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

                        THE ROLE OF FEDERAL HOUSING AND
                         COMMUNITY DEVELOPMENT PROGRAMS
                        TO SUPPORT OPIOID AND SUBSTANCE
                      USE DISORDER TREATMENT AND RECOVERY

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

                                    HEARING

                                   BEFORE THE

                                SUBCOMMITTEE ON
                             HOUSING AND INSURANCE

                                     OF THE

                        COMMITTEE ON FINANCIAL SERVICES

                         U.S. HOUSE OF REPRESENTATIVES

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                AUGUST 16, 2018

                                   __________

           Printed for the use of the Committee on Financial Services

                               Serial No. 115-112

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                  __________

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    31-572 PDF                  WASHINGTON : 2018

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                     HOUSE COMMITTEE ON FINANCIAL SERVICES

                        JEB HENSARLING, Texas, Chairman

    PATRICK T. McHENRY, North Carolina,  MAXINE WATERS, California, Ranking
        Vice Chairman                        Member
    PETER T. KING, New York              CAROLYN B. MALONEY, New York
    EDWARD R. ROYCE, California          NYDIA M. VELAZQUEZ, New York
    FRANK D. LUCAS, Oklahoma             BRAD SHERMAN, California
    STEVAN PEARCE, New Mexico            GREGORY W. MEEKS, New York
    BILL POSEY, Florida                  MICHAEL E. CAPUANO, Massachusetts
    BLAINE LUETKEMEYER, Missouri         WM. LACY CLAY, Missouri
    BILL HUIZENGA, Michigan              STEPHEN F. LYNCH, Massachusetts
    SEAN P. DUFFY, Wisconsin             DAVID SCOTT, Georgia
    STEVE STIVERS, Ohio                  AL GREEN, Texas
    RANDY HULTGREN, Illinois             EMANUEL CLEAVER, Missouri
    DENNIS A. ROSS, Florida              GWEN MOORE, Wisconsin
    ROBERT PITTENGER, North Carolina     KEITH ELLISON, Minnesota
    ANN WAGNER, Missouri                 ED PERLMUTTER, Colorado
    ANDY BARR, Kentucky                  JAMES A. HIMES, Connecticut
    KEITH J. ROTHFUS, Pennsylvania       BILL FOSTER, Illinois
    LUKE MESSER, Indiana                 DANIEL T. KILDEE, Michigan
    SCOTT TIPTON, Colorado               JOHN K. DELANEY, Maryland
    ROGER WILLIAMS, Texas                KYRSTEN SINEMA, Arizona
    BRUCE POLIQUIN, Maine                JOYCE BEATTY, Ohio
    MIA LOVE, Utah                       DENNY HECK, Washington
    FRENCH HILL, Arkansas                JUAN VARGAS, California
    TOM EMMER, Minnesota                 JOSH GOTTHEIMER, New Jersey
    LEE M. ZELDIN, New York              VICENTE GONZALEZ, Texas
    DAVID A. TROTT, Michigan             CHARLIE CRIST, Florida
    BARRY LOUDERMILK, Georgia            RUBEN KIHUEN, Nevada
    ALEXANDER X. MOONEY, West Virginia
    THOMAS MacARTHUR, New Jersey
    WARREN DAVIDSON, Ohio
    TED BUDD, North Carolina
    DAVID KUSTOFF, Tennessee
    CLAUDIA TENNEY, New York
    TREY HOLLINGSWORTH, Indiana

                         Shannon McGahn, Staff Director
                     Subcommittee on Housing and Insurance

                       SEAN P. DUFFY, Wisconsin, Chairman

    DENNIS A. ROSS, Florida, Vice        EMANUEL CLEAVER, Missouri, Ranking
        Chairman                             Member
    EDWARD R. ROYCE, California          NYDIA M. VELAZQUEZ, New York
    STEVAN PEARCE, New Mexico            MICHAEL E. CAPUANO, Massachusetts
    BILL POSEY, Florida                  WM. LACY CLAY, Missouri
    BLAINE LUETKEMEYER, Missouri         BRAD SHERMAN, California
    STEVE STIVERS, Ohio                  STEPHEN F. LYNCH, Massachusetts
    RANDY HULTGREN, Illinois             JOYCE BEATTY, Ohio
    KEITH J. ROTHFUS, Pennsylvania       DANIEL T. KILDEE, Michigan
    LEE M. ZELDIN, New York              JOHN K. DELANEY, Maryland
    DAVID A. TROTT, Michigan             RUBEN KIHUEN, Nevada
    THOMAS MacARTHUR, New Jersey
    TED BUDD, North Carolina

                                C O N T E N T S

                                  ----------
                                                                       Page
    Hearing held on:
        August 16, 2018..............................................     1
    Appendix:
        August 16, 2018..............................................    35

                                   WITNESSES
                           Thursday, August 16, 2018

    Boggs, David, President and Chief Executive Officer, Opportunity
      for Work and Learning..........................................     8
    Fletcher, Hon. Ernie, Former Governor of Kentucky, and Founder of
      Recovery Kentucky..............................................     5
    King, Edwin, Executive Director and Chief Executive Officer,
      Kentucky Housing Corporation...................................    10
    Minton, Lisa, Executive Director, Chrysalis House................    12
    Robinson, Tim, Founder and Chief Executive Officer, Addiction
      Recovery Care..................................................    13
    Thomas, Jerod, President and Chief Executive Officer, Shepherd's
      House..........................................................    15
    Walsh, Sharon L., Director of the Center on Drug and Alcohol
      Research and Professor, Behavioral Science and Psychiatry,
      University of Kentucky.........................................    17

                                    APPENDIX

    Prepared statements:
        Boggs, David.................................................    36
        Fletcher, Hon. Ernie.........................................    40
        King, Edwin..................................................    49
        Minton, Lisa.................................................    52
        Robinson, Tim................................................    55
        Thomas, Jerod................................................    59
        Walsh, Sharon L..............................................    64

                        THE ROLE OF FEDERAL HOUSING AND
                       COMMUNITY DEVELOPMENT PROGRAMS TO
                       SUPPORT OPIOID AND SUBSTANCE USE
                        DISORDER TREATMENT AND RECOVERY

                                  ----------

                           Thursday, August 16, 2018

                         U.S. House of Representatives,
                                        Subcommittee on Housing
                                                 and Insurance,
                               Committee on Financial Services,
                                                       Washington, D.C.
        The subcommittee met, pursuant to notice, at 9:10 a.m., in
    Courtroom A, U.S. District Court of the Eastern District of
    Kentucky, 101 Barr Street, Lexington, Kentucky, Hon. Sean P.
    Duffy presiding.
        Present: Representative Duffy
        [presiding].
        Also present: Representatives Barr and Guthrie.
        Mr. Duffy. The Subcommittee on Housing and Insurance will
    come to order. Today's hearing is entitled, ``The Role of
    Federal Housing and Community Development Programs to Support
    Opioid and Substance Use Disorder Treatment and Recovery.''
    Without objection, the Chair is authorized to declare a recess
    of the Subcommittee at any time. Without objection, all Members
    will have 5 legislative days within which to submit extraneous
    materials to the Chair for inclusion in the record. Without
    objection, Members who are not Members of this Subcommittee may
    participate in today's hearing for the purpose of making an
    opening statement and questioning the witnesses.
        The Chair now recognizes himself for an opening statement.
        I want to thank our witnesses for joining us as we continue
    to look at how existing Federal Government programs can be
    utilized to combat opioid addiction and substance abuse. Today,
    we will be focused on programs run by HUD (U.S. Department of
    Housing and Urban Development) that help low-income families
    and the poverty stricken.
        I want to thank Mr. Barr for hosting us in the fine city of
    Lexington and commend his leadership on the issue of opioid
    addiction and substance abuse, something that impacts the
    entire Nation. This crisis is not going away and it is only
    getting worse in some areas of our country. According to a 2016
    report by the U.S. Surgeon General, 1 in 7 Americans will face
    substance addiction.
        Opioids are now at the forefront of the fight against
    substance abuse.
        On March 29 of last year President Trump signed an
    Executive Order to establish the President's Commission on
    Combating Drug Addiction and the Opioid Crisis and the House
    began its work by moving legislation. We have passed 50 bills
    related to addressing the opioid crisis ranging from treatment
    and recovery, to prevention, to the THRIVE (Transitional
    Housing for Recovery in Viable Environments) Act, championed by
    Chairman Barr.
        Mr. Barr's bill recognizes that sometimes you have to use
    resources outside of traditional rehab programs to treat
    addicts and help them prepare for becoming a productive member
    of society.
        The THRIVE Act would create a program setting aside 10,000
    housing choice vouchers for individuals suffering from
    addiction. Those people would be able to use vouchers with
    transitional housing nonprofits that focus on maintaining
    sobriety, teaching valuable skills for jobs, and obtaining
    employment as they transition back into society. They'll have
    24 months to complete the treatment program but most
    importantly are able to do so in a drug- and alcohol-free,
    clean, safe, and supportive structured environment.
        I know some of you will be commenting on how this bill
    would work in implementation but Mr. Barr's bill is just one
    idea. You are the ones out there dealing with this through your
    organizations.
        We want to hear your ideas.
        Mr. King, you mention in your testimony needing the
    flexibility to meet specific needs at the local level by
    addressing the 20 percent limitation on tenant-based rental
    assistance for specific properties.
        Ms. Minton, you mentioned Continuum of Care and the
    reallocation process to create new projects.
        Mr. Thomas, you talk about a limited expansion of vouchers
    for graduates of THRIVE-based programs.
        Dr. Walsh, your testimony describes what you are doing with
    the First Bridge Clinic and the PATHWAYS programs.
        These are the ideas we need to hear about that can help us
    to combat the opioid epidemic with government programs already
    in place.
        I look forward to today's discussion as it's one of the
    most important issues we should be addressing today.
        I now recognize the gentleman from Kentucky, Mr. Barr, the
    Chairman of the Subcommittee on Monetary Policy and Trade, for
    an opening statement.
        Mr. Barr. Thank you, Chairman Duffy, and thank you to the
    Housing and Insurance Subcommittee for calling this hearing
    today in my home State of Kentucky, which is truly on the front
    lines of the opioid crisis.
        I'd also like to thank my colleague from the Kentucky
    delegation, Congressman Brett Guthrie for joining our Financial
    Services hearing today. Mr. Guthrie has been a leader on opioid
    issues on the House Energy and Commerce Committee and we are
    fortunate to have him here today to offer his insight.
        We all know that the opioid epidemic is a major health
    crisis that has impacted every community and every
    congressional district. Kentucky has the third highest overdose
    mortality rate in the country. Last fall, President Trump
    declared a National Public Health Emergency and Congress
    recently passed a historic package of legislation to address
    the opioid epidemic through research, treatment, and
    prevention.
        H.R. 6, the SUPPORT (Substance Use-Disorder Prevention that
    Promotes Opioid Recovery and Treatment) for Patients and
    Communities Act that was passed in the House this summer,
    builds upon past resources authorized and funded by Congress
    including the 21st Century Cures Act and the Comprehensive
    Addiction and Recovery Act. I was also proud to support the
    Consolidated Appropriations Act earlier this year that
    appropriated $4 billion, the largest Federal investment to
    date, to address the opioid epidemic.
        But there is more work to be done. Over 115 Americans
    continue to die every day from opioid overdoses. We cannot
    continue to focus our Federal efforts on prevention and
    treatment without looking toward long-term recovery through
    housing, job placement, financial literacy, and life skills
    training.
        Too many individuals find themselves with limited housing
    choices after completing in-patient rehabilitation and are
    forced into housing situations where they are surrounded by
    people using the same illegal substances that they went to
    rehab to stop using. This perpetuates the cycle of addiction
    and prevents individuals from rising above substance abuse.
        The opioid epidemic has also presented a major issue for
    workforce development and job placement. Local employers I meet
    with regularly in Kentucky are struggling to find workers to
    fill even low-skill jobs. According to the CDC, the opioid
    epidemic's cost to our economy now exceeds $1 trillion.
        I was proud that H.R. 6, the opioid package which passed
    the House earlier this year, included my legislation, H.R. 5735
    the Transitional Housing for Recovery in Viable Environments or
    the THRIVE Act. This bill would allow a limited number of
    Section 8 Housing Choice Vouchers to be allocated directly to
    transitional housing non-profits that have evidence-based
    models of recovery and life skills training. I am hopeful that
    the Senate will act swiftly to pass this critical legislation.
        I have also introduced H.R. 5736 the Comprehensive
    Addiction Recovery through Effective Employment and Reentry, or
    CAREER (Comprehensive Addiction Recovery through Effective
    Employment and Reentry) Act, which would address the decline in
    workforce participation as a result of the opioid epidemic by
    encouraging local businesses and treatment centers to form
    partnerships to secure job training, employment, and housing
    options for individuals in recovery. This legislation would
    also give States more flexibility to direct Federal funds
    through the Community Development Block Grant (CDBG) to local
    recovery initiatives. I am grateful to Leader McConnell for
    introducing the Senate companion to this legislation.
        Meaningful employment and a safe place to live are key to
    helping individuals maintain sobriety and rise above poverty.
    Today you will hear from several non-profit, government, and
    academic experts who are on the frontlines of the opioid
    epidemic in Kentucky. They will offer their unique perspectives
    on ways our Federal housing and community development programs
    could be improved or further utilized to fight the opioid
    epidemic.
        Reforms to these programs and greater investment in long-
    term recovery would save American lives as well as taxpayer
    funds in the long run by helping more individuals rise above
    addiction and poverty.
        Thank you and I yield back.
        Mr. Duffy. Thank you Mr. Barr.
        I now recognize Mr. Guthrie for an opening statement.
        Mr. Guthrie. Thank you Mr. Duffy, and thank you all for
    being here today. I have heard countless stories of the awful
    effects the opioid epidemic has had on families, communities,
    and the overall workforce. I have been working hard in my
    committee, the Energy and Commerce Committee, to pass
    meaningful legislation that will stop this awful epidemic. The
    SUPPORT bill, H.R. 6 which includes over 50 pieces of
    legislation is currently pending before the Senate. I am
    hopeful the Senate will act quickly to provide relief to so
    many suffering Americans. Most of the 50-something bills have
    come through our committee. And a lot of it comes from hearing
    from people like you, the witnesses here today.
        I wish there was one single bill we could pass and it would
    make the problem go away. It is just not that simple. I wish
    that it was. It is very complicated. And when we hear from
    people like you--and I have heard over the last several days
    even stuff we need to improve in legislation that has already
    been passed out of the House and into the Senate. We do hear
    the insights because you all are the experts, you all are the
    ones on the frontlines dealing with it, and we are trying to--
    where there are roadblocks, we are trying to get flexibility,
    we are trying to move things forward.
        And it is very appropriate we are having this hearing in
    this community today. I was in Elizabethtown about 3 or 4 days
    ago going through a recovery center, and the person who was
    walking me through said basically we get them here in residence
    for 30 days, and we can control that environment. Some of them
    leave and whatever, but for the most part, we can get them
    through our 30-day program because we have control. They are in
    our environment.
        He said the biggest gap is the sober-living piece, and so
    it really struck me. I said, well, we are having a hearing on
    something that Congressman Barr has made great efforts and
    great strides to make sure the sober living piece is, one,
    known throughout--the issue needs to be dealt with and, one,
    hopefully given the tools using money that is already going to
    be spent by the Federal Government in housing to give people an
    opportunity and have that full--not just the in-residence
    service but another piece of the bigger wraparound service. But
    it was stated to me that the biggest loss of people in recovery
    is when they get the sober-living part.
        So I appreciate your leadership on this, Congressman Barr.
    I certainly appreciate the Chairman coming to our wonderful
    Commonwealth, and I appreciate having the Governor here as
    well. We got to serve together in Frankfurt when I was in the
    legislature, and I am pleased to have you here and all of our
    witnesses. So thank you, and I yield back.
        Mr. Duffy. The gentleman yields back.
        Again, I want to now welcome our witnesses. Our first
    witness, who actually is the Governor who I didn't recognize in
    my opening statement, Governor Fletcher, former Governor of
    Kentucky and the Founder of Recovery Kentucky, welcome; our
    second witness, Mr. David Boggs, President and CEO of
    Opportunity for Work and Learning, also known as OWL; Mr. King,
    our third witness, Executive Director and CEO of the Kentucky
    Housing Corporation; Ms. Minton, Executive Director of the
    Chrysalis House. Our fifth witness is Mr. Tim Robinson, Founder
    and CEO of Addiction Recovery Care. Our sixth witness today is
    Mr. Jerod Thomas, President and CEO of Shepherd's House. And
    our final witness, but not least, is Dr. Sharon Walsh, Director
    of the Center on Drug and Alcohol Research and Professor of
    Behavioral Science and Psychiatry at the University of
    Kentucky.
        To all of you, welcome. Thank you for giving us your time
    today. Again, this is important for us to get out of the bubble
    of Washington, D.C., and come and take the testimony and
    insights from those around the country who are on the frontline
    dealing with these issues so we can take that insight back to
    Washington to our colleagues.
        The witnesses in a moment will be recognized for 5 minutes
    to give an oral presentation of their written testimony.
    Without objection, the witnesses' written statements will be
    made part of the record following their oral remarks. Once the
    witnesses have finished presenting their testimony, each Member
    of the subcommittee will have a length of time within which to
    ask the panel questions.
        With that, Governor Fletcher, you are now recognized for 5
    minutes.

