[Senate Hearing 115-787]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 115-787
 
                           THE OPIOID CRISIS:
                           IMPACT ON CHILDREN
                              AND FAMILIES

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                                   ON

  EXAMINING THE OPIOID CRISIS, FOCUSING ON THE IMPACT ON CHILDREN AND 
                                FAMILIES

                               __________

                            FEBRUARY 8, 2018

                               __________

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                                Pensions
                                
                                
                                
                                
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             U.S. GOVERNMENT PUBLISHING OFFICE 
 28-659 PDF           WASHINGTON : 2020       
        
        
        
          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  LAMAR ALEXANDER, Tennessee, Chairman
                  
MICHAEL B. ENZI, Wyoming              PATTY MURRAY, Washington
RICHARD BURR, North Carolina          BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia               ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky                   MICHAEL F. BENNET, Colorado
SUSAN M. COLLINS, Maine               TAMMY BALDWIN, Wisconsin
BILL CASSIDY, M.D., Louisiana         CHRISTOPHER S. MURPHY, Connecticut
TODD YOUNG, Indiana                   ELIZABETH WARREN, Massachusetts
ORRIN G. HATCH, Utah                  TIM KAINE, Virginia
PAT ROBERTS, Kansas                   MAGGIE HASSAN, New Hampshire
LISA MURKOWSKI, Alaska                TINA SMITH, Minnesota
TIM SCOTT, South Carolina

                                 
                        DOUG JONES, Alabama
               David P. Cleary, Republican Staff Director
         Lindsey Ward Seidman, Republican Deputy Staff Director
                 Evan Schatz, Democratic Staff Director
             John Righter, Democratic Deputy Staff Director
             
             
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                       THURSDAY, FEBRUARY 8, 2018

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, Opening statement.........................     1
Murray, Hon. Patty, Ranking Member, a U.S. Senator from the State 
  of Washington, Opening statement...............................     3

                               Witnesses

Savage, Becky, R.N., M.S.N., Co-Founder, 525 Foundation, Granger, 
  IN.............................................................     7
    Prepared statement...........................................     9
    Summary statement............................................    10
Patrick, Stephen W., M.D., M.P.H., M.S., F.A.A.P., Assistant 
  Professor of Pediatrics and Health Policy, Division of 
  Neonatology, Vanderbilt University Medical Center, Nashville, 
  TN.............................................................    10
    Prepared statement...........................................    12
    Summary statement............................................    45
Bell, William C., Ph.D., President and CEO, Casey Family 
  Programs, Seattle, WA..........................................    45
    Prepared statement...........................................    47
    Summary statement............................................    53

                          Additional Material

Alexander, Hon. Lamar:
    Prepared statement of Hon. Mitch McConnell to be submitted 
      for the Record.............................................    73
Murray, Hon. Patty:
    The American College of Obstetricians and Gynecologists, 
      Statement for the Record...................................    74
Port Gamble S'Kallam Tribe, Statement for the Record.............    78
Port Gamble S'Kallam Tribe, ``THOR=Tribal Healing Opioid 
  Response''.....................................................    81
Port Gamble S'Kallam Tribe, ``T.H.O.R. Responds to PGST Opioid 
  Crisis'', newspaper article....................................    83


                           THE OPIOID CRISIS:

                           IMPACT ON CHILDREN

                              AND FAMILIES

                              ----------                              


                       Thursday, February 8, 2018

                                       U.S. Senate,
        Committee on Health, Education, Labor, and Pensions
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:10 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, Chairman of the Committee, presiding.
    Present: Senators Alexander [presiding], Murkowski, Scott, 
Collins, Young, Murray, Hassan, Casey, Kaine, Bennet, Baldwin, 
Murphy, Warren, Jones, and Smith.

                 OPENING STATEMENT OF SENATOR ALEXANDER

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order. This is the 
fourth in a series of hearings in this Congress on the opioid 
crisis. Today, we are looking at its effect on children and 
infants.
    We have a vote, I believe, at 11:30 today, which should, I 
believe, give us time to have a good full discussion with our 
witnesses.
    Before we turn to today's focus, I wanted to say that later 
today, Senator Murray and I and Senators Young and Hassan will 
introduce legislation to help address the opioid crisis. Dr. 
Collins, head of the National Institutes of Health, has 
predicted that the development of a new, non-addictive 
painkiller could be achieved within 5 years with consistent 
funding and more flexible authority to conduct the necessary 
research.
    Our bill would give NIH more flexibility to conduct 
research to address the opioid crisis. This Committee plans to 
hold a markup on this bill, as well as other legislation to 
address the opioid crisis, as soon as March.
    Senator Murray and I will each have an opening statement, 
and then we will introduce the witnesses. After their 
testimony, we'll each have a round of 5-minute questions from 
the Senators.
    The opioid crisis is particularly heartbreaking for 
families and children. No one understands that more than 
Jessie, an East Tennessee woman who lost a baby during the 
nearly two decades she struggled with an addiction to opioids 
and other substances. When Jessie entered recovery in September 
2012 she had no driver's license and no formal education, but 
she did have a calling to help those still battling addiction.
    Today, she is working to complete a degree in Human 
Services before beginning on a Master's, but most important, 
Jessie is a powerful resource for pregnant women in East 
Tennessee who are addicted to opioids. She is a peer advocate 
at 180 Health Partners, a Nashville startup that helps 
coordinate comprehensive care for expecting mothers who are 
struggling with opioid use. In her role as a peer advocate, 
Jessie provides support and encouragement to women going 
through the same battles Jessie fought during her recovery.
    Babies born to mothers using opioids are at risk for 
Neonatal Abstinence Syndrome, or NAS, and may go through 
withdrawal symptoms and face other health issues. 180 Health 
Partners works with Medicaid managed care organizations to help 
expectant mothers begin treatment and stay in treatment after 
their baby is born. It has only been around for about a year, 
but they have seen dramatic results.
    Babies born to mothers working with 180 Health Partners 
stay in the intensive care unit for half the time of other 
babies born with NAS. The average cost to treat a baby born 
with NAS is $66,000. The cost is a lot less for babies born to 
mothers in the program.
    180 Health Partners has also been successful working with 
the state to help mothers in the program keep their babies. 
Jessie says, quote, ``We want these moms to just understand 
that they are pregnant and you should just stop it. Our disease 
does not turn off because we get pregnant. Today, it is about 
continuing to change my life, and through helping other 
addicts. That's the only way that I can breathe. This is my 
entire existence. I have had numerous mothers tell me, `My only 
support is 180 Health Partners.'''
    The work that is being done by that organization is just 
one example of how states, communities, and local organizations 
are dealing with what the Tennessee Department of Health has 
described as a sharp increase in the number of babies born in 
opioid withdrawal. According to the Centers for Disease Control 
and Prevention, the number of infants born in withdrawal from 
opioids has tripled from 1999 to 2013. According to one of our 
witnesses, Dr. Patrick from Vanderbilt, Tennessee has a rate of 
babies born in drug withdrawal that is about three times the 
national average.
    Another example of communities responding to this crisis is 
Niswonger Children's Hospital in Johnson City, Tennessee, which 
treats about 350 infants a year who are born with NAS. The 
hospital has developed programs to help families care for their 
babies born with Neonatal Abstinence Syndrome and to bring 
services that offer addiction treatment to a mother addicted to 
opioids while they are still in the hospital after having their 
baby.
    The opioid crisis affects more than just infants. Many 
grandparents and relatives have taken on the role of caregiver. 
In Tennessee, between 2010 and 2014, there was a 51 percent 
increase in the number of parents who lost parental rights 
because of an opioid addiction.
    This is a problem seen nationwide. After steadily declining 
since 2000, there has been a 10 percent increase in the number 
of children in foster care in the last 3 years. In some places, 
the numbers have even tripled in the same time period. That's a 
lot of numbers, but they represent real children and real 
families whose lives are being affected.
    It is important for this Committee to hear how states are 
helping to ensure that newborns and children impacted by drug 
abuse are being cared for, and if they need changes to Federal 
law to improve that care. I believe the focus should be on 
keeping families stronger.
    States and local communities, those on the frontlines, are 
taking steps to help children and families affected by opioid 
abuse. Tennessee Governor Bill Haslam announced last month a 
new comprehensive proposal to respond to the opioid crisis. 
Included in the plan is a targeted outreach program to educate 
young women addicted to opioids on the risk of Neonatal 
Abstinence Syndrome. And TennCare, our Medicaid program, 
actually saw such a sharp increase in babies born with NAS that 
Tennessee became the first state to create a statewide data 
base to track how many infants were born with NAS each year.
    Congress has taken a number of steps. In 2015, the 
Protecting Our Infants Act, sponsored by Senators McConnell and 
Casey, helped ensure that Federal programs are more effective 
in helping expectant mothers struggling with opioid abuse. In 
2016, the Comprehensive Addiction and Recovery Act--we call it 
CARA--which included input from many Members of this Committee, 
helped states. Included in CARA were updates to the Child Abuse 
Prevention and Treatment Act, which require states to have 
plans of safe care for babies and children impacted by drug 
abuse of both legal and illegal drugs.
    Congress passed the Child Abuse Prevention and Treatment 
Act in 1974 to combat child abuse and neglect and to provide 
funding for states to improve their child protection and child 
welfare services. Due to updates, the law now requires states 
to address the needs of both the infant as well as the affected 
family member and requires states to collect new information. 
Congress also passed the 21st Century Cures Act, which this 
Committee worked on hard, in 2016, which included $1 billion in 
grants for states to fight the opioid crisis.
    What we hope to learn today is: Are these laws helping? Are 
they helping states and communities address the problems faced 
by children and families in the opioid crisis? Are there any 
Federal barriers that states and communities face? We want to 
ensure states are able to coordinate all services a parent 
addicted to opioids and the children who are impacted may need, 
including mental health treatment and substance abuse disorder 
treatment and family supports.
    Senator Murray.

                  OPENING STATEMENT OF SENATOR MURRAY

    Senator Murray. Thank you very much, Mr. Chairman. I am 
really grateful that this Committee is having the opportunity 
to focus on the impact the opioid epidemic is having on 
individuals, families, communities, and what we can do to help 
them. I'm also really grateful to all of our witnesses today 
for bravely sharing their stories and lending your expertise. 
It's vitally important.
    As we have seen again and again, this epidemic doesn't just 
impact one person. It has a ripple effect that impacts entire 
families and entire communities. If we are going to beat this 
public health crisis, we need to make sure we are providing 
resources to everyone who is touched by it. We need to make 
sure we are healing all the damage it does.
    We need to be listening to the full stories, all of them, 
the stories told by hospital staff, like those I recently 
visited in Longview, Washington, who told me that half, half, 
of the babies they delivered were born to mothers battling 
opioid addiction; the stories told by the sharp increase 
nationally in babies born with Neonatal Abstinence Syndrome, 
who are born seizing, shivering, and struggling with other 
symptoms of withdrawal. We need to be listening to the stories 
of the 90,000 children removed from homes deemed unsafe due to 
a parent's challenges with drug use and the stories of the 
children struggling with the impacts of trauma in schools which 
lack the resources they need to meet their unique needs.
    But the story isn't just told by children. It's told by 
parents, parents who have watched as the children they would do 
anything for struggle with a disease they feel helpless to do 
anything against; parents who don't know where to turn for 
help, even if they can afford it, who feel disheartened by a 
child's relapse, who feel silenced by the stigma; and the story 
is told by grandparents and relatives who must step up as 
guardians and caregivers.
    When we fight this disease, we need to fight it on all of 
these fronts and for all of these people. We have to do more 
than stem the tide of the opioid epidemic. We must also 
acknowledge and address the damage it does.
    My constituent Alise's story shows why this is so 
important.
    When she became pregnant with her daughter, she was 
struggling with addiction. She was in and out of jail during 
her pregnancy, and by the time her daughter was born, 2 months 
early and with a small amount of meth in her system, Alise was 
facing a 7-year prison sentence. Her daughter was immediately 
placed in foster care.
    But that's not the end of Alise's story. She received 
treatment in prison. She fought against her addiction, and she 
fought for her family, her daughter, and their future, and she 
won that fight. She beat her addiction and regained custody of 
her daughter. She decided to help others going through the same 
thing.
    Today, she works with Parents for Parents, a program that 
pairs parent mentors with families battling to stay safely 
together. It takes a holistic and evidence-based approach to 
the challenge of healing families. Results have shown that the 
program makes it more likely that families stay together and 
less likely that mothers and fathers lose their parental 
rights. There are many approaches like Parents for Parents that 
serve these broader needs and deserve our full support.
    Congress has to continue its bipartisan work to combat this 
crisis by addressing both the root causes and the ripple 
effects of the opioid epidemic. That means we have to address 
childhood trauma. We have to train teachers to understand how 
it can affect children and how to avoid knee-jerk discipline 
that does more harm than good. We have to make sure young 
people understand the grave risks of misusing opioids and that 
they are equipped to avoid making decisions that could take 
their lives in just one night.
    We have to support parents who need information amid the 
uncertainty of how to help a struggling family member, support 
amid the fear of stigma in discussing the disease, and 
reassurance amid the common trials of relapse. We need to 
address the needs of pregnant women, postpartum women, and 
their infants with substance use treatment that allows them to 
safely stay together.
    We must reorient our child welfare system toward prevention 
services for families. Programs like Head Start offer a two-
generation approach so that children and families get the 
support they need to heal, grow, and succeed together. Research 
has shown that children brought to the attention of child 
protective services who are enrolled in Head Start programs are 
94 percent less likely to be in foster care a year later.
    We need to confront the challenges of everyone this crisis 
affects, and we need to do it in partnership with everyone who 
can help effect change. That means working closely with 
stakeholders ranging from Federal, state, and local 
governments, to health care providers, to educators, to public 
safety officials, and, most importantly, families.
    Unfortunately, while President Trump has declared the 
opioid crisis a public health emergency, his promise to address 
it rings hollow today in light of the actions. At a time of 
public health emergency, President Trump's administration has 
been sabotaging our healthcare, making it harder for people to 
get Medicaid, which helps provide substance use disorder 
treatment, proposing dramatic cuts to drug control offices and 
programs that are designed to promote evidence-based 
treatments, and leaving key leadership positions empty.
    The President may not be taking meaningful action, but I've 
been really heartened to see Congress continuing to work in a 
bipartisan way to solve this issue, like when we passed the 
21st Century Cures Act to fund state efforts in prevention, 
treatment, and recovery; and when we passed the Comprehensive 
Addiction and Recovery Act which supports specific outreach for 
veterans and pregnant and postpartum women, expands access to 
medication-assisted treatments, and more. I am very encouraged 
that the recent bipartisan funding deal includes additional 
resources as well.
    Of course, even as we act, we have to continue to listen to 
those stories like Alise's, which is why I'm incredibly 
grateful to hear from all of our witnesses today and why I am 
already planning to meet with more parents like Alise and more 
children like her daughter when I get back to Washington State 
later this month.
    Finally, before we begin, I do want to submit a statement 
for the record from the American College of Obstetricians and 
Gynecologists on this topic as well.
    Thank you.
    [The following information can be found on page 74 in 
Additional Material:]
    The Chairman. Thank you very much, Senator Murray, and 
thanks for your cooperation in planning the hearing, and your--
it will be submitted.
    We'd like to ask our witnesses to summarize their testimony 
in about 5 minutes. That will leave Senators time to have a 
conversation with you afterwards.
    We'll ask Senator Young to introduce our first witness.
    Senator Young. Thank you, Chairman.
    This morning, I am honored to introduce Becky Savage. She 
is a nurse and a mother from Indiana. She has turned 
unimaginable heartbreak into lifesaving action. She is joined 
today by her husband, Mike, and her son, Matthew. I welcome 
them as well.
    Becky's passionate efforts to combat the opioid crisis 
began after a tragic event, losing her two oldest sons, Nick 
and Jack. She lost them on the same night to alcohol and 
prescription drug overdoses. Both boys graduated high school 
with honors, and both were captains of their high school hockey 
team.
    Nick had already completed a year of college and was home 
for the summer. Jack was preparing for his first semester of 
college when their family changed forever.
    As a father of four, my heart breaks for the Savage family. 
I had the opportunity to visit with Becky yesterday, and I just 
want to reiterate how much respect I have for you, Becky, and 
how much gratitude I have for your bravery and your willingness 
to share your story here today as you have in the past.
    In a display of incredible strength and in the face of 
unimaginable pain, Becky has turned grief into hope. She formed 
the 525 Foundation to help raise awareness of the dangers of 
drug and alcohol abuse. Her organization strives to educate 
young people about the dangers of under-aged drinking and the 
misuse and abuse of prescription drugs. The 525 Foundation also 
collaborates with other local groups, law enforcement, and 
state agencies to make an impact on the opioid crisis.
    Becky has been a tireless advocate and a source of comfort 
for parents who share in her grief. Her advocacy today, paired 
with legislative action, can help curb the opioid epidemic 
that's devastated too many Indiana families and communities, 
and I look forward to hearing Becky's testimony today.
    Thank you.
    The Chairman. Thank you, Senator Young.
    Ms. Savage, welcome to you and to your husband, Mike, and 
to Matthew. We appreciate your willingness to be here.
    Dr. Stephen Patrick is Assistant Professor of Pediatrics 
and Health Policy at Vanderbilt University Medical Center. His 
research focuses on improving outcomes for opioid-exposed 
infants and women with substance abuse disorders and on state 
and Federal drug control policies. Dr. Patrick has served as an 
expert consultant for the Substance Abuse and Mental Health 
Services Administration. His research has been published in the 
New England Journal of Medicine and other leading scientific 
journals. He has received several prestigious awards for his 
work.
    Dr. Patrick, we welcome you to the hearing today.
    Senator Murray will introduce our third witness.
    Senator Murray. Thank you.
    I'm really honored to welcome and thank Dr. William Bell 
for joining us today from my home State of Washington. He is 
the President and Chief Executive Officer of the Casey Family 
Programs. It's a national organization headquartered in Seattle 
with a mission to provide and improve and ultimately prevent 
the need for foster care.
    He previously served the organization as its Executive Vice 
President for Child and Family Services, and before joining 
Casey Family Programs, he was Commissioner of New York City's 
Administration for Children's Services. All together, Dr. Bell 
has 35 years of experience working to keep children safe and to 
keep families together.
    Dr. Bell, thank you for your testimony, and thank you for 
making that long flight out here from Washington State.
    The Chairman. Senator Murray knows about that long flight.
    Senator Murray. I do.
    The Chairman. Now, we'll begin with our witnesses.
    Ms. Savage, why don't you go first.

