FORUM/TOWN HALL A ROUNDTABLE DISCUSSION ON THE GROWING PROBLEMS OF PRESCRIPTION DRUG ABUSE AND DIVERSION THROUGHOUT NEW YORK STATE, AND POSSIBLE POLICY SOLUTIONS

Treatment, NYC Health Department 13 14 ---oOo--- 15 16 17 18 19 20 21 22 23 24 25 1 SENATOR KEMP HANNON: This hearing is being 2 webcast. Presumably the Internet will be working 3 fine, but if it's not, we'll be preserving it, and 4 it will be available on our respective websites; 5 Alcohol Abuse website, Investigations website, 6 Health website, all part of the Senate website. 7 I am Kemp Hannon, Chair of the 8 Health Committee. 9 The impetus for this hearing was, 10 Senator Klein, who's Chair of the 11 Alcoholism Committee, and continued with, 12 Senator Marcellino, in Investigations and 13 Government Operations Committee. 14 We'll each just say a few remarks. 15 The first concept is, this is a roundtable. 16 And it is very deliberately a roundtable because 17 hearings, to my mind, don't produce an exchange of 18 ideas. They allow people to come, give their 19 thoughts, and then leave, and then we don't have the 20 interaction. And, I think I value the interaction 21 more than anything else. 22 The fact of where we are is a long way. 23 As Chair of the Health Committee, a decade 24 ago, we were dealing with removing 40-year-old 25 restrictions from the use of painkillers, which 1 then were narcotics, that were in State statute, 2 and treated anybody getting pain relief as a subset 3 of being a narcotic addict. That was the type of 4 registration you had to do. 5 And there was huge examination of what the 6 healthcare system was doing for pain relief. 7 Well, modern pharmacy has now given us the 8 opioids. We have now had the abuses. We have a 9 whole different viewpoint as to what's going on, and 10 we need to move forward. 11 And as we speak about dealing with people, 12 what people perceive as a problem, the very way that 13 the State is going to be paying for pharmacy under 14 Medicaid will shift in a couple of months, as it 15 goes from a State-administered program, to it being 16 administered by each of the Medicaid managed care 17 programs, a very large and significant population, 18 and a dispersed responsibility for all of that. 19 So, that will be changing as we go through. 20 There's certainly lots of other proposals 21 that have been made. 22 We're joined by Bridget Brennan, who, 23 earlier, with us and the committee, participated in 24 a hearing on non-controlled substance and the 25 illegal market for that. 1 A statute that was -- resulted in a statute. 2 It passed the Senate. It's still pending in the 3 Assembly. 4 And the Department, along with the 5 Attorney General, has put forward different ideas in 6 regard to the use of the database for people who 7 use, especially opioids, in the -- for pain 8 relief, but misuse it, black market, reselling, 9 whatever. 10 A large, large problem. 11 So, the hearing notice sets forth, in really 12 good detail, the ideas what we're looking to 13 pursue today, and pursue as we move forward past 14 this roundtable. 15 And, I look forward to your participation 16 now. And, to anybody who has a submission, idea, 17 proposal, after we end today, we would be all 18 welcome to hear from you. 19 Senator Klein. 20 SENATOR JEFFREY KLEIN: I want to thank my 21 two colleagues, Chairman Hannon and Chairman 22 Marcellino. 23 This is truly an important issue, and I know 24 most of us know how important it is, but I think 25 it's time that the State, and through the 1 State Senate, and my committee and the two 2 respective committees, we come up with a 3 comprehensive approach. 4 Like most of the issues that I have been 5 involved in my career, and usually it starts at 6 the local level, I have been bombarded over the last 7 several years with calls from my constituents, 8 about the so-called "pain-management clinics," 9 where the lines start at 7:00 in the morning, and 10 they don't subside until the afternoon. 11 Why are so many people anxious to get into 12 these places? 13 And I think the answer is very simple: 14 controlled substances. OxyContin. 15 Controlled substances, this is a problem. 16 And I know the health department has a 17 mechanism in place to monitor this, but I think we 18 really need to come up with a comprehensive 19 approach: Education, tougher laws on the books, 20 and a better tracking system. 21 And I think that's why it's so important that 22 the people here today are really all the 23 stakeholders, to probably try to solve these 24 problems. 25 I think it's worth mentioning some of the 1 statistics. 2 If you look at the numbers, they're quite 3 startling. 4 If prescription for powerful narcotic 5 painkillers continues to rise in this city, 6 there's 10.7 prescriptions for OxyContin for every 7 100 people in the city of New York. 8 In my home county of the Bronx, the rate is 9 13.8 prescriptions for every 100 people. 10 And, Staten Island has the dubious 11 distinction of having the highest, at 12 23 prescriptions per every 100 people. 13 And that's 2009 data. The most recent data 14 is probably even higher. 15 This is a problem. 16 And when you look at the numbers 17 nationally, they are no better. 18 When the drug of choice for minors is, 19 second, for controlled substances, you know, 20 painkillers, things of that nature -- the only one 21 that beats that is marijuana -- this is a problem, 22 and a growing problem. 23 So, I'm hopeful today that we're going to 24 listen, we're going to learn, and really come up 25 with a real comprehensive approach, where we can 1 deal with this problem, and help New Yorkers. 2 SENATOR CARL MARCELLINO: Thank you. 3 I'm Carl Marcellino. I chair, as we said 4 before, the Investigations Committee & Government 5 Operations. 6 My concern is piqued, because we've recently 7 had a rash of pharmacy robberies on Long Island, two 8 in my district, one resulting in the deaths of 9 three people by some nut who decided to shoot 10 everybody rather than just walk away with nothing. 11 This kind of tragedy has got to stop. 12 We have young people, as Senator Klein 13 pointed out, are moving into OxyContin. When they 14 can't get that, they are being flipped to heroin. 15 So, there is an increase in heroin abuse and 16 heroin use amongst young people, which is scary, 17 because everybody knows the end result of heroin 18 is, in many cases, death. We're not talking about 19 something that is a pleasure drug for too long. 20 It doesn't last, and you can't last too long 21 on it. Yet, they are doing that. 22 And the pushers are flipping them. When they 23 can't get the prescription drugs, they are flipping 24 them to heroin. 25 So, this problem is growing. 1 It is not only a New York State problem, 2 clearly. 3 New Jersey has a task force on just this 4 issue. And, I saw a presentation from this task 5 force, and one of lawyers who was in charge of the 6 task force, at a recent conference that I attended. 7 This kind of thing, as I said, and my 8 colleagues have intimated, are growing. It's a 9 growing problem, and it's got to stop. We need a 10 way of controlling it. 11 Part of it is education, obviously. People 12 have to know that the drugs that are in their 13 medicine cabinets in the bathroom, or wherever, 14 have got to be taken care of, and locked up in some 15 cases. 16 You just can't mix them. Kids are having 17 actual parties, where they throw all the 18 prescription drugs in a bowl. Mix that with 19 alcohol, grab what they want, pop some in their 20 mouth, and have a party. 21 After all, it can't be dangerous. They're 22 prescription drugs that grandma takes, or my 23 mother and father take, so how bad could they be? 24 Clearly, we need an education process. 25 Clearly, we have to have a situation, where, 1 if a patient needs 3 pills to tide them over, they 2 can't get a 10-day prescription. 3 That's something that we -- that the doctors 4 have to pay attention to, and the pharmacies have to 5 pay attention to. 6 We're all involved here. There's a chain 7 that goes on. So, we need to be able to work 8 together on this. 9 If you need new laws, that's what we're 10 here for. We're looking for that. 11 If new laws are the issue, and new laws are 12 the way to go, fine. 13 If new regulations are the way to go, we'll 14 work that out too. 15 But, we need some advice, and that's the idea 16 of this roundtable. 17 And I'm pleased to see the participants that 18 are here, because we should get some very good 19 information out of this, and hopefully move ahead 20 with some joint policy ideas, and ideas for 21 legislation if necessary. 22 So, I thank you, and I look forward to the 23 conversation. 24 SENATOR KEMP HANNON: Okay, we're now going 25 to ask each of the participants to give an opening 1 statement of about three minutes, each. 2 And we'll start right on my left, with 3 Dr. Farley. 4 And then, I just ask, if you each would pick 5 up as you will, but, if you would say your name for 6 the webcast, because you all are important people 7 with long titles, and it's impossible to read this 8 print. 9 DR. THOMAS FARLEY: Thank you. 10 I'm Tom Farley, the health commissioner for 11 the city of New York. 12 The New York City Health Department takes 13 very seriously the problem of prescription drug 14 abuse; a problem that we see as one of our major 15 pressing health problems, and one that is clearly 16 growing. 17 Let me just throw out some of the statistics 18 that we are following on this. 19 We track it, really, in three ways: By 20 monitoring the number of drug overdose deaths that 21 occur in New York City; by monitoring the number of 22 people coming to emergency departments with health 23 problems -- acute-health problems related to 24 prescription drug use; and, then, by monitoring use 25 in the general population through surveys. 1 As far as the drug overdose deaths, in 2 New York City now, we have about 150 deaths per 3 year from drug overdose deaths -- from drug overdose 4 in which prescription drugs -- prescription opioids 5 are included. 6 Now, they're often in combination with other 7 drugs, but 150 people, per year, in New York City 8 dying of this problem. And that number is 9 increasing. 10 That represents about 25 percent of the 11 drug overdose deaths that are occurring in the city, 12 each year. 13 It used to be, our major problems with drug 14 overdose were from heroin and cocaine. Those 15 problems appear to be on the decline, but this 16 problem is increasing. 17 We are also seeing an increase in the number 18 of emergency-department visits for prescription 19 drug overdose. I'm forgetting the percentage 20 increase, but let me just say that it's increased -- 21 okay, we've had about a doubling, from 2004 to 2009, 22 in the number of visits in the emergency departments 23 for that problem. 24 On surveys, we are now hearing that 25 4 percent of all New Yorkers, age 12 and over, 1 report the non-medical use of prescription 2 opioids. That means that they're using these 3 pills even though they were not prescribed by a 4 physician. "4 percent." 5 And, in another survey of teenagers -- or, 6 children aged, from 7th grade through 12th grade, 7 10 percent reporting having used, at least once, a 8 prescription opioid that was not prescribed for 9 them. 10 So this is a very, very common problem as far 11 as use goes. 12 It's common, as far as, it's causing people 13 to get health problems, seen in the emergency 14 department. 15 And, it's common, as far as the number of 16 people it's killing. 17 We have ideas about what we want to do about 18 it, but I don't want to jump ahead in the agenda, 19 so, I'll stop there. 20 SENATOR KEMP HANNON: Bridget. 21 BRIDGETTE BRENNAN: Thank you very much. 22 I'm Bridget Brennan, and I'm the City's 23 special narcotics prosecutor. We have 24 jurisdiction over felony narcotics prosecutions 25 throughout New York City. 1 And for most New Yorkers, I think the word 2 "narcotics" conjures up images of illegal drugs 3 coming in from South America, transported by bloody 4 Mexican cartels, or of street dealers, or 5 high-end personal delivery services. 6 However, the most widely abused narcotic 7 drugs in our city today are manufactured by major 8 pharmaceutical companies, they're prescribed by 9 doctors, distributed by pharmacies, and have 10 familiar names like, oxycodone, Vicodin, and are 11 found in our own medicine cabinets. 12 Just 15 years ago, we saw very little of 13 this kind of problem. 14 And, perhaps it was because there were many 15 more restrictions on the prescribing of narcotic 16 drugs. I think New York is late coming to this 17 epidemic, compared to some of the other places 18 around the country. And it may be that we had more 19 stringent regulations in place, regarding our 20 stringent oversight regarding the prescribing of 21 narcotic drugs because of New York's sad history 22 with narcotics epidemics. 23 However, what we have seen from the 24 enforcement side is very alarming. When we start to 25 see the problem, when the police start to see the 1 problem, and the prosecutors start to see the 2 public health problem spilling over into our cases, 3 you know we have a very, very serious problem to 4 confront, and that's what we're dealing with now. 5 We have robberies, burglaries. The tragic 6 instance in Suffolk County in June. We have all 7 those events occurring in the city and surrounding 8 areas. 9 In law enforcement, in my office, about 10 one year ago, I was startled when I saw how many 11 "pill" cases we were handling. 12 Typically, the "pill" cases that we 13 confronted were more community-nuisance problems. 14 There are areas in the city where it's well known 15 that you can buy pills on the street. Typically, 16 those were the kinds of cases we handled, and rarely 17 did those rise to the felony level. 18 All of a sudden, last year, when I reviewed 19 our cases, I saw a good 15 to 20 percent of our 20 cases involved opiate drugs, opiate drugs mixed with 21 heroin and cocaine, opiate drugs mixed with guns, 22 opiate drugs found in search warrants, all over 23 the city. 24 And it was clear to me we had a problem. 25 I then tried to figure out the source of the 1 problem because there is a very robust black market 2 in these drugs. But, I was working with the 3 Bureau of Narcotics Enforcement, stunned to learn 4 that the number of opiate prescriptions in 5 New York City had increased by about 100 percent, 6 between 2007 and 2010. 7 So I knew, that, while we may have a 8 black-market problem on our hands, we also had a 9 problem with respect to the drugs being prescribed. 10 Our priorities are to cut it off at the 11 supply. We're looking at pill-mill-type cases of 12 the nature that Senator Klein described. 13 And, I have to thank Senators Klein, 14 Hannon, and Marcellino, for bringing us all together 15 for this kind of a hearing. I think we need to 16 increase the public knowledge about this. We need 17 to all join hands. 18 I've worked individually with so many of 19 these agencies, and it's great to have this communal 20 effort. 21 One of the big impediments I see in my 22 investigations, is a lack of a consistent standard 23 for doctors in the prescription of these narcotic 24 drugs. And that is one of the things that I'm very 25 anxious to have, because, for me, when I'm looking 1 at a pill-mill case, and I'm looking to determine if 2 a doctor is a drug dealer or prescribing for medical 3 purposes, it's critical for me to have some kind 4 of a standard that all doctors are trained on, so 5 that I can compare that against the conduct that I'm 6 seeing. 7 So, with that, again, my thanks. 8 And, I will pass off the microphone. 9 DR. STEVE KIPNIS: Thank you. 10 Senator Klein, Senator Hannon, 11 Senator Marcellino, my name is Steve Kipnis. I'm 12 the medical director for the New York State Office 13 of Alcoholism and Substance Abuse Services. 14 And on behalf of my commissioner, 15 Arlene Gonzalez-Sanchez, it's a great pleasure for 16 the opportunity to speak with you today about what 17 we consider a very important issue: prescription 18 drug misuse. 19 The Commissioner thanks you for bringing this 20 important issue to the forefront. 21 And, as you noted, prescription drugs account 22 for the second most commonly abused category, after 23 one looks at marijuana being first, and ahead of 24 cocaine, heroin, and methamphetamines. 25 Prescription drug misuse goes across all 1 social, economic, geographic, and cultural groups. 2 But one thing we have to watch out for, is that 3 prescription drug misuse poses a really unique 4 challenge, because one has to balance prevention, 5 education, and enforcement with the legitimate use 6 of these controlled medications for pain, and also 7 for opiate dependence. 8 According to a 2008-2009 national survey, 9 51.8 million people in the United States use 10 prescription drugs for non-medical reasons. That's 11 20 percent of the population of the United States. 12 So, clearly, it's not just a New York issue, 13 but a national, and probably international, issue. 14 When we looked at our surveys in New York, we 15 have, unfortunately, a significant increase in the 16 residents, in all age groups, using non-medical 17 prescription drugs. And when we look in the 18 18- to 25-year-olds, in the past year, non-medical 19 use went from 10.45 percent to 12 percent. 20 So, how do we address this growing problem? 21 Well, I think we have to look at each of our 22 unique roles: parents, healthcare 23 professionals, and the government. 24 Government partners are very important, and 25 OASAS continues to work to address this very 1 important issue within our agency, and also with 2 ongoing collaborations with other agencies, such as 3 New York City Department of Health and Mental 4 Health, and New York State Department of Health. 5 We have identified some areas of focus, 6 which we include as, data analysis, prevention 7 programs, education, enforcement, outreach, and 8 screening and referrals. 9 Healthcare practitioners also need to 10 understand the consequences of overprescribing 11 prescription medications. This is done through 12 educational efforts by the Department of Health and 13 OASAS, and the medical field in partnership with us. 14 Physicians should talk with their 15 patients directly, to ascertain whether they are 16 misusing or abusing prescriptions and other drugs. 17 It is important that they include the risk of -- 18 associated with the practices of borrowing or 19 sharing prescription medications. 20 And, finally, bringing it down to the level 21 of the parent. 22 The parent needs to educate themselves about 23 which medications can be misused or abused, and 24 learn about the very real dangers of the risks 25 of this behavior. They need to communicate it in an 1 effective and honest way with the risk to their 2 children, dispelling the notion that it is safe to 3 use unnecessary or unprescribed medications. 4 Parents also need to safeguard medications 5 by limiting access to those in their house, with 6 watching, tracking, and -- quantities that they keep 7 in their medicine cabinets. 8 They also need to properly dispose of their 9 medications. 10 Parents should work together to help their 11 children be safe, and healthy. 12 And, again, I would like to thank you, on 13 behalf of my commissioner, for inviting us to this 14 panel. 15 ANTHONY MEROLA: Good morning. 16 My name is Tony Merola. I'm a pharmacist 17 with the New York State Medicaid Program. 18 Prior to coming to the Medicaid program, I 19 was a community pharmacist out there, dispensing 20 medications. That "gentleman behind the counter 21 in the white coat." 22 Just a couple of comments with regards to 23 Medicaid, for those of you who may not be familiar 24 with the Medicaid program. 25 The Medicaid -- Medicaid insures over 1 4 million people in the state, and a payer of over 2 62 million pharmacy claims, with annual 3 expenditures of over $4 billion. 4 And we're here just to inform the roundtable, 5 the members here at the committee, of what 6 Medicaid is doing to make sure prescriptions are 7 being used appropriately within the context of 8 Medicaid. 9 Like many large payers, Medicaid 10 administrators a Drug Utilization Review Program, 11 and clinically based Prior-Authorization Programs, 12 used to ensure and promote the appropriate use of 13 prescription drugs. 14 I would just like to talk a little bit about 15 the DUR program. 16 In the formal sense, DUR was created back in 17 the early 1990s, and it was created to establish 18 and implement medical standards and criteria for 19 retrospective and prospective drug-utilization 20 review for Medicaid beneficiaries. 21 The primary purpose of the Drug-Utilization 22 Review Program is to identify and determine 23 interventions based upon appropriate utilization. 24 The program also provides an avenue to 25 identify and report suspected cases of fraud and 1 abuse, aberrant use, to the Office of the Medicaid 2 Inspection General. 3 As I mentioned, the DUR program has two 4 components: a prospective drug-utilization review 5 component, and a retrospective drug-utilization 6 review component. 7 The "prospective" component we call 8 "pro-DUR." It's an electronic pharmacy editing 9 system, which alerts pharmacists at the point of 10 service or the point of dispensing. 11 Warnings are provided electronically to the 12 dispensing pharmacist. Warnings include: 13 drug-disease precautions, drug-to-drug 14 interactions, high dose/low dose, drug-age 15 precautions, therapeutic duplication, 16 overutilization. 17 The "retro-DUR" program, or the retrospective 18 DUR program, that's more of an analysis of the 19 historical Medicaid claims information, based upon 20 pre-determined clinical criteria. It's more of an 21 educational program for prescribers and 22 pharmacists. 23 Education letters are sent to providers, 24 requesting the evaluation of the pharmaceutical 25 regiment based upon those clinical criteria. 1 Another program that we have in place is 2 called our "Clinical Drug Review Program" which 3 legislation was established back in '05, implemented 4 in '06. We use the acronym "CDRP." 5 "CDRP" is a clinically based 6 prior-authorization program aimed at assuring 7 specific drugs or drug classes are used in a 8 medically appropriate manner. 9 Under the CDRP, certain drugs require prior 10 authorization, due to concerns related to safety, 11 public health, potential for significant fraud and 12 abuse or misuse. 13 The prior-authorization requirement is 14 employed to ensure medically appropriate 15 utilization. 16 And we also have a Medicaid Drug Utilization 17 Review Board, and Pharmacy and Therapeutics 18 Committee, that evaluate these drug for inclusion 19 into this program. And, they provide 20 recommendations to the Commissioner of Health for a 21 final determination. 22 One last point I would like to make, with 23 regards to "MRT"; or, as we know, the 24 Medicaid Reform Team, Initiative Number 15. And 25 it's actually, a subset of that whole initiative is 1 quantity and limits associated with opioids. 2 While opioid analgesics play a significant 3 role in pain management, there's been a significant 4 increase in opioid prescribing in New York State, 5 and nationally. 6 As utilization increases, evidence 7 demonstrates that fraud, abuse, misuse, and 8 diversion also have a tendency to increase. 9 To address this issue, the Medicaid is 10 looking to implement MRT15-K, which will limit 11 opioid prescriptions to four in a 30-day period. 12 But, prescribers that feel that they need 13 more than four for a particular patient will have 14 the ability to request a prior-authorization 15 override. 16 Thank you very much. 17 SEAN DOOLIN: Good morning. 18 I'm Sean Doolin, outside counsel for 19 Empire Blue Cross and Blue Shield. 20 Thank you, Senators, for inviting us to 21 have a seat at the table. 22 A couple of other analysis to magnify that 23 this is a legitimate problem. 24 The Office of National Drug Policy, in a 25 2010 study, found that there has been a 400 percent 1 increase in prescription drug abuse, treatment, 2 hospital admissions. 3 Likewise, in 2010, the NCSL concluded, in its 4 study, that there has been a 96 percent increase in 5 prescription drug abuse deaths over a 6 five-year period. 