                    STATEMENT OF HON. ERNIE FLETCHER

        Mr. Fletcher. Chairman Duffy and other Members, Congressmen
    Barr and Guthrie, thank you for this opportunity. And, Chairman
    Duffy, welcome to Kentucky. I hope you do get to spend some
    time and see what a wonderful State it is.
        You have my testimony there, but let me just speak a little
    bit from the heart. It is obviously a public health crisis. It
    is a very challenging, complex crisis that we face. There is
    not a simple solution, as has already been noted. And even with
    the reports yesterday, every 7 minutes someone dies of
    overdose, if we look at combining that with alcohol where every
    6-1/2 minutes someone dies from alcohol abuse and its
    consequences, and then if you combine that with about every 12
    minutes someone dies from suicide, many of those suicides are
    related to substance abuse disorder, you can see the complexity
    of the problem of addiction that plagues this Nation.
        Going back 10 years, we looked at models that worked in a
    residential program out of The Healing Place in Louisville and
    the Hope Center in Lexington, Kentucky. It is a residential
    program where folks come in. We use a peer-support 12-step
    model, and we had fairly good efficacy from that. I will say
    that it is not for everyone, and we think we can improve on
    that model.
        But we took that model, we developed some very creative
    funding. This was done by an individual by the name of Don
    Ball. Don Ball is a builder/philanthropist here who had worked
    with the Hope Center. I appointed him as Chair of Housing
    Corporation, and he brought together several funding streams to
    fund the expansion of centers modeled after the Hope Center.
    Now, we have 18 of those. We have 2,100 beds at any one time.
    University of Kentucky's Drug and Alcohol Research Center does
    our surveys. Eighty-four percent are drug-free at 1 year.
    Seventy-five percent are gainfully employed at the end of that
    program. Recidivism rate, as the criminal justice system, is
    very low, and so it is an effective program.
        I will give you the caveat that at the beginning, 30
    percent of folks, as a voluntary program, walk away and it is
    not for them, and I think that would address the need for
    medication-assisted treatment and more of a comprehensive
    approach than just one-size-fits-all.
        The bottom line is we have 18 centers here that are working
    very effectively and transforming lives, and we are taking and
    expanding that nationally. As you look at what we face
    expanding that nationally, let's look at the funding streams.
    We use low-income housing tax credits, we use some other
    Federal home-loan moneys for the capital construction of these
    facilities. That runs about $5-6 million.
        We use Section 8 vouchers, food stamps, per diems from
    corrections because up to 70 percent of our residents come out
    of corrections, whether it is parole, probation, or diversion
    from drug courts. And these are nonviolent offenders. It is a
    good investment for them. They pay a per diem, and as I
    mentioned, the recidivism rate is very, very low for these
    individuals, so it works for the benefit of the recipient, as
    well as for the Department of Corrections in saving money
    substantially.
        As we are taking this nationally, though, what we find is
    that Section 8 housing is a little more challenging to get in
    the operational side of things, and for that reason, we are
    very supportive of the THRIVE Act, Congressman Barr, that you
    have put forward, because it sets aside some of these moneys
    for this type of program. And there are two advantages of that.
    One, we think it recognizes that these programs, when they are
    evidence-based or have some outcomes that show that they work,
    they help make sure that we are not funding programs that don't
    work. Unfortunately, in the recovery industry, let's face it;
    there are some scams out there and a lot of families spend a
    lot of money on recovery only to find that their loved one
    comes back and is not truly recovered or treated. Folks end up
    financially broke trying to get their loved ones the treatment
    they need. So this Act, making a stipulation, focuses on making
    sure that only quality programs are funded. So, thank you,
    Congressman, for that insight.
        As you look at some of our other funding, we are working
    with the Department of Corrections. We have worked with
    Secretary Ben Carson. He has been here to Kentucky. We have met
    with him here, and Congressman Barr was in that meeting. We
    also met with him at his office, and they are very supportive
    looking at how can we work with HUD to make sure that we expand
    these programs and make it available. We are working in other
    States now, and Georgia is one of our first States that we are
    working. We want to expand them in Kentucky because we still
    have a need here. We are also working with other programs. Tim
    Robinson is here, and we are glad to collaborate with other
    programs to make sure that we provide as many people as
    possible with this type of recovery.
        The other thing that I want to say about the congressional
    funding, you have nearly $6 billion that is coming, funding to
    fight this opioid crisis, much of that is going to medication-
    assisted treatment because it is the gold standard of
    treatment. Dr. Walsh will address a lot of this.
        In our recovery program, what we find--and we are expanding
    because we see that it doesn't fit everyone. We have 30 percent
    at the beginning that may drop out, and they would likely, very
    likely benefit from MAT, or medication-assisted treatment.
        We also have some folks that end up relapsing as they
    leave, so a program that combines the best of these I think is
    something that Congress needs to make sure that, as you are
    looking at the funding, as you--final passage of these bills,
    that you recognize this full continuum of care.
        These vouchers that are set aside in Section 8, I think are
    very important. Congressman Guthrie, your bill, the
    Comprehensive Opioid Recovery Centers Act, I think is important
    and recognizes the issue we have talked about, so I appreciate
    and hope we can pass that.
        I have a few specific recommendations, and I will close
    with that. One, I would like to recommend obviously passage of
    the THRIVE Act through the Senate as it becomes a part of this
    larger package to fight this public health crisis. There is
    always a challenging--and I think some of the criticism is
    that, well, you may be taking some money from some other folks
    that need it. Let me say there is no greater need than these
    folks that are held captive by addiction. If you look at the
    sequelae of their life, it is abysmal without some kind of
    treatment, so there is no greater need.
        I would like you to consider to take some of the $6 billion
    that you are looking at and making sure that it might be
    allocated toward more of these because we have a proven model.
    It is not the only model, but we have a proven model that we
    can take nationally, collaborating with MAT and collaborating
    with other centers to expand the treatment, and so let me ask
    you to take a look at that.
        I would like to--part of our funding is Community
    Development Block Grants. That is always threatened. The
    President's budget usually cuts those. And when I was in
    Congress, and you all--usually, we have to put them back. But I
    would like you to take a look at a similar program.
        You will find that part of what we are doing--and according
    to the CAREER Act is we want to be able to provide the skills
    that an individual needs in order to enter the workforce. What
    is important in recovery is having meaning and purpose, and a
    good job and a purpose in life with a skill is extremely
    important in preventing relapse. And so I think that is
    important as you look going forward at where you are putting
    the funding. And Community Development Block Grants, this is
    community development, so I would like you to take a look at
    that and see if there is not some other way that you can make
    that funding a little more assured and sustainable because,
    right now, our funding for these programs is sustainable, and
    that is what makes them strong.
        Last, I will recommend--and this is just probably out of
    nowhere and you all don't have the jurisdiction except for--or
    maybe Guthrie in that second-best committee. But this is a
    public health crisis. We have the EOC, Emergency Operations
    Center, activated at the CDC right now for polio. It is
    affecting three countries right now, and they are: Pakistan,
    Congo, and I think Nigeria. It is not activated for this. I
    think it is a perfect center. This is an epidemiological
    problem. It is a public health problem, and I just encourage
    you to take a look at activating the Emergency Operations
    Center out of CDC for this. It will allow them to bring a lot
    of the silos that we have with NIDA (National Institute on Drug
    Abuse), NIH (National Institute of Health), SAMHSA (Substance
    Abuse and Mental Health Services Administration), other parts
    of HHS together.
        So let me close with that and say thank you for this
    opportunity.
        [The prepared statement of Mr. Fletcher can be found on
    page 40 of the Appendix.]
        Mr. Duffy. Thank you, Governor Fletcher.
        Mr. Boggs, you are now recognized for 5 minutes.

