[Senate Hearing 116-]
[From the U.S. Government Publishing Office]
DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION, AND
RELATED AGENCIES APPROPRIATIONS FOR FISCAL YEAR 2020
----------
THURSDAY, FEBRUARY 28, 2019
U.S. Senate,
Subcommittee of the Committee on Appropriations,
Washington, DC.
The subcommittee met at 10:02 a.m. in room SD-124, Dirksen
Senate Office Building, Hon. Roy Blunt, (chairman) presiding.
Present: Senators Blunt, Alexander, Capito, Hyde-Smith,
Rubio, Murray, Durbin, Shaheen, Merkley, Murphy, Manchin, and
Leahy.
ADDRESSING THE OPIOID EPIDEMIC IN AMERICA:
PREVENTION, TREATMENT, AND RECOVERY AT THE STATE AND LOCAL LEVEL
opening statement of senator roy blunt
Senator Blunt. The Subcommittee on Labor, Health and Human
Services, Education, and Related Agencies will come to order.
Good morning, glad you are here. We have decided it is okay
to start on time, so we are starting on time and anxious to
hear from you. I want to thank our witnesses for being here.
This is a critical issue in this committee, as Senator
Murray and I began to work together on this committee 4 years
ago, we really made the first substantial percentage increase
that year on the effort to combat opioids. I think we increased
the funding by about 300 percent. That was not an insignificant
amount of money but compared to what we are spending now it was
pretty easy to make a 300 percent increase. And then that
discussion was driven in so many ways by members of this
committee, from our States, from New Hampshire, from West
Virginia, and other places, has gotten us to where we are and
we are anxious to hear from you.
In 2017, almost 50,000 lives were lost due to this crisis.
That equates to about one life every 11 minutes. It is the
deadliest--2017 was the deadliest year on record for this
disease, killing more people than those who lost their life at
the peak of the HIV crisis in the 1990's. While those numbers
are bad, the overdose deaths obviously are not redeemable, they
only reflect the tip of the iceberg, for every person that
loses their life to overdose there are 300 other people who are
misusing prescription opioids during that same period of time.
Every State across the country feels the impact of this
crisis. My State, Missouri, is no exception--my staff was
recently talking to the mother of a St. Louis native and Navy
veteran, Derek, who was just 2 months shy of his 30th birthday
when he lost his life to the battle that had been going on for
12 years. And during that 12 years Derek had graduated from
college, earned an MBA, served in the Navy proudly, but the
addiction that had started from a high school football accident
finally led to his death.
His mother, Kelly, is really a powerful voice in the fight
against this epidemic. I want to thank her and so many other
people who have taken their tragic experience and moved forward
to try to help others prevent that tragedy and deal with what
they are really dealing with.
We have had a steady increase of synthetic opioid use, and
the DEA (Drug Enforcement Administration) in St. Louis recorded
more than a 1600 percent increase in fentanyl seizures from
2016 to 2017. We saw in our State a 40 percent increase in
fentanyl-related overdoses during that same period of time.
It is clear that the crisis is not behind us. This
subcommittee has, I said to start, really been at the forefront
of talking about this before even we had the kind of expanded
legislative authority. Over 80 percent of the investment the
Government has made has come through this subcommittee, nearly
$9 billion in the last 4 years, and I think we are beginning to
see some signs of improvement, and that is one of the things we
want to talk with you about today.
Federal funding in Missouri has provided over 4,000 people
with treatment, saved, we believe, 2,000 lives through overdose
reversals, and the rate of overdose deaths is beginning finally
to drop. However, there is a lot more to do.
First, I think we have to realize that behavioral health
issues have to be treated like all other health issues. That
mood, anxiety, and other disorders can double the risk of
addiction, and also just realize if you don't have a behavioral
health issue before you become addicted, you certainly have a
behavioral health issue after you become addicted.
Secondly, we need to reduce the number of people who become
addicted in the first place. The committee has provided
resources to expand surveillance in every State, to educate
physicians through prescribing guidelines, and to start an
education campaign. There is evidence that these efforts are
beginning to work. The amount of opioids prescribed in 2017
declined by nearly 30 percent from the year before, but we have
to continue to talk to both the prescribers and to patients.
And lastly, we need to look for better ways for pain
management, and we are trying to do that through the research
dollars, that again, this committee is making available.
This is an area that we have moved forward on together in a
bipartisan dedicated way. Senator Murray has certainly been a
great partner and a great part of this.
[The statement follows:]
Prepared Statement of Senator Roy Blunt
Good morning. Thank you to our witnesses for being here today to
talk about a critical issue that continues to impact thousands of lives
across our Nation--the opioid epidemic.
In 2017, over 49,000 lives were lost due to this crisis. That
equates to one life every 11 minutes. It was the deadliest year on
record, killing more people than at the peak of the AIDS crisis in the
1990s. These numbers are deeply troubling, but overdose deaths are only
the tip of the iceberg. For every one person who died, 273 people
misused prescription opioids in the past year.
Every State across the Nation feels the impact of this crisis, and
Missouri is no exception. St. Louis native and Navy veteran Derek was
just 2 months shy of his 30th birthday when he lost his life to a 12-
year battle with addiction. Derek graduated from college, earned an
MBA, and proudly served our Nation, but struggled with an addiction
that began after he was prescribed powerful opioids for a football-
related injury in high school. His mother, Kelly, is now a powerful
voice in the fight against the opioid epidemic. I thank her for what
she, and so many others are doing, to help prevent other families from
suffering the same loss that she and her family have suffered.
Missouri has seen a steady increase in synthetic opioid use and the
DEA in St. Louis recorded more than a 1,600 percent increase in
fentanyl seizures from 2016 to 2017. Alarmingly, Missouri has seen a 40
percent increase in fentanyl related overdoses during that same period.
It is clear that the crisis is not behind us. However, as Chairman
of the Appropriations Subcommittee that has provided over 80 percent of
the U.S. Government investment, or nearly $9 billion in the last 4
years, to address the epidemic I am pleased that we are starting to see
some positive signs of improvement. Early data suggests that the 12
month opioid mortality rate is leveling off for the first time since
the 1980's. In my home State of Missouri, Federal funding has provided
over 4,000 people treatment, saved 2,000 lives through overdose
reversals, and the rate of overdose deaths is dropping.
But we have more to do. As I hear from constituents back home and
experts in the addiction field, I continue to believe that we need to
focus on three major areas to address the crisis.
First, we must recognize that behavioral health issues should be
treated like any other physical health issue. Mood and anxiety
disorders double the risk of addiction. If we are going to effectively
address opioid addiction, we need to ensure that those suffering can
access effective treatment--and that should include mental health
services.
Second, we need to reduce the number of individuals who become
addicted in the first place. The Committee has provided resources to
expand surveillance to every State, educate physicians through
prescribing guidelines, and start an education campaign. There is
evidence that these efforts are working as the amount of morphine
prescribed in 2017 declined by nearly 30 percent. But we must remain
vigilant by improving the speed of surveillance and revising guidelines
to keep physicians up-to-date with the latest best practices.
Lastly, we need better pain management. Over 63 percent of opioid
misuse stems from pain. Without reasonable access to non-addictive pain
medications or alternative treatments, it will be difficult to truly
get this crisis under control.
I am pleased to welcome today's panel of researchers and State and
local experts to discuss how taxpayer dollars are allocated and
prioritized at the State and local level. We all know there is no one-
size-fits-all solution to solve this crisis, and we must remain
committed to a comprehensive plan to get the opioid epidemic under
control. As we move forward, I am interested to hear our witnesses'
perspectives on what programs and proposals have made a difference,
where we should focus future funding, and what strategies from States
can be applied Nation-wide.
Thank you.
Senator Blunt. Senator Murray I would like to turn to you
for your opening statement.
STATEMENT OF SENATOR PATTY MURRAY
Senator Murray. Well, thank you very much, Mr. Chairman.
Thank you for calling this hearing and all of your work on this
really serious public health crisis.
I am very pleased today to welcome Dr. Charissa Fotinos who
is the Director--Deputy Medical Director of Washington State
Healthcare Authority. Thank you so much for traveling out here
from, from the better Washington to this one. Great to have you
all here. I am looking forward to hearing your testimony as
well from our other State witnesses about how they are using
Federal resources to make a real difference in the lives of
patients and families who struggle with addiction and what
additional actions are needed to stem this epidemic.
Since 1999, almost 400,000 people have died from an
overdose involving opioids from prescription painkillers to
illicit opioids such as heroin, to synthetic opioids such as
fentanyl. Approximately 130 people in this country die every
day from an opioid overdose, and the White House's own Council
of Economic Advisors estimated the economic cost to our country
of the opioid crisis is over $500 billion each year. This does
not begin to capture, of course, the emotional devastation
caused by the opioid crisis from health providers who are
treating babies born addicted to opioids, to more kids who are
placed in our foster care, to parents who have lost children to
an overdose and some even now raising their children's children
as a result, to veterans in chronic pain who are struggling
with addiction, and the list goes on.
So, I am concerned the Trump administration has been
shockingly silent when it comes to addressing this crisis of
addiction here at home. Earlier this month the administration
released its first-ever National drug control strategy. It
contained nothing new, identified no funding needs, and is 20
pages long and easily summarized in two words--Not Enough. But
despite the administration's inaction, Congress has taken steps
to address the epidemic. With bipartisan support, the Congress
passed two major pieces of legislation through the Help
Committee to deal with the epidemic, our chairman and Senator
Lamar Alexander is here, thank you for your work on this, and
this subcommittee, Senator Blunt has worked hard and provided
an increase of $2.6 billion in new resources to combat opioid
abuse, which includes, $1.5 billion in block grants to States
through the State Opioid Response program. But we know that
this barely addresses the scale of the problem.
Medicaid is by far the Nation's largest payer for
Behavioral Health Services, including services for people with
substance use disorders. Together, the Affordable Care Act and
Medicaid expansion have expanded access to treatment for
millions of families, providing a critical lifeline for people
with substance use disorders.
The Trump administration does claim to be fighting the
epidemic, but the reality is, it has done everything in its
power to undermine access to treatment, which is so important,
including taking Medicaid coverage away from people who cannot
meet bureaucratic hurdles to prove they have reached a minimum
number of working hours, causing tens of thousands of people to
lose their vital coverage, and supporting healthcare repeal
efforts that would cause millions of people to lose health
coverage, and make coverage worse or less affordable for
millions more with pre-existing conditions.
I hope to hear today from some of our witnesses about how
their using Medicaid expansion and other Federal resources to
address the epidemic. And I hope we will hear from our
witnesses about how to address areas where there are treatment
gaps, such as in rural areas and among Native American
populations.
There is a lot more that needs to be done so, I hope as we
listen to our witnesses today we will continue listening to
each other and looking for additional opportunities to address
this crisis in a bipartisan way.
Thank you, Mr. Chairman.
Senator Blunt. Thank you Senator Murray.
We are lucky to have the Vice Chairman of the full
Committee with us here today, Senator Leahy, do you have some
opening remarks?
STATEMENT OF SENATOR PATRICK J. LEAHY
Senator Leahy. Yes, Mr. Chairman and I will put my full
statement on the record, but I do want to thank you and Senator
Murray for having this hearing. I think you have demonstrated
the fact that the efforts we are trying to do are bipartisan
efforts. We want to provide resources and we know the opioid
epidemic is the health crisis of our time. Every community,
every family has been touched in some way by this tragic loss
of life, or the struggle of addiction.
I was telling the witness from Vermont, whom I will mention
in just a moment, when Marcelle and I got off the plane last
week in Burlington to be home for a few days, a friend of ours
we have known for years was getting on the plane, and his son
just died of an opioid overdose. A wonderful family, well-
educated, everything else. We just hugged each other. There is
nothing you can say. I mean, what the heck do you say? A life
just wiped out like that; we held each other and just,
basically sobbed.
The one good thing, I think that Vermont is ahead of the
country in many ways, we have openly identified the problem. We
even had a Governor who in his State of the State speech spoke
just about that. Public health leaders, addiction specialists,
doctors, State leaders coming together; whether you are a
Republican or a Democrat, we in Vermont, this is what we do to
help.
We started the ``hub-and-spoke'' model to help support
those in recovery, nine regional hubs, daily medication-
assisted treatment, patients receive follow-up care,
counseling, general welfare.
Beth Tanzman is here and I'm so pleased that she came down.
We admire her in Vermont. She is the Executive Director for
Vermont's Blueprint for Health that helped design/implement the
hub-and-spoke model. I will let her talk about it but I--you
know, Dick Shelby, Chairman Shelby and I, as well as you, Mr.
Chairman, Senator Murray--we have come together. We have said
this committee, the Senate Appropriations Committee, will
address this. We will get money, we will continue to get money.
But it is the people you are going to hear from who are the
ones who then have to make sure that money is well spent.
I don't want to meet friends of mine when I go to Vermont
like that, knowing the story of what happened to somebody who
had nothing but great promise ahead of them.
Thank you.
Senator Blunt. Thank you, Senator Leahy.
Let me introduce our witnesses. We are anxious to hear from
you and then have that discussion between all of us, but, let
me start over here with Dr. Berry, and I will introduce
everybody and then we will come back to you Dr. Berry to make
your opening statement.
Dr. James Berry is an Associate Professor and Director of
Addictions at West Virginia University; Dr. Charissa Fotinos is
the Deputy Chief Medical Officer at the Health Care Authority
of Olympia, Washington; Mark Stringer is the Director of the
Missouri Department of Mental Health; Dr. Karen Cropsey is a
Professor of Psychiatry at the University of Alabama at
Birmingham; Beth Tanzman, already well introduced by Senator
Leahy, and Dr. Daisy Pierce is the Executive Director of the
Navigating Recovery in New Hampshire.
We have your statements in the record, you can share as
much of that as you would like. You can read it or summarize it
but if we can get all of this done in 30 minutes or less we
will have that much more time to talk to you about the
questions we have.
Dr. Berry, thank you again for being here and go ahead and
start.
STATEMENT OF DR. JAMES BERRY, DO, ASSOCIATE PROFESSOR
AND VICE CHAIR, DIRECTOR OF ADDICTION
SERVICES, DEPARTMENT OF BEHAVIORAL MEDICINE
AND PSYCHIATRY, WEST VIRGINIA UNIVERSITY,
MORGANTOWN, WV
Dr. Berry. Good Morning Chairman Blunt, Ranking Member
Murray, and members of the Senate Labor HHS Subcommittee.
My name is Dr. James H. Berry and I am a physician from
West Virginia University who specializes in treating addiction
and mental illness. I have been invited by Senator Shelley
Moore Capito to share my experience and thoughts with you
regarding our Nation's addiction epidemic. Having completed
medical school in Michigan, I moved to West Virginia in 2002 to
pursue residency training and psychiatry. At that time I had no
idea we were on the eve of an evolving opioid crisis and that
West Virginia would prove to be the bellwether of the rest of
the Nation.
Early in my tenure, most of the patients seeking addiction
treatment were doing so because of alcohol problems. Before
long patients began trickling in seeking help for addiction to
opioid pain pills. In a relatively short amount of time, the
trickle became a tsunami and we became overwhelmed by the
incredible demand to provide services for opioid use disorders.
We quickly had to adapt and develop innovative strategies to
expand access to and keep people in treatment. Over the past
decade and a half, we have treated thousands of these patients
through our university-based treatment program and have learned
much from them about the nature of addiction and the path
forward.
I would like to share with you a few brief observations:
first, and most importantly, addiction is a treatable
condition. There are very few areas of medicine where a
healthcare provider can witness dramatic change in a patient's
health and well-being like that afforded in addiction
treatment. The process can be slow, and often painful, but the
rewards are unparalleled. People get their lives back, they
become better parents, they finish school, they enter the
workforce, and they inspire others. Unfortunately it is
estimated that only 20 percent of the people who need addiction
treatment ever receive it. We desperately, desperately need to
expand access to evidence-based treatment that works.
Second. Addiction is a multifaceted problem that requires
multifaceted solutions. There is no silver bullet. Addiction is
biologic, psychologic, social, and spiritual manifestations.
Genetics, environment and experience all play a part. Addiction
is a mental disorder that is often present with other mental
disorders such as anxiety and depression. There are incredibly
high rates of traumatic experiences, such as sexual and
physical abuse during childhood that lead to the development of
addiction. None of this can be ignored and the best treatment
incorporates all elements, medications proven to improve
outcome should be readily available and barriers preventing
widespread use should be removed.
People should also have ready access to psychological
therapies known to improve functioning and increased quality of
life. We are creatures that thrive in community and addiction
is a very isolating condition. Supporting the use of peer
support groups such as Twelve-Step programs are incredibly
valuable in forming healthy connections that are reparative.
In addition, we are creatures hungry for meaning and
purpose, involvement in faith-based and other purpose-driven
community organizations foster healthy relationships in
addition to supporting a drive to reach beyond one's limits.
Third. Our addiction epidemic extends beyond opioid and is
rapidly evolving. Opioids have captured our National attention
and rightly so, due to the staggering jolt of acute overdose
deaths. However, please note that these deaths remain out
past--outpaced by the number of people who die every year from
alcohol or tobacco related causes.
Furthermore, many of us in the addiction treatment and
research community are preparing for a significant increase in
cannabis-related health problems as States moved to legalize
marijuana and the public perception of harm diminishes. The
epidemic continues to evolve as more and more people are using
stimulants, such as methamphetamine an incredibly lethal
synthetic opioids such as fentanyl that account for the
sharpest increase in overdose deaths over the past several
years.
Finally, the epidemic will require long-term solutions,
there is no quick fix. We now have two generations that are
severely impacted. Turning this epidemic around will require
strategic investment in mental health treatment and prevention
resources to meet today's adult generation and the ballooning
child and adolescent population at risk.
We are woefully short of such personnel nationally and even
more so in rural areas hardest hit by the epidemic, such as
Appalachia. An investment in much-needed addiction training
programs and incentives to encourage laborers to work in areas
of greatest need are paramount.
Thank you for your time and attention and know that I am
happy to answer any questions you may have.
[The statement follows:]
Prepared Statement of James H. Berry, DO
Good Morning Chairman Blunt, Ranking Member Murray and members of
the Senate Labor- HHS Subcommittee. My name is Dr. James H. Berry and I
am a physician from West Virginia University who specializes in
treating addiction and mental illness. I have been invited by Senator
Shelley Moore Capito to share my experience and thoughts with you
regarding our Nation's addiction epidemic. Having completed medical
school in Michigan I moved to West Virginia in 2002 to pursue residency
training in psychiatry. At the time, I had no idea we were on the eve
of an evolving opioid crisis and that West Virginia would prove to be
the bellwether for the rest of the Nation. Early in my tenure most of
the patients seeking addiction treatment were doing so because of
alcohol problems. Before long, patients began trickling in seeking help
for addiction to opioid pain pills. In a relatively short amount of
time, the trickle became a tsunami and we became overwhelmed by the
incredible demand to provide services for opioid use disorders. We
quickly had to adapt and develop innovative strategies to expand access
to and keep people in treatment. Over the past decade and a half, we
have treated thousands of these patients through our university-based
treatment program and have learned much from them about the nature of
addiction and the path forward. I would like to share with you a few
observations.
First, and most importantly, addiction is a treatable condition.
There are very few other areas of medicine where a healthcare provider
can witness dramatic changes in a patient's health and wellbeing like
that afforded in addiction treatment. The process can be slow and
painful, but the rewards are unparalleled. People get their lives back.
