1 COMMONWEALTH OF PENNSYLVANIA HOUSE OF REPRESENTATIVES 2 HUMAN SERVICES COMMITTEE

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4 140 MAIN CAPITOL HARRISBURG, PENNSYLVANIA 5

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7 THURSDAY, JUNE 16, 2011 10:47 A.M. 8

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10 PUBLIC HEARING ON PHARMACEUTICAL ACCOUNTABILITY MONITORING SYSTEM 11

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13 BEFORE:

14 HONORABLE GENE DIGIROLAMO, CHAIRMAN HONORABLE MARK COHEN, CHAIRMAN 15 HONORABLE MATT BAKER HONORABLE ROSEMARY BROWN 16 HONORABLE SHERYL DELOZIER HONORABLE JOE EMRICK 17 HONORABLE ELI EVANKOVICH HONORABLE MARCIA HAHN 18 HONORABLE DOYLE HEFFLEY HONORABLE SUE HELM 19 HONORABLE THOMAS KILLION HONORABLE THOMAS MURT 20 HONORABLE BRAD ROAE HONORABLE MICHELLE BROWNLEE 21 HONORABLE PAMELA DELISSIO HONORABLE EDDIE DAY PASHINSKI 22 HONORABLE TONY PAYTON HONORABLE KEN SMITH 23

24 JANIS L. FERGUSON, RPR, CRR 25 REPORTER - NOTARY PUBLIC

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3 NAME PAGE

4 DEB BECK 6

5 DANA HECKARD 10

6 HARRISON HECKARD 15

7 SHERRY GREEN 18

8 DR. MICHAEL ASHBURN 25

9 PATRICIA EPPLE 39

10 JANET HART 46

11 TOM PLAITANO 52

12 TONY MARCOCCI 59

13 MARTHA KING 63

14 KAREN FLEXER 70 15 16

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3 CHAIRMAN DiGIROLAMO: Okay, good morning and 4 welcome, everyone. We're real excited about this 5 hearing and about the issue that we're going to be 6 dealing with. 7 And just maybe a couple ground rules as 8 we start out. We were not supposed to be in session 9 today, on Thursday, but because we're dealing with a 10 very big issue, we voted on second consideration last 11 night, so we'll vote it on final passage today. We 12 have to go in session at 11:00, so the members need to 13 be out -- out of here five or 10 minutes before 11:00. 14 And I know many of you that are testifying have 15 traveled a long way, so we want to make sure that you 16 all get your testimony in. So what I thought I might 17 do is allow everyone to testify and ask the members 18 not to ask any questions, and that way we'll get 19 everybody in. If we have any time at the end of the 20 hearing, if somebody has some questions, we'll 21 entertain that. Or, if not, if the members have 22 questions and want to submit them in writing to 23 Melanie Brown, and then she will submit the questions 24 to the testifiers, and then maybe we can get them 25 answered that way.

3 1 So how about if we start out by I'll 2 allow the members to introduce themselves, and just 3 say what their district is and where they're from. 4 I'm Gene DiGirolamo. I am the Majority 5 Republican Chairman of the Committee, and I'm from 6 Bucks County. 7 REPRESENTATIVE BROWN: Rosemary Brown, 189th 8 District, Monroe and Pike County. 9 REPRESENTATIVE HAHN: Good morning. I'm 10 Marcia Hahn from Northampton County, 138th District. 11 REPRESENTATIVE EVANKOVICH: Eli Evankovich, 12 54th Legislative District, Westmoreland and Armstrong 13 Counties. 14 REPRESENTATIVE HEFFLEY: Doyle Heffley, 15 122nd District, Carbon County. 16 REPRESENTATIVE HELM: Sue Helm, Dauphin 17 County. 18 REPRESENTATIVE MURT: Tom Murt, Montgomery 19 County and Philadelphia County. 20 REPRESENTATIVE SMITH: Good morning. Ken 21 Smith, Lackawanna County, 112th District. 22 CHAIRMAN DiGIROLAMO: And I believe our 23 Democratic Chairman, Representative Cohen -- oh, I'm 24 sorry. 25 REPRESENTATIVE DELOZIER: Sheryl Delozier,

4 1 88th District, Cumberland County. 2 CHAIRMAN DiGIROLAMO: And Mark Cohen, who is 3 the Democratic Chairman of the Committee, will be here 4 shortly. 5 So with that, why don't I invite our 6 first panel to come up and testify. And that is Deb 7 Beck, who is the president of the Drug and Alcohol 8 Service Providers Organizations of Pennsylvania. And 9 we have two parents, Harrison and Dana Heckard. 10 And I would like to also remind 11 everybody that the -- we are recording, the TV cameras 12 are on. 13 And, Representative Baker, do you want 14 to just -- good morning. And do you want to say hello 15 to everyone and let us know where you're from. 16 REPRESENTATIVE BAKER: I'm Representative 17 Matt Baker, Tioga and Bradford County. Good morning, 18 Deb. 19 MS. BECK: Good morning. 20 CHAIRMAN DiGIROLAMO: And I would also like 21 to acknowledge Representative Baker, because last 22 session he did an awful lot of work on this issue; him 23 and the committee that he had last session, and was 24 gracious enough to allow me to take over the issue. 25 Thank you -- thank you, Matt.

5 1 And with that, we can begin our 2 testimony. 3 MS. BECK: Thank you very much. I'm going 4 to make a few introductory remarks and turn the 5 microphone over to my friends on my right. 6 Good morning, Chairman DiGirolamo, 7 members of the Committee and staff. I just want to 8 say to you, I'm grateful as the dickens that you've 9 taken this issue up. 10 And I want to cut to the chase and tell 11 you I'm here on behalf of the Drug and Alcohol Service 12 Providers Organization. I'm here with direction from 13 my members to beg you to pass some kind of 14 prescription drug-monitoring legislation for the State 15 of Pennsylvania. I know this is in a preliminary 16 phase. We need some legislation. And I'm here to 17 basically tell you that and thank you, and tell you 18 how grateful we are for the opportunity. 19 When I talk to my treatment programs 20 and prevention programs and our recovering community 21 around Pennsylvania, they tell me, without my 22 soliciting, and I know from my handling people on the 23 phone myself, Pennsylvania is awash in prescription 24 drugs of addiction, and many of them are tragically 25 lethal. The streets are full of prescription drugs of

6 1 addiction. Doesn't mean people with medical needs 2 don't need access to them. They do. But we've got to 3 stop the diversion and the easy and tragic access on 4 our streets. 5 Our admissions are going up. The 6 statewide admissions for treatment for prescription 7 drug addiction and overdoses are going up. Some 8 statistics are in the packet for you. And Joe Emrick 9 set this up for you, so you can see that the overdose 10 death rate from prescription drug addiction is higher 11 than for heroin and cocaine. That's a change since I 12 got in the field in 1936. 13 The prescription drugs on the street -- 14 he looked puzzled. He didn't laugh. Ken's the only 15 one up there who got that. Thank you, Ken. 16 But, anyway, these are highly lethal, 17 highly addictive drugs. We need to cut down on their 18 supply. 19 Pennsylvania is matching national 20 trends. National trends. The Office of National Drug 21 Control Policy, they have a major campaign going. 22 They call this an epidemic in America, and 23 Pennsylvania is matching those trends. You have some 24 statistics in the packet. 25 One state has a headline here, "Legal

7 1 Drugs Kill More People Today than Illegal Drugs on the 2 Street." Owen DCP (phonetic) calls it an epidemic. 3 The Center for Disease Control calls it a "rising 4 tide". And listen to this, folks. A small community 5 in Ohio, because there were so many deaths, called 6 this problem "a pharmaceutical atomic bomb going off 7 in our communities". "A pharmaceutical atomic bomb 8 going off in our communities". 9 So we urge you, I plead with you, 10 enact -- good morning, Representative Cohen. 11 (Inaudible.) 12 MS. BECK: We plead with you again. Please 13 enact legislation on this area. And here's why: Look 14 at the statistics. From the year 2007, five times 15 more prescription drug overdose deaths than heroin. 16 Here is why we need this: Unintentional deaths 17 because of prescription drug overdoses are four times 18 higher than they have been before. It's the second 19 leading cause of unintentional deaths in America 20 today. Here is why; why I'm here from our membership 21 to say, please pass some kind of legislation in this 22 area. 23 And kind of -- kind of summarizing, I 24 want to make the pitch one other way. We need this 25 legislation. Let me tell you why. And, please, bear

8 1 with me. Bear with me. 2 Rodney and Cynthia Myers, would you 3 please stand for just a moment. These folks are from 4 Cumberland County. They tragically lost their 5 17-year-old son Kyle, third-party diversion, their son 6 Kyle to Fentanyl patches. Diverted drugs. Thank you. 7 Karen -- Karen and Randy, I believe 8 you're here. From Carbon. Same issue. Just lost 9 their son Brett. 20 years old. 10 Phil Bower, York County, Pennsylvania, 11 lost his son Mark, his beloved son Mark, age 18. 12 And also a moment of tribute to Louise, 13 who couldn't make it down here from Luzerne County, 14 who frequently comes and speaks about the tragic death 15 of her young son to diverted Oxycontin. 16 Friends, that's why we need to do this. 17 So I plead to you again, and I close with my pleading. 18 Please pass some kind of legislation on this as soon 19 as you possibly can. Please pass it. Let's stop the 20 heartbreak. 21 Those are my opening comments. And I 22 need to turn the microphone over now to these -- the 23 people in the audience and these kind folks who have 24 agreed to put a face on why we need to do this. 25 Harrison and Dana Heckard.

9 1 MRS. HECKARD: Hello. This is my daughter 2 Jennifer -- our daughter Jennifer, and my 3 grandchildren. Jennifer died almost a year -- it will 4 be a year in August, from an overdose of Vicodin and 5 Percocet. She was seeing a physician who prescribed 6 these meds to her; 120 every two weeks for scoliosis. 7 I don't think that scoliosis needs to be treated with 8 Vicodin and Percocet. But he gave them to her, and 9 she became addicted. 10 And one day she tried to change the 11 date on a prescription, and she got caught. The 12 pharmacist called the physician, and the physician 13 told her -- the pharmacist to destroy the 14 prescription. And then he sent her a letter cutting 15 her off and told her that she needed help. And I 16 said, well, he should help her. He gave her the 17 medication. She could take five of these pills at one 18 time. 19 She would visit ER's and get 20 prescriptions for pain that she didn't even have. And 21 when she passed away, we received all these bills in 22 the mail from different physicians that she would go 23 to, to try to get these pills. She would doctor-shop. 24 And I don't know which ones gave them to her, which 25 ones didn't. But she would manage to get them, and it

10 1 destroyed her liver. It was the morphine in them, is 2 what killed her. 3 She was my best friend. We all 4 miss her. This shouldn't be able to happen. You 5 should be able to tell when these prescriptions are 6 getting filled constantly. Someone should have known. 7 She was in a drug rehab. She was on an 8 Oxycontin program. Or, I'm sorry, a Suboxone program. 9 And they threw her out because she missed an 10 appointment, because she had to go to work. But that 11 was one of the stipulations of the program; that you 12 work. And I begged them to take her back, and they 13 didn't. And then I guess she went back on the pills, 14 and this -- that's when she started to doctor-shop. 15 She went to all these physicians for 16 different things. She even had surgeries. I don't 17 know if they were necessary or not. Just so that she 18 could get the pills. 19 She died August 17th on her 32nd 20 birthday. She was an organ donor. She saved lives, 21 even though she lost hers. 22 She came to me a few weeks before she 23 died and told me that her pastor told her that God has 24 a plan for her, and she wanted to know what it was. 25 Well, they -- this was the plan. This Bill needs to

11 1 be passed so that people can't do this and get these 2 pills legally and go and get them filled. 3 You know, you use your insurance, you 4 don't -- whatever. They just fill them. If they're 5 monitored, they can look and say, you just got these; 6 you shouldn't be able to get any more. Cut them off. 7 Even if the physician would have pressed charges for 8 her changing the prescription, she would have gotten 9 help. But she didn't, and now she's gone. 10 And a month after she died, her 11 daughter's birthday, she turned five, and I went to 12 Emmy's birthday, and Emmy said she wanted her mommy to 13 be here, but she's in heaven. And my grandson turned 14 13 right after that. So she missed both of that. 15 But I miss her terribly. I struggle 16 with depression. I struggle to go to work. We both 17 do. We don't understand how this could happen. 18 Please, I'm begging you, please, put a stop to this. 19 These poor parents, everybody loses 20 their children because of something that can be 21 controlled. We control so many other things in this 22 country. This is just -- it's not that hard. By 23 name, by Social Security number. Stop these 24 physicians from giving these drugs out. 25 I work -- where I work, a nurse came to

