[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]



 
   A PUBLIC HEALTH EMERGENCY: STATE EFFORTS TO CURB THE OPIOID CRISIS

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

                                HEARING

                               BEFORE THE

              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               __________

                            JANUARY 14, 2020

                               __________

                           Serial No. 116-87
                           
                           
                           
     [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]                    
                           
                           


      Printed for the use of the Committee on Energy and Commerce

                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov
                        
                        
                        
                        
                    ______                       


             U.S. GOVERNMENT PUBLISHING OFFICE 
 47-788 PDF           WASHINGTON : 2022 
 
                        
                        

                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
ANNA G. ESHOO, California              Ranking Member
ELIOT L. ENGEL, New York             FRED UPTON, Michigan
DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           PETE OLSON, Texas
JERRY McNERNEY, California           DAVID B. McKINLEY, West Virginia
PETER WELCH, Vermont                 ADAM KINZINGER, Illinois
BEN RAY LUJAN, New Mexico            H. MORGAN GRIFFITH, Virginia
PAUL TONKO, New York                 GUS M. BILIRAKIS, Florida
YVETTE D. CLARKE, New York, Vice     BILL JOHNSON, Ohio
    Chair                            BILLY LONG, Missouri
DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon                BILL FLORES, Texas
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
    Massachusetts                    MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
RAUL RUIZ, California                TIM WALBERG, Michigan
SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                MIKE BLOOMQUIST, Minority Staff Director
              Subcommittee on Oversight and Investigations

                        DIANA DeGETTE, Colorado
                                  Chair
JAN SCHAKOWSKY, Illinois             BRETT GUTHRIE, Kentucky
JOSEPH P. KENNEDY III,                 Ranking Member
    Massachusetts, Vice Chair        MICHAEL C. BURGESS, Texas
RAUL RUIZ, California                DAVID B. McKINLEY, West Virginia
ANN M. KUSTER, New Hampshire         H. MORGAN GRIFFITH, Virginia
KATHY CASTOR, Florida                SUSAN W. BROOKS, Indiana
JOHN P. SARBANES, Maryland           MARKWAYNE MULLIN, Oklahoma
PAUL TONKO, New York                 JEFF DUNCAN, South Carolina
YVETTE D. CLARKE, New York           GREG WALDEN, Oregon (ex officio)
SCOTT H. PETERS, California
FRANK PALLONE, Jr., New Jersey (ex 
    officio)
                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Diana DeGette, a Representative in Congress from the State 
  of Colorado, opening statement.................................     1
    Prepared statement...........................................     3
Hon. Brett Guthrie, a Representative in Congress from the 
  Commonwealth of Kentucky, opening statement....................     4
    Prepared statement...........................................     6
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     7
    Prepared statement...........................................     8
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, opening statement......................................     9
    Prepared statement...........................................    11
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, prepared statement.............................   124

                               Witnesses

Jennifer Smith, Secretary, Pennsylvania Department of Drug and 
  Alcohol Programs...............................................    13
    Prepared statement...........................................    16
    Answers to submitted questions...............................   217
Monica Bharel, M.D., Commissioner, Massachusetts Department of 
  Public Health..................................................    30
    Prepared statement...........................................    32
    Answers to submitted questions...............................   228
Christina Mullins, Commissioner, Bureau of Behavioral Health, 
  West Virginia Department of Health and Human Resources.........    39
    Prepared statement...........................................    41
    Answers to submitted questions...............................   243
 Kody Kinsley, Deputy Secretary, Behavioral Health and 
  Intellectual and Developmental Disabilities, North Carolina 
  Department of Health and Human Services........................    55
    Prepared statement...........................................    57
    Answers to submitted questions...............................   255
Nicole Alexander-Scott, M.D., Director, Rhode Island Department 
  of Health......................................................    84
    Prepared statement...........................................    86
    Answers to submitted questions...............................   265

                           Submitted Material

Letter of January 10, 2020, by Arlene Gonzalez-Sanchez, 
  Commissioner, New York State Office of Addiction Services and 
  Supports, to Ms. DeGette and Mr. Guthrie, submitted by Ms. 
  Clarke.........................................................   125
Letter of January 14, 2020, from Rep Frank Pallone, Jr, et al., 
  to Uttam Dhillon, Acting Administrator, Drug Enforcement 
  Administration, submitted by Ms. DeGette.......................   130
Letter of January 14, 2020, by Rep Frank Pallone, Jr, et al., to 
  Mr. Chad Wolf, Acting Secretary, Department of Homeland 
  Security, submitted by Ms. DeGette.............................   136
Letter of January 14, 2020, by Rep Frank Pallone, Jr, et al., to 
  Mr. Alex M. Azar II, Secretary, Department of Health and Human 
  Services, submitted by Ms. DeGette.............................   142
Letter of January 14, 2020, by Chris Fox, Executive Director, 
  Voices for Non-Opioid Choices, to Ms. DeGette and Mr. Guthrie, 
  submitted by Mr. McKinley......................................   148
Article of ``Association of Medicaid Expansion With Opioid 
  Overdose Mortality in the United States'', JAMA Network, from 
  Nicole Kravitz-Wirtz, Ph.D., et al., submitted by Mr. Ruiz.....   150
Article of ``The Geographic Distribution of Fentanyl-Involved 
  Overdose Deaths in Cook County, Illinois'', Research and 
  Practice, from Elizabeth D. Nesoff, Ph.D., et al., submitted by 
  Ms. Schakowsky.................................................   161
Article of January 28, 2019, ``Separate, Unequal and 
  Overlooked'', by Joseph P. Williams, Senior Editor, U.S. News 
  and World Report, submitted by Ms. Schakowsky..................   169
Letter of October 31, 2019, by Ron DeSantis, Governor, State of 
  Florida, to Mr. Pallone and Mr. Walden, submitted by Ms. 
  DeGette \1\
Letter of October 8, 2019, by Eric J. Holcomb, Governor, State of 
  Indiana, to Mr. Pallone and Mr. Walden, submitted by Ms. 
  DeGette........................................................   179
Letter of October 17, 2019, by Matthew G. Bevin, Governor, State 
  of Kentucky, to the Committee of Energy and Commerce, submitted 
  by Ms. DeGette \2\
Letter of October 18, 2019, by Jessica M. Pollard, PhD., 
  Director, Maine Department of Health and Human Services, 
  Substance Abuse and Mental Health, to Mr. Pallone, et al., 
  submitted by Ms. Degette.......................................   189
Letter of October 21, 2019, by Larry Hogan, Governor, State of 
  Maryland, to Mr. Pallone and Mr. Walden, submitted by Ms. 
  DeGette \3\
Letter of October 18, 2019, by Marylou Sudders, Secretary, 
  Commonwealth State of Massachusetts, Executive Office of Health 
  and Human Services, to Mr. Pallone and Mr. Walden, submitted by 
  Ms. DeGette \4\
Letter of October 30, 2019, by Michelle Lujan Grisham, Governor, 
  State of New Mexico, to Mr. Pallone, et al., submitted by Ms. 
  DeGette \5\
Letter of November 7, 2019, by Arlene Gonzalez-Sanchez, 
  Commissioner, State of New York, Office of Addiction Services 
  and Supports, to Mr. Pallone, et al., submitted by Ms. DeGette 
  \6\
Statement from the State of North Carolina, to Committee of 
  Energy and Commerce, et al., submitted by Ms. DeGette \7\
Letter of October 24, 2019, by Mike DeWine, Governor, State of 
  Ohio, to the Committee of Energy and Commerce, submitted by Ms. 
  DeGette \8\

----------
\1\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD011.pdf.
\2\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD013.pdf.

\3\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD015.pdf.
\4\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD016.pdf.

\5\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD017.pdf.

\6\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD018.pdf.

\7\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD019.pdf.

\8\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD020.pdf.
Letter of October 18, 2019, by Kate Brown, Governor, State of 
  Oregon, to Mr. Pallone, et al., submitted by Ms. DeGette \9\
Letter of October 18, 2019, by Tom Wolf, Governor, Commonwealth 
  State of Pennsylvania, to Mr. Pallone, et al., submitted by Ms. 
  DeGette \10\
Letter of October 18, 2019, from State of Rhode Island and 
  Providence Plantations, by Gina M. Raimondo, Governor, to Mr. 
  Pallone, et al., submitted by Ms. DeGette \11\
Letter of October 30, 2019, by Bill Lee, Governor, State of 
  Tennessee, to Mr. Pallone, et al., submitted by Ms. DeGette....   202
Letter of October 18, 2019, State of West Virginia, Department of 
  Health and Human Resources, Bureau for Behavioral Health, by 
  Christina R. Mullins, Commissioner, to Mr. Pallone, submitted 
  by Ms. DeGette \12\
Letter of October 16, 2019, by Tony Evers, Governor, State of 
  Wisconsin, to Mr. Pallone, et al., submitted by Ms. DeGette....   204

----------
\9\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD021.pdf.

\10\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD022.pdf.

\11\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD023.pdf.
\12\The information has been retained in committee files and also 
  is available at https://docs.house.gov/meetings/IF/IF02/
  20200114/110367/HHRG-116-IF02-20200114-SD025.pdf.


   A PUBLIC HEALTH EMERGENCY: STATE EFFORTS TO CURB THE OPIOID CRISIS

                              ----------                              


                       TUESDAY, JANUARY 14, 2020

                  House of Representatives,
      Subcommittee on Oversight and Investigations,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:09 a.m., in 
the John D. Dingell Room 2123, Rayburn House Office Building, 
Hon. Diana DeGette (chair of the subcommittee) presiding.
    Members present: Representatives DeGette, Schakowsky, 
Kennedy, Ruiz, Kuster, Castor, Sarbanes, Tonko, Clarke, Pallone 
(ex officio), Guthrie (subcommittee ranking member), Burgess, 
McKinley, Griffith, Brooks, Mullin, and Walden (ex officio).
    Also Present: Representative Latta.
    Staff present: Mohammad Aslami, Counsel; Joe Banez, 
Professional Staff Member; Kevin Barstow, Chief Oversight 
Counsel; Jeffrey C. Carroll, Staff Director; Tiffany Guarascio, 
Deputy Staff Director; Zach Kahan, Outreach and Member Service 
Coordinator; Chris Knauer, Oversight Staff Director; Kevin 
McAloon, Professional Staff Member; Lino Pena-Martinez, Staff 
Assistant; Emily Ryan, GAO Detailee; Benjamin Tabor, Policy 
Analyst; Rebecca Tomilchik, Staff Assistant; C. J. Young, Press 
Secretary; Jennifer Barblan, Minority Chief Counsel, Oversight 
and Investigations; Mike Bloomquist, Minority Staff Director; 
Tyler Greenberg, Minority Staff Assistant; Peter Kielty, 
Minority General Counsel; and Alan Slobodin, Minority Chief 
Investigative Counsel, Oversight and Investigations.
    Ms. DeGette. The Subcommittee on Oversight and 
Investigations hearing will now come to order.
    The Chair now recognizes herself for purposes of an opening 
statement.

 OPENING STATEMENT OF HON. DIANA DeGETTE, A REPRESENTATIVE IN 
              CONGRESS FROM THE STATE OF COLORADO

    Today, the subcommittee on Oversight and Investigations is 
holding a hearing entitled ``A Public Health Emergency: State 
Efforts to Curb the Opioid Crisis.`` The purpose of today's 
hearing is to examine states' efforts and successes in 
addressing the opioid epidemic, as well as opportunities for 
future federal support.
    And just to let everybody know, Dr. Alexander Scott, the 
reason why we are getting started a little late, the plane was 
delayed. But now the doctor is on her way. And so, we will 
swear in the witnesses when we get to that point. And if we 
have to do that one later, we will.
    The Chair will now recognize herself for an opening 
statement.
    As I said, today, the Committee continues its bipartisan 
efforts to combat the opioid crisis.
    As we know, the country is in the midst of an epidemic 
unlike any in recent history. According to the Centers for 
Disease Control and Prevention, from 1999 to 2017, nearly 
400,000 people died from opioid overdoses. In 2017, more than 
two-thirds of drug overdose deaths involved opioids.
    The crisis has continued to evolve, and the challenges that 
we face have continued to evolve along with it. The first wave 
of this crisis began in the 1990s with the over-prescribing of 
pain medication. The second wave began in 2010, with increased 
deaths due to heroin overdoses.
    Like the first two waves, the third wave--marked by the 
rise of synthetic opioids like fentanyl--has shattered lives, 
traumatized families, and devastated communities.
    Now, unfortunately, it looks like a fourth wave of the 
crisis may have already arrived. The opioid epidemic has fueled 
a huge increase in methamphetamine use. In 2018, there were 
more than twice as many deaths involving meth as in 2015, and 
meth is increasingly turning up in overdose deaths and drug 
busts across the country.
    Given the complexity of the epidemic and its ability to 
evolve, states, federal government agencies, and Congress must 
remain vigilant.
    To that end, this Committee has taken numerous steps to 
investigate the origins and drivers of the crisis so we can 
learn from it as we try to get ahead of the next wave. Through 
committee hearings, we have heard from states, federal 
agencies, and drug distributors about their roles and 
responses.
    The groundbreaking work by the Committee uncovered some of 
the failures that led to where we are today. And looking 
forward, we're focused on identifying ways to stem this crisis 
and bring relief to the millions of Americans who are 
suffering.
    As part of that effort, our committee has worked across the 
aisle to pass bipartisan legislation designed to give states 
the tools and resources needed to help those impacted by 
substance use disorder.
    These legislative packages provided states with billions of 
dollars in federal funding to assist in the opioid response, 
treatment, and recovery efforts.
    And we have made some progress. CDC provisional data 
indicates that drug overdose deaths have fallen for the first 
time in decades. While this downward shift is welcome news, the 
crisis is far from over, and we must continue to look for ways 
to bring relief to struggling cities and towns throughout the 
country.
    Today's hearing continues those bipartisan efforts. Day in 
and day out, states are on the front lines of this epidemic 
that kills more than 130 Americans every day. As the epidemic 
now enters a new decade, states face the challenge of keeping 
pace with an evolving crisis.
    In keeping with this Committee's bipartisan commitment to 
finding solutions to this national emergency, last September, 
the Committee sent letters to 16 states requesting information 
about on-the-ground efforts to curb the epidemic.
    The Committee has sought to understand whether federal 
funds actually reached the hardest hit communities, how states 
used the funds provided by Congress, and what strategies have 
proven to be successful.
    Today, we have five key states that have each received a 
letter from this Committee. These states represent the first 
line of defense against the crisis, and they each play pivotal 
roles in treatment, recovery, and prevention efforts.
    I want to thank all of you for coming today.
    The states compose a large swath of the country. While 
their demographics, geography, and challenges vary, each has 
felt the effect of this epidemic, and they all rank among the 
states with some of the highest overdose death rates. As such, 
each of them has taken a number of steps to curb the epidemic.
    For example, Pennsylvania was able to distribute nearly 
13,000 naloxone kits free of charge in 2018 and again in 2019, 
thanks to a combination of state and federal funding.
    North Carolina provided treatment to 12,000 uninsured 
persons, thanks again to federal funding.
    And Rhode Island has been able to expand medication-
assisted treatment in the prison system, resulting in a 62 
percent reduction in overdose deaths.
    These are just a few examples of how the states are 
fighting this epidemic and helping communities.
    As Congress considers future action to address this crisis, 
all of our witnesses today provide important insights on how 
federal funds are being used to combat the epidemic, what 
efforts are proving successful, and what we need to do for 
further improvement.
    I thank the witnesses for their service, for being here to 
testify on behalf of their states. And I look forward to 
hearing how we can all continue to work together to find the 
desperately needed solutions.
    [The prepared statement of Ms. DeGette follows:]

                Prepared Statement of Hon. Diana DeGette

    Today, the Committee continues its bipartisan efforts to 
combat the opioid crisis.
    The country is in the midst of an epidemic unlike any in 
recent history. According to the Centers for Disease Control 
and Prevention, from 1999 to 2017, nearly 400,000 people died 
from opioid overdoses. In 2017, more than two-thirds of drug 
overdose deaths involved opioids.
    This crisis has continued to evolve, and the challenges we 
face have evolved along with it. The ``first wave'' of this 
crisis began in the 1990s with the over-prescribing of pain 
medication. The ``second wave'' began in 2010 with increased 
deaths due to heroin overdoses.
    Like the first two waves, the ``third wave''--marked by the 
rise of synthetic opioids such as fentanyl--has shattered 
lives, traumatized families, and devastated communities.
    Now a ``fourth wave'' of the crisis may have already 
arrived. The opioid epidemic has fueled a huge spike in 
methamphetamine use. In 2018, there were more than twice as 
many deaths involving meth as in 2015, and meth is increasingly 
turning up in overdose deaths and drug busts across the 
country.
    Given the complexity of the epidemic and its ability to 
evolve, states, federal government agencies, and Congress must 
remain vigilant.
    To that end, this Committee has taken numerous steps to 
investigate the origins and drivers of the crisis so we can 
learn from it as we try to get ahead of the next wave. Through 
Committee hearings, we have heard from states, federal 
agencies, and drug distributors about their roles and 
responses.
    That groundbreaking work by the Committee uncovered some of 
the failures that led to where we are today. Looking forward, 
the Committee is focused on identifying ways to stem this 
crisis and bring relief to the millions of Americans who are 
suffering.
    As part of that effort, our Committee has worked across the 
aisle to pass bipartisan legislation designed to give states 
the tools and resources needed to help those impacted by 
substance use disorder.
    These legislative packages provided states billions of 
dollars in federal funding to assist in opioid response, 
treatment, and recovery efforts.
    And we have made some progress. CDC provisional data 
indicates drug overdose deaths have fallen for the first time 
in decades. While this downward shift is welcome news, this 
crisis is far from over--and we must continue to look for ways 
to bring relief to struggling cities and towns throughout the 
country.
    Today's hearing continues those bipartisan efforts. Day in 
and day out, states are on the front lines of this epidemic 
that kills more than 130 Americans every day. As the epidemic 
now enters a new decade, states face the challenge of keeping 
pace with an evolving crisis.
    In keeping with this Committee's bipartisan commitment to 
finding solutions to this national emergency, last September, 
our Committee sent letters to 16 states requesting information 
about on-the-ground efforts to curb the epidemic.
    The Committee has sought to understand whether federal 
funds reached the hardest hit communities, how states used 
funds provided by Congress, and what strategies have proven 
successful.
    Today, we have before us five key states that each received 
a letter from this Committee. These states represent the first 
line of defense against the crisis and each play pivotal roles 
in treatment, recovery, and prevention efforts.
    These states compose a large swath of the country. While 
their demographics, geography, and challenges vary, each has 
felt the impact of the epidemic, and they all rank among the 
states with some of the highest overdose death rates.
    As such, each of these states has taken a number of steps 
to curb the epidemic.
    For example, Pennsylvania was able to distribute nearly 
13,000 naloxone kits free of charge in 2018 and again in 2019, 
thanks to a combination of federal and state funding.
    North Carolina has provided treatment to 12,000 uninsured 
persons, thanks again to federal funding.
    And Rhode Island has been able to expand medication-
assisted treatment in the prison system, resulting in a 62 
percent reduction in overdose deaths.
    These are just a few examples of how states are fighting 
this epidemic and helping communities.
    As Congress considers future action to address this crisis, 
the witnesses today provide important insights on how federal 
funds are being used to combat the epidemic, what efforts are 
proving successful, and what areas need additional improvement.
    I thank the witnesses for their service, and for being here 
today to testify on behalf of their states. I look forward to 
discussing how we can all work together to find solutions to 
resolving this public health emergency.