They become better parents. They finish school. They enter the
workforce. They inspire others. Unfortunately, it is estimated that
only twenty percent of the people who need addiction treatment ever
receive it. We desperately need to expand access to evidence-based
treatment.
Second, addiction is a multifaceted problem that requires
multifaceted solutions. There is no silver bullet. Addiction has
biologic, psychologic, social and spiritual manifestations. Genetics,
environment and experience all play a part. Addiction is a mental
disorder that is often present with other mental disorders such as
anxiety and depression. There are incredibly high rates of traumatic
experiences, such as sexual and physical abuse during childhood that
lead to the development of addiction. None of this can be ignored and
the best treatment incorporates all elements. Medications proven to
improve outcomes should be readily available and barriers preventing
widespread use should be removed. People should also have ready access
to psychological therapies known to improve functioning and increase
quality of life. We are creatures that thrive in community and
addiction is a very isolating condition. Supporting the use of peer
support groups such as 12-step programs are incredibly valuable in
forming healthy connections that are reparative. In addition, we are
creatures hungry for meaning and purpose. Involvement in faith-based
and other purpose-driven community organizations foster healthy
relationships in addition to supporting a drive to reach beyond one's
illness.
Third, our addiction epidemic extends beyond opioids and is rapidly
evolving. Opioids have captured our national attention and rightly so
due to the staggering jolt of acute overdose deaths. However, please
note that these deaths remain outpaced by the number of people who die
every year from alcohol or tobacco-related causes. Furthermore, many of
us in the addiction treatment and research community are preparing for
a significant increase in cannabis-related health problems as States
move to legalize and the public perception of harm diminishes. The
epidemic continues to evolve as more and more people are using
stimulants such as methamphetamine and incredibly lethal synthetic
opioids such as fentanyl that account for the sharpest increase in
overdose deaths over the past several years.
Finally, the epidemic will require long-term solutions. There is no
quick fix. We now have two generations that are severely impacted.
Turning this epidemic around will require strategic investment in
mental health treatment and prevention resources to meet today's adult
generation and the ballooning child and adolescent population at risk.
We are woefully short of such personnel nationally and even more so in
rural areas hardest hit by the epidemic such as Appalachia. Investment
in much needed addiction training programs and incentives to encourage
laborers to work in areas of greatest need are paramount.
Thank you for your time and attention, and know that I am happy to
answer any questions you might have.
Senator Blunt. Thank you Dr. Berry.
Dr. Fotinos.
STATEMENT OF DR. CHARISSA FOTINOS, DEPUTY CHIEF MEDICAL
OFFICER, WASHINGTON STATE HEALTH CARE
AUTHORITY, OLYMPIA, WA
Dr. Fotinos. Chair Blunt, Ranking Member Murray, members of
the committee, I'm honored to be here today. My name is
Charisse Fotinos and I'm the Deputy Chief Medical Officer for
the Washington State Healthcare Authority, the agency that
administers the State Medicaid program. I am a board certified
Family Medicine and Addiction Medicine physician.
Washington State continues to struggle with the opioid
epidemic. There were 739 opioid deaths in 2017, up from 694 in
2016. This increase was primarily due to an increase in deaths
involving fentanyl. From a health disparity perspective, Native
Americans in Washington experience opioid overdose death rates
that are three times higher than non-Hispanic, whites.
Despite these challenges, we are making some progress. Our
efforts to increase access to treatment has seen an increase in
the number of persons by Medicaid receiving medication-assisted
treatment for opiate use disorder from about 5,000 in 2013 to
over 21,000 in 2017, a fourfold increase.
Initiating and retaining people with opiate use disorder on
medications is essential since medications reduce a person's
risk of overdose death by 50 percent. In 2018, 37,900 naloxol
kits were distributed across Washington, exclusive of any
pharmacies. Over 3,000 overdose reversals were reported from
syringe service programs alone.
Several metrics also suggest our prevention efforts are
headed in the right direction. Our last healthy use survey
reported the proportion of 10th graders using prescription pain
pills to get high was 4.4 percent, a steady 50 percent decline
since 2006. The number of 10 to 24 year olds receiving an
opiate prescription decreased almost 40 percent during 2015 to
2017, and in 2018 our prescription monitoring program database
was queried over 20 million times, far exceeding the total
number of controlled substances dispensed.
Washington published one of the first prescribing opiate
guidelines in 2006 after a notable increase in the rate of
prescription opioid overdose related deaths, by 2017 this rate
had declined by 44 percent.
In addition, Governor Inslee in 2016 issued an Executive
Order organizing the State agencies and implementing a State
plan. Our State legislator has--legislature has appropriated
resources and we are working across agencies and with multiple
stakeholders on the plan.
Scientific studies show that opiate replacement medication
save lives. In order to better treat people on these
medications we recognize the need to work toward integration of
our currently distinct physical, mental health and substance
use disorder systems of care. Each system has different funding
streams and different conceptual frameworks. By leveraging the
$21 million of the $34 million awarded to the State between the
State targeted response and State Opiate Response Grants and
funds--allocated by the State, we are working to create this--
infrastructure and improve integration.
Loosely modeled after Vermont's hub-and-spoke in
Massachusetts Nurse Care Manager models, Federal and State
funds have been used to develop regional networks of care for
persons with opiate use disorder across the State. The networks
are responsible for getting new patients stabilized on opiate
treatment medications and for providing and coordinating their
medical mental health and substance use disorder treatment
needs. Monies from the State Opiate Response Grant are being
used to develop linkages to jails, emergency departments, and
syringe service programs. Funding technical to support to
assist in the development of these networks has been a critical
part of this work.
We are now focusing our efforts on two particularly
vulnerable populations, persons who are pregnant and parenting
and those who justice involved. The governor has requested
State legislation and additional funds to expand programs
focused on persons who are pregnant and parenting and their
newborns. Federal funds allocated the Child Abuse Prevention
and Treatment Act and the Kinship Navigator programs will
further support efforts at achieving positive health outcomes
for parents struggling with opiate use disorder and their
children.
The governor has also advanced the funding proposal to
support a Law Enforcement Assisted Diversion program. We are
also pursuing a Medicaid waiver that would allow persons
eligible for Medicaid to start or continue medications for
opiate use disorder while in jail.
Despite all of this work, challenges remain. Stigma and the
shame of persons experiencing opiate use disorder and that of
their families remains a barrier to care and delays recovery.
Maintaining Medicaid expansion and the pre-existing
conditions protections and essential benefits of the Affordable
Care Act is critical. Between 2013 and 2015, the number of
people covered by Medicaid with an opiate use disorder doubled.
It is likely that many of these persons would have experienced
an overdose without Medicaid expansion.
It is important to note that while Washington's overall
rate of opioid overdose death remains below the National
average, the rate of methamphetamine-related deaths in
Washington has doubled since 2013 and is higher than the
National average. Many of our opiate users are poly-substance
users. This highlights the need for us to develop systems
capable of addressing multiple substance use disorders in
responding to this epidemic. That is why we are focused on
building a behavioral health integrated system.
Continued funding of the Substance Abuse Block grant,
continued leadership at the Federal level to promote evidence-
based care, continued work to reduce barriers to information
exchange across provider types and the elimination of barriers
that prohibit States from combining money across funding
streams to support what will be an ongoing response to this
crisis, would be paramount.
Through my experience as a family physician, I have
witnessed the effects of substance use disorders on families
and individuals. In my previous role as the medical director of
the county health department and now in my current role with
the State, I have gained a broader perspective. Families,
communities and a generation of children are being impacted.
Developing a long-term coordinated response that recognizes and
helps address the breadth of these impacts will be necessary to
help restore fractured communities and reduce the risk of
future generations experiencing the same.
Thank you for the opportunity to testify. I look forward to
answering your questions.
[The statement follows:]
Prepared Statement of Charissa Fotinos, MD, MSc
Chair Blunt, Ranking Member Murray, Members of the Committee: I am
honored to be here today. My name is Charissa Fotinos, and I am the
deputy chief medical officer and director of behavioral health
integration for the Washington State Health Care Authority; the agency
that administers the State Medicaid program. I am a board certified
Family Medicine and Addiction Medicine physician and have spent a large
part of my career practicing medicine serving people with behavioral
health conditions. In my current position I have spent much of the last
4 years working with my colleagues across the State to address the
opioid crisis. I appear before you today to review our progress,
describe some of our efforts, present some of our ongoing challenges
and to ask for your continued support in responding to this public
health emergency.
Washington State continues to struggle with the opioid epidemic.
There were 739 opioid overdose deaths in 2017, up from 694 in 2016.
This increase was primarily due to an increase in deaths involving
fentanyl. As is true with many health conditions, huge disparities
among communities exist, Native Americans in Washington experience
opioid overdose death rates that are 3 times higher than non-Hispanic
whites.
Despite these challenges we are making some progress. My colleague
Dr. Gary Franklin first discovered the problem with overdose deaths
related to prescription drug overdoses, and since that discovery we
have implemented collaborative practice guidelines that have
contributed to a sustained 44 percent decline in the rate of
prescription opioid related deaths.
Our efforts to increase the number of waived prescribers and
increase access to medications has seen an increase in the number of
persons covered by Medicaid receiving medication assisted treatment for
opioid use disorder or OUD, from about 5,000 in 2013 to over 21,000 in
2017, a 4 fold increase. Through the 2nd quarter of 2018 about a third
of people on Medicaid with a diagnosis of OUD were receiving treatment.
Across the State 90 day retention rates for medication are about 72
percent. Initiating and retaining people with opioid use disorder on
medications is essential since medications reduce a person's risk of
death by more than 50 percent.
In 2018 37,900 naloxone kits were distributed across Washington,
exclusive of any provided by a pharmacy. Over 3,000 overdose reversals
were reported from syringe service programs alone.
Several metrics also suggest our prevention efforts are headed in
the right direction. Our last Healthy Youth Survey reported the
proportion of 10th graders using prescription pain pills to get high
was 4.4 percent, a steady 50 percent decline since 2006. The number of
10--24 year olds receiving an opioid prescription decreased almost 40
percent during 2015 to 2017. And, in 2018, our Prescription Monitoring
Program database was queried over 20 million times, far exceeding the
total number of controlled substances dispensed.
We believe part of this success has been due to the fact that in
2015 multiple State agencies along with our tribal nations and external
stakeholders collaborated to develop a State opioid response plan.
Governor Inslee's executive order issued in 2016 called attention to
the epidemic and directed State agencies to implement the response plan
which focuses on 4 goals: prevention, treatment, overdose response, and
measurement. The plan has provided a blueprint for action, reduced
duplication of effort and helped identify ongoing gaps as strategies
are developed and activities implemented. In addition, the States' nine
accountable communities of health, created through a Medicaid
transformation project, are required to implement and will be measured
on improvements made from their own regional opioid response plans. The
transformation project also allows Medicaid funds to be used for
housing and employment supports; critical elements of many people's
recovery.
There are 17 strategies and 105 activities in the State opioid
response plan. Included is a copy of our State plan, an example of a
routine report and some of our metrics.
Scientific studies show that opioid replacement medications like
methadone and buprenorphine are highly effective in reducing opioid
related overdose risk and in improving outcomes. In order to better
support people on these medications, we recognized the need to work
towards integration of our currently distinct physical health, mental
health and substance use disorder systems of care. Each system has
different funding streams and different conceptual frameworks. This has
highlighted the need to develop a coordinated infrastructure of care
for persons struggling with opioid and other substance use disorders.
By leveraging $21.3 million of the $33.4 million dollars awarded the
State with the State Targeted Response, STR, and State Opioid Response,
SOR, grants and funds allocated by the State, we are working to create
this infrastructure.
Loosely modeled after Vermont's hub and spoke and Massachusetts'
nurse care manager models, Federal and State funds have been used to
develop regional networks of care for persons with opioid use disorder
across the State. By providing funds to hire nurses, care coordinators
and provide additional administrative support to practices, we have
expanded capacity and started to build what we hope will be more
integrated systems of care. The networks are responsible for getting
new patients stabilized on opioid treatment medications and for
providing and coordinating their medical, mental health and substance
use disorder treatment needs. Monies from the SOR grant are being used
to develop linkages to jails, emergency departments and syringe service
programs. Funding technical support to assist in the development of
these networks has been a critical part of this work.
We are focusing our efforts on two particularly vulnerable
populations, persons who are pregnant and parenting and those who are
justice involved. The Governor has requested additional funds to expand
programs focused on persons who are pregnant and parenting and their
newborns. Federal funds allocated to the Child Abuse Prevention and
Treatment Act and the Kinship Navigator programs will further support
efforts at achieving positive health outcomes for parents struggling
with OUD and their children. The Governor has also advanced a funding
proposal to support a Law Enforcement Assisted Diversion program. We
are also pursuing a Medicaid waiver that would allow persons eligible
for Medicaid to start or continue medications for opioid use disorder
while in jail.
Despite all of this work, challenges remain. Stigma and the shame
of persons experiencing opioid use disorder and that of their families
remains a barrier to care and delays recovery. Maintaining the pre-
existing conditions protections of and essential benefits of the
Affordable Care Act is critical. In 2013, 22,250 people covered by
Medicaid in Washington had a diagnosis of OUD. A year after
implementation in 2015 that number was 48,688. It is likely that many
of these persons would have experienced an overdose without Medicaid
expansion.
It's important to note that while Washington's overall rate of
opioid overdose deaths remains below the national average, the rate of
methamphetamine related deaths in Washington has doubled since 2013 and
is higher than the national average. This highlights the need for us to
develop systems capable of addressing multiple substance use disorders
in responding to the epidemic.
While we are moving in the right direction, our efforts should be
considered crisis triage and just the start of a long term response
effort. As is true of many chronic conditions there are periods of
stability and episodes of relapse. We need to rethink how we fund
treatment in the context of chronic disease management to include
funding peers and recovery supports. We also need to work closely with
our other government partners to make available supported housing and
employment.
Continued funding of the substance abuse block grant, continued
leadership at the Federal level to promote evidence based care,
continued work to reduce barriers to information exchange across
provider types, and the elimination of barriers that prohibit States
from combining money across funding streams to support what will be an
ongoing response to this crisis will be paramount.
Through my experience as a family physician, I have witnessed the
effects substance use disorders have on individuals and their families.
In my previous role as the Medical director of a county health
department and now in my current role at the State, I have gained a
broader perspective. Families, communities and a generation of children
are being impacted. Developing a long term coordinated response that
recognizes and helps address the breadth of these impacts will be
necessary to help restore fractured communities and reduce the risk of
future generations experiencing the same. Thank you for the opportunity
to testify, I look forward to answering your questions.
Senator Blunt. Thank you Dr. Fotinos.
Director Stringer.
STATEMENT OF MARK STRINGER, DIRECTOR, MISSOURI
DEPARTMENT OF MENTAL HEALTH, JEFFERSON
CITY, MO
Mr. Stringer. Mr. Chairman, members of the committee,
Ranking Member Murray, my name is Mark Stringer and I am
Director of the Missouri Department of Mental Health. I also
serve as chair of the Public Policy Committee of the National
Association of State Alcohol and Drug Substance Abuse Directors
or NASADAD.
I truly appreciate the opportunity to testify before you
today to discuss Missouri's actions to address the opioid
crisis, with a huge boost from the State Targeted Response and
State Opioid Response Grants, both programs managed by the
Substance Abuse and Mental Health Services Administration at
the Federal level, and by State alcohol and drug agencies like
mine, at the State level.
Before I get started I want to applaud the SAMHSA
(Substance Abuse and Mental Health Services Administration)
under the leadership of Dr. Elinore McCance-Katz. She and her
strong leadership team have worked hard to ensure that these
vital grant programs are distributed quickly and implemented
effectively.
So State agencies like mine play a critical role in
overseeing and implementing the publicly funded prevention,
treatment, and recovery services system. All State substance
use agencies develop a comprehensive plan for evidence-based
practice and capture data describing the services provided.
Missouri had 951 overdose deaths in 2017, which means we
were losing about three people a day. Preliminary death numbers
from 2018 are even higher that we are bending the rate sharply
downward. The largest driver of overdose deaths continue to be
fentanyl. In the St. Louis region, which accounts for 70
percent of overdose deaths in Missouri, about 90 percent of
those deaths involve fentanyl.
My main message today is that these services--the services
to prevent, treat, and maintain recovery from substance use
disorders help millions in Missouri and across the country. The
STR and SOR funds have literally transformed our system and
saved lives. For example, under the STR grant, Missouri
received $10 million for 2 years and under the SOR grant we
received $18 million for 2 years.
These grants, the largest investment in addiction treatment
that I have seen in my 35-year career, enabled us to develop
what we call the Medication First model of treatment for people
with opioid use disorder, which seeks to remove barriers to
evidence-based medical care being delivered in a prompt manner.
We are committed to leveraging and coordinating all dollars
and grants, both local, State and Federal to make sure all
money is spent as efficiently and effectively as possible on
prevention, treatment, and recovery efforts. To that end, my
agency directs a tremendous amount of energy to building
relationships and working collaboratively with partners and
stakeholders. We have worked with other State departments and
boards, professional organizations, associations, coalitions,
local governments, hospitals and healthcare systems, law
enforcement and the courts, and faith-based and social service
agencies. Specific partnerships are listed in my written
testimony.
Collectively, we focused our efforts in three areas: again,
prevention, treatment, and recovery. In terms of prevention, we
trained nearly 15,000 individuals in opioid overdose education
and the use of naloxone. We have distributed nearly 60,000
doses of naloxone and collected over 2,000 reports of lives
saved through these grants.
With regard to treatment, we have trained over 4,000
medical and behavioral health providers on best practices for
OUD treatment, reached over 2,000 overdose survivors in
emergency departments, and provided evidence-based medical
treatment to over 4,000 individuals under our new Medication
First treatment model.
Additionally, with STR and SOR funds we have seen
improvements in access to medications for OUD, faster access to
those medications, improved treatment retention at 1, 3 and 6
months and 26 percent lower average monthly cost of treatment.
With regard to recovery, we funded four recovery community
centers that have served over 14,000 people, provided secure
housing to over 700 people and trained 338 individuals to
become certified peer specialists.
So, here are my recommendations submitted with all due
respect to the committee and in light of the tremendous demands
on you. First, we are fighting an urgent and very steep uphill
battle here. As much as these generous grant dollars have
helped, we still have people who cannot get into lifesaving
treatment. We know this--We know this becomes a death sentence
for many and yet we still do not have enough resources to help
everyone who needs it, we need more.
Second, I recommend a transition from time--over time from
opioid specific resources to investing funds in the SAPT Block
Grant. This allows for flexibility in directing funds to a
range of alcohol or drug issues across the continuum.
Third, please ensure that Federal addiction initiatives
work through State substance use agencies like mine, for
reasons I mentioned earlier. To not do so threatens to fragment
systems, create inefficiencies, and open the door to
questionable practices.
Finally, I recommend that Congress maintain robust support
for the SAPT Block Grant, which is an effective and efficient
program supporting prevention, treatment, and recovery
services. In fiscal year 2018, the block grant provided
treatment services for 1.5 million Americans.
I want to thank you again for the opportunity to be here
and look forward to your questions.
