U.S. GOVERNMENT PUBLISHING OFFICE

48–361 PDF WASHINGTON : 2022

S. HRG. 114–853

FIGHTING AGAINST A GROWING

EPIDEMIC: REDUCING THE MISUSE

AND ABUSE OF OPIOIDS IN AMERICA

HEARING

BEFORE THE

SPECIAL COMMITTEE ON AGING

UNITED STATES SENATE

ONE HUNDRED FOURTEENTH CONGRESS

SECOND SESSION

JEFFERSON CITY, MISSOURI

JANUARY 19, 2016

Serial No. 114–17

Printed for the use of the Special Committee on Aging

(

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
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C O N T E N T S

Page

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

PANEL OF WITNESSES

Bob Twillman, Ph.D., Executive Director, American Academy of Pain Management, Kansas Missouri ........................................................................................ 3

Hon. Holly Rehder, Missouri House of Representatives District 148, Sikeston,

Missouri ................................................................................................................ 5

William Maurice Redden, M.D., Assistant Professor, Department of Neurology

and Psychiatry, Division of Geriatric Psychiatry, Saint Louis University

School of Medicine, St. Louis, Missouri .............................................................. 8

Paul Walker, Pharmacy Benefit Manager, Veterans Integrated Service Network 15, Veterans Health Administration, United States Department of

Veterans Affairs, Washington, D.C. ................................................................... 10

Paul E. Tatum, III, M.D., Associate Professor, Department of Family and

Community Medicine, University of Missouri-Columbia, and Medical Director, Compassus, Columbia, Missouri .................................................................. 11

APPENDIX

PREPARED WITNESS STATEMENTS

Bob Twillman, Ph.D., Executive Director, American Academy of Pain Management, Kansas Missouri ........................................................................................ 29

Hon. Holly Rehder, Missouri House of Representatives District 148, Sikeston,

Missouri ................................................................................................................ 36

William Maurice Redden, M.D., Assistant Professor, Department of Neurology

and Psychiatry, Division of Geriatric Psychiatry, Saint Louis University

School of Medicine, St. Louis, Missouri .............................................................. 39

Paul Walker, Pharmacy Benefit Manager, Veterans Integrated Service Network 15, Veterans Health Administration, United States Department of

Veterans Affairs, Washington, D.C. (no written testimony submitted) ........... —

Paul E. Tatum, III, M.D., Associate Professor, Department of Family and

Community Medicine, University of Missouri-Columbia, and Medical Director, Compassus, Columbia, Missouri .................................................................. 42

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FIGHTING AGAINST A GROWING

EPIDEMIC: REDUCING THE MISUSE

AND ABUSE OF OPIOIDS IN AMERICA

TUESDAY, JANUARY 19, 2016

U.S. SENATE,

SPECIAL COMMITTEE ON AGING,

Washington, DC.

The Committee met, pursuant to notice, at 9:45 a.m., in 65101

Ballroom, Governor’s Office Building, 200 Madison Street, Jefferson

City, Missouri, Hon. Claire McCaskill, Ranking Member, presiding.

Present: Senator McCaskill.

OPENING STATEMENT OF SENATOR

CLAIRE MCCASKILL, RANKING MEMBER

Senator MCCASKILL. This hearing of the United States Senate

Committee on Aging will come to order.

We will begin our hearing that is focused on the problem of

opioid addiction in this country.

I am really happy to be here in Jefferson City. I spent a number

of years here, working right down the street. I certainly sat

through a lot of hearings during those years. This is the first time

that we have had a field hearing of one of my Senate committees

here in Jefferson City and I am very happy to be here.

I want to thank you all for coming out for this much needed

hearing. I am proud to hold another Senate Aging Committee hearing in Missouri, this time in Jefferson City.

First, I want to thank my dear friend and Chairman of this Committee, Senator Collins. By the way, she is my dear friend and I

think it is important to mention that because I think that there are

a lot of people out in America that do not think any of us get along

that are of different parties. That is not true. Susan is a Republican, I am a Democrat and we work closely together, and have

throughout my time in the Senate, cosponsoring many pieces of legislation and now working closely together as the Chairman and

Ranking Member on this particular committee. [dropped audio.]

[continuing]. . . . program to prevent doctor shopping, control

the. . . [inaudible] prescription drug abuse, and outline drug use

and abuse trends to aid public health initiatives.

Tackling this complex issue requires a unified effort. I look forward to hearing from our panel of witnesses as they discuss their

work to reverse this epidemic by reducing the misuse and abuse of

opioids.
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First, we have Dr. Bob Twillman. Dr. Twillman is the Executive

Director for the American Academy of Pain Management. He is responsible for overseeing Federal and State pain policy developments and advocating for those supporting an integrated approach

to managing pain. He also serves as the Chair of the Prescription

Drug Monitoring Program Advisory Committee for the Kansas

Board of Pharmacy.

Today, Dr. Twillman will testify on behalf of the Missouri Prescription Drug Monitoring Program NOW Coalition, a bipartisan

organization composed of individuals, groups and associations that

support a prescription drug monitoring program for Missouri.

Next is State Representative Holly Rehder. Representative

Rehder is a Republican member of the Missouri House of Representatives, representing District 148, Scott and Frances County.

She was elected to the State House in 2012. She has worked tirelessly to address Missouri’s prescription drug abuse problem. She

is committed to reducing the misuse and abuse of prescription

drugs in Missouri.

She will discuss her efforts in the State House to pass legislation

House Bill 130 that would establish a statewide prescription drug

monitoring program in Missouri.

Dr. Paul Tatum is an Associate Professor at the University of

Missouri—Columbia and the medical director for the Compassus

Program. He practices in the area of family medicine, geriatrics

and hospice and palliative medicine.

Dr. Tatum also serves on the American Academy of Hospice and

Palliative Medicine Board of Directors. He helped write their guidelines for prescription drug monitoring programs.

Today Dr. Tatum will testify on behalf of the Missouri Hospital

Association.

Dr. Maurice Redden is an Assistant Professor in the Department

of Neurology and Psychiatry for the Division of Geriatric Psychiatry for the Saint Louis University School of Medicine. Dr. Redden

specializes in psychiatric care for geriatric patients suffering from

delirium, depression, dementia or other degenerative diseases, including Alzheimer’s.

In that role, he works with older adults, specifically ages 65 and

older, who are battling with illicit and licit substance abuse issues,

and finally, Mr. Paul Walker is the Pharmacy Benefit Manager for

Veterans Integrated Service Network 15 with the Veterans Health

Administration. Mr. Walker will discuss the implement of the Department of Veterans Affairs Opioid Safety Initiative, which was

developed to reduce the use of opioids among Americans veterans.

OSI is a comprehensive effort to improve quality of life for veterans

suffering from chronic pain. It emphasizes patient education, intensive monitoring with frequent feedback and complementary and alternative medicine practices.

Thank you all for joining us and we will begin with your testimony, Dr. Twillman.
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STATEMENT OF BOB TWILLMAN, PH.D.,

EXECUTIVE DIRECTOR, AMERICAN ACADEMY OF

PAIN MANAGEMENT, KANSAS MISSOURI

Dr. TWILLMAN. Thank you. It is a pleasure to be here this morning.

Just by way of background. . . [inaudible] pain management.

The Academy is a organization in the country for pain management clinicians. Half of our 4,200 members are physicians while

the others represent 30 distinct disciplines and all of them treat

pain.

Since it was founded in 1988, the Academy has promoted a

model of integrated pain management, recognizing phenomenon

that is best addressed by a care team and a care plan that is multidisciplinary, multimodal and comprehensive in its approach to caring for each individual person in pain.

Today, in the United States, we find ourselves wrestling with two

extraordinarily complex and stubborn public health crises. On the

one hand, we have about 12.5 million Americans who report using

prescription pain relievers non-medically each year, a costly and

persistent problem that results in thousands of deaths.