                        STATEMENT OF DAVID BOGGS

        Mr. Boggs. Thank you very much. Good morning, Chairman
    Duffy, Congressman Barr and Congressman Guthrie, and other
    guests. It is an honor to address this committee this morning
    in regards to the epidemic of opioid addiction in our Nation
    and the serious housing challenges that this population faces.
    Since housing is a vital step in the recovery and reentry
    process, the Acts that we have already talked about that have
    been introduced by Congressman Guthrie and Congressman Barr,
    THRIVE and CAREER Act and others, will have a major impact on
    abolishing this crisis that we are facing across our Nation.
        Considering that this epidemic touches every family in our
    Nation, something needs to be done in the seriousness of it.
    Just this morning on our national news it was announced that
    the national lifespan for individuals has dropped because of a
    leading factor of drugs, and that is tragic for us to reach
    that point in our Nation today.
        I would like to share with you the role of Opportunity for
    Work and Learning and how it plays with the topic at hand and
    some views of how the Federal Government, through our
    organization, can use existing housing and our community
    development program to complement community efforts to treat
    individuals experiencing the opioid epidemic. OWL provides key
    elements in the transitional path to self-sufficiency through
    job training and employment services.
        Housing and employment definitely go hand-in-hand, so it is
    difficult to successfully maintain one without the other. And
    yet, too often, our offender reentry population, whom we work
    with a great deal, have at least one of these or both of these
    once they are released from incarceration. Consistent housing
    cannot be obtained without employment that will provide enough
    income to meet the demands of either renting or owning in the
    long term. Many of these individuals lose their employment due
    to the challenges faced through inconsistent living through a
    term that we often hear called ``couch surfing,'' and that is
    very real for this population that we all serve, along with the
    homelessness.
        Individuals come to OWL from many different paths. Some of
    them are coming from incarceration, some of them are coming
    from short- or long-term recovery programs, and there are a lot
    of people entering our program that are still struggling with
    the opioid addiction but yet trying to maintain employment. The
    struggle is overwhelming and often leads to more serious
    consequences for these.
        The mission of OWL is, simply, OWL partners with
    communities to help individuals overcome barriers to achieve
    personal and professional growth. We have been doing that since
    1961. But in our Nation there is--annually, 600,000 people are
    being released every year from incarceration, and the number of
    people at risk of falling back into this lifestyle that led
    them there in the first place continues to climb because of
    inadequate housing or the lack of employment. In addition to
    the criminal record preventing these individuals from finding
    jobs, statistics show that ex-offenders far too often have
    limited education and work experience and therefore do not have
    the skills necessary to enter today's workforce with the
    adequate skills.
        The Lexington Manufacturing Center (LMC), which is a wholly
    owned subsidiary of OWL, is an on-site advanced manufacturing
    center that provides training in the essential skills that are
    so desperately needed and demanded by today's employers in
    every job sector. LMC employees earn more than minimum wage,
    and while they are there, they get benefits, the opportunity
    for bonuses, and they have the opportunity to work for other
    companies and earn a greater income because we are just a
    training facility in many aspects.
        The various training programs that we provide such as our
    forklift certification, our manufacturing certification and
    material handling, third-party inspection, kitting, assembly,
    woodworking, all of these offer new opportunities for these
    individuals to reenter into the workplace and become
    successful. The programs that OWL and LMC have in place have
    proven to be successful as a research-based program in the path
    to self-sufficiency and attainment of stable housing and
    employment.
        OWL has maintained a strong partnership with the Kentucky
    Office of Vocational Rehabilitation since its beginning in
    1961. Over these years, our organization has successfully
    provided services for 23,000 individuals in central Kentucky.
    Through OWL's services and programs in Fiscal Year 2018 alone,
    over 74 individuals found full-time employment, not temp
    service or not part-time but full-time employment with job
    benefits. Yet while this is successful numbers, over 60 percent
    of them had some type of opioid and substance abuse while they
    entered our program.
        OWL completely adheres to the work being done with WIOA,
    the Work Innovation Opportunity Act, and we support all the
    mandates of community rehabilitation programs required in that
    through our youth grant, out-of-school youth grant.
        Paul, a good example of our work, came to OWL as a result
    of an ongoing opioid addiction that cost him his home, his
    family, and also some incarceration time. Fortunately, after a
    period of time, Paul became involved at a drug court diversion
    program, and they opened their doors to him instead of the
    long-term incarceration. Today, he is reunited with his family.
    He now has adequate funding and support through his job at OWL,
    and now he has homeownership. This is what we are all striving
    to reach together through this funding mechanism.
        James came to us after serving 24 years in our Federal and
    State judiciary systems and still struggled with opioid
    addiction time after time. But thanks to our partnership with
    community housing agencies that we work with within our
    community, many of them represented here today, James was able
    to begin his pathway to a new life. Today, he has been fully
    employed at OWL for over 5 years and lives independently.
        Paul and James are just two examples of individuals who
    have struggled because of the impact of the opioid addiction on
    their lives. Sadly, they are not alone, as we have already
    heard here today. There is an overwhelming need for housing and
    employment services for others trying to escape the opioid
    crisis in their life. Funding must be accessible--it is not an
    option--it must be accessible for research-based programs like
    OWL and others represented here today and have a proven track
    record of employment training, job placement, and housing.
    Programs that can easily be replicated and expanded upon in our
    individual communities must be provided oversight and guidance
    to establish consistency in collaboration among agencies to
    maximize resources and human capital.
        Yes, we applaud the work being done by this committee and
    the leadership of our local Congressmen in Kentucky through
    bills that have already been sponsored and passed, but the
    battle against the housing and opioid crisis is not just a
    Kentucky epidemic but a national pandemic that has no borders.
        Thank you again for this opportunity to share with you this
    morning.
        [The prepared statement of Mr. Boggs can be found on page
    36 of the Appendix.]
        Mr. Duffy. Thank you, Mr. Boggs. And it has no borders; you
    are right.
        Mr. King, you are recognized for 5 minutes if we can figure
    out the microphone situation.

                         STATEMENT OF EDWIN KING

        Mr. King. Hopefully, you can hear me. Chairman Duffy,
    Congressman Barr, Congressman Guthrie, thank you all for
    holding this hearing. As you said, I am the Executive Director
    of the Kentucky Housing Corporation, the Commonwealth's housing
    finance agency. And on behalf of KHC's board of directors and
    staff, again, we thank you for conducting this hearing and
    affording me the opportunity to speak with you today.
        I want to thank Congressman Barr and Congressman Guthrie
    publicly for bringing attention to the problem of the opioid
    addiction in the Sixth and the Second Districts. Thank you all.
    Congressman Barr, the passage of your bill, the Transitional
    Housing for Recovery in Viable Environments, the THRIVE Act,
    demonstrates your commitment to housing solutions for those on
    the road to recovery, so thank you for that.
        It is my pleasure to share information about Kentucky's
    accomplishments through leveraging housing resources to help
    our citizens on the path of recovery from substance use
    disorders. There are multiple effective recovery strategies
    depending on the personal circumstances of those that are
    caught in the grip of addiction, as Governor Fletcher has
    alluded to. Access to stable housing is a basic human need and
    one of the primary social indicators of public health.
        One of the most successful recovery strategies that we have
    seen here in Kentucky is of course the Recovery Kentucky model.
    In 2004, the late Don Ball took the helm as the Chair of
    Kentucky Housing Corporation under Governor Fletcher's
    administration. Mr. Ball brought with him a personal
    commitment, a strong will, and a solid plan to establish a
    network of recovery centers across Kentucky. Because of Mr.
    Ball's vision, Kentucky now has 14 recovery centers that have
    helped thousands of our residents start a new life of recovery
    from addictive substances. These 14 centers are in addition to
    the other four centers, two in Louisville--The Healing Place--
    and then the two Hope Centers here in Lexington. Today, these
    18 recovery centers serve and help over 2,000 men and women
    daily.
        The Recovery Kentucky Centers follow a peer-to-peer
    education and self-help model to provide sustained addiction
    recovery services. Peer mentors model behaviors and spiritual
    principles that focus on providing life skills to residents by
    following the spiritual principles of the 12 steps of
    Alcoholics Anonymous. Information from U.K.'s Center for Drug
    and Alcohol Research points to the significant successes that
    we have seen here in Kentucky, and I mention those in my
    written testimony.
        Additionally, the program has saved taxpayer dollars
    through avoided cost to society or costs that would have been
    expected based on the rates of drug and alcohol use, and that
    can't be understated. For every dollar we spend on these
    recovery centers, we save $2.60.
        Recovery Kentucky would not have been possible without
    housing program dollars appropriated by Congress and
    administered by the Kentucky Housing Corporation (KHC). The
    recovery centers rely on a complex array of Federal funds for
    construction and operation, including the following: The bricks
    and mortar are built with the low-income tax credits and also
    HOME dollars and some affordable housing trust fund dollars
    that we have here in the State of Kentucky. There is also CDBG
    funds that are used, as well as Section 8 Housing Choice
    Vouchers for rent subsidies for the residents at these
    facilities, and also, as has been mentioned, food stamps.
        It has become increasingly difficult to develop more of
    these recovery centers for two primary reasons. The first is of
    course less funding in Federal housing programs, but the second
    I really want to draw attention to, and that is red tape that
    surrounds certain Federal programs. For example, KHC has
    experienced significant challenges recruiting landlords to
    participate in the Section 8 Housing Choice Voucher tenant-
    based program, with many citing programmatic red tape as an
    obstacle. Additionally, Federal statutes restrict the amount of
    tenant-based rental assistance that may be used for a specific
    property to 20 percent of a public housing authority's housing
    choice vouchers. One useful reform would be to raise that 20
    percent cap and allow public housing authorities like KHC to
    project-base more housing choice vouchers to meet our specific
    needs here in the Commonwealth.
        I sit on the board of directors of the National Council of
    State Housing Agencies, so I have the opportunity to speak with
    many of my colleagues across the country, including my
    distinguished colleague in Wisconsin--Mr. Winston does great
    work in Wisconsin--and I can tell you that, nationally, this
    would be accepted on a bipartisan basis. It is an option that
    allows housing choice vouchers to be project-based, but each
    State doesn't necessarily have to do that. So it would be a
    significant reform to potentially look at building more
    recovery-type models, regardless of treatment methods.
        I will conclude my remarks with these key statements:
    Recovery Kentucky is a housing-based model that has produced
    remarkable outcomes and has proven to be highly cost-effective;
    housing is a key component of successful recovery programs and
    essential for long-term recovery; and greater flexibility with
    Federal housing program regulations will provide States with
    more control of the resources needed to achieve the goals of
    the President's Commission on Combating Drug Addiction and the
    Opioid Crisis.
        Thank you for taking on this difficult but important work
    to help ensure access to effective recovery programs. Kentucky
    Housing Corporation led the way more than a decade ago, and we
    stand ready as a dedicated partner in the continuing effort.
    Thank you.
        [The prepared statement of Mr. King can be found on page 49
    of the Appendix.]
        Mr. Duffy. Thank you, Mr. King.
        The Chair now recognizes Ms. Minton for 5 minutes.

