[Senate Hearing 115-383]
[From the U.S. Government Publishing Office]
S. Hrg. 115-383
OPIOIDS IN INDIAN COUNTRY: BEYOND THE CRISIS TO HEALING THE COMMUNITY
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HEARING
BEFORE THE
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
MARCH 14, 2018
__________
Printed for the use of the Committee on Indian Affairs
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COMMITTEE ON INDIAN AFFAIRS
JOHN HOEVEN, North Dakota, Chairman
TOM UDALL, New Mexico, Vice Chairman
JOHN BARRASSO, Wyoming MARIA CANTWELL, Washington
JOHN McCAIN, Arizona JON TESTER, Montana,
LISA MURKOWSKI, Alaska BRIAN SCHATZ, Hawaii
JAMES LANKFORD, Oklahoma HEIDI HEITKAMP, North Dakota
STEVE DAINES, Montana CATHERINE CORTEZ MASTO, Nevada
MIKE CRAPO, Idaho TINA SMITH, Minnesota
JERRY MORAN, Kansas
T. Michael Andrews, Majority Staff Director and Chief Counsel
Jennifer Romero, Minority Staff Director and Chief Counsel
C O N T E N T S
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Page
Hearing held on March 14, 2018................................... 1
Statement of Senator Barrasso.................................... 4
Statement of Senator Cantwell.................................... 35
Statement of Senator Cortez Masto................................ 27
Statement of Senator Daines...................................... 56
Statement of Senator Heitkamp.................................... 33
Statement of Senator Hoeven...................................... 1
Statement of Senator Lankford.................................... 23
Statement of Senator Murkowski................................... 4
Prepared statement........................................... 5
Statement of Senator Smith....................................... 25
Statement of Senator Tester...................................... 31
Statement of Senator Udall....................................... 2
Witnesses
Anderson, Hon. John C., U.S. Attorney, District of New Mexico,
U.S. Department of Justice..................................... 6
Prepared statement........................................... 8
George, Jolene, Behavioral Health Director, Port Gamble S'klallam
Tribe.......................................................... 35
Prepared statement........................................... 37
Jones, Captain Christopher, Pharm.D., M.P.H., Director, National
Mental Health and Substance Use Policy Laboratory, Substance
Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services........................ 10
Prepared statement........................................... 12
Moose, Samuel, Treasurer and Bemidji Area Representative,
National Indian Health Board................................... 47
Prepared statement........................................... 48
Toedt, Rear Admiral Michael, M.D., Chief Medical Officer, Indian
Health Service, U.S. Department of Health and Human Services... 15
Prepared statement........................................... 17
Appendix
Lucero, Esther, CEO, Seattle Indian Health Board, prepared
statement...................................................... 63
National Congress of American Indians (NCAI), prepared statement. 64
Response to written questions submitted by Hon. Heidi Heitkamp
to:
Stacy A. Bohlen.............................................. 93
Captain Christopher Jones.................................... 89
RADM Michael Toedt........................................... 92
Response to written questions submitted by Hon. Tom Udall to:
Stacy A. Bohlen.............................................. 82
Jolene George................................................ 80
Captain Christopher Jones.................................... 84
RADM Michael Toedt........................................... 90
Southcentral Foundation (SCF), prepared statement................ 69
Sullivan Hon. Jeromy, Chairman, Port Gamble S'Klallam Tribe,
prepared statement............................................. 67
Tanana Chiefs Conference (TCC), prepared statement............... 72
United South and Eastern Tribes Sovereignty Protection Fund (USET
SPF), prepared statement....................................... 75
Written questions submitted to Hon. John C. Anderson by:
Hon. Heidi Heitkamp.......................................... 95
Hon. Lisa Murkowski.......................................... 95
Hon. Tom Udall............................................... 94
OPIOIDS IN INDIAN COUNTRY: BEYOND THE CRISIS TO HEALING THE COMMUNITY
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WEDNESDAY, MARCH 14, 2018
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:30 p.m. in room
628, Dirksen Senate Office Building, Hon. John Hoeven,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. JOHN HOEVEN,
U.S. SENATOR FROM NORTH DAKOTA
The Chairman. I call this oversight hearing to order.
Today we will examine the opioid abuse crisis and its
effect on Indian Country.
On November 9, 2017, this Committee held a roundtable on
the opioid abuse epidemic in Indian Country. The roundtable
highlighted how the opioid abuse epidemic is particularly
complex in tribal communities given the lack of access to
medical care, shortage of law enforcement and insufficient data
on substance abuse. This hearing will build on that discussion
and examine how Congress, the Administration, tribes and tribal
organizations can work together to combat the crisis and heal
Indian communities.
The facts of the opioid abuse epidemic are tragic. Our
Country has witnessed an 18-year increase in deaths from
prescription opioid overdoses and a recent surge in illicit
opioid overdoses. According to the U.S. Centers for Disease
Control and Prevention, CDC, drugs now kill more Americans,
nearly 40 percent more, than car accidents.
Native American communities have been among those hit
hardest by the opioid abuse crisis. The Substance Abuse and
Mental Health Services Administration reports that the rates of
opioid abuse are consistently the highest among Caucasian and
Native peoples.
According to the CDC, in 2016, 4.1 percent of American
Indian and Alaska Natives age 12 and older reported opioid
misuse in the past year, similar to whites at 4.4 percent.
These statistics are serious, but they may not represent the
magnitude of the crisis in Indian Country, as the epidemic may
be underreported.
Many witnesses at the roundtable highlighted that Native
Americans are sometimes incorrectly classified as another race.
Without accurate data, Congress, the Administration and tribes
are limited in their ability to allocate resources to the area
of greatest need. The Committee is dedicated to engaging with
tribes and finding ways to advance the Federal Government's
role in combating the dangers that opioids and other substances
present to tribal communities.
The Indian Health Service has established the National
Committee on Heroin, Opioids, and Pain Efforts, the HOPE
Committee. The HOPE Committee has been tasked with promoting
appropriate and effective pain management, reducing overdose
deaths from heroin and prescription opioids and improving
access to culturally appropriate treatment. The IHS also now
requires all IHS Federal prescribers, contractors, clinical
residents and trainees to complete a course on treating pain
and addiction.
On March 29, 2017, President Trump signed an Executive
Order establishing the President's Commission on Combating Drug
Addiction and the Opioid Crisis. On October 26, 2017, the
President declared the opioid abuse crisis a national public
health emergency and one week later, the President's Commission
released its comprehensive final report.
The final report contains more than 50 recommendations to
agencies and to Congress. The Commission recommended that the
IHS remove reimbursement and policy barriers to substance abuse
treatment. Removing these barriers would help Native American
communities access much needed treatment. It is important to
begin implementing these recommendations. I look forward to
hearing from our witnesses on these and other efforts to find a
path toward healing for Indian communities.
Finally, I am also mindful that when Congress does
appropriate funding to combat this epidemic, it is important
that Indian Country receives an adequate share of the funding
and receives this funding in a manner that will ensure
maximized impact to their communities.
With that, I would like to welcome our witnesses. Thank you
for testifying today. I will now turn to our Vice Chairman,
Senator Udall, for his opening comments.
STATEMENT OF HON. TOM UDALL,
U.S. SENATOR FROM NEW MEXICO
Senator Udall. Thank you, Chairman Hoeven, for calling this
oversight hearing and continuing this Committee's work to
address the opioid crisis in Indian Country.
Before I begin my formal remarks, I would like to welcome
New Mexico's newest U.S. Attorney, John Anderson. Thank you,
John, for your testimony and hard work on behalf of DOJ and New
Mexicans. I look forward to working with you on some of these
important Indian Country issues.
Last November, we held a roundtable on this very same
issue. Tribal leaders and Native organizations joined us to
engage in a dialogue with agency officials from the Indian
Health Service, Department of the Interior, Department of
Justice, and the White House.
These participants brought with them a lot of good
information on the need for more treatment and prevention
resources, especially culturally-based services. We were
reminded that Congress must build in flexibility when making
these resources available.
Native communities require and deserve the right to design
behavioral health programs that suit local needs. Any
successful response to the opioid and substance abuse crisis in
Indian Country must be driven by the tribes. Congress must
support tribal efforts by holding Federal agencies accountable
and providing sufficient resources.
We are also working with our colleagues over at the Health
Education Labor and Pensions Committee. Just last week, at the
HELP hearing on State responses to the opioid crisis, three
Senators, Ranking Member Murray, Senator Warren and Senator
Smith, spoke about tribal opioid challenges and the need for
better State-tribal coordination.
As members of the Indian Affairs Committee, we are
obligated to educate our Senate colleagues about what is
happening on this Committee so that Indian Country's priorities
and the voices of tribal leaders are heard beyond these four
walls. When members work across committees to amplify tribal
needs, good things happen. The ideas we heard on addressing
Native substance abuse disorders at the roundtable resulted in
the introduction of S. 2437, the Opioid Response Enhancement
Act, a bill led by Senator Baldwin and joined by 15 Senate
colleagues, including myself and three other Indian Affairs
Committee members.
The legislation refines the 21st Century Cures Grant
Program to make tribes eligible to receive funds, provide
tribes with programmatic flexibility and includes a 10 percent
tribal setaside to further ensure that these funds actually
make it out to Indian Country. Last week, I joined a group of
ten Senators, led by Senator Heitkamp, on a letter to the
Appropriations Committee leadership outlining the dire need for
tribal-specific funding streams within the $6 billion in opioid
funding put in place as part of the recent budget cap
agreement.
Finally, just this morning, I joined Senator Smith and four
other colleagues to introduce the Native Behavioral Health
Access Improvement Act. Modeled after the Special Diabetes
Program for Indians, this legislation would create a special
behavioral health program for Indians, a mandatory program
funded at $150 million annually.
I am heartened by this robust response to Indian Country's
call for action but as we will learn from our witnesses today,
there is much left to do. The substance abuse crisis has sent
ripple effects through Native communities, straining already
overtaxed tribal systems. Tribal schools, housing departments,
social services, law enforcement and the courts are all being
asked to address the broader community disruptions caused by
this public health emergency.
I look forward to hearing from all of our witnesses today
about how Congress can work to address the full impact of the
opioid crisis in Indian Country. I look forward to continuing
those efforts at next week's oversight hearing on the
President's fiscal year 2019 budget proposal.
Thank you again, Mr. Chairman, for getting this here today.
The Chairman. Senator Barrasso.
STATEMENT OF HON. JOHN BARRASSO,
U.S. SENATOR FROM WYOMING
Senator Barrasso. Thank you very much, Mr. Chairman.
I just want to take a moment to thank you personally, Mr.
Chairman, for holding this important hearing today. As a
doctor, I have given a great deal of attention during my time
as a member of this Committee to the delivery of health care in
Indian Country, especially in rural areas.
I have long been concerned about the serious drug addiction
crisis facing our Nation. Nowhere is the challenge more
apparent than it is in tribal communities. I have been working
hard with my colleagues on this Committee to finalize my bill
to restore accountability in the Indian Health Service, which I
believe is a step in the right direction but specific action
for opioid addiction is critical.
Just yesterday before the Senate Energy and Natural
Resources, we are joined now by the Chairman of that committee,
Secretary Zinke shared his concerns and his commitment to
addressing the opioid crisis. Successful implementation of
programs requires cooperation and coordination from all sides,
Interior, Justice, Health and Human Services and the tribes
themselves.
Last year, the Northern Arapaho and Eastern Shoshone Tribes
joined several Montana tribes to hold the Wind River War Staff
Symposium in an effort combat drug and alcohol abuse. The
symposium was held in conjunction with their youth winter
retreat. While symposiums are not specific to opioid addiction,
it is the prime example of the need to educate and engage youth
if we are going to be successful in the fight to end opioid
addiction.
I thank you, Mr. Chairman, for your continued leadership.
The Chairman. Are there other Committee members who would
like to make an opening statement? Senator Murkowski.
STATEMENT OF HON. LISA MURKOWSKI,
U.S. SENATOR FROM ALASKA
Senator Murkowski. Thank you, Mr. Chairman. I too
appreciate that you have brought this very important issue
before the Committee and thank you to the Ranking Member.
In the State of Alaska, we joined six other States in the
Country in declaring a public health crisis in response to the
opioid epidemic. We have joined Arizona, Florida, Virginia,
Maryland, Massachusetts and now Alaska has issued a State
disaster declaration.
As many in this Committee know and have heard from me, our
very rural communities are predominantly Alaska Native
communities that are being devastated by substance abuse and
now opioids. The rate of overdose deaths attributed to opioids
has increased and, in many cases, has greatly exceeded the
national average.
In 2012, our prescription opioid pain reliever overdose
death was more than double the national average. Our heroin-
associated overdose deaths were over 50 percent higher than the
national rate. The overdose death rate by race was the highest
amongst Alaska Native people. Our statistics are troubling to
the core.
There is a much reported story of four people who overdosed
in the Native Village of Quinhagak a couple years ago.
Quinhagak has a population of 700. One of these individuals did
die as a consequence of that overdose. It was determined that
it was Fentanyl, more Fentanyl than heroin. We are seeing this
in a remote, tiny, tiny community.
We clearly have an opioid epidemic, Mr. Chairman. We must
deal with it but I must say that we must not lose sight of the
other killer we are facing in our Native communities, not only
in Alaska but around the Country. That killer is alcohol and
how alcohol has wrought devastation.
The Napaskiak Tribal Council passed a resolution on March 5
asking that the governor declare a disaster of emergency to
close the liquor store in Bethel due to high rates of alcohol-
related deaths, accidents and injuries in the surrounding area.
It is one more reminder to me that when we think about those we
serve and their cries for help, we have so very much to do.
I thank you for bringing opioids to the attention of the
Committee this afternoon. Whether it is opioids, alcohol or
anything in between, know that I am committed to working with
you.
I do ask that my full statement be included as part of the
record. Thank you, Mr. Chairman.
[The prepared statement of Senator Murkowski follows:]
Prepared Statement of Hon. Lisa Murkowski, U.S. Senator From Alaska
Chairman Hoeven, Vice Chairman Udall, I appreciate this oversight
hearing to discuss the impacts of the opioid epidemic in Native
American and Alaska Native communities. Alaska may be a very rural
state, but we are not shielded from this epidemic and in fact opioid
abuse in Alaska has rapidly become one of our most pressing issues.
Last year, Alaska Governor Bill Walker issued a State Disaster
Declaration to address the growing opioid epidemic in Alaska. This
meant that Alaska became one of the six states in the Nation to declare
a public health crisis in response to the opioid epidemic. (Others:
Arizona, Florida, Virginia, Maryland, Massachusetts)
Many of our communities, including our very rural ones who are
predominantly Alaska Native, are being devastated by opioids. The rate
of overdose deaths attributed to opioids have steadily increased in
Alaska, and in many cases has greatly exceeded the national average.
For example, in 2012, Alaska's prescription opioid pain reliever
overdose death rate was more than double the national average (10.5 vs.
5.1 per 100,000 persons, respectively), and Alaska's heroin-associated
overdose death rate was over 50 percent higher than the national rate
(3.0 vs. 1.9 per 100,000 persons, respectively). Furthermore, the
overdose death rate by race was the highest among the Alaska Native
people (20.2 per 100,000).
The opioid epidemic has been increasingly more prevalent in the
Alaska Native communities. For instance, the Native Village of
Quinhagak, with a population of about 700, saw four people overdose
(one fatally) in the span of one week in August 2016. The heroin used
in Quinhagak was tested at the Alaska State Crime Lab and it was
discovered that the heroin used in Quinhagak contained more fentanyl
than heroin. That was only the second time in Alaska's history that a
drug submitted to the state crime lab had been confirmed as mixture of
heroin and fentanyl and it wasn't heroin from the streets of Anchorage
or Fairbanks. But in a rural village in remote Southwest Alaska.
Alaska certainly has an opioid epidemic. But, I think this is
indicative of a much larger substance abuse problem in Alaska and other
areas across the country. According to the Alaska State Troopers 2016
Annual Drug Report, the single most abused substance in Alaska is
alcohol. Not heroin, not cocaine, but alcohol. To date, there are 109
villages in rural Alaska that have prohibited the sale, importation,
and possession of alcoholic beverages. I do understand wholeheartedly
the seriousness of the growing issue of opioids, but I do not want to
lose focus of some of the other issues we have that have gut-wrenching
statistics as well. I have said this before, but we must have an all
hands on deck, and an all-of-the-above strategy for solutions to make
it through these complex substance abuse issues.
Just recently, the Native Village of Napaskiak voted on and passed
a resolution that formally asked the Governor to declare a disaster of
emergency to close down a liquor store in Bethel, Alaska. One of the
many reasons that Napaskiak voted on this resolution was because they
saw an increase in the number of preventable deaths in their community
related to alcohol abuse. In addition to that, the tribe saw an
increase in the number of cases brought before their ICWA program, a
decrease in the attendance rate at the local school because kids
weren't getting enough sleep due to alcohol disturbances, and an
increased caseload for law enforcement officials in the region.
The Tribal Council specifically asked to close the liquor in
Bethel, Alaska, because that was the primary means for their members to
obtain alcohol. Napaskiak is one of the 109 villages that has banned
alcohol and there was still alcohol in the village because the alcohol
was imported illegally from the liquor store in Bethel.
Despite the prevalence of opioids in rural Alaska, bootlegging
alcohol continues to be the most lucrative and profitable criminal
enterprise in Alaska. In 2016 alone, the Alaska State Troopers arrested
225 people for the possession or sale of alcohol in dry villages. This
was more than any other drugs, including cocaine, heroin, and
prescription medication.
Alaska Native communities don't just have an opioid epidemic, many
have a substance abuse epidemic. There are tribes who are standing up
against this. There are community members who are going out on a limb
in their own communities to be the one to stand up against it. We must
stand with them. I look forward to working with my colleagues in this
committee to find a solution to this epidemic and thank you to all of
the witnesses that came here today to address this issue.
The Chairman. Without objection.
Are there other opening statements?
[No audible response.]
The Chairman. Hearing none, our witnesses today are: The
Honorable John C. Anderson, United States Attorney for the
District of New Mexico, U.S. Department of Justice,
Albuquerque, New Mexico; Captain Christopher Jones, Director,
National Mental Health and Substance Use Policy Laboratory,
Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services, Rockville, MD; and
Rear Admiral Michael Toedt, MD, Chief Medical Officer, Indian
Health Service, U.S. Department of Health and Human Services,
Rockville, MD.
I want to remind the witnesses that your full written
testimony will be made a part of the official record and to
please keep your statements to five minutes.
With that, we will begin with you, Mr. Anderson.
STATEMENT OF HON. JOHN C. ANDERSON, U.S. ATTORNEY, DISTRICT OF
NEW MEXICO, U.S. DEPARTMENT OF JUSTICE
Mr. Anderson. Chairman Hoeven, Vice Chairman Udall and
members of the Committee, thank you for inviting us today to
discuss this critical issue and the Department of Justice's
efforts to support Native communities dealing with the
devastating aftermath of the opioid epidemic.
The Department has been uncompromising in our commitment to
combating drug abuse and drug crimes, particularly opioids, in
Indian Country and across the Nation. In my district, New
Mexico, the opioid crisis in Indian Country is particularly
acute.
Despite its staggering natural beauty, northern New Mexico
and Espanola, New Mexico in particular, has one of the highest
opioid death rates in the Country. For decades, Espanola has
had a severe heroin problem. As you may know, Espanola is
surrounded by Indian reservations. Many New Mexico Indian
pueblos, including the pueblos of Santa Clara, Okawingay, San
Ildefonso, Pecurist, Owakay, Nambe, and Tuzukay are all within
a short distance of the Espanola area.
The opioid epidemic knows no boundaries, so our Pueblos are
equally affected by heroin and prescription opioids.
Individuals and communities alike continue to be plagued by the
opioid scourge and its secondary effects.
At a recent consultation in New Mexico, one Pueblo governor
shared photographs of the parking lot of their casino. The
photos were of the discarded needles, syringes and other drug
paraphernalia scattered about the parking lot.
At the same consultation, a Pueblo chief of police
emotionally described losing a brother to a heroin overdose and
a sister to a prescription opioid overdose. The chief of police
explained that the drug epidemic is dire in northern New Mexico
and that something needs to be done to address the problem.
The catastrophic impact opioid abuse can have at every
level of a community, from family units to infrastructure and
economic stability, demands our best efforts to offer effective
and sustainable support to communities in crisis. The
Department has developed a multifaceted approach to addressing
the threat and the impact of opioid abuse. Our approach in
Indian Country is based on the belief that the tribes are in
the best position to identify solutions to the problems in
their communities.
An important element of the Department's support is in
providing opportunities for funding. In fiscal year 2017, the
Department awarded nearly $59 million to strengthen drug
programs and combat the opioid epidemic.
The Office of Justice Programs administers the Department's
Comprehensive Opioid Abuse Program. The goals of the
Comprehensive Opioid Abuse Program are twofold. First is to
reduce opioid misuse and the number of overdose fatalities.
Second is to support the implementation of prescription drug
monitoring programs to prevent the diversion of controlled
substances.
The Department understands that effective coordination
among Federal agencies is crucial to ensuring the success of
our efforts. We have participated in the High Intensity Drug
Trafficking Areas Program, the HIDTA Program, which increases
collaboration and information sharing between tribal law
enforcement and Federal, State and local agencies to improve
investigation and interdiction in Indian Country.
The Indian Country Law Enforcement Coordination Working
Group, co-chaired by the Department of Justice and the Bureau
of Indian Affairs, includes representatives from 13 Federal law
enforcement agencies. This group is an important tool for
enhancing interagency Federal law enforcement coordination in
tribal communities.
We recognize that the crisis requires more than a law
enforcement response. The Department is working closely with
Indian Health Service to ensure that other Federal agencies are
aware of the updated prescription drug monitoring protocols in
IHS facilities.
We have also developed a number of training opportunities
to better equip law enforcement and secondary providers working
in Indian Country in addressing drug crimes and the secondary
effects of opioid abuse.
The DEA has conducted a prolonged community outreach in
Indian Country to educate tribal leaders and citizens on
opioids and other drugs. On October 28, 2017, the Department
and the BIA collaborated on the most recent prescription drug
takeback day.
This initiative provided a safe and convenient means of
disposing of prescription drugs while also educating Native
communities on the potential for opioid abuse. Over 115 tribal
communities participated and we intend to repeat this
initiative in the near future.
Our goal is clear. We must continue working in partnership
with tribal, Federal, State and local partners to respond to
the opioid epidemic and to support communities affected by the
crisis. We appreciate this Committee's focus on the issue and
look forward to working with you in combating this threat to
the health and well-being of our Native communities.
Thank you again for the opportunity to participate today.
[The prepared statement of Mr. Anderson follows:]
Prepared Statement of Hon. John C. Anderson, U.S. Attorney, District of
New Mexico, U.S. Department of Justice
Chairman Hoeven, Vice-Chairman Udall, and Members of the Committee:
Thank you for inviting us today to discuss this critical issue and
the Department of Justice's (the Department) efforts to support Native
communities dealing with the devastating aftermath of the opioid
epidemic. The Department has been uncompromising in our commitment to
combatting drug abuse and drug crimes, particularly opioids, in Indian
country and across the nation.
In my district, New Mexico, the opioid crisis in Indian Country is
particularly acute. Despite its staggering natural beauty, northern New
Mexico, and Espanola, New Mexico in particular, has one of the highest
opioid overdose death rates in the country. For decades, Espanola has
had a severe heroin problem. And as you may know, Espanola is
surrounded by Indian reservations. Many New Mexico Indian Pueblos,
including the Pueblos of Santa Clara, Ohkay Owingeh, San Ildefonso,
Picuris, Pojoaque, Nambe and Tesuque are all within a short distance of
the Espanola area. The opioid epidemic knows no boundaries, and so our
Pueblos are equally affected by heroin and prescription opioids;
individuals and communities alike continue to be plagued by the opioid
scourge and its secondary effects.
At a recent consultation in New Mexico, one Pueblo Governor shared
photographs of the parking lot of their casino. The photos revealed
discarded needles, syringes and other drug paraphernalia scattered
about the casino parking lot.
At the same consultation, a Pueblo Chief of Police emotionally
described losing a brother to a heroin overdose and a sister to a
prescription opioid overdose. The Chief of Police explained that the
drug epidemic is dire in Northern New Mexico and that something needs
to be done to address the problem.
The catastrophic impact that opioid abuse can have at every level
of a community, from family units to infrastructure and economic
stability, demands our best efforts to put forth effective and
sustainable support to communities in crisis. The Department has
developed a multi-faceted response to addressing the threat and the
impact of opioid abuse. Our approach in Indian country is based on the
belief that the Tribes are in the best position to identify solutions
to problems in their communities. We have sought to develop resources
and initiatives that rely on partnership with the Tribes and are
continually interested in hearing from our Tribal and federal partners
as we adjust our efforts to better meet the needs of Native
communities.
An important element of the Department's support is in providing
opportunities for funding. In fiscal year 2017, the Department awarded
nearly $59 million to strengthen drug court programs and combat the
opioid epidemic. The Office of Justice Programs (OJP) administers the
Department's ``Comprehensive Opioid Abuse Program.'' The goals of the
Comprehensive Opioid Abuse Program are twofold: First, the program aims
to reduce opioid misuse and the number of overdose fatalities. Second,
the program supports the implementation, enhancement, and proactive use
of prescription drug monitoring programs (PDMPs) to support clinical
decisionmaking and prevent the misuse and diversion of controlled
substances. Tribes are eligible to apply for a variety of funding
opportunities under this program. As an example of recent awards under
this program, in Fiscal Year 2017, the Seneca Nation Peacemakers Court
was awarded funds to create a community-driven, culturally competent
diversion project aimed at helping Native American opioid users. The
Port Gamble S'Klallam Tribe was awarded funds in Fiscal Year 2017 to
support drug courts and programs that support veterans. The Department
will continue to offer these opportunities to Tribes going forward.
The Department understands that effective coordination among
federal agencies is crucial to ensuring our efforts are successful. We
have participated in the High-Intensity Drug Trafficking Areas (HIDTA)
program, funded through the Office of National Drug Control Policy, for
many years now. The HIDTA program increases collaboration and
information sharing between Tribal law enforcement and federal, state,
and local agencies to improve investigation and interdiction in Indian
country. As the Department continues to participate in the HIDTA
program, our law enforcement agencies, particularly the Drug
Enforcement Administration (DEA), have been working to build stronger
relationships with other law enforcement agencies and service providers
active in Indian country so that we are able to adjust our Task Force
presence in Indian country most effectively.
The Indian Country Law Enforcement Coordination Working Group,
cochaired by the Department of Justice and the Bureau of Indian Affairs
(BIA) at the Department of the Interior, has become important to
enhancing inter-agency federal law enforcement coordination in tribal
communities. The group includes representatives from 13 federal law
enforcement agencies and has focused heavily on several aspects of the
opioid epidemic including proliferation, identifying top challenges to
law enforcement, and coordinating responses. We will continue to use
this working group to strengthen our coordinated efforts. For example,
trafficking through the mail is a significant concern and we intend to
use this working group as a forum to develop better ways to stop the
movement of opioids through the postal service.
We recognize that the crisis requires more than a law enforcement
response, so our efforts to coordinate go beyond law enforcement. For
example, the Department is working closely with the Indian Health
Service (IHS) of the Department of Health and Human Services to ensure
that other federal agencies are aware of updated Prescription Drug
Monitoring Program (PDMP) protocols in IHS facilities. The updated
protocols have an impact on how some drug crimes are investigated and
prosecuted, and on efforts to introduce safeguards against opioid
abuse. Additionally, we have developed a number of training
opportunities to better equip law enforcement and service providers
working in Indian country to address the drug crimes and the familial
and community impacts of opioid abuse. The Department has presented
recent trainings, often in coordination with BIA, on opioid trends,
investigative techniques, drug handling precautions regarding opioids,
naloxone use, and indicators that opioids are present in a community.
Other training is available on violent crime associated with opioids,
prescription drug diversion, and investigating and prosecuting medical
professionals and others involved in distributing prescription
medications outside the scope of legitimate medical practice. These
training opportunities are available to Tribal law enforcement and, in
some cases, entirely geared for a Tribal audience. The Department is
currently working with BIA on a new opportunity tentatively slated for
this summer that will bring Tribal law enforcement representatives
together with a number of federal law enforcement agencies to train on
a wide range of drug-related topics.
Community outreach is another important aspect of our approach to
this issue. The DEA has conducted a prolonged community outreach effort
in Indian country to educate Tribal leaders and citizens on opioids and
other drugs. Additionally, on October 28, 2017, the Department and BIA
collaborated on the most recent Prescription Drug Take Back Day, which
is a nationwide program that has also allowed the successful
collaboration between BIA and DEA. This initiative provided a safe,
convenient, and responsible means of disposing prescription drugs,
while also educating Native communities on the potential for opioid
abuse. Over 115 Tribal communities participated; we intend to repeat
this initiative and expand participation in the future.
Improved information sharing plays a crucial role in any law
enforcement effort, even more so in the context of opioids as we all
work to get ahead of this terrible epidemic. The Tribal Access Program
for National Crime Information (TAP) is an effective tool for
participating Tribes to track and contribute data on opioid-related
crimes and to perform required background checks. TAP assists Tribes by
providing a means of access to national crime databases maintained by
the FBI Criminal Justice Information Services (CJIS) Division for both
criminal justice and civil background check purposes. This has been an
especially important tool for performing checks on those who have
regular contact with children in Indian country, including schools and
foster care. Service providers in Indian country carry much of the
burden of healing communities in the wake of opioid abuse, so we
believe TAP plays an equally necessary role in ensuring safe providers
as it does in sharing important law enforcement information.
The use of data analytics to combat the opioid crisis is among the
new tactics that are under development Department-wide. Attorney
General Sessions formed the Opioid Fraud and Abuse Detection Unit to
utilize data analytics, such as distribution and inventory figures, to
identify patterns, trends, and statistical outliers that can be
developed into targeted law enforcement operations. As we better
understand the data across the country we will be able to better
understand patterns and trends in Indian country.
Our goal is clear: we must continue working in partnership with
Tribal, federal, state, and local partners to respond to the opioid
epidemic and to support communities that are affected by the crisis. We
are committed to putting forth our best efforts in this joint
undertaking. We appreciate this committee's focus on this issue and
look forward to working with you going forward. Thank you again for the
opportunity to participate today.
The Chairman. Thank you.
Captain Jones.
STATEMENT OF CAPTAIN CHRISTOPHER JONES, PHARM.D., M.P.H.,
DIRECTOR, NATIONAL MENTAL HEALTH AND
SUBSTANCE USE POLICY LABORATORY, SUBSTANCE ABUSE AND MENTAL
HEALTH SERVICES ADMINISTRATION, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Jones. Thank you, Chairman Hoeven, Vice Chairman Udall
and members of the Committee. Thank you for the opportunity to
testify at this important hearing focusing on tribes and tribal
entities.
From the start of his Administration, President Trump has
been addressing the opioid epidemic as a top priority. At
SAMHSA, we share the President's commitment to ending the
crisis in the U.S.
The American Indian and Alaskan Native population has been
significantly impacted by the opioid epidemic. Among this
population, 4 percent of people 12 and older reported
prescription opioid misuse in 2016. More than 1 percent had an
opioid use disorder.
Most concerning are the continued increases in overdose
deaths. In 2016, American Indians and Alaska Natives had the
second highest overdose death rate in the United States, 13.9
deaths per 100,000 people, which represents a 400 percent
increase since 2000.
To combat the opioid crisis, HHS launched a five-point
opioid strategy in April 2017. The strategy aims to improve
access to prevention, treatment and recovery support services;
target the availability and distribution of overdose-reversing
drugs; strengthen public health data reporting and collection;
support cutting-edge research that advances our understanding
of pain and addiction; and advance the practice of pain
management.
As the Department's lead agency for behavioral health,
SAMHSA has been at the forefront of the HHS response to the
opioid crisis. Today, I want to focus on how SAMHSA is working
with tribal communities under the HHS opioid strategy.
Since joining SAMHSA, Assistant Secretary McCance-Katz has
prioritized efforts to support the behavioral health needs of
the American Indian and Alaska Native population. She has
charged SAMHSA leadership with identifying every possible
opportunity for tribal entities to engage with SAMHSA. This
includes making tribal entities eligible for discretionary
grant programs wherever possible; ensuring flexibility in how
tribal entities incorporate cultural practices into their
programs; and providing assistance to ensure that tribal
entities are set up for success.
Under the HHS strategy, SAMHSA focuses its work in three
areas: building prevention, treatment and recovery capacity
through funding; providing technical assistance and training;
and leveraging key stakeholders to support incorporation of
tribes and tribal populations into the opioid response.
In the area of funding, SAMHSA administers the State
Targeted Response to the Opioid Crisis Grants, a two-year
program authorized under the 21st Century Cures Act. Although
tribal entities were not eligible for funding under the
statutory structure of the STR Program, SAMHSA has taken a
number of steps to support inclusion engagement of tribes in
State plans.
Specifically, we required States to assess the needs of
tribal communities and include them in their strategic plans
and reviewed each State plan for tribal engagement. We held a
webinar with States to clarify our expectation that American
Indians and Alaska Natives be incorporated as a population of
focus and provided examples of how States are working with
tribes on the STR Program.
Most recently, Dr. McCance-Katz sent a letter to governors
calling on them to work with tribes and allocate funds directly
to them so they can offer the essential and life-saving
services their communities need to respond to the opioid
crisis. Our assessment of the State STR plans indicates that of
the 35 States with federally-recognized tribes within their
borders, at least 12 have specifically identified tribes as a
population of focus or specified actions that are working to
combat opioids in tribal communities.
Tribes have also received funding from a number of SAMHSA's
other discretionary programs. Under the Strategic Prevention
Framework Partnerships for Success Program, First Nations
Community Healthsource of New Mexico is using funding to
develop prevention strategies for tribal communities.
Under the Strategic Prevention Framework for Prescription
Drugs Program, four tribes are working with their States to
incorporate tribal data into State prescription drug monitoring
programs to better target prevention efforts and reduce
prescription drug misuse. Last September, SAMHSA awarded
funding to four tribes under our First Responders Naloxone
Grant Program. We also recently released a funding announcement
for Treatment and Recovery Services for Adolescents,
Transitional Aged Youth and Their Families that actually, for
the first time, includes a $5 million setaside for tribal
entities.
In the area of technical assistance, Assistant Secretary
McCance-Katz recently reinstated SAMHSA's American Indian and
Alaska Native Support Center which is part of our Addiction
Technology Transfer Center Network. This center provides
critical support to develop and strengthen the specialized
behavioral and primary healthcare workforce that provides
treatment and recovery services to tribal communities.
We also fund a Tribal Training and Technical Assistance
Center which actively engages and serves tribes across the
Country. In fact, today, this center is conducting the first of
two webinars on opioids in Indian Country.
Finally, SAMHSA is committed to leveraging a broad range of
stakeholders to ensure that the behavioral health needs of
tribal populations are a part of our Nation's response to the
opioid crisis. To support this commitment, SAMHSA is currently
planning a tribal-State Policy Academy for August 2018 that
will bring States and tribes together to develop specific,
actionable plans for how they can collaborate to address the
opioid crisis and substance use issues in their community.
Thank you for inviting me to testify. I look forward to
your questions.
[The prepared statement of Dr. Jones follows:]
Prepared Statement of Captain Christopher Jones, Pharm.D., M.P.H.,
Director, National Mental Health and Substance Use Policy Laboratory,
Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services
Chairman Hoeven, Vice Chairman Udall, and members of the Senate
Committee on Indian Affairs, thank you for inviting me to testify at
this important hearing. The Substance Abuse and Mental Health Services
Administration (SAMHSA) has been actively engaged in the
Administration's effort to combat the opioid epidemic. SAMHSA works
with our colleagues at the Department of Health and Human Services
(HHS), state and local governments, tribal entities, and other key
stakeholders.
Thank you for the opportunity to discuss the opioid crisis in the
United States and the Federal response, particularly in relation to
tribes and tribal entities. From the start of his Administration,
President Trump has made addressing the opioid epidemic a top priority,
and at SAMHSA we share the President's commitment to bringing an end to
this crisis, which is exacting a toll on individuals, families, and
communities across the country. The Department, including SAMHSA, has
made the crisis a top priority and is committed to using our full
expertise and resources to combat the epidemic.
Over the past 15 years, communities across our Nation have been
devastated by increasing prescription and illicit opioid abuse,
addiction, and overdose. According to SAMHSA's National Survey on Drug
Use and Health (NSDUH), in 2016, over 11 million Americans misused
prescription opioids, nearly 1 million used heroin, and 2.1 million had
an opioid use disorder due to prescription opioids or heroin. The
American Indian/Alaska Native (AI/AN) population is likewise affected
by the opioid crisis. According to NSDUH, 5.2 percent (72,000) of AI/AN
aged 18 and older reported misusing a prescription drug in the past
year and 4.0 percent (56,000) of AI/ANs aged 18 and older reported
misusing a prescription pain reliever in the past year. Over the past
decade, the United States has experienced significant increases in
rates of neonatal abstinence syndrome (NAS), hepatitis C infections,
and opioid-related emergency department visits and hospitalizations.
Most alarming are the continued increases in overdose deaths,
especially the rapid increase since 2013 in deaths involving illicit
fentanyl and other highly potent synthetic opioids. Since 2000, more
than 300,000 Americans have died of an opioid overdose. Opioids were
involved in 42,249 deaths in 2016, and opioid overdose deaths were five
times higher in 2016 than 1999.
The opioid epidemic in the United States can be attributed to a
variety of factors. For example, there was a significant rise in opioid
analgesic prescriptions that began in the mid-to-late 1990s. Not only
did the volume of opioids prescribed increase, but also well-
intentioned healthcare providers began to prescribe opioids to treat
pain in ways that we now know are high-risk and have been associated
with opioid abuse, addiction, and overdose, such as prescribing at high
doses and for longer durations. One additional factor is a lack of
health system and healthcare provider capacity to identify and engage
individuals, and provide them with high-quality, evidence-based opioid
addiction treatment, in particular the full spectrum of medication-
assisted treatment (MAT). It is well-documented that the majority of
people with opioid addiction in the United States do not receive
treatment, and even among those who do, many do not receive evidence-
based care. Accounting for these factors is paramount to the
development of a successful strategy to combat the opioid crisis.