12 1 me the other day. I work with special, like, staff 2 nurses with special needs children, and she knew about 3 my daughter. And she asked me what I do to get 4 through this, because her daughter is in rehab right 5 now for the exact same thing. And she gets them from 6 a pain management physician. She just calls him up, 7 and he gives them to her. 8 This should be illegal, first of all, 9 it shouldn't be allowed. They just give them out. If 10 you say you're in pain, they just give them out. It's 11 not right. It won't bring her back, but it could 12 probably save a lot of lives. And these people -- 13 these parents wouldn't have to go through -- I know 14 they all hurt. I hurt every day knowing that this 15 could have been prevented. If they would have just 16 not filled these prescriptions, she would have maybe 17 got sick, went through withdrawal, whatever. She 18 would have had to get help. She would have had to go 19 somewhere and get help. She wouldn't be dead. And 20 she was such a wonderful person. She had a heart of 21 gold. 22 So, please, I'm begging you, please, do 23 something to stop this. Because it's just going to 24 keep taking these kids. They're just too young, and 25 they have too much to live for. It's just not worth

13 1 it. 2 So if you could see in your heart and 3 make it -- she didn't even get them illegally. She 4 got them legally. She may have gotten some illegally, 5 but most, she got them legally from different doctors, 6 different ER's. She would get in the ER and say her 7 tooth hurt. Prescription for 20 Vicodin and get it 8 filled. Next night go to another ER, get in a 9 (unclear). And they would fill them, because they 10 didn't know. She would go to a different pharmacy. 11 But if there was a -- if there was a database that 12 showed she got these filled, they would not have 13 filled them. And that's what I'm asking, begging you 14 to do. 15 I'm not against the drug either. I've 16 had surgeries. I have used them. They're -- they're 17 good medication when you need them, but not when 18 you're addicted and you can get them like this. I 19 just -- okay. I think it needs to stop. But -- 20 CHAIRMAN DiGIROLAMO: Thank you so much for 21 being here today. 22 MRS. HECKARD: Thanks for having us here 23 today. 24 CHAIRMAN DiGIROLAMO: Your courage. Mr. 25 Heckard?

14 1 MR. HECKARD: We have a son that's in jail 2 pretty much for the same thing, and he swears up and 3 down -- him and his sister were really, really close. 4 And he -- he wrote a letter to his sister just lately. 5 She's going to read it. 6 MS. BECK: The family asked that I read 7 this, not -- worried that they wouldn't be able to 8 read it. 9 "Dear Jen," he writes to his sister, 10 "there isn't a day that goes by that I don't think of 11 you and break down and cry. All of the great times we 12 had together. You could always put a smile on my face 13 when I was down the most. You were the greatest 14 sister anyone could ever ask for and also the best 15 friend anyone could have. I know you're up in heaven 16 watching over us. I can't wait to see you again one 17 day. I'll never forget you, and I'll always cherish 18 the relationship we had. I miss you every day, and I 19 love you very much. Love, your brother Harrison." 20 CHAIRMAN DiGIROLAMO: Okay. And I want to, 21 again, thank you very much, to you and the other 22 family members that are here present today for your -- 23 not only your testimony, but your courage in coming in 24 front of us and sharing your story and sharing your 25 pain. And we hear you. Believe me, we hear you.

15 1 We're going to -- we're going to do everything we can 2 to get this Bill passed. 3 MRS. HECKARD: That would be 4 (unintelligible). 5 CHAIRMAN DiGIROLAMO: And, again, just for 6 the information of everyone, what the Bill simply does 7 is create a prescription drug-monitoring database that 8 doctors and pharmacists will be able to go on and 9 access, where if they suspect somebody is doing what 10 these parents explained that their daughter was doing, 11 doctor-shopping or pharmacy-shopping, that they are 12 going to be able to go on a database and check and see 13 if they're abusing these prescription drugs, and, 14 hopefully, talk to these people about getting help, 15 getting into treatment. At the very least, stop them 16 from obtaining these drugs, which they're not entitled 17 to legally, so. 18 MRS. HECKARD: That would be wonderful. 19 CHAIRMAN DiGIROLAMO: Thank you. Thank you 20 for being with us. 21 MS. BECK: Chairman DiGirolamo, I just want 22 to -- if everyone could take a moment when the 23 hearing's over to thank the families. Many families 24 spoke out to put a face on this for the first time 25 today. Thank you for that.

16 1 CHAIRMAN DiGIROLAMO: Thank you. And, 2 again, I know some of -- some of the members have just 3 come in. And maybe if you just want to say hello. 4 Ed, say hello and introduce yourself. 5 REPRESENTATIVE PASHINSKI: Eddie Day 6 Pashinski, Northeast, 121st District, Luzerne County. 7 REPRESENTATIVE BROWNLEE: I'm representative 8 Michelle Brownlee, Philadelphia County. 9 THE COURT: And I know my Chairman, 10 Representative Cohen, is in attendance. And also 11 Representative Tom Killion I saw come in the room. 12 Brad? 13 REPRESENTATIVE ROAE: I'm Brad Roae, 14 Crawford County. 15 CHAIRMAN DiGIROLAMO: Tom, go ahead. 16 REPRESENTATIVE KILLION: Tom Killion, 17 Delaware, Chester County. 18 CHAIRMAN DiGIROLAMO: And, again, for the 19 members who just came in, I think what we're going to 20 try to do, because a lot of the people who are 21 testifying have come a long way, they're going to 22 allow everybody to testify first, and then at the end, 23 if we have any time left over, because we have to be 24 in session at 11:00, we might open it up for a few 25 questions.

17 1 I might ask next, Sherry Green, who is 2 the Chief Executive Officer for the National Alliance 3 for Model State Drug Laws. And Sherry is joining us 4 from the beautiful state of New Mexico. And I had a 5 great opportunity to chat with Sherry a little bit 6 this morning. 7 So, Sherry, welcome to Pennsylvania. 8 MS. GREEN: Thank you, Mr. Chairman. 9 CHAIRMAN DiGIROLAMO: And you can begin 10 whenever you are ready. 11 MS. GREEN: All right. Mr. Chairman and 12 members of the Committee, thank you very much for 13 allowing me, on behalf of the National Alliance for 14 Model State Drug Laws, to join you here today. 15 The parents that you just heard from 16 have spoken far more eloquently than I ever could 17 about the importance of PMP. So what I'd like to do 18 is share with you some information that's going to 19 reinforce the statements that they've made. 20 NAMSDL is a nonprofit successor to the 21 President's Commission on State Drugs Laws. Congress 22 funds us specifically to help states create a more 23 comprehensive, balanced, and integrated system of drug 24 and alcohol services through improvements in state law 25 and policy. Over the last 17 years, I've had the

18 1 privilege of working with almost all of the 48 states 2 that currently have PMP laws. 3 One of the most significant changes 4 we've witnessed is the use of the PMP as a public 5 health tool, specifically to change prescribing 6 behaviors of doctors and other health professionals 7 and to help us professionals identify as early as 8 possible patients who may be addicted, so that they 9 can be referred for addiction treatment. 10 The information in the PMP database is 11 going to tell the doctor things about a patient that 12 she's never going to find out anywhere else. What is 13 she going to learn? She's going to learn whether that 14 patient has been seeing several other doctors to get 15 the same or a similar prescription within a very short 16 period of time. It's usually 30 days. 17 It's also going to tell that doctor 18 whether or not that patient is actually filling 19 multiple prescriptions at multiple pharmacies within 20 that same period of time. It's even going to allow 21 her to see whether or not that patient is refilling a 22 prescription at an unreasonably faster rate than the 23 rate prescribed. For example, two and a half times 24 the rate prescribed is not unusual in some of these 25 cases.

19 1 It's also going to tell that doctor if 2 there are prescriptions listed in that database 3 listing that doctor as the prescribing physician, when 4 that doctor never wrote any of those prescriptions, 5 signaling that they are forged and false and 6 fraudulent prescriptions. 7 Why can't PMP provide some of this very 8 important information? Because of the basic operation 9 of a PMP, which I'm sure most of you know about. When 10 a pharmacist fills a prescription, that pharmacist is 11 going to electronically submit to the PMP agency 12 certain information about that prescription, including 13 the doctor's name, the name of the medication, the 14 amount of the medication, the number of refills, the 15 frequency of refills. And it's going to collect -- 16 that PMP is going to collect all that information on 17 every prescription that's dispensed to that patient 18 within the state, creating a prescription history. 19 The doctor of that patient is going to 20 be able to register with that PMP agency, set up an 21 account, and through a pass code, actually access that 22 PMP database, which is usually kept in a secured 23 website, and view that prescription history and use 24 that prescription history in making treatment 25 decisions.

20 1 Now, PMP's, at this particular point in 2 time are in various stages of development among the 48 3 states. And as they are doing evaluations, those 4 evaluations are also in various stages of development. 5 But what we are seeing is that as they are releasing 6 their studies, those studies are reinforcing the value 7 of the PMP as a public health tool. 8 For example, the University of Kentucky 9 in 2010 evaluated the Kentucky PMP, which is 10 considered one of the leading PMP's in the country. 11 And it concluded that that PMP was useful in making 12 treatment decisions, and that it has a positive impact 13 on the prescribing practices of approximately 14 80 percent of the prescribers who use that PMP. 15 A recent (unintelligible) study 16 confirmed that ER physicians also changed their 17 prescribing practices after they reviewed the PMP 18 data. 19 Based on this type of information, 20 we're seeing states develop certain legislative 21 measures that will actually facilitate the public 22 health objective of PMP's. For example, states are 23 now expanding the amount of controlled substances that 24 they monitor. 44 states monitor Schedules II through 25 IV substances. Currently Pennsylvania is actually the

21 1 only state that only monitors Schedule II substances. 2 Why the expansion? Because when they 3 monitor Schedule II, they saw an increase in abuse of 4 Schedule III. When they monitored Schedule III, they 5 found an increase in the abuse of Schedule IV, and so 6 on. 7 What happened? State officials began 8 to realize that addiction doesn't know nice legal 9 categories like schedules or class substances, so they 10 wanted to begin comprehensively monitoring substances 11 so they could identify problems as early as possible. 12 State PMP's are also now notifying 13 prescribers and dispensers when a patient begins to 14 see a designated number of doctors or other 15 prescribers or pharmacists within a very short period 16 of time, so that prescriber knows that there's 17 something that has to be checked into. 18 States are also starting to share PMP 19 data with other states, under certain conditions, that 20 have a PMP and also with other types of appropriate 21 health professionals and law enforcement officials in 22 those other states. Why? Because people often cross 23 state lines in order to fill prescriptions, and each 24 PMP wants to have a comprehensive picture of all the 25 prescriptions that are being dispensed to residents of

22 1 that state. 2 Now, what we're also finding is that 3 when states have these comprehensive databases of 4 personal health information, sometimes concerns are 5 arising about states having that kind of information. 6 So we're seeing that PMP laws will often include 7 certain types of language that is specifically 8 designed to protect the privacy and the 9 confidentiality of PMP's. 10 Now, there's four common statutory 11 safeguards we see when we look at these 48 states' PMP 12 laws. 13 For example, the PMP law will exempt 14 the PMP data from any kind of public record or 15 Right-To-Know Act. They will also specifically lay 16 out who is allowed to have access, under what 17 circumstances, and the purposes for which the 18 information can be used. They will specify that the 19 state PMP agency has to develop procedures and 20 policies with the intention of protecting the 21 confidentiality of the data. And they will be sure to 22 penalize unlawful use access and also disclosure that 23 is in violation of the statute. 24 And now we have 17 state laws that have 25 actually instituted a type of purging requirement, so

