Tim Murphy

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, I yield to the gentleman from Wisconsin (Mr. Gallagher).

Mr. MURPHY of Pennsylvania. Mr. Speaker, I yield to the gentlewoman from Ohio (Ms. Kaptur) to talk about some of the issues dealing with substance abuse.

Mr. MURPHY of Pennsylvania. We have to make sure we have more border security so that we are intercepting these drugs as they come across the border. We need funding for the post offices because, in many cases, unwittingly, the letter carriers are the ones who are delivering to people's homes fentanyl and other drugs. In the incarceration system, we have to make sure we are testing inmates for the presence of drugs in their system during their incarceration. We can offer them medications which, upon discharge, actually block any effects of some of these drugs. We need to also make sure that Medicaid and other insurance companies' payments resume immediately upon release from their incarceration to prevent them from relapsing or returning to the drug culture. We also have to make sure we have solid data collection. In many cases, when we show the charts about death rates around the country, the charts may be grossly inaccurate. In many cases first responders, paramedics, and coroners do not keep accurate data on these rates. The persons themselves may not even be tested to see if they died from a drug overdose. There are several items in here listing what we can be doing here as a nation, and there are many more. The point is we have fallen short and we have seen some problems with this. There is more that we can do and we must do in order to save lives. I know I just have about 3 minutes left, Mr. Speaker, am I correct?

Mr. MURPHY of Pennsylvania. Mr. Speaker, I thank my colleague and friend for his dedication on this issue. And, yes, he is right: we have to cross party lines and work on this together. Mr. Speaker, I yield to the gentleman from Ohio (Mr. Chabot), another friend, who has seen these problems, as well, in his district and knows full well how these problems have merged well into the Ohio area, as it is an insidious problem.

Mr. MURPHY of Pennsylvania. Mr. Speaker, I appreciate the gentleman's comments and his dedication to helping his State of Washington. Mr. Speaker, I yield to the gentleman from Pennsylvania (Mr. Rothfus), whose district is just north of Pittsburgh, Pennsylvania, to talk about some of the problems, in his experience, and his thoughts about what we should be doing about substance abuse.

Mr. MURPHY of Pennsylvania. I thank the gentleman for his impassioned words and dedication here. I want to refer back to my map here a moment. Dr. Bucshon was referring to his district in southern Indiana here, which, on this 2014 map, was already showing high mortality rates for those who have drug overdoses. Look here in the State of Washington, also an area that, on this 2014 map, showed a lot of problems, and now the problem is getting worse. Mr. Speaker, I yield to the gentleman from Washington (Mr. Newhouse) to speak on this issue.

Mr. MURPHY of Pennsylvania. I thank the gentleman from Ohio. I want to next recognize the gentleman from Indiana (Mr. Bucshon). Certainly he sees this issue, too. As I mentioned before, one of the problems physicians have, if they do not know what kind of prescriptions that person is on, for example, a medical record may show if a person has an allergy to penicillin or something, but you may have no idea that that patient may, for example, be taking buprenorphine or methadone unless they tell you or you test for it. And as a surgeon, what happens when they go to get anesthesia and the complications come from that, but it is part of the reasons why we have to make sure that you as a physician have access to these records, things we can clean up. Mr. Speaker, I yield to the gentleman from Indiana (Mr. Bucshon).

Mr. MURPHY of Pennsylvania. I appreciate that. That is a problem we are going to have to fix in our committee. I want to call up the gentleman from Ohio (Mr. Johnson), eastern Ohio. Speaking of being able to jump across State lines and have prescriptions filled, minutes away from the Pennsylvania/West Virginia border, could travel down there, and also part of that deadly area along the Ohio Valley where so much of this is occurring. Mr. Speaker, I yield to Mr. Johnson.

Mr. MURPHY of Pennsylvania. But as the gentleman knows, that is data within the State, but across State lines, that data is still not populated.

Mr. MURPHY of Pennsylvania. Now, what if they wanted to pick up an opioid prescription? Do they have to show an ID? Are they required by law to have the same kind of restrictions?

Mr. MURPHY of Pennsylvania. As a pharmacist, when people come into the pharmacy, for example, if they want to get Sudafed, a cold medication, they have to go through some special process. It is behind counter. Is that right?

