentially inappropriate uses of these medications.
    Forty-nine states, the District of Columbia, Guam, nine of 
10 Canadian provinces, and one Canadian territory have PDMPs in 
operation or in development. The one place in this country that 
does not have a PDMP is Missouri. That is not because we have 
not tried to pass legislation to establish it.
    PDMPs are useful in addressing both public safety and 
public health concerns. The public safety aspect involves 
feeding investigations involving controlled substances while 
deterring and detecting drug diversion activity. The most 
common form of this is often called doctor shopping and 
pharmacy hopping where individuals obtain controlled substance 
prescriptions for multiple prescribers and fill them at 
multiple pharmacies so as to avoid detection.
    PDMPs can be used to identify people's abuse and 
misbehavior so they can be investigated, evaluated, and treated 
appropriately.
    From a public health standpoint, PDMPs enable clinicians to 
do two things: one to be reassured when prescribing for a new 
patient when the PDMP report says. . . [inaudible] appropriate 
behavior. Two, to detect behavior that may be indicative of 
substance abuse so that disorder can be diagnosed and treated 
appropriately, and three, to detect the presence of other 
prescriptions that, when combined with the new prescription, 
could produce a fatal overdose.
    Missouri's failure to establish a PDMP undoubtedly 
contributes to increased rates of prescription drug abuse and 
overdose deaths and it undoubtedly makes it harder for 
clinicians to effectively treat pain and other conditions that 
require the use of controlled substances.
    The second key solution, oddly enough, is treating chronic 
pain the right way. I believe that doing this not only improves 
the effectiveness of pain care received by each person with 
chronic pain, but it also reduces the risk of prescription drug 
abuse and all of the untoward consequences that result.
    Every comprehensive guideline for treating chronic pain, 
the IOM's 2011 report, and the draft national pain strategy 
that grew out of it, all call for treatment that uses a 
comprehensive, integrated approach. This approach treats each 
person with pain as a unique individual and develops a pain 
care plan that is just as unique.
    In addition to being individually tailored, these care 
plans use a variety of methods to treat pain, not just the 
procedures and the controlled and non-controlled medications 
that we commonly think of, but other types of care such as 
physical and occupational therapy, behavioral health 
interventions, chiropractic care, massage therapy, acupuncture, 
good nutrition and weight loss, exercise, and a whole host of 
other interventions.
    We have lots of good research that says this approach is 
more effective and more cost effective. Importantly, it also 
reduces the need for opioid pain relievers, reducing exposure 
to them and thus, lessening the risk of developing substance 
abuse disorder.
    Unfortunately, this type of care is not widely available 
and even less widely recommended by clinicians. Many of these 
non-pharmacologic treatments are poorly covered or not covered 
by third-party payers. For instance, Medicare limits the number 
of physical therapy and psychotherapy visits a patient can 
have. It covers chiropractic care, but only for certain 
diagnoses and only certain types of manipulations, and it does 
not cover acupuncture, biofeedback or massage therapy which the 
Department of Defense and the VA have endorsed as effective in 
treating chronic pain.
    An additional barrier is a lack of education clinicians 
receive for these two health problems. The IOM report documents 
that the leading exposure to pain management for medical 
students is only 9 hours, while the Association of American 
Medical Colleges found a median of only 5 hours on substance 
abuse with fully one-third of programs having no content at 
all.
    Education on these two topics is necessary but not 
sufficient to change practice but it is necessary. Even if we 
are able to provide the comprehensive integrated care we need, 
an uneducated clinician is not likely to steer patients toward 
it.
    Pain management clinicians and organizations want to be 
part of solving both of these public health crises. We are 
eager to propose solutions that address both effectively and we 
are eager to work with policymakers to craft policies that 
enable us to use those solutions. We think we have a good idea 
about what needs to be done, and now the challenge is making 
that possible.
    Thank you.
    Senator McCaskill. Thank you, and before I turn to 
Representative Rehder, I would like to acknowledge the number 
of legislators that we have here this morning. If you are a 
member of the Missouri legislature, would you stand and 
introduce yourself briefly before we go to Representative 
Rehder's testimony?
    Mr. Lynch. Representative Steven Lynch. I represent the 
Fort Leonard Wood area.
    Ms. Lavender. Representative Deb Lavender, District 90, 
Kirkwood, Missouri.
    Mr. Otto. Representative Bill Otto, the 70th House District 
in St. Louis County and St. Charles County.
    Mr. Keaveny. Senator Joey Keaveny. I am the Senator from 
the 4th District, St. Louis, Missouri.
    Ms. McNeil. Margo McNeil. I am the State Representative 
from the 69th, which is part of the Florissant area, 
unincorporated, St. Louis County.
    Ms. Hubrecht. Tila Hubrecht, I am the Representative from 
Southeast Missouri District 151 and I also have a background in 
nursing.
    Mr. Basye. I am Chuck Basye, Representative from District 
47, central Missouri including Boone, Howard, Randolph and 
Cooper.
    Senator McCaskill. I really appreciate you all being here--
oh, I am sorry. I did not see you, sweetie.
    Ms. Mims. That is okay, I am from the best part of 
Missouri, South Kansas City. I am Bonnaye Mims, Representative 
from District 27 and I have a background in forensics.
    Senator McCaskill. Good to see you, sorry I missed you.
    Anybody else?
    [No response.]
    Representative Rehder.

