[Senate Hearing 117-392]
[From the U.S. Government Publishing Office]


                                                      S Hrg 117-392

                  STRENGTHENING FEDERAL MENTAL HEALTH
                  AND SUBSTANCE USE DISORDER PROGRAMS:
                       OPPORTUNITIES, CHALLENGES,
                          AND EMERGING ISSUES

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                                   ON

    EXAMINING STRENGTHENING FEDERAL MENTAL HEALTH AND SUBSTANCE USE 
DISORDER PROGRAMS, FOCUSING ON OPPORTUNITIES, CHALLENGES, AND EMERGING 
                                 ISSUES

                               __________

                             MARCH 23, 2022

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
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        Available via the World Wide Web: http://www.govinfo.gov
        
                              __________

                                
                    U.S. GOVERNMENT PUBLISHING OFFICE                    
48-903 PDF                  WASHINGTON : 2023                    
          
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                    PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont          RICHARD BURR, North Carolina, 
ROBERT P. CASEY, JR., Pennsylvania       Ranking Member
TAMMY BALDWIN, Wisconsin             RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut   SUSAN M. COLLINS, Maine
TIM KAINE, Virginia                  BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire         LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota                MIKE BRAUN, Indiana
JACKY ROSEN, Nevada                  ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico            TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado          MITT ROMNEY, Utah
                                     TOMMY TUBERVILLE, Alabama
                                     JERRY MORAN, Kansas

                     Evan T. Schatz, Staff Director
               David P. Cleary, Republican Staff Director
                  John Righter, Deputy Staff Director
                            
                            
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                       WEDNESDAY, MARCH 23, 2022

                                                                   Page

                           Committee Members

Murray, Hon. Patty, Chair, Committee on Health, Education, Labor, 
  and Pensions, Opening statement................................     1

Burr, Hon. Richard, Ranking Member, a U.S. Senator from the State 
  of North Carolina, Opening statement...........................     3

                               Witnesses

Delphin-Rittmon, Miriam E., Ph.D., Assistant Secretary for Mental 
  Health and Substance Use, Substance Abuse and Mental Health 
  Services Administration, Rockville, MD.........................     6
    Prepared statement...........................................     7

Johnson, Carole, Administrator, Health Resources and Services 
  Administration, Rockville, MD..................................    16
    Prepared statement...........................................    17

Gordon, Joshua A., M.D., Ph.D., Director, National Institute of 
  Mental Health, National Institutes of Health, Bethesda, MD.....    24
    Prepared statement...........................................    25

Volkow, Nora D., M.D., Director, National Institute on Drug 
  Abuse, National Institutes of Health, Bethesda, MD.............    28
    Prepared statement...........................................    30

                         QUESTIONS AND ANSWERS

Response by Miriam E. Delphin-Rittmon to questions of:
    Senator Casey................................................    59
    Senator Baldwin..............................................    63
    Senator Hickenlooper.........................................    65
    Senator Murkowski............................................    67
    Senator Braun................................................    74
    Senator Tuberville...........................................    76
Response by Carole Johnson to questions of:
    Senator Casey................................................    78
    Senator Rosen................................................    80
    Senator Hickenlooper.........................................    82
    Senator Murkowski............................................    85
    Senator Braun................................................    94
    Senator Tuberville...........................................    95
Response by Joshua A. Gordon to questions of:
    Senator Casey................................................    96
    Senator Rosen................................................    97
    Senator Hickenlooper.........................................   101
    Senator Murkowski............................................   102
    Senator Scott................................................   108
    Senator Tuberville...........................................   111
Response by Nora D. Volkow to questions of:
    Senator Casey................................................   112
    Senator Murkowski............................................   114
    Senator Tuberville...........................................   121

 
                  STRENGTHENING FEDERAL MENTAL HEALTH
                  AND SUBSTANCE USE DISORDER PROGRAMS:
                       OPPORTUNITIES, CHALLENGES,
                       AND EMERGING ISSUES

                              ----------                              


                       Wednesday, March 23, 2022

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.

    The Committee met, pursuant to notice, at 10:01 am, in room 
430, Dirksen Senate Office Building, Hon. Patty Murray, Chair 
of the Committee, presiding.

    Present: Senators Murray [presiding], Baldwin, Murphy, 
Kaine, Hassan, Smith, Rosen, Burr, Collins, Cassidy, Murkowski, 
Braun, Marshall, Scott, and Tuberville.

                  OPENING STATEMENT OF SENATOR MURRAY

    The Chair. Good morning. Senate Health, Education, Labor, 
and Pensions Committee will please come to order. Today we are 
holding a hearing on our Nation's growing mental health and 
substance use disorder crisis. I will have an opening 
statement, followed by Ranking Member Burr. We will then 
introduce our witnesses. And after they give their testimony, 
Senators will each have 5 minutes for a round of questions.

    Again, we are unable to have the hearing fully opened to 
the public or media for in-person attendance. As always, live 
video is available on our Committee website at 
help.senate.gov,. And if you are in need of accommodations, 
including close captioning, you can reach out to the Committee 
or to the Office of Congressional Accessibility Services.

    I hope that everyone on this Committee found our hearing in 
February with mental health and substance use disorder experts, 
care providers, and advocates to be informative and compelling. 
We are all hearing from families in our States about the need 
for action.

    Parents worried about their kids well-being after the 
stress and trauma of this pandemic. People struggling with 
depression and anxiety themselves and unsure where to go for 
help. Communities fighting a rise in substance abuse, as well 
as a surge in overdose deaths fueled by a deadly increase in 
fentanyl use.

    Mental health and substance use disorder professionals who 
are feeling overworked, overwhelmed, and just burned out. We 
all want to address these challenges, which is why Senator 
Burr, and I are working in a bipartisan way on legislation to 
support our communities and help people get the services for 
mental health and substance use disorders that they need. We 
continue to make progress on that effort, and our hearing today 
represents another important step forward.

    I spoke last time about the work that Lifeline Connections 
and Neighborhood House and the Confederated Tribes and bands of 
Yakama Nation and other local organizations are doing to 
address the mental health needs of families in Washington 
State. And I am glad to have this opportunity to discuss how 
the Federal Government can better support frontline efforts to 
screen and provide services for mental health challenges, 
support people who are struggling with substance use disorder, 
increase access to addiction treatment, prevent drug overdoses 
and suicide, and more.

    Because COVID-19 has made it clearer than ever that while 
our communities are doing valuable, lifesaving work, we need to 
do much more to help them. Youth health emergencies have 
skyrocketed during this pandemic, with sharp increases in kids' 
visits to the emergency room for mental health crises, thoughts 
of suicide, suicide attempts, especially among girls, and as of 
February, over 200,000 children have had their world shattered 
after losing a parent or caregiver to COVID-19.

    This pandemic has also set us back catastrophically when it 
comes to substance use disorders. We saw an estimated 106,000 
drug overdose deaths in a single year. That is a record high. 
And fentanyl has been especially devastating for families in my 
state. Fentanyl deaths in our largest county doubled last year. 
But nationally we are also seeing a concerning rise in 
methamphetamine and cocaine use.

    Meanwhile, our mental health and substance use disorder 
workforce, which was already stretched thin, is nearly 
threadbare. I said this before, but it really stands out to me 
that almost 130 million Americans live in areas with less than 
one mental health provider per thousand people. And in my home 
State of Washington, our mental health care workforce is only 
able to meet 17 percent of our state's needs.

    Meanwhile, nationwide, not even a tenth of people who need 
treatment for substance use disorder actually get it. And these 
problems are especially pronounced for rural areas, communities 
of color, and people with disabilities. And it is important to 
remember that the many people who are personally facing mental 
health and substance use disorders or struggling to get the 
support they need, aren't the only ones feeling this. We all 
have friends and family who are, whether we realize it or not.

    We all rely on first responders, health care providers, and 
other frontline workers who are experiencing burnout and 
trauma. We all have a stake in making sure people can get the 
help they need. So let's make sure we act accordingly. Now we 
are starting here on square one. We have a long, bipartisan 
track record of addressing mental health and substance use 
disorders in this Committee.

    But we are also not close to where we need to be, 
especially considering the ways this pandemic has worsened 
preexisting challenges. We need to rise to this moment by 
strengthening the tools that communities are already using 
effectively to help people get care and providing new ones to 
address the gaps and emerging issues this pandemic has made so 
much worse.

    That means putting together a bipartisan package that 
supports suicide screening and prevention, help schools and 
communities meet kids' mental health needs, reduces drug 
overdose deaths and gives patients more options to get 
substance use disorder treatment, addresses the mental health 
needs of new mothers, tackles barriers that make it hard for 
people to get the care they need, like stigma, health inequity, 
and a strained workforce, and more.

    I know Members on both sides of the aisle share these goals 
and have ideas about how to make them a reality, and I look 
forward to continuing to work with all of you on this. As 
Ranking Member Burr and I have announced, it is our goal to 
pull the Committee's mental health package together in early 
summer so we can move legislation to the floor. We both hope to 
have more to say on that in the days ahead and appreciate the 
many ideas that Members on and off this Committee have for the 
package as we work together to address this crisis.

    This pandemic has done so much to damage our Nation's 
mental well-being. There are so many people who are stressed 
and anxious and traumatized, struggling with addiction, or who 
are grieving over the loss of a loved one and don't know where 
to turn. But there are also people in our communities who care 
about them and who are working right now to get them help.

    As this Committee works on bipartisan legislation to 
reauthorize and improve Federal programs on mental health and 
substance use disorder, I look forward to hearing from all of 
our witnesses today about the steps that we can take to help 
bolster the efforts of those on the front lines of our mental 
health and substance use disorder crisis, and make sure that 
every person who is struggling can get the care they need 
without worrying about stigma or cost, without having to travel 
for hours or wait for weeks, and without feeling like they are 
all on their own.

    With that, I will turn it over to Senator Burr for his 
remarks.

                   OPENING STATEMENT OF SENATOR BURR

    Senator Burr. Thank you, Madam Chair. Thank you for holding 
this hearing. Even before the pandemic, we knew the need to 
address mental health and substance use disorders were dire. 
Opioids took hold and the result was a crisis, with families 
and communities who had not dealt with that for some time. As 
we look to reauthorize a number of these programs, we face 
problems that have been compounded by the pandemic but can be 
informed by our COVID response.

    We learned that research, innovation, partnerships, and 
real time data are the key to our success in overcoming an 
unprecedented public health challenge. Today's hearing will 
help us determine how to apply these lessons and those actions 
to mental health and substance use challenges that continue to 
devastate our communities.

    The last time the Committee examined our mental health and 
substance use programs, we heard from Sam Quinones, excuse me, 
on opioids, who shared his belief that isolation and lack of 
community was a driving factor in the substance use disorder 
crisis facing America. Isolation only worsened when the 
pandemic struck. Months on end of remote learning, time 
separated from aunts, uncles, grandparents, friends, teachers, 
families, were critical--with critically ill and dying loved 
ones who could not say goodbye has taken a tremendous toll on 
America, especially on children.

    We are seeing the results of the past 2 years at an 
alarming rate of people, particularly young children, arriving 
in the emergency room in a state of mental health crisis. In 
2020 alone, the number of young people seeking care for their 
mental health in the emergency room increased by 31 percent. 
Between 2016 and 2020, the number of children experienced 
depression increased by 27 percent.

    The number of children experiencing anxiety rose by 29 
percent. Last year, more than 100,000 people lost their lives 
to drug overdose, a nearly 30 percent increase from the year 
before. Two-thirds of these adults were linked to synthetic 
opioids such as fentanyl. But in the face of these tragedies, 
we see strength and resilience, families turning tragedy into 
action to bring awareness and understanding to help others.

    In hearings over the past year, we have heard examples of 
leaders in local communities ready to meet these challenges, 
partnering to bring local solutions to address local 
challenges. As we consider reauthorizing these programs, it 
would serve us well to remind to remember this too. Since 2016, 
we have authorized or reauthorized more than 40 different 
Federal programs to address mental health and substance use 
disorder.

    In addition, the Fiscal Year 2022 omnibus appropriations 
bill provided nearly $5 billion for mental health and substance 
use disorder related programs. But at least nine of these 
authorized programs did not receive funding. We have seen time 
and time again that creating a new program that does not get 
funded is a false promise. That creating new programs for the 
press release of a markup isn't actually a solution.

    We need to figure out what we can do with the tools that we 
have and improve the current programs and fund the programs 
that we do create. We should be honest with ourselves and the 
country and terminate the programs that haven't received 
funding in the last 5 years. If a program hasn't received 
funding, it shouldn't stay on the books. We will have to 
prioritize and answer key questions like how to better target 
our programs to make sure that they are both meeting the needs 
of today, but also have the flexibility to address the needs of 
tomorrow.

    To our witnesses, welcome. We need your expertise to ensure 
we have the right performance measures in place to track 
progress in the programs you oversee. GAO recently found that 
many of our mental health and substance abuse programs lacked 
the measures we need to know whether the programs work. You 
only know what you can measure. If we cannot track programs in 
a meaningful way, we will not know how to improve the programs 
to better meet the needs of the people that are intended to be 
served and reprioritize those that are underperforming.

    Additionally, we need to make sure that we are using up to 
date data to inform our response and addressing emerging 
issues. States and local communities must be empowered to 
address these issues, and they need accurate information to 
identify the problems that they are facing, like emergence--or 
emergence or reemergence of a new drug in an area or 
identifying increased rates of suicide in certain populations. 
Sometimes this requires thinking outside the box.

    We saw communities pull together during the pandemic to 
come up with solutions that worked, and we need the same spirit 
and ingenuity with this challenge. One of the trends in that 
success was partnerships with the private sector. Local public, 
private partnerships are the foundation of many of our 
successful Federal mental health and substance disorder 
programs.

    I look forward to hearing more about how SAMHSA is 
encouraging partnerships and facilitating local engagement 
through these programs, and how this can be improved going 
forward. Leveraging innovation to help address our mental 
health and substance use disorder crisis is another area I look 
forward to focusing on and hearing more about. Critical to all 
of this strong workforce, this Committee reauthorized a number 
of health workforce programs in 2020, in addition to those 
included in the pandemic package.

    The health workforce, particularly our doctors, nurses, 
counselors, and therapists, have been through a lot. They rose 
to the challenge during this pandemic, and it has taken its 
toll. Earlier this Congress, the Committee passed the Dr. Lorna 
Breen Health Care Provider Protection Act, which was just 
signed into law, to make sure that these providers get the 
support and care they need for their own mental health and 
substance use concerns, especially if they continue to care for 
all of us.

    Madam Chairman, I look forward to hearing more about how 
HRSA is leveraging and prioritizing existing Federal health 
workforce programs to fill gaps in the mental health and 
substance use disorder workplace. I yield floor.

    The Chair. Thank you very much. With that, I will introduce 
today's witnesses. Our first witness is Dr. Miriam E. Delphin-
Rittmon. She is the Assistant Secretary for Mental Health and 
Substance Use at the Department of Health and Human Services, 
who leads the Substance Abuse and Mental Health Services 
Administration. Welcome. Good to see you here today.

    Our next witness is Ms. Carole Johnson. She is the 
Administrator of the Health Resources and Services 
Administration. Welcome to you. We are also joined today by Dr. 
Joshua Gordon, the Director of the National Institute of Mental 
Health. We appreciate you being here today.

    Our final witness is Dr. Nora Volkow, Director of the 
National Institute on Drug Abuse. Thank you for being with us 
as well. With that, we will start with you, Assistant Secretary 
Delphin-Rittmon.

   STATEMENT OF MIRIAM E. DELPHIN-RITTMON, PH.D., ASSISTANT 
SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE, SUBSTANCE ABUSE 
    AND MENTAL HEALTH SERVICES ADMINISTRATION, ROCKVILLE, MD

    Ms. Delphin-Rittmon. Thank you, and good morning, Chair 
Murray, Ranking Member Burr, and Members of the Committee for 
inviting me here to testify today. I am the Assistant Secretary 
for Mental Health and Substance Use at SAMHSA, the agency that 
leads the public health efforts to advance the behavioral 
health of the Nation and improve the lives of individuals 
living with mental health and substance use disorders, as well 
as their families. It is an honor to lead this agency, and I am 
a proud product of one of its programs, the Minority Fellowship 
Program.

    I am pleased to be here with my colleagues from HHS, from 
HRSA, NIH to discuss the growing mental health and substance 
use challenges that we are facing as a country. As President 
Biden noted, our Country faces an unprecedented mental health 
crisis among people of all ages and backgrounds. Even before 
the pandemic, rates of depression and anxiety were inching 
higher. But grief, trauma, physical isolation of the last 2 
years have driven Americans to a breaking point.

    In addition, drug overdose deaths have reached a historic 
high, devastating families and communities. More than 104,000 
Americans died due to drug overdose in the 12 month period 
ending in September 2021. For these reasons, the Biden-Harris 
Administration has included addressing mental health and 
addiction as two of the four pillars of the unity agenda that 
was outlined in the President's State of the Union address.

    SAMHSA is actively working to advance the unity agenda, 
including helping to implement the National Mental Health 
Strategy. This strategy includes strengthening capacity, 
connecting more Americans to care, creating a continuum to 
support--a continuum of support that aims to transform our 
health infrastructure to address mental health holistically and 
equitably. To help advance SAMHSA advance this mission, I have 
identified five core near-term priorities for the agency.

    The first is preventing overdose. Giving the escalating 
overdose crisis and the negative impact of COVID-19 pandemic, 
the HHS has created a new--created a new comprehensive overdose 
prevention strategy meant to strengthen our primary prevention 
efforts and increase access to a full continuum of care and 
services for individuals with substance use disorder and their 
families.

    The second is enhancing access to suicide prevention and 
crisis care. Preparing the National Suicide Lifeline for full 
9-8-8 operational readiness requires a bold vision for a system 
that provides direct lifesaving services to all in need and 
links them to community based providers uniquely positioned to 
deliver a full range of crisis care services.

    SAMHSA sees 9-8-8 as a linchpin and a critical catalyst to 
transform the behavioral health system of care. The third is 
promoting children and youth behavioral health. To focus our 
efforts on improving behavioral health wellness for our 
Nation's youth, SAMHSA has developed the HOPE framework, 
health, opportunity, potential, and equity for children, youth, 
and families across the country.

    The fourth is integrating primary care and behavioral 
health. We know that individual's first interactions with 
health system is typically through a primary care provider or 
an emergency room. During the COVID-19 pandemic, while 
providers were initially focused on acute medical concerns, we 
heard that many were not adequately resourced to consider the 
behavioral health effects of the pandemic.

    The fifth is using performance measures, data, and 
evaluation. For example, SAMHSA recently released the 
Behavioral Health Equity Report 2021, drawing on data from our 
national survey on drug use and health. My written testimony 
also outlines four additional cross-cutting principles, several 
SAMHSA programs that bolster our work to support these 
priorities.

    These principles are greater equity within the behavioral 
health system, enhancing the behavioral health workforce, 
promoting and supporting recovery practices, and working to 
ensure financing of a robust behavioral health system of care. 
I will close by echoing President Biden's call in his State of 
the Union to support the millions of Americans who are in 
recovery. Early on and throughout my career, I have been 
inspired both personally and professionally by family members, 
friends, colleagues, and acquaintances who with courage and 
resilience have striven for wellness and recovery.

    On behalf of my colleagues at SAMHSA, I want to thank you 
for your interest and support for our programs, and for 
supporting the Nation's behavioral health. I look forward to 
answering any questions that you have.

    [The prepared statement of Ms. Delphin-Rittmon follows:]

            prepared statement of miriam e. delphin-rittmon
    Good morning Thank you, Chair Murray, Ranking Member Burr, and 
Members of the Committee for inviting me to testify during this hearing 
focusing on mental health and substance use.

    My name is Miriam Delphin-Rittmon, and I am the Assistant Secretary 
for Mental Health and Substance Use at the U.S. Department of Health 
and Human Services (HHS) In this role, I lead the Substance Abuse and 
Mental Health Services Administration, also known as SAMHSA, SAMHSA is 
the agency within HHS that leads public health efforts to advance the 
behavioral health of the Nation and improve the lives of individuals 
living with mental and substance use disorders, as well as their 
families.

    It is an honor to lead this agency In fact, I am a proud product of 
one of SAMHSA's programs--the Minority Fellowship Program (MFP) The MFP 
program provided me, and other mental health and substance use disorder 
clinicians, an educational scholarship and training to more effectively 
treat and serve people of different cultural and ethnic backgrounds.

    I am pleased to be here, along with my HHS colleagues from the 
Health Resources and Services Administration and the National 
Institutes of Health to discuss the growing mental health and substance 
use crisis.

    As President Biden has noted, our Country faces an unprecedented 
mental health crisis among people of all ages and backgrounds Two out 
of five adults report symptoms of anxiety or depression and minoritized 
communities are disproportionately undertreated Even before the 
pandemic, rates of depression and anxiety were inching higher But the 
grief, trauma, and physical isolation of the last 2 years have driven 
Americans to a breaking point In addition, drug overdose deaths have 
reached a historic high, devastating families and communities More than 
104,000 Americans died due to a drug overdose in the 12-month period 
ending in September 2021 For these reasons, President Biden included 
addressing mental health and addiction as two of the four pillars of 
the unity agenda he outlined in the State of the Union Address.

    SAMHSA is actively working to advance the unity agenda and the 
national mental health strategy, which includes strengthening system 
capacity, connecting more Americans to care, and creating a continuum 
of support that aims to transform our health and social services 
infrastructure to address mental health holistically and equitably.

    Though this testimony, I will expand on how SAMHSA is working to 
achieve the goals of the President.
               SAMHSA's Role, Priorities, and Principles
    SAMHSA's mission of reducing the impact of substance use and mental 
illness on American communities is more relevant than ever To help 
advance our mission, I have identified five core near-term priorities 
for the agency:

          1. Preventing overdose;

          2. Enhancing access to suicide prevention and crisis care;

          3. Promoting child and youth behavioral health;

          4. Integrating primary and behavioral healthcare; and

          5. Using performance measures, data, and evaluation

    I have also outlined four critical cross-cutting principles to 
bolster SAMHSA's work on our near-term priorities These principles 
include:

          1. Greater equity within the behavioral health system;

          2. Enhancing the behavioral health workforce;

          3. Promoting and supporting recovery practices; and

          4. Working to ensure financing of a robust array of 
        behavioral health services

    These priorities and principles are aligned with the focus of the 
HHS Behavioral Health Coordinating Council (BHCC), which I have the 
honor of co-chairing with Admiral Rachel Levine, the Assistant 
Secretary for Health The purpose of the BHCC is to more efficiently 
identify and facilitate collaborative, innovative, transparent, 
equitable, and action-oriented approaches to addressing HHS's 
behavioral health agenda, priorities, and strategic planning.
                           RECENT SAMHSA DATA
              2020 National Survey on Drug Use and Health
    In October 2021, SAMHSA released findings from the 2020 National 
Survey on Drug Use and Health (NSDUH) \1\, \2\ The data suggest that 
the COVID-19 pandemic had a negative impact on the nation's well-being 
Americans responding to the NSDUH survey reported that the coronavirus 
outbreak adversely impacted their mental health, including by 
exacerbating use of alcohol or drugs among people who had used drugs in 
the past year.
---------------------------------------------------------------------------
    \1\  Substance Abuse and Mental Health Services Administration 
(2021) Key substance use and mental health indicators in the United 
States: Results from the 2020 National Survey on Drug Use and Health 
(HHS Publication No PEP21-07-01-003, NSDUH Series H-56) Rockville, MD: 
Center for Behavioral Health Statistics and Quality, Substance Abuse 
and Mental Health Services Administration Retrieved from https://
wwwsamhsagov/data.
    \2\  Several changes to the 2020 NSDUH prevent its findings from 
being directly comparable to recent past-year surveys.

    Based on data collected nationally from October to December 2020, 
it is estimated that 259 million past-year users of alcohol and 109 
million past-year users of drugs other than alcohol reported they were 
using these substances ``a little more or much more'' than they did 
before the COVID-19 pandemic began During that same time period, youth 
ages 12 to 17 who had a past-year major depressive episode (MDE) 
reported they were more likely than those without a past-year MDE to 
feel that the COVID-19 pandemic negatively affected their mental health 
``quite a bit or a lot'' Adults 18 or older who had any mental illness 
(AMI) or serious mental illness (SMI) in the past year were more likely 
than adults without mental illness to report that the pandemic 
negatively affected their mental health ``quite a bit or a lot''.
                           SAMHSA PRIORITIES
                          Preventing Overdose:
    Although overdose deaths involving heroin and prescription opioids 
have decreased, the overdose crisis continues to be a challenge for 
this country Synthetic opioids like illicitly manufactured fentanyl and 
the use of other substances, like stimulants such as cocaine and 
methamphetamine, and polydrug use, have led to significant increases in 
overdose deaths. \3\
---------------------------------------------------------------------------
    \3\  O'Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J Trends 
in and Characteristics of Drug Overdose Deaths Involving Illicitly 
Manufactured Fentanyls--United States, 2019--2020 MMWR Morb Mortal Wkly 
Rep 2021;70:1740-1746 DOI: http://dxdoiorg/1015585/
mmwrmm7050e3external--icon.

    Given the escalating overdose crisis and the negative impact of the 
COVID-19 pandemic, HHS experts came together to create a new, 
comprehensive Overdose Prevention Strategy (Strategy) meant to 
strengthen our primary prevention efforts and increase access to the 
full continuum of care and services for individuals with substance use 
disorder (SUD) and their families \4\ I will discuss several SAMHSA 
efforts that support this Strategy and the care continuum below.
---------------------------------------------------------------------------
    \4\  Haffajee, RL, Sherry, TB, Dubenitz, JM, White, JO, Schwartz, 
D, Stoller, B, Swenson-O'Brien, AJ, Manocchio, TM, Creedon, TB, 
Bagalman, E U.S. Department of Health and Human Services Overdose 
Prevention Strategy (Issue Brief) Washington, DC: Office of the 
Assistant Secretary for Planning and Evaluation, U.S. Department of 
Health and Human Services October 27, 2021.
---------------------------------------------------------------------------
     Establishing an Office of Recovery and Advancing Peer Supports
    Recovery is a key pillar in our Overdose Prevention Strategy That 
is why during Recovery Month last fall, SAMHSA announced it would be 
establishing a new Office of Recovery This office will promote the 
involvement of people with lived experience throughout agency and 
stakeholder activities, foster relationships with internal and external 
organizations in the mental health and addiction recovery fields, and 
identify health disparities in high-risk and vulnerable populations to 
ensure equity for support services across the Nation.

    We know that recovery is enhanced by peer-delivered services These 
services have proven to be effective as the support, outreach and 
engagement with new networks help sustain recovery over the long term 
Investing in peer services is critical, given the significant workforce 
shortages in behavioral health That is why, as part of the President's 
Strategy to Address Our National Mental Health Crisis, SAMHSA will 
convene stakeholders to explore the benefits of national certified peer 
specialist certification and how it could accelerate universal 
adoption, recognition, and integration of the peer mental health 
workforce across all elements of the health care system.
          Substance Abuse Prevention and Treatment Block Grant
    The Substance Abuse Prevention and Treatment Block Grant (SABG) 
helps states in addressing substance use treatment and prevention needs 
through support of prevention, treatment, and other services not 
covered by commercial insurance and non-clinical activities and 
services that address the critical needs of state substance use service 
systems The SABG supports state prevention, treatment, and recovery 
systems' infrastructure and capacity, thereby increasing availability 
of services and development and implementation of evidence-based 
practices.

    The Administration supports the addition of a 10 percent set-aside 
within the SABG for recovery support services aimed at significantly 
expanding the continuum of care both upstream and downstream This 
proposed set-aside would support the development of local recovery 
community support institutions (ie, recovery community centers, 
recovery homes, recovery schools); develop strategies and educational 
campaigns, trainings, and events to reduce addiction/recovery-related 
stigma and discrimination at the local level; provide addiction 
recovery resources and support system navigation; make accessible peer 
recovery support services that support diverse populations and are 
inclusive of all pathways to recovery; and collaborate and coordinate 
with local private and non-profit clinical health care providers, the 
faith community, city, county, state, and Federal public health 
agencies, and criminal justice response efforts.
                State and Tribal Opioid Response Grants
    The State Opioid Response (SOR) grant program aims to address the 
overdose crisis by increasing access to FDA-approved medications for 
the treatment of opioid use disorder (OUD), reducing unmet treatment 
needs, and reducing opioid overdose related deaths through the 
provision of prevention, treatment, and recovery activities for OUD.

    States and communities across the country are also dealing with 
rising rates of stimulant use and its negative health, social, and 
economic consequences To address the growing rate of stimulant-involved 
overdose deaths, Congress has allowed the use of State Opioid Response 
grants to include methamphetamine and other stimulants to give states 
and tribes flexibility to address their unique community needs.

    Harm reduction is also an important pillar of the Strategy That is 
why HHS announced, in April 2021, that grantees in certain programs 
such as SOR may now purchase rapid fentanyl test strips to help curb 
the dramatic spike in drug overdose deaths largely driven using strong 
synthetic opioids, including illicitly manufactured fentanyl. \5\
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    \5\  Centers for Disease Control and Prevention, ``Federal Grantees 
May Now Use Funds to Purchase Fentanyl Test Strips'', (April 7, 2021).

    Like the SOR program, the Tribal Opioid Response Grants program 
also aims to address the overdose crisis, but directs funding to tribal 
communities.
                 Pregnant and Postpartum Women Program
    The Pregnant and Postpartum Women program (PPW) uses a family 
centered approach to provide comprehensive residential substance use 
disorder treatment, prevention, and recovery support services for 
pregnant and postpartum individuals, their minor children, and for 
other family members The family centered approach includes partnering 
with others to leverage diverse funding streams, encouraging the use of 
evidence-based practices, supporting innovation, and developing 
workforce capacity to meet the needs of these families The PPW program 
provides services not covered under most public and private insurance 
SAMHSA continues to prioritize states that support best-practice 
collaborative models for treatment, as well as provide support to 
pregnant individuals with OUD The Comprehensive Addiction and Recovery 
Act increased accessibility and availability of services for pregnant 
individuals by expanding the authorized purposes of the program to 
include the provision of outpatient and intensive outpatient services.
                         Harm Reduction Grants
    This year, SAMHSA launched its first-ever Harm Reduction grant 
program and expects to issue $30 million in grant awards This 
opportunity, authorized by the American Rescue Plan Act, will help 
increase access to a range of community harm reduction services and 
support harm reduction service providers as they work to help prevent 
overdose deaths and reduce health risks often associated with drug use 
Providing funding and support for innovative harm reduction services is 
a key pillar for the Strategy This funding will allow organizations to 
expand their distribution of overdose-reversal medications and fentanyl 
test strips, provide overdose education and counseling, and manage or 
expand syringe services programs, which help control the spread of 
infectious diseases like HIV and hepatitis C.
     DATA Waiver, Treatment Capacity, and Buprenorphine Guidelines
    In an effort to get evidenced-based treatment to more Americans 
with OUD, last April SAMHSA and HHS announced buprenorphine practice 
guidelines that remove certain training and certification requirements 
which some practitioners have cited as a barrier to treating more 
people \6\ The Practice Guidelines for the Administration of 
Buprenorphine for Treating Opioid Use Disorder (Practice Guidelines) 
provides an exemption from certain statutory certification requirements 
for eligible physicians, physician assistants, nurse practitioners, 
clinical nurse specialists, certified registered nurse anesthetists, 
and certified nurse midwives, who are state licensed and registered by 
the Drug Enforcement Administration to prescribe controlled substances 
Specifically, the exemption allows these practitioners to treat up to 
30 patients with OUD using buprenorphine without having to make certain 
training-related certifications This exemption also allows 
practitioners to treat patients with buprenorphine without certifying 
as to their capacity to provide counseling and ancillary services As of 
March 11, 2022, 12,005 providers have obtained a waiver through the 
revised Practice Guidelines.
---------------------------------------------------------------------------
    \6\  Substance Abuse and Mental Health Services Administration, 
``HHS Releases New Buprenorphine Practice Guidelines, Expanding Access 
to Treatment for Opioid Use Disorder'' (April 27, 2021) https://
wwwsamhsagov/newsroom/press-announcements/202104270930.
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        Enhancing Access to Suicide Prevention and Crisis Care:
    Suicide rates increased 30 percent between 2000--2018 and declined 
in 2019 and 2020 Suicide is a leading cause of death in the United 
States, \7\ with 45,979 deaths in 2020 This is about one death every 11 
minutes The number of people who think about or attempt suicide is even 
higher In 2020, an estimated 122 million American adults had serious 
thoughts of suicide in the past year, 32 million made a suicide plan, 
and 12 million attempted suicide \8\ Among adolescents 12 to 17, 12 
percent had serious thoughts of suicide, 53 percent made a suicide 
plan, and 25 percent attempted suicide in the past year These findings 
vary by race and ethnicity, with people of mixed ethnicity reporting 
higher rates of serious thoughts of suicide Among people of mixed 
ethnicity 18 or older, 11 percent had serious thoughts of suicide, 33 
percent made a suicide plan and 12 percent attempted suicide in the 
past year Among Hispanics or Latinos 18 or older, 42 percent had 
serious thoughts of suicide, 12 percent made a suicide plan and 06 
percent attempted suicide in the past year.
---------------------------------------------------------------------------
    \7\  CDC WONDER: Underlying cause of death, 1999--2019 Atlanta, GA: 
U.S. Department of Health and Human Services, CDC; 2020 https://
wondercdcgov/Deaths-by-Underlying-Causehtml.
    \8\  Substance Abuse and Mental Health Services Administration 
(2021) Key substance use and mental health indicators in the United 
States: Results from the 2020 National Survey on Drug Use and Health 
(HHS Publication No PEP21-07-01-003, NSDUH Series H-56) Rockville, MD: 
Center for Behavioral Health Statistics and Quality, Substance Abuse 
and Mental Health Services Administration Retrieved from https://
wwwsamhsagov/data/.

    Suicide is a complex public health problem There is no single cause 
and no single solution As we work with our Federal agency partners to 
improve suicide prevention efforts across the Nation, we are focused on 
addressing upstream risk factors, expanding access to mental health and 
substance use services, and improving the crisis services 
---------------------------------------------------------------------------
infrastructure.

    SAMHSA has several programs aimed at supporting Americans in 
crisis.
     The National Suicide Prevention Lifeline and Transition to 988
    The National Suicide Prevention Lifeline (Lifeline), currently 1-
800-273-TALK, is a network of more than 200 local, independent crisis 
centers equipped to help people in mental health related distress or 
experiencing a suicidal crisis via call, chat, or text The Lifeline 
provides free and confidential support to people in suicidal crisis or 
mental health related distress 24 hours a day, 7 days a week, across 
the United States.

    In 2020, the FCC and Congress designated the number 988 as the 
nation's new, three-digit, national suicide prevention and mental 
health crisis number On July 16, 2022, the U.S. will transition to 
using the 988-dialing code The creation of 988 is a once-in-a-lifetime 
opportunity to strengthen and expand the Lifeline and transform 
America's behavioral health crisis care system to one that saves lives 
by serving anyone, at any time, from anywhere across the Nation.

    Preparing the Lifeline for full 988 operational readiness requires 
a bold vision for a system that provides direct, life-saving services 
to all in need and links them to community-based providers uniquely 
positioned to deliver a full range of crisis care services SAMHSA sees 
988 as the linchpin and catalyst for a transformed behavioral health 
crisis system in much the same way that, over time, 911 spurred the 
growth of emergency medical services in the United States.

    Through the American Rescue Plan Act, the Administration has 
provided $180 million to support local capacity to answer crisis calls 
and establish more community-based mobile crisis response and crisis 
stabilizing facilities to minimize unnecessary emergency department 
visits.
              Community Mental Health Services Block Grant
    The Community Mental Health Services Block Grant (MHBG) continues 
to serve as a safety net for mental health services for some of the 
nation's most vulnerable populations By statute, MHBG funds must be 
used to address the needs of adults with SMI and children with serious 
emotional disturbances (SED) Ten percent of MHBG funds are set-aside 
for evidence-based programs that address the needs of individuals with 
early serious mental illness, including psychotic disorders The set-
aside helps reduce costs to society, as intervening early helps prevent 
deterioration of functioning in individuals experiencing a first 
episode of serious mental illness MHBG also includes a set-aside to 
support state efforts to build much needed crisis systems to address 
the needs of individuals in mental health crisis in a high quality, 
expeditious manner The development of these services will promote 24/7 
access to well-trained mental health professionals in the time of acute 
mental health crisis.
                    Garrett Lee Smith Grant Program
    The Garrett Lee Smith (GLS) Memorial Act authorizes SAMHSA to 
manage two significant youth suicide prevention programs and one 
resource center The GLS State/Tribal Youth Suicide.

    Prevention and Early Intervention Grant Program supports 
development and implementation of youth suicide prevention and early 
intervention strategies involving public-private collaboration among 
youth serving institutions The GLS Campus Suicide Prevention program 
supports institutions of higher education, including tribal colleges 
and universities, working to prevent suicide and suicide attempts A 
peer reviewed research paper found that a sustained reduction in youth 
suicide mortality rates was observed among youths in counties exposed 
to GLS Memorial Youth Suicide Prevention Program programming compared 
with matched control counties that were not exposed to GLS. \9\
---------------------------------------------------------------------------
    \9\  Garraza, Kuiper, Goldston, McKeon, Walrath Long-term impact of 
the Garrett Lee Smith Youth Suicide Prevention Program on youth suicide 
mortality, 2006--2015, Journal of Child Psychology and Psychiatry 
(2019).
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                    Adult Suicide Prevention Grants
    The 2012 National Strategy for Suicide Prevention (NSSP) seeks to 
reduce the overall suicide rate and number of suicides in the U.S. 
nationally. The NSSP grant program supports the efforts of states, 
tribes, primary and behavioral healthcare organizations, public health 
agencies, and emergency departments to implement the NSSP While the 
NSSP addresses all age groups and populations with specific needs, the 
goals and objectives of the NSSP grants focus on preventing suicide and 
suicide attempts among adults over the age of 25.

    The Zero Suicide model is a comprehensive, multi-setting approach 
to suicide prevention in health systems The purpose of the Zero Suicide 
program is to implement suicide prevention and intervention programs 
for individuals who are 25 years of age or older by systematically 
applying evidence-based approaches to screening and risk assessment, 
developing care protocols, collaborating for safety planning, providing 
evidence-based treatments, maintaining continuity of care during high 
risk periods, and improving care and outcomes for such individuals who 
are at risk for suicide being seen in health care systems.
              Promoting Child and Youth Behavioral Health:
    Even before the pandemic, our nation's children and youth were 
struggling with mental health and substance use challenges, and during 
the pandemic rates of anxiety and depression have skyrocketed, which is 
why it is critical that we promote the behavioral health of young 
people across the country To focus our efforts on improving behavioral 
wellness for our nation's youth, SAMHSA has developed the ``Health, 
Opportunity, Potential and Equity (HOPE) Framework for Children, Youth 
and Families''.

    SAMHSA wants to bring HOPE to children and families across the 
country by creating and expanding programs and initiatives that provide 
Health for every young person--and you can't have health without 
mental, emotional, and behavioral health--improve Opportunity for youth 
who may be at-risk through early identification and intervention, and 
ensure that young people who experience serious emotional disturbances 
or substance use disorders can reach their full Potential and we will 
emphasize the need for Equity to deliver all our services and supports 
in culturally and linguistically appropriate ways.

    The HOPE Framework will guide efforts to expand access to proven 
treatments, interventions, and other recovery supports, while 
developing new and innovative solutions to strengthen behavioral health 
services for America's children and young adults.
                             Project AWARE
    Project AWARE (Advancing Wellness and Resiliency in Education) is 
comprised of the Project AWARE grants, Resilience in Communities after 
Stress and Trauma (ReCAST) grants, and the Mental Health Awareness 
Training (MHAT) grants Project AWARE grants promote comprehensive, 
coordinated, and integrated state efforts to make schools safer and 
increase access to mental health services ReCAST assists high-risk 
youth and families to promote resilience and equity in communities 
struggling with civil unrest, trauma, and violence through 
implementation of evidence-based violence prevention and community 
youth engagement programs and linkages to trauma-informed mental health 
services The MHAT grants train school personnel, emergency first 
responders, law enforcement, veterans, armed services members, and 
their families to recognize the signs and symptoms of mental disorders.
                             Project LAUNCH
    Project LAUNCH (Linking Actions for Unmet Needs in Children's 
Health) works to ensure that the systems that serve young children 
(including childcare and education, home visiting, and primary care) 
have the resources and knowledge to foster their social, emotional, 
cognitive, and behavioral development The program also ensures that the 
systems intervene to prevent, recognize early signs of, and address 
mental, emotional, and behavioral disorders in early childhood and into 
the early elementary grades.
                  Children's Mental Health Initiative
    The Children's Mental Health Initiative (CMHI) supports ``systems 
of care'' (SOC) for children and youth with SED and their families to 
increase their access to evidence-based treatment and supports SOC is a 
strategic approach to the delivery of services and supports that 
incorporates family driven, youth-guided, strength-based, and 
culturally and linguistically competent care to meet the physical, 
intellectual, emotional, cultural, and social needs of children and 
youth throughout the U.S. Services are delivered in the least 
restrictive environment with evidence-supported treatments and 
interventions Individualized care management ensures that planned 
services and supports are delivered with an appropriate, effective, 
family driven, and youth-guided approach This approach has demonstrated 
improved outcomes for children at home, at school, and in their 
communities For example, CMHI grantee data show that suicide attempt 
rates significantly decreased within 12 months after children and youth 
accessed CMHI-related services.
                Infant and Early Childhood Mental Health
    The purpose of the Infant and Early Childhood Mental Health program 
is to improve outcomes for children, from birth to 12 years of age, who 
are at risk for, show early signs of, or have been diagnosed with a 
mental illness, including an SED Grantees improve outcomes for children 
through training early childhood providers and clinicians to identify 
and treat behavioral health disorders, including in children with a 
history of in utero exposure to substances such as opioids, stimulants, 
or other drugs that may impact development, and through the 
implementation of evidence-based multigenerational treatment approaches 
that strengthen caregiving relationships.
   National Child Traumatic Stress Initiative and the National Child 
                        Traumatic Stress Network
    The National Child Traumatic Stress Initiative (NCTSI) aims to 
improve behavioral health services and interventions for children and 
adolescents exposed to traumatic events SAMHSA funds a national network 
of grantees known as the National Child Traumatic Stress Network 
(NCTSN) to develop and promote effective community practices for 
children and adolescents exposed to a wide array of traumatic events 
The NCTSN has grown to 116 funded and over 150 affiliate centers 
located nationwide in universities, hospitals, and a range of diverse 
community-based organizations with thousands of national and local 
partners The NCTSN's mission is to raise the standard of care and 
improve access to evidence-based services for children experiencing 
trauma, their families, and communities A component of this work has 
been the development of resources and delivery of training and 
consultation to support the development of trauma informed child-
serving systems.
        Center of Excellence on Social Media and Mental Wellness
    While technology platforms have improved our lives in some ways, 
there is mounting evidence that social media is harmful to many kids' 
and teens' mental health, well-being, and development Therefore, over 
the next year, SAMHSA will launch a National Center of Excellence on 
Social Media and Mental Wellness, which will develop and disseminate 
information, guidance, and training on the full impact of adolescent 
social media use, especially the risks these services pose to their 
mental health.
             Integrating Primary and Behavioral Healthcare:
    We know that an individual's first interaction with the health 
system is typically through a primary care provider or the emergency 
room During the COVID-19 pandemic, while providers were initially 
focused on acute medical concerns, we heard that many were not 
adequately resourced to consider the behavioral health effects of the 
pandemic The following programs support efforts to integrate primary 
and behavioral healthcare.
     Certified Community Behavioral Health Clinics Expansion Grants
    The Certified Community Behavioral Health Clinics (CCBHC) Expansion 
program is designed to increase access to and improve the quality of 
community mental and substance use disorder treatment services CCBHCs 
funded under this program must provide access to services for 
individuals with SMI or SUD, including OUD; children and adolescents 
with SED; and individuals with co-occurring mental and substance use 
disorders This program improves the mental health of individuals by 
providing comprehensive community-based mental and substance use 
disorder services; treatment of co-occurring disorders; advancing the 
integration of mental/substance use disorder treatment with physical 
health care; utilizing evidence-based practices on a more consistent 
basis and promoting improved access to high quality care.

