Skip to main content

tv   Opioid Crisis Day Two Hearing  CSPAN  March 26, 2018 2:03pm-5:36pm EDT

2:03 pm
and commerce subcommittee on health held two days of hearings on the opioid epidemic. on day two lawmakers heard from recovering addicts as well as several health care providers who treat patients addicted to opioids. this is three and a half hours. [inaudible conversations] >> ask all of our guests to please take their seats. the subcommittee on health will come to order. i want to welcome everyone to our second day of our hearing on combating the opioid crisis through prevention and public health solutions. i want to thank our witnesses for taking time to testify before the subcommittee today. the good news for you is you don't have to listen to us. we spoke yesterday, so we will hear from you this morning. each witness will have the opportunity to give an opening statement that will be followed by questions from members. as i mentioned to some of you, the brief housekeeping detail,
2:04 pm
we will have a vote on the floor probably around 10:20 to 10:40, and the committee will recess briefly when we have to go vote on the floor. but today we are going to hear from dr. eric strain, the director for the center for substance abuse treatment and research at johns hopkins university, dr. kenneth martz, special projects consultant, gaudenzia, mr. brad bauer, senior vice president of new business adopt and customer relations -- adopt and customer relationships, director william banner of the oklahoma city for poison and drug information and the board president of the american association of poison control centers and dr. michael kill kinney, physician director department of west virginia. we appreciate all of you being here today and, dr. strain, you're recognized for five minutes to summarize your opening statement, please. >> thank you. thank you, chairman burgess,
2:05 pm
ranking member green and members of the subcommittee. thank you for inviting me to participate in today's hearing and for devoting two full days to legislative solutions to address the opioid crisis and the scourge of addiction in our communities. a topic which has been the focus of my professional career. my name is eric strain, i'm a physician who practices as a psychiatrist and conducts substance abuse research, and i'm the director for the johns hopkins center for substance abuse treatment and research. i've seen the devastating impact of drug bruise and the current federal regulations that limit the disclosure of records. and i'm pleased that this congress is taking a proactive step to update the law to be more in keeping with modern day, multidisciplinary medical practice and the best patient care. the amendment in the nature of a substitute to h.r. 3545 as offered by representative mullin
2:06 pm
will enhance our about to share information in a timely manner. though well-intentioned at its enactment more than 40 years ago, 42cfr part two is outdated and impedes the relationship between providers and their patients. full alignment of federal privacy rules with hipaa for the purposes of treatment and health care operations will insure that patients with substance use disorders receive accurate diagnoses, integrated, coordinated treatment and patient-centered care. under 42cfr part two, records must remain separate and segmented from any other medical record or and cannot be shared with a patient's primary care provider or other specialist without the express written consent of the patient. obtaining this consent can be a challenge under a variety of scenario e, and the current segmentation of records runs counter to the idea of holistic
2:07 pm
and coordinated treatment of the patient. not knowing a patient is in substance abuse treatment increases risks. for example, with medication interactions or in delivering care under an emergency situation. it also can interfere with effective integrated care. let me give you an example. the johns hopkins center for addiction and pregnancy is a substance abuse treatment program that helps pregnant women and their babies and includes substance abuse staff as well as ob/gyn, pediatrics and psychiatry. this multidisciplinary program needs ready communication between providers. full information is essential to support clinicians' effort toss care for the pregnant woman preterm and then both patients, the mother and her child, postpartum. this example clearly demonstrates the very teams of caregivers such as neonaytologists, obstetricians, case managers, etc., who need timely access to substance abuse
2:08 pm
treatment information. our health care system does not put records for other medical seasons such as hiv and aids in a separate and protected system. we don't put a patient's social history behind a wall and tell other providers they can't have ready access to information about what may be sensitive topics. the various work-arounds that are offered introduce more impediments in an already busy health care system and further contributes to the idea that substance abuse is different from all other medical care. in my opinion, continuing to consider substance abuse disorder information distinct from other medical information actually perpetuates stigma. concerns about inappropriate release of information are addressed in the mullin amendment which includes vital anti-discriminatory language as well as protections against criminal prosecution. finally, i've reviewed jesse's law as well, and i support any effort to promote dialogue that encourages coordination of care and the sharing of necessary
2:09 pm
information so long as it is paired with the mullin amendment. jesse's law relies on patient-volunteered information, and and it's my experience that -- through no fault of the patient -- it's excitement inaccurate or incomplete or places a large burden on the patient. therefore, as i've already expressed, a system that relies on consents or patient-volunteered information is fundamentally flawed. health care providers are on the front lines of treating opiate and other substance use disorders. we're uniquely positioned to help, but we cannot do so without an unobstructed view of a patients' medical records. -- patient's medical records. you have an opportunity to move be us forward and help those on the front lines of treating people who suffer from drug abuse. i urge the committee to support legislation amending 42cfr part two that allows the sharing of records for the purposes of treatment and health care operations. thank you, and i'd be pleased to
2:10 pm
answer any questions you may have. >> thank you, dr. strain. dr. martz, you're recognized for five minutes, please. >> good morning. thank you so much, chairman burgess and ranking member green, for this opportunity to come here and testify on this important issue. you know, this is an issue that's affecting 23 million americans who are in recovery from substance abuse disorder who have had their experience with treatment and are now working new the system in addition to those who are actively in substance use disorder. i'm dr. kenneth martz, i'm a licensed psychologist, i'm working with gaudenzia, in state and public settings as well as private for 25 years. this has been my life's work and my passion, and i love this work, and i really appreciate this opportunity. 42cfr protections are critical to maintain, to insure that people enter treatment for substance use disorder. this is something we know from
2:11 pm
samsa which has studied this extensively, and i find the top reasons why people do not go to treatment continue to be fear of stigma, what will my employer think, my neighbors think, what harms will come of me if i disclose those secret harms and guilts and shames. the research finds that this fear of impacts is a primary reason. you know, the congress recommended this as well back in 1972, they statemented that the conferees wish to stress the conviction that the strictest adherence to the provisions of the section is absolutely essential to the success of all drug abuse prevention programs. this was echoed by the supreme court as well which affirmed, like if spousal attorney/client privilege, it's rooted in the imperative need for confidence and trust. treatment by a physician for physical ailments can often be perceived successfully on the basis of physical examination and the results of diagnostic tests. effective psychotherapy, by contrast, depends on the
2:12 pm
atmosphere of confidence and trust with the patient who is willing to make frank and complete disclosure of facts, emotions, memories and fears. for this reason, the may possibility of disclosure may impede the relationship necessary for successful treatment. i urge you to remember the wisdom of these chambers. oddly, it's funny, we walk in here today, and the news of the day is about hacking and data breaches and cambridge analytica with a new focus on there being death penalty for those who have substance abuse history and have sold a drug. so if my child hands over some drugs to his girlfriend, she dies, he is now potentially at risk. we don't know what the laws will change in the future. this is, has a chilling effect on people being willing to attend treatment. you know, the impact on patients, you know, i know you're hearing from many health care organizations that find this very inconvenient, but this is not about inconvenience. this is about patient care.
2:13 pm
this is about patient health and being able to access exactly what they need. if we want to discuss coordinated care, the best way to do that is direct conversation with the patient and direct conversation therapist to therapist which is not impeded by 42cfr protections, it actually gives the patient the respect of being involved in that process. if you're going to share my information about my trauma and my trauma histories, please, do me the respect of asking me and letting me know where it's going to go to before it gets shared to thousands of other people potentially having access. now, put simply, some of the importance of protections include once they are labeled -- it can affect clinical decision making for a lifetime. it cannot be amended. these are professionals we're talking about like teachers, physicians, government workers who may avoid treatment for fear of harm, for fear of being disclosed and, there are, they make it -- therefore, they make it worse because they didn't get the care they needed because they delayed. you know, the stigma is still
2:14 pm
alive long and strong. looking at recent comments, one was said overdose is nature's way of taking out the trash. oh, my gosh. overdose is nature's way of taking out the trash. i have plenty of compassion for those who deserve it, i have no compassion for those who have made their own problems such as dopers, pedophiles and murderers. it's hard to even say these words. these are the level of stigma that our clients are facing on a daily basis, and it's very difficult to identity and manage these harms that may arise. in eliminating these part two protections, it will brand these individuals with a scarlet letter. they walk in the door, they can be identified immediately as having this problem, this history, as well as the risks associated. stigma affects all of us in many different ways. remember every time we make these changes, i need to learn about them, i need to train the field and, worse, tell the clients every day what they told me yesterday in private is no longer private today.
2:15 pm
you know, in all my years i can't tell you how important this is. and if there was only one other thing that you could possibly do in addition to this, i'd be happy to answer other things, please, get rid of that imd exclusion. it's harming people and stopping care. thank you. >> thank you, dr. martz. mr. bauer, you're recognized for five minutes, please. >> thank you and good morning. chairman burgess, ranking member green and members of the health subcommittee, thank you for the opportunity to testify today on the role of prescription drug monitoring programs, or pdmps, in the opioid crisis. my name is brad bauer, and i am senior vice president with apras health. we provide a common platform and software solution for 42 of the 52 established pdmps throughout the united states and u.s. territories. state-based pdmps continue to evolve and innovate in the face
2:16 pm
of our nation's opioid crisis. while each state faces unique challenges, tremendous progress has been made within a few critical areas, each of which have been identified by government and research organizations as best practices to insure effective and impactful pdmps. first, the ability for states to share data with other states provides subscribers and pharmacists with a more complete view of a patient's controlled substance history. in 2011 the national association of boards of pharmacy created a pmp interconnect with technical assistance to allow states the securely and efficiently share data in realtime at no cost to the states. as you can see on the monitors, the number of states participating has grown rapidly to 45 pmps today. for the remaining states not currently participating, policy issues -- not technology -- are the only barriers. most recently florida passed legislation allowing the state
2:17 pm
to share their pmp with other states effective july 1, 2018. second and probably the most impactful developments for state pdmps, has been deseparation of data and analytics within the electronic pharmacy system to enable one click or in some cases no-click access for prescribers and pharmacists. the majority of states are moving in that direction with about 20% of providers currently having access to integrated pdmp reports. however, broader adoption has been slow due to the need for funding to cover costs of integrations. integration of pdmp data and analytics promotes efficient and consistent use by providers when making clinical decisions. for example, ohio has seen a 1,000% increase in usage of the pdmp as a result of their statewide efforts. states are also in the process
2:18 pm
of transforming their basic pdmp systems into substance abuse disorder platforms that deploy the capabilities necessary to impact the epidemic and bend the overdose death curve down, not just drive down the number of controlled substances prescribed. states like indiana, oregon, michigan, delaware, iowa, ohio and virginia are just a few examples of states that have already taken steps to transform their pdmps. examples of new developments in capabilities include inclusion of additional data sources such as history of non-fatal overdoses, drug court information and toxicology data, patient risk scores to help a practitioner quickly assess the risk and engage the patient accordingly, the ability to refer patients to treatment -- often referred to as a warm handoff within the pdmp -- and facilitation of care team communications. all of these capabilities and clinical tools are designed to help the practitioners identify prescription drug overdose
2:19 pm
sooner versus later, mitigate the chance of an illicit drug encounter and engage with their patients and assure they have and receive the help they need. the pdmp discussion graft from ranking member pallone would incentivize states to continue their pdmps through evidence-based prevention grants along with evaluating interventions to prevent overdoses and implementing new projects to respond to the evolving crisis in innovative ways. as you've heard from one of panels yesterday, the centers for disease control is engaged in a number of these activities, but the legislation authorized would help to improve the work. second, the draft would establish grants for enhanced surveillance of controlled substance overdoses which would authorize or and provide funding for an existing cdc program to collect more comprehensive, timely and quality data on overdoses. we would recommend this day be incorporated into the pdmps. this discussion draft would allow states to continue their pdmp innovations to provide
2:20 pm
prescribers and pharmacists with near instantaneous access to interstate pdmp information combined with the clinical tools to intervene in a meaningful way when a patient presents with a possible risk of overdose misuse. thank you for your leadership on this critical issue facing so many communities and for the opportunity to address the committee today. i look forward to your questions. >> thank you. thank you, mr. bauer. dr. bean, you are recognized for five minutes, please. >> chairman burgess, ranking member green and members of the subcommittee, thank you for the opportunity to testify in support of the reauthorization of the national poison center program entitled point center network enhancement act of 2018. this legislation was first enenacted into law in 2000 and has been reauthorized three times. the measure before the subcommittee today would reauthorize the poison center program through fiscal year 2024. my name is dr. bill banner, and i currently serve as the
2:21 pm
president of the american association of poison control centers. i'm also the medical director of the oklahoma center for poison and drug information. for over 30 years, i've been privileged to care for critically ill children and currently practice in the pediatric intensive care unit at baptist integris medical center in oklahoma city. i also happen to be down homing to a -- downsizing to a home in congressman mullin's district. we cover all u.s. states and territories and receive three million calls annually including about 70,000 calls a year for exposures to opioids. nearly one-quarter of our calls come from emergency rooms and urgent care facilities. calls are answered by highly trained medical professionals with 24-hour oversight from physicians who are board certified medical and clinical toxicologists, many of whom are trained in addiction medicine.