Further, there is a need for more rigorous research to better
understand how existing programs or policies might be contributing to
or mitigating the opioid epidemic.
HHS Five Point Strategy
In April 2017, HHS outlined its five-point Opioid Strategy, which
provides the overarching framework to leverage the expertise and
resources of HHS agencies in a strategic and coordinated manner. The
comprehensive, evidence-based Opioid Strategy aims to:
Improve access to prevention, treatment, and recovery
support services to prevent the health, social, and economic
consequences associated with opioid addiction and to enable
individuals to achieve long-term recovery;
Target the availability and distribution of overdose-
reversing drugs to ensure the broad provision of these drugs to
people likely to experience or respond to an overdose, with a
particular focus on targeting high-risk populations;
Strengthen public health data reporting and collection to
improve the timeliness and specificity of data and to inform a
real-time public health response as the epidemic evolves;
Support cutting-edge research that advances our
understanding of pain and addiction, leads to the development
of new treatments, and identifies effective public health
interventions to reduce opioid-related health harms; and
Advance the practice of pain management to enable access to
high-quality, evidence-based pain care that reduces the burden
of pain for individuals, families, and society while also
reducing the inappropriate use of opioids and opioid-related
harms.
As HHS lead agency for behavioral health, SAMHSA's core mission is
to reduce the impact of substance abuse and mental illness on America's
communities. SAMHSA supports a portfolio of activities that address the
HHS Opioid Strategy.
Today, I will address how SAMHSA is working with tribes and tribal
organizations as that work relates to this strategy.
Improving Access to Prevention, Treatment, and Recovery Support
Services
SAMHSA administers the State Targeted Response to the Opioid Crisis
Grants, a two-year program authorized by the 21st Century Cures Act
(P.L. 114-255). By providing $485 million to states and U.S.
territories in Fiscal Year (FY) 2017, this program allows states to
focus on areas of greatest need, including increasing access to
treatment, and reducing opioid overdose related deaths through the
provision of the full range of prevention, treatment, and recovery
services for opioid use disorder. Specific areas in which states and
tribes collaborate on prevention activities include: Prescription Drug
Monitoring Program (PDMP) data-sharing; State Epidemiological Outcome
Workgroups; overdose education on naloxone distribution; and media
campaigns. In Minnesota, the state is supporting five Native American
communities to service high-risk pregnant women with opioid use
disorder (OUD) in order to strengthen and enhance peer recovery support
services. In Montana, the state is working with the Rocky Mountain
Tribal Leaders Council to develop culturally tailored versions of the
current peer monitoring trainings and peer supervisor trainings.
Tribes receive SAMHSA prevention grant funds to address opioid
misuse and abuse. Prevention programs include a focus on change at the
community level that will, over time, lead to measurable changes at the
state and tribal levels. Under the Strategic Prevention Framework-
Partnerships for Success (SPF-PFS) grant program, First Nations
Community HealthSource in New Mexico serves four tribes: Pueblo de
Cochiti; Pueblo of Laguna; Native American Community Academy; and Zuni
Pueblo. First Nations Community HealthSource has developed prevention
strategies based on research and tribal traditions, culture, language,
and values that reduce prescription drug abuse and misuse; improve the
capacity of tribal leadership to understand and support prevention
strategies designed to decrease prescription drug abuse and misuse; and
develops a tribal strengths based method to decrease prescription drug
abuse and misuse.
Other tribes are developing capacity and expertise in the use of
data from state-run PDMPs. Under the Strategic Prevention Framework for
Prescription Drugs (SPF Rx) grant program, four tribes (Cherokee
Nation, Southern Plains inter-tribal, Nooksack, and Little Traverse Bay
Band of Odawa Indians) currently work with their states to bring tribal
data into the system and decrease prescription drug misuse in their
communities. For example, in Oklahoma, the Cherokee Nation has used the
PDMP data to develop a tribal-wide media campaign, ``Think SMART,''
that is educating community members on the responsible use of opioids
and the risks associated with overprescribing.
Since coming to SAMHSA, the Assistant Secretary for Mental Health
and Substance Use, Dr. Elinore McCance-Katz, has reviewed all of our
discretionary funding announcements and has looked for opportunities to
improve tribal access to SAMHSA's discretionary grant funds. For
example, tribal leaders informed her they have a great concern about
the vulnerability of tribal youth to developing mental and substance
use disorders. With clarity that tribal youth are a priority, Assistant
Secretary McCance-Katz was able to ensure that a funding opportunity
announcement (FOA) that SAMHSA recently released entitled ``Enhancement
and Expansion of Treatment and Recovery Services for Adolescents,
Transitional Aged Youth, and their Families'' included at least a $5
million set-aside for tribes, tribal organizations, urban Indian health
programs, and consortia of tribes or tribal organizations. This amount
is approximately 34 percent of the total anticipated $14.6 million
available for this program.
Targeting Overdose-Reversing Drugs SAMHSA has been a leader in
efforts to reduce overdose deaths by increasing, through funding and
technical assistance, the availability and use of naloxone to reverse
overdose. SAMHSA's ``Opioid Overdose Prevention Toolkit,'' first
released in 2013, is one of SAMHSA's most downloaded resources. The
Toolkit provides information on risks for opioid overdose, recognition
of overdose, and how to provide emergency care in an overdose
situation. The Toolkit is intended for community members, first
responders, prescribers, people who have recovered from an opioid
overdose, and family members, as well as communities and local
governments.
SAMHSA provides a number of funding streams that can be used to
expand access to naloxone. In September 2017, SAMHSA awarded funding
for the First Responders-Comprehensive Addiction and Recovery Act (FR-
CARA) grant program, which includes grants to four tribes: White Earth
Band of Chippewa Indians; Cherokee Nation; Choctaw Nation of Oklahoma;
and Lac Du Flambeau Band of Lake Superior Chippewa Indians. The First
Responders grant program provides resources to first responders and
treatment providers who work directly with the populations at highest
risk for opioid overdose. For the White Earth Band of Chippewa Indians
in Minnesota, prescription opiate and heroin admissions for American
Indians on the Reservation totaled almost 30 percent of the treatment
admissions. SAMHSA's grant helps support the tribe's collaborative
approach to addressing the crisis throughout its community, including
partnerships with public health, law enforcement, behavioral health,
first responders, public relations, and cultural representatives.
Strengthening Public Health Data and Reporting
NSDUH provides key national and state level data on a variety of
substance use and mental health topics, including opioid misuse. NSDUH
is a vital part of the surveillance effort related to opioids, and the
data from NSDUH has been used to track historical and emerging trends
in opioid misuse, including geographic and demographic variability.
According to the 2016 NSDUH, 5.2 percent (72,000) of AI/AN aged 18
and older reported misusing a prescription drug in the past year and
4.0 percent (56,000) of AI/ANs aged 18 and older reported misusing a
prescription pain reliever in the past year, compared to national
averages of 7.1 percent and 4.3 percent respectively. The 2016 NSDUH
also found that 4.1 percent (63,000) of AI/ANs aged 12 and older
reported opioid misuse in the past year, in line with the national
average of 4.4 percent. The 2016 NSDUH found that 1.1 percent (16,000)
of AI/ANs aged 12 and older reported having an opioid use disorder in
the past year.
Working with Tribes and Tribal Organizations to Reduce Opioid Misuse
and Abuse
Assistant Secretary McCance-Katz reinstated SAMHSA's Addiction
Technology Transfer Center (ATTC): American Indian and Alaska Native
Support Center Cooperative Agreement (AI/AN ATTC). The purpose of this
program is to provide support for the ATTC Network, AI/AN, tribal
organizations, urban Indian programs, state and local governments, and
other organizations to develop and strengthen the specialized
behavioral healthcare and primary healthcare workforce that provides
substance use disorder (SUD) treatment and recovery support services to
tribal communities. The University of Iowa, the grantee, works directly
with SAMHSA and in collaboration with the FY 2017 ATTC National
Coordinating Center and the 10 Regional ATTC Centers. The Centers focus
on activities aimed at improving the quality and effectiveness of
treatment and recovery, as well as working directly with providers of
clinical and recovery support services, and others that influence the
delivery of services, to improve the quality of workforce training and
service delivery to tribal communities.
SAMHSA also funds the Tribal Training and Technical Assistance
Center, which actively engages and serves tribes across the Nation.
Through onsite and virtual training, targeted resources, learning
communities, assistance with Tribal Action Plans, and intensive
community engagement, our technical assistance guides tribal
communities and organizations in using cultural knowledge and strengths
to support wellness, including addressing the opioid crisis. For
example, today, this Center is conducting the first of two webinars
targeting opioids in Indian Country. SAMHSA is in the process of
assessing the technical assistance provided to assure that the funding
is appropriate to the need and that the tribal entities get the support
they need while maximizing grant funds to communities.
SAMHSA received input from our Tribal Technical Advisory Committee
(TTAC) and shared TTAC's recommendations with the Secretary's Tribal
Advisory Committee. Based on input from these tribal leaders, SAMHSA is
partnering with the Centers for Disease Control and Prevention, Indian
Health Service, Centers for Medicare & Medicaid Services, and National
Institutes of Health to host a Joint Tribal Advisory Committee (JTAC)
meeting. The JTAC will bring together tribal leaders from the tribal
advisory committees for these operating divisions to discuss related
priorities. Our plan is to host the joint meeting immediately preceding
the National American Indian and Alaska Native Behavioral Health
Conference this summer.
We have heard from tribal leaders that SAMHSA also has a
responsibility to improve tribal-state relationships. In response, the
Agency is hosting a Tribal-State Policy Academy (TSPA) to advance
tribal behavioral health planning. The TSPA will have a particular
emphasis on improving current efforts to address the impact of the
opioid epidemic in Indian Country but will also include an opportunity
for tribes and states to work together on other primary substances of
abuse affecting local tribal communities. Beyond supporting improved
working relationships and planning, proposed outcomes include joint
tribal-state plans for combating drug use in tribal communities and
collaborative models that may be replicated by other states and tribes.
Up to ten tribal-state teams will be able to participate in the Academy
that is targeted for this summer. Additionally, Assistant Secretary
McCance-Katz recently sent a letter to governors urging them to assess
the behavioral health needs of AI/ANs in their states and to equitably
distribute federal funds directed to states to address the opioid
crisis and mental health needs.
Finally, SAMHSA has had discussions with tribal leaders about the
importance of recognizing and elevating tribal behavioral health as a
critical step toward collaborative improvements. SAMHSA is in the
process of engaging Federal and tribal organization partners to host a
national town hall on combatting substance use in tribal communities.
The town hall will bring together senior government officials and
tribal leaders to explicitly address opportunities, and identify a
clearer path forward, for combatting substance use in AI/AN
communities.
Thank you again for inviting me to testify today. I look forward to
answering your questions.
The Chairman. Rear Admiral Toedt.
STATEMENT OF REAR ADMIRAL MICHAEL TOEDT, M.D., CHIEF MEDICAL
OFFICER, INDIAN HEALTH SERVICE, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Dr. Toedt. Good afternoon, Chairman Hoeven, Vice Chairman
Udall, and members of the Committee.
I am Dr. Michael Toedt, Chief Medical Officer for the
Indian Health Service. Today, I appreciate the opportunity to
provide information on the work that IHS has been doing to
address the opioid crisis, which is a top priority for the
agency and the Department of Health and Human Services.
The impact of the opioid crisis on American Indians and
Alaska Natives is immense. American Indians and Alaska Natives
have had the highest drug overdose death rates in 2015
according to the CDC, and the largest percentage increase in
the number of deaths over time from 1999 to 2015 compared to
other racial and ethnic groups.
During that time, deaths rose more than 500 percent among
American Indians and Alaska Natives. Collaborating and
consulting with tribes to address the opioid crisis in Indian
Country is important. We work with our tribal advisory
committees to gather input on critical next steps. The opioid
crisis has been and will continue to be a priority for the
advisory committees.
IHS strengthened and prioritized efforts to address the
opioid crisis in 2012 and developed a number of recommendations
focused on six areas: patient care; policy development and
implementation; education; monitoring; medication storage and
disposal; and law enforcement.
To address these areas, in March 2016, IHS chartered the
National Committee on Heroin, Opioids and Pain Efforts referred
to as the HOPE Committee. The Committee works to advance the
Department's multifaceted plan to combat opioid abuse
including: better prevention; treatment, and recovery services;
better targeting of overdose reversing drugs; better data on
the epidemic; better pain management; and better research.
Our Prescription Drug Monitoring Program policy strengthens
the monitoring and deterrence of prescription misuse and
diversion. It requires IHS providers to check State PDMP
databases prior to prescribing opioids for longer than seven
days. IHS has partnered with all States where IHS Federal
facilities are located and successfully connected so far with
17 out of 18 State PDMP databases. As a result, 99 percent of
IHS facilities offering pharmaceutical services have access.
IHS pharmacies must report opioid-prescribing data to State
PDMPs, a proactive requirement not currently required by law.
We are not working alone. IHS partners with SAMHSA to train
nearly 70 physicians to treat opioid use disorders, increasing
access to treatment services in tribal communities. In 2008,
IHS established a Telebehavioral Health Center of Excellence to
provide clinical services, provider education and technical
assistance through the Indian Health system. This center
supports remote, isolated Native communities with limited
access to behavioral health services.
We partner with the Bureau of Indian Affairs to train and
equip law enforcement officers to recognize symptoms of
overdose and intervene when necessary. As of December 2017, we
have trained and provided naloxone at no cost to BIA for more
than 300 law enforcement officers. We also certified 47 BIA law
enforcement officers as naloxone trainers.
Addiction is complex but treatable. There is no single
treatment that is right for everyone. The IHS Alcohol and
Substance Abuse Program provides funding, training and
technical assistance to IHS tribal and urban Indian programs.
This ensures a variety of treatment options exist.
Approximately 90 percent of the fiscal year 2017 Alcohol and
Substance Abuse Program budget of $205 million is administered
by tribes.
IHS also supports prevention efforts through the Substance
Abuse and Suicide Prevention Program. As of fiscal year 2017,
program funds are approximately $30 million for 175 IHS tribal
and urban Indian Health organizations. The funds are used to
develop and implement culturally-appropriate, evidence-based
and community-driven models. We fund 19 projects that focus
specifically on methamphetamine and substance abuse prevention
treatment and recovery programming.
The majority of substance abuse and suicide prevention
projects focus on reducing risk factors for suicidal behavior
and substance use among Native youth. Furthermore, we work with
tribes to develop and implement models of care that are
sustainable to combat the opioid crisis. We focus on treatments
that are evidence-based and culturally-appropriate that will
have significant impacts on the prevention, treatment and
recovery efforts.
IHS collaborates with key stakeholders to develop viable
reimbursement models for services provided. This comprehensive
strategy will allow for a more unified approach with tribal
communities.
We will continue to work with tribes to develop coordinated
responses using every available resource possible to battle the
opioid crisis in tribal communities. Thank you for your
commitment to improving healthcare for American Indians and
Alaska Natives by addressing the opioid crisis as a top
priority.
I will be happy to answer any questions the Committee may
have.
[The prepared statement of Admiral Toedt follows:]
Prepared Statement of Rear Admiral Michael Toedt, M.D., Chief Medical
Officer, Indian Health Service, U.S. Department of Health and Human
Services
Chairman and Members of the Committee:
Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members
of the Committee. I am Dr. Michael Toedt, Chief Medical Officer, Indian
Health Service (IHS). I earned my Doctorate of Medicine from the
Uniformed Services University of the Health Sciences in Bethesda,
Maryland. I am board certified in family medicine and I am a fellow of
the American Academy of Family Physicians. I have served as a
Commissioned Officer for 26 years in both the National Health Service
Corps and the Indian Health Service. Today, I appreciate the
opportunity to provide information on the work that IHS has been doing
to address the opioid crisis, which is a top priority for the
Department of Health and Human Services (HHS).
IHS is a distinct agency in HHS, established to carry out the
responsibilities, authorities, and functions of the United States to
provide health care services to American Indians and Alaska Natives. It
is the only HHS agency whose primary function is direct delivery of
health care. The mission of IHS, in partnership with American Indian
and Alaska Native people, is to raise the physical, mental, social, and
spiritual health of American Indians and Alaska Natives to the highest
level. The IHS system consists of 12 Area offices, which oversee 170
Service Units that provide care at the local level. Health services are
provided through facilities managed by the IHS, by Tribes and tribal
organizations under authorities of the Indian Self-Determination and
Education Assistance Act (ISDEAA), and through contracts and grants
awarded to urban Indian organizations authorized by the Indian Health
Care Improvement Act.
The impact of the opioid crisis on American Indians and Alaska
Natives is immense. The Centers for Disease Control and Prevention
(CDC) reported that American Indians and Alaska Natives had the highest
drug overdose death rates in 2015 and the largest percentage increase
in the number of deaths over time from 1999-2015 compared to other
racial and ethnic groups.1 During that time, deaths rose more than 500
percent among American Indians and Alaska Natives. In addition, because
of misclassification of race and ethnicity on death certificates, the
actual number of deaths for American Indians and Alaska Natives may be
underestimated by up to 35 percent. \1\
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\1\ https://www.cdc.gov/mmwr/volumes/66/ss/pdfs/ss6619.pdf
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Addressing the Opioid Crisis in Indian Country
IHS recognizes the importance of collaborating and consulting with
tribes to develop a comprehensive plan for addressing the opioid crisis
in Indian country. IHS partners with its tribal advisory committees,
including the Tribal Self-Governance Advisory Committee, the Direct
Service Tribes Advisory Committee, and the National Tribal Advisory
Committee on Behavioral Health to gather input on critical next steps
to address the opioid crisis. The opioid crisis has been a priority on
recent meeting agendas for the advisory committees and will be a topic
for future meetings as well.
IHS strengthened and prioritized efforts to address the opioid
crisis in 2012 and developed a number of recommendations focused on six
areas: patient care, policy development/implementation, education,
monitoring, medication storage/disposal, and law enforcement. In March
2017, IHS chartered the National Committee on Heroin, Opioids and Pain
Efforts (HOPE). The HOPE committee, which consists of multidisciplinary
health care professionals across IHS, works to advance the Department's
multifaceted plan to combat opioid abuse: (1) better prevention,
treatment, and recovery services; (2) better targeting of overdose
reversing drugs; (3) better data on the epidemic; (4) better pain
management; and (5) better research. To address better research, IHS
partners with the National Institutes of Health on research addressing
health disparities and health priorities within Indian communities.
The HOPE committee is reviewing and updating IHS policies to ensure
they are aligned with the most current national guidelines and
addressing the most urgent needs. For example, the IHS ``Chronic Non-
Cancer Pain Management'' policy, originally published in 2014, was re-
released earlier this year to align with the 2016 CDC Guidelines for
Prescribing Opioids for Chronic Pain. This policy also requires
mandatory opioid training for all Federal controlled substance
prescribers with required refresher training every three years.
The IHS Prescription Drug Monitoring Programs (PDMP) policy
strengthens the monitoring and deterrence of prescription misuse and
diversion by requiring IHS providers to check state PDMP databases
prior to prescribing opioids for longer than seven days. IHS has
partnered with all states where IHS federal facilities are located and
has successfully connected with 17 out of the 18 state PDMP databases,
allowing access for 82 of the 83 IHS facilities offering pharmaceutical
services. The IHS PDMP policy also requires IHS practitioners to
conduct peer reviews of prescriber activity. Additionally, under the
IHS policy, pharmacies must report opioid prescribing data to state
PDMPs--a proactive requirement not currently required by law. IHS is
also working to establish two additional policies to expand access to
medication assisted treatment (MAT), and to standardize how first
responders in American Indian and Alaska Native communities are
provided naloxone, a medication for reversing opioid overdoses.
To address the shortage of specialists who can provide MAT in rural
tribal communities, IHS is training its current workforce to provide
these specialty services. Over the last two years, IHS partnered with
the Substance Abuse and Mental Health Services Administration (SAMHSA)
to train nearly 70 physicians to obtain their Drug Addiction Treatment
Act waivers to treat opioid use disorders, which increases access to
treatment services in American Indian and Alaska Native communities. In
2008, IHS established the Telebehavioral Health Center of Excellence
(TBHCE) which provides, clinical services, provider education and
technical assistance throughout the Indian health system. The TBHCE was
developed to support remote and isolated American Indian and Alaska
Native communities and areas with limited access to behavioral health
services. These services directly equip IHS staff to reduce morbidity
and mortality surrounding the opioid epidemic. Currently, the TBHCE is
providing training on MAT for opioid use disorder, which uses Food and
Drug Administration approved pharmacological treatments, in combination
with psychosocial treatments and social supports.
Additionally, IHS offers weekly continuing education on pain and
addiction as well as consultation on complex cases to further train
primary care clinicians to provide these specialty MAT services.
Consultation is offered through virtual clinics hosted by the
University of New Mexico to connect primary care clinicians with expert
teams to share knowledge and elevate the level of specialty care
available to patients. There are some promising signs of the positive
outcomes as a result of these efforts. For example, a preliminary
analysis of available IHS data indicates a 13 percent decrease in the
average number of opioid prescriptions per 100 of all IHS users from FY
2013-2016. \2\
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\2\ IHS--National Data Warehouse
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The Tribal Law and Order Act requires HHS, the Department of
Justice, and the Department of Interior to coordinate efforts on
alcohol and substance use issues in Indian country. IHS is actively
involved in interagency coordination and collaboration on tribal
alcohol and substance use programs. As part of this effort, tribes are
encouraged to develop Tribal Action Plans (TAP) to address substance
use and opioid use in their communities. IHS is an integral part of the
TAP workgroup that works with tribes to help them gain access to
government resources and coordinate efforts in order to achieve our
shared goals of preventing and treating substance use disorders.
IHS partners with the Bureau of Indian Affairs (BIA) to train and
equip law enforcement officers (LEOs) to recognize signs and symptoms
of overdoses and intervene when the overdose is occurring. As of
December 2017, the IHS trained and provided naloxone at no cost to BIA
for more than 300 LEOs and certified 47 BIA LEOs as naloxone trainers.
In direct care facilities, IHS has also been providing naloxone
supplies, training and tool kits to tribal law enforcement. IHS
encourages its pharmacists to co-prescribe naloxone to patients who are
at higher risk for opioid overdose based on criteria developed with
primary care clinicians, and as a result the number of naloxone
prescriptions has increased by 518 percent from FY 2013 to FY 2017.
IHS has developed a data reporting system that will provide
prescribing data on national, regional, and local levels. We will track
data focusing on the overall improvements and monitoring of prescribing
practices and procurement. Regional data will be used for comparison
with state-level data from the CDC and among other facilities in their
region, as well as nationally. We will use the information to identify
areas of improvement, monitor trends, intervene early and effectively,
and enhance efforts to train medical providers.
IHS Behavioral Health and the Alcohol and Substance Abuse Program
Addiction is complex, but treatable. Unfortunately, there is no
single treatment that is right for everyone. The IHS Alcohol and
Substance Abuse Program (ASAP) provides funding, policy, training, and
technical assistance to local IHS, tribal, and urban Indian programs to
ensure a variety of treatment options exist. Approximately 90 percent
of the FY 2017 ASAP budget of $205 million is contracted or compacted
by Tribes enabling those programs to deliver treatment services
tailored to meet their local needs. These programs provide services at
all stages of recovery from detoxification, behavioral counseling,
outpatient and residential treatment, and long-term follow up to
prevent relapse.
IHS also targets suicide and substance use and misuse prevention
through the Substance Abuse and Suicide Prevention (SASP) program. As
of FY 2017, SASP funds approximately $30 million to 175 IHS, Tribal,
and Urban Indian Health organizations to develop and implement
culturally appropriate, evidence-based and/or practice-based, community
driven models. We fund 19 projects that focus specifically on
methamphetamine and substance abuse prevention, treatment, and recovery
programming. The majority of the SASP projects focus on prevention and
early intervention strategies to reduce risk factors for suicidal
behavior and substance use among American Indian and Alaska Native
youth. A total of 108 funded projects work with Native youth to
increase resiliency, teach coping skills, promote family engagement,
and hire behavioral health providers who specialize in treating
children, youth, and families. The SASP program is currently in its
third year and IHS will evaluate SASP data to better understand the
full impact of the program, what is working in tribal communities,
disseminate best practices, and share lessons learned.
IHS is addressing the need to assist youth with substance use
disorders including opioid dependency through twelve Youth Regional
Treatment Centers (YRTCs). The YRTCs provide a range of clinical
services to provide treatment rooted in culturally relevant, holistic
models of care.
IHS actively solicits feedback and works with the tribes to develop
and implement models of care that are sustainable to combat the opioid
crisis. We focus on treatments that are evidence-based and culturally
effective that will have a significant impact on the prevention,
treatment and recovery efforts. To sustain this strategy, IHS is
collaborating with key stakeholders to develop viable reimbursement
models for services provided, while advocating for reimbursement for
traditional and culturally based practices, a critical approach to
opioid recovery in tribal communities. This comprehensive strategy will
allow for a more unified approach with tribal communities and also
afford IHS the time to evaluate the impact of these interventions. IHS
will continue to work with Tribes to develop coordinated responses
using every available resource possible to battle the opioid crisis in
tribal communities.
Thank you for your commitment to improving health care for American
Indians and Alaska Natives by addressing the opioid crisis as a top
priority. I will be happy to answer any questions the Committee may
have.
The Chairman. Thank you.
We will now start five minute rounds of questioning.
Captain Jones, your written testimony outlined the
Department of Health and Human Services' five point strategy
which establishes a framework for substance abuse and mental
health services and SAMHSA's efforts to combat the opioid
addiction epidemic.
I would like to hear about benchmarks for success and how
you gauge the effectiveness of these kinds of programs? What
are your metrics?
Dr. Jones. Thank you for the question.
Through the Department, we are currently working through a
process to finalize what are the exact measures we want to have
over time, looking at shorter term behavioral changes, such as
changes in opioid prescribing, increases in the number of
people who are receiving addiction treatment, morbidity and
mortality measures and reductions in emergency department
visits and overdose deaths. Through that process of the five
point strategy, we are working to do that.
We have not specified exactly what our points of success
are but we have learned from prior experience that oftentimes,
as in the case of naloxone, we previously had a goal of
increasing by 25 percent the prescriptions dispensed for
naloxone. We actually found that there was such a tremendous
movement at the State level on standing orders and other things
for naloxone that we saw about a 1,000 percent increase. We
want to make sure we are calibrating this with the facts
happening on the ground. It is a process we are working through
and have not finalized yet.
The Chairman. You are setting metrics but are working
through a process?
Dr. Jones. Yes.
The Chairman. Rear Admiral Toedt, the same question?
Dr. Toedt. Thank you, Mr. Chairman.
IHS has committed to addressing the opioid crisis in
American Indians and Alaska Native communities. The key to this
approach is partnering with tribal communities, listening to
them and being responsive to their concerns.
Some of the examples IHS is looking at for metrics and is
measuring at the national level include pain management and
opioid-related policy implementation. This is evidenced on our
National Accountability Dashboard which is on our website.
We are looking at opioid prescribing trends, access to
medication-assisted treatment, use of telebehavioral health and
naloxone. There will be many more metrics that we need to
develop. We want to partner with tribes to do that.
The Chairman. Mr. Anderson, could you talk a bit more about
the HOPE Initiative? Also, could you touch on why right now the
High Intensity Drug Trafficking Program is under the control of
the Office of the National Drug Control Policy and why the
Administration wants to move that?
Mr. Anderson. Chairman Hoeven, the HOPE Initiative, as it
has been coordinated and implemented in my District of New
Mexico, is a partnership between the U.S. Attorney's Office in
New Mexico and the University of New Mexico Health Sciences
Center. It has a number of prongs including prevention,
education, public outreach, law enforcement, as well as
rehabilitation and reentry components to it.
The principal efforts of the HOPE Initiative at this point
have been public outreach to educate the public, in particular,
the youth, on the dangers of opioid abuse. In connection with
the U.S. Attorney's Office, the HOPE Initiative has developed
an educational program called Roll the Dice that is directed at
educating youth on the dangers of opioid misuse. That program
is culturally tailored for presentation in our Native
communities.
The other aspect of this is the Naloxone Initiative. We
have been at the forefront of educating first responders about
the benefits of naloxone and educating them about how to
properly use that in the hope that it is more widely deployed
for its live-saving potential.
The Chairman. Thank you.
Rear Admiral Toedt, could you talk a bit about how IHS is
doing in terms of partnering with State-based prescription drug
monitoring programs?
Dr. Toedt. Yes, Mr. Chairman.
Our partnership includes linking the ability for the
electronic medical record to upload that prescription data to
the prescription drug monitoring programs. In sites where the
Indian Health Service Federal pharmacies exist, we have been
able to successfully partner with 17 out of the 18 States so
far. We are working with the final State to connect the
prescription drug monitoring programs to the electronic medical
record.
We also work with tribes in their States as well at their
request if they are using the IHS electronic medical record to
link to the prescription drug monitoring programs.
The Chairman. Are you seeing that making a real difference?
Dr. Toedt. Absolutely. Prescribers are able to see which of
their patients are getting prescriptions perhaps from other
providers. One of the things patients will do is sometimes they
will have to seek medications from different providers both
inside and outside our system. Using the State Prescription
Drug Monitoring Database ensures we get the broadest input as
to where they may be getting prescriptions.
The Chairman. Vice Chairman Udall.
Senator Udall. Thank you, Mr. Chairman.
Mr. Anderson, as the new U.S. Attorney for New Mexico, you
will be directly responsible for upholding the Federal
government-to-government relationship with each of the 23
tribes in New Mexico, several of whom you mentioned in your
testimony.
What are your plans to engage with tribes in New Mexico to
address public safety issues like the opioid epidemic in Indian
Country?
Mr. Anderson. Senator, the United States Attorney's Office
in New Mexico has an active outreach program, some of which is
mandated by statute through the Tribal Law and Order Act. We do
an annual consultation with all the tribes to address matters
of concern.
We also host regular educational outreach and communication
opportunities. Just last week, prosecutors from my office were
presenting to both the Navajo Nation and in the Espanola area
on this very topic, heroin and opioid awareness. The thrust of
that presentation was to educate in particular tribal law
enforcement on this opioid crisis we are discussing today.
In addition, my office has a dedicated tribal liaison
tasked with ensuring open and prompt communication between the
U.S. Attorney's Office and the tribes and ensuring that any
issues they raise in the course of those communications are
properly addressed.
On a more basic level, line prosecutors in my office
routinely communicate with their tribal counterparts in tribal
law enforcement, in particular, on a case basis. In that
context, they address any concerns the tribes may have.
Senator Udall. Thank you. Can I get your commitment that
you will meet regularly with New Mexico's tribal leaders to
develop your office's Indian Country public safety priorities?
Mr. Anderson. That is certainly something we are committed
to doing, Senator. Again, I believe we have an active and
robust communication process and will maintain that in the U.S.
Attorney's Office.
Senator Udall. Just last December, DOJ's OIG released a
report confirming what tribes have told us. According to this
report, nationally, Indian Country case declinations increased
by 20 percent between 2013 and 2015. Even more of a concern,
the report showed the number of referrals from DEA for crimes
in Indian Country decreased by 81 percent.
Based on this OIG report, Mr. Anderson, should DOJ law
enforcement and the U.S. Attorney's Office be doing more to
investigate and prosecute drug crimes in Indian Country?
Mr. Anderson. Senator, the U.S. Attorney's Office and the
Department, in general, are committed to robust enforcement of
drug laws in Indian Country. The DEA is actively involved in
that in coordination with the BIA and the Department of Justice
and my office will continue to focus on robust enforcement of
those laws in our tribal communities.
Senator Udall. Do you know how many current Indian Country
cases are pending before your office and how many of those
cases are drug-related?
Mr. Anderson. Senator, in preparation for today's remarks,
I looked into that. I can tell you in fiscal year 2017, we
prosecuted 49 violent crimes in Indian Country cases. That is a
subset of the total number of cases we addressed in Indian
Country. It does not include drug crimes, assaults on law
enforcement officers or sexual assaults in Indian Country which
would vastly increase that number.
We do not track at this point for drug cases, which ones
arise in Indian Country and which ones do not because it is a
statute of general applicability but again, I can tell you that
in New Mexico, enforcement is robust.
Just last year, we recently did the first Title III wiretap
case in Indian Country. We also had a substantial seizure of
methamphetamine on a case developed and worked on the Navajo
Nation. Those efforts are ongoing and are certainly a priority
for us in the Department.
Senator Udall. Can I get your commitment that you will
speak to your Federal law enforcement counterparts about
increasing their investigation efforts in Indian Country?
Mr. Anderson. Certainly, Senator. We will continue to
promote those communications. Again, Federal law enforcement is
quite active in Indian Country in partnership with the BIA and
our tribal law enforcement.
Senator Udall. Will you also commit to reviewing your
office's Indian Country declination rates and working with
tribal leaders to identify and resolve any barriers to
prosecution?
Mr. Anderson. We will certainly do that, Senator. We
constantly reevaluate the process by which we decline cases. We
carefully scrutinize those brought to us. We do our very best
in that area, Senator, and will continue to make that a
priority.
Senator Udall. Great. Thank you very much. I appreciate it.
The Chairman. Senator Lankford.
STATEMENT OF HON. JAMES LANKFORD,
U.S. SENATOR FROM OKLAHOMA
Senator Lankford. Gentlemen, thank you for being here and
for the conversation. You all know this is exceptionally
important, not only to the Nation, but obviously to Indian
Country and all of us as well. This is a big issue and affects
a lot of families and our communities.
Let me start where I typically like to start. We have not
had an opportunity to talk about it. In Indian Country, can you
tell me a good example in a tribal area either in interdiction,
recovery or prevention, any of those three, that you would say
this particular tribe or this particular location or State is
doing an exceptional job in one of those three that you can
pull out and say what they are doing is working? Mr. Anderson.
Mr. Anderson. Thank you, Senator.
There is always room for improvement in our efforts to
combat the opioid epidemic. I think we have had successes along
the way in both the prevention and enforcement areas,
recognizing there is continued room for improvement in terms of
our collaborative efforts with State, local and tribal
authorities.
In New Mexico, we have had some successes to include a
prosecution that centered on the Navajo Nation that happened to
be a methamphetamine case. My office viewed it as a substantial
victory on the enforcement front against trafficking in Native
communities.
Again, we are tribal partners and are working to improve,
recognizing that certainly given the state of affairs, there is
room for improvement.
Senator Lankford. Can you give me a good example of any one
location that really stands out to you more than others at this
point?
Mr. Anderson. Senator, the case we had on the Navajo
Nation, I think, was a real victory.
Senator Lankford. I will take that. Any others?
Dr. Toedt. Thank you, Senator Lankford. I appreciate the
opportunity to highlight a program.
The Indian Health Service has 12 Federal and tribal youth
regional treatment centers. One of those youth regional
treatment centers, Desert Visions Youth Wellness Center, has
made tremendous efforts on incorporating traditional practice
into the evidence-based care. It was highlighted in the Surgeon
General's report, Facing Addiction in America, as a best
practice. Desert Visions used dialectical behavior therapy, an
evidence-based approach for the treatment of substances, while
incorporating sweat lodge ceremonies, talking circles and
smudging ceremonies.
Senator Lankford. Thank you.
Captain Jones.
Dr. Jones. I will just identify Project HOPE which is in
Alaska. It is not tribal specific but has had a large tribal
component that uses SAMHSA's funding for naloxone training.
When you look at some of the metrics, there were 1,300 people
trained, 8,900 naloxone kits distributed, and 45 overdose
reversals.
In particular, in a very disparate, rural State like
Alaska, I think this is an example, in particular, of where
tribes can engage with States. I would highlight that as an
example.
Senator Lankford. Captain Jones, we have been able to
identify exactly the makeup of what is the typical overdose and
that individual in Indian Country, male, female, a certain age,
and marital status. What is the normal on that?
Again, I know it will be all over the map. Opioid addiction
is no respecter of persons, but is there something we have
identified to say is more typical?
Dr. Jones. I would say the typical makeup of an overdose
case is not necessarily different among American Indians and
Alaska Natives than it is for say, non-Hispanic Whites, which
the group that looks most similar as far as overdose death
rates. You tend to see higher overdose death rates among males
and more than one drug involved. Although we often label them
as opioid overdose deaths, they often involve alcohol or
benzodiazepines, and other substances of abuse.
When you look at age groups, it is very interesting because
of the rise in heroin use and the proliferation of illicit
fentanyl and fentanyl analogs. We actually now see two age
groups that are most impacted.
The highest overdose death rates for fentanyl, synthentic
opioids and heroin are among 25 to 34 year-olds. For
prescription opioids, it is 45 to 54 year-olds. For many years,
we just sort of saw the top point at 45 to 54 but now we see
the distribution that is quite different depending on the drug.
We know those things about individuals. We tend to see
variations for more heroin or synthetic opioids in more urban
areas and rural areas still tend to be heavily influenced by
prescription opioids.
Senator Lankford. Tell me about the cooperation with the
Office of National Drug Control Policy and how that is working
specifically in coordination with Indian Country because when I
see the total budget, I have gone through it, for the Bureau of
Indian Affairs and drug control funding, it is about $9.7
million.
Obviously, brings out other areas. What is the cooperation
like? Obviously that is not going to be enough to be able to
cover it.
Dr. Jones. I will speak from my perspective at SAMHSA. We
work very closely with ONDCP and other components at the White
House to plan out the national drug control strategy and the
broader framework for addressing substance abuse issues in the
U.S.
From the SAMHSA perspective, in fiscal year 2017, we issued
$36 million in substance use funding to tribes. There is about
$83 million currently eligible for tribes in fiscal year 2018
as part of the larger pot of grant funding that is available.
I cannot comment specifically on BIA but we do work
closely.