   STATEMENT OF BECKY SAVAGE, R.N., M.S.N., CO-FOUNDER, 525 
                    FOUNDATION, GRANGER, IN

    Ms. Savage. Thank you, Senators, for inviting me to speak 
with you today and for allowing me to share our family's story 
of loss in the hopes of helping others.
    I am a wife, a nurse, and a mother of four boys. Our family 
is just like a lot of other families, including yours. We like 
to spend time together, laugh together, and dream about the 
future. On June 14th of 2015, our lives changed forever. That 
is the day that our two older sons were pronounced dead of an 
accidental alcohol/opioid related overdose.
    Our sons, Nick and Jack, were like many other 18 and 19 
year olds. They were athletes, had a great circle of friends, 
and had dreams and aspirations in life. Nick had just finished 
his freshman year at Indiana University, and Jack had just 
graduated high school and was heading into his first year at 
Ball State University. They were best friends.
    Nick and Jack had attended graduation parties the night 
before. They came home at curfew and checked in with me. I went 
to bed as they headed to the kitchen to make a snack. The next 
morning, I went into Jack's room and found him unresponsive. I 
did what I was trained to do and initiated CPR after I called 
911. I was yelling. I yelled for Nick to come help me, but he 
never came. You see, Nick was sleeping in the basement with 
friends, and when I called for help, his friends heard me and 
tried to awaken him, but he had passed as well.
    How could two boys who have always seemed to make good 
decisions in life make such a choice that would ultimately cost 
them their life? My husband and I don't understand. How could 
this happen? How did somebody's prescription end up in the 
pocket of a teenager at a graduation party? Why wouldn't they 
just say no? We may never know the answers to all these 
questions, but what we do know is that bringing awareness to 
this issue could save a life.
    Our kids were talked to about drugs and underage drinking 
and knew that it was wrong. So why would they take a 
prescription that did not belong to them? Prescription drug 
misuse and abuse was not even on our radar two and a half years 
ago and, therefore, never discussed with our children.
    In the spring of 2016, we were approached by a local 
coalition that was doing a Community Town Hall meeting that was 
being funded by SAMHSA. The topic was underage drinking. Since 
underage drinking contributed the poor choices our boys made 
that night, we decided to participate. This marked the first 
time that we spoke publicly about losing Nick and Jack, and it 
began a partnership with other community advocates and 
lawmakers who are also looking for answers to this epidemic.
    Since that time, Nick and Jack's story has been told to 
over 20,000 students across the United States to help spread 
awareness of alcohol and prescription drug misuse and abuse. 
Every time I tell Nick and Jack's story, it takes my breath 
away. It still doesn't seem real. It would be so easy to be 
consumed by grief and never heard from again, or we could talk 
about what happened to us to increase awareness in the hope of 
helping others. This is what we have chosen to do. Nick and 
Jack may no longer be able to live their dreams, but by telling 
their story we can help others live to reach their dreams and 
their potential in life.
    We have created the 525 Foundation in memory of Nick and 
Jack; 5 was Jack's hockey number and 25 was Nick's. This 
foundation has allowed us to reach thousands of high school 
students, parents, and educators. Their story makes an impact, 
and kids listen. You can hear a pin drop in many of the 
auditoriums that I speak in. If we can reach one person every 
time we tell their story, then we have made a difference.
    Our goal for our foundation is to make a significant 
difference in our communities. We have partnered with our 
police, fire departments, and other local coalitions to hold 
pill drops to get opioids and other prescription drugs off our 
streets. At our last community pill drop, we collected over 500 
pounds of unused or expired prescription medications. When you 
think that just one pill could take a life, that's a lot of 
lives saved. There is a need for safe disposal of medications.
    We have joined drug and alcohol abuse task forces in 
Indiana in collaboration with doctors, community leaders, and 
police personnel. We've partnered with our local health 
departments to help expand educational programs. We are working 
with Indiana University's Grand Challenge to establish long-
term plans to combat opioid misuse and abuse in our state. Our 
goal for our future is to expand educational curriculum to 
include prevention at all age levels.
    There is a need for increased awareness and education 
related to opioids. Every week, when I talk to a new group of 
teenagers about our family and the dangers of prescription drug 
misuse and abuse, it is evident that there is a knowledge gap. 
There are still people in this country that are unaware of the 
dangers like we were two and a half years ago.
    Time is of the essence when you look at the statistics. 
According to the Centers for Disease Control, 115 people die 
every day of an opioid overdose. That means that today, 115 
families are going to suffer a loss like we did. Who will it be 
today? This story will repeat itself 115 times a day, and 
families will continue to be destroyed until we move forward as 
a nation on all levels, community, state, and Federal, to 
address this crisis.
    The reason I am in front of you is to impress upon you and 
everyone listening that this epidemic is real and it can happen 
to anyone. Thank you for your time and, once again, for the 
opportunity to speak with you.
    [The prepared statement of Ms. Savage follows:]
                   prepared statement of becky savage
    Thank you Senators, for inviting me to speak with you today and for 
allowing me to share our family's story of loss in the hopes of helping 
others. I am a wife, a nurse and a mother of four boys. Our family is 
just like a lot of other families including yours, we like to spend 
time together, laugh together and dream about the future. On June 14, 
2015 our family changed forever, that is the day that our two older 
sons were pronounced dead of an accidental alcohol/opioid overdose. Our 
sons Nick and Jack were like many other 18 and 19 year olds. They were 
athletes, had a great circle of friends, and had dreams and aspirations 
in life. Nick had just finished is freshman year at Indiana University 
and Jack had just graduated high school and was heading into his first 
year at Ball State University. They were best friends.

    Nick and Jack had attended graduation parties the night before, 
came home (at curfew) and checked in with me. I went to bed as they 
headed to the kitchen to make a snack. The next morning, I went to 
Jack's room and found him unresponsive. I did what I was trained to do 
and initiated CPR after I called 911. I yelled for Nick to come help me 
but he never came. You see, Nick was sleeping in the basement with 
friends and when I called for help his friends heard me and tried to 
awaken him but he had passed away as well.

    How could two boys who have always seemed to make good decisions in 
life make a choice that would ultimately cost them their life? My 
husband and I don't understand. How could this happen? How did 
someone's prescription end up in the pocket of a teenager at a 
graduation party? Why wouldn't they just say no? We may never know the 
answers to all these questions, but what we do know is that bringing 
awareness to this issue could save a life. Our kids were talked to 
about drugs and underage drinking and knew that it was wrong. So why 
would they take a prescription that did not belong to them? 
Prescription drug misuse and abuse was not even on our radar 2 and a 
half years ago, and therefore never discussed with our children.

    In the Spring of 2016 we were approached by a local coalition that 
was doing a Community Town Hall meeting that was being funded by 
SAMHSA. The topic was underage drinking. Since underage drinking 
contributed the poor decisions of Nick and Jack that fatal night, we 
agreed to participate. This marked the first time we spoke in public 
about losing Nick and Jack, but it began a partnership with other 
community advocates and lawmakers who are also looking for answers to 
this epidemic. Since that time, Nick and Jack's story has been told to 
over 20,000 students across the United States to help spread awareness 
of alcohol and prescription drug misuse and abuse.

    Every time I tell Nick and Jack's story it takes my breath away. It 
still does not seem real. It would be so easy to be consumed by grief 
and never heard from again. OR , we could talk about what happened to 
us and increase awareness in hopes of helping others. This is what we 
have chosen to do. Nick and Jack may no longer be able to live their 
dreams, but by telling their story we can help others live to reach 
their dreams and potential in life. We created the 525 Foundation in 
memory of Nick and Jack (5 was Jack's hockey number and 25 was Nicks). 
This foundation has allowed us to reach thousands of high school 
students, parents and educators. Their story makes an impact, kids 
listen. You can hear an a pin drop in many of the auditoriums that I 
speak in. If we can reach one-person every time we tell their story, 
then we have made a difference. The goal of our foundation is to make a 
significant difference in our communities. We have partnered with our 
police, fire departments and other local coalitions to hold pill drops 
to get opioids and other prescription drugs off our streets. At our 
last community pill drop, we collected over 500 pounds of unused or 
expired prescription medications. When you think that just one pill 
could take a life, that's a lot of lives saved. There is a need for 
safe disposal of medications.

    We have joined drug and alcohol abuse task forces in Indiana in 
collaboration with doctors, community leaders and police personnel; we 
partnered with our local health department to expand educational 
programs; we are working with Indiana University's Grand Challenge to 
establish long term plans to combat opioid misuse and abuse in our 
state. One goal for our future is to expand educational curriculum to 
include prevention at all age levels.

    There is a need for increased awareness and education related to 
opioids. Every week, when I talk to a new group of teenagers about our 
family and the dangers of prescription drug misuse and abuse, it is 
evident that there is a knowledge gap. There are still people in this 
country that are unaware of the dangers like we were 2 and a half years 
ago.

    Time is of the essence when you look at the statistics. According 
to the Center for Disease Control, 115 people die every day of an 
opioid overdose. That means today, 115 families are going to suffer a 
loss like we did. Who will it be today? This story will repeat itself 
115 times a day, and families will continue to be destroyed until we 
move forward as a nation on all levels, community, state and Federal to 
address this crisis.

    The reason I am in front of you is to impress upon you and everyone 
listening that this epidemic is real and it can happen to anyone.

    Thank you for your time and once again the opportunity to speak 
with you.
                                 ______
                                 
                  [summary statement of becky savage]
    On June 14, 2015 our family changed forever, that is the day that 
our two older sons were pronounced dead of an accidental alcohol/opioid 
overdose. In memory of Nick and Jack we created the 525 Foundation (5 
was Jack's hockey number and 25 was Nicks). This foundation has allowed 
us to reach thousands of high school students, parents and educators. 
Their story makes an impact, kids listen. If we can reach one-person 
every time we tell their story, then we have made a difference.

    The goal of our foundation is to make a significant difference in 
our communities. We have partnered with our police, fire departments 
and other local coalitions to hold pill drops to get opioids and other 
prescription drugs off our streets. Our last community pill pick-up 
collected over 500 pounds of unused or expired prescription 
medications! When you think that just one pill could take a life, 
that's a lot of lives saved. There is a need for safe disposal of 
medications.

    We have joined drug and alcohol abuse task forces in Indiana in 
collaboration with doctors, community leaders and police personnel; we 
partnered with our local health department to expand educational 
programs; we are working with Indiana University's Grand Challenge to 
establish long term plans to combat opioid misuse and abuse in our 
state. One goal for our future is to expand educational curriculum to 
include prevention to all age levels.

    There is a need for increased awareness and education related to 
opioids. Every week when I talk to a new group of teenagers about our 
family and the dangers of prescription drug misuse and abuse it is 
evident that there is a knowledge gap. There are still people in this 
country that are unaware of the dangers like we were 2 and a half years 
ago.

    Time is of the essence when you look at the statistics. 115 people 
died everyday of an opioid overdose, who will it be today? I can 
promise you it will be a loved one of someone, and families will be 
destroyed today and every day unless we move forward as a nation on all 
levels, Federal, state and community to address this crisis.
                                 ______
                                 
    The Chairman. Thank you, Ms. Savage. Your story takes our 
breath away, and we're grateful for your courage.
    Ms. Savage. Thank you.
    The Chairman. Dr. Patrick.

STATEMENT OF STEPHEN W. PATRICK, M.D., M.P.H., M.S., F.A.A.P., 
 ASSISTANT PROFESSOR OF PEDIATRICS AND HEALTH POLICY, DIVISION 
     OF NEONATOLOGY, VANDERBILT UNIVERSITY MEDICAL CENTER, 
                         NASHVILLE, TN

    Dr. Patrick. Chairman Alexander, Ranking Member Murray, and 
honorable Members of the Committee, thank you for the 
opportunity to speak here today about the impact the opioid 
epidemic is having on our Nation's families.
    My name is Stephen Patrick. I'm a neonatologist at 
Vanderbilt Children's Hospital, and I direct a National 
Institutes of Health-funded research program focused on the 
effect that the opioid epidemic is having on pregnant women and 
infants. My written testimony contains a range of 
recommendations, but I'd like to highlight a few here today.
    Recently, I was caring for a sick infant who had been 
transferred to our neonatal intensive care unit. The infant had 
trouble feeding, was jittery, and had rapid weight loss, more 
than 10 percent in just a few days. Something was clearly 
wrong.
    The infant was exhibiting classic signs of Neonatal 
Abstinence Syndrome, a postnatal drug withdrawal syndrome that 
most commonly occurs after in utero opioids. But like many 
conditions, Neonatal Abstinence Syndrome can be difficult to 
diagnose in the newborn.
    Over the next few days, the infant was increasingly 
irritable, had difficulty feeding, increased muscle tone and 
muscle jerking. We suspected opioid withdrawal, but his mother 
denied using any substances. After a week in the hospital, the 
umbilical cord drug screen came back positive for an opioid.
    As I walked into the infant's room to talk to his mother, I 
could sense her guilt and anxiety. She cried as I talked to her 
about the drug test, and she wondered aloud if she would lose 
custody of her infant. She had been afraid of my response and 
the response from child welfare all along. Like too many women 
I see, she became dependent on an opioid after an accident. She 
wasn't able to get the treatment for opioid use disorder during 
pregnancy, and she was too scared or ashamed to ask for help. 
This combination is potentially disastrous.
    The rapid rise of opioid use and its complications caught 
hospitals, communities, and Federal programs off guard. As 
opioid use became more common throughout the United States, 
rates of Neonatal Abstinence Syndrome grew exponentially. Our 
team's research found that from 2000 to 2014, the number of 
infants diagnosed with the syndrome grew nearly seven-fold. Put 
another way, nearly one infant is born every 15 minutes with 
the syndrome nationwide. This escalating public health problem 
needs urgent attention.
    The 21st Century Cures Act, CARA, and the Protecting Our 
Infants Act moved forward important child health priorities 
addressing the opioid epidemic. These important pieces of 
legislation would benefit from additional action, funding, and 
implementation efforts. The Protecting Our Infants Act, for 
example, resulted in a comprehensive strategy document from 
SAMHSA. But as the document notes, full implementation is 
contingent upon funding.
    Congress should consider additional actions to improve 
outcomes for pregnant women and infants impacted by the opioid 
epidemic focused on prevention, expansion of opioid use 
disorder treatment, improving care for opioid-exposed infants, 
and improving outcomes after discharge by bolstering both the 
child welfare and early intervention systems.
    For pregnant women with opioid use disorder, accessing 
treatment is difficult, and, in fact, most women in the United 
States with opioid use disorder aren't receiving highly 
effective therapies like buprenorphine and methadone, both of 
which reduce risk of death for the infant and for the mother 
and increase the likelihood that the infant will go to term. 
There remains urgent need for an expansion of treatment for 
opioid use disorder, particularly for pregnant women.
    Throughout the United States, opioid-exposed infants 
experience variable treatment resulting in variable outcomes. 
State and national perinatal quality improvement groups and 
hospital teams like ours at Vanderbilt are working to decrease 
this variability, but this work could be accelerated. Because 
Medicaid is financially responsible for 80 percent of infants 
diagnosed with Neonatal Abstinence Syndrome, it should play a 
key role in standardizing care and breaking down 
discontinuities in care from pregnancy through the postnatal 
period.
    Last, the already-taxed child welfare system is being 
stretched even more thinly by the opioid epidemic. In 2015, the 
number of children entering foster care grew to nearly 270,000. 
One-fifth of them are infants. Imagine if this scared mother I 
described earlier was proactively engaged in child welfare 
before birth, linked to treatment and closely monitored after 
her infant was born. How might her story be different?
    Our child welfare system is in urgent need of attention 
from Congress. The passing of CARA added important requirements 
for states to develop infant plans of safe care that also 
address the needs of the family. This was a great step forward. 
Unfortunately, those requirements came without clear guidance 
and, more importantly, sufficient resources for implementation. 
There is an urgent need for additional guidance and resources 
from the Federal Government to ensure infant safety and to keep 
families intact when that's appropriate.
    The opioid epidemic is taking a terrible toll on pregnant 
women and infants. Congress must act to address the urgent need 
for additional resources and coordination. For women and 
infants, like the one I cared for at Vanderbilt, the current 
system is disjointed, and it doesn't consider the needs of both 
the pregnant woman and the infant.
    Every day, people are dying. Pregnant women are not getting 
the treatment they need, and infants are spending their first 
few weeks in withdrawal. In just the time we're sitting here, 
eight infants will be born with Neonatal Abstinence Syndrome, 
and 10 people will die from an opioid related overdose. These 
are our brothers and sisters and our children. They need our 
help now perhaps more than ever.
    Mr. Chairman, thank you for the opportunity to speak today, 
and I look forward to your questions.
    [The prepared statement of Dr. Patrick follows:]
                 prepared statement of stephen patrick

    Chairman Alexander, Ranking Member Murray and Honorable Members of 
the Committee, thank you for the opportunity to speak here today about 
the impact of the opioid epidemic on our Nation's families. My name is 
Dr. Stephen Patrick, and I am a board-certified pediatrician and 
neonatologist at the Monroe Carell Jr. Children's Hospital at 
Vanderbilt. At Vanderbilt I direct a National Institutes of Health-
funded research program focused on the effect that the opioid epidemic 
has had on pregnant women and infants. I have published extensively on 
this topic, including in JAMA, Pediatrics, The New England Journal of 
Medicine and Health Affairs. I also serve on the American Academy of 
Pediatrics Committee on Substance Use and Prevention and have 
previously served as an advisor to the White House Office of National 
Drug Control Policy.

    Recently, I was caring for a sick infant at Vanderbilt who had been 
transferred to our neonatal intensive care unit from the newborn 
nursery. The infant had trouble feeding, was jittery and had rapid 
weight loss--more than 10 percent of his body weight in a few days. 
Something was wrong.

    The infant was exhibiting classic signs of neonatal abstinence 
syndrome, a post-natal drug withdrawal syndrome that most commonly 
occurs after in utero exposure to opioids, but like many conditions, 
neonatal abstinence syndrome can be difficult to diagnose in the 
newborn. Over the next few days, the infant was increasingly irritable, 
continued to have difficulty feeding, increased muscle tone and muscle 
jerking. We suspected opioid withdrawal, but his mother denied using 
any drugs. Despite this, we started treating the infant as we would any 
infant with the syndrome.

    After a week in the hospital, the umbilical cord drug screen came 
back positive for an opioid. As I walked into the infant's room to talk 
to his mother I could sense her guilt and anxiety. She cried as I 
talked to her about the drug test, and wondered aloud if she would lose 
custody of her infant. She had been afraid of my response and the 
response from child welfare. Like too many women I see, she became 
dependent on an opioid after an accident, was not able to get treatment 
for her opioid use disorder while pregnant and was too scared and 
ashamed to ask for help. This combination was dangerous to her and her 
infant.

    Had I known this mother was using an opioid, I could have started 
treating the baby earlier by controlling the environment, making 
adjustments to the baby's care to make the withdrawal less severe while 
teaching his mother how to recognize and mange his symptoms. Perhaps 
more optimally, his mother could have already had access to 
comprehensive treatment during her pregnancy.

    As a practicing neonatologist, I have seen first-hand the 
destructive impact of opioids on families. Neonatologists like me are 
trained to care for very premature infants and infants with severe 
birth defects. However, a few years ago we began to see an influx of a 
different type of infant--those having withdrawal from opioids, known 
as neonatal abstinence syndrome. These infants can be inconsolable, 
have muscle tremors, have trouble feeding, difficulty sleeping and 
breathing problems. Infants experiencing severe neonatal abstinence 
syndrome require treatment with an opioid like morphine or methadone, 
and stay in the hospital an average of more than 3 weeks. \1\
---------------------------------------------------------------------------
    \1\  Results embargoed, but permission to cite given by editor. 
Paper will appear online in the journal Pediatrics in March.

    Once rare, this diagnosis has become increasingly common. Our 
team's research has found that from 2000 to 2014, the number of infants 
diagnosed with neonatal abstinence syndrome grew nearly 7-
fold.31-3 Put another way, nearly one infant is born every 
---------------------------------------------------------------------------
15 minutes with signs of drug withdrawal in the US.\3\

    This rise in the incidence of neonatal abstinence syndrome happened 
in parallel with increases in opioid use nationally. In 2015, Americans 
were prescribed three times as many opioids as they were in 1999.\4\ 
That year, more than 37 percent of American adults were prescribed at 
least one opioid pain reliever.\5\ Research, including our own, has 
found similarly high rates of opioid prescribing in women of 
reproductive age\6\ and pregnant women.\7\ More recently, we have 
experienced a surge in use and complications due to heroin and fentanyl 
use. In 2016, more than 42,000 Americans died from an opioid overdose 
death\8\ and some of them were pregnant or had recently been pregnant.
                 Implementation of Existing Legislation
    I applaud the Committee and the Congress for the passage of the 
21st `Century Cures Act, the Comprehensive Addiction and Recovery Act 
and the Protecting Our Infants Act. Together, these pieces of 
legislation have moved forward important child health priorities for 
addressing the opioid epidemic. Even with the passage of these landmark 
pieces of legislation, there is an urgent need for additional 
legislative action and executive branch implementation of these laws. 
For example, there remains confusion at the state and provider level 
around some provisions of the Comprehensive Addiction and Recovery Act 
and, while SAMHSA has released its final report for the Protecting Our 
Infants Act, it is unclear how the recommendations contained in the 
report are being implemented.
                       Protecting Our Infants Act
    The Protecting Our Infants Act was passed just after a Government 
Accountability Office (GAO) report highlighted large gaps in research 
and service delivery for mothers and infants impacted by opioid use.\9\ 
The Act required that the Department of Health and Human Services (HHS) 
conduct a review of its planning and coordination of activities related 
to prenatal opioid use and neonatal abstinence syndrome. It also 
mandated that HHS study and develop recommendations for preventing 
prenatal opioid exposure, treating opioid use disorder among pregnant 
women, and preventing, identifying and treating neonatal abstinence 
syndrome and its consequences. Last, the Act required HHS develop a 
strategy to address gaps in research, Federal programs and 
coordination. Last year, SAMHSA released its final strategy focused on 
three domains: prevention, treatment and services. While these 
recommendations are important, it remains unclear how they will be 
implemented, funded and coordinated.
 Comprehensive Addiction and Recovery Act & the Child Abuse Prevention 
                           and Treatment Act
    The already-taxed child welfare system is being stretched even more 
thinly by the opioid epidemic. In 2015, the number of children entering 
foster care increased to nearly 270,000, up from 251,352 in 2012. In 
2015, infants represented nearly one-fifth of all removals of children 
from their families to foster care, totaling 47,219. Parental substance 
use was a factor in the foster care placement in nearly one-third of 
all cases.\10\

    Congress has a role in helping to improve collaboration among 
health care providers, the child welfare system and substance use 
disorder agencies in responding to the rise of substance use disorders 
among pregnant and parenting women and affected infants and those who 
experience neonatal abstinence syndrome. Your actions in 2016 to amend 
the Child Abuse Prevention and Treatment Act (CAPTA) in passing the 
Comprehensive Addiction and Recovery Act added important clarifications 
to the requirements for states to develop infant ``plans of safe care'' 
that also address the needs of the family or caregiver in instances 
when an infant is identified as affected by substance abuse, 
experiences withdrawal symptoms or fetal alcohol spectrum disorder. The 
goal of these plans is to engage child health and welfare professionals 
in collaborating to ensure the safety of these vulnerable infants upon 
discharge from the hospital.

