tv Senate Health Hearing on Pain Management and New Treatments CSPAN February 13, 2019 7:59pm-10:07pm EST
were and abraham lincoln's pocket on the night of the assassination. you can see the remnants of the blood on these gloves today. >> join us on book tv this saturday at noon as we speak with local springfield authors and this sunday at 2 p.m., to learn about lincoln's ties to springfield and the political history of this town on american history tv. watch the cspan cities tour of springfield, illinois. working with our cable affiliates, as we explore the american story. >> next, hearing to examine pain management alternatives to opioids. the senate health committee heard from physicians, a pharmacist and an addiction advocate on efforts to end the epidemic of opioid addiction. the hearing is just over two hours. >> the senate committee on health education labor and pensions will please come to order. senator murray and i will both have an opening statement and
then we will introduce witnesses. after the testimony, senators will have a five minute round of questions. a man who is a constituent of mine in tennessee recently wrote to me about his wife who has a rare disease that causes chronic pain. he is concerned because it has become more difficult for her to find access to painkillers. this is what he wrote. "she is not an abuser and is doing everything right. now it is harder for her to get the medicine she needs.." >> his life is one of 100 million americans who according to a 2011 report by what is now the national academy of medicine, are living with some pain. that is about 30% of americans. 25 million of those, the academy said, have moderate to severe pain. in a report in 2018 by the center for disease control and prevention says that about 50 million americans have chronic pain. about 20 million of those americans have high impact
chronic pain. here is the reality. we are engaged in a massive bipartisan effort to make dramatic reductions in the supply and use of opioids, which is the most effective painkiller that we have. on the theory that every action has an unintended consequence, we want to make sure that as we deal with the opioid crisis, that we keep in mind those americans who are hurting. we are holding this hearing to better understand the causes of pain, how we can improve care for patients with pain, where we are on developing new medicines and ways to treat pain. we know that pain is one of the most frequent reasons that people see a doctor. and according to the mayo clinic, the number of adults in the united states with pain is higher than the number of people with diabetes, heart disease and cancer combined. these americans need more effective ways than opioids or other addictive painkillers to
manage pain. opioids, which are commonly used to treat pain, can lead to addiction and overuse. we know that well. one -- more than 70,000 americans died of drug overdoses last year including prescription opioids, making it the biggest public health crisis in our country affecting nearly every community. last year, in the midst of the acrimony of the brett kavanaugh hearing, congress saw 72 different senators -- 70 senators offering 72 different suggestions for a comprehensive opioid legislation which passed the congress and which president trump signed and called the largest single bill to combat a drug crisis in the history of our country. that legislation from all the senators included eight committees in the house and five in the senate. it included reauthorizing training programs for doctors and nurses who prescribe
treatments for pain, increasing access to behavioral and mental health providers, encouraging the use of blister packs for opioids such as three or seven day supplies and safe ways of disposing unused drugs. we also took steps to ensure our new law would make life harder for patients with pain but now we have to take the next step to find new ways to help them. first, we gave the national institutes of health more flexibility and authority to spur research and development of new nonaddictive painkillers. we also asked the food and drug administration to provide guidance for those developing painkillers and get them to patients more quickly. i am pleased to see the announcement this morning that the agency is developing new guidances on how fda evaluates the risks and the benefits of new opioid treatments for patients with pain and to help the development of non- opioid treatments for pain. a witness that one of our hearings called new nonaddictive painkillers the
holy grail to solving the opioid crisis. we have backed up those new authorities with substantial funding. most recently, 500 million to help the national institutes of health find a new nonaddictive painkiller. second, we included provisions to encourage new pain management strategies such as physical therapy. third, the new law requires experts to study chronic pain and report to the director of the national institutes for health on how patients can better manage pain. fourth, the new law requires the secretary of health and human services to report the impact on pain patients that federal and state laws and regulations that limit the length, quantity and dosage of opioid prescriptions. now that we have started to turn the train around and head in a direction that is different on the use of opioids, everyone of us, doctors and nurses, patients, senators, congressmen, will have to think about the different ways that we treat and manage pain.
there are other things the federal government is doing to see what causes pain and how we treat and manage it. for example, the national pain strategy developed by the end or agency coordinating committee, which develops recommendations to prevent, treat, manage and research pain. through the national institute on drug abuse and the national institute of health heel initiative, researchers are working to better understand pain and why some people experience it differently then others. this will help us find more ways to more effectively treat pain and help get people the treatment they need. for example, physical therapy or exercise may be the best course of treatment for some kinds of back pain. it may also help us understand why some people can take opioids or manage pain for years without becoming addicted while others more easily become addicted. today, i hope to hear more about how close we are to having nonaddictive painkillers
and how doctors and nurses can better treat americans who live with pain. senator murray. >> thank you very much mr. chairman and thank you to all of our witnesses for joining us today. this committee has done a lot of important work on the opioid crisis that families and communities across the country are facing. i was glad we were able to come together last year to take strong bipartisan steps to address some of the causes and ripple effects of the opioid crisis. i hope we can continue to build on that work. however the hearing does offer an important opportunity to take a slightly different perspective on some of the challenges related to the use of opioids. and i hope it can serve as a reminder that while we are working to address substance use disorder and health and help the families facing it, we cannot forget the people facing pain, both acute and chronic. and we cannot overlook how important it is that they get the tools they need to manage their pain and find relief.
for too long, providers were incentivized to think of opioids as an easy and harmless solution to addressing pain. and the lack of understanding about pain management and the risks of opioid prescribing meant healthcare providers prescribed opioids far more often then was necessary contributing to the tragic increase in opioid misuse. but that does not mean the solution to the opioid crisis is to stop finding ways to help patients manage pain. we have to find responsible, comprehensive solutions for pain management that ensure that opioids are marketed, prescribed and used responsibly. but at the same time, are within reach for people dealing with chronic pain. it is important to remember that for many people who are elderly, people who have been seriously injured, people with chronic health conditions or who are undergoing aggressive health treatments and for people who have a disability. pain seriously impacts their day-to-day lives. 15 million
people nationwide suffer from pain that persists for weeks or even years. for almost 20 million people, this pain can interfere with their work and daily life activities. pain management is an absolutely critical quality-of- life issue for these people and their families. acute and chronic pain can make it harder to keep a job and earn a paycheck. even when treated, pain can make it difficult to travel to and from work and sit at a desk for long stretches of time. and pain doesn't just affect a person's livelihood. it affects every aspect of their life. without pain management, patients may not be able to tackle the tasks they need to live independently like getting dressed or driving a car or doing laundry. they may not be able to spend quality time with loved ones as pain can make it hard to enjoy a meal with friends or family or attend a grandkid's soccer game or even leave the house. without the right pain management tools, some patients struggle to get a decent night sleep. for people living with pain, the ability to get treatments
that help them manage it can impact their entire lives and i am very interested to hear from one of our witnesses today to offer her first-hand perspective on this. we appreciate you being here. it is so important that we listen to patients about their healthcare needs. whether that is finding ways to address that person's pain or recognizing, when asking for painkillers as a result of addiction, which requires an entirely different form of treatment. of course, another part of what makes this issue so challenging is that no two people experience pain the same way. how pain is felt, how severe it is, how long it lasts and how much it impacts their life can vary -- can differ widely from person to person. pain is not a one-size-fits-all and the tools we use to manage it cannot be either. we need to do more to make sure everyone facing pain is able to get treatment that works for them. this means ensuring research is done to better understand the biological basis of pain and the factors that determine what might work best for of
patients. it means training providers to understand pain symptoms and truly listen to needs of the patients and to consider lower risk, less invasive options before turning to more extreme measures. and it means making sure it ensures policy, support access to these options rather than incentivizing providers to simply write a prescription for in opioid without taking the time to understand what might work best for that patient. and for somewhat severe pain, it may mean responsible opioid prescribing. but for many others, there options that will work better and have lower risk of addiction. other type of drugs may better fit needs, to services like physical therapy, to treatments that help address the psychosocial dynamics of pain, by a cognitive behavioral therapy come to support for modifying lifestyles in ways that might help manage pain like their exercise. and it means addressing threats to their healthcare like the
partisan legal threat from the republican lawsuit that could strike down protections for people with pre-existing conditions including people affected by pain. during our hearing today, i am interested to see what insights our witnesses have to offer about these very complex problems and what steps we can take to help people get the support they need to manage pain. for example, what can we do to make sure that insurers cover pain management options that patients need and do so in ways that help them quickly find the treatment that works best for them. how can we tackle the workforce shortage and make sure people in pain are able to find a cure provider that can serve them close to their home. what can we do to address health disparities when it comes to pain treatment and how can we make sure employers understand their obligations to accommodate employees who are struggling with chronic pain under the americans with disabilities act and help them learn how best to support those
employees. as we continue our efforts to respond to this opioid crisis and build on the strong bipartisan steps we took last year, i am really glad that we have this opportunity to take a look at another very important angle of this challenge. thank you. >> thank you senator murray and thank you to you and your staff for working to make this bipartisan hearing which is an important follow-up to our work on the opioids bill last year. each witness will have up to five minutes for his or her testimony. we welcome each of you and thank you for coming. our first witness is cindy steinberg. she is a national director of policy and advocacy at the u.s. pain foundation and chair of the policy council of the massachusetts pain initiative. she was appointed in may of 2018 by the secretary of the department of health and human services to serve on the pain management best practices interagency task force and she previously served on the interagency pain research coordinating committee of the national institutes of health.
