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


                                                     S. Hrg. 115-872

                           THE OPIOID CRISIS
                          RESPONSE ACT OF 2018

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                                   ON

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

                             APRIL 11, 2018

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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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

                              ----------                              

                               STATEMENTS

                       WEDNESDAY, APRIL 11, 2018

                                                                   Page

                           Committee Members

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

                               Witnesses

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

 
                           THE OPIOID CRISIS
                          RESPONSE ACT OF 2018

                              ----------                              


                       Wednesday, April 11, 2018

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

                 OPENING STATEMENT OF SENATOR ALEXANDER

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

                  OPENING STATEMENT OF SENATOR MURRAY

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

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

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

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

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

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

           3. Providing grants to states to improve data collection.

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

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

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

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

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

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

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

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

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

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

    Thank you very much for the opportunity to speak with you today 
about infants with prenatal substance exposure and I welcome any 
questions you may have.
                                 ______
                                 
    The Chairman. Thank you, Ms. Donahue.
    Mr. Morrison, welcome.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

    NASADAD's overarching recommendations:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

    1. Help Families in Crisis

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

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

    2. Expand Treatment Access and Integration into Healthcare

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

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

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

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

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

    3. Drive Discovery in Research and Cures

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

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

    4. Expand Recovery Supports

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

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

    5. Advance Evidence-Based Prevention

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

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

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

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

    6. Protect Children Impacted by Parental Substance Use Disorder

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

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

    7. Reframe the Criminal Justice System:

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

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

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

    8. Educate and Raise Awareness

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

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

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

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

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

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

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

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

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

    Thank you for the opportunity to testify today and for your 
commitment to addressing such an important issue that impacts millions 
of American families every day.
                                 ______
                                 
              [summary statement of jessica hulsey nickel]
    I started the Addiction Policy Forum to help patients, families and 
stakeholders across the country advocate for a comprehensive response 
to addiction--including prevention, treatment, recovery, overdose 
reversal, criminal justice reform and law enforcement. Our nonprofit 
convenes key partners from throughout the field around one table with 
shared goal: to help create a world where fewer lives are lost to 
addiction and help exists for the millions of Americans who need it.

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

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

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

    These provisions include comprehensive opioid recovery centers, 
national recovery housing best practices, first responder training, 
improving access to telemedicine, disposal of controlled substances by 
hospice care providers, and increased education and training for 
providers. These and many other provisions in this bill are important 
components to the comprehensive response we need in our Nation to 
address the addiction crisis.
                                 ______
                                 