Mr. MURPHY of Pennsylvania. I thank the chairman for his passion and hard work on the Energy and Commerce Committee. We know this is a life- and-death issue. This is one of those things where Members are coming together from both sides of the aisle to deal with. Let me lay out the background here. How did we get here? About 80 percent of addictions begin with a prescription. When we see what has happened here on this chart of heroin increased use and prescription opioids, there is something that occurred at the beginning of this millennium where things really began to take off. On this next poster, seeing here how this is increasing at such a rate--about 9 or 10 percent--it is understandable you are looking at some of these rates increasing severalfold just in the last decade, with increasing jumps. As fentanyl has gotten here, it is even worse. Back in 1980, Dr. Hershel Jick, a Boston doctor, wrote a letter in The New England Journal of Medicine, and he said this: ``Out of nearly 40,000 patients given powerful pain drugs in a Boston hospital, only four addictions were documented.'' Since he published that letter, it has been cited again about 600 times. Doctors, academics, pharmaceutical companies, and others use it as evidence of the unlikeliness of developing addiction. But it has been criticized soundly, saying that never should have been said. In fact, The New England Journal of Medicine took the unusual step of posting a one-sentence warning over the so-called Porter and Jick letter to the editor that the Journal published in 1980, and it says: ``For reasons of public health, readers should be aware that this letter has been heavily and uncritically cited as evidence that addiction is rare with opioid therapy.'' Accompanying this note was an analysis from Canadian researchers exploring the frequency the letter had been cited, which was almost 600 times. Here is the tragedy of this. Many physicians and many pharmaceutical companies said: See, prescribe these opioids; people will be okay. That was found not to be the case. Jump ahead to 2001, when The Joint Commission released their pain management standards, and then shortly after that the American Medical Association said: let's make pain one of the vital signs. The other vital signs being blood pressure, heart rate, respiratory rate, and temperature. But when pain was also made one of those as well, doctors began asking questions about that, and basically screening people along the lines of: On a scale of 1 to 10, what is your pain level? Everything else is measured with an instrument objectively, but pain is subjective. In fact, it is so subjective that it was found that 51 percent of people who are on an opioid have a mood disorder, such as depression or anxiety. There is a huge amount there. The thing about this, if a person fails to screen for presence of a mood disorder, along with other aspects, you really increase their risk for addiction. About 50 million Americans, for example, have low back pain. Twenty- five million of those are on an opioid. Of that group, about 40 percent have been found to have depression. If you combine depression and opioid use, you could triple or quadruple your risk for misuse, abuse, and addiction. It would make sense that before a doctor prescribes in these cases, concurrently they would also be screening for mood disorders. That does not appear to be the case. Here is another part of the problem. Under the Affordable Care Act, hospital payments are tied to patient pain satisfaction surveys, which reward hospitals financially when patients give them a high rating for managing pain. In turn, the hospitals get less money if the patient says: my pain was not handled. That is actually question 14 of the Hospital Consumer Assessment of Healthcare Providers and Systems survey. It asks the question: How often did the hospital or provider do everything in their power to control your pain? Doctors feared negative responses, as did many hospitals, and it was found that probably had an impact on increasing prescriptions. Another part of the problem is treatment access. Quite frankly, if you want to get help, you can't find it. Unfortunately, getting access to high-quality treatment is unlikely in the United States. Of the 27 million Americans suffering from addiction, less than 1 percent receive evidence-based treatment. We have a shortage of trained providers, and half the counties in America have no psychologists, no psychiatrists, and no clinical social workers. Let me add to this also that medication-assisted treatment is one of those things put up here as a treatment method. If I show you here, medication-assisted treatment is when a person is replacing their illegal drug with something like methadone or Suboxone, which Chairman Walden just referred to. But here is part of the problem. It is supposed to be the doctor writing the prescription and then the patient is getting other treatment. But as is found with medication-assisted treatment, just in Pennsylvania alone, nearly 60 percent had no counseling in the year they received the buprenorphine. Forty percent were not drug-tested in the year they received the buprenorphine. This is important because a person may receive a prescription but still remain on heroin or another drug. Thirty-three percent have between two to five different prescribers writing them a prescription for this. Where do all those prescriptions go? This is one of the top diverted drugs. Many times, the patients simply take those drugs, sell them, and buy the street drugs. Twenty- four percent of those buprenorphine prescriptions didn't see a physician in the prior 30 days. In other words, with medication-assisted treatment, we simply have a failure to provide other treatment and a low expectation for improvement, in many cases thinking we will replace one addiction with another. Another part is in the area of hospital care. When treating opioid and heroin addiction, inpatient and residential treatment is crucial for full recovery, but there are simply not enough treatment centers and beds. Today, our Nation suffers a shortage of 100,000 inpatient treatment beds. Further, we don't have enough providers. When we do have providers, many times they end up overprescribing. There was a law in the United States back in the Nixon era called 42 C.F.R., consolidated federal registry. Basically, it made it so that physicians could not find out in the record if a patient was on other opioids, in treatment for that, or taking buprenorphine or methadone. So what happened? Someone shows up in the emergency room, they are in pain, perhaps a doctor looks in the record and doesn't see anything there, and writes a prescription. If that person was in treatment and was recovering from an addiction, and at that point not taking other drugs, look at what just happened. The doctor may prescribe some opioids for that patient who was used to taking quite a few at any given time to have an effect. Now they have this, and they are no longer thinking: I will take just one or two. They may take more. So you risk overdose. The second thing you do is risk a relapse. That person was perhaps clean for months or years. Now they have OxyContin or some other opioid, they take it, and they have a relapse. But there is a third problem that goes with that, and that is the person may be on other drugs, such as benzodiazepines or other respiratory suppressants, and that becomes a problem because then the doctor doesn't know about drug interactions. So we have this law in place which prohibits sharing of information about substance abuse treatment between doctors. Doctors unknowingly prescribe these for people. It causes more problems. We need to deal with this. Another level here is fentanyl. Fentanyl is a synthetic opioid which is a staggering 50 times more potent than heroin and 100 times more potent than morphine. It has a high potential for abuse. A mere 2 milligrams is fatal. A single packet of sweetener for your coffee is 1,000 milligrams. Take two of those and that is enough to kill you. Since last 2013, fentanyl has contributed to at least 5,000 overdose deaths in the U.S., and that is soaring. However, due to gaps in the data collections, it is likely the number of overdose deaths in the U.S. is actually much higher. A low-cost, high-profit, hard-to-detect profile of fentanyl is increasingly more trafficked to traffickers and relatively easy to manufacture. China is a major part of this, in that the illegally manufactured fentanyl shipped to the U.S. via labs in Mexico, smuggled across the border, then hits our streets. One other thing I want to point out here, in terms of this problem. If we look at what some have analyzed in terms of areas that are hotspots for substance abuse, you can see in here for persons on disability, look at the sections in Kentucky, West Virginia, Virginia, along the Mississippi Valley, up the Ohio Valley, and parts out West. This isn't the only causal factor. Many times you have people on disability and pain, and what happens is they may be prescribed opioids as part of that. When you look here, where age-adjusted death rates occur for drug poisoning--those overdose deaths--look at the hotspots in America. It is just about the same out here in the Mississippi-Ohio Valley, portions out West, where you have these problems. All of these come together in terms of crime, in terms of drug cartels, in terms of fentanyl, in terms of poor access to treatment. I mentioned the hospital beds. By the way, over half the counties in America have no psychiatrist, no psychologist, no social worker, and no licensed drug treatment provider. It is no wonder we are in this mess. We will talk more about some solutions here, but I wanted to recognize a number of Members who might want to talk about this. Let me first go to the gentleman from Georgia (Mr. Carter). Representative Carter is also a pharmacist. Let's hear some of his perspective. Mr. Speaker, I yield to the gentleman from Georgia (Mr. Carter).

