U.S. GOVERNMENT PUBLISHING OFFICE

48–286 PDF WASHINGTON : 2022

S. HRG. 114–852

FIGHTING AGAINST A GROWING EPIDEMIC:

OPIOID MISUSE AND ABUSE

AMONG OLDER AMERICANS

HEARING 

BEFORE THE

SPECIAL COMMITTEE ON AGING

UNITED STATES SENATE

ONE HUNDRED FOURTEENTH CONGRESS

SECOND SESSION

LEESBURG, VIRGINIA

FEBRUARY 1, 2016

Serial No. 114–18

Printed for the use of the Special Committee on Aging

( 

Available via the World Wide Web: http://www.govinfo.gov
(II) 

SPECIAL COMMITTEE ON AGING

SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah

MARK KIRK, Illinois

JEFF FLAKE, Arizona

TIM SCOTT, South Carolina

BOB CORKER, Tennessee

DEAN HELLER, Nevada

TOM COTTON, Arkansas

DAVID PERDUE, Georgia

THOM TILLIS, North Carolina

BEN SASSE, Nebraska

CLAIRE MCCASKILL, Missouri

BILL NELSON, Florida

ROBERT P. CASEY, JR., Pennsylvania

SHELDON WHITEHOUSE, Rhode Island

KIRSTEN E. GILLIBRAND, New York

RICHARD BLUMENTHAL, Connecticut

JOE DONNELLY, Indiana

ELIZABETH WARREN, Massachusetts

TIM KAINE, Virginia

PRISCILLA HANLEY, Majority Staff Director

DERRON PARKS, Minority Staff Director
(III) 

C O N T E N T S 

Page 

Opening Statement of Senator Tim Kaine, Member of the Committee .............. 1 

PANEL OF WITNESSES

Mark Herring, Attorney General, Commonwealth of Virginia ............................ 8 

Jane Terry, Director of Government Affairs, National Safety Council ............... 10 

Katherine Neuhausen, M.D., M.P.H., Assistant Professor, Department of

Family Medicine and Population Health, and Associate Director, Office

of Health Innovation, Virginia Commonwealth University .............................. 12 

Lisa Wilkins, Acting State Director, Virginia Change Addiction Now ................ 15 

Mellie Randall, Director, Office of Substance Abuse Services, Virginia Department of Behavioral Health and Developmental Services ................................. 18 

APPENDIX 

PREPARED WITNESS STATEMENTS

Mark Herring, Attorney General, Commonwealth of Virginia ............................ 43 

Jane Terry, Director of Government Affairs, National Safety Council ............... 48 

Katherine Neuhausen, M.D., M.P.H., Assistant Professor, Department of

Family Medicine and Population Health, and Associate Director, Office

of Health Innovation, Virginia Commonwealth University .............................. 54 

Lisa Wilkins, Acting State Director, Virginia Change Addiction Now ................ 64 

Mellie Randall, Director, Office of Substance Abuse Services, Virginia Department of Behavioral Health and Developmental Services ................................. 70 

(1) 

FIGHTING AGAINST A GROWING EPIDEMIC:

OPIOID MISUSE AND ABUSE

AMONG OLDER AMERICANS

MONDAY, FEBRUARY 1, 2016

U.S. SENATE,

SPECIAL COMMITTEE ON AGING, 

Washington, DC.

The Committee met, pursuant to notice, at 10:34 a.m., in the

Loudoun County Government Center, 1 Harrison Street, S.E., Leesburg, Virginia, Hon. Tim Kaine, Member of the Committee, presiding.

Present: Senator Kaine.

Ms. Phyllis RANDALL. [Speaking off microphone.]—so this issue

for me has been close to my heart for many years... [inaudible]

great opportunity in speaking about it right now. I welcome you all

to Loudoun County for such an important issue, such an important

event, and I want to first acknowledge some people in the room.

Of course, our Attorney General, Loudoun’s own Mark Herring is

with us... [inaudible] Kristen Umstattd, Supervisor from the Leesburg District, and the acting Mayor of Leesburg, Kelly Burk, has

joined us.

Next, we have people from the County’s Area Agency on Aging.

If you are here, would you raise your hand. Look at that. Thank

you for coming... [inaudible] this issue is such an important issue.

Opiate abuse or substance abuse in general is something that really has affected our country, our Commonwealth, and our county,

and there are different demographic... [inaudible] it hits in different ways, and we often do not think about how it actually affects

the 65-and-over population, and it does affect it in so many different ways, so without further adieu, I welcome to the county and

welcome Senator Tim Kaine.

OPENING STATEMENT OF SENATOR

TIM KAINE, MEMBER OF THE COMMITTEE

Senator KAINE. Well, good morning, and thank you all for being

with us today.

Let me do the official business and first bring to order a meeting

of the Senate Special Committee on Aging. This is a field hearing

of the Aging Committee and the title of the presentation, as you

know, is ‘‘Fighting Against a Growing Epidemic: Opioid Misuse and

Abuse Among Older Americans.’’

I am very happy to be back in Leesburg, back in Loudoun County. This is a committee I have been on for about a year and they
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like to do field hearings and get out among the community and I

have been looking forward to this, and I appreciate everybody who

was planning to come last Monday who we all decided that it

would be better to come today, and how good to come, and there

is still snow on the ground, but the weather is going to be 60 degrees and it is a little easier for everybody to come, but the fact

that you adjusted your schedules, I also appreciate. We have got

a great group of witnesses.

This is a huge problem, and what I thought I would do, just to

kind of give you a sense of how we will run this hearing until about

12:30, is I will make some opening comments. I will introduce the

witnesses that we have before us who are going to testify. They will

each testify for 5 minutes or so, and then I am going to be a lawyer

and cross examine them. I have a lot of questions for these witnesses, and all of this testimony will be available on the record in

the—if you just go to the Aging Committee of the Senate, this testimony will be available.

We have had hearings on this issue and meetings on this issue

in D.C. and we are looking to have field hearings so that we can

make appropriate policy.

Just a word about the Aging Committee, wonderful Chair Susan

Collins of Maine and the Ranking Democratic Member is Claire

McCaskill of Missouri. It is a committee that works very hard, and

unlike some Senate committees where the main focus of those committees is pushing through legislation or nominations, the Aging

Committee’s primary purpose is to shine a spotlight on problems.

It is really more of a, you know, let us raise issues to the public

consciousness. 

One example that we have, for example, on the Aging Committee, we have a 24/7 hotline for seniors to call and report abuse,

financial scams or consumer scams that trap seniors, so our main

interest in this Committee is to kind of raise the profile of tough

issues, and then once raised, often, individual members or sometimes even other committees, like the HELP Committee—HELP,

Health, Education, Labor, Pension—will take the issues whose profiles have been raised when we do these field hearings and then

we will put through legislation about them, but let me just start

and now make some opening comments and then we will move to

the witnesses and their testimony.

Let me thank Loudoun County Government. Let me thank the

Loudoun County Area Agency on Aging. These local Areas on

Aging, Loudoun County does such a good job around Virginia, and

the Loudoun County Government has been gracious to host this

today, along with officials from Leesburg, who have been introduced. These Areas on Aging throughout Virginia, and I learned

when I was Mayor and Governor they do great work for our seniors

and they work to improve quality of life in so many different directions. I want to thank my committee staff and committee chair and

my personal staff for helping with this issue, and it is an issue of

passion for me because it is an issue that affects every last zip code

and region of Virginia. It respects not race, not region, not income,

not age, and I have had town hall meetings about the issue of

opioid addiction in far Southwest Virginia, in Winchester, meetings

in Richmond with Governor McAuliffe, and now here in Leesburg.
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All across the Nation, we are seeing a scourge of prescription

drug and heroin epidemic, and they interrelate very significantly,

and they impact communities everywhere. From the coal mines of

Appalachia to suburban Fairfax County, I have heard from parents

who have buried children, law enforcement officials, and employers

who struggle to find employees who can find a drug test. I have

heard from law enforcement officials who have talked about the

struggles that their own children have had with opioid addiction.

Deaths from drug overdoses have jumped in nearly every county

across the United States, and it has been driven largely by an explosion in prescription pain killers that often then connect with

heroin addiction.

The number of deaths from opioid addiction reached a new peak

in 2014, 47,055 people, 125 Americans every day, and nationally,

opioids were involved in more than 61 percent of overdose deaths

in 2014, so there are other drug categories, obviously, that can lead

to overdose deaths, but opioids is now the driving force, and the

deaths from heroin overdoses has tripled just since 2010. From

2010 to 2014, overdose deaths have tripled.

This is a problem that really begins largely in our medicine cabinets. Opioids, including hydrocodone, which is commonly known as

Vicodin, oxycodone, which is commonly known as Oxycontin, and

oxymorphone, or Opana, are among the most commonly prescribed

medicines in the United States. Over the past 15 years, the rate

of opioid pain reliever use in the United States has soared. Over

259 million prescriptions for opioid pain killers were written in the

United States in 2013, and, obviously, a prescription contains multiple pills, so the number of actual pills prescribed has been dramatic.

This is a kind of pain killer that has a very important use. It was

developed primarily for palliative end-of-life care when someone is

dealing with terminal pain at the end of their life, or with very

acute pain management, for example, following surgery. That was

how these important medicines were developed, and they do have

an important purpose in that area, but what has happened is that

they have been prescribed far beyond their original intent to include chronic pain management, which was not the original purpose of these medications, and as that has happened, the prescription of opioids—prescription opioids has gone dramatically up.

According to the Centers for Disease Control, the rise in opioid

pain reliever consumption has led to, and this is the CDC talking,

quote, ‘‘the worst drug epidemic in history,’’ and that is a mouthful.

The CDC has recently added opioid overdose prevention to its list

of the top five public health challenges in the United States.

The opioid epidemic closely is related to the increase in heroin

use, so a common etiology of addiction that we see is people who

get prescribed for legitimate reasons a prescription opioid. They

then become addicted to it. The cost of it becomes to hard to bear,

and because of some changes in heroin, especially its production

now in Central America and Mexico, not just in Turkey and Afghanistan, the price of heroin drops, and so people who get addicted and then cannot afford the prescription opioid decide to try

to see if they can buy heroin, which is cheaper, and so, then they

become addicted to heroin, and often heroin that is cut with all
4 

kinds of other drugs. They do not know the purity of it. They do

not know what other problems are in it.

Four-fifths of those who die from heroin overdoses started their

addiction to opioids with prescription drugs, so these prescription

drugs not only cause a problem in and of themselves when used

improperly, but they also become kind of a gateway into heroin and

the heroin overdose problem that is directly connected to it.

This is a crisis that a lot of people in their mind’s eye think

about young people, and certainly, the effect of opioid addiction and

overdoses on young people have been staggering. I was fortunate

enough—‘‘fortunate’’ is kind of a hard word, but I was fortunate

enough to have as my guest at the State of the Union this year a

wonderful Fairfax dad whose son—this is Don Flattery—whose son

was a UVA grad who moved to L.A, and then got hooked on prescription drugs and died, and he has turned his tragic experience

into a real passion in advocating for others, and we often think

about this problem in connection with young people, and that is appropriate. However, this does not respect age and this problem is

beginning to have a very particular and dramatic impact on older

Americans. 

Deaths from drug overdoses have steadily increased among older

adults. According to the CDC—this is now 2013 data—more than

12,000 Baby Boomers died of accidental drug overdoses, more than

the number who died in car accidents or from the flu or pneumonia

combined. 

The age group with the fastest rise in overdose deaths due to

prescription abuse is the age group of 55 to 64 years old, and this

is an indicative pattern of the larger problem of opioid abuse. It

normally does not start with illicit drug use. It starts with getting

a prescription that is written for a, you know, a standard medical

problem involving pain management, but this expansion of how

opioids are prescribed beyond palliative and acute pain management to chronic pain management has been one of the major problems.

Among older adults, there are some other challenges that compound this. Older adults take more medications, on average, than

younger people, and there are some particular problems of the combination of opioids with other drugs and the medical effects that

they can have.