2:22 pm
we handle calls related to over 430,000 products and substances and their related toxicities. poison control centers are on the front lines of the opioid epidemic handling approximately a half million cases of opioid misuse and abuse since 2011. that's an average of 192 per day every day. we assist first responders and hospital personnel. as you can see from the slide, the percent of opioid exposure calls from health care facilities to poison centers are op on the rise, and we believe this will continue in 2018. we deliver countless hours of education on topics like identifying emerging drugs of abuse and the safe storage and disposal of prescription opioids. through national surveillance activities, poison centers have identified trends and evolving fentanyl and other opioid penetration into communities which is then shared with federal, state and local law enforcement. centers also educate on the
2:23 pm
proper use of naloxone. with the rise of heroin mixed with the more potent fentanyl, the administration of naloxone has become far more complex and dangerous for emergency responders to administerment centers also -- administer. centers also contribute to medical education on pain management, prescribing and addiction treatment. consultation with a poison control center can also significantly decrease the patient's length of stay in a hospital and decrease hospital costs. in fact, poison control centers save more than $1.8 billion annually including $382 million in medicaid and $307 million in medicare per year. poison center data can often be utilized to identify new and emerging drugs of abuse faster than virtually any other resource. for example, this past center the georgia poison control center -- which serves subcommittee carter's district -- was the first public health entity to detect and
2:24 pm
respond to a novel be opioid outbreak. yellow pills stamped with percocet that, in fact, contained a mixture of fentanyl an -- an a -- analogs, this unique capability exists at every poison center in the country. centers are also a critical resource for emergency preparedness and response. for example, centers have served in response to zika, ebola, synthetic cannabinoids, e-cigarettes, h1n1, marijuana misuse, toxic exposures following natural disasters and even the social phenomenon the so-called tide pod challenge. additionally, each center has an educator working to increase public awareness on the dangers of poisoning and opioid misuse. in fact, this week is national poison prevention week. examples of education outreach surrounding the opioid crisis include presentations to parent
2:25 pm
groups regarding medicine literacy and substance misuse prevention as well as participation in local community events. in summary, poison control centers are a unique combination of clinical care, cost effectiveness, public health surveillance and interaction with those on the front lines of the opioid crisis from first responders to law enforcement and everyone in between. i want to thank representatives brooks, engel, and degette for their can'ts support of this -- critical support of this legislation. it is most deserving of full congressional support and reauthorization. i am happy to answer any questions you may have. thank you again for this opportunity. >> thank you, dr. banner. the vote on the floor has been called by, dr. kilkinny, let us hear from you, and then we will recess until after votes. so you're recognized for five
2:26 pm
minutes. >> chairman burgess, ranking member green and members of the subcommittee, thank you for inviting me today to testify on behalf of local health departments across the country that are facing unprecedented threats in the form of opioid-related death and disease. my name is michael kill kinney be, i'm the physician-director of the cabal huntington health department. i'm representing health departments today as a member of the national association of county and city health officials. more than 100 americans die each day from overdose with a staggering economic toll impacting the work force of this generation and threatening generations to come. my state has nation-leading rates of overdose death, hepatitis b, hepatitis c and neonatal abstinence syndrome. my county, along with 28 other counties in my state and 220
2:27 pm
counties across the nation, face the real threat of catastrophic hiv outbreaks. these challenges, however, create remarkable opportunities for us to save lives and prevent disease. in 2015 huntington leaders implemented a comprehensive opioid response plan that's changing those statistics at home. with help from cdc, we started the first sanctioned harm reduction program in west virginia, we trained and supplied all our law enforcement agencies with naloxone, and cabell county community members and first responders reversed more than 2500 overdoses last year, saving countless lives. and a new quick response team is linking overdose survivors to treatment. without federal support, we would not have been so
2:28 pm
successful. regarding infectious disease, the opportunity to prevent is now. in my county we've been able to decrease rates of new hepatitis c cases by 60% using harm reduction strategies and training from cdc. and cdc assistance in surveillance has allowed us to identify and implement specific strategic measures to prevent an hiv outbreak. the eliminating opioid-related infectious diseases act of 2018, authored by representativeland nance of this -- leonard nance of this committee, would provide an additional $40 million to cdc, money needed for help kites c and hiv -- hepatitis c and hiv facilities. especially infections associated with injection truck use. on behalf of my group, i'd like
2:29 pm
to suggest it be expanded to include surveillance of hepatitis b. opioid overdose requires special surveillance and rapid intervention to address emerging drug threats. fentanyl, a particularly deadly opioid due to its potency, struck my city and other parts of our nation especially hard in 2016. it remains the drug most frequently found in overdose autopsies from my county. any street drug product might contain fentanyl and neither users, police officers nor public health officers know if it's there or not to. a bill to improve fentanyl testing and surveillance authored by representative ann custer addresses this threat with assistance to public health laboratories and detecting fentanyl and its many analogs. we recommend that in addition to
2:30 pm
agencies named in this bill, cdc should be included in these efforts. i also support the pilot program authorized in this bill which would allow point of use testing that could save lives and modify drug use behavior. local health departments like mine are working 24/7 to save lives and reduce the risk of opioid overdose and the risk of life threatening infections. in closing, i hope that congress will make an increased investment in funding for cdc and other public health agencies engaged in this fight. we've seized our opportunity in huntington, and we're succeeding. nato represents nearly 3,000 other local health departments big and small ready to fight this opioid epidemic, and we need your ongoing help. thank you. >> thank you, dr. kilkinny. again, chair observes we do have a vote on the floor, so we are going to take a recess so
2:31 pm
members can go and be recorded on a procedural vote on the floor of the house, and we will reconvene immediately after votes where we will start the member questions. so thank you all for your testimony. we stand in recess. [inaudible conversations] >> call the subcommittee back to order. i began want to thank our witnesses for their -- i began want to thank our witnesses for their testimony. i do want to recognize the gentleman from texas first for a unanimous consent request. >> thank you, mr. chairman. representative ann cus kerr, who actually sat through some of our hearing yesterday, in sport of her draft under consideration to approve testing as well as bills featured as part of bipartisan heroin task force legislative agenda for 2015. i ask unanimous consent the statement go into the record. >> without objection, so ordered. the chair will recognize himself for five minutes for questions.
2:32 pm
dr. banner, on the -- in your testimony you referenced the difficulty of treating fentanyl with naloxone. could you elaborate on that just a little bit? >> [inaudible] fox cologic problem as you where, i'm sure, recognize fentanyl's phonety means that that -- potency means that naloxone may at times be required to give in increased doses to reverse it because it's binding to the new receptors. i know i'm not talking to most of the people in the room -- >> just talk to me, it's okay. [laughter] that's why i'm sitting in this chair. [laughter] >> the, with that affinity, it takes a lot of naloxone sometimes to reverse them. plus, if they have -- if they're chronically using fentanyl and their body burden increases, then the apparent duration of action of fentanyl can exceed
2:33 pm
the duration of naloxone, and you may have to give a repetitive dose. and the third issue is that there are good, pretty good case reports where reversing fentanyl produces such a surge in adrenaline that you actually can get non-cardiogenerallic pulmonary adee ma or -- edema or a flooding of the lungs with fluid. and that, of course, can convert a life threatening situation into a life threatening situation. so we feel like that has upped the ante quite a bit. heroin reverses pretty easily, and it has the duration of action of heroin itself is 7-8 minutes. so it's a rapid high. if you get in trouble, you reverse it, and the naloxone usually coffers it. but drugs like methadone, when they're involved, or some of these fentanyl derivatives can really prolong the toxicity and, therefore, the need for repetitive doses. and it makes it more complex -- >> all right, thank you. the way you were in your testimony that the
2:34 pm
administration of naloxone is far more complex and dangerous for emergency responders to administer, i misinterpreted. i thought for some reason it would be dangerous to the er doc, but you're saying it's dangerous to the patient during the administration episodes. very good. thank you for clearing that up. and, dr. kilkinny, let me just ask you, we had -- we started this week in another subcommittee, the oversight investigation subcommittee, with the acting administrator of the drug enforcement administration and focusing more on sort of the enforcement side of this equation. and your state, obviously, came up for some discussion because of the delivery of pharmaceutical product to locations that seemed far in excess of the population that would be making itself available to that retail establishment. be i'm trying to say that as carefully as i can. but then in your testimony you talked about in 2016 fentanyl
2:35 pm
sort of butched up. bumped up. were you aware in your communities that this problem of the excess delivery was occurring? was that something that was novel when it was discovered? just kind of let us know what you saw on the ground as those years were unfolding. >> because i live there and i've seen the pill mills operating and i knew when i was practicing how that worked, i was not surprised to know that there was an overabundance of supply to very small towns that were servicing certainly the vehicles parked in those parking lots had license plates from all over the
2:36 pm
country. so i was aware of that practice. but i wasn't aware of the staggering numbers until they came in later. that distribution, i think, temporally occurred before the big switch to injection drug use that we saw using heroin, and there was always fentanyl around. but in 2016 something appeared to us to happen in the supply chain. and we saw -- >> well, let me just interrupt you. fentanyl's not coming through the supply chain, right? >> we're talking about an illicit supply chain. >> okay. >> the illicit supply chain of fentanyl seemed to change really remarkably in the second half of 2016. and the entry of the fentanyl
2:37 pm
analogs really picked up then. that's when we started seeing a massive increase in overdoses and overdose death. >> that seems to have been catalyzed by the initial excess distribution phenomenon that was happening in your neighborhoods. >> i certainly do not argue with that component, that this started with prescription drugs. >> i guess our frustration when we talked to the dea on monday was it seems like there was a blinking red light on the dashboard. why didn't anybody check the engine, you know what i mean? i always lived in fear of the, the ea when i was many practice. i thought they knew everything about me, every prescription that i wrote, every patient i treated. then it turns out on monday he hear they really weren't paying that much attention. it was startling information to me. >> apparently not, but i don't think that we as physicians were
2:38 pm
as red flagged as we should have been while we were prescribing under the pain as a fifth vital sign rule. >> sir. let me recognize mr. green of texas five minutes for questions. i have some additional questions that i may try to get to at the end but, mr. green, you're recognized for five minutes. >> thank you, mr. chairman. i want to welcome our panel here today. i want to thank all our witnesses joining us. we agree that the opioid epidemic is a multi-sided problem and will require a multi-part solution. as part of the solution, it's essential that we expand access to treatment. we must also identify strategies that occur in individuals with substance use disorders to seek and remain in treatment. i'm concerned that the proposal to roll back protections under code federal regulations titled 42 part two commonly known as part two would do the opposite.
2:39 pm
dr. martz, in your testimony you state that patient with substance use disorders are afraid their treatment records will be used against them, they will not enter treatment. could you explain the important role confidentiality plays for individuals with substance use disorders in entering treatment and working towards recovery? >> [inaudible] >> you want to turn on your mic? >> thank you. the, it is -- it plays a critical role. if you are working to decide whether or not i'm going to enter treatment, whether or not i'm going to deal with the issues that are most relevant in treatment, that's a critical protection to have. we know that folks will not come to treatment be they are afraid of what the impacts will be. so, for example, i worked with parole and probation for quite some time, and there would be some question of, you know, someone goes and they're having a holiday party, and they go and they show up, and there's drinking there. not a surprise. but then they start to have cravings. so the work of treatment has to do with having a safe space to
2:40 pm
be able to discuss these issues clearly and directly without having to say, oh, no, i didn't have any problems. nothing was going on here so that for near i would disclose it to somebody else. it's a role more like a priest/ penitent relationship. >> one of the protections provided creating the safe environment for treatment for individuals which substance use disorder that you described in your testimony. >> it's critical for the safety. one of the key respect elements -- key elements is that there's a therapeutic alliance. and sometimes it takes weeks or month toss build a relationship. i've had clients that were with me for six months before they suddenly say, all right, now i'm going to tell you the truth about what's really behind this. it takes time to build a relationship, to have that safety, and anything that's going to damage that safety such as fear that this will be disclosed, it will impact that and prevent it from entering or staying in treatment or working on the critical elements within
2:41 pm
it. >> according to a letter submitted to the committee from the campaign to protect patient privacy rights, rolling back the part two protections to the hipaa standard will contribute to the existing level of scrip nation and harm to people -- discrimination and harm to people with substance use disorder and will only result in more people who need treatment being discouraged and afraid to seek the health care they need during the nation's worst opioid crisis. dr. martz, would you discuss how rolling back part two protections to hipaa standard harms efforts to create a safe treatment environment and potentially leads individuals with substance abuse disorders not to enter or remain in treatment? >> thank you. many of our folks have dealt with trauma, for example. and so one of the things that's really a critical difference between hipaa and 42cfr is that with 42cfr chen i disclosed to my clinician, i know that's private unless i disclose -- i sign and get information that it
2:42 pm
will be shared with somebody else. when i share with my clinician about the sexual trauma and assault that i faced previously, that's a private conversation, and before that gets shared with multiple other people without my knowledge -- which is what the standard would be under hipaa -- that's a problem. so when information comes back to me from some other clinician that gets the information from the clinical record rather than having that conversation with me directly when i'm not willing to share it, severe damage to the trust that's needed for a relationship for treatment. >> thank you. i support strongly the efforts to expand access to treatment and encourage individuals to remain and seek treatment. i'm concerned that proposed changes to 42cfr part two miss the mark, and in my last few seconds, in my earlier life i did probate work. and in houston, texas, the probate judges are also the mental health judges. and i was honored, i think, when the judge decided he wanted to appoint me to be on the mental health docket for about three
2:43 pm
weeks. and this is before hipaa. it was in the '80s. and we still had that protection though. i don't know if it was under state law or federal law at that time, that even the lawyers had to destroy all our information. and believe me, it would have been really difficult to get people in treatment if they knew that would be available to potential employers and that. now, if there's a danger, we all have a responsibility of that whether you're a medical professional or what. but just that average letting people know someone's under care, it really bothers me. thank you, mr. chair, with i know i'm out of time. >> mr. guthrie, five minutes. >> thank you, mr. chairman. appreciate the opportunity to be here and all the witnesses being here. i'm going to focus my questions or direct them to mr. bauer. we've had several kentucky
2:44 pm
witnesses over the last, yesterday and today and been fantastic witnesses. says we have a big issue in our state, like surrounding states, and it is spreading. so that's why what we're doing here is so important to make sure that we move forward. but i'm going to focus on the prescription drug monitoring program. so when providers check their pdmps, to mr. bauer, what is the evidence that this actually changes their prescribing or dispensing behavior resulting in improved patient outcomes and lives saved? >> i thank you, vice chairman, for the question. today with the pdmp programs, the one most impactful issue with the programs is integration of that information into work flow, and we're finding that that really helps to enable efficient access to the pdmp so they're checking. there are 40 states that have mandated use laws in place today which mandate the checking of the pdmp in one way, shape or
2:45 pm
form. so we've seen the use of the pdmps have an impact on the overall volume of opioids prescribed. we think that's in conjunction with policy at a state level as well. from an outcomes perspective, there are current studies that are underway, one of which is a study underway to understand the actual outcome of checking the pdp or on opioid depths, the death curve. so that study is not completed yet. we're about three or four months into that study. >> okay, thank you. and also you mentioned some states are turning the pdmp into a substance use disorder platform. can you elaborate on what that means and how it would help someone who might be at risk of addiction or substance misuse? >> sure. when pdmps were first formed many years ago, they were more of a during their tool that was used to understand drug diversion.
2:46 pm
the programs have since morphed into more of a public safety tool. so today information in the form of data, prescription data is sent to the prescriber or pharmacist for review. states are now moving past that, what they call the phonebook of data, trying to understand within that information what is the issue with this patient or what is the risk that this patient represents from an overdose perspective. and we're moving that into more of a substance use disorder platform to describe more clinical information so they can engage with that patient while that patient is right there in front of them versus trying to read through a phonebook of data in the 20-30 seconds they have. adding additional sets such as nonfatal overdose, providing referral treatment while they're in their pdmp, etc., are all clinical tools that are designed to truly engage that patient before they go through an illicit drug event. >> okay, thank you. and i have a final question for
2:47 pm
you. pdmps are critical for providing went fisheries, but also -- beneficiaries, but also avoiding potentially dangerous drug interactions. pdmps are not allowed of the data, are prevented of the data on patients reffing meth -- receiving methadone. on the other hand, why are methadone and wound nor for instance treated unequally, and we do anything to include this information but still protect patient privacy? >> thank you for that question. what we find today from the pdmps as far as collecting that data such as methadone or because of nor teen prescriptions, because of nor teen, for example, is a prescription that is actually prescribed and typically picked up at a retail pharmacy, therefore reported to the pdmp. methadone, on the other hand, is typically administered within a
2:48 pm
substance use disorder -- clinic. and, therefore, by law, not reported to the pdmp. so that is, that's the difference as far as -- >> well, could somebody get methadone in a methadone clinic and also have a prescription for wound nor for instance, or are they -- >> the short answer is it is possible. >> i guess just to the question, because i'm about out of time, can we address that? i know the idea for the methadone is patient privacy. can we address that? >> yeah. obviously, we want to take privacy into consideration from a pdmp perspective. obtaining that methadone administration, administered methadone is critical to understanding the overall risk of that patient. >> okay. thank you. five seconds, i yield 'em back. >> chair thanks the gentleman. chair recognizes ms. matsui for five minutes for your questions, please. >> thank you, mr. chairman. i want to thank the witnesses for being hered to. dr. martz, thank you for your
2:49 pm
compelling testimony. i've been a champion of building greater education about hipaa privacy regulations particularly as applies to tricky mental health situations because i recognize the necessary balance between patient privacy and access to information for purposes of quality treatment. i appreciated your nuanced understanding of the importance of confidentiality for patients suffering from a substance use disorder and the different ways a stigma plays into the situation. i'm also sympathetic to the caregivers and doctors who are trying to better serve patients and to stories that patients who are harmed because the provider didn't have the right information to make the right clinical decision. i'm hopeful that working together we can find the appropriate path forward on this issue. from your perspective, how well do you think patients know their rights under hipaa, and specifically, under 42cfr part two and the recent samsa update?