    Unfortunately, those requirements came without clear guidance or, 
importantly, sufficient resources for implementation. States need 
additional guidance, funds, and resources from the Federal Government 
to ensure infant safety and to keep families intact when appropriate. 
States and communities need assistance to develop their key definitions 
and need funding for services to address these families' needs. I have 
experienced first-hand how these changes in statute are being 
interpreted with great variability among doctors, hospitals and child 
protective services. I would encourage the Committee to continue to 
exercise robust oversight of the Federal agencies working with states 
on implementing and monitoring CAPTA, and to provide funding additional 
legislative clarity where needed.

    In addition to the severe gap in funding the CAPTA-required plans 
of safe care, funds to ensure family centered treatment are currently 
lacking. Congress should act to ensure that funds allocated across 
Medicaid, CAPTA, Title IV of child welfare services, and the Substance 
Abuse Prevention and Treatment Block Grant are flexible, but also 
targeted to prevent children from being removed from their family 
whenever possible. Removing children is itself a form of trauma and one 
that can often be avoided if we provide families with the treatment and 
services they need to stay safely together.

    Treatment programs for pregnant and parenting women funded under 
the block grant need expansion because the program has not changed in 
nearly 20 years.\11\ It is time for Congress to revisit the funding 
mechanisms for these two-generation programs and encourage expansion of 
services for this population through Medicaid, the Block Grant, CAPTA 
and grants to pregnant and parenting women programs.
                            Recommendations
    Addressing the complexity of perinatal opioid use and neonatal 
abstinence syndrome requires a thoughtful public health approach 
targeting the pre-pregnancy, pregnancy and post-pregnancy periods for 
women and infants. Our goal should be to promote healthy mothers and 
infants by supporting prevention and recovery:

    My recommendations fall into three broad categories: improving care 
for mothers, improving infant outcomes, and research.
                       Improving Care for Mothers
    Primary prevention of opioid use disorder begins with preventing 
unnecessary opioid use well before pregnancy. Non-medical use of 
opioids among adolescents commonly begins with opioids not prescribed 
to them, but rather to a family member or friend. Congress should take 
steps to decrease the opioid supply, including through responsible 
prescribing and drug takeback programs.

    Too many health care providers are still unaware of the implication 
of their prescribing patterns for their patients. It is clear that 
additional provider education in this area is greatly needed. Congress 
should also bolster prescription drug monitoring programs\12\ by 
providing states with additional resources to modernize them and 
integrate them better into physician work flow and electronic medical 
records.

    Improving access to contraception, including long-acting reversible 
contraception, is vitally important because research suggests that 
women with opioid use disorder are nearly twice as likely to have an 
unplanned pregnancy.\13\ Congress should protect and expand women's 
access to all forms of contraception approved by the U.S. Food and Drug 
Administration, including coverage of contraceptives without cost-
sharing.

    Congress should also act to expand access to opioid treatment 
programs, especially for pregnant women and postpartum. Untreated 
opioid use disorder among pregnant women leads to poor outcomes for the 
mother and infant;\14\ however, treatment with opioid agonist therapies 
like buprenorphine and methadone are highly effective,\15\ especially 
for pregnant women.\14\ These therapies improve treatment 
retention,\16\ reduce relapse risk,316-19 reduce HIV-
risk,\16\,\20\ reduce criminal behavior,\18\ reduce risk of overdose 
death\21\ and improve birth weight.\22\ Despite evidence that treatment 
is effective in mitigating adverse outcomes from opioid use disorder, 
evidence suggests that the majority of women in need of treatment do 
not receive it.\23\ Congress should work toward ensuring that treatment 
is available when it is needed, including opioid agonist therapies when 
appropriate, and it should be comprehensive, trauma-informed, gender-
specific and inclusive of obstetric and pediatric care. Gender-specific 
treatment must include the ability of the mother to bring her children 
with her so that she is not faced with the unfair choice of getting 
treatment or caring for her children.

    Congress should resist any efforts to pursue punitive measures 
against pregnant women using opioids as some state legislatures have 
done. Major medical associations, including both the American College 
of Obstetricians and Gynecologists\24\ and the American Academy of 
Pediatrics,\25\ endorse non-punitive approaches to opioid use in 
pregnancy. SAMHSA estimates that more than 400,000 infants every year 
are exposed to alcohol or illicit substances.\26\ Punitive approaches 
are unethical, impractical and incentivize women to avoid care or not 
report their substance use to their provider. If a woman is fearful of 
criminal punishment, she may avoid prenatal care, go to another state 
to deliver, or even deliver at home, potentially resulting in adverse 
outcomes for mother and baby. \2\ Infants are routinely discharged at 
24 to 48 hours of life, but signs of drug withdrawal may not develop 
until 72 hours of life or later.\27\ If women are unwilling to disclose 
substance use, their infants are at risk of experiencing withdrawal at 
home with potentially dire health consequences including death.
---------------------------------------------------------------------------
    \2\  http://www.wbir.com/article/news/local/mother-of-drug-
dependent-baby-tells-her-story/51-63840991
---------------------------------------------------------------------------
                       Improving Infant Outcomes
    Throughout the US, opioid-exposed infants experience variable 
treatment\28\ resulting in variable outcomes.\29\ State and national 
perinatal quality improvement groups and hospital teams like ours at 
Vanderbilt are working to decrease this variability, but Congress 
should act to accelerate this vital work. Medicaid in particular could 
play a key role in standardizing care and breaking down discontinuities 
in care from pregnancy through the post-natal period. Medicaid is 
financially responsible for 80 percent of infants diagnosed with 
neonatal abstinence syndrome.\2\ Our team's research, due to be 
published next month, found that in 2014 neonatal abstinence syndrome 
accounted for 6.7 percent of all birth related expenditures for 
Medicaid nationally.3iii In that study there was some 
evidence that infants in Medicaid are being treated differently than 
those with private insurance, with higher rates of transfer to another 
hospital and longer hospital stays for infants covered by Medicaid.\3\ 
Medicaid programs are well-positioned to achieve the ``triple aim'' for 
families impacted by opioid use, by improving population health, 
improving the experience for pregnant women and infants and reducing 
cost.\30\ Congress should urge the Centers for Medicare and Medicaid 
Services to play a more active role in working with state Medicaid 
programs to address care for substance-exposed infants, including those 
with neonatal abstinence syndrome.

    Our nation has a long way to go to improve care for infants with 
neonatal abstinence syndrome, from better identification and treatment 
(including non-pharmacologic treatment) to improvements in the 
structure of care and minimizing separation of the maternal/infant 
dyad. Systems need to be agile, responding to new complications of the 
opioid-epidemic like hepatitis C. In a study conducted in partnership 
with the Tennessee Department of Health, my colleagues and I found that 
hepatitis C rates among pregnant women nearly doubled in the US from 
2009 to 2014.\31\ Some states were more affected than others, with the 
highest rates in West Virginia, where one in fifty infants was exposed 
to the virus in 2014. Exposed infants are completely asymptomatic and 
it is not possible to tell if they will acquire the virus until they 
are several months old. Screening for hepatitis C during pregnancy is 
not universal, and emerging data suggest that most exposed infants are 
not followed up to see if they become hepatitis C virus-positive.\32\ 
Congress should support and fund Centers for Disease Control and 
Prevention efforts to better identify pregnant women with hepatitis C 
virus. Congress should also urge the Centers for Medicaid and Medicare 
Services to develop programs to ensure exposed infants are 
appropriately followed.

    We also must do a better job of supporting families in the 
transition to home through initiatives like home visiting. The 
Maternal, Infant, and Early Childhood Home Visiting program provides 
funding to states to implement and expand effective home visiting 
programs that improve the early health, school readiness and economic 
stability of children and families. High-quality home visiting services 
to infants and young children can improve family relationships, advance 
school readiness, reduce child maltreatment, improve maternal-infant 
health outcomes, and increase family economic self-sufficiency.\33\ 
However, funding for the program expired September 2017, and Congress 
has yet to renew this funding. Congress should renew funding for the 
program as quickly as possible at the current level of $400 million 
annually for five more years, so that this program can continue its 
successes at the local level for the most vulnerable children and 
families.

    Next, the Individuals with Disabilities Education Act (IDEA) Part C 
supports early intervention services, like speech therapy, physical 
therapy and occupational therapy to infants with developmental delays. 
In 2004, reauthorization of this program extended to substance-exposed 
infants and infants having drug withdrawal after birth; however, 
adoption has been uneven. While as a provider I refer substance-exposed 
infants to early intervention services, it is not clear how many others 
are. Congress should ensure better linkages between child welfare, 
substance use disorder treatment for pregnant women and early 
intervention services.
                                Research
    In 2015, the GAO highlighted research gaps and reasons for the 
difficulty of conducting research on prenatal substance use and 
neonatal abstinence syndrome.\9\ As the GAO report noted, the Federal 
Government spent only $21.6 million over a 7-year period on research 
related to perinatal opioid use and neonatal abstinence syndrome--a 
small investment considering neonatal abstinence syndrome birth 
hospitalizations cost Medicaid $462 million in 2014.\3\ The 21st 
Century Cures Act provided urgently needed funding to states to support 
treatment and prevention, but an urgent need remains for additional 
National Institutes of Health funding specifically targeting the opioid 
epidemic. Congress should direct additional funding to the National 
Institute on Drug Abuse to expand research focused on improving 
outcomes pregnant women and infants impacted by the opioid epidemic.
                                Summary
    The opioid epidemic is taking a terrible toll on pregnant women and 
infants. Congress must act to address the urgent need for additional 
resources and coordination. For women and infants, like the ones in my 
introduction, the current system is disjointed and does not consider 
the needs of the mother and infant together. Without treatment, 
pregnant women are at risk of overdose death. Discharging infants home 
to a safe environment could be achieved by a more proactive and better 
funded child welfare system.

    Every day, people are dying, pregnant women are not getting the 
treatment they need and infants are spending their first days or weeks 
of life in drug withdrawal. In just the time we are meeting here, 8 
infants will be born with neonatal abstinence syndrome and 10 people 
will die from an overdose. These are our brothers and sisters and our 
children--they need us, now perhaps more than ever.

    Mr. Chairman, thank you for the opportunity to speak today. I look 
forward to your questions.
                              References:
    1. Patrick SW, Davis MM, Lehmann CU, Cooper WO. Increasing 
incidence and geographicdistribution of neonatal abstinence syndrome: 
United States 2009 to 2012. J Perinatol.2015;35(8):650-655.
    2. Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister 
JM, Davis MM. Neonatalabstinence syndrome and associated health care 
expenditures: United States, 2000-2009.JAMA. 2012;307(18):1934-1940.
    3. Winkelman TNA, Villapiano NL, Kozhimannil KB, Davis MM, Patrick 
SW. Incidence and Costsof Neonatal Abstinence Syndrome among Infants 
with Medicaid: 2004-2014. Pediatircs, InPress. 2018.
    4. Guy GP, Jr., Zhang K, Bohm MK, et al. Vital Signs: Changes in 
Opioid Prescribing in theUnited States, 2006-2015. MMWR Morb Mortal 
Wkly Rep. 2017;66(26):697-704.
    5. Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. 
Prescription Opioid Use, Misuse,and Use Disorders in U.S. Adults: 2015 
National Survey on Drug Use and Health. Ann InternMed. 2017;167(5):293-
301.
    6. Ailes EC, Dawson AL, Lind JN, et al. Opioid prescription claims 
among women of reproductiveage - United States, 2008-2012. MMWR Morb 
Mortal Wkly Rep. 2015;64(2):37-41.
    7. Patrick SW, Dudley J, Martin PR, et al. Prescription opioid 
epidemic and infant outcomes.Pediatrics. 2015;135(5):842-850.
    8. Hedegaard H, Warner M, Minino AM. Drug Overdose Deaths in the 
United States, 1999-2016.NCHS Data Brief. 2017(294):1-8.
    9. Prenatal Drug Use and Newborn Health: Federal Efforts Need 
Better Coordination andPlanning. Washington, D.C.: United States 
Government Accountability Office;2015.
    10. U.S. Department of Health and Human Services, Administration on 
Children, Youth, andFamilies, Children's Bureau. The AFCARS Report FY 
2015. 2016;https://www.acf.hhs.gov/sites/default/files/cb/
afcarsreport23.pdf. Accessed February 3, 2018.
    11. Substance Abuse Prevention and Treatment Block Grant 
(SABG).https://www.samhsa.gov/sites/default/files/sabg--set-aside--
for--women--r021014a--rev.pdf.Accessed February 5, 2018.
    12. Patrick SW, Fry CE, Jones TF, Buntin MB. Implementation Of 
Prescription Drug MonitoringPrograms Associated With Reductions In 
Opioid-Related Death Rates. Health affairs (ProjectHope). 
2016;35(7):1324-1332.
    13. Heil SH, Jones HE, Arria A, et al. Unintended pregnancy in 
opioid-abusing women. Journal ofsubstance abuse treatment. 
2011;40(2):199-202.
    14. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and 
addiction in pregnancy.Obstet Gynecol. 2012;119(5):1070-1076.
    15. Fullerton CA, Kim M, Thomas CP, et al. Medication-assisted 
treatment with methadone:assessing the evidence. Psychiatr Serv. 
2014;65(2):146-157.
    16. Sees KL, Delucchi KL, Masson C, et al. Methadone maintenance vs 
180-day psychosociallyenriched detoxification for treatment of opioid 
dependence: a randomized controlled trial.Jama. 2000;283(10):1303-1310.
    17. McCarthy JJ, Leamon MH, Parr MS, Anania B. High-dose methadone 
maintenance inpregnancy: maternal and neonatal outcomes. Am J Obstet 
Gynecol. 2005;193(3 Pt 1):606-610.
    18. Schwartz RP, Kelly SM, O'Grady KE, Gandhi D, Jaffe JH. Interim 
methadone treatmentcompared to standard methadone treatment: 4-month 
findings. Journal of substance abusetreatment. 2011;41(1):21-29.
    19. Schwartz RP, Kelly SM, O'Grady KE, Gandhi D, Jaffe JH. 
Randomized trial of standardmethadone treatment compared to initiating 
methadone without counseling: 12-month findings.Addiction. 
2012;107(5):943-952.
    20. Wilson ME, Schwartz RP, O'Grady KE, Jaffe JH. Impact of interim 
methadone maintenance onHIV risk behaviors. Journal of urban health : 
bulletin of the New York Academy of Medicine.2010;87(4):586-591.
    21. Schwartz RP, Gryczynski J, O'Grady KE, et al. Opioid agonist 
treatments and heroin overdosedeaths in Baltimore, Maryland, 1995-2009. 
Am J Public Health. 2013;103(5):917-922.
    22. Kandall SR, Albin S, Lowinson J, Berle B, Eidelman AI, Gartner 
LM. Differential effects ofmaternal heroin and methadone use on 
birthweight. Pediatrics. 1976;58(5):681-685.
    23. Substance Abuse and Mental Health Services Administration OoAS. 
Results from the 2014National Survey on Drug Use and Health: Summary of 
National Findings. Rockville, MD:Substance Abuse and Mental Health 
Services Administration;2015.
    24. Committee Opinion No. 711: Opioid Use and Opioid Use Disorder 
in Pregnancy. ObstetGynecol. 2017;130(2):e81-e94.
    25. Patrick SW, Schiff DM. A Public Health Response to Opioid Use 
in Pregnancy. Pediatrics.2017;139(3).
    26. Young N, S G, C O, et al. Substance-Exposed Infants: State 
Responses to the Problem.Rockville, MD: Substance Abuse and Mental 
Health Services Administration;2009.
    27. Hudak ML TRCoD, Committee on Fetus and Newborn, American 
Academy of Pediatrics.Neonatal drug withdrawal. Pediatrics. 
2012;129(e540-560).
    28. Patrick SW, Schumacher RE, Horbar JD, et al. Improving Care for 
Neonatal AbstinenceSyndrome. Pediatrics. 2016;137(5).
    29. Patrick SW, Kaplan HC, Passarella M, Davis MM, Lorch SA. 
Variation in treatment of neonatalabstinence syndrome in US Children's 
Hospitals, 2004-2011. J Perinatol. 2014.
    30. Patrick SW. The Triple Aim for Neonatal Abstinence Syndrome. J 
Pediatr. 2015;167(6):1189-1191.
    31. Patrick SW, Bauer AM, Warren MD, Jones TF, Wester C. Hepatitis 
C Virus Infection AmongWomen Giving Birth - Tennessee and United 
States, 2009-2014. MMWR Morb Mortal WklyRep. 2017;66(18):470-473.
    32. Kuncio DE, Newbern EC, Johnson CC, Viner KM. Failure to Test 
and Identify PerinatallyInfected Children Born to Hepatitis C-Positive 
Women. Clin Infect Dis. 2016.
    33. Duffee JH, Mendelsohn AL, Kuo AA, Legano LA, Earls MF. Early 
Childhood Home Visiting.Pediatrics. 2017;140(3).

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                 [summary statement of stephen patrick]
    The number of infants diagnosed with neonatal abstinence syndrome, 
a post-natal drug withdrawal syndrome that most commonly occurs after 
in utero exposure to opioids, grew nearly 7fold from 2000 to 2014. By 
2014, one infant was born every 15 minutes in the US with the syndrome. 
The rise of neonatal abstinence syndrome occurred with concurrent 
increases in opioid use and opioid use disorder among pregnant women. 
The 21st Century Cures Act, the Comprehensive Addiction and Recovery 
Act and the Protecting Our Infants Act moved forward important child 
health priorities addressing the opioid epidemic. These important 
pieces of legislation may benefit from additional action, funding and 
implementation efforts. In addition, Congress could consider several 
actions to improve outcomes for pregnant women and infants impacted by 
the opioid epidemic, focused on prevention, expansion of opioid use 
disorder treatment, improving care for opioid-exposed infants and 
improving outcomes after discharge by bolstering the child welfare 
system and early intervention systems.
                                 ______
                                 
    The Chairman. Thank you, Dr. Patrick.
    Dr. Bell, welcome.

