    [Senate Hearing 115-872]
    [From the U.S. Government Publishing Office]

                                                         S. Hrg. 115-872

                               THE OPIOID CRISIS
                              RESPONSE ACT OF 2018

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

                                    HEARING

                                     OF THE

                        COMMITTEE ON HEALTH, EDUCATION,
                              LABOR, AND PENSIONS

                              UNITED STATES SENATE

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 SECOND SESSION

                                       ON

             EXAMINING AN ORIGINAL BILL ENTITLED, ``THE OPIOID CRISIS
                                 RESPONSE ACT OF 2018''
                                   __________

                                 APRIL 11, 2018

                                   __________

     Printed for the use of the Committee on Health, Education, Labor, and
                                    Pensions

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                  __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    48-493 PDF                 WASHINGTON : 2022

    -----------------------------------------------------------------------------------

              COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

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

                   David P. Cleary, Republican Staff Director
             Lindsey Ward Seidman, Republican Deputy Staff Director
                     Evan Schatz, Democratic Staff Director
                 John Righter, Democratic Deputy Staff Director

                               C O N T E N T S

                                  ----------

                                   STATEMENTS

                           WEDNESDAY, APRIL 11, 2018

                                                                       Page

                               Committee Members

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

                                   Witnesses

    Donahue, Jennifer, Esq., Child Abuse Investigation Coordinator,
      Delaware Office of the Child Advocate, Georgetown, DE..........     6
        Prepared statement...........................................     8
        Summary statement............................................    42
    Morrison, Robert I.L., Executive Director, National Association
      of State Alcohol and Drug Abuse Directors, Washington, DC......    42
        Prepared statement...........................................    44
        Summary statement............................................    54
    Nickel, Jessica Hulsey, President and CEO, Addiction Policy
      Forum, Washington, DC..........................................    55
        Prepared statement...........................................    56
        Summary statement............................................    63
    Casey, Jr., Hon. Robert P.:
        Letter submitted for the Record from former Congressman James
          C. Greenwood...............................................    85

                               THE OPIOID CRISIS
                              RESPONSE ACT OF 2018

                                  ----------

                           Wednesday, April 11, 2018

                                           U.S. Senate,
           Committee on Health, Education, Labor, and Pensions,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 10:08 a.m., in
    room SD-430, Dirksen Senate Office Building, Hon. Lamar
    Alexander, Chairman of the Committee, presiding.
        Present: Senators Alexander [presiding], Isakson, Collins,
    Cassidy, Roberts, Murkowski, Murray, Casey, Bennet, Baldwin,
    Murphy, Warren, Kaine, Hassan, Smith, and Jones.

                     OPENING STATEMENT OF SENATOR ALEXANDER

        The Chairman. The Senate Committee on Health, Education,
    Labor, and Pensions will come to order. This hearing is for
    reviewing the Opioid Crisis Response Act of 2018, which Senator
    Murray and I have recommended with input from virtually every
    Member of this Committee.
        Our intention is to mark up the bill and report legislation
    to the full Senate on April 24th, along with cosmetics
    legislation and some other pending bipartisan legislation that
    we've been working on. I want to thank Senator Murray and her
    staff and our staff for the way we've been able to work on the
    opioid legislation.
        This is our seventh bipartisan hearing since October. I
    think our work reflects the urgency of the need for a prompt
    response to our country's most serious public health crisis,
    which despite enormous efforts seems to get worse.
        Senator Murray and I will each have an opening statement,
    and then we will introduce the witnesses. After the witnesses'
    testimony, Senators will each have 5 minutes for a round of
    questions.
        Last week, I was in Tennessee, visiting the upper east
    Tennessee area. I was talking with our witnesses beforehand. I
    met with two of the four criminal judges in the upper east
    Tennessee area, who told me that out of the 6,000 cases that
    they addressed and closed last year that fully two-thirds of
    them were related to the opioid crisis.
        Then a little later in the day, I went down to Greeneville,
    Tennessee, to the home of Andrew Johnson, President Andrew
    Johnson, and his upstairs bedroom is his son's bedroom, and
    there on the bedside table is a bottle laudanum. His son at age
    35 died of basically an opiate overdose, probably mixed with
    alcohol, even back then. So this is a severe crisis, and it's
    not a new phenomenon.
        Last week, also, I visited the Neonatal Intensive Care Unit
    at Niswonger Children's Hospital in Johnson City, Tennessee.
    The hospital opened a new separate unit within their NICU last
    May to help deal with all the infants being born in drug
    withdrawal. Of the 30 babies in the unit last week, 10 were in
    drug withdrawal. The babies stay in the hospital for at least 5
    days. Some stay for weeks.
        While at Niswonger, I heard heartbreaking stories of how
    the opioid crisis has claimed the lives of loved ones too soon.
    One story is about a man named Dustin Iverson.
        After serving two tours in Iraq and Afghanistan with the
    Mississippi National Guard, Dustin settled in a small town in
    Alabama. A year and a half ago, Dustin was found dead at 29
    years old from an apparent overdose. His death turned a
    national crisis from a news headline into a painful personal
    experience for his aunt, Trish Tanner.
        Trish is currently the Chief Pharmacy Officer at Ballad
    Health, a regional healthcare provider. She was enrolled in an
    executive fellowship program when Dustin died, and as part of
    her program, she worked on an in-depth project on ways to
    reduce opioid prescribing. She has said about the project, ``I
    researched the opioid crisis in our region. As Dustin's aunt
    and as a pharmacist, I have a duty and a desire to bring about
    change now. This is a way for us to redeem what has been
    lost.'' As a result of Trish and her colleagues' efforts, the
    health system she was working for at the time, now part of
    Ballad Health, reduced the number of inpatient opiate doses
    administered in its hospitals by more than 40 percent last
    year.
        In January, Sam Quinones testified before our Committee
    that we need a moonshot to solve this crisis. I think it may
    require the effort and resources of a moonshot, but I also
    think it will be different and harder than a moonshot because
    this is not something that can be undertaken by a single agency
    in Washington, DC. It will require all-hands-on-deck work and
    solutions from states, communities, and local partners.
        However, the Federal Government can and should play an
    important role. Last Congress we passed new laws, the
    Comprehensive Addiction and Recovery Act and the 21st Century
    Cures Act, to help address the crisis. In the last 3 years, we
    have provided additional funding targeted at easing the opioid
    crisis, including $1 billion in state grants in Cures over 2
    years and over $3 billion of additional funding in the omnibus
    bill we passed last month.
        But the opioid crisis continues to destroy families and
    communities, and so we need to examine what more we can do and
    make sure we're best possible partner. In December, Senator
    Murray and I wrote to every Governor and state insurance
    commissioner asking for ideas on how we could do that. And this
    Committee has spent the last 6 months hearing from Governors,
    state officials, doctors, officials from the Food and Drug
    Administration, National Institutes of Health, Centers for
    Disease Control and Prevention, and the Substance Abuse and
    Mental Health Administration, families, and other experts at
    our hearings.
        As we have heard, this crisis touches more than just those
    suffering from an opioid addiction. It touches children and
    grandparents and doctors and nurses and law enforcement. And so
    the response from the Federal Government must be bipartisan,
    urgent, and effective.
        Last week, Senator Murray and I released this draft
    legislation based on the input we have heard, as well as ideas
    from Senators on both sides of the aisle, to give new
    authorities and create grants and programs at six Federal
    departments and agencies. So far in this draft, there are 29
    proposals from nearly every Member of this Committee, including
    legislation introduced by Senators Murray, Young, Hassan, and
    myself to spur development of a non-addictive painkiller by
    giving the National Institutes of Health more flexibility. I
    see a non-addictive painkiller really as the Holy Grail of
    solving the opioid crisis.
        There are millions of Americans who suffer from chronic
    pain, and I have heard from many of them. They rely on opioids
    for relief. Developing new, non-addictive ways to treat is
    crucial to helping prevent people from becoming addicted to
    opioids while ensuring those who need relief have access to it.
        Our proposal would also give the FDA the authority to
    require drug manufacturers to package certain opioids for a set
    duration, like in a blister pack that contains medication for
    three or 7 days, and require manufacturers to give patients
    simple and safe ways to dispose of unused opioids. It would
    also help do a better job of stopping illegal drugs, such as
    fentanyl, at the border by strengthening coordination between
    the FDA and Customs and Border Protection.
        At our hearings, we heard about the importance of sharing
    data, and how sharing data would help state prescription drug
    monitoring programs. So this draft would help states collect
    and share data so doctors and pharmacies can know if patients
    are doctor shopping. We asked for written comments on the draft
    by close of business today on what more the Federal Government
    can do. We look forward to hearing more about that from our
    witnesses.
        Senator Murray.

                      OPENING STATEMENT OF SENATOR MURRAY

        Senator Murray. Thank you very much, Mr. Chairman, for your
    bipartisan work throughout this process.
        I want to thank all of the witnesses who are here today. I
    look forward to your testimony.
        As the Chairman said, 6 months ago, we began a series of
    bipartisan hearings on the opioid crisis, asking questions and
    seeking answers to learn more about its root causes and ripple
    effects and what meaningful action we can take to help our
    families and communities. In the course of listening to those
    most directly facing this crisis, both here and back home in my
    home State of Washington, I've heard many stories about this
    challenge: families who are strained by a loved one's battle
    with opioid addiction; parents who lost the children they would
    do anything for to a disease they felt helpless to do anything
    against; children separated from parents who are suffering from
    opioid addiction and unable to care for them; grandparents,
    relatives, and others who have stepped up to support a victim's
    family.
        The burden of this crisis isn't just borne by individuals
    or families, but by entire communities. An elementary principal
    back in Washington told me about the kids at his school who are
    unable to focus on their studies because of the trauma of their
    parents' disease and the teachers who have to face the
    challenge of supporting these students and addressing their
    trauma in the classroom. The staff at a hospital in Washington
    told me about how many of the babies they deliver are born to
    mothers suffering from addiction, including opioid addiction.
        This Committee has heard from experts in the field who are
    fighting this epidemic. We've heard from community leaders and
    state officials about the tools they are using, the tools they
    still need, and the role of data and technology. We've heard
    from agency heads and researchers about the need for new
    resources and authorities and the potential for new discoveries
    to help treat those struggling with addiction.
        We've heard from a journalist, who followed the crisis
    closely, about how we got here and how our communities are in
    the frontlines turning the tide. We've heard from Governors
    about the lessons they've learned in the laboratories of
    democracy that we can put to use on the national level. We have
    heard about the challenges and opportunities, the successes and
    failures, the hope and the heartbreak of this crisis. So today,
    we are responding with strong steps that build on our recent
    work to address it.
        The bipartisan Opioid Crisis Response Act of 2018 was
    drafted with serious attention to the concerns we heard. It
    offers some serious solutions to help address them. This
    legislation answers the call for more resources to expand
    effective treatment programs on the state level by
    reauthorizing and improving the targeted response grants from
    the 21st Century Cures Act. It answers the call for better
    tools to diagnose, prevent, and treat pain and addiction by
    empowering the National Institutes of Health with more
    flexibility to support high impact research on public health
    threats, including this opioid epidemic.
        It answers the call for new products and solutions by
    clarifying the Food and Drug Administration's authority to
    require special packaging and safe disposal options, encourage
    the development and review of non-addictive pain treatments,
    and keep illicit products from entering our country. The
    legislation addresses the need for better data and technology
    practices so health providers and pharmacies can spot patterns
    of potential misuse by expanding the Centers for Disease
    Control and Prevention's efforts to support states in improving
    Prescription Drug Monitoring Programs and encourage better and
    faster data collection and sharing between states.
        It addresses the need to help our schools and children by
    developing a task force and grants to help support trauma-
    informed care programs, increasing access to mental health care
    for children, and supporting state efforts to improve plans of
    safe care for children born to mothers battling addiction. And
    it addresses the need to help our strained behavioral health
    workforce so that patients can get the care they need, even if
    they live too far from a doctor's office, by expanding loan
    repayment to behavioral health providers who practice in
    underserved areas, increasing access to behavioral health
    services in areas hardest hit by this epidemic and facing
    provider shortages, and authorizing new grants to target the
    workforce shortages in substance use and mental health
    treatment.
        It addresses the need to increase access to treatment by
    allowing the Substance Abuse and Mental Health Services
    Administration to provide grants to help providers establish
    new recovery centers, by allowing health centers to treat
    addiction patients with innovative telehealth models and
    technology that can help them serve rural or remote areas, and
    by building on our work in the Comprehensive Addiction and
    Recovery Act to permanently allow nurse practitioners and
    physician assistants to prescribe medication-assisted
    treatment.
        It addresses the need to give those affected by this
    disease a path forward by providing grants for workforce
    training to help them get back on their feet. And it addresses
    many other challenges, big and small, that we've heard from
    people across the country working to turn the tide of the
    opioid epidemic.
        While this legislation will not be the last step we take to
    respond to this crisis, it is a major step. And I want to thank
    all of our colleagues, both on and off this Committee, from
    both sides of the aisle, for their bipartisan work and their
    dedication to getting this done.
        I especially want to thank Chairman Alexander for working
    with me and for sharing my focus on bringing as many voices as
    possible to the table so that we could hear their stories,
    concerns, and needs firsthand.
        This bill is a testament to the value of listening, and
    we're not done listening yet. Many of the policies presented
    here are still works in progress, and we are committed to
    working together with stakeholders to help make sure we can
    include as many of the good ideas out there as possible.
        I look forward to hearing what our witnesses have to say
    today to add to this conversation as we work to get this very
    important bill to the finish line for families across the
    country.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Murray, and thank you for
    your words.
        Each witness will have up to 5 minutes to give his or her
    testimony. That will allow more time for conversation with the
    Senators, with their questions.
        I'm pleased to welcome you today. I thank you for taking
    the time to be here.
        The first witness is Jennifer Donahue. She is Chief Abuse
    Investigation Coordinator in the Office of the Child Advocate
    for the Delaware courts. She's worked in family law since 2000,
    with the Office of the Child Advocate since 2007. She reviews
    cases involving substance-exposed infants and their families.
        The second witness we'll hear from is Robert Morrison,
    Executive Director of Legislative Affairs at the National
    Association of State Alcohol and Drug Abuse Directors. That is
    a nonprofit organization that specializes in the development of
    effective alcohol and other substance abuse prevention and
    treatment programs. He's been with the organization for 16
    years.
        Third is Jessica Hulsey Nickel, Founder, President, and
    Chief Executive Officer of the Addiction Policy Forum. The
    Addiction Policy Forum is a nonprofit that works to elevate
    awareness around addiction and improve public policy to help
    patients with substance use disorders and their families. Ms.
    Nickel's 25-year career focusing on addiction comes from
    personal experience, as both of her parents struggled with
    heroin addiction.
        We welcome our witnesses, and, Ms. Donahue, let's begin
    with you.

    STATEMENT OF JENNIFER DONAHUE, ESQ., CHILD ABUSE INVESTIGATION
    COORDINATOR, DELAWARE OFFICE OF THE CHILD ADVOCATE, GEORGETOWN,
                                   DE

        Ms. Donahue. Chairman Alexander, Ranking Member Murray, and
    honorable Members of this Committee, thank you for the
    opportunity to speak here today about how the proposed Opioid
    Crisis Response Act of 2018 will further support and strengthen
    states' response to this problem.
        My name is Jennifer Donahue, and I am an attorney with the
    Office of the Child Advocate in Delaware. In my role, I review
    and monitor cases involving serious physical injury, death, and
    sexual abuse of a child and infants with prenatal substance
    exposure.
        My testimony today will focus on the following three areas
    of the proposed bill as it relates to infants with prenatal
    substance exposure and their families: providing further grant
    opportunities and technical assistance support to states for
    the implementation of Plans of Safe Care, providing further
    funding and support to states to strengthen their healthcare
    workforce to increase access to much needed substance use
    disorder treatment and access to mental health services in
    schools for our children, and providing grants to states to
    improve data collection.
        My office extends its gratitude to this Committee and
    Congress for the passing of the 21st Century Cures Act and the
    Comprehensive Addiction Recovery Act. These pieces of
    legislation have helped states begin to address the damage that
    the opioid epidemic has caused to children and families.
        Delaware has already embarked on developing draft Plans of
    Safe Care and implementing them in several of our area
    hospitals. However, additional funding and support from our
    Federal counterparts is critical. The Opioid Crisis Response
    Act of 2018 could be a means to that end.
        The prevalence of pregnant women struggling with opioid
    addiction has increased substantially in Delaware, and access
    to treatment, particularly medication-assisted treatment, is
    often difficult. The number of notifications to Delaware's
    Child Welfare Agency involving infants with prenatal substance
    exposure has also increased. In 2015, there were 294
    notifications, and that number jumped to 450 notifications in
    2017.
        The data further shows that for infants who are prenatally
    exposed to two substances, opioids were involved in 63 percent
    of those cases. For infants who are prenatally exposed to three
    or more substances, opioid exposure was present in 78 percent
    of those cases. The correlation between these infants and the
    risk of future abuse and neglect cannot be ignored,
    particularly when parents have not been successful in accessing
    treatment.
        From 2015 to 2017, 14 infants with prenatal substance
    exposure sustained serious physical injuries in Delaware, and
    nine died after being discharged home to their parents. Aiden
    was one of those infants. He was born in 2015 and was
    prenatally exposed to opiates. Aiden spent 17 days in the
    hospital after his birth, receiving morphine to assist with his
    withdrawal. He was subsequently released to his parents, both
    of whom were addicted to heroin.
        During the 9-weeks Aiden was in the care of his parents, he
    sustained severe traumatic injuries to both his brain and his
    body. Aiden was hospitalized for 4 months and received
    extensive medical care, including life support measures. His
    child welfare treatment worker, Jennifer Perry, who is here
    with me today, spent countless hours by his side in the
    hospital to provide comfort and support. Aiden died in
    September 2015. His parents pled guilty to murder by abuse and
    neglect and are currently incarcerated.
        Aiden's passing devastated our small State of Delaware,
    especially our local community. But it also compelled us to
    look more deeply and objectively into our state's and Federal
    policies and procedures that ultimately failed him.
        The Delaware Child Abuse and Neglect Panel, known as the
    CAN Panel, reviews all child deaths and near deaths due to
    abuse or neglect. A review of the cases between 2010 and 2014
    resulted in approximately 17 findings of policy failures that
    involved infants with prenatal substance exposure. As a result,
    in May 2015, we formed the Substance Exposed Infant Committee
    to address those areas of critical concern.
        In an effort to further strengthen our response, Delaware,
    in August 2016, applied for in-depth technical assistance to
    the National Center on Substance Abuse and Child Welfare.
    During the past 2 years, our technical assistance leaders have
    worked with our team in drafting Plans of Safe Care, which are
    now being utilized in four of our six birthing hospitals.
        No single agency has the resources to address the full
    spectrum and unique needs of this population and families.
        Pending Delaware House Bill 140, known as Aiden's Law,
    reinforces the requirements under CAPTA and CARA. It's a non-
    punitive public health oriented bill, and it sets forth what
    we, as Delaware, believe should be included in the Plans of
    Safe Care.
        However, states need more guidance and financial support.
    We are hopeful that the proposed Opioid Crisis Response bill
    will provide additional grant moneys to not only help us
    implement these plans, but also to provide us guidance on what
    we believe are the most important aspects of it: communication
    between those system partners and ongoing monitoring of the
    family. Plans of Safe Care are likely going to be monitored for
    much longer than a typical child welfare investigation. The
    child welfare workforce on a national level is already severely
    underfunded and cannot assume this additional responsibility
    without concurrent funding.
        Approximately 34 percent of Delaware mothers who gave birth
    to an infant with prenatal substance exposure in 2017 also had
    a mental health condition or diagnosis, and that's probably an
    underreported number. Approximately 40 percent of mothers had a
    history of trauma or DFS involvement when they were a child.
        Strengthening states' healthcare workforce, specifically
    substance use disorder treatment, coupled with trauma informed
    mental health services will likely reduce the number of infants
    born with substance exposure. Mental health services in school,
    ideally at the elementary level, will address the trauma that
    our youth has experienced that may often lead to mental health
    concerns and substance use. In 2015, Delaware created a
    specific independent Excel spreadsheet capturing data for this
    population.
        The Chairman. We want to try to keep it within 5 minutes.
        Ms. Donahue. Yes. I will finish up right now. Thank you.
        As far as the data collection is concerned, we do have a
    small Excel spreadsheet for capturing this population. But we
    need more funding and support for comprehensive data collection
    and analysis of these infants and their families, and we
    believe this is a critical part of the bill.
        Thank you very much for this opportunity to speak with you
    today, and I welcome any questions you may have.
        [The prepared statement of Ms. Donahue follows:]
                     prepared statement of jennifer donahue
        Chairman Alexander, Ranking Member Murray and honorable Members of
    the Committee, thank you for the opportunity to speak here today about
    the impact of the opioid epidemic on our nation's families and how the
    proposed Opioid Crisis Response Act of 2018 will further support and
    strengthen states' response to the problem.

