[House Hearing, 114 Congress]
[From the U.S. Government Publishing Office]
ADDRESSING VA OPIOID PRESCRIPTION AND PAIN MANAGEMENT PRACTICES
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FIELD HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FOURTEENTH CONGRESS
SECOND SESSION
__________
FRIDAY, MARCH 4, 2016
FIELD HEARING HELD IN CONCORD, NEW HAMPSHIRE
__________
Serial No. 114-58
__________
Printed for the use of the Committee on Veterans' Affairs
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado CORRINE BROWN, Florida, Ranking
GUS M. BILIRAKIS, Florida, Vice- Minority Member
Chairman MARK TAKANO, California
DAVID P. ROE, Tennessee JULIA BROWNLEY, California
DAN BENISHEK, Michigan DINA TITUS, Nevada
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
JACKIE WALORSKI, Indiana KATHLEEN RICE, New York
RALPH ABRAHAM, Louisiana TIMOTHY J. WALZ, Minnesota
LEE ZELDIN, New York JERRY McNERNEY, California
RYAN COSTELLO, Pennsylvania
AMATA COLEMAN RADEWAGEN, American
Samoa
MIKE BOST, Illinois
Jon Towers, Staff Director
Don Phillips, Democratic Staff Director
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION
MIKE COFFMAN, Colorado, Chairman
DOUG LAMBORN, Colorado ANN M. KUSTER, New Hampshire,
DAVID P. ROE, Tennessee Ranking Member
DAN BENISHEK, Michigan BETO O'ROURKE, Texas
TIM HUELSKAMP, Kansas KATHLEEN RICE, New York
JACKIE WALORSKI, Indiana TIMOTHY J. WALZ, Minnesota
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
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both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Friday, March 4, 2016
Page
Addressing VA Opioid Prescription and Pain Management Practices.. 1
OPENING STATEMENTS
Mike Coffman, Chairman........................................... 1
Ann M. Kuster, Ranking Member.................................... 2
Honorable Frank Guinta, U.S. House of Representatives, 1st
Congressional District; New Hampshire.......................... 4
WITNESSES
Mr. Peter Kelleher, Chief Executive Officer, Harbor Homes........ 6
Prepared Statement........................................... 26
Ms. Christine Weber, Director of Substance Abuse Services, Easter
Seals Farnum Center............................................ 8
Prepared Statement........................................... 27
Mr. Joseph Foster, Attorney General, New Hampshire Department of
Justice........................................................ 10
Prepared Statement........................................... 28
Julie Franklin, M.D., Pain Medicine Practitioner, White River
Junction, VT, VA Medical Center................................ 13
Prepared Statement........................................... 29
Accompanied by:
Grigory Chernyak, M.D., Chief of Anesthesiology, Manchester,
NH, VA Medical Center
ADDRESSING VA OPIOID PRESCRIPTION AND PAIN MANAGEMENT PRACTICES
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Friday, March 4, 2016
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight
and Investigations,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:30 a.m., at
National Guard Headquarters, 1 Minuteman Way, Concord, New
Hampshire, Hon. Mike Coffman [Chairman of the Subcommittee]
presiding.
Present: Representatives Coffman and Kuster.
Also Present: Representative Guinta
OPENING STATEMENT OF CHAIRMAN MIKE COFFMAN
Mr. Coffman. Good morning. This hearing is to come to
order.
I want to welcome everyone to today's hearing on opioid
addiction and VA's implementation of alternative treatments for
chronic pain. First, as a preliminary matter, I would like to
ask unanimous consent that Representative Frank Guinta be
allowed to join us on the dais today.
Hearing no objection, so ordered.
I would like to begin by putting today's hearing in
context. According to media reports, in 2003 the Los Angeles
listed Dr. John Sturman, Jr. in its section on ``bad docs.''
That same year, the Medical Board of California reported
administrative actions against Dr. Sturman for failures
pertaining to a controlled drug. In 2012, Dr. Sturman's medical
privileges were reportedly suspended after a number of patients
died due to opiate-related prescriptions while under his care.
In April 2015, Dr. Sturman was hired by VA, and by August
2015, Dr. Sturman was arrested at the VA Medical Center in
Danville, Illinois due to the many years of investigative work
by Indiana's Medicaid Fraud Control Unit. Dr. Sturman is now
facing multiple felony charges for over prescribing narcotics
related to pain management. In all, media reports that
``Fifteen patients died of overdose or toxicity within a month
of receiving treatment from Dr. Sturman between 2009 and
2015.''
It is bad enough that VA did not properly review Dr.
Sturman's history before hiring him, but what makes this issue
even more egregious is that with nearly a decade of public
failures related to opiates, Dr. Sturman was hired to be the
chief of opiate safety.
Now, looking at opiate safety from a broader perspective,
according to an inspector general's report issued in May 2014,
more than 50 percent of the veteran population experiences
chronic pain. VA's response to chronic pain has mainly been
prescribing larger amounts of opioids as evident in VA's own
data which showed an increase of 77 percent between 2004 and
2014 in VA outpatient care.
In 2013, VA unveiled the Opioid Safety Initiative, which
was supposed to promote alternative methods of pain control
such as acupuncture and chiropractic care while reducing the
dosages of prescriptions for opioid medications. But I am
concerned that VA's promotion of alternative methods of pain
control may be limited. According to the National PTSD Center,
VA states that, ``Most Medicaid Center of Mental Health
Programs offer alternative therapies,'' but it's the qualifier
most that has me concerned.
One of the issues I want to get into today is how VA's
central office captures data on efficacy of alternative
treatments. As we talked about in our hearing on this topic on
June 10th, 2015, there have been countless examples of veterans
being over medicated or experiencing adverse drug reactions due
to improper treatment or nonexistent monitoring.
We know that some VA medical centers are exploring new ways
of controlling chronic pain. According to an article published
in April 2015, the Bronx VA is focusing on physical
rehabilitation, and that effort has resulted in the lowest rate
of opiate prescriptions in any hospital in the VA health care
system. Likewise, the VA Medical Center in White River Junction
is said to have designed programs to relieve pain without
strong medications, to include acupuncture, yoga, and aquatic
therapy as alternatives. However, what is unclear is whether or
not this effort is managed at VA Central Office, and how best
practices are implemented or shared across the VA.
The Department cannot simply introduce well-intended
programs and then fail to manage them properly. If these
alternative treatments truly work, they need to be implemented
throughout VA and not merely be relegated to a SharePoint
server for others to access if they are interested.
With that, I now yield to Ranking Member Kuster for any
opening remarks that she may have.
OPENING STATEMENT OF ANN M. KUSTER, RANKING MEMBER
Ms. Kuster. Well, thank you, Chairman Coffman, and thank
you for being with us here in New Hampshire. I just want to
express my appreciation for bringing the House Veterans'
Affairs Oversight and Investigations Subcommittee to New
Hampshire. It is a great honor for me to have you here, and
thank you, Mr. Guinta for joining us.
I want to thank all of our witnesses who are here with us
today and express my pride that New Hampshire and, in
particular, our White River Junction VA, right on the border
with Vermont, but serving New Hampshire patients and
Manchester, both have stories to tell that we can share across
the VA to make sure that we are treating veterans both for
managing their pain and to make sure we bring down the rate of
opioid use.
You know, this is a big issue. I do not need to remind
anyone in the audience from New Hampshire this now polls as the
number one issue in New Hampshire for voters and constituents
in terms of their concern above even the economy and jobs. Tim
Rourke of our Governor's Commission on Alcohol and Drug Abuse
has stated, ``No group is immune to it.'' It is happening in
our cities, our rural areas, and our affluent communities.
And I have been traveling for the year through the 2nd
Congressional District bringing together community groups,
treatment providers, hospital, physicians, mental health
providers, veterans organizations, and law enforcement to try
to address this at the local level. I have also been involved
with Congressman Guinta and our bipartisan task force to combat
the heroin epidemic, and we now have 70 Members of Congress on
both sides of the aisle who are concerned about the heroin use
in their districts and about how we can do better.
Some of this, we need to unlock some of the inadvertent,
probably well-intended public policies of the time, but there
are unintended consequences, and we need to unlock and unravel
those along the way. We need to make sure that people have
access to treatment, to lifelong recovery, and, of course, we
need to support our law enforcement.
In New Hampshire alone, we had last year 420 opioid related
deaths, up from 326 the year before. Tragically, more people
die from overdoses than in car accidents, and this is an
astonishing fact. In New Hampshire, we are nearly 4 times more
likely to die from an opioid overdose than a car accident.
Think about that, 4 times.
Across the country, nearly 260 million prescriptions were
written for opioids, enough, according to the Centers for
Disease Control, for every American adult to have their own
bottle of pills. And we hear stories every day about people
getting surgery, car accidents, OB, having a baby by cesarean,
or even dentistry.
Part of the stories are young people, teenagers, who are
going to get their wisdom teeth removed, and walking out with
30 Percocet. So we have got to do better. And as always, as we
look for a way to address the epidemic, we need to call upon
all of our citizens and all our institutions to come together.
As many in the room know, while our State has one of the
highest rates of addiction in the country, we are sadly second
to last in access to treatment. The Granite State spends only
$8 per capita on treatment for substance abuse.
One of the issues that I want to address is try to get
upstream on this issue. So this morning we will hear about the
severity of the epidemic and how the veterans community has
been especially hard hit, but how the VA and the veterans
community of treatment can be on the cutting edge and bring
solutions to our civilian health care, as well as obviously to
help veterans who have been historically prescribed opioid at a
much, much higher rate, and often, as the chair pointed out, to
manage chronic pain.
There is growing awareness that the long-term prescription
of opioids to manage chronic pain can have severe and sometimes
tragic consequences. It has been reported that veterans are
twice as likely to die from accidental overdose compared to
non-veterans.
The good news is that the VA has shown success in reducing
the amount of opioids prescribed to veterans, but I share the
chair's concern that without access to effective alternative
treatments and therapies to manage chronic pain, access to
mental health services, and access to substance abuse treatment
for veterans who become dependent upon prescription opioids,
that veterans may illegally obtain and abuse opioid
prescriptions, heroin, and fentanyl because they are not
receiving the care that they need.
As part of that care, we need to understand and spread the
use of alternative treatments and better pain management
techniques. We hear reports that veterans with chronic pain are
sometimes unable to receive alternative treatments, such as
acupuncture therapy, or are unable to get recurring
appointments at VA pain clinics. We also hear reports of
veterans who struggle with substance use or addiction issues,
and they sometimes have to wait months to receive treatment.
This is simply unacceptable.
I was proud to join Congressman Guinta in helping to
introduce, and I believe Congressman Coffman as well, the Jason
Simcakoski Promise Act, which would help improve opioid
prescription practices at the VA. And our Full VA Committee
passed this out of Committee unanimously last week, and it sent
the bill the House floor with our approval. But much more still
needs to be done.
One of the issues that I would like to focus on this
morning, is how the VA can better share practices in pain
management techniques across the country. This is an ongoing
concern with the VA. We know that innovative treatments are
being developed, but they are in one area, and I am proud to
say one, we need to share them throughout the rest of the
system.
We will hear today about successful programs to manage and
treat chronic pain in Manchester and White River Junction. We
will also hear from great programs at Easter Seals of New
Hampshire and Harbor Homes, two organizations providing
treatment to their veterans struggling with substance use
issues and opioid dependence.
And finally, we must explore how we can quickly and
effectively implement the best pain management opioid
prescription monitoring practices used at Manchester and White
River Junction VA at facilities all across the country to
prevent veterans from becoming addicted to opioids. I want to
know how the VA community providers and State and local
governments can come together to get veterans struggling with
opioid addiction the most effective treatments they need, and
then share these best practices with communities all across the
country.