[The statement follows:]
Prepared Statement of Mark Stringer
Chairman Blunt, Ranking Member Murray, and members of the
Subcommittee, my name is Mark Stringer, and I serve as Director of
Missouri's Department of Mental Health. I also serve as the Chair of
the Public Policy Committee of the National Association of State
Alcohol and Drug Abuse Directors (NASADAD). Thank you for the
opportunity to testify before the Subcommittee today to discuss actions
Missouri is taking to address the opioid crisis. In particular, thank
you for the opportunity to share with the Committee the importance of
the State Targeted Response to the Opioid Crisis Grants (STR) and the
State Opioid Response Grants (SOR)--grants managed by the Substance
Abuse and Mental Health Services Administration (SAMHSA) at the Federal
level and State alcohol and drug agencies at the State level.
critical role of the ssa
Critical Role of the Single State Agency (SSA) for Substance Use:
The State agency plays a critical role in overseeing and implementing
the publicly funded prevention, treatment, and recovery service system.
All State substance use agencies develop a comprehensive plan for
service delivery and capture data describing the services provided. It
is important that Federal grant opportunities be coordinated and
leveraged with the Federal block grants to assure effective and
efficient use of resources.
An important focus of State directors across the country is the
promotion of effective, high quality services. In Missouri, for
example, we use our contracts as a mechanism to promote the use of
evidence-based practices. In addition, we utilize onsite ``fidelity
reviews'' in order to assess the extent to which providers are
employing best practices in the right way. We also engage in on-site
certification surveys or recognize national accreditation to ensure
that providers are adhering to standards of care set by the Department
of Mental Health. These standards apply to a number of areas related to
service delivery, from staffing requirements (number of staff,
qualifications of staff, continuing education required, etc.) to
important rules governing the facilities within which services are
delivered.
State directors focus on another important task: collecting and
using data to improve service delivery. In Missouri, we obtain data in
a number of categories, including abstinence from the use of alcohol,
abstinence from the use of drugs, impact of services on housing, impact
of services on employment, connectedness to community, and others. The
Division tracks other measures such as the number of children returned
to their parents' custody and the number of individuals receiving
recovery services. A great deal of prevention data comes from the
Missouri Student Survey, which provides information at the county and
local levels, with a sample size of nearly 200,000 students.
State substance use agencies represent a key source of technical
assistance to the workforce in each State. In Missouri, we partner with
the University of Missouri St. Louis, Missouri Institute of Mental
Health (UMSL-MIMH) to run our statewide opioid grants, as well as a
number of other initiatives, including our Spring Institute that
provides training to thousands of staff and administrators in the
behavioral health field. We work with the State provider association to
plan, coordinate, and present trainings on evidence-based practices. My
staff at the department also regularly work directly with providers,
offering technical assistance and training in a variety of areas.
missouri crisis
Scope of the Substance Use Disorder Problem in Missouri: It is
worth stepping back for a moment to first examine the impact of all
substance use disorders in the State before focusing on the unique
issues related to prescription drug misuse and heroin. Overall, it is
estimated that 379,000 Missourians have a substance use disorder. Of
these, 17,000 are between the ages of 12 and 17 years old.
We know that approximately 8,600 parolees and 27,200 probationers
in the State need substance use disorder treatment (Missouri Department
of Corrections, 2017). Close to 28,400 Missouri veterans have a
substance use disorder (Missouri Department of Public Safety, 2017) and
8,300 pregnant women struggle with drug or alcohol use (Missouri
Department of Health and Senior Services, 2016).
In fiscal year 2018, about 47,820 Missourians received treatment
for substance use disorders through the publicly funded system. The
majority are individuals who lack resources to pay for treatment.
Nearly one-half (45 percent) are referred through the criminal justice
system. Alcohol is the most common substance problem presented at
treatment admission (31 percent) followed by methamphetamine (21
percent), marijuana (21 percent), heroin (15 percent), and other drugs
(12 percent). The State has been affected by methamphetamine use
predominantly in the rural areas and heroin use in Eastern Missouri,
including metropolitan St. Louis. Intravenous (IV) drug use is
problematic statewide due to methamphetamine and heroin use.
Prescription Drug Use, Heroin, and Illicit Fentanyl: More than
52,000 Missourians meet clinical criteria for opioid use disorder
(OUD). The epicenter of Missouri's overdose crisis spans the eastern
region, including both urban St. Louis City and County and rural
surrounding counties. The highest rates of overdose deaths in Missouri
are in urban, predominantly African- American communities that are
underserved and stricken by poverty.
Missouri had 951 opioid overdose deaths in 2017--meaning we are
losing nearly three people a day. And despite our tremendous efforts,
preliminary death numbers from 2018 are looking even higher. The
largest driver continues to be illicitly-made fentanyl, which has
infiltrated our heroin supply and effectively resulted in an acute
poisoning crisis, particularly in the eastern side of our State in and
around St. Louis. We are also starting to see fentanyl in the
methamphetamine supply. In the St. Louis region, which accounts for
about 70 percent of opioid overdose deaths in the State each year,
upwards of 90 percent of these deaths involve fentanyl.
Financial Burden: In 2018, analysis by the Missouri Hospital
Association found the economic burden of the opioid crisis was
approximately $12.6 billion each year. These costs are linked to
premature death, hospital and emergency room visits, lost productivity,
vehicle crashes, and more.
Benefits of Prevention, Treatment, and Recovery: A primary message
for this Committee is that services to prevent, treat, and maintain
recovery from substance use disorders help millions in Missouri and
across the country. These services literally save lives. We have made
dramatic improvements in prevention activities, treatment service
delivery, and recovery support services in the last 2 years, largely
because of the generous Federal funds we have received, combined with
the urgency we all feel to put an end to this overdose crisis. As I
will describe shortly, our evidence-based treatment efforts have shown
incredible growth and improvement, resulting in nothing less than a
system transformation in Missouri.
introduction to grant efforts
Missouri received two large grants from the Substance Abuse and
Mental Health Services Administration (SAMHSA) to address the opioid
crisis-- the State Targeted Response (STR) grant of $10 million for 2
years (fiscal year 2017-2018) and the State Opioid Response (SOR) grant
of over $18 million for 2 years (fiscal year 2018-2019). As a State
Department, we have become even more rigorous in our prioritization of
evidence based models of care for prevention, treatment, and recovery.
This includes our transformative approach to opioid use disorder
(OUD)--what we call the ``Medication First'' Model of treatment. The
key tenets of this model include:
--People with OUD receive pharmacotherapy as quickly as possible,
prior to lengthy assessments or treatment planning sessions;
--Maintenance pharmacotherapy is delivered without arbitrary tapering
or time limits;
--Individualized psychosocial services are offered but not required
as a condition of pharmacotherapy;
--Addiction medications are discontinued only if it is worsening the
patient's condition.
In addition to the STR and SOR grants, we have pursued and secured
multiple other grants to address the overdose crisis. We used a
Prescription Drug and Opiate Addiction (PDOA) grant to expand access to
medication assisted treatment (MAT) in our hardest hit areas and it
afforded us the opportunity to begin work on the Medication First
model. We also utilize the Prescription Drug/Opioid Overdose grant to
expand overdose education and naloxone to emergency responders and
social service agents out in the field. We are committed to leveraging
and coordinating all dollars and grants--local, State, and Federal--to
make sure all money is spent as efficiently and effectively as
possible.
Consistent with SAMHSA's target domains, the goals of the Missouri
Opioid STR/SOR project included:
--Increase student-focused opioid use and overdose prevention
initiatives and programs;
--Increase access to evidence-based MAT for uninsured and
underinsured individuals with OUD through provider training,
direct service delivery, healthcare integration, and improved
transitions of care;
--Increase the number of individuals with OUD who receive recovery
support services; and,
--Enhance sustainability through policy and practice changes as well
as demonstrated clinical and cost effectiveness of grant-
supported protocols.
For more information about our STR and SOR efforts, visit our
website: www.MissouriOpioidSTR.org.
stakeholders and collaborations
Planning and Coordination with Other State Agencies, Providers,
Stakeholders: In Missouri, we understand that substance use disorders
impact every aspect of our society. No one is immune from developing
this disease, and resources must be used wisely to impact this
community crisis. As a result, our agency directs a tremendous amount
of energy building relationships and working collaboratively with
stakeholders in order to ensure a coordinated, effective, and efficient
approach to addressing substance use disorders in general, and the
opioid epidemic in particular.
Specific Partnerships:
State Departments and Boards:
--Department of Health and Senior Services
--Department of Social Services
--Department of Corrections
--Departments of Natural Resources and Conservation
--Department of Public Safety
--Missouri Board of Pharmacy
Professional Organizations, Associations, and Coalitions:
--Missouri Coalition for Community Behavioral Healthcare
--Missouri Hospital Association
--Missouri Primary Care Association
--Missouri Pharmacy Association
--Missouri Association of Osteopathic Physicians and Surgeons
--The St. Louis Regional Health Commission
--Missouri Coalition of Recovery Support Providers
Local Governments:
--Dozens of city and county health departments
--Sheriffs' departments
--City and county courts, treatment courts, and jails
Hospitals, Healthcare Systems, Provider Networks:
--Cox, Mercy, Barnes Jewish, SSM Hospital systems
--federally Qualified Health Centers (FQHCs)
--Community Mental Health Centers
--Certified Community Behavioral Health Clinics
--Rural Health Clinics
Faith-based and Social Service Institutions and Agencies:
--Multiple churches, places of worship
--Homeless shelters
--Domestic violence shelters
--Transitional living facilities
--Food pantries
Domains of Collaboration:
Prevention Collaborations:
--Partners in Prevention is Missouri's higher education substance use
consortium dedicated to creating healthy and safe college
campuses. The coalition is comprised of 21 public and private
college and university campuses across the State. Campus
judicial officials, law enforcement, and campus prevention
professionals are encouraged to take part in both their local
coalition efforts and the statewide Partners in Prevention
coalition.
--National Council on Alcoholism and Drug Abuse (local prevention
organization)
--Community Partnership of the Ozarks (local prevention organization)
--Boys and Girls Clubs of America (10 clubhouses statewide)
Treatment Collaborations:
--Close partnership with the Missouri Coalition for Community
Behavioral Healthcare
--Missouri Primary Care Association and FQHCs
--Missouri Hospital Association and hospital/healthcare networks
Law Enforcement and Corrections Collaborations:
--Teams have provided training and naloxone to over 50 police
departments and 38 of 44 State park rangers
--Partnered with city and county jails and drug treatment courts
--Partnered with State and Federal probation and parole divisions for
overdose training and education on evidence-based treatment and
recovery practices
Recovery-focused Collaborations:
--Partnered with the Missouri Coalition of Recovery Support Providers
and recovery housing providers throughout the State to
establish and improve accreditation processes for recovery
housing entities
--Collaborated with community recovery leaders to activate four
Recovery Community Centers in high-need areas of the State
--Partnered with the Missouri Credentialing Board to launch a
comprehensive Certified Peer Specialist training program to
grow our peer workforce
Universities and Academic Collaborations:
--Partner with the University of Missouri St. Louis Missouri
Institute of Mental Health to help administer, implement, and
evaluate STR and SOR
--Work with the University of Missouri--Columbia's Missouri
Telehealth Network to launch two opioid-focused ECHO programs
(Pain Management and Opioid Use Disorder Treatment)
--Contract with Washington University in St. Louis to enhance and
disseminate a mobile app for pregnant and postpartum women with
OUD
--Contract with faculty from the St. Louis College of Pharmacy and
Southern Illinois University of Edwardsville to lead pharmacy-
based naloxone and treatment training and education
--Partner with faculty from the University of Central Missouri to
develop, run, and evaluate a family support network through a
Recovery Community program
missouri outcomes of federal opioid funding
We are extremely grateful for the resources that Congress has
provided States, as well as all the time and energy placed on loosening
the grip this crisis has on our whole Nation.
We have spent these dollars on what we believe must be prioritized
in this current public health emergency: increasing access to life-
saving services, including naloxone for overdose reversal and
maintenance medical treatment for opioid use disorder. Our efforts
focus on three broader, sequential goals: survival, stabilization, and
thriving. This broadly represents our efforts in three areas:
prevention, treatment, and recovery.
prevention (survival)
Survival Snapshot: Our focus has been on preventing the development
and consequences of addiction by training youth to avoid drug misuse,
training providers how best to treat chronic pain, and saturating high-
risk communities with naloxone, the opioid overdose antidote.
--Trained over 10,000 youth how to avoid prescription drug misuse
--Trained nearly 450 predominantly rural medical providers how to
manage chronic pain safely and effectively
--Trained nearly 15,000 individuals in opioid overdose education and
the use of Narcan/naloxone.
--Distributed nearly 60,000 doses of naloxone
--Collected 2,230 reports of lives saved through the Overdose Field
Report system we created with these grants.
Addressing Overdose: Through the STR/SOR and PDO grant projects
combined, 14,340 individuals have been trained in overdose education
and naloxone distribution, 17,827 boxes of naloxone have been
distributed, and OUD treatment has been initiated for 4,072
individuals.
Through STR/SOR, OEND trainings have been provided to 6,155
individuals including criminal justice staff and justice-involved
persons, pharmacy management and frontline technicians, recovery
housing providers, and recovery support group members. Eight thousand
seven hundred nineteen (2-dose) naloxone kits have been distributed
through STR (in addition to 3,100 intra- muscular naloxone provided by
Direct Relief, a humanitarian aid organization that provides free
naloxone to non-profit entities.) Through MO-HOPE, OEND trainings have
been provided to 8,185 individuals including emergency responders,
treatment and medical providers and other social service agency staff.
Seven thousand six hundred thirty three (2-dose) naloxone kits have
been distributed (in addition to 3,499 intra-muscular naloxone provided
by Direct Relief.) Community Pharmacy Naloxone Expansion: Over 1,169
pharmacists and pharmacy students across the State have participated in
an overdose and naloxone information training. Criminal Justice
Overdose Prevention Program--Mo' Heroes: 1,314 individuals, both staff
and criminal- justice involved individuals, have received OEND
training.
Notably, prior to the start of these grants, MO was well above the
national average for rate of increase in opioid overdose deaths (35
percent increase in MO vs. a 28 percent increase nationally); after, we
were well below the average rate of increase (5 percent increase in MO
vs. a 16 percent increase nationally) See below figure:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Addressing Opiate Prescribing: The Missouri Telehealth Network
(MTN) conducts numerous Extension for Community Healthcare Outcomes
(ECHO) projects. For STR/SOR, MTN created an ECHO on Chronic Pain
Management for primary care providers. The ECHO team has conducted 33
sessions, reaching 136 unique providers. The most recent session took
place on December 20, 2018, with seven more sessions planned over the
rest of the grant year.
Preventing Use/Misuse: Though the focus of our spending has been on
helping those already in the throes of addiction and at greatest risk
of death, we have also dedicated robust efforts towards prevention
initiatives. We've provided school-based training and education about
prescription drug misuse to over 11,000 students, and have partnered
with the Boys and Girls Clubs of America to implement novel prevention
programs in their clubhouses so we can reach youth who are likely at
highest risk of developing addiction later in life.
treatment (stabilization)
Stabilization Snapshot: Our focus has been on improving access to
medical treatment for OUD by providing rigorous multidisciplinary
training and consultation, connecting overdose survivors to community
treatment, and delivering effective, evidence-based treatment services
to thousands of Missourians struggling with opioid addiction.
--Trained over 4,000 medical and behavioral healthcare providers on
best practices for OUD treatment.
--Reached over 2,000 overdose survivors in emergency departments to
connect them with treatment and other services.
--Provided evidence-based medical treatment to over 4,000 individuals
under our new Medication First treatment model.
The following improvements have been realized when comparing
treatment prior to STR and SOR grants: (1) better access to medications
for OUD, (2) faster access to those medications, (3) improved treatment
retention at 1, 3, and 6 months, and (4) 26 percent lower average
monthly cost of treatment.
Sustainable Treatment
Intervention Post-Overdose: Through Opioid STR/SOR funding,
Missouri has expanded the Engaging Patients in Care Coordination
(EPICC) project and was able to secure State funding to replicate the
model statewide. Patients routinely present to emergency departments
seeking help with opioid withdrawal and--all too often--needing
emergency resuscitation for opioid overdose. Emergency Department (ED)
physicians are uniquely positioned to change the life trajectory of
patients who present due to opioid overdose and can serve as a link for
at-risk patients into treatment and recovery support services.
Utilizing evidenced-based, FDA-approved medicines (e.g. buprenorphine)
in the ED improve patient engagement and connection to opioid use
disorder treatment services, and ultimately reduce patient mortality.
The EPICC project expedites access to MAT and improves the coordination
of care between emergency departments and community-based settings.
Recovery coaches meet patients post-overdose in the emergency
department and connect patients to SUD treatment agencies. This peer
outreach has been provided to more than 2,200 individuals since May
2017.
Medical Treatment Providers: A key concern when utilizing time-
limited grant dollars is sustainability of efforts. Missouri realized
that trainings in key areas represented core sustainability in use of
naloxone (identified above) addiction medications. Unfortunately,
access to evidence-based addiction medications is limited by a lack of
knowledge by medical professionals and exacerbated by the need for
prescribers to obtain a DEA waiver in order to offer the gold standard
of care in the initial treatment of OUD: buprenorphine. Prescribing and
managing this medication requires eight hours of training for
physicians and 24 hours of training for mid-level practitioners
(advance practice nurses and physician assistants). Missouri worked
hard to outreach to prescribers already working in behavioral health,
but also primary care providers working in federally Qualified Health
Centers and emergency department physicians. We have also provided
technical assistance directly to FQHCs to promote the treatment of OUD
within the primary care health system. Under these grants, Missouri has
thus far secured waiver training for nearly 150 professionals and most
of them have successfully obtained the waiver needed to prescribe
buprenorphine products.
We have also recognized the need for ongoing training and clinical
support for prescribers, so an ECHO specific to the management of OUD
was developed by the Missouri Telehealth Network (MTN). The MTN has
also launched a Project ECHO on OUD Treatment. The OUD ECHO team has
conducted 22 sessions, reaching over 179 unique providers. The second
round of OUD ECHO is set to begin in April.
Medical Treatment Model: Maintenance pharmacotherapy with
buprenorphine or methadone can reduce fatal opioid overdose rates by
50-70 percent, reduce illicit drug use, and increase treatment
retention. However, in traditional treatment programs for addiction,
the vast majority of patients are offered no ongoing medical treatment.
Those who do receive medical care often face intensive psychosocial
service requirements that make treatment both burdensome and costly.
Though we wholeheartedly believe all clients should be offered a full
menu of psychosocial support services such as counseling, family
therapy, job training, case management, and more, we also believe
medication should not be withheld as a condition of mandatory
participation in these services. In Missouri we set forth with renewed
focus to promote individualized psychosocial treatment rather than
arbitrary requirements, ensuring each client gets exactly what he or
she needs--nothing more, nothing less.
Through STR, we finalized and disseminated a treatment model we
refer to as ``Medication First.'' The name and principles of Medication
First are borrowed from the Housing First approach to homelessness. The
National Alliance to End Homelessness explains: ``Housing First is a
homeless assistance approach that prioritizes providing people
experiencing homelessness with permanent housing as quickly as
possible--and then providing voluntary supportive services as needed.''
This approach prioritizes client choice in both housing selection and
service participation. Our Medication First model similarly prioritizes
rapid and sustained access to a lifesaving resource--medication for
opioid use disorder--as a central tenet of treatment.
The Medication First (or low-barrier maintenance pharmacotherapy)
approach to the treatment of Opioid Use Disorders (OUD) is based on a
broad scientific consensus that the epidemic of fatal accidental
poisoning (overdose) is one of the most urgent public health crises in
our time. Increasing access to buprenorphine and methadone maintenance
is the most effective way to reverse the overdose death rate. Increased
treatment access will best be achieved by integrating buprenorphine
induction, stabilization, maintenance, and referral throughout
specialty addiction programs, as well as primary care clinics and other
medical settings throughout the mainstream healthcare system.