    The Chairman. Thank you, Ms. Nickel, for your touching 
stories and your testimony, and to all of you for your work and 
your time for being here. As you can see, you have our full 
attention, and we welcome your advice.
    We'll now begin a round of 5-minute questions with 
Senators.
    Senator Collins.
    Senator Collins. Thank you very much, Mr. Chairman, and 
thank you for the very important work that this Committee is 
doing.
    In Maine, we experienced a record high number of overdose 
deaths last year, claiming some 418 lives. This past weekend, 
there were nine overdoses as a result of some fentanyl-laced 
heroin. Fortunately, first responders were able to save these 
individuals. But it's so clear that we need to take an all-of-
the-above approach to addressing the opioid epidemic.
    This week, I'm introducing three bipartisan bills to 
address this crisis, and I look forward to working with the 
Chairman and Ranking Member in the hopes of incorporating them 
into the Committee's tremendous legislative effort.
    Ms. Nickel, I want to start with you, and I want to first 
thank you for sharing your extraordinary personal tragedy with 
our Committee and also telling us of other families that have 
been affected. It's very poignant. It puts a human face on this 
epidemic, and that's very important.
    One way that families are finding support is through peer-
to-peer recovery groups. I toured a volunteer-led Bangor Area 
Recovery Network in Brewer, Maine, last year that is a model 
for peer-led counseling and brings hope, recovery, and healing 
to those who are struggling with substance abuse. Have you seen 
peer-to-peer groups make recovery more sustainable? Do you have 
any advice for us on that approach?
    Ms. Nickel. Absolutely. Peer recovery support specialists 
are a key component to making sure we provide the services that 
are needed for folks that are in recovery, those that need 
treatment--individuals that have lived experiences and can make 
that connection. We've learned this with peer programs in the 
mental health lane, peer programs in veterans services, and 
it's the same for our patient group.
    A few of the programs we've seen--Addiction Policy Forum 
has six peer recovery support specialists that work for us. 
They provide crisis support to individuals in recovery and the 
connection to services that are needed, and I think it's a 
critical element. In Rhode Island, there's an amazing program 
called AnchorED where peer recovery support specialists connect 
with a patient that's had a nonfatal overdose and gets them the 
services that they need.
    I think we've learned on the ground and from a lot of 
anecdotal evidence that this is a key component. We need more 
research to make sure that we're putting this in the right 
direction, and we definitely need more funding support.
    Senator Collins. Thank you, Ms. Nickel. The other issue 
that I want to bring up in my remaining time is the fact that 
when people are receiving hospice care in their homes, they 
frequently need powerful painkillers. I am a big proponent of 
hospice care. I believe that most people would prefer to die at 
home if they can, and, obviously, we want to provide effective 
relief.
    Unfortunately, there oftentimes are powerful painkillers 
that are left over at the time of death, and yet hospice staff 
are not allowed to dispose of these unused medications, even 
after the patient has died. So this opens the door to 
diversion, to theft, to abuse. Another bill that I'm developing 
with Senators Warren, Hassan, and Rubio would allow hospice 
staff, nurses, physicians, and paramedics to dispose of unused 
medication, to collect them and take them out of the household.
    Do you believe that this would be helpful in stopping some 
of the diversion and theft and misuse that occurs now?
    Ms. Nickel. Absolutely. We know that the disposal of unused 
prescription painkillers is a key component to making sure they 
don't fall into the wrong hands, whether that's diverted onto 
the streets, to be sort of picked up by an adolescent in that 
household. It's a critical component.
    We have two programs every year to encourage our families 
to work with stakeholders in communities to make sure that 
we're disposing of medications. I think, particularly focusing 
on hospice care, making sure that any of the barriers that 
those workers have to making sure that they have the authority 
to dispose of those medications is a key component to keeping 
our communities safe.
    Senator Collins. Thank you so much.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Collins.
    Senator Murray.
    Senator Murray. Thank you, Mr. Chairman, and thank you to 
all of our witnesses today.
    When I talk to teachers and parents and other community 
members back at home, they tell me we need to prevent this 
generation of children from becoming the next generation of 
adults who have substance use disorders. It is really a 
heartbreaking conversation. Children of parents who struggle 
with substance use disorders--Ms. Nickel, you talked about 
that--too often experience trauma that puts them at a higher 
risk of negative health outcomes, including developing 
substance use disorders themselves and even early death.
    Ms. Donahue, let me start with you. How do you see our 
discussion draft helping to address those issues, and what more 
could we do to address trauma among young people in light of 
this crisis?
    Ms. Donahue. Thank you for your question. I think it's key 
that we provide mental health services in schools, particularly 
at the earliest possible time. Children who experience trauma 
will often have the adverse childhood experiences that will 
buildup over time if they are still in that dysfunctional home 
or environment. So if mental health services are provided early 
in schools and the school can sort of be that support person 
along with the teachers for that child, I think we will very 
much greatly reduce the number of children who grow up and 
develop mental health conditions themselves or turn to 
substance use. I think that is extremely important. I also--and 
I believe that bill covers that funding for that.
    The other issue is for pregnant women who are struggling 
with addiction. I think mental health services coupled with 
their substance use disorder is key as well. Often, as my 
statistics indicated, there is a dual diagnosis of these women 
who are struggling with substance use and mental health 
conditions.
    Senator Murray. Thank you very much.
    In 2017, the Centers for Disease Control and Prevention 
supported grants in actually 43 states that enhanced 
prescription drug monitoring programs in support communities 
and health systems; prevention efforts as well as grants to 33 
of our states for enhanced surveillance of drug overdoses. 
Those grants have actually played a very critical role in 
supporting many hard hit areas.
    But they were not funded at a level to reach the entire 
nation until we just passed the recent omnibus, and I'm really 
glad we had bipartisan support for expanding these programs. I 
know on our side, Senators McCaskill and Tester worked really 
hard on those provisions that would promote this effort in the 
bill we're talking about today. But we know that successful 
prevention efforts need sustained commitments.
    Mr. Morrison, let me ask you--in achieving your 
organization's mission for drug abuse prevention and treatment, 
how vital is national data?
    Mr. Morrison. Absolutely critical. Our members are 
beneficiaries from a lot of the data sets that are available at 
the Federal level. We also feed up data to SAMHSA, for example, 
through the Treatment Episode Data Set. But we know the 
National Survey on Drug Use and Health has about 75,000 people, 
looking at their use patterns, demographics, and the like, and 
SAMHSA has done a nice job to work with states in order to look 
at--to try to localize that data at state level estimates.
    Senator Murray. How important is it that we have data from 
every state?
    Mr. Morrison. Critical. For example, you mentioned PDMPs. 
Our members very much appreciate the data from PDMPs, because 
they can utilize that data for hot-spotting, looking at the 
state, identify data to particular areas, and then you can 
target prevention messaging based on that hot-spotting in your 
state. That's done with a state-Federal partnership. The 
resources are important as well. It can be expensive.
    Senator Murray. You know, over the past few years and even 
in the past few weeks, I've heard a lot about the gaps in our 
behavioral health workforce and how that is crippling our 
efforts to fight this crisis. I've heard about the need to make 
sure patients fighting addiction have support in navigating and 
access to comprehensive services, whether it's to stay on track 
with medication-assisted treatment once they have that, mental 
health treatment, rebuilding relationships, getting back into 
the workforce, all of that. But we don't have enough 
professionals who provide those critical services.
    Mr. Morrison, let me ask you--what role do those providers, 
that workforce, play for patients fighting addiction?
    Mr. Morrison. They're critical, and the expertise and that 
therapeutic relationship they have with a particular person is 
a key predictor of success. We need them to have that 
expertise, but it can be a challenge. I was talking to 
