[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
COMBATING AN EPIDEMIC: LEGISLATION TO HELP
PATIENTS WITH SUBSTANCE USE DISORDERS
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND
COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
SECOND SESSION
----------
MARCH 3, 2020
----------
Serial No. 116-106
[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
53-685 PDF WASHINGTON : 2024
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 Health
ANNA G. ESHOO, California
Chairwoman
ELIOT L. ENGEL, New York MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina, Ranking Member
Vice Chair FRED UPTON, Michigan
DORIS O. MATSUI, California JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon BILLY LONG, Missouri
JOSEPH P. KENNEDY III, LARRY BUCSHON, Indiana
Massachusetts SUSAN W. BROOKS, Indiana
TONY CARDENAS, California MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont RICHARD HUDSON, North Carolina
RAUL RUIZ, California EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex
officio)
C O N T E N T S
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Page
Hon. Anna G. Eshoo, a Representative in Congress from the State
of California, opening statement............................... 1
Prepared statement........................................... 3
Hon. Michael C. Burgess, a Representative in Congress from the
State of Texas, opening statement.............................. 4
Prepared statement........................................... 5
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, prepared statement..................................... 157
Witnesses
ADM Brett P. Giroir, M.D., Assistant Secretary for Health,
Department of Health and Human Services and Senior Advisor to
the Secretary for Opioid Policy................................ 10
Answers to submitted questions............................... 305
Kimberly Brandt, Principal Deputy Administrator for Operations
and Policy Centers for Medicare & Medicaid Services............ 12
Joint statement.............................................. 14
Answers to submitted questions............................... 317
Thomas W. Prevoznik, Deputy Assistant Administrator, Diversion
Control Division, Drug Enforcement Administration.............. 28
Prepared statement........................................... 30
Answers to submitted questions \1\
Michael Botticelli, Executive Director, Grayken Center for
Addiction, Boston Medical Center............................... 84
Prepared statement........................................... 87
Answers to submitted questions............................... 330
Smita Das, M.D., Ph.D., American Psychiatric Association......... 91
Prepared statement........................................... 93
Answers to submitted questions............................... 334
Patty McCarthy, Chief Executive Officer, Faces and Voices of
Recovery....................................................... 100
Prepared statement........................................... 102
Answers to submitted questions............................... 337
Robert I. L. Morrison, Executive Director, National Association
of State Alcohol and Drug Abuse Directors...................... 107
Prepared statement........................................... 109
Answers to submitted questions............................... 339
Margaret Rizzo, Executive Director/CEO, American Association
Treatment of Opioid Dependence (NJ Board Member), JSAS
Healthcare, Inc................................................ 125
Prepared statement........................................... 127
Shawn Ryan, M.D., MBA, Chair, Legislative Advocacy Committee,
American Society of Addiction Medicine......................... 131
Prepared statement........................................... 133
Answers to submitted questions............................... 342
Submitted Material
H.R. 1329, Medicaid Reentry Act, submitted by Mr. Tonko.......... 159
H.R. 2281, Easy Medication Access and Treatment for Opioid
Addiction Act, submitted by Mr. Ruiz........................... 161
H.R. 2466, State Opioid Response Grant Authorization Act,
submitted by Mr. Trone......................................... 163
H.R. 2482, Mainstreaming Addiction Treatment Act of 2019,
submitted by Mr Tonko.......................................... 165
H.R. 2922, Respond to the Needs in the Opioid War Act, submitted
by Ms. Kuster.................................................. 171
H.R. 3414, Opioid Workforce Act of 2019, submitted by Mr.
Schneider...................................................... 188
H.R. 3878, Block, Report, And Suspend Suspicious Shipments Act of
2019, submitted by Mr. McKinley and Ms. Dingell................ 198
H.R. 4141, Humane Correctional Health Care Act, submitted by Ms.
Kuster......................................................... 201
H.R. 4793, Budgeting for Opioid Addiction Treatment Act,
submitted by Mr. Norcross...................................... 205
H.R. 4812, Ensuring Compliance Against Drug Diversion Act of
2019, submitted by Mr. Griffith................................ 213
H.R. 4814, Suspicious Order Identification Act of 2019, submitted
by Ms. Matsui and Mr. Johnson.................................. 216
H.R. 4974, Medication Access and Training Expansion Act of 2019,
submitted by Ms. Trahan........................................ 227
H.R. 5572, Family Support Services for Addiction Act of 2020,
submitted by Mr. Trone......................................... 239
H.R. 5631, Solutions Not Stigmas Act of 2019, submitted by Mr.
Kim............................................................ 245
Statement of Young People in Recovery, by Danielle Tarino,
President and CEO, submitted by Mr. Eshoo...................... 250
Statement of March 3, 2020, from National Association of Chain
Drug Stores, submitted by Ms. Eshoo............................ 251
Statement of March 3, 2020, by Mark W. Parrino, President,
American Association Treatment Opioid Dependence, submitted by
Ms. Eshoo...................................................... 257
Graphics ``Huge Surge in Clinicians Taking MAT Waiver Training'',
from Providers Clinical Support System, submitted by Ms. Eshoo. 265
Statement of March 3, 2020, from National Safety Council,
submitted by Ms. Eshoo......................................... 266
Letter of March 3, 2020, to Ms. Eshoo, and Mr. Burgess, from
Medication Assisted Treatment Leadership Council, submitted by
Ms. Eshoo...................................................... 278
Letter of March 3, 2020, to Ms. Eshoo and Mr. Burgess, from David
Houghton, M.D., System Chair, Telemedicine, Vice Chair, Ochsner
Health System, submitted by Ms. Eshoo.......................... 284
Letter of March 3, 2020, to Ms Eshoo and Mr. Burgess, by Joel
White, Executive Director, Opioid Safety Alliance, submitted by
Ms. Eshoo...................................................... 287
Letter of March 3, 2020, to Ms. Kuster and Mr. Booker, by Paul
Earley, M.D., President, American Society of Addiction
Medicine, submitted by Ms. Kuster.............................. 292
Letter of March 3, 2020, to Mr. Bilirakis, by Saul Levin, M.D.,
CEO and Medical Director, American Psychiatric Association,
submitted by Ms. Eshoo......................................... 294
Letter of March 3, 2020, to Ms. Eshoo, by Mr. Greer, President,
SMART Recovery, submitted by Ms. Kuster........................ 297
Letter of March 3, 2020, to Ms. Eshoo and Mr. Burgess, by Mary
Dale Peterson, M.D., President, American Society of
Anesthesiologists, submitted by Ms. Eshoo...................... 302
List of Supporting Organizations, submitted by Ms. Kuster........ 304
COMBATING AN EPIDEMIC: LEGISLATION TO
HELP PATIENTS WITH SUBSTANCE USE DIS-
SORDERS
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TUESDAY, MARCH 3, 2020
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:00 a.m., in
the John D. Dingell Room 2123, Rayburn House Office Building,
Hon. Anna G. Eshoo (chairwoman of the subcommittee) presiding.
Members present: Representatives Eshoo, Engel, Butterfield,
Matsui, Castor, Sarbanes, Lujan, Schrader, Kennedy, Cardenas,
Welch, Ruiz, Dingell, Kuster, Kelly, Blunt Rochester, Pallone
(ex officio), Burgess (subcommittee ranking member), Shimkus,
Guthrie, Griffith, Bilirakis, Long, Bucshon, Brooks, Mullin,
Hudson, Carter, Gianforte, and Walden (ex officio).
Also present: Representatives Tonko, Johnson, and Soto.
Staff present: Joe Banez, Professional Staff Member;
Jeffrey C. Carroll, Staff Director; Waverly Gordon, Deputy
Chief Counsel; Una Lee, Chief Health Counsel; Meghan Mullon,
Policy Analyst; Joe Orlando, Staff Assistant; Rebecca
Tomilchik, Staff Assistant; Kimberlee Trzeciak, Senior Health
Policy Advisor; Rick Van Buren, Health Counsel; Madison
Wendell, Intern; C. J. Young, Press Secretary; S. K. Bowen,
Minority Press Secretary; William Clutterbuck, Minority Staff
Assistant; Caleb Graff, Minority Professional Staff Member,
Health; Tyler Greenberg, Minority Staff Assistant; Peter
Kielty, Minority General Counsel; James Paluskiewicz, Minority
Chief Counsel, Health; Kristin Seum, Minority Counsel, Health;
and Kristen Shatynski, Minority Professional Staff Member,
Health.
Ms. Eshoo. Good morning, everyone. The Subcommittee on
Health will now come to order.
The Chair now recognizes herself for 5 minutes for an
opening statement.
OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
According to recently reported CDC data, in 2018, 67,000
Americans died of a drug overdose. Overdoses in 2018 killed
more Americans than those lost in the Vietnam War.
So this is a national crisis. In 2016, Congress passed the
21st Century Cures Act and CARA, and in 2018, the SUPPORT Act
was signed into law to stem the tide of addiction and
devastation that the opioid crisis has created.
Yet, despite our legislative efforts to give Medicaid more
flexibility and increase access to medication-assisted
treatment, or MAT, according to a 2019 National Academies of
Science report, more than 80 percent of the two million people
with opioid use disorder are not receiving MAT and families and
children affected by the opioids crisis also are not receiving
the care they need. We will learn more about why during our
questions and answers.
I think it is painfully clear that much more work needs to
be done. But we also need to know how the administration is
carrying out responsibilities that the Congress gave to them in
carrying out the laws that we created. We will learn about
where and why previous efforts have fallen short. We will
grapple with what is needed to truly end these overdoses. Our
next steps will require overcoming stigma and they will require
spending money.
From 1999 to 2018, more than 750,000 Americans died from an
overdose and we all have to ask ourselves the question: are we
willing to do what is needed to be done to avoid another near
million deaths?
Among the 14 bills we will discuss today, Representative
David Trone and Representative Annie Kuster propose providing
$1 billion annually to states and $5 billion annually to
federal programs already in place that provide treatment and
support prevention activities.
Another part of the solution requires investing in a
healthcare workforce to treat underserved areas.
Representatives Tonko, Ruiz, Schneider, Brooks, Trahan, who---
Lori Trahan who I understand--where is Lori? She is in the
audience today. There you are. Thank you very much.
And Andy Kim have bills to create a brand-new healthcare
workforce trained to recognize substance use disorder and are
able to prescribe the medication-assisted treatment that we
know saves lives.
And it will require spending federal dollars to address the
stigma against people in jails and prisons who, despite their
sentences, deserve healthcare. People who are released from
prisons and jail are 12 times more likely to die of an overdose
than the general public.
Currently, federal law bars Medicaid recipients from
accessing their federal health benefits while incarcerated, so
state and local governments face challenges to provide needed
medication-assisted treatment to people that are incarcerated.
Bills by Representatives Tonko and Kuster address these
inequities by expanding Medicaid coverage during and after
incarceration.
And lastly, we will be considering bills from
Representative Matsui, McKinley, and Griffith to fight back
against suspicious drug orders and diversion to stop the
illicit flow of opioids into our communities.
So I look forward to discussing the impact of these 14
bills and the effect they can have and hearing from the federal
agencies in charge of implementing our past legislation, which
are now the laws.
[The prepared statement of Ms. Eshoo follows:]
Prepared Statement of Hon. Anna G. Eshoo
According to recently reported CDC data in 2018, 67,000
Americans died of a drug overdose. Overdoses in 2018 alone
killed more Americans than the Vietnam War. This is a national
crisis.
In 2016 Congress passed the 21st Century Cures Act and
CARA, and in 2018 the SUPPORT Act was signed into law to stem
the tide of addiction and devastation that the opioid crisis
has created.
Yet, despite our legislative efforts to give Medicaid more
flexibility and increase access to medication-assisted
treatment or MAT, according to a 2019 National Academies of
Science report, more than 80 percent of the 2 million people
with opioid use disorder are not receiving MAT and families and
children affected by the opioids crisis also are not receiving
the care they need.
It's clear much more work needs to be done.
Today we will hear from Administration officials
responsible for carrying out these laws.
We'll learn about where and why previous efforts have
fallen short.
And we will grapple with what is needed to truly end these
overdoses.
Our next steps will require overcoming stigma. And they
will require spending money.From 1999 to 2018 more than 750,000
Americans died from an overdose. What are we willing to spend
to avoid another million deaths?
Among the 14 bills we'll discuss today, Representative
David Trone and Representative Annie Kuster propose providing
$1 billion annually to states and $5 billion annually to
federal programs already in place that provide treatment and
support prevention activities.Another part of the solution
requires investing in a healthcare workforce to treat
underserved areas. Representatives Paul Tonko, Raul Ruiz, Brad
Schneider, Susan Brooks, Lori Trahan (who is in the audience
today), and Andy Kim, have bills to create a brand-new
healthcare workforce trained to recognize substance use
disorder and are able to prescribe the medication-assisted
treatment that we know saves lives.
And it means spending federal dollars to address the stigma
against people in jails and prisons who, despite their
sentences, deserve healthcare. People who are release from
prisons and jail are 12 times more likely to die of an overdose
than the general public.
Currently federal law bars Medicaid recipients from
accessing their federal health benefits while incarcerated, so
state and local governments face challenges to providing needed
medication assisted treatment to people incarcerated. And when
an individual leaves jail or prison, they are often left
without coverage and can't continue treatment.
Bills by Representatives Tonko and Kuster address these
inequities by expanding Medicaid coverage during and after
incarceration.
And lastly, we're considering bills from Representative
Doris Matsui, David McKinley, and Morgan Griffith to fight back
against suspicious drug orders and diversion to stop the
illicit flow of opioids into our communities.
I look forward to discussing the impact these 14 bills can
have and hearing from the federal agencies in charge of
implementing our past legislation.
I yield the rest of my time to a leader on addressing the
opioid epidemic, Representative Annie Kuster.
It is a pleasure now for me to yield my remaining time to
Representative Annie Kuster, who has just been a superb leader
relative to the opioid epidemic.
Ms. Kuster. Thank you so much, Chairwoman Eshoo, and thank
you for scheduling these bills for a hearing.
As founder and co-chair of the bipartisan Congressional
Opioid Task Force, now a hundred members of Congress, this
issue is one that impacts Republicans and Democratic districts
across this country.
Every community no matter race, region, intergenerational--
in short, this crisis knows no bounds. The complexity of the
crisis is urgent and it has devastated communities across my
district, and one thing we recognize the solution must be
comprehensive. There is no silver bullet. It is a silver
buckshot approach.
So that is why I am so pleased to see my bill with
Representative McKinley, the Humane Correctional Health Care
Act, be included. We need to bring treatment to every part of
our community and I look forward to working with you all. It
saves lives and I would be shocked for anyone to speak out
against innovative solutions to address the root cause of this
incredibly high recidivism rates in this country.
Thank you, Chairwoman Eshoo, and I yield back.
Ms. Eshoo. And the gentlewoman yields back.
The Chair now recognizes Mr. Burgess, the ranking member of
our subcommittee, for his 5 minutes for an opening statement.
OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF TEXAS
Mr. Burgess. And I thank the Chair and I appreciate that we
are holding this hearing to continue this subcommittee's
important work on addressing the opioid epidemic in our nation.
Last Congress, we conducted a member-driven process that
began in October of 2017 with an Energy and Commerce Committee
Member Day and concluded with President Trump signing the
SUPPORT Act one year later.
Throughout that process we held four subcommittee hearings,
a subcommittee markup, two full committee markups. This process
allowed members to hear from relevant stakeholders, offer
amendments to improve the legislation under consideration and,
perhaps most importantly, allow the public a window into the
process.
While I am grateful that we are continuing our work on
opioids I still believe it is critical that we have a
standalone SUPPORT Act implementation hearing. This committee
does important work. We have passed many landmark laws over the
last five or ten years.
But one thing I have learned our job does not stop at the
signing ceremony. We must monitor the implementation as it goes
through the agency process and be sure that the agencies are
implementing the law as Congress intended and we can accomplish
that through oversight hearings and implementation hearings.
We need to monitor what is or what is not working, what
deadlines the agencies might have missed. I appreciate that we
have agency witnesses here today and I promise I will take full
advantage of that.
But I hope we will have a separate implementation hearing
soon. I also hope that any future legislative hearings will
include some of the outstanding issues such as aligning 42 CFR
Part 2 with HIPAA, a bipartisan effort that Representatives
Mullin and Blumenauer have championed and passed the House by a
vote of 357 to 57 in the last Congress.
The 14 bills before us today cover a broad range of ways to
address substance use disorder, from solving problems with
suspicious orders to requiring increased levels of education
and training.
A number of these have the potential to provide quality
assistance to individuals with substance use disorders and to
prevent future addiction. As we look at these bills we must be
mindful of what we did in the SUPPORT Act to ensure that there
are not duplicative provisions or policies that will complicate
the implementation of the SUPPORT Act.
I especially appreciate the inclusion of Representative
Griffith's H.R. 4812, the Ensuring Compliance Against Drug
Diversion Act of 2019, and Representative McKinley's H.R. 3878,
the Block, Report, and Suspend Suspicious Shipments Act of
2019.
H.R. 4812, Mr. Griffith's bill, requires that the DEA
registrants must obtain written consent from the DEA to assign
or transfer a registration. This is a common sense step to
prevent fraud and maintain up-to-date DEA records.
Mr. Griffith's bill, H.R. 3878, builds off the Oversight
and Investigations' important work last Congress on opiate pill
dumping, particularly in the state of West Virginia. The
sharing and reporting of suspicious order data is critical in
ensuring we can prevent similar situations in the future.
While I appreciate that the attention of H.R. 2483, the
Mainstreaming Addiction Treatment Act of 2019, which is to
increase the availability of medication-assisted treatment. We
still do not have the reports that were mandated in the last
legislation that we passed in the SUPPORT Act as to whether
expanding prescribing power under the data waivers has made a
meaningful difference.
I understand that access to buprenorphine is important,
sometimes limited, especially in rural areas. But we need to
make certain that the policies for which we are advocating are
effective and we should allow our current laws to be enacted
and examined.
I do have concerns with H.R. 3414, the Opiate Workforce
Act, as it would require the secretary of the Department of
Health and Human Services to establish an additional 1,000
residency positions paid for by the Medicare program for the
purpose of combating the opiate epidemic.
Ensuring an adequate workforce can certainly be part of
this discussion. But we need to keep in mind the danger of
having a centralized government dictate how many healthcare
professionals we need practicing which specialties. We already
have health professional shortages and establishing this new
requirement could create shortages in other areas.
While I am grateful we are having the conversation today,
the crisis continues to ravage communities across our nation.
We have all heard from our constituents who have been affected
in one way or another.
I hope we will be able to soon have a standalone SUPPORT
Act implementation hearing to do our due diligence in ensuring
that the law is having a positive impact on our communities.
Thank you, and I will yield back my time.
[The prepared statement of Mr. Burgess follows:]
Prepared Statement of Hon. Michael C. Burgess
Thank you, Madam Chair. I appreciate that we are holding a
hearing to continue this subcommittee's important work on
addressing the opioid epidemic in our nation. Last Congress, we
conducted a Member-driven process that began with an Energy and
Commerce Committee Member day and concluded with President
Trump signing the SUPPORT for Patients and Communities Act into
law. Throughout that process, we held four Health Subcommittee
hearings, one subcommittee markup, and two full committee
markups. This process allowed Members to hear from relevant
stakeholders, ask questions, and offer amendments to improve
the legislation under consideration.
While I am grateful we are continuing our work on opioids,
I do still believe it is critical we have a standalone SUPPORT
Act implementation hearing. Our job does not end at the signing
ceremony.
We must continue to ensure that the agencies are
implementing our laws as Congress intended through oversight.
We need to monitor what is or is not working or what deadlines
the agencies have missed. I appreciate that we have some agency
witnesses here today and will take advantage of that, but I
hope we will have a separate implementation hearing soon.
I also hope that any future legislative hearings will
include outstanding issues, such as aligning 42 CFR Part 2 with
HIPAA--a bipartisan effort Reps. Mullin and Blumenauer have
championed, and which passed the House by a vote of 357-57 last
Congress.
The 14 bills before us today cover a broad range of ways to
address substance use disorder, from solving problems with
suspicious orders to requiring increased levels of education
and training.
A number of these have the potential to provide quality
assistance to individuals with substance use disorders and to
prevent future addiction. As we look at these bills, we should
be mindful of what we did include in the SUPPORT Act to ensure
that there are not duplicative provisions or policies that will
complicate implementation of SUPPORT Act.
I especially appreciate the inclusion of Rep. Griffith's
H.R. 4812, the Ensuring Compliance Against Drug Diversion Act
of 2019, and Rep. McKinley's H.R. 3878, the Block, Report, and
Suspend Suspicious Shipments Act of 2019. H.R. 4812 requires
that DEA registrants must obtain written consent from DEA to
assign or transfer a registration. This is a commonsense step
to prevent fraud and maintain up-to-date DEA records.
H.R. 3878 builds off the Oversight and Investigation's
important work last Congress on opioid pill dumping,
particularly in West Virginia. The sharing and reporting of
suspicious order data is critical in ensuring we can prevent
similar situations in the future. This bill will also hold
manufacturers and distributors accountable in that effort.
While I appreciate the intention of H.R. 2483, the
Mainstreaming Addiction Treatment Act of 2019, which is to
increase the availability of medication assisted treatment, we
still do not have the reports mandated by the SUPPORT Act as to
whether expanding prescribing power under the DATA waivers has
made a meaningful difference. I understand that access to
buprenorphine is limited, especially in rural areas, but we
should make sure that the policies for which we are advocating
are effective and should allow our current laws to play out.
I do have concerns with H.R. 3414, the Opioid Workforce
Act, as it would require the Secretary of the Department of
Health and Human Services to establish an additional 1,000
residency positions, paid for by the Medicare program, for the
purpose of combating the opioid epidemic. Ensuring an adequate
workforce can certainly be part of this discussion, but we need
to keep in mind the dangers of having the government dictate
how many healthcare professionals we need practicing certain
specialties. We already have healthcare professional shortages
and establishing this new requirement could create new
shortages in other areas.
I am grateful we are having this conversation today because
the opioid crisis continues to ravage communities across our
nation. We have all heard from constituents who have been
affected in one way or another by this epidemic, and it
deserves our attention.
I hope that we will be able to have a standalone SUPPORT
Act implementation hearing to do our due diligence in ensuring
that the law is having a positive impact on communities, and to
address any other issues as they evolve.
Thank you, Madam Chair. I yield back.
Ms. Eshoo. The gentleman yields back.
It is a pleasure to recognize the chairman of the full
committee, Mr. Pallone, for his 5 minutes for his opening
statement.
OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Madam Chair.
Today, the subcommittee will continue its bipartisan work
to combat an ongoing and devastating epidemic involving opioids
and substance use.
We all know the statistics. In 2018, over 67,000 Americans
died from a drug overdose. Well over half of these deaths
involved opioids. There are approximately 20 million Americans
living with a substance use disorder while only a fraction are
receiving treatment.
This committee has taken action to reverse this trend. We
advanced major pieces of legislation through the committee in
recent years, including the Comprehensive Addiction and
Recovery Act, the 21st Century Cures Act, and the SUPPORT for
Patients and Communities Act.
These were important legislative achievements that invested
in critical treatment and I look forward to hearing from our
witnesses about the implementation of these laws, and what gaps
remain to be addressed.
Nationwide, opioid prescribing rates and overdose deaths
are decreasing but our work in fighting this epidemic is far
from over. There are still a lot of people and communities
struggling and we must continue to do more.
We must also address the emergence of synthetic opioids
like illicit fentanyl, and the rise in deaths attributed to
stimulants like cocaine and methamphetamine.
Our first panel of witnesses includes officials from both
the Department of Health and Human Services and the Drug
Enforcement Administration. I look forward to hearing more
about the progress the administration has made in implementing
the SUPPORT Act.
Among some of the key provisions of this law, HHS was
charged with providing grant support and guidance to states and
other stakeholders, while DEA was charged with issuing
telemedicine regulations aimed at helping more patients in
areas with doctor shortages, and I hope to drill down on these
provisions and many others.
I am concerned that the administration may be falling
behind on some of the deadlines in the SUPPORT Act and I want
to understand why that is happening.
Our second panel includes experts on the ground of this
epidemic, all of which are working to turn the tide for
Americans across this country.
I look forward to hearing testimony about the impact that
recent federal funding and policy changes are having and what
more we can do. I thank all of our witnesses for their ongoing
dedication.
As I said, when all the prior substance use packages passed
out of this committee, we have made progress, but our work is
far from complete. So today, we will be considering 14 pieces
of legislation aimed at providing more help and more resources
to those still struggling across the country.
Some of these policies were Democratic priorities that were
not included in the SUPPORT Act but that we continue to feel
are critical to effectively responding to this national
epidemic. Others are new ideas to address new and emerging
problems that my colleagues on both sides of the aisle have
identified.
The unique jurisdiction of this subcommittee spans the work
of both HHS and DEA, which allows us to approach this problem
from multiple angles. That said, it is critical that we look at
substance use disorder as a complex but treatable disease of
the brain.
Whether an individual has a substance use disorder in a
hospital or within a criminal justice setting, they are a
patient and we must address this epidemic as the true public
health crisis that it is.
Many of the bipartisan bills we will be discussing today
take this public health approach. This includes proposals to
address the need for more addiction medicine providers, to
dismantle barriers to treatment, and to bolster public health
and recovery programs in the states.
And I thank all my colleagues for your continued dedication
to combating this devastating epidemic.
[The prepared statement of Mr. Pallone follows:]
Prepared Statement of Hon. Frank Pallone, Jr.
Today, the Subcommittee will continue its bipartisan work
to combat an ongoing and devastating epidemic involving opioids
and substance use.
We all know the statistics. In 2018, over 67,000 Americans
died from a drug overdose--well over half of these deaths
involved opioids. And there are approximately 20 million
Americans living with a substance use disorder--while only a
fraction are receiving treatment.
This Committee has taken action to reverse this trend. We
advanced major pieces of legislation through the Committee in
recentyears--including the Comprehensive Addiction and Recovery
Act, the 21st Century Cures Act, and the SUPPORT for Patients
and Communities Act. These were important legislative
achievements that invested in critical treatment. I look
forward to hearing from our witnesses about the implementation
of these laws, and what gaps remain to be addressed.
Nationwide, opioid prescribing rates and overdose deaths
are decreasing, but our work in fighting this epidemic is far
from done. There are still a lot of people and communities
struggling and we must continue to do more. We must also
address the emergence of synthetic opioids like illicit
fentanyl and the rise in deaths attributed to stimulants like
cocaine and methamphetamine.
Our first panel of witnesses includes officials from both
the Department of Health and Human Services (HHS) and the Drug
Enforcement Administration (DEA). I look forward to hearing
more about the progress the Administration has made in
implementing the SUPPORT Act. Among some of the key provisions
of this law, HHS was charged with providing grant support and
guidance to states and other stakeholders, while DEA was
charged with issuing telemedicine regulations aimed at helping
more patients in areas with doctor shortages. I hope to drill
down on these provisions and many others. I am concerned that
the Administration may be falling behind on some of the
deadlines in the SUPPORT Act, and I want to understand why this
is happening.
Our second panel of witnesses includes experts on the
ground of this epidemic--all of which are working to turn the
tide for Americans across this country. I look forward to
hearing testimony about the impact that recent federal funding
and policy changes are having, and what more we can do. I thank
all of our witnesses for their ongoing dedication to the
communities they serve.
As I said when all the prior substance use packages passed
out of this Committee--we have made progress, but our work is
far from complete. So today, we will be considering 14 pieces
of legislation aimed at providing more help and more resources
to those still struggling across the country. Some of these
policies were Democratic priorities that were not included in
the SUPPORT Act, but that we continue to feel are critical to
effectively responding to this national epidemic. Others are
new ideas to address new and emerging problems that my
colleagues on both sides of the aisle have identified.
The unique jurisdiction of this Subcommittee spans the work
of both HHS and DEA, which allows us to approach this problem
from multiple angles. That said, it is critical that we look at
substance use disorder as a complex but treatable disease of
the brain. Whether an individual has a substance use disorder
in a hospital or within a criminal justice setting--they are a
patient. We must address this epidemic as the true public
health crisis it is.
Many of the bipartisan bills we will be discussing today
take this public health approach. This includes proposals to
address the need for more addiction medicine providers, to
dismantle barriers to treatment, and to bolster public health
and recovery programs in the states.
I thank all my colleagues for your continued dedication to
combating this devastating epidemic.
Thank you, I yield the remainder of my time.
And I yield the remaining time to my colleague from New
Mexico, Mr. Lujan
Mr. Lujan Thank you, Chairman Pallone, and I am proud to
have Lauren Reichelt, the Health and Human Services director
for Rio Arriba County in New Mexico here with us in DC Rio
Arriba County is a state-funded behavioral health investment
zone.
In the past five years, they have made incredible progress
in reducing overdoses and overdose deaths with intensive case
management to connect patients to services. We should learn
from their success.