23 1 that information from the database would actually have 2 to be deleted or removed within a certain number of 3 years after that data has been collected. Now, the 4 range of years used in states can be anywhere from one 5 to six years, and some states will allow data to be 6 retained if it's part of an active investigation. 7 Now, the House Bill you are 8 considering, I have reviewed it, and it actually 9 contains many of these types of legislative provisions 10 that I've actually discussed, but it takes a leading 11 role among 48 state laws, all -- all of the laws that 12 I have read, because it includes education and 13 treatment. It places a priority on education and 14 treatment that I rarely see among PMP laws. And so I 15 commend the committee for this. Because for 17 years, 16 what my organization has done is advocated those same 17 provisions, because it is exactly those sections that 18 allows the PMP to work most effectively and optimally 19 as an intervention tool to prevent some of the 20 situations that you heard about this morning. 21 So, Mr. Chairman, members of the 22 committee, I want to thank you, again, for allowing me 23 a few minutes to share my experience in working with 24 the 48 state PMP Laws. Thank you. 25 CHAIRMAN DiGIROLAMO: Good, Sherry. Thank

24 1 you. And that was very powerful testimony. And I'm 2 glad you mentioned the part about the treatment and 3 the education, because I think that's a -- that's a 4 really important part of this legislation. 5 MS. GREEN: Yes, it is, Mr. Chairman. And 6 on behalf of the work I do with other states, I want 7 to thank you for taking the lead on that, because I 8 can now use -- I can now use Pennsylvania's PMP law as 9 an example for other states. Thank you. 10 CHAIRMAN DiGIROLAMO: We really like that. 11 Thank you, Sherry. 12 Next, I'd like to call up Dr. Mike 13 Ashburn, who is director of Pain Medicine at the 14 University of Pennsylvania. And he's also testified 15 on behalf of the PA Society of Anesthesiologists. 16 Mike, welcome. 17 DR. ASHBURN: Thank you very much. Mr. 18 Chairman, and Representatives of this Committee, thank 19 you very much for the opportunity to present. 20 Since I come from academics, of course, 21 I can't speak without Power Point, so I have some 22 Power Point slides. Unfortunately, you may not be 23 able to see them, but we did include the longer 24 version of the presentation in the -- in the handouts. 25 First of all, I wanted to recognize as

25 1 a -- that common -- chronic pain is a very common 2 condition. It affects about 50 million people in the 3 United States. Chronic pain comes from a number of 4 different resources or causes, including advancing age 5 and the diseases that accompany advancing age, 6 particularly osteoarthritis, which leads to hip and 7 knee pain and other joint pain. It's also a very -- 8 fairly common complication to medical care, including 9 surgery, diseases, such as infection. It's a 10 consequence of injury, even when that injury is 11 appropriately treated, and certainly can also come as 12 a result of radiation and chemotherapy from cancer 13 treatments. 14 There are a number of things that can 15 be done in order to treat chronic pain, and many 16 physicians are involved in the care of chronic pain, 17 including the evaluation and treatment of those 18 patients, the administration of medications, the use 19 of interventional care, such as nerve blocks, and then 20 advanced pain techniques that are done by pain 21 specialists, including neurolytic procedures or 22 implantations. 23 One thing to be -- that is important to 24 note is, is that about 40 percent of all chronic 25 opioids are not administered by specialists, but are,

26 1 rather, administered by primary care physicians. And 2 why I mention that is, is that it's important to note 3 that there's going to be tension in any effort to try 4 to protect or try to address diversion. And that is 5 increased burden on the care of patients, and a busy 6 physician in a rural area may have the unintended 7 consequence of limiting access to healthcare, because 8 those physicians will withdraw providing opioids as 9 part of their care. And, quite simply, there are not 10 enough pain physicians, such as myself, to take on 11 40 percent more patients who need these medications 12 and this care. 13 In addition, there are many patients in 14 rural Pennsylvania who have no interest in driving to 15 inner-city Philadelphia in order to receive specialty 16 care once a month. 17 Now, opioids are a fairly important 18 part of the care of patients who have chronic pain. 19 That's particularly true for individuals who are 20 suffering from cancer or cancer-related sort of care. 21 But it's also important for people who have chronic 22 non-cancer pain. 23 One thing that's important to note, 24 though, is, is that both the patient and the physician 25 have to recognize that opioids, when they are used for

27 1 the treatment of chronic non-cancer pain, have 2 limitations. 3 Indeed, well-controlled trials show 4 that opioids only relieve about 40 percent of the pain 5 that people have when they're used for chronic 6 non-cancer pain. That's important because of 7 expectations, both by the physician and the patient, 8 of complete relief. Then physicians and the patients 9 tend to push for higher and higher doses, and the 10 higher the dose, the increase the risk of harm [sic], 11 including addiction and inappropriate use of these 12 medications. 13 In addition, opioids have risk of harm, 14 both to the patient, the patient's family, and to 15 society as a whole. And that's particularly true when 16 these medications are used for non-medical purposes. 17 Well, what is the risk of society? And 18 I think you've seen some of that risk already in prior 19 testimony, but I want to briefly review and provide 20 you with some data. 21 First of all, prescription drug abuse 22 is one of the fastest growing drug problems in the 23 United States, and it's recognized now by the Centers 24 for Disease Control as a public health epidemic. From 25 1998 to 2008, there's been a four-fold increase in

28 1 addiction treatment admissions related to individuals 2 who are abusing prescription drugs. Not drugs from 3 the street, but prescription drugs. Most of those 4 drugs that are abused are opioid analgesics, the pain 5 medications that are -- that I'm speaking about. 6 In 2009, six out of the top 10 7 substances used by twelfth graders, our children, in 8 the last year were pharmaceutical agents. So these 9 medications, controlled substances that are often 10 obtained through legitimate sources or from friends, 11 not off the street, are perceived by our children as 12 being safer. And as a result, they're frequently used 13 for non-medical purposes, for recreational purposes at 14 parties and other things. 15 They're a significant impact on 16 healthcare costs, both to the state, to the Federal 17 Government, and to public payers. The estimated 18 number of emergency department visits linked for 19 non-medical use of prescription drugs doubled between 20 2004 and 2008. 28,000 Americans died from 21 unintentional drug overdoses in 2007 alone. Opioids 22 contributed to at least 40 percent of that. 23 Now, here is a statistic that I think 24 is -- is a -- tops -- tops the list with regard to 25 clear evidence that prescription drug abuse is a

29 1 public health epidemic. In 17 states and the District 2 of Columbia, drug-induced deaths now are the leading 3 cause of injury-related death, exceeding car 4 accidents. 5 Now, what's the toll in Pennsylvania? 6 In 2005, it is estimated that more than a half a 7 million adults, almost one in 20 in Pennsylvania, used 8 an opioid in the last year for non-medical purposes. 9 One in 20. 10 The death rate in Pennsylvania due to 11 overdose of medications is 12.1 per 100,000. That 12 equates to 1,663 deaths a year. That's 31 a week or 13 four a day. Four people a day dying from drug 14 overdoses in the state. 15 Now, there are very good, well-written 16 evidence-based clinical practice guidelines to guide 17 physicians' care in the use of opioids for the 18 treatment of pain, including chronic non-cancer pain, 19 that have been published in a number of different 20 areas. So there are good evidence-based guidelines to 21 guide physicians' decision-making on how to use these 22 medications. 23 One of the key things that these 24 guidelines state is that physicians have to work hard 25 to strike a balance between using these medications

30 1 for their intended purpose, so people can obtain pain 2 relief, while making appropriate measures and using 3 some diligence on making sure that the medications are 4 not diverted, that they are used appropriately, and 5 the patient is actually experiencing benefit. 6 When I speak to other physicians, I 7 actually say that the use of these medications is no 8 different than how you would use a medication to treat 9 hypertension, in that when you diagnose a patient with 10 a high blood pressure, you have a goal for therapy, 11 you administer a treatment, and then you monitor the 12 patient to make sure that the treatment has actually 13 lowered the blood pressure. That's no different in 14 how pain medications are used, but somehow physicians 15 and patients don't see it that way. 16 So when we diagnose pain, we should 17 understand what we're treating. We should use 18 medications with a goal of lowering the pain and 19 improving physical and mental functioning. We should 20 institute some way of monitoring the patient to make 21 sure those goals have been accomplished. And, of 22 course, if our therapy doesn't lead to those goals, or 23 it leads to adverse side effects, such as 24 inappropriate use of the medication, then the 25 medication needs to be discontinued.

31 1 And so what -- what are the things that 2 we monitor patients for? A number of different side 3 effects are associated with chronic use of opioids, 4 including inappropriate use, which we use the term 5 aberrant drug-related behavior, evidence of addiction, 6 and evidence of diversion. 7 Now, how do we monitor patients in 8 order to try to do that? First of all, we risk 9 stratify. We identify patients who may be at high 10 risk for these behaviors, and then we institute higher 11 levels of diligence for those patients. We engage in 12 medication agreements, which, essentially, require me 13 to sit down with a patient when I start the therapy 14 and make sure that I explain the risk, the 15 alternatives, the potential benefits of chronic opioid 16 therapy, and the conditions under which I would use 17 those medications, and make sure that the patient 18 understands it. And, generally, I have the patient 19 sign a document to make sure that they've -- we have 20 some documentation that that conversation has 21 occurred. 22 I monitor outcomes and monitoring how 23 patients do. I obtain regular urine drug screens, and 24 I tell the patients we do it on everybody on every 25 visit in our program, and we're looking for the

32 1 presence of the prescribed drugs and the absence of 2 the non-prescribed drugs or illegal drugs. 3 One thing that's missing in 4 Pennsylvania is a controlled substances database. As 5 you all -- as you all know, the existing controlled 6 substance database only looks for Schedule II 7 medications and is not accessible by healthcare 8 providers. So that data are not available for me to 9 use to guide decision-making, whether it's Schedule II 10 or otherwise. 11 I want to briefly talk about, from a 12 clinician's point of view, what the key attributes of 13 a controlled substance database are. As you've 14 already heard, such a database would collect key data 15 on controlled substances dispensed in the Commonwealth 16 with appropriate exceptions. And what that -- and as 17 other speakers have pointed out, it is vital that 18 includes all scheduled controlled substances, so not 19 to have the unintended consequence of having 20 inappropriate use of the medications that are not 21 monitored. 22 The data need to be entered in a timely 23 matter. And as this Bill proposes, ultimate goal is 24 essentially realtime data entry so that data are 25 available. And, again, the data need to be quickly

33 1 available to me to guide decision-making. 2 If the burden for the physician to 3 obtain the data are high, and I'm seeing somewhere in 4 the neighborhood of 30 or 32 patients a day on an 5 outpatient basis, where I've got 15 people in the 6 queue in the emergency room, then that burden will 7 prevent me from using that data, and I'll miss an 8 opportunity to provide, hopefully, better care to that 9 patient based on that information. 10 I wanted to quickly walk you through 11 how the database would work in realtime. And the 12 slides that are here, I apologize -- and it's in a 13 brochure -- are screenshots from the controlled 14 substances database that exists in the State of Utah, 15 where I came from before moving in 2007 to join the 16 faculty of University of Pennsylvania. 17 Patients in this one -- this is an 18 Internet-based database, as you've heard before. 19 Physicians have to be registered and have an 20 appropriate password. They can sign on. And now 21 there's an iPhone app. But when you see the patient, 22 you can log on, and you place your -- and then you get 23 a screen, that looks like this slide, which 24 essentially warns you that you should only access the 25 database for appropriate, legitimate medical purposes

34 1 and only search for data on patients that are your 2 patients or you're about to engage in a meaningful 3 professional relationship with. 4 Then you put in the data; the patient's 5 name and usually date of birth, and any other 6 demographic data you receive. And then you 7 immediately receive a search result within a few 8 seconds of that patient and all the prescriptions that 9 have been prescribed. 10 Key data for a physician is also 11 knowing that the -- the patient's name, confirming 12 their date of birth, make sure that you're looking at 13 the right patients, and looking at what medication was 14 prescribed, how many, and who was the prescribing 15 physician. And that's key, particularly in the era of 16 multi-specialty practice, because many times it won't 17 just be me prescribing for my patients, but it will be 18 me and my five other partners who are prescribing for 19 that patient. So it's important for me to understand 20 who is prescribing what and whether or not the patient 21 has obtained medications outside of our particular 22 care. 23 Now, physicians, like other folks, vote 24 with their feet. And what I mean by that is that if 25 the data that are available in controlled substances