2:50 pm
>> thank you for the question. patients are pretty widely available, and it's usually one of the first questions we'll be asked, who's going to get this information. even if they don't ask that up front, it's our responsibility as clinicians to immediately give them that information about what you're going to be sharing, what are the limits of confidentiality and what are the conditions under which it would be released or exclusion colluded. excluded. one of the challenges with the multiple changes we've had in the past year is every time samsa comes out as a change, we have to identify the regulation, update our forms, we have to retrain the field and re-have that conversation with the client which is very damage dog the relationship. >> right. so -- [inaudible] amongst the doctors and caregivers need to be updated. >> absolutely. i -- across the field, physicians and other allied
2:51 pm
professionals that are interacting so we can better coordinate the care. very often the problems that are found from confidentiality are are really training issues rather than -- >> sure. >> -- actual burdens. >> do you think there's certain situations or circumstances under which sharing a patient's substance use record would be beneficial to their coordinated care? so, for example, in the case of accountable bl care organizations that are specifically targeting comprehensive services for those with multiple conditions such as substance use disorder co-occurring with something like diabetes or depression? >> yes. it's very common to coordinate care, and it's actually an expectation of myself and all the clinicians that i've worked with that we are to coordinate substance use, mental health, medical conditions. the difference is that there is a protected element for them to discuss the private areas, and it's a clinical issue to engage them to have that trust, to open the relationship and dialogue
2:52 pm
with other clinicians and maintain that constant communication. >> okay, thank you. dr. strain, thank you for your testimony. as i mentioned previously, i'm committed to advancing coordinated patient care without sacrificing patient privacy. especially around a sensitive and stigmatized disease. recently samsa released regulations that broadened rules about redisclosure and 42cfr part two. do you think that's been helpful to providers? alternatively, did it go far enough? >> so i -- thank you for that question, representative. i think that we haven't gone far enough. i think that we need to provide a mechanism whereby information can be more seamlessly shared between providers who are not in a substance abuse treatment program and those who are in a substance abuse treatment program. i think that at the end of the day i'm interested in seeing us do better in terms of
2:53 pm
coordinating care across those two finishing work to ci -- foci, and the current barriers make that difficult. >> yeah. so in your testimony, you've provided compelling examples particularly if a patient is incapacitated. things like asking patients about history of substance use, what type of training do. doctors currently receive about best practices? >> so training by physicians is variable by medical school. there's not a national standard for training. federal standard. but there's increasing amounts of train anything medical schools for physicians in terms of substance abuse and education. >> sure. >> and it's a critical part, it's become a critical part especially in the current climate. >> i can see that we need more probably continual education about this. generally if a patient is incapacitated or unconscious, your testimony prime is there's -- implies there's no way for a there to know if a patient has a history of a
2:54 pm
substance abuse disorder. is that absolutely true? for example, can a doctor make inquiries of next of kin? >> i'm sorry? >> a doctor make inquiries of next of kin? >> certainly they can attempt to determine that if they're -- >> we're pushing up against votes. >> okay, thank you. >> thank you, the gentle lady yields back. now recognize mr. griffith for five minutes. >> thank you very much, mr. chairman, over here. and i'm going to continue. dr. strain, doctor, you were just talking about what the doctor can find out by asking the next of kin. and one of the issues that we dealt with -- not opioid directly related, but dealing with violent tendencies and violence that we were trying to deal with in cures and some other things was trying to figure out how we keep privacy for individuals but at the same time have some family involvement where the family is actually involved in a perp's life. because if they have a
2:55 pm
significant mental illness -- and maybe also a drug addiction on top of that -- it's sometimes very difficult for the family to get information because of the hipaa laws. so dr. martz raises good points. but how do we reach that balance where, particularly if you're living in the home with parents or a sibling, that they can have enough information to know whether, a, they're in danger or, b, how they can be of most assistance to their loved family member. any ideas for us? >> i think that -- thanks. it's a critical question, representative griffith. it really comes down to, i think, the provider-patient relationship and that judgment that occurs in that relationship in terms of where do i -- i treat patients, and where do i go in terms of when i've got information that i believe has reached a critical point where i need to bring in a family member and inform them that? and there can be instances where i may do that even if the patient is saying i don't want
2:56 pm
you to do that. so for, obviously, for example, if there's issues of abuse of a child or a parent or things like that, i may be compelled to do so. or if somebody is reporting that they're suicidal or homicidal. but at the end of the day, it does distill down to i think that relationship and the provider having determination of where do they need to go with the information that they're receiving. i think that trying to create a systematic answer to that may be challenging. >> well, we've found it to be a challenge, but we're still working on it because, obviously, with the number of violent situations we've had in our country, these tragedies that have occurred, we're trying to figure out what's both right for the patient and right for society as a whole. switching gears and continuing to talk about the opioid tragedies that are afflicting us, dr. kilkinny, you work in huntington and cabell county.
2:57 pm
do you find that -- because we had, in oni, we had a hearing earlier this week on pill dumping and particularly a couple of towns in west virginia. do you find that those drugs coming into the small towns outside of your community about 56 miles away was one of them, kermit -- and the reason i know that is because it's only about 53 miles from my district in western virginia. do you find that has a spillover with the patients that you're seeing, some of those folks are coming from these rural areas where all these drugs were dumped? >> yeah. i think the evidence in west virginia indicates that the current injection drug use, the ill illicit trade was spawned by an overprescribing and then a more responsible set of prescribing. >> so it would be reasonable to conclude that your testimony would also affect my district which is about an equidistance,
2:58 pm
although it takes longer to get through the mountains to get to my district from kermit or from the other towns, that the problems would be very similar. it'd be reasonable to make that conclusion, would it not? >> i think that those are -- i think that virginia, west virginia, kentucky, tennessee, any of the appalachian districts in those states are going to be affected the same as we are. >> yeah. that's pretty much my district. mr. bauer, thank you for for beg here as well, and thank you for saying some nice things about our draft legislation on pdmps. i was really sleazed to see the graph -- pleased to see the graph that showed just a few years ago there were a few states, one of which was my state in 2011, but now we have more than 40 states are now there. at one point martinsville had the highest per capita use -- and there's a formula that you would know, morphine -- >> yes. give lens --
2:59 pm
>> equivalence of any place in the country. and north carolina was not a part of it so, hopefully, that will be of some help. can you explain what we need to do to get all the states on the same page so that we're able to compare apples to apples? i understand in some of the pdmps that there's a difference in the data. could you give us a few seconds on that? >> yes, i can. thank you for that question. today, as you know, there are 45 states that do share data securely and efficiently are with each other. it's up to the state's purview as to what state they wish to share data with. typically, it's surrounding states and in another concentric circle. the states that are not sharing data today, it is truly a policy issue. the example was i mentioned florida. florida just recently passed legislation that will enable them to share effective july 1st of 2018. california is the same way. so these are certainly policy issues that are involved in not being able to share data right now. >> and i'm out of time so i've
3:00 pm
got to yield back, but ill love to know if we can get everybody on the same page. thank you. >> thanks, gentleman. the chair recognizes the gentleman from new jersey, mr. pallone, five minutes for your questions, please. >> thank you, mr. chairman. i have some questions of dr. martz. i'd like to thank all the witnesses for joining us today. i stated in my opening statement yesterday that i was concerned that h.r. 3545, the overdose prevention and patient safety act, could dangerously erect a barrier to patients seeking and remaining in treatment and, therefore, harm our effort toss respond to the opioid cry -- efforts to respond to the opioid crisis. .. even incarceration.
3:01 pm
dr. martz, i was hoping you could help us better understand these consequences. i understand you work in a number of cases with a diverse mix of patients. based on that experience can you provide context on the issues facing individuals with substance abuse disorder that made part two confidentiality protection important? >> thank you. in response to your question, we may have to respond with a brief note from the last listening session of samsara, notes that were submitted to, regarding 42 cfr from the folks affected here. i have a criminal record in attending recovery, i don't want my history to become a burden. i realize individuals have discussedmedical care will be compromised . but available to one's you must see them. i don't want to list risk
3:02 pm
losing my family or housing due to someonefinding out i've been treated with addiction. i don't want to jeopardize my future because i'm doing the right thing . i'm writing to ask that these records be maintained. i do not wish for this to be a lifelong burden. my privacy records are important. i'm applying for a job and i fear i will never have a chance to better myself otherwise. thank you for considering we are but little valued by society but even to become trash men would be the best for us as free men. there are scads of these letters from these individuals. i also worked in the past with the pardons project in pennsylvania where we worked with folks seeking clemency and there were folks seeking clemency because they couldn't get jobs, they couldn't become nurses, they couldn't become promoted. they had various challenges they couldn't work with so even many years later it was a lifelong stigma attached.
3:03 pm
>> a recent study published in the journal of addiction medicine found a significant portion of the study population ofphysicians at johns hopkins had low regard for patients with substance abuse . 50.4 percent of responders indicated they agreed that they would not work with patients with substance abuse will have pain 54 percent agreed that patients like that irritate me. do individuals with substance abuse disorder sometimes fake stigma and discrimination from medical providers? >> there's an old term in the profession, was called a gomer, get out of my er. there is a disdain and even in recent weeks and months, there were a couple quotes out there from recent providers, some of which i mentioned before. for example, the best way to be addiction. opioids are eliminating the bad folks in our community.
3:04 pm
they stop providing them, there would be less usage. there's a level of stigma and vitriol out there and it's widespread in which is what we aretrying to protect our folks from because some of the discrimination would be over but someone be covert . you're fired, we're not going to use you rather than saying it's because you have a history of this. >> my last question deals with the dramatic increase in the presence of substance abuse treatment records and electronic health records and health information exchanges. these records would be vulnerable to cyber attacks and breaches. one of my republican colleagues noted in reference to our community inquiry into cyber security that as technology becomes integrated with all levels of healthcare, it poses a challenge to the entire sector. you want to just explain the impact of such risk?
3:05 pm
there was a recent survey that found half of people, organizations exposed patients at some point in improper disclosures on patients with substance abuse. i know weare almost out of time . >> absolutely. cyber security has been a growing threat we know in 2015 eight anthem blue cross blue shield association had a 37.5 million records :. the brands our president and ceo of college informationmanagement said healthcare is ground zero for cyber attack . dhs, all industries face a growing threat but the size of the attacks on the healthcare industry have accelerated rapidly in the past two years. this is valuable information that can be bought and sold so cyber attacks are a serious risk and has been growing rapidly. >> thank you mister chairman. >> thanks, the chair
3:06 pm
recognizes the gentleman from indiana. >> i want to respond a little bit to this study about er doctors. there are people who come to the er legitimately drug seeking trying to get legal ways to get drugs. this has nothing to do with people who are drug addicted. they are treated just like everybody else. if you've ever spent any time in an emergency room and i have because i was a heart surgeon, there are legitimately large numbers of people trying to get legal prescriptions or legal narcotics through coming to the emergency room and it's honestly insulting for studies to try to show that the er physicians insome way are not treating patients in an ethical or moral way. it's just not right. let me comment on what it's like to be a physician . and my wife nancy is
3:07 pm
testifying also and have patients taking unknown medications or have an unknown medication history this is a serious problem . if as a surgeon you don't know if they are on opioids, in many cases certain dietary supplements,i myself personally have to patients who almost bled to death after heart surgery because they were taking supplements for vascular health . and my wife tells me every day she's still in practice, she still have patients that have unexplained difficulty in being and hospitalized with narcotics or benzodiazepine waste agents and looking at the medical records, there should be no reason for that and the reason is because it's undisclosed but there is a balance here and dr. martz makes breakpointsbut i wanted to point out that it's a difficult problem for medical providers and we need to find a balance . >> doctor strain, there are concerns if we amended the statute to allow substance
3:08 pm
abuse treatment information to be disclosed it could be used in criminal proceedings and cause someone to lose their employment or child custody but does the amendment to hr 3545 include safeguards to prevent this from happening? >> thank you for those comments and thank you for the question. absolutely. my understanding is that there are safeguards within the amendment that does prevent those sorts of concerns. >> and many substance abuse people with substance abuse disorder struggle with mental illness or conditions such as diabetes or hypertension. how is 42 cfr to prevent quality care coordination? >> that's a great question and the dilemma is as you illustrated earlier is that the provider may be seeing a patient who's in substance abuse treatment and not know about that and then can coordinate their care in terms of other medical
3:09 pm
problems that have arisen. related to their substance. and the patient may not be telling them about that or may not be fully disclosing for example what medications they are on through their substance abuse treatment. we want to be holistic about treating people,absolutely . at the end of the day that's what should be striving to do and right now we are figuring out this part. >> i want to point out that again, as a physician, family members may not know the medical history of their loved ones and i think congressman griffith was talking about that and we tried to in a mental health bill a year or two ago, we tried to chip a little bit to allow parents have adult children who have severe mental illness to have some minimal access and we
3:10 pm
couldn't get that done because of the privacy issues. in your state, we had a state senator whose son had an episode and tried to kill him and subsequently killed himself so the system failed both of them, really but if you look at for example the directed donor program, say you're going to have your hip or knee done and you want your family members to donate blood, there's a substantial instance of that one being rejected by the blood bank the cause of a blood board problem. usually appetite is history and family members don't necessarily know who that their family member has had history and they don't want disclosed and i understand that. i think we should look back at what happened in the 80s and 90s with hiv and the critical issue we had there with privacy and we've worked through that, i think. and maybe this is where we are going with drug addiction also. we clearly don't want people discriminated against but we
3:11 pm
also want to be to have holistic medical care that includes knowledge of a patient's addiction history. i yelled back. >>. >> right you very much mister chairman and thank you witnesses. >> it's good to have you here on a subject that is well, it's really wrecking communities and directing people's lives and there is enormous loss of life surrounding this issue. over the last at least a month or five weeks, i have had five friends and my sister, so six individuals thathave shared with me the following . they the replacement surgery,
3:12 pm
i'm directing this to doctor strain. they were sent home, with a bottle of100 tablets . of either oxycontin or percocet. now, 100 tablets either is i think over-the-top, i'm not suspicious but that's a lot of pills. why is that the case? why is so much being prescribed? i would think that if you're not an addict, you may have a new hit by the time you are finished with your recovery, you will be in a related can you, is there a kickback on these drugs? can you enlighten us as to why so much as being prescribed? >> this is the second most common surgery in the country.