            STATEMENT OF HON. HOLLY REHDER, MISSOURI

             HOUSE OF REPRESENTATIVES DISTRICT 148,

                       SIKESTON, MISSOURI

    Ms. Rehder. Thank you so much, Senator McCaskill, for 
having me here today and for your interest in this very 
important topic.
    You have requested that I testify to the critical need for 
a PDMP, our efforts here in Missouri, my personal story related 
to this, and my commitment to reducing the misuse and abuse of 
prescription drugs in Missouri.
    As you know, and we have already touched, Missouri is the 
only State that does not have this important program in place.
    PDMPs have proven successful in curtailing drug diversion, 
increasing patient care and overdose rates. Since Kentucky's 
PDMP took effect in 2012, they have seen a decrease in doctor 
shopping by 52 percent. A California survey of physicians 
showed 74 percent had changed their prescribing practices to 
patients as a result of using their PDMP's patient activity 
reports. Since Florida implemented their PDMP, deaths related 
to oxycodone overdoses has dropped 41 percent.
    With Missouri surrounded by eight states, we are not only 
harming their own population. My district is the majority of 
Scott and Mississippi counties down in the boot heel. My 
Charleston pharmacies are oftentimes the first stop for doctor 
shoppers coming from Illinois and Kentucky. My district is also 
only an hour from Arkansas, all states that have PDMPs in 
place.
    My pharmacists, physicians, law enforcement, churches and 
social services department see the result of Missouri's 
inaction on a daily basis.
    Our efforts to pass a PDMP in Missouri, I have been in 
office since 2013, fighting for this legislation. 
Representative Engler carried it even before my arrival while 
he was a Senator. Privacy concerns has caused threats in the 
Senate for a filibuster. Last year, 2015, the Senate did pass 
out a Senate compromise bill but once the fiscal note was 
completed, it had a $6 million a year price tag and those in 
the trenches, our pharmacists, physicians and law enforcement, 
said it was not a workable program, so we were back to square 
one.
    This year I filed House Bill 1892, the Narcotics Control 
Act. We changed the name due to many fear that prescription 
drug monitoring includes all of their medications and it does 
not. It is mainly those narcotics that are misused and abused, 
Schedule II through IV.
    My personal story that is related to the need for this. I 
was raised on welfare in the drug culture, as many call it 
``the wrong side of the tracks.'' My mother had to deal with 
mental illness. One of my stepfather's was a dealer. My sister 
married a dealer at 16 and was a mainline addict. My cousin 
died at 39 from many years of drug abuse.
    Right after I turned 15 we were in a terrible car accident 
and I was needed to help take care of my mother and younger 
sister. I dropped out of school, got married and pregnant soon 
after. At 15 I looked at my life. I was a pregnant high school 
dropout destined to raise my children in the same cycle of 
poverty and dependency, around the same type of people who harm 
others and children because of their drug abuse.
    I went to work, working multiple jobs in whatever I could 
get hired to do. At 18 I took my GED and then took college 
classes when I could. It took my 17 years to finish my degree 
because I did it full time and raising a family.
    My children have been raised in the same church, where we 
have attended for 27 years now. Through their lives, I have 
served as youth leader, Sunday school teacher, making sure they 
understand that God is the only reason their lives are 
different than many in our family.
    My children were raised in a middle class home with two 
parents working and participating in their school activities, 
church activities and their lives in general. They came home to 
home-cooked meals at night and parents who knew where they were 
at all times.
    At 17 my daughter worked in a local restaurant while 
attending high school and was an honor roll student. She was 
accepted to SLU, a very bright, positive, normal teenager 
raised in a two parent middle class home with many goals and 
dreams to become a pediatric physical therapist and live a 
successful life.
    She cut her thumb opening a bag of okra at work and was 
sent to the ER to get it stitched up. There, they gave her a 
prescription of opiates for the pain. Once she ran out of that 
prescription she started buying them from co-workers. They were 
easy to get and seemed harmless since they were a prescription, 
and she loved the euphoric feeling.
    That was 13 years ago. We have had 13 years of ups and 
downs, rehabs, prison, and my grandson born with opiates in his 
system. You see, the pills become too expensive because your 
body adjusts to them and you need more and more to stay at that 
euphoric level. Where heroin and meth might be the boogeyman to 
a teenager who has not experienced drugs, once they are hooked 
and cannot afford the pills, that is where they turn. Their 
mind is no longer afraid, and their body simply needs the 
opiate.
    My daughter became a mainline user as well, meth, bath 
salts, whatever, to feel her need. My grandson, who I have 
guardianship of now, was pulled out of a meth lab at only 1 
year old. He slept within a few feet of the shake and bake 
operation.
    I tell you this story of both of our lives to show that 
drug addiction is no respecter of persons. It crosses all 
socioeconomic statuses. When you go into a high school and ask 
the kids what do you want to be when you grow up, their answers 
are a doctor, a lawyer, a nurse, a business owner. None say I 
want to be an addict. Yet, addiction is the growing epidemic of 
our time.
    My commitment to reducing the misuse and abuse of opiates. 
I realize that PDMP is not the silver bullet. It is one major 
tool in our toolbox and I will continue to fight until we see 
it come to fruition. I am also working with the Recovery 
Network of Missouri to start a bipartisan recovery caucus.
    Our goals are these: to enhance recovery outcomes in 
Missouri; to identify a Missouri solution to fund recovery 
support and services; to educate legislators on the needs and 
gaps in recovery services.
    I met with several legislators from different states in 
D.C. last month. Their states all had active PDMPs and were on 
a phase two, per se, of their recovery efforts, working to 
identify addiction early, to put people back on the path to a 
health life, and curtail the state's costs by putting money 
into recovery efforts on the front side, versus the penal 
system which we know has a residual effect through social 
services and mental health departments.
    In closing, we must change the face of addition. That is 
why I am here.
    Senator McCaskill. Thank you very much for your brave. . . 
[inaudible].
    I think we all--this is such a big problem that I doubt 
there is anyone in this room that does not have a story they 
can tell, a heartbreaking story, about someone that they love. 
That is how serious this problem is and we certainly respect 
your ability to tell yours. I congratulate you on your fight.
    Dr. Redden.