 STATEMENT OF WILLIAM C. BELL, PH.D., PRESIDENT AND CEO, CASEY 
                  FAMILY PROGRAMS, SEATTLE, WA

    Dr. Bell. Good morning, Chairman Alexander, Ranking Member 
Murray, and honorable Members of the Committee. My name is Dr. 
William C. Bell, and I'm the President and CEO of Casey Family 
Programs, the Nation's largest operating foundation focused on 
safely reducing the need for foster care and building 
communities of hope for children and families across America.
    Casey Family Programs works in all 50 states, the District 
of Columbia, Puerto Rico, and the U.S. Virgin Islands, and with 
more than 16 tribal nations to influence long-lasting 
improvements to the safety and success of children, families, 
and the communities where they live. I thank you for the 
opportunity to be here today to discuss the disruption and 
trauma the opioid crisis is causing for our children, families, 
and communities.
    Data and our work with states and communities show that 
parental substance abuse is a key reason that the number of 
children being separated from their families and placed into 
foster care has been increasing significantly since 2012. As 
you've heard, approximately 270,000 children entered the foster 
care system in fiscal year 2015.
    Governors, mayors, child welfare leaders, nonprofit 
leaders, and tribal leaders across the country have been 
working tirelessly to overcome the challenges they face on a 
daily basis as they struggle to support and strengthen the 
families impacted by this opioid crisis. Increasingly, 
challenges involving recruiting foster parents, providing 
treatment services, treating babies born with prenatal 
exposure, and healing the mental trauma experienced by families 
have left child welfare systems strained and challenged to 
target resources in the best way to help families in devastated 
communities.
    There should be nothing more important to our Nation than 
ensuring the safety of our children and ensuring that they have 
the opportunity to grow up surrounded by a community of hope. I 
applaud this Committee for its leadership in the passage of the 
Comprehensive Addiction and Recovery Act of 2016. Among its 
provisions, CARA strengthened the requirement that states have 
infant plans of safe care in place that address both the needs 
of the infant and the needs of their parents. This legislation 
and the Protecting Our Infants Act of 2015 make it clear that 
our national child welfare--child/family response systems 
cannot continue operating as though it is possible to fully 
address the well-being of children without addressing the well-
being of their families and their communities.
    Current research has found that when parents can access 
treatment programs on demand and can enter treatment while 
keeping custody of their children, they are much more likely to 
successfully complete that program and, more importantly, 
continuing to improve their capacity to care for their 
children.
    One such example of an intervention is Kentucky's Sobriety 
Treatment and Recovery Teams program, or START, an evidence-
based program that provides services to safely maintain child 
placement in the home and provide parents with rapid access to 
intensive addiction and mental health assessment and treatment. 
Kentucky's START families have had twice the sobriety rates and 
half as many children in foster care as compared to their peers 
who did not participate in the Kentucky START program.
    Nationally, grandparents and other relatives are caring for 
more than one-third of all children who have been placed into 
foster care due to the parental substance abuse. Research on 
kinship foster care tells us that children who cannot remain 
with their birth parents are more likely to have stable and 
safe childhoods when raised by relatives.
    Frequently, relative caregivers have told us that the 
supports they need most include respite care, treatment, 
financial support, and mental health services for individuals 
and family members to deal with the enormous strain that this 
epidemic is placing on them. But, most critically, we hear from 
parents, foster parents, youth, kinship caregivers, child 
welfare leaders, and tribes that prevention services that 
promote long-term sobriety, services that improve parenting 
capacity, and the availability of sustained services for 
families once children return home from foster care are among 
the most important improvements that we can make.
    But despite everything that we know that works to both keep 
children safe and support their families, the vast majority of 
our Federal child welfare funds support a different approach. 
For every $7 that we spend on foster care, we spend only $1 on 
prevention. We must change how we spend Federal child welfare 
funds to make sure that we are funding the efforts that are 
most likely to get the results that our children and their 
families need.
    We know it is important that we intervene as early as 
possible. States need the ability to target their existing 
Federal resources into an array of prevention and early 
intervention services to keep children safe, to strengthen 
families, and to reduce the need for foster care whenever it is 
safe to do so.
    We also know that one of the most traumatic experiences 
that a child can have is to be forcefully removed from their 
family.
    In 2018, this Committee will consider the reauthorization 
of the Child Abuse Prevention and Treatment Act. Casey Family 
Programs stands ready to be a resource to you and to assist 
this Committee in any way that we can to reduce the impact of 
child abuse and neglect, to increase the availability and 
quality of prevention programs, and to increase levels of well-
being in vulnerable communities across America.
    In spite of all the devastation that we have witnessed and 
all that you've heard from us today, I still believe that there 
is hope, and I believe in the inherent power that hope brings 
to those in need of help. And I also believe in the power that 
hope brings to those of us who have chosen to be the bearers of 
that help.
    We are a nation of overcomers. Throughout our history when, 
as a Nation, we decided that a specific challenge confronting 
us as Americans had to be resolved, we have always come 
together and found a way to be victorious. We have found a way 
to overcome every challenge once we truly decided that it must 
be done. This epidemic is no different. This must be done. 
Mothers and fathers and sisters and brothers and entire 
communities and tribes have cried enough tears. This must be 
done.
    This isn't a problem that people like Ms. Hegle or the 
Savage family and others in similar situations should be left 
to solve on their own. All of us together must face this 
challenge with them as a nation united, with Federal, state, 
county, city, and local communities making sure that every 
child has a permanent and loving home where they can thrive and 
grow up to live to the fullest whatever dreams they have for 
themselves.
    Thank you very much for this opportunity to speak with you 
today, and I'm happy to answer any questions that you may have.
    [The prepared statement of Dr. Bell follows:]
                 prepared statement of william c. bell
    Good morning Chairman Alexander, Ranking Member Murray and Members 
of the Committee. My name is William Bell and I am the President and 
Chief Executive Officer of Casey Family Programs. Casey Family Programs 
is the Nation's largest operating foundation focused on safely reducing 
the need for foster care and building communities of hope for children 
and families across America.

    Casey Family Programs was founded in 1966 and has been analyzing, 
developing and informing best practices in child welfare for more than 
50 years. We work with child welfare agencies in all 50 states, the 
District of Columbia, Puerto Rico, the U.S. Virgin Islands, and with 16 
American Indian tribal nations, and with the Federal Government on 
child welfare policies and practices. We partner with child welfare 
systems, policymakers, families, community organizations, American 
Indian tribes and courts to support practices and policies that 
increase the safety and success of children and strengthen the 
resilience of families.

    I thank you for the opportunity to be here today to discuss the 
critical impact the opioid crisis is having on our Nation, and in 
particular the disruption it is causing for children, families and 
communities. This is not the first time that substance abuse has 
devastated families, leading to their involvement in the child welfare 
system--take for example the crack epidemic of the 1980's. Data and our 
work with states and communities continues to show that parental 
substance abuse overall is a key factor associated with children coming 
into foster care--separated not only from their families--but often 
from their neighborhoods, schools, friends and everything familiar.

    While parental substance abuse is not a new challenge for child 
welfare agencies, the current opioid epidemic is proving to have an 
immeasurable impact on foster care caseloads and child welfare budgets 
across the country.

    The National Center on Substance Abuse and Child Welfare (NCSCAW) 
explains it this way, ``In the past three decades, the United States 
has experienced at least three major shifts in substances of abuse that 
have had dramatic effects on children and families. However, the 
increase of opioid misuse has been described by long-time child welfare 
professionals as having the worst effects on child welfare systems that 
they have seen. Studies indicate that there is substantial overlap 
between parents involved in the child welfare and substance use 
treatment systems . . .'' \1\
---------------------------------------------------------------------------
    \1\  See https://ncsacw.samhsa.gov/resources/child-welfare-and-
treatment-statistics.aspx
---------------------------------------------------------------------------
    This is what the data tells us: Following years of decline in the 
national foster care population, there has been a steady increase in 
the number of children in foster care. In fiscal year 2016, there were 
437,465 children in foster care in the United States. \2\ Many 
jurisdictions have attributed this increase to be directly correlated 
with opioid use disorders and overdoses among parents.
---------------------------------------------------------------------------
    \2\  AFCARS fiscal year 2016
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
         Number of Children in Foster Care in the United States
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    At least 35 percent of the entries into foster care were identified 
as due to parental substance use--a percentage that has steadily risen 
in recent years and a percentage that represents an undercount, due to 
the varying approaches states take to documenting removal reasons. \3\ 
This impact may be even higher for American Indians and Alaska Natives 
who are at least twice as likely as the general population to become 
addicted to drugs and alcohol, and three times as likely to die of a 
drug overdose. \4\
---------------------------------------------------------------------------
    \3\  Ibid. Children enter care for many reasons. These categories 
represent the standard removal reasons states provide as part of their 
required AFCARS submission. How states utilize these standard fields, 
and whether or not they use all fields, is impacted by two key things: 
1) how the removal reasons in their case management system are mapped 
to these categories; and 2) how caseworkers are instructed to determine 
removal reasons for a child. State policy and practice vary.
    \4\  American Journal Drug and Alcohol Abuse (2012) Epidemiology 
and Etiology of Substance Use among American Indians and Alaska 
Natives: Risk, Protection, and Implications for Prevention. Retrieved 
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4436971/
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    We have heard directly from states that the opioid crisis continues 
to directly impact the well-being of children and families and has 
increased pressure on their child protection systems. Just last month, 
the National Governors Association (NGA)--a bipartisan organization of 
the Nation's Governors--released recommendations to Congress and the 
Administration calling for action to bolster the Federal response to 
---------------------------------------------------------------------------
the opioid crisis. The NGA's recommendations included the following:

          Increased Federal support to states, with flexibility 
        to meet communities' needs;
          Improved coordination across Federal agencies;
          Federal training and education requirements for 
        opioid prescribers;
          Statutory flexibility for state Medicaid programs to 
        provide the full continuum of evidence--based treatment;
          More flexibility for providers to prescribe 
        medications to treat opioid use disorder;
          Additional training and technical assistance to 
        facilitate data and information sharing across public health 
        and public safety; and
          Enhanced Federal support for justice-involved 
        populations, including the option for state Medicaid programs 
        to cover substance use and mental health services prior to 
        conviction and up to 30 days prior to release from prison or 
        jail. \5\
---------------------------------------------------------------------------
    \5\  National Governor's Association, press release from January 
18, 2018, retrieved from https://www.nga.org/cms/Governors-
recommendations-opioid-crisis.

    We recently partnered with the State of Tennessee to host a Safety 
Culture Summit that explored Tennessee's progress in reframing their 
system--at all program and policy levels--to recognize safety as a key 
priority in how they work and engage with families and their children, 
including around the impact of opioids and substance abuse. More than 
20 states attended this summit, illustrating strong interest from 
states in exploring how they might work to reform their systems in a 
similar manner.
    I want to applaud this Committee for its leadership to address the 
opioid and other substance abuse crisis through passage of the 
Comprehensive Addiction and Recovery Act of 2016 (CARA). CARA included 
language to strengthen the requirement that states--as a condition of 
receiving funds through the Child Abuse Prevention and Treatment Act 
(CAPTA)--have infant plans of safe care in place that address both the 
needs of the infant as well as the caregiver. But there is so much more 
we can, and should, be doing.
    Children can experience specific trauma as a result of parental 
opioid addiction--including emotional or physical abandonment--which is 
often magnified by the additional trauma that comes from removal from 
the home. Studies indicate that such Adverse Childhood Experiences--or 
ACEs--can have negative, lasting effects on health and well-being and 
are strongly related to the development of risk factors for disease, 
such as increased illness and morbidity, as well as negatively 
impacting future well-being through higher unemployment and reduced 
productivity. One of the key ACEs is parental substance abuse, which 
not only endangers children at the time it occurs, but has negative 
downstream effects on child development, and on the ability of those 
children to parent their own children in the future. \6\
---------------------------------------------------------------------------
    \6\  https://www.cdc.gov/violenceprevention/acestudy/about.html
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
     Mechanism by Which Adverse Childhood Experiences Influence Health 
and Well-being Throughout the Lifespan \7\
---------------------------------------------------------------------------
    \7\  Ibid.
---------------------------------------------------------------------------
    Casey Family Programs partners with states, localities and tribes 
throughout this country, and we hear directly from youth and families, 
child welfare leaders, judges, and other professionals in the field. 
Through their own work and experiences, they have identified certain 
strategies as effective in supporting families at risk or involved with 
child welfare due to a substance use disorder. I'd like to share some 
of those with you today.
    Parents have highlighted that timely access to comprehensive 
substance use treatment options--including family residential and 
family centered treatment, peer mentors, medication assisted therapy 
(MAT), residential treatment for pregnant mothers and recovery 
supports--have been effective in their recovery and reunification with 
their children. \8\ Research has shown that when parents are able to 
get into treatment programs with their children in a timely manner, 
two-thirds of them complete the program \9\ compared with only one-
fifth of parents who complete the program when their children are not 
allowed to stay in the treatment facility with them. \10\
---------------------------------------------------------------------------
    \8\  What Parents Say About Substance Abuse Recovery. National 
Alliance for Children's Trust and Prevention Funds, 2017.http://
www.bpnn.ctfalliance.org/BPNN percent20Brief--What percent20Works 
percent20in percent20Substance percent20Abuse percent20Rec overy.pdf
    \9\  https://www.ncbi.nlm.nih.gov/pubmed/11291901
    \10\  https://www.ncbi.nlm.nih.gov/pubmed/11291900
---------------------------------------------------------------------------
    For example, Kentucky's Sobriety Treatment and Recovery Teams 
(START) is an evidence-based program for families with substance use 
disorders and child abuse and neglect that provides services to safely 
maintain child placement in the home when possible and provides parents 
rapid access to intensive addiction and mental health assessment and 
treatment. Kentucky START has demonstrated that the families they serve 
have twice the sobriety rates and half as many children in foster care 
compared to their peers who did not participate in Kentucky START. \11\
---------------------------------------------------------------------------
    \11\  Huebner, R. A., Willauer, T., & Posze, L. (2012). The impact 
of Sobriety Treatment and Recovery Teams (START) on family outcomes. 
Families in Society Journal of Contemporary Social Services, 93(3)196-
203. See also Testimony of Tina Willauer. May 18, 2016. U.S. House of 
Representatives Committee on Ways and Means Hearing ``The Heroin 
Epidemic and Parental Substance Abuse: Using Evidence and Data to 
Protect Kids from Harm'' http://waysandmeans.house.gov/wp--content/
uploads/2016/05/20160518HR-Testimony-Willauer.pdf
---------------------------------------------------------------------------
    To address rising placement rates and challenges recruiting and 
retaining foster parents shortages--in some states resulting in 
children sleeping in offices and hotels--child welfare systems are 
increasingly placing children with grandparents and other relatives. 
Nationally, over a third of all children placed in foster care because 
of parental alcohol or drug use, are placed with relatives. \12\ Many 
relatives and child welfare professionals have cited a direct 
correlation between the spike in relatives caring for children and the 
national opioid epidemic. \13\
---------------------------------------------------------------------------
    \12\  Raising the Children of the Opioid Epidemic: Solutions and 
Supports for Grandfamilies. Generations United, 2016 http://gu.org/
OURWORK/Grandfamilies/TheStateofGrandfamiliesinAmerica/
TheStateofGrandfamiliesinAm erica2016.aspx
    \13\  Testimony of Bette Hoxie. March 21, 2017. U.S. Senate Special 
Committee on Aging Hearing ``Grandparents to the Rescue: Raising 
Grandchildren in the Opioid Crisis and Beyond'' https://
www.aging.senate.gov/imo/media/doc/SCA--Hoxie--3--21--17.pdf; Testimony 
of Sharon McDaniel. March 21, 2017. U.S. Senate Special Committee on 
Aging Hearing ``Grandparents to the Rescue: Raising Grandchildren in 
the Opioid Crisis and Beyond'' https://www.aging.senate.gov/imo/media/
doc/SCA--McDaniel--3--21--17.pdf
---------------------------------------------------------------------------
    Extensive research confirms that children who cannot remain with 
their birth parents are more likely to have stable and safe childhoods 
when raised by relatives compared to children raised by non-relatives. 
\14\
---------------------------------------------------------------------------
    \14\  Children Thrive in Grandfamilies. Generations United, 2016. 
http://grandfamilies.org/Portals/0/16--Children-Thrive-in-
Grandfamilies.pdf

          Kinship placements tend to be more stable than non-
        relative foster care placements, and there are fewer placement 
        disruptions. \15\
---------------------------------------------------------------------------
    \15\  Rubin, Downes, O'Reilly, Mekonnen, Luan, and Localio (June 
2008). Impact of kinship care on behavioral well-being. Pediatrics 
Adolescent Medicine. Volume 162, No. 6; Webb, Dowd, Harden, Landsverk, 
and Testa. (2010). Child Welfare and Well Being. New York: Oxford 
University Press; Wonokur, Holtan, and Valentine. (2009). Kinship care 
for the safety, permanency, and well-being of children removed from the 
home for maltreatment. Campbell Systemic Review. 2009:1.
---------------------------------------------------------------------------
          Children placed with relatives are more likely to be 
        placed with siblings and maintain relationships with birth 
        parents and relatives. \16\
---------------------------------------------------------------------------
    \16\  Child Welfare Information Gateway. (2013). Sibling issues in 
foster care and adoption. Washington, DC: U.S. Department of Health and 
Human Services, Children's Bureau; Obrien and Fechter-Legget. (2009). 
The effects of kinship care on adult mental health outcomes of alumni 
of foster care. Children and Youth Services Review. V. 31, pages 206-
213.
---------------------------------------------------------------------------
          Children in kinship care are more likely to remain in 
        their community of origin and maintain connections to cultural 
        identity, as well as remain in the same school and benefit from 
        their school support system. \17\
---------------------------------------------------------------------------
    \17\  Pew Charitable Trust. (2007). Time for reform: Support 
relatives in providing foster care and permanent families for children. 
Retrieved from http://www.pewtrusts.org/?/media/legacy/uploadedfiles/
www.ewtrustsorg/reports/foster--care--reform/sup 
portingrelativespdf.pdf
---------------------------------------------------------------------------
          Children in kinship care tend to be as safe, or 
        safer, than children in foster care. \18\
---------------------------------------------------------------------------
    \18\  Haskins, R., Wulcyzn, F., and Webb, M.B. (2007). Child 
Protection: Using research to improve policy and practice. Washington 
DC: Brookings Institution Press.
---------------------------------------------------------------------------
          Children in kinship care are less likely to re-enter 
        care than children in foster care. \19\
---------------------------------------------------------------------------
    \19\  Casey Family Programs. (2011). Does kinship care work well 
for children? A summary of the research. Seattle: Casey.