Coordinating only works when there is treatment available.
One way we can ensure more patients have access to the
treatment they need is by eliminating outdated requirements for
providers who are qualified and willing to provide medication-
assisted treatment. That is why Congressman Tonko and I
introduced the Mainstreaming Addiction Treatment Act. In states
where there are high rates of substance use disorder and a
shortage of healthcare providers, removing these hurdles is an
easy step that will immediately improve access to treatment.
I would also like to highlight Project ECHO, a
telementoring program for health professionals developed at the
University of New Mexico by Dr. Sanjeev Arora. ECHO has a
curriculum to support rural primary care providers who want to
start or expand medication-assisted treatment in their
communities.
Nearly 90 programs in 40 states are using ECHO to treat or
prevent substance use disorder. I urge my colleagues to yet
again come together and work together on this issue as we have
in the past.
And I thank the chairman. I yield back.
Ms. Eshoo. The gentleman yields back. Is there anyone on
the Republican side that would like to claim the time since Mr.
Walden is not here?
If not, we will go directly to our witnesses.
So I would like to introduce our first panel and thank them
for being here with us today. Admiral Brett Giroir--beautiful
name. Thank you, and welcome to you. He is the assistant
secretary for health and senior advisor to the secretary on
opioid policy, U.S. Department of Health and Human Services.
Ms. Kimberly Brandt, principal deputy administrator for
policy and operations, Centers for Medicare and Medicaid
Services. Welcome to you.
And Mr. Thomas Prevoznik, welcome to you, sir. Deputy
assistant administrator, diversion control.
So we look forward to your testimony. I think you are
probably familiar with the lights. Green is go, yellow is a
warning, and everyone knows what a red light is, right? Stop
sign, so and you have a minute remaining when the light turns
yellow.
So Dr. Giroir, you can begin your testimony. You have 5
minutes. Make sure your microphone is on, and we look forward
to hearing you.
STATEMENTS OF ADM BRETT P. GIROIR, M.D., ASSISTANT SECRETARY
FOR HEALTH AND SENIOR ADVISOR TO THE SECRETARY ON OPIOID
POLICY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; KIMBERLY
BRANDT, PRINCIPAL DEPUTY ADMINISTRATOR FOR POLICY AND
OPERATIONS, CENTERS FOR MEDICARE & MEDICAID SERVICES; THOMAS W.
PREVOZNIK, DEPUTY ASSISTANT ADMINISTRATOR, DIVERSION CONTROL
DIVISION, DRUG ENFORCEMENT ADMINISTRATION
STATEMENT OF BRETT P. GIROIR, M. D.
Dr. Giroir. Thank you, Chair Eshoo, Ranking Member Burgess,
and distinguished members of the committee. Thank you for the
opportunity to update you on the status of America's overdose
epidemic, HHS's implementation of the SUPPORT Act, and how the
SUPPORT Act has catalyzed our efforts to address America's
evolving substance use crisis.
Because of the SUPPORT Act, we have enhanced the scale and
effectiveness of HHS's substance use-related programs within
the HHS strategy designed to achieve the following five
objectives.
One, improve the access to prevention, treatment, and
recovery services.
Two, strengthen public health data reporting and collection
to inform real-time public health responses.
Three, advance the practice of pain management.
Four, enhance the availability of overdose reversing
medications, namely, naloxone.
And five, support cutting-edge research that improves our
understanding of pain and use disorders, leads to new
treatments, and identifies effective public health
interventions.
In my opening statement, I will provide just a few examples
of how the SUPPORT Act has directly benefitted and enabled HHS
programs.
First, MAT, or medication-assisted treatment, is a standard
of care essential component of evidence-based treatment.
Section 3201 of the SUPPORT Act broadened eligibility to allow
other qualified practitioners like nurse-midwives and clinical
nurse specialists to become trained and prescribe
buprenorphine.
Section 3201 has contributed significantly to the now over
110,000 providers currently approved to prescribe buprenorphine
and that translates into over 1.3 million Americans now
receiving MAT.
Similarly, Section 3202 decreases the burden on physicians
who have received appropriate training in medical school to
obtain a waiver to prescribe MAT. SAMHSA has already provided
48 grants to universities to train providers to became data
waived immediately upon graduation and we will continue this
program in fiscal year 2020.
To further strengthen public health data reporting and
collection, Section 7162 authorizes the CDC's support for
states to improve their prescription drug monitoring programs,
or PDMPs.
To implement this provision, in 2019 CDC awarded $301
million in cooperative agreements through the Overdose Data to
Action program, which will enable providers to make better
clinical decisions.
And very important to me as a physician, the program funds
the effort to assure PDMPs are easy to use and do not interrupt
the physician-patient relationship.
Section 7041 of the SUPPORT Act recognizes the critical
importance of cutting--edge research. In fiscal year 2019, NIH
awarded $945 million through their HEAL initiative for such
topics as basic and applied research on pain, new approaches in
medications to treat addiction, treatment of infants with NAS,
and perhaps most immediately impactful, the $350 million
Healing Communities Study aimed at reducing overdose mortality
by 40 percent within three years in communities in Kentucky,
Massachusetts, New York, and Ohio.
So where are we now? Since 1999, over 810,000 Americans
died of drug overdoses, the majority of which were caused by
opioids, and the latest data from our National Survey on Drug
Use and Health showed that approximately two million Americans
currently have an opioid use disorder.
But we are making progress. Over 1.1 million fewer
Americans misused opioids last years compared to the year
before. The total amount of opioids prescribed to Americans
decreased 32 percent since January 2017 and naloxone
prescriptions have increased by 405 percent in addition to the
literally millions of doses that have been directly distributed
to those at risk, first responders and family members.
As a result of these and other whole of society programs,
drug overdose deaths fell by 4.1 percent in 2018 compared to
2017, the first year to year decrease in deaths in almost three
decades.
But we have a long way to go and we should not believe for
one moment that the crisis is over or even substantially
abating. While deaths from prescription opioids continue to
decrease, deaths associated with synthetic opioids like
fentanyl continue to rise at approximately ten percent
annually.
Even more concerting, data indicate that we have now
entered the fourth wave of the crisis, characterized by a
shocking increase in deaths from methamphetamine.
From 2012 to 2018, the rate of drug overdose deaths
involving methamphetamine increased by nearly 500 percent and
our most recent data demonstrate that that continues to
increase 25 to 30 percent annually.
Certainly, as the assistant secretary for health but also
as a physician, parent, and grandparent, I want to thank you
all, all the members of Congress, for your visionary work on
the SUPPORT Act. I am absolutely certain that working together
we can provide Americans with not only hope but the lifesaving
results they deserve.
Ms. Eshoo. Thank you very much, Admiral.
I now would like to recognize Ms. Brandt. You have 5
minutes for your testimony and thank you again for being with
us.
STATEMENT OF KIMBERLY BRANDT
Ms. Brandt. Thank you.
Chairwoman Eshoo, Ranking Member Burgess, and distinguished
members of the subcommittee, thank you for inviting me to
discuss the Centers for Medicare and Medicaid Services' work to
combat the opioid epidemic.
CMS is committed to a comprehensive strategy to address
this public health crisis and we appreciate Congress's
leadership in passing the SUPPORT Act, which has given us
important new tools to use in this fight.
Over 140 million people receive health coverage through CMS
programs and the opioid epidemic affects every one of them as a
patient, family member, caregiver, or community member.
The SUPPORT Act was a historic step in helping us address
the opioid epidemic. CMS has implemented 18 of its 49
provisions to date and is hard at work to build on that
progress.
Just yesterday we completed a provision with the issuance
with a state health official letter that provides guidance to
states on enhanced behavioral health coverage for separate
children's health insurance programs as required by Section
5022 of the SUPPORT Act.
This, and all of our opioid work, is focused on three
goals: improving prevention, expanding treatment, and using
data.
Key components of any strategy to combat this crisis
include insuring that opioid prescriptions are limited to those
patients who have a clinical need and prescriptions follow
appropriate safeguards.
CMS expects all our Part D sponsors to limit initial opioid
prescriptions for acute pain to no more than a seven-day
supply, which is consistent with guidelines issued by the
Centers for Disease Control and Prevention.
We have seen progress in this area. The number of those
receiving opioids for the first time who were prescribed
opioids of seven days or less increased from 68 percent in 2017
to 75 percent in 2018.
Also in 2018 the percentage of Part D beneficiaries who
were prescribed opioids fell to 29 percent, down from 35
percent in 2013. As a payer for opioid use disorder, or OUD
treatment, CMS plays an important role by incentivizing
clinicians to provide the right services to the right patients
at the right time while at the same time working to expand the
services that are available to our beneficiaries.
Beginning this January, for the first time CMS is now
covering OUD treatment services furnished by opioid treatment
programs in Medicare Part B. As of mid-February, 334 out of
about 1,500 opioid treatment programs have already enrolled in
Medicare with another 400- plus in the application queue.
As part of our prevention efforts, we are also reviewing
coverage and payment barriers for non-opioid pain relief. As of
January, Medicare now covers acupuncture for Medicare patients
with chronic lower back pain. This is a significant expansion
of our non-opioid treatment options.
We are building on important lessons learned from the
private sector in this critical aspect of patient care. Over-
reliance on opioids for people with chronic pain is one of the
factors that led to this crisis. So it is vital that we offer a
range of treatment options for our beneficiaries.
The opioid epidemic has had a significant on some of our
most vulnerable beneficiaries and the surge in substance use
related illness and deaths in recent years has particularly
affected pregnant women.
In response, CMS had developed the maternal opioid misuse,
or MOM, model. The model addresses fragmentation in the care of
pregnant and post-partum Medicaid beneficiaries with OUD
through state-driven transformation of the delivery system
surrounding this vulnerable population.
But supporting the coordination of clinical care and the
integration of other services critical for health, well-being
and recovery, the MOM model has the potential to improve
quality of care and reduce costs for mothers and infants. CMS
has ordered ten states a total of $64.5 million for this five-
year model.
We have also worked collaboratively with our state partners
to provide the flexibility they need to meet the unique needs
of their populations through Medicaid Section 1115
demonstrations targeting substance use disorder treatment.
In November of 2017, we announced a streamline process for
states interested in covering the continuum of OUD services
including inpatient care, and to date, we have approved 27 SUD
treatment waivers and we are starting to see results from
those.
Virginia has experienced a four percent decrease in acute
inpatient SUD admissions during the first ten months of
implementation, along with a six percent decrease in opioid use
disorder inpatient admissions.
Finally, responding quickly and effectively to the changing
nature of the crisis requires easily accessible data and CMS
has leveraged our wealth of data to confront the crisis.
In November of 2019, we released the Substance Use Disorder
Data Book, the first nationwide analysis using data from
Medicaid's new data system that transformed Medicaid's
Statistical Information System, or T-MSIS.
As required by Section 1015 of the SUPPORT Act, the Data
Book details Medicaid beneficiaries' SUD diagnosis, enrollment
type and service utilization by state to help CMS, researchers,
and policymakers better understand where to focus their
efforts.
Along with the SUD Data Book, we released the underlying
data that we used to develop the report so that the states and
policymakers can understand their challenges in facing the
crisis.
With the SUPPORT Act, Congress has equipped CMS with
important tools to combat this emergency and we look forward to
continuing working toward our shared goals.
Thank you for your interest in our efforts and I look
forward to answering your questions.
[The prepared statements of Dr. Giroir and Ms. Brandt
follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you, Ms. Brandt.
Mr. Prevoznik, you have 5 minutes for your testimony. Thank
you again for being here with us today.
Put your microphone on, please.
Mr. Prevoznik. I am sorry.
Ms. Eshoo. That is all right. Get it close. Thank you.
STATEMENT OF THOMAS W. PREVOZNIK
Mr. Prevoznik. Chairwoman Eshoo, Ranking Member Burgess,
and distinguished members of the committee, on behalf of Acting
Administrator Dhillon and the Drug Enforcement Administration,
I appreciate the opportunity to update you on the actions of
DEA as well as our future intentions to combat the opioid
epidemic and protect public health and safety.
My name is Tom Prevoznik. I am the deputy assistant
administrator of the Policy Office in the DEA's Diversion
Control Division. I am a diversion investigator by training and
have been with the DEA since 1991.
As you know, on October 24th, 2018, President Trump signed
H.R. 6, the SUPPORT Act, into law. This legislation is a
comprehensive government-wide approach to reduce the national
opioid epidemic.
DEA was one of many entities charged to implement policies
and expand existing programs to obtain this goal. Although work
remains to be completed for DEA to fully execute the
requirements of this law, DEA has successfully implemented key
provisions to its enactment.
In October of 2019, DEA made available to all DEA
registrants the newly-created centralized database for
reporting suspicious orders. Specifically, this database was
created to better track suspicious orders and prevent the
diversion of controlled substances.
Also, in October of 2019, the DEA published a notice of
proposed rulemaking in the Federal Register to change
regulations that improved DEA's ability to oversee the
aggregate production quotas for Schedule One and Two controlled
substances.
The goal of these changes is to further limit excess
quantities of medications that might be diverted. The SUPPORT
Act also requires DEA to provide additional information from
the existing Automation Reports and Consolidated Order System,
or ARCOS, to monitor controlled substances.
In February of 2019, DEA enhanced the ARCOS Buyer Lookup
Tool. It now includes the total number of distributors and
total quantity and type of ARCOS reportable drugs, including
opioids, sold by each distributor to a pharmacy or
practitioner.
The SUPPORT Act also requires DEA to provide state law
enforcement and other entities standardized reports containing
analytical information on ARCOS distribution patterns.
DEA is currently providing these reports on a biannual
basis. DEA was also tasked with promulgating regulations that
will expand access to treatment and availability of controlled
substances in rural areas.
DEA is resolute in enacting regulatory obligations all in
the final step of the review process. An area of great interest
for DEA is the data contained in prescription drug monitoring
programs, or PDMPs.
PDMPs are state-run data collection programs that, when
used properly, could help prescribers, pharmacists, and law
enforcement prevent and identify over prescribing and
indiscriminate dispensing controlled substance prescriptions.
Currently, there are over 1.7 million practitioners
registered with the DEA, 71,000 pharmacies, and 18,000
hospitals. These registrants constitute 99.1 percent of the DEA
registrant population. Manufacturers and distributors, the
entities that report ARCOS reportable transactions, constitute
only .06 percent of registrants.
It is important to note that ARCOS data represents what is
received by a pharmacy, whereas PDMP data represents what is
dispensed by a pharmacy. At present, DEA's access to PDMP data
is limited to information relating to the ongoing investigative
matter. The means by which DEA obtains this information varies
from state to state with approximately half of the states
requiring some kind of court or grand jury process.
However, without PDMP data from every state, DEA faces
challenging knowledge gaps that hinder its ability to fight
prescription drug diversion, protect public health and safety.
Additionally, since the SUPPORT Act requires DEA to estimate
diversion and reduce manufacturers' quotas based on those
estimates, DEA requires access to state PDMP data to assist in
fulfilling its statutory obligation to calculate diversion.
I would like to thank our federal partners here at the
table today for our continued work together to address the
opioid crisis. The department and DEA thank Admiral Giroir for
his support and guidance in the collaborative efforts of the
department, DEA, CDC, HHS, OIG, and the Commission Corps to
address patient continuity and treatment for patients impacted
by enforcement actions taken on healthcare providers.
This is a collaborative effort in conjunction with state
departments of health contacts. The goal is to ensure that
persons suffering from addiction to opioids are provided
treatment resources.
Finally, I would be remiss if I didn't extend DEA's sincere
gratitude to the members of this subcommittee and Congress at
large for extending DEA's emergency order controlling fentanyl-
related substances.
However, this order will expire in May 2021 so a permanent
solution to a controlled fentanyl-related substances remains a
necessity for DEA and the department. We look forward to
working with this committee and others in the coming weeks and
months to find that permanent solution.
[The prepared statement of Mr. Prevoznik follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you very much. We have now concluded the
opening statements of our witnesses. We thank you again. We
will now move to members and I will recognize myself for 5
minutes.
First, I would like to enter into the record Inside Health
Policy report dated February 24th, 2020, titled
``Administration's Delays in Implementing Major Opioid Law
Hinder Efforts to Curb Crisis.''
Are there any objections?
Certainly. OK. I will move to my questions. But I just want
to comment. This report found that CMS has not published six
guidance documents required under the SUPPORT Act within the
statutory time frame.
So I want to begin with Ms. Brandt. I am going to describe
each guidance document and ask you to give me the date you
expect it to be published. The first document is about
reimbursement options for substance use disorder treatments,
including medication-assisted treatment than can be delivered
via telehealth. When do you expect this to be published?
Ms. Brandt. We expect to publish that----
Ms. Eshoo. Turn your microphone on.
Ms. Brandt. Apologies, Chairwoman. We expect to issue that
yet this spring. It is currently being in final----
Ms. Eshoo. Let us just keep it short. Spring means what----
Ms. Brandt. OK. Spring.
Ms. Eshoo. --April? May?
Ms. Brandt. Hopefully, no later than May.
Ms. Eshoo. All right. The first day of summer is June 21st
so----
Ms. Brandt. Duly noted.
Ms. Eshoo. The next document is about opportunities to
finance and improve family-focused residential treatment
programs. When do you expect that to be published?
Ms. Brandt. That is also one for this spring. May.
Ms. Eshoo. May. The next are recommendations for improving
care for infants with neonatal abstinence syndrome and their
families. When do you expect that to be published?
Ms. Brandt. We hope to have that one also this spring.
Hopefully, no later than May.
Ms. Eshoo. You are also behind on publishing a best
practices for ensuring Medicaid coverage of former foster
youth. When do you expect that to be published?
Ms. Brandt. That one we are currently working on. We hope
to have that by April.
Ms. Eshoo. Got a lot of work to do before spring. You are
also behind on publishing best practices for prescription drug
monitoring programs and privacy protections for Medicaid
beneficiaries. When do you expect that to be published?
Ms. Brandt. That is one we are working with our federal
partners on and we also expect that by the end of the spring.
Ms. Eshoo. By the end of spring. All right. Well, you have
a full portfolio there and we will track with you and to make
sure that they actually take place.
To the admiral, I would like to ask you what is the status
of your efforts in coordinating with NIH and FDA to support
research and development for nonopioid pain management?
Dr. Giroir. Thank you for that. There are efforts nearly
every day to do that. We are coordinating with all the
speciality societies to make sure that nonopioid uses are being
done. We have issued guidance on the appropriate tapering of
opioids. That was in the fall in substitution of other
activities.
The HEAL initiative, as you know, has applied research,
meaning not just in the, you know, in a laboratory and a mouse
but, really, applied research on pain management. That is, you
know, coordinated----
Ms. Eshoo. What is your--let me ask you this. What is your
assessment of a near outcome relative to the R&D?
Dr. Giroir. I am sorry, ma'am. I didn't----
Ms. Eshoo. The outcome of the R&D between NIH and FDA.
Dr. Giroir. Well, the research and development is ongoing.
Again, the HEAL initiative just started. There are----
Ms. Eshoo. It just began?
Dr. Giroir. Well, the funding for the HEAL initiative--
there was $945 million last year and there is ongoing research
with I think there is going to be very near-term deliverables.
It is really defined--you know there is some basic research
that will take years or a decade to go but there are near-term
deliverables with actual clinical trials, including neonatal
abstinence syndrome, including----
Ms. Eshoo. And when do you expect those clinical trials to
begin?
Dr. Giroir. Oh, most of these have already begun. We expect
new--you know, new data, new results, on an ongoing basis.
Ms. Eshoo. But where are they? I mean, the first trial is
the easy one. Second phase is longer, more expensive. I still
don't have a sense of exactly where we are and when--I mean,
are deliverables three years off? Two years off? Four years
off?
Dr. Giroir. So deliverables are being done now. As we said,
opioid prescribing is down almost 34 percent even in the last
two years. Substitution of ibuprofen, multi-modal management--
that is all going on now with existing technologies that we
use.
Ms. Eshoo. Those are the easy things.
Dr. Giroir. But they are also effective. They are also very
effective. There are trials--
Ms. Eshoo. Oh, I am not--I am not diminishing that. I am
just saying those are the easy things.
Well, I think that my time has expired and I now recognize
the ranking member for his 5 minutes of questions.
Mr. Burgess. Just before we start my time, my initial
perusal of this, since I am quoted accurately, I will not
object to its inclusion.
Ms. Eshoo. So ordered.
[The information appears at the conclusion of the hearing.]
Ms. Eshoo. I wouldn't think of putting something in the
record where you are misquoted, Doctor.
Mr. Burgess. Mr. Prevoznik, let me just ask you a couple of
questions about the PDMP because, of course, that is something
this committee worked on, really, since my first term in this
committee so many, many years ago and with the several time
reauthorization of NASPER, to the extent that you are able to
utilize it in your investigative activity, has that been
helpful?
Mr. Prevoznik. Absolutely.
Mr. Burgess. So what extent are you utilizing PDMP data? Is
that something that happens frequently or just occasionally?
Mr. Prevoznik. It is typically used in investigative
matters so the current investigations that we are doing it we
will--the access is through each state. So it varies state by
state how we gain access to that data. But it is case specific.
Mr. Burgess. And just to refresh everyone's memory is
there--may a physician or other practitioner query the PDMP
before issuing a prescription to a patient?
Mr. Prevoznik. That, again, varies by state by state,
whether the state requires the prescribers or the pharmacist.
DEA fully encourages all prescribers, all pharmacists, to look
at the PDMP data either prior to or at whatever point that they
feel that they need to look at to assess the patient that is in
front of them.
Mr. Burgess. So yes, that is the aspect I was going to
get--if we want it to be effective; preventative medicine
probably works best. Query before writing the prescription. I
think that is something that maybe some of our follow-up can
look at as to how that is working, what are the best practices
of various states--other ways we can extend that best practice
to other participants.
On the--Admiral Giroir and Ms. Brandt, on the--in Section
5052 of the SUPPORT Act there's an option for state Medicaid
programs to cover care for 21 to 64-year-olds in certain
institutions for mental disease--the so-called IMD exclusion--
which otherwise would not have been federally reimbursement--
federally--eligible for federal reimbursement because of the
IMD exclusion. So how many states have utilized or expressed
interest in utilizing this option?
Ms. Brandt. Sir, we issued guidance to states in November
of last year on this and we are working with states and, as of
yet, we are still working to assess their interest.
Mr. Burgess. That is really too soon to tell because last
November was--this is--you know, we all see the problems, the
news stories about the numbers of homeless in various cities
and I think it was Dr. Drew who correctly identified it is one
thing to put someone in an apartment or a room but you are not
going to fix their homelessness.
The cause of their homelessness if you don't address the
underlying mental health disorder and so oftentimes that is a
substance use disorder. So to the extent--and I do want to
continue to work with you. I know there are other pieces of
legislation out there--the IMD exclusion, I recognize it is
expensive when you get the Congressional Budget Office
involved.
But it does seem to me that we are being penny-wise and
pound-foolish in not making the investment in the actual fixing
the problem for someone rather than just continuing to respond
to their symptoms.
Are there any other tools that you think would be helpful
for the states or the Center for Medicare and Medicaid Services
to increase utilization of this option?
Ms. Brandt. I think continuing to have a dialogue with
members such as yourself and continuing to talk to the states
about this option and the flexibilities they need is really
what we think would be most helpful so that we can understand
exactly where the issues are and how we can best used our
levers to help with them.
Mr. Burgess. And, Dr. Giroir, do you have anything to add?
Dr. Giroir. I don't have--I don't have anything to add to
that.
Mr. Burgess. Well, I do hope that is one of the things that
we, as a committee--as a subcommittee--can explore because I
think it is terribly important.
One of the things, and Admiral, you mentioned in your five-
point strategy the alternative pain treatments for alternative
management of pain. So how are we doing? What actions is HHS
taking to address the alternative pain treatments?
Dr. Giroir. Thank you for that. There are both informal
mechanisms and formal mechanisms. The formal mechanisms often
come through CMS issuing a number of guides and guidelines to
all practitioners about the use of alternative pain medications
including, most recently, acupuncture but also the normal
things that we do, and as you understand, most of this is
driven by our interactions with medical societies.
Mr. Burgess. Yes. I would be interested to know what the
discussion was about the coverage determination for
acupuncture. Were commercial insurance companies covering that
and CMS was late to the table or was CMS on the vanguard here?
Ms. Brandt. There are some private insurers which were
covering it. We did, certainly, consulted with the private
insurers. But this was a groundbreaking and very aggressive
move on our part to cover this particularly in a broad base,
not just in a clinical capacity.
Mr. Burgess. OK. Thank you. I yield back.
Ms. Eshoo. The gentleman yields back. It is a pleasure to
recognize the gentlewoman from California, Ms. Matsui, for her
5 minutes of questions.
Ms. Matsui. Thank you very much, Madam Chair.
Addiction is a devastating disease that knows no bounds and
we must provide solutions in a comprehensive manner. This
includes extending and expanding community- based behavior
health clinics, improving enforcement of mental health parity
laws, putting greater transparency on the drug supply chain,
and addressing outstanding barriers to using telehealth to
expand access to care.
Telemedicine is a critical tool that should be leveraged to
expand the ways a patient can receive medication-assisted
treatment, especially in rural areas. That is why I
reintroduced the Improving Access to Remote Behavioral Health
Treatment with several of my colleagues on this committee.
The Ryan Haight Act of 2008 allowed for legitimate entities
to register with DEA to use telemedicine to remotely prescribe
controlled substances in a regulated way. However, these
guidelines were never issued.
As such, Congress included in H.R. 6, the SUPPORT Act, a
provision requiring DEA to issue regulations around the special
registration process within one year of enactment of the law.
SUPPORT was passed into law in October 2018. As of today, DEA
still has not set the ground rules for providers with a special
registration to prescribe controlled substances.
Mr. Prevoznik, can you provide an update on the agency's
work on the special registration rule? When can we expect the
proposal to be published?
Mr. Prevoznik. Thank you for that question. Telemedicine is
being practiced today, being done now. The regs are in the
review process. As I said, we are in the final stages of the
review process. It is very much an interagency process in that
it is not just DEA equities that are involved in this.
This is a lot of different equities that are involved from
various agencies and we want to ensure that patients are truly
getting legitimate care and that we do not reopen this up to
the Wild West, which required the passing of the Ryan Haight
Act. So we are working very closely with our interagency
partners on this. We are working diligently and very hard to
get it done.
Ms. Matsui. Well, thank you. It has been 11 years since the
Ryan Haight Act originally called for this process and amid
this addiction epidemic, we have to expand access to treatment,
particularly through legitimate community addiction and mental
health centers that are regulated in a way that does not
currently comply with the DEA registration process, and I urge
the agency to issue a proposal as soon as possible.
Current regulations require all DEA-registered
manufacturers, distributors, and dispensers of controlled
substances report suspicious orders to DEA. These suspicious
orders may include orders of unusual size, orders deviating
substantially from a normal pattern, and orders of unusual
frequency, which could indicate that controlled substances are
being diverted out of legitimate use.
Among other things, the SUPPORT Act tasks DEA with
evaluating the utility of real-time reporting of suspicious
orders.
Mr. Prevoznik, to what extent has the DEA engaged in
capabilities to develop a system to identify real-time reports
and how does the DEA propose to share this data with suppliers
before orders are filled?
Mr. Prevoznik. I appreciate that question as well. As you
know, in October, we--October 23rd we released the newly-
created centralized database to report suspicious orders. This
requires all registrants that distribute amongst registrants to
report suspicious orders.
Currently right now, we are getting data that is inputted.
Prior to that, we did not have that data into that newly-
created centralized database system. We want to ensure that the
data that is in there is it valid and correct because garbage
in is garbage out. So we are working with the industry as well
to ensure that the data that is going in there is correct and
valid, and then that data will be shared with the state
attorney generals. We are working on a portal system now to
share that data with the state attorney generals law
enforcement.
Ms. Matsui. Well, thank you. We just want to make sure that
we do this in a timely manner because it does hinder the
ability of manufacturers and distributors to identify
suspicious activity and that is why Representative Johnson and
I have introduced the Suspicious Order Identification Act of
2019, legislation that sets up a workable real-time reporting
system through DEA to help us prevent diversion and maintain
integrity in the supply chain.
We would like this going--I understand what you mean
about--you know, garbage in--But, you know, we really need to
do this in an expeditious manner and I believe you can handle
this. So, please, we have this law--this bill going through the
process right now, bipartisan. We would like to have it done.
Thank you. Yield back.
Ms. Eshoo. The gentlewoman yields back. A pleasure to
recognize Dr. Bucshon for his 5 minutes of questions.
Mr. Bucshon. Well, thank you very much.
There is one of the bills that we are talking about today
that I want to express some concerns about. It is H.R. 2482,
Mainstreaming Addiction Treatment Act of 2019. This would--it
eliminate the separate registration requirement for dispensing
narcotic drugs in Schedule III, IV, or V such as buprenorphine
for maintenance or detoxification treatment and for other
purposes.