    Data from intake to most recent reassessment for individuals served 
in the CCBHC program demonstrate that as of March 2022, clients have a 
72 percent reduction in hospitalization and a 69 percent reduction in 
Emergency Department visits, as well as a 25 percent increase in mental 
health functioning in everyday life Additionally, the data demonstrates 
that 12 percent had an increase in employment or started going to 
school.
             Primary and Behavioral Health Care Integration
    The Primary and Behavioral Health Care Integration (PBHCI) program 
addresses the intersection between primary care and treatment for 
mental illness and co-occurring disorders This program awards grants to 
community mental health centers and states to support coordination and 
integration of primary care services and publicly funded community 
behavioral health services for individuals with SMI and a co-occurring 
substance use disorder served by the public mental health system The 
PBHCI program encourages grantees to engage in necessary collaboration, 
expand infrastructure, and increase the availability of primary 
healthcare and wellness services.
    Screening, Brief Intervention and Referral to Treatment Program
    The Screening, Brief Intervention and Referral to Treatment (SBIRT) 
program is intended to help primary care physicians identify 
individuals who misuse substances and help them intervene early with 
education, brief treatment, or referral to specialty treatment The 
program's goal is to increase the number of individuals who receive 
treatment and reduce the rate of substance misuse Studies have shown 
that this approach is effective in helping reduce harmful alcohol 
consumption \10\, \11\, \12\ A SAMHSA-funded cross-site evaluation 
found that allied health professionals, rather than the physicians 
themselves, were more likely to implement SBIRT with their patients The 
SBIRT Student Training and Health Professionals Training grant programs 
support SBIRT training efforts for medical students, medical residents, 
nurses, social workers, psychologists, pharmacists, dentists, and 
physician assistants These efforts aim to develop further the primary 
healthcare workforce in substance use disorder services.
---------------------------------------------------------------------------
    \10\  7 Bertholet, N, Daeppen, J-B, Wietlisbach, V, Fleming, M, & 
Burnand, B (2005) Reduction of alcohol consumption by brief alcohol 
intervention in primary care: systematic review and meta-analysis 
Archives of Internal Medicine 165, 986--995.
    \11\  Kahan, M, Wilson, L, & Becker, L (1995) Effectiveness of 
physician-based interventions with problem drinkers: A review Canadian 
Medical Association Journal, 152, 851--859.
    \12\  Wilk, AI, Jensen, NM, and Havighurst, TC (1997) Meta-analysis 
of randomized control trails addressing brief interventions in heavy 
alcohol drinkers Journal of General Medicine, 12 (5), 274-283.
---------------------------------------------------------------------------
           Using Performance Measures, Data, and Evaluation:
                    Behavioral Health Equity Report
    In October 2021, SAMHSA released its ``Behavioral Health Equity 
Report 2021: Substance Use and Mental Health Indicators Measured from 
the National Survey on Drug Use and Health (NSDUH), 2015--2019'' \13\ 
This report disaggregates the behavioral health indicators by selected 
determinants of health: race and ethnicity (White, Black or African 
American, Native Hawaiian or Other Pacific Islander, American Indian/
Alaska Native, Asian, Two or More Races, and Hispanic or Latino), 
income level, county type, and health insurance status In this report, 
the array of indicators presented across racial/ethnic groups and other 
selected determinants of health provides a unique overview of 
population-based variations in behavioral health at a point in time.
---------------------------------------------------------------------------
    \13\  Center for Behavioral Health Statistics and Quality (2021) 
Behavioral health equity report 2021: Substance use and mental health 
indicators measured from the National Survey on Drug Use and Health 
(NSDUH), 2015--2019 (Publication No PEP21-07-01-004) Rockville, MD: 
Substance Abuse and Mental Health Services Administration Retrieved 
from https://wwwsamhsagov/data.

    This effort--although a beginning step in addressing the complexity 
of behavioral health issues and social determinants of health--provides 
a mechanism for systematically tracking changes, trends, and 
disparities over time.
                       Drug Abuse Warning Network
    SAMHSA re-established the Drug Abuse Warning Network (DAWN) in 2018 
as a nationwide public health surveillance system to monitor emergency 
department visits related to recent substance use, including those 
related to opioids Authorized by the 21st Century Cures Act, DAWN 
provides necessary information such as patient demographic details and 
substances used in order to respond effectively to the overdose crisis 
in the United States and to better inform public health, clinicians, 
policymakers, and other stakeholders to respond to emerging substance 
use trends.
     Updating SAMHSA's Government Performance and Results Act Tools
    The Government Performance and Results Act (GPRA) requires agencies 
to engage in performance management tasks such as setting goals, 
measuring results, and reporting progress SAMHSA's discretionary grants 
and block grants are required to collect and report GPRA data Based on 
feedback from the field, SAMHSA is working to modify its existing 
client-level GPRA tools with the goal to improve the agency's ability 
to assess the impact of our programs on key outcomes of interest and to 
gather vital information about clients served.
                               CONCLUSION
    On behalf of my colleagues at SAMHSA, thank you for your interest 
in, and support for, our programs, and for supporting the nation's 
behavioral health I would be pleased to answer any questions you may 
have.
                                 ______
                                 
    The Chair. Thank you.

    Administrator Johnson.

 STATEMENT OF CAROLE JOHNSON, ADMINISTRATOR, HEALTH RESOURCES 
           AND SERVICES ADMINISTRATION, ROCKVILLE, MD

    Ms. Johnson. Good morning Chair Murray, Ranking Member 
Burr, and Members of the Committee. I am Carole Johnson, 
Administrator of the Health Resources and Services 
Administration. I appreciate the opportunity to speak with you 
today about HRSA's programs that support the mental health and 
well-being of our Nation.

    As you know, HRSA supports health care services in 
communities across the country, including, for example, for the 
nearly 29 million people who receive care through HRSA funded 
community health centers, the more than half a million people 
diagnosed with HIV who receive care through the Ryan White HIV-
AIDS program, about 60 million pregnant individuals and 
children who benefit from HRSA funded infant screenings, 
preventive care visits, and other services, and individuals in 
more than 1,500 rural counties who receive HRSA supported 
substance use disorder services.

    HRSA also plays an important role in supporting the health 
care workforce. We provide scholarship and loan repayment 
assistance to thousands of clinicians in return for them 
practicing in underserved communities. This year marks our 
largest scholarship and loan repayment cohort yet, with more 
than 22,000 clinicians in these programs. We also invest in 
recruiting, training, and retaining health professionals, from 
community health workers to mental health professionals to 
advanced practice nurses.

    Like you, we recognize that mental health is essential to 
overall health for people of all ages, including for parents 
and children who have been affected by the pandemic. So today I 
would like to highlight two HRSA maternal and child mental 
health programs that are currently up for reauthorization, the 
Screening and Treatment for Maternal Depression Program and the 
Pediatric Mental Health Care Access Program.

    The Screening and Treatment for a Maternal Depression 
Program supports states in integrating mental health care into 
maternal health care. There is tremendous demand for this 
program, but to date we have only been able to fund about a 
quarter of the applicants. Grantees provide training to help 
maternal health care providers screen and treat their patients' 
mental health conditions.

    In a critical part of the program design, grantees give 
maternal health care providers the opportunity to connect with 
mental health care clinical experts through teleconsults to 
help them treat their individual patient's mental health 
conditions. As a result, more pregnant and postpartum women are 
being screened for depression, and maternal care providers are 
growing their capacity to support the mental health needs of 
their patients. Of note, where those needs are more complex, 
maternal care providers have the benefit of an expert 
teleconsult to support them.

    For example, through our program, a midwife in Montana and 
her pregnant patient with emergent mental health needs got real 
time mental health help from a perinatal psychiatrist through 
teleconsultation. In the normal course of business, the midwife 
would have had to refer the patient to a provider hours away 
who likely would have had troubles easily squeezing the patient 
in.

    Similarly, the Pediatric Mental Health Care Access Program 
promotes mental health care integration in pediatric primary 
care. These grants provide teleconsultation, training, and care 
coordination to help local pediatric primary care providers 
diagnose, treat, and refer children for mental health care.

    Similar to the Maternal Depression Program, our Pediatric 
Program both provides training that is building the capacity of 
pediatric primary care providers to respond to children's 
immediate mental health care needs, while also giving them the 
additional support of teleconsultation with a mental health 
expert to ensure that they have backup and the resources they 
need to serve their patients.

    Funding from the American Rescue Plan allowed us to broaden 
the program's reach from 21 to 45 states, territories, and 
tribal areas, and we are currently taking additional 
applications as well. There is considerable interest and demand 
for these programs, and we look forward to working with the 
Committee on their reauthorization.

    In addition to our programs that support mental health 
services, HRSA's workforce programs are training the behavioral 
health workforce and creating incentives to encourage them to 
practice in the communities where they are needed most. Our 
Behavioral Health Workforce Education and Training Program 
supports the training of psychologists, school and clinical 
counselors, marriage and family therapists, as well as the 
critical community connectors to mental health and substance 
use disorder care, like community health workers and peers and 
others.

    Our scholarship and loan repayments are increasingly 
supporting behavioral health care providers as well. We also 
recently launched a new program with American Rescue Plan 
funding to help support health care workers' mental health 
resilience and reduce provider burnout. In closing, I want to 
thank the Committee for your ongoing support for HRSA's 
programs and your commitment to the mental health and well-
being of America's families. Thank you.

    [The prepared statement of Ms. Johnson follows:]
                  prepared statement of carole johnson
    Chair Murray, Ranking Member Burr, and Members of the Committee:

    Thank you for the opportunity to speak with you about the Health 
Resources and Services Administration's (HRSA) programs to support the 
mental health and well-being of our Nation I am Carole Johnson, 
Administrator of HRSA.

    As you know, the Biden-Harris Administration is committed to 
bipartisan solutions to address mental health challenges In his State 
of the Union Address, the President announced a national strategy to 
tackle the nation's mental health crisis as part of his Unity Agenda 
This strategy centers on three pillars: strengthening system capacity, 
connecting Americans to care; and, supporting Americans by creating 
healthy environments Secretary Becerra has launched a national tour 
focused on strengthening mental health and is hearing directly from 
Americans across the country about the mental health challenges they 
are facing and the opportunities to improve our mental health and 
crisis care systems At HRSA, we recognize that mental health is 
essential to overall health I appreciate the opportunity to speak with 
you today about how HRSA is working to achieve the President and 
Secretary's goals and how we are actively working to advance mental 
health priorities through our programs.

    HRSA supports health care services in communities across the 
country, including for the nearly 29 million people who receive care 
through HRSA-funded health centers; the more than a half a million 
people diagnosed with HIV who receive care through the Ryan White HIV/
AIDS program; an estimated 60 million pregnant individuals and children 
who benefit from HRSA-funded infant screenings, preventive care visits, 
and other services; and individuals in more than 1,500 rural counties 
who receive HRSA-supported substance use disorder services HRSA also 
supports multiple programs to grow and sustain the health care 
workforce, including providing scholarship and loan repayment 
assistance to more than 22,700 clinicians in return for working in 
underserved communities--the highest number ever for these programs--
and investing in recruiting, training, and retaining a wide range of 
health professionals, from community health workers to psychiatrists to 
advance practice nurses.

    Two of HRSA's mental health programs are currently up for 
reauthorization:

          The Screening and Treatment for Maternal Depression 
        and Related Behavioral Disorders Program helps train maternal 
        health care providers on how to screen for, assess, treat, and, 
        as necessary, refer pregnant and postpartum individuals with 
        mental health conditions or substance use disorders as part of 
        routine maternal health care Maternal health care providers 
        also receive real-time psychiatric consultations for their 
        patients through telehealth services and care coordination 
        support.

          The Pediatric Mental Health Care Access Program aims 
        to make early identification, diagnosis, treatment, and, as 
        needed, referral for behavioral health conditions a routine 
        part of children's health care services The program promotes 
        the integration of behavioral health services into pediatric 
        primary care through statewide and regional pediatric mental 
        health care telehealth programs These statewide or regional 
        networks provide tele-consultation, training, technical 
        assistance and care coordination to community-based pediatric 
        health care providers in order to expand the reach of critical 
        mental health services and support children's needs.

    HRSA also received COVID-response funding to enhance our 
investments in supporting the mental health needs of parents and 
children, grow the mental health workforce, and reduce health care 
provider burnout and promote resiliency HRSA has many other investments 
that support behavioral health initiatives. \1\
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    \1\  Behavioral health is inclusive of mental health and substance 
use disorders.
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     HRSA Health Workforce Programs that Support Behavioral Health.
    HRSA programs play an important role in growing and training the 
behavioral health workforce and creating supports and incentives to 
help encourage providers to practice in the communities that need them 
most Our programs include the Behavioral Health Workforce Education and 
Training Program, which supports the training of social workers, 
psychologists, school and clinical counselors, psychiatric nurse 
practitioners, marriage and family therapists, community health 
workers, outreach workers, social services aides, mental health 
workers, substance use disorder workers, youth workers, and peers; the 
Graduate Psychology Education Program, which supports innovative 
doctoral level health psychology programs that foster a collaborative 
approach to providing mental health and substance use disorder 
prevention and treatment services in high need and high demand areas 
through academic and community partnerships; the Children's Hospitals 
Graduate Medical Education Program, which supports the training of 
pediatric residents, including pediatric psychiatry residents, in 
freestanding children's teaching hospitals; the Teaching Health Center 
Graduate Medical Education Program, which supports residency training, 
including for psychiatry, in community-based ambulatory care settings; 
and the National Health Service Corps, which provides scholarships and 
loan repayment for clinicians, including mental health and substance 
use disorder providers, who commit to practice in underserved 
communities we also launched new programs with American Rescue Plan 
funding to address mental health and promote resilience in the health 
care workforce through the Promoting Resilience and Mental Health Among 
the Health Professional Workforce and the Health and Public Safety 
Workforce Resiliency Training Program.

    Our workforce programs also include initiatives specifically 
focused on substance use disorder training, which is a vital component 
of behavioral health training These programs include the Addiction 
Medicine Fellowship Program, which focuses on increasing the number of 
board certified addiction medicine and addiction psychiatry specialists 
trained in providing behavioral health services, including prevention, 
treatment, and recovery services in underserved, community-based 
settings; the Integrated Substance Use Disorder Treatment Program, 
which supports training and expansion of the number of nurse 
practitioners, physician assistants, health service psychologists, and 
social workers trained to provide mental health and substance use 
disorder services in underserved community-based settings that 
integrate primary care and mental health and substance use disorder 
services; the Substance Use Disorder Treatment and Recovery Loan 
Repayment Program, which focuses on recruiting and retaining medical, 
nursing, and behavioral health clinicians and paraprofessionals who 
provide direct treatment or recovery support of patients with or in 
recovery from a substance use disorder through loan repayment in return 
for providing services in high need areas; and the Opioid-Impacted 
Family Support Program, which trains paraprofessionals to support 
children and families living in underserved areas who are impacted by 
opioid use disorder and other substance use disorders.
   HRSA Health Care Services Programs that Support Behavioral Health
    HRSA's health care services programs also play a key role in 
providing mental health and substance use disorder services, with a 
focus on delivering care and supports in underserved and rural 
communities These programs include the Health Center Program, which 
helps provide primary care in underserved communities across the 
country and are increasingly focused on integrating behavioral health 
into primary care services; the Health Care for the Homeless Program, 
which supports coordinated, comprehensive, integrated primary care 
including substance abuse and mental health services for individuals 
experiencing homelessness; the Rural Communities Opioid Response 
Program, which supports high need rural communities in establishing, 
expanding, and sustaining prevention, treatment, and recovery services 
for opioid use disorder; the Ryan White HIV/AIDS Program, which funds 
and coordinates with cities, states, and local clinics/community-based 
organizations to deliver HIV care, treatment, and support, including 
mental health and substance use disorder services, to people with HIV 
who have low incomes.

    In addition to the two programs up for reauthorization, our 
programs focused on maternal and child health include the Maternal, 
Infant, and Early Childhood Home Visiting Program, which supports 
voluntary, evidence-based home visiting services during pregnancy and 
to parents with young children where trained professionals address 
needs such as conducting screenings and providing referrals to address 
caregiver depression, substance use, and family violence; the Maternal 
and Child Health Block Grant, which supports states in improving access 
to and the quality of health services for mothers, children, and their 
families, including initiatives to address national or regional needs, 
priorities, or emerging issues including mental health and substance 
use disorder; and the Bright Futures Preventive Services Program, which 
develops national guidelines to support children receiving high 
quality, efficient, and comprehensive pediatric care, including 
behavioral health services Bright Futures' recommended preventive 
services are covered without cost-sharing by most health plans In 2022, 
Bright Futures updates include adding universal screening for suicide 
risk to the current depression screening category for individuals ages 
12 to 21, and new guidance for behavioral, social and emotional 
screening.
        Mental Health is Essential to Maternal and Child Health
    Last week, HRSA published a study in the American Medical 
Association's journal JAMA Pediatrics based on our National Survey of 
Children's Health that found significant increases in the number of 
children diagnosed with mental health conditions between 2016 and 2020 
During the study timeframe, the number of children ages 3-17 years old 
diagnosed with anxiety grew by 29 percent and those with depression 
grew by 27 percent The survey also showed declines in parental well-
being during this time: there was an 11 percent decrease in parents' 
reported ability to cope with the demands of raising children and a 5 
percent decrease in parents' mental and emotional well-being.

    HRSA funds the National Survey of Children's Health, which is the 
largest national and state-level annual survey of the health and health 
care needs of children, their families, and their communities to 
regularly assess the state of children' health Data from the 2020 
national survey found that 149 percent of U.S. children ages 3-17 
years--just over 9 million--had a current, diagnosed behavioral health 
condition, and about one-third (347 percent) of these children had two 
or more conditions Yet only half (505 percent) of those with a current 
behavioral health condition received treatment or counseling from a 
mental health professional in the past year This can have long-term 
effects on health, well-being, and opportunity As noted in the 2021 
Surgeon General's Advisory on Protecting Youth Mental Health, the 
pandemic has compounded many of these adverse impacts by disrupting 
educational, social, and service supports and opportunities upon which 
so many vulnerable children, youth and families depend \2\ Children and 
families have weathered the sudden interruption of in-person learning, 
prolonged isolation during stay-at-home orders, loss of regular school-
based behavioral health services, family economic stressors like 
housing instability and food insecurity, and the trauma and grief 
associated with personal and family experiences and loss during the 
COVID-19 pandemic.
---------------------------------------------------------------------------
    \2\  https://wwwhhsgov/sites/default/files/surgeon-general-youth-
mental-health-advisorypdf.

    The Centers for Disease Control and Prevention reports that nearly 
1 in 5 children \3\ have a mental, emotional, or behavioral disorder 
and that suicide is the second leading cause of death for people ages 
10 to 24 \4\ In 2019, 188 percent of high school students, ages 14-18 
years, had seriously considered attempting suicide, and 89 percent had 
attempted suicide one or more times, based on self-reporting \5\ Data 
from the Substance Abuse and Mental Health Services Administration's 
2016-2019 National Surveys of Drug Use and Health found that while 
nearly half of White adolescents with a depressive episode (460 
percent) received treatment in the past year, the same was true for 
only one-third of their Black and Hispanic counterparts (363 and 356 
percent, respectively) and one-quarter of Asian adolescents (262 
percent) \6\ In 2017-2018, depression, anxiety, and behavioral 
conditions were more prevalent among rural children ages 3-17 years 
compared to urban children. \7\
---------------------------------------------------------------------------
    \3\  National Research Council and Institute of Medicine (2009) 
Preventing Mental, Emotional, and Behavioral Disorders Among Young 
People: Progress and Possibilities E O'Connell, T Boat, & K E Warner 
Eds Washington, DC The National Academic Press.
    \4\  https://wwwcdcgov/injury/wisqars/indexhtml.
    \5\  https://wwwresearchgatenet/publication/343795548--Suicidal 
Ideation and Behaviors Among High School Students-Youth Risk Behavior 
Survey United States 2019.
    \6\  Substance Abuse and Mental Health Services Administration 
Report: Racial/Ethnic Differences in Mental Health Service Use among 
Adults and Adolescents (2015-2019).
    \7\  https://mchbhrsagov/sites/default/files/mchb/data-research/
rural-urban-differencespdf.

    Research also shows that maternal mental health conditions are the 
most common complications of pregnancy \8\ About 1 in 8 women 
experience symptoms of postpartum depression \9\ Mental health 
conditions, including suicides, drug overdoses or poisonings, and 
unintentional injuries related to a mental health condition, are among 
the leading underlying causes of pregnancy----related deaths \10\ As a 
result of pandemic-related worries and stressors, pregnant and 
postpartum people in the United States and internationally report 
elevated symptoms of depression, anxiety, post-traumatic stress, and 
loneliness \11\, \12\ Several empirical studies related to the pandemic 
have reported higher prevalence of mental health problems among women 
compared to men In this context, pregnant and new mothers could be more 
vulnerable \13\ Yet, only 75 percent of mothers who need treatment are 
finding and getting it \14\, \15\ Without treatment, mothers are at 
increased risk for a range of poor outcomes In addition, substance use 
during pregnancy can have serious consequences for maternal and infant 
health, including preterm labor and complications related to delivery.
---------------------------------------------------------------------------
    \8\  Fawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM The 
Prevalence of Anxiety Disorders During Pregnancy and the Postpartum 
Period: A Multivariate Bayesian Meta-Analysis J Clin Psychiatry 2019 
Jul 23;80(4):18r12527 doi: 104088/JCP18r12527 PMID: 31347796; PMCID: 
PMC6839961.
    \9\  https://wwwcdcgov/mmwr/volumes/69/wr/mm6919a2htm's--
cid=mm6919a2--w.
    \10\  Davis NL, Smoots AN, Goodman DG Pregnancy-Related Deaths: 
Data from 14 U.S. Maternal Mortality Review Committees, 2008-2017 
Atlanta, GA: Centers for Disease Control and Prevention, U.S. 
Department of Health and Human Services; 2019.
    \11\  Liu, CH et al ``Risk Factors for Depression, Anxiety, and 
PTSD Symptoms in Perinatal Women during the COVID-19 Pandemic'' 
Psychiatry Review DOI: 101016/jpsychres2020113552.
    \12\  Basu A, Kim HH, Basaldua R, Choi KW, Charron L, Kelsall N, et 
al (2021) A cross-national study of factors associated with women's 
perinatal mental health and well-being during the COVID-19 pandemic 
PLoS ONE 16(4): e0249780 https://doiorg/101371/journalpone0249780.
    \13\  Thapa SB, Mainali A, Schwank SE, Acharya G Maternal mental 
health in the time of the COVID-19 pandemic Acta Obstet Gynecol Scand 
2020 Jul;99(7):817-818 doi: 101111/aogs13894 PMID: 32374420; PMCID: 
PMC7267371.
    \14\  Byatt, Nancy et al ``Enhancing Participation in Depression 
Care in Outpatient Perinatal Care Settings: A Systematic Review'' 
Obstetrics and gynecology vol 126,5 (2015): 1048-1058 doi:101097/
AOG0000000000001067.
    \15\  Wright, TE, Terplan, M, Ondersma, SJ, Boyce, C, Yonkers, K, 
et al (2016) The role of screening, brief intervention, and referral to 
treatment in the perinatal period American Journal of Obstetrics & 
Gynecology, 215(5), 539-547.

    Access to mental health care is related to the volume and 
distribution of maternal and child mental health and substance use 
disorder providers In fact, ratios of child and adolescent 
psychiatrists range by state from 1 to 60 per 100,000 children, with a 
median of 11 child and adolescent psychiatrists per 100,000 children 
\16\ As of December 2021, an estimated 136 million people in the United 
States--over 40 percent of the total U.S. population--live in 
designated ``Mental Health Professional Shortage Areas'' \17\ Only 28 
percent of the need for mental health care in these Mental Health 
Professional Shortage Areas has been met The need for prevention, 
treatment, and recovery services to support children and families' 
mental health are important drivers of the President's national 
strategy to tackle the nation's mental health crisis and Secretary 
Becerra's National Tour to Strengthen Mental Health.
---------------------------------------------------------------------------
    \16\  https://wwwaacaporg--AACAP--Press--Press--Releases/2018/
Severe--Shortage--of--Child--and--Adolescent--Psychiatrists--
Illustrated--in--AAACP--Workforce--mapsaspx.
    \17\  Health Services and Resources Administration (2021) Fourth 
Quarter of Fiscal Year 2021 Designated HPSA Quarterly Summary As of 
December 31, 2021 Available at https://datahrsagov/Default/
GenerateHPSAQuarterlyReport.
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         HRSA's Maternal and Child Behavioral Health Programs.
    HRSA's maternal and child health work focuses directly on improving 
the health and well-being of our nation's mothers, children and 
families so they can thrive and reach their full potential Our program 
investments in behavioral health have four primary aims:

    First is to increase identification of behavioral health conditions 
By that, we mean linking women and families to treatment and supports 
through routine screening, referral, and direct service to prevent 
mental health and substance use disorders whenever possible and treat 
them appropriately when necessary.

    The second aim is to improve access to quality services Patients 
should be able to see care providers either in person in their local 
communities or through telehealth This care should be high quality, 
patient-centered, and culturally and linguistically appropriate.

    The third aim is to advance equity we must eliminate health 
disparities, including racial and geographic disparities that affect 
far too many Our programs seek to address systemic and social 
inequities and promote protective factors for families.

    The fourth aim is to strengthen the maternal and child health 
workforce to meet the behavioral health needs of families That includes 
offering the training that our health care workers need to integrate 
all best practices--including those that are culturally and 
linguistically appropriate, equitable and trauma informed.

    The two HRSA programs up for reauthorization, the Screening and 
Treatment for Maternal Depression and Related Behavioral Disorders 
Program and the Pediatric Mental Health Care Access Program, are key 
investments that support primary care providers' ability to routinely 
screen and treat behavioral health conditions.
Screening and Treatment for Maternal Depression and Related Behavioral 
                           Disorders Program
    HRSA's Screening and Treatment for Maternal Depression and Related 
Behavioral Disorders Program supports states in integrating behavioral 
health into maternal health care using telehealth The 21st Century 
Cures Act (PL 114-255) authorized the program through fiscal year (FY) 
2022 This program supports new or expanding state telehealth access 
programs, including in rural and underserved areas The Screening and 
Treatment for Maternal Depression program gives providers the tools to 
integrate behavioral health care into routine maternal health care 
through telehealth services that can help local providers bridge the 
gap in access to psychiatrists, especially perinatal psychiatrists \18\ 
With telehealth support from the program, maternal health care 
providers are able to receive real-time psychiatric consultations and 
care coordination support Community-based maternal health providers 
also are offered training on how to screen for, assess, treat, and 
refer pregnant and postpartum individuals for mental health and 
substance use disorders.
---------------------------------------------------------------------------
    \18\  https://bhwhrsagov/data-research/projecting-health-workforce-
supply--demand/behavioral--health.

    The Screening and Treatment for Maternal Depression program is 
implemented through 5-year cooperative agreements to states and funded 
at approximately $45 million in total per year Each state health 
department receives approximately $650,000 per year we are currently in 
the fourth of 5 years of funding HRSA received tremendous interest in 
the program--demonstrating the acute need for it--but is only able to 
fund approximately a quarter of applicants The seven states that 
---------------------------------------------------------------------------
currently receive awards are Florida, Kansas, Louisiana.

    Montana, North Carolina, Rhode Island and Vermont In fiscal year 
2020, awardees trained 1,085 health care providers, participating 
providers screened 24,500 pregnant and postpartum individuals for 
depression, and providers sought and received expert mental health 
consultation for nearly 7,500 pregnant and postpartum individuals, with 
nearly half being from rural and underserved areas.

    One example of the impact of the program is the story of a 
pregnant, Native American woman from a Montana reservation who went to 
a satellite site of a large hospital system to seek prenatal care Her 
midwife noticed that the patient presented with symptoms of psychosis 
and was not receiving medication or therapy The patient lived in a part 
of the reservation that does not have cell service or internet, so the 
only time the patient could seek telehealth services was when she was 
at the satellite clinic The midwife called the Montana Screening and 
Treatment for Maternal Depression program, which is called PRISM for 
Moms, in order for the patient to be seen by the perinatal psychiatrist 
The psychiatrist was able to see the patient that day and made 
medication recommendations The psychiatrist also talked with the 
midwife about options to get the patient to see a mental health 
provider regularly If this midwife did not have access to Montana's 
teleconsultation line, she likely would have referred the patient to a 
prescribing provider in Billings (the largest city in the state), a 2-
hour drive from the reservation.

    As another example, the Vermont awardee is helping to build a 
statewide system of supports and services for expectant parents and 
families with young children The program helps the perinatal population 
in accessing perinatal mental health providers and other resources 
Through this program, medical and mental health clinicians are able to 
screen and provide culturally respectful and tailored services to 
patients Over time, there has been an increase in the complexity of 
calls from maternal health care providers to the program's mental 
health expert consultation line, suggesting that the program's training 
not only expands access to expertise, but also results in maternal 
health providers addressing more and more of their patients' needs.

    In short, the Screening and Treatment for Maternal Depression and 
Related Behavioral Disorders Program has provided important tools to 
support the mental health of pregnant and post-partum individuals The 
fiscal year 2022 appropriation of $65 million, a $15 million increase, 
will help us further address the maternal behavioral health needs we 
are seeing in the Nation, and we look forward to working with the 
Committee on its reauthorization.
              Pediatric Mental Health Care Access Program
    Just as the Screening and Treatment for Maternal Depression program 
helps fill the gaps in behavioral health care for pregnant and 
postpartum mothers, the Pediatric Mental Health Care Access program 
helps do the same for pediatric care providers.

    The 21st Century Cures Act (PL 114-255) authorized the Pediatric 
Mental Health Care Access program through fiscal year 2022 The program 
promotes behavioral health integration in pediatric primary care 
through new or expanded statewide or regional pediatric mental health 
care telehealth programs These statewide or regional networks of 
pediatric mental health care teams provide tele-consultation, training, 
technical assistance and care coordination With this support, pediatric 
primary care providers can diagnose, treat and refer children to the 
care they need for behavioral health concerns The telehealth 
technologies promote long-distance clinical health care, clinical 
consultation, and patient and provider education, helping to address 
challenges in accessing psychiatrists, developmental-behavioral 
pediatricians, and other behavioral health clinicians who treat 
behavioral concerns in children and adolescents.

    Beginning in fiscal year 2018, HRSA initially funded 18 awardees 
for 5 years In fiscal year 2019, we funded 3 additional awardees for 4 
years These awards are funded at $445,000 per year The American Rescue 
Plan allowed HRSA to broaden the program's reach to 45 awards in 40 
states, the District of Columbia, the U.S. Virgin Islands, the Republic 
of Palau, and two Tribal areas--the Chickasaw Nation and the Red Lake 
Band of the Chippewa Indians On January 5, 2022, HRSA released a Notice 
of Funding Opportunity for a second round of American Rescue Plan 
funding to further expand the Pediatric Mental Health Care Access 
program This funding will support up to 10 awards at $445,000 each for 
a 4-year period In addition, in the coming year, HRSA plans to 
establish a technical assistance resource center for program grantees 
The resource center will develop online resources accessible to all 
states.

    Grantee work in Alabama, particularly in rural areas, illustrates 
the program's impact The Alabama Pediatric Access to Tele-Mental Health 
Services (PATHS) program consultation team is composed of 
psychiatrists, psychologists, psychiatric Nurse Practitioners, licensed 
counselors and social workers An early childhood mental health 
consultant on the PATHS consultation team enables team members to 
address a broad range of questions during consultations before 
providing a psychiatric diagnosis Through PATHS, pediatric providers 
have access to consultation typically within an hour, and all 
consultations are usually addressed the same day PATHS also offers 
Project ECHO, a tele-mentoring program that links providers with the 
PATHS team to review cases together as a group PATHS can provide 
children and adolescents with specialty interventions not available in 
the community through tele-therapy at Children's Hospital of Alabama 
Care coordinators provide community-based resources to providers and 
families The program reaches children and families across the state. As 
one pediatric provider noted about the impact of the program: 
``Participating in PATHS has improved my education to treat psychiatric 
illnesses in patients PATHS has had a huge impact on my patient 
population I can treat illnesses more immediately and not have my 
patients waiting months for care''.

    As the program expands to new states through funding provided 
through the American Rescue Plan Act, we expect to see more providers 
and children benefit from these services For example, the Washington 
Partnership Access Line (PAL) received a HRSA Pediatric Mental Health 
Care Access grant in September 2021 that will allow the program to 
expand existing and offer new supports and services PAL has been in 
operation since 2008, and currently delivers over 2,000 consultations a 
year for primary care providers, four mental health training 
conferences a year, and distributes thousands of copies of the 
program's care manual for primary care mental health The service also 
delivers a statewide mental health referral service for parents, 
provides training and support to primary care clinic based mental 
health therapists, and provides second opinion psychiatric medication 
reviews for Washington State Medicaid.

    With Pediatric Mental Health Care Access funding, PAL will expand 
efforts to provide crisis support services for youth in rural 
Washington In the remote, primarily rural counties of eastern 
Washington State, the numbers of children and adolescents showing up in 
primary care and at community hospitals with suicidal ideation and 
psychological distress is of significant concern Through a partnership 
with the Department of Health, Seattle Children's Hospital, and 
Frontier Behavioral Health, the Supporting Adolescents and Families 
Experiencing Suicidality (SAFES) project will address the behavioral 
health patient surge due to the COVID pandemic, assist children in 
crisis and their families, develop enhanced access to telehealth 
behavioral services, provide access for primary care providers to 
psychiatric consultation for children and adolescents, increase the 
capacity of community therapists to safely care for suicidal youth in 
outpatient settings, decrease the need for mental health emergency 
department utilization, and address disparities in behavioral health 
care in rural eastern Washington communities.

    In short, the Pediatric Mental Health Care Access Program is 
helping states fill critical needs for children's mental health The 
fiscal year 2022 appropriation of $11 million will help us to continue 
to address the pediatric behavioral health needs we are seeing across 
the Nation, and we look forward to working with the Committee on 
reauthorizing the program.
                               Conclusion
    Thank you for the opportunity to discuss HRSA's key investments to 
address the nation's behavioral health with you today we are looking 
forward to working with the Committee on this critical issue and 
reauthorizing the Screening and Treatment for Maternal Depression 
Program and the Pediatric Mental Health Care Access Program.
                                 ______
                                 
    The Chair. Thank you.

    Director Gordon.

STATEMENT OF JOSHUA A. GORDON, M.D., PH.D., DIRECTOR, NATIONAL 
  INSTITUTE OF MENTAL HEALTH, NATIONAL INSTITUTES OF HEALTH, 
                          BETHESDA, MD

    Dr. Gordon. Chairman Murray, Ranking Member Burr, Members 
of the Committee, the Biden Administration is committed to 
addressing the unprecedented mental health crisis affecting 
communities across the United States, using a strategy built on 
a foundation of research carried out by the National Institute 
of Mental Health, the lead Federal agency charged with setting 
and supporting the national agenda for mental health research. 
It is my privilege to represent NIMH before you today and to 
discuss our ongoing collaborations with partner agencies to 
support the President's strategy.

    The NIMH is one of 27 institutes and centers of the 
National Institutes of Health. NIMH's mission is to transform 
the understanding and treatment of mental illnesses through 
basic and clinical research, paving the way for prevention, 
recovery, and cure. Guided by our strategic plan, NIMH supports 
a research pipeline that includes basic efforts to understand 
the brain and behavior, translational science focused on 
developing transformative new therapies, and clinical research 
aimed at maximizing the public health impacts of these 
therapies.

    The translational pathway is well illustrated by 
considering one recent advance, in the treatment of postpartum 
depression, a mental illness that impacts one in nine mothers 
and can be life threatening. Working diligently over decades, 
neuroscientists supported by NIMH discovered that a naturally 
occurring brain chemical might have a role in postpartum 
depression.

    This led to the eventual FDA approval of brexanolone and 
analog of that chemical as the first ever drug specifically for 
postpartum depression. NIMH's role doesn't stop with the 
development of transformative therapies like brexanolone. We 
also collaborate extensively with other Federal agencies with 
the goal of ensuring that effective treatments are accessible 
to all who need them.

    One such collaboration has transformed care for psychosis 
in the United States. An ambitious NIMH supported research 
program, the RAISE initiative, proved that coordinated 
specialty care could cost effectively improve outcomes for 
those experiencing their first episode of psychosis. Based on 
these findings, our colleagues at SAMHSA used the Mental Health 
Block Grant Program to fund first episode psychosis clinics 
across the country.

    Now, over 350 such clinics are providing this cutting edge 
care to thousands of Americans each year. NIMH collaborations 
are also making progress in preventing suicide. NIMH research 
forms the backbone of the zero suicide approach, a systematic 
framework for suicide prevention supported by SAHMSA, the 
Department of Defense, the Indian Health Service, and numerous 
others.

    For example, NIMH research has demonstrated that emergency 
room screening for suicidal thoughts, combined with brief 
interventions and follow-up contacts, can reduce suicide 
attempts by 33 percent. NIMH continues to work with public and 
private partners to promote the use of zero suicide and other 
evidence based approaches.

    While it is too early to declare victory, we were gratified 
to see rates of death by suicide decline for two consecutive 
years following 2018, after two decades of inexorable 
increases. The COVID-19 pandemic has brought additional 
challenges to the mental health system.

    The rates at which individuals note symptoms of depression, 
anxiety, substance use, and suicidal thoughts have all gone up, 
as has the demand for mental health services, especially among 
children. These impacts have not been felt equally, with black, 
latino, and other underserved communities, as well as care 
practitioners and others on the front lines of the pandemic, 
bearing the brunt of both the physical and mental health 
impacts.

    Yet even during the pandemic, research has offered hopeful 
solutions, NIMH research so that mental health care can be as 
effective as in-person mental health care, supporting the rapid 
switch to remote care in early 2020.

    NIMH research during the pandemic has also demonstrated 
that social supports, such as providing meals to families 
threatened by food insecurity, builds resilience to the mental 
health impacts of the pandemic.

    Additional challenges await solutions. The Surgeon General 
has declared a crisis in youth mental health, noting the impact 
of media and technology use and the rise in suicide rates among 
black youth and other vulnerable groups.

    We also face continuing challenges in caring for 
individuals with serious mental illness and the equitable 
delivery of mental health services. To address these 
challenges, NIMH continues to collaborate with our Federal 
partners, including those joining us today, to ensure that 
evidence based solutions reach those in need.

    In short, we stand ready to help. Thank you for your 
opportunity to provide this testimony, and I would be pleased 
to answer any questions you might have.

    [The prepared statement of Dr. Gordon follows:]
                 prepared statement of joshua a. gordon
    Chair Murray, Ranking Member Burr and Members of the Committee, The 
Biden administration is committed to addressing the unprecedented 
mental health and substance use disorder crisis that is affecting 
adults and children of all races in urban and rural communities across 
the United States During the State of the Union, President Biden 
announced the strategy to address our national mental health crisis as 
part of his Unity Agenda[1] The three pillars of the President's mental 
health strategy are: (1) Strengthen System Capacity; (2) Connect 
Americans to Care; and (3) Support Americans by Creating Healthy 
Environments A These three pillars are built on a foundation of 
research carried out by the National Institute of Mental Health (NIMH) 
the lead Federal agency charged with setting and supporting the 
national agenda for mental health research It is my privilege to 
represent NIMH before you today, and to discuss our ongoing 
collaborations with partner agencies to support the President's 
strategy.

    The NIMH is one of the 27 Institutes and Centers that make up the 
National Institutes of Health (NIH), the largest biomedical research 
agency in the world The NIMH mission is to transform the understanding 
and treatment of mental illnesses through basic and clinical research, 
paving the way for prevention, recovery, and cure The NIMH Strategic 
Plan for Research guides the Institute's priorities for funding 
research, from basic neuroscience aimed at understanding how the brain 
produces behavior, to translational efforts to develop transformative 
treatments, to clinical studies testing novel approaches in community 
settings \1\ Indeed, research has driven significant progress in 
several key areas of public health, providing hope that drives us 
forward.
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    \1\  https://wwwnimhnihgov/about/strategic-planning-reports.

    This translational pathway from basic science to clinical 
application is well illustrated by considering one recent advance in 
the treatment of postpartum depression (PPD), a mental illness that 
impacts 1 in 9 mothers and can be life-threatening \2\ Until recently, 
there were no specific treatments for PPD But thanks to NIMH-supported 
science, that is no longer the case This pathway to treatment 
development started in the early 1990's, when scientists with NIMH and 
the National Institute of Neurological Disorders and Stroke discovered 
that naturally occurring brain chemicals called neurosteroids were 
important for reducing the adverse effects of stress in laboratory 
animals Subsequent work funded by NIMH showed that levels of one of 
these chemicals, allopregnanolone, fluctuate through pregnancy and drop 
rapidly at the time of birth, suggesting that low levels of 
allopregnanolone might lead to PPD and that giving extra 
allopregnanolone to women might treat PPD Subsequent clinical trials 
published in 2018 confirmed this hypothesis, finding that brexanolone, 
a synthetic version of the natural chemical, can rapidly reverse the 
symptoms of PPD This decades-long scientific effort culminated in the 
spring of 2019 with Food and Drug Administration (FDA) approval of 
brexanolone as the first ever treatment specifically for PPD. \3\
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    \2\  https://wwwnimhnihgov/about/director/messages/2019/a-bench-to-
bedside-story-the-development-of-a-treatment-for-postpartum-depression.
    \3\  https://wwwfdagov/news-events/press-announcements/fda-
approves-first-treatment-post-partum-depression.

    We are proud of NIMH research, and its role in developing 
transformational new therapies like brexanolone and NIMH's role does 
not stop there; we also collaborate extensively with other Federal 
agencies, including the Substance Abuse and Mental Health Services 
Administration (SAMHSA), the Health Resources and Services 
Administration (HRSA), the Centers for Medicare & Medicaid Services 
(CMS), and others, with the goal of achieving mental health equity by 
ensuring that effective treatments are accessible to the people who 
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need them.