    Relatives who step in to care for children are often older and on 
fixed incomes, perhaps lacking adequate supports to care for their 
relative children. Caregivers report that they need a range of 
supports, including mental health services for the child and the 
family, kinship navigators, respite care, and financial assistance. 
\20\
---------------------------------------------------------------------------
    \20\  Raising the Children of the Opioid Epidemic: Solutions and 
Support for Grandfamilies. Generations United. 2016.http://gu.org/
OURWORK/Grandfamilies/TheStateofGrandfamiliesinAmerica/
TheStateofGrandfamiliesinAm erica2016.aspx
---------------------------------------------------------------------------
    Parents, youth, and kinship caregivers report tremendous value in 
services to safely prevent the need for foster care by strengthening a 
family's ability to keep their children safe and help them thrive and 
by stabilizing a family before maltreatment occurs. \21\ Examples 
include peer support, evidence-based parenting education programs, 
supportive housing and individual and family mental health services. 
Federal foster care funding through Title IV-E does not currently allow 
children or their caregivers to access such prevention services.
---------------------------------------------------------------------------
    \21\  Testimony of Sandra Killett. August 4, 2015. U.S. Senate 
Committee on Finance Hearing ``A Way Back Home: Preserving Families and 
Reducing the Need for Foster Care''. https://www.finance.senate.gov/
imo/media/doc/04aug2015-KillettTestimony.pdf; What Parents Say About 
Prevention and Early Intervention. National Alliance for Children's 
Trust and Prevention Funds, 2017.http://www.bpnn.ctfalliance.org/BPNN 
percent20Brief--Prevention percent20Strategies percent20That 
percent20Work.pdf
---------------------------------------------------------------------------
    Youth and parents also report that reunification after a stay in 
foster care can be a very vulnerable time when the family may need 
additional in-home services to ensure the children remain safely at 
home and avoid repeat maltreatment. The majority of children in foster 
care have a case plan goal of reunification with their parent or 
primary caregiver. In fiscal year 2016, 125,975 (51 percent) \22\ 
children left foster care and were reunified with their parent or 
primary caregiver. However, Federal foster care funding through Title 
IV-E does not currently allow children or their caregivers to access 
aftercare services.
---------------------------------------------------------------------------
    \22\  AFCARS fiscal year 2016
---------------------------------------------------------------------------
    Despite all of what we know works to both keep children safe and 
support their development within their families, the vast majority of 
our Federal funds for child welfare support a different decision. For 
every $7 the Federal Government spends on foster care, only $1 is spent 
on prevention. We must reform how we spend Federal child welfare funds 
to allow states and localities to be nimble and targeted in how they 
support those families that come to our attention.
    Research and the stories of youth and their families tell us that 
children need permanent and loving homes, preferably with their 
families, to thrive and grow up to be happy and productive adults. Our 
goal is for children to be free from abuse and neglect, surrounded by 
strong families and supportive communities. We believe that this can be 
achieved by allowing states to invest Federal child welfare resources 
in an array of prevention, early intervention, after care services, 
treatment, and other efforts that would reduce the unnecessary and 
costly need for foster care when it is safe to do so.
    To truly help these families, we know it's important that we 
intervene as early as possible. As the other witnesses have testified, 
we must support and ensure our programs and policies encourage parents 
and families to be more forthcoming with their challenges in a manner 
that is not punitive.
    This Committee will consider the reauthorization of the Child Abuse 
Prevention and Treatment Act. Nationally, more than 4 million calls are 
made to hotlines of reports of abuse and neglect, a very small number 
of which ever reach a response that warrants removal. \23\ States and 
communities are challenged every day with how to respond to each of 
these calls, often early warning signs that a family is at risk of 
child maltreatment, in a way that connects these families for life-long 
success. Casey Family Programs looks forward to being a resource for 
assistance to the Committee for child abuse and prevention programs.
---------------------------------------------------------------------------
    \23\  U.S. Department of Health & Human Services, Administration 
for Children and Families, Administration on Children, Youth and 
Families, Children's Bureau. (2018). Child maltreatment 2016. Available 
from https://www.acf.hhs.gov/cb/research-data-technology/statistics-
research/child-maltreatment
---------------------------------------------------------------------------
    Jurisdiction leaders from the public and private sectors in Johnson 
County, Kentucky, \24\ Hagerstown, Maryland \25\ and Gainesville, 
Florida \26\ have demonstrated that when public and private agencies 
working with children and families come together the safety, permanency 
and well-being outcomes for children and families can be improved. 
Families have shared that they often interact with multiple systems of 
care, including the courts, housing, child welfare, and healthcare. 
Coordination among systems positively impacts families' ability to 
successfully and efficiently get the help they need and keep their 
children safe. \27\ For families at risk of child welfare involvement 
and for families reunifying, access to affordable housing along with 
services--supportive housing--has demonstrated improved child safety 
and family stability, as well as sobriety for the families that entered 
with a substance abuse problem. \28\
---------------------------------------------------------------------------
    \24\  https://cdn.casey.org/media/hope2017.pdf
    \25\  https://cdn.casey.org/media/Hagerstown--brief.pdf
    \26\  https://www.casey.org/media/Gainesville--brief.pdf
    \27\  Testimony of Toni Miner. November 8, 2017. U.S. House of 
Representatives Committee on Education and the Workforce Joint 
Subcommittee on Early Childhood, Elementary, and Secondary Education, 
and Higher Education and the Workforce Hearing ``Close to Home: How 
Opioids are Impacting Communities.''https://edworkforce.house.gov/
uploadedfiles/toni--miner--written--testimony----final.pdf
    \28\  http://www.csh.org/wp-content/uploads/2011/12/Report--
KFTFindingsreport.pdf
---------------------------------------------------------------------------
    I'd like to end my testimony with just one example of why we 
believe there is hope, and why we believe it is important that we not 
forget how each and every family we interact with has the same 
opportunity for a bright future. Just last month, I had the privilege 
to recognize Alise Hegle as one recipient of the 2018 Casey Excellence 
for Children Awards. \29\ Ms. Hegle's daughter was removed at birth due 
to her struggles with substance use and a pending prison sentence. 
However, Ms. Hegle participated in a treatment program and was 
reunified with her daughter. Ms. Hegle has become a compassionate ally 
and forceful advocate for birth parents. As a peer mentor in Washington 
State, Ms. Hegle uses her own life lessons to engender hope in families 
involved in the dependency system. Part of Ms. Hegle's message is the 
critical importance of working in and with communities, connecting 
parents together to ensure their needs are met, and shifting resources 
toward prevention and reunification efforts.
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    \29\  See https://www.casey.org/2018-casey-excellence-for-children-
awards/
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    I have highlighted some of the strategies that are critical to 
combatting this crisis and ensuring safety, stability and success for 
children and families across the country. However, it will take a 
coordinated network of services with the support and advocacy from all 
levels of government, to begin to repair and halt the destructive 
impact that the opioid crisis is having on children and families.
    Thank you again for this opportunity, and I'd be happy to answer 
any questions you may have.
                                 ______
                                 
                  [Summary Statement of William Bell]
    Casey Family Programs was founded in 1966 and has been analyzing, 
developing and informing best practices in child welfare for more than 
50 years. Headquartered in Seattle, we work with all 50 states, tribal 
nations and communities throughout the country to ensure safe children, 
strong families, and supportive communities.

    The opioid crisis is having a critical impact on children, families 
and communities. Jurisdictions have attributed the recent increase in 
the number of children entering foster care as directly correlated with 
opioid use and overdoses among parents. At least 34 percent of the 
entries into foster care were due to parental substance use.

    Every child welfare leader will tell you of the challenges they are 
facing each and every day as they struggle to support and strengthen 
families impacted by substance abuse. Throughout the country, we are 
seeing more and more children separated from their parents and more and 
more child welfare systems strained and challenged to target resources 
to help these families. There is nothing more important than ensuring 
the safety of a child, but the path we have chosen of disrupting 
families and imposing unnecessary trauma on these children must change.

    The passage of the Comprehensive Addiction and Recovery Act (CARA) 
of 2016 bolstered efforts to help states support families and protect 
children but there is much more we can and should be doing. States are 
working to ensure infant plans of safe care are in place for families 
and children at risk.

    Parents need timely access to comprehensive substance use treatment 
options--including family residential and family centered treatment, 
peer mentors, medication assisted therapy, residential treatment for 
pregnant mothers and recovery supports. We have evidence-based programs 
that work. One example is Kentucky START in which participants had 
twice the sobriety rates and half as many children in foster care when 
compared to those not in the program.

    More children are being cared for by relatives due to the opioid 
epidemic. Kin providers need a range of supports to care for these 
children. Research confirms that children who cannot remain with their 
birth parents are more likely to have stable and safe childhoods when 
raised by relatives compared to children raised by non-relatives.

    States need the flexibility to invest their existing Federal 
resources into an array of prevention and family support services to 
keep children safe, provide treatment and recovery supports for 
families. However, Federal child welfare funding predominantly only 
supports foster care placement. The Federal Government spends $7 for 
foster care for every $1 spent for prevention.

    Coordination and shared services between multiple systems of care--
including the courts, housing, child welfare, and healthcare--helps 
families be successful.

    We look forward to being a resource for the Committee for child 
abuse and prevention programs.
                                 ______
                                 