           STATEMENT OF WILLIAM MAURICE REDDEN, M.D.,

          ASSISTANT PROFESSOR, DEPARTMENT OF NEUROLOGY

       AND PSYCHIATRY, DIVISION OF GERIATRIC PSYCHIATRY,

           SAINT LOUIS UNIVERSITY SCHOOL OF MEDICINE,

                      ST. LOUIS, MISSOURI

    Dr. Redden. Good morning, Senator McCaskill, and thank you 
for allowing me to speak about the rising epidemic of illicit 
and licit substance use and misuse among older adults.
    As previously stated, I am a geriatric psychiatrist at 
Saint Louis University School of Medicine.
    This issue is of particular concern to me both as a 
clinician and researcher because of my interest in overall 
mental health and ways to improve cognitive function in late 
life. One way to do this is to address any potential risk 
factors that can be removed or modified, including substance 
use and misuse.
    Historically, substance abuse has been considered a problem 
affecting younger adults that was thought to decrease as one 
ages. In my experience as a clinician, I have begun to 
encounter patient abuse of both illicit and licit drugs more 
often. The main illicit substances include marijuana, cocaine 
and heroin. However, an often overlooked problem of 
prescription, non-prescription and over-the-counter misuse of 
drugs is also on the rise.
    The pattern of use can appear in early onset and late-onset 
users. The former describes individuals with a long history 
that persists as they age, while the latter includes 
individuals who develop a new habit in late life. Some of the 
risks factors that lead to new onset or continued use in the 
elderly include social isolation, financial difficulties, and 
poor support systems. In most instances, there may be mental 
health conditions that have not been properly diagnosed and/or 
treated.
    When older adults use illicit and licit substances, even in 
small amounts, the negative effects can be magnified. In 
addition, one-third of elderly patients take, on average, five 
prescription medications daily. This increases the risk of drug 
interactions, which can complicate medical problems. This all 
leads to increased emergency department visits, as well as 
prolonged hospital stays.
    For the sake of time, I would like to focus more on the 
rise of opioid use, which include both heroin and prescription 
opioids. One of the driving forces in this rise has already 
been mentioned, which includes the increased prevalence of 
chronic pain. Prescription opioid medications have been the 
most prevalent treatment options. When these options are not 
available, older adults have resorted to using someone else's 
prescription, buying medications off the street or 
straightforwardly using heroin. They have also been known to 
doctor shop in order to acquire more medications than actually 
needed.
    The overuse and misuse of opioids is of particular concern 
to those in the mental health field because it can lead to 
suicide by self-poisoning. The same factors that lead to drug 
abuse, which include social isolation and mental health 
illness, also are risk factors for suicide, and now with the 
increased distribution of prescription opioids, this vulnerable 
group has lethal means to carry out the intent.
    Screening of the elderly, however, is very difficult as 
most available screening tools have been designed for younger 
patients. Recently, the DSM-V has been updated and the 
diagnostic criterion is called substance use disorder instead 
of abuse and dependency. However, relying solely on this 
diagnosis and criterion may exclude elderly patients.
    One of the key features of substance use disorder is 
tolerance. Due to the age-associated physiologic changes that 
increase the effects of even small amounts that may be more 
pronounced in the elderly, making the diagnosis of substance 
use disorder extremely difficult.
    The first step in recognizing elder drug abuse as a problem 
is to consider it a possibility. As clinicians, we are often 
pressed for time, but there are screening tools, such as CAGE-
AID, which is alcohol and illicit drugs, are designed to help 
began the discussion.
    Once elderly patients have been identified as having a 
substance use disorder, treatment interventions need to be 
tailored to meet the needs of this unique group. As such, 
medications that are typically used in younger patients may not 
be suitable for older adults. Therefore, risk versus benefit 
analysis needs to be made before seeking such options.
    There is still some debate on whether elderly patients 
should participate in inpatient-treatment programs that are 
specifically geared for younger people. However, sometimes 
integrated programs may also be beneficial. In choosing 
appropriate programs, other factors should be considered, such 
as comorbid medical and psychiatric conditions that need to be 
addressed during treatment.
    Another tool that every other State has enacted, that has 
already been mentioned, is prescription drug monitoring 
program. These programs vary across settings, but the main 
purpose is to detect and reduce diversion, abuse and misuse of 
schedule II prescription medications, such as opioids. 
Hopefully in the future, this will include all prescription 
medications that have high abuse potential such as 
benzodiazepines.
    Prescription drug monitoring programs have shown to reduced 
over-prescription and doctor shopping by patients. They have 
also helped identify any suspected fraudulent prescribing or 
illegal activities of the dispensing of controlled substances, 
so therefore, in conclusion, substance abuse in the elderly is 
a growing problem and includes both illicit and licit 
substances. The identification of substance use is difficult, 
but first has to be acknowledged as a real possibility. Then, 
an assessment that is respectful and non-stigmatizing can be 
approached.
    Clinicians should be mindful of the roles of comorbid 
medical and psychiatric conditions when diagnosing and treating 
elderly patients who exhibit symptoms of substance use. The 
over-prescribing of opioids for the treatment of chronic pain 
can contribute to this problem; however, having deterrents in 
place such as a prescription drug monitoring programs and 
utilizing other methods to treat chronic pain can help 
clinicians to combat this devastating problem.
    Thank you for time and efforts in addressing this growing 
concern of me and my colleagues.
    Senator McCaskill. Thank you, Dr. Redden.
    Mr. Walker.

           STATEMENT OF PAUL WALKER, PHARMACY BENEFIT

        MANAGER, VETERANS INTEGRATED SERVICE NETWORK 15,

         VETERANS HEALTH ADMINISTRATION, UNITED STATES

        DEPARTMENT OF VETERANS AFFAIRS, WASHINGTON, D.C.

    Mr. Walker. Good morning, Ranking Member McCaskill.
    I appreciate the opportunity to discuss prescriptions and 
the safety initiative currently being implemented by the 
Department of Veterans Affairs.
    The 2011 study by the Institute of Medicine established 
chronic pain as a serious health issue in America. 
Particularly, the study recognized that 60 percent of veterans 
returning from combat theaters in the Middle East and 50 
percent of VHA-enrolled veterans suffered from a form of 
chronic pain.
    Veterans suffer from multifaceted conditions, unlike 
counterparts in civilian hospitals. This involves battlefield 
injuries encompassing musculoskeletal and nerve systems. These 
impediments may be coupled with traumatic brain injuries. 
Traumatic brain injuries have lasting effects to overall brain 
structure and emotional health. This can independently increase 
the risk of substance abuse disorder.
    It is well documented that uncontrolled pain, coupled with 
functional impairments, leads to a decreased quality of life. 
These conditions greatly increase the risk for overdose, 
substance use disorders, and consequently, suicide. The 
complexity of multiple conditions makes the accurate delivery 
of pain management challenging and intensifies risks of 
complications due to over-and underuse of opioid... [inaudible] 
therapies. In as much, veterans continue to call upon VA 
clinicians to alleviate their pain.
    This country is now in the midst of an epidemic of misuse 
and overuse of opiate medication. The appropriate use of 
opioids is particularly important for VA due to the number of 
veterans who have musculoskeletal injuries and permanent nerve 
damage.
    Shifting our prescribing practices has required a cultural 
change and changes to the modalities we use for pain 
management. This implemented approach is twofold. First, we 
immediately address the issue of inappropriate high dosage of 
opioid medications. Second, we develop an effective system of 
interdisciplinary pain management to provide safe and effective 
pain control.
    To address the varied discretion in opioid prescribing, VA 
developed the Opioid Safety Initiative, or OSI. OSI was 
designed to make opioid prescribing visible throughout the VA. 
This platform includes key clinical indicators, such as the 
number of unique pharmacy patients dispensed opioids, unique 
patients on long-term opioids who receive urine drug screens, 
and the average morphine equivalent daily dose of opioids.
    The system analyzes prescribing practices and provides 
feedback, ensuring opioid prescriptions are disbursed 
effectively and judiciously. This system has demonstrated 
considerable promise in minimizing harm and promoting safe, yet 
effective, pain care.
    After a brief pilot period, the VA implemented the OSI 
system nationwide in 2013. To monitor the impact, quarterly OSI 
trending data is circulated through VA medical centers, network 
offices, and the VA Central Office. Facilities with data 
outliers are required to submit action plans to VA Central 
Office. This monitoring is continued until data outliers have 
been resolved. The recent data results demonstrate the level of 
achievement obtained by utilizing this system.
    VA facilities throughout the Missouri region, where 19 
percent of chronic opioids are above the age of 70 years, we 
have reduced the number of veterans on opioid-based medications 
by 21 percent. The number of veterans on both an opioid and 
benzodiazepine medication has decreased by 47 percent. Last, we 
reduced the number of veterans on high dose opioids by 37 
percent.
    The OSI initiative has been augmented by deploying the 
Opioid Therapy Risk Report. This additional practice protects 
veterans using high dose opioid prescriptions or with risk 
factors placing them at risk for complicates. The report, used 
nationally, allows clinical staff to view narcotic and sedative 
dosage information and medical diagnoses. This all-inclusive 
data platform provides an efficient veteran-centric approach 
previously unavailable to primary care providers. VA continues 
to distribute training aids promoting the use of the system in 
daily practice.
    Overall, we are proud of our advancements in promoting 
opioid safety, particularly in the State of Missouri. VA 
remains dedicated to providing the best care to veterans and 
continues to research innovative methods to continue this 
progression.
    This concludes my testimony and I look forward to any 
questions you may have.
    Senator McCaskill. Thank you.
    Dr. Tatum.

