pleased that the director from the white house office of national drug control policy is here today to tell us about their action plan. in a perfect world, the answer to this problem is personal responsibility. but in the real world it's clear the federal government does have a defined role to play. we need to provide greater support for education programs for young people so they can learn at an early age the dangers of misusing prescription drugs. we need to provide greater sur rehabilitation initiatives t who are addicted to prescription drugs have access o the help they dacally need. and we need to make sure dea has access to the resources it needs to scrutinize all the players invoed in the manufacturer, distribution, and dispensing of controlled substances. most involved in this process are good and honest pel@ and the dea needs to find the ones who are not. and so i'd like to personally on

behalf of the democrats on this committee thank all of you for coming today. and i look forward to your testimony. i stand ready to work with each of you, madam chair and our colleagues and witnesses to curtail prescription drug abuse in the united states of america. thank you so very much. i yield back. >> thank you, mr. butterfield. chairman upton has yielded his fife minutes for an opening statement to me in accordance with committee rules. as his dissignee. >> thank you. very important. i'm also very pleased to have and welcome our attorney general, florida's own attorney general, pam bondi. she is here to testify on this important hearing. she is florida's 37th attorney general, worn in january of last year. she is a native of florida, and she graduated from the university of florida, which i represent. so i'm proud to have her as

so-called constituent. she also graduates from stetson law school and was a prosecutor for almost 18 years. among her top priorities is strengthening penalties to stop pill mills in the sunshine state, which from our last hearing, madam chair on this issue was a prevalent problem in our state. and with her dedication and leadership against prescription drug abuse, florida went from having 98 of the top 100 dispensing physicians for oxycontin pills to having 13 dispensing physicians residing in florida. so frankly, her success in this effort results in recognition for the national association of drug diversion investigators, the florida police chiefs association, and from the florida board of medicine. so i want to welcome her, and i thank you, madam chair, for the opportunity to do so. >> thank you. and i just want to point out that there is a hearing going on in the health subcommittee with a cabinet secretary. so a lot of members are bouncing in and out. if they're able to attend, i want to thank the members who

are here. >> madam chairman, that's where i was until i figured out i was in wrong place. >> i'm glad you figured out. but we do have three panels before us today. each of our witnesses has prepared an opening statement that will be placed into the record. each of you will have five minutes to summarize the statement in your remarks. the good news is the clock is working and there is a timer in front of you now. on the first panel we have the honorable gil kerlikowske. good morning, director, and once again thank you very much for being here. we're happy to recognize you now for five minutes for your statement. >> thank you, chairman and ranking member butterfield and distinguished members of the subcommittee. it's a great opportunity for us to update you on this important issue of prescription drug abuse in the united states. prescription drug abuse has been a major focus of the office of national drug control policy since my confirmation. i'm particularly indebted to chairman bono mack for calling me up to her office in the first week that i was in office to

really begin to educate me about an issue that frankly three years ago was not on the public's radar screen, but is clearly in front of the public today. i included prescription drug abuse as a initiative as part of the administration's national drug control strategy. as has been mentioned, it's been categorized as a public health epidemic by the centers for disease control and prevention. the scope of nonmedical use of pharmaceuticals is striking. cdc found in 2008 that the opioid pain relievers were involved in 8,000 deaths and are involved in more overdose deaths as has been mentioned than heroin and keck cain combined. the vast majority of pharmaceutical drugs originally enter into circulation through a prescription. the quantity of prescription painkillers sold to pharmacies, hospitals and doctors offices has quadrupled from 1999 to 2010. when i testified last year before this subcommittee in

april, the administration had just released that month its comprehensive prescription drug abuse prevention plan. and the plan focuses on four major pillars. the first pillar is education. most prescription painkillers are prescribed by primary care doctors, internists and dentists, not pain specialists. the fda is requiring manufacturers of these opioids to develop educational materials and training for prescribers. the administration is working with congress to amend the federal law to require mandatory education and training for prescribers. and we are also working very hard to educate the general public about the risks and the prevalence of prescription drug abuse and about the safe use and proper storage and disposal of these medications. on the second pillar, monitoring, we focused on expanding and monitoring state prescription drug monitoring programs. 48 states have those laws. despite the progress, some states lack operational