        My name is Jennifer Donahue and I am an attorney with the Office of
    the Child Advocate for the State of Delaware. In my role, I review and
    monitor cases involving serious physical injury and death of a child,
    sexual abuse of a child, and infants with prenatal substance exposure.
    My office facilitates a multidisciplinary team response with our child
    welfare partners in these cases to ensure child safety and that
    appropriate services are delivered to the family. My testimony today
    will focus on the following three sections of the proposed Opioid
    Crisis Response Act of 2018 as it relates to infants with prenatal
    substance exposure and their families:

               1. Providing further grant opportunities and technical
            assistance support to states for the implementation of Plans of
            Safe Care for infants with prenatal substance exposure and
            their families;

               2. Providing further funding and support to states to
            strengthen their healthcare workforce to increase access to
            substance use disorder treatment, including medication assisted
            treatment (MAT), and access to mental health services in
            schools; and,

               3. Providing grants to states to improve data collection.

        My office extends its gratitude to this Committee and Congress for
    the passing of the 21st Century Cures Act and the Comprehensive
    Addiction and Recovery Act. These important pieces of legislation have
    helped states begin to address the damage that the opioid epidemic has
    caused to children and families in our Nation. Plans of Safe Care for
    infants with prenatal substance exposure and their families should not
    only ensure the safety of the infant, but also provide necessary
    treatment services to the family for long term success. Delaware has
    already embarked on developing draft Plans and piloting them in several
    area hospitals; however, additional funding and support from our
    Federal counterparts is critical for states' ultimate success. The
    Opioid Crisis Response Act of 2018 could be a means to that end.
                        SCOPE OF THE PROBLEM IN DELAWARE
        The opioid epidemic has overwhelmed our entire nation and Delaware
    has not been spared. The problem is deep in our State and the
    consequences are tragic. The prevalence of pregnant women struggling
    with substance use disorders has increased substantially and access to
    treatment, particularly medication assisted treatment, is often
    difficult. Consequently, the number of notifications to Delaware's
    child welfare agency (termed ``DFS'') involving infants with prenatal
    substance exposure has also increased. In 2015, there were 294
    notifications to the child welfare agency. That number jumped to
    approximately 450 notifications in 2017. \1\ The data further shows
    that for infants who were prenatally exposed to 2 substances, opioids
    were involved in 63 percent of those cases. Furthermore, for infants
    who were prenatally exposed to 3 or more substances, opioid exposure
    was present in 78 percent of those cases. The approximate number of
    infants who were treated for Neonatal Abstinence Syndrome (NAS) in
    Delaware in 2017 was 413 and approximately 191 of those infants
    required pharmacological interventions. \2\
    ---------------------------------------------------------------------------
        \1\  Investigation Coordinator SEI Data base.
        \2\  Delaware Perinatal Cooperative in partnership with the March
    of Dimes.

        The correlation between infants with prenatal substance exposure
    and the risk of future abuse or neglect cannot be ignored, particularly
    when parents have not been successful in engaging in substance use
    disorder treatment. During 2015 through 2017, 14 infants with prenatal
    substance exposure sustained serious physical injuries and 9 died after
    being discharged home to their parent(s). Aiden was one of those
    infants. He was born in 2015 at 34 weeks gestation and was prenatally
    exposed to opiates. Aiden spent 17 days in the hospital after his birth
    receiving morphine to assist with his withdrawal symptoms. He was
    subsequently released to his parents, both of whom were addicted to
    heroin. During the 9 weeks Aiden was in the care of his parents, he
    sustained severe traumatic injuries to both his brain and his body.
    Aiden was hospitalized for four months and received extensive medical
    care, including life support measures. His child welfare treatment
    worker, Jennifer Perry, who is here with me today, spent countless
    hours by his side in the hospital to provide comfort and support. Aiden
    succumbed to his injuries in September 2015. His parents pled guilty to
    murder by abuse and neglect and are currently incarcerated. Aiden's
    passing devastated our community but it also compelled us to look
    deeply and objectively into our state's policies and procedures that
    ultimately failed him.
                             ADDRESSING THE PROBLEM
        The Delaware Child Abuse and Neglect Panel, known as CAN Panel,
    reviews all child deaths and near deaths due to abuse or neglect. The
    review of cases between the years 2010 and 2014 resulted in
    approximately 17 findings of system weaknesses or policy failures
    involving infants with prenatal substance exposure. \3\ In May, 2015,
    the Substance Exposed Infant Committee (SEI Committee) was formed to
    address the identified areas of critical concern. The SEI Committee is
    co-chaired by myself and Dr. Allan Delong who is a pediatric child
    abuse expert at A.I. Dupont Hospital for Children. Our
    multidisciplinary team includes professionals from various domains
    including child welfare agencies, substance use disorder treatment
    providers, public health, medical care, mental health providers, home
    visiting nursing services, developmental disability agencies education
    and many more. In an effort to further strengthen our response to these
    infants and their families, Delaware filed an application in August
    2016 for In-Depth Technical Assistance (IDTA) through the National
    Center on Substance Abuse and Child Welfare (NCSACW). During the past
    two years, IDTA change leaders have worked with our team on significant
    policy and practice changes. For example, the IDTA change leaders
    assisted our State with drafting a Plan of Safe Care and Family
    Assessment template (attached as Exhibit 1) which is now being utilized
    through our Plan of Safe Care Hospital Pilot Program. The Pilot Program
    was launched in 2 of our 6 birthing hospitals in October 2017 and has
    now expanded to 4 hospitals. There are currently 4 identified child
    welfare agency workers who are assigned to each of the 4 hospitals to
    handle the preparation, implementation and monitoring of the Plans of
    Safe Care. During the past 6 months, our Pilot Program teams have
    identified issues and concerns that need further assistance and support
    from our Federal Government. One thing is certain--no single agency has
    the resources or expertise to address the full spectrum of needs of
    infants with prenatal substance exposure and their families.
    ---------------------------------------------------------------------------
        \3\  Delaware Child Abuse and Neglect Panel Data 2015
    ---------------------------------------------------------------------------
                       OPIOID CRISIS RESPONSE ACT OF 2018
        1. Grant Opportunities for the Implementation of Plans of Safe Care

        Pending Delaware House Bill 140, known as Aiden's Law (attached as
    Exhibit 2) reinforces the requirements under CAPTA and CARA that
    healthcare providers notify DFS of infants born with and affected by
    substance abuse, withdrawal symptoms or FASD. Our non-punitive, public
    health oriented bill sets out the parameters of what we believe should
    be included in Plans of Safe Care. However, states need more guidance
    and financial support than CARA can provide. We are hopeful that the
    Opioid Crisis Response Bill will provide additional grant moneys to
    help us not only implement Plans of Safe Care but to also provide us
    guidance on what we believe are the most important aspects of it--
    communication between system partners who are involved with providing
    services under the Plan of Safe Care and the ongoing monitoring of the
    family to ensure both the safety of the infant and delivery of
    services, particularly substance use treatment. Parents who are
    struggling with an opioid addiction and the stress of parenthood often
    do not find their way to recovery quickly. If families and infants are
    to be supported through this time, the ``monitoring'' requirements for
    the Plans of Safe Care are likely going to be much longer than a
    typical child welfare investigation. As such, child welfare workers (or
    some other child welfare entity) who are already struggling with
    caseloads that are beyond the statutory limit, will have additional
    cases to monitor and for longer periods of time. The child protective
    services workforce is already woefully underfunded and cannot assume
    this additional responsibility without concurrent funding. The hospital
    Pilot Program teams have identified practical issues for consideration
    as well, such as what is the appropriate duration of monitoring of the
    Plans and how can we create an electronic version of a Plan of Safe
    Care that can be easily and confidentially shared with the plan
    participants.

        2. Access to Substance Use Disorder Treatment, MAT and Mental
    Health Services in Schools

        Federal resources need to be funneled toward prevention and
    awareness programs. Primary care physicians and obstetricians/
    gynecologists must routinely screen pregnant women for substance use
    disorders and link them to appropriate treatment prior to the birth
    event. Appropriate treatment should include access to medication
    assisted treatment and trauma-informed mental health services. Last
    year, our. Division of Public Health issued educational materials to
    medical providers on how to screen pregnant patients for substance use
    disorders and alcohol abuse, a fact sheet on the negative effects of
    different drugs during pregnancy, and about www.helpisherede.com, a
    website that provides information about where and how to seek substance
    use disorder treatment in Delaware. (See Exhibit 3) \4\. Approximately
    34 percent of Delaware mothers who gave birth to an infant with
    prenatal substance exposure in 2017 also had a mental health condition
    or diagnosis. In addition, approximately 40 percent of mothers had a
    history of trauma or DFS involvement as a child. \5\ Strengthening
    states' healthcare workforce, specifically substance use disorder
    treatment providers and trauma-informed mental health services in
    schools, through additional funding opportunities under the Opioid
    Crisis Response Act, will likely reduce the number of infants born with
    substance exposure. Ideally, women of childbearing age will be able to
    access necessary treatment for their opioid addiction and seek
    recovery. Mental health services in schools will address the trauma
    that our youth have experienced and break the cycle of
    multigenerational trauma that may often lead to mental health concerns
    and substance use.
    ---------------------------------------------------------------------------
        \4\  Delaware Health and Social Services, Division of Public
    Health.
        \5\  Delaware Investigation Coordinator data base 2017

    ---------------------------------------------------------------------------
        3. Data Collection for Policy Change and Research Studies

        Collecting rich and informative data will help identify system
    weaknesses, determine the effectiveness of services delivered to
    families and support research studies. Under CARA and the Opioid Crisis
    Response Act, states are required to collect and report out on data
    involving substance exposed infants and Plans of Safe Care--information
    that has not been routinely collected in the past and for which current
    data bases may not have the capability to track. Funding will be
    necessary to update data bases so that child welfare agencies may
    comply with the reporting requirements under CARA. In 2015, Delaware
    created a specific independent Excel spreadsheet for infants with
    prenatal substance exposure and their families to gather information
    about maternal and infant characteristics and specific information
    about the type of exposure, and many other areas. Our office and the
    child welfare agency have also partnered with the child abuse experts
    at A.I. Dupont Hospital for Children to conduct a research study on
    this population. We are hopeful that this study will identify maternal
    risk factors and infant characteristics that will help us determine
    which families are in need of more in-depth treatment services.
    Certainly, a system cannot be sustained long term on an Excel
    spreadsheet and would not be viable in the vast majority of states.
    Funding and supports for comprehensive data collection and analysis of
    these infants and their families is a critical component of this bill.
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                    [summary statement of jennifer donahue]
        Infants with prenatal substance exposure and their parents
    struggling with opioid addiction have multiple and complex needs that
    require a collaborative response by a multidisciplinary team. The 21st
    Century Cures Act and the Comprehensive Addiction and Recovery Act have
    helped states begin to address the damage that the opioid epidemic has
    caused to children and families in our nation.

        Plans of Safe Care for infants with prenatal substance exposure and
    their families should not only ensure the safety of the infant, but
    also provide necessary treatment services to the family for long term
    success. Delaware has already embarked on developing draft Plans and
    piloting them in several area hospitals; however, additional funding
    and support from our federal counterparts is critical for states'
    ultimate success.

        Additional grant opportunities under the Opioid Crisis Response Act
    for states to implement and monitor Plans of Safe Care, to strengthen
    their healthcare workforce to increase access to substance use disorder
    treatment, including medication assisted treatment (MAT), and access to
    mental health services in schools, as well as support to collect rich
    and informative data, is another beneficial step forward in our fight
    against the devastating effects of the opioid epidemic on our infants
    and families.

        Thank you very much for the opportunity to speak with you today
    about infants with prenatal substance exposure and I welcome any
    questions you may have.
                                     ______

        The Chairman. Thank you, Ms. Donahue.
        Mr. Morrison, welcome.

    STATEMENT OF ROBERT I.L. MORRISON, EXECUTIVE DIRECTOR, NATIONAL
        ASSOCIATION OF STATE ALCOHOL AND DRUG ABUSE DIRECTORS,
                             WASHINGTON, DC

        Mr. Morrison. Thank you very much. Chairman Alexander,
    Ranking Member Murray, Members of the Committee, I appreciate
    this opportunity to testify. It's a privilege.
        I'm Rob Morrison. I do serve as Executive Director of the
    National Association of State Alcohol and Drug Abuse Directors,
    or NASADAD. We're nonprofit, serving state alcohol and drug
    agency directors. Our board is led by our president, Cassandra
    Price, from the great State of Georgia. Our members are
    grateful for the program funding authorized by this Committee.
    These programs are housed in HHS agencies, such as SAMHSA, CDC,
    HRSA, and NIH.
        I'd like to thank you for your work to draft and approve
    the 21st Century Cures Act, which, among other provisions,
    included the creation of a $1 billion fund known as the STR
    Grant. STR is supporting innovative and lifesaving programs
    across the country. We're also very thankful for the work to
    draft and pass the Comprehensive Addiction Recovery Act.
        It's a privilege to offer observations regarding the
    discussion draft titled the Opioid Crisis Response Act of 2018.
    In general, we offer the following principles.
        First, we recommend ensuring that provisions work through
    and coordinate with a state alcohol and drug agency to promote
    efficiency, effectiveness, and to avoid creating parallel or
    duplicative systems of care.
        Second, ensure consistent, predictable, and sustained
    Federal resources to avoid creating a fiscal cliff by extending
    the duration of Federal grants beyond the typical one or 2-year
    funding cycle and allow states more time to expend dollars
    provided by the annual appropriations process.
        Third, continue to work to address the opioid crisis, but
    also elevate efforts to address all substance use disorders.
        Fourth, maintain investments in SAMHSA, as a lead agency
    within HHS focused on substance use disorder service delivery.
        I'd like to focus on the benefits of working through the
    State Alcohol and Drug Agency. Our members draft and implement
    coordinated statewide plans for program service delivery. This
    plan is comprehensive, utilizes cross-agency collaboration, and
    spans a continuum of prevention, treatment, and recovery.
        From child welfare to transportation, employment to
    criminal justice, our members work with a diverse set of state
    level agencies and stakeholders who are NGO's to coordinate an
    interconnected system of care.
        State alcohol and drug agencies ensure oversight of
    providers through tools such as performance management and
    reporting, contract monitoring, corrective action planning,
    onsite technical reviews, and technical assistance. Our members
    also work to promote quality through state established
    standards of care, promoting evidence-based practices,
    collecting and analyzing data, and using these tools to drive
    management decisions.
        The foundation of this work is SAMHSA's Substance Abuse,
    Prevention, and Treatment Block Grant. This program is designed
    to be flexible to meet the unique needs of states and addresses
    all substance use disorders for the Nation's poor and most
    vulnerable. Twenty percent of the SAPT Block Grant is dedicated
    to much needed substance abuse prevention programming. In fact,
    of the budgets our members manage for prevention, on average,
    70 percent comes from the SAPT Block Grant.
        I look forward to a dialog on the discussion draft's
    current provisions, ways to improve the text, and ideas and
    enhancements. One idea for the Committee's consideration is
    adding a section to authorize a new grant program within
    SAMHSA's Center for Substance Abuse Prevention. This initiative
    would help enhance collaboration between state alcohol and drug
    agencies and state education agencies to enhance their ability
    to partner on statewide planning and implementation of
    evidence-based, school-based prevention activities.
        I'll end by noting I recently visited programs funded by
    STR in South Carolina and North Carolina to see how these
    dollars were making a difference in the battle to address the
    opioid crisis. This trip included a visit to the Charleston
    Center, which is in Charleston, South Carolina. This complex,
    which is supported in part by our South Carolina member, Sara
    Goldsby, and her department, offers all three FDA medications
    for opioid use disorders, residential services for pregnant and
    postpartum women, therapeutic services for kids, outpatient
    services, recovery support, and much more. The Program
    Director, Dr. Chandra Brown, concluded the tour by simply
    saying, ``Thank God for STR.''
        Now, in addition to the Almighty, I thought I would take a
    minute to thank you, this Committee, and reiterate that your
    efforts are truly making a difference. We've lost too many
    lives. We have a lot more to do. But I believe our collective
    work is making a difference, and we can and will tackle this
    problem.
        Thank you.
        [The prepared statement of Mr. Morrison follows:]
                     prepared statement of robert morrison
        Chairman Alexander, Ranking Member Murray, and Members of the
    Committee, my name is Rob Morrison and I serve as Executive Director of
    the National Association of State Alcohol and Drug Abuse Directors
    (NASADAD). Thank you for the opportunity to testify before the
    Committee today to discuss The Opioid Crisis Response Act.

        About NASADAD: NASADAD is a private, not-for-profit educational,
    scientific and informational organization originally incorporated in
    1971 and located in Washington, DC. NASADAD's mission is to promote
    effective and efficient state substance use disorder prevention,
    treatment and recovery systems. NASADAD seeks to:

              Serve as the national voice of state alcohol and drug
            agencies,

              Foster partnerships among states, Federal agencies
            and other key national organizations,

              Develop and disseminate knowledge of innovative
            substance use disorder programs policies and practices,

              Promote key competencies of effective state alcohol
            and drug agencies, and

              Promote increased public understanding of substance
            use disorder prevention, treatment and recovery processes and
            services.

        In the process, NASADAD works closely with the National Governors
    Association (NGA). Governors across the country have been providing
    critical leadership regarding the opioid crisis. We appreciate NGA's
    recommendations related to the opioid issue that was released in
    January 2018 (https://www.nga.org/files/live/sites/NGA/files/pdf/2018/
    OGR/NGA percent20Recommendations percent20for percent2 0Federal
    percent20Action percent202018.pdf).

        Further, we are pleased to coordinate with other state-based
    groups, such as the Association of state and Territorial Health
    Officials (ASTHO), the National Alliance for State and Territorial AIDS
    Directors (NASTAD), the Safe States Alliance, the National Association
    of State Mental Health Program Directors (NASMHPD) and many others.