3:13 pm
number one is cataract surgery, number two is surgery. >>. >> so certainly if we were having this conversation, in five years ago i would have said the reason there's large numbers of painkillers being prescribed is because the medical profession has had drummed into his headthat we need to be more aggressive about treatment . but something that goes back to 18 and 20 years. >> i think it's important to stay ahead of the pain but 100? >> i agree. >> they were at different hospitals that they were discharged from the current cdc guidelines do not recommend doing that. the current thinking by other professional organizations is not to be prescribing those sorts of medications. >> i don't know the particulars of these situations, but it is alarming to hear and i think
3:14 pm
that the medical profession hopefully -- >> what would you suggest. what would you prescribed? i'm not asking you what prescription or how many pills you would prescribed, i'm thinking in terms of policy. >> in terms of policy i would say there should be a much lower number that is prescribed whether it's oxycodone or whatever. i would follow things like this cdc guidelines for a week, reevaluating the patient, using non-opioid prescriptions. i'm not a pain treatment doctor. i'm a psychiatrist doctor . i think a lot about this because of this issue and my recommendations would be along those lines. >> with this cdc have guidelines now on this? they do. >> they issued a guideline about a year ago. >> seems to me they either don't know about it or
3:15 pm
they're just not paying any attention to it. do you have any suggestions to use the expression, more cheap in it? >> i think on a systems level, what we could do, i think we need to continue to be aggressive in our education of all healthcare providers. >> but we really have a crisis obviously on our hands but it seems to me that in the system itself, professionally, we are creating a whole other wave of it. >> i like to hope that we are turning the corner on that. >> let me switch gears because i don't have very much time left. i'm an original cosponsor of congressman lance and kennedy's bills which makes investments in cdc surveillance of injections, drug related infections.
3:16 pm
what barriers currently exist to state implementing drug-related infection surveillance systems today? >> are you asking me that question or -- i think you were commenting on that. >> i think i can that. the barriers are mostly manpower. we need more people to do the adequate case tracking and we need more communication amongst the agencies, not the same level of communication at this end of the table we're talking about but in the public health sectors. to basically identify the risk, the risky individuals
3:17 pm
and track them and work that epidemic with the methods that we used. it's a labor-intensive method . >> i'm not sure i understand the answer but i know we're going to have the opportunity to submit questions to the witnesses and i'll yield back, thankyou everyone . >> the chair recognizes the gentleman from florida . >> i appreciate it. i think mister bauer, florida law as of 2018 requires all controlled substances dispensed to an individual be reported as soon as possible but no later than the close of the next business day to florida's pdm b electronic order online reporting of controlled substance
3:18 pm
evaluation . if the controlled substance is dispensed on a saturday and pharmacy is closed on sunday, it could result in a 48 hour latency. this typical notification latency makes from two hours, seven days depending on the state. >>. >> thank you, there are 43 states requiring submission of controlled substance prescriptions no later than 24 hours. there's one state that has a real-time, oklahoma and there are the remaining states are either on a seven day to eight day cycle. >> thank you. and elaborate a little bit, as far as how important it is. >> absolutely, thetimely submission of information is extremely important . the 43 states that do submit the information no later than 24 hours are typically multiple submissions are made of the dispensation when it
3:19 pm
leaves the pharmacy. and when it comes into our system, the we append the information and provide our logic as far as attending to the right patients and make that information available in about five minutes time so it's very much near real-time but that information is received by the pdm b in the case of florida, that information is made available within about five minutes time. >> every good. >> i understand in many states are able to share pdm b data across state lines. however, even if states are connected to an information on, isn't it true that those dates do not necessarily have a cross stateline information for all their states connected to that half, is that true? >> today the 45 states that do participate in interconnected, they can share with all 45 states if
3:20 pm
they wish. it's up to the discretion of the state as to what states they wish to share information with. again, most states, all states share data with at least their border states . they draw a concentric circle and others look at different migration paths as far as the i-95 corridor, or the northeast states as far as sharing information. >> i think i know the answer to this question so let me ask it. in any state, pdm b dothey stop the fraudulent prescriptions , i'm believing the pharmacy patient obtained multiple prescriptions within the same day. potentially across state lines. >> that's a great question, built into today's pdm fees, they are an efficient and effective way where the states are actually proactively sending alerts based on various thresholds of the data, both within their state and combined with
3:21 pm
multistate data for example, understanding that the patient is traveling from state to state, the state accumulating prescriptions from multiple providers, multiple dispensers, that information can be made available via alert, is what we call it, based on specific threshold that states, so those alerts are sent out proactively to the actual prescriber or pharmacist checking on the patient. >> what are we doing to call out those. >>. >> that a great question. again, it is more of a policy issue in california. and florida are addressing those issues as we speak. florida will be online hopefully by july 1 and california later this year. the remaining states are in process, nearing the actual ou, memorandum of understanding required to share data among states and review. the only states that exception to that are nebraska and hawaii, those states have not yet engaged on the ou process.
3:22 pm
washington state and my only path. >> thank you, i your back. >> the gentleman you chair. >> i wanted to make the gentleman aware that the appropriations bill will be on the floor of the house, the master language in the fiscal year 18 omnibus bill. that strong attention to the fact that the bill about these drug monitoring programs including implementation of activities prescribed in the schedule prescription electronic reporting act of 2005, that was this committees product and it includes as amended by the comprehensive addiction and recovery act of 2016 this shall include efforts continuing to expand enhanced utility pdm fees in the state and communities making them more interconnected real-time , usable for public health surveillance , medical decision-making .
3:23 pm
pdc shall use $10 million of the funds provided. an opioid admission nationwide awareness education campaign so that's a little bit different. now we've got we've worked on this in this committee as long as i've been on the subcommittee, they are actually receiving funding in the still alive. now i like to recognize the gentleman from new mexico. >> i'd like to thank all the witnesses with us today. my questions today will specifically be for "after words" six. i was taken aback by the conversation about how providing individuals who continue to face stigma and discrimination and heightened to protections with our the right to decide whether to share their records. it stigmatizes individuals with substance abuse disorder. i was surprised to hear fafsa
3:24 pm
modernizing party regulation that explicitly acknowledged the stigma and discrimination faced by individuals with substance abuse disorder. all of america's antidiscrimination laws to the fair housing act describe heightened protections for populations like individuals with substance abuse disorder face stigma and discrimination because of who they are and frankly i have a hard time understanding the argument that protections stigmatize these individuals so dr. martz, described the stigmatizationthat individuals with opioid disorder face . >> thank you, excellent question and a critical area because to the point earlier, this is not implemented to the ers. this is stigma that goes across the way. one in four families as someone in the family now
3:25 pm
with substance abuse disorder so often my experience of substance disorder is causing joining so the stigma runs deep and it's very different from the aspect of other medical conditions which are very unique to the substance abuse disorder which for example, crimes are associated so you don't get thrown in jail for having depression. you don't have your kids taken away for acne. you don't have a loss of your job because you have a heart attack. medical conditions are not all the same. there are reasons why there may be some segregation even though there are ways to coordinate that care effectively. the stigma issues are critical and to say, to suggest that the stigma is caused by these laws is a little bit of a misunderstanding. for example, we don't have laws protecting anti-discrimination in the workforce because we are creating a stigma in the workforce. we have laws protecting things like gender and race and ethnicity and religion because things have been
3:26 pm
discriminated against in the past so even if we've come a long way, as we have with hiv, we have not yet come that far with substance abuse disorder so we still maintain that critical protection, maybe someday we will understandthese are brothers and mothers and sisters and children we are talking about and move beyond that discrimination but we are not there yet . >> yes, sir noquestion, is that discrimination the result of heightened protections ? >> no. >> i was also taken aback by something in doctor strange's testimony, in his discussion of rolling back to for payment purposes he states that quote, patience could retain the ability to keep their substance abuse disorder treatment from the health by choosing to pay out-of-pocket for services. because the right guarantees. >> so to me this means a person's ability to protect the privacy of their substance abuse treatment
3:27 pm
record would be based on their income, their ability to pay out-of-pocket for treatment. >> the rich, and keep that private. >> dr. martz, is it appropriate to make a person's ability to keep their substance abuse information private based on a person's ability to pay cash for treatment? >> my gosh, that is such a fundamental civil right to be able to be private and have my own pace when i'm ready and able.that shouldn't be something only available to the rich can afford it. many folks that we deal with our peace officers and teachers and students and all walks of life. they have these opportunities should they choose to use that option. >> one thing i was struck with as i learned it was estimated that 20 million people in the us have some form of substance abuse disorder.
3:28 pm
apparently 4 million people are seeking treatment as has been reported but the fear of not being provided confidentiality, one of the primary reasons people do not seek treatment, so mister chairman, i know this is an important part of the conversation and legislative package that we have and i hope that we take this into consideration as we tried to make things better versus taking protections away from individuals and i yelled back. >> thank you, the gentleman you back and i'm sure tim is not one but 15different codes . the chair recognizes the mister from illinois for questions. >> you mister chairman and great to have you here. we've had two days of hearings and as i mentioned yesterday, it's just not, we're focused on opioids but there's a lot of other addictive drugs out there and challenges. now i'm going to be brief, i'm going to focus on what gusto iraq is was saying and to really mister bauer on the prescription drug monitoring programs, one way we can
3:29 pm
change the five states is to call them out. we can do it ourselves and we use the bully pulpit to say you guys need to start sharing information, we've got to stop easy access across state lines or in other examples, i really lived in the state, a metropolitan area. from illinois. and the jury does not, i think, eileen, st. louis county has one. which really is, it makes it difficult to make sure we have the procedures in place to be able to access them, when a state doesn't allow the state to have a memorandum of understanding and work through those processes. >> we've seen these type of things when they can communicate in the next challenges. we've seen be successful. we need your help in figuring out how to really force this
3:30 pm
national vocation across state lines. >> to address this. i'm curious if you can expand on ways we can help ensure that these multiple systems are working together as opposed to creating new burdens and confusions . >> that's another excellent question around interoperability and state able to share data among themselves . today with the current pmp interconnection system, that is facilitating about 18 million transactions a month through 45 states . we said earlier, it's more a matter of policy. we are making progress with the florida coming on board and the remainingstates , they are making measurable progress towards that. i think it's not out of the question that all remaining states that are not consequently sharing data and
3:31 pm
sharing data, there's an effective means to do that today. with the single mo you in place to accommodate four different state laws and security concerns. >> once someone's in prescribed illegally, and they go to the pharmacist, they should be able to get to spend but they should be able to go across the state line and there should be a red flag saying sorry, that's what we need towork on, that would be helpful . >> i'm going to yield back so you can give them a chance to ask. >> we appreciate it, gentleman. the chair recognizes the gentle lady from indiana. >> thank you to our colleague from illinois for yielding. i wanted to ask doctor banner, i am the lead sponsor on hr 5329, a bipartisan bill to enhance our poison control center's in the country of which there are 55 i understand across the country but most people don't realize that poison control center's field about 3 million calls.
3:32 pm
but recently about 192 calls a day on average. and opioids of use and abuse and really i want to talk about the importance of not only the hotline but the service that poison control center's provide. how can poison control center's work with the educators, caregivers, people who call, children, what's poison control center's rule? it's one of those that has a number and you dress thereand i had to visit once or twice when my kids were young as well. i hate to admit it but we all do at some point .and what is the rule poison control center's with education? >> we so very much appreciate your sponsorships involvement in this . if we've got a couple hours i could really explain this to you. we have a very small staff approach to education. personally, i have emergency
3:33 pm
medicine residents rotating with me at all times. poison center and in the icu and we are educating them on teaching in the college of pharmacy as part of my responsibilities poison center and i think the other 54 centers are similar. we are actively engaged in that level ofeducation . we also have the certification requirements for centers to have an educator whose principally pointed at the public and to the national poison prevention week is one of their big times but they are engaging kids at the elementary and early on levels about the dangers of things and as we have evolved, they incorporated more about substance abuse into those educational packages. teaching teachers, etc. >> in your written testimony you actually mention that a quarter of calls to our poison control center's, from the healthcarefacilities .
3:34 pm
and just your testimony now about rotating residents in and so forth, there is a significant need, is there not, to continue to increase the education of poison issues to the leading industry caused by the cdc in this country. with our medical professionals? >> this was a simple job back in the 90s. the explosion occurred with bath salt drugs, synthetic cannabinoids, synthetic opioids has changed the landscape and i would agree with you, the reason we get 25 percent of our calls from other healthcare professionals is because the level of training of the medical toxicologist and the people working in the poison centers is very unique . the other issue is oklahoma have a lot of rural hospitals
3:35 pm
as does many of the poison control center's and my ability to reach out to a physician in a very rural hospital who has never seen this before , and i have is very helpful. plus, with a critical care doctor, the vast majority of the doctors that are medical toxicologist are trained in emergency medicine or critical care and we are reaching out to rural areas with high levels, intensive care emergency medicine and toxicology all at the same time and providing that and educating them at the same time. >> in our bill, we are directing hhs to implement call routing based on the caller's actual location because that's not necessarily how you receive that information now, is that correct? >> that is correct. when this was initially funded back in 2000, it was reasonable to have where your area code. and since then, area codes now, people are taking their
3:36 pm
funds, their moving all over the country and one of the benefits of a regional poison control center is i'm speaking to a doctor that i know in that area and if i'm suddenly faced with a caller who happens to have the oklahoma area code and there in california, i can't really say you need to go down the doctor hospital because i don't know them. so the gop routing sounds fairly simple, it is a little more technical complicated but it's something we need the causewe got to , we have the reasonable resources to help people and it's where they're at right now, not where they used to be's thank you for your leadership and on behalf of the citizens of indiana cross-country and my colleagues, we appreciateyour advocacy for poison control center's, i yield back . >> thanks to the gentle lady, we yield back in the chair
3:37 pm
recognizes the gentleman from texas . >> committee chairman like to ask is entering the letters nano recovery, the campaign to protect patients from privacy rights in pennsylvania recovery organizations alliance into the official record. >> so ordered, the chair recognizes the gentleman from oklahoma . >> roger bannon, good to see you here. we were taking a little friendly wager of year to see if you have your boots on or not. i suggest you probably got your cowboy hat outside you. we do appreciate the knowledge you bring and thank you so much forcoming up here. i know it's hard to leave our beautiful state, especially where we live . doctor, i want to dig in on the stuff you've been saying and i respect your opinion, but i have a problem with the fact that you are trying to push it off as fact. when we start talking about privacy, i want a yes, sir no because you kept referring
3:38 pm
back to this. is it legal for treatment to be shared with an employer right now? >> the answer to that is no. >> is it legal, yes, sir no. >> there are conditions with which you can really take emily. >> only if the individual has been set. >> is it legal or no. >>. >> i'm an employer, i have several hundred employees. employee legal. i'm also alandlord. is it legal for treatment information to be shared with the landlord? yes, sir no . >> no, absolutely not. >> is it legal for information to be shared in a criminal case or divorce hearing? >> no. >> so what you're saying about privacy is irrelevant. this is about patient, not opinion or maybes. it already is illegal and the legislation, it stays illegal. so when you are testifying, please be a little bit more factual, with what you are saying instead of making a broad statement and drawing
3:39 pm
fears into these people. we bring you here because you are considered anexpert . please, be that expert. i know you've got a wealth of knowledge of your your misleading us and the panel when you don't put facts with it. you start talking about the stigma that's put in place and you referred back to answers several times. and i sent a letter to the assistant secretary askingfor their information on our bills . and what their thoughts were. let me review", my favorite letter. send the practice of requiring substance abuse disorder information to be any more private information regarding chronic illness such as cancer, heart disease may itself be stigmatizing. that's from samsung. it's plain and simple there. they think itself it shouldn't be treated any different. let's talk about finds.