35 1 database have no value, they won't use it. If it does 2 have value, they will. And as you see on this slide, 3 from the marked increase in utilization from the 4 control substances database in Utah, the utilization 5 in 2009 included 140,000 queries of the data by 6 physicians. 7 Now, just to put that in perspective, 8 there are 2 million people in the entire State of 9 Utah, so you can expect large, large utilization of 10 this database in the Commonwealth with a much larger 11 population. 12 And, lastly, can this be used as a tool 13 for the state public health entities to guide 14 physicians in identifying patients who may not be 15 using their medication appropriately. One thing 16 that's important is the data itself will not allow you 17 to identify people who are addicted. It will not 18 necessarily allow you to find people who are diverting 19 medications. It will allow you to find data on people 20 who may not be using the medication appropriately, but 21 you need additional information in order to confirm 22 what the diagnosis is. The data from the database 23 won't do that for you. 24 But this is a -- this is a report on 25 the number of letters that the State of Utah

36 1 published, sending a warning letter to prescribing 2 physicians when the patients that they were caring for 3 had received a controlled substance prescription from 4 eight different doctors in the last month. And most 5 of us would say that's a clear sign that patients are 6 in trouble, if they're getting opioids from eight 7 different doctors in the last four weeks. 8 Now, how often did that occur? Again, 9 this is a state with 2 million people. That occurred 10 3,700 times during the report structure. So these are 11 large evidence that the database can be used to 12 provide valuable information, identify patients who 13 are misusing the medication. And, of course, that may 14 have financial implications to the state health 15 system, in the sense that if patients are using their 16 insurance to obtain medications for non-medical 17 purposes, particularly if they are using them to 18 divert those medications, then identifying people who 19 are not appropriately obtaining those opioids, who are 20 not benefiting from the medications prescribed, can 21 allow the state not to prescribe those medications or 22 pay for those prescriptions when they are 23 appropriately identified. 24 Now, HB 1651 provides a wonderful 25 opportunity to provide a valuable tool. It will not

37 1 solve substance abuse. It will not solve addiction. 2 It will not make the rate go to zero with regard to 3 the tragedy that addiction of these medications 4 causes. But it will provide an extremely valuable 5 cost-effective tool that helps us guide 6 decision-making and allows physicians to make a 7 good-faith effort to strike a balance between access 8 and use of these medications for legitimate purposes 9 in avoiding the huge harm to individuals, their 10 family, and society when these medications were -- are 11 misused. Thank you very much. 12 CHAIRMAN DiGIROLAMO: Mike, I thank you for 13 that very informative testimony, and I'm glad you 14 brought up the economics of the issue, because I think 15 for a very, very small cost to the Commonwealth, 16 there's the potential there to be an enormous savings. 17 So thank you very much for your testimony. 18 DR. ASHBURN: Thank you. 19 CHAIRMAN DiGIROLAMO: Just for the 20 information of the members, the Cancer Society are not 21 going to be speaking today, but they have submitted 22 written testimony, and I will make sure that all the 23 members receive the testimony. 24 And before we start, we have a couple 25 other members who have come into the room, and -- I

38 1 know Representative Emrick was there a little bit 2 earlier. Representative Emrick and Representative 3 DeLissio is here also. So welcome to the hearing. 4 And with that, next we have a panel -- 5 Patty Epple from the -- who is the CEO of the 6 Pennsylvania Pharmacists Association. Patty, welcome. 7 And also joining her is Janet Hart, who is the 8 Director of Governmental Affairs for the Rite Aid 9 Corporation and also the president of the Pennsylvania 10 Association of Chain Drug Stores. 11 So whenever you're ready, you can begin 12 your testimony. 13 MS. EPPLE: Okay. Good morning, Chairman, 14 members of the Committee, staff. We decided in the 15 interests of time to combine our testimony. 16 So let me first just introduce myself 17 again. I'm Pat Epple with the Pennsylvania 18 Pharmacists Association. Our association is made up 19 of nearly 2,000 pharmacists, pharmacy technicians and 20 students across the Commonwealth. And those 21 pharmacists practice in a variety of different 22 settings, from chain, to independent pharmacy owners, 23 to hospitals across the board. Our biggest makeup is 24 independent pharmacies and some of my specific points 25 in my testimony here this morning will be regarding

39 1 those independent pharmacies. 2 MS. HART: Good morning. My name is Janet 3 Hart. I am a registered pharmacist in the State of 4 Pennsylvania. And as I stated, I am the President of 5 the Pennsylvania Association of Chain Drug Stores. We 6 have 16 member companies and operate 1500-plus 7 pharmacies in the State of Pennsylvania. We employ 8 6,750 pharmacists, and from a revenue standpoint, we 9 pay an estimated 13 -- 1.37 billion in state taxes 10 annually. 11 MS. EPPLE: I'd like to start out by saying 12 right off the bat that we're fully supportive of this 13 initiative. I think pharmacists, probably more than 14 anyone, can definitely see some of the effects of 15 diversion abuse. And they're often put in the hard 16 decision point of whether to dispense or not. 17 And this -- this would be a tool that 18 they believe would help them, you know, identify 19 patients who might be physician-shopping or 20 pharmacy-shopping. So there are some very good points 21 in this legislation. 22 We do have a couple concerns, though. 23 And one of our biggest ones is that nothing in the 24 Bill requires the mail-order pharmacies to participate 25 in this program. Most of those mail-order pharmacies

40 1 are not located in Pennsylvania. They're mailing in 2 controlled substances from out-of-state facilities. 3 And under this legislation, they would not be required 4 to participate. And that could represent as much as 5 10 percent of the prescription drugs in this area. 6 And I don't know that you have a real good solution 7 available. 8 There's a couple options to look at. 9 One, requiring that they participate. I'm not sure if 10 you can do that legally. Two, require them to have an 11 in-state license, which would then address that, which 12 currently they do not. Or, three, just simply 13 prohibiting them from mailing in controlled 14 substances. 15 Our biggest concern with number one and 16 two is that one of the requirements in this 17 legislation is that positive I.D. of the person that 18 gets it. A mail-order pharmacy can't comply with 19 that. I don't think you're going to get the mailman 20 to ask for I.D. when they get that in the mailbox. 21 But I think that that's a big concern. These 22 controlled substances are sitting in mailboxes and 23 being mailed in. 24 The other -- one of the other concerns 25 we have is the requirement for the I.D. Many of the

41 1 independent pharmacies do not have point-of-sale 2 systems, which would allow them to easily collect that 3 positive I.D. I think they can get to that point, and 4 I'm not saying that that should be changed, 5 necessarily, but I think we need to realize that it is 6 a problem, and there needs to be a timeline for 7 implementation that allows them to meet that. 8 The problem is when people are filling 9 prescriptions, they are compiling all the other data, 10 the prescription is ready for pickup, and then it 11 could be a day, two days, three days, maybe even more 12 until they come in and pick it up. So matching that 13 I.D. portion of the claim that you're looking for 14 versus everything else is problematic. Yeah, it's 15 problematic. And I think Janet is going to go into 16 some of the other issues with I.D. in just a moment 17 too. 18 Another thing, I know the legislation 19 does not require pharmacies to pay a fee to 20 participate. We think that's a great idea. Quite 21 frankly, we wouldn't be supportive if you were 22 charging us, because of all the society good that I 23 think this can offer. 24 However, I think everyone has to be 25 aware that this is not without cost to pharmacies.

42 1 Many of our independent pharmacies do not currently 2 have the software. Yes, the standards are available, 3 yes, they can upgrade their system, but it's not going 4 to be without cost. So please keep that in mind, that 5 there is going to be a cost and a timeline connected 6 with all of this. 7 Even chain pharmacies and even our more 8 technologically advanced independents are going to 9 have to make a few changes to their operations, to 10 their policies, to their workflow, and those are 11 critical. Not saying we can't do it, not saying that 12 we don't want to do it, because we do. But just 13 saying that that challenge is out there. 14 As far as the timeline, obviously, once 15 this legislation successfully passes, you're going to 16 have to establish the department, get all the 17 regulations, the policies, et cetera in place. Once 18 that's done and the system is ready to implement, I 19 think there needs to be a time period for -- in which 20 the -- the penalties and stuff are not applicable, 21 because I do think there is going to have to be a 22 learning curve for pharmacies. I think there has to 23 be a time period where we try this out while we work 24 with it. 25 Want -- again, want to do it, but just

43 1 be aware that we need to be very careful on how we 2 educate and promote this to pharmacies. Our 3 association is very eager to work with you to make 4 that happen, to make it happen easily, but I am going 5 to tell you that our independents in some of the rural 6 areas of the state, who just don't have the ability to 7 easily do it like that, there's going to need to be 8 some time. 9 As I said earlier, we're very eager to 10 work with you on doing that. I think we can mount a 11 very good education campaign. I think that some of 12 our members who are very eager for this can be a very 13 strong advocate for it, so we can make it happen, and 14 we do want to make it happen, but we need to be part 15 of that from the get-go when the department gets 16 established. 17 A couple of other things. I know that 18 there are opportunities, perhaps, in the system to set 19 up some opportunities for red flags or queries when 20 problems are arising and let that come to the pharmacy 21 counter. I want to make sure that that's happening or 22 there's a way to make it happen. 23 For instance, when a prescription 24 packet is stolen from a doctor, that should be put in 25 there right away as a red alert so pharmacies can look

44 1 for that. 2 But at the same time, I don't want 3 there to be a liability that the pharmacists must act 4 in a certain way or must always check that database, 5 because sometimes that's just not going to happen. 6 And you want to avoid questions of always profiling 7 certain people as well. So just wanted to mention 8 that. 9 I do think it's a great thing that you 10 have covered interoperability as in a future thing, 11 because I do know there are many states who are 12 already involved in the National Association of Board 13 of Pharmacies -- Board of Pharmacies. I believe 14 there's something like eight states who have already 15 signed on to their PMP Interconnect. And some of 16 those are our neighboring states; Ohio, Virginia, West 17 Virginia. And I believe someone mentioned earlier 18 that chance of going across state lines. So that is 19 very, very important, very crucial. And we do support 20 the -- involved in all controlled substances, II 21 through V. If you're going to do it, do it right from 22 the get-go. 23 The only other thing I want to finally 24 mention is I'm not sure that I saw this covered in 25 here, but when the system is up and operable, we need

45 1 to repeal the current requirement to report Schedule 2 II to the Attorney General's Office. We can't have 3 pharmacies having to report two different ways. First 4 of all, it's redundant, and it would be cost -- cost 5 and time-consuming. So I just want to also mention 6 that. 7 So, again, just want to reiterate our 8 support for the legislation and our interest in 9 working with you. 10 Janet has some additional points, I'm 11 sure. 12 MS. HART: Thank you, Pat. Thank you again. 13 Yes, the positive I.D. portion of the 14 Bill also represents a problem for many of our chain 15 pharmacies. Because keep in mind that they -- we have 16 members that have four pharmacies, and we have members 17 that have 585 pharmacies. So it's all across the 18 board, and many of our member companies have those 19 same type of limitations of positive identification. 20 And to give you some idea of what that 21 would involve, pharmacies have a dispensing 22 prescription system that they fill your prescriptions 23 through. They check your third party, they do all of 24 that information along those lines. 25 Requiring the I.D. at pickup, that's a

46 1 different system. That's a register system that you 2 ring through the register. It does MasterCard, it 3 does Visa. For many pharmacies, it might even take 4 your license for a meth-check type thing, if you're 5 buying pseudoephedrine in the pharmacy. But those two 6 systems are not integrated. And so to have to take 7 that positive I.D. at pickup and integrate it is a 8 tremendous burden, both from a technological side and 9 from a time side, as Pat stated, as far as having to 10 go back and perhaps add information once the 11 prescription was dispensed. And from our perspective, 12 that time is very critical to our pharmacist. And we 13 would like to -- that takes away from the patient care 14 aspect of the pharmacy and their relationship with 15 their customer. So we'd just like you to consider 16 that impact. 17 I'm responsible at Rite Aid for 18 reporting to 25 states at present, so I'm pretty 19 familiar with prescription monitoring programs 20 throughout the country. And one of the issues that I 21 see with this particular Bill is that you're requiring 22 the name of the dispensing pharmacist. In the 25 23 states that I report to, that is not a data 24 requirement field. You know. And that does present 25 the problem -- most systems have some type of a log-in