        Critical role of the state alcohol and drug agency: Each state's
    alcohol and drug agency plays a critical role in overseeing and
    implementing the publicly funded prevention, treatment and recovery
    service system.

        Planning, oversight and accountability: To begin, all state alcohol
    and drug agency directors work to craft and implement annual plans for
    statewide program and service delivery. In the process, our members
    capture data and information describing top challenges, populations
    served and the types of services provided. State alcohol and drug
    agencies use such tools as performance management and reporting,
    contract monitoring, corrective action planning, onsite technical
    reviews and technical assistance.

        Promoting quality: State agencies work to ensure quality services
    through state established standards of care. NASADAD members are
    dedicated to continuous quality improvement and participate in
    initiatives to promote innovative practices and programs. For example,
    state directors use data described above to help advance these
    practices and drive management decisions.

        Management of the Substance Abuse Prevention and Treatment (SAPT)
    Block Grant: An important role played by NASADAD members is the
    management and oversight of the SAPT Block Grant--a $1.8 billion
    Federal formula grant that is allotted to NASADAD members. By statute,
    20 percent of the SAPT Block Grant must be dedicated to critical
    primary substance abuse prevention programming. We have attached a two-
    page issue brief for the Committee's convenience that provides
    additional details regarding the SAPT Block Grant.

        Promoting coordination across state government: NASADAD members
    promote cross-agency collaboration given the impact of alcohol and
    other drug use has on other sectors. For example, state directors
    engage with criminal justice entities on issues like offender reentry,
    drug court programs and diversion initiatives. State alcohol and drug
    agencies also coordinate with sectors related to child welfare,
    transportation, employment, education and others.

        Unique relationship with the provider community: State alcohol and
    drug agencies have a very unique and important relationship with the
    provider community. State agencies observe this connection is critical
    given the increased pressures on those delivering prevention, treatment
    and recovery services. NASADAD members assist providers by offering
    training, continuing education, oversight and other support.

        Reporting data: The management of the SAPT Block Grant requires
    states to collect and report data describing the services and programs
    funded by this important funding stream. This data includes information
    on the number of people served by the SAPT Block Grant. In addition,
    states collect and report data to help demonstrate the positive impact
    services have on: reducing the use of alcohol and other drugs; the
    impact of services on employment status; the impact of services on
    criminal justice involvement and more.

        States appreciate action taken by Congress to address the opioid
    crisis: NASADAD is appreciative of this Committee, along with Congress
    and the Administration in general, for work to address the opioid
    crisis.

        We applaud passage of the 21st Century Cures Act which included the
    creation of a $1 billion fund for fiscal year 2017 and fiscal year 2018
    to help state alcohol and drug agencies enhance treatment, prevention
    and recovery services. This funding, known as the State Targeted
    Response to the Opioid Crisis (STR) Grants, is supporting innovative
    and lifesaving programs across the country. We are also thankful for
    the additional resources provided to the Substance Abuse and Mental
    Health Services Administration (SAMHSA) in the fiscal year 2018 omnibus
    package that included an additional $1 billion to further enhance
    prevention, treatment and recovery efforts.

        STR dollars at work: We include below of some specific state
    examples of STR grant dollars at work:

        Tennessee: The funds prioritize addressing neonatal abstinence
    syndrome (NAS) given a tenfold increase in NAS in Tennessee over the
    past 10 years. STR funds will help expand access to services for
    pregnant women. The state is also moving forward to expand access to
    services through outpatient tele-health initiatives--an important
    initiative given the difficulties in reaching rural parts of the state.
    The funding is allowing the state to conduct Train-the-Trainer events
    on the Stanford Chronic Pain Self-Management Program (CPSMP)--an
    evidence-based approach to managing chronic health conditions that
    helps avoid readmissions. STR funds are also supporting a statewide
    media campaign and allowing the state to share resources and
    information to educate the public about the opioid crisis. The funds
    are supporting opioid overdose trainings and helping purchase and
    distribute overdose safety kits and naloxone to selected areas of the
    state.

        Washington State: In Washington State, STR funds are expanding
    statewide access to Medication Assisted Treatment (MAT) and reducing
    unmet need by developing and implementing 6 Hub and Spoke model
    initiatives. Hubs are regional centers serving a defined geographical
    area. Spokes (there are five per hub) are facilities providing opioid
    use disorder treatment, primary health care, and wrap around services.
    STR grant funds are also supporting a collaboration with the Washington
    State Department of Corrections (DOC) to develop and operate programs.
    For example, one program is identifying incarcerated individuals with
    opioid use disorders, expected to be released, and connecting these
    individuals with MAT services in the county of their release and
    expedite their enrollment in an Medicaid health plan. STR grant funding
    is allowing the state to develop community prevention initiatives in 5
    high need communities to support local strategic planning and
    decisionmaking to focus on addressing local needs by implementing
    evidence-based strategies and programs. STR is supporting the state to
    design, test and disseminate various public education messages that
    promote public education with tribes to meet their community needs.

        Alaska: In Alaska, the STR grant has been distributed to launch
    office-based opioid treatment (OBOT) services to expand treatment to
    persons with an opioid use disorder, including those recently
    incarcerated, veterans, and young adults. For example, the Cook Inlet
    Council on Alcohol and Drug Abuse (CICADA) in Kenai received STR grant
    dollars to help provide comprehensive substance use disorder services,
    including Medication Assisted Treatment (MAT) for those struggling with
    an opioid use disorder. The Council partners with the Peninsula
    Community Health Services, a local federally Qualified Health Center
    (FQHC), to provide access to MAT and, in collaboration with community
    organizations, provide access to an array of comprehensive services.
    The STR grant provides technical assistance for physicians and care
    managers to address questions and concerns related to OBOT services.
    The STR grant has also facilitated reducing the amount of unused
    prescription opioids in Alaskan communities through the ongoing
    statewide distribution of medication deactivation disposal bags in
    communities. To date, 28,000 of these bags have been distributed,
    successfully allowing Alaskans to destroy over 1 million opioid
    tablets.

        Connecticut: In Connecticut, STR grant funds allowed the state to
    expand the number of hospitals, from 4 to 8, with on-call recovery
    coaches in their Emergency Departments. Through STR funding, the state
    alcohol and drug agency worked with the Department of Corrections (DOC)
    to implement MAT induction at the Osborne DOC pre-release center and to
    expand DOC's ``Living Free'' re-entry initiative that involves
    extensive in-reach, pre-release, followed by treatment during post-
    release. The STR funds are helping to expand the number of outpatient
    clinics that have MAT available with a subset of these clinics
    receiving support to provide employment services, peer coaching and
    case management. STR grant funds support important prevention efforts
    by providing 75 mini-grants to community coalitions with preference
    given to local prevention councils. STR also supports a peer prevention
    program in which youth facilitators coach their peers on skills to make
    healthy choices.

        Georgia: STR funds in Georgia are supporting increased prevention,
    treatment and recovery services across the state's 5 Service Regions.
    The STR grant is supporting a school transition pilot program for
    opioid/prescription drug misuse and abuse prevention. STR funds will
    help implement recovery specialist programs in 2 hospital Emergency
    Departments. In addition, the state is directing STR funding to ensure
    fidelity to the Georgia Association of Recovery Residences recovery
    housing standards. Further, the funds are enabling a pilot program by
    the Department of Community Supervision to use vivitrol before release.
    The state is also utilizing STR dollars to support naloxone education
    for first responders, law enforcement and public safety.

        Louisiana: The STR grant is Louisiana helped the state alcohol and
    drug agency enhance collaboration with providers across the state
    regarding opioid use disorders. For example, STR grant is supporting
    the existing Strategic Prevention Framework (SPF) infrastructure as a
    basis to prevention prescription drug misuse and abuse through
    statewide awareness and education campaign with special activities
    planned within the state's ten Local Governing Entities (LGE) and
    coordination with the state's 10 opioid treatment programs (OTPs). The
    STR grant supported collaboration between the state alcohol and drug
    agency and the State Department of Corrections (DOC) to allow treatment
    services for opioid use disorders for offenders participating in
    reentry programs at 2 designated facilities. The STR grant is also
    helping build capacity for the 10 LGE regions to increase access to
    recovery support specialists.

        Missouri: STR funds in Missouri have been used to train 4,000
    students on prescription opioid misuse prevention. These funds have
    helped over 1,600 uninsured individuals with opioid use disorders to
    receive evidence-based treatment services. Over 3,600 naloxone kits
    have been distributed to individuals at risk of experiencing or
    witnessing an overdose. Additionally, STR funds have afforded 8,000
    providers and community members the opportunity to receive training on
    effective opioid use disorder prevention, treatment, and recovery
    strategies.

        New Hampshire: In New Hampshire, STR grant funding is supporting
    the expansion of MAT in integrated care settings (substance use
    services, obstetrics, pediatric, and primary care) for pregnant and
    postpartum women. This includes parenting education and supports to
    hospitals dealing with neonatal abstinence syndrome (NAS), including
    funding for childcare to enable women to be able to participate in the
    programming. Additionally, STR funds support peer recovery support
    services for pregnant and parenting women. Grant funds are also being
    used for Regional Access Points across the state, which are in-person
    and telephone links to rapid evaluations and referrals to services,
    case management, continuous recovery monitoring.

        North Carolina: The state has placed an emphasis on increasing the
    number of individuals gaining access to MAT and supportive services for
    opioid use disorders. The STR grant allocations are made largely to the
    Local Management Entities/Managed Care Organizations (LMEs/MCOs) and
    contracts then move forward to accomplish programmatic goals. The STR
    grant in North Carolina is helping purchase 6,600 naloxone kits
    statewide. The state is investing STR funds in recovery support
    services that include culturally and linguistically appropriate
    services that assist individuals and families working toward recovery.
    The state is including such services as peer coaching and mentoring,
    services to aid in accessing sober housing, life coaching, and more as
    identified through individual comprehensive clinical assessments and
    person-centered treatment and recovery plans. In addition, North
    Carolina is investing STR funds to expand effective prevention
    strategies for non-medical use of prescription drugs in high need
    counties. This includes support for local community coalitions to
    address prescription drug misuse.

        South Carolina: The STR grant in South Carolina is supporting the
    expansion of peer support specialists to facilitate the transition from
    prisons and jails back to the community in Anderson and Spartanburg
    counties. In addition, peer support specialists shall work with
    hospital Emergency Departments to help connect overdose survivors to
    services post release. STR funds are supporting the development of
    community recovery centers in York County and Horry County. The grant
    is also supporting the statewide multi-media campaign that will include
    Public Service Announcements (PSAs) in Columbia, Charleston, Myrtle
    Beach/Florence and Greenville. South Carolina is also directing STR
    funds to help expand clinically appropriate, evidence-based practices
    for adolescents with opioid use disorders by supporting the Adolescent
    Community Reinforcement Approach/Assertive Continuing Care model in
    Horry and Pickens Counties.

        Virginia: In Virginia, STR grant funding is supporting 25
    community-based treatment providers to help serve individuals with MAT
    and other clinical supports to address their opioid use disorder. The
    grant supported the purchase of 3,664 units of Narcan (1,600 for local
    departments of health to distribute and 2.064 for state Police to
    carry). These funds supported the development of a video-training
    curriculum about opioid use disorders for child protective service
    workers and early intervention home visitors. STR has supported a
    Recovery Warm Line in each of Virginia's five health planning regions.
    In addition, STR grant funds help support community coalition building
    in at least 25 communities.

        More on the importance of Cures and CARA: The 21st Century Cures
    Act also included key provisions reauthorizing SAMHSA. This included
    the reauthorization of programs within SAMHSA's Center for Substance
    Abuse Treatment (CSAT), Center for Substance Abuse Prevention (CSAP),
    Center for Behavioral Health Statistics and Quality (CBHSQ), and the
    creation of the National Mental Health and Substance Use Policy
    Laboratory. NASADAD supports actions to ensure a strong SAMHSA and
    appreciates the leadership of Dr. Elinore McCance-Katz, who serves as
    Assistant Secretary for Mental Health and Substance Use--a position
    created by the 21st Century Cures Act. NASADAD is grateful for the
    Committee's work to pass the Comprehensive Addiction and Recovery Act
    (CARA), which authorized programs seeking to promote a coordinated and
    multi-sector approach to address the opioid crisis. CARA created
    several important initiatives, including:

        Improving Treatment for Pregnant and Postpartum Women (Section
    501): Reauthorized the Residential Treatment for Pregnant and
    Postpartum Women program to help support family centered treatment
    services--where women and their children can receive the help they need
    together in a residential setting. CARA also created a pilot program to
    afford state alcohol and drug agencies flexibility in providing new and
    innovative family centered substance use disorder services in non-
    residential settings. Earlier this year, Virginia, Massachusetts and
    New York were the first three states to receive resources for this
    pilot.

        State Demonstration Grants for a Comprehensive Opioid Response
    Grant (Section 601): This initiative is designed to help promote
    coordinated planning on issues related to substance use disorders for
    those involved with the criminal justice system. For state applications
    for this grant, there is an emphasis on coordination between an
    applicant's state alcohol and drug agency and its corresponding state
    administering authority for criminal justice.

        Community Coalition Enhancement Grants (Section 103): This section
    authorizes the Office of National Drug Control Policy (ONDCP), in
    coordination with SAMHSA, to make grants to community anti-drug
    coalitions to implement community-wide strategies to address their
    local opioid and methamphetamine problem.

        Building Communities of Recovery (Section 302): Authorizes SAMHSA
    to award grants to recovery community organizations (RCOs) to develop,
    expand and enhance recovery services, RCO's across the country are
    doing an excellent job of helping individuals with the assistance they
    need to once again contribute to their families, employers and
    communities.

        States are now working diligently to implement these and many other
    important provisions authorized in CARA and Cures.
                     NASADAD's overarching recommendations:
              Ensure provisions work through state alcohol and drug
            agencies to promote coordination and avoid creating parallel,
            duplicative, or bifurcated systems of care: As noted earlier,
            state alcohol and drug agencies play a critical role in
            overseeing and implementing a coordinated prevention, treatment
            and recovery service system. These agencies develop annual
            statewide plans to ensure an efficient and comprehensive
            system. Further, state alcohol and drug agencies promote
            effective systems through oversight and accountability.

               A core recommendation for the Committee's consideration is
            to ensure Federal programs and policies designed to address
            substance use prevention, treatment and recovery flow through
            the state alcohol and drug agency. This approach allows Federal
            initiatives to enhance and improve state systems and promotes
            an effective and efficient approach to service delivery.
            Federal policies and programs that do no link with the state
            agency run the risk of creating parallel or even duplicative
            publicly funded systems and approaches.

              Ensure consistent, predictable and sustained
            resources to avoid a financial cliff: As indicated earlier,
            NASADAD appreciates the resources provided by Congress to
            support prevention, treatment and recovery services. state
            alcohol and drug agencies appreciate the $1 billion in STR
            grants initially authorized in the 21st Century Cures Act.
            NASADAD applauds Congress for its work in raising the caps and
            passing the Bipartisan Budget Act of 2018 which paved the way
            to clear a final fiscal year 2018 omnibus appropriations bill.
            This bill included the second installment of STR grants and
            added $1 billion for states to continue this critical work.

               This predictable and sustained provision of resources is key
            to allow states and providers to plan and rely on future year
            commitments. It can be difficult if not impossible to
            successfully plan and operate programs if providers are not
            confident resources will be available beyond a 1-year
            commitment. NASADAD strongly supports NGA's call to extend the
            duration of Federal grants beyond the typical one-or 2-year
            funding cycle.

               Further, the financial burden associated with substance use
            disorders is staggering. The National Institute on Drug Abuse
            (NIDA) estimates that illegal drugs, alcohol, and tobacco cost
            society roughly $700 billion every year or $193 billion for
            illegal drugs, $224 billion for alcohol, and $295 billion for
            tobacco. According to SAMHSA's 2016 report, National
            Expenditures for Mental Health Services and Substance Abuse
            Treatment, 1986-2014, expenditures for substance use disorder
            services represented only 1.2 percent of all health
            expenditures in 2014.

               As we look at the SAPT Block Grant, this critical program
            has not kept up with health care inflation. In particular, over
            the past 10 years, the SAPT Block Grant has experienced a 29
            percent decrease in the real value of funding. In order to
            restore the SAPT Block Grant to the purchasing power the
            program had in 2006, Congress would need to allocate an
            additional $542 million to the SAPT Block Grant in fiscal year
            2019.

               Yet the National Institute on Drug Abuse (NIDA) notes that
            for every dollar spent on substance use disorder treatment
            programs, there is an estimated $4 to $7 reduction in the cost
            of drug related crimes. With outpatient programs, total savings
            can exceed costs by 12 to 1. Substance abuse prevention is also
            a cost-effective way to reduce the financial burden of
            substance abuse and substance use disorders. According to the
            Surgeon General's 2016 Report on Alcohol, Drugs, and Health,
            every $1 spent on effective, school-based prevention programs
            can save an estimated $18 in costs related to problems later in
            life.

              Continue to work to address the opioid crisis but
            also elevate efforts to address all substance use disorders,
            including those linked to alcohol and other substances: The
            opioid crisis is one of the worst public health tragedies in
            our Nation's history. The sheer volume of death linked to this
            epidemic is difficult to grasp. We also know this country faces
            distinct challenges related to all substances--whether it's
            prescription drug misuse, heroin, alcohol, marijuana,
            methamphetamine, cocaine or others. According to SAMHSA's
            National Survey on Drug Use and Health (NSDUH), alcohol remains
            the No. 1 problem in the country with 15 million Americans
            battling an alcohol use disorder. As we look at those receiving
            treatment, 36 percent of all admissions to treatment had a
            primary alcohol use disorder; 30 percent had a primary heroin
            or other opiate problem; 15 percent had primary marijuana use
            disorder. State directors in certain states are also observing
            increases in problems related to methamphetamine and cocaine.
            As a result, NASADAD promotes policies that can be flexible yet
            also address the specific needs associated with the current
            opioid crisis. The flexibility included in the SAPT Block Grant
            also affords states the opportunity to target resources to
            address all substances.

              Maintain a strong SAMHSA: We support maintaining
            investments in SAMHSA as the lead agency within HHS focused on
            substance use disorders in general, and opioid use disorders in
            particular. The nation benefits from a strong SAMHSA given the
            agency's longstanding leadership in the field and the
            stewardship of Assistant Secretary McCance-Katz. NASADAD
            appreciates the role Assistant Secretary McCance-Katz plays in
            coordinating work across HHS to promote a coordinate Federal
            response to the opioid crisis.

               NASADAD also appreciates SAMHSA's focus on a healthy state-
            Federal partnership as the cornerstone of sound public policy.
            This theme is demonstrated through several important state-
            based programs support by SAMHSA in addition to the SAPT Block
            Grant. One example is the Strategic Prevention Framework (SPF)
            Partnerships for Success (PFS) Grants. These 5-year grants,
            administered by SAMHSA/CSAP, help states strengthen prevention
            capacity and infrastructure at the state level while addressing
            the state's top prevention priorities. The grants use a five-
            step model (assessment, capacity, planning, implementation,
            evaluation); promote the principles of cultural competency and
            sustainability; and enhance the link between state alcohol and
            drug agencies and community anti-drug coalitions to promote
            local solutions.
       NASADAD's observations on selected provisions: NASADAD offers the
      following observations on the Committee's discussion draft based in
                   part on those principles described above.
              Reauthorization and Improvement of State Targeted
            Response Grants (Section 101). NASADAD applauds the Committee
            for recognizing the need for predictable and sustained funding
            to address the opioid crisis by considering the reauthorization
            and improvement of the STR grants. As discussions on the
            provision move forward, we hope these resources would continue
            to align with the plan and work of state alcohol and drug
            agencies to continue the momentum gained to date from the STR
            grants. Further, NASADAD would be eager to engage in
            discussions regarding ways to utilize the SAPT Block Grant as
            an effective and efficient way to funnel resources through its
            well-established system.