Washington State--Chris Imhoff, the state director, just 
yesterday, and she expressed appreciation for the loan 
repayment provisions included in the proposal, because that can 
be a deterrent to going into the field, because we know also 
that salaries aren't--so any additional help, such as a loan 
repayment provision specific to substance use disorders is 
appreciated.
    Senator Murray. Okay, I really appreciate that. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murray.
    Senator Roberts.
    Senator Roberts. Thank you, Mr. Chairman. Let me make the 
observation that, once again, you and Senator Murray are 
working together in a bipartisan fashion with the rest of the 
Members of this Committee to address an extremely serious 
problem that we're facing in this country, and I thank you for 
your leadership, and, somehow, you are always able to pull the 
chestnuts out of the fire and get something done.
    I want to thank the staff for working with my staff on 
legislation that I would like to introduce on behalf of Heidi 
Heitkamp, who is my Co-Chair of the Senate Rural Healthcare 
Caucus, with regard to telemedicine. So thank you for your 
efforts.
    Ms. Nickel, Senator Collins referenced your testimony as 
being very poignant, and I was trying to think of a word that 
could trump that. I don't think I can. Thank you for that 
testimony, and I hope I'm not out of order in stating that I 
feel very sure that your mom and dad are very proud of you with 
regard to what you're doing and putting a face on this terrible 
scourge in our country with Courtney, Larry, Emmett, and Dylan.
    That's the way to approach this, Mr. Chairman. I think we 
really need to do that. We can get some things done.
    You made some suggestions on page 8, where you talk about 
getting our schools involved, which I think is pretty much a 
commonsense approach and would recommend that to our leadership 
here. You say comprehensive school, community-based assessment 
and early intervention activities, and programs such as student 
assistant programs--there's an acronym for that. Everything has 
to be an acronym--SAP. I don't think we're saps for considering 
it--but, at any rate, in middle and high school settings, can 
play a critical role in stopping the addiction cycle, and I 
certainly agree with that.
    I'm popping over to page 13, where you address 
telemedicine. I've heard from many Kansans who have had to 
travel long distances, sometimes across state lines, in order 
to access any kind of substance use treatment. For example, the 
nearest methadone clinic for southeast Kansas is in Joplin, 
Missouri. We Kansans--still, when traveling to Missouri, it's a 
traumatic experience, Mr. Chairman. We're always glad to get 
back. But that shows you what we're facing.
    Both Senator Heitkamp and I are very interested in 
telemedicine's potential to assist these patients in receiving 
the necessary diagnosis and treatment. We've been working with 
telemedicine just in terms of access to healthcare for a long 
time.
    So, Ms. Nickel, what services can be used via telemedicine 
to best treat patients with substance abuse disorder?
    Ms. Nickel. Telemedicine is a key component to meeting our 
treatment capacity gaps that we have. Right now, only 10 
percent of our 21 million people that need treatment are going 
to receive it this year. Can you imagine 10 percent of cancer 
patients receiving treatment? And, in particular, for rural 
communities, telemedicine can be a game changer on getting the 
treatment components that you need for a long-term recovery 
plan--treatment and recovery plan, and there's a couple of 
different pieces of that.
    One is treatment itself: telemedicine's capability for 
prescription of medication-assisted treatment, which is 
particularly important if you're in a rural community and you 
don't have a provider that's even within hours of a drive and 
you need to be able to have that medication for that patient, 
but also telemedicine for counseling services, for behavioral 
health support, and even intervention such as cognitive 
behavioral therapy. There's some red tape that exists that 
makes this difficult to deliver these services across state 
lines and to streamline the availability. So all of these 
different components made available through telemedicine could 
be a game changer.
    Senator Roberts. I appreciate your response.
    Mr. Chairman, I also want to thank Ms. Donahue and Mr. 
Morrison for their contribution, and I'm going to yield back 
time, which I know is most unique for me, but----
    The Chairman. We'll mark that as an important event. Thank 
you very much.
    [Laughter.]
    The Chairman. Thank you, Senator Roberts.
    Senator Warren.
    Senator Warren. Thank you, Mr. Chairman.
    You know, I'm very glad to see this Committee working 
together to address the opioid crisis. In Massachusetts, more 
than five people are dying every day, on average, from opioid 
overdoses, and we need action now on this. Senator Capito and I 
have been working together for several years on a bill to allow 
partial filling of opioid prescriptions so that people only get 
the opioids that they actually need. The idea is to reduce the 
number of pills that are in circulation.
    We got this legislation passed in 2016, and we recently 
introduced a bill to improve implementation of this law by 
clarifying the FDA's authority to make sure that doctors and 
patients actually knew about the partial fill option. You know, 
this is one of those bipartisan, consensus, commonsense 
provisions that would reduce unused medications that are lying 
around in the home, and I'm hoping that we will be able to get 
it included in the final passage as it goes through Committee, 
and we'll continue to work together on this.
    Let me just ask a question about the risk posed by unused 
medications.
    Mr. Morrison, why might unused medications lying around the 
house pose a risk of misuse or diversion?
    Mr. Morrison. Sure. We know from data that SAMHSA collects 
that the source of the use of medications that are not 
prescribed to folks--about half come from that particular 
situation, friends and family. So efforts to make sure that 
doesn't happen are real important.
    Senator Warren. Right. And, for instance, family--they may 
not even know about it, but it's up there on the shelf and 
imposes a risk.
    Mr. Morrison. That's right.
    Senator Warren. Yes. So one of the times that individuals 
are most likely to use opioids to manage pain is at the end of 
life. But right now, in many states, hospice employees are not 
legally allowed to dispose of opioid medications on behalf of a 
patient who has passed away.
    I've, again, been working on a bipartisan basis with 
colleagues to try to address this issue and make sure that 
hospice employees can safely dispose of medications. Families 
dealing with the loss of a loved one shouldn't also have to 
worry about dealing with dangerous leftover drugs.
    Here's something else that families shouldn't have to worry 
about, whether a sober living home is actually helping their 
loved ones recover or pushing them back into addiction.
    Mr. Morrison, can recovery housing be an important piece of 
the puzzle for individuals in recovery from addiction?
    Mr. Morrison. It's a critical part of the continuum. I know 
in Massachusetts, you all worked with the National Association 
of Recovery Residences. They've developed a tier level of 
explanation about different options. We've been working closely 
with them, other states as well. Recovery housing is critical.
    Senator Warren. And can you just say another word about the 
quality of recovery housing? Is there some variation here?
    Mr. Morrison. There can be, and I think the bill that is 
before the Committee, the discussion draft, seeks to put out 
standards, models, so that states can look at those, talk to 
each other, and look at best ways to implement recovery housing 
with important standards.
    Senator Warren. Good. You know, most of these facilities do 
a great job, but there are too many examples of ones that 
don't. I led a bipartisan request to get the GAO to look into 
this problem, and this discussion draft also contains language 
that I've been working on with Senator Kaine and others to try 
to establish best practices for recovery homes to help patients 
make the best choices in their recovery.
    My view on this is we need to use every single tool in the 
toolbox to tackle this epidemic, and these bipartisan efforts 
will help, and I'm glad to work on it. But let me be clear on 
this. Congress has nibbled around the edge of this problem for 
years, and the problem has gotten worse and worse. This latest 
round of policy changes is no substitute for giving communities 
the resources and the expertise they need to fight this fight 
on the ground.
    That's why Congressman Cummings and I are introducing new 
legislation based on the Ryan White Care Act, the landmark bill 
that Senator Kennedy and Senator Hatch passed back in 1990 to 
tackle the HIV-AIDS epidemic. I hope Senators on both sides of 
the aisle will support it, because the AIDS crisis taught us 
that what it takes to beat an epidemic like this is that we 
really have to put the resources and the energy behind it, and, 
right now, I just don't think we're doing what it takes. We 
need to do better.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Warren, and thanks for 