3:40 pm
under part two, how many leases have been issued under part two, violations? >> on federal or state level? >> federal. >> federal, there has not been one. >> how many has been brought up underneath hippa? >> that's out of my scope. >> let me put this out there. 173,426 cents 2003. now, why is that? because you talked about this in your opening testimony and i want to make sure we are factual so you understand what we're talking about. a lot of people want to talk about privacy and not separating a wide to and hippa need to be separatedbut under part two the penalty is $50 .
3:41 pm
that information is mishandled for the patient, $50. >> but is it worth the court's time to deal with it? only two cases. underneath hippa, the range is between $150,000 per violation and a maximum of 1.5 billion per year. >> this is about patients. but what we're trying to do is treat the patient. but how can you treat the patient when the doctor can't see all the medical information? >> how can he do it? the reason why i'm so passionate about it is because it touches my family. we are currently dealing with this. i don't with this situation yesterday over the phone. because we have a family member that has a disorder of being addicted to drugs because it started with a elective surgery. now her life is completely
3:42 pm
ruined and she keeps going to doctors and they keep prescribing her stuff and i can't see her complete records and how many times she's been in treatment so they start diagnosing her, prescribing her more pain medicine because she's in pain. what's the difference between pain and withdrawal? because at some point you start coming off and you start having withdrawals and that painful to. >> so we're talking about combining those two. are you following me on that? >> so what is wrong with my legislation that allows a patient to be treated completely? >> and don't tell me about the stigma because it's not about stigma, it's about treatment, it's about giving the patient back to the person they were before. >> thank you for your passion and your information and i agree with the point you're making but would add respectfully acouple points in addition to that . in good clinical care, for
3:43 pm
the treatment of the disorder, >> it short because i didn't know i was overtime. >> it's critical to have patience be involved in collaboration so that can be the best collaboration. and even more treatment because they are addicted to drugs >> which will all be noted in the pb nt . >> which is important for the doctor to have that same information, that's what we're trying to compare the two and make sure both of themare combined so that the doctor can give the patient the treatment they need . they are professionals, just like you are professional, ideal back . >> the gentleman you'll back andy gentleman recognizes the individual for five minutes. >> thanks to all of you for being here and this is a great panel and i appreciate your participation. mister bauer, as a member of the georgia state, i sponsored legislation
3:44 pm
creatingprescription drug monitoring program in the state of georgia so i'm interested . i appreciate you throughout your testimony clearing up the fact that when states are sharing information, they're not sharing it with allstate. they're only sharing it with certain states. and initially, that was confusing so i hope my colleagues understand just because you're sharing information, you're not sharing it with allstate, your only sharing it with states you choose to share it with so i want to make sure we got that straight. mister drucker asked you a question mister bauer about who's mandated to see this information that's on the pdmp and you said 40 states mandate. mandate who to see it? pharmacists or doctors? >> currently prescribers. of the 40 states that have a mandated use of law or statute, typically that is the prescriber and a handful
3:45 pm
of states that also includes the dispenser which would include the pharmacist. >> i'm not sure that i agree with that but i will take your word on that. in fact, the state of georgia, we created it it was the pharmacist that had to look at it. starting july 1 doctors will have to look at it and in most states it's for the pharmacist and notfor the doctors . but anyway, will you clarify that for me and follow-up in my office on that? i appreciate that very much. i wanted to ask you, i had a number of companies come in were showing me how they can incorporate the pdmp's with the electronic health records though we're not disrupting workflow and that's something that's important and something we've experienced in the pharmacies when we're trying to incorporate the pdmp's with our workflow. it is a disruption in the more we can incorporate it into our workflow, the better the program will work and i'm sure that's the case physicians as well and i know it's a case pharmacist.
3:46 pm
i'm also going to ask you, craft prescriptions, are they being included in your pdmp? >> all prescriptions controlled substances typically schedules two through five. including cash are. >> let's talk about schedule five prescriptions because sometimes that can cause a problem, particularly with patients getting medications at our schedule five and not necessarily medications of abuse, for instance epilepsy patients may get some schedule five prescriptions and sometimes this can cause a disruption in their therapy as well. have you seen anything with that, is that something you are looking at the mature we don't disrupt that therapy? >> at the great question from a pdm be perspective. that's not something that we weigh in on. >> is more of a state policy decision is made. our responsibility is to collect the information. >> one last question, you
3:47 pm
talk about methadone which i believe it was represented three at the end. he said methadone clinics were notrequired to support to the pdmp. >> methadone administered, in a clinic . >> what about pharmacy? i'm required, if it's filled by apharmacy, that is reported to the pdmp . >> if it's sold by a pharmacy but a clinic, it's not? >> correct. >> for a while we didn't have the va and that was a problem. now i want to go to you mister banner because one thing that has concerned me and i wanted to get your opinion was the use of the lots owned and the dependency that seems to be getting. i know we've had situations where some of the ambulances have been carrying so much of it and had to administrate so much that is bankrupting literally some of their budgets and they had to stop
3:48 pm
and only carry a certain amount. can you see that sometimes happening? >> we have areas where there are bikes that are concentrated activities. and that's concerning in and of itself and yes, there are a lot of, for a lot of reasons a lot of shortages a lot of drugs and that, that just prices up and that is a problem. i think it is going through, this should work for everything face. no, only works for the opiate receptor. >> but i think one of the problems is that abusers are getting depending on knowing that if i od, you're going to come rescue me and i'll be okay. >> i think it does encourage people in some ways to push the envelope. >> exactly. also, you mentioned something that throughout these hearings i have not heard anyone mention marijuana. has been a big problem in georgia. thankyou for mentioning that
3:49 pm
because we want to continue that as well and i know i'm out of time and i you'll back . >> iq, chair, the gentleman from new jersey, mister lance. >> thank you mister chairman and my thanks to the distinguished panel. where having several hearings today. on the subcommittees and of course on the floor. i want you to know. that it's an important topic to the entire nation. and you are among these experts on it. >> doctor kilkenny, could you speak briefly about the opiate crisis and the rise of the infectious disease rates and how the two issues are linked? >> yes sir. airborne pathogens are spread by sharing blonde and injecting drug use, when people who are engaged in injecting drug use are sharing syringes or other
3:50 pm
imperials of a injection, they are often sharing blood. so there's a clear correlation between those blood-borne pathogens that have hepatitis b, dais c and hiv and injection drug reuse. >> how have your efforts been successful bringing together community partners in huntington. to address infectious diseases associated withthese opiates . >>. >> the city of huntington as a remarkable history of working together against common threats. and with the opioid epidemic, reaching a level that it impacts every family. but we have no problem bringing every entity aligned in a strategy against, we brought in virtually every other entity in the
3:51 pm
community. into the strategic plan. >> thank you. i introduced legislation regarding the opiate issue and infectious diseases and my cosponsor is congressman kennedy on the other side of the dais. and he's completely bipartisan and i hope that the experts might have the opportunity to review the legislation. i think there is a growing awareness among the various avenues we have to pursue that there is a significant correlation between them. between the opiate crisis and the infectious disease rates and where in this battle together and i'm sure that we will overcome based on our joint efforts so my partisan is bicameral innature on hill but also with leading experts
3:52 pm
across the country including this distinguished panel. thank you, i you'll back the balance of my time . >> thanks to the gentleman. the chair will recognize misterwaldron of michigan, not a member of the subcommittee. you want to label on for questions, is that correct? the gentleman is recognized for five minutes for questions . >> i appreciate the opportunity to join the august committee. >> i have a great interest in this, personal interest and i appreciated hearing i've been able to listen to today about b fuller subjectthat we're addressing in the course of the fashion, there has to be a willingness of the patient to see , firstand foremost , but there also have to be certainly a willingness of the medical professions society in general to reach out on the problem as well. earlier, this congress i introduced jesse's law. with congresswoman debbie ingle . in an effort to try to find a solution to something that tragically took place in michigan with jesse grabber residents who had been doing
3:53 pm
very well. >> beating her addiction and growing. >> they were involved in a sports accident injury in preparation for a marathonand had a surgery . her family as well as effie herself notified the attending physician, the surgeon of her problem with addiction . but it didn't reach the attention, for some reason of the discharging physician, so she was sent home from the hospital with a prescription of oxycodone. she ultimately overdosed on the next day and lost her life. we want to find a solution to that and doctor strain, are currently examining both jesse's law and hr 3545, the overdose prevention patient take the. can you elaborate on major differences between the bills
3:54 pm
and if so, why it would be helpful to have both . >>. >> i'm sorry for that loss. >> for the family, for you. >> and how you had an impact on you as well.>> is a tragedy. >> i think that both bills have value. >> i think both have great value. i think that both illustrate the fact that as a physician, i teach my residents and interns. when in doubt, get more data. and that is something that we are in a situation now where we may not know how to get more data, so i could for example see jesse and not know about her addiction
3:55 pm
history if she didn't tell me about that. i think that's as i understand, jesse's bill is bringing together stakeholders who can't look at how can something like this not happen in a medical record again? it's a worthwhile thing to do and to see if there's some way that can be codified. i don't think it's enough. i think that we have a situation right now where we got a whole treatment system of substance abuse programs that can be taking care of somebody and how do you not know about that? and it's artificial at this point, i can say, if i can take a moment to say. it's artificial. i can know somebody's got a substance abuse problem documented in the record .
3:56 pm
but it's only if they are in a particular program that i may not know about what's going on at that program . so i have plenty of patients with substance abuse problems. they told me, i got documented in my records and those records can be accessed by obstetricians, by orthopedic surgeons. however, they can get access to that for my records. they can't get access to the treatment records which is artificial. >> so what will give that access, what are the additional things we need to do? >> i think it's 4035,45 . >> mandatory and automatically shared with any and all who need to know that . >> with the proper protections in place that are required. which represent as mullen pointed out in those questions.
3:57 pm
>> thanks for the opportunity to ask those questions. i see my time is about expired . >> the chair recognizes the gentleman from new york, five minutes for your questions and that was the vote being called so we will left mister engle who will reassess and we can reconvene with the next panel. but mister angle, you are recognized. >> this week congresswoman brooks and iintroduced the poison center network enhancement act so that will reauthorize the nation's poison center program for an additional five years . speedy access to poison centers with a national toll-free number, one 800 2222 is an essential resource for all americans, especially parents who take polis in the fact that there 55 poison centers across the us available 24 hours a day, seven days a week, 365 days a
3:58 pm
year. these centers are a smart investment, they offer real-time lifesaving assistance while saving hundreds of millions in federal dollars by helping to avoid the unnecessary use of medical services, shortening the amount of time a person bends in the hospital with hospitalization due to poisoning is necessary. most know about much of the work poison centers do thanks to a map on the refrigerator displaying the poison center phone number. many may not know about the critical role poison centers are playing to fight in the opioid crisis. since 2011, our nations poison centers have handled nearly 200 cases per day involving opioid misuse. data from poison centers help detect trends in the epidemic
3:59 pm
and experts have helped educate americans about the crisis and ways they could potentially save the lives of their loved ones. for example the upstate new york poison center used the new york state fair to educate new yorkers about the proper use of naloxone. this bill would ensure the co-author of the last poison center reauthorization in 2014, i am proud to be a part of this legislation and i want to thank congresswoman brooks for working with me on this important bill as well as congresswoman jacket and martin, being original cosponsors . >> doctor banner, let me ask you this. >> you for being here, i appreciate you sharing your expertise. this bill would authorize additional funding for poison control centergrant programs. would you talk about how this funding will help build capacity at poison centers, enhance their ability to respond to the opioid crisis . >> i appreciate everything you'vedone , congressmen and onbehalf of the poison centers i really appreciate you . we hope to continue this
4:00 pm
fight. we hope to expand our educational activities as we go forward. we have a big state, we go to you and getting, reaching out particularly to rural areas where education is critical is difficult and expensive. so having extra funding and improving our funding base else us in those outreach activities. we are also actively seeking the first responders to get a hold of the poison control center as part of naloxone administration, as the good gentleman from georgia pointed out, it can be misused or overused and we want to actively supervise and help in that program and our ability to continue that activity is very critical so we see a lot of opportunities , reaching out to minority communities for these problems as well. it's an important issue for us. so we thank you.
4:01 pm
>> thank you doctor banner. you mentioned in your testimony that poison centers have helped identify trends in the opioid epidemic. how do you think this information, poison centers could help us as policymakers respond to a crisis more effectively? >> i think it already has in a lot of ways. this is thekind of data when you see it makes coming from the cdc, we work closely with them every eight minutes, we upload from all 55 centers into a central database . plus, conversations we have our list serves and there's a lot of human intelligence going on where we are identifying things very early. the increasing oxycontin, a lot of our recognition of those came from the npdes database which is that contributory public health or valence activity that we do so we are constantly updating that database so that the
4:02 pm
fda, the cdc and the monitoring activities, we do that in real time for some acute events, but we also are looking over long-term. every year we publish people rely upon it heavily to look at trends and what drugs are becoming more prevalent and identifying new substances, so i think you do will rely upon us. you may not need know it came from a poison center but our data is there and it is i hope reallyhelpful in guiding you to see where the future lies . >> thank you very much and thank you for your good work andthank you mister chairman . >> the gentleman yields back, the chair recognizes the gentleman from virginia . >> i have a request that we introduce into the record and letter from the president and ceo of tyson pharmaceuticals related to pharmaceuticals related to opioids . >> so ordered. >> the chair wishes to thank
4:03 pm
this family, they've been very informative area it's been a lively morning and that's what we wanted so we appreciate your expertise and your sharing it with us. we are going to take a recess and this panel may be excused and we will reconvene 10 minutes after the vote series on the floor with our fourth and finalpanel so the subsequent committee stands in recess . >> i want to thank all of our witnesses for being here this afternoon and taking the time to testify before the
4:04 pm
subcommittee. each witness will have the opportunity to summarize their opening statement , followed by two rounds of questions from the members and this afternoon for our fourth and final panel of this today hearing we are going to hear from this jessica nichols, founder and president of addiction policy for him, miss carlene deal smith, her support specialist, presbyterian medical services, mister ryan hampton, recovery advocate facing addiction , doctor mark rosenberg, chairman of emergency medicine and chief innovation officer, st. joseph's healthcare system board of directors, the american college of emergency physicians. they see bohlen, alexis karen, vice president of relation, clean slate centers and thank you all for being with us today. ms. nickel, you are recognized for five minutes please. >> thank you chairman burgess and ranking member green.
