Agency, dea, to try to get scheduled narcotics on to electronic prescribing. And after years of bureaucratic battle, finally the regulations came out. I think that facilitates via electronic prescribing Prescription Drug monitoring, when you no longer have to go and ask for the paper scripts from individual doctors or from individual pharmacies, you can look at a database and you can see, wait a minute this, fellow is a podiatrist. Why are they prescribing oxycodo oxycodone . They prescribed 500 capsules last month and now theyre prescribing 5,000. Wait a minute. This person has gone to five doctors in five pharmacies for the same prescription. Whats going on . It opens investigatory doors. And yet, years later, its now electronic prescribing for all this stuff. The Prescription Drug monitoring programs dont seem to have yet really come online as a proper investigative tool to give us the common sense information that we need to make these determinations. What are the best next steps that we should be pursuing to try to get this program to a place where were getting these warnings before we have to go and run up a fake pain clinic that sold 100,000 prescriptions . You should be able to catch that a lot sooner if youre actually watching the data as it comes up. Whats our what are our best next steps . Miss volkow let me ask you first because you talked about this very well. Well, i would say that we should put the resources that are necessary to make the systems the way they should be. Immediate information right away and access to data that is relevant. Theres no reason technologically that we cant do it. Privacy concerns . The prif privacy concerns are equivalent to those you have in Electronic Medical records. That is there anyway, were just not accessing it in an innocent fashion . Correct. Dr. Clark. Working with onc and rhode island promulgated Electronic Health record integration interoperability programs. We have a small portfolio. We work with the department of justice which has the lions share or the primary focus. But we have been working with rhode island to improve access to pdmp data for Health Care Providers by integrating Rhode Islands fugess into Electronic Software used by hospital and physicians offices and by integrating the functions in the pharmacy dispensing software of a pharmacy and sharing data with other states, including two geographically bordering states, this has to be to make this effective with new technology you dont necessarily get greater efficiency unless you iron out the bugs. Were working with Rhode Island Health department to address this so we can establish models that we can share. I think mike fine, director of health, is probably the best person in the country on this. Thank you Michael Botticelli for nodding your head. And Andrew Kolodny is nodding your head. Im glad to hear rhode island get some cheers here. Let me wrap up by thanking Phoenix House has an Important Role in rhode island. And to urge that as we particularly as dea does the enforcement in this area, lets not throw the baby out with the bath water. Lets do remember that these drugs have a purpose, to alleviate human suffering. My particular concern is that when you have people who are weak and not particularly good advocates for themselves, particularly elderly people, in nursing homes, if they run into an episode of very, very severe pain and you have ratcheted it down so tight that you need to wake up a doctor at 2 00 in the morning to prescribe them their medication, in the real world, theyre going to suffer for hours until somebody can be found to come in. I hope that you will be balanced and thoughtful and precise in the way we go about pursuing this and not risk the beneficial effects of these drugs in the pursuit of eradicating their abuse. May i respond briefly . I believe the clinics and the practitioners that we investigate and prosecute are not doing any type of medical care. You would not want an elderly person, let alone a healthy person go to them. What we see are drug seekers go to them. Theyre just facilitating addiction. I dont defend the pain clinics for one second. Thats a racket out there. If you have a situation where you need a doctor to prescribe somebody at 2 00 in the morning in a nursing home and you have to wake somebody out of bed, thats a problem i think. A legitimate nursing home that has been there for years, you need to think of differently than a pain mill that got stood up six weeks ago. Thank you, senator. Senator udall. Thank you, senator feinstein. Good to be here with you. Good to have you here. Let me thank you and senator grassley for focusing on a tremendously important issue. This testimony weve seen, this chart that i think was in your package, this astronomical growth is astounding. In light of senator klobuchars discussion with me, i want to first turn to you, doctor and ask you on Prescription Drug monitoring issue, i think you wanted to Say Something there. So i hope that you have an opportunity to do that. I did. Thank you for asking me. Most states as we have heard have Prescription Drug monitoring programs. We can invest in interstate data sharing. Unfortunately, they are not being used. They may be one of the best tools we have in country for bringing this crisis under control. And except in new york, kentucky and tennessee, the three states that made it mandatory for doctors to use them, they are just not being used. If there is some way that you can incentivize states to make it mandatory for their physicians to use them, i think that would be very helpful. Use what . Prescription drug monitoring. Well, we ought to do that. Thats something that we can do. Thats what you are saying we should