senator smith, would you like to introduce the next witness. >> thank you chair alexander. i am honored today to introduce dr. dr. gazelle. her work represents the healthcare innovation that is happening in minnesota and at the mayo clinic. she is the director of inpatient pain services and the division of pain management at rochester. and she is also an assistant professor of anesthesiology at the mayo clinic college of medicine. she is dedicated her professional life to pain medicine and palliative medicine. she has worked extensively in opioid management as well as acute and chronic pain management. most recently, she was appointed by hhh secretary alex cesar to serve on the pain management best practices interagency task force. a mouthful and very important
work. she attended the university of minnesota medical school and completed her residency and fellowships at the mayo clinic college of medicine. i think that her professional experience makes her perfectly suited to testify before us today on pain management during this opioid crisis. and i know that we will all benefit from your expertise. so thank you so much for taking time away from your practice and your patients to be with us today. >> thank you, senator smith. dr. andrew cooper is the next witness and professor of academic affairs at the maryland school of pharmacy. currently researching a new opioid analgesic that may have less potential for abuse and diversion finally, senator burr, will you introduce our remaining witness. >> thank you for holding this important hearing. i welcome all of our witnesses today. and i have a great pleasure to introduce a doctor from durham, north carolina.
the current role as lead medical director at blue cross blue shield of north carolina. doctor patel is responsible for making coverage decisions for healthcare services and prescription drugs for a number of health benefit plans offered by north carolina blue cross. she has also spent much of her career treating patients with chronic and painful conditions such as lower back pain and migraine headaches. dr. patel is board certified in physical medicine and rehabilitation and an active member of the american academy of physical medicine and rehabilitation and the american medical association. before moving to north carolina, dr. patel received her medical training and medical degree from louisiana state university. she completed her internship in internal medicine at earl long hospital in baton rouge and residency training in physical medicine and rehabilitation at sinai hospital university of maryland in baltimore. i was overly impressed with her
background until i found out that her attending physician and her internship was docked at cassidy. i do know that she had a hard charging attending as she went through that internship. dr. patel, thank you for all of the important work you do on behalf of north carolina. i look forward to hearing your testimony before the committee today on how we approach pain management in north carolina during a very devastating time of opioid crisis in this country. >> dr. cassidy, do you have any comment on your former resident? >> so gratifying to see someone who was a former student do so well. so i am incredibly proud that you are here. i would is limited to that. >> thank you senator cassidy. why don't we began with ms. steinberg and if each of you would summarize your remarks and about five minutes, we will go right on the line.
welcome ms. steinberg. >> thank you for the introduction and for holding this hearing on a really important issue with pain management. it is a conversation that is long overdue. my life changed in an instant more than two decades ago when i was crushed in a serious accident that left me with severe back pain that has never gone away. on an otherwise typical day, my job as a manager at a technology company, i opened my file drawer and unbeknownst to me, there were cubicle walls stacked against it. the cabinet and all the walls fell on me, crushing me and causing extensive damage to my back and spine. i was suddenly plunged into a search for relief from an unrelenting burning band of hot coals across my mid-back and crushing pressure of clinched muscle spasms. chronic pain is very different from acute pain. it is relentless. it never ends. i often say that it feels like you are a prisoner in your own body only you are a prisoner
being tortured 24/7 and there is no escape. after a discouraging, difficult at times demeaning five year journey of searching for help, while trying to hold on to the career that i loved, i finally found a doctor that helped me pick even so, the pain eventually forced me to give up my career. out of my sense of loss and isolation, i decided to start a support group for others living with chronic pain. i was shocked at how many people started showing up for monthly meetings. all ages. men and women, all backgrounds. 18 years later, i am still running that group and more than 400 people have come to this group in a suburb of boston. i learned that my story is everyone's story with pain in america. although the causes of pain differ, each of us had had the same experience of struggling to find adequate care.
everyone had to see number for or five practitioners and had gone through years of discouraging and expensive trial and error treatments before they could find help. the scope of chronic pain is enormous. the number of americans impacted by pain and the human suffering involved and the cost of the healthcare system in society is staggering. you have said some of these things yourself. 50 million americans live with chronic pain. 20 million have high-impact chronic pain which is pain that affects their ability to work, live, socialize on a daily basis. pain is the number one reason why americans access the healthcare system. it is the leading cause of disability in the united states. pain cost the economy $600 billion a year in lost productivity and direct medical cost. despite the impact of pain, we failed as a country to effectively address it. we under invested in pain
research relative to its burden. less than 2% of the nih's annual budget has gone to pain research. we still do not understand the basic neurobiological mechanism of pain in the human body. medical students receive an average of nine hours of pain management training and four years. veterinarians get 87 hours. your pet is getting better pain management often then people do. and less than 1% of physicians are specialized in pain management. in the midst of the opioid crisis, there has never been a more important time for policymakers to improve pain management. some well-intentioned measures to contain the crisis have resulted in unintended consequences for chronic pain patients. we and other groups have heard from thousands of chronic pain patients who have been forcibly tapered off of medications or dropped from care completely by their doctors. this is inhumane and morally
reprehensible. opioids are one treatment among many. they should not be a first-line treatment for chronic pain. patients with providers must work together closely to carefully balance the benefits and risks for each person. nevertheless, for many pain sufferers, particularly those with severe pain, opioids can be a lifeline for lessening pain. in the near term, we can and must restore balance to opioid prescribing. in the long term, we must invest in the discovery of new, effective and safer options for people dealing with pain. there are however many steps we can take now to get people with chronic pain and the quality of care they so desperately need and deserve. from some examples, they include reducing insurance barriers to ensure that a full range of pharmacological and nonpharmacological treatment, including complementary treatment and medical devices
and technology are available and reimbursement models that encourage providers to dedicate the time and resources necessary to treat complexities of pain and to visualize multi- care plans, and reporting epidemiological data on pain. increasing research and understanding pain in the human body. and investing an ongoing patients support and teaching self-management skills for dealing with the chronic illness. congress has an excellent policy blueprint for implementing these measures to that blueprint is the report you mention. the report is due out in may and it has many excellent suggestions that i hope you will all implement. thank you. >> thank you so much for making the trip and for being here today. doctor, welcome. >> thank you. chairman alexander and members of the committee, thank you for allowing me to testify today.
i am an anesthesiologist practicing pain medicine at the mayo clinic in rochester, minnesota. the mayo clinic cares for more than 1.3 million patients annually. from all 50 states and from over 140 countries. the needs of our patients range from primary care to vary complex and serious conditions. i am honored to serve those in need of both acute and chronic pain care and palliative care. i am privileged to share my insight as a provider and leader at an organization that is thoughtfully addressing the pain management needs of our patients. pain management is at its essence, individualized medicine . no patient is the same as another and therefore, each condition, treatment and surgery has a unique impact with relation to pain. to ensure that patients receive appropriate training payment -- pain treatment, the mayo clinic started the program and 2016 which i chair. due to these efforts, we realize a dramatic reduction in the amount of opioids provided to our patients.
our program evaluated surgical specialties and we surveyed thousands of patients to develop internal prescribing guidelines. but they are not a replacement for clinical judgment. using these guidelines, some of our department have realized a reduction in opioid prescribing of up to 50%. all while maintaining a high level of patient satisfaction. the goal is not only to provide the best care at mayo clinic but to share our work with others. our experience has helped other healthcare organizations improve pain management, reduce opioid -related morbidity and decrease diversion. established in 1974 in rochester, the mayo clinic pain rehabilitation program has helped bring hope and management strategies to thousands with chronic pain over the past number for. similar centers have been established at our florida and arizona practices. while pain rehab is very effective, insurance coverage for it is limited.
for instance, it is covered medicare but not medicaid. today, i would like to convey number for points to you. first, dosage limits on opioids such as three and seven-day limits will not satisfy the acute pain requirements for patients equally patients and procedures differ significantly. a patient recovering from the removal of their wisdom teeth will have a very different pain management requirement than a patient recovering from a major orthopedic surgery or a trauma. these variations are the basis for our procedures specific and pay saint -- patient specific guidelines. chronic pain lasting for months to years could be related to cancer or could be as common as back pain for example. as a condition and the needs of all, physicians should utilize evidence-based interventions, medical therapy and restorative therapies to ensure proper management.