    The Chairman. Thank you, Ms. Savage and Dr. Patrick and Dr. 
Bell.
    We'll now have 5-minute rounds of questions. I'm going to 
try to keep the exchange back and forth within 5 minutes 
because we have a vote at 11:30, and we have--I had that 
noisy----
    Senator Murray. Siri didn't like that.
    The Chairman. Siri didn't like that.
    [Laughter.]
    The Chairman. Life used to be simpler.
    Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    Ms. Savage, I want to thank you for sharing your story 
publicly and for being here today. You are clearly a family of 
tremendous strength, and by coming forward, you are truly 
saving lives. I just want to tell you that I am just 
overwhelmed by your ability to take such a tragedy and turn it 
into something that is going to help other families avoid what 
you went through.
    Just yesterday, I met with a group of Mainers, a large 
group of Mainers, from all over the state who had received 
funding from the Drug-Free Communities program, and I was 
impressed by a group of students from Fort Kent, Maine, way in 
the north near the Canadian border, who have developed their 
own program to try to help their peers avoid alcohol abuse, 
tobacco, and opioids, a crisis that we're in the midst of in 
Maine.
    What do you think of those kinds of peer counseling or peer 
groups to help teach high school students and younger children 
that there are alternatives to drugs and alcohol?
    Ms. Savage. I think any time a conversation is started, 
it's a positive, and those peer mentor groups are incredible. I 
think a lot of times just talking about it can start a 
conversation where maybe a child goes home and talks to their 
parents about the issue, and any time that can happen, of 
course, that's a success. So I think that's a wonderful thing.
    Senator Collins. Thank you. I couldn't help, when you were 
testifying, thinking that I'm going to send your testimony to 
all of the members of that group, because I think they would be 
inspired by it. They're doing great work as are you. Thank you.
    Dr. Bell, the Aging Committee, which I chair, held a 
hearing in March on grandparents raising grandchildren due to 
the opioid crisis, and in Maine, we have seen the number of 
such families soar by 24 percent over a 5-year period due to 
the opioid crisis. As you pointed out, compared to children who 
are placed in non-relative care, these children in the care of 
their grandparents have better outcomes. They have more 
stability in their lives, they have greater preservation of 
their identity, and they have better behavioral and mental 
health outcomes.
    But what we also learned is how difficult it is for these 
grandparents, who thought that they were going to be entering 
into an easier time of life and all of a sudden, they're 
raising children, in some cases, infants. The grandparents 
talked to me about their need for support, and that's why 
Senator Casey and I have introduced the Supporting Grandparents 
Raising Grandchildren Act.
    The bill would create a task force to help develop and 
distribute information designed to help kinship parents, 
because what we heard is it was really hard for them to learn 
to navigate the school system all over again--it may have been 
many, many years--that the parents that they were dealing 
with--or it could have been their children--that they didn't 
have the kind of supports.
    Do you have some ideas on what we could do in addition to 
respite care, which you mentioned, to better support 
grandparents who find themselves in this unexpected role?
    Dr. Bell. Absolutely. Thank you, Senator, and also for the 
effort that you and Senator Casey are approaching. You know, 
unfortunately, opioids is not the first time we've been in this 
position. I was in New York City during the crack epidemic, and 
we dealt with exactly what you're describing, and at that point 
in time, we called it skip-generational parenting. Because of 
the loss of frontline parents, grandparents and other relatives 
stepped in to care for children. What we found was that they 
needed support groups. They needed financial support. They 
needed a navigator type program that would help them understand 
where to go.
    One of the things that we created through the Department 
for the Aging in New York City during that epidemic was 
something that was called a Grandparent Resource Center, which 
was run through Aging, connected senior centers, and other 
community resources so that grandparents would not be alone or 
aunts or uncles would not be left alone to care for this child, 
but the community would be surrounding them. I think that's 
something that we could do in this situation as well.
    Senator Collins. Thank you so much.
    The Chairman. Thank you, Senator Collins, and thanks to you 
and Senator Casey for your work on Supporting Grandparents 
Raising Grandchildren. We plan to consider that bill in our 
markup later this month.
    Senator Murray.
    Senator Murray. Thank you.
    Ms. Savage, thank you so much to you and your family for 
being here. I can't imagine the loss and the tragedy and how 
hard it has been for you and your family to get through this. I 
think every parent in the room just went, ``Oh, my God. That 
could be me,'' and your courage in coming and telling this is 
incredible and also inspiring that you use the strength you 
obviously have to get past what happened to your family to make 
sure it happens to no one else, and we're all really grateful 
for that.
    Let me ask you--we've had a lot of witnesses here with 
really great ideas from renovating state prevention--or 
prescription drug monitoring programs to treating this as a 
disease and not as criminalizing it. But let me ask you what 
every parent would like to ask you, which is: What is your best 
advice to parents in their own communities? What should they be 
doing within their own families and their own communities to 
make sure this doesn't happen?
    Ms. Savage. Sure. Thank you for the question. I think what 
parents can do is just start the conversation. Start talking. 
If they hear of an issue, just bring it up with your children 
and start talking about it. I also talk with parents, and I 
encourage them to go clean out their medicine cabinets, because 
I know when I talk to crowds, I ask for a show of hands of how 
many people have expired medications in your medicine cabinet 
that you're not using, and probably about 75 percent to 80 
percent of the crowd raise their hands.
    I encourage them to go home and clean out their medicine 
cabinets and be responsible with the medications that they do 
have. Make sure that they know where they're at and keep them 
under lock and key. Treat it as a lethal weapon.
    Senator Murray. I think most people think you keep them out 
of the hands of 2 years olds, and they don't think past that.
    Ms. Savage. Right, right, a good lesson to push forward.
    Senator Murray. Well, thank you again to you and to all 
your family, and we so appreciate it.
    Ms. Savage. Thank you.
    Senator Murray. Dr. Bell, thank you again for being here. 
You know, the goal of the Casey Family Programs is to keep 
families safely together, as you said, and the opioid epidemic 
is clearly a challenge to that. We know that in the past 5 
years, we've seen almost a 10 percent increase in the number of 
children in foster care, as you talked about, much of it which 
can be attributed to substance abuse, and that trend is really 
concerning, really concerning.
    Children in foster care disproportionately face significant 
trauma, as you well know, and adverse childhood experiences 
that put them at higher risk all through life for disease and 
addiction and early death. What are some of the resources that 
communities need to prevent the need for foster care and keep 
children and their families safely together?
    Dr. Bell. Thank you, Senator Murray. You know, one of the 
things that we've seen, that we've spent a lot of time focused 
on, are the foster care rolls that have been increasing during 
the last 3 years. But in New York City, the foster care roll 
has continued to go down over the course of this time period. I 
believe that one of the reasons that is there is because of the 
immense amount of prevention services that are available in the 
city.
    One of the biggest challenges for families who are raising 
kids and kids who are at risk of coming into foster care is 
social isolation. If communities are going to strengthen their 
ability to keep kids out of foster care, we've got to make sure 
that families have access to prevention services, that there 
are community-driven support services available to them, and 
that they're not left alone.
    Unfortunately, too many of our families have moved away 
from extended family and they're living in communities where 
they're set apart. We've got to create school-based programs, 
we've got to create support-based programs, we've got to create 
community-driven programs so that somebody can see every child 
every day, so that support is there, because when you think 
about the protective factors, one of the five core protective 
factors is preventing social isolation and having community 
supports available for families, and I think that's what all 
communities need to strive to do.
    Senator Murray. Thank you, and thank you for your 
expertise.
    Dr. Patrick, I just have a minute left, but I wanted you to 
talk just a little bit about NAS and what you're seeing and how 
important it is that we focus on a comprehensive approach to 
preventing NAS both through helping women plan for when they 
want to become pregnant through programs like Medicaid, which 
is so important, and through improving access to evidence-based 
treatment for all women.
    Dr. Patrick. Senator Murray, thank you for the question. 
Yes, I think a comprehensive approach to substance use 
overall--we know that SAMHSA estimates around 400,000 
substance-exposed infants born every year--so a comprehensive 
approach to all substances to have healthy moms and babies, and 
I think that begins with some of the things we've been talking 
about here, like prescription drug monitoring programs, 
controlling prescribing, improving access to treatment, and 
then throughout the entire continuum, pre-pregnancy, pregnancy, 
and beyond, to really focus on improving outcomes for families.
    Senator Murray. I would just point out that recent studies 
showed nine out of every 10 pregnancies for women who misuse 
opioids are unintended, and we can't leave that out of our 
discussion. So thank you very much. Thanks for being here.
    Dr. Patrick. Thank you.
    The Chairman. Thank you, Senator Murray.
    Senator Bennet.
    Senator Bennet. Thank you, Mr. Chairman, and thank you and 
the Ranking Member for holding this important hearing.
    Ms. Savage, like the others, I want to thank you for your 
strength. In the 9-years that I've been in the Senate, I've 
never heard as moving a testimony as the testimony you've given 
this morning, and as a father of three teenage girls, daughters 
who I can't get to read anything that I work on when I'm here, 
I have no doubt that they will read the testimony that you gave 
today, and for that, I am eternally grateful to you.
    I wonder whether you could tell the Committee a little bit 
about what efforts at education you find work particularly well 
with adolescents, what things seem not to work terribly well. 
Sometimes people try to communicate with young people, and it 
either makes matters worse or just bounces off them. That may 
be only my problem with teenagers, but I suspect others have it 
as well.
    Ms. Savage. Sure. Thank you for the question. I'm no expert 
on teenagers, either. I have a few of them in my home as well. 
However, what I'm noting when I go to the schools to talk is 
that the kids really listen to real stories, real things that 
happened. You know, statistics and things are nice, and they'll 
kind of listen to that for a little bit, but they like to hear 
real stories and how this can affect them.
    I show pictures of my boys before I start talking so that 
they can connect with the pictures, hockey pictures--there 
could be hockey players or athletes out in the crowd, and so I 
try to make that connection with them, and then I tell our 
story, and they really seem to connect with that. So I think 
just telling personal stories, and I usually open it up to 
questions and answers.
    Senator Bennet. What kind of questions do you typically get 
from them?
    Ms. Savage. The questions I get are about prescription 
drugs. Some of the kids don't understand why prescription drugs 
are dangerous if they're prescribed by a physician, and so we 
talk about that any prescription that's not prescribed to you 
by your doctor could be lethal to you. So they're trying to 
make that connection between street medications or street drugs 
and prescription drugs, and we're trying to show them that they 
both can be lethal to you. Just because one is prescribed by a 
physician doesn't mean it's any less dangerous.
    Senator Bennet. Is it your impression when you're with 
these young people that they're hearing about this for the 
first time?
    Ms. Savage. In some crowds, yes. In some of the schools I 
go to, we'll talk about it, and it's like the first time they--
they don't understand that you can die from one time trying 
something. They don't understand that there's different 
strengths of medications, which I tell them, ``And you 
shouldn't. You're not a pharmacist or a medical professional. 
But there are different strengths, and you don't know what 
you're taking when somebody gives you something out of a vial 
or out of a Ziploc bag, and why would you trust them with your 
life? These are life choices that we're trying to help you 
make.''
    Senator Bennet. Thank you for being here again.
    Ms. Savage. You're welcome. Thank you.
    Senator Bennet. Dr. Bell, thank you for your work. You 
described the benefits of programs where parents have access to 
treatment and also don't lose their children.
    Dr. Bell. Right.
    Senator Bennet. I wonder whether you could describe for the 
Committee, from the point of view of families, a more typical 
experience in America today if you're somebody who is 
struggling with opioid addiction.
    Dr. Bell. I would hesitate to go typical, because I know 
that our systems are in various levels of trying to figure out 
how to make this happen. But when you think about when a parent 
who has been reported for abusing a substance--so the START 
program that I talked about. The referral to the START program 
begins when a mother is--or an expecting mother is tested 
positive either in the second trimester or the third trimester 
for a substance, and there is an immediate referral to child 
welfare. You know, in many states, it has become prima facie 
child abuse and neglect to have a positively exposed child in 
utero.
    We are working to help folks to understand that in that 
parent's mind, they are wrestling with a disease. I like to do 
the comparison between what happened when crack was the issue 
and what we're trying to do right now in the opioid crisis. I 
believe that what we're trying to do right now is a much more 
humane approach to dealing with families who are struggling 
with a disease.
    Under the crack epidemic, that woman would have been 
referred to child welfare, we would have done an investigation, 
and in all likelihood, we would have removed her child and 
placed the child in foster care. She would have been in the 
court system, maybe represented by a quality attorney, maybe 
not. Her child would have been languishing in foster care. She 
would have had a long list of things that she had to complete 
in order to get her child back, including housing, including 
parenting skills, including overcoming substance abuse 
treatment.
    But at the same time, we also know that stress exacerbates 
the use of substances, and we would be contributing to that 
stress by holding her child over here and restricting her 
access to that child. One of the things that grew out of that 
particular piece was that courts started to use drug treatment 
courts, which began to work in a conversation with parents to 
say, ``We know that you want your child back. We want you to 
have your child back, but we also know that you need to 
overcome this disease that you have. We will work with you to 
increase your capacity to see your child as long as you're 
working to achieve the sobriety that we know is necessary and 
that you want to have.''
    I think that where we are right now is a mix of people who 
some states still say, ``It's still prima facie child abuse and 
we need to keep you away from this child.'' There are other 
states that are saying, ``No, this is a person who is wrestling 
with a very devastating disease, and we need to change our 
systems and protocols so that we can help lift them up.'' I 
mentioned earlier when I was responding to Senator Murray----
    The Chairman. We need--we're well over time, sir. We need 
to go on to----
    Dr. Bell. Okay.
    The Chairman. Thank you, Senator Bennet.
    Senator Casey.
    Senator Casey. Thanks very much. I wanted to raise a 
question that may have already been asked, but I think it's 
important to reiterate, and I'm particularly grateful for the 
witnesses and your testimony.
    One of the real horrors of the--or I should say one of the 
worse manifestations of what we've been dealing with in the 
opioid crisis is that you have individuals who have lived full 
lives and then reach the point where, because a son or daughter 
might have a problem and they have children, the grandparents 
have to raise the grandchildren or at least play a role in 
raising them.
    I know that Senator Collins has worked on this with me and 
worked on legislation. But this is both a human challenge, but 
it's also a--the reality is that these families end up helping 
all of us in the dollars they save. We're told that, by one 
calculation, grandparents and other relatives who raise 
children outside of the foster care system save something on 
the order of $4 billion each year. So not only are they 
sacrificing a lot of their golden years, but they're, in fact, 
helping all of us by taking on that substantial burden. 2.6 
million grandparents are raising grandchildren, and that's a 
huge number.
    As I mentioned, Senator Collins and I have the legislation 
called Supporting Grandparents Raising Grandchildren Act, which 
creates a Federal task force to serve as a one-stop resource 
for resources and information for grandparents who are, in 
fact, having to raise their grandchildren.
    I wanted to start with Mr. Bell and ask whether you think 
having this information will help support these grandparents 
and relatives who are raising these children as a result of the 
opioid epidemic.
    Dr. Bell. Thank you, Senator Casey.
    Senator Casey. Dr. Bell. I'm sorry.
    Dr. Bell. Thank you. Senator Collins did raise this before 
she left, and as I indicated, we are very supportive of what 
you are trying to do here. It's something that we learned from 
the crack epidemic, that these grandparents need support 
centers. They need navigation programs. They need financial 
resources, because the notion of the $4 billion savings is 
because many of these grandparents have not necessarily been 
informed that they can become kinship providers.
    I wouldn't advocate that we take all of these grandparents 
and bring them into the foster care system, because many of 
them can do better outside. But we do need to figure out a way 
to provide financial support, provide respite, provide 
opportunities for them to continue to live their lives so that 
they are not burdened down overly with these children, because 
one thing that we saw during the crack epidemic was that their 
health started to deteriorate when they didn't have the support 
that they needed. So I think that you're definitely on the 
right pathway, and we would fully support working with you on 
that.
    Senator Casey. Well, Doctor, I appreciate it, because you 
bring particular experience and expertise to these issues, so 
we're grateful for that help, and it will give us momentum for 
passing the bill. So I appreciate that.
    Dr. Patrick, I wanted to raise with you a question that I 
know that the Chairman, Chairman Alexander, referred to. He and 
I worked together on the implementation of the Plan of Safe 
Care legislation, and I know that this may also be reiterating 
what was spoken of earlier. But we have this GAO report that 
just came out yesterday. I had requested that the GAO examine 
the so-called Infant Plan for Safe Care Improvement Act, and 
what the GAO found was a lack of guidance from HHS on how 
states should be implementing the law. So we're going to 
continue to work on full implementation and sufficient support 
for states in being able to carry out their responsibility on 
plans of safe care.
    I guess I'd ask you, as a neonatologist who's on the 
frontlines, when it comes to identifying these substance-
affected infants--many of them, I guess, burdened by the so-
called NAS syndrome, the Neonatal Abstinence Syndrome--have you 
identified any best practices for ensuring a coordinated 
multidiscipline area approach to this?
    Dr. Patrick. Well, Senator Casey, I think, just as the GAO 
report suggested, there's a lot of confusion at the state level 
as to what defines an infant safe plan of care and what that 
should look like and resources to be able to carry those out. 
There are models. There's a couple of models--one that I'm 
familiar with. It's called CHARM in Vermont, where they 
proactively engage families that are in substance use treatment 
well before birth, meet with those families throughout, develop 
plans throughout the pregnancy, and work toward a safe 
discharge.
    What I experience is far more reactive, where a referral is 
made to DCS around the time of birth, and there's no action 
taken until around the time of discharge, and it tends to be 
reactive. In part, I think that's because our overburdened 
child welfare system is simply reacting to the problem instead 
of having the resources and training to address it head-on.
    I'll point out one other point, which is that in many 
states, they treat substance exposure just as they would severe 
physical or sexual abuse, and I think that's the paradigm that 
many child welfare systems engage in. So reframing that 
specifically on how to work with families early on to keep 
families together where it's appropriate is really needed, and 
I think your work on this and the Infant Safe Plan of Care, 
implementing that, and getting more resources is really vital 
to improving outcomes for families.
    Senator Casey. Thank you, Doctor.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Casey.
    We have our vote at 11:30, so I'm going to ask the 
witnesses and the Senators to try to keep the exchange within 5 
minutes and then supplement the answers in written form after 
the hearing.
    Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman, and I would 
hope that I could do follow-up questions with members of the 
panel, because this is very important.
    I go around the state. The meetings that I have--the 
meetings that I have with folks here--I don't care if you're 
the Alaska Association of School Boards or whether you're here 
as a mayor talking about an infrastructure project, we always 
end up talking about addiction and what is happening in our 
small communities. And when we think about the addict, we 
cannot think about the addict without thinking about the 
families and the children that are now part of this world of 
addiction. It is just something that breaks your heart.
    I was at a meeting down on the Kenai Peninsula just this 
past Friday and was told--and this is still anecdotal--but that 
when OCS, the Office of Children's Services, takes a case, 
takes children in--not even taking them into the system, but 
just reviewing them--they do a hair follicle test to test for 
drugs, and nine out of 10 of the kids in the system right now 
are testing positive for drugs because of drugs that are in the 
household that they have been exposed to.
    When you think about the addict, you don't necessarily 
think about the impact, again, to our children, the impact on 
pre-maternal care, women who are pregnant who are choosing not 
to get care because they're afraid they're going to be told by 
their doctor that they are bad people, that when they--if they 
are mothers who have young children, they're not telling their 
doctors about their use because they're afraid they're going to 
lose their children. It is just beyond belief, the impact to 
the children.
    We had Mr. Sam Quinones, who's the author of Dreamland, 
before the Committee some weeks ago. He suggested we need a 
Moon Shot approach in order to really get this social movement 
for recovery, and I suggested that Moon Shot was a different 
thing, because it gave something for us as Americans to aspire 
to, some big lofty goal. When it comes to addiction, it's much 
harder for the communities at large to embrace this as 
something that we need to do because there is still such a 
stigma attached to it.
    When I asked him what we as lawmakers could do, he said, 
``You need to give a forum to the families to speak out so that 
we view differently those that are addicts.''
    Ms. Savage, I want to ask you as the mother of two young 
men who are no longer with you and your family because of 
addiction--when we think about the addict of days gone by, it 
is a different mental image in people's minds. Recognizing that 
the addict today is a different person, how can we do more to 
facilitate a conversation about the fact that people who are 
dealing with this--they're not losers. They're not bottom of 
the barrel. They are not these people at the bottom of society. 
These are boys, these are our brothers, our sisters, our 
parents, people that we love. How do we change this so that 
there is this ability as a society to embrace what we have to 
do to solve addiction?
    Ms. Savage. Sure. Thank you for the question, Senator. Our 
boys, I just want to clarify, were not addicts. They had 
experimented with a medication that was brought to a graduation 
party, so it was a one-time use that did kill them.
    However, we are faced with the stigmatism, because every 
time somebody says, ``Oh, you lost your two older boys. How did 
they pass away?'', you have that split second of, ``Oh, my 
gosh. Here we go.'' And when you tell them they died of an 
overdose, you do get the stigmatism, and we talk about it. We 
tell exactly what happened. But there is that stigmatism out 
there.
    There are some school systems that I know parents have 
contacted me about going to talk to, and the school systems 
maybe aren't ready to have someone come in and talk about 
opioid misuse or abuse or prescription pills because of the 
stigmatism. They're afraid that they're going to be classified 
as having an issue at their school.
    I'm not sure how to combat that, other than just talking 
about it and being more open with talking to people. We talk 
about it all the time, obviously. I would like to say it's 
getting easier. But I think just talking about it, hopefully, 
will help fight some of that stigmatism.
    Senator Murkowski. Well, I thank you for the courage as a 
parent for coming forward and helping others as they deal with 
the losses and the challenges in their personal lives.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murkowski.
    Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman.
    I knew when I saw the announcement about this hearing that 
it was going to feel awfully personal. I want to thank you all 
for being here and for your advocacy.
    Ms. Savage, thank you. You are saving lives. You talked 
about the power of storytelling when you meet with students. So 
I want to share just a little of mine. I think most of the 
people on this Committee know that I was raised by my 
grandparents, because I talk about them all the time, 
oftentimes in the context of Committee hearings that we're 
having.
    I worked with Senator Collins on a different caregiver 
measure that was signed into law just 2 weeks ago, dealing more 
with supporting families who are caring for elderly people who 
are becoming frail or adults with disabilities.
    But I don't think I've often shared why I was raised by my 
maternal grandparents. My mother was 19 when I was born and 
going through a divorce and moved back home, but throughout her 
life struggled with mental illness and physical illness and 
chronic pain, for which, in the days well before we labeled an 
opioid epidemic, she was prescribed a multitude of 
benzodiazepines, narcotics, and other medications.
    I always knew and had a lot of contact with my mother when 
I was growing up. She lived very close by. But my grandparents 
were heroes and gave me a stable upbringing, and they thought 
they were empty nesters. They were both in their mid 50's. Both 
of their daughters had left the home, and I don't think they 
imagined that they were going to get an infant. I moved in when 
I was 2 months old--I actually had the same grade school 
principal that my mother had when she was in grade school--and 
I know they struggled.
    One of the issues they struggled with was health insurance 
coverage for me. They weren't in the foster system. This was an 
informal arrangement. But I saw what my mother struggled with, 
misusing, addiction, and I saw my grandparents, again, just my 
rocks, my--folks who just were with me the whole time. I had 
the honor of returning to care for my grandmother when she was 
in her 90's and needed caregiving.
    The issue of supporting our families in these roles from 
all perspectives, whether getting the person with substance 
abuse issues the help they need or supporting the families and 
foster parents who step forward and give a kid a chance--I 
cared so deeply about this.
    I wanted to--having taken so much of my questioning time, I 
suspect I will give you some questions for the record. But I 
wanted to ask a little bit about the infants, Dr. Patrick and 
Dr. Bell, who have significant health impacts of their own 
because of neonatal abstinence syndrome. I have long championed 
a measure that has yet to become law that would expand access 
to therapeutic foster care, employing Medicaid funds for 
children who will need lifelong care, but to empower family 
members and foster parents to provide more than just custodial 
care and love, but also more intensive services.
    I wonder if you could talk about the importance of the role 
of therapeutic foster care and our ability to get Medicaid 
funds to support those families.
    Dr. Patrick, why don't we start with you?
    The Chairman. Dr. Patrick, if you could--you have 13 
seconds left, so if you could summarize that and then perhaps 
in writing answer Senator Baldwin's questions.
    Tammy, thank you for your story, too. That was--thank you 
for doing that. But please go ahead.
    Dr. Patrick. I think one of the things we often miss is 
that substance exposure often leads to pre-term birth. I sent 
home a baby in the last week that had been in the hospital for 
8 months, was born at 23 weeks, and the amount of support that 
family needs is extensive. For many of our babies, they, 
unfortunately, don't have families to go to. So what you're 
talking about is vitally important as we support families, 
particularly, foster families that come in and care for infants 
that have complex needs. So thank you for that.
    The Chairman. Thank you very much, Senator Baldwin.
    Senator Scott.
    Senator Scott. Thank you, Mr. Chairman.
    To Senator Baldwin, thank you. I came in halfway through 
your story. Thank you for sharing your personal story with all 
of us. I think it's informative and instructive as well, and 
we're all appreciative of family members who step up to the 
plate when challenges arise with our primary caregivers.
    Ms. Savage, the power of your personal testimony is 
unmatched, and I can't imagine the excruciating pain and misery 
that your family has endured. But the ability to articulate 
your story in these conditions will have impacts throughout 
this Nation that we'll never hear about, but lives will be 
saved because you have the power and the strength to testify, 
and thank you to your family, your husband and your son, for 
being here as well.
    Dr. Patrick, I know you've answered this question a couple 
of times already, and I had to go to a Banking hearing and 
other hearings. But in South Carolina, according to many 
reports, from 2007 to 2015, the number of babies born with NAS 
has gone from 4 per 1,000 to 7 per 1,000. It's my understanding 
that it's very difficult to treat these babies.
    Can you once again illuminate, perhaps briefly, how we 
could do a better job, first? And, second, my question is--when 
I was here and listening to your testimony, you talked about 
the difficulty within the first couple of weeks. Can you speak 
to the challenges for the next several years for some of these 
kids as they grow up?
    Dr. Patrick. Thank you for the question. When I describe a 
baby that has drug withdrawal, I often describe them as a 
colicky baby times five. These are infants that are 
increasingly fussy. They have difficulty breathing, difficulty 
feeding, sometimes difficulty breathing, and, less commonly, 
they can also have seizures. So you can imagine what that's 
like for a family to go through and for the infant to go 
through.
    Our approach has changed substantially at Vanderbilt based 
on best practices around the country. So no longer do infants 
that have drug withdrawal come to the neonatal intensive care 
unit. They stay with their mom, if possible, in the newborn 