My concerns are that buprenorphine can be effective if
administered by properly educated and trained providers who
counsel and educate the patient. However, the vast majority of
individuals currently receive--are receiving no counselling.
Medication-assisted treatment may not be effective unless
there is a more comprehensive treatment plan in place, and so
my concern of waiving a DEA requirement is significant.
I have been working in this--in Congress to implement
prescribing limits and increase prescribers education for
buprenorphine to mitigate the practices that led to the current
opioid epidemic.
However, some of my friends in Congress continue to want to
expand the scope of practice to allow almost anyone regardless
of their qualifications and/or training to prescribe
buprenorphine, and there are other medication-assisted
treatments but we seem to be focusing on this one.
In my opinion, that is exactly what H.R. 2482, the
Mainstream Addiction Treatment Act does. It removes education
requirements and limits making it easier to prescribe a
medication known to be highly diverted and misused.
The bill may only expand access to the medication but not
real and effective treatment for individuals with substance
abuse disorder.
The last thing Congress should be doing, in my view as a
physician, is limit and relax requirements for prescribing and
dispensing narcotic drugs like buprenorphine, even when there
is political pressure and sometimes social pressure to do so.
With that said, I have a few questions. Pain management is
real and we must all look to find nonopioid alternatives to use
to help individuals that suffer from pain daily.
Admiral, I want to thank you for making improving pain
management a key component of the HHS opioid strategic plan and
for your leadership of the Pain Best Practices Task Force.
Can you tell us specifically what HHS is doing to promote
pain best practices and improve patient and provider education
about nonopioid alternatives?
Dr. Giroir. Yes, sir. Thank you for that.
There are both formal and informal mechanisms. Again, we
tend to use CMS as a formal mechanism to reach all prescribers
with their guidelines and guidances about nonopioid treatment
and, again, we are not just talking about acupuncture but we
are talking about the things that you and I know to do--anti-
inflammatory agents, multi-modal behavioral therapy. All those
things are there.
Mr. Bucshon. And there may--and there is devices, medical
devices that can be useful.
Dr. Giroir. And devices. We are in really a
transformational period of understanding how medical devices in
and of themselves can control or modify pain to a great degree.
And, again, this is an interagency process. As you also know,
the medical societies have really taken this up on their own
with individual guidelines for dental procedures, for
outpatient surgery, for knees, hips--all the issues. So we are
working with them actively and on a weekly basis.
Mr. Bucshon. Great. And Ms. Brandt, the HHS pain management
report calls for breaking down barriers, improving patient
access, and expanding coverage to nonopioid treatment options
for pain. Will the task force recommendations be reflected in
the forthcoming CMS Opioid Action Plan?
Ms. Brandt. Yes. We plan on using that as well as
information we got from a request for information that we
issued last fall where we specifically asked for input on
things that have enhanced or impeded access to nonopioid
treatment so that we can take that into account as well.
Mr. Bucshon. Great. That is important. I just want to say
as a physician I do think that the physician community is
becoming more and more aware of their prescribing habits. I
will speak specifically for Indiana.
That is based on a lot of factors, both state and federal--
the federal government but also on the media and the society at
large, and I think our physicians are trying to do their part
to help mitigate this opioid crisis.
I do, again, want to reiterate my concerns about lifting
regulatory requirements on qualifications required to prescribe
these medications for MAT and I think that they are there for a
reason. Although I am for expanding treatment but in--but,
again, as a physician, I have serious concerns about expanding
the treatment in that way.
So with that, and I also want to thank the chairwoman for
this hearing, for all of these opioid-related bills as it is a
critical problem that our nation needs to continue to address.
I yield back.
Ms. Eshoo. The gentleman yields back and I appreciate the
good words. Let us see who is next.
The gentleman from California, Dr. Ruiz, is recognized for
5 minutes.
Mr. Ruiz. Thank you very much for holding this hearing.
We passed comprehensive legislation that was signed into
law last Congress and the Congress before that to address the
opioid crisis that has swept our nation. But the crisis is far
from over and it is important that we look back at our past
work on this issue to assess the results and see what we can
further do to make a positive impact on this public health
epidemic.
When we passed the SUPPORT Act last Congress, one of my
bills was included in that package and that is what I want to
focus on today. As we all know, seniors are at heightened risk
for opioid use disorder and the severe consequences of the
respiratory depression that they may cause.
The purpose of the Advancing High-Quality Treatment for
Opioid Use Disorders in Medicare Act is to help ensure our
seniors have access to high quality evidence-based opioid
misuse disorder treatment.
Specifically, this voluntary demonstration project will
create an alternative payment model through Medicare for
comprehensive treatment and care programs for opioid misuse
disorder.
Participating providers or institutions will receive a case
management fee to enable them to provide wraparound services to
Medicare beneficiaries and receive a higher fee if the
coordinated care team includes an additional specialist.
For Medicare beneficiaries participating in this program in
addition to medication-assisted treatment, they will receive
psycho social support such as psychotherapy, treatment
planning, and appropriate social services to treat substance
use disorder.
This coordinated care approach is considered the gold
standard of care and if we want to successfully address this
crisis we need to ensure that individuals have access to
treatments that will result in successful outcomes. I have seen
firsthand the importance of this with my patients and beginning
medication-assisted treatment is important.
But the success of that treatment is enhanced if the
patient is also participating in psychotherapy and receiving
the appropriate social services. It is of the utmost importance
that all Americans, regardless of their age or how much money
they make, have access to high-quality comprehensive treatment.
Our entire healthcare system is moving towards a more
coordinated care and incentive programs for performance
outcomes and our seniors should not be left behind. This
demonstration project is slated to begin in January of 2021.
So Ms. Brandt, can you tell me where you are in the
development process at this time including which specialists
you have consulted with?
Ms. Brandt. Thank you, Dr. Ruiz. We are actually very
actively working on this and hope to meet the implementation
deadline. Thus far, because this is a very hands-on
demonstration, we have been working very closely with
stakeholders, including clinicians in the primary care
community and those in the field of addiction medicine to help
us with designing the demonstration.
We did a series of listening sessions in April and May of
last year with both stakeholders and beneficiaries to help us
better be able to understand the issues and design the
demonstration, and we are hopeful that within the next month
that we will start to be able to work on the application
process and start moving forward.
Mr. Ruiz. So what are steps that still need to be taken to
roll out this program?
Ms. Brandt. We need to finish designing the demonstration,
finish the cost estimates, and begin with the applications.
Mr. Ruiz. OK. And are you on schedule for the demo to be up
and running in January as required?
Ms. Brandt. As of right now we are on track and we are
pushing hard to remain on track.
Mr. Ruiz. Good. Well, that is important for our seniors. We
need to address all the other social determinants of health and
that could be as simple as do they have transportation to their
treatment and psychotherapy. That can be as simple as looking
at some of their addiction behaviors and start creating
psychotherapy for them to understand their own physiology.
Seniors in particular are more at risk to have pain issues
because of the musculoskeletal wear and tear throughout their
lifetime.
At the same time, they are more sensitive to opioids. They
are more at risk of getting addicted and an opioid of the same
dose can cause respiratory depression, severe drowsiness to a
point where they can fall, where they can regurgitate from
their food, which can cause pneumonia more so than somebody who
is, let us say, in their 30s. So that is why we need to pay
special attention to our seniors and we need to ensure that
this program is ready, up, and running by the due date this
January.
Thank you very much. I yield back.
Ms. Eshoo. The gentleman yields back.
A pleasure to recognize Mr. Long, our good friend.
Mr. Long. Thank you, Madam Chairwoman.
And Ms. Brandt, the opioid epidemic continues to devastate
families and communities in my district and across the country,
as you know, and I myself have some personal experience with
opioids over about a four or five day period when I was in the
hospital for eight days right before Christmas after I was
trying to get a four-pound poodle out of the middle of the
street.
That wasn't a very good idea, and I shattered my shoulder.
So that led to a long stay and a few days of opioids in there,
which--the hallucinations, the bugs and things crawling on the
wall. I saw pain relief I did not get. So I am not sure how
people get addicted to these but I know that it is a very, very
serious issue.
One thing we can do at the federal level is to ensure
Medicare patients have access to safe and effective
alternatives to opioids to manage their pain. Unfortunately,
Medicare payment policies can keep these alternatives out of
the reach of many of our nation's seniors by failing to
adequately reimburse hospitals for the cost of the therapy.
I was proud of the work Congress did in the SUPPORT Act to
provide CMS with new authorities to adjust payment for
evidence-based nonopioid therapies under Section 6082 and I was
very disappointed to learn that the agency declined to make
payment adjustments for any alternative therapies in its 2020
payment rule.
What more do you need from Congress to make payment
adjustments necessary to ensure seniors can access these safe
alternatives that reduce opioid use?
Ms. Brandt. Well, first of all, I hope you are recovered
from your experience, sir, and I am sorry to hear about that.
But from our perspective at CMS, we are really open to
working with you all to get feedback on how we are implementing
this section and what else we can do.
I, personally, have met with dozens of stakeholders on
this. We have been taking into account additional research and
additional information that we have gotten from them about we
can better look at how we are adjusting our payment policies to
reflect this, and right now we are working with an interagency
task force to look into this issue and see how we can continue
to evolve on this.
Mr. Long. OK. How do we ensure that the reimbursement
policies don't create a disincentive, I guess you would say,
for prescribing opioid alternatives?
Ms. Brandt. Well, one of the things that has been most
helpful to us is continuing to have the dialogue not only with
you all but with the stakeholder community about the evidence
showing the impact of those costs and what we can do to be able
to adjust our payment policies to reflect that.
Mr. Long. OK. Thank you.
And, Admiral Giroir, you briefly mentioned in your
testimony that you are witnessing new and highly dangerous
patterns of use, including a combination of polysubstance
methamphetamines and illicit fentanyl?
And I might add that I toured a drug facility. It wasn't
really a drug facility but in the Kansas City, area they have
a--if the police pick you up instead of taking you to jail,
they will take you to this facility for 24 to 48 hours. The
first thing they do is drug test you and they got a guy in
there and they said, what are you on, and he said, oh man, I am
on opioids.
They tested him and they said, sir, you don't have one
opioid in your system. They said, you have fentanyl. He said,
what is fentanyl. He said, I bought opioids. So I know what an
issue is it. Can you explain what is going on here? Can you
discuss how the opioid crisis is evolving and how that
substances like these can threaten the overall progress being
made against opioids and heroin?
Dr. Giroir. Yes. Yes, sir. Thank you.
Overall, the numbers looked good. Prescription opioid
deaths are down 10, 12, 14 percent. Heroin deaths are
decreasing. Fentanyl deaths are still going up at ten percent
but they were going up 30 and 40 percent. So we are starting to
make headway into this.
You have characterized it. Really, the fourth wave is
methamphetamines and methamphetamines combined with drugs like
fentanyl that are really a deadly potion. In many parts of the
country, particularly in the West, methamphetamines absolutely
dominate over opioids now as the cause of death and despair.
A very important thing that Congress did on the State
Opioid Response Grants for this year allowed flexibility so
states could use the money not just for opioids but
predominantly for methamphetamine if that is an issue, and in
that regard, the Tribal Opioid Response Grants for this year
will be announced today at $50 million to get relief to the
tribes on methamphetamines.
So, again, sir, all the investments that you are making--
workforce, training, incentive payments--these will all go
across the board to help methamphetamine but we do need the
flexibility and there are some specifics about methamphetamine
that are critical.
And, again, there are cartels manufacturing hundreds of
thousands of pounds of pure methamphetamine. This is not
someone cooking it in the kitchen next door anymore. This is
industrial-scale methamphetamine that is an all out for DEA,
DOJ----
Mr. Long. How about you down the table? I was going to ask
Mr. Prevoznik, would you care to comment? What is the DEA
seeing in terms of new patterns of use?
Mr. Prevoznik. The biggest thing that we are seeing is the
counterfeiting--the counterfeiting of these very--fentanyl,
methamphetamine, they are being pressed into pills so that the
public does not know what they are getting. This is a very
scary time.
As the admiral pointed out, that it is highly
industrialized. We have the pill press issue of where they are
coming from, who is getting them, who is using them. We are
attacking it. We have just started Operation Crystal Shield,
which we are targeting eight distribution hubs for
methamphetamine and we are doing a full court press on that
right now.
Mr. Long. OK. And I yield back. Thank you all.
Ms. Eshoo. The gentleman yields back.
Pleasure to recognize the gentleman from Massachusetts, Mr.
Kennedy, for 5 minutes.
Mr. Kennedy. Thank you, Madam Chair, and I want to thank
Ranking Member Burgess for convening this hearing today and for
taking proactive steps to combat the Opioid epidemic.
To our witnesses, thank you for being here. Thank you for
your service. A few minutes ago, I left a roundtable discussion
with mental health and substance use disorder experts and
dozens of healthcare leaders from providers to insurers to
researchers and advocates.
All of them are intimately familiar with our past failure
to prevent this crisis from taking root and all of them have
seen how our efforts to confront it today far too often fall
short.
Because it simply is not enough to try to smooth out the
edges of what ends up being a completely hollow system for far
too many Americans. As long as there are Americans out there
without healthcare coverage or who are underinsured or covered
by junk insurance plans or have plans that simply do not
provide adequate coverage for mental and behavioral health
services because they do not consider them to be a priority, we
will not be able to overcome an opioid epidemic.
Even worse, as long as this administration continues to cut
holes into the very safety net system and programs that are
meant to catch those who fall through the cracks, we will fail
without a doubt.
Ms. Brandt, do you know what program is the largest payer
of substance use disorder treatment in the country?
Ms. Brandt. Medicaid.
Mr. Kennedy. Do you know, roughly, how much Medicaid pays
annually for that treatment?
Ms. Brandt. I do not know that exact amount.
Mr. Kennedy. Well, about $7 billion or so.
Admiral Giroir, is that--did I pronounce your name anywhere
close to correct? I am sorry, sir.
Dr. Giroir. Anything close is fine, sir.
Mr. Kennedy. Apologies, sir.
Dr. Giroir. Cajun names are a problem.
[Laughter.]
Mr. Kennedy. Forgive me. Would you agree that Medicaid is
the largest payer of mental behavioral services in the country?
Dr. Giroir. Yes, that is correct.
Mr. Kennedy. And so, Ms. Brandt, are you familiar with the
statistics showing that the percentage of people hospitalized
with a substance use disorder who did not have health insurance
dropped from 20 percent to just five percent in states that
expanded Medicaid coverage in just two years?
Ms. Brandt. I have heard those statistics.
Mr. Kennedy. And, Admiral, does that sound familiar to you
as well?
Dr. Giroir. Yes, sir.
Mr. Kennedy. So, Admiral, have you seen studies showing
that Medicaid work requirements or Medicaid block grants would
increase access to addiction treatment options?
Dr. Giroir. Have I seen studies that block grants will
increase the access?
Mr. Kennedy. Yes.
Dr. Giroir. No, sir. I have not seen those.
Mr. Kennedy. How about work requirements? Would they
increase access to treatment options?
Dr. Giroir. I have not seen studies either way on that,
sir.
Mr. Kennedy. Ms. Brandt?
Dr. Giroir. I have not either.
Mr. Kennedy. So, Ms. Brandt, in your experience, does
cutting a program by, roughly, $1 trillion usually make it more
or less effective in treating a population that is already
horrifically under-served and under-treated?
Ms. Brandt. Our efforts are to try and keep the program
sustainable at all costs for all of our vulnerable
beneficiaries.
Mr. Kennedy. And cutting a trillion dollars make that
easier to do or harder to do?
Ms. Brandt. It will make it so that the program hopefully
will be able to be sustainable in the long term to be able to
cover those people that need those services.
Mr. Kennedy. And so when you cut a trillion dollars out of
it, who gets--who feels the basis of that cut?
Ms. Brandt. The cut is in the growth of spending, not the
actual spending itself and it is to help to sustain the program
over the long term.
Mr. Kennedy. So your position then is that cutting a
trillion dollars out of Medicaid will not actually harm the
beneficiaries from being able to access their care?
Ms. Brandt. It is to help be able to make the program more
long-term sustainable.
Mr. Kennedy. I understand that is the hope. What do you
think the reality is of cutting a trillion dollars out of the
healthcare program?
Ms. Brandt. That is the genesis behind our budget proposal
is to go ahead and keep the program sustainable in the long
term.
Mr. Kennedy. And, Admiral, are you familiar with the ten
essential health benefits mandated by the Affordable Care Act?
Dr. Giroir. Yes, generally.
Mr. Kennedy. Yes. I won't quiz you on all of them. But one
of those essential health benefits, again, mandated by the ACA
is mental health and substance use disorder services.
Yet, this administration will be arguing before the Supreme
Court in just a few months that the entire Affordable Care Act
should be struck down.
Admiral, if the ACA is struck down in its entirety and
substance use disorder services are no longer considered an
essential health benefit, would that be good or bad for
patients in need of addiction treatment?
Dr. Giroir. So, as you know, the last thing I am would be
to pretend to be a lawyer. But, clearly, having access to
substance use and mental health services is absolutely key to
eliminating the crisis and also preventing the next one.
Mr. Kennedy. Thank you.
And is there a possibility that health insurers will see
mental and behavioral health conditions as preexisting
conditions if the ACA is struck down?
Dr. Giroir. If you are asking me, I am sorry, I don't
really have expertise to comment.
Mr. Kennedy. The idea being that if it was in fact, the
Affordable Care Act that mandated coverage for substance use
disorder and mental behavioral health coverage, that if somehow
those protections were taken away that insurance companies
would step into that void voluntarily. They never did in the
past. Is there any reason to believe they would now?
Dr. Giroir. Again, you know, I am sorry. I can't predict
insurance coverers' behavior. But it is absolutely vital that
everyone with substance use disorder, the potential for it and
mental illness, get the care they need as soon as possible
because the spiral goes very badly over the decades as they--as
they progress.
Mr. Kennedy. Agree, sir. Thank you very much.
Yield back.
Ms. Eshoo. The gentleman yields back.
A pleasure to recognize the ranking member of the full
committee, the gentleman from Oregon, Mr. Walden, for 5
minutes.
Mr. Walden. Good morning, Madam Chair, and I want to thank
our panellists. We got another subcommittee going on, so some
of us are bouncing back and forth between the two.
Admiral, I want to ask you about 42 CFR Part 2. Are you
familiar with that regulation and the impact it has on sharing
critical medical information back and forth among providers?
Dr. Giroir. Yes, sir. Of course, I am. Dr. McCance-Katz
really is the expert in our department on that, but I am
certainly familiar with it.
Mr. Walden. In the last Congress, when I had the great
honor to chair the committee, we moved legislation as part of
our opioids package dealing with--to provide some reforms to 42
CFR Part 2. We had instances where there had been loss of life
because that information had not been shared.
I know the Trump administration has attempted to do what we
failed to do legislatively. Not in the House. We passed it in
the House.
Can you speak to the importance of making these changes and
what other legislation might be helpful in this area? Or Ms.
Brandt, if you are involved in this?
Dr. Giroir. I think we could probably all speak. But it is
clear that the administration believes, and I do as well, and
certainly all the experts that I know that we need reform in 42
CFR. It is really meant for a time that is 40 or 50 years ago
and does not address the crisis as we have today and, thus, we
proposed regulations, as you know, to do as much as we can
without legislation. That is still limited in what can be done.
But, clearly, to be able to have information for one
provider to know that the patient is in an opioid treatment
program and has a long-term substance use issue can be
lifesaving and I think there are many examples when it is.
Mr. Walden. That is right.
Dr. Giroir. I think there is a balance that we can protect
patients' privacy like through HIPAA but still get lifesaving
information to providers.
Mr. Walden. Ms. Brandt, do you have any additional comments
on this matter?
Ms. Brandt. Well, in our meetings with stakeholders, this
is one of the issues that has come up that is very important.
Mr. Walden. You know, I did a lot of roundtables in my
district and this almost above any other with the provider
community, was the top issue, and we protected patients'
privacy rights. I think the bill we passed in the House was
stronger than existing HIPAA requirements.
We don't want this information used against them in any
way--their, you know, employment or anything else. But failure
to share in a modern environment is deadly and so we worked
together on that, and I know it was an issue for Mr. Kennedy as
well.
Unfortunately, I have to confess, my dear friend, the
chairman of the committee now was the lead opposition to this
and we had a problem in the Senate. We got it passed through
the House but not in the Senate. So, regretfully, I doubt we
will see any forward motion on this, going forward, with those
that are in charge right now.
Admiral, how is HHS monitoring the use and determining the
success of the Opioids Dashboard? That is something else that
my colleague, Mr. Latta, was lead on, and the National Help
Line and findtreatment.gov. Mr. McKinley was big on this as
well. Are you getting that dashboard up and running?
Dr. Giroir. Yes, sir. The dashboard is up and running at
hhs.gov/opioids, and we tried to certainly highlight and
prioritize the things that could be lifesaving like
findtreatment.gov, which was completely redone to make sure
that people who are in need or need a hotline have that right
there.
But as you look down it gives the up-to-date statistics.
There is a quick link to make sure that everybody who wants a
grant--that is one thing we heard, is there a quick way to just
click to it.
Mr. Walden. That is right.
Dr. Giroir. And also, although you can tell it is made by
accountants and not by some of the digital folks, but there is
a basic, easy-to-use map about where the money has gone and who
it has gone to----
Mr. Walden. Oh, good.
Dr. Giroir [continue].To be transparent. Again, it is not
beautiful but it is easily seen----
Mr. Walden. Right.
Dr. Giroir [continue]. And downloadable so Congress or the
private can have some sunlight on that and see how we are
doing.
Mr. Walden. Ms. Brandt, do you have a comment on that?
Ms. Brandt. I would just add that in addition to the
dashboard that the Admiral mentioned, we at CMS have our own
opioid heat map that is available using our CMS data that
allows you to see down to the zip code level trends in
utilization and prescribing.
Mr. Walden. One of the things that--great joys of serving
in the Congress people from different districts and different
issues and I will never forget the moment Bobby Rush from
Chicago made it clear to me it is more than just opioids, and
we changed the legislative intent to include all substance use
disorder.
In my district, meth is still a huge issue, probably bigger
than opioids. Can you speak in the last 20 seconds to what we
are doing in methamphetamine and what you see?
Dr. Giroir. Dr. McCance-Katz and I formed a task force last
March actually when we saw this really rolling across the
states. One of the major issues is we provided technical
assistance so the State Opioid Response Grants could be used
because----
Mr. Walden. Right.
Dr. Giroir. California, Oregon, Washington----
Mr. Walden. It is meth.
Dr. Giroir [continue]. New Mexico, Arizona, it is really
meth, meth, meth, and you were--you were hand tied. SAMHSA has
also opened up a completely nationwide technical assistance
programs because there is not MAT for methamphetamine.
Mr. Walden. Right.
Dr. Giroir. And just to be sure, the NIH and FDA are
working together to try to develop the MAT but also open the
doors to industry to let them know that every power of the FDA,
priority reviews, all those kinds of things will be used
because we really need to focus on that, and methamphetamine,
as you know, is devastating. And, again, more deaths from
methamphetamine now than prescription opioids or heroin and it
will overtake cocaine within the next month or two.
Mr. Walden. Yes. I know Bobby talked about crack cocaine
and the impact in his community, and we want to be on all of
these. We don't want to just isolate to specific drugs.
So thank you, Madam Chair. You have been most generous with
the time.
Ms. Eshoo. For you, Mr. Chairman.
It is now a pleasure to recognize the gentlewoman from
Michigan, Mrs. Dingell.
Mrs. Dingell. Thank you, Madam Chair and to Ranking Member
Burgess for holding this hearing and--to evaluate the impact of
opioid legislation passed last Congress and to examine
bipartisan legislation to continue to address this epidemic,
and I do want to associate myself with the comments that were
just made that it is not just opioids but it is a number of
other drugs, and I thank all of the witnesses for being here.
As we all keep saying, the Opioid epidemic is one of the
defining public health challenges of our time. It was good that
we witnessed in 2018 a reduction in drug overdose deaths for
the first time in years.
There were still 67,000 people that lost their lives and,
you know, I am one of those families that lost a sister and
whose father--he lived with it but it impacted his whole life.
So I know firsthand what a challenge we are dealing with.
And there is not a member on this committee or in the
Congress that has not heard about it from their constituents,
hasn't seen it firsthand. So that is why we have got to
redouble our efforts to understand what is working and what
else we need to be doing to help you.
So, Admiral, I want to ask you the first question. The
SUPPORT Act included the ACE Research Act, which I introduced
with my colleague, Fred Upton, to encourage the development of
nonaddictive pain medications. We have talked about
alternatives but we have really not talked about what the
status is in developing new drugs that aren't addictive.
Earlier this year, Dr. Volkow, the director of the National
Institute of Drug Abuse, stated that it would likely take years
before new pain medicines could replace today's opioids and
reach the market.
Can you discuss some of the challenges that remain with
developing these new treatments and what action we can take
further to develop these new medicines in a faster way?
Dr. Giroir. So I am going to answer your question but I
just want to be clear that we have a number of nonaddictive
medications that are highly effective when used in a multi-
modal service. And, again----
Mrs. Dingell. So what--so talk about that because the anti-
inflammatory drugs or the other ones you talk about can't be
taken by many older people. They get bleeding in their stomach.
They have side effects that causes increased high blood
pressure. For many, especially older people, who have kidney
disease, et cetera, opioids are the only thing they can take.
Dr. Giroir. So there are always going to be exceptions to
all pain categories and part of the Pain Management Task Force
is we have said like anyone knows, you need a patient-centered
approach. You can't just make a rule and have it apply to
everyone----
Mrs. Dingell. Right.
Dr. Giroir [continue]. And we actually go through many
special populations, including women, including patients with
sickle cell disease exactly to work on that. But for many
patients, in fact, most patients, it has been--it has been
shown that high dose ibuprofen can be as good as opioids coming
out of the emergency room. That multi-modal----
Mrs. Dingell. But not for long term.
Dr. Giroir. Not for long term. Not for long term at all. So
there are a variety of devices--physical therapy, all the kinds
of things that you know about and I know you know about that.
On the----
Mrs. Dingell. I have spent a lot of time--I am not a
doctor, but--and that is what I am worried about. We really do
need nonaddictive----
Dr. Giroir. So we do have a lot that we can do now. But
your point is correct. Unfortunately, it takes a long time to
develop new drugs. Fortunately, the incentives are there.
Congress has provided the money to support NIH very
dramatically and there are very exciting--I mean, extremely
exciting things on the horizon. But it will take years for a
nonaddictive opioid-like substance or antibody to come onto the
market.
Mrs. Dingell. We are not doing it quick enough. This is the
real world for me. I have lived with it on both sides, as you
know.
I am going to do, quickly--additionally, Rep. Walberg and I
worked on legislation, Jesse's Law, which included as a
provision--it was included as well in the SUPPORT Act. It
ensures that doctors have access to a consenting patient's
prior history of addiction in order to make fully informed care
and treatment decisions--my colleague, Mr. Walden, was talking
about this--because we want to protect people's privacy but we
also need to make sure people who are addicted--Jesse was a
young woman in our district that died of a drug overdose
because her doctor didn't know.
Ms. Brandt, can you discuss the additional steps that
providers are now taking as a result of the SUPPORT Act to
ensure that those with a history of addiction are not receiving
opioids as pain treatment and the impact that this has had on
opioid misuse?
Ms. Brandt. So one of the things that we have done is to
have it as part of the visits that Medicare beneficiaries do
with their doctors to encourage the doctors to discuss with
them issues of opioid addiction and to help them understand----
Mrs. Dingell. OK. But Medicare is someone that is over 65
or is disabled. Jesse was just out of college.
Ms. Brandt. Right. And, in general, we also have been
giving issuance guidance to states to encourage states to work
with their providers.
A lot of this is especially for people who are like Jesse--
younger adults--are not necessarily people that are covered
directly by Medicare or Medicaid. They might, you know, be just
on their own. So part of this----
Mrs. Dingell. Like a lot of young people in this country.
Ms. Brandt. Correct. And so as a result we have done all we
can within our programs to make sure that we are spreading the
word to providers.
Mrs. Dingell. So do we need to do more in this area?
Ms. Brandt. I think we can all work together to do more in
this area.
Mrs. Dingell. I would like to do that. My time is up so I
have to yield back.
Ms. Eshoo. The gentlewoman yields back.
Pleasure to recognize the gentleman from--oh, from
Kentucky, Mr. Guthrie, for 5 minutes.
Mr. Guthrie. Thank you, Madam Chair. I appreciate the--I
appreciate that, and I am glad we are here to discuss the
implementation of the SUPPORT Act in the ongoing opioid
epidemic.
My home state is Kentucky and it has been hard hit by the
this tragic epidemic, and I believe implementation of the
bipartisan SUPPORT Act deserves our full attention in addition
to examining where the gaps remain in policy.