Supporting System Change: Understanding how to successfully and
efficiently manage a clinic that offers addiction medications, as well
as how to provide psychosocial services that complement the use of
these medications, also requires training. Changing practices and
attitudes were essential to adopting evidence-based treatment that
lasts longer than the life of the Federal funding.
--Training and Consultation to Address Provider-Level Knowledge and
Attitudinal Barriers: To address gaps in knowledge about MAT
and reduce attitudinal barriers to MAT, we developed a
multimodal, multidisciplinary training curriculum called Opioid
Crisis Management Training (OCMT) in collaboration with
consulting physicians, nurses, counselors, social workers, and
people who use drugs and/or are in recovery. The training
curriculum includes a content lecture on the role of brain
chemistry in opioid addiction, the science of MAT, the role of
the counselor in treating OUD, a panel of individuals sharing
how MAT has helped them achieve recovery, and profession-
specific breakout sessions to promote dialogue and problem-
solving about MedFirst implementation. Preliminary evaluation
shows OCMTs improve knowledge and attitudes surrounding MAT and
serve as an opportunity to connect with providers and encourage
utilization of our ongoing training and consultation services.
--Steps to Address Agency-Level Barriers: To support MedFirst
implementation, we assessed program readiness through
environmental scans and site visits; held bi-monthly, statewide
open ``Office Hours'' calls to discuss administrative and
clinical questions; and provided data-driven, program-specific
``Treatment Barometers'' comparing data from Pre-STR and STR
timeframes. Many State-contracted treatment agencies are in
rural areas where transportation and access to waivered
prescribers are limited. Thus, to increase access to care and
reduce frequency of canceled or ``no-show'' appointments, STR
funds were used to purchase telemedicine equipment and
reimburse agencies for client transportation. Additionally,
cross-agency collaboration was facilitated to increase
prescriber capacity.
--Process, Policy, and Procedural Changes to Address Structural and
Systemic Barriers: We anticipated several structural and
systemic barriers to implementing MedFirst. These included:
--State billing requirements and intake procedures;
--buprenorphine prior authorizations and step-down dosing
requirements in our Medicaid program;
--over-utilization of group services, non-medical detoxification,
and residential services;
--high administrative burden coupled with low reimbursement rates
for medical services; and
--a dearth of buprenorphine waivered providers in our State.
To address (1) we altered State billing requirements to allow 30
days for completion of STR client assessments, facilitating faster
client access to medical providers. Regarding (2) through collaboration
with the Missouri Medicaid program, prior authorizations for initial
buprenorphine prescriptions were removed, as were requirements for step
down dosing and tapering plans. (Though uninsured individuals were the
target of STR treatment funds, we also worked simultaneously to remove
barriers in the Medicaid system.) Over utilization of group services,
non-medical detoxification, and residential services (3) was addressed
by removing these from the STR services menu and only allowing for
their reimbursement through existing agency allocations. To begin to
remedy (4), we increased the provider administrative payments on
medical services from 7 percent to 15 percent for the STR program.
Last, STR leaders addressed Missouri's lack of buprenorphine
prescribers (5) by offering State-sponsored DATA 2000 trainings and a
reimbursement to medical providers who obtained their waiver.
These system-level changes, coupled with the provider- and agency-
focused efforts, aimed to incentivize best practice and remove as many
obstacles to MedFirst implementation as possible.
Our early findings are very promising. As stated above, through STR
and SOR, we have treated over 4,200 people with OUD and found they are
more likely to: obtain medical treatment; be connected to that medical
treatment faster; be retained in treatment at 1, 3, and 6 months; and
have lower average monthly costs of treatment than prior to the STR and
SOR grants.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
recovery (thriving)
Thriving Snapshot: Our focus has been on building fulfillment and
meaning in peoples' lives while they seek or complete formal treatment
programs. We have accomplished this through the establishment of
Recovery Community Centers in high-need areas, providing safe recovery
housing to individuals in need, and building the workforce of peer
specialists.
--Funded four Recovery Community Centers that have served over 14,000
people to help them find jobs, housing, and community
connections.
--Provided secure housing to over 700 people who were engaged in
treatment but didn't have anywhere safe to live while they did
so.
--Trained 338 individuals to become Certified Peer Specialists so
they can join the workforce and give back by sharing their
lived experience with people who can benefit from what they've
been through.
Recovery Community Centers: With support from STR/SOR, Recovery
Community Centers (RCCs) have been an integral part of Missouri's work
on the opioid epidemic. RCCs are independent, non-profit organizations
that help individuals recovering from substance use disorders. They
help build recovery capital by providing advocacy training, recovery
information, mutual-help or peer-support groups, social activities, and
other community-based services. In 2018, Missouri RCCs served over
14,000 people. About 58 percent of those people were individuals with
an Opioid Use Disorder (OUD).
Our RCCs were open over 9,000 hours, offered 3,569 activities, and
distributed over 3,000 Narcan kits. RCCs completed outreach to 3,296
people with OUD. The RCCs served over 8,000 total individuals with OUD
in 2018.
Safe and Sober Housing: Through STR/SOR, and the Missouri Coalition
of Recovery Support Providers (MCRSP), Missouri has built a network of
National Alliance for Recovery Residences (NARR) accredited and
medication-friendly recovery housing entities for individuals enrolled
in STR/SOR treatment programs. To date, more than 52 houses have been
approved to receive STR/SOR funds. Over 700 individuals have received
more than 15,000 bed nights to support individuals with OUD as they
receive Medication First treatment through STR/SOR contracted treatment
site.
recommendations for federal action
First, I want to applaud a strong SAMHSA under the leadership of
Dr. Elinore McCance-Katz. She and her management team have worked hard
to ensure that these vital grant funds are distributed quickly and
implemented effectively.
In this report, I have outlined what Missouri has been able to
accomplish in the areas of prevention, treatment, and recovery specific
to opioid use disorders. While we've done so much with the Federal
opioid dollars, we need to think about a bigger, longer-term investment
in these efforts to make a significant impact and make death rates go
down.
We are fighting an urgent and very steep uphill battle here--as
much as these generous grant dollars have helped, we still have people
who cannot get into lifesaving treatment or find affordable recovery
housing in our State. We know this becomes a death sentence for many,
but we still don't have enough resources to help everyone who needs it.
Broader SUD Focus: Again, while we appreciate the opioid specific
resources, we would recommend a transition over time from opioid
specific resources to investing funds in the SAPT Block Grant. This
allows for flexibility in directing funds to a range of alcohol or drug
issues across the continuum--prevention, treatment, and recovery. This
approach would benefit all States and territories. An important feature
of the SAPT Block Grant is flexibility. Specifically, the program is
designed to allow States to target resources according to regional and
local circumstances instead of predetermined Federal mandates. This is
particularly important given the diversity of each State's population,
geography, trends in terms of drugs of use/misuse, and financing
structure. We know that alcohol use disorders kill as many, or more,
individuals per year--but does so more insidiously. We also know that
some States or regions are impacted more by methamphetamine, which also
causes devastation in families and communities.
Ensure Federal Addiction Initiatives Work through State Substance
Use Agencies: State substance use agencies work with stakeholders to
craft and implement a statewide, coordinated system of care for
substance use disorder treatment, prevention, and recovery. In so
doing, State agencies employ a number of tools to ensure public dollars
are dedicated to effective programming. These tools include performance
and outcome data reporting and management, contract monitoring,
corrective action planning, onsite reviews, training, and technical
assistance. States also redirect, redistribute, or eliminate support
for programs that are not achieving results. In addition, State
substance use agencies work to ensure that services are of the highest
quality through State or nationally established standards of care.
Federal policies that promote working through the State substance use
agency ensure that initiatives are coordinated, accountable, effective,
and efficient.
Maintain a strong commitment to the Substance Abuse Prevention and
Treatment (SAPT) Block Grant without ever losing focus on prevention
services: We recommend that Congress maintain robust support for the
SAPT Block Grant, an effective and efficient program supporting
prevention, treatment, and recovery services. In fiscal year 2018, the
SAPT Block Grant provided treatment services for 1.5 million Americans.
During the same year, of patients discharged from treatment, 76 percent
were abstinent from alcohol and approximately 60 percent were abstinent
from illicit drugs.
By statute, States must dedicate at least 20 percent of SAPT Block
Grant funding for primary substance use prevention services. This
prevention set-aside is by far the largest source of funding for each
State agency's prevention budget, representing on average 70 percent of
the primary prevention funding that States, U.S. territories, and the
District of Columbia coordinate. In 35 States, the prevention set aside
represents 50 to 100 percent of the substance use agency's budget.
We appreciate the difficult decisions Congress must face given the
current fiscal climate. We believe it is equally important to note that
trends in Federal appropriations for the SAPT Block Grant have led to a
gradual but marked erosion in the program's reach.
Senator Blunt. Thank you, Director Stringer.
Dr. Cropsey.
STATEMENT OF DR. KAREN CROPSEY, PSY.D., CONATSER TURNER
ENDOWED PROFESSOR OF PSYCHIATRY, UNIVERSITY
OF ALABAMA AT BIRMINGHAM, BIRMINGHAM, AL
Dr. Cropsey. Thank you Chairman Blunt, Ranking Member
Murray, and members of the committee for the opportunity to
come before you today to talk about the devastating opioid
epidemic.
I am a clinical psychologist and professor in the
Department of Psychiatry at the University of Alabama at
Birmingham. I am both a clinician and researcher focused on
addiction treatment. During my 20-year career conducting NIH
funded research, I have completed several trials of
buprenorphine treatment. I have also directed a trial training
the public to recognize and treat opioid overdose using
naloxone.
More recently I led a group of about 60 physicians,
researchers, policymakers, and business partners to develop a
comprehensive response to the opioid epidemic in our State that
could serve as a model across the Nation as part of an internal
grand challenge grant competition.
Overdose deaths, in conjunction with suicide, are
responsible for a decline in life expectancy in the United
States over the past 3 years. This pattern has not been seen
since 1915 and differs from other developed countries where
life expectancy continues to increase. And deaths from opioids
are only predicted to rise in the next few years particularly
with the continued influx of illicit fentanyl and fentanyl-
derived drugs mixed into deadly cocktails with other pain
medications and heroin.
Alabama has the dubious distinction as the State with the
most opioid prescriptions written per capita in the Nation. In
2017 there were 107 prescriptions written for every 100
residents. This problem is particularly severe in some rural
areas of the State. In addition to high rates of opioid
prescriptions, we have the second highest rates of
benzodiazepine prescriptions in the Nation. These two
medications when taken together are particularly deadly.
Today, I would like to talk to you about three areas of
intervention and additional research that may impact these
numbers, both in Alabama and the United states.
Number one, expanded access to quality addiction treatment
is needed. Alabama, like much of the country, has a provider
shortage. There are not enough providers who have completed the
prerequisites required by law to prescribe buprenorphine, one
of the medications used to treat opioid addiction. The
regulations surrounding buprenorphine prescribing are a barrier
to treatment. Also, the medications available to treat opioid
use disorder are expensive and often unaffordable for uninsured
patients.
In addition to decreases in the cost of current
medications, the development of novel medications to treat
opioid use disorder and other addictions is critical. We also
need research that focuses on evaluating treatment outcomes for
inpatient and outpatient substance abuse treatment programs.
Finally, patients with addiction are complicated and often
have other psychiatric conditions, such as--have other
psychiatric conditions, chronic pain, and other health
conditions that have gone untreated. Increasing parity for--in
reimbursement for providers who treat these complicated
patients is imperative for expanding the workforce.
Number two, reduce deaths associated with opioid use
disorder we must target infectious diseases that result from
injection drug use. In addition to injection drug use putting a
person at heightened risk for overdose, sharing needles and
injection equipment puts these people at risk for infectious
diseases such as HIV, hepatitis C, and bacterial infections,
such as infections of the heart, bone, skin, and soft tissue.
Across the United States, hospitals have experienced a
surge in admissions related to these bacterial infections.
These hospitalizations are expensive. Treating one case of
endocarditis, which is infection of the heart valves, cost over
$50,000. Total hospital costs associated with just this one
infection has increased 18-fold from 2010 to 2015.
Attention needs to be given to the development of limited
harm reduction programs to stem the threat of infectious
diseases. In addition, research should be expanded to evaluate
the efficacy of these types of programs.
Number three, we must focus on healthy alternatives to
opioids for chronic pain management. There is not a single
study that shows any clear benefit of long-term opioid use for
chronic pain over other nonpharmacological treatments or non-
opioid programs or non-opioid treatments. We need to employ
non-opioid techniques for chronic pain that have been proven to
be efficacious and that do not have serious consequences
associated with their use. These treatments include cognitive
behavioral therapy, meditation, physical therapy and yoga, and
exercise. However, in order to utilize these non-opioid
treatments, insurance companies need to be willing to pay for
these services, and our workforce needs to be developed and
trained to meet the demand.
In summary, we can improve the health of patients with
opioid use disorder by increasing access to treatment through
reimbursement parity; reducing buprenorphine regulations;
reducing costs of medications; and increasing research dollars
for behavioral and novel medication development and outcomes
research.
Two: Reducing life-threatening complications and injection
through harm reduction strategies and evaluating these
strategies through research.
Three: Developing effective opioid-free treatments for
pain.
Thank you for the opportunity to speak with you today on
this critical issue.
[The statement follows:]
Prepared Statement of Dr. Karen Cropsey, Psy.D.
Thank you Chairman Blunt, Ranking Member Murray and members of the
committee for the opportunity to come before you today to talk about
the devastating opioid epidemic. I am a Clinical Psychologist and
Professor in the Department of Psychiatry at the University of Alabama
at Birmingham. I am both a clinician and researcher focused on
addiction treatment. I provide direct care for patients with addiction,
many of whom have psychiatric problems such as depression,
posttraumatic stress disorder, and anxiety disorders. During my 20 year
career conducting NIH-funded research, I have studied addiction,
including opioid use disorders, particularly among disadvantaged
populations such as individuals in the criminal justice system and
persons living with HIV/AIDS. I have conducted several trials of
buprenorphine treatment. I have also conducted a trial training the
public to recognize and treat opioid overdose using naloxone. More
recently, I led a group of about 60 physicians, researchers, policy
makers, and business partners to develop a comprehensive response to
the opioid epidemic in our State that could serve as a model across the
Nation as part of an internal University of Alabama at Birmingham Grand
Challenge grant competition.
As you all know, opioid overdose is now the number one cause of
accidental death in the United States, killing approximately 72,000
Americans each year. That's more than car accidents, gun violence or
HIV/AIDS, even at the height of the epidemic. Overdose deaths, in
conjunction with suicide, are responsible for a decline in life
expectancy in the United States over the past 3 years. This pattern has
not been seen since 1915 and differs from other developed countries
where life expectancy continues to increase. And deaths from opioids
are only predicted to rise in the next few years, particularly with the
continued influx of illicit fentanyl and fentanyl-derived drugs mixed
into deadly cocktails with other pain medications and heroin.
Alabama has the dubious distinction as the State with the most
opioid prescriptions written per capita in the Nation; in 2017, there
were 107 prescriptions written for every 100 residents. This problem is
particularly severe in some rural areas of the State. For example,
Walker County, AL which is a primarily rural county located next to
Birmingham, has one of the highest prescribing rates in the country,
with 216 prescriptions for every 100 residents. The CDC recently
identified Walker County as #37 out of 220 counties at highest risk of
an HIV and/or hepatitis C outbreak due to the scope of the opioid
epidemic in that region. In addition to high rates of opioid
prescriptions, we have the second highest rate of benzodiazepine
prescriptions in the Nation; these two medications, when taken
together, are particularly deadly.
Today, I would like to talk about three areas for intervention and
additional research that may impact these numbers both in
Alabama and the U.S.
Number one: expanded access to quality addiction treatment is
needed. Alabama is 48th in the Nation in wealth, with over 19 percent
of our citizens living in poverty. Gaps in healthcare access across the
State have left many of our most vulnerable citizens without access to
healthcare. Alabama, like much of the country, has a provider shortage.
There are not enough providers who have completed the prerequisites
required by law to prescribe buprenorphine, one of the medications used
to treat opioid addiction.
The regulations surrounding buprenorphine prescribing are a barrier
to treatment. Providers need to attend a full day of training or online
course to learn to prescribe buprenorphine, a safer medication to use
than opioid pain medications. Such specific training is not required
for providers to prescribe these other medications, such as fentanyl or
oxycodone.
In addition, patients with addiction are complicated and often have
other psychiatric conditions such as depression, posttraumatic stress
disorder, or other psychiatric illnesses. They often have chronic pain
and other health conditions that have gone untreated. Increasing parity
in reimbursement to providers who treat these complicated patients is
imperative for expanding the workforce.
Thus, one recommendation is to increase reimbursement parity for
providers treating addiction. In addition, reducing the
regulations for prescribing buprenorphine is one way to expand
access to treatment.
Also, the medications available to treat opioid use disorder are
expensive and often unaffordable for uninsured patients. For example,
injectable, long-acting naltrexone, the life- saving anti-opioid drug,
is about $1,300 per month. Buprenorphine is several hundred dollars per
month.
Reducing the costs of these prescription medications would further
expand access and save lives.
At UAB, some of our patients are not interested in treatment with
medication-assisted therapy for opioid use disorder, even if they are
able to access it. This is likely due to stigma of taking a medication
or not wanting to take a medication to treat addiction. Finding
effective and patient- acceptable forms of treatment is important.
While we know that cognitive-behavioral treatments are effective for
addiction, ensuring that patients can access these evidenced-based
treatments is another gap in care. Further, other psychosocial
interventions, including peer-support programs such as 12-step, have
not been rigorously evaluated and a better understanding of these
treatments is needed. Most treatment programs do not provide their
success rates, which makes it difficult for consumers, policy makers
and others to know if what these programs are doing is effective or to
compare across different programs. Research that focuses on treatment
outcomes for inpatient and outpatient substance abuse treatment
programs could provide this important information. Finally, development
of novel medications to treat opioid use disorder and other addictions
is critical. While deaths due to opioids have been devastating, we are
also seeing a rise and transition to methamphetamine and other
stimulant use and we currently have no FDA-approved medications to
treat stimulant use disorders.
Thus, increased research dollars are needed to expand pharmacotherapy
treatment options as well as provide access to effective
behavioral treatments for addiction.
Number two: to reduce deaths associated with opioid use disorders,
we must target infectious diseases that result from injection drug use.
In addition to injection drug use putting a person at heightened risk
for overdose, sharing needles and injection equipment puts these people
at risk for infectious diseases such as HIV, hepatitis C, and bacterial
infections, such as infections of the heart, bone, skin and soft
tissues. Across the United States, hospitals have experienced a surge
in admissions related to these bacterial infections. These
hospitalizations are expensive. Treating one case of endocarditis
(infection of the heart valves) costs over $50,000. Total hospital
costs associated with just this one infection has increased 18-fold
from 2010 to 2015. Attention needs to be given to the development of
limited, harm reduction programs to stem the threat of infectious
diseases. In addition, research should be expanded to evaluate the
efficacy of these types of programs.
Number three: We must focus on developing alternatives to opioids
for chronic pain management. There is not a SINGLE STUDY that shows any
clear benefit of long-term opioid use for chronic pain over other non-
pharmacological treatments or non-opioid treatments. Not one. We need
to employ non-opioid techniques for chronic pain that have been proven
to be efficacious and that do not have the serious consequences
associated with their use. These treatments include cognitive
behavioral therapy, meditation, yoga, physical therapy, and exercise.