              Comprehensive Opioid Recovery Centers (Section 401):
            NASADAD members certainly support the goal of enhancing access
            to holistic care and the array of services that help people
            enter recovery. This includes our strong support for access to
            Medication Assisted Treatment (MAT). NASADAD will continue to
            review the details of this proposal and work with the
            Committee. As noted above, consistent with the Association's
            principles, we would recommend Federal proposals flow through
            the state alcohol and drug agency to ensure coordination and
            maximize effectiveness and efficiency.

              National Recovery Housing Best Practices (Section
            403): NASADAD applauds the provision that would require the
            Secretary of Health and Human Services (HHS) to identify or
            facilitate the development of best practices for operating
            recovery housing. We would hope that state alcohol and drug
            agencies would be specifically referenced as a stakeholder to
            help with the development of these models. NASADAD has been
            engaging in a dialog about this important issue with our
            members and other important groups such as the National
            Association of Recovery Residences (NARR). NARR's mission is to
            support persons in recovery from substance use disorders by
            improving their access to quality recovery residences. In 2011,
            NARR released a national standard for recovery residences. This
            standard defines the spectrum of recovery oriented housing and
            services and distinguishes four different types, which are
            known as levels or levels of support. This work was then
            updated in 2015. We hope the Committee consider NARR as a
            valuable partner in this effort.

              Addressing Economic and Workforce Impacts of the
            Opioid Crisis (Section 404): NASADAD is still reviewing the
            details and assessing the implications associated with this
            section. There is certainly no doubt that substance use
            disorders impact job performance or cause people to be
            underemployed or unemployed. We are also aware of jobs that
            remain unfilled because certain skilled workers are unable to
            pass a drug test. As the Association dialogs with the members
            and others about this provision, NASADAD will continue to
            support the creation of Federal programs that flow through or
            collaborate with the state alcohol and drug agency. This
            ensures the enhancement of the state system as opposed to the
            creation of a duplicative or parallel set of services.

              Plans of Safe Care (Section 406): We support the
            provision that proposes to amend the Child Abuse Prevention and
            Treatment Act (CAPTA). Specifically, this provision would
            authorize grants to help state child welfare agencies, state
            alcohol and drug agencies and others facilitate collaboration
            in developing, updating and implementing plans of safe care.
            The Office of the Assistant Secretary for Planning and
            Evaluation (ASPE) Research Brief, The Relationship between
            Substance Use Indicators and Child Welfare Caseloads, found
            that nationally ``rates of drug overdose deaths and drug-
            related hospitalizations have a positive relationship with
            child welfare caseload rates. After accounting to county
            socioeconomic and demographic characteristics, counties with
            higher overdose death and drug hospitalization rates have
            higher caseload rates.'' As a result, we look forward to
            working with you on this important issue.

              Loan Repayment for Substance Use Disorder Treatment
            Providers (Section 410): We applaud the discussion draft's
            inclusion of a provision to help with our Nation's substance
            use disorder workforce. Specifically, we support the provision
            that would authorize funding for a loan repayment program for
            substance use disorder treatment providers. There is no doubt
            that more must be done to bolster our Nation's substance use
            disorder workforce. This is particularly true in our rural and
            frontier states. As the Committee deliberates on the discussion
            draft, we would like to offer our assistance in promoting
            support for our substance abuse prevention workforce as well.
            State alcohol and drug agencies seethe value in utilizing
            Certified Prevention Specialists (CPS). These certified
            professionals are trained in industry standards and evidence-
            based practices and represent an important component of the
            field.

              Surveillance and Education Regarding Infections
            Associated with Injection Drug Use and Other Risk Factors
            (Section 510): We support the provision seeking to improve data
            and therefore our knowledge about infections associated with
            injection drug use and other risk factors. According to the
            Centers for Disease Control and Prevention (CDC), 30 states are
            experiencing, or at risk for, significant increases in viral
            hepatitis or an HIV outbreak due to injection drug use. In
            addition, between 2004 and 2014, the CDC found that admissions
            to substance use treatment programs for those who inject
            opioids increased by 93 percent while acute hepatitis rose in
            parallel by 133 percent. As mentioned earlier, we appreciate
            our partnership with NASTAD at the national level and engage in
            work to promote similar collaboration between our members at
            the state level.

        NASADAD's considerations for additional provisions: NASADAD
    appreciates the tremendous amount of work that went into developing the
    discussion draft. We also appreciate the Committee's request for
    additional ideas to help strengthen the draft. We offer the following
    recommendations for consideration:

              Enhancing School-based Substance Abuse Prevention
            Through Coordination Between State Alcohol and Drug Agencies
            and State Educational Agencies: Substance abuse prevention
            programs and activities are critical given the benefits of
            delaying the use of alcohol and other drugs during adolescence.
            For example, compared to youth who wait until their 20's to
            initiate alcohol use, adolescents who initiate by 15 years of
            age are five times more likely to abuse alcohol or become
            dependent (Grant & Dawson, 1997). State alcohol and drug
            agencies recognize the fact that the education system
            represents an important partner given the importance of school-
            based prevention activities. As a result, NASADAD recommends
            the authorization of a grant program within SAMHSA/CSAP to
            enhance collaboration between state alcohol and drug agencies
            and state educational agencies to enhance their capacity to
            support the implementation of effective, school-based substance
            abuse prevention activities. This would also help support a
            comprehensive planning process in addition to the
            implementation of evidence-based programs.

              Recovery coaching in the emergency department: On
            November 30, 2017, NASADAD Board Member Rebecca ``Becky'' Boss,
            State Director in Rhode Island, presented testimony during a
            hearing before this very Committee. Director Boss discussed the
            2014 launch of a pilot program developed in Rhode Island using
            recovery coaches to respond to overdose survivors while they
            were receiving treatment in hospital Emergency Departments. She
            noted that on-call coaches respond to overdose survivors and
            offer support, referrals, resources, family support and
            training on naloxone. Becky noted that the coaches helped
            engage clients with an 85 percent follow-up rate with treatment
            and/or recovery support services. We understand there are
            proposals in the House and Senate to enhance the use of this
            model. We support these initiatives and recommend that any
            final version (1) specifically references coordination with and
            connection to state alcohol and drug agencies and (2) ensures
            the program is placed within SAMHSA.

        Thank you: Thank you very much for inviting NASADAD to testify. We
    look forward to working with the Committee as the process moves
    forward.
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                     [summary statement of robert morrison]
        About NASADAD: NASADAD is a private, not-for-profit organization
    that promotes effective and efficient State substance use disorder
    (SUD) prevention, treatment and recovery systems. NASADAD seeks to:
    serve as the national voice of State alcohol and drug agencies; foster
    partnerships among States, Federal agencies and other national
    organizations; develop and disseminate knowledge of innovative SUD
    programs policies and practices; and promote key competencies of
    effective State alcohol and drug agencies.

        Critical role of the State alcohol and drug agency: Each State's
    alcohol and drug agency plays a critical role in overseeing and
    implementing the publicly funded prevention, treatment and recovery
    service system. In addition to planning and oversight, these State
    agencies: ensure quality services through State-established standards
    of care; manage the Substance Abuse Prevention and Treatment (SAPT)
    Block Grant; promote coordination across State government; maintain a
    unique relationship with providers by offering training, continuing
    education, oversight, and other support; and collect and report data
    that describes the services/ programs in the publicly funded system.

        States appreciate action taken by Congress to address the opioid
    crisis: NASADAD applauds passage of the 21st Century Cures Act and the
    resulting State Targeted Response to the Opioid Crisis (STR) Grants.
    The State alcohol and drug agencies are working diligently to use these
    STR funds to enhance evidence based prevention, treatment, and recovery
    services for individuals impacted by the opioid crisis. NASADAD is also
    grateful for the Committee's work to pass the Comprehensive Addiction
    and Recovery Act (CARA). CARA created several initiatives. States are
    working to implement the many important provisions authorized in CARA.

        NASADAD's overarching recommendations:

              Ensure provisions work through and coordinate with
            State alcohol and drug agencies to promote efficient and
            effective systems and avoid creating parallel, duplicative, or
            bifurcated systems of care.

              Ensure consistent, predictable and sustained
            resources to avoid a fiscal cliff by extending the duration of
            Federal grants beyond the typical one-or 2-year funding cycle.

              Continue to work to address the opioid crisis but
            also elevate efforts to address all SUDs.

              Maintain investments in SAMHSA as the lead agency
            within HHS focused on SUDs.
      NASADAD's observations on selected provisions of the Opioid Crisis
                                 Response Act:
        Reauthorization and Improvement of STR Grants: NASADAD applauds the
    Committee for considering the reauthorization and improvement of the
    STR grants. As discussions on the provision move forward, we hope these
    resources would continue to align with the plan and work of State
    alcohol and drug agencies. NASADAD is eager to discuss how the SAPT
    Block Grant could also be utilized to efficiently direct funds to
    support service delivery.

        National Recovery Housing Best Practices: We applaud this provision
    and hope that State alcohol and drug agencies would be specifically
    referenced as a stakeholder to help with the development of these
    models.

        Plans of Safe Care: We support the provision and look forward to
    working to address SUDs in child welfare system.

        Loan Repayment for Substance Use Disorder Treatment Providers: We
    applaud this provision that supports loan repayment for SUD treatment
    providers, and recommend support for substance abuse prevention
    workforce as well.

        Surveillance and Education Regarding Infections Associated with
    Injection Drug Use: We support this provision that seeks to improve
    data and therefore our knowledge about infections associated with
    injection drug use.
              NASADAD's recommendations for additional provisions:
        Enhancing school-based substance abuse prevention through enhanced
    agency collaboration: NASADAD recommends the authorization of a grant
    program within SAMHSA/CSAP to enhance collaboration between State
    alcohol and drug agencies and State educational agencies to enhance
    their capacity to support the implementation of effective, school-based
    substance abuse prevention activities.
                                     ______

        The Chairman. Thank you, Mr. Morrison.
        Ms. Nickel, welcome.

        STATEMENT OF JESSICA HULSEY NICKEL, PRESIDENT AND CEO,
                 ADDICTION POLICY FORUM, WASHINGTON, DC

        Ms. Nickel. Thank you, Chairman Alexander, Ranking Member
    Murray, and Members of the Committee, for your focus on this
    important issue, and I'm honored to be here with you today.
        My name is Jessica Hulsey Nickel, and I'm the President of
    the Addiction Policy Forum. I started APF to focus on a
    comprehensive response to this issue that has prevention,
    treatment, recovery, overdose reversal, law enforcement, and
    criminal justice at the table, but also has families and
    patients at the table. We have one goal: a world where fewer
    lives are lost and help exists for the millions of Americans
    that are affected by addiction.
        I'm grateful to discuss this issue and also pleased with
    the many provisions and amazing ideas found in the Opioid
    Crisis Response Act, and I'm here to be supportive as that
    legislation moves forward.
        I know firsthand what this crisis does to families. I've
    actually been in this field for 27 years, which gives away my
    age, so I try not to mention that all the time. But I lost both
    of my parents to heroin use disorder, and as a child impacted
    by this disease, for me, that meant homelessness and hunger. It
    meant foster care and, ultimately, being raised by my maternal
    grandparents.
        I lost my dad when he was 48, and he never made his way out
    of this disease and died on the streets. I lost my mom when she
    was 50 because of the long-term health consequences of
    addiction, even though she was in recovery at the time. I'm not
    alone. There are millions of families like mine that are
    suffering and isolated and looking for help and not always able
    to find it every single day.
        We lose 174 people every day to drug overdoses in this
    country. That's like a plane crash every day. Now, if there was
    actually a plane crash, we'd have sort of things that we could
    do. We would fix that air traffic issue. But, as Chairman
    Alexander mentioned, this is a complicated issue, and it
    requires multiple committees and agencies and all of us to come
    together in a different and a new way to tackle this disease.
        I think it's important to remember the individuals and the
    families that are at the epicenter of this crisis. So I'd like
    to take a few minutes to share stories from our families.
        This is Courtney. Doug and Pam lost their daughter,
    Courtney, when she was just 20 years old. He describes Courtney
    as a shining star. The room lit up when she walked in, and
    everyone loved her. We were told that because it's not a matter
    of life or death, there would be no coverage for treatment, and
    on the advice of local authorities, they were told that they
    should ask her to leave their home and cancel her insurance so
    she would be homeless. By doing this, she could be eligible to
    receive treatment. Courtney died alone, away from home, the day
    before she was scheduled to enter treatment.
        Lorraine describes her brother, Larry, her twin brother, as
    amazing, charming, funny, popular, and the most talented
    drummer you've ever heard. Larry died from a drug overdose,
    leaving behind his 1-year-old son, who Lorraine raised, making
    her a single parent overnight.
        This is my friend, Aimee, and her son, Emmett. He died of a
    drug overdose at just 20 years old. He was in college, studying
    computer science. He liked BMX bikes, taught Sunday school, and
    Emmett was a hero to his younger siblings, Zachery and Alice.
        After they lost Emmett, they found out that he had seven
    overdoses reversed at local hospitals, seven. But family had
    never been notified, primary care had never been notified,
    healthcare systems within the college campus had not been
    notified or engaged. So we had seven missed opportunities to
    get Emmett the help that he needed.
        This is Dylan. My friend Jennifer lost Dylan when he was
    just 19. She says, ``Every day when I walk into my house, I see
    Dylan's shoes sitting on the floor where he kicked them off and
    his jacket draped across the bannister where he left it,'' and
    she can't move those. He will never have a chance to get
    married, to have kids, to travel, to do all the things that a
    19-year-old should have the chance to experience.
        I commend the Committee for your leadership on these
    issues, and I cannot tell you how important that leadership is
    for us, the millions of families that want to see a different
    path forward for our families, for our loved ones, for people
    in recovery, our whole community. There are many components of
    the Opioid Crisis Response Act that are critical to see moved
    forward, to be out in our communities to help us improve care
    for our patients and families, and we're here as a partner and
    a resource as families and patients any time we can be of help.
        It gives us hope to see leadership from Congress to move
    this in a direction that treats this disease with new
    advancements in medicine, with treatments, with medications to
    treat the disease of addiction, and a comprehensive response
    that includes all these key components. So we're very grateful
    to you for your time.
        [The prepared statement of Ms. Nickel follows:]
                  prepared statement of jessica hulsey nickel
        I would first like to thank Senate Health, Education, Labor and
    Pensions Committee Chairman Lamar Alexander, Ranking Member Patty
    Murray, and the Members of the Committee for hosting this series of
    hearings and for inviting me to testify on behalf of important
    legislation that can help address our Nation's addiction crisis.

        My name is Jessica Hulsey Nickel, and I am the President of the
    Addiction Policy Forum. I started the non-profit to help patients,
    families and stakeholders across the country advocate for a
    comprehensive response to addiction--including prevention, treatment,
    recovery, overdose reversal, criminal justice reform and law
    enforcement. We convene key partners from throughout the field around
    one table with a shared goal: to help create a world where fewer lives
    are lost to addiction and help exist for the millions of Americans who
    need it.

        I am grateful to be with you today to discuss the need for a
    comprehensive response to address the addiction crisis. I know
    firsthand the devastating impact that addiction can have on families.
    Both of my parents struggled with heroin addiction and ultimately lost
    their lives to this preventable, treatable disease. My story is just
    one of the millions repeated daily across our nation--and I have heard
    these stories from the thousands of mothers, fathers, sisters, brothers
    and other loved ones who have reached out to the Addiction Policy Forum
    in need, in grief, in hope and wanting to be a part of the solution to
    this crisis.

        Last December the Centers for Disease Control (CDC) released a
    haunting report stating that over 63,300 people died from a drug
    overdose in 2016--a 21 percent increase from the previous year, largely
    due to an increase in opioid overdose deaths.

        In 2016, 174 people died every day from a drug overdose in our
    country. 174. That's equivalent to more than two commuter planes
    crashing every day for an entire year. But you can bet that if those
    planes were actually going down the FAA would stop operations until
    they found out exactly what was going on. Addiction is a more muted
    killer. In 2016, the Addiction Policy Forum launched the 129aDay
    campaign to honor those we have lost and their families, who sit at the
    epicenter of this crisis. Each year, we update the campaign to reflect
    the increasing number of lives that are lost each year. The latest data
    available show 174aDay and all indications suggest that this number is
    continuing to rise.

        Amidst the horrific numbers, it's important to put real faces to
    the scope of this crisis and I'd like to take a moment to share the
    stories of some of our families.

        Doug lost his daughter, Courtney, when she was just 20 years old.
    He describes Courtney as ``a shining star. The room lit up when she
    walked in and everyone loved her.'' Doug writes: ``We were told that
    because `it is not a matter of life or death' there would be no
    coverage for treatment. On the advice of our local authorities, we
    asked [Courtney] to leave our home and canceled her insurance. By doing
    this, she would be homeless and then could be eligible to receive
    treatment. Courtney died alone, away from our home and the day before
    she was scheduled to enter a treatment facility.''
    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Lorraine describes her twin brother, Larry, as ``amazing, charming,
    funny, popular and the most talented drummer you've ever heard.'' Larry
    died from a drug overdose almost 30 years ago, leaving behind his 1-
    year old son, who Lorraine raised as a single parent.
    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Aimee describes her son, Emmett, as ``the average American teen; he
    loved video games and BMX biking. He was a caring, funny, smart young
    man with the potential for greatness. He was the adored older brother
    to Zachary (age 18) and Alice (age 9). He had a smile and charm that
    could light up a room--but heroin stole that from him, and from us.''
    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Jennifer describes the day her son, Dylan, died: ``I don't remember
    much about that day, but I do know that my life will never be the same.
    Every day when I walk into my house, I see Dylan's shoes sitting on the
    floor where he kicked them off and his jacket draped across the
    banister where he left it. We will never have another one of our
    midnight snacks. He will never have the chance to get married, have
    kids, travel and do all of the things that a 19-year-old should have
    the chance to experience.''
    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Of the 21 million people that need treatment for a substance use
    disorder, only about 10 percent will receive it. Ten percent. Can you
    imagine a world where only 10 percent of cancer, Alzheimer's, or
    diabetes patients got the treatment they needed? We lose 174 sisters,
    sons, husbands, daughters, and mothers every single day.
                     A Comprehensive Response to Addiction
        As a community of families, patients and key stakeholders, we have
    long been advocating for a comprehensive response to addiction in this
    county and are excited to see this approach reflected in the numerous
    legislative proposals that are being considered.

        Last year, through rigorous dialog and consideration, we identified
    key priorities for action and we are grateful to this Committee and its
    Members for focusing on so many of the following crucial components.

        1. Help Families in Crisis

        In our field there is a profound lack of accurate resources and
    guidance available for individuals and families who are in crisis and
    need proper treatment and care. We consistently hear families describe
    desperate, agonizing attempts to get help-turning to Google to search
    for treatment options and basic information, reaching out to physicians
    or local contacts who have neither answers nor referrals, not knowing
    who to call without being judged, or calling what seemed like leads but
    turn out to be dead ends with no capacity and a 3-month wait list, no
    insurance coverage, or the haunting drone of a disconnected number.