                        STATEMENT OF LISA MINTON

        Ms. Minton. Thank you, Chairman Duffy, Congressman Barr,
    and Congressman Guthrie. I am the Executive Director of
    Chrysalis House, and I am very pleased to be with you today.
    And I would be remiss if I did not introduce our wonderful
    board president, Lindy Karns, who is also here today. That just
    shows what a wonderful program Chrysalis House is. Our board,
    our staff, our community partners, and everybody that we work
    with, we come together to do the best that we can for the women
    and children that we serve.
        And we have been saving lives for over 40 years. We are
    Kentucky's oldest and largest licensed substance abuse
    treatment program for women. And the chrysalis is the protected
    stage just before the beautiful butterfly emerges, and that is
    what we want for the 200 women and babies that we serve every
    year.
        As reported in the Herald Leader this past weekend, the CDC
    report recently stated that Kentucky had one of the highest
    rates in the Nation of pregnant women using opioids, and that
    is another example of the State's struggle with abuse of pain-
    killing drugs.
        At Chrysalis House, we prioritize pregnant and parenting
    women, and we are one of the few programs in the Nation that
    allow women to bring their babies with them into treatment. We
    believe the opportunity for our clients to be with their babies
    and young children is a powerful incentive for recovery.
        A brief snapshot of the women that we are currently
    serving: Their average age is 26 to 30, 41 percent are
    pregnant, 61 percent report their primary substance abuse is
    heroin or other opioid, 85 percent have had one or more prior
    treatment episodes, 98 percent are unemployed, and 60 percent
    meet the homeless criteria for transitional housing. This
    population needs additional recovery supports. Housing and
    employment are imperative to long-term sobriety.
        Chrysalis House received our first HUD Transitional Housing
    Grant in 1990, and we've received HUD permanent housing funding
    for over 20 years. In 2016, our $200,000 grant was cut by our
    continuum of care due to the change in HUD's vision for moving
    forward and serving the chronically homeless and housing first,
    which we agree with, but we do think that there is room for
    transitional housing because our women and their children,
    after they go through 3-to-6 months of treatment at Chrysalis
    House, need sober, stable living in order to achieve long-term
    sobriety.
        The next year, we lost our $93,000 scattered-site apartment
    funding and our $60,000 permanent-housing bonus apartments, so
    we have gone from $360,000 a year in HUD funding to zero. And
    so this shift in HUD's view, I can see that, but we also think
    that there is room for transitional housing. And so we look
    forward to working with you all on the CAREER Act and the
    THRIVE Act and any other ways to help the women and children
    that we serve at Chrysalis House.
        So I thank you for allowing me to speak today, and I am
    glad to take any questions.
        [The prepared statement of Ms. Minton can be found on page
    52 of the Appendix.]
        Mr. Duffy. Thank you, Ms. Minton.
        Mr. Robinson, you are recognized for 5 minutes.

                        STATEMENT OF TIM ROBINSON

        Mr. Robinson. Good morning, Chairman Duffy, Congressman
    Guthrie, Congressman Barr. My name is Tim Robinson. I am the
    CEO of Addiction Recovery Care. More people died from overdoses
    than car accidents last year, making addiction a national
    public health crisis that is taking too many lives and
    threatening our economic security, as employers struggle to
    find and retain employees. Last year, our Kentucky Chamber of
    Commerce CEO wrote in an op-editorial and he called addiction
    the number one economic concern in our State.
        Everyone is looking for a silver bullet to address the
    addiction crisis. The reality is there isn't a silver bullet.
    Addiction recovery requires a whole-person approach, which
    starts with intervening with treatment, investing in someone's
    economic future by providing access to transitional housing,
    vocational rehabilitation, workforce development, and inspiring
    them from day one that there is hope to go from their crisis to
    a career.
        I am thankful for the opportunity to speak to you because
    recovery is personal to me. I started drinking in my first year
    of law school at the University of Kentucky to cope with my mom
    passing away during finals. For the next 8 years, I almost
    drank myself to death. Eleven years ago while I was a
    prosecuting attorney in Lawrence County, Kentucky, a court
    bailiff, who was a recovering alcoholic and pastor, led me to a
    spiritual awakening at my desk. He became my sponsor and my
    pastor. And addiction recovery is personal to me because I am a
    survivor.
        Two years later in 2008, I resigned as prosecutor and in
    2010 opened a residential center for women in rural eastern
    Kentucky. Today, we have 350 residential clients and 500
    outpatient clients and centers across 12 counties in Kentucky.
    Our experience has taught us that addiction is a disease that
    devastates all aspects of a person's life, impacting someone's
    mind, their body, their spirit, and their purpose. And we have
    been determined to treat addiction holistically, medically,
    clinically, spiritually, and vocationally.
        Our centers are led by an addictionologist and are
    nationally accredited. We have developed a spirituality program
    that inspires hope and offers redemption. Much like hospice
    centers, we employ chaplains who work alongside our clinical
    staff, and though we consider the spiritual aspect of our
    centers to be the heart of our success, our spirituality
    program does not replace medical and evidence-based clinical
    practices. It is in addition to them and makes our care more
    comprehensive.
        Treating the whole person has led to great success. One of
    our payers recently reported to us that our centers reduced
    their members' healthcare costs by 33 percent during the 6
    months after they completed our program.
        We created an internship program with the promise that
    everyone who completes the program would be guaranteed a job.
    Today, 190 of our 380 employees are in recovery, and of those
    380 employees, 130 are graduates of our programs.
        We are a State-certified peer-support training program. A
    peer-support specialist is a Medicaid-billable professional who
    has 1 year of sobriety and completes a certification program.
        We partnered with a workforce board, Eastern Kentucky CEP,
    and with Sullivan University to expand our internship into a 6-
    month career academy. Our graduates earn State certification
    and college credit. In just 1 year, a person in addiction can
    go from an IV heroin user to supporting themselves, literally
    going from their crisis to a career.
        To date, 41 of our 46--or 85 percent--of our academy
    graduates are clean and sober, working full-time, paying taxes,
    and transitioning off public assistance. Some of the graduates
    have been promoted to management, and others are continuing
    their education for careers such as counseling. Prior to the
    academy, 40 percent of our clients chose to continue treatment
    beyond detox in residential care. After giving folks an
    opportunity to go from crisis to career, 70 percent of our
    clients now choose to continue treatment, doubling treatment
    motivation.
        Vocational education that leads to a meaningful career that
    provides the dignity of work gives those reentering the
    workforce the confidence necessary to establish career goals
    and plan for their future. Because of this success, we are
    adding other programs such as an auto mechanics academy.
        Kentucky may be leading the Nation when it comes to our
    drug crisis, but Kentucky is also leading the way in access to
    treatment because of the national leader on this issue,
    Congressman Hal Rogers, who has been working on this issue for
    more than a decade, and the efforts of our Governor Matt Bevin,
    who is making Kentucky a second-chance State.
        But the two biggest challenges preventing us from taking
    more people from crisis to career is a lack of funding for
    workforce development and transitional housing. That is why I
    am so excited about Congressman Andy Barr's bill, the THRIVE
    Act, and our Senate Majority Leader Mitch McConnell's CAREER
    Act, and that Congressman Guthrie has convened joint committee
    hearings on the issue of helping people in addiction who are in
    recovery get the workforce development they need. And these two
    historic pieces of legislation have the potential to transform
    the national effort to combat the drug epidemic.
        In closing, the hope of America is not merely surviving.
    The hope of America is an opportunity to flourish. That is what
    our brothers and sisters in addiction need. They need an
    opportunity, an opportunity for treatment, transitional
    housing, and workforce development that leads to a meaningful
    career path. And when the opportunity is given, I have seen not
    just survive but thrive. Our current human capital and labor
    shortage can be solved at the same time we combat the drug
    epidemic as we take those struggling with addiction from their
    crisis to a career.
        [The prepared statement of Mr. Robinson can be found on
    page 55 of the Appendix.]
        Mr. Duffy. Thank you, Mr. Robinson.
        Mr. Thomas, you are recognized for 5 minutes.

                        STATEMENT OF JEROD THOMAS

        Mr. Thomas. First, let me thank you for including me today.
    It really is an honor. My name is Jerod Thomas. I am the
    President and CEO of the Shepherd's House. The Shepherd's House
    is a nonprofit, long-term transitional living home for men 18
    years and older that have a drug or alcohol addiction. We have
    been providing this treatment for 29 years, since 1989. We are
    one of the few transitional-living houses that offer recovery
    care for our clients 24/7. We offer a lot more than just a roof
    over your head.
        Our long-term residential recovery program is very similar
    to the model of the THRIVE Act. We are a therapeutic community,
    and our primary focus is on helping these men acquire daily
    living skills. In our day, we offer individual counseling,
    group counseling, conflict resolution, anger management
    classes, parenting classes, education programs, money
    management classes, and art therapy. We also feature a one-of-
    a-kind jobs program in which 90 percent of our clients get a
    job within 3 weeks of entering our transitional-living house.
        Employment is mandatory at the Shepherd's House. To prepare
    our clients for employment, we provide professional assistance
    with resume building, interview skills training, personal
    presentation, employment goalsetting, and teambuilding. We
    partner with DVA Kitchen, Employment Solutions, Vocational
    Rehab of Lexington, and OWL.
        The Shepherd's House has never received any Federal grant
    money for any of our programs, but we have received grant money
    from Federal Home Loan Bank and Kentucky Housing Corporation in
    the form of brick-and-mortar grants, which require income and
    special-needs verifications, which are similar to the Section 8
    rental assistance voucher program, so we are very familiar with
    the process.
        Under our transitional housing model, clients pay a portion
    of their income as rent. That does not cover my utilities, my
    food, and my professional therapies cost. The bulk of our
    expenses are funded by the donations the Shepherd's House
    receives, so basically what I am telling you all today is the
    good people of Lexington, Kentucky, keep my doors open. Because
    we have had so much success, the donations have increased. I
    believe the THRIVE Act will have similar results. The financial
    support the THRIVE Act could provide would ensure our continued
    success, as well as allowing us to serve more people.
        And I really wanted you guys to hear me today, but I
    thought it was more important that you feel me today, so I
    brought Donna Schuler with me today. Donna, could you stand up?
    Thank you, Donna.
        Donna is a great friend of mine and a wonderful mother. Her
    28-year-old son Luke Andrew Schuler died of a drug overdose on
    December 9, 2016. Luke was on my waiting list at the Shepherd's
    House. He was 2 weeks away from his bed date. We live with that
    every day, knowing a life was lost because we didn't have room.
    There are perhaps countless others who are waiting that we
    don't know about. Luke's mother Donna, in spite of her
    unimaginable grief, rose to the challenge and has worked
    tirelessly to get contributions to grow the Shepherd's House so
    that no other parents have to bury their son because a bed
    wasn't available.
        The Shepherd's House currently has a 6-month waiting list.
    The funding the THRIVE model facilities will receive would
    allow us to expand our current bed capacity and offer more
    services to more individuals. The housing cost burden will be
    significantly reduced, and these precious funds will be freed
    up to provide more services and more beds.
        We currently follow all the Section 8 housing rules but
    with more restrictions and services for the client. Like
    Section 8, we require our clients to stay drug-, alcohol-, and
    crime-free, but unlike Section 8, we provide the programs and
    support to help them do so. We provide a 24-hour-a-day, 7-day-
    a-week therapeutic community that gives you access to the daily
    living skills necessary to stay sober and participate in the
    game of life. Our focus is on the whole person. Our aim is to
    meet all the client's needs while they are in our safe and
    drug-free environment. The THRIVE-based model includes programs
    like the Shepherd's House that have proven results of long-term
    sobriety. Most of our clients are either income-eligible for
    Section 8 or qualify as homeless, so the reallocation of these
    vouchers still meets the letter and spirit of Section 8.
        In preparing to give testimony today, I have looked at the
    support offered by Section 8 vouchers, and I am excited that we
    may be able to use those funds for people who want to live
    sober, but the Section 8 voucher in and of itself is not the
    end game. There are more pieces to this puzzle of life than the
    housing issue. The THRIVE Act takes the intent of Section 8 to
    provide safe and stable housing and partners that with the very
    best treatment model we know of today. The union of these three
    things--a treatment model with daily living skills
    incorporated, job placement and education to secure a financial
    future, and stable and adequate housing--that is the end game.
    Through those relationships and funds, the THRIVE Act will give
    drug addicts and alcoholics tools for change and solutions for
    life.
        Let me leave you with the sobering facts we live with here
    in Kentucky. By the end of the day today, five more Kentuckians
    will have died of a drug overdose. That means five more sets of
    parents will bury kids, and five more kids will lose their
    parents. Kentucky is always in the top five in overdose death.
    At the end of our day today, let's use the THRIVE Act and the
    CAREER pilot program in Kentucky to save those five lives.
    Thank you.
        [The prepared statement of Mr. Thomas can be found on page
    59 of the Appendix.]
        Mr. Duffy. Thank you, Mr. Thomas. And, Donna, thank you for
    being here today, and we are sorry for the loss of your son
    Luke. Thank you.
        Dr. Walsh, you are recognized for 5 minutes.