And I also want to mention, and I know Dr. Giroir--Admiral
Giroir--I went to Army so it is hard to say admiral. I am
kidding.
[Laughter.]
Mr. Guthrie. So I really appreciate the Navy, actually. So
but I want to--you mention the NIH Healing Communities grant
and it will help--and what it will do to help communities
affected by the opioid epidemic. I was very pleased that the
University of Kentucky was awarded one of the community grants
and I look forward to seeing them and other awardees reducing
opioid-related overdose deaths by 40 percent over the course of
three years.
Well, my question is, Ms. Brandt, in your testimony, you
mentioned Section 1003 of the SUPPORT Act, which authorized CMS
to increase the capacity of Medicaid providers to deliver SUD
treatment to recovery--recovery service in a two-phase
demonstration. Kentucky was included in the 15 states for phase
one. Can you please explain the current progress of the 15
states and what are next steps through translation to phase
two?
Ms. Brandt. Sure. Thank you, sir. I am happy to talk about
that. We were excited last September to issue $48.5 million to
15 states including, Kentucky for an 18-month demonstration
project to be able to have them look at, you know, the benefits
of additional types of flexibilities for SUD treatment.
We are currently monitoring the demonstration. We look
forward to evaluating the results. The program will end in
March of 2021 at the end of the period. At that point we will
select no more than five of the 15 states to participate in the
final 36 months of the demonstration and there will be an
additional $5 million that will go to those states at that
point.
Mr. Guthrie. So, next, to Ms. Brandt and to Admiral, how
does HHS ensure that opioid federal grant funds are not
diverted for unauthorized purposes and do you periodic--do you
do periodic check-ins or are these done annually?
I just want to make sure the money and resources are
getting to those who need the resources the most. So how do you
do oversight of the funding?
Dr. Giroir. Well, I think we can all take a bit of that. It
depends on the--it really depends specifically on what grant
category it is. The State Opioid Response Grants from SAMHSA,
as you know, by design provide great flexibility to the states
because we want the states to be able to use the funds that are
needed for the states but there is, clearly, reporting
requirements about what category there are clear stipulations
about it has to be evidence-based therapy, right.
So you can't do things that are not supported by science
and medicine, and in other programs, they are much more, you
know, specifically managed. It just depends on the programs.
But, obviously, we are--we are getting into a phase right now--
not that we haven't been there before but we are really getting
to a phase that there is a lot of money on the streets and we
have at least four different groups right now doing modelling
and simulation to determine where is the best bang for the
buck.
In other words, so we can advise you if you put a dollar
here it will be better than putting a dollar there right now.
It's a very complex system but we are getting to the point of
being able to do that.
Mr. Guthrie. OK. Thank you.
Ms. Brandt?
Ms. Brandt. So for ours because there are demonstrations
where we give federal moneys to the states directly or we have
models where we give money directly to entities, we track those
very closely. That is part of the demonstration agreement is
that we look at their spending. We look at how it is being
spent.
In particular, with the demonstration you mentioned we have
reports to Congress that we are required to give, the first of
which I believe we are going to be issuing in October of this
year and that would continue to have it so that we would be
able to say how the money is being spent and holding them
accountable.
Dr. Giroir. And, for example, some are very easy to monitor
like the CDC grants to improve data reporting. So we now know
there has been astronomical progress in being able to report
data on deaths and on real-time in the emergency rooms.
This was an exercise in history a couple of years ago where
you were always two years behind. Now for fatalities within six
months we have 99.8 percent done down to the level of fentanyl
or the analogs. So there are some very specific things that are
easy to monitor and we see those results.
Mr. Guthrie. Thank you. My time has expired and I yield
back.
Ms. Eshoo. The gentleman yields back.
A pleasure to recognize the gentleman from California, Mr.
Cardenas, for 5 minutes.
Mr. Cardenas. Thank you, Madam Chair, and also the ranking
member for having this important committee.
I am happy that this committee is continuing its work on
the opioid epidemic and also looking forward to talking about
how we can help patients with other substance use disorders.
This is a public hearing and I just want to read off some of
the legislation that had been introduced by my Republican
colleagues and Democrat colleagues in Congress.
The Medicaid Reentry Act. Another one is Easy Medication
Access and Treatment for Opioid Addiction Act. Another one is
State Opioid Response Grant Authorization Act. Another one is
the Mainstreaming Addiction Treatment Act of 2019.
Another one is Respond to the Needs in Opioid War Act.
Another one is Opioid Workforce Act of 2019. Another one is
Block, Report, and Suspend Suspicious Shipments Act. And the
list goes on.
The reason why I wanted to point that out is because I
think the people who have gathered in this room they are all
familiar with these bills but the issue that I think that we
need to convey to the American people is that we have too many
people saying that Congress is doing nothing, and the fact of
the matter is we are trying to tackle issues in Congress.
That is why my colleagues on both sides of the aisle,
Republican and Democrat, are introducing bills so that we can
have legislative hearings like this so that we can actually
hear from the experts and try to figure out how do we make life
better for the American people on a day-to-day basis, and much
of it has to do with making sure that we take the resources
that come to the United States Congress, the taxpayer dollars,
and make sure that we put it to good, good use.
So I first want to thank my colleagues for the attention
that many of my colleagues are putting on this issue but also
the experts who are in fact working with the various
departments at the federal level, working with our state and
local governments to make sure that American lives are in fact
being addressed when it comes to issues of opioid addiction and
other issues.
I would also like to point out that data from the agencies
testifying today tell us that while we are seeing positive
signs with the opioid epidemic, our work is far from over.
Adding to the need to continue work on substance use
disorders in this country is the rise in availability and use
of stimulants like methamphetamine and cocaine. The Drug
Enforcement Administration's 2019 National Drug Threat
Assessment states that methamphetamine remains widely available
and the DEA field divisions are reporting an increasing
availability of the drug compared to the previous year.
Mr. Prevoznik, is there a difference between the
methamphetamine use we saw in the early 2000s compared to what
we are seeing now and how is your agency working to reduce its
availability?
Mr. Prevoznik. I can address the latter part of your
question in that we are currently working Operation Crystal
Shield that we just launched that we are targeting the eight
districts--eight city hubs where we have the transport hubs of
methamphetamine, which we have seized. Over 75 percent of the
methamphetamine that we have had are in these eight different
cities. So we are full-court press in those cities. I believe
what you--I am not the expert on--the whole expert on the
methamphetamine of the 2000s compared to that. But if----
Mr. Cardenas. OK. Please.
Dr. Giroir. So the methamphetamines we are seeing now are
essentially--they are industrial scale. So it is 100 percent
pure. It is cheap, very cheap. Much less expensive than it was
before and it is being intentionally put in other supplies like
fentanyl and heroin to create mixed addictions. So this is a
whole different ball game. Not that it wasn't severe before but
this is really a true national security issue with hundreds of
thousands of pounds of industrialized methamphetamine coming
in.
Mr. Cardenas. So the intensity that we are seeing on the
streets of America today is higher and then also the activity
is more?
Dr. Giroir. Yes, sir. And methamphetamine is, by itself, an
extraordinarily addictive drug that you know is toxic to--it is
really toxic to the brain and if you have seen individuals who
are on methamphetamines for a period of time you understand the
devastation it has to the person and to the community.
Mr. Prevoznik. And if I could add to that. The
counterfeiting of the pills themselves is huge because the
public just does not know what they are getting. It looks like
Adderall but it's not, and we don't know what it is mixed with.
Mr. Cardenas. OK. Doctor, HHS has a five-point opioid
strategy. Is your agency considering a five-point stimulant
strategy?
Dr. Giroir. We have a much larger strategy than--the five
points is a good overriding and, in general, access to
treatment and prevention that really works, right. There are so
many things that work with that.
But, again, we have an intra-agency methamphetamine task
force of the leaders of every single one of our divisions that
have moved forward with a number of actions specific for
methamphetamines and also working with DOJ and ONDCP. Director
Carroll has been really on top of this coordinating across the
agencies as well.
Mr. Cardenas. So you do have a stimulant strategy as well?
And many others?
Dr. Giroir. Yes, sir.
Mr. Prevoznik. Yes.
Dr. Giroir. And we briefed--I think we just briefed your
staff on this very recently, maybe a few weeks ago. Is that
right? On our methamphetamine approaches. Yes, sir.
Mr. Cardenas. Thank you so much.
I yield back.
Ms. Eshoo. The gentleman yields back. Excuse me.
Pleasure to recognize the gentleman from Florida, Mr.
Bilirakis, for 5 minutes.
Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so
much.
I am going to yield to Representative Brooks my 5 minutes.
If she doesn't take the entire 5 minutes I will take whatever
is left. Appreciate it.
Ms. Eshoo. Well, we can recognize you as well.
Mr. Bilirakis. OK. That would be great. I was going to----
Ms. Eshoo. I know that Congresswoman Brooks has another----
Mr. Bilirakis. She has another----
Ms. Eshoo. Exactly. So you are recognized for 5 minutes.
Mrs. Brooks. Thank you so much, Madam Chairwoman. I thank
my colleague for yielding to me, and I want to thank each of
our witnesses for your incredibly important work.
I must say that given how bipartisan our work has been for
quite some time, I do have one concern about one of the bills
that is being put forth, the H.R. 2466, the State Opioid
Response Grant Authorization Act.
This committee worked so hard on CARA, 21st Century Cures,
and the SUPPORT Act, and we, in 21st Century Cures, passed--I
am sorry, with the SUPPORT Act we actually already have put
forth state and local grant programs. And so I am very
concerned that H.R. 2466 might undermine the State Opioid
Response Grants that the states are already very much working
hard on. And so I would be--I would like to see us remain
focused on the grant programs we have already initiated rather
than create a whole new set of grant programs.
With that, I would also like to focus on Section 101 of the
CARA Act, which I was involved--the Pain Management Best
Practices Task Force. And we know that that is one of the great
challenges in this opioid crisis is trying to figure out ways
to treat real chronic and the need for implementation of best
practices has never been greater.
In fact, a Harris poll found that 80 percent of primary
care physicians believe that the opioid crisis has made it
actually more difficult to treat pain patients and they need
more information on nonopioid options. Many of the front-line
providers have actually stopped seeing pain patients because
they are concerned about what they can do for pain patients.
Admiral Giroir, you mentioned already in your testimony the
Pain Management Best Practices Task Force and, Madam
Chairwoman, this report, which was--which was the product of
really our legislation that we worked on so hard together was
issued May 9th. With unanimous consent, I would like for this
to be entered into the record.
Ms. Eshoo. So ordered.
[The information appears at the conclusion of the hearing.]
Mrs. Brooks. And I also would ask us to consider
potentially even having a future hearing relative to these are
incredible recommendations that dozens of providers worked very
hard on for an entire year.
But I am very concerned as to what Health and Human
Services is doing to ensure that these pain best practices are
disseminated. It is a lot for providers. How is this being
disseminated to our nation's primary care physicians?
Admiral Giroir, if you know.
Dr. Giroir. Well, it--first of all, it is being
disseminated through the mechanisms that we normally
disseminate--having it posted, speaking about it, having the
Surgeon General amplify it.
But we are picking out specific pieces of it and amplifying
it on a regular basis. For example, one of the largest issues
we are facing is that, as you pointed out, because of all the
issues, physicians and other providers are too rapidly tapering
people from opioids or taking them off of them acutely. This is
really one of the most urgent issues that we face and we have
put out sequential guidance for that. The CDC--I put out
guidance from my office in the fall of 2018 with opioid
tapering guidelines. So we are doing it generally but our
strategy is also to take small buckets of it and to disseminate
that as the priorities exist and that is just--that is just one
example of them. Another one and, again, that I am, as a
pediatric ICU doctor, sickle cell patients is one of those
categories who have tremendous needs for pain. Not only have we
worked with the national program with prescribers through our
Office of Minority Health, but even CMS has put out letters
that said that you need to exempt these kinds of individuals
from their regs.
Mrs. Brooks. So is there a strategic plan, though, to
implement these task force reports? As I look at the content--
table of contents--medications, restorative therapies, and
interventional procedures--there are--I mean, that is just to
name the first half of the----
Dr. Giroir. Yes.
Mrs. Brooks [continue]. Special populations there is--this
report is actually I think chock full of incredible
information. So is there a strategic plan rather than each of
the different agencies taking small buckets at a time?
Dr. Giroir. Yes. So there is an overall--we--part of my job
is to coordinate across the agencies and you will see in that
report almost every section has an individual recommendation
associated with that and not every one of those recommendations
is being implemented.
But they are sort of being parsed out. For example, some
of the pain research that went directly into the HEAL program.
So research on special populations, on women's pain, on pain in
special needs populations went directly into the HEAL program.
So there is no independent strategic plan to implement that.
But it is coordinated through our normal activities.
Mrs. Brooks. Well, thank you.
Dr. Giroir. But I hear what you are saying.
Mrs. Brooks. Very proud of this work and all of the work
that all the providers and patients put into this, and so would
strongly urge that somehow, Madam Chairwoman, we get if not
either part of the hearing or that we get more information out
about all of this good work that has been done.
With that, I yield back.
Dr. Giroir. And I do think it is one of the best documents
and it was incredible. The people who worked on the committee
and the thousands of people who provided input makes it a
really special contribution and thank you for making that
requirement. It was great to do that.
Mrs. Brooks. Thank you, and I yield back.
Ms. Eshoo. The gentlewoman yields back.
Pleasure to recognize the gentlewoman from New Hampshire
who once again I want to say has exhibited terrific, very
important leadership on the issue of opioids, Ms. Kuster, 5
minutes of questions.
Ms. Kuster. Thank you so much, Chairwoman Eshoo, and thank
you again for including H.R. 2922, the Respond NOW Act, and
H.R. 4141, the Humane Correctional Health Care Act, as part of
today's hearing.
I am also grateful to see our discussion include the
Opioids Workforce Act, which I introduced with Congressman
Schneider. This important bill would increase the number of
physicians trained in pain medicine, addiction medicine, and
addiction psychiatry.
I have heard from treatment and recovery providers, law
enforcement and first responders all across New Hampshire about
the need for additional resources to support their efforts on
the front line and that is why I introduced the Respond NOW
Act, which creates a $25 billion opioid epidemic response fund.
This bill provides those tangible sustained resources of $5
billion a year over five years to our front line. This funding
spans across agencies to fund programs like the State Opioid
Response Grants and the Child Abuse Prevention and Treatment
Act.
This epidemic is complex and what we have learned in New
Hampshire is there is no silver bullet approach. I call it a
silver buckshot approach with all hands on deck, and because I
have heard what many others can attest to, we will not arrest
our way out of this epidemic. So that is why I introduced H.R.
4141, the Humane Correctional Health Care Act, bipartisan
legislation to repeal the Medicaid inmate exclusion and allow
justice-involved individuals to access quality healthcare,
including mental health and substance use treatment.
Across New Hampshire we have seen the difference it can
make to have appropriate healthcare in our criminal justice
system. In Sullivan County in my district beginning in 2010 at
the beginning of this crisis the jail superintendent had a
choice to make to deal with an incredibly high recidivism rate.
He could build a new jail for $42 million or bring treatment
in- house for $7 million, and thankfully, he chose the latter.
As a result, we saw recidivism in that country drop from 54
percent down to just 18 percent, and even those a substantial
number were parole violations. It was only six percent new
crimes.
That is the difference that appropriate healthcare can make
for our most vulnerable population. We can build off of the
success that we have seen in New Hampshire by bringing this
model to correctional facilities across the country. I am
pleased to see that Michigan is implementing a similar program.
So my bill will do just that, improve access to treatment
for justice-involved populations by allowing healthcare to
follow the person into incarceration. We have heard in this
committee that Rhode Island has opioid addiction treatment for
justice-involved populations that reduced post-incarceration
death by 61 percent. These aren't just statistics.
These are real lives of people in our communities. If we
are serious out overcoming addiction we must treat this as a
disease, not a moral failing, and because let me tell you, if
we were to design a system to fail this would be it. A system
that strips healthcare from a person at their most vulnerable
point. A system that leaves the crippling disease of addiction
untreated and a system that perpetuates recidivism instead of
prioritizing rehabilitation.
So it is time to look at the evidence, listen to our
communities on the front line, and end this outdated policy. I
want to thank Chairwoman Eshoo and Chairman Pallone for
including this bill in today's discussion. This bill presents
our committee with the opportunity to turn the tide. I have
seen how it works in our state.
I would love to hear your comments on how it could work
across this country if we eliminated the Medicaid exclusion for
justice-involved individuals, if you have any comment.
Ms. Brandt. I will address that, at least from the Medicaid
perspective. We are in the process right now of finalizing
implementation of support at Section 1001, which requires
states to suspend, not terminate, Medicaid enrollment for
juveniles and that is going to be finalized within the next few
months.
And then we also have two budget proposals, one which
would, again, suspend, not terminate, Medicaid enrollment for
not only all incarcerated individuals but for those covered
under CHIP, the Children's Health Insurance Program, as well.
Both of those would be for six months.
Ms. Kuster. And what I am hoping is that you would consider
supporting our bill that would take it a further step. I
appreciate the efforts you are doing but your hands are tied.
We need to go a further step and actually have the Medicaid
coverage follow the individual during their incarceration so
that they can get access for their co-occurring mental health
and substance use.
And so my time is up, but I do want to submit for the
record the wonderful letters of support from all of the great
organizations that will be on our next panel that support this
approach.
And I thank you and I yield back.
Ms. Eshoo. And so ordered, and we thank the gentlewoman.
[The information appears at the conclusion of the hearing.]
Ms. Eshoo. Those are dramatic figures that you cited.
Excellent. The gentlewoman yields back.
Pleasure to recognize Mr. Griffith for 5 minutes.
Mr. Griffith. Thank you very much, Madam Chair, and I
appreciate having this hearing and considering one of my bills.
Before we get to that, I do want to address some of the
comments that were just made. And Ms. Brandt, I really
appreciate the fact that you are working on the juvenile issue
and suspending, because it is one of the concerns that we have
had back home.
When a juvenile goes into custody and then has to reapply
when they get out, and so suspending instead of terminating
will make a huge difference so that when that juvenile gets
back out, we don't start the process all over again and take
60, 90, or more days to get them back into the system to make
sure they have their healthcare. So I appreciate that, and you
mentioned CHIP as well. Is there anything else you wanted to
say on that?
Ms. Brandt. No. We do think these are important
flexibilities that will, to your point, be able to allow these
individuals to have that much needed coverage.
Mr. Griffith. I am concerned about going that extra step
and I think it is probably a good bill that Representative
Tonko has that says we will start--for adult prisoners we will
start the process 30 days before they are released so that if
they are eligible for Medicaid they can--they can receive it
but not while they are in prison.
How much would the bill that Ms. Kuster was talking about a
minute ago, her H.R. 4141, what would that cost if we suddenly
took on the responsibility for all the prisoners, whether they
be local--and most of them would be local and the state because
we are already responsible, maybe not through Medicaid but
through other federal coffers, to pay for medical care for
those in federal prisons. But how much would it cost if we
suddenly took on all the state and territory, local and state
folks who are incarcerated and in jail for some reason?
Ms. Brandt. That would be something, sir, where I would
have to get back to you. But we would be happy to work with you
all to be able to provide estimates based on our information.
Mr. Griffith. I would assume it would be billions and
billions of dollars. Isthat a fair assessment?
Ms. Brandt. It would be substantial, yes.
Mr. Griffith. Yes, ma'am. I thought so.
Now, we are also--you know, we have been talking about a
lot of different things and I want to make sure I get in a plug
for a bill that I am carrying and that is--and that we are
considering today, the Ensuring Compliance Against Drug
Diversion Act.
H.R. 4812 would terminate controlled substance registration
belonging to someone who dies, ceases to legally exist, or
discontinues business or professional practice. It would also
require registrants to obtain written consent from the DEA to
assign or transfer their registration.
Can you tell us a little bit about the process of
registering to manufacture, distribute and dispense controlled
substances and remind us of why it is important for DEA to be
involved in these changes to controlled substance
registrations?
Mr. Prevoznik?
Mr. Prevoznik. Yes, sir. Thank you for that question.
The current way that it works is that we work with each
registrant to assess are they terminating, how they are
terminating, where are they being sold, how are they being
sold. So we work with each individual to assess that particular
situation.
It would be helpful to engage them more on that because
what we do see is we are seeing some transactions in which it
is just the actual shares are being sold. So it kind of makes
it convoluted on who actually is owning it. So we would
certainly work with you on that to discuss that.
Mr. Griffith. Well, whatever you--if you have got
suggestions now is the time to make them because I think it is
something that is a good idea and we are going to go forward.
But if there is something we need to tweak, let me know.
Mr. Prevoznik. Absolutely.
Mr. Griffith. Absolutely. We brought up--one of the members
on the other side brought up methamphetamine. It is a serious
problem.
Mr. Prevoznik, I will continue with you for just a second.
You indicated that there were counterfeits that were looking
just like Adderall. Adderall is a prescription drug. Are we
seeing any problems in our drug supply chain or is it just on
the street--in the street market for Adderall?
Mr. Prevoznik. On the street market.
Mr. Griffith. On the street market. And are there some
people who--we talked about how cheap it was to get these meth
products. Is this a lot cheaper than they can get through their
prescription--regular supply chain--the Adderall? If you
actually had a prescription but is it a lot cheaper on the
street?
Mr. Prevoznik. It would depend on the supply.
Mr. Griffith. Depend on the supply.
Mr. Prevoznik. Yes.
Mr. Griffith. And, Admiral, you indicated that we had a big
supply of this--of meth coming in. I remember, you know, when
we had a previous spike, we had what was known as shake and
bake. People were making it themselves. Is that what we are
seeing today with this higher quantity or higher intensity
meth?
Dr. Giroir. Because of the law enforcement efforts, there
is essentially negligible production in the United States. This
is transnational Mexican cartels that are making it on an
industrialized basis at the hundreds of thousands of pounds per
factory and every cartel has a number of factories and they are
pouring into our country.
Mr. Griffith. And what is the main way of bringing that in?
Is it over the border or are they flying it in?
Mr. Prevoznik. It comes from all different ways.
Mr. Griffith. But isn't it true that most of it would be
coming across the border in the South?
Dr. Giroir. Yes.
Mr. Prevoznik. That is true.
Mr. Griffith. Thank you very much. I yield back.
Ms. Eshoo. The gentleman yields back.
And now I would like to recognize the gentlewoman from--oh,
no, the gentleman from New Mexico, Mr. Lujan, for 5 minutes.
Mr. Lujan Thank you, Madam Chair. I want to thank
Chairwoman Eshoo, Ranking Member Burgess, Chairman Pallone, and
Ranking Member Walden.
I mentioned earlier that I have Lauren Reichelt, the Health
and Human Services director for Rio Arriba County, New Mexico,
here with us today. Lauren, thank you for your work and thank
you for what you do.
Five years ago, Rio Arriba County received funding from the
state of New Mexico to establish a behavioral health investment
zone. As part of the investment zone, her department leads an
Opiate Use Reduction Network, which allows the various
healthcare agencies and providers to work collaboratively to
manage individual cases and connect patients to services.
The network had an immediate impact in 2015 when it made
overdose reversal drugs available throughout the county. Right
away they saw a 30 percent drop in overdose deaths. Over the
past few years, overdose deaths in the county have continued to
decline.
While ER visits for overdose initially increased because
people's lives were saved and they were able to receive
treatment, those numbers are now being driven down as well with
better prevention in the community.
Rio Arriba County was selected for this project because it
was a national leader in overdose deaths. Now they are a leader
in showing the rest of the nation how to address substance use
disorder head on with a network of community supporters.
So, Lauren, again, I want to recognize your work and that
of your team.
Mr. Prevoznik, you mentioned in your testimony that there
are just over 75,000 D-A-T-A, DATA-waived practitioners who are
authorized to provide medication-assisted treatment with
buprenorphine. Is that correct?
Mr. Prevoznik. Correct.
Mr. Lujan And how does that number compare to the number of
practitioners who are registered to prescribe controlled
substances?
Mr. Prevoznik. It is a much smaller percentage.
Mr. Lujan How much smaller? A little bit? A lot?
Mr. Prevoznik. Quite a lot.
Mr. Lujan According to the Diversion Control Division's
website, there are over 1,756,677 practitioner registrants,
including over 1.3 million doctors, over 400,000 mid-level
practitioners. We have nearly 12--and just to compare that
number, so 75,000 on the other side, 1.7 million on the other.
In New Mexico, we have nearly 12,000 practitioners who are
registered with the DEA to prescribe controlled substances
including opioids. Yet, only 1,200 who can prescribe
buprenorphine for medication-assisted treatment. Isn't that
something that we should fix?
Mr. Prevoznik. Yes. I mean, it is a requirement by SAMHSA
that they have certification for the treatment so they have to
take the training in order to get--to be DATA-waived.
Mr. Lujan So if there is the ability to prescribe the
opioid, shouldn't those practitioners or others be able to also
help treat people to prevent overdose?
Mr. Prevoznik. Those that--those that are certified, yes.
Mr. Lujan Well, how do we close the gap for 1.7 million to
75,000? How do we close that gap?
Mr. Prevoznik. Well, I mean, one of--one of the things that
we did do that was part of the SUPPORT Act is we just passed a
notice of proposed rulemaking for mobile NTPs so that NTPs--
that brick and mortars can now have mobile units that can go
out to the rural areas or those areas of need so that we have
proposed that and it is out and looking forward to comments
from the industry on that. So that should help out some.
Mr. Lujan And there is another piece of legislation that
Senator Tonko and I have introduced called the Mainstreaming
Addiction Treatment Act to eliminate the outdated requirements
for providers to go through additional hurdles to provide the
treatment that patients need and which are qualified to
provide, and I hope that is an area that we can work on
together and that the committee is willing to be supportive of
as well.
I urge my colleagues to support this legislation and I am
proud to support several of the other proposals that we are
considering here today including the State Opioid Response
Authorization Act to make sure these crucial grants make it to
states and the Opioid Workforce Act to create more residency
slots for physicians to enter the field of addiction medicine.
And lastly, just because it was mentioned, the importance
of Project ECHO, which has been highlighted by the Office of
National Drug Control Policy in their new action guide for
drug-free rural communities.
ECHO provides a telemonitoring program to train and support
primary care providers who want to start or expand medication-
assisted treatment in their communities. It is proven to be a
cost saver and a lifesaver. It has been expanded to the VA as
well and I am certainly hopeful that we can continue to be
supportive of this.
Admiral, I see you nodding in agreement there. So anything
you might want to add there on Project ECHO?
Dr. Giroir. I just think Project ECHO and Dr. Sanjeev Arora
at University of New Mexico has been transformational and a
game changer, whether it is opioids, whether it is sickle cell
or now they are doing ECHOs on coronavirus, it really is a gift
from New Mexico and the University of New Mexico to the world.
I could not be more impressed with that program.
Mr. Lujan Glad to hear you say that. Dr. Sanjeev Arora is a
real hero of mine and someone that I appreciate very much, sir.
Thank you so much. I yield back.
Ms. Eshoo. The gentleman yields back.
A pleasure to recognize the gentleman from Florida, Mr.
Bilirakis, whose father was chair of this Health Subcommittee
when he served in the Congress.
Mr. Bilirakis. Thank you.
Ms. Eshoo. Another true gentleman. Five minutes.
Mr. Bilirakis. Yes, he is a good man. Thank you. Thank you
very much.
Ms. Eshoo. Sure.
Mr. Bilirakis. I appreciate it, Madam Chair. Thank you so
much.
The first question is for Mr. Prevoznik. I hope I got that
right.
Mr. Prevoznik. It is OK.
Mr. Bilirakis. I will get it right the next time.
One of the bills we are considering would eliminate the
separate DEA registration requirement for providers prescribing
buprenorphine for SUD treatment.
Why does a patient limit exist today for buprenorphine and
what is its extent post-SUPPORT Act?
Mr. Prevoznik. So it is buprenorphine and----
Mr. Bilirakis. Yes. Sorry.
Mr. Prevoznik. That is OK. The requirement is actually an
HHS SAMHSA requirement.
Dr. Giroir. It is statutory.
Mr. Prevoznik. Statutory as well.
Mr. Bilirakis. OK. Very good.
Admiral, Congress commissioned an HHS study due later this
year in the SUPPORT Act that will include recommendations on
where patient limits should be set.
Does the HHS have any concerns with Congress removing this
limit without this study idea? The data, in other words. The
study data idea.
Dr. Giroir. So two points, sir. The main problem we have
are not with people bumping up against their limit but people
not even prescribing even close to their limit. So we are
trying to work on that set of barriers that are--that are there
that keep people prescribing for five or ten people instead of
120 or 130 people.
The general concern and it is not an overwhelming concern,
but the concern is, as all of you have pointed out, people in
my generation or even younger do not get appropriate training
for addiction medicine in medical schools.