Older adults may, for other reasons, eyesight and others, start to

have a little more challenge with operating motor vehicles, and

again, any use of prescription drugs or something like that, when

combined with some of the challenges that some of our seniors

have with operating heavy vehicles, motor vehicles, can lead to

these problems.

Now, we talked about the problem from a national problem, but

just quickly some of the Virginia stats. As I said, I have done

roundtables on this issue in all corners of the State. The Virginia

Department of Health—and we are going to hear from patient advocates, people who have had these experiences touch them deeply

in their own family, Virginia and local officials—you know, this is

the work Phyllis has done in her other 24-hour-a-day job next to

being Chairman of the Board, and also my good friend Attorney

General Herring, who has worked so significantly on this—we see
5 

it all over Virginia, and the Virginia Department of Health reported that the increase in deaths in prescription opioid and heroin

overdoses just between 2012 and 2014, a 2-year period, the increase in opioid-related deaths went up by nearly 40 percent in 2

years. The Attorney General is going to focus on some additional

statistics that are Virginia-specific as he testifies, so what is the solution to this challenge? Well, it is going to take a big cultural shift

to get away from a culture of over-prescription and a culture that

uses other methods for managing chronic pain. Again, these

opioids, the prescription opioids, have a legitimate and important

use. They definitely do, but the challenge we have is one of an

over-prescription that has really kind of run wild, and there is no

single thing that will affect that. Raising awareness is part of it,

but there are also steps that we must take.

Just quickly, some of the things that I have been involved with

in the Senate is, first, as a member of the Armed Services Committee, I have been very involved in efforts to go into our DOD

medical facilities, hospitals, clinics, and our VA medical facilities

and clinics and to make sure that they are using appropriate

standards in terms of how they deal with pain, that there is a place

for prescription opioids, but they should not be over-prescribed, and

other pain management strategies, especially for chronic pain, are

really important to make sure that we pursue, so in those areas,

I have been working a lot on my committee.

I have introduced a bill called the Co-Prescribing Saves Lives

Act, which deals with the co-prescription of naloxone. Now, many

in this room are much more expert about this than me, but

naloxone is a drug that has been used, really, since the early 1990’s

or so that can bring someone back from an opioid overdose, commonly an opioid overdose that is driven by respiratory failure, and

naloxone is an easily administered drug that will—it is not pleasant. It is like going through withdrawal immediately, but it brings

you back out of the respiratory failure that an opioid overdose creates.

It has been very common for naloxone to be carried by first responders and used by first responders if people are in an OD situation. One of the virtues of naloxone is if you think somebody has

overdosed and you administer it and it turns out there is something else wrong, that naloxone does not have a negative side effect

if it is actually something else other than an OD, but if it is an

OD, it will bring folks back, but the use of naloxone has kind of

been limited to first responders, but there is a growing awareness

that naloxone should be co-prescribed and should be in the medicine cabinet of people who get prescribed opioids, especially if they

have other risk factors. Like, if they have a history of respiratory

illness, that would be a circumstance where the co-prescription of

naloxone as an automatic would make a lot of sense, so I have introduced one bill called the Co-Prescribing Saves Lives Act, which

will push the feds to establish a meaningful set of protocols around

when naloxone should be co-prescribed.

We have a bill called the Stopping Medication Abuse and Protecting Seniors Act, which would prevent inappropriate access to

opioids for at-risk beneficiaries. There is already a program in Medicaid that sort of—it is called a pharmacy lock-in where you can
6 

choose your own pharmacy, but you cannot go to multiple pharmacies to get an opioid prescription if there are certain risk factors

that are connected with your individual case. That is part of Medicaid already, and we are trying to take that same concept and put

it in Medicare so that people going to multiple pharmacies and taking multiple medications does not contribute to opioid abuse, so

these are some examples, working in the DOD and VA, the co-prescription issue, the idea of a pharmacy lock-in for seniors to impose

some controls over how opioids are prescribed to seniors, that we

are working on, but you know, what I have learned in 3 years in

the Senate is you put legislation on the table that you believe passionately in, but it is really important to go out and reality check

it against the people who are doing the job full-time to make sure

that the solutions that we are proposing are as close a match as

can be for the actual problem and how the problem will be solved,

and that is one of the reasons that I wanted to come today and to

hear from you.

I really appreciate everybody coming. This is an incredibly important topic, and let me just—I have a number of staffers here,

but I just want to introduce two for followup purposes, in case

something you hear today makes you want to say, wow, I really

want to followup, and that is Kristen Molloy, who is right here in

the brown jacket. Kristen is my advisor on health matters, and so

works with me on this particular issue in the D.C. office, and then

Joe Montano, who is standing at the back with the purple vest on

under his suit jacket. Joe runs my Northern Virginia office, which

is in Manassas and covers Loudoun, so if you have a followup today

and you want to reach out, either reach out to my Northern Virginia office or my policy team.

Let me now talk about the witnesses that we have. I am very,

very glad to have everybody here.

Mark Herring is the Attorney General for the Commonwealth of

Virginia, and you know Mark very well because he is Leesburg and

Loudoun born and bred. He is a wonderful AG and a wonderful

friend. 

Some of you know this. When Mark was a law student at the

University of Richmond, I was his ethics professor, so that makes

me particularly proud of him. I used to teach part-time at UR when

I practiced law. In the spring of 1987 to 1993, I taught legal ethics

and ended up having Mark as a student, and it has been wonderful

to reconnect with him and work with him in so many ways.

Mark works to keep Virginia families safe in their communities

and neighborhoods and provides legal services to every agency of

State government, the colleges and universities. He does a lot, but

on this particular issue—and you are going to hear about some of

his office’s initiatives—he has launched a five-point plan to combat

heroin and prescription opiate abuse by creating and implementing

partnerships and creative solutions with stakeholders in all regions

of the State to solve this complex problem, and we are very, very

glad to have him.

Let me go to Jane Terry. Jane is the Director of Government Affairs for the National Safety Council. The NSC is a congressionally

chartered nonprofit safety organization whose mission is to prevent

injury and save lives in homes, communities, and in the workplace.
7 

She is an experienced policy and legislative leader. She has nearly

20 years of experience working with local, State, and Federal Government officials on transportation, telecom, workplace safety, community development, and health care initiatives, and she is going

to speak about the NSC’s work on opioid safety issues. Thank you,

Jane, for being here.

Dr. Katherine Neuhausen is the Assistant Professor of the Department of Family Medicine and Population Health at VCU,

which is my neighborhood university. I live in Richmond just a

mile or so from the VCU campus. She is also the Associate Director

of the Office of Health Innovation. Katherine has led the development of innovative statewide models to integrate mental health

and substance abuse treatment and primary care and also to address the needs of-—high needs—high costs, high needs, and complex patient populations. Dr. Neuhausen conducts research on the

health care costs associated with untreated mental illness and substance abuse, and she recently co-authored a policy brief on the

opioid crisis among Virginia Medicaid beneficiaries. Dr.

Neuhausen, thank you so much for being here.

Lisa Wilkins is the Acting State Director for Virginia Change Addiction Now, and Lisa has a very, very powerful story. She is a

resident of Berryville. She comes to us today with a full range of

experience with this most challenging issue and understands its

complexities well. Despite a very stable working family with loving

and involved parents, both of Ms. Wilkins’ sons fell prey to the epidemic plaguing our State and our country. She lost her oldest son

in 2011 at age 23 to a heroin overdose. Her youngest son, who is

now 26, is currently in recovery from his own battles with prescription pain medication and heroin. She is a primary caregiver of her

disabled mother for 15 years, until her mother passed in 2013, and

she is familiar with many of the issues that face not only the young

population I was describing earlier, but also with the families and

with seniors. It is so hard for somebody who has been through such

a tragic experience to just come and be willing to share it, but

sharing it is what she is doing so that she can try to lift the burden

and, hopefully, create a path for others, and Lisa, we are really,

really happy you are here.

We do have one other witness who might come, and let me go

ahead and just do the—she is 10 minutes out? Okay. Well, we will

make her speak last and she will come here, but let me just tell

you about her. She will eventually come in and sit next to Attorney

General Herring, and it is Mellie Randall. She is the Director of

the Office of Substance Abuse Services for the Virginia Department

of Behavioral Health and Developmental Services.

For 27 years while Mellie has been at the Department, she has

focused on planning and policy related to treatment services for

people with substance abuse disorders. She played a key role in a

statewide project focusing on improving access to integrated treatment for individuals with co-occurring mental illnesses, and she

has just worked on this in so many different ways, but most recently and especially, and Attorney General Herring knows this,

she has been serving as staff to Governor McAuliffe’s Task Force

on Heroin and Prescription Drug Abuse. Former Congressman Wolf

and I and a bunch of the Virginia legislators wrote a letter to Gov-
8 

ernor McAuliffe at the start of his term and asked that he set up

a statewide task force on this and Mellie has been the key staffer

helping that task force succeed.

The last thing I will say, and then I am going to have the witnesses testify, is, you know, when you are in public life, you work

very hard to do good things, but then it is important also to look

back at what you have done and say, hmm, was that the right

thing, or did we miss an opportunity, or what did we learn from

it, and you know, I had an interesting experience when I was Governor. We had a very, very serious problem with methamphetamine

during those times really kind of taking root. Now, we still have

a methamphetamine problem in Virginia, but this was really acute,

and this was the one that was getting attention, and we worked

together. Mark was in the State Senate, and we worked together

with others to do some things to tackle the meth problem to basically take some of the precursor drugs for meth that could be

bought out in the drug store and move them behind the counter so

that they would be harder to do, and it did have an effect and we

felt pretty good about it.

I was starting into my tenure in the Senate and traveling around

the State and hearing about the opioid abuse problem, it suddenly

struck me that what we did was we treated a symptom when we

did that, but we really did not treat the cause. You know, we made

it harder for people to get some of the drugs to create methamphetamine, so that was good, but that was creating a symptom. We

were not really going into the cause, and so, if we made it harder

to get meth, but we did not deal with the cause, people would figure out another way to use some other kind of drugs, and so, I

think what we are really grappling with is treating symptoms is

fine. You have got to treat symptoms, but the more we understand

so that we can move to a model where we are really addressing

causes, then, we are going to be even more successful, and I feel

very dedicated to doing that and I look forward to learning from

these witnesses today and bringing that learning to the attention

of my committee members, and with that, I applaud my friend

Mark Herring for coming, and Mark, I will turn it to you.

STATEMENT OF MARK HERRING,

ATTORNEY GENERAL, COMMONWEALTH OF VIRGINIA

Mr. HERRING. Senator Kaine and members of the United States

Senate Special Committee on Aging, thank you for shining a light

on issues of addiction among older Virginians, an affected population that too often goes unnoticed.

To help set the stage for today’s discussion, I would like to share

some information about the scale of the problem in Virginia, efforts

underway at the State level, including from my office to combat the

problem, and some senior-specific strategies that we are employing

and opportunities to do even more to protect this potentially vulnerable population.

During my time as Attorney General, I have seen firsthand the

impacts of a heroin and prescription drug crisis that is claiming the

lives of hundreds of Virginians every single year and touching families in every corner of the Commonwealth. In 2014, heroin and

prescription drug overdoses claimed the lives of 728 Virginians.
9 

That is more than car crashes, and that number is shocking and

it is heartbreaking. Over the last 5 years, more than 3,000 Virginians have lost their lives. This is a problem that is cutting

across all social and demographic lines.

After speaking with so many mothers and fathers who have buried a child after a fatal overdose, or friends and family who are trying to carry on after the loss of a loved on, I have also learned that

what is often described as a heroin epidemic is really an opioid addiction epidemic. Something as common as a sports injury, a car

accident, or a minor surgery can expose a person to opioids, leading

to abuse, dependency, and in the worst cases, leading to the cheaper, more available, more potent and deadlier heroin that can be

found on the streets.