On the other hand, we have chronic pain. By the Institute of

Medicine in its 2011 report ‘‘Relieving Pain in America’’, it can affect more than 100 million American adults. Twenty-five million of

those report suffering from daily pain and 10 million are disabled

by their painful condition.

This problem costs our economy $560 to $630 billion per year, according to the IOM and brings with it a doubling of a risk of completing suicide.

The author H.L. Mencken said ‘‘For every complex problem,

there is a solution that is neat, simple, and wrong.’’ These are two

complex problems, we may encounter twice as many separate solutions that are neat, simple and wrong, complex problems often

produce negative unintended consequences.

In the case of these two problems. . . [inaudible] attempt to fix

one problem makes the other problem worse.

Fortunately, there is. . . [inaudible].

I would like to talk very briefly about two of these. . . [inaudible].

Prescription drug monitoring programs, or PDMPs are state-run

electronic data bases that collect, analyze and record information

on controlled substance prescriptions dispenses to patients. This information is then accessible to prescribers and dispensers for use

in the clinic, and to law enforcement and regulatory agencies investigating and adjudicating cases involving potentially inappropriate

uses of these medications.

Forty-nine states, the District of Columbia, Guam, nine of 10 Canadian provinces, and one Canadian territory have PDMPs in operation or in development. The one place in this country that does

not have a PDMP is Missouri. That is not because we have not

tried to pass legislation to establish it.

PDMPs are useful in addressing both public safety and public

health concerns. The public safety aspect involves feeding investigations involving controlled substances while deterring and detecting drug diversion activity. The most common form of this is
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often called doctor shopping and pharmacy hopping where individuals obtain controlled substance prescriptions for multiple prescribers and fill them at multiple pharmacies so as to avoid detection.

PDMPs can be used to identify people’s abuse and misbehavior

so they can be investigated, evaluated, and treated appropriately.

From a public health standpoint, PDMPs enable clinicians to do

two things: one to be reassured when prescribing for a new patient

when the PDMP report says. . . [inaudible] appropriate behavior.

Two, to detect behavior that may be indicative of substance abuse

so that disorder can be diagnosed and treated appropriately, and

three, to detect the presence of other prescriptions that, when combined with the new prescription, could produce a fatal overdose.

Missouri’s failure to establish a PDMP undoubtedly contributes

to increased rates of prescription drug abuse and overdose deaths

and it undoubtedly makes it harder for clinicians to effectively

treat pain and other conditions that require the use of controlled

substances.

The second key solution, oddly enough, is treating chronic pain

the right way. I believe that doing this not only improves the effectiveness of pain care received by each person with chronic pain, but

it also reduces the risk of prescription drug abuse and all of the

untoward consequences that result.

Every comprehensive guideline for treating chronic pain, the

IOM’s 2011 report, and the draft national pain strategy that grew

out of it, all call for treatment that uses a comprehensive, integrated approach. This approach treats each person with pain as a

unique individual and develops a pain care plan that is just as

unique.

In addition to being individually tailored, these care plans use a

variety of methods to treat pain, not just the procedures and the

controlled and non-controlled medications that we commonly think

of, but other types of care such as physical and occupational therapy, behavioral health interventions, chiropractic care, massage

therapy, acupuncture, good nutrition and weight loss, exercise, and

a whole host of other interventions.

We have lots of good research that says this approach is more effective and more cost effective. Importantly, it also reduces the

need for opioid pain relievers, reducing exposure to them and thus,

lessening the risk of developing substance abuse disorder.

Unfortunately, this type of care is not widely available and even

less widely recommended by clinicians. Many of these non-pharmacologic treatments are poorly covered or not covered by third-party

payers. For instance, Medicare limits the number of physical therapy and psychotherapy visits a patient can have. It covers chiropractic care, but only for certain diagnoses and only certain types

of manipulations, and it does not cover acupuncture, biofeedback or

massage therapy which the Department of Defense and the VA

have endorsed as effective in treating chronic pain.

An additional barrier is a lack of education clinicians receive for

these two health problems. The IOM report documents that the

leading exposure to pain management for medical students is only

9 hours, while the Association of American Medical Colleges found
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a median of only 5 hours on substance abuse with fully one-third

of programs having no content at all.

Education on these two topics is necessary but not sufficient to

change practice but it is necessary. Even if we are able to provide

the comprehensive integrated care we need, an uneducated clinician is not likely to steer patients toward it.

Pain management clinicians and organizations want to be part of

solving both of these public health crises. We are eager to propose

solutions that address both effectively and we are eager to work

with policymakers to craft policies that enable us to use those solutions. We think we have a good idea about what needs to be done,

and now the challenge is making that possible.

Thank you.

Senator MCCASKILL. Thank you, and before I turn to Representative Rehder, I would like to acknowledge the number of legislators

that we have here this morning. If you are a member of the Missouri legislature, would you stand and introduce yourself briefly before we go to Representative Rehder’s testimony?

Mr. LYNCH. Representative Steven Lynch. I represent the Fort

Leonard Wood area.

Ms. LAVENDER. Representative Deb Lavender, District 90, Kirkwood, Missouri.

Mr. OTTO. Representative Bill Otto, the 70th House District in

St. Louis County and St. Charles County.

Mr. KEAVENY. Senator Joey Keaveny. I am the Senator from the

4th District, St. Louis, Missouri.

Ms. MCNEIL. Margo McNeil. I am the State Representative from

the 69th, which is part of the Florissant area, unincorporated, St.

Louis County.

Ms. HUBRECHT. Tila Hubrecht, I am the Representative from

Southeast Missouri District 151 and I also have a background in

nursing.

Mr. BASYE. I am Chuck Basye, Representative from District 47,

central Missouri including Boone, Howard, Randolph and Cooper.

Senator MCCASKILL. I really appreciate you all being here—oh,

I am sorry. I did not see you, sweetie.

Ms. MIMS. That is okay, I am from the best part of Missouri,

South Kansas City. I am Bonnaye Mims, Representative from District 27 and I have a background in forensics.

Senator MCCASKILL. Good to see you, sorry I missed you.

Anybody else?

[No response.]

Representative Rehder.

STATEMENT OF HON. HOLLY REHDER, MISSOURI

HOUSE OF REPRESENTATIVES DISTRICT 148,

SIKESTON, MISSOURI

Ms. REHDER. Thank you so much, Senator McCaskill, for having

me here today and for your interest in this very important topic.

You have requested that I testify to the critical need for a PDMP,

our efforts here in Missouri, my personal story related to this, and

my commitment to reducing the misuse and abuse of prescription

drugs in Missouri.

As you know, and we have already touched, Missouri is the only

State that does not have this important program in place.
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PDMPs have proven successful in curtailing drug diversion, increasing patient care and overdose rates. Since Kentucky’s PDMP

took effect in 2012, they have seen a decrease in doctor shopping

by 52 percent. A California survey of physicians showed 74 percent

had changed their prescribing practices to patients as a result of

using their PDMP’s patient activity reports. Since Florida implemented their PDMP, deaths related to oxycodone overdoses has

dropped 41 percent.

With Missouri surrounded by eight states, we are not only harming their own population. My district is the majority of Scott and

Mississippi counties down in the boot heel. My Charleston pharmacies are oftentimes the first stop for doctor shoppers coming

from Illinois and Kentucky. My district is also only an hour from

Arkansas, all states that have PDMPs in place.

My pharmacists, physicians, law enforcement, churches and social services department see the result of Missouri’s inaction on a

daily basis.

Our efforts to pass a PDMP in Missouri, I have been in office

since 2013, fighting for this legislation. Representative Engler carried it even before my arrival while he was a Senator. Privacy concerns has caused threats in the Senate for a filibuster. Last year,

2015, the Senate did pass out a Senate compromise bill but once

the fiscal note was completed, it had a $6 million a year price tag

and those in the trenches, our pharmacists, physicians and law enforcement, said it was not a workable program, so we were back

to square one.

