[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]


           COMBATING THE OPIOID CRISIS: BATTLES IN THE STATES

=======================================================================

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 12, 2017

                               __________

                           Serial No. 115-43
                           
                           
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      Printed for the use of the Committee on Energy and Commerce
                        energycommerce.house.gov
                        
                        
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                    COMMITTEE ON ENERGY AND COMMERCE

                          GREG WALDEN, Oregon
                                 Chairman
JOE BARTON, Texas                    FRANK PALLONE, Jr., New Jersey
  Vice Chairman                        Ranking Member
FRED UPTON, Michigan                 BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois               ANNA G. ESHOO, California
TIM MURPHY, Pennsylvania             ELIOT L. ENGEL, New York
MICHAEL C. BURGESS, Texas            GENE GREEN, Texas
MARSHA BLACKBURN, Tennessee          DIANA DeGETTE, Colorado
STEVE SCALISE, Louisiana             MICHAEL F. DOYLE, Pennsylvania
ROBERT E. LATTA, Ohio                JANICE D. SCHAKOWSKY, Illinois
CATHY McMORRIS RODGERS, Washington   G.K. BUTTERFIELD, North Carolina
GREGG HARPER, Mississippi            DORIS O. MATSUI, California
LEONARD LANCE, New Jersey            KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky              JOHN P. SARBANES, Maryland
PETE OLSON, Texas                    JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia     PETER WELCH, Vermont
ADAM KINZINGER, Illinois             BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia         PAUL TONKO, New York
GUS M. BILIRAKIS, Florida            YVETTE D. CLARKE, New York
BILL JOHNSON, Ohio                   DAVID LOEBSACK, Iowa
BILLY LONG, Missouri                 KURT SCHRADER, Oregon
LARRY BUCSHON, Indiana               JOSEPH P. KENNEDY, III, 
BILL FLORES, Texas                       Massachusetts
SUSAN W. BROOKS, Indiana             TONY CARDENAS, California
MARKWAYNE MULLIN, Oklahoma           RAUL RUIZ, California
RICHARD HUDSON, North Carolina       SCOTT H. PETERS, California
CHRIS COLLINS, New York              DEBBIE DINGELL, Michigan
KEVIN CRAMER, North Dakota
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia

              Subcommittee on Oversight and Investigations

                        TIM MURPHY, Pennsylvania
                                 Chairman
H. MORGAN GRIFFITH, Virginia         DIANA DeGETTE, Colorado
  Vice Chairman                        Ranking Member
JOE BARTON, Texas                    JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas            KATHY CASTOR, Florida
SUSAN W. BROOKS, Indiana             PAUL TONKO, New York
CHRIS COLLINS, New York              YVETTE D. CLARKE, New York
TIM WALBERG, Michigan                RAUL RUIZ, California
MIMI WALTERS, California             SCOTT H. PETERS, California
RYAN A. COSTELLO, Pennsylvania       FRANK PALLONE, Jr., New Jersey (ex 
EARL L. ``BUDDY'' CARTER, Georgia        officio)
GREG WALDEN, Oregon (ex officio)
  
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Tim Murphy, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     1
    Prepared statement...........................................     3
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     5
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     6
    Prepared statement...........................................     8
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     9

                               Witnesses

Boyd K. Rutherford, Lieutenant Governor, State of Maryland.......    11
    Prepared statement...........................................    14
    Answers to submitted questions...............................
Brian J. Moran, Secretary of Public Safety and Homeland Security, 
  State of Virginia..............................................    24
    Prepared statement...........................................    26
    Answers to submitted questions...............................
John Tilley, Secretary of The Justice and Public Safety Cabinet, 
  State of Kentucky..............................................    45
    Prepared statement...........................................    47
    Answers to submitted questions...............................
Rebecca Boss, Director, Department of Behavioral Healthcare, 
  Developmental Disabilities and Hospitals, State of Rhode Island    50
    Prepared statement...........................................    52
    Answers to submitted questions...............................

                           Submitted Material

Statement of the National Association of Medicaid Directors Board 
  of Directors, submitted by Ms. Castor..........................    95
Article entitled, ``Why taking morphine, oxycodone can sometimes 
  make pain worse,'' Science, May 30, 2016, submitted by Mr. 
  Murphy.........................................................    97
Article entitled, ``51 percent of opioid prescriptions go to 
  people with depression and other mood disorders,'' STAT, June 
  26, 2017, submitted by Mr. Murphy..............................   100
Committe memorandum..............................................   104

 
           COMBATING THE OPIOID CRISIS: BATTLES IN THE STATES

                              ----------                              


                        WEDNESDAY, JULY 12, 2017

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:02 a.m., in 
room 2123, Rayburn House Office Building, Hon. Tim Murphy 
(chairman of the subcommittee) presiding.
    Present: Representatives Murphy, Griffith, Barton, Brooks, 
Collins, Walberg, Walters, Costello, Carter, Walden (ex 
officio), DeGette, Schakowsky, Castor, Tonko, Ruiz, Peters, and 
Pallone (ex officio).
    Also Present: Representatives Guthrie, Bilirakis, Bucshon, 
and Kennedy.
    Staff Present: Elena Brennan, Legislative Clerk, Energy/
Environment; Zachary Dareshori, Staff Assistant; Paul Edattel, 
Chief Counsel, Health; Ali Fulling, Professional Staff Member; 
Brittany Havens, Professional Staff Member, Oversight and 
Investigations; Katie McKeough, Press Assistant; John Ohly, 
Professional Staff Member, Oversight and Investigations; Chris 
Santini, Professional Staff Member; David Schaub, Detailee, 
Oversight and Investigations; Kristen Shatynski, Professional 
Staff Member, Health; Alan Slobodin, Chief Investigative 
Counsel, Oversight and Investigations; Evan Viau, Staff 
Assistant; Hamlin Wade, Special Advisor, External Affairs; 
Christina Calce, Minority Counsel; Jeff Carroll, Minority Staff 
Director; David Goldman, Minority Chief Counsel, Communications 
and Technology; Chris Knauer, Minority Oversight Staff 
Director; Miles Lichtman, Minority Policy Analyst; Kevin 
McAloon, Minority Professional Staff Member; Dino 
Papanastasiou, Minority GAO Detailee; Andrew Souvall, Minority 
Director of Communications, Outreach and Member Services; and 
C.J. Young, Minority Press Secretary.

   OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Murphy. Good morning, everyone. Today, the Subcommittee 
on Oversight and Investigation holds a hearing entitled 
Combating the Opioid Crisis: Battles in the states. Make no 
mistake, the term ``combating'' and ``battle'' are entirely 
appropriate. Our nation is in the midst of a tremendous fight 
against death and devastation affecting every corner of our 
Nation.
    In 2015, there were more than 52,000 deaths from drug 
overdose in the U.S., with more than 33,000 deaths involving an 
opioid, a 24 percent increase from the prior year. The overdose 
death rate in 2015 was almost seven times the rate of deaths 
from the heroin epidemic of the 1970s. For 2016, we have 
learned from an analysis by The New York Times that we have 
lost roughly 60,000 people to drug overdoses. That is more in 1 
year than all the names on the Vietnam Veterans' Memorial Wall, 
and likely, that number is underestimated because much of the 
data will not be in until the end of this year, 2017. It is 
staggering.
    For every fatal overdose, it has been estimated there are 
20 nonfatal overdoses. And for 2016, that could be near 1 
million. More than 183,000 lives have been lost in the U.S. 
from opioid overdoses between 1999 and 2015. That is about 
500,000 that will be lost over the next decade. The roots of 
this crisis began back in 1980 when a letter to the editor by 
two doctors published in the New England Journal of Medicine 
was misinterpreted as evidence. It was unlikely that someone 
would become addicted. Out of 40,000 cases, they said there 
were only four addictions.
    Twenty years later, the Joint Commission on Accreditation 
of Healthcare Organizations following the American Medical 
Association recommendation that pain be assessed as the fifth 
vital sign, and established standards for pain management 
interpreted by many doctors as encouraging the prescribing of 
opioids. Under the Affordable Care Act, prescribing pain 
killers is incentivized by patient questionnaires where a 
question specifically asked if their pain was adequately 
addressed to their satisfaction. Based upon their answer, a 
hospital may receive more or less money.
    As we learned in our oversight hearing held in March, the 
opioid epidemic is an urgent public health threat fueled by 
fentanyl, a much more dangerous and potent synthetic opioid and 
a clear and present danger to America.
    Two states represented on today's panel, Rhode Island and 
Maryland, were the first ones hit by the fentanyl wave, and 
unfortunately, it seems certain that this wave will sweep the 
Nation as low-cost, high-profit, hard-to-detect profile of 
fentanyl is increasingly attracted to traffickers and easy to 
manufacture, or obtain over the Internet.
    This is an in extremis moment requiring all the experience, 
resources, cooperation of our Federal, state, and local 
governments, as well as all the different industries, 
professionals, and experts to curb this terrible outbreak. With 
this hearing, we will focus on the actions of our state 
governments to find out what efforts are working, what is not 
working, how we can work together to save lives. To the panel, 
I say, we want to know the problems, and please be candid with 
us, because as you know, there are millions of families being 
torn apart by this.
    As drug policy expert Sally Satel noted, ``It is at the 
state and county levels that the real progress will be made. It 
makes sense that the efforts to find inspired solutions would 
be most concentrated there. We should invest in those solutions 
and learn from them.''
    Serving the front lines of the opioid epidemic, state 
governments have been pursuing their own innovative 
initiatives, such as more inventive use of incentives, more 
structured medication-assisted treatment, more comprehensive 
prescription drug monitoring.
    States such as Maryland are making the best use of the 
Center for Disease Control opioid prescribing guidelines to 
help push back on the overprescribing. Kentucky's All Schedule 
Prescription Electronic Reporting system, more known as KASPER, 
a web-based monitoring system to help prescription use across 
the state, is helping state regulators identify questionable 
prescribing practices by physicians and abuse by patients.
    Virginia has greatly expanded access to Naloxone, the drug 
that can rapidly reverse an opioid overdose, but then again, 
can have its own risk and its use. Some states are expanding 
the availability of Naloxone by permitting third-party 
prescribing by family and friends of individuals who are at 
high risk of overdose. Rhode Island has developed the AnchorEd 
Program that matches overdose victims with peer recovery 
coaches to encourage treatment, who follow up with the patient 
for the next 10 days after the overdose.
    Much of the work of the states should help inform the 
President's Commission on Combating Drug Addiction and the 
Opioid Crisis. Two years ago, the subcommittee held a similar 
hearing on what the state governments were doing to combat the 
opioid abuse epidemic. Such oversight helped Congress enact 
provisions in the Comprehensive Addiction Recovery Act, or 
CARA, and it will help the administration.
    We put $1 billion into grants over the next 2 years, but we 
want to know if this money is being used wisely, and what is 
working. We are eager to learn about those programs. But the 
21st Century Cures state program is just the beginning. Our 
state government witnesses can help this committee develop a 
more effective and national strategy to combat the opioid 
crisis in such areas as substance abuse prevention and 
education, physician training, treatment of recovery, law 
enforcement, expanded access to Vivitrol, while testing for 
drugs in correctional facilities, data collection, examining 
what reforms can be made to the 42 CFR Part 2, so there is 
better coordination of care among physicians, and we can help 
prevent relapses and overdose and improve patient safety.
    We are in one of the worst medical tragedies of our time, 
perhaps the worst. And although this subcommittee has given its 
attention to many other problems in the past, we recognize this 
is paramount among them. This is a national emergency. And we 
look forward to hearing from the states and what you are doing 
on the front lines of this.
    [The prepared statement of Mr. Murphy follows:]

                 Prepared statement of Hon. Tim Murphy

    Today, the Subcommittee holds a hearing entitled, 
``Combating the Opioid Crisis: Battles in the States.'' Make no 
mistake. The terms ``combating'' and ``battles'' are entirely 
appropriate; our nation is in the midst of a tremendous fight 
against death and devastation affecting every corner of our 
nation.
    In 2015, there were more than 52,000 deaths from drug 
overdoses in the U.S., with more than 33,000 deaths involving 
an opioid, a 24 percent increase from the prior year. The 
opioid overdose death rate in 2015 was almost seven times the 
rate of deaths from the heroin epidemic during the 1970's. For 
2016, we have learned from an analysis by the New York Times--
not from the Federal government--that we have lost roughly 
60,000 people to drug overdoses, more than all the Americans 
who died in the Vietnam War. The staggering number of deaths is 
only part of the picture. For every fatal opioid overdose, it 
has been estimated that there are approximately 20 non-fatal 
overdoses. For 2016, the number of overdoses could be nearing 
one million.
    More than 183,000 lives have been lost in the U.S. from 
opioid overdoses between 1999 and 2015. A recent forecast from 
STAT News projects that almost 500,000 lives will be lost from 
opioid overdoses in the U.S. over the next decade.
    The roots of this crisis began back in 1980, when a letter 
to the editor from two doctors published in the New England 
Journal of Medicine was misinterpreted as evidence of the 
unlikelihood that patients given pain drugs would develop 
addiction. About twenty years later, the Joint Commission on 
Accreditation of Healthcare Organizations, following the 
American Medical Association recommendation that pain be 
assessed as the fifth vital sign, established standards for 
pain management interpreted by many doctors as encouraging the 
prescribing of opioids. Under the Affordable Care Act, 
prescribing painkillers is incentivized because hospital 
payments are tied to patient satisfaction surveys that reward 
hospitals financially when patients give them high ratings.
    As we learned in our oversight hearing held in March, the 
opioid epidemic is an urgent public health threat fueled by 
fentanyl, a much more dangerous and potent synthetic opioid and 
a clear and present danger to America. Two states represented 
on today's panel, Rhode Island and Maryland, were the first 
ones hit by the fentanyl wave. Unfortunately, it seems certain 
that this wave will sweep the nation as the low-cost, high-
profit, hard-to-detect profile of fentanyl is increasingly 
attractive to traffickers and is relatively easy to manufacture 
or obtain on the street or over the internet.
    This is an in extremis moment requiring all the experience, 
resources, and cooperation of our federal, state, and local 
governments, as well as all the different industries, 
professionals, and experts to curb this outbreak. With this 
hearing, we will focus on the actions of our state governments 
to find out what efforts are working, what is not working, and 
how we can work together to save lives, restore communities, 
and repair the millions of families torn apart by the deadliest 
drug crisis in United states history. As drug policy expert 
Sally Satel noted ``[it] is at the state and county levels that 
the real progress will be made.It makes sense that the effort 
to find inspired solutions would be most concentrated there; we 
should invest in those solutions and learn from them.''
    Serving on the front lines of the opioid epidemic, state 
governments have been pursuing their own innovative 
initiatives, such as more inventive use of incentives, more 
structured medication assisted treatment and more comprehensive 
prescription drug monitoring. states such as Maryland are 
making the best use of the Centers for Disease Control Opioid 
Prescribing Guidelines to help push back on the overprescribing 
of opioids. Kentucky's All-Schedule Prescription Electronic 
Reporting System, or KASPER--a web-based database to monitor 
opioid prescription and use across the state--is helping state 
regulators identify questionable prescription practices by 
physicians and abuse by patients. Virginia has greatly expanded 
access to Naloxone, the drug that can rapidly reverse an opioid 
overdose.
    Some states are expanding the availability of Naloxone by 
permitting third party prescribing by family and friends of 
individuals who are at high-risk of overdose. Rhode Island has 
developed the AnchorED program that matches overdose victims 
with peer recovery coaches to encourage treatment, who follow-
up with the patient for the next 10 days after the overdose. 
Much of the work of the states should help inform the 
President's Commission on Combating Drug Addiction and the 
Opioid Crisis.
    Two years ago, the Subcommittee held a similar hearing on 
what the state governments were doing to combat the opioid 
abuse epidemic. Such oversight helped Congress enact provisions 
in the Comprehensive Addiction Recovery Act and 21st Century 
Cures Act which authorized the Substance Abuse and Mental 
Health Services Administration to administer nearly one billion 
dollars in grants over the next two years to states and 
territories for substance abuse prevention programs, treatment, 
and training for health professionals. We are eager to learn 
about how the states represented here today plan to use these 
grants, to ensure the grants are reaching local communities in 
need, and that the help provided is really working.
    However, the 21st Century Cures state grant program is just 
a beginning. Our state government witnesses can help this 
Committee develop a more effective national strategy to combat 
the opioid crisis in such areas as: substance abuse prevention 
and education, physician training, treatment and recovery, law 
enforcement, expanding access to Vivitrol while testing for 
drugs in correctional facilities, data collection, and 
examining what reforms can be made to 42 CFR Part 2 so that 
there is better coordination of care among physicians.
    We are honored to have our distinguished witnesses join us 
this morning. We thank you for appearing today and look forward 
to hearing your testimony.