    And with that, I am pleased to yield for purposes of an 
opening statement, Mr. Guthrie, 5 minutes.

 OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN 
           CONGRESS FROM THE COMMONWEATH OF KENTUCKY

    Mr. Guthrie. Thank you. Thank you, Chair DeGette, for 
holding this important hearing on state responses to the opioid 
crisis.
    Our local communities are suffering. On average, 130 
Americans die every day from an opioid overdose. And opioids 
were involved in 47,600 overdose deaths in 2017, which 
accounted for 67.8 percent of all drug overdose deaths.
    In Kentucky, there were 1,160 reported opioid-involved 
deaths in 2017.
    The Energy and Commerce Committee has been steadfast in its 
efforts to help combat the opioid epidemic, with both 
investigations and legislation. Whether it was the Committee's 
investigations into the prescription drug and heroin epidemic, 
opioid distributors, patient brokering, or the major opioid 
manufacturers, we have continued to ask questions and get 
answers for the American public.
    When it comes to legislation, this Committee led the way on 
the passage of the 21st Century Cures Act, the Comprehensive 
Addiction Recovery Act, and the SUPPORT for Patients and 
Communities Act. I was proud to work on all three of these 
comprehensive laws, which are designed to combat the opioid 
crisis through prevention, advancing treatment and recovery 
initiatives, protecting communities, and bolstering our efforts 
to fight synthetic drugs like fentanyl.
    This hearing is a critical opportunity for us to check in 
with the states, those that are on the front lines battling the 
nation's opioid epidemic, to see how the federal money Congress 
provided has been allocated and spent, what successes they are 
having in combating the epidemic, but also what challenges they 
are still facing, and what additional authorities and resources 
could be helpful.
    The good news is that each state testifying before us today 
has seen a decrease in their overdose death rates. Federal 
assistance is making a difference. In addition, states are 
creating and implementing innovative approaches to combating 
the epidemic.
    Examples include expanding efforts to connect people to 
treatment through EMS and emergency departments, expanding and 
increasing the availability of naloxone and medication-assisted 
treatment, increasing non-emergency transportation options to 
treatment for those in rural areas, and expanding neonatal 
abstinence syndrome treatment programs for pregnant and 
parenting mothers, and efforts to address workforce issues 
through the initiatives such as a loan repayment program, and 
broadening the curriculum in training in medical schools.
    This hearing is a great platform for the states to share 
how the federal funding has made a difference in what programs 
are working. Not only is it helpful for us in Congress as we 
continue to conduct oversight and legislate, but also to the 
states as they learn from each other about new ideas or 
innovative approaches that can be implemented.
    While progress is being made and some of the overdose death 
rates are declining, the Director of National Institute of Drug 
Abuse, Dr. Nora Volkow, declared this week that this country 
still has not controlled its addiction problems. Some states 
are continuing to see a high number of first responder 
emergency department encounters due to an overdose.
    In addition, states are still facing many challenges, 
including a lack of qualified workforce and infrastructure, 
varying requirements and time length in different federal 
funding streams, and restrictions on funding, including that 
some funds have been restricted to opioids, impeding 
flexibility to address emerging challenges.
    In addition to the continuing threat of opioids, states are 
starting to see more instances of polysubstance abuse and 
polysubstance overdose deaths, with states specifically citing 
stimulants such as methamphetamine and cocaine as a growing 
concern.
    Nationally, since last year methamphetamine, has been 
detected in more deaths than opioids such as oxycodone and 
hydrocodone. In 14 of the 35 states that report overdose deaths 
to the Federal Government on a monthly basis, methamphetamine 
is involved in more deaths than fentanyl.
    The threats are evolving and the fight is not over. We want 
to continue partnering with state and local entities to combat 
the opioid epidemic as well as emerging threats, which is why 
it is important not to let our foot off the gas. Congress needs 
to continue supporting the states, and this Committee needs to 
continue conducting oversight of these critical issues.
    I want to thank all the witnesses for being here today. I 
look forward to hearing from you about all your successes we 
have had in combating our nation's opioid epidemic, but also 
how the threat has changed, what challenges remain, and what 
more we in Congress can do with our partners, you, in this 
fight.
    And I yield back.
    [The prepared statement of Mr. Guthrie follows:]

                Prepared Statement of Hon. Brett Guthrie

    Thank you, Chair DeGette, for holding this important 
hearing on state responses to the opioid crisis.
    Our local communities are suffering. On average, 130 
Americans die every day from an opioid overdose and opioids 
were involved in 47,600 overdose deaths in 2017, which 
accounted for 67.8 percent of all drug overdose deaths. In 
Kentucky, there were 1,160 reported opioid-involved deaths in 
2017.
    The Energy and Commerce Committee has been steadfast in its 
efforts to help combat the opioid epidemic, with both 
investigations and legislation. Whether it was the Committee's 
investigations into the prescription drug and heroin epidemic, 
opioid distributors, patient brokering, or the major opioid 
manufacturers--we have continued to ask questions and get 
answers for the American public.
    When it comes to legislation, this Committee led the way on 
passage of the 21st Century Cures Act, the Comprehensive 
Addiction and Recovery Act, and the SUPPORT for Patients and 
Communities Act. I was proud to work on all three of these 
comprehensive laws, which are designed to combat the opioid 
crisis through prevention, advancing treatment and recovery 
initiatives, protecting communities, and bolstering our efforts 
to fight synthetic drugs, like fentanyl.
    This hearing is a critical opportunity for us to check in 
with states-those that are on the front lines battling the 
nation's opioid epidemic-to see how the federal money Congress 
provided is being allocated and spent, what successes they are 
having in combatting the epidemic, but also what challenges 
they are still facing, and what additional authorities and 
resources could be helpful.
    The good news is that each state testifying before us today 
has seen a decrease in their overdose death rates. Federal 
assistance is making a difference. In addition, states are 
creating and implementing innovative approaches to combatting 
the epidemic. Examples include: expanding efforts to connect 
people to treatment through EMS and emergency departments; 
expanding and increasing the availability of naloxone and 
medication-assisted treatment; increasing nonemergency 
transportation options to treatment for those in rural areas; 
expanding neonatal abstinence syndrome treatment programs for 
pregnant and parenting mothers; and efforts to address 
workforce issues through initiatives such as loan repayment 
programs and broadening the curriculum and training in medical 
schools.
    This hearing is a great platform for the states to share 
how the federal funding has made a difference and what programs 
are working. Not only is it helpful for us in Congress as we 
continue to conduct oversight and legislate, but also, to the 
states as they learn from each other about new ideas or 
innovative approaches that can be implemented.
    While progress is being made and some of the overdose death 
rates are declining, the Director of the National Institute of 
Drug Abuse, Dr. Nora Volkow, declared this week that this 
country still has not controlled its addiction problems. Some 
states are continuing to see a high number of first responders 
and emergency department encounters due to an overdose. In 
addition, states are still facing many challenges, including a 
lack of a qualified workforce and infrastructure, varying 
requirements and timelines in different federal funding 
streams, and restrictions on funding, including that some funds 
have been restricted to opioids, impeding flexibility to 
address emerging challenges.
    In addition to the continued threat of opioids, states are 
starting to see more instances of polysubstance use and 
polysubstance overdose deaths, with some states specifically 
citing stimulants such as methamphetamine and cocaine as a 
growing concern. Nationally, since late last year, 
methamphetamine has been detected in more deaths than opioids 
such as oxycodone and hydrocodone. In 14 of the 35 states that 
report overdose deaths to the Federal Government on a monthly 
basis, methamphetamine is involved in more deaths than 
fentanyl.
    The threats are evolving, and this fight is not over. We 
want to continue partnering with state and local entities to 
combat the opioid epidemic, as well as other emerging threats, 
which is why it's important to not let our foot off the gas. 
Congress needs to continue supporting the states and this 
Committee needs to continue conducting oversight of these 
critical issues.
    I want to thank all of the witnesses for being here today. 
I look forward to hearing from all of you about successes we 
have had in combatting our nation's opioid epidemic, but also 
how the threat has changed, what challenges remain, and what 
more we, in Congress, can do to be partners in this fight.

    Ms. DeGette. I thank the gentleman.
    The Chair now recognizes the chairman of the full committee 
Mr. Pallone for 5 minutes.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Chairwoman DeGette.
    Today's hearing continues the Committee's ongoing, 
bipartisan efforts to combat the opioid epidemic. Whether 
fueled by prescription drugs or illicit synthetic opioids, this 
epidemic is a constantly evolving threat, putting people, 
families, and communities at grave risk.
    This is not a crisis that we can solve overnight; and it 
requires ongoing federal and state attention.
    And states are on the front lines of this national 
emergency, providing much of the support for those in need. 
They are our eyes and ears on what is occurring on the ground. 
And that is why this hearing is so important.
    It is the latest in a series of hearings we have held on 
the opioid crisis. In the past, we have heard from several 
states, including Rhode Island, about on-the-ground efforts to 
curb the epidemic. Last year, we also heard from federal 
agencies about the urgent threat posed by fentanyl.
    The Committee also conducted a 2-year bipartisan 
investigation into opioid distribution practices.
    The Energy and Commerce Committee has also been at the 
forefront of passing critical legislation that gives our 
federal, state, and local partners the tools and resources 
required to succeed in this fight, including three pieces of 
legislation--all bipartisan--that were designed to give states 
funding and support.
    In 2016, the Committee passed, and President Obama signed 
into law, the Comprehensive Addiction and Recovery Act, 
``CARA,`` and the 21st Century Cures Act; of course I have to 
mention Chairwoman DeGette's major role in that. These two laws 
authorized over $1 billion in state-specific grants and helped 
states bolster evidence-based treatment, prevention, and 
recovery efforts.
    In 2018, the SUPPORT Act was passed and signed into law 
reauthorizing, opioid-specific funding, increasing opioid abuse 
and overdose prevention training, and improving coordination 
and quality of care.
    And then, in December, the House passed H.R. 3, the Lower 
Drug Costs Now Act, which included $10 billion in additional 
opioid funding.
    This Committee is committed to making sure communities are 
receiving the support they need to get relief from this crisis. 
And that is why we sent letters to 16 states last year 
requesting information on how federal funds have assisted 
states in this fight, and what additional help Congress can 
provide as we consider future action.
    We wanted to know how states are using federal opioid 
funds, what is being done to ensure those funds reach the 
hardest-hit regions, and how funds have helped transform state 
treatment systems. Based on the responses, we heard that the 
federal money has allowed states to take important and 
innovative approaches to addressing opioid addiction.
    One of the most effective tools that are available to the 
states is Medicaid. Several states elaborated on the important 
role of Medicaid in stemming this crisis in their responses to 
the Committee. A study released last week found that about 
8,000 lives have been saved from an opioid overdose thanks to 
the expansion of Medicaid under the Affordable Care Act.
    We also want to hear about any emerging trends in substance 
abuse that they are seeing. For example, several states 
informed the Committee that while they continue to fight the 
opioid epidemic, they are also seeing an increase in 
methamphetamine and polysubstance use. And this, of course, is 
an alarming trend that threatens to become the next epidemic. 
And I want to hear how Congress can help states confront this 
unfolding danger.
    So, again, I thank the witnesses. I look forward to hearing 
about their efforts.
    Thank you, Madam Chair, for continuing your efforts on 
this. I don't think anybody wants my time. If not, I am going 
to yield back. Thank you.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Today's hearing continues the Committee's ongoing, 
bipartisan efforts to combat the opioid epidemic. Whether 
fueled by prescription drugs or illicit synthetic opioids, this 
epidemic is a constantly evolving threat--putting people, 
families, and communities at grave risk.
    This is not a crisis that we can resolve overnight, and it 
requires ongoing federal and state attention.
    States are on the front lines of this national emergency, 
providing much of the support for those in need. They are our 
eyes and ears on what is occurring on the ground, and that's 
why this hearing is so important.
    It is the latest in a series of hearings we've held on the 
opioid crisis. In the past, we've heard from several states, 
including Rhode Island, about on-the-ground efforts to curb the 
epidemic. Last year, we also heard from federal agencies about 
the urgent threat posed by fentanyl.
    The Committee also conducted a two-year bipartisan 
investigation into opioid distribution practices.
    The Energy and Commerce Committee has also been at the 
forefront of passing critical legislation that gives our 
federal, state, and local partners the tools and resources 
required to succeed in this fight, including three pieces of 
legislation--all bipartisan--designed to give states funding 
and support.
    In 2016, this Committee passed, and President Obama signed 
into law, the Comprehensive Addiction and Recovery Act 
(``CARA'') and the 21st Century Cures Act. These two laws 
authorized over $1 billion in state-specific grants, and helped 
states bolster evidence-based treatment, prevention, and 
recovery efforts.
    In 2018, the SUPPORT Act was passed and signed into law 
reauthorizing opioid-specific funding, increasing opioid abuse 
and overdose prevention training, and improving coordination 
and quality of care.
    And then, in December, the House passed H.R. 3, the Lower 
Drug Costs Now Act, which included $10 billion in additional 
opioid funding.
    This Committee is committed to making sure communities are 
receiving the support they need to get relief from this crisis.
    And that's why we sent letters to 16 states last year 
requesting information on how federal funds have assisted 
states in this fight, and what additional help Congress can 
provide as we consider future action.
    We wanted to know how states are using federal opioid 
funds, what is being done to ensure those funds reach the 
hardest hit regions, and how funds have helped transform state 
treatment systems.
    Based on the responses, we heard that the federal money has 
allowed states to take important and innovative approaches to 
addressing opioid addiction.
    And one of the most effective tools that are available to 
the states is Medicaid. Several states elaborated on the 
important role of Medicaid in stemming this crisis in their 
responses to the Committee. A study released last week found 
that about 8,000 lives have been saved from an opioid overdose 
thanks to the expansion of Medicaid under the Affordable Care 
Act.
    We also want to hear about any emerging trends in substance 
abuse that they are seeing. For example, several states 
informed the Committee that while they continue to fight the 
opioid epidemic, they are also seeing an increase in 
methamphetamine and polysubstance use.
    This is an alarming trend that threatens to become the next 
epidemic, and I want to hear how Congress can help states 
confront this unfolding danger.
    I thank the witnesses for being here today, and look 
forward to hearing about their states' efforts in combating 
this crisis.
    I yield back.

    Ms. DeGette. I thank the gentleman.
    The Chair now recognizes the ranking member of the full 
committee Mr. Walden for 5 minutes.

  OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF OREGON

    Mr. Walden. Good morning, Madam Chair. And thanks for 
holding this critically important hearing.
    As I was preparing for this, I noticed that in my biggest 
country in my district, they have a yellow alert up for 
opioids. They have two overdoses on average per week in Jackson 
Country, Oregon. They had seven last week--fortunately no 
deaths.
    The first responders administered naloxone injections in 
the county five times last week, and they believe that it is 
probably heroin with a pretty heavy dose of fentanyl in it. So, 
the deadly scourge continues.
    For many years, as you have heard, the Energy and Commerce 
Committee, and this subcommittee, in particular, has been at 
the forefront of congressional efforts to address the opioid 
crisis and substance use disorder issue. And we have done a lot 
of work on prevention. We know we have a lot more work to do.
    This Committee has held hearings, and conducted 
investigations on opioids and the opioid epidemic for nearly 
two decades, bringing in Purdue Pharma to testify in 2001 about 
the abuse of OxyContin, through our bipartisan investigations 
last Congress into the rise of fentanyl, opioid manufacturing, 
opioid distribution, and the substance use disorder treatment 
industry.
    These early hearings helped inform our legislative work, 
including the Comprehensive Addiction Recovery Act, or 
``CARA,`` the 21st Century Cures Act which authorized the 
state-targeted response to the opioid crisis grants, and 
billions more in federal appropriations to produce programs 
that fight, treat, and stop substance abuse and support access 
to mental health services. These efforts culminated in the 
signing into law of the SUPPORT Act in the last Congress.
    In my home state of Oregon, we have seen the results, a 3.1 
percent reduction in opioid deaths based on the most recent 
statistics from the CDC.
    I am pleased we have continued to work together in this 
space. It is important, including by continuing our work on 
fentanyl and, with this important hearing today, examining how 
the states are utilizing the funding and the authorities 
provided by Congress.
    But there is so much more we could do together. Earlier 
this year Energy and Commerce Republicans published a Request 
for Information about the substance use disorder treatment 
industry. The RFI was built off the patient brokering 
investigation that we conducted in the last Congress. And this 
investigation brought us to the question of what is good 
treatment and, conversely, what is bad treatment, which is the 
central question posed by our RFI.
    With the billions of dollars we are sending into the states 
for prevention and treatment, we need answers. Just yesterday, 
Energy and Commerce Republicans sent a letter to the three 
opioid manufacturers we began investigating together last 
Congress, asking them to complete production to our request. It 
is critical we fully understand the causes of the opioid 
epidemic in order to ensure that our solutions are the right 
ones. And it is important that they answer our questions.
    We should also hold a comprehensive series of hearings to 
conduct oversight and implementation of the SUPPORT Act. For 
example, relevant to today's hearing, the SUPPORT Act included 
the INFO Act, sponsored by Mr. Latta, which calls for the 
creation of a public and easily acceptable electronic dashboard 
linking to all the nationwide efforts and strategies to combat 
the opioid crisis. The INFO Act was designed to meet a specific 
need of local stakeholders who were telling us that despite 
Congress having devoted record numbers of federal dollars to 
combat the opioid crisis, they had trouble finding what 
resources were available and where they were--certainly an 
issue we heard a lot about from Mr. McKinley and others.
    This provision is absolutely critical in helping those on 
the front lines of the opioid crisis. And I am really concerned 
about its slow implementation.
    In addition to oversight of the SUPPORT Act, we also need 
to begin working on the next wave of legislation to address not 
only the opioid crisis but also substance use disorders more 
broadly. Most urgently, we need to reauthorize the fentanyl 
ban, which is set to expire in a matter of weeks. Reauthorizing 
the prohibitions on various forms of fentanyl has broad 
bipartisan support. We should do that expeditiously.
    And today's hearing is an important step, though, to 
understand the impact that federal grant dollars are having on 
states. I want to thank all of our witnesses for being here and 
being part of this equation. And I look forward to hearing from 
you.
    [The prepared statement of Mr. Walden follows:]

