[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: \*\
---------------------------------------------------------------------------
    \*\ [Clerk's note: The material can be found in ``Material 
Submitted for the Record.'']
---------------------------------------------------------------------------
  --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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