47 1 when you're dispensing a prescription, whether it be a 2 thumbprint, a biometric scan, a secure typed password, 3 but the name of the pharmacist in full is not included 4 in most data -- in most systems when that process 5 occurs. That's in a separate system, again, that's 6 housed perhaps with human resources for payroll 7 reasons and things along those lines. And to avoid 8 marrying those two systems together would be very 9 difficult for member companies. 10 One state did actually propose it, 11 Alabama, and what they've done is made that what they 12 call a situational field, which means you can or you 13 can't submit it. It's not a mandatory field for 14 submitting. So if you don't have that capability, you 15 don't have to. Perhaps that one -- an independent 16 that owns one or two stores may be able to do that 17 easier than one of our chain members. 18 The reporting frequency as far as the 19 two days, from -- from our perspective, we would 20 recommend seven days, which is really the mandate that 21 comes from getting any of the federal grants or 22 anything. The data in that particular time is 23 referenced every -- frequency, every seven days. And 24 really what that does is it does allow the 25 practitioner and the pharmacist to view a patient's

48 1 history. You're not looking for a person who is 2 getting one prescription on that day. They're going 3 to have a history for weeks prior or months prior to 4 it. So for seven days versus two days, seven days is 5 much better from a reporting standpoint. Many member 6 companies report this data with a person in their 7 corporate headquarters that has to log on to an 8 Internet -- Internet site and transmit data. And to 9 do that every two days would be burdensome, especially 10 weekends, holidays, things along those lines. 11 So we would ask you to consider that 12 the reporting be every seven days, as it is in the 13 majority of other states. 14 Let's see. What else? Oh, one other 15 additional point that we would like to add. From a 16 practitioner/dispenser liability standpoint, I put 17 some language in my testimony, and it can be massaged 18 a little bit. But what we would like is language that 19 states that no practitioner or no pharmacist has to 20 check the database. So they would not be subject to 21 civil liability if they do or if they do not. Because 22 it's unfortunate, but as major corporations, I 23 remember companies see lawsuits on both sides; you 24 checked the database or you didn't check the database. 25 And so from that perspective, we would like some type

49 1 of language in there -- some type of language in there 2 to protect us. 3 Oh, one other -- my last and final 4 point, the Bill deals with Internet access to the 5 database, and I would state that many of our member 6 companies do not allow Internet access in our 7 particular pharmacies, because of HIPAA reasons and 8 other security and data breach reasons. The Virginia 9 program was compromised in 2009. All the prescription 10 records were stolen or taken through theft purposes, 11 and there was a ransom note to the state for 12 $10 million. And to the best of my knowledge, they 13 have not found the person that was involved in that 14 data breach at this time. So from our perspective, we 15 have some concerns. 16 But we do have, as opposed to Internet 17 services in our pharmacies, intranet services, which 18 are a computer-based system that we control in our own 19 chains that allows our pharmacists to tap into 20 prescription monitoring programs, but it's not what 21 you would call true Internet. It's called an 22 intranet. And we would ask that the Committee 23 consider that as part of what you would say is 24 Internet. 25 As far as online access, the Bill can

50 1 be interpreted as that you would have to have the 2 database open at all times that the pharmacy is 3 dispensing prescriptions, and, again, that represents 4 a problem because most of the pharmacy systems, 5 independent and chain, have some sort of a time-out 6 system for HIPAA, because there is patient information 7 there. After 15 minutes, typically, 20 minutes, 8 depending on the individual company, that database 9 will shut down -- or the system will shut it down, 10 because there's PHI that is exposed in that period of 11 time. 12 So we would ask, as you just stated, 13 that when there's a need, the practitioner or the 14 pharmacist has a need to check the database, exactly 15 how the system operates, and not that it be open for 16 the entire time the pharmacy is open. 17 And, again, I thank you for allowing 18 comments, and, again, from the Pennsylvania 19 Association of Chain Drug Stores, we look forward to 20 working with the committee on this particular 21 legislation. 22 CHAIRMAN DiGIROLAMO: Okay, Janet and Patty, 23 thank you so much for your testimony. I can assure 24 you we are still working the details. You know, we're 25 going to listen to your concerns and your comments and

51 1 take them under consideration. Again, we're still 2 trying to work out the details on the Bill. So thank 3 you for being here today and sharing your testimony. 4 I would also like to recognize Matt 5 Franchak, who is here from -- he's the Chief of Staff 6 of Senator Mike Stack's office, and Senator Stack will 7 be introducing the identical Bill over in the Senate. 8 So, Matt, great to have you here today. 9 Next we have a panel. We have Tony 10 Marcocci, who is a detective from the Narcotics 11 Division of Westmoreland District Attorney's Office. 12 Tony. And also Tom Plaitano, who is the Project 13 Director of MedTech Rehabilitation and Chairman of the 14 Westmoreland County Criminal Justice Advisory Board 15 Jail Diversionary Program. 16 Gentlemen, welcome, and you can begin 17 your testimony whenever you're ready. 18 MR. PLAITANO: Good morning. Mr. Chairman, 19 Members of the Committee, I would like to initially 20 apologize for reading my testimony, but I'm somewhat 21 passionate about this issue, and I wanted to stay 22 focused. 23 We have passed around some photographs 24 depicting some prescription medications that were 25 found by the Coroner. We also provided you with a

52 1 photograph of an ad from a pharmacy -- a pain 2 clinic -- I'm sorry -- in Florida, advertising for 3 out-of-state people and providing reimbursement for 4 pick-up and delivery from the airport and bus station, 5 and, also, $25 off your first visit with the ad. 6 The fact that we are discussing this 7 issue confirms that we have a prescription drug 8 problem in Pennsylvania. This problem has no 9 socio-economic bias, and it is affecting all age 10 groups. The greatest impact is not only on the adult 11 end user, or some may say abuser, it is our youth, the 12 must vulnerable victim of this epidemic. 13 This is very important, and I think 14 that other people have mentioned this today, but it 15 absolutely is true. Pills are the new drug of choice 16 of our kids. A recent survey showed that children 12 17 years old and older are abusing prescription drugs at 18 a greater rate than cocaine, heroin, hallucinogens, 19 and methamphetamine combined. Only marijuana is 20 abused more commonly. Shockingly, every day 7,000 21 children, 12 and older, abuse prescription narcotics 22 for the first time. 23 From January to June of 2010, 24 Pennsylvania ranked seventh out of all states in doses 25 of Oxycodone dispensed. Now, something that's really

53 1 interesting is Ohio was second. 2 West Virginia has a database, and what 3 we are seeing is that people are coming from out of 4 state here, because we do not have a database. 5 Florida dispensed in the double-digit millions of 6 prescriptions at the same time. When they were going 7 through their argument over the prescription drug 8 database, they are paying for the fact they did not 9 have one five years ago. And the expense is enormous 10 to try to fix the problem down there. 11 This is the new crack epidemic, except 12 this is far worse. These drugs are more easily 13 obtained, the supply is seemingly endless, and our 14 youth falsely believes that prescription narcotics are 15 safer alternatives to illicit drugs. 16 Something that's really scary is that 17 all of these drugs are not coming from outside the 18 home or the family. In a recent study of youths aged 19 12 to 17 years old, 55 percent of those youths 20 obtained the drugs from a relative or friend for free. 21 Now, when I say "free", they didn't pay for it, but 22 something I think in this budgetary concern that we 23 have today, they are being paid for. 24 I've been a practicing lawyer for 22 25 years in Westmoreland County, primarily handling

54 1 Workers' Compensation, auto accidents, and Disability. 2 A large majority of these drugs are being paid for by 3 Workers' Compensation, auto accident insurance, and 4 Medicare and Medicaid. So there is -- although people 5 are using the drugs and some are paying cash, and some 6 are diverting them for free, they are being paid for. 7 And some were from the legal distribution of these 8 drugs to the illicit use of these drugs, that monetary 9 amount is changing hands. 10 The story of the typical addict is also 11 somewhat unique. Many start as legitimate injured 12 individuals that are seeking medical treatment for 13 pain. They are unaware of the dangers of prescription 14 pain medication, sleep aids, and muscle relaxers. 15 Many, when they cannot find a quick solution for the 16 pain, they seek several doctors or specialists to 17 determine that they have a problem. Once this is 18 determined that they are starting to have an addiction 19 problem, most of the legitimate doctors, 20 unfortunately, have choices of either reducing the 21 amount or discharging them as a patient or stopping 22 the prescription of these medications. And the 23 problem with that is that once these people are 24 addicted, they're not going to stay with the doctor 25 and be voluntarily weaned. They're going to leave and

55 1 look for another physician. 2 Also, one of the greatest concerns of 3 something that I see now -- and I spoke with members 4 of the DEA before coming here today -- the amount of 5 distribution of pain medication from the provider, not 6 pharmacies, has increased tremendously. I was 7 actually unaware that providers were actually 8 dispensing medications right from their office, not 9 writing a script and sending that script to a 10 pharmacy. So that is -- that is a problem, and it's a 11 great concern of the DEA. 12 Typically, when a doctor does, in fact, 13 discharge a patient or stop prescribing, this drives 14 the patient to the street, or worse, the well-known 15 pill mill down the street or to another state. 16 A recent hospital study proved that in 17 states that had a monitoring system, patients received 18 more appropriate care. In the study, 61 percent of 19 emergency room patients received fewer or no opiate 20 pain medication because they were already taking it 21 from another source. But most interestingly, in terms 22 of the concern that some people have about legitimate 23 pain patients needing medication and not getting it, 24 39 percent of the patients in the emergency room 25 received more opiate medication than previously

56 1 planned, because the physician could confirm that the 2 patient did not have a history of controlled substance 3 use. 4 I think that this will actually stop 5 some of the stigma for the young person or the person 6 that comes in that the doctor may believe is 7 doctor-shopping. 8 In speaking with law enforcement, it's 9 become common for an out-of-state person to hand a 10 Pennsylvania pharmacy a prescription from a Florida 11 physician. How is this possible, you ask? It's 12 possible because it's not currently illegal. 13 Currently, 35 states have prescription drug-monitoring 14 programs. Another 11 have legislation planning it. 15 As a result, many drug seekers are flooding 16 Pennsylvania due to the ease in obtaining prescription 17 drugs here. 18 Looking at statistics on where people 19 get these drugs, this is a problem that's beyond the 20 scope of traditional law enforcement. In speaking 21 with representatives of the DEA, the current system in 22 Pennsylvania is so archaic that they are at least five 23 months behind on reports of large-scale drug shipments 24 to providers. Currently, agents are forced to 25 manually go through filled prescriptions in each

57 1 pharmacy and look for irregularities. 2 I actually find it ironic that I can go 3 to a pharmacy and pick up Oxycontin without a 4 prescription, but I can't buy Sudafed D without giving 5 my driver's license. 6 In closing, last week I was contacted 7 by a mother and father who I have known for a lot of 8 years. Their 22-year-old daughter died in her sleep 9 from what was thought to be a cerebral hemorrhage. 10 They were deeply distraught, and they blamed 11 themselves for not seeking more invasive medical care. 12 The father actually told me that he told his daughter 13 to take the medication the doctor had given and to go 14 upstairs and go to bed, and he would wake her up in 15 the morning. When they went to wake her up, she had 16 died in her sleep. 17 They were deeply concerned as to what 18 had occurred and had believed that possibly there was 19 some doctor error in regards to missing some type of 20 diagnosis. That she was relatively healthy, although 21 for the -- she was suffering from recurrent migraine 22 headaches. The most interesting thing was she was a 23 Westmoreland County prison guard, and she was 24 drug-tested at work. 25 I asked for the autopsy report several