nursery, and then they go to a different part of the hospital 
outside the ICU. We find that keeping moms and babies 
together--it decreases the severity of the drug withdrawal, and 
it keeps the bonding of the dyad from early on. It's so 
important.
    Your questions around long-term outcomes are really 
important. One of the things that we need is additional 
research to understand that. There really aren't large 
prospective studies to follow infants as they go to 
kindergarten. We have some older studies that suggest that 
there may be some issues with attention, maybe with language. 
But there really aren't robust studies. It's an area that 
certainly needs to be funded.
    But as we think through this, as we sort of react to what 
we're doing now, one of the vital things that we do is support 
infants for those first years of life, and that includes 
partnering with child welfare, but also early intervention 
services. So every infant that is substance-exposed should be 
referred for early intervention services, and that includes 
speech therapy, occupational therapy, so that we can maximize 
their outcome, and I think that period of time going home is 
just so critical. Right now, the way it feels for me when I 
discharge an infant home is that it's uncoordinated and it puts 
a lot of stress on a family that already has a lot of stress.
    Senator Scott. Thank you very much.
    Dr. Bell, I thank you for being here as well. One of the 
comments that we've been thinking about as I've been listening 
is the thought that shame and the consequences of one's actions 
leads many folks to hide the challenges and the addiction. I 
know that there's a strong push toward allowing parents who are 
going through treatment not to lose their children, which 
sounds like a good idea, but also a double-edged sword. Can you 
walk me through that as well?
    Dr. Bell. The approach really is one that says, ``We want 
to honor your relationship with your child. We also want to 
acknowledge that having that child connected to you is a great 
motivator to overcoming the challenge that you're dealing 
with.''
    But in doing that, we also acknowledge the need to make 
sure that there's constant monitoring of the children, that 
there is constant support for the children, that there's 
respite for the child, time periods for the child to be away 
from the parent, so that child welfare is not doing what we've 
done--typically done in the past, which is having this complete 
distance, but that we are not leaving the child just with the 
parent so that something might possibly happen, and we're 
continuously working with that mother and fathers and other 
family members to improve their capacity to care for the 
children.
    Senator Scott. Thank you. Using my last 14 seconds here as 
wisely as I can, which means I'm going to go over my 14 
seconds, Senator Baldwin's story as it relates to the 
involvement of her grandparents--how often do you see the 
grandparents----
    The Chairman. Senator Scott, I'm going to have to--I've 
told the--we have a vote right now and four Senators waiting.
    Senator Scott. Oh, is that right? Okay. Well, I'll wrap it 
up in just about seven more minutes.
    [Laughter.]
    Senator Scott. I'll submit that in writing to you.
    Thank you, Mr. Chairman.
    The Chairman. I'm sorry to cut you off, but----
    Senator Scott. I fully understand.
    The Chairman ----I've been trying to be a little bit--
Senator Murphy?
    Senator Murphy. Thank you very much, Mr. Chairman.
    I wanted to add my thanks to Senator Baldwin for sharing 
that story with us, and I actually may have a question 
pertaining to how we make sure that families are truly involved 
in the care for their loved ones, if I have time with my strict 
5-minute limit.
    But I wanted to come back to Dr. Patrick to expand on this 
conversation about neonatal abstinence syndrome. A few years 
ago, Yale Children's Hospital conducted a quality improvement 
study to look at how to best care for these kids, and what they 
attempted to do was build a really comprehensive non-
pharmacological approach to caring for these infants. That 
meant low stimulation rooms, swaddling, soothing, feeding on 
demand, trying to enhance the bond between mother and child. 
The results were really extraordinary. Average length of stay 
in the NICU went from 28 days to just over 8 days. Morphine 
treatment in the NICU decreased from 98 percent to 44 percent.
    My question is how important is it to prioritize non-
pharmacological treatment for NAS, and are our hospitals ready 
for this? I mean, you have to have more nurses. You have to 
have dedicated physical space in order to do this right. How 
important is this treatment, and are we ready to do more of it?
    Dr. Patrick. Well, my colleagues at Yale have done a 
wonderful--built a wonderful program. It's vital. Non-
pharmacologic care is vital. We find as we do that in our 
hospitals, we're using less morphine. So what would you rather 
have? Would you rather have your mother or morphine? Putting 
moms and babies together and creating that environment is so 
important.
    As far as whether hospitals are ready for it, I think we do 
have challenges in many communities, particularly rural 
communities. We know in states like ours, in Tennessee, and my 
birth state, West Virginia, there's a really high number of 
opioid-exposed infants, and sometimes the neonatal intensive 
care unit is the only pediatric place in that hospital.
    I think when we think about how this is implemented and how 
do we begin to deescalate the care that we provide for infants 
and create a model where families can stay together, I think it 
may look slightly different in different hospitals, hospitals 
that may not have the resources that Vanderbilt has to support 
lactation. We have a child life specialist who's building a 
cuddler program, so when moms can't be there, we're able to 
support that. I think it's going to look different a little bit 
everywhere, but it is vital.
    Senator Murphy. I'll direct this to Dr. Bell, but, Ms. 
Savage, if you have thoughts as well--I want to talk about what 
happens when a child hits the age of majority. One of the 
things we talked about in the Mental Health Reform Act of 2016 
that this Committee and this Congress passed is looking at 
HIPPA laws and how they may create barriers at age 18 for the 
parents to stay involved in the care of a loved one, a child 
who may have complicated comorbidities, addiction and mental 
illness.
    We want to respect the privacy rights of adults, but we 
also want to make sure that if a doctor feels it's in the best 
interest of that child, when they go from 17 to 18, that the 
parents can still, at the very least, know about when the 
appointments are so that they can help that 18-year-old stay on 
schedule. I just wanted to pose that question to you, about how 
you think about making sure that families stay integrated in 
care when you have that transition to the age of majority.
    Dr. Bell. You know, I think that it is important for young 
people, particularly entering adulthood, to have as strong a 
support system around them as possible. One of the things that 
we have wrestled with in the child welfare service area around 
privacy has always been being able to help the individual 
understand why this is helpful to them. It's a very complicated 
legal matter in trying to override someone's right to privacy.
    But I do believe the relationship is the most important 
factor in getting people to accept that this is helpful to me, 
as opposed to invasive to me. We have to respect privacy, but I 
do believe that there are possibilities through relationship 
for being able to get that done.
    Senator Murphy. Well, I know we've got other people who 
want to speak, so I'll yield back the rest of my time. Thanks, 
Mr. Chairman.
    The Chairman. Thank you, Senator Murphy. That's good of 
you. We have several Senators, some of whom have been here for 
the whole hearing.
    Senator Young.
    I believe the vote may have been moved to 11:45, so that 
may help us.
    Senator Young. Well, thank you, Chairman.
    Ms. Savage, you and I talked in my office about how you've 
been able to reach so many high school students, not only in 
the State of Indiana but really increasingly across the country 
through work with the 525 Foundation, which you established. 
You indicated how so many of these kids have no idea whatsoever 
or very little idea about the risk associated with prescription 
pills and the risk they pose to their health and the health of 
loved ones. I think a lot of adults lack that awareness as 
well.
    How in your mind do we bring more awareness to this issue 
to high school students? And do you think we might need a 
broader public awareness campaign to address it?
    Ms. Savage. Thank you for your question. Absolutely. Not 
just with high school students, but also middle school age 
students and also elementary age students and also adults, I 
think a big campaign with a public service announcement, a 
national campaign, would be awesome, because it would touch so 
many different people, different age groups, absolutely.
    Senator Young. Thanks, and we had a little dialog about 
that last night----
    Ms. Savage. Yes, we did.
    Senator Young ----recalling the ``This Is Your Brain On 
Drugs'' ad from years ago----
    Ms. Savage. Yes, that we still remember.
    Senator Young ----and there might be an analog to that.
    Dr. Bell, I'm going to turn to you, sir, and I would like 
to discuss the issue of predictive analytics. By way of 
background, Marilyn Moores is a juvenile court judge in the 
Indianapolis area, and she recently said that our traditional 
systems of early warning related to child welfare cases are 
overwhelmed. With caseworkers stretched too thin, we end up 
with a bunch of kids who are falling through the cracks, not 
just in Indiana, but we see this around the country.
    But imagine if we could use existing data to help those 
caseworkers in targeting much needed services to those children 
who are most at risk. Child welfare expert and former Michigan 
Supreme Court Justice Maura Corrigan said, ``If we're able to 
mine data in child welfare and intervene with good casework by 
the mining of that data, perhaps we would reduce the 1,500 to 
3,000 deaths from child abuse and neglect in this country each 
year.''
    I'm going to ask you, Dr. Bell, how might we use data to 
estimate risks for children, and should we be using data from 
past cases in order to inform decisions about current ones?
    Dr. Bell. Thank you, Senator Young. You know, I would just 
say about predictive analytics that we must first understand 
that it is a tool and not a solution unto itself. But 
predictive analytics is a very valuable tool that has been used 
for years in the healthcare field, in law enforcement, in 
meteorology, and it is essentially taking the things that we 
know, analyzing them, to help us better predict the things that 
we don't know.
    If we can utilize this tool that has shown so much value 
for others--aviation, I mean, airplane crashes--predictive 
analytics has been paramount to reducing those. So I think that 
we have to explore every possible opportunity to do better for 
our children, and we believe predictive analytics is one of 
those things that we can explore.
    Senator Young. Well, thank you, and I agree with you. I 
think sometimes we come up with fancy names for things that 
have been around a while. I guess this is forecasting, and we 
ought to apply it to this field to improve the lives of our 
children. So thank you.
    With my remaining time, I'm going to ask you about 
reporting, sometimes a boring issue, but if you don't have 
clarity about an issue and there's not proper reporting, you 
don't really have a clear picture of what's going on and 
oftentimes a solution is poorly targeted. So nearly 11,000 
children entered the foster care system in Indiana in fiscal 
year 2016, with at least 58 percent of these children entering 
care because of parental substance abuse.
    However, both experts and child welfare agencies believe 
this percentage to be underestimated. Nancy K. Young of 
Children and Family Futures said in a 2016 Senate Finance 
Committee hearing, ``Not a single state believes these data 
accurately reflect their experience and tell us that these 
numbers greatly understate the vast majority of cases in which 
a child is placed in protective custody related to parental 
substance use disorders.''
    I guess--I've got about 15 seconds left, and I, too, want 
to be respectful of my colleagues. Yes or no, do we know the 
full extent substance use disorders are associated with the 
number of children being placed in the foster care system?
    Dr. Bell. No, we don't, but we can.
    Senator Young. Thank you.
    Dr. Bell. We can correspond on that.
    Senator Young. I look forward to that.
    The Chairman. Thank you, Senator Young.
    Senator Warren.
    Senator Warren. Thank you, Mr. Chairman.
    The Massachusetts Department of Health recently released 
some astonishing data about the impact of the opioid crisis in 
our state. They wanted to better understand the relationship 
between pregnancy and overdose. So they linked up a lot of data 
bases around the state to track the records of mothers who gave 
birth and then also died in a 4-year period between 2011 and 
2015. They found something that was really heartbreaking. For 
four out of every 10 women in this group, the cause of death 
was opioid overdose.
    During the same time period, our foster care system grew by 
19 percent across the state. About 10,000 grandparents are now 
primary caregivers for their grandchildren, grandchildren who 
have often landed in their grandparents' arms because of this 
crisis. Now, this crisis isn't just about the lives that are 
lost. It is also about the struggle of those who have to cope 
when lives are lost.
    Dr. Bell, you're an expert in the foster care system. When 
a parent dies from an opioid overdose, what kind of financial 
impact does it have on a child?
    Dr. Bell. I would start by just referring to ACEs, and one 
of the leading ACEs as documented through Child Trends is 
separation from a parent--death, loss of a parent. When a 
parent dies, that is a traumatic experience for a child that 
lasts throughout a lifetime, and the result of that is loss of 
finances, loss of this role model who was there for them, loss 
of this protector, this chief advocate, and our systems have to 
be designed to focus on how do we replace those lost elements 
of that child's development.
    Senator Warren They lose the emotional support. They lose 
the financial support. Let's fast-forward to when the child is 
18 years old. In about half of our states, foster care ends at 
age 18. So if a child stayed in foster care, they'll be aging 
out just about the time they finish high school. If a child 
ended up, say, with their grandparents after the death of a 
parent from an opioid overdose, those grandparents may be in 
their 70's by that point, maybe older, living on a fixed 
income.
    Dr. Bell, at age 18, do youth who have lost a parent face 
financial burdens in continuing their education?
    Dr. Bell. They absolutely do, and far too many of them do 
not complete their post-high school education, and far too many 
don't even complete their high school education.
    Senator Warren. One of the ways that we try to take care of 
kids who have lost a parent is through the Social Security 
system. When a working parent dies, the child is eligible for 
Social Security survivor benefits, which are designed to help 
out in these kinds of tragic circumstances.
    Until a couple of decades ago, Social Security survivor 
benefits were available for a child until they were 22, if they 
were full time students. In 1981, Congress changed the rules 
and cut the benefits off at 18, even for students.
    The Bipartisan Policy Center, a group of both Democrats and 
Republicans, has recommended restoring eligibility up to age 
22.
    Now, Dr. Bell, the average size of these benefits is about 
$820 a month. Is that enough money to make a difference for 
these young people?
    Dr. Bell. Given the cost of living, it clearly is not. But 
I would say to you that there are a number of possibilities 
that we need to work on putting together to actually deal with 
this issue, because I don't believe that there's any single 
avenue that will solve this challenge that we're talking about.
    Senator Warren. But will it help us push in the right 
direction?
    Dr. Bell. If we combine it with many other things that are 
possible, absolutely. And this is definitely a conversation I 
would love to be able to continue with you, because I think 
that it's pointing in a direction that we must go in.
    Senator Warren. Good, and I think that's important. You 
know, as Ms. Savage testified, the opioid epidemic is not fair 
to anyone, and too many kids are also left to deal with the 
emotional and economic costs of losing a parent. We could make 
a common sense change to Social Security survivor benefits. It 
won't solve every problem, but it certainly moves us in the 
right direction, and I think the least we could do is restore 
benefits up to age 22 for full time students so that these 
young people who are eligible for benefits could have a little 
bit better lifetime chances going forward. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren.
    The vote has started, but we should have time for Senator 
Smith and then Senator Hassan to ask their questions.
    Senator Smith.
    Senator Smith. Thank you very much, Chair Alexander and 
Ranking Member Murray.
    I'd like to start out by talking about what is actually an 
urgent need for immediate action on a program that provides 
health coverage to Minnesotans, about 100,000 Minnesotans, 
including coverage for the treatment and recovery for exactly 
what we're talking about today. So in Minnesota, we have 
something called a basic health plan. It's called MinnesotaCare 
at home, which serves as a lifeline for working families. It 
offers low-cost comprehensive health coverage for people who 
make too much to qualify for Medicaid, but simply can't afford 
health coverage on the private market.
    Yet, unfortunately, recent actions by the administration 
have jeopardized the long-term stability of this program and is 
putting MinnesotaCare coverage at risk for families. So, 
actually, in total, my state stands to lose $800 million in 
Federal funding for MinnesotaCare, which is a big blow.
    I want to thank Chair Alexander and Ranking Member Murray 
and all the Members of this Committee for working with me to 
reverse these cuts.
    I'm really hoping and counting on a bipartisan effort to 
stabilize this market and to help us in Minnesota who count on 
this, because it relates directly to what we're talking about 
today, the need to not only recognize a desperate public health 
crisis, but also have the resources to provide treatment and 
recovery to people who need it. So I want to thank you for the 
opportunity to just mention that, and we'll just turn to a 
question.
    Ms. Savage, I'm so grateful for you being here today. I'm a 
mother of two sons. I have also sat around tables in coffee 
shops in Minnesota and talked to moms, I want to say with 
similar stories, but every single one of these situations is a 
unique tragedy, and I want to recognize that.
    Ms. Savage. Thank you.
    Senator Smith. I've talked to a lot of parents and teachers 
and school officials in Minnesota about this epidemic, and I 
hear a lot about the need to strengthen mental health systems 
in our schools and especially the mental health workforce. It's 
kind of like an early warning system in schools. In Minnesota, 
we have done some unique things to try to strengthen this link 
between schools and community health providers, and it's a big 
problem. I'm actually working with Senator Murkowski on a way 
of making this work better.
    But I'd be really interested to hear from your 
perspective--you've spent a lot of time in schools--how you 
think a stronger mental health system in our public schools 
would help with this.
    Ms. Savage. Well, I think any time you can strengthen 
anything in the school system, it's a good thing, and mental 
health being no different with that. I know that a lot of 
students who maybe do have some substance abuse issues, it's 
because of a mental health issue as well. So I think if you can 
strengthen that, you might be able to help on the other aspect 
of this addiction process as well.
    Senator Smith. Right. Thank you very much.
    I want to ask a follow-up question--this is to Dr. 
Patrick--around this question of family based treatment and how 
that might work. Last week, I had a chance to meet with some 
representatives from Minnesota Head Start providers, and they 
were telling me about what pressure it has put on the Head 
Start system--this opioid public health emergency that we have. 
They said we literally do not have enough arms to hold the 
infants that need to be held because of what's happening.
    I'm wondering if you could talk a little bit about how we 
might use existing systems like Head Start to help support 
families, parents and children who are dealing with neonatal 
abstinence syndrome.
    Dr. Patrick. Thank you for the question. I think it 
actually begins before--it begins with a comprehensive approach 
that includes prevention and bolstering prevention early on, 
well before pregnancy. But as far as our existing resources to 
engage the family, I think many of the things that have been 
said, including by Dr. Bell a bit ago, in terms of having a 
more proactive child welfare system that can engage families 
holistically and utilize and coordinate some of those resources 
from child welfare, early intervention, throughout the 
continuum of care--I think that's really vital.
    Senator Smith. Thank you very much.
    The Chairman. Thank you, Senator Smith, and thank you for 
your remarks about the Minnesota Healthcare plan. Senator 
Murray and I are working on a way to lower insurance rates that 
would specifically solve that problem, and I hope we can finish 
that work promptly.
    Senator Smith. I appreciate that very much.
    The Chairman. Senator Hassan.
    Senator Hassan. Thank you very much, Mr. Chair and Ranking 
Member Murray.
    To our panelists, thank you for your work and for your 
patience and attention this morning.
    Before we start, I do want to address the bipartisan 
funding agreement that the Senate reached yesterday to 
significantly increase Federal funding to combat the opioid 
crisis, which is an important next step in strengthening our 
response to this epidemic. These new dollars need to be 
prioritized for states like my own, New Hampshire, which has 
been terribly and disproportionately hit by this crisis, and 
I'm going to continue to work with my colleagues to ensure that 
happens.
    We also know that we will ultimately need far more funding 
beyond this measure over the years to come to truly address 
this crisis. So there are a number of us here this morning who 
will continue to fight to do that.
    I want to thank the leadership of this Committee, because I 
think they have assembled an extraordinary panel. You all 
represent really the full scope of this terrible epidemic, the 
individual loss, and the lives changed forever as a result of 
the long-term effects for our next generation that both Dr. 
Patrick and Dr. Bell are talking about as well.
    Ms. Savage, as I heard your testimony, I was reminded of 
the experience of two granite staters, Jim and Jeanne Moser, 
who lost their 26-year-old son, Adam, in a somewhat similar 
experience to what you described with your sons. One of the 
steps they've taken is called the Zero Left campaign, and I 
take it from your nodding that you know a little bit about it. 
Would you like to address it?
    Ms. Savage. Yes. It's a wonderful campaign that I actually 
just became familiar with. Jim has reached out to our 
organization about perhaps partnering with it to kind of help 
spread what they're trying to do. What it is--it's Zero Left, 
and it's a campaign to try to get people to clean out their 
closets and their medicine cabinets to leave zero left behind. 
They also have safety disposal for prescription medications 
that they can put them in a pouch and mix it with water, and it 
disposes of the prescription medication. So it's a wonderful 
campaign.
    Senator Hassan. Yes, and they're working with five 
hospitals in our state, so that when a doctor prescribes an 
opioid, they're given that pouch along with a warning about the 
impact that--even though legally prescribed--drugs can have. So 
I'm glad you guys have connected. It's a real example of the 
work that so many families are doing to try to prevent this 
from happening to anyone else. So thank you.
    Dr. Bell, last week, I was honored to have a woman named 
McKenzie Harrington-Bacote join me as my guest for the state of 
the Union. McKenzie works as the program administrator for the 
Office of School Wellness in the Laconia School District in New 
Hampshire. That office focuses on preventing substance misuse 
and addressing students' all around behavioral health and 
wellness. Laconia has been very hard hit by the epidemic, and 
the schools are really working with Federal funds to stem the 
tide. They have seen a great improvement in student well-being 
by providing kids with counseling, meals, and other supports so 
that they are better able to learn, engage in the classroom, 
and cope with challenges at home.
    Dr. Bell, you have worked with school age children your 
entire career. Can you speak to what more schools should be 
doing to help facilitate student well-being, especially in 
schools where children may be exposed to substance misuse in 
their homes or communities, and how can we here in Congress 
support those efforts?
    Dr. Bell. Thank you, Senator, for the question. You know, I 
think schools have always been and should continue to be a core 
frontline institution in whatever ailments we are challenging 
in our communities, and I think particularly with the opioid 
crisis, the school can become a very safe haven for young 
people.
    But as we know, there's a lot going on in our schools, and 
that means that we've got to change our approach that we're 
taking. I think that we need to focus less on the policing that 
we're doing in our schools and more on the protecting, and that 
we need to have conversations with the community, and that our 
schools should not close down at 3 o'clock. The schools have to 
become that school-based community center where our children 
and our families can go to get protection, to be safe, and to 
learn how to protect their lives and to improve the conditions 
that they're living in, and I think there's much more that we 
can do in that area.
    Senator Hassan. Well, I thank you, and to both you and Dr. 
Patrick, one of the things you've both been talking about is 
the importance of integrated care and services and prevention 
that can come with that kind of integrated service. In my 
experience as a Governor, it takes resources to actually 
coordinate and integrate things. You can't just kind of say 
it's a good thing. So there are a number of us here, myself 
included, who will be fighting to get you guys on the front 
lines those kinds of resources. We are so grateful for your 
work.
    Thank you, Mr. Chair.
    The Chairman. Thank you, Senator Hassan.
    Senator Jones, have you voted yet?
    Senator Jones. Not yet. But I just have one quick question 
for Ms. Savage and we can move on, if that's Okay. This won't 
take but a second.
    The Chairman. Sure.
    Senator Jones. Ms. Savage, I appreciate your testimony, and 
as a lawyer before I came here, I had clients that had issues, 
similar issues, and I saw the devastating--but one of the 
things that I would like to talk about as opposed to the money 
and the legislation--you mentioned the community pill drop. I 
think Senators can also use their positions as community 
engagement.
    Just briefly, I'd like to know just a little bit more about 
what you did, how you put that together, so that perhaps in 
Alabama we can go back and try to organize that. We don't have 
much time, so I apologize.
    Ms. Savage. I'll be quick. What we did is we worked with a 
lot of other community coalitions, and we organized a pill 
drop, where we picked a Saturday, and we got DEA approval, and 
we manned five different locations across our community from 10 
o'clock to 2 o'clock p.m. And in those 4 hours is where we had 
picked up those 500 pounds of pills.
    Senator Jones. Did you advertise that?
    Ms. Savage. We advertised it, and we had--through Facebook, 
and the local media picked it up and advertised that, and it 
was just a constant flow of traffic coming through. We went 
through the fire department, the stations. They would pull in. 
They would hand out their pills in little Ziploc baggies that 
we asked that they bring them in, and they put them in a box, 
and then they would drive through.
    Senator Jones. Well, that was just briefly it, Mr. 
Chairman. I wanted to hear a little bit about that. I 
appreciate your indulgence on that. And I look forward to 
hearing back from you.
    Ms. Savage. Thank you.
    The Chairman. Thank you, Senator Jones, and you're welcome 
to supplement that answer, any of you.
    Thanks to all of you. We need to go vote, and I'm going to 
wind up the hearing. But this, as you can tell, has been a very 
helpful hearing, and we respect and appreciate the effort that 
each of you has made to come.
    I would ask unanimous consent that the statement by Senator 
McConnell be submitted into the record.
    [The prepared statement of Senator McConnell follows:]
                prepared statement of senator mcconnell
    Mr. Chairman, Ranking Member Murray, Fellow Senators:
    In Kentucky and across our Nation, the scourge of opioid abuse 
continues to devastate communities and tear families apart. One of the 
most heartbreaking aspects of this crisis is the increasing number of 
infants born dependent on opioids. These infants are the most innocent 
among us, and it is heartbreaking to learn that so many start off their 
life suffering from drug dependency.
    Last May, I shared an article on the Senate floor entitled ``A 
Generation of Heroin Orphans.'' It told the story of a Kentucky family 
with a single-mother who was suffering from heroin addiction and the 
five young children were sent to live with their grandparents. The 
youngest of the children--twins--were born addicted to heroin. Because 
of the incredible love and care from their grandparents, these five 
children are now going to school and living happy lives. However, this 
is not always the case for the nearly 70,000 kids in Kentucky who live 
with their relatives because their parents are struggling and with 
addiction and are unable to care for them.
    Heartbreaking stories as a result of opioid abuse are too common 
across the United States. Through strong bipartisan efforts, we have 
passed significant laws to help fight back--including the Protecting 
Our Infants Act (POIA), the 21st Century Cures Act, the Comprehensive 
Addiction and Recovery Act, and most recently the Senate-passed 
Jessie's Law. As the Members of this Committee know, the opioid 
epidemic cannot be solved by a single program or piece of legislation. 
But by building upon our successful efforts we can continue to make a 
real difference in the lives of those who need it most.
    Today, I would like to focus on one law that is of particular 
importance to me and relates to the topic of today's hearing. In 2015, 
I was proud to sponsor and lead to enactment the bipartisan POIA. The 
POIA aims to prevent prenatal exposure to opioids, to treat infants 
born with opioid withdrawal, and to improve the states' public health 
response to this problem. Specifically, it instructed the Secretary of 
Health and Human Services to develop a comprehensive strategy to 
address gaps in research and programs. Further, it directed the 
Secretary to develop recommendations for preventing prenatal opioid 
abuse and treating infants born dependent on opioids. After working 
with my colleagues to challenge Federal agencies to meet timelines 
established by the POIA, I was proud to see these recommendations 
published last year.
    I am extremely proud that POIA became the first Federal law to 
address prenatal opioid exposure, and I thank my colleagues for joining 
me in the effort to see it signed into law.
    To address a complex issue like the opioid epidemic, it is critical 
that the Federal Government continues to collaborate with states, 
communities, and localities to find comprehensive solutions through 
prevention, treatment, and law enforcement efforts. Earlier this week, 
during her trip to Cincinnati, First Lady Melania Trump visited the 
Children's Hospital Medical Center to spend time with patients 
suffering from the consequences of opioid abuse. Her visit, in addition 
to providing comfort and support to the children, brings national 
attention to the struggles of some of our youngest and most vulnerable 
citizens.
    I would like to thank Chairman Alexander and Ranking Member Murray 
for holding this important hearing today to focus on how this epidemic 
has specifically affected children and families, and I commend them for 
their continued work in this space. By continuing to fight the opioid 
epidemic, we can help those suffering from its effects. I will continue 
working with my colleagues in this effort to help make the scourge of 
opioid abuse a thing of the past.
                                 ______
                                 