So there needs to be a gradual process as people get
trained under a DATA waiver that eventually--now it is moving
very quickly, that people are getting more and more training,
there is funds to do that.
But right now, we are sort of in that unstable period where
we don't want to just give people the ability--it is not just
give a pill. These are people with a chronic brain disease and
there needs to be some training.
It is only eight hours training, right? It is only eight
hours of training for a physician. So we would, of course, like
to do the study and work with you on that.
But again, we have been focused on the main problem of
people--only 110,000 prescribers by our data, or 70,000, have
waivers, and they are prescribing only at a small fraction of
their prescribing ability.
Mr. Bilirakis. So you are saying it is mandated now in the
medical schools that they get the training. How many hours you
said?
Dr. Giroir. So the DATA waiver, it is only eight hours or
physicians----
Mr. Bilirakis. Eight hours.
Dr. Giroir [continue]. And, you know, that is not a big
burden. Most states you have to do 20 or 30 hours of continuing
education a year, and for nonphysician prescribers in general
it is 24 hours of training.
Mr. Bilirakis. All right. Thank you very much.
Next question is for Ms. Brandt. What can CMS do to
encourage or utilize nonopioid-related quality initiative
programs to incentivize providers to use less opioids during
pain management to decrease the long-term opioid addiction
risk? This is a question--I mean, this affects all our
communities, as you know. So if you could answer that I would
appreciate it.
Ms. Brandt. Sure. As I mentioned in my opening statement,
one of the things we have recently done is expand coverage to
things like acupuncture. So we are really looking to, you know,
expand our use of nontraditional opioid alternatives.
We also did the RFI, or request for information, in
September of last year where we basically sought feedback on
ways that we, as an agency, could help address the crisis and
look particularly at, you know, what are the Medicare and
Medicaid payment and coverage policies that have enhanced or
impeded nonopioid treatments--where are the barriers that we
have that we can potentially change.
We have really been working very closely with the
department and taking the recommendations that were discussed
earlier from the interagency pain task force to really look at
how we can pull our levers to try and expand our coverage as
much as possible for these nonopioid alternatives.
Dr. Giroir. And maybe I will just----
Mr. Bilirakis. Yes, sir?
Dr. Giroir [continue]. Mention that we have many ongoing
work streams. So under CDC but being done by AHRQ, the Agency
for Health Research and Quality, there is a report that is
going to be published in April on nonopioid pharmacologic
treatments to chronic pain that reviews the entire world's
literature as well as one that talks about noninvasive
nonpharmaceutical treatments coming in April.
So there is going to be a whole lot more guidance coming
out that we want to be evidence-based, right? We got into this
problem because we didn't look at the evidence and opioids got
over-prescribed.
So we are trying to be very careful through CDC and AHRQ to
make sure the best evidence is considered as we roll this out,
again, in the spring. The spring is going to be a busy time.
Ms. Brandt. Busy.
Mr. Bilirakis. Very good. I am on the VA Committee as well
and, you know, we have been exploring these alternative
therapies for PTS and TBI but also for opioids, whether they
are alternative or complementary, to reduce the dosage of the
opioids.
So we all have to work together and think outside the box
because this is a true epidemic in this country.
Thank you very much, and I yield back, Madam Chair.
Ms. Eshoo. The gentleman yields back.
It is a pleasure to recognize the gentlewoman from
Illinois, Ms. Kelly, for 5 minutes.
Ms. Kelly. Thank you, Madam Chair, and I thank the
committee for holding this hearing for all the witnesses for
being here today.
We have all heard the statistics about the opioid epidemic
and how it is impacting Americans. As chair of the
Congressional Black Caucus Health Brain Trust, I have worked
with my colleagues to create legislative and policy solutions
to reduce health disparities and promote good health outcomes
in all communities.
I also think it is important to have a conversation about
how we are making sure minority individuals with substance use
disorder are receiving equal treatment opportunities.
I understand that there is a number of barriers that exist
for patient show seek to receive treatment. However, I was
concerned to hear that some of the barriers have also
heightened racial inequities.
An article written last year in JAMA Psychiatry found that
although opioid use disorder rates are similar for white
patients and black patients, white patients received a
prescription for medication-assisted treatment at much higher
rates than black patients.
Admiral, were you aware of this study when it was published
last May and these statistics?
Dr. Giroir. Yes, ma'am. I don't remember what date it was
published by we are acutely aware of that, and it, clearly, is
our position and it should be our position that this is a
chronic brain disease.
It doesn't matter what color you are. Everybody deserves
medication-assisted treatment for opioids as the cornerstone of
therapy along with all the psychosocial and other issues.
Stigma is an issue no matter where you go and we are trying
to work through those issues specifically not only with racial
and ethnic minorities but also for women.
So in my office, the Office of Women's Health and the
Office of Minority Health, focuses on disparities across the
board but specific efforts throughout the regions to make sure
that MAT and other evidenced, based treatments are provided.
I will also say that Dr. McCance-Katz, who we are all a fan
of, is absolutely adamant that the State Opioid Response Grants
will only support evidence-based treatment. So if you are in a
program that doesn't offer MAT or doesn't offer meaningful MAT,
you are not going to get funded by that.
So anything we can do, and I would love to work with you to
enhance those treatments for everyone.
Ms. Kelly. A morbidity and mortality report issued last
year by the Center for Disease Control and Prevention reported
that opioid overdose rates for African Americans increased more
than any other group from 2016 to 2017.
Admiral, what do you believe are the barriers or challenges
facing African Americans with opioid use disorder and accessing
treatment?
Dr. Giroir. So it is very complicated and my office tried
to do studies as well because it is very interesting. I don't
mean interesting in an academic way. It is really challenging
because it is not even across the board for African Americans.
It is really segmented into certain age groups that are
seeing the higher rates and whether they are urban or rural,
and all of those have different--you know, all of those have
different challenges.
On the urban side, particularly recognizing that many
minorities are socioeconomically in a challenged position, we
have been working very closely with HRSA and the community
health center program, which I love. Now takes care of 30
million Americans and one out of three in poverty, and they
have made a full-court effort to integrate SUD behavioral
health and physical all within the same environment.
In many cases, I think they are a model for how the U.S.
healthcare system should go forward. You know, that is one
example on the urban side and we have been--really been
focusing with FQHCs and, you know, rural is a whole another
topic but happy to get into that with you as well.
Ms. Kelly. And how do you think Congress can help HHS
agencies manage inequities and treatment access? What more can
we do?
Dr. Giroir. So, you know, that is a--that is a big
question. Number one, we need to--we need to take care of
treatment across the board, right--across the board.
We are also--so number one. Number two, we do need a
workforce and that is critically important, and as you know,
the workforce tends to be disproportionately not in areas where
minorities are in rural.
So, for example, funding the Addiction Medicine Fellowships
that are proposed, we think that is very important. And I just
want to make the point is it is not--it is OK to train
addiction psychiatrists. We need that. But we need a lot of
primary care practitioners who work in rural, just internists,
OB/Gyns, to get that one year of addiction training, because
they are really on the front lines and we are trying to incent
that with the National Health Service Corps, with HRSA loan
repayments, a $5,000 incentive if you get your DATA waiver--all
those kinds of things.
So I would say that still workforce is a real issue as well
as parity and reimbursement through systems like Ms. Brandt's.
I mean, that is very important. If you have the workforce but
you don't have the appropriate reimbursement for care, you are
not going to have a long-term solution.
Ms. Kelly. And through the Brain Trust we try to make sure
that we are pushing for a diverse workforce. And lastly, I just
want to say to Ms. Brandt I totally believe in acupuncture. I
had a pinched nerve and that is the only thing that worked. So
good luck.
Ms. Brandt. Thank you. My mother was also very happy about
that.
Dr. Giroir. You can now be covered under Medicare for that
once you get to that age. Yes.
Ms. Kelly. I am not far away.
[Laughter.]
Ms. Eshoo. Well, thank God you are feeling terrific. We
need you.
The gentlewoman yields back, and now I will recognize the
gentleman from North Carolina, Mr. Hudson, for his 5 minutes.
Mr. Hudson. Thank you, Madam Chair. Thank you for holding
this important hearing and thank you to our panel for the great
work you do every day. Thank you for your time being here with
us.
Congress took strong bipartisan action in 2018 to combat
opioids epidemic but I have always believed that that was the
first step. In North Carolina, we have four of the top 25 worst
cities for abuse in the country, one of which is in my
district, the city of Fayetteville.
This issue is personal for me. It is personal for my
constituents, just as I know it is personal for everyone in
this room. I believe this hearing gives us a good opportunity
to examine what we have done and what the next steps are.
Admiral Giroir, I understand that as a senior advisor for
opioid policy at HHS you are responsible for coordinating the
department's response to the opioid epidemic. I know the
primary focus of today's hearing is on treatment and recovery,
but I have had many providers in my office tell me that
prevention is often the best treatment.
As we discussed in this committee before and you and I have
discussed, most addictions start in the medicine cabinet.
Getting unused medications out of the home in a safe and timely
manner is critical, particularly if a household has teenagers
or other susceptible family members.
Unfortunately, federal disposal recommendations are
inconsistent, ineffective, and out of date. Let me just go over
a few points that have been a concern to me.
First, we need consistent messaging out of HHS. For
example, FDA includes a list of drugs that could be flushed
down the toilet, including fentanyl. SAMHSA discourages this
practice altogether.
Second, we need someone to review the adequacy of the
current federal recommendations. I understand GAO put out a
report in September highlighting that very few people actually
follow the federal recommendations.
And third, it has been over a decade since these federal
recommendations have been updated. And so given all those
issues, I do believe it is appropriate to advise people to
mix--I don't believe it is appropriate to advise people to mix
their pills with kitty litter, as it says on one of the
websites, or coffee grounds, and I know there are better
options for in-home disposal that we could--that we could talk
about instead.
Can you commit to me to look in these issues and get back
to me on sort of the next steps on trying to address these
disparities?
Dr. Giroir. Yes, sir. I absolutely do. It is an area that
we really do need to work on. We focused on take back days and
other things that we know have been highly effective.
But it is not just in HHS. There is DEA and many agencies
involved with this. And yes, sir, I will do that and I think
that is a really good direction for us to move in the next
level.
Mr. Hudson. I appreciate that and, sir, from DEA's
perspective do you--interested in commenting?
Mr. Prevoznik. Absolutely. We would certainly work with
you, yes.
Mr. Hudson. OK.
Mr. Prevoznik. And we want to make April 25th as the next
Take Back Day. So----
Mr. Hudson. April 25th?
Mr. Prevoznik. -- Get it out of the cabinets.
Mr. Hudson. Absolutely. Well, thank you. I appreciate that.
Ms. Eshoo. Mr. Prevoznik, I can't--I am losing some of your
words and I think they are important for everyone to hear. Can
you just answer the gentleman's question again?
Mr. Prevoznik. Yes. The next--I just want to put a plug in
there that the next National Take Back Day is April 25th.
Ms. Eshoo. I see.
Mr. Prevoznik. So please get that medicine out of your
cabinets.
Mr. Hudson. That is great. Madam Chair, I think it is
important we continue to promote that. But I think it is also
important that we look at these federal recommendations and
make sure they make sense. Make sure that different agencies
don't have, you know, guidance that contradicts other agencies'
guidance and that we are giving the best information to folks.
Ms. Eshoo. Well, it is wonderful that you are pointing out.
I wasn't even aware of it. So thank you.
Mr. Hudson. With that, I will be happy to yield back.
Ms. Eshoo. You still have some time. Do you want to yield
time to someone?
Mr. Hudson. If anyone would be interested in the time I
would be happy to yield.
Ms. Eshoo. Can I take 10 seconds?
Mr. Hudson. Please.
Ms. Eshoo. Does anyone on the panel know--Medicare has been
referenced more than once in our hearing this morning. Do you
know what the addicted population of Medicare beneficiaries is
in our country?
Ms. Brandt. We can get back to you with an exact number on
that, ma'am. But of our Medicare Part D or our drug coverage
beneficiaries it is a fairly small but meaningful percentage
that we definitely focus on.
Ms. Eshoo. That we what?
Ms. Brandt. It is a--it is a small percentage of our Part D
beneficiaries. But I will get you the exact number. I would be
happy to get back to you with that exact----
Ms. Eshoo. Because there was a lot of emphasis about
benefits and what they need in the Medicare population, and, I
mean, I think Medicaid is the main player in this. But I would
appreciate getting that information.
The gentleman yields back. Thank you.
The Chair is pleased to recognize the gentleman from
Maryland, Mr. Sarbanes, for 5 minutes.
Mr. Sarbanes. I thank--thank you, Madame Chair, and thank
you too to the panel.
Admiral, you started to speak a moment ago. I want to pick
up on this topic of the workforce because I think it is really
critical and, you know, we can put resources behind expanding
our capacity in terms of the general delivery framework that we
have to address this crisis.
But if we don't have the professionals in place to actually
deliver the care then that, obviously, is going to impede
progress on our efforts.
Two years ago, and this is--the workforce issue is
something I have brought some special attention to in my time
here in Congress, even going back to the passage of the ACA and
pushing the idea of developing a national healthcare workforce
commission to kind of look at where the shortages are.
But two years ago, I joined my colleagues, Katherine Clark
and Hal Rogers in introducing the Substance Use Disorder
Workforce Loan Repayment Act. So that is a bipartisan bill that
would help increase a number of healthcare professionals
working in addiction treatment in substance use disorder
programs around the country by offering student loan
forgiveness when they provide direct patient care at opioid
treatment programs, and then that bill was included in the
SUPPORT Act, I am glad to say.
I am also a co-sponsor of one of the bills that we are
looking at today, which is H.R. 3414, the Opioid Workforce Act.
We know many communities across the country are facing
shortages of these kinds. Professionals lack access to the
services they need as a result.
This is especially true, as you know when it comes to
mental health and substance use disorder providers, and in
addition to the affordability the provider capacity is clearly
a barrier to treatment.
H.R. 3414 would help expand treatment by growing the
provider workforce. It would make a thousand new graduate
medical education slots available under Medicare. Those slots
would be targeted towards training providers in addiction
medicine, addiction psychiatry, pain medicine, or prerequisites
of those programs.
So I will just give you the opportunity maybe just to speak
broadly about the importance of meeting these workforce needs,
where you seen the bottlenecks. Another kind of iteration of
this, a kind of second-degree issue relates to you can put
money in programs in place to train providers but then finding
the folks that can deliver the training sometimes also can be a
challenge.
So how do we make sure that we fill these gaps in terms of
the workforce and to the extent you would kind of prioritize or
triage that effort, can you speak to that as well?
Dr. Giroir. So thank you, sir, and this is--this is a
critically important long-term issue. This is not a put a Band-
Aid on it but this is how we sustainably begin to fix the
system.
There are shortages of psychiatrists for mental illness and
shortages of addiction psychiatrists. There are also shortages
across the board. Being a physician, I can say don't just focus
on physician training.
It is social workers. It is community health workers. It is
peer counsellors and peer coaches, all the--all the different
aspects that you need. What we have done is a couple of things,
number one, and you will be seeing this coming out this year.
We have asked, and HRSA has been working very much on not
just, like, drawing the line. Like, so many psychiatrists die
this year and we will draw a line on how many need to come. But
what is the impact of the new models of care and what is the
impact of things like telemedicine on changing the entire model
and how do we move the workforce to that--just to park that.
Secondly, we have focused on ancillary providers through
the National Health Service Corps, you know, nurses, you know,
all the healthcare providers that are non-physician.
But, again, I do want to say that the addiction medicine
fellowships, we are very excited about that because it brings
people--like, if you want to decrease neonatal abstinence
syndrome, let us train obstetricians to have a year of
addiction medicine so they can provide the treatment that is
right there.
Pediatrics--you know, a lot of this starts in--I am a
pediatric ICU doctor in 14, 15, of 16 years of age. So we are
very bullish and I think there is broad support in the
community to supply these kinds of one-year fellowships and you
could imagine a family practice group that may have eight
physicians and two are trained in addiction medicine. It really
changes the way how we deliver care.
So but you can really say all of the above, sir. We really
need all of the above types of professionals because they will
help not only in opioids but in methamphetamine, in alcohol
addiction, in marijuana addiction, all the kinds of things that
our society faces. This truly--if we get the workforce right
and we get the model right and we get the incentive payments
right, this will work out in the long term.
Mr. Sarbanes. Thanks very much.
Yield back.
Ms. Eshoo. The gentleman yields back.
Please to recognize the gentleman from Georgia, Mr. Carter,
for 5 minutes.
Mr. Carter. Thank you very much. I thank all of you for
being here.
Ms. Brandt, I am going to start with you. I need to
understand exactly the rule proposals, the rule changes that
you are proposing. If someone is incarcerated, their Medicaid
would be suspended for 60 days and then reinstated?
Ms. Brandt. Six months, sir.
Mr. Carter. Six months?
Ms. Brandt. It would be for six months.
Mr. Carter. OK. How do you--is it six months or less or is
it--I mean, how do you determine how long somebody--is that he
usual sentence or what?
Ms. Brandt. So it's a great question and we came up with
six months because there were a number of people whose
sentences were less than the six-month period of time. Usually,
it's much more serious types of things that would incarcerate
them for longer than that.
Mr. Carter. If they are less than six months and they get
out after three months, they got to wait three months before it
kicks back in?
Ms. Brandt. No, it's up to six months.
Mr. Carter. Up to?
Ms. Brandt. Up to six months.
Mr. Carter. OK.
Ms. Brandt. So that way, we give them that flexibility.
Mr. Carter. OK. All right. And let me--let me say that I
know what a big problem this is. I have been to the jails
visiting them. I know what a struggle they are having paying
for these anti- psychotics, paying--and I can see the value
that this would have.
However, I wanted to ask you specifically about 4141, the
Humane Correctional Health Care Act. Do we--and you have been
asked this in this hearing--do we have any idea how much that
would cost?
Ms. Brandt. You know, that particular provision actually
would not impact us at CMS but we don't have--I don't have a
good number----
Mr. Carter. It is going to impact somebody in the--I don't
need to hear that it is not going to impact me so I am washing
my hands of it.
Ms. Brandt. No, absolutely. No, and we would be happy to
work with you to give us any data we have----
Mr. Carter. Well, as I understand it, the bill has got--
part of the bill in there is to do a study to see how much it
would cost. But it seems to me like that is after the fact.
I mean, if we were to implement this and then find out how
much it costs, this is going to be billions upon billions of
dollars that we are looking at here. And what about the impact
on the state? The states is going to--the states are going to
have to take up their part of it as well. This could bankrupt
some of these states.
Ms. Brandt. Again, we share your concern. That is why our
budget proposals are up to six months and happy to work with
you to provide whatever information and data we can.
Mr. Carter. OK. Good. If I could switch over to Mr.
Prevoznik.
Mr. Prevoznik, I was a practicing pharmacist for over 30
years and while I was serving in the Georgia state Senate I
sponsored the legislation that led to the establishment of the
Prescription Drug Monitoring Act. I have seen what a problem
this is.
But I have also been a frustrated pharmacist because, over
the years, I have reported physicians whose practices--whose
prescribing habits in their practices have been questionable.
Reported it to the DEA as a number of pharmacists have only to
get no response whatsoever.
I just want to ask you has that changed any? Are you
helping pharmacists now to identify those physicians that are
out of control and to try to get them under control?
Mr. Prevoznik. That is a great question and I appreciate
that. As a diversion investigator, when I heard from a
healthcare professional such as a pharmacist, that
unequivocally sent all the tentacles up on the back of my neck
that this is very important because this is a pharmacist who
knows the community, he knows the practice of medicine. When
they say, what are you doing about Dr. Candyman--the candyman--
what are you going to do about this, you have our undivided
attention on that.
As a law enforcement agency we--well, sometimes we cannot
come back to you to talk about the investigation because we are
investigating the candyman or whoever you are presenting as a
person who is diverting.
I can't overemphasize how important your voice is and that
the pharmacists do need to speak up and let us know what is
going on because you do have the pulse of that community.
Mr. Carter. And you see what a difficult position--and I
can appreciate the fact that you can't always communicate with
us what is going on. You are, obviously, building a case.
But at the same time it puts us in a precarious position as
well because we don't know whether to fill the prescriptions or
not fill the prescriptions and, you know, I have always said
the only thing worse than filling a prescription for someone
who doesn't need it is not filling a prescription for someone
who does need it.
Now, having said that, I want to ask you this. I am
continuing to get calls now at home, I get them in my office, I
get them from constituents, I get them from people who know
that I am the only pharmacist currently serving in Congress.
But they want to know, there is a problem here with some of
these people who do need this medication getting this
medication. I think it was mentioned earlier that we are trying
to help soften that blow, if you will.
But we get calls. It was always my fear and I tried to
communicate this and articulate it to my colleagues, we got to
be careful how far we swing that pendulum. Now we have got
people out there who truly need these medications who can't get
them and that is creating a big problem.
Admiral, are we addressing that?
Dr. Giroir. Yes, sir. It is one of our biggest concerns. We
have heard from, you know, hundreds of patients if not
thousands about patient abandonment or too abrupt
discontinuation of opioids and when you have an opioid use
disorder and your opioids get taken away what do you do? You go
to the streets because if I can ask you to stop breathing for
ten minutes you can ask them to stop cold turkey.
So we put out--the CDC and my office put out guidance. We
published it in the literature. We are referencing that all the
time in order to make sure that, you know, if you do this do
this very slow and in a patient- centric noncoercive way, and I
just want to echo how important--we can swing the pendulum to
the other direction and I think we have kind of gone too far,
at least for many patients in a significant way.
Mr. Carter. Absolutely. Well, again, I want to thank all
three of you for what you are doing. This is extremely
important. I witnessed this firsthand when we were at the
epitome of this and I have seen improvements and it is
encouraging.
So thank you, and I yield back.
Ms. Eshoo. Gentleman yields back.
Pleasure to recognize the gentlewoman from Delaware, Ms.
Blunt Rochester, for 5 minutes.
Ms. Blunt Rochester. Thank you, Madam Chairwoman, and thank
you so much to the witnesses for this very important hearing
today.
Our nation's ongoing overdose crises isn't represented by
one community, one region, or one socioeconomic class. We are
all being touched.
I am proud to have worked with my colleagues to address the
rise of overdose deaths by passing the 21st Century Cures Act
and the Support for Patients and Communities Act.
Despite these efforts, Delaware continues to be in the
middle of a public health crisis. As our nation's overdose
death rate dropped for the first time in two decades, my state
remained fifth in the nation due to higher rates in 2018 and
2017.
Looking at the highest age- adjusted drug overdose death
rates in 2018, Delaware is second in the nation. Those aren't
just numbers. It means we are losing someone every 22 hours to
an overdose.
The rise in synthetic opioids is playing an increasing role
in overdose deaths. In 2009, almost all of Delaware's overdose
deaths were due to prescription opioids like oxycodone.
However, in 2017, synthetic opioids contributed to 72 percent
of our 400 overdose deaths.
As our committee continues to combat the opioid epidemic, I
look forward to working with my colleagues on a comprehensive
public health response to the proliferation of synthetic
opioids.
My first question is to you, Admiral, and I just want to
follow up on Ms. Kelly's line of questioning. You got a chance
to talk about the urban area. Delaware is urban, suburban, and
rural, and I was hoping that you could speak specifically to
the unique challenges and solutions for rural communities.
Dr. Giroir. Yes, ma'am. So rural communities have a whole
plethora of issues. Some are the same and some are different.
If you look at many of the rural areas they have higher
prescribing but many people are also--have jobs that take a
toll on your bodies, right, so you are in chronic pain.
So it really goes that way. So they have that problem. We
find that in rural areas actually the economic issues are more
important than provider issues for neonatal abstinence
syndrome.
Urbanly, it is providers. Rurally, it is actually the
socioeconomic issues and opportunity. But I think we all know
that provider shortages in the rural area is really the 800-
pound gorilla in the room and the way to solve that is, of
course, increasing providers, National Health Service core
issues like that and trying to bring people to under-served
areas. And I can't--I can't overestimate--I can't over
emphasize the importance of things like telemedicine.
Telemedicine for MAT is really a game changer because it
allows people who may not have a DATA-waived provider to gain
access to that provider remotely and I would personally like to
see as many efforts as possible to enhance telemedicine--
telemedicine reimbursement across the board.
Ms. Blunt Rochester. Thank you. I appreciate that CMS has
also taken steps to increase the capacity of Medicaid providers
to deliver substance use disorder treatment through funding
grants authorized by the SUPPORT Act.
Delaware was fortunate to be one of the 15 states to
receive a planning grant. Sixty percent of Delawareans who died
from an overdose in 2017 were Medicaid eligible the previous
year.
We know that the Agency for Healthcare Research and Quality
will consult with CMS to report back to Congress on the
experiences of states who were awarded planning grants.
Ms. Brandt, I would like to ask if you would just pay
particular attention to how states dealt with one of the
greatest barriers that has been discussed here today, which is
providers' lack of willingness to treat SUD because of stigma
and also knowledge gaps. If I could just have you confirm that
that will be a focus.
Ms. Brandt. We will certainly take that into account,
ma'am.
Ms. Blunt Rochester. And, Ms. Brandt, also additional
statutorily-required reports in these will CMS track or measure
whether physicians who receive a waiver through the grant are
actively prescribing or treating at the patient capacity they
are currently allowed.
Ms. Brandt. I will have to get back to you to confirm that.
But I will certainly take it back to make sure whether or not
that will be our requirement.
Ms. Blunt Rochester. I only have about ten seconds, and one
of the things that I did want to ask about and I will follow up
on is the ability for physician assistants and nurse
practitioners to prescribe buprenorphine and I want to make
sure that states don't have laws that are preventing us from
this expanded opportunity. So we will follow up with you
afterwards. But thank you so much and I yield back the balance
of my time.
Ms. Eshoo. The gentlewoman yields back. It is a pleasure to
recognize the gentleman from Montana, Mr. Gianforte, for 5
minutes.
Mr. Gianforte. Thank you, Chairwoman Eshoo and Ranking
Member Burgess, for holding this hearing today. This is a very
important topic, and thank you for the witnesses for being here
for this ongoing discussion of the opioid and substance abuse
issues that are facing--crisis that is facing our country.
This committee has a successful history of working together
to respond to this issue. In 2016, we passed the CARE Act and
the 21st Century Cures Act. In 2018, the committee followed
that with the SUPPORT Act.
These laws expanded substance abuse disorder treatment
funding for treatment recovery and prevention, the expanded
Medicaid and Medicare coverage for medication-assisted
treatment, and Congress has continued to fund these treatment
and prevention programs with billions of dollars.
The funding was also made available for stimulant treatment
programs like those that treat meth addiction. Meth is the
largest substance abuse issue in Montana, accounting for a
majority of our substance--our addiction cases.
I am glad that we have this panel here today to discuss the
ongoing implementation and outcomes of these efforts. I think
we need more of that and I wish we could have a full committee
hearing on this effort.
I am somewhat less excited about some of the new
legislation that is also the topic of this hearing. H.R. 2292
creates a new $5 billion mandatory grant program. It also
permanently extends what was meant to be a temporary waiver of
authority to prescribe opioid treatment medication. That may be
useful and we should certainly consider it. But the current
waiver does not expire until 2023. So we might best focus our
efforts elsewhere.
I can appreciate also the desire to ensure that our state
and tribal health agencies have the resources they need. I saw
this firsthand.
Last month I spoke to a group of students in Montana at a
trade school. There were about 50 of them. Many, if not most,
had experienced the heartbreak of substance abuse addiction
either directly or in a family member.
I heard their stories. They included family separations,
incarceration, and the death of loved ones. It was in their
eyes. The pain in the room was palpable.
One gal told me that it was easier for her to get meth on
the street than it was to get treatment, even when she was
looking for treatment. Another young man recounted being
permanently separated from his brother due to the addiction of
his parents and even as a young man now has not been reunited.
Doesn't know the whereabouts of his brother.
Drugs are ripping our communities and families apart and we
must make sure we get this right.
Admiral, a question for you. You are currently senior
advisor for the opioid policy at HHS and I appreciate that HHS
has a website dashboard to track the stats on the funding,
treatment providers, overdose deaths and other metrics,
tracking results as a basis for evaluating success or failure
of these programs. Where do you feel the department has been
most successful in working to deal with the opioid crisis?
Dr. Giroir. For the opioid crisis specifically, I do think
the overall--the overall approach to approaching it as a public
health issue, that is the underlying philosophy that people
need treatment and you are not going to get well unless you get
treatment. That is the number-one issue.
Number two, emphasizing medication-assisted treatment as
well as other evidence-based forms of treatment. But we still
have a long way to go. There is absolutely no question about
that.
One point three million on MAT is good but we still have a
long way to go and, as you know, for methamphetamine, our
treatment is--can be effective but it is just behavioral. We
don't have any medications to support that treatment right now.
So we really are on a full-out dash with FDA and NIH trying
to develop adjuncts to therapy that could be as useful as
buprenorphine is for opioids.