Senator Lankford. You have funding that is separate, BIA
has funding, and others have funding. I am trying to figure out
how the coordination between all of those is going as far as
planning out how it is going to go and where it is going?
Dr. Jones. ONDCP has responsibility for the drug control
budget. They issue letters to departments each year as the
budget process is in the works. We respond to those requests
from the Department's perspective.
We say what is ONDCP asking of SAMHSA in their coordination
role, we would respond that these are the President's
priorities, here is where we think our budget lines up with
this or we can add money here or there in the budget's request
and then ONDCP, OMB and others work out those things.
Senator Lankford. Thank you.
Thank you, Mr. Chairman.
The Chairman. Senator Smith.
STATEMENT OF HON. TINA SMITH,
U.S. SENATOR FROM MINNESOTA
Senator Smith. Thank you very much, Chairman Hoeven and
Ranking Member Udall. Thank you very much to all of you
gentlemen for being here today.
I would like to talk with you a little bit and get your
thoughts on the question of culturally-based treatment and dive
into that a little more.
We often talk a lot about the immediate impacts of the
opioid addiction on people but also we know we need to think
about this in terms of two generations or multiple generations.
Children of mothers who are addicted to opioids are at risk of
being born of course with Neonatal Abstinence Syndrome which is
a particularly terrible problem.
The Leech Lake Band in Minnesota has actually declared a
public health emergency related to the opioid epidemic in
maternal and child health because so many babies are being born
with Neonatal Abstinence Syndrome.
I would like to hear from Captain Jones or Rear Admiral
Toedt if you could tell us a little bit about what you are
doing to expand access to treatment for pregnant women?
Dr. Jones. Thank you for the question.
I think this is an important area and certainly an area
that has received increased attention over the last several
years. Our perspective at SAMHSA is that we need to look at
this comprehensively, not neonates who are born physically
dependent and siloed from the mother who was addicted during
the pregnancy.
A couple of programs we have in place are trying to build a
comprehensive suite of services to address the needs of mother
and baby and even family, and include our pregnant and
postpartum women grant programs.
We have two different programs. One is a residential-based
program. We funded 19 grantees last year. Under CARA
legislation, we have a new pilot program at the State level for
essentially outpatients, trying to move that comprehensive
suite of services to the outpatient setting.
We know sometimes going in-patient is very much needed for
post-partum women or someone who is pregnant. Also that brings
its own constraints of, how do you manage your responsibilities
as a parent if you have older kids and trying to make sure
those systems are in place to support residential care when
needed. Also looking at, if we provide high quality evidence-
based treatment in the outpatient setting, how does that help
connect them to the regular part of their day, to other kids or
other family responsibilities? We are looking at both of those.
We also have family treatment drug courts which use the
drug court model but try to address the family aspect of this
issue. I think across all three of those programs, it is very
important that it is not just about providing the medication or
addiction treatment, it is what are the recovery supports, the
housing, employment and what are the other supports that really
set a family as well as the individual who is addicted up for
success as they are leaving?
We have also issued a variety of different guidance
documents and communications around how to do this in practice.
If you are not one of our grantees, how do you go about doing
it because many communities are affected by this?
Most recently, we issued a clinical guidance for treating
pregnant and parenting women who have opioid use disorder and
treating of the infants. It is really the playbook of how the
clinicians go about doing this in a comprehensive manner. We
are trying to address both through our funding streams as well
as training and technical assistance that system that needs to
be built to address the needs of those individuals.
Senator Smith. Thank you very much. I think what you said
is very important because the old way of thinking about this is
to separate moms from their babies. Oftentimes, that is exactly
the wrong thing to do if you want everyone to recover.
Dr. Jones. We know people often do much better if they are
there. Certainly, if you are a mom and preoccupied with
thinking about what is going on with your kids, it is really
hard to pay attention to treatment and address the things right
in front of you.
Senator Smith. Thank you very much.
Admiral Toedt, would you like to add anything?
Dr. Toedt. Yes, Senator Smith. Thank you.
I agree entirely with your comment about the importance of
bonding between mothers and infants. All of our hospitals in
the Indian Health Service which deliver babies are baby
friendly hospitals in support of the mother-baby dyad of
keeping them together.
The Indian Health Service is partnering with professional
organizations such as the American College of OB-GYN and the
American Academy of Pediatrics to create culturally appropriate
guidelines for care such as the Neonatal Withdrawal Syndrome
guideline.
We also are increasing screening to mothers identified as
at risk who may benefit from early referral to medication-
assisted treatment programs. We are increasing the number of
treating providers by training nurse practitioners and midwives
through increased authority through the Comprehensive Addiction
and Recovery Act.
Senator Smith. Thank you very much.
Mr. Chairman, I see I am almost out of time but I want to
thank Senator Lankford for his question about giving us
examples of what works.
The Chairman. I am sorry, Senator Smith. We do not have
time for thanking Senators.
Senator Smith. I am still learning all the rules, Chairman
Hoeven.
The Chairman. Please go ahead.
Senator Smith. I appreciated that question. I wanted to
mention that on the White Earth Reservation in Minnesota, we
have a program called the MOMS Program which specifically
focuses on what we have just discussed, how to help support
pregnant women and then moms and babies. I think it is a good
example of something that could be applied in lots of different
places.
Thank you.
The Chairman. Thank you, Senator.
Senator Cortez Masto.
STATEMENT OF HON. CATHERINE CORTEZ MASTO,
U.S. SENATOR FROM NEVADA
Senator Cortez Masto. Thank you.
Thank you, gentlemen, for being here today. Let me start
with Captain Jones and Rear Admiral Toedt.
After talking with our Washoe Tribes of Nevada and
California, what I am hearing from many of our tribes is that
tribal-specific funding streams to address the opioid epidemic
in our tribal communities was not included in the 2017 State-
targeted response to the opioid epidemic grants. Is that true?
Dr. Jones. Correct. The statute basically limits
eligibility to States.
Senator Cortez Masto. Don't you think there should be
targeted grant funding to address these issues in tribal
communities?
Dr. Jones. We certainly would be willing to carry forward
however Congress appropriates or authorizes those dollars.
Senator Cortez Masto. Are they needed?
Dr. Jones. I think we have described today that there is a
substantial problem in Indian Country. We have taken as many
flexibilities as we can.
Senator Cortez Masto. I will take that as a yes.
My colleague talked to you about culturally-appropriate
treatment. I believe in it. I think not only do we need
culturally-appropriate but we need trauma-informed treatment as
well. Can both of you talk a bit about that? Do you provide
trauma-informed treatment as well when we talk about substance
abuse needs and treatment in the tribal communities?
Dr. Toedt. Yes, ma'am.
We entirely support trauma-informed care. It is very
important to get to the root of the problem. So many patients
that are seeking relief from opioids may actually be suffering
from untreated mental illness. They may also be suffering from
economic disparity, historical trauma, or a lot of issues that
came up through childhood as well.
Having an understanding of a person's background and
culture, where a person is coming from, is very important to
being able to effectively bond with them, make a connection and
deliver effective treatment.
Senator Cortez Masto. Thank you.
Dr. Jones. I think trauma-informed care and the importance
of addressing co-occurring substance use and mental disorders
are infused throughout our grant programs.
Senator Cortez Masto. Fantastic.
Rear Admiral, do you have the resources you need to provide
that level of care?
Dr. Toedt. I appreciate the question.
The IHS wants to be responsive to tribal concerns. I have
heard from tribes that there are not enough resources out
there. Certainly any funding that Congress can provide will
definitely be appreciated.
Senator Cortez Masto. I also hear from our tribes that it
is difficult to get that treatment. I have heard a lot of
conversation about working with our States but the States
already have tapped out trying to find the treatment they need
for substance abuse within their States.
Requiring our tribes to work with the States to fight for
that money is difficult and makes it much harder to get the
resources to our tribal communities. Wouldn't you agree with
that?
Dr. Jones. I think building the capacity is really the
importance of the STR funding and other training and technical
assistance we are applying broadly across the U.S., even
specific to tribes around training and technical assistance.
We could have multiple billions of dollars that could be
spent on treatment but if we do not have providers who can
provide that care, whether you are in Indian Country or not,
you are not going to be able to get access to evidence-based
care. Really a core part of the work we are doing is to build
that foundational capacity.
Senator Cortez Masto. Would you agree that a special
behavioral health program for Indians that parallels the
structure of the existing Special Diabetes Program for Indians
to provide substance abuse prevention, intervention and other
needed behavioral health services might be an answer to
addressing these substance abuse needs in tribal communities?
Do you think the Diabetes Program is a good model to
emulate?
Dr. Toedt. Thank you, Senator.
We absolutely think that the Diabetes Program has been an
excellent model. Emulation of that funding model is something
we have heard from tribes. Yes, it is an excellent idea.
Senator Cortez Masto. Thank you.
I have one final question for Mr. Anderson. Thank you for
everything you do.
First of all, I do know U.S. Attorneys and AUSAs across the
Country are working very hard in our tribal communities. You
are tapped for resources. I know that. I will say that as
somebody who worked in my State in law enforcement.
Chairman Hoeven asked you about the impact of moving HIDTA
out of the Office of National Drug Control Policy. Can you talk
a bit about HIDTA and how important those grants are and how
effective HIDTA is in our communities?
Mr. Anderson. Senator, HIDTA certainly is an important part
of what we do with the Federal partnership focusing on those
high intensity drug corridors throughout the Country.
In terms of the structure of HIDTA or its funding, that is
not something I can discuss today but I can tell you that they
are, from the Federal law enforcement perspective, a critical
aspect of our efforts to interdict the flow of illegal drugs,
including opioids, heading to and that end up in our tribal
communities.
Senator Cortez Masto. Thank you. Critical and effective,
right?
Mr. Anderson. Yes.
Senator Cortez Masto. Let me just say this. We are
combating opioids now and it is a crisis across the Country.
Ten years ago, it was methamphetamines. It is black tar heroin.
I can promise you that unless we address this through
treatment, dollars and fighting, not just assuming law
enforcement will do it all, we are going to constantly see this
shifting from methamphetamines to black tar heroin to the
opioids in our communities.
It is a scourge that we need to address. We have to come
together on the treatment and law enforcement sides and
adequately fund in all of our communities, including our tribal
communities to really combat the crisis we have across this
Country.
Thank you.
The Chairman. Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman.
Gentlemen, thank you all for what you do respectively. I
apologize that I was not able to hear some of the colleagues'
questions. Again, these are issues that are so key and
important.
Captain Jones, I appreciate you mentioning the Project HOPE
Program and how it is working or helping in Alaska.
I mentioned in my opening not just the opioids and how that
has ravaged us but also alcohol. I will just cite our annual
drug report which acknowledges the multifaceted drug abuse
problem in the State. Drug abusers in Alaska tend to abuse more
than one substance, oftentimes multiple substances. The drug of
choice is alcohol, heroin, meth, cocaine, prescriptions and
marijuana. They emphasize that alcohol was the single-most
abused substance.
As we have been focusing our efforts here in Congress on
opioid, opioid, opioid, I don't want us to lose sight of the
fact that underlying so much of this is alcohol and fail to
provide the support for programs and grants in that alcohol
space as well. When we talk about substance and substance
abuse, we need to make sure that it is alcohol and substance
programs. Everyone is shaking their heads like you agree with
me. We do not need to bifurcate these. These are all one big,
ugly, horrible problem with which we are dealing.
Let me ask about what I will call a workforce issue. Our
reality is that we have identified the problem and some of the
solutions. However, we know so much of this comes back to
making sure we have mental professionals able to be there, to
be that support.
I have been working with my colleague from Indiana, Senator
Donnelly, on an effort that would incentivize those to go into
substance use disorder treatment work. Basically, it is a loan
forgiveness program we think will be helpful in incentivizing
more.
I have to assume part of the challenge we are facing is we
simply do not have enough mental professionals to help us. Is
that so? I am getting head nods. We need to work on that as
well.
Here is my question to you. This is intended to help at
least three individuals in the audience. I met with the Mayor
of Utqiagvik who is with us today and two others who are part
of her council. They mentioned that in Utqiagvik, formerly
Barrow, the issue relating to opioids and drugs, again the
intensity we cannot single out enough.
From an enforcement perspective, I will look to you, Mr.
Anderson. They say they do not have a district attorney there
and that prosecution for these drug offenses is not moving
forward.
The drugs come in by mail and plane. We know how they get
in but we cannot get attention on anything unless it is at the
full felony level. People know that they can sell, deal, and
use. There is no follow up, consequence and no enforcement.
What would you tell the Mayor of Utqiagvik?
Mr. Anderson. Senator, I would urge the Mayor to work to
seek Federal grants to develop that type of thing. There are
Federal grants available through the Department of Justice's
Comprehensive Opioid Abuse Program. I would hope those could be
used to develop that type of legal infrastructure described in
your question in posing that issue.
Certainly it is an important component of addressing this
crisis, that we have that law enforcement infrastructure in
place. I understand that in your State and many of our tribal
communities, there is a shortage of access to courts and
related resources.
I would urge those communities to apply to the Department's
grant program to be able to fund that type of infrastructure. I
think that is critical to proper enforcement in combating the
opioid epidemic.
Senator Murkowski. I appreciate that.
Mr. Chairman, I also recognize we hear from a lot of our
constituents that we are basically setting tribes up to compete
with other tribes when they all have significant need. You have
some tribes that perhaps might not have the band width to
submit. I think a community like Utqiagvik is probably
positioned a bit differently.
It is something I recognize. We have some gaps. We have
been talking about tribal courts and the opportunities they may
present to help address some of these issues on the enforcement
side. We know we have a lot of work to do.
I am over my time. I could spend all afternoon with you.
Thank you again and thank you for your work.
The Chairman. Senator Tester.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Mr. Chairman.
I want to thank you all for being here. I want to follow up
a bit on the Ranking Member's line of questioning on
declinations.
Ten years ago, if my memory serves me correctly, when Byron
Dorgan was chairman of this Committee, we talked about how
declinations were way, way too high in Indian Country. From
2013 to 2015, the U.S. Attorney's Office declinations increased
by another 20 percent, according to the Ranking Member's
information.
In this case, increase is not a good thing. Declinations
increased by 20 percent. Can you tell me why?
Mr. Anderson. Senator Tester, we are committed, obviously,
to constantly look at why the declination rate in Indian
Country moves the way it does. It is an important figure for us
to follow and to work to reduce that declination figure.
Senator Tester. I got you. But that does not answer my
question. It does not make any sense to me. Is it that we do
not have enough FBI agents or you do not have enough people on
your staff? What is going on?
As I said, it has been fully 10 years, probably 11, and was
probably a problem 10 years before that. I am not blaming you.
I just need to know why because it is unacceptable. What can
this Committee do to make it work so there aren't these kinds
of declinations in Indian Country? In Montana, that is what the
highest crime rate is.
Mr. Anderson. Senator, I am not sure I can give you an
answer for why over a period that long, for example, 10 years,
the declination rate has gone the way it did. I can hypothesize
and am hopeful that it may be an increasing number of reported
crimes. Obviously, every case that is opened by my office in
New Mexico is carefully examined by an Assistant U.S. Attorney
and worked by an FBI agent.
Senator Tester. I will use the Ranking Member's numbers
again. Between 2011 and 2014, the numbers referred to the U.S.
Attorney's Office decreased by 81 percent.
Here is the problem and what I would love to have you do. I
know you are fairly new to this position. Could you take it
back to your group and tell us why? That is all I want. Is it
because of the sovereignty issue and there is no cross work
being done as far as law enforcement or is it because the FBI
has not put enough people in this Country? As I said, is it
your staff?
We are not getting it done. I think it is a big issue in
Indian Country because of violence against women, which could
have to do with drugs, poverty or something else but it is
crimes and is serious stuff.
I think it is something we have always talked about. People
have come before committees like this and answered and it
continues to get worse. This position is not forever for you
but maybe it is. Udall says you are a good guy, by the way.
The truth is, in fact, if you can do something about this
and give us some instruction, put it back on us. Say, Indian
Affairs Committee, here is what you need to do and we can get
this fixed. We would be more than happy to work with you.
I want to talk to you, Captain Jones. You discussed the
budget request for fiscal year 2019 being $10 billion in new
resources across the Department of Health and Human Services.
This follows a question maybe Senator Smith asked.
Would you be opposed, when the Appropriations Committee
gets done with massaging these numbers, if they carve out a
certain percentage of that $10 billion for Indian Country?
Dr. Jones. Again, we are absolutely ready to carry forward
what direction we get from Congress.
Senator Tester. The question is if you oppose it, we will
never get it done. If you do not oppose it, then we would
probably do it and get it done.
Dr. Jones. I will say our posture has been where we have
been able to be flexible in putting setasides in place, when
there is not a statutory prohibition that funds can go to
different groups, we have tried to include tribe in setasides
or other means.
Senator Tester. I will try, and I think Senator Murkowski
would probably maybe do the same thing, to peel some of this
money off and dedicate it to Indian Country. I would hope you
would not oppose that when it comes through, okay? That is just
a little heads up.
I will make the last thing quick because I know Heidi has
some important questions to ask you guys. Can the money only be
used for opioids? Can it be used for meth also?
Dr. Jones. The STR dollars are an opioid-specific grant but
certainly we recognize that individuals have co-occurring
disorders using other substances.
Senator Tester. Are the STR dollars the $10 billion in
resources? Is STR what that is called?
Dr. Jones. The STR Program is the program created under the
21st Century Cures Act in the 2019 budget.
Senator Tester. That is fine, that is different. I am
talking about the $10 billion of new resources across the
Department of Health and Human Services. Can that be used for
opioids, meth and heroin, as far as that goes?
Dr. Jones. STR would be a component of that. Under the 2019
budget, that is an increase of $1 billion for the STR Program,
which is specific to prescriptions or illicit opioid. Heroin
would be in that group. The specifics of the remainder of the
dollars are still being worked out.
Senator Tester. Would meth be a part of it?
Dr. Jones. Again, to the extent they are co-occurring and
co-use of other substances.
Senator Tester. But it would not be in and of itself. That
is good. I would just ask you go back to your people.
Dr. Jones. I just want to say in the budget, we also have
requested $30 million for the Tribal Behavioral Health Grant
which is much broader.
Senator Tester. Did you say $30 million?
Dr. Jones. Yes, $30 million. Again, we try to be very
flexible.
Senator Tester. I am way, way over. I would just say we
need your help on this stuff. This is your budget and not mine.
I need to know what you had in mind when you crafted your
budget for this.
With that, I appreciate you being here.
Thank you, Mr. Chairman.
The Chairman. Senator Heitkamp.
STATEMENT OF HON. HEIDI HEITKAMP,
U.S. SENATOR FROM NORTH DAKOTA
Senator Heitkamp. Mr. Anderson, I want you to know that I
have asked all these questions of FBI Director Wray as well, so
I am not just picking on you. Do you think we need more FBI and
DEA agents in Indian Country, yes or no?
Mr. Anderson. Senator, I would have to figure it out. I
think it depends on each specific reservation.
Senator Heitkamp. No. I will tell you this. We need more
DEA and FBI agents in Indian Country. It does not depend on
anything.
The reason why you have declinations is you do not have
quality investigations. I will tell you that. The other reason
why you have declinations is because your limit in FBI and DOJ
is too high. It is too high because you guys treat it the way
you would if you worked in Indian Country.
You are the only jurisdiction in Indian Country. When you
do not show up, we do not have law enforcement. When there is
no law enforcement, we have mayhem and give out jail free zones
for drug dealers.
We have to have protection for people in Indian Country. I
can tell you it frustrates me to no end to hear a discussion,
Captain Jones, about well, you know, if you use opioids but
maybe you have a co-utilization. That is nonsense. Our problem
in North Dakota is not opioids. It is methamphetamine. It is
methamphetamine. It is killing whole generations of people in
my State. It has to end.
It has to end first from a law enforcement standpoint. We
can do all the treatment in the world but if these drugs flow
freely into Indian Country with no opportunity for change, we
will not change anything. We have to get law enforcement.
Mr. Anderson, you are just the brunt of my frustration
today. I have had this conversation with Directory Wray, the
then-nominee for the Attorney General and with DOJ officials
who deal with Indian Country, on drugs and trafficking in
Indian Country. We are screaming for help. We are screaming for
help. There is no one who lives in Indian Country who does not
recognize this. I just want to read the comments from Vice
Chairman Headdress from the Ft. Peck Assiniboine and Sioux
Tribes who attended our roundtable on this issue.
He asked ``Why service units or tribes cannot funnel some
of their purchase and referred care dollars for prevention and
treatment of opioid misuse?'' I will tell you in our neck of
the woods, there does not seem to be a coordinated response to
this problem in Indian Country. I mean across the board. You
see it right there.
I am telling you we are an endangered species in many
tribal organizations. It is because we are losing generations
to addiction whether it is alcohol, opioids or
methamphetamines. I cannot state it more clearly.
We need to do better. Hearings like this give us a chance
to vent but I hope a unified plan comes out of this. We are all
going to support setasides. I do not think there is any doubt
about it. Maria has been working on setasides for tribal
organizations.
To give you just a little example, in my State, the first
grants that went out, the opioid grants, there were I think
seven or eight applications. Two were denied; both were in
Indian Country. We eventually complained and the Governor found
some additional money to send to Indian Country.
It has to be culturally significant in the way Senators
Cortez Masto and Smith discussed. We need a plan. It cannot
just be about treating the addiction. It has to be a plan about
getting law enforcement on the ground. I hope you guys will
take from this an opportunity to sit down and actually come up
with a plan in consultation with the tribes because they are
screaming for help.
I ask to tell one story. A friend of mine, Paul Iron Cloud,
who was Chairman and head of housing for Pine Ridge, came to me
in one of his last visits. Unfortunately, he died of cancer
after his visit with me.
He was very frustrated. He said, ``Senator Heitkamp, we
need help. We need law enforcement. We need the FBI. We need
people to come help us.'' I said, ``Paul, where are the tribal
elders and where are the tribal communities?'' He looked at me
incredulously and said, ``We are afraid. All the good people
are hiding. They are afraid of what is happening in their
homes.''
This cannot continue, not in the United States of America.
We have murder rates that are unsurpassed in any other part of
the Country. This is driven by drugs and addiction and we need
to get to the bottom of this.
I am pleading with you, on behalf of all the people that I
represent who are pleading with me, please, please, please,
make this a top priority. If you care about law and order, this
has to be a top priority. If you care about Indian healthcare,
this has to be a top priority. If you care about changing the
dynamic for children in the future, this has to be a priority
or we will be nowhere.
I want to thank the Chairman for having the hearing. I want
to thank this Committee for being so engaged and involved. And
I want to pledge to you, as Senator Tester did, tell us what
you need and what will change the outcome. We will work with
you to make it happen. Tell Director Wray I had some strong
words.
The Chairman. I would like to thank our witnesses. Members
may also submit follow-up questions for the record. The record
will be open for two weeks. I want to thank the witnesses for
being here and for your testimony today. Panel One is
adjourned.
We will now set up our second panel. We will now hear from
our second panel. Our witnesses today are: Ms. Jolene George,
Behavioral Health Director, Port Gamble S'Klallam Tribe of
Kingston, Washington and Mr. Samuel Moose, Treasurer and
Bemidji Area Representative, National Indian Health Board,
Bemidji, Minnesota.
Ms. George.
Ms. George. Thank you, members of the Committee, on behalf
of the Port Gamble S'Klallam Tribe.
The Chairman. Ms. George, I am sorry to interrupt. I
understand Senator Cantwell wanted to give you a glowing
introduction and I do not want to get in the way of that. I
apologize.
Senator Cantwell.
STATEMENT OF HON. MARIA CANTWELL,
U.S. SENATOR FROM WASHINGTON
Senator Cantwell. Thank you, Mr. Chairman. I know we are
tight on time because there is a vote.
I did want to point out that Ms. George is Behavioral
Health Director for the Port Gamble S'Klallam Tribe in
Kingston. S'Klallam means ``strong people,'' by the way.
I am really happy she is here because she has been on the
front lines of the opioid crisis with her tribe and the
surrounding community. They have had numerous overdoses and
deaths stem from the opioid epidemic. Many of these deaths stem
from the fact that the drugs were prescribed by medical
professionals.
I believe Ms. George will talk about this crisis, how it
has impacted families and put a strain on law enforcement and
tribal services. She is also going to talk about the
collaborative approach that the Port Gamble S'Klallam Tribe has
used to address this abuse.
I think the Federal Government can learn something from her
and the Port Gamble S'Klallam Tribe in tackling this epidemic.
Thank you for being here today and thank you for the good work
in this area.
STATEMENT OF JOLENE GEORGE, BEHAVIORAL HEALTH DIRECTOR, PORT
GAMBLE S'KLALLAM TRIBE
Ms. George. Thank you again, members of the Committee, on
behalf of the Port Gamble S'Klallam Tribe, for this opportunity
to present the impacts of the opioid epidemic on our tribe and
what we need from Congress to effectively confront this issue.
I ask that my written statement also be included in the
record.
My name is Jolene George. I am a tribal member and the
Behavioral Health Director. We are a federally-recognized,
self-governing tribe, owning 100 percent of our reservation
lands with over 1,200 enrolled members.
As this Committee knows, we are disproportionately impacted
by opioids. The statistics you hear reflect our heartbreaking
reality as we struggle to confront the drug epidemic caused by
opioids flooding our community. Every family on our reservation
has been impacted by this epidemic. Many are grieving the loss
of loved ones because of it.
At a government level, these impacts cut across all
departments, complicating funding priorities and creating
competition for already scarce resources. I shared statistics
from our department to highlight the strain on staff and
resources.
At least 75 percent of our substance abuse patients are
opioid-dependent. These complex patients often utilize
behavioral health resources at a higher rate than other
patients. In our health clinic, pain management patients
overwhelm the schedule. Our family medicine physician has
become a pain management specialist.
In social services, 98 percent of our dependency cases are
due to drug use. In one year, 100 percent of our housing
program evictions were drug-related. Creating homeless drug
addicts does nothing but perpetuate the vicious cycle.
Opioids have increased crime and police focus on drug
interdiction means less time for other police priorities. Our
court system has had a 90 percent increase in drug and alcohol-
related cases over the past four years. Again, the impacts of
the opioid crisis cut across all aspects of our community and
our government.
The opioid epidemic is a complex issue and there is no
quick and easy fix for resolving it. We need a multi-faceted,
comprehensive approach with tactics that work.
We took note of the November 2016 Surgeon General's report
on Alcohol, Drugs and Health, which identified prevention as
key to the fight against abuse and addiction. Our tribe has
been working to implement just such an approach but we need
your help.
We have shown leadership and are aggressive in our
comprehensive response to the opioid epidemic with the
following. We have developed THOR which stands for Tribal
Healing Opioid Response. Unique about THOR is the coordination
among all departments, community engagement and the custom
strategies. THOR has three main goals: preventing opioid misuse
and abuse; expanding access to opioid use and disorder
treatment; and preventing deaths from overdose. We have self-
funded the opioid response.
While we have made a thoughtful and deliberate attempt to
combat this epidemic, we still experience many barriers.
Adequate and direct funding is necessary to continue our
coordinate efforts.
We support Senator Daines' bill which reflects the
government-to-government relationship and would make the tribes
eligible for direct funding. Our tribe participated in the
Indian Health Service Tribal Budget Formulation Work Group and
we support that request, including full funding of contract
support costs.
Forty-two CFR Part 2 is our biggest regulatory hurdle
towards behavioral health integration. Segmented care does not
work. Health care providers need to see a patient's complete
health record, including CD records to provide whole person
care. Congress can eliminate this hurdle by aligning the status
of chemical dependency records with medical and mental health
records under HIPPA.
The lack of co-location of primary care and behavioral
health services on our reservation only adds to our struggle.
We look to Congress for innovative ideas, perhaps through its
infrastructure package, for facilitating construction of co-
located health care facilities on tribal lands.
We support Senator Cantwell's bill, the CARES Act. This is
a good bill that would increase opioid prevention and treatment
funding, limit opioid prescriptions and enhance prescription
drug monitoring programs. We appreciate her work on behalf of
Indian Country and her early consultation with us on the bill.
As our chairman said, ``Our tribe has been devastated by
this epidemic. Opioids keep taking from our community. They
have torn apart our families and taken away loved ones.'' It is
my hope that, with your help and the agencies here, we can put
an end to the opioid crisis. The Port Gamble S'Klallam Tribe is
happy to share any of the resources we have developed with
other tribes. We formally invite the Committee members to visit
our tribe to learn more about our ongoing work and continue
this discussion.
I am going to leave with you a postcard with our THOR logo
designed by our tribal member and comic book artist, Jeffrey
Veregge, with our three main goals on the back.
I thank you for this opportunity to testify and I am happy
to answer any questions.
[The prepared statement of Ms. George follows:]
Prepared Statement of Jolene George, Behavioral Health Director, Port
Gamble S'klallam Tribe
Thank you, members of the Committee, on behalf of the Port Gamble
S'Klallam Tribe, for the opportunity to present the impacts of the
opioid epidemic on our Tribe, our response, and what we need from
Congress in order to effectively confront this issue.
I. About the Tribe, our Health Care System and Relevant Programs
The Port Gamble S'Klallam Tribe 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 Tribe's Reservation is home to about two-thirds of the
Tribe's 1,200 enrolled members. The Tribe is the only Indian health
care provider of both primary and behavioral health services in Kitsap
County, and proudly provides culturally appropriate health care to our
members and approximately 800 other American Indians and Alaska Natives
(AI/AN) and community members living on our Reservation.
The Tribe joined the Tribal Self-Governance Project, a consortium
of self-governing Indian Tribes, in 1990 and has directly provided
health services to its members for over 20 years. We fund our health
services though a compact with the Indian Health Service under the
Indian Self-Determination and Education Assistance Act, and operate and
manage our entire health system on our Reservation.
Our health system includes primary care, dental, mental health and
substance abuse services. We provide our primary care services out of
our outpatient primary care health clinic, which is staffed with 2
physicians, a physician assistant, and 4 registered nurses. Our dental
building is next door and includes 2 dentists, 1 dental health aide
therapist, and a dental hygienist. Our behavioral health clinic is
approximately two miles away. It includes 1 physician, 1 Advanced
Registered Nurse Practitioner (ARNP), 4 substance abuse counselors, 5
mental health counselors and 2 prevention specialists. It provides
outpatient substance abuse treatment, relapse prevention, group,
individual and family mental health counseling, psychiatric evaluation
and medication management, and Medication Assisted Treatment (MAT).
Over 98 percent of our behavioral health clients are also served by our
primary care clinic. Community Health Representatives and transporters
fill an essential role for both clinics, providing clinical linkages to
the community and transportation services.
In addition, relevant to the opioid issue, our Tribe operates a
police department, which consists of nine officers and places a strong
emphasis on community-oriented policing for all residents and visitors.
We also operate a Tribal Court with jurisdiction over criminal, civil
and juvenile matters. Appeals are heard by our three-judge Court of
Appeals.
Our Children & Family Services Department includes our Behavioral
Health Division and the Community Services Division and works to
enhance the quality of life of our Tribal members and their families
through a culturally sensitive approach that encourages living a
healthy lifestyle and promotes self-sufficiency. The Port Gamble
S'Klallam Tribe operates all eligible programs under Title IV of the
Social Security Act; Temporary Assistance to Needy Families (TANF) Part
A, Child and Family Services (Part B), Child Support (Part D), and
lastly, Foster Care and Adoption Assistance (Part E).
II. Impacts of the Opioid Crisis on the Tribe
In Washington State, the Native American overdose rate is more than
twice as high as that of white Washingtonians. \1\ The data shows that
AI/AN in Washington State die of drug overdoses at a rate of 34.4 per
100,000 people, more than twice the rate of the next highest group
(15.1 for Pacific Islanders), and almost three times that of whites at
12.4 and African Americans at 12.3. Other rates are 1.1 per 100,000 for
Latinos, and 1.2 for Asian Americans. \2\ For every opioid overdose
death, there are 10 treatment admissions for abuse, 32 emergency room
visits, 130 people who are addicted to opioids, and 825 nonmedical
users of opioids. \3\
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\1\ Austin Jenkins, Inslee Wants Washington State to Declare Opioid
``Public Health Crisis,'' KUOW.org (Jan 12, 2018), available at http://
kuow.org/post/inslee-wants-washington-state-declare-opioid-public-
health-crisis.
\2\ Washington Department of Health Death Certificate Data.
\3\ National Institute on Drug Abuse. Opioid Abuse Crisis.
Available at https://www.drugabuse.gov/drugs-abuse/opioids/opioid-
overdose-crisis (last accessed March 8, 2018).
---------------------------------------------------------------------------
Misuse of prescribed opioids frequently leads to other drugs such
as heroin. According to the National Institute of Drug Abuse, 21 to 29
percent of patients prescribed opioids for chronic pain misuse them,
and 4 to 6 percent who misuse prescription opioids transition to
heroin. About 80 percent of people who use heroin first misused
prescription opioids. The death rate for heroin overdoses among Native
Americans has also skyrocketed, rising 236 percent from 2010 to 2014.
\4\
---------------------------------------------------------------------------
\4\ Dan Nolan and Chris Amico, How Bad is the Opioid Epidemic?,
PBS.org (Feb. 23, 2016), available at https://www.pbs.org/wgbh/
frontline/article/how-bad-is-the-opioid-epidemic/ (last accessed Feb.
27, 2018).
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The CDC reports that American Indians/Alaska Natives had the
highest national drug overdose death rates of any race in 2015, and a
519 percent increase in the number of non-metropolitan overdose deaths
from 1999-2015. \5\ Alarmingly, approximately 1 in 10 American Indian
youths ages 12 or older used prescription opioids for nonmedical
purposes in 2012, double the rate for white youth. \6\
---------------------------------------------------------------------------
\5\ CDC Morbidity and Mortality Weekly Report (MMWR), available at
https://www.cdc.gov/mmwr/volumes/66/ss/ss6619a1.htm?s_cid=ss6619a1_w
(last accessed March 8, 2018).
\6\ National Congress of American Indians, Reflecting on a Crisis
Curbing Opioid Abuse in Communities (Oct. 2016), available at http://
www.ncai.org/policy-research-center/research-data/prc-publications/
Opioid_Brief.pdf (last accessed Feb. 27, 2018).
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These statistics reflect the heartbreaking reality on the Port
Gamble S'Klallam Reservation as we struggle to confront the drug
epidemic caused by opioids flooding our community. We have had numerous
overdoses and deaths in our community as a result of the opioid crisis,
and not only from the vast supply of drugs available on the black
market. It has been estimated that approximately 60 percent of the
opioids that are abused come, directly or indirectly, through doctors'
prescriptions.
On our Reservation, the deaths include members who were prescribed
opioids as pain medication and accidentally overdosed. In the recent
past, the Tribe experienced an overdose by a young mother and the death
of a toddler, just two years old, who got into his parents' opioid
medication. We have grieving children, parents, grandparents, and
great-grandparents who have lost family due to this scourge. Every
family on our Reservation has been impacted by this epidemic.
At a government level, these impacts cut across all departments,
complicating funding priorities and creating competition for scarce
resources. Our Health, Behavioral Health, Children & Family Services,
and Housing Departments, as well as our courts, law enforcement, and
administration, all have a role to play in responding to this crisis.
Our Children & Family Services Department feels the effects of the
opioid crisis acutely. One of its roles is to keep children with their
families. When children are removed, we have both relative placements
and 20 Tribal licensed foster homes, but the increased number of
dependency cases due to opioid abuse or overdose has challenged our
capacity. Opioid abuse impacts the whole family. Our Tribal member
grandparents are often raising their grandchildren. In addition to this
role, they often struggle to help their own child who is suffering from
addiction.
One specific example of the impacts we face involves dependency
cases that the Tribe files to ensure a child's safety and well-being.
Ninety-eight percent of all dependency cases are due to drug use. In
the first eight weeks of 2018, the Tribe filed four new dependency
cases, three of which were related to parent(s) opioid abuse. This
already surpasses the total new cases filed in 2017. These new cases
are in addition to the open dependency cases that the Tribe has already
filed.
The increased number of dependency proceedings burden existing
child welfare services staff and resources, and require additional
hires. Every child who comes into the Tribe's care and custody needs an
array of intervention and services, including mental health counseling,
medical services, substitute care, and housing. The parents who survive
need treatment and counseling as well. Children who are exposed to
opioids in utero suffer from opioid withdrawal and Neonatal Abstinence
Syndrome, and often bear scars that will last a lifetime. These infants
are immediately transferred to a neonatal intensive care unit for a
period of days, weeks, or even months, frequently requiring emergency
evacuation for care to save the infant's life. Such emergency
transportation costs the Tribe thousands of dollars for each
occurrence.
The crisis has forced the Tribe to staff new positions at great
expense, including additional substance abuse counselors to deal with
the substantial increase in opioid addiction, a nurse specializing in
substance abuse disorders for case management related to the opioid
epidemic, and physicians to provide Medication Assisted Treatment with
drugs such as naltrexone for opioid addiction and abuse.
The Tribe has provided naloxone HCl, also known as ``Narcan'', a
nasally administered overdose reversal drug, and the training to use
it, to all law enforcement personnel and natural resource officers. Due
to their work in the field in our Tribal community, those officers and
personnel regularly encounter individuals suffering from opioid
overdose symptoms who can only be assisted and saved from death by
timely administration of Narcan. The Tribe provides Narcan and training
in its use to other members of our community, because the need for such
emergency treatment is severe. Approximately 120 Tribal members have
been provided with Narcan and trained on how to administer the drug.
These steps are necessary, but they also cost money, which affects our
Tribe's budget and priorities for budget spending.
In terms of housing, the Tribe receives federal funding under the
Native American Housing Assistance and Self-Determination Act (NAHASDA)
to develop and operate affordable housing for low-income Indian
families. Due to the substantial increase in opioid abuse, the Tribe
has seen a parallel increase in evictions of Tribal members and other
Indian families (since NAHASDA requires all leases to have language
authorizing eviction for ``drug-related criminal activity''). When
those families are evicted from the Tribe's housing they generally
become homeless, and as a result they are then in even greater need of
social, medical, and child welfare services from the Tribe.
