[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
MEDICAL EXPERTS:
INADEQUATE FEDERAL APPROACH
TO OPIOID TREATMENT AND
THE NEED TO EXPAND CARE
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON
OVERSIGHT AND REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
JUNE 19, 2019
__________
Serial No. 116-35
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Printed for the use of the Committee on Oversight and Reform
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COMMITTEE ON OVERSIGHT AND REFORM
ELIJAH E. CUMMINGS, Maryland, Chairman
Carolyn B. Maloney, New York Jim Jordan, Ohio, Ranking Minority
Eleanor Holmes Norton, District of Member
Columbia Justin Amash, Michigan
Wm. Lacy Clay, Missouri Paul A. Gosar, Arizona
Stephen F. Lynch, Massachusetts Virginia Foxx, North Carolina
Jim Cooper, Tennessee Thomas Massie, Kentucky
Gerald E. Connolly, Virginia Mark Meadows, North Carolina
Raja Krishnamoorthi, Illinois Jody B. Hice, Georgia
Jamie Raskin, Maryland Glenn Grothman, Wisconsin
Harley Rouda, California James Comer, Kentucky
Katie Hill, California Michael Cloud, Texas
Debbie Wasserman Schultz, Florida Bob Gibbs, Ohio
John P. Sarbanes, Maryland Ralph Norman, South Carolina
Peter Welch, Vermont Clay Higgins, Louisiana
Jackie Speier, California Chip Roy, Texas
Robin L. Kelly, Illinois Carol D. Miller, West Virginia
Mark DeSaulnier, California Mark E. Green, Tennessee
Brenda L. Lawrence, Michigan Kelly Armstrong, North Dakota
Stacey E. Plaskett, Virgin Islands W. Gregory Steube, Florida
Ro Khanna, California
Jimmy Gomez, California
Alexandria Ocasio-Cortez, New York
Ayanna Pressley, Massachusetts
Rashida Tlaib, Michigan
David Rapallo, Staff Director
Lucinda Lessley, Policy Director
Ali Golden, Chief Health Counsel
Miles Lichtman, Professional Staff Member
Laura Rush, Deputy Chief Clerk/Security Manager
Christopher Hixon, Minority Chief of Staff
Contact Number: 202-225-5051
C O N T E N T S
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Page
Hearing held on June 19, 2019.................................... 1
Witnesses
Dr. Susan R. Bailey, President-elect, American Medical
Association
Oral Statement............................................... 5
Dr. Yngvild K. Olsen, Vice President, American Society of
Addiction Medicine
Oral Statement............................................... 6
Dr. Arthur C. Evans, CEO/Executive Vice President, American
Psychological Association
Oral Statement............................................... 8
Ms. Jean Ross RN, President, National Nurses United
Oral Statement............................................... 10
Ms. Angela Gray BSN, RN, Nurse Director, Berkeley-Morgan County
Board of Health, WV
Oral Statement............................................... 11
Dr. Nancy K. Young, Executive Director, Children and Family
Futures
Oral Statement............................................... 13
Written opening statements and witness' written statements are
available at the U.S. House of Representatives Repository:
https://docs.house.gov.
----------
The documents entered into the record during this hearing are
listed below, and are available at: https://docs.house.gov.
* New Yorker article, ``Who is Responsible for the Pain Pill
Epidemic?''; submitted by Rep. Wasserman Schultz.
* American Psychological Association article; submitted by
Chairman Cummings.
* Statement from Bill Greer, President, SMART Recovery, USA;
submitted by Chairman Cummings.
* Letter from Faces and Voices of Recovery; submitted by
Chairman Cummings.
MEDICAL EXPERTS: INADEQUATE FEDERAL APPROACH TO OPIOID TREATMENT AND
THE NEED TO EXPAND CARE
Wednesday, June 19, 2019
House of Representatives
Committee on Oversight and Reform
Washington, D.C.
The committee met, pursuant to notice, at 10:03 a.m., in
room 2154, Rayburn House Office Building, Hon. Elijah Cummings
(chairman of the committee) presiding.
Present: Representatives Cummings, Maloney, Norton, Clay,
Connolly, Krishnamoorthi, Raskin, Rouda, Hill, Wasserman
Schultz, Sarbanes, Welch, Speier, Kelly, DeSaulnier, Khanna,
Ocasio-Cortez, Pressley, Tlaib, Jordan, Amash, Massie, Meadows,
Grothman, Comer, Cloud, Gibbs, Higgins, Norman, Roy, Miller,
Green, and Steube.
Chairman Cummings. The committee will come to order.
Without objection, the chair is authorized to declare a recess
of the committee at any time. The full committee hearing is
convening to hear from medical experts regarding the Inadequate
Federal Approach to the Opioid Treatment and the Need to Expand
Care.
I now recognize myself for five minutes to give an opening.
First of all, I want to thank all of you very much for
being here this morning. We're honored to have some of our
Nation's most accomplished medical experts and practitioners
working on the frontlines, and they are here to testify today.
Today, the committee will be examining legislation that
could significantly increase access to treatment across the
country for those suffering from substance use disorder.
Substance use disorder is a generational health crisis, but
most people suffering from it are not able to get the evidence-
based treatment that they so urgently need.
More than 270,000 Americans died from drug overdoses from
2013 to 2017. Despite this staggering loss of life, a study
based on the National Survey on Drug Use and Health found that
those who have substance use disorder, and I quote, ``Only 10.8
percent receive specialty treatment.''
The National Academies of Science, Engineering, and
Medicine reported earlier this year that in 2016 just 36
percent of the specialty treatment facilities offered any form
of FDA-approved medication for opioid use disorder. It
concluded, ``Only six percent of facilities offered all three
medications'' approved to treat this disease.
The National Academies also warn, and I quote, ``Efforts to
date have made no real headway in stemming this crisis, in
large part because tools that are already in existence, like
evidence-based medications, are not being deployed to maximum
impact.''
The response of the Administration and Congress has been
woefully inadequate. For the entire first two years of the
Trump Administration the President failed to issue a national
drug control strategy, even though it was required by law.
Finally, in this past January, the Administration released
its first strategy, but it failed to meet even the most basic
requirements of the law. Even more shocking, its stated goal is
to reduce the overdose deaths by only 15 percent over the next
five years. And ladies and gentlemen, I'm convinced that we can
do better than that. Not only can we do better than that, we
must do better than that, because these are people's children,
their mothers, their fathers, their classmates, who are dying.
And there are so many in the pipeline to die.
And so, let me put all of that into context. Even if the
Administration reaches its stated goal, more than 200,000
Americans will still die of overdoses by 2022. Congress has
also failed to act with the urgency this crisis demands. Last
year, Congress passed a support act. Although that bill took
small steps to expand treatment, it only nibbled at the edges
of this generational health crisis.
Meanwhile, nearly 200 Americans continue to die every
single day during this epidemic. The CARE Act offers a
comprehensive evidence-based approach to getting people the
treatment they need to save their lives. And it is endorsed by
the medical professionals across the country. The CARE Act is
co-sponsored by more than 100 members of the House, including
every single democratic member of this committee.
Even the Trump Administration's director of the Office of
Drug Control Policy, Jim Curiel, has commended, and I quote,
calling it ``The heart and the spirit of this legislation,'' is
something that he likes.
The CARE Act would apply the proven model we've adopted on
a bipartisan basis to fight HIV, the AIDS epidemic. I can
remember when people questioned whether or not we would be able
to address AIDS, and we have done an effective job. Is there
more to do? Yes. But we didn't just throw up our hands and say,
``Let folk die.'' We said we were going to do something about
it.
So, the CARE Act would authorize $10 billion for a year to
provide states and local communities with stable funding to
build robust treatment infrastructure. And what we're talking
about is effective and efficient treatment. I'm not talking
about people that throw up a shop on the corner, like I see
some places in my town, and distribute certain types of
medications, and then call themselves giving people treatment.
I'm talking about real evidence-based treatment.
And it would expand access to medication assistant
treatment, and the wraparound services that are necessary. It
would incentivize states to adopt model standards for treatment
programs and recovery residences. It would provide $500 million
per year to buy the overdose anecdote Naloxone, and distribute
it to first responders, public health offices, and the public.
The CARE Act has been endorsed by more than 200 organizations.
For example, the American Medical Association has endorsed the
CARE Act, noting, ``The CARE Act is intended to fill the
current funding gap. It sets up a framework to do so.''
The American Society of Addiction Medicine supports the
CARE Act, because it will, ``Help communities of all shapes and
sizes, provide critically needed and evidence-based addiction
prevention, treatment, engagement, and recovery services.''
The American Psychological Association endorsed the CARE
Act, noting that, ``The CARE Act acknowledges that a
fundamental requirement for successfully addressing the drug
overdose epidemic is treating the whole person.''
Finally, the National Nurses United endorse the CARE Act,
and wrote, ``In order to effectively combat this horrible
epidemic and save the lives of our patients, it is necessary
for this committee and Members of the Congress in full to
commit to fully fund the response to the opioid crisis. We urge
you to support and pass the Comprehensive Addiction Resources
Emergency Act of 2019, and look forward to working with you to
do so.''
I've often said that, at 68, I've been seeing this drug
problem a long time. The first person that I've ever heard of
dying of an overdose was somebody who died in my neighborhood
when I was eight years old. And I didn't even know what an
overdose was. But the fact is that I've seen many people die
over the years.
But we have not come here just to speak for those who have
died. We've come to speak for the living and the dead. There
are so many people who have been in so much pain that they
didn't even know they were in pain. There are so many people
that were suffering from psychological problems, and did not
realizes how much trouble they're in.
Even in my neighborhood, I can see people sometimes at
three at night chasing death, trying to get drugs, trying to
again put themselves out of pain. And so, we cannot look at
them as collateral damage. We have to address them. Again,
these are our neighbors, these are our friends, these are our
church members. These are our fellow students. These are our
fellow workers.
And so, I am looking forward, and I want to thank all of
the associations that have joined us today. We can do this. And
again, I thank you. And now we will hear from distinguished
ranking member of our committee, Mr. Jordan.
Mr. Jordan. Mr. Chairman, thank you. I know you care
passionately about this, and we appreciate that, the commitment
to dealing with this crisis. And this is one of the most trying
issues of our time. And this committee has rightfully treated
the ongoing epidemic as an issue of the utmost importance.
Chairman Cummings and I both represent states that have been
severely affected, and the situation, as the chairman
described, is nothing short of heartbreaking.
Our home state of Ohio has the second worst opioid overdose
death rate in the country. In Ohio more people die from
overdoses than from car accidents. Over the course of a single
year Ohio has witnessed almost 5,000 fatal drug overdoses.
That's nearly 14 deaths every single day.
As all too many of you know, this staggering death toll
does not begin to capture the devastation inflicted on families
and communities. Today, we will discuss the sad fact that many
Americans suffering with addiction are not able to access
evidence-based treatment options. The witnesses her today, who
help us understand the extent of this problem, how we can get
to the solution. And I appreciate you all being here, and look
forward to hearing what you have to say.
This is an issue deserving of Congress's attention, and I'm
pleased that this committee has made it a priority. I'm also
encouraged the Trump Administration is fully committed, fully
committed to addressing the problem. As we have heard during
two recent hearings with Office of National Drug Control
Policy, the Administration has a plan to reduce opioid demand,
cutoff the flow of elicit drugs, and save lives by increasing
access to treatment.
The plan is producing results. Since President Trump took
office there has been a 34 percent decrease in the total amount
of opioids that pharmacies dispense monthly. Also, the number
of patients receiving a form of medication-assisted treatment
has increased dramatically.
Monthly prescribing of lifesaving Naloxone, as the chairman
talked about, has increased 484 percent. The Trump
Administration has invested $500 million in the HEAL Initiative
to bring new non-addicted pain med management therapies to
patients in need. And this Administration is making great
strides to enforce parity rules so more insurers are providing
the services that their members are entitled to.
Last year, President Trump signed into law legislation that
allocates $6 billion specifically dedicated to combatting the
crisis. This crisis does not strike each community in the same
way. What prevention and treatment efforts may be effective in
one area may not work as well in another? What we know for sure
is that this is not a problem that funding alone can solve. We
need to thoughtfully empower communities to address their
unique needs to reduce the supply of drugs, prevent drug use,
and provide access to needed treatment.
It would also be a mistake not to address one of the root
causes of the opioid crises. We should consider securing our
borders, a necessary part of this effort to deal with this
problem. Earlier this year enough Fentanyl was seized in one
drug bust, in one seizure, enough Fentanyl to kill 57 million
people. It's scary to think of how much is getting through.
I'm grateful for medical processionals who are with us this
morning. You are on the front lines battling this problem
daily. Thank you. Thank you for taking the time to be here to
discuss this health crisis.
And I should just point out, too, that there are a number
of important things going on this morning. This one is
certainly one of them, but there's a reparation's hearing next-
door. There's a former White House adviser upstairs in a
deposition. And I'm supposed to be at all three places at the
same time. So, I will be in and out, but I do look forward to
hearing from what you have to say. Other members will be in
that same position.
But, again, Mr. Chairman, thank you for this hearing. And,
again, I want to thank our witness for being here. And I yield
back.
Chairman Cummings. I want to thank you, Mr. Ranking Member.
Now I would like to welcome our witnesses. Dr. Susan Bailey
is the President-elect of the American Medical Association. Dr.
Yngvild Olsen is the Vice President of the American Society of
Addiction Medicine, and Medical Director of the Institutes for
Behavior Resources, Inc., REACH Health Services, in Baltimore.
Dr. Arthur C. Evans, Jr., is the Chief Executive Officer and
Executive Vice President of the American Psychological
Association. Ms. Jean Ross is a registered nurse, and is the
President of the National Nurses United. And Ms. Angela Gray is
a registered nurse, and is the nurse-director of the Berkeley-
Morgan County Board of Health, in West Virginia. Dr. Nancy
Young is the Executive Director of Children and Family Futures.
If you all would please rise, and raise your right hand,
and I will begin to swear you in.
Do you swear or affirm that the testimony you are about to
give is the truth, the whole truth, and nothing but the truth,
so help you God?
You may be seated. Let the record show that the witnesses
answered in the affirmative.
Let me just let you know that the microphones are very
sensitive. Make sure that they're on when you speak. We will
hear from each of you, and understand that we have your
testimony. And basically, what we're looking for you to do is
summarize it.
As you can see, we've got a--this is a pretty big panel.
Usually we only have four people. So, we just ask that you stay
within the five-minutes. Of course, you're familiar with the
lighting system. If you see a red light you might want to wrap
it up. Okay?
Dr. Bailey?
STATEMENT OF SUSAN R. BAILEY, PRESIDENT-ELECT, AMERICAN MEDICAL
ASSOCIATION
Dr. Bailey. Good morning. Chairman Cummings, Ranking Member
Jordan, committee members, the American Medical Association
commends you for holding today's hearings. My name is Dr. Susan
Bailey, and I am president-elect of the AMA. I'm a practicing
allergist immunologist from Ft. Worth, Texas, and I thank you
for this opportunity to testify today.
The nation's epidemic of opioid-related overdoses and
deaths continues to worsen. Nearly 20 million people in the
United States have a substance use disorder, putting them at a
greatly increased risk of early death from overdose, infectious
diseases, trauma, suicide, and more than 92 percent of these
patients receive no treatment.
According to the National Institute on Drug Abuse more than
130 people per day, we heard the chairman say upwards of 200,
die in the United States every day from an opioid-related
cause.
If there's any good news in this epidemic is that we know
what works. There is clear evidence that medication-assisted
treatment, commonly referred to as MAT, is a proven medical
model that supports recovery, saves lives, reduces crime, and
improves quality of life. Methadone, buprenorphine, and
Naltrexone are approved medications to treat this disorder.
The bad news, however, is that only a small portion, maybe
about a third of people with opioid use disorder, receive any
type of treatment, and only a small set of those receive MAT.
So, if we know what works----
Chairman Cummings. Wait a minute. Hold----
Dr. Bailey [continuing]. why is it so hard for people to
get the treatment?
Chairman Cummings. Hold up. Hold up. Hold up. We've got to
keep those doors closed. I can barely hear what you were
saying.
Dr. Bailey. Thank you.
Chairman Cummings. All right.
Dr. Bailey. So, if we know what works, why is it so hard to
get treatment? There are several reasons that I would like to
highlight.
First, there are administrative barriers imposed by payers
and pharmacy benefit management companies on MAT drugs, such as
prior authorization and step therapy. The AMA calls on all
payers, both private and public, as well as PBMs, to end these
administrative burdens for the treatment of opioid use
disorder.