This year I filed House Bill 1892, the Narcotics Control Act. We

changed the name due to many fear that prescription drug monitoring includes all of their medications and it does not. It is mainly

those narcotics that are misused and abused, Schedule II through

IV.

My personal story that is related to the need for this. I was

raised on welfare in the drug culture, as many call it ‘‘the wrong

side of the tracks.’’ My mother had to deal with mental illness. One

of my stepfather’s was a dealer. My sister married a dealer at 16

and was a mainline addict. My cousin died at 39 from many years

of drug abuse.

Right after I turned 15 we were in a terrible car accident and

I was needed to help take care of my mother and younger sister.

I dropped out of school, got married and pregnant soon after. At

15 I looked at my life. I was a pregnant high school dropout destined to raise my children in the same cycle of poverty and dependency, around the same type of people who harm others and children because of their drug abuse.

I went to work, working multiple jobs in whatever I could get

hired to do. At 18 I took my GED and then took college classes

when I could. It took my 17 years to finish my degree because I

did it full time and raising a family.

My children have been raised in the same church, where we have

attended for 27 years now. Through their lives, I have served as

youth leader, Sunday school teacher, making sure they understand

that God is the only reason their lives are different than many in

our family.
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My children were raised in a middle class home with two parents

working and participating in their school activities, church activities and their lives in general. They came home to home-cooked

meals at night and parents who knew where they were at all times.

At 17 my daughter worked in a local restaurant while attending

high school and was an honor roll student. She was accepted to

SLU, a very bright, positive, normal teenager raised in a two parent middle class home with many goals and dreams to become a

pediatric physical therapist and live a successful life.

She cut her thumb opening a bag of okra at work and was sent

to the ER to get it stitched up. There, they gave her a prescription

of opiates for the pain. Once she ran out of that prescription she

started buying them from co-workers. They were easy to get and

seemed harmless since they were a prescription, and she loved the

euphoric feeling.

That was 13 years ago. We have had 13 years of ups and downs,

rehabs, prison, and my grandson born with opiates in his system.

You see, the pills become too expensive because your body adjusts

to them and you need more and more to stay at that euphoric level.

Where heroin and meth might be the boogeyman to a teenager who

has not experienced drugs, once they are hooked and cannot afford

the pills, that is where they turn. Their mind is no longer afraid,

and their body simply needs the opiate.

My daughter became a mainline user as well, meth, bath salts,

whatever, to feel her need. My grandson, who I have guardianship

of now, was pulled out of a meth lab at only 1 year old. He slept

within a few feet of the shake and bake operation.

I tell you this story of both of our lives to show that drug addiction is no respecter of persons. It crosses all socioeconomic statuses.

When you go into a high school and ask the kids what do you want

to be when you grow up, their answers are a doctor, a lawyer, a

nurse, a business owner. None say I want to be an addict. Yet, addiction is the growing epidemic of our time.

My commitment to reducing the misuse and abuse of opiates. I

realize that PDMP is not the silver bullet. It is one major tool in

our toolbox and I will continue to fight until we see it come to fruition. I am also working with the Recovery Network of Missouri to

start a bipartisan recovery caucus.

Our goals are these: to enhance recovery outcomes in Missouri;

to identify a Missouri solution to fund recovery support and services; to educate legislators on the needs and gaps in recovery services.

I met with several legislators from different states in D.C. last

month. Their states all had active PDMPs and were on a phase

two, per se, of their recovery efforts, working to identify addiction

early, to put people back on the path to a health life, and curtail

the state’s costs by putting money into recovery efforts on the front

side, versus the penal system which we know has a residual effect

through social services and mental health departments.

In closing, we must change the face of addition. That is why I

am here.

Senator MCCASKILL. Thank you very much for your brave. . .

[inaudible].
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I think we all—this is such a big problem that I doubt there is

anyone in this room that does not have a story they can tell, a

heartbreaking story, about someone that they love. That is how serious this problem is and we certainly respect your ability to tell

yours. I congratulate you on your fight.

Dr. Redden.

STATEMENT OF WILLIAM MAURICE REDDEN, M.D.,

ASSISTANT PROFESSOR, DEPARTMENT OF NEUROLOGY

AND PSYCHIATRY, DIVISION OF GERIATRIC PSYCHIATRY,

SAINT LOUIS UNIVERSITY SCHOOL OF MEDICINE,

ST. LOUIS, MISSOURI

Dr. REDDEN. Good morning, Senator McCaskill, and thank you

for allowing me to speak about the rising epidemic of illicit and licit

substance use and misuse among older adults.

As previously stated, I am a geriatric psychiatrist at Saint Louis

University School of Medicine.

This issue is of particular concern to me both as a clinician and

researcher because of my interest in overall mental health and

ways to improve cognitive function in late life. One way to do this

is to address any potential risk factors that can be removed or

modified, including substance use and misuse.

Historically, substance abuse has been considered a problem affecting younger adults that was thought to decrease as one ages.

In my experience as a clinician, I have begun to encounter patient

abuse of both illicit and licit drugs more often. The main illicit substances include marijuana, cocaine and heroin. However, an often

overlooked problem of prescription, non-prescription and over-thecounter misuse of drugs is also on the rise.

The pattern of use can appear in early onset and late-onset

users. The former describes individuals with a long history that

persists as they age, while the latter includes individuals who develop a new habit in late life. Some of the risks factors that lead

to new onset or continued use in the elderly include social isolation,

financial difficulties, and poor support systems. In most instances,

there may be mental health conditions that have not been properly

diagnosed and/or treated.

When older adults use illicit and licit substances, even in small

amounts, the negative effects can be magnified. In addition, onethird of elderly patients take, on average, five prescription medications daily. This increases the risk of drug interactions, which can

complicate medical problems. This all leads to increased emergency

department visits, as well as prolonged hospital stays.

For the sake of time, I would like to focus more on the rise of

opioid use, which include both heroin and prescription opioids. One

of the driving forces in this rise has already been mentioned, which

includes the increased prevalence of chronic pain. Prescription

opioid medications have been the most prevalent treatment options. When these options are not available, older adults have resorted to using someone else’s prescription, buying medications off

the street or straightforwardly using heroin. They have also been

known to doctor shop in order to acquire more medications than actually needed.

The overuse and misuse of opioids is of particular concern to

those in the mental health field because it can lead to suicide by
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self-poisoning. The same factors that lead to drug abuse, which include social isolation and mental health illness, also are risk factors for suicide, and now with the increased distribution of prescription opioids, this vulnerable group has lethal means to carry

out the intent.

Screening of the elderly, however, is very difficult as most available screening tools have been designed for younger patients. Recently, the DSM-V has been updated and the diagnostic criterion

is called substance use disorder instead of abuse and dependency.

However, relying solely on this diagnosis and criterion may exclude

elderly patients.

One of the key features of substance use disorder is tolerance.

Due to the age-associated physiologic changes that increase the effects of even small amounts that may be more pronounced in the

elderly, making the diagnosis of substance use disorder extremely

difficult.

The first step in recognizing elder drug abuse as a problem is to

consider it a possibility. As clinicians, we are often pressed for

time, but there are screening tools, such as CAGE-AID, which is

alcohol and illicit drugs, are designed to help began the discussion.

Once elderly patients have been identified as having a substance

use disorder, treatment interventions need to be tailored to meet

the needs of this unique group. As such, medications that are typically used in younger patients may not be suitable for older adults.

Therefore, risk versus benefit analysis needs to be made before

seeking such options.

There is still some debate on whether elderly patients should

participate in inpatient-treatment programs that are specifically

geared for younger people. However, sometimes integrated programs may also be beneficial. In choosing appropriate programs,

other factors should be considered, such as comorbid medical and

psychiatric conditions that need to be addressed during treatment.