7 So, the problem is real. 8 From the health plan's perspective, one 9 particular area that I would like to draw attention 10 to, and that has become quite pervasive, is what is 11 commonly referred to as "drug-shopping." 12 "Drug-shopping" is where an individual 13 patient sometimes -- actually, more times than 14 not, has a legitimate health issue, and they will go 15 to a number of different providers, and fill 16 prescriptions at a number of different pharmacies. 17 And, without a plan properly coordinating -- 18 health plan properly coordinating with a -- with the 19 providers and the pharmacies, they will pay the 20 claim. 21 There are loopholes in the current insurance 22 law that allows this to happen. 23 Likewise, there is a shortfall, in terms of 24 collaboration between plans and providers. 25 And I'll give you one anecdotal example, 1 through the State Health Insurance Plan, that 2 dramatizes how people can, intentionally, and 3 fraudulently, slip through the cracks. 4 Just recently, it was brought to -- in 5 two thousand -- or, in February of this year, it was 6 brought to our attention by the State Health -- or, 7 Civil Service Department, that they had picked up an 8 anomaly of claims that were being filed by one 9 State employee. 10 And what we found, in digging through it, was 11 that, over a two-week period, the individual 12 patient, who had, in this case, a very legitimate 13 health issue, went to 10 different emergency 14 rooms, and filled prescriptions at 12 different 15 pharmacies over that two-week period, for pain 16 relief. 17 And the problem, was that there was no 18 coordination between the providers and the 19 pharmacies, obviously. 20 The fact that it was the State Health 21 Insurance Plan magnified the problem, because you 22 had the drug benefit being administered by one plan, 23 doing their own fraud detection; the emergency room 24 visit being administered by a separate plan; and, 25 the outpatient, or medical benefit, being 1 administered by a third plan. 2 That all being said, I think this particular 3 individual was somewhat savvy, in that, they were 4 going to the emergency room, which, in the case of 5 the New York State Insurance Law, there's no prior 6 authorization. 7 So, the plan would require -- was required to 8 pay for the treatment, and pay for the 9 prescription drug benefit without pre-approving and 10 reviewing the claim. 11 Now, I'm not suggesting that that law should 12 be changed. There's some valid policy reasons to 13 having, what they call, the prudent layperson 14 standard at emergency rooms. But, there needs to 15 be greater data sharing and data mining by the 16 plans themselves, as well as greater collaboration 17 between the provider community, the plans, and the 18 retail pharmacy. 19 The State Health Department does have -- many 20 states have tried to address this through a drug 21 monitoring and database program. And the 22 State Health Department does have a drug monitoring 23 program, that was initiated in 1972, went through 24 some enhancements last year, to improve data 25 sharing amongst providers, although there still 1 are a number of challenges, both, providers 2 have -- in terms of, providers having access to 3 the data, but, also, the plans having access to 4 the data, and comparing it to its own data-mining 5 systems. 6 So, the problem is real. Certainly, we're 7 here to help. 8 I mean, obviously, prescription drug abuse, 9 as well as healthcare fraud, increases the cost of 10 healthcare coverage, and oftentimes leads to 11 employers dropping coverage altogether, especially 12 the prescription drug benefit. 13 Thank you. 14 JOANNE HOFFMAN BEECHKO, R.Ph.: Yes, my name 15 is Joanne Hoffman Beechko. I am the pharmacist, in 16 or out of the white coat, that practices day in and 17 day out. 18 I'm a board member of the Pharmacy Society of 19 the State of New York, and the president of the 20 Long Island Pharmacists Society. 21 I have a store in East Northport, Huntington, 22 and was directly involved with all of the pharmacy 23 events out there. 24 We're pleased to be here. We think this is a 25 crucial meeting, multi-faceted approach to the 1 problem of prescription drug abuse. 2 The pharmacists on Long Island, in 3 particular, of course, send out their hearts to all 4 those that are grieving. We know them personally. 5 We have many ideas in terms of addressing 6 this issue. 7 Our first being, that we do need to develop a 8 triad of cooperation between the patients, the 9 prescribers, and the pharmacists. And this will 10 ensure the informed healthcare and appropriate 11 definable outcomes for patients. 12 This can be done, initially, with different 13 kinds of discussions between the State associations, 14 the physician associations, and the pharmacy 15 associations, I think, is the primary starting point 16 for many of these discussions. 17 Secondly: Pharmacies are, in fact, medical 18 homes. We see patients, sometimes three and 19 four times a week. The same patients, three and 20 four time as week. 21 We know them personally. We know everything 22 about their families, what their conditions are. 23 We know them as people. 24 We need to access that electronic data that 25 was just spoken of. We don't have access to, not 1 only the BNE information that is available to 2 physicians at this point, but not available to 3 pharmacists, but, all of the electronic data. 4 Through this roundtable discussion, 5 hopefully, we will bring some of these points out. 6 If we had access to patients' records, we 7 could determine, for example, if liver-function 8 changes were happening, and why is that. 9 Is it possibly because of too much Vicodin 10 prescriptions, which has an enormous amounts of 11 Tylenol in them. 12 That's just a small example of how we could 13 participate. 14 We would like to require both prescribers 15 and pharmacists to complete courses in pain 16 management and in addiction, to heighten our 17 awareness for the signs of addiction. 18 Right now, in my store, we're talking about 19 numbers of prescriptions, personally in my 20 store, about 10 percent of the prescriptions are 21 controlled substance prescriptions, which, in a 22 store of, maybe, 150 prescriptions, that's 15 -- 23 12 to 15 prescriptions. Of those, maybe 1 percent 24 are cash-paying customers. 25 And this is something that becomes 1 important for people to understand: Pharmacists, 2 every day, as we fill prescriptions, we're 3 transmitting this information through to the health 4 insurance. And that data comes directly back to 5 us immediately. 6 So, 95 percent of my customers, I know 7 already -- or, my patients, I know already, if 8 they have had another prescription filled elsewhere, 9 inclusive of the Medicaid program. 10 The Medicaid program does send back DURs to 11 us on a regular basis, so we know what is happening. 12 And it is really a small percentage of 13 patients, those that are paying cash, that we 14 really don't know what their history is about. 15 So, being available to have the information 16 from the BNE is important, but it's certainly not 17 the end of the discussion. 18 We also would like to increase the public 19 awareness of addiction potential, and the signs of 20 addiction, and all of the treatment options that are 21 in the community. 22 I've had meetings recently with people out 23 in Suffolk County, and we know for a fact that there 24 are not sufficient addiction centers available. 25 A lot of it could be due to monies available, 1 but we need more facilities for patients who do 2 have problems. And, we need more public 3 awareness. 4 I think the horrible occurrences out in 5 Medford has brought this to public awareness now -- 6 clearly brought this to public awareness -- and now 7 is the time that we need to address all of these 8 different aspects. 9 And, finally, we are considering, as a 10 profession, establishing policy guidelines, as has 11 already been discussed, in limiting the amount of 12 controlled substances of pain-control prescribed, 13 per patient, per month, with the caveat, that we are 14 100 percent behind pain management, because we all 15 need to have that. That is 100 percent a necessary 16 part of medical management for patients, and we 17 can't lose sight of that. 18 Thank you. 19 DR. ANDREW KOLODNY: Hi. My name is 20 Andrew Kolodny. I'm chairman of the Department of 21 Psychiatry at Maimonides Medical Center. I'm also 22 an addiction psychiatrist. 23 The patients that I treat in my clinical 24 practice are addicted to opioid analgesics. Some 25 of my patients are young adults who became 1 addicted through recreational use. 2 SENATOR KEMP HANNON: Let me just ask you, 3 before you start: I see you have a projector for 4 the benefit of those of us here. 5 Would you be able to give us slides later, so 6 we could put them on the website, so people who are 7 just watching it on the webcast will be able to 8 access those, that information, also? 9 DR. ANDREW KOLODNY: Yes, I would be happy 10 to. 11 SENATOR KEMP HANNON: Great. Thanks. 12 DR. ANDREW KOLODNY: So, among the patients 13 I treat, who are addicted to opioid analgesics, 14 some are -- a large number are young adults who 15 became addicted to opioids through recreational 16 use. Usually, they started with drugs like 17 hydrocodone, or "Vicodin." 18 And, I also treat a good number of, usually a 19 little bit older patients, who became addicted to 20 opioids through a medical treatment, what one 21 would call "iatrogenic opioid addiction"; addiction 22 caused by medical treatment. 23 I'm also the president of a recently formed 24 organization called "Physicians for Responsible 25 Opioid Prescribing." This is a group of docs 1 from -- in the fields of pain, addiction, public 2 health, emergency medicine, primary care. 3 The mission of our organization is focused 4 solely on the epidemic of opioid overdoses. 5 Our goal is to reduce morbidity and mortality 6 from opioid analgesics by promoting more 7 responsible, cautious prescribing practices. 8 And, many of our new members are actually 9 emergency room physicians, who will send me an 10 e-mail, saying, that: I'm tired of declaring young 11 people dead in the emergency room. We're having 12 people, addicted, show up in the emergency room, 13 looking for drugs. 14 There are things that could be done to bring 15 this problem under control. And they want to get 16 involved, and they want to do something. 17 [Slide-show presentation commences.] 18 The first slide -- and I'm going to go 19 quickly through these slides, and many people today 20 have already pointed out some of the very disturbing 21 trends and statistics. 22 This slide is from the Center for Disease 23 Control. 24 And what the CDC is saying, is that we are 25 facing our worst drug epidemic in the United States 1 history. They're saying that, because they're 2 looking at the heroin epidemic of the 1970s. This 3 was 40 years ago. 4 And they're looking at the crack-cocaine 5 epidemic in, the late '80s, early 90s. 6 And they're pointing out that the deaths 7 today, largely due to opioid analgesics, are 8 greater than deaths that we were seeing in those 9 epidemics, combined. 10 As you can see, all of the overdose deaths 11 are certainly not opioid analgesics, but opioid 12 analgesics account for more than heroin and 13 cocaine, combined. 14 As was mentioned earlier, we're seeing an 15 increase in heroin use. 16 So, if I were to show you this slide in a few 17 years, I think, I would be willing to bet, that we 18 would see heroin overdose deaths increasing as 19 well. 20 We have got, right now, a total of about 21 30,000 drug deaths a year. This is likely an 22 undercount. 23 When you think about 30,000 drug deaths, 24 that number is hard to grasp. You can try and 25 compare that, perhaps, to the AIDS epidemic. 1 And, if the current trends continue, within 2 the next two or three years, we will probably have 3 as many deaths from drug overdoses in the 4 United States as we had during the height of the 5 AIDS epidemic. 6 You could think about deaths in wars. 7 Since the start of the Afghanistan war, we've 8 had about 2,600 deaths. 9 This is 30,000 deaths a year in the 10 United States right now. 11 The other thing to point out, just quickly, 12 is that, we are still paying a price for the heroin 13 epidemic in the 1970s, today, 40 years later, in 14 terms of, infectious diseases, HIV, hepatitis C, 15 in terms of social problems, and in terms of crime. 16 The problem that we've got today is far 17 worse, and there is no evidence that it's anywhere 18 near under control. This is something we're going 19 to be dealing with for many years to come. 20 So, you can measure the epidemic in different 21 ways. 22 I think what's important here, this is 23 looking at treatment admissions. These are people 24 who are addicted, showing up to state-licensed 25 drug-treatment facilities, saying that the drug that 1 they're addicted to is an opioid analgesic. 2 This is, the U.S. data. 3 This is, New York State data. 4 This is -- it's the same trend. 5 This is, roughly, a 300 percent increase. 6 What's important, I could show you slides of 7 overdose deaths, emergency room visits, drug-use 8 surveys; you'll see the same trend. You'll see 9 that this problem begins in the late '90s, and just 10 seems to get worse. 11 And, I'll explain why that might be in a 12 moment. 13 When you look at the people who are showing 14 up for drug treatment, saying that they're addicted 15 to opioids, one of the things that's striking, and 16 very different from our past opioid -- or past drug 17 epidemics, is that these individuals are 18 disproportionately White. 19 "Blue" on this graph represents people who 20 are White. 21 Other races are, you can barely register on 22 this graph. 23 This epidemic is disproportionately White. 24 It's disproportionately middle-class and 25 working-class. 1 Again, very different from past drug 2 epidemics which were disproportionately low-income 3 individuals and disproportionately minority. 4 So, why is this happening? What happened in 5 the late '90s? What's causing this epidemic? 6 According to the CDC, what's causing this 7 epidemic is a change in physician-prescribing 8 practices. 9 In the late '90s, physicians began to 10 change the way in which they were treating pain. 11 They began to treat pain much more aggressively with 12 opioids than they ever had before. 13 And, this is New York State data. 14 What you see, beginning in the late '90s, 15 is a very impressive increase in prescribing of 16 oxycodone. 17 Oxycodone is the active ingredient in 18 Percocet, and it's the active ingredient in 19 OxyContin. 20 And, you see this taking off in 1996. 21 1996 was the year that Perdue Pharma 22 introduced OxyContin, and there was large marketing 23 campaign. 24 But, it wasn't just oxycodone that increased 25 at the time. It was also hydrocodone. This is the 1 active ingredient in, Vicodin, and Norco. 2 And, something that we may discuss a little 3 later today, hydrocodone is a Schedule III drug. It 4 is not a Schedule II drug, which means that 5 restrictions on prescribing are much looser than 6 they are for Schedule II drugs. 7 So, how do you get physicians to change the 8 way in which they practice? 9 In my hospital, we're trying to gets docs to 10 wash their hands when they come in and out of 11 patient rooms. And we've been trying to do that for 12 years, and we struggle. 13 And there are many things we'd like docs to 14 do, and it's very hard to get them to change their 15 practice. 16 How did you get physicians to suddenly 17 start prescribing opioids far more aggressively 18 than they ever had before? 19 That was done through very aggressive 20 pharmaceutical marketing. 21 So, by 2001, the tall bar on this graph 22 represents the money that Purdue Pharma was spending 23 marketing OxyContin. Purdue was spending up to 24 $30 million a year in convincing doctors to treat 25 pain with opioids. 1 This spending on industry-sponsored 2 education, to get physicians to treat pain with 3 opioids, continues to this day. 4 The messages in these educational 5 industry-sponsored campaigns, are that opioid 6 addiction is rare in pain patients. 7 So the -- and this may seem hard for many 8 non-physicians to actually believe, because we 9 know that opioids are -- that oxycodone and 10 hydrocodone are the same class of drug as heroin. 11 So, I think, for a non-physicians, the idea that 12 you could treat someone's back pain, indefinitely, 13 with a drug very similar to heroin, and expect them 14 not to get addicted, that would strike many 15 laypeople as odd. 16 Of course, people -- a large number of people 17 might become addicted. 18 But, the messaging for physicians was: 19 That, patients don't actually get addicted to 20 these medications. That, the rate of addiction is 21 extremely rare. That, you can prescribe much more 22 liberally. 23 This was false. 24 And, actually, the company that promoted that 25 message got into quite a bit of trouble for that 1 message. 2 The other message was, that we're -- 3 That, doctors are letting patients suffer 4 needlessly. That, we should be more compassionate. 5 That, we should be using opioids more 6 aggressively. And, if we're afraid to prescribe an 7 opioid, because we don't want to get our patient 8 addicted, we're suffering from "opiophobia." 9 And that term is still used today. 10 Opioids are not a safe and effective 11 treatment for chronic non-cancer pain. 12 Opioids are a very important class of 13 medication in the treatment of cancer pain, and in 14 palliative-care settings. 15 Opioids are extremely important in the 16 treatment of acute pain. 17 Opioids are not a good medication for the 18 treatment of chronic non-cancer pain. 19 There may be some people who benefit, but 20 it's very difficult to figure out who they are, 21 without getting other patients addicted along the 22 way. 23 The other message, and a message that's still 24 promoted today, to doctors, is that: 25 If you have a patient coming into your 1 office, and they're coming in early -- they're 2 saying, I ran out of my medicine; or, the dog ate 3 the pills; or, I accidentally flushed it down to 4 toilet -- and, you've got a patient that looks 5 addicted to you, well, probably, Doc, the patient is 6 not addicted, and you shouldn't treat them like an 7 addict and stigmatize them. The problem may be you. 8 You're undertreating their pain. You should 9 escalate the dose. And if you give them a higher 10 dose of medication, you'll see that they don't come 11 back early, asking for more, so that there should be 12 no ceiling limit. You should continue escalating 13 the dose. 14 Which is something that we now know is 15 causing a large number of overdose deaths in pain 16 patients. 17 So, what needs to be done to bring this 18 epidemic under control? 19 There are really three broad strategies. 20 The first thing we need to do is, primary 21 prevention. We need to prevent less people from 22 becoming addicted. That means, we need to expose 23 less patients, unnecessarily, to opioids. We 24 need -- we need to do something about an environment 25 in which we're saturated with opioid analgesics. 1 Secondary prevention: If we were -- it 2 means, that we have to provide treatment to people 3 who are already affected by this epidemic. 4 So, if we were to wave a magic wand, and 5 suddenly ensure that doctors were going to be 6 prescribing responsibly, and that there would be -- 7 and even if we were to try and see that there was 8 less availability for -- in medicine chests, we're 9 not going to see an end to this epidemic. 10 We might see a decline in the number of 11 overdose deaths, but it's not going to do all that 12 much, because people who are opioid-addicted are not 13 going to stop using opioids because their doctor 14 isn't going to prescribe it for them anymore. They 15 are going to go to the black market, or they'll 16 transition to heroin use. 17 If we want to see a decline in overdose 18 deaths, you have to provide effective treatment for 19 people who are opioid-addicted. 20 And for this epidemic, that's probably going 21 to mean buprenorphine. 22 Methadone maintenance clinics were an 23 effective response in the 1970s, when you had an 24 epidemic that was disproportionately urban. 25 When you have an epidemic that may be 1 disproportionately suburban and rural, having people 2 show up in a clinic every day to take methadone is 3 not going to be an effective strategy. 4 And, then, lastly, we have to do something 5 about black-market availability. 6 It's very difficult to provide effective 7 treatment to people if they can very easily -- if 8 opioids are just so available for them. 9 If the cost of a doctor's visitor, or a 10 co-pay, on a Suboxone prescription is greater than 11 it is to purchase Vicodin on the street, it's going 12 be very difficult to provide effective treatment for 13 those individuals. 14 There are things that we could be doing, that 15 we're not, but I think they're in our grasp. 16 We've got terrific data in New York State. 17 Probably better data than anyplace else in the 18 country, but we're not using it so we know who the 19 high prescribers are. 20 And some of the high-volume prescribers are 21 docs who are really no better than drug dealers. 22 But, I think a bigger problem, and what our 23 group feels, Physicians for Responsible Opioid 24 Prescribing, is, the bigger problem is not the 25 doctor who is are really criminals. 1 The bigger problem is well-meaning 2 physicians, who, when they write an opioid 3 prescription, they think they're doing the right 4 thing for a patient, and don't realize they're 5 harming the patient. 6 We need to allow providers to utilize the 7 prescription data that's available. 8 Right now, it does -- the system we've got 9 does not work for clinical practice. 10 New York State allows physicians to go onto a 11 database, and find individuals who meet a 12 definition for a "doctor-shopper." 13 But, if you want to see whether or not a 14 patient is already on an opioid before writing them 15 on opioid; or, in the case of psychiatrists, 16 before writing them a prescription for 17 benzodiazepine, to see whether they're on an opioid, 18 you get no data back unless they fit this definition 19 of a "doctor-shopper." 20 And that's despite the fact that it takes 21 many steps to even get into this very non-user 22 friendly program. 23 And we have also got terrific data about who 24 the people are that are probably addicted. We could 25 be linking them to treatment. We're not doing that. 1 And, then, one other thing that could be 2 done, very simply, and that's very important: 3 Physicians should be able to get a monthly 4 statement, or an E-statement, of all of the 5 prescriptions that they're writing. 6 If I'm going in and out of my office, and my 7 prescription pad is on my desk, I have no way of 8 knowing if people are taking a few pads. 9 And, one of the cases that Bridget prosecuted 10 this year, involved prescriptions that were being 11 taken from a doctor's office. 12 Doctors are not -- doctors do not know when 13 prescriptions go missing from a thick pad. 14 And I'll show you what the pad looks like. 15 Physicians should, on a monthly basis, be 16 able to see a record of everything they're 17 prescribing. To see whether there are names 18 appearing there for patients they've never seen. 19 To see whether quantities are being changed. 20 Maybe the doc wrote "30" -- Dispense 30 -- 21 and someone changed the number to 80. 22 Doctors should be able to get a report like 23 they would for a credit card statement. 24 As I mentioned, many -- this is data that 25 comes from Canada, it's likely to be very similar in 1 New York State, but, a small number of docs 2 account for a very large number of the 3 prescriptions, which means that we've got -- there 4 are interventions, that shouldn't be that expensive, 5 where we could target these physicians. 6 The physicians that are really drug 7 dealers, and no better than drug dealers, we ought 8 to be able to identify them. 9 And for the physicians who are prescribing 10 inappropriately, and, either, need better education, 11 or medical-board sanction, we've got the data. We 12 ought to be using it. 13 These are some of the items I've already 14 mentioned. 