We will not solve the opioid use epidemic in New Hampshire
or in the country or help our veterans without dedicated and
coordinated efforts. And for that, I thank you, Mr. Coffman,
our Chairman, for coming to New Hampshire, and I yield back.
Mr. Coffman. Thank you, Representative Kuster, Ranking
Member. We will now recognize Representative Guinta for 5
minutes for his opening remarks.
OPENING STATEMENT OF HONORABLE FRANK GUINTA
Mr. Guinta. Thank you, Mr. Chairman. Thank you for the
opportunity to participate in this event here in New Hampshire.
I appreciate the opportunity for the Subcommittee to address VA
opioid prescription and pain management practices. This is
something that has clearly become a critical issue not just
within the VA community, but in the community at large.
I want to thank the Subcommittee for its diligent work on
the issue. I want to thank my colleagues, the Chairman of the
Subcommittee, Mr. Coffman, and the Ranking Member, my colleague
from New Hampshire, Ms. Kuster, for her work and for our work
in the bipartisan Congressional Task Force to combat heroin and
opioid use.
She mentioned that we have upwards of 70 Members now on the
task force. That is, I think, indicative of the importance that
Congress is placing on this issue. When we began this effort a
year ago, we had to explain in many circumstances the
importance of why Congress needs to be engaged. Today,
fortunately, so many Members appreciate the concern, not just
here in New Hampshire, but all across the country. This is an
epidemic that we have to fight. This is an epidemic that we
will win.
But having opportunities like this to bring the Committee
to New Hampshire, to see firsthand what we are doing, utilize
best practices, and improve also what we are doing, I think, is
critical. So I thank you both for your time and your tireless
effort.
I have spent quite a bit of time talking with New Hampshire
veterans, New Hampshire civilian individuals who are impacted
by opioid use, either over prescription management. And I find
that we are at a point where we need to not only review our
practices, but we need to pay close attention to the practices
we currently utilize, because unfortunately in some
circumstances, we may be falling short.
I know here in New England we strive to achieve the best
and highest quality of medical care for our veterans. Our
veterans here in New Hampshire who have a great opportunity and
great energy in working with us on this issue continue to want
to press our VA system in the region to be the best it can be.
And this hearing, I hope will entertain opportunities for us to
make those options better.
I know that over the years in different parts of the
country there has been a lot of critique and criticism of the
VA system. We are here to try to make sure that we protect the
good parts of it and improve those areas that need to be
improved, because ultimately the quality and care of our
veterans is what is most important to me and to this Committee.
But seeking alternative treatment to opioid use is
something that we must shed a greater light upon. For years,
opioid use has been the primary practice, not just within the
VA system, but outside of the VA system, for pain management.
And we have now seen the challenges that it has created. I
think a multipronged approach, whether it is within the VA
system or outside of the VA system to ensure that we provide
proper medical access through drug treatment programs, through
recovery or drug courts, is incredibly important, and one of
the only ways we are going to try to help manage addiction.
But also on the public safety and criminal side, focusing
all of our efforts on making sure that those who are breaking
the law, particularly in the areas of distribution, pay the
full price. That debate will continue here in New Hampshire and
around the country.
I will be visiting the border next month to get a better
sense of how illicit and illegal drugs are coming through the
border. After briefings with the DEA, I am shocked and
disturbed about the mechanisms that people like El Chapo and
others have used to bring drugs into our country. This is
something that we are committed to stopping in Congress, and I,
again, very much appreciate the Chairman, Mr. Coffman, and the
Ranking Member, Ms. Kuster, for their attention not just on the
Committee, but within the task force as well.
And I yield back.
Mr. Coffman. Thank you, Mr. Kuster. Mr. Guinta.
I would like now to introduce our panel. On the panel we
have Mr. Peter Kelleher, Chief Executive Officer of Harbor
Homes; Ms. Christine Weber, Director of Substance Abuse
Services at the Easter Seals Farnum Center; the Honorable
Attorney General, Joseph Foster, New Hampshire Department of
Justice; and Dr. Julie Franklin, pain medicine practitioner at
the White River Junction, Vermont VA Medical Center, who is
accompanied by Dr. Grigory Chernyak, chief of anesthesiology at
the Manchester, New Hampshire VA Medical Center.
I ask the witnesses to pleased stand and raise your right
hands.
[Witnesses sworn.]
Mr. Coffman. Thank you. Please be seated. And let the
record reflect that all of the witnesses have answered in the
affirmative.
Mr. Kelleher, you are now recognized for 5 minutes.
STATEMENT OF PETER KELLEHER
Mr. Kelleher. Thank you, Mr. Chairman, and thank you,
Congresswoman Kuster, and other distinguished Committee
Members.
Mr. Coffman. Could you please move the microphone a little
bit closer to you? Thank you. If somebody could assist that.
Thank you.
Mr. Kelleher. Thank you. Thank you, Mr. Chairman, and
Congresswoman Kuster, and other distinguished Committee Members
and guests for this opportunity to address this important issue
that is plaguing our veterans and their families. In my role on
the Federal Secretary of the VA's Advisory Committee on
Homeless Veterans, we have discussed a wide range of topics on
homeless veterans, and I look forward to delving further into
this conversation.
I am here representing Harbor Homes, Keystone Hall, and
other Partnership for Successful Living agencies, a
collaboration of six nonprofits in the greater national area
that integrate care on the topics of homelessness, behavioral
health care, and primary health care. We offer over 80 programs
and operate a federally-qualified health center for low income
and homeless individuals where we often serve veterans who may
not qualify for VA health care.
We operate eight veteran specific programs: supportive
services for veterans and their families, a highly successful
homeless veteran reintegration program which provides
employment service, four grant and per diem programs, and a
project based VASH program, and also a robust SAMHSA program,
which provides behavioral health services to veterans as well.
As a partnership, we offer a myriad of mental health,
substance use, and dual diagnosis programs, especially out of
our Harbor Care Health and Wellness Center, a federally
qualified health center, and Keystone Hall, one of the largest
substance use providers and treatment centers in the State. In
our clinic, we offer medication assisted treatment and are
endeavoring to provide a full range of medication assisted
treatment services, including methadone, under one roof.
Data is varying, but our agency staff reports that
approximately 45 to 65 percent of active veterans we are
serving are suffering from a substance use disorder, and that
15 to 25 percent of them are specifically struggling with
opioid abuse.
The population of veterans who are willing to reflect
addiction as a disability on intake into the congressionally
mandated Homeless Management Information System frequently cite
both alcohol and drug use. For example, in 2014 and 2015, 99
percent of the veterans citing substance abuse reported a
disability with both alcohol and drugs. The majority of
veterans we work with prefer to admit to alcohol abuse, despite
their addiction to other substances.
Our population frequently represents individuals who have
not been affiliated with the VA health care system, and,
therefore, have not been prescribed opioids for pain
management, and instead self-medicate with whatever is readily
available.
We have and continue to work in tandem with the VA and
other statewide veteran-serving organizations to combat the
substance use crisis. It is indisputable by all veteran-serving
stakeholders that access to more treatment and more lengthy
aftercare is critical to solving this opioid crisis.
Please allow me to offer three suggestions. First, broaden
access to the VA health care system to serve more veterans;
second, approval for VA medical centers to provide a full range
of medication assisted treatment services, such as those
provided at the VA Causeway Center in Boston; three,
transitional probationary period of 28 days in the grant and
per diem programs with co-located outpatient services with
veterans with substance use disorder who would not be
successful in the present-day iteration of GPD programs.
This means that any veteran that goes into a grant per diem
program has a requirement that is part of the congressionally
mandated definition of the grant per diem program has to agree
to go into a sober living environment, which serves maybe
persons with alcohol abuse a little bit more, and is less
useful and problematic with people who have opioid addiction.
Allow me to share a recent story of a veteran challenged by
his substance abuse who found a path to recovery and
independence as a result of the veteran services provided by
Harbor Homes and fellow organizations. Our SSVF and HVRP staff,
again, worked with the 46-year-old veteran who was not eligible
for VA services.
He had been laid off from his job, and then evicted from
his home rendering him homeless. During the needs section of
his intake assessment, he disclosed that he was in treatment
for opioid addiction, and was currently taking Suboxone. The
SSVF and HVRP staff were able to move him into permanent
housing with some financial assistance and secure him a full-
time job.
He received a full benefit package from his employer, which
came with a very high deductible. Because of the major increase
in his co-pay for Suboxone treatment through private insurance,
he could no longer afford it and slipped back into heroin
again. The veteran was facing eviction from his housing, and
his job was at risk due to his job performance. They then tried
to seek through SAMHSA, but because he had been housed through
SSVF, he couldn't fit into their criteria.
The SSVF representative knew that Easter Seals had launched
a new program with Farnum Center and had five beds for
veterans, and within 2 hours he was admitted. He successfully
completed the 28-day program, and today is maintaining his
Suboxone treatment with financial assistance through Easter
Seals Veteran Account Program, and is maintaining his stable
housing and employment.
This story is a clear illustration of how we can move the
dial with our veterans in crisis when we can rely on each other
and reach a common goal. I know we all agree on the premise
that substance misuse among veterans can be the result of many
interrelated moving parts, struggling with opioid drug usage
from readjustment challenges back into civilian life, which
often stem from post-traumatic stress disorder, physical
injuries, and associated pain management.
Although more attention is being given to the issue of drug
addiction among our veteran population, the percentage of
veterans who seek help is still disturbingly low. In our
experience, veterans are more apt to avoid mentioning at the
point of intake that they have a substance abuse addiction or
that they are currently using for fear of stigma, creating
barriers to getting help, and housing, especially when they're
experiencing homelessness.
From my perspective, to evaluate real change in the lives
of veterans we serve, we need to look at housing as a critical
form of health care. By first tending to the veteran's housing,
we can create one tenable link in the braid that is our
involvement with their ultimate success.
Along with other supportive services, we can increase our
connection with them and can encourage their improved mental
and physical health, reduce their dependency on substances, and
increase their earning potential through education and
employment support. All of this will produce a much higher
percentage of those who will be able to maintain their
independence, connect with government and nonprofit services,
and achieve more successful living.
Thank you.
0[The prepared statement of Peter Kelleher appears in the
Appendix]
Mr. Coffman. Thank you, Mr. Kelleher, for your testimony
today.
Ms. Weber, you are now recognized for 5 minutes.
STATEMENT OF CHRISTINE WEBER
Ms. Weber. Good morning, and thank you. I'll speak as a
provider of substance abuse disorder treatment, in Manchester,
New Hampshire, as Ms. Kuster said, the number one public health
concern for New Hampshire citizens, veterans and civilians.
The program that I direct in Manchester serves over 2,000
people a year, and I say ``people'' instead of addicts, or
alcoholics, or other terms that can be used to really separate
us here in this room--
[Disturbance in the hearing room.]
Ms. Weber. Should I speak up? Is that okay?
Ms. Kuster. There you go. You are back on.
Ms. Weber. I am afraid of the microphone now. We are good?
Okay.
So as I was saying, I just wanted to use the term
``people'' because that is who I work with. That is who are
referred to me, military service Member or other--
Mr. Coffman. Just one second. Can those in the audience in
the back hear? Okay, good. Thank you.
Ms. Weber. Great. Thanks.
Mr. Coffman. Please proceed.
Ms. Weber. So my staff is tasked to specifically screen our
prospective clients by asking the question, ``have you ever
served in the military,'' because there are differences with
the citizens that we serve, to inform their care. It is
critical that treatment providers, first responders, emergency
departments, and treatment liaisons understand how to move
forward when a man or a woman answers ``yes'' to that question.
It is not just asking the question. It is informing care
afterwards.