Another tool that every other State has enacted, that has already

been mentioned, is prescription drug monitoring program. These

programs vary across settings, but the main purpose is to detect

and reduce diversion, abuse and misuse of schedule II prescription

medications, such as opioids. Hopefully in the future, this will include all prescription medications that have high abuse potential

such as benzodiazepines.

Prescription drug monitoring programs have shown to reduced

over-prescription and doctor shopping by patients. They have also

helped identify any suspected fraudulent prescribing or illegal activities of the dispensing of controlled substances, so therefore, in

conclusion, substance abuse in the elderly is a growing problem

and includes both illicit and licit substances. The identification of

substance use is difficult, but first has to be acknowledged as a real

possibility. Then, an assessment that is respectful and non-stigmatizing can be approached.

Clinicians should be mindful of the roles of comorbid medical and

psychiatric conditions when diagnosing and treating elderly patients who exhibit symptoms of substance use. The over-prescribing

of opioids for the treatment of chronic pain can contribute to this

problem; however, having deterrents in place such as a prescription

drug monitoring programs and utilizing other methods to treat
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chronic pain can help clinicians to combat this devastating problem.

Thank you for time and efforts in addressing this growing concern of me and my colleagues.

Senator MCCASKILL. Thank you, Dr. Redden.

Mr. Walker.

STATEMENT OF PAUL WALKER, PHARMACY BENEFIT

MANAGER, VETERANS INTEGRATED SERVICE NETWORK 15,

VETERANS HEALTH ADMINISTRATION, UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS, WASHINGTON, D.C.

Mr. WALKER. Good morning, Ranking Member McCaskill.

I appreciate the opportunity to discuss prescriptions and the

safety initiative currently being implemented by the Department of

Veterans Affairs.

The 2011 study by the Institute of Medicine established chronic

pain as a serious health issue in America. Particularly, the study

recognized that 60 percent of veterans returning from combat theaters in the Middle East and 50 percent of VHA-enrolled veterans

suffered from a form of chronic pain.

Veterans suffer from multifaceted conditions, unlike counterparts

in civilian hospitals. This involves battlefield injuries encompassing

musculoskeletal and nerve systems. These impediments may be

coupled with traumatic brain injuries. Traumatic brain injuries

have lasting effects to overall brain structure and emotional health.

This can independently increase the risk of substance abuse disorder.

It is well documented that uncontrolled pain, coupled with functional impairments, leads to a decreased quality of life. These conditions greatly increase the risk for overdose, substance use disorders, and consequently, suicide. The complexity of multiple conditions makes the accurate delivery of pain management challenging

and intensifies risks of complications due to over-and underuse of

opioid... [inaudible] therapies. In as much, veterans continue to call

upon VA clinicians to alleviate their pain.

This country is now in the midst of an epidemic of misuse and

overuse of opiate medication. The appropriate use of opioids is particularly important for VA due to the number of veterans who have

musculoskeletal injuries and permanent nerve damage.

Shifting our prescribing practices has required a cultural change

and changes to the modalities we use for pain management. This

implemented approach is twofold. First, we immediately address

the issue of inappropriate high dosage of opioid medications. Second, we develop an effective system of interdisciplinary pain management to provide safe and effective pain control.

To address the varied discretion in opioid prescribing, VA developed the Opioid Safety Initiative, or OSI. OSI was designed to

make opioid prescribing visible throughout the VA. This platform

includes key clinical indicators, such as the number of unique pharmacy patients dispensed opioids, unique patients on long-term

opioids who receive urine drug screens, and the average morphine

equivalent daily dose of opioids.

The system analyzes prescribing practices and provides feedback,

ensuring opioid prescriptions are disbursed effectively and judi-
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ciously. This system has demonstrated considerable promise in

minimizing harm and promoting safe, yet effective, pain care.

After a brief pilot period, the VA implemented the OSI system

nationwide in 2013. To monitor the impact, quarterly OSI trending

data is circulated through VA medical centers, network offices, and

the VA Central Office. Facilities with data outliers are required to

submit action plans to VA Central Office. This monitoring is continued until data outliers have been resolved. The recent data results demonstrate the level of achievement obtained by utilizing

this system.

VA facilities throughout the Missouri region, where 19 percent of

chronic opioids are above the age of 70 years, we have reduced the

number of veterans on opioid-based medications by 21 percent. The

number of veterans on both an opioid and benzodiazepine medication has decreased by 47 percent. Last, we reduced the number of

veterans on high dose opioids by 37 percent.

The OSI initiative has been augmented by deploying the Opioid

Therapy Risk Report. This additional practice protects veterans

using high dose opioid prescriptions or with risk factors placing

them at risk for complicates. The report, used nationally, allows

clinical staff to view narcotic and sedative dosage information and

medical diagnoses. This all-inclusive data platform provides an efficient veteran-centric approach previously unavailable to primary

care providers. VA continues to distribute training aids promoting

the use of the system in daily practice.

Overall, we are proud of our advancements in promoting opioid

safety, particularly in the State of Missouri. VA remains dedicated

to providing the best care to veterans and continues to research innovative methods to continue this progression.

This concludes my testimony and I look forward to any questions

you may have.

Senator MCCASKILL. Thank you.

Dr. Tatum.

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

ASSOCIATE PROFESSOR, DEPARTMENT OF FAMILY

AND COMMUNITY MEDICINE, UNIVERSITY OF

MISSOURI-COLUMBIA, AND MEDICAL DIRECTOR,

COMPASSUS, COLUMBIA, MISSOURI

Dr. TATUM. You know, before I begin, Representative Rehder,

thank you for sharing your story. That was so powerful and brave.

Thank you.

Senator McCaskill——

Senator MCCASKILL. Would you pull your microphone a little bit

closer.

Dr. TATUM. A bad combination of a geriatrician taking care of

older adults who have hearing problems and a low talker. Is that

adequate?

Senator MCCASKILL. That is great.

Dr. TATUM. Thank you.

Senator McCaskill, thank you for so much for scheduling a public

forum on opioid abuse among older adults. I find today’s topic so

important both from a national, public health standpoint, but also

for me personally, as a physician, this impacts me day-to-day, but

also my family’s experience.
12

I have seen both the terrible toll of misuse of pain medicine, and

I have also seen the tremendous relief they can bring when used

appropriately to allow a person bed-ridden with cancer pain find

the relief to spend their last few days holding up her grandchildren.

Two brief stories highlight the complexity and critical importance

of the meeting today. First let me tell you about a patient of mine.

As a physician who has had additional training in both geriatrics

and palliative medicine, I am often asked to help doctors with difficult pain cases. I remember a patient with severe pain, as well

as limited life expectancy. In the hospital, our teams’ recommendations made a big difference. He left, he went home doing better. I

was surprised to hear, in fact, later on he had died much earlier

than we would have anticipated. I reviewed his meds and they

seemed appropriately dosed. I was devastated to learn from autopsy that he had not one but multiple duplicative pain medications in his system provided by multiple other doctors.

We need better coordination of care systems for patients with

pain.

I am so glad that we are before this Committee today because

opioid deaths are not just about younger people with addiction. The

statistically significant rise in opioid deaths occurs in older adults

over 65 as well as younger adults. The CDC has declared pain

medicine misuse and the deaths associated with it an epidemic.

The common factors the CDC finds in deaths from opioid include:

prescriptions at very high doses, and I am pleased to hear the VA’s

efforts to really impact that, prescriptions from multiple providers,

and finally, a mixture of opioids with other medications. We have

heard the impact you guys had on benzodiazepine sedatives, one of

the major medicines.