    Mr. Murphy. Now I yield to my colleague for 5 minutes, Ms. 
DeGette of Colorado.

 OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Ms. DeGette. Thank you so much, Mr. Chairman. And I 
appreciate this most recent hearing on opioid addiction. As you 
said so accurately, this crisis is really devastating America, 
as all of us on the dais have seen it play out in our 
communities, urban and rural alike. Not a day passes without a 
report about children watching their parents overdose, about 
librarians and school nurses being trained to administer 
Naloxone to overdose victims, or about local and state 
governments trying to respond to the myriad of issues 
surrounding addiction, all, at the same time, trying to stay 
within their budgets.
    There is some good news. Recently, the CDC reported that 
opioid prescriptions peaked in 2010, and have since fallen by 
41 percent. That is the good news. The bad news is, opioid 
prescribing remains untenably high. And I am hoping our future 
investigations will concentrate on this.
    In addition, as you pointed out, Mr. Chairman, is the 
emergence of illegal fentanyl, which is an exceptionally potent 
opioid. In 2017, fentanyl overtook both heroin and prescription 
opioids as the leading cause of death in many places. Each of 
the states who are here today, and I want to thank you all for 
coming, have faced alarming overdose outbreaks due to this 
drug's pervasive dangerous nation.
    This committee has done some good work, in particular, 
investigating the seemingly voluminous amount of pills 
distributed in West Virginia. And I know that we are planning 
to do more. As you know, a number of state Attorneys General 
are investigating manufacturers, and, in some cases, 
distributors. The attorney general in my home State of 
Colorado, for example, has joined a bipartisan coalition of 
states nationwide, looking into whether manufacturers engaged 
in illegal or deceptive practices when marketing opioids.
    Coming up with an effective solution to the opioid epidemic 
will require us to understand the actions of all actors. I hope 
to hear from some of the states today on what role they believe 
drug manufacturers and distributors may be adding to the 
crisis. Also, I look forward to hearing from the panel about 
the impact of fentanyl on the towns and communities in which 
they work. states really are on the front lines of fighting 
this crisis, and I look forward to hearing from all of you.
    I know that Rhode Island, for example, has led the way in 
connecting people with substance abuse disorders to highly 
trained coaches to guide them through recovery. Virginia is 
working to implement a similar peer recovery program. And 
Kentucky has established a program to provide medication-
assisted treatment to individuals in correctional facilities 
and to continue supporting them after they are released. 
Maryland has just committed to establishing a 24-hour crisis 
center in Baltimore City.
    Mr. Chairman, I know these are all great state efforts. We 
have made some efforts here in Congress, and I appreciate you 
referring to the 21st Century Cures legislation that 
Congressman Upton and I sponsored, and that this whole 
committee worked together on a bipartisan basis to pass. But as 
we move forward on this issue, we really need to work together 
to continue to address this, and that is why I kind of hate to 
be the fly in the ointment, and talk about what these efforts 
to repeal the Affordable Care Act will do to the fight against 
the opioid epidemic. As you know, the ACA has helped nearly 20 
million Americans obtain healthcare coverage. In addition, it's 
enabled governors to expand Medicaid services that are critical 
tools in the fight.
    For example, studies that show that since 2014, 1.6 million 
uninsured Americans gained access to substance abuse treatment 
across the 31 states that expanded Medicaid coverage. This is 
particularly true for hard-hit states like Kentucky, where one 
study reports that residents saw a 700 percent increase in 
Medicaid beneficiaries seeking treatment for substance abuse. 
Many people think that the House-passed bill that undermines 
the ACA will threaten people's ability to get opioid treatment. 
In its assessment, the non-partisan CBO said the House bill 
would cost 23 million, or 22 million, Americans to lose health 
insurance. A lot of these people need opioid treatment.
    Now, there have been discussions, both in the House bill 
and the Senate discussions, about adding some money for opioid 
treatment. But, for example, the most recent Senate suggestion 
of additional $45 billion to help combat opioid addiction, 
Governor John Kasich said, ``It is like spitting in the ocean, 
it is not enough.''
    We have got to get real and understand that access to 
healthcare treatment is what is going to help with the health 
of all Americans, including treatment of opioid addiction. And 
we have got to move forward to work on this together. I hope we 
can do that. And with that, I will yield back, Mr. Chairman.
    Mr. Murphy. The gentlewoman yields back. I now recognize 
the chairman of the full committee, Mr. Walden.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Thank you very much, Mr. Chairman. Addiction is 
an equal opportunity destroyer. It is a crisis that does not 
pick people based on their age, race, or socioeconomic status, 
and it most certainly does not pick them based on political 
parties. From my roundtables throughout the Second District of 
Oregon, it didn't matter if I were in a rural community or a 
more populated city, the tragic stories were very similar. We 
all know someone who has been impacted by this epidemic.
    In my state, more people die from drug-related overdoses 
than from automobile accidents, and sadly, that is not unique. 
According to a preliminary data analysis, drug overdose deaths 
in 2016 likely exceeded 59,000 people. That is the largest 
annual jump ever recorded in the United states. And what's 
worse, some of the preliminary numbers from the states indicate 
that their numbers within the first 6 months of this year are 
already surpassing last year's total numbers. And over the past 
7 years, opioid addiction diagnoses are up nearly 500 percent, 
according to a recent report.
    Despite a report released by the Centers for Disease 
Control last week, which indicates the number of opioid 
prescriptions has decreased over the last 5 years. That's the 
good news. The rates are still three times as high as they were 
just back in 1999. And the amount of opioids prescribed in 2015 
was enough for every American to be medicated around the clock 
for 3 weeks. That report also found that counties in Oregon 
have some of the highest levels of opioid prescriptions in the 
country. Of the top 10 counties in my state for opioid 
prescriptions, five of them are in my rural district.
    Moreover, Oregonians, aged 65 and over, are being 
hospitalized for opioid abuse, overdoses, and other 
complications at a far higher rate than any other state in the 
Union. Sadly, overdose deaths continue to escalate, and this 
epidemic is simply getting worse and more severe. So challenges 
remain and we need to get after it.
    First, we need to improve data collection. In a few states, 
we are already requiring more specific information related to 
overdose deaths. Quite simply, we cannot solve what we do not 
know. We need to be able to have more timely and reliable data 
so we can better understand and address the full scope of the 
problem. There also needs to be an increase in overdose 
prevention efforts, improvement with respect to the utilization 
and interoperability of prescription drug monitoring programs. 
And we need to increase access to evidence-based treatment, 
including medication-assisted treatment.
    Combating this epidemic requires an all-hands-on-deck 
effort from Federal, state and local officials, and all of us 
spanning from healthcare experts to our local law enforcement 
communities, that's precisely why we are having this hearing 
today. Last year, Congress took action to combat this crisis by 
passing legislation, including the Comprehensive Addiction 
Recovery Act, and the 21st Century Cures Act, and states have 
pursued programs to strengthen our fight against this epidemic. 
But much more needs to be done. We need to work together to 
ensure that the tools and funding Congress has created are 
reaching our state and localities, and that they are being used 
effectively.
    We hope to hear from the state officials today to see how 
they are utilizing these funds, and whether these programs work 
or not. We greatly appreciate the witnesses who have agreed to 
appear before us today. We hope to have a constructive dialogue 
about what the states are doing, how we can improve data 
collection, what initiatives are working, what isn't working, 
and how the Federal Government can be a better partner in this 
collective fight.
    I look forward to your testimony and working with all of 
you and our community leaders to help get our hands on this 
horrific crisis. So thank you for being here. With that, I know 
I have two members that want to introduce witnesses, so I will 
go first to Mr. Guthrie, and then I'll go to Mr. Griffith.
    [The prepared statement of Mr. Walden follows:]

                 Prepared statement of Hon. Greg Walden

    Addiction is an equal opportunity destroyer. It is a crisis 
that does not pick people based on their age, race, or 
socioeconomic status. And it most certainly does not pick based 
on political parties.
    From my roundtables throughout the Second District of 
Oregon, it didn't matter if I was in a rural community or a 
more populated city; the tragic stories were similar. We all 
know someone who has been impacted by this epidemic. In Oregon, 
more people now die from drug-related overdoses than from 
automobile accidents--and sadly, that is not unique to my home 
state.
    According to a preliminary data analysis, drug overdose 
deaths in 2016 most likely exceeded 59,000--the largest annual 
jump ever recorded in the United states. What's worse? Some of 
the preliminary numbers from the states indicate that their 
numbers within the first six months of this year are already 
surpassing last year's total numbers. And over the past seven 
years, opioid addiction diagnoses are up nearly 500 percent, 
according to a recent report.
    Despite a report released by the Centers for Disease 
Control last week which indicates that the number of opioid 
prescriptions has decreased over the past five years, the rates 
are still three times as high as they were in 1999, and the 
amount of opioids prescribed in 2015 was enough for every 
American to be medicated around the clock for three weeks.
    That report also found that counties in Oregon have some of 
the highest levels of opioid prescriptions in the country. Of 
the top 10 counties in Oregon for opioid prescriptions, five of 
them are in my rural district. Moreover, Oregonians age 65 and 
older are being hospitalized for opioid abuse, overdoses, and 
other complications at a far higher rate than any other state 
in our union.
    Sadly, overdose deaths continue to escalate. This epidemic 
is getting more severe. Challenges clearly remain.
    First, we need to improve data collection, and a few states 
are already requiring more specific information related to 
overdose deaths. Quite simply, we can't solve what we don't 
know.
    We need to be able to have more timely and reliable data so 
we can better understand and address the full scope of the 
problem. There also needs to be an increase in overdose 
prevention efforts, improvement with respect to the utilization 
and interoperability of Prescription Drug Monitoring Programs, 
and we need to increase access to evidence-based treatment, 
including Medication-Assisted Treatment.
    Combating this epidemic requires an all-hands-on-deck 
effort from federal, state, and local officials--spanning from 
health care experts to our law enforcement community. That is 
precisely why we are having this hearing today.
    Last year Congress took action to combat this crisis by 
passing legislation, including the Comprehensive Addiction and 
Recovery Act and the 21st Century Cures Act, and states have 
pursued programs to strengthen our fight against this epidemic. 
But much more needs to be done. We need to work together to 
ensure that the tools and funding Congress has created are 
reaching our state and localities, and that they are being used 
effectively. We hope to hear from the State officials before us 
today to see how they are utilizing these funds and what 
programs have proven to be successful.
    We greatly appreciate the witnesses who have agreed to 
appear before us today. We hope to have a constructive dialogue 
about what the states are doing; how we can improve data 
collection; what initiatives are working, what isn't working; 
and how the federal government can be a partner in this 
collective fight. I look forward to your testimony, and working 
with all of you to help our communities and solve this horrific 
crisis.

    Mr. Guthrie. Thank you, Mr. Chairman. Thank you, Mr. 
Chairman, for letting me sit in for purposes of introduction. I 
want to introduce our Secretary of Justice and Public Safety in 
Kentucky, Secretary Tilley. We have been friends for a long 
time. We served in the general assembly together. Secretary 
Tilley had a strong reputation, strong work as fiduciary 
chairman in the House, working with the Senate to produce 
legislation that I think is landmark and was very important. 
And we have so much to do in Kentucky. We have 1404 people that 
passed away last year from opioid addiction.
    There is so much to be done. So we are sitting here saying 
thank you for the work that you have done. I know we have 
enormous work to be done, and I tell my colleagues on the 
committee here and my friends, I can think of nobody else in 
Kentucky I'd rather have in sitting where you are and leading 
this effort, and I applaud Governor Bevin for making the 
choice, and asking you to serve in his cabinet, and appreciate 
your willingness to do so. I think you will make a big impact. 
And I yield back.
    Mr. Walden. Now I recognize the gentleman from Virginia, 
Mr. Griffith, for purpose of introduction.
    Mr. Griffith. Thank you very much. I appreciate that. I 
would like to introduce Secretary Brian Moran. Brian was a 
prosecutor first, and then he came to the Virginia House of 
Delegates, where he and I served together for a number of 
years. He was a leader on the other side of the aisle, but he 
was always a pleasure to work with, and appreciate his work 
very, very much. And then he became the first Secretary of 
Homeland Security in Virginia's history, and has oversight over 
11 agencies. But he is generally well-reasoned; every now and 
then we would disagree on the floor of the House, but not 
always. But we worked together on a number of things. And I 
apologize, both Mr. Guthrie and I have to run to another 
committee where we have two bills that are upstairs, so I won't 
be able to stay, but I will read with interest your testimony 
and learn from my colleagues the good words that you have to 
say. And I welcome you to our committee, and I apologize that I 
can't be here because I'm defending a bill upstairs.
    Mr. Walden. With that, I will yield back the balance of my 
time. Unfortunately, I, too, must go to that subcommittee.
    Mr. Murphy. Come on back. This is where it's going to be 
exciting. I note Secretary Moran is a spitting image of his 
brother. I now recognize the gentleman from New Jersey, Mr. 
Pallone, for 5 minutes.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Mr. Chairman. Thanks for holding 
this hearing on this critical issue. Our committee has held 
several hearings on the ongoing opioid crisis, including one in 
March. The opioid epidemic is not letting up, and neither can 
our efforts to fight it. Since our last hearing many more lives 
have been destroyed. There is no community that remains 
completely untouched by the opioids crisis.
    Recently, the CDC reported that the opioid prescribing rate 
has peaked, but remains far too high, with enough opioids to 
keep every American medicated around the clock for 3 weeks. I'm 
glad we have the states here today so we can hear about what 
they're seeing on the front lines, what successful approaches 
they have found that deserve to be replicated, and what 
challenges they still face.
    I'd also like to hear from our witnesses about how the 
Federal Government can help. While it is important the states 
be empowered to address the particular challenges of their 
communities, our response to this epidemic cannot be 51 
separate efforts. We must harness our national resources data 
in cooperation to get this crisis under control.
    But as we talk about a public health crisis of this 
magnitude, there is an elephant in the room that needs to be 
addressed. Coverage for substance abuse treatment is how an 
individual in society has a fighting chance to kick the opioids 
epidemic for good. Health coverage is one of our strongest 
weapons in the battles against opioids, the epidemic, and the 
devastation it causes to our families.
    Yet, Republicans persist in their attempts to gut the 
Medicaid program by capping it permanently, and ending Medicaid 
expansion as part of its efforts to repeal the Affordable Care 
Act. Repealing the Affordable Care Act and replacing it with 
TrumpCare would be devastating to 74 million Americans who 
receive critical healthcare services from the program. Today, 1 
in 5 Americans receive their health insurance from Medicaid. 
Half of all the babies born in this country are financed by 
Medicaid. And to the working poor, many of whom are hit hard by 
the opioids epidemic, and are eligible for Medicaid for the 
first time through the ACA's expansion. Medicaid is, quite 
literally, the only affordable health insurance available. And 
make no mistake, state Medicaid programs are at the center of 
the opioids epidemic.
    Yet, in the House-passed TrumpCare, the CBO determined that 
23 million Americans would lose coverage, the majority of them 
covered through Medicaid, with $834 billion in cuts to the 
program. The Senate's version of TrumpCare is no better, 
cutting Medicaid by a full 35 percent over the next two 
decades. These cuts could not come at a worse time from the 
perspective of the opioids crisis for states and for people who 
depend on the coverage Medicaid provides. There's no substitute 
for coverage for our states or for the people that need the 
care.
    As the Senate continues to make cosmetic changes to its 
bill with only one goal in mind, passing any bill out of the 
Senate. Let's be very clear, no one-time amount of funds, 
whatever that amount may be, will ever replace the certainty of 
comprehensive coverage. No cosmetic changes can effectively 
offset the damage that could be caused by repealing the ACA and 
cutting hundreds of billions of dollars from the Medicaid 
program.
    So, Mr. Chairman, we must stay vigilant in this fight and 
remain open to any solution that shows promise. So I thank you 
for having this hearing. But I believe that there is no way 
that this crisis can be solved with one-time infusions of 
resources, and it will only get worse if Medicaid dollars are 
removed from the fight. We must invest in our healthcare system 
and its critical public programs for the long term, and 
Medicaid is clearly a critical pillar that should be 
strengthened, not decimated.
    And I fear that if Republicans are successful in passing 
TrumpCare, we will end up going in the opposite direction when 
it comes to fighting the drug problem that has so devastated 
our communities. Thank you, and I yield back. I don't think 
anybody on my side wants the time, so I yield back, Mr. 
Chairman.
    Mr. Murphy. Thank you for your comments. I ask unanimous 
consent that the members' written opening statements be 
introduced into the record, and without objection the documents 
will be entered into the record. I also note that two former 
members of this committee, Representative Mary Bono and Dr. 
Phil Gingrey, are present. Thank you for being here. And I, 
believe you said Mr. Stupak was around, too. Obviously, this is 
an important issue to those who are alumni committee as well.
    We heard so many introductions. Let me introduce the rest 
of our panel for today's hearings, the Honorable Boyd 
Rutherford, Lieutenant Governor of Maryland, welcome to the 
hearing. As mentioned before, Secretary Moran, Secretary 
Tilley; and the Honorable Rebecca Boss, Director of the 
Department of Behavioral Healthcare, Developmental Disabilities 
and Hospitals from the State of Rhode Island.
    Thank you for being here today and providing testimony. We 
look forward to our continued discussion on the opioid crisis 
facing our nation. As I mentioned before, I really want you to 
be brutally candid with us on what the problems are, what we 
need to do, and what are the gaps. You are all aware the 
committee is holding an investigative hearing, and when doing 
so has had the practice of taking testimony under oath.
    Do any of you have any objections to testifying under oath? 
Seeing no objections, the chair then advises you that under the 
rules of the House and rules of the committee, you're entitled 
to be advised by counsel. Do any of you desire to be advised by 
counsel during testimony today? Seeing none, then, in that 
case, please rise, raise your right hand and I will swear you 
in.
    [Witnesses sworn.]
    Mr. Murphy. Seeing all have answered in the affirmative, 
you are now under oath and subject to the penalties set forth 
in Title 18, Section 1001, United states Code. We'll ask you 
each to give a 5 minute summary of your statement. Please pay 
attention to the time here. We'll begin with you, Governor 
Rutherford, you may begin.