So servicemembers present to treatment with us having
struggled to navigate when and how to ask for help. If you have
heard of the difficulties servicemembers face in accessing
adequate medical surgical care, imagine that struggle and add
on top of it limited bed availability or substantial substance
abuse treatment within the VA system.
For those that are able to identify that they are in need
of help, the highest hurdle next to accessing care is the
stigma associated with it. Our clients have been in country, in
the Yugoslav region, Kuwait, South America, Desert Storm,
Desert Shield, OIF, OEF, New Dawn, various regions of
Afghanistan, multiple stations throughout the world. None of
them imagined the values, conflicts, and the isolative nature
of returning to the United States and contemplating suicide
because of their need to access substance use disorder
treatment.
Prescribers must take the responsibility of opiate
prescribing very seriously. Implementing and enforcing
substance use disorders curricula for students and licensed
practitioners through continuing medical education is an
important step in ensuring that physicians are exposed to the
nature of the biology of chemical dependence. It's my hope that
the VA and other important health care institutions provide
their personnel with ongoing and comprehensive training by
American Society of Addiction Medicine Board, certified peers
and licensed clinicians, not just their own physicians.
Physicians in this State have met with New Hampshire State
Rep Rosenwald to discuss recent bills to include H.B. 1423,
relative to prescribing practices, as well as the PDMP, the
Prescription Drug Monitoring Program, in New Hampshire. It's
concerning to me as a substance disorder treatment provider
that these efforts might result in legislation that's embraced
in language only without enforcement or oversight by the Board
of Medicine.
Prevention efforts, utilization of the esprit and referral
process, physician training and coordination access to
substance treatment, facilities like Vets Choice, are concrete
actionable steps. I'm happy to say within the last couple of
days Vets Choice has finally approved Farnum Center and its
affiliates to be a Vets Choice provider through Medicare. That
was a substantial hurdle in the credentialing process.
Regardless of the MOS discharge status for military
service, we're seeing an increased population in need of
structured clinical intervention support. Without providers and
prescribers taking initiative, the mortality rate for this
chronic and progressive illness will continue to rise.
Thank you for the opportunity to speak here today. I
appreciate it.
[The prepared statement of Christine Weber appears in the
Appendix]
Mr. Coffman. Thank you very much for your testimony, Ms.
Weber.
Mr. Foster, attorney general for the State of New
Hampshire, you are now recognized for 5 minutes.
STATEMENT OF JOSEPH FOSTER
Mr. Foster. Thank you, Mr. Chairman, and I do have some
slides. There we are. Great.
Like many States, the illegal and prescription drug opioid
crisis is the most pressing public health and public safety
challenge facing New Hampshire. It penetrates every aspect of
our society, all socioeconomic groups, all races, each gender,
all age groups. And it adversely impacts our neighborhoods, our
schools, our health care system, our courts, our prisons, our
first responders, our businesses, and our highways.
While prescription opioids and heroin remain extremely
problematic, unlawfully manufactured fentanyl is at the center
of New Hampshire's epidemic. I am going to show some slides
that illustrate the depth of the opioid problem here in New
Hampshire. They were prepared by the State medical examiner,
who is part of our office, and the Department of Safety that
houses our State police.
First slide, please.
As you can see, and as Congresswoman Kuster mentioned
earlier, in 2000 we had about 50 overdose deaths, and in 2015,
420 confirmed with 14 still awaiting toxicology. And I have
been informed as of late February, we already had 60 overdose
deaths here in New Hampshire, so the rate is not decreasing.
Next slide, please.
15 years ago, there were about twice as many highway deaths
as overdose deaths. Today there are 4 times as many overdose
deaths as highway deaths in New Hampshire.
Next slide.
The overdose deaths are prevalent in every region of the
State. This shows places where individuals have fatal
overdoses. As you can see, it is in the most northern part of
the State as well as the southern part of the State. It doesn't
matter what part of the State you are, folks are suffering
overdose deaths.
Next slide, please.
And this shows nonfatal overdoses. Thousands of them have
occurred statewide. The New Hampshire Bureau of EMS reported
that in 2015, 4,235 doses are Narcan were administered around
the State. Sometimes more than one dose is necessary when you
are dealing with a fentanyl overdose. 1, 2, 3, or 4 can be
required to bring the person back.
Next slide, please.
Now, fentanyl and other agents do not discriminate by age.
Every age group has experienced sharp increases in overdoses,
but for the very young, and the very young as you can see from
that slide.
Next slide, please.
Deaths from heroin and fentanyl are fairly new. As you can
see, a decade ago deaths from heroin were quite rate, and
fentanyl deaths did not exist at all. That changed and has done
so with a vengeance.
Next slide, please.
This slide here shows the percentages of deaths that were
caused by fentanyl in New Hampshire. 65 were caused exclusively
or partially by fentanyl, and we're talking about illegally
manufactured fentanyl that comes up mostly from Mexico, and
makes it way often to Lawrence, Massachusetts or New York City,
and then into our State.
And you can take the slides down.
So what actions is the State doing to address the epidemic?
Very broadly speaking, there's really two areas to address the
problem. On the supply side, that's mostly a law enforcement
function, and on the demand side, broadly speaking, a public
health and education function. We cannot arrest our way out of
the problem. We need to reduce demand, and with that supply
will drop. That said, addressing supply and demand both are
critical.
There are a number of law enforcement initiative taking
place within the State and across State lines. This morning I
was, in fact, talking to Attorney General Healey from
Massachusetts to try to coordinate around the problem in
Lawrence. But the problem simply doesn't stop at the State
borders. Interrupting supply requires cooperation by and
between our Federal, State, county, and local law enforcement
agencies, and that is ongoing.
One initiative recently underway is treating overdose
deaths as crime scenes. You would think that has happened, but
it generally has not happened in the past. They're now being
investigated as a crime scene because a crime has been
committed there. The goal is to hold those who sold drugs to
the victim accountable, and also gather information so it can
get the ultimate source of the drugs and try to disrupt the
supply into the State.
A lot has happened on the public health side, and in many
ways I would say that's more important. In November, our
governor called for a special session of our legislature. The
House and Senate convened and passed a bill to form a 25-member
opioid task force made up of representative and senators. The
task force worked aggressively over several weeks and came up
with a number of legislative proposals. Many of those proposals
were recommended by the governor's office working closely with
a group of her department heads, who she gets together every
Wednesday morning. A number of departments are impacted. HHS,
Education, Corrections, my office, and other departments, we
meet and we make sure this issue is being moved along. So this
has been truly a bipartisan effort as it should be.
Some of the legislation already passed includes requiring
physicians to query the State's prescription drug monitoring
program in most instances. Before, they only had to register
but not use it. And it also requires prescription data to be
submitted daily. It mandates safe opioid prescribing education
for prescribers, and it places pain specialists on the Board of
Medicine to ensure expertise when reviewing treatment providers
for professional misconduct.
Legislation that's still in process includes expanding
funding for our drug courts, reauthorizing New Hampshire's
Health Protection Plan. That's our unique form of Medicaid
expansion that was adopted in the State. This is key to
expanding the State's inadequate treatment network. The plan
includes, among other things, of course a substance abuse
benefit. If the plan is reauthorized, the provider network will
follow because for the first in the State, providers will have
a reliable source of payment.
Finally, there's a bill--it was mentioned by Ms. Weber--
mandating the adoption of safe and responsible opioid
prescribing rules by the professional boards which oversee
prescribers of opioids, and my office has been a key driver in
that. And so why is that important? Simply put, we need to stop
creating new addicts. Overprescribing is a huge problem in our
country with about 5 percent of the world's population. Some
way, Americans consume 80 percent of the world's opiates. In
New Hampshire, the problem is more severe than in many other
parts of the country as we rank near the top in the amount
long-acting extended release opioids and high dose pain
relievers prescribed.
Overprescribing of prescription opiates had led to our
heroin problem. According to the CDC, 4 out of 5 heroin addicts
were first addicted to prescription opiates. In other words,
the prescription opiates led to the fentanyl and heroin deaths
I was showing in the slides earlier.
That's why the CDC has issued draft opioid prescribing
guidelines, which is supported in a letter co-authored with
Attorney General Pam Bondi of Florida, which was joined by 34
other States attorneys general in just 2 business days. So it
gives you a sense of the depth of the problem nationwide.
The rules before the legislature adopt many of those
guidelines and will require a thoughtful approach to
prescribing opiates, and with that, over time, less patients
becoming dependent or addicted on opioids. I'm pleased to
report that that bill recently passed its first hurdle in
Committee with an 18-0 ought to pass recommendation to the full
House.
Thank you for allowing me to provide you with an overview
of the problem here in New Hampshire. While many of the actions
being undertaken at the State level will benefit the veteran
population, more needs to be done I know. As you know, the
veteran population has been hit especially hard by the
epidemic, and I applaud the work of your Subcommittee. And
thank you for you taking the time to come here to New Hampshire
to hear from myself and the rest of the speakers.
Thank you, Mr. Chairman.
[The prepared statement of Joseph Foster appears in the
Appendix]
Mr. Coffman. Mr. Foster, thank you so much for your
testimony.
Dr. Franklin, you are now recognized for 5 minutes.
STATEMENT OF JULIE FRANKLIN, M.D.
Dr. Franklin. Good morning, Chairman Coffman, Ranking
Member Kuster, and Members of the Committee. Thank you for the
opportunity to discuss VA's pain management programs and the
use of medications, such as opioids, to treat veterans
experiencing acute and chronic pain. I am accompanied today by
Dr. Grigory Chernyak, chief of anesthesiology and pain service
at the Manchester VA Medical Center.
Chronic pain affects a large portion of the veteran
population with about 50 percent of veterans in VA's health
care system living with some form of chronic pain. The
treatment of veterans' pain is often very complex. Many
veterans have survived severe battlefield injuries resulting in
lifelong, moderate, to severe pain related to damage to their
musculoskeletal system and permanent nerve damage, which can
impact their physical abilities, emotional health, and central
nervous system.
Chronic pain management is challenging for veterans, their
families, and clinicians. VA continues to focus on identifying
veteran-centric approaches that can be tailored to individual
needs using medication and other modalities. Opioids are an
effective treatment for some patient, but they're use requires
constant vigilance to minimize risks and adverse effects.
VA launched a system-wide opioid safety initiative in
October of 2013, and has seen significant improvement regarding
the use of opioids. Today, 105,000 fewer patients are on long-
term opioid therapy, and the overall dosage of opioids in the
VA system is decreasing.
In March 2015, VA launched the new Opioid Therapy Risk
Report tool, which provides detailed information on the risk
status of veterans taking opioids. This assists VA primary care
clinicians with pain management treatment plans. The tool is a
core component of VA's reinvigorated focus on patient safety
and effectiveness.
VA data, as well as peer reviewed medical literature,
suggests that VA is making progress relative to the rest of the
Nation. In December 2014, NIDA-sponsored health service
researcher, Dr. Mark Edlund, and his colleagues published an
article in the journal Pain. This study of VA pharmacy and
administrative data looked at VA opioid prescribing practices
for the treatment of chronic non-cancer pain.
The study found that approximately 50 percent of veterans
in this cohort received an opioid as part of treatment. Half of
these veterans only received them short-term for less than 90
days per year. The average daily dose in VA is 20 morphine
equivalents, which is considered modest. VA patients with
substance use disorder did not receive high-volume opioids at
increased rates as has been documented in the non-VA
population.
The improvements reflected in this study and since signal
an important downward trend in VA's use of opioids. VA expects
this trend to remain as it continues its efforts to promote
safe and effective pain management therapies.