Mr. MURPHY of Pennsylvania. Mr. Speaker, tonight, I am joined by a number of Members here to talk about one of the most insidious problems our Nation has faced in a long time. It is the problem of opioid abuse. We are in a crisis mode. We have now reached a point where we will have more deaths from drug overdoses this year than there are names on the Vietnam Veterans Memorial Wall in Washington. That is a frightening concept. There is almost no county, no State in America, that is not affected by this. Some areas have much more. Places in eastern Kentucky, southern West Virginia and up the Ohio Valley, and places in New England and out West have seen this as a growing problem as death rates rise. There are things we can do about this. But in order to have some discussion of what we can do about this, we are going to talk about how we got to this problem and then what we can do to go beyond that. I want to start off by yielding to the gentleman from Oregon (Mr. Walden), the chairman of the Energy and Commerce Committee, to talk about what this means in one State alone, the State of Oregon.

Mr. MURPHY of Pennsylvania. Mr. Speaker, I thank the gentleman from Ohio. I point also on this map here to the Cincinnati area in southern Ohio, which is one of the hot spots in 2014 that has continued to grow as a problem. We recognize this is both a local problem and a nationwide problem. I want to tell a story here. Last December, when the President was signing into law the 21st Century Cures Act, which included my legislation, the Helping Families in Mental Health Crisis Act, a former State Senator from West Virginia took the stage to introduce it. David Grubb talked about his daughter, Jessie, who, herself, had been in rehab, in treatment, something like three or four times, had had several drug overdose instances and had been revived. But what happened to her also is part of what they called the loaded gun that never should have happened. She went into the hospital for some surgery, but the doctors and nurses never told her discharging doctor that she was in recovery for heroin addiction. The point we made before about the NASPA list, or the other lists there, or the 42 C.F.R., blocks information from going into the medical record. So while someone was out to protect her privacy, they didn't protect her from death. She was given a prescription of 50 opioid painkillers. Remember, I said before that when a person is given this prescription, they run the risk of relapse, overdose, or bad drug interactions. In her case, it was an overdose that finally took her life--another important reason why we have to deal with this 42 C.F.R. and get rid of that arcane and, quite frankly, deadly law. Let me talk about some other recommendations of what I believe Congress can do to help. The references made before by Dr. Bucshon and others about the prescription drug monitoring program--and also Buddy Carter of Georgia mentioned this, too--where a pharmacist or a physician can say, ``Is this person on other opioids? Have they jumped across the border? Have they seen four, five, or more physicians for some opiates?'' by having a better PDMP, prescription drug monitoring program, or National All Schedules Prescription Electronic Reporting program, we have to make sure that all States use the same system and that it collects data from across borders so doctors can easily see this. But part of this, too, in dealing with the 42 C.F.R., is understanding Federal law prohibits including buprenorphine and methadone in the PDMP. How absurd and how cruel that is that a doctor would not even be able to know that a patient is taking one of those prescriptions. Also, some of these drugs can end up being a respiratory suppressant, and when the patient takes another drug such as benzodiazapine, it can add to that effect and add to further complications. Another aspect, too, which we must be further engaged with is vigorous public education programs across all age groups, beginning with early elementary school. When schools have some of these programs--and we will bring forth some models that talk about these programs in a future hearing I will be holding in the Oversight and Investigations Subcommittee--these are very, very important to help students, early on, understand the dangers of this. This is not just recreation, but it is so easy to slip into addiction. Given that 80 percent of drug abuse begins with a prescription, whether it is a student, athlete, perhaps a football player who injures a leg or something and he is given some of these drugs, it is essential the whole family be counseled from the onset, understanding the concerns and dangers of continuing to take these drugs. We also have to have drug take-back programs and public education programs stressing the importance of proper disposal of unused opiates and pain prescriptions to prevent them from being stolen or misused. For example, if a family is selling their home and they are having an open house and strangers come into the house and while they are there they say, ``Can I use your restroom?'' and the family lets them do that, don't be surprised if that person has no intention of buying a house but does have an intention of going into the bathrooms and checking the medicine cabinets and finding any medication and taking it. Also, when teens come over to the house for parties or socializing, don't be surprised if they also go into medicine cabinets, look in drawers in the bathrooms or drawers in other places of the house looking for some of those drugs which they, themselves, will take or sell. We have to make sure we have vigorous patient education programs about doctor-prescribed opioids to make sure people know about that before the addiction takes foot. And taking one of these prescriptions may only take 3 or 4 weeks before it begins to kick in and cause problems. I know myself, back in 2005, I was in a rollover accident in Iraq with a couple of other Members of Congress. Our vehicle rolled, and as a result of that accident, I ended up having a mild concussion, snapping my neck, having some temporary paralysis, and a great deal of pain. Well, battlefield medicine is one that gets you out of the area, stops the bleeding, stops the pain, and ships you off to some other hospital, and that was the case for me. But I know what happens. Everywhere I landed in a helicopter or an ambulance, appropriately so, the physicians would ask me a number of orienting questions, but also say: ``Are you in pain? On a scale of 1 to 10, how much pain are you in?'' And when I proceeded to say that number, immediately, as they would do for many other people in the battlefield, they would administer morphine or some other pain reliever and move you on from there. What happened, though, returning to the United States, where pain continued for me, I was prescribed some pills for that pain, but I was also prescribed fentanyl. Never once was it ever described to me: ``Be careful with this. This is highly addictive. This is a problem.'' Now, after a few weeks on this and recognizing it was hard to even do my job because I couldn't keep my head clear, I just said: ``That it is. I am not taking this anymore.'' But at that point, my body had already begun to develop some tolerance for this, and when I stopped taking it, I had some reaction. Granted, it was not as severe as some of those who have been taking these drugs at a higher dosage and longer, but I could feel myself actually saying I understand what people mean when they say their skin feels like it is peeling off of them and they feel a sense of nausea and other problems as well. Now, I can't even imagine what it is like for someone who is taking higher doses for longer periods of time. But it is extremely important that, every time a prescription is written, pharmacists have an opportunity to counsel patients and doctors are also doing more than simply passing out a prescription. Pharmacists should do what Buddy Carter was saying before: make sure they have the person showing a photo ID. Is this, indeed, a prescription they are picking up for themselves or claiming they have it for someone else? Perhaps that prescription was stolen from someone. We have to make sure that we also understand, for those out there trying to legalize marijuana, I caution you, because the marijuana that is out there on the streets or presented in many areas can cause tremendous psychiatric problems for those who are already at risk. The longer you are on some of the types of marijuana, the greater risk you have for things like delusional behavior. We have to make sure we also eliminate Medicaid payments for those question 14 responses I made reference to before when you are in the hospital to ask if the hospital adequately addressed your pain. In the area of treatment and recovery, we have to expand the mental health workforce. As I said before, half the counties in America have no psychiatrists, no psychologists, no drug and alcohol counselors, and those who are out there likely have their schedule so filled, they don't even have room to treat someone. Not all of them even know how to treat addictive disorders. The fact that a majority of people who may have an addiction disorder also have a concurrent mental health disorder is another reason why we have to increase this workforce by tens of thousands. Just for child and adolescent psychiatrists alone, we need another 21,000 of those. We need tens of thousands more psychologists. It is important that the schools of medicine, schools of psychology, and schools of social work are graduating more people with these degrees and getting them into our workforce. I have had legislation before, and we passed some things in the 21st Century Cures Act and in my Helping Families in Mental Health Crisis Act, to provide more funding so that more of these folks can continue with their education. It is essential. It is like trying to fight a war without soldiers, trying to fight this war, which is killing more people every year than the entire war in Vietnam, but we do not have the soldiers to fight this. We also have to make sure that, with regard to the government- sponsored medication-assisted treatment which I referred to before, we cannot simply rely on synthetic opioid maintenance alone. We have to make sure there are requirements to have that person in counseling and treatment. I have heard from some persons that go to those treatment programs that they have no counseling at all, and some have great counseling. In some cases, sitting in the waiting room, perhaps a nurse or someone simply checks up on them: ``What are you doing? How are you doing?'' That is considered and written down as group therapy. That is not acceptable in any way, shape, or form. We need 100,000 more inpatient psychiatric beds, and we have to make sure insurance companies recognize that an addictive disorder is a chronic disorder. Simply giving someone a weekend or a few days for withdrawal and then putting them back on the street is not an answer. That is why we have to encourage private insurance companies and Medicaid and Medicare. And I say Medicare because a large number of people who are having some of these problems are also the elderly. We have to make sure that we increase the availability of fast-acting opiate blockers for first responders, such as Narcan. But let's keep this in mind: In some cases, we hear of some of those pushers of these drugs who also give an accompanying dosage of Narcan, recognizing that the drug will bring that person to a near-death experience. We have heard from first responders and others, law enforcement, where someone may actually have a party where someone will remain there expecting that someone will actually have an overdose and die in order to bring them back to life. That is how some of these people are seeking some of those experiences. We have to make sure that States review their laws, as some are doing, that if you take one of these opiates and you do have that near- death experience, perhaps that should be treated the same as a suicide attempt, that that person is in imminent danger of harming themselves or someone else and perhaps determine if they need an inpatient psychiatric stay. We have to make sure we have support of employment for those in recovery to break the cycle of recovery and reexposure. Many times, persons who are trying to stay clean, they can't get a job because they can't pass the drug test, so they may be in a job and have exposure to other people who still end up with substance abuse. We have to make sure they have higher standards and increased accountability for payment models that require evidence-based treatment in halfway houses, three-quarter houses, and residential treatment facilities. We have to deploy certified addiction counselors to emergency rooms because we know that, when a person comes to an emergency room, if they see an addiction counselor there, they are not just simply given a business card and told, ``Call someone next week and we hope you get treatment''; but if they see an addiction counselor in the emergency room, they increase their chances of follow-up by 50 percent, according to a Michigan study. We must make sure the FDA is working with companies to find alternatives to opioids and that, again, Medicaid and other physicians are educated on some of those aspects. Physician training has to also be ramped up: require them to have training in opioid prescribing practices on risk for addiction and abuse and prescribing limited dosages. Instead of prescribing dosages for a month, perhaps just a couple of days. In many cases, they are not adequately trained in alternatives to opioids and the potential harm of overprescribing. We have to increase training requirements for healthcare providers who deliver this medication-assisted treatment. Right now, in many cases, they only have a few hours of training, and then they can go and prescribe this and have very little, if any, training at all in drug addiction counseling. Before doctors write a prescription, we can make sure they are looking at the NASPER list or other lists as well. In the area of law enforcement, it is critical that what is called the High Intensity Drug Trafficking Areas program is made more available, with greater access around the country. Mr. Speaker, how much time do I have left in our segment here?