tip of the, patients with chronic pain, particularly when it is not cancer related, may be better candidates for non- opioid therapy is. individualized approach to care is paramount. and policies should promote the use of effective, none opioid treatments. further research is needed to determine why some patients with acute pain develop chronic painful conditions and to find a means to interrupt that progression. secondly, federal policy should embrace multifaceted approaches to the treatment of opioid use disorder including access and prevention. medicare and medicaid must develop additional coverage of and reimbursement for non- opioid. >> reporter: therapies and treatment regimens for chronic pain to prevent the contact with opioids that may ultimately lead to addiction. particularly for chronic pain where little medical evidence exists in support of long-term opioid use. other solutions to manage pain
maybe cost prohibitive, time- consuming and lack appropriate coverage by insurers. the basis of chronic pain management is focused on treating the whole individual with restorative, behavioral, psychosocial, medical and procedural elements combined appropriately to the patient and the condition. there is not only pain management providers and resources but in cases where opioid use disorder does complicate management, not enough treatment programs exist to satisfy that need. third, the optimization and standardization of prescription drug monitoring programs should be pursued. while most states currently utilize them, the existing programs are varied and the administered a burden is additive. nationally there is a greater need for coordination and consistency. finally, we believe that empowering patients is a major key to solving the epidemic. we must increasingly engage patients and shared decision- making and educate them on
treatments, risks and alternatives. we also believe the role of communities and local governments are important. because opioids provide only one facet of the problem, the epidemic will only be solved with a collective approach. thank you for the opportunity to join you today and for your efforts and ensuring proper pain management among the opioid crisis. i am happy to answer any questions. >> thank you, doctor. doctor cook. >> committee members, thank you for the opportunity to testify today. i am the associate dean for academic affairs at the university of maryland school of pharmacy. i am a chemist. i make new drugs. i was trained over the pond. a guy called john lewis who many people have forgotten about. he was the guy that discovered -- he trained me that academics are here to make discoveries but unless those discoveries translated to the
patient, it is all for nothing. i applaud the federal funding agencies for there on translational research. as we have heard, chronic pain is horrendous. we just owe everybody a better solution. there is a wonderful outstanding class of opioids and we should ensure that patients that require opioids get them. but we need to respect them. it is like a big dog. we have to respect them. i have been asked today about the new analgesics coming down the pipeline including, full disclosure, the compound i am working on. so there are a lot of other options. what about opioids. first of all, we need to define what we are talking about. if we don't define where we are trying to get, we are never going to get there, which is the reason i do not use the
word addiction. it is very hard to defined -- defined. i use the terms dependence and reinforcement. the two concept need to be solved when we are developing new opioid medications. what are they? dependence is when you chronically take a drug, and your body adapts so it becomes normal to have the drug present. you stop taking it and you go into withdrawal. there is only one surefire way of eliminating withdrawal. that is taking more drug. that happens in the clinic to patients. reinforcement is the high. taking a drug recreationally. it is acute. it is instant. you get high from taking the drug. so recreational seeking of a drug is seeking to get the high. long-term chronic is the dependence. they are two very different
concepts. we need to address both. so. we need to address both. if you think about formulations, they are designed so that they cannot be abused on the street. they are used in the clinic. that is great. they will not be diverted. but they will still cause dependence. so discontinuation was still cause withdrawal. so what is being done? we have -- activating one pathway or another. we have approaches where opioids only go to one place in the body. we have what i am doing and what many others are doing. where we actually target two biological systems where the second biological system prevents the dependence. many development in many academic -- and continuing
this funding for which thankfully neither in the nih -- we need the consistent funding. the fda has a critical role in addressing these drugs as mentioned by the chairman but not only does the fda need to do this rapidly but it needs to be safe. safe and effective. we need to ensure that we don't bring drugs to the market that make things worse. non- opioid medications. we have gone through some of these. some that were not mentioned. ibuprofen often works very well for many patients and we need to remember that. we have local anesthetic. we have channel blockers. we have nonpharmacological treatments. and yes, we need to do further research and yes, it is controversial. but we really should look at the potential of cannabinoids. the studies are not out there
if we don't have the studies, we cannot make the decision for the potential of cannabinoids. in the last two minutes, i want to talk quickly about my profession of pharmacy. pharmacists pretty much often get ignored in this crisis. they are accessible. they are trained. they are doctors. they are able to help with counseling patients on the appropriate medications to use and one major impact that the federal government could make is to expand the prescribing for medication assisted treatment to include pharmacists. it is called getting a waiver. so that pharmacists under a collaboration could prescribe you pronouncing in a very accessible pharmacy. thank you. >> welcome.
>> good morning. thank you chairman alexander and ranking member murray and distinguished members of the committee another staff for providing me the opportunity today to talk about the management of pain. during the opioid crisis. i am a lead medical director at blue cross blue shield of north carolina. my background is in physical medicine and rehabilitation. prior to joining blue cross four years ago, i was in private practice doing chronic pain management and management of addiction. i continue to remain clinically active. i see patients regularly in addition to my primary role at blue cross. i hope to provide any prospective today to the committee based on my clinical training and practice as a board certified podiatrist. my perspective as a medical director at blue cross north carolina as well. i have submitted written testimony that also expands on my comment. at blue cross north carolina, we serve close to 4 million customers. we are in every zip code of
every county. the ppo network has healthcare providers and includes 96% of medical doctors and 99% of general acute care hospitals. blue cross north carolina is accredited by the national committee for quality assurance. we are all aware of the scope of the issues with the opioid crisis, both the human and the financial toll it is having. in north carolina alone, the attorney general josh stein stated that four people died every day from an overdose and between 2017 and 2018, the number of fatal overdoses in north carolina increased by 33% and that is even with efforts to reduce overdose deaths by disturbing the locks on to reverse narcotic effects. blue cross and blue shield companies are strongly committed and doing our part to combating the epidemic of use disorder while ensuring patients living with chronic pain get access to appropriate evidence-based treatment. it as evidence of this unified commitment, i am listing several examples of things that we cover. we provide coverage for non- opioid pharmacological alternatives for pain management including anti-
inflammatories, antidepressants, anticonvulsants, topical analgesics and others. we provide coverage for non- pharmacological alternatives for pain including physical therapy, occupational therapy, aquatic therapy, chiropractic care, trigger point injections, interventional pain procedures, including blocks, epidural injections, spinal cord stimulator is. intra-articular acid injections for osteoarthritis. botox for migraine as well as others. we have endorsed the cdc guidelines purpose driving opioids for chronic pain and we are working collaboratively with the prescriber community to implement these, understanding that there is not a one-size-fits-all approach to managing pain. we support access to medication therapy including the associated counseling and behavioral therapy. we support a wide availability of no locks on.
we support enhanced operability of prescription drug monitoring systems and encourage providers to access this data before prescribing. as chronic pain is a legitimate and debilitating medical issue, there are many opportunities for physicians to continue to manage pain effectively with or without the use of opioids. physicians must incorporate universal precautions and the use of pain medicine for the treatment of chronic pain including making an accurate diagnosis, informed consent with the patients, treatment agreements, pre-and post intervention assessment to assess pain and function. the goal of long-term pain management is to support the patient improvement of function and quality of life as much as possible despite the ongoing pain symptoms. opioids are certainly an option to manage symptoms and should be prescribed thoughtfully and judiciously as part of a broader pain management regimen. in addition, patients must have realistic and honest expectations of pain management goals including understanding
in some circumstances, elimination of pain in its entirety is not a possibility but certainly a goal. providers it should continue self-education on appropriate prescribing and in pain management as well as participation in state and medical licensing boards on continuing medical education requirements. there must also be increased training in medical school along with residency programs and pain as well as addiction as well as increased research nationally on pain. finally, physicians and payers must understand, as mentioned several times that there is no one-size-fits-all approach to manage chronic pain unless you incorporate a holistic multimodal and thoughtful approach similar to any other chronic medical condition. thank you again for including me in this discussion. blue cross blue shield companies shares your commitment in addressing america's opioid crisis and ensure those who suffer from chronic pain get the help they deserve. >> we will have a five minute round of questions.