Mr. Gianforte. OK. My colleague just asked you about rural
substance abuse and that is, certainly, an issue in Montana. I
want to ask you to spend a minute just talking about the unique
challenges in Native American tribal environments.
We have about seven percent of our population is Native
American and the substance abuse issues there are chronic and I
am just interested in what you--what you have learned and what
resources you are applying to that problem.
Dr. Giroir. So today we are releasing $50 million in tribal
opioid response grants which are going to be flexible because
of the Congress's action to use on methamphetamines. So that is
going to give a very good boost to the tribes to be able to use
that money flexibly.
I met with the secretary's Tribal Advisory Committee maybe
two or three weeks ago and we spoke specifically about some of
the issues, and some of the--you know, we have to meet people
where they are and understand what the best solutions are.
One thing that we are, clearly, doing is trying to--and
there's a program out of my office--using community health
workers in tribal settings, right, because often you need to
bring the care to the people instead of the people to the care,
and our preliminary evidence is that is really very successful.
But we are trying to work--you know, a tribe in Alaska is
very different than a tribe in Montana, trying to be, you know,
very specifically geared to the solutions that they need and we
have an ongoing dialogue. I meet with Admiral Weahkee at least
every couple of weeks trying to----
Mr. Gianforte. Admiral, I would just ask that if you could
follow up with my office on any specific substance abuse
programs for rural or tribal. We would like to stay in touch on
that.
Dr. Giroir. Absolutely, yes.
Mr. Gianforte. And with that, Madam Chair, I yield back.
Ms. Eshoo. Gentleman yields back.
A pleasure to recognize the gentleman from New York, Mr.
Engel, for 5 minutes.
Mr. Engel. Thank you, Madam Chairwoman, for holding today's
hearing on the drug epidemic plaguing our communities. In my
home state of New York, opioids alone claimed 3,000 lives in
2017.
Last Congress, this subcommittee led the efforts to deal--
to draft the legislative response to this ongoing public crisis
which culminated in the enactment of the Support for Patients
and Communities Act.
This package included my bipartisan Results Act, which
directs the National Mental Health and Substance Use Policy
Laboratory to issue new guidance to applicants seeking federal
funding to treat and prevent mental health and substance abuse
disorders.
Support For Patients and Communities Act was an important
step forward. It lacked the federal funding necessary to expand
access to treatment. To that end, I am a co-sponsor of the
comprehensive Addiction Resources Emergency Act, which would
provide $100 billion to combat the drug epidemic. This epidemic
also disproportionately affects communities of color, which
face additional barriers and challenges in accessing treatment.
I am working on legislation which would direct the
Department of Health and Human Services to commission a study
that would look at ways to expand access to substance use
disorder treatments in minority and under served communities. I
look forward to hearing from our witnesses on the federal
government's ongoing response to this crisis and ways that we
could strengthen it.
My home state of New York is one of the leading states for
training physicians. Training hospitals in my state constantly
tell me we need additional residency training slots in the
field of addiction medicine to promote access to substance use
disorder treatments.
The Opioid Workforce Act, which I have co-sponsored and is
under consideration today would increase the number of
federally-supported residency slots in addiction medicine,
addiction psychiatry, and pain medicine by a thousand over five
years.
Admiral Giroir, I hope I am not ruining your name too much.
I apologize.
Dr. Giroir. It is all good. I respond to anything. It is
great, sir.
Mr. Engel. I know before you spoke about Cajun accents. So
I figured when it gets to be my turn am I going to blow it. Do
you agree, sir, that we need additional providers in these
specialties?
Dr. Giroir. Absolutely.
Mr. Engel. Thank you. The ongoing drug epidemic has had a
tremendous impact on children, whether it is witnessing their
parents overdose on opioids or being torn away from their
families and put into foster care.
Admiral, let me ask you again and let me also ask Ms.
Brandt. What efforts have your respective agencies take--are
your respective agencies taking to ensure that children who
have experienced trauma as a result of this crisis are getting
access to the services and supports they need?
Ms. Brandt. So, sir, Admiral Giroir has deferred to me to
answer at least a couple of these. So one of the things that we
have done is I mentioned in my opening testimony about our MOM,
Maternal Opioid Misuse model, where we are looking to allow for
more coordinated care and support for mothers, particularly
post-partum, when their children have neonatal abstinence and
when they themselves have addiction problems.
We also, and accompanying with that, gave grants to a
number of states for what we call Integrated Care for Kids, or
InCK model, where it actually allows for things like
occupational, behavioral, and physical health services to be
covered. So the full suite of wraparound services to really be
able to treat children with those addiction issues.
Dr. Giroir. I wanted her to highlight that because I am
very, very positive about those programs. We are also trying--
and think it is an important point. As a pediatrician, I would
be remiss to say that a child with neonatal abstinence syndrome
is not well once they become nondependent.
We now have good data that over the long term they will
have continuing issues and it is really the responsibility of
our society to nurture them through their childhood, make sure
they get the interventions they need. So we have a very
specific program trying to create the long-term data that we
can have to support these children so they can overcome that
neonatal experience that we know stays with them for many
years.
Mr. Engel. Well, thank you both for the good work you are
doing. And thank you, Madam Chair. Since you have been chair of
this subcommittee you have done so many important and wonderful
things and, of course, this ranks with them as well. So thank
you.
Ms. Eshoo. I thank the comments of the gentleman. We are
all here to give and do for our country and this subcommittee
has--is front and center with some of the really challenging
public health issues. So we have to keep the pedal to the
metal.
And now, not seeing any other members, the gentleman from
New York, Mr. Tonko, is here. He is waiving on to our
subcommittee and we are very--I am really pleased that he is
here. He has been very important in this--in this battle to
address opioids in our country. So welcome to our committee and
you have 5 minutes to question.
Mr. Tonko. Thank you, Madam Chair, for your focus. Thank
you for allowing me to waive on.
Admiral Giroir, I championed a provision in the SUPPORT Act
based on my Medicaid Reentry Act which we are considering today
that aimed to improve care coordination for Medicaid-eligible
individuals who are reentering the community post-incarceration
as this group is particularly vulnerable to opioid overdose,
dying at a rate of 120 times that of the general population in
the first two weeks post-release.
Section 5032 of the SUPPORT Act required HHS to convene a
stakeholder group with a deadline of April 2019 to develop best
practices on smoothing healthcare transitions including best
practices for ensuring continuity of health insurance coverage
or coverage under the state Medicaid plan for individuals
reentering the community post-incarceration.
Has HHS convened this stakeholder panel?
Dr. Giroir. The answer is it is in process but we received
guidance from our Office of General Counsel that this is a
FACA. So we have to go through all the FACA processes to what
delayed it. But I want to get back to your point. We actively
need to work with this population because we recognize that
they are at high risk and there is specific guidance that we
have already delivered. But yes, sir, that is not up and
running. It is in the FACA process.
Mr. Tonko. OK. And let me just make the point that it is
pretty concerning that you have missed a deadline by almost a
year at this point. Can you commit to when we might see
additional action on this? Quickly, so I can move on.
Dr. Giroir. I am going to have--we will--we will--I will
get back to you on that.
Mr. Tonko. Thank you. Thank you.
Administrator Brandt, similar to the provision described to
Admiral Giroir, Section 5032 of the SUPPORT Act also required
CMS to publish by October 2019 guidance to state Medicaid
directors on how they can pursue 1115 waivers to provide
coverage to Medicaid-eligible individuals 30 days prior to
release from a public institution.
My home state of New York is currently applying for a
Medicaid waiver in this space and because this guidance hasn't
been issued by CMS I am concerned that they don't have a
roadmap for how CMS will ultimately evaluate their request.
Despite the missed deadline, do you have a time line for
when this guidance is expected to be published?
Ms. Brandt. Thank you, sir, and appreciate your concern. We
are working closely with the department because the stakeholder
group that the Admiral mentioned is critical for the feedback
for us to be able to use that to be able to have the data
needed to issue the letter.
Mr. Tonko. Well, these are critical deadlines that have
been missed, and so I strongly encourage that we meet them
quickly. Thank you.
Let us--moving on to another issue, one of my top
priorities in this epidemic has been to move to a system of
treatment on-demand for the disease of addiction, ensuring that
when an individual has that moment of clarity and is ready to
seek help that we have a medical system ready to meet the need.
One of the limiting factors holding us back for treatment
on demand is that we have institutionalized through law this
concept that medications for addiction should somehow be
treated differently than those for other chronic diseases, even
when there isn't any underlying safety profile to medications
like buprenorphine that merits this special treatment.
We can see this legal stigma clearly through a medication
like buprenorphine, which provides--which providers can freely
prescribe without jumping through additional hoops for the
treatment of pain. But for some reason, when it comes to the
treatment of addiction, providers have to seek a special waiver
from the DEA and complete onerous training and paperwork
requirements.
If there were any other medication for any other disease
that reduced mortality by up to 50 percent we would be doing
everything in our power to make certain that it was an easy to
access--was as easy to access as possible.
Admiral Giroir, are you familiar with the report from the
National Academies of Science, Engineering, and Medicine from
March of 2019 entitled, ``Medications for Opioid Use Disorders
Save Lives?''
Dr. Giroir. Absolutely.
Mr. Tonko. So, as you know, some the major conclusions of
the report were there, and I will repeat, opioid use disorder,
is a treatable chronic brain disease. FDA-approved medications
to treat opioid use disorder are effective and save lives.
A lack of availability or utilization of behavioral
interventions is not a sufficient justification to withhold
medications to treat opioid use disorder. Most people who could
benefit from medication-based treatment for opioid use disorder
do not receive it and access is inequitable across subgroups of
the population, and confronting the major barriers including
existing laws and regulations for the use of medications to
treat opioid use disorder is critical to addressing the opioid
crisis.
So, Admiral, do you have any reason to disagree with the
principal conclusions of the National Academies study?
Dr. Giroir. Those conclusions I not only generally agree
with but use. The only thing I don't agree with is the fact
that we have made so much progress. About 1.3 million people
are now on MAT, about two million people--with opioid use
disorder.
So some of the statistics are older. But in general, of
course, MAT is important and we support it. It needs to be
available to everyone who had opioid use disorder.
Mr. Tonko. So you do agree with the principal conclusions?
Dr. Giroir. From what you just said, yes. I am not
commenting on the data waiver and whether that should be
waived. That is a very complicated and important issue. But
those conclusions I do agree with.
Mr. Tonko. Well, thank you very much, and let us move on
and fight this illness of addiction.
With that, I yield back.
Ms. Eshoo. I thank the gentleman for the work that he has
done. I want to thank the witnesses for not only being here
today, answering our questions, your willingness to answer
written questions that will be submitted to you by members and
answering them in a timely way.
This concludes the first panel and I want to ask the staff
to ready the table for the second panel of witnesses, and I am
going to step out to a meeting and Congresswoman Annie Kuster--
no, women are in charge, Doctor.
[Laughter.]
Ms. Eshoo. Congresswoman Kuster is going to chair until I
return and I want to thank her in advance for her willingness
to do that. Thank you again to you.
Ms. Brandt. Thank you.
Ms. Eshoo. Keep the pedal to the metal.
[Whereupon, the above-entitled matter went off the record
at 12:52 p.m. and resumed at 12:57 p.m.]
Ms. Kuster [presiding]. Good afternoon. We will now hear
from our second panel of witnesses on this critically important
issue.
I would like to introduce Mr. Michael Botticelli, executive
director, Grayken Center for Addiction from Boston Medical
Center; Dr. Smita Das, clinical associate--assistant professor,
psychiatry and behavioral sciences, Stanford University School
of Medicine; Ms. Patty McCarthy, chief executive officer, Faces
and Voices of Recovery; Mr. Robert Morrison, director of
legislative affairs, National Association of State Alcohol and
Drug Abuse Directors; Ms. Margaret Rizzo, executive director,
ISAS Health Care, Inc.--JS, excuse me. I am so sorry. JSAS
Health Care Inc. And Dr. Shawn Ryan, president and chief
medical officer of Brightview.
Thank you to our witnesses for joining us today on the
second panel and we look forward to our testimony--to your
testimony.
Mr. Botticelli, you are recognized for 5 minutes.
STATEMENTS OF MICHAEL BOTTICELLI, EXECUTIVE DIRECTOR, GRAYKEN
CENTER FOR ADDICTION, BOSTON MEDICAL CENTER; SMITA DAS, MD,
PHD, MPH, ADDICTION PSYCHIATRIST, DUAL DIAGNOSIS CLINIC,
CLINICAL ASSISTANT PROFESSOR, PSYCHIATRY AND BEHAVIORAL
SCIENCES, STANFORD UNIVERSITY SCHOOL OF MEDICINE; PATTY
MCCARTHY, CHIEF EXECUTIVE OFFICER, FACES & VOICES OF RECOVERY;
ROBERT I. L. MORRISON, EXECUTIVE DIRECTOR/DIRECTOR OF
LEGISLATIVE AFFAIRS, NATIONAL ASSOCIATION OF STATE ALCOHOL AND
DRUG ABUSE DIRECTORS; MARGARET RIZZO, EXECUTIVE DIRECTOR, JSAS
HEALTHCARE, INC.; SHAWN RYAN, MD, MBA, CHAIR, LEGISLATIVE
ADVOCACY COMMITTEE, AMERICAN SOCIETY OF ADDICTION MEDICINE
STATEMENT OF MICHAEL BOTTICELLI
Mr. Botticelli. Thank you, Congresswoman Kuster, Ranking
Member Burgess, and members of the committee for the
opportunity to speak with you today about legislation to help
patients with substance use disorders including continued
efforts against the national opioid crisis.
My name is Botticelli. I am the executive director of the
Grayken Center for Addiction at Boston Medical Center. BMC is
the largest safety net provider and busiest trauma and
emergency service center in New England.
Our patient population has the highest public payer mix of
any acute care hospital in Massachusetts. For decades, BMC has
been a leader in substance use disorder treatment and research.
Many of our programs have been replicated across
Massachusetts and nationally. The Grayken Center for Addiction
encompasses over 18 clinical programs for substance use
disorders and serves as an umbrella for all of BMC's work,
including addiction treatment, research, medical education, and
training.
I offer my perspective not only as an executive director
but insights gained from my over 30-year career in the
addiction field, formerly serving as the director of the White
House Office of National Drug Control Policy, the director of
the Massachusetts Bureau of Addiction Services, and I am also a
person in long-term recovery.
In previous sessions of Congress this committee has taken
the lead on and leadership on passing landmark legislation to
improve addiction treatment and prevention through the 21st
Century Cures Act, CARA, and, most recently, the Support for
Patients and Communities Act of 2018. These laws have gone a
long way to bring much-needed funding and comprehensive reforms
to how our system treats and supports people with substance use
disorders.
That said, still over 67,000 people have died from a drug
overdose in 2018 and the death rate from fentanyl and other
analogs has increased by ten percent.
This epidemic continues to evolve as polysubstance use,
namely, mixing opioids or stimulants like cocaine and
methamphetamine has increased and disparities have widened
within certain segments of the population including racial and
ethnic minorities, youth and young adults, members of the LGBTQ
community and incarcerated individuals who are
disproportionately burdened by addiction and lack sufficient
access to culturally competent care.
The epidemic target challenges our treatment system and
providers with other notable longstanding challenges. Notably,
in the 2019 report on addressing the opioid crisis that was
discussed earlier, the National Academies of Sciences,
Engineering, and Medicine recognized opioid use disorder as a
chronic and treatable brain disease while underscoring, and I
quote, inadequate professional education and training as a key
barrier to addressing the addiction epidemic. The bills before
the committee today for consideration in many ways rise to meet
those challenges and I would like to discuss a few of those
areas that I think are most pressing for action.
The 100,000--I wish it was 100,000--the 1,000 additional
addiction residency slots funded through the Opioid Workforce
Act of 2019 would significantly accelerate our ability to fight
the mounting burden of addiction faced by individuals and
communities nationwide.
BMC was among the first institutions in the country to
establish a credited fellowship program in addiction psychiatry
and addiction medicine. Graduates of an addiction program like
ours go on to hold faculty and clinical leadership roles in
medical centers and treatment programs across the country.
Under the direction of BMC--under the Grayken Center BMC
has taken initiative to provide comprehensive education and
training to staff on safe opioid prescribing and over the last
several years we have systemically reduced opioid prescribing
across both inpatient and outpatient settings.
Notably, we require all of our physicians across our system
to receive waiver training as part of their commitment to
dramatically expand our workforce license to prescribe
medication for opioid use disorder treatment and we readily
offer addiction training to other staff members.
We also know that addiction affects more than individuals.
It impacts families as well. Families struggle with knowing how
best to be supportive of their loved ones and avoid doing harm.
We also know that getting evidence-based guidance into the
hands of family and community support systems can dramatically
influence the trajectory of individuals' care and treatment.
We are, therefore, highly supportive of the Family Support
Services Act and appreciate the committee's attention to this
often overlooked aspect of addiction.
Two years ago, in testimony before this committee I shared
the disparity insights gleaned from overdose data in
Massachusetts that we heard today, that individuals recently
released from incarceration overdosed at 120 times the rate of
the general population.
Nationally, there remains much to be done to improve
treatment for individuals while incarcerated and upon release
into the community and I am, therefore, pleased that several of
these bills under review by the committee intend to make
substantial progress in those areas.
While we are seeing modest progress against this epidemic,
I think we all agree that we can and should do more.
This will require continued leadership at the federal,
state, and local levels, additional resources, particularly the
reauthorization of SOR funding that can continue to make sure
that we have constant surveillance as this epidemic evolves.
As I have said many times before and I will say it again,
addiction is a disease and recovery should be the expected
outcome. The work lies in getting our systems to a place where
patients with addiction are treated in a way that affects this
reality.
Thank you for your time and I look forward to your
questions.
[The prepared statement of Mr. Botticelli follows:]
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Ms. Kuster. Thank you, Mr. Botticelli. And I do recall my
experience working with you when you were in the White House,
and thank you for your expertise.
Dr. Das, you are recognized for 5 minutes.
STATEMENT OF SMITA DAS, M. D.
Dr. Das. Thank you.
Congresswoman Kuster, Ranking Member Burgess, and
distinguished members of the Energy and Commerce Health
Subcommittee, thank you for allowing me the opportunity to
serve on today's panel.
My name is Smita Das. I am a clinical assistant professor
of psychiatry and behavioral sciences at Stanford. In addition
to being a medical doctor, I have completed a Master's of
public health and a Ph.D. in community health. I am also board
certified in psychiatry, addiction psychiatry, and addiction
medicine.
My testimony today is on behalf of the American Psychiatric
Association, an organization representing over 38,000
psychiatrists, including addiction psychiatrists.
With help from federal grants, the APA provides thousands
of psychiatrists ongoing education and training to improve the
diagnosis and care of patients with all substance use
disorders.
With your help, we have made strides in reversing the
upward trend of opioid overdose deaths and reducing stigma
surrounding addiction over the past few years and these efforts
must continue.
Given this committee's history on focusing on opioids, I am
not going to use my time today to recite statistics aloud or
tell you how real the opioid crisis is. Each of you already
know this.
We also know that addiction is a chronic brain disease, a
chronic medical illness that can be effectively treated.
However, we cannot treat addiction without investing in several
areas.
We need to increase workforce capacity, increase provider
literacy on addiction treatment, and alleviate fragmentation
and barriers to care like cost and stigma. On workforce,
psychiatrists are uniquely positioned to treat the substance
use disorders with the ability to diagnose and treat co-
occurring psychiatric disorders and recognize suicide risk.
However, the shortage of psychiatrists and trained in
addiction medicine, addiction psychiatry, or pain management
has created a longstanding acute treatment gap for those with
or at risk of substance use disorders.
Funding new residency positions, expanding loan repayment
and forgiveness, and offering incentives to work in under-
served areas can help mitigate the effects of the overall
physician shortage.
As we invest in our workforce, we also need to ensure that
clinicians have the support, education, and training that is
essential to treating patients with substance use disorders and
co-occurring illnesses.
We have been working to improve education while
acknowledging that the complexity of substance use disorders
requires thoughtful integration of training across the
continuum from medical school to residency fellowship and
continuing education.
Turning to the issue of fragmentation, people with
substance use disorders are more likely to have physical co-
morbidities like chronic pain, cancer, heart, and liver
disease. We need more integrated care and for all physicians to
be aware of the risk and impact of substance use disorders.
Despite the progress we have made, mental health and
addiction treatments are still often siloed. Breaks in
continuity of care leave patients at higher risk for relapse
and overdose.
Though not the focus of today's hearing, I would be remiss
not to mention how lack of compliance with the 2008 Mental
Health Parity and Addiction Equity Act has aggravated the lack
of access to substance use treatment.
Stigma in seeking help is already an enormous obstacle for
our patients. But forcing both the patients and the providers
to engage in bureaucracy to get coverage makes treatment that
much more inaccessible.
We need to ensure that the intent of the law is enforced
appropriately and that patients receive seamless and timely
care to lifesaving treatment.
We want to thank the committee for working with us on this
critically important issue. Also, as fears spread about the
impact of coronavirus, we urge the committee to consider how to
reduce barriers to telemedicine including telepsychiatry while
also eliminating originating site restrictions.
Lastly, ensuring that incarcerated individuals have
continuity of care so that they can get treatment for substance
use disorders and mental illness to prevent recidivism when
they are released from custody is vitally important.
Using evidence-based common sense policy like allowing
incarcerated individuals to enroll in Medicaid prior to
discharge defragment care and coordinates support to allow
patients to successfully reenter their communities.
Though I am encouraged that the committee has chosen to
continue its focus on the opioid epidemic, I want to make one
last point, that it is not just opioid misuse that is
problematic.
We must treat substance use disorders as the chronic
diseases they are and pursue solutions that address all
substances including opioids, methamphetamine, alcohol, and
tobacco.
I encourage the committee to look beyond opioids and ensure
consideration of all substance use disorders as it considers
legislation. While we discuss the 67,000 deaths related to drug
overdose, let us not forget the impacts of alcohol, responsible
for 88,000 deaths, or tobacco, responsible for nearly 500,000
deaths annually in the United States.
Solutions to close the gap must focus on increasing access
and literacy, decreasing stigma, coordinating care, and working
together to help our patients and communities recover from the
impact that this crisis has had on our country.
Thank you again for inviting us here today. The APA and I
look forward to working with members of the subcommittee on
substance use disorders and health, more broadly.
I am happy to answer any questions. Thank you.
[The prepared statement of Dr. Das follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Kuster. Thank you very much, Dr. Das, for your insights
and for your passionate advocacy. We appreciate it.
Ms. McCarthy, you are recognized for 5 minutes.
STATEMENT OF PATTY McCARTHY
Ms. McCarthy. Thank you, Congresswoman Kuster and members
of the subcommittee for this opportunity to testify today on
behalf of Faces and Voices of Recovery. We are a national
recovery advocacy organization based in Washington, DC, with
members and affiliates nationwide. Our mission is to organize
and mobilize the over 23 million Americans in recovery.
I have had the honor of being the chief executive officer
for five years and I have been in recovery from substance use
disorder since 1989. Over the past 30 years of my recovery, I
have seen firsthand the impact of addiction and have
experienced the loss of friends and colleagues to alcohol and
other drug-related fatalities.
However, over my 20-year career in the addiction field I
have also witnessed the healing power of recovery for tens of
thousands of individuals who courageously overcome addiction to
go on to rebuild their lives.
So several of the bills being considered here by this
committee are of particular importance to the recovery
community. The first pertains to the State Opioid Response
Grant Authorization Act.
While medications play an important role in addiction
treatment, medication alone is not a complete solution. In
fact, the success of medication often depends on additional
recovery support services in the community and millions of
Americans find recovery from addiction without the use of
medication.
The 2018 Surgeon General's report states that individuals
who participate in substance use disorder treatment and
recovery support services typically have better long-term
recovery outcomes than individuals who receive either alone.
The 2017 President's Commission report recommends that the
government partner with appropriate hospital and recovery
organizations to expand the use of recovery coaches, especially
in hard-hit areas.
Federal funding for medication-assisted treatment can be
measured in the hundreds of millions while federal funding for
recovery support services is still only a fraction of all
funding for the opioid crisis.
Recovery community organizations, recovery housing,
recovery high schools, collegiate recovery communities and harm
reduction, all of which are evidence-based models, have no
reliable and sustainable funding sources.
There is, clearly, an issue of scale here and substantial
investment in recovery support is needed. In my written
testimony, I have included a more detailed plan to make this
significant investment by reauthorizing the State Opioid
Response Grants, moving that funding into the block grant for
long-term, setting aside 20 percent of the block grant funding
for recovery support services, and increasing the funding for
the BCOR, Building Communities of Recovery, grant program to
$25 million. Treatment is short-term. Recovery is long term and
investments must reflect that.
The second bill we strongly support is the Family Support
Services for Addiction Act. Parents, children, and other family
members including those who have lost loved ones need support
groups and they need help navigating the complexity of the
treatment system.
However, $5 million per year is not nearly enough to
establish this new grant program. Not only do we need funds, we
need an entire paradigm shift on how we view the importance of
the family's role in recovery.
We must be bold in this pursuit and we must send a signal
to families and the recovery community that we are truly vested
in their continued well-being.
That being said, increasing the authorization to $25
million is warranted.
Third, we strongly support the Medicaid Reentry Act, which
would allow medical assistance for incarcerated individuals 30
days prior to release. This new policy will make it easier for
states to provide effective treatment and recovery support
services, allowing for smoother transitions to care in the
community and reducing the risks of preventable overdose
deaths.
If we are truly serious not only about treating addiction
but also moving individuals out of incarceration and into long-
term recovery, we must take this legislation seriously and see
to its passage.
I will conclude by thanking you on behalf of the recovery
community for all the work that Congress has done to address
the addiction crisis in America. There is much more to be done
and we want you to know that we are fighting this battle on the
ground every day in communities across the nation.
We focus on providing effective recovery support services,
eliminating the stigma of addiction, and celebrating the
successes of individuals and families who have found their
chosen pathway of recovery, and will continue to be vocal,
visible, and valuable part of the solution working with
Congress to save lives.
And with that, I conclude my remarks. Thank you.
[The prepared statement of Ms. McCarthy follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Kuster. Thank you, Ms. McCarthy, and I can certainly
say as a sister of a brother in recovery, I am very grateful
for your organization and for bringing Voices of Recovery here
to us in Washington. So thank you.
Mr. Morrison, you are recognized for 5 minutes.
STATEMENT OF ROBERT I. L. MORRISON
Mr. Morrison. Thank you, Congresswoman Kuster, Ranking
Member Burgess, and members of the subcommittee. I appreciate
you providing us the opportunity to testify. It is a privilege.
I am Rob Morrison. I serve as executive director of the
National Association of State Alcohol and Drug Abuse Directors,
or NASADAD. We are a nonprofit serving state alcohol and drug
agencies directors across the country.
Our board is led by our president, Cassandra Price. She is
from the state of Georgia, and our members are very grateful
for the program funding authorized by this very committee.
These programs are housed in HHS agencies such as SAMHSA, CDC,
HRSA, and NIH, and I would like to thank you for your work to
pass the Comprehensive Addiction Recovery Act, or CARA, the
21st Century Cures Act, and the SUPPORT Act.
We note our particular appreciation for what is now known
as the State Opioid Response Grant, or SOR, which is authorized
by this very subcommittee and is being managed by SAMHSA.
SAMHSA is directing $1.5 billion in SOR funding to our
members' state alcohol and drug agencies. These resources are
supporting evidence-based, innovative, and lifesaving programs
at the local level. In short, this program has been a game
changer.
In written testimony, we have outlined some SOR-funded
activities for a handful of states, those on the subcommittee,
our webpage. We have profiles for all states regarding SOR-
funded activities for your review.
And it is a privilege to offer some following principles
for your consideration as you examine the legislation before
you regarding substance use disorders in general and the opioid
crisis in particular.
First, ensure provisions work through and coordinate with
the State Alcohol and Drug Agency. This approach promotes
efficiency, avoids creating parallel systems and duplicative
systems of care.
Second, ensure consistent, predicable, and sustained
federal resources to avoid creating a fiscal cliff. We
recommend extending the duration of federal grants beyond the
typical one- or two- year funding cycle and affording states
three year, even five years time frame to allocate funding.
Third, continue to address the opioid crisis but also
elevate efforts to address all substance use disorders. This
can be achieved in part through a gradual transition from
directing funds to opioid-specific grants to the substance
abuse prevention treatment block grant.
Fourth, maintain investments in SAMHSA as the lead agency
within HHS, focus on substance use disorders program and
service delivery.
Finally, work to ensure new legislation complements and
builds from the current system. In the process, consider
provisions affording state and federal agencies adequate
resources to effectively administer these programs, both the
previous programs and new ones.
Added people power will be required to additionally manage
addictional programs. I would like to focus on the benefits of
working through the State Alcohol and Drug Agency for a minute.