do, we should make that mandatory. Absolutely. Unfunded mandate. A worthwhile one though. Let me i had an opening statement, too. Madam chair, i will ask to put that in the record and go on to questioning. I think such good issues have been raised here. Last month, and this goes to dr. Rannazzisi, last month i dont think you are a doctor, but anyway. Last month senator portman and i sent a letter signed by 14 of our colleagues to attorney general holder urging the department of justice to draw on the many evidencebased strategies that are being successfully employed in states to address heroin and opiate addicti addiction, the opiate addiction epidemic. Can you explain what efforts are under way to find solutions that are working in the states and then expand them nationwide . I think for starters, the states have taken a lead in having Prescription Drug summits, not only for the prescribers, pharmacists, nurses, but also for community leaders. The states have basically leveraged their Community Coalitions and have them out there doing education. Using that as a force multiplier, we get the word out to schools. I think the states are doing a remarkable job. Were working together with an investigation related to rogue pain clinics and rogue practitioners. I think that this problem, if we dont work as a team, both state and federal, local investigators and regulatory boards, its going to get worse. We are we have more collaboration with regulatory boards and state and local task forces now than ever before just to address this problem. Florida is a perfect example. I think the states and the federal government together are doing a fine job. Well, the great thing about our system is having the states as laboratories. As you said, theyve come up with some very good examples that i think we can spread nationwide. Dr. Botticelli, drug abuse i have a very large native american population, 23 tribes in new mexico. Drug abuse in Indian Country is a significant problem. According to a survey, the rate of nonmedical use of Prescription Drugs among American Indian or alaskan native adolescents was almost twice the national rate. During fiscal years 2006 and 2009, the High Intensity Drug Trafficking Areas Program provided a small amount of discretionary funding for a native American Program to combat Drug Trafficking on tribal lands. Is this something you would be willing to consider as director . Sure. We have been significantly concerned in terms of Substance Use and particularly this issue on tribal lands. We have been working with the Indian Health service to increase capacity around medication assisted treatment. We have also actually gotten great cooperation from the Indian Health services in making sure that all of their prescribers are appropriately trained on safe prescribing. We have great coordination with that. We are working and we will continue to work with how we might look at discretionary dollars to focus on that population. Thank you very much. Thats a perfect, i think, collaboration between the Indian Health service and you to move this whole issue forward. Thank you very much, madam chair. Thank you very much, senator. Appreciate it. Senator markey, welcome. Thank you for inviting me. I very much appreciate it. Drf botticelli, thank you for your good work in massachusetts. Thank you for your good work for the country. As you know, we have been a pioneer in massachusetts in programs that distribute that lox naloxone widely in the community to those who are likely to observe an overdose. These programs save thousands of lives. My understanding is that some physicians, first responders, Community Volunteers have expressed concern about being held liable for lawsuits if they administer this drug in emergency overdose situations. Have you also heard these concerns . I have. If we were to eliminate those liability concerns, do you think we could increase the number of people who are ready, willing and able to save the lives of people who overdose . I do. I think guaranteeing some level of immunity for people who respond to an overdose is a strategy that we should continue to investigate. I agree with you. I dont think anyone should be afraid to save the life of a Family Member or a loved one because of legal liability. I recently introduced a bill called the opiate overdose reduction act. Its a really simple solution to a problem. It extends protections to people who step in to save the lives of a person who is overdosing by administering a drug and that we need a National Good samaritan law so that people will step in. How many lives do you think would be saved if we had such a law . We know one of the prime issues why people overdose and die is failure to call 911 in an emergency. Clearly, signaling to people that they shouldnt be afraid to call 911 is a significant advancement in how were going to reduce overdose deaths. So a Good Samaritan law would really help here . Absolutely. Do you all agree with that . Yes. And i think thats really something we can do to pass a law which does provide that Good Samaritan protection. Dr. Volkow, isnt it true that for opiate addicts in prison, the treatment approach that works best is combining medication assisted therapies with communitybased treatment at reentry . Yes, indeed we have the best outcomes on prisoners that when they leave the prison system to go into the community, were initiated on methadone and are sustained with it not just in their ability to stay off drugs, but also in decreasing the number of overdoses because that transition from prison into the community increases the risk of dying from overdose Something Like 13 or 17 fold. There are currently very few medication assisted therapy