             STATEMENT OF PAUL E. TATUM, III, M.D.,

           ASSOCIATE PROFESSOR, DEPARTMENT OF FAMILY

             AND COMMUNITY MEDICINE, UNIVERSITY OF

            MISSOURI-COLUMBIA, AND MEDICAL DIRECTOR,

                 COMPASSUS, COLUMBIA, MISSOURI

    Dr. Tatum. You know, before I begin, Representative Rehder, 
thank you for sharing your story. That was so powerful and 
brave. Thank you.
    Senator McCaskill----
    Senator McCaskill. Would you pull your microphone a little 
bit closer.
    Dr. Tatum. A bad combination of a geriatrician taking care 
of older adults who have hearing problems and a low talker. Is 
that adequate?
    Senator McCaskill. That is great.
    Dr. Tatum. Thank you.
    Senator McCaskill, thank you for so much for scheduling a 
public forum on opioid abuse among older adults. I find today's 
topic so important both from a national, public health 
standpoint, but also for me personally, as a physician, this 
impacts me day-to-day, but also my family's experience.
    I have seen both the terrible toll of misuse of pain 
medicine, and I have also seen the tremendous relief they can 
bring when used appropriately to allow a person bed-ridden with 
cancer pain find the relief to spend their last few days 
holding up her grandchildren.
    Two brief stories highlight the complexity and critical 
importance of the meeting today. First let me tell you about a 
patient of mine. As a physician who has had additional training 
in both geriatrics and palliative medicine, I am often asked to 
help doctors with difficult pain cases. I remember a patient 
with severe pain, as well as limited life expectancy. In the 
hospital, our teams' recommendations made a big difference. He 
left, he went home doing better. I was surprised to hear, in 
fact, later on he had died much earlier than we would have 
anticipated. I reviewed his meds and they seemed appropriately 
dosed. I was devastated to learn from autopsy that he had not 
one but multiple duplicative pain medications in his system 
provided by multiple other doctors.
    We need better coordination of care systems for patients 
with pain.
    I am so glad that we are before this Committee today 
because opioid deaths are not just about younger people with 
addiction. The statistically significant rise in opioid deaths 
occurs in older adults over 65 as well as younger adults. The 
CDC has declared pain medicine misuse and the deaths associated 
with it an epidemic.
    The common factors the CDC finds in deaths from opioid 
include: prescriptions at very high doses, and I am pleased to 
hear the VA's efforts to really impact that, prescriptions from 
multiple providers, and finally, a mixture of opioids with 
other medications. We have heard the impact you guys had on 
benzodiazepine sedatives, one of the major medicines.
    In my experience, another factor this Committee in 
particular can help policymakers understand is the 
underappreciated fact of just how complicated opioid 
prescribing is for older patients. Physicians, despite their 
training in pain management, and we heard limited numbers of 
that from Dr. Twillman, have not been well trained in geriatric 
medicine and the necessary adjustments for patients as they 
age. Due to the physiologic changes associated with aging, a 
standard dose is too strong for older adults, and the body 
cannot process the drug as quickly. In short, a little medicine 
goes a long way.
    Failure to recognize the unique prescribing adjustments 
needed for our seniors is another key factor in opioid 
misadventures, which must be addressed with better geriatrics 
education. I think your committee can really make a statement 
on that.
    The good news is we can work to reduce opioid deaths. You 
know, Congress's Secure and Responsible Drug Disposal Act of 
2010, which allows unused opioids to be disposed of at 
pharmacies, is going to keep leftover medicine that was needed 
for grandmother's hip replacement from becoming the drug that 
starts a grandkid on the path to addiction. This is important 
legislation and we need to let more people know about it. Thank 
you for that.
    The good news is that physicians and organizations are 
working to make opioid prescribing safer. I would like to share 
with you the Missouri Hospital Association--I may refer to it 
as MHA's--response. The Missouri Hospital Association noted 
between 2005 and 2014, hospitalization for opioid overuse has 
increased 137 percent in our State. At the University of 
Missouri we found that the impact of overdose is particularly 
serious for older adults. Unlike younger adults, the seniors 
admitted with an overdose had twice the need for intensive care 
unit admission. This has real impact.
    The MHA had partnered with a coalition of the Missouri 
State Medical Association, the Missouri Association of 
Osteopathic Physicians and Surgeons, the Missouri Academy of 
Family Physicians, the Missouri College of Emergency Physicians 
and, importantly, the Missouri Dental Association. They felt, 
in the coalition, that steps to reduce misuse and abuse in 
emergency room prescribing practices was a key initial step.
    Based on national guidelines and evidence the coalition put 
together emergency department protocols which include that a 
comprehensive pain assessment plan is a key part of the 
emergency physician's work before prescribing. The diagnoses 
are made on evidence-based guideline. Especially important, 
non-narcotic treatment should be given for non-traumatic tooth 
pain. A huge impact on emergency rooms when people come in 
asking for pain med.
    When possible, the emergency department should coordinate 
with the opioid prescriber when people come in asking for 
additional adjustments in meds, and that the emergency room 
prescribers should limit their prescriptions to 72 hours, then 
coordinate with the primary care physician, as well as other 
protocols, and importantly, the policy also asks for emergency 
departments to partner with other health officials to make 
naloxone available for dispense in pill form.
    The good news is physicians are thinking about how to solve 
this on a national level. The AMA, the American Medical 
Association Task Force to Reduce Prescription Drug abuse states 
that ``physicians have a professional obligation to reverse the 
Nation's opioid epidemic.''
    As this Committee thinks about policies to make prescribing 
safer, I personally would like ask that you focus on the AMA's 
recommended areas. They are excellent. They have five: 
increasing physicians' registration and use of effective PDMPs, 
Prescription Drug Monitoring Programs; enhancing physicians' 
education on effective pharmaceutical prescribing; reducing the 
stigma of pain and promoting comprehensive assessment, not just 
pills; but also reducing the stigma of substance use and 
enhancing access to treatment of substance abuse, and then 
finally, the AMA again endorses access to naloxone in the 
community, but in closing, the other story that is so important 
is that of my father. My father died of a rare disease in a 
small town in East Texas. During his last days, as he writhed 
in pain, my mother was told, ``I am sorry, we cannot give him 
morphine. That might kill him.''
    We have a public health crisis that demands response both 
to prevent unnecessary deaths to prevent them, but also a 
response to meet the true pain needs, which are often untreated 
or undertreated.
    My colleague, Dr. Smith at UCSF and his colleagues, found 
25 percent of older adults have significant pain in the last 2 
years of life, rising to as much as 50 percent in the last year 
of life.
    As we think about policies to reverse the opioid epidemic I 
think this Committee is especially positioned to help older 
adults. Speaking personally as a geriatrician, I think a key 
policy need is to improve geriatric medical education for all 
practitioners, and improve care coordination, in particular, 
between practitioners, other health care workers, hospitals, 
pharmacists and patients and their families.
    Congress could expand Geriatric Academic Career Awards so 
we have the teachers needed to help providers understand the 
intricacies of prescribing to older adults. We could pass the 
Palliative Care and Hospice Education and Training Act, or 
PCHETA, which actually create regional centers that improve 
care of the seriously ill and enhance end-of-life education, 
which is a gap in some of our physicians, but foremost this is 
about safety and real suffering. With your supportive actions 