The Centers for Disease Control estimate that one in 15 persons

who take prescription pain killers for non-medical purposes will try

heroin within 10 years, and that is a fast and frightening slide, so

to properly address what is often called the heroin epidemic, we

must acknowledge that this is a heroin and prescription drug abuse

epidemic that has its roots not in the streets, but in our medicine

cabinets, and given the amount of opioids prescribed to older Virginians, we should begin accounting for their needs and risk factors

as we work to address addiction.

According to preliminary numbers from the Virginia Office of the

Chief Medical Examiner, through September 2015, 120 Virginians

age 45 to 54 died of a heroin or prescription drug overdose. That

is the third highest age cohort, and fourth highest is age 55 to 64.

More Virginians age 55 to 64 died of heroin and prescription drug

abuse—drug overdose—than age 15 to 24.

It is almost unimaginable to think about someone becoming dependent on a drug for the first time at that age, but that is the

power of these drugs and it is a reality that more and more of our

friends, neighbors, and parents are confronting. These are the Virginians who are about to age into certain medical assistance programs and whose struggle with addiction is likely to place an even

greater strain on limited public budgets.

For example, in 2014, Virginia’s Medicaid program spent approximately $27 million on prescription pain killers. That is up

about 30 percent from 2011. I think it would be safe to assume that

the Federal Government is noticing similar increases and will continue to, especially as our population ages.

In Virginia, I feel somewhat fortunate because it seems like we

have recognized and are responding to this problem somewhat faster than other states. In my office, we are coming at the problem

with a multifaceted strategy that includes prosecutions and enforcement as well as legislative solutions, prevention, and education.

In the last year and a half, we have worked with our local and

Federal partners to prosecute more than 28 cases against dealers

and traffickers involving more than 95 kilograms of heroin with an

estimated street value of more than $19 million. That is about

238,500 daily doses.

We have also launched a number of prevention and education

initiatives to make sure everyone—young people, parents, adults,

even seniors—understand just how dangerous these drugs can be.
10 

One of the centerpieces of our prevention efforts is a documentary

film called, ‘‘Heroin, the Hardest Hit,’’ which really puts a face on

addiction in Virginia. It features Virginians sharing their own stories of addiction, even overdose, and, thankfully, recovery. It also

tells the story of some wonderful young people who, unfortunately,

lost their lives to these drugs, and the parents and families left to

carry on without them.

We also worked with the General Assembly in 2015 to enact

three life-saving overdose prevention laws with bipartisan support.

One created a Good Samaritan provision to encourage people witnessing an overdose to call 911 and get help.

Another expanded the availability of naloxone, a life-saving overdose antidote, so that all law enforcement and first responders can

carry it and more families can get it without a prescription, and,

finally, we expanded access to the Prescription Monitoring Program

to make sure that probation officers can monitor their probationers

to make sure they are not getting drugs that they are not allowed

to have.

Those last two bills, I think, offer some lessons that could be particularly applicable to senior populations and to our efforts to address addiction among older Virginians. I look forward to discussing them throughout today’s hearing.

To conclude my remarks this morning, I will just again say

thank you to this Committee and thank you to Senator Kaine for

keeping the issue of addiction in the forefront and for giving particular attention to seniors and older Virginians who may be struggling with addiction, and I join you in sounding the alarm about

the heroin and prescription drug crisis and I want every family in

Virginia to be talking about it now, not once there is already a

problem, or, God forbid, after a loved one is lost. We have to start

now, because I have heard from so many heartbroken parents who

have lost a child and so many devastated families who have lost

a loved one, and they all say, ‘‘I never thought this could happen

to my family.’’

Thank you for allowing me to join you today, and I look forward

to discussing those issues and answering any questions the Committee may have.

Senator KAINE. Thank you, General Herring.

Jane Terry.

STATEMENT OF JANE TERRY, DIRECTOR

OF GOVERNMENT AFFAIRS, NATIONAL SAFETY COUNCIL

Ms. TERRY. Thank you, Senator Kaine, for inviting the National

Safety Council to participate in this hearing today. NSC is a 100-

year-old organization dedicated to fighting the causes of unintentional death and injury. As such, we took note of the alarming

trend of increasing drug poisonings due to prescription opioid pain

killers over the last decade.

As you mentioned, Senator Kaine, this is an epidemic that knows

no income or age restrictions and one that touches the lives of so

many Americans. I appreciate your highlighting the specific impact

this epidemic has had on our aging population.

The data clearly show the scope of this epidemic. Opioid overdose

deaths, once rare in the United States, have resulted in more than
11 

220,000 lives lost in the past 15 years, 175,000 from pain killers

and 45,000 from heroin. Each day, over 50 people die from an

opioid overdose.

As stated previously, addiction can occur at any age. Here are a

few of the facts about older adults and opioids. Nine million Medicare Part D beneficiaries fill prescriptions for opioids to treat conditions not associated with cancer or hospice. More than 1.7 million

of these patients received a dose that put them at increased risk

of overdose, and nearly 225,000 received these high doses for more

than 90 days.

Also, older adults who take opioids are five times more likely to

suffer a fracture, and falls are the leading cause of unintentional

death for adults 65 years of age and older. They are also over twice

as likely to have a heart attack. They are 50 percent more likely

to have kidney damage and 50 percent more likely to die while taking the medication.

Together, we can do more to stop these trends. NSC strongly

supports your legislation, the Co-Prescribing Saves Lives Act. This

is important legislation that would enact meaningful changes in

the Federal health care system to save lives, where in 2012 nearly

14 million people received health care through the VA or military

health systems.

This legislation also takes the important step of co-prescribing

naloxone, as we have mentioned here today. Naloxone saves lives

and it should be easily accessible and readily available to those

who are taking opioids. Also, loved ones of people addicted to heroin and first responders should also be able to access naloxone.

Today, I brought a naloxone demonstration device to show how

easy it can be to administer. There is no needle or medication with

this. 

[A demonstration was shown.]

Ms. TERRY. As you can see, some of these devices are extremely

easy to administer, so NSC appreciates your support for——

Senator KAINE. I cannot resist in saying that method for delivering naloxone, and it used to be common as a nasal spray or delivered otherwise, was developed by a Virginia company called Kaleo

that used that same technology to deliver other kinds of drugs, but

it basically tells you how to do it. You do not have to memorize the

instructions. You tear a strip and then it talks you through what

to do so that in the event of an emergency or somebody who has

not been trained can follow it. It is a really simple way of administration.

Back to you, Jane.

Ms. TERRY. The opioid epidemic has been largely fueled by prescribers who are not aware of the fatal risks associated with their

use. NSC believes that doctors who apply to the DEA to prescribe

controlled substances should be required to take classes about effective pain treatment and signs of addiction. Some states have already implemented this requirement and it should be a national requirement.

DEA has done great work removing the excess supply of opioids

and other medications from homes through drug take-back days.

The one held just this last October collected 350 tons of unused
12 

drugs. The next take-back day will be on April 30, and we urge

continued congressional support of these events.

Finally, NSC supports the CDC prescribing guidelines as proposed and we believe these should be quickly implemented. We appreciate your support of these guidelines, as well. These guidelines

incorporate the best evidence available at this time. They encourage better information sharing between doctor and patient. They

discuss the dangers of long-acting and extended release opioid pain

relievers. They support co-prescribing of naloxone, encourage the

use of PDMPs, and educate providers about dangerous opioid interactions with other medications. The guidelines will save lives without evidence that pain treatment will be diminished.

Thank you, Senator Kaine, for inviting the National Safety Council to participate today, and I look forward to responding to your

questions. 

Senator KAINE. Thank you very much, Jane.

Dr. Neuhausen.

STATEMENT OF KATHERINE NEUHAUSEN, M.D., M.P.H.,

ASSISTANT PROFESSOR, DEPARTMENT OF FAMILY

MEDICINE AND POPULATION HEALTH, AND ASSOCIATE

DIRECTOR, OFFICE OF HEALTH INNOVATION,

VIRGINIA COMMONWEALTH UNIVERSITY

Dr. NEUHAUSEN. Senator Kaine, thank you for this opportunity

to examine the growing epidemic of prescription opioid misuse and

abuse among older Americans.

I am a family doctor in practice in Virginia Commonwealth University’s Hayes E. Willis Health Center, which is located in an underserved community in the south side of Richmond. I am here

today because of the many patients I care for of all ages, races, and

socio-economic classes who have experienced the devastating effects

of the opioid epidemic.

I would like to share a patient story that illustrates the potential

long-term harm from taking opioids, even when prescribed by a

physician. One of my former colleagues started an older female patient on opioid pain relievers for her chronic pain several years ago.

This physician continued to increase the dose over time without

adequately screening for side effects. One evening, her patient fell

down the stairs after taking her evening dose of the opioid, likely

because of dizziness and confusion caused by the medication. The

fall resulted in a severe foot injury that required surgery. The patient’s foot never fully healed and she ended up in a wheelchair,

and she is requiring even higher doses of opioids now for the chronic foot pain resulting from her fall.

Today, I will discuss how this patient’s story is not unique, but

is part of the epidemic of prescription opioid misuse and abuse

among older Americans and the general population. I will also explain the potential risks and harms of prescription opioids, including the fact that people, especially the elderly, can overdose even

when they take opioids as prescribed.

I will talk about three possible solutions to this epidemic. First,

we need better provider education. Second, we need to increase the

use of evidence-based guidelines among providers prescribing

opioids, and third, we need to increase access to evidence-based addiction treatment.
13 

Prescription opioid pain relievers are the molecular cousins of

heroin and are just as addictive as heroin. Prescription opioid

abuse and misuse has become a public health crisis in our country.

In 2014, overdoses from opioid pain relievers far exceeded deaths

from any other legal or illegal drugs.

Opioid pain relievers can be harmful whether they are taken

without a prescription or start with a prescription from a doctor.

Many individuals who end up addicted to opioids start out with a

legal prescription given to them by a health care provider. The provider may have given them too high a dose, or too many pills, or

too many refills, causing them to become addicted and to take even

higher doses to obtain the same pain relief until often they eventually overdose.

In fact, opioid overdoses appear to occur more frequently in people using opioids for medical reasons, such as chronic pain, than

in recreational users. One study found that over 90 percent of the

individuals who overdosed in a State had received a legitimate prescription for an opioid pain reliever from a health care provider.

A number of recent studies have concluded, as Senator Kaine

mentioned, that opioids are not very effective in treating chronic

non-cancer pain or improving function and can cause a number of

harmful side effects, and this is not surprising considering that all

the studies of their effectiveness were conducted for patients with

chronic cancer-related pain, palliative care needs, and acute pain,

so there are also high rates of death from intentional overdoses, especially at high doses of opioids that tend to be given to treat

chronic non-cancer pain.

Older Americans have the highest risk of these harmful side effects. Many other medications are more effective than opioids in

the treatment of chronic non-cancer pain and have far fewer risks,

but these other medications are not always tried first.

We can take several steps to address this public health crisis.

First, greater Federal and State funding is required to train health

professional students and medical residents in pain management

and opioid prescribing, as well as in screening and treatment of

substance use disorders.

States should be encouraged to create mandatory annual continuing medical education requirements in appropriate opioid prescribing for providers. Virginia does not currently have this requirement, but proposed legislation under consideration by the

General Assembly would require all physicians to obtain this education.

Second, health care providers need prescribing guidelines that

decrease the risks of addiction and overdose for their patients. I applaud Senator Kaine for his recent letter urging the Centers for

Disease Control to release long-awaited opioid prescribing guidelines. As a practicing primary care physician, I strongly support

these guidelines and believe that they should be released as soon

as possible. I am not alone. A survey showed that 87 percent of

physicians support the CDC’s guidelines and would use these

guidelines in practice.

The Co-Prescribing Saving Lives Act sponsored by Senator Kaine

is also an important step in the right direction. By creating physician education and guidelines that encourage doctors to co-pre-
14 

scribe naloxone when they prescribe opioids, this legislation would

prevent opioid overdose deaths.

