WASHINGTON — Sen. Dick Durbin (D-Ill.) took aim at Big Pharma during a Senate hearing Thursday on the opioid crisis.
“A few years ago there was a committee hearing, and they dislcosed that the pharmaceutical industry asked for permission to produce 14 billion opioid doses a year … so that every adult in America could then fill a prescription for 3 weeks,” he said at the hearing held by the Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies. “They came up with 14 billion because they thought they could make money selling [that amount], and it was approved by the Drug Enforcement Administration. Think of that — at a time when we’re facing the worst drug epidemic in our history, a government agency is giving this industry permission to make 14 billion tablets!”
“How does that fit with what the CDC sends out as a notice to doctors?” Durbin asked, then read from a CDC flyer: “‘Start low and go slow — for acute pain, prescribe fewer than a 3-day supply — more than 7 days rarely required.’ And here the pharmaceutical industry asks for 14 billion opioid doses despite another agency of the government saying, ‘This is preposterous.'”
“So, being a senator, I decided to raise hell about 14 billion and boy, did we make progress,” he said. “You know what we have now as an annual production quota? 13 billion.”
Physician Overprescribing — and Underprescribing — Questioned
Durbin also took a swipe at physician overprescribing. “The thing that troubles me greatly is that we dance around the obvious — we dance around the fact that somebody is writing prescriptions for opioids to reach 13 billion; that somebody is a doctor or a dentist or a nurse practitioner.” He asked the witnesses at the hearing why the country isn’t seeing a “real response” when it comes to curbing overprescribing.
Charissa Fotinos, MD, deputy chief medical officer at the Washington State Health Care Authority, in Olympia, said she had noticed a difference recently. “We’ve seen a decrease in the number of prescription opiates prescribed over the last several years of about 44%,” she said, adding that reports now being sent to doctors about how many opiates they’re prescribing compared with their peers are one factor.
Sen. Lamar Alexander (R-Tenn.), however, expressed concern about underprescribing. After the CDC issued its opioid prescribing guidelines in 2016, “we heard that many people across the country accept those as law, and that even some physicians are giving up the prescribing of opioids, even in small amounts” for fear of getting in trouble, he said. Alexander then asked the witnesses, “Do you believe that the CDC guidelines should be revised in any extent, and do you believe they’re taken as law when they’re [really] only advice?”
“The message that a lot of physicians have gotten is that the opioid epidemic is their fault,” said Fotinos. “We know they don’t work for chronic pain, but we put so much emphasis on the fact that too many opioids are prescribed — and they are — that there’s been too far of a pendulum swing … We know that somewhere there’s a right amount.”
“Part of the challenge is that we have to change the way we talk about pain,” she continued. “Everybody’s pain tolerance and ability to manage pain is different. … I do think [the CDC guidelines] are reasonable guidance. Should they be law? No, because everyone’s different.”
Witnesses also discussed how their organizations were addressing the opioid crisis in their state. Fotinos said her state had gone from providing medication-assisted treatment to 5,000 Medicaid patients in 2013 to 21,000 in 2017, “a four-fold increase,” and had also distributed 37,900 naloxone kits in 2018. And that same year, the state’s prescription drug monitoring program (PDMP) database was queried more than 20 million times, “far exceeding the number of controlled substances dispensed,” she said.
Beth Tanzman, a health official in Vermont, discussed her state’s “hub and spoke” program for opioid addiction treatment now reaching 8,000 people. The Medicaid home health program “links primary care ‘spokes’ and addiction treatment program ‘hubs’ together,” she explained. “Patients can move between hubs and spokes based on their need.” The program works so well that the state has no waiting list for treatment, and Vermont has the lowest opioid overdose death rate in New England, she added.
Witnesses also had suggestions for further funding. “Medication-assisted treatment — the combination of medications and counseling — is the most effective treatment for opioid use disorder, and as such, it should be consistently available as the standard of care for this condition,” said Tanzman.
“Expanded access to quality addiction treatment is needed,” said Karen Cropsey, PsyD, professor of psychiatry at the University of Alabama at Birmingham. In addition, “the regulations surrounding buprenorphine prescribing are a barrier to treatment.”
Cropsey had another request. “The development of novel medications to treat opioid use disorder and other addictions is critical,” she said. In addition, “Patients with addiction are complicated and often have other psychiatric conditions, chronic pain, and other health conditions that have gone untreated. Increasing parity in reimbursement for providers who treat these complicated patients is imperative for expanding the workforce.”
She also asked for more research into treatment outcomes. Although MAT is lifesaving, “what’s less known is if someone goes to a specific treatment facility, what happens 30 days or 3 months or 6 months after they leave that facility. If you were able to … provide resources to [be] able to collect that kind of data, we would better [know] what happens after an inpatient treatment program.”
A Bigger Workforce Needed
“We have a dire need to increase the [treatment] workforce,” said James Berry, DO, director of addiction services in the behavioral medicine and psychiatry department at West Virginia University, in Morgantown. “There’s such a precious window of time that’s an opportunity when people are ready to get help; we need to act on it as soon as we possibly can.”
Mark Stringer, director of the Missouri Department of Mental Health, in Columbia, had a more general request: money. “We’re fighting … a very steep uphill battle here,” he said. “As much as these grant dollars have helped, we still have people who cannot get into lifesaving treatment.”
Alexander noted that although Congress has accelerated funding for alternative, non-addictive painkillers, “we have a ways to go. Many patients with chronic pain would not be satisfied … with yoga and ibuprofen and therapy, as useful as they can be.”
Several witnesses praised the increased federal funding of addiction treatment programs. Asked by Sen. Jeanne Shaheen (D-N.H.) what would happen if that funding were to be cut, Cropsey replied, “As a clinician, before these federal funds, I had no place to refer people with addiction who were uninsured, and we would go back to the days where people just died.”
Committee chairman Sen. Roy Blunt (R-Mo.) told MedPage Today afterward that he thought the hearing served a useful purpose. “This is probably the best hearing we’ve had on people talking about how they’re applying the help they’re getting.”
The committee will be looking at “the relatively new funding at [the] CDC and at [the National Institutes of Health], looking at the funds they have to both try to help seek other non-opioid based pain medicine, and the new funding they have to try to evaluate what’s working,” he said.