On June 21 at The Washington Post, policymakers, researchers and health care experts examined the roots of the country’s opioid crisis and discussed solutions for combating addiction in America. They discussed the role of doctors in managing patients’ pain and helping to fight the epidemic and described what’s being done to reduce the abuse of opioids as recreational drugs.

 

 

Addiction Crisis: A Nation Responds:

DeBonis:         Thanks.  Hello.  All right, bear with me here, I’ve got all this technology in my hands.  But thank you, everyone, for coming today.  Welcome to The Washington Post.  I’m Mike DeBonis.  I cover Congress for The Post.  We’re here today to discuss the nation’s opioid crisis, and I know I don’t need to tell the people in this room about the scope and the scale of that crisis.  The victims, the families, doctors, public health officials, journalists like me and lawmakers like these fine folks have been spreading the word about what’s been going on, and we’re going to begin our program today with the discussion of the policy and the government response.  I’ll invite you all to sit down now.

Joining me on stage, and pardon me just a moment while I adjust this, first off, we have Congresswoman Diana DeGette of Colorado.  She is a senior Democrat on the House Energy and Commerce Committee.  She’s the ranking Democrat on the Oversight Investigation Subcommittee.  She co-authored the 20th Century Cures Act, which put a billion dollars of new federal funds into the opioid epidemic to combat it.  She’s also the chief deputy whip of the Democratic House Democratic Caucus.  Thank you very much, Congresswoman.

Senator Ed Markey is here of Massachusetts, Democrat and member of the Senate Commerce Committee, which has broad jurisdiction over private industry, including the pharmaceutical industry.  He’s done numerous investigations and authored numerous pieces of legislation to address this crisis.  He’s going to talk quite a bit about that.  And last but not least, Chairman Greg Walden is with us today of Oregon, Republican of Oregon.  He has drawn attention to the opioid epidemic as its effected his district in rural Eastern Oregon.  He also plays a key role in overseeing the health sector of our economy.  He played a key role in drafting the American Healthcare Act, which is now going through the Congressional process, and we’re going to give you an opportunity to talk about that legislation and the oversight that you’ve done on your committee.  Thank you very much for being here.

Let me start with Senator Markey.  This is a question I’m going to throw to everybody on the panel today.  But tell me how you first experienced this crisis as a crisis?  When did you understand that this is something that needed your attention and what did you see in your state that compelled you to act?

Markey:           It was Taunton, Massachusetts; it was Martin Luther King Day, January 15, 2014.  I was standing in the back of the room getting ready to give my speech and I said to the police chief and the mayor, Mayor Hoye in Taunton, “What’s the biggest issue?”  And he said, “Well, we’ve lost seven people to overdoses in just the last couple of weeks.”  And then I said to the chief, I said, “Well, what’s the issue?”  And he said, “Well, they’re now lacing the heroin with fentanyl.”  Then he explained to me about fentanyl.  And I brought back Gil Kerlikowske, the drug czar for the United States the next month into Taunton.

And the numbers are huge.  In Massachusetts in 2016, we lost 2,000 people to overdose deaths, opioid-related death.  We’re only two percent of America’s population.  If the whole country was dying at our rate, that would be 100,000 people in a year.  That would be two Vietnam Wars every single year.  Of those who died, the 2,000, 70 percent had fentanyl in their system.  That would be 1,400 people in Massachusetts last year.  You extrapolate that out for the whole country, that would be 70,000 people dying from fentanyl-related overdoses in one year.  That is now something that is going to hit the rest of the country, slowly but surely.

Massachusetts is the preview of coming attractions.  Only 33,000 people died from opioid overdoses in the whole country last year.  We’re three times worse than the national rate.  But unless we put in place the prevention and treatment programs, we are going to see this epidemic just explode even further.  And from that moment in Taunton when the police chief and the mayor told me about fentanyl, it has been just a predictor of this catastrophe spreading inexorably, inevitably across the country.

DeBonis:         And what year was that, Senator?

Markey:           January of 2014.  So it was ‘14, ‘15, ‘16; we’re now halfway through 2017 and the numbers have skyrocketed since 2014 in Massachusetts as they have across the whole country.

DeBonis:         And to just put in a plug for my distinguished colleagues, if you pick up a copy of today’s Washington Post, there’s a story in there with an amazing statistic that illustrates the scope of this issue, that in 2014 you had nearly 1.3 million emergency room visits or inpatient stays for opioid-related issues in 2014.  That’s a 99 percent jump for emergency room treatment compared to 2005.  It’s a remarkable statistic.

Markey:           And by the way, that 2014 number, which is—and that’s a great story in The Washington Post today, that number is much, much higher today in Massachusetts.  And we were the second-worst state on that list in the study that the Post had today, and we have a much worse problem today than we had in 2014.

DeBonis:         Chairman Walden, let me ask you.  You represent Eastern Oregon.  It’s a rural community, largely rural, some of the most beautiful country in America.  But what’s happening there?  What have you seen and what was the moment when you realized there was something that needed to be done?

Walden:           Right.  I’ve done a series of roundtables a couple of years ago, and I always remember just a couple examples.  There was a woman in Hermiston, Oregon, rural Eastern Oregon, who talked about her addiction to opioids.  She’s now a treatment counselor.  But trying to get off of it was almost impossible.  She wanted to get onto Suboxone I think that helps you get off of it.  There was no physician in the immediate area that could help her, so she would commute five and a half hours each way into Washington State where she could get treatment and finally get off.

Then down in Southern Oregon in Medford, I did a roundtable, law enforcement, addictions specialists, hospital people, and family.  And this fellow that was sitting in the back, he wasn’t actually part of the roundtable, but I called on him and said, what brings you here?  He said, “My son.  My son was an athlete in high school and got injured and got prescribed opioids to deal with the pain and tragically got hooked.  And he went to the cheaper, more potent version of that; you would know it as heroin.”  And he said, “He succumbed to that.  My sister was a nurse, same sort of scenario.  She got hooked on it.  She would write her own prescriptions, forging the doctor’s prescription pad, got caught, moved on somewhere else, took it up again.  The addiction overwhelmed her and she too had died.”

And then you begin to talk to everybody else in your communities, how they’re affected.  And this addiction explosion has been going on now in Oregon, we’re ninth in the country, fourth among women, but we predate that with the other scourge, which was methamphetamine and the cooking and all that.  Oregon really led in this.  We did work here in Washington on it like we’re doing on opioids to get the precursor chemicals out.  That still remains a big issue in Eastern Oregon.

One of the leaders in trying to push back on this, Dr. Chuck Hoffman, is a friend of mine.  He was quoted recently in a news series about how he was trained as a physician to prescribe opioids to relieve pain.  They were never really trained in alternative pain relief practices.  And now it’s just write the pills.  And so he’s trying as a physician leading an effort to turn this around.  We’re also seeing a dramatic increase by the way in 65 and older that are being treated as inpatients in hospitals because of this addiction; so it’s affecting every age group.

And finally, I would say there was a really troubling story as part of this series the Argus Observer ran about a physician who engages in the treatment and one of his patients is a rancher who keeps preloaded syringes in the cab of his tractor so when he’s out there, he can just shoot up during the day, and they’re loaded with heroin.  And so I mean this is having unbelievable consequence across our country, and I think we’re all together in trying to figure out strategies to reduce the illegal pills in the market and to—we passed legislation to reduce the prescription amounts that have to be given.  I mean there’s a lot we can do.

DeBonis:         Congresswoman, let me ask you this.  You represent a different kind of district.  You represent a good part of Denver and its suburbs.  It’s an urban and suburban district.  So much of the reporting on this is talked about this as a rural phenomenon in communities like in Eastern Oregon.  Is that the whole picture or is that not the whole picture?

DeGette:         Oh, no.  I mean this opioid problem, it pervades—I think people focus on rural areas because they expect that drug and addiction issues will be urban issues, so they’re shocked when it’s in rural Oregon.  But I remember you were asking my colleagues when did this hit home.  A couple of years ago, I was at the Booklover’s Ball, which is the annual fundraiser for the Denver Public Library.  And I was sitting next to the Denver public librarian, and I said, “What are the issues you’re facing here at the Denver Public Library?”  And I thought she would say something like cybersecurity or access to books.  She said, “You know, we have people overdosing in the library every day and we need to get our librarians naloxone so that they can give it to people who have overdosed.”  At the Denver Public Library.  And now there was just a story the other day in the Denver Post that they finally did get the librarians naloxone.  But they actually had a guy die in the main library last year.  They’ve had a number of overdoses and the librarians just open up their desks and run over.  I mean imagine that.

And I think what all three of us have recognized is this really does seem to have exploded on the scene.  We’ve heard stories about addiction for some years and cautions about overuse of opioids.  But these stories are just exploding.  And in our committee, the Oversight and Investigation Subcommittee of Energy and Commerce, we did a whole series of hearings about a year or two ago on opioids, and it was amazing how many misconceptions there were about the extent and the nature of the problem, and how much confusion there was about what you do about it.  And so it’s not always that you have hearings that really educate the members of Congress, but I think we all learned a lot about what we need to be doing.  And of course, that was part of what informed the CARA Bill last summer that we passed, and then the funding that you mentioned that Fred Upton and I put in our 21st Century Cures Bill.

DeBonis:         Yeah, let’s talk about Cures briefly.  That was a really remarkable bill not only for what was in it, but the fact that it came together at all at a time when the parties weren’t last year and still aren’t working together on a whole lot in a productive manner.  But this is one area where Republicans and Democrats came together.  You worked with Fred Upton, Chairman Walden’s predecessor in Energy and Commerce to make this happen.  Talk specifically about the addiction part of that bill and how that got brought into this bill that was also about so much more, including pharmaceutical development and things like that.

DeGette:         Well, I mean this was a bill that we worked on for about three years, and it wasn’t just me and Fred.  It was also Greg and it was Ed and his Democratic and Republican colleagues in the Senate.  So it was really an effort to focus on primarily research at the NIH and the FDA, but as the bill moved into its final stages, we realized that there were some funding issues in the healthcare space where we could really get bipartisan bicameral consensus.

And as I said, we had passed that CARA Bill the year before.  It had a lot of really good administrative programs for opioid prevention and treatment, but it had no money.  And that was one of the biggest criticizes everybody had at that time.  And so when we did the Cures Bill, we were able to then say let’s really put some oomph here.  Let’s put a billion dollars in grants for state governments.

DeBonis:         Mr. Chairman, let me ask you this.  Pardon me for putting it in these terms, but it can be difficult for Republicans, especially House Republicans to spend money on anything sometimes.  But this issue was one where there was a wide agreement that something had to be done.  Talk about what the feeling has been among your Republican colleagues in trying to come together and address this.

Walden:           Yeah, I would suggest too that in 21st Century Cures, we did mandatory spending for NIH because we believe in medical research, and really the big increases in NIH’s budget go clear back to the days of Newt Gingrich, who believed in investing in medical research.  And doubling the NIH budget, we did that, then there was kind of a pause.  Now we’re trying to ramp it back in a bigger direction.  And clearly Diana’s work and Fred’s and others, Tim Murphy and others really passionate about this; these issues don’t pick parties when they show up on your doorstep.  And I think they help bring us all together in common cause.

The billion dollars, in my state we just got $65 million in grants out of that.  So in pretty short order I would argue that money not only got in there but now is getting out onto the ground into the field, hopefully into the hands of those professionals in our communities who know best what to do with it to address this issue.  So I think there are really good mechanical pieces to Diana’s point.  In terms of changing how many people a physician could treat with Suboxone, my friend from Hermiston who had to go out of state to get treatment, now they can treat more people.  You don’t have to fully fulfill the prescription; that gets excess pills out of the market, hopefully.