Third, we must increase access to evidence-based addiction treatment. Only one in ten people with addiction involving alcohol or

drugs other than nicotine receive any form of treatment, and of

those who receive treatment, few receive evidence-based care, and

I believe that this is part of the root cause that Senator Kaine mentioned. When supply is shut down to drugs of choice and people remain addicted and do not receive the counseling, psycho-social

therapy that they need to get better and to address the past childhood trauma or adult trauma that often leads to the addiction, they

will just switch drugs and continue to find a drug to treat the emotional physical pain, so medication assisted treatment, or MAT,

with suboxone or methadone and counseling is an evidence-based

treatment for opioid addiction that can help people with addiction

recover and become functioning members of society, and I compare

MAT for opioid addiction to insulin for diabetes. The vast majority

of people with opioid addiction will not get better without the medication assisted treatment.

Over 4.5 million people need but are not receiving substance

abuse treatment in the U.S., many with opioid addiction. The

shortage of physicians trained in MAT has created long waiting

lists, requiring people to wait many months to receive life-saving

treatment. Federal and State health agencies should offer more

grant opportunities to train physicians and support primary care

practices in offering MAT.

Congress could also make a difference by passing the Comprehensive Addiction and Recovery Act, which would designate up

to $80 million to advancing substance abuse prevention and treatment in State and local communities. Since every one dollar invested in substance abuse treatment returns seven dollars in cost

savings to the health care and criminal justice system, this would

be a wise use of taxpayer dollars.

Finally, Virginia’s Medicaid program, like Medicaid in many

states, pays very poorly for addiction treatment. As a result, providers do not provide treatment. Many would like to, but it is not

worth their time. To increase access to treatment, Virginia’s General Assembly is currently considering a proposed substance use

disorder treatment benefit that would reform Medicaid so that Virginians currently eligible for Medicaid would have access to the evidence-based treatment proven to cure addiction. This includes inpatient detox, residential treatment, outpatient treatment including medication assisted treatment, care coordination, case management, and peer recovery coaches. Since Medicaid members are

twice as likely to be prescribed opioids as their peers with commercial insurance and have a six times greater risk of overdose deaths,

this benefit would help a vulnerable population and save lives.

As a family doctor, I see the devastating consequences of opioid

abuse daily. The steps that I have outlined today—increasing provider education, implementing evidence-based guidelines, and increasing access to evidence-based addiction treatment—should be

part of a comprehensive strategy. We have a tremendous amount

of work to do to end this epidemic.
15 

I would like to thank Senator Kaine for the opportunity to testify

and for his leadership in addressing a public health crisis that is

impacting all Americans.

Senator KAINE. Thank you, Dr. Neuhausen.

Ms. Wilkins—and Director Randall, it is great to have you, and

after Ms. Wilkins testifies—your timing is perfect, so thank you.

Ms. Wilkins.

STATEMENT OF LISA WILKINS, ACTING

STATE DIRECTOR, VIRGINIA CHANGE ADDICTION NOW

Ms. WILKINS. Thank you, Senator Kaine, distinguished witnesses, and guests for including me in this important field hearing

to discuss potential solutions to what the Centers for Disease Control has declared the worst opioid epidemic our country has ever

faced. This public health crisis has arrived in every corner of the

country, in Virginia, and with a vengeance in Northern Virginia

and my home in the Shenandoah Valley.

My name is Lisa Wilkins. I am a 20-year resident of Berryville,

Virginia, and speaking today as a concerned citizen and a duespaying member of the sandwich generation. I have been impacted

as both a parent and as a daughter.

I have recently been named Acting Director of Virginia CAN,

Change Addiction Now, an advocacy organization dedicated to

bringing the family voice to addiction and recovery in Virginia communities, assisting families seeking information about treatment

and recovery, reducing the stigma associated with addiction, and

promoting harm reduction and public policy designed to stem this

tide of substance use disorder. I am also a chapter leader for the

local Grief Recovery After a Substance Passing peer support group,

which reaches out to support families who have lost a loved one to

this devastating disease.

I come to you today with several perspectives, all of which have

had varying degrees of personal impact, and I will put a picture

and faces to our story. I believe these perspectives illustrate the

range of those in our society whose pathways to addiction can be

the result of non-medical use or abuse as well as those who become

addicted through medically prescribed pain medications through

overuse or misunderstanding. Both pathways are implicative in today’s explosive crisis.

In the case of my sons, the youngest, that you see in the picture

below with a hat on, was exposed to prescription opioids, like many

youth today, through their widespread availability among peers

and schoolmates. Both sons were treated with prescription opioids

after childhood injuries, the oldest after being mauled by a dog at

age 11, and the youngest after a motor vehicle accident at age 15.

In addition to the youth affected by prescription opioid misuse,

an often overlooked population at risk are older patients. One such

case involved my mother. She was exposed to prescription opioids

as a course of treatment for her chronic pain. Throughout her care,

her doctor and I had to consider a myriad of safety issues in treating her with opioids, from falls, to unintentional use through confusion, to kitchen fire potential, to actually becoming a victim of

crime. Those risks were evaluated against her comfort, quality of

life, as well as the anticipated dosages and length of treatment.
16 

Very often, alternative treatments were explored, and when higher

dose opioid therapy was necessary, she was treated under 24-hour

supervision by myself or admitted to a skilled nursing facility.

The lesson I learned from my mother’s pain treatment is that

this type of doctor, patient, and family medical decisionmaking

should be the standard of care, not the exception. My mother and

our family were very lucky. Others who may not have had engaged

family members or attentive physicians may have had far more

tragic experiences.

With over 259... [sic] opioid prescriptions written in the U.S. as

recently as 2012, these drugs are filling our communities, our

workplaces, our schools, and our medicine cabinets, making them

widely available for misuse. It is easy for our youth and elderly

alike to misjudge the addictive nature of prescription opioids, not

realizing that they are a family to their synthetic cousin heroin,

and often believe that using prescription opioids are safe. One of

the lessons here is that more widespread education and awareness

aimed at both the youth and the elderly is a critical part of any

solution to address this crisis.

As you mentioned, the age group with the fastest rate of overdose deaths due to prescription opioids is 55 to 64 years old. In addition, according to the National Association of Medicaid Doctors,

Medicaid patients are two times more likely to be prescribed

opioids and six times more likely to suffer overdose death. These

populations are overlooked as medical practitioners, clinicians, and

policymakers pursue strategies to address the opioid addiction and

mortality crisis. This must change.

I am pleased to learn through your leadership you have developed two specific legislative proposals which will have a dramatic

impact in preventing further prescription opioid misuse, abuse, and

potentially save the lives of those at risk from overdose events. The

Co-Prescribing Saves Lives Act is a common sense measure to provide access to the overdose-reversing and life-saving drug naloxone.

The availability of this drug to family members, especially to those

involved in elder care, is a powerful mechanism to save lives. There

is no good reason to fail in prescribing naloxone with opioid prescriptions.

Further, family caregiver education and inclusion goes hand-inhand with offering this life-saving antidote, which can but is unlikely to be self-administered. The bill will ensure that anyone at

risk for experiencing or witnessing an opioid overdose will be thoroughly educated in both the signs and symptoms of overdose as

well as the administration of naloxone.

As further justification for co-prescribing naloxone and the involvement and education of family members and caregivers, I

would like to point out that primary caregivers rarely provide a

heart patient with a prescription for nitroglycerine without reviewing its use and administration with family members. Likewise, diabetes care education includes family members of the diabetic by the

very nature of its risks and treatment. Opioid therapy should be

no different.

I am also supportive of the Stopping Medication Abuse and Protection Seniors Act, which will authorize the use of patient review

and restriction programs in Medicare. The proposed lock-in or pri-
17 

mary pharmacy use just makes logical sense to ensure the reduced

risk of dangerous drug combinations and interactions, as well as

providing a vehicle to identify potential drug-seeking behaviors and

facilitate early intervention.

There may be a tradeoff between the perceived privacy issue and

the very high risks associated with opioid therapies. Additionally,

while many seniors and their families, like mine, may shop multiple pharmacies as a method to contain the high cost of prescriptions, the risk of potentially overlooking one single adverse interaction can be fatal and should not be taken lightly. Caregivers may

need to start helping seniors manage the total cost of their prescriptions rather than the cost of each individual medication.

I believe that these two bills will support a more integrated team

approach to caring for our seniors. I am convinced that these bills

are about protecting our most vulnerable citizens while making

sure that they receive the best medical care that we can provide.

Finally, I would like to end with an endorsement of the development of opioid prescribing guidelines—a familiar theme today—to

better educate physicians in opioid therapies and risks. The two

bills being discussed today in parallel with these guidelines will set

the stage for primary care providers, their patients, and the patients’ caregivers consider adding opioid therapy where benefit outweighs the risk and the patient fully understands and can weigh

in on that risk-benefit analysis. The risk-benefit analysis should be

used in the development of treatment goals, where the parties work

together to set realistic expectations for pain management and relief based on the nature of the chronic pain, with the primary drivers being function, patient safety, and quality of life versus what

may only be an illusion of living pain-free. This was a difficult but

necessary conversation with my mother.

Regular evaluation of the treatment plan effectiveness and any

changes to the risk-benefit analysis can and should be conducted

in a manner that does not place undue hardship on the patient in

receiving treatment, obtaining refills, and filling prescriptions.

These two bills, combined with the additional prescribing guidelines, will ensure that family members and caregivers are given

similar levels of patient education, including the signs and symptoms of overdose as well as opioid-related harms. Family members

must be included in the decision process, as their observations may

not be consistent with patients’ perception.

Thank you for the opportunity to discuss this with you today,

and I would like to place a face on the numbers you are hearing.

You are talking about 125 faces a day. This is 1 weekend’s worth

of prescription opioid and heroin overdose. Two days’ worth.

Senator KAINE. Ms. Wilkins, if I could, during the rest of the

hearing, let me just—I am going to take your family photo, if I

could—— 

Ms. WILKINS. Certainly.

Senator KAINE [continuing]. your mother and your boys, who you

have described, because I want to make sure folks who are here

can see this, too, and, so, kind of make it personal for the rest of

the hearing, if I can.

Director Randall, it is time for your testimony. We really appreciate you coming. I introduced you and talked about your role with
18 

the Governor’s task force a few minutes before you came in, so the

crowd is anxious to hear you and I am, too. Thank you for participating in this today.

STATEMENT OF MELLIE RANDALL, DIRECTOR, OFFICE

OF SUBSTANCE ABUSE SERVICES, VIRGINIA DEPARTMENT

OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES

Ms. RANDALL. Thank you so much. I apologize for being late. I

made a wrong turn coming up here from Richmond today.

Senator Kaine, distinguished panel members and guests, thank

you so much for this opportunity to participate in this important

hearing. My name is Mellie Randall and I am the Director of the

state’s publicly funded substance abuse treatment services that are

provided through the 40 Community Services Boards, or CSBs,

which are entities of local government. I work for the Virginia Department of Behavioral Health and Developmental Services.

The Community Services Boards provide treatment services to

about 33,000 individuals each year, and they are funded by a combination of State and Federal funding that totals about $90 million.

Local tax dollars and fees also help.

In my role of guiding the use of these resources to provide the

best possible treatment services, I was privileged to provide staff

support to Governor McAuliffe’s Task Force on Prescription Drug

and Heroin Abuse. Jointly chaired by Secretary of Health and

Human Resources Dr. William A. Hazel, Jr., and Secretary of Public Safety and Homeland Security Brian Moran, the task force

began its work in the fall of 2014 in response to the growing number of deaths resulting from overdose of pain medication such as

hydrocodone, fentanyl, and the street drug of heroin.

Currently, at least two Virginians die each day from an opioid

overdose. Between 2012 and 2014, this number increased by 38

percent, and current information from the Department of Health

indicates that deaths continue to rise in 2015.

The 32 members of the task force represented State agency

heads, the Office of the Attorney General, judges, law enforcement

offices, physicians, pharmacists, providers of substance abuse treatment, individuals in recovery, and parents whose children had died

from overdose.