    One such collaboration has transformed care for psychosis in the 
United States Maximizing the likelihood of recovery for individuals 
with schizophrenia and other psychotic illnesses requires delivering 
the very best care as early as possible in the course of their illness 
But just what ``the very best care'' meant was unclear as recently as a 
decade ago In the late 2000's and early 2010's, NIMH supported an 
ambitious research program--the Recovery After an Initial Schizophrenia 
Episode (RAISE) initiative--that tested the efficacy of Coordinated 
Specialty Care for those experiencing their first episode of psychosis. 
\4\ This research showed that individuals receiving this set of 
wraparound services did significantly better than those who received 
treatment as usual, particularly when interventions were offered early 
on Perhaps even more importantly, the RAISE study showed that these 
services can be effectively delivered in community settings and are 
cost-effective when compared to usual care Based on these findings, our 
colleagues at SAMHSA have used the Mental Health Block Grant program to 
fund First Episode Psychosis clinics around the country that offer 
Coordinated Specialty Care Now over 350 such clinics are providing 
cutting-edge evidence-based care to thousands of Americans each year In 
other interagency collaborations related to the treatment of early 
psychosis, NIMH has partnered with SAMHSA in their efforts to establish 
community treatment programs for those at clinical high risk for 
psychosis, partnered with HRSA to implement psychosis screening in 
primary care settings, and assisted the Department of Veterans Affairs 
(VA) in assuring high-quality services for Veterans with early 
psychosis.
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    \4\  https://wwwnimhnihgov/health/topics/schizophrenia/raise.

    Similarly, in the area of suicide prevention, NIMH is collaborating 
in science-to-service and service-to-science cycles of learning 
healthcare NIMH research has shown that the majority of those who have 
died by suicide were seen by their doctor or another healthcare 
provider in the weeks or months prior to their death Accordingly, NIMH 
has worked with numerous partners to improve suicide prevention efforts 
in healthcare settings \5\ For example, findings from NIMH research 
have been incorporated into the ``Zero Suicide'' model, a systematic 
framework and multilevel approach to implementing evidence-based 
practices; this framework is now supported by grants from SAMHSA, the 
Department of Defense, and the Indian Health Service \6\ Initiated by 
the National Action Alliance for Suicide Prevention--a public-private 
partnership--the Zero Suicide model is based on systematic 
implementation and continuous improvement of suicide reduction efforts, 
resulting in fewer suicide events within healthcare systems.
---------------------------------------------------------------------------
    \5\  Gordon JA, Avenevoli A, Pearson JL Suicide Prevention Research 
Priorities in Health Care JAMA Psychiatry 2020 Sep 1;77(9):885-886 doi: 
101001/jamapsychiatry20201042 PMID: 32432690.
    \6\  Hogan MF, Grumet JG Suicide Prevention: An Emerging Priority 
For Health Care Health Aff (Millwood) 2016 Jun 1;35(6):1084-90 doi: 
101377/hlthaff20151672 PMID: 27269026.

    NIMH research has yielded relevant, practice-ready tools that form 
the backbone of the Zero Suicide approach \7\ For example, NIMH funded 
the Emergency Department Screen for Teens at Risk for Suicide (ED-
STARS) study, conducted in HRSA-supported pediatric emergency rooms, to 
demonstrate the efficacy of screening for suicide prevention in these 
settings A similar study in adults showed that emergency room screening 
combined with brief interventions and follow-up contacts can reduce 
suicide attempts by 33 percent NIMH research has also supported the 
development of computational methods to identify suicide risk using 
electronic health records, an approach that has already been 
implemented in the Army, Veterans Affairs clinics, and many healthcare 
systems around the United States \8\ Finally, NIMH research has 
demonstrated the efficacy and cost-effectiveness of interventions that 
can reduce suicide risk once detected, including Cognitive and 
Dialectical behavioral therapies, safety planning, caring contacts, and 
treating underlying mental illnesses.
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    \7\  https://wwwnimhnihgov/archive/news/2016/nimh-funds-3-zero-
suicide-grants.
    \8\  https://wwwnimhnihgov/news/science-news/2018/predicting-
suicide-attempts-and-suicide-deaths-using-electronic-health-records.

    To ensure that these evidence-based approaches to identifying and 
reducing suicide risk in individuals are being utilized, NIMH is 
working with SAMHSA, HRSA, CMS, the Centers for Disease Control and 
Prevention and other public and private partners to promote the use of 
Zero Suicide and other suicide prevention approaches throughout the 
United States and while it is too early to declare victory, we are 
gratified to see rates of death by suicide decline for two consecutive 
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years since 2018, after two decades of inexorable increases.

    These and other efforts to improve mental health services through 
evidence-based solutions have been confronted with another challenge; 
the Coronavirus Disease 2019 (COVID-19) pandemic The impact of the 
pandemic on mental health in the United States has been significant 
Research supported by NIMH and others has confirmed much of what we 
knew based on prior research on disasters and epidemics Through the 
course of the pandemic, the rates at which individuals note symptoms of 
depression, anxiety, substance use, and suicidal thoughts have all gone 
up \9\ The demand for mental health services has also increased, 
especially amongst children and the effects on our youth, though still 
not fully quantified, are substantial These impacts have not been felt 
equally across American communities, with Black, Latinx, and other 
underserved communities as well as care practitioners and others on the 
front lines bearing the brunt of both the physical and mental health 
impacts of COVID-19 Suicide rates among Black youth, for example, have 
been rising for the past 5 years, eclipsing rates among White youth for 
the first time ever.
---------------------------------------------------------------------------
    \9\  Czeisler M, Lane RI, Petrosky E, et al Mental Health, 
Substance Use, and Suicidal Ideation During the COVID-19 Pandemic--
United States, June 24--30, 2020 MMWR Morb Mortal Wkly Rep 
2020;69:1049--1057 DOI: http://dxdoiorg/1015585/mmwrmm6932a1.

    Yet even during the pandemic, research has offered hopeful 
solutions Prior NIMH research conducted over the past two decades has 
demonstrated that telemental health care can be as effective as in-
person mental health care when delivered appropriately; this research 
supported the rapid switch to remote care delivery in early 2020 NIMH 
research during the pandemic has demonstrated that social supports, 
such as the provision of meals to families threatened by food 
insecurity, help build resilience to the mental health impacts of the 
pandemic and subsequent economic disruption and perhaps the most 
optimistic finding is that despite the increased rates of mental 
illness symptoms and increased demand for mental health services, 
overall suicide rates in the United States continued to decline through 
the first year of the pandemic. \10\
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    \10\  Curtin SC, Hedegaard H, Ahmad FB Provisional numbers and 
rates of suicide by month and demographic characteristics: United 
States, 2020 Vital Statistics Rapid Release; no 16 Hyattsville, MD: 
National Center for Health Statistics November 2021 DOI: https://
dxdoiorg/1015620/cdc:110369.

    Of course, we must nonetheless strive to do better NIMH continues 
to gather evidence and collaborate with Federal agencies and other 
partners to widely disseminate evidence-based preventative and 
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therapeutic interventions Some additional examples include:

          Family Navigator Models, which provide assistance to 
        youth and families to navigate healthcare and social service 
        systems with the goal of improving outcomes and retaining more 
        people in care;

          The Collaborative Care Model for integrated care, 
        which uses a team-based approach to incorporate mental health 
        care into primary care;

          Learning Healthcare Networks, which utilize clinical 
        data to constantly improve and innovate in providing effective, 
        high-quality care to all patients; and,

          School-based Mental Health programs, which provide 
        behavior management skills training and other interventions to 
        reduce symptoms of depression and other serious emotional 
        disturbances.

    One quick fact to underscore this last example: NIMH-sponsored 
research has shown that mental health care for school-aged children is 
more readily accessed and more effective when delivered through school-
based programs, especially for Latinx and other children from 
underserved communities. \11\
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    \11\  Sanchez AL, Cornacchio D, Poznanski B, Golik AM, Chou T, 
Comer JS The Effectiveness of School-Based Mental Health Services for 
Elementary-Aged Children: A Meta-Analysis J Am Acad Child Adolesc 
Psychiatry 2018 Mar;57(3):153-165 doi: 101016/jjaac201711022 Epub 2017 
Dec 24 PMID: 29496124.

    We are faced with numerous challenges to the mental health of 
Americans, including the lingering effects of the COVID-19 pandemic, 
the crisis in youth mental health, including the impacts of media and 
technology use, challenges in caring for individuals with serious 
mental illness, rising suicide rates among Black youth and other 
vulnerable populations, and the limited efficacy of many existing 
treatments for mental illnesses In this context, research to develop 
novel, effective, and scalable preventive and therapeutic interventions 
is more urgent than ever At the same time, recent advances--such as 
novel technologies that are revolutionizing the understanding of the 
human brain, discoveries in the genetics of mental illnesses, and the 
successful development of novel, rapid-acting interventions for 
depression--provide an unprecedented opportunity to capitalize on 
mental health research and make significant progress for the future 
Meanwhile, NIMH continues to collaborate with our Federal partners, 
including those joining us here today, to ensure that evidence-based 
solutions reach those in need now In short, we know what works, and we 
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stand ready to help.

    Thank you for the opportunity to provide this testimony, and I 
would be pleased to answer any questions you might have.
                                 ______
                                 
    The Chair. Thank you.

    Director Volkow.

STATEMENT OF NORA D. VOLKOW, M.D., DIRECTOR, NATIONAL INSTITUTE 
   ON DRUG ABUSE, NATIONAL INSTITUTES OF HEALTH, BETHESDA, MD

    The Chair. If you can turn your mic on.

    Dr. Volkow. Can you hear me?

    The Chair. Yes, yes.

    Dr. Volkow. Good morning, I was saying, Chairwoman Murray, 
Ranking Member Burr, and Members of the Committee. Thank you 
for inviting me to speak to you today. The Biden Administration 
is committed to addressing the unprecedented mental health and 
substance use disorder crisis affecting our Country, and I 
welcome the opportunity to discuss how research supported by 
the National Institute on Drug Abuse is advancing this goal. We 
are experiencing the worst drug overdose crisis in the Nation's 
history.

    Exacerbated by the COVID pandemic, overdose deaths have 
escalated across states and demographics. Now, for the first 
time ever, we are seeing fentanyl overdoses in adolescents 
rising dramatically. Substance use disorders frequently co-
appear with other mental illnesses. Half of people with mental 
illnesses will have a substance use disorder at some point in 
their lives, and the reverse is also true.

    These conditions share many common biological and 
environmental risk factors, such as discrimination, trauma, and 
economic deprivation. Since 2016, the rise in overdose 
fatalities has been driven by potent synthetic opioids, 
primarily fentanyl. In the meantime, social isolation and 
stress during the pandemic have contributed to a rise in 
emotional suffering and an increase in substance use and 
overdoses.

    This and twin public health crisis highlights the need to 
implement prevention and treatment interventions. Preventions, 
interventions work. They protect from the devastation of drug 
use, and when delivered early in life, they can also help avert 
adult mental illnesses. Prevention interventions aim to 
decrease risk factors while enhancing resiliency and are 
implemented through family, schools, communities, and health 
care.

    Evidence based prevention saves lives and money. And some 
studies show these benefits even extend to future generations. 
The Healthy Brain Study and the Child and the Adolescent Brain 
Cognitive Development Study are two large longitudinal 
investigations of human brain development. Together, they span 
the prenatal period through young adulthood. And the findings 
have already started to illuminate biological and environmental 
influences on mental health and are expected to inform 
prevention interventions.

    The health care system can also play a key role in 
prevention and treatment, through screening for substance use 
and delivery of brief interventions or referral to specialty 
treatment. Identification of drug use can also serve as a 
sentinel symptom of a mental disorder that can then be treated. 
When substance use disorders occur along with other mental 
illnesses, both disorders must be treated.

    Medications and behavioral therapies are effective in 
treating substance use disorders with or without comorbidities. 
However, less than 13 percent of people with substance use 
disorders receive treatment. This percentage is even lower 
among black Americans, among whom we are currently seeing the 
fastest rate of growth in overdose deaths.

    Even for individuals with substance use disorders and 
psychiatric conditions, fewer than half received any treatment. 
To address this gap, NIDA is prioritizing implementations and 
services research. The NIDA clinical trial network or CTN has 
shown that opioid use disorders can be successfully treated in 
emergency departments and other health care settings. CTN is 
now assessing new models of treatment delivery through 
pharmacies and telehealth.

    The NIDA Justice Community Opioid Innovation Network is 
testing ways to expand addiction treatment in jails and other 
justice settings. And are Healing Communities Study conducted 
in conjunction with SAMHSA is investigating how evidence based 
interventions can reduce opioid overdoses in some of the 
hardest hit communities in our Country.

    NIDA also helps biotech startups develop technologies that 
connect people to care, provide or support treatment, help 
people sustain their recovery, and even facilitate overdose 
prevention. While there are effective medications for opioid, 
alcohol, and tobacco use disorders, high relapse rates still 
remain.

    Critically, there are no medications for other drug use 
disorders. Thus, NIDA is prioritizing the development of 
addiction medications and treatment, including those that 
address the intersection between substance use and other mental 
illnesses.

    The escalating loss of life due to drug addiction has made 
evident the urgent need for interventions to prevent and treat 
emotional distress and mental disorders as key strategies for 
addressing the overdose crisis. Thanks for inviting me to 
testify.

    [The prepared statement of Dr. Volkow follows:]
                  prepared statement of nora d. volkow
    Chair Murray, Ranking Member Burr, and Members of the Committee, 
thank you for inviting the National Institute on Drug Abuse (NIDA), a 
component of the National Institutes of Health (NIH), to participate in 
this hearing NIDA's mission is to advance the science on the causes and 
consequences of drug use and addiction and apply that knowledge to 
improve individual and public health I am pleased to speak to you today 
about the intersection of substance use and mental health.

    The Administration is committed to addressing the unprecedented 
mental health, and substance use disorder crisis that is affecting 
adults and children of all races in urban and rural communities across 
the United States During the State of the Union, President Biden 
announced his Unity Agenda This includes a focus on fighting the 
overdose epidemic as well as addressing our national mental health 
crisis \1\ The three pillars of the President's mental health strategy 
are: (1) Strengthen System Capacity; (2) Connect Americans to Care; and 
(3) Support Americans by Creating Healthy Environments Today I will 
detail for you how NIDA science is advancing these goals.
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    \1\  FACT SHEET: President Biden to Announce Strategy to Address 
Our National Mental Health Crisis, As Part of Unity Agenda in his First 
State of the Union--The White House.

    We are experiencing the worst drug overdose crisis in the nation's 
history Exacerbated by the COVID-19 pandemic, overdose deaths exceeded 
100,000 from September 2020 to September 2021, the highest number ever 
recorded in a 12-month period and a staggering 50 percent increase over 
the previous 2 years Large increases in many kinds of drug use have 
been seen over the course of the pandemic: Several reports have 
revealed increases in positive urine drug screens for fentanyl, 
cocaine, heroin, and methamphetamine \2\, \3\, \4\ There have been 
increases in cannabis and alcohol use, especially among people with 
anxiety and depression and those experiencing COVID-19-related stress, 
\5\, \6\, \7\ underscoring the close relationship between drug use and 
mental health.
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    \2\  Millennium Health's Signals Report to COVID-19 Special Edition 
Reveals Significant Changes in Drug Use During the Pandemic 
(prnewswirecom).
    \3\  Analysis of Drug Test Results Before and After the U.S. 
Declaration of a National Emergency Concerning the COVID-19 Outbreak--
Emergency Medicine--JAMA--JAMA Network.
    \4\  The Opioid Epidemic Within the COVID-19 Pandemic: Drug Testing 
in 2020--Population Health Management (liebertpubcom).
    \5\  Alcohol Consumption during the COVID-19 Pandemic: A Cross-
Sectional Survey of U.S. Adults (nihgov).
    \6\  Increased alcohol use during the COVID-19 pandemic: The effect 
of mental health and age in a cross-sectional sample of social media 
users in the U.S.--ScienceDirect.
    \7\  Changes in Alcohol Consumption Among College Students Due to 
COVID-19: Effects of Campus Closure and Residential Change: Journal of 
Studies on Alcohol and Drugs: Vol 81, No 6 (jsadcom).

    Substance use disorders (SUDs) are considered mental illnesses, and 
these conditions frequently co-occur with other mental illnesses 
including depression, anxiety, post-traumatic stress disorder (PTSD), 
and others Half of people with mental illnesses will have an SUD at 
some point in their lives, and the reverse is also true The reasons 
that SUDs often co-occur with other mental illnesses are complex 
Sometimes they arise independently as a result of shared risk factors 
(common genetics, common environmental adverse factors) Their 
development may also be intertwined, with one contributing to the other 
Chronic, problematic drug use can disrupt the activity of the brain's 
reward, stress, and executive-control systems, making it more difficult 
for people to experience the pleasures associated with daily living and 
contributing to negative emotional states, such as depression, stress, 
and anxiety while impairing their capacity for self-regulation In other 
cases, people use drugs to self-treat an underlying mental disorder 
Over time, chronic drug use can lead to an SUD, which in turn can 
worsen the original mental illness Genetics may also mediate the 
relationship between drug use and mental illness For example, cannabis 
use raises risk of psychosis in those who have an underlying genetic 
vulnerability Research also points to a concordance between increases 
in schizophrenia associated with cannabis use disorder and concurrent 
---------------------------------------------------------------------------
rises in cannabis use and cannabis potency over the past two decades.

    Although genes play a role in some of the synergies between drug 
use and mental illness, many of the common risk factors are social 
determinants of health such as racial and other forms of 
discrimination, adverse childhood experiences like abuse and neglect, 
and economic deprivation including poverty and lack of access to 
quality education and healthcare The stigma that attaches to both SUDs 
and other mental illnesses is another important factor, which 
contributes to and compounds adverse social determinants of health 
including social isolation, job loss, incarceration, and reluctance to 
seek care or difficulties accessing it.

    Social isolation and stress have likely contributed to the rise in 
substance use and overdose observed over the course of the pandemic 
Social isolation can make people with SUDs more vulnerable to negative 
outcomes because it interferes with many of the support systems that 
can help them to reach and sustain recovery Although exposure to stress 
is a common occurrence for many of us, it is also one of the most 
powerful triggers for relapse to substance use for people with SUD, 
even after long periods of abstinence and for the exacerbation of 
depression and anxiety among with people with mental illnesses.

    Notably, there are increased reports of mental distress since the 
COVID-19 pandemic emerged, including among individuals with no history 
of mental disorders and among younger adults, racial/ethnic minorities, 
essential workers, and unpaid adult caregivers \8\, \9\, \10\, \11\ 
This increased mental distress is occurring in the context of a drug 
supply that is dominated by potent synthetic opioids and 
psychostimulants, underscoring the need for focused investment in 
prevention and treatment to mitigate the impact of the pandemic on the 
ongoing overdose epidemic Suicide is often linked to depression and 
other mental illnesses including SUDs, and in the United States, and it 
has significantly risen particularly among youth and, to a lesser 
extent, the elderly Moreover, in a recent study, we found that although 
suicide by overdose went down in most groups between 2015 to 2019 (the 
most recent year available), it rose in young people aged 15-24, in 
older adults aged 75-84, and in Black women The highest suicide-by-
overdose rate in all years studied was seen in women aged 45-64. \12\
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    \8\  Mental Health--Household Pulse Survey--COVID-19 (cdcgov).
    \9\  Early Release of Selected Mental Health Estimates Based on 
Data from the January--June 2019 National Health Interview Survey 
(cdcgov).
    \10\  Mental distress during the COVID-19 pandemic among U.S. 
adults without a pre-existing mental health condition: Findings from 
American trend panel survey--ScienceDirect.
    \11\  Mental Health, Substance Use, and Suicidal Ideation During 
the COVID-19 Pandemic--United States, June 24--30, 2020--MMWR (cdcgov).
    \12\  Intentional Drug Overdose Deaths in the United States 
American Journal of Psychiatry 2022 179:2, 163-165.
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     NIDA Is Advancing Research on SUDs and Other Mental Illnesses
    NIDA-supported research has led to the development of effective 
prevention and treatment interventions for SUD, providing hope for the 
more than 20 million people in the United States with SUD and their 
loved ones Although significant strides in establishing evidence-based 
practices have been made, there is far more work to be done to develop 
new prevention and treatment interventions and to deliver existing 
effective interventions with fidelity, for diverse populations, and at 
scale There is a particularly urgent need for interventions for 
comorbid SUD and mental illness; just as SUD and other mental illnesses 
may exacerbate one another, effective treatment for each of a person's 
psychiatric condition improves overall outcomes.
                               Prevention
    Two large NIH-funded longitudinal studies, the Adolescent Brain 
Cognitive Development (ABCD) study and the HEALthy Brain and Child 
Development (HBCD) study, will add greatly to our understanding of risk 
and protective factors for SUDs and other mental illnesses Launched 
last year, the HBCD study will examine, from the prenatal period 
through age 9-10, both normal brain development and how environmental 
factors, including social determinants of health, maternal drug 
exposure, substance use, and COVID-19 influence brain development and 
clinical outcomes ABCD is following nearly 12,000 children from age 9-
10 through the subsequent decade This study, too, has been examining 
how childhood experiences affect brain development and social, 
behavioral, academic, and health outcomes, including substance use and 
COVID-19 Together, these studies will provide valuable information for 
the development and implementation of prevention interventions.

    It is already clear that interventions in early childhood or 
adolescence can be beneficial for averting substance use and other 
mental illnesses later in life Research has also provided evidence that 
interventions for low-income families can ameliorate some of the 
adverse neurobiological impacts of poverty \13\ Substance use and 
behavioral disorders exact a monetary as well as a human cost, with 
impacts felt across sectors of society including healthcare, the 
justice system, education, and taxpayers in general Studies of 
prevention's return on investment show that communities could not only 
save lives but save money by investing in prevention programs A recent 
analysis of one state's healthcare costs incurred by various risky 
behaviors in pre-adolescents and adolescents pointed to great potential 
cost savings from implementing relatively low-cost measures including 
screening in primary care and referral to family based prevention. \14\
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    \13\  Family centered prevention ameliorates the longitudinal 
association between risky family processes and epigenetic aging--
Brody--2016--Journal of Child Psychology and Psychiatry--Wiley Online 
Library.
    \14\  Addressing Barriers to Primary Care Screening and Referral to 
Prevention for Youth Risky Health Behaviors: Evidence Regarding 
Potential Cost-Savings and Provider Concerns--SpringerLink.

    Indeed, screening is crucial to better prevention of SUD and other 
mental illnesses, and it is an important area to focus our efforts As 
it now stands, within primary and ambulatory care settings, rates of 
screening for depression are quite low \15\, \16\ Screening for 
depression and other mental health conditions needs to become part of 
standard practice along with asking about substance use Only when 
providers screen for and diagnose all coexisting psychiatric conditions 
can treatment plans be developed that address the patient's unique and 
combined needs.
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    \15\  National Rates and Patterns of Depression Screening in 
Primary Care: Results From 2012 and 2013--PubMed (nihgov).
    \16\  Depression Screening Patterns, Predictors, and Trends Among 
Adults Without a Depression Diagnosis in Ambulatory Settings in the 
United States--Psychiatric Services (psychiatryonlineorg).

    Under the Helping to End Addiction Long-term or HEAL Initiative, 
NIDA leads prevention research aimed at adolescent and young adult 
populations that are at highest risk for opioid misuse and opioid use 
disorder. (OUD) \17\ Ongoing studies are modifying an existing alcohol 
and drug prevention intervention designed for American Indian/Alaska 
Native (AI/AN) youth to be appropriate for opioid prevention in young 
adults; preventing OUD among adolescents/young adults experiencing 
homelessness; exploring whether providing housing in addition to risk 
reduction services could improve outcomes; and leveraging technology 
that is appealing to adolescents and young adults to facilitate 
delivery of an emergency-department-based intervention via health 
coaches Preventing harms related to substance use is another critical 
priority and includes strategies to prevent overdose and other medical 
consequences of substance use such as infectious diseases.
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    \17\  Preventing At-Risk Adolescents from Developing Opioid Use 
Disorder--NIH HEAL Initiative.
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                         Behavioral Treatments
    Only 13 percent of people with drug use disorders receive any 
treatment, and more than half of those with co-occurring conditions in 
a given year will receive treatment for neither Behavioral therapies 
can be effective for treating SUDs For example, contingency management, 
a therapy that provides incentives for behavior change, is the most 
effective treatment for stimulant use disorders, though it is 
unfortunately not widely available to patients Other behavioral 
treatments, like cognitive behavioral therapy, have been shown to be 
effective in treating both SUDs and some other mental illnesses 
together But by and large, treating SUDs and other mental illness will 
require a combined approach and coordination of care among different 
specialists In a person with OUD and depression, for instance, it could 
mean a combination of buprenorphine and an antidepressant, ideally in 
combination with some form of behavioral therapy Overall interventions 
need to be personalized to the severity of the disorder and the 
different needs of patients NIDA is supporting research to develop 
behavioral treatments to reduce substance use by addressing symptoms of 
anxiety and depression; to simultaneously intervene on substance use 
and symptoms of PTSD in adolescents; and to develop SUD treatment 
approaches that are tailored to the needs of people with schizophrenia 
or symptoms of psychosis.
                         Medication Development
    Developing effective medications for SUDs is one of NIDA's highest 
priorities and is critical to improving treatment for people with 
addiction While effective medications exist for OUD, these medications 
are underutilized Suboptimal patient retention in treatment regimens, 
policy barriers that limit opioid prescribing, and stigma around opioid 
agonist medications all contribute to their underutilization More 
options are needed to help people with OUD achieve long-term recovery 
NIDA is supporting research on medication development for OUD and 
overdose, including through funds provided by the NIH HEAL Initiative 
The NIH HEAL Initiative has allowed investigators to file 21 
Investigational New Drug Applications with the Food and Drug 
Administration (FDA) in the past 25 years to initiate clinical trials 
These studies focus on a variety of drug targets, as well as monoclonal 
antibodies and vaccines that could prevent opioids from entering the 
brain.

    An increased focus on patient wants and needs, as well as a growing 
understanding that SUD treatment needs to be personalized and 
responsive to patients' unique changing sets of symptoms, is leading to 
a broadened conception of treatment that can include addressing 
multiple co-occurring symptoms of a disorder Sleep problems, 
depression, and anxiety, for instance, are among SUD-associated 
symptoms identified at patient-focused drug development meetings held 
by the FDA in partnership with NIDA to solicit input from SUD patient 
populations to help guide drug development Studies are underway to 
investigate the possibility of repurposing existing medications for OUD 
indications, such as the FDA-approved insomnia medication, suvorexant, 
based on known overlaps between brain signaling systems involved in 
sleep and addiction.

    We are also prioritizing the development of medications to treat 
stimulant use disorders for which there are currently no FDA-approved 
medications Numerous compounds are being tested, and approaches span 
identifying novel biological targets for new medications, developing 
anti-cocaine and anti-methamphetamine vaccines, repurposing existing 
FDA-approved medications, and testing the benefits from medication 
combinations (ie, naltrexone buprenorphine for the treatment of 
moderate to severe methamphetamine use disorder) NIDA's medication 
development program is also supporting research on compounds that 
specifically address intersecting substance use and psychiatric 
symptoms, including potential treatments for mood disorder symptoms 
associated with cocaine use and co-occurring bipolar and cannabis use 
disorders.

    More coordinated and targeted approaches to incentivize drug 
development related to addiction are sorely needed The pharmaceutical 
industry has historically underinvested in research and development of 
substance use disorder treatments, due to the biological complexity of 
these disorders, the stigma that surrounds them, and concerns around 
the profit potential of substance use disorder medications.
                             Harm Reduction
    Abundant research shows the value of interventions and services 
aimed at reducing harms associated with drug use Overdose deaths are 
significantly reduced in communities that distribute naloxone to people 
who use drugs and to their families or other potential bystanders An 
important part of NIDA's medication-development research involves 
developing new and improved overdose reversal medications, particularly 
formulations of naloxone that are effective for high-potency opioids 
like fentanyl, as well as compounds that could reverse opioid overdoses 
involving other drugs such as methamphetamine Syringe-services programs 
are effective at reducing the spread of HIV and other infectious 
diseases like hepatitis C, and they also help link people who inject 
drugs to addiction and HIV screening and treatment NIDA continues to 
support research on these and other harm reduction practices such as 
drug checking technologies like fentanyl test strips.
         Translating Research into Practice in Diverse Settings
    Providing prevention and treatment services across health care, 
justice, and community settings is key to addressing SUD and is the 
most promising way to improve access to treatment Persistent challenges 
continue to keep mental health care largely separate from general 
medical care, and addiction care is often further sequestered to 
specialized settings This leads to difficulty in providing patients 
with coordinated, wholistic treatment In order to promote provision of 
quality care, NIDA places a high priority on implementation research in 
diverse settings, including through the NIDA Clinical Trials Network 
(CTN), the Justice Community Opioid Innovation Network (JCOIN), and the 
HEALing Communities Study (HCS).
                        Clinical Trials Network
    The primary goal of CTN, which comprises 16 research nodes and more 
than 240 community-anchored treatment programs across the country, is 
to bridge the gap between the science of drug treatment and its 
practice through the study of evidence-based interventions in real-
world settings NIDA's CTN allows medical and specialty treatment 
providers, treatment researchers, patients, and NIDA to cooperatively 
develop, validate, refine, and deliver new treatment options to 
patients The CTN is conducting studies to evaluate strategies for 
integrating OUD screening and treatment into emergency departments, 
primary care clinics, infectious disease programs and rural and AI/AN 
communities It also tests alternative models of care for SUD such as 
the use of pharmacies for delivering medication for OUD and the 
integration of telehealth for support of treatment The CTN supports 
research based on data relevant to SUD by taking advantage of 
electronic health record (EHR) systems It is currently developing and 
testing a clinical decision support tool that integrates with EHR 
systems to help doctors diagnose OUD and provide treatment or refer 
patients to appropriate care The CTN also supports research to examine 
the role of pharmacies in providing medications for OUD, an approach 
that could be especially useful in rural communities located far away 
from traditional treatment programs.
              Justice Community Opioid Innovation Network
    NIDA's JCOIN, which is funded though the NIH HEAL initiative, is 
testing strategies to expand effective OUD treatment and care for 
people in justice settings in partnership with local and state justice 
systems and community-based treatment providers. \18\ JCOIN includes a 
national survey of addiction treatment delivery services within the 
justice system; studies on the effectiveness and adoption of new 
medications, prevention and treatment interventions, and technologies; 
and use of existing data sources in novel ways to understand care in 
justice populations Together, these studies are generating real-world 
evidence to address the unique needs of individuals with OUD in justice 
settings JCOIN also responded in real time to the COVID-19 pandemic 
with additional research to study COVID testing protocols in justice-
involved populations.
---------------------------------------------------------------------------
    \18\  Justice Community Opioid Innovation Network--NIH HEAL 
Initiative.
---------------------------------------------------------------------------
                       HEALing Communities Study
    The HEALing Communities Study, also funded through the NIH HEAL 
Initiative, is a multisite implementation research study investigating 
coordinated approaches for deploying evidence-based strategies to 
prevent and treat opioid misuse and OUD and prevent overdose deaths 
that is tailored to the needs of local communities Research sites are 
partnering with 67 communities highly affected by the opioid crisis 
across four states (NY, MA, KY, and OH) to measure the impact of these 
efforts. \19\ The ambitious goal of the study is to reduce opioid-
related overdose deaths by 40 percent over 3 years Despite the impacts 
of COVID-19 on research and its severe exacerbation of the overdose 
crisis, the HEALing Communities study was able to launch a key aspect 
of its program, a diverse communications campaign to increase awareness 
and demand for evidence-based practices and to reduce stigma against 
people with OUD and those taking medications for OUD. \20\
---------------------------------------------------------------------------
    \19\  HEALing Communities Study--NIH HEAL Initiative.
    \20\  Introduction to the special issue on the HEALing Communities 
Study--ScienceDirect.
---------------------------------------------------------------------------
  Leveraging Telehealth, Digital Solutions, and Innovation to Expand 
                             Access to Care
    A component of translating research into practice is leveraging 
existing opportunities and developing new ways to bring healthcare to 
hard-to-reach populations The COVID-19 pandemic brought about 
significant drug treatment policy changes that expanded telehealth and 
facilitated access to medications for OUD--including by facilitating 
remote prescribing of buprenorphine and take-home dosing of methadone 
These flexibilities were rapidly implemented by providers, and evidence 
to date suggests that they were not associated with an increase in 
adverse outcomes NIDA is funding research on telehealth utilization and 
the effects of recent changes in policy and practice.

    NIDA is also leveraging the Small Business Innovation Research 
(SBIR) and Small Business Technology Transfer (STTR) programs and other 
funding mechanisms to help biotech startups develop technologies that 
connect people with SUDs to care, provide or support treatment, help 
individuals sustain their recovery, and even facilitate overdose 
prevention For example, a smartphone app originally designed to connect 
patients to open acute care beds has been adapted to facilitate 
referrals to addiction treatment facilities and is currently being used 
by several state governments and hospital systems NIDA has also helped 
develop tools that put evidence-based psychosocial treatment for SUDs 
right in the hands of anyone with a smartphone For example, reSET and 
reSET-O are apps that deliver cognitive behavioral therapy in 
conjunction with treatment that includes buprenorphine and contingency 
management to people with non-opioid SUDs (reSET) and OUD (reSET-O), 
and were the first prescription cognitive behavioral therapy mobile 
apps to receive FDA clearance to help increase retention in an 
outpatient treatment program A NIDA SBIR grant is now being used to 
make these apps more accessible by converting them into a game Other 
apps help doctors and patients monitor and maintain their OUD 
medication, and connect individuals to behavioral therapies, peer 
support groups, and community interventions Research is also ongoing to 
develop automatic overdose detection devices that can inject naloxone 
when a person overdoses, along with tools and methods to accurately 
assess types of drugs detected in blood or urine for use in healthcare 
or by medical examiners and coroners, among many other innovations 
These and other innovative products demonstrate that pairing sound 
science with biotechnology entrepreneurship has great potential to 
expand the research of addiction treatments and support services.
              Addressing Health Inequities and Disparities
    Disparities by race, socioeconomic status, sex, and geography have 
always created an inequitable landscape in care for SUDs and other 
mental illnesses For example, Black people are much less likely to be 
prescribed buprenorphine for OUD than white people and despite parity 
laws, insurance coverage for SUD and other mental health treatment 
remains limited, meaning that less advantaged populations have less 
access to needed, potentially life-saving services The COVID pandemic 
has illuminated and, in many ways, exacerbated many of these 
disparities However, flexibilities in healthcare practice adopted 
during the pandemic (eg, expanded telehealth) along with new tools to 
facilitate telehealth may help overcome some of the existing barriers 
to finding SUD treatment and psychiatric care, particularly for 
currently underserved populations Ongoing research will help optimize 
the most cost-effective interventions to mitigate the exacerbation of 
health disparities due to COVID-19 Indeed, finding solutions to reduce 
and ultimately eliminate health disparities, especially those related 
to structural racism, is a NIDA research priority Racial disparities 
also persist in the addiction science workforce NIDA's Racial Equity 
Initiative is working to identify disparities and systemic barriers and 
implement programs and funding opportunities to equitably enhance, 
promote, and sustain engagement of people from diverse backgrounds, 
including those from historically underrepresented groups, in addiction 
science.

    Substance use impacts women differently than men, conferring unique 
challenges that warrant particular attention Women are more likely to 
use substances to cope, progress more quickly from use to addiction, 
and have greater co-occurrence of addiction with symptoms of mood 
disorder. \21\, \22\ This increased vulnerability bears out in women 
experiencing homelessness, who have higher rates of substance use than 
their male counterparts and are a group more likely to have been victim 
to physical and sexual abuse \23\, \24\ Worldwide, women are less 
likely than men to receive treatment for their SUD. \25\ Negative 
outcomes associated with substance use are also a serious concern among 
women; women who use drugs experience gender-related violence at much 
higher rates than those who do not, women have a greater likelihood 
than men of contracting blood-borne infections from injection drug use, 
and women are more likely than men to intentionally overdose. \26\, 
\27\ These elevated risks not only impact women who use drugs, but 
their children and family units as well It is imperative that the 
specific needs of women are considered--from biological differences, 
through childcare, personal safety, and transportation needs--to ensure 
that addiction prevention and treatment are as effective as possible.
---------------------------------------------------------------------------
    \21\  Full article: Women and Addiction: The Importance of Gender 
Issues in Substance Abuse Research (tandfonlinecom).
    \22\  Sex differences in vulnerability to addiction--ScienceDirect.
    \23\  Women, Homelessness, and Substance Abuse: Moving Beyond the 
Stereotypes--Lisa J Geissler, Carol A Bormann, Carol F Kwiatkowski, G 
Nicholas Braucht, Charles S Reichardt, 1995 (sagepubcom).
    \24\  Recognizing and responding to women experiencing homelessness 
with gendered and trauma-informed care--BMC Public Health--Full Text 
(biomedcentralcom).
    \25\  WDR21--Booklet--2pdf (unodcorg).
    \26\  Women who inject drugs more likely to be living with HIV--
UNAIDS.
    \27\  Intentional Drug Overdose Deaths in the United States--
American Journal of Psychiatry (psychiatryonlineorg).
---------------------------------------------------------------------------
                         Building Partnerships
    Partnerships are critical to make a positive impact on public 
health, and NIDA is engaged in productive collaborations at all levels 
of government we value our partnerships with our sister agencies in 
HHS, including the Substance Abuse and Mental Health Services 
Administration (SAMHSA), the Health Resources and Services 
Administration (HRSA), as well as the FDA, which is crucial to our 
efforts to develop medications and devices for SUD medications NIDA 
also partners closely with the Centers for Medicare & Medicaid Services 
(CMS) to build the evidence base for healthcare funding decisions, with 
the Office of National Drug Control Policy (ONDCP) to advance the far-
ranging goals of the National Drug Control Strategy, and with the 
Department of Justice to improve addiction care in incarcerated 
populations and promote research on controlled substances.

    Collaborations also provide valuable and complementary perspectives 
and infrastructures that NIDA leverages to advance research and 
maximize its benefit for all people Some of the largest projects funded 
under the NIH HEAL Initiative rely on such collaboration with our 
Federal partners and others The HEALing Communities Study is led by 
NIDA in close partnership with SAMHSA to ensure that this research is 
poised to impact service delivery toward ameliorating the opioid crisis 
in hard hit areas JCOIN fosters collaboration between investigators, 
justice, and behavioral health stakeholders in search of creative ways 
for improving the capacity of the justice system to respond to the 
opioid crisis.
                               Conclusion
    The issues of substance use and SUD are inseparable from the larger 
landscape of mental health and mental illness Consequently, we cannot 
hope to make headway against the drug overdose crisis unless we make 
screening, preventing, and treating all mental illness, including SUDs, 
one of our top priorities Continued research is also critical, and NIDA 
is actively supporting research in each of these areas with a focus on 
SUDs, their entwined psychiatric problems, and overcoming the various 
infrastructural barriers and stigma that have historically impeded 
these goals Thank you for the opportunity to address these critical 
issues.
                                 ______
                                 
    The Chair. Thank you very much to all of our witnesses. We 
appreciate your being here today. We will now begin a round of 
5 minute questions. And I again ask my colleagues to keep track 
of your clock and stay within those 5 minutes. Assistant 
Secretary Delphin-Rittmon, this pandemic, as I said, has been 
especially difficult for children. They have dealt with major 
disruptions in their daily lives.

    Many have lost loved ones due to COVID-19. And meanwhile, 
parents and caregivers are really stressed, making what has 
been a really difficult time even harder for families and for 
kids. I know as a mother and a grandmother and a former 
preschool teacher, I am very committed to making sure we are 
doing everything to meet the needs of our children and our 
adolescents, and to address this real national emergency in 
youth mental health.

    Can you tell all of us why it is important to provide kids 
with high quality mental health screening and prevention and 
intervention and treatment services?

    Ms. Delphin-Rittmon. Thank you so much again for convening 
us, Chair Murray. You know, it is so critical to address the 
mental health needs of young people. We know even before the 
pandemic, young people were struggling with a range of mental 
health challenges. And as a function of the pandemic, we have 
seen those challenges increase.

    Putting programs and strategies and training and technical 
assistance in place to be able to address the needs of children 
struggling with mental health challenges is a priority of 
SAMHSA. For example, one program that we have is Project Aware, 
that is promoting awareness and resiliency in schools.

    It is a wonderful program that provides training and 
technical assistance for school personnel to be able to 
recognize children that are struggling, but then also connect 
children who are struggling to care and to resources. And so 
that is a program that we, in fact, have been able to scale up 
through American Rescue Plan resources and one where we are 
seeing significant impacts across the country.

    We will also develop, as I mentioned, the HOPE framework. 
So working to ensure that children and families are connected 
to health, so healthy opportunities and opportunities to be 
able to improve and advance health, again, opportunity to be 
able to reach their full potential and be screened for any 
risks.

    Then equity, you know, certainly ensuring that those 
services are equitable. And so that is a framework that 
essentially encapsulates a range of programs and initiatives 
across SAMHSA to be able to ensure that--and promote the mental 
health and well-being of children. But this, especially now, is 
an important time to address mental health. And again, we have 
a range of programs.

    To include mental health first aid, that is an additional 
training program that provides training and support for 
communities, again, for schools and individuals on request 
really, faith communities as well, to be able to recognize the 
needs of--and recognize when young children are struggling.

    The Chair. Great. Okay, thank you. According to estimates 
released actually just last week, more than a 105,000 Americans 
died from drug overdoses from October 2020 to October 2021. 
That is the highest annual total on record. In my home State of 
Washington, we have seen a real drastic rise in synthetic 
opioid use. Our largest county, King County, set a record high 
of overdose deaths.

    Those are really tragic and unacceptable numbers, and they 
make clear that we really need to invest in treatment, 
including medication assisted treatment, or MAT, and prevention 
services for opioid use disorder. But right now, as I said, 
just one in five Americans with opioid use disorder receive 
MAT, and there are significant disparities in access to that 
treatment.

    Overdose rates are rising fastest among black people, we 
also know black communities are less likely than white ones to 
have access to those that they need. So as this Committee looks 
at putting together legislation to combat substance use 
disorders and overdose deaths, I really think we have to do 
everything we can to expand access to prevention and treatment 
services and reduce those disparities in care.

    Director Volkow, I wanted to ask you, how would you improve 
access to treatment, including medication assisted treatment, 
help reduce those disparities?

    Dr. Volkow. We know that the most effective intervention 
that we have against overdoses is providing medication for 
opioid use disorder. It increases your risk of overdosing by at 
least 60 percent.

    But unfortunately, as you mention, a very relatively small 
percentage of people that can benefit are given access to 
treatment, and the treatment also is not necessarily continued. 
So we need to not only expand the number of individuals that 
can be treated but ensure that we have the support systems that 
will allow them to remain in treatment.

    We have to take advantage of health care systems and 
involve partnerships with justice settings so that we ensure 
absolute equity in access to these treatments. The parity law 
determines that you should be treating addiction as a medical 
condition. And yet this has not been properly implemented, and 
we need to ensure that the workforce is able to provide the 
treatment, so.

    The Chair. Okay, thank you. Thank you very much. And 
Senator Burr, you are deferring to Senator Collins. Senator 
Collins.

    Senator Collins. Thank you. Thank you, Senator Burr. Dr. 
Delphin-Rittmon, in Maine last year we had 636 deaths, a 23 
percent increase, primarily as a result of fentanyl. This is 
the highest level we have ever experienced. But what is equally 
traveling is if you look at total overdoses in 2021, the number 
exceeds 9,500.

    What I am hearing from law enforcement and public health 
officials is that they need data on non-fatal overdoses in 
order to identify and investigate the sources of opioids and 
fentanyl and other drugs in their communities, and to be able 
to direct people to drug treatment programs.

    I am working on a bill based on recent GAO recommendations, 
which would require the Administration to improve the 
timeliness, accuracy, and accessibility of both fatal and non-
fatal overdose data. During our meeting, prior to your 
confirmation, you described yourself as a data person. Would 
you support legislation to provide better information on non-
fatal overdoses? Because if we are just looking at the tragic 
deaths we are missing the picture.