In addition, MAT should be available on the lowest cost-
sharing tier to promote affordability as well as promote
availability. There is no clinically valid reason to deny or
delay access to these lifesaving evidence-based medications.
A second reason for limited access to treatment is the lack
of enforcement of mental health and substance use disorder
parity laws. Very high rates of mental disorders coexist among
patient with opioid use disorders, as well as among patients
with chronic pain conditions, leading to an increased risk of
suicide.
More than 10 years after the passage of the Mental Health
Parity and Addiction Equity Act, huge gaps in treatment for
substance use disorder and mental health disorders are simply
unacceptable. The AMA continues to call on policymakers to
enforce the parity laws provisions. Insurers need to be held
accountable for not complying with their obligations required
by law.
Insurers must have addiction medicine and psychiatric
physicians in their networks, and the networks have to be
accepting new patients, as well as have mental health and SUD
coverage that is on par with surgical and medical benefits.
A third reason for the gap in treatment is funding and
infrastructure. There is an enormous need for long-term funding
and policy to build a robust, flexible, evidence-based public
infrastructure that can handle the opioid epidemic, and
prepares us to treat other growing concerns, including the
increased use of methamphetamine, which brings me to the CARE
Act.
Its funding level is a substantial increase and in keeping
with the enormity of the subject. At the patient level, the
bill would provide grant preferences to states that have
prohibited prior authorization and STEP therapy for NIT.
Overall, the bill will help create the nationwide
infrastructure needed to address this and future epidemics, and
the AMA is pleased to support it.
Thank you.
Chairman Cummings. Thank you very much. Dr. Olsen?
STATEMENT OF YNGVILD K. OLSEN, VICE PRESIDENT, AMERICAN SOCIETY
OF ADDICTION MEDICINE
Dr. Olsen. Thank you. And good morning, Chairman Cummings,
Ranking Member Jordan, esteemed members of this committee. And
thank you so much for inviting me to participate in this
important hearing.
My name is Dr. Yngvild Olsen. I'm a general internist,
board certified in addiction medicine, and care for patients
with addiction in the state of Maryland. I'm also the vice
president of the American Society of Addiction Medicine, or
ASAM, a national medical society representing over 6,000
physicians and other clinicians who specialize in the treatment
and treatment of addiction.
And I'd like to start with a story of one of my patients,
whom I will call Andy. In 2011, Andy walked into my office and
told me was addicted to heroin. His life was in shambles, and
his mother and ex-wife were unwilling to let him see his two
children.
Andy began taking methadone and receiving counseling in our
clinic. And slowly he began to escape Heroin's grip.
Previously, he had struggled for years to maintain a job while
suffering with addiction. But since starting treatment, he has
stopped problematic substance use for long periods of time, has
been able to work, has been able to pay child support, and has
been able to support himself and his new wife. And he is an
involved father in the life of his children.
However, out of his 11 close high school friends, Andy is
the only sole survivor. The others have all died of drug
overdose. And I think of Andy and his high school friends every
time I see the statistic in the 2016 surgeon general's report
that only about one in ten people with addiction receive
specialty treatment.
And inspired by Andy, and by many of my patients, who have
overcome incredible challenges in their lives to achieve
recovery, I've three points to make to you today.
First, everywhere we look we are missing opportunities to
save lives. Evidence-based addiction treatment reduces crime,
increases employment, and reduces the transmission of
infectious disease. And specifically, we have medications for
the treatment of opioid addiction that reduce the risk of fatal
overdose by half or more.
Yet, we can leave this hearing room today together and
visit emergency departments and jails across the country, where
we will find people with addiction unable to start treatment
meeting generally accepted standards of care. And we can walk
together around cities, towns, and rural areas in every single
one of your districts, and we will find people using drugs
without hope for the future, and without access to lifesaving
care.
And second, to end the addiction and overdose crisis, we
must pay for it. I deeply appreciate that Congress has
appropriated several billion extra dollars in the last few
years to support efforts in every state. And there's no
question that these investments have saved lives. But about
70,000 Americans each year are dying from drug overdose.
Far more resources are necessary in the interventions shown
to have the most impact to save more lives. It requires more
than more funding. It requires smart funding. Paying to save
lives starts with comprehensive insurance coverage, including
private insurance, Medicare, and Medicaid.
My patient Andy is covered by Medicaid. He relies on that
coverage not only for the care I provide, but also for mental
health treatment that has allowed him to overcome a terrible
legacy of trauma related to childhood sexual abuse.
But payment for treatment alone is just the beginning.
Communities need additional resources to create systems of care
and social services that give every individual the opportunity
to achieve and sustain recovery. And one terrific model is the
Ryan White Care Act. Ryan White is the act of Congress that has
made it possible for our national goal today to be the end of
the HIV epidemic.
We need a similar investment so that we can one day achieve
the national goal of ending our addiction and overdose crisis.
And that's why ASAM supports the CARE Act. This legislation,
modeled on the Ryan White Care Act, authorizes $100 billion
over the next decade to help communities of all shapes and
sizes provide critically needed and evidence-based addiction
prevention, treatment, harm reduction, and recovery services.
And third, ending the addiction and overdose crisis
requires more than new resources. It requires a new attitude.
Because drug addiction is not a moral failure. It is a complex
and chronic disease. And people with addiction deserve care and
support, not stigma and ostracism. All practitioners who care
for patients should learn to identify and treat patients with
addiction, and take pride in doing so.
Police departments should measure success by fewer
overdoses and less crime, not by the number of arrests of
people who have a disease. And instead of only focusing on some
people with addiction, based on address, or class, or race, or
ethnicity, we should embrace the following, that everyone with
addiction deserves the opportunity for treatment and recovery.
Because looking back more than a century, historians have
called opiate addiction the American disease. It's time to
write the final chapter of this history. It's time for the
United States to take a compassionate, humane, and public
health approach to this crisis.
So, thank you for the opportunity to testify today, and I
look forward to your questions.
Chairman Cummings. Thank you very much. Dr. Evans?
STATEMENT OF ARTHUR C. EVANS, JR., CEO AND EXECUTIVE VICE
PRESIDENT, AMERICAN PSYCHOLOGICAL ASSOCIATION
Dr. Evans. Chairman Cummings, Ranking Member Jordan, and
members of the Committee on Oversight and Reform, thank you.
I'm Dr. Arthur C. Evans, chief executive officer of the
American Psychological Association, which has a membership of
over 118,000 psychologists and affiliates.
Mr. Chairman, psychologists are on the front lines of
providing clinical services, conducting research, developing
policy, and providing education to help combat the opioid
crisis. I want to convey two key points today.
The first is that successfully treating opioid and
substance use disorders really requires a whole-person
approach, articulated by SAMSO. Second, we need to incorporate
non-pharmacological pain management in dealing with the opioid
epidemic.
So first, let me talk about the whole-person approach.
Substance use disorders are very complex. They have behavioral,
biological, and social underpinnings. Research indicates that
you have to address all of these areas if we're going to be
effective in treating and helping people to achieve long-term
recovery.
My understanding of these conditions is informed by 30
years of work in the field, including as a clinician, as a
researcher doing treatment studies, a faculty at medical
schools training psychologists and physicians, and as a program
director overseeing treatment programs for people with opioid
dependency.
I also spent 20 years of my career as a policymaker in the
state of Connecticut and in Philadelphia overseeing large
behavioral health treatment systems.
One of the things that I've learned in my career is that we
must based our practices and policies on the best available
research. And the research is clear that the most effective
treatment for opioid use disorders include psychosocial
interventions in combination with medications. In other words,
medication-assisted treatment means medications are used to
assist in the treatment process, not be the treatment.
This is important, because as a former director of a
medication-assisted treatment program, I know how easy it is to
give short shrift to psychosocial interventions, and in doing
so we are not giving people the best opportunity for long-term
recovery.
Our policies and funding strategies should ensure that
people have access to the full range of services and supports
that they need. This is why APA supports the CARE Act, because
it embraces this whole-person approach. Grantees would be able
to use CARE Act funding to provide a wide range of treatment,
as well as recovery support services, including those that have
helped people to access education, housing, and job training.
People could receive these services through multiple
pathways, including faith-based organizations, vocational
rehabilitation agencies, housing agencies, and community-based
entities.
Turning to my second point. We need to make non-
pharmacological pain management more available to people,
because this is critical if we're going to help reduce the
misuse and dependency on opioids.
Research has shown that pain involves a complex interaction
of physiological, psychological, and social factors.
Psychologists have been at the forefront of using this research
to develop interventions that help people more effectively
manage their pain and approve their functioning. However, these
interventions are not as widely used as they should be. So, we
were pleased to see the Administration's Pain Management Best
Practices Interagency Task Force report just released last
month. The report notes that the importance of--notes the
importance of psychological interventions and the management of
pain, and recognizes the importance of non-pharmacological
interventions in the Nation's overall strategy to address the
opioid crisis.
Finally, one thing that I've learned in my 20 years as a
policymaker, that if you see one treatment system, you've seen
one treatment system. What communities need depends on a
variety of factors. Depends on the population of the community,
depends on the nature of the treatment system, depends on the
nature of the epidemic within the community. And it depends on
the non-treatment resources that are available to help people
in their recovery.
So, the unique mix of each community is going to be
different. The CARE Act recognizes this by targeting resources
to those hardest hit communities, and giving them the
flexibility to address their unique needs. And that's why we
are supportive of this legislation.
Thank you for this opportunity to testify today on behalf
of America's psychologists and the people whom we serve. And I
look forward to working with you on moving this legislation
through Congress, and welcome any questions that you might
have.
Chairman Cummings. Thank you very much. Ms. Ross?
STATEMENT OF JEAN ROSS, PRESIDENT, NATIONAL NURSES UNITED
Ms. Ross. Good morning. Thank you, Chairman Cummings,
Ranking Member Jordan, and the rest of the members of the
committee for inviting me to testify at this very important
hearing today.
I've been a registered nurse for over 40 years, and I am
president of National Nurses United, the largest union of
bedside nurses in the United States, representing over 155,000
members.
Registered nurses take care of people with substance use
disorder and opioid use disorder specifically every single day
across this country. We provide care to them while they undergo
treatment and when they overdosed. Far too often we are next to
them and their families when overdose kills them.
We also witness how barriers to accessing much needed
treatment and prevention services has caused and exacerbated
the opioid epidemic. We witness how poverty, income and
equality, racism, and unethical profiteering by the
pharmaceutical and health insurance industries all have
contributed to this horrible crisis.
I want to make three main points in my testimony today,
which summarize the detailed testimony I've submitted for the
written record.
First, there is an abject lack of access to treatment,
prevention, and harm reduction services for patients with or at
risk of opioid use disorder. Across the country there are far
too few or no local providers who offer medication-assisted
treatment. Harm reduction services are far too rare. And in
many communities early intervention programs and recovery
services are non-existent.
NNU nurses across the country have observed how a lack of
these services means that patients do not have access to
treatment for underlying health conditions, and only get care
when overdosing.
For example, in Stark County, Ohio, such services are rare,
and the county has lost several mental health and acute care
facilities. Stark County has almost twice the rate of opioid
overdose deaths than the U.S. as a whole.
Second, inequality and specifically health inequity is a
main driver of the opioid epidemic. Although the epidemic
impacts every segment of our Nation, it has grown exponentially
in our most vulnerable communities, where safety net services
are underfunded, under resourced, or simply nonexistent.
Health inequity can drive people who have pain, whether
physical or psychological, toward substance use disorders.
Patients may be unable to afford comprehensive services whether
or not they have health insurance. Research has shown that
unemployment increases opioid fatalities by 3.5 percent.
Moreover, longstanding healthcare inequities in communities
of color are reflected in how our Nation currently addresses
the epidemic. Opioid overdoses in African-American communities
are rapidly increasing, faster than other groups. The way in
which our country has thus far approached the crisis serves to
perpetuate and exacerbate health inequality.
It is critical that the Federal Government moves away from
law enforcement and criminalization, and instead responds to
all substance use disorders through public health
interventions.
Third, despite well-meaning steps forward, the national
response to the opioid epidemic is inadequate, and it must be
sufficiently increased to ensure that people receive the care
that they need to treat and prevent substance use disorder. In
order to address the massive scale of this epidemic, it is
necessary to invest a significant amount of financial resources
into a dramatic scale-up of treatment, prevention, and harm
reduction services.
Medical science has given us the treatments we need to
prevent disorder from killing our patients, but high prices and
lack of resources are preventing us from saving lives. The CARE
Act of 2019 provides us multipronged approach to slow and halt
the epidemic.
Most importantly, it would appropriate an adequate and
sustained financial commitment that would allow our Nation to
sufficiently address the scale of the epidemic. The approaches
prioritized in the CARE Act would drastically reduce overdoses,
increase access to treatment for patients, and provide the
services necessary to help people manage their pain. It puts
funds into the hands of the communities impacted by this
crisis, like the Ryan White Care Act did so successfully for
HIV AIDS.
While we fully support the CARE Act, it's important to note
that in order to address the fundamental health inequities that
pervade and fuel the opioid crisis, we must adopt a guaranteed
healthcare system. This is why National Nurses United supports
Medicaid for all.
I urge all the members of this committee to work to pass
the CARE Act, and adequately scale-up the Federal response to
this crisis.
Thank you, Mr. Chairman. Thank you to all the members of
this committee for hearing our concerns.
Chairman Cummings. Thank you very much. Ms. Gray?
STATEMENT OF ANGELA GRAY, NURSE DIRECTOR, BERKELEY-MORGAN
COUNTY BOARD OF HEALTH
Ms. Gray. I'd like to thank Chairman Cummings, and Ranking
Member Jordan, and the committee for giving me the opportunity
today to share my front-line experience. I am the Nurse-
Director of the Berkeley-Morgan County Board of Health. I cover
Berkeley County, which is the second largest county in West
Virginia, of about 118,000. And then the neighboring county of
Morgan is a smaller county of about 18,000. So, I have a good
perspective on rural and urban. I am a Robert Wood Johnson
public health nurse leader. There are 25 of us in the Nation.
My state is hemorrhaging, and without long-term funding,
and commitment, and plan, we will continue to bleed. We are
appreciative of the funding that we are getting, but we need
infrastructure support. To this date, none of the SOR money has
hit the community level. I have not seen one penny.
In March I was asked to put an order in for Naloxone. Our
state has the highest number of overdoses in the country. I've
yet to see one dose of that Naloxone from the million dollars
that's at the state level for it, that was supposed to cover
from March of this year to March of next year.
I'm getting local support. Our county commission and our
city commission has supported us in helping get a harm
reduction program up and running in Berkeley County before the
state had funding from the Federal level, or any guidelines on
it.
Our Medicaid expansion has been crucial. Before that we
were unable to link people to care. However, it still has many
gaps. Providers won't accept it, and those who do, it creates a
financial burden because there are three to four months getting
reimbursement.
There's huge gaps in the MAT. We have more providers trying
to get waived, but a lot of our providers are very leery,
because it requires a waiver. But OxyContin and Percocet
doesn't require them a waiver to prescribe.
And when you get them linked to MAT it doesn't stop there.
I get a couple to MAT. They give me a call and say, ``Hate to
bother you, you've helped me so much, but I can't get my
prescription, because I don't have a valid ID.'' So, I meet
them at the pharmacy, and use my personal ID, so they can get
their medications, and then link them to nonprofits that will
help them get through the process of getting their ID.
The tentacles of this crisis and epidemic reach every level
of our community. And with what we know about the adverse
childhood experiences, we are perpetuating generations of
addiction and substance use disorder.
In President Trump's State of the Union address he said
that there was a plan to end domestic HIV within the next 10
years. I literally responded back to the TV and said, ``Not an
attainable goal with the way we are addressing the opioid
epidemic.'' West Virginia has always been a low-incident state
for HIV, and we have 52 new cases in Huntington, West Virginia
right now, all linked to injection drug use.
My colleague explained and gave an analogy of substance use
disorder the best I've ever heard it. Imagine a carousel
spinning around. We offer support before people enter by
prevention and trying to prevent our children from first drug
use. We offer support at the end, when people need recovery,
although there is much more work that needs to be done. But as
you're spinning out of control and you're the most vulnerable
we do not intervene at all. And that's where in harm reduction
programs, with syringe access, can intervene and are vitally
important of reducing the spread of disease such as HIV,
Hepatitis A, B, and C, and other things such as endocarditis,
abscesses that's costing our healthcare dollars billions.