for enhanced practitioner education in geriatrics and pain 
management, as well as systems which really help coordination, 
I think we can simultaneously reduce the prevalence of opioid 
addiction, reduce the harms from opioids, while ensuring that 
older adults who do have significant needs receive adequate and 
appropriate pain management and avoid unnecessary suffering.
    Thank you for having us here today.
    Senator McCaskill. Thank you.
    I think it is true that with older Americans, especially 
those who have diagnoses of a terminal illness, where the 
medical protocol acknowledges chronic pain associated with 
that, that is obviously not a problem, but let me just start 
with a global question to the doctors, the medical doctors, and 
to Dr. . . . [inaudible] on the panel. We are prescribing, by 
multiples, more narcotic pain medication in American today than 
we were 40 years ago. My multiples. Now, are we in that much 
more pain? I mean, you know, I do not understand what happened 
that all of a sudden America had so much more pain than we had 
40 years ago.
    I want to figure out, was this a solution looking for a 
problem and driven by the pharmaceutical injury and doctors 
that were not paying attention? Or did somehow, all of a 
sudden, America had more pain?
    Dr. Twillman. If I may, I think it is, as usual, not a 
simple answer to that question. Part of what happened----
    Senator McCaskill. I am afraid it is. Money.
    Dr. Twillman. Well actually, there is an element of that 
involved. One of the things, I talked about the sort of 
comprehensive care that we need to provide for people who have 
chronic pain that is not necessarily related to a terminal 
illness. If you go back 30 or 40 years in this country, we had 
a lot of programs that were set up that way. They were very--
people would come in, they would be assessed by a number of 
providers with different perspectives, they would put together 
a comprehensive plan, and the data showed that that provided 
better pain management at a lower cost and got more people back 
to work than the traditional approach that we have now, which 
is prescribing medication after medication after medication.
    The problem is insurance stopped paying for that, and so 
those programs went away. I think the numbers are something 
like they went from 1,000 programs to 80 programs in the course 
of less than 10 years.
    What happened is now physicians are reimbursed for having a 
very brief visit with a patient, for spending 15 minutes or 
less with every patient that is in the room with them, and the 
fastest way to get somebody out of the room is to write them a 
prescription and hand it to them like it is their ticket to get 
out of the room.
    Unfortunately, what we have come to is a system that 
reinforces that kind of behavior and does not provide us the 
kind of reinforcement we need to give the care that we need to 
be giving.
    Senator McCaskill. Is that an accurate assessment, Dr. 
Redden and Dr. Tatum?
    Dr. Redden. Yes, I would agree with that also. I do not 
prescribe a lot of opioids as a psychiatrist. I do mostly 
benzodiazepines, which are in the same category.
    Fortunately for me, I am at an academic institute and my 
time slots are. . . [inaudible] so I have 25 minutes to fully 
assess a patient. I have colleagues who are chiropractors who 
get paid by the number of patients that they see versus the 
quality of medicine that they provide to the patient, so as he 
said, the easiest way to get people in and out is just to 
prescribe a medication without doing a full assessment.
    Senator McCaskill. I was never offered a narcotic pain 
medicine at the dentist 30 or 40 years ago, I am that old. I am 
older than dirt. I am now. What is up with that? Why would her 
daughter be given a narcotic pain medication for a cut on her 
hand? I mean, this is not chronic pain. This is episodic pain.
    Dr. Tatum. I think if all you have is a hammer, everything 
looks like a nail, and I think that it is true that the 
patients who are on the older side, with multiple chronic 
diseases, as you go through severe arthritis where you no 
longer may be operable, opiates remain a potential tool, but 
there is a wonderful study just in the last few months in the 
Journal of the American Medical Association looking at back 
pain. It suggests if you compare standard regimens versus 
opioids, simple old-fashioned anti-inflammatories probably have 
better outcomes over time, and the problem is once you have 
started a prescription, it is--a subset are going to remain on 
it.
    Senator McCaskill. Of course, they are.
    Dr. Tatum. I think the fact of----
    Senator McCaskill. It feels really good.
    Dr. Tatum [continuing]. the matter is if you ask physicians 
and look at it from a physician education standpoint, as Dr. 
Twillman pointed out, they think that pain management, in some 
sense, has a short shrift in terms of the complexities and 
nuance. At the same time, culturally we have this move to pain 
as the fifth vital sign.
    You know, to me, as you mentioned, chronic pain is cancer 
pain. There is pain at the end of life, which is one thing, and 
you treat that pain. A subset of chronic, non-malignant pain I 
think we need to think about is not what is your pain score? 
Certainly not a quality metric that might impact reimbursement 
if you did not get to a certain quality score. The real 
question is did we improve your function and your well-being?
    A wonderful book by Eric Cassell, ``The Nature of 
Suffering'', describes in the beginning a person who has come 
in multiple times, seen multiple doctors again and again and 
again for pain, a back pain in particular, a younger person, 
and her suffering was, in part, what was this? The simple 
process that he recognized her pain was two levels above where 
everybody had shot an x-ray and found she had a compression 
fracture and a wedging down of the back vertebra from a trauma 
she had, and by naming it, what relief that brought to her.
    I think Dr. Twillman has mentioned how complex systems, not 
just another pill, is the key. We need more than just the 
hammer.
    Senator McCaskill. Why are not doctors offering a--by the 
way, I have some outpatient surgery coming up, and I will say 
for the first time a doctor said to me I will write you a pain 
medication if you want it, but most people find that Advil 
works just as well. That is the first time that has ever been 
said to me, but he still did not say by the way, that 
prescription, if you want it, it is addictive.
    Why are doctors not telling patients that what they are 
prescribing for them is addictive? What is that not said? 
Nobody says that. Do you say, this is addictive when you 
prescribe opioids to patients?
    Dr. Redden. I do when I prescribe benzodiazepines. I said I 
am not in the habit of prescribing opioids, but with 
benzodiazepines, I let--I also see younger patients--I let all 
my patients know that it is habit forming and that you can 
develop a physiological dependence where your body needs it, 
and a psychological dependence where you feel you need this, 
and often it starts with someone like you, getting a benzo or 
an opioid for short-term use and they like the feeling and they 
begin to seek it more and more, for whatever reason, and then 
they are on it for the rest of their lives. I see patients that 
take opioids when they are young and they come see me at 60 and 
70 and they are wondering why they are not thinking right, why 
other mental health issues are going on, and no one has 
addressed that problem.
    I do not know, I think it is lack of medication education, 
especially from medical school up into residency with focus on 
other things and they often do not want to make the patient 
feel bad either. If someone admits they have a problem, that 
may make them feel shameful or have that measure of stigma 
attached where they may not want to seek out help or treatment 
anymore.
    I do not know why others----
    Senator McCaskill. I certainly understand that in the 
psychiatric field. We have stigmatized mental illness in this 
country to the point that we are all suffering from it, but 
what about doctors that for--why are they not telling patients 
that these drugs are addictive?
    Dr. Tatum. You know, I have a funny alternative take. I 
think you are right that that is a key issue.
    The funny alternative, as a geriatrician when I think it is 
very appropriate for someone to have an opioid, if I do not 
address addiction with an 80-year-old, they are so afraid of 