    Ms. Delphin-Rittmon. Yes, you know, thank you so much for 
that question. And, you know, I think it is right on. It is so 
important that we have a good sense of both overdose data as 
well as non-overdose data.

    Would be definitely interested in talking with you further 
about that. I think to the extent that we can understand some 
of the non-overdose trends as well, it could help to inform 
programs and services and interventions. So happy to have 
further conversations about that. I do believe that will be an 
important area of work.

    Senator Collins. Thank you. The next question I want to ask 
is for you also. Maine has the terrible distinction of having 
the second highest rate of neonatal abstinence syndrome in our 
Country, even though the number of babies born in our state 
with neonatal abstinence syndrome has declined somewhat.

    But still, in 2020, 901 babies were born drug affected. As 
some Members of the Appropriations Committee, I have encouraged 
the Administration to enhance efforts to screen, treat, and 
support infants through the WIC program. USDA designates 
neonatal abstinence syndrome as a nutrition risk, but WIC 
programs do not currently have uniform, evidence based 
nutrition educational materials.

    Does SAMHSA coordinate with USDA on this issue?

    Ms. Delphin-Rittmon. Yes, so the WIC program is, and thank 
you for that question, is a USDA program, although we do have 
coordination and collaborations with USDA and can certainly, 
you know, develop additional work in this area. We currently 
have collaborations related to rural technical assistance 
related to opioid use but can certainly expand our work in 
collaboration in terms of the WIC program as well which they 
administer.

    Senator Collins. I certainly hope that you will. It is 
really a terrible problem. Ms. Johnson, my final question is 
for you. It has to do with the STAR Loan Repayment Program that 
is administered by HRSA. It offers loan repayment to eligible 
substance abuse disorder professionals who agree to work in 
areas that are located in the country with overdose races that 
are greater than the national average or have mental health 
professionals shortages.

    Unfortunately, what we are finding in Maine is said some 
clinicians have been denied loan repayment because HRSA does 
not consider telehealth patient care unless both the 
originating site where the provider is located and the distant 
site where the patient is, meet the geographic criteria.

    That is in conflict with the flexibilities that Congress 
enacted to enable access to telehealth during the COVID public 
health emergency. I have written to HRSA on this, and I am told 
that you need a legislative fix. Would you support making such 
a change to ensure that qualified substance abuse disorder 
professionals are not disadvantaged because the care delivery 
for vulnerable patients has shifted to telehealth during this 
pandemic, particularly for rural areas and underserved 
communities?

    Ms. Johnson. Thank you so much, Senator, for the question. 
As you know, HRSA is the home of the Federal Office of Rural 
Health Policy. We are very dedicated to making sure that we are 
doing everything we can to get services and supports to rural 
communities. And increasingly, as you note, our loan repayment 
programs are reaching into rural communities, and we are doing 
everything we can to ensure those programs continue to grow in 
rural areas.

    We also have used a number of COVID flexibilities, as many 
as we can, throughout the pandemic for our loan repayment 
program, so I am very interested in having a follow-up 
conversation with your staff about the opportunities here 
because we want to support rural communities as much as 
possible.

    Senator Collins. Thank you.

    The Chair. Thank you very much.

    Senator Smith.

    Senator Smith. Thank you, Madam Chair. Thank you to all of 
you for being here today. Just following up on Senator Collins' 
line of questioning. This issue of building out and expanding 
the mental health care workforce is a crucially important 
issue. I hear about this all the time.

    People who finally kind of break through the stigma and the 
systemic challenge is to say, okay yes, I am ready to get help, 
and then they face long waiting lists, wait times that 
sometimes that Minnesota will reach to months. And of course, 
we would never put up with that kind of waiting time if 
somebody was having a heart attack or had a broken limb. And so 
I think addressing this workforce shortage, which is often the 
cause of this waiting challenge, is really important.

    Let me just ask Ms. Johnson a follow-up question. I mean, I 
get from what you were saying that these loan repayment 
programs work to build out the mental health care workforce 
across the broad spectrum of providers. Because it is not just 
psychiatrists. It could be a whole--you know, across a whole 
range of providers. Is that right?

    Ms. Johnson. That is correct. There are a whole range of 
mental health professionals who are eligible to participate in 
the National Health Service Corps. We also have a nurse corps, 
a loan repayment program.

    The advantage of these programs is that not only are we 
helping those individuals with loan repayment in return for 
service in underserved communities, but our data consistently 
shows that people tend to stay in the communities in which they 
originally practice. And so it is a long term investment in 
those communities.

    Senator Smith. Now, another issue that I hear about all the 
time is that we have loan repayment programs that are getting 
folks into--you know, that are getting people ready to go into 
training but then we have a shortage of trainers. We have a 
shortage of educators. This is a challenge in Minnesota around 
nurses, not only in mental health training programs, but more 
broadly. So could you just talk about what we need to do to 
address that challenge of educators in the field?

    Ms. Johnson. I just really appreciate you raising the 
question, Senator, because before the pandemic, nurse faculty 
was a challenge. The critical issues that our heroic frontline 
nurses have dealt with throughout the pandemic has made it even 
harder for us to recruit individuals who have the time and 
resources and capacity to apply to function in nurse faculty 
roles.

    We have a loan repayment program to encourage people into 
nurse faculty. We would love to continue to grow and expand 
that work. But we also are--in my role in HRSA, I am 
increasingly reaching out to health professions, leaders, and 
health systems leaders who have a shared interest in ensuring 
that we have a viable nursing workforce for the future.

    Because I think this is, as Ranking Member Burr pointed to 
earlier, a place for public, private partnership to encourage 
individuals to work in nurse faculty is an important 
partnership.

    Senator Smith. Right. Because if you might have been a 
practitioner, the thing you would like to see is practitioners 
who then come into training and become an instructor. But often 
that requires--I mean, you know, people are going to be hard 
pressed to do that if they are taking a salary cut.

    Ms. Johnson. That is right. I mean, what we can offer is 
the loan repayment for you to be able to do the educational 
piece. But given the current dynamics of where the workforce 
is, it is a challenge on the salary side.

    Senator Smith. I, so I think there is more work that we 
should think about doing together on this because if we are--I 
see in Minnesota pumping lots of resources, good resources into 
loan repayment and scholarships, but then there aren't any 
spots because of this issue that we are talking about.

    Ms. Johnson. I would welcome the opportunity to work with 
you on this. This is a huge priority for us as well.

    Senator Smith. That is fantastic. That is great. Dr. 
Delphin-Rittmon, I would like to ask you--would like take a bit 
of time to talk about this question of how we integrate 
behavioral health care better into primary care settings. We 
know that this is a powerful way to expand our national mental 
health treatment and behavioral and substance abuse treatment 
capacity. And this strategy, of course, recognizes that it is 
health, it is not mental health separate from physical health.

    The better we integrate, the more we are going to undo the 
barriers that we have up there to block access to mental health 
care. So in just a few seconds I have left, can you just talk a 
little bit about some of the models that are out there for 
doing this kind of integration and where you see the greatest 
opportunity?

    Ms. Delphin-Rittmon. Yes, and thank you for that question. 
So, absolutely. I mean, this is an area that is one of the 
SAMHSA priorities as well. We have an initiative called PBHCI, 
Primary Care Behavioral Health Integration, that is a grant 
program that essentially integrates behavioral health screening 
into primary care settings.

    We know that is so important because often individuals will 
go to a primary care setting first before they will contact or 
connect with a behavioral health provider. So if screenings can 
be done in that setting, it allows for the individual to be 
connected to appropriate services and supports.

    We also have a CCBHC model which integrates behavioral 
health or primary care integration into behavioral health 
settings, so Certified Community Behavioral Health Clinics, 
provides that integration as well, which is critical.

    Senator Smith. Madam Chair, I know there is lots of 
interest in this topic. On the Committee, I am working with 
Senator Moran, among others, to try to figure out how to 
support this, and I want to just thank the Biden 
Administration. I know that both of these issues I have raised 
are part of their broad national strategy to address these 
challenges, so appreciate it very much.

    The Chair. Thank you. Senator Cassidy. And Senator Cassidy, 
just let me say to you, we are all thinking of you and all the 
people in New Orleans for the horrific tornadoes that we were 
watching. Wish you all the best.

    Senator Cassidy. Well, thank you. Thank you. Thank you, 
Madam Chair. Thank you all for your service to our Country on 
this issue. Ms. Volkow, you in your written testimony, and then 
several years ago, mentioned the potential role of marijuana, 
cannabis upon the adolescent brain as being a precipitate of 
serious mental illness. Is that a correct statement of your 
concern?

    Dr. Volkow. Definitively, this is one of the areas that we 
are most concerned off with the legalization of marijuana.

    Senator Cassidy. So let me ask you, that would suggest that 
states which have had a more liberal legalization of marijuana, 
say Colorado, would have an increased incidence of serious 
mental illness among adolescents and young adults than a state 
with more restrictive laws and presumably less prevalence of 
usage. Is that a finding that you have had?

    Dr. Volkow. In the United States, there are no studies that 
have documented that. In Europe and across the world, yes.

    Senator Cassidy. Now, hang on. It is documented that more 
relaxed legalization of marijuana is associated on a population 
scale with increased incidence of serious mental illness, just 
to be sure.

    Dr. Volkow. Specifically, in the United States, 
legalization by some states of marijuana has not been 
associated with an increase in adolescents marijuana use. That 
is something that has not happened.

    Senator Cassidy. Well, that surprises me because 
increased--if you relax blue laws for alcohol, there ends up 
being more alcohol use by adolescents in that given county or 
parish.

    Dr. Volkow. We are seeing significant increases in adult 
use of marijuana and young people, but not in adolescence, 
which is different exactly from what you are saying with the 
alcohol.

    Senator Cassidy. Now what about the young adults? Because 
the brain, as I recall, continues to develop maybe up to 30. If 
you are a male, probably 35. So does that young 20, is there an 
association with increased incidence?

    Dr. Volkow. Yes, there is. There is--for example, there is 
a significant increase in the risk for suicidal behaviors and 
suicidality associated with marijuana use among young people.

    Senator Cassidy. And that is when controlling for other 
factors. And so that is just not a cause--that is just not an 
association, but it is suspected that it is causal?

    Dr. Volkow. It is an association after controlling for 
factors like depression. But in order to establish causality, 
you need to--you require prospective studies that we are 
currently carrying on, on the ABCD.

    Senator Cassidy. Now let me ask, and you may not have this 
data, but we have worked hard to expand the ability of Medicaid 
to address addiction disorder. Have you found that states with 
Medicaid expansion and, or state regulations being more--
employing these tools Congress has given, have had better 
outcomes for adolescent and adult addiction or not?

    Dr. Volkow. There is evidence that some of the states that 
have expanded Medicaid have been able to provide extended 
access to medications for opioid use disorders among young 
adults and adults. The data for adolescents is not as clear. 
There is--because very--the sample sizes are much smaller.

    Senator Cassidy. And are we seeing better outcomes or are 
we just seeing greater utilization of drugs?

    Dr. Volkow. We are seeing better outcomes.

    Senator Cassidy. That is great. Dr. Delphin-Rittmon, Dr. 
Gordon spoke about RAISE Grant, and Senator Murphy and I worked 
in 2016 to expand access to these RAISE grants. Now in my 
state, though, I just found out I got 30 people statewide 
enrolled, 20 in New Orleans, 10 in Baton Rouge, and no other 
city has these programs.

    Now is that a function of inadequate funding or is that a 
function of my state not completely employing, because 
adolescent suicide we hear is a huge issue, serious mental 
illness, and yet something that Murphy and Cassidy were 
attempting to employ has not been widely deployed. What can we 
learn from you about this?

    Ms. Delphin-Rittmon. And thank you for that question. And 
we can certainly have, you know, additional follow-up 
conversations about this as well. I would have to look 
specifically in terms of, you know, were there other 
organizations that applied for the resources or applied for----

    Senator Cassidy. Is there adequate money there for it?

    Ms. Delphin-Rittmon. For the----

    Senator Cassidy. RAISE Grant, for the coordinated specialty 
care, I think it is called, the CSC. As a 10 percent set aside 
within SAMHSA for mental illness, is that adequate or does 
Congress need to look at that? Because from Dr. Gordon's 
testimony and what I have learned before, this highly 
effective. So I guess my question is, do we need to give you 
more money for this or is it just get our states to apply for 
it?

    Ms. Delphin-Rittmon. Yes, I mean, it is definitely an 
effective program, and if we are appropriated more money, we 
will gladly receive it because it is a program that----

    Senator Cassidy. I still not getting an answer to my 
question, is more money needed or is a state just not applying?

    Ms. Delphin-Rittmon. You know, I would have to go back and 
look specifically in terms of the number of states that have 
applied for that. I don't have that with me, but we certainly 
could follow-up.

    Senator Cassidy. Can I ask Dr. Gordon--Dr Gordon any 
insight on that?

    Dr. Gordon. In regards to the--I mean, whether additional 
moneys would----

    Senator Cassidy. No, no whether or not--what is the reason 
why it is not more widely deployed?

    Dr. Gordon. Well, I think we--it is a challenging program 
to administer. You have to be willing to implement some changes 
at a clinic level. But I can't speak to Louisiana's case, but 
we--one of the things that the research project demonstrated is 
that you can implement it in clinical settings, but you still 
have to have the will at local level to do so. I can't speak to 
the level of funding and whether it is adequate for the 
situation.

    I will say that while there are thousands of Americans 
currently enrolled in these clinics, there are probably 
thousands more who would benefit from it. And so expanding 
access to coordinated specialty care for first episode 
psychosis is a good thing.

    Senator Cassidy. Got it. Thank you, Madam Chair.

    The Chair. Thank you. I am going to call on Senator Baldwin 
next. I am going to turn the gavel over to Senator Kaine while 
I go and vote.

    Senator Baldwin. Thank you, Madam Chair. Along with the 
increase in overdose deaths that we have seen in the past few 
years, I have been very alarmed to learn of really 
heartbreaking reports of college students in my home state 
dying from accidental fentanyl overdoses on campus.

    Dr. Delphin-Rittmon, what can we do to bolster the efforts 
of the residential colleges and universities to play a role in 
preventing these tragic overdose deaths on campus, particularly 
deaths as a result of fentanyl contamination?

    Ms. Delphin-Rittmon. Thank you for that question. And it is 
true, the patterns and trends are we are seeing as it relates 
to the fentanyl related overdoses is truly troubling across the 
country, on college campuses and communities, really across the 
board.

    In terms of college campuses and, you know, within each 
state, there are prevention networks, really robust prevention 
networks that we fund through our prevention, in part through 
the prevention set aside as well as the SPF Rx Grant.

    Those grants provide opportunities for community based 
training related to the dangers of fentanyl. It allows for 
dissemination, wide dissemination of naloxone and training 
around naloxone Administration. As you know, naloxone is a 
vital overdose reversal medication.

    Continuing to scale up programs and initiatives like that 
to blanket college campuses and you know, our strategy has 
really been to work to disseminate naloxone far and wide across 
the country as part of the--in fact, the HHS overdose 
prevention strategy. But certainly some of the prevention work 
that is happening at the community level, again funded by Block 
Grant but also funded by SOR, the State Opioid Response Grant, 
can be real valuable resources that states can use to provide 
training, you know, and technical assistance to college 
campuses and others about the dangers of fentanyl.

    Senator Baldwin. Thank you. You actually anticipated my 
second question, which is how can we get more naloxone 
distributed on and available in community settings, at college 
campuses, and the like. So I will move onto the implementation 
of the 9-8-8 three digit suicide prevention hotline.

    In 2019, I introduced that measure and it was signed into 
law in 2020, converting from the ten digit numbers that are 
available throughout the states to 9-8-8, to make it easier for 
Americans to get the help they need. I am concerned that states 
may not be ready to respond to calls when the new dialing code 
becomes available in July of this year.

    Dr. Delphin-Rittmon, how is SAMHSA working with states to 
make sure they are prepared for the 9-8-8 launch this summer, 
and how many states are ready right now for this transition?

    Ms. Delphin-Rittmon. And thank you for that question. And I 
have to say also, thank you for your leadership in terms of 
helping this important piece of legislation come about. It is 
significantly transformative for our Nation in terms of how we 
approach crises responsiveness and addressing the needs of 
individuals that are in crisis and experiencing suicidal 
ideation. So I mean, there are many--states are in many 
different places.

    We have recently invested $282 million in the crisis 
infrastructure within states. That is allowing them to shore 
up, scale up, staff up the crisis call centers. That is an 
integral part of the 9-8-8 transformation, as you know. But we 
are thinking beyond that. It is not really just about the 
crisis call center, it is also about the full continuum of 
care.

    States are getting ready, and we are watching their metrics 
regularly and they are improving in terms of the influx of 
calls and their responsiveness to the calls, texts, and chats, 
in fact that they are getting.

    In fact, later this week, we have a convening with states 
as well as a number of other community providers and national 
organizations around just this thing, operational readiness and 
working to ensure that the 9-8-8 launch in July, that we are 
ready to go.

    Senator Baldwin. Yes. So right now, I am aware only four 
states have taken action to approve additional funding needed 
to support the 9-8-8 services, and my home State of Wisconsin 
is not one of them, so I am very concerned that states will not 
act to make this funding available.

    I believe that we should be taking a look at additional 
Federal funding opportunities for states to make sure that this 
works across the country for people regardless of where they 
live. Can you comment--is that your knowledge also that the 
states are not accepting and implementing this additional 
funding yet?

    Ms. Delphin-Rittmon. You know, states are taking different 
strategies. I mean, some states have put legislation in that 
will that add in an additional tax that will help to support 
the call center.

    Other states and in fact, we had a convening in partnership 
with CMS around thinking about Medicaid resources and funding 
to be able to support the crisis care continuum. So states are 
looking at a number of different strategies to include in some 
instances state funding. Many--all states except for two 
applied for, you know, the $282 million that I mentioned and 
otherwise all states and in fact territories are engaged with 
us on a regular basis, having discussions around operational 
readiness, we will be doing resource materials and guides to 
ensure that states have the materials that they need.

    Senator Baldwin. Thank you.

    Senator Kaine. Senator Tuberville.

    Senator Tuberville. Good morning. Welcome. Thank you for 
what you do. You are kind of on a boat that is taking on a lot 
of water, and you got one cup trying to get it out. I have been 
in a coach in preparation for 40 years. I felt like that every 
day when it came to mental health addiction around kids. It is 
tough. I just hope we start getting some answers to this. But 
you know, I walk to work every day, not too far from here. And 
the see 6 to 8, 10 people on drugs, passed out.

    You can go within several blocks here and you probably find 
one person a day that passed away from it. Seemed like we 
just--we want to do something about it, but we really don't 
know how, how to start from the bottom up. And again, I have 
dealt with it all my life, and it is a sad situation. It is 
something that if we don't get in control of it, we are going 
to look at a huge--we have got an epidemic now, but we are 
going to--we are looking at 400,000 that are going to start 
dying from this.

    Is there any work with any of you all with Homeland 
Security that determines or gets any reports from what is 
happening at the border from fentanyl? I am not getting into a 
border wall--I am not getting into all this political stuff, 
but I was down there not too long ago. I saw enough fentanyl in 
the back of a truck to kill everybody in this country.

    Most of us hadn't heard of fentanyl. Most people in here 
hadn't heard of fentanyl until last year or so. And it is 
getting bad. It is going--it is an epidemic. So anybody got any 
thoughts on that?

    Dr. Volkow. I guess definitively. I mean, what happens with 
fentanyl, it is very lucrative for the illicit drug market. So 
it started in 2016 and it just has grown increasingly. 
Extraordinarily potent drug, so very few milligrams actually 
can generate a very intense high, but it can also kill you.

    It is much easier to transport across the border. You don't 
need to cultivate. The synthesis of this compound is relatively 
easy. So what we have seen was initially it was used to 
contaminate heroin, and now we are seeing it contaminated 
basically almost all illicit drugs. And that includes 
prescriptions--illicit prescriptions.

    This is probably one of the reasons why we are seeing 
increases in deaths from overdoses among teenagers and young 
people. Is being used to contaminate methamphetamine and 
cocaine. And these accounts for the very steep rise in deaths. 
So it is a lucrative drug, and it is much harder to contain.

    Senator Tuberville. And it is synthetic.

    Dr. Volkow. And it is synthetic.

    Senator Tuberville. Chinese are making it, and a lot of it 
has been made in Mexico and it is coming up to our border. And 
hopefully sooner or later, you know, we wake up. You know, they 
could put just a certain amount in our air duct system in this 
building and either make all of us sick or kill us all. I mean, 
that is how deadly this stuff is.

    I don't--I really don't understand it. But I want to thank 
all of you for your work. One problem that I ran into when I 
was coaching is, I would bring in 25 kids a year that I would 
sign, and a few years ago--it went over 10 years ago, one or 
two of them would have insulin problems, you know, diabetics, 
and not very many of them on drugs.

    Recently, you can ask coaches now have two, three, four on 
something, Adderall or Ritalin. Where is that taking us, Dr. 
Gordon? Where are we headed with this?

    Dr. Gordon. ADHD is an illness that strikes many young 
people around the globe and in the United States.

    Senator Tuberville. Is it a disease? Do you inherit it?

    Dr. Gordon. It is a good question. There is a genetic 
component, as well as likely environmental factors that 
contribute to the risk for ADHD. The treatment of ADHD with 
Adderall and other drugs can be very, very effective, but we 
have both an undersupply and oversupply problem.

    We have many, many children who could benefit from 
treatment for ADHD who are not getting adequate treatment or 
evidence based treatment. And then we probably also have 
children who are getting it that maybe don't need it or 
misusing it. And so you have both of those situations in the 
United States.

    I think what we try to urge at the NIMH is an adherence to 
evidence based principles. So quantitative evaluation of 
symptoms, appropriate treatment with medication for those 
symptoms. And when that happens, children with ADHD can do very 
well.

    Senator Tuberville. Yes. Well, thank you. All this 
symptom--is kind of like the--you can buy it anywhere, you 
know, in colleges now. A lot of these kids, I don't know which 
one of them they take, but they take it to stay up all night, 
to absorb, you know, cramming for a test. Which one would that 
be? Would it be Adderall?

    Dr. Gordon. It could be. There are several different 
versions.

    Senator Tuberville. Yes, and you know, it is just--that is 
another drug that we are going to have a huge problem with. But 
I just hope we understand we are dipping water out by spoon in 
a boat, and we are going to be in real deep trouble if we don't 
get control of the substances coming in this country. We got 
enough problems without those. But thank you for your help and 
dedication in dealing with this because it is an ongoing 
problem that is getting worse and worse. Thank you.

    Senator Kaine. Senator Murphy.

    Senator Murphy. Thank you very much. Thank you to all of 
you for your tremendous work and for your time before the 
Committee today. Senator Cassidy and I, along with Senator 
Murray help and others, have been really focused on this issue 
of mental health parity. We have passed several different 
pieces of legislation through this Committee, got signed by the 
President since 2016.

    The latest piece of legislation we passed required the 
Administration to do audits of insurance plans to see if they 
were actually in compliance with Federal parity laws. What we 
know is that, well your statement of benefits will often tell 
you that you have access to mental health treatment. When you 
go to get that treatment, you will face what we call non 
quantitative treatment limitations, all sorts of 
prioritization, bureaucracy, red tape that stands in the way of 
you getting that treatment.

    I forget the exact number that the Department surveyed, but 
about 50 plans and the report we were given in January 
essentially came to the conclusion that not a single one of 
these plans was in compliance with parity laws. And 
interestingly, when they notified the plans that they had set 
up these burdensome barriers to mental health care that they 
didn't have on the physical health side, the plans fixed those 
issues, and all of a sudden thousands of people had access to 
mental health that they didn't have.

    Secretary Delphin-Rittmon, great to see you. I want to ask 
you a question because I noticed that in the SAMHSA Joint Block 
Grant application, there is some language in there that says 
resources should be used to support, not supplant, services 
that will be covered through the private--through private and 
public insurance.

    You kind of reference the fact that, you know it is 
supposed to be insurance that is on the front lines here and 
then we are going to come in on the back end. But that sentence 
also sort of suggests a knowledge that insurance is not 
actually providing the kind of reimbursement that it should.

    Can you talk a little bit about how you approach this 
issue? I mean, we don't want Federal dollars to essentially be 
filling in what insurers should be covering. And this report we 
got in January tells us that we just have massive noncompliance 
in the insurance industry with existing parity laws.

    Ms. Delphin-Rittmon. Yes, thank you, Senator Murphy, and it 
is good to see you as well. And, you know, parity is such an 
important issue for the American people in terms of health care 
and ensuring that both primary care and behavioral health is 
appropriately covered. I mean, as you know, SAMHSA has no 
regulatory authority here, but we do see ourselves as a, in 
some instances, a convener or we help to give states 
information around how they can advocate and even families.

    You know, we have been policy academies. We feel that it is 
important for individuals as well states and communities to 
know what the parity laws are. And so those policy academies 
that we are looking to bring back, additional policy academies, 
are one strategy for helping states have information around how 
to, you know, how to work with providers and to promote 
advocacy in this area.

    We have resources as well for individuals and families, and 
we feel that is important as well because people need to know 
how to advocate if they are not having coverage for services 
and support which they feel that they should be covered.

    Senator Murphy. I think that is important but insufficient, 
right. I mean, families ultimately are not going to be able to 
enforce this right because the sort of details of obstruction 
of care are so byzantine. Often it really is has to be 
regulators that do this job, and we definitely have more 
opportunity at the Federal level to enforce those laws. Just 
one quick another topic for you, Ms. Johnson.

    I want to talk to you about the state of pediatric mental 
health. We talk about this problem we have with getting enough 
practitioners, but we have got tens of thousands of 
pediatricians who often frankly don't have a lot of background 
in mental health.

    It seems to me one of the easy things we could do is just 
have a conversation with the profession to make sure that 
either in the initial training or in some post-graduate 
training opportunity, more pediatricians have a background in 
mental health and substance abuse, but particularly in mental 
health.

    Ms. Johnson. Thank you for the question, Senator. I think 
that is where we should be headed in pediatric and all clinical 
training, that clinicians across the board need to have 
training and exposure to mental health and substance use 
disorder needs and conditions. We need, in my view, we need 
primary care to be inclusive of mental health.

    That is what we are working on at HRSA, and we are going to 
continue to push forward, ongoing forward. Thank you for your 
leadership on the Pediatric Mental Health Access Program. We 
really see that as an exciting model for how we can continue to 
help clinicians who are in practice now get the kind of mental 
health support that they need, buildup their capacity.

    What we are seeing anecdotally from that program is really 
people being able, clinicians being able to handle more and 
more mental health conditions and refer fewer. So we are 
excited about continuing to grow that program.

    Senator Murphy. And it is very clear, that program is a 
mechanism by which pediatricians can get a phone or virtual 
consult with a mental health practitioner. I agree that 
program, which is included in the 2016 Mental Health Reform 
Act, has already shown positive results, but that can be 
partnered with the pediatricians themselves having a greater 
level of expertise and something that hopefully this Committee 
will work on. Thank you, Mr. Chairman.

    Senator Kaine. Absolutely. At the request of Senator 
Cassidy, we will introduce a statement for the record submitted 
by the Children's Hospital Association. Senator Murkowski, you 
are up next.

    Senator Murkowski. Thank you, Mr. Chairman. And thank you 
to the panel here. I just came from a meeting of a group of 
Close Up Kids from Taylor, Alaska, pretty remote little 
community north of Nome. And Close Up Kids have all kinds of 
probing questions that they want to ask. But when I told them 
that I was coming to a hearing on mental health and 
particularly mental health as it may impact young people, all 
of a sudden the chatter stopped because they knew that this 
issue was something that was immediate, it was real.

    I think they were somewhat relieved to know that the 
grownups were talking about it. So I want to ask you, Dr. 
Delphin-Rittmon, specific to these behavioral health issues 
that we are seeing in younger kids and the number, the rising 
number of suicide attempts. I have worked with Senator Rosen to 
introduce the youth mental health and suicide prevention, which 
would authorize SAMHSA to expand their work and services to 
address mental health in K-12 schools.

    I have got a letter that I would asked to be included as 
part of the record, where we have a statement from the 
President and CEO of the Mat-Su Health Foundation, and she 
shares that they had a forum with all of them at Mat-Su Borough 
School District nurses and the nurses were effectively 
demanding that we change our conversation from access to health 
care to access to behavioral health care.

    What they did in the program there, they would launched 
this back in 2017, they launched a behavioral health in schools 
program. They then did a survey just recently. When schools 
were asked whether they felt that the providers have helped 
support students and whether they are satisfied with the 
responsiveness of providers to meet the changing needs of 
students and staff, 100 percent strongly, strongly agreed, 100 
percent of the parents surveyed that they were satisfied, and 
66 percent of those parents said that they made changes as 
parents to better support their child.

    I mean, when you have this level of, wow, we didn't know we 
needed this, but I guess we needed this, and this is actually 
something that makes us feel better or allows us to feel that 
we have got a place to speak to this.

    I would ask whether--I would ask you to speak to the 
importance of authorizing SAMHSA to provide this kind of 
support, direct funding to local schools, so that we can be in 
the schools talking, raising this issue, not just talking about 
health care, but talking about access to behavioral care. So if 
you would speak to that, if you would.

    Ms. Delphin-Rittmon. Yes, thank you for that question. And, 
you know, we are in full support of something like that. I 
mean, we have seen significant impacts and positive impacts 
from our Project Aware grant, which is, you know, very much 
what you are talking about. It is a program, a school based 
program that is about increasing mental health awareness. It 
provides training and education for school personnel.

    It also provides components around linking students to 
services and supports. And we see positive impacts there. We 
see students being connected to care, being identified who are 
struggling, who might not be connected otherwise. So I think 
behavioral health with programs, initiatives within school 
settings, are highly valuable. We know students are there, you 
know, throughout the week.

    If they are struggling, if teacher or school personnel, if 
they are trained to be able to identify a student that is 
struggling, can help to connect that student to services. So I 
think those types of programs are very valuable.

    Senator Murkowski. Well, I know that this is something that 
we want to continue to push on. And let me then ask this next 
question. Equally concerning in Alaska, but really around the 
country, and that is military suicides.

    We have seen really an alarming increase up North that has 
caused a real focus to this from the top of the military 
command as they are trying to do everything to improve quality 
of life and just address everything from sleep deprivation, 
because it is sunny most of the day in the summer and dark most 
of the day in the wintertime, how you deal with all of this. 
But we know there were still dealing with stigma.

    We know that we are still dealing with concerns from those 
that say that seeking care is going to harm their career 
opportunities. I have been--I have worked over the years on the 
Garrett Lee Smith Memorial Act and we are looking to 
reauthorize that. It has proven itself, I think, to be 
effective.

    The law always authorizes the Suicide Prevention Resource 
Center, which ensures that the grantees get appropriate 
information training, technical assistance on suicide 
prevention. So a question, again, to you, if I may, as to 
whether or not you think there are opportunities for the 
Suicide Prevention Resources Center to collaborate with DOD to 
provide technical assistance?

    I want to make sure that we are not just leaving DOD alone 
in its own silo there to address suicide issues that 
unfortunately are more broadly symptomatic of what is happening 
across our society. So can you speak to whether or not there 
might be some relationship there with these two programs?

    Ms. Delphin-Rittmon. Yes. And thank you for that question. 
You know, I think there are opportunities there. I in fact co-
chair the Interagency Task Force on Veterans Mental Health with 
DOD and VA. And this is one of the very issues that we are 
looking at, suicide. And so there are--it is an ongoing 
collaboration.

    There are a number of--it is a whole of Government 
approach. So a number of different Federal agencies there. But 
I think there certainly are opportunities here in terms of 
collaboration and providing technical assistance, you know, for 
VA as well and DOD as well.

    Senator Murkowski. Thank you. Thank you, Madam Chair.

    The Chair. Thank you. And Senator Murkowski asked unanimous 
consent to introduce a letter. Without objection, so ordered.

    The Chair. And I believe Senator Kaine introduced a 
statement on behalf of Senator Cassidy that needs unanimous 
consent. Without objection, so ordered on that.

    The Chair. Senator Hassan.

    Senator Hassan. Thank you, Madam Chair. I want to thank you 
and the Ranking Member for holding this hearing and for your--
for the witnesses, for the work that you do and to be here 
today to discuss what are incredibly important issues.

    Dr. Delphin-Rittmon, the last time you testified before the 
Committee, we discussed the State Opioid Response Grant 
program. You spoke about the importance of reliable, consistent 
funding and firmly committed to ensuring that states like New 
Hampshire would avoid significant cliffs in state opioid 
response grants.

    I very much appreciate that commitment. I know that our 
staff have been working together to develop a solution so we 
can achieve the shared goal and I look forward to continuing 
those efforts.

    How do large swings in Federal funding to states from year 
to year, particularly funding for programs that are responding 
to the substance use disorder crisis, undermine those state's 
public health infrastructures?

    Ms. Delphin-Rittmon. Yes, you know, appreciate that 
question, and you know, our staff did have a productive 
conversation this week, and so we are looking to continue the 
work that we discussed. You know, consistent, stable funding, 
it is important.

    As a former State Commissioner, I am aware of that, that 
funding cliffs or swings or changes in funding can be 
destabilizing for the system. So some of our work around 
looking at the current SOR grant is around looking to sort of 
mitigate or reduce any of those impacts. Some of our challenge 
there though is that we receive significantly less than what 
was proposed in the President's budget.

    We are working with the resources we have to try to 
minimize those cliffs that we discussed.

    Senator Hassan. Thank you.

    The Chair. Senator Hassan, let me just say that I agree 
that we need consistent and reliable funding. It is really 
critical to our state's efforts to respond and prevent those 
drug overdoses. And it is important that Federal funding is 
allocated in ways that don't result in usually large funding 
restrictions--reductions between years, so I appreciate you 
bringing that up.

    Senator Hassan. Well, thank you. I appreciate that very 
much. And I just wanted to note as well, I know there was a 
discussion earlier about the importance of medication assisted 
treatment as we deal with substance use disorder. And I want to 
note that there are still barriers at the Federal level that 
prevent more providers from prescribing medication assistant 
treatment.

    It is why I am so grateful to be working with Senator 
Murkowski on this bipartisan Mainstreaming Addiction Treatment 
Act to eliminate these outdated prescribing restrictions for 
medication assisted treatment. So I look forward to working 
with all of you and with my colleagues on the Committee to get 
this done.

    Following along the line of the substance use disorder 
crisis, I want to ask you another question, Dr. Delphin-
Rittmon. Frontline workers in New Hampshire have shared with me 
that they are seeing a resurgence in methamphetamine use, and 
data show that deaths involving methamphetamines roughly 
doubled between 2018 and 2021. How is HHS responding to that 
trend?

    Ms. Delphin-Rittmon. So one thing that we have done there, 
because we are looking at that data and we see some of those 
trends as well, is states are now able to use the state opioid 
response grant to be able to address the patterns and trends 
and needs that they are seeing related to methamphetamine usage 
as well.

    The saw resources can be used to address and put together 
programs or initiatives, awareness campaigns to be able to 
address the methamphetamine challenges as well.

    Senator Hassan. Okay, thank you. That is an important step 
forward. This is a question to the panel. Maternal mental 
health conditions are among the most common complications of 
pregnancy and childbirth. However, these conditions often go 
undiscussed and untreated due to insufficient resources and 
pervasive stigma.

    I would like to ask the panel, what barriers have you seen 
to a federally coordinated maternal mental health response? And 
why don't we start with you, Dr. Volkow, and just work down on 
the panel.

    Dr. Volkow. Yes, thanks for the question. And for us, we 
have focused very much on the challenges of ensuring that we 
are able to screen and provide for treatment for women when 
they are pregnant, ideally before they get pregnant, for any 
substance use disorder. Because the data shows that without 
treatment, the outcomes can be very negative for the mother 
herself and also for the newborn infant.

    The research shows that intervention is necessary not just 
during pregnancy, but also the support that follows post-
pregnancy to ensure that the woman is able to stop taking drugs 
or maintain--or stay in treatment. The data also shows that 
pregnancy actually is a moment where women are much more likely 
to be receptive for accessing treatment, and thus, is a lost 
opportunity not to provide it.

    Our research is ongoing to try to figure out which are the 
models of care that are most effective and which medications we 
can give to pregnant women safely, and how to monitor once the 
baby is born to ensure that they will have the greatest 
likelihood of success.

    Senator Hassan. Thank you. And Dr. Gordon, if we can just 
go down quickly because we are running out of time here and 
then I can follow-up.

    Dr. Gordon. Yes. One quick challenge I see is ensuring that 
maternal health care providers have the expertise and 
consultation necessary. So expanding collaborative care for 
maternal health care providers is one potential solution to 
that challenge.

    Senator Hassan. Well, thank you because I have introduced 
the bipartisan Plan for New Moms Act to improve this kind of 
coordination. The bill would create a Federal task force, a 
national strategy to expand mental health resources for new 
mothers. So I look forward to working with my colleagues and 
all of you, and I don't know, Madam Chair, if the last two 
panelists can quickly answer--?

    The Chair. If they could do it for the record, that would 
be great.

    Senator Hassan. Okay. We will do it for the record. Thank 
you so much.

    The Chair. Thank you. Senator Braun.

    Senator Braun. Thank you, Madam Chair. Thank you all for 
coming in today. It is obviously an important topic. The 
question will be for Dr. Gordon and then one for all of you. 
And after being subjected for so many--such a long time on 
wearing masks and when the guidelines came out recently, most 
Americans in the country can now be mask free. And of course, 
it always comes back to kids.

    That still seems that there is an err on the side of 
masking when maybe they are in that group that is least prone 
to significant impacts from it. So what is your feeling on, you 
know, whether that is a good decision?

    How has that impacted other developmental, emotional issues 
that come along with, you know, being confined with a mask for 
all this time?

    Dr. Gordon. Data show that across a broad range of social, 
behavioral, and emotional outcomes, allowing kids to attend 
school in person is of the utmost importance. Accordingly, the 
Biden Administration has prioritized that in their COVID 
response plan. Now, mask wearing can be a crucial part of a 
layered prevention strategy to allow children to remain in 
school when the conditions of the pandemic merit it.

    It has been shown to reduce closures of at least daycare 
centers. The data for schools are not yet available. NIMH and 
other institutes, including NICH, continue to study the impacts 
of both the pandemic and mitigation strategies like mask 
wearing on social, cognitive, and emotional development.

    To date, there are no studies that reveal any significant 
harms of mask wearing, but they have shown significant harms of 
school closures. So we look forward to continuing that research 
and making sure that we know for sure the effects of mask 
wearing and other mitigation measures to the COVID pandemic on 
children.

    But so far, we have not seen any adverse consequences of 
those particular ones.

    Senator Braun. Thank you. And one of the tragic 
consequences of trying to manage COVID from the mental health 
side has been, you know, the overdoses that we have had to 
contend with. I would like you to comment, particularly on 
fentanyl, and is there anything else that has cropped up, you 
know, or is contributing to that, and the other three panelists 
as well. We have got about two and a half minutes left.

    Dr. Volkow. Yes, there are two elements that are 
contributing. One of them is the social isolation and the 
uncertainty of stress can increase the risk of people to take 
drugs, and those are more likely to be exposed to synthetic 
drugs like fentanyl and others. And the second crucial element, 
since the pandemic, the seizures of fentanyl has been 
increasing quite dramatically, making it very available.

    Also as I have mentioned before, it is increasingly used to 
contaminate other drugs. So those two elements, people being 
more vulnerable to taking drugs while at the same time access 
to extremely dangerous drugs in the illicit drug market.

    Ms. Johnson. I certainly defer to Dr. Volkow on the 
fentanyl question. On the other, as an agency that focuses on 
maternal and child health, let me just reinforce Dr. Gordon's 
point about the critical importance of children being in 
school, we have seen because we serve underserved communities, 
how important it is for children to be in school to receive a 
series of services, whether those are health care services or 
whether that is cooking, nutritional support and the like.

    In order to do that, we want to make sure that children are 
following the appropriate public health mitigation guidance and 
responding to that as CDC continues to update that.

    Ms. Delphin-Rittmon. Yes. And I will just add that, you 
know, in terms of the fentanyl, because of the patterns and 
trends that we are seeing, it is increasingly more important 
that we have naloxone disseminated far and wide. So again, 
through our state opioid response grant, as well as block grant 
dollars even, states and communities can purchase naloxone to 
help reverse overdoses.

    Senator Braun. Very good. And I think it is sad that most 
of it gets produced somewhere else, comes through the Southern 
border, and I think fixing that source would make a job a lot 
easier for all of you that have to contend with it.

    I just hope that we get our hands around it to stop it at 
its source, and that looks like it is still to be accomplished. 
So keep up in the meantime, all the good work to try to 
remediate it. Thank you.

    The Chair. Yes, Senator Rosen.

    Senator Rosen. Thank you, Chair Murray. Thank you for 
holding this hearing, for your commitment to a bipartisan 
process to reauthorize, to improve, to expand these key Federal 
mental health and substance abuse disorder programs. And I just 
look forward to ensuring that Nevada's voices are heard 
throughout the process.

    I want to build a little bit about, Senator Murkowski and I 
have been doing a lot of work together on this and so one 
program that has been incredibly helpful in Nevada is SAMHSA's 
Mental Health Awareness Training Grant Program, you alluded to 
it earlier. We have a dire shortages of mental health care 
providers, workforce training. That is a subsequent question we 
have to address.

    We can give all these dollars, but we need a workforce. But 
this Federal program has been a critical lifeline, particularly 
in rural parts of our state like Nye, Esmeralda, and Lincoln 
Counties. They have used this grant funding to improve access 
to evidence based mental and behavioral health training for 
first responders, for parents, teachers, school staff, 
community members, to first of all, better recognize and then 
respond to unmet mental health needs of our communities and 
help prevent mental and behavioral health issues from 
escalating.

    Dr. Delphin-Rittmon, as this Committee works to reauthorize 
this important program, what has SAMHSA learn over the past 5 
years about potential improvements we might make to make it 
more accessible for everyone, particularly in our underserved 
or rural communities? What should Congress be looking at to 
help fix this?

    Ms. Delphin-Rittmon. Yes. Thank you for that question and 
for your leadership on this issue. This has been such a 
critical program for us. Mental health first aid and the mental 
health awareness training programs provide a wonderful 
opportunity just to increase awareness about mental health 
challenges.

    These trainings are done across the board, in school 
settings, in faith communities, within, you know, other 
community centers. And what it does is it allows community 
members to be able to recognize children that are struggling or 
just anyone that is struggling. What we find is that people do 
get connected to care. And I actually have some data on that I 
would like to share.

    Last year alone, so 2021, 38,000 individuals were trained 
in mental health, mental health awareness training, and 125,000 
individuals were connected to care as a function of those 
trainings. So I think one thing we have learned is that it 
makes a difference, it makes an impact. People are being 
connected to care as a function of this increased awareness.

    Senator Rosen. Well, I think it just increases our 
compassion and empathy for others and allows us to reach out. 
Sometimes that is maybe the most important first step, right. 
But speaking of reaching out, I am working with Senator 
Murkowski and being sure that we use these SAMHSA dollars down 
at our K through 12 schools because Nevada's Clark County 
School District were top of a list that no one wants to be top 
of. We have lost 20 students in 2020 to suicide.

    We have to do a lot more to be sure that our students are 
just being taken care of, particularly through COVID. And so we 
have to get that funding directly to the students. We need 
workforce training. I know you have spoken about this about, 
but Project Aware doesn't allow the funding to go directly to 
local school districts, and you would think that is really 
important.