programs. many states operate pdmps that lack interoperability with other states. but i'm pleased to report the administration worked with congress to secure legislative language to allow the department of veterans affairs to share prescription drug data with these pdmps. our third pillar focuses on safe disposal of unused and expired medications. and through the national prescription drug take-back days that the dea has collected and was talked about by the chair. the administration also recognizes the significant role that pill mills and rogue prescribers play in this issue. our surveys and research show that with chronic addiction to prescription drugs they're more likely to obtain their drugs from the pill mills than the recent initiates. and the final pillar of the administration's plan focuses on improving law enforcement capabilities to address diversion. across the country, law enforcement regulatory and legislative actions are forcing

doctors and shoppers -- doctor shoppers and others seeking the sources of prescription drugs to be apprehended. the problem, of course, was highlighted in the state of florida which was in 2010 the epicenter of the nation's pill mill epidemic. but i have to tell you that working with the attorney general in the state of florida has led to marked changes in that state. and i couldn't be more pleased that not only she, but attorney general conway are here. in 2011 ondcp, our office, supported training events because we know if you're going to do the enforcement, it can't be just at the federal level. it has to be at the state and local level also. and experts at law enforcement need that kind of training in order to investigate these complex cases. we're undertaking a data analysis project right now to examine the ways the prescription drugs are purchased, purchasing behaviors, and whether those patterns are

indicative of suspicious behavior. we held a roundtable with members of the pharmacy community and law enforcement to discuss pharmacy robberies and burglaries. we called in the heads of organizations that work on the security of the manufacturers and distributors to make sure that we were knowledgeable what they were doing to secure these very potent pharmaceuticals. in closing, just let me thank the members of congress for their support on the ondcp and my executive branch colleagues who know that without your efforts and without your support, we would not make a difference in this very important area. thank you. >> thank you very much, director. i will recognize myself now for five minutes for questioning. and just ask you, with everything that your office is doing together, the dea and the fda, why are we losing this battle against the prescription

drug epidemic? and you have mentioned a lot of progress we have made, particularly in florida. but prescription drug abuse has not decreased. what is the next step? >> i think the fact that all of these things are coming together, that we actually are starting to see some fruition to all of the work that has been going on. for instance, in the most recent monitoring, the future survey, 8th, 10th, and 12th graders have actually reduced their use of prescription drugs. but i couldn't agree with the chair more that it is an epidemic, that it is so widespread, and that people still don't get it. they don't understand that these are dangerous. they can be deadly, and they can certainly be addictive. i think that one of the greatest hopes will be in the next step forward, and that is mandatory prescriber education. physicians must be told and must have unequivocal information about the dangers of addiction,

pain management, tolerance, dependence, and they really don't get that in medical school. the second part i know you'll hear from the drug enforcement administration is on enforcement. the laws have to be enforced, and people have to be prosecuted. >> i appreciate that. and especially your viewpoint on prescriber education. but a problem for me too as we examine this problem is there are clearly gaps in the data. and we don't really know the extent of the problem. what are the gaps and how can they be filled? >> well, quite often we rely, for instance, on fatal data to come from the individual states. and we know that depending on the particular state whether it's a medical examiner system or others, those states can often be delayed. we also know that at times, whether it's from the fatalities from driving accidents or others that the level of examination ises to determine what the cause and whether or not that person had the drugs in their system is