 TESTIMONIES OF HON. BOYD K. RUTHERFORD, LIEUTENANT GOVERNOR, 
  STATE OF MARYLAND; HON. BRIAN J. MORAN, SECRETARY OF PUBLIC 
  SAFETY AND HOMELAND SECURITY, STATE OF VIRGINIA; HON. JOHN 
  TILLEY, SECRETARY OF THE JUSTICE AND PUBLIC SAFETY CABINET, 
 STATE OF KENTUCKY; HON. REBECCA BOSS, DIRECTOR, DEPARTMENT OF 
     BEHAVIORAL HEALTHCARE, DEVELOPMENTAL DISABILITIES AND 
                HOSPITALS, STATE OF RHODE ISLAND

              TESTIMONY OF HON. BOYD K. RUTHERFORD

    Mr. Rutherford. Thank you, Chairman Murphy, Ranking Member 
DeGette. Honorable members of the subcommittee, thank you for 
the opportunity to join you today to discuss the State of 
Maryland's response to heroin and opioid crisis. Tackling this 
emergency necessitates a coordinated response from Federal, 
state and local government. And Maryland looks forwards to 
working together with our Federal partners to address this 
challenge.
    Governor Hogan and I first became aware of the level of 
this challenge while traveling throughout the state during our 
2014 gubernatorial campaign. We quickly realized the epidemic 
had crept into every corner of our state, cutting across 
demographics.
    Maryland, like most states, has experienced an increase in 
the number of deaths related to opioids. In 2016, 2089 
Marylanders died from alcohol or drug-related intoxication; 66 
percent increase over the deaths and 2015. And 89 percent of 
those deaths were related to opioids. Maryland has seen an 
increase in prescription opioid-related deaths, and so we must 
address this particular element of the crisis. We must focus on 
reducing the inappropriate use of prescription opioids, while 
ensuring patients have access to appropriate pain management.
    In Maryland, there were over 8.8 million total CDS 
prescriptions dispensed in 2016. This is 8.8 million in a state 
with 6 million souls. Further, the challenge we face has 
evolved. As was mentioned, cheap, powerful, and deadly 
synthetic opioids have burst onto the market, bringing a much 
higher overdose rate. Deaths related to fentanyl have increased 
from 29 in 2012 to over 1100 in 2016 in Maryland.
    Accordingly, as one of the Governor's first acts in 2015, 
was to establish the Heroin and Opioid Emergency Task Force, 
which he asked me to chair. After nearly a year of stakeholder 
meetings and expert testimony and research, the task force 
adopted 33 recommendations. Those recommendations range from 
prevention, access to treatment, alternatives to incarceration, 
enhanced law enforcement, and more. And they form the 
foundation of our statewide strategy. Building on those 
recommendations of the task force, the Maryland General 
Assembly passed several comprehensive pieces of legislation.
    In 2016, we reformed our prescription drug monitoring 
program to require mandatory registration for all CDS 
providers. We passed the Justice Reinvestment Act to reform our 
criminal justice system to shift from incarceration to 
treatment for offenders who are struggling with addiction.
    What we set out to do was make a distinction between those 
who we are upset with, and those who we are afraid of. This 
past legislative session, Maryland passed the Heroin and Opioid 
Prevention Effort, or HOPE Act, and the Treatment Act of 2017, 
which contains provisions to improve patient education, 
increase treatment services, and provide greater access to 
Naloxone.
    The Governor signed the Start Talking Maryland Act, which 
will continue to build school and community-based education and 
awareness efforts to bring attention to this crisis. Educating 
young people on the dangers of opioids at an earlier age was 
something that our task force felt was extremely important. As 
I have said over and over again, virtually every third grader 
can tell you how bad it is to smoke cigarettes, but they can't 
tell you how dangerous it is to take someone else's 
prescription medications.
    With the deadly surge of synthetics on the scene, we saw 
the death toll continue to rise. Accordingly, in January of 
this year, Governor Hogan established the Opioid Operational 
Command Center. The Center brings opioid response partners 
together to identify challenges and establish a systemwide 
priority and capitalize on opportunities for collaboration. It 
is a formal and a coordinated approach, utilizing the National 
Incident Management System to develop both state and local 
strategic operational and tactical level concepts for 
addressing the heroin and opioid crisis.
    Shortly after its creation, the Governor declared a state 
of emergency in response to this crisis. By executive order, he 
dedicated--delegated emergency powers to state and local 
emergency management officials to enable them to fast track 
coordination with state and local agencies. Thanks to your 
leadership and commitment, funding of the 21st Century Cures 
Act, has greatly aided in this effort. And these dollars will 
be used in expanding educational efforts in the schools, 
building public awareness, improving treatment, expanding our 
peer recovery specialist program, and increasing the 
availability of Naloxone.
    The one thing that I would add that we would like to see 
from the Federal Government is to consider utilizing FEMA as 
outlined in the national emergency framework to centralize and 
coordinate the Federal response to this crisis. The national 
response framework is a guide to how the Nation responds to all 
types of disasters and emergencies, and it would allow Federal 
agencies to work more seamlessly with each other and with the 
agencies at the state level. We can't afford to have delays due 
to agency silos and bureaucracies. I appreciate this 
opportunity to talk to you and await any questions you may 
have.
    [The prepared statement of Mr. Rutherford follows:]
    
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Murphy. Thank you. Thank you, Governor. Secretary 
Moran, you're recognized for 5 minutes.

                TESTIMONY OF HON. BRIAN J. MORAN

    Mr. Moran. Mr. Chairman and members of the committee, it is 
still very much an honor to be with you this morning, and to be 
able to discuss with you Virginia's response, as well as 
working with you to request assistance from the Federal 
Government to combat this epidemic. As has all been agreed and 
said this morning, America is in the midst of an opioid and 
heroin addiction epidemic. The epidemic does not discriminate; 
it is an equal opportunity killer.
    In Virginia, in 2016, 1133 individuals died from opioid 
overdose. The sad truth is that Virginia actually ranks 18th 
among the 50 states in overdose deaths. Sadder than that, 17 
states are doing worse than we are. And in all likelihood, the 
other 32 states would be facing similar devastation if we don't 
take effective action now.
    As Secretary of Public Safety and Homeland Security, I am 
very proud of Virginia sworn law enforcement officers who work 
24/7, 365, to keep us safe. But what they tell me over and over 
and over again is, we cannot arrest our way out of the heroin 
and opioid addiction crisis. And we can't simply tell those 
living with addiction to get over it. Why is that? Because 
addiction is a disease.
    Arrest and incarceration of those addicted will no more 
cure this disease than it would cure cancer or diabetes. There 
are a number of causes, multiple causes of this dramatic rise 
in the deadly epidemic of overprescribing, failure to safely 
dispose, easy access, and affordability. But over the last 
several years, we have seen a sharp rise in illegally 
manufactured synthetic opioids such as fentanyl and 
Carfentanil. Lethal in even tiny amounts, they contribute 
significantly to the increased numbers of heroin and opioid 
deaths. From 2015 to 2016, the number of fatal overdoses 
involving fentanyl increased to 175 percent, and accounted for 
618 of the 1133 deaths in the Commonwealth.
    Virginia's response to this epidemic began immediately upon 
Governor McAuliffe taking office in 2014. He convened a broad 
coalition of healthcare providers, criminal justice 
representatives, and community stakeholders to participate in 
the prescription drug and heroin use task force. The Secretary 
of Health and Human Resources cochaired the committee with 
myself. The task force developed over 50 recommendations. I am 
proud to say we have implemented the vast majority of those 
recommendations, the full list of which can be found in my 
submitted written testimony. Of course, the work continues in 
Virginia.
    Our executive leadership team works across state government 
and with regional and local agencies and individuals to 
effectively align goals, share best practices, and work to 
overcome barriers to success. The leadership team organized a 
statewide approach to opioid crisis and provided leadership 
from the Virginia state Police, Department of Health, and from 
our local community service providers. Again, that is a theme 
that this is not just a law enforcement problem, but, rather, 
one that requires healthcare providers to be at the table along 
with their community service providers.
    They support coordination among local grassroots 
organizations, task forces, and other collaborations, including 
those that exist within Virginia's HIDTA designated areas, 
which cover parts of Northern Virginia, Appalachia, and Hampton 
Roads. So there is more work to be done. Let me highlight some 
of our accomplishments. The General Assembly enacted 
legislation expanding the deployment of Naloxone. Lay people, 
law enforcement officers, state agencies like our Department of 
Forensic Science and others working with potentially dangerous 
drugs, are being trained in using this overdose reversal agent 
through the Department of Behavioral Health and Developmental 
Services Revive program. Our Commissioner of Department of 
Health issued a standing order for pharmacies to dispense 
Naloxone. The Department of Criminal Justice Services issued 
grants to pay for increased Naloxone to be used by law 
enforcement. In fact, the city of Virginia Beach has used 
Naloxone now, and they have had over 60 deployments to save 
lives in that community.
    Now, our requests. I came into this job with a mandate from 
my 11 public safety agencies that we would rely on data-driven 
decision making. If we are going to effectively wrap our arms 
around this epidemic and reverse the devastating upward trend 
in deaths, overdoses, and related crime, we need to know what 
the problems are, where they are, and what is working. To do 
that, we need good data. Here are some of the identified needs 
that Congress and the administration can help us address.
    Craft limited exceptions to current regulatory and 
statutory barriers under HIPAA, in 42 CFR, Part 2, which is the 
substance abuse privacy protections. For example, our 
prescription drug monitoring program is prohibited from 
accessing any data from our methadone clinics. That is, we need 
to know how they work and who they are providing care for, and 
how it is working; provide technical assistance or fund staff 
positions for states and localities in developing metric-
sharing data in analyzing results; support development of 
consistent national metrics; incentivize private providers or 
mandate data collection as a requisite for Federal funding; 
change how the Federal agencies do business; increase support 
for SAMHSA and HIDTA; break down Federal funding silos, reduce 
demand; support, train, incentivize law enforcement to focus on 
mid and high level dealers; and help us divert those who are 
addicted into treatment programs. Our treatment programs are 
currently insufficient to address this epidemic.
    Those with addictions shouldn't become law enforcement's 
problem, they belong in the healthcare system. Examples of 
programs to explore further, include assist localities to 
pilot, analyze, and determine the efficacy of Angel programs in 
police departments, fully fund the dissemination and 
utilization of Naloxone or other overdose drugs. My time is up. 
There are a lot of requests, but you invited the requests, Mr. 
Chairman, but I will stop if----
    [The prepared statement of Mr. Moran follows:]
    
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Murphy. We will get more into that as we cover 
questions. Thank you, Mr. Moran. Secretary Tilley, you are 
recognized for 5 minutes.

                 TESTIMONY OF HON. JOHN TILLEY

    Mr. Tilley. Mr. Chairman and members, thank you so much for 
allowing me the chance to be here. I want to thank Governor 
Matt Bevin from Kentucky for that chance as well. He sends his 
regrets. He wanted to be here himself. He's been outspoken on 
this topic. I will share with you a quick story. When I first 
met Governor Bevin, he was interviewing for this position, for 
this job, and he walked into a room with Dreamland under his 
arm, and he said, have you read this book? And thankfully, I 
had. So I said, yes, sir, I have read the book. And, actually, 
I am trying to reread it because it is, again, I think the best 
chronicling of this problem and how it began that I know of.
    So that, again, illustrates to you our commitment and our 
shared understanding of this problem. I want to thank 
Congressman Guthrie for that far-too-kind introduction as well. 
Dreamland, again, is relevant to us because, as you know, the 
problem really has its origins in Kentucky and Ohio. We lost 
1404 Kentuckians, as the Congressman said. Fentanyl is now the 
driving force behind these overdoses. We had 13,000 ER visits, 
13,000 ER visits in a state of 4 1A\1/2\ million people. We 
lose, in this country, as you've heard those numbers, nearly a 
commercial airplane a day. If this were a communicable disease, 
we would be wearing hazmat suits to combat it.
    But again, I think overdoses and those visits only tell 
half the story. This devastates communities. As soon as we got 
our arms around heroin, we began to see fentanyl. Our State 
Police tells us that in the last 6 years alone, we have seen a 
6,000 percent increase in fentanyl in our labs. 6,000 percent 
increase. I think all of us know the devastation it's had on 
our criminal justice community. Our jails and prisons are at 
capacity. We have no more room at the inn.
    The Public Health crisis is on full display. In Kentucky, 
we have a Hep C rate, Hepatitis C, a form of viral hepatitis 
that is seven times the national average. Right across the 
river in Indiana, they had an outbreak of HIV that rivaled that 
of Sub-Saharan, Africa. One of the first southern states to 
pass a comprehensive--maybe the only comprehensive syringe 
exchange program. Now in Kentucky, we have 30 programs all 
passed by local option in our state. We know that that 
increases the treatment capacity by five times. When someone 
just walks over the doorstep of one of those programs, and it 
battles back these diseases like Hep C and HIV.
    Sadly, Kentucky, as the CDC reports, has 54 of 220 counties 
most susceptible to a rapid outbreak of HIV. So what has our 
response been in Kentucky to battle this? Again, taking a bold 
step as a southern state on the syringe exchange program; 
passing comprehensive legislation in consecutive years on 
prescription pills and pill mills; the second state in the 
country to battle back synthetics; dealing with heroin directly 
and fentanyl; being the first state in the country to mandate 
usage of what we call KASPER, our PDMP, our prescription drug 
monitoring program.
    Now we have become the first state in the country now to 
require physicians, when prescribing, for acute pain, to limit 
prescriptions to 3 days. Some have done 7, some have done 10. 
We limited that to 3 days. And I could promise you, our 
Governor has spent some capital on that. That's how important 
it is to him.
    We have doubled down on things like rocket dockets and 
alternate sentencing worker programs, and help for those who 
are addicted through various forms of treatment. Again, looking 
at things like neonatal abstinence syndrome. We have 1900 cases 
in Kentucky. We've increased funding many times to combat that 
and to help for the suffering of those addicted there. We have 
put it in our jails and our prisons. Again, I think I mentioned 
rocket dockets with prosecutors, again, to try to make these 
cases, put them on a separate plane, to deal with them in the 
most appropriate way possible.
    We have increased treatment at the Department of 
Corrections by nearly 1100 percent since 2004. We validate that 
treatment every year, and our return on investment now is 
almost $5. Some of the innovative programs you may have heard 
about, it was just recently chronicled in The New York Times, 
is the way we use Naltrexone, or Vivitrol, as it's known, in 
our jails, on the front lines. We give an injection prior to 
release, and an injection upon release. And then we try to link 
that offender, that returning individual, to those services in 
the community to see if they are Medicaid-eligible, to see what 
kind of resources they had to continue that particular 
treatment. And I know a question will be, do we link those 
folks up to counseling? We do our best to do it. It is not 
mandated. We do our best to do that.
    In fact, in Kentucky, I will tell you both, validated and 
anecdotally, we are seeing tremendous results from using MAT 
and counseling together, but counseling in the form of 
cognitive behavioral therapy, like moral reconation therapy. We 
are seeing that used in both our jails and prisons, and that is 
yielding some tremendous results. We intend to emulate what's 
been going on in Rhode Island with the AnchorED program. We 
visited there with Director Boss some time ago through an NGA 
project. And I can promise you, we are doing peer recovery and 
bridge clinic soon. We'll do some innovative awareness. We'll 
use a hotline to get folks linked up to treatment. We're even 
educating our medical and dental schools. And overall, as I 
close out and conclude at the end of my time, I will tell you 
that I think we have the most comprehensive effort I've seen in 
my 25 years in criminal justice with something called KORE, the 
Kentucky Opioid and Response Effort.
    So with that, I will look forward to questioning. Thank 
you, Chairman.
    [The prepared statement of Mr. Tilley follows:]
    
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Murphy. Thank you, Mr. Secretary. Director Boss, you 
are recognized for 5 minutes.