Diet and nutrition can also be important for reducing pain. However, in
order to utilize these non-opioid treatments, insurance companies need
to be willing to pay for these services and our workforce needs to be
developed and trained to be able to meet the demand.
If we live long enough, each of us will experience pain that lasts
longer than we would like. Having strategies to manage this
pain is important.
In summary, we can improve the health of patients with opioid use
disorder by
--Increasing access to treatment through reimbursement parity,
reducing regulations, reducing costs of medications, and
increasing research dollars for behavioral and novel medication
development.
--Reducing life threatening complications of injection through harm
reduction strategies and evaluation of these strategies through
research.
--Developing effective opioid-free treatments of pain.
Thank you for the opportunity to speak with you today on this
critical issue.
Senator Blunt. Thank you Dr. Cropsey.
Director Tanzman.
STATEMENT OF BETH TANZMAN, EXECUTIVE DIRECTOR, VERMONT
BLUEPRINT FOR HEALTH, DEPARTMENT OF VERMONT
HEALTH ACCESS, WATERBURY, VT
Ms. Tanzman. Chairman Blunt, Ranking Member Murray, and
Senator Leahy and staff, thank you for the opportunity to
outline what we are learning in Vermont about addressing the
opioid epidemic. We are here before you because Vermont has
successfully scaled treatment availability for opioid use
disorder statewide. Through our Hub-and-Spoke program we are
currently treating over 8,000 Vermonters--that is 1.6 percent
of our adult population. We treat a higher percentage of people
of opioid use disorder than any other State in the Nation and
we have no waiting list for treatment.
We provide medication-assisted treatment in primary care
offices called spokes, and in specialty addictions treatment
programs called hubs. Through a health home Medicaid plan, we
built a programmatic framework that links primary care spokes
and addictions treatment programs hubs together. Patients can
move between hubs and spokes based on their needs, and clinical
expertise is shared across the primary care and substance abuse
treatment systems.
There are strong signals that the Hub-and-Spoke program is
facilitating positive outcomes. Vermont has the lowest opioid
overdose death rate in New England. Vermonters receiving
medication-assisted treatment have lower rates of
incarcerations, hospitalizations, and emergency department use
than do Vermonters with opioid use disorder who receive
substance abuse care, as usual.
Our system of deploying teams of nurses and counselors to
primary care spokes, two FTE for every 100 Medicaid members,
combined with strong backup from hub programs, has dramatically
increased the number of primary care providers willing to offer
medication-assisted treatment in Vermont.
What we are learning may be helpful to others and a few
conclusions stand out. First: medication-assisted treatment,
the combination of medications and counseling, is the most
effective treatment for opioid use disorder and as such, it
should be consistently available as the standard of care for
this condition. Insurance should pay for medication-assisted
treatment. In Vermont, we developed a Medicaid Health Home
State Plan Amendment under the authority of section 2703 of the
Affordable Care Act to create the Hub-and-Spoke program.
There are other approaches using Medicaid that States can
employ, including 1115.B, Substance Use Waivers; State plan
amendments, including medication-assisted treatment and managed
care organization contracts; and simply increasing
reimbursement rates for targeted services.
Commercial payers should also participate. In Vermont, our
two major commercial plans are piloting payments for hub-and-
spoke services. The healthcare system, most especially primary
care, has a key role in treating opioid addiction. The
addictions treatment system cannot do this alone, there is just
simply not enough treatment capacity to meet the demand brought
on by this epidemic. The participation of primary care can
affect greater integration of care, especially by coordinating
pharmacological treatments with counseling, rehabilitation and
recovery supports.
The barriers to primary care participation in medication-
assisted treatment, not enough provider time, patient
complexity, difficulty integrating counseling supports can be
addressed by adding nursing and counseling services to primary
care prescribing teams, as we have done in Vermont.
Treatment is only one element of a comprehensive response
to this epidemic. Other elements include prevention, reducing
people's exposure to opioids in the first place, harm
reduction, such as a wide availability of the overdose reversal
medication Narcan, and recovery supports, including vocational
services to help people in recovery participate fully in our
communities.
Finally, leadership focus matters. I have had the honor of
serving under two consecutive governors, Democratic and
Republican, who have both provided leadership and resources to
address this epidemic in Vermont.
In closing, we have made much progress, much with the
support of our Federal partners, and yet while in Vermont we
have some of the best access to treatment in the Nation, we
have not solved this problem. Every week, two Vermonters die
from a drug overdose and tragically we are also experiencing
high numbers of children under the age of five who come into
State custody due to this crisis.
We must learn how to do better by our communities and
families.
Thank you.
[The statement follows:]
Prepared Statement of Beth Tanzman, MSW
Chairman Blunt, Ranking Member Murray, and Senator Leahy and staff
thank-you for the opportunity to outline what we are learning in
Vermont about addressing the opioid epidemic.
Vermont is here before you because we have successfully scaled
treatment availability for Opioid Use Disorder state- wide. Through our
Hub and Spoke program we are currently treating over 8,000 Vermonters
(1.6 percent of the adult population) with Medication Assisted
Treatment (MAT). Vermont treats a higher percentage of people with
Opioid Use Disorder than any other state in the nation.
We provide Medication Assisted Treatment in primary care offices
(Spokes) and in specialty addictions treatment programs (Hubs). Through
a Health Home Medicaid plan we've built a programmatic framework that
links primary care (Spokes) and addictions treatment programs (Hubs).
Patients can move between Hubs and Spokes based on their needs.
Clinical expertise is shared across primary care and substance abuse
treatment providers.
There are strong signals that the Hub and Spoke program is
facilitating positive outcomes. Vermont has the lowest opioid over dose
death rate in New England. Vermonters receiving Medication Assisted
Treatment have lower rates of: incarceration, hospitalizations, and
emergency department use than do Vermonters with Opioid Use Disorder
who receive care as usual. Our system of deploying teams of nurses and
counselors to primary care Spokes--2 FTE for every 100 Medicaid
Members--combined with a strong back-up from Hub programs has
dramatically increased the number of primary care providers offering
Medication Assisted Treatment in Vermont.
What we're learning may be helpful to others and a few conclusions
stand out.
Medication Assisted Treatment, the combination of medications and
counseling, is the most effective treatment for opioid use disorder and
as such, it should be consistently available as the standard of care
for this condition.
Insurance should pay for Medication Assisted Treatment. In Vermont
we developed a Medicaid Health Home State Plan Amendment under the
authority of section 2703 of the Affordable Care Act to create the Hub
and Spoke Program. There are other approaches to using Medicaid that
states can employ including: 1115 B Substance Use Waivers, State Plan
Amendments, including MAT in managed care organization contracts, and
increasing reimbursement rates for targeted services. Commercial payers
should also participate: in Vermont two of our major commercial plans
are piloting payments for Hub and Spoke Services.
The barriers to primary care participation in MAT (not enough
provider time, patient complexity, difficulty integrating counseling
supports) can be addressed by adding nursing and counseling resources
to the primary care prescribing teams, as we did in Vermont.
Treatment is one element of a comprehensive response to the opioid
epidemic. Other elements include prevention--reducing peoples' exposure
to opioids in the first place, harm reduction such as wide availability
of the overdose reversal medication Narcan to help prevent overdose
deaths, and recovery supports--including vocational services to help
people in recovery participate fully in our communities.
Leadership focus matters. I have had the honor of serving under two
consecutive Governors, democratic and republican, who have both
provided leadership and resources to address the opioid epidemic in
Vermont.
In closing, we have made much progress in Vermont, much of it with
the support our Federal partners. Yet while we have some of the best
access to treatment in the nation, we have not solved this problem.
Every week two Vermonters die from a drug overdose. Tragically we've
also experienced high numbers of children under the age of five, who
come into state custody due to this crisis. We must learn how to do
better by our families and communities.
Thank-you.
Material Submitted for the Record: \*\
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\*\ [Clerk's note: The material can be found in ``Material
Submitted for the Record.'']
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--2-page description of the Vermont Hub & Spoke Program 2017.
--Detailed program description accompanying Vermont's Health Home
State Plan Amendment, 2013.
--Mohlman MK, Tanzman B, Finison K, Pinette M, & Jones C. (2016)
Impact of Medication Assisted Treatment for Opioid Addiction on
Medicaid Expenditures and Health Services Utilization Rates in
Vermont. Journal of Substance Abuse Treatment (67) pp 9-14.
--Brooklyn JR & Sigmon, SC. (2017). Vermont Hub-and-Spoke Model of
Care for Opioid Use Disorder: Development, Implementation, and
Impact. Journal of Addiction Medicine, 11(4), 286-292.
--Levine ML, & Fraser M. (2018) Elements of a Comprehensive Public
Health Response to the Opioid Crisis. Annals of Internal
Medicine.
--Rawson R, Cousins SJ, McCann M, Pearce R, Van Donsel A. (2018).
Assessment of medication of opioid use disorder as delivered
with the Vermont hub and spoke system. Journal of Substance
Abuse Treatment (97).
Senator Blunt. Thank you Director.
Director Pierce.
STATEMENT OF DR. DAISY PIERCE, PhD, EXECUTIVE DIRECTOR,
NAVIGATING RECOVERY OF THE LAKES REGION,
LACONIA, NH
Dr. Pierce. Senator Blunt, Ranking Member Murray, Senator
Shaheen, and members of the subcommittee, thank you very much
for this opportunity to testify about the opioid epidemic
plaguing our Nation's communities. It is an honor to present
information to you from the viewpoint of a recovery community
organization in Laconia, New Hampshire.
As the Executive Director of Navigating Recovery of the
Lakes Region, I have spent the last 3 years working closely
with community partners to provide recovery support services to
residents in Belknap County, the Lakes Region and surrounding
towns in New Hampshire. Most recently, Navigating Recovery
became one of the primary spokes for the Doorway at LRG
Healthcare as part of the hug--hub-and-spoke system led by
Governor Sununu.
The hub-and-spoke model, also known as New Hampshire
Doorway, is how the New Hampshire Department of Health and
Human Services chose to disseminate the funds from the State
Opioid Response Grant for the purposes of increasing access to
medication-assisted treatment, reducing unmet treatment needs,
and reducing opioid overdose--overdose related deaths through
the provision of prevention, treatment, and recovery support
services for opioid use disorder.
The goal of New Hampshire's plan is to create clear points
of entry for any resident with an opioid use disorder, to
access services no more than an hour driving distance from
their hometown. The design is meant to feature regional
approach for addressing the public health crisis at nine hubs
throughout the State.
The SOR grant funding has been an incredible infusion of
financial assistance to the State of New Hampshire in the fight
against the public health crisis of OUD (opioid use disorder).
Since the announcement of the funding and the opening of the
nine New Hampshire Doorways, the State has been able to ensure
residents that help is available, there are ways to access
services, and fighting this disease has bipartisan support and
commitment at all levels of government.
It is important to note however, that even in a small State
like New Hampshire each region started out with vastly
different services as a base. This model does allow for each
doorway to design and staff the hub and establish connections
with community spokes to meet the needs of that particular
region, but there are still gaps in services that the spending
does not address.
Some of the challenges or barriers we still need to find
solutions for are the fact that there are not any additional
services on the other side of New Hampshire Doorways. We still
have the same number of treatment beds as before, but now more
people are trying to access them. We also have a workforce
shortage that has left some positions unfilled at New Hampshire
Doorway locations. Many of these positions require specific
training, education, and certifications that take time.
Finally, the SOR grant focuses on opioid use disorder, but
what about alcohol, methamphetamine, benzodiazepines, and other
non-opioid addictions. We must not be so nearsighted that we
only focus on overdose fatalities when alcohol is still the
most widely used substance in the country and methamphetamine
presents a whole array of challenges when it comes to
treatment.
States with epidemic level overdose deaths are incredibly
grateful for funding opportunities like the SOR grant. We truly
appreciate the time and effort this Appropriation Subcommittee
has spent addressing the public health crisis we are all
committed to combating. This process has highlighted how
incredibly innovative, collaborative, and hard working the
community service providers are who treat people suffering from
substance use disorder and co-occurring mental health diseases.
When faced with a crisis or an epidemic, people often feel
overwhelmed and hopeless, but the SOR grant and New Hampshire
Doorway Program has demonstrated that this public health issue
will be fought head on by passionate providers and the support
of Federal funding.
In a matter of just 6 months, New Hampshire Department of
Health and Human Services was able to conceptualize the hub-
and-spoke model as offered by Vermont, identify the nine
regions of the State for the New Hampshire Doorway locations,
and launch the program. I can only imagine how successful the
program could be if we had more time to prepare.
Therefore, I earnestly ask this committee today that the
more commitment we can have at the Federal level that States
will receive funding again, gives us more time to prepare.
States need certainties so that community service providers are
ready to roll out programs in a timely manner. The earlier we
know the funding is coming, the more we can do with the money.
Thank you very much for your time and I look forward to
answering any questions you have for me today about how New
Hampshire is using the SOR Grant funding and the role of
recovery community organizations in this fight.
[The statement follows:]
Prepared Statement of Daisy Pierce, PhD
Dear Senator Blunt, Ranking Member Murray, and Members of the
Subcommittee:
Thank you very much for the opportunity to testify about the opioid
epidemic plaguing our Nation's communities. It is an honor to present
information to you from the viewpoint of a Recovery Community
Organization in Laconia, New Hampshire. As the Executive Director of
Navigating Recovery of the Lakes Region, I have spent the last 3 years
working closely with community partners to provide recovery support
services to residents of Belknap County, the Lakes Region, and
surrounding towns in New Hampshire. Most recently, Navigating Recovery
became one of the primary ``spokes'' for The Doorway at LRGHealthcare
as part of Governor Sununu's Hub & Spoke system. The Hub & Spoke model,
also known as NH Doorway, is how the NH Department of Health and Human
Services chose to disseminate funds from the State Opioid Response
(SOR) Grant, for the purposes of increasing access to medication-
assisted treatment, reducing unmet treatment needs, and reducing opioid
overdose related deaths through the provision of prevention, treatment
and recovery support services for opioid use disorder (OUD). This
written testimony will outline the recovery support services that
already existed in NH prior to the SOR Grant, the Hub & Spoke model
design, and preliminary experiences.
recovery community organizations and peer recovery support services
As one of several Recovery Community Organizations (RCOs) in New
Hampshire, Navigating Recovery of the Lakes Region is a non-profit,
grassroots collaborative organization creating a supportive, recovery
informed community for those afflicted with a Substance Use Disorder
(SUD), and their family, friends, and coworkers. Navigating Recovery is
focused on providing an open door for those seeking and/or embracing
recovery as people begin and maintain the path for a productive life
without alcohol or other drugs. The center endeavors to close the
continuum of care gap between emergency departments, correctional
facilities, fire departments, police departments, and treatment/rehab
facilities. This is achieved primarily through peer-to-peer recovery
coaching. Peer-to-peer coaching helps an individual willing to start
their recovery journey to bridge the time before and after treatment
services are available, when they are most susceptible.
The Lakes Region of NH is an area with a great need for a Recovery
Community Organization. In 2015, Laconia, the largest municipality in
the region, had 90 opiate overdoses resulting in 10 deaths, 70
overdoses with 5 fatalities in 2016, and in 2017 there were 146
overdoses and 8 deaths. These overdose statistics are only for Laconia,
and do not include the other towns in the region that Navigating
Recovery serves (including all of Belknap County). This demonstrates
how the community reflects the greater New Hampshire statistics of
substance use disorder, overdoses, and fatalities. In 2016, there were
437 opioid-related overdose deaths--a rate of 35.8 deaths per 100,000
persons--nearly three (3) times higher than the national rate of 13.3
deaths per 100,000. From 2013 through 2016, opioid-related deaths in
New Hampshire tripled. Since Navigating Recovery opened its doors in
November 2016, we have assisted over 900 community members, responded
to over 250 overdose and substance use related hospital calls, and
distributed over 200 Narcan (naloxone) kits.
Recovery Coaching is a peer-based service that is developed and
provided mainly by persons who are in recovery themselves and as a
result have gained knowledge on how to attain and sustain recovery. The
U.S. Department of Health and Human Services, Substance Abuse and
Mental Health Services Administration describes these as developing a
one-on-one relationship in which a person with recovery experience
encourages, motivates, and supports another person seeking their own
path to recovery. The recovery coach may also connect the peer in
recovery with professional and nonprofessional services and resources
available in the community. Such services include:
--Helping participants sign up for health insurance
--Making referrals to resources for Primary Care Physician, Mental
Health Center for co-occurring mental healthcare needs, a
Licensed Alcohol and Drug Counselor (LDAC) for an evaluation to
determine the level of care needed
--Linking participants with withdrawal management, or in-patient
treatment/rehab facilities
--Linking participants with Medication Assisted Treatment or
Intensive Outpatient Programs
--Hosting group meetings to expand social network support, such as
12-step or SMART Recovery
--Assisting with an assortment of other recovery related issues, such
as helping participants find stable housing, identifying
transportation options, getting ID cards, looking for
employment, quitting smoking, etc.
In addition to connecting participants with other services and
resources, recovery coaches provide interim support if a participant
has to wait for access to those services. For example, if there is a 3-
6 week wait for a bed at a treatment facility, the recovery coach will
meet with a participant as often as necessary to help them maintain
their recovery.
Finally, recovery coaches help participants to create a Recovery
Wellness Plan, and work to reduce/remover barriers to assist the
participant achieve the goals of that plan. Recovery Wellness Plans are
individually designed for each participant's personal needs in order to
maintain stable, long-term recovery. The wellness plan is a continually
evolving road map, with achievable goals, that are adjusted accordingly
as a person's recovery path progresses.
RCO's throughout the State recognize that recovery means more than
abstinence from alcohol and other drugs. Recovery requires a person-
centered, holistic, wraparound approach to helping an individual and
their loved ones achieve a healthy, productive lifestyle, where their
SUD and any co-occurring mental health illnesses are effectively
managed. It is important to note that RCOs do not provide any clinical
services. All recovery support programs offered are non- clinical,
peer-based. However, the professionals providing recovery coaching at
RCOs are often Certified Recovery Support Workers (CRSWs), licensed by
the NH Licensing Board for Alcohol and Other Drug Use Professionals. Of
important note, since 2016 there has been an increase from one (1) RCO
operating in NH to 12 RCOs with 14 locations.
Hospital Support Program
``Partners in Recovery Wellness'' is a program between Navigating
Recovery and LRGHealthcare. Since June 2017, recovery coaches and
hospital staff have been working together to improve outcomes for
patients with substance use disorders. This is an innovative and
successful approach because it capitalizes on community partnerships
and local resources. Partners in Recovery Wellness increases access to
medication-assisted treatment, reduces unmet treatment needs, and aims
to reduce opioid overdose related deaths through the provision of
prevention, treatment and recovery activities for individuals and
families afflicted and affected by SUD. This program includes the
following:
--Certified Recovery Support Workers (licensed recovery coaches) from
Navigating Recovery: 24/7 on-call support provided for any
overdose survivor in the Emergency Department and CRSWs meet
with any other patient at the hospital identified as having a
SUD.
--In-person meeting with patient to help link them to Medication
Assisted Treatment, rehab/detox, support group meetings,
LADC/MLADC and IOP referrals, and telephone or face-to-face
coaching, etc.; thereby beginning to close the treatment
gaps.