                 Prepared Statement of Hon. Greg Walden

    Madam Chair, thank you for holding this critically 
important hearing
    For many years, the Energy and Commerce Committee--and this 
Subcommittee in particular--has been at the forefront of the 
Congressional effort to address the opioid crisis, as well as 
substance use disorder prevention and treatment more broadly.
    This Committee has held hearings and conducted 
investigations on opioids and the opioid epidemic for nearly 
two decades--from bringing in Purdue Pharma to testify in 2001 
about the abuse of OxyContin, to our bipartisan investigations 
last Congress into the rise of fentanyl, opioid manufacturing, 
opioid distribution, and the substance use disorder treatment 
industry.
    These early hearings helped inform our legislative work 
including the Comprehensive Addiction and Recovery Act, or 
CARA, the 21st Century Cures Act, which authorized the State 
Targeted Response to the Opioid Crisis grants, and billions 
more in federal appropriations to boost programs that fight, 
treat, and stop substance abuse, and support access to mental 
health services. These efforts culminated in the signing into 
law of the SUPPORT Act last Congress. In my home state of 
Oregon, we've seen the results, with a 3.1% reduction in opioid 
deaths based on the most recent statistics from the CDC.
    I am pleased that we have continued to work together in 
this space, including by continuing our work on fentanyl, and 
with this important hearing today examining how the states are 
utilizing the funding and authorities provided by the Congress.
    But there is so much more that we could do together. 
Earlier this year, Energy and Commerce Republicans published a 
Request for Information about the substance use disorder 
treatment industry. This RFI built off of the patient brokering 
investigation we conducted together last Congress. This 
investigation brought us to the question of what is good 
treatment--and conversely, what is bad treatment--which is the 
central question posed by the RFI. With the billions of dollars 
we are sending into the states for prevention and treatment, we 
need answers.
    Just yesterday, Energy and Commerce Republicans sent a 
letter to the three opioid manufacturers we began investigating 
together last Congress, asking them to complete production to 
our requests. It is critical that we fully understand the 
causes of the opioid epidemic in order to ensure that our 
solutions are the right ones.
    We should also hold a comprehensive series of hearings to 
conduct oversight of the implementation of the SUPPORT Act. For 
example, relevant to today's hearing, the SUPPORT Act included 
the INFO Act, sponsored by Mr. Latta, which calls for the 
creation of a public and easily accessible electronic dashboard 
linking to all of the nationwide efforts and strategies to 
combat the opioid crisis. The INFO Act was designed to meet a 
specific need of local stakeholders who were telling us that 
despite Congress having devoted record numbers of federal 
dollars to combat the opioid crisis, they had trouble finding 
what resources were available and where they were. This 
provision is absolutely critical in helping those on the front 
lines of the opioid crisis and I am concerned about its slow 
implementation.
    In addition to oversight of the SUPPORT Act, we also need 
to begin working on the next wave of legislation to address not 
only the opioid crisis, but substance use disorders more 
broadly. Most urgently, we need to reauthorize the fentanyl 
ban, which is set to expire in a matter of weeks. Reauthorizing 
the prohibitions on various forms of fentanyl has broad 
bipartisan support and we should be able to do this 
expeditiously.
    Today's hearing is an important step to understanding the 
impact that the federal grant dollars are having in the states, 
and I thank all of our witnesses for being a part of this 
conversation. I look forward to hearing not only about the 
successes in each of your states--and there are many--but also 
understanding the barriers that still exist, either in federal 
law or in the conditions of the federal dollars, and the ideas 
you have for how the Congress can continue to assist as you and 
your communities fight this battle on the front lines.

    Mr. Walden.With that, I would yield the balance of my time 
to the ranking member on the Subcommittee on Health, Mr. 
Burgess.
    Mr. Burgess. I thank the gentleman for yielding. And, of 
course, it was under your leadership of the full committee that 
last year we worked in a bipartisan manner to produce 
legislation that ultimately was signed into law by President 
Trump in October of 2018. And it really began in this 
subcommittee with a member day that we did. And we heard from 
over 50 members, of not just the Committee but throughout the 
Congress, the problems they had in their districts and the 
ideas that they were bringing to the table that we could, we 
could work on.
    The SUPPORT Act was written to help advance treatment and 
recovery initiatives for those affected by opiate habituation.
    I, too, want to thank our witnesses for being here today. 
You will be helpful in understanding the challenges that we 
face continuing this fight against opioid addiction and death, 
while ensuring that patients can manage their pain. It is 
important for Congress to have hearings like this where we can 
ensure the effectiveness of legislative efforts and identify 
gaps where they exist.
    Thank you, Mr. Chairman. I yield back.
    Mr. Walden. And, Madam Chair, I would yield back with the 
notation that some of us have the other subcommittee upstairs, 
so we will be coming and going between hearings.
    So, thank you, and I yield back.
    Ms. DeGette. Thank you. Thank you.
    I ask for unanimous consent that the Members' written 
opening statements to be made part of the record.
    Without objection, so ordered.
    I now want to introduce the witnesses for today's hearing.
    Ms. Jennifer Smith, who is the Secretary of the Department 
of Drug and Alcohol Programs, Commonwealth of Pennsylvania. 
Welcome.
    Dr. Monica Bharel. Dr. Bharel is the Commissioner, 
Department of Public Health, Commonwealth of Massachusetts.
    Dr. Nicole Alexander-Scott. I think they beamed you here 
from the airport, so congratulations. She is the Director of 
the Department of Health, the State of Rhode Island.
    Ms. Christina Mullins, Commissioner, Bureau of Behavioral 
Health, Department of Health and Human Services, State of West 
Virginia. Welcome.
    And Mr. Kody Kinsley, Deputy Secretary, Behavioral Health 
and Intellectual and Developmental Disabilities, Department of 
Health and Human Services, State of North Carolina. Welcome to 
you.
    Thanks to all of you for appearing in front of the 
subcommittee today. As you are aware, the Committee is holding 
an investigative hearing. And when we do so, we have the 
practice of taking all of our testimony under oath.
    Do any of you have an objection to testifying under oath 
today?
    Let the record reflect the witnesses responded no.
    The Chair then advises you that under the rules of the 
House and the rules of the Committee, you are entitled to be 
accompanied by counsel. Does any of you wish to be accompanied 
by counsel?
    Let the record reflect the witnesses have responded no.
    So, if you would, would you please rise and raise your 
right hand so that you may be sworn in.
    [Witnesses sworn.]
    Ms. DeGette. You may be seated.
    Let the record reflect that the witnesses responded 
affirmatively. And all of you are now under oath and subject to 
the penalties set forth in Title 18, Section 1001 of the U.S. 
Code.
    The Chair now recognizes our witnesses for 5-minute 
summaries of their written statements. In front of each of you, 
there is a microphone, a timer, and a series of lights. The 
timer counts down your time, and the red light turns on at the 
end when your 5 minutes have come to an end.
    And so now, Ms. Smith, I am pleased to recognize you for 5 
minutes.

TESTIMONY OF JENNIFER SMITH, SECRETARY, DEPARTMENT OF DRUG AND 
ALCOHOL PROGRAMS, COMMONWEALTH OF PENNSYLVANIA; MONICA BHAREL, 
 M.D., COMMISSIONER, DEPARTMENT OF PUBLIC HEALTH, COMMONWEALTH 
 OF MASSACHUSETTS; CHRISTINA MULLINS, COMMISSIONER, BUREAU OF 
 BEHAVIORAL HEALTH, DEPARTMENT OF HEALTH AND HUMAN RESOURCES, 
  STATE OF WEST VIRGINIA; AND KODY KINSLEY, DEPUTY SECRETARY, 
     BEHAVIORAL HEALTH AND INTELLECTUAL AND DEVELOPMENTAL 
DISABILITIES, DEPARTMENT OF HEALTH AND HUMAN SERVICES, STATE OF 
 NORTH CAROLINA; AND NICOLE ALEXANDER-SCOTT, M.D., DIRECTOR OF 
        THE DEPARTMENT OF HEALTH, STATE OF RHODE ISLAND

                  TESTIMONY OF JENNIFER SMITH

    Ms. Smith. Thank you, Chairman, Ranking Member, and members 
of the subcommittee. My name is Jennifer Smith, and I am 
Secretary for Pennsylvania's Department of Drug and Alcohol 
Programs, as well as a member of the National Association of 
State Alcohol and Drug Abuse Directors.
    Thanks for your interest in how Pennsylvania is using the 
state opioid response funding to promote prevention, treatment 
and recovery efforts.
    Acting as the state's single authority for substance use 
disorder services, my department coordinates efforts with 
federal and local entities, as well as across state 
departments. Our ability to orchestrate resources and direct 
policy during the opioid crisis has been a crucial component in 
effecting long-term changes and maximizing resources available 
to our communities.
    We are grateful for these federal grant opportunities at a 
time of hopelessness and despair for families and communities. 
I can say with certainty that this funding has saved lives.
    With a population of 12.8 million, Pennsylvania is the 
fifth most populous state, consisting of 67 counties that range 
from large urban centers to rural counties. Our state is among 
those hardest hit by the nation's prescription opioid and 
heroin epidemic. In 2014, we lost more than 2,700 
Pennsylvanians to drug-related overdoses, which equates to 
seven deaths per day.
    By 2017, that number had tragically doubled to more than 
5,400 lives lost, or 13 deaths per day. As statistics rose year 
over year, our primary focus became simple: keep Pennsylvanians 
alive.
    That meant infusing naloxone into communities, implementing 
warm hand-off protocols to transition overdose survivors from 
emergency departments into treatment, expanding access to 
evidence-based practices such as medication-assisted treatment, 
and launching a 24/7 Get Help Now Hotline.
    I am proud to say that in 2018, Pennsylvania reported an 18 
percent decrease in overdose deaths.
    While it's not clear whether this promising trend will 
continue in 2019, it is clear that the more than $230 million 
in federal funding that the state has received is making a 
tremendous impact. We have used these resources and the 
momentum of the crisis to collaborate, modernize, and innovate, 
using dollars across the full continuum.
    In prevention, we reduced opioid prescribing by 25 percent, 
developed prescribing guidelines, incorporated addiction 
content into medical school curriculums, and established over 
800 prescription drug take-back boxes across the state.
    In treatment, we established a naloxone standing order, and 
distributed over 55,000 free kits, developed a warm hand-off 
model that's been used over 6,400 times, expanded treatment 
capacity through 45 Centers of Excellence and eight hub-and-
spoke programs, increased our DEA X waiver physicians to over 
4,000, offered loan repayment, awarded 3. million to expand 
supports for pregnant women and women with children, and 
expanded MAT into our state correctional institutions.
    In terms of recovery support, we awarded 2.1 million to 
expand community recovery services, developed a Web site to 
share recovery stories and spread hope, and awarded grant funds 
to build recovery housing support.
    In the coming months, Pennsylvania will be focused on 
integrating quality into our four major goals of reducing 
stigma, intensifying primary prevention, strengthening the 
treatment system, and empowering sustained recovery. Without 
sustainable federal funding, the collaboration necessary to 
accomplish these goals will be greatly diminished.
    Although we've made significant strides, our work is not 
done, and we need your help. In terms of funding, we need 
flexibility to address the system, not a substance.
    We need consistency with funding vehicles and reporting 
mechanisms where possible, such as utilizing the block grants, 
as well as continued use of the single state authority as the 
central coordinating entity; sustainability to allow for the 
continued relationship fostering, stigma reduction, and 
integration of services.
    Moving an entire system of care is a monumental task. We 
are working diligently and we've made staggering progress. But 
please don't give up. The long-term success of our programs and 
communities depends on sustained funding and support.
    Just two other quick considerations would be to address 
stigma in a more uniform way across the nation through language 
and action, and to seek ways to address the dire workforce 
shortage challenges experienced by every state.
    Thank you again for allowing me to share what Pennsylvania 
is doing and our suggestions for moving the system forward. I 
look forward to answering any questions you may have.
    [The prepared statement of Ms. Smith follows:]
    
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

   
    
    [
    Ms. DeGette. Thank you so much. And don't worry, we don't 
intend to give up.
    Dr. Bharel, you are recognized now for 5 minutes.

                TESTIMONY OF MONICA BHAREL, M.D.

    Dr. Bharel. Chair DeGette, Ranking Member Guthrie, and 
members of the subcommittee, thank you for the opportunity to 
speak with you today.
    In my role as Commissioner of Public Health and as the 
state's chief physician, I am dedicated to addressing the 
opioid epidemic in Massachusetts. I commend Congress and our 
federal agencies for funding those working tirelessly on the 
front lines every day.
    Our data indicates that in Massachusetts our public health-
centered approach to the opioid epidemic is working. I'm 
heartened to let you know that from 2016 to 2018, our opioid 
overdose deaths have declined by four percent. We continue to 
focus on prevention and education, naloxone availability, 
medication treatment, behavioral health counseling, and 
sustained recovery support.
    We have made progress, but it's still unacceptable that 
nearly 2,000 individuals in Massachusetts die from this 
preventable disease each year.
    In my clinical practice, I cared for people with this 
disease. And I will never forget that behind these numbers, 
which we will talk about today, are real people, their 
families, and their communities.
    Since 2016, we have been awarded approximately $159 million 
in federal funding specific to opioid use disorder prevention, 
treatment, and recovery. And we've allocated approximately $111 
million of those funds.
    We've used federal funding to support expansion and 
enhancement of our treatment system through a data-driven 
approach that targets high-risk, high-need priority populations 
and disparities, with a goal of reducing opiate overdoses and 
deaths.
    In 2015, Governor Baker appointed a working group who 
developed an action plan emphasizing data to identify hotspots 
and deploy appropriate resources. Additionally, a law referred 
to as the Public Health Data Warehouse enabled us to link 28 
different data sets across state government and establish a 
public-private partnership to maximize the use of data to study 
this major public health crisis. This is unprecedented in 
Massachusetts.
    So, our approach started with data analytics and research, 
allowing us to gain a deep understanding of who is dying, where 
and why, so that new investments could be strategic and 
impactful. Our data led us to quickly focus our efforts on five 
key populations that we saw were still suffering from overdoses 
and overdose deaths:
    Persons released from incarceration, communities of color, 
persons with co-occurring mental health and substance use 
disorders, people with a history of homelessness, and mothers 
with opioid use disorder.
    Our data showed, in fact, that the rate of opioid overdose 
death for mothers with opioid use disorder was more than 300 
times higher for mothers without it. In response, one of the 
programs we set up was Moms Do Care, which is currently 100 
percent federally funded. This innovative approach built a 
seamless, integrated continuum of care for pregnant and 
parenting women with substance use disorder.
    It provides access to medication, prenatal and postnatal 
care, maternity and pediatric care, behavioral health 
counseling, and peer-to-peer recovery supports, and so much 
more.
    With federal funds, we are also supporting and expanding 
our prescription drug monitoring program, allowing all 
Massachusetts prescribers enhanced access to this vital system.
    While we have had many successes, we do see opportunities 
for federal assistance so we can continue to make progress. 
This includes funding that is flexible. When funding 
requirements restrict us to addressing only opiates, states are 
limited in our flexibility to address the changing landscape of 
substance use disorder. Flexibility would enable us to address 
other substances connected to this epidemic, such as cocaine 
and methamphetamine.
    Additionally, there are currently federal barriers to 
medication-assisted treatment such as methadone and 
buprenorphine, and these barriers should be removed. This would 
allow medication-assisted treatment to be regulated more 
similarly to other chronic disease treatments, and available in 
traditional healthcare settings to increase access and reduce 
stigma.
    In conclusion, we are grateful to Congress for the 
commitment to address this opioid epidemic. Much of our 
progress can be attributed to federal funding we receive. And I 
encourage Congress to continue these critical funding efforts. 
This crisis did not build overnight; and it will take time to 
reverse.
    Addiction is not a choice; it is a disease. And with the 
continued support of our federal partners, we will build a 
solution to tackle this epidemic in Massachusetts and this 
country.
    Thank you.
    [The prepared statement of Dr. Bharel follows:]
    
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    Ms. DeGette. Thank you so much.
    Ms. Mullins, you are recognized now for 5 minutes.