i will try to hold the combined questions and answers too minutes. we have a lot of senators interested in discussion today. i will begin with senator isaacson. >> thank you chairman alexander. ms. steinberg, i hate to make you get up off of your cotton. >> i am used to going back and forth. >> we appreciate all you are doing to help us learn more about it. and i appreciate the pronunciation of all of those words. i cannot pronounce any of them. i do numbers but of the letters. you to all of you. i lost her grandson to an overdose and an addiction. and so this issue is important to me. much of the stuff on the streets now is taken from medicine cabinets in homes. and it may have come from
mexico or it may have come from canada or somewhere else. but kids get in the medicine cabinet and take them and it causes big problems. my first question, is hydrocodone the most prescribed? is at the most prescribed pain medicine? >> yes, it is. >> it is in opioid. the reason i ask that question is i had a major back operation two years ago. major. major pain. the surgery works. i had to finally go to surgery and have fusion and all that stuff. i noticed i was always getting hydrocodone. i was getting dental work done in terms of implants. i was getting a back fusion done. i got so much hydrocodone that it seemed like an excess. is it prescribed more than anything else because it is
less addictive than other types of opioid based pain medicine? or is it just the most popular? >> i think that is probably a culture. it is a very popular medication. it has always been combined with acetaminophen. so people assume that you needless opioid with a combination of acetaminophen. it is sort of a culture and dental schools and other outpatient arenas particularly to prescribe hydrocodone. >> it is equally as addictive, is it not? >> it is. >> one of you talked about addiction. i think that is the problem. you talked about encouraging new developments. and the pharmaceutical companies and others to find replacements for opioid-based painkillers to help with the problem. i think that is exactly it. we can take all the hydrocodone prescribed in american and substitute some new development
that does not use opioids as a base, we would solve a lot of problems on addiction, i think. do you know how many pharmaceutical companies are working on that? is there a lot of work being focused on finding a replacement for that? >> i have a list here of about 12 different -- current workings toward new opioids. they are also working on the non- opioid replacement. >> i think that is the most important. i am convinced -- and i am not a physician. i am an expert at having pain. i think the opioids are a problem. and i think addiction is a problem. if we can find a way to cure addiction or reduce dependence and addiction, we will be a lot better off. i think that is what you said. >> if i can make a comment. i think so much of the legislation and a lot of it has been concentrated on treating current addiction which is
incredibly important. we have a country full of people who have substance use disorders. i think what you touched on is really important. the prevention of future addiction. presenting contact with pain medications that teenagers are finding in their parent's medicine cabinet or they are coming into contact with when they have wisdom teeth removed in high school. i think that is really going to be essential for future generations. >> i think so too. and having three children and nine grandchildren, i see what we have in the medicine cabinet at home and it is important that it is managed as well as possible. my grandson who i lost, a step grandson, was not with meal his life but a lot of his life, he was addicted before anybody in the family knew what he was getting or where he was getting it. it was the medicine cabinet that got him started and peer pressure that kept him on it
and dependence that caused the problems. i appreciate what you said and what you are working on. and god bless all of you for doing it. >> i am very sorry for your loss. we do know that 80% of people that eventually develop heroin use disorders or other substance use disorders start with the legitimate prescription that somebody received. not necessarily themselves. >> i totally support your emphasis on researching as i mentioned. the heel initiative is a great start. but we have under invested in research. the number one reason people go to the doctor, less than 2% of the nih budget was dedicated toward pain. and we still don't understand the basic mechanism of pain in the body. so we really need an investment in research with the burden of pain. and i think we are going in the right direction but we have to keep going there. >> thank you senator
isaacson. senator murray. >> thank you to all of the panel. we appreciate it. throughout the committee's bipartisan work on the opioid misuse crisis, we have heard from people that have supported legislative efforts and we are grateful. i also heard from people with disabilities that experience pain and feared that restricting access to treatment could affect independent living merely because they were unable to manage pain. so doctor, maybe you can take this on. have we struck the right balance and our work to reduce misuse and also make sure treatments are available which can be vital for people with disabilities? >> it is a very good question. i worry that we have gotten ahead of ourselves with wanting to restrict opioids. a lot of people, a lot of providers are scared to provide opioids to patients. they have been prescribing them to them for many years. but that does not necessarily mean that those patients have
come into contact with the pain provider that can help them manage pain but with other means. most opioids in the united states prescribed chronically are prescribed by chronic care providers. many of them who don't have any education in managing chronic pain. they don't have time to go into the details that it takes to talk to patients about other options. they don't have access to pain providers. i think, and some ways, we have done what needs to be done, which is to drastically reduce opioid prescribing, i think. but i worry that we are getting ahead of ourselves with having other options available. >> thank you. i know people experience pain in a lot of different ways. one thing i am concerned about is how bias and the healthcare system can affect treatment for pain. despite the fact that women experience pain at higher rates than men, they are more likely than men to receive sedatives or be diagnosed with a mental health condition when they seek
treatment for pain. and when it comes to cardiac care, women are less likely to have heart attack symptoms recognized or to receive painkillers after a cardiac surgery. and patients are not listened to and the results can be debilitating or fatal. so maybe i can ask you, doctor. have you seen female patients being treated differently than male patients? >> i have a patient who has encouraged me. in 2017, a lady went to her local provider and a small town in minnesota with abdominal pain. she had been very active and running before this. as the year progressed, she became less functional. her primary care provider did not know what else to do for her other than ordering a ct scan of her abdomen and note any difficulty there. she started presenting to the emergency room locally. after multiple presentations, the emergency room physician set her down and said, misses b, you have chronic pain.
you will need to go home and figure out how to manage this. she was frustrated. so came to the emergency room and eventually ended up on my schedule in the plain -- pain clinic. when i saw that on the schedule and i read her history, i felt a little irritated that morning having to go into the room. but i stood outside of her room and i told myself, you are going to listen to her like this is the first time she has told her story. i went in and i listened to her. i ordered an mri that showed that she had metastatic lung cancer eating through her rib and the nerve that innovated that area of her abdomen. it had been present for at least a year and ignored because people felt that she was seeking opioids. biased is a significant problem in all areas of medicine. it is a problem in research. it is a problem when we see patients and it contributes significantly to the stigma that surrounds the treatment. not only of chronic pain but of addiction and of mental health
disorders. i think it is a significant issue. >> i'm not sure how we address that. being aware of that is certainly a critical part of it. >> i think awareness and i think education, both for patients and providers. >> and i understand, people of color, the same. >> there are definitely studies that show that, yes. >> i wanted to ask you, can you share your experience in providing a healthcare provider who helped you manager pain and your thoughts on how congress can help make sure providers have the tools they need to support patients who live with pain? >> it is a great question. i have asked myself after five years, why did it take so long to find somebody and what was so special about this doctor that finally helped me? it wasn't anything miraculous. i think that is the important message. he empathized with me.
he believed me. a lot of people with pain don't get believed because it is an invisible disability. he said, i will work with you to help you find things to manager pain. but understand that there is no cure for to manage her pain. understand that there is no cure now for chronic pain. you probably have chronic pain and you will need to learn to live with this. i will partner with you. he was honest, he was empathetic as i said. he worked with me to find things to help me. we often say in pain management now if you do a program of several different things, and what i do is i take medication, limit the amount of time i am up. everyone has different limitations with activities with pain. i do physical therapy program and a land-based program. if each a thing takes down your pain 15 or 20% it adds up to a 50 to 60% reduction in pain. you can live that way. it's a matter of having doctors
have the time to do the coordinated care, our system is so fragmented that people go from doctor to doctor. nothing is coordinated and they try one thing and it doesn't work and they go to another person because they are desperate. if we had a coordinated care, think about cardiac rehab. heart disease has been a huge cost for us. we focused on cardiac rehab and said we are going to have rehab program that puts everything together. we have had great success with that. we need that kind of approach. whether it's integrated care center, doctors are trying to provide that care. you can try different things and have someone help you so you are not isolated. it would go a long way to
saving a lot of wasted cost from trying different procedures and different injections. this is what happens to people with pain. that is my suggestion. it is not miraculous. we can do this. if we rethink and realign. and we think about models of care that are created that way. >> thank you senator murray. i will try to keep the questions and answers to five minutes each. let me go back to recognizing, only have five minutes miss steinberg. we have 300,000 primary care doctors in the country. how do we empower them to do a better job as you just described? >> that is a great question. i have been working and policy in massachusetts for 11 years now. i work with lawmakers to try innovative things. we just passed a law. something i worked on. patients are being dropped from care right now. you have heard that doctors are afraid to take care of people with pain. the bulk of people with pain, end up being taken care by primary care physicians. who don't get much training in it.