--Narcan provided by CRSW to individual with SUD
--Provide family and friends with educational opportunities
(science of addiction, naloxone trainings, healthy
boundaries, etc.) and support services
--Medication Assisted Treatment induction through the Emergency
Department
--Education to hospital staff about MAT so that they feel more
comfortable explaining this type of treatment. The goal is
to help staff to see SUD as a medical disease and to find
ways to help them encourage treatment. Staff members are
educated about the LRGH Recovery Clinic that operates out
of both hospital campuses (Lakes and Franklin) and about
how to make a soft hand off from the ED to the clinic.
--Educational opportunities for ED staff about how and when to do
an induction with Suboxone (medication assisted treatment).
--Partners in Recovery Wellness: Improving Outcomes for Patients
with SUD is a stigma reduction training provided to all
hospital staff. The workshop is taught by Daisy Pierce, PhD
and Corey Gately, MLADC, and has now been taught to other
hospitals and healthcare providers across the State of NH.
nh state opioid response funding--the hub and spoke model
The goal of New Hampshire's plan is to create clear points of entry
for any resident with an OUD to access services no more than an hour
driving distance from their hometown. The design is meant to feature a
regional approach to addressing the public health crisis at nine (9)
``hubs'' throughout the State.
The Doorway at LRGH is the hub located at Lakes Region General
Healthcare in Laconia for 34 towns within a 1-hour driving distance,
open Monday through Friday, 8am-5pm. The SOR Grant has provided The
Doorway at LRGH the opportunity and funding to bring together a
Certified Recovery Support Worker (CRSW), a Licensed Alcohol and Drug
Counselor (LADC), a Licensed Mental Health Counselor (LMHC), and
administrative support into a shared space. This communal working
environment brings together staff from various community ``spokes'',
creating a multifaceted approach to providing OUD supports without a
wait time and transportation between organizations. The concept of The
Doorway does resemble that of RCOs with the exception of having
clinical professionals working side-by-side with non-clinical peer
supports (i.e. Licensed Alcohol and Drug Counselors working in a shared
setting with Certified Recovery Support Workers).
As described above, in the Lakes Region, LRGHealthcare and
Navigating Recovery already had a working relationship through the 24/7
On-Call Hospital Support Program. This positioned the hub in this
region to be able to quickly launch The Doorway with already
established lines of communication, policies and procedures in place.
When a person seeking helps enters The Doorway at LRGH, that individual
is met by a CRSW from Navigating Recovery. The CRSW begins by
determining what the person's most urgent needs are, linking them with
the LADC for any evaluations necessary, and making the appropriate
level of care referrals. For example, if the appropriate level of care
includes medication assisted treatment, the CRSW can walk the person to
the Emergency Department for their first dose of Suboxone. This is just
one model of how the nine (9) different hubs are operating. In each
region, the hub is staffed and operated based on the resources
available and needs of that particular community.
Another significant change with the funds provided by the SOR Grant
is the ability to assist an individual with non-reimbursable costs
associated with treatment and recovery. When an individual who is
currently experiencing homelessness comes to The Doorway for help, the
team is able to identify the level of care necessary, make the referral
phone calls to locate a treatment bed, and then help that individual
find a safe place to sleep if the bed is not immediately available.
Other examples include providing transportation to a treatment center
or offering a meal to someone who is hungry. Working with this
particular population, we are often faced with someone whose primary
needs are shelter and food. We recognize that these needs must be met
before we can begin to, or simultaneously address the best pathway to
recovery for that person. In the Lakes Region, temporary shelter is by
far the largest gap in services available.
Again, the identified largest gap in each region is dependent on
the local resources that were previously available in that particular
community.
The NH Doorway hubs are also directly linked with a statewide
hotline: 2-1-1. Anyone standing within the State boundaries can dial
211 and be connected to a resource specialist who has access to the
most up to date list of community service providers closest to that
individual. Anyone can call at anytime to ask for help. Since the
opening of the hubs, when a person calls 211 and needs to access OUD or
co-occurring OUD and mental health services, the resource specialist
will call the closest Doorway and connect the person over the phone.
This statewide hotline has made it easier for someone to find out what
resources are available.
early observations of nh doorway hub and spoke program
The SOR Grant funding has been an incredible infusion of financial
assistance to the State of NH in the fight against the public health
crisis of OUD. Since announcement of the funding and the opening of the
nine (9) NH Doorways, the State has been able to assure residents that
help is available, there are ways to access services, and fighting this
disease has bipartisan support and commitment at all levels of
government.
It is important to note, however, that even in a small State like
NH, each region started out with vastly different services as a base.
This model does allow for each Doorway to design and staff the hub and
establish connections with community spokes to meet the needs of that
particular region, but there are still gaps in services that this
funding does not address. For example, respite beds and temporary
shelter are the greatest need in the Lakes Region. The city of Laconia,
with a population between 16,000 to 17,000 people, only has one
homeless shelter with 30 beds. Between the months of October and May,
The Belknap House is a cold weather shelter open for families
experiencing homelessness. The next closest homeless shelters are in
Concord or Plymouth, each a 30-minute drive from Laconia. There are no
respite beds (a safe place for a person who is under the influence of
substances to sleep) available in the area. The expectation of the
funding clearly states that the money cannot be used for bricks and
mortar, which would be necessary to create new beds. This means NH
Doorway at LRGH must use flex funds for a hotel room if someone has
nowhere else to go. Therefore, these flex funds, meant to help with
costs of transportation, food, and temporary shelter, are one of the
key elements of the SOR Grant.
Some of the challenges/barriers we still need to find solutions
for:
--No additional services on the other side of NH Doorway. We still
have the same number of residential treatment beds as before,
but now more people are trying to access them. Additionally,
not all treatment centers will take patients with co-occurring
disorders, which reduces the services available for that
population.
--Workforce shortages have left some positions unfilled at NH Doorway
locations. Many of these positions require specific training,
education, and certifications that take time.
--Many sober living houses are abstinence-based and do not accept
residents on opioid- based medication assisted treatment.
--The SOR Grant focuses on OUD, but what about alcohol,
methamphetamine, benzodiazepines, and other non-opioid
addictions? We must not be so nearsighted that we only focus on
overdose fatalities, when alcohol is still the most widely used
substance in the country, and methamphetamine presents a whole
array of challenges when it comes to treatment (no MAT, no
withdrawals, can cause long-term brain damage and drug- induced
psychosis).
conclusion
States with epidemic level overdose deaths are incredibly grateful
for funding opportunities like the SOR Grant. We truly appreciate the
time and effort this appropriation subcommittee has spent addressing
the public health crisis we are all committed to combatting. This
process has highlighted how incredibly innovative, collaborative, and
hard working the community service providers are who treat people
suffering from SUD and co-occurring mental health diseases. When faced
with a crisis or epidemic, people often feel overwhelmed and hopeless,
but the SOR Grant and NH Doorway program has demonstrated that this
public health issue will be fought head-on by passionate service
providers and the support of Federal funding. This infusion of support
helped to build upon the work RCOs had started by letting people
affected and afflicted know there is something everyone can do to help,
and it brings hope to both communities and individuals affected by SUD.
In a matter of just six (6) months, NH DHHS was able to
conceptualize the hub and spoke model, identify the nine (9) regions of
the State for NH Doorway locations, and launch the program. Due to this
condensed timeline, for several months there was uncertainty about the
dissemination of funds, and some community agencies are still left
thinking that each hub has 1/9 of $22.8 million to distribute to
spokes. Requests for Proposals (RFPs) came out before community
stakeholders really understood the hub and spoke model. Now that
community forums have helped to educate regions about each of the local
Doorways, other organizations want to be spokes, but the RFPs have
already closed. If we were able to launch the program we did in such a
short period of time, I can only imagine how successful the program can
be with more advanced notice to prepare. Therefore, I earnestly ask
that the more commitment we can have from the Federal level that States
will receive funding again next year, gives us more time to prepare.
States need certainty so that community service providers (contractors)
can submit proposals and are ready to roll out programs in a timely
manner; the earlier we know the funding is coming, the more we can do
with it.
We have been referring to the ``opioid crisis'' or ``opioid
epidemic'' for a few years now. I urge everyone to reframe how we
discuss this problem. To begin with, we have a substance use crisis,
not just an opioid epidemic. Very rarely do we work with an individual
who has only ever used opioids. Most people suffering with SUD use a
variety of substances, each one of them with their own dangers. The
rate at which we are losing community members to overdoses is tragic,
but opioids will only be replaced by another drug if we do not work
diligently to address all substances. Furthermore, Substance Use
Disorder has been an illness plaguing people since at least the 1800's,
and long before that alcohol has caused health problems and societal
issues. We need to stop envisioning the approach to this public health
crisis as similar to a post-natural disaster recovery effort. Although
we often describe the wreckage SUD leaves in its wake as a tornado
ripping through a community, our efforts to address the disease must be
sustainable long-term.
Finally, we must continue to be proactive and bring together
dedicated service providers to brainstorm how to we can advance our
progress addressing this disease, even as the primary drug of
destruction changes and funding sources come and go. As with so many
other diseases, we must remember that this illness does not have a
``one size fits all solution.'' Based on our experiences so far, when
it comes to replicating systems that work, it is important to recognize
that community partnerships are crucial! If each community service
provider is willing to work together, and organizations are armed with
the knowledge of what resources are available, we can close most of the
gaps, and not only save more lives, but help to make those lives happy,
healthy, and productive again.
Thank you very much for your time and commitment to helping us
combat substance use disorder.
Senator Blunt. Thank you, Director.
All of you did a good job with your 5 minutes. We will see
if we can do an equally good job with ours. I do think there
will be a chance for a second round of questions; if you have
more questions and your time is up, let's remember that other
people would like to ask their questions too.
Let me ask a couple of questions here to start with and
then will go to Senator Murray after that.
STATE'S ROLE IN OPIOID CRISIS
Director Stringer, you mentioned, one, the importance of
getting the money out the door and that SAMHSA has gotten that
money to the States quickly, and my real question, I think, is
on your observations about how important it would be to
continue to work through the States. I assume that means as
opposed to working directly with local providers.
You all know from the way we have dealt with this, we have
not tried to prescribe a solution here because we do not know
the solution, but we are giving the States a great deal of
flexibility.
So, first of all, I am going to ask you Mark about the
importance of working through the States and then Dr. Cropsey,
I am going to come to you and talk about and ask you about ways
we can evaluate how the States are doing. We have given money
to the NIH (National Institutes of Health) specifically to do
that, but I think there are other tools out there in addition
to the NIH.
So, first of all Director Stringer, the importance of
working with the States and the importance of getting that
money out the door.
Dr. Stringer. Sure, and I very much appreciate the question
Senator. Working with the States, number one, allows the States
the flexibility to direct those funds where the need is the
greatest. Which is exactly what we did with the STR and the SOR
grants where our worst problem has been in the Eastern region
primarily, the Eastern region of the State in the Boot Hill,
some in the Southwest. So we were able to target those areas
with those funds.
Secondly, we were able to coordinate those funds with other
Federal grant programs, with our existing programs funded with
block grant, and with State general revenue, so that we did not
have redundancy, we did not have inefficiency, but it was--it
is a well-
coordinated system that I am very proud of.
So I think that--I think again, that the flexibility, the
consistency and the quality is what we see when these funds
come through the States.
EVALUATION OF PROGRAMS
Senator Blunt. I would assume from this panel that there is
no disagreement with that, at least, until we find out what
works, and maybe after we find out what works. But on that
topic again, we've given specific directions, some specific
money to NIH, but Dr. Cropsey, I know a lot of your work has
been in trying to figure out what treatment works. How do we
evaluate whether inpatient is better than outpatient? The--is a
30 day intense program better or is a longer commitment, and
just talk about evaluating what is out there and how we share
what appears to be working and share what appears not to be
working.
Dr. Cropsey. Well, thank you.
So, we do know that obviously, medication-assisted therapy
has been life-saving and has been critical in saving lives, as
we have heard from other panelists. I think that is well known
and well established.
I believe also that the behavioral treatments that go along
with medication-assisted therapy, cognitive behavioral therapy,
also, are critical in reducing addiction and are important.
You know, I think what is less known is if someone goes to
a specific treatment facility, what happens when they leave 30
days, you know, 3 months, 6 months after that facility. And I
think that if you were able to incentivize facilities to
collect that kind of data or to provide resources to be able to
collect that data, we would know, we would have a better idea
of how we could figure out what happens after an inpatient
treatment program or what happens after someone is in an
intensive outpatient program.
Right now that data is not captured particularly well at
the individual agency, like treatment facility level and so I
do think that that would be important to be able to collect.
And whether it be some sort of outside evaluator that partners
with those agencies, or whether it is the agencies who are
incentivized to collect that data.
Senator Blunt. Thank you.
Senator Murray.
MEDICAID EXPANSION
Senator Murray. Well, thank you very much to all of you for
your testimony. You know, the evidence really shows pretty
clearly that States that opted to expand Medicaid increased
access to substance use disorder treatment for millions of
families and that expansion provided critical resources that
made it possible for those states to implement those innovative
systems like the hub-and-spoke model that you spoke about Ms.
Tanzman.
That also made it possible for Washington State to adopt
the hub-and-spoke model providing access to life-saving
treatment for thousands of families with opioid use disorder,
particularly by covering essential services like early
intervention, and outpatient and residential treatment, and
medication-assisted treatment.
So, that to me, is another reason why the administration's
efforts to undermine Medicaid are really troubling.
Dr. Fotinos, I wanted to ask you: How would Washington
State's response to the epidemic be impacted if Medicaid were
scaled back or converted into a block grant program?
Dr. Fotinos. In Washington State we know that the vast
majority of people currently covered by Medicaid right now, who
also have an opiate use disorder, are members of the expansion
population. And what we know when people do not have access to
treatment is the incidents of HIV and hepatitis C infection
goes up, the number of people who die due to overdose-related
death goes up, also eliminating those persons' ability to have
coverage would increase burdens on hospitals and clinics that
would be using charity care essentially, to take care of folks
when they were much more sick and needed a valve replacement
for instance, as opposed to just daily medication.
The criminal justice system would see an increased number
of people who were doing illicit activities to get their drugs;
the child welfare system would see an increase in the number of
children and parents referred because they were suffering from
addiction and not able to manage it in the appropriate way. And
those costs would then drive up healthcare cost; employers
would have to pay more because the hospitals would charge more.
So it would unfortunately start this cycle of increased costs,
less support in help for the people who are struggling with
this disorder and would really set us back a long way.
The expansion has allowed people to be able to have life-
saving medications, the Federal funds have allowed us to
provide the manpower and the supports that are outside the
funds of Medicaid to really help providers manage what is such
a complex condition.
Senator Murray. Dr. Berry how about you. How has the
Medicaid expansion affected West Virginia's ability to respond?
Dr. Berry. Well--to speak personally in the sense that
prior to the expansion, many of the folks were coming in for
treatment were private pay and so many just had to scrounge up
the funds as best they could to get into treatment and to stay
in the treatment. We had to do a good degree of charity care at
the time.
After we became an expansion State, I did see a significant
number of people being able to come in and afford treatment,
and be able to stay, and retain in treatment. So, I do know at
least for me personally in the practice that we have been doing
in our area, it has been a significant improvement in the lives
of the patients we have been able to treat.
FOSTER CARE INTERVENTIONS
Senator Murray. Okay. Thank you. You know, I often hear
about the ripple effect that opioid crisis is having on
children, families--the number of babies born with withdrawal
symptoms due to neo-natal abstinence syndrome grew seven-fold
from 2000 to 2014. The number of children in foster care, one
of you mentioned this in your testimony, has risen by more than
10 percent since 2013, much of which has been attributed to
substance abuse disorder. And we know from research that
children who are removed from their family placed in an out of
home care often suffer serious long-term consequences.
So for that reason I have fought very hard for more
resources dedicated to early identification and intervention
and treatment for substance abuse to infants and their mothers,
with the goal of keeping these families together, safely. That
has been incredibly important.
I wanted to ask, and I just have 45 seconds so I might have
to come back to this, but what are some of the resources that
have been shown to successfully connect infants and their
mothers to treatment and prevention - and prevent the need for
foster care. Any of you?
Mr. Stringer and then Ms. Tanzman.
Mr. Stringer. Senator, in Missouri we have specialized
programs for women with children in which women--or children
can come with their mothers to treatment settings.
Senator Murray. So, keeping them with their mothers.
Mr. Stringer. Absolutely.
Senator Murray. Yes. Ms. Tanzman.
Ms. Tanzman. We try to act a little earlier and work with
women as they are pregnant to first of all get them in
treatment. And so while we have very high rate of babies born
exposed to opioids, that is often because their moms are in
treatment, those children do very well, and in fact, our
inpatient costs and length of stay for opiate exposed newborns
is much less than the National averages. Indicating the
difference between women in treatment and their outcomes
compared to women who are using for instance, heroin from the
streets.
We identify key linkage of programs to connect the OB/GYN
and medical providers with our community partners. Our CHARMS
program--Children and Mothers in Recovery--is an example of
doing this through structured agreements between the different
partners that play in children's care.
Expanding these types of services to not just the immediate
birth and prenatal and postnatal period, but through 0 to 5,
would make a really big difference, because that is such a
critical window.
Senator Murray. Okay. I think this is so important because
I hear so often that separating those mothers and sending those
kids to foster care is actually the worst thing for the mother
who is being treated, and obviously for the child, long-term.
So, I am very interested in how we can do a better job here.
Senator Blunt. Thank you Senator.
Senator Alexander.
Senator Alexander. Thank you, Mr. Chairman and I want to
thank you and Senator Murray for this hearing and for your
early leadership on the opioids issue.
I often say to Tennesseans that I hope they look at
Washington, D.C. as if it were a split screen television. Take
last September, you had a big food fight over the Justice
Cavanaugh nomination in one screen, but on the other screen you
had 72 United States Senators of both parties working with five
committees and House members to pass what the President said
was ``The most significant piece of legislation ever passed to
deal with a public health epidemic.'' So, there is as Senator
Leahy said, a strong bipartisan commitment to the subject we
are discussing today.
We were careful in the bill that we worked on, Senator
Murray and I are the ranking members on the committee that help
do this, not to prescribe Federal prescription limits or a
number of other Federal rules about how States dealt with the
opioid epidemic. I have a strong bias about that as a former
governor, and I'm glad we did that, because last week in our
Health Committee we had a hearing on pain. And the reason we
scheduled that was because whenever you have an action you
usually have a reaction and when you take away what for many
patients with chronic pain, the most effective painkiller, you
are going to create trouble for those patients, and we wanted
to assess that.
As Chairman Blunt said, we knew that would--could be a
problem and we have accelerated funding and consideration of
alternative, non-addictive painkillers, but we have a ways to
go. Many patients of chronic pain would not be completely
satisfied, I don't think, Dr. Cropsey, with yoga and ibuprofen
and therapy, as useful as they can be.
CDC OPIOIDS GUIDELINES
So, I wanted to ask you specifically about the Center for
Disease Control guidelines. While the committee and the
Congress did not prescribe a Federal law about prescription
limits, CDC (Centers for Disease Control and Prevention) in
2016 did issue guidelines. And what we heard in our hearing is
that many physicians, many people across the country accept
those as law, and that even some physicians are completely
giving up the prescription of opioids even in a small amount,
for people who have had serious surgery for fear of getting in
trouble with the drug agencies.
Do you believe, any of you, that the Center for Disease
Control guidelines should be revised in any extent; and do you
believe they are being taken as law when they are only advice?
Dr. Fotinos.
Dr. Fotinos. That is an excellent question and I think it
is complicated. I think that the message that a lot of
physicians has gotten is that the opiate epidemic is their
fault. It is their fault because they prescribed too many
opioids and an obvious reaction to that has been, ``Okay, well
if it's my fault even though I didn't do anything, I'm just
going to stop prescribing opioids altogether.''