your work on partial fill and the hospice legislation that you 
and Senator Collins and others--and, Senator Roberts, thanks 
for your work on the telecommunications provisions of the bill.
    Senator Isakson.
    Senator Isakson. Thank you, Mr. Chairman, and thanks to you 
and Ms. Murray for the job you all are doing on the opioid 
issue, which is a big issue.
    Ms. Nickel, I agree with you that it's important to put a 
face on the problem, because it is a terrible problem in our 
country. My grandson died of an overdose in 2016. He was one of 
the 63,300 that you listed in your testimony who died in 2016 
from an opioid overdose. He died two nights before he was going 
to get a summa cum laude diploma in mathematics from the 
University of Georgia Southern. He had been out of recovery for 
4 years, had been in a great program. We thought he was back.
    He was doing terrific in school, obviously, getting a summa 
cum laude diploma, but he also was working. He had a job when 
he finished. We were excited. Then we got the phone call late 
at night, 2 days before the graduation, that he had been found 
dead in his apartment in Statesboro, Georgia, which I bring up 
to say this. You never know where narcotics and opioids and 
overdose death is going to come from. You never know who it's 
going to affect. You never know how they got exposed, and many 
times, most of the subjects around it are a mystery.
    But the better you can know your children, your kids and 
your grandkids, the more you can look for things and ask 
questions, the more you can try and be aware of the symptoms of 
drug abuse or addiction, the better off all of us are going to 
be, and addiction is the big problem. I mean, I'm personally--I 
mean, Charlie was a great kid, smart as he could be, but he was 
hooked, and no matter how long you stay out in recovery and are 
free of drugs, it only takes one, and that's all it took for 
him 4 years after he had gone into recovery. That's a sad 
testimony.
    Yesterday, in a hearing we had in another Committee, we 
heard that children 13 to 26 are five times as likely to become 
addicted to narcotics as adults. Do you all agree with that 
number? Is that about right, in your mind?
    [Nonverbal response.]
    Senator Isakson. Well, that shows you, Mr. Chairman, one of 
the places we've got to put a face on the opioid epidemic is 
with our young people, to really know what they're facing and 
can happen. The meth project, which started in the upper 
Midwest with methamphetamine a few years, did a lot of good to 
knock down the growth rate in terms of meth laboratories and 
meth addictions in that part of the country, and it helped us 
in Georgia. We adopted a meth project in Georgia and put the 
billboards up like you've got with your examples with your 
speech.
    But all that education, all that awareness, all that 
talking about the subject in public and with your kids and 
families is critically important, because awareness is the key 
to catching things early, if you're lucky enough to be able to 
do that. If you don't catch it early enough, catch it early 
enough to get treatment, and then sustain the treatment and the 
benefits of that treatment long enough so the person can lose 
the addictive habits that they developed in taking the 
narcotics or the opioids.
    I just want to commend you on what you've focused on in 
terms of awareness and putting a face on it. It's a terrible 
tragedy that many, many Americans face every day and more are 
going to face in the future unless we do get our arms around 
it, and we can do it, but we've got to talk about it without 
fear. We've got to look for the symptoms without any prejudice. 
We've got to do everything we can to support those who are 
having problems rather than demonizing them because they have 
them. They need our support and our love and our assistance and 
our help, and we can help a lot of people end what is a 
terrible problem.
    I would just say, Mr. Chairman--I want to end where I 
started. Addiction, to me, is the one thing that is so 
overpowering--I can't explain it. I know there are things I 
like to eat that I shouldn't eat. There are things that I buy 
at the grocery store and my wife goes crazy. It's a good thing 
that Oreos are not addictive, because I would be on them every 
day.
    [Laughter.]
    Senator Isakson. But addiction and the habits that come 
with it and the things you do to support the habit early on 
that are so detrimental to your health in the future and your 
life in the future--it's unbelievable. So what we're doing in 
this Committee, what the Chairman and the Ranking Member are 
doing, is critically important, and what all of us need to do 
in this country is make sure that drug abuse is not a stigma. 
It's a problem. And addiction is not a stigma. It's a disease, 
and that we treat it, we find a way to cure it, and we save 
lives in the future, and that's what this Committee is all 
about, and I commend you and Senator Murray for what you're 
doing to make that happen.
    The Chairman. Thank you, Senator Isakson.
    Senator Jones.
    Senator Jones. Thank you, Mr. Chairman, and let me also 
thank the Chairman and the Ranking Member for the work on this. 
This is the work you're doing is why I came to the Senate, to 
that bipartisan work that we can really address this crisis.
    Let me also say, Ms. Nickel, while I also appreciate your 
putting a face on this, I cannot help but say how much I 
appreciate Senator Isakson, who I admire so much, putting a 
personal face on this for the U.S. Senate. It's really 
important to do that. When you have a colleague that will do 
that and step out like that, it hits home to all of us, even 
more than I think the witnesses.
    Thank you, Senator, for doing that.
    Ms. Nickel, one of the things that seems to be in my 
state--we hear the stories. Senator Isakson's grandson was 
going to school. We hear people at employment--they seem to be 
fine below the radar with these problems. But yet it also seems 
to me that employment is an important part of recovery.
    I was pleased to introduce the Jobs Plus Recovery Act with 
Senator Kaine and Senator Young about the need for employment 
and workforce development and helping people overcome these. 
The answer would seem to be obvious. But I'd like for you to 
just talk about that a little bit--Mr. Morrison, you may want 
to chime in too--about how important having that job and 
training will be to help these people overcome the addiction so 
they don't fall back into the crisis they were in.
    Ms. Nickel. Absolutely. I think employers are a key 
component of how we address addiction on two levels. For those 
that are in recovery and coming back into the workforce, having 
that job is so incredibly important. To have your sense of 
self-worth, your ability to provide for your family, and to get 
your life back in order is critical, and the stigma that is 
attached to this disease can make it--recovering and the 
family--make it difficult for the family as well. So how do we 
make sure that we make those connections so there's a pathway 
to employment, to having a job, to paying taxes, and being able 
to take care of your family as part of your recovery plan?
    On the other side of it, though, this is a disease that 
worsens over time, like any other disease, and one of the first 
things that starts to happen is you lose your job as this 
disease starts to take hold. So employers that have programs, 
like employee assistance programs, and can initiate--instead of 
losing that job because you're late or you have a positive 
urinalysis screen--to connect that employee with the services 
that they need, and having that relationship with your boss, 
your employer, helps you to get the care that is really 
required.
    Senator Jones. Thank you.
    Mr. Morrison, do you briefly want to say anything about 
that?
    Mr. Morrison. Absolutely critical. Our members work with a 
variety of different agencies and support providers to help 
them with job readiness, job training, things such as how to 
write a resume, how to prepare for interviews. Charles Curie 
was a SAMHSA administrator quite some time ago, and he would 
always say critical indicators of what we're trying to do is 
help people get better, get housing, a place to live, a job, 
and a date on the weekend. And it kind of describes the goals 
of what we're trying to do with our folks.
    Senator Jones. Right. Thank you, Mr. Morrison.
    Shifting focus a little bit, the proliferation of the 
deadly synthetic drug, fentanyl, is also a real concern, I 
think, for Congress these days. Recently, we have seen a lot of 
warnings going out to first responders. I know that recently, 
DEA has been working on this a good bit. The surgeon general 
was just--an advisory recommending that all Americans, just 
about, carry naloxone--whatever that's called. I get real 
confused. Between acronyms and medical terms, I'm gone.
    So, Ms. Nickel, what can we do? Do we need to provide more 
resources to first responders? Because these first responders--
it would not take much, but a little bit of an inhalation or 
some kind of contact with fentanyl to be deadly to the first 
responders. As a former U.S. Attorney, I'm really especially 
into police, fire, medical personnel that get on the scene 
sometimes very quickly. They do such an incredible job, but 
they're facing this danger. What can we do to provide more 