``Those who do not learn from history are doomed to repeat
it,'' so said President Roosevelt. Have we not learned from the
HIV and AIDS epidemic that's slow to respond and putting the
money in the funding, and the resources where it's needed, it
does work. Ryan White has proven that. I support this CARE Act
to help heal our communities and give the actual funding that's
needed to address substance use disorder and mental health in
our country.
Communities are letting their morality and lack of
education get in the way of harm reduction programs and syringe
access. I was raised Pentecostal, and I remember my Bible
stories from when Jesus walked this earth. And when he did, he
did not seek the rich, and the kings and the queens. He would
seek the poor. He sought out the leper, those of disease, and
the prostitutes. And I have no doubt today that if Jesus walked
this earth right now he would be working and alongside the harm
reduction clinics, because I do God's work every day, and so
does the staff, my small staff, that works so hard to help
accomplish that.
This is very personal to me, because our state has been
riveted, and we lost our family members, people we went to high
school with, our children. You can see the data, and it's very
important, but beyond the numbers, at the local level we see
the faces every day.
I would like to invite you. I'm not far away from you. Less
than two hours. Come visit my clinic. See what the front lines
look like. Arrange a meeting that you can sit down with the 30-
plus community partners that meets, and work, and try to
manipulate the systems and the barriers to get people help.
We need force multipliers. There's not enough of us. We
need real infrastructure, and I'm sure that's why the SOR money
hasn't even touched the community level yet. They're just
floundering at the state level, and we are at the community
level, too.
Besides myself, there are two other nurses that are trying
to do this for 118,000 population. We need help, and I'm asking
you please to support this CARE Act and give the real funding
that's needed to address substance use disorder and mental
health in this country.
I hear people say, ``Well, don't you just think you've got
to wait for this generation to die out before the opioid
epidemic will be over?'' And my response is, ``Which
generation. I'm seeing three now, and more are coming on every
day.'' Our children being born right now in West Virginia are
at a high risk of having substance use disorder because of the
ZIP Code that they live in. How sad is that?
I've a great nice who's a year-and-a-half year old who is
just the joy of my family, and I want to change this before she
gets to middle school and becomes at higher risk.
Thank you for the opportunity for me to speak today. And
please do the right thing for the people who are suffering in
my state as well as others.
Chairman Cummings. Thank you very much. Dr. Young?
STATEMENT OF NANCY YOUNG, EXECUTIVE DIRECTOR OF CHILDREN AND
FAMILY FUTURES
Dr. Young. Thank you, Ms. Gray for the work that you and
your colleagues are doing.
Ms. Gray. Thank you.
Dr. Young. Chairman Cummings, Ranking Member Jordan, two
months ago I had the opportunity to spend the afternoon in
Coshocton County, Ohio, Mr. Gibbs' district. I was there to
visit the family treatment court. And my time included about an
hour with a young woman, I'll call her Monica, who graduated
from the family treatment court. And she shared her family's
story to opioid addiction and her recovery.
Opioids entered her life when her husband had a work
accident that almost severed his leg. He was sent home from the
hospital with a large supply of opioid-based pain medication.
Today, in hindsight, healthcare professionals might recognize
that supplies too many pills for his prescription, but his
brain became triggered, and he became dependent on that supply
of semi-synthetic opioid pills.
Later, Monica had her first baby by a C-section, and she,
too, was sent home from the hospital with many opioid pain
pills, and her family was forever changed.
As the committee knows, much progress has been made across
the country in restricting the availability of prescription
drugs over the past several years. But that restriction has
been filled by other forms of opioids. For Monica, a young
mother in Coshocton, who is struggling with an opioid use
disorder, the birth of her third baby brought child protective
services into her life, and she found her way to the county's
family treatment court.
I don't know all the details of her case, but what happened
for Monica is the goal of child welfare services. She was able
to keep her children in her custody while she worked her
program of recovery through the Coshocton County Family
Treatment Court.
Monica is not unlike other mothers who have gotten trapped
in opioid addiction, but it's all too rare for them to have
services like Coshocton and the 30 other Ohio counties with
family treatment courts, or the 31 counties with the Start
Program in Ohio, or 13 counties in Maryland where Start is
available to them. These are good programs, and they are
helping some parents and children who desperately need them.
But I want to make clear that these are still patchworks, not
systems.
The most recent estimate of babies who are diagnosed with
neonatal abstinence syndrome is from 2014 data, 8 babies per
1,000 hospital births, or about 30,000 babies per year. This is
a dramatic increase from a decade ago. There are not clear data
available that would connect these infants with NAS to the
increasing number of infants who are being placed in child
welfare services, but in 2017, out of the 269 children placed
in protective custody, just over 50,000 were infants.
Why can't all parents who need treatment like Monica obtain
it? It's not news to anyone on this committee that for decades
our country has neglected the infrastructure of the substance
us and mental health treatment systems. The National Office of
Volunteers of America recently completed a national inventory
of residential facilities that can accept parents with their
children. And there are 362 programs in the country. The
painful reality is that there hasn't been a national effort to
expand parent and children programs since the cocaine epidemic.
There's been a tremendous effort to provide service dollars
over the past couple years, and ongoing support is needed, but
maybe we need an infrastructure we can, Congress, that's about
building infrastructure of substance use and mental health
facilities for families. The infrastructure just isn't there.
In the child welfare arena, even though Title 4E funds are
being made available for children to remain with their parents
in treatment, there remains an enormous infrastructure gap of
bricks and mortar, as well as professional staff who can work
across substance use, child welfare, and courts with families.
Have the responses from the Administration and Congress
been adequate? No. Every single one of us can do better, from
churches, and community groups, to local governments, states,
Federal officials, and private enterprises, we all have a role.
I also believe it's critically important that new funding
build on the existing planning, licensing, and certifications
of state and local governments. Often, those are the barriers
to building those new facilities. I've had the opportunity to
work with various grant programs from Federal and state
governments over the past 25 years, and what I know is that
grants often don't go to the communities of greatest need. They
go often to the community who is able to hire the best grant
writer. From my perspective connecting funding through existing
planning and operational methods makes the most sense for
evaluation of programs and for long-term sustainability.
At the end of my conversation with Monica, I told her that
from time to time I have the opportunity to make
recommendations to state and Federal officials. And I asked her
what she would want me to tell them. She said, ``Tell them that
the drugs are still here, that there's still a lot of diversion
of pills, and even meds for treatment of opioid addiction.''
Of course, I wasn't able to hear that, as I'm sure members
of this committee are not. But she also said, ``Tell them
there's not enough support for people who are in recovery.''
So, Monica would say she's in recovery, the family treatment
court helped save her, but families like hers still need more
help to sustain the recovery. And I would add more help is
needed to heal the trauma for her children, and to focus on
both generations. That support will need to be there a day at a
time for the rest of her life, and our job is to make sure that
the community support is there, as well as the front-line
treatment in an organized system, not a patchwork of fragmented
programs.
Thank you very much.
Chairman Cummings. Thank you very much. And I yield myself
five minutes to ask a few questions.
Ms. Gray, I'm going to take you up on your offer. I'm going
to come visit. Sometimes I think that we----
Ms. Gray. Yes.
Chairman Cummings [continuing]. forget that drug addiction
has no boundaries. And I want to thank you for, all of you for
what you're doing. And I'm going to thank you, in particular,
because I know it must be very difficult trying to address this
problem with very limited resources.
A lot of people will say that you don't--I think a lot of
people have gotten to the point where they've become kind of
cynical, Dr. Bailey, about drug treatment. They've seen people
relapse. And then they combine it with it's more failing, and
they say it's their fault.
So how do we deal with that? Because, you know, one of the
things up here in Congress, the first thing you'll hear is, you
know, we're going to be wasting money. I didn't mean to say it
like that, but that's basically what the result is.
So how do we deal with that? Do you follow what I'm saying?
In other words, what do we--how do we guarantee as best as we
can something that works?
And Dr. Olsen, you may--any of you may chime in. When we
were putting together the CARE Act, we tried to take all of
that into consideration, but I'd like to see your viewpoint.
Dr. Bailey. Thank you, Mr. Chairman. The stigma around
substance use disorder is pervasive in our society. And I think
all of us need to re-set our thinking that it's not a moral
failing. Substance use, opioid use disorder is a brain
disorder. It is a disease that requires treatment.
Unfortunately, it's a disease that features frequent relapses.
And the treatment aspect of it is very, very difficult, but it
can be successful. And I think that the more success that
society sees, the less we'll have to deal with the stigma and
the judgment surrounding the treatment.
Chairman Cummings. I think one of you all said, remind who
it was, said that when people do get treatment, and I've seen
this research, that they have less problem. They're able to
keep a job. Who talked about that? Dr. Olsen, would you talk
about that?
Dr. Olsen. Absolutely. So, thank you for the question. You
know, we have a long history in this country of
misunderstanding around addiction and what addiction is, and
what it's not. And you are absolutely correct that it is not a
moral failing.
Over the past 50 years we have really developed an
understanding of addiction as a chronic brain disease that is
complicated. It involves interactions between genetics. So, 40
to 60 percent of the risk of developing a substance use
disorder is genetically based.
It also involves interactions between our environments.
There was mention of the adverse childhood experiences. So
early childhood trauma increases the risk of developing a
substance use disorder.
In any one individual it is not entirely clear to what
extent the genetics versus the environment and other
psychiatric conditions that also increase the risk, exactly how
do those all play into together to develop--how some people
develop an addiction while other people don't.
And the stigma around what this is and what it's not is
still very profound. But what we know through decades of
research is that medications, treatment, particularly when
we're talking about an opioid use disorder that medications
such as Methadone, Buprenorphine, and injectable naltrexone
reduce crime, increase employment, reduce the risk of HIV and
hepatitis C transmission by six-fold, and improve quality of
life.
And I think particularly now, with the number of overdoses
that we're seeing, it reduces mortality. In fact, there's a
study from Baltimore City that looked at the expansion of
access to Buprenorphine and Methadone treatment several years
ago that found that it reduced the overdose from heroin-related
deaths by over 50 percent, between 50 and 75 percent.
So, we know what to do. We know that this works.
Chairman Cummings. Do all of you agree that the majority of
Americans who have a disorder are not getting the treatment
that they need? Anybody disagree with that?
Dr. Evans. No.
Voice. No.
Chairman Cummings. Do you agree that the Federal
Government, including both the Congress and the executive
branch, could be doing more to address this generational public
health crisis? Anybody disagree?
And third, do you agree that we need a comprehensive
Federal approach to expand access to treatment and wrap-around
services, the kind of approach that's laid out in the CARE Act?
All of you agree. Dr. Young?
Dr. Young. I would say for most things it's a Federal,
state, and local partnership. I mean states and local
government play a role in most public policy, and particularly
when it comes to healthcare----
Chairman Cummings. Yes.
Dr. Young [continuing]. delivery, and social service
delivery. So, I would hope that Congress would be seeking help
from NGA and NCSL. Most grant programs that takes a partnership
at the state level to ensure sustainability, so I'm sort of
making an assumption that the Congress has already sought their
advice in this. And I'm hopeful that that partnership could be
made, so that it is all three, state, and local, and Federal
Government.
Chairman Cummings. I want to just ask you, Ms. Gray, there
are--we have a situation where I think you and others
mentioned, children, and our children are affected. A lot of
times we don't see the impact on its surface. I mean we think
about the drug-addicted adult.
Ms. Gray. But they were children, and they started when
they were children.
Chairman Cummings. Yes. So, what impact do you see on their
children? You follow what I'm saying?
Ms. Gray. Yes.
Chairman Cummings. And somebody else might want to address
that, too.
Ms. Gray. Go ahead.
Ms. Ross. I would just say I think we sometimes forget
about the effects of the families of that member, including the
children. So, when we talk about getting that money, and
getting it to the local areas so you don't have to go through
the state and Medicaid red tape, when we talk about that, some
of the things that those--the substance users have to deal with
is time off work. It's childcare. And, again, that's where the
child is affected.
It's just such a huge array of things that is needed in
that treatment. And so, children are affected in that respect,
too.
Chairman Cummings. You know, when we talk about wraparound
services, we had Elizabeth Warren in my district and we were
talking about the CARE Act, and we had all these experts to
come in, and they were talking about the kinds of things that
you're talking about today.
And then at the end of the, at the end of the session, a
gentleman got up, and he says, you know, he says, ``I've got a
drug problem.'' He said, ``I'm 62 years old.'' And he said,
``All those programs are nice. All the stuff you're talking
about is nice,'' but he asked this question, and it really made
me think. He said, ``How am I going to get there?'' He said,
``How am I going to get there?''
Voice. Exactly.
Ms. Ross. Yes.
Chairman Cummings. I mean, and it's--would you please turn
cell phones off, please?
He asked the question, ``How am I going to get there?'' In
other words, going back to these wraparound services, I mean--
and I guess that's one of the good things about the flexibility
of the CARE Act.
Dr. Evans. Could I speak to that?
Chairman Cummings. Yes.
Dr. Evans. I think that is a critical point. You know, it
is really clear that, as I said in my testimony, that substance
use disorders are very complex. They affect a lot of parts of
people's lives. They affect their ability to hold employment.
Most of the people who are at the late stages of their
addictions have lost not only their family, they've lost their
job, they have lost their housing.
And the basic things that people need in order to live are
just as important, in fact, more important than the treatments
that we can give them. Many people that I've seen we've
provided treatment after treatment, but what has really helped
them is to get into stable housing, for example.
When I was in Connecticut, the commissioner in Connecticut,
we had a program called the basic needs program. So we were
providing treatment services for people, but what made the
difference in terms of people being able to engage in long-term
recovery were things like giving people money so that they
could get a haircut, so they could go and do a job interview,
helping people to get from point A to point B, giving people
small grants so that they could start a business, so that they
could take care of themselves, and they wouldn't be dependent
on state aid.
Those small things can make a tremendous difference, and
it's one of the reasons why I think as we talk about this
issue, we can't simply talk about evidence-based treatments, we
have to talk about the whole range of services that people
need.
Chairman Cummings. Thank you very much. I am going to have
to--let me go to Mr. Higgins. But I wanted to just throw out a
series of questions as I did, and you may want to--in answering
other people's questions you may want to chime in and bring--
but I want to get to Mr. Higgins now.
Mr. Higgins?
Mr. Higgins. Thank you, Mr. Chairman. And I thank the
gentleman and the ladies for being here today. It's an
important subject.
Dr. Young, let me jump straight into drug courts, if I
could. In Louisiana, the state that I'm proud to represent, we
have 49 programs state-wide. Thirty-seven have been in
existence for 10 years or longer, drug courts, adult and
juvenile drug courts.
The difficulties in drug courts, in reality, as compared to
the programs that are created by, passed by bureaucrats, and
well-meaning administrators that are not necessarily deeply
rooted in the street, create these programs that include
expenses for the offender that is sometimes quite difficult or
even impossible for the offender to meet.
And as well-intentioned as the diversion programs are, and
the drug court is something I support, I've seen it work very
well, and I've seen it work horribly, but the percentages are
alarming of failures in the first phase of drug court, and
overall, through the phases of graduation through drug court,
we're running, in 2018, 1,747 admitted into the programs in
Louisiana, 829 graduated. But, of course, this is graduating
through all phases. The first-phase failure rate is much
higher.
In Louisiana there is a requirement for $100 a month for 15
months, plus restitution. If there's some ancillary crime
attached to the drug conviction, through the diversion program,
the offender has to pay restitution, if there was a burglar
involved, criminal damage, et cetera.
They have to essentially maintain a job or the effort to
find a job. They are frequently very challenged to earn any
money. And I've seen men actually driven to crime in order to
pay the drug court costs, and fees, and expenses, because of
the difficulty being employed.
Would you please share with America what are the success
rates for drug courts, and what do you think the major problem
is, especially in the first phase? And what can we do as a
nation to respond to that realistically?
Dr. Young. Well, I apologize that I am not an expert on the
adult criminal drug court model. I'm much more focused on the
family treatment court model that operates in the child welfare
arena.
Mr. Higgins. They're very similar. Please use that as your
expertise.
Dr. Young. In the family treatment court arena, we do see
much higher rates of reunifications. And the biggest outcome is
that the children don't come back into foster care with long-
term studies. There's a meta-analysis that I included the
results in my written statement that looked at, I believe it
was 16 evaluations of family treatment courts that says in the
written statement that this is a model that should be used in
child welfare for----
Mr. Higgins. So, you see the family preservation and
intervention courts, I don't mean to interrupt you, but we're
limited on time----
Dr. Young. I understand.
