U.S. Sen. Susan Collins pressed a top federal health official Wednesday about whether patient satisfaction surveys at hospitals are counterproductive and contributing to the country’s heroin epidemic.

Collins, R-Maine, chairwoman of the Special Committee on Aging, convened a hearing in Washington, D.C., on Wednesday that discussed how over-prescribing of opioids has helped exacerbate the heroin epidemic, which is especially acute in Maine. Seventy-one people died in Maine of heroin overdoses through the first nine months of 2015, an all-time high.

Nationally, four out of every five new heroin users started their opioid addiction with prescription pills, according to the American Society of Addiction Medicine.

Collins pointed out that patient satisfaction surveys given at hospitals – which are tied to federal funding by the U.S. Centers for Medicare and Medicaid Services – ask patients whether the hospital staff has “done everything they could to help you with your pain.” A better score on the surveys can put a hospital in line for more federal funding.

“That puts pressure on providers to over-prescribe,” Collins said. “They don’t want to get dinged on these questions.”

Sean Cavanaugh, a deputy administrator for Medicare, said that it was not the intent of the questions to encourage over-prescribing of opioids, but the department is reviewing the surveys. He said a letter sent in February by Collins that was co-signed with 26 senators spurred discussion on the topic at the Centers for Medicare and Medicaid Services.

“Clearly, we need to re-think this,” Cavanaugh said. “The work is underway. We are absolutely studying better phrasing of the questions.”

Other countries do not prescribe opioids at such high rates as the United States. For instance, in the United States, doctors prescribe painkillers at twice the rate as Canadian doctors, according to the U.S. Centers for Disease Control.

Dr. Steve Diaz, senior vice president and chief medical officer of MaineGeneral Health in Augusta, told the committee that the U.S. needs to change the culture around pain. Since the late 1990s, patients started to expect that doctors would alleviate most or all of their pain, corresponding with an increase in opioid use.

“Pain is a natural neurological response to something, and it’s triggered in many ways. We’ve given credibility to the belief that there shouldn’t be pain,” Diaz said.

Numerous research studies have shown that prescription opioids are not effective in treating chronic pain.

Despite the research and awareness in the medical profession of the dangers of opioids, over-prescribing is still a problem, said Dr. Jerome Adams, the Indiana state health commissioner. Adams told the committee that he was given 90 Vicodin pills after having his wisdom teeth removed, and he kept the extra pills that he didn’t need in a locked safe, estimating that they were worth thousands of dollars on the street.

“Ninety Vicodin for a wisdom tooth extraction? This is craziness,” said U.S. Sen. Tim Kaine, D-Virginia.

Kaine said the opioids were originally intended for acute pain after surgery or end-of-life pain, but their use has expanded to chronic pain.

“This is a marketing scam. It has wrecked the lives of thousands of people in this country,” he said.

Kaine and Adams agreed that better prescribing rules should be established to prevent patients from receiving more pills than necessary.

In Indiana’s Scott County, the heroin problem has led to a massive increase in HIV and Hepatitis C infections, from shared needles.

Diaz agreed with U.S. Sen. Elizabeth Warren, D-Massachusetts, that the federal government should relax prohibitions on studying marijuana to see whether medical marijuana is effective at controlling pain, a potential alternative to opioids.