                    STATEMENT OF DR. SHARON L. WALSH

        Dr. Walsh. Thank you. Chairman Duffy and distinguished
    Members of the committee, thank you for the opportunity to
    appear today to discuss the role of Federal housing and
    community-development programs to support opioid and substance
    use disorder treatment and recovery. I want to thank
    Congressman Andy Barr from Kentucky's Sixth congressional
    District for inviting the committee to Lexington--I wish that
    the weather was better for you--to discuss the Nation's opioid
    crisis and how Kentucky leaders are responding.
        My name is Sharon Walsh, and I am the Director of the
    Center on Drug and Alcohol Research at the University of
    Kentucky, and for the past 25 years, I have been engaged in
    conducting research on opioid misuse, dependence, its medical
    complications, best practices, and the development of novel
    treatments for opioid use disorder. I have been fortunate to
    have had funding throughout my career from the National
    Institute on Drug Abuse, along with other sources, including
    SAMHSA and the FDA (U.S. Food and Drug Administration). I am
    here today representing the University of Kentucky.
        The University of Kentucky has launched many initiatives to
    increase access to care and accelerate the discovery of novel
    approaches to address the opioid crisis in the Commonwealth and
    the Nation. I will highlight only a few with my limited time
    today.
        The University of Kentucky Hospital emergency rooms see
    approximately 1,000 non-fatal opioid overdoses in a given year
    with approximately 50-plus cases of fatal overdoses. This does
    not include those patients who present with significant and
    life-threatening medical complications from injecting drug use
    behavior who present virtually every day, nor does it include
    all of those individuals who never make it to the emergency
    department. Historically, emergency departments in our region
    would treat the presenting problem and return the patient to
    the street without attempting referral or linking patients to
    care for their opioid addiction.
        With the support from the CURES funds, through SAMHSA and
    the State of Kentucky and the Cabinet for Health and Family
    Services, a new service has been developed to address this
    critical gap in care. The First Bridge Clinic is a new
    initiative that allows our emergency departments to directly
    refer individuals at high risk for fatal overdose and link them
    to care. Patients can quickly begin receiving evidence-based
    care, including medication-assisted treatment and start on the
    path to remission and recovery. However, these patients often
    have many other psychosocial problems that are barriers to
    treatment success and retention in treatment. For example, a
    criminal record is a barrier to employment, and unemployment is
    a barrier to housing. Linking all patients to the requisite
    supportive services is essential for long-term recovery,
    especially housing when needed.
        Another U.K. program that is having a profound impact that
    Congressman Barr mentioned earlier is PATHWAYS, a program
    designed specifically for the care of pregnant women suffering
    from opioid use disorder. PATHWAYS opened in 2014 and has
    treated more than 200 women and their newborns. Women are able
    to receive evidence-based care, medication-assisted treatment,
    and good prenatal care. The large majority of women achieve
    abstinence and deliver their babies with no illicit opioids in
    their systems. And the incidence of babies suffering from
    neonatal abstinence withdrawal has been reduced by more than
    half. U.K. just opened a specialized NACU unit that is an
    eight-bed unit that is specifically for the care of babies born
    with drug exposure. Our postpartum program for the support of
    new mothers, Beyond Birth, is also expanding with the help of
    Medicaid assistance.
        Young mothers with new babies may be the most vulnerable of
    all the patients that we see. This is a high-risk group that
    may require housing services, housing that allows infants and
    other children in order to promote retention in care and
    sustained remission.
        In Kentucky, there was little to no opioid abuse before the
    current prescription opioid epidemic began. There was no
    heroine historically. Most existing treatment facilities and
    housing services were not designed to address the unique issues
    associated with opioid use disorder that set it apart from
    other substance use disorders. This is a very unforgiving
    disorder. A single lapse or relapse can lead to the immediate
    death of a person who is striving to sustain their recovery. A
    single mistake ends a life.
        Federal agencies, including the FDA, SAMHSA, and NIH, all
    agree that the most effective approach to the treatment of
    opioid use disorder is pharmacotherapy, also known as
    medication-assisted treatment, including buprenorphine,
    methadone, and naltrexone, and all are calling for its expanded
    use. These medications effectively reduce drug use, improve
    health, reduce the transmission of infectious disease, and,
    most importantly, protect individuals from fatal overdose.
        It is commonly recommended that part of the path of
    recovery is to change the people, places, and things that are
    associated with one's past drug-using lifestyle. This may
    involve moving into residential care or recovery housing.
    Unfortunately, many of these facilities prohibit or exclude
    patients who are receiving all or specific FDA-approved
    medications under the supervision of a trained physician.
    Providing healthy- and safe-living housing environments for all
    patients seeking recovery is essential, and programs receiving
    government support should not only allow but should also
    promote the use of all evidence-based practices in treatment
    and housing programs.
        The University of Kentucky looks forward to working with
    Congress and other leaders to leverage the expertise and
    resources of the Federal Government in a strategic and
    coordinated manner. As a historic land-grant and flagship
    research university, the University of Kentucky was founded for
    the people of Kentucky 150 years ago. That is why we are here,
    to keep a deep and abiding promise of better tomorrows for our
    community, our region, and the Commonwealth.
        I sincerely appreciate the opportunity to present testimony
    before the subcommittee, and I am happy to address any
    questions. Thank you.
        [The prepared statement of Dr. Walsh can be found on page
    64 of the Appendix.]
        Mr. Duffy. Thank you, Dr. Walsh. I want to thank our panel
    for their insights and their testimony. The Chair now
    recognizes himself for roughly 5 minutes for questioning.
        First, I neglected to mention how grateful I am for the
    warm welcome that you have given me in Kentucky, especially
    after Wisconsin ended your undefeated season in 2015 in the
    Final Four. Mr. Guthrie was at that game.
        With that said, listen, this is a heart-ripping
    conversation. I was a prosecutor for 10 years, and over 10
    years ago in my small county we saw more deaths from opioids
    than anything else in our community. And there was really no
    national conversation or even a Statewide conversation at that
    time, and so we put together a community taskforce. That is
    what we do, right? We try to go, how do we help our other
    community members when we see a crisis that burns? We don't
    always look up the food chain; we look to ourselves to try to
    address the problem.
        And I was the prosecutor, so I had the D.A., I had the
    judge, we had the school, law enforcement, the pharmacist,
    everyone was getting involved, and one of the problems that we
    had was--if we have any doctors in the room, I am sorry--but
    the doctors were the ones where, again, they were the flow of
    the OxyContin, which was our issue of opioids. They were the
    flow-out, and we couldn't get their participation early on to
    even deal with random pill counts, to do random testing. And
    when someone comes in on a Friday afternoon and says that the
    dog ate their Oxy and they want another 30-day supply and they
    were getting it, this was insane stuff.
        And so no wonder we have a crisis on our hands that was
    made not by the drug dealers, but whether we want to talk about
    pharmaceuticals or whether we want to talk about doctors and
    hospitals, and it has absolutely ravaged all of our communities
    across America.
        In Wausau, Wisconsin, I did a roundtable with many of my
    sheriffs and our attorney general, and what you see is how it
    is even addressing our kids, parents that are doing heroin in
    the car outside the drug house and the kids are in the back
    seat in the carseats as the parents are strung out in the front
    or what is happening inside homes of cereal being dumped on the
    floor for kids to eat for a couple days as the parents are on a
    drug binge.
        And some of the sheriffs were talking about how some of
    their deputies have started to drink more to cope with what
    they are seeing in our community, so you have seen drug use
    that translates even to some of our law enforcement deputies
    starting to consume more alcohol to deal with the pain of what
    they are seeing in their community with kids and with adults.
    And there is no silver-bullet answer here I don't think, but
    trying to find bright spots that can help our communities deal
    with these issues is incredibly important.
        Just to the panel, I don't know if you guys have this
    scenario. Are you seeing more out-of-home placements for
    children in your community because of this epidemic? Is that a
    fair assessment, Governor?
        Mr. Fletcher. Yes, we are involved with the group in
    Georgia, Rome, Georgia, and up to 70 percent of foster home
    placements are related to substance use disorder. And a lot of
    the data across the country shows increase in foster care, and
    we don't have near the adequate number of foster parents or
    volunteers to accommodate that, so we are facing--one of the
    consequences of opioid use disorder is going to be a tremendous
    impact on the children going forward, and the NAS that Dr.
    Walsh mentioned as well.
        Mr. Duffy. And just for my smaller counties, we don't come
    from a wealthy area in America or in Wisconsin. We have some
    pretty poor counties. The counties don't have the resources to
    actually fund the out-of-home placements, which you want money
    to address addiction, but then you are spending money to
    address the consequences of it with the out-of-home placement
    for children, which a lot of our counties are struggling to go,
    how do we deal with this? It is a financial problem; is that
    fair to say, Governor?
        Mr. Fletcher. Yes. One of the things that I think as we put
    this in the context of other works being done with NIH and the
    healing communities and NIDA is--and we are starting a project
    in Rome, Georgia, where we are looking at a group that handles
    foster care in addressing women. It is going to have to be a
    community-wide program of having a community that addresses
    these issues comprehensively, similar to what you started off
    with, your effort with the taskforce on opioids in your
    community.
        But I do think the healing community and having part of
    MAT, residential continuum of care that even addresses to
    reduce the incidence or the need of foster care by addressing
    these generally single moms early on or maybe both parents that
    are under substance use, but getting them into recovery so that
    you can reunify that family, which has historically been the
    best impact on a child's well-being is reunification.
        Mr. Duffy. Yes. Mr. King?
        Mr. King. And what we are seeing in housing, we are really
    focused on two populations: Seniors and children. And you are
    seeing this spillover effect among youth and youth who are
    aging out of foster care. We have dedicated our resources to
    try to alleviate some of the issues with seniors, grandparents
    housing, having to house or find the resources to house their
    grandchildren.
        Mr. Duffy. Yes.
        Mr. King. I talk often about a holistic approach to
    housing. When you are looking at the spillover of an increasing
    population of youth and youth aging out of foster care, another
    housing approach that we have introduced in Kentucky is the
    Scholar House model, which helps single parents go to college
    or technical school and receive a degree and become a
    participating member of society. We are now over the next year
    going to be introducing a Scholar House model for youth who
    have aged out of foster care. But we are definitely seeing an
    uptick in housing resources going specifically for seniors who
    are caring for their grandchildren.
        Mr. Duffy. Anyone else want to comment?
        Ms. Minton. Well, I want to say that is one of the great
    things about Chrysalis House is that we allow the babies and
    children under 2 to live with their mothers while in treatment
    and older children come and spend the night on the weekends.
    Then the whole family reunites when they move into transitional
    housing. And so we can help them all along the way. And here in
    Kentucky the DCBS has a specialized team called START, which
    stands for sobriety, treatment, and recovery teams. And
    Chrysalis House works closely with the START team and with the
    court system because a lot of times the judges would take the
    children away, put them in out-of-home placement. But if the
    woman is at Chrysalis House and is doing well and working on
    her treatment plan, then they will allow the children to stay
    with the mother, and so that does save our citizens a lot of
    tax money.
        Mr. Duffy. I don't know if anyone knows the answer to this
    question. In regard to how we treat pain in America and if you
    have been to the doctor--my wife and I, we have eight kids, so
    at least every 2 years I have been to the doctor dealing with
    pain in childbirth, not my pain but my wife's pain, and the
    little smiley faces to the grimacing frown of the little face
    in the doctor's office. And anyone have any comment about the
    reimbursement method as it is tied to pain treatment with
    people in hospitals? And if your assessment of pain is low and
    doctors get a benefit for that, don't we start pushing drugs on
    people when we should say, well, we don't want to actually push
    some of these high-octane, highly addictive drugs on folks to
    necessarily manage pain. Maybe a little bit of pain might be