In my experience, another factor this Committee in particular

can help policymakers understand is the underappreciated fact of

just how complicated opioid prescribing is for older patients. Physicians, despite their training in pain management, and we heard

limited numbers of that from Dr. Twillman, have not been well

trained in geriatric medicine and the necessary adjustments for patients as they age. Due to the physiologic changes associated with

aging, a standard dose is too strong for older adults, and the body

cannot process the drug as quickly. In short, a little medicine goes

a long way.

Failure to recognize the unique prescribing adjustments needed

for our seniors is another key factor in opioid misadventures, which

must be addressed with better geriatrics education. I think your

committee can really make a statement on that.

The good news is we can work to reduce opioid deaths. You

know, Congress’s Secure and Responsible Drug Disposal Act of

2010, which allows unused opioids to be disposed of at pharmacies,

is going to keep leftover medicine that was needed for grandmother’s hip replacement from becoming the drug that starts a

grandkid on the path to addiction. This is important legislation and

we need to let more people know about it. Thank you for that.

The good news is that physicians and organizations are working

to make opioid prescribing safer. I would like to share with you the

Missouri Hospital Association—I may refer to it as MHA’s—re-
13

sponse. The Missouri Hospital Association noted between 2005 and

2014, hospitalization for opioid overuse has increased 137 percent

in our State. At the University of Missouri we found that the impact of overdose is particularly serious for older adults. Unlike

younger adults, the seniors admitted with an overdose had twice

the need for intensive care unit admission. This has real impact.

The MHA had partnered with a coalition of the Missouri State

Medical Association, the Missouri Association of Osteopathic Physicians and Surgeons, the Missouri Academy of Family Physicians,

the Missouri College of Emergency Physicians and, importantly,

the Missouri Dental Association. They felt, in the coalition, that

steps to reduce misuse and abuse in emergency room prescribing

practices was a key initial step.

Based on national guidelines and evidence the coalition put together emergency department protocols which include that a comprehensive pain assessment plan is a key part of the emergency

physician’s work before prescribing. The diagnoses are made on evidence-based guideline. Especially important, non-narcotic treatment should be given for non-traumatic tooth pain. A huge impact

on emergency rooms when people come in asking for pain med.

When possible, the emergency department should coordinate

with the opioid prescriber when people come in asking for additional adjustments in meds, and that the emergency room prescribers should limit their prescriptions to 72 hours, then coordinate with the primary care physician, as well as other protocols,

and importantly, the policy also asks for emergency departments to

partner with other health officials to make naloxone available for

dispense in pill form.

The good news is physicians are thinking about how to solve this

on a national level. The AMA, the American Medical Association

Task Force to Reduce Prescription Drug abuse states that ‘‘physicians have a professional obligation to reverse the Nation’s opioid

epidemic.’’

As this Committee thinks about policies to make prescribing

safer, I personally would like ask that you focus on the AMA’s recommended areas. They are excellent. They have five: increasing

physicians’ registration and use of effective PDMPs, Prescription

Drug Monitoring Programs; enhancing physicians’ education on effective pharmaceutical prescribing; reducing the stigma of pain and

promoting comprehensive assessment, not just pills; but also reducing the stigma of substance use and enhancing access to treatment

of substance abuse, and then finally, the AMA again endorses access to naloxone in the community, but in closing, the other story

that is so important is that of my father. My father died of a rare

disease in a small town in East Texas. During his last days, as he

writhed in pain, my mother was told, ‘‘I am sorry, we cannot give

him morphine. That might kill him.’’

We have a public health crisis that demands response both to

prevent unnecessary deaths to prevent them, but also a response

to meet the true pain needs, which are often untreated or undertreated.

My colleague, Dr. Smith at UCSF and his colleagues, found 25

percent of older adults have significant pain in the last 2 years of

life, rising to as much as 50 percent in the last year of life.
14

As we think about policies to reverse the opioid epidemic I think

this Committee is especially positioned to help older adults. Speaking personally as a geriatrician, I think a key policy need is to improve geriatric medical education for all practitioners, and improve

care coordination, in particular, between practitioners, other health

care workers, hospitals, pharmacists and patients and their families.

Congress could expand Geriatric Academic Career Awards so we

have the teachers needed to help providers understand the intricacies of prescribing to older adults. We could pass the Palliative

Care and Hospice Education and Training Act, or PCHETA, which

actually create regional centers that improve care of the seriously

ill and enhance end-of-life education, which is a gap in some of our

physicians, but foremost this is about safety and real suffering.

With your supportive actions for enhanced practitioner education in

geriatrics and pain management, as well as systems which really

help coordination, I think we can simultaneously reduce the prevalence of opioid addiction, reduce the harms from opioids, while ensuring that older adults who do have significant needs receive adequate and appropriate pain management and avoid unnecessary

suffering.

Thank you for having us here today.

Senator MCCASKILL. Thank you.

I think it is true that with older Americans, especially those who

have diagnoses of a terminal illness, where the medical protocol acknowledges chronic pain associated with that, that is obviously not

a problem, but let me just start with a global question to the doctors, the medical doctors, and to Dr. . . . [inaudible] on the panel.

We are prescribing, by multiples, more narcotic pain medication in

American today than we were 40 years ago. My multiples. Now,

are we in that much more pain? I mean, you know, I do not understand what happened that all of a sudden America had so much

more pain than we had 40 years ago.

I want to figure out, was this a solution looking for a problem

and driven by the pharmaceutical injury and doctors that were not

paying attention? Or did somehow, all of a sudden, America had

more pain?

Dr. TWILLMAN. If I may, I think it is, as usual, not a simple answer to that question. Part of what happened——

Senator MCCASKILL. I am afraid it is. Money.

Dr. TWILLMAN. Well actually, there is an element of that involved. One of the things, I talked about the sort of comprehensive

care that we need to provide for people who have chronic pain that

is not necessarily related to a terminal illness. If you go back 30

or 40 years in this country, we had a lot of programs that were set

up that way. They were very—people would come in, they would

be assessed by a number of providers with different perspectives,

they would put together a comprehensive plan, and the data

showed that that provided better pain management at a lower cost

and got more people back to work than the traditional approach

that we have now, which is prescribing medication after medication

after medication.

The problem is insurance stopped paying for that, and so those

programs went away. I think the numbers are something like they
15

went from 1,000 programs to 80 programs in the course of less

than 10 years.

What happened is now physicians are reimbursed for having a

very brief visit with a patient, for spending 15 minutes or less with

every patient that is in the room with them, and the fastest way

to get somebody out of the room is to write them a prescription and

hand it to them like it is their ticket to get out of the room.

Unfortunately, what we have come to is a system that reinforces

that kind of behavior and does not provide us the kind of reinforcement we need to give the care that we need to be giving.

Senator MCCASKILL. Is that an accurate assessment, Dr. Redden

and Dr. Tatum?

Dr. REDDEN. Yes, I would agree with that also. I do not prescribe

a lot of opioids as a psychiatrist. I do mostly benzodiazepines,

which are in the same category.

Fortunately for me, I am at an academic institute and my time

slots are. . . [inaudible] so I have 25 minutes to fully assess a patient. I have colleagues who are chiropractors who get paid by the

number of patients that they see versus the quality of medicine

that they provide to the patient, so as he said, the easiest way to

get people in and out is just to prescribe a medication without

doing a full assessment.

Senator MCCASKILL. I was never offered a narcotic pain medicine

at the dentist 30 or 40 years ago, I am that old. I am older than

dirt. I am now. What is up with that? Why would her daughter be

given a narcotic pain medication for a cut on her hand? I mean,

this is not chronic pain. This is episodic pain.

Dr. TATUM. I think if all you have is a hammer, everything looks

like a nail, and I think that it is true that the patients who are

on the older side, with multiple chronic diseases, as you go through

severe arthritis where you no longer may be operable, opiates remain a potential tool, but there is a wonderful study just in the

last few months in the Journal of the American Medical Association looking at back pain. It suggests if you compare standard regimens versus opioids, simple old-fashioned anti-inflammatories

probably have better outcomes over time, and the problem is once

you have started a prescription, it is—a subset are going to remain

on it.