not always as thorough as it can and should be. there are data gaps. but i'll be happy at another time to tell you about this new initiative to take some of the data and really identify and drill down into it. >> i'd be happy to work with you on that. i think they're critical, even for policymakers. we need that data critically. the dea is going to testify that there are 1.4 million dea registrants. that seems awfully high. you think that 1.4 million registrants is about right for aherica? or is that kind of a crazy number? >> chairman, i actually wouldn't know what the right number would be. but i think when you look at nurse practitioners, physicians, and all of the other people that hold those dea registration licenses across the country and in the health care field, that the number doesn't seem completely out of line to me. i think more importantly, it's

how they're policed. >> thank you. and lastly, should we be thinking about creating new classification schedules under the controlled substances act with stricker regimes for the drugs that are clearly the biggest problems? >> i know that issue has come up before. to put those into the higher schedule. i think the more important part is to try and keep them out of the hands of the abusers, but not at the same time make it so restrictive that the issues that led us to where we are today 15 years ago, which was the clear indication that pain was not being adequately treated in the united states, i think the pendulum was too far over there. clearly today the pendulum is too far over here. when it comes to the available of these. i'm not sure scheduling would be the right answer, but we have to bring this back to some eek l

equilibrium. >> are you working that this is hurt mortgage people than it is saving? >> i have. i heard from a number of physicians that want to be much more flexible in understanding and treating pain, rather than writing prescriptions for 30, 60, or 90 days' worth of very powerful painkillers. they also want to make sure that there are systems in place where they can be adequately rehm b rd for what right now seems to be a simple and effective but not always effective in writing a skrip. >> the opiate babies. can you speak briefly to what you have learned about opiate babies? >> i can. i can tell you in the past and having visited one of the centers for newborns in seattle, the issue always centered around newborns and the addiction through heroin. today when i met and saw all of those infants and actually held

one of those infants, the issue was all about prescription drugs. and there was very little discussion about mothers using -- using heroin. and so we're building some tremendous health care costs as a result of not treating this adequately. >> thank you very much, director. i'm happy to recognize mr. butterfield for five minutes. >> thank you. again, thank you very much for coming forward today with your testimony. we have heard your testimony, and we appreciate so much what you do. i have a question that i would li o ask, and i may even ask it of the other panels as well. but i believe it's very critical, and it's central to the problem that we are dealing with. efforts in one state may yield declines in the number of pills dispensed, hospitalizations or deaths, any which are very

depend commendable achievements. how can we be certain that they simply don't go to another state? >> i think the key and the example would be the fact that florida had become such as has been talked about so publicly an epicenter for not only the use of these very powerful -- use and misuse of these very powerful prescription drugs for people within the state of florida, but for people traveling all the way through appalachia nationally, new york, connecticut, and other places. the regulation of medicine is done at the state level. it is not done at the federal level. and we have to provide the training, the technical assistance, the startup money for the computer systems, and the assistance to law enforcement, particularly state and local law enforcement to understand how to investigate these complex cases. i would tell you that greater use of the pdmps is necessary. not as many physicians or people

in the health care industry utilize them as should. and that they need to be real-time, and that they need to be interoperable across states. when those things come together, and i think we're seeing some of this in a number of states that are sharing the information, i think that that way we can stop that balloon effect that you were talking about, congressman. >> we've been looking at the data in our office, and the data seems to suggest that the total number of elicit drug users was constant for two years, even though we have seen great strides in states like kentucky d florida and even ohio. are we on the right path with this? >> i think we are on the right path with this, with what i believe is a very balanced way and a very comprehensive way of looking at this. if i go back and look at where we were, and believe me, i'm the first one to tell you that a lot more has to be done, particularly in redoubling our efforts in some of these areas. but i look at where we were

three years ago as a chief of police of a city of almost 700,000 people. i was really unaware of this prescription drug problem. and i think that my colleagues who were sworn to protect people in their city and learn about what are the dangers, when you don't realize it, when we didn't realize it, and prosecutors and judges and many others did not realize it, we weren't paying attention to it. because after all, it's a prescription. it's coming out of a medicine cabinet. it was huge mistake. this is on the front page of every major newspaper on a regular basis. it's on television. we're moving in the right direction. >> let me talk about travel communities for a minute. as the national drug control strategy points out, tribal communities have been particularly hard hit by unemployment. and combined with problems accessing health care, education, and other services, tribal communities can be