15 One of the single most important things that 16 New York State could do to affect this epidemic, 17 would be to reschedule hydrocodone as a II, from a 18 III. 19 And I'll talk a little most more about that 20 later today. 21 As Bridget mentioned, we need standards of 22 care for the treatment of pain, so that -- right 23 now, there are no requirements. 24 Physicians who are treating chronic pain with 25 opioids don't have to check a urine. They can 1 prescribe any doses, any amounts. And they're 2 not, right now, at all required to take a look at 3 prescription monitoring data before writing 4 prescription. 5 I don't think we can require them to do that, 6 though, until we've got a system that works. 7 A physician doesn't ask a patient even for an 8 ID when the patient comes in for treatment of 9 pain. So, they're writing controlled substances 10 without seeing a photo ID, without seeing a 11 driver's license. 12 To go into a pharmacy and buy Sudafed, you 13 have to show your driver's license. But, very few 14 pharmacies, that I'm aware of -- 15 And maybe you know otherwise. 16 -- ask patients for photo IDs when they 17 come in to have a controlled substance filled. 18 They're supposed to be doing it. 19 Physicians, right now, are not required to 20 do that. 21 So, in summary: We've got a really severe 22 epidemic in New York State. 23 Physicians, and the public, need much 24 better information about how dangerous these 25 medications are. 1 And there are things we could do time impact 2 this epidemic that are really within our grasp. 3 Thanks. 4 SENATOR KEMP HANNON: Actually, Paul, start 5 off, and then, Greg. 6 GREGORY KRACKOWER: Well, I actually wanted 7 to take the lead, if that's okay? 8 SENATOR KEMP HANNON: No. 9 PAUL MAHONEY: Thank you, Senators. 10 And, I'm Paul Mahoney. I'm assistant deputy 11 attorney general for the New York State Medicaid 12 Fraud Control Unit. I'm sort of the day-to-day case 13 manager of that organization. 14 And it's -- this is a fantastic panel, 15 because it brings together so many elements that 16 we see in our practice. 17 And rather than repeat, and reiterate, some 18 of the information my counterparts are indicating 19 today, I'd like to just throw an additional element 20 into the mix, from the Medicaid Fraud Control 21 perspective, and that is, the money that's involved. 22 As we heard from the representatives of the 23 insurance programs -- Medicaid, Blue Cross, and 24 the many others -- there is a tremendous amount of 25 money moving through this system. 1 And from the point of view of a wrongdoer, 2 controlled substances and, generally, prescription 3 drug abuse, is a wonderful system for making illegal 4 money, and ill-gotten gains. 5 The Medicaid Fraud Control Unit has 6 traditionally approached it from a larceny 7 standpoint; that, the State of New York, through its 8 Medicaid program, is paying out, recent data is, 9 approximately $1 billion, over four years, from 10 pharmacy-side distribution of controlled substances. 11 That is a huge pot of money, and extremely 12 attractive to people who would commit crimes. 13 When you couple the problem of addiction to 14 that, you have an almost -- it's a trite phrase, an 15 overworked phrase -- "perfect storm" of criminality. 16 You have people who want to make money from 17 engaging in an illegal activity, but want to do it 18 in a safe way. They have the veneer, or the facade, 19 of the medical system prescribing a drug, thereby 20 making it prima facie, legally. 21 And the beauty, from the criminal's 22 perspective, is that, the government, or a 23 health-insurance entity, is going to be paying for 24 most of it. 25 And the fraction that is not being paid for 1 by the government, or a private health-insurance 2 company, can be paid, legally, by the customer who 3 wants the drugs. 4 The entire aura of traditional criminality, 5 of having people do street-level drug dealing, is 6 therefore removed. 7 The cash doesn't have to be generated from 8 people engaging in illegal activity. The cash is 9 generated by people engaging in activity that is 10 prima facie legal. 11 It's really quite -- it's quite remarkable. 12 When you add on to that, the fact that some 13 of the players have an incentive, even if they are 14 legitimate, and acting in good faith, they have few 15 incentives to look deeply into the root cause, 16 because, the addict, the person who needs that drug, 17 but needs it in a medically inappropriate need, 18 nonetheless, has a physiological need for it. 19 The doctor who is writing -- the 20 prescriber -- that's not limited to physicians -- 21 who is writing the prescription, has the ability to 22 get paid through an insurance company for their 23 activity in seeing the patient. And the pharmacy is 24 getting paid for dispensing it. 25 Now, the vast majority of those people are 1 good-faith actors. But when you're talking about 2 so much money moving through the system, you're 3 creating powerful incentives to, groups of 4 criminals, groups of people, the addicts who are 5 out of control, in terms of drawing a clear line 6 between criminal and non-criminal activity. 7 So, from Medicaid Fraud Control perspective, 8 we had traditionally attacked this from the 9 overpayment of State money for these activities. 10 We had, actually, because of the existence of 11 special narcotics prosecutors and traditional 12 prosecutor office and the traditional DAs' 13 offices, we had concentrated on the non controlled 14 substances, which also have a great street value and 15 have the same effect on the same economic causes. 16 But we're finding, more and more, that, 17 because of the addictive element added on to this, 18 that the incentives, and the drain on State 19 finances, are even greater. 20 And, we've been moving more and more into 21 looking at controlled substances. 22 It seems a little bit crass to look at the 23 problem of addiction from a financial perspective, 24 but, every dollar that is going out on to -- to pay 25 for a controlled substance that is being misused, is 1 a dollar that is not available for substance abuse 2 treatment, for better focused medical treatment for 3 these patients. 4 And, therefore, as a system, it has a lot of 5 built-in misincentives. 6 And we are encouraged to see so many parties 7 interested, aligning incentives more 8 appropriately. 9 Thank you, Senator. 10 SENATOR KEMP HANNON: Greg. 11 GREGORY KRACKOWER: Well, thank you. 12 And the Attorney General thanks, 13 Senator Marcellino and Senator Klein and 14 Senator Hannon, for this extremely important 15 roundtable, and distinguished panelists here. 16 Dr. Kolodny, who I never met before, had a 17 very important slide about the three prongs that you 18 need to do to solve the problem. 19 And one of the things that the 20 Attorney General wanted us to talk about here, is a 21 solution that he has proposed in his first, and 22 only -- one of the two program bills that he's 23 established to deal with the third prong, which is 24 controlling the illegal supply of what is a legal 25 substance of a legal schedule of narcotic. 1 And that is an improvement, if not a 2 revolution, in the State's prescription drug 3 tracking base. 4 You know, this was the number one topic at a 5 recent national conference of attorneys general, 6 run by a group called "NAAG"; The National 7 Association of Attorneys General. 8 And states across the country are starting 9 to upgrade these databases, some of which are not 10 existent. But New York's is, actually, from our 11 perspective, one of the weaker ones, at least where 12 it's going. 13 The lock-tight solution, in terms of 14 monitoring the prescription and the dispensing of 15 drug, must require as Senator Marcellino said, a 16 partnership of doctors and pharmacists and law 17 enforcement. 18 The Attorney General has proposed a new 19 database, that would require -- 20 And it was in parentheses in one of your 21 slides, but it's actually in the Attorney General's 22 bill. 23 -- that would require doctors, prior to 24 issuing a script, to check what would be a 25 real-time, on-line prescription monitoring program, 1 which would have, in secure fashion, and compliant 2 with HIPPA, not just a doctor's prescription 3 history, but all of the doctors's prescription 4 history for a particular patient, prior to issuing 5 the script, so the doctor could see, at the time he 6 wrote the script, or at the time she set up the 7 appointment, that patient's drug history, for 8 writing the script. 9 And would be required to look at this data, 10 which would be on-screen, and require to enter the 11 script. 12 Then, in real-time, or in near real-time -- 13 the bill, currently, is in real-time -- the 14 pharmacist would have to double-check, to see, when 15 you cross the street, to cash-in the script to get 16 the dispensary pain medication, that there is a real 17 doctor. 18 The pharmacist would have to check, and it's 19 prior to dispensing, this system, and look for a 20 matching doctor, to see: Oh, that is a real doctor. 21 That is not a stolen script pad. That is not a 22 forged script pad. 23 And, by the way, the data that would also 24 show up, would be: Yeah, that's the fourth doctor 25 this 24-hour period; or this week-period -- or, I 1 think Mr. Doolin said in his example -- in a 2 two-week period, there were 10 different doctors -- 3 10 different ERs that wrote 12 different scripts, 4 that would show up on, Doctor 3, Doctor 4, Doctor 5, 5 and Pharmacist 3, 4, and 5, or one pharmacist. 6 That is a tool that solves the 7 four problems of the illegal flow of these 8 otherwise legal substances. 9 You have a proof record that the physician 10 has seen the prescription data, so that they can say 11 to themselves: Oh, this is really an addict. This 12 person might not look like an addict, but the 13 computer is telling me, this is the fourth doctor 14 they've seen in four weeks with this problem. 15 So, the Attorney General data base, which he 16 calls the "ISTOP" -- the Internet System for 17 Tracking Overprescribing -- database, is, both, a 18 law enforcement tool, and it is also a diagnostic 19 tool. 20 And we think that is critical to the support 21 of the program. 22 If there is a stolen script pad, the 23 pharmacist won't dispense the drug. And the 24 pharmacist will be protected from all liability for 25 that, because they'll say: You know, I went into 1 the computer, and there was no doctor, with a doctor 2 number, that actually entered in the script. 3 And stolen script pads, and forged script 4 pads, until the State moves to an E-script 5 system, which is very, very far in the future, is, 6 with a stolen script pad, you can do a lot of damage 7 in a very short amount of time. 8 So, part of what we wanted to talk about 9 today is solutions and problems. 10 And, to complete that third bullet point of 11 Dr. Kolodny's excellent presentation, technology 12 has to be brought into the fold, because the tools 13 that law enforcement has used against illegal 14 substances, cocaine and heroin, are semi-effective, 15 even less-than-effective, in the prosecutions for 16 illegal substance, because -- an illegal substance 17 of a prescribed drug, because, the doctor can always 18 say, and our Medicaid Fraud Unit, which has criminal 19 jurisdiction over these, does say, "Oh, the patient 20 lied to me." 21 And that's a great defense. Juries tend to 22 believe physicians over drug-addicted patients. 23 Now, yes, you can do undercovers in there, 24 and sort of give the doctor every way out. 25 And Paul can talk about some of the cases 1 that Medicaid Fraud has -- has accomplished. 2 But, to stop it at the source, to really do a 3 holistic tracking program, technology is the answer. 4 Oklahoma is also talking about a real-time 5 database. 6 New York is behind the times in its current 7 program, with the general lack of doctors even 8 accessing the system, although some can. 9 We think, given the cost of our Medicaid 10 program, it is actually very cost-effective. 11 Ultimately, it will pay for itself; although, we are 12 working on, exactly, costing the bill. 13 And, we'll have an answer for that by next 14 session, certainly. 15 And the Attorney General is taking this time 16 to partner with many of the people here. 17 We want to partner with pharmacists and 18 doctors and law enforcement, and, of course, the 19 Department of Health, who has done an incredible job 20 in administering all of the programs that we have. 21 And, partnering with other stakeholders too, 22 including advocates for patients and Medicaid 23 providers and the Medicaid Redesign Team, and 24 everything. 25 So, this is an opening salvo, in terms of 1 bill. It was introduced late last session. 2 And we -- it's a deeply important problem 3 that has come to the AG's attention, not only 4 because of the slides and the drug problem, but, 5 also, this is nationwide. 6 This what attorneys generals are talking 7 about. 8 And this is where the nation is going. And, 9 New York has a chance to be a leader here. 10 You know, we were a leader in Medicaid fraud. 11 We created the first Medicaid Fraud Control Unit. 12 And everyone thought: Well, it's too expensive. It 13 won't work. 14 It was so effective, the federal government 15 mandated that all states have one. 16 And we think this is an opportunity for 17 New York to be a leader again. 18 SENATOR KEMP HANNON: Dr. Dowling. 19 DR. FRANK DOWLING: Thank you. 20 I'm Dr. Frank Dowling, clinical associate 21 professor of psychiatry at SUNY at Stony Brook; the 22 medical advisor to "POPPA" -- Police Organization 23 Providing Peer Assistance -- here in New York City; 24 and I have a private practice in Suffolk County, in 25 Happauge. 1 I'm also counselor for the Medical Society of 2 the State of New York, and one of my chief roles 3 is to oversee the committees on Addiction and 4 Psychiatric Medicine, and, Preventive Medicine and 5 Family Health. 6 We greatly appreciate the opportunity to 7 participate in this important discussion on ways to 8 address the problems of prescription drug abuse 9 and diversion. And we're eager to work with all of 10 you in this room, to identify and implement 11 targeted, workable solutions to the problem that 12 will not unduly interfere with the ability of 13 patients to obtain prescriptions that are needed 14 to treat illnesses or manage pain related to illness 15 or injury. 16 In preparation for this meeting, physicians 17 from the Addiction and Psychiatric Medicine, and 18 Preventive Medicine and Family Health, committees 19 had a spirited discussion last week regarding ways 20 to address this problem. 21 Several points came from this meeting, but 22 the key theme of the discussion, is that there have 23 to be -- a multi-pronged solution. 24 This will include law enforcement efforts to 25 prevent and punish inappropriate diversion and 1 misuse of prescriptions. 2 It also includes the need for increased 3 accessibility of treatment for patients suffering 4 addictions, to reduce the likelihood of 5 inappropriate diversion, and, frankly, the market 6 for people who are legally profiting from the 7 system. 8 It includes better use of existing 9 databases, such as the one New York State has on 10 all controlled substances. 11 And, it includes the need for additional 12 resources for associations representing prescribers, 13 as well as dispensers, so they can be educated, and 14 their members can be educated, about the existence 15 of the database, and circumstances of patients 16 presenting themselves in healthcare settings that 17 should trigger someone to check the database. 18 In addition, it's imperative that the 19 Department of Health educate the public regarding 20 the dangers of prescription misuse and diversion, as 21 well as the legal requirements to inform all 22 prescribers of any controlled drugs that they are 23 taking. 24 It's important to note that the media have, 25 in our view, inaccurately portrayed that 1 New York State does not have a database as other 2 states have. 3 We do have a database, and New York has been 4 collecting data for many years. 5 The issue is, the information that already 6 exists, how it could best be used, and improved, to 7 inform physicians, and other non-physician 8 prescribers, including pharmacists who dispense, 9 so that we can reduce doctor-shopping and diversion 10 and misuse. 11 If it has to be a new database, we're 12 certainly open to discussing that, but, we wonder 13 how the current database can be improved. 14 It's only the last two years that 15 physicians have had access to this database. 16 And one of the key points that came out of 17 our discussion, is that the current database is 18 cumbersome, to get onto the database and to access 19 the information. 20 Getting a health commerce account and 21 maintaining the account is challenging for a lot of 22 physicians. And if a physician wants to look up a 23 given patient, the current system is cumbersome and 24 slow. 25 In addition, a physicians's staff; a 1 physician cannot designate someone in their office 2 to check the database, which would be a more 3 efficient use of time. 4 The current database is very limited to a 5 short time frame of information available, and too 6 high a threshold of filling multiple prescriptions 7 from multiple prescribers, and being filled at 8 multiple pharmacies. 9 What should be there, is that, if a physician 10 can look up any patient, anytime, and get any 11 information on controlled substances that have been 12 prescribed, as far back, and as recent, as the 13 database goes, even if it's one prescription. 14 And, finally, the database does need to be 15 promoted to the medical community. And MSSNY would 16 be happy to partner with the Department of Health in 17 that area. 18 We also would be supportive of legislation 19 that would permit pharmacists to check the 20 database, so they can better communicate with 21 physicians regarding questions or concerns in 22 this area. 23 It's also important to keep in mind, that as 24 we look at ways to prevent misuse and 25 inappropriate diversion, we need to be careful that 1 we don't actually overcorrect the problem. 2 Physicians, in fact, are often criticized, 3 that we actually undermedicate pain, and are 4 uncomfortable with prescribing medications to 5 patients with legitimate needs. 6 So, physicians have concerns on both ends of 7 the spectrum. 8 We are also concerned that mandatory 9 reporting, and checking of a database, could have an 10 unintended negative impact that could reduce 11 prescribing when it is necessary. And also add 12 additional administrative and time-consuming 13 burdens to physicians' practices, where 14 physicians are already struggling to keep 15 practices running. 16 We look forward to further discussion that 17 we're going to have today. And we are optimistic 18 that we really can work together to come up with 19 many workable solutions, balancing the need to 20 assure prescribing medications only to those where 21 there is a legitimate medical need, while also not 22 interfering with patients' ability to obtain 23 prescriptions when they are needed to treat 24 legitimate pain and other medical conditions. 25 Thank you. 1 SENATOR KEMP HANNON: David. 2 DAVID VIZZINI: Good morning, everyone. 3 I want to start by saying, thank you for 4 inviting me. 5 I work for Outreach. 6 Outreach is an alcohol and substance abuse 7 provider for New York State. 8 I have been working with adolescents and 9 young adult for about 15 years. We service people 10 between the ages of, 12, all the way to 25, 11 outpatient and residential. 12 And, I kind of wanted to talk to you about 13 their story a little bit. 14 When I meet a client for the first time, over 15 the last five years, who is addicted to some type 16 of painkillers, it's always the same story. 17 It starts with, that, their friends talked 18 about it. You know, they were 14-, 15-, 19 16-years-old, in high school. They went to a 20 party. Somebody tried it. Then they rummaged 21 through, mom, or grandma's, medicine cabinet to see 22 what they got. Used the Internet to figure out what 23 they have, and if it's something that can get them 24 high or not get them high. 25 From there, they start buying it from their 1 friends. And then, from there, they go to dealers. 2 And then, from dealers, you know, they end up, 3 hurting themselves, or doing some things, so they 4 can get to a doctor, and get to, like, you know, the 5 full force of the medication, and get as much 6 quantity as possible. 7 I permanently work out in, Nassau, and 8 Suffolk, County, on Long Island. And a lot of the 9 things that were said was about providing treatment. 10 You know, and I think treatment is very 11 important. I think that education and prevention is 12 important. 13 But, the people that we're talking about 14 here, who are addicted to these substances, you 15 know, they need treatment. And they need 16 high-quality comprehensive treatment, working with 17 their families, working with the schools, working 18 to deal with their behavioral issues, and the 19 issues that are causing them to self-medicate 20 through these substances that are becoming so easily 21 available to them. 22 If you know, we have to link better, I 23 believe, with the treatment providers, to the 24 legal referents, to the doctors, to the 25 pharmacists, because, if you go out on 1 Long Island, I don't know any treatment provider 2 that is full; as in, like they can't take another 3 client in. 4 Most of them are, you know, undercapacity, 5 because, that they're not get enough referrals from 6 the people who need it. 7 I think that, you know, one of the efforts 8 of this committee, and other committees to come, is 9 to really look at that issue, and linking people to 10 the services they need to get. 11 And people that are addicted, and using 12 OxyContin and Percocets, and all different types of 13 drugs, that, you know, the kids call the "Roxys" and 14 the "Oxys," and so on and so forth -- I mean, they 15 have their own names for these things -- these 16 people are taking them, weekly, and daily. 17 You know, they need good residential 18 treatment. They have to get away from their 19 environments. 20 You know, social pressure behind these 21 substances are the killer for young people. 22 And, the bottom line is, is that until that 23 we help them, the problem is just going to keep 24 going and going, around and around and around. 25 We have to treat them, as well as everything 1 else that we're doing. 2 And, I would like to say: Thank you, again, 3 for having, you know, a treatment provider at the 4 table at this time with everyone else, because it 5 means a lot to us. 6 So, thank you. 7 SENATOR KEMP HANNON: Mr. Fogarty. 8 ANDY FOGARTY: My name is Andy Fogarty. I'm 9 the director of government affairs for the 10 Health Plan Association of New York. 11 I would like to thank Senators Marcellino, 12 Klein, and Hannon, for inviting us here today. 13 The Health Plan Association represents 14 25 managed care plans in New York State that cover 15 approximately 6 million New Yorkers. 16 Healthcare plans in this discussion are 17 sort of an important element, as touched on by the 18 OMIG and the -- you know, the State Attorney General 19 representatives here today. And that, you know, 20 much of the money that is focused through, you know, 21 the healthcare system is paid for by the plans, as 22 well as by the State. 23 So, when it comes to traditional, sort of, 24 healthcare fraud, all plans have, you know, units 25 in place to monitor those elements. 1 With the advent, or sort of the increase, in 2 prescription drug abuse, plans have had to adapt 3 to meet these, you know, emerging issues as well. 4 Many plans, right now, have programs in 5 place that monitor, you know, prescription drug 6 abuse. In many cases, what it is, is, as Sean 7 pointed out, it really does boil down to care 8 coordination. 9 Plans look at the claims data that we 10 get, and, you know, we sort of identify those 11 instances where you may have a doctor-shopper; 12 somebody that's going to visit a physician or an 13 emergency room at a very frequent basis. 14 At that point, the plan would reach out to 15 the individual. And, you know, perhaps see, if 16 they're using the emergency room, about a 17 primary-care physician. 