The task force met five times to gather in-depth information from

experts and to discuss recommendations from the five work groups,

which met numerous times between the task force meetings. In addition to the task force members, the work groups also included

subject matter experts and individuals who had day-to-day knowledge of the issues being explored. Work groups focused on education, treatment, storage and disposal, data and monitoring, and

enforcement, and at the conclusion of the task force, 51 recommendations had been adopted for consideration by the Governor.

In the 2015 session of the General Assembly, when the task force

had only met twice, four of its initiatives were enacted into law,

and we are hopeful that many of the final recommendations will

be enacted in the 2016 session.

Today, I want to share with you some of the most relevant initiatives and recommendations resulting from the task force and how

they tie in with legislation that Senator Kaine has introduced.
19 

When the task force began, Virginia had implemented a pilot

program to train laypeople to use naloxone, a medication that you

have heard about already. It reverses the effects of opioid overdose.

The pilot had focused on two areas of Virginia that were most affected at the time, the very rural area of Southwest Virginia that

borders North Carolina, Tennessee, Kentucky, and West Virginia,

and the metropolitan area of Richmond.

With the backing of the task force, this project, called REVIVE!,

went statewide last April. In addition to legislation, this legislation

permitted law enforcement and firefighters who had been trained

to carry the medication with them, as they are often the first to

encounter an overdose victim. Furthermore, to increase access to

the medication, which could previously be obtained only with a prescription, pharmacists were empowered to dispense the medication

if they have a collaborative practice agreement with a prescriber

similar to that which enables them to administer the flu shot and

other vaccines.

I want to take this opportunity to personally thank you, Senator

Kaine, for your support of REVIVE! and for the distribution of

naloxone. In addition to personally being trained to use naloxone,

Senator Kaine is sponsoring S. 2256, which, if enacted, would include training for prescribers in co-prescribing naloxone whenever

opioid pain medication is prescribed. While there are legitimate

needs for strong pain medications, co-prescribing naloxone can reduce the possibility of accidental overdose by the patient, who may

accidentally take too much medication, or who takes a combination

of medications that make the effects of the pain medication stronger than intended. Naloxone can also reduce accidental overdose

that results from curious children confusing brightly colored pills

with candy or risk-taking adolescents who impulsively experiment

with their family members’ medicine.

Senator Kaine’s legislation also supports prescribers being

trained in appropriate guidelines for the use of opioid pain medications, pain management, identification of addiction, referral to

treatment, and proper methods of disposal. These practices are encompassed in an evidence-based practice known by the acronym

SBIRT, which stands for screening, brief intervention, and referral

to treatment, endorsed by the World Health Organization and the

Substance Abuse and Mental Health Services Administration and

widely discussed in both the education and treatment work groups

of the task force in their recommendations for expanded education

for physicians.

Task force staff have already begun having conversations with

medical schools in the State about what and how they are teaching

their students about addiction and pain management so that they

are able to provide the best medical care possible and prevent individuals from slipping into abusive medication that could develop

into a serious and life-threatening problem. This gives them the

tools to use in the unfortunate instance when addiction does occur.

Another major theme of the task force was increased use of the

state’s Prescription Drug Monitoring Program, which is a data base

of all the prescriptions for medications that are at high risk for

abuse that are filled in the State. The idea is that before writing

a prescription for a medication that has high potential for abuse,
20 

such as an opioid pain medication or some medications that help

individuals to sleep or reduce anxiety, a prescriber would check

this data base to see if the patient had recently had another prescription for a similar type of drug filled. If the prescriber found

that was the case, he or she could discuss this with the patient. In

addition, pharmacists can also check this data base when they fill

the prescription and either discuss it with the patient or notify the

physician. This kind of check can help physicians and pharmacists

work together to coordinate patient care, help identify potential

problems, and prevent dangerous situations and potential

overdoses. 

The task force was successful in getting legislation passed that

requires all prescribers and dispensers to register to use the Prescription Monitoring Program and protects the data in the program

from use in a civil suit, such as a divorce or a child custody case.

Task force sponsored legislation was also enacted that requires

hospice facilities to notify the pharmacy of record when a patient

dies so that a relative of the decedent cannot fill a prescription for

a pain medication that would then be misused.

Legislation also passed that refines the types of information collected and provided by the Prescription Monitoring Program, requires pharmacists to report dispensing of medication more frequently, and gives the Prescription Monitoring Program authority

to send reports to enforcement authorities when needed.

Senator Kaine’s legislation, S. 1913, Stopping Medication Abuse

and Protecting Seniors Act of 2015, also seeks to prevent abuse of

prescription medication by establishing a drug management program for Medicare beneficiaries who are at risk of abusing their

medications. This legislation would also utilize the same SBIRT

model I previously described to assist at-risk individuals in getting

treatment and would limit the number of pharmacies where the

person could use his or her Medicare benefits to pay for prescriptions, thus reducing opportunities for possible misuse.

The task force also recognized the significant role that treatment

plays and the resources that are necessary to support a robust system of care. The 2015 session of the General Assembly passed legislation that requires health insurance plans operating in Virginia

to comply with the Mental Health Parity and Addiction Equity Act

passed by Congress in 2008. This gives the State the power to enforce the legislation without having to wait for Federal enforcement

to occur. We are currently working with the Bureau of Insurance

to develop methods of measuring compliance and developing an annual report. This will also reduce discrimination and stigma often

experienced by individuals who develop addiction, and it will help

them access care using the resources they have already paid for,

thus reducing reliance on public sector resources.

In addition, the task force recommended that Virginia’s Medicaid

benefits for treating substance abuse and addiction be expanded to

support a more extensive range of services, and a budget request

has been submitted to support this action.

In closing, I want to reiterate that although the task force is no

longer meeting, its recommendations are providing a blueprint for

action that will serve Virginians well for years to come, and we are

so pleased to support Senator Kaine’s legislation at the Federal
21 

level, which is congruent with these strategies, and again, I very

much appreciate the opportunity to represent the work of the task

force and I am happy to answer any questions.

Senator KAINE. Thank you, Director Randall, and thank you to

all the witnesses who testified.

This hearing, if you came and watched a hearing in the Dirksen

Building downtown, it would be exactly like this. We have witnesses offer testimony, usually that is submitted as written testimony, and then we ask them questions, and so I am going to ask

these witnesses questions, probably for about 50 minutes or so.

We are scheduled to stop at 12:30. I do not have to leave at

12:30. I have another 15 minutes or so before I have to go, so what

I will do for the folks who have attended to watch this, I will interact with some of you, because you may have questions or suggestions that we would like to hear, as well, but for the next 50 minutes, we will focus on the witnesses and I will kind of go in the

order in which you testified, although there is some overlap in the

testimony, so I may ask two of you at a time, and if one of you

want to weigh in to answer a question I direct to somebody else,

please feel free to do that, too.

I am going to start with General Herring, and actually Director

Randall was touching upon this issue, too, so maybe first General

Herring, and Director Randall might want to talk about it. Talk

about the Prescription Drug Monitoring Program, because I think

that is a good model, and in particular, how voluntary is it and

should it be more—you know, how many of our health care providers participate in it and how many do not? Would it be better

if the degree of participation were higher? Is it sufficient to have

different states do their own programs, or does that lead to kind

of gaps where, especially in communities that are near State lines,

people can go back and forth? Talk a little bit about the current

program and how you think it could be strengthened. First, to General Herring.

Mr. HERRING. Thank you, and definitely, the Prescription Monitoring Program is another tool that I think could be used in a much

more powerful way to hold both patients and prescribers accountable for the number of opioids being made available, and Senator,

you probably remember a little bit about the program from your

time in State government.

In Virginia, we now have mandatory registration for prescribers

and pharmacists, and that has resulted in a more robust registration. It is up from 26,000 to now about 70,000, but it has not resulted in more robust usage. The current query rate is about 9 percent. More than 8,600 practitioners have written prescriptions for

covered drugs but never queried the data base, and there were 121

practitioners who wrote more than 1,000 covered prescriptions but

never queried the PMP at all.

The Prescription Monitoring Program can be a really valuable

tool to combat doctor shopping or even to identify practitioners that

might be prescribing opioids in a potentially dangerous way, but it

has to be used and it has to be accessible.

There are some bills in the legislature this year to strengthen the

PMP, to get more folks using it. I think access for some of the public health assistance providers, like Medicaid and Medicare, could
22 

be valuable. If the public is going to be paying for health care services, then it makes sense that the agencies running those programs

should be able to find out whether its participants are showing

signs of addiction or if a provider is engaging in potentially dangerous behavior.

Senator KAINE. Can I ask you one followup, just to make sure

I understood your answer, so when you say we have gone from

26,000 registrations to 70,000, that is folks are being registered in

the system who are the recipients of opioid prescriptions, so when

there is an initial prescription, is that the number that are being

registered, but the physicians are not checking to see before they

offer that?

Mr. HERRING. These are prescribers——

Senator KAINE. Oh, these are prescribers.

Mr. HERRING [continuing]. who are registering to use the system,

but the number of those who are registered to use it has gone up,

but the query rate is still very low——

Senator KAINE. Very, very low.

Mr. HERRING [continuing]. and they are not—the prescribers are

not using it as much as I think they could.

Senator KAINE. Okay. That is very helpful testimony.

Director Randall, would you like to further——

Ms. RANDALL. Well, I support what General Herring said in

terms of the issue of lack of use. I think that there perhaps could

be considered some mandatory checks, and I also think that physicians are allowed to write very large prescriptions, large numbers

of prescriptions, for instance.

I had a relative who went in with a sprained ankle. She sprained

it a week before. It was still hurting her. She went just to have it

checked. It was not broken, it was just sprained, and she walked

out with 30 hydrocodone, which she really did not need.

I have concerns that prescribers are writing—are able to write

for such a large number of these pills when maybe five are enough,

you know, so I think that is something that also should be considered by the General Assembly.

Senator KAINE. Could I ask, just following up on this, because I

think this is a fascinating question, why would prescribers register

but then not query? Is it complicated? Does it take too long to get

an answer back? What can you determine in your discussions with

prescribers about the low query rate?

Mr. HERRING. Well, Mellie may have more information on the

hurdles to getting prescribers to use it more. It may be a factor of

time, or it could be that as we continue to inform, really, the medical community about these issues and how many people are developing dependencies and addiction from prescription pain killers,

that more prescribers will understand the importance of checking

it and—everybody is pressed for time. We want to try to make improvements in the efficiency of the medical system, but at the same

time, this is something that I think has the potential to help save

a lot of lives and prevent a lot of addiction if the Prescription Monitoring Program is used more.

Senator KAINE. Other comments on that particular question?

Yes. 
23 

Dr. NEUHAUSEN. I would love to speak from the provider perspective. I actually serve on the Board of the Virginia Academy of Family Physicians, where there has been very active debate about the

PMP legislation currently under consideration in Virginia. The

General Assembly does have a Senate bill they are debating that

would require all providers to check the PMP if they are writing

an opioid prescription for more than 14 days or a benzodiazepine

prescription for more than 30 days, and that would address what

Attorney General Herring raised, where physicians would actually

have to log in and check before signing that script, but what I have

heard from my colleagues—in my practice, because we serve a

large Medicaid uninsured population and a high-risk population,

we have—all the physicians are registered. It is very simple to register for the PMP. The issue is, you have to log out of—you have

your electronic medical record. You have to go to a separate

website, log in, remember your password, pull up the report, go

through it, which can take five to 10 minutes, and a lot of physicians that have a 15-minute visit, if you are a primary care physician, that seems very burdensome.

In my clinic, we have dealt with it by making all the nurses our

proxies, so the nurses pull up the PMP and share the report, and

I know that physicians are talking with the Director of Virginia’s

PMP, Ralph Orr, about making it easy to have any member of your

clinic staff be able to just access and pull up the report.