Senator MCCASKILL. Of course, they are.

Dr. TATUM. I think the fact of——

Senator MCCASKILL. It feels really good.

Dr. TATUM [continuing]. the matter is if you ask physicians and

look at it from a physician education standpoint, as Dr. Twillman

pointed out, they think that pain management, in some sense, has

a short shrift in terms of the complexities and nuance. At the same

time, culturally we have this move to pain as the fifth vital sign.

You know, to me, as you mentioned, chronic pain is cancer pain.

There is pain at the end of life, which is one thing, and you treat

that pain. A subset of chronic, non-malignant pain I think we need

to think about is not what is your pain score? Certainly not a quality metric that might impact reimbursement if you did not get to

a certain quality score. The real question is did we improve your

function and your well-being?
16

A wonderful book by Eric Cassell, ‘‘The Nature of Suffering’’, describes in the beginning a person who has come in multiple times,

seen multiple doctors again and again and again for pain, a back

pain in particular, a younger person, and her suffering was, in

part, what was this? The simple process that he recognized her

pain was two levels above where everybody had shot an x-ray and

found she had a compression fracture and a wedging down of the

back vertebra from a trauma she had, and by naming it, what relief that brought to her.

I think Dr. Twillman has mentioned how complex systems, not

just another pill, is the key. We need more than just the hammer.

Senator MCCASKILL. Why are not doctors offering a—by the way,

I have some outpatient surgery coming up, and I will say for the

first time a doctor said to me I will write you a pain medication

if you want it, but most people find that Advil works just as well.

That is the first time that has ever been said to me, but he still

did not say by the way, that prescription, if you want it, it is addictive.

Why are doctors not telling patients that what they are prescribing for them is addictive? What is that not said? Nobody says

that. Do you say, this is addictive when you prescribe opioids to patients?

Dr. REDDEN. I do when I prescribe benzodiazepines. I said I am

not in the habit of prescribing opioids, but with benzodiazepines,

I let—I also see younger patients—I let all my patients know that

it is habit forming and that you can develop a physiological dependence where your body needs it, and a psychological dependence

where you feel you need this, and often it starts with someone like

you, getting a benzo or an opioid for short-term use and they like

the feeling and they begin to seek it more and more, for whatever

reason, and then they are on it for the rest of their lives. I see patients that take opioids when they are young and they come see me

at 60 and 70 and they are wondering why they are not thinking

right, why other mental health issues are going on, and no one has

addressed that problem.

I do not know, I think it is lack of medication education, especially from medical school up into residency with focus on other

things and they often do not want to make the patient feel bad either. If someone admits they have a problem, that may make them

feel shameful or have that measure of stigma attached where they

may not want to seek out help or treatment anymore.

I do not know why others——

Senator MCCASKILL. I certainly understand that in the psychiatric field. We have stigmatized mental illness in this country

to the point that we are all suffering from it, but what about doctors that for—why are they not telling patients that these drugs

are addictive?

Dr. TATUM. You know, I have a funny alternative take. I think

you are right that that is a key issue.

The funny alternative, as a geriatrician when I think it is very

appropriate for someone to have an opioid, if I do not address addiction with an 80-year-old, they are so afraid of it, they are never

going to take a pill that might be very appropriate for them.
17

I think one of the real challenges is we do not have great tools

that help screen for a person who is going to be a risk abuse. I

think a PDMP is one part of that. I think the future, if I can think

what NIA can accomplish with research in the future, would it not

be amazing if, with personalized medicine, I could do a drug test

before I prescribe an opiate? Would it not be amazing if with that

blood test, number one, I can see the type of receptor that person

has and know which ones are going to cause side effects to avoid

versus which ones. . . [inaudible] even more importantly.

We are not anywhere near that. This is a dream. Would it not

be amazing in personalized medicine if I could say this is the person who is going to be addicted? I think there is so much potential

and research and, in particular, that is an exciting thing to think

about in the future.

In the hear and now, I think it is a challenge, and the key thing

that would help me in the short term in our local State, is a PDMP

so I can recognize the person who has addiction issues up front.

Partly, so I can refer them for treatment.

Senator MCCASKILL. By the way, the people who are addicted, it

is always 10. I mean, they are trained to come in and say my pain

is a 10, my pain is a 10 plus, my pain is a 10 plus. Now I do not

know what asking somebody who is addicted what their pain is accomplishes.

Dr. TATUM. A Marine whose pain is a three is a problem.

Senator MCCASKILL. Right.

Representative, talk a little bit about your legislation. Why don’t

you take a stab—I would do it, but I would like to hear it from you

instead—about this paranoia about people’s privacy. That seems to

be the problem.

Ms. REHDER. Yes, ma’am.

Senator MCCASKILL. To me it is an irrational paranoia, but why

don’t you address that so that we have it in the hearing record.

You know, when 49 states have done it and one has not, my Missouri common sense tells me we are the problem, not the 49 other

states, so why don’t you help out with why this is not going to violate people’s privacy as it relates to their health records.

Ms. REHDER. Yes, ma’am. Thank you.

I look at this as an extension of electronic medical records. This

is something very less invasive than electronic medical records. It

is housed with the State, and just as Missouri HealthLink has

never had a breach, nor have any of the other PDMPs. California

implemented theirs in the late 1930’s.

I think, since there has not been a breach in all of these years,

we already have a smaller PDMP working in the State that has

never harmed anyone with our Missouri health plan, with our Medicaid, so to me, the privacy issue that continually gets brought up

is just a red herring.

We have—PDMPs fall under HIPAA laws and so they are just

as safe—your electronic medical records—they are just as safe.

They are just an extension of that, and many people get their prescriptions filled at Walmart. Walmart has a national PDMP of

their own. Walgreens, the same.

The small pharmacies are the ones that, you know, the singleowned pharmacies. They cannot look to see what you have gotten.
18

Walmart cannot look to see if you have gotten something from the

pharmacy across town, and so that is the only element that we are

trying to pick up, and so your doctor can look on the front end and

say okay, what we actually need to be talking about is your addiction and address addiction on the front end, and so to me the privacy issue is just a red herring. That is something that has been

thrown in here to say the sky is going to fall when it is not. It has

not fallen and these have been in place in some form since the late

1930’s.

Senator MCCASKILL. Mr. Walker, I assume that our heroes and

our brave and amazing men and women who have stepped across

the line and said take me, we do have a PDMP for our veterans;

correct? I mean, we know if veterans—with the veterans system,

you can track the use of opioids?

Mr. WALKER. Yes, within our electronic health record we are able

to track the use of opioids. We also have some-——

Senator MCCASKILL. Have any of the veterans complained to you

about violating their privacy as it relates to that?

Mr. WALKER. No, and we also have the ability to have links to

the Department of Defense, in terms of medications patients are on

when. . . [inaudible]. We do have comprehensive medication information available through our electronic health record.

We also have our—recommend to our providers and our health

care teams that they do access the State PDMPs. That is one of our

universal precautions, in terms of our Opioid Safety Initiative, and

so within our network we do have providers who access, and health

care teams, access the information from the State of Kansas, the

State of Illinois, and possibly from the State of Arkansas, and we

also have, in the State of Missouri, the Missouri VA facilities that

border those states and they actually do make some queries to

those states to try to find out of the patients are taking any medications from other sources or other pharmacies outside of the VA.

That is considered to be an important part of our universal precaution, the process. . . [inaudible].

