Governor Christie:
Welcome, good Morning. Welcome to
the next meeting of the President’s
Commission on Combating Drug Addiction
and the Opioid Crisis. I welcome the members
of the Commission who have joined me
here today. Congressman Kennedy,
Governor Cooper, Governor Baker,
Professor Madras, thank you for being here. And to all of you
who have come here today to help bring greater
clarity to this issue, we appreciate you
all being here. I want to first turn
things over to our — I love this title, Designated
Federal Officer. It sounds important,
Michael, you know. So, make it be important. Michael Passante
from ONDCP, who is our designated
federal officer to do the orientation and then we’ll begin
the meeting. Officer Passante:
Thank you, Governor. I would like to welcome
everyone to the fourth meeting of the
President’s Commission on Combating
Drug Addiction and the Opioid Crisis. The topic of
today’s meeting is insurance issues related to
the opioid crisis. On the
Commission’s website you can find the agenda
for this meeting, minutes and videos
of past meetings, and a copy of
the Commission’s internal report. That’s at
www.whitehouse.gov/omdcp, and there’s a link there to the
President’s Commission. The Commission plans
to hold its fifth and final meeting here on Wednesday,
November 1st from 1:30 to 3:30 PM,
Eastern Time. It will issue its final
report at that time. That final meeting is
will also be livestreamed on www.
whitehouse.gov/live. The public is also
invited to submit written comments for the Commission’s
consideration by emailing them to
[email protected] So, I’d like to thank
Chairman Christie, the Commission members,
Richard Baum, the Executive Director
of the Commission, and Secretary Shulkin, Secretary Acosta,
Secretary Hargan, and Deputy Attorney
General Rosenstein, and other Federal Agency
representatives and the witnesses. And with that,
I will hand it back to Governor Christie, Chairman of the
President’s Commission. Governor Christie: Michael, thank you
very much. Welcome to everybody. The Commission members
have been working hard on our final report, which will be issued
on November 1st. I want to particularly
thank Professor Madras, who as I announced
at the last meeting is taking
the laboring war on drafting this report, and I can tell you from having read
early portions of it, this is —
this is a report that I think will not
only be comprehensive in terms of its
recommendations to the President
and the Administration, but also extraordinarily
instructive in terms
of how we got here, which is an important
thing to — for this Commission
to acknowledge. 64,000 deaths
in the United States from this crisis, and a crisis that
has been, in my view, self-inflicted. You know, if we had
64,000 Americans being killed
in some other way, I think that the reaction would be
significantly different than it has been, leading up to
the establishment of this Commission
by the President. I think the President
has acknowledged by establishing
this Commission how extraordinarily
important this issue is and how devastating it
is to American families in every state
in this country. And so, I want you
to know that every one of the members of this
Commission are taking this extraordinarily
seriously, and I can’t thank
Congressman Kennedy and Governor Cooper,
Governor Baker, and Professor
Madras enough for their extraordinary
hard work. And we’ve got
a lot more to do and a lot more to read,
and a lot more to decide in the next
11 days or so. So, I thank all of them
for their hard work, and thank you all
for being here. We are fortunate to have
a number of people from the
President’s Cabinet and his Senior Staff
here today to talk to
the Commission a bit, and then we have
some other folks from the private sector who will be
talking as well. So, we’re — we’ve got
a very full agenda. So, we’re going
to get right to it. I want to start
with the person who is the President’s
point person on this in the White House. She has been
indispensable to me as the Chairman
of this Commission in being able to get
the resources of the White House
available to us to be able to do the
things that we need to do to make this report meaningful
for the President and meaningful
for the Country. And so, Kellyanne Conway, Counselor
to the President, thank you for your
incredible hard work, and the folks
on your staff. And I turn the microphone
over to you. Counselor Conway: Thank you
very much, Governor and Chairman and members
of the Commission, thank you again
for your hard work. We anticipate
the final report and we’re
all looking forward to finding the best way
to implement that administration-wide. It is no accident that members
of the Cabinet are here and stand ready to act
on those recommendations fully as we move forward
on an issue that really is touching
every area of America. This is no longer
someone else’s coworker, someone else’s community,
someone else’s kid. This is affecting
everyone everywhere. And we are, as an
Administration, as a White House, beginning with
the President and now the First Lady, putting a very
significant effort behind
educating Americans as to the crisis
next door, the epidemic next door. And we believe that everyone is affected
by the problem. We will be calling
upon Americans to join in
on the solution. I would note publicly
that a week from tomorrow
is National Take Back Day that occurs two
times a year. So, on October 28,
National Take Back Day, the more that everybody
— members of the media, thank you for
connecting America with the information it
needs in this regard — the more people
can make folks aware that they can bring back
unused prescriptions, no questions asked,
to any number of places. It’s run by the DEA, but I would like to
publicly urge folks to think about that and to encourage others
in their circle of life, family friends,
colleagues, coworkers and the like to join
and to participate there. I had occasion last week
to tackle and to witness
a different aspect of this crisis that we’ve not really
touched upon here very much, which is, I traveled
with First Lady, Mrs. Melania Trump
to Huntington, West Virginia,
to Lily’s Place, a first of its kind
center in this nation where they’re doing
tremendous work in administering care to newborns who are born
physically dependents on opioids and other
drugs sometimes. And it was remarkable
to see intervention, treatment and recovery among our youngest
victims of this crisis. So, without taking
anybody else’s time, I would just like to thank
everybody for being here, including representatives
of the insurance industry to find out
how best your role fits in us
moving forward, identifying the problem,
finding the solutions. Thank you very much,
Mr. Chairman. Governor Christie:
Thank you, Kellyanne. I appreciate
it very much. Another person
who has been an extraordinary
resource and advisor in the White House, both for the Commission
and for the President is the President’s
Assistant for Intergovernmental and Technology
Initiatives, in the Office of American Innovation, Reed Cordish. Reed and I
have known each other for a long time, and he has been
an incredible help as well to
the Commission. So, I turn the microphone
over, Reed, to you. Reed Cordish:
Thank you, Governor, and thank you to the
Commission for your work to date and for
your upcoming work leading to the final
report on November 1st. Governor, you’re right
that it is important to look
at how we got here. If we’re going to
fix the problem, we need to understand
how it came to be. And this is a problem
that has been building in this country
for over a decade. And it’s a problem
whose trajectory is truly startling, and it’s a problem
that deserves the absolute
highest attention of the government
and of our citizens. And clearly, the creation of the President’s
Commission is a signal of that, as is the President directing his Secretaries
and our offices, our sub-cabinet
to treat it as one of
the highest priorities of the Administration. Men like Director
Collins of NIH and Director
Gottlieb of FDA, Secretary Shulkin
of the VA are personally handling
their agencies and their office’s
response to this epidemic. And the Administration
has been moving aggressively, based on recommendations
of the interim report and recommendations of
our cabinet secretaries. To give some examples,
the FDA has been engaging aggressively
with clinicians to change their opioid
prescribing behavior, to prevent addiction
before it starts, and they’ve been
working to develop over-the-counter Naloxone
for overdose reversal, and taking steps
to protect public health by removing dangerous
drugs from the market where the public health risks outweigh
the benefits. NIH has placed it as an
absolute top office objective to come up and work
with the private sector to come up
with better cures and better pain
addiction medicines. The Department of Justice
has placed it as a priority, funding 50 million
for drug courts and alternatives
to incarceration for addicts, and the President
has placed a priority on securing our borders
to prevent illicit drugs from flowing
into our country. And then, lastly, the
Administration has called for the largest
single sum ever dedicated to
the opioid crisis in the form of state-
targeted response grants totaling
485 million dollars. We eagerly await
the final report. It has
our highest attention and it’s going to — we know that to solve
this problem we have to deal with it
in a holistic manner, and that’s what
we intend to do. But thank you very much. Governor Christie: Reed,
thank you very much. Appreciate your help
and your comments today. Myself and
Congressman Kennedy traveled with
Kellyanne Conway to visit the Louis Stokes
VA hospital in Cleveland Ohio. It was a really
eye-opening visit and it was coordinated,
organized, and led by the Secretary
of Veterans Affairs. So, for Secretary Shulkin
we thank you for the extraordinary
amount of time you’ve already invested
in the Commission’s work including that trip
to Cleveland. And I turn the microphone over to you Secretary
Shulkin for remarks. Great. David Shulkin: Thank you,
Governor. I also wanted to join in and offer
my sincere gratitude for all the work
of the Commission. I watched the way that you’ve dealt
with this issue. You’ve taken it
seriously. You’ve brought great
public attention to this
much-needed issue. And I think all
of us eagerly await your recommendation so that we
can implement it with an aggressive
time frame. This issue, of course,
is very important to VA; 50 percent of returning
combat veterans suffer from chronic pain
and acute pain, 50 percent — close to 50 percent
of our older veterans suffer from chronic pain. And so VA has addressed and begun to address
this issue starting back in 2010. And I think VA has two
particular contributions that we hope may be
reflected in the report. The first is what
we’ve done so far over the last seven years that has resulted
in a 36 percent reduction in opioid use, and that is in VA
if it is meaningful it has to have
an acronym, so our acronym
is STOP PAIN. S is for our stepped
model of care, T is for our
treatment alternatives like complementary care, O is for ongoing
monitoring usage, P is for our practice
guidelines that we’ve put out
with the department in the defense, the second P is for
prescription monitoring, the A is for
academic detailing, the I is for informed
sense for patience, and the N is for
naloxone distribution. We think that’s
a multi-faceted way to address this issue because no one — there’s not one easy
solution out there. So, we certainly
are very pleased to have been able
to share our experience of what we feel
has worked. I think the future
of where VA is investing is in a new way
of delivering healthcare and that’s what we call
the whole health model of healthcare. And this is really
empowering our veterans with the decision-making to make the best choices
for themselves and to really own
and be accountable for their own
health care. So, under this model
what we’re doing is we’re bringing
in groups of veterans at the beginning of their
entry into the VA system in a peer-to-peer
approach and teaching them how to be more
knowledgeable, informed, and empowered
in being responsible for their own navigation
of the healthcare system. And in this we’re
teaching them tools that are very helpful
particularly in pain management like the use of
complementary therapies, mindfulness, and how to ask
and be informed in the right questions. so, we believe that part
of the future solution should include
a holistic approach to navigation through our complex
healthcare systems, because I think
Governor as you said, this is really a symptom
of the failures of the American
healthcare system, the gaps in care, the
fragmentation in care, patients not in
some cases trusting too much these
decisions to other people and then they
become addicted. So thank you very much. Governor Chris Christie:
Secretary Shulkin, thank you. A decade ago I had the opportunity
to work as a fellow United States Attorney
with Secretary Acosta. He in Miami and me
in New Jersey. And I grew to have
great respect and affection for Alex and was thrilled when
the President named him to be Secretary of Labor. And very happy to have
the opportunity to have him here today. Some of you may wonder, why is the Secretary
of Labor here? There’s a whole bunch
of crossovers for labor that you’ll learn
more about today. And we have a person
who I know knows how to take a very
aggressive approach to solving problems. As our labor Secretary,
we’re lucky to have him. So turn it over to you,
Alex, for remarks. Alexander Acosta:
Governor, thank you and it’s nice
to recall the day when you I and Rod
here were US Attorneys and so it’s great to be
working with you again. As you mentioned there, there a number
of crossovers. And I’d like to approach
the opioid issue from three
different perspectives because the Department
of Labor looks at this
as a workforce issue, but we also have about
two million individuals through the workers
compensation programs for whom this is an issue and we’re also
a regulator and enforcer vis-a-vis
insurance policies. And so I’d like to take
each of those in turn. First
as a workforce issue. Nationally,
our unemployment rate is four point
two percent. That is amazingly low, the lowest in nearly
seventeen years. So, that’s great news
on the one hand. On the other hand,
labor force participation has been dropping
since 2007. And it is a fairly
low number. And so one of
the questions is why? Why are so many people
not in the labor force? And I want to answer that
by citing the chairman of President Obama’s Council
of Economic Advisers because I really
do think opioids should be
a bipartisan issue and I want to cite him to sort of create
bipartisanship around us. He recently came out
with this study. And he looked at a Bureau of
Labor Statistics survey, the American time
use survey that found that forty four percent
of prime aged males, males twenty-five
to fifty four who are not working had taken a painkiller
the prior day. Not the prior week,
or the prior month, but the prior day. Forty four percent of
males outside the labor force in prime
working years. And so he said this is
a very high number. So let me do a more
in-depth survey. And he went back
and he asked what kind of painkillers
did you take and he found that a high
percentage of them, two-thirds of those, had taken prescription
pain medication the prior day. So in essence 31 percent
of prime aged males not in the labor force took prescription
pain medication the prior day. Now there
are approximately 94 million Americans not in the labor force. What number of those
are men? And of those 31 percent the prior day took a
prescription painkiller. So if we want to look
at labor force participation rate, this is the number
one issue. And that’s according
to the prior chairman of the President’s
Council of Economic Advisers,
he estimated that 20 percent
of those individuals not in the labor force
were not in the labor force because of opioids. Secondly, the Office
of workers compensation. Through the OWCP, we cover more than two
million federal employees and others through our Office of workers
compensation program. And so as a result, you know we can set
parameters and we did something
this past June. We required
prior authorization and a letter of medical
necessity for opioids. We had
a very quick spike. People wanted to get
their prescription before we required this. And then a massive
drop-off. A very very sharp drastic
drop off to almost none. Now it’s going to come
back up a little bit and we’re waiting
to get the data because we just put this
in place two months ago. But something as simple
as prior authorization and a letter
of medical necessity, among these two
million individuals, has changed behavior
substantially. And I think that’s
something that’s worthy of consideration and we’re
keeping the data. And by December I think
we’ll have enough time that has gone by that we’ll have good data on how much
this has impacted. But that really does
tell you information both about the necessity and how small actions that government can take can have
substantial impact. Thirdly, EPSA which is
one of our sub agencies the employment benefits
sub agency. And EPSA has jurisdiction
to maintain, to enforce the parity law
that ensures that Americans receive
benefits they’re entitled to with respect
to substance abuse. And EPSA works very hard. It’s cited more than
300 individuals, 300 employers
for non-compliance. And so it is enforcing
this non-parity law. But there are two points
that I want to make. One under the non-parity
law there are no civil fines. and so those that have been
an enforcement understand you can cite someone
for non-compliance but if there is no fine,
you know, I’m a big believer
in compliance assistance, I’m a big believer
in the carrot, but along with
compliance assistance and a carrot you have to
have a negative outcome if folks don’t want
to work with you, right? And so there is no fine. The second point
I’d make about the way that this is enforced, is it is enforced under current
law employer by employer. And so we’ve actually
gone to several insurance companies in this room and we’ve worked with you
and you have assisted us in making sure that your
employers are complying. But we have
no enforcement authority as against
the insurers themselves. And so we’re having
to go employer by employer by employer, as opposed to the much
more efficient approach which is to work directly with the insurance
companies that have thousands and
thousands of employers that they’re working with to ensure
that there is parity. And so I want
to highlight that because as the Commission
does its work it’s something
that I think the Commission
should consider, what is
the most efficient and effective mechanisms? And finally, let me say
I think the vast majority of folks want to do
the right thing here. And I think if there’s
an issue here, it’s an issue around
lack of knowledge, lack of sort of
thinking it through, because people want to do
the right thing. Because you know reducing
the number of opioids is a win-win
across the board. It’s a win
for the individual who doesn’t want
to get hooked and once they’re hooked
they want to get off it. It’s a win for the
insurance companies who don’t want to be
paying for medicines that people don’t need. And it’s a win for
the American workforce. Because if we can get
people back to work and paying taxes and participating fully,
that’s a win for them and it’s a win
for the country. And so, I thank you
for your time and I thank you
for your focus. Governor Chris Christie:
Alex, thank you and I think
that the two issues that you pointed out
in your third point are ones that are of not
only particular concern to the Commission
but most particular concern to
Congressman Kennedy. and so I would hope in
the in the period of time we have left that you
and the department would be willing to work
with congressman Kennedy as our designee
to drill down on those and make sure that if
there are recommendations the Commission
wants to make, they’re ones that are
in line with your departments desires and your ability
to be most as you said effective and efficient. Alexander Acosta: Gladly. Governor Christie:
Thank you. Appreciate that. Next, Acting Secretary
of HHS Eric Hargan. Eric, thank you
so much for coming. We appreciate
it very much. And obviously HHS is a huge part of dealing
with this issue. And so turn over to you
for remarks. Eric Hargan: Thank you,
Governor. Obviously, HHS I could probably spend the rest of the time you have here
just going through the list of things
that the roles that HHS has to play
in combating the opioid crisis. We have a number
of sub components that are going to be — that are and continue
to be very active in all different aspects
of addressing this. We have overall strategy. but we also have
within our components National Institutes
of Health have been obviously
very active in developing treatments and treatment modalities
that can address it in the individual
clinical level. We have SAMHSA, our substance abuse and
mental health services administration
that sort of front center in dealing with issues
of substance use and an abuse. So,
and they have developed a lot of innovative
practices. and the new head
of SAMHSA is someone who
is sort of — comes from
the entire background in fact having been
at SAMHSA before as chief
medical Officer having worked
at the state level on a number of different
aspects of this issue, is kind of is, pretty much
an ideal leader for this for SAMHSA
for this exact issue. And she’s also been
a practitioner who was dedicated to the issue of substance
use and abuse. So from her point of view she actually comes with
a clinical background in this exact area. So we’re actually pretty
fortunate to have her as one of the leaders
of one of our agencies, one of the ones it’s
going to be most forward facing and public
facing for this issue. also we have
the FDA obviously, which has also
been targeted as one of the main
response agencies for us dealing also
with developing not just with helping
sort of industrialize and bring to use
and bring to the bedside the treatments that are
going to be developed by private sector
as well, and also helping
to work with DOJ as they always end up
on the front line in terms of interdiction
in many cases of and finding out
where we get shipments in and issues
on that front. We also have HRSA
which runs a lot and funds a lot
of the places where the opioids
we think are accessed. So down in
the communities, the community
health centers and areas definitely are going to be part
of the solution here and HRSA’s monitoring
on this. And even well
of course CMS and that the payment that
Alex was referencing. obviously CMS
is the largest payer and either
through Medicare or through its
partnership with Medicaid and working with the
state Medicaid agencies to work on how
we can address that not just from the medical point
of view at NIH, not from the product
point of view at FDA, not through this,
the actual addressing of the substance
abuse through SAMHSA but also through
the payment issues that,
as Alex pointed out, it can be pretty central
to finding out where and how
we can address this. And also in fact
monitoring where it’s being accessed and where it’s being — where we’re having
real problems with opioids
being taken up. In fact I can’t name
a component of the department that doesn’t have
a role to play here. even the Office of
the National Coordinator health IT
has been working with some of
our other agencies and the state agencies
to help develop, work with software that’s
going to monitor easily where we get
prescription drug use particularly
across state lines, where we have people
sort of going across state lines and through
the PDMP plans that we’ve developed