4:05 pm
>>. [inaudible] i would ask the audience to please be seated and allow our panel to be heard. the gentleman does not sit down, i will instruct counsel to remove you from the hearing. the gentleman will sit down. gentleman will be seated. but gentleman will be seated. the gentleman will be seated and allow our panel. >> we ask the questions and no one will tell us. >> the gentleman will be seated. >> can i ask committee staff to ask capitol police to give us assistance in getting the gentleman seated? >> i will leave on my own. >> you are recognized for five minutes. >> thank you mister chairman
4:06 pm
for your leadership on this important issue. it's facing so many families and communities nationwide. my name is tessa cut nickel and dime with the addiction policy forum. i started before him bringing stakeholders together to ask for a comprehensive response to addiction including prevention, treatment, recovery, support, overdose reversal, criminal justice reform and to bring a voice for families. we have one goal, to create a world where fewer lives are lost through addiction and help the millions of americans who needed. i'm grateful to be with you today to discuss legislation and how it will help address the addiction crisis.i know firsthand the devastating impact of substance abuse disorders on families and communities. i lost both my parents to addiction and there are substance abuse disorders for me and my little sister who
4:07 pm
lived in foster care and was a ward of the state until i was 10 and both of our grandparents, i lost both my grandparents years ago. every day we lose 174 people to drug overdoses in our country. 174 and that's like a plane crash every day. it's important to the scope of this crisis and the real families and communities at the epicenter so we wanted to share with you some of the tories from our family. is doug and pam who lost their daughter courtney when she was 20 years old. she describes courtney as a shining star. the room lit up when she walked in and everyone loved her. we were told that because it's not a matter of life or death there would be no coverage for treatment, on the advice of our local authorities we asked to leave
4:08 pm
our home and canceled her insurance. by doing this she would be homeless and could beeligible to receive treatment. courtney died alone away from her home and the day before she was scheduled to go into a treatment facility. lorraine describes her brother larry as amazing, charming, funny, popular and the most talented drummer you've ever heard. larry died from drug overdose leaving behind his one-year-old son and larry became a single-parent overnight . jennifer lost her son dylan when he was 19 years old . he says to us every day when i walked into my house, i see these shoes sitting on the floor where he kicked them off and his jacket draped over the banister. he will never have the chance to get married, travel, do all the things a 19-year-old should have two experience. amy, who runs our massachusetts chapter lost her son and that's when she was 20 years old. in college studying computer science, and it had six overdoses reversed at his local hospital. treatment was not initiated and the family was not notified. each of these overdoses was an opportunity to engage in the help he needed. the community of families and
4:09 pm
patients and key stakeholders, we are pleased to see the comprehensive approach this committee is pursuing with the legislative proposals have been considered. i liketo address three pieces of legislation that will help us respond to this crisis . first off is the comprehensive opioid recovery centers act 2018. we have an enormous treatment gap in this country. of the 21 million people that need treatment, only 10 percent will receive it. can you imagine if 10 percent of cancer or diabetes patients received treatment? our healthcare system has many issues that continue to limit the implementation of evidence-based practices to treat substance abuse disorders. there's integration, general and specialty care and there's a lot of screening for substance abuse disorders in healthcare, with inconsistencies providing all three fda approved indications for opioid disorder. the comprehensive opioid recovery zach will address
4:10 pm
these barriers and the development of integrated care models based on best practices which will build up pathways for the comprehensive healthcare infrastructure that must be achieved to ensure everyone suffering has access to quality treatment. this is a preventable and treatable illness. addiction is an adjustment of course, the comprehensive opioid recovery centers act which will help fill the need for coordinated care for patients. thanks to congressman guthrie, congressman green for their leadership on this. i'd also like to address the training, education and community health act to combat addiction. there is an alarming lack of substance abuse education in school curriculums and among additions, according to the 2016 surgeon general's report, only eight percent of us medical schools have a separate required course on addiction and only a handful of medical schools have
4:11 pm
robust ricky lim on the diagnosis and treatment of substance abuse disorder. health providers do not feel prepared to deal with patient populations because of the lack of education for students and experienced practitioners, students can be denied access to evidence-based treatment options. physicians around the country report not having enough treatment on prescribing of pain medications and alternativetreatments for chronic pain with particular gaps in physician education in the midst of a worsening opioid epidemic . keisha incentivizes education and curricula and legislation would fund institutions and centers of excellence in substance abuse disorder education and require such institutions to collaborate with stakeholders on the front lines of this crisis. we are in support of the teach act and i thank congressman bill johnson and paul taco for their work on this legislation. finally very briefly, we are also very pleased to see the preventing overdoses while in emergency rooms act.
4:12 pm
this makes me think of emmett and his mom amy and how we can do a better job of equipping our emergency room physicians to address a nonfatal overdose and to use this as an intervening moment is a high priority with the eviction but policy room and we are in support of the power act and are grateful for the committee and your commitment to these issues. and i just wanted to express on behalf of all the families that your focus on this issue in such a comprehensive manner that includes all six of the key components, prevention, treatment, recovery support, the focus means the world to us. we have millions of families struggling, some alone, some trying to come together and fight for better responses so i'm here to also transmit that heartfelt thank you for your leadership and focus.
4:13 pm
thank you for having me today we appreciate your testimony and all those so focus on enforcement during our first panel as well as scientific discoveries to expand the universe of medications to treat pain. mister steele smith, you are recognized for five minutes good afternoon ladies and gentlemen. my name is carlene smith, a nativeamerican of the navajo tribe from farmington new mexico. i'm employed with presbyterian medical services . i work with homeless individuals who have substance abuse problems. due to my own struggles with alcoholism, i am able to assist with what they are struggling with. i understand the impacts abuse has on their lives, i understand them when they say nobody cares . the low self-esteem and employment they suffer with,
4:14 pm
the relative, we call our clients relatives because that's how we relate. we have a program that helps them get their lives back . sometimes it's easier for them to achieve sobriety. you have to be consistent with being available to them. each day is a new day, if it doesn't matter if they had a bad day yesterday. in their support, you have to model being healthy by your own recovery, sobriety can be achieved in your model, you are taking care of yourself. being healthy is a key to help the relatives that still suffer. i come to you to show my support for your support program,these programs offer more than just support, they offer jobs and independence . thank you. >> thanks to the gentle lady for her testimony. doctor hampton, you are recognized for five minutes . >> you mister chairman.
4:15 pm
writing member green, my name is ryan hampton and i'd like to thank the committee for inviting me to speak on the sober living act on behalf of facing addiction which represents over 800 community organizations , 75 regional affiliates across the united states, a network reaching over 35 million americans. as a person in sustained recovery and a member of the recovery community, it is an honor to speak about the impact hr 8464 will have on americans with substance abuse disorder. i spent a decade struggling with an addiction to heroin. the addiction is not the result of bad decisions but rather a health condition exacerbated by drug use. i am one of millions of americans affected by it.
4:16 pm
addiction affects people from all backgrounds, constituencies, races, classes, religions and party affiliations. it does not discriminate. unlike other chronic illnesses like cancer and diabetes we have a solution. we are not struggling to find a cure. this issue is one we can address together and prevent further loss of life. one of the ways we can do this is by supporting ethical guidelines for recovery housing. the person you see sitting in front of you today is in remission from potentially fatal illness of addiction in spite of the broken system we have in place. long waiting lists, abstinence requirements for housing, abstinence and unethical treatment practices all undermined my recovery. some facilities discriminate against harm reduction measures . that's a barrier to access. i went through multiple treatment centers, detoxes and sober livinghomes before i was finally able to sustain my recovery .not everyone has been so lucky. i am here today because my friend tyler died of a heroin overdose in a sober living house.
4:17 pm
because there was no naloxone on site and because the staff works trained to deal with overdoses, my friend lost his life. not having naloxone in a sober living home is like refusing to put lifeboats on an ocean liner. it doesn't mean you are planning on a shipwreck. it means in case of a disaster, the passengers will make it safely to land. when i heard how tyler had died i was outraged and i approach my congresswoman. thanks to her health and supportive facing addiction and the national alliance of recovery residents, i stand before you asking for bipartisan support of hr 4684 as a solution. i know it is not a silver bullet but it will help get best practices in recovery housing implemented across the country. tyler's death was 100 percent
4:18 pm
preventable and hr 4684 addresses the changes we need in order to ensure that recovery homes are doing what they are supposed to do saving lives and not endangering americans. recovery should never be about luck and it shouldn't be a guessing game for people in desperate need of help . hr 4684 is a step in the right direction that will for the first time allowed samsung to develop best practices that can be disseminated to state and help people and prevent more tragic overdoses like the one killed my friend. polity, access, care and choice are key parts of the existing standards for recovering residences. quality means defining the elements of a properly operated recovery residents. access means providing a roadmap for developing the full spectrum for recovery housing to better match needs and a blue point for housing providers to rise to the occasion. care means evaluating the key support components of a residence recovery environment.
4:19 pm
choice means empowering recovery housing choices with regard to placement and resource allocation. everyone should have equal access to recovery services, not just prevention and treatment what continuing care that includes peers support and housing. the 2016 surgeon general's report on alcohol, drugs and health, the white house on opioids report recommend the use of the recovery support and recovery housing. providing ethical safe housing and support post clinicalservices is linked to higher rates of recovery . without these measures in place, we will continue to lose people like tyler. millions of americans access treatment and continuing care asked for help in good faith. we must ensure their safety net is strong, safe and ready to catch them and mister chairman, on a personal note to close i would like to say that not a single day goes by where i do not think about the friend i have lost in the people i have loved that are gone from this crisis and i showed up to testify today for them, because of them and
4:20 pm
in memory of them. thank youthank you for your rosenberg, you are recognized for five minutes .>> iq mister chairman. my name is doctor mark rosenberg and i'm chairman of the emergency center. >> may i ask is your microphone list? >> sorry. my name is doctor mark rosenberg and i am chairman of emergency medicine at st. joseph's university medicine center at paterson new jersey. i serve on the board of directors at the emergency physicians so on behalf of st. joseph's university medical center and its hundred 70,000 visits in the emergency department per year, and 38,000 members of the american college of emergency physicians and the great state of new jersey i would like to thank the committee for this opportunity to provide testimony in support of two bills. the alternative to opioid and emergency department act and power, preventingoverdose while in the emergency room act .
4:21 pm
there are two cornerstones to the opioid epidemic. prevention and treatment and they are represented by these two bills i am supporting today. the prevention program is alternative to opioids and the treatment program is an 80 or the power act andthose are necessary to stopthe continued opioid misuse , abuse and overdose . prevention, hr 5197 . that was developed by my team at st. joseph's university medical center in new jersey in 2016 to address the variation in prescribing habits and to decrease the reliance on opioids emergency physicians. we started the program with a simple premise. the best way to avoid opioid misuse and addiction is to never start a patient on opioids. the alcove program is
4:22 pm
evidence-based protocols, using non-addicting drugs and therapy that target receptor sites and enzymes. that mediates the pain. an example of the patient with back pain. instead of giving them opioids, i give them a treatment of therapies that include non-addicting medications and trigger point , resulting in better pain management and improved patient care. i'm proud to say after two years of implementation at st. joseph's, the alco program has witnessed tremendous success and the first year there was a 657 percent reduction of opioid use and by the end of the second year, there was over an 80 percent reduction of opioid use. these statistics reveal education , evidence-based clinical treatment protocols have a dramatic impact on the fight against opioid addiction and overdose. more importantly, alto
4:23 pm
programs can save lives and already there are position acceptance across the country to use alto protocols. emergency department initiated, and 80 or medical assistant treatment represents the treatment arm of the equation. let me give you a moment to tell you about every single patient and it did was dependent on opioids for heroin, their fears are going into withdrawal. experiencing withdrawal experiences a feeling of being sick, agitation. these patients either have to do another dose of opioids to stop the withdrawal or they need medical assistant treatment to stop feeling sick and stop the withdrawal. ed initiated medical assistant treatment alone has shown positive results in getting patients with substance use disorders into addiction treatment but an
4:24 pm
80+ a warm hand often yields the best opportunity for success in getting patients into addictiontreatment as well as decreasing the need for inpatient addiction treatment services . hr 5176 requires that healthcare sites have to essential ingredients that emergency physicians would like. providers that are trained and licensed to provide mad and number two, agreements with community providers and facilities continued services , a warm handoff. we appreciate that congress has done to help the opioid epidemic. that $6 billion included in the bipartisan budget act of 2018 will be helpful in turning the tide against opioid issues . we urge you and your colleagues to not only authorize hr 5197 and hr 5176 , but to support full funding of these programs.
4:25 pm
this is one of the biggest healthcare challenges of our generation. it took many years to get to this point and unfortunately it will take some time to resolve the epidemic that we are on the right track. provide us with alto and nat tools and funding and emergency physicians will be able to provide a better future for our patients as well as society. >> thank you doctorrosenberg, you are recognized for five minutes . >> thank you chairman. mister burgess and ranking member greene, members of the committee, on behalf of the national indian health board of the 573 really recognized tribal nations we serve, thank you for holding this hearing . i'm stacy bohlen, advisor of the indian health board and a member of the tribe of chippewa indians in michigan.
4:26 pm
current opioid epidemic represents one of the most pressing public health crises affecting tribal communities. while this epidemic is impacting many communities through america, it is disproportionately impacted tribes and has further strained the limited public health and healthcare resources available to the tribe. american indians and alaska natives have the highest rate of drug overdose deaths every year from 2008 through 2015. 519 percent increase in drug overdose deaths from 1999 to 2015 is also one of our statistics. these demonstrate the critical need for more comprehensive interventions in tribal community to improve dimension through treatment measures. the epidemic is so bad that several tribes through the country have declared a state of emergency to tackle the crisis. historical and intergenerational trauma including trauma across the lifespan, lack of funding at
4:27 pm
the indian health service and a failure by states to include tribes at state level prevention and public health programs all contribute to this crisis. in minnesota, american indian women were 8.7 times more likely to be diagnosed with maternal opioid dependency and american indians were 4.7 times more likely to be born with neonatal syndrome given the repercussions of the trauma and this crisis are intergenerational. but the lack of funding for the indian health system overallis one of the greatest systemic contributors to this crisis . needed care due to lack of funding, physician workforce shortages and ihs has created a greater dependence on opioids. limited funding means denial of immediate care, nearly 80,000 times in 2016 alone.