Mr. MURPHY of Pennsylvania. I yield to the gentleman from Oregon (Mr. Blumenauer).

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, last week's shooting in Alexandria left our friend and colleague Mr. Steve Scalise badly wounded. Two brave U.S. Capitol Police officers and a young congressional staffer were also injured. We continue to pray for their quick and their full recovery. I know that other Members, other staff members, their friends, their families have been affected by this, too. Too often, after a shooting or some other traumatic event, we focus on those injuries that are physical, the ones we can see, while forgetting about those injuries we can't see. I continue to practice psychology in the Navy at Walter Reed Hospital in Bethesda, where I work with veterans who suffer from post-traumatic stress disorder, or PTSD, and traumatic brain injury. These veterans come back from witnessing traumatic events while in combat, and some have come close to committing suicide. These brave men and women fight every day against the horrific images that replay in their minds. The wound is invisible; the damage is often long term. They can and do recover with help. Since last week, I have thought about other groups who witness trauma in their homes and in their neighborhoods. These are the forgotten ones: young kids in Chicago who have become desensitized to the sound of a gunshot or the sounds of police sirens throughout the night, victims of sexual assault on college campuses and elsewhere, children who witness domestic abuse, and youth in foster care. Most youth in foster care have traumatic family histories and life experiences, including their removal from the birth family, resulting in an increased risk for mental health disorders. A recent study published in Pediatrics found that children placed in foster care were three to five times more likely to suffer from mental health problems such as depression and attention deficit disorder than children who were never in foster care. Another study revealed that PTSD was diagnosed 60 percent of the time in sexually abused children and 42 percent of the time in physically abused children. A staggering 18 percent of foster children have never been the primary victim of abuse, yet they still suffer from PTSD probably because they witnessed domestic or community violence. The American Academy of Pediatrics Healthy Foster Care America initiative identifies mental and behavioral health as the ``greatest unmet health need for children and teens in foster care.'' And since most of these kids are not receiving mental health treatment, their problems carry on into adulthood. Adults who formerly were placed in foster care, known as foster care alumni, have disproportionately high rates of emotional and behavioral disorders; 21.5 percent of foster care alumni suffer from PTSD compared to just 4.5 percent of the general population. Each year more than 20,000 young people age out of foster care without being ready to live independently. Discharged from care without social support or assistance, these youth are at higher risk for drug use and mental illness, depression, anxiety and post-traumatic stress, and others. Too often they experience higher rates of unemployment, homelessness, and dependence on public assistance programs. A lack of a comprehensive mental health screening of all children entering out-of-home care and the need for more thorough identification of youth with emotional and behavioral disorders contribute to these dismal statistics. As well, insufficient youth access to high-quality mental health services highlights our Nation's shortage of providers, in that half the counties in America have no psychologists, no psychiatrists, no clinical social workers, or workers who are licensed as substance abuse providers. Given the evidence from studies indicating that children in care have significant developmental, behavioral, and emotional problems, quality services for these children are an essential societal investment. Mr. Speaker, I am proud that the House yesterday took up legislation to address this important issue. H.R. 2847, the Improving Services for Older Youth in Foster Care Act, expands and improves the John H. Chafee Independence Program, which helps current and former foster care youth achieve self-sufficiency. Specifically, the bill will widen the age range of foster youth who can receive assistance under the program. I am proud to support this bill and will continue to shed light on those who suffer from trauma, who, as a consequence, suffer from either PTSD, depression, or other emotional sequelae. These bills we voted on will continue to give our foster children both help and hope.

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, last November, Canonsburg, Pennsylvania, Police Officer Scott Bashioum was shot and killed as he and his partner responded to a domestic disturbance call. They were ambushed as they approached the home. Officer Bashioum was also a United States Air Force veteran. He retired as a senior master sergeant with 29 years of service. He will be remembered for his service both in the Canonsburg community as a police officer, and to the country as a veteran. Mr. Speaker, when our brothers and sisters are killed in the line of duty, we can memorialize them by building monuments. We can remember them by renaming buildings. We can support them by raising funds to help their widows and their orphaned children. But most importantly, we can make sure we do all we can so that they return home at the end of their watch and that we protect their right to raise their children and their children's right to be raised by them. The community needs to know that we do all we can to make sure that thin blue line does not break and that thin blue line does not bend. We need to work together as a nation to protect those who protect the safety of all of us.

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, in my district over the time span since the Affordable Care Act, ObamaCare, was passed, I fielded many, many a call from persons who said they could not afford health care. In some of those instances, even though a person was able to afford the premium, they could not afford the deductible. A gentleman aged 55 and his wife said they would have to pay $27,000 out of pocket between premium deductibles and copays before they could use their first benefits. He was one of the 19.2 million Americans who chose to pay the fine rather than get on the Affordable Care Act, ObamaCare. We suspect that many more will continue on with saying they would rather pay a fine or find a way out rather than continue to pay for it if this continues on as is. In the past, we have been battling many things under this with regard to mental health care. The past administration attempted to strip the protected drug class status for lifesaving psychiatric medications. We fought back on that. We also worked together, however, in a bipartisan way to make sure we had assured things for mental health care. This bill has several provisions which are extremely important. It has $100 billion which States may use to help in their stabilization fund to fund mental health care. There is another $15 billion focused on mental health care. There is $500 billion for substance abuse. Funding will be in there. My hope is that States make a decision. It is in their hands with the passage of this bill so they can make the right choice to continue mental health care, and I trust they will do that.

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, our Nation's HIPAA patient privacy laws should be improved to allow for compassionate communication between doctors, primary caregivers, families, and patients. Recently, the editorial board of the Observer-Reporter joined the conversation in support, citing a specific instance in Greene County, Pennsylvania. They wrote: Christopher was arrested in early December and attacked police officers at the scene. Witnessing his erratic behavior, the officers decided to take him to a hospital for a mental health evaluation. Christopher was released from the hospital after there was apparently no communication between the hospital's medical staff and the arresting police officers. Less than 4 weeks later, Christopher was shot to death by his brother, Ryan, in what Ryan and others described as self-defense. If only the doctors were allowed to share limited, critically important information with the family, with law enforcement, and with supportive community specialists, this tragedy could have been avoided. The leading predictor of success in treatment for a person with serious mental illness is family involvement. We must change Federal regulations to help, not block, treatment. Until then, there will be more sad stories like Christopher's every day.

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, I was unavoidably detained. Had I been present, I would have voted ``yea'' on rollcall No. 54.

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, today, four people were charged with a violent crime after a Facebook showed 30 minutes of horror. The criminal charges barely scratch the surface in describing the terror experienced by an 18-year-old boy who suffers from mental disabilities. He was forced for 5 hours to cower in a corner scared, stunned, and powerless by people he thought were his friends. His mouth was duct taped shut. His hands and feet were tied. They cut his clothes, his hair, and scalp with a knife. He was burned, punched, and beaten. He was humiliated and berated. This was not just bullying, this was violent, perverse torture perpetrated by heartless young adults. His psychological trauma will haunt him for years. He is not alone because children with disabilities are four times more likely to be assaulted than the general population. We enacted major mental health reforms just a few weeks ago. Unfortunately, we cannot litigate compassion, mandate morality, nor legislate common decency for perpetrators who have no sense of shame. But today, as a Nation, we should all be ashamed and recommit to teach our children there is never any excuse to harm a disabled person. Never. I pray for the victim and his family.