    I know you have already committed to working with Senator 
Murkowski. We work together on this bill, so I won't ask you to 
repeat your answer. I know you will be glad--I hope you will be 
glad to work with all of us, and I am sure you will on that. 
And to your point, what I really want to talk about in the 
remaining time is address that workforce issue or training 
issue, whether it is lay people or people who are going to be 
put to the schools, because if we bring this money down, it is 
no good if we don't have the counselors.

    Can you talk to us about the workforce shortage, and how do 
you think Congress can help provide--expand our provider 
capacity for health, in the health professional area?

    Ms. Delphin-Rittmon. Yes, thank you for that. I mean, we 
certainly are seeing a workforce shortage. You know, programs 
like Minority Fellowship Program make a difference or other 
fellowship programs. Loan repayment programs make a difference 
as well. And, you know, my colleague, HRSA, can share about 
that as well. But you know, I think programs that essentially 
create incentives for people going to--you know, entering the 
behavioral health professions. For me, it made an impact.

    As it came up earlier in this Committee, often individuals 
will stay and continue to work in the communities where they do 
their internships or where they do, you know, some of their 
training programs. So those types of programs do make a 
difference. And then also, certainly our loan repayment 
programs make a difference as well.

    Senator Rosen. Thank you. I appreciate that. I am out of 
time. I just will ask Dr. Gordon for the record, you can submit 
it offline, about seniors' mental health. We also have a lot of 
issues there with social isolation and some of those 
challenges. So we will submit that----

    Dr. Gordon. Happy to do that.

    Senator Rosen [continuing]. submit your response for the 
record. Thank you. Thank you, Madam Chair.

    The Chair. Thank you very much. And I will turn to Senator 
Kaine for wrap up and thank you again for filling in for me.

    Senator Kaine. Absolutely, Chair Murray. And thanks to the 
witnesses. This has been a really good hearing. I want to stick 
right where Senator Rosen was at the end of her questioning 
about workforce issues, and particularly workforce in helping 
folks with substance use disorders. My experience has been, and 
I wonder if this is more than anecdotal, that some very 
effective folks in this workforce are people who have had 
substance use disorders themselves.

    But I also find as I travel around Virginia and talk to 
people, that they--and how legit this is, or whether it is a 
perception, they still feel like if they have had a substance 
use disorder, particularly that has led to any criminal 
conviction, that they can be challenged in licensure and 
regulations often get in their way in terms of being able to be 
in the workforce.

    They can volunteer, they can be part of a support group, 
but if they want to make it a profession and help others using 
the experience that they have gone through, there can be 
barriers in their way.

    I wonder if you might talk about that because if we are 
looking for a bigger workforce, we wouldn't want to keep out of 
the workforce people who have had a life experience that would 
make them particularly effective.

    Ms. Delphin-Rittmon. Yes. I am happy to comment on that. I 
mean, we have absolutely seen that individuals in recovery, so 
peer support specialists, recovery support specialists make a 
meaningful difference in terms of connecting people to care and 
giving people hope. Often we find recovery coaches share their 
own stories of lived experience and often are able to help 
connect people to services and supports.

    In fact, we have seen with our state opioid response grant, 
many states now have programs where they have recovery coaches 
connecting with emergency departments. So when an individual is 
brought to an emergency department, they are linked up with a 
recovery coach, and then the recovery coach helps with system 
navigation, helps them get connected to care, or helps them 
with whatever they need.

    Often, they say their first question is, you know, how can 
I help you in your recovery today? So those programs make a 
difference. We have seen recovery coaches also in working in 
methadone programs, working in supported employment programs. 
And it is an area in terms of SAMHSA that is a priority for us 
in terms of expanding our recovery work, and we recently 
announced a recovery--Office of Recovery. Recovery is also one 
of the pillars of the HHS Overdose Prevention Strategy as well.

    Ms. Johnson. I would just add----

    Senator Kaine. Ms. Johnson----

    Ms. Johnson [continuing]. if you don't mind, sorry. Peers, 
people with lived experience are part of the solution here, and 
we are not going to succeed in the way that we want to in 
combating the opioid epidemic, combating the substance use 
disorder challenges, without engaging people who have lived 
experience. They have a unique ability to connect people to 
care, and we want to support that.

    The licensure issue that you raise, I suspect, is a state 
by state issue. Prior to this role, I was the Human Services 
Commissioner in New Jersey. We didn't experience that issue 
there. But I will commit to you, if you are seeing that in 
other places, Miriam and I want to be vocal and help address 
those issues because we want peers to be part of the solution.

    Senator Kaine. Excellent. A related topic that I want to 
ask about is folks who are incarcerated. So 2 million people in 
the United States, 25,000 in Virginia. Of this population, 
about two-thirds have a substance use disorder history, often a 
current challenge, and about one-quarter of those have opioid 
use disorders.

    The data shows that folks who receive treatment, including 
medication assisted treatment, are more likely to engage in 
post-conviction--post-release treatment and to stay in 
treatment longer.

    There is challenges with medication assisted treatment in 
prisons and jails. What might we do to enable people to get 
this kind of treatment that is going to help them while they 
are incarcerated, but more particularly when they are no longer 
incarcerated?

    Ms. Delphin-Rittmon. Yes, thank you for that question. And 
such an important area that individuals who are connected to 
the justice system get connected to services and supports. So 
SAMHSA has a drug court initiative and grants which help to 
divert individuals from further involvement in connection with 
the justice system and into behavioral health treatment.

    Individuals are then able to get connected to medication 
assisted treatment or other services and supports that they 
need. So that is one initiative. I think diversion programs 
really make a difference in terms of connecting people to care. 
But also In Reach Programs. So programs that connect people to 
services and supports prerelease, and those programs can help 
to ensure----

    Senator Kaine. How about particularly the issue of 
medication assisted treatment for those who are incarcerated?

    Ms. Delphin-Rittmon. Yes. So we are supporting a number of 
prisons and providing technical assistance around administering 
buprenorphine or other forms of MAT within criminal justice 
settings. So we have done some technical assistance there. And 
so it is--that is an important area as well. So for individuals 
that are in prison for them to get connected to MAT as well.

    Senator Kaine. I have one last question that I want to 
raise. The Committee was very helpful in getting a bill passed 
that President Biden signed last week, called the Lorna Breen 
Health Care Provider Protection Act, which was to try to 
provide mental health assistance to our frontline health care 
workers who have had a lot of challenges even before COVID and 
in particularly since COVID.

    I was thinking about that bill and talking with the Breen 
family when we were at the bill signing last Friday, I started 
to think about other parts of our workforce who have really had 
challenges during COVID. And a friend of mine said, what about 
last responders? And I said, I haven't heard that phrase, what 
do you mean by that? And talking about people who work in 
nursing homes and long term care facilities where the illness 
and death tolls have been extremely high.

    Often these workers are paid very little. These are some of 
the, you know, lowest paid workers in our system, and yet they 
have seen and experienced themselves, many of them have gotten 
sick and died, too. What have you seen with our long term care 
workforce in COVID, and how might we approach this issue of 
mental health resources for them?

    Ms. Johnson. I would say, thank you, Senator, for your 
leadership on this issue and to the Chair as well. We were with 
American Rescue Plan resources able to do $103 million in 
awards to 45 grantees to support health care provider 
resilience and help reduce burnout.

    As part of that, one of those awardees is a Technical 
Assistance Center, which we are hoping to leverage all the 
learnings from this work so that it is not just the 44 grantees 
and the Technical Assistance Center that get the benefit of 
those resources, but that we can help health care providers 
across the country in addressing this issue.

    But you raise a very important point about frontline long 
term care workers who have been heroes throughout the pandemic, 
and I look forward to working with you on ways that we can 
address their mental health needs going forward.

    Senator Kaine. Great. Thank you. Thank you, Chair Murray.

    The Chair. Thank you. Very, very good point. That concludes 
our hearing today. And I want to thank all of our colleagues 
and all of our witnesses, Assistant Secretary Delphin-Rittmon, 
Administrator Johnson, Director Gordon, and Director Volkow. 
Really important hearing and appreciate all of your thoughtful 
input.

    For any Senators who wish to ask additional questions, 
questions for the record will be do in 10 business days, April 
6th at 5 p.m.. And the Committee will next meet Tuesday, March 
29th in 430 Dirksen for a hearing on how we can strengthen 
families' finances and improve their retirement security. With 
that, the Committee stands adjourned.

                         QUESTIONS AND ANSWERS

Response by Miriam E. Delphin-Rittmon to Questions From Senator Casey, 
   Senator Baldwin, Senator Hickenlooper, Senator Murkowski, Senator 
                     Braun, and Senator Tuberville

                             SENATOR CASEY

    Question 1. There are more than 26 million grandfamilies 
and kinship families in the United States who are at a higher 
risk of experiencing challenges related to mental health and 
substance use disorder The pandemic has exacerbated the 
difficulties that many of these families face, and more than 
200,000 children have been orphaned by COVID-19, losing at 
least one parent or primary caregiver to the disease The 
Advisory Council to Support Grandparents Raising Grandchildren, 
established by the Supporting Grandparents Raising 
Grandchildren (SGRG) Act (Public Law 115-116), has emphasized 
the importance of addressing the trauma experienced by 
grandfamilies Page 3 of the SGRG Act Initial Report to Congress 
notes that many children in need of homes have experienced 
multiple adverse childhood experiences and require support 
beyond what a kin or grandparent caregiver can provide Without 
connections to publicly available assistance, grandfamilies and 
kinship families may spend down their savings on services or go 
without needed support The SGRG Act Initial Report to Congress 
identifies awareness of and outreach to kin and grandparent 
caregivers as a priority.

         LQuestion 1(a). What, if any, systematic efforts have 
        been undertaken by the Biden administration to identify 
        (1) children who have been orphaned and now live with 
        multi-generational families and (2) the adults now 
        serving as caretakers?

         LQuestion 1(b). What efforts are underway, or being 
        planned, to expand outreach to kinship families and 
        grandfamilies--including through schools and community 
        organizations--to connect them with information, 
        services, and supports? How can Congress support these 
        efforts?

    Answer 1. SAMHSA is a member of the Administration for 
Community Living's Recognize, Assistant, Include, Support, and 
Engage (RAISE) Family Caregiving Advisory Council, which is 
responsible for developing a national family caregiving 
strategy The RAISE Family Caregiving Advisory Council delivered 
its initial report to Congress on September 22, 2021 The report 
outlines a review of the current state of family caregiving and 
includes 26 recommendations on how the government and private 
sector can better Recognize, Assist, Include, Support, and 
Engage family caregivers, including grandparents.

         LAnswer 1(a). SAMHSA also administers the Mental 
        Health Technology Transfer Center (MHTTC) Network and 
        National Child Traumatic Stress Network (NCTSN) These 
        entities have hosted webinars, developed resources, and 
        provided resources about trauma, grief, and loss 
        related to the pandemic.

         LAnswer 1(b). MHTTC's training, technical assistance 
        products, and resources are all available online 
        (Responding to COVID-19 Grief, Loss, and Bereavement) 
        The site also includes a compilation of resources from 
        other reputable organizations.

    The NCTSN has several resources to assist parents/
caregivers cope with trauma, guides for mental health providers 
on family resilience, and other resources to promote 
theoretical and practical perspectives on family resilience and 
the clinical and research implications for children and 
families who have experienced trauma The NCTSN has hosted and 
issued the following webinars and fact sheets specifically 
related to the COVID-19 pandemic:

         LApplying Evidence-Based Treatments for Child 
        Traumatic Stress Reactions to COVID-19-Related Deaths 
        webinar and fact sheet.

         LChild and Adolescent Traumatic Stress 
        Reactions to COVID-19-Related Deaths webinar and fact 
        sheet.

         LGrief, Loss, and COVID-19 webinar.

         LGrief, Loss, and COVID-19: Recommendations 
        for Supporting Children and Families webinar.

         LHelping Children with Traumatic Separation or 
        Traumatic Grief Related to COVID-19 fact sheet:

         LThe Power of Parenting During the COVID-19 
        Pandemic: Mourning the Death of a Loved One fact sheet.

         LSchools and COVID-19: Recommendations for 
        Supporting Students, Families, Educators and Staff 
        webinar.

         LTrauma-Informed School Strategies during 
        COVID-19 fact sheet.

         LSuicide, Substance Use, and COVID-19: 
        Recommendations for Supporting Children and Families 
        webinar.

         LUnderstanding The Impact of COVID-19 Through 
        the Lens of the Core Concepts webinar.

         LWhere Do we Go from Here? A Call to Action in 
        Response to the Impact of COVID-19.

    Finally, SAMHSA administers multiple school-based mental 
health and early childhood grant programs, in which teachers, 
healthcare professionals, families, and community members are 
trained to identify, screen, and assess children and youth who 
are experiencing distress (including grief and loss) and ensure 
that they receive the services that they need These programs 
include the Infant and Early Childhood Mental Health 
Consultation, Project LAUNCH (Linking Actions to Unmet Needs of 
Children), and Project AWARE (Advancing Wellness and Recovery) 
SAMHSA's Mental Health Awareness Training program provides 
mental health literacy to teachers, school personnel, first 
responders, and other important community members so children 
can be connected with needed supports and services, such as 
when a child has experienced a familial loss.

    All too often, when someone has a mental health crisis, 9-
1-1 is called and law enforcement arrives, putting both the 
person having the crisis and police officers in situations they 
should not be expected to be in My Human-services Emergency 
Logistic Program (HELP) Act would divert non-criminal, non-
fire, and non-medical emergency calls from 9-1-1 to state and 
regional 2-1-1 or 9-8-8 systems to address both immediate and 
longer-term needs.

    Question 2. What is being done or needs to happen to 
support the 2-1-1 and 9-8-8 system in being able to handle 
mental health and substance use crisis calls that do not 
require law enforcement and would benefit from human service 
professionals? How is SAMHSA working to coordinate the two 
systems?

    Answer 2. In most states, the 211 system provides health 
and social service assistance information and referrals At the 
same time, 988 crisis counselors will provide support for 
people in suicidal crisis, mental health or substance use 
crisis, or any other kind of emotional distress in the very 
moments they need it most While generally being different in 
scope, these systems need to be aligned, and in many cases, 
local Lifeline centers also respond to 211 contacts That is 
why, for example, SAMHSA partnered with the National 
Association of State Mental Health Program Directors to publish 
988 Playbooks, such as the playbook for Lifeline Contact 
Centers, which provides examples of what a solidified 
relationship between a contact center and 211 service may look 
like Ultimately, we envision that 988 crisis centers will need 
to continue to coordinate with 211 and other warmlines This 
will help ensure an all-inclusive approach regardless of which 
number a person may use first.

    SAMHSA's Minority Fellowship Program (MFP) aims to reduce 
health disparities and improve behavioral health outcomes for 
racial and ethnic minority populations Grants through this 
program increase the number of professionals who can support 
patient-centered care for underserved populations with mental 
health or substance use disorders.

    Question 3. How has the Minority Fellowship Program (MFP) 
worked to address child and adolescent mental health in 
minority populations, and how many child and adolescent 
psychiatrists or residents are currently supported through the 
program?

    Answer 3. Through national behavioral health professional 
organizations (American Academy of Addiction Psychiatry; 
American Association for Marriage and Family Therapy; American 
Nurses Association; American Psychiatric Association; American 
Psychological Association; Council on Social Work Education; 
NAADAC: The Association for Addiction Professionals; and 
National Board for Certified Counselors and Affiliates), 
SAMHSA's Minority Fellowship Program (MFP) assists people who 
seek doctoral-and master's-level degrees and plan to work to 
improve behavioral health outcomes for minority communities The 
program increases behavioral health practitioners' knowledge of 
issues related to prevention, treatment, and recovery support 
for mental illness and drug/alcohol addiction among racial and 
ethnic minority populations, including children and adolescents 
Each professional organization supports their fellows in 
addressing youth mental health by providing networking 
opportunities with mentors who specialize in that area, hosting 
webinars, guest lectures, virtual simulations, additional 
readings, and trainings One professional organization, the 
American Association for Marriage and Family Therapy, has 
developed its MFP-Master's program with a goal to increase the 
number of culturally competent marriage and family therapists 
whose specialty will be racial and ethnic minority youth and 
adolescents as they transition into adulthood.

    The program also seeks to encourage more racial and ethnic 
minorities to join the behavioral health workforce, which in 
turn will help address child and adolescent mental health in 
minority populations Racial and ethnic minorities make up more 
than 28 percent of the Nation's population, while less than 20 
percent of the behavioral health workforce consists of racial 
or ethnic minorities The relative scarcity of professionals who 
are from culturally and linguistically diverse backgrounds 
constitutes a workforce issue that contributes to the current 
disparities in quality of care and access to behavioral health 
treatment.

    Currently, the MFP is supporting 26 psychiatric residents 
(through the American Psychiatric Association) who plan to 
pursue the child and adolescent psychiatric sub-specialty The 
MFP is also supporting nearly 150 other healthcare 
professionals (nurses, psychologists, counselors, social 
workers, and therapists) who plan to pursue work in child and 
adolescent mental health.

                            SENATOR BALDWIN

    Question 1. 988 and State Fees:. In 2019, I introduced the 
bipartisan National Suicide Hotline Designation Act, which was 
signed into law in 2020 Converting from the existing ten-digit 
number to 988 will make it easier for Americans to get the help 
they need, but I'm concerned that states may not be ready to 
respond to calls when the new dialing code becomes available.

         LQuestion 1(a). How many states have enacted 
        service fees to provide the additional state funding 
        needed to support 988?

         LQuestion 1(b). Given that many states will 
        not enact services fees, what information is SAMHSA 
        making available to states regarding additional options 
        for funding 988?

    Answer 1. As you mention, the National Suicide Hotline 
Designation Act gave states the ability to enact new 
telecommunications fees to financially support 988 operations, 
yet very few states have done this so far As of March 2022, 
four states have passed legislation creating a 988-cell phone 
fee.

    Success of 988 will rest heavily upon state, territorial 
and local leadership in leveraging the resources already 
available, in addition to making new investments That is why 
SAMHSA has awarded nearly $105 million in grant funding to 54 
States and territories in advance of the transition of the 
National Suicide Prevention Lifeline to help strengthen our 
crisis care infrastructure.

    We will continue to work in close partnership with them to 
meet the crisis care needs of people across our Country For 
example, there are several existing Federal resources that can 
be leveraged to support 988 implementation Examples from SAMHSA 
include the crisis set-aside through the Community Mental 
Health Services Block Grant as well as funding through the 
Certified Community Behavioral Health Clinic (CCBHC) program 
Last, SAMHSA, in coordination with the National Association of 
State Mental Health Program Directors and others, issued 988-
related playbooks for states and other entities to help states 
transition to 988.

    Question 2. Performance Metrics:. In order to make sure 
that 988 works, we need goals and metrics in place to make sure 
that calls and texts are answered, and answered quickly.

         LQuestion 2(a). Right now, what percentage of 
        calls to the National Suicide Prevention Lifeline are 
        answered within 20 seconds? What is SAMHSA's goal for 
        the percentage of calls answered within 20 seconds once 
        988 goes live this summer?

         LQuestion 2(b). What percentage of texts are 
        answered in less than 5 minutes? What is SAMHSA's goal 
        for the percentage of texts answered within 5 minutes 
        once 988 goes live this summer?

         LQuestion 2(c). How is SAMHSA conducting 
        oversight of the administration of 988 and what tools 
        does SAMHSA have at its disposal in the event that 
        SAMHSA's established performance metrics are not met?

    Answer 2(a),(b),(c). With almost 200 crisis call centers 
across the U.S., the Lifeline has increased the size of its 
network, expanded training, and improved response rates since 
it began in 2005--yet demand continues to exceed capacity For 
years, this network has been massively underfunded and under-
resourced In the past, this patchwork of local, state, and 
private funding for the network has fallen way short of meeting 
the need Despite the tireless work of crisis call centers 
across the country, the network has not been able to keep pace 
with demand.

    Given the extent to which the Lifeline has been 
historically under resourced, current demand significantly 
exceeds available capacity The 988 Appropriations Report 
highlighted that Lifeline capacity was only sufficient to 
address 85 percent of calls, 56 percent of texts, and 30 
percent of chats.

    These deeply challenging statistics were one of the driving 
forces for investing 10 times more in funding in fiscal year 
2022 than fiscal year 2021 to support crisis call center 
services across our Country we are hopeful that these 
investments will play a meaningful role in driving higher 
answer rates No call, text, or chat should ever go unanswered 
That said, key metrics of success will include data around the 
number of calls, chats, and text received and answered by the 
Lifeline, and the average speed to answer, among other things.

    In terms of specific answer rates, in February 2022, the 
Lifeline answered 81 percent of incoming calls The average 
speed to answer was 53 seconds In June 2022, the Lifeline 
answered 83 percent of incoming calls The average speed to 
answer was 45 seconds These statistics represent a roughly 13 
percent increase in calls answered and a roughly 15 percent 
improvement in average speed to answer in the last 4 months The 
long-term aspirational targets for response are answering 95 
percent of all contacts within 20 seconds, consistent with 
standards for 911 and the Veterans Crisis Line While SAMHSA 
expects recent investments to continue improving system 
performance over the coming months, it will take time and 
continued investments to reach these long-term targets Since 
calls are first routed locally, overall network performance 
will rest heavily on the pace of state crisis call center 
capacity increases.

    Additionally, in February 2022, the Lifeline answered 44 
percent of incoming texts The average speed to answer for these 
answered texts was 29 minutes and 43 seconds However, In June 
2022, the Lifeline answered 96 percent of incoming texts The 
average speed to answer for these answered texts was 6 minutes 
and 47 seconds These statistics represent a roughly 200 percent 
increase in texts answered and a roughly 400 percent 
improvement in average speed to answer in the last 4 months 
These significant improvements in system performance were 
driven mainly by the influx in Federal funding, which began to 
reach centralized chat/text centers in March 2022 The long-term 
aspirational targets for response are answering 95 percent of 
all contacts within 20 seconds, consistent with standards for 
911 and the Veterans Crisis Line While SAMHSA expects recent 
investments to continue improving system performance over the 
coming months, it will take time and continued investments to 
reach these long-term targets.

    Over the course of several decades, 911 has developed 
sufficient capacity to address 95 percent of calls within 20 
seconds Robust and sustainable funding across all levels of 
government will be essential in building toward this vision.

    To help steer us toward these goals, SAMHSA has a number of 
ways to oversee network performance, both through the 
Cooperative Agreement with the Lifeline administrator and 
directly with states and territories through the 988 state and 
territory grant program There are regular reporting 
requirements, and SAMHSA will engage in corrective action 
planning processes in the event performance is off track or not 
meeting expectations.

    We are grateful for the support Congress provided for the 
Lifeline so far However, the success of 988 will also rest 
heavily upon state and local leaders, as well as local crisis 
centers in the Lifeline network, as we work in concert with 
them to meet the crisis care needs of people across our 
Country.

                          SENATOR HICKENLOOPER

                           Suicide Prevention

    When I was Governor of Colorado, we passed a suicide 
prevention plan modeled on the Zero Suicide approach.

    Studies have shown that about 45 percent of those who die 
by suicide saw a primary care provider in the month before 
their death.

    The idea behind this approach is that no person slips 
through the cracks.

    The approach, which has been adopted in many communities 
across the country, has shown significant reductions in 
suicides among those receiving care.

    Question 1. How can we incorporate on-the-ground examples 
like these, to our national approach to the growing mental 
health crisis?

    Answer 1. SAMHSA oversees the Zero Suicide grant program, 
which funds a comprehensive, multi-setting approach to suicide 
prevention in health systems and tribes The purpose of this 
program is to implement suicide prevention and intervention 
programs for individuals who are 25 years of age or older by 
systematically applying evidence-based approaches to screening 
and risk assessment, developing care protocols, collaborating 
for safety planning, providing evidence-based treatments, 
maintaining continuity of care during high-risk periods, and 
improving care and outcomes for such individuals who are at 
risk for suicide being seen in health care systems.

    Zero Suicide is an effective strategy in the national 
approach to the growing mental health crisis The model 
addresses goals 8 and 9 of the National Strategy for Suicide 
Prevention (NSSP) goals: (8) for suicide prevention to become a 
core component of health care, and (9) to promote and implement 
effective clinical and professional practices for assessing and 
treating those identified as being at risk for suicidal 
behaviors.

    In fiscal year 2021, SAMHSA supported the continuation of 
30 Zero Suicide continuation grants and a new cohort of 10 Zero 
Suicide grants The fiscal year 2023 President's Budget request 
for the Zero Suicide program is $232 million This funding will 
support 25 Zero Suicide continuation grants and 21 new Zero 
Suicide grants Continuing the Zero Suicide program is an 
important part of our Nation's mental health strategy and we 
look forward to continuing to see promising results come from 
more grantees.

                988 Implementation and Staffing Issues.

    988, the Suicide Prevention Lifeline, can be exactly that 
for people in crisis, a lifeline.

    We are looking forward to the official transition to the 
three-digit 988 number this summer.

    It is critical that as 988 is stood up, we support 
increased staffing at the crisis centers that get the phone 
calls we know these crisis centers have been stretched quite 
thin as it is.

    We passed critical investments in the recent Omnibus bill 
to further support the transition to 988.

    Question 2. How is SAMHSA prioritizing this investment to 
support a robust and resilient workforce to adequately 
implement the 988 Lifeline?

    Answer 2. To support transition to 988, SAMHSA 
significantly increased--by over 10 times--the Federal 
Government's contribution to the Lifeline in fiscal year 2022.

    SAMHSA announced a $282 million investment to support 988 
efforts across the country to shore up, scale up and staff up 
the lifeline Most of these funds are going to Lifeline crisis 
centers around the country to ensure crisis centers that will 
be answering 998 have the staff that they need, SAMHSA issued a 
grant opportunity that will provide direct workforce support 
for state, regional, territorial, and tribal call centers that 
are part of the Lifeline 988 Network.

    The President's Fiscal Year 2023 budget will build on this 
investment with an additional nearly $700 million to staff up 
and shore up local crisis centers while also building out the 
broader crisis care continuum: someone to call, someone to 
respond, and somewhere for every American in crisis to go.

    Preparing for 988 is an imperative for SAMHSA and all of 
HHS--we are steadfast in our planning efforts A smooth 
transition to national access to the Lifeline via 988 in July 
2022 is SAMHSA's top priority.

                               Upskilling

    We are facing a constantly growing need for behavioral 
health providers, particularly in rural and underserved areas.

    During a recent Subcommittee hearing that I Chaired on the 
health care workforce, we heard from Dr. Margaret Flinter with 
the National Nurse Practitioner Residency and Fellowship 
Training Consortium.

    The Consortium is using innovative approaches to train 
Nurse Practitioners in behavioral health.

    Question 3. How can we further support the inclusion of 
behavioral health within primary care settings?

    Answer 3. SAMHSA administers the Promoting Integration of 
Primary and Behavioral Health Care (PIPBHC) program The purpose 
of the PIPBHC program is to promote full integration and 
collaboration in clinical practice between primary and 
behavioral healthcare; support the improvement of integrated 
care models for primary care and behavioral health care to 
improve the overall wellness and physical health status of 
adults with a serious mental illness (SMI) or children with a 
serious emotional disturbance (SED); and promote and offer 
integrated care services related to screening, diagnosis, 
prevention, and treatment of mental and substance use 
disorders, and co-occurring physical health conditions and 
chronic diseases In fiscal year 2021, the PIPBHC grant program 
served over 12,028 consumers and provided training to over 
9,000 individuals in the mental health and related workforce.

    SAMHSA also funds a technical assistance center, the 
National Center of Excellence for Integrated Health Solutions 
(CIHS) CIHS offers technical assistance and training for 
communities, individual practitioners, providers, and states on 
evidence-based and effective strategies to address the 
integration of primary and mental health care for individuals 
with mental disorders or co-occurring mental and substance use 
disorders In 2020, CIHS provided training to 23,880 individuals 
in the mental health and related workforce.

    Congress can further support the inclusion of behavioral 
health within primary care settings by continuing to authorize 
and fund the PIPBHC program and National Center of Excellence 
for Integrated Health Solutions The President's fiscal year 
2023 Budget request is $103 million The proposed funds increase 
will fund a new cohort of 37 PIPBHC grants and continue to fund 
the National Center of Excellence for Integrated Health 
Solutions.

                           SENATOR MURKOWSKI

    Question 1. Fentanyl Overdose Deaths: Overdose deaths from 
fentanyl are on the rise, including in Alaska, which saw deaths 
triple from 2019 to 2020 The loss of a loved one impacts 
friends, families, and communities who continue to bear the 
trauma of addiction long after someone passes I have heard 
directly from Alaskans who have lost their children, and are 
now dedicating their lives to prevent future overdose deaths 
from fentanyl.

    Unfortunately, this drug has a high lethality that can harm 
both the user and responder I was horrified to learn about five 
young men and women who overdosed on fentanyl-laced cocaine a 
couple weeks ago while on spring break in Florida What is 
particularly distributing, is that two of these young men 
didn't consume the substance, but were performing CPR on their 
friends when they went into respiratory arrest They were 
exposed to fentanyl while they were performing mouth-to-mouth 
resuscitation.

    Congress needs to take action before fentanyl claims one 
more American we need to start by educating people about the 
lethality of fentanyl and the risk of contaminated drugs.

         LQuestion 1(a). Dr. Delphin-Rittmon, I understand that 
        SAMHSA is broadly tasked with addressing substance use, 
        but what action is SAMHSA taking to educate Americans, 
        particularly at-risk youth, on the lethality of 
        fentanyl and the dangers of contaminated drugs?

    Answer 1. On April 7, 2021, SAMHSA and CDC issued guidance 
aimed at reducing drug overdose deaths, specifically that 
certain Federal funding (eg, SAMHSA's State Opioid Response--
SOR grant) may be used to purchase rapid fentanyl test strips 
(FTS) Providing tools to identify the presence of fentanyl 
combined with referrals to evidence-based treatment options 
complements SAMHSA's daily work to reduce the impact of 
substance use disorders and mental illness on communities FTS 
save lives by allowing individuals to rapidly determine the 
presence of a lethal substance in their drug supply, while also 
facilitating education on the harms of fentanyl and methods to 
avoid it.

    Additionally, the Drug Abuse Warning Network reports 
fentanyl cases across various demographics and monitors trends 
in the hospitals recruited SAMHSA is planning to use this 
information to educate the public on fentanyl and the risks 
associated with fentanyl use.

    In December 2021, SAMHSA issued a Notice of Funding 
Opportunity for a new Harm Reduction Grant Program, which will 
help increase access to a range of community harm reduction 
services and support harm reduction service providers as they 
work to help prevent overdose deaths and reduce health risks 
often associated with drug use Purchase of FTS for community 
distribution are an allowable expense.

    More broadly, SAMHSA has taken concrete steps to educate 
providers and those who misuse substances on the harms of 
fentanyl Through this, the treatment community and providers 
receive education on the impact of fentanyl, empowering them to 
educate individuals on the harms of synthetic opioids and to 
provide evidence-based advice on avoiding exposure to this 
substance This work is augmented through cross-agency 
collaboration SAMHSA representatives regularly meet with other 
agencies to foster synergy in the expansion or improvement of 
SUD treatment, and how public education might be augmented.

    SAMHSA also encourages the inclusion of robust curriculums 
on substance misuse, addiction and treatment among all medical 
and professional schools, and residency programs Robust 
education on substance misuse is essential as it not only 
normalizes discussions around substance misuse and treatment in 
the provider's office, but it also reduces stigma and treatment 
hesitancy A health workforce that is knowledgeable and skilled 
in the treatment of SUDs means that there is no wrong door 
through which an individual can seek treatment or information 
about substance misuse.

    Lastly, below are several training and technical assistance 
resources on fentanyl which are available via the Prevention 
Technology Transfer Centers and the Addiction Technology 
Transfer Centers:

         LFentanyl Test Strips: Fact Sheet--https://
        pttcnetworkorg/centers/great-lakes-pttc/news/fentanyl-
        test-strips-fact-sheet-now-available.

         LFentanyl Test Strips: A Grassroots Harm 
        Reduction Strategy--https://pttcnetworkorg/centers/
        great-lakes-pttc/product/fentanyl-test-strips-
        grassroots-harm-reduction-strategy.

         LCross-promotion of DEA press release--https:/
        /pttcnetworkorg/centers/central-east-pttc/news/urgent-
        press-release-and-public-safety-alert-issued-dea.

         LDe-escalating the Opioid Crisis--An overview 
        of promising prevention strategies--https://
        pttcnetworkorg/centers/northeast-caribbean-pttc/event/
        de-escalating-opioid-crisis-overview-promising-
        prevention.

         LFentanyl Related Products and Events--https:/
        /attcnetworkorg/centers/attc-network-coordinating-
        office/fentanyl-resources.

                     Medication Assisted Treatment

    Question 2. The Anchorage Daily News reported recently that 
the U.S. has passed a ``never-before-seen milestone'' in losing 
more than 100,000 Americans to drug overdoses in a year Sadly, 
the CDC reports that the number of drug overdoses in Alaska 
rose by more than 45 percent as of June 2021 That's more than 
double the rate of increase for the United States.

    One treatment that we know is critical to stemming the 
overdose crisis is medication that prevent withdrawal symptoms 
and stem opioid cravings These medications, like buprenorphine, 
can cut the risk of overdose death in half when a person starts 
taking them But, outdated Federal laws and stigma are 
restricting access to these life-saving medications I have 
introduced the Mainstreaming Addiction Treatment Act with my 
colleague, Senator Hassan, to help more Americans have access 
to life-saving medication and eliminate burdensome Federal red 
tape.

         LQuestion 2(a). How is the administration supporting 
        expanding access to medications to treat substance use 
        disorder so they reach all communities in need?

    Answer 2. Medications for Opioid Use Disorder (MOUD) save 
lives, and we have seen the importance of MOUD during the 
COVID-19 Public Health Emergency (PHE) To expand and improve 
access to MOUD, SAMHSA has approved 81 additional opioid 
treatment programs (OTPs) since August 2021 and during the PHE, 
it issued guidance related to flexibilities in the provision of 
unsupervised doses of methadone, and in the provision of 
buprenorphine through telehealth by OTPs The response from 
SAMHSA's monthly meetings with the State Opioid Treatment 
Authorities has been overwhelmingly positive These entities as 
well as individual Opioid Treatment programs have reported 
greater patient and provider satisfaction The lack of increased 
reports of methadone overdoses or diversion further 
demonstrates that these flexibilities are safe and that they 
promote patient centered paradigms of care that enhance 
engagement in treatment and promote recovery.

    Moreover, HHS published new buprenorphine practice 
guidelines that have expanded access to buprenorphine by 
exempting certain practitioners from certification requirements 
related to training, counseling, and other ancillary services 
Indeed, implementation of these guidelines has seen the 
addition of 12,822 waivered providers since April 28, 2021, 
almost double the number of practitioners who were certified 
during the same timeframe in the prior year In all, 22,561 more 
providers were certified in the last year, bringing the total 
number of waivered prescribers to 121,111 (as of March 2022) 
This further expands access to buprenorphine with SAMHSA also 
supporting prescribers through technical assistance programs 
and continued production of evidence-based guides and 
resources.

    We further support access through the expansion of SAMHSA's 
grant programs and the recent announcement that funds for the 
State Opioid Response (SOR), Substance Abuse Block Grant 
(SABG), and Medication Assisted Treatment for Prescription Drug 
and Opioid Addiction (MAT-PDOA) could be used to purchase 
mobile treatment units This reduces geographic disparity and 
promotes innovation in the delivery of care Evaluation efforts 
also allow for an understanding of what is working, and what 
requires innovation SAMHSA is engaged in an HHS-wide evaluation 
of the revision to the buprenorphine practice guidelines, and 
this expansive undertaking will assess disparity in the 
provision of treatment as well as factors that support the 
provision of care to those with substance use disorders, or 
hinder treatment activities Such information will allow for 
data driven decision making that will facilitate SAMHSA's work 
moving forward.

    SAMHSA's grant programs such as the State Opioid Response 
(SOR), Tribal Opioid Response (TOR) program, and Medication 
Assisted Treatment for Prescription Drug and Opioid Addition 
(MAT-PDOA) seek to address urgent, unmet, and emerging 
substance use disorder treatment and recovery support service 
capacity needs that remain a critical issue for the Nation The 
SOR program provides resources to states, territories, and 
tribes to continue to enhance the development of comprehensive 
strategies focused upon preventing, intervening, and promoting 
recovery from issues related to opioid misuse, and increasingly 
stimulant misuse The TOR program provides dedicated resources 
for this to Indian Tribes and Tribal organizations Both of 
these programs aim to address the overdose crisis by increasing 
access to the three FDA-approved medications for the treatment 
of opioid use disorder, reducing unmet treatment need, and 
reducing opioid-related overdose deaths through the provision 
of prevention, harm reduction, treatment, and recovery 
activities for OUD (including prescription opioids, heroin and 
illicit fentanyl and fentanyl analogs) and stimulant use 
disorder as so elected by states Since the SOR program began, 
approximately 971,372 patients have received treatment 
services, including 409,086 who have received an FDA-approved 
MOUD Of that number, 166,091 received methadone, 218,518 
received buprenorphine, and 24,477 received naltrexone Through 
the SOR program, 686,998 patients received recovery support 
services.

    Similarly, the MAT-PDOA program for community-based 
organizations addresses treatment needs of individuals who have 
an OUD by expanding/enhancing treatment system capacity to 
provide accessible, effective, comprehensive, coordinated/
integrated, and evidence-based MOUD and recovery support 
services Medications are often combined with evidence-based 
psychosocial interventions tailored to an individual's needs 
This approach is a safe and effective strategy for decreasing 
the frequency and quantity of opioid misuse and reducing the 
risk of overdose and death Recovery support services include 
linking patients and families to social, legal, housing, and 
other supports to improve retention in care and increase the 
probability of positive outcomes.

    SAMHSA also subsidizes recovery housing as one component of 
the SUD treatment and recovery continuum of care through 
various grant programs Recovery houses are safe, healthy, 
family like substance-free living environments that support 
individuals in recovery from SUD SAMHSA supports recovery 
houses that do not prohibit prescribed medications taken as 
directed by a licensed practitioner, such as pharmacotherapies 
specifically approved by the Food and Drug Administration (FDA) 
for treatment of OUD as well as other medications with FDA-
approved indications for the treatment of co-occurring health 
conditions Additionally, recovery housing facilities must have 
mechanism(s) in place in their jurisdiction to assure that the 
funding they receive supports and provides clients access to 
evidence-based treatment, including all forms of medication for 
opioid use disorders, in a safe and appropriate setting SAMHSA 
funding recipients must also confirm how recovery housing 
supports appropriate and legitimate facilities (eg, state or 
other credentialing or certification or an established or 
recognized model).

    Last, in order to further the evidence base, the 
administration supports the CDC to conduct a study of MOUD that 
will examine how health and other patient outcomes vary across 
the three types of medications used in MOUD and for patients 
receiving counseling only treatment Patient, site, and provider 
characteristics will also be examined to determine how they may 
impact health and other outcomes

                Infant and Early Childhood Mental Health

    Question 3. The first years of life are an incredible 
opportunity to promote positive mental health for babies, and 
health and well-being during this time period affects future 
learning, behavior and health.

         LQuestion 3(a). Have you seen a marked impact by 
        Federal investment in infant and early childhood mental 
        health (IECMH)?

    Answer 3. SAMHSA's Infant and Early Childhood Mental Health 
Consultation (IECMH) program aims to improve outcomes for 
children, from birth to 12 years of age, who are at risk for, 
show early signs of, or have been diagnosed with a mental 
illness, including a serious emotional disturbance IECMHC has 
been shown to improve children's social skills and emotional 
functioning, promote healthy relationships, reduce challenging 
behaviors, reduce the number of suspensions and expulsions, 
improve classroom quality, and reduce provider stress, burnout, 
and turnover.

    Grantees improve outcomes for children through service 
provision to children and families, mental health consultation 
to early childhood programs such as Head Start, and training 
early childhood providers and clinicians to identify and treat 
behavioral health disorders of early childhood, including in 
children with a history of in utero exposure to substances such 
as opioids, stimulants or other drugs that may impact 
development, and through the implementation of evidence-based 
multigenerational treatment approaches that strengthen 
caregiving relationships.

    In fiscal year 2021, grantees accomplished the following:

         LTrained 4,003 clinicians and early childhood 
        providers on evidence-based mental health treatments 
        for infants and young children.

         LScreened and assessed 9,883 young children 
        for developmental and behavioral disorders (including 
        screening parents for behavioral health issues such as 
        depression and substance misuse).

         LReferred 3,551 children and parents for 
        treatment.

         LProvided infant and early childhood mental 
        health treatment (including multigenerational 
        therapies) to 5,009 children and families

             Suicide Screening in the Emergency Department

    A recent CDC report on emergency department visits for 
people age 12-25 found an over 50 percent increase visits for 
suspected suicide attempts during early 2021 This underscores 
the devastating mental health impact of the pandemic on our 
youth and highlights yet another way that COVID-19 has strained 
our hospitals and medical staff.

    I introduced a bill, the Effective Suicide Screening and 
Assessment in the Emergency Department Act, to improve the 
screening and treatment of patients in hospital emergency 
departments who are at high risk for suicide It will make sure 
that we can better identify our most vulnerable mental health 
patients so they do not slip through the cracks when they are 
treated in hospitals, and make sure hospitals have the 
resources they need to provide these critical services

         LQuestion 4. What is the need for improved suicide 
        screening protocols in the Nation's emergency rooms?

         LQuestion 4(a). Do you support efforts to bolster the 
        resources available to emergency rooms so they can 
        enhance their screening for high-risk suicide patients?

    Answer 4. Screening is a key component in SAMHSA's Zero 
Suicide grant program The Zero Suicide program funds a 
comprehensive, multi-setting approach to suicide prevention in 
health systems and tribes, including in emergency departments 
The purpose of this program is to implement suicide prevention 
and intervention programs for individuals who are 25 years of 
age or older by systematically applying evidence-based 
approaches to screening and risk assessment, developing care 
protocols, collaborating for safety planning, providing 
evidence-based treatments, maintaining continuity of care 
during high-risk periods, and improving care and outcomes for 
such individuals who are at risk for suicide being seen in 
health care systems In fiscal year 2021, SAMHSA supported the 
continuation of 30 Zero Suicide continuation grants and a new 
cohort of 10 Zero Suicide grants.

    As you correctly noted, suicide risk screening is 
particularly important in emergency departments A multi-site 
research study found that suicide risk screening, discharge 
resources, and brief interventions resulted in a 5 percent 
decrease in the proportion of patients who attempted suicide in 
the year after the visit and a 30 percent decrease in the 
number of suicide attempts in that period Screening tools 
validated for use in emergency departments include the Ask 
Suicide-Screening Questions screening tool and Patient Safety 
Screener.

    In addition to the Zero Suicide grant program, the Suicide 
Prevention Resource Center (funded under a grant by SAMHSA) has 
publicly available resources on suicide screening and 
assessment.

    The fiscal year 2023 President's Budget request for the 
Zero Suicide program is $232 million This funding will support 
25 Zero Suicide continuation grants and 21 new Zero Suicide 
grants.

                                  FASD

    During COVID, we have seen a sharp rise in substance misuse 
specifically alcohol, the most widely used and misused 
substance Unfortunately, a landmark NIH study in 2018 
established that 1 in 20 school-aged children are affected by 
fetal alcohol spectrum disorders--FASD Due to its significance 
and status as an overlooked disability that includes 
debilitating stigma, I introduced S 2238, the FASD Respect Act 
My legislation establishes common standards of care and 
increases the capacity to manage FASD in medical and mental 
health settings.