These are all things we learned, I learned in the roundtables that I did back home, and they gave the money in there.  And in the AHCA, we put another $15 billion toward this, addiction and other things, but it’s certainly in there.  It’s not always about the money, it’s about changing behaviors and finding best practices.  I think that was part of the debate I heard at least was better understanding the physician prescribing community about what they should do, what they shouldn’t do.  It kind of goes back to an original study that said there’s no addictive nature to this, so feel free.  If you go back, the foundation for where we are today was built I think on a false premise that it was okay, that these pills wouldn’t be addictive.  Now we know 90 days is danger zone, so we need to do this education.

DeBonis:         Right.  It turns out it wasn’t even a study; it was a very short letter in the New England Journal of Medicine that the pharmaceutical industry used as an explanation for prescribing these drugs.  Senator, let me ask you this.  There continue to be bipartisan efforts to address this.  Can you talk about what you’re working on, the Interdict Act and other efforts in the oversight realm as well to take action?

Markey:           Well, I’m working with Marco Rubio on a bill to give customs and border patrol the technologies they need in order to detect fentanyl and other substances at our border so that before it comes in from Mexico or from China, they’re able to do that.  I actually said to Mitch McConnell two years ago that Lexington, Kentucky, Lexington, Massachusetts, it doesn’t make any difference.  We need a surgeon general’s report on addiction.  What I suggested to him was the smoking report, the surgeon general’s report in 1964 was a seminal moment.  We, that is Mitch, you and I, we should ask the surgeon general to do it.  And he completed it in one year, which laid out now the parameters of the problem and what needs to be done.  To that extent, there is a lot of bipartisanship.  I was able to pass legislation with Rand Paul on Suboxone, on medication assisted therapy, so that became a part of the law as well.

On the other hand, we’re having a big battle right now about funding in the Affordable Care Act and whether or not the slashing of that funding is going to have a profound effect upon the ability for people to gain access to the treatment which they need.  The Centers for American Progress have concluded that $91 billion under the Affordable Care Act would have been spent on substance use disorders over the next ten years.  And that money will not be there if the Affordable Care Act is repealed.

And so we’re going to have a huge debate over whether or not this funding is going to be there because honestly, a vision without funding is a hallucination.  You’ve got to have the funding there in order to provide these programs, and this debate is now really escalating in the Senate because we, the Democrats, are saying that this opioid epidemic, the substance use disorder epidemic is something that is going to get seriously shortchanged if the proposal as it is currently constructed becomes the law in our country.

DeBonis:         Let me talk to Chairman Walden.  As Chairman of the Energy and Commerce Committee, you know more than anybody else in the Capital about what’s in the American Healthcare Act, which is the Republican healthcare bill that’s now moving through the process.  Certainly, that is not a bipartisan effort, as we all know.  This is the Republican response to the Affordable Care Act.  You’ve heard folks like Senator Markey and even some people in your own party on the Senate side talk about the potentially difficult effects this bill could have on addiction treatment.  Just give us some facts as you see them of what this bill would do and what’s in that bill to help folks who are suffering from addiction.

Walden:           Yeah, thank you.  First of all, you have to bifurcate it because what we do know is the individual insurance market has a lot of problems on the exchanges.  And so you have a group of people who we want to make sure have insurance or access to choices in affordable insurance, and right now state after state, county after county, we’re seeing more and more limited choices.  Some counties may have no choice.  So if you’re in need of treatment and you can’t get insurance, you have really no options, or very few options.

So we’re trying to fix that insurance market.  This is difficult work to do.  It’s difficult in the House, it’s difficult in the Senate because we’re all—we share a common goal of trying to make coverage available, make it affordable.  On the other hand, on the Medicaid side, we believe that there’s enough headroom in there, in the about $90 billion that’s there that we put in under a provision to allow increased deductibility of health insurance costs.  It was really just to move about $90 billion to make it more flexible for the Senate to make some changes.

We put specifically $15 billion in for addiction treatment and some other related causes in addition to the flexibility of the Patient State and Stability Fund, which gives states great flexibility to use the money either to bolster their insurance markets and/or use it for other purposes, which could be addiction.  So I think there’s a lot there.  And it’s not always about the money.  And remember, early on I said that in my state we’re seeing an enormous percentage uptick in people that are 65 and older; most likely they’re on Medicare, not Medicaid.  That’s a problem area as well that needs help.  So I mean what we have to do is get to the root cause.  You have to get the prescription issues, you have to get to the treatment issues.  I understand.  But we think there’s room there to do that.

DeBonis:         Congresswoman DeGette, I imagine you might have a differing perspective.

DeGette:         I agree.  Money’s not always the panacea, but the problem is that if people don’t have insurance to pay for their treatment, then they can’t get the treatment no matter what funds you set up or whatever else.  And according to the nonpartisan Congressional Budget Office, under the House proposal, 23 million people will lose their insurance even after all these funds were added at the 11th hour on the floor.  And so when you have 23 million people who are either on the Medicaid expansion or are going to lose their insurance because their premium support is reduced or whatever it is, if they can’t get access to mental health treatment programs because they don’t have insurance, then it doesn’t do any good.  And that’s why many, many commentators in the mental health space say that the AHCA would be very, very—it would be a huge backwards step for opioid treatment because people just simply wouldn’t be able to get access to those programs.

And frankly, as much as I love my former Energy and Commerce colleague Ed Markey, I don’t ever legislate in the hopes that the Senate—to say, “Well, okay, this is a problem with this bill but I know it will be fixed over in the Senate.”  I think we should get it right the first time.  And I’m really concerned right now, frankly, that maybe Ed could talk about this, that Mitch McConnell saying he’s going to bring up some bill.  Not only have the Democrats not seen it, most of the Republicans haven’t seen it either.  We have no idea what that bill is going to do in terms of access to Medicaid in the states or to premium support or anything else.

Markey:           And Diana is right.  The only thing more secret than this Republican healthcare bill in the Senate are Donald Trump’s tax returns.  We have no idea what’s in it, the public has no idea what’s in it.  It’s being put together in secret.  We know it could have a profound impact on substance use disorder, treatment.  And so the consequences for public health in our country are profound.  And right now, this is a process that has not allowed for any public input, any Democratic bipartisan input.  Just the opposite of the way in which the Cures Act and CARA were put together.

DeBonis:         Let me ask Chairman Walden to jump back in here.  You’ve got Republican colleagues in the Senate, people like Rob Portman, Shelly Morcapito, who have been very outspoken on the effect of this crisis on their states.  Are you confident that they’re not going to vote for a bill that they think is going to harm their constituents in this way?

Walden:           Well, first of all, I’m not going to speak for any senator, let alone Senator Portman.  They can speak for themselves how they’re going to vote or anything else.  I do know they care deeply about these issues.  I do know that throughout the discussions in the House, I made a couple of presentations at the Senate Republican Conference.  So none of this was a secret within our world in terms of moving things back and forth.  I mean the legislative process is built upon give and take between the House and the Senate and understanding and flexibility.  I’m sure that’s how we got to 21st Century Cures, it’s how we got to CARA.  It’s how we get to major legislation.  There’s always give and take between the Senate and there’s communication between the Senate.  Reconciliation traditionally is a pretty partisan process by both sides, used by both sides.

As you know, when the Affordable Care Act was first fully implemented, the final bill, we weren’t allowed a single amendment on the House floor because it couldn’t be changed because in my friend’s state, Senator Kennedy passed away and was replaced by Scott Brown.  They couldn’t allow a single word to be changed, so we had no amendment capability, and then they chased it with reconciliation to try and clear up the mess.  And that’s the law we have today.

And it’s crashing around the country when it comes to the individual insurance markets.  You’ve got five states that may be down to one or no options, multiple counties, premiums have not gone down $2,500, they’ve gone up.  And the CBO scores has consistently been wrong based on the principle they put on, or the power they put on the individual mandate that is going to force people to buy insurance.  They’ve been off two to one in their estimates in 2016, and their estimates in 2017, I mean they get it wrong.  They’ve got a tough job, but their numbers are off.  We’re trying to rescue that market so people have access to affordable insurance.

And by the way, if you’re not in that subsidized pool, I remember the woman the other day, $600 a month in premium, $16,000 in deductible.  That’s hardly insurance.  You’ve got a whole group of people out there that are suffering today, and we’re trying to fix that market so it’ll work in the future and people can get access to coverage.

DeBonis:         I’ll just say obviously there’s a partisan divide on this bill that we’re not going to overcome today on this stage.  I did want to in our last few minutes here ask about another part of this.  We’ve talked about this from the industry perspective, the public health perspective, the oversight perspective.  This is also a criminal issue that people are breaking the law here.  Senator Markey, you talked about fentanyl and the very serious problem that that very potent opioid has created.  We have a proposal on the table now from Senator Grassley and Senator Feinstein, a bipartisan proposal to give the federal prosecutors, the Justice Department, more powers to take action in that regard.  Have you had the chance to look at that legislation?  Is that something that you’re able to support or is there another way to go about it?

Markey:           Well, look, we have to crack down on the really bad actors, that is these drug cartels coming in from Mexico, what China is doing.  We have to elevate this importation of fentanyl up to the same level as nuclear nonproliferation and copyright protection in our discussions with the Chinese.  That’s the level, that’s the terrorist threat on the streets of America.  There’s no two ways about it; that’s how the American people see it.

But let’s be honest, we owe an apology to an entire generation of African American young men who we incarcerated as part of the crack cocaine epidemic in the 1990s.  So let’s not think again that we can incarcerate our way out of this problem.  We can only provide treatment to get out of this problem.  And while there might be some targeted law enforcement measures that we can all come together to support, the overriding issue is providing the funding, the access to treatment and prevention for families in our country.

DeBonis:         Mr. Chairman, what are you hearing from the law enforcement in your district and what other tools do you think they need?

Walden:           Yeah, there are some communication issues that we need to carefully think through between the law enforcement and the prescribing community.  How do you manage patient privacy in that realm?  When the law enforcement pick somebody up, what are they on, how do you treat them?  There are some communication issues there.  And I think it really gets back to who is issuing the prescription in the first place, and are they getting the proper consultation and best practices?  Because that’s where it starts; we have this other issue, and I concur, we have to deal with in terms of treatment for people who are hooked.

But if we’re now making some progress, instead of issuing a 90-day prescription, it’s 21, there’s fewer pills out there.  And we’re investigating, ONI is investigating, or will, the fentanyl issue.  We’re investigating the issue in West Virginia.  How does a community with a few hundred people have a hundred million pills going into it?  I mean we’re doing a lot of that sort of work as well.  I commend the Chinese for the steps they have taken, but obviously there’s more to take to reduce access to fentanyl.  And let’s look at the postal service.  Most of this stuff is coming in through the U.S. Postal Service because they don’t have the tools to adequately screen it out.  So we’ve got some of this on our own hands here that we have to do more work on, and we’re going to be investigating all of those through the Oversight and Investigation Subcommittee.

DeBonis:         Congresswoman, I’m going to give you the last word.

DeGette:         I’ll just end on a collegial note here, is that what both my colleagues said is really true.  We need so much more coordination, understanding of the problem, coordination with the whole system.  The prescription system, the law enforcement system.  We didn’t have that before.  We also need to have a medical understanding of those these opioids work and what the best treatment is.  In Colorado, we have a consortium that has formed.  I just met with them the other day.  And they’re looking at this holistic approach.

How do we work on controlling how these opioids are prescribed?  How do we prevent people and educate doctors and patients?  And then how do we work at it from the law enforcement perspective?  And then how do we help people who have become addicted?  I think more and more people realize that holistic approach is really the approach that’s going to work.  And in Congress, what we need to figure out is both how to get the funding for that and also how to get the programs that work.

Walden:           I want to end—

DeBonis:         Real quick.