Mr. Higgins [continuing]. as having a higher success rate
than traditional adult drug courts diversion programs.
Dr. Young. And I think, as Dr. Evans said, when you see one
treatment system, you've seen one treatment system. And we know
that there's a lot of variability in adult drug courts as well
as in family treatment courts.
Mr. Higgins. Let me jump into the--perhaps Dr. Bailey or
Dr. Evans can respond regarding treatment options. I think as a
nation we have to explore this treatment options for opioid
abuse other than medication-assisted treatments.
Which alternatives would you doctors recommend, perhaps Dr.
Evans and Dr. Bailey, to medication-assisted treatments? What
do you recommend for opioid and substance abuse programs,
including through drug court?
Dr. Evans. So, the research is pretty clear that opioid
treatment is--that medications are very effective in treating
opioid addiction. But if you look at the way the regulations
and the way those programs are designed, they're really
designed, as I said in my testimony, to be medication plus
psychosocial interventions. And in the absence of psychosocial
interventions embedded within those programs are not going to
be as effective. And let me give you a few reasons why.
Many of the people who come into medication-assisted
treatment programs have occurring mental health conditions. And
so, you have to have the capacity to treat those conditions
effectively.
Second, many of the people who come into those programs are
using other substances. I ran a medication-assisted treatment
program, and I will tell you that most of the people, the
overwhelming majority of people who come into those programs
are not only using opioids, but they're using alcohol, they're
using cocaine, they're using a lot of other substances. And if
you're only using a medication to address the opioids, you're
missing the opportunity to address the other conditions which
actually keep people from engaging in long-term recovery.
And finally, as I said in my testimony, these are very
complex conditions. And even if we can arrest people's
symptoms, we can help people through the acute phase of their
withdrawal so that they are physically stable, if they don't
have proper housing, if they have family situations that are
very problematic, one of the things that we know from the
research is that one of the best interventions for people is
helping them with family interventions.
If you can imagine someone who's living in a family, who
the family system has gotten accustomed to that person as a
person who is not in recovery, when that person goes into
recovery, it throws the family system off, and families can
unwittingly undermine people's recovery. That is something that
is not very well known, but it's something that we know from
the research. But more specifically, outside of medication-
assisted treatment, there's contingency management, which is an
evidence-based treatment approach. There's cognitive behavioral
therapy. There's multidimensional family therapy. All of those
have been shown to be effective in treatment opioid addiction.
Mr. Higgins. Sir, thank you for your answer. It was very
thorough. I thank the chairman for indulging, and perhaps, Mr.
Chairman, the remaining panelists can submit an answer
regarding alternatives to medication-assisted treatments.
Perhaps they could submit in writing, Mr. Chairman.
Chairman Cummings. Very well.
Mr. Higgins. My time has well expired. Thank you for
indulging.
Chairman Cummings. Very well, Mr. Higgins. Thank you, Mr.
Higgins. Ms. Maloney?
Mrs. Maloney. Thank you, Mr. Chairman. Dr. Bailey, in 2017
there were over 70,000 deaths in the United States due to drug
overdose, with the majority, over 67 percent due to opioids.
In your testimony you mentioned the importance of taking
individualized approaches and responsibility in prescribing
opioids. And does your research show evidence that certain
prescribing practices can be helpful in preventing addiction to
or abuse of opioids.
Dr. Bailey. Thank you. I am not aware of any research that
shows differences in prescribing practices making a difference.
We know what works. Using medication-assisted therapy works,
but other things need to be studied, and that's one reason why
we support the CARE Act, to provide the funding and the
infrastructure, so that we can find out what makes a
difference, what can prevent addiction, what can treat it, and
what works the best on the local level.
Mrs. Maloney. Thank you. Now Dr. Olsen, in the district I
represent in New York City, it's home to some of the leading
medical research institutions in the country. And education and
training in treatment addiction is an important component. And
I'd like to ask you about certain proposals that have come
forward. One is from Representative Schneider. He's introduced
the Opioid Workforce Act, which would increase the number of
graduate medical education slots for residency positions and
addiction medicine programs.
And also, the chairman has introduced the CARE Act with
Senator Warren, which would provide considerable funding for
programs, and also training. And it would give preference in
awarding this funding to projects that would train providers to
provide substance and disorder treatment to underserved groups.
How would Baltimore and other communities benefit from
efforts to expand the work force in addiction treatment?
Dr. Olsen. Thank you for that question. The work force
currently that we have across the country, not only in
Baltimore, but elsewhere, is woefully inadequate to address not
only the current opioid epidemic, but really, the future
addiction epidemics or other public health issues related to
addiction. So, we need to build the infrastructure, and we need
to really build it now in terms of increasing that work force.
Medical schools, nursing schools, pharmacy schools, health
professional schools across the country, as well as graduate
medical education, and even faculty education, one of the
important pieces of the CARE Act also focuses not just on the
students themselves, and making sure that they receive the
appropriate education in terms of not only diagnosing
addiction, but treating it, but the CARE Act also provides for
funding to shore up the faculty that are needed in order to
actually train all those students.
So ASAM is extremely supportive of any legislation,
including the CARE Act that would really be able to do that.
Mrs. Maloney. Thank you. Ms. Gray, I was very moved by your
testimony, and I'd like to hear your comments on the challenges
you face in staff retention at your clinics in West Virginia,
and would like to join the chairman in visiting your clinic.
But what was really compelling to me were the obstacles
that you put out there that are systematically put in front of
you in order to stopping you from giving the treatment you
want. I'd like your comments specifically on, if anybody wants
information and treatment options to assist someone who's over
18, they can't give it to you. It has to go to the person,
which is sometimes hard to coordinate. That's an obstacle.
And then you mentioned that the MAT accessibility is
difficult. A provider is not required to have a special waiver
to prescribe opioids like Oxycontin, but you have to get a
waiver to prescribe the treatment, such as the MAT thing. And
the accessibility, you said, is difficult. I find that
startling. Why would we have obstacles to getting treatment
options?
Ms. Gray. And those are just a few. Like I said, you come
to visit, and meet the other 30 partners that I work with, we
will just unload on you. But yes, I mean we have very few MAT
providers in either of the counties that I work in. Actually,
in Morgan County, we have one, and they only see people one day
a month. So yes, it's pretty rough.
Mrs. Maloney. But your providers can't prescribe that, but
they can prescribe an opioid.
Ms. Gray. Right. But they can prescribe----
Mrs. Maloney. What is the logic of that?
Ms. Gray. From my knowledge it comes from legislation
that's from the early 1900's, that maybe you guys can look at
and change.
[Laughter.]
Mrs. Maloney. Maybe we should update that legislation.
Ms. Gray. Yes. Yes. And it makes them very leery. And also,
when we talk about the next epidemic, people are talking about
the next epidemic as meth. I wish Representative Jordan was in
the room, because he talked about, you know, hitting the
supply, and how much Fentanyl and things, it is pure Fentanyl.
They're not shooting heroin in Berkeley County or Morgan
County. It's pure Fentanyl. We've tested. It's pure Fentanyl.
But it's time that we put as much funding and effort into
the demand as we do the supply, because you hit the supply all
you want, and you haven't dealt with the addiction. I can trace
it in my clinic, whenever there's been a hit on the opioid or
heroin supply, it's going to be a heavily meth clinic, because
they have to--you haven't addressed the addiction, so they have
to move to the next drug that keeps them going.
And you can make meth in your home. You can make it in a
backpack. So, unless we really put some serious effort into
treating addiction, you can hit that supply all you want. I'd
love to know how much goes in the criminal justice system that
hits that supply.
Chairman Cummings. Mr. Gibbs?
Mr. Gibbs. Thank you, Chairman. Thank you to the witnesses
for being here.
I'm from Ohio, and Ohio is unfortunately is one of the
problem states, challenging states. And last year I held half-
a-dozen or so roundtables around my district, brought in faith-
based community, all the stakeholders, medical, first
responders. And it was very educational and very helpful.
But I think we've made some progress. I think this is the
first step, but you've got to have--awareness and education is
a problem. And I think at all levels of government, local,
state, and Federal, I think we've crossed that hurdle. So
that's the first corner of addressing this. So, I think we're
probably all in agreement that we're in a lot better place we
were a couple years ago. Hopefully, the trends start going the
right way.
But one thing I did learn, and I've had this confirmed by
numerous doctors in these hearings, and even the Cleveland
Clinic pain specialists, a physician, I was amazed to learn
that some people can get addicted to these opioids after maybe
three days of taking them.
And I just think about my wife when she broke her kneecap
10 years ago, and we had surgery, and she left the hospital. I
think she had like two weeks of Oxycontin. She only took it for
a day. I had no idea. And so, the medical community takes a lot
of blame, you know, I think in prescribing.
So, I want to talk about, I know, Dr. Olsen, you talked
about current guidelines for opioid prescribing. And I
understand you've been teaching appropriate prescribing as
early as the 2000's. Do you recommend revisiting the guidelines
for surgical procedures?
Dr. Olsen. Thank you for that question. So, it is clear, so
the CDC in 2016 came out with prescribing guidelines for
chronic pain targeted at primary care physicians. And those
guidelines are very comprehensive. They are guidelines, and
they are actually the first guidelines that also include a
recommendation for primary care physicians to be able to
identify and treat opioid use disorder in their clinic and in
their patients when they find it.
There are currently also efforts in various different
states, including in my state of Maryland, the Johns Hopkins
School of Medicine, where there are surgical specialties, from
orthopedics to neurosurgery, that are really looking at very
specific guidelines for different surgical techniques, and
various different procedures. And so, having those types of
guidelines is going to be very important.
Mr. Gibbs. When I had my roundtables last year, I saw a
lot--some of the counties, or pretty much all my counties, but
some were doing maybe a little bit better job of getting out a
person that was overdosed, and they get, you know, stabilized.
And I learned that if they could get out and get to them in the
next week, and get them into treatment, had fairly good
success.
So, does anyone want to comment about where we are? It
seems like to me that the treatment, 'cuz you've got to give
them the treatment, and then with un-treatment, I think that's
where the faith-based community can play a huge part. But then
also, hopefully, when they get out of treatment, and they're
going up the right path, having them be employable, or else
they're probably going to revert back to where they were.
So, does someone want to comment about where we are at the
treatment centers? You know, we've done a lot on education, the
different stakeholders I've mentioned, getting money out there.
But where do we stand on treatment centers and the status, I
guess. Go ahead, Ms. Ross.
Ms. Ross. One of the things I would like to say, and this
is why I talked about a guaranteed healthcare system, since we
don't have a system. Hospitals, clinics, centers are open and
closed depending on profit. They aren't set up in the areas in
which people need them. One of the things we do as nurses is
protest every time they close a community hospital. So, we have
too few of them to start with, and then they get closed down.
The treatment isn't there for the people when they needed it.
That's one thing we have to guard against.
And then before I stop here, I just wanted to kind of put
in a plug, because many of us nurses, when we became aware of
this crisis that we're in now, said to ourselves, and I was one
of them, ``Oh, no, they're going to go overboard, and the
people who really do need these opioids aren't going to get
it.'' And we do see signs of that happening right now.
So, the education has to include the fact that there are
chronic disorders, certainly hospice care, where those drugs
are necessary.
Mr. Gibbs. I'm almost out of town, but you're talking about
community hospitals. I'm not so sure I----
Ms. Ross. And treatment centers.
Mr. Gibbs. Yes. Treatment centers.
Ms. Ross. And treatment centers.
Mr. Gibbs. I think someone mentioned Stark County. That's
one of my counties, my largest county. And CommQuest, they are
doing some good thing there, getting those people into
treatment. And I know Senator Portman and myself, we've visited
there numerous times, but that's key. And then getting them
employable, and getting them, you know, back into a job. So, it
goes far beyond what I would expect a community hospital to do.
So, I yield back my time.
Chairman Cummings. Thank you very much. Mr. Clay?
Mr. Clay. Thank you, Mr. Chairman. You know, by the latest
estimate, last year opioids took the lives of over 70,000
Americans. And I want you all to stop and think about that
startling number.
The opioid war has taken more lives than the Vietnam War,
when you think about the--and across my home state of Missouri,
over 1,500 people died last year. More than those who lost
their lives in traffic accidents. And opioid abuse is an equal
opportunity killer. It does not respect geography, race,
religion, age, or educational level. So urban and rural, we're
all in this mess together.
And let's not kid ourselves. Only with a substantial
increase in Federal support and a national commitment to
expanding community-based treatment will we have even the basic
tools to combat this epidemic.
So, let me start with Dr. Evans, and I'd like to ask you,
when a person is suffering from a substance use disorder, is
that typically their only health issue, or do they often have
other health issues?
Dr. Evans. It would be the exception if a person had a
substance use disorder and didn't have other health or mental
health conditions. And it's the reason why it's really
important to have a holistic whole person approach to
treatment. And I can't stress that enough, because if you
listen to the debates right now----
I should step back just for a moment and say, prior coming
to APA I was a commissioner of behavioral health in
Philadelphia. And before I left, the mayor asked me to chair a
task force to look at the opioid epidemic. And one of the
things that we did before we started that work is we looked
around the country to see all of the other recommendations that
had been done on this issue.
And if you do that, what you will find is that there are no
set of recommendations. And frankly, I believe that we have
oversimplified this problem. It is a tremendously complex
problem. And you will hear often, ``Well, if we can just get
people medication-assisted treatment,'' and what people mean by
that, if we can just give people medication, we will solve this
problem. That is not the case. We have to deal with all of the
other issues that people bring into their addiction, if we're
going to be successful.
And so treating people's health conditions, making sure
that they are stable from a social standpoint. All of those
things are necessary to increase the likelihood that people are
going to have long-term recovery.
Mr. Clay. I see Ms. Gray is shaking her head in agreement.
Would you like to add?
Ms. Gray. I think the hashtag 'holistic treatment' behind
me is definitely the key. You need to look at the whole of the
family. We have families where multiple people are injecting in
the same home. How do you even start there? And do we want to
continue this route? Absolutely not. So, we definitely need to
look at the whole of the family.
In my neighboring county, Jefferson County, they've started
what's called a circles program. And it was designed for moms
and babies just through pregnancy to help so babies aren't born
and withdraw. But they found that the moms loved the support so
much they wanted to stay in their groups even after delivery.
And they look at the whole of everything, the childcare,
getting clothes and their hair done, so they can go to job
interviews. They're bringing in--the grandma comes with them.
So, then you're getting in that next--above generation, who is
also abusing drugs.
Mr. Clay. Let me ask you. So do people with substance use
disorder often have other significant challenges in their
lives, like homelessness----
Ms. Gray. We expect more out of----
Mr. Clay [continuing]. and unemployment?
Ms. Gray [continuing]. out of substance--people who suffer
from substance use disorder than we do any other disease that
we treat. If someone comes in in a diabetic coma, I'm not going
to scold them because they ate so much sugar that they ended up
in the hospital four times that month. But yet, if somebody
comes in and has overdosed and relapsed, we shame. The way we
approach people, we keep people from getting care.
People will come through my lobby when they first engage
with us, grown men will walk out with tears running down their
face, because they haven't been treated like a human being
before.
Mr. Clay. Let me ask Dr. Olsen real quickly, do you see
those similarities, too?
Dr. Olsen. Absolutely. And I think that is one of the
reasons why we also need to be very cognizant of what the goals
are in treatment. Initially, the goal, particularly for opiate
use disorder, is we want to help keep people alive. And that is
where medications have such an important role. And so, the
National Academies actually came out with their recent report
calling medications and treatment with medications medication-
based treatment. And then you wrap all these other things also
kinda around that to address all those other conditions that
have been mentioned.
I also just wanted to reference one thing, which is that in
terms of the question around treatment and treatment standards,
you know, you've heard that hospitals, emergency departments,
that people show up in different places. They're not
necessarily walk into an addiction treatment clinic
immediately.
So, we need to have healthcare professionals who are
educated to be able to start treatment wherever the person
walks in the door. And we need to be able to standardize the
treatments across the specialty treatment settings, so that
when people go to a specialty addiction treatment center,
whether it is residential or outpatient, the people, not only
the individuals themselves, but their family members, and
payers, and others, know what it is they're going to be
getting. And that is another really key part of the CARE Act,
is that it speaks to standardizing the care that is provided.
Mr. Clay. Thank you. And Mr. Chairman, my time has expired.
I appreciate it.
Chairman Cummings. Ms. Miller?
Mrs. Miller. Thank you, Mr. Chairman. And thank you all for
being here today. And I want to give a special shout-out to Ms.