                 TESTIMONY OF HON. REBECCA BOSS

    Ms. Boss. Thank you, Chairman Murphy. Thank you, Chairman 
Murphy and Ranking Member DeGette. As the director of Rhode 
Island's Department of Behavioral Healthcare, Developments, 
Disabilities and Hospitals, I oversee the state's treatment, 
prevention and recovery system. I am also a longstanding member 
of the National Association of State Alcohol and Drug Abuse 
Directors, and currently serve on their board.
    Thank you for the invitation to appear before you today to 
share Rhode Island's work in combating the opioid crisis, an 
effort that has been proposed as a national model. Our 
strategies to address this epidemic are clearly outlined on our 
Web site: preventoverdoseri.org. And I will be sharing slides 
from this Web site during this testimony.
    Our goal is to make these efforts open to the public with 
complete transparency on outcomes and available for replication 
throughout the country. First and foremost, I would like to 
thank Congress for the action taken last year passing the 21st 
Century Cures Act with $1 billion to help support prevention, 
treatment, and recovery. In a time of tight budgets, we fully 
appreciate the significance of this action.
    Addiction and overdose are claiming lives, destroying 
families, and undermining the quality of life across states in 
the United states, and Rhode Island has been one of the hardest 
hit. In 2015, newly elected Governor Gina Raimondo recognized 
the need for this state to develop a comprehensive strategy to 
prevent, address, evaluate, and successfully intervene to 
reverse the overdose trends. She signed an executive order 
establishing the Governor's Overdose Prevention and 
Intervention Task Force, which is comprised of stakeholders and 
experts from a broad array of sectors. The resulting plan has 
one overarching goal: reduce overdose deaths by one-third in 3 
years. Governor Raimondo's plan focuses on four specific 
strategies, which I will briefly outline and focus on two 
specific areas, others are described fully in my written 
testimony.
    The first is prevention. We take aggressive measures to 
ensure appropriate prescribing of opioids, promote safe 
disposal of medication, and encourage the use of alternative 
pain management services.
    Next is Naloxone, rescue. Naloxone is a standard of care 
for first response. Naloxone saves lives by reversing overdose. 
And our plan supports increasing access to Naloxone across 
various sectors of the state.
    Third, we believe that every door is the right door for 
treatment, and our goal is to increase access to evidence-based 
treatment. To do this, Rhode Island developed Centers of 
Excellence, which provide rapid access to treatment, including 
induction on all FDA-approved medications for opioid use 
disorder. These specialized programs provide thorough clinical 
assessments and intensive treatment services with wraparound 
support. This program is designed to provide opportunities for 
stabilization with referrals to community physicians for 
continued treatment, offering continued clinical and recovery 
support through the Centers of Excellence. This program is 
supported through private insurance and Medicaid.
    In addition, Rhode Island released the Nation's first 
statewide standards for treating overdose and opioid use in 
hospitals and emergency settings. And the Rhode Island 
Department of Corrections is providing medication-assisted 
treatment to the population most at risk for overdose. We have 
worked diligently to increase data-waivered physicians in Rhode 
Island. For example, Brown University Medical School is the 
first in the Nation to incorporate data-waivered training into 
its curriculum.
    Finally, recovery. We are looking to expand recovery 
supports. Recovery is possible. To support successful recovery 
from more Rhode Islanders, we are expanding peer recovery 
services, particularly at moments when people are most at risk. 
The AnchorED program was started in June of 2014, and is now a 
statewide, 24/7 service. It connects overdose survivors with 
peer recovery coaches in hospital emergency departments. These 
coaches share their own stories of hope and inspiration to 
engage those in crisis, as well as providing continued 
services, and follow up in connection. To date, over 1600 
individuals have met with recovery coaches; and as a result, 
over 82 percent have accepted a referral to treatment.
    The Anchor MORE Program exists as a statewide peer outreach 
effort to opioid hotspots that are identified through data, not 
waiting for someone to overdose to be seen. We are now facing a 
fentanyl crisis. As you can see in this slide, with 
approximately two-thirds of overdoses, fentanyl-related, we 
must develop new strategies to address the changing face of 
this epidemic.
    As we speak, the Rhode Island Governor is signing an 
executive order expanding our efforts to include more focus on 
primary prevention, engaging families and youths in these 
efforts, harm reduction strategies, and access to treatment. I 
cannot state strongly enough that Rhode Island's strategies 
rely on sustainable funding through Medicaid and health 
insurance held to standards of parity with SUD treatment as an 
essential benefit. Any action taken on a Federal level which 
would threaten this funding would weaken this plan 
substantially.
    I would also recommend that any Federal initiatives 
specifically include involvement of state agencies given their 
expertise in these matters. I would advocate for continued 
support of the Substance Abuse Prevention Treatment block grant 
as the foundation of comprehensive state systems. And finally, 
I would encourage continued consideration of targeted funds to 
address these issues.
    Thank you for this opportunity to testify. I look forward 
to answering questions.
    [The prepared statement of Ms. Boss follows:]
    