Walden:           I think it’s really important.  We also should not overreact.  These drugs are very important in pain management when administered appropriately.  And so we have to understand there are a lot of people managing pain effectively with opiates.  We have to make sure that we don’t overreact and hurt them along the way by accident.  So it’s a balance.

DeBonis:         Thank you very much Congresswoman Diana DeGette, Senator Ed Markey and Chairman Greg Walden.  And thank you all.  We’ll have more panels for you very shortly.  They’ll be in very good hands with my colleague Lenny Bernstein.  Thank you very much.

 

An Epidemic in America: Cause and Effect:

Bernstein:        Morning, everybody.  Thanks very much for coming.  I’m Lenny Bernstein; I’m the Health and Medicine reporter here at The Post.  And joining me on stage to talk about this public health crisis from a medical perspective and how doctors and healthcare providers are responding to the opioid epidemic in America, we have Dr. Andrew Kolodny.  He is the co-director of opioid research at the Heller School for Social Policy and Management at Brandeis University.  Dr. Leana Wen, she’s the chief medical officer and health commissioner for the city of Baltimore.  More fortunately for us, these are two of the most far-sighted thinkers on this subject.  They have been talking about this for many years.

Dr. Kolodny was sounding the alarms about irresponsible opioid prescribing before most of us were listening.  Dr. Wen has taken steps in Baltimore that many cities have yet to take in combating this crisis.  So we’re very fortunate to have them here.  Andrew, it seems that when we throw the full weight of our public health resources at other epidemics, HIV, drunk driving, car accidents, that we much more quickly were able to bend the curve on fatalities.  Here we are 17 years into the opioid crisis.  If the latest data is correct, the numbers are just continuing to escalate, and escalate rather sharply.  What’s different here?  Why haven’t we been able to solve this?

Kolodny:         That’s a good question.  I think one of the main reasons that we have failed to respond appropriately to the opioid crisis is that it was misframed, and intentionally so.  Certainly by 2000, 2001, there were reports coming from Appalachia and New England about Oxycontin overdoses and addiction, and it was clear we were having a problem with opioids.  From the beginning of the crisis, the way the issue was framed, particularly by pain organizations that were getting funding from opioid manufacturers, the way the issue was framed for policy makers was as if all of the bad things that we’re hearing about, all of the opioid harms policymakers were told, were limited to so-called drug abusers and that millions of patients were being helped by the increase in prescribing.

And so policymakers were told that your challenge is to try and do something about this drug abuse problem without making the chronic pain problems worse.  Millions of Americans are suffering from chronic pain, and if you were to promote any kind of intervention that would result in reduced prescribing, you’ll be punishing the pain patients for the bad behavior of the drug abusers.  You’ve got to balance these two competing problems.  And the reality is that we don’t have these two distinct groups, and opioids are not safe and effective treatments for the vast majority of people suffering with chronic pain.  Millions of patients with pain have become opioid addicted.  Thousands of patients have lost their lives.

So the opioid crisis is not an issue of drug abuse.  It’s not an abuse crisis.  If you frame it that way, it suggests that the problem is people behaving badly, taking dangerous drugs because it feels good, and they’re accidently killing themselves.  And that maybe the intervention is to make the pills hard to crush so people can’t abuse them.  It’s not an abuse crisis.  It’s an addiction epidemic.  The reason we have historically high levels of overdose deaths, the reason we’re seeing heroin and fentanyl flood into non-urban areas, the reason we’re seeing a soaring increase in infants born opioid-dependent, children winding up in the foster care system, outbreaks of injection-related infectious diseases is because we’ve had this very sharp increase in the prevalence, the number of Americans suffering from opioid addiction.  And if we’re going to bring the epidemic under control, we have to stop creating new cases of addiction through more cautious prescribing, and we have to see that the millions who are addicted have access to effective treatment.

Bernstein:        But Andrew, just very briefly, you and I have both spoken to dozens and dozens of people, many of them older folks who swear they couldn’t get through the day without their opioids.  It might be a small dose.  They may never have increased that dosage over the years, but they say, “Look, I’m in this wheelchair if I don’t have opioids.”

Kolodny:         Well, there are about 10 to 12 million Americans who have been put on long-term opioids and certainly when you write a story about opioids, you’ll sometimes see in the comments section people writing in saying, “I’m not an addict and you’re punishing me.  You’re calling me an addict.  I shouldn’t lose access.”  You’ve got many of these people who may truly believe the opioids are helping them, but if they’re on daily long-term opioids, they’re probably not being helped.  What they may experience as relief when they take an opioid is probably relief of withdrawal pain rather than relief of an underlying pain problem.  If you’re taking opioids every day around the clock like an extended-release opioid, Oxycontin you take in the morning and at night, and if you’re doing that for months and years, it’s unlikely that you’re still getting pain relief from the drug.  If you’re on opioids chronically in order to get pain relief, you’ll need higher and higher doses.  And as the doses get higher, we see that people’s functioning begins to decline.  And we know that opioids can even make pain worse.  It’s a phenomenon called hyperalgesia.

I wouldn’t say that we should never give opioids to people with chronic pain, but the way in which they might be effective for people who suffer from chronic pain is if they’re used intermittently on a really bad day.  Around the clock opioids are not helping these patients, and millions of Americans are now stuck on opioids.  I think we should really be thinking of that population as victims of our era of aggressive prescribing.  We need a compassionate response for those folks.  We don’t want their primary care docs to just fire them.  For some of those patients, we’d probably see them turn to heroin if they can’t get opioids anywhere.

Bernstein:        Understood.  Leana, the truth is that we know what works in the battle against opioid addiction.  The science is there.  The policy is there.  Could you tell us what works and why we still have an epidemic if we know those things?

Wen:                That’s right.  This is why all of our discussions today are so frustrating.  There are a lot of diseases out there for which we don’t have a cure, we don’t have a treatment, we don’t have prevention, and we really struggle with those and we need more research.  And yes, we need more research when it comes to opioids as well, but we actually know what works.

And to your question earlier, Lenny, about why has this been so different from any other public health crisis, there’s one word.  Stigma.  There are myths and misconceptions around the disease of addiction that’s very different from other illnesses.  I hear for example in Baltimore, you had mentioned that we’ve been putting out our antidote medication, Narcan or Naloxone.  I wrote a blanket prescription for this medication to every single one of our 620,000 residents because everyone should be able to save a life.  And yet I hear people all the time say, “Well, why give this medication to people?  Isn’t that just going to make them use more drugs?”  Would you ever say to someone who is dying from a peanut allergy, “I’m sorry, I’m not going to give you an Epi-pen because it might make you eat more peanuts next time?”  But we don’t hear that.

Naloxone works.  It’s immediately lifesaving.  It’s non-addictive.  It’s safe.  And we have to save someone’s life today to get them into treatment tomorrow.  So that’s one thing that works, and yet we don’t have nearly enough of it because of stigma.  There’s also huge stigma around treatment.  We don’t say to someone with diabetes, “Well, why are you still on insulin?  Why can’t you get off of your insulin and isn’t lifestyle changes, shouldn’t that be enough?”  And yet we make those assumptions about people with the disease of addiction all the time.  And we—

Bernstein:        In regard to Suboxone and methadone?

Wen:                That’s right.  When actually the science is clear that medication-assisted treatment with methadone, buprenorphine, combined with psycho-social counseling are what works for the treatment of addiction.  And for so long, we have treated addiction as a moral failing, as a crime.  I go back to what I think are Senator Markey’s excellent points about a whole generation of people who we have to apologize to.  In Baltimore City, I’ve had our residents at community forums come up to me and say, “I don’t understand why suddenly the opioid epidemic is a public health crisis.  Why is it an emergency when it’s been a state of emergency my entire life?”  Because it was poor minorities in inner cities who had this illness, and therefore it was seen as a choice and a moral failing.  Therefore, if you end up in jail or dead, it’s your fault.  I’m glad that we’re now seeing it as a disease.  But then we need to treat it as any other disease and devote the resources that are necessary to fight it.

Bernstein:        And very quickly, what percentage of the people who need it get treatment?

Wen:                The Surgeon General’s report said that it’s about one in ten people.  One in ten people with the disease of addiction are able to get the help that they need.  Now, what other disease would we find that to be acceptable?  Would we find it acceptable if only one in ten people with cancer can get chemotherapy?

Bernstein:        One of the things that has changed in the last few years is that prescription opioids, the rate of overdose and addiction from those is going up much more slowly, but we have this explosive fentanyl/heroin crisis.  Does that change the epidemic for us and what do we do about that?

Kolodny:         I think it’s important to understand the trends and to interpret the data appropriately.  What we’ve seen over the past couple of years has been a leveling off and maybe even a slight decline in overdose deaths involving prescription opioids.  But starting in 2011, we’ve seen a soaring increase in overdose deaths involving heroin.  And I think that many are misinterpreting that data.  What they’re thinking is that we’ve seen this leveling in prescription opioids while heroin has gone up, so that means that the drug users are all switching from the pills to heroin and that the painkiller problem has turned into a heroin problem.

That’s not really correct.  It’s half correct in that the vast majority of people who started using heroin post-1995 were first addicted to prescription opioids.  So the switching part is correct, but the switching didn’t begin in 2011.  From the beginning of the prescription opioid crisis, young people who are becoming opioid addicted were switching to heroin.  A young person who becomes opioid addicted through use of prescription opioids and the addiction begins from either recreational use or medical use or sometimes a combination, brief medical exposure followed by recreational use.

The young people are becoming opioid addicted.  Once addicted, they have a hard time maintaining their supply visiting doctors.  And it isn’t that doctors and dentists don’t like to give young people lots of pills; unfortunately, we’re too comfortable doing that.  But doctors don’t like to give healthy looking 25-year-olds a large quantity on a monthly basis.  So young people who are becoming opioid addicted, to maintain their supply—and once addicted, you have to maintain your supply.  You’re not using because it’s fun; you’re using because you have to keep using to avoid feeling awful.

Once addicted and they have to maintain their supply, they wind up on the black market.  The pills are very expensive on the black market.  If they’re in a region of the country where heroin is available, they switch because it’s cheaper.  And what’s happened steadily, not starting in 2011 but steadily from the beginning of the prescription opioid crisis, is we’ve seen heroin flood into more regions of the country where it wasn’t previously available to meet the demand for it by these young people who are opioid addicted.

What starts happening in 2011 is that the heroin supply becomes more dangerous; increasingly it has fentanyl in it, or increasingly it’s fentanyl being sold as heroin.  So we’ve seen this sharp increase in deaths among young heroin users, but not a sudden switching.  But what’s also very important to understand with regard to the prescription opioid overdoses is that we really have two populations that have become opioid addicted over the past 20 years; the younger group that I just described, but an older group as well, people in their 40s up through their 80s.

The older group is developing their opioid addiction almost entirely through medical treatment.  The older group, when they become addicted, is generally not turning to the black market.  When they become addicted, they generally don’t have a hard time finding doctors who will maintain them on a large quantity of opioids on a monthly basis.  And up until pretty recently, we were seeing far more overdose deaths in the older group that gets pills more easily from doctors than we were seeing in the younger group that’s been switching to heroin.

Fentanyl is now causing that younger group to catch up, but in 2015, the last year for which we have the national data, it was about equal in terms of the number of prescription opioid overdoses to the heroin overdoses.  I think next year we will see more deaths in the younger heroin using group because of fentanyl.

Bernstein:        Okay.  Hang onto that thought because I want to get back to it.  Baltimore has had a heroin problem for decades.

Wen:                That’s right.

Bernstein:        What are you seeing out there?