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, today is a day of joy, and it was, indeed, a long time in coming, but here we are. My time in Congress was redefined 4 years ago, on December 14, 2012, when 26 innocent lives were taken at Sandy Hook Elementary School in Newtown, Connecticut. Now, it is neither my district nor my State, but when it comes to children, all of us represent all children. Afterwards, when I met with the families, they gave me pictures of their children and spouses whom they lost that day, and I made a promise--the promise that we would not continue to watch passively or just offer moments of silence as these tragedies continue, that we should deliver, instead, treatment before tragedy. Today, Mr. Speaker, I say thanks to the Members of Congress who changed the course with me--who teamed up to finally change the way the United States treats the mentally ill. We set our eyes on one goal: to fix our Nation's broken mental health system. Since then, we have come together to work towards protecting millions of Americans who suffer from mental illness. We traveled to every corner of this Nation and listened to doctors, psychologists and psychiatrists, experts and advocates--most importantly, to patients, consumers, and their families. Through congressional hearings and investigations, we have discovered the abhorrent and sometimes fatal disconnect between the 112 Federal agencies that were assigned to treat the mentally ill. We exposed $130 billion spending in a system that has done little but to watch the rates of homelessness, incarceration, suicide, and drug overdose deaths soar. We came together across party lines and went to work. We passed legislation that will save lives. I thank Fred Upton for his leadership on our Committee on Energy and Commerce with regard to H.R. 2646, the Helping Families in Mental Health Crisis Act, and for his tremendous medical innovation bill, the 21st Century Cures Act. I thank Eddie Bernice Johnson of Texas for her conviction and determination and for applying her experience as a psychiatric nurse to champion the cause that someone in crisis should be able to get treatment in a hospital and not just be locked up in a jail cell. I thank Speaker Ryan, who, in his very first days as Speaker of the House, pledged his support and determination to ensure that we would take action in the way that we treat the mentally ill in this Nation. To all of my colleagues in the House who spoke up, stepped up, and teamed up in our efforts to end the mental health crisis in America, thank you. I thank our colleagues in the Senate as well--Senator Chris Murphy, Dr. Bill Cassidy, and Senators Cornyn and Alexander--for their leadership in bringing this bill to a vote before the Senate. As the Senate takes up the bill today, I ask them all to cast their votes while being mindful of the millions of American lives it will save. Most importantly, I close by thanking the millions who had the courage to come forward and share their stories of pain and suffering under this broken system--those who have lost a loved one, those who have a loved one who is sitting in a jail cell or who is homeless in the streets. To those who have been the last, the least, the lost, and the lonely, know that we will continue to listen. In the final version of the Helping Families in Mental Health Crisis Act, we did not get everything we needed, but we needed everything we got, and we will continue to work together. When we began this journey 4 years ago, I challenged us all to realize the sad reality of, where there is no help, there is no hope. Know now that, as we pass and enact this bill, we will finally be able to say there is help and, most assuredly, there is hope.