         LQuestion 5. How can we address the social and 
        environmental factors that contribute to prenatal 
        alcohol exposure and reduce the traumas FASD creates 
        for individuals and families?

         LQuestion 5(a). What steps are being taken by the 
        administration to provide more education and training 
        on FASD? How can stigma be lessened for individuals 
        living with behavioral health conditions, like FASD?

    Answer 5. SAMHSA participates in the Federal Interagency 
Coordinating Committee on FASD (ICCFASD) The mission of the 
ICCFASD is to enhance and increase communication, cooperation, 
collaboration, and partnerships among disciplines and Federal 
agencies to address health, education, developmental 
disabilities, alcohol research, health and social services and 
justice issues that are relevant to disorders caused by 
prenatal alcohol exposure This Committee fosters improved 
communication, cooperation, and collaboration among disciplines 
and Federal agencies that address issues related to prenatal 
alcohol exposure The Committee also coordinates the activities 
of all Federal agencies who seek to solve the challenges posed 
by FASD, such as stigma.

    Additionally, SAMHSA administers two programs that support 
screening of pregnant and postpartum women, minor children of 
the mothers, and other non-residential adults or family members 
who are included in treatment planning, age 18 years or older, 
for alcohol misuse or Fetal Alcohol Spectrum Disorders (FASD).

    One program works to expand comprehensive treatment, 
prevention and recovery support services for women and their 
children in residential substance use treatment facilities, 
provide services for non-residential family members of both the 
women and children, and support evidence-based parenting and 
treatment models including trauma-specific services in a 
trauma--informed context.

    The other pregnant and postpartum women program, which is a 
pilot, is meant to support family based services for pregnant 
and postpartum individuals with a primary diagnosis of a 
substance use disorder, including opioid disorders, help state 
substance abuse agencies address the continuum of care, 
including services provided to individuals in nonresidential-
based settings, and promote a coordinated, effective and 
efficient state system managed by state substance abuse 
agencies encouraging new approaches and models of service 
delivery.

    SAMHSA also has a Screening, Brief Intervention and 
Referral to Treatment (SBIRT) Program that aims to implement 
screening, brief intervention, and referral to treatment 
services for children, adolescents, and/or adults in primary 
care and community health settings (eg, health centers, 
hospital systems, health maintenance organizations, preferred-
provider organizations, federally Qualified Health Care 
systems, behavioral health centers, pediatric health care 
providers, Children's Hospitals, etc) with a focus on screening 
for underage drinking, opioid use, and other substance use 
There are several grantees focused on SBIRT with pregnant and 
postpartum women and women of childbearing age The SBIRT 
programs in this area are targeted at reducing the use of 
alcohol and other drugs during pregnancy to reduce the 
incidence of FASD and increase child and maternal health.

                             SENATOR BRAUN

    In December 2020, a GAO report found that as of May 2020 
only 6 percent of U.S. counties have all levels of substance 
use disorder treatment available--that includes outpatient, 
residential, and hospital inpatient services Even more 
unsettling: nearly one-third of counties had no levels of 
treatment available at all GAO concluded that SAMHSA's lack of 
reliable reporting data contributes to these persistent gaps in 
the treatment system.

    Question 1. What concrete actions is SAMHSA taking to 
address these issues?

    Answer 1. SAMHSA has been focused on expanding access to 
medication for opioid use disorder (MOUD) by promoting and 
supporting opioid treatment programs (OTP) services and 
increasing the number of practitioners able to address opioid 
use disorder (OUD) in their practices Since March 2021, over 
22, 500 practitioners were certified (as of the end of March 
2022), and since August 2021, 81 more OTPs were added to the 
treatment system To target these efforts, SAMHSA has been 
mapping services and highest areas of need to enable greater 
focus on local needs, using a regional approach to identify 
needs and plan for support.

    To help overcome geographic disparity in the provision of 
comprehensive substance use disorder (SUD) treatment, since 
November 2021 SAMHSA has allowed mobile treatment units to 
provide OTP services, and it has been fostering telehealth 
activities and assessing ways in which the COVID-19 Public 
Health Emergency flexibilities might be made permanent , 
including work to review 42 CFR part 8 to make permanent some 
regulatory flexibilities for opioid treatment programs to 
provide extended take home doses of methadone SAMHSA also 
promotes innovative models of care through the State Opioid 
Response grant In addition, SAMHSA has been focusing on 
expanding SUD education and supports for providers seeking to 
treat OUD in their offices It has augmented provider education 
through the Provider Clinical Support System, fostering the 
development of a robust and responsive workforce that is 
capable of providing compassionate and evidence-based care to 
vulnerable individuals.

    To further align services with areas of need, SAMHSA is 
engaged in evaluation of the revised buprenorphine practice 
guidelines This revision removed the education and attestation 
requirements for those wishing to treat up to 30 patients with 
buprenorphine As part of this evaluation effort, we will assess 
geographic disparity, prescribing practices and prescriber 
barriers and facilitators in the provision of MOUD The 
information underlying this evaluation is obtained from 
existing data sets as well as voluntary provider surveys Such 
information provides detailed insight into the provision of SUD 
treatment across America, while not imposing a reporting burden 
on providers.

    SAMHSA is also working to augment its data collection and 
evaluation practices This undertaking recognizes the need to 
collect data that provides insight into the provision of 
comprehensive SUD treatment across America, the impact of such 
treatment, and emerging practices that should be fostered 
through grant funding or further assessment It is also 
important to consider ways to collect this data so that it 
provides detailed information without imposing a burden on 
providers or institutions.

    Question 2. Prior to the COVID-19 pandemic, patients 
typically had to travel to an opioid treatment program on a 
daily or near-daily basis Studies show that opioid treatment 
programs that took advantage of the methadone take-home 
flexibility have experienced significant increases in the 
number of patients receiving take-home doses and the number of 
take-home doses per patient, without increases in diversion or 
overdose Importantly, patients indicate they've benefited from 
reduced travel time to opioid treatment programs while still 
feeling they are receiving the care they need.

         LQuestion 2(a). Given SAMHSA has already announced it 
        will extend the methadone take-homes flexibilities for 
        1 year post the public health emergency declaration, 
        does the agency plan to make this change permanent?

    Answer 2. The 1-year extension of this flexibility was 
designed to allow SAMHSA the opportunity to engage in processes 
that will make this flexibility permanent SAMHSA has indicated 
in the HHS Unified Agenda that it intends to issue a notice of 
proposed rulemaking for this purpose.

                           SENATOR TUBERVILLE

    Question 1. we know that one in four Americans reports 
having been a victim of crime in the past 10 years, and half of 
those were victims of a violent crime Most report receiving no 
help in the aftermath Police, corrections leaders, and the 
courts agree that untreated mental health or co-occurring 
substance abuse disorders are core drivers of the cycle of 
crime and that they lack the infrastructure to respond 
appropriately.

         LQuestion 1(a). What do you see as the individual and 
        societal impacts of untreated trauma as it relates to 
        mental health and substance use disorder?

    Answer 1. Trauma is a common experience for adults and 
children SAMHSA describes individual trauma as resulting from 
``an event, series of events, or set of circumstances that is 
experienced by an individual as physically or emotionally 
harmful or life threatening and that has lasting adverse 
effects on the individual's functioning and mental, physical, 
social, emotional, or spiritual well-being''.

    The effects of traumatic events can place a heavy burden on 
individuals, families, and communities Although many people who 
experience a traumatic event will go on with their lives 
without noticeable lasting negative effects, others may have 
difficulties and experience traumatic stress reactions.

    Research has shown that traumatic experiences are 
associated with both behavioral health and chronic physical 
health conditions, especially those traumatic events that occur 
during childhood Substance use (such as smoking, excessive 
alcohol use, and drug use), addiction, and mental health 
conditions (including depression, anxiety, or PTSD) have been 
linked with traumatic experiences, as have asthma, stroke, and 
heart disease Because its symptoms appear as other health 
conditions, trauma can be overlooked in medical and behavioral 
health assessments.

    Although experiencing trauma may contribute to developing 
risk factors for violence, it is important to note that the 
majority of individuals who experience trauma do not engage in 
violent crime \1\ However, the behavioral health concerns 
associated with trauma can present challenges in relationships, 
careers, and other aspects of life For this reason, SAMHSA 
believes addressing trauma is an important part of effective 
behavioral health care and an integral part of the healing and 
recovery process SAMHSA addresses the impact of trauma on 
individuals, families, and communities by leading the 
Interagency Task Force on Trauma-Informed Care and overseeing 
programs such as National Child Traumatic Stress Initiative 
(NCTSI) and ReCAST (Resiliency in Communities after Stress and 
Trauma).
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    \1\  Daniel J Neller PsyD & John Matthew Fabian PsyD (2006) Trauma 
and its contribution to violent behavior, Criminal Justice Matters, 
66:1, 6-7, DOI: 101080/09627250608553387.

    Question 2. Federal data shows that 37 percent of people 
sentenced to prison, and 44 percent of people arrested and 
jailed, have experienced a mental health issue At the same 
time, we know that an estimated 1 in 10 police service calls 
are responding to an untreated mental health issue Across the 
country, we've seen community-based programs that seek to 
divert individuals experiencing mental health issues, direct 
individuals to treatment and resources, and do so in a way so 
---------------------------------------------------------------------------
the police department does not have to be involved.

         LQuestion 2(a). What is the Federal Government doing 
        to ensure that mental health emergencies are being 
        responded to appropriately, early on, before a 
        treatable illness becomes a safety issue?

    Answer 2. There is, unfortunately, an inaccurate perception 
that mental illness is a cause of violent crime, wherein in 
actuality, people with mental illness are more likely to be 
victims of violent crime than perpetrators \2\ Most people who 
have mental illness are never violent toward others and 
research has found only 3-5 percent of violent acts in the 
United States are attributable to mental illness alone \3\
---------------------------------------------------------------------------
    \2\  Desmarais SL, Van Dorn RA, Johnson KL, Grimm KJ, Douglas KS, 
Swartz MS Community violence perpetration and victimization among 
adults with mental illnesses Am J Public Health 2014 Dec;104(12):2342-9 
doi: 102105/AJPH2013301680 Epub 2014 Feb 13 PMID: 24524530; PMCID: 
PMC4133297
    \3\  Swanson JW Mental disorder, substance abuse, and community 
violence: an epidemiological approach In: Monahan J, Steadman H, 
editors Violence and mental disorder University of Chicago Press; 
Chicago: 1994 pp 101--136.

    This bias extends to the criminal justice system, where 
people with mental illness are over incarcerated and often 
experience worse outcomes compared to the general population 
People with serious mental illness (SMI) are often booked into 
jail for non-violent, minor offenses \4\ Once in jail, these 
individuals are incarcerated twice as long, and few receive 
needed treatment Many of these situations could be diverted if 
there was more awareness and resources available. \5\
---------------------------------------------------------------------------
    \4\  Swanson JW, Frisman LK, Robertson AG, et al Costs of criminal 
justice involvement among persons with serious mental illness in 
Connecticut Psychiatr Serv 2013;64:630--7
    \5\  https://bjsojpgov/content/pub/pdf/imhprpji1112pdf.

    SAMHSA supports community-based programs that seek to 
divert individuals experiencing mental health issues, direct 
individuals to treatment and resources, and do so in a way so 
the police department does not have to be involved One such 
programs is the Behavioral Health Partnerships for Early 
Diversion (BHP-ED) This grant program supports grantees in 
establishing or expanding programs that divert adults with 
serious mental illness or co-occurring mental and substance use 
disorder from the criminal justice system to community-based 
services prior to arrest and booking Early diversion programs 
establish collaborative partnerships between law enforcement 
and community providers Special consideration is given to 
---------------------------------------------------------------------------
programs that support early diversion services for veterans.

    There are certain periods when a subset of individuals with 
serious mental illness may be at elevated risk for violence, 
such as the period around first episode psychosis To best 
support these individuals, SAMHSA oversees the Assisted 
Outpatient Treatment Grant Program for Individuals with Serious 
Mental Illness (AOT) program and the Assertive Community 
Treatment (ACT) program AOT aims to reduce the incidence and 
duration of psychiatric hospitalization, homelessness, 
incarcerations, and interactions with the criminal justice 
system while improving the health and social outcomes of 
individuals with a serious mental illness (SMI) AOT facilitates 
the delivery of community-based outpatient mental health 
treatment services to individuals with SMI that are under court 
order as authorized by state mental health statute.
                                ------                                


  Response by Carole Johnson to Questions From Senator Casey, Senator 
  Rosen, Senator Hickenlooper, Senator Murkowski, Senator Braun, and 
                           Senator Tuberville

                             SENATOR CASEY

    The National Health Service Corps (NHSC) programs help 
expand the health care workforce in underserved areas, 
including the workforce for mental health care services 
Currently, the NHSC Loan Repayment Program (LRP) offers 
behavioral health care clinicians loan repayment in exchange 
for serving communities with limited access to care Programs 
require participants at approved sites to work full-time or 
half-time.

    Question 1. Has HRSA-NHSC considered program flexibilities 
to encourage greater provider participation in its programs to 
address urgent mental health workforce needs, such as a 
reduction in the number of hours required?

    Answer 1. HRSA's National Health Service Corps (NHSC) 
offers a number of flexibilities to recruit, maintain and 
support the health care workforce, including behavioral health 
care providers NHSC awardees are able to select a half-time 
service option over 2 years or a full-time service option over 
2 years, at NHSC approved sites.

                         COVID-19 Flexibilities

    Another flexibility is through the CARES Act (Section 3216) 
which allows the Secretary to assign members of the NHSC to 
provide health services as the Secretary determines necessary 
to respond to the COVID-19 Emergency, which gives participants 
more options as to where they can complete their service The 
CARES Act COVID-19 flexibilities are not permanent.

    HRSA also has provided COVID-19 flexibilities for NHSC 
participants to adjust their commitment if their work is 
impacted by the pandemic.

    Unless an NHSC participant is eligible for a waiver as a 
result of experiencing an ``extreme hardship'' under section 
338E(d) of the Public Health Service Act, and implementing 
regulations under 42 CFR 6212, 6228, the Secretary does not 
have the statutory authority to shorten the length of a 
participant's service requirement or cancel a participant's 
obligation under a contract Section 338E(d)(2) states that the 
Secretary may waive a participant's service obligation in whole 
or in part whenever compliance is impossible or would involve 
extreme hardship, and if enforcement of the obligation would be 
unconscionable   .

    There are more than 26 million grandfamilies and kinship 
families in the United States who are at a higher risk of 
experiencing challenges related to mental health and substance 
use disorder The pandemic has exacerbated the difficulties that 
many of these families face, and more than 200,000 children 
have been orphaned by COVID-19, losing at least one parent or 
primary caregiver to the disease The Advisory Council to 
Support Grandparents Raising Grandchildren, established by the 
Supporting Grandparents Raising Grandchildren (SGRG) Act 
(Public Law 115-116), has emphasized the importance of 
addressing the trauma experienced by grand families Page 3 of 
the SGRG Act Initial Report to Congress notes that many 
children in need of homes have experienced multiple adverse 
childhood experiences and require support beyond what a kin or 
grandparent caregiver can provide Without connections to 
publicly available assistance, grand families and kinship 
families may spend down their savings on services or go without 
needed support The SGRG Act Initial Report to Congress 
identifies awareness of and outreach to kin and grandparent 
caregivers as a priority.

    Question 2. What efforts are underway, or being considered, 
at HRSA and other relevant agencies to expand outreach to 
kinship families and grand families to connect them with 
information, services, and supports? How can Congress support 
these efforts?

    Answer 2. HRSA reaches families and caregivers, including 
kinship and grand families, with information, services, and 
other supports to address behavioral health needs.

    For example, HRSA's Infant-Toddler Court Program (ITCP) 
funds a National Resource Center (NRC) to improve the health, 
well-being, and development of infants, toddlers, and families 
in the child welfare system The program aims to improve direct 
services, ensure community-level partnership-building, and 
strengthen early childhood systems to serve families with 
significant trauma and substance use histories ITCP provides 
technical assistance and implementation supports to child 
welfare judicial systems to educate judges, case workers, and 
other professionals on the importance of kinship care and ways 
to support young children and families in kinship placements As 
part of direct support to families and caregivers, local court 
teams also provide information, connection to services and care 
coordination, and other supports for families, including 
kindship and grand families ITCP received an increase of $3 
million in the fiscal year 2022 annual appropriations for HRSA 
to provide state grant awards which will support states to 
build capacity for or expand implementation of the ITC approach 
in local ITC sites.

    The HRSA-funded School-Based Health Alliance maintains and 
updates resources for families to learn about school-based 
health, including behavioral health HRSA's Collaborative 
Improvement and Innovation Network on School-Based Health 
Services increases children's access to behavioral health care 
by promoting evidence-based models of school-based health 
services, including Comprehensive School Mental Health Systems 
Additionally, HRSA, in collaboration with CDC, leads the 
National Coordinating Committee on School Health & Safety 
(NCCSHS), which is a partnership among Federal and non-
governmental organizations to coordinate communication and 
support implementation at the state/local levels of school-
based approaches including expanding comprehensive, trauma-
informed mental health services in schools and the Whole 
School, Whole Community, Whole Child Model.

    The Family to-Family Health Information Center Program is 
another investment that HRSA supports to assist families and 
children Family to-Family information centers provide 
information, education, and peer support to families with 
children and youth with special health care needs, including 
behavioral health needs--in addition to health professionals 
who serve families Families served through the program can 
include kinship and grand families.

                             SENATOR ROSEN

    Question 1. As we talk about addressing the mental health 
workforce shortage, we need to also think about the diverse 
needs of children--especially those who have experienced 
significant trauma Over the last 2 years, that number has 
unfortunately grown It is estimated that in the U.S., 167,000 
children have lost a parent or caregiver due to COVID-19, and 
13,000 lost their only caregiver Others dealt with social 
isolation and now struggle with the challenge of two lost years 
The pandemic caused stress and anxiety for so many children, 
only compounding the trauma that some children already faced 
due to abuse, homelessness, or living in foster care These 
children not only need mental health support, they need care 
from a professional who has been specifically trained to 
address their particular needs Ms. Johnson, what 
recommendations do you have for Congress on how to expand our 
provider capacity by helping mental health professionals become 
further specialized?

    Answer 1. Integrating behavioral health into primary care 
and growing the behavioral health workforce, are two of HRSA's 
strategies for expanding provider capacity to address the 
mental health needs of children.

    HRSA's Behavioral Health Workforce and Education Training 
(BHWET) Professionals Program has a particular emphasis on the 
integration of behavioral health into primary care, , and a 
special focus in the BHWET Program is placed on the knowledge 
and understanding of children, adolescents, and transitional-
aged youth at risk for behavioral health disorders The program 
helps increase the supply of children's behavioral health 
professionals as well as to increase access to children's 
behavioral health services by funding institutions of higher 
education and accredited professional training programs that 
expand field placement programs in school social work, school 
psychology, behavioral pediatrics, and school counseling The 
program's emphasis on community-based partnerships promotes the 
integration of behavioral health into primary care by 
increasing the number of experiential training sites where such 
training takes place In this way, the program emphasizes 
interdisciplinary collaboration by utilizing team-based care in 
integrated behavioral health and primary care settings By 2025, 
the BHWET Professionals Program is projected to eliminate over 
40 percent of the projected shortfall of behavioral health 
providers Thanks to the American Rescue Plan, HRSA made 56 
additional BHWET awards to behavioral health and training 
programs in June 2021 In fiscal year 2022, HRSA is supporting 
168 BHWET Program professional grantees, totaling $66 million 
Continued funding for the BHWET Program allows HRSA to build on 
this important work of integrating the behavioral health 
workforce.

    Continued investments in training and workforce development 
that help providers prevent and treat diverse child health 
conditions, including behavioral health, are key to expanding 
provider capacity This includes integrating culturally and 
linguistically appropriate, equitable, and trauma-informed best 
practices HRSA supports several programs that are helping to 
increase access to specialized mental health providers and 
build provider capacity.

    HRSA supports the Pediatric Mental Health Care Access 
Program (PMHCA). This program promotes behavioral health 
integration in pediatric primary care through new or expanded 
statewide or regional pediatric mental health care telehealth 
programs These statewide or regional networks of specialized 
pediatric mental health care teams provide tele-consultation, 
training, technical assistance, and care coordination to assist 
pediatric primary care providers.

    Through the Pediatric Mental Health Care Access Program, 
pediatric primary care providers are able to diagnose, treat 
and refer children to the care they need for behavioral health 
concerns The telehealth technologies promote long-distance 
clinical health care, clinical consultation, and patient and 
provider education, helping to address challenges in accessing 
psychiatrists, developmental-behavioral pediatricians, and 
other behavioral health clinicians who treat behavioral 
concerns in children and adolescents In fiscal year 2020, 
approximately 3,000 children and adolescents benefited directly 
from telehealth consultations through the PMHCA Program, (with 
approximately 2/3 living in rural and underserved counties) 
However, the reach of the program extends far beyond the 
children for whom providers contact the consultation line.

         L61 percent of participating providers report 
        screening more patients in their practices, extending 
        the impact of the program to more children and 
        adolescents.

         L61 percent of participating providers also 
        report that they are now providing behavioral health 
        treatment in their practices, expanding the 
        availability of these services within our communities.

         LThe number of primary care providers enrolled 
        in the PMHCA Program increased from 1,963 in fiscal 
        year 2019 to 4,511 in fiscal year 2020.

    Authorization for the PMHCA program expires at the 
conclusion of fiscal year 2022.

    In addition, the Developmental Behavioral Pediatrics 
Training Program (DBP). trains Fellows in developmental 
behavioral pediatrics to address the broad range of behavioral, 
psychosocial, and developmental concerns that present in 
primary care pediatric practice The program also builds 
capacity for practitioners to provide evidence-based 
interventions to children's behavioral and developmental 
concerns, including for individuals with autism spectrum 
disorder and other developmental disabilities who may have co-
occurring behavioral health disorders In fiscal year 2020, the 
DBP Training Program provided training to over 1,400 DBP 
Fellows, medical students and pediatric residents DBP graduate 
survey results indicate that 100 percent of DBP Fellows 
demonstrated leadership, worked in an interdisciplinary manner, 
and worked with maternal and child health populations, 
including those considered to be underserved (5 years following 
completion of the program).

    HRSA's Leadership Education in Adolescent Health (LEAH) 
Program prepares maternal and child health leaders in 
adolescent and young adult health The program builds MCH 
workforce capacity by preparing health professionals for 
leadership roles in public health, health services, and 
academic sectors to address the unique needs of adolescents, 
including their behavioral health The program incorporates 
evidence-based patient-centered, culturally relevant care to 
build provider capacity and promote optimal mental health and 
well-being for adolescents and young adults LEAH graduate 
survey results show that 98 percent were engaged in work 
related to MCH populations (5 years following completion of 
program). \1\
---------------------------------------------------------------------------
    \1\  Data from 2020 Discretionary Grants Information System.

    While HRSA leads a number of programs to address mental 
health care needs of children, there is so much more to do when 
it comes to mental health care, especially considering the 
impact the pandemic has had on the mental and emotional well-
being of people all ages HRSA looks forward to working with you 
to build on these efforts as we carry out the President's 
national strategy to tackle the Nation's mental health crisis.

                          SENATOR HICKENLOOPER

                      Behavioral Health Workforce

    If we are serious about building the pipeline of behavioral 
health workers, we need to make it easier for those without 
college degrees, working parents, and those without previous 
experience to break into early stage health care jobs According 
to the Bureau of Labor Statistics, we will need more than 
150,000 new mental health support staff over the coming decades 
Even greater than the outstanding demand for psychologists.

    Question 1. How can we more effectively recruit for these 
jobs to address this growing need?

    Answer 1. HRSA has multiple pathways to recruit, train and 
place new behavioral health care providers in communities that 
need them most Below are examples of HRSA programs that support 
the priorities you have shared for building a pipeline of 
behavioral health workers.

    HRSA's Behavioral Health Workforce Education and Training 
(BHWET) Program for Paraprofessionals develops and expands 
community-based experiential training to increase the supply of 
students preparing to become peer support specialists and other 
mental health-related support workers while also improving 
distribution of a quality behavioral health workforce In fiscal 
year 2022, HRSA supported 44 paraprofessional grantee 
organizations.

    The Opioid-Impacted Family Support Program (OIFSP) trains 
health support workers to support children and families 
impacted by opioid use disorder (OUD) and other substance use 
disorders (SUD) in underserved areas The Program also provides 
professional development opportunities and educational support 
to increase the number of paraprofessional trainees receiving a 
certificate upon completion of the Program.

    HRSA's Rural Public Health Workforce Training Network 
Program expands public health capacity by supporting health 
care job development, training and placement in rural 
communities HRSA supports rural health networks (which may be 
composed of, but are not limited to, minority-serving 
institutions, community colleges, technical colleges, rural 
hospitals, community health centers, nursing homes and 
substance use providers) to address the critical need for more 
trained health professionals, which has been amplified by the 
COVID-19 pandemic.

    HRSA also funds several pipeline programs to help people 
prepare for and enter health professions The Health Careers 
Opportunity Program (HCOP): National Academies provide 
individuals from economically and educationally challenging 
backgrounds opportunities to develop skills to help enter and 
graduate from schools of health professions, including allied 
health professions Program support includes tailored academic 
counseling and highly focused mentoring services, scholarships 
and stipends, financial planning resources, and health care 
careers and training information.

    Additionally, HRSA offers the Centers of Excellence (COE) 
Program, which provides grants to health professions schools 
and other public and nonprofit health or educational entities 
to serve as innovative resource and education centers for the 
recruitment, training, and retention of underrepresented 
minority (URM) students and faculty.

                               Upskilling

    We are facing a constantly growing need for behavioral 
health providers, particularly in rural and underserved areas.

    During a recent Subcommittee hearing that I Chaired on the 
health care workforce, we heard from Dr. Margaret Flinter with 
the National Nurse Practitioner Residency and Fellowship 
Training Consortium The Consortium is using innovative 
approaches to train Nurse Practitioners in behavioral health.

    Question 1. How can upskilling opportunities, like these 
training programs, help train more providers to increase access 
to behavioral healthcare?

    Answer 1. Upskilling increases the number of providers and 
health support workers in the field with the skillset required 
to treat mental and behavioral health issues One of the most 
effective ways HRSA is growing the behavioral health workforce 
is by integrating behavioral health into primary care training 
while providing opportunities for providers across different 
disciplines such as pediatricians and maternal care providers 
to receive training in behavioral health care needs.

    For example, HRSA funds two mental health programs that are 
currently up for reauthorization The first program, the 
Screening and Treatment for Maternal Depression and Related 
Behavioral Disorders Program, helps train maternal health care 
providers on how to screen for, assess, treat, and, as 
necessary, refer pregnant and postpartum individuals with 
mental health conditions or substance use disorders as part of 
routine maternal health care Maternal health care providers 
also receive real-time psychiatric consultations for their 
patients through telehealth services and care coordination 
support.

    The second program, the Pediatric Mental Health Care Access 
Program aims to make early identification, diagnosis, 
treatment, and, as needed, referral for behavioral health 
conditions a routine part of children's health care services 
The program promotes the integration of behavioral health 
services into pediatric primary care through statewide and 
regional pediatric mental health care telehealth programs These 
statewide or regional networks provide tele-consultation, 
training, technical assistance and care coordination to 
community-based pediatric health care providers in order to 
expand the reach of critical mental health services and support 
children's needs.

    Additionally, HRSA funds a training program focused on 
integration of primary care and behavioral health through the 
Primary Care Training and Enhancement: Integrating Behavioral 
Health and Primary Care Program, which aims to increase the 
preparedness of primary care providers to identify and treat 
mental health and substance use disorders In fiscal year 2021, 
HRSA supported nine Primary Care Training and Enhancement: 
Integrating Behavioral Health and Primary Care Program grants.

    HRSA also has funded a new and innovative initiative to 
train community health workers, through the Community Health 
Worker and Health Support Worker Training Program This new 
program will expand the public health workforce through the 
training of CHWs and other health support workers These CHWs 
will provide services, including behavioral health services in 
underserved communities Training community health workers and 
supporting job placement creates new opportunities to bring 
people into the health professions and grow their career ladder 
and upskilling opportunities over time.

    HRSA's Rural Public Health Workforce Training Network 
Program expands public health capacity by supporting health 
care job development, training and placement in rural 
communities HRSA supports rural health networks (which may be 
composed of, but are not limited to, minority-serving 
institutions, community colleges, technical colleges, rural 
hospitals, community health centers, nursing homes and 
substance use providers) to address the critical need for more 
trained health professionals, which has been amplified by the 
COVID-19 pandemic Similarly, HRSA's Regional Public Health 
Teaching Center Program seeks to increase the number of 
individuals in the public health workforce, enhance the quality 
of such workforce, and improve the ability of this workforce to 
meet national, state, and local health care needs Specifically, 
this program aims to strengthen the public health workforce 
through tailored training and technical assistance through 
collaborative community-based projects.

    Another way we are integrating behavioral health into 
primary care is by growing the behavioral health provider 
pipeline by promoting the inclusion of health support workers 
as members of behavioral health treatment teams For example, 
the Behavioral Health Workforce Education and Training Program 
for Paraprofessionals develops and expands community-based 
training for students preparing to become peer support 
specialists and other behavioral health-related health support 
workers

                           SENATOR MURKOWSKI

                        Mental Health Workforce

    Question 1. I am deeply concerned by the worsening, 
widespread shortage of mental health professionals, which has 
only been exacerbated by the COVID-19 pandemic Over half of 
Alaska's population--380,000 people--live in a designated 
Mental Health Professional shortage area Workforce shortages 
create another serious barrier to accessing mental health care 
services, especially for those living in rural communities, 
like many Alaskans Last May, I joined Senator Smith in 
introducing the Mental Health Professionals Workforce Shortage 
Loan Repayment Act This bill establishes a student loan 
repayment program for mental health professionals who work in 
these shortage areas My hope is that this legislation will help 
expand the mental health workforce and incentivize 
professionals to provide much-needed mental health care to 
those living in rural communities and other underserved areas.

    Question 1(a). What steps is the administration taking to 
address mental health workforce shortages, specifically with 
regard to the shortages facing Americans in underserved and 
rural areas?

    Answer 1. HRSA is investing in both growing the behavioral 
health workforce in underserved and rural communities and in 
integrating behavioral health training into primary care 
training and practice to expand access to care.

    HRSA's National Health Service Corps program provides 
scholarships and loan repayment assistance to clinicians who 
agree to work in health professional shortage areas Thanks to 
American Rescue Plan funding, we now have a record number of 
participants in this program, with over 9,000 participants 
providing mental health services, and more than a third of 
these providers are providing mental health services in rural 
areas.

    With American Rescue Plan funding, we also have expanded 
our Behavioral Health Workforce and Education Training Program, 
which has increased the number of behavioral health providers 
entering and continuing practice.

    To address workforce needs in rural areas, HRSA funds 
several programs that either focus on workforce development in 
rural communities or allow communities to propose a unique 
workforce program to meet the needs of a community In fiscal 
year 2021, HRSA funded the Rural Behavioral Health Workforce 
Centers--Northern Border Region as part of the Rural 
Communities Opioid Response Program (RCORP), a multi-year HRSA 
initiative with the goal of reducing morbidity and mortality 
resulting from substance use disorder (SUD) These centers are 
improving behavioral health care services in rural areas 
through educating and training health professionals and 
community members to care for individuals with behavioral 
health disorders, including SUD This program supports HRSA's 
collaboration with the Northern Border Regional Commission 
(NBRC) to provide career and workforce training activities that 
assist individuals with behavioral health needs, particularly 
SUD HRSA will continue funding for these centers in fiscal year 
2022.

    More broadly, through RCORP's other community-based grant 
programs, award recipients serving over 1,500 rural communities 
in 47 States and two territories have been able to leverage 
grant funds to recruit, train, and retain interdisciplinary 
teams of health and social service providers to support 
behavioral health care interventions Since RCORP's inception in 
2018, Alaska has received $22 million in RCORP funding.

    In fiscal year 2022, HRSA will be awarding new grants under 
the Rural Public Health Workforce Training Network Program to 
expand the public health capacity by supporting health care job 
development, including around behavioral health Additionally, 
several of HRSA's rural community-based programs offer funding 
opportunities that allow applicants in rural communities to 
propose and build a program in response to an area of need HRSA 
has funded many programs that focus on workforce development 
through the Rural Health Network Development, Rural Health Care 
Coordination, Rural Health Care Services Outreach, and Delta 
States Rural Development Network grant programs.

    Question 2. What can and should be done to grow the 
employee pipeline in this field?

    Answer 2. HRSA is regularly working to grow the pipeline 
including through multiple pathways to recruit, train and place 
new behavioral health care providers in the communities that 
need them most One way we are growing the behavioral health 
provider pipeline is by promoting the inclusion of health 
support workers as members of behavioral health treatment teams 
For example, the Behavioral Health Workforce Education and 
Training Program for Paraprofessionals develops and expands 
community-based training for students preparing to become peer 
support specialists and other behavioral health-related support 
workers HRSA will also support a new program this year to 
expand the public health workforce through the training of 
community health workers (CHWs) and other health support 
workers and to extend the knowledge and skills of current CHWs 
and other health support workers These CHW's will provide 
services, including behavioral health services in underserved 
communities.

    Question 3. Provider Burnout: Throughout the pandemic, I 
have been concerned about our health care workforce Now, with a 
workforce shortage across the country, acute shortages in 
workers as infected staff isolate, and mounting burnout as we 
enter year three of this pandemic, I am more concerned than 
ever about the future of our health workforce.

    Question 3(a). In the mental health care sector, what steps 
are you taking to help support the mental health needs of 
health providers, and expand and improve retention in an 
already-depleted workforce?

    Answer 3. Supporting the mental health needs of health care 
providers is a top priority for HRSA This past January, HRSA 
announced $103 million in new grant awards to help support our 
health professionals' resilience as they continue to face the 
stress and challenges of responding to COVID-19 and other 
health care needs These awards are funding evidence-informed 
programs, practices and training, with a specific focus on 
providers in underserved and rural communities.

    Funding is allocated across the following programs:

         LPromoting Resilience and Mental Health Among 
        Health Professional Workforce. HRSA awarded $286 
        million to 10 grantees to help health care 
        organizations establish, improve, or expand evidence-
        informed programs and practices to promote mental 
        health and well-being among the health workforce, 
        including their employees.

         LHealth and Public Safety Workforce Resiliency 
        Training Program. HRSA awarded $682 million to 34 
        grantees to support tailored evidence-informed training 
        development within health profession and nursing 
        training activities This curriculum will help reduce 
        burnout and promote resilience among health care 
        students, residents, health care professionals, 
        paraprofessionals, trainees and public safety officers, 
        such as firefighters, law enforcement officers, and 
        ambulance crew members.

         LHealth and Public Safety Workforce Resiliency 
        Technical Assistance Center. HRSA awarded $6 million to 
        provide tailored training and technical assistance to 
        the awardees discussed above.

    HRSA also has several programs under the Behavioral Health 
Workforce Development Program that aim to expand and support 
the behavioral and mental health workforce, including:

        Y LBehavioral Health Workforce Education and Training 
        (BHWET) Programs: BWHET increases the number of 
        behavioral health providers entering and continuing 
        practice, with special emphasis on prevention and 
        clinical intervention and treatment for those at risk 
        of developing mental and substance use disorders, and 
        the involvement of families in the prevention and 
        treatment of behavioral health conditions BWHET 
        includes the activities described below.

        Y LBWHET Program for Professionals: The BHWET Program 
        for Professionals aims to increase the supply of 
        behavioral health professionals while also improving 
        distribution of a quality behavioral health workforce 
        and thereby increasing access to behavioral health 
        services In fiscal year 2022, HRSA supported 168 BHWET 
        Professional grantee organizations.

        Y LBHWET Program for Paraprofessionals: The BHWET 
        Program for Paraprofessionals develops and expands 
        community-based experiential training to increase the 
        supply of students preparing to become peer support 
        specialists and other behavioral health-related 
        paraprofessionals while also improving distribution of 
        a quality behavioral health workforce In fiscal year 
        2022, HRSA supported 44 paraprofessional grantee 
        organizations.

    Other programs to expand the behavioral and mental health 
care provider workforce include:

         LSubstance Use Disorder Treatment and Recovery 
        Loan Repayment Program (STAR LRP): The STAR LRP 
        recruits and retains medical, nursing, behavioral/
        mental health clinicians and paraprofessionals who 
        provide direct treatment or recovery support of 
        patients with or in recovery from a substance use 
        disorder STAR LRP participants must provide services in 
        either a county (or a municipality, if not contained 
        within any county) where the mean drug overdose death 
        rate per 100,000 people over the past 3 years exceeds 
        the national average, or in a Health Professional 
        Shortage Area (HPSA) designated for Mental Health.

         LGraduate Psychology Education (GPE) Program: 
        This Program supports innovative doctoral-level health 
        psychology programs that foster an inter-professional 
        approach to providing behavioral health and substance 
        use prevention and treatment services in high-need and 
        high-demand areas through academic and community 
        partnerships.

         LOIFSP: OIFSP trains paraprofessionals to 
        support children and families impacted by OUD and other 
        SUD in underserved areas The Program also provides 
        professional development opportunities and educational 
        support to increase the number of paraprofessional 
        trainees receiving a certificate upon completion of the 
        Program.

         LAddiction Medicine Fellowship (AMF) Program: 
        The AMF Program seeks to increase the number of board-
        certified addiction medicine and addiction psychiatry 
        specialists trained in providing inter-professional 
        behavioral health services, including OUD and SUD 
        prevention, treatment, and recovery services, in 
        underserved, community-based settings The AMF Program 
        is designed to foster robust community-based clinical 
        training of addiction medicine or addiction psychiatry 
        physicians in underserved, community-based settings who 
        see patients at various access points of care and 
        provide addiction prevention, treatment, and recovery 
        services across health care sectors.

    Question 3(b). What more do you need from Congress to 
support these efforts?.

    Answer 3(b). HRSA continues to prioritize and grow our 
provider resiliency efforts to retain and maintain a strong 
health care workforce To ensure success in our efforts, we hope 
to continue to have regular communication, collaboration and 
support from Congress.

    Question 4. Maternal Mental Health: Studies have found that 
approximately 800,000 mothers are affected by maternal mental 
health conditions each year, and yet 75 percent will go 
entirely untreated In Alaska, only 1 in 4 pregnant and 
postpartum women impacted by maternal mental health conditions 
is diagnosed and receives the treatment needed I recently 
worked with Senators Gillibrand, Capito, and Baldwin on a bill, 
the Into the Light for Maternal Mental Health Act, that focuses 
on supporting mothers mentally as well as physically, so that 
they can better support their babies The bill would support 
maternal mental health specific training and resources for 
health care professionals to identify and treat patients at-
risk for or suffering from maternal mental health conditions.

    Question 4(a). How is HRSA working to ensure pregnant and 
postpartum mothers are screened, supported, and treated for 
maternal mental health?

    Answer 4(a). HRSA supports several programs that are 
focused on maternal mental health The Screening and Treatment 
for Maternal Depression and Related Behavioral Disorders 
Program (MDRBD) gives providers the tools to integrate 
behavioral health care into routine maternal health care 
through teleconsultation services that help local providers 
bridge the gap in access to psychiatrists, especially perinatal 
psychiatrists With teleconsultation support, maternal health 
care providers are able to receive real-time psychiatric 
consultations and care coordination support In addition, 
community-based maternal health providers are offered training 
on how to screen for, assess, treat, and refer pregnant and 
postpartum individuals for mental health and substance use 
disorders.

    HRSA has received tremendous interest in the MDRDB 
program--demonstrating the acute need for it--but is only able, 
with current resources, to fund approximately a quarter of 
applicants The seven states that currently receive awards are 
Florida, Kansas, Louisiana, Montana, North Carolina, Rhode 
Island, and Vermont.

    HRSA will also launch the National Maternal Mental Health 
Hotline later this year The Hotline will be available 24/7 to 
provide free, confidential support, resources and referrals to 
any pregnant and postpartum mothers facing mental health 
challenges and their loved ones Those in need can contact the 
Hotline via phone or text and will receive culturally 
appropriate support from counselors in English or Spanish; 
interpreter services are also available in 60 languages Parents 
and families who contact the Hotline will speak to licensed or 
certified counselors The Hotline's counselors also are trained 
in providing trauma-informed support.

    HRSA additionally supports the Maternal, Infant, and Early 
Childhood Home Visiting Program (MIECHV). This program supports 
voluntary, evidence-based home visiting services for pregnant 
people and parents with young children up to kindergarten entry 
living in communities at risk for poor maternal and child 
health outcomes Home visiting programs support maternal mental 
health by screening for maternal depression and connecting 
caregivers to needed treatment and services The MIECHV Program 
also funds a Home Visiting Collaborative Improvement and 
Innovation Network (HV CoIIN) that supports home visiting 
programs to use quality improvement strategies to better screen 
for and address maternal depression and intimate partner 
violence, and disseminate best practices widely.

    The Healthy Start Program supports community-based 
strategies to reduce the rate of infant mortality, improve 
perinatal outcomes, and address disparities in perinatal health 
Healthy Start grantees provide screening and referral to 
services for depression, substance use and interpersonal 
violence Grantees support client and family behavioral health, 
address toxic stress, and employ trauma-informed care Grantees 
also address maternal depression through health education and 
support groups to promote mental wellness for mothers 
Currently, there are 35 States, the District of Columbia, and 
Puerto Rico which have a Healthy Start site.

    Finally, HRSA's Title V Maternal and Child Health Services 
Block Grant (Title V) Program is a Federal-state partnership 
that awards formula grants to 59 States and jurisdictions to 
address the health needs of mothers, infants, and children, 
including children with special health care needs The purpose 
of the Maternal and Child Health Block Grant is to improve the 
health of the Nation's mothers, children, and families through 
Federal/state partnerships that provide each state with needed 
flexibility to respond to its unique maternal and child 
population needs An estimated 60 million pregnant women and 
children benefited from a service supported by the Title V MCH 
Block Grant in fiscal year 2020 While states have always used 
their Block Grant to address mental and behavioral health 
needs, there was a dramatic increase in the number of states 
identifying it as a priority need in the past two reporting 
years--from 36 States in 2015 to 51 States and territories in 
2020 Access to behavioral health care, including integration of 
behavioral health and primary care, is a major priority for 
states and territories Title V strategies for women and 
maternal health include promoting screening and referral for 
mental health and substance use among pregnant women, training 
providers on maternal mental health needs, and continuing work 
to address opioid and other substance use and its impact on 
women, infants, and families.

    Question 5. Medication Assisted Treatment: The Anchorage 
Daily News reported recently that the U.S. has passed a 
``never-before-seen milestone'' in losing more than 100,000 
Americans to drug overdoses in a year Sadly, the CDC reports 
that the number of drug overdoses in Alaska rose by more than 
45 percent as of June 2021 That's more than double the rate of 
increase for the United States.

    One treatment that we know is critical to stemming the 
overdose crisis is medication that prevent withdrawal symptoms 
and stem opioid cravings These medications, like buprenorphine, 
can cut the risk of overdose death in half when a person starts 
taking them But, outdated Federal laws and stigma are 
restricting access to these life-saving medications I have 
introduced the Mainstreaming Addiction Treatment Act with my 
colleague, Senator Hassan, to help more Americans have access 
to life-saving medication and eliminate burdensome Federal red 
tape.

    Question 5(a). How is the administration supporting 
expanding access to medications to treat substance use disorder 
so they reach all communities in need?