We know they don't work for chronic pain but I think when
we have put so much emphasis on the fact that too many opioids
are prescribed, and they are, there has been sort of, too-far
of a pendulum swing.
I think that what we do not know is we do not know how many
opiates are enough to treat particular types of pain. We know
that more than a week is too many; we know that the longer
people are on them the higher their risk of people becoming
dependent is, so we know somewhere there is a right--
Senator Alexander. Well, we had a witness who is head of
the pain clinic at Mayo Clinic, who said that that depended on
what a physician --- and would say to a patient and that--and I
pressed her a little bit for examples and she said, ``Well, 3
days for maybe an emergency room problem or maybe as much as 16
days for after a knee surgery.'' Is there--that exceeds the CDC
guideline.
Dr. Fotinos. And, I think everyone is different. I think
part of the challenge here is that we have to change how we
talk about pain. Some pain is physical but a lot of pain is
emotional and it relates not just to something we can see on an
examination, and everybody's pain tolerance, and ability to
manage it is different.
So, I think we have to, as providers, be thoughtful and
taking care of the person in front of us, but from a larger
population perspective we have to be mindful that often, too
many medications are prescribed, and they are left in the
community where they are at risk of being used by people who
either just want to see what it is like or who already have a
dependency problem.
So, I do think they are reasonable guidance; should they be
law, no, because everyone is different. That said, we know that
there are too many opioids in the community that people have
used and become dependent upon.
Senator Alexander. Thank you, Mr. Chairman. My time is up
but I expect we will be addressing this subject more in our
HELP Committee.
Senator Blunt. Thank you, Senator.
Senator Leahy.
AFFORDABLE CARE ACT
Senator Leahy. Thank you Mr. Chairman, and Ms. Tanzman
again, thank you for coming down from snow-covered Vermont to
be here.
You talked about our hub-and-spoke system. 8,000 Vermonters
in treatment for opioid use disorders, and I--in a State of
around 600,000 people, that is a lot. What percentage of those
8,000 rely on Medicaid coverage?
Ms. Tanzman. Well over 80 percent, Senator Leahy.
Senator Leahy. How has the Affordable Care Act allowed
Vermont to expand treatment?
Ms. Tanzman. It has been incredibly important. I mentioned
our Health Home State Plan amendment under section 2703 of the
Act that allows us to create essentially a health home treating
opioid use disorder as a chronic condition as you would any
other chronic condition. We were able to use Medicaid funds,
therefore, to support the nurses and counselors that we
described deployed to the teams.
I would also like to say that the importance of insurance
coverage for people to be able to stay in treatment,
medication-assisted treatment is a long-term treatment, it is
best given continuously over time, and so insurance coverage
makes a critical difference. If you lose your coverage you may
in fact, need to step away from treatment, which can be
terribly dangerous.
Senator Leahy. Thank you. And you mentioned the commercial
coverage under a pilot in that. How did that improve access?
Ms. Tanzman. Currently, if you are implementing a care
guideline in for instance, a practice--a primary care practice,
you want to treat all of your patients who have that condition
with the same approach to treatment, regardless of whether they
are insured or not. So for instance, if you are managing a
panel for diabetes, everybody gets the same standard of care in
your practice.
In our situation, because Medicaid is the only payer for
the spokes staff and other payers do not pay for hub services,
what happens is the Medicaid resources are spread more thinly
across the whole population, because care providers are going
to behave in an insurance agnostic way, as we want them to. So
by increasing participation of other payers in medication-
assisted treatment you allow that same standard of care to be
supported across all of the people who have the condition.
CHILDREN AND RECOVERING MOTHERS COLLABORATIVE
Senator Leahy. You know, when Senator Murray talked about
pregnant women and the children, Vermont has worked to
integrate medication assisted treatment on that. I'm told the
program is called the Children and Recovering Mothers (CHARM)
collaborative. How does that--what do you see from that in our
State--because, and I mention this because we are such a rural
State; you have some parts are very, very small. The town where
my mother was born; the town my wife was born, very small
towns. How does this work?
Ms. Tanzman. So, it really works as an organizing structure
to knit together the very different social service and
healthcare service organizations that all have some
responsibility for moms in early childhood. And it is a big
complex number of different organizations that all have a piece
of it.
And, so what they did with CHARMS, and then it has been--
there are versions of this for instance, the Central Vermont
Response Team in central Vermont, the SMART team in rural
Northeast Kingdom, that combines collaboration between the
healthcare providers so the OB/GYN or other providers who are
taking care of a woman through pregnancy, because we need that
expertise, married to the expertise of addictions treatment and
care coordinators and also include partners often Probation and
Parole may be involved, the Department of Children and Family
Services may be involved.
And so what CHARM and all of these programs do is provide a
small organizing backbone that helps integrate literally MOUs,
or Memorandums of Understanding between all of the different
partners about how they will each bring their unique expertise
and resources to bear on a mom and her family and children. And
so it is just an organizing framework to do what is
essentially, a shared care plan.
FENTANYL
Senator Leahy. And finally, I will submit some other
questions for the record, but fentanyl--has that created as bad
a problem as it appears to be?
Ms. Tanzman. It is. Fentanyl is what is driving lethality,
right now and it is----
Senator Leahy. I see a lot of heads nodding yes. I think
the whole panel--go ahead.
Ms. Tanzman. And it makes me very careful about speaking
about overdose death rates. We are I believe today in our
largest city, in Burlington, there is a press conference that
the mayor is holding because we have been able to in that
region, in Chittenden County, to see a decrease in our overdose
death rates.
But,if you look under the hood a little more, law
enforcement will also tell you that the heroin supply coming
into Chittenden County seems to be more of a black tar and does
not seem to have quite as much fentanyl in it; whereas, the
supplies coming in to southeastern Vermont have more fentanyl
and we see continued spikes in overdose death rates. And so, it
is like the wild card that can drive lethality regardless of
what we are doing in terms of service systems.
Senator Blunt. Thank you Senator.
Senator Leahy. Thank you, Mr. Chairman.
Senator Blunt. Senator Capito.
Senator Capito. Thank you, Mr. Chairman. I thank you and
the ranking member for this really great, informative panel. I
want to thank Dr. Berry for coming from WVU. I thank you for
your service and what you are doing today to help us understand
it, and I would also like to welcome your wife Cindy, who I
think is--I see her back there, and your son Noah. So thank you
both for coming and for supporting this great--the cause that
we have here.
I would like to go first. Well, I want to say something
anecdotally because I think we need to make sure that we see
that in 2015 this HHS funding in this area was $271 million, in
the last bill that we passed it was $3.7 billion. I think there
is a recognition with this panel and with all of your
leadership, and certainly leadership in the Congress in
general, that this is an emergency, a health emergency.
Certainly West Virginia is having the highest overdose death
per capita we know; we lived it, we know people, it is
exceedingly sad.
WORKFORCE CHALLENGES
Dr. Berry, in an article you were quoted as saying, ``The
three hardest words for a user to say is, I need help. If they
don't get it when the window is open the opportunity quickly
fades. Every community should be able to provide immediate
access.''
I know that one of the things that you talked about and
concerns really everybody on the panel, is the workforce
challenges. How do you see that evolving in West Virginia? Do
we need more paraprofessionals? Do we need more residencies in
addiction treatment? How can we solve this problem?
Dr. Berry. Yes, thank you, Senator. Absolutely. And you
know, that--there is such a precious window of time that is an
opportunity when people are ready to get help and we need to
act on that as soon as we possibly can. And so there is nothing
that has been more frustrating as a treatment provider over the
last 15 years of doing this, to know so many people who have
died on waiting lists.
Senator Capito. Right.
Dr. Berry. People who have died trying to get into
treatment, who wanted treatment.
Senator Capito. Is it getting better in terms of----
Dr. Berry. So, in some ways it is getting better.
Certainly, a number of the funds that we have been able to use
through the STR and the SOR funds have helped. We have a dire
need to increase the workforce, and I describe it as there are
two generations that are affected by the addiction as far as
suffering, but then there is also two generation of workforce
areas that need to be developed.
We need to develop the areas of people who are current
providers; these include the physicians, as well as social
workers, as well as therapists, as nurses, PAs. So many of
these providers have not gotten good addiction treatment in
their training. We have been woefully unprepared to provide
that kind of training for existing providers. So we need to
incentivize them and be willing to do it. They need to get
reimbursed for the treatment; usually, costs a lot more to give
treatment than the reimbursement that they get.
Senator Capito. Right.
Dr. Berry. And then the other generation is the next
generation of treatment providers that need to enter the
workforce. So we need to do what we can to increase residency
training slots, addiction psychiatry, addiction medicine slots,
for instance, the Support Act with the $25 million in funding
that should go towards supporting residency loan repayment----
Senator Capito. Right.
Dr. Berry [continuing]. Would be important, as well as the
$10 million in the Cures Act for the training demonstration
programs. Give opportunities for these providers to learn how
to do this in the rural setting, and once you have a provider
in training to see treatment and see treatment works, then you
have got them for the rest of their lives, because they know
how valuable that is.
Senator Capito. Thank you. Thank you for that and we want
to be supportive of those efforts because it is a spectrum
disease, it--we have talked about children, babies. I would
like to mention Lilly's Place in West Virginia does a great job
with NAS (neonatal abstinence syndrome) babies treating them
outside the hospital setting, keeping them as much as they can
with the mother and it has been sort of, modeling across the
country.
BUPRENORPHINE
I have also been impressed with what WVU is doing with
their COAT buprenorphine program. Would you like to speak it--
to that a little bit?
Dr. Berry. Yes, I would love to. So, you know, this is a
program that again, is one of those things that necessity is
the mother of invention. We started prescribing buprenorphine
in 2004 once we realized that there were not many other tools
to keep people engaged in treatment and to keep them alive. And
really when you are looking at any addiction or treatment for
general there is two main goals. One is to keep the person
alive and two is to increase their quality of life. We realized
pretty quickly that if we were not offering buprenorphine
people were not staying alive, and then we could not increase
their quality of life. Once we started getting them on the
medicine and keeping them in treatment, they started doing what
they could to learn how to live. And we realized that if we
just started doing this one patient at a time in a single
medical visit, we were going to be swamped.
So, what we started doing was, we had group medical visits
where we see 10 to 12 patients at a time within a medical visit
directly linked after that with an hour therapy visit. And so
we are able to have these small groups of patients who were
able to help one another and then also get the help they need
from us as the professionals, frequent visits as well.
And one of the things that we started doing in--in our MAT
program is also having folks go to regular community peer
support groups as well and making that a huge component.
Because those are in many of the communities and have a long--
have a long track record of helping other folks.
Senator Capito. Right. Thank you. Thank you.
Dr. Berry. Thank you.
Senator Capito. Thanks for being here.
Senator Blunt. Thank you, Senator.
Senator Shaheen.
MEDICAID EXPANSION
Senator Shaheen. Well, thank you Mr. Chairman and thank you
to you and Senator Murray for holding this hearing and thank
you all very much for being here to testify and for the work
that you are doing in your States.
I am thrilled that Dr. Pierce is here from New Hampshire,
she heads, as she said, a recovery center in the Lakes Region
of New Hampshire, which has been particularly hard-hit by the
epidemic. And, I wanted to--I know that you wanted to respond
to the question about what difference has Medicaid expansion
made for treatment. Can I get you to do that now?
Dr. Pierce. Yes, thank you for that question. So as a
recovery community organization we are a local nonprofit, so we
are always thinking about revenue sources and with the Medicaid
expansion program, we have been able to now become certified at
the National level and at the State level so we can begin
billing Medicaid, as part of Medicaid expansion for recovery
support services. So, these are for nonclinical services that
are provided by peers in recovery themselves.
So we have created a system in which someone who with lived
experience who is in long-term recovery, can become a certified
recovery support worker. They actually have a profession, they
get a certification at the State level and their work giving
back to their peers is now billable through Medicaid.
Also through Medicaid expansion, recovery community
organizations like Navigating Recovery are part of the
integrated delivery network system in New Hampshire, and
through that integrated delivery network system, we have been
able to have incredible levels of care coordination.
We focus mainly on people with substance use disorder and
high utilizers of the emergency department and we--through that
we now have technical assistance that allows all community
service providers to have a shared coordination care plan,
which means that when somebody that we work with ends up in the
emergency department we are immediately notified. If that
person is also working with their mental health clinician, that
clinician is notified; their primary care physician is
notified. So we are all on the same page about where that
person is in real time and we can--you know, have intervention
in that moment.
RECOVERY SERVICES
Senator Shaheen. One of the things that several people
mentioned is the importance of the recovery services that are
available. I think one thing that we are now beginning to
recognize, and I know everybody here understands this, but that
substance use disorder is a chronic condition. It is something
that has to be treated throughout your whole life.
So, can you talk about how important those recovery
services are to people as--who may have gone through, maybe
getting medication-assisted treatment and other treatment
plans, but who really need the services that come through
recovery centers.
Dr. Pierce. So, recovery supports are provided before,
during and after treatment. So it allows somebody to establish
a connection with a recovery coach that will be with them for
as long as they need that person in their life.
So, one, it is free other than billing Medicaid, so it is
affordable for somebody who is maybe experiencing other high
costs of treatment. We help somebody with employment, housing,
transportation, getting their children back. We work with
probation and parole. We work with educational programs,
prevention and intervention, so if their children are in high
school or at an appropriate age where we can work with them, we
start working with them as soon as we can.
So we map out recovery at the whole life process, not just
abstinence from alcohol and other drugs, but everything else
that is involved in someone's life, a recovery support system
is what helps as the basis of that.
IMPORTANCE OF FEDERAL FUNDING
Senator Shaheen. Thank you. One of the things that Senator
Capito talked about was the increase in resources, and I think
everybody who spoke talked about how important that increase
has been to address this epidemic in your States.
Can I just ask each of you to give a very brief answer to
what is the alternative if this Federal funding goes away? What
do you see coming in to replace it, and what will happen in
your State to address this epidemic?
I will ask you to go first Dr. Pierce.
Dr. Pierce. Well as a small nonprofit, I am thinking bake
sales.
[Laughter.]
Senator Shaheen. Yes. So, there is no alternative.
Dr. Pierce. Right. No.
Ms. Tanzman. People would lose access to treatment and you
would stop developing strong systems of care for addictions.
Senator Shaheen. Dr. Cropsey.
Dr. Cropsey. In Alabama as a clinician before these Federal
funds, I had no place to refer people with addiction who were
uninsured. So, we would go back to those days when people just
die.
Senator Shaheen. Mr. Stringer.
Mr. Stringer. Yes, Senator we would definitely have to take
a step backwards, particularly in terms of the number of people
that we can serve with evidence-based treatments.
Dr. Fotinos. In Washington, one of the most successful ways
in which we have increased the ability to provide medication is
to provide practices with nurses and care coordinators to
support them; the Federal funds support those folks. Providers
would not be able to treat the number of people that they do,
and more folks would die.
Senator Shaheen. Dr. Berry.
Dr. Berry. We will fight as hard as we can, but my fear is
that we would continue to see the death rate increase
exponentially.
Senator Shaheen. So it sounds like you would all agree that
the progress that we have made in addressing this epidemic is
directly related to the Federal resources that have been
available, and that we need to make sure that those resources
continue to be available if we are going to defeat this
epidemic.
Thank you, Mr. Chairman.
Senator Blunt. All right, thank you Senator.
Senator Hyde-Smith.
TELEMEDICINE
Senator Hyde-Smith. Thank you, Mr. Chairman and ranking
member and thank you for the panel that is here today. It sure
has been informative.
You know, I live in a very rural State like many of the
other members here, in Mississippi, and it is a great place to
be but it is challenging when we have the addiction problems
and trying to treat that.
We have set up a program through the University Medical
Center and the Department of Mental Health that does provide
the Telemed programs, that, you know, when somebody has a
severe addiction, or moderate addiction that, they have
availability to.
Dr. Cropsey, can you tell us maybe, anything in Alabama,
because I am relating to you and that southeastern corner of
the United States that you have done that can address this
rural issue in making sure that those who live daily with
addictions, that we are doing all we can do. I compare
Mississippi to Alabama in many cases and, as I said, a great
place but just, the challenges are there. Do you have any
insight or something you could share, possibly, maybe similar
to Telemed programs?
Dr. Cropsey. To be honest, in our rural communities it is
still a very--it is very challenging. People will try to come
to Birmingham and other places--medical centers to get
treatment, but we do not have as many programs as we need. It
is a--it can be a very resource poor State in that way, I
guess, similar to Mississippi.
So, you know, I think naloxone has been a harm reduction
strategy that has been helpful, but again, trying to reach
people in the rural community has still remained a challenge.
Senator Hyde-Smith. That is--well, thank you for sharing
what you have.
Mr. Stringer, can you tell us more about how the Missouri
Department of Mental Health is partnered with the Missouri
Telehealth network to address the opioid epidemic?
Mr. Stringer. Sure, Senator. That is a great question we
have--of the people we serve with our SOR and STR dollars,
about 30 percent have had some kind of Telehealth service, and
most of those are people who are in very rural settings. So,
that is one way that we have partnered, and that project is
expanding.
The other one, I think the other partial solution to the
rural situation is just very aggressive training of people who
are certified peer specialists; people who been there, people
who can go out, can spread out across the country, across the
State and be available to make connections, to make human
connections with people, to facilitate connections to
Telehealth and then to be there for recovery support.
Senator Hyde-Smith. Thank you very much. And one more,
since I have a little time.
OPIOID RESEARCH
You know, of course the opioid misuse is growing no doubt,
but methamphetamines and the synthetic products like spice
remain, you know, just a huge substance abuse challenge in
Mississippi.
Dr. Berry, have you found that the additional opioids
research have helped also address other abuse of other drugs
like, the meth?
Dr. Berry. Yes, you know, what we are seeing is again, that
this is constantly evolving. So what has been good as far as
the attention that has been placed on the opioids, it is--
helped us really focus on strategies that work. I would say,
and argue that, from my experience in what I see nationally,
and based on the evidence that the best strategies incorporate
not only medications, when possible. We have medications for
opioids; we do not have medications for methamphetamine.
So, if we could develop and continue to pour research
dollars into developing medications like we have for the opioid
users, that would be great. But we have also got time-tested
psychotherapies and social therapies as well that have been
around and that we have known those are effective, and as much
as we can, incorporate every piece of those elements. Those are
things that we have learned and we can continue to build upon,
but we need to have these systems in place so that people can
access this care and work through those systems.
Senator Hyde-Smith. Good. Thank you very much, Mr.
Chairman.
Senator Blunt. All right, thank you Senator.
Senator Manchin.
Senator Manchin. Thank you Mr. Chairman, and thank all of
you. I am so sorry, I was in another meeting and--Energy--
enough--I am sorry.
Senator Blunt. No, no you are fine.
COMPREHENSIVE OPIATE ADDICTION TREATMENT CLINIC
Senator Manchin. You sure? Energy and Resources--and I am
sorry I missed some of this, but it is so important.
Dr. Berry, it is really good to have you here and your wife
Cindy, and know I see them in back and I appreciate everybody
coming.
We have had many conversations and I do not think--I do not
need to reiterate what Senator Capito has spoken about, about
the horrific rate, that, and the scourge it has caused in our
State. We led the Nation in drug overdose again, over 2\1/2\
times the National average. We have talked about that. It shows
it is an 11 percent increase compared to the States 2016 rate;
preliminary data shows the prescription opioid deaths fell in
2018. The numbers overall remain high with an increase of
synthetic opiate deaths that we have been talking about, and
West Virginia remains the hardest hit in the Nation.