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Murphy. Thank you all. I recognize myself now for 5 
minutes. Starting with Governor Rutherford, regarding the 42 
CFR, Part 2, a couple of effects. One is, as also as pointed by 
Secretary Moran and others, if someone is using a PDMP, the 
data is simply not in there. A physician prescribing will not 
know if that patient is on methadone, suboxone or some other 
synthetic opioid.
    Secondly, if a person shows up in an emergency room--our 
former colleague, Patrick Kennedy, talks about this incident--
shows up there with an injury, and when asked if that person 
has any allergies or any drugs, and he says, ``Please don't 
give me any opioids.'' They do it anyway, because there's 
nothing in the record that's prohibitive of being in the 
record. We can list if a person has an allergy, but an opioid 
sensitivity should be in there as well. But the law in place 
since the Nixon administration does not allow that to be in 
there. So the person then may leave that hospital with a vial 
of opioids, and then saying, ``Well, when I used to be 
addicted, I used to take 20 of these at a time, I'll take 20 
now.'' Overdose and death. Or they may take them and then they 
relapse, or they may be on other medications, such as 
benzadine, the PNN, a bad drug interaction.
    What do you recommend we do with that 42 CFR Part 2?
    Mr. Rutherford. Well, that does have to be addressed. 
You're exactly right. And Secretary Moran was correct in terms 
of that particular challenge. A person who goes in who may be 
receiving methadone treatment, they go in for a knee 
replacement. There's nothing to tell that doctor that this 
person is also receiving methadone, when they prescribe 
oxycodone or OxyContin or something of that nature. It doesn't 
show up in our prescription drug monitoring system as well.
    So it is a particular challenge. It needs to be addressed. 
There are some areas with regard to HIPAA that also go to other 
areas of behavioral health, and I know you talked about that. 
When we talk about mental health and the challenges associated 
with getting assistance for an adult family member, once that 
person goes from 17 to 18, you lose a lot of control when you 
can help this person. So, yes, if you can make some type of 
exceptions or clarification----
    Mr. Murphy. At least in the----
    Mr. Rutherford. That is also a misunderstanding among some 
of the doctors as well.
    Mr. Murphy. At least in the medical record to be able to do 
a 42 CFR----
    Mr. Rutherford. Yes, that would be a start.
    Mr. Murphy. Let me ask another quick survey. Noting that 
most people with an addiction disorder have a co-occurring 
mental health disorder. I was just wondering if any of you have 
taken a survey in your states? Do you have a sufficient number 
of psychiatrists, psychologists? I believe the national numbers 
say that half the counties in America have no psychiatrists, no 
psychologists, no clinical social worker, no licensed drug 
treatment counselor.
    If you know? If you don't know, tell me. But if you do 
know, do you have ever a sufficient number in your state to 
meet the need?
    Mr. Rutherford. I can only speak anecdotally. There are 
some counties in our state that have a substantial shortage of 
those types of professionals, including drug counselors. That 
is the challenge that we have.
    Mr. Murphy. Secretary Moran, real quick, yes or no.
    Mr. Moran. Yes. And it varies by geography in southwest 
Virginia, Congressman Griffith represents a very insufficient 
shortage of such counseling.
    Mr. Murphy. Secretary Tilley.
    Mr. Tilley. Urban areas, yes; rural areas, no. We do have a 
community mental health network we're proud of. But, again, in 
the rural areas, they are still struggling to find the 
qualified professionals.
    Mr. Murphy. Thank you. Director Boss?
    Ms. Boss. Rhode Island shares in the Nation's struggle with 
the number of psychiatrists needed to meet the demands. So I 
would say, yes, there is a psychiatrist shortage.
    Mr. Murphy. Thank you. The other issue is medication-
assisted treatment, Director Boss, with regard to that. In 
Pennsylvania, we had some data that says that people who are in 
an MAT and may be getting suboxone or something. The question 
is, are they getting treatment? And I'm wondering if your state 
and other states, too, if people have actually reviewed that? I 
heard in some cases, the treatment is no more than a nurse in 
the waiting room, saying, ``So how are you doing today?'' And 
they call that group therapy if a doc says, ``Is everything all 
right?''
    But in Pennsylvania, 59 percent had no counseling in the 
year that they received buprenorphine, 40 percent were not drug 
tested in the year they received it, 33 percent have between 
two and five different prescribers, and 24 percent of them 
didn't see a physician in the prior 30 days.
    Can you describe if you have the data in Rhode Island and 
other states? Is that something to really find out if they are 
getting real counseling?
    Ms. Boss. No. In Rhode Island, our opioid treatment 
programs are required to provide counseling, and they are----
    Mr. Murphy. But do you know if they are really doing it?
    Ms. Boss. Yes. We actually do reviews of our programs. So 
the state licenses the opioid treatment programs, and goes out 
to review records and to make sure that they are abiding by the 
counseling standards as well----
    Mr. Murphy. I appreciate reviewing the records. I am going 
to push on this, because we need to know this. I have heard 
from people who go to centers who tell me that they are listed 
in the records as having counseling, and they have no more than 
someone saying, How are you doing? I'm just curious. Not Rhode 
Island. I have heard other states.
    Ms. Boss. Mr. Chairman, without actually being able to sit 
in on sessions and time the sessions and make sure that they 
are happening, we have to rely on the validity of the record 
with which we review. And so, unless people are willing to 
commit fraud and put their licenses on the line by documenting 
something that didn't happen, I would have to say that I 
believe that what I read in the record to be true.
    Mr. Murphy. OK. I think this committee has dealt with so 
much fraud. We have to move on. Ms. DeGette, you're recognized 
for 5 minutes.
    Ms. DeGette. Mr. Chairman, it's called medically assisted 
treatment, and you're right, counseling has to be an important 
part of that. So if they are not giving the counseling, I would 
think they should. But I don't think we have any evidence that 
there's fraud being committed in Rhode Island.
    Mr. Murphy. No, I'm not picking on Rhode Island. We love 
Rhode Island.
    Ms. DeGette. Yes, we do. My daughter went to Brown 
University, and we love Rhode Island. So I want to talk to you 
a little bit, Director Boss, about this issue of states being 
able to pay for treatment. And this is--the full range of 
treatment--and I think it applies in all the other three 
states, too. I would assume that paying for treatment on this 
scale is really an ongoing challenge facing your state. Would 
that be a fair statement?
    Ms. Boss. Congresswoman, that would be a fair statement 
prior to 2014. But we have seen significant increases in the 
number of people being able to access treatment, post Medicaid 
expansion.
    Ms. DeGette. And so the Medicaid expansion has helped. And 
we hope 21st Century Cures helped, too, but we know that 
there's a lot more work that needs to be done. In fact, in your 
statement, you said Medicaid has laid the foundation for 
treatment coverage. Is that correct?
    Ms. Boss. That is correct.
    Ms. DeGette. So I wonder if you can just tell me, quite 
briefly, how Medicaid funds are helping Rhode Island fight this 
epidemic?
    Ms. Boss. So Medicaid funds in Rhode Island cover 
medication-assisted treatment, all three forms of FDA approved 
medications, methadone, buprenorphine, and injectable 
Naltrexone. They support something known as OTP health homes, 
and that's a comprehensive program to integrate healthcare with 
individuals who are receiving methadone treatment, as well as 
all other forms of treatment. And Rhode Island has a full 
continuum of treatment from inpatient detoxification to 
outpatient treatment to residential treatment to the use of 
medication and assistant treatment as well.
    Ms. DeGette. Now, have you looked at these bills that House 
Republicans have passed, and that the Senate Republicans are 
looking at, which would severely reduce the Medicaid aid to the 
states?
    Ms. Boss. I have.
    Ms. DeGette. How would those impact your State of Rhode 
Island?
    Ms. Boss. So any bill that would reduce access to Medicaid 
and Medicaid expansion, or reduce access to affordable health 
insurance would have negative impact on Rhode Island, as 77,000 
lives are covered, approximately, by Medicaid.
    Ms. DeGette. You have 77,000 people in Rhode Island covered 
by the Medicaid expansion?
    Ms. Boss. Correct.
    Ms. DeGette. Now, Secretary Tilley, a recent AP analysis 
showed that the Medicaid expansion accounted for more than 60 
percent of the total Medicaid spending on substance abuse 
treatment in Kentucky. Between 2012 and 2014, there's been a 
more than 700 percent increase in substance abuse treatment 
provided to Kentucky residents due to Medicaid's expansion.
    So, I guess I want to ask you, it looks to me like Medicaid 
has been particularly helpful in Kentucky's fight against the 
opioid crisis. Would you agree with that?
    Mr. Tilley. Let me say this: I will tell you unequivocally 
of our Governor's commitment, and again, exampled by the 1115 
waiver, and our effort at this very moment to expand our 
treatment options under that----
    Ms. DeGette. Let me ask you my question. Would you agree 
that Medicaid has been particularly helpful in Kentucky's fight 
against the opioid crisis?
    Mr. Tilley. I would agree----
    Ms. DeGette. Thank you.
    Mr. Tilley. I would agree. Yes. I would agree that through 
a number of sources of funding, we have increased treatment 
dating back to 2014 by 1100 percent dating to today.
    Ms. DeGette. Let me ask you this: Let me ask you this. If 
the Medicaid expansion went away, would that impair your 
efforts to fund this in Kentucky?
    Mr. Tilley. Ma'am, I'm the Secretary of the Justice and 
Public Safety cabinet, and I do have five major----
    Ms. DeGette. You're not going to answer my question, so I 
am going to ask Secretary Moran a question. Secretary Moran, 
Governor McAuliffe attempted to expand Medicaid twice in 
Virginia, but the Republican legislature rejected both of the 
attempts. So I want to ask you, I know Virginia is making the 
most out of the tools it has, but if you had had Medicaid 
expansion, more money in Virginia, would this have helped you 
be able to reach out to more people on this opioid issue?
    Mr. Moran. Simple answer is yes. That's an emphatic yes.
    Ms. DeGette. Why is that?
    Mr. Moran. More people would have access to treatment. Now, 
I will give credit to our Department of Health, they are using 
a very innovative ARTS program, addiction, recovery and 
treatment services, to carve out a Medicaid waiver to try to 
address these individuals' addiction needs. But with Medicaid 
expansion, 400,000 Virginians would be covered, and Governor 
McAuliffe has attempted to do that at every opportunity.
    Ms. DeGette. Thank you very much, Mr. Chairman. I yield 
back.
    Mr. Murphy. I recognize Mr. Collins for 5 minutes.
    Mr. Collins. Thank you, Mr. Chairman. I think maybe I'll 
start this question with Secretary Moran.
    All of us all agree here that opioid addiction is a 
disease, it is an addiction, and we all experienced the tragic 
deaths of many of our young children when it comes to the 
overdose. And as was just pointed out, we also have the 
fentanyl issue.
    So my question really is surrounding Naloxone, or Narcan, 
as we know it. And could you help the committee understand some 
of the key issues on availability--because we do hear there may 
be some shortages, cost. Who is picking up the tab for this? Is 
it patients? Is it the state? Is it the Federal Government--to 
maybe give us a little bit of an overview on how we are at 
least attempting to deal with that piece.
    And, also if someone is obviously in an OD, are they given 
Narcan without really--you don't know. Are they OD on opioids 
or fentanyl?
    Mr. Moran. Thank you very much for the question, 
Congressman. We are attempting to expand the coverage of 
Naloxone in every community. With the law enforcement 
community, there is some resistance, particularly from our 
rural jurisdictions because--merely because they are not the 
first to respond typically in a large jurisdiction. Usually it 
is the emergency medical services. EMS does carry it. The 
majority of our jurisdictions in law enforcement communities, 
and certainly in urban areas, now carry it. And as I mentioned, 
Virginia Beach has a tremendous success rate. They are saving 
up towards of a life a week with the use of Naloxone.
    Now, that's law enforcement. That's EMS. We appreciate the 
Federal grants through the Department of Criminal Justice 
Services so that we can provide, without any cost to the local 
jurisdiction that uses Naloxone. Now, in terms of lay people, 
our Department of Health commissioner issued an order so that 
anyone now can go into a pharmacy and receive the prescription 
for Naloxone.
    So we are attempting to expand coverage in any way 
possible. It is obviously a lifesaver, and the more people who 
will have it, more lives will be saved.
    Now, obviously then once you revive that individual, there 
are consequences after that in terms of needs for treatment. 
But the Narcan itself is truly a lifesaver, and more people 
that carry it--within our Department of Forensic Science, for 
instance, one issue with respect to the carfentanil and 
fentanyl, because it is so dangerous and lethal, we are 
provided authority now for all of our lab technicians to carry 
it, that they may be subject to a lethal dose when they're 
analyzing evidence in the criminal case. And so, again, as many 
people can have it, it is a very significant piece in this 
entire puzzle.
    Mr. Collins. Now, we have heard that the FDA is considering 
making Narcan over-the-counter. Now, you just mentioned anyone 
could go in and fill a prescription. But that, I guess, would 
certainly indicate they have to have a prescription to start 
with issued by a doctor. And I don't know if there is--people 
sometimes do have different kinds of concerns in admitting that 
they've got an issue. Could you expand on that a little bit on 
what you may know of the FDA making over-the-counter and, also, 
how does someone get this prescription, which obviously they 
would then fill.
    Mr. Moran. Congressman, that's what the standing order did 
is that you do not need a prescription now. You can actually go 
in and obtain the Narcan without a doctor's written 
prescription. And that was the standing order from our 
commission of health.
    Mr. Collins. So that's statewide.
    Mr. Moran. That is correct.
    Mr. Collins. And that's what the FDA is actually looking to 
expand nationwide. And what's your experience with that? Are 
you tracking how many people--are these, perhaps, family 
members who know that someone that's got this addiction and 
they're being anticipatory, to use that word, just in case?
    Mr. Moran. That is certainly the intent to--if you have a 
loved one who is addicted, you would take the proactive step of 
obtaining the Narcan in case of an overdose. And we have been 
trained--myself, the first lady of Virginia, the Governor the 
Virginia. We received revived training. It is very simple. It 
truly is. And we would encourage people to have access to 
Narcan in case of an overdose.
    Mr. Collins. That's a great example, and I'm just thrilled 
you have shared that with us. Maybe that's a message, if the 
FDA doesn't move, that other states obviously could take those 
same steps, because if we can save lives, then you should be 
able to go home and say job well done.
    Thank you for sharing that. And I yield back.
    Mr. Murphy. Mr. Tonko, you are recognized for 5 minutes.
    Mr.Tonko. Thank you, Mr. Chair, and thank you, chair 
witnesses, for their public service and for the testimony that 
they shared today.
    Before I get to my questions, I would be remiss if I didn't 
echo my colleagues' remarks on the devastating impact that 
TrumpCare, in its iterations, would have in the fight against 
the opioid epidemic. This mean, and might I say very mean, bill 
will rip hope away from people in communities across my 
district who depend on coverage from the Affordable Care Act 
and Medicaid expansion to help them recover from the scourge of 
opioid addiction. Medicaid by far is the single largest payer 
for behavioral health services in our country. In Rhode Island, 
Medicaid pays for nearly 50 percent addiction treatment 
medication. In Kentucky, it's 44 percent; Maryland, 39 percent; 
Virginia, 13 percent.
    The bill being considered in the Senate would cut $772 
billion, or 26 percent, from Medicaid over the next decade. 
There is no way this highly efficient safety net program could 
sustain this type of funding loss and continue to provide 
services for all that require it.
    Simply put, passing TrumpCare would be the single biggest 
step backward in providing treatment for substance use and 
mental health services in our Nation's history. That being 
said, last year I collaborated with my friend Dr. Bucshon on 
legislation that expanded buprenorphine prescribing privileges 
to nurse practitioners and physician assistants. And I would 
like to gather your feedback on how this law is being 
implemented in your states?
    Director Boss, you mentioned in your testimony that Rhode 
Island is actively working to provide DATA 2000 training to 
interested practitioners. Have you seen significant interest 
from the nurse practitioners or physician assistants 
communities in becoming waivered practitioners?
    Ms. Boss. Congressman Tonko, I'm not sure that I have data 
on how many nurse practitioners and physicians assistants have 
applied to take data-waiver training. I know that we are 
actively working with medical schools to get that interest and 
to increase the training available, but I'm not sure that I 
would be able to answer that comprehensively.
    Mr. Tonko. But as you are aware, there is interest in it?
    Ms. Boss. Absolutely. There is interest, and there is 
active work with the Department of Health and within my 
department to provide those trainings to any and all interested 
parties. And we've seen increased number of data-waivered 
physicians. We will be working with the nurse practitioners in 
PA schools to increase those as well.
    Mr. Tonko. Are there any projections you've made in terms 
of these additional classes of practitioners being able to 
prescribe MAT's improved addiction treatment access in Rhode 
Island?
    Ms. Boss. We track through our overdose Web site and our 
regular performance management meetings the number of people 
receiving buprenorphine treatments. So we're able to look at 
the increases and, through our prescription drug monitoring 
program, track the number of waivered physicians that are 
actively prescribing. And so we are seeing increases in the 
number of people receiving buprenorphine treatment through 
these efforts.
    Mr. Tonko. But I would assume that the further expansion of 
the DATA 2000 waiver, either in higher patient caps or 
additional classes of practitioners prescribing would have a 
positive impact on access to treatment in Rhode Island?
    Ms. Boss. I would absolutely agree with that. I'm not sure 
that there has been enough time for us to document how much 
increase that will result in. But yes, I do agree. And I thank 
you for your efforts with that legislation.
    Mr. Tonko. Our pleasure.
    And to all of our panelists, what barriers do you face in 
trying to recruit practitioners to become waivered DATA 2000 
practitioners?
    Start with the lieutenant governor, please.
    Mr. Rutherford. Well, we talked about, in certain cases, in 
certain parts of the state, there are limitations in terms of 
the number of practitioners in some of our more rural areas of 
the state. Also, some of the anecdotal feedback, in some cases, 
there is a stigma associated with treating individuals of 
substance use disorder, and there are some doctors that just 
don't want those patients. But the lifting of the cap has 
helped us with regard to being able to provide the services for 
more individuals, but stigma is still a challenge.
    Mr. Tonko. Thank you, Lieutenant Governor. Secretary Moran.
    Mr. Moran. I would agree, though, most of that information 
would be within our secretary of health and human resources as 
opposed to me. But we have heard from the practitioner. There 
is a shortage of personnel to address this issue. And in their 
defense, it's an epidemic that has really exploded over the 
last several years. Any assistance you can provide for 
additional funding in flexibility would be much appreciated by 
the Commonwealth and other states.
    Mr. Tonko. Thank you. And Secretary Tilley.
    Mr. Tilley. Yes. I would reiterate my colleagues, we have a 
number of physicians, I think nearly 700, who are prescribing. 
However, many of them have not applied to prescribe over that 
100 up to the 285 cap. And in many of them, we don't know, as 
has been stated earlier, whether they are requiring counseling. 
We do know we require counseling in our correction settings and 
jails and prisons. We encourage it. We do urinalysis. But we 
don't know--that's one of the things we have to get our arms 
around. We are doing that now.
    We have to look beyond why some of these physicians are not 
applying to do more in their communities. Again, we struggle 
with the same challenges with rural versus urban in getting 
those folks out to those areas largely. In Appalachian, this 
problem hit first there, and it's more acute there in many 
ways. So that's a challenge for us.
    Mr. Tonko. Thank you.
    Director Boss, we were going across the board. Can we just 
have a quick response, Director?
    Mr. Murphy. Real quick.
    Ms. Boss. All right. Thank you.
    So I would agree with all of my colleagues. But I would 
add, in our discussions with physicians, they want to do the 
right thing, and they want to be able to make sure that people 
are receiving counseling and toxicology screen but lack the 
office staff and the management to do that. So they need 
increased supports in the offices to do the kind of evidence-
based practice that's needed to use buprenorphine 
appropriately.
    Mr. Tonko. Thank you.
    Thank you, Mr. Chair. I yield back.
    Mr. Murphy. The committee likes those words, evidence-based 
practices. Thank you.
    Mr. Walberg, you're recognized for 5 minutes.