Gray. I'm from Huntington, West Virginia. I understand, and
we've been dealing with a lot of this since the 1990's, really.
Because of some of the comments that have just been made
I'm going to go off some of my questions, and immediately go to
the holistic aspect. And I'd like quick, short answers from the
entire panel.
Is faith-based recovery utilized to its full potential? Any
one of you can give me quick answers?
Dr. Evans. I'll jump in. I think faith-based is very
important. You know, one of the things we know from the
research is that different things work for different people.
And even if we say that there is a treatment that is the gold
standard, I will tell you that gold standard does not work for
everyone.
I have seen, as a medication-assisted treatment program, a
provider, and as a detox provider, people have gone through
treatment after treatment after treatment, and what really
helped them was to get involved into a faith community that
really supported them. And that was what made the difference.
So, I think as treatment professionals, particularly as
scientists, we ought to be open to all of the pathways that
people find to get recovery. I'm agnostic to that, to some
degree. What I really care about is at the end of the day that
people are well.
Mrs. Miller. Go ahead.
Dr. Olsen. And I would just also add that those
individualized needs and what every person is going to need is
going to be different.
Mrs. Miller. Absolutely.
Dr. Olsen. That starts with a very through needs
assessment, and that can identify what have people tried in the
past, what has worked, what maybe hasn't worked, and what all
the options are, including medications, as well as other mutual
support services, counseling services, other medical and
psychiatric services, so really getting to that whole person.
Mrs. Miller. That's my whole point, is often we're afraid
to mention that, but I have found in my experience that every
single piece can make a difference.
Go ahead.
Ms. Gray. Yes. Very important. And the faith-based
community is at my table with the 30 that I keep refereeing to.
I think, though, that we know with the way the dopamine
rides so high with the opioid that abstinence-based programs
are about 90 percent fail rate. So, I see the medically
assisted treatment getting them stable, functioning back into
normal society, linking them to the counseling, and to the
group sessions, and that type of thing, that will help lead
them to those things, and the faith-based programs, and stuff.
There's a few people in the movie that was done on
addiction in West Virginia where they were MAT for four years,
and now they're faith-based programs, so----
Mrs. Miller. The recovery is so very important that, you
know, we've--it's like throwing spaghetti against the wall, and
trying to see what sticks. But recovery, to me, is the key.
Let's see. Dr. Young, on Sunday we had a 60 Minutes
session, which I'm sure you have at least watched on your
phone, if you didn't watch it on T.V. I've worked closely with
the police department, and... very aware of what has gone on.
What is your opinion? What are the best practices that you see?
Dr. Young. I was preparing for this hearing, and I'm sorry,
I haven't seen the 60 Minutes----
Mrs. Miller. You need to.
Dr. Young [continuing]. from this week. I will make a--I
will watch that. I am somewhat familiar with what's going on in
Huntington, West Virginia, however. But maybe you could----
Mrs. Miller. Well, we now have an addiction specialist
meeting with the police, talking to them directly. So, you can
watch it on YouTube. It really is fantastic.
Dr. Young. Great. Great.
Mrs. Miller. Okay. I'll switch my question to you about
drug courts, because I think drug courts are very, very
important. Tell me what you think of their success rate.
Dr. Young. I certainly would refer to any DCP for the
overall success rate for the adult drug courts, but we know
that they've been very successful when they follow the
standards that have been set. And I'm very pleased that family
treatment court standards will be announced next month at the
annual conference. So, we have enough research now to say what
kinds of standards should these courts be following?
Mrs. Miller. Thank you. And one other thing is, we've been
very lucky to have Lily's Place in West Virginia. What patterns
do you see can help emerge from this, with the neonatal
abstinence syndrome?
Dr. Young. There are many hospitals that are testing
different strategies for non-pharmacological based kinds of
treatments, and certainly kinds of things that are keeping moms
and babies together, in stepdown nurseries, or even in the
hospital, in non-NICU kinds of settings that are keeping moms
and the babies together, are certainly being tested in lots of
places, and we're very encouraged by that.
Mrs. Miller. I just read in the paper that we now have new
program for babies from six weeks to two years, very much what
you all have been talking about, having the mothers to be able
to get their hair done, and involving the whole family. And I
just feel that it's so important, because this neonatal
abstinence syndrome, the principals are seeing kids that are
five and six years old coming into school, and they're not able
to cope. Their mechanisms are, anger very quickly.
Dr. Young. Right.
Mrs. Miller. There's just so many aspects that I'm sure we
could all sit around for a month and talk about, and share
ideas of what's important.
Dr. Young. I would say every time we talk about treatment
for an adult, we need to say 'and the children, and the
children' every single time along the panel and in the
questions.
Chairman Cummings. Thank you very much.
Mrs. Miller. Thank you.
Chairman Cummings. Mr. Welch?
Mr. Welch. Thank you, Mr. Chairman. Thank you so much for
this hearing, and for your proposed legislation. We've been
having in Vermont a series of roundtables all around the state,
inviting in folks like you who, in Vermont, are providing
frontline services. But also, everyone from the police, who is
incredibly involved at walking that fine line between
enforcement and dealing with a person who's got a medical
problem, to grandparents who are raising their grandchildren,
because their child is in the grip of opioid addiction, to
community volunteers.
And just yesterday we had a hearing in Morrisville, and two
parents who lost their daughter to a recent opioid overdose are
starting a local treatment facility, buying up, hopefully, the
Catholic Church to provide some help to people who are in the
grip of this addiction.
And as incredibly challenging and heartbreaking as this
issue is, and several of my colleagues have mentioned, this
knows no boundaries. There's no political favorites here. I
think it's really tougher even in rural areas and urban, but it
knows no boundaries, whatsoever.
The experience I've had in Vermont is also inspiring,
because if we're going to address the one by one challenge, and
Congresswoman Miller, you were speaking about that very
eloquently, it has got to be done in the community. That is
where it has to happen.
And what I've seen, and I'd be interested in your reaction
on this, is there's such pressure, especially in our rural
communities, where a lot of local institutions are really under
attack, or they're fraying. Our local hospitals are having a
hard time keeping the doors open. Many of our schools in rural
communities are closing. The rural economy is under an immense
amount of stress.
And so many of the people that are on the frontlines tell
me that oftentimes this decision to start going to opioids is
just a decision of hopelessness, a lack of hope. So, I view our
role here federally fundamentally as getting the resources back
to the communities, and it's only in the communities where the
work can be done. And in Vermont it's being done. I know in
West Virginia it's being done.
But this is why I think, Mr. Chairman, your bill is so
important because it acknowledges our role is to get taxpayer
resources. And by the way, that money belongs to the people we
all represent. This is no big deal for us. This is us getting
resources back to the people who sent it here in the first
place, so they can do the important work in their communities.
So that, as I see it, is our role.
Dr. Evans, you were talking about all of the above, you
know, whether it's faith-based, or community-based, or a local
parent helping a friend. So much of this is whether that
individual gets some hope through, I believe, a human
connection of any kind. And absent that, and I'll just ask you
for your comment on that, as somebody who's been so much
involved in the treatment.
Dr. Evans. What you're saying is so important and critical,
and I'm so glad that you brought that into this discussion,
because we're talking about all the technical aspects of
treatment. But I will tell you that what makes the difference
for most people is that human connection.
I sort of joke when I'm talking to providers, and I say,
``You know, when you ask people what helped them in treatment,
rarely do they say, 'You know, doc, it was the paradoxical
intervention that you did on the third session that made all
the difference.'"
[Laughter.]
Dr. Evans. They rarely say that. You know what they say
when you ask them that question? They will say, ``You called me
sir.''
Mr. Welch. Right.
Dr. Evans. ``You called me mister.''
Mr. Welch. Dignity.
Dr. Evans. You treated me with respect. That is a critical
ingredient. We are talking about all of the other aspects, but
if treatment doesn't have that aspect----
Mr. Welch. Right.
Dr. Evans [continuing]. I can tell you it doesn't work. And
the reason it doesn't work is that people will not come back,
they will not engage, and they will not do the work that they
need to do.
Mr. Welch. Thank you. Ms. Gray, I'll ask you. I went to
West Virginia with my colleague, Congressman McKinley, and I've
gotta say I was pretty impressed with the people in your state,
and I know folks are facing challenging times there. Same
question to you.
Ms. Gray. I'll give you an example of something in my
clinic. I was walking through the lobby one day, and a
gentleman that was in his 50's stopped me, and he said, ``Do
you know that girl back there, that short girl with the short
black hair?'' And I said, ``Yes.'' And it happens to be my
daughter, because I'm bringing in anybody I can to help us,
because we're in that much need working the program.
And I said, ``Yes. I know her.'' And he said, ``She gave me
a hug last week.'' And I said, ``Oh, she did.'' He said, ``You
don't know what that meant to me. I haven't had a hug for over
three years.'' So, I walked around and I gave him another one,
and I said, ``Well, you're getting one today.'' So, when he
comes back every week, that's what he gets.
We have just, as a society, we have isolated ourselves
more. We're not interacting more, and we are definitely
interacting with people with substance use disorder as they are
human beings, and how they need. It's very important.
Relationship building is everything.
Mr. Welch. Well, thank you. My time is up, but I do just
want to reemphasize the importance of your bill, that we get
this money back to folks in the communities, in all our
communities that are doing this hard work. Thank you.
Chairman Cummings. Mr. Comer?
Mr. Comer. Thank you, Mr. Chairman, and I wanted to just
first say this. I'm a big believer in faith-based recovery
programs. In fact, yesterday, in my district, stopped in
Washington County at the Isaiah House, really impressive faith-
based recovery center that I think has a tremendous business
model of trying to not only help people recover from drug
addiction, but to get back into society.
Helps them find employment. Takes them to work. Helps them
make sure that when they leave there, if they have bills, like
child support, outstanding child support payments, to try and
help them get on their feet, to where when they leave, they're
debt free, and even with a little money in the bank.
I think that's an important part of recovery, helping
people get back into society. So, I wanted to mention that.
The other thing, and what my question is, I'm a believer in
alternative sources of pain relief, because we have people in
America that truly have pain. The business model, and I've said
this many times, for treating pain, the old business model,
where you prescribe opioids, has been a disaster in rural
America. And part of my district covers the western part of
Appalachia, and I have all of Southern Kentucky, all the way to
Western Kentucky.
So, my question for Dr. Bailey and Nurse Ross, what are the
barriers to patients having access to non-opioids to manage
pain?
Dr. Bailey. Thank you. There are many barriers. Even if a
patient is employed and has insurance, many of those therapies
are not covered, or if they are covered, extensive prior
authorization and approvals are needed. And that's one of our
biggest points that we'd like to make today is removing the
barriers, like prior authorization. That's just not just for
drugs. It's also for procedures. It's for therapies.
And these things need to be studied. We don't really--pain
is such a pervasive part of our culture and our being a person,
and the notion that life should be completely pain free, and
that the ultimate state of pain is a zero pain is not
necessarily very realistic. And we need to have research, but
we need to limit the barriers.
There's also still not parity between mental health
services, and, say, surgeries and medications, and we need the
funding and the infrastructure to make all these things work.
Mr. Comer. Okay. Great.
Ms. Ross. I would agree with everything that the doctor
said, and I would also point out, as we've mentioned several
times, you know, it's--all right. Let's just have an example of
someone that could use PT. Physical therapy----
Mr. Comer. Right.
Ms. Ross [continuing]. works for a lot of people right off
the bat. It depends on your circumstances. So, you start with
whether or not you have insurance. Then you go whether or not
it's covered. Then how many sessions are covered. If the doctor
says it's going to take you this many weeks, and at least 16
treatments, let's say you're living out of your car. Poverty
has an effect on that.
Mr. Comer. Mm-hmm.
Ms. Ross. It's often the things that do work, but they work
over time----
Mr. Comer. Right.
Ms. Ross [continuing]. that are more difficult to get
insurance companies to pay for, and the patients to participate
in. Then sad to say there is some awful things, like you've got
a work-related injury, and from the employer's perspective,
it's quicker to give you some pills that work fast, as opposed
to being out of work longer. So, all those things have an
effect.
Mr. Comer. And I agree, and hopefully, we can come together
on this committee in a bipartisan way to make it easier for
patients to have access to alternative sources of pain relief
that work.
Mr. Chairman, I have a little bit of time left. I'd like to
yield to my friend, Dr. Green.
Dr. Green. Thank you, Mr. Chairman. And thank you, Mr.
Comer. As an ER physician, I see these patients both in the
seeking role and in the crashing role, whether it's withdrawal,
or, you know, an overdose. And I have a unique perspective on
it, but I want to say first to anyone in the room, or who's
watching, who may be struggling with this issue, if you've
gotten victory over it, you've done the hardest thing that a
human being will ever do in their life.
I've done hard. I'm an ex-army ranger, combat veteran,
cancer survivor. If you have overcome addiction, you have done
the hardest thing that a human being will ever have to do. If
you're struggling with it now, and you're watching on
television, get help. You can do it. You can overcome it. But
please seek help.
One quick couple things from a physician's perspective. We
need to always question the data. When I was in residence, I
was told, and the literature said, that a six-day prescription
of opioids will not cause addiction. Now that we know that
three days for some people who are genetically predisposed,
will cause addiction.
That also means that we need to push the advancements in
genetic research on metabolizing medications, and physicians
need to prescribe, based on that genetic profile in the future.
CMS needs to approve abuse-deterrent drugs, so that
physicians can give these things that will prevent patients
from abusing. I want to say about Narcan, it saves lives.
Narcan availability needs to be everywhere. It needs to be in
restaurants. It needs to be in schools. It needs to be on rigs.
It needs to be on policeman. Narcan saves lives, and we need to
use it, and we need to distribute it.
Thanks for talking about neonatal abstinence syndrome. We
don't want to forget those children. I will, if I have just a
second more, Mr. Chairman, just a second more, and I appreciate
the indulgence.
We've also got to make sure that physicians get to make
these decisions about medications, because the pressure from
administrators in hospitals to make patients satisfied creates
an incentive for physicians to just write the prescription,
make the patient happy, and the patient's satisfaction scores
go up. We have to be aware of this dynamic in medicine, and
make sure that the physician gets to make the call.
Thank you, Mr. Chairman.
Chairman Cummings. Thank you. Thank you very much.
Voice. Amen.
Chairman Cummings. Mr. Connolly?
Mr. Connolly. Thank you, Mr. Chairman. And I want to pick
up where Dr. Green just left off, because I think there's a
burden on physicians as well. I mean my experience, frankly, is
that physicians are all too ready to prescribe opioids, and
look at you kind of funny as a patient if you object.
If you're a patient in a hospital, it is more likely you're
actually going to go to battle with the physician, the
attending physician, after surgery, with an accident, in which
you do have acute pain. And their focus correctly is on trying
to make sure the patient can sleep and recover. If you're in
acute pain you're not going to do either one of those two
things.
Pain management is tricky, but I don't think it's yet in
the heads of a lot of physicians that, you know, there's a real
risk here if I prescribe this, or if I prolong its use in an IV
drip. And I just want to know if you might comment on that,
because I--yes, maybe there's administrative pressure on
physicians to have happy customers, but I also think that
there's a Hippocratic compulsion, all motivated for good
reasons, to keep a patient out of pain, which is why we ask
them on a scale of one to ten, ``How you feeling today?'' And
we try to address it.
Leaving people in acute pain is not the answer to this
crisis. And I wanted to give you an opportunity, especially Dr.
Bailey and Dr. Olsen to comment on that.
Dr. Bailey. Thank you very much. The, I think we actually
have made a good deal of progress changing the mindset of the
medical community. Opioid prescribing went down 33 percent
between 2013 and 2018.
Mr. Connolly. But can I just interrupt you, Dr. Bailey.
That sounds impressive. But we were so overprescribing, it had
to come down. I mean in and of itself that doesn't tell us a
lot. And if you have patient experiences, you know, with the
medical community, I mean I don't know whether I want to
describe it as overprescribing, but a quick readiness to tell
you, ``This is good for you, you need to take it, it won't hurt
you,'' continues to, in my experience, dominate much of medical
opinion in interaction with patients, motivated for good--I
mean the motivation's good, but the outcomes are very, very
risky.
Dr. Bailey. I actually have often the opposite reaction
from my patients when I prescribe medications for asthma. Very
often, many of my patients do not want to take things. They
don't even want to take an aspirin. They don't want to take an
antihistamine.
Mr. Connolly. Right.