58 1 weeks ago, and yesterday I received it in the mail and 2 was looking forward to see if there was a problem. 3 The cause of death was acute drug toxicity. No 4 illegal drugs were found in her system, and each of 5 the drugs that were in her system were legally 6 prescribed by a physician. I cannot help but believe 7 that if there was a prescription drug-monitoring 8 program in Pennsylvania, that this young lady might be 9 alive today. Thank you. 10 DETECTIVE MARCOCCI: Good morning, Mr. 11 Chairman, Committee Members. First of all, I'd like 12 to tell you it's an honor to be here before you to 13 talk to you today about the prescription drug problem 14 that I see on our streets daily in Westmoreland 15 County. I'm a narcotics detective in Westmoreland 16 County and have been working narcotics for 17 approximately 26 years. 18 Addressing the problems of drug use in 19 our county has presented quite a challenge over the 20 years. We thought that through public education, drug 21 awareness programs, and dedicated police work, we 22 could curtail or eliminate the drug problem in our 23 county. We were wrong. 24 Oftentimes people believe that this is 25 just an inner-city problem, but it's not. People

59 1 believe that it's a problem only with our youth, but, 2 once again, it's not. 3 If you're not familiar with 4 Westmoreland County, we're a typical rural suburban 5 county; population of about 400,000. And no family is 6 immune. In Westmoreland County, we have had 57 7 overdoses resulting in death in the year 2010, all of 8 which were between the ages of 19 and 71. 31 were 9 male, 26 were female. The photographs that you had 10 saw earlier about -- with the prescription bottles, 11 those were recovered at the 57 overdose scenes. You 12 can see the volumes of prescription pills prescribed. 13 And if that number isn't shocking 14 enough, over the past three years in Westmoreland 15 County, we have averaged 560 individuals who have 16 overdosed and been taken to local hospital emergency 17 rooms. These are only individuals who have overdosed 18 on Schedule II and Schedule III controlled substances, 19 not counting heroin or Schedule I. These substances 20 were all prescribed medications, both legally and 21 illegally obtained. 22 I would like to tell you that the 23 individuals have overdosed on specific medications, 24 but that's not the case. In most of these instances, 25 a variety of medications were found to have been

60 1 consumed by these individuals. 2 Law enforcement is aware of the 3 monumental issues facing us in the future as it 4 relates to our growing prescription drug abuse 5 problem. Because of the growing problem with Schedule 6 I and Schedule II abuse, we are seeing the abuse of 7 Schedule III and IV controlled substances to help 8 alleviate the symptoms of withdrawal. Currently, the 9 Attorney General's office data bank only pertains to 10 Schedule II controlled substances, but we believe that 11 at least Schedule III and IV should be monitored by 12 law enforcement also. 13 A prescription-monitoring program is 14 the vehicle needed by us in law enforcement to 15 assist -- to identify these individuals who have 16 problems with addiction and individuals who use 17 diversion to obtain these medications. This program 18 should be kept and maintained by an agency such as the 19 Pennsylvania Attorney General's Office so that the 20 information can by disseminated through local law 21 enforcement. Furthermore, local law enforcement 22 should not have to have any undue restrictions placed 23 upon them in obtaining this information in attempting 24 to ensure the safety of the community. 25 Also, I passed around a document which

61 1 outlines the overdoses we have seen in Westmoreland 2 County for the year 2010 and the various prescription 3 drugs that were identified in the individual systems. 4 Thank you. 5 CHAIRMAN DiGIROLAMO: Tom and Tony, thank 6 you very much for your testimony today. 7 And in my District we have a -- a 8 really -- a very good D.A.R.E. program for all the 9 elementary schools and the middle schools. And I try 10 to attend the D.A.R.E. graduations as much as I can, 11 and many times a lot of the parents are there. And 12 what our police officers are teaching the children is 13 about the dangers of prescription drugs. And what I 14 like to tell the parents is that, you know, in our 15 community, there's a new drug dealer in town, and it's 16 the medicine cabinet in your own home is the new drug 17 dealer in town. 18 And we have started in Bucks County -- 19 I know where I'm at, the Bensalem Police Department 20 have started a prescription drug turn-back program, 21 where you're able to come into the police department 22 24 hours a day and in a safe, secure location put your 23 unused prescription medications or other drugs that 24 you don't want in your homes. So, I mean, I think 25 that's a really -- also an important tool.

62 1 So, again, I really appreciate your 2 testimony. 3 MR. PLAITANO: Many parents will lock the 4 liquor cabinet, but not lock the medicine cabinet, and 5 that's also a concern. 6 CHAIRMAN DiGIROLAMO: Okay. Thank you 7 again. And next we have Martha King, from the 8 Awareness Group of Hanover, who's on the Board of 9 Directors. 10 Martha, welcome, and you can begin your 11 testimony whenever you're ready. 12 MS. KING: Thank you. I need to get closer. 13 All my references are in your packages, so. 14 Good morning, Mr. Chairman and 15 Distinguished Members. I'm honored to be here. My 16 name is Martha King. I'm on the Board of Directors of 17 a non-profit organization, Hanover, Pennsylvania, the 18 Awareness Group of Hanover, and also a Board member of 19 Pennsylvania Parent Advisory Council. Thank you for 20 the opportunity to appear before you. 21 A new danger is lurking in many homes 22 throughout our communities, states, and across the 23 nation. It is dangerous like an unattended weapon. 24 Incidents of its abuse are greater than those of the 25 five leading illicit drugs combined. It's not alcohol

63 1 or marijuana or even cocaine. The culprit is 2 prescription medication, a major public health -- an 3 epidemic. 4 Our nation is very obsessed with 5 medications, and because of it, our homes become candy 6 stores. Storing unneeded medicines in our homes or 7 disposal of unattended medicines in trash contributes 8 to the risk of accidental poisons, abuse, and 9 diversions. 10 As a mother of a loved one with a 11 terrible disease called addiction, who started with 12 marijuana, alcohol, and heroin and used prescription 13 drugs for non-medical purposes, I know very well 14 first-hand. 15 Prescription drug abuse is the fastest 16 growing drug problem in our country. The National 17 Survey on Drug Use and Health reports that in 2000, 18 3.8 million people aged 12 and older reported the 19 current nonuse [sic] of medication abuse drug [sic]. 20 In 2006, that figure increased more than 84 percent to 21 7 million Americans, with the misuse of pain relievers 22 representing three-quarters of the overall problem. 23 In 2009, the survey showed that nearly 24 one-third of people aged 12 and older, who used drugs 25 for the first time, began using a prescription drug

64 1 for non-purpose medical [sic]. 2 The U.S. Drug Enforcement Agency 3 reports that in 2009 there were 7 million Americans 4 abusing prescription pain and anxiety drugs, up 13 5 percent from the prior year, and the agency expects 6 the 2010 numbers to show another double-digit 7 increase. 8 Because their parents are taking them, 9 and they are prescribed by doctors, our youth thinks 10 the drugs are safer. In 2009, the National Survey of 11 America Attitude on Substance Abuse found that nearly 12 one in five teens, 4.7 million, can get prescription 13 drugs in order to get high in one hour. And more than 14 1/13th [sic], 8.7 million, can get prescription drugs 15 within a day. 16 The Pennsylvania Youth Survey reported 17 that in 2009, 14.8 percent of twelfth graders have 18 misused prescription pain relievers at least once in 19 their lifetimes, and overall 5 percent of students 20 surveyed in the state reported misusing prescription 21 pain relievers at least once in the last 30 days. 22 I am optimistic that through a 23 combination of law enforcement and education of 24 healthcare professionals and the public, we can 25 greatly reduce the terrible toll that prescription

65 1 drug abuse is taking on our state and our nation. As 2 leaders, it is our job to work to educate our 3 community members on the harms of prescription drug 4 abuse and enact programs that can help get some of 5 these harmful drugs off the streets. 6 In an effort to stop the abuse and 7 create awareness, our organization joined the nation 8 last year on September 25th, 2010. We held the first 9 medication take-back event. This was part of a 10 national event intended to control dangerous 11 medications, prescriptions, and to create awareness in 12 local communities. 13 By all measures, the event was 14 successful. Over 200 people showed up at our event. 15 In four-hours' time, we collected 462 pounds of 16 medications. A grand total for the state of 17 5,951 pounds. We held the second one this year, 18 April 30th. We collected 322 pounds. A grand total 19 for the state of 20,449 pounds. 20 Despite this success, there is still a 21 lot of work to do, especially in the area of 22 awareness. 23 Community involvement is an important 24 ongoing tool to reduce prescription drug abuse. 25 However, we cannot do it alone. We must work together

66 1 to enact legislation that will limit the diversion of 2 the drugs and keep them out of the hands of those who 3 are not using them under the prescription [sic] for 4 medical professional. One way we can do this, by 5 enhancing our current prescription drug-monitoring 6 program, PDMP. To date, 48 states have enacted 7 legislation creating PDMP's. 35 of those programs are 8 currently operating, and two states, Missouri and New 9 Hampshire, have pending legislation. 10 Several studies have examined the 11 PDMP's effects on overall state rates regarding 12 prescription drugs. The U.S. Department of Justice, 13 Office of Justice Programs, contracted with Simeone 14 Associates to evaluate PDMP's impact on the supply and 15 abuse of controlled substances. At the time of the 16 study, 20 states have implemented systems to monitor 17 the prescriptions and sale of drugs identified as 18 controlled substances by the DEA. 19 The results of the study indicate that 20 the per-capita supply of prescription pain relievers 21 and stimulants increased substantially over the 1993 22 to 2003 period, and that this growth was much more 23 pronounced in states that did not have PDMP's than in 24 states that did have PDMP's. 25 The analysis also show -- found that

67 1 PDMP's were associated with lower rates of substance 2 abuse treatment admissions. 3 A later study using Poison Control 4 Center contacts in states with and without PDMP's 5 found that PDMP's were associated with slower rates of 6 increase in abuse/misuse over time. 7 According to the Alliance of States 8 with Prescription Monitoring Program, there are 48,730 9 practitioners/prescribers and 2,950 pharmacies in 10 Pennsylvania. While our state is listed as having a 11 current prescription-monitoring program, what many may 12 not realize, that the current program is only 13 accessible by law enforcement and only monitors 14 Schedule II drugs. Enhancements needs to be made to 15 make it a fully functioning program. 16 HB 1651 would allow dispensers to log 17 each filled prescription into a state database to help 18 prevent abusers from obtaining prescriptions from 19 multiple doctors. Enhancing our current program would 20 provide data to public health and law enforcement 21 communities, upon request, and assist health 22 professionals to identify those who may be addicted to 23 prescription medications so they can receive proper 24 treatment. 25 HB 1651 would require that certain

68 1 individuals present specific identification in 2 obtaining prescriptions. This requirement will 3 provide safeguards to protect patient confidentiality 4 and access to prescriptions, while providing a more 5 technologically advanced way to track criminal 6 activity. 7 Enacting a comprehensive PDMP would not 8 interfere with the appropriate use of medicine. The 9 goal of the database is to reduce the diversion and 10 misuse of powerful prescription drugs, enables 11 informed and responsible prescribing by practitioners. 12 As a state, we must take action to 13 balance the lifesaving benefits these medications 14 offer to legitimate patients and the risks that they 15 pose when diverted for non-medical use and abuse. 16 Prescription drug diversion hurts the State of 17 Pennsylvania in loss of lives, increased crime, 18 addiction, increased healthcare costs, medical 19 expenses, and Medicaid fraud, which all citizens 20 ultimately pay. 21 I urge you to please support HB 1651. 22 The families of Pennsylvania are counting on your 23 support to help prevent prescription drug abuse. 24 Thank you for your time and allowing me to speak. 25 CHAIRMAN DiGIROLAMO: Martha, thank you very

69 1 much for being here today and for your testimony. 2 For our last person that's going to 3 testify today, I'm going to let Representative Doyle 4 Heffley introduce their -- a constituent of his. 5 Representative. 6 REPRESENTATIVE HEFFLEY: Yeah. I'd like to 7 recognize a few of my constituents who have come down 8 today, who have all been impacted by prescription 9 drugs on the streets. Lisa Chiver (phonetic), Wendy 10 Grinsky (phonetic), and testifying today will be Karen 11 Flexer and her husband Randy. If you could, please. 12 And thank you for your courage and leading on this 13 issue. 14 MS. FLEXER: Good morning. 15 CHAIRMAN DiGIROLAMO: Good morning and 16 welcome. 17 MS. FLEXER: I would like to tell you why 18 I'm here and why I think the passage of this Bill is 19 important. 20 My life changed forever on April 23rd, 21 2011, when I found my 20-year-old son Brett had passed 22 away in his sleep. Before I talk about how he died, 23 let me tell you about how he lived. 24 Brett was an active and fun-loving boy. 25 He loved sports and outdoor activities. At a young