it, they are never going to take a pill that might be very 
appropriate for them.
    I think one of the real challenges is we do not have great 
tools that help screen for a person who is going to be a risk 
abuse. I think a PDMP is one part of that. I think the future, 
if I can think what NIA can accomplish with research in the 
future, would it not be amazing if, with personalized medicine, 
I could do a drug test before I prescribe an opiate? Would it 
not be amazing if with that blood test, number one, I can see 
the type of receptor that person has and know which ones are 
going to cause side effects to avoid versus which ones. . . 
[inaudible] even more importantly.
    We are not anywhere near that. This is a dream. Would it 
not be amazing in personalized medicine if I could say this is 
the person who is going to be addicted? I think there is so 
much potential and research and, in particular, that is an 
exciting thing to think about in the future.
    In the hear and now, I think it is a challenge, and the key 
thing that would help me in the short term in our local State, 
is a PDMP so I can recognize the person who has addiction 
issues up front. Partly, so I can refer them for treatment.
    Senator McCaskill. By the way, the people who are addicted, 
it is always 10. I mean, they are trained to come in and say my 
pain is a 10, my pain is a 10 plus, my pain is a 10 plus. Now I 
do not know what asking somebody who is addicted what their 
pain is accomplishes.
    Dr. Tatum. A Marine whose pain is a three is a problem.
    Senator McCaskill. Right.
    Representative, talk a little bit about your legislation. 
Why don't you take a stab--I would do it, but I would like to 
hear it from you instead--about this paranoia about people's 
privacy. That seems to be the problem.
    Ms. Rehder. Yes, ma'am.
    Senator McCaskill. To me it is an irrational paranoia, but 
why don't you address that so that we have it in the hearing 
record. You know, when 49 states have done it and one has not, 
my Missouri common sense tells me we are the problem, not the 
49 other states, so why don't you help out with why this is not 
going to violate people's privacy as it relates to their health 
records.
    Ms. Rehder. Yes, ma'am. Thank you.
    I look at this as an extension of electronic medical 
records. This is something very less invasive than electronic 
medical records. It is housed with the State, and just as 
Missouri HealthLink has never had a breach, nor have any of the 
other PDMPs. California implemented theirs in the late 1930's.
    I think, since there has not been a breach in all of these 
years, we already have a smaller PDMP working in the State that 
has never harmed anyone with our Missouri health plan, with our 
Medicaid, so to me, the privacy issue that continually gets 
brought up is just a red herring.
    We have--PDMPs fall under HIPAA laws and so they are just 
as safe--your electronic medical records--they are just as 
safe. They are just an extension of that, and many people get 
their prescriptions filled at Walmart. Walmart has a national 
PDMP of their own. Walgreens, the same.
    The small pharmacies are the ones that, you know, the 
single-owned pharmacies. They cannot look to see what you have 
gotten. Walmart cannot look to see if you have gotten something 
from the pharmacy across town, and so that is the only element 
that we are trying to pick up, and so your doctor can look on 
the front end and say okay, what we actually need to be talking 
about is your addiction and address addiction on the front end, 
and so to me the privacy issue is just a red herring. That is 
something that has been thrown in here to say the sky is going 
to fall when it is not. It has not fallen and these have been 
in place in some form since the late 1930's.
    Senator McCaskill. Mr. Walker, I assume that our heroes and 
our brave and amazing men and women who have stepped across the 
line and said take me, we do have a PDMP for our veterans; 
correct? I mean, we know if veterans--with the veterans system, 
you can track the use of opioids?
    Mr. Walker. Yes, within our electronic health record we are 
able to track the use of opioids. We also have some-----
    Senator McCaskill. Have any of the veterans complained to 
you about violating their privacy as it relates to that?
    Mr. Walker. No, and we also have the ability to have links 
to the Department of Defense, in terms of medications patients 
are on when. . . [inaudible]. We do have comprehensive 
medication information available through our electronic health 
record.
    We also have our--recommend to our providers and our health 
care teams that they do access the State PDMPs. That is one of 
our universal precautions, in terms of our Opioid Safety 
Initiative, and so within our network we do have providers who 
access, and health care teams, access the information from the 
State of Kansas, the State of Illinois, and possibly from the 
State of Arkansas, and we also have, in the State of Missouri, 
the Missouri VA facilities that border those states and they 
actually do make some queries to those states to try to find 
out of the patients are taking any medications from other 
sources or other pharmacies outside of the VA.
    That is considered to be an important part of our universal 
precaution, the process. . . [inaudible].
    We also have, as part of our universal precaution, doing 
routine and periodic urine drug screens, and we also, for all 
of our patients that are on chronic opioids, and we have a 
definition of that, more than 90 days. They have to have a 
consent done, and within that consent, we talk about taking 
opioids responsibly, and that is really the starting point, to 
have that conversation with the patient or with their family, 
to start to talk about what are realistic expectations in terms 
of what medications can help you, what are other alternatives, 
and then that is kind of the starting point for a shared 
decisionmaking with our veterans in terms of deciding okay, 
what is going to happen with their pain management in terms of 
whether it is opioids or they are going to be referred to an 
interdisciplinary team for pain management to have access to 
other integrated health-type services, to help the veteran 
self-manage their pain in their lives and how they react to it, 
so those are all things that are readily available through the 
Department of Veterans Affairs.
    Senator McCaskill. You would be a good person to start with 
on this. The other flip side of this is when either the VA 
system or a doctor or an emergency room recognizes that someone 
is an opioid addict and they sound the alarm and cut them off 
without appropriate care for withdrawal. Can you all address?
    I was talking to Representative Lavender, she has a 
constituent where that happened to a woman where the doctor 
said we are cutting you off, that is it, without any kind of 
medical plan for the withdrawal. I assume that you all are 
aware that that can be as dangerous--that is where the heroin 
comes in if the plan is not one that is sound and that the 
patient buys into.
    Dr. Twillman. I tell practitioners that I think that is 
malpractice to do that. There has been a big push to have 
patient agreements where patients who are on these medications 
sign agreements and say I will do certain things, and 
oftentimes those are written in such a way that if they violate 
the terms of that, the consequence is to stop all of their 
therapy. I think that is malpractice, because what has happened 
is you have just identified a new medical disorder, the 
disorder of addiction, and that needs appropriate treatment. 
Appropriate treatment is not cutting somebody off and kicking 
them out the door. Appropriate treatment is finding somebody 
who can treat that person appropriately for their disease of 
addiction.
    Most often, the most effective treatments are some sort of 
medication-assisted treatments with methadone or buprenorphine 
products, and that is what needs to be done. People need to 
understand that that is the appropriate treatment for that 
disorder.
    Senator McCaskill. Do you believe that there is an increase 
in the prescriptions being given in more reasonable amounts 
for--this is really more ER than it is--or orthopedic surgeon, 
the--I remember when I finished having my knee replaced. Well, 
I had a whole bunch left over and I was not interested in them. 
I was wondering why they prescribed so many. I think the doctor 
gave me like 90 days or something for a knee replacement, or 