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, I thank the gentleman for yielding and heading up this very important Special Order on a topic that affects every single family in America, and that is their health. As the gentleman said, yesterday we passed a very important bill, the 21st Century Cures Act, with the charge led by the chairman of the Committee on Energy and Commerce, Fred Upton. I was pleased that they included in that package our mental health reform bill, which we moved out of the Committee on Energy and Commerce unanimously in July. We have spoken about this issue at great length for the last few years because it is worthy of that time. We have spoken because of the 60 million Americans who suffer from some level of mental illness and the 10 million Americans who suffer from severe mental illness and the fact that 40 percent of them cannot get care; that half the counties in America have no psychiatrists, psychologists or social workers; that we do not have enough hospital beds for people in crisis, a shortage of 100,000; that there are only 9,000 child and adolescent psychiatrists when we need 30,000, particularly important because severe mental illness in half the cases emerges by age 14 and 75 percent by age 24; that we have seen too many lives lost, that the body count in this Nation last year related primarily and secondarily to mental illness exceeds the total combat body counts of United States soldiers in World War I, Korea, Vietnam, Desert Storm, Bosnia, Afghanistan, and Iraq combined; because millions of families continue to suffer, because our prisons are filled with the mentally ill, our emergency rooms are backed up with people with mental illness-related disorders, and because our morgues are also filled. Yesterday, the House took a definitive bipartisan approach in changing that trajectory. The issues we have covered on mental health, along with the advances in the 21st Century Cures bill, sets a new direction for where we need to be going in this Nation to approaching health care overall. When we look at the research changes that we have made in advancing cures not only in small population orphan diseases, but also with regard to the total 10,000 diseases out there, we will be able to sufficiently and more effectively identify medical disorders and psychiatric disorders early on and get them treatment sooner. One of the aspects that was taken care of in the Helping Families With Mental Health Crisis Act is a program called RAISE, Response After Initial Schizophrenic Episode. As we know, research tells us that when you provide medication and effective targeted counseling early on, you can reduce the trajectory of severe mental illness and improve the prognosis greatly. But when that is not provided, every crisis moment of severe mental illness leads to other neurological damage, worsens the prognosis and, sadly, increases the chances that a person will have time in prison 10 times more likely than to be in a hospital when they are in crisis. We are changing that trajectory. New research will get us in that direction. Let me lay out for a few minutes today where this takes us as Congress is looking to change the Affordable Care Act. People have spoken ad nauseam about the problems with that act, how it has cost families a great deal, how it is supposed to be affordable but it is not, how premiums have gone up dramatically in double digits and triple digits over the last few years, how the deductibles and copays put it out of families' reach, and how it is not really a comprehensive approach because it does not stem the tide of increasing healthcare costs. There are some specific reasons for that. As long as we have a system that is based on a fee-for-service model and as long as we have a system that does not put the patient at the center of this focus, we are going to continue to have problems with cost overruns and, quite frankly, care problems. We have seen changes in the trajectory of improvements in reduction in mortality and morbidity. For example, over the last couple decades, we have seen a reduction in mortality rates for cancer, for heart disease, for stroke, for accidental deaths, for HIV/AIDS; but we have seen increases in mortality rates for suicide and also for drug overdose deaths. This really means we need to be looking at a different kind of model, and that model is the integrated care model, the model where behavioral medicine and physical medicine work together. Why is that important? We know that 75 percent of the people with a severe mental illness will have some other chronic illness like heart disease, lung disease, diabetes, infectious disease; and 50 percent of them have at least two chronic diseases; a third will have at least three. We know that a person with severe mental illness has triple the chance of moving into poverty, and we know that people in poverty have three times the rate of mental illness. Beyond that, if we look at people who enter into using the medical field from the area of chronic illness, that perhaps the first diagnosis might be anything from cancer, inflammatory bowel disease, diabetes, et cetera, the chances of them developing a psychological problem such as depression, panic disorder, anxiety, is massive, twice the rate of the rest of the population. This is where the costs begin to soar, because when a person recognizes they have this long-term problem with pain, with doctors' appointments, with disruption of their lifestyle, with immobility, with disability, et cetera, it is expected and it is common for them to develop other psychiatric disorders. But we have had a system that has ignored that. What happens when we ignore that? If a person has a chronic illness and depression, for example, untreated depression, it doubles. It doubles their healthcare costs. When there are models out there, however, that say let's integrate behavioral medicine and physical medicine so that a physician, being a coordinated care model, when they have a patient with one of those illnesses, a chronic illness, they begin to treat the whole patient, the patient-centered model, the team approach between the doctor and patient there. What can it do? Well, I want to cite a study done by a young doctor by the name of Jeffrey Brenner, who was out in New Jersey. You recognize that people with complex health and social issues have these high rates of going to emergency rooms. They are called super- utilizers. Medicaid points out that 5 percent of the people on Medicaid account for 50 percent of Medicaid spending and, I might add, virtually all of those are people who have a concurrent psychiatric disorder, such as depression. But what Brenner did in his particular study is recognize that there were a number of people who had a huge number of visits to emergency rooms in a very costly way. He said, for example, nearly half of the city of Camden's 77,000 residents were visiting an emergency department annually, most often for head colds, viral infections, ear infections, and sore throats. Thirteen percent of the patients accounted for 80 percent of hospital costs, and 20 percent of the patients accounted for 90 percent of the costs. What he looked at were models that police use called hot spotting-- where are the areas of a city where you have a great deal of crime, and, instead of avoiding those areas, the police would go in and work to prevent crime. Well, similarly, in Brenner's model, he looked at managing these patients' care instead of ignoring them. If you ignore them, they go to emergency rooms repeatedly. Studies done, for example, at the University of Pittsburgh Medical Center with inflammatory bowel disease found when you ignore folks, they continue to go to emergency rooms. Over-utilizers of the system. And on a fee-for-service model, it is worth it for the doctor. They made a lot of money. Hospitals made money, as long as the people continued to come back. But what was it that was driving people repeatedly to get this care at an emergency room, or expensive care, instead of doing something else? What Brenner did and other studies have found is that people could not access their