on that front. So, as I say I will
I will keep it as short as that because I don’t think — I think we could spend
all day here with me walking
through everything that we’re doing at HHS. Thank you. Governor Christie: Secretary,
thank you very much. Appreciate you being here
and know that HHS is going to be
an enormous part of our ability to deal
with this problem. And appreciate you
recognizing that as well. continuing the Bush
43 US Attorney alumni roll call, I turn to the
Deputy Attorney General of the United States,
Rod who spent 12 years as the US Attorney
in Maryland and did an extraordinary
job there, and is now has what
I’ve always believed the most difficult job in the Department
of Justice, which is being the
Deputy Attorney General and make sure that the
running of that Office is ended all of
its components. And so he has
extraordinary responsibility
for law enforcement across
the entire country. And we are in very
very good hands with that authority
and that responsibility being with Deputy Attorney
General Rosenstein. So, Rod it’s good
to see you again. Turn it over to you. Rod Rosenstein: Thank
you, thank you, Governor. I did have a great
fortune to work with you and Secretary Acosta
in the aftermath of the September
11 terrorist attacks many years ago. We then worked together
as US Attorneys on project
Safe Neighborhoods which brought
historic reductions in violent crimes. So we know the impact that law enforcement
can have and your New Jersey
State Police in fact have been
a leader in developing
a comprehensive program to combat opioid abuse. So I know firsthand
the tremendous leadership that you bring
to this effort and I want to thank
the Commission for your commitment to helping us
solve this problem. The opioid crisis
is a result of three types
of substances. The first is prescription
painkillers, which get a lot
of attention. The second is heroin, which has long
been a problem. And the third is a
relatively new phenomenon known as fentanyl, which is a synthetic
opioid drug. there’s no doubt
that over prescribing pharmaceutical drugs is a primary contributor
to that opioid crisis but today we face a new and disturbing facet
of the crisis. More and more
of our citizens are being killed
by fentanyl. The synthetic opioid
is far more lethal far more dangerous
than heroin. More than
20,000 Americans died of drug
overdose deaths in 2016 with fentanyl
in their systems. And we believe
that fentanyl, imported from China, is a primary cause
of the recent surge in opioid
overdose deaths. In addressing the role
of pharmaceutical drugs, in the opioid crisis
we must be cautious about unintended
consequences. For example, medically
assisted treatment certainly can help people
defeat addiction but the most
common medications used in treatment are also opioid drugs, which are prone to
abuse and diversion. We have reports about
treatment clinics that themselves can
resemble pill mills. But because treatment
is so important in solving this crisis we need to be vigilant
to prevent bad actors from hijacking
that system and exploiting
the solution to the opioid epidemic. The use of medication assisted treatment
in jails and prisons poses
unique challenges. Incarceration gives us
an opportunity to keep prisoners
from abusing drugs and to prepare them
for a drug-free life on the outside. Several cases prosecuted
in my home state of Maryland highlight the risk
of diversion and abuse of opioid drugs
like suboxone, which also is
highly addictive. So treatment
is important, but treatment alone
is not the solution. We need to focus
on prevention. If you want to stop cars
from speeding, you can post speed
limit signs, you can
run advertisements about the risks
of speeding, but the most important
and effective form of prevention is to actually
enforce the laws. And the Department
of Justice specializes in law enforcement. Enforcing our laws
helps to prevent unlawful prescribing of highly
addictive drugs, and thus the creation
of future addicts. It also helps
to keep heroin and illicit fentanyl
out of our country and away
from our children. Opioid addiction
is different than most public
health problems because it doesn’t
spread on its own. Fentanyl reaches victims only if people
produce it in labs, people ship
it across borders, and people
distribute it to users. So we can stop it
if we prevent and disrupt any one of
those pathways. Drug overdose deaths rose by about 50 percent
from 2011 to 2016. But federal
drug prosecutions fell by 33 percent. Aggressive enforcement
of our laws is an essential part of the solution
of this crisis. But consistent with
President Trump’s goals, Attorney General Sessions
is committed to restoring
federal drug enforcement. We are not
devoting resources to prosecuting low-level
drug dealers. We are focusing
on disrupting drug supply chains. The department
recently announced the largest
healthcare fraud takedown in
American history. We arrested more
than 400 defendants including doctors and
medical professionals. We also created
an opioid fraud and abuse task force. This is a unit
that’s committed to investigating
and prosecuting opioid related health
care fraud. And we recently
dismantled the largest internet website that was committed to and used for the sale
of illegal drugs. Most fentanyl
comes from China. And we’re taking steps
to disrupt that supply chain. I visited China
last month and met with
leading Chinese law enforcement officials
to discuss what we can do working together to disrupt
Chinese manufacture and distribution
of fentanyl. On Tuesday, the Department of Justice
announced, for the first time, charges against
Mae Chinese traffickers of fentanyl. And in September,
our department announced almost sixty
million dollars in grants for state and local law
enforcement, state local treatment
of opioid abuse. So the Department
of Justice is fully engaged
in this effort and I want to thank
the Commission for your commitment
and your efforts on this initiative
the Department of Justice looks forward
to continuing to work with you to protect
the American people from the devastation
of opioid abuse. Thank you, Governor. Governor Chris Christie:
Rod, thank you very much. I want to thank
all the members of the President’s
senior leadership who gave remarks and I hope that
you’ll all stay with us. I want to give
our invited guests an opportunity to make their remarks
as well. And then give Commission
members the opportunity to ask questions of all of the folks
around the table that have contributed
remarks today. So I thank
the President’s senior leadership for being here,
for your efforts. First, I want to go
to Marilyn Tavenner. Marilyn is
the President CEO of America’s health
insurance plans and I turn over to you. Thank you for
being here, Marilyn. And I turn it over
to you for remarks. Marilyn Tavenner: Thank
you, Governor Christie and members
of the Commission for inviting us
here today. And thank you
for your leadership in this very
severe problem that we are
all interested in immediately
addressing. I won’t go back
through the statistics because I know that the
members of the Commission know them as well
as anyone in this room. And so I’ll not
repeat any data. But what I’ll do
is go directly to the commitment
that the health plans have to helping
solve the problem. And it is something
that we worry about both from the standpoint
of our role in between employers
and the community, our role
in between employers and their
individual employee, and this is going
to take action by all the individuals
that you have here today, if we’re going
to dramatically reduce this problem. So let me start about
some of the action steps that we have taken. We’ve been engaged
both at the federal and state level
with leaders, with doctors
and hospitals, with community
organizations, and many others. And I think
it’s important that this is as much
education and support as it is about
prescription control. So we have looked
at other ways of treating chronic pain that work that are not
just a substitution of one drug for another. We tried to understand
the crisis and develop strategies working
with our communities in order to address it. We’ve tried to understand
prescribing patterns and how they may
affect dependence on an addiction and ensure patients
struggling with addiction get the treatment and
the support they need. we support —
let me start by saying, going back to HHS, we support the CDC
guidelines from when and where
to prescribe opioids which also includes
prescribing non-opioid medication first, limiting both
the dosage and the duration
of prescription opioids, and reviewing a patient’s
medical history to look for signs
of addiction. We also support
and review the latest
medical research to find better ways
to manage pain and adopt new evidence
into developing coverage policies for pain
management treatment. Our plans have robust
checks and balances in place to ensure that patients
get the right medication and the right dosages
and these include things like building high
quality provider networks and I cannot stress
that enough. If you’re dealing
with quality physicians and pharmacies than
some of the problems that law enforcement
talks about go away. So we work with
credentialed, doctors, pharmacies
and facilities. We have a sequenced
approach which guides patients through evidence-based
pain management before prescribing
an opioid. We do require prior
authorization for opioids so plans clinical experts can work with their
individual physicians to ensure that
they are adhering to evidence-based
protocols and offer the most
effective treatments. And when the opioid
is prescribed, we work to do
the lowest dosage and shortest duration to effectively treat
the individuals plan. We also analyze
their data to try to identify
potentially concerning prescribing patterns that trigger
further review. We’re making progress
and we strongly agree that more can
and must be done, and that’s why our teams
are implementing programs that work at finding
new solutions. And I go back
to Secretary Shulkin. We released initiative
yesterday called STOP, not STOP PAIN, but STOP. So we are aligned. Yes. Our STOP stood for
safe transparent opioid prescribing, and this initiative
really supports a widespread adoption
of clinical guidelines by all of our plans with the idea of
making sure that we’re following
guidelines for pain care and for reviewing
prescribing. our first piece
of this obviously is making sure that
we have data available on how plans are adhering
with provider practices that match the CDC
guidelines because that’s
a good place to start and if you can get
all the physicians and all the plans
supporting that, that goes a long way. We’ve also engaged with
Pew Charitable Trusts and Shatterproof to discover new ways
to improve treatment for those with substance
use disorder. And I know that we have
many leaders here today and so I’m going to
make my comments short. But I will say
I think we have some of the brightest
people in this room, they represent plans
across the country, large CEOs of
health plans, small CEOs physicians
who serve as chief medical Officers,
pharmacy directors, and government
and state relations. And so I hope
that we’ll give you some good ideas today. We all agree that this
has not one solution, it’s a multi-faceted
approach. We’ll need more research
to find alternative ways to treat pain. We need more
pain specialists which gets back to the
HRSA and workforce issue. And we need
more providers who are equipped
and well trained to help those going
through the treatment and recovery process. We are actively engaged with social
service agencies, State Medicaid programs,
health care providers, pharmacists, and
pharmaceutical companies to find more solutions. Again, we appreciate
this opportunity to engage today. I look forward to
the questions, thank you. Governor Christie: Marilyn,
thank you very much. Appreciate it. Next to Pamela Greenberg. Pamela’s a President CEO
of the Association for behavioral
health and wellness. We appreciate you taking
the time to be here today and look forward
to your remarks. Pamela Greenberg:
Governor Christie and members
of the Commission, thank you for
inviting me here today. As the Governor said, my
name is Pamela Greenberg and for the last 19 years I have served
as the President and CEO
of the Association for behavioral
health and wellness. ABHW member companies provide
specialty services to treat mental health,
substance use, and other behaviors
that impact health and wellness to over
170 million people in both the public
and private sector. Our members include
both specialty behavioral health organizations and health
insurance companies. I’d like to start
by reminding everyone that addiction to opioids or other substances
is a chronic illness, not a bad habit
or a failure of will. If we can shift
the public’s perception and eradicate stigma associated with substance
use disorders, we can make progress in helping people
feel comfortable, sharing their
personal stories, and seeking the
treatment they need. ABHW
and its member companies run a campaign stamp
out stigma and the goal
of that campaign is to do just that. ABHW and its members
are committed to helping defeat
the opioid epidemic. our members work
to identify and prevent addiction
where they can, and where they can’t
they help individuals with an opioid
use disorder get the appropriate
treatment to recover and lead full productive
lives in their community with their families
and loved ones, today, I will
highlight three areas our member
companies focus on to address
the opioid crisis. I will also touch
on a few ABHW’s recommendations to the Commission
for your final report. All of our
recommendations are included
in my written statement that I’ve submitted
for the record. First, the identification
of individuals at risk of opioid
dependence is a critical step in helping stop opioid
overdose and death. To do this, some ABHW members employ
drug utilization review programs. These programs
flag members who are being treated
for opioid dependence but are still filling
opioid prescriptions. DUR programs notify
a pharmacist when individuals are also filling opioid
prescriptions at another pharmacy or have prescriptions
for other drugs that may have
a counter interaction with their opioids. Other companies
analyze claims data to detect opioid
use patterns that suggest possible
misuse by individuals and then they reach out
to the person or notify their health
care provider about the situation. Second, we are all
painfully aware that there are
an inadequate number of qualified substance
use treatment providers. ABHW members build
provider networks in a manner
that helps ensure that they have capacity to meet the needs
of their consumers. Some companies have also
found peer services and community supports to be useful
in helping people engage and remain in treatment. At least one member
company partners with project Echo, a tellement
mentoring platform that link specialists with non-specialists
through virtual clinics. The specialist mentor
helps educate providers about the latest advancements
in evidence-based care and improves access
to treatment. And third every 25
minutes a baby is born suffering from
an opioid withdrawal. ABHW member companies follow established
standards of care for newborns with neonatal
abstinence syndrome. One example
is the company that identifies
pregnant women with a substance
use disorder and engages them
in case management. If allowed the infant
is also followed for at least a year. Our first recommendation
for the Commission relates to 42 CFR part 2, an outdated regulation
that limits the use and disclosure of patients’
substance use records. This regulation
severely constrains the healthcare
community’s efforts to coordinate care for persons with
substance use disorders. And ABHW members say Part two
is one of the biggest, if not the biggest
barrier to fighting the opioid crisis. We urge the Commission to
support aligning Part two with the treatment
payment and healthcare operations
language in HIPPA through a legislative fix or pending
regulatory guidance. Second, very few
states permit Medicaid managed care
organizations and private health plans
access to prescription drug
monitoring program data. If allowed access, these entities
could identify patients at risk of overdose
or complications and become a strategic
partner in preventing and identifying abuse. The Commission should
instruct each state to have a PDMP which health plans
can access and which
allows information to be exchanged
across straight lines. The creation
of a national PDMP would also be useful. Excuse me. Third, ABHW recommends
easing the burden on primary care providers willing to prescribe MIT. Development
of educational resources and additional training will help make PCP’s more
comfortable with MAT. Another idea is
to provide incentives to encourage PCPs to take care of their
own opioid dependent patients. Fourth, the standard
of care for opioid use disorder
is to treat the disease with a combination
of medication and evidence-based
psychosocial interventions. As such, ABHW suggests
creating a mechanism to ensure providers
are practicing in accordance
with national standards, such as the American
Society of addiction medicine national
practice guideline. Finally, given the rise
in the opioid epidemic and the growing shortage of
behavioral health providers, the expansion
of telehealth is an important option for the Commission
to consider. A significant barrier
is the Ryan hate act. ABHW recommends making
changes to this law to eliminate the requirement
face to face evaluation. Additionally, removing
the restrictions to Medicare reimbursement
of telehealth would provide better
access to treatment to Medicare
beneficiaries. Thank you
for the opportunity to speak to you today. We hope that you will
include our recommendations in your final report. And we support the goals
of the Commission and we are committed to working
with interested parties to help eradicate
the opioid epidemic in this country. Governor Christie:
Pamela, thank you very much. Thank you for
your recommendations. And you can be assured
that we will give it a real consideration as we put together
the final report. Next I want to turn
to some of our other invited organizations and the folks who are
here representing them. We first want to say
how much we appreciate you all taking the time
to be here today and to share your
experiences with us. Very very important
for us to be hearing from as many
constituencies as possible on this because it’s going to take all
of us to deal with this problem. I want to turn first
to Dr. Harold Paz who is the executive vice
President and chief medical Officer
of Aetna. Our — as you can tell
from our folks today, our insurance companies
are going to be a very
very important part of whether we’re able
to stem the tide here or whether we’re not. So we’ll turn over
to you Dr. Paz. Dr. Harold Paz: Well
thank you very much, Governor Christie and members of the
Commission for the work that you do
in bringing attention to the opioid
abuse epidemic and for pulling together
a diverse set of healthcare
stakeholders to identify
and propose solutions to this terrible crisis. I appreciate
the opportunity to share and this perspective on this critical
public health issue. I serve as the lead of Aetna’s enterprise-wide
opioid task force. Aetna is a leading
diversified health company that provides
individuals, employers, and health care
professionals, and others with
innovative benefits products and services and we serve over
46 million individuals in the United States
and around the world. Aetna’s strategy is to
build a healthier world and to help individuals
achieve their unique health ambitions in part by addressing
the holistic needs of each individual
physical, mental, and social well-being. Addressing holistic
needs for our members is even more important
when we look at those that are afflicted
with addiction and behavioral
health concerns, which is why
I’m proud to say that Aetna is committed
to working tirelessly to help reverse
the devastating trend of opioid addiction
and abuse. Aetna’s taking
a comprehensive and holistic approach to addressing
the opioid epidemic. Our three prong
strategy is focused on preventing
misuse and abuse, intervening
when we identify at risk provider
and member behavior, and supporting members
by providing access to evidence-based
treatments. In order to protect
our members and assist those struggling
with addiction to regain their lives and to restore
their dignity, we’re holding
ourselves accountable as a company
by committing to three ambitious
data-driven goals. By 2022,
we’re committed to one, increase the percent of
members with chronic pain treated by
an evidence-based non-opioid option by 50 percent. Second, reduce
the percentage in appropriate opioid prescribing for our
members by 50 percent. And third, to increase
the percent of members with opioid abuse
disorder treated with medication
assisted therapy and other evidence-based
treatments by 50 percent. Consistent with
the Commission’s recommendation for greater
provider education, Aetna’s taking
a proactive approach working with providers
to reduce opioid prescribing
misuse and abuse, and we’re using
considerable data resources to encourage prescribers
to reduce misuse and prevent diversion
of unused pills. Starting in 2016,
I began sending letters to the top one
percent of opioid prescribers within their
respective specialties to alert them to their
prescribing pattern. These 1000 opioids
super prescribers were also provided
the CDC guidelines regarding appropriate
opioid use in the treatment
of chronic pain. This program
continued this year with separate outreach to dentist
and oral surgeons. In May we identified
and sent letters to more than 700 super prescribing dentists and oral surgeons. This effort was
in collaboration with the
American Association of oral and maxillofacial
surgeons. We’re now rerunning
our analysis and planning more
aggressive interventions for those providers
who haven’t improved their opioid prescribing habits over the past
several months. For most of our members,
opioids should not be the first choice
for treating pain. We’re working to
encourage our members to explore alternatives
prior to taking opioids. That includes
ensuring our products appropriately cover
evidence-based non-opioid
treatment options and working
with stakeholders from across
the healthcare ecosystem to incentivize greater
options for consumers. This past month, we
announced a partnership with an innovative
new jersey-based pharmaceutical company and the American
Association of oral and maxillofacial
surgeons to provide an alternative to opioids
for our dental members following wisdom
tooth extraction. By providing
safer alternatives for pain control, fewer opioids
are prescribed, and we avoid
the risk of misuse and diversion
of unused pills. We cannot simply reduce
generic opioids with abuse
to turn opioids. We need to promote
holistic treatment options that include
non-opioid therapies such as non-steroidal
anti-inflammatory drugs, acetaminophen, as well as non-pharmacological
modalities such as physical therapy,
acupuncture, and chiropractic care when medically
appropriate. The federal government
has a critical role to play in addressing
this epidemic. First, we believe
that federal legislation and regulations should be modernized
to provide health care organizations the flexibility to
confront this epidemic. We strongly support
the Commission’s recommendation to modernize
privacy regulations, 42 CRF part 2
to allow greater data sharing and coordination to prevent
opioid overdoses. Current part
2 regulations prevent health plans and providers from
sharing information needed to treat members
with addiction. Furthermore,