        Additionally, there is a lack of readily available information
    regarding what we do know about substance use disorders in all of their
    complexity. Addiction shares many features with other chronic illnesses
    such as diabetes, cancer and heart disease, including a tendency to run
    in families, an onset and progression that is influenced by behavior
    and an ability to respond to appropriate treatment, which can include
    both medication and lifestyle modifications. Even relapse rates for
    substance use disorders are similar to those of comparable chronic
    illnesses. There is also an alarming lack of cultural understanding
    with regard to what we know about effective treatment, recovery,
    prevention, early intervention, overdose reversal and other key topics.

        2. Expand Treatment Access and Integration into Healthcare

        Substance use disorder (SUD) remains one of the only illnesses that
    is treated outside of general healthcare systems. Because of this there
    is little, if any, communication between specialty SUD treatment
    providers and primary care doctors. This affects the overall quality of
    care and health outcomes of the patient. We need to close the gap
    between the number of people who need treatment for an SUD and the
    number of people who actually receive it.

        Evidence-based SUD treatment needs to be integrated into general
    healthcare systems, including primary care, emergency departments,
    inpatient, mental health programs, etc. Ideally, SUD would be treated
    like any other chronic, relapsing disease. Patients could receive
    treatment and care coordination from their primary care doctor, who
    would bring in specialty providers as needed, as would be the case for
    a patient diagnosed with diabetes or heart disease.

        Studies have shown that the mainstream healthcare workforce is
    inadequately trained to deal with SUD-related issues, and that the
    substance-use-related workforce does not currently have the capacity to
    handle the population of patients who need care.

        Major investments are needed in both arenas if a proper and
    sustainable integration of care delivery is to take place. Because
    physical health conditions impact and are impacted by SUDs integrating
    substance-use-related services in healthcare systems promises to add
    value to both systems, reduce health disparities and costs. and improve
    general health outcomes.

        Healthcare systems have many shoes to fill in the configuration of
    a comprehensive, effective plan to address SUDs: expand efforts to
    identify patients in need of treatment; integrate comprehensive
    assessments for patients who screen positive for substance use
    problems; treat patients along the wide spectrum of SUD severity,
    including intervening early when substance misuse is identified in
    order to curtail escalation of the disorder and related health
    consequences; connect patients with the appropriate treatment provider
    and proceed to coordinate care across both healthcare and social
    services systems (criminal justice, housing and employment support,
    child welfare ); and implement long-term patient monitoring and
    recovery support follow-up.

        3. Drive Discovery in Research and Cures

        Innovative scientific advancements in the field from many arenas
    within phromacotherapy and technology are emerging, but funding for
    research remains scant and the number of addiction-related scientists
    too few. As a result. new discoveries that could help people struggling
    with SUD are slow to emerge.

        To achieve our vision of a world free of addiction and all of its
    associated burdens we must dramatically increase research investments
    in order to attract and enable experts throughout the scientific,
    medical and technology communities to work together to accelerate
    progress.

        4. Expand Recovery Supports

        While evidence strongly suggests that effective treatment and
    recovery plans should cover a span of at least three to 5 years for an
    individual based on their needs and the severity of their disorder, we
    have a long way to go to adequately prioritize and fund the quality and
    amount of recovery support programs and resources needed in every
    community. Today, 23 million Americans are in recovery from SUD. As we
    work toward closing the treatment gap by providing services for more
    individuals who need them, investing in the necessary framework for
    sustained recovery is critical.

        Key components of recovery-ready communities include a variety of
    programmatic supports, including recovery community organizations,
    alternative peer groups, collegiate recovery programs, jail and prison-
    based recovery, peer recovery coaching, medication-assisted recovery
    support, mutual aid groups, recovery high schools, recovery housing,
    and technology and tools for recovery support.

        5. Advance Evidence-Based Prevention

        We know that 90 percent of individuals with a SUD started using
    substances in adolescence. Increasing the age of initiation is key to
    ensuring that fewer people develop an addiction.

        There are numerous evidence-based prevention interventions that
    have been shown to not only prevent or delay the onset of substance
    use, but also help prevent broader behavioral health problems. Early
    interventions can also help to prevent problematic substance use from
    progressing to a use disorder. Advancing implementation of these
    evidence-based programs will help prevent addiction as well as criminal
    justice system involvement that can happen when these disorders go
    untreated. Evidence-based prevention approaches (both individual and
    environmental) can lead to major societal cost-savings over time and
    dramatically reduce the prevalence of both substance use and mental
    illness.

        Comprehensive school/community-based assessment and early
    intervention activities and programs, such as Student Assistance
    Programs (SAP) in middle and high school settings, can play a critical
    role in stopping the addiction cycle before the disorder becomes more
    complex and difficult to treat.

        Prescription drug misuse can have serious medical consequences and
    its prevention is a key element of a comprehensive prevention strategy.
    Increases in prescription drug misuse over the last 15 years are
    reflected in increased emergency room visits, overdose deaths
    associated with prescription drugs and treatment admissions for
    prescription drug use disorders, the most severe form of which is
    addiction. Among those who reported past-year non-medical use of a
    prescription drug, nearly 12 percent met criteria for prescription drug
    use disorder. Unintentional overdose deaths involving opioid pain
    relievers have more than quadrupled since 1999, and have outnumbered
    those involving heroin and cocaine since 2002. To address prescription
    drug misuse, we must educate patients about its dangers and empower
    them with the tools to safeguard their own homes by securing medicine
    cabinets and disposing of unused medication.

        6. Protect Children Impacted by Parental Substance Use Disorder

        Over nine million children in the United States live in a home with
    at least one parent who uses illicit drugs, according to the National
    Alliance for Drug Endangered Children. These children are at an
    increased risk for depression, suicide, poverty, delinquency, anxiety,
    homelessness and most significantly, substance misuse. Children living
    with an addicted family member are four times more likely to misuse
    drugs or alcohol themselves, SAMHSA reports.

        Many children who have a family member in active addiction live in
    kinship or foster care. Healthcare and child welfare organizations, as
    well as foster parents and guardians, need training so that they
    understand the complexities of SUD and can help impacted youth learn
    positive coping skills and strategies that can decrease their
    likelihood of developing a SUD of their own. There are promising
    interventions being implemented within the child welfare system. For
    example, START, a Child Protective Services program for Kentucky
    families with parental substance misuse and child abuse/neglect, is an
    integrated intervention that pairs a social worker with a family mentor
    to work collaboratively with a few families, providing peer support,
    intensive treatment and child welfare services. The program's goal is
    to make sure children are safe and reduce placement of these children
    in State custody, keeping families together when appropriate.

        7. Reframe the Criminal Justice System:

        Approximately 68 percent of people in jail, 53 percent of people in
    State prison and 45 percent of people in Federal prison have SUDs,
    compared to just 9 percent of the general US population. With limited
    access to treatment while in custody, people with SUDs often return to
    their communities and re-engage in the same behaviors that resulted in
    their incarceration in the first place. Criminal justice reform is
    necessary to stop this revolving door.

        The current landscape provides a unique opportunity to re-envision
    how the criminal justice system responds to addiction. Within the
    criminal justice field, there is a growing focus on how to best
    approach mental illness and SUDs. Public opinion overwhelmingly
    supports rehabilitation through diversion to community treatment rather
    than past practice, which focused on punitive responses. The passage of
    the Comprehensive Addiction and Recovery Act (CARA) in 2016 marks a
    sea-change in the role of criminal justice and provides additional
    resources for pre-arrest diversion and Medication Assisted Treatment
    (MAT) within criminal justice facilities.

        As we envision and actualize much-needed reforms within and without
    criminal justice as we know it, emphasis should be placed on preventing
    individuals with SUDs from penetrating into the criminal justice system
    by ``intercepting'' them at the earliest point of contact. The
    Sequential Intercept Model is well-established in the mental health
    field and can easily be applied to SUD populations. The model provides
    a conceptual framework for communities to use when addressing concerns
    about the criminalization of people with SUDs and considering the ideal
    interface between the systems of criminal justice and treatment.

        8. Educate and Raise Awareness

        The field of addiction is steeped in myth and misinformation, which
    has kept our country from treating and providing for the disorder as we
    do any other medical condition. The stigma that unfortunately surrounds
    SUD also acts as a major barrier to treatment access. In order to
    transform the field of addiction, we must change the narrative that has
    misconstrued this disease and failed to provide for the millions of
    Americans who are struggling. By educating people of all ages about
    this disease by way of real stories instead of scare tactics and
    accessible language instead of statistics, we can help cultivate more
    compassionate, resourceful and knowledgeable communities.

        These priorities were developed by the people and families
    struggling with substance use disorder; families and friends that have
    lost a loved one; policymakers, volunteers, researchers, health
    professionals, law enforcement officials and advocates. As an
    integrated whole, they realize an aggressive, comprehensive approach
    that includes practical tools, sound policies and new collaborations
    that will empower and equip communities to better treat and prevent
    addiction and ultimately, save lives.

        Our community is energized by and united in our goal of helping to
    forge a world where fewer lives are needlessly lost to this disease.
    But our work is far from finished--as the opioid crisis worsens across
    the Nation, we are emboldened to do more. The legislative proposals
    being considered contain critical components that would help both to
    curb the opioid crisis and to ensure that the future of this field is
    one founded in hope and guided by science.
                       OPIOID CRISIS RESPONSE ACT OF 2018
        I commend the Committee for your leadership and for the
    comprehensive approach you have taken to address this crisis as
    evidenced by the legislation being considered today. While there are
    many important provisions in this bill, I would like to focus
    specifically on a number of provisions supported by the Addiction
    Policy Forum.
                     COMPREHENSIVE OPIOID RECOVERY CENTERS
        The Comprehensive Opioid Recovery Centers provision will help
    address these barriers through the development and promotion of
    integrated care models based on best practices, which will build a
    pathway toward the comprehensive healthcare infrastructure that must be
    achieved to ensure that everyone suffering with a substance use
    disorder has access to quality treatment. Specifically, the legislation
    will authorize resources to operate these centers, which will provide
    the full spectrum of evidence-based treatment services including intake
    evaluations and regular assessments, all Food and Drug Administration
    (FDA)-approved treatments for substance use disorders, detoxification,
    counseling, residential rehabilitation, recovery support services,
    pharmacy and toxicology services, and interoperable electronic health
    information systems.

        The Addiction Policy Forum supports the quick enactment of CORCs,
    which will help fill the need for coordinated, comprehensive care for
    patients with opioid use disorder. In so doing, these Centers will also
    address those at risk for overdose, arrest or other criminal-justice
    involvement receive the healthcare they need to return to their
    families, work and a healthy life.
                    NATIONAL RECOVERY HOUSING BEST PRACTICES
        Addiction is a chronic, relapsing disease and most patients who are
    treated for a substance use disorder (SUD) require long-term recovery
    support. While a wide range of evidence-based services, programs, and
    organizations have been developed to provide structured and supportive
    environments for people in recovery from an SUD, the critical role of
    recovery in the continuum of SUD treatment is too often omitted from
    conversations regarding the current crisis. Despite extensive research
    showing that services such as recovery housing dramatically increase
    the likelihood that a patient will achieve long-term recovery, such
    programs tend to be in short-supply, lack dedicated funding and vary
    significantly in quality by payer and region due to a lack of widely
    recognized national standards and guidelines.

        The Addiction Policy Forum supports the provision in this bill
    requiring the Department of Health and Human Services (HHS) to develop
    and disseminate guidelines for best practices in the operation of
    recovery housing.
                            FIRST RESPONDER TRAINING
        Our nation's first responders serve daily on the front lines of the
    addiction crisis, and they encounter first-hand the effects that
    illicit substances can have on our communities. With the proliferation
    of substances like fentanyl in the illicit drug supply chain, first
    responders are at an increased risk to deadly exposure to these
    substances.

        First responders need additional training and resources to safely
    respond to incidents of drug overdose involving fentanyl so they can
    more effectively carry out their duty to save lives, and the Addiction
    Policy Forum supports the Committees efforts to provide first
    responders with these essential resources.
                        IMPROVING ACCESS TO TELEMEDICINE
        The use of telehealth is an important solution to be utilized in
    the diagnosis and treatment of SUDs, particularly in rural areas. There
    is a large workforce shortage of clinicians trained to treat SUDs, and
    while some regions of the Nation have strong SUD treatment workforces,
    increasing access to telehealth services would allow vital clinical
    services for SUDs to be provided in areas of the Nation that lack, or
    may not need, full-time addiction medicine specialties.

        The Addiction Policy Forum supports the provision of the bill
    allowing mental health and addiction treatment centers to register with
    the Drug Enforcement Agency, which would expand the use of telemedicine
    and allow for the treatment of additional patients with SUD.
          DISPOSAL OF CONTROLLED SUBSTANCES BY HOSPICE CARE PROVIDERS
        Many of the first-time encounters with opioids happen in homes with
    leftover medications that were initially prescribed by a physician. The
    Journal of the American Medical Association reported that two-thirds of
    surgical patients end up with unused pain medications, such as
    oxycodone and morphine, after recovering from a procedure. These
    prescribed drugs are often neither secured nor disposed of properly,
    but stashed in medicine cabinets and bedside table drawers. Getting rid
    of a bottle of pills may seem like a shuffle step on the long path
    toward addressing the opioid crisis, but decreasing access to these
    medications is as crucial as it is easy.

        Because of this, the Addiction Policy Forum supports giving hospice
    care providers greater ability to dispose of unused controlled
    substances for the deceased.
                      EDUCATION AND TRAINING FOR PROVIDERS
        Medical education about the identification and treatment of
    substance use disorders needs to be improved for practicing healthcare
    professionals as well as those in training. While there is certainly
    good work going on to improve medical professional education related to
    substance use and addiction, we must ensure speedy dissemination of the
    most current research and best practices. Often, healthcare providers
    do not feel prepared to deal with what is commonly perceived as a
    difficult patient population. Because of the lack of education for
    students and experienced practitioners, patients are denied access to a
    large portion of evidence-based treatment options that are only
    available in medical settings. Physicians around the country also
    report not having had enough training on the prescribing of pain
    medication and alternative treatments for chronic pain. This particular
    gap in physician education in the midst of a worsening opioid epidemic
    must be addressed.

        Providing additional educational resources to providers to both
    detect substance use disorders and address acute or chronic pain in
    order to mitigate the risk of a patient developing a substance use
    disorder is an important piece of a comprehensive response to our
    Nation's drug crisis. As such, the Addiction Policy Forum supports this
    provision.
                                   Conclusion
        I look forward to working with you and the Members on this
    Committee to advance meaningful legislation built on a comprehensive
    response that includes prevention, treatment, recovery, overdose
    reversal, law enforcement and criminal justice reform.

        Thank you for the opportunity to testify today and for your
    commitment to addressing such an important issue that impacts millions
    of American families every day.
                                     ______

                  [summary statement of jessica hulsey nickel]
        I started the Addiction Policy Forum to help patients, families and
    stakeholders across the country advocate for a comprehensive response
    to addiction--including prevention, treatment, recovery, overdose
    reversal, criminal justice reform and law enforcement. Our nonprofit
    convenes key partners from throughout the field around one table with
    shared goal: to help create a world where fewer lives are lost to
    addiction and help exists for the millions of Americans who need it.

        In 2016, we launched 129aDay, an initiative to honor those we've
    lost to addiction and their families. Each year, we update the campaign
    to reflect the increasing number of lives that are lost. The latest
    data available show 174aDay and all indications suggest that this
    number is continuing to rise. We seek to put faces to the scope of the
    opioid crisis to further advocate for swift and aggressive reform. I
    know firsthand the devastating impact that addiction can have on
    families--both of my parents struggled with heroin addiction and
    ultimately lost their lives to this preventable, treatable disease.

        Our community of families, patients and key stakeholders has long
    been advocating for a comprehensive response to addiction--one that is
    guided by science and energized by hope. I commend the Committee for
    your approach to, and leadership on this issue, which is evidenced by
    the important legislation being considered today.

        I would like to focus your attention on a set of provisions within
    this bill that directly align with our strategic priorities and would
    immediately improve our current situation and lay the groundwork for
    better treatment outcomes.

        These provisions include comprehensive opioid recovery centers,
    national recovery housing best practices, first responder training,
    improving access to telemedicine, disposal of controlled substances by
    hospice care providers, and increased education and training for
    providers. These and many other provisions in this bill are important
    components to the comprehensive response we need in our Nation to
    address the addiction crisis.
                                     ______