resources?
    Ms. Nickel. Support and resources, training, wrap-around 
support for our first responders is critical, and I commend the 
Committee for having a component for training and resources in 
the draft legislation. Both our fire and police officers are on 
the front line, and both with the increasing threats because of 
synthetic opioids. Those warning systems to alert jurisdictions 
when we're seeing fentanyl enter that market is critically 
important; resources to provide naloxone--you got it right--to 
have naloxone on hand that we need to reverse overdoses; and 
then we need to make the connection between that reversal and 
connecting them to treatment.
    If you treat someone with a heart attack and use the 
paddles, you get them to a cardiologist. If we treat someone 
with naloxone to reverse an overdose, we need to get them into 
treatment and use that opportunity as a life-changing moment 
for that individual and that family. And, absolutely, we need 
to help first responders with resources, training, the support 
that they need. This is a very difficult job. You're going to 
the same houses, oftentimes many times in a row, and it's tough 
work, and not having the resources to make those connections, I 
think, can be very demoralizing. So we need to wrap them up.
    Senator Jones. Great. Thank you.
    Thank you all for your presence here today.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Jones.
    Senator Cassidy.
    Senator Cassidy. Thank you all.
    Ms. Nickel--again, incredibly moving testimony, and, 
unfortunately, we all have an experience similar to that. One 
thing you said, though, that I--as a physician, my ears perk 
up--that one of the young men had been hospitalized or in the 
ER seven different times, and family never notified. I think, 
for the record, that is a misunderstanding of HIPAA laws, that 
is, HIPAA, which, normally, has confidentiality requirements.
    I was trying to double check, but was specifically told 
yesterday by someone in a position to know that HIPAA does 
not--HIPAA does allow someone to call the family of somebody in 
an overdose and to inform them that they've been--any comment 
on that?
    Ms. Nickel. You are absolutely correct. We actually have 
drafted a memo for counsels at hospitals to fully explain that 
this is an allowable activity, to notify a family, to notify 
healthcare providers, after a nonfatal overdose, and we need to 
change a lot of the practices. How we respond to nonfatal 
overdoses in this country is the most important and one of the 
first things we should be doing. Of the nearly 64,000 people 
that we're losing annually to overdoses, 70 percent of them had 
a previous nonfatal overdose.
    Senator Cassidy. Let me just interrupt----
    The Chairman. Well, let me interrupt just a moment without 
taking your time, Senator Cassidy.
    Would it be a good idea to include in our legislation any 
language that would make it clearer, the point that you're 
making, so hospitals and their counsels would know that?
    Senator Cassidy. I was about to just ask you and the 
Ranking Member if we could something like that.
    [Laughter.]
    Senator Cassidy. When I was on Energy and Commerce 
Committee, we once had a panel of HIPAA experts, and they were 
disagreeing with each other to the degree to which you could 
share with somebody. And I can tell you if you're the ER 
physician at 3 in the morning, you've got 10 people waiting, 
your default is to not share information. So the degree to 
which we can promulgate that ideally, put a tattoo on 
somebody's head saying, ``Oh, yes, I remember that now''--we'll 
be doing an incredible service.
    The Chairman. Why don't we, first, not deduct from your 
time for my interruption, and, second, why don't Senator Murray 
and I work with you? And if the witnesses would like to provide 
us with suggestions about how to do that--we respect the HIPAA 
law, but I think it's not just overdoses. It's emergencies 
where families can be notified, but people are afraid to do 
that.
    Ms. Nickel. That would be wonderful.
    The Chairman. So, Senator Cassidy, if you would work on 
that, that would be very helpful.
    Senator Cassidy. Yes, absolutely.
    Next--again, thank you all. My office has kind of initiated 
something we call Safer Families and Healthier Communities.
    Ms. Donahue, you seem to be plugged into that. Indeed, the 
people you're serving, those children born of parents addicted, 
is kind of the beginning of Ms. Nickel's testimony. You're 
acquiring all this great data. Can I ask what you are doing 
with that data?
    Ms. Donahue. Yes. So in our data base, we are tracking 
maternal characteristics, such as where that particular woman 
resides. We are tracking what type of substance----
    Senator Cassidy. Try to speak quickly, because I have 
limited time.
    Ms. Donahue. I'm sorry. We are tracking what type of 
substance is involved and whether or not the particular mother 
has prior substance-exposed infants.
    Senator Cassidy. But with that data, can you then say, 
``Okay, we know this child is born to a mother who is addicted. 
Therefore, we are going to proactively send support out 
there?''
    Ms. Donahue. That's correct.
    Senator Cassidy. Now, you imply that there is, one, Federal 
resources that enabled you to begin, but a lack of resources 
for which to fully go to scale and/or continue. Is that true?
    Ms. Donahue. Especially with the Plans of Safe Care, yes.
    Senator Cassidy. Now, there was in 21st Century Cures a lot 
of money which, apparently, has had a hard time getting out to 
the states. Is it just that this money hasn't gotten out, or 
that money which is even allocated will not be adequate?
    Ms. Donahue. We've actually seen some of the benefits of 
the Cures Act through peer recovery coaches through our 
Delaware chapter of SAMHSA. So the peer recovery coaches are 
actually being utilized in some of our substance use treatment 
disorder centers, including the medication-assisted treatment 
for pregnant women, and the peer recovery coaches have been 
fabulous.
    Senator Cassidy. It is getting there, but perhaps not for 
this particular program.
    Ms. Donahue. Correct.
    Senator Cassidy. Ms. Nickel, quickly, I think we have a 
shared interest in what we can do to improve access to 
addiction treatment medicine. One think I'll again point out--
some addicts, after their recovery from an overdose, really 
don't want to be treated. They want to take another hit. So the 
issue is can we give them some sort of long-acting drug that, 
if they do take another hit, it'll be kind of ``Oh, my gosh, I 
don't want to do that again.'' Any comments quickly on that?
    Ms. Nickel. We do have new long-acting formulations of 
medication-assisted treatment, and I think we need to clear 
some barriers to making that new medication available to our 
patients. I believe this Committee worked on some language to 
help with that in S. 916, I believe.
    Senator Cassidy. Yes, my bill. I love it.
    [Laughter.]
    Ms. Nickel. Thank you for that. But I think as we have 
advancements in medications, we need to make sure we can 
actually get those medicines to our patients.
    Senator Cassidy. Yes, and this is--that one provision I'm 
not sure is in the final version so far. But just to say long-
acting--again, to my colleagues, sometimes someone takes an 
overdose, and all they want is another hit.
    Ms. Nickel. Well, you wake up in active withdrawal, so 
you're having your worst day and feel crappy. The quickest way 
to fix that is to use again or to get someone connected----
    Senator Cassidy. But these long-acting preventions will be 
something which will then----
    Ms. Nickel. Exactly.
    Senator Cassidy ----although you're in withdrawal, you 
won't go back so immediately and, hopefully, get into recovery.
    Ms. Nickel. Absolutely.
    Senator Cassidy. Mr. Morrison, I had a question for you on 
accountability, but I'm almost out of time, so I'm going to 
yield back. But I am interested--for a question for the 
record--these programs that we're doing--we're interested in 
evaluating to make sure that they work. It's just not a place 
to send Federal dollars.
    The question for the record you'll receive is: How do we 
consistently have outcome measures which tell us what we should 
do or perhaps what we should not do?
    Senator Cassidy. Thank you all for your good work.
    The Chairman. I took--I stole at least a minute from you. 
So if you want to pursue that, please do.
    Senator Cassidy. Yes, I know. So how do we do that?
    [Laughter.]
    Senator Cassidy. Because we're interested in that 
accountability, and I know there's some people who just make 
money off of government contracts, and I know that because I 
used to work for the government. But there's others who 
actually use it to good end. How do we have that accountability 
measure to know these programs are working well?
    Mr. Morrison. Sure. We work with SAMHSA on looking at 
different measures regarding the use of alcohol, the use of 
drugs, the impact of treatment on employment, the impact of 
treatment on criminal justice involvement, and then 
connectedness back with the society. So we're eager and 
actually embrace----
    Senator Cassidy. Do those measures work? I mean, sure, 
you're doing them. Do they work?
    Mr. Morrison. Well, they're helpful, and we also would 