I mean, I firmly believe that all physicians should be checking

the PMP before ever writing an opioid script. It is my practice. It

is my colleagues’ practice. I do think a couple policy solutions that

would overcome some of the physician resistance, because doctors

are stressed and are seeing 25, 30 patients a day. If you could arrange funding so the PMP uploads automatically into our electronic

medical record, so you can just click a button and it pulls up—one

doctor has figured out how to do that with EPIC—that would make

it much easier, just a click of a button.

Washington State did that. They had an ER system, and when

they were able—physicians were able to just click a button and

look—they want to look, it is just they do not want to take the

time—they showed a dramatic, I think, 30 to 40 percent decrease

in opioid scripts written in Washington State just with having the

PMP available, and then you also could—and physicians have actually requested that the PMP proactively send reports to doctors

saying, these are your high-risk patients that are multiple doctor

shopping and multiple pharmacies. These are patients who have

dangerous medications, maybe a benzodiazepine and an opioid.

I think that just making it easier for physicians, they would be

really willing to do this, because I think there is increasing awareness that this is an epidemic and doctors have played a role in creating it and need to help address the epidemic.

Senator KAINE. I am going to come back to Attorney General

Herring. Those are very good suggestions, and so to kind of switch

the topic for a minute, just in terms of the magnitude of the problem, this hearing today is just focused really on kind of a narrow

slice of the program, which is the focus really is, from the Aging

Committee’s standpoint, the effect of opioids on our seniors, and we

have heard broader testimony because it is a broader problem, but
24 

we could have had a hearing on looking at law enforcement professionals in the room, and the state’s chief law enforcement official.

We could have a hearing just on the law enforcement side of this

and we would have had as many or more witnesses.

Talk a little bit about, in the average court docket in a Virginia

county or city, the percentage of cases, whether it is people engaged in thefts and robberies trying to get things that they can use

to sell to get drugs, or the persistence of these issues as affects domestic violence issues, or as it affects automobile accidents. We

could have a whole separate hearing on this, and as Attorney General, you must see the ramifications of this problem over on the

civil and criminal justice side, as well.

Mr. HERRING. Well, let me answer your question this way, by

starting to—by telling you a little bit about how I began to see how

serious a problem this was.

Almost immediately after taking office, one of the very first

things I did was to go on a public safety tour, and we covered 2,500

miles in a 2-week period. We did 22 local and regional meetings

with local law enforcement, and I did that because I wanted to

hear directly from them what were the law enforcement challenges,

what were the public safety challenges in your locality and what

could I do as Attorney General to help.

We had over 60 different agencies represented from around the

State in those meetings. I was really struck by how many told me

heroin and prescription drug abuse was a problem in their areas,

a significant problem and getting worse. I think three-quarters of

the agencies told me that. That was in February and March 2014.

On the heels of that, I was up in Northern Virginia, in Loudoun,

at a Fraternal Order of Police event and a woman came up to me,

thanked me for being there, introduced herself, and she said, ‘‘I

wanted to talk to you to let you know that my husband and I have

lost our daughter to a heroin overdose just a month earlier.’’ This

was a law enforcement family, so we talked about her daughter for

a while. She was in her early 20’s. They did not know she was

using, but like so many families, she said that they are struggling—you know, they never thought it would happen to them or

to their family, anyone in their family, and she looked me right in

the eye and she said, ‘‘Do not let this happen to another child in

Virginia.’’ That is when I committed to myself, after hearing from

three-quarters of the law enforcement agencies I spoke to out of the

60 that were represented about how serious a problem this was,

and then hearing directly from someone who was affected in that

way, that we had to do more, and also in those meetings, they told

me about how there is a rise in theft and other types of crime because so often there is that progression that we have heard about,

starting perhaps with an accident or a surgery where prescription

pain killers are prescribed, and then prescriptions renewed a couple of times until the prescriptions run out. Then they look for

them out on the black market on the street and in time cannot afford that habit, slip to—or cannot afford the prescription pain killers out on the street, switch to heroin, and they will steal in order

to help support that habit, so there is a lot of other spillover crime.

One other point I would mention, though, is that while there are

law enforcement components to this issue, and we have stepped up
25 

our prosecutions and are going to continue to go after the dealers

and the traffickers, most law enforcement that I speak to recognize

that it is also a public health issue as much as it is law enforcement and that they are working in their community on prevention,

education, and treatment, and if we are ever going to get this problem turned around, we have to have robust components for those

kinds of programs, prevention and education and treatment.

Senator KAINE. Thank you.

I want to ask a question that sort of—I think the answer should

be directed to Attorney General Herring and me, but it really

stems from something that Lisa talked about, the need for family

education, so one of the themes of the testimony of all of you is to

educate prescribers, and that is very important and consistently,

and there is much that can be done about that within the profession, et cetera, but how about the education of family members?

Ms. Wilkins, I am going to ask you this question first and then

maybe all of you give advice to those of us who are in kind of the

elected official side. What should we be doing to educate family

members and citizens? As your youngsters were being prescribed

these medications for an auto accident, for a bad dog bite, I am just

curious, how much warning did you get right at that time of prescription, hey, this is, like, really short-term, but be careful about

this, or——

Ms. WILKINS. None.

Senator KAINE [continuing]. did you feel like you were educated

well about the risks?

Ms. WILKINS. I got absolutely no information. Keep in mind, my

youngest is 26 now. Chip would be 28, so this has been many,

many years ago, but no, we go no information about how dangerous

those drugs were. I got bottles of them, you know, 30, 60 in a bottle, and refills without question.

Senator KAINE. It sounds like, then, with respect to your testimony about your mother, that by the time she was being prescribed these drugs, either the prescriber was educating more or

you were asking tougher questions and really engaged in the management——

Ms. WILKINS. Right.

Senator KAINE [continuing]. of that prescription, so talk about

that a little bit.

Ms. WILKINS. I was asking tougher questions, still did not know,

still did not have a clue I had a child in my house using heroin.

It was seeing the effects of the opiates on her when she would get

pain medication. My mother was partially disabled from a stroke.

She used a wheelchair for safety reasons, but she could get up and

move around with a cane. She would get very shaky. She would get

violently ill and unable to get to the bathroom quickly, just different side effects that I saw when they would give her prescriptions.

Senator KAINE. Well, then, so——

Ms. WILKINS. I would start to say, no. No.

Senator KAINE. Well, let me ask this then——

Ms. WILKINS. We do not want them.

Senator KAINE [continuing]. to all of you, and again, this is more

for Generally Herring and me to take this back. If we are focusing
26 

on family and patient education and we are particularly focused on

patients and the families of patients who are seniors, what are

good educational strategies that you would suggest to us, you

know, either the places where we ought to be doing the education

or the kind of education that would have the greatest impact on

seniors and their families, and I will just open that to all of you.

Yes, please.

Ms. WILKINS. I would actually like to continue on that.

Senator KAINE. Yes, please.

Ms. WILKINS. She mentioned only having 15 minutes with a patient. My mother’s doctor was the most patient man on the face of

the earth. He spent—he would spend 20, 30 minutes with us answering questions, and I think it starts with the doctors. There is

a trust relationship there. There is a trust relationship there, and

I know this is a very complicated issue, but it behooves them to

move quickly through their patients through the day, but we have

lost that ability to build those relationships and I think that is key.

The freedom to talk to the family members. He would signal me.

We would step out in the office. We would talk about risks.

He would ask me if what she was saying was my perception. Was

it really that difficult? Again, you get back to that risk-benefit way

that you weigh your care.

Senator KAINE. I cannot remember, Ms. Wilkins, if it was your

testimony or one of the other witnesses, that often the patient’s

perception—— 

Ms. WILKINS. Yes.

Senator KAINE [continuing]. is so very different than a family

member’s perception when we are in this area, and if a caregiver

does not understand the big picture, then they may focus on the

wrong things.

Director Randall.

Ms. RANDALL. One of the things that the task force became very

aware of and spent a lot of time talking about was prescriber education, and we really became aware that in medical training, routine medical training, physicians and other prescribers get very little training about actual pain management and very little training—less than 8 hours in 4 years—on addiction, and so, the education part of the task force really laid out a very specific plan to

work with the medical schools in Virginia to see what they are providing and how it can be enhanced, and we are actually working

with some assistance from the Substance Abuse and Mental Health

Services Administration in this regard, as well.

I think that, you know, for the physicians that are already out

there, though, there needs to be some continued continuing education, and I know Dr. Neuhausen is well aware of this and can

speak to this well. There has been a lot of debate back and forth

about when does provider education become mandatory? When

does the subject matter become mandatory? How do you engage

prescribers in education about pain management and about identifying addiction and learning how to treat it?

Senator KAINE. Yes, please, Dr. Neuhausen.

Dr. NEUHAUSEN. I would like to add to those comments. We have

an entire generation of doctors that were not trained appropriately,

that were mistrained. I remember in medical school in the early
27 

2000’s, I was at Emory in Atlanta and we were taught that opioids

were safe. There were very few risks. Do not be afraid to give these

medicines. Pain is the fifth vital sign. You need to treat pain appropriately.

Senator KAINE. You are saying, not only—you are saying folks

were not just not trained, in some instances, they really were

mistrained. 

Dr. NEUHAUSEN. Yes, that is exactly what happened, so we—and

even now, I precept third year VCU medical students at my clinic

at Hayes E. Willis and I always ask them, you know, we know that

25 percent of our patients have substance abuse, 50 percent have

chronic pain, many have opioid addiction, and I always ask them,

have you received any addiction training, and they look at me and

say, ‘‘No.’’ I mean, they may have gotten a tiny bit and it just did

not stick.

We currently are—and it is not just VCU, it is the vast majority

of medical schools, so I agree, it is kind of, I think, there is a twofold. I think we do have to reach—the best time is to reach doctors

in training, pharmacists, nurses. It needs to be interprofessional.

VCU actually just applied for the SBIRT training grant, the substance abuse screening that Director Randall mentioned. They applied to SAMHSA for a grant that would be nearly a million dollars

over 3 years to train all VCU medical students, all nurse practitioner students, and all primary care psychology students, to have

mandatory required training, not just a lecture, but where they

would actually work with a standardized patient, an actor who acts

out having substance abuse, and would get feedback, and then they

would go to a low-income senior nursing home—a low-rise apartment building, primarily African American, called Dominion Place

in Richmond and actually interact and screen patients.

Senator KAINE. In my former City Council district.

Dr. NEUHAUSEN. Yes, so you know Dominion Place well, so and,

I think it requires that kind of training, not just the lecture, but

the practical practicing with a standardized patient and then practicing with a real patient, so VCU should find out soon. The principal investigator on that is Dr. Pablo Bedoya.

That would be a great step, and then that grant would also offer

optional training, continuing medical education, to the practitioners. That is the second pathway. You have all these practitioners out there who are mistrained who need to have the education, and once you educate the physicians—and also, I mean, we

need to have alert systems where physicians—in an ideal world,

physicians would find out if their patients overdosed. They would

get a real-time alert saying their patient had a non-fatal overdose

and they could examine what happened, because right now, there

is actually a study in a recent journal showing that 80 percent of

patients who had a non-fatal opioid overdose went back and got

more opioids from their—from another doctor.

Senator KAINE. Eighty?

Dr. NEUHAUSEN. Eighty percent went back and got more.

Senator KAINE. Eighty percent of patients who had a non-fatal

overdose were able to go back and get additional opioids prescribed

by their caregiver.
28 

Dr. NEUHAUSEN. Right, because their prescriber had no idea they

had overdosed. If a physician knew, they would never write another prescription for that patient.

Senator KAINE. Right.

Dr. NEUHAUSEN. I think once—as Lisa pointed out, I think once

you educate the physicians, they can have those conversations with

patients. I, honestly—we now know that children who take opioids

when they are young, it imprints on their brain and—there is

emerging evidence that it likely imprints and they are at higher

risk for addiction later on, so I would personally never let a physician give an opioid to my daughter unless it were, you know, no

other medication worked, there was no other option. I think parents need to ask really hard questions. Does my child actually need

this medication?