        The Chairman. Thank you, Ms. Nickel, for your touching
    stories and your testimony, and to all of you for your work and
    your time for being here. As you can see, you have our full
    attention, and we welcome your advice.
        We'll now begin a round of 5-minute questions with
    Senators.
        Senator Collins.
        Senator Collins. Thank you very much, Mr. Chairman, and
    thank you for the very important work that this Committee is
    doing.
        In Maine, we experienced a record high number of overdose
    deaths last year, claiming some 418 lives. This past weekend,
    there were nine overdoses as a result of some fentanyl-laced
    heroin. Fortunately, first responders were able to save these
    individuals. But it's so clear that we need to take an all-of-
    the-above approach to addressing the opioid epidemic.
        This week, I'm introducing three bipartisan bills to
    address this crisis, and I look forward to working with the
    Chairman and Ranking Member in the hopes of incorporating them
    into the Committee's tremendous legislative effort.
        Ms. Nickel, I want to start with you, and I want to first
    thank you for sharing your extraordinary personal tragedy with
    our Committee and also telling us of other families that have
    been affected. It's very poignant. It puts a human face on this
    epidemic, and that's very important.
        One way that families are finding support is through peer-
    to-peer recovery groups. I toured a volunteer-led Bangor Area
    Recovery Network in Brewer, Maine, last year that is a model
    for peer-led counseling and brings hope, recovery, and healing
    to those who are struggling with substance abuse. Have you seen
    peer-to-peer groups make recovery more sustainable? Do you have
    any advice for us on that approach?
        Ms. Nickel. Absolutely. Peer recovery support specialists
    are a key component to making sure we provide the services that
    are needed for folks that are in recovery, those that need
    treatment--individuals that have lived experiences and can make
    that connection. We've learned this with peer programs in the
    mental health lane, peer programs in veterans services, and
    it's the same for our patient group.
        A few of the programs we've seen--Addiction Policy Forum
    has six peer recovery support specialists that work for us.
    They provide crisis support to individuals in recovery and the
    connection to services that are needed, and I think it's a
    critical element. In Rhode Island, there's an amazing program
    called AnchorED where peer recovery support specialists connect
    with a patient that's had a nonfatal overdose and gets them the
    services that they need.
        I think we've learned on the ground and from a lot of
    anecdotal evidence that this is a key component. We need more
    research to make sure that we're putting this in the right
    direction, and we definitely need more funding support.
        Senator Collins. Thank you, Ms. Nickel. The other issue
    that I want to bring up in my remaining time is the fact that
    when people are receiving hospice care in their homes, they
    frequently need powerful painkillers. I am a big proponent of
    hospice care. I believe that most people would prefer to die at
    home if they can, and, obviously, we want to provide effective
    relief.
        Unfortunately, there oftentimes are powerful painkillers
    that are left over at the time of death, and yet hospice staff
    are not allowed to dispose of these unused medications, even
    after the patient has died. So this opens the door to
    diversion, to theft, to abuse. Another bill that I'm developing
    with Senators Warren, Hassan, and Rubio would allow hospice
    staff, nurses, physicians, and paramedics to dispose of unused
    medication, to collect them and take them out of the household.
        Do you believe that this would be helpful in stopping some
    of the diversion and theft and misuse that occurs now?
        Ms. Nickel. Absolutely. We know that the disposal of unused
    prescription painkillers is a key component to making sure they
    don't fall into the wrong hands, whether that's diverted onto
    the streets, to be sort of picked up by an adolescent in that
    household. It's a critical component.
        We have two programs every year to encourage our families
    to work with stakeholders in communities to make sure that
    we're disposing of medications. I think, particularly focusing
    on hospice care, making sure that any of the barriers that
    those workers have to making sure that they have the authority
    to dispose of those medications is a key component to keeping
    our communities safe.
        Senator Collins. Thank you so much.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Collins.
        Senator Murray.
        Senator Murray. Thank you, Mr. Chairman, and thank you to
    all of our witnesses today.
        When I talk to teachers and parents and other community
    members back at home, they tell me we need to prevent this
    generation of children from becoming the next generation of
    adults who have substance use disorders. It is really a
    heartbreaking conversation. Children of parents who struggle
    with substance use disorders--Ms. Nickel, you talked about
    that--too often experience trauma that puts them at a higher
    risk of negative health outcomes, including developing
    substance use disorders themselves and even early death.
        Ms. Donahue, let me start with you. How do you see our
    discussion draft helping to address those issues, and what more
    could we do to address trauma among young people in light of
    this crisis?
        Ms. Donahue. Thank you for your question. I think it's key
    that we provide mental health services in schools, particularly
    at the earliest possible time. Children who experience trauma
    will often have the adverse childhood experiences that will
    buildup over time if they are still in that dysfunctional home
    or environment. So if mental health services are provided early
    in schools and the school can sort of be that support person
    along with the teachers for that child, I think we will very
    much greatly reduce the number of children who grow up and
    develop mental health conditions themselves or turn to
    substance use. I think that is extremely important. I also--and
    I believe that bill covers that funding for that.
        The other issue is for pregnant women who are struggling
    with addiction. I think mental health services coupled with
    their substance use disorder is key as well. Often, as my
    statistics indicated, there is a dual diagnosis of these women
    who are struggling with substance use and mental health
    conditions.
        Senator Murray. Thank you very much.
        In 2017, the Centers for Disease Control and Prevention
    supported grants in actually 43 states that enhanced
    prescription drug monitoring programs in support communities
    and health systems; prevention efforts as well as grants to 33
    of our states for enhanced surveillance of drug overdoses.
    Those grants have actually played a very critical role in
    supporting many hard hit areas.
        But they were not funded at a level to reach the entire
    nation until we just passed the recent omnibus, and I'm really
    glad we had bipartisan support for expanding these programs. I
    know on our side, Senators McCaskill and Tester worked really
    hard on those provisions that would promote this effort in the
    bill we're talking about today. But we know that successful
    prevention efforts need sustained commitments.
        Mr. Morrison, let me ask you--in achieving your
    organization's mission for drug abuse prevention and treatment,
    how vital is national data?
        Mr. Morrison. Absolutely critical. Our members are
    beneficiaries from a lot of the data sets that are available at
    the Federal level. We also feed up data to SAMHSA, for example,
    through the Treatment Episode Data Set. But we know the
    National Survey on Drug Use and Health has about 75,000 people,
    looking at their use patterns, demographics, and the like, and
    SAMHSA has done a nice job to work with states in order to look
    at--to try to localize that data at state level estimates.
        Senator Murray. How important is it that we have data from
    every state?
        Mr. Morrison. Critical. For example, you mentioned PDMPs.
    Our members very much appreciate the data from PDMPs, because
    they can utilize that data for hot-spotting, looking at the
    state, identify data to particular areas, and then you can
    target prevention messaging based on that hot-spotting in your
    state. That's done with a state-Federal partnership. The
    resources are important as well. It can be expensive.
        Senator Murray. You know, over the past few years and even
    in the past few weeks, I've heard a lot about the gaps in our
    behavioral health workforce and how that is crippling our
    efforts to fight this crisis. I've heard about the need to make
    sure patients fighting addiction have support in navigating and
    access to comprehensive services, whether it's to stay on track
    with medication-assisted treatment once they have that, mental
    health treatment, rebuilding relationships, getting back into
    the workforce, all of that. But we don't have enough
    professionals who provide those critical services.
        Mr. Morrison, let me ask you--what role do those providers,
    that workforce, play for patients fighting addiction?
        Mr. Morrison. They're critical, and the expertise and that
    therapeutic relationship they have with a particular person is
    a key predictor of success. We need them to have that
    expertise, but it can be a challenge. I was talking to
    Washington State--Chris Imhoff, the state director, just
    yesterday, and she expressed appreciation for the loan
    repayment provisions included in the proposal, because that can
    be a deterrent to going into the field, because we know also
    that salaries aren't--so any additional help, such as a loan
    repayment provision specific to substance use disorders is
    appreciated.
        Senator Murray. Okay, I really appreciate that. Thank you.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Murray.
        Senator Roberts.
        Senator Roberts. Thank you, Mr. Chairman. Let me make the
    observation that, once again, you and Senator Murray are
    working together in a bipartisan fashion with the rest of the
    Members of this Committee to address an extremely serious
    problem that we're facing in this country, and I thank you for
    your leadership, and, somehow, you are always able to pull the
    chestnuts out of the fire and get something done.
        I want to thank the staff for working with my staff on
    legislation that I would like to introduce on behalf of Heidi
    Heitkamp, who is my Co-Chair of the Senate Rural Healthcare
    Caucus, with regard to telemedicine. So thank you for your
    efforts.
        Ms. Nickel, Senator Collins referenced your testimony as
    being very poignant, and I was trying to think of a word that
    could trump that. I don't think I can. Thank you for that
    testimony, and I hope I'm not out of order in stating that I
    feel very sure that your mom and dad are very proud of you with
    regard to what you're doing and putting a face on this terrible
    scourge in our country with Courtney, Larry, Emmett, and Dylan.
        That's the way to approach this, Mr. Chairman. I think we
    really need to do that. We can get some things done.
        You made some suggestions on page 8, where you talk about
    getting our schools involved, which I think is pretty much a
    commonsense approach and would recommend that to our leadership
    here. You say comprehensive school, community-based assessment
    and early intervention activities, and programs such as student
    assistant programs--there's an acronym for that. Everything has
    to be an acronym--SAP. I don't think we're saps for considering
    it--but, at any rate, in middle and high school settings, can
    play a critical role in stopping the addiction cycle, and I
    certainly agree with that.
        I'm popping over to page 13, where you address
    telemedicine. I've heard from many Kansans who have had to
    travel long distances, sometimes across state lines, in order
    to access any kind of substance use treatment. For example, the
    nearest methadone clinic for southeast Kansas is in Joplin,
    Missouri. We Kansans--still, when traveling to Missouri, it's a
    traumatic experience, Mr. Chairman. We're always glad to get
    back. But that shows you what we're facing.
        Both Senator Heitkamp and I are very interested in
    telemedicine's potential to assist these patients in receiving
    the necessary diagnosis and treatment. We've been working with
    telemedicine just in terms of access to healthcare for a long
    time.
        So, Ms. Nickel, what services can be used via telemedicine
    to best treat patients with substance abuse disorder?
        Ms. Nickel. Telemedicine is a key component to meeting our
    treatment capacity gaps that we have. Right now, only 10
    percent of our 21 million people that need treatment are going
    to receive it this year. Can you imagine 10 percent of cancer
    patients receiving treatment? And, in particular, for rural
    communities, telemedicine can be a game changer on getting the
    treatment components that you need for a long-term recovery
    plan--treatment and recovery plan, and there's a couple of
    different pieces of that.
        One is treatment itself: telemedicine's capability for
    prescription of medication-assisted treatment, which is
    particularly important if you're in a rural community and you
    don't have a provider that's even within hours of a drive and
    you need to be able to have that medication for that patient,
    but also telemedicine for counseling services, for behavioral
    health support, and even intervention such as cognitive
    behavioral therapy. There's some red tape that exists that
    makes this difficult to deliver these services across state
    lines and to streamline the availability. So all of these
    different components made available through telemedicine could
    be a game changer.
        Senator Roberts. I appreciate your response.
        Mr. Chairman, I also want to thank Ms. Donahue and Mr.
    Morrison for their contribution, and I'm going to yield back
    time, which I know is most unique for me, but----
        The Chairman. We'll mark that as an important event. Thank
    you very much.
        [Laughter.]
        The Chairman. Thank you, Senator Roberts.
        Senator Warren.
        Senator Warren. Thank you, Mr. Chairman.
        You know, I'm very glad to see this Committee working
    together to address the opioid crisis. In Massachusetts, more
    than five people are dying every day, on average, from opioid
    overdoses, and we need action now on this. Senator Capito and I
    have been working together for several years on a bill to allow
    partial filling of opioid prescriptions so that people only get
    the opioids that they actually need. The idea is to reduce the
    number of pills that are in circulation.
        We got this legislation passed in 2016, and we recently
    introduced a bill to improve implementation of this law by
    clarifying the FDA's authority to make sure that doctors and
    patients actually knew about the partial fill option. You know,
    this is one of those bipartisan, consensus, commonsense
    provisions that would reduce unused medications that are lying
    around in the home, and I'm hoping that we will be able to get
    it included in the final passage as it goes through Committee,
    and we'll continue to work together on this.
        Let me just ask a question about the risk posed by unused
    medications.
        Mr. Morrison, why might unused medications lying around the
    house pose a risk of misuse or diversion?
        Mr. Morrison. Sure. We know from data that SAMHSA collects
    that the source of the use of medications that are not
    prescribed to folks--about half come from that particular
    situation, friends and family. So efforts to make sure that
    doesn't happen are real important.
        Senator Warren. Right. And, for instance, family--they may
    not even know about it, but it's up there on the shelf and
    imposes a risk.
        Mr. Morrison. That's right.
        Senator Warren. Yes. So one of the times that individuals
    are most likely to use opioids to manage pain is at the end of
    life. But right now, in many states, hospice employees are not
    legally allowed to dispose of opioid medications on behalf of a
    patient who has passed away.
        I've, again, been working on a bipartisan basis with
    colleagues to try to address this issue and make sure that
    hospice employees can safely dispose of medications. Families
    dealing with the loss of a loved one shouldn't also have to
    worry about dealing with dangerous leftover drugs.
        Here's something else that families shouldn't have to worry
    about, whether a sober living home is actually helping their
    loved ones recover or pushing them back into addiction.
        Mr. Morrison, can recovery housing be an important piece of
    the puzzle for individuals in recovery from addiction?
        Mr. Morrison. It's a critical part of the continuum. I know
    in Massachusetts, you all worked with the National Association
    of Recovery Residences. They've developed a tier level of
    explanation about different options. We've been working closely
    with them, other states as well. Recovery housing is critical.
        Senator Warren. And can you just say another word about the
    quality of recovery housing? Is there some variation here?
        Mr. Morrison. There can be, and I think the bill that is
    before the Committee, the discussion draft, seeks to put out
    standards, models, so that states can look at those, talk to
    each other, and look at best ways to implement recovery housing
    with important standards.
        Senator Warren. Good. You know, most of these facilities do
    a great job, but there are too many examples of ones that
    don't. I led a bipartisan request to get the GAO to look into
    this problem, and this discussion draft also contains language
    that I've been working on with Senator Kaine and others to try
    to establish best practices for recovery homes to help patients
    make the best choices in their recovery.
        My view on this is we need to use every single tool in the
    toolbox to tackle this epidemic, and these bipartisan efforts
    will help, and I'm glad to work on it. But let me be clear on
    this. Congress has nibbled around the edge of this problem for
    years, and the problem has gotten worse and worse. This latest
    round of policy changes is no substitute for giving communities
    the resources and the expertise they need to fight this fight
    on the ground.
        That's why Congressman Cummings and I are introducing new
    legislation based on the Ryan White Care Act, the landmark bill
    that Senator Kennedy and Senator Hatch passed back in 1990 to
    tackle the HIV-AIDS epidemic. I hope Senators on both sides of
    the aisle will support it, because the AIDS crisis taught us
    that what it takes to beat an epidemic like this is that we
    really have to put the resources and the energy behind it, and,
    right now, I just don't think we're doing what it takes. We
    need to do better.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Warren, and thanks for
    your work on partial fill and the hospice legislation that you
    and Senator Collins and others--and, Senator Roberts, thanks
    for your work on the telecommunications provisions of the bill.
        Senator Isakson.
        Senator Isakson. Thank you, Mr. Chairman, and thanks to you
    and Ms. Murray for the job you all are doing on the opioid
    issue, which is a big issue.
        Ms. Nickel, I agree with you that it's important to put a
    face on the problem, because it is a terrible problem in our
    country. My grandson died of an overdose in 2016. He was one of
    the 63,300 that you listed in your testimony who died in 2016
    from an opioid overdose. He died two nights before he was going
    to get a summa cum laude diploma in mathematics from the
    University of Georgia Southern. He had been out of recovery for
    4 years, had been in a great program. We thought he was back.
        He was doing terrific in school, obviously, getting a summa
    cum laude diploma, but he also was working. He had a job when
    he finished. We were excited. Then we got the phone call late
    at night, 2 days before the graduation, that he had been found
    dead in his apartment in Statesboro, Georgia, which I bring up
    to say this. You never know where narcotics and opioids and
    overdose death is going to come from. You never know who it's
    going to affect. You never know how they got exposed, and many
    times, most of the subjects around it are a mystery.
        But the better you can know your children, your kids and
    your grandkids, the more you can look for things and ask
    questions, the more you can try and be aware of the symptoms of
    drug abuse or addiction, the better off all of us are going to
    be, and addiction is the big problem. I mean, I'm personally--I
    mean, Charlie was a great kid, smart as he could be, but he was
    hooked, and no matter how long you stay out in recovery and are
    free of drugs, it only takes one, and that's all it took for
    him 4 years after he had gone into recovery. That's a sad
    testimony.
        Yesterday, in a hearing we had in another Committee, we
    heard that children 13 to 26 are five times as likely to become
    addicted to narcotics as adults. Do you all agree with that
    number? Is that about right, in your mind?
        [Nonverbal response.]
        Senator Isakson. Well, that shows you, Mr. Chairman, one of
    the places we've got to put a face on the opioid epidemic is
    with our young people, to really know what they're facing and
    can happen. The meth project, which started in the upper
    Midwest with methamphetamine a few years, did a lot of good to
    knock down the growth rate in terms of meth laboratories and
    meth addictions in that part of the country, and it helped us
    in Georgia. We adopted a meth project in Georgia and put the
    billboards up like you've got with your examples with your
    speech.
        But all that education, all that awareness, all that
    talking about the subject in public and with your kids and
    families is critically important, because awareness is the key
    to catching things early, if you're lucky enough to be able to
    do that. If you don't catch it early enough, catch it early
    enough to get treatment, and then sustain the treatment and the
    benefits of that treatment long enough so the person can lose
    the addictive habits that they developed in taking the
    narcotics or the opioids.
        I just want to commend you on what you've focused on in
    terms of awareness and putting a face on it. It's a terrible
    tragedy that many, many Americans face every day and more are
    going to face in the future unless we do get our arms around
    it, and we can do it, but we've got to talk about it without
    fear. We've got to look for the symptoms without any prejudice.
    We've got to do everything we can to support those who are
    having problems rather than demonizing them because they have
    them. They need our support and our love and our assistance and
    our help, and we can help a lot of people end what is a
    terrible problem.
        I would just say, Mr. Chairman--I want to end where I
    started. Addiction, to me, is the one thing that is so
    overpowering--I can't explain it. I know there are things I
    like to eat that I shouldn't eat. There are things that I buy
    at the grocery store and my wife goes crazy. It's a good thing
    that Oreos are not addictive, because I would be on them every
    day.
        [Laughter.]
        Senator Isakson. But addiction and the habits that come
    with it and the things you do to support the habit early on
    that are so detrimental to your health in the future and your
    life in the future--it's unbelievable. So what we're doing in
    this Committee, what the Chairman and the Ranking Member are
    doing, is critically important, and what all of us need to do
    in this country is make sure that drug abuse is not a stigma.
    It's a problem. And addiction is not a stigma. It's a disease,
    and that we treat it, we find a way to cure it, and we save
    lives in the future, and that's what this Committee is all
    about, and I commend you and Senator Murray for what you're
    doing to make that happen.
        The Chairman. Thank you, Senator Isakson.
        Senator Jones.
        Senator Jones. Thank you, Mr. Chairman, and let me also
    thank the Chairman and the Ranking Member for the work on this.
    This is the work you're doing is why I came to the Senate, to
    that bipartisan work that we can really address this crisis.
        Let me also say, Ms. Nickel, while I also appreciate your
    putting a face on this, I cannot help but say how much I
    appreciate Senator Isakson, who I admire so much, putting a
    personal face on this for the U.S. Senate. It's really
    important to do that. When you have a colleague that will do
    that and step out like that, it hits home to all of us, even
    more than I think the witnesses.
        Thank you, Senator, for doing that.
        Ms. Nickel, one of the things that seems to be in my
    state--we hear the stories. Senator Isakson's grandson was
    going to school. We hear people at employment--they seem to be
    fine below the radar with these problems. But yet it also seems
    to me that employment is an important part of recovery.
        I was pleased to introduce the Jobs Plus Recovery Act with
    Senator Kaine and Senator Young about the need for employment
    and workforce development and helping people overcome these.
    The answer would seem to be obvious. But I'd like for you to
    just talk about that a little bit--Mr. Morrison, you may want
    to chime in too--about how important having that job and
    training will be to help these people overcome the addiction so
    they don't fall back into the crisis they were in.
        Ms. Nickel. Absolutely. I think employers are a key
    component of how we address addiction on two levels. For those
    that are in recovery and coming back into the workforce, having
    that job is so incredibly important. To have your sense of
    self-worth, your ability to provide for your family, and to get
    your life back in order is critical, and the stigma that is
    attached to this disease can make it--recovering and the
    family--make it difficult for the family as well. So how do we
    make sure that we make those connections so there's a pathway
    to employment, to having a job, to paying taxes, and being able
    to take care of your family as part of your recovery plan?
        On the other side of it, though, this is a disease that
    worsens over time, like any other disease, and one of the first
    things that starts to happen is you lose your job as this
    disease starts to take hold. So employers that have programs,
    like employee assistance programs, and can initiate--instead of
    losing that job because you're late or you have a positive
    urinalysis screen--to connect that employee with the services
    that they need, and having that relationship with your boss,
    your employer, helps you to get the care that is really
    required.
        Senator Jones. Thank you.
        Mr. Morrison, do you briefly want to say anything about
    that?
        Mr. Morrison. Absolutely critical. Our members work with a
    variety of different agencies and support providers to help
    them with job readiness, job training, things such as how to
    write a resume, how to prepare for interviews. Charles Curie
    was a SAMHSA administrator quite some time ago, and he would
    always say critical indicators of what we're trying to do is
    help people get better, get housing, a place to live, a job,
    and a date on the weekend. And it kind of describes the goals
    of what we're trying to do with our folks.
        Senator Jones. Right. Thank you, Mr. Morrison.
        Shifting focus a little bit, the proliferation of the
    deadly synthetic drug, fentanyl, is also a real concern, I
    think, for Congress these days. Recently, we have seen a lot of
    warnings going out to first responders. I know that recently,
    DEA has been working on this a good bit. The surgeon general
    was just--an advisory recommending that all Americans, just
    about, carry naloxone--whatever that's called. I get real
    confused. Between acronyms and medical terms, I'm gone.
        So, Ms. Nickel, what can we do? Do we need to provide more
    resources to first responders? Because these first responders--
    it would not take much, but a little bit of an inhalation or
    some kind of contact with fentanyl to be deadly to the first
    responders. As a former U.S. Attorney, I'm really especially
    into police, fire, medical personnel that get on the scene
    sometimes very quickly. They do such an incredible job, but
    they're facing this danger. What can we do to provide more
    resources?
        Ms. Nickel. Support and resources, training, wrap-around
    support for our first responders is critical, and I commend the
    Committee for having a component for training and resources in
    the draft legislation. Both our fire and police officers are on
    the front line, and both with the increasing threats because of
    synthetic opioids. Those warning systems to alert jurisdictions
    when we're seeing fentanyl enter that market is critically
    important; resources to provide naloxone--you got it right--to
    have naloxone on hand that we need to reverse overdoses; and
    then we need to make the connection between that reversal and
    connecting them to treatment.
        If you treat someone with a heart attack and use the
    paddles, you get them to a cardiologist. If we treat someone
    with naloxone to reverse an overdose, we need to get them into
    treatment and use that opportunity as a life-changing moment
    for that individual and that family. And, absolutely, we need
    to help first responders with resources, training, the support
    that they need. This is a very difficult job. You're going to
    the same houses, oftentimes many times in a row, and it's tough
    work, and not having the resources to make those connections, I
    think, can be very demoralizing. So we need to wrap them up.
        Senator Jones. Great. Thank you.
        Thank you all for your presence here today.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Jones.
        Senator Cassidy.
        Senator Cassidy. Thank you all.
        Ms. Nickel--again, incredibly moving testimony, and,
    unfortunately, we all have an experience similar to that. One
    thing you said, though, that I--as a physician, my ears perk
    up--that one of the young men had been hospitalized or in the
    ER seven different times, and family never notified. I think,
    for the record, that is a misunderstanding of HIPAA laws, that
    is, HIPAA, which, normally, has confidentiality requirements.
        I was trying to double check, but was specifically told
    yesterday by someone in a position to know that HIPAA does
    not--HIPAA does allow someone to call the family of somebody in
    an overdose and to inform them that they've been--any comment
    on that?
        Ms. Nickel. You are absolutely correct. We actually have
    drafted a memo for counsels at hospitals to fully explain that
    this is an allowable activity, to notify a family, to notify
    healthcare providers, after a nonfatal overdose, and we need to
    change a lot of the practices. How we respond to nonfatal
    overdoses in this country is the most important and one of the
    first things we should be doing. Of the nearly 64,000 people
    that we're losing annually to overdoses, 70 percent of them had
    a previous nonfatal overdose.
        Senator Cassidy. Let me just interrupt----
        The Chairman. Well, let me interrupt just a moment without
    taking your time, Senator Cassidy.
        Would it be a good idea to include in our legislation any
    language that would make it clearer, the point that you're
    making, so hospitals and their counsels would know that?
        Senator Cassidy. I was about to just ask you and the
    Ranking Member if we could something like that.
        [Laughter.]
        Senator Cassidy. When I was on Energy and Commerce
    Committee, we once had a panel of HIPAA experts, and they were
    disagreeing with each other to the degree to which you could
    share with somebody. And I can tell you if you're the ER
    physician at 3 in the morning, you've got 10 people waiting,
    your default is to not share information. So the degree to
    which we can promulgate that ideally, put a tattoo on
    somebody's head saying, ``Oh, yes, I remember that now''--we'll
    be doing an incredible service.
        The Chairman. Why don't we, first, not deduct from your
    time for my interruption, and, second, why don't Senator Murray
    and I work with you? And if the witnesses would like to provide
    us with suggestions about how to do that--we respect the HIPAA
    law, but I think it's not just overdoses. It's emergencies
    where families can be notified, but people are afraid to do
    that.
        Ms. Nickel. That would be wonderful.
        The Chairman. So, Senator Cassidy, if you would work on
    that, that would be very helpful.
        Senator Cassidy. Yes, absolutely.
        Next--again, thank you all. My office has kind of initiated
    something we call Safer Families and Healthier Communities.
        Ms. Donahue, you seem to be plugged into that. Indeed, the
    people you're serving, those children born of parents addicted,