The opioid crisis is overwhelming to our law enforcement and social
services programs as they are not presently resourced sufficiently to
meet the needs arising from the 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 are needed to
combat the myriad problems the opioid crisis causes.
This epidemic 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. Our Tribe has been
working to implement just such an approach, but we need your help.
III. What Port Gamble S'Klallam Tribe is Doing to Combat the Crisis
The Tribe has shown leadership in its aggressive and comprehensive
response to the opioid epidemic through our cross-governmental Tribal
Healing Opioid Response (THOR) program, collaboration with Washington
State, through participation in the Three County Coordinated Opioid
Response Project (3CCORPS), and, most recently, like many other state
and tribal governments, by seeking to cut the flow of opioids into our
community by filing a lawsuit against the manufacturers and
distributors of these drugs.
A. THOR--Tribal Healing Opioid Response
The Tribe convened two Tribal town hall meetings last year to share
the local impacts of the opioid crisis and determine a path forward.
The extraordinary attendance at these community events demonstrated the
intense and widespread impact of the crisis. Our Tribal Council then
met with Kitsap County officials to discuss a response to the opioid
crisis. The Tribe recognized that the crisis affects all our members
and Tribal agencies and requires a cross-government response. These
efforts led to the creation of our Tribal Healing Opioid Response, a
project led by the Tribe's Behavioral Health and Health Services
Departments. THOR is now the heart of our opioid response on our
Reservation.
THOR has three main goals, and Departments across the Tribe--not
just health-related entities--are responsible for achieving them. These
three main goals and the associated strategies are:
(1) preventing opioid misuse and abuse by changing
prescription practices, raising awareness of the danger of
overdose, youth prevention programs, safe storage and disposal
education, and drug supply reduction;
(2) expanding access to opioid use disorder treatment by
training health providers to recognize disorder symptoms,
increasing access to treatment, applying treatment practices in
the criminal justice system, implementing syringe exchange and
overdose prevention/treatment training, and reducing instances
of opioid withdrawal in newborns; and
(3) preventing deaths from overdose by educating the Tribal
community in how to recognize and respond to an overdose, and
expanding access to overdose reversal medication.
Since January 2017, the Tribe has convened monthly THOR workgroup
meetings composed of Tribal Council Members, Department Directors,
staff, and other community members to implement the THOR goals. The
workgroup is responsible for developing, reviewing and updating the
Tribe's local response plan. It reviews the statewide opioid response
plan and other best practices, identifies appropriate strategies, and
assigns tasks and responsibilities to workgroup members.
Significantly, our Tribe took note of the November 2016 Surgeon
General's Report on Alcohol, Drugs and Health which identified
prevention as key to the fight against abuse and addiction. We pulled
strategies from this report and put them into practice in our effort to
get ahead of potential addictions by creating a Prevention Team. Our
Prevention Team is responsible for numerous programs that focus on
youth and using evidenced-based approaches to keep youth active in the
community. The youth services program offers extended hours, a safe
space, and education about substance abuse and suicide prevention 6
days a week. Through our Chi-e-chee Tribal Coalition, we collaborate
with adults in the community and provide substance abuse education and
prevention activities to adults and families. Chi-e-chee can be
translated to ``the workers or the do-ers.'' The coalition has been
active for over 20 years and is identifying and implementing events and
activities around issues that are significant to our community.
The Tribe provides education to the community, focusing on pain
treatment with exercise, mental health and non-opioid medications. Our
ultimate goal through this effort is to significantly reduce the number
of opioid prescriptions. Town hall meetings are held quarterly to help
educate the community on current issues/topics that are significant to
the community and are well attended.
THOR assigns specific responsibilities to each of the Tribe's
departments to reach the THOR goals. \7\ For prevention, the Health
Department is responsible for promoting best practices in prescribing
and promoting safe storage and disposal of prescriptions; the
Behavioral Health Department is responsible for awareness programs;
Chi-e-chee is responsible for preventing misuse in youth; and the
Police Department is responsible for attempting to interdict and
decrease the supply of illegal opioids. For treatment, the Health and
Behavioral Health Departments, along with the Police Department, train
providers to recognize abuse, and the Behavioral Health Department,
Health Department and Re-Entry Program work together to increase access
to treatment and offer syringe and needle exchange. To prevent overdose
deaths, Chi-e-chee, Human Resources, Behavioral Health and Health work
together to educate the entire community to recognize and respond to
overdoses, including through the administration of naloxone.
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\7\ Tribal Healing Opioid Response Program, https://www.nihb.org/
docs/12032017/Tuesday%20Sessions/THOR%20Presentation.pdf (last accessed
March 11, 2018).
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As a tribal government, we are focused on providing culturally
appropriate treatment to our members suffering from opioid addiction
and the host of health and mental health issues that come with it.
These include programs such as our wellness activities, talking
circles, and group therapy. The Healing of the Canoe Project is a
collaborative project among the Port Gamble S'Klallam Tribe, the
Suquamish Tribe, and the Alcohol and Drug Abuse Institute at the
University of Washington. Its central mission is to develop a life
skills curriculum for tribal youth that includes drug abuse materials.
The Project has made its curriculum available and has trained a total
of 350 attendees from 46 Tribes and 14 tribal organizations in how to
adapt and implement the curriculum.
One of central reasons why our THOR program is so effective is
because the Tribe is not only a health care provider for our community,
we are also a government with the ability to coordinate with State,
County, and regional groups. Our clinics, Police Department and social
services departments have the ability to quickly work through
bureaucracy for cross departmental collaboration, providing better
services to both Tribal members and the community as a whole.
B. Collaboration with Washington State and Accountable Communities of
Health (ACH)
Washington State has a Section 1115 waiver under the Social
Security Act which funds experimental, pilot, or demonstration projects
that are found by the United States Secretary of Health and Human
Services to be likely to assist in promoting the objectives of the
Medicaid program. These demonstration projects provide states
additional flexibility to design and improve their programs with an eye
toward evaluating state-specific policy approaches to better serve
Medicaid populations. Through its Section 1115 waiver authority,
Washington State has created Accountable Communities of Health, which
bring together leaders from multiple health sectors around the state
with a common interest in improving health and health equity. ACHs seek
to align resources and activities to support wellness and a system that
delivers care for the whole person. ACHs are also working to shift
health care reimbursement strategies away from a system that pays for
volume of service to one that rewards quality and outcomes.
Through the Section 1115 waiver and the creation of these ACHs, the
Tribe has been able to form partnerships that were not otherwise easily
accessible or workable. Now, on the opioid issue, specifically, the
Tribe has multiple partners at different levels with whom it can and
has been coordinating to develop and implement a variety of tactics to
address the many issues arising from the epidemic. The Tribe
collaborates with Washington State on the Washington State Opioid
Response Plan and, on the regional level, the Olympic Community of
Health (OCH) which is implementing the Three County Coordinated Opioid
Response Project (3CCORPS).
C. Olympic Community of Health and 3CCORPS
OCH is an Accountable Community of Health whose objectives are to
improve patient care, reduce the cost of health care and improve the
health of the population in Clallam, Jefferson and Kitsap Counties.
Each of the seven Tribal Nations within the three county region,
including our Tribe, is represented on the OCH Board of Directors.
3CCORPS, OCH's specific opioid response, was launched in September
of 2016 and convened an opioid summit in January 2017. It was not long
before this summit that one of our Tribal members died due to missing a
dose of naltrexone. This tragedy spurred momentum for our Tribe's
active opioid response.
3CCORPS is currently in the implementation phase of its opioid
response plan. Addressing the opioid epidemic is a required project in
the Medicaid Transformation Project (MTP) of the OCH. 3CCORPS'
foundations are the same 3 goals and strategies that the Tribe has
adopted and adapted as our own opioid response plan. They also align
with the statewide plan. The alignment of goals and strategies allows
for quick duplication of evidence-based strategies and the ability to
coordinate within the broader regional and state level, and also
facilitates evaluation and data collection efforts.
3CCORPS is our work on the regional level with the OCH. Other
groups that participate in 3CCORPS are independent clinics, police
departments, and social service agencies that serve many different
communities.
D. Litigation to Curtail Oversupply of Opioids
On March 5, 2018, the Port Gamble S'Klallam Tribe, along with the
Suquamish Tribe and the Jamestown S'Klallam Tribe, filed a complaint in
federal district court naming various opioid manufacturers and
distributors, including Purdue Pharma LP, McKesson Corp., Cardinal
Health Inc., AmerisourceBergen Corp. and others. Our complaint alleges
that these companies spread false and misleading information about the
safety of opioids, negligently created an illicit market for opioids,
and failed to control the flow of opioids to our Tribal members. The
complaint details the same devastating impacts that we report to you
today, and asks the court to find that the defendants broke the law
though fraud, negligence, public nuisance, violation of Washington
State consumer protection laws, other laws, and racketeering. Through
the lawsuit, we seek compensation for the cost of responding to and
treating opioid-related addiction and punitive damages. In filing this
lawsuit, we join over 400 other plaintiffs across the country, \8\
including state and tribal governments, in seeking to hold these
companies accountable for the destruction caused by the opioid crisis.
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\8\ ``Can This Judge Solve the Opioid Crisis?'', New York Times,
March 5, 2018, available online at https://www.nytimes.com/2018/03/05/
health/opioid-crisis-judge-lawsuits.html, (last accessed March 8,
2018).
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IV. Lessons Learned and Strategies All Tribes Can Choose to Put in
Place
A. Cross-Government Coordination
Through THOR and our 3CCORPS program with the OCH, we have learned
many lessons in the fight against opioid addiction and efforts to treat
those affected. At the forefront, we learned that coordination and
communication across our government is key as well as ensuring that all
of our Departments pitch in to the effort however they can. As the
opioid epidemic affects all facets of our community, we have taken an
``all-hands-on-deck'' approach as a government. As explained above, we
draw on any and all of our Departments that can help so that we can
attack the crisis from many angles. Our monthly THOR workgroup meetings
have been key to synchronizing our programs and generating action items
to address the opioid problems in our community.
B. Culturally Appropriate Care
Recognizing that traditional healing practices, cultural beliefs
regarding approaches to treatment, and differences in interpersonal
communication contribute to significant variances in effectively
meeting the healthcare needs of AI/AN, cultural competency is an
inherent part of who we are, who we serve and what we do.
C. Abuse Prevention
Prevention is the cornerstone for any opioid response, as the
Surgeon General's Report on Alcohol, Drugs and Health (November 2016)
states. We realize that availability of resources is different in
different parts of Indian Country. Yet, there are strategies that any
Tribe can put into place in its fight against the opioid epidemic. Our
Tribe has a ``toolkit'' which we share with other Tribes in their
opioid fight. We are happy to share our ``toolkit'' with any Tribe who
would like access to it. Our ``toolkit'' includes:
(1) Our Pain Agreement--used in the clinic for clients with
opioid prescriptions for chronic pain;
(2) Our Narcan Standing Orders & Policy--provides Narcan to
any Tribal member or household that requests it, and to any
patient with an active opioid prescription; and
(3) Our Good Samaritan Tribal Code--provides liability
protection for those who act in good faith and seek medical
assistance for any person who is experiencing a drug-related
overdose.
Collaborating with federal agencies has been very helpful in our
Tribe's fight against the epidemic. We suggest that Tribes regularly
call upon their regional federal agency officials from IHS, SAMHSA,
HRSA, BIA, DOJ, and others. These agencies have resources, technical
assistance and connections that they can share. Further, Tribes may
find that partnering with their neighboring governments on this
particular issue yields a variety of benefits. Accessing additional
resources is always a benefit, whether they are financial resources or
non-financial resources such as experience, expertise and technical
assistance. Brainstorming and sharing ideas with federal agencies and
neighboring governments with mutual interest in stemming the opioid
crisis can lead to innovation and cooperation.
The Tribe has benefited from having close collaboration with
federal agencies at the regional level. The Acting Regional Director of
the Department of Health and Human Services (HHS), and the Regional
Director of the Substance Abuse and Mental Health Services
Administration (SAMHSA), have both visited the Tribe recently,
participating in robust discussions on opioid prevention. As a specific
example, our SAMHSA discussion helped clarify 42 CFR Part 2 updates and
requirements.
V. Barriers and Needs to More Effectively Fight the Opioid Crisis
A. Funding Needs
There are several barriers that Tribes face in their efforts to
overcome the opioid epidemic. We have run into several.
1. Adequate Funding and Direct Funding
Adequate funding to combat this behemoth opioid crisis is, of
course, a major barrier. Getting funding out to Tribes for their on-
the-ground work is an issue not only in the amounts, but also in the
manner in which such monies flow to Tribes. We strongly encourage
Congress to not only work on increasing available funding, but to also
provide direct funding to Tribes and ensure that any additional funds
for opioid crisis response do not decrease services in other areas.
We truly 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 the Committee to advocate for
full funding of the authorization and ensure that these funds go
directly to tribal governments for them to spend in their own
communities. Such funds should not be passed through the States. Direct
funding of tribal programs is important as it ensures that funds are
available to tribal governments like ours that have culturally
appropriate programs and mechanisms in place for fighting the opioid
epidemic.
An important bill that includes the requested direct funding
mechanism is S. 2270, the Mitigating the Methamphetamine Epidemic and
Promoting Tribal Health Act. This bill, introduced by Senator Daines, a
member of this Committee, would make Tribes and tribal organizations
eligible for direct funding under the 21st Century Cures Act, which
provides an allocation to states for opioid prevention and response. S.
2270 would allow such allocation to also be used for prevention and
response for other substances, such as methamphetamines, if they are
having a substantial impact on the state or Tribe.
2. Full Funding of IHS Budget
Additionally, we ask you to work toward providing sufficient
funding to the Indian Health Service (IHS) for opioid treatment and
prevention. The FY2019 Budget Request provides $10 billion in new
resources across HHS to combat the opioid epidemic and address serious
mental illness. As part of this effort, the Budget Request includes an
initial allocation of $150 million to IHS to provide multi-year
competitive grants based on need for opioid abuse prevention,
treatment, and recovery support in Indian Country. \9\
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\9\ 2019 Budget in Brief https://www.hhs.gov/sites/default/files/
fy-2019-budget-in-brief.pdf. As of the preparation of this testimony,
HHS has not released its detailed FY 2019 Budget Justification,
including for IHS.
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The Public Health Service Commissioned Corps plays a vital role in
providing direct patient care throughout the Indian Health Service, and
also has a direct role in the work of Tribes combating the opioid
crisis. Any restructuring of the Corps should be done in close
collaboration and consultation with Tribes.
The FY 2019 Budget Request eliminated both Community Health
Representatives and Health Education from the IHS budget. These two
line items support the front line work of Tribes and the IHS on both
the opioid crisis and daily operations and patient care.
They need to be restored.
3. Full Funding of Contract Support Costs
The FY 2019 Budget Request fully funds Contract Support Costs at an
estimated $822 million and continues the use of an indefinite
appropriation, which allows IHS to guarantee full funding of this
program. Funding for Contract Support Costs supports the costs incurred
by Tribes for activities that are necessary for administering health
care service programs under self-determination contracts and self-
governance compacts. \10\ This is an important funding mechanism for
self-governing Tribes like ours to administer our opioid prevention and
treatment programs.
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\10\ Id.
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B. Barriers Beyond Funding
1. Regulatory Hurdles
There are several barriers in the fight against the opioid crisis
that are beyond funding. One such barrier relates to funding, but is an
administrative limit on accessing already available funding. The Health
Resources and Services Administration (HRSA) has behavioral health
integration funding available, but it is restricted to rural locations.
Kitsap County does not qualify as ``rural'' and so the Tribe is
ineligible for these grants. We recently raised this issue to HRSA, and
received assurances that this issue would be addressed. However, it
would be helpful for members of Congress to encourage HRSA to
reconsider the rural restriction and develop a mechanism for channeling
such monies to Tribes. This could be through revising the definition of
``rural'' to include Tribes regardless of location or ``geographic
trait'' of its reservation.
2. Barriers to Medication Assisted Treatment
We also want to point out certain other barriers to our efforts to
combat the opioid crisis. Current regulations impose onerous training
and waiver requirements for providers of Medication Assisted Treatment
(MAT) prescribing drugs such as buprenorphine, 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, an
opioid addiction treatment drug also known as Suboxone, 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 evidence-based
practice in treating opioid addiction. We need to expand Tribes' access
to this treatment.
3. Physician Access to Medical Records
Federal regulations at 42 CFR Part 2, related to the privacy of
substance abuse treatment records, currently prevent the Tribe's
primary care and mental health providers from accessing patient records
from dependency providers so the whole person can be treated.
This lack of access is a barrier to coordinated, safe, and high-
quality medical care and can cause significant harm. Part 2 regulations
may lead to a doctor treating a patient and writing prescriptions for
opioid pain medication for that individual without knowing the person
has a substance use disorder.
In August 2017, Congressmen Tim Murphy and Earl Blumenauer
introduced bipartisan legislation that would help align 42 CFR Part 2
with HIPAA rules, ensuring that substance use disorder patients can
receive proper care while their data remains secure. The Overdose
Prevention and Patient Safety (OPPS) Act (HR 3545) allows access by
doctors to patients' full medical records with all the safeguards of
HIPAA, but also makes use of such information in criminal
investigations unlawful. The Tribe joins others such as the Partnership
to Amend 42 CFR Part 2, a coalition of over 20 healthcare stakeholders
including the American Hospital Association, in support of HR 3545.
4. The Lack of Co-location of Health Services on Our Reservation
The Tribe 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. As stated, our Health Facility and
Dental Facility are nearby each other, but our Mental Health Facility
and Rehabilitation Facility are some distance away. This causes extra
administrative burden and expense of resources. Co-locating these
services would improve behavioral health integration, but a new
integrated facility for all health services would cost over $8 million
dollars. We suspect other Tribes face similar problems with respect to
the lack of co-location of services. We look to Congress for innovative
ideas, perhaps through its infrastructure package, for facilitating the
construction of co-located health care facilities on tribal lands.
5. The Need to Modernize the IHS's Health Information System
This issue impacts the ability of Tribes to confront the opioid
epidemic. Barriers to integration within the health information system
are being addressed at significant cost to the Tribe as we left the
Indian Health Service RPMS system for direct patient care documentation
years ago, although we continued to utilize that system for Purchased &
Referred Care (PRC). The system we use, NextGen, is adequate for
primary care, but has limitations for mental health and substance
abuse. This has impacted our behavioral health integration work.
The Veteran's Administration announcement that it will pursue a
contract with Cerner as a replacement for the RPMS Parent system may
provide an opportunity for both IHS and Tribes. IHS needs to ensure
that the replacement of RPMS will include options for non-RPMS tribes
and pathways for cost saving programs such as the VA Consolidated Mail
Outpatient Pharmacy Service (CMOPS).
6. The Need for Pilot Projects for Residential Post-Treatment
Facilities on Tribal Lands
Our Tribe is particularly interested in initiating a pilot program
for residential post-treatment facilities. The Tribe would like to
provide treatment and support past the prevailing 28-day model,
utilizing evidenced-based practices with a robust evaluation component.
The Tribe has partnerships with Oxford House and Habitat for Humanity
to construct and operate such facilities, and is well positioned to
start such a pilot program. We ask Congress to support the
establishment of a pilot program by an agency such as SAMHSA, HUD, or
IHS to fund residential post-treatment facilities on reservations to be
operated by Tribes for their members and families.
7. Lack of Easy Access to Methadone Clinics
Our Tribal Members must travel to Tacoma or the greater Seattle
area to a methadone facility to receive such treatment. We are working
with OCH to obtain a methadone facility in Kitsap County to save our
Members the burden and cost of traveling so far for that treatment. We
ask Congress to consider ways it can facilitate the construction and
operation of these facilities in locations accessible to tribal and
rural communities like ours. Kitsap County, where we are located, has a
restriction limiting service to one methadone clinic in the county.
This limitation hampers our ability to provide expanded services in the
future.
C. Beneficial Legislation: Senator Cantwell's Bill, S. 2440
In addition to S.2270 (Senator Daines' bill), we ask this Committee
to support S.2440, introduced by our Senator and Committee Member,
Senator Cantwell. We appreciate Senator Cantwell's work on behalf of
Indian Country and, specifically, on the opioid issue. We also note
that the Senator's consultation with our Tribe for receiving early
input about this bill could serve as a model for tribal consultation
when developing legislation. Our Tribe supports S. 2440.
S. 2440, known as the Comprehensive Addiction, Recovery, Education
and Safety (CARES) Act, would, among other things, hold opioid
manufacturers accountable for failure to report suspicious drug orders.
The intent of the CARES Act is to increase opioid prevention and
treatment funding, limit opioid prescriptions and enhance prescription
drug monitoring programs. The Act would increase civil and criminal
penalties on companies that fail to reasonably curtail their drugs from
entering the illicit drug market. The legislation increases civil
penalties from $10,000 to $100,000 per violation for negligence in
reporting suspicious transaction activity, and doubles the maximum
criminal penalty from $250,000 to $500,000 for willful violations. The
Act increases funding for the DEA's Tactical Diversion Squad which
investigates drug manufacturers that fail to prevent their drugs from
entering the illicit drug market. The legislation also authorizes $50
million for the DEA's heroin enforcement groups.
This important bill aligns with the Tribe's goals in our federal
lawsuit to hold drug companies responsible for failing to track orders
and for creating an illicit market for their drugs, and will be an
enormous boost in the fight against opioid addiction. We applaud
Senator Cantwell and ask all on this Committee to cosponsor and support
this bill. Increased response funding and manufacturer accountability
could drastically curtail shipments of the prescription pills that
result in crippling addiction for our Tribal members.
VI. Conclusion
The crisis has ripped the fabric of our community. The loss
(through death or addiction) of parents, children, brothers and
sisters, uncles and aunts, nieces and nephews, and cousins to this
crisis has been devastating, and will impact the Port Gamble S'Klallam
Tribe for generations. We are doing what we can to fight it, and we
want to work with you to eradicate this crisis once and for all.
Thank you for the opportunity to provide this testimony. We invite
you to visit our Tribe to learn more about our ongoing work.
The Chairman. Senator Smith, I believe you wanted to give
an introduction of Mr. Moose.
Senator Smith. Very briefly, Mr. Chair, because I know we
are rushed for time.
I want to welcome you to this Committee. It is wonderful to
see you.
Mr. Moose is a member of the Mille Lacs Band of Ojibwe from
Minnesota and is an important leader on Native health issues
broadly, not just issues related to the opioid epidemic. As
Chairman Hoeven said, he serves as Treasurer and the Beidji
Area representative to the National Indian Health Board. Thank
you so much for being here.
I am going to have to run to go vote but I have read your
testimony and look forward to hurrying back so that I can ask
you a question or two.
Senator Cantwell. [Presiding] I thank the witnesses for
their testimony. Did you want to ask a question at this moment?
If you want, go ahead, Senator Smith.
Senator Smith. I will do that. That way I don't have to run
back. Thank you.
Mr. Moose, I am very interested in talking to you about the
opportunities we have with the special behavioral health
program modeled on the Diabetes Program. Earlier today, I was
able to introduce legislation that several Committee members,
including Senators Udall, Tester, Cortez Masto and Heitkamp,
also introduced.
This bill would provide Native communities with flexible
funding, as we have discussed so much today, to create programs
that can really build on the work you are already doing. Could
you talk a bit from your perspective on what we could do at the
Federal level to make sure we are not just reacting to current
events but are really giving tribes the flexibility they need
to take action?
Mr. Moose. One of the things that is really good about the
bill you are looking at introducing is the fact that it does
look at long range infrastructure funding for Indian Country.
One area we often struggle with is grants, from time to time,
are kind of dropped into Indian Country and then go away.
One of the issues we have in Indian Country is
infrastructure development, ongoing support and flexibility to
utilize funding that meets our specific needs. Unfortunately,
at times, States, under good pretenses, provide funding large
areas of tribes within their State systems.
Oftentimes that funding gets so specific that it does not
meet the needs of every tribe within the State. Some States may
need that specific direct funding, whether it is recovery, case
manager support or other specific support. However, other
tribes may have moved on from that funding and have a hard time
utilizing that funding or using that funding to leverage other
funding. I think it is really good to see that the bill
supports ongoing funding for Indian Country, specifically what
we have seen with the Special Diabetes for Indians.
Senator Smith. Thank very much. I will leave it at that but
I thank you and look forward to working with you on the bill.
Also, thank you very much, Ms. George, for being with us.
Senator Cantwell. Thank you, Senator Smith.
Ms. George, you mentioned the CARES Act, which we have
introduced. One key focus of that legislation is putting
stiffer penalties on manufacturers who fail to meet the
standard DEA has set up for some drugs as addictive as opioids.
The DEA really wants to follow the distribution of that
product and make sure the failure to report distribution of
something as highly addictive as opioids is penalized if
manufacturers fail to do that. That is what I and Senator
Harris of California have introduced.
In our State, we have had over 10,000 fatal overdoses in
basically a 17-year period of time. I know the rate in Indian
Country is more than twice as high as the rest of the
population. What do you think this kind of partnership with law
enforcement in tracking and distribution of drugs would do to
help the problem in Indian Country?
Ms. George. I really believe that collaboration between law
enforcement and all sectors needs to be represented in this
process to really combat this crisis as a whole. Law
enforcement is definitely key.
In our community, although we are a small community, our
law enforcement sometimes is the only people that have
interactions with some of our folks having overdose incidents.
Not only are they able to keep them alive in that instance they
experience, but also bring them directly to our programs that
service them. They play a very integral part in fighting this.
At least in our community, I think our law enforcement
recognizes that and is willing to take the steps necessary to
move forward.
Senator Cantwell. Thank you for that answer.
Unfortunately, we are going to have to take a short recess
and will resume shortly. The Committee will be in recess.
[Recess.]
Senator Udall. [Presiding.] The Committee is reconvened.
We apologize for the inconvenience. These votes are an
occupational hazard and if we do not vote, we get in a lot of
trouble. Thank you for your patience.
I believe we were at the point in the proceeding where next
to testify was Mr. Samuel Moose, the Treasurer and Bemidji Area
Representative of the National Indian Health Board.
Before you start, Sam, both of you obviously have real
admirers in Senators Cantwell and Smith who really appreciate
all the good work you are doing.
Thank you.
STATEMENT OF SAMUEL MOOSE, TREASURER AND BEMIDJI AREA
REPRESENTATIVE, NATIONAL INDIAN HEALTH BOARD
Mr. Moose. Chairman Hoeven, Vice Chairman Udall and members
of the Committee, on behalf of the National Indian Health Board
and the 573 tribal Nations we serve, I thank you for holding
this important hearing.
My name is Samuel Moose. I am the Human Services Director
for the Fond du Lac Band of Lake Superior Chippewa and an
enrolled member of the Mille Lacs Band of Ojibwe.
The current opioid epidemic represents one of the most
pressing public health crises affecting tribal communities.
While this epidemic is affecting many communities throughout
America, it has disproportionately impacted tribes and has
strained the limited public health and health care resources
available to tribes.
American Indians and Alaska Natives have had the highest
rate of drug overdose deaths every year since 2008 to 2015. In
my home State of Minnesota, the age adjusted death rate due to
drug poisoning is five times higher among the American Indian
population compared to Whites.
American Indians accounted for 15.8 percent of those who
entered drug treatment for opioid use despite only being 1.1
percent of tribal or the State population. These statistics
demonstrate the critical need for more comprehensive
intervention in tribal communities to improve prevention and
treatment services.
This epidemic is so bad that several tribes throughout the
Country, including three within Minnesota, declared a state of
emergency to tackle this crisis. Historic and intergenerational
trauma along with current trauma that spans a lifetime for
American Indians, a lack of funding for IHS, and the failure to
include tribes in State level prevention and public health
programs all contribute to the current crisis in tribal
communities.
In Minnesota, pregnant American Indian women were 8.7 times
more likely to be diagnosed with maternal opioid dependence.
American Indian infants were 7.4 times more likely to be born
with Neonatal Abstinence Syndrome, meaning that the
repercussions and trauma of this crisis are intergenerational.
The deferral of healthcare in the Indian health care system
due to funding and workforce shortages has created greater
dependency on opiates. Limited funding resulted in nearly
80,000 Purchased/Referred Care service denials in fiscal year
2016 alone. Instead of being referred for surgeries and support
treatment, patients are simply placed on prescription opiate
medication as they wait for access to additional care. This
endless cycle of deferral and opiate dependency is a direct
result of underfunding in the IHS system contributes to the
issue.
Solutions should focus on allowing tribes to access long
term, sustainable resources, improve data and disease
surveillance and enhance tribal practice of traditional healing
and culturally-based treatment. Congress should allow tribes
access to the State Targeted Response to Opiate Epidemic
Grants. NIHB supports the provisions in S. 2270, the Mitigating
METH Act, and S. 2437, the Opioid Response Enhancement Act.
Congress should: establish tribally-specific funding
streams such as a Special Behavioral Health Program for
Indians, modeled after the very successful Special Diabetes
Program for Indians; ensure parity between States and Tribes in
any new opioid-related legislation advanced in Congress, not
only including tribes as eligible entities, but also requiring
tribal consultation, information and data sharing, and funding
set asides; establish trauma-informed interventions in
coordination with tribes to reduce the burden of substance use
disorders including those involving opioids; and include set
asides for tribes within the $6 billion in opioid program
funding for fiscal years 2018 and 2019.
In addition, health IT and data issues represent a serious
challenge when it comes to the opiate crisis. IHS' current
Electronic Health Record system has difficulty tracking data
across various systems, including those tribes who operate
different EHRs. RPMS is often not compatible with State-based
prescription drug monitoring programs which makes tracking
access to opiates a severe challenge.
Congress should make investments in the health IT resources
at IHS, especially as the VA system begins to transition from
Vista. It should require that States consult with tribes on use
of prescription drug monitoring programs and incentivize
providers to adopt E-Prescribe as a way of reducing the
needless and harmful spread of opiates.
I would also like to highlight the importance of
integrating traditional healing practices with conventional
strategies in Indian Country and tribal communities that have
been healing their people for thousands of years. Although
Federal grants and Medicare do not reimburse for traditional
healing services, it is critical that Congress support these
traditional practices by providing funding and including them
in the Medicaid reimbursement.
Again, thank you for allowing this time for me to be here
with you today and holding this hearing.
[The prepared statement of Mr. Moose follows:]
Prepared Statement of Samuel Moose, Treasurer and Bemidji Area
Representative, National Indian Health Board
Introduction
Chairman Hoeven, Vice Chairman Udall, and Members of the Committee,
the National Indian Health Board (NIHB) thanks you for holding the
hearing, ``Opioids in Indian Country: Beyond the Crisis to Healing the
Community.'' On behalf of NIHB and the 573 federally-recognized Tribes
we serve, I, Sam Moose, Director of Human Services at Fond du Lac Band
of Lake Superior Chippewa submit this testimony.
NIHB is a 501(c)3, not for profit, national Tribal organization
founded by the Tribes in 1972 to serve as the unified, national voice
for American Indian and Alaska Native (AI/AN) health in the policy-
making arena. Our Board of Directors is comprised of distinguished and
highly respected Tribal leaders in AI/AN health. They are elected by
the Tribes in each region to be the voice of all 573 Tribes at the
national level.
Since 1972, NIHB has advised the U.S. Congress, Indian Health
Service (IHS), and other federal agencies about health disparities and
service issues experienced in Indian Country. The current opioid
epidemic represents one of the most pressing public health crises
affecting Tribal communities. While this epidemic is affecting many
communities throughout America, it has disproportionately impacted
Tribes and has further strained the limited public health and
healthcare resources available to Tribes. The Federal Government must
take concrete action to ensure Indian Country has the tools it needs to
address opioid abuse and heal Tribal communities.
Trust Responsibility
The federal promise to provide Indian health services was made long
ago. Since the earliest days of the Republic, all branches of the
Federal Government have acknowledged the nation's obligations to the
Tribes and the unique trust relationship between the United States and
Tribes.
The Indian Health Service is the primary agency by which the
Federal Government meets the trust responsibility for direct health
services. IHS provides services in a variety of ways: directly, through
agency-operated programs and through Tribally-contracted and operated
health programs; and indirectly through services purchased from private
providers. IHS also provides limited funding for urban Indian health
programs that serve AI/ANs living outside of reservations. Tribes may
choose to receive services directly from IHS, run their own programs
through contracting or compacting agreements, or they may combine these
options based on their needs and preferences.
Today the Indian healthcare system includes 46 Indian hospitals (1/
3 of which are Tribally operated) and nearly 630 Indian health centers,
clinics, and health stations (80 percent of which are Tribally
operated). When specialized services are not available at these sites,
health services are purchased from public and private providers through
the IHS-funded purchased/referred care (PRC) program. Additionally, 34
urban programs offer services ranging from community health to
comprehensive primary care. To ensure accountability and provide
greater access for Tribal input, IHS is divided into 12 geographic
Service Areas, each serving the Tribes within the Area. It is important
to note that Congress has funded IHS at a level far below patient need
since the agency's creation in 1955. In FY 2017, national health
spending was $9,207 per capita while IHS spending was only $3,332 per
patient.
Overview of the Opioid Epidemic in Indian Country
The national opioid epidemic represents one of the great public
health challenges of the modern era. The Centers for Disease Control
and Prevention (CDC) noted over 64,000 drug overdose deaths in 2016
alone, largely driven by prescription and illicit opioids. \1\ Among
AI/ANs, the rate of drug overdose deaths is twice that of the general
population, according to the IHS. Deaths from prescription opioid
overdoses increased four-fold from 1999 to 2013 among AI/ANs. \2\ The
CDC reported that AI/ANs consistently had the highest drug overdose
death rate by race every year from 2008-2015, and the highest
percentage increase in drug overdose deaths from 1999-2015 at 519
percent. \3\ Deaths from prescription opioid overdoses increased four-
fold from 1999 to 2013 among AI/ANs, with an opioid overdose death rate
of 9.6 per 100,000 in 2015--second only to whites.
---------------------------------------------------------------------------
\1\ National Institute on Drug Abuse. 2017. Overdose Death Rates.
Retrieved from https://www.drugabuse.gov/related-topics/trends-
statistics/overdose-death-rates
\2\ Indian Health Service. New effort targets drug overdoses in
Indian Country. Retrieved from https://www.ihs.gov/newsroom/
pressreleases/2015pressreleases/new-effort-targets-drug-overdoses-in-
indian-country/
\3\ Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit
Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and
Nonmetropolitan Areas--United States. MMWR Surveill Summ 2017;66(No.
SS-19):1-12. DOI: http://dx.doi.org/10.15585/mmwr.ss6619a1
---------------------------------------------------------------------------
Regional data trends further demonstrate the high burden of the
opioid epidemic within Tribal communities. According to the State of
Alaska Epidemiology Center, AI/ANs had the highest overdose death rate
by race from 2009-2014 at 20.2 deaths per 100,000 population.
Similarly, the Washington State Department of Health reported that from
2011-2015, the opioid overdose death rate was highest among AI/ANs at a
rate of 29 deaths per 100,000 compared to 12 deaths per 100,000 for
Whites.
In my home state of Minnesota, the Department of Human Services
reported that the age-adjusted death rate due to drug poisoning is four
times higher among AI/ANs compared to whites. Further, despite
representing roughly 1.1 percent of the population for the state, AI/
ANs accounted for 15.8 percent of those who entered treatment for
opioid use disorder. These statistics illuminate the critical need for
more comprehensive interventions in Tribal communities to improve
prevention and treatment measures.
The Indian Health system is chronically underfunded, understaffed
and overextended. Limited Tribal and IHS public health and healthcare
resources have been further inundated by this highly deadly and
superbly costly epidemic. While the treatment and recovery costs are
certainly great, the human toll of the epidemic on our Tribal
communities is even greater. The state of Minnesota reported that
pregnant AI/AN women were 8.7 times more likely to be diagnosed with
maternal opioid dependency, and that AI/AN infants were 7.4 times more
likely to be born with neonatal abstinence syndrome (NAS)--meaning that
the repercussions and trauma of this crisis are intergenerational.
Other secondary impacts include the undue burdens imposed on many AI/AN
families struggling with opioid and substance use disorders, the
children forced into foster care, and the kinship care networks that
are strained beyond their ability.
While Tribal communities are certainly in need of expanded
treatment resources, public health prevention must not be forgotten.
This includes upstream prevention activities such as comprehensive
substance use education in youth, expanded substance and alcohol use
education and training for our providers, prevention of adverse
childhood experiences, healing from historical and intergenerational
trauma, and investment in culturally appropriate and Tribally-driven
programming.
Bolstering Tribal public health surveillance infrastructure is also
a major need. The CDC noted in 2017 that the actual drug overdose death
count among AI/ANs may be underestimated by as much as 35 percent due
to racial misclassification on death certificate data. That is truly
unacceptable. Data is the backbone of any public health system, and
without it the Tribes and IHS are unable to maintain accurate records
of vital statistics, to quantify disparities in health outcomes between
AI/ANs and other populations, and to ultimately make true assessments
of need. More importantly, Tribal leaders must have this information to
make informed policy decisions and implement targeted programs.
Tribes also remain behind many other communities in their public
health infrastructure, capacity, and workforce capabilities as a result
of being largely left behind when the United States was modernizing its
public health infrastructure. These obstacles have made it particularly
difficult for Tribal communities to assemble a coordinated and
comprehensive defense against major health emergencies, including the
opioid epidemic.
At IHS, and indeed even at many Tribal facilities, deferral of care
due to funding and workforce shortages has pushed more and more Tribal
members towards prescription opioids to treat health conditions that
would otherwise successfully be treated with non-opioid therapies. For
instance, limited funding resulted in nearly 80,000 Purchased/Referred
Care (PRC) services (an estimated total of $371 million) being denied
in FY 2016 alone. This endless cycle of deferral and opioid dependency
is a direct result of the underfunding of the IHS system, and must be
stopped.
The CDC Guideline for Prescribing Opioids for Chronic Pain
describes how opioid therapy should not be the first line of treatment
for acute or chronic non-cancer related pain management, and should
rarely, if ever, be prescribed with other medications such as
benzodiazepines. Nevertheless, many Tribal members still report that
opioids are some of the only options available to them to address their
pain symptoms. Lack of reimbursement and access to non-opioid
therapies, traditional medicine and other alternatives leaves both
providers and patients in a catch-22 that ultimately leads to more
harm.