Senator KAINE. This is—many of us in the Senate have been

really focused on the FDA approval of certain opioid prescription

medicines for young people and been highly, highly critical of that,

so that is an issue that is kind of a little off the main topic here,

but it is connected to it.

I want to ask Ms. Terry a couple of questions. You touched upon

a few themes that became common, but you were the one to kind

of bring it up in a very good way, and that was the CDC prescription guidelines and then this question of oversupply.

Let me go with the oversupply first. My wife two Good Fridays

ago fell off our back porch and broke and dislocated her shoulder,

and so she had to get both it reset and pinned back together at St.

Mary’s Hospital in Richmond, and they gave her a massive prescription in terms of opioids, and she used about a day and a half

of it and did not like it. Then it just sat in our prescription cabinet

until we participated in a drug take-back earlier—I guess late in

2015. 

What drives this sort of over-prescription? I guess there are different ways to describe over-prescription, and that is the dosage is

too high, or the number of pills that somebody gets is just too

much. Talk a little bit about that problem, because you guys at the

NSC, with your Injury Facts Report, do such a good job of really

giving information to us about all kinds of conditions, but talk a

little more about that problem.

Ms. TERRY. I think it is exactly what Dr. Neuhausen described

of doctors were trained when this fifth vital sign of pain started

being put into use that these were okay medications to use and

that they were the Cadillac of pain treatment, and doctors who give

these have no, for the vast majority of them, have no ill intent.

They want to try to help their patients and treat the pain appropriately, but there is this lack of education and that is where we

at NSC have said, for those doctors who are going to prescribe controlled substances, they need to take another step and get further

education before the DEA grants them a license. Some states have

already taken that step, but really, it should be a national requirement, because there needs to be a reset, and in the full testimony

that I submitted, it has a graph on there that was done by

Cochrane Reviews of effective pain relief and it shows that the

opioids are not as effective as over-the-counter medications, and in

fact, the most effective pain relief was one acetaminophen and one
29 

ibuprofen taken together provided the best pain relief for patients,

and so, that reset is needed.

Senator KAINE. That, I guess, is one of the reasons to segue to

the next topic. You talked about, and others, too, your strong support for the CDC prescriber guidelines. Now, let me make a statement, but correct me if I get this a little bit wrong.

The CDC has had in process guidelines for the prescription of

opioids for some time and were on the verge of releasing it. It has

become controversial. There are some who are asking that they not

release the guidelines, but my understanding is these are not mandates. These are not legal requirements, but they are sort of best

practices with respect to the prescription of opioid medications that

would be put out to the medical community at large so that they

can, in fact, be educated and, hopefully, know when and when not

to prescribe opioids.

Is that generally kind of a fair description of the status of this

discussion about the CDC guidelines at this point?

Ms. TERRY. Yes, sir, and it is exactly as you described it. It does

not mean that people are going to be cutoff from their prescriptions, and for those who are cancer patients who may be taking

these and it is giving effective relief, you know, they just need to

have a conversation with their doctor.

My understanding, too, is that some doctors really want these

guidelines, because they are having people come into their offices

demanding these types of medications, so it would give them something to fall back on, too, as, look, the CDC is advocating this as

the best prescribing guidelines for the type of pain that you are experiencing.

Senator KAINE. You talked a little bit about the take-back days.

Could you repeat that one statistic that you used about the last

take-back day, how much medicine out of people’s drug cabinets

was returned on this take-back day?

Ms. TERRY. Sure. This last October, it was 350 tons of unused

medications, and that is not just opioids, but a variety of things,

and I did not really ever know that these existed until a few years

ago, and it was right after my mother had passed away. I found

out this was happening and we had unused medications at my

house, and thank goodness I found out about it and was able to

take those to the local sheriff’s office to drop those off.

Senator KAINE. It is a very, very significant challenge.

I would encourage, for those who are here, this Injury Facts Report that the NSC does every year is a great source of data about

this and about all kinds of other health issues in the country and

I would encourage people to check it out.

General Herring.

Mr. HERRING. Senator, I just wanted to add one more thing on

the drug take-backs. Our office does work closely with the DEA and

the U.S. Attorney’s Offices in promoting those, so in addition to the

general education that is needed about opioids and the risk of addiction, promoting those drug take-back days are extremely important, and also, some other things that our office is doing that are

more senior-specific involve reaching out into the community. One

of the changes that I have made is to really try to push our office’s

services out around the State. We have got some really talented
30 

people in our office and they should not all just be holed up in

Richmond, so I want to point out that Michele Leith is our Regional Outreach Coordinator here in Northern Virginia, and we

work very closely with local law enforcement and the senior community on programs like TRIAD, where we are helping to inform

seniors about how to stay safe from crimes and other things but

that dovetails nicely with education about some of these issues, and

we help provide prescription drug lockboxes and those types of

things to help make sure that drugs that may be in the medicine

cabinet do not get into the wrong hands.

Senator KAINE. Dr. Neuhausen, I wanted to talk to you. You

were not the only person who talked about this, but you led your

testimony with the story of a patient who, you know, because of

consequences of opioid use, was maybe a little groggy and then had

a fall, and then the fall led to a foot injury that did not heal, and

then that led to more opioid use.

I think one of the issues that I had not focused on so much until

your testimony today is the consequences of opioids on things like

falls, or heart risk, or other risk to organs. Talk a little bit about

that, because I think that is an important set of consequences to

understand as we grapple with this issue with seniors.

Dr. NEUHAUSEN. Sure, so some of the most common side effects,

other, of course, than the non-intentional overdose, opioids can

cause sleep breathing disorders, of course, respiratory depression,

respiratory failure in sleep. That is when overdoses usually happen. They can also cause irregular heart rhythms. They can cause

infertility. They can also cause—very often cause confusion, dizziness, and that—as well as kind of impaired perception—and that

is what often leads to the falls, and we have seen increases in ER

visits for falls, which then cause fractures, particularly among the

elderly linked to opioid use, and once——

Senator KAINE. Falls are such a common health problem for seniors. I have a 90-year-old mother-in-law who fell 2 days before

Christmas and was in the hospital for a fall. It is a very common

health problem for seniors, so anything that would exacerbate that

problem, obviously, we need to watch pretty carefully.

Dr. NEUHAUSEN. Exactly, and falls can also be devastating for

seniors. I mean, a hip fracture is often kind of very difficult to recover from, and then, particularly because of the physiology of the

elderly, often their kidney and liver function is somewhat impaired,

which then causes the opioid medicines to stay in the body for

longer, which then increases the risk of overdosing, because lower

doses are much more powerful in an elderly person with lower

functioning kidneys, so that is why you particularly see the elderly

at even higher risk of all these side effects.

Senator KAINE. You have done a good bit of research on Medicare

Part D and opioid drug claims in Virginia under that program. Can

you talk about that research, the data and what it suggests about

the scope of opioid prescribing in the Commonwealth in the Medicare Part D population.

Dr. NEUHAUSEN. Sure, and this was really my Office of Health

Innovation took the data that Centers for Medicare and Medicaid

Services released showing the Part D opioid prescription claims

and we mapped it by Virginia county and city, and we saw kind
31 

of the—I mean, prescription opioids are a problem in every county,

every zip code, as Attorney General Herring mentioned, but we saw

particular hot spots in Northern Virginia and Hampton Roads and

Metro Richmond, and particularly in Southwest Virginia, far

Southwest. There were certain counties down in far Southwest Virginia where there were four times as many Medicare opioid prescriptions as there were people living in that county, people of all

ages. 

Senator KAINE. Repeat that again. I want to make sure I understand.

Dr. NEUHAUSEN. There were, in certain counties in far Southwest

Virginia, there are four times as many Medicare opioid prescriptions as there are people of all ages living in that county.

Senator KAINE. There would be other opioid prescriptions, too,

but you are just talking about just the Medicare opioid——

Dr. NEUHAUSEN. Just the Medicare, and that is not even looking

at commercially insured, Medicaid, and when I—yes, and our denominator is all people, not just the elderly. When you think about

that tsunami of pills in these small counties, I mean, to me, that

was just a really terrifying statistic.

Senator KAINE. Is that research that you have discussed, is that

published research?

Dr. NEUHAUSEN. There is a—on the Centers for Medicare and

Medicaid Services, there is a link and you can map your county

and your State. This is all publicly available through CMS, and

then my office kind of created more specific Virginia maps which

we would be happy to post on the website.

Senator KAINE. If you could. I have the capacity to ask questions

for the record and keep the hearing open so it could be submitted.

I would like to have that report with the Virginia specific data and

have it submitted in the record of this hearing. If you have no problem with that, I think that could be very helpful.

Dr. NEUHAUSEN. Yes, we would be happy to.

Senator KAINE. One other question for you, so I am going to lean

on you as the physician of the group. What about sort of the addition of pain as the sort of fifth vital sign and how does that kind

of factor into the whole culture of over-prescription we have, because, obviously, we have got to have strategies for dealing with

pain and it is a very important matter that physicians have to

query any patient about, but sort of adding that to one of the vital

signs, and even to how physicians and institutions are surveyed—

you know, there are patient surveys that focus on things like did

they help you manage your pain—have we hit the balance right in

how we look at pain management as a kind of definer of this quality of medical service?

Dr. NEUHAUSEN. I think we are far from balanced. I think we

have kind of gone into the deep end. I hear from colleagues who

work in urgent care centers or ERs where they are evaluated on

patient satisfaction, including did you adequately treat the patient’s pain, and they are terrified to not give the opioid prescription because they are worried that the patient will give them a zero

out of ten, and that will then hurt their salary, so I think physicians are actively afraid to say no when patients who may already

be struggling with addiction demand opioids.
32 

Then I also think, you know, in medical school, you are taught

to take care of people. You really want to fix people, and chronic

pain is so hard, because people have the expectation that you will

give them a magic pill and they will feel 100 percent better, and

it is tempting for doctors—and if a patient comes in—and I have

had patients yell at me saying, opioids are the only thing that

works. Why will you not treat my pain? And, I have looked and

seen that they have gotten opioids from ten doctors in the past

year at 14 different pharmacies and had to have the long half-hour

discussion about I am worried about this pattern of addiction, and

I have had patients—you know, I had a patient storm off and

threaten to sue me, which, of course, could not happen, but it takes

half an hour to explain why an opioid is not safe and I will offer

you all these other medicines that are not addictive that could treat

your pain, whereas to just write a script takes 5 minutes.

I think the combination of the time pressures, the patient ratings, and then just doctors are initially altruistic and maybe do not

understand the harms, have kind of created this perfect storm

where it is just so much easier to write the prescription than it is

to say no and have the difficult conversation to educate the patient.

Senator KAINE. Ms. Wilkins, I want to ask you about Virginia

Change Addiction Now. You talked about your own personal experience, but the role of community organizations, whether they be

nonprofits or whether they be the Area Agencies on Aging, can

have a big impact—are having a big impact and can have a big impact in especially educating family members. Talk a little bit about

what Virginia Change Addiction Now does.

Ms. WILKINS. We have been active now for about a year and a

half. We go out into the community. We speak at health fairs. We

have done two rallies. We did one at the Fairfax Government Center in May last year, Steps of Change, and we have speakers.

Mellie came out and spoke. Don Flattery spoke for us, and we have

tables with information booths.

I think we need to better address the needs of the elderly community. We just had an International Overdose Awareness Day

rally in August in Berryville. These are things we need to do. We

need to get out there. They need to understand what the risks. We

are trying to reach the kids, but we are overlooking our senior citizens. We are not educating them. They think we want to cutoff

their medicine. They think that we want to make it harder for

them to get their medicine.

I just had a call last night from Texas from a woman that is a

friend of mine. She is 65. She cares for her 90-year-old mother. She

said, ‘‘Do not throw us under the bus.’’ You know, it is just so hard

to get the medication anymore, and there is a balance.

I do not think they understand the risk and I think we need to

talk about what that risk is, and it is not just—we are not accusing

them of being drug seekers. We are not accusing them of being

junkies. I hate that word.