Our members draft and implement coordinated statewide plans
for program and service delivery. These plans are
comprehensive, work across state agencies, and span the
continuum of prevention and treatment recovery.
State Alcohol and Drug Agencies ensure oversight of
providers through tools such as performance management and
reporting, contract monitoring, corrective action planning,
onsite technical reviews, licensure and certification.
Members also work to promote quality through state-
established standards of care, evidence-based practices,
collecting and analyzing data, and using these tools to drive
management decisions.
The foundation of this work is the Substance Abuse
Prevention Treatment Block Grant. This program is designed to
be flexible to meet the unique needs of states and to address
all substances in its backyard.
Twenty percent of the SAPT block grant by statute is
dedicated to much needed primary prevention programming. In
fact, of the budgets our members manage for primary prevention,
on average approximately 70 percent comes from the SAPT block
grant.
So we look forward to a continued dialogue regarding the
different proposals before this committee. Again, we appreciate
the opportunity.
[The prepared statement of Mr. Morrison follows:]
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Ms. Kuster. Thank you, Mr. Morrison. I appreciate your
remarks as well.
Ms. Rizzo, you are recognized for 5 minutes.
STATEMENT OF MARGARET RIZZO
Ms. Rizzo. Good afternoon. My name is Margaret Rizzo. I am
the executive director and CEO of JSAS Health Care. We are
currently treating 700 patients with opioid use disorder. Our
agency has been treating this population since 1973 and this is
my twenty-ninth year in the field.
I am here to testify on the views of the American
Association of the Treatment of Opioid Dependence, ATOD, of
which are a New Jersey member.
ATOD represents over 1,000 OTPs throughout the United
States. All OTPs are under the regulatory oversight of SAMHSA,
the DEA, as well as the individual states' opioid treatment
authorities.
We also are required to be accredited every three years
through a rigorous process from our SAMHSA-approved
accreditation bodies. Only OTPs are authorized to use all three
federally approved medications to treat OUD.
At the outset, our association members want to express our
appreciation to this committee for authorizing the development
of the first ever Medicare reimbursement rate for OTPs in the
United States. It will make a profound difference in the lives
of Medicare-eligible patients entering and remaining in
treatment.
As you discuss the various legislative proposals before you
today, we urge you to consider the following. When DATA 2000
was passed, Congress wisely imposed reporting requirements in
order to properly evaluate the quality and integrity of this
new expanded program and identify any unintended consequences.
However, we have not seen any publications from SAMHSA
reporting the quality of care provided, the effectiveness of
the services nor the degree of compliance with current federal
regulations.
Thus, any changes being considered today would be in the
absence of data. Such policymaking is dangerous and we
recommend SAMHSA publish and analyze this data before any
changes are made to existing caps, training, or oversight.
We are concerned that proposed legislation would increase
buprenorphine diversion. The data clearly shows that opioids
are most frequently diverted from private physician offices.
In 2011, the radar surveillance system reported 45.5
percent of individuals presented in a treatment facility used
buprenorphine intravenously and 16.3 percent of individuals
reported misuse of the buprenorphine naloxone combination
medication.
Also, the assertion that training is a barrier to providers
using buprenorphine in their practices is not supported by the
evidence. In a survey of MAT waiver prescribers who have taken
the waiver course, 83 percent indicated they needed to know
more about the topic. There are currently more than 113,000
waiver prescribers who under the current system have collective
capacity to prescribe buprenorphine to more than 6.3 million
patients.
This nearly triple the estimated 2.5 million people in the
United States with OUD. Clearly, this suggests adequate
capacity in our current system. Instead of eliminating
oversight that will result in greater diversion and abuse, we
suggest solutions to expand access to areas where there are
limited treatment options.
We are still in the midst of a changing opioid use epidemic
which has shifted from prescription opioid misuse to heroin use
and, more currently, fentanyl combined with methamphetamine
use.
This is not a time to be removing clinical training
requirements which are, at best, quite simple. For all of these
reasons, we oppose the passage of H.R. 2482.
Regarding H.R. 4141 and 1329, there is a greater interest
for correctional facilities and other parts of the criminal
justice system including drug courts to increase the use of MAT
for opioid use disorder.
Model programs in Connecticut, Rhode Island, Philadelphia,
Baltimore prison systems and Rikers Island in New York City are
certainly moving the right direction.
Accordingly, there has been a 55 percent decrease in post-
release recidivism as reported in Rhode Island in addition to a
60 percent reduction in post-release mortality as inmates are
transitioned from correctional facilities into outpatient
treatment settings.
Furthermore, ensuring the newly released inmates have
Medicaid coverage in place prior to the release as proposed in
H.R. 1329, Improve Access to OUD Treatment.
This is all very encouraging news and we encourage the
House to support such measures. This is why we are supporting
the passage of H.R. 4141 introduced by Congresswoman Kuster,
and H.R. 1329 introduced by Congressman Tonko.
Other bills under consideration today have our strong
support. H.R. 5631 would provide funding for addiction
education in medical and nursing schools. H.R. 2466 extends the
SOR grants. H.R. 2922 provides opioid funding of $5 billion.
H.R. 3414 proposes additional residency positions in
hospitals and H.R. 4974 proposes training and education
requirements which we support. However, such requirements
cannot replace the current oversight and patient limits which
are critical to preventing medication diversion and abuse.
Thank you for accepting this testimony. I am happy to
answer any questions that you may have.
[The prepared statement of Ms. Rizzo follows:]
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Ms. Kuster. Thank you, Ms. Rizzo. That was very helpful and
I appreciate it. I would love to follow up with you after.
Dr. Ryan, you are recognized for 5 minutes.
STATEMENT OF SHAWN RYAN, M. D.
Dr. Ryan. Thank you. Congresswoman Kuster, Ranking Member
Burgess, and esteemed subcommittee members, thank you for
inviting me to participate in this important meeting.
My name is Dr. Shawn Ryan. I am a board certified addiction
specialist and an emergency physician. I take care of patients
in Ohio. I am also the chair of the Legislative Advocacy
Committee of the American Society of Addiction Medicine, known
as ASAM, a medical society representing over 6,000 clinicians
who specialized in the prevention and treatment of addiction.
I would like to begin by recognizing the phenomenal work
Congress has done to advance crucial pieces of legislation and
funding to address this crisis. It has made a life or death
difference for many.
However, we must do more to create a sustainable and robust
treatment infrastructure, one that addresses addiction as the
treatable chronic medical disease that it is.
To realize this addition, we must focus on three primary
issues: strengthening the addiction treatment workforce,
standardizing the delivery of individualized addiction care by
rethinking our largest federal grant programs, and reforming
payment policies and strongly enforcing mental health and
addiction parity.
Focusing first on our workforce needs, there are only about
3,000 board certified addiction specialist physicians,
according to ABMS, and in a recent survey in Massachusetts only
one in four healthcare providers report receiving on addiction
during medical education. I know that I did not.
For a country that prides itself on the medical care
available to its citizens, this is simply unacceptable. That is
why ASAM supports the Opioid Workforce Act legislation that
will provide additional GME slots to hospitals with programs in
addiction medicine and addiction psychiatry.
To ensure more healthcare providers receive basic training
in addiction, ASAM supports the MATE Act, legislation that
would require all DEA-controlled medication prescribers to have
at least a baseline knowledge about addiction.
Dr. James Baker, who is with us here today and behind me,
has been a determined champion of the MATE Act, in honor of his
son, Max, whose life was, unfortunately, cut short in part
because the medical community has yet to reckon fully with
addiction.
After or concurrent with the passage of the MATE Act, ASAM
supports the passage of the MAT Act, legislation that would
eliminate what would then be a redundant separate waiver to
prescribe buprenorphine for addiction along with the waiver of
patient limits and regulations.
Secondly, this workforce shortage is exacerbated by a long
history of treating addiction in silos, as has been stated many
times today, and available treatment is, largely, determined by
local culture rather than nationally recognized standards of
care.
This must change. To that end, ASAM supports the State
Opioid Response Grant Authorization Act with certain technical
amendments and the addition of a new provision. This would
strengthen the program by applying a Medicaid provider
requirement included in both the bipartisan Ryan White Care Act
and in the late Elijah Cummings CARE Act.
Such a provision would require certain grantees to enroll
in Medicaid, ensure that they can meet--ensuring that they can
meet minimum standards and grant funds are used as they are
intended to pay for crucial services that cannot be billed to
Medicaid.
Investments above this foundation, however, need to be used
efficiently and effectively and they should drive sustainable
change. For example, Congress should--could establish a new
supplemental grant program with conditions that require states
and localities to adopt certain strategic policies.
To qualify for this supplemental funding, states could be
required to adopt nationally recognized levels of care
standards for the regulation of the addiction treatment
programs. This would make oversight and payment more efficient
and set baseline expectations for care as we have with the rest
of American medicine.
States could be incentivized to require health plans to use
medical necessity criteria for addiction treatment as defined
by national medical societies and certain grantees could be
required to offer all medication for addiction treatment.
Over time, the largest federal grant programs in this space
could be combined with a common set of modernized requirements.
But let us be clear. We need these sizeable grants because to
this day mental health an addiction parity is not a reality.
Payers continue to discriminate and there is wide disparity
in network use in provider payment rates. That brings us to the
bills being considered that will improve insurance coverage
specifically to those in the criminal justice system, the
Medicaid Reentry Act, and Humane Correctional Health Care Act.
Continuation of Medicare and Medicaid coverage during
detention and incarceration or reinstatement immediately prior
to release will facilitate treatment continuity, retention, and
save lives. ASAM is proud to support these bills.
In conclusion, ASAM is actively building, implementing, and
advocating for the tools and resources to secure a solid and
sustainable foundation for addiction treatment in this country.
While change won't be easy, it is both necessary and worth
it to end the suffering being experienced across our nation and
our communities and by American families.
Thank you, and I look forward to your questions.
[The prepared statement of Dr. Ryan follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Kuster. Thank you, Dr. Ryan.
I need to inform all of you that we are about to be called
for votes and so we are going to take a recess to go vote but
we will come back, and we will proceed with the questions for
the second panel.
So thank you so much for all of you being with us, and
patience.
[Pause.]
Ms. Kuster. Actually, it turns out that our votes were not
quite called. They are about to be called. So we are going to
go ahead, Representative Brooks and I, and get started on our
round of questions, and use your time wisely and then we have
15 minutes to get to the floor once they are called. There they
are.
So I want to just take a minute for my own questions and
then I will turn it over to Mrs. Brooks.
It is our job to continue to bring attention to this opioid
crisis and, as you have all pointed out, other drugs as well
and to find solutions that will save lives, and that is why I
founded the bipartisan Opioid Task Force and it is why I waited
and worked for six years to get on this committee. So I am
delighted to be with you today.
For folks in New Hampshire and families across the United
States, this hearing is one of the most important that we will
hold. These issues that we are discussing are critical and we
need to end the stigma of addiction.
Many of you mentioned that, in my view, stigma is just
another word for bias and discrimination. When it comes to
physical health, we as a society are quite understanding and
the same should be said for mental health and addiction
treatment.
So I would like to focus my remarks on my bill, H.R. 4141,
the Humane Correctional Health Care Act. In New Hampshire, we
saw again and again incredibly high rates of recidivism
directly related to substance use disorder and mental health
issues.
As it turns out, there are many jails and prisons that are
not providing adequate healthcare, especially when it comes to
these co-occurring illnesses. I have said it before. I will
continue to say it. If we wanted to design a system the fail,
this would be it.
This bill is a game changer. It ensures that the justice-
involved population gets access to the treatment that they
need. It is co-sponsored by many of my friends on both sides of
the aisle here on the Energy and Commerce Committee and I am
proud to have introduced this bipartisan legislation.
I am particularly appreciative of the many organizations,
some of whom are with us today, that have supported this bill,
the American Society of Addiction Medication--Medicine Smart
Recovery, the American Corrections Association, the American
Psychological Association, the National Council for Behavioral
Health, and Faces and Voices of Recovery, among many others.
So let me jump into the questions. Mr. Botticelli, could
you please describe the Grayken Center's direct experience in
treating individuals upon release and the importance of
seamless care in reducing overdose risk and recidivism?
Mr. Botticelli. So Boston Medical Center we have the
largest office space addiction treatment program in New
England. We have about 800 active clients.
Directly across the street from us is the Suffolk County
House of Correction and literally our job is to get them
seamlessly from the County House of Correction into our office-
based addiction treatment program without any interruption in
care and continuity of providers.
You know, so it is very clearly important. Besides all of
the incredible salient points that you already raised about,
you know, being able to not just move beyond suspending their
Medicaid but actually enrolling them in Medicaid while they are
behind the walls so that there is absolutely no interruption in
care while people are coming out.
I do want to address the issue of payment because I do
think it might not be Medicaid funding but we are paying for
those services anyway.
Whether it is State Opioid Response money or state
appropriation dollars or moneys that the sheriffs are paying to
implement medications behind the wall. So whether it is
Medicaid funding or another funding source we are already
paying for those services.
Ms. Kuster. I appreciate that, and I hope the CBO is
listening when they take that into consideration.
Mr. Ryan, are you aware of any estimates on the percentage
of those who suffer from substance use disorder that become
involved with the criminal justice system at some point and
with either mental health or substance use disorder?
Dr. Ryan. Absolutely. Thank you for the important question.
So statistics show as high as 50 to 70 percent of
individuals in the incarcerated population in any way, shape,
or form have mental health and addiction, and in many locations
where opioid use disorder is the most pervasive, there are
places seeing as high as 75 to 80 percent of their justice
population involved.
So I have actually worked a fair bit with an institution
that does jail healthcare across the state of Ohio and other
areas. Because I recognize that in this country we are not
disconnecting criminal justice involved and substance use
disorder probably ever. And so it is really important that we
do--speak these transitions and I can tell you first hand in
taking patients on in our treatment centers right out of, you
know, criminal justice settings, the transition is quite hard
and we do really need to work to improve that.
Ms. Kuster. So are there any estimates suggesting how many
more could receive MAT and jails and prisons if such treatment
was widely available?
Dr. Ryan. I cannot say that I have seen an estimate in
regards to what this particular or these particular bills
would--how much it would increase the access to medication
assisted treatment.
I will tell you in those localities where I have been
involved and the sheriffs have been very supporting in doing
this and we have seen the estimates and you described in Rhode
Island, if we put a pervasive and sustained effort to deliver
the absolutely necessary and evidence-based treatments such as
MAT to these justice-involved individuals, they will do better.
Ms. Kuster. Thank you very much. I appreciate it.
And that has certainly been our experience in Sullivan
County and now in Merrimac County in New Hampshire where the
recidivism rate dropped from as high as in the high 50 percent,
58 percent, all the way down to 18 percent.
So I don't care if you are left, right, or center, that is
a savings of tax dollars, if we can get people back to the
community, going to work taking care of their families and
living in recovery.
So thank you, and I guess I say, Madam Chair, I want to
recognize my good friend and colleague, Representative Susan
Brooks.
Mrs. Brooks. Thank you, Madam Chairwoman, and thank you so
much to all of our witnesses and for your important work. I
just want to spend a few minutes talking about H.R. 3414, the
Opioid Workforce Act.
As I stated earlier, the crisis continues to plague so many
of our communities. That is not to say we haven't made
progress. In fact, yesterday an Indiana state public health
official shared with our office that Indiana has--my home
state--has seen a 13 percent reduction of opioid overdoses last
year.
But we also increased by 75 percent the number of available
inpatient treatment beds. Pretty significant increase. But
despite these improvements, one thing that continues to be
clear is we have to have more care providers in order to staff
and in order to take care of the beds.
Doesn't matter how many beds we have in the hospitals if we
don't have the doctors and the professionals to treat those
patients, and so that is why I introduced with you, Madam
Chairwoman, along with Representative Schneider and
Representative Stefanik the Opioid Workforce Act, providing a
thousand Medicare-funded residency slots to hospitals.
So I just have a couple of questions, briefly, before we
have to probably take a break to vote.
Mr. Botticelli, in your written testimony, you talked about
the additional thousand addiction residency slots. How
specifically do you believe those additional slots would
improve our ability to help these patients?
And if you could--your mic, please.
Mr. Botticelli. You think I would know after all these
years.
One of the things that the opioid epidemic has laid bare
the lack of trained professionals that we have to provide
treatment. So we can put out all the funding dollars that we
want without a prepared workforce in terms of implementing it.
I think this act has the potential to dramatically expand
access to treatment by having a trained pool of professionals,
of physicians who are able to understand and treat addiction.
I think it is really important for us to ensure that while
we are doing other activities such as integrating addiction
treatment into medical residency training that having a trained
workforce both of addiction medicine and addiction
psychiatrists are really critical. I think this is a critical
piece of legislation. We have known this since the beginning of
the epidemic that this is one of the prime areas in terms of if
we are going to make an impact.
Mrs. Brooks. Thank you, and thank you for your long decades
of work.
Dr. Ryan, in your written testimony you too, emphasized
just how under served individuals struggling with substance
disorder are and, in fact, there are only about 3,000 board-
certified specialists in the country really highlights for me
how short staffed our treatment facilities might be.
How do you think the addiction specialists would best be
used if we were to improve and increase fairly dramatically the
number of addiction specialists which, as we have said, would
also be trained not just on substance--I mean, whether it is
alcohol, whether it is drug, whether it might be other
addictions, you know, addiction just generally, can you just
share with us how you believe it would make a meaningful impact
on this significant challenge?
Dr. Ryan. Absolutely. A couple of points. So I am board
certified in addiction medicine as those of us who are. Not in
opioid medicine.
So we are broadly trained in all of the substance use
disorders. Understanding that alcohol still had huge impact on
our society and we have to understand how to address that and
every other substance so that drug use transitions to
methamphetamine, et cetera, that theworkforce is trained to
manage any substance use disorder it becomes the topic of most
importance at that time. So I just want to make that point.
Also we do have a system of care in this country for
specialists and primary care to interact through different
mechanisms.
So as I would--the way that I would probably put it,
Representative, is that a specialist like myself should be
taking care of the sickest patients. Not all opioid-use
disorder patients need the highest level of care or the highest
trained specialists but many do.
And so we have these systems of care in place for chronic
disease management. We should simply reflect back to those as
so for diabetes so that we, again, diabetes best managed the
same way in a whole holistic model for patients. We should
really parallel those types of systems of care and use those
trained addiction specialists in that.
Mrs. Brooks. Besides residencies, do you believe that our
med schools and the education higher ed institutions are doing
enough relative to addictions?
Dr. Ryan. Enough is a loaded question, I guess, a little
bit. But no, I don't believe so. Actually, in my personal
opinion I feel like there is more to be done. I have spent
thousands of hours myself educating, you know, medical
students, residents, and I am sure that others on the panel
have done the same. I do believe we are behind the eight ball
on that and I would say with the workforce at hand we are also
under educated in relation to the disease of addiction.
Mrs. Brooks. Thank you, and with that I yield back. Thank
you for your work.
Ms. Kuster. With that, I recognize Dr. Raul Ruiz from
California.
Mr. Ruiz. Thank you all for being here.
Congress has passed multiple pieces of legislation to
address the opioid misuse public health crisis and more still
needs to be done.
That is why I introduced the H.R. 2281, the Easy Medication
Access and Treatment for Opioid Addiction Act, or EASY MAT Act.
This bill will remove a rule that restricts doctors from giving
a patient more than one day's worth of buprenorphine or other
medication assisted treatment at a time.
Under current DEA regulation, physicians are authorized to
give a patient one day's worth of MAT for three consecutive
days while the patient is secure long-term treatment.
However, they can only give the patient the MAT one day at
a time. Meaning, the patient has to go back to the doctor, back
to the emergency department, every 24 hours for three days
which, as you can imagine, is huge barrier to a patient who may
not have access to their provider.
Under this bill, physicians will be allowed to provide
three days worth of MAT at one time so that patients don't have
to come back every 24 hours to be seen by a doctor while they
are waiting to get into long-term treatment.
This will increase the chances that a patient will remain
on medication-assisted treatment and off of illegal and illicit
drugs.
It will save money for the healthcare system by requiring
fewer visits and it will maintain all of the other safeguards
currently in place under DEA regulation. Most importantly, it
will save lives.
As an emergency department physician, I know that once a
patient walks out of the door of the hospital, the fewer
barriers there are to get someone in treatment, the higher the
chances of success, and I believe that this bill will remove
one of those barriers.
Dr. Ryan, I understand that you, too, are an emergency
physician and you are also an addiction specialist, correct?
Dr. Ryan. Correct.
Mr. Ruiz. When there isn't long-term treatment on demand,
how important is it to have this bridge of care in the interim?
Dr. Ryan. It is very important, and thank you for the good
question. I would say two things.
One of which we worked very hard in the state of Ohio where
I practiced to develop treatment on demand with ready access to
medication-assisted treatment, and in some areas of the state,
we are there. But in most parts of the country, we are not.
And so I said, you know, I would say that the second point
is given the safety profile of buprenorphine that what you are
proposing makes sense to me and I would support it, as was
already said.
Mr. Ruiz. Thank you. And as an emergency physician, what is
the practical implication of this current restriction?
Dr. Ryan. Well, the practical implication, as you know,
emergency departments are very busy across the country. By and
large, it is more common than not that they are overwhelmed.
And so when you add this increased burden of a patient
having to come back, not only is transportation for that
patient an issue it is almost a big issue for patients with
opiate disorder.
But you burden the emergency department with more
unnecessary visits for the simple administration of a very safe
medication.
Mr. Ruiz. What would you say the return rate would be if
you are in a rural area and your emergency department is quite
far from your area?
Dr. Ryan. I would say it would be very poor. I cannot quote
a specific statistic. I am not sure if anyone else on the panel
is aware. I have not seen such a study.
But knowing the return rates we have on the second day of
admission for outpatient programs it would be----
Mr. Ruiz. So they would be lost to follow up. They might
receive the first dose but then take an incomplete three-day
course?
Dr. Ryan. It would seem that that would be fairly common,
yes.
Mr. Ruiz. OK. So what are the implications of reversing
this restriction for the provider and, in your experience,
would this lead to greater rates of success for patients trying
to access long-term treatment programs?
Dr. Ryan. We do note, from some studies, that emergency
department initiation medication-assisted treatment with the
appropriate transition to care can lead to substantially better
retention rates in treatment and recovery and lower rates of
relapse.
Mr. Ruiz. So is there is--this is evidence-based programs
that actually work to improve success in compliance as a bridge
into long-term treatment with successful treatment for opioid
misuse disorders, correct?
Dr. Ryan. Correct.
Mr. Ruiz. Thank you. I yield back my time.
Ms. Kuster. Thank you, Dr. Ruiz. You have convinced me and
I will co-sponsor your bill.
Thank you very much. Now I will ask for your patience. The
subcommittee will stand in recess for 20 minutes while we go
vote and then we will come back to resume questions.
[Whereupon, the above-entitled matter went off the record
at 1:46 p.m. and resumed at 2:14 p.m.]
Ms. Eshoo [presiding]. The Subcommittee on Health will come
back to order. Thank you to our witnesses. I know I had to go
out to have a meeting. I want to thank Congresswoman Kuster,
who held the fort down. And I understand that you have all
testified and that those of us that are still here can ask our
questions.
I am going to recognize myself for some questions. Let me
start with the following. A federal court in northern
California recently found that United Behavioral Health
rejected the insurance claims of tens of thousands of people
seeking mental health and substance use disorder treatment
based on defective medical review criteria.
I have heard from many constituents about this and how
harmful these denials, obviously, are to their recovery. To the
practicing clinicians and, Dr. Das, I mean, you are all
wonderful and brilliant and we are all so grateful to you but a
special welcome to you, my constituent from Stanford. Very
proud. Very proud to represent Stanford and who is there and
what you do.
So to the practicing clinicians--Dr. Das, Dr. Ryan, and to
Mr. Botticelli--what a beautiful name. What a beautiful name.
Have you encountered burdensome prior authorization processes
or denials from private insurance when you try to get your
patients the mental health and substance abuse care both
medication and services that they need?
Mr. Botticelli. I think it is probably most appropriate. At
Boston Medical Center we, largely, serve Medicaid clientele,
and actually I think we know that generally Medicaid and access
to benefits under Medicaid has been better, quite honestly,
than under most commercial plans. That may vary by state. But I
think my colleagues on the panel probably have more experience
with commercial insurance.
Ms. Eshoo. That is wonderful what you just shared with us.
That is very good to hear. There are so many on the committee
that have worked so hard over the years to bolster, make
stronger and better Medicaid. So I appreciate what you said.
Dr. Das?
Dr. Das. I will add that before Medi-Cal covered
buprenorphine I would sometimes spend more time on the phone
trying to get buprenorphine approved than compared to how much
time I was able to spend with a patient. It is one of the most
frustrating things when we have evidence-based treatments that
work and there are hoops that we need to jump through to get
our patients connected with that care.
And as recently as last week, I was ordering nicotine
replacement therapies for a patient wanting to quit smoking.
Really severely needed to quit smoking, and that wasn't covered
by the insurance. And I was just blown away and the reasoning
was that it is over-the-counter.
But, again, another barrier for somebody who is already
disadvantaged who is already struggling to get the treatments
that they need. It is frustrating as a psychiatrist.
Ms. Eshoo. Thank you.
Dr. Ryan?
Dr. Ryan. I thank you for the question. So I was actually
the chair of Peer Relations in my past tenure at the American
Society of Addiction Medicine. So a lot of insurance
interaction.
I would say that there are substantial utilization
management techniques such as the one you described of
prioritization and other efforts to block access to care. That
can be inadequate networks, it could be inadequate payments in
many cases whether it be commercial or Medicaid.
And so there are many obstacles to accessing appropriate
reimbursement for good mental health and addiction care. There
is also a lack of following science or national standards.
So they will often have their own criteria. It may or may
not be something that is nationally recognized as a standard.
And so the--in finality I would say the need to hold insurers
accountable to the science and the evidence is----
Ms. Eshoo. Is Medicare or Medicaid different with regards
to a prior authorization for these types of claims?
Dr. Ryan. It is state-by-state in my experience with
Medicaid specifically, obviously. Medicare, you know, coverage,
for opioid use disorder is a new thing, as was talked about
earlier. And so I readily don't know that we have an answer to
that last part yet. But for Medicaid it is state-by-state
variance.
Ms. Eshoo. Yeah. So for those who are in recovery from
substance use disorder or work directly with patients, and we
have some of you here with us, have you had trouble getting
your care covered by insurance? I mean, you just touched on
some of it. Is it--you all agree that you have trouble? Any
smooth sailing anywhere?
Ms. Rizzo. Yes, as Dr. Ryan said, it's state by state. New
Jersey did away with prior authorizations for Medicaid. So we
don't have that barrier anymore, which was a big help.
Ms. Eshoo. That is a--that is big.
I don't have any other questions. You were all here
listening this morning. Is there something that if you were up
here you would have asked that we didn't, of the first panel?
Dr. Ryan. I would say actually how to better enforce parity
is probably the number one thing that we deal with because that
would actually answer some of the questions you just asked. We
were actually performing oversight and regulation and adherence
to parity. We wouldn't be having a conversation about a safe
and fairly cheap medication and prior authorizations.
Ms. Eshoo. Yes?
Mr. Botticelli. I would add to this, you know, while we
simultaneously build up our treatment system, we know there are
considerable number of people who are not ready for treatment
but who are also getting infected with HIV. They are getting
hepatitis C.
So having access to things like sterile syringes, access
to naloxone I think become really important priorities. So I
think that part of what I didn't hear as part of kind of the
larger federal strategy is how do we significantly expand what
we kind of commonly term harm reduction services.
I think it is particularly important priority for those
folks who are not ready to enter treatment. We know it's a
glide path for people to get into treatment. We know it reduces
overdose and infectious disease rates.
You know, I think we have seen outbreaks in other parts of
the country that were caused by lack of access to things like
sterile syringes. So part of what I think we really have to
focus on is not just how do we build up our treatment system
but also how do we create those glide paths and those harm
reduction services for folks who are not ready to enter care.
Ms. Eshoo. Thank you very, very much. My time has expired.
And is there anyone that hasn't been called on that I need
to recognize? Dr. Burgess?
Mr. Burgess. Thank you. I thought you would never ask.
Ms. Rizzo, actually my questions are along the same lines
as the discussion that has just been going on on the prior
authorization. In fact, I was rather startled in your testimony
that hey, the eight-hour educational requirement is not a
barrier--it is prior authorization and utilization review, I
guess, by inferences is more of a barrier.
Prior authorization, something that we live with at a lot
of different levels. As someone who has sat in the prescriber's
chair, I hated prior authorization; how dare you second guess
my intuition and medical knowledge. I guess it is something
that we just have to live with but at the same time there ought
to be a way to streamline so it's not--it's not the barrier
that certainly you have encountered.