>> i'm not trying to cut you off but i have several questions. >> we try to program where primary care doctors can call pain management specialist for consultation, free of charge to them. so the state will pay for specially trained teams of pain management specialist to consult with the doctors. so the doctor feels more comfortable handling the patient. they have a network of alternative providers. >> does the mayo clinic have such a system to connect with primary care doctors around minnesota or other states? >> we do have a system. within our electronic medical record. we allow for ee consults. providers can contact especially -- specialty physician. >> this hearing for obvious
reason is called human nature. you set out one direction and it's the right direction. you know for sure something is going to happen. that could cause you to go in the other direction that you did not anticipate. let's say i have a loved one who is about to have a serious surgery. how do i think about opioid prescriptions in a state like tennessee? where the state has said with our encouragement, three days per prescription. is this something you don't use at all? i know that blue cross in tennessee will not reimburse oxycontin. although i don't think that may be true for other opioids. how should one think about that looking at it from the point of view from your own family? and someone headed towards a painful surgery? >> maillot family takes opioids. i am fully supportive of them taking them. if somebody needs opioids, they should get them.
i really don't think, one of the issues is the pendulum has swung way too back to limiting, and people suffering from pain. we need to get to the middle ground where opioids are used in limited quantities, but we also add all the other approaches. >> what is limited quantity? three days or three weeks? >> i am not a physician i cannot answer that. >> what is limited quantity? >> that varies by the patient and the procedure. >> what with the range be? >> between three days is very reasonable for emergency room presentation.
i think for a knee surgery we know from research it's about 16 days of opioids that a patient takes. what is appropriate is to educate the patient. perhaps with the participation of a pharmacist. educate the patient that you should take this for the shortest amount of time possible. the risk for maintaining long- term opioid use increases dramatically at 10 days of use. >> i have about a minute left. what are the most promising non- addictive painkiller treatments or medicines coming down the road? you can mention your own. >> my own would not be approved. it does in d's -- indeed cause less dependence. it is reinforcing. the fda needs to fully address all of these drugs. my drug should not be approved. it would be the worst thing to put on the market. i am working on the next- generation. the drugs that are coming, i mentioned cannabinoids. i really do. i know there is a controversial topic. >> why is it controversial? >> certain states have legalized in the federal
government has not legalized. the studies out there have potential, but the studies have been done with no systematic approach. we need systematic approach. >> are talking about medical marijuana? >> yes. >> we are laymen most of us. >> medical marijuana yes. i think it has great potential. >> thank you very much. senator baldwin? >> as our witnesses have all noted pain is a complex issue. it is especially true for patients who are struggling with serious conditions such as cancer, who often need palliative care services to manage pain symptoms from treatment. my home state of wisconsin has embraced palliative care is a critical component. it focuses on patients needs,
and it explains the treatment options and gives patients and their families a real voice. in their care. many who need palliative services can ultimately recover and continue to leave -- live meaningful lives. i worked with my colleague senator and a bipartisan legislation. it would help grow and sustain the palliative and hospice workforce. to help fill the needs and wishes of patients and their families. the bipartisan bill passed the house with unanimous support. i look forward to continuing to work with my colleagues on this committee to advance this measure through a committee this year. you stated that clinical
guidelines were developed after extensive research on prescribing practices among providers but also with feedback from patients. i wonder if you could discuss how the mayo clinic continues to refine these guidelines. for patients with palliative care needs. what else is really needed to improve the training that palliative care professionals get to provide the best care possible. >> that is a topic that is near and dear to my heart. i think palliative care is essential. what you said is key. not all patients who receive palliative care are dying. they are people who have
serious medical illnesses. chronic medical illnesses. study show they perform better if they received those types of services. we have a robust palliative care service at mayo. it's a new specialty. training is important. most guidelines, including the cdc guidelines and other state laws have exemptions. they exclude cancer patients and patients receiving palliative care. at mayo we started out in the same vein. but recognizing the treatment for cancer and with the palliative care measures we are able to provide, patients are surviving and being cured of their cancer or their cancer is becoming a chronic disease rather than a terminal illness. their risk of addiction is high. it is as high as any other patient who takes an opioid medication.
we have focused efforts on instituting the same guidelines within our palliative care clinic. as we have elsewhere in our clinics. appropriate opioid use, opioids we call the stewardship program for a reason. they are the best painkillers around. they have been around for thousands of years. and probably will continue. very important, but we need to be good stewards of them and teach our patients to be good stewards as well. >> the dangerous misuse of opioids at a va facility in tomah, wisconsin a few years back resulted in the tragic death of a marine veteran named jason some koski. his story inspired me to offer the jason some koski memorial and promised act. which since has been signed into law.
including by creating paintings that incorporate provider education and expand access to complementary and integrative health services. dr. koop you noted that the safe use of opioids requires a multifaceted team-based approach to pain care that includes patient and provider education. can you discuss what your research has been shown to be necessary for such comprehensive care to truly address chronic pain, and describe the important role that pharmacist play as a part of those teams? >> the research behind this is that those teams do not always work together. we need to ensure those teams do work together.
one of the things we need to do is to ensure that the financial incentives are there to ensure the team works together. so that we educate people and put the money at the front end. so we are not putting the money at the backend. >> thank you mr. chairman. dr. giselle:, a hearing was held on opioids in seniors. many of us when we think of the face of the opioid addiction we automatically think of a young person. usually a young male person. however, what our hearing showed is that this epidemic also affects our older adults. if you think about it, it is not surprising.
since nearly half of older americans do suffer from chronic pain. in the incidence of chronic pain increases with age. the centers for disease control estimates the number of people age 55 or older treated in emergency rooms for opioid overdoses increased by nearly a third from 2016-2017. some research suggests, however, that opioids are really not effective in treating chronic long-term pain. except in cancer patients. first i want to ask if you agree with that. >> for the most part yes. however, i have found in my own practice, and with other pain providers it is commonly, we do
use opioids for patients who do not have other options. many times as patients are aging they may not have some of the options such as surgical interventions, procedural interventions and plants and etc. that might be available to a younger patient, simply because of their medical comorbidities. >> no steinberg? >> i do want to address your question. i talked about the doctor who helped me. when i went to him i did not want to take any medication. i had heard horrible things about pain medication. he tried me on gabapentin, and it made me so tired i could not function. he convinced me to try hydrocodone, tylenol medication. i tried that medicine and it helped me. i never got high from the medicine. i took a relatively low dose of it. i took the same medicine, and
it allowed me to function. i still had pain but it allowed me to function and become the advocate that i could. i took that medicine for 10 years. at the same dose, i never had to change my dose. i never got a high. most people with pain have that experience. unfortunately people with substance abuse disorder it is a genetic disease. you start with tobacco or alcohol or other things. i want to draw the distinction. the misunderstanding is people think every time you take an opioid you get addicted. there is a distinction between two separate populations. people with pain tend to be women over the age of 40. people with substance abuse disorder tend to be men under the age of 30. we are talking largely about two separate populations. norah wrote a prominent article that said people living with chronic pain, less than 8% of
those become addicted. 92% don't. clearly some people do become addicted. i think you need to make a distinction and understand that for some people they are helpful and they are the right thing. >> i am not implying that they are not. there is research that the long- term use for chronic pain, for many people, that there are better alternatives for opioids. dr. koop very quickly. my time is almost done. a substance abuse expert has told me that an individual who is given opioids who is under age 20 is far more likely to become addicted than someone who is older.
because of the brain not being fully developed. is that accurate? >> that has been widely studied, yes. if you for instance look at when people start experimenting with any drug attends to be at that age group. the brain is still developing until the early 20s. that is why. >> it is interesting. you think of young people having their wisdom teeth taken out. and being given opioids. many of the dentist may have switched to strong doses of ibuprofen followed by tylenol and alternating it every two hours. and have found that the pain relief is just as effective and safer. i see two of you nodding your head. >> acute pain is where we have had to cut back with opioids. for dental procedures it's usually unnecessary.
hopefully they have gotten the message now. >> thank you senator collins. senator hassan. >> thank you for holding this hearing. thank you to all of the witnesses for being here. we appreciate your presence and your expertise and commitment. new hampshire has been especially hard-hit by the opioid epidemic. we also have many patients who are suffering from chronic pain. we need to make sure that all of our patients, that they need to access care. provider shortages and all of those areas is a real issue in my state. for example -- between 750 and 800 open positions at any time.
this first question is to dr. koop, as faculty of pharmacy and medical schools i'm interested in what you see as the greatest workforce challenges and your views on the graduate -- in the next generation of physicians. and the follow-up to that, how could additional residency slots particularly feel like pain management addiction medicine and addiction psychiatry improve access to patients? >> i think it's not a popular thing to talk about. the cost of medical school and the loans that the students accumulate during the time they are in their medical training or cost prohibitive in some cases.
such as primary care and psychiatry. at the time i was in medical school at the university of minnesota the dean kamen spoke to art class. he said so many of you are planning to go into specialties you need to go into primary care. we need primary care physicians in minnesota. at the same time the university of minnesota medical school is the most expensive state for medical school at that time. those considerations have to be taken. i think finding some way to encourage students to go into specialties that are needed would be important in that regard. >> dr. koop? >> approaching this specifically from the pharmacy. pharmacist, as i mentioned, are often the most underutilized healthcare professionals. they are the medication experts. they are.