    beneficial instead of the possibility of getting hooked on a
    very powerful drug. Am I off base, Dr. Walsh? Am I crazy up
    here?
        Dr. Walsh. You are not crazy. So I think the contingencies
    are a little bit different, though, than what you have
    described, so the contingencies aren't really about
    reimbursement. Where the requirement came for physicians to
    treat pain came out of JCAHO, the Joint Commission on
    Accreditation of Hospitals, when they adopted the policy that
    pain was going to be a vital sign--
        Mr. Duffy. Right.
        Dr. Walsh. And that initiative was I think unknowingly
    pushed by groups that appeared to be legitimate scientific and
    medical societies, but they were actually funded by the
    pharmaceutical industry.
        Mr. Duffy. That is right.
        Dr. Walsh. So they were able to persuade the accreditation,
    which every hospital needs to maintain in order to operate,
    that pain was going to need to be treated well. And then the
    other thing that drives it are patient satisfaction scores
    because that is another thing that hospitals pay attention to
    and that doctors are held accountable for.
        Mr. Duffy. Have we changed that model now?
        Dr. Walsh. So JCAHO certainly is reevaluating things, and
    at the national level, there are a lot of physician
    organizations that are really trying to do a better job with
    coming up with guidelines. The CDC, I am certain, released new
    pain treatment guidelines, but they are guidelines so they are
    not mandatory. So we see some of the same bad practices
    continuing both in hospital settings, outpatient settings,
    dentist, mid-level providers. So while there is a lot of
    popular news about this, you cannot possibly not know that this
    is the biggest crisis that we are facing.
        We still see a lot of bad prescribing practices. And just
    as an example, in our State, the State Government changed the
    law so that you could only have a 3-day prescription for a
    Schedule II agent, and so what a responsible doctor would do
    would give a 3-day prescription. What some who don't want to
    get called on the weekends do instead, they will give a 3-day
    prescription for 4 times as much as they would have prescribed
    for a 3-day prescription so that there is more available so
    that they are not getting patients calling up and saying that
    they are in pain.
        So I think that is really important when we are thinking
    also about how we do both regulations around this, guidelines,
    what is it that we are incentivizing because sometimes we are
    missing the mark a little bit and--
        Mr. Duffy. And we want to manage pain. We don't want people
    not to be able to get medicine to manage their pain, but also
    we don't want to push that pendulum too far over, which I think
    you have mentioned, Dr. Walsh, that we have and it has to be
    reevaluated. And frankly, we are not done with that process. It
    is a little bit shocking based on the crisis that we are seeing
    across America.
        I have to end in one moment, but you all agree that housing
    is a key component to recovery. We are all agreeing on that.
    Good. We are on the same page. And just I thought that, Mr.
    Boggs, you made an interesting point. When we are talking
    about, you are dealing with those that have been convicted of
    crimes who have served sentences, I don't know if you have the
    same problem in Kentucky, but in Wisconsin, we don't have
    enough workers to fill our jobs, and if we can move people,
    whether it is from incarceration with skill sets into jobs or
    from those who have drug abuse issues to skills sets to
    meaningful jobs that give purpose in life, not only does it
    help the individual, their family, but it helps our broader
    economy because they are filling places in our workforce that
    aren't being filled right now.
        You talk about a--this is a holistic issue that we face as
    a community and as a country. Mr. Thomas?
        Mr. Thomas. That is a perfect example. What better place to
    get your employees than living at our facility where they are
    being drug-tested 3 days a week, and if you are positive, we
    will not send a guy that is under the influence of drugs or
    alcohol to work. We will simply call the employer and say he is
    not going to be available today, but we have a guy that we can
    send to you and you can start training today.
        So we are actually doing that for you, so we take the cost
    of the drug test and we monitor, so if you are in our
    facilities or any of our facilities getting drug tests, you
    have a safe and sober employee. That also saves money on the
    other end almost like an employee assistance program would.
    There are not as many workplace accidents when nobody is drunk
    or high.
        Mr. Duffy. That makes sense. I am going to pass it over in
    a second to Mr. Barr, but again, we are talking about 10,000
    vouchers out of 2.1, 2.2 million as a demonstration project to
    see if this works. Again, this is how the government should
    work to say let's take a little sliver and see if we can have a
    real impact, and if it works, we can expand it, but it is only
    10,000 vouchers, again, out of 2.2 million. I think that point
    needs to be made also.
        The fact that we are trying to address an opioid crisis is
    different than--we have all dealt with alcohol and alcohol
    abuse in many of our families. This is a new animal we are
    trying to get our hands around and how we address addiction. I
    know we are not talking about meth today, but that is a whole
    other problem as well, and it is going to be all of us
    partnering together. And I want to thank you all for the work
    that you do to make Kentucky a healthier place, to help
    families, individuals who are going through this incredibly
    difficult time, helping them get to a place of health. And to
    hear stories like Donna's, to make sure we don't have those
    five people today, Mr. Thomas, go through what she had to go
    through in her family, it is heartbreaking, and I appreciate
    her strength and willingness to help other families and have
    her and her son's story be told.
        So with that, my time is expired, and I recognize the
    gentleman from Kentucky, Mr. Barr, for as much time as he may
    consume.
        Mr. Barr. Thank you, Mr. Chairman. And again, thank you,
    Mr. Chairman, for coming to Kentucky and listening to our
    constituents about models of hope, about models of recovery.
    Wisconsin has a crisis, Kentucky has a crisis, the whole
    country is dealing with an opioid addiction crisis, an overdose
    crisis. And the fact that you have spent the time and the
    willingness to come to Kentucky and hear from people on the
    frontlines who are offering solutions and taking our testimony
    is something that I really appreciate.
        Mr. Chairman, since you did mention the 2015 NCAA
    tournament, I just respectfully remind the Chairman about 2014
    and the 30-foot shot with 2 seconds left by Aaron Harrison that
    knocked out your Badgers, so just for the record. I can say
    that to the Chairman because--
        Mr. Duffy. Duly noted.
        Mr. Barr. --he is a good friend of mine.
        On a more serious note, I do just want to make note of the
    fact that it is altogether appropriate that this field hearing
    is taking place in the United States District Courthouse. In my
    conversations with members of the Federal judiciary, the
    criminal docket here in the Eastern District is
    disproportionately inundated with criminal cases that are
    connected in some way or another to the opioid addiction
    crisis.
        Well, all of you have made very good points today, but let
    me start my questions with Governor Fletcher. Thank you for
    your testimony. Thank you for your leadership. Thank you for
    your innovation with Mr. Ball a decade ago and for your
    continued work in trying to take the Recovery Kentucky model
    nationwide. It is a unique model. We know it works. My question
    to you is besides the THRIVE Act--and we thank you for your
    words of support for more Section 8 vouchers for addiction
    recovery, but you mention the CDBG program, the Community
    Development Block Grant, and I fully agree with you that
    recovery is community development because of the connection to
    the workforce development issue.
        What statutory changes does the Congress need to make,
    continue to make besides the THRIVE Act to provide more CDBG
    funds or other resources to take the Recovery Kentucky model
    nationwide?
        Mr. Fletcher. That is a tough question. Congressman, let me
    say this. As I have thought about the CDBG grants, 15 percent
    of those are available for service, and we are using those, but
    they are very competitive because most of the communities out
    around the State, knowing that these funds are controlled
    primarily by the Governor, make it very difficult to direct
    some of these moneys to a recovery effort.
        I do think, maybe similar to what you are doing in the
    THRIVE Act under the CDBG funding, is looking at considering
    setting aside, taking some of that $6 billion that is going and
    set aside for community development similar to the CAREER Act
    but making sure there is a funding stream available that is
    sustainable, that helps us address directly that particular
    need. That could be tied with the quality measures that you
    have already done in the THRIVE Act. It could be tied with
    making sure that they have job training, that they are involved
    with the local economic development, all part of this healing
    community effort.
        What particular piece of legislation? I think the CAREER
    Act might be a place, but looking also at the--I guess the
    appropriations for CDBG but the authorization for CDBG and
    where those come from and looking at the language in that
    authorization bill to see if we couldn't specify, as you have
    done in the THRIVE Act, some moneys for that particular
    development effort.
        Mr. Barr. Thank you. That is helpful.
        Mr. Boggs, I appreciate all the good work that you all do
    at OWL to take people from a period of incarceration into
    sustainable employment. Do you have any specific suggestions
    for how Federal housing programs can work more closely with
    nonprofits like yours to help residents find jobs and rise
    above poverty? And the question is animated by my own personal
    experience traveling the central Kentucky area and talking to
    employers.
        And, Mr. Thomas, you made a great point about providing
    sober workers. It is ubiquitous. Every single employer in
    central Kentucky, whether it is a farm, whether it is a
    manufacturing firm, whether it is a healthcare-related
    business, whatever the business is, the hiring manager, the
    H.R. manager, the plant manager, they all tell me the same
    thing, which is we have job openings we can't fill because
    people can't pass a drug test. How can Federal programs partner
    more with organizations like you to provide that labor supply?
        Mr. Boggs. Yes. As I mentioned several times, the
    correlation between housing and employment is so critical
    because of--simply for the fact if people do not have a place
    to stay, they do not feel like getting up and going to work in
    the morning. They are not capable of getting up to work in the
    morning. So if they have stable housing, then that provides
    them a place, a residence, a place of safety that enables them
    to go to a place like OWL and receive the necessary job
    training.
        And you are correct; every individual that comes through
    our doors that wants to work, we can find employment for them.
    The big issue is so many times they come to work and then the
    next day they don't show up. That is because they don't have
    transportation. That is another big barrier that goes in this
    whole piece that none of us have mentioned today. So getting
    back and forth to work and having that stable place to live
    brings that full circle together.
        And when we do have partnerships like I stressed earlier,
    that makes it so meaningful to connect it all together, and the
    collaboration is going to be the ultimate key for all this
    among agencies and maximum utilization of dollars.
        Mr. Barr. Mr. King, can you expand on how the current cap
    on project-based vouchers--you mentioned the 20-percent cap--
    has limited specifically here in Kentucky. How has that limited
    the Kentucky Housing Corporation's ability to invest in housing
    programs that serve those who are recovering from opioid
    addiction?
        Mr. King. Yes, and when I--thank you. When I mentioned that
    earlier, there are PHAs throughout the Nation who have done
    some demonstration projects where they can exceed that 20-
    percent cap. However, Kentucky Housing Corporation is not one
    of those. What you have seen in Kentucky is 14 recovery centers
    that do great work, but they all use housing choice vouchers
    that are project-based to those centers, so you have those 14
    recovery centers. You also have, I believe, 13 Scholar Houses,
    which I just mentioned a little bit earlier where, again, those
    vouchers are attached to those projects.
        So these have been very innovative approaches to address a
    particular issue like the opioid epidemic and like education
    and workforce training. However, because of those efforts, we
    have hit that cap. And so allowing us more flexibility, maybe
    increasing that 20-percent cap to potentially 40 percent or
    greater, to me it presents an option for States to utilize
    those resources. I think we have to take--as a country, I think
    we have to take a holistic approach to housing, and we can't
    just look at providing a roof over somebody's head. We have to
    address the things that lead to chronic homelessness like the
    opioid addiction epidemic and like educational opportunities
    for parents. So by raising that cap, we are allowed to target
    individuals into particular housing models.
        The purpose of the housing choice voucher was a good
    purpose, to give people choice in where they want to live. That
    is a good and noble goal. The problem is that you have a lot of
    landlords who are not willing to take tenants. So someone might
    get a voucher and they might not be able to find a house to
    live in because there are no landlords that will take them. So
    by increasing that, you are guiding them into a particular
    project.
        We administer at Kentucky Housing approximately 4,600
    vouchers, Housing Choice Vouchers. There is a waiting list of
    5,600. So while the increase in cap, the 20-percent cap would