                 TESTIMONY OF CHRISTINA MULLINS

    Ms. Mullins. Thank you. Chairwoman DeGette, Ranking 
Members, and members of the subcommittee, my name is Christina 
Mullins, and I am the Commissioner for the Bureau for 
Behavioral Health within the West Virginia Department of Health 
and Human Resources. And I also serve as a member of the 
National Association of State Alcohol and Drug Abuse Directors.
    First, I want to thank you for your commitment to address 
this crisis. Without the resources provided by this Committee, 
West Virginia would be in a considerably worse position.
    I also want to thank you for the opportunity to discuss the 
importance of the initiatives in West Virginia to address the 
opioid crisis and the impact of the funding made available 
through this Committee to promote prevention, treatment, and 
recovery for substance use disorder.
    It is no secret that West Virginia has been Ground Zero of 
the opioid crisis, with the highest overdose rate in the 
nation. There are award-winning documentaries and Pulitzer-
Prize winning stories that describe what happened to our state. 
And I am sure these efforts have played a significant role in 
bringing much-needed resources to West Virginia. But today, I 
would like to tell you a different story.
    With your help, West Virginia has reduced overdose deaths 
for the first time in over ten years. Both opioid prescriptions 
and opioid doses have decreased by about 50 percent, while 
naloxone prescribing has increased by 208 percent. 
Additionally, we have distributed over 10,000 doses of naloxone 
to local health departments.
    Treatment capacity has been transformed. The number of 
people that can prescribe buprenorphine has more than doubled, 
from 243 to 584 since 2017. We have increased the number of 
residential treatment beds from 197 to 740. And our records 
indicate that those beds are about 85 percent full at about all 
times.
    Additionally, nearly all birthing facilities have access to 
integrated substance use disorder treatment in their community. 
This extraordinary increase in infrastructure and capacity is 
the result of a significant financial investment of federal, 
state, and drug settlement funds.
    West Virginia leveraged federal investment to increase 
outpatient treatment capacity, increase the number and quality 
of its workforce, distribute lifesaving naloxone, conduct 
rigorous provider education on opioid prescribing, increase 
evidence-based prevention programs and stood up quickly 
response teams to follow up on individuals who experience non-
fatal overdoses.
    In addition to these efforts, the state also increased its 
infrastructure for surveillance and data analysis. And this 
work drives all of our programmatic decision-making.
    The state complemented the work of its federal projects by 
using settlement funds and general revenue to undertake the 
development of construction projects that expanded the 
availability of residential treatment, including facilities 
that specialize in pregnant and postpartum women. The scope of 
this problem required a historic financial investment to 
adequately respond to this crisis.
    Rating funding sources allowed West Virginia to balance the 
need for immediate intervention and services with the long-term 
need to address the systemic issues that serve as an ongoing 
challenge to the state's opioid response.
    While significant progress has been made, certain barriers 
and challenges remain. West Virginia continues to experience 
substantial workforce shortages. Gaps in training related to 
psychostimulants and polysubstance use, and a lack of capacity 
to serve children impacted by this crisis.
    In addition, a key concern when utilizing time-limited 
grant dollars is sustainability of effort in thinking about a 
bigger longer-term investment of these endeavors or to have a 
continuing impact in increasing treatment availability and 
reducing overdose deaths. The predictable and sustained 
provision of resources is key to allow states and providers to 
plan and rely on future year commitments. It can be tough to 
successfully plan and operate programs if providers are not 
confident resources will be available beyond a 1-year 
commitment.
    It would be difficult to believe that West Virginia could 
have accomplished so much without the support of this 
Committee. These funds have allowed West Virginia to have the 
resources that it needed to respond to this crisis, and 
resulted in a decrease in overdose deaths, and transformed our 
system of care. Our overdose deaths are down at this point, our 
records say, by ten percent.
    The financial resources are crucial to our continuing 
success and maintaining momentum. Ongoing funding for state 
alcohol and drug agencies to coordinate substance use 
prevention, treatment, and recovery services at the state level 
will ensure continued progress.
    While barriers remain, West Virginia is better poised to 
address future challenges and continue its forward progress.
    In summary, West Virginia wishes to say thank you to this 
Committee, SAMHSA, and CDC. Thank you for your support. Thank 
you for the resources. And thank you for allowing us to share 
what is happening and what is working in West Virginia.
    [The prepared statement of Ms. Mullins follows:]
    
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    Ms. DeGette. Thank you.
    Now, Mr. Kinsley, I would like to recognize you for 5 
minutes.

                   TESTIMONY OF KODY KINSLEY

    Mr. Kinsley. Good morning. Thank you, Chair DeGette, 
Ranking member Guthrie, and the honorable members of the 
subcommittee for this opportunity to testify on North 
Carolina's response to the opioid epidemic.
    On behalf of the 10.4 million North Carolinians, 
approximately 426,000 of whom misuse prescription or illicit 
opioids; I want to express my deepest gratitude, for your 
support of funding that has helped us turn the tide on the 
epidemic. This investment has saved lives, transformed 
communities, and has made the downpayment on breaking the cycle 
of addiction, trauma, and poverty in our state.
    I'm also grateful to the committed staff of numerous 
federal agencies that have worked quickly to support a 
concerted strategy, working across interconnected systems of 
healthcare, housing, employment, and justice.
    North Carolina was hit hard by the crisis. In 2016, 1,407 
North Carolinians died of an unintended opioid overdose. For 
each death, there were six overdose hospitalizations. And we 
were one of the top eight states for fentanyl overdose deaths.
    Since the start of the epidemic, nearly 100,000 workers 
have been kept out of the workforce because of the opioid 
misuse alone. Today, close to half of the children in North 
Carolina's foster care system have parental substance use as a 
factor in their out-of-home placement. And, of course, the 
human cost, the loss to communities and families, is 
immeasurable.
    The scale of the problem underpins our magnitude of 
accomplishment. Our state's comprehensive response, the North 
Carolina Opioid Action Plan, is organized into three pillars: 
prevention, harm reduction, and connections to care.
    These pillars encompass numerous strategies; all made 
possible because of federal funding: cutting the supply of 
inappropriate opioid prescriptions; making access to lifesaving 
naloxone ubiquitous; supporting syringe exchange programs; 
making addiction medicine a core of medical education; 
partnering with county and local communities; launching 
interventions at the starts of treatment that start treatment 
at the time of overdose reversal; and blending together broader 
efforts to support recovery in the housing, employment; and 
address the root causes of substance use disorder.
    With these efforts, North Carolina saw the first decline in 
deaths in five years, decreasing nine percent between 2017 and 
2018. We have also seen a 24 percent decline in opioid 
prescribing, and a 20 percent increase in the number of 
uninsured individuals receiving treatment.
    One million North Carolinians do not have health insurance. 
And half of the opioid overdose visits to the emergency room 
are uninsured. Therefore, our highest priority has been 
expanding evidence-based treatments to those without insurance.
    We have focused on medication-assisted treatment as the 
gold standard of care, providing treatment to an additional 
12,000 people.
    Our success is clear, but with your help, there is much we 
can do. We could stretch grant fathers--grant dollars further 
if doctors were no longer required to obtain a separate DEA 
waiver to prescribe buprenorphine for addiction. There is no 
additional waiver requirement to prescribe the exact same 
medication that is being prescribed for other conditions.
    We should strengthen our focus on justice-involved 
populations. A recent study found that exiting North Carolina 
prisons were--prisoners leaving North Carolina prisons were 40 
times more likely to die of an opioid overdose than the general 
population. We are grateful to have recently received a $6.5 
million grant from the Department of Justice to create pre-
arrest diversion programs and expand jail-based treatment in 
our state. But, with 56 prisons and 96 jails, we have a long 
way to go.
    But most significant of all would be giving us more time. 
Sustaining funding over longer windows of time, or permanently, 
would allow states to ready systems for the next waive of the 
epidemic. That waive is already cresting, as we are starting to 
see rising rates of overdose deaths from methamphetamine and 
benzodiazepine.
    Before major federal funding for this epidemic became 
available, 12,000 people in North Carolina had already died. 
Meanwhile, North Carolina's share of the substance abuse, 
prevention, and treatment block grant has not changed in recent 
years, while North Carolina was one of the fastest-growing 
populations in the country, growing nine percent between 2010 
and 2018.
    Growing the block grant at pace with population and 
inflationary costs, and an updated allocation formula would 
allow states to make better use of short-term funding, prevent 
the next epidemic, and save lives.
    Most of all, safeguarding Medicaid expansion and the 
Affordable Care Act is critical to our long-term success in 
fighting the opioid epidemic. States with higher rates of 
insurance coverage have a more sustainable way of providing 
treatment, and are able to prioritize their precious federal 
block grant dollars and opioid response grants on system 
investments. This is why we are working hard every day to 
expand Medicaid in North Carolina.
    In closing, I want to applaud the flexibility of much of 
the federal funding we have received, which has allowed each 
state to respond to its own pressing needs. Our strategies are 
working, but our eyes are on the horizon. We appreciate your 
leadership. And I welcome your questions.
    [The prepared statement of Mr. Kinsley follows:]
    
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    Ms. DeGette. Thank you.
    Dr. Alexander-Scott, you are now recognized for 5 minutes 
for your opening statement.

           TESTIMONY OF NICOLE ALEXANDER-SCOTT, M.D.

    Dr. Alexander-Scott. Thank you. Chairwoman DeGette, Ranking 
Member Guthrie, and distinguished members of the Committee, 
thank you for inviting me to join you today to discuss Rhode 
Island's efforts to address the opioid overdose epidemic.
    Collaboration between states, federal agencies, and federal 
leaders such as yourselves is critical to our shared goals of 
preventing overdoses and saving lives.
    This issue has taken a staggering toll on my state. Since I 
became the Director of the Rhode Island Department of Health in 
2015, an overdose death has occurred in every city and town in 
Rhode Island. During this time, more Rhode Islanders have lost 
their lives to drug overdoses than to car crashes, firearms, 
and fires combined.
    Almost immediately after coming into office in 2015, 
Governor Gina Raimondo formed an Overdose Prevention and 
Intervention Task Force to develop a centralized, strategic, 
data-driven comprehensive plan to prevent overdoses. The task 
force includes stakeholders and experts in various fields, 
including public health, law enforcement, behavioral health, 
community-based support services, education, veterans' affairs, 
and recovery.
    As a co-chair of this task force, I have helped steer our 
efforts into our four focused areas: prevention, treatment, 
recovery, and rescue or reversal. We have changed the culture 
of prescribing in Rhode Island and have dramatically reduced 
our prescribing numbers.
    We now have a vast statewide treatment network in place.
    We have cultivated a group of certified peer recovery 
specialists who work side-by-side with people in recovery.
    We have put thousands of naloxone kits onto the streets.
    And, most importantly, we have started to give people hope. 
And we're focusing at the community level.
    We have learned that regardless of your race or ethnicity, 
regardless of your ZIP Code, income, or insurance status, every 
door for every person should make treatment and recovery 
services available. We believe that addiction is a disease, and 
recovery is possible.
    One prime example is the story of Jonathan Goyer from East 
Providence, Rhode Island. Jonathan became dependent on opioids 
at 15 years of age. At 25, after more than 30 tries, and after 
reaching depths that many of us could not fathom, he was 
finally able to find, sustain, and maintain a life in long-term 
recovery.
    He is now thriving as an expert advisor to Governor 
Raimondo's task force, and he leads our state's recovery-
friendly workplace program.
    When you talk to Jonathan about his journey, he says, ``The 
opposite of addiction is not sobriety. The opposite of 
addiction is connection.'' This is true for every community.
    We are trying to make the connection and the sense of 
community that brought Jonathan and so many others back from 
the brink a part of every overdose prevention effort we put in 
place in Rhode Island. We have had some success.
    After the number of drug overdose deaths increased each 
year in Rhode Island for the better part of a decade, that 
number decreased by 6.5 percent between 2016 and 2018. However, 
significant challenges remain. Fentanyl-related overdose deaths 
continue to increase. And the opioid conversation must be 
considered within the larger context of an addiction epidemic 
that has alcoholism, tobacco use, cocaine use, and other 
substances involved.
    We can broaden the scope even further to talk about the 
health implications of social and emotional isolation, and the 
need to address the root causes of these challenges in our 
community. All of this requires us to look beyond what many 
believe to be our traditional focus areas in public health.
    We need to look at the socioeconomic and environmental 
determinants of health which determine roughly 80 percent of 
what makes you healthy and what makes me healthy. These are 
factors like access to quality education, access to fresh 
fruits and vegetables, and reliable transportation.
    We need to ensure that all children grow up in homes and go 
to schools where they feel safe, supported, and loved; to 
ensure that people have the houses that are healthy, safe, and 
affordable; and to ensure that people have jobs that offer fair 
pay. This is a part of our response.
    The efforts and the progress that I've outlined today would 
not have been possible without the tremendous contributions of 
Congress and the federal agencies you fund. I thank you for 
that sincerely. I look forward to partnering with you to 
address what lies ahead on behalf of Rhode Island and on behalf 
of the Association of State and Territorial Health Officials, 
where I served as immediate past president.
    Thank you.
    [The prepared statement of Dr. Alexander-Scott follows:]
    