Tribes throughout the country are finding that the systemic
problems with the current Indian health system are impacting their
ability to confront the opioid crisis. Bay Mills, a Tribe located on
the Upper Peninsula in Michigan, has capacity issues so severe that,
even if that Tribe received federal funds to operate an opioids
treatment outpatient program, the Tribe reports that their facilities
are too small and outdated to be able to operate such a program on-
site. NIHB has noted in previous testimony to Congress that IHS's
facilities construction budget is so underfunded that a facility built
today would not be able to be replaced for 400 years. These chronic
funding issues have limited the ability of Tribes to confront the
opioid crisis without additional, sustained Congressional support.
The Red Cliff Tribe of Chippewa Indians in Wisconsin lacks
resources to keep up with the latest training practices available to
healthcare providers. While the Tribe has started a Harm Reduction
Program to provide access to Naxolone, lack of substance abuse and
addiction training among Tribal providers limits the program's reach
and uptake in the community. The Red Cliff Police Department reported
346 investigations on drug use in 2016, an increase of almost 100 from
the year prior. The total population of the reservation is under 1,000.
Tribal Response to Opioids
Despite these challenges and setbacks, Tribes across Indian Country
have engaged in multifaceted response efforts that traverse the
prevention, treatment and interdiction landscape. For instance, after
declaring a state of emergency on the opioid epidemic in March 2016,
the Mashpee Wampanoag Tribe in Massachusetts partnered with the IHS to
assemble more resources to address the growing number of overdose
deaths in their community. The Tribe worked towards establishing an
integrated community intervention model, implementing the CDC Guideline
for Prescribing Opioids for Chronic Pain, and developing an opioid
response grounded in the social determinants of health. The Tribe
worked with Tribal Police and Homeland Security to create prescription
drug drop boxes, developed a 24-hour call line for crisis intervention,
and established a Tribal Coordinating Committee to create a 5 year
Tribal Action Plan to address alcoholism and substance abuse issues.
In Washington State, the Muckleshoot Tribe has been operating a
successful behavioral health program for the past few years. The
initiative includes a medication-assisted treatment program where
Tribal members are able to receive Suboxone or Vivitrol for treatment
of opioid use disorder. The program has proven successful, as
compliance with the program reached 94 percent in July, 2017.
Muckleshoot has distributed close to 4,000 kits of Naloxone as of
August 2017, and also operates a syringe service program to help reduce
the risk of co-occurring health conditions such as HIV and Hepatitis C.
In Oklahoma, the Chickasaw Nation launched the ``Define Your
Direction'' campaign, which is an education initiative encouraging
Tribal youth to make healthy choices and be positive role models when
it comes to resisting prescription drug misuse and underage drinking in
their communities. Some outcomes of the program thus far include
equipping all Chickasaw Nation Lighthorse officers with Naloxone;
distributing more than 400 medication lockboxes to Elders; recording
significant reductions in prescription drug misuse within the past 30
days among 6th, 8th, 10th and 12th graders; and reductions in risk
factors such as early drug use initiation and low neighborhood
attachment among Tribal youth.
NIHB encourages the Committee Members to connect with the Tribes in
your home states to learn more about current initiatives and gain
further insight into technical assistance and funding needs, so that
programs such as these are replicated in more and more Tribal
communities.
Policy Solutions
A) Access to Federal Opioid Resources
Addressing the opioid epidemic is a nationwide priority; however,
access to critical opioid prevention and treatment dollars are not
reaching many of the Tribal communities that are in serious need of
these funds. As sovereigns, Tribes are not systematically included
within statewide public health initiatives such as the recent
prevention and intervention efforts created through the new opioid
crisis grants found in the 21st Century CURES Act, passed by Congress
in 2016.
The CURES Act provided $1 billion in funding over a two-year period
to states and territories to combat the opioid crisis. Tribes were not
eligible entities for this critically important funding. Although a
small number of states subsequently allocated CURES funds to Tribes,
access was not at the level of need, nor was it equitably distributed.
Furthermore, as the trust responsibility is exclusive to Tribal Nations
and the Federal Government, Congress must not circumvent this sacred
duty by forcing Tribes to go through state agencies for these funds. In
addition, many Tribes have historically had complicated relationships
with state governments as a result of having to compete for limited
dollars. Providing direct funding to Tribes would solve this issue.
An example of this can be seen in Ho-Chunk Nation in Wisconsin.
Like many Tribes, Ho-Chunk has seen an increased number of infants born
with substance addiction and NAS, as well as an increase in opioid-
related overdose deaths in the community. The Tribal government
declared a State of Emergency regarding the opioid crisis and is in the
process of developing a Tribal Action Plan within their departments. A
major problem for the Tribe is that the grant money the state receives
and distributes to the Tribes is not sufficient to meet the added
burden the Tribe's behavioral health facility is experiencing.
To correct this dynamic and ensure that needed opioids funding is
reaching the Tribes, Congress should:
Amend the CURES Act, specifically the State Targeted
Response to Opioid Epidemic grants, to ensure Tribes can
receive funding directly from the Federal Government to address
the opioids crisis. NIHB supports the provisions in S. 2270,
the Mitigating METH Act, and S. 2437, the Opioid Response
Enhancement Act, that address this.
Establish Tribally-specific funding streams such as a
Special Behavioral Health Program for Indians, modeled off the
very successful Special Diabetes Program for Indians, so that
Tribes can develop their own programs to address substance
misuse and dependence in their communities. NIHB supports House
legislation that has been introduced for this purpose, H.R.
3704 the Native Health Access Improvement Act.
Ensure parity between states and Tribes in any new opioid-
related legislation advanced in Congress. This means not only
including Tribes as eligible entities, but also requiring
Tribal consultation, information and data sharing, and funding
set asides, where applicable. For example, the newly introduced
``Comprehensive Addiction and Recovery Act (CARA) 2.0'' (S.
2456) legislation should include Tribes and Tribal
organizations in several sections of the bill. This includes
Section 6 which establishes funding for regional technical
assistance centers to focus on addiction recovery and naloxone
training/dissemination; Section 7 which allows states to
increase the 3-day limit on first time opioid prescriptions
found in Section 3 if the state passes a law or implements a
statewide regulation should include Tribal law as well; and
Section 10 which provides funding to states for addiction
treatment programs targeted toward pregnant and post-partum
women. Finally, we recommend adding language to Section 13 that
would require states to consult with Tribes on the
implementation of prescription drug monitoring programs.
Establish trauma-informed interventions in coordination with
Tribes to reduce the burden of substance use disorders
including those involving opioids.
Include set asides for Tribes within the $6 billion in
opioid program funding for Fiscal Years 2018 and 2019
appropriated in the February 2018 Continuing Resolution.
FY 2019 Budget Proposal
NIHB and Tribes were glad to see that the FY 2019 President's
budget request proposed $150 million in funding to ``provide multi-year
competitive grants based on need for opioid abuse prevention,
treatment, and recovery support in Indian Country.'' \4\ Tribes are
supportive of this additional funding, but many Tribes have expressed
concerns that competitive grant programs are not the solution to long-
term, broad-based funding. Competitive grants erode Tribal sovereignty
and do not honor the federal trust responsibility. Furthermore, when
Tribes are forced to apply for grants it takes away scarce staff and
resources from other program-oriented work leading to diminished
program effectiveness across the board. We look forward to working with
you as this policy is developed to ensure that the proposed funds truly
reach the areas with greatest need and fully honor the promises made to
our ancestors. In addition, we note that other federal agencies--such
as the Substance Abuse and Mental Health Services Administration and
the Centers for Disease Control and Prevention--should have funding
made directly available to Tribes.
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\4\ U.S. Department of Health and Human Services. ``FY 2019 Budget
in Brief.'' February 12, 2018. Pg. 28.
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B) Health Information Technology (IT) within the Indian Health System
The Federal Government has not met its trust responsibility as it
relates to updating and modernizing the physical and technological
infrastructure within IHS and Tribal health facilities and health IT
systems. The current primary Electronic Health Record (EHR) system IHS
uses is the Resource and Patient Management System (RPMS), an
integrated public health information system based on the U.S.
Department of Veteran's Affairs (VA) VistA system. It is a
comprehensive suite of applications that supports virtually all
clinical and business operations at IHS and most tribal facilities,
from patient registration to billing. RPMS is comprised of over 80
software applications and is designed to track patient and population
based clinical and practice management applications. However, various
concerns and challenges have been cited regarding RPMS. Some notable
issues are:
Many Tribes utilize different EHR systems instead of RPMS;
Smaller Tribal health facilities do not have the bandwidth
to fully operationalize RPMS, and would benefit from the
ability to share new components such as files that contain all
available drugs instead of just some;
Some smaller Tribal health clinics are in need of greater
training and technical assistance on how to utilize the system
most efficiently;
There is a need to further streamline the system and align
it with other EHRs utilized by Tribes;
Robust and timely IT support is not routinely available;
Interoperability is incomplete, meaning that if a patient is
referred to another clinic that utilizes a different system,
the patient records are more than likely not cross-referenced
which leads to inconsistencies in patient records.
Issues also exist in terms of RPMS interactions with Prescription
Drug Monitoring Programs (PDMPs). PDMPs are state-run electronic
databases that track controlled substance prescriptions. Across the
board, utilization of PDMPs is inadequate. A national survey of primary
care physicians found that 86 percent of the time, physicians did not
check their statewide PDMP prior to prescribing an opioid, despite the
fact that 72 percent of primary care physicians are aware of their
state's PDMP. \5\
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\5\ Office of Management and Budget. Circular A-130. Appendix III.
Security of Federal Automated Information Resources.
---------------------------------------------------------------------------
It is important to note the limitations of the PDMP system, both
generally and in its usefulness for IHS and Tribal providers,
pharmacists and public health practitioners. One, PDMP laws and
regulations differ by state. In other words, whereas one state may
require providers to update the system within a 24 hour period, other
states only require updating the system every few days, or even over a
longer period of time. Further, interstate sharing of PDMP data is not
streamlined, which creates gaps in monitoring especially for
individuals living in border towns, or for reservations that traverse
multiple state boundaries. Additionally, to NIHB's knowledge, only the
state of Alaska decreed a special consideration for IHS providers to
access the PDMP system, which may explain why IHS established
memorandums of understanding (MOU) with state agencies to permit IHS
access and reporting. Also, there is currently no Tribally-specific
PDMP system. The FY2017 House Appropriations Bill authorized $1 million
to IHS to establish such a system; however, to NIHB's knowledge, this
system has not yet been implemented.
Finally, no PDMP system collects racial demographics, limiting its
value as a tool for public health monitoring for Tribes and Tribal
Epidemiology Centers.
Due to budgetary constraints, IHS has not been able to support
operations and maintenance for the certified RPMS site. Other federal
agencies, like the Veterans' Administration, are in the process of
moving away from RPMS-like systems toward more integrated software
platforms, where EHRs and PDMPs can communicate under an interoperable
platform. Unless Congress intervenes, this will create a disconnect
between IHS and other agencies.
NIHB supports E-prescribing, especially given its potential to
reduce the spread of prescription opioid abuse, and encourages IHS to
utilize it where practicable. However, most IHS and Tribally run health
facilities are in rural areas where limited broadband make widespread
adoption of E-prescribing unrealistic without Congressional
intervention. To ensure that E-prescribing is a viable tool in the
Indian health system, Congress must first continue, and expand, its
investment in rural broadband to incorporate rural Tribal communities.
Telehealth is a much-needed and successful innovation in rural
areas. For example, the Eastern Aleutian Tribes, a healthcare provision
organization serving 8 Alaska Native communities, has begun using
telemedicine to diagnose conditions, prescribe treatment, and conduct
follow up examinations. Many Tribes in remote Alaska communities, often
disconnected by the road system and only accessible by plane or boat,
do not have access to medical providers regularly and have come to rely
on telemedicine to fill a gap in healthcare provision. However, this
was only accomplished through sustained investment in rural broadband.
Greater network bandwidth and broadband access is a critical need,
demonstrated by a 2018 FCC report that found as many as 35 percent of
individuals living in Tribal lands lack broadband access, while in some
Tribal communities as much as 80 percent lack broadband access.
To ensure Tribes are able to utilize Health IT to the greatest
extent possible in confronting Indian Country's opioid epidemic,
Congress should:
Provide adequate support, funding, and oversight as IHS
moves away from the RPMS system toward a more integrated
platform that can better interact with E-prescriptions and
EHRs.
Provide oversite to IHS to implement a Tribally-specific
PDMP system than can interact with state PDMPs.
Review and support IHS's list of Tribal broadband projects,
and also include direct funding to Tribes to improve their
broadband and telehealth infrastructure.
Mandate State-Tribal consultation on changes to state PDMPs.
Incentivize providers to adopt E-prescription as a way to
reduce the needless and harmful spread of opioids. Should
Congress provide a grant program to that end, a set aside of 3-
5 percent would be appropriate to ensure Tribes are not at a
disadvantage in tapping into those funds.
Eliminate the requirement for Tribal providers to obtain the
Secretary's authorization to be designated as an Internet
Eligible Controlled Substances Provider, as it imposes an undue
burden that delays the delivery of much-needed treatment
resources, especially given that no other providers are subject
to this requirement. \6\
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\6\ (21. U.S.C. 829) Section 311(g)(2)
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Conclusion
Again, NIHB would like to thank the Committee for holding this
hearing and soliciting input from a variety of stakeholders. Indian
Country has seen over the past several years that opioids do not face
barriers in entering Tribal communities. To truly address this problem,
Congress must ensure that Tribes receive direct funding, and are
included any type of national-level opioid legislation moving forward.
______
Supplemental Testimony of the NIHB
Chairman Hoeven, Vice Chairman Udall, on behalf of the National
Indian Health Board (NIHB) and the 573 American Indian and Alaska
Native (AI/AN) Tribes we serve, I would like to thank you for holding
the hearing, ``Opioids in Indian Country: Beyond the Crisis to Healing
the Community,'' and for NIHB to offer testimony at the hearing.
NIHB is a 501(c)3, not for profit, national Tribal organization
founded by the Tribes in 1972 to serve as the unified, national voice
for American Indian and Alaska Native health in the policy-making
arena. Since 1972, NIHB has advised the U.S. Congress, Indian Health
Service (IHS), and other federal agencies about health disparities and
service issues experienced in Indian Country.
The current opioid epidemic represents one of the most pressing
public health crises affecting Tribal communities. While this epidemic
is affecting many communities throughout America, it has
disproportionately impacted Tribes and has further strained the limited
public health and healthcare resources available to Tribes. The Federal
Government must take concrete action to ensure Indian Country has the
tools it needs to address opioid abuse and heal Tribal communities.
While each witness brought a wealth of knowledge and experience to
the committee, NIHB wishes to ensure the Senators on the committee have
all of the information they need to make informed decisions on how best
to support Tribes and Tribal health programs in confronting the opioid
crisis.
The 21st Century CURES Act included two years of funding to states
to develop State Targeted Responses. As CAPT Jones from the Substance
Abuse and Mental Health Services Administration (SAMHSA) mentioned in
his testimony, of the 36 states with Tribes, only 12 have incorporated
Tribes into their State Targeted Responses or identified American
Indians/Alaska Natives (AI/ANs) as a specific population under the
state plan. The funding is not reaching Tribal communities. NIHB is
supportive of the provisions in S. 2270, the Mitigating METH Act, and
S. 2437, the Opioid Response and Enhancement Act, which would open
CURES Act funding to Tribes directly. These needed revenue streams
would allow all Tribes to replicate success seen in several Tribal
programs across America. In her questioning at the hearing, Senator
Cortez Masto asked witnesses from federal agencies if direct Tribal-
specific funding streams were needed to combat the opioids crisis. Had
that question been asked of the Tribal witnesses, the committee would
have heard an unambiguous ``Yes.''
There is an inherent structural problem with the system of Tribes
through states to access federal funding. There is no established legal
relationship between the states Tribes. States are not compelled to
have consultation with the Tribes, or even listen to their needs. There
is no treaty, constitutional relationship or law that sets forth
Tribal-state collaboration. Using this type of construct essentially
just cuts Tribes out of the system all together. Forcing Tribes to go
to states diminishes the federal trust Tribes are not subservient to
the state governments, but are recognized as sovereign nations within
the federal system. In practice, this means, that few tribes actually
see this funding, and if they do it is usually insufficient to meet
need.
Senator Tester similarly asked federal agency witnesses if some of
the $10 billion for opioids included in the President's Fiscal Year
2019 Budget Request should be set aside for Tribes. Again, the answer
from Tribal witnesses would have been, ``Yes.''
We were also pleased to see that the Consolidated Appropriations
Act of 2018 contained a $50 million set-aside for Tribes in the State
Targeted Response (STR) to opioid grants as well as a $5 million set
aside for medication assisted treatment for Tribal communities. This
funding is a critical first step in ensuring that Indian Country has
access to the resources it needs to combat this deadly epidemic. Thank
you for the advocacy that you and other committee members undertook to
make this possible. We look forward to working with you to build on
these gains in the coming year so that there is long-term sustained
funding going to fight substance abuse among Tribal Nations.
Senator Smith asked CAPT Jones how SAMHSA and other agencies were
looking at intergenerational addiction, especially as relates to
addicted mothers and newborns. He answered correctly that the agency is
looking at the issue holistically and trying to break down siloes.
However, it is crucial to note that neither program he cited, the
residential program with 19 grantees, nor the outpatient program
authorized by the Comprehensive Addiction and Recovery Act (P.L. 114-
198), are open to Tribes. Because Congress did not list Tribes, Tribal
organizations, and Urban Indian Health Centers as eligible entities,
the funding for the grant programs does not reach Tribal communities
and should not be cited as a success story in Indian Country.
Furthermore, even if Congress authorized funding from those
programs to go directly to Tribes, the competitive grant program is
unfair to smaller Tribes which may lack capacity but which do not lack
need. As Senator Murkowski said, the current competitive grant program
``sets Tribes up to compete with other Tribes.'' We could not agree
more. Instead, Congress should work to empower IHS and Tribal health
programs to implement successful, community-based, culturally competent
care geared toward helping Tribal communities confront and heal from
the opioid epidemic.
While evidence-based care has many advantages in opioids treatment,
Congress dictating a one-size-fits-all approach to this challenge will
not work in Indian Country. Tribes often utilize traditional,
culturally-based and promising practices as well as evidence-based
practices. Culturally-based programming helps Tribes tailor initiatives
to the specific needs of their community, while also honoring Tribal
sovereignty and the right to self-determination. Evidence-based
practices that do not integrate traditional Tribal practices are not
always as effective at improving health outcomes as programs that do.
Many Tribal public health programs--including the well-known and highly
successful Special Diabetes Program for Indians (SDPI)--combine Tribal
best practices with evidence-based practices. This model has worked and
should be replicated to confront opioid addiction, with support and
oversight from Congress.
We hope this information clarifies some of the questions raised at
the hearing. NIHB thanks you and the Senate Committee on Indian Affairs
for holding the hearing and using Congress's authority to support
Indian Country as our communities confront and heal from the opioid
epidemic.
Senator Udall. Thank you, Mr. Moose. Thank you, Ms. George
for your testimony. Please be assured there will be a lot of
questions. The staffs of all the Senators who are here and will
be following very closely your testimony. We are really happy
to have you here.
Senator Daines, we are happy to see you back. Please
proceed with your questions.
STATEMENT OF HON. STEVE DAINES,
U.S. SENATOR FROM MONTANA
Senator Daines. Thank you, Ranking Member Udall. We have
votes going on right now, as you understand. There is a lot of
interest and they will be coming back from the Floor soon.
I hail from the State of Montana. Opioid abuse is an issue
in my home State. Meth use is increasingly a crisis. We know it
is even more concentrated among Montana's Indian tribes. That
is why I have introduced the Mitigating METH Epidemic and
Promoting Tribal Health Act also known as the Mitigating METH
Act.
As a matter of this government-to-government relationship
between the United States and tribes, this legislation would
make tribes, like States, directly eligible for funding that is
authorized in the 21st Century CURES Act to combat the opioid
crisis. Additionally, it would give States and tribes the
flexibility to address the substance abuse and disorders most
prevalent among their constituencies, which in Montana, would
include meth. This legislation enjoys the support of eight co-
sponsors from both sides of the aisle, including members of
this Committee and is the only bipartisan legislation in the
U.S. Senate that makes tribes directly eligible for this
funding.
Mr. Moose, I know you and Ms. George both discussed the
benefits of my bill in your testimony. Could you expand on why
you see it as important that the bill make tribes directly
eligible for Federal funds to combat substance abuse?
Mr. Moose. Thank you for the question.
I think probably the most important thing we talk about
among tribal program administrators and tribal providers is
getting direct funding. Tribal leaders throughout Minnesota,
Wisconsin and Michigan are always looking at direct funding for
their tribal programs. It helps us enhance the things we
currently do well and helps us target the things we need
funding to expand or create access for. Anything that will
provide sustainable funding for our tribal programs, something
we can change or redirect based on how we see the need in our
communities is critical to our addressing this issue.
Senator Daines. Thank you, Mr. Moose.
Ms. George, I have the same question to you. Why do you see
my bill, the Mitigating METH Act, as so important and
beneficial?
Ms. George. I think there are a couple areas where we saw
significant support for us. Really, it reflects the government-
to-government relationship with the tribe, allowing direct
access and also recognizing grant funding limits creates
competition for resources not just between tribes but even
other local agencies we work with.
We are often forced to choose between two or more very
important issues. We sometimes do not get where we need to get.
Senator Daines. I think one of the underlying foundational
principles is really tribal sovereignty and this government-to-
government relationship and how the U.S. Government should be
viewing the direct access for these funds to address the crisis
we are seeing right now with meth and opioid abuse.
I agree with both of you and I appreciate your support.
These are the very reasons why I have authored this crucial, I
think very timely, piece of legislation.
I would like to turn to a discussion of CARA 2.0. I applaud
Senator Portman for continuing to lead the charge on this
legislation to combat the drug overdose crisis and would like
to explore ways to ensure tribes are appropriately included in
this effort.
Mr. Moose, what change would you like to see in CARA 2.0 to
help address the drug abuse crisis in your community? I would
be especially interested in your perspective on needed changes
to the section which provides funding to States for addiction
treatment targeted toward pregnant and post partum moms.
Mr. Moose. We recommend allowing tribes to access the
program outlined in Section 6 which establishes funding for
regional technical assistance centers to focus on addiction
recovery and naloxone training and dissemination. We recommend
in Section 7 allowing States to increase the three-day limit on
first-time opiate prescriptions found in Section 3 of the bill,
if the State passes a law or implements statewide regulations,
tribal law should have the same authority.
Tribes should also have access to Section 10 which provides
funding to States for addiction treatment programs targeted
towards pregnant or postpartum women. Finally, we recommend
adding language to Section 13 that would require States to
consult with tribes on implementation of their prescription
drug monitoring program.
Senator Daines. Thank you. That input will be relayed to
Senator Portman who is a great colleague and leader here in the
Senate. I appreciate that testimony.
I want to thank you for the input. I want to continue to
work with you, the NIHB and my colleagues to see how we might
be able to work some of these changes into that legislation.
Indian tribes cannot afford to be left out. They cannot be left
out of these discussions. I remain committed to seeing that
their needs are addressed.
Thank you.
Senator Udall. Thank you so much, Senator Daines. I really
appreciate your questions.
Early on, I think this is mentioned in your testimony,
there were issues about the cuts that were going to take place.
I think you all are familiar with those. These are program
areas, many of them when you talk about programs and needing
services, these are the same program areas where President
Trump has Indian line items where he has proposed cutting in
the 2019 budget request.
I want to ask you both what impact would cuts to Federal
funding for tribal housing, human services and public safety
programs have on your tribe's ability to continue its efforts
to combat the opioid crisis?
Mr. Moose. Thank you for the question, Senator.
Funding for social safety net programs is very much linked
with healthcare programs. When individuals do not have access
to social safety net services, the effect of substance abuse
disorder will be exacerbated because patients will not have the
comprehensive services to support them in recovery. This
includes protections of SNAP, Medicaid, TANF, and the Indian
Housing Block Grant.
For instance, if the proposed cuts to the Medicaid Program
were to be enacted, it would place additional burden because
there would be less resources available for medical treatment.
Further, many of these programs are effective in preventing
substance use altogether.
Research has shown access to healthy and traditional foods,
stable housing and other social programs reduces substance use
later in life. This is a very important aspect of the public
health approach. Comprehensive care, the kind that promotes the
whole health of a person, is the most effective in improving
the health outcomes related to substance use and opioid abuse
disorder.
Senator Udall. Ms. George?
Ms. George. I fully support the comments Mr. Moose just
made. In addition to that, any cuts to tribal programs hamper
the tribe's ability to sufficiently provide services to its
members, run our governmental programs and initiate new
projects.
Senator Udall. Aside from more direct tribal funding for
behavioral health programs at HHS, for what other departments
should we request more dedicated resources for tribal opioid
and substance abuse efforts?
Mr. Moose. Would you repeat the question?
Senator Udall. Aside from more direct tribal funding for
behavioral health programs at HHS, for what other departments
should we, the Committee looking into this, request more
dedicated resources for tribal opioid and substance abuse
efforts?
Mr. Moose. One of the areas we have talked about within our
system of care at Fond du Lac is prevention funding such as
public health, infrastructure support and support for youth
programs and youth prevention programs. One of the initiatives
we are looking at starting is a children's initiative. Having
support with regard to these types of prevention programs is
critical in our heading off the issue of opioid and substance
abuse and healthcare disparities in general. I think anything
that would fund prevention, public health infrastructure,
surveillance and those types of issues would be important for
us.
Senator Udall. Ms. George, do you want to add to that?
Ms. George. For us, increased funding for tribal courts and
law enforcement is important. Our tribal court also operates a
reentry program because once we get help for these people, they
also need to be reentered to their community, gain skills to
maintain employment and be successful, thriving members again
in our community. Those are areas I think we would identify as
well.
Senator Udall. Thank you very much.
One issue I have focused on throughout my entire time in
Congress is Federal information technology reform. Just last
year, I worked with another member of this Committee, Senator
Moran, to get our bill, the Modernizing Government Technology
Act, passed as part of another bill. The opioid crisis is just
one more example of how outdated information technology can
slowdown efforts to gather real-time data, in this case,
prescription monitoring, people getting prescriptions from
multiple areas.
You both testified about the inadequacy of RPMS and PDMP
systems coordination putting limitations on tribes' trying to
look at opioid prescription patterns. Do you believe that
information technology challenges at the Indian Health Service
led to shortcomings in implementation of a robust PDMP system?
Mr. Moose. Yes, I do. I was the Commissioner of Health and
Human Services for the Mille Lacs Band. We utilized the RPMS
system. Unfortunately, the RPMS system had challenges with
regards to its being robust. I know that within our behavioral
health program, in 2014, we started looking at implementing the
Behavioral Health Electronic Health Record. That was in 2014,
mind you.
We have many programs concerning the program that I am at
right now. The Fond du Lac Band of Lake Superior Chippewa
purchased an off-the-shelf electronic health record system. We
were far more advanced than we are at Mille Lacs. I definitely
would support that.
Senator Udall. Thank you, Mr. Moose.
Ms. George, did you have anything else to add? I have
another question focusing on you, but go ahead, please.
Ms. George. I just wanted to add that our tribe has had to
spend an enormous amount of money creating custom templates for
our information system. It is still not as adequate as we would
like. That was a big burden to us.
Senator Udall. Ms. George, has the IHS, or any other
Federal agency, offered support to help your tribe, or any
other tribe that operates its own health facilities, coordinate
with State-run PDMPs?
Ms. George. No, they have not.
Senator Udall. Ms. George and Mr. Moose, what advice would
you give the Administration and this Committee when evaluating
replacements for RPMS systems, especially in light of the need
to improve opioid prescription monitoring?
Mr. Moose. We would suggest tribal consultation, working
with tribes to identify the systems, creating a work group that
looks and combs the landscape for what is best for Indian
Country, along with hearing that input from specific Indian
Country practitioners, tribes and tribal units for health
service systems.
Senator Udall. Do you have anything else to add to that?
Ms. George. I would just like to add that interoperability,
reporting and population health are also important aspects.
Senator Udall. Thank you very much.
Ms. George, I am impressed by your testimony describing
Port Gamble's experience combating the opioid crisis through
State and local partnerships. These partnerships seem to be
working and could be a model for other tribes across the
Country.
What advice would you give to other tribes considering
partnering with their State and local counterparts? Do you have
any advice for those whose State or local governments are not
as willing as that of Washington to engage in similar
partnerships?
Ms. George. I am not sure that I have any advice to other.
I would like to add that I do not believe there is a community,
county or State that this epidemic is not touching right now. I
think tribes would be surprised how quickly our local and State
governments come to the table because none of us know how to
handle this epidemic.
Senator Udall. Mr. Moose, based on your experience in
developing cross-governmental partnerships, could Congress help
encourage more fruitful partnerships by providing tribes with
their own direct funding to leverage and bring to the table
these other partners?
Mr. Moose. Yes, Senator. I believe it would be important to
have tribes. One thing I keep thinking about is the discussion
in our region with regards to some of the State-targeted
response funding that a few of us put together specifically to
address the opioid issue.
We were trying to change our services to fit those grants.
When I say services, I look at our traditional and cultural
practices. Oftentimes when we have to go with that approach, it
really takes us away from some of the internal infrastructure
or development we have to deal with in some of our cultural
practices or traditional approaches. Oftentimes, it takes up
time and space when we should be concentrating on those issues,
trying to fit our programs to the grant funding or other
funding that is competitive, along with administrative time of
managing those grants.
Senator Udall. I know I have asked a number of questions
and you also heard from a number of Committee members with
questions. Is there anything off the top of your head right now
that you wanted to say in conclusion?
Mr. Moose. One of the areas we were looking at as part of
the information I just provided is we have a young practitioner
in our tribal clinic. She is looking at doing her dissertation.
In that dissertation, she came across something that was really
interesting to her as a non-Indian practitioner.
Several months ago, we started traditional healing services
within our clinic. We gave access to a traditional healer we
had hired within our clinic system to patients. This mental
health practitioner was able to send her clients to this
traditional healer. She looked at the clients going through our
Core 12 program, our comprehensive opioid response program that
utilizes suboxone as part of its treatment modality along with
traditional healer services.
One of the things she recognized, which became part of a
passion that she wanted to do her dissertation on, was the
impact those traditional healer services had on those clients.
She saw incredible improvement in their depression rates, their
anxiety and the overall treatment outcome for these clients
which were incredibly important to us.
Our course our tribe is definitely supporting her in
identifying this as a piece within her research and her
dissertation. I think it really came to us, and my comments
before, that these are the services tribes in Indian Country
need to reinvest in, our traditional and cultural practices as
part of our treatment modalities.
When we are trying to fit our services into a square peg,
oftentimes we lose the ability to make that type of impact. If
we could concentrate on those things within our communities
that really enhance treatment services or gets a patient to
accept that type of modality, I think it is really good for
Indian Country.
Senator Udall. Thank you.
Ms. George. I would just like to again extend the
invitation to the Committee members and the agency directors to
come and visit the tribes, see what we are doing and see what
is working for us to get a better understanding of where our
needs really lie.
Senator Udall. Thank you for that invitation. You have the
Rear Admiral in the audience, so he certainly heard that. I
will convey that information to all the members of the
Committee. I would love to visit you both in your respective
States.
Today, you have given very enlightening testimony and
answers for the Committee. We really look forward to digesting
all of this and trying to work on getting the legislation just
right so we can get resources into Indian Country. As I
mentioned earlier, you may get additional questions from
Committee members that will be submitted to you in writing
after today's hearing.
If there are no more questions today, which looking around,
I do not think there are, members may also submit follow-up
written questions for the record. The hearing record will be
open for two weeks.
Once again, I want to thank these witnesses for their
testimony here today.
The hearing is adjourned.
[Whereupon, at 4:55 p.m., the Committee was adjourned.]
A P P E N D I X
Prepared Statement of Esther Lucero, CEO, Seattle Indian Health Board
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
Prepared Statement of the National Congress of American Indians (NCAI)
On behalf of the National Congress of American Indians (NCAI), the
oldest, largest, and most representative American Indian and Alaska
Native organization serving the broad interests of tribal governments
and communities, we hereby submit the following testimony for the
record of the Senate Committee on Indian Affairs Oversight Hearing on
``Opioids in Indian Country: Beyond the Crisis to Healing the
Community.''
Impact of Opioid Epidemic on Indian Country
While the opioid crisis is plaguing communities across the country,
studies indicate that American Indians and Alaska Natives (AI/ANs) are
impacted at a higher rate than other groups. According to the Centers
for Disease Control and Prevention (CDC), AI/ANs had the highest drug
overdose death rates compared to all other races in 2015. Further, the
same CDC study found that the drug overdose death rates for AI/ANs in
nonmetropolitan areas increased by more than 500 percent between 1999
and 2015. Additional studies indicated that pregnant AI/AN women are
nearly 9 times more likely than others to be diagnosed with opioid
dependency or abuse, and one in 10 AI/AN youths age 12 or older used
prescription opioids for nonmedical purposes, which is double the rate
for Caucasian youth. These statistics illuminate the critical need for
a comprehensive strategy to curb the opioid epidemic in tribal
communities.
NCAI's Efforts and Recommendations
NCAI has been addressing this crisis in various ways, by utilizing
NCAI's Policy Research Center to conduct related research, convening
meetings of NCAI's Substance Abuse Prevention Task Force, developing
policy objectives during its resolution process, collaborating with the
Substance Abuse and Mental Health Services Administration (SAMHSA) on
developing the Tribal Behavioral Health Agenda, holding a roundtable
during Executive Council Winter Session, hosting a webinar series on
the crisis, and congressional advocacy. Based on the findings and
feedback from these undertakings, NCAI would like to provide the Senate
Committee on Indian Affairs with the following recommendations:
Direct Funding to Indian Country
Tribal governments need parity with state and local governments.
When Indian tribes have to go through states in order to access federal
funding, the result is often unfavorable. Instead, direct federal
funding to address the opioid crisis should be made available to Indian
tribes. Currently, tribes are forced to petition states for access to
opioid-related grants stemming from the 21st Century Cures Act (Cures
Act).
Several pending bills would amend the Cures Act to include Indian
tribes and tribal organizations alongside states as eligible entities.
These include S. 2270, the Mitigating METH Act (Daines, MT); H.R. 5140,
the Tribal Addiction and Recovery Act (Mullin, OK); and S. 2437, the
Opioid Response Enhancement Act (Baldwin, WI). NCAI strongly supports
the goals of these bills.
Tribal Representation on Federal Task Forces
Tribal representatives need a seat at the table in order to ensure
the unique challenges facing Indian tribes are considered. While Indian
Country was disappointed about the lack of tribal representation on the
President's Commission on Combatting Drug Addiction and the Opioid
Crisis, going forward it is crucial that tribal representatives have
the opportunity to serve on federal task forces or commissions that are
seeking to address the opioid epidemic.
In September 2017, NCAI, along with the National Indian Health
Board, sent a letter to former Secretary Tom Price asking him to
include a tribal representative on the Department of Health and Human
Services Pain Management Best Practices Inter-Agency Task Force (Task
Force). NCAI remains hopeful that a tribal representative will be
selected to serve on the Task Force.
In addition, NCAI recommends that the Indian Health Service's
National Committee on Heroin, Opioid, and Pain Efforts (HOPE) include
tribal representation. While the committee is comprised of IHS subject
matter experts, it is important to collaborate with tribal leaders in
order to fulfill the HOPE Committee's purpose--promoting appropriate
and effective pain management, reducing overdose deaths from heroin and
prescription opioid misuse, and improving access to culturally
appropriate treatment.
Collaboration and Coordination among Agencies and Tribes
In 2016, NCAI passed Resolution #PHX-16-027, which calls upon all
federal agencies to increase resources in order to advance education,
prevention, treatment services, and public safety programs designed to
address heroin and opioid abuse and addiction within Indian Country. As
Congress makes more resources available, effective collaboration and
coordination among federal agencies is needed in order to pool together
the resources that are available to tribal communities. Further, Indian
tribes needs flexibility in using various funding sources to develop
culturally appropriate programs to address the crisis.
NCAI agrees with Senator Barrasso's statement at the hearing:
``Successful implementation of programs requires cooperation and
coordination from all sides--Interior, Justice, Health and Human
Services, and the tribes themselves.'' A memorandum of understanding
between these agencies may be a valuable tool to help achieve this
objective. NCAI is equipped to help ensure that Indian Country is made
aware of the resources available throughout the Federal Government, and
able to bring agencies together at various NCAI forums.
There are two other important aspects to federal agency cooperation
with tribes. First, tribal governments have increasing law enforcement
and public safety needs as they work to address the crisis with opioids
and other forms of substance abuse. Interagency Task Forces are a
proven method of leveraging available resources by increasing
cooperation among tribal, federal and state law enforcement, and we
urge further consultation on using the Task Force model to address the
substance abuse crisis. In addition, tribal courts and correctional
systems need additional resources for treatment that can serve as
alternatives to incarceration.
Second, the conduct of large pharmaceutical companies has been a
focal point in opioid-related litigation. Numerous state, local and
tribal governments have filed lawsuits against opioid manufacturers and
distributors in various state and federal courts, alleging that they
helped create the crisis by improperly marketing the drugs. Tribes are
seeking medical costs, social services costs, child welfare costs, and
public safety costs. More importantly, tribes are seeking injunctive
relief to reduce the flow of unregulated opioids. U.S. District Judge
Dan Polster of the Northern District of Ohio is overseeing more than
200 of the opioid cases filed in federal court, in multidistrict
litigation under 28 U.S.C. 1407. The Department of Justice has filed a
statement of interest on behalf of the Federal Government. There is an
opportunity for the Committee to urge the Department to coordinate and
consult with tribal governments, and ensure that tribal interests are
properly considered in the nationwide multi-district litigation.