    be beneficial, vouchers are the single most effective resource
    to address a homelessness issue, so obviously increasing those
    would certainly help.
        Mr. Barr. Thank you for your testimony, Mr. King, and I
    look forward to working with you and the Kentucky Housing
    Corporation to address that arbitrary statutory cap and looking
    forward to working with Chairman Duffy to achieve that once we
    get the THRIVE Act signed into law.
        Ms. Minton, you talked a lot about--and we applaud the
    great work of the Chrysalis House and what you do for women and
    newborns suffering from neonatal abstinence syndrome. And we
    want to work with you on the problems that you described with
    HUD. We want to fix those problems, so I look forward to
    working with you on that. That is precisely why we introduced
    the THRIVE Act, to provide alternative resources to replace
    some of the funding that you lost. And I think your respectful
    pushback of the Housing First program I think is appropriate
    for us to take into consideration as we exercise oversight over
    HUD and encourage HUD to reevaluate the priorities and the need
    for more transitional housing services.
        But my question to you, Ms. Minton, is because you are at
    the frontlines of the neonatal abstinence syndrome issue, could
    you just describe for the record, at least here in central and
    eastern Kentucky, the dimension of the problem of women who
    come to you with newborns who are suffering from this problem?
        Ms. Minton. Well, Chrysalis House prioritizes pregnant
    women, so we try to get the women in before the baby is born,
    and that we are working with U.K. PATHWAYS and Beyond Birth to
    ameliorate the effects so that the baby is born healthy or as
    healthy as possible. And so we are working closely with the
    doctors.
        And Lindy left, but we have our board meeting tonight at 6
    o'clock to officially vote on opening a new 16-bed facility on
    the grounds of Eastern State Hospital for 16 pregnant and
    postpartum women, working very closely with U.K. PATHWAYS and
    Beyond Birth, and so we will have access to MAT services--the
    buildings are right next door on the campus--and hep C services
    because that is another problem with many of the women that we
    work with, and just trying to partner as best we can to help
    the women and their babies because they do recover and they do
    get better.
        I think that one of the things that Dr. Walsh alluded to is
    the number of women in rural Kentucky who do come to Lexington
    for services but are often reluctant to enter into treatment,
    especially long-term treatment. And so that is one of our
    obstacles that we are working on, and trying to do the
    telehealth I think is making great strides for our State.
        Mr. Barr. Thank you. Mr. Robinson, thanks for your powerful
    personal testimony, and I wanted to ask you from your
    experience, do the program participants that you contemplate
    coming into your program, how will they have success finding
    work, and how will they have success moving out of government
    assistance? What are some of the factors that will, in your
    judgment, lead to hope and thriving as you say, as opposed to
    just getting by?
        Mr. Robinson. Well, there has been a big effort for reentry
    programs, whether that is helping people transition out of
    prison or transition out of 30-day treatment programs or detox
    facilities. We have put a lot of effort there. And the problem
    is that often when that person leaves jail, if they leave a 30-
    day treatment program, there is a big gap from that moment when
    they walk out the jail cell, they walk out the treatment center
    until they are able to even be employed. And there are some
    things on the life skills side; there are some things on
    financial literacy. Those things have to be a part of that gap
    between when they come in crisis to putting them in a career.
        The other thing is you have to get them on a path where
    they can see a career path that is better than a petty drug
    dealer because we compete in their mindset with why should I go
    work a minimum wage job when I can do one petty drug deal. And
    so the hope has to be a real hope. It has to be a real economic
    opportunity. It has to be that you can become somebody who can
    support yourself, support your family, and we are not competing
    with that.
        And so I think having wraparound services like what the
    Shepherd House is doing, what we are doing, what others are
    doing, Recovery Kentucky, to get people in that zone where we
    lose most of them and make sure they have peer support, make
    sure they have counseling, make sure that they have people that
    really are reparenting them because a lot of the things that we
    do we take for granted, getting up every morning, knowing what
    is appropriate to wear to work. If we leave that to them when
    they have never done that, we are setting them up to fail. So
    our efforts, whether it is MAT, whether it is abstinence,
    whether it is whatever, all of those are going to require us to
    have transitional housing, workforce development.
        One of the things in the CAREER Act is not only giving more
    targeted project-based vouchers, not only giving more targeted-
    based community block grants, but giving targeted workforce
    development, that the WIOA funds have a certain amount that are
    targeted for people coming out of addiction because I have seen
    time and time again if somebody doesn't have that hope, then
    they are going to go right back to petty drug dealing, and it
    is not going to be long before they are going to relapse and
    they are going to be right back in the mess that we have
    already once rescued them out of. Instead, if we will make the
    investment with a whole-person approach, we can see them
    succeed.
        Mr. Barr. Thank you for that. And, Mr. Thomas, first of
    all, let me just address Donna and express my condolences to
    you for the loss of your son Luke, and that is exactly why we
    are here today. Luke is exactly why we are holding this
    hearing, and we want to make sure that we bring every resource
    to bear from Congress to prevent this happening to any other
    family.
        And the Shepherd's House is a wonderful program that needs
    resources, and Congress has responded to this epidemic with
    billions of dollars in appropriations, but guess what? Not all
    of the resources that we have appropriated are actually
    addressing the transitional housing need. And so I fully, fully
    agree with Mr. Thomas' testimony that we need to make sure that
    there are no shortages of beds, and we need to rethink all of
    the priorities within the context of these appropriations so
    that organizations, not-for-profits like Shepherd's House, are
    eligible to receive some of the resources. And again, that is
    what is motivating the THRIVE Act.
        So, Mr. Thomas, you mentioned no Federal funding to the
    Shepherd's House outside of some Federal Home Loan Bank and KHC
    funds. How would the THRIVE Act specifically help Shepherd's
    House and similar programs?
        Mr. Thomas. Point-blank, it is a game-changer. I spent a
    ton of time reading it and researching it. We made a joke in
    getting ready for this. We are at the Shepherd's House, we are
    the forgettables. And by that I mean, my clientele falls
    through the cracks. We don't qualify for anything. I understand
    why pregnant ladies will go first. It makes absolute sense to
    me. But again, we are getting left behind. We are the
    forgettables. So our guys fall through the cracks.
        But what I love about it, what I love about the THRIVE Act,
    I think it was the fact that it ties it all together as the
    whole person as opposed to just addressing one issue because
    that is what always happens to a drug addict now. It is always
    one issue that takes them out, so you get them sober, but then
    they don't have anywhere to live so they get high. Well, you
    get them sober and then it turns out they are bipolar and you
    didn't provide them any mental health services, so they
    relapse. You get them sober and they get fired from their job
    and they can't get another job, so they get high.
        The thing I love about the THRIVE Act is it ties it all
    together and it allows us to work as a team on this panel with
    the THRIVE Act. So now, when you are putting them and giving
    them vouchers for a place to live, you are not just saying here
    is your money, good luck. You are saying here is your money,
    here is peer support, here is job training, here is mental
    health counseling, here is individual counseling, here is group
    therapy. Well, now, you have provided them with all the tools
    they need to take that voucher.
        And eventually the endgame always has to be--I would
    honestly say this and hope not to offend, but if I had a guy
    that was 10 years' sober still living in Section 8, I would be
    extremely upset because the endgame has to be move them on in
    life. And I think that gives them the start that they need. And
    I thought it was genius. I am so excited about it, so thank
    you.
        Mr. Barr. Well, thank you for the testimony.
        And, Dr. Walsh, we want to get to Congressman Guthrie here,
    so just a quick comment and a quick question. The comment is a
    follow up from Chairman Duffy's exchange with you about pain
    management reimbursement and narcotics avoidance. The American
    Society of Anesthesiologists and some anesthesiologists in
    Kentucky are doing some groundbreaking work on enhanced
    recovery after surgery. We need to pursue that. I think
    Congress needs to appropriate funding to tie narcotics
    avoidance to pain management, and we need to work with our
    physician community to do that. So I appreciate the fact that
    the accreditation standards may be revisiting that issue, and I
    want to work with you and U.K. and other healthcare facilities
    to achieve that.
        The question is, following their treatment at the
    University of Kentucky--and the PATHWAYS program is a wonderful
    program; I had the privilege of visiting with the fine people
    there at U.K.--are there currently sufficient housing options
    for these women and their babies to have a safe place to live
    in a sober environment?
        Dr. Walsh. So I think that, overall, hearing from the other
    panelists that there are insufficient opportunities for
    housing, when we hear about waitlists and the need for an
    additional, what was it, over 4,000 vouchers to meet the needs.
    And so we really need expanded access, but we need expanded
    access to meet people where they are.
        So, for example Chrysalis House, which is an outstanding
    program, allows women with their children. Many programs don't
    allow that. As I said in my testimony, many programs will not
    allow people who medication is part of their recovery to
    participate in their programs. And I think that we need to
    align what it is that we know from the evidence that works.
        Let me be clear: My position is not that medication is the
    sole answer, but it is an important component. And so I think
    that for places to actually make a decision and say we are
    going to exclude this evidence-based practice that has been
    endorsed by the Federal Government and not allow that in their
    setting I think is a disservice to the patients that we are
    trying to reach. So I think that we need additional resources,
    but we also need to have a more integrated approach.
        And so Mr. Thomas just talked about integrating and
    everyone is talking about holistic, but I think that we really
    need to think about who the patients are, where they are, and
    then what unique things they bring and then loosening up some
    of the reins around some of the restrictions that we put on
    some of the programs. And some of them are from within.
        Mr. Barr. Thank you, Dr. Walsh. And my time is more than
    expired, but again, as I yield back, I want to thank Chairman
    Duffy for coming all the way from Wisconsin to be with us in
    Kentucky, for your leadership on this issue, for helping as you
    chair the subcommittee, moving the THRIVE Act through the
    markup process and off the House floor over to the Senate.
    Thank you for your continued dedication and commitment to this
    very important issue.
        And, Congressman Guthrie, thank you as well for your
    leadership and for joining us here today in Lexington.
        I yield back.
        Mr. Duffy. The gentleman yields back.
        The Chair now recognizes the other gentleman from Kentucky
    from the Energy and Commerce Committee, a Ranking Member on the
    Health Committee, also the author of the Comprehensive Opioid
    Recovery Centers Act, which passed the House almost
    unanimously, but like many other bills, is still waiting action
    I believe in the Senate.
        Mr. Guthrie. Right.
        Mr. Duffy. That is the story of our life.
        With that, the gentleman from Kentucky, Mr. Guthrie, is
    recognized for as much time as he may consume.
        Mr. Guthrie. Thank you very much. I appreciate it. I guess
    I should take back all my nice comments about Wisconsin after
    your comment about that ballgame, but, no, it is great. It is a
    great rivalry. It is a great rivalry.
        So I was going to ask my first question, and I think it has
    really been answered. But I think, Mr. King, since you are in
    the housing world more than the recovery world really, just
    what specifically the THRIVE Act was empowering you to do that
    you can't do now. I know a lot of people--so we come to the
    agreement, we all agree, and then I said earlier that leaving
    inpatient care and going into sober living is vital. So what
    specifically does the THRIVE Act allow you to do that you can't
    do now?
        Mr. King. Well, I think the THRIVE Act goes directly to the
    participants. It is a set-aside of the Housing Choice Vouchers,
    and it goes directly to the nonprofits.
        Mr. Guthrie. The Section 8 isn't administered to you at
    all?
        Mr. King. It is a portion, I believe, the funds. And I--
        Mr. Guthrie. OK. So I thought Section 8 probably went
    through you guys as well, but it doesn't, so--
        Mr. King. No, it--
        Mr. Guthrie. I am not on this committee so--
        Mr. King. It--
        Mr. Guthrie. --I don't know how Section 8 was administered
    through--
        Mr. King. Yes. But I think it is good in the fact that it
    targets a need for housing in recovery services. And again, it
    goes back to my suggestion that we increase that cap of 20
    percent because we need to target specifically those
    individuals in recovery.