18 If you're seeing that, you know, at that 19 point, also reaching out to the physician, providing 20 them with sort of informational details regarding, 21 you know, the member, and, you know, the use of the 22 drugs that are being prescribed. 23 And then, as well, goes to the pharmacists. 24 The plans reach out and provide, you know, sort 25 of, informational details to the pharmacies, in -- 1 you know, when we're seeing a prevalence in, you 2 know, these type of prescriptions that are most 3 likely to be abused. 4 So, from the plan perspective, you know, this 5 is something that is definitely very, you know, 6 important to us. And, certainly, you know, as 7 everyone here has, you know, already stated, an 8 important issue across the board, especially to, you 9 know, the individuals who are putting themselves in, 10 you know, sort of an increasing spiral of either, 11 you know, hurting themselves, or, you know, moving, 12 to, you know, sort of greater criminal activity. 13 So, this, you know, it is a very important 14 discussion to have today, and I want to thank you 15 for inviting us. 16 SENATOR KEMP HANNON: Thank you. 17 We've now gone through the opening, which has 18 actually meandered into what we wanted to do in 19 Phase 2 and 3 and 4, but, that's okay. That's fine. 20 Actually, we'll take -- we have two more 21 phases -- three more phases, and I'm going to 22 discuss them, and then just want to address the 23 first one, because it may give us some immediate 24 action, which government legislators always like. 25 And, then, the second would be, policy 1 changes. 2 But the three things were: 3 What's your organization doing right now to 4 deal with the problem? Not what you want to do, 5 but, what are you doing right now? 6 Dr. Kolodny mentioned, what the hospital is 7 trying to do to get doctors just to wash their 8 hands. 9 It's an incredible ongoing public health 10 problem. 11 But -- so, that's going -- I'm going to come 12 back and ask each one of you: What are you doing 13 right now? 14 Afterwards, we want to talk about, some 15 people have already discussed the --and the attorney 16 general have talked about what programs you have 17 now, that are working. 18 And, what would you do to change those 19 programs? 20 And, some of you have touched on it, others 21 haven't. 22 So, that's where I want to divide it, in two 23 rounds. 24 The first will be: What's working now? 25 And then, then, specifically: What do you 1 want to see take change? Whether it's government, 2 or it's state or local, or federal. 3 And, what do, you, yourself? Maybe you need 4 greater power. 5 And, we're from the State. One of the things 6 that people always come and talk to us about is, the 7 need for money. 8 And we always agree, but, we have a certain 9 set of circumstances that are going on. 10 So, you might temper those thoughts. 11 So, I'm going to do the next round. 12 What are you doing right now? 13 Now, your boss left, he left you in charge. 14 What's the City doing? 15 DAHLIA HELLER: Thank you, and good morning. 16 My name is Dahlia Heller. I'm the assistant 17 commissioner for the Bureau of Alcohol and Drug Use 18 Prevention, Care, and Treatment at the New York City 19 Health Department. 20 So, what are we doing right now? 21 I think -- well, you have, actually, evidence 22 of, one of our pieces of work that we found was 23 really important, was to actually look at: What is 24 the scope of this problem in New York City? 25 You have an Epidata brief in your packet. 1 And, I believe another one was distributed before we 2 began the roundtable. 3 So, that just kind of reviews. And, the 4 Commissioner discussed that a little bit when he 5 spoke. 6 What we see right now are the trends around 7 prescription opioid misuse and health-related 8 problems, morbidity, and mortality. 9 It doesn't speak to the whole state, it 10 speaks to the City as our purview. 11 So, what are we doing about this? 12 We've heard a lot already, talking. And it's 13 actually very heartening to hear the support for 14 improving and strengthening the use of the 15 prescription drug monitoring program and the 16 database. And, we see that as very important. 17 We've been speaking with, and working with, 18 our partners at the State Health Department, and 19 collaboration with our partners at State OASAS, to 20 look at what are the opportunities for that. 21 And, I guess I'll hold off on our specifics, 22 for Round 3. I don't want to miss my chance, but 23 I'll hold off. 24 What we're doing, then, immediately, and in 25 the meantime, is, we're in the final stages, 1 actually, of preparing "City Health Information," 2 which are the publications we developed for 3 healthcare providers; go out to healthcare 4 providers across the city, to promote best 5 practices in clinical practice. 6 And, so, we developed, and we found it was 7 very important, and we've actually been spending 8 quite a bit of energy on this. It's a very nuanced 9 topic, but, the need for a "City Health 10 Information," to look at the -- at pain-management 11 treatment, and, specifically, really looking at 12 opioid prescribing, and talking about both acute- 13 and chronic-pain management, because I think we 14 sometimes forget acute pain when we start talking 15 about the subject. 16 In particular, we get caught up in the 17 chronic-pain management, and how opioids are 18 prescribed; specifically, for non-cancer 19 chronic-pain, you know, standard, we think about 20 back pain, for example. But, we often forget, also, 21 about how opioids are prescribed for acute pain as 22 well. 23 And that, even if they're prescribed for a 24 short-course treatment, they can be prescribed in 25 large quantities. And, without follow-up with the 1 patient, with the physician-patient relationship. 2 And, it's an opportunity to really talk about 3 what we mean when we talk about pain, and then, how 4 we look at pain management. 5 So, we look forward to putting that 6 "City Health Information" out next month. 7 I can get into details, but I'm not going to 8 bore you with the details of, maybe, very nuanced 9 clinical practice around this. 10 I think it's important to say, a number of 11 the strategies that Andrew talked about in his 12 presentation, such as, urine-test monitoring for 13 ongoing chronic-pain management. A real 14 relationship between the physician and the patient, 15 very important. 16 And really thinking about looking at -- and I 17 think we do issue some recommendations in there, 18 about, what is the value of chronic non-cancer pain 19 management over the long term. 20 And that's, I think, really where a lot of 21 our energy needs to be focused, is, how we think 22 about chronic non-cancer pain management. 23 Another point I think we make in there, and 24 that's made in our Epidata brief, loud and clear, 25 is, when we think about drug overdose deaths, what 1 we've seen in the data is that, as the Commissioner 2 mentioned, when he spoke earlier, we don't see 3 deaths from a single drug alone, or a single 4 substance alone. 5 98 percent, and in some years 100 percent, 6 of deaths in unintentional drug-poisoning deaths 7 in New York City are involving polysubstance use; 8 or, polysubstances. 9 And the drugs we typically see on board with 10 prescription opioids include, buprenorphine, 11 another prescription medication that we're not 12 talking about here today, but I think is important 13 to recognize that it's widespread. It's used very 14 commonly to treat a number of psychiatric and 15 low-level psychiatric issues. 16 And, in combination -- not alone, but in 17 combination with a prescription opioid, or any 18 opioid, it can cause respiratory depression, leading 19 to death. So, that's a drug overdose. 20 Important to note, that we're seeing these 21 two together because that's another medication 22 that's widely available in New York City. 23 DR. ANDREW KOLODNY: [Inaudible comment.] 24 DAHLIA HELLER: What did I say? 25 DR. ANDREW KOLODNY: Buprenorphine. 1 DAHLIA HELLER: Oh, I'm sorry. 2 "Benzodiazepine." 3 Oh, wow! 4 Not talking about buprenorphine. 5 My apologies. 6 "Benzodiazepine." 7 SENATOR KEMP HANNON: Thank you, Doctor. I 8 was totally going, wait a minute, that's the 9 antidote. 10 DAHLIA HELLER: Thank you. 11 Yes, I mean, benzodiazepine. 12 Please pull back on that, and actually 13 scratch that out. This is a live webcast. 14 My apologies. 15 Really, actually, benzodiazepine, very 16 important, many, many, many prescriptions. Many, 17 many, many more than buprenorphine. 18 We have thousands of benzodiazepine 19 prescriptions going out in New York City every 20 year. And, I'm talking about on drugs like, Xanax, 21 and Clonopin, for example. 22 So, alcohol is the other substance we see 23 commonly on board with a prescription 24 opioid-involved accidental drug overdose deaths. 25 Also important to recognize the relationship, 1 drinking is legal, it's a social behavior widely 2 accepted. But, drinking with prescription 3 opioids, even -- and unbeknownst to the patient, 4 patient might be on prescription opioids, and 5 maybe took one too many today, and then has a few 6 drinks, and is really putting themselves at risk for 7 overdose. 8 So, we need a lot better education around 9 that. 10 So, working on the "City Health Information," 11 and we look forward to issuing that next month. I 12 think we'll be talking about it widely when it does 13 come out. 14 In addition, we've been working for many 15 years now, to expand access and availability of 16 buprenorphine, the drug I mistakenly mentioned 17 earlier, which is actually an enormous step forward 18 from the treatment of opioid dependence, because it 19 is the first -- the second drug we have made 20 available for the first time in 40 years, after 21 methadone, to be able to successfully use a 22 medication to treat opioid dependence. 23 And that not -- treatment does not mean 24 you're on buprenorphine forever. And especially 25 when we're talking here, about patients who may 1 develop a dependence on a prescription opioid, such 2 as an oxycodone, such as OxyContin, through 3 treatment with their provider, with their physician, 4 their physician should be able to offer that patient 5 the opportunity to taper the tolerance and 6 dependence that develops when a patient is on an 7 opioid for even more than a few days. 8 And I think that's very important to 9 recognize here. 10 It's been mentioned around this table, 11 patients don't develop drug tolerance because they 12 have a preponderance towards addiction. Drug 13 tolerance develops with opioids because that's 14 the nature of the physiological mechanism of an 15 opioid. 16 So, it's important to make buprenorphine 17 available for treating dependence, and tapering 18 patients who have become tolerant to an opioid and 19 have completed a course of treatment. 20 We also worked -- are working on, continue to 21 work on, expanding availability and information on 22 no-lock zone, which is an opioid antagonist used in 23 emergency medicine, and is being made available 24 through the advent of opioid overdose prevention 25 programs, which are authorized, or registered, or 1 certified by the State Health Department, and can 2 train laypeople to recognize and respond to an 3 opioid overdose with the administration of no-lock 4 zone after calling 911. 5 We have seen over 400 reversals now, 6 reported in New York City, using no-lock zone by 7 laypeople responding to a recognized opioid 8 overdose. 9 And, in the -- in partnership with calling 10 911, we think this is a very important opportunity 11 to prevent and reduce opioid overdose mortality in 12 New York City. 13 Of note, most of that work is going on 14 through groups and organizations who work largely 15 with individuals using, for the most part, heroin. 16 And we've seen deaths involving heroin actually 17 start to decline in this city. 18 So, we don't see the same pattern in 19 prescription opioid-involved deaths. 20 Finally, we're partnering with community 21 coalitions around the city. 22 For example: There's a group in 23 Staten Island, where we are seeing a much higher 24 rate of prescription opioid-involved death; a group, 25 Take Care Staten Island, that is really -- has 1 identified this as one of the major issues they're 2 working on, and want to develop a 3 community-coordinated response to. 4 And, so, we're working closely with them, and 5 look forward to more of that, to really doing 6 targeted information and interventions to reduce 7 this problem. 8 Thank you. 9 SENATOR KEMP HANNON: Bridget. 10 BRIDGETTE BRENNAN: Thank you. 11 The main thing that we have done, of course, 12 is prosecute cases with respect to these drugs. 13 And, these are very non-traditional investigations 14 for us. 15 Typically, our work has involved illegal 16 substances which comes -- which come in from outside 17 the country. And there are relatively predictable 18 organizations behind the distribution of these 19 drugs, cocaine and heroin primarily. 20 With prescription drugs, it's a whole 21 different ballgame. 22 We have jurisdiction over narcotic drugs, and 23 that includes oxycodone. It does not include, for 24 example, Xanax. 25 So, even there, we have some unusual issues 1 to deal with. 2 The means that they're coming in, that 3 they're finding their way to the streets, that 4 they're finding their way to be abused, are -- you 5 can't count the number of ways. 6 And we have formed a prescription drug unit 7 in order to deal with these issues. 8 The cases are tremendously 9 resource-intensive. They take a lot of time of 10 investigators, and of assistant district 11 attorneys. 12 And, it takes specialized knowledge as 13 well. We work very closely with the Bureau of 14 Narcotics Enforcement from the State Department of 15 Health. 16 There are very important confidentiality 17 issues involved that we have to be aware of. We 18 have been doing a lot to educate our 19 assistants, as to the law, as to the health 20 issues. 21 Dr. Kolodny has been to visit us, and to 22 discuss these issues with us. 23 And, we have worked with the City medical 24 examiners, in order to help us prioritize our 25 cases. 1 When we are investigating a particular 2 prescriber, we, of course, want to know, because we 3 have been deluged with referrals, how high a 4 priority should we give this particular prescriber. 5 One way of analyzing that, is to work with 6 the medical examiner, and to find out, for example, 7 how many overdose deaths are related to a 8 particular prescriber. 9 And, so, we have been doing a tremendous 10 amount of work in the area. 11 Have created a specific unit; designated it 12 to handle these cases. 13 And, of course, we have asked the City to 14 help us fund this unit because the resources 15 involved are just tremendous. 16 We have been working with the 17 Drug Enforcement Administration on drug disposal. 18 One of the biggest issues that we are 19 finding, one of the most common calls we get, is: 20 What do I do with these drugs? 21 The calls come from nursing homes; from 22 private people; from people whose parents have 23 died and have all kinds of drugs left. 24 I think it's an issue that's probably more 25 easy to deal with than any of the other ones that 1 we're facing, but there's not, right now, an easy 2 protocol to refer people to. 3 The DEA has had some "Drug Take-Back" days. 4 It is critically important just to take drugs 5 out of supply, off the market, and that's one of the 6 big fixes. 7 You'll hear us making a lot of noise, if we 8 can, whenever we make one of these prescription drug 9 cases. It's part of our education effort. 10 We've handled a case in Staten Island, where 11 there was a drug-distribution ring actually 12 distributing drugs out of a -- OxyContin out of an 13 ice cream truck. 14 And whenever we make a case, we try to draw 15 attention to it, because it's one way of educating 16 the public about the dangers of addiction, about 17 the dangers of these drugs. 18 The other thing we continue to work on is the 19 heroin supply. 20 There's a huge heroin supply now in the city. 21 We're seeing a bigger-than-ever -- 22 bigger-than-in-recent-years market for it. We see 23 it as going hand-in-hand with the prescription 24 drugs. 25 So, that's an area that we're working on. 1 And in addition, as Senator Kemp mentioned 2 earlier, we have been working on the issues that are 3 not currently addressed by State law. 4 We have seen what we believe to be huge fraud 5 involved with the non-controlled substances. 6 We have submitted a bill. We've been working 7 with Senator Kemp on that. 8 But, it also addresses some issues that we 9 have seen with the prescription drugs; some 10 oversights in laws that were drafted when 11 prescription drugs were not a big currency, were not 12 a big problem. 13 So, we've submitted legislation in that 14 regard. 15 And, I think that summarizes our work in 16 that area. 17 SENATOR JEFFREY KLEIN: I just had one 18 question, Bridget. 19 When you're actually, prosecuting, 20 investigating, these cases, how are they different 21 from your standard, you know, elicit drug case? 22 I know that it's probably -- when you do 23 undercover, it must be very difficult in some of 24 these cases, as far as, you know, a doctor is held 25 to a very, very high standard in prescribing drugs. 1 BRIDGETTE BRENNAN: Well -- 2 SENATOR JEFFREY KLEIN: Or, maybe not a high 3 standard. Probably can do almost anything in 4 prescribing drugs. 5 BRIDGETTE BRENNAN: Yes. 6 And I think, probably, what I can clearly 7 talk about, is the case we did with the 8 Attorney General's Office a few years ago, about a 9 doctor -- regarding a doctor in Staten -- 10 Long Island who was convicted, Dr. Chait, I think 11 his name was. 12 And in that case, we did have undercover 13 officers going into the doctor's office, and 14 asking specifically for oxycodone, to treat -- 15 because of the undercover, I think, said that he was 16 trying to quit smoking. 17 I mean, the -- in order to prosecute a 18 doctor, there's only -- there's really a limited 19 number of statutes you can prosecute them under. 20 And, the conduct has to be egregious. 21 And, so, merely looking at data that 22 indicates a doctor is a big prescriber of drug, 23 you know -- 24 SENATOR JEFFREY KLEIN: Not enough. 25 BRIDGETTE BRENNAN: -- certainly, not enough. 1 And rightfully so. 2 I mean, there are doctors who specialize in 3 pain management, there are doctors who treat a lot 4 of cancer patients, but, that's not how we focus 5 our investigations. 6 We get information in the traditional way: 7 from the street; from the street-level sales, from 8 the guys over in Union Square Park, who are 9 selling their drugs. 10 And then we find out from them, where they're 11 obtaining their drugs. 12 Or, I passed out a packet of information, 13 including some photographs, of seizures. 14 We focused on a drug delivery service that 15 was delivering to individual customers, cocaine, 16 heroin, fentanyl, OxyContin, Vicodin. And, again, a 17 huge supply of drugs inside the car when we stopped 18 it. 19 And, again, we track it back, where are those 20 drugs coming from. And that's how we can identify 21 a -- a medical provider who has gone off -- gone off 22 the path. 23 SENATOR JEFFREY KLEIN: So, in other words, 24 it's probably much easier to get an office manager 25 that steals a prescription pad than the actual 1 doctor? 2 BRIDGETTE BRENNAN: Exactly. And those 3 aren't easy either, frankly. 4 That was -- our Staten Island case was an 5 office manager who stole prescription pads and 6 supplied them -- sold the pads. But, it took 7 months to make that case. 8 And, actually, the most interesting thing 9 about that case -- and this is addressed in the 10 legislation we proposed -- is that the office 11 manager, ultimately, was facing a less-severe 12 penalty and less-severe sanction than the people who 13 were recruited to present the prescriptions in the 14 pharmacy and have the pharmacy deliver the drugs to 15 them, and they turned around and kept some of the 16 drugs because many of them were addicts, and sold 17 the rest to the Lickety-Split ice cream man, who 18 then sold them out on the streets in Staten Island. 19 SENATOR KEMP HANNON: Bridget, you know, we 20 passed that legislation in the Senate. 21 One of the things the State did, about 22 six years ago, is introduce, what they call 23 "forge-proof prescription pads," which were 24 dealing with the certain problem at that point. 25 But, I'm wondering if you have encountered, 1 besides the simple theft of it, what Dr. Kolodny 2 referred to as "other scams," in regard to the 3 current pads, and what steps might be taken on -- 4 BRIDGETTE BRENNAN: Yes. 5 I mean, we've heard from our colleagues 6 around the state about -- you know, with people 7 being as savvy as they are about computers, 8 duplicating things, et cetera, et cetera, I think 9 there's no proof any -- there's no forge-proof 10 anything anymore. 11 And, certainly, we have heard from our 12 colleagues around the state, that there have been 13 people arrested, who presented prescriptions that 14 were -- that they produced with their own 15 computers. 16 SENATOR KEMP HANNON: Now, the federal DEA 17 has proposed some regulations for electronic 18 prescribing of the controlled substances. 19 And I know the State DOH is working on trying 20 to implement what would have to be legislation or 21 regulations on that regard. 22 And I don't know if you've worked with the 23 DEA, and those -- the electronic prescribing, and 24 whether that, cures, or introduces, the problems 25 we're talking about. 1 BRIDGETTE BRENNAN: That, I couldn't really 2 answer. I don't know whether it will. 3 I mean, you know, conceptually, the link that 4 was described earlier, that a -- in real-time; a 5 pharmacist could see that in real-time, a physician 6 prescribed a drug, would eliminate certain aspects 7 of it. But, then, you know, it's like one of those 8 games, where you pound down one peg, only to have it 9 come up a different way. 10 And that's what we have seen in this area. 11 The diversion is more -- it's not so crude, it's 12 more clever. There's big money involved. 13 And, so, I can't really say whether or not 14 that would be an effective remedy. 15 I'm sure there are people who would know 16 better than I. 17 I was recently down in Washington, to meet 18 with the director of the Office of the National Drug 19 Control Policy, who is talking about other things 20 DEA wanted to do, including, make training mandatory 21 for doctors who are going to prescribe Schedule II 22 opioid analgesic medication before they would be 23 licensed to prescribe those drugs. 24 Something like that would be helpful to me, 25 only from the perspective of, now I have a standard, 1 now I know doctors have been trained, with regard 2 to the prescribing of the drugs. 3 Some of the things that are seen in pill-mill 4 clinics, I mean, when Ms. Heller referred to 5 prescribing Suboxon, plus an opioid drug at a time, 6 your ears rang, because you knew that was wrong. 7 Well, we see it. 8 And, I don't know if it's written in any 9 brochure or pharmaceutical manual that you're not 10 supposed to do it, but that's the kind of thing that 11 indicates to us, a physician who is not 12 necessarily prescribing drugs just to treat pain. 13 SENATOR CARL MARCELLINO: Can I just, before 14 you go ahead? 15 Is it a crime right now -- I mean, out of 16 complete ignorance. 17 Is it a crime right now for someone to go 18 from doctor to doctor, I have a problem. My back is 19 killing me. I've got severe pain. I can't -- 20 Dr. so-and-so, I need help. 21 Dr. so-and-so prescribes five days of 22 oxycodone...whatever. 23 I go to Dr. Smith. "Doctor, I've got a 24 problem." 25 Five more days. 1 Go to Dr. Jones. "Doctor, I've got a 2 problem." 3 Five more days. 4 Is that a crime right now? 5 BRIDGETTE BRENNAN: Yes. I mean, there are 6 crimes you could prosecute right now. 7 Specifically, do we have a crime that 8 addresses it? 9 I think we do, under the Public Health Law, 10 maybe. But, you can also address it through some of 11 the other crimes that are more general crimes. 