Wen:                It’s getting worse.  So we have had the crack epidemic, heroin epidemic; we also have prescription pills.  That’s a big issue in our city as well.  And also fentanyl.  I mean we’re hearing a lot about fentanyl today, but fentanyl is many times stronger than heroin.  And it’s now being mixed in with heroin and people who are using it don’t know it.  So if they’re using what they think is their usual amount and now there’s fentanyl in it, they’re overdosing and they’re dying.

The number of people in our city overdosing from fentanyl has increased by 35 times in the last three years.  Not 35 percent; 35 times in the last three years.  No doubt it’s a public health emergency.  But as with all public health emergencies, it’s complicated and there are at least two components.  There’s the supply issue and there’s a demand issue.  We heard about the supply issue and the need for law enforcement.  Sure, that’s one issue.  But then we’re going to continue to have a problem unless we can address demand.  Unless we can get people who have addictions into treatment, whether they’re addicted to heroin or prescription pills, they need treatment.  And unless we can address that, we’re still going to see this crisis escalate.  And now because of how deadly this drug is, it’s only going to get worse.

So what we’ve done in the city is first, we’ve gotten Narcan or naloxone into the hands of every individual as much as we can.  In the last two years, actually, we’ve gotten this drug not only into the hands of first responders like paramedics and police officers, we’ve gotten it into the hands of everyday people.  And every day people have saved the lives of over 950 of their fellow residents in the last two years; 950.  Now, we do have a problem where we’re now being priced out of the ability to save lives.  We simply don’t have the money to purchase enough Narcan; so that’s a problem.

Bernstein:        Is that why Baltimore is running low on Narcan because you simply are running out of money to buy it?

Wen:                That’s correct.  We don’t have a shortage of Narcan in the sense that there’s plenty of this medication out there.  But we don’t have enough resources to be able to purchase it for everyone who needs it.  So we’ve got to ration this lifesaving medication.  And then we’ve also been trying to increase treatment, but we also don’t have enough resources to do so.

Bernstein:        Is that because some people need four, five, six shots of Narcan when they take fentanyl?

Wen:                There are multiple reasons.  One is that fentanyl is such a strong drug that you do need multiple doses of Narcan.  But the other reason is we have reduced the regulatory barriers so that everyone can carry it.  Well, now everyone wants to carry it.  People are calling the Health Department every day saying, “I’m a faith leader.  I run a neighborhood association.  People are overdosing outside my door every day.  I want to have this medication here.”  We don’t have nearly enough to supply everyone in our city who can save a life to be able to do so.

Bernstein:        I want to get back to a point you made and maybe I’ll start with Leana on this one, though.  You’re both physicians.  I thought back in 2015 towards the end of the year when the CDC put out the guidelines for physicians and then that was soon followed by work by the AMA, one of the more conservative physician’s organizations.  They started to get the message out to doctors, you don’t need to give 30 pills when someone has a tooth pulled.  You don’t need to prescribe 60 when someone has a very minor surgical procedure.

It seems to be universally agreed that physicians are going to have to step up in some regard and take responsibility for this epidemic.  Are they changing their philosophies?  Everybody in this room has a friend who went home with a bottle of Vicodin, 30 or 40 for a procedure that really didn’t call for it.

Wen:                From my standpoint, the medical profession is changing, but slowly; but in the right direction.  When I was going through medical training, I didn’t really learn about how addictive opioids were.  We had big pharma around all the time, really misleading people about how important it is to address pain.  Yes, it’s important to address pain, but becoming pain free actually shouldn’t be our goal.  If you fall down and you sprain your ankle or you bruise your knee, I don’t know that you need to take opioids to take away that pain.  Maybe living with the pain is okay.

But we didn’t really learn about that, and now we are.  We are learning about it, but physicians too are very frustrated because we went into medicine to take away people’s suffering.  We don’t have a lot of tools when it comes to pain control.  We’re not really taught about physical therapy, we’re not really taught about alternatives to opioids.  That’s something that we have to work on.  The guidelines are helpful and physicians at least in my city are beginning to use the guidelines and hold onto these guidelines to do better by their patients.

But I would say one more thing, which is that we continue to be frustrated every day in our practice.  I’m an emergency physician, and in the ER, I have patients coming in who know that they need treatment.  They will tell me they need treatment.  Every nurse, every social worker, every physician that sees them know that they need treatment.  They may even have overdosed multiple times, and now they’re seeking treatment.  But I tell them, “I’m sorry, the next available treatment slot is in three weeks, or two months.”  Again, what other disease would we find that to be acceptable?  Do we ever say to someone, “Sorry you’ve had a heart attack.  If you’re not dead in three months, come back and maybe we can get you to see someone then”?

Bernstein:        Is that an insurance reimbursement issue?

Wen:                It’s a capacity issue.  It’s a reimbursement issue.  It’s also something that will only be worsened if we are to repeal the ACA, but a whole different story.  There’s a lot more that needs to be done, but we physicians should be seen as partners in this process.  We should push physicians, but physicians are trying to do the right thing as well.

Bernstein:        Andrew, are doctors getting the message?

Kolodny:         I’m not so sure.  The increase in opioid prescribing that would ultimately lead to this epidemic, it starts in 1996.  From 1996 until around 2012, opioid prescribing was still increasing.  The medical community was responding to a multifaceted campaign that misinformed us, led us to believe that the risk of addiction was very low and the compassionate way to treat just about any complaint of pain was with an opioid prescription.  So prescribing starts going up in ‘96.  Since 2012, it’s plateaued and come down a little bit.  But it really hasn’t come down very far.  We are still massively overprescribing opioids in the United States.  We want doctors to be able to weigh risks versus benefits better when prescribing opioids, but they’re not doing that very well.

And I think one of the problems has really been the Food and Drug Administration.  I think that unfortunately, the Food and Drug Administration is not properly enforcing the Food, Drug and Cosmetic Act.  Had it been properly enforcing that law back in ‘96 when Oxycontin hit the market, the FDA would have told Purdue, “Great.  You have extended release oxycodone, you can market that drug for use in hospices.  You can send your sales reps to the palliative care doctors, to the hospices.  But we’re not going to let you promote oxycontin for back pain.  We’re not going to let you do this in primary care and family practice because the risks of using opioids for back pain outweigh the benefits.”

And so if they had properly enforced the law, they would have done that, and I don’t think we’d have an epidemic today.  By 2001, 2002, it was very clear the prescribing had taken off at a rate far beyond what could be clinically needed.  FDA is beginning to hear from members of Congress whose constituents are overdosing.  They’re holding meetings and they’re saying, “Should we be changing the way in which we allow these drugs to be marketed?  Should we be changing the way in which we’re approving these drugs?”

And they asked that at a meeting in 2002, and unfortunately the experts they called in to advise them were the same docs who were leading the campaign to increase prescribing.  And FDA decided not to make any changes, and in fact they went in the opposite direction.  Other pharmaceutical companies saw how well this was working for Purdue; they wanted their extended release opioids on the market as well.  And FDA actually made it easier for new opioids to hit the market.

So despite the fact that we had a clear problem, we’ve seen a steady stream of new opioid approvals.  Each time a new opioid hits the market, the company that brings that opioid to market has to recoup the investment, a considerable investment.  The way they do that is with a campaign to increase prescribing.  So at a time when the CDC and health officials across the country are urging the medical community to prescribe more cautiously, you’ve got new products hitting the market with campaigns to increase prescribing.

Bernstein:        Didn’t they just ask one company to take an opioid off the market because it’s being so widely abused?

Kolodny:         Yes.  The FDA just asked Endo Pharmaceuticals to remove Opana from the market.  And hopefully this could signal that FDA is beginning to change its opioid policies.  It’s unclear whether or not that decision was based on a change at FDA or might have had something to do with a battle between FDA and Endo over whether or not Opana should have been labeled abuse deterrent.  It’s hard to say.  There is quite a bit FDA could do, and if they start taking the proper steps, it would be very helpful.

Bernstein:        We have about five minutes so I’m just going to give you each about half of that.  You’re the drug czars, and I don’t mean ONDCP.  I mean you’ve got all the power in the world to change this epidemic.  Leana, what would you do?  What’s your list of policies?

Wen:                It sounds amazing, first of all.  I have to get used to this.  First, I would ensure that there is treatment on demand.  Not treatment in three months, but treatment at the time that people need and the right treatment.  We shouldn’t be telling people there’s only one thing available.  You get methadone or you get counseling.  We should give people the medication, the counseling, the services that they need.  So first of all, ensuring treatment on demand.

Second, I would support those on the front lines with the resources that they need.  We in Baltimore City, we work very closely with law enforcement, the district attorney’s office, with our nonprofit partners.  We know what we need in the city.  We have made requests of our state and federal partners and as long as we are able to get the resources, we know what works best in our community.  So support those on the front lines with getting the treatment that we need.  The third is I would change the culture; something that might take a little bit longer.  But we need to change the culture by asking the difficult questions, including why is it that we have this mentality of a pill for every pain?  How can we change prescribing practices, advertising practices, approval, but also the culture, the mentality that patients have too, that we all have for a pill for every pain?

And we need to ask the question too, what pain is it that we’re treating?  Because we’re not just treating physical pain; we’re also treating deep trauma, deep disparities, mental health issues that may need to be addressed in another way.  So there needs to be a systemic and holistic approach that can only come from us asking the hard questions and taking the difficult approach.  When we see that this is a solvable problem, we know what works, we just need the resources to get there.

Bernstein:        And that was less than two and a half minutes, so I’m going to ask you a really quick yes or no question before Andrew gives us his list.  Safe injection sites?  They’re against the federal law right now, but yay or nay here in the United States?

Wen:                I would do it.

Bernstein:        Would you tell people what a safe injection site is?

Wen:                Sure.  Safe injection site is a facility where people can come in and be monitored while they are using drugs.  So they’ll have a nurse who can take their blood pressure, their oxygen saturation and et cetera while they are using drugs.  This is a harm reduction approach, similar it’s an extension of needle exchange, which we’ve had in Baltimore for over 20 years.

Bernstein:        There’s on in Vancouver that has never lost anyone to an overdose.

Wen:                That’s right.  And there is evidence saying that it is one approach to be taken to reduce the number of overdose deaths.  Since there is evidence for it and because it is a harm reduction public health approach, it’s something that we would explore in Baltimore City if it were legal because we don’t really want to go to jail and don’t want all of our federal funding to be pulled in order for us to do this.

Bernstein:        So that’s a yay.

Kolodny:         I’ll answer the safe injection and then—

Bernstein:        And then tell us how you would—

Kolodny:         I don’t know that it will really help or hurt.  Where it makes sense to have safe injection facilities is where you have—in urban areas where there are homeless or people who are injecting drugs, and they can go in and inject someplace where they can be monitored.

Bernstein:        Like Baltimore.

Kolodny:         Yeah.  But our opioid addiction epidemic is disproportionately suburban and rural.  We just saw a big fight in Ithaca, New York, over whether or not there should be a safe injection facility there.  In suburban or rural areas, I think it’s very unlikely people are going to commute into town to inject in a facility.  I think if they built it, nobody would come.  And you have many areas where there are waiting lists for addiction treatment, waiting lists to get buprenorphine, which can effectively treat opioid addiction and save lives.  And you’ve got these debates over whether or not to have a safe injection facility.  So I think it’s a bit of a red herring.  I think there are interventions that would be much more effective.

Bernstein:        You’re the drug czar for 82 seconds.  Tell us what you’re going to do.

Kolodny:         There are many different policies, and I heard an economist talk about the problem recently, and he said, “There’s no magic bullet.  We need magic buckshot.”  So what I’ll just mention in my few seconds is the big picture strategies for controlling the problem.  This is an addiction epidemic and the way that we respond to this disease epidemic is similar to the way you respond to other disease epidemics.  You have to prevent people from getting the disease and you have to see that the people who are suffering from the disease have access to effective treatment.