Dr. Bailey. So, there are a lot of patients out there that
will push back against that. But I think the 33 percent
decrease in prescribing is significant, because it's going in
the right direction. It may have started way too high, but it's
going in the right direction. And I think the greater use of
prescription drug monitoring programs around the country has
increased. An incredible amount of education has been
delivered.
The AMA, and ASAM, and other organizations are being very
active in prescribing from the medical student level, on up,
focusing on the treatment of pain, and non-drug modalities that
treat pain.
Mr. Connolly. I have to interrupt you, only because I'm
running out of time, but thank you, Dr. Bailey.
Dr. Olsen, let me ask you a question about treatment.
Criticism, if you read Beth Macy's book, Dope Sick, a lot of
rehab, you know, people put out a shingle saying, you know,
``Addiction Rehab Center Here.'' They're not licensed, or
they're not really permitted. And two-third of them still
practice no drugs allowed here at all.
And the experience with opioid addiction is that is almost
guaranteed to lead you to another addiction, probably heroin.
It doesn't work, and neither does cold turkey. And neither does
faith-based alone rehab, which Mr. Comey talked about. I wish
they did, but they don't, and I want to give you an opportunity
to comment a little bit about what we're dealing with in terms
of rehab, and what works, and what doesn't.
Dr. Bailey. Great. Thank you so much.
So, you know, I think that this is an issue that ASAM is
working extremely hard on, and making sure that we have
standards, that we have generally accepted medical standards.
This is a medical disease, so, therefore, we really need to be
approaching this as the medical disease that it is. That means
medications. That means a trained work force of physicians,
nurses, psychologists. It takes a multidisciplinary team, as I
think you've heard today on the panel. But it also means that
we do have 50 years of robust scientific evidence that shows
that medication-based treatment saves lives and improves lives.
So, we talked a little about that earlier. And making sure that
we then actually have those standards. ASAM----
Mr. Connolly. If I can interrupt you here, too, and I thank
the indulgence of the Chair, but this is so important for
people to hear. We still have two-thirds of the rehab centers
in this country saying otherwise, saying ``no drugs here at
all.''
Dr. Olsen. Right. Right.
Mr. Connolly. And that is--we know that does not work. We
know, in fact, it condemns people who are sincerely seeking
treatment to a relapse.
Dr. Olsen. Yes. Yes.
Mr. Connolly. Because the brain chemistry is changed to the
point where they can't control that.
Dr. Olsen. Yes.
Mr. Connolly. And so, you've got to have stepdown drugs.
Dr. Olsen. Yes.
Mr. Connolly. I'm sorry.
Dr. Olsen. No. You're absolutely correct. And I think, you
know, there has been newspaper articles, there have been public
awareness campaigns really demonstrating that people, when they
come out of residential treatments, or incarceration settings,
where there is no access to those medications, people die.
The death rates from and the risk of overdose--relapse and
overdose from now Fentanyl is upwards 20 times higher in people
who are coming out of settings like the residential treatment
facilities, like incarcerated settings, where there is no
access to those medications.
And so, therefore, I think the CARE Act really speaks to
evidence-based effective treatments need to be available and
standardized across the board.
Mr. Connolly. Which is why I support this, Mr. Chairman.
Thank you.
Chairman Cummings. Mr. Roy?
Mr. Roy. Thank you, Mr. Chairman, I appreciate that. Thank
you to all the witnesses. You've taken time out of your day to
be here and appear before the panel. More importantly, thank
you for what you do on a daily basis on the frontlines in a way
that most of us don't understand or comprehend what you're
facing, and the good that you're doing, and appreciate that all
your commitment, both from a medical and also from a faith
perspective.
And appreciate very much your testimony about faith, and
about your appropriate recognition of what Christ would teach
us to do today, and what he would do today. And appreciate your
statement in saying that.
Let me ask you all a question, if I can go down the table.
How overwhelmed are we, as a society, clinics, and all the
hospitals, and all the front lines in terms of dealing with
this crisis? If you can just go down the table and just kind of
give me just a--I've got limited time. I'd like sort of a 10
second synopsis of how overwhelmed you would characterize our
current situation.
Dr. Bailey. I would say very overwhelmed, and any barrier
that's placed between the physician, or the treating provider
and the patient is just going to make that logarithmically
worse.
Mr. Roy. Thank you. Dr. Olsen.
Dr. Olsen. Our emergency departments, our hospitals, our
police, our EMS, I mean everywhere we are overwhelmed, but we
know what to do. We have the evidence and the science, and we
can actually get people started in treatment in so many
different places.
Mr. Roy. Thank you. Dr. Evans?
Dr. Evans. I would say two things are really important. One
is that we have to talk about attitudes, about substance use,
and substance users, that it will make a big difference in our
policies. And I think the other thing is that we have to use
the whole body of research, and not narrow parts of the
research to make sure that we're using all of the tools that we
have available to us.
Mr. Roy. Thank you. Ms. Ross?
Ms. Ross. I think we are overwhelmed, but we are not
helpless, and we are not hopeless, which is why we support this
bill. When Representative Cummings mentioned the AIDS epidemic,
we didn't just throw up our hands. We got to business and did
something. We can do that here, too.
Mr. Roy. Ms. Gray?
Ms. Gray. I would say we are busting at the seams. Every
public service area there is is overtaxed. Our first
responders, they've been out there for the last 10 years on
their own, walking in while children are doing CPR on their
families. It's affecting them in their trauma.
Mr. Roy. Thank you. And Dr. Young?
Dr. Young. Our welfare system, I would agree that they've
documented that this is straining the child welfare system
completely.
Mr. Roy. Thank you. Well, I appreciate that. I know there's
been a lot of conversations here back and forth to the members
of the panel and you all about the cultural problem, and that
that is a significant part of that. And I'm not sure that the
bill necessarily, you know, obviously hits that head-on, but I
do think that is a critical part of what we're talking about.
The other thing that I--it will not surprise my colleagues
that I will bring up, as I'm wont to do when we're talking
about the opioid problem, is the crisis at our border, and the
extent to which that the flow of elicit Fentanyl into our
country is driving a significant portion of what we're dealing
with, in terms of what you all were just describing, in terms
of being overwhelmed.
If you look at the data, and you look at the charts, this
chart, which, forgive the pen-drawn addition there, because I
don't have the chart from 2017, but you're seeing the spike in
the red, and the numbers are going up of that portion being the
elicit Fentanyl that we are now seeing spiking over the last
two or three years. And I note a lot of head nodding.
This portion, which is now truly drowning us in the numbers
of people, is something that I think we as a country need to at
least recognize the problem at the border. And I would implore
my colleagues on the other side of the aisle to recognize that
problem, and not to bury one's head in the sand about what
we're facing as a nation as a result of our failure to secure
the border.
Mr. Connolly. Would my colleague yield just for a question
on that?
Mr. Roy. I would be glad to yield----
Mr. Connolly. Thank you.
Mr. Roy [continuing]. for a brief question from my
colleague.
Mr. Connolly. Just what percentage of the illegal Fentanyl
coming into the United States is crossing the border versus
from China?
Mr. Roy. I don't have that data right in front of me, but
happy to have that conversation.
Mr. Connolly. I think that's an important conversation
before----
Mr. Roy. It is.
Mr. Connolly [continuing]. you get us to agree with your
analysis of the border.
Mr. Roy. Taking my time back.
Mr. Connolly. Take it back.
Mr. Roy. What I would suggest to you is that a significant
amount of that coming from China data shows is coming through
Mexico. And the 144 pounds that was caught by border patrol
between the ports of entry, a data, a fact we have in hand, is
ample evidence of the significant amount of opioids that is
flowing across our southern border into my home state of Texas,
devastating communities locally in Texas, because this body
fails to do its job to secure the border.
I yield back.
Chairman Cummings. Let me just ask you one thing, and you
all can incorporate this in your answers, and perhaps it would
be best, Dr. Olsen. Do we have a shortage of physicians that
are trained to do what you do? Because it seems like we haven't
touched on that, whether the stigma with regard to doctors who
say, ``I don't want to be bothered with that type of patient.''
You can answer that. You can answer it very briefly now, but
then we'll go on to Ms. Hill.
Dr. Olsen. Yes. So, thank you for that question. And, you
know, we know there are surveys that have been done of
physicians, not only in training, but also post-training that
identify that the regard that they have for people with
substance use disorders is much lower than the regard that they
have for people with other chronic conditions, such as
diabetes, or high blood pressure. And that even among the
substance use disorders there is lowest regard for people who
have an opioid use disorder.
What is, I think, inspiring, at least for me now, is that
we are seeing a younger generation of trainees, of graduate
medical students, residents, who are really starting to embrace
their role as treatment providers for people with substance use
disorders. Where I work, we have an agreement with the Johns
Hopkins Addiction Fellowship. We have an agreement with the
urban and pediatric residencies. We have an agreement with the
school of nursing.
So, we have students who rotate through with us, and really
see that people can and do recover. And that is, I think, one
of the biggest pieces. If we can help students and other
healthcare professionals see that people can and do recover,
their attitude changes dramatically. And so we need the funding
to actually then be able to expand the graduate medical
education fellowships to really standardize and to get medical
education on not only pain, but also addiction, into all
medical schools, into all nursing schools, pharmacy schools, so
that we really have a robust and qualified work force to treat
individuals now and for the future.
Chairman Cummings. Ms. Hill?
Ms. Hill. Thank you, Mr. Chairman. And thank you all so
much for the work that you do and for being here.
I actually used to be more on your side of things. I was
the executive director of a large homeless services
organization, and oversaw one of the only harm reduction
facilities for veterans experiencing homelessness in Los
Angeles.
And what I saw over and over again was the number of people
who needed that kind of help so far exceeded the capacity that
we had, and that any program had. My teams would do outreach.
They would go out to people who were experiencing homelessness,
and you would build a relationship so that once someone is
finally ready to get help, once they're finally saying ``This
is the moment. I saw a friend die from a heroin overdose,'',
or, you know, they know that it is time, they are ready to get
treatment, and you can't. That moment passes, and before, you
know, the months' long waiting lists are open, then they've
died, or they've disappeared.
I want to address a couple of things in terms of what my
colleagues have talked about. One is that we've mentioned the
stigma around it. And I think we have only recently, relatively
recently started kind of universally referring to addiction as
a disease. Can you talk a little bit more about how not
understanding addiction as a disease impacts this treatment
gap, and whether you think that the work that we're doing with
this bill will help to close that?
This is really to anyone who feels like answering it.
Dr. Olsen. So, thank you for that. And I think that, you
know, the stigma is real. The stigma is profound. We have a lot
of work to get around that. I do think that all of the pieces
of this bill really together and collectively are going to help
reduce that stigma.
Because the bill includes focus on education of healthcare
professionals, so that they really see it as their role, and
they understand what to do when people walk through their
doors, that there are resources for local service agencies and
counties in coordination with states, and their state, single-
state agencies, so that everything is also coordinated, that,
really then, are able to provide the resources needed for all
those wraparound services, so that we can support people in
their recovery, and in their remission.
But also, as you pointed out, that we can then get people
and identify them when perhaps they're actually not quite ready
for treatment, because we know that this is a disease, much
like other chronic conditions, where people are--it's a chronic
thing that people have to accept that they have the condition,
and then actually want to be able to--and be ready to receive
the help that they need.
It doesn't mean that we should just kind of, you know, put
people in jail, and to throw our hands up and say there's
nothing we can do. We really absolutely can have the harm
reduction and the preventions efforts to help engage people,
keep them alive, keep them as healthy as possible before we
also then kind of move along that continuum. And all those
pieces are in this bill.
Ms. Hill. So, I want to followup with Mr. Connolly said,
which is that so many of the facilities and the programs that
treat--that are intended to treat addiction really are this
zero-tolerance policy. They're based on the AA model, which I
think has a role, but it places the responsibility entirely on
the person suffering with the addiction.
I think that one of the reasons that the AA model is so
proliferate is that it's the only free and largely universally
accessible kind of program. And so, there are many programs
that just don't--they don't feel like they can release a
patient into the world when there's no other followup that they
can say other than to join your local AA/NA.
Can you talk about how----
Mr. Connolly. Would my friend just yield for a second?
Ms. Hill. Sure.
Mr. Connolly. The data shows, I believe, that that model,
the AA model, has only a 10 percent success rate, whereas the
stepdown drug----
Ms. Hill. Right.
Mr. Connolly [continuing]. has a 30 percent-plus.
Ms. Hill. Right. No. Correct. Correct. And I think that's
what I wanted to get at was with the--with the expansion such
as that is covered in this bill, do you believe that it will
expand the access of MAT, and of these stepdown programs. Do
you think we can have regulations in place that will make it so
that more facilities need to adopt these evidence-based
practices, and that we will have the resources to provide that
aftercare, so that when someone leaves an in-patient setting,
the answer isn't just, ``Go to your local NA.''
Dr. Evans. If I could answer that. I was a policymaker
commissioner for 20 years, and my last position I managed a
$1.5 billion budget. So everyday we spent $2 million
approximately of taxpayer money. And as someone trained as
scientist, I was very concerned that we were spending money on
the things that we knew from the science what was working, so
much so that we created an evidence-based practice and
innovation center, because I know, as having been a
practitioner, that if you don't, and if you're not intentional
about helping providers to incorporate what the science says,
they will not do it. That's No. 1.
No. 2, in the addictions field more than probably any other
field that I've been affiliated with, there is a very strong
philosophical bent that is sometimes not open to data, facts,
science, and I think we have to be very intentional about
making sure that if we're going to use taxpayer money that we
need to ensure that people are using what the science says
about what works.
So, the point you're raising is a good one. I will tell you
that it is not easy to change clinical practice. A lot of these
programs have been in existence for decades. The people who are
running those programs are often people who went through those
programs, and have gotten into their recovery that way. And so,
they believe that the only way that people can get into
recovery is to go through that same process.
So, it's very difficult, and I really believe that--you
know, I mentioned we spent somewhere between 1 and $2 million
every year on trying to retrain providers. You know, my strong
recommendation is that we not only provide new resources for
communities, but we also provide the resources to help people
with the implementation of those new practices, because it
won't happen otherwise.
Ms. Hill. Yes. So, with this Act we really need to have
the--not just the enforcement mechanisms, but the regulations
that say you have to have the evidence-based practices
involved. It's not just money going out there. It needs to be
evidence-based, and it needs to be----
Dr. Evans. Well, I would be very careful about regulations.
As someone who's worked on both sides as a policymaker and as a
provider, I think that the model is more about how you create
resources and technical assistance so that people can actually
make the practice change.
One of the providers in Philadelphia that was a very
strong, what we call concept program, they were very
philosophically bent toward sort of the AA model. We thought
would be one of the last programs to incorporate evidence-based
training programs, but with a fairly significant investment
with consultants and trainers, they turned out to be one of the
shining stars. So, it's possible, and I personally believe that
using a hammer is not as effective as using other kinds of
strategies.
Ms. Hill. I agree. I was on the provider side, too, so----
Dr. Evans. Okay.
Ms. Hill. Thank you so much. I yield back.
Chairman Cummings. Mr. Grothman?
Mr. Grothman. Yes. Can anyone guess, say, in the last five
years the amount that we have spent on treatment nationwide?
Anybody have a stab at it? Oh, guess. It's a rhetorical
question almost. Can somebody just take a wild stab? Nobody
knows how much we're spending on treatment in the country.
Dr. Bailey. It's gotta be billions.
Mr. Grothman. Billions. It's a lot. And the thing that
bothers me, you know, a lot of people, particularly because the
treatment community gets involved in this stuff, say the answer
is to spend billions more. But things keep getting worse. And
if things keep getting worse no matter how much we spend on
treatment, it seems to me the problem overwhelmingly is not to
spend more money on treatment, but to focus on what type of
treatment works and what type of treatment doesn't.
I'll give you another general question. We are told that
there was a lot of heroin usage in Vietnam. I don't know if
it's true, but we're told it's true. And nevertheless, when all
these guys came back from Vietnam there were very few people
who wound up addicted to heroin.
Can you take a stab as to why that's true? Anybody want to
take a stab as to why that's true?
Dr. Olsen. So I'd like to actually address a couple of your
points, one of which is believe that the White House Office of,
I can't remember exactly what the office is, has put forth that
we've spent--in 2015 we had spent a total of about $500 billion
on addiction and the opioid addiction crisis. So, I think
that's an important number to just keep in perspective when
we're talking about the $100 billion that has been put forth in
terms of the CARE Act.
And in terms of the----
Mr. Grothman. And it hasn't worked, right?
Dr. Olsen. Well, actually, that was my second point.