    Answer 5. Health centers remain at the forefront in 
addressing behavioral health issues nationwide, as many health 
centers offer a wide range of integrated primary care, mental 
health, and substance use disorder services including but not 
limited to counseling and psychiatry, Screening, Brief 
Intervention, and Referral to Treatment (SBIRT), medication-
assisted treatment, and recovery support HRSA provides all 
health centers with access to technical assistance resources to 
promote the integration of behavioral health/substance use 
disorder services in primary care and support improvements in 
access to SBIRT, MAT, and tele-behavioral health services 
Nearly 8,400 health center providers were eligible to prescribe 
MAT in 2020.

    HRSA also provides payments to physicians and practitioners 
to furnish opioid use disorder treatment services through its 
implementation of Section 6083 of the SUPPORT for Patients and 
Communities Act (SUPPORT Act), which authorizes payments to 
federally Qualified Health Centers (FQHCs) and Rural Health 
Clinics (RHCs) for completing training and obtaining a DATA 
2000 waiver The payments were intended to increase the 
availability of treatment by incentivizing FQHCs and RHCs to 
have their providers receive the training that was originally 
required to receive a waiver to prescribe medication assisted 
treatment Though providers are no longer required to take the 
training in order to prescribe medication assisted treatment, 
HRSA has obligated the $6 million appropriated for FQHCs and 
continues to promote the program for payments to Rural Health 
Clinics.

    HRSA has also increased the availability of substance use 
disorder treatment through targeted health workforce programs 
The National Health Service Corps (NHSC) Substance Use Disorder 
Workforce Loan Repayment Program provides loan repayment 
assistance to medical, nursing, and behavioral health 
clinicians in exchange for a service commitment to provide 
direct services at substance use treatment facilities in 
underserved areas These sites include outpatient services at 
opioid treatment programs and office-based opioid treatment 
facilities Additionally, the NHSC Rural Community Loan 
Repayment Program has made loan repayment awards in 
coordination with the Rural Communities Opioid Response Program 
initiative within the Federal Office of Rural Health Policy to 
provide evidence-based substance use treatment, assist in 
recovery, and to prevent overdose deaths across the Nation.

    The Substance Use Disorder Treatment and Recovery Loan 
Repayment Program (STAR LRP) recruits and retains medical, 
nursing, behavioral/mental health clinicians and 
paraprofessionals who provide direct treatment or recovery 
support of patients with or in recovery from a substance use 
disorder STAR LRP participants must provide services in either 
a county (or a municipality, if not contained within any 
county) where the mean drug overdose death rate per 100,000 
people over the past 3 years exceeds the national average, or 
in a Health Professional Shortage Area designated for Mental 
Health.

    HRSA's Primary Care Training and Enhancement Program 
further supports efforts to expand access to medications for 
SUD treatment Specifically, this program funds innovative 
training programs that integrate behavioral health care into 
primary care, particularly in rural and underserved settings 
with a special emphasis on mental health and the treatment of 
opioid use disorder Additionally, the Residency Training in 
Primary Care Program requires that residents in the program are 
provided with dedicated clinical experiences with at least one 
provider with a DATA-2000 waiver who provides MAT services for 
patients with opioid use disorder.

    HRSA's Addiction Medicine Fellowship, Graduate Psychology 
Education and Rural Communities Opioid Response Programs also 
contribute to expanding access to SUD medications and 
treatments across a variety of communities in need The 
Addiction Medicine Fellowship Program supports the clinical 
training of addiction medicine or addiction psychiatry 
physicians in underserved, community-based settings The 
Graduate Psychology Education Program supports innovative 
doctoral-level health psychology programs that foster an inter-
professional approach to providing behavioral health and 
substance use prevention and treatment services in high need 
and high demand areas through academic and community 
partnerships The Rural Communities Opioid Response Program aims 
to reduce the morbidity and mortality associated with SUD, 
including opioid use disorder, in high need rural communities 
by establishing, expanding, and sustaining prevention, 
treatment, and recovery services at the county, state, and/or 
regional levels.

    Question 6. Infant and Early Childhood Mental Health: The 
first years of life are an incredible opportunity to promote 
positive mental health for babies, and health and well-being 
during this time period affects future learning, behavior and 
health.

    Question 6(a). Have you seen a marked impact by Federal 
investment in infant and early childhood mental health (IECMH)?

    Answer 6. The Maternal, Infant, and Early Childhood Home 
Visiting Program (MIECHV) supports voluntary, evidence-based 
home visiting services for pregnant people and parents with 
young children up to kindergarten entry living in communities 
at risk for poor maternal and child health outcomes The program 
is built on decades of scientific research, which shows that 
home visits by a nurse, social worker, or early childhood 
educator during pregnancy and in the first years of life, 
improve child and family outcomes like maternal and newborn 
health MIECHV programs support Infant and Early Childhood 
Mental Health (IECMH) Consultation, which pairs a mental health 
specialist with a home visitor to help them strengthen and 
support the healthy social and emotional development of 
children ages 0--5 HRSA provides technical assistance to state 
awardees and local programs to expand use of IECMH in home 
visiting Federal investment in IECMH improves the capacity of 
home visiting programs to meet families' needs and promote 
healthy child development Authorization and funding for the 
MIECHV program expires at the conclusion of fiscal year 2022 
without further legislative action.

             Suicide Screening in the Emergency Department

    Question 7. A recent CDC report on emergency department 
visits for people aged 12-25 found an over 50 percent increase 
visits for suspected suicide attempts during early 2021 This 
underscores the devastating mental health impact of the 
pandemic on our youth and highlights yet another way that 
COVID-19 has strained our hospitals and medical staff.

    I introduced a bill, the Effective Suicide Screening and 
Assessment in the Emergency Department Act, to improve the 
screening and treatment of patients in hospital emergency 
departments who are at high risk for suicide It will make sure 
that we can better identify our most vulnerable mental health 
patients so they do not slip through the cracks when they are 
treated in hospitals, and make sure hospitals have the 
resources they need to provide these critical services.

    Question 7(a). What is the need for improved suicide 
screening protocols in the Nation's emergency rooms?

    Question 7(b). Do you support efforts to bolster the 
resources available to emergency rooms so they can enhance 
their screening for high-risk suicide patients?

    Answer 7. The HRSA Emergency Medical Services for Children 
(EMSC) Program's Pediatric Emergency Care Applied Research 
Network (PECARN) examined suicide among adolescents to help 
identify those most at-risk Although the second leading cause 
of death among youth, only a fraction of adolescents who die of 
suicide have ever been treated for a mental or behavioral 
health problem \2\ As many at-risk adolescents remain 
unidentified, emergency departments are particularly suited for 
suicide risk screening PECARN investigators implemented an 
observational study to validate the Computerized Adaptive 
Screen for Suicidal Youth (CASSY) survey which predicts 
adolescent suicidality using a 1-2 minute screening strategy 
Investigators found that the CASSY correctly identified 824 
percent of youth who went on to attempt suicide in the 3-months 
following screening The results suggest this screener could 
serve as an easy-to-use way for providers to detect youth 
suicide risk in emergency department settings \3\ Though this 
looks to be a promising screening tool for use in emergency 
departments, the study suggests that it needs further testing 
for validity and reliability HRSA continues to support efforts 
to improve suicide screening protocols and bolster the 
resources available in emergency departments to prevent youth 
suicide.
---------------------------------------------------------------------------
    \2\  King CA, Brent D, Grupp-Phelan J, Gibbons R, etal (2021) 
Prospective Development and Validation of the Computerized Adaptive 
Screen for Suicidal Youth Pediatric Emergency Care Applied Research 
Network JAMA Psychiatry 2021 May 1;78(5):540-549
    \3\  King CA, Grupp-Phelan J, Brent D, etal (2019) Predicting 3-
month risk for adolescent suicide attempts among pediatric emergency 
department patients J Child Psychol Psychiatry 2019 Oct;60(10):1055-
1064 doi: 101111/jcpp13087 Epub 2019 Jul 21.

                                  FASD

    Question 8. During COVID, we have seen a sharp rise in 
substance misuse specifically alcohol, the most widely used and 
misused substance Unfortunately, a landmark NIH study in 2018 
established that 1 in 20 school-aged children are affected by 
fetal alcohol spectrum disorders--FASD Due to its significance 
and status as an overlooked disability that includes 
debilitating stigma, I introduced S 2238, the FASD Respect Act 
My legislation establishes common standards of care and 
increases the capacity to manage FASD in medical and mental 
health settings How can we address the social and environmental 
factors that contribute to prenatal alcohol exposure and reduce 
the traumas FASD creates for individuals and families?

    Question 8(a). What steps are being taken by the 
administration to provide more education and training on FASD? 
How can stigma be lessened for individuals living with 
behavioral health conditions, like FASD?

    Answer 8. HRSA supports the Supporting Fetal Alcohol 
Spectrum Disorders (FASD) Screening & Intervention Program, 
called the SAFEST Choice Learning Collaborative This program 
trains primary care providers with the aim to reduce the 
incidence of prenatal alcohol exposure, and improve 
developmental outcomes in children with suspected or diagnosed 
FASDs This program reaches providers in states, territories, 
tribes, or communities that have high rates of binge drinking 
among pregnant women, especially in rural areas The SAFEST 
Choice program successfully recruited providers from community 
health centers to participate in the first cohort, including 10 
maternal health practices and 12 pediatric practices from seven 
states: IA, MA, ME, MI, MN, RI, SD Five of the 22 practices are 
in tribal health clinics and several other practices serve 
tribal communities SAFEST Choice offers a range of technical 
assistance to providers such as strategies to improve practice, 
change systems including quality improvement approaches, and 
identify and access community resources Provider trainings 
include a focus on reducing stigma and bias

                             SENATOR BRAUN

    Senior caregivers working across assisted living and memory 
care have been instrumental in successfully mitigating the 
spread of COVID-19 among the most vulnerable populations, even 
without Federal relief Nearly half of the 30,000 seniors in 
assisted living in Indiana have Alzheimer's or dementia, which 
created complex challenges for their caregivers during the 
pandemic Assisted living and memory care communities continue 
to be proven effective in addressing the social determinants of 
senior health: proper nutrition, housing, and most importantly, 
social interaction.

    Question 1. Administrator Johnson, how does HRSA plan to 
engage assisted living and memory care communities as important 
stakeholders as alarming data finds the need for 14 million 
additional senior caregivers to keep pace with America's 
rapidly aging population, which shows 10,000 individuals 
turning 65 every day?

    Answer 1. HRSA's Geriatrics Workforce Enhancement Program 
improves health care for older adults by developing a health 
care workforce to provide value-based care that improves health 
outcomes for older adults by integrating geriatrics and primary 
care delivery sites/systems The Program maximizes patient and 
family engagement in health care decisions and provides 
training focusing on inter-professional and team-based care 
across the educational continuum (students, faculty, providers, 
direct service workers, patients, families, and lay and family 
caregivers).

    An essential component of the program is developing 
academic-primary care-community-based partnerships to address 
gaps in health care for older adults and transforming clinical 
training environments into integrated geriatrics and primary 
care sites/systems to become age-friendly health systems and 
dementia-friendly communities

                           SENATOR TUBERVILLE

    Question 1. we know that one in four Americans reports 
having been a victim of crime in the past 10 years, and half of 
those were victims of a violent crime Most report receiving no 
help in the aftermath Police, corrections leaders, and the 
courts agree that untreated mental health or co-occurring 
substance abuse disorders are core drivers of the cycle of 
crime and that they lack the infrastructure to respond 
appropriately.

    Question 1(a). What do you see as the individual and 
societal impacts of untreated trauma as it relates to mental 
health and substance use disorder?

    Answer 1. Untreated trauma can result in an individual or a 
community experiencing emotional challenges including suicidal 
ideation, depression, anxiety, increased substance use, an 
inability to thrive in interpersonal relationships and more The 
impact of trauma can be subtle, insidious, and destructive \4\ 
There is, unfortunately, an inaccurate perception that mental 
illness is a cause of violent crime, wherein actuality, people 
with mental illness are more likely to be victims of violent 
crime than perpetrators \5\ Data implies there is a benefit of 
trauma informed care regardless of an individual's mental 
health status
---------------------------------------------------------------------------
    \4\  Understanding the Impact of Trauma--Trauma-Informed Care in 
Behavioral Health Services--NCBI Bookshelf (nihgov)
    \5\  Desmarais SL, Van Dorn RA, Johnson KL, Grimm KJ, Douglas KS, 
Swartz MS Community violence perpetration and victimization among 
adults with mental illnesses Am J Public Health 2014 Dec;104(12):2342-9 
doi: 102105/AJPH2013301680 Epub 2014 Feb 13 PMID: 24524530; PMCID: 
PMC4133297.

    HRSA is working to increase not only the pipeline of mental 
and behavioral health care professionals but also to increase 
the access and touch points for mental and behavioral health 
services in the community through community health workers, and 
---------------------------------------------------------------------------
other professionals.

    Question 2. Federal data shows that 37 percent of people 
sentenced to prison, and 44 percent of people arrested and 
jailed, have experienced a mental health issue At the same 
time, we know that an estimated 1 in 10 police service calls 
are responding to an untreated mental health issue Across the 
country, we've seen community-based programs that seek to 
divert individuals experiencing mental health issues, direct 
individuals to treatment and resources, and do so in a way so 
the police department does not have to be involved.

    Question 2(a). What is the Federal Government doing to 
ensure that mental health emergencies are being responded to 
appropriately, early on, before a treatable illness becomes a 
safety issue?

    Answer 2. The HRSA Health Center Program supports mental 
health and substance use disorder services in primary care 
settings These investments support health centers to integrate 
mental health/substance use disorder services into the primary 
care setting to better address the significant unmet need for 
these services in their communities.
                                ------                                


 Response by Joshua A. Gordon to Questions From Senator Casey, Senator 
  Rosen, Senator Hickenlooper, Senator Murkowski, Senator Scott, and 
                           Senator Tuberville

                             SENATOR CASEY

    Question 1. Postsecondary age youth are often in need of 
greater access to mental health resources than the general 
population With 2 years of the pandemic causing social 
isolation and greater levels of stress and anxiety, their needs 
are likely even greater Prior to the pandemic, the number of 
postsecondary students using their college counseling centers 
increased by 30-40 percent, whereas enrollment had only 
increased by 5 percent How the pandemic has affected the need 
for additional mental health services has yet to be determined 
as we do not yet have systematic, quality data on the mental 
health impacts of the pandemic on postsecondary students My 
Higher Education Mental Health Act would establish a national 
Commission to study the mental health concerns facing students 
at institutes of higher education and report on services 
available to students with mental health disabilities The bill 
also charges the Commission to provide detailed recommendations 
to improve the mental health services available to students at 
institutes of higher education.

    Question 1(a). If passed, what data would you recommend be 
collected by the Commission and do you have preliminary 
recommendations the Commission should consider to assist 
institutes of higher education to better serve the mental 
health needs of young adults entering postsecondary education?

    Answer 1. The National Institute of Mental Health (NIMH) 
supports research aiming to develop and test sustainable 
approaches to college-based mental health interventions and 
services NIMH-supported researchers are evaluating the use of a 
mobile prevention and intervention platform that includes 
population-level screening for college students and tailored 
services to address common mental disorders (clinical anxiety, 
depression, eating disorders) Additional NIMH-funded 
investigators are testing the effectiveness and implementation 
of two separate prevention and early intervention strategies 
for eating disorders among college populations, and other NIMH-
funded researchers are aiming to test the effectiveness of 
sequential suicide prevention interventions for college 
students Another team of NIMH-supported researchers are 
examining changes in mental health over the course of the 
undergraduate experience through a longitudinal study.

    The neurodiversity of young adults entering postsecondary 
education, including the diversity of needs experienced by 
adolescents and young adults with autism spectrum disorder 
(ASD), is also important to consider NIMH recently supported 
researchers examining the Stepped Transition in Education 
Program for Students with ASD (STEPS), a multipronged approach 
to prepare students with autism for the transition to post-
secondary education The study demonstrated that STEPS helped to 
increase participants' college readiness and decrease 
depressive symptoms over the transition period. \1\, \2\
---------------------------------------------------------------------------
    \1\  White et al (2021), pubmedncbinlmnihgov/31609666/
    \2\  Capriola-Hall et al (2021), pubmedncbinlmnihgov/32468396/.

    Youth mental health is a priority for the National 
Institutes of Health (NIH) Both NIMH and the Eunice Kennedy 
Shriver National Institute of Child Health and Human 
Development (NICHD) prioritize research focused on social 
determinants of health and the impact of health disparities on 
intervention efforts during adolescence NIMH prioritizes 
research to understand the mechanisms by which social 
determinants of health drive risk of, and resilience to, the 
development of mental illnesses NICHD supports research to 
determine how exposure to social and environmental factors such 
as diet and nutrition, technology and digital media use, sleep 
habits, and physical activity affect neurodevelopment and 
health outcomes Advances in our understanding of the mechanisms 
by which these social and environmental factors impact mental 
health could lead to improved interventions for youth with, or 
at high risk for, mental illnesses--including interventions 
delivered through non-specialty settings such as colleges and 
universities.

                             SENATOR ROSEN

    Question 1. Over the last 2 years, we saw the devastating 
impact of social isolation on seniors' mental health As we look 
back at measures taken to protect the physical health of the 
most vulnerable during the pandemic, we also must take to heart 
the lessons learned for how to do better in the future One area 
of particular concern is how many seniors were not allowed a 
family member or caregiver to be with them during inpatient 
hospital stays--even when dealing with anxiety, depression, 
temporary psychosis, or delirium--regardless of whether their 
caregiver was vaccinated or willing to use protective gear AARP 
also has noted how critical it is to find a balance between 
protecting patient health and how the absence of caregivers 
puts additional pressure on clinical staff.

    Question 1(a). Dr. Gordon, how would you recommend Federal 
guidance be adjusted in the future to best protect both the 
physical and mental health of seniors, especially when they are 
particularly vulnerable during hospital stays?

    Answer 1. NIH continuously strives to build a strong 
foundation of evidence to inform Federal guidance, including 
through research on evidence-based practices to optimally 
protect the physical and mental health of older adults across 
multiple care settings To this end, the NIMH supports 
interdisciplinary research to improve diagnosis, treatment, and 
prevention of mental illnesses in older adults NIMH recognizes 
the ongoing need for research to develop and test strategies 
that speed dissemination, adoption, and implementation of 
evidence-based interventions, and the importance of sustaining 
these practices over time For example, universal screening for 
suicidal thoughts and behaviors in older adults is shown to 
double the rate of suicide risk detection \3\ While effective 
evidence-based practices like these could improve diagnosis, 
treatment, and prevention of mental illnesses in older adults, 
more NIH research is needed to inform broader Federal guidance.
---------------------------------------------------------------------------
    \3\  Betz et al (2016), pubmedncbinlmnihgov/27596110/.

    NIMH supports the Partnership for the Implementation 
Science in Geriatric Mental Health (PRISM) Hub, which aims to 
establish a collaborative network of institutions and 
individuals to carry out and utilize research that answers 
policy-relevant questions related to reducing the treatment gap 
for older adults with mental health problems Recently, and 
historically, NIMH has supported studies related to reducing 
suicidal ideation in older adults with depression, including 
research on person-centered approaches for understanding 
suicidal ideation and behaviors among nursing home residents 
and research on reducing suicidal ideation and depressive 
symptoms in depressed older primary care patients \4\, \5\, \6\
---------------------------------------------------------------------------
    \4\  reporternihgov/project-details/10163269
    \5\  Bruce et al (2004), pubmedncbinlmnihgov/14996777/
    \6\  Untzer et al (2006), pubmedncbinlmnihgov/17038073/.

    NIMH Director Dr. Joshua Gordon has highlighted the need to 
further examine the impact of social isolation and loneliness 
among older adults and the impact the COVID-19 pandemic might 
have on this vulnerable population \7\ NIMH also encourages 
research that examines novel treatment delivery paradigms that 
might reach underserved populations, more innovative approaches 
to the ways in which care is delivered, and improved 
understanding of the negative impact of social isolation and 
loneliness on the mental health of older adults relatedly, in 
December 2021, NIMH issued a pair of calls for applications to 
examine the role of social disconnection and risk of suicide in 
late life. \8\, \9\
---------------------------------------------------------------------------
    \7\  Gordon and Evans (2021), pubmedncbinlmnihgov/35132392/
    \8\  grantsnihgov/grants/guide/rfa-files/RFA-MH-22-135html
    \9\  grantsnihgov/grants/guide/rfa-files/RFA-MH-22-136html.

    NIMH has also supported research to examine the impact of 
telehealth approaches to the provision of treatment for 
isolated and homebound elders Further, NIMH highlights a 
commentary discussing potential mechanisms of risk and 
resilience among older adults at risk for the development of 
prolonged grief disorder. \10\
---------------------------------------------------------------------------
    \10\  Goveas and Shear (2020), pubmedncbinlmnihgov/32709542/.

    In addition, other NIH Institutes and Centers, including 
the National Institute on Aging (NIA), directly support 
research which informs policies related to older adults' health 
and well-being, particularly in the context of the COVID-19 
pandemic and associated social isolation and loneliness NIA has 
a robust history of promoting research to help understand how 
we can reduce loneliness and enhance social connection among 
older adults to improve physical and mental health outcomes The 
pandemic underscored that rigorous research on the health 
effects of social isolation and loneliness--and the development 
of interventions to prevent or address these conditions--are 
needed now more than ever \11\ To this end, NIA supports the 
following:
---------------------------------------------------------------------------
    \11\  Necka (2021), wwwnianihgov/research/blog/2021/06/after-covid-
research-social-isolation-and-loneliness-needed-more-ever

         LStudies examining how COVID-19-associated 
        social isolation and loneliness impact the health and 
        well-being of midlife and older adult populations. \12\
---------------------------------------------------------------------------
    \12\  grantsnihgov/grants/guide/notice-files/NOT-AG-21-015html.

         LResearch on the biopsychosocial aspects of 
        social connectedness and isolation and their 
        association with health, well-being, illness, and 
        recovery, via two funding opportunity announcements. 
        \13\, \14\
---------------------------------------------------------------------------
    \13\  grantsnihgov/grants/guide/pa-files/PAR-21-144html
    \14\  grantsnihgov/grants/guide/pa-files/PAR-21-145html.

         LObservational studies as well as intervention 
        research to identify quality of life and health 
        outcomes for people with dementia, with particular 
        interest in those who are socially isolated. \15\
---------------------------------------------------------------------------
    \15\  grantsnihgov/grants/guide/notice-files/NOT-AG-18-056html.

         LAn NIA-hosted Facebook Live Q&A event on 
        social isolation and loneliness, \16\ in which NIA 
        experts shared insights on how social isolation and 
        loneliness affect health, and how to stay connected 
        during and after the COVID-19 pandemic.
---------------------------------------------------------------------------
    \16\  youtube/WBJclABlg--U.

         LA Focus on Aging: Federal Partners' Webinar 
        on social isolation and loneliness, \17\ conducted by 
        NIA in partnership with the Administration for 
        Community Living, the Centers for Disease Control and 
        Prevention, and the Health Resources and Services 
        Administration.
---------------------------------------------------------------------------
    \17\  youtube/tKOAO09PsFU

    In concert with the efforts above, NIA supports research to 
understand the effect of the COVID-19 pandemic on older adults' 
health and well-being, particularly as a result of shifting 
patterns of social contact Researchers found that greater 
levels of concern about becoming infected with SARS-CoV-2, the 
virus which causes COVID-19, were associated with greater 
loneliness in older adults \18\ Researchers showed that weekly 
in-person contact fell substantially during the pandemic among 
older adults in both residential care and community settings 
This effect was particularly pronounced among older adults 
living in residential care facilities and was not 
counterbalanced by an increase in video contact for these 
individuals \19\ In addition, older adults with cognitive 
impairment living alone during the pandemic reported 
significant distress, including isolation, fear, confusion, and 
variable access to essential services \20\ In addition to 
experiencing these effects, older adults may also be relatively 
resilient to the negative psychosocial effects of the COVID-19 
pandemic, showing lower levels of stress, better psychosocial 
functioning, and more effective coping behavior than younger 
adults. \21\
---------------------------------------------------------------------------
    \18\  Polenick et al (2021), pubmedncbinlmnihgov/33641513/
    \19\  Freedman et al (2021), pubmedncbinlmnihgov/34529083/
    \20\  Portacolone et al (2021), pubmedncbinlmnihgov/33404634/
    \21\  Minahan et al (2021), pubmedncbinlmnihgov/33320191/.

    Question 1(b). Dr. Gordon, can you please speak to how the 
presence of a trusted caregiver impacts the well-being of 
---------------------------------------------------------------------------
vulnerable seniors when they are in an unfamiliar setting?

    Answer 1(b). NIA conducts research to better understand the 
pivotal role that caregivers play in providing support to older 
adults Older adults, particularly those living with chronic 
disease, disability, or cognitive impairment or dementia, may 
be vulnerable in unfamiliar settings and especially reliant 
upon a caregiver Below are several examples of NIA-and other 
NIH-supported research which indicate the potential 
significance of these trusted caregivers.

    In the context of COVID-19, the presence of a trusted 
caregiver may be indispensable given what is known about the 
presentation of COVID-19 in older adults For example, NIA-
funded researchers showed that older adults may present with 
COVID-19 in an atypical manner, showing altered mental status 
or functional decline, and that an atypical presentation may 
lead to less aggressive care \22\ Similarly, NIA-funded 
researchers showed that 28 percent of older adults with COVID-
19 present with delirium, and 37 percent of these older adults 
with delirium did not show typical COVID-19 symptoms, such as 
fever or cough \23\ Delirium in this context was also 
associated with an increased risk of death In such situations, 
the presence of a trusted caregiver might enhance recognition 
of these atypical COVID-19 symptoms (eg, altered mental status/
delirium, functional decline) in an older patient, particularly 
in an emergency room, hospital, or other potentially novel and 
unfamiliar setting, and could enhance the likelihood of 
appropriate intervention.
---------------------------------------------------------------------------
    \22\  Marziliano et al (2022), pubmedncbinlmnihgov/34279628/
    \23\  Kennedy et al (2020), pubmedncbinlmnihgov/33211114/.

    In addition, the COVID-19 pandemic led to restrictions 
regarding in-person visits in residential care settings, 
thereby limiting interactions between older adults and their 
families and trusted caregivers NIA-supported researchers 
examined communication methods which replaced face-to-face 
visits with the onset of the COVID-19 crisis and their impact 
on the emotional well-being of long-term care residents These 
researchers showed that the ability to communicate through 
familiar and synchronous modes of communication (eg, phone 
calls, email) improved residents' emotional well-being, whereas 
less familiar and asynchronous methods of communication (eg, 
letters delivered by a staff member) negatively affected their 
emotional well-being. \24\
---------------------------------------------------------------------------
    \24\  Monin et al (2020), pubmedncbinlmnihgov/33004262/.

    NIH's Inclusion Across the Lifespan initiative, \25\ which 
seeks to increase the recruitment and retention of older adults 
and children in NIH research, has identified a need to engage 
caregivers in older adults' care and well-being This 
recommendation stems from the NIA-supported ``5Ts'' framework, 
\26\ in which a team-based approach, incorporating geriatric 
care professionals, as well as family members, caregivers, and 
community partners, is posited to support the needs and well-
being of older adults in clinical research settings, including 
those related to studies of COVID-19.
---------------------------------------------------------------------------
    \25\  grantsnihgov/policy/inclusion/lifespanhtm
    \26\  Bowling et al (2019), pubmedncbinlmnihgov/30693952/
---------------------------------------------------------------------------

                          SENATOR HICKENLOOPER

    Across the Nation, suicide is the second leading cause of 
death for children and young adults In Colorado, it is number 
1.

    The pandemic has exacerbated mental health challenges for 
kids, including increased isolation and distance from social 
and emotional support.

    I was proud to vote for the Omnibus bill, which included 
more than $100 million for the Department of Education to 
increase mental health services in schools.

    Question 1. What does the data indicate about the benefit 
of school interventions and support for students struggling 
with mental health needs?

    Answer 1. Youth have been disproportionately impacted by 
the pandemic; globally, in the first year of the pandemic one 
in four children reported elevated depression and one in five 
reported elevated anxiety \27\ Numerous causes likely 
contributed to these mental health impacts, including loss of 
caregivers and family members, fear of being infected, loss of 
family income, and social isolation.
---------------------------------------------------------------------------
    \27\  Racine et al (2021), pubmedncbinlmnihgov/34369987/.

    For more than one in three adolescents, schools provide 
their primary access to mental health care \28\ School-based 
health centers (SBHCs) have been recommended by the American 
Academy of Pediatrics as a safety net care delivery model for 
youth who do not have access to a consistent source of health 
care \29\ However, more research is needed to investigate the 
effectiveness of SBHCs To this end, NIMH issued a funding 
opportunity announcement to support research on the delivery, 
implementation, and sustainability of evidence-based mental 
health interventions provided by SBHCs that also addresses 
health disparities and advances health equity among underserved 
populations. \30\
---------------------------------------------------------------------------
    \28\  Hertz and Barrios (2021), pubmedncbinlmnihgov/33172840/
    \29\  Kjolhede et al (2021), pubmedncbinlmnihgov/34544844/
    \30\  grantsnihgov/grants/guide/pa-files/PAR-21-287html.

    School settings also present a critical opportunity for 
identifying risk and preventing youth suicide NIMH recently 
hosted a webinar, titled ``School-based Suicide Prevention: 
Promising Approaches and Opportunities for Research,'' in which 
presenters discussed preliminary research efforts and 
challenges, as well as ways to overcome common barriers to 
implementing suicide prevention in schools, including data 
collection and evaluation \31\ NIMH-supported investigators are 
testing a universal school-based suicide prevention program, 
and other NIMH-supported researchers are examining school-based 
interventions to prevent depression in adolescents with 
attention-deficit hyperactivity disorder (ADHD).
---------------------------------------------------------------------------
    \31\  wwwnimhnihgov/news/events/2022/school-based-suicide-
prevention-promising-approaches-and-opportunities-for-research
---------------------------------------------------------------------------

                           SENATOR MURKOWSKI

                     Medication Assisted Treatment

    Question 1. The Anchorage Daily News reported recently that 
the U.S. has passed a ``never-before-seen milestone'' in losing 
more than 100,000 Americans to drug overdoses in a year Sadly, 
the CDC reports that the number of drug overdoses in Alaska 
rose by more than 45 percent as of June 2021 That's more than 
double the rate of increase for the United States.

    One treatment that we know is critical to stemming the 
overdose crisis is medication that prevent withdrawal symptoms 
and stem opioid cravings These medications, like buprenorphine, 
can cut the risk of overdose death in half when a person starts 
taking them But, outdated Federal laws and stigma are 
restricting access to these life-saving medications I have 
introduced the Mainstreaming Addiction Treatment Act with my 
colleague, Senator Hassan, to help more Americans have access 
to life-saving medication and eliminate burdensome Federal red 
tape.

    Question 1(a). How is the administration supporting 
expanding access to medications to treat substance use disorder 
so they reach all communities in need?

    Answer 1(a). Methadone, buprenorphine, and naltrexone are 
effective for the treatment of opioid use disorder (OUD) and 
the prevention of overdose deaths, but they are highly 
underutilized The Department of Health and Human Services (HHS) 
released the Overdose Prevention Strategy (OPS) in October 2021 
to expand access to substance use prevention, treatment, harm 
reduction, and recovery support services. \32\
---------------------------------------------------------------------------
    \32\  wwwhhsgov/overdose-prevention/.

    To identify best approaches to expand access to and speed 
the uptake of medications for OUD (MOUD) in diverse settings 
and diverse populations, the National Institute on Drug Abuse 
(NIDA) funds implementation research in healthcare settings, 
justice settings, and community settings through the Clinical 
Trials Network, \33\ the Justice Community Opioid Innovation 
Network (JCOIN), \34\ and the HEALing Communities StudySM \35\ 
These studies are evaluating strategies for expanding OUD 
screening and treatment into emergency departments, primary 
care clinics, infectious disease programs, rural and American 
Indian/Alaska Native communities, and criminal justice 
settings.
---------------------------------------------------------------------------
    \33\  nidanihgov/about-nida/organization/cctn/clinical-trials-
network-ctn
    \34\  healnihgov/research/research-to-practice/jcoin
    \35\  healnihgov/research/research-to-practice/healing-communities.

    NIDA also funds research on the provider-and systems-level 
barriers and facilitators to adoption of MOUD, particularly 
among people experiencing homelessness, women, and racial/
ethnic minority groups, as well as testing new strategies to 
expand MOUD access to pregnant people, rural areas, and 
---------------------------------------------------------------------------
justice-involved populations.

    During the COVID-19 pandemic, people with OUD can now 
obtain a 14-28 days' take-home supply of methadone, which may 
particularly benefit people who live in rural areas or who 
otherwise have had trouble accessing treatment in the past 
NIDA-funded research is examining clinicians' and patients' 
experiences with telehealth services for the treatment of OUD 
and studying the implementation and outcomes of changes in OUD 
health services delivery policies This research will be 
critical for determining how to optimize access to effective 
MOUD through flexibilities in the provision of MOUD.

    Question 2. Infant and Early Childhood Mental Health: The 
first years of life are an incredible opportunity to promote 
positive mental health for babies, and health and well-being 
during this time period affects future learning, behavior and 
health.

    Question 2(a). Have you seen a marked impact by Federal 
investment in infant and early childhood mental health (IECMH)?

    Answer 2. NIMH supports biomedical research to understand 
the mechanisms that underlie neurodevelopment, and how typical 
and atypical development affects future learning, behavior, and 
mental health Novel biomarkers and behavioral indicators hold 
promise for identifying at the earliest possible point who is 
at risk, when development or aging is going off course, or 
which preventive and treatment interventions will produce the 
best outcomes for which individuals To identify promising 
targets for new interventions, studies of risk factors--
including those related to genetics, experience, and the 
environment--help provide clues to how mental disorders and 
developmental disorders emerge.

    NIMH-supported investigators found that early life stress, 
for example, can cause alterations in neural circuitry and 
impair social interactions later in life \36\ Other NIH-funded 
studies are examining measurements of sleep and brain activity 
related to mental health in children In addition, as a result 
of the growing focus on mental health during the COVID-19 
pandemic, NIMH is supporting research on COVID-19 mother and 
baby outcomes for brain and behavior function, as well as 
neurobehavioral consequences of COVID-19-related stressors on 
maternal mental health and infant and child neurodevelopment 
\37\, \38\
---------------------------------------------------------------------------
    \36\  Opendak et al (2021), pubmedncbinlmnihgov/34706218/
    \37\  Shuffrey et al (2022), pubmedncbinlmnihgov/34982107/
    \38\  reporternihgov/project-details/10414939.

    NIMH is committed to supporting research to identify autism 
spectrum disorder (ASD) at the earliest age possible to enable 
early intervention and better long-term outcomes NIMH-funded 
researchers have demonstrated that differences in brain 
development and function (eg, eye gaze patterns, brain growth, 
and how different parts of the brain develop connections), as 
well as some subtle behavioral differences, emerge in the first 
months of life, before ASD symptoms begin to appear \39\, \40\ 
Building on these findings, NIMH is partnering with other NIH 
Institutes to support researchers developing and validating new 
screening methods for ASD that can be used in the first year of 
life \41\ For example, NIMH and the NICHD supported researchers 
developed an eye-tracking app that successfully distinguished 
toddlers diagnosed with ASD from typically developing toddlers 
\42\ Study results indicate that an app-based approach could be 
used to screen infants and toddlers for ASD and refer them for 
early intervention when likelihood for treatment success is 
greatest (ie, at younger ages) In addition, a network of NIMH-
funded researchers has tested different models of service 
engagement and coordination to determine how best to eliminate 
disparities in diagnosis, and how to diagnose children within 
underserved populations at earlier ages \43\, \44\
---------------------------------------------------------------------------
    \39\  Hazlett et al (2017), pubmedncbinlmnihgov/28202961/
    \40\  Stallworthy et al (2022), pubmedncbinlmnihgov/33965519/
    \41\  wwwnimhnihgov/news/science-news/2019/nih-awards-funding-for-
early autism-screening
    \42\  wwwnimhnihgov/news/science-news/2021/media-advisory-
prototype-app-for-mobile-devices-could-screen-children-at-risk-for-
autism-spectrum-disorder
    \43\  Sheldrick et al (2022), pubmedncbinlmnihgov/34982099/
    \44\  Pierce et al (2019), pubmedncbinlmnihgov/31034004/.

    In addition, NICHD is committed to supporting research to 
identify and examine the psychological and behavioral factors 
and processes that influence social/emotional development and 
expression in individuals with intellectual and developmental 
disabilities NICHD-funded researchers recently examined the 
role of behavioral and mindfulness-based interventions in 
promoting parent and child well-being in families with children 
demonstrating intellectual and developmental disabilities. \45\
---------------------------------------------------------------------------
    \45\  McIntyre (2020), pubmedncbinlmnihgov/32936889/.

    Question 3. Suicide Screening in the Emergency Department: 
A recent CDC report on emergency department visits for people 
age 12-25 found an over 50 percent increase visits for 
suspected suicide attempts during early 2021 This underscores 
the devastating mental health impact of the pandemic on our 
youth and highlights yet another way that COVID-19 has strained 
---------------------------------------------------------------------------
our hospitals and medical staff.

    I introduced a bill, the Effective Suicide Screening and 
Assessment in the Emergency Department Act, to improve the 
screening and treatment of patients in hospital emergency 
departments who are at high risk for suicide It will make sure 
that we can better identify our most vulnerable mental health 
patients so they do not slip through the cracks when they are 
treated in hospitals, and make sure hospitals have the 
resources they need to provide these critical services.

    Question 3(a). What is the need for improved suicide 
screening protocols in the Nation's emergency rooms?

    Answer 3. Developing suicide risk screening tools and 
testing their effectiveness in real-world settings such as 
emergency departments (EDs) remains a high-priority research 
area for NIMH Approximately 80 percent of U.S. suicide 
decedents accessed health care services in the 12 months 
preceding their death, and nearly 30 percent had a health care 
visit in the week before suicide, demonstrating that health 
care systems can play a vital role in identifying individuals 
at risk and preventing suicide attempts. \46\
---------------------------------------------------------------------------
    \46\  Gordon, Avenevoli, and Pearson (2020), pubmedncbinlmnihgov/
32432690/.

    NIMH-funded researchers demonstrated that the use of brief 
screening tools in EDs can improve providers' ability to 
identify individuals at risk for suicidal behavior and refer 
them to treatment \47\ As one example, the NIMH-funded ED 
Safety Assessment & Follow-up Evaluation (ED-SAFE) study found 
that universal screening of ED patients doubled the rate of 
risk detection (from 3 percent to 6 percent), and that ED-
initiated interventions reduced subsequent suicidal behavior by 
30 percent \48\ Additionally, NIMH-funded researchers developed 
the Ask Suicide-Screening Questions tool--a very brief (four-
question) screening instrument that was shown to identify risk 
for suicide in pediatric emergency departments and has now been 
adapted for use across multiple other settings and populations. 
\49\, \50\
---------------------------------------------------------------------------
    \47\  wwwnimhnihgov/news/science-news/2021/adaptive-screener-may-
help-identify-youth-at-risk-of-suicide
    \48\  Boudreaux et al (2016), pubmedncbinlmnihgov/26654691/
    \49\  Horowitz et al (2012), pubmedncbinlmnihgov/23027429/
    \50\  wwwnimhnihgov/research/research-conducted-at-nimh/asq-
toolkit-materials.

    Question 3(b). Do you support efforts to bolster the 
resources available to emergency rooms so they can enhance 
---------------------------------------------------------------------------
their screening for high-risk suicide patients?

    Answer 3(b). Since emergency departments and other health 
care settings have a critical role in identifying and providing 
preventive interventions for individuals at risk of suicide, it 
is important that these settings have the resources they need 
to implement effective screening tools and evidence-based 
preventive interventions NIMH remains committed to supporting 
research on developing and validating tools and interventions 
for use in such settings, and also on identifying innovative 
and sustainable service delivery models to ensure that such 
tools and interventions are widely available.

    Question 4. FASD: During COVID, we have seen a sharp rise 
in substance misuse specifically alcohol, the most widely used 
and misused substance Unfortunately, a landmark NIH study in 
2018 established that 1 in 20 school-aged children are affected 
by fetal alcohol spectrum disorders--FASD Due to its 
significance and status as an overlooked disability that 
includes debilitating stigma, I introduced S 2238, the FASD 
Respect Act My legislation establishes common standards of care 
and increases the capacity to manage FASD in medical and mental 
health settings.

    Question 4(a). How can we address the social and 
environmental factors that contribute to prenatal alcohol 
exposure and reduce the traumas FASD creates for individuals 
and families?

    Answer 4. The risk for use of alcohol during pregnancy is 
influenced by a range of environmental and social factors such 
as social isolation, living in environments where alcohol 
misuse is common and accepted, and having limited resources for 
prenatal care Stigma can serve as a barrier to pursuing and 
receiving care for alcohol misuse or an alcohol use disorder as 
part of prenatal care This is particularly concerning given 
recent research indicating that during 2018--2020, 135 percent 
of pregnant adults in the United States reported current 
drinking, 52 percent reported binge drinking, and those with no 
routine health care provider or with frequent mental distress 
were more likely to consume alcohol The risk of an individual 
being born with a fetal alcohol spectrum disorder (FASD) is 
influenced by factors such as the level and frequency of 
alcohol exposure during prenatal development and when during 
prenatal development alcohol exposure occurs Maternal factors 
that can also influence this risk include inadequate nutrition 
and smoking or other substance use, among other factors In 
addition to the physical, cognitive, and other challenges 
individuals with FASD may face, stigma can be a barrier to 
seeking and receiving the health, educational, and professional 
care and support they need.

    Evidence-based prevention and treatment interventions, 
improved access to care, and substance misuse and mental health 
services integrated into routine health care are among the 
strategies needed to prevent and reduce prenatal alcohol 
exposure For children who are prenatally exposed to alcohol, 
widespread screening (including when screening for 
developmental disabilities), accurate diagnosis, early 
intervention, and access to support services are needed to 
improve the health and quality of life for individuals with 
FASD and their families.

    The National Institute on Alcohol Abuse and Alcoholism 
(NIAAA), part of the NIH, supports a broad research portfolio 
on the etiology, prevention, diagnosis, and treatment of FASD A 
major research program funded by NIAAA is the Collaborative 
Initiative on Fetal Alcohol Spectrum Disorders (CIFASD) with 
the goal to improve prevention of FASD, diagnosis of the full 
range of birth defects associated with prenatal alcohol 
exposure, and interventions for affected individuals One recent 
study includes the development and evaluation of mobile apps to 
give caregivers of children with FASD to help them learn new 
skills to manage their children's behavior and to provide 
adults with FASD tools to promote their own self-management and 
health advocacy goals.

    To facilitate widespread screening and early diagnosis of 
FASD, CIFASD researchers have developed three-dimensional 
photography and computerized image analysis that can enhance 
the detection of a broad range of alcohol-induced facial 
characteristics in children with prenatal alcohol exposure This 
approach is being refined and could improve access to FASD 
diagnosis in underserved regions Other projects are developing 
screening tools that distinguish neurobehavioral features 
associated with FASD from other neurodevelopmental conditions 
NIAAA-supported studies also focus on the use of novel 
methodologies such as 3D fetal ultrasound, blood-based 
biomarkers, and physiological measures to improve earlier 
identification of prenatal alcohol exposure and risk of 
neurodevelopmental delay among neonates, infants, or young 
children.