benefit from additional resources to look at long-term studies, 
looking at post-discharge, six, 12 months----
    Senator Cassidy. I'm a minute over. I'll stop. But our QFR 
will ask you to put a finer point on that answer.
    Mr. Morrison. I look forward to it, sir.
    Senator Cassidy. Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Cassidy, for your 
suggestions.
    Senator Murphy.
    Senator Murphy. Thank you very much, Mr. Chairman.
    Thank you all for being here today. While Senator Cassidy 
is still here, let me just put a plug in for the Mental Health 
Reform Act that we both worked on in consultation with the 
Chair and Ranking Member that passed in 2016. As part of that 
piece of legislation, we included some pretty important changes 
to the Mental Health Parity Law which allow for Federal 
regulators to make sure that insurance companies are not just 
putting in their statement of benefits your behavioral health 
and addiction benefit, but that they are also administering 
your benefit in a way that is not discriminatory.
    I wanted to maybe direct this question to you, Mr. 
Morrison. Secretary Acosta came before President Trump's Opioid 
Commission and talked about the lack of tools that he has in 
order to enforce this requirement under Federal law that when 
you have insurance, you have an equal addiction benefit to your 
non-addiction benefits. The reality is that anybody out there 
who has tried to access insurance reimbursement knows that it 
is a whole lot harder to get an insurance company to pay for 
addiction treatment than it is to fix your broken leg or to 
address heart disease.
    He specifically--Secretary Acosta--asked Congress to give 
him two new authorities. He said, ``I need the power to level 
civil fines.'' There are no civil fines right now in the Parity 
Law. And, second, he wanted to be able to come after not just 
the employers but the insurance companies themselves.
    Let me just ask you a general question, which is: Do you 
believe that, as you look at it, there are still enforcement 
challenges when it comes to administering the Mental Health 
Parity Law?
    Mr. Morrison. I think there are. I think there's been 
studies, as you referred to, in terms of accessing the benefit, 
and there's been a look at accessing substance use disorder 
benefits as opposed to physical benefits, and there have been 
challenges and barriers. Our members know this issue based on 
folks that they see are uninsured or underinsured, and so 
they've worked with state health insurance commissioners, 
plans, and the like to educate them.
    But the bottom line is we have a law on the books and 
resources to help enforce and implement the law would be 
helpful, and the Governor's Association has included that as 
part of their recommendations, as has the Commission that the 
President convened under Governor Christie.
    Senator Murphy. Well, Senator Alexander, we're lining up 
requests as we go through this hearing. But one of mine would 
be that we take a look at these authorities that the 
Secretaries ask for. They're actually included in President 
Trump's Commission's recommendations to us.
    We have new reports that we've been given showing that 
there is just an unjustifiable disparity in terms of how 
insurance companies reimburse on the addiction side and the 
non-addiction side, and we have a Republican administration 
asking for some new authorities, I think some commonsense 
authorities, and I hope that we can talk about that.
    Another subject I wanted to bring up to the panel is the 
subject of recovery coaches. I think, again, Mr. Morrison, you 
referenced it in your testimony. We've had a lot of success in 
Connecticut with recovery coaches. We've seen an increase 
across the country in emergency room visits for opioid 
overdoses by 30 percent. And I've had so many people in 
Connecticut talk to me about how we need to lengthen out the 
spend on addiction, treat it more like a chronic disease than 
simply a crisis illness, and recovery coaches are one of the 
ways to do that.
    I'm maybe going to ask the question to you, Ms. Nickel, 
because it's already in your testimony, Mr. Morrison.
    You talked about the need to get parents and family members 
more involved and have policy that facilitates them being part 
of this conversation. It seems to me that recovery coaches is a 
way to do that, to have somebody who can be that liaison but 
also bring in the family members. I just wanted to sort of ask 
your thought on whether it's worthwhile.
    Senator Capito and I have two pieces of legislation that 
would do this. I just wanted to ask your opinion on this.
    Ms. Nickel. Absolutely. Addiction is a family disease. It 
affects every member of the family, and peer recovery support 
specialists, recovery coaches, can play an integral role in 
making sure that long-term plan is in place. We also know from 
literature that treatment and recovery plans need to be three 
to 5 years long, not 14 days, not 28 days. So you think about 
if you have a hip replacement, and what--my grandma had one 
last year--you have the recovery plan on the things that you 
need. It's the same with treatment for addiction, and we know 
that we need a much longer runway for the recovery support to 
make sure that patient is well and has the services they need.
    Senator Murphy. It's such a hard problem, because we need 
to spend more money, but we do need to be having a conversation 
about how we're spending the money today, whether it's best 
served, as we primarily do today, in intensive supports right 
up front or whether we need to lengthen out that span. Recovery 
coaches is a way to do that.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murphy, and we'll ask 
staff to follow-up Secretary Acosta's recommendations that you 
mentioned.
    Senator Baldwin? Oh, excuse me. I didn't see Senator 
Murkowski.
    Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman.
    I wish that I had been here for the beginning. We're 
beginning Appropriations hearings, and we're all in different 
places at the same time. So thank you for your contributions 
here today. We've been so focused on what is going on with the 
opioid crisis and the epidemic in this country. Sometimes I 
worry that we forget we have other very serious significant 
issues as they relate to substance abuse.
    Mr. Morrison, you have noted that we don't want to forget 
the other substances. In Alaska, it's alcohol, has been 
alcohol, will be alcohol. We just had two villages request by 
way of resolution to our Governor that he declare a state of 
emergency and to shut down a liquor store that had opened in an 
adjoining village, because one village is dry, and the other 
village sells alcohol. We've seen individuals go through the 
river, die--the tragedies continue.
    As I've talked to our enforcement agencies in the state, 
they tell me it seems like that heroin is tapering off, but 
meth is now escalating through the roof. So I'm concerned that 
here in Congress we're so focused on opiates as the drug du 
jour, if you will, and that in 5 years or so, when this crisis 
ends or abates or tapers, that we're going to have a bunch of 
Federal programs that are specifically aimed at a problem that 
may not be as significant to the detriment of others who are 
dealing with other types of addictions.
    Mr. Morrison, I'll ask you. Do you have similar concerns? 
Are we being too focused? Do we need to be broader to 
addiction, in general? How do we make sure that these policies 
are going to really be the umbrella that we need to help those 
who have such significant challenges?
    Mr. Morrison. Our members have expressed concern about not 
affording the flexibility needed in order to allow states to 
address the issues that they face that are unique to their 
state. The Substance Abuse Prevention and Treatment Block 
Grant, as you know, is a program that allows a state to target 
resources based on their own unique needs. Alaska receives 
about $6 million in that program. We also know your interest in 
fetal alcohol syndrome. Your leadership there is appreciated. 
There really isn't a Federal program within, particularly, 
SAMHSA that provides the service side, as you probably know.
    But I must say the sheer volume of death connected to 
opioids is something that cannot be ignored, and I know you're 
not ignoring it. The ability, though, for states to address 
whatever it is the person walks in the door with is critical, 
and alcohol is, indeed, the No. 1 problem in the United States. 
So it's a balance, and we appreciate the leadership of this 
Committee.
    That's why our members, again, appreciate the Substance 
Abuse Prevention and Treatment Block Grant and its flexibility. 
It's consistent, and there's a specific set-aside for 
prevention that is so critical. Seventy percent of our members' 
budget for substance abuse prevention, on average, comes from 
the block grant, so it's vital. So I appreciate the question.
    Senator Murkowski. That's good to keep in perspective.
    Ms. Donahue, in your written testimony, you state that 
providing mental health services in schools will address the 
trauma that our youth have experienced and break the cycle of 
multi-generational trauma that may lead to mental health 
concerns and substance abuse, and we certainly agree. We see 
the multi-generational trauma in places like Alaska, perhaps 
higher there than anywhere else in the country. So much of this 