the dentist wanting to give a patient 30 days after a trip to 
the oral surgeon. Why not three pills? Why not four pills? Why 
is it typical that it is 30 or nothing, or sometimes even more 
than that? Is that something that has just been traditional in 
medicine, and prescribing just a handful of pills does not 
happen?
    Dr. Tatum. I think this is a critical issue because I think 
of the young child who starts the pathway to addiction is often 
not that they received the prescription. It is that they got 
grandmother's prescription.
    Senator McCaskill. Right.
    Dr. Tatum. I think that you learn the pharmacology----
    Senator McCaskill. That happened in my family, by the way.
    Dr. Tatum [continuing] but the real world practice, 
frankly, is doctors learn from another doctor how to put the 
number on the pulls as they are writing the script the first 
time is not a good process, and I think as we start speaking 
more and more to the issue of opiate abuse, I think you are 
seeing efforts. You are starting to see efforts in 
Massachusetts on issue about the--cutting back on the number of 
prescribed--Missouri Hospital Association statement really 
speaks for emergency room physicians, in particular, limiting 
that to a 72 hour supply.
    The danger, I think the danger in particular was in a South 
Carolina response, if you so limit the number and do not 
appropriately describe the physician you are talking to, they 
have the potential to make it very hard for a hospice physician 
who might take care of a very large rural area to be able to 
prescribe medication for that person where they may not be able 
to physically see them for a week or so because it is the nurse 
seeing them.
    Senator McCaskill. I see.
    Dr. Tatum. I think the smart policy is education to help 
physicians limit the number down, limits particularly in the 
emergency room that are smart precautions. I think Texas had 
some good examples in their legislation about making smart 
exemptions for say palliative care patients and hospice 
patients.
    Senator McCaskill. Maybe the most important--I am sorry, 
did I interrupt you?
    Dr. Twillman. Sorry, Senator. I think there is a piece of 
research here that also would be very helpful to us and it 
would be easy to do and inexpensive to do.
    My wife had arthroscopic knee surgery and was prescribed 80 
Percocet tablets for that, and took 2.5.
    What is happening is people are prescribing so that the 
patient never runs out of medication and needs a second 
prescription. They are estimating what that patient, whose need 
is at the 99th percentile, is. I think most of them do not know 
what the average patient uses because I think when people come 
back for post-op followup appointments they never ask the 
question, how much of that medication did you use?
    Senator McCaskill. Right.
    Dr. Twillman. It would be really simple for something like 
Medicare or Medicaid, where you have got the prescription 
records, to simply contact the patients afterwards and say how 
much did you use? If we found out that the average number used 
was five pills, maybe we would not be prescribing 80.
    Senator McCaskill. Yes. Well, that is a good idea for 
Medicare to take a look at. There is an awful lot of joint 
replacement going on in the Medicare population, a lot of hips, 
a lot of knees, a lot of shoulders. That would be a reasonable 
place for us to do the research about the average amount that 
is used.
    Maybe the most important question I need to ask is for. . . 
[inaudible] this is the Committee on Aging, and I certainly 
know that there are lots of elderly out there that are addicted 
to opioids. What are the things I need to know? Obviously, if I 
could wave a magic wand and put a certain Senator locked in a 
closet, we could get this done in Missouri, but I am pretty 
sure that the law enforcement representatives that are here 
would have to arrest me for that, so that would get ugly and it 
probably would go viral.
    I am not going to do that, and we know that is the obvious. 
That is the low-hanging fruit here, is for Missouri to join the 
rest of the country here in doing a basic, simple, common sense 
thing, but what are the things that we could be doing at the 
Federal level, both through the Medicaid and Medicare 
population, and through NIH, and through the ability to 
proscriptively change the Medicare program. Give me good ideas 
of what I can take back to Washington this afternoon and share 
with Senator Collins that perhaps we should take a closer look, 
a more detailed look, at a part of this in a hearing in 
Washington where we could look at perhaps some legislation that 
might be helpful in this area.
    Dr. Tatum. It is funny, in the Show Me State, the good 
thing is we have let 49 other states do this, so we will learn 
from their best practices. I think a Federal piece about 
absolute best practices on PDMPs would be very helpful, 
particularly as we build one here. Let us do it right because 
everybody else has done what is wrong.
    The second piece, and looking at our State, if you look at 
hot spots about where the addiction issue is, the hot spots of 
opioid issues, really St. Louis and Kansas City are part of 
that. A Federal solution, with appropriate privacy safeguards, 
I think is the interoperability where one state's PDMP can talk 
to another's so that my patients--if I were in St. Louis or 
Kansas City--actually got their prescriptions also in Illinois 
at the same time.
    I think a third key Federal response that comes to my mind 
is, again, the opportunity to really enhance geriatric 
education for this Committee, as mentioned.
    Senator McCaskill. We have got a shortage of geriatric help 
in this country right now. John Morley is my husband's doctor 
and when I go to appointments I have to bring a lunch.
    Dr. Tatum. Sadly, Dr. Morley is not shy.
    Senator McCaskill. Dr. Morley will never let me out of the 
room until he explains to me the crisis facing America in terms 
of a lack of doctors ready to care for my generation, that 
geriatric medicine is not one of the big money glamourous 
specialties and we are sorely lacking geriatric professional 
medical help in this country.
    What can we be doing, through the Medicare program, that 
would help with this problem of just having enough doctors that 
have enough time? Is it reimbursing the doctors more for their 
time with patients as it relates to preventative care?
    Dr. Redden. Yes. We have a record system and within that we 
have measures to do certain screenings. I always get things, I 
do not do tobacco screenings, someone else can do it, but if we 
had screening measures of any substance abuse that would come 
across that would affect someone's pay or--we get paid through 
RVUs--if that would affect that some kind of way, many doctors. 
. . [inaudible] and start there.
    Another thing I wanted to add is once you identify someone 
with substance use disorder, especially the elderly, the 
treatment options are very limited and treatment places to go 
for the elderly are very limited. Programs are always geared 
for younger adults, mainly with alcohol, and studies generally 
exclude elderly patients, 65 and up.
    Senator McCaskill. Yes, that is really interesting. I had 
not thought about that. The treatment facilities are geared 
toward 18 to 35, not for 65 and older.
    Dr. Redden. Who also may have some cognitive impairments. 
You have to tailor programs specifically geared toward the 
elderly, as well. That is something that can be done----
    Senator McCaskill. Are there any elderly drug treatment 
programs in Missouri?
    Dr. Redden. None that I know of, specifically in St. Louis. 
Everyone, especially my older patients who have problems, have 
to go with the younger people, the younger patients, and they 
also worry about taking their medical medications and having 
those conditions addressed and most of the programs do not have 
doctors onsite on a daily basis, so they worry about that, as 
well.
    Senator McCaskill. When you identify somebody who is 
addicted to opioids and they are, say, 72 years old, you have 
really no treatment options, especially if they have chronic 
conditions of other types?
    Dr. Redden. Right, other than----
    Senator McCaskill. Diabetics and heart disease.
    Dr. Redden. Right. Usually detoxing is very hard also, to 
bring them to the hospital and God forbid, have some insurance 
cover that. If they understand that this is a chronic problem, 
nothing acute going on, then they are not reimbursed, as well, 