To prevent opioid addiction, that really boils down to much more cautious prescribing so that we don’t directly addict patients or indirectly cause addiction by stocking everybody’s home with a highly addictive drug.  There’s quite a bit that could be done on a state level and a federal level to produce more cautious prescribing.  And for the millions who are addicted, you have to see that they have access to effective treatment.

And when I say effective treatment, I’m not talking about counseling or rehabs or detoxes or even the Vivitrol injection, which I think is really only appropriate for a small subset of people who are opioid addicted.  I’m talking about buprenorphine treatment and methadone maintenance.  We have to see that it’s much easier to access buprenorphine than it is to access pills, heroin or fentanyl or we’re not going to be able to reduce overdose deaths.

And then just one other point.  We’re failing in every aspect of responding to this problem, but if we’re going to respond appropriately, we need better surveillance of the problem.  We need to know how many Americans have opioid addiction.  There was a report yesterday in The Washington Post that over a million Americans have received a hospital treatment for opioid addiction, yet the national estimate of the number of people who are opioid addicted is 2.5 million; a total underestimate.  It’s certainly well over 5 million that are addicted.  We need to be able to measure the incidents, an estimate of the number of new cases of opioid addiction occurring each year so that we’ll know whether or not our efforts to prevent opioid addiction are working.  So we need much better public health surveillance of this problem.

Bernstein:        Thank you so much.  We really appreciate it.  That’s about all the time we have.  Dr. Leana Wen, Dr. Andrew Kolodny, thank you so much for joining us.  We look forward to speaking with you more in the future.

 

Battelle Sponsored Segment-

Addressing Addiction: A Look at Medication Assisted Treatment:

 

M:                    We now want to introduce our sponsor segment and bring to the stage Joe Berger, vice president and general manager for Health and Consumer Solutions at Battelle, and Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse.

Berger:            So, we’ve heard a lot of statistics this morning about the opioid problem, and I live in Ohio, and we have the unfortunate honor of leading the nation in this problem.  In fact, I was driving to the airport yesterday, and heard the most recent statistics on central Ohio, which is mostly urban and suburban.  And that the opioid deaths are on track to go from 350 last year to 500 this year, so we continue to be faced with this problem.  And, so, now the question is what can we do about it?

So, today I’m joined by Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse, to discuss evidence-based treatment strategies to reduce the number of people developing addiction problems, and to treat those who become addicted.  So, Dr. Compton, thanks very much for joining me.

Compton:        I’m glad to be here today.

Berger:            So, let’s start.  What are some of the biggest areas of progress we’ve made in stemming the tide of opioid addiction?  We obviously are making some progress, but we still have a long way to go.

Compton:        Well, I think you’ve just reminded us that even as we are making progress in a few areas, the number of deaths overall continues to increase, and that has every public health official and every policy maker concerned.  So, how can we do a better job of addressing this public health crisis?  We do see some improvements in two areas I want to highlight for you.  One, and we heard this from some of the earlier speakers, that the overall number of prescriptions written for opioids has begun to decline.  It leveled off starting in about 2012, and we’ve seen a reduction in the physician’s willingness, and overall over-prescribing of these medications.

That’s a little bit of a hopeful sign, but we need to do a better job, not just level off, but actually decrease the number of prescriptions significantly.  The second hopeful sign is, we’ve actually seen a terrific improvement in the recreational or illicit use of these medications by teenagers. About 10 or 15 years ago, we saw that about 10% of 12th graders were using a prescription opioid, or misusing it, for its intoxicating properties. They wanted to get high and they were using these medications recreationally.  That number has dropped to under 4%, so that’s a terrific improvement, and this is the future of the field.  These are the people who will go on to misuse during their early 20s and really develop the serious problems that end up with the addictions and deaths that we’re seeing now.  So, I think that’s very hopeful.

Berger:            I’d love to dig into that more, but let’s talk about—we’ve heard this morning about medication-assisted treatment a lot, so I’d like you to talk a little bit about what that is, maybe for our audience who aren’t as familiar with it as soon.

Compton:        I think it’s a great question.  You know, what is medication-assisted treatment? Well, basically, what that means is that means using a prescription medication to combat the disease of addiction.  We’re very lucky in this field of opioid use disorder, opioid addiction that we have three FDA-approved medications.  We’ve had methadone for about 50 years in our country, to treat people who are addicted to opioids.  We added buprenorphine just a few years ago, and we’ve had naltrexone, both in its oral form for a number of years, and then more recently we had a long-acting version of naltrexone.  That’s a blocking agent.

So, these come in two different classes.  Buprenorphine and methadone are both medications that substitute for opioids and allow people, when doses properly, to enter recovery, to get back their functioning and save their lives.  Naltrexone has sort of the opposite effect; it blocks how opioids work in our brains, and so it’s a blocking agent, and now this new formulation can last as long as a month with a single injection.

Berger:            And are you seeing—so, are there trends?  Are some of these becoming more popular?  Are some of them being used less? What’s happening in that area with these three different treatments?

Compton:        Of course, we’d like to see these medications be available to every patient that needs them, everywhere in the country, on demand.  That’s actually our goal, and that’s the goal of all the public health system, is to increase the availability so that if you or a loved one has a problem with addiction, and you go to your physician, or you show up at an emergency room, they can get you treatment on demand.  Unfortunately, that is not the case.  We have seen increases in both methadone availability—these have to be in specialized methadone treatment programs.

We see the increased in buprenorphine prescribing, because we have a greater number of prescribers, and due to changes in the rules that our colleagues at SAMHSA implemented, we see an improvement in the number of people that clinicians can treat with buprenorphine.  We also see increases in the availability of the long-acting naltrexone injection.  But despite those improvements, there are tremendous barriers in many parts of our country, and a lack of educated clinicians to take care of patients that need this care.

Berger:            So, what’s keeping—what are some of the policy issues, what’s keeping us from getting it more broadly available to patients who do need it?

Compton:        I think we’ve heard this theme already this morning, that the fundamental issue is the stigma around addiction; that we’ve spent way too long thinking of addiction as purely a moral failing and a decision-making.  So, you’re making bad choices; just quit doing that, is sort of the message people get.  If it were that simple, all of my patients and others who have addiction would have quit long ago.  They suffer tremendous harms, and yet, because of the compulsive behavioral origins of this condition, they keep engaging in the behavior.  That’s why we need effective medications that can combat it, and I think forums like this, that help educate the public and others about the medical nature of this disease can really make a big difference.

Berger:            So, we both live in the research world.  So, let’s talk a little bit about some of the research you think that needs to be done in this area, and maybe talk a little bit about some of the research that you’re doing at NIDA these days, to help us understand the problem better, and help us address the problem.

Compton:        Well, of course, I’m very proud of the work we’re conducting at the National Institutes of Health, and particularly at the National Institute on Drug Abuse, to try to address this public health crisis.  I sort of put the research in two main buckets; one is we have treatments that have effects.  We have treatments that are useful.  We have prevention approaches that can provide communities and families the tools they need to raise healthy children and keep them from moving into the addiction sphere.

So, why aren’t we implementing these widely and universally?  That’s sort of a key research question. What can we do to improve the access and availability of the current treatments?  Now, as much as I like our current treatments, and I’m thrilled that we have multiple approaches to prevent and treat these diseases, they are not as effective or as good as I would like.  I would like something that was perfectly effective.  I’d like something as good as ampicillin for an ear infection, where you go to the doctor, you have a sore ear, you get the medication, and you’re better.

That’s not the case with our addiction treatments.  They work; they help people, but they only help a minority of the people that start them.  People stop their treatment; this is a long-term condition, and yet people often don’t take their medications as long as they need to, to benefit from it.  So, these are some of the issues where I think research can provide tools that can be the solutions to these long-term problems, if we invest in research successfully.

Berger:            And, so we’ve talked a little bit this morning about how this really is a rural—a bigger rural problem than maybe an urban problem.  So, what are some of the ways that maybe we can help that rural community access some of these treatments more effectively?  It’s probably—we’ve heard it’s much easier, maybe, to put this in an urban setting, but what about the rural settings?

Compton:        It’s not just limited to addiction.  We struggle to get healthcare to rural populations across a range of issues.  If you need a cardiologist, and you live outside a major urban area, it’s really difficult to access that care.  We have addiction specialists in many locations, we have family doctors in more locations, but there are some parts of the country that don’t even have access to general medicine, or family medicine.  So, what can we do to use telehealth?  What can we use to use part-time practices that may come into these locations? What can we do to get nurse practitioners, physician assistants, other forms of care that are a part of helping people enter recovery, in all the regions that need them?

Can we use the internet to provide care long distance?  Some of that has been shown to be possible, but how can we do that on a more widespread basis? Research can help with that, as can the new funding that we’ve seen with the 21st Century Cures Act, and other novel ideas that the states and local areas are coming up with.

Berger:            So, you got a little bit ahead of me there.  So, what public health policies that have been implemented, at either federal or state or community levels, even, do you see having a positive impact, other than maybe the Cures Act?

Compton:        Well, there are multiple policies and practices that need to be implemented.  What can we do to change the availability of medication-assisted treatment, for example?  Some states still have regulations that require to fail non-medication treatment before you can even start medications.  That seems counterintuitive.  As a physician, I want my patients to have access to the effective medications, when they have the problem, and not have to fail some other ineffective approach before they can take what might help them.

That’s just one example of policies that can change.  When it comes to the provision of naloxone, we heard Dr. Wen [ph] describe how she’s written a prescription so that everyone in the city of Baltimore can gain access to this life-saving medication.  There are certain states and locations that have done that in other parts of the country, as well, but that’s not universal.  So, what can we do to make sure that this immediate, life-saving, non-addictive medication is universally and easily accessible when people have an overdose.  In those libraries we’ve been hearing about, which is really a remarkable story, or in other places where people may experience this death.

Berger:            So, Dr. Compton, thank you very much for joining me this morning.  Thank you to our audience for coming today, and to The Washington Post for focusing on such an important public health issue.  I also encourage you after the speakers are done to talk to our subject matter experts who are outside.  And now it’s time to turn it back over to The Washington Post for the next discussion.  Thanks.

Compton:        Thanks very much.

 

Preventing Abuse: Seizing the Opportunity:

Bernstein:        Welcome back again.  Today, in this segment, we have Anne Pritchett, she is the vice president for research and policy at PhRMA, the association that represents large pharmaceutical manufacturers, and we are going to talk about their role in the epidemic, and what might be done about it.  And I think I’m supposed to remind you that if you would like to tweet us questions, we can take them off of here and ask.

So, let’s start with the premise that this country has more opioids than it may need for legitimate pain control.  Why is that?  What is the manufacturing company’s role in that?  And why are we seeing that, and its contribution to this epidemic?

Pritchett:         Well, I would say CDC is actually said that there are enough prescription opioids being prescribed so that every person in America has a 30-day supply.  So, clearly we have a problem.  In terms of what the sources are of the problem, there are a number of different factors that have contributed to the situation we’re in now.  There are inappropriate opportunities to identify inappropriate prescribing.  There have been lack of clinical guidelines to inform physicians prescribing, and we’ve seen major changes in that space over the past couple of years, particularly with CDC releasing guidelines on the treatment of chronic pain, but clearly more needs to be done.

There is insufficient use of prescription drug monitoring programs.  These are state-run databases that allow you to identify potential doctor shoppers, as well as identify potential inappropriate prescribing behavior, and yet, only 22 of 49 states require that physicians access those databases.  So, we need to do more in terms of using the resources we have.  We have seen that the DEA this past year reduced the quota, which in essence was taking away a supposed cushion in terms of opioids.