is tied to alcohol and other drug use, sexual assault, domestic 
violence, and it's not just limited to the family members who 
are addicted.
    These are small villages, a couple of hundred people. There 
is not access to a licensed social worker or a psychiatrist or 
a psychologist. It's not feasible to fly the children into 
Anchorage for care, both from a practical and a financial 
standpoint. So I've been working with Senator Smith here to 
allow National Health Service Corps members to provide services 
in schools so we effectively bring the providers to the 
schools.
    We're in a position where it's just really challenging, if 
not impossible, to fund a mental health professional in the 
schools that need them. Do we have other policies that we can 
perhaps look to get providers into schools without putting a 
burden on our already underfunded school districts?
    Ms. Donahue. Thank you very much for that question. In 
Delaware, we do have behavioral health consultants that are in 
the middle schools for ages 12, 13, and 14, and those have been 
proven to be very effective. However, the funding, as you said, 
with education is very difficult to overcome.
    There are some models out there, such as the Compassionate 
School Model, that our office is working toward, which does 
incorporate trauma informed care. So that would, in essence, 
provide a team approach in the school to provide those children 
to have that access to mental health in a trauma informed 
environment where they can trust to come to school, and it's a 
safe place for them to speak about their trauma.
    The prevalence of trauma in Delaware and children coming 
into foster care is putting an extreme toll on our child 
welfare workforce as well. So we have to also look at not only 
mental health access for these children, but also the fact that 
there will be child welfare protection services that must also 
be funded in order to keep these children safe when abuse or 
neglect is identified during that mental health treatment or 
school atmosphere.
    Senator Murkowski. Well, thank you for that. Know that 
these are issues that, working with Senator Smith and others, 
we'd like to pursue.
    With that, Mr. Chairman, thank you.
    The Chairman. Thank you, Senator Murkowski.
    Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman.
    I really appreciate the opportunity to have you here as 
witnesses today to talk about the discussion draft of the 
Opioid Crisis Response Act. I'm really grateful to my 
colleagues for some of the ideas that are being proposed for 
additional discussion and inclusion.
    Mr. Morrison, I wanted to start with you. You've already 
been questioned about this. You noted it in your testimony. We 
have right now a place holder in this discussion draft in terms 
of renewal and improvement of the STR Grant. You noted the 
fiscal cliff, and you also made note of the flexibility that 
would be welcomed for dealing with drugs beyond those described 
as opioids.
    I wanted to just mention in my travels around the State of 
Wisconsin--and I've been hosting roundtables with various 
stakeholders in various parts of my state for several years 
now, almost since I joined the Senate in 2013-2014. I have seen 
regions of the state that are dealing with a meth crisis and 
regions of the state that are dealing with an opioid crisis. It 
was very distinct when I first started.
    Now, in the last couple of months when I've had recent 
roundtables, I'm being told that almost everybody who is either 
encountering law enforcement or is encountering emergency 
treatment has multiple drug--they're presenting with multiple 
drugs. There's no clean distinction, just as we were hearing 
from Senator Murkowski about Alaska, although I'm sure we have 
local differences.
    I wonder if you could speak to the importance of that 
flexibility. It may be that what brings all of this together is 
just the spike we call it an epidemic, because between 2000 and 
today, whether it's the--pain is the fifth vital, or whatever 
other contributing factors there are, we've seen such a deluge, 
such a crisis. But it does seem to me like it's going from 
prescribed opioids to heroin and fentanyl to now people 
accessing whatever they can when the addiction has really 
gripped them.
    Mr. Morrison. I agree that we should look at it, at its 
core as a problem with addiction, and look at ways to be 
flexible, allowing states to target areas of need based on 
their particular drug of choice. I think with the opioid 
epidemic, we also saw the need for medication-assisted 
treatment, and those efforts have been critical, and looking at 
evidence-based approaches to also keeping the families 
together--important work that this Committee did was to create 
a pilot program for pregnant postpartum women to look at 
different ways they could support family centered services. So 
the bottom line is in Wisconsin, about half of your admissions 
to treatment are from alcohol.
    Senator Baldwin. I know I'm not going to have time to ask 
all the questions I'd like. Let me just note a couple of issues 
on the record that I will hopefully be able to get answers 
after the hearing.
    I wanted to add my words to Chris Murphy's question 
relating to recovery coaches. We have a very innovative program 
going on in the State of Wisconsin. Jesse Heffernan of 
Appleton, Wisconsin, a longtime advocate and recovery coach, 
was inspired by his own experience with substance use disorder 
to start a Recovery Corps program to integrate recovery coaches 
into the entire substance use care curriculum, and it's being 
piloted by Marshfield Health System. So I'd love to ask some 
specific questions for your feedback on that.
    Senator Baldwin. One other question, Ms. Nickel, if I can 
ask you, with clearly inadequate time to answer it now. We need 
everyone at the table to work together to appropriately combat 
this epidemic, and I'm encouraged that your organization is 
committed to a comprehensive response. But I'm also concerned 
with the pharmaceutical industry's role in the opioid crisis 
and believe that we need to do more to hold drug makers 
accountable.
    More than half the counties in my state have filed lawsuits 
against pharmaceutical companies, and I've heard from 
Wisconsin's substance abuse and recovery leaders about their 
continued concerns with the drug companies' influence in our 
response efforts, and we certainly know of their influence here 
on Capitol Hill. So I would love to hear from you sort of best 
practices and how you work with many industry partners, 
including drug companies; what policies we need to enact to 
prevent conflicts of interest as we continue to fight this 
epidemic.
    The Chairman. Ms. Nickel, we're out of time, but please go 
ahead and answer the question. Then you may want to follow-up 
with a written answer to Senator Baldwin.
    Ms. Nickel. Absolutely. You know, this is an issue about 
addiction, and we don't have a medication-assisted treatment 
for methamphetamine use disorder. We don't have a medication 
for cocaine use disorder, and we're seeing an increase in drug 
overdoses and drug overdose deaths, particularly in our African 
American communities, to cocaine use disorder overdoses. We 
don't have great medications for alcohol use disorder. We need 
more.
    We firmly believe that in the treatment and the advancement 
of science and research and innovation and a cure that we need 
to be partnering with scientists and universities and companies 
that have R and D budgets, because you don't cure a disease 
without having the smart white lab coats at the table with you. 
So our commitment to having everyone at the table includes 
those that can give us the medications that we need to survive 
this illness.
    The Chairman. Thank you very much, Senator Baldwin.
    Senator Hassan.
    Senator Hassan. Thank you very much, Mr. Chair, and I want 
to thank you and the Ranking Member for your bipartisan work on 
this discussion draft of this bill, and I want to thank the 
witnesses for being here.
    I want to speak for a minute to the continuing work we're 
doing on the bill and note that as we continue our work 
together, it's really critical that we ensure that we are 
adequately prioritizing Federal funding for states that have 
been hardest hit by the opioid crisis, a priority that has 
bipartisan support. I appreciate you recognizing that this is 
something that needs to be included. I look forward to 
partnering with the Chair and Ranking Member and others on 
this.
    You know, I just did a ride-along in my home State with the 
Manchester, New Hampshire, police department, and in my first 
hour and a half, we responded to three overdoses. So when we 
are hit hard right now with the fentanyl epidemic, in 
particular, that is so lethal, we really need to make sure that 
we're doing everything we can to help the hardest hit states 
and help the hardest hit states develop expertise.
    I also appreciate that the draft legislation includes a 
number of other priorities I've championed, including the 
Comprehensive Opioid Recovery Centers Act, which I introduced 
with Senator Capito. There's a similar bipartisan bill in the 
House of Representatives as well.
    The bill would create a pilot program allowing HHS to award 
grants to expand existing centers to serve as comprehensive 
opioid recovery centers. These centers would provide a full 