programs in our prisons . Unfortunately, that is correct. What do you think are the barriers to expansion of medication assisted therapies in federal and state prisons . I think that it does relate to a culture that we observe in many of the Treatment Programs that rejects the use of opioid assisted programs. It is the belief that you are changing one drug for the other when, in fact, we know they are very different and theyre beneficial and cost saving. Mr. Botticelli, after a life is staved from an overdose, people with chronic addiction need to be linked into effective ongoing treatment for their conditions. I understand that you were instrumental in massachusetts in helping to increase access to medication assisted Treatment Programs within Community Health centers. Do you believe this model, the massachusetts model, can be used to expand access to these therapies across the country . I do. You know, one of our challenges is how do we continue to expand access without building bricks and mortar. And our federally qualified Health Centers are uniquely situated to look at doing that. We found that by giving minimal assistance to federally qualified Health Centers, we could increase by 10,000 the number of massachusetts residents who were able to get very effective treatment with the rest of the services they needed. Do you agree, doctor, that expansion of medication assisted therapies into primary care settings such as Community Health centers would be helpful . One of the things that we supported is integrated treatment, which would include federally qualified Health Centers. The other thing we would support is the transition from criminal Justice System back to the Community Using medications which buys both the addict and the community enough time so that the person can reengage in followup treatment. What often happens is the person uses shortly after being discharged from the penal facility and then they overdose. So if we could have injectable drugs administered prior to discharge, we would have a months time to engage and a Community Health center or a substantial abuse treatment plan that would be using the drug to help facilitate reentry into the community. Thank you. May i continue . Go ahead. Thank you. Dr. Volkow, im kind of surprised at how remarkable it is that we have so few medications available to treat addiction. Im concerned that our desire to find treatments that completely eliminate drug use may keep us from finding treatments that will reduce drug use or reduce the Harms Associated with drug use, harms like incarceration, family instability, difficulty holding a job. What do you think is needed to further the development of treatments that reduce drug use or related harms . Well, its unfortunately a paradoxical situation because we have a disease that has a tremendous impact in terms of morbidity and mortality. Science has identified several potential targets that if developed could be beneficial for the treatment. We do not have the interest from the pharmaceutical industry in developing medications for a srs series of reasons. One of the recommendations is how to incentivize a pharmaceutical industry in order for them to invest in the development of medications. The targets are there. You have a condition that actually is chronic. So one of the arguments that they would not be able to recover their investment is not even correct. The institute of medicine went further and identified ways that they could the government could incentivize pharmaceuticals without it costing a single dollar to the government. But they have not been implemented. If i may ask one final question. Of all of the prescription opiate painkillers prescribed in the world of 6 billion people, 90 of them were prescribed in the United States, 4 of the population of the world has 90 of the prescription opiate painkillers. What does that tell us about the United States . What does it tell us about our society . I think the numbers speak for themselves. I dont think they that we can argue we have more chronic pain than other countries. The numbers are telling us something very clear. We are overprescribing. While at the same time it does not negate that we are not necessarily properly treating patients that suffer with chronic pain. I thank each of them for their tremendous service. At the end of the day, theres one thing we can do and that is pass a Good Samaritan law. I think thousands of peoples lives would be saved immediately across the country because people would not be afraid to just inject someone or to give them that the help that they need for fear that they would be sued if something went awry. We know that most people would just thank god that the fear is gone. I think firefighters across the country, policemen across the country, they would be more willing to rush in and apply if do you it in a timely fashion, you save the life. Then you need to deal afterwards with what happens to the person. Do you have a bed for them . Do you have the treatment for them . At least you kept them alive. Then we have a responsibility subsequently. We dont have either right now. Until we put both in place, i think this problem is just going to continue to escalate. Thank you, madam chair. Thanks, senator markey. Just in conclusion, three things jump to me. Of course, thats the pill mill that exists. What proportion of the problem is the pill mill . I think we always say that 99 99 plus of the practitioners that are prescribing, the doctors, are doing a great job doing what they do. But that very small percentage of doctors that have crossed the line are truly hurting a lot people. I cant give you a percentage because i just dont know what that number is. But what i