they are also taught how to counsel patients and how to appropriately counsel patients with medications. one of the biggest issues we have with patients taking medications is actually taking the medications. if the medication doesn't get to the patient it will not do any good. again, part of the financial model is reimbursement with those cognitive services. it is getting the reimbursement for the cognitive services that can bring the pharmacist into that healthcare team. which would expand that access you are talking about. >> thank you. that brings me to my next question. which was about reimbursement and again to, we know can be a powerful tool. the lack of appropriate reimbursement to dr. koop's point can create tremendous
berries for patients who need access to a variety of services. insufficient reimbursement policies and federal programs like medicaid and medicare as well as private insurance can sometimes create barriers to access to therapies and services. it can reduce opioid use. including acupuncture and chiropractic services and multimodal pain strategies. we take important steps over the last few years. to help address some of these barriers and certainly dr. patel talked about things that blue cross blue shield is doing to eliminate some of those barriers. can you give me some specific concrete action that congress can take related to reimbursement in order to improve patient access to non- opioid pain management therapies and services? >> i do modulation.
in many cases it's very difficult to get those covered. i find that medicare is one of the most difficult when i have a patient on medicare to have access to those therapies. the therapies are proven in europe to be extremely useful for chronic -- so patients don't have to pursue further stent places etc. or use opioids for chronic headaches. the coverage for them is poor. i also think i have rarely met a patient who wouldn't benefit from behavioral and psychosocial. it is vital that we treat those areas in patients. they are not covered. in the hospital we would like to allow patients who are having surgery to have access
to a non-opioid management. we did a survey recently at the mayo clinic showing 94% of patients would choose something other than opioids acutely after surgery if they could. we cannot provide acupuncture massage, or extensive physical therapy. >> thank you. >> senator hassan? professor cassidy? >> thank you. i remember when i was first year and congress having a slipped disc in my neck with a radiating pain down my ulnar distribution. it was so incredibly painful. i was imprisoned by the pain. all day long i waited for my every six-hour dose of motrin and or, and i staggered it with my tylenol. for three or four months that's all i did. it sapped my emotional energy. i was eventually helped by
epidural injections. this is up my next question. when i looked at the research on epidurals and for people who -- it would give me instant relief that would then wear away. i look at the data and it said it was no good. the data says that epidural has no long-term benefit in the management of chronic pain. after my third one it just went away and never came back. the cdc guidelines for management of chronic pain, they say going back to senator collins questions, that there is no evidence of use of opioid long-term versus no opioids versus etc. it seems like we have evidence in which empirically worked in me. it doesn't have the evidence to support it. briefly count on that. my former student, to ask if blue cross is covering things
which have no evidence, but nonetheless empirically do work in some. >> dr. cassidy i don't have to explain to you you can find studies almost to backup whatever you are looking to backup. you had acute pain, epidurals very effectively manage acute pain. radicular pain. probably for patients who have spinal stenosis or other types of chronic radicular pain they be not be as effective. do we use them yes, they are held. sometimes patients don't have other options available. definitely for acute pain those are helpful. >> my last three months, my neurosurgeon -- by the way at all it also once read give me
statistics and i can prove rhode island is bigger than texas. i see your point. will blue cross pay for that which evidence suggest that does not work. number two, all these wonderful things that can be used in lieu of opioids. this ultimately comes to your decision. how does that handle? >> along with her comment there
are studies that show for acute pain injections like epidural steroid injections work. there is multiple kinds of injections for spinal pain. depending on where the pain generator is. there are things that blue cross blue shield does cover. several of the things we have discussed like physical therapy and occupational therapy and chiropractic care, those are all a multitude of things that we cover without any type of prior authorization. if a provider feels this is an appropriate intervention for the patient and their pain they can go ahead and do a procedure. >> clearly given a prescription for opioids would be cheaper then a whole can happily of that that might be less likely to -- it seems like -- how do you employ that which is more significantly inspected and -- and's expensive. we participated with multi- stakeholders. >> our approach has been a
multimodal approach. >> go back to the question of a bundled payment. i don't know if blue cross uses bundled payment. again my pain management physician says postsurgically we can do this or that. it's more expensive than giving them a prescription or giving them an injection of an opioid. how do we manage that? how do we approach as policymakers, bundled payments will we know it may increase the cost to do something which would decrease the use of opioids? >> the reason we bundle payments is to be more cost efficient overall. again we are not trying to limit the options that providers have in managing pain. we are encouraging to use a multimodal approach in terms of management. >> if your cost basis giving a prescription for opioids but
the alternative is this, and he is slightly tapping his thing to tell me to shut up. >> maybe you could provide, senator murray would like to know the answer. we will extend the discussion and ask you if you have any comment on what he just said. >> yes, again like i said, the things for example i am aware of , post surgery let's say a patient has a knee replacement or a hip replacement. the preoperative period in the postoperative period is bundled in terms of payment. it is more of a payment question. i could get back to you on and specifically what we bundle. there are instances where we bundle payments in order to contain the cost.
>> thank you. she said she wants to submit some homework to you. it is terrific to have a united states senator who has a former resident student. >> i feel like i am in his clinic right now. >> senator smith? >> thank you. i feel a little intimidated following senator cassidy. my knowledge of physiology is dramatically less than yours. i really appreciate this hearing so much. miss dean berg -- steinberg, pardon me. and this committee we all have our personal stories. we focus in on the policy issues. some of us have our own experiences with pain in our families. to be able to have you bring it
down to reality is extremely helpful. thank you very much. when i meet with healthcare professionals and families all across minnesota what i hear over and over again is the need for a coordinated approach to health problems that are complicated and cannot be resolved in one way. with just one provider. especially when you think about all the related issues that relate to whatever the one primary diagnosis is. this is particularly true for pain management. we know that chronic pain is associated with all sorts of issues like frustration and stress and depression. isolation, and i know that the mayo clinic understands this so well. mail is renowned for the collaborative approach that you bring to all different kinds of challenges. not only this challenge but this seems to be particularly appropriate. i'm wondering if you could talk a little bit about the
connection between pain management and mental health disorders and the tools that you see, i'm interested in getting from you what we ought to be doing at the federal government level to encourage that kind of coordinated approach. when it comes to pain management and mental health disorders. >> it is well understood and well known that anxiety depression and other mental health disorders are far more prevalent in patients who suffer from chronic pain. they are highly prevalent. in treating the whole patient with pain you must treat their anxiety and their mental health disorders. an excellent example is the pain rehabilitation center at mail. it is an integrative approach. involves pain physicians physical and occupational therapy, and it is a multi specialty.
we have gotten away from the pain clinics of 30 years ago. were patients would come in and essentially see a team. a team that included a physician, that included a psychologist typically. it also included a physical therapist or someone involved in a storage of therapies. reimbursement for that type of model declined and became more interesting to do interventional procedures for patients which are a rapid fix me. i think that a return to that model of chronic pain management is essential for caring for patients. integrating those services is very important. addiction medicine, i can't tell you, we do so many surgeries a year. i couldn't tell you the number. a lot of patients come in on chronic pain medications. they have issues with addiction.
they are hospitalized. that takes coordination with our addiction medicine colleagues as well. just because you have addiction doesn't mean you will not need a surgery or chronic pain management at some point in your life. they also suffer from substance abuse disorder. we've had to coordinate care for those patients so they can have appropriate management for their pain but also for their mental health issues and substance abuse disorders. we think about what we can do at the federal level to encourage that kind of approach. how the reimbursements don't support a comprehensive approach. is that fair? >> i think that's true. it's very hard.
we have providers throughout the united states, even at the mayo clinic we don't have addiction medicine services in our hospital. patients have to see those providers in outpatient. reimbursement is poor for that. at a point where they could be touched and significantly altered in their course. they are not able to have that type of contact. >> that leads to so much fragmentation. >> even talking about for mrs. providing for nor frame. you can give a patient that medicine. that can be a drug of abuse. you have to give a patient the other addiction management services they require to be successful. >> thank you.>> senator romney? >> i appreciate the comments of
the panelists. particularly ms. steinberg who has made a real sacrifice at being here. your testimony reminds me of my experience. we noted that we were spending a lot of money on medicaid and on psychotropic drugs. we couldn't quite figure out why. we determine that most of these drugs are being prescribed by primary care physicians who had very little experience in deciding what the most effective psychotropic drug might be. after some consultation we said, medicaid is no longer going to reimburse psychotropic drugs to young kids unless the doctor prescribing it contacts a physician at the university of massachusetts medical school
and is a psychiatrist or in that trained field. that doesn't mean the psychiatrist had to approve the prescription. they had to have a conversation. in doing so the number of prescriptions dramatically came down. the quality of care substantially improved, we believe. each of you has spoken about the fact that most of this prescription of opioids is being done by people who are not specialist in the field. i wonder where the lack of best practices is something that is affecting the challenges we are facing. both with chronic pain and those who are abusing these products. should we have some mechanism that one gathers data from all over the country. from everyone who is using the drugs to see what the effect is. number two, a place where physicians go to get a consult before they prescribed for someone that has chronic pain.
do we not need something of that nature? how would something like that be structured at a state or national level? i am happy to turn to anyone of you that would like to comment on that. >> the program i mentioned is one attempt to do that. we are doing that in a small model. pcps can call for consultation. one thing that is not a good idea, i think, that we tried. in washington state. no one could get an opioid prescription without having seen a specialist. there's a handful of specialists in the state. people with pain who really did need their prescriptions could not get their medication. they had to go out of state to get their medication. it was a disaster. i really encourage us to think through the way we implement that. clearly education is the other side of what you are talking about. pain education, we have not been training people on what we now know. medical schools are ignoring this.