vulnerable to prescription drug abuse. a 2009 study by the substance abuse and mental health administration found that american indians are more than twice as likely as whites to abuse prescription drugs. what is the administration doing to help tribal communities address these unique challenges? >> we started looking at that almost immediately. and a couple of things are done. first, the assistant secretary, echohawk from the department of the interior has been a great partner, along with the indian health service and along with the bureau of indian affairs. we've made trips to a number of the tribal lands, for example, to tahonto odom nation that is around the prescription drug issue. >> are you working with it instead of databases? >> so the education and

prevention and working through the indian health service and treatment service. and let me just mention on the enforcement side, for the first time, one of our high intensity drug trafficking groups in portland includes a member of a tribal chief to help direct those needed enforcement resources back on to tribal lands. >> that includes databases and resources? >> i don't know about the database in particular. i would think that the health source would be more knowledgeable that. >> thank you. you've been very kind. >> thank you. > chair recognizes mr. stearns for five minutes. >> thank you, madam chair. is it true that prescription drug overdose deaths now surpass our car-related fatalities? >> it's true that all overdose deaths from drew, misuse and abuse, not accidental are the number one cause of accidental

death in this country, ahead of gunshot wounds and ahead of car crash deaths, driven by prescription drugs. >> that's a startling fact, don't you think? >> yes. >> do you think based upon that that we should have a radical change in our approach? >> i think that we haven't gotten anywhere near the attention or near the traction to something that is killing more people in this country than the car. >> 10 or 20 years ago i wouldn't find the statistic like it is today? >> not at all. >> and why do you think that has occurred? >> one, i think the driver of the prescription drugs as we've been -- as has been mentioned a little bit, people don't see them as addictive, they don't see them as dangerous and they don't see them as deadly. because they're after all a prescription. >> i think in your opening statemen q are talking about opiates are sold in 2010 to medicate every american adult six times for a month. that was in your statement. >> yes.

>> you put a lie to the claim that we're just getting better at pain management? >> when have i spoken with the physicians who looked at and were instrumental in the early days of undertreating and the recognition of undertreating pain, i think that was a clear recognition. and as i mentioned a minute ago, i think the pendulum was there, and that in very good faith ways, they worked very hard to make sure that people actually were adequately treated for pain. two things were missing. one is the amount of education that a physician would need to clearly understand and recognize some of the dangers of these. the other is that as many people have mentioned, we have become kind of an overmedicated society. >> how would we educate americans to not be an overly medicated society? >> it's a pretty tough issue. it's kind of like dealing with the obesity issue. >> do you think it's something

to do with our culture today? >> i think that the more important part is to educate the physicians around this as physicians are so much more knowledgeable about dietary issues and the causes. i don't see the same level of knowledge among them and among health care practitioners when it comes to the addictive problems of these drugs. >> could you from your department make it more difficult for the doctors to provide prescription drugs in the areas that are causing the overdose? is there something that you could do? >> we are kind of a small policy shop. >> you couldn't make any recommendations. >> these folks together. i think the key will be education, and then making sure that they follow the rules. and i think that we're well on the way to hopefully getting that done. >> you mention in your opening statement the actual costs to society estimate at 56,207,000 and maybe likely higher toda

so you have any what the cost in terms of devastating effects on families and communities? if it was $56 million in 2007, what do you think it is today? >> well, i think the most recent study on the costs to the united states taxpayer on drug abuse was well around $190 billion. >> 190 billion? >> and that includes all types of heroin, cocaine, marijuana issues, et cetera. but i think that you couldn't be more correct in putting forward the fact that it's not only a huge cost in our health care system, it's a huge personal cost and a huge personal tragedy. the child that doesn't graduate from high school, the employer that wants to start a new business and can't find people that are drug-free so that they will have less accidents and be more productive. all of these things play a huge part. and to the dollar cost is one