12 Unlawful possession of a controlled 13 substance, you could prove that -- you might be able 14 to do it. 15 But, I do believe there's something specific 16 in the Public Health Law that would address that. 17 Unfortunately, I just got back from vacation 18 a few days ago, and my head isn't back into the 19 narcotics world, otherwise I would have that at my 20 fingertips for you. 21 But, I can get back to you on that. 22 PAUL MAHONEY: If I may jump in for a second. 23 It all depends, Senator, on whether the 24 person who is going from doctor to doctor, is going 25 for a medical reason, or to obtain the drugs. 1 And the law enforcement proof problem is the 2 interaction between that patient and the doctor, as 3 a -- 4 SENATOR CARL MARCELLINO: I go to seven 5 doctors. I tell them I have the same problem. 6 Maybe I legitimately have the problem. 7 And, I go to seven different doctors, each 8 one gives me the same prescription. 9 I know I'm gaming the system. You know I'm 10 gaming the system. 11 The question is: Can you prove it, and is it 12 a crime? 13 What do we do to stop that? 14 PAUL MAHONEY: That's exactly right, Senator. 15 The problem is, that the contrast to 16 Ms. Brennan's traditional heroin and cocaine 17 cases, are that, if you're in possession of heroin 18 or cocaine, you're already committing a criminal 19 act. And you're, at least presumptively, committing 20 a criminal act. 21 When you're in possession of the pill form of 22 a controlled substance, you are in possession of 23 something that, under the right circumstances, 24 you're entitled to have. 25 And so many of the players have the ability 1 to point to someone else in the chain, and say, it 2 was their misjudgment, or their wrongful act, that 3 put me in possession of that drug, that it makes 4 these cases very difficult to prosecute. 5 If your name is on the pill bottle, you are 6 presumptively entitled to be in possession of that. 7 SENATOR CARL MARCELLINO: So there is no 8 limit to the amount of OxyContin an individual can 9 have? 10 PAUL MAHONEY: As a raw number, that's 11 correct. 12 UNIDENTIFIED MALE SPEAKER: If there's a 13 health insurance claim involved, it would be 14 insurance fraud. 15 SENATOR CARL MARCELLINO: Okay, so now we're 16 getting somewhere. 17 So, there is a potential, that, I'm gaming 18 the system clearly. I don't need to go to 19 seven different doctors, get the same 20 prescription, and build up my supply more than -- 21 you know, ten times more than I possibly could 22 need to resolve my medical problem. 23 I'm assuming each doctor -- big assumption -- 24 that each doctor is giving me the appropriate 25 prescription for the problem. 1 So, now, I've gone -- and the insurance 2 company is reimbursing me each time. Paying the 3 claim each and every time. 4 So, I'm defrauding the insurance company. 5 I'm in possession of a drug I don't need, a certain 6 amount of -- 7 DR. FRANK DOWLING: Can I make a comment in 8 regards to this issue, that's very important? 9 I don't know whether it's law or regulation, 10 but I am certain that it is one or the other. 11 And as a physician, I think of law and 12 regulation as being equivalent. 13 That, if a patient has been given any 14 controlled drug prescription in New York State, from 15 one prescriber, the patient is expected, under 16 New York State law, to inform any other potential 17 prescriber what they're getting, from whom they're 18 getting, et cetera. 19 The fact is, many patients don't report 20 that, so patients don't have the information -- 21 doctors may not have the information unless the 22 patient is willing to be open and honest, and report 23 it. 24 And that's one of the reasons why a 25 database that will report any prescriptions would 1 be very useful. 2 But, I'm pretty certain. We've had several 3 discussions with OASAS, Department Health, Bureau of 4 Controlled Substances, about this issue; that that 5 is a matter of law regulation, that a patient must 6 report any controlled substance prescriptions 7 being given from another prescriber if they're 8 seeing a current potential prescriber of any 9 medications. 10 JOANNE HOFFMAN BEECHKO, R.Ph.: May I add 11 something to that as well? 12 As the dispenser of the medication, we 13 currently do see, in 95 percent of the 14 prescriptions, we do get the information 15 immediately back from the insurance companies. 16 We see -- and Medicaid as well, we'll get a 17 notice back that says, other prescriber, other drug. 18 So, we know -- 19 SENATOR KEMP HANNON: How quickly do you get 20 that notice? 21 JOANNE HOFFMAN BEECHKO, R.Ph.: When we 22 submit a prescription through to Medicaid, or when 23 we submit through the private insurance, it's 24 instantaneous. 25 So, we know immediately, whether a 1 prescription has been written for that same patient, 2 for most patients, when it's electronically 3 allowed, when we can see this information, 4 immediately. 5 And then you said, What are we doing? 6 Currently -- we are, currently, every single 7 prescription that is coming through to us, we are 8 monitoring this flow of medication. 9 If I get a prescription back that says that a 10 patient has filled something somewhere else, with 11 another doctor; or even the same doctor, another 12 medication, we, as pharmacists, are obligated by 13 many different laws and regulations, to question, 14 both, the patient and the physician, as to whether 15 they are aware of the medications that are being 16 prescribed for this patient. 17 So, it is already, currently, an ongoing 18 entity. 19 It's something that you need to keep in mind. 20 SENATOR KEMP HANNON: You spoke before about 21 wanting to access, and the Attorney General has 22 recommended accessing a database. 23 But, if you're now getting this 24 information -- 25 JOANNE HOFFMAN BEECHKO, R.Ph.: For Medicaid? 1 SENATOR KEMP HANNON: -- for Medicaid, and 2 for anybody covered by health insurance. 3 JOANNE HOFFMAN BEECHKO, R.Ph.: Uh-huh? 4 SENATOR KEMP HANNON: So, that would account 5 for, 75 percent of your prescriptions? 6 JOANNE HOFFMAN BEECHKO, R.Ph.: More. 7 SENATOR KEMP HANNON: More? 8 JOANNE HOFFMAN BEECHKO, R.Ph.: I would have 9 to say -- I would have to say, probably 90 percent 10 of my prescriptions that come through to me now, I 11 can see if the patient has had a prescription 12 prescribed to them already. 13 And I would like to point out -- 14 SENATOR KEMP HANNON: No, no, I'm just trying 15 to see is, what -- what is it that you're seeking 16 additional to what you're getting now? 17 JOANNE HOFFMAN BEECHKO, R.Ph.: The 18 remaining -- the patients that come in, who are -- 19 who are buying their prescriptions with cash, 20 those -- that's the only information right now that 21 I don't have. 22 But, the information is available to the 23 State. Every prescription, because of the coding on 24 the bottom, that data goes through to the State. 25 SENATOR KEMP HANNON: For a controlled 1 substance? 2 JOANNE HOFFMAN BEECHKO, R.Ph.: For a 3 controlled substance, yes. 4 So, what currently happens now is, once a 5 month, pharmacies are required by law to submit that 6 data to the State. 7 The State then -- I don't know, honestly, 8 what the State does with that data, but the data is 9 there. 10 And, so, that all -- all of the 11 prescriptions, any controlled substance 12 prescription, that has been prescribed, and 13 dispensed, that data is available, monthly, to the 14 State. 15 DAHLIA HELLER: Can I just -- I'll just speak 16 to that. 17 Yeah, the prescription drug monitoring 18 program that's run by the State Health Department, 19 Bureau of Narcotics Enforcement, actually does 20 contain all of that information. 21 And the issue which was raised, I think by 22 several people in their opening statements here, 23 with respect to the threshold for information access 24 on patients, is really the issue that a lot of 25 providers face when they want to look up a 1 patient's medication history. 2 So, you can only get information now, on a 3 patient's medication history. 4 I think somebody's already mentioned this, 5 but just to remind everybody: For the past 30 days, 6 if they've gone to two or more doctors, and had a 7 medication -- controlled substance medication 8 dispensed by two or more pharmacists. 9 So, that's a very high threshold, you can 10 imagine. 11 And, if I go to one doctor, and 12 five pharmacists, and pay cash, or -- or, the 13 pharmacist is not using the claims database, 14 really, to look at my history, and have that 15 conversation, either, with the prescriber, or with 16 the patient right there, or both, then you won't be 17 able to see my history, and you won't know. 18 And I think, really, if we move upstream a 19 little bit, into, what's the source of the 20 medications? 21 Because, I think -- and what's -- what are 22 the structural -- what's the structural environment 23 influencing how doctors prescribe, I think we can, 24 maybe, make a little bit more of a dent in the 25 problem, because I think this whole problem is, that 1 the drug-seeking patient -- I think it's been 2 mentioned here -- represents a very small 3 proportion of the group of people who are adversely 4 affected by opioid prescribing in this society. 5 Right? 6 Opioid prescribing has become very common. 7 As Dr. Kolodny showed us, the graphs, 8 we've had this enormous increase in prescriptions 9 going out. And those weren't drug-seeking 10 patients necessarily. I think those were folks 11 who were getting prescribed legitimately by their 12 provider. 13 So, if we made data more accessible, more 14 timely, in the prescription drug monitoring program. 15 And, I think that's been raised here several 16 times. 17 There's a bill the Attorney General's Office 18 has introduced, that would actually create a brand 19 new system, that would be immediate. 20 But, in the absence of that, our existing 21 program can actually be tweaked to do some of this; 22 to make data available soon after it's been 23 prescribed. Much sooner than now. It could be up 24 to a 45-day time lag. 25 And to make information available on all 1 controlled substances prescribed to a patient, 2 regardless of, whether, or how many providers, or 3 pharmacists, they visited, to access or receive 4 prescriptions in the past, whatever time period. 5 So, those are all opportunities for improving 6 existing systems that are at our fingertips, 7 really. 8 And I know we've been talking to the 9 State Health Department about that, and I think it's 10 something we've heard around this table, it would 11 really change the environment. 12 SENATOR KEMP HANNON: I've skipped over, but 13 I have to make a comment, that, all of the 14 electronic systems in this nation, starting from, 15 prior to healthcare reform, under -- and then 16 accelerated under the Stimulus Act with billions 17 of dollars of money, for electronic health 18 records, for regional health-exchange information, 19 the State of New York, starting with Eliot Spitzer, 20 had a technology chief in the Health Department, 21 who's been succeeded by someone else right now, 22 Commissioner Block. 23 So, they're moving, in a major way, for 24 electronic health records, what you're finding. 25 And, then, the State itself has had several 1 revisions, and things going on, in regard to 2 E-MEDNY, and trying to coordinate it, because the 3 City of New York has a very sophisticated system. 4 So, they're in the -- there's -- in the 5 middle of all of this, there's a lot of information. 6 And the question is, I think, as 7 Ms. Beechko pointed out today, is, how do you best 8 use it, and find gaps that are not being addressed? 9 And maybe the best way to do is, to address 10 those gaps first. 11 But, this is an enormously instructive 12 discussion. 13 BRIDGETTE BRENNAN: Yeah, I might just point 14 out, that, in the cases that we've seen, the 15 patients tend to use cash insurance and Medicaid, 16 the ones who are drug-seeking patients, they're 17 trying to get their drugs. 18 And, so, that would avoid the detection by 19 either Medicaid or the insurer, when they keep 20 bouncing around for different -- you know, using 21 different methods of payment. 22 SENATOR KEMP HANNON: Those would tend to be 23 the people who are addicted? 24 BRIDGETTE BRENNAN: Yes -- well -- yeah. 25 Or -- 1 SENATOR KEMP HANNON: And then there's -- 2 would there be another pattern for people who are 3 doing this for profit? 4 BRIDGETTE BRENNAN: See, the ones who are 5 addicted or the ones who are doing it for profit 6 would use the same mechanisms. 7 Because, the ones who are doing it for 8 profit -- in Staten Island, in that case, all the 9 people who were using the prescriptions, almost 10 all used cash, because, they could pay $200 for a 11 prescription for OxyContin. 12 Get 30 pills. Each pill, they might sell 13 for $20. So, they make a nice profit on it. 14 Now, if you can use insurance, you'll make an 15 even bigger profit on it, see, because then you pay, 16 you know, dollars for the prescription, and your 17 profit is still the same. 18 Same thing for Medicaid. 19 And, so, these organizations, just depends on 20 what they can get away with. It's -- 21 SENATOR JEFFREY KLEIN: It also appears to be 22 that, Medicaid is looking for Medicaid fraud, and 23 the insurance industry is looking for insurance 24 fraud. And, the cash payment, also, isn't being 25 tracked. 1 BRIDGETTE BRENNAN: Right. Cash is -- if 2 they're really trying to skate under the radar, then 3 they use cash. 4 However, especially if you see really highly 5 organized groups that are just trying to maximize 6 profit, then you'll see them using more insurance or 7 Medicaid. 8 You see a nice industry, a nice corrupt 9 industry, where they'll use Medicaid dollars to 10 buy the pills, sell the pills back to an 11 unscrupulous pharmacy, which will then sell the 12 pills again for Medicaid -- you know, bill 13 Medicaid again for the same pills. 14 So, there are just a lot of different 15 variations on the same theme. 16 SENATOR JEFFREY KLEIN: Thank you so much. 17 SENATOR KEMP HANNON: All right, we've jumped 18 all around. 19 Senator Marcellino. 20 SENATOR CARL MARCELLINO: I'm sorry. 21 You're raising an issue here of, people 22 paying cash, beating the system, in that sense, 23 because it's not in the prescription scheme, but, 24 that goes to the point of the pharmacist. 25 Is there a control, as to the amount of -- 1 pick a drug -- that you have? Do you have to 2 report, I've got so many pills of OxyContin, so 3 many numbers of pills of this drug, X drug, 4 Y drug; do you have to make a report? 5 And I've dispensed so many of them, via 6 prescription, or cash. 7 I'm assuming, you're not going sell a 8 controlled drug without a prescription, so there has 9 to be a prescription, cash or not. 10 So, is there any control as to the number of 11 pills that, you, the druggist, has to dispense? 12 JOANNE HOFFMAN BEECHKO, R.Ph.: There is no 13 report that we're required to, except for the fact 14 that you have to keep in mind, that every single 15 prescription, that, for a controlled substance, that 16 data does go through to the State. 17 So, the State has information on every 18 controlled substance that is prescribed, dispensed, 19 and where it's being dispensed, and who the 20 patients are. 21 So, in essence, yes, we already are reporting 22 all of that information. 23 SENATOR CARL MARCELLINO: See, I recently had 24 to go -- I went on this trip to -- where I met the 25 New Jersey Inspector General. 1 And, I went to the doctor, and I needed my 2 prescriptions filled for the drugs that I take. 3 The pharmacist filled one of the two. 4 I said, "Why didn't I get the second?" 5 "You're not due yet. The insurance company 6 will not pay. It's another week before we can fill 7 this prescription." 8 I said, "But I'm traveling." 9 "Doesn't matter. You got to call, get 10 permission." 11 A week later -- I had enough. But a week 12 later, I got a call from the drug store: Your 13 prescription is here. We'll hold it for another 14 couple of days, because the time had passed. 15 Another couple of days, for you to come pick it up. 16 So, they kept it. They kept the 17 prescription, and filled it afterwards. 18 So, my point is, the information, apparently, 19 is available, that we're all looking for. 20 JOANNE HOFFMAN BEECHKO, R.Ph.: Uh-huh. 21 SENATOR CARL MARCELLINO: You're saying the 22 State has it all already. 23 It's a matter of, putting it all together? 24 DR. ANDREW KOLODNY: Not really. 25 The patient you described -- 1 SENATOR CARL MARCELLINO: I thought it was 2 going to real simple. 3 DR. ANDREW KOLODNY: -- no, the patient is a 4 doctor-shopper, whether they're doctor-shopping 5 because they're suffering from addiction; or 6 whether, because they're selling the pills. Or, 7 very often it's both. 8 They know very well, that if they try to use 9 their insurance twice in a month, to pick up a 10 prescription, that it's going to get stopped, and 11 that somebody may even call the doctor who wrote the 12 prescription. 13 So, they may fill the first prescription with 14 an insurance plan, and then they'll pay cash for the 15 other prescriptions. 16 The State has the data. 17 If the data was available to the pharmacist 18 before the pharmacist filled the prescription, the 19 pharmacist would know immediately, that this is a 20 patient who's been to five different doctors, and 21 you could stop it right there. 22 Or, if the doctors had that information 23 available to them. 24 BRIDGETTE BRENNAN: Yeah, a little caveat on 25 that. 1 I think the pharmacies have to fill out the 2 information, not simultaneously, but by the end of 3 the month. 4 JOANNE HOFFMAN BEECHKO, R.Ph.: By the 15th. 5 BRIDGETTE BRENNAN: Okay, by the 15th. 6 And, again, those people who are involved in 7 these diversion rings know what the reporting 8 requirements are. 9 The big chains tend to fill it out 10 simultaneously. 11 The smaller pharmacies tend not to, and 12 that's where we see, either the doctors -- you 13 know, the addicts or the diversion rings hit up 14 the mom-and-pop pharmacies a lot. 15 They know the tricks. 16 JOANNE HOFFMAN BEECHKO, R.Ph.: One thing 17 that you didn't -- 18 PAUL MAHONEY: Fundamentally -- 19 JOANNE HOFFMAN BEECHKO, R.Ph.: -- oh. 20 PAUL MAHONEY: [inaudible.] 21 So, the prescription, it's recording, not the 22 presentation of a prescription, but the dispensing 23 of the prescription. So, by the time the data 24 hits the existing database, the drugs are already 25 out on the street. 1 SENATOR KEMP HANNON: This is the database 2 that's in the Department of Health? 3 PAUL MAHONEY: That's correct. 4 SENATOR KEMP HANNON: And, then, do you have 5 real-time access to that? 6 PAUL MAHONEY: No, we do not. 7 SENATOR KEMP HANNON: Does the Office of 8 Medicaid Inspector General have real-time access to 9 that? 10 PAUL MAHONEY: I believe not. 11 I believe that every law enforcement agency 12 has to make a request of some sort to the Bureau of 13 Narcotics Enforcement in order to comply with the 14 restrictions on data confidentiality. 15 So, without going too deeply into the 16 law enforcement aspects, we can request, or, in 17 some cases subpoena, a report, but, it's historical 18 data at the time we do it. 19 SENATOR KEMP HANNON: Is that what you're 20 reporting to; you're reporting it to the DOH, 21 Department of the -- Bureau of Narcotics? 22 JOANNE HOFFMAN BEECHKO, R.Ph.: Correct. 23 ANDY FOGARTY: If I may, I also understand, 24 that -- 25 SENATOR KEMP HANNON: Mr. Fogarty. 1 ANDY FOGARTY: -- I also understand, there's 2 a month lag in your reporting. 3 So, you report once a month, so that's not 4 exactly current data upon which the State has. 5 They may have all the data, but it's not 6 current because it's reported once a month by the 7 pharmacies. 8 And, also, one of the things I think that's 9 important to note on, that's missed in that data 10 collection, is the formulations of the drugs. 11 That, you may be taking one form of a drug, 12 but you can take, like, you know, one version of an 13 opiate, and then there's another opiate with a 14 little bit of Tylenol in it, so it's a different 15 drug. 16 So, it's one of those things, you maybe have 17 the -- sort of the chemical formula be slightly 18 different, so that you're still getting an opiate, 19 but, it's -- you know, when you look at what scripts 20 are being filled, are two different drugs. 21 SENATOR CARL MARCELLINO: But the information 22 reported has, the drug, whichever; the doctor who 23 prescribed it, and the person who claimed it? 24 ANDY FOGARTY: Correct. 25 SENATOR CARL MARCELLINO: Okay, so you've got 1 all the information, which is what was said before. 2 ANDY FOGARTY: Yeah. 3 SENATOR CARL MARCELLINO: You got all the 4 information, someplace. 5 And I frankly don't care if it's historical 6 because, eventually, you'll be able to track, that, 7 John Jones has picked up all of these prescriptions, 8 and you go chase John Jones. 9 ANDY FOGARTY: No, absolutely, the State does 10 have the data. It's just a question of, how 11 quickly. 12 You know, like I said, if you're looking for 13 real-time, you know, that's where -- 14 SENATOR CARL MARCELLINO: There's real-time, 15 and there's real-time. 16 PAUL MAHONEY: Senator Marcellino, not to 17 interrupt, but can I give one illustration, of: 18 It's a question of degree, but, the question of 19 degree and timing is very significant, especially 20 for prosecution purposes. 21 Earlier, Ms. Brennan mentioned the 22 Chait case, and we can use that one because it's 23 fully public. 24 Dr. Chait was prosecuted, served 25 three years. 1 Under what is essentially the existing 2 system, he was, nonetheless, able to write, have 3 filled -- we don't even know how many he actually 4 penned -- but, he was able to have filled, 5 490 controlled substances in a 3-month period. 6 Total billings to all insurers, and 7 traceable cash, were about $900,000-and-change, just 8 shy of a million dollars. And, some 400 patients 9 were affected. 10 And, he was reported, he was picked up, but 11 not -- by the existing system, and variations on it, 12 in the sense that, he was so flagrant, that he 13 raised red flags. But, nonetheless, he -- to get 14 a proveable case against him required very 15 sophisticated undercover tactics. The same sort 16 of undercovers that you would send in for a 17 drug -- a classic drug raid, because, at the end of 18 the day, we had to be able to show, through the 19 investigative techniques of several offices, 20 that this fellow was writing the scripts 21 regardless of what the patient was saying to him. 22 That, the investigators had to come in, and 23 say: I need OxyContin because I have a really bad 24 hangnail. 25 And, then, a little bit facetiously: Okay, 1 do you want 30-days or 60-days supply? 2 He was actually much more leery than that. 3 And, it was a much more sophisticated case. 4 Yes, the data was there, but the intent was 5 not clear from the data. It still had to go back to 6 traditional law enforcement techniques. 7 SENATOR JEFFREY KLEIN: So, in other words: 8 It's enough for a doctor to ask the question, you 9 know, "What hurts?" 10 Touch someone's knee, and say, "Yeah, it 11 hurts there"; and, they can write a prescription? 12 PAUL MAHONEY: The standard is not much 13 higher than that. 14 SENATOR KEMP HANNON: I want to jump ahead, 15 since we smashed protocol here. 16 Dr. Kolodny, the question is: What are you 17 doing now? 18 Not so much in the sense we've been talking 19 about, but, you know, heading the Department of 20 Psychiatry at Maimonides, you're trying to deal with 21 the other doctors. Dealing with the doctors in 22 the ER, who are being, probably gamed, if people 23 come in to doctor-shop. 24 And then, also, just, how do they deal in a 25 regular course of treating people who have chronic 1 pain? 2 DR. ANDREW KOLODNY: I'll tell you about one 3 of the things we tried to do, that didn't work, and 4 I'll tell you why. 5 But, psychiatrists don't generally 6 prescribe opioids for the treatment of pain, but 7 we do prescribe benzodiazepines for anxiety. 8 Hopefully, less often, Xanax, which is more abusable 9 than some of the other. 10 But, we had -- in our clinic, which serves 11 about 1,200, in the course of a few months, we had 12 a few of our patients die of -- were dead. And, 13 we had to do an investigation, because our clinic is 14 licensed by Office of Mental Health. Every time one 15 of our clinic patients dies, whether it's for a 16 natural cause or not, we have to take a close look. 17 So, we had four deaths of patients in our 18 clinic. We took a close look. 19 And, all four of those patients, within a 20 short period of time, were patients who are were 21 getting benzodiazepine prescriptions from our 22 psychiatrists, and they were getting opioid 23 prescriptions prescribed elsewhere. 