    Mr. Walberg. Thank you, Mr. Chairman. And thanks to the 
panel for being here.
    Secretary Moran, according to the Centers for Disease 
Control and Prevention, approximately one in five deaths that 
are attributable to a drug overdose failed to list specific 
drug in the death certificate. Could you explain why this data 
gap is problematic and what efforts the Commonwealth is taking 
to ensure that it has sufficient data to understand the true 
scope of the opioid epidemic?
    Mr. Moran. Thank you, sir. The theme of my remarks is the 
need for additional data, the state silos, which are we trying 
to break down, and then there are, of course, the privacy 
provisions with respect to some of the Federal laws and HIPAA.
    In a criminal investigation, our Department of Forensic 
Science will do the investigation. We have good data with 
respect to what drugs were involved, because they are 
collected. If it is an accidental death, it eventually goes to 
the OCME, Office of Chief Medical Examiner. But with respect to 
the data, it is challenging. And some individuals may not be 
anxious to reveal the cause of death under some circumstances. 
Family members may not choose to reveal that type of source. So 
it is a challenge. It's one we're trying to get our arms 
around, because if we have better data, we know how to respond 
better and what to do and what, if anything, is working with 
respect to addressing this epidemic.
    Mr. Walberg. Is there anything that you're attempting to 
get your arms around that data that is working for you, at 
least with some families?
    Mr. Moran. Well, you've seen a dramatic rise in the use of 
fentanyl over the last year. That helps inform not only our 
healthcare providers but our law enforcement.
    Where is the fentanyl coming from? And if it is located in 
a particular community, there can be a rapid response with 
respect to education and response and to interdict the 
fentanyl, because it's typically being manufactured overseas 
and coming into in the commonwealth and the country.
    So that type of information I think is critical to the 
interdiction of these drugs in addition to the healthcare in 
response to the individual. So I think it's imperative that we 
collect more data and have more access to data because we can 
better respond to the crisis.
    Mr. Walberg. Director Boss, your written testimony notes 
that Rhode Island's multiple disciplinary overdose prevention 
and intervention task force makes use of a date-driven 
strategic plan to combat addiction and substance abuse. Could 
you tell us more about how the state utilizes data to develop 
its strategy to address this opioid crisis?
    Ms. Boss. That is a wonderful question. And thank you for 
asking it, because----
    Mr. Walberg. As specifically as you can.
    Ms. Boss. So we have two things that I will point to. We 
have something called MODE, which is the multidisciplinary 
overdose drug response team. Basically, we look at a number of 
specific overdoses to look for trends, and there is a 
multidisciplinary team that consists of individuals from Brown 
University, hospitals, Department of Health, my department. And 
we review cases in depth in terms of looking at where those 
individuals were, what kind of treatment services they were 
receiving, if any, and then develop specific interventions as a 
response that we propose statewide.
    The others are surveillance response intervention team. We 
receive weekly reports on 48-hour overdose reporting. All of 
our hospitals are required to report overdoses or suspected 
overdoses within 48 hours, and our medical examiner is able to 
determine whether or not fentanyl is a factor in those 
overdoses. As a result, we put out alerts to communities when 
overdoses, whether fatal or not, exceed a specific target in 
that particular area. And we're able to notify law enforcement, 
first responders, treatment providers, and other individuals in 
the community that there is an increased overdose--fatal or 
nonfatal, in their communities.
    Mr. Walberg. OK. You mentioned that your state still lacks 
comprehensive data relating to fentanyl even with this approach 
that you're taking. If I understand it correctly, what are the 
obstacles preventing hospitals from developing comprehensive 
testing of fentanyl and how could they obtain more robust data?
    Ms. Boss. So I think the fentanyl question is regarding the 
drug supply. Our hospitals are now able to test for fentanyl as 
are our drug treatment providers. And so we are looking at how 
much fentanyl is in the drug supply. And as we see increases in 
hospital testing, in the testing that's done in our drug 
treatment providers, we're able to know what kind of fentanyl 
is out there, but not necessarily as quickly as we could if we 
had more rapid response in law enforcement in looking at what's 
in the drug supply.
    Mr. Walberg. Thank you.
    I yield back.
    Mr. Murphy. Thank you. Mrs. Castor, you're recognized for 5 
minutes.
    Ms. Castor. Well, thank you, Mr. Chairman. I'd like to 
thank all of the witnesses here for your attention to this very 
serious issue. And I think at the outset it's important that 
America just cannot go backwards on this.
    This is a very costly, severe problem for families and all 
of us. And to watch what is happening with proposals from the 
GOP on healthcare really would take us backwards, whether 
that's ripping coverage away that's been provided under the 
Affordable Care Act, under healthcare.gov, or the very serious 
assault on Medicaid. The most serious retrenchment of Medicaid 
in its 50-year history would be just disastrous for our ability 
to support families and address this crisis.
    In fact, I'd like to ask unanimous consent to submit, for 
the record, a consensus statement from the National Association 
of Medicaid Directors on the Senate version of the GOP health 
bill.
    It states, in part, Medicaid is a successful, efficient, 
and cost-effective Federal-state partnership. It has a record 
of innovation and improvement of outcomes for the Nation's most 
vulnerable citizens including comprehensive and effective 
treatment for individuals struggling with opioid dependency.
    No amount of administrative or regulatory flexibility can 
compensate for the Federal spending reductions that would occur 
as a result of the bill. Medicaid or other forms of 
comprehensive, accessible, and affordable health coverage in 
coordination with public health and law enforcement entities is 
the most comprehensive and effective way to address the opioid 
epidemic in this country.
    Earmarking funding for grants for exclusive purpose for 
treating addiction in the absence of preventative medical and 
behavioral health coverage is likely to be ineffective in 
solving the problem.
    So I'll ask unanimous consent that that be admitted for the 
record, Mr. Chairman.
    Mr. Murphy. We're reviewing. We'll get back to you before 
you're done.
    Ms. Castor. OK.
    Mr. Murphy. Thank you.
    Ms. Castor. Because this is very important. Now, this 
committee, to its credit, spearheaded the 21st century cures 
initiative that did provide substantial funds to our states. 
And I've heard from local experts back home in Florida, held a 
number of roundtables with law enforcement, treatment 
professionals, anesthesiologists, ER docs--the panoply. And 
they say the key is long-term coverage to treat this as the 
chronic disease that it is. And that's why, when you rip away 
coverage and instead say, in its place, we're going to have 
another fund, an opioid fund, where maybe you provide a few 
dollars to an ER, that's not going to provide that long-term 
coverage that we need to treat this chronic disease. So I just 
had to get that off my chest here right off the bat.
    In fact, Director Boss you have a lot of experience with 
this. Do you think we'll be able to effectively address this 
crisis if this retrenchment on Medicaid and ripping coverage 
away for millions of Americans were to succeed?
    Ms. Boss. So I believe that Rhode Island's efforts to 
address this crisis would not be able to be sustained if we 
were not able to continue to offer insurance through Medicaid 
expansion to the number of Rhode Islanders that depend on it. 
And I thank you for your pointing out the fact that providing 
substance use disorder treatment alone is not enough. If we 
dedicate dollars toward that, that's wonderful. However, 
oftentimes there are comorbid conditions that are interrelated 
with an individual's addiction, that if we don't have access to 
affordable health care for the rest of the body, then we're not 
going to be able to treat the person well enough to sustain any 
kind of recovery.
    Ms. Castor. So are you able right now to provide the type 
of long-term treatment that is needed for an opioid appointed 
addiction?
    Ms. Boss. Yes, we are.
    Ms. Castor. In fact, you've instituted a program called 
AnchorED which connects individuals struggling with addiction 
to recovery coaches who help them navigate the treatment 
process. How successful has this program been to helping an 
individual recover?
    Ms. Boss. So of the individuals that meet with recovery 
coaches in the emergency department, 82 percent are receiving 
referrals to treatment and engage in treatment and recovery 
services, which is pretty phenomenal, actually. And the actual 
AnchorED program itself is not supported by Medicaid.
    But the fact that we are not required to use substance 
abuse prevention treatment block grant funds to fund treatment 
itself, now that individuals can access, it frees up that 
opportunity to use block grant funding to support recovery 
activities that may not be supported by Medicaid or other 
insurance, although the program is so successful that many 
insurances, including third-party commercial insurances, are 
paying for the recovery coaching program.
    Ms. Castor. Is that a requirement under Rhode Island law, 
or is that something that you found to be so cost-effective 
that they are participating?
    Ms. Boss. It is not a requirement.
    Ms. Castor. OK. Thank you very much.
    Mr. Murphy. Can I just ask a follow-up question, what 
you're saying? Recovery coaches have what kind of credentials?
    Ms. Boss. So we have a certification process for our 
recovery coaches that are standardized and involves training 
and a test and voluntary hours for certification in order to 
respond. They are not degree----
    Mr. Murphy. OK. No degree.
    And do you have, in emergency rooms, then, people who are 
themselves licensed treatment providers? Not recovery coaches, 
not peers, but people who are actually--this is their 
licensing. Do you have them in the ERs as a requirement?
    Ms. Boss. We do not.
    Mr. Murphy. Let me just ask: Does Kentucky have them? Or 
Virginia? Maryland?
    There was a study done out of Michigan, and I believe also 
one done at Yale, that when there is a licensed addiction's 
counselor in the ER providing treatment, not referral, 
providing treatment, they increase the chance that person is 
going to follow up by 50 percent.
    So just saying here's some place you can call, 82 percent--
do you know if they actually follow through in the event--
that's my question that I have now. I'd love to hear that from 
each state, but I next have to go to Ms. Walters.
    Ms. DeGette. Before you do, are--is Ms. Castor's unanimous 
consent request?
    Mr. Murphy. Yes. We're fine with that. Yes. Thank you. 
Sorry about that.
    [The information appears at the conclusion of the hearing.]
    Mr. Murphy. But I was saying that information is critically 
important. And I've heard from a lot of places, give them a 
card, they may not follow through. So 80 percent may not be 
valuable to us. But to know they're actually getting treatment, 
just like you wouldn't send someone home and say, ``You broke 
your arm. Could you, please, make sure you see an orthopedic 
surgeon next week,'' but to make sure it's being done.
    Mrs. Walters, You're recognized for 5 minutes.
    Mrs. Walters. Thank you, Mr. Chairman.
    We can all acknowledge that, despite increased societal 
awareness and government resources, the opioid crisis continues 
to devastate our communities. In my home of Orange County, 
California, there were 361 overdose deaths in 2015. That 
accounts for a 50 percent increase in overdose deaths since 
2006. A majority of those deaths are attributed to heroine, 
prescription opioids, or a combination of the two.
    One of the challenges in responding to the crisis is the 
stigmatizing of the victims which limits their responsiveness 
to treatment outreach.
    There has been discussion today of the importance of drug 
courts. And these courts can help overcome the stigma and treat 
the underlying addiction as opposed to focusing on the 
resulting criminal behavior I recently became aware of a 
specialized drug treatment court in Buffalo, New York, that is 
focused solely on opioid interventions.
    My question is for everybody on the panel. Do you have an 
opinion whether some drug treatment courts need to be 
specialized to handle opioid addiction?
    Mr. Rutherford. We have extensive drug courts in most of 
our jurisdictions across the state. They essentially are 
specific to opioid addiction. And there's been good results 
from most of those courts.
    The one challenge that we have is that, depending on how 
long that period that you're involved with the drug court is 
maybe 18 months to 2 years. And if you're someone who commits a 
crime at a local jail and you're not ready for treatment, that 
person will say, ``I'd rather do the 6 to 8 months than to have 
to commit to 2 years. Even though I'm outside the fence, I'd 
rather sit in jail.''
    Mr. Moran. We're big proponents of drug courts. 
Unfortunately, Virginia is deficient in drug courts. We have 
about 37 yet we have over 200 courts. They are used for a 
variety of different specialities. There's mental health 
courts; there's veterans dockets. The drug courts, however, 
provide some coercion. I mean, the individual needs to want to 
address their addiction, and then the court can provide that 
coercive element. And we have a tremendous success rate. I 
mean, we should expand.
    The one issue I would ask Congress to help us with, 
however, is the medically-assisted treatment. Some of our 
judges in the drug courts are reluctant, and as of now, it is 
required. And so we would request, on behalf of those judges, 
some flexibility with respect to mandating MAT.
    Mr. Tilley. And again, I would concur. We have mental 
health courts, veterans courts, and drug courts I think that do 
expand. We did lose our juvenile drug courts due to a funding 
issue. We're trying to rebuild that program now. Some of the 
same issues exist. Oftentimes that offender chooses a shorter 
prison sentence and that 2-year, again, very strenuous program. 
But we're addressing that as well.
    I would say that oftentimes too we find that there are 
cherry picking the best instead of focusing on the more high-
risk folks. We do have a program called SMART that deals with 
high-risk probationers keeping them--again, a modified drug 
court that does specialize in opioid, at least one part of it 
does. And that's being done at seven pilot sites. It's modelled 
after the HOPE program that began with Judge Steven Alm in 
Hawaii that many of you know about now.
    And I would also add that what we're finding as well is, 
again, this combination of specializing in medically assisted 
treatment and the cognitive behavioral therapies that, again, 
we're trying to integrate that model with some of our existing. 
And we also have passage of recent legislation in Kentucky, 
through the Department of Corrections, a modified drug court 
through a reentry program that we'll be rolling out soon that 
will specialize in the opioid addictions.
    Ms. Boss. I would agree with my colleagues as well, 
especially Lieutenant Governor Rutherford in the fact that our 
drug courts have been addressing opioid use disorder for a very 
long time. In Rhode Island, the drug court has been accepting 
of medication assisted treatment as appropriate treatment for 
individuals long before it was required to do so.
    Probably the biggest issue that we have with drug court is 
that it's not able to reach enough people. And while it's very 
successful and effective, the difficulty in getting the numbers 
through that system is challenging, and we really would like to 
look at a broader perspective of diversion efforts and getting 
people connected to treatment prior to arrest as our primary 
focus.
    Mrs. Walters. Thank you.
    Mr. Tilley. Mrs. Walters, may I add an interesting thought 
here? We had, again, a conference recently in Kentucky that 
offered a legal opinion from one of our law firms that there--
and, again, as Secretary Moran pointed out, if a judge denies 
someone medically assisted treatment which then affects the 
liberty interest if they return to prison, that denial might 
invoke some protection of the Americans with Disabilities Act. 
And I think that's an interesting thought moving forward. And I 
think it's a little bit of a chilling effect on our judiciary 
in Kentucky to be--again, might be more accepting of medically 
assisted treatment.
    Mrs. Walters. Thank you. Thank you all. I yield back my 
time.
    Mr. Murphy. Mr. Ruiz, you're recognized for 5 minutes.
    Mr. Ruiz. Yes. Thank you, Mr. Chairman. Thank you all for 
being here. It's such a very important topic. And as an 
emergency medicine doctor, I cannot emphasize enough the 
devastating effect it has on individuals, families, 
communities.
    I've treated patients who have been dumped, blue, not 
breathing, in front of our doors, and we go into the emergency 
care mode providing Naloxone and the other cocktails for 
somebody who you don't know anything about, and they're there 
unconscious right about to die. And thankfully we've saved many 
of them because we've had the medication.
    We know that one of the primary determinants of successful 
treatment is that they get medication, follow-up, and 
counseling. And one of the factors for success is that they 
have health insurance that has guaranteed coverage for those 
medications, guaranteed coverage for mental health, and that's 
why it's so devastating for me and for my patients that we're 
on the verge of repealing the Medicaid expansion, repealing for 
some states who choose not to have the mental health and 
prescription drug guaranteed coverage, that those people who 
need coverage and want coverage won't be able to have it. And 
it can be a situation of life and death, as we know.
    In a report on addiction released last year, the U.S. 
Surgeon General found that Medicaid expansion meant that 
millions of Americans with substance-use disorders now have 
access to health coverage and, subsequently, substance abuse 
treatment. And additionally, because substance-use treatment is 
now a covered essential health benefit, which is at risk of 
going away, individuals, a small group market participants also 
gain access to those lifesaving services.
    But it's not just about coverage. OK. I've seen some parts 
in my district but if you don't have providers, if you don't 
have psychiatrists, if you don't have psychologists, if you 
don't have healthcare centers or counseling centers or programs 
in those communities that are underserved or in rural areas, 
then coverage does you no good.
    So you need to also think about making sure that we have 
more psychiatrists, more psychologists, more mental health 
providers in those areas, especially for the youth and young 
adults.
    According to data from HHS, the number of children in 
foster care increased 8 percent between 2012. Experts have 
suggested that this rise is due in large part to increased 
opioid abuse. Moreover, the substance abuse and Mental Health 
Services Administration, SAMHSA, has estimated that over 8 
million children of parents who need treatment for substance 
abuse disorder.
    The Wall Street Journal, the Washington Post, and the New 
York Times have all recently reported on children who have 
experienced the impact of their parents' opioid abuse and are 
being raised by grandparents who have been placed into foster 
care as a result.
    Secretary Tilley, can you please describe how children in 
your state have been impacted by the opioid crisis, and are 
there unique challenges facing children in these epidemics?
    Mr. Tilley. I think it's an excellent question. With a 
focus on correction, sadly I can report that, in Kentucky, as 
it exists now, more children are living with an incarcerated 
parent than any other state in the country. In fact, have had 
or have an incarcerated parent. And, again, our prison 
population largely being driven by the epidemic, I think that 
would be the first thing that comes to mind.
    I also believe that it puts an incredible strain on our 
cabinet for health and family services. We have a record number 
of children in foster care at the moment. So that certainly is 
an issue.
    And beyond that, I think it just puts a tremendous strain 
on our community mental health centers as well. I think, again, 
the absence of proper funding for community mental health in 
this country is a huge issue. It exists all over. It certainly 
is acute in Kentucky as well. We rely on our 14 community 
mental health centers that fan out through our state to provide 
those services to children.
    We have seen an increase with the focus in recent years on 
addiction issues that increase and proper treatment for 
children, and so I think that's been critical for some of our--
--
    Mr. Ruiz. So Secretary Tilley, let me just warn you that, 
by turning Medicaid into per-capita grant, the funding for new 
addicted folks are--I should say the need for funding is going 
to increase. States are going to have to make decisions: One, 
change their eligibility criteria; two, their reimbursement 
rates; and three, the benefits that they would cover. And 
oftentimes, unfortunately, the mental health and these 
community center treatments are the first on the chopping 
block. So it's going to get worse if this bill is going to 
pass.
    Director Boss, SAMHSA stated that families have a central 
role to pay in the treatment of individuals with substance 
abuse disorders. Can you discuss what efforts Rhode Island has 
taken to provide treatment that covers a person's entire 
family?
    Ms. Boss. All of our treatment providers are encouraged to 
engage families in treatment and--as part of effective 
treatment. We know that addiction is a family disease, and 
engaging family members is critical in order to have success.
    One of the things that the state has done is engage family 
members in the development overdose task force and plan, and 
we're creating a family and parent task force as well as 
engaging youth to help us shape our efforts for the overdose 
crisis in----
    Mr. Ruiz. Have you found positive results on those?