I want to talk about, Dr. Berry, if you can, on the
comprehensive opiate addiction treatment clinic, or the COATs;
what we have been doing, what you have done, what extent that
has been going around the State. If you have been able to
expand upon that, has other parts of the State taken that up,
any other parts of the country. Have they worked with you or
reached out?
Dr. Berry. Yes, they have. Just to give you kind of a
picture and the context of the problem, there was a time when
we were treating 500 patients within our university-based
treatment program and had about 600 people on the waiting list
to try to get in.
And once we were able to have resources from, like the STR,
initially and then the SOR funds, and now the State decided to
make a concerted effort to try to expand the model that we
found worked, then we were able to develop somewhat of a hub-
and-spoke type model where we train some of these other
providers at local communities to become experts in this. The
idea being learn one, teach one or do one, then teach one.
Since that time we have been able to expand to another
about 550 patients that would not have been able to be treated
before, and patients who are closer to their local home,
because it is so important that if we are--again, looking at
this as a long-term chronic condition, that we need to be able
to keep people in their communities. They may have to go
somewhere else to get stabilized, that may be the case but not
always, but--the primary mission is to get them back home, get
them back in their communities and have treatment providers who
are competent and capable to do that then.
Senator Manchin. Let me just speak to that because that is
the biggest challenge we have. Our State, because of the
addiction all over our State, every community could warrant
having an addiction center, basically a treatment center.
Dr. Berry. Yes.
Senator Manchin. We do not have the resources for that.
Dr. Berry. Yes.
Senator Manchin. I have a bill called Lifeboat, and I would
encourage all of my colleagues here--Lifeboat basically says
this, the pharmaceutical industry, basically has put a product
out that they knew it was a business model, it was not a
healing or a health model. The opiates come on the market, did
not come on basically to try to relieve your pain or help you
improve the quality of your life. They come onto addict you and
basically hold you hostage for what is happening in this
pharmaceutical industry.
So I said this, they should pay at least one penny per
milligram for every opiate that they produce and sell in
America. That one penny produces over $2 billion a year. Two
billion would go over the most affected areas that got hit the
hardest. We could help rural areas, we cannot help them now. In
your State, we--there is not enough money going around. Dr.
Berry will tell you in our State, the hardest hit county I have
is down in McDowell County, right? Not one center can--treat
down there, and the people do not have enough money to travel
anywhere to treat.
This is--not, it is--and we have not even seen the tip of
the iceberg. Look at the children that are being affected. What
is coming on in the next decade? We have not even seen what is
going to, yet. If you think you have got it bad now, you wait
another 10 years and see.
LABELING OPIOID PRESCRIPTIONS
So anything labeling. One little thing. We will go on. I
led a bill now and all of our colleagues are on this, it is
labeling, changing the labeling of how you use these opiates.
It is not for long term, these were supposed to be intended for
short-term use basically not even be used out of the hospital
and if so, only for 2 or 3 days. Do you think, and I would--I
guess it would be Dr. Cropsey--if you could comment on that
because--do you think that would be a step in the right
direction to help a little bit? Because the doctors have not
done it voluntarily, they are just giving it out like M&Ms.
Dr. Cropsey. Yes. I think that that could be one solution
you know, and I mentioned before the alternatives to therapies
for chronic pain. This is something that should start at the
beginning rather than opioids as the first step for chronic
pain. And now we are in a situation where we have a lot of
people who are prescribed opioids for chronic pain and we do
not know the best strategies to try to get them transitioned to
something that is not an opioid.
We know that when we start reducing their opioids some
people will relapse and will relapse to other drugs like heroin
or fentanyl. So, it is really--it is very much a problem that
we need to--some answers through research to try and figure
out. Also, how to best detox people is also another important
issue.
Senator Manchin. But would you all support the labeling,
changing the labels on opiate prescriptions?
Dr. Cropsey. I think that might be a very good idea.
Senator Manchin. Any comments on that, because my time is
up. I am so sorry. You want--real quick?
Ms. Tanzman. Our health commissioner, Commissioner Levine
would say in--we prescribed, so, probably too many opioids too
long and too often. In Vermont we are seeing a decrease in the
number that we are prescribing and clearly the labeling is
saying take as prescribed should really be more like take as
needed, for example, and----
Mr. Manchin. How about no longer than 3 days?
Ms. Tanzman. Right, but, even so with our decrease right
now in prescribing, we are still prescribing three times as
many as we did in 1999.
As a Medicaid payer we are really struggling to figure out,
well, now what should we be buying in terms of chronic pain
management, because we cannot just take one tool away and not
have it create tremendous pain and suffering for people who
are, in fact, accustomed to using these opioids long term.
Senator Blunt. Thank you Senator.
Senator Rubio.
MEASUREMENT OF OPIOIDS
Senator Rubio. Thank you all for being here. A lot of
attention gets paid to the problem overall and there has been
some questions already about opioid use for chronic pain. I do
not know what the numbers are at this point, but back in 2011,
25 percent of disabled Medicaid beneficiaries under 65 were
using an opioid for chronic pain. I do not know if that number
has declined, or what have you, but, there are a couple of
things I think that are interesting tools and I wanted to get
your perspective.
The first is the, maybe I am saying it the wrong way, the
morphine equivalent calculation. I know Washington State is an
example, as one State that has one of these tools available
online, and I know practitioners in the pain field do use it.
There is a correlation even. There is no safe use of opioid
for chronic pain, but there is a correlation between the
morphine equivalent and the rates of opioid dependence. There
is a terminology used that is not your typical when users are
out there in the street shopping for opioids, but after chronic
opioid use for a specific period of time there is some level of
dependence and that lessens when you get under a certain
morphine equivalent.
Is that a tool that is widely available, the morphine
equivalent calculator for all practitioners? Is that tool being
applied in the pain management field, in general?
I don't know who to give it to but, whoever.
Dr. Fotinos. I can just comment from Washington's
perspective. It is a tool that you can find a number of
different calculators on line, so there are availability tools.
I believe Oklahoma actually puts that into their prescription
monitoring program so that when something is prescribed, and
then these will show up. So there are some clever ways to do
that, and you are absolutely right, the higher the dose of
opiate morphine equivalence that someone's on, the greater the
risk of overdose death.
What we also know in Washington is that the majority of
people who died of an opiate related overdose death have other
drugs with them. So it is just as important to be mindful of
prescribing any other sedative drugs, like Valium, or other
benzodiazepines or----
Senator Rubio. Anything that is respiratory or that is
suppressive.
Dr. Fotinos. Absolutely, and so the combination is equally
important to be mindful of the amount.
Senator Rubio. But, in the--just in the prescription field,
when a practitioner has that calculator available it is not
just about the milligrams, you know, 50 milligrams of one thing
is not the same of another substance. So, in order to find sort
of, not just a lower intensity drug, but to ensure that the
dosage level is safe--the higher you get in that scale of
morphine equivalent--is that an accurate and good measure of
risk even in the acute phase?
Dr. Berry. Yes, it is an accurate measure.
Senator Rubio. And is widely used?
Dr. Berry. I cannot speak for other States. I know that in
West Virginia it is part of our prescription drug monitoring
program and then also, at least in our university-based setting
you have the tool available, so you could always immediately
just hit a button and calculate that.
Dr. Fotinos. I would add that the one challenge we faced,
we have put in some prescription limits and trying to make
folks mindful of the MME, but people who are on methadone for
long-term treatment for their opiate use disorder, or even
buprenorphine now, you kind of have to throw those calculations
out of the window, because their--have developed tolerance with
their treatment.
Senator Rubio. Right.
Dr. Fotinos. So, they will require a lot more medication in
the event of a surgery or an injury.
CHRONIC OPIOID USERS
Senator Rubio. Well, and at its core the reason why opioid
use for chronic pain is problematic is because there is no dose
you can sustain for the rest of your life; you will develop a
tolerance and have to continue to increase it until you get to
levels that are problematic.
So, here is the second question, just hypothetical. A 52-
year-old disabled, Medicaid recipient was injured in a
workplace accident years ago, suffers from chronic pain, and
has been on different pain medications over the years.
This person is functional. It is not somebody who is
overdosing. There are a lot of people out there that fit this
mold, right? They are not overdosing, they are not out there,
you know, shopping in the street or what have you, but if they
stop using from one day to the next they are going to have real
problems for a significant period of time.
What do you do for someone like that, do they go into a
treatment center? Do they go to their physician or for a
tapering schedule; how is that demographic managed? Because I
think that is the piece that does not show up at the emergency
room overdose but has a problem that if they were cut off from
a supply because of some new law. They are going to have some
really bad days ahead of them, and could lead to some of those
behaviors.
Ms. Tanzman. Absolutely agree. And as physicians and
practices begin to look at their patients who they are
prescribing high levels of MME equivalents to, we are finding
them systematically in our primary care roles and in other
roles.
We are struggling to figure out what are the best range of
treatments to help provide as alternatives and also, how to
help focus more on people's functioning like walking and moving
and working, not so much on their pain symptoms, because we may
not be able to fully remediate the pain symptoms, but the
importance of improving function has all of the difference in
terms of quality of life.
Senator Blunt. Thank you, Senator.
Senator Durbin, and then if anybody has second questions,
we will have a few minutes for them.
Senator Durbin, thank you.
PRESCRIBING GUIDELINES
Senator Durbin. Yes, Mr. Chairman, a few years ago there
was a committee hearing and they disclosed that the
pharmaceutical industry asked for permission to produce 14
billion--14 billion opioid doses a year--14 billion. So that
every adult in America could then fill a prescription for 3
weeks of opioids. I thought to myself, How did they ever come
up with 14 billion and who approved it?
Well, they came up with 14 billion because they thought
they could make money selling 14 billion opioid doses and it
was approved by the Drug Enforcement Administration of the
United States Government.
Think of that. At a time when we are facing the worst drug
epidemic in our history, a Government agency is giving this
industry permission to make 14 billion tablets. And how does
that fit with what the CDC sends out as a notice to doctors? It
says here ``When you prescribe, doctor, start low and go slow.
For acute pain--acute pain--prescribe fewer than a 3-day
supply, less than a 3-day supply, more than 7 days rarely
required.''
And here the industry, the pharmaceutical industry, asked
for 14 billion opioid doses despite another agency in the
Government saying, ``This is preposterous. It is beyond any
good medical practice.''
So, being a Senator, I decided to raise hell, about 14
billion and boy did we make progress. You know what we now have
as an annual production quota? Thirteen billion.
[Laughter]
Senator Durbin. Thirteen billion, and we are having
hearings here about figuring out what to do with the results of
that. And the thing that troubles me greatly is, we dance
around the obvious. We dance around the fact that somebody is
writing a prescription for opioids to reach 13 billion, or
something near it. Somebody is ignoring this and the somebody
is a doctor, or a dentist, or a nurse practitioner.
What is going on here? Why are they not responding to this
crisis? Why not have some real response when it comes to
prescribing? What have you seen in your own States? Have the
medical societies and doctors awakened to the reality that they
are pushing more pills than can possibly be justified under CDC
guidelines?
Anybody? Yes, Dr. Fotinos.
Dr. Fotinos. We have seen a decrease in the number of
prescription opiates prescribed over the last several years of
about 44 percent and that is--I think a lot of reasons for
that, one of the things that we have been more successful at
recently is giving reports to providers. Some of the Washington
State Hospital Association decided to, by large healthcare
institutions, get the reports of their prescribing doctors by
specialty. So, they show them here is how many chronic opioids
you prescribed; here is how many you prescribed with people on
sedatives and hypnotics.
And one thing a provider does not want to do is be
different in a bad way from their peers. So, they have also
looked at that to say, are you following prescribing
guidelines? And that sort of individual feedback has been
really helpful in correcting some provider behavior. That is
one of the tools we have used.
FEDERAL FUNDING PRIORITIES
Senator Durbin. I sure hope we do. In Illinois, we wrote to
all the medical societies, only one, the Chicago Medical
Society said continuing medical education was going to be
required of every doctor to come in and pay attention to this.
In the meantime there are courts where these doctors who ignore
this can be held responsible for violating a standard of care.
I only have a minute and a half but I want to make one
point. This is an Appropriation Subcommittee. I am honored to
be on it. We talk about money. We are providing some money to
you and your States, as we should, to face this drug epidemic.
When Senator Shaheen asked the question, I believe it was
Dr. Pierce who said if we did not get this money we would have
bake sales to try to deal with it.
So I want you to reverse your thinking to an alternative
universe for a moment. In 1998 we reached a master tobacco
settlement agreement, we sued the tobacco companies across the
board. State after State ended up recovering $250 billion over
25 years and the purpose of that, among other things, was to
respond to the tobacco public health crisis. What happened? The
money was diverted. The money was spent on highways, and
stadiums, and pension fund liability issues in the States.
Now there is currently a case pending in Cleveland, and
this case, this multidistrict Federal litigation could in a
matter of weeks, come up with a similar settlement against the
pharmaceutical industries and the opioid producers. They could
conceivably decide to dedicate some of that money to try to
respond to what we are talking about today in this hearing.
My question to you and the organizations you belong to is,
What should we ask for? What are the top three things we should
ask this court to consider when it comes to this drug epidemic?
Is it loan forgiveness for those who will major or get graduate
degrees in areas where we do not have enough professionals?
What is it? Have your organizations or any of you thought of
the highest priorities that you would spend Federal dollars on
to deal with this?
The floor is open for a few minutes, a few seconds.
Dr. Berry. Sure. I had mentioned earlier about the
importance of the workforce and that we need to equip the
current treatment providers and the future treatment providers.
And so, the Support Act as well as the Cures Act, and loan
forgiveness, as far as the training programs that are so
necessary. So if we need to be thinking in the future of how we
are we are going to have any ability to counteract this
epidemic, we need to have people who are working in it.
Senator Durbin. Thanks.
Thanks, Mr. Chairman.
MENTAL AND BEHAVIORAL HEALTH
Senator Blunt. Let me get to another topic here on the
question of what we would do without this $3.7 billion. I just
want to be sure the record reflected that in 2015 we had the
Affordable Care Act, this is not in my view a hearing about
that. We had States--most States that were going to expand
Medicaid, had, but that was not doing the job; in 2015 60
percent of the people estimated that needed mental health help
did not get it; 25 percent of that 60 percent did not know
where to get it, and some others just chose not to get it but
it generally was not available.
I continue to think that treating behavioral health like
all other health is important addition to our system.
So, Director Stringer, we are one of the eight States in
the eight State pilot, where we are doing that with certified
community behavioral health centers. You and I were at one of
them last Friday and really one of the most rural counties in
our State. We had pretty good access for this pilot period all
over the State.
Would you talk a little bit about how that was--that being
available at the same time we got into the opioid response,
made a difference in how our State could respond to that.
Mr. Stringer. Sure, Senator--and we heard from a lady at
the roundtable who benefited from the comprehensive set of
services that were available there, so that she was able to get
treatment for her substance use disorder, as well as for her
mental health needs, as well as for her living needs, and
consequently was successfully in recovery.
So I think the comprehensive approach that you and Senator
Stephen Allen have designed has really, again--it has
transformed healthcare. And when I say healthcare now, in the
spirit of what you are talking about, I am including mental
healthcare and substance use disorders.
So, when we--when someone comes in to one of our certified
community behavioral health clinics now, they are seeing not as
a diagnosis but as a person with complex needs that we address
in a holistic way, and as thoroughly as possible. And we
continue those services so that person gets in recovery, stays
in recovery, and thrives.
Senator Blunt. Beginning to see at any emergency room
numbers responding to that or part of the pilot is to, frankly,
see what impact this has on people's overall health needs if
you are also being--treating their behavioral health needs like
you would treat any other health problem. Do you see, 2 years
into this or a year and a half into this are you beginning to
see anything you can share with us?
Mr. Stringer. Yes, we have absolutely seen improvements in
a number of domains, and I can get that data to you Senator.
Senator Blunt. Okay.
Mr. Stringer. But, we were followed out--as Dr. Gaudi and I
left the roundtable discussion we were followed out by a
juvenile judge who came up to our vehicle and was saying how
much he appreciated some of the services made available through
the CCBAC, that were again comprehensive, that were--that
allowed us to go into schools, that allowed us to go really,
where people are, find them, and give them the assistance that
they needed.
So we are seeing improvements in healthcare, we are seeing
improvements in a criminal justice system, we are seeing
improvements in employment, and just, an overall quality of
life.
Senator Blunt. Right. In one of the--Oklahoma is one of the
other States. And I was in a meeting the other day where they
said at one of their major hospitals that has developed through
the law enforcement and other network, other places to go, a 70
percent reduction in the emergency room in that system. Because
almost all of the behavioral health people that were coming
there now have a better path to somewhere that they can not
only just go that night but can also begin to develop a
permanent place to be.
Senator Murray.
CDC FUNDING
Senator Murray. Yes, thank you Mr. Chair, and I just have
one more appropriations related question. On the CDC funding
side of this, in addition to the new funding that this
subcommittee provided to States through block grants, we did
give CDC a lot of new money to address opioids through a public
health approach.
Let me just ask you quickly, Dr. Fotinos, What are some of
the investments, for example Washington State made with that,
those dollars?
Dr. Fotinos. A number of the CDC funds have been used for
overdose prevention, so helping to establish a training program
to put naloxone out in the communities to train the providers,
train first responders. We have seen a huge uptake in
utilization and dispensing of naloxone and the numbers of folks
that are receiving it for overdose reversal.
There has also been some of that money used to increase
surveillance, so when someone is admitted to the emergency room
that is--we are developing a system to sort of, have that real
time notification. We also have a hospital and an emergency
room based system called EDIE that also can generate notices to
providers when their patients show up for an opioid overdose.
A lot of the money has been sent to local health
jurisdictions to help them figure out what they need regionally
to respond to the epidemic. And some of those funds have been
used to support staff to work on overdose reports; some of the
ones I mentioned earlier that we can give feedback to
providers, who may or may not know their patient has
experienced an overdose.
Senator Murray. Okay, some of the rest of you can give the
committee response back in writing about how some of that
funding is being used.
And Dr. Fotinos, is it true that your grant funding ends in
August?
Dr. Fotinos. There are a number of different CDC funds. I
can look and share with you a list of the Department of Health,
how they are spending those monies and the duration of them.
Senator Murray. Okay. I just wondered what would happen if
that grant is not continued.
Dr. Fotinos. Well, we do know that the staffing that
provide the overdose reports is going away, but the hospital
association has picked that up and the Department of Health has
received some funds to continue that at a different level. But
again, we would reduce the ability to train folks to use
naloxone, some of those surveillance activities would be cut.
Some of that money has also been used to help train coroners
who may not be medically trained to accurately identify
overdose deaths so that we could actually have an accurate
count. It is also being used to improve some of our
surveillance systems so we can know how many babies are born
affected with substance exposure. So really it is being used to
help support infrastructure as well, so we can get accurate
information and respond.
Senator Murray. Okay, very helpful. Thank you, Mr.
Chairman.
SUBCOMMITTEE RECESS
Senator Blunt. Well, thanks Senators. Thank you all of our
witnesses, we really appreciated what you--the information you
brought to us today.
The record will stay open for one week for additional
comments.
The subcommittee will stand in recess.
[Whereupon, at 11:51 a.m., Thursday, February 28, the
subcommittee was recessed, to reconvene subject to the call of
the Chair.]
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