    The Chairman. The record will remain open for 10 days. 
Members may submit additional information for the record within 
that time if they'd like. Our Committee will meet again on 
Tuesday, February 13, at 10 a.m. for a hearing entitled 
Improving Animal Health: Reauthorization of FDA Animal Drug 
User Fees.
    Thank you for being here today. The Committee will stand 
adjourned.

                          ADDITIONAL MATERIAL

        THE AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS

    Chairman Alexander, Ranking Member Murray, and 
distinguished Members of the Senate Committee on Health, 
Education, Labor and Pensions, thank you for the opportunity to 
submit written testimony in response to your February 8, 2018 
hearing titled ``The Opioid Crisis: Impact on Children and 
Families.'' The American College of Obstetricians and 
Gynecologists (ACOG), representing more than 58,000 physicians 
and partners dedicated to advancing women's health, appreciates 
the thoughtful way that the Committee is approaching this 
sensitive topic. I hope you will view ACOG as a resource and 
trusted partner as you continue to examine this important 
issue.

    As ACOG's Executive Vice President and Chief Executive 
Officer, I am keenly aware of the increase in opioid dependence 
and its impact on our patients and their families. My testimony 
will focus on the need for greater access to evidence-based 
treatment for pregnant and parenting women and the importance 
of family preservation.

    The instance of opioid use disorder has risen dramatically 
over the past few years, including among pregnant and parenting 
women. The unplanned pregnancy rate among women with an opioid 
use disorder is 86 percent, a number that far surpasses the 
national average of 45 percent. \1\ This speaks to the need for 
increased access to contraception among women with opioid use 
disorder, as well as the fact that many of these women did not 
intend to be pregnant.
---------------------------------------------------------------------------
    \1\  Heil S, Jones H, Arria A, et al. ``Unintended pregnancy in 
opioid-abusing women.'' J Subst Abuse Treat. 2011 Mar, 40(2): 199-202.

    During pregnancy, most women who use substances, including 
opioids, are motivated to change unhealthy behaviors and quit 
or cut back. Those who cannot stop using have a substance use 
disorder. In other words, continued substance use in pregnancy 
is a characteristic of addiction, a chronic, relapsing brain 
---------------------------------------------------------------------------
disease.

    Evidence-based treatment for pregnant and breastfeeding 
women with substance use disorders includes the use of 
medication-assisted treatment (MAT) such as methadone and 
buprenorphine. MAT is the recommended therapy for treating 
pregnant women with opioid use disorder, and is preferable to 
medically supervised withdrawal, which is associated with 
higher relapse rates and poorer outcomes, including accidental 
overdose and obstetric complications. Use of MAT also improves 
adherence to prenatal care and addiction treatment programs. 
MAT, together with prenatal care, has been demonstrated to 
reduce the risk of obstetric complications. Neonatal abstinence 
syndrome (NAS) is an expected and treatable condition that can 
follow prenatal exposure to opioids, including MAT. \2\
---------------------------------------------------------------------------
    \2\  Opioid use and opioid use disorder in pregnancy. Committee 
Opinion No. 711. American College of Obstetricians and Gynecologists. 
Obstet Gynecol 2017;130:e81--94.

    Tragically, overdose and suicide are now the leading causes 
of maternal mortality in a growing number of states. \3\, \4\ 
Threats of incarceration, immediate loss of child custody, and 
other potential punishments drive pregnant and parenting women 
away from vital prenatal care and substance use disorder 
treatment. Non-punitive public health approaches to treatment 
result in better outcomes for both moms and babies. Immediately 
postpartum, women who bond with their babies, including via 
skin-to-skin care and breastfeeding, are more likely to stay in 
treatment and connected to the health care system. Further, 
breastfeeding is associated with decreased severity of NAS 
symptoms and reduced length of hospital stay for the newborn. 
\5\ Substance use disorder treatment that supports the family 
as a unit has proven effective for maintaining maternal 
sobriety and child well-being.
---------------------------------------------------------------------------
    \3\  Metz TD, Rovner P, Hoffman MC, Allshouse AA, Beckwith KM, 
Binswanger IA. Maternal deaths from suicide and overdose in Colorado, 
2004--2012. Obstet Gynecol 2016;128:1233--40.
    \4\  Maryland Department of Health and Mental Hygiene Prevention 
and Health Promotion Administration. Maryland Maternal Mortality 
Review: 2016 Annual Report. Retrieved from http://healthymaryland.org/
wp-content/uploads/2011/05/MMR--Report--2016--clean-copy--FINAL.pdf
    \5\  Klaman SL, Isaacs K, Leopold A, Perpich J, Hayashi S, Vendor 
J, Campopiano M, Jones HE. Treating Women Who Are Pregnant and 
Parenting for Opioid Use Disorder and the Concurrent Care of Their 
Infants and Children: Literature Review to Support National Guidance. J 
Addic Med 2017;11(3):178-190.

    However, in 2015 the Government Accountability Office (GAO) 
found that ``the program gap most frequently cited was the lack 
of available treatment programs for pregnant women. . .'' \6\ 
In 2017, the GAO again cited barriers faced by pregnant women 
with opioid use disorder, including ``the stigma faced by women 
who use opioids during pregnancy'' and ``limited coordination 
of care for mothers and infants with NAS,'' making it 
``difficult for families to get the resources or support they 
need.'' \7\
---------------------------------------------------------------------------
    \6\  U.S. Government Accountability Office. (2015, February). 
Prenatal Drug Use and Newborn Health: Federal Efforts Need Better 
Planning and Coordination. (Publication No. GAO-15-203). Retrieved from 
http:/www.gao.gov/products/GAO-15-203.
    \7\  U.S. Government Accountability Office. (2017, October). 
Newborn Health: Federal Action Needed to Address Neonatal Abstinence 
Syndrome. (Publication No. GAO-18-32). Retrieved from https://
www.gao.gov/assets/690/687580.pdf.

    As the Committee considers approaches to improve outcomes 
and mitigate the impact of the opioid crisis on children and 
---------------------------------------------------------------------------
families, we urge you to consider the following:

         LThe need for the US Senate to pass S. 1112, 
        the Maternal Health Accountability Act, introduced by 
        Senators Heitkamp (D-ND) and Capito (R-WW) to assist 
        states with the creation or expansion of maternal 
        mortality review committees (MMRCs). Urgent action is 
        needed to bring down the rising maternal mortality rate 
        in the United States. States with MMRCs bring together 
        local health care professionals to review individual 
        maternal deaths and recommend specific ways to prevent 
        future deaths. MMRCs are critical tools to 
        understanding why women die related to pregnancy, 
        including those linked to opioid overdose, and 
        identifying opportunities for prevention.

         LThe need for increased access to residential 
        and nonresidential treatment options for pregnant and 
        parenting women with opioid use disorder. Section 501 
        of the Comprehensive Addiction and Recovery Act (CARA; 
        Public Law 114-198) authorized funds to increase access 
        to out-patient treatment options that are responsive to 
        pregnant and parenting women's complex 
        responsibilities, often as the primary or sole 
        caregivers for their families. Ensure this program 
        receives adequate funding to improve access for all 
        women seeking treatment.

         LThe Protecting Our Infants Act: Final 
        Strategy, created pursuant to Public Law 114-91, made 
        several recommendations to address gaps in research; 
        gaps, overlaps, or duplication in relevant Federal 
        programs; and coordination of Federal efforts to 
        address neonatal abstinence syndrome (NAS) with 
        recommendations regarding maternal and child 
        prevention, treatment, and services. The October 2017 
        GAO report made one recommendation: to implement the 
        Strategy. \8\ However, the Strategy includes a 
        disclaimer that ``full implementation will be 
        contingent upon funding.'' \9\ Congress should direct 
        Federal funds to ensure full implementation of the 
        Protecting Our Infants Act: Final Strategy.
---------------------------------------------------------------------------
    \8\  Ibid.
    \9\  Protecting Our Infants Act: Final Strategy. Submitted by the 
Behavioral Health Coordinating Council Subcommittee on Prescription 
Drug Abuse. Retrieved from https://www.samhsa.gov/sites/default/files/
topics/specific--populations/final-strategy-protect-our-infants.pdf

         LCritical gaps in public and private insurance 
        coverage lead to gaps in care or discontinuation of 
        treatment. Women receiving pregnancy coverage through 
        Medicaid or the Children's Health Insurance Program 
        (CHIP) may lose their access to MAT weeks after giving 
        birth, during a particularly vulnerable time when 
        relapse risk increases if treatment is not continued. 
        Further, continued and improved coverage is needed for 
        nonpharmacological pain relief, and should include 
        transportation and childcare options for women seeking 
        treatment. Explore coverage policies that ensure 
---------------------------------------------------------------------------
        continued access to treatment for women postpartum.

         LFacilitate better collaboration between 
        health care providers and the child welfare system in 
        responding to the rise of opioid use disorder among 
        pregnant and parenting women and NAS. This epidemic is 
        increasingly leading to children being placed in 
        kinship care or foster care homes. State child welfare 
        agencies do not currently have the resources necessary 
        to address the impact of this epidemic on families. Our 
        shared priority is that infants born to families 
        struggling with opioid use disorder have safe homes, 
        and that the family unit is preserved when possible.

            LSection 503 of CARA added requirements for 
        states to develop plans of safe care for infants born 
        with NAS. Unfortunately, those requirements came 
        without resources for implementation or clear guidance, 
        and may unintentionally lump together women who use 
        illicit substances with those in active treatment or 
        with a current valid prescription. States need 
        additional guidance, funds, and resources from the 
        Federal Government to ensure infant safety and to keep 
        families intact when appropriate.

            LAdvance S. 1268, the Child Protection and 
        Family Support Act introduced by Senators Daines (R-MT) 
        and Peters (D-MI) to expand access to treatment 
        services for vulnerable families while helping them 
        stay together and heal. Unfortunately, our current 
        system too often relies on punitive approaches that 
        deter women from seeking treatment and places children 
        in foster care when they could safely remain at home 
        with the appropriate treatment and support services.

            LReauthorize the Maternal, Infant, and 
        Early Childhood Home Visiting (MIECHV) program that 
        serves at-risk families via evidence-based programs 
        with goals to improve maternal and child health, 
        prevent child abuse and neglect, and encourage positive 
        parenting. Home visiting programs are an important tool 
        as we work toward ensuring safe homes and family 
        preservation.

         LImprove access to primary care and the full 
        range of contraceptives with no cost sharing for women 
        with opioid use disorder, to drive down the high rate 
        of unplanned pregnancies in this group as well as the 
        rate of babies born with NAS. Advance S. 1985, the 
        Protect Access to Birth Control Act introduced by 
        Ranking Member Murray to ensure continued access to 
        coverage for women with private insurance.

         LPromote research into pharmacological and 
        nonpharmacological treatments for both pregnant and 
        breastfeeding women with opioid use disorder; non-
        opioid pharmacotherapies for pain management for women, 
        including pregnant women; and both pharmacological and 
        nonpharmacological treatments for newborns with NAS.

    Thank you again for the opportunity to submit written 
testimony, and for your thoughtful approach to this issue. We 
look forward to working closely with you and the Committee as 
you consider additional strategies to address the impact of the 
opioid crisis on children and families. I hope that you will 
consider ACOG a trusted partner and will let us know if we can 
provide any additional assistance.
                                ------                                


              TESTIMONY OF THE PORT GAMBLE S'KLALLAM TRIBE

         ``The Opioid Crisis: Impact on Children and Families''

    The Port Gamble S'Klallam Tribe (PGST) provides these 
comments for the record for the Committee's hearing held on 
February 8, 2018, entitled, ``The Opioid Crisis: Impact on 
Children and Families.'' We look forward to further 
opportunities for discussion on this important topic and invite 
the Committee to contact us with any follow-UP questions.

    PGST is a federally recognized, self-governing tribe owning 
100 percent of its reservation lands. We are located on the 
northern tip of the Kitsap Peninsula in Kitsap County 
Washington. The PGST Reservation is home to about two-thirds of 
the Tribe's 1,200 enrolled members, and the Tribe also provides 
services to approximately 800 other American Indians, Alaska 
Natives and non-Indians living on the reservation in Kitsap 
County.

    PGST is actively involved in providing culturally 
appropriate care, as the only Indian health care provider of 
both primary and behavioral health services in Kitsap County. 
The Tribe joined the Tribal Self-Governance Project in 1990 and 
has administered health services to its members for over 20 
years. The Tribe provides primary care, dental, mental health 
and substance abuse services. Over 98 percent of clients served 
by behavioral health are served by primary care also.

    In Washington State, Indians die of drug overdoses at a 
rate of 29 in 100,000, compared to a rate of 12 for whites. The 
opioid epidemic is devastating to families and children in our 
Tribal community. This is a real and heartbreaking crisis for 
the Tribe. We have had numerous overdoses and deaths in our 
community as a result of the opioid crisis, and not only from 
the vast supply available on the black market. The deaths 
include members who were prescribed opioids as pain medication 
and accidentally overdosed. In just the past few months we had 
an overdose by a young mother and the death of a toddler, just 
2 years old, who got into his parents' opioid medication. We 
have grieving parents, grandparents, and great-grandparents who 
have lost children due to this scourge. It would be hard to 
find a family on our reservation that has not been impacted by 
this epidemic.

    Since January 1, 2018, the Tribe has filed four new 
dependency cases, all but one was related to opioid abuse. 
These new cases are in addition to the open dependency cases on 
which the Tribe had already filed. Significantly, this is more 
cases than what we filed the entire year of 2017.

    Our Children & Family Services Department's mission is to 
enhance the quality of life of our members and their families 
through a culturally sensitive approach, which encourages 
living a healthy lifestyle and promotes self-sufficiency. Our 
Department has two divisions: the Behavioral Health Division 
and the Community Services Division. Our Department offers a 
wide range of services and partners with Behavioral Health to 
address the opioid epidemic in our community. We use a wrap-
around service approach and tailor a service plan for each 
family to meet its specific needs. These service plans include, 
among other things, treatment, parenting, and counseling. Our 
Department also offers prevention services to avoid court 
involvement and the removal of the children from their family 
home. If removal of a child from the home is necessary, 
placement is often an issue. We have a large number of 
relatives as placements as well as 20 Tribal licensed homes, 
but with the increased number of dependencies, we often 
struggle to find homes for the children. Opioid abuse impacts 
the whole family. Our Tribal member grandparents are often 
raising their grandchildren. In addition to this role, they are 
also often struggling with their child who is involved with the 
addiction.

    The opioid crisis is overwhelming to our law enforcement 
and social services as they are not presently resourced 
sufficiently to meet the needs arising from opioid epidemic. We 
are working as hard and as efficiently as we can with the 
resources we have, but additional resources in terms of 
funding, personnel and authorities would go a long way in our 
efforts to combat the myriad problems the opioid crises causes. 
Opioid use disorder is a complex issue, and there is no quick 
and easy fix for resolving the problem. Rather, we need a 
multifaceted, comprehensive approach with tactics that work.

    Importantly, PGST is taking important steps to address the 
opioid epidemic. Our Tribe launched a Tribal Healing Opioid 
Response (THOR) to coordinate a cross-governmental approach to 
combat the crisis. We joined a tri-county group to strengthen 
collaboration with partners in the community to implement our 
plan that is focused on effective treatment, harm reduction, 
prevention, and reducing the role of criminalization. The goal 
is to address increasing rates of opioid dependence, overdose, 
and other negative consequences stemming from opioid use. More 
information about THOR is attached in a one-page briefing paper 
and in an article published in our tribal newspaper.

    PGST is particularly interested in initiating a pilot 
program for residential post-treatment facilities. PGST would 
like to provide treatment and support past the prevailing 28-
day model, utilizing evidenced-based practices with a robust 
evaluation component. PGST has partnerships with Oxford House 
and Habitat for Humanity, and is well positioned to start such 
a pilot program.

    Culturally appropriate care is of critical importance to 
Indian Country, where traditional healing practices, cultural 
beliefs regarding approaches to treatment, and differences in 
interpersonal communication may contribute to significant 
variances in effectively meeting the healthcare needs of 
American Indian/Alaska Native populations.

    Prevention is the cornerstone for any opioid response, as 
The Surgeon General's Report on Alcohol, Drugs and Health 
(November 2016) noted. The PGST prevention team has numerous 
programs that focus on youth and using evidenced-based 
approaches to keep youth active in the community. PGST also 
provides education to the community and to the providers 
treating pain, with a focus on treating pain with non-opioid 
medications. Currently, however, prevention funding is grant 
based and administratively burdensome. A more streamlined 
approach with direct funding would benefit the prevention 
efforts. We strongly encourage Congress to provide direct 
funding to Tribes and ensure that any additional funds for 
opioids does not decrease services in other areas.

    We appreciate Congress's inclusion of authorization for $6 
billion over 2 years for opioid efforts in the recently passed 
Bipartisan Budget Act of 2018. We ask that you work to make 
sure Congress appropriates this full amount. We also urge 
Congress to ensure that these moneys make their way directly to 
tribal governments for them to spend in their own communities. 
Such funds should not be passed through the state. We also ask 
you to support S. 2270, the Mitigating the Methamphetamine 
Epidemic and Promoting Tribal Health Act, which would increase 
funding in the 21st Century Cures Act, and specifically make 
tribes and tribal organizations eligible applicants for direct 
funding under the Act. Additionally, we ask you to work toward 
providing sufficient funding to the Indian Health Service (IHS) 
for opioid treatment and prevention.

    We also want to point out certain other barriers to our 
efforts to combat the opioid crisis. Current regulations 
require providers of medication-assisted treatment (MAT) to 
apply for waivers even though no such limitation exists on 
providers prescribing opioids. This creates barriers to 
accessing MAT. Medicaid dollars used to fund transportation to 
opioid services could be reduced significantly if buprenorphine 
was easier to access at primary care facilities. Those saved 
funds could be used for prevention or treatment. In addition, 
nurse care management as an adjunct to MAT has been shown to be 
successful and is an evidenced based practice in treating 
opioid addiction. We need to expand tribes' access to this 
treatment.

    Two longstanding areas of concern across the IHS are the 
limited funding for construction of new Indian health care 
facilities and the need to modernize the IHS's health 
information system. Both of these issues impact the ability of 
tribes to confront the opioid epidemic. PGST is actively 
working to align substance use disorder treatment with primary 
care to address a person's overall health, rather than treating 
it as a substance misuse or a physical health condition alone 
or in isolation. Co-locating these services provides behavioral 
health integration. Yet, current estimates for a new facility 
for us for all health services is over $8 million dollars. 
Barriers to integration within the health information system 
are being addressed at significant cost to the PGST as we left 
the Indian Health Service RPMS system years ago.

    Thank you for the opportunity to provide comments for this 
important hearing. It will be through your dedication and that 
of your colleagues to ensure that sufficient resources and 
authorities are available to tribal governments, as well as to 
the Federal, state and local governments, to stop this scourge 
on our Nation and communities which takes such a heavy toll on 
our children and families.

    We look forward to working with the Committee to make sure 
the necessary tactics are implemented to combat the opioid 
crisis. Our THOR program is an example of one such tactic, and 
we invite you to visit our Tribe to learn more about it and 
other actions we are taking to do our part in the opioid fight. 
If you have any questions or would like to discuss this 
testimony, please contact our Tribal Chairman, Jeromy Sullivan.
                                ------                                


              THE PORT GAMBLE S'KLALLAM TRIBE THOR PROJECT

                 THOR = Tribal Healing Opioid Response

    THOR Logo was designed by Port Gamble S'Klallam Tribal 
member, Jeffrey Veregge.

    THOR Was developed to address opioid, specifically, heroin 
use on the reservation.

    THOR Team includes tribal departmental staff from the 
police, health, youth, behavioral health and H.R. and also 
Court staff and community members.

    Participants meet monthly to work to address the three 
goals of THOR

    Goals:

         LPrevent opioid misuse and abuse

         LExpand access to opioid use disorder 
        treatment

         LPrevent deaths from overdose

    To date the Health Department has started a needle exchange 
program thereby reducing infection risks and number of used 
needles being found in playgrounds and public areas on 
reservation.

    The Health Department also trains interested staff in the 
administration of Naloxone Hydrochloride Injection (NARCAN) to 
individuals who may be in an overdose.

    Behavioral Health not only provides chemical dependency and 
mental health counseling but also has a suboxone program and 
has tribal members utilizing methadone clinics as well.

    The Police Dept. has a secured medicine take back box that 
has seen increase use since it was first installed 5 months 
ago. The Police and Natural Resource Enforcement officers are 
trained to administer NARCAN.

    Tribal Council approved a Good Samaritan Law.

    Town hall meetings are held at least quarterly to educate 
the community on various topics but most recently, due to the 
rise in opioid use on reservation, the focus has been on opioid 
use. A NARCAN training was held for interested tribal members 
and over 120 tribal members were issued and trained on using 
NARCAN.

    For more information:

    Karol Dixon, Health Services Director, 360-297-9641 
[email protected]
    Jolene George, Behavioral Health Director, 360-297-9674 
[email protected]
    Kara Wright, Admin. Dir. Tribal Services, 360-297-6223 
[email protected]
    Sam White, Chief of Police, 360-297-9685 [email protected]
    Trisha Ives, Prevention Coordinator, 360-297-6276 
[email protected]

    THOR Sweatshirt Valued at $15.
    
    
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
       
                                ------                                

    [Whereupon, at 11:57 a.m., the hearing was adjourned.]

                                   