the federal government should provide greater
resources to States to support programs addressing neonatal
abstinence syndrome. Newborn babies are the
most vulnerable victims of this terrible
epidemic. The federal government
can play a role in increasing attention
and resources to ensure
that pregnant women are screened properly
for opioid abuse and treated
for opioid addiction and that newborn babies
with NAS receive the care and support that
they desperately need. We also believe
more can be done to prevent inappropriate
practices, fraud, waste, and abuse. This includes requiring
electronic prescriptions for all opioids, developing a national
prescription drug monitoring program, and providing health
plans greater flexibility in the Medicare program to crack down on
inappropriate practices. And finally, it’s important
to recognize that as we reduce the supply
of prescription opioids, we’re not solving
the addiction crisis. Where there’s demand
for opioids, there will be supply
in the form of illegal manufacturer, fentanyl as you heard
earlier, and heroin. That is why we need
to focus on expanding the number and quality
of addiction treatment options, and with the support
of the federal government greater
law enforcement action to reduce the supply
of illegal drugs. Aetna is committed
to working to reverse
the trend of opioid use and abuse
across the nation. We’ll continue
to enhance our program to reduce opioid
prescribing, increase non-opioid
pain treatment options, and promote
evidence-based recovery for our members
with addiction. We look forward to
continuing the dialogue with the Commission
and other policymakers to find solutions
to this epidemic. Thank you again
for your leadership and thank you so much for
having Aetna here today. Governor Christie:
Thank you very much. Appreciate your remarks. Want to turn next
to Joseph Swedish who’s the chairman
President CEO of Anthem. Joseph Swedish: Great,
Thank you, Governor Christie and distinguished members
of the Commission. It’s an honor,
truly an honor to be with you today to discuss how we can
collectively work together across the
entire healthcare system and beyond to
combat drug addiction and address
the opioid crisis. With over 1.8 —
excuse me. With over one
in eight Americans served by our
affiliated companies with whom we work
closely to manage their health care, we’ve built programs upon
a foundation of quality to improve
their outcomes. with this
underlying approach to a major
healthcare issue, I’d like to share just a
portion of the extensive actions Anthem is taking to
address the opioid crisis a crisis that crosses all
demographics and impacts commercial Medicare
and Medicaid programs and one that
we are meeting head on through our
holistic strategy, centered around
prevention, treatment, and recovery,
and deterrence. Just last month
we announced our success in reducing opioid
dispensed to our members by 30 percent from the
historic peaks in 2012, more than two years
earlier than forecasted. But we’re not
stopping there. And we’ve just substantially
increased that goal. We’ve aligned
our pharmacy benefit strategies with CDC guidelines limiting an initial short-acting
opioids prescription to 7 days and put in place
prior authorization for all long-acting
opioids. Treatment and recovery
work hand in hand and our approach
extends beyond traditional medications and care programs. Many individuals
facing addiction also have coexisting physical and mental
health conditions. So we’re working to
provide integrated care for all of our members. Non-opioid
pain management is truly a component of a holistic approach. We support coverage
of pain relief drugs and non-drug treatments according to best
clinical practice guidelines and scientific evidence
including CDC guidelines. There are many
non-opioid approaches that we cover both
non-opioid medications and non-drug
treatments alike. We don’t require
prior authorizations for the use of naloxone, a life-saving
emergency drug and we’ve eliminated
prior authorization for certain drugs used in medication
assisted treatment. We’re working to double
the number of members who receive medication
assisted at treatment along with the behavioral
health support services and we’re improving
access to medication assisted treatment in rural
and underserved areas by providing
technical assistance and training
to providers. So, there’s at least
one medication assisted treatment trained physician in each
primary care practice. In this regard, I want to
emphasize the importance of taking evidence-based
character providers by way of training and then paying providers
to do the right thing which we do
through a variety of value-based
payment arrangements. We’re supporting peer
recovery services through partnerships
with organizations like aware
recovery services in Connecticut
and New Hampshire who provide comprehensive
in-home substance use disorder
treatment services. we’ve also
extended access to care and treatment
through telehealth, live health online
our telehealth program permits individuals
to access physicians at any time of day
365 days a year, and now includes opioid
disorder treatment and medication-
assisted treatment through our partnership
with bright heart health, who provides
online addiction support services
for substance abuse. We’re accelerating
best practices in local communities such as funding and
supporting and extension for the community
healthcare outcomes project
in West Virginia, which connects
primary care providers with expert medication assisted treatment
information to treat individuals with substance
abuse disorders. And we’re partnering
with NICU facilities and their providers to
establish care practices that follow established
standards of care for newborns with neonatal
abstinence syndrome which occurs in newborns exposed to addictive
opiates in the womb, while encouraging
non-pharmacological treatment
parental involvement and protocols to decrease
the severity of systems and improve outcomes. As part of our efforts
to address the fraud and abuse element
of the opioid epidemic
through deterrence, we operate a pharmacy
home program across our commercial
fully insured and Medicaid lines
of business. This program
assigns individuals who meet certain criteria related to opioid
utilization to one pharmacy
and one provider to receive their opioid
prescriptions. This program allows
physicians to monitor for dangerous
combinations of medications and access to opioids and help ensure members
are receiving counseling and mental
health support. We’ve seen this program
reduce hospital and emergency room
admissions, increase the number
of individuals in substance abuse
treatment in some states, and reduce cost of care. We also have a range
of strategies that leverage data mining
and analytic capabilities to identify and address
instances of opioid fraud and abuse
as well as diversion. Anthem’s special
investigative unit contains a team
of professionals trained to combat fraud
and abuse utilizing variety
of methodologies. Well we’re proud
of our success. We recognize
we can do more and should do more
to address this crisis. As we look
to further expand our collective efforts, we recommend
the Commission consider the following. First, work with
stakeholders to address the shortage
of qualified substance abuse disorder treatment
providers and licensed health
care professionals trained to support
individuals with substance
abuse disorders in the community utilizing
evidence-based models. Second, continue
to develop more tools to educate patients with chronic
and painful conditions on proper use of
pain medications given the lack of
accessible pain medicine specialists and trained
primary care providers. Third, invest
more resources dedicated to research for establishing more
evidence-based treatment guidelines and innovative
payment models. and finally, improve data
and health information sharing to facilitate
better care which would include
changing 42 CFR part 2 to align with HIPAA which will allow
addiction history to be shared amongst
treating providers, permitting Medicaid and
commercial health plans to access prescription
drug monitoring programs and sharing Medicare
fee-for-service Part A and Part B data with standalone Medicare
prescription drug plans. Thank you for
the opportunity to share
our thoughts today with you to address
this crisis. I look forward to
more discussion today as well as continued
work partnering with all of you
going forward. Governor Christie:
Thank you, sir. Appreciate
that very much. and as I continue
to be unfortunately the monitor of time here, I want to try
to remind everybody who’s going to present
stuff to us today that you know
we asked everybody to kind of give us
their highlights and give us five minutes. I’ve got, I think,
another seven representatives
I want to hear from before we get to ask
you any questions. So I don’t want any of us to wear each other
out in the process. Kim Holland is from Blue Cross Blue
Shield’s Association vice President
for state affairs. Thank you for
being here, Kim. And I turn over
the microphone to you. Kim Holland: Thank you,
Governor Christie, members of the Commission
and honored guests. I lead our system-wide
efforts to respond to our country’s
opioid crisis. It is indeed
one of the most pressing issues of health facing our nation today, and our own data
bears that out. Our recent health of
America report on opioid prescribing which is
being made available to the Commission reveals
that our blue members diagnosed with an opioid
use disorder spiked 493 percent
between 2010 and 2016. On behalf of
the Association, thank you for
the opportunity to join in this discussion. Blue Cross and
Blue Shield companies are strongly committed
to doing our part to combat the epidemic
of opioid use disorder. We very much appreciate the actions
you are taking to bring all stakeholders
to the table as it will take all of us
working together to bring about the needed
systemic change. You’ve heard from
Mr. Swedish of Anthem and we’ll hear
from Dr. Anu Patel of Blue Cross Blue Shield
of North Carolina, two of the thirty-sixth
plans within our system who are leading and engaging
in collaborative initiatives to address this crisis in
their local communities. Just as States
needs will vary, plan initiatives
will vary in response. However,
since early 2016, blue plans have convened their mental
and behavioral health medical and
pharmaceutical experts with a shared goal
of adopting policies and practices that ensure appropriate
opioid prescribing, promote evidence-
based treatment for substance
use disorder, and reduce
the occurrence of fraud and diversion
of prescription opioids. As evidence of this
unified commitment allow me to offer
a few examples that speak to some
of the Commission’s interim report
recommendations. We support provider — prescriber education
initiatives. Blue plans have endorsed
the CDC guideline for prescribing opioids
for chronic pain and are working
collaboratively with the prescriber
community to implement these
or similar guidelines. For instance,
Blue Cross Blue Shield of Massachusetts has instituted a program
which implements best practices for prescribing opioids including,
among other practices, a treatment plan
B the patient and prescriber outlining
responsibilities and behaviors
on both sides. A CDC study has
praised the program finding that it lowered the average monthly
rate of opioid prescribing by
15 percent. And Dr. Patel
will tell you about their successful prescriber
outreach program in North Carolina. We support access to medication
assisted treatment. Blue plans cover
medically necessary MAT and the associated
counseling or behavioral therapy. Plans recognize
substance use disorder as a chronic disease that should be
treated as such. Plans work
with physicians to ensure patients
get the right care in the right setting
at the right time based on each
patient’s individual needs and circumstances. And we’re funding
research in hopes of uncovering
new insights that will lead
to better treatment and prevention efforts for substance
use disorder. We support wide
availability of naloxone. Blue companies cover
naloxone for members and medical claims
for naloxone have increased
significantly over time. Additionally,
many plans provide community funding
for naloxone ensuring access
to all who need it. As one example over the
last two years capital BlueCross in Pennsylvania
has committed a total of two hundred
thousand dollars to fund the purchase
of naloxone for municipal
police departments. And we support
enhanced operability of prescription drug
monitoring programs. We encourage additional
support to states that would improve
the effectiveness and ease of use
of PDMP systems. Currently 37 states and mandates some type
of prescriber use under some circumstance. However, not all states
allow physicians access to PDMP data
before prescribing, and only one
state permits health plan access
to PDMP data. I would echo Miss
Greenberg and suggest that during
the inevitable evolution of improved data
sharing health plans can serve
as another resource, analyzing PDMP patient
data in conjunction with a plans own provides a full picture of prescription
drug utilization. Although blue plans
carefully monitor opioid use and potential misuse, there is a limit to what
our data can tell us. For instance
if someone pays cash for a prescription drugs a claim is not generated. Access to PDMP data
will fill in these blanks and more effective interactions
with physicians to ensure a patient’s
safety as well as appropriate treatment. We support legislation
to better align patient privacy laws specific
to addiction with the Health Insurance
Portability and Accountability Act. The Association joined
over 35 healthcare stakeholders, stakeholder organizations
in a letter urging Congress
to support Jesse’s law and amend 42 CFR part 2
to align with HIPAA privacy regulation access
and use requirements. And we support
mental health parity and addiction equity. We believe all Americans
should have access to high
quality affordable health care and coverage. Plans are vigilant
in their compliance with the MHP, AEA and offer
comprehensive benefits that include access to evidence-based
mental health and substance use
disorder treatment. We have strongly
opposed changes to any existing law that would erode
comprehensive health coverage and not provide
robust mental health and substance use
disorder benefits. In closing, Blue Cross
Blue Shield Association and member plans
share your commitment to addressing
America’s opioid crisis and ensuring that those suffering
with opioid use disorder get the care they need
to place them on a path to recovery. Thank you so much. Governor Christie:
Appreciate it very much. Now we’ll turn
to Dr. Anur Patel who is the medical
director from Governor Cooper’s home state
of Blue Cross Blue Shield of
North Carolina. We are happy
to have you here. And appreciate
your willingness to give us some information
today, Dr. Patel Dr. Anuradha Rao-Patel: Good
afternoon and thank you to the members of
the Commission and everybody here
for having us here from Blue Cross Blue
Shield of North Carolina as part of this
important discussion. As Governor Christy
mentioned my name is Anur Patel,
I’m a physician. I’m board certified
in physical medicine and rehabilitation. Prior to joining Blue
Cross of North Carolina I was in private practice
doing pain management and treating addiction
with medication assisted therapy. I feel uniquely
positioned and fortunate to be here because I’ve
seen the devastation from the opioid
crisis from both sides, both as the provider prescribing
the medications and treating
the addiction as well now as
from the payer side. I’m currently on the BlueCross
BlueShield Association level workgroup which is
chaired by Kim Holland. I’m also chairing
an internal workgroup within our North
Carolina plan. I’m also still
clinically active. I continue to see
patients in addition to my primary role
at Blue Cross. Quickly, in General
about our North Carolina plan we serve close
to more than four million customers
throughout our state. We’re in every zip code
of all 100 counties. We’re our state’s
largest health insurer. We feel very passionate
about the opioid issues because our state
has four of the cities that are in the top
cities in the nation affected
by opioid issues. At Blue Cross Blue Shield
North Carolina, where we’ve heard
this word go around the room
about holistic approaches we do support a holistic
well-rounded approach. We use support and endorse
the CDC guidelines both on an association
level and a plan level. We also support
recent legislation passed this summer
called the STOP Act which Governor
Cooper signed into law. Some of the provisions limit initial
prescriptions for opioids and requiring
providers to check the controlled
substance registry. In terms of our
local plan efforts we have analyzed
and we continue to refresh our data
and analytics which were developed to
understand claims data, opioid prescribing
patterns, outlier providers, costs. We have expanded
our telemedicine program to include
additional codes specifically
for mental health. We work
with our providers in a
collaborative manner. We do view our providers as an extension
of our plan. They are
their providers’ patients but they’re our members. We have provided webinars
on CDC guidelines, on stop back legislation, on the North
Carolina medical board continuing medical
education requirements for prescribers
of opioids. We have sent
numerous letters to providers educational. We have targeted
outlier providers in a very
neutral fashion. We have posted blog posts
on appropriate prescribing
CDC guidelines. And all of these
have actually been well received
by providers. As you can imagine
they’re out in practice busy all day
seeing patients, so we’ve tried to create
an information one-stop-shop
for all of them. In terms of member
education our care
management nurses have been trained
to target members who have opioid
dependency or identify
substance abuse. They make direct proactive outreach
to these members in a way that’s engaging
rather than intrusive. We’ve encouraged them
to have conversations not just about, I’ve noticed you’ve got
a prescription for do you know
how to take it, but do you know what to
do with your medications when they’re
no longer needed? Do you know what signs
or symptoms are of addiction? Do you know how to store
these medications properly in your home? And encouraging them
to even have the conversation
with the provider as, do I even need
an opioid for this? In terms of our
pharmacy initiatives, we have an actionable
point-of-sale message that alerts the
dispensing pharmacist if a member is filling
both an opioid and concurrently
medication assisted treatment medications
such as suboxone. There are currently
quantity limits on all long-acting
opioids. We have Narcan
nasal spray as well
as the injectable — self-injectable vial on
a preferred generic tier. Prime Therapeutics, which is our pharmacy
benefits manager, continues to send
quarterly reports to the members
as well as providers, providing information
on suspicious high-risk
prescription histories. We have partnered
with Walgreens Pharmacy, both at an association/
national level as well as
within our state, to take back —
have drug take-back kiosks
throughout the state. We currently have 20, which will be across the
state of North Carolina, and we’re providing funds
for an additional 22. So our goal is to get
these medications off the street and out of bathroom
medicine cabinets in our members’ homes. So based on our activities
thus far, we believe that we have to take
a comprehensive approach, starting with preventing opioid misuse
and addiction before it begins, improving
addiction treatment, adopting stronger
integration of behavioral health
and pain management, building stronger
community partnerships. We believe the public
and private sectors should work
collaboratively to balance standardization
of approach while also allowing
for local flexibility in developing solutions.
We also believe, along with a lot of my
colleagues that mentioned this, that health plans need
the continued ability to utilize pharmacy
management tools and services to monitor
and prevent overprescribing
and diversion with broader
access to PDMP. And finally, just to
quickly highlight some of the ways we’ve
worked collaboratively, we’ve worked on
an association level on the Substance and — Substance Abuse and
Mental Health Workgroup. I recently met —
we recently went to D.C. and testified at DHHS to the Senate
Finance Committee. We’re involved in
a collaboration called WeCare. We have enlarged — enlisted our national
accounts, labor industry experts. We’re using them
for dialogue and advisory for primary
and secondary prevention. We’ve worked with the
North Carolina Department of Health
and Human Services. We served on
the Prescription Drug Abuse
Advisory Committee. We are on
the Payers Council. We’re key
payer stakeholders within the state
of North Carolina. We’re coming together to
improve health outcomes. We’ve had
several meetings with the Secretary of Department of Health
and Human Services. We are also meeting with in-state drug treatment
facilities and Department of Health
and Human Services to improve treatment
within our own state rather than having
members go out of state, as well as targeting
key entry sites for referrals such
as emergency room and primary care
physicians. We are — we have worked with the North Carolina
Medical Board. They’re having statewide continuing medical
education panels. We will be serving
on those panels. We’ve provided
input on the STOP Act legislation
I mentioned earlier. We are collaborating
with the medical board on how to manage these
outlier prescribers. We are also meeting and
working with the North Carolina Attorney
General’s office. We have a meeting
again in December to work collaboratively and share our internal
workgroup efforts. Finally, nationally,
we have participated — I’ve participated on
the National Appalachia Initiative through the
Bipartisan Policy Center under Senator Tillis, where we gathered
educators, business dealers —
business leaders and advocates to come up with innovative solutions
for many issues, including
the opioid crisis. And locally,
we are working on multiple state panels, as well as sponsorships
to raise awareness, to educate
on opioid addiction and opioid use disorder, taking away the stigma,
educating our providers, educating our members, and joining
forces together. So with that,
I’ll conclude, and I would like to
thank you for your time. And I would also
like to say that we would like
to continue to partner and collaborate
with others, both on a state level as well as on
a federal level, in helping solve
this problem. So thank you. Governor Christie:
Thank you, Dr. Patel Appreciate your
presence here today and your thoughtful
remarks very much. Dr. Douglas Nemecek is the chief medical
officer for Cigna. We appreciate you
being here, sir, and look forward
to your remarks. Douglas Nemecek: Thank you,
Governor Christie. Good afternoon, and thank you to all the
members of the commission for the opportunity
to be here today and talk about the opioid
crisis that we’ve heard is killing
so many Americans, but also is
killing careers, killing families, and
killing our communities. At Cigna, as a global
health services company that serves
95 million relationships around the world,
we’ve seen the impact that opiates
has every day. And we’ve recognized
really, as we’ve heard from
some of my peers today, the impact is
really threefold that we want to address: first, prevention
and education to keep people
from getting addicted in the first place. We want to improve
care and treatment around pain and addiction
of patients who are already sick, and we want to make sure