thing. the tragedy to this country is another important part. >> lots of times all of us talk about the legal war on drugs. but we're also -- i think we have to consider the war on prescription drugs. and so i guess the question is where does the current prescription drug war rank compared to our war on illegal drugs? >> i think my colleagues, particularly in the drug enforcement administration, when they set their goals and they move forward each year in recognizing what the drug threat is, several years ago they recognized this issue much more quickly and actually changed their direction and focus. i think you'll hear about the number of what are called tactical diversion squads, the number of investigations, the number of local law enforcement and prosecutors that have been trained in how to investigate these complex cases, because these are actually legal drugs that are manufactured and often

through prescriptions or pill mills. so those are important steps forward. >> are we winning or losing? >> we're moving ahead. i'm encouraged by a couple of things. one, the number of dispensed opioid prescriptions has flattened. and if you lack at the charts in a number of years, it looked like the space shuttle taking off. with the amount of opioids manufactured has flattened. and the fact that in this most recent monitor in the future, 8th, 10th, and 12th graders actually decreased in their use of one of the very powerful painkillers, vicodin. i think we're moving there. but as the chair and others know so well, it's not enough. and it's not fast enough. >> thank you very much, mr. stearns. and then pleased to recognize mr. mckinley for five minutes for his questions. >> thank you, madam chairman. briefly, i think you and i had a

little conversation beforehand we began, and we were concerned about privacy. i still would -- i'd like you to expand a little bit about that. what to me from an engineering from a small business perspective, i'm a littl concerned about -- very concerned about the privacy. but i know and i think you would recognize that if there were a national registry of all the prescription drug use in america, the pharmacies could be held responsible to check that registry and find out that they just got oxycontin just one day earlier for three months' supply, and they would be able to say no. isn't there something, some form -- i know we don't want to have -- because as we've had other hearing here of somebody being able to hack into that information. >> right. >> there are penalties that are related to that. but we all know if we had a

list, if someone had a list, we could go -- hold those people responsible more so than the distributors that are doing the best they can to curtail that. tell me a little bit about what rts we can do in security, the privatizing those names so that individuals can't be identified, but yet a pharmacy would be able to know that they have now -- this is their third prescription for the same medicine in the last two weeks. isn't there something you're doing on that? i saw this other, and i think that's just great, education. it works so well with teenaged pregnancies and everything else, hasn't it? sanctions against governments that they continue to do. so i really want something with more substance to it that is going to solve the problem. >> sure. i think the answer is the prescription drug monitoring plans that are done by the

state. since the federal government doesn't regulate the practice of medicine and the state does, having the pdmp, that electronic database that would be used by all physicians and health care professionals that would be real-time, and in states, particularly neighboring states, that information could be share aid cross the states. when it's led and directed and the startup money comes from the federal government, but led and directed by the state government, they can put in the protections about patient confidentiality and privacy. i think in the best of all worlds, that national database would be a wonderful thing. i think it would be difficult to implement because of the protections that would be needed to prevent exactly as you said hacking. and i think that part of that national database would be the fact that it would be five or six or seven years in the making

when right now we have all but two states that have pdmps. and as they become more well well-used and more robust, we'll actually make a difference with their use. >> are you suggesting, i think understand, would not work with mail orders because they are ordered some place else other than just in the state. tell me again, do you think that if -- if pharmacists knew, by looking at a computer screen -- that that person, would he, or she, still fill that prescription? if he knew it was being violated? >> when i speak -- with all of the different groups and the individual pharmacists and you look at their -- their ethical standards and their patient safety practices, and the number of pharmacists that have picked up the phone and either said, either called the physician saying something isn't right, or the ones that have told that patient you know what i am not going to fill that because i have that