Manchester VA has established acupuncture and
interventional pain programs, and is developing a chiropractic
program. Eventually, these services will be part of their
functional restorative pain center. Both Manchester and White
River Junction VAs' have interdisciplinary pain teams. These
interdisciplinary teams include pharmacists, mental health
specialists, physiatrists, primary care, and pain specialists.
The teams discuss challenging cases and, when appropriate,
invite patients to participate.
Since 2011, White River Junction Pain Clinic's monthly
patient visits have increased from an average of 40 patient
visits per month to over 160. Our availability to see patients
has increased, and we have added services, including a chronic
opioid therapy clinic, acupuncture, and chiropractic care.
Interventional pain procedure volume has increased during
the same period from 20 per month to over 60. From its May 2014
opening through December 2015, the Chronic Opioid Therapy
Clinic saw a significant decrease in the number of veterans
treated with high dose opioids. Many patients have told us they
feel much better since they've reduced their medication doses.
For example, one patient was able to travel to Florida with his
wife after spending many years homebound.
In conclusion, VA continues to research pain treatment,
complementary and integrative medicine, and opioid abuse. VA
has been at the forefront of pain management techniques, and we
will continue to innovate to better serve the needs of
veterans.
Mr. Chairman, we appreciate this Committee's support and
encouragement in identifying and resolving challenges as we
find new ways to care for veterans. We are prepared to respond
to any questions you may have.
[The prepared statement of Dr. Julie Franklin appears in
the Appendix]
Mr. Coffman. Dr. Franklin, thank you so much for your
testimony and for all you do for our veterans.
Walgreens launches a Safe Medication Disposal Program in 39
States. Dr. Franklin, are you aware of a safe medication
disposal program or drug takeback program available to veterans
at the VA?
Dr. Franklin. Yes. We have, I believe, two different
methods. The one I could speak most accurately is that patients
can pick up an envelope, which we will send their medications
to a centralized repository for disposal.
Mr. Coffman. The media has reported that only 52 out of 153
VA medical centers offer alternative therapies to veterans. Dr.
Franklin or Dr. Chernyak, although both of your facilities do
seem to offer alternatives, why do you think these therapies
are not offered at all VA facilities? Who would like to start
with that?
Dr. Chernyak. I would like to say to you, Mr. Chairman and
Ranking Member--
Mr. Coffman. I do not think your microphone is on. We might
have to shift microphones there.
Dr. Franklin. He can use mine.
Dr. Chernyak. First of all, I would like to thank you,
Chairman Coffman, and Ranking Member Ms. Kuster, and other
Members of the Committee to allow me to be here and speak.
I think one of the problems is that not too many
specialists are trained in alternative techniques, such as
acupuncture. The other problem is that as far as I know, VA
cannot even hire acupuncturists. Acupuncturists are being hired
as health technicians with pretty low salary. That is why for
the most they are not really interested to work at the VA.
And MDs practice acupuncture at the VA, but there are not
too many MDs who are trained in acupuncture. And chiropractors,
too, can practice acupuncture at the VA. And, again, there are
not too many chiropractors who are specialized in acupuncture.
So VA just recently started chiropractors, as far as I
know, a few years ago, and the situation has been improving,
but it is still not as good as we would like it to be.
Mr. Coffman. I think probably the capacity under the Choice
Program is probably somewhat limited in terms of utilizing
practitioners within the community that are not in the VA.
Okay, that is something that I think the Committee could look
into.
Mr. Foster, in your testimony you noted a recent piece of
State legislation that was passed that requires physicians to
query or ask the State's prescription drug monitoring program
in many instances, and it requires prescription data to be
submitted daily. Do you have any idea or any data on the
compliance rate with this requirement?
Mr. Foster. The effective date is that into the future.
Mr. Coffman. Oh, okay.
Mr. Foster. I can tell you, though, that registrations, we
were late to adopt prescription drug monitoring program. I
think we may have been the 48th or 49th State to do it. It went
into effect in October of 2014. It required physicians and
other prescribers to register. We have had very compliance
around that, so I am hopeful that that is a sense of how people
will take it when they have to start utilizing it as well.
I would imagine it is going to be good. I know that there
is commitment to educate folks around it, and also to make the
system more user friendly. It is going to be upgraded so it is
easier to use for physicians.
Mr. Coffman. Do you, if VA physicians are complying with
that? I know probably Federal versus State it would probably
have to be voluntary, but do you know if they are voluntarily
complying with that?
Mr. Foster. I do not, and I know there has been a question
around whether they have to comply.
Mr. Coffman. Okay. Dr. Franklin--
Mr. Foster. Dr. Franklin--
Mr. Coffman [continued].--can you comment on that?
Dr. Franklin. I can address that question.
Mr. Coffman. Sure.
Dr. Franklin. The VA does require annual interrogation of
State prescription drug monitoring programs.
Voices. We cannot hear you.
Mr. Foster. I said the VA does require use of State
prescription drug monitoring databases, and we have begun to
measure this in VISN 1 to make sure that we are looking at
least annually for every patient. Both physicians and
pharmacists can use the database, and we make a note for the
patient's chart.
Mr. Coffman. Okay. But is that reporting just to VA
authorities, or do you also plan to report to the State?
Dr. Franklin. I believe that New Hampshire is reporting at
this time. Vermont was reporting to the State of Vermont, and
because of a switch of vendor had to stop.
Mr. Coffman. Okay. Thank you very much.
Ms. Kuster, you are now recognized for 5 minutes.
Ms. Kuster. Sure, thank you. Just to follow-up on this, one
of the issues where New Hampshire is such a small State, and we
have the border with Vermont and Massachusetts and Maine that
Mr. Guinta and I are addressing is an interstate prescription
drug monitoring. And then also, just to note that our Committee
last week did add an amendment offered by our colleague, Jackie
Walorski from Indiana, to increase VA compliance with
prescription drug monitoring. So I think it is definitely a
critical component.
And part of what made it slow in New Hampshire is it was a
voluntary program, and I think it is critically important that
all physicians and treatment providers participate.
So I wanted to address my questions to Dr. Franklin and Dr.
Chernyak, and if you could just describe a little bit more the
program first at White River and then in Manchester for
engaging the trends. As it was described to me, it is very
hands on. It includes drug monitoring. If you could just share
with our audience, and I want to welcome all who are here. We
have a number of veterans groups and veteran interest groups.
We also have civilian providers. And the goal coming out of
this would be to educate the civilian treatment community on
the success that you have been having, so if you would share.
And you will need to speak like right into the mike. Yeah,
thank you.
Dr. Franklin. Thank you. Thank you, Congresswoman Kuster. I
believe you are referring to our Chronic Opioid Therapy
Treatment Clinic, which it really targets high dose, high-risk
veterans, so patients receiving greater than 100 morphine
equivalent daily dose, or patients with significant risk for
abuse or misuse.
We take all referrals, of course, and give them a two-hour
educational program. We then obtain their consent for treatment
with chronic opioid therapy and a baseline urine drug screen.
They then have a 90-minute individual with our nurse
practitioner where she reviews their history, further educates
them, performs a physical examination, and reviews previous
laboratory results. The veteran and our nurse practitioner then
discuss a treatment plan.
The veterans are followed every 28 days. They come in,
typically again will leave a urine specimen for evaluation, and
other treatments are offered. We may wean doses if we feel that
they are not effective as high doses may actually increase
pain. Patients often voluntarily reduce their dose when they
really understand how risky these medications are, and other
treatments are offered such as acupuncture, chiropractic care,
et cetera.
Ms. Kuster. And have you found that you have been able to
decrease the dosage or decrease the use of opiate medication?
Dr. Franklin. We have decreased the doses significantly. In
our highest dose group, those receiving greater than 400
morphine equivalent daily dose, we have reduced those patients
by 50 percent since the clinic started.
Ms. Kuster. So 50 percent is a dramatic decrease.
Dr. Franklin. It is a dramatic decrease.
Ms. Kuster. And could you just comment, if you will, and
even anecdotally just quality of life for people that had been
essentially debilitated by either chronic pain or the
combination of chronic pain and opiate medication?
Dr. Franklin. Yes. Well, for example, we have some patients
who have become much more functional and are enjoying life
more. Typically, they describe their pain as similar.
Occasionally, they have reduced pain as a result of decreasing
medications that may be causing opioid hyperalgesia. We have
had some patients who are now on Suboxone as they really were
suffering from substance use disorder more than pain, and their
quality of life has also significantly increased.
Ms. Kuster. Great. Dr. Chernyak, I just have a minute left
in my time this round, but we will come back to it. But could
you just add anything from Manchester?
Dr. Chernyak. Yeah. In Manchester, we recently started
developing our pain program because it was pretty much
dysfunctional until recently. And I came on board about 6
months ago, and I established a pretty robust acupuncture
program, and I started doing some pain interventional
treatments. And we recently were able to recruit another
provider who is a chiropractor with strong emphasis in
acupuncture. So he used to work in Oklahoma City VA Medical
Center where I used to work, and I brought him with me
actually. So now he joined our group.
And so, we started treating a lot of patients with
acupuncture, and he started doing some chiropractic
manipulations as well. And we now are going to add one more
treatment modality, which is called for by modulation. It is
like low power laser treatment, which is a pretty powerful tool
for treating pain and other disorders like chronic pain and
some other things like non-healing ulcers, for example.
So we are moving forward, and now we are developing a
program which would consolidate pretty much all services that
are taking care of chronic pain patients under one roof. That
would allow better coordination between services because now
they are all separated and working under separate service
lines, such as psychiatry, rehab, surgery, and anesthesiology.
But we are going to try to solidify them, consolidate them, and
work under one philosophy, if you will. And that would allow
much better care for our patients.
That is our future plans for the nearest future actually.
We are actually working on this project right now.
Ms. Kuster. Great. Thank you so much. I yield back, Mr.
Chair.
Mr. Coffman. Thank you, Ms. Kuster. Mr. Guinta, you are now
recognized for 5 minutes.
Mr. Guinta. Thank you, again, to the panelists for being
here today. I also want to extend our thanks and appreciation
to General Rodell for--
Ms. Kuster. Yes, thank you.
Mr. Coffman. Yes.
Mr. Guinta [continued].--the use of the facility. He was
here in the beginning of the hearing, and I am sure has to
attend to other duties, but wanted to acknowledge him on the
record.
First, I want to talk to Mr. Foster. Thank you for being
here. I agree with you that the focus here has got to be supply
and demand, that you have to deal with both. So there is a
public safety aspect that I think needs to be addressed. If we
have the time later I want to talk to you about that because I
think we need to be on the offense, and we need to be very,
very specific about the tools, particularly whether it is State
or Federal law that we need to utilize.
I want to talk to you more about the demand because you had
talked about a couple of things that the governor's commission
and the legislature is working. One, you talked about drug
court funding. I totally support that. That is completely
necessary in order to deal with this as a tool. But the other
thing you talked about is doctors have the use of the PDMP.
Would it surprise you to know that I have spoken with, and
I agree that they need to utilize that. I have talked to
doctors as recently from New Hampshire as last week who have
told me that it is an old system. You are in a hospital, and it
takes sometimes 45 minutes to access it, and as a result of
that, cannot get current information about a patient that they
are treating at that particular moment. So that has been a
frustration expressed to me. I have talked to the medical
society about it here in New Hampshire. They concur with that
opinion.
So I was asked to bring that up here today and see what
specifically can be done to expedite the improvement of that
system.
Mr. Foster. Thank you for the question. As I mentioned, the
mandatory use of it was pushed forward, and I should say that
House Bill 1423 actually requires even more extensive use of
it, and that effective date is January 1st. And the reason for
that is an acknowledgment that the system is, I guess I will
call it, clunky. It is being integrated into EMRs in certain
hospitals to make it easier to get to, but it does have to be
upgraded.