that we reduce and eliminate the stigma around substance
use disorders so that we’re free
to talk about this in our communities
the same way we talk about other
chronic health issues and chronic disease. Cigna came out
18 months ago and was proud
to make a commitment to reduce commercial
opioid use by 25 percent. Within the first year, we were successful
at getting halfway there, and we’re getting
very close to that full 25 percent
reduction already. But that’s only
the first of our goals. Without repeating
some of the things that we’re doing that are
similar to what others, I want to highlight
just a couple of things that we’re doing
that I think are a little bit unique
or different that haven’t
been mentioned. First, in our partnership
with physicians around the country, we’ve worked to
encourage the use and following
CDC guidelines. But we’ve also worked
to have physicians sign a pledge with us to pledge to
reduce opioid use and join us
to start talking about opioid
use disorders as a chronic disease. We’ve had over
270 physician groups representing 65,000-plus
physicians sign that pledge
to work with us. And then working
with them, we’ve created a playbook of what they’re doing
in their communities that are best
practices around how they work
with their hospitals, their emergency rooms, and their physician
partners in the community so that we can share
that information with other physicians
across the country and hopefully allow
those best practices to be implemented
elsewhere as well. We’re working very hard with building
our network, too, around
making sure access to substance use care
is available — growing a medication-
assisted treatment network by 35 percent
this year and also making sure
that through eliminating prior authorizations for medication-assisted
treatment and services, as well as increasing and placing
prior authorization on long-acting and short-acting
opioid prescriptions, that we’re encouraging
patients to seek care where it is
most appropriate. We’re also focused
on working directly
with our customers who do have issues
with opioid use disorder and chronic pain. We’ve expanded our case
management programs such that not only are we sending
information to physicians
to alert them to their prescribing
patterns in patients who look to have
high-risk prescriptions, but we’re outreaching
to the patients directly so that we can engage
them and educate them on appropriate
pain treatments, alternative
pain treatments, and alternatives
to the opioids and hopefully prevent
them from ultimately having potential
overdoses in the future. Lastly, as we’ve
looked at this, understanding that
we can’t be the solution ourselves,
we’ve focused with partners
in the community. We have partnered
with Shatterproof across the country, and even had 100
of our Cigna employees participate in their
fundraiser in Hartford, Connecticut earlier
this year. We’ve also taken steps
this year to partner with the Iran
and Afghanistan Veterans of America group to try to address some
of the unique aspects in the veteran community
across the country, which we heard
about earlier today. And later this year, we’re opening up
a dedicated hotline that will be open
to all veterans, regardless of whether
they’re Cigna-insured or not, to help provide
support and services to those veterans. So I will wrap up
with that. Certainly, we look
at this as the first step in reducing opioid supply
across the country. It’s a necessary step,
but it’s not sufficient to truly fix
the epidemic. We need to provide
holistic and integrated care. And as a psychiatrist, I’d need to add
that mental healthcare is an important
piece of this. We’ve seen the studies
that show 50 percent
of opioid prescriptions are written
for patients who have a comorbid mental
health disorder as well, so we don’t
want to forget, as we talk about fully
integrated and holistic care, the importance that
mental health plays. So as we all work together to find
these solutions, again, thank you
for the time today, and look forward
to continuing to work with you. Governor Christie:
Doctor, thank you. Thank you
for your mention on the mental health
aspect as well. Dr. Michael Sherman is from Governor
Baker’s home state, Harvard Pilgrim
Health Care. We welcome you here —
senior VP and chief medical
officer — and thank you
for your time. Michael Sherman:
Thank you very much, Governor Christie
and commissioners. I represent
Harvard Pilgrim, which serves over
1 million members in Massachusetts, New Hampshire, Maine,
and Connecticut. We have a strong culture
of supporting the community and working
collaboratively with all stakeholders. We’ve all seen
the impact of opioids on our members,
on our communities, and we really want to be
part of the solution. Let me also add, in the
way of abusing anyone of stereotypes,
I’m a physician. I trained
with individuals, I worked
with individuals, some of whom are dead
from opioid overdoses, some of whom had
their careers destroyed. These are people
who understood, intellectually,
the dangers. I assure you, they were
the people who, in college, were studying
on Friday nights, not out partying. So if it can happen
to people like that, it can happen
to any of us, and we really need
to take this seriously. We are — we’re actually
fortunate that we have, in our largest state,
Massachusetts, a multi-stakeholder
group, the Governor’s Opioid
Working Group. Through this task force, working with all
the stakeholders to agree on solutions that can be put
in place with clear and coordinated
messaging — and again, that’s
really important. Health plans sometimes
are not seen as being the best
arbiter of solutions, and by having
everyone approach this together
with a common goal, we can put these
things in place with less pushback. We also operate, though,
in three other states. And having each state
come up with their own practice can be confusing
and create deterrents. So we strongly urge
the commission to look at best
practices across states and come up with national
guidelines that we can — that we can all adopt. This is a scourge
that doesn’t know any state borders. An example of something
that we’ve implemented has actually emerged
from the Mass. workgroup, which is a
first-in-the-nation law which said
that individuals, adults getting new prescriptions
for opioids, were limited to seven
days for the first fill, and for minors,
for all prescriptions. And for anyone,
they had the ability to ask the pharmacist for something less
than a full fill. And we think we’d like
to see that proceed nationally. And I want to stress, if we’d done that just as a health plan, I think we would have
gotten pushback. Some examples of changes
that originated within our health plan: we do cover naloxone without any
prior authorization. But we don’t
just cover it. We’ve eliminated
any cost share, because we don’t think
that cost should be a deterrent to having
these medications handy. We also, like, many,
cover all sorts and all types
of medication-assisted treatment, again, without
prior authorization. We do cover methadone
maintenance, which in many areas
is covered through public programs. We thought it
important to add it. And when we learned that,
in some cases, individuals had
daily copays because it’s
a daily treatment, we eliminated the cost
share on that as well. We also look at the cutting-edge treatments that are out there. There’s a company, actually, based in Princeton, New Jersey that has an implant,
implanted buprenorphine, for substance abuse
for six months. By implanting,
it eliminates diversion. It eliminates people
not being adherent. As soon as it came out,
we made it available as a benefit
to our members. Again, no prior
authorization, no restrictions. If people need it,
they need to get it. And we all need
to be looking at these newer therapies and working rapidly
to make sure that our members
have access. We’ve also heard today
about the importance of non-narcotic options
for the treatment of pain,
such as acupuncture, to reduce the use
of opioids. We cover acupuncture,
but we go a step further, and we’re actually
working with some large employers to create on-site clinics so that their employees
have easy access to acupuncture and other types of care. We’re also working
to broaden access to newer modalities: yoga, therapeutic yoga,
mindfulness, et cetera. There actually are
published studies that indicate
the benefit of those for certain individuals,
and there actually are specialists
in those areas who work primarily
with pain patients. So it’s important
to make those available. We believe that abuse-
deterrent formulations are part of
a comprehensive solution, but not a panacea. We’re revealing
how best to incorporate these into our
management approach. And for example, based in
Massachusetts Chapter 258, we’re ensuring that these
formulations of opioids are covered in a manner that does not
disadvantage them or make them
more expensive than the non-abuse — than the abuse-deterrent
formulations. We’re also considering
innovative contracts with pharma companies that better
align incentives with respect to the
impact of their products that are awaiting
guidance from groups such as this
and the Massachusetts task force before
moving forward. I would note that there are limited number
of manufacturers making abuse-deterrent
formulations, so we urge the commission
to provide guidance that will assure that
the products are priced in a manner that makes them
available to all who need them. One other thing we do
which is somewhat unique: we have
a quality grant fund which goes back
many years. Over the past few years, we’ve tried to focus
on medical groups that can use these funds
to help address the opioid crisis. An example
would be a grant we gave to Maine
Quality Counts, which works with
many medical groups, and they have a law there
that requires physicians to taper those patients who are on
high-dose opioids. We gave them a grant
to help with education, access to experts
virtually, and other resources —
training, et cetera — so that they can
actually do that. I’m proud to say that
thanks to these efforts and those
in the community, the number of scripts
for opioids per member are down 21 percent
since 2014 to today. Again, that’s not enough. And this feels
like a balloon where you attack
one part, it comes out
somewhere else. So it doesn’t mean
we’re even close to solving this, but it does show
we can make a difference. Some of the challenges —
and these are not new, so I’ll be brief —
as you’ve heard, health plans
do not have access to prescription drug
monitoring programs. I can look them up
as a physician, but I can’t share them
with our pharmacists. Again, physicians
are required in many states
to query these before writing or filling
a prescription, using this information
to help us get a comprehensive
picture and determine early on where people are
at risk and engage. Similarly, you’ve heard
about 42 CFR Part 2. Again, I would ask
the commission to work to repeal that. Again, that’s something
that was put in place with best intentions to
protect people’s privacy, but the reality is
that if we have data that suggests that
there’s a problem, we cannot reach out to a member’s
primary care physician and make them aware. That clearly is
in no one’s interest. One other comment
I would make is that lack of consensus as to best practices
can lead to friction among providers, patients, policymakers,
and health plans. We believe
that clear guidance from this commission
can really help get us around
all of those barriers. And finally, thank you
for being here, and I appreciate
your listening. Governor Christie:
Dr. Sherman, thank you. Some really
interesting things that have come
out of your work in Massachusetts
and New England. Appreciate you
being here. Dr. Edward Ellison is the executive
medical director at the
Southern California Permanente Medical Group. Thank you for coming. Look forward
to your remarks. Edward Ellison: Thank you,
Governor Christie and distinguished members of the commission
for the opportunity to provide Kaiser
Permanente’s perspective in helping to combat
the opioid crisis. This is a difficult
and deadly issue that unfortunately
touches us all. I am Dr. Ed Ellison. I’m a family
medicine physician who also has
the honor of serving as co-CEO of the
Permanente Federation — in that role, representing the
21,000 Permanente physicians who provide care
for 11.8 million members of Kaiser Permanente
in eight states and the District
of Columbia. Kaiser Permanente
is a coordinated, integrated
healthcare system consisting of
a health plan, hospitals, and physicians all working together
in partnership for the benefit
of our patients. It’s this structure
that allows us to provide
a comprehensive strategic and coordinated approach to addressing
complex problems like the opioid crisis. This systematic approach
has improved patient lives and reduced
the destructive potential of this epidemic in our communities
in the following ways. Between 2014 and ’17, we decreased high-dose
opioid prescriptions by 39 percent. We decreased brand-name
oxycontin prescriptions, with their higher
risk of diversion into our communities
and schools, by 75 percent. We’ve decreased adverse
events in our patients and improved
their ability to navigate their lives, with many reporting
actually feeling better once they’re off
the opioids. A summary of our work is available in
the peer-reviewed article that we’re providing
to you. So how did we achieve
these results? Our data systems
and clinical integration led us to recognize the
severity of this problem seven years ago, and that resulted
in the development of what we call our Safe and Effective Opioid
Prescribing Program. Our overriding reason
for this initiative was to assure
our patients’ safety. The cardinal rule
in medicine is, First, do no harm. We are committed
to addressing our patients’ pain needs, but at the same time,
it’s imperative that we do not
create an additional and potentially
deadly problem for them. Our program consists of four elements:
patient education, physician education
and support, patient safety, and community protection. First and foremost, our patients need to understand the dangers of opioids and what other treatment
modalities are available to them to assist them
in managing their pain. They learn that
while opioids may be extremely helpful
in managing pain, these medications
carry significant risk. Education is
available online and in hard copy
around alternatives including non-opioid pain
treatment medications, self care, cognitive-
based therapies, acupuncture, tai chi,
and mindfulness training, and involving the patient
in the decision making process
are all critical. We also believe
that arming physicians with education
and support allows them
to confidently provide our patients
with the expertise and tailored
treatment program that they require. This includes
MAT and naloxone. In essence, we want
to make it easy for the doctors
to do the right thing. We’ve developed evidence-
based clinical algorithms and decision support
tools that are embedded in the electronic
medical record, making physicians
aware in real time of appropriate
prescribing and treatment practices as well as evidence-based
alternatives to opioids
for pain management. If an opioid is medically
appropriate, ensuring the patient
receives a treatment plan that consists
of the right dose for the right
duration tailored for the particular
condition is essential. It’s also about teamwork. Addiction specialists,
mental health specialists,
pharmacists, physical medicine
and rehab specialists, and other experts
are just a phone call or e-consult away. Monthly prescriber-level
opioid safety metrics and prescribing patterns
are readily available to identify opportunities for intervention
and improvement, and opioid
utilization metrics are also available
on patients to identify, track,
and intervene as appropriate
for patients at risk for overuse, abuse,
or drug-seeking behavior. A more holistic approach
has allowed us to taper patients’
medication regiments even when starting
at high doses. We know that
simply cutting off a patient’s
opioid prescription is not an option, as it may drive them
to seek the drugs in other settings,
including the street. Opioid addicted
treatment requires commitment in forming
long-term relationships with patients. By establishing
a bond of trust and better understanding
the patient’s underlying medical,
psychological, and social needs,
we’ve been able to incorporate adjunctive
treatment options and become a trusted
source of help. Kaiser Permanente’s
mission extends to
our communities as well as our patients. We’ve reduced
the prescribing of higher-risk-of-diversion
brand-name opioids, and we share
our successful practices outside our organization and across the community. We also continue
to learn and improve. We believe
a successful approach requires a strong
physician-patient relationship; data-driven,
evidence-based decision making; multi-disciplinary,
team-based care; the use of
modern technology; and old-fashioned
behavior change in an integrated system. We’re ready
and willing to work with all stakeholders to address this
critical national issue. We thank you
for the opportunity to share our story and to be of service to
those who need our help. Thank you very much. Governor Christie:
Thank you, Dr. Ellison. Appreciate that. Fascinated to hear
some of the results that you’ve
gotten already. That’s very interesting. Dr. Migliori,
executive vice president, chief medical officer
of United Health Group. We appreciate
you being here. Large player
in this field, and we appreciate
your presence. Richard Migliori: Thank
you, Governor Christie, and to the members
of the commission, for the opportunity not only to share
our thinking, but for the broader
collaboration that your work
is going to promise. Our enterprise
is very concerned about the impact that the opioid crisis
has had on Americans, and not just
our own clients. And our enterprise
is fully engaged in delivering
a variety of solutions to meet the objective of, first, preventing
the next individual from developing opioid
use disorder, and second, to rescue
those already afflicted by getting them access
to treatments that work. Our prevention solutions are multi-dimensional
and include, first, analytics,
using our big data assets to, first, characterize
prescribing patterns. You know,
despite the fact that the CDC guidelines have been out
for 20 months, only 55 percent
of prescriptions are written in conformity
to those guidelines. Is that right? Male Speaker: That’s
what I said, is 55. [unintelligible] Richard Migliori:
Yeah. Second, these — machine learning
has helped us to be able to create our
first-generation patient-predictive
modeling tools. We’re able to identify
the 2 percent of the population
that are going to get — where 60 percent
of them will go on to develop opioid
use disorder if we don’t intervene. And third,
and very importantly, getting to General
Rosenstein’s comments earlier, fraud detection. Fraud is rampant
in an environment where people are driven by the disease
to compulsive behaviors, and people take
advantage of it. We undertook 71
formal investigations in our fraud unit
last year and made 384 referrals
to federal, state, and community-level
law enforcement and regulatory agency based on the behaviors
we witnessed. The second thing we do
for prevention is at the level
of the pharmacy, scrutinizing each and
every opioid prescription to look for conformity
with CDC standards. Just in four weeks —
in our initial four weeks when we put
in the program to show the opportunity, we saw an
82 percent reduction in first fill
prescriptions to the — to the recommended
CDC dosing. Sixty — I mean,
82 percent. That’s how much fat
there’s in the system. The last thing we’ll talk
about in terms of prevention
is finding alternatives. We’ve been expanding
our already 80,000-provider-strong
base of physical medicine people including
physical therapists, PM and R physicians,
as well as chiropractors. Because what
we’ve found out is when people with such
things as back pain — a very common cause to
get your first opioid — when people went
to one of these docs or practitioners
to get their therapy, only 5 percent of them ever ended up
with an opioid for that episode
of back pain, whereas if they went
to other specialties, it was over 13.4 percent. That’s 62 percent
fewer opioids for acting in that way, and for that reason,
we continue to promote patients receiving alternatives, because we think
it works. Final thing is an issue
about treatment. And let me start off
by saying parity isn’t just the law. It’s an imperative
in order to be able to treat this disease. This disease is
a chronic disease. Much like diabetes
and heart failure and the like, the treatment
has to be ongoing, and it has to be
delivered in a way that aligns with
evidence-based medicine. And the case we’ve used,
it’s — build out the capacity and access to medication-
assisted therapy, competent people for
when it’s indicated, and other forms
of therapy when other alternatives
are called for. We now have some
4,836 locations across the nation
offering this, and a 24-by-7 phone line
that will get people in, typically within
24 hours, for this kind of
management. The other thing is to
make sure that the drugs that are important
for the use — all types of drugs, whether they’re
partial agonist and antagonist
combinations or antagonists
themselves — are readily available
at the hand so that when that
first opportunity to engage one of these
patients occurs, it happens. The final thing I’d say
is we’ve seen some meaningful
and measurable progress, but there’s a lot
of work to be done, and a lot of new
investigation, including opportunities
to really look at the PMDP databases as more than just a place
to look at cases, but as a place
where we could start looking as
a patient registry to find best practices. And with that, I want
to give our appreciation for being included
in this conversation. Governor Christie:
Thank you, Dr. Migliori. Appreciate it. Our final presenter
before questions from the members
of the commission will be Diane Holder. She is the president and
CEO of UPMC Health Plan. Thank you for
your patience, and we look forward
to hearing from you. Diane Holder:
[laughs] Well, thank you.
I really appreciate being able to offer
testimony today, and appreciate
the great work that you’re trying to do. Pennsylvania has been
particularly hard hit, and we’re in one
of those epicenters when you come up
from West Virginia into western
Pennsylvania. I am part of a large
academic medical center. We have 40 hospitals and, you know, almost
5,000 physicians. Cover about 3,000 lives through our insurance
infrastructure. And like Kaiser, I think we have
the opportunity — because we can work
hand-in-glove between our physicians and our hospitals and
our insurance company, we sometimes have a view that’s a little
more holistic, and be able to
share that data and be able to look
at best practices. But I think the other
thing that’s really very important in terms
of our environment is that we train about half the physicians
in Pennsylvania. We train most
of the nurses. We train the pharmacists and the physical
therapists. And the incredible
importance related to how do we get to the next generation
of practitioners to really understand
that, yes, pain is
incredibly important, and we all have
an obligation to use our best science
to control pain in whatever way we can, but we have to look
at the downside. Before I was running
insurance companies, I ran our large
psychiatric systems, and so my background
is in behavioral health and addiction treatments. And so to me, when I look
what what’s happened historically in our
country for folks, I remember when the
Los Angeles County Jail was the largest