    Ms. Boss. Those efforts are just starting. So I will be 
able to report back hopefully.
    Mr. Ruiz. Well, I'm very hopeful that we can work together 
to help this situation get better.
    Mr. Murphy. I appreciate that, because there's some things 
we need to be working on out there. But I want to make sure 
Secretary Tilley has a chance to respond to what you're saying 
about mental health substance abuse, money being first on the 
chopping block. Is that Kentucky's intent? Do you know anything 
about that?
    Mr. Ruiz. That was not the intent, I don't agree----
    Mr. Murphy. No. I didn't know--but you had asked. I want 
him to respond.
    Mr. Ruiz. No. No. I'm just saying that, historically, 
mental health is one of the most underfunded----
    Mr. Murphy. I understand. But you made a claim, and I want 
Secretary Tilley to have a chance to the respond to that, find 
out if it's----
    Mr. Tilley. I would only say that the absence of proper 
mental health funding is not a new phenomenon. I happen to----
    Mr. Ruiz. I agree with that.
    Mr. Tilley [continuing]. In my private life, be associated 
with a mental health center as as general counsel. And I happen 
to know that since the late 1990s we haven't had an increase in 
those reimbursement rates. And that is an issue, and that has 
existed for some time. And so I don't think that's a recent 
phenomenon. That's all I would add.
    Mr. Murphy. No. And that's why I want to amplify what he's 
saying, that when everybody looks at mental health funding gets 
cut or doesn't get increased, if actually increases costs 
overall for healthcare. So----
    Mr. Carter, you're recognized for 5 minutes.
    Mr. Carter. Thank you, Mr. Chairman. I want to thank all of 
you for being here on such an important subject. And I want to 
express my dismay and my discouragement at some of my 
colleagues who have used this as a platform, if you will, for 
political messages about cuts in Medicaid, et cetera. I mean, 
we all understand. It is established this is an epidemic in 
this country.
    As a practicing pharmacist for over 30 years, I have seen 
firsthand, perhaps more than everyone in here collectively, has 
seen the impact that this has had. At no time have I ever asked 
a patient or thought in any way is this a Republican or a 
Democrat or Independent. It's someone who's struggling. That's 
all there is to it. This is a nonpartisan problem, and I just 
frustrated by that.
    Governor Rutherford, you said something earlier that I'm a 
little bit confused about. You were talking about the 
prescription drug monitoring program in the State of Maryland. 
Did you say that methadone is not on it?
    Mr. Rutherford. Well, no. What I was saying is that if you 
go to the prescription drug monitoring program, or the 
database, you will not see that a person has been prescribed 
methadone, that they're in methadone treatment. So----
    Mr. Carter. Why is that?
    Mr. Rutherford. There are privacy restrictions associated 
with drug treatment. And so this was in place prior to our 
developing these prescription drug monitoring programs. There 
are different barriers to getting information, be it mental 
health information or drug treatment and, in some cases, 
healthcare, that there are walls----
    Mr. Carter. Is that something we can help you with, 
legislatively, here?
    Mr. Rutherford. I think that's what we talked about, that 
that would be very helpful, because a practitioner would not 
know that someone that they're prescribing an opioid already 
has a problem associated with opioids.
    Mr. Carter. OK. When I was in the state senate in Georgia, 
I sponsored legislation that created our prescription 
monitoring program. And I can tell you, it has been improved 
since I left. In fact, July 1st of this year, 2 weeks ago, we 
started 24-hour reporting. Before that, we were reporting every 
week. Now, we're not in realtime yet, but we're getting there. 
We're making very good progress there.
    I want to know, in the prescription drug monitoring 
programs within your states--and, Secretary Tilley, I'll tell 
you. I've worked closely with the Kentucky Board of Pharmacy 
and with the Kentucky Pharmacists Association--very strong. 
Very strong programs there. And I compliment you on that.
    But in your experiences with the prescription drug 
monitoring program, are you sharing information across state 
lines?
    Mr. Tilley. We are. I think we have 7 border states. Very 
unique in that regard. I think the only state in which we don't 
at this moment is Missouri. I think that be to the case now.
    Mr. Carter. Yes. Missouri struggled. They were the last one 
to add it on, the PDMP.
    Mr. Tilley. We are working on that. And again, I'd be happy 
to supplement the record to confirm that answer for you. But I 
do believe we are sharing with six of those seven states that 
board us.
    Mr. Carter. OK. Secretary Moran, what about Virginia? What 
are you all doing?
    Mr. Moran. Thank you. And I think this is an area where 
Congress could investigate. We have 21 states. And our neighbor 
to the South, North Carolina, we do not share information. We 
would request some help to better share data across state 
lines.
    Mr. Carter. Right.
    Mr. Moran. Most of our neighbors are not North Carolina. So 
we would look for some more relief there.
    Mr. Carter. Yes. In the State of Georgia, we're sharing 
with South Carolina, Alabama, North Dakota, and someone else 
way out West. I will tell you, in my over 30 years of 
practicing pharmacy, I never filled a prescription for North 
Dakota, for a C2 prescription. I know you find that hard to 
believe. It would have been more useful if I could have seen it 
from Florida. Being in that area, in Savannah, where we're only 
2 hours away, it would have been extremely useful for the State 
of Florida, and hopefully we can get to that point.
    I want to ask you, Secretary Tilley, about a program that I 
thought was pretty interesting that was a result of 21st 
century cures, and that was the peer recovery specialist and 
emergency departments in Kentucky. Can you elaborate on that 
just a minute?
    Mr. Tilley. The expert is sitting to my left. We actually 
had a chance.
    Mr. Carter. Right.
    Mr. Tilley. And again, I, applaud the work in Rhode Island. 
We actually had sort of a model that didn't really meet the 
goals that we wanted. It was not up to par from previous 
legislation. We looked at what Rhode Island was doing. We had 
tried the same thing they did. We just didn't do it as well. I 
think we're on the path to doing it now. And I think we're 
fairly ambitious with trying to do both at once.
    The peer recovery coaches or specialists in our ERs and 
also doing the bridge clinics as well to try to keep people 
there in treatment until we can get them to treatment, maybe 
outpatient or some kind of other bed outside that hospital. And 
so I think what they're doing in Rhode Island is certainly a 
model for the country. And we're emulating them directly.
    Mr. Carter. Great. And I know you are doing great work, 
Director Boss. And I apologize. I didn't get to you. I have 15 
seconds. I just want to add one thing from a pharmacist's 
perspective. One of the things that we didn't cure was to allow 
states to implement laws on C2 prescriptions on how much can be 
filled and whether pharmacists can fill partial quantities. 
That will help.
    We can throw money at this all day long. But we need to be 
smart. If we're smart and we do practical, rational things, 
like limiting--I got so many prescriptions from a dentist for a 
30-day supply of OxyContin. They take one or two, and then the 
rest of them are in the medicine cabinet. That is not being 
smart. If we can have a partial refill, if states can do that 
as a result of 21st Century, or as a result of CARA, that's 
something we need to look at implementing as well.
    Thank you, all. My time is out, and I yield back.
    Mr. Murphy. Mr. Carter, will you yield for a question?
    Mr. Carter. Yes.
    Mr. Murphy. When you refer to partial refill, you mean 
allowing the pharmacist to only give a partial fill at the 
onset, and then the person could come back and get the rest? Is 
that what you're referring to?
    Mr. Carter. That is exactly right.
    Mr. Murphy. So not the position for prescribing partially, 
but you would have that option?
    Mr. Carter. That is one of the options that CARA allowed us 
to do. I would take it even further. And I've been in talks. My 
office has been in talks with the DEA about allowing maybe a 
refill on a C2 for a three-day supply. Because a lot of 
physicians are concerned that the patient's going to run out 
over the weekend, they're going to be bothered, or they're not 
going to be available and they're going to go without. And 
that's a real concern. And I understand that.
    But at the same time, again, if we'll just be smart, if 
allowing them to maybe call in one refill over the phone as 
long as it's limited to a short-day display.
    Mr. Murphy. Thank you.
    Mr. Carter. Thank you, Mr. Chairman.
    Mr. Murphy. Mr. Pallone, you're recognized for 5 minutes.
    Mr. Pallone. Thank you, Mr. Chairman.
    Director Boss, I wanted to ask you the questions. And I 
want to go back to the issue of Medicaid, because, as you know, 
the Republicans are still trying to repeal the ACA's Medicaid 
expansion and making a lot of changes to the program.
    So what role has Medicaid played in Rhode Island's effort 
to provide medication-assisted treatment in your state?
    Ms. Boss. Medication-assisted treatment is covered by 
Medicaid for both the disabled and the expansion populations. 
All Medicaid-covered individuals are able to receive all three 
forms of FDA-approved medications for opioid use disorders. The 
director of Medicaid is a member of our opioid task force and 
has been active in working with the managed care organizations 
that manage our Medicaid product to do things like remove prior 
authorizations for medication-assisted treatment. It is fully 
funded through our Medicaid program.
    Mr. Pallone. All right. Now, my colleagues on the other 
side of the aisle often characterize the Medicaid program as 
inflexible for states. We hear that a lot, that it's 
inflexible. To the contrary, though, I think Medicaid has 
provided for a great deal of innovation in how states have 
responded to the opioid crisis. So could you please tell us 
about the health home program in your state and how Medicaid 
granted Rhode Island the flexibility to develop its own person-
centered care opioid treatment program?
    Ms. Boss. So there are probably two innovations, and the 
OTP health home would be one of them where we worked with the 
Medicaid office for a period of 18 months to develop the 
comprehensive care management function for opioid treatment 
programs to provide to their clients in addressing physical 
health issues as well as their addiction issues. And the 
process with Medicaid was thorough, but it was one that allowed 
us to use a monthly rate to support the work that was really 
improving the health care of individuals in opioid use 
disorder.
    And we know that people who have opioid use disorders often 
have comorbid conditions, don't necessarily have the greatest 
access to care in the community. And the health homes allow 
those programs, which have the greatest access to individuals, 
to provide nursing support. They're overseen by physicians. 
They have case management that help them get to the needed 
appointments, dental appointments. And Medicaid has been 
supporting those efforts with an understanding that improving 
those outcomes will improve outcomes overall and reduce cost.
    The Centers of Excellence are also a Medicaid innovation 
where we allow people to be seen very quickly. And it's the 
issue. You need to have that access to treatment, which was 
noted. A person seen in the emergency room needs to be able to 
follow through and get access to treatment in order for 
anything to be effective.
    Centers of Excellence exist as a Medicaid innovation 
allowing people access to treatment, all FDA-approved 
medications, again, within 72 hours, and have intensive 
services provided in the 6 months of treatment supported by a 
Medicaid rate with as much treatment in case management and 
recovery supports as the individual needs with the intention to 
move that individual into the community once stabilized and 
continue to provide the clinical and recovery supports needed 
again through a Medicaid-supported invasion.
    Mr. Pallone. Obviously, my concern is that, in states most 
heavily impacted by the opioid epidemic, if you have cuts to 
Medicaid that that may lead to cuts in addiction treatment and 
exacerbate the process.
    I have a minute left. Let me ask you: Would you agree that 
deep cuts to addiction services that might result from the 
Senate TrumpCare bill, for example, that if states decided 
because of the cuts in the Senate TrumpCare bill, that those 
kinds of cuts to addiction treatment would have a drastic 
impact on our ability to fight this epidemic?
    Ms. Boss. Our overdose strategy engages 4 different 
components, and three of the four would be effected if Medicaid 
were not available to support. The access to Naloxone, again, 
is supported by Medicaid. Medicaid covers Naloxone for 
individuals. The treatment component is, again, supported by 
Medicaid, our Centers of Excellence--all of the treatment 
components have that as well.
    And the ability for recovery coaches to be funded if not 
for the treatment being covered by Medicaid, our substance 
abuse block grant dollars would have to be redirected from 
those recovery efforts to support individuals in treatment.
    Mr. Pallone. All right. Thank you so much.
    Thank you, Mr. Chairman.
    Mr. Murphy. Mrs. Brooks, you're recognized for 5 minutes.
    Mrs. Brooks. Thank you.
    Director Boss, I want to clarify something that my 
colleague, Congressman Walberg, asked you previously. You 
talked about a data gap with respect to fentanyl in law 
enforcement data. In your written testimony, you've talked 
about hospital systems are testing for fentanyl, but we do not 
yet know the frequency of testing or how many tests are 
returning positive for fentanyl.
    And so I just want to clarify and make sure. So the gap in 
collection on data for fentanyl exists in law enforcement and 
hospitals as well. Is that correct?
    Ms. Boss. So the testing for fentanyl in the hospitals is 
fairly new, and we are not sure how complete the data is. They 
do have the ability. And whether or not all the hospitals are 
testing or not, I'm not exactly sure. And I think it's really, 
for the most part, an issue of timeliness.
    To be able to respond effectively, we need to have access 
to timely data and making sure that, if testing occurs, that 
we're able to get the results quickly and in enough time to 
respond to a community that may be seeing an increase in 
fentanyl.
    Mrs. Brooks. And I guess I'd ask the others on the panel 
whether or not you know if your hospitals are gathering data on 
fentanyl specifically and the frequency and so forth.
    Yes, Lieutenant Governor.
    Mr. Rutherford. I can't speak directly for the hospitals. I 
know that, through our medical examiner's office, through our 
emergency first responders, that they get information with 
regard to fentanyl usage. A little more than 60 percent of our 
fatalities, overdose fatalities, on opiates, are related to 
fentanyl. In most cases, it's a mixture with something else, 
cocaine or heroine. But we're getting most of our information 
from the law enforcement and emergency responders.
    Mrs. Brooks. I want to just talk a little bit more 
specifically about the criminal justice system and would like 
to ask you, Secretary Tilley, the CORE program that you 
mentioned, that is specific to the criminal justice system in 
Kentucky, isn't it?
    Mr. Tilley. Actually, it brings in all stakeholders, even 
education.
    Mrs. Brooks. OK.
    Mr. Tilley. The Cabinet for Health and Family Services, our 
CORE system, certainly many--all elements of the criminal 
justice system but any element affected by the opioid scourge 
is present on that particular effort.
    Mrs. Brooks. I'd like to find out from you, and briefly, 
your states' efforts, because, obviously, when a person is 
incarcerated, which many family members said that saves their 
lives. It's sad and we want them to be diverted, and we 
obviously do want to focus on high level. I'm a former U.S. 
Attorney. So we want to focus on the mid and high level dealers 
and those who were exposing people with addictions. However, at 
times we have a captive audience of participants in treatment.
    And can you talk a bit more about medication-assisted 
treatment in your facilities and then counseling? Is there drug 
testing that is part of your incarcerated population, juveniles 
and adults?
    Mr. Tilley. I'll start with adults. Again, counseling is 
required with any medically assisted treatment we do. Again, I 
described earlier in my testimony I think a pretty innovative 
program where we assessed, through a risk needs assessment, 
those who would need an injection of naltrexone, or more 
commonly called Vivitrol, prior to their release as a 
stabilization mechanism. Upon release, they get another 
injection, and then they are matched with a counselor and a 
peer recovery coach to try to find the necessary resources to 
continue that treatment, whatever it may be and whatever source 
it may come from.
    In our juvenile setting, we do not have medically assisted 
treatment at this time. However, we in Kentucky thankfully have 
a record low in terms of our juvenile detention population at 
the moment. And that doesn't seem to be near the issue in our 
facilities, although we do offer that treatment in the 
facilities, just not medically assisted at this time. And the 
same way you would see it in the corrections setting.
    One thing that's very unique about Kentucky, and one thing 
that was not maybe reflected in the New York Times article 
about that treatment is that Kentucky houses roughly half of 
its state inmate population in county jails. We have 83 full-
service county jails that do that. And that presents some 
challenges. But we are expanding and incentivizing that kind of 
treatment, that kind of medically assisted treatment, like you 
may have read about in Kenton County, which is part of the 
Greater Cincinnati, Northern Kentucky area there. I would also 
add the piece about incarceration.
    We are trying to use elements like involuntary commitment--
we call it Casey's law in Kentucky--to try to bypass the need 
for incarceration for those individuals, again, who stand out 
to their family as someone who needs a forceful hand, maybe a 
judge's contempt power to keep them in treatment.
    Mrs. Brooks. I will be submitting questions for the record 
for each of your states, because I'm interested in knowing 
more, and my time is up, on medically assisted treatment as 
well as counseling and what you're doing with your inmate 
population. And I know you're each doing something but would 
love to learn more about it.
    And I want to thank you all for cooperating with each other 
and learning from each other. Critically important.
    I yield back.
    Mr. Murphy. The gentlelady yields back. I recognize Mr. 
Costello for 5 minutes.
    Mr. Costello. Thank you, Mr. Chairman.
    Some of you may know the chairman and I both hail from 
Pennsylvania. The chairman from the Western part of the state. 
Myself from the Eastern part of the state. And sometimes people 
think they're two different states. But having said that, in 
Pennsylvania, the epidemic is particularly acute. And just a 
few brief comments about what we're doing in Pennsylvania. And 
then Lieutenant Governor Rutherford, I had a couple of 
questions for you.
    With the enactment of the 21st Century Cures Act, 
Pennsylvania received $26.5 million dollars in Federal funding 
to address the epidemic: $3.5 million for drug courts, $23 
million being funded to expand access to medication-assisted 
treatment, increase training opportunities to better connect 
individuals with additional treatment when they visit an 
emergency room as a result of an overdose and also to improve 
access to opioid use disorder treatment for uninsured 
individuals.
    And Lieutenant Governor Rutherford, you spoke about 
establishing a 24-hour stabilization center in Baltimore city. 
I wanted to ask you about that. What services will be provided 
at the facility? Why do you think it is better suited to have 
such a facility to treat substance abuse issues rather than in 
emergency departments? And then, maybe depending upon your 
answer, I'll have some follow-up questions off that.
    Mr. Rutherford. Well, the concept of the stabilization 
center is a place where both first responders support as well 
as law enforcement or family members can take a person who is 
suffering from substance abuse disorder and they may be ready 
for some type of treatment. And the idea is to bring them into 
a locale, not necessarily an emergency room because that is a 
very high cost approach to addressing this challenge where they 
can be stabilized and get them into longer-term treatment.
    So it's an opportunity to get that person, as I mentioned, 
stabilized. They could reside there for a few days before--if 
there's a bed available to get them into treatment.
    Mr. Costello. Any similar facilities that you might be 
modeling this off of?
    Mr. Rutherford. I believe San Antonio has something 
similar. I'd have to get more information and talk to my staff. 
I believe it was San Antonio that I believe was doing something 
very similar to this.
    Mr. Costello. Once stabilized, will the patients then be 
moved into evidence-based treatment and counseling?
    Mr. Rutherford. That is the objective. We haven't stood 
this up as yet, and we're working with the city of Baltimore in 
terms of the parameters and how this is going to actually 
operate and what the state's oversight role will be with this.
    Mr. Costello. Is the hope that the funding that you will be 
utilizing for the facility itself, will that funding extend to 
the treatment and counseling, or are you looking at the 
facility to just be sort of on the front end?
    Mr. Rutherford. The facility is on the front end. We will 
look to the other funding sources, be it through the Cures Act, 
through state revenue, through insurance, through Medicaid to 
pick up the treatment aspects of the challenge.
    Mr. Costello. Can you describe some of the challenges that 
your state currently faces to provide beds in a timely manner 
for individuals seeking treatment for substance abuse?
    Mr. Rutherford. Well, the lifting of the restriction with 
regard to Medicaid reimbursement on the number of beds in a 
facility has helped that particular challenge, because we did 
have situations where we had individuals who would receive 