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    Ms. DeGette. Thank you so much, Doctor.
    It is now time for members to ask questions. And the Chair 
will recognize herself for 5 minutes.
    As I mentioned in my opening statement, and as many of you 
mentioned--and thank you--the Committee has really been 
focusing on the opioid epidemic for quite some number of years. 
And this subcommittee, in particular in the last few 
Congresses, I was the ranking Democrat, now I am the chair, but 
it has been a real bipartisan effort over the years to help 
address this crisis.
    And, ultimately, under, of course, a number of pieces of 
legislation and the 21st Century Cures Act which Congressman 
Upton and I sponsored, we provided the states with a 
considerable amount of funds to address substance abuse. And 
so, we are happy to see that some of those funds have been used 
as part of your efforts.
    But several of you mentioned that we need to give more 
flexibility to the states to address; I believe, Ms. Smith, you 
said to address the system, not the substance. And I'm 
wondering if some of you can talk about what we need to do to 
give that flexibility as some of the substances shift.
    Ms. Smith, do you want to expand on that a little bit?
    Ms. Smith. Yes, I'd be happy to. Thanks for asking that 
question.
    And this goes to in many of your opening remarks you 
mentioned about the polysubstance use and the increase in 
particularly methamphetamine and cocaine that many states 
across the nation are seeing. And I think one of the challenges 
has been for us, with the funding being so focused on opioids, 
it's been a little bit challenging depending on the types of 
programs that we wanted to establish in making sure that we 
were appropriately tying it to opioids, while at the same time 
recognizing that some folks who benefit from the program may 
not identify opioids as their primary substance, or even 
identify them at all as a substance that they're utilizing.
     Ms. DeGette. Do you think that that is getting more, more 
noticeable, that people are moving from opioids?
    Ms. Smith. Absolutely.
    Ms. DeGette. Mr. Kinsley, you are shaking your head yes. 
Are you seeing that as well?
    Mr. Kinsley. Absolutely we're seeing that in North 
Carolina. And I think that in North Carolina, the substance 
abuse prevention and treatment block grant is the only real, 
sustainable tool we have to build the workforce and build the 
treatment sources for those individuals to go to to get ahead 
of the problem.
    Ms. DeGette. Dr. Alexander-Scott, you talked a lot about 
what Rhode Island is trying to do. What about this crisis are 
you dealing with now that you weren't able to see a couple of 
years ago? Are there some new things that you're seeing now?
    Dr. Alexander-Scott. Certainly, the increase in the percent 
of fentanyl with overdose deaths that are occurring.
    We are seeing, also, an increase in polysubstances, and 
multiple substances involved with overdose deaths. And we 
recognize the importance of going upstream more, to really get 
at the root causes of what is driving many of the challenges 
associated with both mental health and substance use.
    Ms. DeGette. And do you think that the federal, the 
language with some of the federal funds you are getting is too 
restrictive for trying to address some of those issues?
    Dr. Alexander-Scott. There is opportunity to be more 
deliberate in allowing for the flexibility so that we can look 
more upstream and engage more at the community level.
    Ms. DeGette. Ms. Mullins, what would you say the key 
challenge you are facing, your state is facing right now with 
addiction?
    Ms. Mullins. Right now, my key challenge is a workforce. I 
do not have enough people to deliver the treatment that is 
needed for the state. We could open more days for prescribers, 
but we do not have the therapists to be able to support that 
prescribing.
    Ms. DeGette. And Dr. Bharel, I wanted to ask you, in your 
written testimony, you said that Massachusetts utilized federal 
funding to support expansion and enhancement of our treatment 
system. Can you tell me specifically about how the federal 
funds enabled you to do that?
    And what could be done more if you had more flexibility?
    Dr. Bharel. Absolutely. Thank you for your leadership in 
this area. What we have been doing in our public health 
approach to this opioid epidemic is focusing on, of course, 
prevention and intervention, but really enhancing our treatment 
system.
    And as has been said before, what we're dealing with now, 
many of us, is trying to build a system in a place that where 
for behavioral issues in general, for many, many decades have 
been underfunded. So, we're really trying to build up systems 
of care so that these individuals can get the treatment that 
they need.
    We have used some of our federal funding to enhance 
treatment opportunities, including increasing our treatment 
beds within our system to over 1,200, including increasing 
training and availability of office-based opioid treatments, 
and enhancing the availability of methadone through opioid 
treatment programs.
    Ms. DeGette. Thank you. So, I just want to, again; I want 
to thank all of you for your efforts and let you know this 
Committee and the full Energy and Commerce Committee is 
committed to helping make the maximum flexibility.
    I will remind you that in the recent federal 2020 
government funding bill, Congress continues to invest $1.5 
billion in SAMHSA's state opioid response grants. And so, in 
response to the changing drug abuse landscape, we allow 
grantees to use this funding to address stimulant use. But if 
there is more we can do, please let us know, because you, we 
want you to consider ourselves to be your partners with that.
    I will recognize Mr. Guthrie for 5 minutes of questioning.
    Mr. Guthrie. Thank you very much. I appreciate it. And 
appreciate you all being here and telling your stories. And 
talking about bipartisan, you asked a lot of the questions that 
I had originally. So, moving forward, and you all have answered 
them well.
    And I guess one thing I want to get at, flexibility. And I 
remember when we did the markup on I guess it was the SUPPORT 
Act, or it might have been the Comprehensive Recovery Act, but 
our colleague on the Committee Bobby Rush, I don't know if he 
had an amendment or he just made a point, that different 
communities have different, different issues. And opioids are 
in every community. He was speaking specifically on his.
    I remember the discussion being on there are X amount of 
resources we are going to--we are focusing on here. And I guess 
my hope is as you bring more workers, using the money you can--
you can't always use the opioid money, for somebody on another 
substance, but it helps you build the infrastructure that has 
the same kind of moving forward. And we do need to open up and 
look at that. That is something I think we absolutely need to 
look at.
    Something that was interesting to me is that as we were 
having our hearing, it was a hearing or a roundtable; we had a 
couple, we had some that had passed away. We had some members 
who experienced that. And they talked about the patient 
brokering. And I just walked away with this appalling that 
there seem to be, not any states that you represent, but he was 
in a state and was just being sent from one broker to the 
other.
    And I know a couple of you guys, a couple of states have 
looked at that. And I think Dr. Alexander-Scott, Rhode Island, 
has looked at patient brokering. So, it is my understanding 
that Rhode Island certifies recovering housing and started this 
certification two years ago.
    Can you talk about the certification process, why Rhode 
Island started it, and about how many recovery homes you have 
certified?
    Dr. Alexander-Scott. Yes, thank you.
    Well, I will be happy to provide additional information to 
support this. Our sister agency, the Department of Behavioral 
Health Care, Developmental Disabilities, and Hospitals, 
recognized the importance of having social determinants of 
health addressed, such as housing. And recovery housing is a 
critical tool for supporting those living the lives of 
recovery, like Jonathan that I mentioned earlier.
    We wanted to make sure that there was a level of quality 
and standards across all of the recovery houses that were 
available. And this sister agency in Rhode Island oversees the 
certifications to help establish those standards.
    I can get back to you on the official number that we have 
of recovery houses that are available. But this has been a 
quality and data-driven program that we have felt to be 
critical to supporting this opioid epidemic.
    Mr. Guthrie. OK, thank you.
    Also, I think, Pennsylvania, it is my understanding that in 
the last year, Pennsylvania passed legislation that enables the 
Department of Drug and Alcohol Programs to regular and license 
recovery housing that receives federal funding. Can you talk 
about why you needed to do this, and the effect of it, and when 
it goes into effect?
    Ms. Smith. Yes, absolutely. I mean, I think it was passed 
by the legislature and our governor for the same reasons that 
it was in other states like Rhode Island. We were definitely 
identifying issues both through parents, through advocacy 
groups, through individuals who were attending recovery housing 
events and noticing that there seemed to be some 
inconsistencies with practices. And so, we felt it was really 
critical to pass some kind of legislation that enables us to 
have some oversight of these entities.
    What's interesting is in Pennsylvania, we don't really know 
the exact number of current recovery houses operating. We know 
that it's in the thousands. And so, what this legislation will 
enable us to do is create regulations so that any house that 
receives referrals or funding from state or federal entities 
will have to be licensed by our department.
    So, it won't require that every recovery house in 
Pennsylvania be licensed, but the hope is that folks are 
utilizing the Web site that contains the licensing information 
to utilize those licensed entities that they know have some 
level of quality services. And maybe it will reduce business at 
some of the more scrupulous entities.
    Mr. Guthrie. OK, thank you.
    I have a cousin who is a neonatologist. And he never talks 
about any individual patient but just the issue in general when 
we talk a lot about this. And so, I know that for the opioid 
mother, the neonatal abstinence syndrome, so I--and I only have 
a few seconds--so maybe one of you, have any of you used 
federal dollars for neonatal abstinence syndrome? And has that 
reduced it in your state?
    And whoever wants to go first. Probably one of you has time 
to answer. Is anybody working with that specifically?
    Ms. Mullins. West Virginia is working very specifically to 
provide treatment to women affected by a substance use 
disorder. It doesn't--the treatment itself sometimes can 
increase neonatal abstinence syndrome with the use of 
medication-assisted treatment. But our babies are being born 
healthier. Their birth outcomes are better.
    So, we're really optimistic that with continued effort 
there, we can make more progress.
    Mr. Guthrie. Thank you. I yield back.
    Ms. DeGette. The Chair now recognizes Mr. Pallone for 5 
minutes.
    Mr. Pallone. Thank you, Madam Chair.
    As Congress and the Committee consider further action on 
the opioid crisis, I would like to hear more about how federal 
funds have been used to make a difference. And based on the 
states' submissions to the Committee, which I mentioned in my 
opening, it appears several states have successfully used 
federal funds to respond to the crisis.
    So, let me see how many I can get through here.
    Mr. Kinsley, in your testimony, you noted that federal 
funding had enabled North Carolina to provide opioid use 
disorder treatment for 12,000 uninsured people. In the same 
testimony, you mentioned that, and I quote, ``Since 2016, when 
the first of the major federal bureau grants were received, 
North Carolina saw its first decline in opioid overdose deaths 
in five years, decreasing nine percent from 2017 to 2018.''
    So, what factors do you attribute to North Carolina's 
success in reducing overdose deaths and providing treatment to 
people who really need it?
    Mr. Kinsley. Thank you. Our focus has been 100 percent on 
medication-assisted treatment and naloxone distribution in 
communities. I believe the naloxone distribution has been 
directly tied to the halt in deaths and the reduction in deaths 
that we have seen.
    And after that, important programs that have linked 
individuals into care have been able to sustain that treatment 
and move individuals in recovery. Programs like Peer Support 
Specialists, individuals who are in recovery themselves, we 
place them in emergency departments.
    We've worked with our local EMS providers to actually 
induct people into treatment, so that if an individual who has 
an opioid reversal through an EMS visit does not want to go to 
the hospital, they can actually begin their treatment then. And 
there's a follow-up group of folks that come out and see those 
individuals after the fact.
    There's been a lot of very scaled, very strategic focused 
interventions like that that have moved people into recovery 
and into the treatment pipeline that have been really important 
for us in North Carolina.
    Mr. Pallone. Thanks.
    Let me go to Ms. Smith. I was encouraged to hear from your 
testimony that Pennsylvania has witnessed an 18 percent 
decrease in overdose deaths from 2017 to 2018. So, what factors 
do you attribute the reduction to?
    And what are the few key areas that Pennsylvania should 
focus on to continue that trend, if possible?
    Ms. Smith. Yes. I think the keys for us are not all that 
different, actually. A big focus on getting naloxone into 
communities. Big focus on what we call a warm hand-off process, 
which is getting overdose survivors from the hospital into 
treatment.
    We had a major issue in our hospitals and health systems 
with individuals overdosing and then being quickly released 
back out onto the street to overdose again repeated times.
    So, I think those two things have been key for us. I think 
moving forward, what we'd like to do is spend a little bit more 
time and energy in the prevention space trying to prevent 
before we get to worrying about needing naloxone and needing to 
activate the warm hand-off process.
    But our primary focus was really keeping people alive. Now 
that we've started to get a handle on that through naloxone, 
and warm hand=off, and expanding treatment, now I think we can 
spend some time and energy really thinking about looking 
upstream and how do we improve our prevention efforts.
    Mr. Pallone. OK, thank you.
    Let me go to Dr. Alexander-Scott with regard to Rhode 
Island's response to the Committee. You noted that federal 
funds had enabled the state to improve data, and surveillance, 
and treatment capacity, and support innovations in delivery and 
treatment.
    Can you give us some specific examples of how federal funds 
have helped Rhode Island in those areas?
    Dr. Alexander-Scott. There are multiple examples, similar 
to what has been mentioned.
    Since you asked about data specifically, we use data in as 
real-time as possible. We obtain 48-hour reporting from our 
emergency departments for any suspected or actual overdose that 
has occurred. And on a weekly basis we have a cross-agency team 
that assesses where overdoses are, GIS-mapped across the state. 
And we release advisories to municipalities, key stakeholders, 
and providers to focus their areas when the overdose deaths 
have increased beyond a certain threshold.
    That allows us to drive out the resources and services that 
we have based on data in real-time at the local level, which is 
one example.
    We continue to expand treatments and recovery services with 
the intention of meeting people where they are. So, going out 
to reach folks through a mobile recovery and treatment vehicle 
is another example.
    Mr. Pallone. Thank you.
    I don't know if I can get West Virginia in. Ms. Mullins 
noted that the state treatment system has been completely 
overhauled in response to the opioid crisis, and much of the 
positive work to date has occurred with and was made possible 
as a direct result of the federal funds awarded since 2016.
    Do you want to give us briefly some examples of how federal 
funds have let West Virginia provide treatment and recovery 
services, particularly in rural and financially-disadvantaged 
parts of the state, if you could?
    Ms. Mullins. Specifically really, it has given us the 
ability to expand our clinical providers who could provide MAT.
    We now have people in all of our 55 counties able to 
receive MAT. And then we have prescribed in, located physically 
in most counties. That's been the number one success we really 
experienced with the federal funds.
    Mr. Pallone. Thank you.
    Thank you, Madam Chair.
    Ms. DeGette. Thank you.
    The Chair now recognizes the gentleman from Oregon for 5 
minutes.
    Mr. Walden. Thank you, Madam Chair. And thanks again for 
the hearing. And to our witnesses, thanks for your 
participation as well.
    I want to start with a question about transportation 
issues. It is a big problem in districts like mine. Just to put 
it in perspective, mine would stretch from the Atlantic to 
Ohio, bigger than almost any state east of the Mississippi. At 
my roundtables for the 2nd District of Oregon, 2017, I heard 
from a witness in Hermiston. She had to travel five hours to 
another state, Washington State, just to find a provider who 
would help her with treatment and get her off of her addiction.
    For each of the witnesses, what is your state doing to 
address access to treatment faced by rural patients where there 
is no local help? If you could be kind of brief on that, 
because I have another one on 42 CFR Part 2 I want to get to as 
well.
    So, if anybody wants to weigh in on how to help in the 
rural areas. Yes, sir.
    Mr. Kinsley. Thank you for the question. North Carolina has 
100 counties. We have, we are dosing currently about 20,000 
people a day at our opioid treatment programs. I think our 
largest two strategies to address rural access has been first 
and foremost moving as much care into office-based outpatient 
treatment programs as possible. That's why we'd love to see the 
DEA X waiver requirement removed to try to make that easier.
    We've doubled the number of physicians in North Carolina. 
We have a long way to go. We're not going to get large-scale 
OTP providers there.
    The second, we've been heavily investing in Project ECHO, 
which is leverage our ability to try to train providers to give 
them the support they need to take on these patients.
    Mr. Walden. Yes, we, as you know, in the SUPPORT Act 
expanded who could administer Suboxone and other treatments.
    Anybody else want to weigh in on this?
    Ms. Smith. Yes, I'd be happy to very quickly.
    So, Pennsylvania is really fortunate in that we have a 
large number of opioid treatment providers already in the 
state. So that's an advantage for us. But beyond that, to 
assist rural communities, we have a particular RAMP grant we 
call it, Rural Access to Medication, where we are expanding 
access to medication-assisted treatment in rural areas thanks 
to the grant from the Federal Government.
    As well as we've offered a loan repayment program for 
practitioners in areas that are hard hit by the opioid epidemic 
but also have workforce shortages, which you can imagine is 
mostly rural areas. And the commitment for that loan repayment 
program is that you have to have two years of experience 
treating SUD patients, and you have to commit to an additional 
two years of treating in that area.
    Mr. Walden. Ah, an incentive to stay. OK.
    I want to move on to this 42 CFR Part 2 issue, the 
confidentiality of alcohol and drug abuse patient records.
    I heard a lot from providers about how this impacts 
negatively the effective exchange of information regarding 
individual substance use disorder treatment and there are other 
health issues. We passed legislation in the House 
overwhelmingly to try and address this, protect patient privacy 
but allow the right flow of information to other medical 
providers. Tragically, it went up on the rocks in the Senate. 
And I would like to see us renew our efforts here.
    Can you all tell me briefly just are you seeing patients 
impacted by this? I sure heard it from providers in my 
district.
    Yes, Doctor?
    Dr. Bharel. In Massachusetts, we provided comments related 
to a 42 CFR and some of the obstacles that that produces. As we 
have started to think about what is the next step or what needs 
to happen to fight this opioid epidemic, one of the issues is 
around appropriate behavioral health integration, both with 
mental health issues and substance use issues, as well as how 
to connect that to the medical care that an individual needs. 
And there are many aspects of 42 CFR that are an obstacle 
there.
    Mr. Walden. Did others run into this? Yes, Doctor?
    Dr. Alexander-Scott. The other place to be aware of where 
it may be considered is within the school system, making sure 
that school nurses and psychologists are able to exchange the 
information needed to care for children who have mental health 
or even substance use challenges.
    Mr. Walden. OK. Do others want to comment on this?
    Mr. Kinsley.
    Mr. Kinsley. North Carolina is fully supportive of 
modernizing 42 CFR in an attempt to both maintain privacy but 
also move us to integrated care. I think what's important is 
that we have to also systematically address stigma to help 
reduce----
    Mr. Walden. Right.
    Mr. Kinsley [continuing]. The systematic exclusion of 
individuals from employment, housing, and everything else that 
they experience as well.
    Mr. Walden. Exactly. Anyone else? Ms. Smith?
    Ms. Smith. He said exactly what I was going to say, that 
really addressing stigma----
    Mr. Walden. He was looking at your notes, I think.
    Ms. Smith [continuing]. Has to be, has to be the primary 
concern here, you know.
    Mr. Walden. Yes.
    Ms. Smith. I think it's important to protect those 
individuals----
    Mr. Walden. Absolutely.
    Ms. Smith [continuing]. Who suffers from this disease. But 
at the same time, I don't know how we move to a truly 
integrated system of care when we treat their record 
differently.
    Mr. Walden. Right.
    Ms. Smith. We keep talking about treating them the same as 
everyone else. Treat them the same as someone who has heart 
disease or diabetes, but access their medical record.
    Mr. Walden. Right.
    Ms. Smith. I think we need to change that conversation.
    Mr. Walden. This has led to death. So, we need to fix this.
    I hope we can, Madam Chair, renew this effort to pass 
reform here. I know the Administration's done some things they 
could within the existing law, but I don't think that gets far 
enough. And you have been generous with the time.
    Ms. DeGette. This is an issue we have been working on for a 
long, long time in this Committee. And we do need; we do need 
to find a resolution.
    Mr. Walden. Thank you, Madam Chair.
    Thank you to all of you.
    Ms. DeGette. The Chair now recognizes the gentle lady from 
Illinois Ms. Schakowsky for 5 minutes.
    Ms. Schakowsky. Thank you, Madam Chair.
    In 2018, the overall rate of opioid overdose deaths in 
Illinois fell for the first time in five years. The decrease 
was likely impacted by the efforts of this Committee and 
Congress to combat the opioid epidemic. But, this trend was 
primarily driven by the decline in deaths among white 
residents.
    Today, in Illinois, opioid overdose deaths among blacks and 
Latinos continue to rise. In fact, my hometown of Chicago 
experienced more opioid overdose deaths than homicides in 2017. 