One of the things I did not mention is, there is additional
funding. Believe it or not, the State until recent legislation
was passed had a requirement that no State funds be utilized
for the PDMP, a very New Hampshire notion I suppose. It was
being funded by grants. They have now changed that, and there
is some funding coming in. There is also some grants that came
in from the Federal government, and it is being utilized to
upgrade the system.
So I have heard that is a problem. It has to be reasonably
easy to use. I happen to be married to a physician. I know how
crazy their day is. It is a dynamic profession with more and
more demands on it, and it has to be easy to use; otherwise, we
are not going to see it.
One of the things I would love to see happen is the State
of New Jersey has developed actually a mobile app for their
State PDMP. It would be wonderful if that could be utilized
nationwide.
Mr. Guinta. Which is very similar, I mean, I have an app
that I use for my health care that I can monitor and manage
exactly from my phone when I need an appointment, what
different levels I have. I mean, we should be able to use that
kind of technology for this specific kind of circumstance.
Do you have a sense of how timely the resources, the funds
would be available to make the upgrade, and then how quickly
the upgrade can be made, or is that something you--
Mr. Foster. Only to a limited degree. The individual who is
responsible, I have talked to her recently. They are talking to
the vendor, and my sense is things are on track and that we can
meet the dates, you know.
Mr. Guinta. I think that is critical. The reason this is
important and physicians are saying it is important is they
want to contribute favorably to knowing when a patient is seen,
whether it is an emergent situation or on a regular basis, to
verify if they are doctor shopping--
Mr. Foster. Absolutely.
Mr. Guinta [continued].--and how they are getting access.
That is why physicians are saying to me it is critical that we
focus on this so they have adequate ability to verify
information.
I want to go to Ms. Weber very quickly. Mr. Kelleher
mentioned 15 to 25 percent of veterans are, and I think he used
the term ``suffering from substance use disorder.'' So that
percentage could probably be wider depending on your
definition. Given your position at the Farnum Center, can you
give us an idea of those 2,000 people, how many are vets, and
then subsequently, what are the obstacles that vets are sharing
with you in terms of access to care here in our State?
Ms. Weber. That is a good question. Since June of last
year, we have served 30 servicemembers in our inpatient
program. That is medical detox and our PHP residential program.
Some of the unique challenges on an outpatient basis, working
with Reserve members and servicemembers that need to report for
drill, is there is concern around what is reported to command.
If a servicemember is working with one of my staff and they
are saying that they are struggling either with substance abuse
or another risk factor with that, not reporting to drill, is
that going to be reported. So there are concerns, and we have
partnered with members of the National Guard in making sure
that that is not a barrier in accessing care, some of that real
legitimate concern. This is their livelihood.
The second piece is really being able to support their
family while they are in treatment. I think there is this
belief that if you have an active substance use disorder, you
do not function in life. But these are people that are working.
They are employed. They are supporting families. They are doing
the best that they can, and they often have relatively unstable
housing situations, like the gentleman at the end of the table
spoke of, where they are not able to leave and invest time in
themselves to take care of the treatment that they need to
support recovery.
Those are a couple of the issues that come to mind.
Mr. Guinta. Thank you. Yield back.
Mr. Coffman. Thank you, Mr. Guinta, for your questions and
for being here today for the people of New Hampshire.
Recently a VA nurse pled guilty to stealing opioids while
on duty. What is VA's policy for tracking opioids within the VA
health care system?
Dr. Chernyak. I can talk only for anesthesia pain division,
so I cannot talk for any other departments. But we have a
machine called Omnicell. In order to check out opioids we need
to sign in, check out necessary dose for a particular patient,
and then if you have not used the entire dose, you have to
waste it with a witness. And both witness and the person who is
wasting medication has to enter this information into this
Omnicell machine and specify how much was used.
Mr. Coffman. I am going to have to ask everybody to speak
up in the microphone. The acoustics in this room are just a
little bit challenging, and--
Dr. Chernyak. I was talking about using Omnicell machine
where we need to sign in, check out medications and then for
every particular patient. And then if something left over, we
need to waste it with a witness. And both witness and the
provider who used the medication should indicate the dose,
which was actually delivered and the dose which was wasted. So
that is how we keep track.
And pharmacy always checks, and if there is any
discrepancy, they immediately send us notifications. That is
the way we do it in our department, anesthesia and pain anyway.
Mr. Coffman. Dr. Franklin?
Dr. Franklin. There are both legal and joint commission
standards related to the tracking and disposal of controlled
substances. The VA complies with those. Typically when a--
Mr. Coffman. Speak up just a little bit more, please.
Dr. Franklin. Typically when a provider, such a nurse or
physician who has access to these medications becomes addicted,
it is about 30 days before they are either discovered or
unfortunately found deceased at work.
Mr. Coffman. Okay.
Dr. Franklin. I think that is how these instances typically
come to light.
Mr. Coffman. Okay. Dr. Franklin, your testimony references
10 different programs, working groups, committees, et cetera,
that were developed to deal with pain management. But what
successes have these group had? Does VA have proof they are
working?
Dr. Franklin. Well, the VA certainly has proof that the use
of opioids has decreased. Measuring such things that are
important to veterans as quality and level of function is much
more difficult and hard to do on an aggregate level. Certainly
people have stories of veterans who are doing well.
Mr. Coffman. Okay. Are there hours or how many hours of
patient care are lost due to these groups? Is that
quantifiable?
Dr. Franklin. It is very hard to quantify. Most of the
groups actually meet over lunch hours and that kind of thing,
so they do not interfere significantly with patient care.
Mr. Coffman. Mr. Foster, your office launched an
investigation into the marketing of pharmaceutical drugs. Can
you comment on the findings of this investigation?
Mr. Foster. I wish I could. The pharmaceuticals are
fighting us in discovery at this point in time, and so we have
not been able to get full-blown discovery from them as of yet.
I know a lot of my fellow AGs are launching similar
investigations.
I heard yesterday that General Schneiderman from the State
of New York reached an agreement with NDO. You may have heard
that in the news last night where they are going to terminate
improper marketing. Obviously the concern here is that use of
opioids, I think, between 1999 and 2010 quadrupled in our
country. There are a fair amount of literature and other
suggestions that part of that was the marketing of some of
these opioids.
The notion was that if your patient had real pain, they
would not become addicted particularly to the long-acting
opioids because they were more uniform in the way they
delivered the medication, and that just does not seem to be
true at all. It seems completely false.
Back some years ago, one or more of the opioid companies
said they would stop mis-marketing. We are trying to determine
whether that is, in fact, the case. We have some doubt about
that.
Mr. Coffman. Okay. Thank you very much, Mr. Foster. Ms.
Kuster, you are now recognized for 5 minutes.
Ms. Kuster. Thank you. Thank you, Mr. Chair. Again,
directing to Dr. Franklin and Dr. Chernyak, one of the concerns
that I have is reports across the country that some veterans
with chronic pain who have their opioid prescriptions reduced
have not been given sufficient support services. So they might
have had the prescriptions reduced, canceled without notice, or
not giving them the full range of treatment options, and, thus,
leading them if they are dependent upon opioids to obtain
prescription opioids illegally or use heroin.
How is the VA ensuring that these veterans receive the
appropriate treatments for chronic pain or opioid dependence?
And how do you balance for veterans with cancer pain or type of
pain that they need treatment going forward? How are you
striking this balance to make sure that they are not becoming
dependent?
Dr. Franklin. To start answering the first part of your
question--
Ms. Kuster. And can you speak up?
Dr. Franklin. Yes.
Ms. Kuster. It is very difficult to hear.
Dr. Franklin. Sorry. I apologize. I believe that this has
to be a case-by-case answer. Every patient needs different
treatment. They are a different point in their disease. They
have different options available to them.
I can speak to our VA, and we offer treatment to every
patient, additional pain treatments. Often, it is not something
they are interested in at the time when we are seeing them. We
are able to offer substance use disorder treatment really
immediately in most cases.
The chief of the Substance Use Disorder Treatment Program
at White River Junction will come and meet with us and meet
with the patient when we are talking about our concern for
substance use disorder driving their use of opioids.
It is hard to, you know, make a rule that will affect this
across the country. But I think hiring good people and making
sure that they have the time to do the work that they need to
do is a right step. And if you would remind me of the second
part of your question.
Ms. Kuster. Well, I think you have addressed it.
Dr. Franklin. Okay.
Ms. Kuster. We will hear from Dr. Chernyak. And then one of
the things that has been very helpful, and I think Mr. Kelleher
brought it up as well, is the concept of ongoing professional
education and medical education on pain management and opioid
prescribing practices.
So, Dr. Chernyak, if you have anything to add.
Dr. Chernyak. Dr. Franklin mentioned that it has to be
addressed case by case, and I completely agree. I am just going
to give you one example. Probably this week, we had a patient
who was expressing some dissatisfaction. He is an opioid
patient. He had pretty significant injuries to his lumbar spine
and thoracic spine.
Mr. Coffman. Please speak up a little bit.
Dr. Chernyak [continued]. In a significant amount of pain.
And he has been on high doses of opioids, and attempts to
reduce the doses or change the opioid regimen was not actually
welcomed by him because he was very concerned. And he did not
feel like he was cured well enough.
So what we did, we invited him for our interdisciplinary
conference and discussed his case with him. It was like three
different physicians, providers. We discussed everything with
him very carefully, and when he left he was in a completely
different mood. So he felt he was really cared about, that he
had three different physicians sharing their opinions not only
between each other, but with him as well. And that actually
changed his attitude completely.
So eventually he agreed with our plan of action. He agreed
to switch from opioid to another to reduce the dose, morphine
equivalent dose. He agreed to add some other complementary
options, such as acupuncture and other things. So that is just
one example how we handle this patient. So we invited him for
our discussions.
Ms. Kuster. Great, thank you. My time is almost up, but,
Mr. Kelleher, and maybe this is something we could discuss
offline for legislation that we hope to introduce. But you
mentioned about the grant per diem programs, and I am wondering
how the VA could do a better job designing the program to best
treat veterans struggling with opioid use disorder.
Mr. Kelleher. The Grant and Per Diem Program was authorized
by Congress quite a while ago. I think it is more than 20 years
ago.
Ms. Kuster. Can you speak right into the mike?
Mr. Kelleher. It predates all of the opioid crisis that we
are facing now. And, you know, it has a requirement that
whenever a veteran enters, they must agree to going into a
sober living environment. And it works better for persons who
are struggling with alcohol abuse, but as we see people coming
in with opioid addiction, their ability to truly be able to
function immediately in a sober living environment is very
hampered.
And so, I think on the front end, we could benefit from
more flexibility to accommodate the opioid addicted population,
say, having the first 30 days or 45 days be a place that will
allow a connection and treatment to occur and detox.
Ms. Kuster. Great. Thank you very much.
Mr. Kelleher. Thank you.
Ms. Kuster. Thank you. And thank you all for your
testimony. I am all set. And thank you, Mr. Chair.
Mr. Coffman. Mr. Guinta, you are now recognized for 5
minutes.
Mr. Guinta. Thank you, Mr. Chairman. I want to follow-up on
what Ms. Custer was just talking about. So the VASH Program you
have, there are some restrictions in terms of the resources
that come from the Federal government to New Hampshire. And I
have talked to LaBrie House, for example, in Manchester about
that express concern.
I think in your original testimony, I do not know if you
used the term of ``housing first.'' I thought that is what I
heard. The housing first model gives more flexibility and would
allow somebody who is using a substance to gain housing first
then treatment. Is that the kind of flexibility that you are
suggesting?
Mr. Kelleher. Yes. Our organization has tried hard to
implement a housing first approach, which basically provides a
roof over somebody's head first, and does not place
requirements on treatment, sobriety, and many other things that
are barriers, especially for veterans trying to access
permanent housing.