4:28 pm
instead of being referred for surgery or simpler treatment, issues are placed on prescription opioidmedication to address their pain as they wait for treatment . and sometimes they wait for years. policy solutions should focus on allowing tribes access to long-term sustained resources improving data and disease surveillance and traditional approaches. what would we like congress to do? allow tribes access to the state targeted response to opioid epidemic grants. health board supports the provisions of hr 5140 two address this. we also request the legislationinclude a 10 percent set aside for tribes . direct funding of tribes reinforces the tribal sovereignty and the government government relationship between the federal government and the tribe. it will ensure tribal communities are directing the programming so it can be most effective.
4:29 pm
number two, establish tribally specific funding streams such as behavioral health programs for indians modeled after the special diabetes program for india. hr 3704, big access health improvement act, number three, ensure parity between states and tribes in any opioid -related legislation enhanced by this congress. this means specifically including tribes as eligible entities and requiring tribal consultation information, data sharing and funding set aside at the state level. number four, ensure that cultural and traditional healing practices are able to be utilized as federal resources, that include medical funding. tribal communities have been healing our own people for thousandsof years and these practices are highly effective in the communities where they are used . finally, establish coordination with tribes to reduce the burden of
4:30 pm
substance abuse disorders including those involving opioids. and we just learned that tribes received a $50 million set aside in the fiscal year 28 omnibus for the state opioid response grant and 5 million was set aside for tribal medication assisted treatment. this is very important to us. we know members of this committee were activists in getting this effort to happen and we say a big thank you chairman glitch, this is an excellent start. health information technology and data also represents a serious challenge when it comes to the opioid crisis. i understand my time is expired and i want to be respectful of the other witnesses sold the rest of my remarks appear in written testimony. >> thank you for your testimony and your full remarks will be made part of the record. you are recognized for five minutes .>> chairman burgess, ranking member greene and subcommittee
4:31 pm
members, my name is alexis horn, vice president of government relations for clean slate addiction centers. clean slate is grateful for the opportunity to testify on hr 3692, the addiction treatment improvement act and hr 5102, the substance abuse disorder workforce loan repayment act, two bills that will expand access to treatment and promote the growth of a stable high-quality substance abuse disorder workforce capable of meetingthe growing demand for evidence-based treatment for opioid abuse disorder. clean slate is an opioid treatment program , that means we help patients overcome therapies commonly known as suboxone individual ..
4:32 pm
massachusetts, indiana, texas, florida, wisconsin and connecticut with 8000 patients under our active care since 2009 we have treated 28000 patients which gives us a key understanding of the role medical treatment for opioid addiction plays in ending the epidemic. we plan to open our first centers in ohio and kentucky this spring. our decision to open a new center attempts to recruit and contract community outreach effort. sadly there is no shortage of demand for treatment services. providing service to meet demand is difficult due to the challenges we face in finding willing subscribers in support of our program.
4:33 pm
some are at or near the prescription limits. despite our workforce efforts. we are not able to meet the demand for treatment in the communities we serve. the comprehensio comprehensive addiction act took important steps to close the gap but it continues to grow while the workforce is not grow commensurately. to get a sense of the dynamic we face, they hired and trained 85 providers to our internal program. 58 of 85 providers did not have the prescribing waiver before they came to clean slate. even with these additions we still face challenges. the addiction treatment act and hr 5102, the substance abuse disorder loan repayment act will close key parts of the treatment gap that exists
4:34 pm
in our country we appreciate that these measures are under active consideration by the committee today. [inaudible] allow me too share the experiences of some of our centers to illustrate this point. the indiana treatment center employees for prescribers who are authorized to prescribed for a combined total of 190 patients. still we have 60 patients on a waiting list. as a result some patients drive an hour away to another clean slate program to access treatment. it may sound like a lot of capacity but in january 85 new patients joined. our capacity to treat more people could and likely be filled by the end of april.
4:35 pm
the addiction treatment act improvement act introduced by representative paul addresses these challenges by allowing a larger pool of technicians to prescribe and make that authority permanent and by allowing highly credentialed prescribers and those working in qualified practices to treat up to 100 patients at the outset instead of just 30 as with current law. i've stated before prescription limitations are not the only barrier to expanding access to treatment. the remains of provider to our willingness to work due in part to the complex, medical needs of patients with opioid abuse disorder as well as the stigma associated with population. these make recruiter provider challenging. hr 5102, substance abuse disorder workforce loan repayment act represented by catherine clark authorizes a robust repayment program for
4:36 pm
wide range of professionals provide treatment in underserved areas. not only will it allow them to begin careers treating substance abuse disorders but it will also help stabilize workforce by meeting payments for over six years. clean slate supports these important bills. together hr 3692 and hr 5102 directly address barriers. thank you chairman and members of the subcommittee for the opportunity to speak in support of these bills and on behalf of my organization and the addiction treatment fuel that large. they are building support for the policy changes needed in our field and we look forward
4:37 pm
to assisting you in anyway. >> we thank you for your testimony. >> thank you for your testimony. it has been a long day. at this time will move into the question portion and members are each recognized for five minutes for a series of questions. first i have an opening statement and then i'll ask members of the panel. prescribing without wraparound services is substandard care. i'm supportive of doing every weekend to combat the price of affecting the country. however, it's important to do
4:38 pm
so in a thoughtful way. i was a heart surgeon before. i'm a medical person. professional with no expertise can now prescribe, ultimately, up to 275 patients, that's about 14 patients. day. they are seeing this just once. month. do you think providers seeing 14 patients a day is consistently able to provide comprehensive therapeutic services to fit the needs of his or her patients? >> thank you for that question. the training part, i can only speak on behalf of clean slate and how we train our physicians, they do come from a wide range of backgrounds regardless of their background, they are all put through a four week training program including on-site learning and training. in terms of the wraparound services, all of our
4:39 pm
clinicians are trained to make sure the patient has at least access too, and not just access in terms of here's a business card, but a warm connection to the referrals that we've made as part of the community outreach in terms of how we set up in a new community. we believe our providers are providing extensive supportive counseling and relying on the expertise within the community to fill their primary care, dental care, ob/gyn care and other need. >> i guess if you hired someone new and they had to go through your trading, would you think they should be able to see 14 patients a day all month? and that's in your testimony. based on the legislation is what you're implying that they should be able to go right into the full amount right off the bat. >> we do because we believe we have established programs that provide the administration care coordination and clinical support necessary to enable that position or that nurse
4:40 pm
presse practitioner to really attend to the addiction treatment needs. >> if he were trying to expand the scope of the can do this with a three year, with the pilot type of practitioner. do you think we should really lock in this big of an increase in the number of patients before we've seen a single piece of data from hhs as was part of care, to see if these practices are successfully treating patients and adhering to the evidence-based guidelines and ensuring you can offer and or methadone which is one of the most diverted medications which is not being further diverted. if we expanded this to get data to see if it was successful. >> again, i will speak on behalf of clean slate and i will answer this in two parts. we feel like we have some data that shows our treatment programs are successful. we work with a pair to look at
4:41 pm
our patient outcome and they showed patients with been in treatment with us for six months as compared to the treatment six months prior, for 35% rejection in use of er, 25% use of reduction in any hospital stay and reduce their conversion to hepatitis c by about 80%. we feel that in our program that really wraps the patients with services in the providers that work with them, the tools they need to do their job. we have worked for almost a year with advanced practice commission thanks in part to the carrabelle and they are incredible and additions to our team. there's no way we could meet the demand for treatment in the community without them and they work in collaboration with our physicians. >> i just say this, sometimes the end doesn't justify the
4:42 pm
mea mean. i get that there's a lot of people on the waiting list but as a healthcare provider i think we also want to be cautious. your program is excellent, but there are others out there that probably are not. we try to put public policy in place, we want to make sure, i do at least, we want to make sure we think about the patient at the end of the day and across country, what is going to work. i would argue against immediately expanding to 275 without some sort of a ramp-up. that's my personal view. i go back mr. chairman. >> thank you but they yelled back. the gentleman from mr. texas is recognized. >> thank you. one think all our panelists and i'll start my questions with ms. nicole. you note in your testimony that i've been working with congressman guthrie to introduce a comprehensive
4:43 pm
centers act. in your testimony, you highlight that of the 21 million americans who need treatment for substance use disorder, only 10% receive such treatment. this is almost begs the questio question, why are more americans in need receiving the treatment? >> our treatment system has a lot of gaps we need to fill in there's lots of silos and fragmentation's. i believe the act will help us fill some of those gaps and make sure that going to three different places, for example, to receive the medication if you haven't opioid use disorder can be very difficult and we need to make sure we are streamlining how to have patient centered care so the right medication is identified and given to the patient based on the doctor's advice and not just on who you happen to find near you or on google search or by calling someone offered a commercial pet we need to make sure this is led by healthcare and have better
4:44 pm
provision of evidence-based service. >> one of the most common barriers to receiving the treatment? >> i think we have some pear issues with certifying coverage and how do you pay for this, we have a lot of navigation problems that when this is your family, your usually thinking about how i google someplace and empty out my savings account rather than how i go find the right position or a counselor to help me build a treatment plan for myself for my loved one. i think the external healthcare, removing the summer healthcare system is one of the biggest barriers to making sure we get the treatments for all the patients who need it. >> one unique requirement of legislation is the need for treatment centers to have trained personnel responsible for outreach as key community holders. can you speak to the importance of this community
4:45 pm
integration as part of the treatment and recovery? >> absolutely. addiction is an illness, but mostly in adolescence or young adulthood. most who have a substance abuse disorder began in those earlier years. it's very important make sure you are initiating treatment and intervening early. right now this is the only disease that we wait for it to worsen before we treat it. can you imagine for waiting for an invitation before you would treat diabetes? when you have those community outreach functions, to make sure were getting the help we need in the places where you can intervene earlier and have better outcomes for patients. >> i know you work with the addiction policy form. you have expressed with treatment that has included outreach to these key community stakeholders? if so can you share how it has not improved the treatment outcomes? >> i think any opportunity you have for community outreach will improve your outcomes and your access to care. we need to vastly expand that
4:46 pm
type of service and coronation, we need to go into younger ages and figure out how to get into families and communities so they know how to ask for help the way to go for evidence-based care. high schools and employers and workplace, through colleges, through churches, it doesn't really matter how they come in the door, but you need to make sure that they found the right help so they don't get taken advantage of or directed to a non- evidence-based care. >> in your work with your family members, people who unfortunately have lost their battle with addiction, as a result of the opioid overdose, how, common is it that they complete treatment without being offered a range of treatment options, and necessary support services. >> unfortunately, all of our families a very large majority could not find evidence-based care or they were denied care were offered very short
4:47 pm
periods of treatment, 14 days or 21 days instead of a long-term wraparound care that's needed. as i mentioned, trouble accessing medications to treat addiction, not providing mat for someone who has an opioid use disorder or has a very difficult time having a positive outcome. this is common in the stories we hear over and over again of not having that quality care. >> mission, thank you. last month the cdc published troubling data showing will between july and september, opioid overdose visits in emergency room departments increased by 30%. in addition they are increasing among men and women of all ages from all parts of the country. this data highlights increasing severity and the critical role departments must play in response to this. i yield back what little time i have.