mental health center in the country,
perhaps it still is. And I think one of
the key messages I would have for
the group today is that it is
the partnership between public health
and public safety that has to
come together, but in a unique
and novel way. So a year ago this month
— because we, like you, have been working on
the opioid problem for many, many years —
we held the — our insurance
company hosted, for our network,
a large gathering, a large conclave. And we had
the U.S. Attorney — who had been very active
working with us — the School
of Public Health, the medical school,
the nursing school. We had federal and state
representatives, hospitals, doctors,
our insurance company, families who were trying
to help their loved ones, and people in recovery. And the — it was a
day of dialogue where we basically
just needed to hear from each other in terms
of what was missing. And I would say
if there was one thing that I think it would be
really important for this commission
to do, it would be to try
to figure out how do you
fund communities to come together. And I know there are
some grants being issued, but how do you
fund communities? Because healthcare
is local. Their resources
are different from place to place. The epicenters
are different. The prevalence rates
are different. We are seeing fentanyl as the
leading cause right now of what we’re trying
to get out ahead of. It’s devastating. There were eight deaths
in 70 minutes a couple of years ago
in one of our counties, just, you know, 20 miles
from our headquarters. So we are doing
what we can. And I would say,
pretty much, the strategies
you’ve heard today I think are
best practices. I think the industry
is trying to, you know,
look at formularies and look at how you can
get in front with, you know, authorizations
for certain things. But when you look at
what we’re dealing with, we’re dealing
with subpopulations. The reason people become addicted is different. You know, there are different groups of people, and the solutions
have to be different for the different
subgroups. And that’s why I’m saying if you can help local
communities with funding, if you can get rid of some of
the privacy problems that we have that people
have mentioned, and if you can help us
come together differently, I think we could do
something different and really get on top of
this in meaningful ways. So I don’t want to
take any more time. I would just say,
Ditto, to most of the things
I’ve heard here, and welcome
your questions. Governor Christie: Diane,
thank you very much. And I want to go first
to Congressman Kennedy for any questions
or remarks he has. Congressman Kennedy:
Thank you, Governor. First, let me just repeat that the historic
treatment of addiction
and mental illness has been a separate
and unequal process. All of you as insurers
and payers have treated mental
health and addiction as if it’s something
other than the rest of medicine. And so we’re in the midst
of, really, a new era, much like when we passed
the ’64 Civil Rights Act. We had to now begin
to implement it and ensure that people
are not treated differently simply
because their illness is an illness
of the brain. I appreciate
Secretary Acosta’s strong endorsement that parity needs
to be strongly enforced, and I want to thank Amy
Turner [phonetic sp], who’s here from his office, who is in charge
of that oversight. But as he said,
they are ill-equipped to properly deal
with that oversight given the current
statutory authority. And I appreciate
you, Governor, agreeing that we need
to enhance that authority in order to be able
to hold accountability where it needs
to be held, amongst many of those
who are in this room who are in charge
of trying to ensure that that accountability
takes place. The fact
of the matter is, as Frederick Douglass
said, Power concedes nothing
without demand. Never has,
and never will. And there’s a reason why some of these
companies in this room no longer have
preauthorization on MAT and fill first. It was because
the attorney general of the state of New York put them into
a consent decree. And the fact
of the matter is, we shouldn’t be relying
on one attorney general in one of the 50 states to be really trying
to enforce federal policy with respect to parity. I believe, as many of
these payers are part of, trying to get clarity on what those common
law standards of what falls in, you know, the parity law,
what falls out. How do we better define the non-quantitative
treatment limits? Because that, Governor, is where the rubber
meets the road. We’ve dealt with
the quantitative co-pays, deductibles,
lifetime limits, and premiums, but what we really
need to deal with now is those non-quantitative
treatment limits, the application and medical
management practices. To reiterate,
the law says inpatient in-network, outpatient in-network,
inpatient out-of-network, outpatient
out-of-network, pharmacy and ER — they must be compatible
for mental health and addiction just as they would
for the rest of medicine and surgical care. We need strong analytics,
comparability — analytical tools
that are agreed to — and I appreciate
the support of many in this room — in order to apply those
evidentiary standards, as has been said already, in an equal way across
all of you as payers so that there is
a bright runway as to what that comparability
needs to look like, especially as the field
of addiction medicine evolves and as our knowledge
as to how to better treat
this illness evolves. Let me say,
I do not believe the costly
inpatient treatment that many
of you providers are paying for
out of network is the evidence base
in most cases, and you’re stuck
having to pay for it because of parity,
frankly. And I’d like to see
that per-capita payment that you’re spending
on that inpatient spent on the
community resources and supports
that will allow them to maintain
their recovery with medication-assisted
treatment if they have an OUD — which is, by the way,
ASAM standard criteria for evidence-based
treatment. But we all need
to work together, and I would ask Pam, since she kind
of represents the association, to talk about the need for those kinds
of common law standards that could be helpful
for providing that common nomenclature
amongst all plans as to what
really qualifies as a parity
violation, per se. Female Speaker:
Thank you, Congressman. Appreciate it. And as you know, we were
leaders in supporting and getting the passage of the MHPAEA
legislation — thank you — and now, our members
are working diligently to implement the law, and frankly,
understand the law. There are a lot
of gray areas, and we meet with Amy
a lot to make sure that we understand
and implement them well. But one of the other
things that we’re working on, because we share
your concern that there’s not
consistency in understanding
and implementation, mostly at a state level,
frankly, and being asked for different pieces
of information, different types of
analyses from each state, we’re working with
the Center for Healthcare Quality
Improvement, CHQI. It’s a group
of stakeholders that are working
to try to develop a parity
accreditation tool so that we can have
that commonality that you’re talking
about in understanding what we believe
is expected of the law and the regulations
and in how we then respond to
the requirements. Congressman Kennedy: Well,
thank you very much. And I thank you,
Governor, for giving me the chance
to speak about this, and especially the chance
to help represent this commission
and follow on meetings with Secretary Acosta and with Amy Turner. Sorry, thank you. Governor Christie:
Thank you. I will turn next to
Attorney General Bondi. Attorney General Bondi:
Thank you. And thank you
for letting me go after
Congressman Kennedy, because we share
many of the same views. In fact, I have
personal friends who are, in a pro bono
capacity right now, suing over
parity violations. We’ve got to
work this out. This parity stuff, we’ve
got to work this out. We’ve got to, or we’re
not going to stop until we do. We need your help
on this, desperately. So Congressman Kennedy,
thank you for everything you’ve been doing
on that issue. I spoke plenty last time. I just want
to say something to Attorney
General Rosenstein. I cannot thank
you enough. We can talk about this
problem all day long. Your guys at DEA, they are the boots
on the ground. They are the ones
making the difference in just cutting
the snake off the head, and I cannot
thank you enough for the great
DEA agents you have. I think all the governors
would echo that. But, you know, we A.D.
Wright, we have Jeff Walsh, we have Jamie
Pelacek [phonetic sp] and Ray Sachs [phonetic sp] in Florida. Second to none. And thank you, thank you [inaudible]
on the enforcement side. Governor Christie:
Thank you, Pam. Governor Cooper? Governor Cooper:
I’m good. Governor Cooper:
Governor Baker? Governor Baker:
I’m okay. Governor Christie:
All right. [laughter] Governor Baker:
There are lots of things that I’d like
to ask about. We’d be here
until Tuesday. Governor Christie:
Professor Madras [phonetic sp]?
Professor Madras: I’m just going to
fire off a few questions, and anyone who wishes
to weigh in, please feel welcome to. Screening for opioid
use disorder — is it a requirement
for reimbursement if you are going
to project and develop measures to cut down on
opioid prescribing? Because we are aware that a number
of people transition to heroin and fentanyl because they were
cut off at the source. And so why or why not
is there a mandate to require screening for
an opioid use disorder before a primary
care physician cuts down on opioids? The second question
I have is there is
very good evidence that most primary
care physicians are unaware
of their patients having overdosed. There is no communication between emergency
departments or first responders
and primary care physicians that’s mandated
across the country, and I’m wondering
if AHIP and AHA, the American
Hospital Association, should get together in coordinating the kind of information flow between
health insurers as well as hospitals and other
first responders? The third thing that
I would like to question is whether or not, based on the CDC
guidelines, is there a consensus
that they are adequate having arbitrary
cut offs of three days or seven days has
received some push back from certain
medical specialties. Others have said
there isn’t enough time, there aren’t billing
codes to explain alternatives and I’m wondering
how the insurance companies
would address it. And finally,
my final question and I have at least
eight others but for privity
I’ll keep it to this. If every major health
insurance company and CMS have specific
goals, metrics, on cutting down on unnecessary
prescription opioids, why not have
the unified goals? Why are there
such disparities between you with regard to what you hope
to accomplish? And also, how to
protect patients who in fact have
progressed to addiction. And included in that
in terms of patient protection is the absolute need
for screening for substance
use disorders prior to prescribing
these drugs as well as mental health. Male Speaker:
Let me respond to maybe one or two questions. Thank you for
asking those. Under 42 CFR which was discussed
earlier to your point, if a health plan becomes
aware of a patient having a drug overdose
and going to the ER, we’re not able to inform the primary care
physician. If the ER is part
of their system, they may learn anyway but if not,
they probably won’t. So, again we ask
your help in eliminating
that barrier because we really would
like to inform them. One other point
I’ll just briefly, you spoke about why do we
have different targets. I would love
this Commission and some of this is happening organically, but the states have
their own approaches and you know everyone is well
intentioned etcetera. This Commission is well
positioned to come out with appropriate
targets and measures that we should
all work to promote. Ms. Tavenner:
So, let me add one thing to the targets. From the Medicaid
and Medicare perspective. If you look today right now in Medicare health insurance plans, health plans are handling about a third
of those individuals. They are also
handing in states probably about 75 percent
of all the Medicaid. So, your right states may want their own
specific targets, but I think for CMS, HHS, to set some targets
that we could all work together to create
makes a lot of sense. Because so much of it
is government funded, all or in part. Chairman Christie: Anyone
else want to respond to? Doctor Dimeric:
Yeah, I just want to add a couple of things
that at Cigna we have
180-200 accountable care organizations, primary care groups
that we’re working very closely with on these very issues. They are begging us
for more information on their patient’s
mental health and substance use
disorder histories. And because of 42CFR
you heard we’re unable to share a lot of that information
and data with them. Where we are
working with them is to your other
questions of educating them
on how best to screen, how to set up integrated
systems of care either by imbedding
mental health and substance
use professionals in their primary
care groups or bringing that
in virtually or from the community
to support that integrated
and holistic care. So, there’s a lot
of education and a lot of building
of the system to allow that care
to occur there in the primary care
setting. Male Speaker:
I was just going to say regarding the
CDC guidelines. Before we even begin to
talk about changing them we have to make sure
that physicians, and dentists,
and providers, that prescribe
in all 50 states are fully aware
of those guidelines and are actually acting
consistent with them. I have to say we recently
visited one community in a state that has been
devastated by the epidemic and it was
shocking to me, the lack of understanding
of those guidelines and how in some cases
poorly enacted they are. It’s incredibly important
that we start there and this education piece beginning
I medical school, beginning in
dental school, all the way through
residency and practice is extraordinarily
important. Doctor Patel:
And I’ll just echo what my colleague said which is that I think
it’s important for our providers to understand
the CDC guidelines, but I don’t I’d
also like to say with my physician hat on that there’s not
a one size fits all. So, there are going
to be patients that will be outliers from the
CDC guidelines and those are
entirely appropriate. The key is that
the physician understands how to manage
that patient, understands how
the opioids work, and is monitoring patient
to make sure that they’re taking
them appropriately, that they’re not
being diverted, that they’re not taking
other medications concurrently that
would cause side effects. So, what I would say again
along with what he says, is that I think the education
piece is important because when we sent out
letters we had providers not understanding
CDC guidelines, not understanding
sort of the basics because they were
not taught it, number one and number two
they’re too busy in practice to keep up
with everything. But there are going
to be providers that will be
managing patients that will fall out
of these guidelines. And that’s one of the
things that we’ve talked with the North Carolina
Medical Board as well, is that they are
meant as guidelines. So, just like
with opioids or just like if you were managing
a patient’s hypertension or diabetes, there might be occasions
that you go above what
the recommendations are and it’s entirely
appropriate for that patient
if it’s being monitored appropriately by
the physician. Governor Christie:
Diane. Ms. Holder:
What I was going to add to the question around how do we get
screening and training. I think we have
a tremendous problem in our rural areas where we have a lot this
kind of opioid problem. And one of the things
our state has just received
a SAMHSA grant and they’ve
contracted with us as the primary contractor to basically train
the rural communities and physicians in trying to figure out
how do you screen. And if you’re going
to do medication assisted treatment, which is what we’re
hoping we can facilitate, you have to help
people to train and to do
treatment plans. Very few of the current
physician community got much if any training on addiction
in medical school. I mean it’s just
not something that was spent
a lot of time on. And so, we need really to
help people to learn that. And as we know addiction
and mental health are co-travelers, depression is often
a co-traveler, and we have
to treat people and look holistically. So, it’s not just
a simple as an addiction which is never simple
to begin with, it’s a really more
complicated issue. Doctor Ellison:
If I could just add quickly on the CDC
guidelines. I mean we endorse them I think to the earlier
point physicians today studies show
that they’re spending for every hour
they’re spending with a patient they’re
spending at least an hour in documentation
and paperwork. So, it’s an overwhelming
amount of work to do to take care of patients. And so, we need to make it easy
to do the right thing. We need to embed it
in their day to day life and make it easy
to do the right thing and provide access
with telemedicine and other resources. It is correct
that the guidelines are a great foundation
and there is an opportunity
with telemedicine and other ways
to connect specialists and primary care
physicians to know when to refer and when to ask for help to customize
to that patient. Professor Madras:
I just foresee the decline of supply with regard to
prescription opioids in the future
being a problem that is relatively
containable. But, the Justice
Department’s role will increase
dramatically over the next few years because of the increase of new psychoactive
substances. And I think
the insurance companies that are represented here are going to have
to take care of patients of a wide range
of addictions to opioids
which are derived either iatrotogenically or through
illicit sources. Chairman Christie:
I want to turn back to — Congressman Kennedy:
One more question is MAT. Obviously, we’ve got such
a dearth of physicians who are trained to
provide the evidence base that’s going to
help us address the immediate crisis
of people out there. I’d like to ask
the folks here how do we get the rest of the physician
community i.e. not your addiction folks, but the rest of your
physician community to throw in
with this crisis. And actually, train up
to be you know authorized providers and maybe do it
in partnership with some of your
community health folks to help them so that
they’re not feeling as if they’ve got
to take these patients on all alone but if they have
the support maybe they’ll start meeting the need
that’s out there. Female Speaker:
We’re training a lot of our primary
care doctors to actually deliver
these treatments and we’re embedding
mental health specialists in the primary
care offices. Doctor Ellison: I’d say the same thing. In a system like ours we train the physicians, we can monitor, and we have metrics
to measure, we can again embed it
in our electronic medical record
the protocols, the guidelines
in real time with the patient
in front of them. They have the triggers
right there the guidelines
and they have immediate access either
by phone call or via consult to the
specialist they need. So, it’s a network
that we can provide a lot of support
to education around, so the physician
feels supported in doing the right thing. Chairman Christie:
Yeah. Ms. Holland: If I may.
I was just going to add, and and I think that’s
an important thing in terms of the support. What we hear
from physicians across the country that
are part of our networks is we’re dealing with
very complex patients. And aside from
just training in terms of
the delivery of MAT it is really dealing with
the patient themselves that are complicated
that often times don’t want to be treated or are resisting
treatment. So, I think
it goes beyond just how
to administer MAT and more broadly
about the complexities, the psychosocial
and medical issues related to these patients
that are going to have to be
addressed fundamentally. Male Speaker: As I’ve
said we have a program on how to have the
difficult conversation with the patient that’s
not an easy thing to do. And so just training
in that goes a long way in making the physician
more comfortable. Ms. Holder:
And you have to have I think what you’re
saying the team based care
that surrounds it. So, for example
primary care given the limited
amount of time you have in primary care cannot do this
by themselves. And so, you know I think
some of the things that we knew 20 years ago or 30 years ago
in how you help people with serious mental
illness or addiction you need crisis
treatment teams you need in home teams, you need people with
addiction specialty to be able to actually
be in the community and go to where
people are because it’s what
you said people aren’t necessarily
running towards you to get the care
they need. But you’ll find
them soon enough in your emergency room. Chairman Christie:
Governor Baker. Governor Baker: So, I very much
appreciate all the conversation. I was going to pass
but I’m just going to throw out
a few thoughts and if anybody wants
to expound on feel free. One is next week we have
a whole bunch of people from the pain business and a whole bunch of
people from the addiction world meeting
in my office. To the best
of my knowledge that’s never happened. One question I would
have for you folks, it’s more of a thought, you should just
think real hard about getting
the pain people and the addiction people
in the same place. They don’t talk
to each other, they never have,
they really should. They would learn a lot
from one another I think. My second thought is
we don’t give out C-Pak’s for antibiotics five day you just
take this for five days. I think part of
the opioid epidemic came about as a result
of docs just writing 30 and 60-day supplies for
pretty much everything. I would love it if
the insurance industry and the physician
community would say how about
a three-day C-Pak equivalent for opioids
for dentists. And a lot of the baloney
that frankly you probably shouldn’t give anybody
an opioid for it all but they’re still
getting them. And even a state like
Massachusetts where we have a seven-day limit
on first prescriptions and a really terrific PMP that you know had five million
inquires last year and a 25 percent drop
in overall prescriptions, every single day somebody
tells me about somebody getting a 30-day supply
for something stupid. And I think part of this
is if we really want docs and dentists, and nurses,
and everybody else, to write two
or three pills or three days
we’ve got to give them a packaging solution
for this that works. I don’t know
what it looks like but it’s just not
going to happen if everybody
is just doing what they’ve been
doing forever. It might happen
by 2025 or 2030 but it’s not going
to happen before that. And it would be great if
somebody came up with a solution that looked more like
the packaging solutions people did for
an antibiotic treatment. The third thing is, 60 Minutes did
a thing last week that basically said you’ve lost some
of your authority to chase drug
distributors and to make arrests and to deliver on your enforcement
opportunities. In Massachusetts
fentanyl was about — fentanyl was present
about 17 percent of the time opioid deaths now it’s present
in about 80 percent in the deaths
in Massachusetts. If you took fentanyl
out of the mix you know our heroin
and opioid numbers have dropped like a rock
over the past few years. But because fentanyl
has sort of come in to replace it’s totally
changed the game. I agree with you if you
don’t have the tools you need you need to tell
us what tools you need so that we can make sure
they get into the report and you get back whatever kind of