Mr. Grothman. You could say it could be worse, I suppose.
Dr. Olsen. So, the second point is that we actually now
have--so the latest data from Maryland, for the first quarter
in 2019 we saw a 15 percent decline in opioid-related overdose
deaths. And so, we are seeing that. And in Rhode Island they
have seen a reduction in overdose deaths, especially when they
expanded access to medications in all of their correctional
settings.
So, we are seeing that there are now the beginnings of kind
of a decline in these overdose deaths, and hopefully, we'll be
able to kind of have those continue.
The third point, in terms of the Vietnam experience, so Dr.
Jerry Jaffe was the physician, he was a psychiatrist, who
actually was hired by Nixon to really study the problem of the
Vietnam vets who were coming back. You know, one of the
things--so he works at the Defense Research Institute in
Baltimore, and I've had some conversations with him about this.
One of the things that he says is that probably the biggest
missed opportunity from a scientific perspective with that
experience was not having done sufficient studies on the people
who actually stopped using heroin once they came back to the
U.S.
However, what we do know is that because the 40 to 60
percent of the risk of developing opioid use disorder is
genetically based, that the presumption is that the men who
continued to use substances probably had a different genetic
predisposition to developing that addiction, as well as perhaps
some of the other factors that we know about, traumatic
childhood experiences, they may have had other psychiatric
conditions. But there certainly is a difference between the
population of people who develop an addiction when they are
exposed to substances, even if that substance is heroin, versus
those who don't.
Mr. Grothman. So, you're saying the reason we were so much
more effective during the Vietnam era without doing anything,
than compared to today, is because the original data bases of
people who used heroin, today the people who use heroin are
more genetically predisposed than to the average soldier in
Vietnam.
Dr. Olsen. So, I actually wouldn't even say that we didn't
do anything with Vietnam. Jerry Jaffe was appointed by Nixon to
actually establish the first opioid treatment programs back
then, called methadone maintenance programs. After several
studies in Lexington, Kentucky, and in New York, had
demonstrated that methadone had tremendous efficacy in reducing
crime, in reducing relapse to heroin. So, it was Nixon really
who actually established the first treatment programs.
Mr. Grothman. Okay. But I am under the impression that most
people stopped using heroin when they came home from Vietnam
without a program. They just quit. Is that accurate?
Dr. Young. And there were detox programs that were set up.
One of my----
Mr. Grothman. But most people, that's the question I'm
trying to bring up.
Dr. Young. And most people who take prescription opioids
now don't develop a heroin problem, but for some people, they
do convert to an opioid use problem, and may convert to heroin
use disorders when those prescription drugs. So, it's not 100
percent of people who take prescription opioids convert to
heroin use disorders. I think that's what Dr. Olsen is saying.
It's not 100 percent, but for some people, they do.
Chairman Cummings. Thank you very much. Ms. Wasserman-
Schultz?
Ms. Wasserman Schultz. Thank you, Mr. Chairman. And I want
to thank the panel for joining us to help address this really
crisis-proportion issue.
I want to ask unanimous consent to enter this article from
The New Yorker in 2013, if that's okay, Mr. Chairman.
Chairman Cummings. Without objection, it's ordered.
Ms. Wasserman Schultz. Thank you. In it it describes the
joint commission which is responsible for establishing pain
management criteria, and accredits health facilities' issues,
and they issued pain management standards in 2001 that
instructed hospitals to measure pain.
And this was really the elephant in the room, I think, that
we aren't addressing in terms of a solution, because
essentially, we're on a hamster wheel. I mean we can really
find strategies to help people get off of their addiction to
opioid abuse, but we keep replacing them with more people who
become addicted, because this pain scale that was established
in 2001, that this is the smiling-to-crying faces scale, the
joint commission essentially instructed hospitals to prioritize
its use, and the treatment of pain with narcotics.
As Elizabeth Zoni, a spokeswoman for the Joint Commission,
told the author of the article that, ``Standards were based
upon both the emerging and compelling science at that time, and
upon the consensus, a broad array of professionals.'' Yet,
Perdue, according to a report issued by the U.S. Government and
Accountability Office, helped fund a pain management
educational program organized by the Joint Commission, a
related agreement allowed Perdue to disseminate educational
materials on pain management. And this, in the words of the
report, ``May have facilitated its access to hospitals to
promote OxyContin.''
So essentially these pharmaceutical companies bought their
way into the official medical guidance committees. And in 2007,
Perdue Pharma, and three of its top executives, pleased guilty
to criminal charges that they had misled the FDA, clinicians,
and patients about the risks of OxyContin addition and abuse by
aggressively marketing the drug to providers and patients as a
safe alternative to short-acting narcotics.
The elephant in the room, to me, is that this pain scale
still exists. My husband just had emergency back surgery a
little over a week ago, and I can't describe to you the number
of opioids he left the hospital with. Now we are very well
aware of how cautious you have to be, but many aren't. And
people have a different level of--different levels of pain
tolerance.
But Dr. Bailey, and any of the other experts on the panel,
I'd like to know what steps are being taken and should they be
taken to eliminate or dramatically alter this pain scale, and
the whole idea that as soon as you walk in the door someone's
immediately asking you, ``On a scale of one to ten, describe
your pain.'' And no one wants to be in pain. We all understand
we should stay ahead of pain. But the entire focus of a
hospital stay is on pain, and that's important, but it's become
an obsession. And if we don't change it, and if we don't change
the amount of pills that people are sent out the door with,
then we are never going to get a solution, then a resolution to
this problem.
Dr. Bailey. Thank you. The treatment of acute and chronic
pain is a very complex area. The AMA has been very involved in
educating physicians about the use of opioids----
Ms. Wasserman Schultz. Okay. But I want to specifically ask
you if you believe that the pain scale and its use, the smiley-
to-crying faces scale, and the entire focus of the way people
have pain addressed in a hospital setting, in a medical
setting, after an injury, or any other type of pain situation,
needs to be altered.
Dr. Bailey. I think there's no question that there's an
overemphasis on measuring--trying to quantify pain. The
physicians undoubtedly have been encouraged by their hospitals,
by those that----
Ms. Wasserman Schultz. Pharmaceutical companies.
Dr. Bailey [continuing]. provide patient satisfaction
surveys, you've got to treat pain, you're got to treat pain,
and I think part of that was what helped create this problem.
Ms. Wasserman Schultz. But you do think it needs to be
changed.
Dr. Bailey. Yes.
Ms. Wasserman Schultz. Okay. I hope, since you are the
president of the AMA, that you would lead that effort. Yes, Dr.
Olsen? Or I'm sorry. Dr. Evans?
Dr. Evans. I think this is a really good point that you're
raising. There are more sophisticated ways to figure out who's
going to be more likely to be susceptible to opioid addiction.
In many hospitals now you have what are called clinical health
psychologists who are embedded within surgical units and other
units within hospitals who do sophisticated psychological
assessments of people prior to an operation to determine
whether they are more likely to engage in opioid misuse.
That's very effective in helping to identify people who are
more likely. Those psychologists are working with physicians to
help alter the protocols around how they're going to manage
pain. And not enough of that's done.
I talked about the importance of non-pharmacological
interventions for pain management. And the reality is that pain
is not only physiological, it's psychological. And we have
completely ignored the psychological aspects of pain. We're not
treating it.
And my colleagues who work in this area will tell you that
there are a lot of effective ways of helping people to not only
manage pain, but to improve their daily functioning. And we
have to incorporate more of that into our healthcare system.
Ms. Wasserman Schultz. Mr. Chairman, could Dr. Olsen just
answer?
Chairman Cummings. Dr. Olsen, and then we'll----
Ms. Wasserman Schultz. Thank you so much.
Dr. Olsen. So, thank you. So, I agree with----
Ms. Wasserman Schultz. What he said.
Dr. Olsen [continuing]. Dr. Evans. What he said.
[Laughter.]
Dr. Olsen. That essentially that really doing broad
education, not only of physicians and other healthcare
providers, but also the community, so that we really can get to
a point where the pain scale that you reference, that may have
a role in terms of kind of an acute episode of pain, where we
want to actually decrease the pain, but particularly in people
who have chronic pain, or acute chronic pain, that really is
not the best way to look at the outcomes and the appropriate
outcomes for people who have chronic pain.
Ms. Wasserman Schultz. Thank you. Thank you. Mr. Chairman,
I hope we can change that. Thank you so much.
Chairman Cummings. Mr. DeSaulnier.
Mr. DeSaulnier. Thank you, Mr. Chairman. I just want to
thank the panel. This is both incredibly depressing and
frustrating, and also inspiring, your work, and gives me hope,
as somebody who has dealt with behavioral health issues
personally. My dad had substance abuse problems, and he ended
up committing suicide.
But 30 years ago, when that happened, this support system,
and his substance abuse was not heroin, we have come so far.
Part of the frustration is we know the neuroscience. We know
what the evidence-based research is. As you have said so well,
you know it works.
And having been in San Francisco in the 1970's and 1980's,
having been in the restaurant business, and had employees and
friends pass away because of AIDS and HIV, knowing people at
UCSF, who were supported by NHS funding, that did remarkable
things, that now keeps friends alive, who are HIV positive,
this is an example of we know both the policy and the politics
to implement it. And we're overcoming the stigma, and the
blame, and the denial slowly but surely that I was impacted
through my dad's experience.
But I can't tell you how frustrating it is, and you share
this, about the lives we're losing and the money we're wasting.
So, sort of going on a cost benefit should be pretty clear,
both by the research and anecdotally, that passing that bill,
implementing this kind of investment, insisting on the best
practices, insisting on support services, as you've all settle
on with the medication.
And then last, to followup with what Congressman Wasserman
Schultz said, what Perdue Pharma, and I appreciate my
colleague's concern about the border, but it should be
proportionate here, and effective, what Perdue Pharma did was
clearly criminal and morally unethical. I think every penny
that all of these states, county lawsuits are not--most of it
should go back into the system. We should punish them,
obviously, but I hope it doesn't go off in the general funds in
local and state government.
So, if you had those kind of resources, do you think you'd
have the same outcomes that we had when we were dealing with
AIDS and HIV? Dr. Olsen? Dr. Bailey? Dr. Evans? And how quickly
could we see that?
Dr. Olsen. Yes.
Mr. DeSaulnier. Could we save generations, like we did with
HIV?
Dr. Olsen. I would believe so. You know, I think that we
have started to see, as I mentioned, kind of a little bit of a
dip in some of the overdose, the opiate-related overdose
deaths. But I think as you mentioned, that, you know, that
opioids are kind of--that's today.
Mr. DeSaulnier. Mm-hmm.
Dr. Olsen. Tomorrow, it is probably going to be
methamphetamine.
Mr. DeSaulnier. Yes.
Dr. Olsen. We're seeing that coming down the line. Alcohol
kills more people in the U.S. every year. 88,000 people lose
their lives every year to alcohol, and alcohol is a slowly
progressing killer.
So, you know, really being able to have a trained work
force that is multidisciplinary, but that includes physicians,
and nurse practitioners, and others that are really able to
recognize when people have a substance abuse disorder or a risk
for that, being able to then make that diagnosis and treat it.
That, and then getting people into wherever they are, whatever
door they walk into, really having those opportunities.
You know, as I mentioned in my testimony, whether it's in
jails, or emergency departments, or hospitals, specialty
treatment clinics, primary care, we really need that continuum
of services, and we need to standardize it. We know that there
are effective evidence-based interventions for opiate-use
disorder. We have----
Mr. DeSaulnier. Dr. Olsen, can I just jump in----
Dr. Olsen. Sure. Yes.
Mr. DeSaulnier [continuing]. because I want to--if we have
time to respond.
Dr. Olsen. Yes.
Mr. DeSaulnier. But you triggered another thing. I've had
psychologists, behavioral health people come and tell me
because of the ACA and parity, we have a 75 percent increase in
people seeking services. We know the numbers here aren't very
good, one in ten. But they've also told me that they have a 25
percent decrease in young people going in other fields. So, in
the context of what we just said, we're not providing the
infrastructure that would save lives.
Dr. Olsen. Correct. Correct. And so, we need the
infrastructure. We need the resources. We need to teach it,
standardize it, and really cover it.
Mr. DeSaulnier. Dr. Bailey?
Dr. Bailey. Thank you. The money that has been invested in
this crisis is undeniably just tremendous, but I'd like to give
an example of what the state of Virginia was able to do with
their Medicaid 1115 waiver funds. They established a program to
increase reimbursement to physicians for the treatment of
substance use disorder patients. They provided training for
medically assisted therapy, and they provided incentives to the
patients for behavioral health. So, they kind of went all the
way around.
And they found that there was an increase in Medicaid
enrollees that had had medication-assisted therapy. There was a
dramatic decrease in the number of ER services that were needed
by that patient population. Too early to say anything about
overdose deaths, but I think--and the punchline is that the
program basically broke even. They saved as much money as they
spent. So, I think that there are ways that we can invest
wisely.
Mr. DeSaulnier. Thank you, Mr. Chairman.
Chairman Cummings. Ms. Tlaib?
Ms. Tlaib. Thank you, Mr. Chairman. Thank you all for your
incredible work. I think everything you're saying is to be
true. This is a multifaceted kind of approach, from holistic to
the mental health, to the wraparound, talking about community-
based or faith-based. I think it's a combination of all of
those things.
I do want to share a story, if I may, chairman, that's
happening in my district. Janet, she's a social worker and a
recovery coach at Covenant Community Care, a federally
accredited clinic in 13th congressional District. She's
relentless at her job. Ellis, he's about a middle-aged man, the
same age as many of my colleagues here in this chamber, and was
addicted to heroin.
They met at a local church, where Ellis went for free
meals, and Janet reached out to him at the church and offered
to help him. They had come up with a pact that when he was
ready, because he wasn't ready at that moment, that he put his
thumb up. And one Sunday he finally did that. He put his thumb
up, and Janet and Covenant Community Care was there for him,
and their role at community health center, and the opioid
treatment center played a really, really incredible role.
Because it was very local level, and frankly, they need more
resources, and that's why the CARE Act is so critically
important. So, I thank the chairman for his leadership on that.
According to the 2018 report to Congress from the Medicaid
and CHIP Commission, it said that many areas of the country
simply lacks substance use treatment facilities, and we talked
about this. I want to take a deeper dive in that, because in
the report it said roughly 40 percent of counties do not have
an out-patient substance abuse disorder treatment program.
Ms. Ross, in your experience, are there areas of the
country that have a high number of residents with substance
abuse disorders, but lack the adequate treatment facilities?
Ms. Ross. I actually think that's all over.
Ms. Tlaib. Yes.
Ms. Ross. They're just plain aren't enough of them. And as
I mentioned before, we've had some close. So, unless there's
something like this CARE Act, that's what you're going to see.
And so yes, we do need more of them, and they need to stay
open.
Ms. Tlaib. No. And I agree. And I think there's always this
constant debate whether we need--and it always is people pause,
because it costs money, I mean a lot of money in resources to
combat something like this that has to come from--you know,
from different kinds of forms.
Ms. Gray, are there people in your community who have
overdosed because they were waiting for access for treatment?
Ms. Gray. Currently, we are driving people four to six
hours away to get treatment. There is no in-patient treatment
center anywhere near us. We even have grassroots people like
the Hope dealers, who are moms who just got up and got tired of
watching their children die, and they're driving the people to
the treatment programs.
Hopefully, that will change in my community this fall,
because we're working on an in-patient treatment program, but
that is definitely a huge gap. I mean even when they're ready
there was nowhere to take them. That's how I actually got into
this and harm reduction. People were literally coming into my
clinic for other services, and crying on my lap because they
wanted help, and I had nowhere to send them. Six-month waiting
list on behavior health units.
And I'm glad that you have talked about peer recovery
coaches, because that is key. Peer recovery coaches in my
clinic are amazing human beings. And if you want to see that
there's life in recovery, come visit them, because they just
really--it's a huge piece of this. It really is. And every
person that walks through my clinic I think, ``Are they going
to be my next peer recovery coach?''
Ms. Tlaib. Yes. And it's because they offer love and
respect.
Ms. Ross. They offer love.
Ms. Tlaib. All of you have said some sort of form of, if it
wasn't in the form of a hug, a form of--and, you know, a lot of
this is creating this extended family----
Ms. Ross. Yes.
Ms. Tlaib [continuing]. that you have, and this is my
family in Congress, by the way. You feel less alone.