I was also intrigued your testimony that we forget
buprenorphine is not always a benign drug. There are some times
that it can be misused. It can be diverted. In fact, there is
actual harm that can occur with buprenorphine.
So that is I think something that is important for us to
bear in mind as we do things that, yes, we want to get more
treatment in the hands of more people but at the same time
there are--there are controls because there is a reason to have
the control and if we just remove all of that, we may
inadvertently be causing harm.
I guess, Dr. Ryan and Dr. Das, both of you, been through
training programs, you know what they are like. So the--I will
just--I am conflicted because we have a bill that says we need
a thousand new residency slots. So I presume these are
psychiatric residencies that are three years in duration. Is
that correct?
Dr. Das. I believe the bill is for residency slots where
there could be addiction treatment provided at the end of it so
it would be psychiatry which is four years as well as other
programs that support addiction medicine and addiction
psychiatry training.
Mr. Burgess. So but it would be in conjunction with an
established training program training program that may be
several years in length. In other words, a significant
investment of time that someone is going to undergo, correct?
Dr. Das. It could be a significant investment in time.
However, an addiction psychiatry or an addiction medicine
fellowship could be just one year of additional training in
addition to the residency.
Mr. Burgess. Right. You are starting with somebody who has
already been through your rigorous four-year program that is
not everyone can do it, right?
How about you, Dr. Ryan? Are you a psychiatrist by
background?
Dr. Ryan. No, sir. Emergency medicine originally and then
went back through and trained in addiction. So to the doctor's
point, I think that fellowships are a good route to educate
folks.
I will tell you that we over the past ten years have
definitely increased our availability of those folks. But they
are few and far between still. And the recruiting of them is
challenging. You know, we live out of Cincinnati, basically.
It is not exactly Denver or Miami or San Diego. It is not a
particularly great place to recruit folks. It is a little
challenging and in the rural areas in tri-state where I work is
even more so. So anything we can do to improve and increase the
education of folks and so funding and support for that is
greatly appreciated.
Mr. Burgess. So what I am hearing is actually fellowships
might be a wiser course of action than actually creating
residency programs de novo. Is that a fair assessment?
Dr. Ryan. I would say it is part of the overall plan.
Dr. Das. I would also add that only a handful, 5 to 7
percent of U.S. medical graduates go into psychiatry residency
training programs and so----
Mr. Burgess. There is a reason for that.
Dr. Das. Residencies are important. But it is not just
about residency. I think having an additional thousand spots
would emphasize the importance of this problem in our country
and that we need to make changes, not just at residency but
through medical education all the way up to continuing
education.
Mr. Burgess. So going back to Ms. Rizzo's point about prior
authorization, it was my opinion back in the early '90s, late
'80s that managed care wasn't doing a thing for the practice of
psychiatry and in fact probably was a barrier for young people
considering that as a speciality.
Then on the other hand we have the bill that is--well,
during the SUPPORT Act we said you don't really even need any
special training. If you are a nurse practitioner with no
additional credentials, if you are a nurse anaesthetist who may
not have ever practiced clinical medicine in a clinic, if you
are a nurse midwife who may have never practiced outside labor
and delivery, you can also prescribe buprenorphine.
So it seemed like on the one hand we are making additional
requirements and training. On the other hand, we are loosening
the requirements. So how do you resolve that discrepancy or
that dilemma?
Is more training good or is more training just superfluous
and it doesn't matter--we need to push more stuff out and get
it out there, even though Ms. Rizzo has testified that there is
harm that is potential from some of these medication?
Dr. Ryan. So I would come into the--I think it was the
previous section when you were out, which is basically we have
parallel paradigms of this type of training, meaning as an
emergency physician I went through a very rigorous, you know,
training program in emergency medicine at the University of
Cincinnati and had wonderful NPs and PAs who came on board with
me that had been trained in family medicine. But because I had
the, you know, upper level of training was capable of bringing
those folks along and educating them.
So I would draw that parallel and saying that I think we
need, you know, education at all levels. In fact, that is why
ASAM supports the MATE and the MAT Act together in order to
increase the education.
Mr. Burgess. Right. But in some states, as you know, there
is not--in Texas there is. There is supervisory requirement.
Dr. Ryan. Same in Ohio.
Mr. Burgess. I don't know about Ohio. But as some states
there is not.
Dr. Ryan. Understood.
Mr. Burgess. And that is what I know Dr. Bucshon when we
had those hearings he was concerned about, as a cardiothoracic
surgeon. I think it is something that we need to bear in mind
that we are being asked now to extend the program before its
expiration. We have a report due. I just think we ought to
evaluate the report before we make a new decision.
So thank you and I will yield back.
Dr. Ryan. Thank you.
Ms. Eshoo. The gentleman yields back.
You know, when we hear these numbers, a thousand--a
thousand new physicians--when you divide that by 50 states it
is a handful of people and the needs in our country are great.
I think this discussion about residencies and all of that are
really important.
I think that what we approve we want to make sure that it
truly is the tip of the spear and that we don't miss the mark
because of the demands of human beings across the country. We
have to meet these demands.
This is--I mean, that statistic I gave that more people
have lost their lives to this public health challenge than all
of the lives that were lost in Vietnam. It's a huge number.
It's a huge number.
So, collectively, we have our work cut out for us but this
is the first place where the table is set and we thank you for
travelling across the country to come here to testify.
Oh, we still have Doris. I am sorry. I thought you had
already been recognized. There you are. I would never leave her
out.
The gentlewoman from California, Ms. Matsui, 5 minutes. I
am sorry. I apologize.
Ms. Matsui. Thank you very much, Madam Chair, for
acknowledging me. I know you would never forget me.
And I want to thank the witnesses for being here today on
this very important topic. And before I get into my questions,
I want to take a quick moment to recognize the important role
hospitals are playing in the substance abuse fight.
In building upon our work here, I believe we should look
for ways to streamline funding for these entities to improve
care coordination efforts, reduce emergency room use and scale
abuse prevention initiatives.
Now, the availability and use of stimulants like meth and
cocaine are definitely on the rise, according to the DEA 2019
National Drug Threat Assessment and it remains widely available
and the DEA field divisions are reporting an increasing
availability of drug compared to the previous years and I do
have to say that I hear it from my healthcare providers all the
time. It is a cheap drug, easy to make, and the people who get
it are the ones who are basically on the streets, a lot of
them.
Mr. Morrison, your organization convenes stakeholders who
play a key role in ushering federal dollars into communities
that need it the most. In your testimony, you mentioned that
state directors are observing increases in stimulant use. Is
that correct?
Mr. Morrison. Yes, it is. In certain states there are
increases in admissions to treatment that they are reporting.
Ms. Matsui. Right. I would like to note that when we passed
the fiscal year 2020 funding package we continued our
investment in State Opioid Response Grants while also allowing
grantees to use this funding to address stimulant use.
Dr. Ryan and Dr. Das, can you describe the differences in
how we treat a patient with meth use disorder?
Dr. Das?
Dr. Das. For psychiatrists and addiction psychiatrists
generally we would take the same overall approach where we
assess for things that may be occurring along with that primary
diagnosis.
The difference with stimulant use disorder is that we don't
have a medication in place for us to utilize. However,
oftentimes with most substance use disorders, they don't occur
by themselves. They are going to occur with some co-occurring
disorder, either physical co-morbidities or generally more
often other mental illnesses.
And so taking a comprehensive approach to treating all of
the patients needs gives them the best options and chance for
recovery.
Ms. Matsui. Sure. Dr. Ryan, like to make a comment?
Dr. Ryan. I concur with Dr. Das.
Approaching the patient in that holistic biosocial model is
exactly how we should address this. It is unfortunate that we
do not have medications developed for stimulant use disorder
and probably was a failure of, you know, 20 or 30 years ago of
the last stimulant crisis that we had.
So it is my hope and I am working with the different folks
and I know that the FDA and other entities are working on
developing and approving a medication so that we would have the
full biopsychosocial model.
Ms. Matsui. Absolutely, because I mean, as sad and as
severe as the opioid crisis we do have something there and we
have no pharmacological way to help these people.
Currently, no law enforcement agency or private party has
the ability to provide real-time nationwide oversight of all
orders for controlled substances, which is a major contributing
factor to disproportionate prescription opioid shipments to
certain pharmacies across the country.
Distributors especially lack any visibility into the total
volume of opioids that customers purchase from other suppliers,
severely hindering their ability to make fully informed
assessments of an order that could potentially be suspicious.
Mr. Botticelli, given your experience would you agree that
the identification of patterns and trends in detecting real
time drug diversion would be an important step in addressing
this country's opioid epidemic?
Mr. Botticelli. Incredibly helpful. You know, one of the
things that I felt hamstrung by during my time in Washington,
both on the law enforcement side and the public health side is
lack of access to real time data, and I always felt it was hard
to see where you are going if the only tool you have is a rear
view mirror. And I really felt hampered by our ability to
understand things like where parts of the country--hot spots in
parts of the country or where we were seeing--where we needed
to plow additional public health resources.
And, unfortunately, it was only until people died that we
actually had that information. So I think anything that the
committee can do to really strengthen both our law enforcement
and public health data in a real timely way.
Ms. Matsui. Right. And I agree with you. I believe creating
a DEA program that collects and shares in real time data of
every sale, delivery, or disposal of controlled substances is
essential.
So I ask my colleagues to support my bill with
Representative Johnson, the Suspicious Order Identification Act
of 2019, to achieve this goal. You need as much information as
possible and we would like to get there.
So thank you very much. I yield back.
Ms. Eshoo. The gentlewoman yields back.
Anyone--no, Mr. Tonko is not here. I thought he was coming
back to waive on.
Timing is everything. Mr. Welch of the great state of
Vermont, you are recognized for 5 minutes.
Mr. Welch. Thank you very much.
Some of you might have been here for the first panel.
Incredible challenge. But the big challenge for a lot of us is
the workforce. It is unbelievable, as you know, I mean,
especially in a state like Vermont.
But Vermont is not at all atypical. I mean, the number of
nurses we had, LPNs, among others, doctors, regular physicians,
it is really declining precipitously just in the last 15 years.
And, first of all, I would just ask Mr. Morrison, that
dynamic that I am talking about, is it your awareness that that
is very typical of a lot of communities across the country?
Mr. Morrison. In terms of struggles with workforce and
workforce development, absolutely. I would say it is consistent
across our members across the country.
Mr. Welch. Yes. Dr. Das?
Dr. Das. In California, yes, we are also facing workforce
shortages and with the APA we are wanting to increase the
number of psychiatrists that there are and the amount of
training that psychiatrists would get in substance use
disorders.
Mr. Welch. So we are looking for solutions and one of the
proposals is to have more GME residency options. Anybody want
to comment on whether that would be helpful or not?
Go ahead.
Mr. Botticelli. I will start. I think it is incredibly
helpful. You know, we do a significant amount of medical
residency training and fellowships for addiction medicine.
But we don't have enough slots to meet demand for it and I
think having more trained professionals, quite honestly, you
know, we need a trained workforce at all levels of the
organization. Not only at the physician and psychiatrist level
but at the nurse level, at the licensed counselor level and
even with people with experience.
Mr. Welch. Right. And is it the case--I don't know what the
stats are--that if you get your degree at a local institution
the likelihood is that you will--there is a higher likelihood
you will stay rather than leave?
Mr. Botticelli?
Mr. Botticelli. I think that anything that we can do to
kind of recruit and retain a workforce is incredibly important.
I will tell you that as states have expanded services, we are
poaching from each for a trained workforce, which is not what
we want to be doing here.
Mr. Welch. Right. And then a lot of hospitals are having
travellers, right. Ms. Rizzo, do you want to comment on that?
You know, it makes me nervous. I had a relative in a
hospital and we had great nursing care. But then we had a lot
of people who were coming and going.
Ms. Rizzo. Yes, it is difficult. In New Jersey medical
directors and physicians are very hard to come by. We are
required to have an opioid treatment program. We have to have a
medical director and a medical director designee who has the
same certifications as the medical director.
But, again, counselling is another area that is greatly
lacking. Again, we have to have 50 percent--50/50 ratio of
licensed counselors to counsel interns, and as programs are
opening, broadly, throughout the state we are all scrambling to
build up the workforce so it is very difficult.
Mr. Welch. So what are the impediments to having a
workforce?
Ms. Rizzo. Well, I think one of the things, and I think it
was in the SUPPORT Act about the loan forgiveness, I think that
is really important.
But it is just enticing people to come into the field. So
it is just--it is a battle that we all face.
Mr. Welch. But the pay is reasonably good, right? I mean,
it is not like----
Ms. Rizzo. No.
[Laughter.]
Mr. Welch. All right. We want a raise.
Ms. Rizzo. You know, it is getting better. With Medicaid
reimbursements and now Medicare we have definitely been able to
grow with our census and we have been able to lift the salaries
of our staff.
But it is difficult to compete and especially, you know, we
are a private nonprofit and we are competing against some of
the larger for profit programs and it is difficult.
Mr. Welch. Yes. OK. Well, I just want to thank you all, and
I will yield back. Thank you very much.
Mr. Burgess. Will the gentleman yield his last 46 seconds?
Ms. Eshoo. Yes.
Mr. Welch. I will. Thank you.
Mr. Burgess. Just before this panel, it is such a smart
panel and before you leave and I think, particularly, Dr. Das,
I wanted to ask you--you might have heard me ask our agency
group about the IMD exclusion, and I thought we had dealt with
that in the SUPPORT Act.
Perhaps we didn't deal with it as effectively as we might
have. Do you have any thoughts on the IND exclusion and how it
is contributing to the ongoing problems that we are having?
Dr. Das. Continued exclusions further silo the access to
care problem that we have and so I would say that while there
are many things that were part of the SUPPORT Act enforcement
and having those carried out properly still are panning out.
Mr. Burgess. Well, Medicaid has been held up to us as
perhaps one of the better providers but with the Institute of
Mental Disease exclusion, you can only have 16 beds with
Medicaid patients who are hospitalized. It just seems to me to
be an impediment as to way the world is now. It is different
from what it was in 1960.
I think--maybe we can have a hearing on that at some point.
I think that will be a good idea. I will yield back to the
gentleman.
Ms. Eshoo. The gentleman from Vermont yields back and I see
that Mr. Bilirakis has returned. The gentleman from Florida--
you are recognized for 5 minutes.
Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so
very much. Thanks for holding this hearing. I thank the ranking
member as well and, of course, the presenters.
Dr. Das, is telepsychiatry an effective--an evidence-based
method for improving access to mental health and substance use
disorder treatment?
Dr. Das. During my time at the VA as the director of
addiction treatment services, I had the honor of using
telepsychiatry to reach veterans in remote areas, veterans who
not only were in remote areas but also oftentimes as a result
of their co-occurring mental illnesses or PTSD, for example,
couldn't get to our clinic sometimes 40 miles, 80 miles away.
In using telepsychiatry I was able to assess them
oftentimes in person when there was something acute but then
continue to treat them through telepsychiatry very effectively
with them going to the local community-based outpatient clinic.
These folks felt and told me more than once throughout
their treatment that they felt like this was a lifesaver, that
had they not learned about this option, they wouldn't be around
and that having the ability to see me through the video was
life changing for them.
Mr. Bilirakis. OK. So needless to say--suffice it to say
that you endorse it?
Dr. Das. Yes.
Mr. Bilirakis. OK. Are there patient populations like
patients with autism spectrum diagnosis, severe anxiety
disorders, or geriatric patients with physical limitations who
may prefer and benefit from telepsychiatry compared to its in-
person counterpart?
So, again, elaborate on how effective it is but let me ask
one more question here because it is related. How can
telepsychiatry lead to improved overall patient outcomes
including shorter hospitalizations and improved medication
adherence? What barriers still exist to telepsychiatry, in your
opinion?
Dr. Das. I think one of the----
Mr. Bilirakis. What barriers still exist?
Dr. Das. So the care is available and we have been able to
do it--for example, at the VA we have been able to use
telepsychiatry. Telemedicine is available across the VA across
all disciplines and we use it, for example, in wound care so
that somebody doesn't--somebody who may be an older patient who
is limited physically may not be able to come in for wound care
post-surgery and so they are able to do wound care even through
telemedicine.
And so the same sort of things apply for telepsychiatry,
that we would be able to have continuity of care, easier access
to care. I think the--you asked about barriers, I think, and
kind of--I have been speaking about the VA because that is
where I have done most of my telepsychiatry work. But the
barriers to care in the general public are reimbursement for
telepsychiatry.
Mr. Bilirakis. Reimbursements. OK. Thank you.
And in your opinion across the board in the medical
community, particularly in the psychiatric community,
professionals endorse this form of therapy, correct? Across the
board.
Dr. Das. Well, the APA has----
Mr. Bilirakis. In general.
Dr. Das [continue]. A telepsychiatry initiative. They have
resources available for telepsychiatry and information on the
evidence base for telepsychiatry across the board, across all
physicians. I wouldn't be able to speak for all physicians but
I think there is a movement towards getting people quicker
access to care and removing barriers.
Mr. Bilirakis. Absolutely. Access is definitely the key.
Madam Chair, I recently co-sponsored a bipartisan bill with
Congressman Soto called the Enhanced Access to Support
Essential, or EASE for short, Act--Behavioral Health Services
Act and it is H.R. 5473. H.R. 5473 builds upon the SUPPORT Act
to connect patients without a primary diagnosis of an SUD to
the Behavioral providers they need via telehealth.
My bill enables Medicare reimbursements, to your point--
Medicare reimbursements for behavioral health services
delivered via telehealth while also supporting school-based
behavioral health services delivered via telehealth--so very
important as well.
I ask for unanimous consent to include a letter of support
of H.R. 5473, the EASE Behavior Health Services Act, from the
American Psychiatric Association, and I have the letter here
somewhere, Madam Chair.
Ms. Eshoo. Well, you find it and we will put it in the
record.
[The information appears at the conclusion of the hearing.]
Mr. Bilirakis. Thank you. I appreciate that. Thank you. I
am going to yield back, Madam Chair. Thank you very much for
giving me the time.
Ms. Eshoo. The gentleman yields back.
We have been joined by the gentleman from New York, Mr.
Tonko, and we are glad that you are back and waiving on.
Mr. Tonko. Thank you.
Ms. Eshoo. It is really nice to see you here. You have 5
minutes.
Mr. Tonko. Thank you, Madam Chair. Thank you for allowing
me to waive on and welcome to our panellists.
Ms. Rizzo, let us start with you. I would like to begin by
asking you some questions that require a simple yes or no. Does
a medical provider need to obtain a special waiver from the DEA
in order to prescribe fentanyl?
Ms. Rizzo. No.
Mr. Tonko. Does a medical provider need to obtain a special
waiver from the DEA in order to prescribe codeine?
Ms. Rizzo. No.
Mr. Tonko. How about morphine?
Ms. Rizzo. No.
Mr. Tonko. How about hydrocodone?
Ms. Rizzo. No.
Mr. Tonko. I think you see what I am getting at here. Now,
let us talk about buprenorphine for a moment. Wouldn't you
agree that buprenorphine has a much stronger safety profile
than the drugs I just mentioned, specifically in that it has a
ceiling effect that doesn't increase with dosage and that the
risk of respiratory depression leading to overdose is much
lower with buprenorphine compared to the other medications that
I just mentioned? Yes or no?
Ms. Rizzo. Yes. Can I follow up?
Mr. Tonko. Thank you, Ms. Rizzo. What I am trying to make
clear here is that buprenorphine doesn't have a safety profile
that distinguishes it from other medications that providers can
freely prescribe.
So I am trying to rationalize why we continue to make this
medicine, which has been shown to reduce mortality associated
with overdose by up to 50 percent, again, reduces mortality by
up to 50 percent and has a safety profile that is much more
benign than the powerful opioids that got us into this crisis
so difficult to obtain. Perhaps it is because there is
something unique about the practice of addiction medicine.
So let me ask you, Ms. Rizzo, do you need a special DEA
waiver to prescribe naltrexone, one of the three FDA-approved
medications to treat opioid use disorder?
Ms. Rizzo. No.
Mr. Tonko. But, Ms. Rizzo, without a special waiver for
naltrexone how are we going to ensure the quality of care that
patients are receiving? How are we going to impose the
reporting requirements that you find so essential for
buprenorphine? And that is, largely, a rhetorical question but
let me ask you this.
Because you seem to think that addiction medicine uniquely
needs these bureaucratic safeguards in place do you believe
Congress should require all providers who want to prescribe
naltrexone have a special DEA waiver?
Ms. Rizzo. No.
Mr. Tonko. And the answer is no because it would be
ridiculous for Congress to impose such barriers to lifesaving
medicine in the middle of an epidemic. So just to recap here,
we have an overdose crisis that is killing 67,000 to 70,000
individuals a year.
We have a medication that will treat the vast majority of
these individuals and reduce their chance of death by up to 50
percent. This medication has a strong safety profile,
especially when compared to other controlled substances that
don't require jumping through special hoops.
Other addiction medications can be freely prescribed
without a waiver and yet we have set up a system where
somewhere less than ten percent of our medical professionals
can offer this lifesaving medication.
Does anyone actually have any rational defense of this ex-
waiver system that is causing people to die on our streets
other than it is simply the status quo? Would any of you
honestly set up a system like this from scratch today? Anyone?
Ms. Rizzo. Can I respond to that?
Mr. Tonko. Would you set up a system like that?
Ms. Rizzo. I wouldn't set up a system like that but our
concern is the diversion potential for buprenorphine on the
street and----
Mr. Tonko. Diversion on the streets when you have a better
established system for treatment--I don't think it is an
appropriate argument that there were be a diversion.
You know what I think? I think this is simply stigma
written into our laws. It is right there and crystal clear in
the fact that you don't need a special waiver to prescribe this
exact same medication for pain.
But once you want to help someone struggling with the
disease of despair that is substance use disorder, all of a
sudden, we throw up all kinds of barriers to a literal miracle
drug because we simply don't trust the people we are
prescribing them to.
Shame on us. We can fix this by passing the Mainstreaming
Addiction Treatment Act. We can't afford to wait and I thank
those witnesses and organizations who have offered support for
this critical legislation.
Now, Dr. Ryan, can you explain briefly how the current
waiver system limits access to care, particularly for the one-
third of Americans largely in rural counties who don't have
access to a single waivered provider?
Dr. Ryan. Thank you, sir. So I would--I guess I would
summarize by saying there are many barriers to access to care
for medication-assisted treatment, specifically buprenorphine,
and that this is one of them. There are also stigma,
reimbursement challenges, et cetera, but in--kind of in
totality it creates quite a barrier for folks to access
treatment.
Mr. Tonko. Well, thank you, and let me be clear before I
wrap up. I agree with many aspects of your testimony, Ms.
Rizzo, including that there are numerous other barriers we need
to address like prior authorizations, clinical support for
providers and better access for our incarcerated populations.
But the idea that just because other barriers exist that we
shouldn't knock down the one that is staring us in the face is
tough to swallow.
With that, I thank you and I yield back the balance of my
time, Madam Chair.
Ms. Eshoo. The gentleman yields back. Seeing no one else, I
think that our hearing is coming to an end.
Thank you to each one of you again for travelling across
the country and, most importantly, for what you do day in and
day out. This is a huge challenge for all of us and your
knowledge, your considerable knowledge, is not only a source of
inspiration to me, I think to all of the members. But it also
gives me confidence that what you have testified to and the
answers that you have given will help us to shape legislation
that is really going to make a difference for people in our
country and that is what we are here for. So I consider you all
healers.
I would also like to submit the following statements for
the record and request unanimous consent to do so.
Testimony from Danielle Tarino, president and CEO of Young
People in Recovery; a statement from the National Association
of Chain Drug Stores; a statement from Mark Parrino, president
of the American Association for Treatment of Opioid Dependence;
a graphic on MAT waiver training produced by Providers Clinical
Support System; a statement from the National Safety Council; a
statement from the Medication-Assisted Treatment Leadership
Council. Never ceases to amaze me all of the organizations we
have in our country.
A letter from Ochsner Health System--I think I am
pronouncing it correctly; a letter from the Opioid Safety
Alliance; a letter from the American Society of Addiction
Medicine; a letter from Bill Greer, president of SMART
Recovery; a letter from the American Society of
Anaesthesiologists; a letter from the American Psychiatric
Association.
I don't hear any objection so I will say so ordered.
Ms. Eshoo. And I know that each one of the witnesses will
on a timely basis, respond to any written questions that are
submitted to you and I want to thank you in advance for that.
Bless you in your work, and with that the subcommittee will
now adjourn. Thank you, everyone.
[Whereupon, at 2:53 p.m., the committee was adjourned.]
[Material submitted for inclusion in the record follows:]
Prepared Statement of Hon. Greg Walden
The United States remains in the midst of an opioid crisis
that is a national emergency. Under my leadership in the last
Congress, the Energy and Commerce Committee took the lead in
addressing this crisis head on. We took input from Members on
both sides of the aisle, from both on and off the committee, at
our Member Day before this subcommittee. We then held numerous
bipartisan hearings, briefings, and roundtables with experts,
stakeholders, law enforcement, individuals in recovery, and
family members of opioid abuse victims in order to build off
the prior work of both the Comprehensive Addiction and Recovery
Act and the 21st Century Cures Act in the previous Congress.
Our efforts culminated into one of the most significant
congressional efforts against a single drug crisis in history:
the Substance Use-Disorder Prevention that Promotes Opioid
Recovery and Treatment, or SUPPORT for Patients and Communities
Act, which was signed into law by President Trump on October
24, 2018.
Yet, we made clear that the SUPPORT Act would not our last
effort to address this crisis. Careful and thorough evaluation
of the law's implementation is necessary even as we continue to
explore additional needs for new legislation. I know that our
side will have questions about the SUPPORT Act's
implementation. We want to be sure deadlines are being met, and
Congress' intent is being fulfilled by the Administration. I
hope that today's testimony will allow us all to learn more
about the Federal Government's shared efforts and to drill
deeper to learn what's working and what's not working.
However, I'm disappointed at the rushed nature of today's
hearing, and that the majority has seemingly combined a SUPPORT
Act implementation hearing with a legislative hearing. While
both are necessary, this feels more like an exercise to "check
the box" instead of a meaningful discussion of next steps.
On the legislative front, I am pleased that we are
reviewing H.R. 2281, the Easy MAT for Opioid Addiction Act,
along with H.R. 3878, the Block, Report, And Suspend Suspicious
Shipments Act, H.R. 4812, the Ensuring Compliance Against
Opioid Diversion Act, and H.R. 4814, the Suspicious Order
Identification Act.
These bills address policy issues that were identified in
the committee's 2018 report summarizing the committee's
bipartisan investigation into the distribution of prescription
opioids by wholesale drug distributors, and enforcement
practices by the Drug Enforcement Administration (DEA).
However, I am disappointed that H.R. 2062, the Overdose
Prevention and Patient Safety Act, a bipartisan bill that would
make meaningful changes to 42 CFR Part 2, was not included in
today's hearing. This bill passed the House in the last
Congress 357-57 and has been identified numerous times as a
potential game-changer in addressing the crisis.
Also worth noting is the absence of H.R. 4963, the Stop the
Importation and Manufacturing of Synthetic Analogues (SIMSA)
Act, bipartisan legislation introduced today by Reps. John
Katko (R-NY) and Kathleen Rice (D-NY) to combat illicit
fentanyl. Fentanyl and other synthetic drugs are devastating
our communities at a rapid pace and SIMSA would provide law
enforcement with the tools they need to stopthese deadly drugs
from entering our country, without compromising important
public health and research protections.
These bills and others today represent additional
bipartisan steps Congress could take-right now-to continue to
combat this crisis.
Some of the bills included in today's hearing are
problematic for our side. Two bills, H.R. 2922 and H.R. 2482,
make significant changes to the waiver requirements for the
administration of medication-assisted treatment, or MAT. These
initiatives are extremely costly and premature, given we just
made changes to the waiver process as part of the SUPPORT Act.
The SUPPORT Act also commissioned a report to access the care
provided by qualifying practitioners who are providing MAT to
high numbers of patients. We need to see the data and
recommendations of that report to make the appropriate next
steps in this area.
Finally, H.R. 4141 would repeal the Medicaid Inmate
Exclusion in its entirety. This bill is a non-starter. Instead,
we have H.R. 1329, a bill that would allow Medicaid coverage 30
days before leaving the Jail or Prison. This "warm hand-off"
approach is something I think merits further consideration and
I am happy it is included here today.
One additional item we could explore having the Medicaid
Inmate Exclusion not apply until a person is convicted of a
crime. About 60 percent of people in jail have not been
convicted. This approach could alleviate the burden jails face
of providing care for people who are still considered innocent.
That, in conjunction with Mr. Tonko's 30 day prior to release,
seems like an area ripe for bipartisanship.
We have a lot of ground to cover today and it is my hope
that we can work with the majority to address our concerns so
that we have bipartisan consensus before any markup. To our
witnesses today, I thank you for providing your feedback as we
need your help to continue to address this critical issue.
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