so oftentimes, the medical side may to get rid of them quicker. 
We have been facing that problem, as well. There is no sites, 
intense outpatient programs specifically for the elderly with 
substance abuse. . . [inaudible].
    Senator McCaskill. Derron, we have got to--one of the 
things we need to--this is Derron Parks. Raise your hand. 
Derron is my Staff Director for the Committee on Aging.
    We have got to get national statistics on drug treatment 
programs for the elderly, because there is not one in Missouri. 
I bet you there are a bunch of states where there are not any, 
because if there were one in Missouri, you would know about it; 
right?
    Dr. Reddon. Correct.
    Senator McCaskill. You know, it is funny, reimbursing---you 
know, this is a dangerous area to go down because I want to 
take this just because I like to explain this to folks.
    The irony about the death panel controversy on the 
Affordable Care Act, that irony was so rich because all that 
was was reimbursing doctors for the time they spent with 
patients and their families explaining end of life decisions. 
We were going to pay doctors--right now, doctors are not 
reimbursed for the time they take to explain nutrition, 
hydration, those issues that occur at the end of life, and of 
course, when someone is there, usually they are not able to 
weigh in, so you have family members making very difficult 
decisions about continuing life support, whether it is 
hydration, nutrition or actually oxygen, without the benefit of 
having input from their loved one, and that is why we have 
these incredibly high costs near the end of life, because the 
loved ones do not want to make that decision for the person who 
is no longer capable of making it, so it just makes sense that 
if you can talk to your doctor about it when you are able to 
make those decisions, and then memorialize them so your family 
understands--I was lucky. My mother did that. She beat in our 
head a million times, if you put me on a breathing machine, I 
will haunt you until the end of time. If you put me on a 
feeding tube, I will haunt you until the end of time, so our 
decision was easy for my family, but reimbursing doctors for 
that time they spend with the elderly making those decisions, 
that is all it was. That is all it was, and we had to get rid 
of it because it became so controversial because the doctors 
were turning it into people who were telling people it was time 
to die. Of course, that is not what the doctors were doing, so 
it is another way we need to look at how we address some of the 
costs, so that maybe we can have more money to, in fact, do 
drug treatment programs and reimburse doctors for other kinds 
of preventative care that they need to be administering to 
those folks between the ages of 65 and 80, 90. In my mind, 80 
is the new 50, I am just saying. Since I am rapidly approaching 
the Medicare age myself.
    Anything else that we need to be doing at the Federal 
level, besides what has been suggested so far. Yes, Dr. Tatum?
    Dr. Tatum. Senator, first, thank you for your comments on 
the advance care planning importance.
    I think of my father's physician who as uncomfortable 
caring for somebody at the end of life. There was a tremendous 
gap. I think we are really doing a much better job of educating 
physicians about this now. I think there is a tremendous gap 
from the average practitioners out in practice who has been 
there for 25 or 30 years who is not getting this.
    The Palliative Care Hospice and Education and Training Act 
is one of the bills that has a neat aspect of it. It sets of 
regional training centers, so how do we actually get to that 
person who is out in practice now, not just the up and comers? 
That is a very nice way to address this important gap. I think 
it covers both pain as well as underlying care.
    The second thought that comes to mind from a Federal 
standpoint, as we have been talking, is the AMA, I mentioned 
their task force to really address this, and I think would be a 
good partner. The AMA is very concerned about burnout of 
physicians. A key part of that is the electronic medical record 
not working well for them, and going out to the PDMP is a 
problem if it is not integrated very, very well. I think 
something like 35 percent of physicians actually registered 
with a PDMP if it is not mandatory in the State.
    I think the Federal response that could be very helpful is 
actually push to make PDMPs integrate into electronic medical 
records. Give doctors the tools they need at the points of care 
that are easy to use and effective.
    Senator McCaskill. Is that capability there now? In other 
words----
    Dr. Redden. From the Missouri perspective?
    Senator McCaskill. Obviously, not, but in other states? In 
Kansas--you work in Kansas, Dr. Twillman, is that software 
capability embedded, for example, in the Cerner products?
    Dr. Twillman. Well, we have two health information 
exchanges in Kansas, one of which is the LACIE exchange, which 
also covers parts of Northwest Missouri. We are actually fully 
integrated with the LACIE Health Information Exchange now.
    Senator McCaskill. What is the LACIE?
    Dr. Twillman. Lewis and Clark Information Exchange, so 
health information exchanges basically link medical records 
across practices so that if you encounter a new patient, you 
can pull up their records that they have accumulated in other 
practices as well and see everything that is going on with the 
patient.
    The problem right is for PDMPs, if you are in the medical 
records, you have to get out of that, go into a different place 
to get the PDMP report, hop back and forth. It is a challenge. 
The way we have set it up in LACIE is you open up a patient's 
record, you have got all of the information there and it is a 
one button click to get the report from the Kansas PDMP, so it 
has been done. It is possible to do it. It is a matter of 
money, is really all that is keeping us from doing that.
    Senator McCaskill. Okay.
    Dr. Tatum. I think if we are going to have PDMPs, they need 
to be useful and that is a powerful. . . [inaudible].
    Senator McCaskill. Derron? Okay.
    Anything else? He is going to cut me off.
    Dr. Reddon. There are legal ramifications if someone does 
have a red flag within these prescription drug monitoring 
programs, that should also include education to the public. I 
have a lot of patients that are worried about disclosing 
information that may get them into trouble from a legal 
standpoint. They do not know what the legal ramifications are 
going to be if they have been doctor shopping or abused the 
system, whether they would be prosecuted or not.
    Senator McCaskill. Well, I think, you know, I think most of 
the medical records and most of the information that is 
contained within the medical system is considered private 
unless it is subpoenaed and there would have to be probable 
cause to subpoena it that would come from somewhere other than 
the medical community, so I think patients can be reassured 
that what you tell your doctor is going to put you in jail, but 
if you are dealing heroin on the side, they may very well 
subpoena your doctor's records.
    I think there is a little--but I think it is important to 
look at that, though, because you are right, we do not want to 
put up any barriers to people being honest about where they are 
and they need help. In the long run, we are much better off 
treating them than putting them in prison, which is what the 
drug courts have all been about and they have been great.
    Senator McCaskill. Well listen, I have learned a lot today. 
I think that I have got a good list of to-dos to go back to 
Washington with.
    I want to thank all of you for your input and for your 
work. Thank you, Representative Rehder. I am going to cross my 
fingers and toes that you can figure out a way to get the 
Senator locked in a closet. I mean that metaphorically, not 
literally. Metaphorically only.
    Thank you all for the work you do every day, and we will 
try very hard to see if we cannot help with this problem 
through the Medicare and Medicaid system in Washington to see 
if we cannot deal with this tragedy that is gripping our 
country right now.
    Thank you very much.
    [Whereupon, at 10:52 a.m., the Committee was adjourned.]
    
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                                APPENDIX

    
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                      Prepared Witness Statements

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