range of treatment and recovery services to not only treat 
patients but also to provide them with the wrap-around services 
they need to move to successful and drug-free lives.
    The centers would also have outreach to community partners 
to provide information about the services available at the 
centers to help ensure that those seeking treatment know what 
their options are. The kind of wrap-around support offered by 
CORC is critical for those in recovery and is especially needed 
in states hardest hit by the opioid epidemic.
    I want to just add my to-do list to Senator Murphy's and 
others. I hope that the Chair and Ranking Member will continue 
to work with me and others to make sure we're adequately 
prioritizing those hardest hit states in this provision 
concerning the CORC centers as well. I've heard from a number 
of providers and stakeholders in the granite state in support 
of this legislation, and I hope we can get this bill passed.
    With that statement, now I do have actually a couple of 
questions.
    To Mr. Morrison: During our hearings on the opioid crisis, 
we heard from a stakeholder from New England who is utilizing a 
really unique model to increase access to medication-assisted 
treatment, a model I'm working on legislation to replicate on a 
national level. This model was actually developed with the help 
of our current Assistant Secretary for Mental Health and 
Substance Use, Dr. Elinore McCance-Katz, when she was working 
in Rhode Island.
    Under this model, medical students are getting training in 
medical school on addiction issues and medication-assisted 
treatment. Once the students graduate, move on to their 
residencies, get licensed to practice, and get their DEA 
number, they can apply right away for a so-called data waiver 
to prescribe buprenorphine. They don't have to take an 
additional 8-hour course for it. They're just set to go.
    I really think what they're doing in Rhode Island is a 
great idea. So I'm working on a bill that I hope will be 
included in the bipartisan Opioid Crisis Response Act, what 
we're talking about today, to facilitate this program for other 
medical schools who want to do it. My legislation, the 
Enhancing Access to Addiction Treatment Act, will provide 
voluntary grants to support medical schools and residencies in 
developing their own programs to train students and establish a 
new pathway to let these trained, practicing physicians apply 
right away to prescribe medication-assisted treatment, the same 
time they can start prescribing opioids.
    Mr. Morrison, what do you think about this idea? Will it 
help to increase patient access to medication-assisted 
treatment?
    Mr. Morrison. I think it will, and I appreciate your 
leadership. I know our member, Becky Boss, when she presented 
testimony here, referred to that program as well, and she said 
it's a tremendous success to increase--or decrease barriers and 
make it easier to get waived and actually dispensing and 
providing the care we need, and we know we need additional 
folks prescribing and increasing MAT. So I look forward to 
working with you on it.
    Senator Hassan. Well, thank you very much. And in my last 
half a minute, I just wanted to also talk with you, Mr. 
Morrison, about some really important work being done in 
schools relating to substance use prevention. One of the 
overdoses we responded to--we got there--in Manchester, there 
were firefighters, EMTs, police, and DCYF, our child protection 
services, because the ripple effect here is hitting everyone. 
In the Laconia School District in New Hampshire, they've been 
really hit hard.
    I think there is more to do to encourage collaboration and 
cooperation. We have some examples, and I will follow-up with 
you, because I'm already overtime, on your thoughts on how we 
can better address efforts for school and treatment, behavioral 
health collaboration to really help our kids and our families 
who are traumatized and struggling with this. I'll follow-up 
with you in writing. Thank you.
    The Chairman. Thank you, Senator Hassan.
    Senator Casey.
    Senator Casey. Mr. Chairman, thank you very much. I want to 
thank you and Ranking Member Murray for the work you've done, 
not only to bring us to this point with regard to the Opioid 
Crisis Response Act but also the hearings that have been 
undertaken over many weeks now. We're grateful for that help, 
and also thank you, in particular, for including provisions to 
further strengthen state efforts to protect infants affected by 
substance abuse, known as the Plan of Safe Care provision of 
the Child Abuse Prevention and Treatment Act, so-called CAPTA 
legislation.
    Chairman Alexander and I worked together on the Infant Plan 
of Safe Care Improvement Act in 2016, and I appreciate that 
work. This current bill builds on that law by providing a new 
grant program to support state efforts to provide these Plans 
of Safe Care. I'm also grateful for the additional $60 million 
in funding that was included in the omnibus for CAPTA at my 
request, and I look forward to advancing this new proposal to 
create a more permanent program to support states in this work.
    Ms. Donahue, I know I'm the last questioner, so I'll get to 
questions now for you. I may not get to our other witnesses. 
But I wanted to start with a statement that you made at the end 
of your testimony, page 7, and I'm quoting at the bottom of 
page 7, quote, ``Infants with prenatal substance exposure and 
their parents struggling with opioid addiction have multiple 
and complex needs that require a collaborative response by a 
multi-disciplinary team,'' unquote.
    Can you talk about what that looks like in reality on the 
ground? Who are the multi-disciplinary participants involved in 
creating the typical Plan of Safe Care?
    Ms. Donahue. Thank you. Our SEI Committee, our Substance 
Exposed Infants Committee, is made up of public health, family 
courts, social workers in the hospitals, child welfare workers. 
Every birthing hospital has representation on there. We have, 
of course, the substance use treatment providers, and, of 
course, our State is one of the smaller states, and we're doing 
this on a statewide basis. But we do have a very broad 
representation on our committee because of the fact that it's 
not just one agency that has their responsibility and 
accountability in this issue. It's very vast.
    Our Plans of Safe Care--I did attach a copy of one of the 
drafts that we're utilizing right now in four of our six 
hospitals, and so far, it's been a challenge. It's been a very 
difficult challenge, not necessarily implementing it, but the 
monitoring piece. We know that this population of women are 
very vulnerable. Pregnant women struggling with addiction have 
a stigma that is great, and women fear coming to get prenatal 
care because of the possible stigma by medical providers. They 
are fearful that when the birth event comes, that child welfare 
will take their infant.
    There's lots of aspects to this population that we have to 
be mindful of, and coming together in a collaborative way and, 
hopefully, having these Plans of Safe Care begin prenatally so 
that mother has the supports around her from all of these 
different multi-disciplinary members, the birth event will go 
much more smoothly and she'll have trust of all of us to move 
forward with helping her and her family.
    Senator Casey. I appreciate that, and I know you've 
emphasized the importance of those teams. Also, I wanted to 
indicate that you've noted that it's important to have a non-
punitive, public health oriented approach to working with these 
vulnerable families, and we know that's critical. It's also 
something that's a key part of CAPTA. In fact, we have a former 
member of the Pennsylvania delegation, then Congressman Jim 
Greenwood, who is the original sponsor of the Plan of Safe Care 
and has said that this was his original intent.
    I would ask Chairman Alexander for unanimous consent to 
include in the record of the hearing a letter from former 
Congressman Greenwood in which he says the following. I'll just 
read portions of it in short fashion: ``In 2003, I worked with 
my congressional colleagues to ensure that CAPTA was written so 
that this, quote, 'appropriate referral,' unquote, and the 
development of a Plan of Safe Care for the infant was not 
wrongly interpreted as Congress establishing a Federal law of 
what constitutes child abuse and neglect. Also, Congress' 2003 
amendment of CAPTA did not advance a tool to encourage the 
criminal prosecution of a woman who consumed drugs or alcohol 
during pregnancy,'' unquote.
    I'd ask consent to have the letter included.
    The Chairman. It will be included, Senator.
    Senator Casey. Thank you, Mr. Chairman.
    [The information referred to follows:]
    [GRAPHIC] [TIFF OMITTED] T8493.001
    
    [GRAPHIC] [TIFF OMITTED] T8493.002
    
    [GRAPHIC] [TIFF OMITTED] T8493.003
    
    Senator Casey. I have one more question, but I'll maybe 
submit that for the record for Ms. Donahue, and I may have some 
questions for the other panelists. Thank you for your testimony 
and your good work. \6\
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    \6\  No responses were submitted for the Record.
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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.]

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