Culturally Based Solutions
For Indian Country, factors related to historical and
intergenerational trauma will have to be taken into account when
addressing this crisis. The high rates of depression, suicide, and
substance abuse in Indian Country are often deeply rooted underlying
issues. The National Tribal Behavioral Health Agenda (TBHA), which is
the result of a collaborative effort between Indian Country and its
federal partners, serves as a valuable guide in the efforts to address
the opioid crisis in Indian Country. A major tenant of the TBHA is the
recognition and support of ``tribal efforts to incorporate their
respective culture wisdom and traditional practices [sic] in programs
and services that contribute to improved well-being.''
Legislation such as the Native Health Access Improvement Act (H.R.
3704 (Pallone, NJ) and S. 2545 (Smith, MN)) is a step in the right
direction. These bills would establish a Special Behavioral Health
Program for Indians (SBHPI) grant program for the prevention and
treatment of mental health and substance abuse disorders. The proposed
SBHPI program is modeled after the Special Diabetes Program for Indians
(SDPI), which has been highly successful, in part, due to its allowance
for the incorporation of culture and flexibility in utilizing the
funding.
Data Collection
In March 2018, NCAI's Policy Research Center (PRC) published a
brief titled, ``The Opioid Epidemic: Definitions, Data, Solutions.''
The PRC brief highlights the need for more reliable data related to the
opioid epidemic. It finds that the data on death rates are often
underestimated in AI/ANs due to misidentification on death certificates
and that national data does not reveal potential regional/local
differences in impact. While some tribes indicate that opioids are a
huge problem in their communities, others point to greater problems
with other abused substances. This underscores the need to understand
local and regional trends to inform action. As Chairman Hoeven
indicated at the hearing, ``[w]ithout accurate data, Congress, the
Administration and tribes are limited in their ability to allocate
resources to the area of greatest need.'' In addition, it is important
for agencies to establish benchmarks for success.
Conclusion
NCAI applauds the Committee for holding the hearing on this urgent
matter and appreciates the opportunity to submit this testimony for the
hearing record. Addressing this epidemic will require a multifaceted,
collaborative approach across all levels of government.
______
Prepared Statement of Hon. Jeromy Sullivan, Chairman, Port Gamble
S'Klallam Tribe
Dear Chairman Hoeven:
On behalf of the Port Gamble S'Klallam Tribe (the ``PGST''), thank
you for inviting us to testify on March 14, 2018 at the Senate
Committee on Indian Affairs (the ``Committee'') hearing titled
``Opioids in Indian Country: Beyond the Crisis to Healing the
Community.'' We would also like to thank Senator Cantwell for her very
kind introduction of our witness, Jolene George, a member of the PGST
and our Behavioral Health Director.
We were pleased to share our experiences with the Committee and are
proud of the steps we have taken towards formulating and implementing a
multi-faceted, comprehensive approach to respond to the opioid epidemic
in our community. It is encouraging to hear the Committee member's
commitment to bipartisan and cross-committee efforts. We are hopeful
that this dedication will result in the adoption of legislation
specifically targeting the opioid crisis devastating Indian Country. As
the Committee continues its endeavors. the PGST is delighted to
continue assisting it in whatever way we can.
One lesson that we have learned is that incorporation of
traditional healing practices, cultural beliefs regarding approaches to
treatment, and differences in interpersonal communication contributes
significantly to the quality of care Native people need. It is also key
for helping our members escape the destructive cycle of substance
abuse. For over 20 years, the PGST has been actively involved in
directly providing culturally appropriate health care services to our
tribal members and Native community members living on the Port Gamble
S'Klallam Reservation. Since joining the Tribal Self-Governance
Project. a consortium of self-governing tribes, in 1990, we have funded
our health care services through a compact with the Indian Health
Service under the Indian Self-Determination and Education Assistance
Act. We operate and manage our entire health system on our Reservation,
which includes primary care, dental, mental health, and substance abuse
services.
As Ms. George testified, the heart of our opioid response is THOR:
Tribal Healing Opioid Response. The Tribe convened THOR out of
necessity to address the intense and widespread impact of the crisis on
our community. The main goals of THOR are: (1) preventing opioid misuse
and abuse; (2) expanding access to opioid use disorder treatment; and
(3) preventing deaths from overdose. Every department across the PGST
is responsible for implementing strategies to achieve these goals. \1\
Additionally, we coordinate with the State of Washington, Jefferson and
Kitsap Counties, and other nearby tribes to fight opioid addiction and
treat those affected.
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\1\ Through THOR, each of the Tribe's departments have specific
responsibilities for reaching the THOR goals. See Tribal Healing Opioid
Response Program, https://www.nihb.org/docs/12032017/
Tuesday%20Sessions/THOR%20Presentation.pdf (last accessed March 15,
2018).
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Support for Specific Legislation
We have shown leadership by implementing an aggressive and
comprehensive approach for responding to the opioid epidemic in our
community. However, as testified, we still need the help of this
Committee, Congress, and Federal agencies to continue our effective
efforts to respond to the opioid crisis. We support several pieces of
legislation introduced in the Senate with the hope that Congress will
enact them soon and aid our efforts in combating the crisis.
S. 2440, the Comprehensive Addiction, Recovery, Education and
Safety (CARES) Act. This bill introduced by Committee Member Senator
Cantwell--our Senator--would provide law enforcement with more tools to
hold drug companies accountable for ensuring that their drugs do not
enter the illicit drug market. Specifically, the bill increases civil
and criminal penalties on companies that fail to keep proper records or
report suspicious opioid distribution practices. Additionally, the bill
authorizes funding for the Drug Enforcement Agency (DEA) to investigate
suspect drug companies and drug trafficking organizations. The PGST
supports S. 2440 because it aligns with our goals in our federal
lawsuit to hold drug companies accountable for the destruction caused
by the opioid crisis that stems from their failure to track orders and
for creating an illicit market for their drugs.
S. 2270, the Mitigating the Methamphetamine Epidemic and Promoting
Tribal Health Act (the ``Mitigating METH Act''). This bill, introduced
by Committee Member Senator Daines, would make tribes and tribal
organizations eligible for direct funding (no set-aside) under the 21st
Century Cures Act, which provides funding for prevention and response
to opioids, or other substances--such as methamphetamines--if they are
having a substantial impact on the state or tribe. The bill would
increase the allocation of $500 million to $525 million. The PGST
supports S. 2270 because it gives us access to direct funding and
important resources for combatting the crisis, in recognition of the
government-to-government relationship we have with the Federal
Government.
S. 2437, the Opioid Response Enhancement Act. This bill, introduced
by Senator Baldwin, would also make tribes and tribal organizations
eligible for funding under the 21st Century Cures Act but through a 10
percent tribal set-aside. Like S. 2270, tribes and states could use
this funding for prevention and response to other substances
threatening public health--such as methamphetamines. Additionally, the
bill requires the Substance Abuse and Mental Health Services
Administration (SAMHSA) to provide technical assistance to both states
and tribes for grant applications, formulating outreach and support
efforts, and collecting data. The PGST supports S. 2437 because it has
targeted funding for Indian Country, where Native families and
communities feel the disparate impacts of the crisis hardest.
S. 2545, the Native Behavioral Health Access Improvement Act of
2018. Recently introduced by Committee Member Senator Smith, this bill
aims to help combat the opioid epidemic by creating the Special
Behavioral Health Program for Indians (SBHPI): a grant program modeled
after the Special Diabetes Program for Indians (SDPI) and administered
by the Indian Health Service (IHS), in coordination with SAMHSA. The
SBHPI would provide IHS, tribes and tribal organizations, and urban
Indian health programs with access to much-needed resources for
addressing mental health needs and substance use disorders,
specifically providing $150 million in annual mandatory funding from FY
2018 to FY 2022. The grants would give tribes needed flexibility to
provide tribally driven, culturally appropriate behavioral health care
to meet the specific needs of their communities. The bill also provides
that IHS, in coordination with SAHMSA, would create a technical
assistance center responsible for developing grant-reporting standards
in consultation with tribal grantees.
The PGST has operated a robust SDPI program for many years and is
confident that its use as a model for the SBHPI will be a success.
However, we caution against providing tribes resources through another
program funded in the form of grants because competitive funding pits
struggling tribes and local governments against each other for access
to limited resources when we should be working together. One of the
reasons why our THOR program is so effective is that the PGST has good
relationships with State, County, and regional groups to coordinate on
response strategies. The PGST does support S. 2545, but suggests, as an
alternative to grant funding, that self-governance tribes--such as the
PGST--be able to receive funding through their self-governance
compacts.
Additional Information in Response to Committee Member Questions
During the Committee's March 14 Opioid Hearing, Committee Members
were actively engaged in questioning the witnesses and we wanted to
follow-up on several of those questions to make sure the Committee has
ample information about our specific needs and those of Indian Country.
In response to Vice-Chairman Udall's questions about the impacts of
funding cuts on the PGST's ability to respond to the opioid crisis and
what departments--other than behavioral health--should have direct
funding, we would answer that any reduction in funding harms our
ability to respond and every department that the PGST operates needs
direct funding for its programs and services. At a government level,
our Health, Behavioral Health, Children & Family Services, and Housing
Departments, as well as our courts, law enforcement, and
administration, all have a role to play in responding to this crisis.
It affects all of our members and Tribal agencies. Adequate direct
funding means reliable resources and flexibility for the PGST to
continue implementing our culturally appropriate, multi-faceted,
comprehensive approach to abating the opioid epidemic sweeping the
community. Additionally, adequate direct funding allows us to plan long
term for infrastructure development, program enrichment, and service
enhancements necessary for the well-being of our members and local
community.
Thank you for the opportunity to speak on behalf of the PGST
regarding the opioid epidemic. We look forward to further opportunities
for discussion and to actively working with the Committee to tackle the
opioid epidemic.
We hope that you and the entire Committee will accept our
invitation to come visit the Port Gamble SiKlallam Reservation to see
our work--and significant needs--to respond to the opioid crisis.
______
Prepared Statement of the Southcentral Foundation (SCF)
Southcentral Foundation (SCF) submits written testimony to the
Senate Committee on Indian Affairs to supplement its March 14, 2018
hearing entitled: ``Opioids in Indian Country: Beyond the Crisis to
Healing the Community.'' SCF is the Alaska Native tribal health
organization designated by Cook Inlet Region, Inc. (CIRI) and eleven
Federally-Recognized Tribes--the Aleut Community of St. Paul Island,
Igiugig, Iliamna, Kokhanok, McGrath, Newhalen, Nikolai, Nondalton,
Pedro Bay, Telida, and Takotna--to provide healthcare services to
beneficiaries of the Indian Health Service (IHS) pursuant to a contract
with United States government under the authority of the Indian Self
Determination and Education Assistance Act (ISDEAA) P.L. 93-638.
SCF provides a variety of medical services, including dental,
optometry, behavioral health and substance abuse treatment to over
65,000 Alaska Native and American Indian people. This includes 52,000
people living in the Municipality of Anchorage, the Matanuska-Susitna
Borough to the north, and 13,000 residents of 55 rural Alaska villages.
Our services cover an area exceeding 100,000 square miles. SCF employs
more than 2,300 people to administer and deliver these critical
healthcare services.
We appreciate Committee Chairman Hoeven calling the hearing and
hosting a roundtable discussion last November concerning opioid misuse.
At the March 14th oversight hearing, Senator Hoeven remarked: ``The
roundtable highlighted how the opioid abuse epidemic is particularly
complex in tribal communities given the lack of access to medical care,
shortage of law enforcement and insufficient data on substance abuse.''
We applaud the efforts by Committee Vice Chairman Udall, and other
members of the Committee, who wrote to Senate Appropriations Committee
leaders earlier this month to urge them to provide ``robust direct
funding to tribal communities'' in the FY 2018 omnibus measure for
federal programs that will aid in the prevention, treatment and
recovery from opioid misuse ``to address the disparate impacts of the
opioid crisis in Indian Country''.
We also appreciate the day-to-day work that Committee members
perform to educate your Senate colleagues about the challenges tribes
and tribal organizations like SCF face to prevent drug abuse,
successfully treat individuals with addiction disorders, and save the
lives of high-risk individuals who would otherwise overdose.
If Alaska Native healthcare providers are to stop the misuse of
prescription opioids and illegal drugs like heroin and fentanyl, and
begin to heal our Alaska Native customer-owners, we, together with the
Federal Government, must attack the root causes that drive demand for
such drugs: lack of access to appropriate care for medical conditions
requiring pain management, trauma (domestic abuse, child abuse,
historic trauma, etc.), mental health disorders, poverty, unemployment,
overcrowded housing, and lack of access to prevention, treatment, and
recovery services.
We urge the Committee and the Congress to ensure that Alaska Native
communities receive an appropriate share of federal funds to stop the
illegal distribution of opioids, reduce overdoses, support educational
awareness programs, and provide the facilities and medication-assisted
treatment (MAT) programs that Alaska Native communities require to
combat the opioid epidemic. It is crucial in the battle against opioid
misuse that Indian tribes and tribal organizations, like SCF, are
direct recipients of federally appropriated funds to fight the opioid
crisis, consistent with the government-to-government relationship.
We therefore strongly support legislation such as Senator Daines'
``Mitigating METH Act,'' S. 2270, and Senator Baldwin's ``Opioid
Response Enhancement Act,'' S. 2437. These measures would amend the
21st Century Cures Act to include ``Indian tribes and tribal
organizations'' and ``Tribal entities'' as direct recipients of federal
appropriations to fight the opioid epidemic; provide tribes greater
flexibility to prevent and treat other substances, such as
methamphetamines; establish set-asides for tribes; and increase overall
federal appropriations. We recommend that federal appropriations for
tribes and tribal organizations be distributed in a manner similar to
the Special Diabetes Program for Indians (SDPI) to ensure that every
tribe receives funds based on well documented need.
The opioid epidemic did not occur overnight. In April 2017, the
State of Alaska Epidemiology noted that overdose deaths steadily
increased in Alaska and throughout the country due to three sequential
epidemiological phenomena:
The first episode began in the mid-1990s with changes in
standards for pain management, approval of new, extended
release prescription opioid pain relievers, and aggressive
pharmaceutical marketing to encourage the use of prescription
opioids. A four-fold increase in prescribing led to a roughly
four-fold increase in prescription opioid deaths and created a
widespread increase in opioid dependency and addiction. The
second wave emerged over the last 10-15 years as heroin prices
decreased, and the purity increased, offering an alternative to
prescription opioids for persons who were addicted to or
dependent on opioids. The third wave developed over the past 3
years as illicit fentanyl began to enter the opioid black
market. \1\
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\1\ State of Alaska Epidemiology, Bulletin No. 11, April 20, 2017,
http://www.epi.alaska.gov/bulletins/docs/b201711.pdf
According to the Centers for Disease Control and Prevention (CDC),
and confirmed by Rear Admiral Michael E. Toedt, Chief Medical Officer,
IHS, in his appearance before the Committee on March 14, 2018, Alaska
Natives and American Indians (AN/AIs) ``had the highest drug overdose
death rates in 2015 and the largest percentage increase in the number
of deaths over time from 1999-2015 compared to other racial and ethnic
groups.'' \2\ During that time, deaths rose more than 500 percent among
AN/AIs. \3\ According to IHS, among AN/Ais, the rate of drug overdose
deaths is twice that of the general population. Rear Admiral Toedt
cautioned that due to misclassification of race and ethnicity on death
certificates, the actual number of deaths for AN/AIs may be
underestimated by up to 35 percent.
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\2\ Testimony of RADM Michael E. Toedt, MD, FAAFP, Chief Medical
Officer, IHS, March 14, 2018.
\3\ Id., p. 3.
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According to the State of Alaska Epidemiology, from 2009-2015,
there were 774 drug overdose deaths in the State and AN/AIs had the
highest overdose death rate by race from 2009-2014, at 20.2 deaths per
100,000. \4\ In February 2017, Alaska Governor Bill Walker declared the
opioid epidemic a public health disaster. According to the CDC, in
2016, there were 64,000 drug overdose deaths in the United States,
largely driven by prescription and illicit opioids. In a March 2017
study prepared for the Alaska Mental Health Trust Authority, the
McDowell Group estimated the economic cost of the opioid crisis in
Alaska alone was $1.2 billion in 2015 when measured in terms of lost
productivity, motor vehicle crashes, health care, criminal justice and
protective services and public assistance. \5\
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\4\ State of Alaska Epidemiology Bulletin, No. 6, March 24, 2016,
http://www.epi.alaska.gov/bulletins/docs/b2016_06.pdf.
\5\ See https://www.mcdowellgroup.net/wp-content/uploads/2017/03/
mcdowell-group-economicimpacts-of-drug-abuse-final-3.10.17.pdf.
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Senator Lisa Murkowski has remarked: ``Alaska may be a rural state,
but we are not shielded from this epidemic. . . . Opioid abuse in
Alaska is devastating our communities throughout the state and has
rapidly become one of our most pressing issues.'' Senator Dan Sullivan
also knows the great harm that the epidemic is causing to Alaska
families. In August 2016, he convened a summit in Palmer, Alaska. He
recognized that the communities hit hardest by opioid misuse are often
those in economic distress. The opioid epidemic places a tremendous
strain on Native communities already stretched too thin. SCF and other
tribal healthcare providers need more federal resources if we are to
stop the epidemic and reverse its harmful effects on Alaska Native
families and our State. At that summit, SCF President and CEO,
Katherine Gottlieb stated that SCF wants to expand our capacity to
provide treatment for individuals struggling with addiction disorders
but recurring federal resources to sustain and expand such programs
remains our greatest obstacle.
President Trump declared a nationwide public health emergency
concerning the opioid crisis on October 26, 2017. In February 2018,
Congress passed the ``Bipartisan Budget Act of 2018,'' Pub. L. 115-123,
which includes $6 billion over two years (FY 2018 and FY 2019) to
supplement federal appropriations for opioid addiction by funding
grants, prevention programs, and law enforcement services. That
legislation, however, did not make tribes and tribal organizations
direct recipients of federal funding. As noted above, dedicating
funding for Alaska Natives and American Indians is the best means to
ensure that federal funds reach Indian Country and the tribal
organizations that can make a difference in fighting the opioid
epidemic. Give us the resources and we will expand our demonstrated
ability to successfully treat patients with opioid addiction by using
evidence-based treatment protocols performed in culturally appropriate
and familiar settings.
Sam Moose, the Treasurer of the National Indian Health Board
(NIHB), testified at the March 14 hearing that the opioid epidemic is
``one of the most pressing public health crises affecting tribal
communities,'' and has ``further strained the limited public health and
healthcare resources available to tribes.'' NIHB noted that Congress
has historically funded IHS at a level below patient need. In FY 2017,
Moose testified that national health spending was $9,207 per capita
while IHS spending was only $3,332 per patient, nearly one-third less
for Alaska Native/American Indian individuals.
In April 2017, the U.S. Department of Health and Human Services
(DHHS) outlined a five-point, evidence-based Opioid strategy:
1. Improve access to prevention, treatment, and recovery
support services to prevent the health, social, and economic
consequences associated with opioid addiction and to enable
individuals to achieve long-term recovery;
2. Target the availability and distribution of overdose-
reversing drugs to ensurethe broad provision of these drugs to
people likely to experience or respond to an overdose, with a
particular lbcus on targeting high-risk populations;
3. Strengthen public health data reporting and collection to
improve the timeliness and specificity of data and to inform a
real-time public health response as the epidemic evolves;
4. Support cutting-edge research that advances our
understanding of pain and addiction, leads to the development
of new treatments, and identifies effective public health
interventions to reduce opioid-related health harms; and
5. Advance the practice of pain management to enable access to
high-quality, evidence-based pain care that reduces the burden
of pain for individuals, families, and society while also
reducing the inappropriate use of opioids and opioid-related
harms.
Last year, IHS chartered the National Committee on Heroin, Opioids
and Pain Efforts (HOPE) to help implement the Department's five-part
strategy to combat the opioid epidemic. Alaska Governor Walker also
established a similar Program HOPE (Harm reduction, Overdose
Prevention, and Education) which is providing overdose reversal kits
with naloxone and launching a public information campaign. We
wholeheartedly agree with these approaches.
Last December, the heads of three federal agencies; the Substance
Abuse and Mental Health Services Administration (SAMHSA), the National
Center for Injury Prevention and Control, Centers for Disease Control
and Prevention (CDC), and the National Institutes of Health (NIH),
presented joint testimony to Congress concerning the opioid epidemic.
The agency officials confirmed the first cause of the epidemic noted by
the State of Alaska Epidemiology; the significant rise in the
prescription of highly addictive opioid drugs. In addition, the agency
officials stated that delays by the U.S. healthcare system in providing
effective treatment programs, especially medication-assisted treatment
(MAT) programs, exacerbated the problem of opioid addiction brought
about by the over-prescription of highly addictive opioids. They noted
that:
It is well-documented that the majority ofp eople with opioid
addiction in the U.S. do not receive treatment, and even among
those who do, many do not receive evidence-based care.
Accounting for these factors is paramount to the development of
a successful strategy to combat the opioid crisis. \6\
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\6\ Testimony of Elinore McCance-Katz, M.D., Ph.D., Assistant
Secretary for Mental Health and Substance Use, Substance Abuse and
Mental Health Services Administration (SAMHSA), Debra Houry, M.D.,
M.P.H, Director, National Center for Injury Prevention and Control,
Centers for Disease Control and Prevention (CDC), and Francis Collins,
M.D., Ph.D., Director, National Institutes of Health (NIH), on
``Addressing the Opioid Crisis in America: Prevention, Treatment, and
Recovery,'' December 5, 2017, before the Senate Appropriations
Subcommittee on Labor, Health and Human Services, Education and Related
Agencies; https://www.nih.gov/aboutnih/who-we-are/nih-director/
testimony-addressing-opioid-crisis-america-prevention-
treatmentrecovery-before-senate-subcommittee. Emphasis added.
Each year, SCF and other tribal organizations have urged IHS to
request, and Congress to appropriate, increased funding for behavioral
health, including funding for the Substance Abuse and Suicide
Prevention (SASP) programs as well as increased funding for the
Purchased Referred Care (PRC) program to address substance abuse,
treatment and recovery programs.
In FY 2017, IHS allocated $30 million in Substance Abuse and
Suicide Prevention (SASP) funds to 175 IHS, tribal and urban Indian
health organizations to develop and implement culturally appropriate,
evidence-based, community driven programs. The average funding level
was only $171,000 for the service providers. The Federal Government
must do better and appropriate greater resources for this important
work so that many more at-risk Alaska Natives and American Indians can
recover from opioid addiction and lead a productive life.
With available federal funding, SCF established The Pathway Home, a
voluntary, comprehensive, and individualized mental health program for
adolescents from 13 to 18 years old. The Pathway Home teaches
invaluable life skills to Alaska Native youth so that they turn away
from harmful behaviors. Many of these youth have already experienced
trauma or have seen family members struggle with drug and alcohol
dependencies, which puts them at greater risk of turning to drugs and
alcohol later. The mission of the Pathway Home is to create a loving
and supportive community environment where Alaska Native children can
develop into independent, serviceminded and productive leaders.
Increased funding to address root causes of substance abuse is crucial
to combating the opioid crisis.
SCF also operates Dena A Coy (DAC), a residential treatment program
that serves pregnant, parenting and non-parenting women who are
experiencing problems related to alcohol and other drugs and
experiencing emotional and psychological issues. This program is open
to all women in Alaska, regardless of ethnicity, and allows some women
to participate in the program with their children under the age of 3.
Our overall philosophy is to treat the person as a whole, let our
customer-owners drive their healthcare decisions, and give them the
tools and skills to make healthy decisions. DAC matches national
standards for successful program completion. The success rate of this
program shows that our approach is working, and with more resources we
could expand this program and treat more people who need these
services.
If tribal organizations such as SCF are to stop the misuse of
opioids, alcohol and other harmful substances and begin the process of
helping individuals and families recover, we must have more resources,
personnel and, equally important, the facilities to house these
programs. With a service population of 65,000 our resources are wholly
insufficient in comparison to the crisis. Timely treatment for opioid
addiction can mean the difference between recovery or death.
Prevention, education and timely medication-assisted treatment
programs remain our most potent tools to raise a new generation of
Alaska Native people who practice positive, life-affirming behavioral
traits and who will, in turn, pass on these life lessons to their
children and grandchildren. Only then will the cycle of trauma and
opioid addiction be broken.
Thank you for convening the March 14, 2018 hearing and for allowing
us the opportunity to provide testimony.
______
Prepared Statement of the Tanana Chiefs Conference (TCC)
Tanana Chiefs Conference (TCC) submits written testimony to the
Senate Committee on Indian Affairs to supplement its March 14, 2018
hearing entitled: ``Opioids in Indian Country: Beyond the Crisis to
Healing the Community.'' TCC is a non-profit intertribal consortium of
37 Federally-recognized Indian tribes and 41 Alaska Native communities
located across Interior Alaska. TCC serves 18,000 Alaska Natives living
in Fairbanks and in the rural villages located along the 1,400 mile
Yukon River and its tributaries. TCC's service area encompasses 235,000
square miles, about the size of Texas.
To help remote, Interior Alaska Native villages combat the opioid
epidemic, Congress must make federal appropriations directly available
to tribes and tribal organizations, and give us the flexibility we
require to use such funds to prevent, treat and help individuals
recover who are already addicted to prescription and illicit opioids
and other illegal drugs.
We applaud the efforts that Committee Chairman Hoeven has taken to
highlight the destructive effect that the opioid epidemic is causing to
American Indian and Alaska Native communities. The March 14, 2018
hearing followed a roundtable discussion Chairman Hoeven convened last
November concerning the opioid misuse in Indian Country. Senator Hoeven
remarked: ``The roundtable highlighted how the opioid abuse epidemic is
particularly complex in tribal communities given the lack of access to
medical care, shortage of law enforcement and insufficient data on
substance abuse.'' At the March 14 hearing, Chairman Hoeven stated
that: ``I am also mindful that when Congress does appropriate funding
to combat this epidemic, it is important that Indian Country receives
an adequate share of the funding and receives this funding in a manner
that will ensure maximized impact to their communities.''
TCC fully supports the Chairman's remarks. If tribes are to stop
the misuse of prescription opioids and illegal drugs, Congress must
help tribes and tribal organizations attack the root causes: deferred
medical treatment of conditions that require pain management, domestic
and child abuse, homelessness, poverty, unemployment, and lack of
prevention, substance abuse treatment, recovery services, and adequate
law enforcement.
In addition to ensuring that tribes and tribal organizations have
access to federal appropriations to educate, prevent, and treat opioid
addiction, Congress must also recognize the challenges tribes and
tribal organizations face to adequately finance essential government
services such as healthcare, education and job training, public safety,
and the facilities to house these programs. This is especially true in
remote, rural areas, such as Interior Alaska where TCC operates. Too
often, federal appropriations make the difference between the success
and failure of tribal initiatives, which in turn, determine whether
economic and social conditions in Alaska Native communities improve or
deteriorate. Promoting and funding Federal programs that keep Alaska
Native families together, and help them prosper, is one of the best
means of combating the opioid epidemic in tribal communities.
To better inform Congress of the magnitude of the problem remote
Alaska Native communities face to fight the opioid epidemic that
threatens our way of life, Congress must better appreciate the degree
of isolation that exists in rural Alaska. We share below excerpts from
the Indian Law & Order Commission's 2013 report: ``A Roadmap for Making
Native America Safer,'' relevant to Alaska:
Forty percent (229 of 566) of the federally recognized Tribes
in the United States are in Alaska, and Alaska Natives
represent one-fifth of the total State population. Yet, these
simple statements cannot capture the vastness or the Nativeness
of Alaska. The State covers 586,412 square miles, an area
greater than the next three largest states combined (Texas,
California, and Montana). There are only 1.26 inhabitants per
square mile-as compared to 5.85 for Wyoming, which is the next
least populous state.
Many of the 229 federally recognized tribes are villages
located off the road system and ``more closely resemble
villages in developing countries'' than small towns in the
lower 48. Frequently, Native villages are accessible only by
plane, or during the winter when rivers are frozen, by snow-
machine. Food, gasoline, and other necessities are expensive
and often in short supply. . . . While Alaska Natives
constitute a majority of the rural population, each community
is nonetheless quite small; typical populations are in the
range of 250-300 residents, many of whom share family or clan
affiliations. Villages are politically independent from one
another. . . .
Problems with safety in Tribal communities are severe across
the United States-but they are systematically the worst in
Alaska. This is evident in an array of data concerning the
available services, crime, and community distress.
Most Alaska Native communities lack regular access to police,
courts, and related services:
Alaska Department of Public Safety (ADPS) officers have
primary responsibility for law enforcement in rural Alaska, but
ADPS provides for only 1.0-1.4 field officers per million
acres. . . . According to ADPS, troopers' efforts ``are often
hampered by delayed notification, long response distance[s],
and the uncertainties of weather and transportation.
Social distress, which can be a cause of crime or other
threats to public safety, is also high among Alaska Natives and
in Alaska's Tribal communities:
The suicide rate among Alaska Natives is almost four
times the U.S. general population rate, and is at least six
times the national average in some parts of the State.
In 2011, over 50 percent of the 4,499 reports of
maltreatment substantiated by Alaska's child protective
services and over 60 percent of the 769 children removed from
their homes were Alaska Native children. \1\
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\1\ Indian Law & Order Commission, November 2013, A Roadmap for
Making Native America Safer, Report to the President & Congress of the
United States, Chapter Two, Reforming Justice for Alaska Natives: The
Time is Now, pp. 35-43. See https://www.aisc.ucla.edu/iloc/report/
files/Chapter_2_Alaska.pdf.
The opioid crisis came as Alaska Native communities were already
confronting daunting public safety and public health challenges. Public
safety services remain one of the biggest challenges for our Alaska
Native communities. Alaska is one of six P.L. 280 States in which
jurisdiction over crimes in tribal communities rests mainly with the
States. The Bureau of Indian Affairs (BIA) simply does not have
sufficient funding for law enforcement services, so it prioritizes its
public safety efforts in non-P.L. 280 States on the false assumption
that P.L. 280 States like Alaska are investing sufficiently in public
safety and law enforcement services in tribal communities. This is not
the case. Without basic law enforcement services for our tribal
governments, and without sufficient funds for tribal governments to
fight opioid addiction, our communities are at much greater risk. The
statistics bear this out. TCC has been using what little resources it
has to build partnerships with State and local law enforcement to curb
the influx of drugs in to our off-road communities. A tribally led,
grassroots effort raised several thousands of dollars to hire and train
a canine unit for the Alaska State Troopers in our hub community. TCC
supports this type of ownership of issues at a local level, but is all
too aware of the limitations of these efforts without continued and
dedicated funding.
According to the Centers for Disease Control and Prevention (CDC),
American Indians and Alaska Natives ``had the highest drug overdose
death rates in 2015 and the largest percentage increase in the number
of deaths over time from 1999-2015 compared to other racial and ethnic
groups.'' \2\ During that time, deaths rose more than 500 percent among
AIANs. \3\
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\2\ Testimony of RADM Michael E. Toedt, MD, FAAFP, Chief Medical
Officer, Indian Health Service (IHS), U.S. Department of Health and
Human Services, before the Senate Committee on Indian Affairs, Hearing
on Opioids in Indian Country: Beyond the Crisis to Healing the
Community, March 14, 2018.
\3\ Id., p. 3.
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The Indian Health Service (IHS) notes that among American Indians
and Alaska Natives, the rate of drug overdose deaths is twice that of
the general population. The actual number of deaths for AIANs may be
underestimated by up to 35 percent. \4\
---------------------------------------------------------------------------
\4\ Id.
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According to the State of Alaska Epidemiology, from 2009-2015,
there were 774 drug overdose deaths in the State and AIANs had the
highest overdose death rate by race from 2009-2014, at 20.2 deaths per
100,000. \5\ In February 2017, Alaska Governor Bill Walker declared the
opioid epidemic a public health disaster. According to the CDC, in
2016, there were 64,000 drug overdose deaths in the United States,
largely driven by prescription and illicit opioids.
---------------------------------------------------------------------------
\5\ State of Alaska Epidemiology Bulletin, No. 6, March 24, 2016,
http://www.epi.alaska.gov/bulletins/docs/b2016_06.pdf.
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The Substance Abuse and Mental Health Services Administration's
National Survey on Drug Use and Health (NSDUH) found that in 2016, 5.2
percent or 72,000 American Indian and Alaska Native persons aged 18 and
older reported misusing a prescription drug in the past year and 4.0
percent of AIANs, or 56,000 individuals aged 18 and older, reported
misusing a prescription pain reliever in the past year. SAMHSA Director
Jones also noted that over the last decade, the U.S. has experienced a
significant increase in the rates of neonatal abstinence syndrome
(NAS), hepatitis C infections, and opioid-related emergency department
visits and hospitalizations. \6\
---------------------------------------------------------------------------
\6\ Testimony of Christopher M. Jones, PharmD., M.P.H., Director,
National Mental Health and Substance Use Policy Laboratory, Substance
Abuse and Mental Health Services Administration (SAMHSA), U.S.
Department of Health and Human Services before the Senate Committee on
Indian Affairs, Hearing on Opioids in Indian Country: Beyond the Crisis
to Healing the Community, March 14, 2018.
---------------------------------------------------------------------------
Alaska Governor Walker declared the opioid epidemic in Alaska a
public health disaster in February 2017 and created project HOPE (Harm
Reduction, Overdose Prevention and Education). Later that year,
President Trump declared a nationwide public health emergency
concerning the opioid crisis. In February 2018, Congress passed the
``Bipartisan Budget Act of 2018,'' Pub. L. 115-123, which includes $6
billion over two years (FY 2018 and FY 2019) to supplement federal
appropriations for opioid addiction by funding grants, prevention
programs, and law enforcement services. Congress has included billions
of additional funding in the Consolidated Appropriations Act, 2018
omnibus measure, making final appropriations for FY 2018, to combat the
opioid epidemic.
Federal legislation, however, has not made tribes and tribal
organizations direct recipients of funding to address the opioid
crisis. Direct appropriations and set-asides in federal legislation for
Alaska Native and American Indian tribes and tribal organizations is
the best means to ensure that federal funds reach Indian Country and
the tribal organizations that can make a difference in fighting the
opioid epidemic.
We therefore respectfully urge Congress and the Administration to
ensure that Alaska Native communities receive an appropriate share of
federal funds to stop the illegal distribution of opioids, reduce
overdoses, support educational awareness programs, and provide the
facilities and medication-assisted treatment (MAT) programs that Alaska
Native communities require to combat the opioid epidemic. Direct
funding for tribes and tribal organizations honors the Federal
Government's trust obligation to tribal nations and the special
government-to-government relationship between the Federal Government
and Indian tribes and Alaska Native Villages.
We strongly support Senator Daines' ``Mitigating METH Act,'' S.
2270, and Senator Baldwin's ``Opioid Response Enhancement Act,'' S.
2437. These measures would amend the 21st Century Cures Act to include
``Indian tribes and tribal organizations'' and ``Tribal entities'' as
direct recipients of federal appropriations to fight the opioid
epidemic, provide tribes greater flexibility to prevent and treat other
substances, such as methamphetamines, establish set-asides for tribes,
and increase overall federal appropriations. We recommend that federal
appropriations for tribes and tribal organizations be distributed in a
manner similar to the Special Diabetes Program for Indians (SDPI) so
that every tribe receives funding.
At TCC we use our available funding to promote substance abuse
recovery, but our resources are limited. We operate the Old Minto
Family Recovery Camp, an Athabascan alternative to substance abuse
treatment where healing is provided in a traditional setting. It is our
belief that for Alaska Native people today, alcohol and drug use/abuse
became a toxic way of coping with a loss of traditional Native values,
cultural patterns identities, relationships, and unresolved trauma.
Using Native cultural and traditional values as a foundation, our goal
is to help people help themselves as they heal from trauma, choose
healthy lifestyles and overcome substance use.
TCC has been working with other stakeholders in the Fairbanks,
Alaska area to address the homeless situation among individuals
suffering from alcohol and opioid addictions. TCC also held a three-day
training session in January on methamphetamine and its impact on brain
and behavior. The program was facilitated by faculty from the
University of California Los Angeles (UCLA), and provided a skill-
building workshop for behavioral health staff and treatment providers
to address the unique challenges meth users bring to health service
providers. We have advocated tirelessly, and will continue to do so,
for equal access to law enforcement and improvement of public safety
services that partially due to extremely limited state funding are
scarce. We can do so much more to reduce harmful and destructive
behavior such as opioid prescription misuse if Congress would only
appropriate more funds for tribes and tribal organizations. If we are
to stop the misuse of opioids and other harmful substances and begin
healing in tribal communities, we must have adequate and recurring
federal resources to attract and retain qualified health professionals
to come to our remote communities and fight this epidemic. We also
require the facilities to house substance abuse programs and services.
TCC and other tribal organizations have successfully demonstrated
what we can accomplish in remote Alaska Native communities when given
the resources. We cannot afford to lose a generation of Alaskans to the
opioid epidemic.
Thank you for allowing us the opportunity to provide testimony.
______
Prepared Statement of the United South and Eastern Tribes Sovereignty
Protection Fund (USET SPF)
On behalf of the United South and Eastern Tribes Sovereignty
Protection Fund (USET SPF), we are pleased to provide the Senate
Committee on Indian Affairs with the following testimony for the record
of the Committee's oversight hearing, ``Opioids in Indian Country:
Beyond the Crisis to Healing the Community,'' held on March 14, 2018.
USET SPF is a non-profit, inter-tribal organization representing 27
federally recognized Tribal Nations from Texas across to Florida and up
to Maine. \1\ Both individually, as well as collectively through USET
SPF, our member Tribal Nations work to improve health care services for
American Indians. Our member Tribal Nations operate in the Nashville
Area of the Indian Health Service (IHS), which contains 36 IHS and
Tribal health care facilities. Our citizens receive health care
services both directly at IHS facilities, as well as in Tribally-
operated facilities under contracts with IHS pursuant to the Indian
Self-Determination and Education Assistance Act (ISDEAA), P.L. 93-638.
