[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

                               __________

      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

                              ----------                              
                                                                   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.]

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