primary care physician or their specialist, so that is where they would go for care. They would panic. Worry, anxiety, depression. They weren't managing their medication well. There are neurobiological things that take place in the system of someone with depression which makes them more prone toward other infections and viruses, et cetera. What Brenner did was identified folks with a fairly complicated model here and developed a care management team where the goal is leaving patients with the ability to manage health care on their own. And how do they do that? By helping them see doctors more frequently. The studies done with the inflammatory bowel disease clinic at the University of Pittsburgh did the same thing. They developed an integrative care team, including psychiatric and psychological consulting, to help the person deal with their pain, help them change their behavior patterns, and make sure they had easy access to the doctors, so even getting the doctor's cell phone number, email address, and respond within 72 hours for doctor visits. What Brenner found, the first 36 patients had a total of 62 hospital emergency room visits per month before they began intervention. It dropped to 37 visits per month afterwards. Then they also found the hospital bill fell from a monthly average of $1.2 million to just over $500,000, savings that benefited State and Federal healthcare plans. Similar results have been found in other areas when this is targeted. Now, we know the Affordable Care Act had some models of this, but the results have been somewhat equivocal because they haven't looked at these as closely and really worked with the patients as closely. But the point is this: Recognizing if we are going to get hold of the cost overruns with health care, it needs to be that integrated care model-- behavioral and physical medicine working together--a coordinated care model, where a primary care physician and/or the specialists are working to coordinate the patient's care instead of leaving them on their own, and, quite frankly, a capitated care model, where it is worth it financially for the physician and patient to work together, not to just say: Go to the hospital whenever you want; go to the emergency room whenever you want; but get the care you need, the time you need it, with the quality you need. The Affordable Care Act started down this road, but it wasn't fully followed. But this bill we passed yesterday, and our hope is that the Senate passes next week, by moving forward on research; by making sure physicians get timely, quality information for what they should do; by making sure that it is disseminated to physicians, whether they are in urban downtown Manhattan or they are out in rural South Dakota, that through telemedicine they have access to the best decisionmaking; and by making sure that, through telehealth, which we funded in the Helping Families with Mental Health Crisis Act, no matter where physicians are in America, to have access to psychologists and psychiatrists and social workers and to integrate that care together, this is what makes a huge difference. Children's Hospital of Pittsburgh did a study of when that behavioral health consultation is done during the pediatrician visit, when there is a warm handoff, right away the family meets the mental health professional, there is over a 90-percent followup for that patient with the doctor. When they are given a card and said to call another day, it plummets to less than half. Similarly, look at the problems we face with opioid abuse in America. Last year, we had a death total of 47,000. We are reaching the point of the number of people who die from opioid substance abuse is reaching that of the level of our combat deaths during the entire Vietnam war. It is an embarrassing, shameful, and painful thing for our Nation to have, and that doesn't even include the many, many folks who still remain addicted. But here is what happens with care for the addicted. Out of every 1,000 persons who has an addiction disorder, 900 will not seek care. Of the 100 who do seek care, 37 can't find it. It is not available in their community. Of the 63 who do seek care and find it, only 6 of them will find evidence-based care. But what if we change that trajectory? What if we say as part of moving forward in our revision of the Affordable Care Act and making it really effective health care we made sure we integrated behavioral and physical medicine together? A study done at the University of Michigan, I believe, or Michigan State--I have to make sure I get those right because I know Chairman Upton would not forgive me, but let's say it was done in Michigan--they did a fascinating study where they made sure when someone came to the emergency room with a drug overdose, they didn't do the typical thing and hand someone a card and say: you know, you have a drug problem; you need to go get help. In those cases, many times the vast majority of people don't follow up. Instead, what they did is they provided qualified drug counseling in the emergency room. From the same model, if a person had a broken arm, the hospital would set it before they went home. They wouldn't say: here is a card; call an orthopedic surgeon on Monday and get that arm set. If a person came in with chest pains, they wouldn't say: why don't you make an appointment in a week or two with a cardiologist. They would treat it right away. Well, the same thing goes with psychiatric disorders and drug abuse. What Michigan found in their study and replicated in other communities is there was a 50-percent increase of people following through on drug treatment. So look at the things that are done. The bill we passed yesterday also invests hundreds of millions of dollars into more effective treatment for people with a substance abuse problem. It isn't enough just to have them in methadone maintenance or buprenorphine programs. Those will not be as effective. You have got to get them into effective counseling programs. So what we see is this: The bipartisan efforts that have worked through here and have made some big differences in where we are going with research and care will set us on a strong trajectory to making a big difference as this Congress and the new President work to change the Affordable Care Act to really being affordable and really being care- focused. That being said, we will still have, tragically, too many stories while we are waiting to get that care out there. We will still have too many episodes: a homicide, or a suicide, or a drug overdose death, or someone has lost their job, or a marriage is broken up, or families who have been abandoned by someone else, or children who are lost, or those who are homeless. It continues on as long as we are not properly addressing the issues of mental illness in America. I tell you, even though we have those long, somber moments of sadness, there is some joy in what this House did yesterday in this strong, bipartisan, coordinated effort to say we are changing the direction of how we recognize mental health care, what we are going to do about that, and how that has to be an integral component as we move forward to change health overall. We can do this. We can reduce costs dramatically by providing better and more effective care. So for all those families who have been contacting us Members of Congress, literally the millions of Americans who are suffering from these diseases of mental illness and the tens of millions of families who recognize the suffering there, help is on its way. The actions that Congress took yesterday, the actions that we anticipate the Senate will take next week, the signature of the President will move these things forward. We will create a new dawn, a brighter horizon for people who, up to this point, had very little hope of where things are. We know we have a long way to go, and we know this next Congress, as we move into the next session next year, is going to have their hands full, but we can do this. And I know there are dedicated people here on both sides of the aisle just waiting and eager to make a big difference for America's families. And where there is help, there is hope.