    is kind of the beginning of Ms. Nickel's testimony. You're
    acquiring all this great data. Can I ask what you are doing
    with that data?
        Ms. Donahue. Yes. So in our data base, we are tracking
    maternal characteristics, such as where that particular woman
    resides. We are tracking what type of substance----
        Senator Cassidy. Try to speak quickly, because I have
    limited time.
        Ms. Donahue. I'm sorry. We are tracking what type of
    substance is involved and whether or not the particular mother
    has prior substance-exposed infants.
        Senator Cassidy. But with that data, can you then say,
    ``Okay, we know this child is born to a mother who is addicted.
    Therefore, we are going to proactively send support out
    there?''
        Ms. Donahue. That's correct.
        Senator Cassidy. Now, you imply that there is, one, Federal
    resources that enabled you to begin, but a lack of resources
    for which to fully go to scale and/or continue. Is that true?
        Ms. Donahue. Especially with the Plans of Safe Care, yes.
        Senator Cassidy. Now, there was in 21st Century Cures a lot
    of money which, apparently, has had a hard time getting out to
    the states. Is it just that this money hasn't gotten out, or
    that money which is even allocated will not be adequate?
        Ms. Donahue. We've actually seen some of the benefits of
    the Cures Act through peer recovery coaches through our
    Delaware chapter of SAMHSA. So the peer recovery coaches are
    actually being utilized in some of our substance use treatment
    disorder centers, including the medication-assisted treatment
    for pregnant women, and the peer recovery coaches have been
    fabulous.
        Senator Cassidy. It is getting there, but perhaps not for
    this particular program.
        Ms. Donahue. Correct.
        Senator Cassidy. Ms. Nickel, quickly, I think we have a
    shared interest in what we can do to improve access to
    addiction treatment medicine. One think I'll again point out--
    some addicts, after their recovery from an overdose, really
    don't want to be treated. They want to take another hit. So the
    issue is can we give them some sort of long-acting drug that,
    if they do take another hit, it'll be kind of ``Oh, my gosh, I
    don't want to do that again.'' Any comments quickly on that?
        Ms. Nickel. We do have new long-acting formulations of
    medication-assisted treatment, and I think we need to clear
    some barriers to making that new medication available to our
    patients. I believe this Committee worked on some language to
    help with that in S. 916, I believe.
        Senator Cassidy. Yes, my bill. I love it.
        [Laughter.]
        Ms. Nickel. Thank you for that. But I think as we have
    advancements in medications, we need to make sure we can
    actually get those medicines to our patients.
        Senator Cassidy. Yes, and this is--that one provision I'm
    not sure is in the final version so far. But just to say long-
    acting--again, to my colleagues, sometimes someone takes an
    overdose, and all they want is another hit.
        Ms. Nickel. Well, you wake up in active withdrawal, so
    you're having your worst day and feel crappy. The quickest way
    to fix that is to use again or to get someone connected----
        Senator Cassidy. But these long-acting preventions will be
    something which will then----
        Ms. Nickel. Exactly.
        Senator Cassidy ----although you're in withdrawal, you
    won't go back so immediately and, hopefully, get into recovery.
        Ms. Nickel. Absolutely.
        Senator Cassidy. Mr. Morrison, I had a question for you on
    accountability, but I'm almost out of time, so I'm going to
    yield back. But I am interested--for a question for the
    record--these programs that we're doing--we're interested in
    evaluating to make sure that they work. It's just not a place
    to send Federal dollars.
        The question for the record you'll receive is: How do we
    consistently have outcome measures which tell us what we should
    do or perhaps what we should not do?
        Senator Cassidy. Thank you all for your good work.
        The Chairman. I took--I stole at least a minute from you.
    So if you want to pursue that, please do.
        Senator Cassidy. Yes, I know. So how do we do that?
        [Laughter.]
        Senator Cassidy. Because we're interested in that
    accountability, and I know there's some people who just make
    money off of government contracts, and I know that because I
    used to work for the government. But there's others who
    actually use it to good end. How do we have that accountability
    measure to know these programs are working well?
        Mr. Morrison. Sure. We work with SAMHSA on looking at
    different measures regarding the use of alcohol, the use of
    drugs, the impact of treatment on employment, the impact of
    treatment on criminal justice involvement, and then
    connectedness back with the society. So we're eager and
    actually embrace----
        Senator Cassidy. Do those measures work? I mean, sure,
    you're doing them. Do they work?
        Mr. Morrison. Well, they're helpful, and we also would
    benefit from additional resources to look at long-term studies,
    looking at post-discharge, six, 12 months----
        Senator Cassidy. I'm a minute over. I'll stop. But our QFR
    will ask you to put a finer point on that answer.
        Mr. Morrison. I look forward to it, sir.
        Senator Cassidy. Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Cassidy, for your
    suggestions.
        Senator Murphy.
        Senator Murphy. Thank you very much, Mr. Chairman.
        Thank you all for being here today. While Senator Cassidy
    is still here, let me just put a plug in for the Mental Health
    Reform Act that we both worked on in consultation with the
    Chair and Ranking Member that passed in 2016. As part of that
    piece of legislation, we included some pretty important changes
    to the Mental Health Parity Law which allow for Federal
    regulators to make sure that insurance companies are not just
    putting in their statement of benefits your behavioral health
    and addiction benefit, but that they are also administering
    your benefit in a way that is not discriminatory.
        I wanted to maybe direct this question to you, Mr.
    Morrison. Secretary Acosta came before President Trump's Opioid
    Commission and talked about the lack of tools that he has in
    order to enforce this requirement under Federal law that when
    you have insurance, you have an equal addiction benefit to your
    non-addiction benefits. The reality is that anybody out there
    who has tried to access insurance reimbursement knows that it
    is a whole lot harder to get an insurance company to pay for
    addiction treatment than it is to fix your broken leg or to
    address heart disease.
        He specifically--Secretary Acosta--asked Congress to give
    him two new authorities. He said, ``I need the power to level
    civil fines.'' There are no civil fines right now in the Parity
    Law. And, second, he wanted to be able to come after not just
    the employers but the insurance companies themselves.
        Let me just ask you a general question, which is: Do you
    believe that, as you look at it, there are still enforcement
    challenges when it comes to administering the Mental Health
    Parity Law?
        Mr. Morrison. I think there are. I think there's been
    studies, as you referred to, in terms of accessing the benefit,
    and there's been a look at accessing substance use disorder
    benefits as opposed to physical benefits, and there have been
    challenges and barriers. Our members know this issue based on
    folks that they see are uninsured or underinsured, and so
    they've worked with state health insurance commissioners,
    plans, and the like to educate them.
        But the bottom line is we have a law on the books and
    resources to help enforce and implement the law would be
    helpful, and the Governor's Association has included that as
    part of their recommendations, as has the Commission that the
    President convened under Governor Christie.
        Senator Murphy. Well, Senator Alexander, we're lining up
    requests as we go through this hearing. But one of mine would
    be that we take a look at these authorities that the
    Secretaries ask for. They're actually included in President
    Trump's Commission's recommendations to us.
        We have new reports that we've been given showing that
    there is just an unjustifiable disparity in terms of how
    insurance companies reimburse on the addiction side and the
    non-addiction side, and we have a Republican administration
    asking for some new authorities, I think some commonsense
    authorities, and I hope that we can talk about that.
        Another subject I wanted to bring up to the panel is the
    subject of recovery coaches. I think, again, Mr. Morrison, you
    referenced it in your testimony. We've had a lot of success in
    Connecticut with recovery coaches. We've seen an increase
    across the country in emergency room visits for opioid
    overdoses by 30 percent. And I've had so many people in
    Connecticut talk to me about how we need to lengthen out the
    spend on addiction, treat it more like a chronic disease than
    simply a crisis illness, and recovery coaches are one of the
    ways to do that.
        I'm maybe going to ask the question to you, Ms. Nickel,
    because it's already in your testimony, Mr. Morrison.
        You talked about the need to get parents and family members
    more involved and have policy that facilitates them being part
    of this conversation. It seems to me that recovery coaches is a
    way to do that, to have somebody who can be that liaison but
    also bring in the family members. I just wanted to sort of ask
    your thought on whether it's worthwhile.
        Senator Capito and I have two pieces of legislation that
    would do this. I just wanted to ask your opinion on this.
        Ms. Nickel. Absolutely. Addiction is a family disease. It
    affects every member of the family, and peer recovery support
    specialists, recovery coaches, can play an integral role in
    making sure that long-term plan is in place. We also know from
    literature that treatment and recovery plans need to be three
    to 5 years long, not 14 days, not 28 days. So you think about
    if you have a hip replacement, and what--my grandma had one
    last year--you have the recovery plan on the things that you
    need. It's the same with treatment for addiction, and we know
    that we need a much longer runway for the recovery support to
    make sure that patient is well and has the services they need.
        Senator Murphy. It's such a hard problem, because we need
    to spend more money, but we do need to be having a conversation
    about how we're spending the money today, whether it's best
    served, as we primarily do today, in intensive supports right
    up front or whether we need to lengthen out that span. Recovery
    coaches is a way to do that.
        Thank you, Mr. Chairman.
        The Chairman. Thank you, Senator Murphy, and we'll ask
    staff to follow-up Secretary Acosta's recommendations that you
    mentioned.
        Senator Baldwin? Oh, excuse me. I didn't see Senator
    Murkowski.
        Senator Murkowski.
        Senator Murkowski. Thank you, Mr. Chairman.
        I wish that I had been here for the beginning. We're
    beginning Appropriations hearings, and we're all in different
    places at the same time. So thank you for your contributions
    here today. We've been so focused on what is going on with the
    opioid crisis and the epidemic in this country. Sometimes I
    worry that we forget we have other very serious significant
    issues as they relate to substance abuse.
        Mr. Morrison, you have noted that we don't want to forget
    the other substances. In Alaska, it's alcohol, has been
    alcohol, will be alcohol. We just had two villages request by
    way of resolution to our Governor that he declare a state of
    emergency and to shut down a liquor store that had opened in an
    adjoining village, because one village is dry, and the other
    village sells alcohol. We've seen individuals go through the
    river, die--the tragedies continue.
        As I've talked to our enforcement agencies in the state,
    they tell me it seems like that heroin is tapering off, but
    meth is now escalating through the roof. So I'm concerned that
    here in Congress we're so focused on opiates as the drug du
    jour, if you will, and that in 5 years or so, when this crisis
    ends or abates or tapers, that we're going to have a bunch of
    Federal programs that are specifically aimed at a problem that
    may not be as significant to the detriment of others who are
    dealing with other types of addictions.
        Mr. Morrison, I'll ask you. Do you have similar concerns?
    Are we being too focused? Do we need to be broader to
    addiction, in general? How do we make sure that these policies
    are going to really be the umbrella that we need to help those
    who have such significant challenges?
        Mr. Morrison. Our members have expressed concern about not
    affording the flexibility needed in order to allow states to
    address the issues that they face that are unique to their
    state. The Substance Abuse Prevention and Treatment Block
    Grant, as you know, is a program that allows a state to target
    resources based on their own unique needs. Alaska receives
    about $6 million in that program. We also know your interest in
    fetal alcohol syndrome. Your leadership there is appreciated.
    There really isn't a Federal program within, particularly,
    SAMHSA that provides the service side, as you probably know.
        But I must say the sheer volume of death connected to
    opioids is something that cannot be ignored, and I know you're
    not ignoring it. The ability, though, for states to address
    whatever it is the person walks in the door with is critical,
    and alcohol is, indeed, the No. 1 problem in the United States.
    So it's a balance, and we appreciate the leadership of this
    Committee.
        That's why our members, again, appreciate the Substance
    Abuse Prevention and Treatment Block Grant and its flexibility.
    It's consistent, and there's a specific set-aside for
    prevention that is so critical. Seventy percent of our members'
    budget for substance abuse prevention, on average, comes from
    the block grant, so it's vital. So I appreciate the question.
        Senator Murkowski. That's good to keep in perspective.
        Ms. Donahue, in your written testimony, you state that
    providing mental health services in schools will address the
    trauma that our youth have experienced and break the cycle of
    multi-generational trauma that may lead to mental health
    concerns and substance abuse, and we certainly agree. We see
    the multi-generational trauma in places like Alaska, perhaps
    higher there than anywhere else in the country. So much of this
    is tied to alcohol and other drug use, sexual assault, domestic
    violence, and it's not just limited to the family members who
    are addicted.
        These are small villages, a couple of hundred people. There
    is not access to a licensed social worker or a psychiatrist or
    a psychologist. It's not feasible to fly the children into
    Anchorage for care, both from a practical and a financial
    standpoint. So I've been working with Senator Smith here to
    allow National Health Service Corps members to provide services
    in schools so we effectively bring the providers to the
    schools.
        We're in a position where it's just really challenging, if
    not impossible, to fund a mental health professional in the
    schools that need them. Do we have other policies that we can
    perhaps look to get providers into schools without putting a
    burden on our already underfunded school districts?
        Ms. Donahue. Thank you very much for that question. In
    Delaware, we do have behavioral health consultants that are in
    the middle schools for ages 12, 13, and 14, and those have been
    proven to be very effective. However, the funding, as you said,
    with education is very difficult to overcome.
        There are some models out there, such as the Compassionate
    School Model, that our office is working toward, which does
    incorporate trauma informed care. So that would, in essence,
    provide a team approach in the school to provide those children
    to have that access to mental health in a trauma informed
    environment where they can trust to come to school, and it's a
    safe place for them to speak about their trauma.
        The prevalence of trauma in Delaware and children coming
    into foster care is putting an extreme toll on our child
    welfare workforce as well. So we have to also look at not only
    mental health access for these children, but also the fact that
    there will be child welfare protection services that must also
    be funded in order to keep these children safe when abuse or
    neglect is identified during that mental health treatment or
    school atmosphere.
        Senator Murkowski. Well, thank you for that. Know that
    these are issues that, working with Senator Smith and others,
    we'd like to pursue.
        With that, Mr. Chairman, thank you.
        The Chairman. Thank you, Senator Murkowski.
        Senator Baldwin.
        Senator Baldwin. Thank you, Mr. Chairman.
        I really appreciate the opportunity to have you here as
    witnesses today to talk about the discussion draft of the
    Opioid Crisis Response Act. I'm really grateful to my
    colleagues for some of the ideas that are being proposed for
    additional discussion and inclusion.
        Mr. Morrison, I wanted to start with you. You've already
    been questioned about this. You noted it in your testimony. We
    have right now a place holder in this discussion draft in terms
    of renewal and improvement of the STR Grant. You noted the
    fiscal cliff, and you also made note of the flexibility that
    would be welcomed for dealing with drugs beyond those described
    as opioids.
        I wanted to just mention in my travels around the State of
    Wisconsin--and I've been hosting roundtables with various
    stakeholders in various parts of my state for several years
    now, almost since I joined the Senate in 2013-2014. I have seen
    regions of the state that are dealing with a meth crisis and
    regions of the state that are dealing with an opioid crisis. It
    was very distinct when I first started.
        Now, in the last couple of months when I've had recent
    roundtables, I'm being told that almost everybody who is either
    encountering law enforcement or is encountering emergency
    treatment has multiple drug--they're presenting with multiple
    drugs. There's no clean distinction, just as we were hearing
    from Senator Murkowski about Alaska, although I'm sure we have
    local differences.
        I wonder if you could speak to the importance of that
    flexibility. It may be that what brings all of this together is
    just the spike we call it an epidemic, because between 2000 and
    today, whether it's the--pain is the fifth vital, or whatever
    other contributing factors there are, we've seen such a deluge,
    such a crisis. But it does seem to me like it's going from
    prescribed opioids to heroin and fentanyl to now people
    accessing whatever they can when the addiction has really
    gripped them.
        Mr. Morrison. I agree that we should look at it, at its
    core as a problem with addiction, and look at ways to be
    flexible, allowing states to target areas of need based on
    their particular drug of choice. I think with the opioid
    epidemic, we also saw the need for medication-assisted
    treatment, and those efforts have been critical, and looking at
    evidence-based approaches to also keeping the families
    together--important work that this Committee did was to create
    a pilot program for pregnant postpartum women to look at
    different ways they could support family centered services. So
    the bottom line is in Wisconsin, about half of your admissions
    to treatment are from alcohol.
        Senator Baldwin. I know I'm not going to have time to ask
    all the questions I'd like. Let me just note a couple of issues
    on the record that I will hopefully be able to get answers
    after the hearing.
        I wanted to add my words to Chris Murphy's question
    relating to recovery coaches. We have a very innovative program
    going on in the State of Wisconsin. Jesse Heffernan of
    Appleton, Wisconsin, a longtime advocate and recovery coach,
    was inspired by his own experience with substance use disorder
    to start a Recovery Corps program to integrate recovery coaches
    into the entire substance use care curriculum, and it's being
    piloted by Marshfield Health System. So I'd love to ask some
    specific questions for your feedback on that.
        Senator Baldwin. One other question, Ms. Nickel, if I can
    ask you, with clearly inadequate time to answer it now. We need
    everyone at the table to work together to appropriately combat
    this epidemic, and I'm encouraged that your organization is
    committed to a comprehensive response. But I'm also concerned
    with the pharmaceutical industry's role in the opioid crisis
    and believe that we need to do more to hold drug makers
    accountable.
        More than half the counties in my state have filed lawsuits
    against pharmaceutical companies, and I've heard from
    Wisconsin's substance abuse and recovery leaders about their
    continued concerns with the drug companies' influence in our
    response efforts, and we certainly know of their influence here
    on Capitol Hill. So I would love to hear from you sort of best
    practices and how you work with many industry partners,
    including drug companies; what policies we need to enact to
    prevent conflicts of interest as we continue to fight this
    epidemic.
        The Chairman. Ms. Nickel, we're out of time, but please go
    ahead and answer the question. Then you may want to follow-up
    with a written answer to Senator Baldwin.
        Ms. Nickel. Absolutely. You know, this is an issue about
    addiction, and we don't have a medication-assisted treatment
    for methamphetamine use disorder. We don't have a medication
    for cocaine use disorder, and we're seeing an increase in drug
    overdoses and drug overdose deaths, particularly in our African
    American communities, to cocaine use disorder overdoses. We
    don't have great medications for alcohol use disorder. We need
    more.
        We firmly believe that in the treatment and the advancement
    of science and research and innovation and a cure that we need
    to be partnering with scientists and universities and companies
    that have R and D budgets, because you don't cure a disease
    without having the smart white lab coats at the table with you.
    So our commitment to having everyone at the table includes
    those that can give us the medications that we need to survive
    this illness.
        The Chairman. Thank you very much, Senator Baldwin.
        Senator Hassan.
        Senator Hassan. Thank you very much, Mr. Chair, and I want
    to thank you and the Ranking Member for your bipartisan work on
    this discussion draft of this bill, and I want to thank the
    witnesses for being here.
        I want to speak for a minute to the continuing work we're
    doing on the bill and note that as we continue our work
    together, it's really critical that we ensure that we are
    adequately prioritizing Federal funding for states that have
    been hardest hit by the opioid crisis, a priority that has
    bipartisan support. I appreciate you recognizing that this is
    something that needs to be included. I look forward to
    partnering with the Chair and Ranking Member and others on
    this.
        You know, I just did a ride-along in my home State with the
    Manchester, New Hampshire, police department, and in my first
    hour and a half, we responded to three overdoses. So when we
    are hit hard right now with the fentanyl epidemic, in
    particular, that is so lethal, we really need to make sure that
    we're doing everything we can to help the hardest hit states
    and help the hardest hit states develop expertise.
        I also appreciate that the draft legislation includes a
    number of other priorities I've championed, including the
    Comprehensive Opioid Recovery Centers Act, which I introduced
    with Senator Capito. There's a similar bipartisan bill in the
    House of Representatives as well.
        The bill would create a pilot program allowing HHS to award
    grants to expand existing centers to serve as comprehensive
    opioid recovery centers. These centers would provide a full
    range of treatment and recovery services to not only treat
    patients but also to provide them with the wrap-around services
    they need to move to successful and drug-free lives.
        The centers would also have outreach to community partners
    to provide information about the services available at the
    centers to help ensure that those seeking treatment know what
    their options are. The kind of wrap-around support offered by
    CORC is critical for those in recovery and is especially needed
    in states hardest hit by the opioid epidemic.
        I want to just add my to-do list to Senator Murphy's and
    others. I hope that the Chair and Ranking Member will continue
    to work with me and others to make sure we're adequately
    prioritizing those hardest hit states in this provision
    concerning the CORC centers as well. I've heard from a number
    of providers and stakeholders in the granite state in support
    of this legislation, and I hope we can get this bill passed.
        With that statement, now I do have actually a couple of
    questions.
        To Mr. Morrison: During our hearings on the opioid crisis,
    we heard from a stakeholder from New England who is utilizing a
    really unique model to increase access to medication-assisted
    treatment, a model I'm working on legislation to replicate on a
    national level. This model was actually developed with the help
    of our current Assistant Secretary for Mental Health and
    Substance Use, Dr. Elinore McCance-Katz, when she was working
    in Rhode Island.
        Under this model, medical students are getting training in
    medical school on addiction issues and medication-assisted
    treatment. Once the students graduate, move on to their
    residencies, get licensed to practice, and get their DEA
    number, they can apply right away for a so-called data waiver
    to prescribe buprenorphine. They don't have to take an
    additional 8-hour course for it. They're just set to go.
        I really think what they're doing in Rhode Island is a
    great idea. So I'm working on a bill that I hope will be
    included in the bipartisan Opioid Crisis Response Act, what
    we're talking about today, to facilitate this program for other
    medical schools who want to do it. My legislation, the
    Enhancing Access to Addiction Treatment Act, will provide
    voluntary grants to support medical schools and residencies in
    developing their own programs to train students and establish a
    new pathway to let these trained, practicing physicians apply
    right away to prescribe medication-assisted treatment, the same
    time they can start prescribing opioids.
        Mr. Morrison, what do you think about this idea? Will it
    help to increase patient access to medication-assisted
    treatment?
        Mr. Morrison. I think it will, and I appreciate your
    leadership. I know our member, Becky Boss, when she presented
    testimony here, referred to that program as well, and she said
    it's a tremendous success to increase--or decrease barriers and
    make it easier to get waived and actually dispensing and
    providing the care we need, and we know we need additional
    folks prescribing and increasing MAT. So I look forward to
    working with you on it.
        Senator Hassan. Well, thank you very much. And in my last
    half a minute, I just wanted to also talk with you, Mr.
    Morrison, about some really important work being done in
    schools relating to substance use prevention. One of the
    overdoses we responded to--we got there--in Manchester, there
    were firefighters, EMTs, police, and DCYF, our child protection
    services, because the ripple effect here is hitting everyone.
    In the Laconia School District in New Hampshire, they've been
    really hit hard.
        I think there is more to do to encourage collaboration and
    cooperation. We have some examples, and I will follow-up with
    you, because I'm already overtime, on your thoughts on how we
    can better address efforts for school and treatment, behavioral
    health collaboration to really help our kids and our families
    who are traumatized and struggling with this. I'll follow-up
    with you in writing. Thank you.
        The Chairman. Thank you, Senator Hassan.
        Senator Casey.
        Senator Casey. Mr. Chairman, thank you very much. I want to
    thank you and Ranking Member Murray for the work you've done,
    not only to bring us to this point with regard to the Opioid
    Crisis Response Act but also the hearings that have been
    undertaken over many weeks now. We're grateful for that help,
    and also thank you, in particular, for including provisions to
    further strengthen state efforts to protect infants affected by
    substance abuse, known as the Plan of Safe Care provision of
    the Child Abuse Prevention and Treatment Act, so-called CAPTA
    legislation.
        Chairman Alexander and I worked together on the Infant Plan
    of Safe Care Improvement Act in 2016, and I appreciate that
    work. This current bill builds on that law by providing a new
    grant program to support state efforts to provide these Plans
    of Safe Care. I'm also grateful for the additional $60 million
    in funding that was included in the omnibus for CAPTA at my
    request, and I look forward to advancing this new proposal to
    create a more permanent program to support states in this work.
        Ms. Donahue, I know I'm the last questioner, so I'll get to
    questions now for you. I may not get to our other witnesses.
    But I wanted to start with a statement that you made at the end
    of your testimony, page 7, and I'm quoting at the bottom of
    page 7, quote, ``Infants with prenatal substance exposure and
    their parents struggling with opioid addiction have multiple
    and complex needs that require a collaborative response by a
    multi-disciplinary team,'' unquote.
        Can you talk about what that looks like in reality on the
    ground? Who are the multi-disciplinary participants involved in
    creating the typical Plan of Safe Care?
        Ms. Donahue. Thank you. Our SEI Committee, our Substance
    Exposed Infants Committee, is made up of public health, family
    courts, social workers in the hospitals, child welfare workers.
    Every birthing hospital has representation on there. We have,
    of course, the substance use treatment providers, and, of
    course, our State is one of the smaller states, and we're doing
    this on a statewide basis. But we do have a very broad
    representation on our committee because of the fact that it's
    not just one agency that has their responsibility and
    accountability in this issue. It's very vast.
        Our Plans of Safe Care--I did attach a copy of one of the
    drafts that we're utilizing right now in four of our six
    hospitals, and so far, it's been a challenge. It's been a very
    difficult challenge, not necessarily implementing it, but the
    monitoring piece. We know that this population of women are
    very vulnerable. Pregnant women struggling with addiction have
    a stigma that is great, and women fear coming to get prenatal
    care because of the possible stigma by medical providers. They
    are fearful that when the birth event comes, that child welfare
    will take their infant.
        There's lots of aspects to this population that we have to
    be mindful of, and coming together in a collaborative way and,
    hopefully, having these Plans of Safe Care begin prenatally so
    that mother has the supports around her from all of these
    different multi-disciplinary members, the birth event will go
    much more smoothly and she'll have trust of all of us to move
    forward with helping her and her family.
        Senator Casey. I appreciate that, and I know you've
    emphasized the importance of those teams. Also, I wanted to
    indicate that you've noted that it's important to have a non-
    punitive, public health oriented approach to working with these
    vulnerable families, and we know that's critical. It's also
    something that's a key part of CAPTA. In fact, we have a former
    member of the Pennsylvania delegation, then Congressman Jim
    Greenwood, who is the original sponsor of the Plan of Safe Care
    and has said that this was his original intent.
        I would ask Chairman Alexander for unanimous consent to
    include in the record of the hearing a letter from former
    Congressman Greenwood in which he says the following. I'll just
    read portions of it in short fashion: ``In 2003, I worked with
    my congressional colleagues to ensure that CAPTA was written so
    that this, quote, 'appropriate referral,' unquote, and the
    development of a Plan of Safe Care for the infant was not
    wrongly interpreted as Congress establishing a Federal law of
    what constitutes child abuse and neglect. Also, Congress' 2003
    amendment of CAPTA did not advance a tool to encourage the
    criminal prosecution of a woman who consumed drugs or alcohol
    during pregnancy,'' unquote.
        I'd ask consent to have the letter included.
        The Chairman. It will be included, Senator.
        Senator Casey. Thank you, Mr. Chairman.
        [The information referred to follows:]
        [GRAPHIC] [TIFF OMITTED] T8493.001