We have a disconnect, though, in that DEA has said there was a cushion, and they’ve reduced the amount of—they’ve lowered the quotas for manufacturers, but at the same time, we have a GAO report saying that when you look at drug shortages, the vast majority are for pain medications.  So, clearly we have a disconnect and this is a very complex issue, as we heard from the prior speakers, that we really need to get our hands around collectively.  And I think we’ve seen tremendous progress from the administration where we have the FDA announcing the new FDA commissioner saying that they’re going to review what their role is, in terms of the crisis; that we have NIH, as you may have heard from Wilson on the previous panel, that NIH and NIDA are looking to develop a public/private partnership with the industry so that we can develop non-opioid analgesics.

So, that would be alternatives that aren’t addictive to opioids, so that we can further the science and technology to allow us to develop abuse deterrent formulations, and that we can explore other ways that we can appropriately treat pain.

Bernstein:        Before we get to those, when we read or unfortunately some of us see on the ground, and others experience, that 780 million opioids are sent into West Virginia over a five-year span, certainly the distributors who are bringing those there know that that is occurring.  The retailers who are selling them in drug stores know that that is occurring.  Don’t the manufacturers know as well?  Shouldn’t they intervene?

Pritchett:         I think that everyone in the supply chain has a role and a responsibility to behave ethically and legally and to ensure that only as much medication as needed is being provided, and I think clearly there is a disconnect in the supply chain, that that’s not currently occurring.

Bernstein:        And what can we do about this? Is it DEA’s responsibility?  Under the law, everyone in the supply chain is supposed to raise red flags.

Pritchett:         I think there’s a collective responsibility.  I do know—I don’t engage directly on a lot of the supply chain issues, but what we have heard, and what I’ve read from different entities is that one of the challenges is that there is a lack of clarity from DEA on what is a suspicious order; what each person—what each actor in the supply chain’s role is, and that I think there does need to be more coordination between DEA and the FDA, in terms of approval of products, setting quotas, and engaging in those areas.

But I think there is a collective responsibility, and I wish I had the silver bullet answer to that.  But I think events like this that are brining attention to these issues, and that we have an administration that has stated that they are very focused on this; we have a Congress that over the past couple of years has really come to the recognition that prescription drug abuse and addiction are bipartisan issues, not political issues, and that we really need to address them holistically.  I think that’s what we need, is all events like this to bring stakeholders together in ongoing dialogue about our collective roles, and how we collectively identify the appropriate solutions.

Bernstein:        So, in what fashion are the manufacturers engaging with the government?

Pritchett:         So, I would say that a number of our companies have been engaging with NIH in the discussion about public/private partnerships, in terms of developing medication alternatives, furthering abuse deterrent formulations that we have been actively engaged with the federal government in terms of supporting the efforts of the FDA to look at things, like should there be mandatory prescribed—should there be mandatory education for prescribers, for pain and addiction?

And I would say that’s something we feel very strongly about.  We know it’s not popular among some provider groups, but the FDA requires as a risk mitigation strategy for the approval of long-acting and extended release opioids, that companies fund continuing medical education to provide training for providers on how to appropriately prescribe opioids, yet what we’ve seen from the FDA is that, unfortunately, only about—they weren’t able to meet their goal of 80,000 prescribers taking that training over a two-year period.

So, for us, we think it is critically important that there be a focus on, unfortunately, while no likes mandates, the reality is prescribers need better education about the treatment of pain, and about addiction.  Studies have found that medical schools only spend a handful of hours on how to treat pain, as well as how to treat addiction.  That’s a huge gap in our system.  And our view is very strongly that you should only—that physicians need the education need to determine when it’s appropriate to prescribe an opioid, when it isn’t, and that when they are prescribing one, they are relying on clinical guidelines to inform at what dosage and for how long, and whether there are alternatives.

And I would say, one of the other areas where we’ve been engaged in is educating—I would say one of the challenges in this area is that a lot of people think—they have this misconception that because it’s a prescription medicine, it’s somehow safer than something like heroin, which is not accurate.  So, we all need to do a collectively better job of educating the public about the dangers in this space, and we need to discourage people from sharing their medications.  It’s very disturbing when the national household survey on drug use and health find that’s of about half of those that use opioids non-medically, they obtain them from a family member or friend.

So, we are engaged in efforts to educate that patients should take their medications as directed; if they have questions, they need to have that discussion with their provider, and that they need to safely secure their medicines, and appropriately dispose of their medicines.  And certainly, sharing medications is not appropriate.

Bernstein:        Okay, so let’s talk about the medications themselves, those pills.  Abuse deterrent pills, or other forms.  It’s been tried; it hasn’t been hugely successful.  Is it possible?  Can you make the medications unusable by abusers?

Pritchett:         So, I would say before I came to PhRMA, I spent almost eight years in the White House drug policy office, more on the illegal drug side.  And what we found is that kind of those that want to do ill will are always kind of one step ahead of the game, and you know, I do want to correct something.  A lot of people think that if it’s an abuse deterrent formulation, that means it can’t be abused at all.  That’s not accurate.

It means that there is less potential for abuse, and there are a variety of forms of abuse deterrents, and the FDA recognizes that the science and technology continues to evolve in this space.  And that’s one of the reasons why the FDA requires post-approval research on these medications, so that we’re continuing to collect real world evidence to assess how well these medications are working, and their level of abuse deterrents.  And that’s one of the areas that the NIH public/private partnership is intended to focus on, is how do we develop better abuse deterrent technologies?  Are there opportunities in terms of developing non-opioid analgesics?  What can we learn about biomarkers so that we can more appropriately target medications, because pain is not one size fits all; addiction isn’t one size fits all.  There’s a lot more that needs to be done.  But abuse deterrent formulations, we believe, are one part of the toolkit.

Bernstein:        So, they should be in the toolkit; they are partly successful, even though, as you said, the folks who are going to abuse always seem to find some way into them.  Now, maybe you could tell folks two things: what a non-opioid analgesic is, and I don’t want to load you up, but the possibility for using opioids that kill pain but don’t provide the euphoric effect.

Pritchett:         So, I’ll just give you a sense of kind of what’s in the pipeline.  So, there are about 40 abuse deterrent formulations in the pipeline right now, about 40 different medications to treat addiction, and that includes a number of those are opioid reversal agents, which we know is an area where people are looking for convenient delivery forms, given the number of first responders is greatly expanding in that area.  And then, one of the areas is non-opioid analgesics.  And in essence, this is looking at alternative medications where they don’t have the potential for addiction, and there are about 30 medications in that space in development.

And I would say that one of the biggest challenges in all of these areas is that when you look at the opioids that are on the market, about 96% of those are generic, and none of those generics have an abuse deterrent formulation.  So, only about 2% of the market is abuse deterrent formulations, and then the other 2% is branded opioids.

Bernstein:        Sorry, why wouldn’t generics have an abuse deterrent formulation?

Pritchett:         Well, the FDA just recently finalized their guidance in that area, so we are hopeful that there will be generics entering the market in that space.  I would say one of the challenges is there is a lot of scientific and regulatory uncertainty as you’re developing abuse deterrent formulations.  The FDA doesn’t kind of have a, you know, black and white of here’s the criteria you have to meet to be approved as having—being an abuse deterrent formulation, so that’s one of the challenges.

But we also have a disconnect in terms of when you look at the commercial coverage policies for these products.  So, what you generally see is that the generics that—you generally see that abuse deterrent formulations are, you know, tier three, tier four.  So, in other words, you’re failing first on everything else, and there’s not kind of a calculation that, from the insurer perspective, that we need to be considering the potential for abuse, and prioritizing that.

The FDA has said that it’s a key priority for them to approve abuse deterrent formulations, yet we have a disconnect when it comes to coverage in payment policies of the value of these medicines.  And again, they’re only one tool in the toolkit, but an important one.

Bernstein:        But I want to make sure I understand.  96% of the drugs—the opioids that folks take routinely, daily, legally, do not have any kind of abuse deterrent.

Pritchett:         Correct, and they’re generic.

Bernstein:        So, if someone—if a kid takes one out of medicine cabinet, there’s nothing there that would keep him from crushing it and snorting it, or cooking it up and injecting it?

Pritchett:         Correct, and that’s one reason why we think it’s so important to increase our prescriber education, and we support mandatory education on a continuing basis, because we’re developing new abuse deterrent formulations.  As I mentioned, we’re going to have new, non-opioid analgesics coming onto the market, but prescribers need to know what the new developments are in terms of what medicines are coming, what the risks and benefits of new medications are.  They also need to know what the current learnings are about the treatment of pain, the potential for addiction.

I would say we’ve seen over the past couple of years, you know, just recently, the American college of physicians altered its guidance—clinical guidelines regarding the appropriate treatment of lower pain.  And we had CDC release the guidelines on how do you treat chronic pain.  And so, given we have these changes on an ongoing basis, we need to ensure that prescribers are up to date, as well.  And that’s critically important, but I would say, again, educating the public, as someone who has had loved ones affected by substance abuse issues, you know, when I’m meeting with a doctor, I’m meeting with a doctor on behalf of one of my family members, I’m perfectly comfortable saying, “You know, is there a potential for—is there an alternative?  What’s the most appropriate treatment?”

And I think we need to educate patients and caregivers, that they need to be asking those questions of prescribers, that we need to empower them to be aware that medicines need to be taken appropriately, that if they have questions, they need to be asking their prescriber so that they are being appropriately treated.

Bernstein:        And if you’re not able to ask the question yourself, perhaps your loved one can ask them for you.

Pritchett:         Yes.  Well, and as one of those who’s in that generation where, increasingly, you’re taking care of your parents, you know, the roles kind of shift a little bit, and so it is important, given that we are seeing a higher prevalence of addiction among actually—so, we have two issues.  It’s non-medical use of opioids, and then it’s the issue of those that are being treated for chronic pain or other conditions, who become addicted.  And I would say, one of the changes I’ve seen over time is that we used to, as a society, simply focus on that non-medical use, and now there’s increased focus on how do we prevent addiction among those that may be taking a number of medications including pain medications, over a long period of time.

Bernstein:        So, I think of a non-opioid analgesic as ibuprofen, or acetaminophen.  Now, clearly, that’s not going to work for post-surgical pain, or the pain of cancer late-stage, near end of life pain.  So, what are we talking about?  What’s in development?

Pritchett:         So, we’ve got about 40 different medications in development at various stages, that hold promise, but I would say that when we are talking about, let’s say, breakthrough cancer pain, late-stage, having seen my grandmother suffer from cancer late-stage, and fentanyl was the only thing that helped her manage that breakthrough cancer pain.  And I was note, as we’ve heard from the other panelists, fentanyl is something that’s being implicated in exacerbating the current crisis.  And I would note that Judge Louis Freeh, former FBI director, recently came out with a report that was bringing attention to the threat of counterfeit fentanyls.

The DEA has said that hundreds of thousands of counterfeit fentanyl pills are being manufactured in China, and coming to the U.S. through Mexico and Canada.  So, this is greatly exacerbating the opioid epidemic, and as we heard from one of the prior panelists, fentanyl is exponentially more powerful than morphine.  And so, we have this challenge of needing to address the need to ensure legitimate—that patients with legitimate medical needs have access to the medicines they need, including fentanyl, but we need to increase our law enforcement efforts, including considering whether we need to increase penalties for those that are involved in criminal organizations that are bringing counterfeit fentanyl into the U.S.

And as we’ve heard some horror stories of an elephant tranquilizer being mixed with other illicit substances, so there’s a lot of progress that needs to be made, and we really need to take a holistic approach, but we need to ensure that where opioids are appropriate, that physicians have the clinical guidelines to inform their prescribing, and to be clear, opioids are a critical medication and when used appropriately, can be incredibly beneficial to patients.  But we do need to balance that with identifying alternatives, including non-medication alternatives, other therapies that are appropriate.