70 1 age, he became interested in football and wrestling. 2 Wrestling soon became his passion. He became what 3 might be referred to as a gym rat. He loved working 4 out and was obsessed with his diet and physical 5 fitness. His hard work paid off as he became a very 6 successful wrestler in high school. My husband and I 7 and my two other sons, Derrick and Dillon, spent many 8 hours at tournaments and matches supporting Brett and 9 his teammates. His free time was spent either at the 10 gym working out or running, whether it be outside or 11 on the treadmill in our house. There were many 12 mornings that I was wakened to the sound of him 13 getting in an early-morning workout on the treadmill 14 before school. 15 Brett was also a good student. I never 16 had to worry about him bringing home a bad report 17 card. His hard work, both in the classroom and in the 18 gym, paid off when he was accepted and agreed to 19 attend and wrestle at Lycoming College. This was not 20 an easy choice for him, because he had received 21 letters of interest from many colleges. 22 His life was falling into place so 23 effortlessly. He was in college pursuing his dream of 24 criminal justice. He even started talking about going 25 for a double major as his interest in psychology

71 1 increased. He was a member of the wrestling team, and 2 his long-time girlfriend was also enrolled in college 3 with him. When he wasn't in class, he could be found 4 at the college gym motivating friends to work out. 5 The end of the semester was near, and 6 we were looking forward to having him home on Easter 7 break. I brought him home Easter Thursday, and on 8 Good Friday, he went out with some of his friends. 9 They had some drinks together, and by all accounts, 10 they were having a good time. 11 Then he did something that was so out 12 of character for him that I still can't comprehend it. 13 One of the people at the party offered him a pill, and 14 he took it. The pill he took was Opana. It is 15 related to Morphine in the same fashion that Oxycodone 16 is to Codeine. Opana is approximately six to eight 17 times more potent than Morphine. It is a controlled 18 substance that when taken with alcohol causes 19 respiratory failure. He was told that the pill he was 20 given was Percocet. 21 Saturday is still a blur. Unable to 22 wake him, calling an ambulance, pronouncing him dead 23 in our home were just some of the horrors that our 24 family was put through. We found out that he only 25 took half a pill, but by taking half of this pill, it

72 1 was more damaging because it is a time-release 2 medication. 3 These young adults are taking these 4 medications and have no idea how they work or the 5 effect it has on their bodies. 6 This one lapse of judgment, whether 7 through peer pressure or cloudy judgment through 8 alcohol consumption, had catastrophic consequences. 9 My athletically-gifted son, a physical fitness 10 fanatic, who was never in trouble, was not a drug 11 user, and, quite simply put, was a good kid, paid the 12 ultimate price for one bad decision; a bad decision 13 that affected his family as well, as we have to live 14 with his loss the rest of our lives. It is my hope 15 that no family has to go through what we have gone 16 through. 17 The reason I come before you today to 18 support this Bill, this legislation would go a long 19 way in establishing a traceable trail in suspected 20 abuse of prescription drug dispensing, if allowed. 21 Under 2704(c), "Purpose", it clearly states that the 22 purpose in obtaining the data as described in the 23 section regarding every prescription of a controlled 24 substance dispensed in the Commonwealth, or any 25 person, other than an inpatient in a licensed

73 1 healthcare facility or by a hospice care provider. By 2 providing more accountability to the dispensing party, 3 it will help prevent prescription drugs from being 4 provided under fraudulent circumstances. It would 5 make tracking down abusers easier for law enforcement. 6 Section 2705 titled "Requirements for 7 Pharmaceutical Accountability Monitoring System" deals 8 with the dispenser's responsibility. This is all good 9 information that, when analyzed correctly, could be 10 useful in spotting abusers. 11 The proposed legislation would be 12 beneficial to law enforcement, making it easier to 13 track potential abusers through the database 14 established under the pharmaceutical accountability 15 monitoring system. 16 You may ask why this legislation 17 concerns me. It is my belief that if this law were in 18 place in April of this year, my son would still be 19 here today. By making pharmaceutical dispensers more 20 accountable, it would reduce the amount of 21 prescription drugs that are being wrongfully 22 prescribed and abused. Accountability has to start 23 somewhere. Thank you. 24 CHAIRMAN DiGIROLAMO: Okay. Mr. and 25 Mrs. Flexer, thank you so much for being here today

74 1 and sharing your story with us. 2 MS. FLEXER: Thank you. 3 CHAIRMAN DiGIROLAMO: I think it's really 4 important that we hear these types of stories as we 5 proceed to let everyone know how important this 6 legislation is. So thank you so much for your courage 7 to be here today and share your pain with us. 8 With that, we have a little bit of 9 time, and I might open it up to some of the members, 10 if they have any comments or questions. 11 Representative Cohen first. 12 CHAIRMAN COHEN: This was certainly very, 13 very moving testimony today. We certainly learned 14 that this is an important problem facing us in 15 Pennsylvania and that we ought to do something about 16 it. 17 I would like to ask that Patricia Epple 18 of the pharmacists -- you spoke in some detail 19 about -- about the needs of pharmacists to have some 20 phase-in period so they -- so they could be up -- so 21 they could master the mechanics and technological 22 skills and software of complying with this 23 legislation. 24 Are you aware of what's happening in 25 other states?

75 1 MS. EPPLE: Yes. And I do believe in some 2 of those states there's been a phase-in period -- 3 maybe, actually, Janet could speak to that a little 4 bit better than I could. 5 But I know from the challenges that 6 both chains and independent pharmacies have, that they 7 have to make some modification. I think once it's up 8 and running -- and I think that if we can just have a 9 time period where maybe some of those penalties aren't 10 assessed as we bring on board different pharmacies was 11 sort of what we were looking at. 12 Janet, I don't know, can you talk? 13 MS. HART: Yes. There are typically 14 phase-in periods, and they run anywhere from six 15 months to a year. And that's because there's a lot of 16 involvement on both ends, from the vendor that the 17 state would choose to implement the program and from 18 the pharmacy perspective. 19 And to sort of put it, Pat, for you to 20 better understand it, depending on the number of 21 stores that a chain store would have -- and here in 22 Pennsylvania, Rite Aid operates over 500 pharmacies. 23 So what would happen in that case, right now, we're 24 sending prescription data for C-II's, which is a 25 limited number of what you're encompassing here.

76 1 What we would have to do is test with 2 your providers as far as the amount of data that we 3 would be submitting on a weekly basis, or whatever the 4 basis would be. Because in many states what's 5 happened is the program can't accept the data file 6 that large, and then we have to tweak it, and we have 7 to manage it and go back and forth a few times, change 8 our programming to be able to get the site to accept 9 that amount of data. So it's -- it's on both sides of 10 it. 11 It's also as far from -- when we test 12 one of these data elements in any of our systems -- 13 and that's an independent or chain system -- it 14 doesn't just impact one part of the dispensing, but it 15 impacts what happens to that prescription business if 16 it's processed through and how the data goes to you. 17 So what you really have to do is test 18 that part of the process to make sure it's not 19 impacted with it. 20 MS. EPPLE: And to just piggyback on that, 21 some of our pharmacies, I imagine, do not have the 22 latest version of the software that their vendor might 23 offer, which would meet the current ASAP standards. 24 They would need to upgrade to that. So that can't 25 always just happen overnight. They have to schedule

77 1 it, and then they have to work with it and test it. 2 So that's why the time request. 3 CHAIRMAN COHEN: Okay. It sounds like a 4 reasonable request to make. Thank you very much. 5 MS. EPPLE: Thank you. 6 MS. HART: Thank you. 7 CHAIRMAN DiGIROLAMO: Representative Helm. 8 REPRESENTATIVE HELM: Thank you. I'd like 9 to thank everyone for their wonderful testimony. I 10 think everyone's testimony greatly supports this House 11 Bill 1651. 12 But I just have a general question. 13 Pat Epple actually brought up the subject, and I don't 14 know who is to answer it. But you talked about the 15 mail order pharmacies. I -- I think that's something 16 we have to figure out how to handle it. I thought if 17 anybody here has any more suggestions -- 18 CHAIRMAN DiGIROLAMO: Maybe we can ask 19 Sherry Green to come up and ask what some of the other 20 states are doing. 21 MS. GREEN: Mail order pharmacies is a major 22 issue in all the states' PMP's. Now, there is a 23 provision. You do have language in this Bill which 24 parallels the Bill that is in the Commonwealth of 25 Kentucky. And what you require in this Bill is that

78 1 prescriptions that are dispensed within the state or 2 dispensed to an address in the Commonwealth, and that 3 is the exact language that's used in the Commonwealth 4 of Kentucky, to also bring in out-of-state 5 non-residential pharmacies. So I know that has worked 6 in their particular instance, and other states are 7 considering language similar to that. So I have noted 8 you do have that particular language. 9 Now, I'm not an expert on Pennsylvania 10 law, so you would have to have appropriate counsel in 11 the state determine if, under the laws in this 12 Commonwealth, that would cover non-residential 13 pharmacies. But I do know it is similar to the 14 language in the Kentucky law. 15 CHAIRMAN DiGIROLAMO: And Mike Ashburn, 16 maybe you'd like to comment on that also. 17 DR. ASHBURN: Actually, I agree with the 18 interpretation. The draft, as written, appears to 19 contemplate including mail order pharmacy 20 prescriptions as part of the reporting database. Now, 21 whether or not that works from a legal point of view 22 is yet to be determined. But the -- but the law, as 23 written, did contemplate including mail order 24 pharmacies. 25 CHAIRMAN DiGIROLAMO: Okay. Patty?

79 1 MS. EPPLE: Can I just read you the language 2 that it says right here? It says that not -- that, 3 "By all professionals licensed to prescribe or 4 dispense such substance in this Commonwealth, 5 including, but not limited to, the practitioner or 6 pharmacist or to dispense to others within this 7 Commonwealth by a pharmacy that has obtained a 8 license, permit, or other authorization to operate by 9 the Pennsylvania Board of Pharmacy." 10 No mail order pharmacy obtains a 11 license from Pennsylvania State Board of Pharmacy. If 12 they are licensed -- if they are working out of state, 13 they don't have a license to operate in Pennsylvania. 14 CHAIRMAN DiGIROLAMO: Thank you, Patty. 15 And, again, we're working out the details on this, and 16 I think that's a really important issue that we have 17 to take under consideration. 18 REPRESENTATIVE HELM: I just have another 19 question for Janet Hart. You said -- maybe I didn't 20 understand this right. But you said about the name of 21 the pharmacist is required for the database. And did 22 you not want that to be required? 23 MS. HART: Yes. The name of the pharmacist 24 should not be reported to the prescription monitoring 25 program. You already have the identification of the

80 1 pharmacy. You have a pharmacy, it has a specific DEA 2 number, you have the DEA number of a physician. You 3 already have qualifiers as far as where that data is 4 coming from. 5 If, from an investigative standpoint, 6 there is an issue or they want to know the individual 7 pharmacy, pharmacies do have that record as part of 8 their dispensing system. The law enforcement, or 9 whoever is looking for it, could just simply ask. But 10 that type of data is not typical when you fill a 11 prescription. That full name, you know, is available 12 as part of the dispensing system. 13 REPRESENTATIVE HELM: All right. So we can 14 track it back. We will know who it is if we want to 15 know. 16 MS. HART: You will be able to know that. 17 As part of a pharmacy, the dispensing process 18 identifies the dispensing pharmacist. 19 REPRESENTATIVE HELM: Okay, thank you. 20 MS. HART: You're welcome. 21 CHAIRMAN DiGIROLAMO: Representative 22 DeLissio. 23 REPRESENTATIVE DELISSIO: Thank you. My 24 question is for Tom Plaitano. He had made a comment 25 that some of the doctors are dispensing from their