Mr. Guinta. And if you can try to speak directly into the
mike if you can. So I support a housing first model. I did not
at first, and I had experience with this when I was mayor of
Manchester. And we saw adopting a housing first model greatly
impacted the opportunity to help somebody who was an abuser or
in a substance use circumstance, whether it was a drug or
alcohol, particularly also because there was a dual diagnosis
component there with a mental health component. So that is
something if we could work on trying to provide flexibility
with HUD, that is something that you would utilize.
Mr. Kelleher. Yes. We are fully supportive of it, you know.
Over decades, veterans trying to access housing with barriers,
really housing first just allows for, just really getting
somebody in a safe, secure place that they can call home, and
then worry about how to access all of the treatment and
whatever else they might need in their life at a later point in
time.
Mr. Guinta. All right. Thank you, Mr. Kelleher. Dr.
Franklin, can you talk to me a little bit about both in New
Hampshire and Vermont, if you feel that we are providing
adequate alternative services to pain management relative to
opioid use.
Dr. Franklin. It is difficult to assess what does
``adequate'' mean. We feel based on our limited experience so
far, that there is a very high demand for alternative services,
particularly acupuncture. We are as a VISN, so the New England
region, increasing availability of acupuncture services.
Whether we will meet the demand is something that we will have
to see. And yesterday, we had a meeting with the network
director and talked about how to measure that and how to
respond if we find access issues.
Mr. Guinta. Do you get a sense of whether is an
appreciation now within the physicians at the VA that
alternatives should be a priority, or is there still an
expectation that ongoing opiate prescription is going to
continue, prescribing is going to continue?
Dr. Franklin. I think what we are looking for is a balanced
treatment. So for some patients, we think that opioids are
appropriate long term, and for other patients they are of
limited or no value. I do not see much resistance among
clinicians at the VA to engaging other therapies.
Mr. Guinta. The reason I ask that because back in 2015,
there was a Center for Complementary and Integrative Health
report that noted specifically, ``Opioids have not been shown
to be superior to non-opioid pain relievers for treating
chronic pain.'' And I think there has been a widely used
threshold that there is not an alternative, whether it is in
the VA or outside of the VA. So I think that is an important
issue to highlight as we try to steer people away from opioid
use, the supply and demand issue that our attorney general had
talked about.
I want to go to the Choice Card because my colleague,
Congresswoman Kuster, and I have co-sponsored the legislation.
Mr. Coffman is an advocate of this, of trying to fix the
challenges within the Choice Card system. I want to make sure
that a veteran, if they cannot access to whether it is
chiropractic care, or acupuncture, or any alternative at the
VA, how can you assist them utilizing the VA Choice Card to go
somewhere else whether they live on the border of New Hampshire
and Vermont, or whether they live in the southern part of our
State, or up north.
Dr. Franklin. Well, we actually refer to Choice frequently
for things like acupuncture. It is an ongoing treatment so the
patient would have to come to White River every week for
several weeks to get treatment, and we prefer--
Mr. Guinta. Well, how can we solve that? If, say, you live
an hour and a half away. You should not have to drive all the
way to White River. The Choice Card, the point behind it is
that if you live in Manchester, you should be access care in
Manchester. If you live in Portsmouth, you should be able, or
Hanover, or Keene. So that is part of the goal of the
legislation that we have filed, and this is what I hear from
veterans. The point of the card was accessibility and localized
accessibility.
If you could work with us on trying to figure out how to
resolve that issue, whether it is technical corrections in the
law or whether it is administrative at the level of the VA in
Washington. I would be happy to work with you on that on behalf
of veterans.
Dr. Franklin. I would be happy to work with you.
Mr. Guinta. Okay. Thank you. I see my time has expired, so
I would yield back.
Mr. Coffman. Thank you, Mr. Guinta. I want to thank
everybody for their testimony today. And one thing I just
confirmed with Ranking Member Kuster that when we go back to
Washington, we are going to certainly look into this issue
about veterans being able to access alternative care within the
Choice Program. When you do not offer a particular service that
they ought to be accessing in terms of for pain management, are
there any regulatory impediments for that under the existing
Choice Program as written. And we will be putting out a joint
statement with Mr. Guinta as a participant in this hearing also
on that statement.
Our thanks to the witnesses. You are now excused.
Today we have had a chance to hear about alternative
treatments for chronic pain management, some provided with VA
and some not provided with the VA. Of those programs provided
by VA, many are limited to only a few facilities, constricting
the value that could be provided to our veterans.
This hearing was necessary to accomplish a number of items,
to demonstrate that there are alternative treatments available
for chronic pain management, to discuss VA processes for
sharing best practices across the country, and to allow VA to
inform this Subcommittee what it plans to do to improve
coordination of care for all of our veterans.
I would like to once again thank all of our witnesses and
audience members for joining in today's conversation,
particularly Ranking Member Kuster for bringing me out here
today.
Ms. Kuster. I look forward to my trip to Colorado.
Mr. Coffman. She is quite the champion for the State of New
Hampshire. And so, there was no option in doing that.
[Laughter.]
Mr. Coffman. I ask unanimous consent that all Members have
5 legislative days to revise and extend their remarks, and
include extraneous material.
Mr. Coffman. With that, this hearing is adjourned.
[Whereupon, at 11:54 a.m., the Subcommittee was adjourned.]
A P P E N D I X
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Prepared Statement of Peter Kelleher
March 4, 2016
Addressing VA Opioid Prescriptions and Pain Management Practices-
Testimony
Peter Kelleher-President and CEO, Harbor Homes and the Partnership
for Successful Living
Thank you to Congresswoman Kuster and other distinguished Committee
Members and guests, for this opportunity to address this important
issue that is plaguing our veterans and their families. In my role on
the Federal VA Advisory Committee on Homeless Veterans, we have
discussed a wide range of topics on veteran homelessness and I look
forward to delving further into this conversation.
I am here representing Harbor Homes and the Partnership for
Successful Living, a collaboration of six non-profits in the Greater
Nashua Area that integrate care on the topics of homelessness,
behavioral and primary healthcare. We offer over 80 programs and
operate a federally qualified health center (FQHC) for low income and
homeless individuals where we often serve veterans who may not qualify
for VA healthcare. We operate 8 veteran-specific programs: a SSVF
program, a highly successful HVRP program, 4 GPD programs, a project-
based VASH program, and a robust SAMSHA program.
As a partnership, we offer a myriad of mental health, substance
abuse, and dual diagnosis programs, especially out of our Harbor Care
Health and Wellness FQHC and Keystone Hall, one of the largest
substance use providers and treatment centers in the state. In our
clinic, we offer medication-assisted treatment (MAT) and are
endeavoring to provide a full range of MAT services including
methadone, under one roof.
Data is varying, but our agency staff reports that approximately
45-65% of the active veterans we are serving are suffering from a
substance use disorder, and that 15-25% of them are specifically
struggling with opioid abuse. The population of veterans who are
willing to reflect addiction as a disability upon intake into the
congressionally mandated Homeless Management Information System,
frequently cite both alcohol and drug use. For example, in 2014 and
2015, 99% of the veterans citing substance abuse reported a disability
with both alcohol and drugs. The majority of the veterans we work with
prefer to admit to alcohol abuse despite their addiction to other
substances. Our population frequently represents individuals who have
not been affiliated with the VA healthcare system and therefore have
not been prescribed opiates for pain and instead self-medicate with
whatever is readily available.
We have and continue to work in tandem with the VA and other
statewide veteran serving agencies, to combat the substance abuse
crisis. It is indisputable by all veteran serving stakeholders, that
access to more treatment options and more lengthy aftercare is critical
in solving this opioid crisis.
Please allow me to list three suggestions that should be
considered:
1)Broaden the VA healthcare services to serve more veterans,
2)Approval for VAMCs to provide a full range of medication-assisted
treatment services such as those provided at the Causeway Center in
Boston,
3)Transitional, probationary period of 28 day GPD beds with co-
located outpatient services for veterans with SUD who would not be
successful in a present day iteration of GPD programs.
Allow me to share a recent story of a veteran, challenged by his
substance abuse, who found a path to recovery and independence as a
result of the veteran services provided by Harbor Homes and fellow
organizations.
Our SSVF and HVRP staff began working with a 46 year old veteran
who was not eligible for VA services. He had been laid off from his job
and then evicted from his home, rendering him homeless. During the
``needs'' section of his intake assessment, he disclosed that he was in
treatment for opioid addiction and was currently taking Suboxone. The
SSVF and HVRP staff were able to move him into permanent housing with
some financial assistance and secured him a full time job. He received
a full benefit package from his employer which came with a very high
deductible. Because of the major increase in the co-pay cost of his
Suboxone treatment through private insurance, he could no longer afford
it and slipped back into using heroin again.
The veteran was facing eviction from his housing and his job was at
risk due to his job performance. They then tried to seek assistance
through SAMSHA but because he had been housed through SSVF, he didn't
fit their criteria. The SSVF representative knew that Easter Seals had
launched a new program with Farnum and had 5 beds for veterans and
within 2 hours he was admitted. He successfully completed the 28 day
program and today, is maintaining his Suboxone treatment with financial
assistance through Easter Seals Veterans Count program, is maintaining
his stable housing and employment.
This story is a clear illustration of how we can move the dial with
our veterans in crisis, when we can all rely on each other to reach a
common goal.
I know we all agree on the premise that substance misuse among
veterans can be a result of many interrelated moving parts; struggling
with opioid drug usage from readjustment challenges back into civilian
life which often stem from Post-Traumatic Stress Disorder, physical
injuries, and associated pain management. Although more attention is
being given to the issue of drug addiction among our veteran
population, the percentage of veterans who seek help is still
disturbingly low. In our experience, veterans are more apt to avoid
mentioning at the point of intake, that they may have a substance
addiction or that they are currently using, for fear of stigma or
creating barriers to getting help and housing, especially when they are
experiencing homelessness.
In my perspective, to effectuate real change in the lives of the
veterans we serve, we need to look at housing as a critical form of
healthcare. By first tending to the veteran's housing, we can create
one tenable link in the braid that is our involvement in their ultimate
success. Along with other supportive services, we can increase our
connection with them and encourage their improved mental and physical
health, reduce their dependency on substances, and increase their
earning potential through education and employment support. All of this
will produce a much higher percentage of those who are able to maintain
their independence, connect with government and nonprofit services, and
achieve more successful living.
Prepared Statement of Christine Weber
Good morning and thank you for the opportunity to speak on such an
important set of issues. Specifically, I will speak as a provider of
substance use disorder treatment in New Hampshire, a state where the
number one public health crisis, active addiction, will require
diligent and informed collaborative efforts if it is to be managed in a
meaningful way.
The program that I direct in Manchester serves over 2,000 people a
year. I say ``people'' instead of addicts, alcoholics, or other terms
that can be used to create distance between us here today and them.
However, amongst the people we serve, there are differences. My staff
is tasked to specifically screen prospective clients by asking the
question, ``Have you ever served in the military,'' to inform their
care. It is critical that treatment providers, first responders,
emergency departments and treatment liaisons understand how to move
forward when a man or woman in their care answers ``Yes'' to this
question.
Service members present to treatment having struggled to navigate
when and how to ask for help. If you have heard the difficulties
servicemembers face in accessing adequate medical/surgical care,
imagine that struggle, and add limited bed availability or substantial
substance abuse treatment within the VA system. For those that are able
to identify that they are in need of help, the highest hurdle next to
access to care is stigma. Our clients have been in country in the
Yugoslav region, Kuwait, South America, Desert Storm, Vietnam,
Operation Iraqi Freedom, Enduring Freedom, New Dawn, various regions of
Afghanistan and multiple stations throughout the world. None of them
imagined the values conflicts and isolative nature of addiction would
lead them to contemplating suicide or treatment for alcohol and drug
dependence.