---------------------------------------------------------------------------
\1\ USET SPF member Tribal Nations include: Alabama-Coushatta Tribe
of Texas (TX), Aroostook Band of Micmac Indians (ME), Catawba Indian
Nation (SC), Cayuga Nation (NY), Chitimacha Tribe of Louisiana (LA),
Coushatta Tribe of Louisiana (LA), Eastern Band of Cherokee Indians
(NC), Houlton Band of Maliseet Indians (ME), Jena Band of Choctaw
Indians (LA), Mashantucket Pequot Indian Tribe (CT), Mashpee Wampanoag
Tribe (MA), Miccosukee Tribe of Indians of Florida (FL), Mississippi
Band of Choctaw Indians (MS), Mohegan Tribe of Indians of Connecticut
(CT), Narragansett Indian Tribe (RI), Oneida Indian Nation (NY),
Pamunkey Indian Tribe (VA), Passamaquoddy Tribe at Indian Township
(ME), Passamaquoddy Tribe at Pleasant Point (ME), Penobscot Indian
Nation (ME), Poarch Band of Creek Indians (AL), Saint Regis Mohawk
Tribe (NY), Seminole Tribe of Florida (FL), Seneca Nation of Indians
(NY), Shinnecock Indian Nation (NY), Tunica-Biloxi Tribe of Louisiana
(LA), and the Wampanoag Tribe of Gay Head (Aquinnah) (MA).
---------------------------------------------------------------------------
The opioid epidemic has had a devastating effect on USET SPF Tribal
Nations and Tribal Nations across the country, who continue to
experience the destructive effects of opioid addiction--often at higher
rates than non-Indian communities. According to data from IHS, American
Indians and Alaska Natives (AI/ANs) are more likely than any other
race/ethnicity to have an illicit drug use disorder in the past year.
In addition, according to the Centers for Disease Control and
Prevention (CDC), AI/ANs are at the greatest risk for prescription
opioid overdose, confronting an opioid overdose rate of 8.4 per
100,000. Though USET SPF is encouraged to see Congress move in an
expeditious manner to identify solutions to the opioid epidemic
nationwide, USET SPF is concerned that Tribal Nations are frequently
left out of the conversation, despite the disproportionate impact the
opioid epidemic has had within Tribal communities. USET SPF reminds the
Committee of the unique federal trust responsibility to Tribal Nations,
and urges the Committee to use its authority to ensure Tribal Nations
are fully included in any subsequent legislation or other Congressional
efforts to address the opioid crisis.
Direct Opioid Funding for Tribal Nations
The Federal Government has a trust responsibility to ensure Tribal
Nations have access to resources, financial and otherwise, to combat
the opioid epidemic. Among these vital resources is access to direct
federal funding for Tribal Nations. While USET SPF is appreciative of
the recent $50 million Tribal set-aside for this purpose within the
Fiscal Year (FY) 2018 Omnibus, more resources are required to fully
address the opioid crisis at the Tribal level. Though our data on this
issue is incomplete, that which is available shows Indian Country,
including USET SPF Tribal Nations, is among the communities affected
most by this crisis. Yet, no direct funding stream currently exists to
combat this epidemic in Tribal communities. Currently, Tribal Nations
are ineligible for a majority of funding available under the 21st
Century Cures Act. Where Tribal Nations are eligible for funding, they
are forced to compete with state and other entities for limited
dollars. Tribal Nations should not have to compete to provide their
citizens with the treatment they critically need. This is contrary to
the federal trust responsibility to provide healthcare to Tribal
Nations, and results in few resources delivered to Tribal citizens. In
addition, the Indian Health System remains chronically underfunded,
leaving many Tribal communities without the critical resources and
funding to address opioid addiction and treatment. During the hearing,
Tribal witnesses testified on the need for direct funding to Tribal
Nations for Tribal opioid treatment and prevention programs due to the
increasing levels of opioid abuse, deaths, and trafficking within
Tribal communities. USET SPF echoes these concerns and urges the
Committee to prioritize addressing this shortfall by working to ensure
Tribal governments have access to direct funding.
Despite the government-to-government relationship between Tribal
Nations and the United States, many federal grant programs, including
those available as part of the 21st Century Cures Act, require funding
to pass through the states before it can be delivered to Tribal
governments. Because of this, a majority of Tribal communities have
difficulty accessing federal funds, with many completely unable to
access them in this manner. Further, when applying for these grants,
states will often include Tribal population numbers in the overall
state population used to determine each state's award. Yet, Tribal
Nations are not provided with outreach for these programs and are left
with minimal resources to address the opioid crisis in their
communities. In order to ensure Tribal Nations are fully accessing
these federal funds in the future, USET SPF recommends the Committee
and Congress:
1. Consider implementing a funding model utilized by the CDC's
Good Health and Wellness in Indian Country initiative, which
allows for a direct, separate funding mechanism specifically
for both Tribal Nations and TECs. This model has proven to be
successful.
2. Expand language within grant funding programs to
specifically include Tribal Nations as direct grantees so that
states cannot exclude them in grant funding disbursements.
3. Recognize that competitive grants are not reflective of the
federal trust responsibility and work to provide more funding
to Tribal Nations via formula-based distribution methodologies.
4. Explore opportunities to deliver opioid funding to Tribal
Nations via self-governance contracting and compacting in
recognition of Tribal sovereignty and self-determination.
With these priorities in mind, USET SPF urges the Committee and
Congress to fully consider the following legislation, as it would
provide critical opioid response resources to Tribal Nations, including
direct funding.
Mitigating METH Act
As discussed above, despite Tribal advocacy, Tribal Nations are
ineligible for a majority of funding delivered to state and local
governments under the 21st Century Cures Act. Where Tribal Nations are
eligible for funding, they are forced to compete with state and other
entities for limited dollars. On December 21, 2017, Senator Steve
Daines introduced S. 2270, the Mitigating the Methamphetamine Epidemic
and Promoting Tribal Health Act, or the Mitigating METH Act. The
Mitigating METH Act would make Tribal Nations eligible to be direct
grantees of federal opioid funding under the 21st Century Cures Act to
combat opioid abuse in our communities. In addition, S. 2270 would
provide an increase in grant funding of $25 million to states and
Tribal Nations under the State Targeted Response (STR) grants within
the 21st Century Cures Act. USET SPF supports this legislation \2\ that
would bring critical direct funding to Tribal communities for the
treatment and prevention of opioid addiction.
---------------------------------------------------------------------------
\2\ USET SPF Board of Directors supporting resolution.
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Native Health Access Improvement Act
In addition to the Mitigating METH Act, USET SPF would like to
convey our support for S. 2545, the Native Health Access Improvement
Act of 2018, which was introduced by Senator Tina Smith on March 14,
2018. This legislation would provide critical behavioral health
resources to Tribal communities by creating a Special Behavioral Health
Program for Indians (SBHPI). The SBHPI is modeled after the Special
Diabetes Program for Indians (SDPI), a successful Tribal health program
that has had a significant impact on diabetes within Tribal
communities. Like SDPI, SBHPI responds to a public health crisis by
providing dedicated, formula-based funding to Tribal Nations to address
behavioral health and substance use disorders, including opioid abuse
and addiction. In addition, it would support cultural competency by
promoting the incorporation of both modern and traditional practices
into Tribal behavioral health programs. Further, this legislation would
require that funding standards and distribution methodology be
developed in consultation with Tribal Nations and would provide the
technical assistance necessary to develop robust programs. USET SPF
requests that the Senate Committee on Indian Affairs ensure this
legislation receive an immediate hearing.
Opioid Response Enhancement Act
USET SPF also conveys our support for the Opioid Response
Enhancement Act, legislation introduced by Senator Tammy Baldwin, which
would make significant investments in Indian Country to fight the
opioid epidemic. The legislation would provide an additional funding of
$10 billion to states and Tribal Nations over five years for the State
Targeted Opioid Response (STR) Grant, including $2 billion for a new
Enhancement Grant for Tribal Nations and states with high morbidity
rates. The Opioid Response Enhancement Act would also include Tribal
Nations as eligible entities for STR Grants, funded by a 10 percent set
aside, which USET SPF feels reflects a commitment to ensuring this
crisis is addressed in Indian Country. Other components of the
legislation include:
Technical assistance delivered from SAMHSA to Tribal Nations
through the Tribal Training and Technical Assistance Center;
and
Flexibility to allow Tribal Nations and states to use
funding to help address other substance abuse issues in
addition to opioid prevention and treatment;
Funding for Comprehensive Opioid Data Collection within the Indian
Health System
As noted by Tribal witnesses during the hearing, the available data
on opioid abuse and mortality within the Indian Health System is
inadequate and fails to fully illustrate the impacts opioids are having
in Tribal communities. . As the Committee moves forward with
recommendations on how to effectively treat and prevent opioid
addiction, the Committee must promote the provision of adequate
resources, including direct funding, to the IHS, Tribal Nations, and
Tribal Epidemiology Centers in order improve opioid data collection.
Expanding data collection and analysis would improve the treatment and
prevention of substance abuse within Indian Country. Though our data on
opioid abuse is incomplete, data that is available shows Indian
Country, including USET SPF Tribal Nations, is among the communities
most impacted by this crisis. Without access to critical data, Tribal
Nations will continue to feel the impacts of the opioid epidemic for
generations. USET SPF urges the Committee to prioritize addressing this
shortfall by working to ensure Tribal Nations have access to resources
to improve opioid data and provide for the treatment and prevention of
substance abuse.
Tribal Prescription Drug Monitoring Programs
During the hearing, witnesses testified on the importance of
partnering with state Prescription Drug Monitoring Programs (PDMP). IHS
stated that the agency has been partnering with certain states to
connect IHS with state PDMP data. USET SPF supports these partnerships
and recommends the Committee and Congress ensure IHS has the necessary
resources to expand and update the Indian Health Service's Resource and
Patient Management System (RPMS) Electronic Health Record (EHR) to
fully include and collaborate with state PDMPs on a multi-state basis.
Integrating PDMP functionality into the RPMS EHR will connect Tribal
Nations to crucial data within state PDMPs and will ensure an efficient
and unified platform for Indian health providers to allow providers to
quickly and easily make accurate and appropriate diagnoses (addiction,
dependence, drug-seeking behavior, etc.) and document those in the RPMS
EHR.
Culturally Competent Treatment
The incorporation of traditional healing practices and a holistic
approach to health care are fundamental to successful opioid treatment
and aftercare programs in Indian Country. Culturally appropriate care
has had positive, measurable success within Tribal communities, and the
incorporation of traditional healing practices and holistic approaches
to healthcare has become central to many Tribal treatment programs.
Tribal communities have unique treatment needs when it comes to
substance abuse disorders, as AI/ANs experience high levels of
substance abuse disorders, with a strong link to historical trauma.
Opioid addiction treatment in Indian Country, then, must be cognizant
of this trauma, respectful of community factors, and utilize
traditional health care practices. Additionally, opioid addiction
treatment within Tribal communities must include adequate culturally
appropriate aftercare programs to help prevent substance abuse relapse.
These services must be accessible through the Indian Health Care
Delivery System.
Even though culturally competent care has had success across Indian
Country, treatment options that incorporate cultural healing aspects
are oftentimes not available within or near Tribal communities due to a
lack of resources. However, some USET SPF member Tribal Nations are
engaging in innovative practices that have the potential to be
replicated across Indian Country. For example, one Tribal Nation's
treatment program incorporates a culturally-based recovery model that
has had great success, including in preventing early relapse following
treatment. Other best practices within USET SPF Tribal Nations include:
Extended, culturally-based recovery support in a sober
living environment; and
Trauma informed care training for health and behavioral
health staff.
Other notable best practices and culturally healing modalities not
currently being employed by USET SPF Tribal Nations include:
Rapid entry into an acute care facility (detox/inpatient
care); and
Prevention and control interventions developed utilizing the
Community Based Participatory Action model.
With additional funding and guidance, these best practices have the
potential provide higher rates of recovery for our people. USET SPF
encourages the Committee to explore how it might expand and promote
these models through legislative action.
Tribal Healing to Wellness Courts
In addition to traditional healing practices, USET SPF urges this
Committee and Congress to support innovative, culturally-appropriate
Tribal restorative justice models through sustained funding. USET SPF
is encouraged that the success of family drug courts, or Healing to
Wellness Courts (HTWC), was discussed during the hearing. Established
as alternatives to conventional sentencing for non-violent individual
offenders, Tribal HTWCs promote long-term recovery through treatment,
community healing resources, and the Tribal justice process by using a
multi-disciplinary approach to achieve the physical and spiritual
healing of participants.
For example, USET SPF member, the Penobscot Nation, has operated an
HTWC since 2011. Any individual Penobscot Nation citizen who is charged
with a non-violent crime can petition to participate in the HTWC
program. Once accepted into the program, the individual must agree to
enter a guilty plea for the crime charged against him/her, but his/her
sentence is ``deferred'' to allow the individual to go through the
program. Then, a comprehensive, holistic plan is developed in
collaboration between 10 Tribal government departments to address the
individual's treatment needs in four phases:
Phase I: Introduction/Education. This phase is focused on
detoxification and beginning treatment and generally lasts 180
days.
Phase II: Personal Responsibility. This phase is focused on
stabilization and treatment and generally lasts 120 days.
Phase III: Cooperation/Accountability. This phase is focused
on maintenance and treatment and generally lasts 120 days. ?
Phase IV: Completion/Continuing Wellness. This phase is
focused on graduation and aftercare and generally lasts 120
days.
Successful completion of the program results in a dismissal of the
participant's guilty plea. Over two dozen individuals have gone into
the program since 2011. Recidivism is extremely low. Regrettably, the
biggest challenge that the Penobscot Nation has encountered is that
they do not have sufficient resources to accommodate all the
individuals who are interested in participating in the program. While,
the program is funded mainly through the Bureau of Indian Affairs, with
supplemental funding from IHS, the Department of Justice, and the
Department of Housing and Urban Development, this is administratively
burdensome and unlikely to result in additional resources for the
Court. Similarly, while some grants offered by the Substance Abuse and
Mental Health Services Administration (SAMHSA) could possibly be used
for this purpose, SAMHSA's application requirements and standards often
serve to preclude smaller, less resourced Tribal Nations from applying.
The recovery model offered by Tribal HTWCs should be supported by this
Congress, as it seeks to incentivize long-term sobriety and reduce
criminal recidivism among drug offenders. In order to accomplish this,
USET SPF urges this Committee to consider dedicated, sustained funding
for this infrastructure in Indian Country.
Tribal Engagement at all Levels of Government
USET SPF reminds the Committee that Tribal Nations are sovereign
governments to which each member of Congress has a trust
responsibility. This trust responsibility is carried out not just
through funding, but through meaningful government-to-government
consultation and coordination to ensure Tribal Nations are included as
full partners. When it comes to addressing the gaps in comprehensive
Tribal programs to prevent, treat, and measure opioid addiction, this
effort must include collaboration between federal, state, and Tribal
governments. During the hearing, Tribal witnesses underscored the
crucial need for collaboration on between Tribal Nations and all levels
of government, including federal, state and local, in addressing the
opioid epidemic. However, Tribal Nations are frequently excluded from
these types of collaborative efforts as other units of government work
together to ensure a coordinated response.
As the trustee to Tribal Nations, the Committee and Congress must
acknowledge the substantial challenges within Indian Country must
fulfill the trust responsibility by facilitating and requiring
collaboration between Tribal governments and state and local
governments in the fight to end the opioid epidemic. Failure to include
Tribal Nations, including when seeking solutions to the opioid epidemic
will result in major gaps in the ability of the United States to
eradicate opioid addiction in this country. These gaps in coordination
are detrimental not just from a healthcare and treatment perspective,
but from a law enforcement perspective, as well. Outreach from the
Committee, as well as future legislation, should promote and require
this necessary intergovernmental collaboration.
Access to Law Enforcement Resources
In addition to opioid addiction and treatment resources, USET SPF
member Tribal Nations report a lack of adequate law enforcement
infrastructure to combat the opioid epidemic within our region.
Currently, there are only seven drug enforcement agents assigned to
serve over one hundred Tribal Nations within our BIA Drug Enforcement
Region (from ME to FL to NM to the central US). This limited number of
law enforcement agents is unacceptable considering the persistent and
growing problem of opioid trafficking within Indian Country,
particularly the USET SPF region. As mentioned during the hearing, law
enforcement within Indian Country needs additional resources to in
order to sufficiently address the growing opioid abuse and trafficking
within our Tribal Nations, including human capital.
Though our Tribal patrol officers perform a vital role in
addressing drug issues within a community, our law enforcement agencies
face underfunding, understaffing, and other failures due to inadequate
appropriations. Though USET SPF is pleased that $7.5 million was
recently appropriated in the FY 2018 Omnibus bill providing funding to
the Bureau of Indian Affairs law enforcement, additional resources and
continued investments must be made available to Tribal Nations when it
comes to critical drug enforcement investigations. These services are
conducted primarily by specialized units or task forces on
departmental, statewide and federal levels and involve enhanced
intelligence gathering, information sharing, controlled buys,
surveillances and other factors. As the Committee approaches this
crisis, it must not forget the importance of stopping the supply of
opioids on Tribal lands through well-equipped law enforcement.
Conclusion
USET SPF appreciates the Committee's continued attention to the
opioid epidemic and the destructive effects that it has had within
Indian Country. We call upon the Committee to take action to ensure
vital resources are directed to Tribal communities. Failure to include
Tribal Nations in future legislation is a failure to recognize the
trust responsibility and will result in an incomplete response to this
crisis. USET SPF urges the Committee to use the crucial information
gathered during these events to educate Senate colleagues on the impact
of the opioid epidemic within Indian Country, and to continue to voice
these priorities beyond the Committee during the legislative process.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Jolene George
Federal Funding Access for Tribes and Native Communities
Question 1. Legislative proposals that would give tribes access to
direct access to dedicated funding to address opioid addition and other
behavioral health challenges. Do you support the correction to the
State Targeted Response program's state pass-through funding model
proposed by S. 2270 and S. 2437?
Answer. Yes, we support direct funding to tribes as authorized in
both S. 2270 and S. 2437. Adequate direct funding means reliable
resources and flexibility for the PGST to continue implementing our
culturally appropriate, multi-faceted, comprehensive approach to
abating the opioid epidemic sweeping our community. Additionally,
adequate direct funding allows us to plan long-term for infrastructure
development, program enrichment, and service enhancements necessary for
the well-being of our members and local community. We support both
bills and are encouraged by the Sponsors' recognition of the importance
of direct tribal funding. However, we note that S. 2437 provides
significant increases in funding for a longer period of time, and we
prefer that approach. The opioid crisis has been a long time in
building, and its impacts are going to be long term. The additional
funding is needed and could be put to use by Indian Country to carry
out important opioid response activities in light of the magnitude and
duration of the crisis.
Further, while the PGST supports both S. 2270 and S. 2437, we would
recommend, as an alternative to the grant funding contemplated in both
bills, that Congress use the self-governance model for this funding for
tribes like ours that already carry out programs and functions through
self-governance compacts . Since joining the Tribal Self-Governance
Project, a consortium of self-governing tribes, in 1990, we have funded
our health care services through a compact with the Indian Health
Service (IHS) under the Indian Self-Determination and Education
Assistance Act. We operate and manage our entire health system on our
Reservation, which includes primary care, dental, mental health, and
substance abuse services along with prevention and community health.
We would much prefer receiving these monies through our self-
governance compact if possible rather than through grants.
Administering programs by competitive grant funding is inappropriate
for meeting the critical needs of Indian Country, as it pits tribe
against tribe to compete for limited funds and fosters uncertainty
since funding cannot be relied on year-to-year. Moreover, having our
Program Directors spend time pursuing grants or reporting for grants
takes their energy away from carrying out the critical program duties.
Finally, if we are competing with the states that will undermine our
working together which is what we should be doing to combat the opioid
epidemic. One of the reasons why our Tribal Healing Opioid Response
(THOR) program is so effective is that we are working with the State,
the County, and regional groups to coordinate response strategies.
Question 1a. Would the authorization of a ``Special Behavioral
Health Program for Indians'' as proposed by S. 2545 help your Tribe in
its opioid response efforts?
Answer. Yes, we support the creation of a Special Behavioral Health
Program for Indians (SBHPI) under this legislation, as it would provide
the Indian Health Service (IHS), Tribes, Tribal organizations, and
urban Indian health programs with access to $150 million in annual
mandatory grant-based funding from FY 2018 to FY 2022. As mentioned
above, we operate and manage our entire health system on our
Reservation, and we have operated a robust Special Diabetes Program for
Indians (SDPI) program for many years. We are confident that using the
SDPI program as a model for the SBHPI will be a success.
The PGST supports S. 2545. However, as with S. 2270 and S. 2437, we
recommend that self-governance tribes--such as the PGST--be able to
receive such funding through their self-governance compacts rather than
through grant funding. As we know from our SDPI experience, grant
reporting requirements take away from clinical time, and the self-
governance model would allow for more administrative efficiency.
Federal, State, Tribal Intergovernmental Coordination
Question 2. What else could Congress do to help encourage states
and local governments to coordinate with tribes on their opioid
response efforts?
Answer. The following are some ideas that Congress could encourage
state and local governments to work with Tribes:
Establish and set aside funding for demonstration/pilot
programs for opioid response activities to show how cooperation
leads to results.
--Congress could base such a program on the PGST's efforts with
the Olympic Community of Health, implementing the Three County
Coordinated Opioid Response Project. A demonstration/pilot
program would provide the framework for bringing tribes and
neighboring governments together in areas where states and
local governments are reticent to work with tribes. The program
could show the successes that are achievable when state, local,
and tribal governments work together.
Create an opioid task force with representatives of state,
local, and tribal governments, and include other relevant
sectors, e.g. housing, schools, law enforcement, corrections,
etc. Doing so would incentivize the governments to come
together with each other and the people who are doing the work
on the ground to develop coordinated and creative approaches to
dealing with the crisis on an ongoing basis. The task force
could advise Congress and/or relevant federal agencies about
the challenges they face and what they need to effectively
fight the opioid crisis.
--Such a task force could be modeled on what the PGST is doing
with Washington State and our neighboring counties. It could be
set up on a regional level with multiple regions.
Encourage the use of Medicaid Demonstration Waivers for
experimental, pilot, or demonstration projects found by the
Secretary of Health and Human Services to be likely to assist
in promoting the objectives of the Medicaid program. Washington
State's waiver formed regional Accountable Communities of
Health, which have helped form partnerships that were not
otherwise easily accessible or workable.
Include a provision in opioid legislation mandating state
and local governments to work together with tribes to respond
to the opioid crisis. One potential vehicle isS. 2437, the
Opioid Response Enhancement Act, which, in part, amends the
21st Century Cures Act of 2017 (the ``Cures Act'') to encourage
community and local government engagement.
--Section 2(a)(2(B)(i)(l) ofS. 2437 would amend Section
1003(c)(2) of the Cures Act to read, ``Grants awarded under
this subsection shall be used for carrying out activities,
including activities supported by community-based organizations
and counties, that supplement activities pertaining to opioids
undertaken by the State agency responsible for administering
[the grant].'' The new language is in italics. Congress could
include a statement that directs state and local governments to
work coordinate with tribes on opioid response efforts.
--Another place in S. 2437 for additional language is Section
2(a)(4), the Technical Assistance provision. Through this
proposed new mandate, Congress could direct the Secretary of
Health and Human Services to assist tribes, states, and local
governments with coordinating strategies and developing
collaborative responses.
Allow special access to funding for consortium projects that
involve tribes together with state agencies or local
governments, which would incentivize intergovernmental
collaboration. Such a provision could be included in pending
opioid legislation.
Provide monetary incentives for states and local governments
to coordinate with tribes.
Include a requirement for a GAO report examining the hurdles
that prevent effective state, local, and tribal government
coordination on opioid response efforts.
--A potential vehicle for this could be H.R. 994, the Examining
Opioid Treatment Infrastructure Act of 2017. This is a
bipartisan bill specific to Indian Country that currently calls
for a GAO report on: (1) inpatient and outpatient treatment
capacity, availability, and needs, including detoxification
programs, clinical stabilization programs, transitional
residential support services, rehabilitation programs, and
treatment programs for pregnant women or adolescents; (2)
treatment availability and effectiveness through Indian health
programs; and (3) the barriers to real-time reporting of drug
overdoses at the federal, state, and local level and ways to
overcome those barriers. The scope of the GAO report under this
bill could be expanded to include an examination of the
barriers relating to positive state and local government
coordination with tribes.
Additional Issue
We would like to make one additional point that is consistent with
our responses above, but which does not neatly fit under any one of the
specific questions asked. At the local level, a major challenge has
been integrating behavioral health with primary care in order to
optimize patient outcomes. This is the work that will reach people
grappling with the opioid epidemic on the front lines. Federal law and
regulations complicate the complexities of integrating health systems
with behavioral health systems. Federal regulations at 42 CFR Part 2,
related to the privacy of substance abuse treatment records, currently
prevent the Tribe's primary care and mental health providers from
accessing patient records from dependency providers so the whole person
can be treated. This lack of access is a barrier to coordinated, safe,
and high-quality medical care and can cause significant harm. Part 2
regulations may lead to a doctor treating a patient and writing
prescriptions for opioid pain medication for that individual without
knowing the person has a substance use disorder. There remains a strong
need for technical assistance and a potential legislative fix to align
the varying levels of patient privacy under the Health Insurance
Portability and Accountability Act of 1996 (HIP AA) and 42 CFR Part 2
that challenge the integration process.
Conclusion
Thank you for the opportunity to speak on behalf of the PGST
regarding the opioid epidemic facing this Nation. We look forward to
further opportunities for discussion and to actively working with the
Committee to tackle the opioid epidemic. We hope that you and the
entire Committee will accept our Tribe's invitation to come visit the
Port Gamble S'Klallam Reservation to see our work and significant needs
in responding to the opioid crisis.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Stacy A. Bohlen
Federal Funding Access for Tribes and Native Communities
Question 1. Your written testimony states, ``access to critical
opioid prevention and treatment dollars are not reaching many of the
Tribal communities that are in serious need of these funds.'' The
Senate is currently considering three different legislative proposals
that would give tribes direct access to dedicated funding to address
opioid addiction and other behavioral health challenges (i.e., S. 2270,
Mitigating METH Act; S. 2437, the Opioid Response Enhancement Act; and
S. 2545, the Native Behavioral Health Access Improvement Act of 2018).
Do you have an estimate of how much funding from the 21st Century CURES
Act State Targeted Response program is reaching Native communities?
Answer. No, we do not have an overall estimate, because states are
not required to report this data. We do know that some states have
chosen to include Tribes in their funding distribution, but this is not
guaranteed or required due to the current funding scheme. Of the 36
states with Tribes, only 13 have included Tribes in their State
Targeted Response (STR) or somehow identified American Indians and
Alaska Natives (AI/ANs) as a target population with specific needs.
California and a few other states have used their funds to create
Tribal MAT projects to improve the delivery of treatment services in
AI/AN communities, and that other states like Minnesota, Washington and
Oregon have outlined AI/ANs as one of their primary target populations
for the funds. In Washington for example, the state is looking to pilot
a low-barrier buprenorphine program in Tribal communities, and is
engaging at least 5 Tribes to develop a Tribal treatment outreach and
education campaign.
But this is far less than adequate. At the Ho-Chunk Nation in
Wisconsin they have seen an increased number of infants born with
substance addiction and neonatal abstinence syndrome, as well as an
increase in opioid-related overdose deaths in the community. The Tribal
government declared a State of Emergency regarding the opioid crisis
and is in the process of developing a Tribal Action Plan within their
departments. A major problem for the Tribe is that the grant money the
state receives and distributes to the Tribes is not sufficient to meet
the added burden the Tribe's behavioral health facility is
experiencing.
Question 1a. Do you support the correction to the State Targeted
Response program's state pass-through funding model proposed by S. 2270
and S. 2437?
Answer. Yes, the inclusion of Tribes in the correction to the STR
program's model is a very important first step Congress must make to
address the opioids crisis in Indian Country. NIHB is supportive of the
provisions in S. 2270, the ``Mitigating METH Act'' from Senator Daines,
and S. 2437, the ``Opioid Response Enhancement Act'' from Senator
Baldwin. By ensuring Tribes can receive federal funds directly,
Congress would ensure that the funds reach Tribal communities
experiencing desperate need of relief. This change would also uphold
the federal trust responsibility by ensuring Tribes do not need to go
through their states' health department or sub-granting process to
receive the care that is historically promised and legally owed.
Finally, allowing Tribes to receive these funds authorized by the 21st
Century CURES Act of 2016 would alleviate the states of the burden of
having to provide care to Tribes. Not all states have the expertise or
capacity to provide care to Indian Country. Changing the STR program to
include direct, formulaic federal funding for Tribes directly would
uphold the trust responsibility, respect states, and most importantly,
ensure Tribes have the resources to care for themselves.
Question 1b. Would the authorization of a ``Special Behavioral
Health Program for Indians'' (SBHPI) as proposed by S.2545 help your
Tribe in its opioid response efforts? And, are there any particular
characteristics of the SDPI model that are important to carry over to
an SBHPI?
Answer. Yes, the creation of SBHPI is a priority for the National
Indian Health Board. American Indian/Alaska Native 12th graders are
roughly twice as likely to have used heroin or OxyContin as 12th
graders nationally. Additionally, the chronic underfunding of the
Indian health system leaves many healthcare facilities unable to offer
preventative services, instead resorting to distributing painkillers
when the health issue becomes acute. The opioids crisis is real in
Indian Country. The proposed SBHPI would provide funding to Tribes to
develop Substance Use Disorder treatments at the Tribal and community
level.
A program like this would provide broad-based funding in Tribal
communities for addressing behavioral health challenges. If the program
is designed in a similar way to SDPI, it will be recurring, formula
based funding that Tribes can count on from year to year. This will
allow for investment in Tribal communities that focuses on traditional
healing combined with clinical measures. The flexibility permits Tribes
to focus on both prevention and treatment, and to create programs that
are tailored to their communities. We know the SDPI model works.
The SDPI model offers Tribes the flexibility they need to develop
culturally competent and tailored programs that have shown enormously
successful results since SDPI began in 1997. By supporting each Tribe's
work, SDPI reflects that a one-size fits all approach is inappropriate
for Indian Country. NIHB is glad to see the same level of flexibility
in Senator Smith's SBHPI legislation.
As impactful as SDPI is, NIHB would suggest that the legislative
model for the program is imperfect. Historically, Congress has renewed
SDPI on a 2-year cycle. Last year, SDPI renewal was tied to the CHIP
reauthorization bill and became caught in a larger political battle.
For several months, Tribal administrators of SDPI-funded programs did
not have the certainty needed for effective long term planning. Long-
term reauthorization for SDPI, such as found in the Vice Chairman's
bill, S. 747, would prevent this from happening again. SBHPI should be
authorized and funded for no fewer than the five years found in S.
2545. Additionally, SDPI's funding level has plateaued since 2004, with
about one third of the buying power lost to medical inflation. NIHB
would recommend that legislation for both SDPI and SBHPI include
funding adjustments over time to compensate for rising healthcare
costs.
As promising as the Native Behavioral Health Access Improvement Act
is, this is really just one small step. The $150 million outlined in
this legislation will not be nearly enough to get to Tribal communities
to generate systems change. What we really need is comprehensive
investments in IHS funding, improved staffing for medical professionals
in our rural communities, and access to training for first responders
and other enforcement activities.
Federal, State, Tribal Intergovernmental Coordination
Question 2. Port Gamble S'Klallam Tribe's testimony lists ``cross-
government coordination'' as one of the most important components of
designing an impactful tribal response to public health crises. It goes
on to cite the Tribe's work with three local county efforts as evidence
of the effectiveness of this recommendation to prioritize
crossgovernment coordination. Unfortunately, not all tribes find their
state and local counterparts willing to partner with them to address
issues that span across multiple jurisdictions. What else could
Congress do to help encourage states and local governments to
coordinate with tribes on their opioid response efforts?
Answer. Port Gamble S'Klallam Tribe is right to point out the
potential of a well-coordinated and interconnected collaboration across
various government entities in creating an effective opioid response
plan. Some Tribes are in ideal positions to leverage intergovernmental
relationships to ensure their members receive services; however, this
cannot be the federal government's fallback strategy to upholding its
trust responsibility to Tribes. As stated in the question, not all
state and local governments have the will, capacity, or expertise to
deliver cross-government coordinated services to Tribal communities
adequately. The most productive course of action would be for Congress
to require Tribal consultation in the earliest stages of opioid
targeted response at the state and local level. Tribes need to be at
the table, not to evaluate an otherwise-final state proposal, but to
help states and local governments craft the proposals from the
beginning, ensuring that the final product respects Tribal needs and
sovereignty.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Captain Christopher Jones
Tribal Access to SAMHSA Grants
Your testimony cites a number of grant programs operated by SAMHSA
that allow communities to address opioid and substance abuse issues. In
your written testimony, you mention several SAMHSA grant programs aimed
at addressing the opioid crisis (e.g., State Targeted Response grants,
two separate Strategic Prevention Framework Programs, the First
Response-Comprehensive Addiction and Recovery Act Program, etc.). In
your oral testimony and in the course of answering questions at this
oversight hearing, you noted a residential program with 19 grantees
that addresses intergenerational addiction and an outpatient program
authorized by the Comprehensive Addiction and Recovery Act.
Question 1a. Are tribes, tribal organizations, and urban Indian
health organizations eligible for all of the SAMHSA grants noted above?
Answer. By statute, eligibility for the State Targeted Response to
the Opioids Crisis (section 1003 of the 21st Century Cures Act) and
State Pilot Grant Program for Treatment for Pregnant and Postpartum
Women (section 508(r) of the Public Health Service Act) grant programs
are limited to states. Tribal entities are eligible for the Strategic
Prevention Framework for Prescription Drugs, Strategic Prevention
Framework Partnerships for Success, First Responders--Comprehensive
Addiction and Recovery Act, and Residential Treatment for Pregnant and
Postpartum Women programs.
Question 1b. If tribal grantees are eligible for the programs
mentioned in your written testimony (e.g., State Targeted Response
grants, two separate Strategic Prevention Framework Programs, the First
Response-Comprehensive Addiction and Recovery Act Program, etc..),what
percentage of grant recipients are tribal grantees? And, what
percentage of total grant funds do those tribal grantees receive from
each of those grants?
Answer. By statute, eligibility for the State Targeted Response to
the Opioids Crisis (section 1003 of the 21st Century Cures Act) and
State Pilot Grant Program for Treatment for Pregnant and Postpartum
Women (section 508(r) of the Public Health Service Act) grant programs
are limited to states.
In FY 2015, tribal entities represented and received the following
funds through the Strategic Prevention Framework Partnerships for
Success Program (awards are for the first year of the grant):
SAMHSA awarded grants to 7 of the 8 applications received
from organizations that self-identified as tribal organizations
(88 percent success rate)
SAMHSA awarded grants to 24 of the 24 applications received
from non-tribal organizations (100 percent success rate)
Tribal entities represented 23 percent of recipients (7 of
31)
Tribal entities received 10 percent of awarded funds
($3,874,777 of $38,687,939)
In FY 2016, tribal entities represented and received the following
funds through the Strategic Prevention Framework for Prescription Drugs
Program (awards are for the first year of the grant):
SAMHSA awarded grants to all 4 applications received from
organizations that self-identified as tribal organizations (100
percent success rate)
SAMHSA awarded grants to 21 of the 24 applications received
from non-tribal organizations (88 percent success rate)
Tribes/tribal organizations represented 16 percent of
recipients (4 of 25)
Tribes/tribal organizations received 19 percent of awarded
funds ($1,751,982 of $9,322,676)
In FY 2017, tribal entities represented and received the following
funds through the First Responders--Comprehensive Addiction and
Recovery Act Program (awards are for the first year of the grant):
SAMHSA awarded grants to all 4 applications received from
organizations that self-identified as tribal organizations (100
percent success rate)
SAMHSA awarded grants to 17 of the 48 applications received
from non-tribal organizations (35 percent success rate)
Tribes/tribal organizations represented 19 percent of
recipients (4 of 21 awards)
Tribes/tribal organizations received 8 percent of awarded
funds ($936,724 of $11,235,881)
Question 1c. If tribal grantees are eligible for the programs
mentioned in your oral testimony and question responses (i.e., a
residential program with 19 grantees and an outpatient program
authorized by the Comprehensive Addiction and Recovery Act), what
percentage of grant recipients are tribal grantees? And, what
percentage of total grant funds do those tribal grantees receive from
each of those grants?
Answer. In FY 2017, there were no tribal recipients of the
Residential Treatment for Pregnant and Postpartum Women Program and by
statute only states are eligible for the State Pilot Grant Program for
Treatment for Pregnant and Postpartum Women (section 508(r) of the
Public Health Service Act).
In FY 2016, there were no tribal recipients of the Residential
Treatment for Pregnant and Postpartum Women Program.
Your testimony also states that Assistant Secretary for Mental
Health and Substance Use McCance-Katz is actively looking for ways to
improve tribal access to SAMHSA's grant programs.
Question 2a. What metrics, if any, has SAMHSA identified to
determine if tribal access to SAMHSA grants is improving?
Answer. Dr. McCance-Katz has provided strong leadership on this
priority and over the past five months, she has:
Reestablished the Addiction Technology Transfer Center
(ATTC) Program: American Indian and Alaska Native Support
Center Cooperative Agreement.
Will be establishing Tribal TA Centers for Mental Health as
well as for Prevention.
Established a $5 million set-aside as part of the SAMHSA
Enhancement and Expansion of Treatment and Recovery Services
for Adolescents, Transitional Aged Youth, and their Families
Program.
Will make awards to three tribal entities, out of the nine
total projected awards, under the Statewide Consumer Network
Program.
Will ensure that at least one of the four Healthy
Transitions grants goes to tribes/tribal organizations.
Will ensure that at least four awards of Project AWARE
grants go to tribes/tribal organizations.
