[Senate Hearing 115-872]
[From the U.S. Government Publishing Office]
S. Hrg. 115-872
THE OPIOID CRISIS
RESPONSE ACT OF 2018
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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
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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
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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
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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.
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\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.''
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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.
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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
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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.]
[all]