Of the 796 people who died from opioid overdose--opioid deaths 
that year, 400 were African American.
    And a recent study from the American Journal of Public 
Health found that black and Hispanic residents of Cook County, 
Illinois, were more likely to experience a fentanyl-involved 
overdose than whites. That doesn't square with the sort of 
public perception of the opioid crisis as a white suburban and 
rural issue.
    So, I wanted to ask you, Dr. Alexander-Scott, I know you 
have experience not only in your state but, as the president, 
former president of the Association of State and Territorial 
Health Officials, can you tell us how the Congress, how we can 
help states to address the overlooked racial disparity in the 
opioid epidemic?
    Dr. Alexander-Scott. Thank you so much for this question. 
It's such a critical issue for us.
     We in Rhode Island are also starting to take a more 
deliberate approach to addressing this by really making sure 
that we have the health equity lens in terms of how we are 
implementing our overdose prevention and intervention efforts. 
We have to make sure that every community that is impacted by 
this has the opportunity to have access to the treatment 
services, as well as continue to look upstream to address the 
root causes that exist.
    We cannot overlook the socioeconomic and environmental 
determinants that are occurring in various communities----
    Ms. Schakowsky. And I appreciate that. Congressman Guthrie 
raised this question to some extent as well. So, go ahead.
    Dr. Alexander-Scott [continuing].To be able to tackle this.
    The start is with what you have done, which is really 
expose the fact that different races and ethnicities are 
impacted by this epidemic in different ways. And we have to 
make sure that we are taking into account the cultural and 
socioeconomic and environmental influences that are 
contributing to why we have different outcomes, and really 
focus on addressing the root causes and making sure that the 
funding that you appropriate is able to take place at the 
community level and be driven by what the community needs to 
make the difference.
    Ms. Schakowsky. Thank you very much.
    Dr. Bharel, is that right? Your testimony mentioned, in 
your testimony, you mentioned that you are focusing on 
communities of color in your state responses. And so, what does 
that look like?
    Dr. Bharel. Yes, thanks for bringing up this important 
issue. One of our five areas where we found an increase in 
overdoses and overdose deaths is in our communities of color. 
So we have been using federal funds to assist us in those 
efforts. To give you an example, as we have all noted as, our 
opiate overdose deaths thankfully have begun to decline; from 
2016 to 2017, when we broke down our death data by race and 
ethnicity, we found that the only group still with an 
increasing rate of opiate overdose deaths was black men. So we 
have rerouted some of our efforts to be able to focus on 
communities of color. Just to give you a few examples, we redid 
some of our campaigns, including prevention campaigns to 
address different communities and provide them in different 
languages.
    Additionally, another example is we have a licensed 
addiction counselor program that we have now focused on Latino 
and African American members of our community so that more 
individuals can be trained and then go back to their 
communities to provide services.
    Ms. Schakowsky. Thank you. I think the statistics are just 
completely unacceptable in Chicago and a lot of metropolitan 
areas and especially among communities of color. And it would 
be a terrible mistake to go with just this overall data and not 
look at the particular communities. Thank you for responding to 
this question. I yield back.
    Ms. DeGette. I thank the gentle lady. I now recognized the 
gentlemen----
    Ms. Schakowsky. Oh, I wondered if I could offer something, 
something for the record as well, I forgot.
    Ms. DeGette. Well, what is it?
    Ms. Schakowsky. If I could put in the study that I 
mentioned. The geographic distribution of fentanyl involved 
overdose deaths in Cook County, in Cook County, Illinois. And 
U.S. News & World Report article titled ``Separate, Unequal, 
and Overlooked.''
    Ms. DeGette. Without objection, both items will be entered 
into the record.
    The Chair now recognizes the gentleman from Texas.
    Mr. Burgess. I thank the Chair for the recognition. Dr. 
Bharel, just briefly, Mr. Guthrie had talked a little bit about 
patient brokering. I will share with you some of the most 
troubling testimony we have had in this subcommittee on this 
issue was from your Assistant Attorney General, I think his 
name was Eric Gold, who came and testified to one of our 
oversight investigation subcommittees about sober homes that 
were located in other states. So his Massachusetts residents 
would be lured to other locations to have their treatment and, 
of course, all covered by my insurance with no real, 
identifiable metrics as to whether or not anyone was getting 
better. And in fact, I think he shared with us data that not 
only did they not get better, but he had had a number of deaths 
of Massachusetts residents that had happened as a result of 
being farmed out to a sober home.
    So, as a kind of follow-up to his testimony, is there 
anything that the--you is the state's sort of Chief Medical 
Officer, is there anything else that you can share with us 
about what he told us that day?
    Dr. Bharel. Absolutely, so the quality of care that our 
patients receive in this system is absolutely critical that we 
all make sure it reaches the highest standards for a very 
vulnerable population.
    There are several things we do at the state level. We take 
very seriously our responsibility to license and contract with 
all of the substance addiction services that we provide through 
the Department of Public Health. And through that licensing and 
contracting authority, which has recently been enhanced 
actually through Massachusetts law, we are able to set the 
criteria and have a feedback loop. We also respond to 
complaints, do re-licensing every two years, and can at any 
time go in to inspect a site.
    Specifically, in terms of sober homes, we now in 
Massachusetts have a voluntary, sober home certification 
program which must meet certain criteria and standards, and we 
have seen improvement and have over 2,000 beds in that system 
as well.
    Mr. Burgess. Very good about that and just to be clear, 
when Mr. Gold came and testified to us, he wasn't talking about 
sober homes within the state or within the Commonwealth of 
Massachusetts. He was talking about sober homes that might be 
in the more agreeable Southern climate, not that there is any 
more agreeable climate than Massachusetts in January, I am 
sure, but I have never experienced that. But that was the deal, 
that people would be--get lured, say OK, you can come to spend 
your winter in a sunny location and you all sort of lose 
control of the situation when that happens.
    So I guess what I am asking, are we doing any better as far 
as being able to communicate between states about when this 
type of activity happens when you lose a resident to addiction 
in another state? Is there some type of follow-up that is done 
on that?
    Dr. Bharel. So, I don't have any specific examples of 
patient brokering to give you, and I can have the Attorney 
General's Office follow up to see what they can provide.
    Mr. Burgess. Sure.
    Dr. Bharel. But I will say one of the things we need to do 
in our state if people are leaving is making sure that we have 
the facilities and the appropriate access to care in the state. 
And we have been working really hard on that.
    One really important success that many of us have in terms 
of cross-state communication is the prescription monitoring 
programs.
    Mr. Burgess. Sure.
    Dr. Bharel. And ours in Massachusetts, which now providers 
are required to use before prescribing opioids and 
benzodiazepines, is connected to 37 other states and 
Washington, DC. And that really helps understand care that 
individuals may have received in other states as well.
    Mr. Burgess. And of course, the whole NASPER program was a 
product of this Committee many, many years ago. I remember us 
working on it, as did we work on Project Echo when Orrin Hatch 
was over in the Senate Finance Committee. So thank you for 
mentioning Project Echo.
    And Mr. Kinsley, let me just ask you if I could, and Mr. 
Walden already addressed the 41 CFR Part 2 issue, but do you 
feel that within your state that your programs are able to 
share the appropriate addiction medical records so that they 
can coordinate care with people undergoing treatment for opiate 
use disorder, substance use disorder?
    Mr. Kinsley. The simple answer is no. We have invested a 
lot of resources through peer support and other tools to try to 
support that coordination of care, care management, et cetera, 
but there is still a huge limitation. And even doctors within 
the same systems can't easily talk to one another to coordinate 
care around their patients.
    Mr. Burgess. Again, I would just in agreement with Mr. 
Walden; I think we should redouble our efforts. We got 42 CFR 
Part 2 reform done on the House floor in 2018. We were not 
able--it didn't survive the Senate. So when President Trump 
signed the big bill into law, that part was removed. We need to 
continue to work on that because it is critically important.
    Thank you, Madam Chair; I yield back.
    Ms. DeGette. The Chair recognizes the gentleman from 
Massachusetts for five minutes.
    Mr. Kennedy. Thank you, Madam Chair. I want to thank the 
witnesses for being here today, your testimony. I want to thank 
our colleagues as well on this Committee for their attention.
    Dr. Burgess, you are welcome to Boston any time in winter. 
The weather might not be the warmest. The Super Bowl rings tend 
to warm you up, though, so we have had our share of those. 
Hopefully, it might be something you guys can experience some 
time soon. But we will move right along, Dr. Bharel.
    You sit on the Massachusetts Harm Reduction Commission, 
which in March 2019 recommended exploring the use of evidence-
based safe injection facilities or safe consumption sites. 
These sites are shown to reduce the risk of infection, improve 
public health outcomes, and increase outreach to treatment 
services. Safe injection facilities are supported by the 
Massachusetts Medical Society and the implementation of these 
sites is currently being explored by the Massachusetts State 
Legislature.
    So Dr. Bharel, can you elaborate a little bit about how the 
Harm Reduction Commission came to recommend highlighting 
evidence-based safe injection facilities. And additionally, as 
addressed briefly in the report, could you explain why the 
state-operated facilities do not violate federal law?
    Dr. Bharel. So thank you, Congressman, and thank you for 
your support of the work happening in Massachusetts and around 
the country.
    Talking broadly about the Harm Reduction Commission, first 
to address the safe injection facilities, these were reviewed 
and the evidence was reviewed, and a recommendation was to look 
at this further through our legislative process, and I 
understand there to be legal barriers both at the states and 
federal level.
    Talking about harm reduction broadly and what we currently 
have the capacity to do in public health, we have really been 
focusing our effort on the high-risk populations I have 
mentioned, and one of the important harm-reduction pieces 
including syringe service programs, we have expanded those in 
Massachusetts several years ago to less than 10 to over 30 now 
and have had markedly good response rates of not only 
collecting syringes, but also providing harm-reduction 
services, decreasing infections, and connecting people to care.
    One statistic that has been very helpful for individuals is 
that for every 100 syringes that are handed out, 120 are 
returned, so we are also cleaning our neighborhoods and 
communities as well, so we have a focused effort in that, as 
well as outreach to communities at highest risk.
    Mr. Kennedy. Are there evidence-based treatment strategies 
such as FDA-approved drugs like buprenorphine, methadone, and 
naltrexone that are considered the gold standard for treating 
those who suffer from opioid use disorder?
    Doctor, our Commonwealth's response to the Committee 
indicated that the state had increased access to medication-
assisted treatment to those who have been incarcerated and are 
reentering the community. Can you describe the types of 
treatments Massachusetts is providing to the incarcerated 
population in the state and if there is any disconnect seeing 
as individuals who are incarcerated lose Medicaid once they are 
incarcerated to any roadblocks that come from that bureaucratic 
disconnect?
    Dr. Bharel. Absolutely. I am proud to say that one of the 
areas where we have had a lot of improvement is in training 
individuals with incarceration. As I mentioned in my testimony 
that one of our five high-risk groups, in fact, we see from our 
data that when individuals are released from incarceration, the 
risk of opioid overdose death is 120 times higher than other 
individuals, especially in the two to four weeks after release. 
That data and information really helped us open up dialogue in 
new ways with our criminal justice colleagues. And now, the 
Department of Corrections is offering FDA-approved medication 
for opioid use disorder, as well as a pilot happening in seven 
of our jail systems.
    We also are expanding our program of post-release 
assistance because as has been mentioned earlier, individuals 
not only need to be connected to medications when they leave, 
but also employment and housing opportunities.
    Mr. Kennedy. Thank you, Doctor. Mr. Kinsley, a study 
published just recently found that states that expanded 
Medicaid had a six percent overall lower rate of opioid use or 
opioid overdose deaths than states that did not choose to 
expand Medicaid. For specific opioids, this rate was as high as 
11 percent lower mortality. Unlike the other four states 
represented here, obviously, North Carolina decided not to 
expand Medicaid.
    Sir, has that diminished the state's ability to provide 
long-term-evidence-based treatment options to uninsured 
citizens?
    Mr. Kinsley. Absolutely, and thank you for the question, 
Congressman. We estimate 426,000 people have an opioid or 
prescription misuse. We have been able to provide treatment to 
12,000 uninsured folks. Half of everybody coming into an ED 
room with an opioid overdose are uninsured. We are digging out 
of this hole with a teaspoon. We are proud of our progress. We 
have so much further to go. Based off the recent JAMA report 
that came out, we estimate 415 North Carolinians would be alive 
today had we expanded Medicaid in 2014.
    Mr. Kennedy. Thank you. I yield back.
    Ms. DeGette. The gentleman from West Virginia is now 
recognized for five minutes.
    Mr. McKinley. Thank you, Madam Chairman. I would like to 
enter into the record this letter from the Voices for Non-
Opioid Choices. It deals with the non-opioid options to treat 
in acute pain. I ask unanimous consent we enter that.
    Ms. DeGette. Without objection.
    Mr. McKinley. Thank you. I guess maybe to focus back on Ms. 
Mullins on some of your testimony and first, I want to 
congratulate you for West Virginia the work you have done. Like 
you said, we have been the epicenter of this problem. We have 
grown from 52 to 57 deaths per 100,000. It is just incredible 
to see what is happening.
    My concern has been from the day one on this that we never 
really understood the contributing factors that have led to 
abuse. We have had people in here from NIH, and CDC. They will 
talk about the socio-economic issues. And we have been able to 
quibble back and forth about it, but there are states like New 
Hampshire that have an absolute opposite socio-economic 
contributing factor as compared to West Virginia, and for 
years, they were the number two in the country.
    So I would like to understand more about what we are doing 
about prevention rather than the treatment. From my engineering 
perspective, that is how we--when we have a building collapse 
or a building failure, we go back and find out what caused it. 
And then we can fix it, but let's so it doesn't happen again.
    So my question back to you, what do you think the 
contributing factors are? Because I look at, for example, and I 
agree with Dr. Scott, who said it is connectivity. I want to 
see how that goes together because Texas, Texas has a rate of 
only 10.5 to our 57. What are they doing right in Texas that 
we, in West Virginia or maybe around the country, can learn 
about what are they doing there? Because we know the drugs are 
coming across. It is not like we don't have access to these 
illegal drugs. We know where they are coming from. What can we 
learn from that to prevent people from abusing drugs?
    Ms. Mullins. So, I think in terms of contributing factors 
West Virginia experienced a perfect storm when we had 
prescribers trying to treat pain. We have individuals in high-
injury occupations, coal mining. And some of the other 
industries that we have in West Virginia are prone to 
accidents. So we had influxes of pills coming into the state. 
We had easy availability. And those things were how the perfect 
storm, if you will, got started with low incomes and people--
the recession and the different things that were happening, 
people becoming frustrated.
    But in my opinion, we have to go further backstream. We 
have to start with our kids. We have kids in absolute crisis. 
They are not living with their parents. Many of them are living 
in foster care.
    Mr. McKinley. Let me interrupt. I would like to have more 
of a dialogue with you about this. So rather than take all the 
time, there are a couple more things because I am concerned if 
we don't stop the prevention, if we don't get into the 
prevention, we are going to see even more neonatal abstinence 
problems with our children. We are going to see the impact it 
is going to have on foster families, and foster children in our 
foster homes as a result of this. So I am really curious about 
how we stop it in the first place or how we mitigate the 
problem into the future.
    So let me go to the last comment. I would like to hear from 
any of you on the panel is that we know when the tobacco 
settlement occurred years ago, 97 percent, 97 percent of the 
money that came in for tobacco settlement payments went for 
non-tobacco use. They were used for fixing potholes. They were 
balancing state budgets. Should we do the same thing? Because I 
would imagine that we are going to see quite a bit of 
litigation over this opioid. And there are going to be some 
federal settlements on this.
    Is there a role for us for the Federal Government to try to 
step in to make sure that that money doesn't go for fixing 
potholes and balancing budgets? Is there some way that we can 
assure it will go for things like prevention, or foster care, 
or neonatal to assure long-term funding for people that are 
making investments in treatment?
    How would you react to a federal involvement in these 
settlements? Any of you.
    Dr. Alexander-Scott. Thank you for the question, 
Congressman. We would welcome the opportunity to have 
sustainable funding that allows us to really focus on this 
epidemic comprehensively and over the long term.
    Many of us have referenced the importance of stability with 
the funding, particularly when you look at making sure that the 
funding can be implemented at the community level. The 
community entities that we are engaged with need to know that 
the funding that is available to them to address determinants 
of health and to address the comprehensive system will be in 
place for a long enough time for there to be an impact and the 
improvement that we want to see. So the assistance that is 
welcome to help us do that across the board is certainly to be 
well received.
    Ms. DeGette. The gentleman from California is recognized 
for five minutes.
    Mr. Ruiz. Thank you very much and thank you all for being 
here for the incredible work that you are doing in your states.
    This Committee has worked in the bipartisan manner over the 
last several years to pass legislation to help states implement 
programs to help curb the opioid crisis sweeping our nation. 
But more can and more must be done.
    While members on both sides of the aisle are committed to 
addressing this issue, at the same time, there are continued 
efforts not to expand Medicaid in some states and even to make 
access to Medicaid more difficult overall, despite the fact 
that increased access to care means increased access to life-
saving treatment.
    In fact, just last week, a new study was published in the 
Journal of the American Medical Association, JAMA, found that 
expanding Medicaid under the Affordable Care Act may have saved 
as many as 8,000 people from a fatal opioid overdose. I would 
like to ask unanimous to insert this for the record.
    Ms. DeGette. Without objection.
    Mr. Ruiz. And according to the Kaiser Family Foundation, 
another study, in 2017, Medicaid covered 54 percent of people 
who received treatment for opioid use disorders. So despite the 
words about wanting to increase access to mental health and 
addiction treatment, there are also efforts to roll back the 
Affordable Care Act, which would eliminate coverage of the 
essential health benefits like mental health services and 
addiction treatment. And we feel the Medicaid expansion, if we 
truly want to address this crisis in a meaningful way, we need 
to work to increase coverage, and expand Medicaid, not take it 
away.
    Time after time, I have cared for a patient who is 
overdosing in the emergency department. They usually come 
unresponsive and blue. And in the emergency department, we 
treat everybody with a life-threatening illness regardless of 
their ability to pay. But once they are stabilized and leave 
the emergency department, leave the hospital, they need to find 
treatment to help them beat their addiction. They need to go to 
the facilities that offer the programs that receive the grant 
money and those facilities often benefit if they have Medicaid. 
And if they don't have Medicaid, they won't go because the 
opioid epidemic is an unprecedented crisis. States have needed 
to make fundamental changes to their treatment systems to 
combat opioid addiction and substance abuse disorder.
    So I would like to hear how federal funding has played a 
role in supporting these treatment systems.
    Ms. Mullins, West Virginia's response to the Committee, 
notes that the state's treatment infrastructure was initially 
not capable of meeting rising demands for opioid treatment 
services. How have the federal funds helped West Virginia 
enhance the treatment infrastructure system, including the role 
that Medicaid has played?
    Ms. Mullins. So Medicaid has been a key component. We have 
used Medicaid--we were approved for an 1115 SUD waiver. So we 
have used that as part of our backbone to pay for treatment 
services. But the 1115 waiver doesn't enable us to train our 
providers. It doesn't enable us to build our infrastructure. So 
we use the grant funds to wrap around that waiver and build 
infrastructure, as well as cover people with no insurance or 
who are under insured. That has been our strategy, to braid 
those funds together. And I don't think that we could have done 
one without the other.
    Mr. Ruiz. And according to a recent study, opioid treatment 
is much more widely accessed in states that expanded Medicaid. 
Rhode Island and West Virginia, two Medicaid-expanded states, 
both noted in their responses to the Committee the importance 
of federal Medicaid dollars and their ability to address the 
opioid crisis.
    Mr. Kinsley, from North Carolina, correct, you raised in 