Bernstein:        Okay, we’re getting close to the end so I want to ask you two more questions.  We’re getting a number of questions here on Twitter about cannabis, and whether PhRMA might go into that area.  I think the point is to try to get me to say cannabinoid in front of all these people.  So, if I got that right, is PhRMA willing to go in that direction?

Pritchett:         So, as you know, there are some medical cannabinoid products available.  We’ve looked at the pipeline, and I think there—it’s a—I want to say it’s a half-dozen products that are in the pipeline, that are in that space.  So, there are companies that are exploring medication uses under—

Bernstein:        And it has both practical potential, and affordability?  Or is it too early?

Pritchett:         I think that I am not in a position to comment on that; that we need the science to tell us what the—whether and what the potential is.

Bernstein:        Okay.  Great.  I did this in the last session, and so for the next minute and 44 seconds, you’re the drug czar, and you are—

Pritchett:         Having worked in the drug czar’s office—

Bernstein:        That’s right.  What’s your list?  What’s your list of—we’re giving you all the power you need to solve the opioid epidemic.

Pritchett:         Right, so, for me, this is a multi-faceted problem, and there’s not a one size fits all solution.  But among—of my top five on the list, it’s that we need to improve education for prescribers.  That means mandated education; that means on an ongoing basis.  As part of that, continuing to educate the public to increase their awareness of opioids and when they’re appropriate and when they’re not.  That, too, we need to mandate the use of prescription drug monitoring programs, because what we have found, studies show that when prescribers are using prescription drug monitoring programs, it does affect their prescribing.  And that many of them say that it has reduced the potential for misuse and abuse.

Bernstein:        Even if they don’t catch doctor shoppers, it affects the way they do their jobs?

Pritchett:         It affects the way they do their jobs, and so I think we need to look at the prescriber patterns, and we need to look at the flags for potential doctor shoppers.  And I would say, in the PDMP space, one of the things that we’ve heard from physicians is that you have to go through ten screens to get to the information you need; we need to make that easier.  We need to increase law enforcement capabilities and capacity to crack down on rogue pill mills, and illicit websites that are illegally provided controlled substances in the U.S.  And we need, as we heard earlier, to increase treatment capacity, and I would say one of the big positives is that while I heard a lot that there’s still a lot of stigma, having worked in this area for the majority of my career, I think we’ve made a lot of progress in reducing stigma, in that we are all here having this conversation today.

Bernstein:        Thank you very, very much.  Your term as drug czar has just ended, perfectly on time.  I’m going to—I’d like to thank Dr. Pritchett first, remembering that, and then I’m going to hand this over to my colleague Mary Jordan.  She’s a national correspondent for the Post, and she’ll be interviewing former congressman Patrick J. Kennedy.

 

Coming Clean: Solutions for Combating Addiction:

Jordan:            Wow, what a morning.  I’m Mary Jordan from The Washington Post and I think you know who I’m with here: Patrick Kennedy.  He was a congressman from Rhode Island and now he’s devoted his life to going around the world in our country and talking about addiction and he’s just joined the White House Commission that’s trying to combat this epidemic.  So we’re delighted to have him here.  Thank you all in the room here at The Washington Post this morning and we encourage those here and online to send in questions.  It’s hashtag #PostLive.  So, Patrick, this matters a lot personally to you.  We’ve heard a lot of statistics and sad, sad ones this morning, but why don’t we talk about what this does to people and maybe you could start with your own personal story.

Kennedy:        Well, my late grandmother on my mom’s side died at the age of 61 and wasn’t found for a week.  Like most people with alcoholism, she pushed away my mother, my aunt, her husband, and she was alone.  And that same disease that she had passed itself to my mother, who had very debilitating both depression and alcoholism, which I grew up with and my dad, of course, had all of these luminaries of the day come over to our house; people who were household names.  And my mom would shuffle through the house clearly incapacitated from her illness and no one would look up and no one would look at her and no one would say anything to her.

So as a young boy, I got the very clear message that these were not things that we should talk about and I, like everyone else, was hoping and praying that my mom would go back into a room and lock the door so that she could spare us the embarrassment of being out amongst everyone in our house.  I had friends come over to the house to play with me when I was little and I was terrified my mom would come to the door if my friend’s mom would ring the doorbell.  And no one talked about it.  Now, my dad, as everyone knows, had a number of traumatic events that happened in his life.  We didn’t know what trauma was back then until 9-11, this idea of post-traumatic stress was not something in our nomenclature.  But my dad, if you wanted to find anyone who qualified for suffering from post-traumatic stress, my dad would be the guy.

He would be like a perfect portrait of someone suffering from post-traumatic stress and he suffered from—

Jordan:            From the assassinations of his two brothers, do you mean?

Kennedy:        Yeah, and until after he died and there was all this stuff written about our house and how there were bulletproof vests in every closet and I didn’t think anything of it.  Someone asked me, “There were bulletproof vests in every closet?”  I said, “Yeah.  Like, aren’t there in your house too?”  That was normal and until I was able to look back on all of it and understand what they were suffering from and the thing I write about in my book, A Common Struggle, is that the common aspect of it is that we don’t talk about these issues.  I, myself, ended up having multiple addictions and suffering from mental illness as well, underlying those addictions.  And even though I was the sponsor of Mental Health Parity and Addiction Equity Act, the law that requires insurance companies to pay for treatment of mental illness and addiction the same way they would pay for any other chronic health condition.  I, myself, still could not wrap my head around the fact that after I went to rehab that I still needed continuity of care.  I still needed chronic care management, just like I got for my asthma because I have very, very bad asthma.

I have to see my primary care physician and pulmonologist all the time.  But somehow, my insurers were paying for my inpatient at Mayo Clinic but weren’t paying for any follow-up.  And these insurance companies know better but they don’t do it and then they complain to people like me who are trying to enforce the Parity Law.  That, “Well, there’s all these fly-by-night rehabs down in Florida that aren’t giving evidence-based treatments.  And I’m like, “You got me.  I’m with you.  I’m not trying to protect them.”  In fact, I’d like to shut those places down because there’s 90% relapse rate for people coming out of those places.  There’s no outcomes-based metrics and insurance companies still have to pay for that.  That’s not what we want.  We want chronic care, continuity of care, recovery living.  And insurance companies aren’t paying for that now.

Jordan:            So we’re going to go back to that super important—

Kennedy:        I jumped right into my policy speech.  [LAUGHTER]

Jordan:            No, but this is important—

Kennedy:        I’m trying to get away from having to talk about—

Jordan:            It’s an important issue.  First of all, thank you for sharing your story.  I think that we’ve heard this morning about stigma and that this still exists and somehow, if it’s in your mind, like it’s not in your body.  And so do you feel like there is some movement forward on that as—

Kennedy:        I think we’re in denial.  I think our country is in deep, deep denial.  If this were an infectious disease, we’d be throwing hundreds of billions of dollars at it right now.  We know what to do.  We don’t need any more White House policy forums.  We don’t need surgeon general’s reports.  We don’t need Washington Post forums.  We know what to do.

Jordan:            Let’s talk about what to do.  What needs to be done?

Kennedy:        Well, it needs to be understood it’s the whole person.  We need to align financial incentives.  The bottom line in all of us is that we need to align financial incentives to encourage prevention, which is the best treatment of all, to encourage chronic care management, and integration of the whole person, i.e., mental health and addiction needs to be treated along with all other physical health conditions.  So that’s got to be our concept and we have to understand that social determinants make a big deal.  Like, if you grow up in a family like Kaiser showed, where your mother or father was alcoholic, in jail, lived in poverty, subject to violence, and witnessed violence.  You check those bars off your trajectory in terms of vulnerability and risk goes through the roof.  So it’s not like we have to spend a lot of money on everybody.  We’ve got to spend the right amount of money on those with the highest risk.

Jordan:            And spend it on prevention and chronic care.  So now, you’re at the White House.  You had your first meeting and who showed up to that meeting?

Kennedy:        So first of all, the commission is really impressive.  Governor Christie, if anybody saw his video that went viral during the presidential about talking about addiction, everybody knows Governor Christie gets it.  Okay, he gets it and we have Governor Cooper, a Democrat.  We have Bertha Madras.  I won’t tell her party affiliation but she works at Harvard out of McLean Hospital.  You guess what her party affiliation.  I’m obviously, a Democrat and then you’ve Baker from Massachusetts, who is not like considered a real hardcore Trump supporter, right?  So the irony is you’ve got a commission that I think is very legitimate.

Jordan:            But does Trump himself care?  He’s talked about this throughout the campaign.  He said, “This was, high, high, high, on this issue.”  And now, we’re going to have to talk about what money is he putting up and especially with what’s going on in healthcare right now and perhaps slashing of Medicaid.  Is the White House really ready to address that?  Because you’re one of the few people in there talking to him.

Kennedy:        Well, obviously, Medicaid—as I said in my opening statement at the commission was the elephant in the room.  And that was because without continuity of care—block grants, I don’t want block grants.  Block grants only pay for non-evidence based treatment.  You don’t fight cancer with block grants.

Jordan:            And is block grants what’s going on in the secret GOP negotiations?

Kennedy:        They’re using block grants as a way of really doing what they don’t want to vote on doing and that’s sharply cutting the amount of money that goes to treatment.  So they say they’re giving the same amount, but they’re letting states to do the dirty work.  Because states’ budgets are going to crowd out the funding and the money is going to be fungible so they’ll use those dollars to fund other things because people with addiction and mental illness are the most unpopular of all constituencies so they’re the easiest people to drop by the wayside.  But I think here’s the big thing for the president is if he’s going to ask for an 18% cut for corporate taxes, I propose that the White House make an objective for our country, at a minimum, to reduce suicide rates and overdose rates by an equal percentage for the American people.  Because if we don’t put our mind to something, we’re never going to start bending the curve and applying ourselves to the goal at hand.

So I think when you see the suicide rates and overdose so high and all of the scientists will tell you, “We can reduce those.  We can reduce those quite dramatically.  We know what to do to reduce those.”  But if we’re not making it a goal of this country to reduce those, we’re never going to get to where we need to go.  So I would say make the reduction in suicide and overdose the same as you make corporate taxes, the reduction in corporate taxes.  And two, if we’re going to repatriate hundreds of billions of dollars of overseas corporate taxes and this is the biggest public health crisis of our times and it affects one in four Americans; why not say that we’re going to spend one in four dollars in repatriated money and put it into this, the biggest public health epidemic of our time and let’s build the infrastructure because you’re hearing from everyone that we don’t have the workforce out there.  We don’t have the availability out there.  We don’t have the telemedicine out there.  Let’s build that out and with that—

Jordan:            What does that look like?  There is an epidemic and everyone knows it.  There’s some encouraging things that there’s bipartisanship in a town, in a country that can’t agree on anything.  You are talking with Newt Gingrich on one of the panels you’re on, right?

Kennedy:        Yes.

Jordan:            And you are with Chris Christie and Donald Trump’s brother had problems with this.  So this is—

Kennedy:        That’s what I’m saying.  This doesn’t know any partisan boundaries, okay?

Jordan:            Okay, and people are talking.  It’s money that we have to watch where if some of these programs are gutted, someone this morning said that $91 billion—

Kennedy:        $91 billion for opiates within the ACA.  If the Republican plan plans to substitute it with a $45 billion path of really basically what the ACA provides to opiate treatment over 10 years.  Half the dollars, at a time when this epidemic is getting worse, not better.  But going back to the bipartisan aspect of this, Speaker Gingrich and I are pushing for a $10 billion “brain bond,” which can be paid for by slowly reducing the costs that are incurred from brain illnesses because of increase in understanding and research of newer therapies.  That’s the kind of marring both conservative and liberal points of view because again, coming back to the dollars, if we were to put the real price tag on this epidemic, we would be including the increase in child welfare costs.  We would be increasing police time, adjudication time, correction time, prison time, parole time.