treatment through Medicaid, and we have beds available in some 
of our facilities, but we could not utilize those. That has 
helped.
    We are working to expand the capabilities, particularly for 
some of the nonprofits that have services and are providing 
services and seeing what we can do to assist them in expanding 
their access. We have close to 800 facilities around the state. 
There is always a discussion about getting additional beds and 
capacity, and so we're working on those things as well.
    Mr. Costello. Thank you.
    My general comment on this epidemic is oriented towards the 
following. I think there are a lot of variables that contribute 
to this. I think everyone knows that. I get concerned when we 
point to one particular actor in this ecosystem and say that's 
the problem, because it is manifold. It is complex. And I think 
what concerns me more than anything is that the life cycle of 
treatment is much longer than the infrastructure that has been 
set up to deal with it.
    And as a consequence of that, no matter how good we might 
be in the first six innings of this, if we're not good in 
innings seven, eight, and nine, it's not going to ultimately 
matter. And we're really just embedding more cost into the 
system by front-loading some of the cost without really 
acknowledging that, on the back end, if we don't finish it off 
with the right kinds of treatment and the right type of 
counseling and the right kind of follow-up off that, we will 
not ultimately be able to drive down the epidemic.
    I think all can identify what some of the front-end issues 
are here, but that would be something I'd just like to submit 
to the record.
    And, Mr. Chairman, I see I'm well over my time.
    Mr. Murphy. Thank you.
    Mr. Rutherford. Can I respond just very briefly.
    Mr. Murphy. Yes.
    Mr. Rutherford. You're absolutely right. And some of the 
thought process behind the crisis center is it's a front end. 
You're right. It's a front end of where the person comes in the 
door, they're in distress at that point, stabilizing them, 
getting them into treatment. But even after the treatment, one 
of the things we've heard over and over again from people who 
have relapsed is they come out of treatment and they go back 
into the same community, the same stimuli, the same issues that 
they had before.
    And one of the areas that we're focusing on going forward, 
including utilizing the Cures Act funding and state funding, is 
transitional housing. For lack of a better word, you can call 
it a halfway house--but transitional housing where a person can 
go and continue to get treatment in terms of the counseling 
aspects of it. But during the day, they can go to work, they 
can do the things that they need to do, but they have to report 
back to this facility. And people have said that that is 
something they need before they go back into the unrestricted 
society, because all the stimuli is still there.
    Mr. Costello. Yes. Thank you much.
    Thank you, Mr. Costello.
    It's the policy of this committee to let other members of 
Energy and Commerce who are not on this subcommittee to ask 
questions. Mr. Bilirakis, you're recognized for 5 minutes.
    Mr. Bilirakis. Thank you so very much. And thank you for 
allowing me to sit in on the hearing. I appreciate it, Mr. 
Chairman.
    Well, I have some prepared questions. But does anyone else 
want to elaborate on that? Any other suggestions as far as a 
long-term, the back end? Is there anyone on the panel that 
would like to talk about that? You mentioned the transitional 
housing. And cooperation, obviously, is so very important. The 
patient needs to cooperate and voluntarily, in most cases. Is 
there anyone that wants to make another comment before I get 
started?
    Ms. Boss. If I could, I would add----
    Mr. Bilirakis. Yes.
    Ms. Boss. The front door is very important, because access 
to care--oftentimes, you'll hear families saying, ``I don't 
know where to turn for help.'' And we're looking at a crisis 
center model as well. And I think that's critically important. 
You don't know which number to call. You've got a family or 
loved one, and you're not sure how to connect them.
    But then the connection to treatment is critically 
important as well. It's like someone with hypertension going to 
the emergency room and getting a pill but not getting a 
prescription. It's not going to help.
    And so without the access to care and the kind of supports 
needed--so recovery housing is critical as well. And in part of 
our Cures Act funding, we are looking to establish that kind of 
transitional housing for individuals who are not able to return 
to their communities. We really need to look at the long-term 
and treating addiction as a chronic disease, not through acute 
episodes.
    So I think that the approach to long-term and looking at 
the long-term needed supports are critically important as well.
    Mr. Bilirakis. Thank you.
    With regard to Florida, in 2010, in response to the opioid 
crisis in Florida, the pill mill problem--I think you probably 
know about that. Florida's legislature enacted a statewide 
tracking of painkiller prescription coupled with law 
enforcement using drug-trafficking laws to prosecute providers 
caught overprescribing. Within 3 years, Florida saw a decrease 
of more than 20 percent in overdose deaths, and I want to give 
Pam Bondi, the attorney general, and others credit for this.
    But now the rise in the fentanyl and its various 
derivatives have presented new challenges to the State of 
Florida and other states as well. However, we remain optimistic 
with recent legislative initiatives in Florida.
    These include requiring doctors to log prescriptions in a 
statewide painkiller database by the end of the next day. I 
think that's important, to curb the so-called doctor shopping 
and setting aside state-sponsored medication that can help 
reduce opioid dependency. So we're working on it.
    But during the August recess, I want to meet with 
stakeholders--and conduct roundtables with regard to this 
issue.
    Do you have any suggestions for me? What has succeeded? 
Obviously, sir, you talked about the Baltimore model, and I 
think that's very important. Are there any other innovative 
ideas or legislative initiatives that you would recommend for 
my State of Florida? Anyone on the panel, please.
    Mr. Tilley. I just might start by adding that one thing I 
wanted to convey to the panel, and I know you're very well 
aware of the STOP Act and this issue of keeping fentanyl and 
carfentanil out of our country where it's manufactured legally, 
sometimes illegally, and still shipped in and mailed into our 
country.
    The DEA recently informed us that the profit margin for 
these cartels that bring fentanyl in, for a $6,000 investment, 
to make that more of a heroin-type substance, is about a $1.6 
million profit. To do it in pill form, just to press it into a 
pill, is a $6 million profit. And so with that kind of profit 
margin out there for their taking, it's very difficult to 
combat this if we're flooded with it with impunity. We've got 
to figure out ways to stop it from coming into our country in 
the first place.
    And I think that would be--again, that's not necessarily 
Florida specific, but I think this idea that's contained in the 
STOP Act--and I won't comment on the specifics, but I 
understand that would again curtail some of that.
    Mr. Bilirakis. Does anyone else? Please.
    Ms. Boss. If I could, fentanyl is changing the face of this 
epidemic, and we need to respond in our interventions. And one 
of the things that I would comment on is that this is a 
marathon, not a sprint. And we really need to take a look at 
prevention efforts as critical to changing the face of this 
epidemic and not cutting our efforts in prevention. Primary 
prevention, working with transitional-aged youth. If we can 
stop their use before they use, we're not going to have them 
dying with fentanyl.
    I think we need more research. Recently, we haven't had any 
new medications. We haven't had any new treatment models 
necessarily proposed for opioid-use disorders. And I'm not sure 
enough effort has been placed into the research needs of this 
epidemic. And we need to start looking at this as we would, the 
focus on cancer.
    This is an epidemic. We need research that's going to 
support the most evidence-based models that are effective in 
treating this.
    Mr. Bilirakis. Thank you very much. I agree.
    I yield back, Mr. Chairman. Thank you for allowing me to 
ask questions.
    Mr. Murphy. Thank you Mr. Bilirakis.
    I recognize Ms. DeGette for follow-up.
    Ms. DeGette. I just really want to commend all of your 
states for leaning in, for moving forward on this, and for 
trying to find robust solutions. It's really important that we 
do that. And I know almost all the states are doing this. My 
State of Colorado has also started really paying attention. 
It's the kind of thing where it crept up on us collectively as 
a society, and so people have had to move really fast. And I 
just want to commend you.
    And I also want to reiterate that we're very flattered. I, 
personally, am very flattered that you're taking this 21st 
Century Cures money and really making something with it and 
developing some programs that are uniquely and appropriately 
tailored to your states. Sometimes when we're in Congress, we 
wonder if anything we do actually impacts people's lives? And 
when I hear what you're doing, it's really gratifying and I 
think it will save lives.
    I hate to sound like a downer, though, but to say that this 
21st Century Cures money, which was $2 billion, it's really 
well used I think by the states with these grants to develop 
programs, but $2 billion is nothing. As Governor Kasich said, 
$45 billion. If you're trying to substitute the Medicaid 
expansion money and other treatment monies that are coming, you 
can't use the money for that.
    We have to make opioid treatment and prevention part of our 
overall mental and physical healthcare in this country. And 
what that does take, and I'm sorry that Mr. Carter left, 
because we're not trying to politicize this. What we're trying 
to say is, if you really want to give treatment to people, you 
have to develop the programs, which is what something like the 
Cures money is good for. But then you have to be able to 
implement them.
    You have to be able to give the counseling to people. You 
have to be able to give the MAT treatment to people. You have 
to be able to build and maintain these housing options that 
people were just talking about. You don't do that with just 
fairy dust. You have to do that with resources. And some of the 
resources can come from the states, but the states are jammed. 
And so that's why the Medicaid expansion has helped so many 
millions of Americans be able to get access to the treatment 
that they need, and that's why we need to be able to keep that 
for these populations.
    So I want you to know that--and it's not that we really 
disagree on that either. Mr. Murphy and I agree on a lot of 
these issues, he just can't say it as forcefully as I can 
sometimes. But we know that we need to make sure that all 
Americans can get this treatment. And we will commit to you 
that we are going to continue to work with the states to make 
that happen.
    Thank you.
    Mr. Murphy. Thank you.
    I have a few questions I want to follow up on. This goes in 
the category of coverage without access is a problem. Coverage 
without access and access without coverage are both problems. 
To this extent, I want to make a note or put in the record, and 
ask unanimous consent.
    One is an article why taking morphine and OxyContin can 
sometimes make pain worse from Science Magazine. And another 
one is an article that 51 percent of opioid prescriptions go to 
people with depression and other mood disorders, from Stanton 
News. I'll let you see that if----
    Ms. DeGette. I don't have an objection.
    Mr. Murphy. There's no objection, it will go in the record.
    [The information appears at the conclusion of the hearing.]
    Mr. Murphy. But I want to make reference to a couple of 
those things. There are about 50 million Americans with lower 
back pain, 25 million of those take an opioid. When a person 
has pain and depression, about 40 percent of them are 300 to 
400 percent, the risk of abuse, misuse or addiction, noting 
that when we're dealing with people with addiction disorders 
and 80 percent of them begin with a prescription for pain, but 
mood disorders are a big, big part of this. Fifty-one percent 
of people on opioids have a mood disorder, anxiety, depression 
or something else.
    And I don't know if any of your states ask physicians to 
screen for that when they are prescribing. I would imagine not, 
because I think in most states they don't. Do any of you know 
if your state's medical society or hospitals ask to screen? 
When you're prescribing a medication for pain, do you also 
screen for depression, anxiety, anything like that? Do any of 
your states--if you don't know, just tell me you don't know.
    Mr. Rutherford. I don't know, but I believe that it's not 
available in the prescription drug monitoring program either.
    Mr. Murphy. Oh, OK. Secretary Moran, do you know if you do 
that in Virginia?
    Mr. Moran. My counterpart, he's a doctor, and the medical 
community was using the chart, and say, 0 to 10, smiley face. 
We were addressing pain and we overprescribed. I'm not aware, 
to answer your particular question, I'm not aware of whether or 
not we----
    Mr. Murphy. Yes. Those emojis are not to do with mood, 
they're to do with pain. I find it amazing that the other vital 
signs, blood pressure we measure. Temperature, we have an 
instrument for that. Respiration. All these are measured, but 
when it comes to pain, 1 to 10 or an emoji is pretty primitive.
    Mr. Moran. We are mandating now 2 hours of continuing 
education in the medical community to address pain. It starts 
in the medical community with better education around how we 
manage pain.
    Mr. Murphy. As far as you know, it doesn't also include 
assessing a mood disorders. I've seen this take place where 
they actually assess it, and there's a big difference. 
Secretary Tilley, do you know, or Director Boss, do you know if 
in your states there's any requirement to also concurrently 
assess patients for mood disorders when prescribing these?
    Mr. Tilley. Not specifically, but I did mention the limit 
to the 3-day supply for acute pain, which again, I think 
presents a bit of a pause for the physician before that 
prescription. Also, I did not get a chance to mention the 
University of Kentucky is piloting a program, our flagship 
institution piloting a program there, to start with everything 
but an opioid in the course of treatment and try to taper--
instead of starting with and tapering down, starting without 
and maybe moving toward it if it's absolutely necessary.
    And then, lastly, I would say we are embarking to your 
question. We actually are embarking on that very thing 
potentially with a statewide mental health approach as to a 
number of best practices across there, and that's one of the 
things we've discussed.
    Mr. Murphy. Thank you. Director Boss do you know if you 
evaluate----
    Ms. Boss. I can't speak as to whether or not it's required. 
I can say that the state has had major efforts toward 
behavioral health integration and primary care. And I know that 
a lot of our collaboratives and a lot of our--asking primary 
care settings, and most large primary care settings are 
screening for mood disorders as well as anxiety.
    Mr. Murphy. I would bet during the time when someone is in 
the emergency room, the chance of someone actually getting a 
screen for that is probably pretty close to zero. And just as 
we have the problems of 42 CFR, a doctor doesn't know if they 
are on methadone with a prescription or monitoring program. 
They don't know if they are on these medications. It's usually 
patch them up, get them out.
    I know when I was prescribed a lot of fentanyl and other 
opiates when I had an injury in Iraq, nobody ever asked me 
about any other questions, just, take these, take these, take 
these. And I ended up with my own issues there, which I didn't 
get an addiction, but my body developed a dependency upon 
those. And when I finally said enough is enough, and I had the 
fun on my own, a mild withdrawal reaction. It was not pleasant 
at all. But going with----
    Director Boss, you mentioned 82 percent of people get a 
referral in the emergency room by talking with, I guess, the 
peers support or a counselor there. Do you know how many of 
that 82 percent actually follow up and follow up consistently 
in an evidence based program?
    Ms. Boss. We are not able to measure where the 82 percent 
go. And so 82 percent, not just are referred, but are connected 
and do follow through with treatment and recovery supports.
    Mr. Murphy. We don't know what the follow up is afterward?
    Ms. Boss. Right.
    Mr. Murphy. That's important to me. So we've identified a 
few things here such as we have a crisis shortage of providers. 
We all agree with that, across the Nation, especially in rural 
areas. Quite frankly, in urban areas, too, if you assess 
providers and say, how many of you actually have openings in 
your schedule, you'll see that they don't. I know in my areas, 
for example, child and adolescent providers are even more rare, 
and some say, I just don't have any appointments open for 
months. And when you're dealing with a substance abuse 
disorder, I need treatment now. Now is the best time for 
treatment. Giving them a waiting list is not helpful at all.
    So even when we do refer people over, the statistic I see 
is of the 27 million people in this county with an addiction 
disorder, 1 percent get evidence-based care. So if you look at 
this, about 90 percent of the people with a substance abuse 
disorder don't seek attention. So out of every 1000, 900 don't 
seek attention.
    Out of the 100 that do seek attention, 37.5 can't find it, 
it's not available. Of those who do get it, get attention, 90 
percent of those don't get evidence based care. So we have a 
crisis that's getting worse. And I might add, too, I think, 
Virginia, you're the only state that doesn't have Medicaid 
expansion right?
    Mr. Moran. We do not.
    Mr. Murphy. You do not. But in this time period of which it 
was available, I would assume that your addiction rate, your 
overdose and death rates have climbed, correct?
    Mr. Moran. They have.
    Mr. Murphy. And in the states that do have Medicaid 
expansion, Maryland, Kentucky, Rhode Island, has your overdose 
and death rates also climbed?
    Mr. Rutherford. Oh, yes. Yes, sir.
    Ms. Boss. Ours have raised but not as significantly as 
other states have experienced in these last few years.
    Mr. Murphy. Yes, I want to help, but we need honest data 
here. Look, we don't even have information on if those numbers 
are accurate, because if your medical examiners and coroners 
are not doing toxicology tests, and if we don't even have data 
for 2016, and we won't have it until the end of this year. We 
just don't know.
    And what this committee likes to do is identify. We need 
the absolute, honest, bare bone problems. And if you tell us, 
look, we don't know, this is probably much worse. We don't have 
enough providers. We had legislation, some of it was reduced 
down and I want to see it reenacted, where we could do more to 
get more psychiatrists, psychologists, clinical social workers, 
and licensed addiction counselors out there.
    We're probably going to have to do things with the states 
and Federal Government providing scholarships or pay for their 
internships or something to get them out there, because who 
would want to go into a field that pays so little and the 
frustration is so high. You're 24/7 on call. You're probably 
going to get called into court and testimony, a lot of 
different problems. And that itself could be, it only requires 
the best who have true altruism in their blood to help fight 
that. But we've got to do it.
    I also want to ask a question, too, with regard to getting 
drugs back to someone who is not using. I know even realtors 
now say when you're putting a home up for sale the first thing 
you should do is go to your medicine cabinet and clean it out. 
I know there are some products, even in rural areas, some 
places will have drug recovery programs, you take it to the 
pharmacist or you take it to the police. There are some 
products--one product called Deterra, which actually--a drug 
deactivation system where you can use in your home and then 
throw it away. Virginia, you have programs where you do drug 
recovery at home?
    Mr. Moran. We do, sir. And we are using those. And I would 
congratulate our private sector partners pharmacies have 
collection boxes now. And I will tell you, DEA does a terrific 
job. In fact, they were going to suspend their take-back 
program, and now they continue their robust take-back program. 
Tons of drugs, it's amazing, I've witnessed it myself, how 
much. And improper disposal in the medicine cabinets.
    As the father of 2 children, teenagers, it's imperative 
that we keep the drugs out of that medicine cabinet because 
we've heard from anecdotal stories, that's where the addiction 
begins. Kids using it out of their medicine cabinets.
    Mr. Murphy. They go into homes for a party and the next 
thing you know----
    Mr. Moran. Exactly, sir.
    Mr. Murphy. I want to thank this panel. We have a long way 
to go. And, unfortunately, at this point we're seeing the 
battles in the states to combat, but I think we have to be 
honest and say we have a long way to go in this war, it's still 
quite a crisis here.
    This committee will continue to take this up on lots of 
different ways, because it isn't just a matter of funding. What 
good is funding if you haven't got a provider? What good is 
some of the jail treatment programs if a person is discharged 
from jail and they're now back on Medicaid, so they go right 
back to the streets, right back to somewhere where they had 
problems before. I hear someone will work in certain 
professions where everybody--a lot of the people in the back 
rooms also have addiction problems and get reexposed. We have 
an awful, awful mess in this country, and the outcome is a 
death rate that is mortifying.
    So I thank the panel here and I thank the members for being 
in today's hearing. And I remind members, they have 10 business 
days to submit questions for the record, and ask the witnesses 
to all agree to respond promptly to the questions.
    Thank you for your honest approaches. Keep fighting the 
good fight. Thank you.
    Mr. Moran. Thank you, Chairman.
    Ms. Boss. Thank you.
    [Whereupon, at 12:16 p.m., the subcommittee was adjourned.]
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