We also have, as part of our universal precaution, doing routine

and periodic urine drug screens, and we also, for all of our patients

that are on chronic opioids, and we have a definition of that, more

than 90 days. They have to have a consent done, and within that

consent, we talk about taking opioids responsibly, and that is really

the starting point, to have that conversation with the patient or

with their family, to start to talk about what are realistic expectations in terms of what medications can help you, what are other

alternatives, and then that is kind of the starting point for a

shared decisionmaking with our veterans in terms of deciding okay,

what is going to happen with their pain management in terms of

whether it is opioids or they are going to be referred to an interdisciplinary team for pain management to have access to other integrated health-type services, to help the veteran self-manage their

pain in their lives and how they react to it, so those are all things

that are readily available through the Department of Veterans Affairs.

Senator MCCASKILL. You would be a good person to start with

on this. The other flip side of this is when either the VA system

or a doctor or an emergency room recognizes that someone is an
19

opioid addict and they sound the alarm and cut them off without

appropriate care for withdrawal. Can you all address?

I was talking to Representative Lavender, she has a constituent

where that happened to a woman where the doctor said we are cutting you off, that is it, without any kind of medical plan for the

withdrawal. I assume that you all are aware that that can be as

dangerous—that is where the heroin comes in if the plan is not one

that is sound and that the patient buys into.

Dr. TWILLMAN. I tell practitioners that I think that is malpractice

to do that. There has been a big push to have patient agreements

where patients who are on these medications sign agreements and

say I will do certain things, and oftentimes those are written in

such a way that if they violate the terms of that, the consequence

is to stop all of their therapy. I think that is malpractice, because

what has happened is you have just identified a new medical disorder, the disorder of addiction, and that needs appropriate treatment. Appropriate treatment is not cutting somebody off and kicking them out the door. Appropriate treatment is finding somebody

who can treat that person appropriately for their disease of addiction.

Most often, the most effective treatments are some sort of medication-assisted treatments with methadone or buprenorphine products, and that is what needs to be done. People need to understand

that that is the appropriate treatment for that disorder.

Senator MCCASKILL. Do you believe that there is an increase in

the prescriptions being given in more reasonable amounts for—this

is really more ER than it is—or orthopedic surgeon, the—I remember when I finished having my knee replaced. Well, I had a whole

bunch left over and I was not interested in them. I was wondering

why they prescribed so many. I think the doctor gave me like 90

days or something for a knee replacement, or the dentist wanting

to give a patient 30 days after a trip to the oral surgeon. Why not

three pills? Why not four pills? Why is it typical that it is 30 or

nothing, or sometimes even more than that? Is that something that

has just been traditional in medicine, and prescribing just a handful of pills does not happen?

Dr. TATUM. I think this is a critical issue because I think of the

young child who starts the pathway to addiction is often not that

they received the prescription. It is that they got grandmother’s

prescription.

Senator MCCASKILL. Right.

Dr. TATUM. I think that you learn the pharmacology——

Senator MCCASKILL. That happened in my family, by the way.

Dr. TATUM [continuing] but the real world practice, frankly, is

doctors learn from another doctor how to put the number on the

pulls as they are writing the script the first time is not a good process, and I think as we start speaking more and more to the issue

of opiate abuse, I think you are seeing efforts. You are starting to

see efforts in Massachusetts on issue about the—cutting back on

the number of prescribed—Missouri Hospital Association statement

really speaks for emergency room physicians, in particular, limiting

that to a 72 hour supply.

The danger, I think the danger in particular was in a South

Carolina response, if you so limit the number and do not appro-
20

priately describe the physician you are talking to, they have the potential to make it very hard for a hospice physician who might take

care of a very large rural area to be able to prescribe medication

for that person where they may not be able to physically see them

for a week or so because it is the nurse seeing them.

Senator MCCASKILL. I see.

Dr. TATUM. I think the smart policy is education to help physicians limit the number down, limits particularly in the emergency

room that are smart precautions. I think Texas had some good examples in their legislation about making smart exemptions for say

palliative care patients and hospice patients.

Senator MCCASKILL. Maybe the most important—I am sorry, did

I interrupt you?

Dr. TWILLMAN. Sorry, Senator. I think there is a piece of research here that also would be very helpful to us and it would be

easy to do and inexpensive to do.

My wife had arthroscopic knee surgery and was prescribed 80

Percocet tablets for that, and took 2.5.

What is happening is people are prescribing so that the patient

never runs out of medication and needs a second prescription. They

are estimating what that patient, whose need is at the 99th percentile, is. I think most of them do not know what the average patient uses because I think when people come back for post-op followup appointments they never ask the question, how much of that

medication did you use?

Senator MCCASKILL. Right.

Dr. TWILLMAN. It would be really simple for something like Medicare or Medicaid, where you have got the prescription records, to

simply contact the patients afterwards and say how much did you

use? If we found out that the average number used was five pills,

maybe we would not be prescribing 80.

Senator MCCASKILL. Yes. Well, that is a good idea for Medicare

to take a look at. There is an awful lot of joint replacement going

on in the Medicare population, a lot of hips, a lot of knees, a lot

of shoulders. That would be a reasonable place for us to do the research about the average amount that is used.

Maybe the most important question I need to ask is for. . . [inaudible] this is the Committee on Aging, and I certainly know that

there are lots of elderly out there that are addicted to opioids.

What are the things I need to know? Obviously, if I could wave a

magic wand and put a certain Senator locked in a closet, we could

get this done in Missouri, but I am pretty sure that the law enforcement representatives that are here would have to arrest me

for that, so that would get ugly and it probably would go viral.

I am not going to do that, and we know that is the obvious. That

is the low-hanging fruit here, is for Missouri to join the rest of the

country here in doing a basic, simple, common sense thing, but

what are the things that we could be doing at the Federal level,

both through the Medicaid and Medicare population, and through

NIH, and through the ability to proscriptively change the Medicare

program. Give me good ideas of what I can take back to Washington this afternoon and share with Senator Collins that perhaps

we should take a closer look, a more detailed look, at a part of this
21

in a hearing in Washington where we could look at perhaps some

legislation that might be helpful in this area.

Dr. TATUM. It is funny, in the Show Me State, the good thing is

we have let 49 other states do this, so we will learn from their best

practices. I think a Federal piece about absolute best practices on

PDMPs would be very helpful, particularly as we build one here.

Let us do it right because everybody else has done what is wrong.

The second piece, and looking at our State, if you look at hot

spots about where the addiction issue is, the hot spots of opioid

issues, really St. Louis and Kansas City are part of that. A Federal

solution, with appropriate privacy safeguards, I think is the interoperability where one state’s PDMP can talk to another’s so that

my patients—if I were in St. Louis or Kansas City—actually got

their prescriptions also in Illinois at the same time.

I think a third key Federal response that comes to my mind is,

again, the opportunity to really enhance geriatric education for this

Committee, as mentioned.

Senator MCCASKILL. We have got a shortage of geriatric help in

this country right now. John Morley is my husband’s doctor and

when I go to appointments I have to bring a lunch.

Dr. TATUM. Sadly, Dr. Morley is not shy.

Senator MCCASKILL. Dr. Morley will never let me out of the room

until he explains to me the crisis facing America in terms of a lack

of doctors ready to care for my generation, that geriatric medicine

is not one of the big money glamourous specialties and we are sorely lacking geriatric professional medical help in this country.

What can we be doing, through the Medicare program, that

would help with this problem of just having enough doctors that

have enough time? Is it reimbursing the doctors more for their time

with patients as it relates to preventative care?

Dr. REDDEN. Yes. We have a record system and within that we

have measures to do certain screenings. I always get things, I do

not do tobacco screenings, someone else can do it, but if we had

screening measures of any substance abuse that would come across

that would affect someone’s pay or—we get paid through RVUs—

if that would affect that some kind of way, many doctors. . . [inaudible] and start there.

Another thing I wanted to add is once you identify someone with

substance use disorder, especially the elderly, the treatment options are very limited and treatment places to go for the elderly are

very limited. Programs are always geared for younger adults, mainly with alcohol, and studies generally exclude elderly patients, 65

and up.