24 And, as Dahlia mentioned, when she meant 25 "benzodiazepine," the two together are a very 1 dangerous combination. 2 So, you know, as we investigated this, it 3 seemed to me, that we should take advantage of the 4 State's new health commerce program, where you can 5 go in and take a look at a patient's prescription 6 record. 7 And my intent, at the time, was to have a 8 policy for our department: Before any psychiatrist 9 is going to write a benzodiazepine prescription, 10 they have to make sure the patient isn't on an 11 opioid. They have to go in and check that database. 12 So, I picked out, to just test out the 13 system, a patient who was in our clinic, who I knew 14 from our own electronic records system, that the 15 patient was on both an opioid and a benzodiazepine. 16 I typed their name into the system. No 17 information came back, because this was a patient 18 who did not fit the current definition, which, as 19 Dahlia mentioned, is -- the patient has to be 20 filling controlled substances from two or more 21 physicians, at two or more pharmacies. 22 So, if the patient is getting all of their 23 medications from one pharmacy, you get no 24 information back. Or, if they're going to different 25 pharmacies, but they're getting all of their 1 prescriptions from the same doctor, you get no 2 information back. 3 So, in effect, the system that we have, it 4 was useless for our purposes. 5 In terms of things that my organization, 6 Physician for Responsible Opioid Prescribing, is 7 doing, many of us are on the front line of this 8 problem in different parts of the country. 9 Some are working in public health 10 departments. Many are working with State 11 legislatures, like -- like I'm here today. 12 And, some states have come up, like 13 Washington State, with very effective legislation to 14 help this problem; for example, dosing limits. 15 One of the issues that's really a problem 16 here is, high-dose prescribing of opioids. 17 So, you've got patients who don't have -- 18 or, individuals who don't have to go to four or 19 five different doctors. You hit the right doctor 20 who's giving you whatever you want, enormous 21 supplies of opioids, and that's what we would call 22 "high-dose prescribing." 23 And, in many cases, there are patients 24 taking all of those opioids. And they're at a 25 very high risk of an overdose death, and they're 1 getting other side effects. 2 But, many of these individuals are 3 diverting, and there is no way for a physician to 4 know if their patient is diverting. 5 Very often, the patient -- 6 SENATOR KEMP HANNON: What's "diverting"? 7 DR. ANDREW KOLODNY: "Diverting" means, 8 somebody who's coming in, getting a prescription, 9 and selling it. 10 And, if you look at the value of these 11 medications, a 40-milligram OxyContin is $40. 12 If you're getting 320 pills a month, you can 13 support a family on that prescription. 14 There's no way for a doctor to know. 15 If the patient is really clever, they'll take 16 a little bit of the medication before they come in, 17 and the doctor would see it on a urine test and it 18 looks like the patient is taking it. 19 But, very few doctors are doing any urine 20 toxicology. 21 Anyway, the high-dose prescribing is 22 something that's very harmful to patients. And, 23 it leads to a tremendous amount of diversion. 24 It's one of the standards of care that could 25 be potentially legislated that could help this 1 problem. 2 Other things that our organization is doing, 3 is advocacy, on the federal level, for a 4 rescheduling of hydrocodone. 5 New York State's Controlled Substance Act, 6 with regard to scheduling of drugs, in many ways, 7 is almost a copy-and-paste from the federal 8 Controlled Substances Act. 9 DEA asked FDA to reschedule hydrocodone 10 several years ago, from a III, to a II. 11 The FDA has been sitting on this for years. 12 This is something New York State could do. 13 The states are allowed to be more respective. 14 SENATOR KEMP HANNON: And we've actually -- 15 we're actively looking into rescheduling it. And, 16 then, looking at any of the trade name drugs that 17 will use it, because it's all -- it's just not a 18 one-to-one type of thing. And, then, looking at any 19 of the other variations that are being -- being 20 mentioned as being misused, including, then, when 21 Ms. Brennan mentioned about one of the drugs, that 22 is Xantax [ph.] -- 23 BRIDGETTE BRENNAN: "Xanax." 24 SENATOR KEMP HANNON: -- Xanax -- 25 BRIDGETTE BRENNAN: We don't have 1 jurisdiction. 2 SENATOR KEMP HANNON: -- you don't have 3 jurisdiction. 4 So there's questions of: What's the most 5 appropriate thing to do in terms of scheduling? 6 But, you know -- and this, obviously, from 7 what you said, it's part of one of the approaches to 8 the problem. 9 DR. ANDREW KOLODNY: Right. 10 And then, the last thing, and the main thing, 11 that our group is doing, is trying to provide 12 physicians and prescribers with better 13 information. 14 We've talked quite a bit this morning about 15 that third prong, and black-market availability, and 16 doctors who are really no better than drug 17 dealers. 18 But a bigger problem here, if we want to 19 prevent new people from getting addicted, are the 20 well-meaning physicians who are overprescribing 21 because they think that's the proper way to 22 practice. 23 They've been given bad information. Much of 24 their education comes from companies that want them 25 to prescribe more. 1 And we're trying to counter that. 2 SENATOR KEMP HANNON: Have you involved 3 yourself with the fact that, about three years 4 ago, the State of New York introduced its own 5 counter to pharmaceutical detailing, which is the 6 selling of drugs by the pharmacies, so that 7 counter-information would be brought by a 8 not-for-profit objective group to physicians? 9 DR. ANDREW KOLODNY: I wasn't aware of that. 10 That sounds very promising. 11 SENATOR KEMP HANNON: I mean, that's along 12 with, many of the universities, many of the medical 13 centers, many of the large group practices, 14 saying, that, they're going to have a whole way of 15 acquiring information about drugs that is different 16 than allowing someone to go in and buy a pizza for 17 lunch, and making a pitch. They want to do it in a 18 more systematic, regulated way. 19 DR. ANDREW KOLODNY: Certainly, my 20 organization would be happy to get involved with 21 that. 22 SENATOR KEMP HANNON: Well, absolutely. 23 Now, I have a question for you, and to 24 Dr. Dowling, is: How do you change the patient -- 25 the physician behavior here, without either 1 overdoing it or burdening them with? 2 I don't know many physicians who tell me 3 that they have a spare time during the course of a 4 day. 5 DR. FRANK DOWLING: That's a great question. 6 And, actually, if you don't mind, I wanted to 7 summarize some of the things that the 8 Medical Society has been doing, in partnership with 9 "ASAM"; American Society of Addiction Medicine. 10 SENATOR KEMP HANNON: As long as you respond 11 to my question. 12 DR. FRANK DOWLING: I'm sorry? 13 SENATOR KEMP HANNON: As long as you respond 14 to my question. 15 DR. FRANK DOWLING: I will. I definitely 16 will, because I think it touches on that question; 17 it's all around that same question. 18 One of the things that's important to keep in 19 mind is, that doctor, who is basically part of a 20 scheme to illegally sell drugs, is a small number, a 21 small percentage of doctors, but they give all 22 doctors a black eye. 23 We certainly want to go after that doctor. 24 I think Dr. Kolodny is correct, that there 25 are many well-intended physicians who, one, aren't 1 getting accurate information from patients; or, 2 two, may not be able to tell, really, what's the 3 limit. 4 Do you really need this med, at this dose, 5 and this number of tablets? Or is it double that? 6 And these are very difficult clinical 7 decisions to make. 8 I don't know if everyone in this room is 9 aware, that, in every hospital in the state of 10 New York, every day, if not every shift, a 11 healthcare worker asks someone about their pain 12 symptoms, and rating it, and to show that it's 13 addressed. 14 That's how far it is on the other side; that 15 doctors are being disciplined, and being sued, for 16 undermedicating pain, while on the other hand, 17 trying not to overmedicate or miss. 18 So, with that information, with what we've 19 been talking with the Department of Health, with 20 OASAS, with Office of Mental Health, is, is we have 21 been requesting that the database threshold be, any 22 and all information. 23 What will it take for the database to do 24 that? 25 Can a staff member from my office, who's been 1 trained by me, and understands privacy 2 regulations, pull up all the information on people 3 I'm going to see today? -- because I may not have 4 time to do that on everyone? And so on. 5 Can information be shared with pharmacies? 6 And so on. 7 Can they have access to the same data? 8 It's very difficult. 9 We've also partnered with the Department of 10 Health in many ways, over the years, to educate 11 physicians in challenging areas. 12 And this is one area where we've had 13 conversations with the Department of Health and 14 OASAS. 15 So, we would like to partner with educating 16 in this area. 17 But, we've also asked that the Department of 18 Health really work hard to educate patients in 19 this area. 20 The physician-patient relationship is so 21 important. And it's very difficult for a physician 22 to ask a patient, how you're doing this, why you're 23 doing it, where you're doing, and it not be seen as 24 someone who is challenging them and critical of 25 them. 1 And, yet, we do need to do that in a delicate 2 way. It takes a lot of special training to be 3 able to do that. 4 Many psychiatrists have the skills. 5 Quite, frankly, some psychiatrists don't. 6 But, for a general practitioner, the 7 non-addiction and non-psychiatric specialists, it's 8 even more challenging to be able to do that 9 balancing act. 10 But, patients just don't know that it's 11 illegal. And for some privacy reasons, stigma 12 reasons, they're often uncomfortable even saying 13 that they're seeing a guy like me, even if they're 14 not on a controlled drug, let alone if they are, 15 because they're afraid they'll be treated 16 differently. And sometimes they are treated 17 differently. 18 So, we've really asked for education of 19 patients on the law, and also on open 20 communications with their doctor. 21 And that needs to come from physicians, but 22 also from outside of physicians' offices, 23 because we can't be seen as, physician and law 24 enforcement, at the same time. It just doesn't 25 work. 1 So, I hope that does answer your question. 2 It's a tough decision, clinically, with every 3 individual patient. And patients and physicians 4 both need to be educated on these issues. 5 SENATOR KEMP HANNON: But to the extent we 6 address the problem, and it needs to be addressed, 7 to what extent do you then deter doctors from an 8 appropriate prescription of medicine? 9 DR. FRANK DOWLING: Well, that's -- if that's 10 the specific question, that's where we would 11 recommend, at this point: Let's look at what we 12 have, and have voluntary looking at the database, 13 but the threshold be any prescriptions. 14 Because, if we go the other way, with 15 mandatory looking and mandatory reporting, and go 16 too strong the other way, patients will be even 17 more afraid to discuss prescriptions they're 18 getting. Patients, particularly with chronic 19 pain, and addiction problems, will be afraid to 20 discuss these issues. 21 And -- and that's where there's a risk on the 22 other side of this. 23 One of the things about diversion; yes, 24 diversion is, certainly, when I get 120 tablets of a 25 prescription, I use 60, and I sell 60, or I share 1 them with someone else for other drugs. 2 That's, certainly, is an example of 3 diversion. 4 But, if someone is in substance abuse 5 treatment, and being prescribed a controlled drug, 6 even Suboxone, which is a good example of a drug 7 that has a double-edged sword, it can be lifesaving, 8 family-saving, career-saving; or, it could be 9 exactly the opposite. 10 Well, if I'm treating someone with addiction 11 to opiates, and I give them Suboxone, for example, 12 if they come in, and they admit that they shared a 13 couple of pills with a friend, or even half that 14 prescription, that's diversion. 15 And they need to be able to do that, openly 16 discussing that with me. And I need to be in a 17 position of discussing that in treatment, and maybe 18 upping the level of care, the intensity of care, and 19 what we do, but not necessarily have to report them 20 to the State of New York, because, even if it's 21 promised that that information is kept private, the 22 perception among patients may be, that it isn't, 23 and that they're going to face consequences. 24 And I don't know where you draw the line. 25 It's very difficult, that, where does diversion 1 become, now it must be reported to law enforcement, 2 and where doesn't it. 3 SENATOR KEMP HANNON: Well, let me -- 4 Suboxone is the trade name for -- I'm going to 5 mispronounce it -- 6 DR. ANDREW KOLODNY: Buprenorphine. 7 SENATOR KEMP HANNON: -- buprenorphine. 8 And that's supposed to be the anecdote to 9 opiate addiction. 10 SENATOR CARL MARCELLINO: "Antidote." 11 SENATOR KEMP HANNON: Antidote? 12 SENATOR CARL MARCELLINO: You said 13 "anecdote." 14 SENATOR KEMP HANNON: Antidote. "Antidote." 15 My problem is, you mentioned that people 16 might misuse it, and share, Suboxone, buprenorphine, 17 with somebody else. 18 Is it also addictive itself, or is it truly a 19 counteragent to opioids? 20 DR. FRANK DOWLING: That's a great question. 21 It is an addicting drug. No doubt about. 22 And it can be used properly, and help someone 23 move away from other addicting opiates. 24 And then, in my view, most often, when 25 they're ready, gradually come off the medication. 1 Addictionologists who I have spoken to, have 2 said to me, there is a subset of people who may need 3 to be on this for a longer period of time, just the 4 office-based analogy of methadone maintenance. 5 But, it can be abused. 6 Almost any drug that can be used to treat 7 addiction, that's a controlled drug, can also be 8 abused. 9 DR. ANDREW KOLODNY: If I could, I have -- I 10 sort of agree, just a slightly different view of it. 11 Buprenorphine is an opioid, like the other 12 opioids, but it acts differently. It's what we 13 would call, a "partial agonist." 14 So, unlike the other opioids, it's very 15 difficult for someone to overdose on it. 16 And for people who are opioid-addicted, when 17 they take buprenorphine, it doesn't produce a 18 euphoria. 19 There is diversion of it. There are people 20 who will trade their buprenorphine to get other 21 drugs, or sell their buprenorphine. It has a street 22 value. 23 It does appear that, much of the street use, 24 are people who are opioid-addicted, who are using 25 itself self-therapeutically in some ways. 1 But, it's still a serious issue. 2 Just to briefly answer your first question: 3 How do we give the right message to docs, but not 4 wind up with physicians undertreating pain? -- 5 and I think the first rule for physicians, with any 6 kind of treatment, whether it's a medication or a 7 procedure, is, first, "Do No Harm." 8 And that forces physicians to weigh the 9 risks and benefits when they're deciding on a 10 course of treatment. 11 When it comes to the treatment of chronic 12 pain with opioids, you have very significant 13 risks. And the best evidence, is that long-term 14 patients don't benefit. 15 So, if physicians had proper education 16 about how to do that risk-benefit analysis, they 17 would prescribe much less frequently. 18 When they had someone with severe intractable 19 pain, who had tried other remedies, they might say, 20 in that case, maybe the benefit -- the potential 21 benefit for this patient outweighs the risk. But, 22 right now, they don't have the proper information. 23 They've been given information, that the 24 medicines are more effective than they are, and 25 they've been given information that they're less 1 risky, so, they don't make the proper risk-benefit 2 analysis. 3 SENATOR KEMP HANNON: One totally different 4 topic, back to Mr. Dowling, though: You talked 5 about a database doctors can now access personally, 6 about the prescription history of one of their 7 patients. 8 To what extent has that been a positive? To 9 what extent does it need tweaking? 10 DR. FRANK DOWLING: That's a great question, 11 as far as the database. 12 My understanding, from conversations with 13 the Department of Health and OASAS, is that the 14 database, overall, is likely underused. And that's 15 for a variety of reasons. 16 One is, it is a slow, clumsy system. And, 17 physicians find it challenging, just to stay 18 updated in the health commerce account, if they 19 don't in the natural course of their practice, just 20 to keep using it on a regular basis. 21 Then, from that health commerce account, if 22 they want to look up an individual patient, you've 23 heard about the threshold, two or more 24 prescriptions from two or more physicians, 25 filled at two or more pharmacies. 1 And if someone meets that threshold -- yes, 2 yes, yes -- then information is given; however, it's 3 only information that's limited to the last couple 4 of months or so, so it doesn't even go back a year 5 or two. And, yet, the information in there could 6 be, say, 30 days behind, depending on when 7 pharmacists enter the information. 8 And, then, I don't know what Department of 9 Health does; if there's anything they do to clean up 10 the information. 11 And I don't mean that to criticize 12 pharmacists at all. They're asked to make sure 13 this data is updated by the end of the month, or the 14 15th of the month. 15 So, if I come in on, the 16th, 17th, it was 16 updated on the 15th, it's pretty accurate. 17 If I come in on the 13th, it may not be. 18 So what happens is, if you try this, and the 19 yield, the likelihood of getting positive 20 information, is so small, after you've jumped 21 through all of these hoops and time. 22 And imagine a primary-care doctor, in a rural 23 county in Upstate New York, where they're treating 24 chronic pain, they're treating addiction, they're 25 treating depression and anxiety, because there 1 aren't enough specialists to do this, seeing 2 40 people a day. And they're challenged to look at 3 this database 15 times out of 40 people, which 4 probably isn't an unrealistic number, and the yield 5 is always nothing, nothing, nothing. 6 If you were seen in the emergency room last 7 night -- or, say, a week ago -- there's got to be 8 some reasonable lag -- and you were given Valium for 9 severe anxiety, and then referred to my practice, 10 and I'm seeing you a week later, and I look you up 11 in the database, I'm not going get anything. 12 You know, it -- so those things have to 13 really be improved, and then physicians would 14 likely use it more. 15 And the other part I mentioned earlier, in 16 opening comments, about, if a designated staff 17 person can look this up. 18 Imagine a surgery center. You just finished 19 surgery. The surgeon is going on to the next case, 20 but they've got to stop and look you up in a 21 database. 22 Imagine a walk-in center, an urgent-care 23 center, an emergency room, and the physician has to 24 look someone up, each and every time, and trying to 25 get information, yet, how positively that 1 information could be used, to find out someone just 2 we want to three different emergency rooms or four 3 different pharmacies in the last month, and change 4 the conversation, if a staff person can look up that 5 information. 6 SENATOR KEMP HANNON: Okay. 7 JOANNE HOFFMAN BEECHKO, R.Ph.: If I might 8 extend this conversation to computers and software, 9 there are, probably, 80 different physician 10 systems out there that's electronically send. 11 I don't know how many different pharmacy 12 systems there are. 13 I would suggest that, that we extend this out 14 to the software community, for this particular 15 instance of information. Because, if you look at 16 the Medicaid system, I get back a response from 17 Medicaid that shows me, any number -- although 18 it's not as much information as I would like -- 19 several different medications that a patient may be 20 on, several different doctors. It doesn't give me 21 specifics, but it will say, you know, you are -- 22 that this drug is conflicting with another drug of a 23 same type, dispensed by another doctor, at a 24 different pharmacy, one, two, three, four. 25 So, I can immediately see. 1 So, I would suggest that the BNE, that this 2 particular program consult the software with the 3 Medicaid program, and see, what are we missing here? 4 There are programs out there that are 5 capturing and providing information. 6 SENATOR KEMP HANNON: Were that it was that 7 easy. 8 [Laughter.] 9 SENATOR KEMP HANNON: There is, right now, an 10 RFP for the Medicaid system, out, that the RFP 11 alone, took out 1,300 pages. 12 And so, there's, that. 13 There's a healthcare exchange. 14 There's the State Information Network for 15 New York, called "SINNY," (ph.) 16 So there's -- many of those things are going 17 on. And the question is, trying to take what is 18 available now to address a problem now. 19 And, so, some of what you've said before is 20 enormously valuable. 21 This is the -- that was the granular thing. 22 I said there would be another part, which is 23 your recommendations. 24 So, we'll call this "the closing roundtable." 25 And since there's no intellectual barriers 1 to wandering into any other topic, that's okay, but 2 let's just go around, and ask the recommendations, 3 from what you've heard, from what you came here 4 with, from what you haven't said. And, we'll see if 5 we can do this in a reasonable order. 6 And just because I was -- we started, here, 7 and everybody jumped in, we'll start, over here. 8 Greg, you can start. 9 We already know your bill, but you can talk 10 more. 11 GREGORY KRACKOWER: Well, thank you, Senator. 12 And, again, this has been very edifying, and 13 funny. 14 We are reaching out too. We are in the 15 process of discussing with software vendors, to 16 both, cost, and analyze what the ultimate system is. 17 One benefit of a government system set up in 18 a universal to, catch all, or catch most -- theres 19 no such thing as a catch-all system; right? 20 There's a catch-most system, and if you take 21 away a functionality, you catch less, is that, it 22 becomes a standard by which vendors can, over time, 23 and stakeholders, over time, you know, log in to 24 connect with. They know what's out there. It's not 25 the -- to analogize 50 different systems. 1 If there's one system that was designed, and 2 continually improved, to deal with this system, that 3 becomes a standard technology. And, presumably, 4 that RFP would allow many act sets. 5 It is important to note, that not every 6 physician has Internet access in this state, 7 particularly in the Southern and Western Tier. 8 The Department of Health, Mr. Clancy, is 9 laughing, because we recently discussed this. 10 And that, pharmacists' system, some are 11 legacy systems. And, not all pharmacists are 12 chains. 13 And that all has to be addressed, both in -- 14 that's one reason why, you know, the RFPs are long. 15 But, technologically, you know, this is not a 16 leap into the future. This is something that the 17 other states all clearly think -- I mean, no one 18 thinks of Oklahoma as a leader in technology; but, 19 yet, they're moving toward something, like what the 20 Attorney General of New York, 21 Attorney General Simon, has produced. 22 So, this is within the -- well within the 23 ballpark of modern technology. 24 A couple of points on suggestions. 25 Absolutely -- 1 SENATOR CARL MARCELLINO: Before we move on, 2 does that bill that you proposed does that have a 3 number? 4 SENATOR KEMP HANNON: I think Senator Lanza 5 has -- 6 GREGORY KRACKOWER: Yes. It's, 7 Senator Lanza, and it's Representative Cusick. 