        [GRAPHIC] [TIFF OMITTED] T8493.002

        [GRAPHIC] [TIFF OMITTED] T8493.003

        Senator Casey. I have one more question, but I'll maybe
    submit that for the record for Ms. Donahue, and I may have some
    questions for the other panelists. Thank you for your testimony
    and your good work. \6\
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        \6\  No responses were submitted for the Record.
    ---------------------------------------------------------------------------
        The Chairman. Thank you, Senator Casey.
        Mr. Morrison, let me especially ask you this, although I'd
    be interested in other comments. You work with a lot of state
    agencies and state directors, and there's always a temptation
    when there's a problem to solve it from Washington, and we have
    to think about that, too--the difference between creating an
    environment in which states and communities and doctors and
    healthcare workers can solve a problem or creating mandates and
    orders from here which sometimes sound good at the beginning
    but get in the way.
        Let me ask you about three or four areas. You've had
    conversation, I'm sure, with Governors, with state directors in
    this area. For example, 28 States have prescribing limits for--
    some limit on the number of opioids doctors can prescribe at
    one time. We don't create a Federal mandate. We leave that to
    states, although we do allow the Food and Drug Administration
    to create blister packs, which would be smaller doses.
        Electronic prescribing--we've heard testimony that that's
    beneficial. Nine states are moving ahead to require that in one
    way or another, creating a digital record. We don't have a
    mandate for that, figuring that States from Alaska to New York
    are different and have better ways to make those decisions.
        Prescription drug monitoring programs--about 45 States
    share data with other states, and 37 states require that
    doctors and pharmacists check their state's PDMPs to help
    prevent patients with substance abuse disorder from doctor and
    pharmacy shopping. We don't create a Federal mandate on PDMPs,
    but we do include support for states to improve their systems
    and their sharing of information, and we have appropriated a
    large amount--or approved a large amount of money, $356
    million, 2 weeks ago to help states do a better job of that.
        Then there's the medical education curriculum. I've
    mentioned dropping in on Governor Haslam in Tennessee, and he
    had everybody there who trains doctors and healthcare workers
    to talk about how they should adjust their curriculum to
    reflect the prescribing of opioids. We don't have a Federal
    mandate on telling states how to do that.
        What's your comment on that? And can you think of other
    ways that our legislation can create an environment in which
    states might more easily prescribe appropriate limits, whatever
    those might be, encourage electronic prescribing, have more
    effective prescription drug monitoring programs, better medical
    education curricula? How can we do that without having the
    heavy hand of Washington tell everybody what to do?
        Mr. Morrison. I appreciate saving the easy stuff for last,
    Senator. But, absolutely. Our model at the association is a
    states helping states model, and they very much appreciate
    hearing from other states about best practices, about ways
    things are done that are working. And as much as it's important
    to know that they're working, the question we get most often
    is: How did you do it? How did you get there? What are the
    components of your state's system? Because they are so
    different--the financing structure, the different rules and
    regs. But at its core, someone has to navigate all this to
    happen.
        Our preference is best practices, these models. The
    recovery residences approach in your bill is a great example of
    what's extremely helpful to states--having a dialog about how a
    particular issue plays out, and then promoting, talking, and
    seeing how they play out.
        Our default is to help states in terms of providing the
    most flexibility to then partner with the Federal Government
    and to make improvements that way. We absolutely adhere to the
    National Governors Association and their principles of how the
    Federal-state partner is critical. So we appreciate that
    perspective, and it's what we do every day, finding that sweet
    spot.
        The Chairman. Let me ask one other question, Ms. Nickel and
    Ms. Donahue, or any of the three of you. In my visit to
    Tennessee last week, I mentioned to you the two criminal court
    judges that I talked with, who said the following: that they
    see--and I mentioned this--60,000 cases--well, this is not the
    figure--this is the other example. They said they see between
    50 and 100 probation violations each month, about 75 percent
    involving offenders testing positive for drugs. But this is the
    point. About half of the 75 percent test positive because the
    offender has taken medication-assisted treatment that was
    prescribed for someone else.
        We've talked a little bit today about allowing more people
    to provide medicated-assisted treatment and how important that
    treatment is to avoiding overdose. But what about the diversion
    of medication-assisted treatment? Are you seeing that in your
    states? I mean, what they're saying they see is that suddenly,
    the basically lower doses of opioids that are used for
    medicated-assisted treatment are being diverted and are showing
    up as more and more of the source of the problem. Do you have
    any comment on that?
        Ms. Nickel. I think we do need to make sure we give the
    right resources and tools to law enforcement and to our
    criminal justice systems to deal with diverted substances. But
    the other reality is that when you see a presence of
    medication-assisted treatment, particularly among our patient
    population who have an opioid use disorder, many are self-
    managing their own symptoms.
        Like if you can get buprenorphine or methadone on the
    street, you can also probably get heroin, which is a much
    better high, and it's going to be a much more powerful drug.
    So, usually, it's almost an indicator that more treatment is
    needed in that community as well, because you have people like
    you and me that are trying to manage a very powerful disease on
    their own.
        The Chairman. Ms. Donahue.
        Ms. Donahue. Thank you. In the child welfare realm, many of
    our pregnant women are utilizing medication-assisted treatment,
    and it's very beneficial for her and her infant.
        The Chairman. I also heard that at the hospital, too,
    that----
        Ms. Donahue. Yes.
        The Chairman ----many of the babies are the result of
    mothers with medication-assisted treatment. Is that what you're
    about to say?
        Ms. Donahue. Yes. However, what we are seeing at times is
    that children may in the home access that medication----
        The Chairman. Oh.
        Ms. Donahue ----and we are seeing at times that two or 3-
    year-old siblings in the home--if the particular parents have
    take-home doses of their medication-assisted treatment, that
    has to be secured, because many of these cases are involving
    children overdosing on those types of medications in the home,
    and that's what----
        The Chairman. They're young.
        Ms. Donahue. Yes, if they're getting access to them. So in
    the child welfare realm, we have to be cautious as well that
    there are certain precautions in place for that type of
    medication.
        The Chairman. Well, let me thank the three of you for very,
    as you've heard the Senators describe, poignant, sensible, and
    effective testimony as you reviewed our proposed legislation.
        Just talking with the staff and with Senator Murray, we're
    on a schedule to mark that bill up on Tuesday, the 24th, which
    means we've got some work to do before that, I'll say to the
    staff, but they're working well together. And we also have
    other legislation that we hope to mark up on that day as well.
    This is our seventh bipartisan hearing on the subject. We hope
    we can make a contribution to the crisis.
        Other committees are working on the area as well, and what
    we hope to be able to do is, after the end of this month, to
    take our bill to Senator McConnell and ask him to find time for
    it on the Senate floor, and then work with the Judiciary and
    Finance Committees to see what suggestions they might have to
    improve or amend the work that we have done.
        I'd like to ask for unanimous consent that the statement
    from the Department of Health and Human Services be submitted
    into the hearing record. \7\
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        \7\  Department of Health and Human Services statement was not
    submitted for the Record
    ---------------------------------------------------------------------------
        The Chairman. The hearing record will remain open for 10
    days. Members may submit additional information for the record
    within that time if they would like.
        Our Committee will meet again on Tuesday, April 24, at 10
    a.m. to mark up the Opioid Crisis Response Act of 2018 and
    other important bipartisan legislation.
        Thank you for being here today. The Committee will stand
    adjourned.
        [Whereupon, at 12:01 p.m., the hearing was adjourned.]

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