Additionally, in report language on the Consolidated Appropriations
Act, 2018, Congress directed SAMHSA to ensure that $5.millionin funding
from the Medication-Assisted Treatment--Prescription Drug and Opioid
Addiction program goes to tribes/tribal organizations; that act also
included a $50 million set-aside in the State Opioid Response Program
for tribal awardees.
The metrics used for success will be the number and proportion of
grant awards made to tribes/tribal organizations in these programs.
Question 2b. Does SAMHSA have any information on the overall number
of tribal applicants for all SAMHSA grant programs? If so, please
provide a summary of that information.
Answer. In FY 2016, SAMHSA received 126 applications from
organizations that self-identified as tribal organizations. In FY 2017,
SAMHSA received 82 applications from organizations that self-identified
as tribal organizations.
Question 2c. Does SAMIISA have any information on the success rate
of tribal grant applicants compared to other types of applicants for
competitive grant programs within the Agency? If so, please provide a
summary of that information.
Answer. In FY 2016, SAMHSA awarded grants to 79 of the 126
applications received from organizations that self-identified as tribal
organizations (63 percent success rate). In FY 2016, SAMHSA award
grants to 527 of the 1,410 applications received from non-tribal
organizations (37 percent success rate).
In FY 2017, SAMHSA awarded grants to 37 of the 82 applications
received from organizations that self-identified as tribal
organizations (45 percent success rate). In FY 2017, SAMHSA awarded
grants to 412 of the 1,025 applications received from non-tribal
organizations (40 percent success rate).
Your testimony notes that Assistant Secretary McCance-Katz included
a $5 million dollar tribal set-aside in a recent funding opportunity
announcement for ``Enhancement and Expansion of Treatment and Recovery
Services.''
Question 3a. Has SAMHSA included a tribal set-aside within this
funding opportunity in previous funding application rounds? Or is this
$5 million set-aside a first time occurrence?
Answer. This set-aside was done at the direction of Dr. McCance-
Katz. FY 2018 is the first time that SAMHSA included a $5 million set-
aside for tribes and tribal organizations in its Funding Opportunity
Announcement (FOA) focused on substance use disorder treatment services
for adolescents, transitional aged youth, and their families.
Question 3b. Please provide information about the number and
amounts of tribes awarded to tribal applicants for this grant program
under any previous grant award rounds.
Answer. SAMHSA previously awarded grants to tribes and tribal
organizations under the State Youth Treatment Initiative from FY 2012
to FY 2017. This Initiative helps to further the use of, and access to,
effective evidence-based family-centered treatment approaches for
adolescents (ages 12 to 17) and transitional age youth (ages 18 to 25)
with substance use disorders and co-occurring substance use and mental
disorders. Under this Initiative, 62 total grants have been made across
35 states/tribes/territories. Of the 62 total awards, seven awards
totaling $13,158,595 have been made to the following tribes and tribal
organizations (the amounts listed represent the first-year funding
award):
--Chickasaw Nation (OK)-one grant award (FY 2013: $555,333)
--Fallon Paiute Shoshone (NV)-one grant award (FY 2013:
$950,000)
--Pascua Yaqui Tribe (AZ)-one grant award (FY 2015: $800,000)
--Fairbanks Native Association (AK)-two separate grant awards
(FY 2016: $464,173; FY 2015: $249,767)
--Kickapoo Tribe (OK)-two separate grant awards (FY 2017:
$800,000; FY 2015: $250,000)
Fostering Tribal-State Partnerships
Your testimony discusses how the Cures Act State Targeted Response
(STR) grant program interacts with Indian Country through state-tribal
partnerships.
Question 4a. Please provide a list of the states receiving STR
funds that used tribal engagement as part of their plans for utilizing
STR resources.
Answer. Please see Chart below.
Question 4b. Please provide a summary of the types of tribal
engagement states identified as part of those STR plans.
Answer.
------------------------------------------------------------------------
State State Plan Information on Tribal Engagement
------------------------------------------------------------------------
Alaska Funding to 17 tribal health organizations
Arizona Arizona's needs assessment included focus on the
Hopi Tribe and Navajo Nation in Chochino and
Navajo counties. As a result, the STR funds are
being used to address prescription drug misuse in
these focus areas.
California American Indian/Native Alaskan (AI/NA) communities
have significant challenges in accessing MAT
services and their issues with the opioid
epidemic are also on the rise. The death rate
from unintentional drug poisoning is almost twice
as high in the AI/NA population compared to the
population nationally. STR project goals for
tribal communities include: improve MAT access;
increase the total number of tribal waivered
prescribers certified; provide expanded MAT
services that include tribal values, culture, and
treatments; provide innovative telehealth in
rural and underserved areas and increase
community capacity to support OUD prevention and
treatment; and, increase treatment engagement by
enhancing clinical decision tools using health
information technology.
Colorado The State will work with the two recognized tribes
to help them each identify needs and develop
their own strategic plans.
Michigan The State identified the following objectives: (1)
build the capacity of the Inter-Tribal Council
(ITC) Tribal OUD Prevention Initiative using
train the trainers combined with extensive
technical assistance (facilitators will be
trained using the Gathering of Native American
Model to either initiate the creation of a Tribal
Action Plan (TAP) or enhance existing TAP efforts
to focus specifically on the opioid epidemic);
and, (2) provide assistance with treatment costs
for American Indian and Alaskan Native (AI/AN)
under and uninsured patients with an OUD (the ITC
will implement the Tribal Opioid Treatment and
Recovery initiative using the existing Access to
Recovery infrastructure, entitled Anishnaabek
Healing Circle). 500 uninsured or underinsured AI/
AN OUD patients will be served.
Minnesota A contract to provide treatment to Native
Americans and five contracts to provide recovery
support services focused on pregnant and
parenting women to tribes. Funds have also been
distributed to develop a culturally appropriate
awareness campaign.
Montana The State will contract with the Rocky Mountain
Tribal Leaders' Council to work with Montana's
Peer Network to develop culturally tailored
version of the current peer mentoring trainings
and peer supervisor trainings. Rocky Mountain
Tribal Leader's Council will also be involved in
the outreach on reservations and with tribal
providers for the implementation of peer
mentoring.
Nevada The STR Director is working with Tribal Health
Medical Directors to promote naloxone
distribution and overdose education and
integration with tribal primary health providers
and public health through sharing of data and
resource referral.
New Mexico New Mexican Pueblo communities will receive
priority for overdose prevention education and
Narcan distribution. Anecdotally, opioid overdose
death rates on tribal lands are increasing.
Tribal leaders, police, community members, and
health and social service providers are all
reporting an increase in heroin and prescription
opioid use. Indigenous champions and local
ambassadors are being identified to build the
necessary and complex relationships with tribal
leaders to expand STR into those communities. The
State is also utilizing its Native American
employees to advise and consult on the project.
The Eight Northern Pueblos (ENP) currently
participate and recently Pojoaque Tribal Police
received training to respond to an opioid
overdose. The ENP are geographically located in
Rio Arriba and Taos Counties--Rio Arriba County
is consistently the county with the highest
overdose death rate in the United States. From
2012 to 2016, the mortality rate in Rio Arriba
County is almost 90 per 100,000. Recent
discussions with tribal members reinforce the
requirement that historical trauma will inform
the development of overdose prevention projects
with the Pueblos and be led by the community.
Intervention and prevention programs will be
coordinated with the Indian Health Service. This
collaboration is already in place with the
central hub through the ECHO project.
Incorporation of current trainings and
consultation regarding OUD treatment, addiction
and Chronic pain, etc. are present in the STR.
Finally, the State behavioral health department
currently holds a liaison position to ensure
incorporation of tribal health agencies and
``638s'' and use of this liaison will occur to
disseminate training materials from the STR.
New York A targeted media campaign is being supported. The
objectives are to: (1) conduct listening forums
for input in developing targeted media campaigns;
(2) deliver statewide media campaigns that
include Native American communities; (3) media
will focus on radio, television, digital, and
social media; and (4) customized messages will
focus on opioid overdose prevention to raise
awareness of the opioid crisis, educate target
populations on the risks and dangers of opioid
use; and inform individuals on how to seek and
access appropriate treatment and recovery
services.
North Dakota The action items within the strategic plan are
inclusive of tribal nations. Proposals have been
received from two tribal nations to increase
access to MAT through the utilization of
telehealth.
Oklahoma Targeted media campaign
South Dakota Develop educational materials that are culturally
sensitive for Native Americans, and work with
providers and service agencies to utilize those
materials. Draft and issue a request for
proposals for a vendor to develop materials and
distribution. Select vendor and execute agreement/
implement scope of work. Distribute materials/
videos to Native American communities through
education and medical services.
Washington Tribal Entities are part of the strategic planning
process and are engaged in all of the strategic
goals for both prevention and treatment.
Wisconsin STR funding has been awarded to tribal entities
through application process to provide SUD/MAT.
Other STR funding initiatives will focus on
working within tribal communities. Areas of
interest we are aware of from tribes are recovery
coaching, naloxone training/distribution,
prevention, and looking to expand OUD treatment.
The application process for Wisconsin counties
and tribes is complete to apply for STR funds to
provide MAT, counseling and recovery support for
individuals on their waitlists. Approximately
$2.4 million was awarded to 19 counties and
tribes who will be able to provide MAT for 841
additional Wisconsin residents with OUDs.
Wyoming Treatment and prevention activities are targeted
for the Wind River Reservation. Volunteers of
America possesses a working relationship with
Indian Health Service and has expressed
intentions in their application to enhance that
relationship to better serve those populations.
VOA is a Wellbriety Certified Treatment Center
through White Bison, Inc. VOA's certification
further enforces a positive working relationship
between the treatment center and regional tribes/
tribal entities by utilizing culturally
appropriate interventions.
------------------------------------------------------------------------
Question 4c. Does SAMHSA have an estimate of what percentage of the
funding awarded to the states identified in response to part (a) is
being used for those tribal-specific portions of the STR plans? If so,
please provide that estimate.
Answer. This level of detail is not required in the STR budgets as
tribal participation is not a statutory requirement.
Your written testimony notes, ``We have heard from tribal leaders
that SAMHSA also has a responsibility to improve tribal-state
relationships.'' It then describes two efforts undertaken by the Agency
and Assistant Secretary McCance-Katz in response to this tribal
feedback--hosting a Tribal-State Policy Academy (TSPA) and a letter to
state governors.
Question 5a. Please provide more specific information about the
TSPA, including any available information on participation, tentative
dates or locations, and goals for the event.
Answer. The TSPA is part of SAMHSA's approach for supporting
improvements in tribal-state relations as well as advancing a more
comprehensive and collaborative approach to addressing opioids and
other substances of abuse in tribal communities. This first academy is
planned for August 2018 and will include approximately 100 participants
(50 state and 50 tribal representatives). Tribes and states with
varying levels of engagement have been identified and planning is
underway.
On February 28, 2018, Assistant Secretary McCance-Katz sent a
letter to governors with federally-recognized tribes within their
borders. The letter shared the disproportionate impact of substance
abuse on tribal communities and that addressing the behavioral health
of American Indians and Alaska Natives is a priority. The letter
further called upon governors to ensure that tribes, tribal
organizations, and American Indians and Alaska Natives are engaged and
involved in state programs in a meaningful and beneficial manner. These
programs include the Substance Abuse Prevention and Treatment Block
Grant and State Targeted Response to the Opioids Crisis Programs. The
collaborative plans developed through the TSPA will help advance the
intent of Assistant Secretary McCance-Katz's letter.
Question 5b. How will SAMHSA and Assistant Secretary McCance-Katz
ensure that any TSPA-identified best practices/takeaways are shared
with states and tribes that are not able to participate directly?
Answer. Outcomes from the TSPA will be shared with tribes and
states immediately following the academy and as tribes and states
complete their plans. Multiple channels will be used to disseminate
information about the tribal-state plans and all completed plans will
be posted on SAMHSA's website to facilitate access.
Question 5c. What other plans or initiatives, if any, does SAMHSA
or Assistant Secretary McCanceKatz plan to undertake to improve state-
tribal coordination for behavioral health challenges that impact both
state and tribal communities?
Answer. Technical assistance for tribal and state collaborators is
planned following the TSPA to support continued engagement and progress
on their plans. Two additional TSPAs are proposed to ensure that the
remaining tribes and states are afforded an opportunity to develop
collaborative plans. SAMHSA is also identifying opportunities for
engaging tribes and states such as the State Block Grant Conference and
other Agency events.
______
Response to Written Questions Submitted by Hon. Heidi Heitkamp to
Captain Christopher Jones
Tribal Access to SAMHSA Grants
It is my understanding tribes must apply through their respective
states to access State Targeted Response (STR) funds made available in
the Cures Act. I worked with colleagues to introduce legislation to
address this barrier for tribes and increase STR resources--the Opioid
Response Enhancement Act (S. 2437) with Senator Baldwin.
Question 1a. How can we better ensure tribes have access to these
funds?
Answer. By statute, eligibility for the State Targeted Response to
the Opioids Crisis (Section 1003 of the 21st Century Cures Act) grant
program is limited to states. However, on February 28, 2018, Assistant
Secretary McCance-Katz sent a letter to governors of states with
federally-recognized tribes within their borders. The letter shared the
disproportionate impact of substance abuse on tribal communities and
that addressing the behavioral health of American Indians and Alaska
Natives is a priority. The letter further called upon governors to
ensure that tribes, tribal organizations, and American Indians and
Alaska Natives are engaged in state programs in a meaningful and
beneficial manner. These programs include the Substance Abuse
Prevention and Treatment Block Grant and State Targeted Response to the
Opioids Crisis Programs.
SAMHSA continues to work with states to encourage them to ensure
tribes have access to these funds and to monitor states' compliance
with their plans as noted in the following State Plan Information on
Tribal Engagement. (See Table in Senator Udall's questions)
Additionally, the Consolidated Appropriations Act, 2018 included a
$50 million set-aside in the State Opioid Response Program for tribal
awardees.
Question 1b. What feedback have you received from tribal
communities on the types of collaborations, technical assistance, and
flexibility they need to ensure STR funds are best serving their
communities?
Answer. As noted in written testimony, tribal leaders have
communicated to SAMHSA their desire to see improvements in tribal-state
relationships. In response, SAMHSA has issued the letters to state
governors noted above, reestablished the Addiction Technology Transfer
Center (ATTC) Program: American Indian and Alaska Native Support Center
Cooperative Agreement and will be hosting a Tribal-State Policy Academy
(TSPA) to improve collaborative relationships.
The TSPA is part of SAMHSA's approach for supporting improvements
in tribal-state relations as well as advancing a more comprehensive and
collaborative approach to addressing opioids and other substances of
abuse in tribal communities. This first academy is planned for August
2018 and will include approximately 100 participants (50 state and 50
tribal representatives). Tribes and states with varying levels of
engagement have been identified and planning is underway.
Outcomes from the TSPA will be shared with tribes and states
immediately following the academy as tribes and states complete their
plans resulting from the TSPA. Multiple channels will be used to
disseminate information about the tribal-state plans and all completed
plans will be posted on SAMHSA's website to facilitate access.
Technical assistance for tribal and state collaborators is planned
following the TSPA to support continued engagement and progress on
their plans. Two additional TSPAs are proposed to ensure that the
remaining tribes and states are afforded an opportunity to develop
collaborative plans. SAMHSA is also identifying opportunities for
engaging tribes and states such as the State Block Grant Conference and
other Agency events.
______
Response to Written Questions Submitted by Hon. Tom Udall to
RADM Michael Toedt
Opioid Prescription Monitoring
Question 1. Your written testimony states that IHS has Prescription
Drug Monitoring Program (PDMP) partnerships with 17 out of 18 states
where federally-operated IHS facilities are located. Please identify
the state with which IHS does not have a partnership. When does IHS
anticipate that it will finalize a partnership with that state?
Answer. Since August 2016, Indian Health Service (IHS) has worked
closely with the State of Nebraska to develop a Memorandum of
Understanding (MOU) for a PDMP partnership. In 2018, Nebraska changed
its PDMP to a web-based system that will now allow IHS pharmacies to
access the PDMP. IHS is waiting for the state to sign the MOU and has
been told it is ``on the roadmap in 2018.'' IHS is eager to start
reporting dispensing data to the State of Nebraska.
Question 1a. Does IHS track whether states are working with
tribally operated facilities and Urban health programs on PDMP database
access?
Answer. IHS does not track states' work with tribal or Urban Indian
Organizations on PDMP access.
Question 1b. What is IHS doing to help tribally-operated facilities
and Urban IHS facilities develop similar partnerships with states to
access their PDMP databases?
Answer. IHS responds to requests for information from tribal/urban
IHS facilities that are interested in developing MOUs with state PDMPs.
Information includes state key contacts, MOU language, and assistance
explaining requirements, and Health Insurance Portability and
Accountability Act provisions related to PDMP reporting. Technical
assistance is provided to tribal facilities that utilize the IHS
Electronic Health Record (EHR), Resource Patient Management System
(RPMS).
Question 2. In FY 2017, Congress gave IHS $1 million to develop its
own PDMP database. Your testimony mentions the ongoing development of a
``data reporting system.'' Is the ``data reporting system'' mentioned
in your testimony the same as the PDMP system for which Congress
appropriated $1million in FY2017?
Answer. The data reporting system referred to in the testimony is
an application developed by IHS called ``Safe Opioid Monitoring.'' It
differs from a PDMP in that it does not provide individual patient and
prescriber level data.
The ``Safe Opioid Monitoring'' software extracts data from the IHS
National Data Warehouse including opioid prescription rates, naloxone
utilization, methadone prescriptions, and percentage of opioids
prescribed compared to all prescriptions. This tool allows IHS to
compile selected data into user friendly reports used to monitor opioid
metrics by service unit and area, to determine trends within IHS. These
reports identify trends and potential areas of concern that require a
deeper look.
Question 2a. What is the status of IHS's efforts to launch its own
PDMP system?
Answer. IHS is working with the states to report to PDMPs through
their systems and is in the planning phases for FY 2018 PDMP funding to
enhance our current interoperability of PDMP reporting.
Question 3. The National Indian Health Board's testimony states
that the Board is not aware of any tribally-specific PDMP system. Their
testimony goes on to state that the organization is not aware of IHS's
efforts to utilize the FY 2017 funding for development of such a
system. Is IHS communicating with tribes and urban Indian health
programs about its efforts to develop a more robust tribal PDMP system?
If so, how?
Answer. Yes. In FY 2017, IHS transferred funding as tribal shares
to support tribal PDMP improvements.
In addition, tribes that use the IHS EHR/RPMS have access to the
IHS PDMP platform and have the ability to submit data to state PDMPs.
As RPMS PDMP improvements are implemented, IHS communicates the
instructions for installation and related procedures for the software
updates to all RPMS users, including the tribes.
Secondary Public Health Implications
Question 4. According to a recent report highlighted by the Centers
for Disease Control and Prevention, the increase to the growing number
of intravenous drug users, including intravenous opiates, correlates to
a simultaneous increase in acute hepatitis C infections. \1\ Does IHS
have any data on changing numbers of IHS patients presenting with
opioid or substance abuse-related blood borne infectious diseases like
hepatitis C or HIV/AIDS? If so, please provide a summary of that data.
---------------------------------------------------------------------------
\1\ Zibbell, Jon E., et al. ``Increases in Acute Hepatitis C Virus
Infection Related to a Growing Opioid Epidemic and Associated Injection
Drug Use, United States, 2004 to 2014.'' American journal of public
health 0 (2018): e1-e7.
---------------------------------------------------------------------------
Answer. IHS does not have data on the changing numbers of IHS
patients presenting with opioid or substance abuse-related blood borne
infectious diseases like hepatitis C (HCV) or HIV/AIDS. Moreover, IHS
does not have the ability to monitor this correlation with its existing
EHR infrastructure or personnel. However, IHS, in collaboration with
the Centers for Disease Control and Prevention (CDC), is currently
undertaking a vulnerability study looking at the risk of HIV or HCV
transmission from injecting drug use.
Question 4a. Is IHS aware of any other increases in secondary
health complications related to rising rates of substance abuse (e.g.,
neonatal abstinence syndrome, respiratory illnesses, etc.)? If so,
please provide a summary and description of any such secondary health
complications.
Answer. The IHS is in the process of quantifying the impact of
secondary health complications related to opioids and developing
strategies to reduce these health complications, such as Neonatal
Abstinence Syndrome (NAS), or also known as Neonatal Opioid Withdrawal
Syndrome (NOWS).
Question 4b. Does IHS have a plan to address any of the increased
demand caused by any increase in secondary health complications related
to rising rates of substance abuse discussed above? If so, please
provide a description of the plan here.
Answer. The HHS five point strategy to address the opioid crisis in
the United States is central to our response to increased demand. This
includes:
Improving access to prevention, treatment, and recovery
support services, including medication-assisted treatment;
Targeting the availability and distribution of overdose-
reversing drugs;
Strengthening our understanding of the epidemic through
better public health data and reporting;
Supporting cutting edge research on pain and addiction; and
Advancing better practices for pain management.
As part of the overall HHS strategy, IHS believes in a holistic
approach integrating physical, mental, spiritual, and cultural
components is essential to addressing substance use prevention,
treatment, and recovery.
The IHS established the Heroin, Opioids, and Pain Efforts (HOPE)
Committee to ensure appropriate and effective pain management, reduce
overdose deaths from heroin and prescription opioid misuse, and expand
access to culturally appropriate treatment. The HOPE response includes
creating guidelines, endorsing best and promising practices surrounding
secondary complication of opioid use, creating training modules for ITU
providers, as well as developing mechanisms to track impact of these
interventions. In addition to the HOPE Committee, IHS has involved all
of the departments within the Agency to be more responsive and
effective in addressing all needs related to substance use, including
secondary health complications.
Specific to HCV, IHS provided all IHS facilities with Guidelines
for Screening, Management and Pre-Treatment for HCV that can be
modified as needed for local or regional use. This guideline follows
national recommendations from established authorities such as the
United States Preventive Services Task Force, CDC, and the American
Association for the Study of Liver Diseases. In October 2017, the IHS
Chief Medical Officer convened the first ever IHS, tribal, and urban
Hepatitis C Elimination Workgroup, which informs overall federal
responses and strategies.
The IHS also actively collaborates with other federal agencies
through MOAs to leverage resources and provide more coordinated
approaches to the substance use crisis. For example, IHS is
collaborating with the American Academy of Pediatrics Committee on
Native American Child Health to develop guidelines to manage NOWS
including early identification and referral of mothers with suspected
opioid use disorders, obstetric care and delivery at IHS facilities,
and care and treatment of babies born with NOWS.
______
Response to Written Questions Submitted by Hon. Heidi Heitkamp to
RADM Michael Toedt
Rear Admiral Toedt, during the opioid roundtable the Committee held
in November, there were a couple of points mentioned that you said you
would look into, and I'd like to follow up on those.
Question 1. Vice Chairman Headdress of the Fort Peck Assiniboine
and Sioux Tribes asked why service units or tribes can't funnel some of
their purchase and referred care (PRC) dollars for prevention and
treatment of opioid misuse, if they have adequate means from third-
party billing. Is this a matter of flexibility or a matter of resources
for IHS?
Answer. The Indian Health Service (IHS) consulted with tribes on
whether or not there should be a set-aside of Purchased/Referred Care
(PRC) funds for prevention services. Input from this consultation
indicated support for funding more prevention services. With this in
mind, IHS Areas or Service Units, in consultation with the tribes, can
decide whether they want to set-aside a percentage of their PRC program
funds for prevention services. This would apply to either individual
patient referrals at the local IHS Service Unit or for area-wide
prevention services available to all IHS Service Units. The IHS area
office and local tribes would have to consult and decide on the best
approach.
Question 2. I also asked you what IHS is doing to build resources
to license practitioners to dispense methadone. You said you would get
back to me on how many providers of Medication Assisted Treatment (MAT)
there are within IHS and where they are located. Have you looked into
this?
Answer. Medication Assisted Treatment (MAT) with methadone is
provided through Opioid Treatment Programs (OTPs), which are certified
by the Substance Abuse and Mental Health Services Administration,
registered by the Drug Enforcement Administration, and licensed by the
state. MAT cannot be provided through office-based settings that are
not OTPs. IHS has focused on buprenorphine containing products for MAT
that are provided through office-based opioid treatment. This form of
office-based MAT has been very effective in the treatment of opioid use
disorders.
Additionally, IHS is in the process of implementing a robust
medical staff credentialing platform that will deliver the capability
to query a national database to determine the number of federally-
credentialed IHS prescribers with Drug Addiction Treatment Act of 2000
(DATA) waivers.
IHS has collected information from its federal facilities and
identified 21 providers who have a DATA waiver and are actively
prescribing MAT in the following locations: Jicarilla Apache Health
Care Facility in Dulce, New Mexico; Gallup Indian Medical Center in
Gallup, New Mexico; Northern Navajo Medical Center in Shiprock, New
Mexico; Hopi Health Center in Polacca, Arizona; Fort Duchesne Indian
Health Center in Fort Duchesne, Utah; Southern Bands Health Center in
Elko, Nevada; and Whiteriver Indian Hospital in Whiteriver, Arizona. In
addition to these federal locations, it is important to note that MAT
services are also provided through a combination of tribal, direct, and
contract health services.
IHS supports tracking buprenorphine prescriptions and acquisitions
data for buprenorphine containing products. While IHS is in the final
stages of implementing its Safe Opioid Monitoring data mart,
preliminary data reveals that buprenorphine prescriptions have
increased significantly. With the completion of this data mart, IHS
will be able to determine the number of facilities providing
buprenorphine directly to patients from IHS pharmacies.
Question 3. Can you share the progress in data sharing and two-way
communication between IHS and state Prescription Drug Monitoring
Programs (PDMPs)?
Answer. IHS has initiated a process to report (share data) and
query (receive data) with Prescription Drug Monitoring Program (PDMP)
partnerships in 17 out of 18 states where federally-operated IHS
facilities are located. IHS is actively pursuing partnership with the
last state to implement PDMP data sharing across all IHS pharmacies and
state PDMPs.
Question 4. When do you expect the IHS Strategic Plan will be
finalized and published?
Answer. The IHS Strategic Plan FY 2018-2022 is expected in
September 2018. A final release date is subject to the feedback
received during a 30-day public comment period, including comments from
tribes and Urban Indian Organizations.
On September 15, 2017, IHS consulted and conferred with tribes and
Urban Indian Organizations on the IHS Strategic Plan. An initial
framework was developed and IHS requested comments from tribal and
Urban Indian Organization leaders, and IHS employees, through October
31, 2017. In November 2017, an IHS-tribal workgroup was formed to
review the hundreds of submitted comments and recommendations. Over a
four month period, the workgroup developed recommendations that form
the basis of the draft IHS Strategic Plan FY 2018-2022. IHS is in the
process of finalizing a Federal Register Notice (FRN) asking for
comments on the draft IHS Strategic Plan FY 2018-2022. The FRN is
expected to be published in July 2018. IHS plans to conduct tribal
consultation and Urban Confer sessions on the draft IHS Strategic Plan
in July and August.
______
Response to Written Questions Submitted by Hon. Heidi Heitkamp to
Stacy A. Bohlen
Question 1. Mr. Moose, On Tuesday, March 13th I spoke on the phone
with Secretary Azar about IHS and what they are doing to support and
improve services. We talked about things like workforce recruitment and
patient wait time data. One thing he said to me is that IHS/HHS should
target a few top priorities from the IHS Quality Framework that was
published in late 2016 and focus on those. In your opinion, what should
the top three priorities be to improve patient experience and outcome
and ensure the delivery of high quality health care?
Answer. Senator Heitkamp, thank you for the question and for your
continued dedication to improving the quality of health services for
all of Indian Country. Ensuring the delivery of the highest quality of
care is a top priority across all IHS health service delivery areas,
but is especially key in curbing the national opioid overdose epidemic.
As you very well know, the excessive and often times indiscriminate
prescribing of opioid analgesics for both chronic and acute pain
symptoms were, and continue to be, a pervasive issue fueling the
crisis. Within the Indian Health System, provider shortages--
particularly behavioral health providers who have the knowledge and
expertise in the intersection of addiction, mental illness and public
health--have forced an overextended health workforce to be overly
reliant on opioid medications to treat pain, as opposed to having
opioid medications be the last resort. According to the IHS, the
physician vacancy rate in 2014 was 22 percent nationally, with some
areas experiencing far higher vacancy rates.
Access to care remains a critical need, but meeting quality of care
goals are just as crucial. While we applaud the IHS for imposing new
rules and procedures such as requiring all federally employed
prescribers and dispensers to check the state prescription drug
monitoring program, and updating the Indian Health Manual to align with
the Centers for Disease Control and Prevention (CDC) Guideline for
Prescribing Opioids for Chronic Pain, much more needs to be done to
improve the delivery of high quality health care. Issues include gaps
in the availability and infrastructure of telemedicine, underfunded and
understaffed substance use treatment facilities, low numbers of
providers with waivers to prescribe buprenorphine for treatment of
opioid use disorder, inconsistent access to naloxone, and low provider
familiarity with and implementation of the CDC Guideline.
Undoubtedly, all five of the quality priorities embedded within the
2016 IHS Quality Framework are essential if we are to stem the tide of
this epidemic. Within the context of the opioid overdose epidemic, the
three most critical priorities are to:
1.) Strengthen Organizational Capacity to Improve Quality of
Care and Systems
Providers need more training and education on the CDC
Guideline and on the signs, symptoms and risk factors for
substance misuse, addiction and overdose. Given that providers
are at the frontlines of this epidemic, it is critical that
concerted investments be made towards raising provider capacity
to effectively deliver care to patients in need of pain
management.
2.)Align Service Delivery Processes to Improve Patient
Experience
IHS efforts to align their policies with the CDC Guideline
are an important step towards ensuring accountability and
consistency in care. NIHB is hopeful that these changes will
lead to reductions in overprescribing, but much more needs to
be done to improve the patient experience overall. For
instance, high provider turnover and chronic workforce
shortages pose significant barriers and create disparities in
the quality of care. In addition, limited attention to
wraparound and comprehensive care that includes mental health
treatment, case management, job training and housing services
mean that patients are encountering gaps across the care
continuum.
3.) Ensure Patient Safety
The crux of reducing unsafe and ineffective prescribing of
opioids is ensuring patient safety. Too often has provider
misconduct and malpractice led to tragic and yet largely
preventable deaths within the Indian Health System. NIHB
encourages Congress to review reports from the United States
Department of Health and Human Services Office of Inspector
General on deficiencies in system security and physical
controls at IHS hospitals and how this impacts patient safety.
______
*Responses to the following questions were not available at the
time this hearing went to print*
Written Questions Submitted by Hon. Tom Udall to
Hon. John C. Anderson
Opioid Funding and Utilization in Indian Country
Question 1. The Department of Justice's FY2019 Budget Request
summary states, ``[The Department's FY2019 Budget Request] provides the
needed resources so that Federal, state, local and trial law
enforcement agencies can fight the opioid epidemic that is destroying
neighborhoods.'' \1\
---------------------------------------------------------------------------
\1\ Staff of Dep't of Just., 2019 Budget Summary (2018). Available
at https://www.justice.gov/jmd/page/file/1033086/download#page=2.
a. Please summarize how this Budget Request reflects the stated
---------------------------------------------------------------------------
goal of addressing the opioid epidemic in tribal communities.
b. What additional law enforcement and prosecution resources,
if any, does this Budget Request propose specifically for
tribal communities?
c. Did the Department consult with tribes about design of the
opioid epidemic response proposals included in this Budget
Request?
d. Did the Department, its budget and performance personnel,
its law enforcement agencies, or the Executive Office for
United States Attorneys coordinate with the Department of the
Interior's Bureau of Indian Affairs-Office of Justice Services
in the design of proposals for Indian country in this Budget
Request?
Question 2. Your written testimony states, ``An important element
of the Department's support [for response to the opioid crisis] is
providing opportunities for funding.'' It goes on to include several
references to Department programs that grantees can use to address the
opioid crisis--including Drug Courts funding and Office of Justice
Programs' Comprehensive Opioid Abuse Program. The testimony highlights
two tribal grantees under these programs. Please provide detailed
information on how much funding the Department awards to tribal
grantees for drug courts and substance abuse prevention, including a
list of tribes that receive such funds and estimates of the amount of
funding available to each such tribal grantee.
Investigations and Prosecutions of Crimes on Indian lands
Question 3. At the hearing, several Members of the Committee
discussed case referral statistics included in a December 2017 report
issued by the Department's Office of the Inspector General. \2\ This
report includes a description of the numbers of investigations referred
to U.S. Attorney Offices (USAOs) for prosecution by various law
enforcement agencies.
---------------------------------------------------------------------------
\2\ Staff of Dep't of Just., Review of the Department's Tribal Law
Enforcement Efforts Pursuant to the Tribal Law and Order Act of 2010 11
(2017). Available at https://oig.justice.gov/reports/2017/e1801.pdf.
a. Please provide an estimate of the number of investigations
referred to USAOs by the Bureau of Indian Affairs, the Drug
Enforcement Administration, the Federal Bureau of
Investigation, and Tribal law enforcement in CY 2015, CY 2016,
---------------------------------------------------------------------------
and (if available) CY 2017.
b. Please provide information on the types of investigations
most frequently referred to USAOs by the law enforcement
agencies listed in part (a) and, if possible, an estimate of
the percentage of referred cases that are related to drug
crimes.
Question 4. The same report notes that the number of declinations
for prosecution of crimes in Indian country by USAOs increased by 20
percent from CY 2013 to CY 2015. \3\ Please provide an estimate of the
number of declinations and the number of defendants against whom
charges were filed for crimes in Indian country nationally in CY 2016
and, if available, CY 2017.
---------------------------------------------------------------------------
\3\ Id. at 10.
---------------------------------------------------------------------------
______
Written Questions Submitted by Hon. Heidi Heitkamp
Hon. John C. Anderson
Question 1. I hear one consistent from all five tribes in North
Dakota when it comes to drugs--not just opioids--but drugs in general.
. . . ``Please help us, we are being overrun''. I know the
jurisdictional challenges, the lack of law enforcement on the
reservations, little to no DEA presence, lack of detention and
treatment facilities, and the tendency for U.S. Attorney's Offices to
not pursue dealers arrested with small quantities on the reservation.
(a) When you hear and know all of this--do you think we can
honestly say that we are upholding our treaty responsibilities to our
tribes? Do you truly think that the Department of Justice is doing
everything it can to shut down the drug trafficking problem in Indian
Country?
(b) Do you think we need more FBI and DEA agents available to
assist in these types of crimes and investigations in Indian Country in
order to stem the flow of illicit drugs? Do you agree that FBI and DEA
agents should be forming relationships with our tribes and operating on
the reservation as much as possible as opposed to only responding in a
crisis or in response to a major crime?
(c) You mentioned HIDTA Drug Task forces in your testimony--do you
know how many of these task forces are currently operating within
Indian Country? My understanding is that right now in North Dakota the
number is zero--is that acceptable if we all admit that there is a
problem of illicit drugs flowing freely into and through Indian
Country?
(d) DOJ also has Safe Trails Task Forces that are specifically
focused on combatting in crime in Indian Country--do you know how many
Safe Trails Task Forces we have in North Dakota? Zero. So why is DOJ
not doing everything in their power to stand up as many of these Task
Forces as possible to address the supply side of the illicit drug
problem in Indian Country?
______
Written Questions Submitted by Hon. Lisa Murkowski
Hon. John C. Anderson
Thank you Mr. Chairman and gentlemen thank you all for what you do,
respectively. I apologize I was not able to hear some of the questions
from my colleagues. But again, these are issues that are so key and so
important and I appreciate your testimony. Thank you Captain Jones for
mentioning the Project Hope Program and how it is working or helping in
Alaska. In my opening statement, I didn't just talk about the opioid
epidemic and how that's ravaged our communities. I also talked about
alcohol and how it seems to be an underlying issue in Alaska.
I will just cite to our annual drug report that says acknowledges
there is a multi-faceted drug abuse problem in the state and that drug
abusers in Alaska tend to abuse more than one substance. Often times
they are abusing multiple drugs at once. The Alaska State Troopers
emphasized in their report that alcohol was the single most abused
substance. So as we have been focusing our efforts here in Congress on
opioids, I don't want us to lose sight of the fact that there is an
underlying issue and that is alcohol. We have to provide the support
for programs and grants in that alcohol space as well and so when we're
talking about substance abuse, we have to make sure that we are talking
about alcohol and substance abuse programs, too. Everyone in the crowd
is shaking their heads, like they agree with me.
We don't need to bifurcate all of these drug issues. We all have
one big, ugly, horrible problem that we are dealing with. Let me ask
you this, I'll call it a workforce issue, but our reality is that we
have identified the problem and some of the solutions. But, we know
that so much of this comes back to making sure that we have mental
health professionals that are able to be there to and support those who
need it. I have been working with my colleague from Indiana, Senator
Donnelly, on an effort that would incentivize those to go into the
field and work to find the best treatments for substance use disorders.
Basically, it's a loan forgiveness program that we think will be
helpful in incentivizing more people to enter the mental health
profession. I have to assume that part of the challenges that we're
facing is we simply don't have enough mental health professionals to
address the substance abuse epidemic in the United States. I'm also
getting head nods for this too.
Question. So, here's my question to you and this is this is
intended to help at least three individuals that are in the audience.
One of which I have met with and she is the Mayor of Utqiagvik. She,
and two others that are part of her council, met with us today and
they've mentioned that Utqiagvik has an issue with drugs, not just
opioids. They said that we can't single out a single drug from a law
enforcement perspective and I'll look to you Mr. Anderson to answer
this. They are saying that they don't have a district attorney and
they're (the City of Utqiagvik) is responsible for the prosecution of
these drug offenses and they are not moving forward as fast as they
would like because the drugs are coming in by mail the drugs and by
plane. And that's it. We know how they get in, but because we can't get
attention on anything unless it's at full federal, full felony level,
that people think they can get away with selling and dealing. They can
use and there's no here's no follow up and no consequence. What would
you tell the Mayor of Utqiagvik?
[all]