authority you need. And that is hugely
important with respect to this particular issue. And then my final thing
is in diabetes, many forms of cancer,
high blood pressure, mental health, pediatric asthma,
asthma generally, across almost every area I can think of that sort
of traditional medicine, people had some idea
about how to keep score about whether or not
we’re succeeding and how we’re doing. I would argue that even
though I heard all of you talk about evidence
based care delivery I didn’t hear
one person say that here’s
how we keep score on whether or not we’re
succeeding with respect. I hear a lot about
how you keep score by whether or not
you’re succeeding in reducing the number
of prescriptions that get written on
the preventive side, right? I didn’t hear anybody
tell me anything about how you actually
keep score with respect to whether or not
your treatment and recovery programs
are working. Do you measure 30-day
readmission rates? I’m telling you
the amount of people who spin through detox,
spin through ER’s, spin through this system,
is mind boggling. And once upon a time
we used to — when we talked
about asthma and we talked about
mental health, we talked about some
of these other issues, if you had that kind of
recidivism you would say that was a failure of the
community base approach to whatever it was
we were doing. And I think one of
the big challenges we all face is how are we actually going
to define success here. I didn’t hear anybody
talk about recovery coaches, I didn’t hear anybody
talk about how long you think somebody
needs to be in treatment before you get
to the point where you really believe
we’re being successful. I didn’t hear
anybody talk about any of a whole
bunch of things that if we were having
a conversation about diabetes
or a conversation about high blood
pressure, or a conversation
about mental health, or a bunch
of other issues. Even mental health,
Patrick, I didn’t hear
any conversation about a whole bunch
of things there that would sort of be a part of
the conversation that would be here’s
how we’re keeping score and keeping track of how we’re actually doing. And in substance misuse there is absolutely
a failure rate. But
nobody seems to know what you know where
do you draw this line and how do you think
about what you’re doing with respect to that. And I would actually
argue that — and I come from
the insurance industry, I would actually argue
that by not doing more when people detox and actually head
to the community and I mean a lot more. You are all probably
spending more money than you would
be spending if you got
really aggressive about the community
based approach to care. So, that’s part
of the reason why I didn’t say anything
because I figured what the hell I was
just kicking over one can after
another if I did. Chairman Christie: Let me
go to Deputy Attorney General Rosenstein first — Deputy Attorney General
Rosenstein: Thank you, governor. Chairman Christie: — to give us
direct response to Governor
Baker’s inquiry. Deputy Attorney General
Rosenstein: Given the time Governor I’ll be very brief,
but I agree with you we certainly need to make sure we have
all the necessary tools and we’re working
with DEA on that. Just to clarify the
publicity last weekend concerned DEA’s
administrative authority to suspend shipments
of pharmaceutical drugs so that has not
impacted our ability to prosecute criminal
violations including fentanyl. With regard to the issue of how we measure
success, I would suggest
the primary bill should be to
reverse the trend, the upper trend
in drug overdose. That’s just to
reverse that trend and then we can focus
on bringing it back towards zero. Thank you. Chairman Christie:
Governor Cooper. Governor Cooper:
Just one thing. I just want
to remind everyone, and I know I sound
like a broken record, but in North Carolina
49 percent of the people who present to
our emergency rooms for opioid overdose are uninsured/self-pay. No Medicare, no Medicaid,
no private insurance, nobody around this table increased access to healthcare coverage is one of the major steps
that we have to take in order to
combat this problem. Chairman Christie:
Any other responses to Governor Baker’s
discussion? Kim? Male Speaker:
You mean complaints? Chairman Christie:
Yeah, close observations is what we’re going
to call them. Ms. Holland: And I just want
to thank you Governor Baker for saying something that
although we may not have said anything
I assure you everyone around this room
has been thinking and is concerned about
the various issues and what the standards
of care are and how do
we measure success in the treatment
of people with substance
use disorder. I think some of it is —
and I’m not a clinician so there are many wiser
on this than me but what I hear
from our clinicians is that much
of it evolves around the stigma
of mental health and that our
clinical community we just not as advanced in the delivery
of services. And again,
in a consistent approach as we are in some of
the other medical teams. We’ve been looking
at what happen in cancer for instance. You know there was
some time ago where you couldn’t — we didn’t have
a means of measuring what we considered success
in cancer recovery. Now we have you know
a five-year gold standard if you will. How could we apply
something similar to that in the mental
health space? So, we are working
with ASAM. We are working and reaching out
with the AMA. We are talking
to certainly the broader clinical community
and others to see if we can find
an answer to that. We are funding research
to look at what happens
neurologically in the brain
with opioids that’s different
than other things and what creates such
a high degree of relapse. So, I think that work is
under way it’s certainly going to take more
than the Blue System. But you certainly articulated well
the challenges we all recognize
and again want to be part
of the solution. Chairman Christie:
Well, I’d say that also that I think
we’re seeing — Charlie and Roy and I are seeing
at our state levels that you know
someone said before there’s not
a one size fits all, I think it was
Doctor Patel. And the fact is that
we’re defining treatment at times in a one
type fits all. And the fact is that
what we’re finding is that you know we have to give
a number of different avenues for people
to walk down and then give them
a tour guide to walk them down there. This is an
extraordinarily complicated set of sometimes
cor morbidities and we need to be able to
give people the guidance. I think if you talk, and I’m sure you
all have as I have and as the other people
sitting up here have, when you talk to families who are in
the midst of this, let’s put aside all
the different statistics we’re talking about
and everything else. Because those statistics
are all sons and daughters
and husbands and wives. They are lost. They don’t know because
we’re not telling them what are effective
treatment options. We’re dealing
with a medicated assisted treatment area where, where you get
sent determines what your treatment
is not how you present. You get sent to
a methadone clinic you’re getting methadone. You get sent someplace
for suboxone and you’re
getting suboxone. You get sent to
a vivitrol place that’s what
you’re getting. Regardless of how
you present. How else, what other
chronic disease do we treat that way. Where you know like
I go in and I’m — Charlie brought up
antibiotics before, I go in and the doctor
says well are you okay, do you need
any Penicillin? I say well I’m allergic
to Penicillin. He goes well you’ll
have to go to Doctor Rosenstein because all I prescribe
is Penicillin. I go hell man I’m sick, there’s
something else, right? There’s other types
of antibiotics. And he says no I
just don’t do that. But go down the street
to Rosenstein and he’ll do it. Well, if I’m sick
and need antibiotics I probably walk
down the street. If I’m someone
who’s on the edge between relapse
and recovery I don’t walk down
the street I give up often and go
back to my heroin dealer or my fentanyl dealer. And that’s the
part of this that I think is
enormously frustrating for families. And when I hear
the discussion at MAT, which I think is a useful
tool in all of this, we’re not requiring
the medical community to use it in the way
that we require them to use every
other medication. Which is the patient
presents, you make an evaluation
of the patient, and what is the most
appropriate medication for that patient. Instead they go into
Rosenstein’s office and they’re
getting suboxone and they come into mine and they’re
getting vivitrol. And it’s just
unacceptable. It’s unacceptable to be
dealing with it that way. So, I think you know
part of this is we need to acknowledge and come up with a plan
for how we’re going to get people on
to the right road. And then have someone who walks them
down that road. And I think Governor
Baker is right paying for that rather
than perhaps blindly paying
for 30 days inpatient, or 60 days inpatient,
or 120 days inpatient, may wind up costing you a
lot more doing that then if we became a little
more nuanced about this. Doctor McGgliori. Doctor Mcgligori: To both
you Governor Christie as well
as to Governor Baker, I fully agree with what
Governor Baker has said. In fact, in a research
unit that we have in I think Governor
Baker’s state, we have
a group that’s working on building what that dashboard
needs to be. Because so far what
we have available are process measures and
we need outcome measures. And the outcome
measures is death. All right. To get to the point
of being able to measure that is why I was
so encouraged by what the Commission
has is already focusing on in terms of broader
uses for the DMP. That can become a patient
registry to do just what you’re describing
Governor Christie, which is to use
as a place where we can track the success of each individual
who’s treated. So, we can start
looking back as what was
the process of care for this individual that got us to success. That’s the only way
we’re going to be able to answer the question that Governor
Baker came up, which is how long do they
need to be in therapy. Well, they probably
need to be in therapy lifelong
right now because we don’t
have proof to say that they’re done. The other side of this
issue is with the PDMP. It will look very much
like the success that American medicine
had with pediatric cancer. When every child
was treated on a protocol and they were tracked. Ninety percent of kids nowadays who have cancer are treated
on these protocols, 95 percent of them
are cured. And the reason
is because we went to doing registry’s. And your focus on PDMP I think is a very big
step in getting there and I would encourage it. Doctor Swedish:
May I also comment. Again, I think
these points are dead on particularly about the
way we’re keeping score. Governor Baker is right,
we need to do better. Let me also share,
I’ve been on more than few committees that look at measures. In Massachusetts
we’ve had the state-wide Quality
Advisory Committee which looks at measures. And we talk philosophically
about the fact you know we’ve got to do better
with behavioral health. We have to do better
with substance abuse. The problem we run in to and this is worth
further dialogue, is we have a lot
of smart people who want to get it right. So, you start scoring it
by things like dose NQF have validated measures
or NCQA etcetera. So, the fact that there
aren’t validated measures and they’re not agreed
upon becomes a barrier to doing anything. You end up
going in circles and its not ready
for prime time. Because we’re trying
really hard to make sure that what we do
put out there is fair to all
the stakeholders. So, I think it’s worth
thinking about how we can use that to
promote better measures. Similarly, AHIP, that actually
is successful endeavor probably about
two years ago where they
brought together not just insurers but
professional societies, CMS was there. And we together looked
at many areas as a group. It took many meetings
and over a year, but it was
a good process. And what we came out
with were measures for various areas that everyone agreed
were the right way to measure results
in progress in those. Whether it is orthopedics
or primary care, et cetera. And that might be
a good venue for doing
something similar looking at the questions
we’re asking. How do we tell
if we’re doing a good job at treating
substance abuse. Because I think
we need a major effort and that needs
to be a major part of what comes out
of this committee. Governor Baker:
I guess I look at the — I mean pediatric you know
as when I was working
with the governor in the 90’s,
pediatric research was a gigantic problem in the health
research program and in the
Medicare program. And when we finely
go everybody together to start talking
about it, one of the things he said was what’s one
obvious measure. How many times does a kid
end up in a hospital who has asthma which is
theoretically treatable and how many times
do they die? And the data originally, when we started
collecting it on this was horrible. But the good news was
we actually had to start. The problem I have
with a lot of the conversation
around this issue in particular
is I sort of feel like there’s
no place to start. The money
that the states spend in the Medicaid program on people have who are dealing
with substance abuse are mind boggling to me. But at least
we collected data which gives us
a place to start. Now the goal then becomes
well how do you get better and the answer
is you try things. And if you find things
for certain who presented
in certain circumstances that work better than
others, you chase them. But I’m telling you
the lack of community follow up
and community support for people who are
dealing with this when they come out of
whatever kind of secure residential
in-patient type setting they’re in is
a big part of the reason, in my opinion, why they just
end up back in there again. And that’s one
where maybe we can push the folks who do a lot of federal
research around this area to do more. But it’s also one
where some of you have data sets that are
definitely big enough where you could
create a baseline and then try things and see what happens
with respect to what moves
the baseline. Chairman Christie:
Diane. Ms. Holder:
I was going to say, I think that part
of the dynamic is we’re coming
out of an era where addiction
and depression and other mental
health conditions have not been considered
chronic illnesses. And we haven’t built a
treatment delivery system that has the full
continuum of care appropriately
in communities. And the reimbursement for
most of those services is very, very, low. We have some
whole counties you know half of a state that will have
no child psychiatrist in them at all. And we’ve been working
on a project for year where we’re trying
to bring down the multiple
antipsychotic dosing that’s going
on for kids under the age of 12. And we have outcome
measures and we look, is it going down. Every single year
is it going down and under what
circumstances. But it’s extremely
challenging because we do have
a reimbursement and a paradigm problem
in my opinion. But I think it’s changing and I think
the only good thing I could think about
this whole tragedy with the opioid problem is that it’s actually
raising these questions and Commissions
like this are existing. We didn’t have
this much before. Congressman Kennedy:
So, Governor Baker, we’ve got to stop
people dying. And I honestly don’t care
how they do in recovery if we can give them
the opioid replacement therapy that will keep their
brain from craving and will stop their
brain from overdosing if they take
additional drugs. We know how to do that. Now that may not be
optimal for hat patient, that’s when we start
the recovery process and hopefully get them
to where they have stability
and life skills. But as the Attorney
General said, this is a matter
of trying to stop the overdose deaths. And everybody coming in
with an overdose ought to automatically
be put on this and monitored. We’ve got to stop
the deaths that’s outcomes
right now. I’d like us to — unfortunately we’ve
had this abstinence only has been
the metric for recovery and that’s another
thing that Diane that we have
to get passed and not think
of this as just in the 12-step model, although that I think has
been crucial to recovery. But first let’s deal with the medical
aspect of this which is the craving
in the brain and get that treated. And tragically we don’t
have enough doctors who are prescribing
this treatment and so there’s not enough
people gaining access so there’s people dying. We ought to be treating
this like a FEMA response and getting the
necessary medication. If this were Ebola, we would be
getting it out there to every practitioner
in this country, we’d wave all the rules
and we’d say get it done and start saving lives. I mean that’s
what we need. Chairman Christie: That’s
what we’ve been saying. Professor Madras:
I agree with Congressman Kennedy
completely. But I think there
are three issues that I think
are major weaknesses and are the
current status. Number one is
in some states, about 75 percent of
people are dying alone. And the problem is there is a vast
number of people who are unidentified. Either through the health
care system or otherwise. Unmotivated to
present themselves and there has to be
creative ways of figuring out how to rescue
those people foremost from death
and then from and then to enable them
to get into treatment. The second issue that I
think is really critical is that outcome
measures and record keeping amongst the 14,000 traditional
treatment centers are very weak compared
to the healthcare system which has much
stronger records over the century
of keeping records and keeping outcome
measures and in implementing measured
based practices. So, I think the weakness
is not only that we don’t even
have guidelines and what the outcome
measures should be, but we don’t even have accountability from
treatment centers that get government
block grants in terms of measuring how many people relapse, how many people
continue treatment, and so on, and so forth. So, record keeping
as well as effective
quality measures and standards of care have to be improved
dramatically. Chairman Christie:
Any other comments from that?
Doctor Elision. Doctor Elision:
I think she’s got the pen with respect to the report
don’t you think? Chairman Christie:
Yeah, yeah, it’s a good decision. (laughter] Doctor Elision: I was just going
to comment on Congressman
Kennedy’s comment and that’s why it’s
so important to shift from abstinence
to harm reduction. All right so that’s
really where the focus has to be,
harm reduction. Chairman Christie:
Well, I want to thank everyone for your candor and for your preparation
and your willingness to spend your time
here today. We appreciate it
a great deal. You know in the time that we’ve spent
in studying this since the President
appointed the Commission and many of us have been
working on this issue in fact every one of us
who’s sitting up here we’re working
on this issue in our own states
in our own disciplines for a long time. You know we knew
that today was going to be
a key part of this. In the end we’re not
going to be able to deal with this problem
effectively unless you all are
partners with us in this. I said the same thing
to the pharmaceutical companies, if they’re not going
to be partners in this not only in terms
of a reduction in the type
of prescribing that’s happening
and all the rest, but you know
the brain power that exists in the RND operations in all of our major
pharmaceutical companies are going to be the folks who going to come
with more MAT. They’re going to be
the folks who are going to develop more nonopioid
pain medications so that the necessity
of using these in any instance will be diminished
significantly. And so, what I would hope
you’re going to see from the report
that we’ll issue in a little less
than two weeks will not only be a
recitation of the problem and where we are
but it’s going to be so your prepared
a real call to action for all of you. And that’s not to say
that you’re not acting now. We’ve certainly heard
from all of you today about the things that you
are attempting to do and in some instances
succeeding with. But when 64,000 people
died last year, it’s not enough. And I heard you
all say that too. But we now have to turn
those words into action. I think for anyone
of the governors up here in particular, we’re the ones
who are confronted, I think most frequently
in the states by the families that are affected
by this epidemic. And I can’t tell you
how many round tables and meetings I’ve held
with those families who are completely
at a loss. They’ve now not only
lost their loved one and so many
of them have died. But also for those
who are still alive they’re at a loss
with them too. And this epidemic is one
that you know I remember and everyone up here is old enough to remember
the AIDS epidemic. And I still have not
seen the passion for this epidemic that I’ve saw
in the AIDS epidemic. Governor Baker:
I agree with that. Chairman Christie:
It’s just not there. I said to these
families all the time who come to see me,
I said, where are the
marches. I remember the marches
on state capitals and this capital, demanding that these
drugs be covered by your companies. And before the drugs
existed demanding that the pharmaceutical
companies develop the treatments
that would change this from an absolutely sure death sentence
to a chronic disease which is now
being treated. And so, we can’t wait
that long in this one. Because while there were
certain isolating factors involved
in the AIDS epidemic in terms of its ability
to be spread, those isolating factors
do not exist in this one. They don’t exist. And so, we’re going to be
looking at 64,000 deaths in ’16. I don’t know
what anybody thinks the projection
will be for ’17, but I’m sure no one’s
predicting it will be less. It’s going to be more. It’s just a multiple
of how much more. And I wonder how much
more pain the people in this country
are willing to accept and not blame us first and foremost
in elected office, the healthcare community, for not taking this
seriously enough, and in some instances
profiting from it, and the health
insurance industry from being the payers
of the people who are profiting
off of it along with whatever profits
you’re making as well. I’m a capitalist. I want everybody
to make profits I think it’s great. But we can’t
any longer go about addressing
this problem this way. So, an anticipate report that will incorporate many of your suggestions but will also place
new demands on all of you that go beyond what
you testify to today. And I hope your
prepared for that and I hope your prepared
to accept that challenge because we know that if it hasn’t got
into our own house yet, it could. And then all of a sudden, your perspective
on this problem becomes
markedly different. So, I want to thank
Professor Madras, Attorney General Bondi,
the governors, Congressman
Patrick Kennedy. We’ll be back here
on November 1st. The meeting
on November 1st will be focused
on testimonials from those families
that I’m talking about. From the individuals
and the parents and the spouses who want the people
of this country through this Commission
to hear what it is like to live through
something like this happening
to someone you love. And I would urge
everybody who sat around
this table today to get on that live
stream on November 1st. Because if you’re
not motivated by anything else
I guarantee you and I think the guys
on either side of me will guarantee
you as well, you’ll be motivated
by listening to those families. They’ll be the ones who
will call you to action even more than any
government agency because they look
just like you. And so, I hope
you’ll join is in one way or another
on November 1st and I thank you all
for being here today.