8 SENATOR KEMP HANNON: 5720. 9 GREGORY KRACKOWER: 5720. 10 And we're also working with 11 Representative Gottfried. 12 And, if I didn't thank those three earlier, 13 as they're -- you know, all thanked, by the AG. 14 The -- so -- sorry. 15 So, the couple of things to think about, is, 16 education. Education is critically important. 17 There is an education component in the 18 Attorney General's legislation. 19 Educating providers, educating pharmacists, 20 educating health insurance providers, that has to 21 be part of any system. 22 Education of, how to use. And education for 23 the diagnostic function of such a system. 24 Right? 25 Someone says, Well, how do you make, you 1 know, doctors change their prescribing, if you 2 believe, as many do, that they're overprescribing? 3 Well, that's tough to do in a law. It's 4 tough to do as a healthcare guideline. 5 One thing you can do, though, is say: Well, 6 here's the information you have. So, when you're 7 making your decision, you have more information on 8 prescription drug history, that a patient doesn't 9 have that exact narcotic, but something similar. 10 You can also, with a database, use it for an 11 immense research tool when it's something like 12 all-encompassing. 13 You could have, you know, we could call it: 14 computer versions of yellow flags. 15 That person who walks into the office -- 16 SENATOR KEMP HANNON: I have to tell you, 17 because it's only due consideration to the current 18 new health commissioner of the state, who 19 recommended that the State embark on getting an 20 "all provider/payer" database. 21 And, so, work at -- it was in the budget, and 22 work has begun. And it's really, ongoing, in a very 23 intensive way, so that, down the road, his goal was, 24 that we would have exactly that. 25 So -- it's in progress. 1 GREGORY KRACKOWER: Right, no, that's 2 absolutely correct. 3 And, in fact, things like this roundtable is 4 part of the progress of designing whatever we're 5 going to design. 6 And, so -- I mean, you know, Senator Hannon, 7 Senator Klein, you know, this is part of that 8 leadership effort. And the Department of Health has 9 been part of the leadership effort. And, you know, 10 the AG is -- is -- is entering -- you know, is -- is 11 entering, in the role of the law enforcement. 12 There were two bullet points in that 13 wonderful slide. We're not even addressing those 14 two -- potentially, not the function of the Office 15 of Attorney General -- there's also a Medicaid 16 component, and a billing. 17 And OMEG has been -- you know, we have one of 18 the most effective Medicaid fraud units in the 19 country. 20 So, we're all sort of doing our part. And 21 this is encouraging. 22 You know, we don't think this is anything 23 radical, or anything anyone's going beyond. In 24 fact, this is a team effort, involving, not only the 25 states, but also the localites. 1 New York City system and New York City's, I 2 think, nationwide, leading prosecution teams -- 3 one of them -- is on this. And it is. 4 And it is. 5 That's what other folks talk about, is: 6 How can we be more like New York City? 7 And California is saying: How can we be more 8 like Oklahoma? 9 And California just updated their system. 10 Something called the "CURE" system out there. 11 So, this is not only happening with 12 leadership all over the state, but all over the 13 nation. And, we just doesn't don't want to fall 14 behind. 15 But, the education component is critical, 16 just to go over my point. 17 And, also, the -- you know, having inputs 18 and having, uhm -- you know, when you have a 19 database, when you have any database, you can see 20 trends, yet you know, we can't target doctors, 21 simply because they write, has been said before, 22 high numbers of narcotics, because they're 23 patient-based, and their practice might involve with 24 that. 25 But, once you have a more universal sense, 1 and more robust data sense, you know, you can do 2 statistical regression, and start weeding out those 3 things. 4 So, for doctors who have those things, you 5 know, who's high and who's low, as a research thing, 6 not as a law enforcement, to give flags for: Hey, 7 you are on the upper end of a doctor with a 8 particular practice. 9 You know, and these would be reports put out. 10 And that is always been a teleological function of a 11 database, as you learn more about what doctors in 12 your state are doing -- 13 "Doctors," as an aggregate, not 14 individuals. 15 -- what doctors are in the western tier. 16 I mean, there are these cost studies 17 involving the price of healthcare, that came up with 18 the debate of the Patient Protection Act, about, 19 prices of surgeries; the Mayo Clinic, versus Boston, 20 versus New York. 21 And that is all available because of robust 22 databases that health insurance companies have. And 23 governments tend to sometimes follow, you know, 24 the private sector. 25 And, so, that -- you know, there are benefits 1 into what everyone's talking about. And whatever 2 degree, you know, everyone's comfortable with, 3 that -- that we can catch. 4 And, I -- again, I think this is all what we 5 must remember: This is all not a catch-all system. 6 There is no catch-all system. 7 Right? 8 But, if New York State does things, we'll 9 catch, we think, a lot more than now. 10 PAUL MAHONEY: Thank you, Senator. 11 I think, the only thing to add to what Greg 12 said, is that, the legislation that the 13 Attorney General is proposing, does have these 14 mandatory elements in it, because we've been 15 considering, from a law enforcement perspective, and 16 a cost-control perspective, for a long time, that 17 the bad guys, the hypothetical one-half of 18 one percent of people in any one of the professions 19 involved, who won't participate voluntarily, 20 nonetheless, if they're not mandated, will have the 21 exact same protections as to intent that the 22 completely bona fide practitioners have. 23 If they have the option to retain the current 24 commoditization of a prescription, that cloaks the 25 transaction with a veneer of legitimacy, the 1 bad-faith practitioner being able to say, "Who do 2 you believe, me, the doctor, or the lying addict, 3 drug-diverting person?" that prosecution is always 4 going to be impaired. 5 The point of the legislation tries to balance 6 some of those elements, tries to find a few 7 abilities. 8 For example: This legislation has a 9 provision, that, an agent of the doctor, a bona fide 10 agent of the doctor, can do the data entry and 11 retrieval. 12 And, so, that to bring these elements into 13 balance, to stop that prescription from getting out 14 on the street, and having it as a valuable commodity 15 in the first place, and doing it, getting these 16 elements together close to simultaneously, rather 17 than waiting for that next sea-change in 18 prescribing, or the next sea-change in insurance. 19 I think if we proceed that way, the 20 Dr. Chaits of the world will be diminished. And 21 each one of those guys seemed to cost us at least 22 a million dollars every time they crop up. 23 GREGORY KRACKOWER: And if I may, I just have 24 one small point; the word "mandate" comes up. 25 You know, one thing we're very cognizant 1 about, as public policy-makers, as we said: Not 2 every doctor has Internet access. Not every 3 pharmacist is a chain, and some have legacy systems, 4 and some are in very small rural communities in the 5 Southern Tier, particularly the Western Tier as 6 well. 7 One of the benefits, you know, I think of a 8 "mandate" as a -- tends to be a bad word sometimes, 9 but, if you had this system, and you didn't have, 10 not only a goal, but an actual timeline of making 11 it, you know, a universal access, with a mandate, 12 the tort system will do it. And, that, no one 13 wants. 14 No one wants a doctor who's a small 15 practice, sued, because they don't have access to a 16 new database that was just developed by the 17 government. And, "Why don't you have access, when 18 you prescribed my daughter a pill without checking 19 this database?" 20 So, the mandate is -- 21 SENATOR KEMP HANNON: Of all the things we 22 have problems with, the tort systems, that's not 23 one of them. 24 GREGORY KRACKOWER: But -- right, but we 25 don't want to augment it. 1 Right. 2 But, you will [unintelligible] a system. 3 In fact, that's why, actually, Senator, just 4 on a historical basis, from care: For anyone who 5 has glasses -- and I've had glasses since 6 4th grade -- you get a glaucoma test. 7 I don't think they told you in law school, 8 that was from a famous lawsuit. That, if you're 9 going to fit someone with glasses, you know, you 10 have the simple blow test. And if you don't do it, 11 you're negligent. 12 If there is a system that enables someone 13 to look up drugs, and some physicians don't have 14 that, the tort system will attempt to address that. 15 I'm just saying, a why of goal of a mandate 16 is less. 17 I'm not suggesting that that's one thing, but 18 that's something to think about; is, if you have a 19 system and some don't use it, and there's no 20 government plan to help to assist to get there, that 21 system does come into play. 22 And, something that you just need to think 23 about. 24 I'm not saying that it's a conclusive 25 argument, but that's something -- 1 SENATOR KEMP HANNON: You don't want. 2 GREGORY KRACKOWER: -- we don't want. 3 Yeah. 4 PAUL MAHONEY: You're asking, at this point, 5 for a proposed solution. 6 SENATOR KEMP HANNON: Proposed solutions. 7 You may have addressed all of them, and you can just 8 say: Well, I'll stick by everything I've said 9 before. 10 That's okay. 11 PAUL MAHONEY: Several of the points I did 12 make before, and I think that we need to continue 13 those discussions, and go further. 14 We all know funding is very tight in this 15 country, and in this state, but we need to find 16 funding for more education of patients, coming 17 from the state. And, physicians, coming from the 18 Department of Health; partnering with physicians 19 to do that. 20 And I'm glad that there's others in the 21 room that we can also partner with, among 22 physicians, to work on that. 23 MSSNY has been communicating with members, 24 and educating members, regarding the database, and 25 use of the database, through print and electronic 1 media. 2 And MSSNY has done some education of, not 3 just members, all physicians, regarding pain 4 management, and the legitimate way of prescribing 5 pain medications, as well as cautions for misuse 6 and diversion. 7 And, that's included some live CME, but also, 8 CMECD, that went to some 10,000 physicians in 9 New York State. 10 And things like that, you know, need to be 11 ongoing, repeated, and updated. 12 And, you know, essentially, we are really 13 glad to be here today. And we really support the 14 intentions of the Attorney General's bill, and, 15 the concerns that have been expressed. 16 And we really want to talk further with the 17 Attorney General's Office, with the pharmacy 18 association, with other interested parties, to come 19 up with practical solutions to make change quickly. 20 I do want to finish, just by saying, that, if 21 we could allow physicians to look up any patient 22 if they feel there's a clinical need to do so, and 23 find any prescription, controlled drug, that's been 24 given, as far back as the database will go, and as 25 recently as it can allow, and, we educate patients 1 of the legal need, and clinical need, to share that 2 information with any potential prescriber, that we 3 will reduce accidental opioid deaths, clinically 4 significantly, and statistically significantly, 5 within months. 6 And over the years, we'll reverse that 7 trend; but, also, treat people with addictions 8 earlier and earlier, when it's much more treatable. 9 SENATOR KEMP HANNON: David, you have been 10 quiet. 11 DAVID VIZZINI: Well, I mean, I'm not a 12 doctor, but it sounds like we do have our hands full 13 with this issue. 14 And I guess my contribution would be, is 15 that, you know, a lot of this committee was 16 addressing it, from the top, down, with the doctors 17 and the computer systems, and kind of stopping 18 them from happening. 19 But, through a member of that, you know, 20 treatment of the addict is also important, because, 21 if we address, from the bottom, up, as well, and 22 meet someplace in the middle, I think that we'll get 23 to the solution of the problem a lot faster than 24 just coming at it from one direction. 25 And I think that, in collaboration with the 1 doctors and pharmacists, like I said before, and 2 the legal agencies, to get these addicted people 3 referred to good-quality, comprehensive treatment 4 services, you know, will definitely provide a great 5 solution, you know, with everything else that's 6 being done by this committee. 7 And I would say, you know, that would be the 8 benefit to the addicted people who are suffering. 9 SENATOR JEFFREY KLEIN: I have a quick 10 question, David. 11 Your clients are coming to you, and your 12 clients could provide a lot of information on how 13 they're getting such easy access to prescription 14 drugs. 15 DAVID VIZZINI: Uh-huh. 16 SENATOR JEFFREY KLEIN: Does that come about 17 a lot, with -- 18 DAVID VIZZINI: Our clients, when they walk 19 in the door, you know, they're not very quick to 20 give us a lot of information, other than the 21 general -- 22 SENATOR JEFFREY KLEIN: But, you know, 23 there's therapy that takes place -- 24 DAVID VIZZINI: Yes. 25 SENATOR JEFFREY KLEIN: -- and there's other 1 things that take place. 2 DAVID VIZZINI: Yes. 3 They do. They give us information about what 4 happens, and how they go about things. 5 Maybe they don't give us, so much specifics, 6 with people, places, and things. 7 You know, I mean, we do have a duty to 8 report, and we also have a duty to a 9 confidentiality. But, you know, through the 10 education of them, and trying to work with them 11 through our therapies, to let them know that the 12 behavior was wrong, and to learn a different way to 13 coping with the issues which made them go and, you 14 know, try to use the substances, is where we spend 15 most of our time, focused on. 16 SENATOR KEMP HANNON: I mean, "duty to 17 report"; this year, we passed a bill to -- what we 18 call "Good Samaritan" bills, so people who had an 19 overdose didn't feel they would be at risk of 20 getting arrested if they turned themselves over to 21 an emergency department; nor would their friends who 22 brought them in. 23 So, there was this balancing. And, what an 24 incredible, difficult way of trying to balance. 25 What do you find with your duty to report? 1 Is that -- does that deter people from coming for 2 treatment? Do they have a feeling of 3 confidentiality? Do they -- what's the -- 4 What's happening on the ground, in the field? 5 DAVID VIZZINI: Well, what I would say is 6 that, again, trust is number one priority in 7 treating these people. 8 I think that, you know, we have a duty to 9 warn, and we have a duty to, you know, protect, you 10 know, other people, and the individuals, if 11 they're going to harm themselves or harm somebody 12 else. 13 But I think that it does -- people are not 14 going to give you information up that they feel they 15 could get themselves in trouble, or other people in 16 trouble, so, it is difficult to come by. 17 But, we always try to tell them that it's in 18 their best interest to be as open and honest in the 19 whole process of their addiction, you know, not just 20 their specific individual acts, you know, in order 21 to try to help the larger problem. 22 And as they get further along in the 23 treatment, I think they can get there. And I think 24 that they become proactive on their owns, to solve 25 the problems, and to reach out to the people, and 1 help other people as well as, if they have to turn 2 people in, or do things like that. 3 I mean, those things do happen. I mean, not 4 regularly, you know what I mean, but, those things 5 do happen. 6 SENATOR KEMP HANNON: People who are on 7 heroin, which is why, especially in the minority 8 communities, people view anybody, now, getting into 9 heroin is, like, crazy. 10 But, people in heroin have been able to 11 maintain lives over 20 and 30 years, using 12 methadone. 13 Is there -- what happens to somebody who's 14 using opioids, after 10 years, or something like 15 that? 16 DAVID VIZZINI: Well, I think that -- first 17 of all, what I want to say about heroin, is, is that 18 heroin is a lot more readily available, and a lot 19 more popular than you may think. 20 I mean, there are -- heroin is probably the 21 cheapest drug that you can buy today. 22 SENATOR KEMP HANNON: Oh, no, on Long Island, 23 I have a feeling that someone's trying to flood the 24 market, and all of that. 25 And I've talked at length with the detectives 1 in the Nassau County Police Force there. 2 No, I'm aware of how much it is. 3 But, I'm just looking, trying to focus on, 4 the nature of the addiction to opioids, and 5 figuring out what will happen to the individual. 6 Do you have a maintenance for them? Do they 7 get -- you know, do they just age-out of using this 8 as a drug? Do they eventually have a premature 9 death? 10 DAVID VIZZINI: Well, I think that, you know, 11 there are the medical treatments like, 12 buprenorphine, Suboxone, which were mentioned, which 13 helps the people. I think that that really works, 14 with conjunction with treatment. 15 You know, you're not going to find somebody 16 that's going to take a pill, to substitute another 17 pill, to solve the problem. You do need treatment. 18 And, normally, through the therapies that 19 treatment providers provide, like at Outreach, we 20 provide behavioral and cognitive therapy with them. 21 And through our program, which is, you know, in 22 great detail, but, by going through the program, 23 we're teaching them the things that they need to 24 learn, to become better people, to become recovered 25 in their addiction, and to learn how to maintain 1 long-term recovery, by, you know, taking care of 2 themselves in better ways. 3 And that's what we try to do. 4 And we hope, through that method of, you 5 know, getting them off all substance, and to 6 maintain their lives, and be, you know, productive, 7 off all substances. 8 But, if people need any type of medication, 9 if it's, Suboxone, buprenorphine, if it's 10 psychiatric medication for mental health issues, 11 which normally go -- coincide with drug addiction, 12 you know, and all those things, that we treat them 13 on site for that. 14 So, I mean, there could be someone who comes 15 in, and never taken a pill in their lives, other 16 than from a drug dealer, but leaves on many 17 different types of maintenance medications for 18 their mental health, as well as for their addiction, 19 but, it makes them better and successful in their 20 lives. 21 So, whatever is necessary for that 22 individual. 23 SENATOR KEMP HANNON: Thank you. 24 Andrew. 25 ANDY FOGARTY: I guess to use the adage, 1 information is power. And on the whole conversation 2 that we've had today, I think we really touched on, 3 that -- you know, we've really focused on data 4 collection, and how that information is used. 5 I think it really comes to play that, you 6 can collect all the data, you can have all the 7 information, but if you don't use it appropriately, 8 you're not going to achieve anything that you're, 9 you know, desiring. 10 So, I think what we need to do is look at the 11 data that is collected. 12 You know, as Senator Marcellino pointed out, 13 you know, if we are collecting all this information 14 on who's prescribing, who's it going to, and where 15 are they getting it filled, you know, we can utilize 16 that to now focus a little bit better, and provide 17 the information to folks, whether, if it's the 18 individual to get treatment, or the prescriber to, 19 perhaps, educate them on their prescribing habits, 20 or to put quantity limits in. 21 If a drug is -- you know, if you utilize 22 something in excess, it's not good for you. So, why 23 should we have -- you know, are you able to get a 24 script for something that would be in a dosage that 25 would be more harmful than beneficial. 1 So, you know, certainly that. 2 And from the pharmacy perspective, you know, 3 give them the ability to access the data so that 4 they can see, that, if this individual's, you know, 5 got four different doctors prescribing the same 6 drug, or if it's being filled at two other 7 pharmacies. 8 You know, it's, again, we have this 9 information; how is the best way to use it? 10 And I guess, you know, that's what makes 11 the discussion, like today, you know, key to that 12 point. 13 SENATOR KEMP HANNON: Okay. 14 Dr. Kolodny. 15 DR. ANDREW KOLODNY: Thank you. 16 I would agree with all of the recommendations 17 that were mentioned previously, so I'm just going to 18 mention a few that haven't been discussed, although 19 I did mention earlier, rescheduling of hydrocodone. 20 Hydrocodone was scheduled by the 21 Controlled Substances Act 40 years ago, and a 22 mistake was made. The actual abuse liability of 23 hydrocodone was not well understood, nor was its 24 potency. 25 The Controlled Substances Act treats the 1 potency like it's six-times weaker than morphine. 2 The potency is identical to morphine, taken orally, 3 in hydrocodone. 4 So, hydrocodone needs to be rescheduled. 5 If we don't want our high schools, our 6 college dorms, our medicine chests, flooded with 7 opioids, it has to be put into the proper 8 classification. 9 Doctors should not be allowed to write a 10 prescription for hydrocodone with five refills. A 11 drug that is as addictive as heroin should not -- 12 you should not be able to write five refills on 13 it. 14 To sort of answer a question you asked about 15 the difference between heroin addiction and 16 pain-pill addiction, it is the same addiction. 17 Hydrocodone, oxycodone, and heroin are all the same 18 drug. 19 People are not switching to heroin because 20 it's got more of an effect or it's a better high. 21 They switch because it's cheaper. 22 The effects from oxycodone and hydrocodone, 23 the high, the euphoria, may actually be better with 24 hydrocodone than oxycodone because they're designer 25 versions of an opioid. 1 Another thing that was mentioned, we really 2 do -- Dr. Dowling mentioned, we need useful 3 prescription clinical data so that can guide a 4 physician prescribing. They should be able to 5 access the patient's records. 6 But, physicians really need to get a report 7 back, or available to them, on a monthly basis, of 8 what they've been prescribing. 9 If somebody takes a -- pulls a bunch of 10 these prescriptions off of my pad -- I went to the 11 bathroom, they pull these prescriptions off, I am 12 not going to know. 13 If a monthly report was made available to me, 14 and I see a bunch of names on it for patients who 15 I've never seen, or I see changes or quantities or 16 doses that I don't typically prescribe, something 17 can be done about it. Otherwise, a doctor has no 18 way of knowing. 19 This is something that would done pretty 20 simply, and it doesn't have to be expensive. 21 And, then, lastly, we really do need to find 22 a way to legislate a standard of care. 23 SENATOR KEMP HANNON: Nothing dealing with 24 computers could be done simply and inexpensively. 25 DR. ANDREW KOLODNY: I hear you. 1 SENATOR KEMP HANNON: Rule One of 2 budget-making. 3 DR. ANDREW KOLODNY: I hear you, but it is -- 4 the tool is available to us. And not treating this 5 problem is extraordinarily expensive. 6 Then, I guess the last thing I wanted to 7 mention is, a need to legislate a standard of care. 8 There should be some requirements. 9 If doctors are going to treat chronic pain 10 with opioids, they should be required to do a 11 random urine test, at least at some point. 12 That doesn't exist. 13 There should be some limits or 14 recommendations on dosing so that physicians can't 15 prescribe extraordinary quantities and doses to 16 patients. 17 And, other key elements of standard of care 18 need to be legislated. 