Prescribers must take the responsibility of opiate prescribing very
seriously. Implementing and enforcing substance use disorder curricula
for students and licensed practitioners through Continuing Medical
Education is an important step in ensuring that physicians are exposed
to the nature of the biology of chemical dependence. It is my hope that
the VA and other important healthcare institutions provide their
personnel with ongoing and comprehensive training by American Society
of Addiction Medicine Board Certified peers and licensed clinicians.
Physicians have met with NH State Representative Rosenwald to
discuss recent bill(s) to include NH HB1423 relative to prescribing
practices as well as the PDMP (Prescription Drug Monitoring Program) in
New Hampshire. It is concerning as a substance disorder treatment
provider that these efforts may result in legislation that is embraced
in language only, without enforcement or oversight by the Board of
Medicine.
Prevention efforts, utilization of the Screening/Brief/Intervention
and Referral process, physician training, and coordinating access to
substance use disorder treatment facilities via Vets Choice are all
concrete, actionable steps.
Regardless of MOS, discharge status, or military service, we are
seeing an increase population in need of structured, clinical
intervention and support. Without providers and prescribers taking
initiative, the mortality rate for this chronic and progressive illness
will continue to rise.
Prepared Statement of Joseph Foster
Like many states, the illegal and prescription drug opioid crisis
is the most pressing public health and public safety challenge facing
New Hampshire.
It penetrates every aspect of our society; all socio-economic
groups; all races; each gender and age groups; and it adversely impacts
our neighborhoods, our schools, our healthcare system, our courts, our
prisons, our first responders, our businesses and our highways.
While prescription opioids and Heroin remain extremely problematic,
unlawfully manufactured Fentanyl is at the center of the State's
epidemic.
I am going to show some slides that illustrate the depth of the
opioid problem in NH prepared by our state Medical Examiner and our
Department of Safety.
Slide 1-Drug Deaths
In 2000.50 deaths
In 2015.420 confirmed with 14 still awaiting toxicology.
Slide 2-Highway Deaths Compared to Overdose Deaths
Fifteen years ago there were twice as many highway deaths as
overdose deaths-today, there are 4 times as many overdose deaths as
highway deaths.
Slide 3--Deaths by Geography
Overdose deaths are prevalent in every region of the State.
Slide 3-Narcan Dosage
Overdoses-thousands of them occurred statewide. The NH Bureau of
EMS reported that in 2015, 4,235 doses of Narcan were administered in
the State.
Slide 4--Deaths by Age
Fentanyl and other agents do not discriminate by age. Every age
group has experienced sharp increases in overdoses, but for the very
young and very old.
Slide 5-Heroin and Fentanyl
Deaths from Heroin and Fentanyl are fairly new. As you can see, a
decade ago deaths from Heroin were rare-and Fentanyl deaths did not
occur. That changed and did so with a vengeance.
Slide 6-2015 Data ---Percentage of Heroin/Fentanyl Deaths and
Opiates
Of the 420 confirmed drug deaths, 65% were caused exclusively or
partially by Fentanyl.
ACTIONS
So, what are we doing in NH to address this epidemic?
Very broadly speaking, there are two areas to address this problem:
on the supply side-mostly a law enforcement function; and on the demand
side-broadly speaking, a public health and education function.
We cannot arrest our way out of the problem. We need to reduce
demand and with that supply will drop. That said addressing both supply
and demand is critical.
There are a number of law enforcement initiatives taking place
within the State and across state lines. The problem does not stop at
our state borders. Interrupting supply requires cooperation by and
between our federal, state, county and local law enforcement agencies.
One such initiative is treating our overdose deaths as crime
scenes. The goal is to hold those who sold the drugs to the victim
accountable and to gather information so we can get the ultimate source
of the drugs and disrupt the supply.
A lot has happened on the public health side and in many ways is
more important.
In November, our Governor called a Special Session of the
Legislature. The House and Senate convened and passed a bill forming a
25-member Opioid Task Force made up of Representatives and Senators.
The Task Force worked aggressively over several weeks and came up with
a number of legislative proposals.
Many proposals were recommended by the Governor's Office working
closely with a group of her Department heads, including my office. This
has truly been a bi-partisan effort-as it should be.
Some of the legislation already passed:
Requires physicians to query the State's Prescription
Drug-Monitoring Program in many instances; and requires prescription
data be submitted daily;
Mandates safe opiate prescribing education for
prescribers; and
Placed pain specialists on the Board of Medicine to
insure expertise when reviewing treatment providers for professional
misconduct.
Legislation in process would:
Expand funding for drug courts.
Reauthorize the NH Health Protection Plan-our unique form
of Medicaid expansion. This is key to expanding the State's inadequate
treatment network. The Plan includes a substance abuse benefit. If the
Plan is reauthorized, the provider network will follow because, for the
first time, providers will have a reliable source of payment.
Mandates adoption of safe and responsible opiate
prescribing rules by the professional boards which oversee prescribers
of opioids. My office has been a key driver behind this legislation.
Why is that important? Overprescribing is a huge problem in this
country. With about 5% of the world's population, some say Americans
consume 80% of the world's opiates.
In NH the problem is more severe than in many other parts of the
country as we rank near the top in the amount of long acting/extended
release opioid and high dose pain relievers prescribed.
Overprescribing of prescription opioids has led to our heroin
problem. According to the CDC, 4 out of 5 heroin addicts were addicted
to prescription opiates first. In other words, prescription opiates led
to the Fentanyl and Heroin deaths I mentioned earlier.
That is why the CDC has issued draft opiate prescribing guidelines
which I supported in a letter co-authored with Attorney General Bondi
of Florida which was joined by 34 other state Attorneys General. The
rules before the Legislature adopt many of those guidelines and will
require a thoughtful approach to prescribing opiates and with that,
over time, less patients becoming dependent or addicted to opioids.
Thank you for allowing me to provide you an overview of the problem
here in NH. While many of the actions being undertaken at the state
level will benefit the veteran population more needs to be done. I know
the veteran population has been hit especially hard by the epidemic and
I applaud the work of your Committee and thank you for taking the time
to come here to NH to hear from myself and the rest of the speakers.
Prepared Statement of Dr. Julie Franklin
Good morning, Chairman Coffman, Ranking Member Kuster, and Members
of the Subcommittee. Thank you for the opportunity to participate in
this hearing and to discuss VA's pain management programs and the use
of medications, particularly opioids, to treat Veterans experiencing
acute and chronic pain. I am accompanied today by Dr. Grigory Chernyak,
Chief of Anesthesia and Pain Service, at the Manchester, New Hampshire
VAMC.
Chronic Pain Across the Nation
Chronic pain affects the Veteran population, with almost 60 percent
of returning Veterans from the Middle East and more than 50 percent of
older Veterans in the VA health care system living with some form of
chronic pain. The treatment of Veterans' pain is often very complex.
Many of our Veterans have survived severe battlefield injuries, some
repeated, resulting in life-long moderate to severe pain related to
damage to their musculoskeletal system and permanent nerve damage,
which can impact their physical abilities, emotional health, and
central nervous system. It is important to note as well that there is
limited clinical trial data supporting the use of opioids for chronic
pain \1\ and so VHA is committed to reducing overreliance on opioid
medicines especially in light of the severe negative consequences many
patients on opioids risk.
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\1\ Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG,
Blazina I, Dana T, Bougatsos C, Turner J. The Effectiveness and Risks
of Long-Term Opioid Treatment of Chronic Pain. Evidence Report/
Technology Assessment No. 218. (Prepared by the Pacific Northwest
Evidence-based Practice Center under Contract No. 290-2012-00014-I.)
AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare
Research and Quality; September 2014. Available at https://
www.effectivehealthcare.ahrq.gov/ehc/products/557/1988/chronic-pain-
opioid-treatment-executive-141022.pdf downloaded 2-24-2016.
---------------------------------------------------------------------------
Current VHA Pain Management Collaboration
To implement effective management of pain, VHA's National Pain
Program oversees several work groups and a National Pain Management
Strategy Coordinating Committee representing the VHA offices of
nursing, pharmacy, mental health, primary care, anesthesia, education,
integrative health, and physical medicine and rehabilitation. Working
with the field, these groups develop, review and communicate strong
pain management practices to VHA clinicians and clinical teams.
For example, the VHA Pain Leadership Group, consisting of Pain
Points of Contact for the Veterans Integrated Service Networks (VISNs)
and facilities, meets monthly with the National Pain Program to discuss
policy, programs, and clinical issues and disseminate information to
the field as well as to provide feedback to VACO leadership about these
programs. Several of these groups are chartered to promote the
transformation of pain care in VHA at all levels of the Stepped Care
Model: the Pain Patient Aligned Care Team (PACT) Initiative Tactical
Advisory Group focuses on primary care issues; the Pain Medicine
Specialty Team (PMST) Workgroup coordinates and provides standards for
specialty pain services; the Interdisciplinary Pain Management
Workgroup focuses on developing Commission on Accreditation of
Rehabilitation Facilities (CARF) certified tertiary care pain
management programs for complex patients.
The Opioid Safety Initiative (OSI) Toolkit Task Force has published
and promoted 16 evidenced-based documents and presentations to support
the Academic Detailing model of the OSI. More information on the OSI
Toolkit can be found at the following link: (http://vaww.va.gov/
PAINMANAGEMENT/index.asp).
The Department of Defense (DoD)-VA Health Executive Council's Pain
Management Workgroup (PMWG) oversees joint projects with DoD including
the two Joint Investment Fund (JIF) projects, the Joint Pain Education
and Training Project and the Tiered Acupuncture Training Across
Clinical Settings, and other projects that aim to standardize good pain
care across DoD and VHA.
Pain Management
In Manchester, VA offers an Interventional Pain Program,
Acupuncture Program, Physical and Occupational therapies, and is in the
process of creating Chiropractic and other Complementary and
Integrative Medicine programs to meet the needs of Veterans. We closely
collaborate with VHA pharmacy on opioid prescribing to monitor
prescribing to our Veterans. We hold Interdisciplinary Pain Team
meetings weekly to collaborate on the treatment we provide to the 488
patients currently in our program. The process lends itself to frank
and open discussions which focus on real time issues and improvements
to the program. Manchester outcomes include: working as a multimodal
team to cultivate change with the culture of prescribing.
Interdisciplinary team prescribers include: Surgical, SPRS (Sensory and
Physical Rehabilitation Services), Primary Care, Mental Health,
Pharmacy, QM, Medical, CLC (Long term care, rehabilitation Palliative
care), and Urgent Care. This Interdisciplinary team has allowed
Manchester providers to decrease opioid dispensing from FY 2011 to 2014
by 6 percent.
Since 2011, our Pain Clinic has seen its monthly patient clinic
visits increase from an average of 40 visits per month to over 160. We
have increased our availability to see patients on an ongoing basis and
have added services for patients including a Chronic Opioid Therapy
Clinic and acupuncture. Our Interventional Pain Procedures volumes have
increased during the same time period from 20 procedures per month to
over 60. We offer evidence-based psychotherapy for chronic pain. White
River Junction is also the lead site for the VISN 1 Pain Mini Residency
program. One of the patients treated with acupuncture started driving
again, as well as taking care of her family after years of disability.
Since our Chronic Opioid Therapy Clinic opened in May 2014 through
December 31, 2015, we have seen a 50 percent decrease in the number of
Veterans treated with the highest doses of opioids (greater than 400
morphine equivalent daily dose). We have seen a 41 percent decrease in
the number of patients treated with high dose opioids (greater than 200
morphine equivalent daily dose) during the same time period. Many of
our patients have expressed that they are feeling much better since
reducing their doses of medications.