97 thoughts on “Meeting of the President’s Commission on Combating Drug Addiction and Opioid Crisis”

  1. I still say Governor Christie would have been the best choice for AG. He would have no problem going after the masses of democraps that should be in jail!

  2. How about removal of poison in vaccines cause death and debilitating diseases? There won't be a healthy future society if this continues. Vaccines are assault with a deadly weapon. Get educated to the real truth.

  3. I am forever grateful fan to Donald John Trump and his family and I will always be forever President Donald Trump's biggest fan LIKE IT OR NOT @🇺🇸👅🖕🔫⚰🔩

  4. We have been fighting against since before Reagan. It failed than and continue to fail. America has an addiction problem that will be not solved by his wall or anything that can be done except killing all addicts. Politicians at the highest levels are on the take. Trump will not have the solution other than to gather the billion dollar into their pocket. East will be done with the addicts place them on a method program. There us no program to solve this problem. Since the Vietnamese war we drug our people and will continue to do so creating Healthcare jobs.

  5. ************** $ PRESIDENT TRUMP $ *******************
    WHY ARE OUR BOYS GETTING KILLED IN AFRICA? You ran on a NON-intervention foreign policy. The people liked that about you, we're tired of the endless wars. Don't send our boys anywhere you wouldn't send your own. Let me remind you why you won, it wasn't for tax cuts, it wasn't for healthcare and it for damn sure wasn't for more wars, if wanted any of that we had 16 other republicans to choose from. YOU MR. PRESIDENT WON BECAUSE OF THE BIG 3, Number One IMMIGRATION, Number Two TRADE, Number Three rebuilding American INFRASTRUCTURE instead of fighting wars that aren't in our interest. You should take zero advice on the middle east from anyone with an emotional connection to Israel, Jared is the worst person you could send to negotiate peace between Israel and Palestine. Also, taking advice from the Generals is like taking advice from gambling addicts, it doesn't matter how much they lose they will continue to believe they can win, if you allow them to continue gambling with American blood and treasure in the middle east they will lose everything. AFGHANISTAN IS WHERE EMPIRES GO TO DIE. One of the reason I loved you President Trump was because you had wisdom, you're a wise man but its worthless if you don't trust your own instincts. Please remember these wise words "THOSE WHO DO NOT LEARN FROM HISTORY ARE DOOMED TO REPEAT". I believe you're trying to serve two masters, one boss is the American people the other boss is a click of greedy internationalists. ANDREW JACKSON WOULD TELL GOLDMAN SACHS TO "FUK OFF" and he'd fight like hell to take his country back the corrupt Washington/Wall Street Establishment. I DON'T WANT TAX CUTS FOR THE TOP 1%, this isn't the 1980's, the wealthy are more wealthy than they've ever been, therefore they do not lack the money to invest. IF you want to do a TAX CUT, pass a law that cuts taxes for every company that manufactures goods in the United States of America and declare a rate of zero federal income tax for married couples and families earning under 50 thousand per year. Because couples and families earning under 50 thousand will spend the extra money, especially families and couples earning under 40k, FAMILIES & MARRIED COUPLES EARNING UNDER 40 THOUSAND PER YEAR ARE JUST BEARLY GETTING BUY, THEY CAN'T AFFORD EVERYTHING THEY NEED, if they had extra money they'd buy a cable subscription, they'd go out to eat more often, they'd buy new sneakers, they'd spend the fukin money unlike these filthy rich people who will just hoard their extra dollars. WHY CUT TAXES FOR JEFF BEEZOS? FUK JEFF BEEZO'S. WHY GIVE TAX CUTS EXON MOBILE OR APPLE? If you wanna give tax cuts big corporations, GIVE TAX CUTS TO COMPANIES THAT MANUFACTURE GOODS IN THE UNITED STATES OF AMERICA AND RAISE TAXES ON EVERY OTHER CORPERATION TO MAKE UP THE DIFFERENCE. To me it doesn't make sense to cut taxes for anyone but American Manufactures and families earning under 50k. Look Mr. President, PEOPLE ARE NOT EXCITED FOR TAX CUTS AND YOUR PEOPLE ARE SPLIT ON OBAMA CARE. You should of took your own advice Mr. President, you shouldn't of touched Obama Care because now the Left will blame you when it implodes. THE FIRST PIECE OF MAJOR LEGISLATION SHOULD OF BEEN INFRASTRUCTURE because People are EXCITED for that! Both Trump supporters and Bernie Sanders support infrastructure, democrats would of looked like dumb obstructionists trying to block infrastructure because everyone wants it, everyone but the Ben Schapiro Mark Levin crowd who are becoming more and more irrelevant on the Right. And even they would of come around if you pitch it as an investment, spending money to make money, becoming competitive with Germany and China. ALSO, you need to go around the country and campaign for the Mr. President, don't let anyone tell you its too late to stop this demographic shift of doom for the right wing. IF YOU BUILD THE WALL & PASS THE RAISE ACT YOU'LL SAVE A GENERATION AND BE A HERO. If we let open borders and mass legal immigration continue in less than 20 years those Leftist nuts at Berkeley will grow up and own the Presidency, THINK ABOUT THAT, ITS A SCARY THOUGHT. So, you just can't allow this demographic shift of doom for the right wing to continue. Allowing mass immigration and open borders to continue is an act of Treason, all those guys hanging up in your Oval Office would agree. It's not an option, you have to fight, fight for your country Mr. President, you didn't have to in the rice patties of Vietnam, so do your duty and fight. Protect our borders and end this madness the 1965 immigration act has created. We cannot allow the Left to turn America into California via immigration, this immigration takeover of the electoral college must be stopped, at the very least you can slow it down and buy some more time. And by the way I'm not partisan, I'm on the right of most issue's but I'm on the left of health care and other issues. ITS LIKE BEN CARSON SAID "AMERICA NEEDS BOTH A LEFT WING AND A RIGHT WING TO FLY". But, if we allow this demographic shift of doom via immigration to continue, we'll be left with only one wing, can't fly without a right wing Mr. President. Even worse the left has adopted this Marxist type of thinking, if we don't stop immigration and they end up owning the presidency we could end up with a Bolshevik Revolution 2.O on our hands. LOOK, IF YOU DON'T KEEP YOUR PROMISE TEXAS GOES BLUE IN LESS THAN 20 YEARS and if we let that happen its goodbye Electoral college, goodbye Supreme Court, goodbye Constitution, goodbye America, hello NAU. So, we can't allow that to happen, it would be the end of America. THE SURVIVAL OF AMERICA LAYS IN YOUR HANDS PRESIDENT TRUMP, DESTINY CHOOSE YOU, YOU'RE NOT JUST AMERICA'S ONLY HOPE AND LAST CHANCE, YOU'RE WESTERN CIVILIZATION'S ONLY HOPE. Don't worry about Israel or Iran right now Mr. President, Israel is going to be fine, BUT WESTERN CIVILIZATION IS GOING TO DIE IF YOU DON'T FIGHT FOR HER. President Trump, you've heard of Andrew Jackson, You've heard of Alexander the Great, these men are remembered for their bravery, they're remembered because they stood up and fought what looked like impossible odds, President Trump if you're bold and brave, if you stand up and fight, I believe you can go down as "Trump The Great". But, if you just go with flow and allow the greatest civilization known to man kind to die, in 50yrs from you'll be "Donald Who". Right now you're like the most popular guy on the planet and it must feel good, but remember its only temporary unless you achieve greatness, and to be great you need fight as Alexander and Jackson did, you need to brave, you need to be bold, you need to be great, you need to fight for America and the West. Order our troops home from Africa and Afghanistan, place them on our southern border to stop the flow of illegal aliens and on the coast of Libya stop the flow of refugee's into Europe. Concentrate on The Wall, The RAISE Act, Trade Policy, Infrastructure and The Culture Wars. PRESIDENT TRUMP, I'VE BEEN SO PROUD OF YOU, YOU MADE ME WANNA BE A WINNER, YOU INSPIRED US, YOU WERE A HERO TO YOUR PEOPLE LONG BEFORE YOU WON THE ELECTION. YOU'VE DONE SO WELL, YOU'RE REALLY A GREAT MAN, BUT IF YOU DON'T STICK TO THE AGENDA YOU RAN ON, IF YOU BECOME MORE MODERATE, IF YOU SHIFT TO REPUBLICAN ORTHODOXY, YOU WONT BE VIEWED AS HERO ANYMORE AND IT WILL BE THE BIGGEST DISSAPOINTMENT IN MODERN HISTORY. You have to trust yourself, you have to get people around you that agree with you, you have to remember that you're older and wiser than Ivanka and Jared, You have to remember you're wiser than the Generals, WISDOM and HIGH IQ are two very different things. High IQ doesn't equal Wisdom, in fact high IQ people are often intellectually arrogant, Remember that Mr. President. YOU HAVE WISDOM, and that is what's lacking in Washington. Washington lacks Wisdom, Morality and Leadership. But, You Mr. President have those qualities, you're a wise man so trust your instincts, lead us to true victory. MAKE YOUR MARK ON HISTORY. Realize the gravity of the situation, History is unfolding before us every moment and you have the power now to shape the course of history. PROTECT THE WEST, SAVE AMERICA, don't get soft on immigration, don't become more moderate, get tougher on immigration, stand your ground and hold your hardline positions. Tell the democrats that you need your 70point immigration plan upfront for DACA or NO deal, the democrats will give into your demands at the last second, they can't say no after promising the DACA aliens they could stay, The democrats cannot walk out of the deal because if they do they're the uncompromising uncompassionate ones. You've got the democrats by the balls so long as you're not afraid to let DACA die. Oh, if you're not afraid to let DACA die the democrats will give you the 70 point plan. Politically its a winner for your Mr. President, because if democrats don't give you your 70 point plan they're the uncompassionate bad guys who wont compromise. WE WON THE ELECTION, so your 70point plan has been mandated by the American people, the democrats will look so bad if they don't accept the olive branch you've extended in return for what the American people voted for. Just don't be afraid to let DACA die and you'll win on this deal. You must win Mr. President bc if you can't get the wall and the rest of your 70pt plan now while you have all this leverage on DACA you never will. UNDERSTAND THAT THE WALL IS YOUR LEGACY WETHER YOU BUILD IT OR NOT, if you build the wall you'll remembered as the guy who built the wall on our southern border, BUT if you don't build the wall you'll be remembered as the guy who promised to build a wall and never built it. UNDERSTAND THAT THE AMERICAN PEOPLE HAVE ONLY GROWN TOUGHER ON ISSUES LIKE IMMIGRATION SINCE YOU ANNOUCED YOUR RUN FOR PRESIDENT, because of Political Correctness we couldnt even discuss it. Since then we've only gotten to

  6. I'm so happy about this! Thank You!
    Please start by going after the deep state criminals that are using our military to bring drugs into our country, not just heroine but cocaine and methamphetamine. Please don't deny those who truly need prescribed pain medication. We don't want those with real pain problems to have to suffer. Denying people who have wisdom teeth removed is not the answer. Those people are examples of one time use cases who need what it takes to not be in pain after the extraction. The focus needs to be on people who are chronic users, not isolated one time users.

  7. Didn't Congress vote to depower the DEA when going after opioid producing corporations last year? All you guys are useless idiots!

  8. THANK YOU ASSHOLES, For making it so hard for us who honestly NEED strong pain meds….I myself have SMA (Spinal muscular atroghy) and have major pain 24/7 and because of obamacare and because of this BS Commission I have to go thru a walk of shame type of step to get my meds for the pain I endure….YES there are abuse in this world but why PUNISH US ALL????? I'm not watching this video but I saw the first one and going thru what this BS commission is doing and its wrong…Want to fix the crisis? MAKE BETTER DRUGS…..IS THERE NO MORE RESEARCHERS????

  9. inflammation causes pain which can be caused by many things unfortunately this friggen government is in support of spraying heavy metals by way of chemtrails that is causing inflammation in all people. Also this friggen government supports Monsanto who is pushing genetically modified food which is toxic and causes inflammation. The government has also screwed up our water supply like adding fluoride a toxic poison that causes calcification of our glands. Then this government mandates what toxic crap to put in our food like TSP in our children's breakfast cereals a substance unsafe to breath in and peels paint. How about the laws this piece of shit government passed beginning Jan 2018 to add heavy metals to our vitamins and supplements. Then there is the Vaccines that this pathetic government is pushing that is full of toxins to cause a plethora of medical issues. I really want to know what else the government is doing to cause us to be in need of pharmaceuticals that also are full of toxins and are killing people daily. Maybe you all need to discuss making a healthier environment how about that one? I don't blame people for having to be numb look around, you all have made this earth a miserable fucking place to be. You need to fix this mess or get the hell out we don't need worthless people who claim to care we have had enough of that kind of government.

  10. Kepada Yth Kepala Pemerintahan Negara Eropa dan Amerika Di Tempat. Dengan Hormat ! ASSALAMUALAIKUM WR WB.Kesimpulannya dan solusinya yaitu 1. Bubarkan Partai politik dan dinyatakan terlarang mendirikan Partai Politik dengan UU (Undang Undang) di seluruh wilayah Hukum Pemerintah Negara Negara Eropa dan Amerika ! 2. Kedaulatan kembalikan ke tangan Rakyat, Umat penduduk ,warga Eropa dan Amerika melalui PEMILU non partai politik yaitu PEMILU Demokrasi murni untuk Eksekutif Legislatif dan Dewan Agama Pemerintah Negara Negara Eropa dan Amerika ! 3. Bikin kerjasama di segala bidang Pemerintah Negara Negara Eropa dan Amerika di tuangkan dalam bentuk MOU di tandatangani bersama dilaksanakan bersama dan pelaksanaannya dilaksanakan bersama Pemerintah Negara Negara Eropa dan Amerika ! 4. Bikin satu mata uang bersama EURO Amerika ! 5. Bikin satu Organisasi EROPA Amerika ! 6. Kita bikin satu kesatuan kekuatan Eropa dan Amerika ! 7. Laksanakan ! Oke ! Pemberi infut dan solusi ! Pagelaran Cianjur Jawa Barat Indonesia 21 Oktober 20017 Ttd Asep Makmur Putra Soekarno Muhamad Hatta Masyumi Pancasila Ahmadiyah Qodiyani Gentur Pemerintah Negara Kesatuan Republik Indonesia Raya

  11. I CANT BELIEVE OBUMMER THE MUSLIM IN DISQUIS LET THIS CRISIS TO GO ON. WOWOW and the democrats let those drug companies kill our poor childrens because they getting alot of money from them

  12. K am impressed with the family and friends for watching out for drugs and alcoholics but as I sit on my porch I see nothing but youngsters who are doing exactly what you mean. Kids included.

  13. What about cannabis?!!! as a solution to chronic pain relief…
    Pharmaceutical compositions comprising hemp and turmeric to treat pain and inflammation
    WO 2015171445 A1
    The present invention comprises compositions comprising therapeutically effective amounts of CBD and curcumin in various combinations to treat pain. CBD and curcumin are preferably from natural sources. A method of using the combination of CBD and curcumin compositions to treat pain is also described.

  14. On response to the score of success..Online Digital Recovery Options.. most people today will find access to online resources and should be easily persuaded to take part… if there was an online community that they could go into and engage with other people into their communities that have success stories..🖐💚☆☆☆☆☆

  15. Oh..also I believe many people get lost in the idea that we are suppose to live completely pain free in this life.. being on pain meds after so long gives people a false sense of reality…that we can actually live pain free…daily..and that's got to change..and people need to be boldly reminded that a little pain here and there is just part of life.

  16. None of these folks look like they used drugs before, in rehab the counselors are normally ex-drug users! I guess get the millionaires high paying jobs to talk about low paid drug users.

  17. The speakers that are the public, need to sound more enthusiastic, or concerned , the tone, is becoming boring and hard to follow, they could sum it up quicker. I think the best think is get illegals out. Dont sell property to anyone without a citizenship, it lets others hide there in houses and business. Get the wall up. Interesting how the correlation of illegals and opiods went up quickly together.

  18. I hope the helping doesnt just become another place non profits and organizations get money from the government to do studies, and hardly help at all.

  19. Our schools are mostly illegals now in California, why would they think they should follow laws and not sell the drugs they provide for them to sell for money? Think of it, they train they 3 year olds to work on the streets while they sit, for money for themselves, what stops them now? They will continue to sell and get them so they can improve their lives.

  20. Apparently, Im gathering that it has become a problem from Medical facilities giving out opiods as pain relievers, so good your cutting back on that, but it is also the kids in High Schools, they think Heroine is a simple drug and no big deal

  21. Peace be unto you

    And He said to him
    Go, wash in the pool of Siloam
    which is translated Sent
    So he went away and washed
    and came back seeing

    Since the beginning of time
    it has never been heard
    that anyone opened the eyes of a person born blind
    If this Man were not from God
    He would not be able to do anything

    They answered him
    You were born entirely in sins
    and you teach us
    Then they threw him out

    Jesus heard that they had put him out
    and finding him
    He asked
    Do you believe in the Son of Man
    He answered
    Who is He, Sir Tell me so that I may believe in Him
    Jesus said to him
    You have both seen Him and He is the one who is talking with you
    And he said
    Lord, I believe
    And he worshiped Him
    Then Jesus said
    I came into this world for judgment
    so that the sightless would see and those who see would become blind

    Behold I am the LORD the God of all flesh is there any thing too hard for me

    It is also written in your law
    that the testimony of two men is true
    I am one that bear witness of myself
    and the Father that sent me beareth witness of me

    But these are written that ye might believe that Jesus is the Christ the Son of God
    and that believing ye might have life through his name

    My beloved America The Great and Beautiful my lovely Uncle Donald John Trump, God bless you
    My beloved America The Great and Beautiful my lovely Lady Melania Trump, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Michael Richard Pence, God bless you
    My beloved America The Great and Beautiful my lovely Lady Karen Sue Pence, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Kennedy, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Roy Asberry Cooper III, God bless you
    My beloved America The Great and Beautiful my lovely Uncle George Herbert Walker Bush, God bless you
    My beloved America The Great and Beautiful my lovely Uncle George Walker Bush, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Barack Hussein Obama II, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Joseph Robinette Biden Jr., God bless you
    My beloved America The Great and Beautiful my lovely Uncle John Forbes Kerry, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Christopher James Christie, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Charlie Baker, God bless you
    My beloved America The Great and Beautiful my lovely Madam Bertha K. Madras, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Michael Passante, God bless you
    My beloved America The Great and Beautiful my lovely Uncle David Jonathon Shulkin, God bless youMy beloved America The Great and Beautiful my lovely Uncle Rene Alexander Acosta, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Eric David Hargan, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Rod Jay Rosenstein, God bless you
    My beloved America The Great and Beautiful my lovely Sister Kellyanne Elizabeth Conway, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Francis Sellers Collins, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Scott Gottlieb, God bless you
    My beloved America The Great and Beautiful my lovely Madam Marilyn Barbour Tavenner, God bless you
    My beloved America The Great and Beautiful my lovely Madam Pamela Greenberg, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Harold L. Paz, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Joseph R. Swedish, God bless you
    My beloved America The Great and Beautiful my lovely Madam Kim Holland, God bless you
    My beloved America The Great and Beautiful my lovely Sister Anuradha Rao Patel, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Douglas Nemecek, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Michael Sherman, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Edward Allison, God bless you
    My beloved America The Great and Beautiful my lovely Uncle Richard Migliori, God bless you
    My beloved America The Great and Beautiful my lovely Madam Diane P. Holder, God bless you
    My beloved America The Great and Beautiful my lovely Madam Amy Turner, God bless you
    My beloved America The Great and Beautiful my lovely Sister Pamela Jo Bondi, God bless you

    God bless America The Great Nation
    a sweet and good Happy New Year with love hugs and kiss yuli':):)

  22. Another product from chemical lobotomists at Janssen Pharmaceuticals of Johnson & Johnson who knowingly lied to the doctors of children to sell billions of dollars worth of Risperdal® that causes gynecomastia and extrapyramidal symptoms. As seen on the new YouTube advertisement:
    https://www.youtube.com/watch?v=bvMf9ypbymE

  23. YOU ARE THE DRUGS, WEAPONS AND CHILD TRAFFICKERS AND ORGAN HARVESTERS! YOU ARE ALL INVESTED IN OPIOIDS USA CORP AND YOU MOTHER FUCKERS LET BIG PHARMA DO WHAT THEY HAVE DONE FOR THE NWO AGENDA OF DESTROYING THE US PEOPLE FOR THE ONE WORLD GOV AGENDA! WE WILL HANG EVERYONE OF YOU FUCKING PIGS OF US CONGRESS THAT HAVE DESTROYED OUR RIGHTS AND PEOPLE! YOU ARE NOT A US CITIZENS SATANIC PIGS!

  24. GUESS your NSA fucking spy whores didn't see any of this? SHUT THE FEDS! SHUT USA CORP! NOT A GOV! A VATICAN SATANIC WHORE GROUP OUT TO DESTROY THE WORLD! CONGRESS & US GOVS GOTTA GO! NAZI WHORES – ALL OF THEM!

  25. GET out of Afghanistan!!!!!!!!!!!!!!!!!!!!!!!!!!! WHERE US MILITARY IS GUARDING POPPY FIELDS! US MILITARY AND CIA ARE THE DRUG TRAFFICKERS! YOU ALL LOOK SO FUCKING STUPID SINCE ALL THESE SPY AGENCY'S EXIST! LOOKS LIKE ALL THE NWO WHORES HAVE INFILTRATED ALL LEVELS OF GOV, CORPS, MILITARY, COURTS – BITCHES GOTTA HANG!

  26. Wipe out the US Deep State Now! Come on US people! Get off your fucking fat football asses and fight for your rights! These fucking pigs, above in the video, are investors of opiods!!! Do you really believe these fucking pigs destroying our rights and spying us in all directions? Wake up US! USA is a corp and we are going hang every treasonous bitch in it!

  27. Washington Navy Yard, Offut AFB and other military bases are bringing in drugs, weapons and children for the elite of the US! They think they are royalty! Wahahaha! YOU ARE THE DNA TRASH OF THE PLANET USA CORP!

  28. HOW ABOUT THE SPY RING IN CONGRESS NAZI WHORES? NO MENTION FROM ANYONE IN USA CORP OF AWAN SPY RING! YOU HAVE NO CRED NWO SATANIC BABY KILLING FUCKING PIGS!

  29. There is something strange about California https://www.youtube.com/watch?v=SdTss9pSMi8 Business burnt but nothing around is burnt. Is this your directed energy weapons from space because this makes no sense! WHO IS SETTING THE CA & US FIRES? Hopefully good guys are burning out ISIS camps! Right Trump. We have ISIS camps in the US forest? CIA NAZI WHORES ARE ISIS! HANG THE FUCKERS!