19 SENATOR KEMP HANNON: Okay. 20 JOANNE HOFFMAN BEECHKO, R.Ph.: I agree with 21 just about everything that people have been saying 22 here. 23 The electronics are not up to par yet, and so 24 we have to be very careful about putting into 25 legislation things that are going to require us to 1 mandatorily review things, when all of our systems 2 are not where they're supposed to be. 3 Better so, it should be made available. This 4 information, we really need to focus on how to make 5 this information available. 6 And I would say that, pharmacies, and 7 pharmacists, would welcome increased knowledge and 8 increased standards for the prescribing of 9 controlled substances. 10 We're on the front lines every day. We are 11 the last people. The prescription comes to my 12 counter, and at that point in time, I have to 13 determine whether or not I can dispense this 14 medication, and whether this person is going to 15 respond to my yes-or-no answer in an appropriate 16 manner. 17 So, we welcome any kind of standards with 18 regards to controlled substances, and enhanced 19 knowledge, both on the pharmacists' and on the 20 prescribers' side, so that understanding of 21 addiction potential and pain management is better 22 understood. 23 And the last thing that I would like to say 24 also, is, if you look at these numbers here, with 25 regards to admissions to hospitals, there is an 1 extraordinary number of patients that are between, 2 10 -- 12 years old and 22 years old, that are 3 being admitted to hospitals. 4 And I would wonder, whether the management of 5 these medications in the homes, is something that we 6 really not have spoken of at all, except with 7 regards to educating the public. 8 And, this has to become a part of the 9 discussion, because, once the medication leaves 10 the pharmacy, once it has been prescribed, we have 11 no control over any of that at that point. 12 And if families don't realize that these are 13 medications that need to be maintained in a safe 14 environment, that the discussions have to be made 15 with the children, with the relatives, with the 16 brother-in-law, that these are not medications that 17 can easily -- that should be taken, that that's -- 18 everything is going to just fall off. 19 So, I would suggest that we look at that as 20 well. 21 DAVID VIZZINI: I also agree with that, 22 because, you know, when we do assessments on 23 children between the ages of, 12, and 15, 16 years 24 old, historically speaking, you would see tobacco, 25 marijuana, alcohol, maybe, you know, here and there, 1 some different things, but, those were your 2 primaries. 3 And over the last couple of years, we have 4 been seeing a real spike in prescription pills. 5 You know, everything from, the oxycodones to the 6 Xanax and to -- you know, to anything and everything 7 in the medicine cabinet. 8 And that's an excellent point, you know what 9 I mean? 10 And, again, we're seeing that, you know, on 11 the lines as well, on the other side. These 12 young, young people coming in, and, you know, it's 13 just as common as marijuana, as you're seeing, you 14 know, a prescription pill that they took. 15 And I can tell you, like, I would say, at 16 least 80 percent of the time, it's coming from a mom 17 or grandma's medicine cabinet. 18 SENATOR KEMP HANNON: Mr. Doolin. 19 SEAN DOOLIN: Clearly, one of, if not the 20 major, theme that's been repeated today, has been 21 the use of data, and the use of data to ascertain 22 patterns of practice. 23 And a primary focus has been on the 24 Health Department's data monitoring program, and 25 whether making it easier to access it, which, 1 obviously, they just did last year by -- for the 2 first time, allowing electronic access -- or, by 3 lowering the thresholds for access, or taking the 4 approach of the Attorney General, by mandating, you 5 know, review of the data, both of which I think has 6 its challenges. 7 Two programs which Empire has developed, that 8 might be worth considering duplication, takes the 9 data, but has the system generate its findings in 10 terms of determining patterns of practice. 11 One is called "Operation Pillbox." Not my 12 title. 13 And, what that does is, it reviews, 14 specifically, prescription drug claims data, for 15 determining -- and it looks at it, not only from 16 the user's perspective, the patient, but also the 17 providers'. 18 In terms of the patient's perspective, they 19 look at prescriptions similar to the State's 20 monitoring program, where, if there are greater than 21 three -- three or more prescriptions that have 22 been written, or three or more providers that have 23 written prescriptions, the system itself will 24 generate, a teaser, or a tickler, that, you may want 25 to look at that particular provider, or that 1 particular patient, for purposes of, either care 2 management -- and this is at the interesting thing, 3 from the health plan's perspective -- it's -- 4 there's a -- two, you know, overriding themes. 5 One is, care management, to determine 6 whether, you know, the appropriate use of a drug 7 that is perfectly legal is inadvertently 8 intersecting, or contravening, the use of another 9 drug: a diabetes medication, or insulin, versus, you 10 know, heart medication. 11 That is one pathway for the use of the data. 12 The other pathway, is for purposes of fraud 13 detection. 14 And having the system generate the use 15 pattern allows us to make a determination from both 16 perspectives. 17 You know, secondly, from the provider's 18 perspective, the system will generate based on 19 utilization patterns. 20 And this gets at, after your Dr. Chait 21 situation, where a particular provider is 22 prescribing an anomalous amount of controlled 23 substances, you know, Level II controlled 24 substances, so that -- and, again, maybe for very 25 legitimate purposes, but the system generates it, 1 we review it, and determine whether it's appropriate 2 or not, for -- both, for purposes of care 3 management, as well as for purposes of fraud and 4 abuse. 5 The second program is more targeted towards 6 the unusual emergency room-visit case, where, for 7 our -- from our perspective, as I mentioned earlier, 8 our hands are somewhat tied in terms of a 9 prospective review, but that clearly is an area 10 where you have the greatest potential for abuse. 11 And, here, what we do, in the -- what we call 12 the "Frequent Flyer Program," is, we will review 13 those members who have submitted claims, who 14 visited the emergency room, at least three times a 15 month. 16 And in those cases, again, you take a look at 17 it, both, from a care management perspective, should 18 they be going to their primary-care doctor as 19 opposed to the emergency room, but also for purposes 20 of abuse of practices as well. 21 Two programs that the plan has just 22 implemented this year, in 2011, that might be worth 23 considering, from either the Health Department's 24 end, or, for that matter, from MUPHOCO (ph.) or the 25 State's end, where the system is generating the use, 1 as opposed to either mandating it on a provider or 2 having voluntarily access. 3 SENATOR KEMP HANNON: Thank you. 4 Tony. 5 ANTHONY MEROLA: Just a quick update with 6 regards to where Medicaid is heading with regards to 7 technology. 8 We're looking to enhance our point-of-service 9 pharmacy systems, scheduled to be implemented by 10 the end of the year. 11 The technology will give us the ability to 12 look at diagnosis, and potentially build more 13 complex algorithms. 14 For example: A patient -- a patient that 15 has -- is getting an opioid for a cancer treatment, 16 being able to build in specific quantity or 17 frequency at its -- for that particular patient 18 population, where being more -- you know, 19 potentially being more stringent on patients that 20 are not diagnosed with cancer. 21 That information will be passed on to the 22 pharmacist so they can make more educated decisions 23 at their level. 24 We continue to work -- you know, work with 25 the pharmacy community. Anytime we send 1 point-of-service messaging to them, we appreciate 2 their phone calls at my office with regards to, 3 trying to fish through some of that information, you 4 know, how complex it is, given some of the real, 5 real complex medical or pharmaceutical regimes that 6 Medicaid patients are taking. 7 SENATOR KEMP HANNON: What's the technical 8 name of the database you're improving? 9 ANTHONY MEROLA: Well, that would be our 10 point-of-service system. I believe the commercial 11 name is RXPERT (ph.), R-X-P-E-R-T. 12 And, again, we're working with our systems 13 people to get that system up and running. And, 14 again, it's scheduled for, somewhere, the end of 15 this year, the beginning of next year. 16 SENATOR KEMP HANNON: Okay. 17 Steve. 18 DR. STEVE KIPNIS: I'm not going to talk 19 anything about data. 20 [Laughter.] 21 DR. STEVE KIPNIS: You're taught in medical 22 school, really, that service coordination is really 23 important, and you should get consultants and 24 people who are experts. 25 My agency looks at it as, agency 1 coordination, and partnerships. 2 Certainly, under 3 Commissioner Gonzalez-Sanchez, we put together a 4 group, in March, which involved just about every 5 agency in New York State, State Ed., the OMIG, 6 Medical Society. 7 And, to address what Bridget brought out, we 8 really need a set of guidelines to help doctors 9 know what's best practice. We need a set of 10 guidelines to help patients know what's the best 11 practice. 12 And we're also leaving out the dentists. 13 I am a physician, but we should consider 14 dentists because they write scripts too. So, we 15 had the Dental Society as one of our members. 16 And we're in Phase 2 of that, working with 17 New York City Department of Health, to really get 18 one set of guidelines, as opposed to 19 twelve different sets that no one is ever going to 20 read. 21 We do think education is important. And a 22 lot of the different initiatives that we put 23 together are for education. 24 We're the only state agency in the country 25 that has an Addiction Medicine Unit, that has 1 education for providers, and also for the public. 2 We get over 50,000 hits a quarter on it, so 3 it's a huge resource for just about everyone. 4 And the last thing that was talked about just 5 a little bit, that I'm really sort of proud of with 6 our work with the Department of Health, is the 7 overdose prevention initiative. 8 While it's important to prevent addiction, 9 and I think we have to go back, and really remember, 10 that the addicted person -- and I hate the word 11 "addict" -- it's the substance-using person, has a 12 disease, and they should be treated as anyone else 13 with a disease. 14 There are people who are addicted, who do 15 illegal things, as well as there are doctors who 16 do illegal things. And lawyers. 17 But -- but the overdose prevention really 18 brings us to someone who has the problem, and we 19 could save their life. And it allows everyone in 20 New York State to be a lifesaver. 21 And I don't know if you're aware of it, but 22 we put in, with the Department of Health, for the 23 Governor to proclaim today, "Opioid Overdose 24 Prevention Day," which he did do. 25 And we look at this as just another way of 1 educating the person in New York State, to know that 2 they could save a life, as well as a doctor could or 3 an emergency tech, or anyone like that. 4 So, we're really pretty proud of the 5 Governor, you know, proclaiming it. And, also, that 6 we continue to get New York State people to look at 7 it as a worthwhile endeavor. 8 SENATOR KEMP HANNON: Thank you very much. 9 BRIDGETTE BRENNAN: [audio/video technical 10 difficulty.] 11 ...with pills, it's a very difficult 12 addiction. 13 And what we've seen with defendants who we 14 normally would refer to rehabilitation programs, 15 are defendants, who are addicted to prescription 16 pills, just aren't interested. 17 So, that, I think is critically important to 18 educate young -- a program -- information campaign 19 directed towards teens and young adults, to 20 inform them about just how addictive these pills 21 are, and how terrible their lives can become as a 22 result. 23 Also, directed towards the public, to 24 convince them to secure their pills. 25 I think we need to develop protocols for 1 disposal of these drugs. 2 Standards for doctors are critical. 3 And, I think the Bureau of Narcotics 4 Enforcement, with the Department of Health, has done 5 an incredible job under very difficult 6 circumstances. 7 They have few investigators. They have a 8 creeky old system that they do their best with. 9 And, I think that we could not have done the 10 kind of work we have done without them. And I think 11 their efforts need to be -- or their resources 12 certainly need to be enhanced, to deal with the 13 problems that they're -- that we're facing right 14 now. 15 And, finally, we've already put together a 16 bill, that we've worked on with Senator Hannon and 17 Senator Klein, that addresses some of the oversights 18 that we see in the current law. 19 Thank you. 20 SENATOR KEMP HANNON: Thank you. 21 Dahlia. 22 DAHLIA HELLER: So, I won't repeat what 23 everyone's said. 24 I do want to clarify a couple of things that 25 have been noted around the tables. 1 Just one is: With respect to the source of 2 prescription opioids that people report, we see, 3 kind of consistently, from the survey that we sort 4 of consider the gold standard on drug use in the 5 country, conducted by SAMHSA, a national survey on 6 drug use and health, 75 percent of people who report 7 past-year non-medical use or use without a 8 prescription or in a manner other than prescribed, 9 of prescription opioids, report that they got them 10 from family or friends. 11 So, this idea of diversion, that makes -- 12 that's what we're talking about being extremely 13 difficult when we talk about, the need for disposal, 14 the need for education...education, education. 15 So, one of the things that's been mentioned, 16 also, around the table a lot, is the idea of 17 clinical guidelines for opioid prescribing. 18 As I mentioned, we're putting out the 19 "City Health Information" publication next month. 20 We see it as a first step in that direction. 21 It's -- obviously, it's a publication. It's intend 22 for educational purposes, but we do want to raise 23 this discussion here in New York State. 24 In Washington State, they have actually -- 25 and I'm not sure, nobody's -- I think it's been 1 alluded to here, but, they did legislate clinical 2 guidelines for opioid prescribing. It's the first 3 state in the country to do that. 4 And, not something that we generally do with 5 clinical practices, is legislate the 6 patient-provider relationship, because we recognize 7 that, there is an art to medicine, and every patient 8 has different, very specific, medical needs. 9 But, there are some aspects of clinical 10 practice that we can pay closer attention to. And 11 that's the intent of that legislation that 12 Washington State has passed. 13 Simple things, like, if you are going to do 14 chronic pain management, do chronic opioid -- 15 prescribe opioids for chronic pain in your practice, 16 requiring the doctor to do a monthly assessment, and 17 have that on file, so it becomes parts of the 18 doctor -- the expectation of the doctor, when 19 they're audited, when their license is reviewed, 20 that they have shown that they have reviewed the 21 treatment plan with the patient. 22 And, then, after a certain period of time, 23 saying that, maybe that treatment -- if that 24 treatment is not working, if they're showing there's 25 no improvement in the patient, it's not appropriate 1 to continue prescribing; there's no improvement in 2 pain. 3 So, things like that, can be opportunities to 4 actually change physician practice, which can be 5 very controversial, because, recognizing that we are 6 intervening on a very specific patient-provider 7 relationship. 8 But, to raise that conversation, hopefully, 9 we'll have having more of that in the future, the 10 task force convened by OASAS, and working with our 11 partners at the State. 12 We've talked a lot about data. I'm not going 13 to get into anymore of that. 14 I've actually learned some additional ideas, 15 listening to folks around the table, so I 16 appreciate that. 17 And -- but, just to say, recognizing 18 Mr. Krackower from the Attorney General's Office 19 mentioned this idea of mining data; you know, 20 thinking about looking, we have this prescription 21 drug monitoring program. We can probably identify 22 patterns and prescribing in there. It can't be too 23 hard to mine that data, and develop a better 24 understanding of the types of doctors, for 25 example, orthopedic surgeons, you know, or the 1 types of doctors, and dentists -- I'm glad they 2 were mentioned around the table -- who tend to 3 prescribe more, or prescribe -- I'm -- you know, for 4 example, a rheumatologist -- 5 And I'm not going to name specialties, 6 because, then I'll start leaving out specialties, 7 and I'm not trying to point fingers. 8 -- just to make the point, that, there may be 9 opportunities with existing data sets to actually 10 identify patterns, and to target specialty 11 practices differently. And, to think about 12 clinical practice differently for different 13 specialty practices. 14 Mentioning emergency departments, also in 15 here, we've thought about. And Washington State has 16 just issued guidelines, voluntarily, for hospitals 17 in Washington State, to limit opioid prescribing 18 from emergency departments, altogether. 19 So, that's very specific. 20 We could, for example, limit, or prevent, 21 eliminate, or restrict, or not allow, the 22 prescription of long-acting sustained-release 23 opioids, such as OxyContin, from emergency 24 departments. 25 And, frankly, I mean, emergency department 1 docs will say, all the time, how difficult it is 2 for them, to have a patient sitting in front of 3 them, saying, they lost their prescription. "It's 4 Friday night, or Saturday morning. You're not going 5 to get any doctor until Monday. Can you just give 6 me"...whatever. 7 And having to deal with that patient, and 8 decide whether they're making the right clinical 9 decision in prescribing, when they've got an 10 emergency department full of patients. 11 So, there's also an opportunity to look at 12 clinical practice, very specifically, in emergency 13 medicine. 14 Thank you for holding this roundtable. 15 SENATOR KEMP HANNON: Thank you. 16 Senator Marcellino. 17 SENATOR CARL MARCELLINO: Yes, thank you very 18 much for everyone who attended, and participated. 19 It's been a very good up one. 20 I thank my two colleague for allowing me to 21 join them in this process. 22 I know I learned a lot today. And we're 23 going to go forward together, and work on some 24 positive legislation. 25 I hope this is not the end of this. I hope 1 this is the beginning; because, again, good valuable 2 information has been put out here, but now it's got 3 to be collated, refreshed, honed, and put together. 4 What I see here is -- you know, we're coming 5 on the tenth anniversary of 9/11. 6 It was always suggested, that the 7 information -- that there was information in 8 different locations that might have been used, if 9 put together, at the right time, to prevent -- or, 10 allow law enforcement to take action that might have 11 prevented the tragedy of 9/11. 12 What I see, a lot of that here today: We 13 have information. A lot of it in different 14 locations. 15 Could we put that together in a location, in 16 a way that it could be utilized, so that we could 17 attack this very serious problem? 18 I think we do, and I think we can, and I 19 think we will, because, the desire is there, and the 20 impetus is there, and the need is there. 21 What I'm seeing also, is, we're emphasizing 22 the doctor, we're emphasizing the system. 23 I'd like to go back to the street. 24 I was a teacher for 20 years. 25 We talk about teenagers, and young people. 1 I did a lot of work with drug abuse in the 2 '60s, '70s, and '80s, in the schools. 3 When you say "teens," when you say 4 "children," involved, somehow that softens it. 5 Somehow that makes it less of a crime situation, 6 more of a, we have to solve it, we have to cure it. 7 This is an organized-crime gang situation. 8 Gangs are involved in the sale of these 9 drugs. They're getting their hands on the pills. 10 How they're getting them, where they're 11 getting them, I think we can all figure out. 12 It's all because there are limited sources; 13 but, they're getting them. 14 The gangs, the pushers, are flipping kids 15 who can't get the money up to buy the oxycodone. 16 They're flipping them to heroin, which is why you're 17 seeing a spike in heroin abuse. 18 It's in all of our schools. It's there. 19 I've talked to number of teachers. 20 I've talked to a number of them, as 21 Senator Hannon has, I'm sure as Senator Klein has. 22 And the law enforcement individuals, they 23 will tell you: It's in the schools. It's in all 24 the neighborhoods. Where there's money, there's 25 drugs. 1 And where there is money, and drugs, there's 2 organized crime. I have no doubt whatsoever. 3 So, I would urge the law enforcement agencies 4 here, please, don't; don't back off on your 5 prosecution of traditional drug crime, because, in 6 my mind, a lot of this is traditional drug abuse, 7 drug crime. 8 Approach it from that. Don't soften it, 9 because a lot of kids are involved, a lot of 10 teenagers may be involved. It may be true. 11 We can deal with that. 12 But, I think that you have to look at it as a 13 crime situation too, and not lose sight of that. 14 And I hope that comes out of this. 15 And, again, this has been very productive. 16 And as I said before, I hope it continues, 17 and I hope we do more of them, because I think 18 there's a need here. 19 And, we can really work together, and get 20 some very good legislation. 21 Work with the Attorney General's bill. I 22 like that idea. 23 Maybe we can soften some of the edges, and 24 work with it, so that we can eliminate some of the 25 problems, and not make it so onerous. 1 But, it's something that we're going to go 2 to, and make the information available to everybody 3 who needs it. 4 Thank you. 5 SENATOR KEMP HANNON: Senator Klein. 6 SENATOR JEFFREY KLEIN: I want to thank, 7 also, my two colleagues: Senator Marcellino, 8 Senator Hannon. 9 This is -- I think was very worthwhile. I 10 know, personally, I learned a lot. 11 And I think what we learned is what we 12 probably already knew: we need to take a 13 comprehensive approach. 14 And I think it starts with education. 15 I think Dr. Kolodny is correct; we need a 16 standard of care for treating chronic pain. 17 I think, as Senator Marcellino said, I think 18 the data could be utilized in a simpler fashion, 19 shared by more individuals in a timely fashion. 20 And I think that's not being done right now. 21 I think, finally, to make 22 Attorney General Schneiderman's job, and 23 Special Prosecutor Bridget Brennan's job, we need to 24 really allow them to prosecute these cases a lot 25 easier. Have a standard which will provide them the 1 ability to prosecute these cases against doctors 2 who are giving out prescriptions illegally. 3 So, I think we learned that we all need to be 4 on the same page. We all need to, I think, share 5 information. 6 I still believe that the providers can play 7 a very, very important role, in letting law 8 enforcement, letting the State Health Department, 9 know about firsthand knowledge of individuals who 10 are very -- where they're getting, from these pain 11 management clinics, very easily, prescription 12 drugs. 13 And I think, by taking this approach, I think 14 we'll be, hopefully, effectively, have a piece of 15 legislation, and deal with this problem. 16 So, I thank my colleagues. 17 And, I thank you all. 18 SENATOR KEMP HANNON: Well, Senator Klein, 19 Senator Marcellino, have said it all. 20 I just want to thank everybody for the 21 enormous amount of time and preparation you've put 22 into this. For the work you're doing on, ongoing. 23 And, if anybody has items that they would 24 like us to consider, please submit them. 25 Thank you. 1 (Whereupon, at 1:37 p.m., the 2 New York State Roundtable Hearing concluded.) 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Forum/Town Hall a Roundtable Discussion on the Growing Problems of Prescription Drug Abuse and Diversion Throughout New York State, and Possible Policy Solutions

Transcript