4:48 pm
>> the gentleman's time has expired. >> thank you, mr. chairman. thank you once again for your continued effort on holding these hearings. it means a lot to me and so many other families. thank you for the panel for being here. thank you for sticking with us. it has been a long day. i do appreciate it. stacy, thank you for working with us on the task force coming in and talking to the staff on monday. thank you for educating us and working with us trying to figure out how we can help better serve indian country as a whole. as you said in your testimony, this accidental overdosing, i represent the great state of oklahoma. i'm jerking myself and it has
4:49 pm
the highest native american population of any district. this hits home really tough. part of what we are trying to do is make sure that it's not overlooked. tribes are unique because we are considered sovereign nations and so by getting funding to indian country is vitally important because most healthcare for native americans are in the system. i understand most people don't understand that, but it's where i grew up my whole life. i'm still living in indian country. i'm still living in the same place i was raised in my family was raised. we are generational there. i got a question for you, what are the benefits to direct funding the tribes and throughout this program? >> thank you congressman. >> first of all, directly
4:50 pm
funding the tribes upholds the federal trust responsibility and as you so eloquently expressed, promises made in the treaties to the tribe, the trust relationship that is established in the constitution federal law and so forth is a relationship between the federal government and the tribes. when funding for programs is set to the states with the hope or maybe even the intention that the state will share that funding with the tribe, there is no legal obligation and there is no accountability whatsoever on whether any of that money will reach the tribe. that is largely because the trust responsibility cannot be delegated to the states. it has to be honored at the federal level. the benefits are tremendous. if i may, special diabetes programs for indians, it's not a large investment from the government to the tribe, but it's a public health program
4:51 pm
that is taking the best of western medicine in the best of tribal traditional practices in implementing the prevention and treatment program that is probably, after immunizations, the most successful public health program in the country. the tribes know how too do this. >> on elaborate for just a second what you said. it's not their obligation. it is not the states obligation. the treaty was made with the federal government and it's not a handout, it's payment from land that was taken from the tribes for years and years ago. that obligation in that payment still stays in place. for tribes to be able to ask the state for it, the state does look at it as it's not our obligation, which is not. it's not any fault to the state, oklahoma deals with this in a very unique way. i have 19 different tribes in my district and we have a unique relationship with the states, but we do have to realize to the grant programs
4:52 pm
they need to be available to the indian country also. one more question for you, can you just discuss the tactical challenge that we have that's hampering indian country with getting the data and the information they need? >> yes, i can talk about that briefly. the help it system in indian country does not have great interoperability among the various electronic health records and so forth that the tribes who are self-governing may choose to use an application that's different from what the indian health service that uses which is the our pms system. that system is very cumbersome in terms of trying to extract data and trying to make the picture you actually want to make out of the desperate ways that data is collected. there needs to be an investment in indian country to advance electronic medical records. the agency states it would
4:53 pm
require $3 billion over ten years to bring that system into par with what the rest of america is expressing. >> thank you so much. thank you again for working with us. thank you german. i yield back. >> the chair recognizes the gentleman from maryland. >> thank you very much mr. chairman. i want to thank the panel for very compelling testimony, i wanted to focus particularly on hr 5102 which has been mentioned, this is a bill that i'm very proud to be cosponsoring with mr. guthrie on this committee, but the prime sponsors are catherine clark of massachusetts and congressman rogers who have really taken the lead on this issue of trying to respond to shortages in the workforce and it's been touched on briefly, but i want to go over some of the statistics and information
4:54 pm
we have that call upon us to have an aggressive and creative response to the providers shortage but we know there are workforce shortages for all of the various substance abuse disorder healthcare professional categories across the united states. according to samson 2012, in addition, the turnover rates in the addiction services workforce range from 18.5% to over 50%. in a recent survey, nearly half of the clinical directors and agencies that specialize in providing substance use disorder treatment acknowledged difficulty in trying to fill these open positions and keep them felt. they are dealing with the lack of qualified applicants on one hand and the inability to keep folks in place on the other hand. in maryland where we are
4:55 pm
certainly facing, as every state in the country is, a severe crisis in terms of substance use disorder and the effects of the opioid addiction epidemic, i have been hearing this as well recently. i met with the head of baltimore medical system which is one of our qualified health centers in maryland and she told me about her own difficulty in finding and keeping healthcare professionals that specialize in this arena. the bill that's been introduced by congresswoman clark, congresswoman rogers and cosponsored in this committee by mr. guthrie and myself would create a pretty creative loan repayment program for substance use disorder treatment providers, participants in this program could receive up to $250,000 in loan forgiveness if they agree to work as a substance use disorder treatment
4:56 pm
professional in an area that is most in need of their services. that could be a mental health professional shortage area or an accounting or minutes pali that has overdose death rates above the national average, that would be one qualifying category. participants can work in a wide range of facilities which is important, community health centers, hospitals, recovery programs, correctional facilities, et cetera wherever the need exists in a significant way. it will be available to a broad range of direct care providers including physicians, registered nurses, social workers, other behavioral health providers, but we are hoping this will allow us to attract new providers into this very important field and it has received strong endorsements from the american society of addiction medicine, national
4:57 pm
council for behavioral health, the addiction policy form, and so forth but i'm very proud to be part of this but i do want to ask you miss one, just to speak if you could with a little more detail to what you have seen and gathered by way of data and otherwise about the shortage in this particular area of practice and what it would mean to have this kind of incentive program in place to address it. >> thank you for the opportunity. again, i will speak from clean slate perspective on this because i think it is a slice of reality that might reflect what other programs like ours are facing. recruitmenrecruitment is an ongoing challenge. there are not a lot of highly trained physicians or advanced practice clinicians with a lot of addiction medicine background or addiction psychiatry background but many that are out there are working in the field are ready so we are always looking for new,
4:58 pm
compassionate, committed talent to try to help us grow our programs across the country and try to keep the programs that we have running. as you mentioned, turner turnover is very high for various reasons in the field and turnover, while it might be a bear for us in terms of the administrative side, the biggest brought one is the danger to patient continuity of care. any effort, particularly this one i think will really help us bring younger talent to the field. the folks were really caring the highest that burden at this point, that's a good thing. i think these are probably folks were graduating in the last couple of years who may have had more of the addiction and pain medication education
4:59 pm
and also who may not have some of the same biases about a addiction treatment that exists in other areas of the treatment. certainly, for us, it's a wonderful tool we have in our toolbox to try to recruit the best so we can provide our patients with left care. >> thank you for testimony. i yield back. hopefully we will get this through and help will be on the way. thank you. >> the chair thanks the gentleman and recognizes the gentleman from georgia for five minutes. >> thank you for being here. i've described this academic as twofold. we have this part that's somewhat tangible that we can put our arms around and how is it that you control these numerous prescriptions being written. limiting the number of prescriptions in the number of pills, those things are somewhat tangible, but then we talk about all those millions of people who are addicted now, and how do you deal with that. that is a whole different
5:00 pm
subject, if you will, and a whole different situation. that's why i'm so glad to see all of you here and i appreciate it very much. doctor rosenberg, i was there with you because as the only pharmacist currently serving in congress, i find it fascinating, i feel like there's a big void that exists right now in medicine. i've preached this to the pharmaceutical manufacturers, that we have opioids and want to get past opioids we really don't have anything else to prescribe. : :
5:01 pm
>> you had to get the antibiotic with a pain pill but now i will acknowledge you so i will study that more. i want you to know how much i appreciate what you are doing. and to attend a conference a couple weeks ago we heard from a retired sheriff who told the story of young man of boy who was always late for school and in a family of opioid addicts
5:02 pm
and instead of a police officer putting him in and out of detention he discarded -- decided to mentor him and he had a birthday he said what do you want? he said i want to clock. he said because i don't want to be late i want to be on time. that is why i find your story so fascinating. how did you break that cycle? what was different? how can we mentor people? we know that in congress it's hard to break the cycles like that. >> when asked the question i come back it is all about finance with evidence-based and prevention programs for those who are impacted like me
5:03 pm
and early and i love that you mention mentoring because that was a key component for me as well. the mental health department in our county assigned me a big sister when i was 11 years old the first person i ever met who went to college and was a professional and a guide for me but also mandated mental health and i was living with my grandparents and we know how to identify children that were impacted so we can identify them early. >> i'm sure many of you read the book by jd van zandt it is fascinating and it is just
5:04 pm
what you are saying. the same scenario. also your testimony is fascinating and thank you for what you are doing. i really want to ask all of you, what works? that is what i am struggling with. so many of my colleagues think we just have to throw money but it is more than that. >> thank you for that question. it is a matter of throwing money at things but throwing money at the right things. so the surgeon general 2016 report said after year number one people like myself are considered in remission after five years we have an 85% chance to maintain long-term recovery so why are we not supporting people within that critical first year but up
5:05 pm
through the five years? >> it is a lifelong challenge. >> it is. me i have been detox multiple times and treatment does work in treatment saved my life but my 18 friends who have died in the last two years all were through treatment and detox. where the system is failing we are not spending enough time on recovery and recovery support services and we are bunching up treatment with recovery but treatment is not recovery. >> i am way over my time but i have to ask, do programs with a spiritual component work better than others? >> congressman there are multiple pathways to recovery. i am a member of the 12 step fellowship and that works for me but i have seen programs
5:06 pm
faith-based, those who are agnostic there are many different ways people do this. >> that is a big challenge. we will fund the programs that work but it is a struggle. >> i will say that every year i go and they released the numbers and we know that how many people are addicted to heroin, cocaine, the age groups, state-by-state data there are 23 million people living in long-term recovery and i don't believe the federal government has spent time studying us and how we achieve that so maybe that is a good first step. >> thanks to all of you for being here. i yield back.
5:07 pm
>> be met as one of the previous members said it has been a long day and we appreciate you being here. i represent 22 counties, mostly world and small cities the biggest is 25000 the smallest of my cities is 3500 we are in the areas that are underserved for drug abuse and mental health we have problems there. and they don't have anywhere to go and trying to do as they can so that is where my
5:08 pm
questions are coming from. so it is important to build a pipeline of qualified healthcare providers trained in disorder treatment pain and management so what type of healthcare workers educate and how does the teach act and if you just do the big ones you will not reach all of my counties. >> it just helps to make sure we have the right curriculum and training to all healthcare providers from physician positions, pediatricians, nurse practitioners we move this to a chronic disease model to make sure we have
5:09 pm
qualified and trained healthcare providers so they can identify and assess. there will not be as much specialty treatment we are ordering -- doing work on the ground in ohio and rule communities it is hard to find treatment and prescribers that can prescribe the medicine that they need. they can do long care follow-up but also so depending on the severity. >> i appreciate that the
5:10 pm
opioid recovery centers act will identify the best centers in america to provide care for addiction and recovery so congress with direct funding in turn they will provide the models of care especially with excellence or is the goal to lift all votes with the rising tide so to reach that level then obviously if it doesn't meet the gold standard but what do you think? >> i do think it could help with both to create the centers of excellence to advance what patient centered care looks like in those
5:11 pm
components manned i do think it has both affects a lot of rural communities are struggling and with protocols in place and i believe the opioid recovery centers will help to do that. >> and for those who came to see me i hope they know we are trying to find something in several of those full that are in recovery it isn't easy we appreciate all of you all of you that have testified -- testified they have had issues now in recovery and i complement you all and we realize there is a lot of talent out there we are wasting.
5:12 pm
>> does a gentleman from oregon seek recognition? >> yes. thanks to the panel for coming and sharing their stories hopefully to craft a better solution at the end of the day. as a colleague of mine i would like to heal to the ranking member. >> things to my colleague for yielding. i've got a question when i was practicing law at the mental health process i saw so many times when it was a revolving door. and a lot of things we don't understand it is a lifelong illness and i would see these patients or clients of mine on a regular basis you were doing fine and then felt so good i didn't think i needed my medication is anybody in your
5:13 pm
house will have heart trouble? you have to take your medication. so this is a lifelong illness in some cases that we need to recognize that. we would like a cure would also like a cure for cancer but we are still trying to manage it. so are you comfortable with sharing? tell us about the background of substance abuse disorder be met my addiction started at an early age. i was 12 years old and it progressed as the years went by and when i was 28 years old i got into trouble with my addiction and i had to go to
5:14 pm
residential treatment over 28 days. and in that treatment center was given the tools to learn about my addiction and how to help myself get through hard times and when i got out of treatment the director that i worked helped me through the process because he was in recovery himself. so i did have support in my recovery so im therefore the people that are in recovery and i help them get along and i take them to the hospital and get the medication they are prescribed i talked to my therapist and counselor's and we find a better way to treat them if it is in opioid they are prescribing then we have
5:15 pm
to say is this for them? or the other alternative to get them through a hard time. and congratulations with the pierce support specialist so what is the most important aspect working with people in recovery? because how that works around the country because the people like me are there you cannot do this or yes you can and to meet them halfway.
5:16 pm
and then to call me when and i am there for them. >> you are recognized and i am grateful like a life or death issue and then choose the congress working together and in particular we had a hand in addiction treatment improvement act combining
5:17 pm
these bills would expand access to medication -assisted treatments in opioid use disorders and prepare the next generation for the workforce to tackle the disease of addiction. so thank you for your testimony of the access improvement act. and as part of the addiction workforce. or high skilled nursing prevention -like substance abuse treatment to help us meet the demand of the community to have that authority if we are willing to
5:18 pm
do it and to save more than those wonderful additions to the team they work alongside with the physicians they are the backbone of our programs. with additional highly interested prescribers and is not easy to find folks who are as eager or willing to work if they want to be part of the solution to join our team we are more than welcome. >> i think traveling without illness is essential. again how do other high
5:19 pm
treatment centers work to work and how does the improvement act specifically encourage expanded treatment capacity like clean slate? >> i'm not sure i talked much about our treatment model it is a high touch models of those patients that come to the centers are seeing with a high level of frequency so the more severe your illness the more frequently you are seeing about twice a week and as you progress with your recovery and that even the most stable and that is important for a number of reasons and to bring them with each visit drug
5:20 pm
screens that we are testing for what you make sure they take the medication properly and also more standard diversion control tactics with patient recalls they have to come in to bring their phones and those things all combined we are secure they are using the medication as prescribed but if for some reason they get rid of the medication then that would be a cold stop that is the reason why we would ask a patient to leave but now having said that that isn't in the interest of the community to make sure that patient is somewhere else in the community so they are not
5:21 pm
exited to nothing but the ideally is when they can rejoin what we do take a pretty hard stance on that. >> your testimony described a waiting list to treatment in your facility but unfortunately it isn't isolated as i have spoken with individuals in my district to have had to wait a year or more for treatment when struggling with addiction waiting for their chance of recovery? >> first and foremost data shows that if access is a relapse prevention tool also greatly reduces chances they will overdose someone they come to the center talk about readiness for change to open the door to bring them in right away to turn a patient away means we feel that we put
5:22 pm
them at risk for relapse or overdose and it is demoralizing to be ready for change and enter treatment and then not be able to access when you are ready. we will do everything we can to ensure that patient is at least seen in a treatment program in the community or that they can access the next closest center but fundamentally it is a lost opportunity that really shouldn't exist. >> i yield back. >> does the gentleman from texas have a request? >> so in support of hr. ninety-seven and also a statement from congress and in
5:23 pm
support of hr 51 substance abuse disorder loan repayment act of 2018 i asked consent to place those in the record. >> without objection. >> to be intrigued by your testimony and alternatives to the emergency department there is an ancillary bill practically related to what you are doing but it seems to me that it does have some connection we were talking about the difficulty of developing new treatments for pain and the data set is sometimes indecipherable. and you seem to be doing some work as you describe as alternative pathways?
5:24 pm
so there is a bill in draft form right now to encourage the fda to develop draft guidance for alternative pain medicines with the breakthrough designation along that pathway end doctor gottlieb referenced how difficult that is with research and regulatory environment and you seem to have find -- found a way to make it useful? >> correct. >> so the principles and their only used to be tylenol and motrin and opioids and to
5:25 pm
guarantee the patient the best treatment we would give them opioids obviously that was a bad decision. but the principles so those existing protocols without use of opioids and to give a quick example if anybody had kidney stones that is tremendously painful but there have been treatment protocols and successes using lidocaine that we use to use commonly for cardiac now it works tremendously well for people with renal colic so it relieves the pain and we have to do more study but it does seem like it passes the kidney stone more quickly. so with those existing protocols and those that are
5:26 pm
out there. these medications with those protocols together to get the maximum benefit of the patient. >> i am old enough to believe that we no longer have those in our toolbox. your testimony is compelling. i assumed you are from california? so with new regulations at the state level?
5:27 pm
>> i wasn't sure but then i googled it. and silver living home california a lot comes up we had some oversight in the subcommittee to say this delicately but apparently all sold for a living homes are not created equal. >> it is correct. we have all seen the advertisements i had wondered about those so if somebody is offering help.
5:28 pm
how do you navigate that? to find a stable home to know firsthand knowledge or referrals on that claims based marketing so by sheer luck that i sit here today finding my way into a stable recovery residence i lived in florida for some time and i have been through unscrupulous homes to have a hard time navigating the system and there is a solution in looking at the
5:29 pm
federal level when we came up with that speech there was no federal standard here is what a recovery residence should look like. and that helped to craft that california legislation and other states are looking for that as well. there is a lot of good places that people could find and we could draw them a roadmap but they don't have these types of budgets and the money they have made. >> and we weren't asked to submit in writing with the
5:30 pm
previous and to be safe is that a fair statement? and i would say that pierce support and without those wraparound services and with the housing issue and i was in the super majority of silver homes in the united states there is a huge disparity with somebody on mat can receive. >> you have been a great panel
5:31 pm
thanks to the witnesses for being here and the american medicine foundation with the academy of addiction psychiatry american association of osteopathic medicine and american nurses association the american society of addiction association for behavioral health and the international certification and the legacy community health national board of certified counselors national council for behavioral health and united states representatives regarding the amendment to hr
5:32 pm
3545 to amend part two and that commission on drug addiction the articles from the following and bloomberg health management and further statements from the following american academy of endocrinology american society of addiction medicine and the association of chain drug stores united southeastern tribes and i would also like to submit patrick kennedy statement for the record and
5:33 pm
pursuant to committee rules to submit additional questions for the record within ten business days and without objection we are adjourned. [inaudible conversations] [inaudible conversations]
5:34 pm
5:35 pm
>> laying out a case there is a lot of competition so why is that the justice department did not see it the way that you did and what do they see different? >> the justice department has a very static view of the marketplace if you look at the definition i think it is the 1990s view not giving back to any of the changes that have happened, they take the market and the comcast of the world and the dishes of the world and they say okay there are virtual mvps but they don't compete with these other things going on in the world and that is a narrow way to look at it it is a very backward looking lawsuit as


info Stream Only

Uploaded by TV Archive on