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, this bill includes in it elements of H.R. 2646, the Helping Families in Mental Health Crisis Act, which is the most revolutionary change to mental health since the Community Mental Health Act of 1963. It includes fundamental changes in how we think about, talk about, and treat serious mental illness. It establishes an assistant secretary for mental health and substance use to disseminate evidence-based practices, ensure grants meet objective outcome measures, conduct ongoing oversight of grantees, and collaborates with other Federal departments on mental health. It creates an interagency coordinating committee to evaluate Federal programs related to mental illness and provide recommendations to better coordinate those programs. It authorizes a national mental health and substance use policy laboratory to promote evidence-based models of care and further develop, expand, replicate, or scale those programs. It provides funding for treatment and recovery for homeless individuals with mental health and substance use disorder services. It authorizes for the first time in law the National Suicide Prevention Lifeline program and the Minority Fellowship Program. It awards grants to develop, maintain, and enhance online psychiatric bed registries. It funds programs for telehealth so that people in rural communities and primary care physicians can have ready access to mental health services so sorely needed for their patients. It reauthorizes the Garrett Lee Smith Suicide Prevention program, increases funding for assisted outpatient treatment and, for the first time, provides Federal grants for assertive community treatment. It increases access to medical residencies and fellowships in psychiatry and addiction medicine in underserved, community-based settings for nurse practitioners, physician assistants, health service psychologists, and social workers. It removes barriers for providing volunteering at community health centers. It updates the National Child Traumatic Stress Initiative, which supports a national network of child trauma centers, including university, hospital, and community-based centers. It requires the Secretary of HHS to clarify how healthcare providers can communicate with the caregiver of an adult with a mental health or substance use disorder. It clarifies the coverage of eating disorder benefits, including residential treatment under existing mental parity requirements. It allows Federal grants to local law enforcement to be used for crisis intervention teams to roll back the tragedies of violence that occur when a mentally ill person encounters a policeman. It provides funding to develop school-based mental health crisis intervention teams. And this list goes on. I am pleased that this has all been merged into one bill here so that we can move forward on this. This truly will provide many lifesaving measures and bring mental health treatment out of the shadows. I encourage my colleagues to support this bill as we move forward and provide help because where there is help, there is hope.

Mr. MURPHY of Pennsylvania

Mr. MURPHY of Pennsylvania. Mr. Speaker, this is a moment of great joy out of a situation of tremendous tragedy. After the last 4 years, since the time of the terrible tragedy at Sandy Hook Elementary School followed by repeated other ones, our Nation has awoken from a slumber of ignoring the problems of mental illness in America, one that when we closed down our institutions decades ago, we turned our eye to those who lay homeless on the street, who filled our prisons, who filled our cemeteries or lay on a gurney in an emergency room or were sent back home to a family who felt helpless and hopeless. We have changed now to a situation where we are coming together on a bill that will save lives. This is a new era of health care and the next generation of hope for Americans that really transcends boundaries. To all of the families who brought their stories out of the shadows, that dared to share their sorrows, their hopes, their shattered dreams, today is a day of joy. And today is only possible, I say to all of those families, because they dared to step forward. There is not time enough to thank all of those involved, but to those families who have helped, I say thank you. I also want to make sure I thank Chairman Upton, Speaker Ryan, Eddie Bernice Johnson, Diana DeGette, Frank Pallone, Senators Bill Cassidy and Chris Murphy, Leader Kevin McCarthy, Whip Steve Scalise, and so many others from our committee who have worked so hard to make this happen. And a special shout-out to some of the staff: Scott Dziengelski, Gary Andres, Karen Christian, Paul Edattel, Susan Mosychuk, and so many other staff who worked so hard on this. We can look back on this moment in history and say today that, although we have much to do and although we didn't get everything we needed, we needed everything that we did get. But this is the moment from this day forward we can say today that we took action to save lives.