81 1 office, and I was curious if that -- if there is any 2 information as to whether they're dispensing as a 3 result of samples, or are they actually writing 4 scripts in some way and then having those scripts 5 filled and then dispensing. Where does their supply 6 come from? 7 MR. PLAITANO: Ma'am, we're seeing this from 8 the -- most typically, the Urgent Care Centers. In 9 our area, there's a large number of MedExpresses. 10 What's interesting in those facilities are that the 11 doctors themselves, the doctors have a DEA number 12 assigned to them for their location, so if they have a 13 family office and then an office at MedExpress, they 14 have two DEA numbers. 15 You can pick up the phone -- Detective 16 Marcocci and I were speaking about this, this morning. 17 And the DEA is very concerned about this issue going 18 on right now. There are wholesale pharmacies that a 19 facility such as MedExpress, a plastic surgery center, 20 a pain center can pick up the phone and order 3,000 21 Xanax from a wholesale pharmacy and have them mailed 22 to the facility. The doctor in the medical record can 23 write in the report that they are dispensing that 24 medication. It's not -- it's not dispensed in the 25 same manner as it is from a pharmacy. And right now,

82 1 they're not being tracked. And that's a big concern. 2 The -- when I mentioned in my testimony 3 that there's a five-month delay, the representative 4 from the DEA indicated that it's about five months 5 from the time he receives the information from the 6 wholesale pharmacy of large-scale drug shipments to a 7 facility. 8 So let's say an Urgent Care Center, the 9 secretary could pick up the phone and call -- you 10 know, call a wholesale pharmacy, order a large number 11 of Xanax. Those Xanax are sent to the facility, and 12 the only record is from the wholesale pharmacy to the 13 facility. So that is a concern. 14 REPRESENTATIVE DELISSIO: So does this 15 database -- and I apologize; I got here a little late. 16 Does this database then account for the wholesalers -- 17 MR. PLAITANO: There is some language -- 18 REPRESENTATIVE DELISSIO: -- in addition to 19 the urgent clinic that you're describing? 20 MR. PLAITANO: I actually had that question 21 in the sense of the description of dispensing. 22 There's language in there discussing dispensing, and I 23 didn't see the definition to include or be more 24 precise in the sense of does that mean is it dispensed 25 by that provider. I see that it excludes

83 1 administered. 2 So if the physician -- and I think that 3 the thought process behind that is if the doctor gives 4 you an injection, that's something that's 5 administered. I'm not sure if "administered" would 6 mean to hand you that medication. It's not a sample. 7 Scheduled drugs can't be sampled. 8 REPRESENTATIVE DELISSIO: I didn't think so. 9 MR. PLAITANO: So what happens, they're 10 ordered and stored there. You know, they're also 11 concerned about it's only a matter of time before we 12 start seeing some brazen armed robberies or 13 business-type invasions on these facilities that are 14 storing large quantities of medications. 15 I also know that the defense attorneys 16 that I speak with that represent insurance companies 17 and Workers' Compensation are very concerned about 18 that, because, typically, what they're getting is two 19 bills. They're getting a bill from the physician and 20 then another company in the physician's office that's 21 dispensing the medications. 22 One other thing I was thinking in 23 regards to the tracking of the out of state -- the 24 mail order pharmacies, Pennsylvania currently does 25 track alcohol sales and cigarette sales by the

84 1 Internet and has been very aggressive in -- in 2 pursuing taxation that's avoided in that manner. And, 3 possibly, we could speak to somebody at the Department 4 of Revenue to see how they're able to track that and 5 figure out these locations. I do know that a lot of 6 those mail order alcohol dispensers and tobacco 7 dispensers will now no longer ship to Pennsylvania 8 because of being chased after the tax revenue. 9 REPRESENTATIVE DELISSIO: So I would think 10 that if this is part of the supply chain, if you will, 11 then the bill in some way should account for these -- 12 the supply, as well, in a database. Otherwise, we're 13 missing a big piece of it, and there's still an 14 underground, if you will, supplier, and not 15 monitored -- I shouldn't say underground. Not 16 monitored. Sounds like they're using a lot of 17 creative ways to do an end run-around of what we 18 traditionally think of as a doctor writing a script on 19 a pad, and you take it to the pharmacy, you get it 20 filled. 21 MR. PLAITANO: This is big business. With 22 the financial reward available, there are going to be 23 ways around this. I mean, this is -- you know, look 24 at the statistics in Florida. I mean, Pennsylvania 25 dispensed in six months of last year -- providers in

85 1 Pennsylvania. Not pharmacies. Providers dispensed 2 about 250,000 doses of Oxycodone, January to June. 3 That same time period, Florida dispensed -- I think 4 it's 10 million. And it's -- it's the revenue. 5 They're -- again, my contact in the DEA 6 indicated that they are seeing doctors in Pennsylvania 7 coming out of retirement and working at pain clinics. 8 And these aren't the legitimate pain clinics run by 9 anesthesiologists and performing injections under 10 fluoroscopy and a wide range of medications. These 11 are facilities that if you drive -- and Detective 12 Marcocci can speak to this -- drive through in the 13 morning, you will see a line out front of people lined 14 up waiting to get in. 15 REPRESENTATIVE DELISSIO: Thank you, Mr. 16 Chairman. 17 CHAIRMAN DiGIROLAMO: Okay, thank you. 18 Representative Heffley? 19 REPRESENTATIVE HEFFLEY: Yeah, I had a 20 question for -- for Pat Epple and Janet. Sorry to 21 make you get up again. 22 I have two questions. One, you had 23 said about the time frame to implement a program like 24 this. Obviously, we know these things take time, and 25 you had talked six months to a year. In your opinion,

86 1 or have you -- what would you need when this law is 2 enacted to make it happen faster? What do you need to 3 make it happen faster? 4 MS. HART: Well, I think from -- from the 5 chain perspective, a lot of our members have the 6 software in place. Some of the smaller members don't, 7 so they have to be able to purchase that and integrate 8 it into their pharmacy systems. And as Pat said, 9 there are different standards out there right now for 10 the prescription-monitoring programs throughout the 11 country. There's anything from an ASAP, American 12 Standard for Automation in Pharmacy, which is what 13 that stands for. There's a standard that some states 14 use, 1995, and the most current standard is a 2009, 15 4.1 standard. 16 So if a member company has the standard 17 or the configuration for the 1995, they would have to 18 configure their system to be able to go to that new 19 standard. And that -- that's not something that 20 happens quickly. 21 The reason that I say that is that the 22 newer standards have -- like when you type something 23 into a field -- let's say it's an NDC number or it's 24 any type of a number. That could have nine 25 characters. Okay? Like similar to a telephone

87 1 number. The newer standard may make that 11 2 characters. 3 So what has to happen is that 4 particular pharmacy has to redo that particular field, 5 change their configurations, make sure that it works 6 and it doesn't impact it. 7 That's why I say, you know, six -- six 8 months minimum for the pharmacies that have to come 9 along, not to mention that from Pat's members and our 10 members, it's going to be an expense to do that update 11 and do the testing of it. 12 MS. EPPLE: We had asked for a year time 13 frame. At least. And that's not that the system 14 couldn't be up and started and those people who are 15 using it could be on it. But that the penalty piece 16 of it isn't applied for that. Because I think some of 17 them -- for some pharmacies, it's going to take longer 18 than others. 19 REPRESENTATIVE HEFFLEY: Are there 20 particular standards or particular software or 21 programs that would be easier for the industry to work 22 with as you look into technologies to implement these? 23 MS. HART: I think if the state would be 24 looking to get grant money from the Federal 25 Government, Harold Rogers or some of the other NAMSDL

88 1 grants that are out there, you really have to use the 2 most current standard. It's just the one that I spoke 3 of; ASAP 2009, 4.1. I think that's part of the 4 requirement of getting grant money, which the majority 5 of states do for startup or for continued enhancements 6 of their program. 7 REPRESENTATIVE HEFFLEY: Thank you. Now, 8 the next question was more in the interim. Personal 9 story. I go to the pharmacist to get -- pick up cards 10 or whatever, and people behind the counter are 11 demanding -- or asking me, what am I going to do about 12 this problem; we have the continuous same people 13 filling prescriptions, and they're selling them in the 14 parking lot. And a lot of times they feel inhibited 15 to report any of this behavior under HIPAA 16 regulations. Now, in doing a little bit investigating 17 (inaudible) folks, I learned that if somebody is 18 selling drugs in the parking lot, it's not going to 19 interfere with HIPAA regulations. 20 What can we do to get that information 21 to the people that are concerned, that maybe want to 22 make an anonymous tip or call something in? Maybe the 23 employee. Not that it's their job. But if 24 somebody -- I mean, is there anything we can do to get 25 that message out to people to kind of give them

89 1 guidance on what the HIPAA regulations are a little 2 bit better? 3 MS. EPPLE: I think some -- you know, it's 4 definitely an education issue; that I had not heard 5 concerning the HIPAA. I would say I've also heard 6 from my pharmacists, is they just don't know sometimes 7 who to call, when to call, what's okay. So maybe we 8 need to develop a unified message with law enforcement 9 as to who they do reach out to and when they can and 10 when they can't. 11 And that's something we'd be eager to 12 do from our association. Because I do get questions 13 on that quite frequently. And they don't know what to 14 do. And, you know, I actually just had someone 15 yesterday call me and said that they had a physician 16 come into -- they had a prescription come into their 17 pharmacy written by a physician, who was a 18 pathologist, for some controlled substances, and they 19 questioned what -- you know, what could they do about 20 that, because they were highly suspicious why they 21 were doing it for a family member. 22 MS. HART: Another thing too that -- and I 23 agree with what Pat said. It all depends on the 24 individual jurisdictions too. Obviously, some things 25 in inner city, if you talk about a fraudulent

90 1 prescription, you're not going to have the same type 2 of police turnaround time as you may in some of the 3 more rural counties where it's a bigger issue. We see 4 that throughout the country from the major markets, 5 not just in Pennsylvania, that that's also an issue. 6 One of the other things that we know 7 for sure is that the Pharmacy Board that puts out a 8 newsletter on a quarterly basis, we might be able to 9 speak with them as far as one of their learning 10 modules or one of their learning articles to put that 11 out there in their -- one of their upcoming 12 newsletters. 13 REPRESENTATIVE HEFFLEY: All right. Thank 14 you. 15 CHAIRMAN DiGIROLAMO: Thank you. And maybe 16 just if I could ask one final question, and that's 17 going to be for Deb Beck. And, you know, we talked 18 about the importance of the treatment component and 19 the -- the education part. And maybe if you would 20 just comment for a couple minutes before we stop 21 about, you know, how important that's going to be as 22 far as your field goes. 23 MS. BECK: Thank you so much. I mean, the 24 Bill, as you have it drafted, models part of what 25 Sherry Green's organization is doing. It creates like

91 1 an intervention; the possibility to intervene, in 2 fact, in some of these tragedies we've heard about 3 today and get assessments and referral to treatment as 4 part of this. This is a -- this could be incredibly 5 lifesaving. 6 I am so excited about this legislation, 7 I can't stand it, because I think it's a prevention 8 tool, it's going to cut down on some access at the 9 front end. It's an intervention tool that will help 10 doctors do an even better job, because I'll know what 11 else I'm getting. Best of all, it's sets up referral 12 to treatment. If you don't do that, I'm going to come 13 back out and do it again. I'm going to come back out 14 and use again. 15 So I'm just really grateful for this. 16 I think this is a lifesaving piece of legislation. I 17 know once we get what I think -- hey, I should not be 18 for this. You know, bring me more patients. We need 19 more patients in the DNA field. We have so many 20 people coming in for help. We desperately need to cut 21 down on the supply of these addictive drugs, and this 22 legislation would do that. Thank you. 23 CHAIRMAN DiGIROLAMO: Thank you very much. 24 Well, I guess that concludes the hearing. We've got 25 to be up on the floor at 11:00, and I just want to

92 1 thank -- 2 (Discussion held off the record.) 3 CHAIRMAN DiGIROLAMO: Next week -- Melanie 4 just reminded me that we're going to have another 5 hearing next Thursday on the same issue. We've got a 6 lot of other people who wanted to testify. So those 7 of you who are interested, next Thursday -- what time, 8 Melanie? 9 (Discussion held off the record.) 10 CHAIRMAN DiGIROLAMO: 9:00 a.m. in G50, 11 which is right below us. 12 And, again, I want to thank everybody 13 for testifying, especially the parents that are here 14 today, for sharing your stories, your pain, and your 15 suffering with all of us. So thank you. 16 17 * * * * * 18 19 20 21 22 23 24 25

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