>> the challenges if you take more time on one subject that's less time on another subject. i'm going to ask about blue cross blue shield, are you able to get expertise to the people who are making these prescriptions? >> to answer your question, often times it needs to be the primary care physician who is managing the pain. in north carolina with a lot of rural areas access to a primary care physician can be challenging. access to a pain management can be even more challenging. we have really worked with the new company. they are bringing behavioral health and mental health into primary care areas. there are things you have heard before, project echo. which is a platform, that several blue cross platforms are already using.
any physician can call in and seek -- it's not meant for just consultative purpose but in educational purpose. >> thank you. >> we have on a small scale at mayo, we need to leverage telemedicine. and electronic medical records. which are more beginning to speak to each other. we have an electronic health record that speaks so we can talk anywhere in the country about our patience and look them out. we have developed a controlled substance advisory group. where specialists sit and hear the cases that are brought by primary care physicians. patients with difficult pain management problems in patients with substance abuse disorder problems. we enter a note in the
patient's medical record. i think i have visions of expanding that. i think it would be incredibly helpful to primary care providers. obviously there are hepa restrictions. >> thank you. my time is up. i want dr. koop to instruct us. on the path forward on cannabis research. we will save that for another day. >> if any of you have additional comments that you would like to make you can submit those in writing after you leave. >> murray and i really appreciate that the panel is here. i hope my acute pain from wrist surgery does not turn into chronic pain. before coming to congress i set
back from my career for several years and was a caregiver to my parents and my in-laws. during my time i became familiar with the field of medicine known as palliative care. the relief from pain symptoms and the stress that the specialized care can provide. palliative care focuses on improving quality of life with life those with life limiting illnesses. between end of care and end-of- life. like my mother. i launched a bipartisan palliative task force in the house to bring attention to this type of care. a couple questions. and your experience is a common for patients diagnosed with chronic pain, or possibly terminal diagnosis to have those conversations with their doctors about palliative care as a treatment option? how can we ensure specifically with primary care physicians that they understand the needs
of terminal or long chronic pain patients. how do we do that? maybe requiring ongoing cme for primary physicians in this area. >> that's a vitally important topic. not common enough. patients make choices they don't want to make. to come in and have treatment for things they would not necessarily choose to have treated. a 100-year-old ending up in the icu because no one had a conversation with them that it's okay to be comfortable and even do this at home on hospice. >> empowering patients to have those conversations with their physicians is vitally important in training physicians and other providers to have those conversations. >> could we provide that by improving the way we continue
medical education. maybe requiring the chronic pain management as an ongoing cme requirement. especially for primary care physicians. is this something that could help? >> i think it would be helpful. we have instituted palliative care in our medical school education program. people need to have not only an understanding of what patient's rights and preferences might be but you know how to have conversations. the skills of having critical conversations that are vitally important. >> requiring just like we do for mammograms, certain requirements. >> i do. >> a question for dr. koop about medical marijuana. in nevada we have ranked 13th in the nation in prescribing opioid painkillers. our former governor took action by forming a new state agency.
we do have legalized medical marijuana in nevada. we have found that using that has reduced the prescriptions for high potency painkillers. in your experience, what do you think are the barriers into effective research for the benefits of cannabis treatments, and how can this possibly be a nonaddictive approach or alternative to chronic pain or another tool in the toolbox? >> it has great potential to be another tool in the toolbox. i don't think it will ever be a one-size-fits-all magic bullet. pain is different in different people. in terms of how to move the research forward in medical marijuana, one of the issues have been because of the unusual legal status in the united states.
research has been limited. there is no consistency between the different types of marijuana. the studies, what we need is good consistent well-designed clinical studies with good consistent material. so we can fully assess the impact. don't get me wrong. also the potential drawbacks. >> senator murkowski >> thank you for this conversation. so important. i appreciate the back-and-forth here with senator romney clearly coming from a very rural state. when you are dealing with how you respond to patient's pain issues you don't have access to
those alternate pain management technologies. the different therapies that are available. the quicken easiest and cheapest to senator cassidy's point, is the it is a prescription drug. this idea of e consul is really critical. making sure that there will be reimbursement for these consoles is important. the words that you use where you are impairing the primary care doctors. translate that to me? do you cover these consoles then? >> we do. like i mentioned -- >> telehealth specific to these types of pain management consults? >> correct.
that was one of the things i was going to mention. that's one thing we developed. increasing access for folks. especially in the rural areas we talked about. to access providers they otherwise would not be able to through telehealth. >> one question for all of you, you can probably jump in on this miss steinberg. the big conversation over the christmas and the new year's holiday back home was what we are seeing with constituents, in our bigger population centers. in anchorage and fairbanks they
are being denied prescriptions. where the prescription drug is opioid-based. some of it goes to the bias issue. it is the pharmacist that are refusing to refill the prescription the doctor has prescribed. certainly the involvement we have had with these constituents, it doesn't appear to be an abusive situation. people who have been legitimately prescribed these medications for these debilitating and long-term pain management issues. i understand it relates to the recent guidance coming out from the cdc. recommending and restricting how much a pharmacy can do. the guidances and controlling law, in an abundance of caution the pharmacists are saying we are not going to do this. you have the patient in the middle of a regulatory debate if you will. it has caused a lid to be blown off the discussions, in my state. i can't imagine it is just in alaska. what are we doing to address this tension and this conflict between prescriber and the pharmacist?
and then ultimately we want to be helping the patient. we have a struggle going on. i do not know who is addressing that. can anyone if you speak to that? >> they don't want to treat people with pain anymore. your example, i had a doctor from a cancer center call me saying a pharmacist will not fill my prescription for patients that have really bad cancer. it has gotten to a point where it has gotten so unreasonable. >> what do we do? >> we need to educate everyone better about this issue. we need public education about pain. and the fact that pain is a disease itself. so people understand that we are not talking about acute pain. chronic pain is devastating.
for the kinds of things you are talking about, pharmacists are not getting proper training in that. i don't think anyone is getting enough training in pain. >> pharmacist who are not getting the training but you also said the physicians don't get enough, correct? >> correct. >> folks do view guidances as being gospel. i think those guidances have been taken too far, and that needs to be rolled back. that's one thing that can be done. yes all healthcare professionals could certainly benefit from more education in this area. >> the other thing i want to add to this whole discussion of specialists is we don't have enough pain management specialist. it takes people more than a year in my pain group to get an appointment with this change
specialist. i can imagine how few there are. for talking about consults, they are not even a specialist to handle the telehealth. we need to incentivize pain management as a specialty. >> i wanted to comment on the unintended consequences, the use of the cdc guidelines there is only number six. it's a very small section talking about acute pain management. three days at the most and at the most seven-day should be considered for acute pain management. it has been jade into law in many states. many insurers have used this. with the pharmacies but a problem of our insurance companies. we are keeping patients in the hospital longer because we cannot get their prescription upon discharge preauthorized.
it has to go to the insurance company. patients can't get a prescription for that length so they stay in the hospital while we work that out. there has been some significant unintended consequences. multiple of the pharmacies as well. larger pharmaceutical companies. some have arbitrarily set seven- day limits on what they will allow patients to have. they cancel the rest of the prescription from the position -- position. this means another co-pay for the patient who has already paid one co-pay when they need a refill. it can be a significant issue. i respect that. >> there are some great recommendations on how they need to be revised.
picking a dosage level is a arbitrary decision. it's not scientific based. it has caused all kinds of problems. >> can i add one thing? a lot of the issue with the cdc guidelines are just that. on gov education on a part of the physician as well as the pharmacist. they are going to be patients who will potentially look like outliers and go higher than what cdc recommendations are. i just wanted to mention that. >> we have apparently revealed something here. >> we are all interested in those answers. it is worth that we rejected the idea of a federal law establishing three and seven- day prescriptions. leaving that to states and physicians and caregivers to work out.
that is proving to be a wise decision. although i hear what you are saying about the cdc. senator jones, you have a doctorate from law school. thank you mr. chairman and thank you all for being here today. one brief comment, about telehealth and telemedicine. we are having rural hospitals and providers lead our area. i've always thought telehealth is one way to try to keep that. it is only as good as our role broadband and access to the internet. that is something my office is continuing to push for. i do want to follow up. with an area, a lot of times when we asked these questions people think we have an agenda.