Senator MCCASKILL. Yes, that is really interesting. I had not

thought about that. The treatment facilities are geared toward 18

to 35, not for 65 and older.

Dr. REDDEN. Who also may have some cognitive impairments.

You have to tailor programs specifically geared toward the elderly,

as well. That is something that can be done——

Senator MCCASKILL. Are there any elderly drug treatment programs in Missouri?

Dr. REDDEN. None that I know of, specifically in St. Louis. Everyone, especially my older patients who have problems, have to go

with the younger people, the younger patients, and they also worry
22

about taking their medical medications and having those conditions

addressed and most of the programs do not have doctors onsite on

a daily basis, so they worry about that, as well.

Senator MCCASKILL. When you identify somebody who is addicted to opioids and they are, say, 72 years old, you have really

no treatment options, especially if they have chronic conditions of

other types?

Dr. REDDEN. Right, other than——

Senator MCCASKILL. Diabetics and heart disease.

Dr. REDDEN. Right. Usually detoxing is very hard also, to bring

them to the hospital and God forbid, have some insurance cover

that. If they understand that this is a chronic problem, nothing

acute going on, then they are not reimbursed, as well, so oftentimes, the medical side may to get rid of them quicker. We have

been facing that problem, as well. There is no sites, intense outpatient programs specifically for the elderly with substance

abuse. . . [inaudible].

Senator MCCASKILL. Derron, we have got to—one of the things

we need to—this is Derron Parks. Raise your hand. Derron is my

Staff Director for the Committee on Aging.

We have got to get national statistics on drug treatment programs for the elderly, because there is not one in Missouri. I bet

you there are a bunch of states where there are not any, because

if there were one in Missouri, you would know about it; right?

Dr. REDDON. Correct.

Senator MCCASKILL. You know, it is funny, reimbursing-—you

know, this is a dangerous area to go down because I want to take

this just because I like to explain this to folks.

The irony about the death panel controversy on the Affordable

Care Act, that irony was so rich because all that was was reimbursing doctors for the time they spent with patients and their

families explaining end of life decisions. We were going to pay doctors—right now, doctors are not reimbursed for the time they take

to explain nutrition, hydration, those issues that occur at the end

of life, and of course, when someone is there, usually they are not

able to weigh in, so you have family members making very difficult

decisions about continuing life support, whether it is hydration, nutrition or actually oxygen, without the benefit of having input from

their loved one, and that is why we have these incredibly high

costs near the end of life, because the loved ones do not want to

make that decision for the person who is no longer capable of making it, so it just makes sense that if you can talk to your doctor

about it when you are able to make those decisions, and then memorialize them so your family understands—I was lucky. My mother did that. She beat in our head a million times, if you put me

on a breathing machine, I will haunt you until the end of time. If

you put me on a feeding tube, I will haunt you until the end of

time, so our decision was easy for my family, but reimbursing doctors for that time they spend with the elderly making those decisions, that is all it was. That is all it was, and we had to get rid

of it because it became so controversial because the doctors were

turning it into people who were telling people it was time to die.

Of course, that is not what the doctors were doing, so it is another

way we need to look at how we address some of the costs, so that
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maybe we can have more money to, in fact, do drug treatment programs and reimburse doctors for other kinds of preventative care

that they need to be administering to those folks between the ages

of 65 and 80, 90. In my mind, 80 is the new 50, I am just saying.

Since I am rapidly approaching the Medicare age myself.

Anything else that we need to be doing at the Federal level, besides what has been suggested so far. Yes, Dr. Tatum?

Dr. TATUM. Senator, first, thank you for your comments on the

advance care planning importance.

I think of my father’s physician who as uncomfortable caring for

somebody at the end of life. There was a tremendous gap. I think

we are really doing a much better job of educating physicians about

this now. I think there is a tremendous gap from the average practitioners out in practice who has been there for 25 or 30 years who

is not getting this.

The Palliative Care Hospice and Education and Training Act is

one of the bills that has a neat aspect of it. It sets of regional training centers, so how do we actually get to that person who is out

in practice now, not just the up and comers? That is a very nice

way to address this important gap. I think it covers both pain as

well as underlying care.

The second thought that comes to mind from a Federal standpoint, as we have been talking, is the AMA, I mentioned their task

force to really address this, and I think would be a good partner.

The AMA is very concerned about burnout of physicians. A key

part of that is the electronic medical record not working well for

them, and going out to the PDMP is a problem if it is not integrated very, very well. I think something like 35 percent of physicians actually registered with a PDMP if it is not mandatory in the

State.

I think the Federal response that could be very helpful is actually push to make PDMPs integrate into electronic medical records.

Give doctors the tools they need at the points of care that are easy

to use and effective.

Senator MCCASKILL. Is that capability there now? In other

words——

Dr. REDDEN. From the Missouri perspective?

Senator MCCASKILL. Obviously, not, but in other states? In Kansas—you work in Kansas, Dr. Twillman, is that software capability

embedded, for example, in the Cerner products?

Dr. TWILLMAN. Well, we have two health information exchanges

in Kansas, one of which is the LACIE exchange, which also covers

parts of Northwest Missouri. We are actually fully integrated with

the LACIE Health Information Exchange now.

Senator MCCASKILL. What is the LACIE?

Dr. TWILLMAN. Lewis and Clark Information Exchange, so health

information exchanges basically link medical records across practices so that if you encounter a new patient, you can pull up their

records that they have accumulated in other practices as well and

see everything that is going on with the patient.

The problem right is for PDMPs, if you are in the medical

records, you have to get out of that, go into a different place to get

the PDMP report, hop back and forth. It is a challenge. The way

we have set it up in LACIE is you open up a patient’s record, you
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have got all of the information there and it is a one button click

to get the report from the Kansas PDMP, so it has been done. It

is possible to do it. It is a matter of money, is really all that is

keeping us from doing that.

Senator MCCASKILL. Okay.

Dr. TATUM. I think if we are going to have PDMPs, they need

to be useful and that is a powerful. . . [inaudible].

Senator MCCASKILL. Derron? Okay.

Anything else? He is going to cut me off.

Dr. REDDON. There are legal ramifications if someone does have

a red flag within these prescription drug monitoring programs, that

should also include education to the public. I have a lot of patients

that are worried about disclosing information that may get them

into trouble from a legal standpoint. They do not know what the

legal ramifications are going to be if they have been doctor shopping or abused the system, whether they would be prosecuted or

not.

Senator MCCASKILL. Well, I think, you know, I think most of the

medical records and most of the information that is contained within the medical system is considered private unless it is subpoenaed

and there would have to be probable cause to subpoena it that

would come from somewhere other than the medical community, so

I think patients can be reassured that what you tell your doctor is

going to put you in jail, but if you are dealing heroin on the side,

they may very well subpoena your doctor’s records.

I think there is a little—but I think it is important to look at

that, though, because you are right, we do not want to put up any

barriers to people being honest about where they are and they need

help. In the long run, we are much better off treating them than

putting them in prison, which is what the drug courts have all

been about and they have been great.

Senator MCCASKILL. Well listen, I have learned a lot today. I

think that I have got a good list of to-dos to go back to Washington

with.

I want to thank all of you for your input and for your work.

Thank you, Representative Rehder. I am going to cross my fingers

and toes that you can figure out a way to get the Senator locked

in a closet. I mean that metaphorically, not literally. Metaphorically only.

Thank you all for the work you do every day, and we will try

very hard to see if we cannot help with this problem through the

Medicare and Medicaid system in Washington to see if we cannot

deal with this tragedy that is gripping our country right now.

Thank you very much.

[Whereupon, at 10:52 a.m., the Committee was adjourned.]
APPENDIX

Prepared Witness Statements

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