The enormity of this crisis as it relates to a number of different budgets, but what CBO and JO have not done is they’ve not quantified across many budgets what this epidemic is doing in terms of its cost to society.  If you took the true, honest, zero-based budgeting on the true costs, I think you could justify to Republicans that it’s smart to have an entitlement where you can track efficacy and quality.  Republicans should be about outcomes-based metrics.  We ought to be about ensuring that we get our quote-unquote “money’s worth” and we’re not paying for what works today and we should pair up with Republicans and say, “Listen, you want to get accountability.  We want to get more people covered.  Let’s get together on this.”

Jordan:            So, so far, Republicans and Democrats are certainly talking about this.  They’re certainly saying, on both sides, this is a massive issue.  They’re like this when it comes to how much money to spend on it, right?  At least through the federal government.  Where in your discussions is there kind of hope that they’re something in agreement?  Is it finally to get rid of the stigma?  I noticed that people keep calling it a brain disease.  And your hashtag is, right?  Tell them what it is.

Kennedy:         #ForBrainHealth.

Jordan:            And stop talking about it like it’s some moral problem, as somebody earlier today said, right?  Where are you seeing agreement?  Where are you seeing the road forward?

Kennedy:         Yeah, but when you’re active in your illness, you do a lot immoral things and that’s why people are looked down upon and that’s why those of us who have been blessed to be in recovery talk about this as a three-fold illness, a physical allergy, a mental obsession, and a spiritual malady.  Because if we’re acting against and hurting other people, we’re hurting our own chances of living in recovery because we all are subject guilt.  We all have consciences and I think we that we need to have the active participation of the medical community.  I was just with Reverend and Kay Warren.  Fantastic people, purpose-driven life.  They lost their son to these illnesses and most churches have no way of talking about these things.  I was asked by my Catholic church, St. Thomas in Brigantine to speak about these issues.

I was denied communion by my bishop in Rhode Island for not having the right kind of set of Catholic checklists.  And yet now, I’m getting messages from the bishop that I’m doing great work and that my parish priest thinks I’m great and I’m there on Sundays.  I don’t know what the point is but I just had to say that.  [LAUGHTER]

Jordan:            But I think one point there is that times are changing.  Everyone is touched by this and people are getting it more and at least that is a step forward.

Kennedy:        I just get approached everywhere.  I often say when I came back from rehab after crashing my car in the capital and everybody knew I was addict-alcoholic, no one else in Congress knows who we are.  But because I was in the newspapers all the time—so when I got to the floor, you would be amazed at how many of my colleagues grabbed me to pull me off the floor of the House to tell me their own stories because they didn’t know amongst all of my other colleagues which one of us was in recovery or struggling with a mental illness or addiction.  And so it was a real eye-opener for me that in this room, there’s a number of us who have been suffering.  There’s a number of us who have already gotten our 12-step meeting in for the day and there’s many of us who also understand, as I do, that it took both medication-assisted treatment and 12-step recovery for me to have the longest period of stability and sobriety in my life.  So it’s not as if it’s one or the other.  But the whole advocacy community is at each other’s throats because the 12-step folks think the MAT is an abomination.  All of the scientists say, “Yeah, but all of the evidence says that MAT, medication-assisted treatment is what is called for with this opiate crisis and we have a scant application of MAT across the country and two-thirds of the rehabilitation centers don’t even practice MAT and yet we’re paying for them.”

And they’re in violation of all of the American Society for Addiction Medicine practices and Wilson Compton can tell you, Nora Volkow can tell you.  I mean, if we’re not offering MAT for an opiate addiction, you’re not providing what the scientists tell you works.

Jordan:            I’ve got to ask you because your father devoted his whole life practically to healthcare and when we see what’s going on now, what do you think he would think about the GOP plan and ripping up Obamacare now and then we’re going to talk about what that means for addiction.

Kennedy:        Well, my dad just believed—he watched my brother Teddy in the early ‘70s get treated for cancer and he was standing in the same children’s ward as all of these other parents who were hoping their own kids could get the treatment, who had to discontinue the treatment because they didn’t have the financial wherewithal.  And I found out later on in my life how many families came up to me and said, “Your father paid for all of our kids’ treatment”—after my brother was released.  Because it was something that he couldn’t abide by the fact that he simply because he had the money, could pay to save his son’s life but the other parents could not save their children’s lives.  He just said, “There’s something morally wrong about that.”  And so this wasn’t a policy.  This was a principle and I think he would just say, “How can we?”  And we could go all into the economics that it doesn’t actually make sense to cut people off because we know they come back through the doors sicker and more costly and we all end up paying for it as a surcharge on our insurance, for those of us who are fortunate enough to have private insurance.

But it’s an inefficient way to treat people through these ERs.  The better way is to cover them and do the prevention that I spoke about earlier.  But taking all that aside, it’s just about treating others as you would want your own loved one to be treated.

Jordan:            And then when it comes to addiction, since you know what you’ve been through and how hard it is, what does a good prevention program look like?

Kennedy:        Wilson Compton could tell you, there’s terrific resiliency, coping mechanism, problem-solving skills that can be brought into education.  Keep in mind, we focus on numeracy and literacy with our children, but we do not focus on emotional strength, resiliency, problem-solving skills.  The very things that they’re going to need in order to be successful.  So our education system really isn’t purely designed to produce the most effective and capable students.  So I would say that we have to do social and emotional learning.  It’s got to be in every class in America.  And this isn’t soft science.  There’s a lot of data out there showing it reduces the dropout.  It actually improves scores in some of the worst, most violent sections of neighborhoods in this country where they’ve tested mindfulness and other things, coping mechanisms.  They find that kids’ scores go up dramatically because their amygdalas are not firing because they’re fight or flight mode, which is what’s going on in the brain if they come to school and there are gunshots and their mother and father is incapacitated from drugs, alcohol, or in jail.

These kids have a lot that they’re bringing to school.  We need to help prepare them and—

Jordan:            I’m looking at a few questions on Twitter.  A lot of questions on Twitter, but several of them about marijuana.  What do you think about marijuana?  As places around the country now are legalizing it.

Kennedy:        I just don’t want it targeting kids and when you look at the products that are being produced by the new big tobacco, it’s gummy bears with—red, white, and blue gummy bears.  It’s like elixirs.  I don’t know if you guys know what elixirs are.

Jordan:            gummy bears with marijuana in them?

Kennedy:        Yeah, THC.  I’m not talking about the smoked kind.  That’s benign.  I’m talking about the kind you put in your e-cigarette.  We all see folks with their e-cigarettes around here.  A dab of this high THC concentrate, but it’s mostly the edibles.  Yeah, there’s all kinds of them.

Jordan:            And you think they’re more addictive?

Kennedy:        Well, first of all, I think we already have seen the dramatic increase in use amongst teenagers.  At the same time that the use of tobacco is going down, thanks to great public health efforts.  Imagine in this country, we’ve done all this work reducing tobacco use—bless you.  [LAUGHTER] Now, we’re like, “Ah, this is no problem.”  And again, it’s the targeting of kids.  So I think we should have an impartial panel of medical experts just reviewing the products that are being sold out there and putting a stop to those products that clearly have a higher penetration amongst kids.  We should all be in agreement that kids should not be using this stuff because it affects their developing brains, because it puts them at risk for all kinds of other addictions, including opiate addiction, and it affects their mental health dramatically.

And if more people use—I know there’s a certain percentage that have a predisposition to having a mental illness for addiction.  Guess what?  That percentage goes up if the larger population of those using goes up.  So we just have to be very conscious as a nation what we’re walking into as a nation with the quote-unquote “legalization”.  But I think it’s the commercialization is the problem and there’s no way public health is going to be able to keep pace dollar-for-dollar with the enormity of the budgets that the big marijuana corporate folks are going to have to market this stuff in all kinds of ways that I think is going to jeopardize all our best prevention efforts.  There’s one thing we can do, but we’ve got big marijuana just flooding with different ads that it’s medical and all the rest.  If it’s medical, then let it go through the usual medical process.  Don’t be selling something out of your basement and, “Oh, it’s medical.”

Don’t know what’s in it, no way of telling you how it might be spiked.  Don’t have any sense of whether it gives you the relief that it’s supposed to give you, but it’s medical.

Jordan:            How many kids—you have four kids now?

Kennedy:        Four kids.

Jordan:            Four kids and three under the age of four or something?  You have a lot of little ones, right?  [LAUGHTER]

Kennedy:        Yes.

Jordan:            So thinking about these little—

Kennedy:        That’s why I’m fixated on gummy bears.

Jordan:            Yeah, okay.

Kennedy:        [LAUGHTER] And I’m not kidding.  Kids pick this stuff up and put it in their mouths and it’s happening.  The poison control—

Jordan:            But as we look to all our kids and it’s tough now.  It seems to be it’s tougher now be to a kid than it ever was.  There’s more stuff on the market.  There’s more everything.  What would you do to fix one thing across the country to make it better and easier for kids today when it comes to addiction?

Kennedy:        Well, I think look the whole family.  If your parents are in crisis, your kids are going to be in crisis.  We can’t think of this as separate issues.  My first bill signed into law was called the Foundations for Learning Act.  It never got voted on in subcommittee, full committee, or even on the floor of the House, but somehow, it because of federal law.  It had nothing to do with the fact that my dad was chairman of the Conference Committee on Education.  [LAUGHTER] So he airdropped it in and basically, it said that if parents need support, support the parents because you’re going to end up helping the kid dramatically if the parent can get the support they need.  If the parent is a wreck, I don’t care what you do for the kid, the kid is going to have a tough time.  And we have to understand with this opiate crisis—the last thing I’ll say is there is a secondary effect of this opiate crisis and that’s all the kids now who have grown up with these family members who have suffered and died as a result of this crisis.  And let me finally say—suicide has not been talked about much at this forum but you cannot divorce the suicide rate from the opiate overdose rate and both of them are way underreported because a quarter of all coroners in this country are elected and there’s no standardization for medical examiners, if you can believe it in this country.  So everything you saw—if it weren’t Carrie Fisher, we would have thought she died of sleep apnea.  She had the extraordinary circumstance of being an uber, uber-celebrity, so we found out everything else that was going on.

We have no clue what the true suicide rate, overdose rate is here in this country.  And not to be too startling, but as I said from the beginning, we’re in denial in this country if we think we can micromanage this a little bit over here and we put a little block grant for opiates over here.  God bless Senator Portman for pushing for that.  But this is along the margins.  We are moving chairs on the Titanic is our current approach to this issue.  We need to fundamentally come to a different approach for how to deal with mental illness and addiction and stress management and mental health in this country.  Unless we celebrate it, support it, through the whole healthcare system, encourage it, pay for it, reimburse for it, all of these other costs, you’re going to be playing Whack-a-Mole.  Diabetes is going to go up.  Cardiovascular disease is going up.  All of this hypertension is going to go up.  Suicide is going to continue to go up.  We have to make this a national priority if we expect to do anything to help change the nature of this illness and actually make a dent in the future suicide and overdose rates.

[APPLAUSE]

Jordan:            Well, I couldn’t think of a better way to wrap up an amazing morning.  Thank you for being so frank and honest and I think a lot of people here are delighted that you’re on the White House Commission and I guess they’ll be hearing over there that they’re rearranging chairs on the Titanic or the country is.  The focus on family, the focus on stopping the denial.  I’m very grateful and on behalf of The Washington Post and Washington Post Live, thank you all for listening here in the audience and those online and we’re going to be putting up clips from today at WashingtonPostLive.com and more comments about this whole amazing morning.  Thank you and thank you, Patrick Kennedy.