  30. Great Job….
    Lesser number of movies that showcase drug abuse is having Very Good Impact….
    Movies have tremendous impact on social life….
    It is one GREAT ACHIEVEMENT BY PRESIDENT BARACK OBAMA which i overlooked….
    Great Movies have Great Impact….
    Even today i look up to old movies like Schindler's List, Seven Samurai, 12 Angry Men….
    Please keep up the Good Work…. 🙂

    It is Collective Effort…..Commendable……
    Love
    Indian

  31. Please help our great State of Alabama… Alabama has the highest level of prescription opioid use in the nation. Our doctors wrote 5.8 million prescriptions for pain pills in 2015, according to the Centers for Disease Control. That amounts to about 1.2 prescriptions per person (compared to the national average of 0.71). This isn't a new trend or one unique to Alabama, as most southeastern and rust belt states are sadly in similar shape. God Bless! #MAGA

  32. We need a Glass RAT CAGE with about 15 to 20 Rats, Put a smoke machine on top plumb it with all the necessary tubes. Lable the Tubes very clearly on top "CHEMTRAIL SMOKE SYSTEM" maybe even with a little miniature replica of the Whitehouse sitting in the bottom, and when you get your turn to talk to Congress or New Media, Turn on the Smoke let it billow inside and while you talk the Rats begin to choke and choke and choke until they die. When they are all Dead in a few min, inform them, this this is the result of CHEMTRAILS….

  33. if we don't seal that border and enforce immigration laws in the interior by 1000x times then this drug problem will grow exponentially.

  34. Vomit Inducing! Want to fix it. Fire yourselves and take Big Pharma and the CIA,EPA,IRS,FBI, DEA,ATF, And any other Feddy Prick I left out with you..

  35. It's great we're talking about alternative methods. Looking into holistic methods in particular. I have good reason to believe that it's possible our drug users have been altered physically. They're oftentimes drained of nutrients, as I was deficient in nutrients when I came off of drugs years ago. They're also drained of mental health, as I was also drained mentally after coming off of drugs. I'm sick & tired of providing my reasoning that's likely the solution. I'm sick & tired of promoting the diet that I sincerely believe may be the answer. Nobody listens. Too controversial. Despite overwhelming research, people maintain that It's controversial. Everyone is skeptical B.C. most medical doctors are oblivious when it comes to nutrition. Not many MD's have nutritional degrees, thus making them not only useless but oftentimes road blocking the route to holistic healing. Either way, I could write a book here on this subject but it wouldn't be enough to convince anyone. So, maybe it will work to put the idea into everyone's heads like this. What drains people of drive? Of good mental health? Hormone production is a good place to speculate, right? Even mainstream antipsychotics/mood stabilizers typically work through promoting good hormone production. First, we need to get it into our heads that drug users need to be studied on a chemical level. What's different about them? Is there something microscopic in nature that they are deficient in or have too much of that is fueling this negative behavior? Ugh, I vowed NOT to preach the gospel about diet & particularly the diet I've found but it truly can't be avoided. It's hard to touch base on this subject without producing scientific findings/leads on it. There has been a diet developed by a neurologist with a nutritional degree. I'm not sure if every bit of it is her findings alone OR if a molecular expert of some sort greatly assisted her. What I do know is in her book that's backed by medical findings, Gut & Psychology Syndrome(GAPS), this woman has directly linked likes & dislikes to the inner ecosystem. Guess what? When people do drugs, they LIKE them. She also notes encountering a high number of GAPS teens/GAPS adults over her long & successful career whom turn to drug use to fill those inner voids that they already had. Her diet calls for natural organic whole foods. We need to create new protocols within our judicial system on a federal level to effectively erase the parodies & bring in new hollistic treatment approaches. Nature always wins, ladies & gents. Let's stop speculating that this crisis is being derived from explicit t.v. programming & poor upbringings & such. My brother whom is a military police officer with strong family values has been separated from his beloved wife due to her drug use in this past year & also parted from his stepdaughter to the court system due to his wife's drug use. NO demographic group has been untouched. As far as that goes, I'm a past drug user. Neither of my parents used drugs drank nor smoked, yet they both showed GAPS symptoms, furthering my trust in it's founder's findings. So recap: Molecular studies needs to be launched on all affected by our drug epidemic, ASAP!
    Moving on, the next thing we need to do once step one gets implemented & I have no doubt it will be proved true, is create a natural chemical reaction within each individual drug users' ecosystems that balances them out. Everything has a chemical structure, even food. Food, and the RIGHT food, is a bodily fuel source that is very effective at creating the perfect environment to accomplish this balance. This truly is not a one bill fits all approach. The particular diet I mentioned has 6 stages. Not everyone has to begin at stage one. It's dependant upon digestive capabilities. We need doctors who are willing to learn & YES change. Or else, they'll continue to be a big part of this problem we're encountering where physicians are prescribing more drugs to treat drug addiction & oftentimes forced therapies & incarcerations that are obviously not assisting enough to apply the change that we desire. This is 2017. Time to turn to our so called advanced medical knowledge that we take so much pride in. When more time goes into testing a roughly $100 DNA test kit than what goes into these "in & out" "one bill fits ALL" drug epidemic related physician visits, we've got a major problem in this country. Your addressing the aftermath of this flaw in our health-care system as we speak. NO excuses. I'm not asking you to believe it. I'm asking for a leap of faith. Launch the studies.

  36. They are like the only way us lying thugs can fix this Opioid problem is to smuggle more of it into poor neighborhoods and have doctors pass it out like candy.. Then we'll rob, kill and kidnap anyone we think is using it..It's a Win,Win For us..

  37. This is bullshit this drug thing is their fault they created it to solve it!! That's right people the way they'll fix it is a cops fat ass hanging out of every car in America a check point at the end of every block and a rubber glove up the ass of everyone of us..

  38. These junkies needs to be locked up. They commit crimes under the influence. I dont want to waste so much money on adult junkies, children YES, adults NO. They need to go to prison and do cheap labor. It's ppl in jail for the smallest offences and now all of the sudden we're going to treat these adults junkies like they're children?? America has been run to the ground by these self loving politicians. America is a dumb country that everyone despises thanks to a certain group of ppl.

  39. Not everyone is harmed by prescription drugs that help with everyday pain as we age.  No punishments for Doctors we have enough trouble keeping good doctors in the profession.  A lot of NASAD's are very harmful to the health of many people and not an option for help with pain.   They made me extremely ill for many years, almost killed me.

  40. Less laws and more action about what causes people to become addicts.  If it is not one thing it is another for the addictive personality.  Go to the root of the problem and do not create more suffering with punitive laws.  PUsh it down here and it comes up there for the addict.

  41. How many people have you interviewed that actually suffer from pain on an hourly and daily basis.  These fine people at this table are not even close to being a senior of a life of heavy work.  All my doctors are wonderful care givers.

  42. This isn't new, Trump didn't invent the wheel, he just inherited the blue print. Its an issue that's span 50yrs and only gained recent traction after a bunch of white folks overdosed and a bunch of young white kids died from secondary contact. Trump didnt understand the epedimic during his election run anymore then he understands it now, his ignorance is shown by his complete lack of attention to the fact that he nominated a big pharma lobbyist to be his "drug czar".

    i hope this panel succeeds, its success im sure he'll be on every news channel claiming victory, its failure will probably be Obama's or Hillary's fault, while in reality it has shit to do with him either way. we've seen what happens when ppl believe the problems solved just because they see a televised conversation, Bush 2003 "Mission Accomplished!"

    My allegiance is to this country just as anyone else's should be, we don't need to have side shows of politicians doing round table circle jerks, constantly hailing Trump. More and more this is sounding like history doing what it does best.

  43. SOMETHING I RARELY HEAR #### Did you know that they've united the statistics that instantly scared the citizens, this fact is that they have joined the overdoses of street heroin and the Opioid Pain Meds together, making those suffering loose treatment that they BADLY NEEDED just to function physically! Since they started cutting in 1/2 the prescriptions that were keeping these Pain Sufferers at least able to do a few house chores daily, we have seen a 40 % increase in NEW Heroin Users in the streets, people who are older and who've never been arrested now have a felony b/c they couldn't stand the pain that was under control, but now isn't, and suicide among these patients has GREATLY increased too! These people who have never been helped by other treatments are emotionally wrecked over this. Its inhumane to remove the treatment that is working for those particular patients. Where is the compassion for those who cant function without high doses they receive, those who are under strict controls of Their Clinics / Doctors? God help us once they take away these treatments.

  44. I'M SUFFERING, PLEASE HELP ME AND PRAY FOR ME! + + + I am a Chronic Pain Sufferer with 2 back surgeries containing screws, bulging discs, degenerative spinal disease, scoliosis, nerve damage, partial paralysis, etc… The Doctors were handed regulations 3 months ago and began cutting the Meds that I've taken for 20 yrs. b/c they work. I've had too MANY other Treatments that gave me very little relief and when they did it was only for 3 hrs. up to 1 wk. a radical treatment that destroyed even more of my nerves and bone! We are going to unite and demand loopholes with STRICT guidelines, to give these Patients who now have NO LIFE after this removal of Medications for the next 2 elections so folks like me and many others, especially cancer patients, can get the dosages needed, have Doctors willing to treat us and Pharmacies to fill said Scripts! I have to drive 70 + miles to see a Dr. one way and another 11 to the only Pharmacy in 3 counties who will fill My Meds! The Govt. is using words like Epidemic to frighten families with teenagers and Our Veterans are suffering under this too, to have you believe that Their Meds are a serious problem, but this has created way more wreckage and the death toll concerning Sufferers like me will soon get worse, we haven't seen anything yet! All I'm pleading is for Politicians and Trump to see that we are part of those who elected him and if this becomes a Campaign Issue, and it soon will, Republicans will see serious challenges. So if you who read this don't suffer EVERY hr. of the day PLEASE help us, please put yourselves in our shoes, if the Meds and Doses you are on after your whole spinal column was displaced, crumbling, had bulging discs above the last surgery, nerve pain and the bruising and inflammation coming from the screws holding your back together, where your body is trying to reject the metal, then you too would be very distraught to know that what has worked for you over the last 20 yrs is being removed, and the little you will be given cant be filled b/c the Pharmacies are too afraid to help you, then how would you feel? These Sufferers are those who take meds as directed, and play by all the rules, and don't get high from them its so they can work and those like me now spend 23 hrs. in bed or a chair now, cant visit my New Grandson, and see my family rarely b/c I cant even go to funerals now, I have NO LIFE at all, but still being punished, WHY ? Speaking of those who have no voice and those whom are forgotten we are those people too! I beg all Politicians who are Drs. to create said Loopholes for the patients like us or you will see these folks go looking for other things to help the pain like weed, drinking alcohol and buying street heroin, and this will give us more drug deaths, more crime, many marriages will fail, and many who quit drinking so they could be treated will begin drinking again. I will stop here, just had to go into the details b/c the public doesn't understand that there are many out there who are NEEDLESSLY suffering and it will only get worse and sadly many of these folks wont make it, as their lives will be cut short for no reason, this can all be avoided so please help us, pray for us, call Your Politicians and stand up with compassion for those dying of cancer and with nightmare pain conditions b/c we have no voice b/c we are now seen as Junkies, but we are not, we are your everyday people you see shopping or sitting and eating with family, we just want to live the life we have left and be treated by Our Doctors like before, NO ONE should be dictated too on something this impactful and private, it should be between the patient and His or Her Dr. not the govt. as to the quality of life they have left and how they choose to be treated, not threatened to be completely shut down b/c they want to do right by their patient. WHAT HAVE WE BECOME, WHAT HAPPENED TO US, AND OUR COMPASSION ? God bless and thank you all who read this comment, to any Official, thank you for listening and reconsider how you approach the chronically ill, have a great day my friends.

  45. A Pain Killer the day before causes loss of work ? That's not true Opioids DO NOT cause a man not to work over 14 hrs. later the next day! They are talking money while folks suffering are dying from Medication Reductions! What I've watched thus far sounds like nothing but threats, false epidemic language, oppression and mechanisms to not treat chronic pain so I cant take anymore, this Treatment Removal is destroying my life for no reason! Its just like the Gun Control Issue, taking away Guns from the law abiding gets them killed, taking Meds from serious disease sufferers will kill us slowly, cause HUGE spikes in 1st time Street Heroin use, spikes in pot use, and alcohol use, and these NEW users are going to be the OLDER patients, and this will turn more folks into FELONS, ruining lives and suicides are already spiking! WHERE IS COMPASSION. You've scared the Doctors and Pharmacies so bad that patients cant find anyone to treat them nor fill their prescriptions! God help us who suffer.

  46. America needs to borrow Philippine's President Rodrigo Duterte who will eliminate America's out of control drug crisis in less than six months. Perhaps President Trump could discuss this matter with President Duterte in the Phillipines next month and get a few pointers from action man Duterte who is no fool and won't be bought off.

  47. Has any in the commission taken a moment to inquire about how these narcotics are getting here? Perhaps they need a refresher course on the goings on in Mena Arkansas under Bill Clinton that hooked a whole generation of inner city kids on crack cocaine.
    Since we entered Afghanistan, productions has skyrocketed. Coincidence? No… CIA
    Want to make a difference, cut the supply. Burn the fields. Cheap, quick, and a supply so small as to force the addicts into rehab. Or we simply ignore the logistics, encourage the afghans to keep producing, and allow all in between the needle and the flower to grow rich off the suffering of the addicts. After a 100 years fighting this failure called the war on drugs, do we not learn anything? Well, we've apparently learned to make the motions and allow certain groups or individuals to become rich. We are our own worst enemies.

  48. Awan Trial Day 3.1. Outline of Complaint Against DWS and Awan Spy Ring in Congress https://www.youtube.com/watch?v=fBd93oOQbH8 Rao Abbass still working for the Spy Ring and emplyeed by the WH. Abbas and the spy ring continue to take US info off phones and sell to other country's. ESPIONAGE! TREASON!

  49. Some in the gov, feds, military, police, sheriffs, courts and corps are ALL INVOLVED IN DRUG, WEAPONS AND CHILD TRAFFICKING! CONGRESS IS INVESTED IN IT! We will arrest all involved and hang you for crimes against humanity! Congress knows about the opiod epidemic as they are NWO and out to kill the US people with so many things: HAARP, chemtrails, vaccines, big pharma, nuc rads, wars and so much more! Nuc rads in your light bulbs and smoke detectors. PSYCHO!

  50. Government cannot stop a person from addiction.  The prior president  & Clinton let the illegal drug lords in,  why are states legalizing more drugs? pharmacy companies and physicians are drug dealers all about $$

  51. Be careful not to harm the truly needy of pain medicines. Get big pharma to build rehabs for all who can use them and we know many can't. Whatever doesn't work, throw it out.

  52. You don't take cancer treatments away from cancer patients. You don't take meds away from diabetics. Heroin addicts get their meds, including addictive ones…but chronic pain patients, who follow the rules, pass all drug screens, taking meds as prescribed, treatments that actually improve quality of life for many being treated with a combination of treatments, one being narcotic medications. These limits your imposing on patients is inhumane. We are pain patients, not addicts!!!!!!!

  53. While chronic pain patients quality of life is going down the toilet. But they aren't going to talk about that…and patients aren't being included in their care, they are being bullied after following all the rules…

  54. Quote @ 1:28…" while opiods are extremely helpful in managing pain" so they acknowledge the benefit, but we are going to recommend ty chi instead.

  55. If only acupuncture lasted 8 or more hrs…or in my case relief only last as long as the needles were in place…

  56. Obama would never put something like this together, they would want all the dependent drug addicts money can buy to vote for them instead

  57. If everyone put their heart and soul into this effort the Good Lord will do the rest, and you will see the results to thank Him.

  58. An Opioid Epidemic? WHAT COMPLETE HORSE SHIT! AND LOOK even a REHAB person that will have an entire new customer base, filled beds and lots of money! Want to know what the REAL PROBLEM IS or do you just want to sensationalize? You know what I don't care anymore here's the REAL REASON PEOPLE ARE DYING… HEROIN CUT WITH FENTANYL! Foreign fentanyl! So how did we get to an #OpioidCrisis if its Heroin? Well PEOPLE WILL NOT LIVE IN PAIN and if they cant get relief from "Dr Real" they will see "Dr Feelgood" and old Doc Feelgood has NO quality control!
    A guy named Andrew Kolodny started calling Pain Patients that HAVE A LEGITIMATE NEED for Opioids, addicts but it seems Kolodny, who worked for a large rehab company as Chief Medical Officer saw "money in them thar pain patients, as a large potential client base if there were just a way to…and it hit him "let's call these pain patients addict"! And then he started to get some graphs and figure out a way to confuse people into believing OPIOIDS given to pain patients made them addicts and caused overdose deaths when its actually HEROIN causing these deaths but more and more are caused by LEGIT PAIN PATIENTS be forced to seek relief from old Doc Feelgood because STATE MEDICAL BOARDS along with certain agencies of the federal government intimidate pain doctors to stop treating pain! This forces old Doc Feelgood into action and the vicious circle grows bigger!
    Here are 2 articles that explain pretty much everything you need to know!
    1
    https://www.acsh.org/news/2017/10/12/opioid-epidemic-6-charts-designed-deceive-you-11935
    2
    https://www.acsh.org/news/2017/08/16/heads-sand-%E2%80%94-real-cause-todays-opioid-deaths-11681
    I'd put a website here where that Foreign Fentanyl will be delivered to your door for just $60

  59. This is turning into a cash grab for REHAB centers! It was the Chief Medical Officer of a REHAB who created the #OpioidCrisis government would never pay for enough #HeroinCrisis rehab patients!

  60. You seriously need feedback from those of us with incurable, chronic, debilitating diseases and illnesses before anything is implemented.

  61. Mr. Christie, you made a comment regarding the number of deaths reportedly, also inaccurately, due to opioid abuse and how if it was different, actions would be taken. What about alcohol? Number of alcoholic liver disease deaths: 19,388; Number of alcohol-induced deaths, excluding accidents and homicides: 30,722; https://www.cdc.gov/nchs/fastats/alcohol.htm;

    What about cancer? Number of deaths: 591,699; Deaths per 100,000 population: 185.6; Cause of death rank: 2; https://www.cdc.gov/nchs/fastats/cancer.htm

    No one speaks about chronic pain patients with proven conditions. "Chronic diseases are responsible for 7 of 10 deaths each year, and treating people with chronic diseases accounts for most of our nation’s health care costs." – https://www.cdc.gov/chronicdisease/index.htm Do we not matter?

  62. This is a joke! What you are doing is HARMING people with complex health issues and you are IGNORING our cries! I have organ failure and can not get the medication I NEED because of ALL of your ignorance and bias! The disabled are coming out to REMOVER you ALL from office for NOT protecting us and giving too much power to GREEDY insurance companies at our expense! YOu NEVER once gave ANY thought to those of us who are fighting serious health issues, this is GENOCIDE! The politicians are forcing our doctors to committ medical genocide. Stop saying you have our best interest at hert because you don't give a crap about those out here suffering. Most of you have NO business even talking abotu this,no medical training and you brought addicts in front of congress but NOT one patient! You are passing out money for addiction by the buckets and addicts are still nnot getting the help they need! You are following Kolodny & Indiviors marketing plan to a T and no one not even addicts want their dirty product that has a 52% relapse rate and does NOTHING for pain. Stop with the LIES and propaganda and STOP hurting people. Our veterans are being tortured too and the suicide rate among htem and the s ick has skyrocketed so your 36% reduction in opioid use but it has increased suicides substantially! SHame on ALL of you for torturing your fellow AMericans who put you in office, but we are coming for your jobs! Who in their tright mind lets a psychologist say what someone with a serious disease needs? Teaching tools to our veterans or anyone else is a damn joke! Ask us if opiates work for us! Kristy should not be anywhere near this committee he is biased because his friend OD'd. All involved in this scam should go to jail!

  63. Does anyone care about the MILLIONS of legitimate pain patients across the country who are needlessly suffering because of this utterly inhumane treatment? Stop the opioid hysteria and go after the true culprit causing the OVERDOSE EPIDEMIC….illicit FENTANYL!

Leave a Reply

Your email address will not be published. Required fields are marked *