Senator KAINE. Mm-hmm.

Ms. WILKINS. We are trying to prevent them from being harmed.

We want them to get the best medication available. We want them

to get the best treatment. There are other treatments. The Tylenol
33 

with the Advil, I have heard that for years. It is wonderful, and

there are other——

Senator KAINE. One of the issues——

Ms. WILKINS [continuing]. chiropractors, other—there are other

therapies out there for pain——

Senator KAINE. Acupuncture. I mean, there are so many different——

Ms. WILKINS. Acupuncture, yes.

Senator KAINE. The DOD and VA both are really now—because

I think there has been a culture in those organizations, too, that

tend to over-rely on opioids, but there is some really good work

being done now in the DOD and VA systems about, okay, there are

others. We have used other strategies in the past. Maybe they are

a little harder. Maybe they are not harder at all, but we can move

back so there is some good work done.

Ms. WILKINS. Right.

Senator KAINE. You touched upon this call that you got from a

colleague last night. There is still some kind of stigma issues, right,

that we have to deal with across the range, and I would imagine

some of the stigma issues would be toughest in dealing with the

senior population who are getting these prescriptions for legitimate

medical needs, and the notion that there is something wrong with

them or we are going to have to limit them because it is a big drug

epidemic, we are going to have to limit what you do, that has got

to really strike a nerve and make people feel pretty uncomfortable

if you do not do it the right way.

Ms. WILKINS. Right, and you talked about the drug take-back

days. I do not know if Loudoun County has them. In Clarke County, we have a box in the Sheriff’s department we can just take and

drop our pills in. We do not have to wait for the twice-a-year——

Senator KAINE. Wait for the DEA.

Ms. WILKINS [continuing]. DEA days.

Patients do not know how to do those. They do not know what

to do with the medications. I found her—one day, I walked into the

house and it was obvious she had taken something. She was confused. She was talking with the tongue, and I said, what did you

take? Did you—I know you did not drink. What did you take? And

she said, ‘‘Well, I had a co-Tylenol.’’ Where did you get that? ‘‘Oh,

it is in my dresser drawer. Years, I have had it.’’ You know, she

had a bottle of 30 of them and they were back in the back of the

dresser. 

We cannot keep those. We need to educate them that you cannot—if you did not use them, get rid of them. Not only is it a danger for you, it makes you a target for crime.

Senator KAINE. Other issues on stigma? Yes, Ms. Terry.

Ms. TERRY. Well, the point that you made, Senator, about the

education, NSC did a survey that we released last year and we

asked people, have you ever taken an opioid, and we had about 29

percent that said yes, and then when we changed the question to

be, have you ever taken Vicodin, Percocet, oxycontin, you had that

jump up to over 40 percent said yes, so even taking it back to just

the basic level of this is an opioid. It is oxycontin. It is Percocet.

It is Vicodin. That is what we are talking about, and just educating

people at all age levels that that is what this epidemic is about.
34 

Senator KAINE. Those of you with a historical perspective and

you are professionals in this area, has there been an epidemic of

drugs like this where the pathway in has been legally prescribed

drugs that have a very legitimate medical purpose and people are

getting them for that reason, but then the effects on them are not

well enough known and then there is this huge consequence that

drives a big drug epidemic?

I am just trying to think, when we were—when Senator Herring

and I, and I was Governor, were fighting the meth problem, that

was not—people were not using legal methamphetamines and then

becoming addicted and going the other way. They were trying to

make money by selling, so it was a very different kind of an epidemic, and I am just kind of stepping back and asking, are we

dealing with a kind of an epidemic that is really different, not just

in degree, but really in kind, than one we have dealt with before?

Doctor. 

Dr. NEUHAUSEN. Thinking back, I mean, I cannot think of precedent in this century. I think maybe initially with opium from

China, and when people got addicted to opium and there were not

really pain killers——

Senator KAINE. Right.

Dr. NEUHAUSEN [continuing], and that was used for pain medicine, and then there really was—and morphine was used by soldiers in, I think, World War II, and there was some addiction to

self-medicate, but then, I think there was a big backlash where

opioids were viewed as very dangerous and very few physicians

gave them to anyone unless they had cancer and you really regulated, and then, I think really in the mid–1990’s with oxycontin

being approved, this is very unique, and I think that is why it is

so hard for physicians, because there is not really a precedent for

acknowledging that the medications that our profession has written

has been driving this. I mean, I think the equivalent of the opioid

epidemic in terms of the scope and the number of lives it has

touched is more like HIV epidemic. I mean, we have more people

dying per year of opioid and drug overdoses than breast cancer. I

mean, it is—so, I think, historically, there has not been any precedent in this century, and that is part of why this is much harder

to solve than any epidemic we have had before.

Senator KAINE. I am going to ask Director Randall one last question, and then I am going to ask each of you if you have something

you want to say to sum up. I will just let you think about that

while I was asking Director Randall.

As part of the Governor’s task force, you came up with recommendations, and some are things the Governor can do or can be

implemented through the CSBs, but some are things where you

need legislative support. I want to ask whether in Virginia, in

Richmond, it is like in D.C. We are divided by partisanship on

many issues in D.C. This is not one where we are divided by partisanship. There is a good working core of Democrats and Republicans in both houses. I have heard Speaker Ryan talk about it. I

have heard President Obama talk about it. The bill that I have on

the Co-Prescribing Saves Lives, it is Senator Shelley Moore Capito,

Republican of West Virginia, among the cosponsors.
35 

Is it the same way so far—I know you have legislation pending

and the General Assembly is in session—but are you seeing this as

an issue where the partisan divisions that sometimes cause us to

stumble are not so significant in this area?

Ms. RANDALL. I am very heartened by how the parties have come

together to address some of the issues and to take on some of the

initiatives that have come out of the task force, and there have

been some pleasant surprises. People who were not on the task

force who were of the opposite party from the Governor have really

stepped up to the plate, and when we constructed—as staff constructing the task force, also, we really wanted to make it bipartisan and we were deliberate in thinking about who would be good

advocacy from both parties.

For instance, Delegate John O’Bannon, who is also a neurologist,

Republican, co-chaired the task force with Deputy Secretary Jennifer Lee, who is also a physician, so you know, there was very

good bipartisanship, and here in the General Assembly as the bills

are making their way through, we are also seeing good partisanship as people are really understanding the impact on their communities and they are beginning to learn a little bit more about the

science of addiction and the public health aspect of addiction.

Senator KAINE. Well, if there is a promising sign in the midst of

all these challenges, the fact that this is not politically divisive, at

least not in the strict partisan way, is a positive sign, so that

means that evidence-based solutions, we ought to be able to rally

around. 

This has been a very, very good hearing and I really appreciate

the witnesses for coming and I appreciate all of you for coming and

participating. Again, this testimony will all be available online

through the Senate Aging Committee, but I would like to ask of

General Herring, then we will just move right across the table, for

our witnesses to offer any final comments that they choose to.

Mr. HERRING. I would just like to, again, thank you for shining

a spotlight on this aspect of the heroin and prescription drug epidemic that we are facing in Virginia, and really not just Virginia,

but all over the country, and addiction among older Virginians is

a group that is often overlooked and I think we are, across the

country, coalescing behind the need for expanding prevention and

treatment and education, and if we are ever going to get this problem turned around, it is going to be with those very robust programs and identifying specific strategies that we can turn it

around, so thank you for shining a spotlight on this.

Senator KAINE. Thank you for your leadership, and I know you

have a great team in your office that is working on it, too, and I

extend my thanks to them, as well, General Herring.

Director Randall.

Ms. RANDALL. I just want to thank you again for this opportunity

and just encourage anything that we can do to answer your questions or to provide any resources, please feel free to call upon us.

Senator KAINE. I will. Thank you, Director Randall.

Ms. Terry.

Ms. TERRY. This epidemic is really one that is going to require

a comprehensive approach, and part of that is going to include removing the stigma around addiction. Addiction is a disease. It is
36 

not a character flaw, and so, getting people to think about it that

way, getting people in treatment who have some of these issues

and really providing holistic solutions here is what is going to be

helpful, and thank you for having us.

Senator KAINE. Absolutely. Thank you.

Dr. Neuhausen.

Dr. NEUHAUSEN. Thank you, Senator Kaine. This has been a

really eye-opening hearing and it is wonderful to see so much attention paid to this issue.

I guess I just wanted to end with a very brief story. When you

had asked earlier about what kind of education is needed for caregivers and families, my 91-year-old grandmother, who grew up in

Clifton, Virginia, was a retired nurse, had an acute neck spasm.

None of the other medicines we tried worked—Tylenol, Advil, overthe-counter, so she did get oxycodone. It was very effective, but my

mom and I—my mom has no medical background—very carefully

weaned her down and took her, you know, down from one pill four

times a day, to one pill three times a day, to twice a day, and so,

I think that family members can be really vigilant, and I really encourage patients and family members to ask what are the side effects and to push for how quickly can I get off this and to get off

it quickly while treating the pain, because I do think that prevention is the first step, and we will need—you know, a lot of these

PMP solutions are going to keep people from getting addicted, but

we need treatment so desperately, because just cracking down with

the PMP, getting rid of the supply, does nothing about the millions

of Americans already addicted, and that, I think, we really need a

massive infusion of funding. We need comprehensive increases in

rates, and we need providers to start offering this life-saving treatment.

Senator KAINE. Excellent. Thank you.

Ms. Wilkins.

Ms. WILKINS. Thank you. Thank you for having us here.

I think education. We need to get the word out and it needs to

be in a more comprehensive manner, to the providers, to the families, and not isolated. This has opened my eyes. Not isolated just

to the young people, but also to the seniors and the impacts it is

having on them. The education with the doctors, getting that treatment, recognizing that there are medications that treat addiction

that are scientifically evidenced, making that available to people.

I think this is treatment, treatment, early intervention. To have,

whether it is an older person or a younger person, come to you and

go, I have a problem, I need to stop, then they have to wait

weeks—— 

Senator KAINE. Yes.

Ms. WILKINS [continuing]. weeks to get treatment——

Senator KAINE. By then, maybe they are over the wanting to ask

for help right away, or, you know, so——

Ms. WILKINS. Yes. If you do not act when they ask for help, you

are setting them up for failure.

Senator KAINE. You may miss an opportunity.

Ms. WILKINS. It is going to be deadly.

Senator KAINE. Well, thank you to you all.
37 

One formality, which is often when we have hearings, we hold

the record open for a few days in case the member, like me, wants

to ask some questions in writing, and I would like to hold the

record open until Friday at 5. My staff and I will kibitz a little bit

and we will potentially submit some questions. Certainly, Dr.

Neuhausen, the Virginia-specific extrapolation of the CDC data

about Medicare Part D prescriptions of opioids in Virginia is something we are interested in, but we may think of some other questions, and I would just ask your cooperation, and if we do direct

questions to you, if you can respond within a reasonable time period, I would appreciate that, and then, second, to those who attended, one thing I would just offer as an encouragement, if you

want to know more, there are a lot of ways to know more, but one

great way is the program that Director Randall talked about, Virginia’s Project REVIVE!, which is a statewide program to teach

people about the administration of naloxone. I took that training in

the summer of 2014 in Lebanon, in Russell County, Virginia, and

it is more than just learning how to administer naloxone. It is

about the opioid problem and the kind of physical challenges it presents, and you learn to administer naloxone, which is—those of us,

every once in a while, if we have learned to administer the

Heimlich maneuver or learned basic first aid, this is now kind of

part of that skill set, where you would both learn information that

could help you or a loved one, but also educate you in ways that

you may be able to educate others, as well, so I would encourage

a very good Virginia program, Project REVIVE!, and if you have

the opportunity to take it, I would encourage you to.

With that, I thank everybody for attending, and this hearing of

the Senate Special Committee on Aging is adjourned.

[Whereupon, at 12:32 p.m., the Committee was adjourned.]

APPENDIX 

Prepared Witness Statements

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