        Mr. Guthrie. So it would help your specific role to do it
    more than this specifically?
        Mr. King. Yes. And I would say that by increasing that cap,
    I can do more at KHC in line with the THRIVE Act.
        Mr. Guthrie. Oh, perfect. Great.
        So, Dr. Walsh, I am interested in the First Bridge Clinic
    you were talking about earlier. So I am on the Healthcare
    Subcommittee of Energy and Commerce, and we had a group of 10
    parents that came in that had lost a child and one that
    specifically just--so when you talk about 50 bills, well, what
    are you doing in 50 bills instead of one big bill? But there
    are a lot of different things we found were roadblocks.
        And we had one family from New Jersey that specifically
    said they got a phone call that their son had overdosed and
    passed away. They didn't get the phone call from the emergency
    room until they came to pick up his body. That was actually his
    eighth trip to the emergency room, and he was over 18. He was a
    college student. They were paying his bills. He was on their
    insurance. The parents were still completely responsible for
    him, but by law, he was an adult.
        So because of HIPAA (Health Insurance Portability and
    Accountability Act), that is what we are trying--some privacy.
    We understand the privacy side, but we also understand that
    parents are wanting the information, too, of their child. And I
    don't know the specifics of every trip to the emergency room,
    but you leave yourself going, if somebody has been there 8
    times, is there not some connection between the emergency care
    and getting them into care? So exactly--if you want to further
    talk about First Bridge, I would love to hear a little more.
        Dr. Walsh. Sure. I am happy to talk about that. But if you
    don't mind, I will just reflect on what you just described
    because what you are describing is exactly what is happening
    all over the country. So people come in and out; it is a
    revolving door. The emergency department staffs are completely
    overwhelmed, and in many places they have absolutely nothing to
    offer to people, so they really are just treating them and then
    getting them out the door. People will come, they will be
    reversed with their overdose in the ambulance. They won't even
    come in the door. They don't want to be at the hospital. So we
    are not really making that connection at that very critical
    time when we have identified someone who is at high risk.
        I can tell you it is actually even very difficult for us to
    count accurately the number of overdoses that are occurring
    within any hospital system because we are not even necessarily
    testing people's urine to determine that they have opioids and
    that is the cause of the overdose because if you give them
    naloxone and it works, then you know that is what it is, and
    they just send them back out. So at every level this has just
    been an incredible challenge.
        And what we are trying to do with the First Bridge Clinic
    is really provide an immediate warm handoff, and that way,
    within an integrated system, the physician can identify that
    this person has either an overdose or maybe they have an ulcer
    from injecting drug use or some other thing that alerts them to
    the fact that the person has an opioid issue. They can do a
    pulldown on the computer to do an electronic referral directly
    to us. If they reach out to us from the emergency department,
    we have actually spoken to patients from their beds in the
    emergency room. We can get hospital transportation to bring
    them to our clinic, and we can try to start them on treatment
    right away.
        We have just started the clinic in January. We now have 5-
    day-a-week coverage. We are working on having some walk-in
    hours so people don't have to deal with making an appointment
    even; they can just show up.
        I can tell you the issue that you are raising about adult
    children whose parents are still really the caretakers, a lot
    of patients we have are brought in by their parents. They are
    adults, but they are brought in by their parents, and they sit
    in the waiting room and they have an argument about things, and
    then the person with the disorder leaves. They don't want to be
    there. They feel like they are being coerced, and the parents
    really have no influence.
        And the HIPAA issue is not just that the systems aren't
    connecting. This area of medicine is so completely separate
    from everything else. If someone is in a methadone program, we
    don't have any way of knowing that in our program because that
    is also siloed by Federal law. So I think that we need to come
    up with some creative solutions for figuring out how we can
    move forward to actually empowering people to get the help that
    they need for their family members.
        I know Massachusetts is working on a law that would
    actually require people to be forced into care. I am not one
    personally who agrees with that, but I think people are looking
    at innovative solutions so that we can try to help people who
    either are failing to recognize that they need help but really
    are on the verge of a complete crisis or death.
        Mr. Guthrie. Yes, trying to get that information where
    emergency rooms will have that information because you are
    right; it is siloed. If you are in treatment or have drug
    issues, it is not in the medical records by law.
        Dr. Walsh. Even if it is in the same health system.
        Mr. Guthrie. Exactly. And so actually what is interesting,
    one of these 50 bills is on specifically--and you couldn't have
    two different Members of Congress. There is one gentleman from
    Portland, Oregon, who would be more you would describe to the
    left, another from Oklahoma would certainly be described more
    conservative, to the right, and those two together--and the
    debate was not really Republican/Democrat, left/right. It was
    more different groups on privacy versus practicality of having
    this done. And that bill did pass. It is in the Senate. So it
    is interesting. I think a lot of people outside of Washington
    think everything is just always a battle, but there are groups
    of people who have different opinions on other things that come
    together and they have common solutions. And that bill has
    passed.
        And I guess I am going along, but what is interesting as I
    walk into every--so I told you the last couple of weeks I have
    been going to recovery centers, and you hear the patients
    there, the people talking, it just seems like everything is
    working well.
        I did bring up the--you talked about the 16 beds. That is
    by Medicaid law, and we are looking for opioids, expanding
    that, because I saw one place that had an eight-bed room and an
    eight-bed room and a different administration so they could
    have--or that is eight beds, 16--or eight rooms had two to a
    room, so they essentially had 32, but they were trying to get
    around the law. We need to fix that so people aren't having to
    game it to get things done.
        But the point we were talking about opening that 16-bed
    exclusion or limit for opioid, and it should be for more but it
    is just funding I guess we get back to. But one person when I
    said that, well, if you do that, people just create these big
    warehouses that have 100 beds. They will have people in them
    and not get the treatment.
        So the question--and in those--so, Dr. Walsh, this is for
    you. In those 10 families we had, there was one specific
    family. They had different issues they were trying to address.
    And one family, typically from high-income families, I will
    spend anything it takes to get my child--so they were from New
    Jersey as well, suburban New York, and they were very high-
    income family, and whatever it takes, and so they sent their
    child to Florida, had passed away. It is everywhere, not just
    Florida, but it seemed to be an industry down particularly in
    southern Florida where it was like patient brokering, which was
    new to me where the intent didn't seem--this parent said that.
    I am not saying it because I don't know, but the parent said
    the intent didn't seem for their son to get out, but son just
    to go from one to the other to the other as long as they were
    paying.
        And so I guess to get into if we are going to warehouse--
    the ones I have seen I have been impressed with, but how do we
    know a good one? I have a bill called the Comprehensive Opioid
    Recovery Centers to try to sort out how do we--what kind of
    evaluations they do in placement, be longer than a few-minute
    answer. But kind of in just--the THRIVE program, the THRIVE
    Act, because it is demonstration, how should we judge these
    things and test them and evaluate them?
        Dr. Walsh. That is a very important question, and there
    really isn't a standard. And I can tell you that the American
    Society of Addiction Medicine does have standards of care, and
    they have different levels of care that they define that may be
    needed depending on the severity of the disorder. And you could
    use that framework, and people have talked about using that
    framework to try and grade treatment facilities.
        However, the problem at least here in Kentucky is that we
    only have a few of those levels of care. We don't have the
    whole complement based on what the ideal circumstance would be.
    We are not the only ones, though, so I do think that there are
    evidence-based practices that have been defined and they are on
    the website for SAMHSA. We know what they are. I think that we
    can start by developing guidelines that check off those boxes
    and that actually are doing the monitoring that is necessary.
        So when somebody is saying that people are successfully
    abstaining, then I want to see your drug screen results from
    that. I don't want to see just self-report. So, like Mr. Thomas
    said, when they are linking with an employer, they are testing
    people 3 times a week, they know exactly what is happening.
    That is not occurring in all settings.
        In some of the treatment programs, there is a lot of drug
    use that goes on. And I am not talking about anybody that is at
    this table. I am just saying that there are places where, as
    you described, they are in it for the profit, and they are less
    concerned about the well-being of people as long as they are
    getting care.
        There was a big expose about some of those programs in
    southern Florida, and there is some suggestion that those same
    places that were pill mills before have been shut down, and now
    this is a different business model for them. We know that there
    are a lot of overdoses, fatal overdoses that take place in some
    of these programs. They are not publicized. That is not a good
    outcome when that happens. But oftentimes, people are not made
    aware of it.
        So I think that we can take what we know from the
    scientific literature about how one would do a study to assess
    the efficacy of a treatment and borrow those same types of
    monitoring practices and implement them and customize them for
    recovery houses and for treatment programs for residential
    because we know what the goals are. If the goals are to get
    jobs, if the goals are to get somebody so that they are
    surviving, these are really objective markers. But I think then
    you want some external source doing that evaluation. You don't
    want to necessarily have people reporting on their own without
    some external evaluation.
        Mr. Guthrie. Thank you. And I am not going to ask another
    question, but I just want to say I know Mr. Robinson has been
    to Washington to testify. Mr. Boggs, I appreciate what you guys
    do specifically, and all of you.
        I am also on the Education and Workforce Committee,
    Chairman of the Higher Ed Subcommittee that has the
    jurisdiction of the Workforce Investment Act or WIOA
    Opportunity Act, and so it is all vital to tie together. And I
    think you are seeing all sides in Washington. As Chairman Duffy
    said, we are all agreeing that we need to put this together,
    and I think once we know we are paying for the good programs
    and the funding, we want to make sure we are, the funding is
    following, and so there is a lot of work to be done but a lot
    of effort is being done and a lot of--trying to understand it
    and trying to comprehend it and trying to move forward and
    getting--and I am left convinced, getting people into sober
    living is probably our most critical part now because we have a
    lot of residential treatment. There may be a waiting list for
    them but not a big control on the sober living side of it, and
    so I appreciate Congressman Barr's leadership and appreciate
    everybody coming together to talk about that because this is
    important to highlight.
        Thank you, Mr. Chairman, and I yield back.
        Mr. Duffy. The gentleman yields back.
        I want to again thank our panel for their participation in
    today's hearing. I want to thank Chairman Barr for all the work
    he did in putting this hearing together, making sure we had a
    well-rounded panel, providing us excellent insights.
        If I could make one parting note, the best ideas for
    legislation come not from Washington, it comes from all of you
    who are on the frontlines doing this work. And there is a great
    partnership that happens. If you have an idea and you get it to
    Mr. Guthrie, Mr. Barr, or myself and we introduce it, one, we
    have stolen your idea and we look really smart; and two, you
    get your idea into legislation. But in the end we are helping
    people. We are getting the right bills, the right legislation
    that do the most to help the most vulnerable among us, and that
    is what is really critical here.
        And I just want to thank all of you for the work that you
    do, for taking the time out of your day to participate in this
    hearing so we can take the information garnered in this hearing
    back to our colleagues in Washington. So thank you for your
    time and your effort and your good work.
        Without objection, all members will have five legislative
    days within which to submit additional written questions to the
    chair, which will be forwarded to our witnesses. If we have any
    of those additional questions, I would ask the witnesses to
    respond as promptly as feasibly possible.
        With that, and without objection, this hearing is now
    adjourned.
        [Whereupon, at 11:05 a.m., the subcommittee was adjourned.]

                                A P P E N D I X

                                August 16, 2018
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