your written statement that Medicaid is ``the most important 
tool in a sustainable response to the opioid epidemic. It would 
bring an additional $4 billion into North Carolina for 
healthcare.''
    How would expanding Medicaid help the state further develop 
its treatment infrastructure to address the opioid crisis?
    Mr. Kinsley. Thank you for the question. The 
interconnection with substance use disorder and employment and 
the fact that the vast majority of individuals get their health 
insurance through employment cannot be overlooked. I remind my 
team every day that they are potentially one drug test away 
from losing their health insurance and ending up in a place 
where they have no way to pay for the treatment that they need 
to recover and get back into the employment workforce.
    In North Carolina, we estimate that 500,000 additional 
people would have insurance with Medicaid expansion. This would 
be our ability to then ship those individuals to get treatment 
through Medicaid, through the 1115 waiver and then use our 
resources to invest in building the system capacity with scale 
and leverage our results.
    Mr. Ruiz. Thank you. You see, we have done some good work 
here that we took a step forward in combating the opioid 
epidemic, but if we make it harder for people to enroll in 
Medicaid, such as repealing the Medicaid expansion from the 
Affordable Care Act, repealing the essential health benefits 
that mandate mental health coverage, by making it difficult for 
people to enroll like work requirements and actually block 
granting Medicaid as well, then we are going to take five steps 
back. And so it is very important to keep that big picture 
perspective in our efforts. I yield back.
     Ms. DeGette. I thank the gentleman. We turn now to the 
gentleman from Virginia for five minutes.
    Mr. Griffith. Thank you very much, Madam Chair. Let me 
first answer a question that Mr. McKinley asked of you all and 
that was how do we treat this money? And we had the tobacco 
settlement and a lot of--many states went for naught.
    In Virginia, they created a separate commission that 
handled the Tobacco Commission Money for economic development 
purposes. Whatever purpose your individual states might want, I 
recommend that model because then you can take that lump sum of 
money and have it stretch out to assist. In this case, it would 
be with whatever issues you all have with substance abuse, but 
that Virginia model has worked well for economic development in 
the former tobacco producing areas of the Commonwealth.
    My district is the area stretched between West Virginia and 
North Carolina, down to Kentucky and Tennessee. And while 
Virginia's numbers look better than West Virginia, my district 
does not. I have both Martinsville in the North Carolina side 
that is heavily impacted and then all the areas in coal country 
in Virginia that look very much like West Virginia when it 
comes to the opioid crisis. And so I am very concerned about a 
lot of these issues.
    And we all are moved by testimony from time to time, and 
earlier, you all had a discussion related to privacy versus 
integrated medical care. The testimony I remember is the man 
who came in to testify for his brother, who could not testify 
because he had died. He had licked the opioid problem and then 
was in a major car accident, and because the doctors had no 
idea that he had an opioid problem and because he was 
unconscious and could not tell anybody don't give him the 
opioids, they gave him the opioids. He survived the injuries 
from the accident. He did not survive the reintroduction of 
opioids to his system. So we have to work on that problem and I 
appreciate all of your testimony in that regard.
    Foster care. Mr. Kinsley, you said half of the children in 
foster care, their parents had some form and it was one of the 
factors, some form of drug addiction, but I didn't see in your 
written testimony how many young people that were.
    Mr. Kinsley. I can get you the exact number. We have about 
12,000 individuals in North Carolina in the foster care system.
    Mr. Griffith. So roughly 6,000?
    Mr. Kinsley. Yes, sir.
    Mr. Griffith. And I thought it was interesting that Dr. 
Alexander-Scott, in your answer to another question, mentioned 
the school systems and making sure that there was money there.
    I know several families that have first gone through foster 
care and then adopted children who came out of households where 
the parents were addicted to various drugs, but particularly 
opioids. And they have significant behavior problems, and it is 
taking a lot of effort.
    What can we do to help our school systems deal with the 
next generation? They may not have drug problems themselves, 
but there are lots of behavior problems.
    Dr. Alexander-Scott. In Rhode Island, we have introduced a 
student assistance services program that allows for counseling, 
peer recovery, and support for both the students and their 
families. And the ability to have that be integrated with 
physical health services are for students in school really will 
allow for a comprehensive approach to addressing the needs to 
our youth and that is----
    Mr. Griffith. Including behavior problems that are a result 
of being around folks who were using drugs at the time of those 
first couple of years. Would that also be included?
    Dr. Alexander-Scott. It does address the mental health, as 
well as behavioral challenges that youth often face.
    Mr. Griffith. I appreciate that. Thank you very much. And 
Ms. Smith, I really want to learn more about what Pennsylvania 
is doing with its drug--excuse me, its doctor loan repayment 
program.
    Ms. Smith. Yes.
    Mr. Griffith. Because representing an area that has both 
significant, as Pennsylvania and West Virginia do, we are all 
right there in the Appalachian Mountains together. We need more 
healthcare providers out in our most affected areas, the rural 
areas, particularly the coal counties that have been affected 
by this. Tell me about that program some more.
    Ms. Smith. Sure. So this was an innovative program that we 
decided to use some of our federal funding for. So we are a 
Medicaid expansion state which means for treatment dollar 
purposes, a lot of our patients are Medicaid patients, which 
means the federal grant dollars we are getting, we can really 
use to be innovative and think of creative ideas. So we have 
done some housing things.
    In this case, we decide how do we address the workforce 
issue because it really is an issue all across the nation. So, 
we decided that you had to be practicing in an area with high 
opioid use. You had to have at least two years of experience 
treating patients with substance use disorder. And you had to 
commit to an additional two years in order to make good on that 
loan repayment.
    Mr. Griffith. Have you had the program long enough to know 
if the doctors, or healthcare providers, stay after their two 
years or their additional two years?
    Ms. Smith. So two years have elapsed. It is the first.
    Mr. Griffith. I look forward to getting that information in 
the future, and my time is up.
    Ms. Smith. I am happy to share some additional information 
about how many we have granted, et cetera.
    Mr. Griffith. I appreciate that and I yield back.
    Ms. DeGette. I thank the gentleman. I turn now to the 
gentle lady from New Hampshire for five minutes.
    Ms. Kuster. Thank you, Madam Chair, and I just want to say 
thank you to you for your leadership. In my seven years in 
Congress, this is one of the best, most productive hearings I 
have been at, and it is an honor to be on this Committee.
    I am the founder and co-chair of the bipartisan Opioid Task 
Force that has close to a hundred members. Just to give you a 
sense of the scope, New Hampshire, as my colleague, Mr. 
McKinley, suggested, was hit very hard, along with West 
Virginia. A perfect storm situation. But what I am proud of is 
that New Hampshire has some very innovative models coming out 
of the opioid epidemic. Yes, indeed, we need to include 
methamphetamines and cocaine and the rest.
    And I want to focus in on a particularly vulnerable 
population and a particularly expensive population, for the 
taxpayers, for our communities, and for individuals' personal 
lives. And that is the incarcerated population where we know 
that at least 65 percent, in some of our counties as high as 85 
percent, of our incarcerated population have co-occurring 
mental health and substance use issues.
    And one of my big a-ha moments in the last seven years was 
to discover that something that passed Congress many, many 
years ago at the inception of Medicaid, called the Medicaid 
Inmate Exclusion, caused people to lose coverage and lose the 
funding for healthcare, namely mental health treatment, 
substance use treatment during that period of incarceration. 
New Hampshire is a Medicaid expansion state, thank God, given 
the discussion today. But literally, the day you go in, you 
lose your coverage. And to me, if we were to design a system 
that would fail American taxpayers, families, and communities, 
it would be this system because what happens is people live 
with very, very high recidivism rates. And we all do. We are 
the taxpayers. And we have people incarcerated for drug-related 
crimes, getting no treatment for their mental health or 
substance use disorder, and when they come out, we all act 
shocked that they go back to their addiction. We are not 
shocked that they go back to their diabetes. And we shouldn't 
be shocked that they go back to their addiction.
    So I have introduced legislation that we call the Humane 
Correctional Health Care Act and what this would do is continue 
Medicaid coverage during incarceration so that we can ensure 
treatment for substance use disorder and mental illness. And 
what happens that we have already demonstrated in New Hampshire 
is a dramatic drop in the recidivism rate, from the upwards of 
50 to 60 percent down to 18 percent. And I don't care if you 
are a Republican or a Democrat, left, right, or center, that is 
saving lives and saving taxpayer dollars and I am very pleased 
that Mr. McKinley agreed to join today, as did Dr. Ruiz.
    So quickly moving on to questions, Dr. Scott, in 2016, I 
know Rhode Island implemented a state-wide treatment program 
for opioid addiction within your Department of Corrections. I 
would love to get the JAMA studies for the record and to share 
them with my colleagues. But can you just explain the overall 
decrease in overdose deaths and what the outcomes so far of 
that program have been?
    Dr. Alexander-Scott. Thank you for that question. The key 
to the program has been making sure that we have all three FDA-
approved medications for medication-assisted treatment 
available to those who are incarcerated. We also allow for 
screening of all incarcerated inmates or substance use 
disorder, so that if they weren't previously on an MAT option 
that was made available to them. And the final key is making 
sure that prior to release from incarceration, they are 
connected to one of our community-based behavioral health 
agencies. They become a client in advance and make sure that 
once they are released, they are able to have a warm handoff 
directly to continue to receive recovery and treatment services 
at the community level.
    Ms. Kuster. And that is one of the key components for our 
programs as well, so as I continue to build bipartisan support 
for this legislation, I would love to work with you and others. 
I know, Ms. Smith, you mentioned housing or maybe the doctor, 
but I would like to work on what those supports are to 
eliminate the barriers to recovery so that people can be 
successful in their lives, get back to raising their children, 
get back to work, get back to paying taxes. So thank you. I 
yield back and I appreciate this hearing.
    Ms. DeGette. I thank the gentle lady. The gentle lady from 
Indiana is recognized for five minutes.
    Mrs. Brooks. Thank you, Madam Chairwoman, and thank you so 
much to you and ranking member for holding this really 
important hearing. I am really pleased that we are focusing 
once again on opioids. It is some of the most important work 
that I have done in my time here in Congress and I want to 
thank each of you and particularly all the states that 
responded to the Committee's questions. It really is wonderful 
to see all of the progress and all of the efforts that each of 
your states are making.
    I think while it is not getting much media attention any 
more, I mean there was a period of time in the last few years 
where opioid issues were on the front pages and on TV all the 
time. And it is not anymore. It has fallen off of the radar, 
sadly, of the American people except for those families and 
those professionals and people who are dealing with this day in 
and day out. So I really want to thank you for your work.
    I want to focus, go back to the workforce issues because 
all of this, whether it is prevention, whether it is treatment, 
whether it is the work that you all are doing, if we don't have 
the workforce, I say the workforce even beyond physicians in 
addiction; we need to stay focused. My friend across the aisle, 
Brad Schneider, from Illinois and I introduced the Opioid 
Workforce Act and it is meant to try to raise the cap on 
graduate medical education residency slots by a thousand more 
residencies across the country in addiction medicine. I know 
that I have spoken to IU Med School in Indiana. I represent 
Indiana and you know, IU has, with its grand challenge, tried 
to put a lot more emphasis on addiction medicine in all levels, 
whether it is in nursing, whether it is in prescribing 
practices, whether it is in addiction medicine.
    I want to go back just briefly to start on your loan 
repayment program and to learn if any other states are doing 
that.
    Ms. Smith, building on what my colleague said, you wanted 
to say a little bit more about your loan repayment and then I 
just want to do like lightning rounds to find out if your 
states are doing it, and if not, why not?
    Ms. Smith. Yes. So very quickly to add, I was able to find 
the data here in my notes. We made 91 awards to individuals 
from 23 different counties that totaled $4.7 million for that 
program. And it was a combination of both mental and behavioral 
health practitioners, so more of the clinician level. And then 
$1.8 million of it was for actual medical professionals, which 
include CRNPs, physician assistants, and physicians. So we 
tried to really capture the full range of professionals as part 
of that program. And the second round of awards is currently 
out, so applications are being submitted to us for a second 
round of awarding for that program.
    Mrs. Brooks. And do you believe if we increased the number 
of residency slots in addiction medicine would that be helpful?
    Ms. Smith. I do believe it would be helpful.
    Mrs. Brooks. Thank you. Dr. Bharel?
    Dr. Bharel. Thank you for this important attention to the 
professional training. In Massachusetts, we were the first 
state to develop voluntarily with all four of our medical 
schools' core competencies that were standardized for all 
medical students. That was quickly then taken up by all of our 
three dental schools, as well as our advanced practice nursing 
programs, physician assistant programs, and training over 8,000 
individuals in a standardized way so that they could balance 
the needs of pain management with the potential for opioid 
misuse.
    Additionally, our social work schools have taken up that 
training as well as physical therapists. So it is enhancing the 
capacity for individuals to treat this medical illness.
    Mrs. Brooks. I know one of the challenges with med schools 
is in the past, they have given very little time to addiction 
medicine and pain issues. Are they starting with the first year 
now in your med schools?
    Dr. Bharel. So the trick with our core competencies is we 
allow each individual medical school to create the curriculum 
the way that they needed to based on what their curriculum is, 
so they imposed it in multiple different ways, but that 
allowed--usually curriculum changes take two to three years. 
This we were able to do in a matter of weeks because the core 
competencies were broad enough for them to incorporate. And we 
know from graduating medical students, they are saying that 
they are seeing the difference and they feel more prepared.
    Mrs. Brooks. Thank you. Ms. Mullins?
    Ms. Mullins. Sure. We are very excited. We just did a loan 
repayment program this year. We had over a hundred applicants; 
I think 102. We funded 22 of those applications in the first 
round with a 2-year requirement to practice within the state. 
That was focused on therapists because some of West Virginia's 
existing loan repayment programs focus on the medical, the 
physician end, so we really wanted something to focus on the 
therapy level. But in addition to that, we also provided about 
154 scholarships which with the same types of requirements that 
eliminated the front-end investment and some of the student 
loan debt as well.
    Mrs. Brooks. Thank you. Mr. Kinsley, very briefly.
    Mr. Kinsley. We have a loan repayment program for both 
doctors and mid-levels; we have worked to train over 900 
residents in North Carolina and currently four of our five 
medical schools have built the training into their core 
curriculum.
    Mrs. Brooks. Thank you, and with the chair's indulgence, if 
we could get Rhode Island to answer.
    Ms. DeGette. Absolutely. I am not leaving Rhode Island out.
    Mrs. Brooks. Thank you. Dr. Alexander-Scott.
    Dr. Alexander-Scott. Thank you. Our loan repayment program 
has also expanded to include behavioral health providers and 
our medical school does now incorporate the data waiver 
training into our medical school curriculum so that as students 
graduate, they automatically have the data waiver to be able to 
prescribe buprenorphine.
    Mrs. Brooks. Thank you all for working so hard with your 
higher ed institutions. It is critically important. It will 
make a difference. I yield back.
    Ms. DeGette. The gentle lady from Florida is recognized for 
five minutes.
    Ms. Castor. Well, thank you, Chair DeGette. I want to thank 
you as well for calling this hearing on the public health 
epidemic that is the opioid crisis and thanks to all of you, 
all of our expert witnesses for everything that you are doing 
to help families deal with the dire consequences.
    In Florida, in the past few years, we have lost well over 
5,000 of our neighbors per year; and while I am really proud of 
the work of this Committee passing 21st Century Cures and the 
Comprehensive Addiction and Recovery Act and the SUPPORT Act; 
there is one glaring problem that has been highlighted by a few 
of my colleagues here today, and that is the lack of continuity 
of care and resources in the minority states that have not 
expanded Medicaid. And unfortunately, the State of Florida is 
one of those.
    Mr. Kinsley, North Carolina has not expanded Medicaid. I 
believe all of the other states have here today, Pennsylvania, 
Massachusetts, West Virginia, and Rhode Island. In your written 
testimony, you noted that ``for every single person who is 
brought to the emergency department, nearly half has no health 
insurance at all.'' Further, you stated that expanding Medicaid 
``would bring an additional $4 billion into North Carolina for 
healthcare.''
    All of the Democratic members of the Florida congressional 
delegation yesterday sent a letter back home to the opening day 
of the Florida legislature. And our message to the governor and 
to our members back in Florida was that you are not doing right 
by our citizens.
    One recent study said if Florida expanded Medicaid, we 
would draw down almost $14 billion for our state over the next 
five years alone. It would improve people's health. It would 
improve people's access to healthcare, and it would do so much 
for families who suffer the consequences of substance use 
disorder.
    Mr. Kinsley, talk to us again about how expanding Medicaid 
in North Carolina would allow the state to better target the 
use of federal grant dollars to address the opioid epidemic.
    Mr. Kinsley. Thank you for the question, Congresswoman. At 
present, more than two-thirds of the Federal state opioid 
response and state targeted response grants that North Carolina 
received are just going for treatment or expanding care for the 
individuals that are uninsured. And that is a laudable and 
notable purpose for those dollars, but we do not have those 
dollars available to building our workforce, to training our 
individuals, to increasing the way that our system works 
together and coordinates care. Instead, we are expanding 
treatment because we do not have Medicaid expansion in North 
Carolina.
    The North Carolina state legislature reopened and 
reconvened today around a budget that has not been able to be 
passed primarily in the debate on Medicaid expansion in North 
Carolina. And I, too, hope that we are able to expand and 
increase access in North Carolina.
    Ms. Castor. Other recent studies have shown that now 37 
states plus the District of Columbia have expanded. The other 
states that haven't, we are sending our dollars to and 
subsidizing the budgets in healthcare of some of these other 
states. Congresswoman Kuster wants to take me to lunch for 
something.
    Ms. Smith, how many lives have you saved in Pennsylvania 
because Pennsylvania expanded Medicaid?
    Ms. Smith. So, in Pennsylvania, as a result of Medicaid 
expansion, we have been able to treat about 125,000 additional 
patients. So for us, that is huge. I can tell you with the 
large amount of funding, over $230 million coming to the state, 
if we did not have Medicaid expansion, you would not be hearing 
me talking about a loan repayment program, about how things--
about expanding MAT and corrections, about any of those things 
because the reality is we would be spending all of those 
dollars just on I will call it plain old treatment.
    So, as a result of Medicaid expansion, we have been able to 
repurpose those dollars in ways that allow us to modernize the 
system, to integrate with physical health, mental health, and 
behavioral health, all together in one system moving forward. 
So I really can't stress enough the importance of having 
participated in Medicaid expansion and certainly, hope that it 
continues for years to come.
    Ms. Castor. Dr. Bharel, how about you in Massachusetts?
    Dr. Bharel. In Massachusetts, the foundation of our 
treatment is having access to the medical treatment that is 
proven and evidence based. Because we have that, we have been 
able to tackle the very challenging and complex issues related 
to getting individuals to that care, preventing disease in the 
first place, and making sure that individuals who are at the 
highest risk not only obtain that care but stay in with 
recovery coaching which is, by the way covered by our Medicaid 
1115 waiver now.
    Ms. Castor. Thank you. And Ms. Mullins, West Virginia, I 
believe, has the highest share of population served through 
Medicaid. And you talked about the importance of 
predictability. How important has Medicaid expansion been to 
opioid and substance use, treatment. You talked about the 
predictability of care and the predictability of those 
resources.
    Ms. Mullins. It is very important in terms of sustaining. I 
talked about the infrastructure that we have been building 
without Medicaid paying for residential treatment. There is no 
way to sustain those valuable services. And according to my 
notes, we have over 21,000 West Virginians receiving 
medication-assisted treatment in our state.
    Ms. Castor. Thank you very much. I yield back.
    Ms. DeGette. Thank you so much. The gentleman from 
Maryland, Mr. Sarbanes, is recognized for five minutes.
    Mr. Sarbanes. Thank you, Madam Chair. Thanks to the panel 
of witnesses, very compelling testimony today, and I thank you 