Our VISN also takes Pain Management seriously. VISN 1 declared Pain
Management as one of its five top priorities in 2015. The VISN
committed to improving opioid safety and increasing access to other
modes of treating pain. We will have an acupuncture clinic at each
facility, four Commission on Accreditation of Rehabilitation Facilities
(CARF)-accredited Pain Rehabilitation programs, and increased access
to, iRest, and evidence-based psychotherapy for pain as a result of
this commitment.
Approximately 4-5 years ago, Dr. Chernyak initiated acupuncture
services and established an acupuncture clinic at the Oklahoma City
VAMC. This clinic turned out to be very successful in helping Veterans.
During this period, many Veterans contacted the administration with
testimonial letters and with requests to expand this service to make it
more accessible for Veterans. As a result, the Oklahoma City VAMC hired
a dedicated Acupuncture specialist, and today this clinic sees
approximately 50 patient visits per week.
Acupuncture has been used in the treatment of different kinds of
acute and chronic pain, chronic headaches, migraines, various addiction
problems, psychological issues such as PTSD, depression, anxiety, and
in many other health disorders. This mode of treatment has withstood
the test of time, as it has successfully survived several thousand
years of clinical practice in various forms and in many different
cultures. It is not unusual to see instances when very difficult health
conditions, especially those resistant to conventional treatment
modalities, are successfully treated with acupuncture.
Currently, new, high tech methods of acupuncture point stimulation
are clinically available, such as the use of low level laser therapy
(i.e., cold laser therapy). This method allows the clinician to achieve
an effect without actually penetrating the skin with a needle and,
without causing the pain sometimes associated with needle insertion.
Cold laser therapy, or photobiomodulation therapy, is a non-invasive
treatment modality that we are working to implement in our Integrative
Pain clinic.
Both Dr. Chernyak and my goal is to build a robust Integrative Pain
Center with a strong emphasis on Complementary and Integrative Medicine
approaches to the treatment of pain at all our facilities. This
approach would also address the issue of opioid overuse. Usually,
health care providers tend to refer their patents for Complementary and
Integrative Medicine therapies for chronic pain issues only after all
other treatment modalities have failed. Therefore, Complementary and
Integrative Medicine therapies are often considered as a last resort or
a therapy of despair. Dr. Chernyak believes that this practice should
be reversed and that Complementary and Integrative Medicine therapies
should be offered at a much earlier stage in the treatment process
along with physical therapy. Complementary and Integrative Medicine
modalities, to include acupuncture, should be considered before more
invasive treatment options are sought and most certainly before chronic
opioid pain management is prescribed. Acupuncture has the added benefit
of being inexpensive, and in our experience has virtually no side
effects when performed by properly trained personnel.
Both Manchester and White River Junction have added positions to
ensure that we have the expertise to provide interventional pain
injections or even surgical help. Furthermore, it is our desire that
both of our facilities will be able to initiate and conduct a number of
research projects and possibly a pain fellowship program in
collaboration with one of the teaching institutions.
VA's Progress in Pain Management
Chronic pain management is challenging for Veterans and clinicians
- VA continues to focus on identifying Veteran-centric approaches that
can be tailored to individual needs using medication and other
modalities. Opioids are an effective treatment, but their use requires
constant vigilance to minimize risks and adverse effects. VA launched a
system-wide OSI in October 2013, and has seen significant improvement
in the use of opioids. The Specialty Care Access Network-Extension for
Community Healthcare Outcomes (SCAN-ECHO) and the OSI, have been
designed to integrate into the Academic Detailing model. Academic
Detailing is a proven method in changing clinicians' behavior when
addressing a difficult medical problem in a population. Academic
Detailing combines longitudinal monitoring of clinical practices,
regular feedback to providers on performance, and education and
training in safer and more effective pain management.
Most recently, in March 2015, we launched the new Opioid Therapy
Risk Report tool which provides detailed information on the risk status
of Veterans taking opioids to assist VA primary care clinicians with
pain management treatment plans. This tool is a core component of our
reinvigorated focus on patient safety and effectiveness.
VA's own data, as well as the peer-reviewed medical literature,
suggest that VA is making progress relative to the rest of the Nation.
In December 2014, an independent study by RTI International health
services researcher, Mark Edlund, MD, PhD and colleagues, supported by
a grant from the National Institute of Drug Abuse, was published in the
journal PAIN \1\. This study, using VHA pharmacy and administrative
data, reviewed the duration of opioid therapy, the median daily dose of
opioids, and the use of opioids in Veterans with substance use
disorders and co-morbid chronic non-cancer pain.
---------------------------------------------------------------------------
\1\ Edlund MJ et al, Patterns of opioid use for chronic noncancer
pain in the Veterans Health Administration from 2009 to 2011. PAIN
155(2014) 2337-2343.
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Dr. Edlund and his colleagues found that:
About 50 percent of veteran with chronic non-cancer pain
in this cohort received an opioid as part of treatment.
Half of all Veterans receiving opioids for chronic non-
cancer pain, are receiving them short-term (i.e.: for less than 90 days
per year);
The daily opioid dose in VA is generally modest, with a
median of 20 Morphine Equivalent Daily Dose (MEDD),
And the use of high-volume opioids (in terms of total
annual dose) is not increased in VA patients with substance use
disorders as has been found to be the case in non-VA patients.
Although it is good to have this information, a confirmation of our
efforts for several years, starting with the ``high alert'' opioid
initiative in 2008 and multiple educational offerings, by no means is
VA's work finished. By virtue of VA's central national role in medical
student education and residency training of primary care physicians and
providers, VA will be playing a major role in this transformation
effort. But we have already started with our robust education and
training programs for primary care, such as SCAN-ECHO, Mini-residency,
Community of Practice calls, two JIF training programs with DoD, and
dissemination of the OSI Toolkit.
A key development is a Joint Incentive Fund DoD-VA project to
improve Veterans' and Servicemembers' access to Complementary and
Integrative Medicine, the ``Tiered Acupuncture Training Across Clinical
Settings'' (ATACS) project. ATACS represents VHA's initiative to make
evidence-based Complementary and Integrative Medicine therapies widely
available to our Veterans throughout VHA. A VHA and DoD network of
medical acupuncturists are being identified and trained in Battlefield
(auricular) Acupuncture by regional training conferences organized
jointly by VHA and DoD. The goal of the project is for them to return
to their facilities and VISNs with the skills to train local providers
in Battlefield Acupuncture, which has been used successfully in DoD
front-line clinics around the world. This initiative ultimately aims to
provide all Veterans with access to this intervention, and a wider
array of pain management choices generally, when they present with
chronic pain. Many providers in VISN 1 have received this training
either through the ATACS program or through the Pain Mini-Residency
program.
Complementary and Integrative Medicine
VHA leadership has identified as its number one strategic goal ``to
provide Veterans personalized, proactive, patient-driven health care.''
Integrated Health Care (IH), which includes Complementary and
Integrative Medicine approaches, provides a framework that aligns with
personalized, proactive, patient-driven care. There is growing evidence
for effectiveness of non-pharmacological approaches as part of a
comprehensive care plan for chronic pain which includes acupuncture,
massage and spinal manipulation. As I have described, these are all
being made available to Veterans.
In 2011, VA's Healthcare Analysis and Information Group published a
report on Complementary and Integrative Medicine in VA. At that time,
89 percent of VHA facilities offered some form of Complementary and
Integrative Medicine however, there was extensive variability regarding
the degree, level, and spectrum of services being offered in VHA. The
top reasons for offering Complementary and Integrative Medicine
included promotion of wellness, patient preferences; and adjunct to
chronic disease management. The conditions most commonly treated with
Complementary and Integrative Medicine include: stress management,
anxiety disorders, PTSD, depression, and back pain.
VA recognizes the importance and benefits of recreational therapy
in the rehabilitation of Veterans with disabilities. Currently, over 30
VA medical centers across the country participate in therapeutic riding
programs. These programs use equine assisted therapeutic activities to
promote healing and rehabilitation of Veterans with a variety of
disabilities and medical conditions (e.g. traumatic brain injury,
polytrauma). VA facilities participating in such programs utilize their
local appropriated funds to contract for these services. Facilities may
also be able to use money in the General Post Fund, a trust fund
administered by the Department, to pay for these services.
A monthly IH community of practice conference call provides VHA
facilities national updates, strong practices, and new developments in
the field and research findings related to IH.
The Opioid Safety Initiative (OSI)
The OSI was chartered by the Under Secretary for Health in August
2012. The OSI was piloted in several VISNs. Based on the results of
these pilot programs, OSI was implemented nationwide in August 2013.
The OSI objective is to make the totality of opioid use visible at all
levels in the organization. It includes key clinical indicators such as
the number of unique pharmacy patients dispensed an opioid, unique
patients on long-term opioids who receive a urine drug screen, the
number of patients receiving an opioid and a benzodiazepine (which puts
them at a higher risk of adverse events), and the average MEDD of
opioids. Results of key clinical metrics for VHA measured by the OSI
from Quarter 4 Fiscal Year 2012 (beginning in July 2012) to Quarter 4
Fiscal Year 2015 (ending in September 2015) there are:
125,307 fewer patients receiving opioids (679,376
patients to 554,069 patients, an 18.44 percent reduction);
42,141 fewer patients receiving opioids and
benzodiazepines together (122,633 patients to 80,492 patients, a 34.36
percent reduction);
94,507 more patients on opioids that have had a urine
drug screen to help guide treatment decisions (160,601 patients to
255,108, a 58.84 percent increase);
105,543 fewer patients on long-term opioid therapy
(438,329 to 332,786, a 24.08 percent reduction);
The overall dosage of opioids is decreasing in the VA
system as 15,172 fewer patients (59,499 patients to 44,327 patients, a
25.5percent reduction) are receiving greater than or equal to 100
Morphine Equivalent Daily Dosing.
The changes in prescribing and consumption are occurring at a
modest pace, and the OSI dashboard metrics indicate the overall trends
are moving in the desired direction. OSI will be implemented in a
cautious and measured way to give VA time to build the infrastructure
and processes necessary to allow VA clinicians to incorporate new pain
management strategies into their treatment approaches. A measured
process will also give VA patients time to adjust to new treatment
options and to mitigate any patient dissatisfaction that may accompany
these changes.
While these changes may appear to be modest given the size of the
VA patient population, they signal an important trend in VA's use of
opioids. VA expects this trend to continue as it renews its efforts to
promote safe and effective pharmacologic and non-pharmacologic pain
management therapies. Very effective programs yielding significant
results have been identified and are being studied as strong practice
leaders. VA intends to implement safe opioid prescribing training for
all prescribers in response to the Presidential Memorandum Addressing
Prescription Drug Abuse and Heroin Use \2\.
---------------------------------------------------------------------------
\2\ The white House Office of the Press Secretary. October 21,
2015. Presidential Memorandum Addressing Prescription Drug Abuse and
Heroin Use-Available at https://www.whitehouse.gov/the-press-office/
2015/10/21/presidential-memorandum-addressing-prescription-drug-abuse-
and-heroin downloaded 2-24-2016
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Conclusion
In conclusion, VA continues to research pain treatment,
Complementary and Integrative Medicine and opioid abuse. While we know
our work to improve pain management programs and the use of medications
will never truly be finished, VA has been at the forefront in dealing
with pain management, and we will continue to do so to better serve the
needs of Veterans.
Mr. Chairman, we appreciate this Subcommittee's support and
encouragement in identifying and resolving challenges as we find new
ways to care for Veterans. My colleague and I are prepared to respond
to any questions you may have.
[all]