this is not one of those. senator rosen asked about the research and development using medical marijuana and cannabis. dr. koop gave a good answer. i would like to hear from the other three of you on this issue. i think it is an important topic. the public's mind is growing throughout the country. with each of our physicians as well as ms. steinberg, we will just start with you miss steinberg. if you could comment on the pros and the cons of what you see in the developing of medical marijuana, cannabis. the alternative and research that would be required to go into it. >> cannabis has helped a number of people living with pain. it's another option. it has helped a significant number of people. it is not legal in a lot of places. even where it is legal it is not standardized. doctors need to be the one prescribing it. they do not know what they are doing with it. without having a good research
significant areas where this may be useful, i have patients using it for nausea, appetite etc. and pain, i think it can be helpful and patients of mine in the past are taking opioids and if you did a urine drug screen they tested positive for marijuana and they found that seem to help more than being prescribed an opioid, i do think that potentially from of physician standpoint there is potential to the utility of
medical marijuana for the management of chronic pain. putting on my other hat that we obviously only cover procedures and drugs that are fda approved so we would need clinical evidence in support to cover those kinds of medications . >> have any of you got any suggestions, other than short of removing it off the schedule one which you could do, what going to, is anything other than that that we can do to open up the ability to research the pros and cons of medical use of cannabis? is that the impediment we have to figure out how to deal with ? >> i would say that this is a decision that the national institute on drug abuse, with the experts could no all of the compounding factors, it would be something i think we should
charge those guys with , coming up with what is the best way forward . >> thank you all for your answers and thank you for being here and thank you mister chairman . >> senator murray, do you have additional comments? >> i like to think our panelists for being here today, this is ben interesting and eye- opening and i think all of you for your help today . >> i agree with senator murray's the sentiments, i only have one question, several of you have mentioned in response to questions from senators that what we could do about this is public education, that's what we attempt to do today. the united states senate is a forum that helped lead the way to recognize opioid abuse and try to deal with it. we should, at the same time, try to lead the way to determine whether there are unintended consequences and whether the millions of americans who live with pain are not able to deal with pain as a result of the
reaction and the effort to stem opioid abuse. we've heard today that reimbursement policies are important and primary care doctors and education is important we've talked about the most promising nonaddictive pain medicine that's been a priority of senator murray in her role as senior democrat on the appropriations committee that deals with health. in this committee were we've attempted to push more funds into the nonaddictive treatments and medicines and dr. collins has been here to testify on that and is working in a variety of ways to accelerate that. we talked today about pharmacists and what the role might be and i wanted to ask one last question about the cdc , the center for disease control
recommendations. they are not law, they're not rules anyone has to follow but, the cdc is anonymously respected in states in the medical fashion and in this environment. it sounds like your experience of using a low-dose hydrocodone and one over-the-counter medicine for 10 years to relieve pain, wouldn't fit in the cdc guidelines for your dr. so, what recommendations you can elaborate after you leave in writing but each of you, what would be a recommendation about the existing guidelines of the center for disease control, guidelines for opioid abuse and how we could make sure that while we are dealing with the opioid epidemic, that
we don't make it difficult or impossible for people who need opioids to relieve their pain to get them . >> yes, i think the best thing you can do is have the cdc guidelines revised. they have really been taken as law as the cdc behind them, people think they are based on strong science but they are not. the pain management task force that congress widely created is producing a report now and the report specifically reviews the cdc guidelines and makes excellent recommendations on how to revise them. i really think that congress should ask the cdc to revise the guidelines based on the task force report. we serve on the task force and they do need to be revised. the cdc are not pain experts and they did not use pain experts to create the guidelines . >> the cdc deals with epidemics
and obviously we have an epidemic but i hear your suggestion and maybe that's a subject for another hearing . >> nih has an office of pain policy, the cdc has no pain section, i've done tons of research to understand why their attitude towards pain is the way it is, they don't have pain experts. nih should decide those things they have the office of pain policy and they know about pain research and they are the best people to make a decision like that and to pull the experts together. they've done their best job with the national pain strategy, i don't think it belongs in the cdc . >> thank you for making the effort to come today . >> i think the best thing that could happen with the cdc guidelines is that people understand what they were intended for. they were intended to advise primary care providers , they were not intended to provide a hard and fast rules. i like the
cdc guidelines, at the risk of having tomatoes thrown at me, we use the guidelines form chronic pain management guidelines at the mayo clinic. i think they have a lot of good advice on how to monitor the patient appropriately when you place them on opioids. the dose is mentioned, are probably not scientifically based as we would prefer they would be but, they don't say don't use chronic opioids, they suggest doses where you might yellow light, red light, become concerned with these. so, the numbers are concerning somewhat. but i think the guidelines basis is sound as far as the intention of them. where the numbers came from is probably more questionable . >> do you see the guidelines as inconsistent with the decision by mao team that for her knee surgery, 60 days of opioids would be appropriate? >> i think there's very little mention of acute pain management.
they were not intended to address acute pain management. they dusek just that you commit to three days or seven days unless there's a compelling reason to do otherwise but i think that leaves room for physician . >> that's per prescription . >> that's correct. for a one time incident or surgery not for chronic pain . >> just for the layperson which most of us are, what the short description of the different between chronic and acute pain? >> we've considered in the medical literature, three months has been used to describe the transition, 45 days to allow our surgeons a shorter time prescribing. i think between 45 days and three months, anything over that time period is typically
considered chronic. >> there's not much i can add that hasn't been added by my colleagues except for the love intended consequences, people take these guidelines as law. so, we need to reassess them and remind everyone that they are indeed, education and a place to start . >> thank you . >> dr. rao-patel ? >> i will just add this comment and it say i agree with everything my colleagues have said that the reason the cdc made the guidelines is part of the reason we haven't opioid epidemic now, because it was a lack of education and knowledge on how to prescribe these medications. so, i won't pick on any other specialty but my own, and they are geared towards primary care physicians that can be used for any specialty. i will say that physiatry us used to write a lot of opioids, we write a lot of opioids, a lot of us are interventional pain management and i do
chronic pain management. i think the goal of what the cdc is doing was correct, there were a lot of guidelines on how to prescribe these medicines, people would go into their physicians on monday morning after having a flareup because they painted their home and come home with a 30 day prescription of opioids which is not necessary. i think the intentions were correct and like any other guideline they are guidelines and there will be people who fall out of the guidelines and it's entirely appropriate to prescribe outside of them. that's where universal precautions come into manage chronic pain and make sure you assess a patient's function and how they respond to pain or are there other risk-benefit ratio, do they have informed consent ? like any guidelines there open for revision. just become something was written one month ago three months ago, it doesn't mean that six months from now the guidelines have not changed. so, what i would say is that they are a revolving door of guidelines.
there is certainly room to improve and change but i do understand the reason they were written and a lot of that is the reason we are here today . >> thank you very much, this has been a follow-up to atwas previously described as the most important federal law to fight a public health epidemic. but, as mentioned earlier, this committee, which as you can see from the personalities has broadly divergent views. generally left to states, physicians and agencies who write guidelines. these decisions about limits, rather than write an inflexible federal law that applies everywhere. is plenty of room for discussion and adjustment if adjustments need to be made. we welcome any follow-up comments you'd like to make and you can
tell by the interest from the senators today that we are very interested in the topic. the hearing record will remain open for 10 days and members can submit additional information during that time. thank you for being here, the committee will stand adjourned. c-span, where history unfolds daily. in 1979, c-span was created as a public service by america's
cable television company. today, we continue to bring you unfiltered coverage of congress, the white house, the supreme court and public-policy events in washington d.c. and around the country. c-span is brought to you by your cable or satellite provider. . there's a funeral service thursday in washington for john dingell who died last week at the age of 92. the former democratic lawmaker was first elected to the house of representatives in 1955 and remained there for nearly 6 decades, making him the longest- serving member of congress in u.s. history. in honor of his public service, gretchen whitmer spoke about his life and legacy during her recent state of the state address, here's a look. >> one of the veterans and one of michigan's greatest leaders,
was congressman john dingell, who passed away last week at the age of 92. from his courageous service in world war ii to his model leadership over 59 years in the united states house of representatives, congressman dingell , devoted his life to serving the people of michigan and he will forever be remembered as the dean of congress. but not simply for the length of his service. he was the epitome of what i think we in michigan no, you don't have to be mean to be strong. [ applause ]. those who live by
this creed can get a lot of things done. i want to extend my deepest and heartfelt condolences to debbie dingell and the entire dingell family for their loss. we are grateful nation and a proud stay for the work that john dingell did.. [ applause ] . live coverage for john dingell continues thursday, funeral mass will be held at holy trinity catholic church, speakers include bill clinton, steny hoyer and john bain are.
watch the funeral services for congressman john dingell live on c-span and c-span.org or listen with the free c-span radio app. south bend indiana mayor was in iowa last week for his first visit to the state since announcing the launch of a presidential exploratory committee. 37-year-old democrat has been mayor of south bend since 2012. is meet and greet with iowa voters runs an hour and 45 minutes. [ applause ]