But I do want to share something. Congressman Raskin had
kind of a sub-hearing around this issue of addiction. And it
was one father who lost his daughter to--lost his son to
addiction. His son described it as like mosquito in his head,
that he just kept wanting to scratch, and it just was constant.
It was very powerful, but one of the things that was consistent
is every single--all three that testified were all from
different income and education backgrounds.
I think his son has like a master's degree, and another
person, you know, just graduated from high school, was in the
service industry, and so forth. Is the fact that we need to
change this culture and this image, that I think, you know,
media, and I think mainstream, like TV, and all this, have
created this image of somebody that suffers from addition looks
like, and where they come from.
And I think that is something that is critically important
for us to push up against. Because I've met people from all
different social backgrounds, all different education
backgrounds, come from all communities, not just mine, that are
suffering from addiction, because of the lack of funding and
resources that is being provided here in the CARE Act.
So, thank you so much, Mr. Chairman. I yield the rest of my
time.
Chairman Cummings. Ms. Ocasio-Cortez?
Ms. Ocasio-Cortez. Thank you. Dr. Olsen, in your book you
discuss the history of opioids in the United States. And you
describe how the United States has a unique history with
opioids, if there's a way in which manifests as a uniquely
American disease. And that the U.S. has kind of cycled between
making opioids widely available and then trying to restrict
their use between treating addiction as a crime, and then
criminalizing it--and criminalizing it, and then treating it as
a disease.
So, this is not the first time we've gone through this
pendulum swing. This is how America has gone from criminalizing
to treating opioids, and then going back again.
So, opioids were first used during the U.S. Civil War to
ease wounded soldiers' pain, and then in the decades after the
war, they were actually widely prescribed to middle-and upper-
class women. You wrote, ``By the early 20th century, with
estimates of habitual users of opioids as high was 250,000,
concern about the overprescribing of opioids led to a
tightening of restrictions.'' That was in the early 1900's, is
that correct?
Dr. Olsen. Correct.
Ms. Ocasio-Cortez. And then eventually Congress passed the
Narcotics Control Act in 1956, which, ``Included the first
mandatory minimum sentences for a first conviction of
possession, as well as the death penalty for drug
trafficking.''
And then after that crackdown--after that crackdown, we
found that heroin use surged. It didn't reduce. It surged
during the Vietnam War, leading Nixon to send a message to
Congress about the tide of drug abuse that swept America in the
last decade, is that correct?
Dr. Olsen. That's correct.
Ms. Ocasio-Cortez. And as you kind of indicated earlier,
Nixon's first instinct was actually to treat opioids as a
disease. This was before the war on drugs really manifested.
And, in fact, he established a network of clinics that offered
treatment with methadone.
So, my question is, how do we move from Nixon's first
approach of treating this as a disease to the war on drugs that
was unleased just a few years later, in the 1980's, and waging
this war on drugs in communities of color?
Dr. Olsen. Yes. So, thank you for that question. You know,
I think the--we have a lot to learn from history, obviously, as
you've--kind of as we indicate in our book. And, you know, part
of what happened in the early 1970's is that treatment became
available, effective treatment became available, and then kind
of that swing back to, ``No. This is moral issue. No. These
are--the people who have substance abuse disorders are
criminals.'' I don't think we've ever really, as a society,
wrapped our heads around what really is this, looking at the
science, and understanding the science.
And the difference I think between the early 1900's and
even 1970 and 1980 is that we now understand so much more about
the brain, and about the disease, and what influences the
development of an addiction, what effective treatments are, and
why.
Ms. Ocasio-Cortez. Mm-hmm.
Dr. Olsen. And that, unfortunately, it really took, you
know, decades of the war on drugs, decades of really--you know,
the cocaine epidemic and the crack epidemic hit communities of
color unbelievably hard, but rather than seeing it as, no,
these are individuals who have a chronic health condition, that
we criminalized those individuals.
Ms. Ocasio-Cortez. So here we've seen, kind of you think of
this pendulum shift. And it starts with the U.S. Civil War, we
made opioids widely available. Then they started impacting
upper middle class, you know, upper middle-class people. And
so, then we decided to criminalize it in 1956. We cracked down
immensely, and then we find that that resulted in another surge
of abuse during the Vietnam War.
So, then we go back to Nixon's initial approach, which is
treating it as--using it as a treatment again.
Dr. Olsen. Mm-hmm.
Ms. Ocasio-Cortez. And then we hit the war on drugs, where
we criminalize communities of color for their use. We go back
to the criminalization. Then we go back to the 1990's, where we
treat pain management as a widespread disease, correct?
Dr. Olsen. Mm-hmm.
Ms. Ocasio-Cortez. So, then we decide that, doctors decide
that pain management needs to be aggressively--needs to be
aggressively treated, and now we're back to an opioid crisis
again.
So, we have it--we're at an inflection point, where we
could potentially criminalize this again, or we could
potentially treat the opioid crisis as a health issue----
Dr. Olsen. Yes.
Ms. Ocasio-Cortez [continuing]. correct? So, my question,
my last question would be, how do we stop this pendulum shift,
and how do we just end----
Dr. Olsen. Right.
Ms. Ocasio-Cortez [continuing]. our addiction as a national
crisis?
Dr. Olsen. Yes. So great question. And, you know, partly I
think we look to the science. We really look to the past to
learn from what happened, and learn from our mistakes. And as I
said in my testimony, I think that we really have to embrace
the saying and the concept that everybody, no matter where they
come from, no matter what class, race, ethnicity, address they
have, that everybody deserves the chance for treatment and
recovery.
Because addiction, as others have said, addiction knows no
boundaries. But really trying to understand where any one
individual is coming from, treating people with dignity and
respect, no matter who they are, that's really important. And
I've had--you know, I've heard police commissioners say, ``We
are not going to be able to arrest our way out of this.'' We
really need to have treatment. We need treatment on demand. We
need to be able to provide services when and where people are
ready.
Chairman Cummings. Ms. Norton.
Ms. Norton. Thank you very much, Mr. Chairman. This is a
very important hearing for all of us. I am concerned, very
concerned that we are experiencing the single highest rates of
overdose deaths in the history of our country, and we still
don't have--we still haven't gotten ahold of it.
Indeed, this committee is concerned that if you were to ask
us what is the national drug control strategy, I think we would
be--we would not have an answer. And in the absence of a
strategy from the Administration, they did issue a document in
January, which nobody would call a strategy, I think this
committee has to come to grips with what the strategy should
be, and enact one.
Dr. Olsen, I'm concerned with how patients continue,
particularly in the absence of a strategy, because in your
testimony you mentioned a patient, Andy, and he was the only
one of his 11 friends to survive addiction, and that that
person, Andy, is on Medicaid. So, I need to know whether
Medicaid is a program of last resort, or whether essentially
these patients are essentially on Medicaid. And is private
insurance just out of the picture for most of them? And is
Medicaid the program of first and last resort for many, or if
not, most of them? We need to know that in order what to do
about Medicaid funding, which the President's budget, nobody
pays much attention to a president's budget, no matter who he
is, will cut Medicaid funding by 1.5 trillion over 10 years.
What is your response to how important or not Medicaid is
as compared to private insurance?
Dr. Olsen. So, Medicaid and Medicaid expansion in the state
of Maryland has absolutely saved hundreds of my patients'
lives. It is extremely important. Seventy-five percent of the
patients that I see are enrolled in Medicaid.
Ms. Norton. So, most of your patients?
Dr. Olsen. Yup. We do----
Ms. Norton. Are most of those essentially middle-class
people?
Dr. Olsen. Some are. Yes. And they are, what happens when
people get into treatment and recovery is, they then can get
hired for jobs. They are stable enough that they actually then
go back to work. And when they go back to work, sometimes they
go back to work in places where their employer is able to
provide them with health insurance. In other places, they now
make too much money, just too much money to qualify for
Medicaid, and so now being able to actually get insurance
through the health insurance market through the ACA has been
helpful for them. And so, we see fluxes between people who are
enrolled in Medicaid, and then no longer enroll in Medicaid.
But if they then lose their job, if they get laid off because
the job market shrinks, then they really need to have that
support and that safety net of Medicaid to be able to continue
their----
Ms. Norton. Yes.
Dr. Olsen [continuing]. lifesaving treatment.
Ms. Norton. The ACA, of course, and Medicaid. Let me ask
about the steps Congress is taking, to see what we should do.
The 21st Cures Act, we call it CARA, and a package of opioid
bills that we passed last year, Dr. Olsen, in your written
statement you noted that while the steps Congress has taken
have saved lives, that more needs to be done. And you said more
funding and smarter funding. Would you clarify that, please?
Dr. Olsen. Absolutely. So, thank you for that question. So
by smarter funding, we really mean that funding, as we've kind
of talked about today, that funding really needs to be targeted
toward those interventions that we know work, that we have
evidence for as being effective, and supporting the education
and the standardization of treatment, and providing those
standards of care across a treatment setting, so that when
people walk into a treatment facility, that they know what to
expect, no matter whether they're in Maryland, in Virginia, in
California, in Ohio, in West Virginia, and that what they are
getting is evidence-based.
Ms. Norton. Thank you. Mr. Chairman?
Chairman Cummings. Thank you very much. Ms. Pressley?
Ms. Pressley. Thank you, Mr. Chairman, and thank you for
holding this important hearing. My father, like millions of
Americans, as someone who battled heroin addiction, opioid
addiction, and was in and out of the criminal justice system,
committing crimes to support that addiction. Ultimately, during
his time, while incarcerated, he was able to get on a path to
healing. And I do believe that was also because that was at a
time when there was access to behavioral health supports and
mental health. My father was someone, like many who were self-
medicating because of a series of life traumas.
And I would love to at some point talk about what is the
course of treatment, or what are we doing for those behind the
wall. I was at Alameda County, Santa Rita Jail, in Oakland,
California, this weekend, a women's jail, and the majority of
those that were there were there for poverty crimes, and/or
crimes to support their addiction.
And so, I do want at some point know what we're doing
behind the wall, because that's about the health and wholeness
of those being able to bring their full contribution to the
world, which now my father is doing as a professor of
journalism and a published author.
But we know many of them will recidivate. And so, I would
love to have that conversation at some point. And I'm grateful
that we are at a point in the pendulum switch shift here that
we are looking at this as a public health crisis and epidemic,
which we did not do with crack cocaine.
I'm reminded in my time on the Boston City Council, where I
was a part of a hearing around safe injectionsites, which I
support. And there was a woman who said, ``I'm sick, and my
life matters, and I don't want to die in a McDonald's
bathroom.'' And, you know, that is what this is really about,
the pain and seeing the dignity and humanity of people, but
also recognizing that it's not just about that one person, but
the impact on entire families this is destabilizing, and
decimating whole communities.
I was recently appointed as the vice chair on the Taskforce
of Aging and Families, and I just was at that taskforce before
coming here, lifting up the growing challenge of grandparents
raising grandchildren, because of this public health problem
and epidemic.
So, we have to move holistically. We have to move with
urgency, and I do believe we need not only on-demand treatment,
but it need to be culturally competent, it needs to be gender
specific and responsive, and it needs to be trauma informed.
But, again, we're here to talk about not only the problem, but,
again, the fixes.
And so, I wanted to talk about the importance of harm
reduction services, which I do think many of those models do
lift up some of the practices that I just asserted and offered
up.
Ms. Gray, your testimony, you used a really fascinating
analogy on our current addiction intervention approaches, which
you likened to a spinning carousel. You say we intervene at the
point of entry of this carousel, but supporting prevention
efforts to avoid--by supporting prevention efforts to avoid
drug use, and then at the end, to provide supports and linkages
to recovery options. However, very little is done to aid people
throughout addiction, or in keeping with your analogy, the
point at which the carousel is spinning out of control.
So, Ms. Gray, how has this current approach exasperated HIV
and hepatitis outbreaks in communities across the country,
specifically harm reduction strategies like syringe services,
and in West Virginia, where you practice? How has this
exasperated HIV and hepatitis outbreaks?
Ms. Gray. If you look at the vulnerability study that the
CDC did that showed the top 5 percent of counties in this
entire nation that are at risk for an HIV and hepatitis C
outbreak, out of those 220 counties, there are almost--about 40
are in West Virginia. And both of my counties are identified.
Berkeley County is 204, or 205, and Morgan County, the smaller
rural county, is 44. It's in the top 50 percent.
Ms. Pressley. Okay. I'm sorry. Just to reclaim my time. So,
opponents of syringe service programs have argued that these
approaches fuel drug use rather than reduce the risk of
disease.
Ms. Gray. Yes.
Ms. Pressley. So, for the record, do you agree with that
assessment?
Ms. Gray. Sorry. No, they do not.
Ms. Pressley. Okay. Thank you. All right.
Ms. Gray. They engage people.
Ms. Pressley. Absolutely. Thank you. In my district there
are four syringe service programs. Ms. Gray, can you explain
how Berkeley County syringe service programs and others like
those, surveying vulnerable communities in the Massachusetts
7th, help to reduce the transmission of HIV and other
infectious diseases?
Ms. Gray. Yes. We have over 30 years of evidence, based
upon the HIV AIDS epidemic that harm reduction programs do work
to reduce HIV, hepatitis C, and hepatitis B.
Ms. Pressley. Okay. Short on time. Just reclaiming my time.
Dr. Bailey, does the American Medical Association have a
position on the use of supervised injectionsites as a way to
prevent opioid deaths and disease transmission?
Dr. Bailey. Yes, Congresswoman, we do. And I don't have the
details of that policy with me right now, but I'd be happy to
provide it for the committee as soon as possible.
Ms. Pressley. Okay. Does anyone else on the panel have any
thoughts on what research has shown relative to save or
supervise injectionsites as another form of hard reduction?
Ms. Ross. They work.
[Laughter.]
Ms. Pressley. Great. And how do these outcomes compare to
cities and communities that do not maintain these types of
syringe service programs or supervise injectionsites?
Ms. Gray. That's what I have been talking about is we have
52 new cases of HIV in Huntington now. We are not getting
supported for syringe exchange in our state. People just don't,
they don't understand it. They thing we're enabling, but that's
not what it is.
And if you look at the New England Journal of Medicines'
article in this past May, it will compare those 220 counties
that I was talking about, where there are syringe exchange
programs, and we're not heeding the warnings. There's not
enough harm reduction programs that match those counties that
are in dire risk.
Dr. Olsen. Syringe exchange programs have really been found
to reduce the risk of HIV and hepatitis C transmission.
Baltimore City has had one for a very long time, and it is now
extremely rare for HIV or hepatitis C to actually be
transmitted in people who use drugs.
Chairman Cummings. Ms. Gray, let me just ask you this. What
would happen in West Virginia if the Medicaid expansion were
rolled back?
Ms. Gray. We'd be back to the days where we couldn't link
anyone for any of their care and recovery. We might as well
just--I'm not a person who gives up very easily, but without
the Medicaid expansion, we're done.
Chairman Cummings. All right. Mr. Jordan.
Mr. Jordan. Thank you, Mr. Chairman. I just wanted to thank
our panel for coming and testifying today, but more
importantly, thank you for the work you do. I especially
appreciated what Ms. Gray said in her opening statement, when
she referenced the fact that Jesus didn't come to save the
perfect people, he came to help all of us who have problems.
And what you are doing is truly a ministry, and we
appreciate that, and we appreciate the chairman's commitment to
helping get a solution, and help people who are trapped in
this. We've got a little difference sometimes, I think, in how
that should play out, but the goal is a good goal, and you are
doing the Lord's work, and we appreciate that. And thank you
for being here today.
Chairman Cummings. Thank you. Thank you. And I, too, want
to thank all of you for being here today. I ask unanimous
consent to enter into the record written statements from Smart
Recovery and Faces and Voices of Recovery. So, ordered without
objection.
Chairman Cummings. I want to thank all of you for being
here. This is a, as you all have described it, a very
significant problem that's been going on a long time. And what
we tried to do with the CARE Act is try to figure out every
possible way that we could effectively and efficiently deal
with it, and trying to really dig down to the core, so that
we're not doing the same things over and over again, and
getting the results that are not satisfactory.
So, we are going to work together. I'm going to push very
hard on this. This proposal has been endorsed by so many, and
your groups, we want to thank you all for standing up for it.
And again, we want to thank you for working with us. And we're
going to continue the battle.
So, again, thank you. All members will have five
legislative days within which to submit additional written
questions for the witnesses--to the chair, which will be
forwarded to the witnesses for their response. I ask our
witnesses to please respond as promptly as you can.
Thank you very much. Meeting adjourned.
[Whereupon, at 12:57 p.m., the committee was adjourned.]
[all]