all for coming.
    We have learned, of course, that one of the root causes is 
inappropriate prescribing practices and a number of you have 
spoken to that today and we know that many states such as 
Virginia and Maine and Rhode Island have set prescribing limits 
for opioids.
    Dr. Alexander-Scott, you highlighted that as part of the 
response to addiction crisis, your state enacted regulations in 
2017 that limited the initial prescription of an opioid for a 
new patient to no more than 30, what are called morphine 
milligram equivalents, or MMEs, per day.
    Could you describe a little bit more for us the danger to 
some patients of exceeding that limit? And do you think that 
the policy has been successful in steering providers to make 
better prescribing decisions for their patients?
    Dr. Alexander-Scott. Thank you, Congressman. We had data 
that said the higher the morphine milligram equivalence a 
patient is on for, the longer period of time, the higher their 
risk is of becoming addicted to opioids over time, and thus 
their risk of an overdose.
    We wanted to make sure that there was flexibility for the 
provider in determining what was needed for the patient; we 
also thought it critical to distinguish between acute pain and 
chronic pain in limiting the opioids prescribed.
    So by cutting off the MME at 30 for an acute reason for 
pain, we have seen a substantial decrease in the number of 
opioids prescribed for an initial use of pain, particularly for 
acute pain scenarios.
    We have chosen to handle chronic pain needs separately 
because oftentimes, people already have an addiction or a 
tolerance to opioids that require a more multi-disciplinary 
approach to addressing that.
    Mr. Sarbanes. Let me drill down on that a little bit more. 
Because I know the CDC, in their recommendations, has indicated 
that providers should avoid prescribing over 90 MMEs a day and 
many states have put that kind of recommendation into code. I 
think Nevada and South Carolina have limited opioid 
prescriptions to 90 MMEs or under in most patient cases. There 
are a lot of products on the market, especially extended 
release and long-acting opioid products, that do exceed that 
even 90 MME a day limit. And some of them even double or triple 
that limit.
    So I understand that the products are intended for patients 
who have become opioid resistant, as you mentioned to these 
lower dose-products, but do these high dosage opioids pose 
enough of an overdose risk that we should at least begin to 
explore methods to limit their market availability in your 
judgment?
    Dr. Alexander-Scott. We have certainly considered that in 
our regulation's approach for acute pain management in addition 
to the 30 morphine milligram equivalents limitation. We have 
also required that long-acting opioids are not used for acute 
pain in those scenarios as well because of the challenge that 
can occur, and again, distinguishing from those patients that 
already are dealing with chronic pain and would need to be 
handled separately.
    Mr. Sarbanes. Well, thank you. I know FDA has taken 
previous action to limit the use of these high-dose products 
and they have imposed something called a REMS, a risk 
evaluation and mitigation strategy program on providers who 
prescribe these products. I also know that there was a recently 
released JAMA study on this topic that failed to find any 
evidence that the REMS program was actually successful at 
achieving those goals of reducing inappropriate prescribing.
    Given the CDC recommendations, state precedent on 
prescribing limits, and the lack of existing action, it may be 
time for FDA or Congress, or both of us, to explore options for 
limiting the market availability of high-dose opioid products 
that are currently on the market and limiting these new high-
dose products, restraining them from entering the market in the 
future. So I think that is something we want to look at, and I 
look forward to exploring a wide array of solutions to 
combating the opioid crisis and making sure states have the 
funding and flexibility to support these affected communities. 
And thank you again for your testimony. I yield back.
    Ms. DeGette. The gentleman from New York, Mr. Tonko, is 
recognized for five minutes.
    Mr. Tonko. Thank you, Madam Chair. Thank you to our panel 
for an interesting and very helpful conversation. In your 
testimony, many of you hit on a topic that is near and dear to 
my heart and that is eliminating bureaucratic and unnecessary 
barriers to substance use treatment. Research has shown that 
individuals who are being actively treated with buprenorphine 
lower their risk of opioid overdose by up to 50 percent, even 
when provided without corresponding comprehensive psychosocial 
supports or services. With any other medication that lowered 
mortality by 50 percent, we would be rightfully hailing this as 
a miracle drug and doing everything in our power to get it out 
to anyone who could possibly need it. Unfortunately, here in 
the United States, we continue to make it harder to obtain 
these medications than the powerful opioids that got us into 
the problem in the first place.
    So Secretary Smith, I was pleased to see that in your 
testimony, you called for the elimination of the requirement 
for providers to obtain a waiver from the DEA in order to 
prescribe buprenorphine for treating opioid dependence. I have 
introduced the bipartisan Mainstreaming Addiction Treatment Act 
with over 100 co-sponsors to do exactly that.
    Can you describe for the Committee why this is such an 
important step to take in expanding access to addiction 
treatment?
    Ms. Smith. Absolutely, and thank you so much for sponsoring 
that legislation that we are fully supportive of. So I 
mentioned earlier in my opening that we have expanded our DEA X 
waivered physicians to over 4,000. And we are near the top of 
the list when you look at states in terms of number of X 
waivered physicians. But looks can be deceiving. So when you 
actually take a look at those 4,000 waivered doctors, and you 
look at what are their prescribing capacities, and then whether 
or not they are actually prescribing up to their capacity or 
not, it is pretty staggering. So we have got a very large 
percentage who are still at that 30 patient capacity level and 
most of them are not even prescribing up to 30 patients. And so 
we have worked with an organization called Vital Strategies to 
design a survey that is going to go out to all 4,000 of our X 
waivered physicians in the state to ask some very specific 
questions about why they aren't treating more patients. Would 
they be willing to treat more patients? Is it an education 
issue? Is it a barrier because of additional oversight?
    And so anecdotally, we definitely heard that efforts to 
over-regulate are what they often say. Doctors who were trained 
to administer any and all kinds of medications but to 
specifically call out this kind of medication and say you need 
a special waiver to administer this; they just don't want to be 
bothered with that. And so Pennsylvania believes that any steps 
we can take to eliminate those barriers, to change the 
conversation around the idea that treating addiction is a 
clinical necessity and we rely on trained physicians to be able 
to provide that treatment.
    Mr. Tonko. If I could have the rest of the panel respond 
yes or no. Do you agree with the assessment just made by 
Secretary Smith?
    Dr. Bharel. Yes, hello. Thank you for that question. The 
access to MAT and decreasing the barriers are critical and we 
often spoke about it in our testimony.
    Mr. Tonko. Do you agree with the waiver?
    Dr. Bharel. Yes.
    Mr. Tonko. I want to use my time here wisely. So thank you. 
Yes.
    Ms. Mullins?
    Ms. Mullins. Yes, but we don't have a therapist to really 
support those physicians once they are--can prescribe. For us, 
the workforce shortage is way more impacted on the therapy and 
the counseling side.
    Mr. Tonko. Mr. Kinsley, please.
    Mr. Kinsley. Yes, we are supportive.
    Mr. Tonko. And Doctor?
    Dr. Alexander-Scott. Yes, we support and also look to 
expand the services available as well.
    Mr. Tonko. OK, and many of you also mentioned individuals 
released from incarceration as a population particularly 
vulnerable to opioid overdose, with Commissioner Bharel noting 
that the justice-involved population has death rates of 420 
times higher than the general population. I heard your exchange 
with my colleague from New Hampshire.
    So, while federal grant opportunities such as the 
Medication and Assistive Treatment Reentry Initiative are 
helping to fill in some of the gaps, I believe a more 
comprehensive and sustainable strategy is required, therefore; 
I have championed the Medicaid Reentry Act which would allow 
states to restart Medicaid benefits for incarcerated 
individuals 30 days prior to release providing a sustainable 
funding stream for medication-assisted treatment, case 
management, and recovery support services, and creating a more 
seamless transition back into community care.
    Commissioner Bharel, would be allowing states the 
flexibility to restart Medicaid benefits for eligible 
incarcerated individuals 30 days prior to release help to 
reduce overdose deaths for that population?
    Dr. Bharel. Making sure there is a continuity of care is 
critical both to medical and the other support mechanisms that 
you stated.
    Mr. Tonko. Thank you. I have exhausted my time. I have 
several other questions which I will submit to the 
subcommittee, and with that I yield.
    Ms. DeGette. I thank the gentleman. The gentle lady from 
New York is recognized now for five minutes.
    Ms. Clarke. Thank you very much, Madam Chair, and I thank 
our ranking member. We have heard a lot of encouraging stories 
from the states today about how they would be able to put 
federal funds to use and make progress. But it is also clear 
that there are still unmet needs and unresolved challenges that 
states face as they work to address the ongoing crisis.
    I would like to explore some of the remaining challenges as 
we consider further support.
    Ms. Mullins, in your testimony, you noted unresolved 
challenges around building a robust addiction treatment 
workforce, including attracting and retaining people to work in 
rural areas throughout the state. Can you describe what steps 
the state is undertaking to address this challenge and what 
additional hurdles remain?
    Ms. Mullins. So there are multiple challenges for this. It 
is a pervasive workforce shortage in all areas of employment in 
West Virginia. We do not have enough people to fill our 
vacancies. But it also is about parity in terms of what we pay 
our mental health and addictions workforce. It is not the same, 
so when students graduate with debt, they are graduating with 
levels of debt that cannot really expect to earn salaries that 
are commensurate with their levels of education. So to me, that 
is a fundamental thing that we must address and end the student 
loan debt to go with it. So we have really been focusing on 
those loan repayment programs, scholarship programs, anything 
that we can to really increase A, our pipeline, but then also 
to provide the ongoing education that we can. And we are 
finding that our individuals that are entering recovery have a 
really strong interest in providing services, so we are paying 
particular attention in our loan repayment programs, even to 
persons who might be in recovery and wishing to take those next 
steps to enter the workforce.
    Ms. Clarke. So is that at the state level? Is it something 
at the federal level that you think can be helpful in sort of 
undergirding and helping to unearth individuals who would move 
into that line of work?
    Ms. Mullins. I think the flexibility to use the funds in 
those creative ways would really be very beneficial.
    Ms. Clarke. Very well. Secretary Smith, in your written 
testimony submitted to the Committee, you also referenced a 
lack of additional treatment, excuse me, addiction treatment 
workforce, and noted that ``Demand on addiction treatment 
workforce will increase as more people move toward treatment 
and recovery.''
    So can you describe how the lack of addiction treatment 
workforce has inhibited Pennsylvania's ability to provide 
services to vulnerable populations? And what steps has your 
state taken to address this problem given, that more people are 
moving toward treatment and recovery?
    Ms. Smith. Yes, certainly. Our workforce challenges, 
particularly in urban centers like Philadelphia and Pittsburgh, 
have really inhibited the ability for some of those more 
vulnerable populations to access treatment. To give you an 
example, we have an advisory council that advises my department 
and one of the members of that council is a practicing 
addiction medicine physician who happens to also treat 
adolescents. But he is part of the Latino community and his 
practice is so overwhelmed with patients that he is working 
well into the night beyond his office closure hours because 
those individuals have nowhere else to go.
    And so part of the challenges that we hear in building a 
workforce where you don't have communication barriers, so where 
you have got doctors who are treating patients that really 
understand them and communicate with them, a lot of the 
challenges come down to the education and training requirements 
and some of those language barriers that exist in being able to 
meet those requirements.
    Ms. Clarke. So you have ID'd a cultural competence 
essentially.
    Ms. Smith. Yes.
    Ms. Clarke. Very well. Mr. Kinsley, in North Carolina's 
response letter to the Committee, the state notes that ``in 
many of North Carolina's communities hardest hit by the opioid 
epidemic it is difficult to implement programs and build 
treatment and recovery access because the community lacks basic 
infrastructure including broadband and cell phone service.''
    So can you describe how broadband and cell phone services 
are important to helping North Carolina address the opioid 
epidemic in these communities; what more could Congress do to 
overcome this challenge?
    Mr. Kinsley. Thank you for the question. Telehealth access 
in our rural communities is the key strategy for our efforts to 
expand access to treatment, yet there are many parts of North 
Carolina that can't sustain more than a 4G signal digitally or 
have access to broadband. And so, without those, we are not 
able to sustain those services. That, of course, is built on 
the fact that it is a sustainable approach for education, for 
all these providers, for parity. I agree with what all of my 
colleagues have said.
    Ms. Clarke. Very well. I have run out of time and Dr. 
Scott, I did have a question for you, but I will submit it for 
your response at a later time.
    But Madam Chair, I would like to ask for this letter from 
the New York State Office of Addiction Services and Support to 
be added to the record.
    Ms. DeGette. Without objection, it is entered.
    Ms. Clarke. OK, thank you. I yield back, Madam Chair.
    Ms. DeGette. The Chair now recognizes the very patient, Mr. 
Latta for five minutes and welcome to the subcommittee.
    Mr. Latta. Well, thank you, Madam Chair, and first, I want 
to thank you very much for letting me to waive on today. I 
really appreciate it because this is a really important and 
very relevant topic.
    Just in one of the major newspapers in the State of Ohio 
yesterday had an article that just came out and something we 
have heard coming. But we know that in 2009 we had 1,423 people 
die of an overdose in the State of Ohio. That number went up in 
2017 to 4,854. And the trend right now, thank heavens, it is 
going down. It was 3,764 last year, but these are all deaths 
that we don't want to see at all, these overdose deaths.
    I know when I have gone around my district, it is very 
important when I am talking to my healthcare providers and 
other folks out there. One of the things they were telling me 
for several years is we can't find help. And it is everything 
from finding the dollars to finding where they can get 
services. So in the last Congress, I introduced what we call 
the INFO Act, which established a dashboard through HHS so that 
states and communities could go out there and find help.
    What I would like to ask you all today are just some 
questions as to what is going on in your states, if I may, and 
if I could ask everyone, I don't have a lot of time, but maybe 
be brief on your answers, but some of your states have 
developed public-facing dashboards. When were these dashboards 
created and what information do you have in them? If we could 
just go right down the line.
    Ms. Smith. Sure. I will be as brief as possible. 
Pennsylvania does have an interactive opioid data dashboard. If 
you go to pa.gov/opioids, you are able to access that. It 
contains information like prescription drug monitoring 
information, overdose deaths, naloxone distributions, NAS, EMS 
leave-behinds, treatment statistics, and the number goes on and 
on and on. So happy for you to check that out and if you have 
questions, let me know.
    And was there a second part to your question?
    Mr. Latta. It was mainly about what information do you have 
contained in them.
    Ms. Smith. Yes, and it was established about two years ago.
    Mr. Latta. Thank you.
    Ms. Smith. You are welcome.
    Dr. Bharel. Thank you for the question. Since 2015, 
Massachusetts has put out a quarterly dashboard that contains 
much of the same information related to a number of deaths, 
both reported and predicable using a predictive model, as well 
as by town and city, so all 351 towns and cities get a report 
on the number of deaths in their communities so they can do 
local-based planning as well, as well as EMS and healthcare 
data.
    We also, since 2015, have put together for the first time 
data across state government, so we are looking for the first 
time at house data as it relates to public health, but also 
criminal justice, schools, et cetera.
    Mr. Latta. Thank you.
    Ms. Mullins. So for West Virginia, over the last couple of 
years, we have been using reports uploaded quarterly that 
highlight things like overdose deaths, prescription drug 
monitoring, and different data points that we have been 
focusing on through our grants with the Centers for Disease 
Control and surveillance. We do that quarterly. But this week, 
actually, we expect to upload and make public a dashboard that 
tracks nonfatal deaths, nonfatal overdoses, and stay tuned. We 
are really looking forward to releasing that this week.
    Mr. Latta. Thank you.
    Mr. Kinsley. North Carolina launched its opioid action plan 
dashboard in 2017. This dashboard not only has key data points 
and is updated consistently around the opioid epidemic, but it 
also broadens into other aspects of substance use disorder. It 
allows counties and local communities to drill down into the 
information in their community which we have seen as being 
incredibly powerful at aligning all of us to the same 
strategies and also getting foundations, nongovernmental 
entities, and private/public partnerships onboard with focusing 
their dollars in the same way that we need to focus.
    And the other thing is that all of these indicators relate 
back to our strategy, those key performance indicators that 
help us measure our success in this effort.
    Dr. Alexander-Scott. Similar to what has been heard, in 
Rhode Island, when the governor activated the Overdose 
Prevention and Intervention Task Force, we understood that 
having a dashboard would be critical to that. And that was 
activated in the 2015 time frame.
    Our dashboard does serve as a metric for each of our 
strategic initiatives on prevention, recovery, reversal, and 
treatment, and also allows for the public to be able to access 
where treatment services are. And naloxone is available, as 
well as access to other recovery services that are needed.
    Mr. Latta. Thank you. In my last 15 seconds, if I could do 
this real quick, if I could just real quick, maybe it is a yes 
or no. Have your communities had problems finding those federal 
dollars out there to get that help? Yes or no, down the line.
    Ms. Smith. Yes and no.
    Mr. Latta. OK.
    Ms. Mullins. Mostly no because of the way our procurement 
system has worked and the capacity to put data out into the 
communities so they know what problems they are seeing and they 
can then ask us for the appropriate funding targeted.
    Ms. Mullins. I would go with Secretary Smith's answer yes 
and no. Many people have no trouble, but there are still some 
folks out there struggling to find that information.
    Mr. Latta. Thank you.
    Mr. Kinsley. We have been able to deploy funds to more than 
50 local communities. Our issue is primarily that we don't have 
enough funds because they are all going to augment treatment.
    Dr. Alexander-Scott. We use a data-driven process to target 
which communities need it most and are really looking, given 
that it is Rhode Island, to make sure that every town and city 
has access to the services needed.
    Mr. Latta. Thank you very much. Madam Chair, again, I would 
like to thank you very much for allowing me to waive on today.
    Ms. DeGette. I thank the gentleman. But I want to thank all 
of our witnesses. One of the members said this was one of the 
best hearings we have had this session and I agree. It is 
really excellent and very good information as we move forward 
to see what our next steps are.
    In response to the Committee's September 18th letter, the 
Committee received responses from 16 states regarding how the 
states address the opioid crisis with the support of federal 
funding. And I move to enter all of those responses into the 
record. And in addition, let us see, we are going to enter them 
all from Florida, Indiana, Kentucky, Maine, Maryland, 
Massachusetts, New Mexico, New York, North Carolina, Ohio, 
Oregon, Pennsylvania, Rhode Island, Tennessee, West Virginia, 
and Wisconsin. Without objection, those will be ordered.
    And in addition, in continuation of our bipartisan work 
looking at addiction and treatment issues today, the Committee 
is sending a bipartisan letter signed by the ranking member, 
myself, and others, letters to the DEA, DHS, and HHS about the 
emergence of what this panel was talking about methamphetamine 
and polysubstance use and what the administration is doing 
about this. I would ask for unanimous consent to enter those 
three letters into the record. Without objection, that will be 
ordered as well.
    The Chair would like to remind Members that pursuant to the 
Committee rules; they have ten business days to submit 
additional questions for the record to be answered by the 
witnesses. Several of the members did ask the witnesses to 
answer additional questions and I would ask all of you to 
respond promptly if you receive any of those questions. And 
with that, this subcommittee is adjourned.
    [Whereupon, at 12:31 p.m., the subcommittee was adjourned.]

             Prepared Statement of Hon. Michael C. Burgess

    Thank you, Madam Chair. Last Congress, the Energy and 
Commerce Committee worked in a bipartisan manner to produce 
legislation that was signed into law by President Trump. The 
Substance Use-Disorder Prevention that Promotes Opioid Recovery 
and Treatment for Patients and Communities Act, or SUPPORT Act, 
was written to help advance treatment and recovery initiatives 
for those affected by opioid addiction.
    I thank our witnesses for being here today. Your testimony 
will be helpful in understanding the challenges we face in 
continuing this fight against opioid addiction and death, while 
ensuring that patients can manage their pain. It is important 
to Congress to have hearings like this one, where we can ensure 
the effectiveness of our legislative efforts and identify gaps 
in which we can improve the health of Americans.
    I yield back.
    
    
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