    Developing culturally appropriate approaches for the 
prevention of alcohol-exposed pregnancies also continues to be 
an important focus of NIAAA research For example, an ongoing 
study is conducting a randomized clinical trial of a culturally 
appropriate prevention program delivered via a smartphone app 
for urban American Indian and Alaska Native women ages 16-20 
This study is also examining the impact of the COVID-19 
pandemic on risk of alcohol-exposed pregnancy NIAAA-supported 
research is also evaluating the effectiveness of nutritional 
supplementation, administered prenatally and during childhood, 
to mitigate the adverse impact of prenatal alcohol exposure 
Studies have shown that screening, brief intervention, and 
referral to treatment (SBIRT) approaches are a significant tool 
for addressing alcohol and other substance use in primary and 
prenatal care settings NIAAA will continue to encourage alcohol 
SBIRT in these settings and provide resources to assist health 
care providers in improving care for patients with alcohol 
misuse, such as our Alcohol Treatment Navigator and soon-to-be 
launched Healthcare Professional's Core Resource on Alcohol.

    Moving forward, NIAAA will continue to encourage research 
on prevention and intervention approaches for FASD through 
funding opportunities \51\, \52\ Among the research topics of 
interest is advancing strategies to reduce stigmatization of 
biological mothers of children with FASD and individuals with 
FASD NIAAA will continue its overall effort in reducing 
alcohol-related stigma by promoting the use of non-stigmatizing 
language when describing alcohol-related issues and the people 
who experience them. \53\
---------------------------------------------------------------------------
    \51\  grantsnihgov/grants/guide/pa-files/PAR-21-097html
    \52\  grantsnihgov/grants/guide/pa-files/PAR-21-098html
    \53\  wwwniaaanihgov/alcohols-effects-health/reducing-alcohol-
related-stigma.

    Question 4(b). What steps are being taken by the 
administration to provide more education and training on FASD? 
How can stigma be lessened for individuals living with 
---------------------------------------------------------------------------
behavioral health conditions, like FASD?

    Answer 4(b). NIAAA sponsors and chairs the Interagency 
Coordinating Committee on FASD (ICCFASD) to foster improved 
communication, cooperation, and collaboration among Federal 
agencies that address issues related to prenatal alcohol 
exposure \54\ Several member agencies of ICCFASD have ongoing 
efforts aimed at improving education and training on FASD and 
reducing stigma for people living with FASD These agencies can 
be contacted for more information Examples of their educational 
efforts are:
---------------------------------------------------------------------------
    \54\  wwwniaaanihgov/interagency-coordinating-committee-fetal-
alcohol-spectrum-disorders

         LThrough its Collaborative for Alcohol-Free 
        Pregnancy, the Centers for Disease Control and 
        Prevention (CDC) works with multiple partner 
        organizations to educate healthcare professionals on 
        the risks of alcohol use during pregnancy and to equip 
        them to help their patients in preventing prenatal 
        alcohol use and identifying and caring for individuals 
        and families living with FASDs Disciplines represented 
        are family medicine, medical assisting, nursing, 
        obstetrics-gynecology, pediatrics, and social work CDC 
        and partners involved in the Collaborative have 
        developed and disseminated a wide range of online 
        courses on alcohol use during pregnancy and FASDs for 
        healthcare providers These free courses offer 
        continuing education and are available at wwwcdcgov/
        FASDtraining \55\
---------------------------------------------------------------------------
    \55\  nccdcdcgov/FASD/.

         LThe Administration for Children and Families 
        Children's Bureau in collaboration with the CDC support 
        the Prenatal Alcohol and Other Drug Exposures in Child 
        Welfare Study which explores the current knowledge, 
        attitudes, policies, practices, and needs of child 
        welfare agencies for identifying and caring for 
        children who were exposed to alcohol and other drugs 
        during pregnancy Findings from this study can be found 
        at https://wwwacfhhsgov/cb/report/prenatal-alcohol-
        drug-exposures-final-report and are being used to 
        inform the development of resources and tools for 
        professionals serving child welfare populations. \56\
---------------------------------------------------------------------------
    \56\  wwwacfhhsgov/cb/report/prenatal-alcohol-drug-exposures-final-
report.

         LCDC, in collaboration with March of Dimes, 
        developed the Beyond Labels Stigma Reduction 
        interactive website Designed for people who work in 
        health-related fields, this site helps users learn how 
        stigma can impact the healthcare and support women 
        need, seek, and receive during pregnancy The site 
        provides information on why stigma happens, stories 
        about the impact of stigma, and specific ways users can 
        become a change agent to reduce stigma in their 
        workplace or community This resource also offers a 
        specific module on stigma around substance use during 
---------------------------------------------------------------------------
        pregnancy.

         LThe Health Resources and Services 
        Administration's Maternal and Child Health Bureau 
        established the SAFEST Choice Learning Collaborative, a 
        primary care provider education and practice 
        improvement effort to reduce prenatal alcohol exposure 
        and improve outcomes in children with suspected or 
        diagnosed FASD. \57\
---------------------------------------------------------------------------
    \57\  wwwbmcorg/addiction/training-education/safest-choice
---------------------------------------------------------------------------

                             SENATOR SCOTT

    School closures have failed America's children, 
particularly students in marginalized communities whose 
families are living paycheck-to-paycheck From learning loss to 
mental health crises, the damaging effects of school closures 
on our Nation's children are undeniable.

    Because of this, I introduced the Kids in Classes Act, 
which would allow families with children in Title I schools to 
put unused Federal education funds toward in-person education, 
should their school close due to COVID-19 or a teachers union 
strike.

    You noted yourself in your testimony before this Committee 
that ``the effects on our youth, though still not full 
quantified, are substantial'' Based on your remarks, I think 
you would agree with me when I say that if we want to move 
forward, we must examine the long-term repercussions of COVID-
19 on students' academic and health outcomes.

    As such, I joined my colleagues on both sides of the aisle 
to introduce the Assessing Children's Academic Development and 
the Emotional and Mental Health Implications of COVID-19 
(ACADEMIC Act), which would help to better assess the impact of 
the pandemic on student outcomes and well-being I am hopeful 
this legislation will pass and am eager to see the results, but 
I am also interested in what the National Institute of Mental 
Health has found in its preliminary research.

    Question 1. Dr. Gordon, what impact do you think school 
closures have had on the youth mental health crisis we are 
facing?

    Answer 1. The COVID-19 pandemic has been challenging for 
many children, due to the fear of being infected, loss of 
economic, food, caregiver, or housing security, in addition to 
over 140,000 children losing at least one parent or caregiver 
to COVID-19 as of June 2021 \58\ Children are also facing 
challenges due to the cumulative social effects of hybrid and 
remote schooling and the need for physical distancing, which 
may leave some feeling less connected with their peers and 
teachers While early data indicate that school closures and 
other mitigation efforts were effective at significantly 
reducing the spread and mortality of COVID-19, \59\, \60\ 
school closures have also been associated with increased mental 
health symptoms among children \61\ It is currently unknown 
whether the benefits of school closures outweigh the drawbacks, 
\62\ and it will likely take years to fully understand the 
long-term effects of the COVID-19 pandemic and mitigation 
efforts.
---------------------------------------------------------------------------
    \58\  Hillis et al (2021), pubmedncbinlmnihgov/34620728/
    \59\  Liu et al (2021), pubmedncbinlmnihgov/34020613/
    \60\  Liyaghatdar et al (2021), pubmedncbinlmnihgov/34849394/
    \61\  Verlenden et al (2021), pubmedncbinlmnihgov/33735164/
    \62\  Mulligan (2021), pubmedncbinlmnihgov/34334835/.

    For more than one in three adolescents, schools provide 
primary access to mental health care \63\ Pandemic-related 
school closures and remote schooling may cutoff or limit access 
to these resources, leaving many youths disconnected from their 
primary sources of social support and mental health treatment 
As schools continue to navigate in-person and remote schooling, 
it will be important to consider ways to ensure that youth with 
or at risk for mental illnesses have access to the supports 
they need.
---------------------------------------------------------------------------
    \63\  Ali et al (2019), pubmedncbinlmnihgov/30883761/.

    NIH is funding research investigating evidence-based 
approaches for children to safely remain in school during the 
COVID-19 pandemic For example, NICHD manages the Safe Return to 
School Diagnostic Testing Initiative, launched in 2021 as part 
of the NIH Rapid Acceleration of Diagnostics-Underserved 
Populations (RADxSM-UP) program \64\ This initiative addresses 
the needs of children with unequal access to COVID-19 testing 
and who face barriers to attending school remotely, including 
those who do not have adequate equipment, internet access, or 
adult supervision at home The RADx-UP Return to School projects 
combine frequent COVID-19 testing with evidence-based safety 
measures to reduce the spread of SARS-CoV-2 \65\ Early results 
indicate that COVID-19 testing is feasible and acceptable in 
the school setting across a range of populations Furthermore, 
these community-engaged projects will aid in our understanding 
of the social, behavioral, and ethical implications of COVID-19 
testing implementation within underserved and vulnerable school 
communities.
---------------------------------------------------------------------------
    \64\  wwwnihgov/research-training/medical-research-initiatives/
radx/funding--radx-up-funded
    \65\  D'Agostino et al (2022), pubmedncbinlmnihgov/34737180/.

    Findings from a nationwide study of 1,290 parents of 
children aged 5-12 years conducted during October and November 
2020, suggest children not receiving full-time, in-person 
instruction and their parents ``might experience increased risk 
for negative mental/emotional and physical health outcomes'' 
\66\ Specifically----
---------------------------------------------------------------------------
    \66\  Verlenden et al (2021), https://pubmedncbinlmnihgov/33735164/

         LParents of children receiving virtual-only or 
        combined instruction more frequently reported that 
        their child's mental/emotional health worsened during 
        the pandemic and that their time outside, time in-
---------------------------------------------------------------------------
        person with friends, and physical activity decreased.

         LParents of children receiving virtual-only 
        instruction more frequently reported their own 
        distress, difficulty sleeping, loss of work, concern 
        about job stability, conflict between work and 
        providing childcare, and childcare challenges than did 
        parents whose children were receiving in-person only 
        instruction.

         LChildren receiving in-person instruction and 
        their parents reported the lowest prevalence of 
        negative indicators of child and parent well-being.

         LParents whose children attended school in-
        person only were less likely to report challenges with 
        employment and childcare.

    Moreover, findings from a similar nationwide survey of 567 
adolescents aged 13-19 years, conducted during October--
November 2020, suggested similar results: \67\
---------------------------------------------------------------------------
    \67\  Hertz et al (2022), https://pubmedncbinlmnihgov/34930571/

         LStudents attending school virtually reported 
---------------------------------------------------------------------------
        poorer mental health than students attending in-person.

         LRacial/ethnic disparities related to mode of 
        school instruction were noted, with virtual instruction 
        only more prevalent among Black (68 percent) and 
        Hispanic students (69 percent) compared to White 
        students (48 percent).

         LAdolescents receiving virtual instruction 
        reported more mentally unhealthy days, more persistent 
        symptoms of depression, and a greater likelihood of 
        seriously considering attempting suicide than students 
        in other modes (in-person or hybrid) of instruction.

         LAfter demographic adjustments, school and 
        family connectedness each reduced the strength of the 
        association between virtual versus in-person 
        instruction for all of the examined mental health 
        indicators

                           SENATOR TUBERVILLE

    Question 1. we know that one in four Americans reports 
having been a victim of crime in the past 10 years, and half of 
those were victims of a violent crime Most report receiving no 
help in the aftermath Police, corrections leaders, and the 
courts agree that untreated mental health or co-occurring 
substance abuse disorders are core drivers of the cycle of 
crime and that they lack the infrastructure to respond 
appropriately.

    Question 1(a). What do you see as the individual and 
societal impacts of untreated trauma as it relates to mental 
health and substance use disorder?

    Answer 1. Traumatic events include any shocking, scary, or 
dangerous event in which someone experienced, or was threatened 
with, death or serious injury, or witnessed the death or threat 
to the physical safety of others Without professional 
intervention, trauma is likely to result in negative mental and 
behavioral health consequences, including post-traumatic stress 
disorder, substance use, and substance use disorders (SUDs).

    Among people diagnosed with SUDs, a history of exposure to 
violence or other traumatic experiences is common, as are 
experiences of mental illnesses such as post-traumatic stress 
disorder SUDs also exacerbate the impacts of trauma exposure, 
with downstream effects on individuals, families, and society, 
including job loss, housing instability, fractured 
relationships, and legal system involvement Despite the known 
bidirectional, deleterious relationship between trauma and 
SUDs, a major gap exists in understanding how trauma history 
affects treatment seeking, treatment retention, and recovery 
from SUDs.

    NIMH supports clinical research focused on developing a 
deeper, more complete understanding of how exposure to 
traumatic stress affects individuals' mental health, with 
particular emphasis on youth and U.S. military service members, 
as these groups are disproportionately impacted by trauma As an 
example of NIMH-supported research in this area, a study of 
over 9,000 youths between the ages of 8 and 21 found that low 
socioeconomic status and the experience of traumatic stressful 
events were associated with alterations in neurodevelopment and 
cognition, as well as greater severity of psychiatric symptoms 
such as anxiety, depression, fear, externalizing behavior, and 
psychosis. \68\
---------------------------------------------------------------------------
    \68\  Gur et al (2019), pubmedncbinlmnihgov/31141099/.

    Similarly, NIDA continues to support studies at the 
intersection of substance use and trauma Current studies aim to 
adapt evidence-based interventions and test novel approaches 
tailored to individuals at the highest risk for comorbid SUDs 
and trauma-related stress, including people who have 
experienced interpersonal violence, multiple adverse childhood 
experiences, or racial trauma In addition, the HEALthy Brain 
and Child Development Study and the Adolescent Brain Cognitive 
Development (ABCD) Study, which NIDA respectively leads and co-
leads with other NIH Institutes, will substantially contribute 
to our understanding of healthy development and the impact of 
adverse childhood experiences on outcomes like substance use 
and post-traumatic stress, paving the way for new prevention 
---------------------------------------------------------------------------
and treatment interventions.

    Question 2. Federal data shows that 37 percent of people 
sentenced to prison, and 44 percent of people arrested and 
jailed, have experienced a mental health issue At the same 
time, we know that an estimated 1 in 10 police service calls 
are responding to an untreated mental health issue Across the 
country, we've seen community-based programs that seek to 
divert individuals experiencing mental health issues, direct 
individuals to treatment and resources, and do so in a way so 
the police department does not have to be involved.

    Question 2(a). What is the Federal Government doing to 
ensure that mental health emergencies are being responded to 
appropriately, early on, before a treatable illness becomes a 
safety issue?

    Answer 2. As noted by the Substance Abuse and Mental Health 
Services Administration, ``preventing mental and substance use 
disorders or co-occurring disorders and related problems is 
critical to behavioral and physical health'' \69\ NIMH shares 
this sense of urgency for ensuring that individuals 
experiencing or at high risk for a mental health emergency are 
able to receive effective, evidence-based interventions as 
early as possible NIMH aims to build the evidence base for 
effective interventions through research For example, NIMH 
recently supported a study designed to examine the 
effectiveness of a new police-to-mental-health linkage system 
that would provide opportunities for officers to involve a 
mental health professional immediately and directly during 
encounters with individuals with serious mental illness NIMH 
also supported a study aiming to evaluate alternative mental 
health crisis services that seek to reduce the incarceration of 
individuals with serious mental illnesses and provide 
alternatives to law enforcement in responding to mental health 
crises.
---------------------------------------------------------------------------
    \69\  wwwsamhsagov/find-help/prevention.

    As well, NIMH supports research focused on identifying 
individuals and populations most at risk for suicide, 
understanding the causes of suicide risk, developing suicide 
prevention interventions, and testing the effectiveness of 
these interventions and services in real-world settings Because 
many suicide decedents in the United States access health care 
services in the 12 months before their death by suicide, \70\ 
NIMH is prioritizing research on practices within health care 
settings that may identify individuals at risk for suicide. 
\71\
---------------------------------------------------------------------------
    \70\  Hedegaard et al (2021), wwwcdcgov/nchs/products/databriefs/
db398htm.
    \71\  wwwnimhnihgov/news/science-news/2020/nimh-leadership-
describes-suicide-prevention-research-priorities.
---------------------------------------------------------------------------
                                ------                                


  Response by Nora D. Volkow to Questions From Senator Casey, Senator 
                   Murkowski, and Senator Tuberville

                              SENATE CASEY

    Without a robust mental health and substance use disorder 
system of care, we are unfortunately asking law enforcement 
officers to be on the frontlines of addressing mental health 
and substance use crises In response, some communities have 
been developing programs like Crisis Assistance Helping Out on 
the Streets (or CAHOOTS) that divert mental health calls to 
mobile crisis teams staffed by a mental health professional 
along with an EMT or nurse.

    Question 1. What models of non-law enforcement mental 
health and substance use crisis interventions are effective and 
which would you want to see made available to communities 
across the country?

    Answer 1. When someone with a substance use disorder (SUD) 
or other mental health condition is in crisis--potentially at 
risk of suicide or overdose--and does not pose a threat to 
public safety, a response aimed at connecting the person to 
treatment should be available CAHOOTS and similar programs 
deploy mental health crisis teams to redirect the person toward 
essential healthcare and away from law enforcement resources in 
appropriate circumstances Given promising results to date, the 
White House Office of National Drug Control Policy has 
commissioned a model law, the Law Enforcement and Other First 
Responder Deflection Act, \1\ to make it easier for states to 
establish deflection programs Existing legislation in this area 
includes the National Suicide Hotline Designation Act of 2020 
which designates ``9-8-8'' as the universal telephone number in 
the United States for the national suicide prevention and 
mental health and substance use crisis hotline system; and new 
funding authorized under President Biden's American Rescue Plan 
to support community-based mobile crisis intervention services 
for persons with Medicaid \2\ In February 2020, NIH issued a 
Notice of Special Interest encouraging research on the full 
continuum of crisis service systems.
---------------------------------------------------------------------------
    \1\  legislativeanalysisorg/model-law-enforcement-and-other-first-
responder-deflection-act/
    \2\  https://wwwCongressgov/bill/116th-congress/senate-bill/2661/
text--overview--closed.

    In addition to crisis response, it is important to invest 
in preventive health programs to reduce the risk of crisis from 
occurring in the first place For this reason, NIH funds 
research to develop and test methods of delivering preventive 
care to people at high risk from substance use and other mental 
health issues For example, to reduce the risk of opioid 
overdose, the HEALing Communities StudySM aims to integrate SUD 
prevention and treatment across primary care, behavioral 
health, justice, and other community-based settings in 
communities hit hard by the opioid overdose epidemic This study 
is part of the NIH Helping to End Addiction Long-term (HEAL) 
Initiative and is funded by the National Institute on Drug 
Abuse (NIDA) and the Substance Abuse and Mental Health Services 
---------------------------------------------------------------------------
Administration (SAMHSA).

    Because individuals involved in the justice system are at 
particularly high risk of suicide and overdose, NIH supports 
research into interventions to reduce these risks For example, 
NIDA's Justice Community Opioid Innovation Network (JCOIN), 
funded by the HEAL Initiative, is testing strategies to expand 
treatment for opioid use disorder (OUD) in justice settings The 
National Institute of Mental Health (NIMH) is supporting 
research on interventions to reduce suicide risk among 
incarcerated youth as they transition to residential placement 
and probation, and among incarcerated adults as they re-enter 
their communities NIMH, the NIH Office of Behavioral and Social 
Sciences Research (OBSSR), and the National Institute of 
Justice (NIJ) are also funding a study to test whether a safety 
plan developed for and by at-risk adults during jail detention 
can reduce their suicide risk after release from jail.

    In addition to efforts to prevent and reduce drug use, NIDA 
supports research into harm reduction, which involves 
strategies to prevent overdose and infectious disease among 
people who use drugs One such strategy is to increase 
availability and use of naloxone, a medication that can rapidly 
reverse opioid overdose Through funds from the HEAL Initiative, 
NIDA plans to establish a Harm Reduction Network that aims to 
increase our understanding of the effectiveness, 
implementation, and impact of existing and new harm reduction 
strategies Projects are expected to begin as early as September 
2022.

                           SENATOR MURKOWSKI

                        Fentanyl Overdose Deaths

    Question 1. Overdose deaths from fentanyl are on the rise, 
including in Alaska, which saw deaths triple from 2019 to 2020 
The loss of a loved one impacts friends, families, and 
communities who continue to bear the trauma of addiction long 
after someone passes I have heard directly from Alaskans who 
have lost their children and are now dedicating their lives to 
prevent future overdose deaths from fentanyl.

    Unfortunately, this drug has a high lethality that can harm 
both the user and responder I was horrified to learn about five 
young men and women who overdosed on fentanyl-laced cocaine a 
couple weeks ago while on spring break in Florida What is 
particularly distributing, is that two of these young men 
didn't consume the substance, but were performing CPR on their 
friends when they went into respiratory arrest They were 
exposed to fentanyl while they were performing mouth-to-mouth 
resuscitation.

    Congress needs to take action before fentanyl claims one 
more American we need to start by educating people about the 
lethality of fentanyl and the risk of contaminated drugs.

    Question 1(a). Dr. Volkow, how can we raise awareness to 
ensure no good Samaritans are harmed when responding to a 
fentanyl overdose?

    Answer 1. Despite media reports alleging first responder 
exposures to fentanyl, the risks for secondhand fentanyl 
toxicity when rendering aid to a person who is experiencing 
overdose are very low Unfortunately, research shows that 
misinformation about risk from accidentally coming in contact 
with fentanyl is abundant among first responders The good news 
is that this study also shows that education shows greats 
promise in correcting these false beliefs \3\ ``Second-hand'' 
fentanyl exposure--eg, through mouth-to-mouth cardiopulmonary 
resuscitation (CPR)--has not been documented and is unlikely, 
given that once consumed, fentanyl is rapidly absorbed across 
mucous membranes into the blood \4\ Common preparations of 
fentanyl include liquid, pills, and powder that can be 
injected, ingested, or inhaled Inadvertent consumption of 
fentanyl by these routes, at a dose required for toxicity, 
would occur only in exceptional cases where a significant 
volume of drug powder, liquid, or aerosol becomes airborne \5\ 
For example, a 2010 medical report describes a veterinarian who 
became drowsy after accidentally splashing himself in the mouth 
and eyes with an animal tranquilizer that contained fentanyl 
\6\ and in 2017, the American College of Medical Toxicology 
(ACMT) and the American Academy of Clinical Toxicology (AACT) 
concluded that a person would have to breathe fentanyl at its 
highest airborne concentrations for 200 minutes to ingest a 
therapeutic does, which still would not be potentially fatal.
---------------------------------------------------------------------------
    \3\  del Pozo, et al Can touch this: training to correct police 
officer beliefs about overdose from incidental contact with fentanyl 
Health Justice 9, 34 (2021) https://doiorg/101186/s40352-021-00163-5
    \4\  Lhtsch, Walter, Parnham, et al (2012) Pharmacokinetics of Non-
Intravenous Formulations of Fentanyl Clin Pharmacokinet 52, 23--36
    \5\  Moss, Warrick, Nelson, et al (2017) ACMT and AACT Position 
Statement: Preventing Occupational Fentanyl and Fentanyl Analog 
Exposure to Emergency Responders J Med Toxicol 13(4): 347--351
    \6\  George, Lu, Pisano, et al (2010) Carfentanil--an ultra potent 
opioid Am J Emerg Med 28(4):530-532.

    Transdermal patches have become a familiar means of 
fentanyl delivery and unfortunately have been linked to 
accidental poisonings Yet these patches are designed to be 
firmly pressed to the skin and worn for many hours, with the 
fentanyl contained in a liquid or gel that aids absorption By 
contrast, accidental skin contact with fentanyl pills or powder 
is exceedingly unlikely to cause harm For instance, a study 
demonstrated that an extreme example of covering both palms of 
a person with fentanyl patches, each specifically designed to 
transmit high doses through skin (unlike powders or tablets), 
would take 14 minutes to reach clinically significant levels, 
\7\ leading the ACMT and AACT to conclude that it ``is very 
unlikely that small, unintentional skin exposures to tablets or 
powder would cause significant opioid toxicity, and if toxicity 
were to occur, it would not develop rapidly, allowing time for 
removal''.
---------------------------------------------------------------------------
    \7\  Rhodes & Phillips (2013) The surface area of the hand and the 
palm for estimating percentage of total body surface area: results of a 
meta-analysis Br J Dermatol 169(1):76-84.

    Despite the low probability of actual opioid toxicity, 
there are other reasons that responders at the scene of an 
overdose might report symptoms of possible exposure Responding 
to an overdose can be a stressful experience, even for 
emergency personnel, and observing known or suspected opioids 
at the scene can cause anxiety about exposure Indeed, analyses 
of responders who report potential exposure to opioids 
typically find no conclusive route of exposure and symptoms 
that are more consistent with anxiety (eg, dizziness, nausea, 
palpitations) than with opioid toxicity (eg, slowed breathing). 
\8\
---------------------------------------------------------------------------
    \8\  https://wwwcdcgov/niosh/topics/opioids/
fieldinvestigationshtml.

    Given the potency of synthetic opioids such as fentanyl and 
their increasing presence in the illicit drug supply, concerns 
about accidental exposure are understandable However, a person 
rendering standard aid to an overdose victim--including CPR or 
naloxone--has little danger of opioid toxicity More dangerous 
is the possibility that the person might decline to render aid 
based on fears about fentanyl exposure.

                     Medication Assisted Treatment

    Question 2. The Anchorage Daily News reported recently that 
the U.S. has passed a ``never-before-seen milestone'' in losing 
more than 100,000 Americans to drug overdoses in a year Sadly, 
the CDC reports that the number of drug overdoses in Alaska 
rose by more than 45 percent as of June 2021 That's more than 
double the rate of increase for the United States.

    One treatment that we know is critical to stemming the 
overdose crisis is medication that prevent withdrawal symptoms 
and stem opioid cravings These medications, like buprenorphine, 
can cut the risk of overdose death in half when a person starts 
taking them But, outdated Federal laws and stigma are 
restricting access to these life-saving medications I have 
introduced the Mainstreaming Addiction Treatment Act with my 
colleague, Senator Hassan, to help more Americans have access 
to life-saving medication and eliminate burdensome Federal red 
tape.

    Question 2(a). How is the administration supporting 
expanding access to medications to treat substance use disorder 
so they reach all communities in need?

    Answer 2. Methadone, buprenorphine, and naltrexone are 
effective for the treatment of OUD and the prevention of 
overdose deaths, but they are highly underutilized The 
Department of Health and Human Services (HHS) released the 
Overdose Prevention Strategy (OPS) in October 2021 to expand 
access to substance use prevention, treatment, harm reduction, 
and recovery support services.

    To identify best approaches to expand access to and speed 
the uptake of medications for OUD (MOUD) in diverse settings 
and diverse populations, NIDA funds implementation research in 
healthcare settings, justice settings, and community settings 
through the JCOIN, and the HEALing Communities Study These 
studies are evaluating strategies for expanding OUD screening 
and treatment into emergency departments, primary care clinics, 
infectious disease programs, rural and American Indian/Alaska 
Native communities, and criminal justice settings.

    NIDA also funds research on the provider-and systems-level 
barriers and facilitators to adoption of MOUD, particularly 
among people experiencing homelessness, women, and racial/
ethnic minority groups, as well as testing new strategies to 
expand MOUD access to pregnant people, rural areas, and 
justice-involved populations.

    Policy changes made at the beginning of the COVID-19 
pandemic have allowed people with OUD to obtain a 14-28 days' 
take-home supply of methadone, which particularly benefits 
people in rural areas or those who otherwise had trouble 
accessing treatment in the past NIDA-funded research is 
examining clinicians' and patients' experiences with telehealth 
services for the treatment of OUD and studying the 
implementation and outcomes of changes in OUD health services 
delivery policies This research will be critical for 
determining how to optimize access to effective MOUD through 
flexibilities in the provision of MOUD.

    Question 3. Infant and Early Childhood Mental Health: The 
first years of life are an incredible opportunity to promote 
positive mental health for babies, and health and well-being 
during this time period affects future learning, behavior and 
health.

    Question 3(a). Have you seen a marked impact by Federal 
investment in infant and early childhood mental health (IECMH)?

    Answer 3. NIMH supports biomedical research to understand 
the mechanisms that underlie neurodevelopment, and how typical 
and atypical development affects future learning, behavior, and 
mental health Novel biomarkers and behavioral indicators hold 
promise for identifying at the earliest possible point who is 
at risk, when development or aging is going off course, or 
which preventive and treatment interventions will produce the 
best outcomes for which individuals To identify promising 
targets for new interventions, studies of risk factors--
including those related to genetics, experience, and the 
environment--help provide clues to how mental disorders and 
developmental disorders emerge.

    NIMH-supported investigators found that early life stress, 
for example, can cause alterations in neural circuitry and 
impair social interactions later in life Other NIH-funded 
studies are examining measurements of sleep and brain activity 
related to mental health in children In addition, as a result 
of the growing focus on mental health during the COVID-19 
pandemic, NIMH is supporting research on COVID-19 mother and 
baby outcomes for brain and behavior function, as well as 
neurobehavioral consequences of COVID-19-related stressors on 
maternal mental health and infant and child neurodevelopment.

    NIMH is committed to supporting research to identify autism 
spectrum disorder (ASD) at the earliest age possible to enable 
early intervention and better long-term outcomes NIMH-funded 
researchers have demonstrated that differences in brain 
development and function (eg, eye gaze patterns, brain growth, 
and how different parts of the brain develop connections), as 
well as some subtle behavioral differences, emerge in the first 
months of life, before ASD symptoms begin to appear Building on 
these findings, NIMH is partnering with other NIH Institutes to 
support researchers developing and validating new screening 
methods for ASD that can be used in the first year of life For 
example, NIMH and the Eunice Kennedy Shriver National Institute 
of Child Health and Human Development (NICHD) supported 
researchers developed an eye-tracking app that successfully 
distinguished toddlers diagnosed with ASD from typically 
developing toddlers Study results indicate that an app-based 
approach could be used to screen infants and toddlers for ASD 
and refer them for early intervention when likelihood for 
treatment success is greatest (ie, at younger ages) In 
addition, a network of NIMH-funded researchers has tested 
different models of service engagement and coordination to 
determine how best to eliminate disparities in diagnosis, and 
how to diagnose children within underserved populations at 
earlier ages.

    In addition, NICHD is committed to supporting research to 
identify and examine the psychological and behavioral factors 
and processes that influence social/emotional development and 
expression in individuals with intellectual and developmental 
disabilities NICHD-funded researchers recently examined the 
role of behavioral and mindfulness-based interventions in 
promoting parent and child well-being in families with children 
demonstrating intellectual and developmental disabilities.

    Question 4. Suicide Screening in the Emergency Department: 
A recent CDC report on emergency department visits for people 
age 12-25 found an over 50 percent increase visits for 
suspected suicide attempts during early 2021 This underscores 
the devastating mental health impact of the pandemic on our 
youth and highlights yet another way that COVID-19 has strained 
our hospitals and medical staff.

    I introduced a bill, the Effective Suicide Screening and 
Assessment in the Emergency Department Act, to improve the 
screening and treatment of patients in hospital emergency 
departments who are at high risk for suicide It will make sure 
that we can better identify our most vulnerable mental health 
patients so they do not slip through the cracks when they are 
treated in hospitals, and make sure hospitals have the 
resources they need to provide these critical services.

    Question 4(a). What is the need for improved suicide 
screening protocols in the Nation's emergency rooms?

    Answer 4. Developing suicide risk screening tools and 
testing their effectiveness in real-world settings such as 
emergency departments (EDs) remains a high-priority research 
area for NIMH Approximately 80 percent of U.S. suicide 
decedents accessed health care services in the 12 months 
preceding their death, and nearly 30 percent had a health care 
visit in the week before suicide, demonstrating that health 
care systems can play a vital role in identifying individuals 
at risk and preventing suicide attempts. \9\
---------------------------------------------------------------------------
    \9\  Gordon, Avenevoli, and Pearson (2020) Suicide Prevention 
Research Priorities in Health Care JAMA Psychiatry 1;77(9):885-886.

    NIMH-funded researchers demonstrated that the use of brief 
screening tools in EDs can improve providers' ability to 
identify individuals at risk for suicidal behavior and refer 
them to treatment As one example, the NIMH-funded ED Safety 
Assessment & Follow-up Evaluation (ED-SAFE) study found that 
universal screening of ED patients doubled the rate of risk 
detection (from 3 percent to 6 percent), and that ED-initiated 
interventions reduced subsequent suicidal behavior by 30 
percent Additionally, NIMH-funded researchers developed the Ask 
Suicide-Screening Questions tool--a very brief (four-question) 
screening instrument that was shown to identify risk for 
suicide in pediatric emergency departments and has now been 
---------------------------------------------------------------------------
adapted for use across multiple other settings and populations.

    Question 4(b). Do you support efforts to bolster the 
resources available to emergency rooms so they can enhance 
their screening for high-risk suicide patients?

    Answer 4(b). Since emergency departments and other health 
care settings have a critical role in identifying and providing 
preventive interventions for individuals at risk of suicide, it 
is important that these settings have the resources they need 
to implement effective screening tools and evidence-based 
preventive interventions NIMH remains committed to supporting 
research on developing and validating tools and interventions 
for use in such settings, and also on identifying innovative 
and sustainable service delivery models to ensure that such 
tools and interventions are widely available.

    Question 5. FASD: During COVID, we have seen a sharp rise 
in substance misuse specifically alcohol, the most widely used 
and misused substance Unfortunately, a landmark NIH study in 
2018 established that 1 in 20 school-aged children are affected 
by fetal alcohol spectrum disorders--FASD Due to its 
significance and status as an overlooked disability that 
includes debilitating stigma, I introduced S 2238, the FASD 
Respect Act My legislation establishes common standards of care 
and increases the capacity to manage FASD in medical and mental 
health settings.

    Question 5(a). How can we address the social and 
environmental factors that contribute to prenatal alcohol 
exposure and reduce the traumas FASD creates for individuals 
and families?

    Answer 5. The risk for use of alcohol during pregnancy is 
influenced by a range of environmental and social factors such 
as social isolation, living in environments where alcohol 
misuse is common and accepted, and having limited resources for 
prenatal care Stigma can serve as a barrier to pursuing and 
receiving care for alcohol misuse or an alcohol use disorder as 
part of prenatal care This is particularly concerning given 
recent research indicating that during 2018--2020, 135 percent 
of pregnant adults in the United States reported current 
drinking, 52 percent reported binge drinking, and those with no 
routine health care provider or with frequent mental distress 
were more likely to consume alcohol The risk of an individual 
being born with a fetal alcohol spectrum disorder (FASD) is 
influenced by factors such as the level and frequency of 
alcohol exposure during prenatal development and when during 
prenatal development alcohol exposure occurs Maternal factors 
that can also influence this risk include inadequate nutrition 
and smoking or other substance use, among other factors In 
addition to the physical, cognitive, and other challenges 
individuals with FASD may face, stigma can be a barrier to 
seeking and receiving the health, educational, and professional 
care and support they need.

    Evidence-based prevention and treatment interventions, 
improved access to care, and substance misuse and mental health 
services integrated into routine health care are among the 
strategies needed to prevent and reduce prenatal alcohol 
exposure For children who are prenatally exposed to alcohol, 
widespread screening (including when screening for 
developmental disabilities), accurate diagnosis, early 
intervention, and access to support services are needed to 
improve the health and quality of life for individuals with 
FASD and their families.

    The National Institute on Alcohol Abuse and Alcoholism 
(NIAAA), part of the NIH, supports a broad research portfolio 
on the etiology, prevention, diagnosis, and treatment of FASD A 
major research program funded by NIAAA is the Collaborative 
Initiative on Fetal Alcohol Spectrum Disorders (CIFASD) with 
the goal to improve prevention of FASD, diagnosis of the full 
range of birth defects associated with prenatal alcohol 
exposure, and interventions for affected individuals One recent 
study includes the development and evaluation of mobile apps to 
give caregivers of children with FASD to help them learn new 
skills to manage their children's behavior and to provide 
adults with FASD tools to promote their own self-management and 
health advocacy goals.

    To facilitate widespread screening and early diagnosis of 
FASD, CIFASD researchers have developed three-dimensional 
photography and computerized image analysis that can enhance 
the detection of a broad range of alcohol-induced facial 
characteristics in children with prenatal alcohol exposure This 
approach is being refined and could improve access to FASD 
diagnosis in underserved regions Other projects are developing 
screening tools that distinguish neurobehavioral features 
associated with FASD from other neurodevelopmental conditions 
NIAAA-supported studies also focus on the use of novel 
methodologies such as 3D fetal ultrasound, blood-based 
biomarkers, and physiological measures to improve earlier 
identification of prenatal alcohol exposure and risk of 
neurodevelopmental delay among neonates, infants, or young 
children.

    Developing culturally appropriate approaches for the 
prevention of alcohol-exposed pregnancies also continues to be 
an important focus of NIAAA research For example, an ongoing 
study is conducting a randomized clinical trial of a culturally 
appropriate prevention program delivered via a smartphone app 
for urban American Indian and Alaska Native women ages 16-20 
This study is also examining the impact of the COVID-19 
pandemic on risk of alcohol-exposed pregnancy NIAAA-supported 
research is also evaluating the effectiveness of nutritional 
supplementation, administered prenatally and during childhood, 
to mitigate the adverse impact of prenatal alcohol exposure 
Studies have shown that screening, brief intervention, and 
referral to treatment (SBIRT) approaches are a significant tool 
for addressing alcohol and other substance use in primary and 
prenatal care settings NIAAA will continue to encourage alcohol 
SBIRT in these settings and provide resources to assist health 
care providers in improving care for patients with alcohol 
misuse, such as our Alcohol Treatment Navigator and soon-to-be 
launched Healthcare Professional's Core Resource on Alcohol.

    Moving forward, NIAAA will continue to encourage research 
on prevention and intervention approaches for FASD through 
funding opportunities Among the research topics of interest is 
advancing strategies to reduce stigmatization of biological 
mothers of children with FASD and individuals with FASD NIAAA 
will continue its overall effort in reducing alcohol-related 
stigma by promoting the use of non-stigmatizing language when 
describing alcohol-related issues and the people who experience 
them.

    Question 5(b). What steps are being taken by the 
administration to provide more education and training on FASD? 
How can stigma be lessened for individuals living with 
behavioral health conditions, like FASD?

    Answer 5(b). NIAAA sponsors and chairs the Interagency 
Coordinating Committee on FASD (ICCFASD) to foster improved 
communication, cooperation, and collaboration among Federal 
agencies that address issues related to prenatal alcohol 
exposure Several member agencies of ICCFASD have ongoing 
efforts aimed at improving education and training on FASD and 
reducing stigma for people living with FASD These agencies can 
be contacted for more information Examples of their educational 
efforts are:

         LThrough its Collaborative for Alcohol-Free 
        Pregnancy, the Centers for Disease Control and 
        Prevention (CDC) works with multiple partner 
        organizations to educate healthcare professionals on 
        the risks of alcohol use during pregnancy and to equip 
        them to help their patients in preventing prenatal 
        alcohol use and identifying and caring for individuals 
        and families living with FASDs Disciplines represented 
        are family medicine, medical assisting, nursing, 
        obstetrics-gynecology, pediatrics, and social work CDC 
        and partners involved in the Collaborative have 
        developed and disseminated a wide range of online 
        courses on alcohol use during pregnancy and FASDs for 
        healthcare providers These free courses offer 
        continuing education and are available at wwwcdcgov/
        FASDtraining.

         LThe Administration for Children and Families 
        Children's Bureau in collaboration with the CDC support 
        the Prenatal Alcohol and Other Drug Exposures in Child 
        Welfare Study which explores the current knowledge, 
        attitudes, policies, practices, and needs of child 
        welfare agencies for identifying and caring for 
        children who were exposed to alcohol and other drugs 
        during pregnancy Findings from this study can be found 
        at https://wwwacfhhsgov/cb/report/prenatal-alcohol-
        drug-exposures-final-report and are being used to 
        inform the development of resources and tools for 
        professionals serving child welfare populations.

         LCDC, in collaboration with March of Dimes, 
        developed the Beyond Labels Stigma Reduction 
        interactive website Designed for people who work in 
        health-related fields, this site helps users learn how 
        stigma can impact the healthcare and support women 
        need, seek, and receive during pregnancy The site 
        provides information on why stigma happens, stories 
        about the impact of stigma, and specific ways users can 
        become a change agent to reduce stigma in their 
        workplace or community This resource also offers a 
        specific module on stigma around substance use during 
        pregnancy.

         LThe Health Resources and Services 
        Administration's Maternal and Child Health Bureau 
        established the SAFEST Choice Learning Collaborative, a 
        primary care provider education and practice 
        improvement effort to reduce prenatal alcohol exposure 
        and improve outcomes in children with suspected or 
        diagnosed FASD.

                           SENATOR TUBERVILLE

    Question 1. In July 2017, you and Dr. Collins co-authored a 
paper entitled: ``The Role of Science in Addressing the Opioid 
Crisis'' That report states, ``The NIH will now work with 
private partners to develop stronger, longer-acting 
formulations of antagonists, including naloxone, to counteract 
the very-high-potency synthetic opioids that are now claiming 
thousands of lives each year''.

    Question 1(a). What innovation is still needed regarding 
these lifesaving medications given that at present, over 80 
percent of opioid overdose deaths have been linked to 
synthetics?

    Answer 1. Deaths involving synthetic opioids (like 
illicitly manufactured fentanyl), cocaine, and 
methamphetamine--as well as combinations of these drugs--have 
increased sharply in recent years Opioid overdose reversal 
agents may not be as effective when opioids, stimulants, 
alcohol or other substances are used in combination NIH and 
NIDA are supporting numerous studies across the therapeutics 
development pipeline to advance treatments for OUD and 
stimulant use disorder, and to develop novel therapeutics to 
treat co-intoxication with stimulants and opioids.

    The opioid overdose reversal medication, naloxone, still 
remains the most effective available agent to save the life of 
someone who is overdosing on opioids, but a recent study found 
that naloxone was not administered in 77 percent of 33,084 
opioid-involved overdose deaths in 2019 \10\ NIDA funds 
research to identify innovative ways to expand access to 
naloxone and promote its use, for example by identifying 
barriers and facilitators to naloxone access through pharmacies 
by testing the effectiveness of overdose education and naloxone 
distribution through churches in Black communities, and using 
simulation models to determine the best local strategies to 
distribute naloxone.
---------------------------------------------------------------------------
    \10\  Quinn, Kumar, Hunter et al (2022) Naloxone administration 
among opioid-involved overdose deaths in 38 United States jurisdictions 
in the State Unintentional Drug Overdose Reporting System, 2019 Drug 
and Alcohol Dependence Volume 235, 1 June 2022, 109467.

    Fifty-six percent of individuals who died from a fentanyl-
involved overdose had no pulse when first responders arrived 
\11\ Timely naloxone administration is critical, particularly 
for overdoses involving highly potent synthetic opioids, and 
because of naloxone's short duration of action, repeat doses 
may need to be administered in some cases NIDA-supported 
research led to FDA approval of KLOXXADO, a higher dose 
naloxone nasal spray formulation NIDA funds research on longer-
acting reversal agents, including methocinnamox (MCAM) and 
implants and injections containing nalmefene, which prevents 
opioid overdose during relapse Other NIDA-funded researchers 
have developed a small molecule intended to act like a sponge 
and clear drugs from the body; they are testing its ability to 
clear either fentanyl or methamphetamine NIDA is also funding 
research to develop antibodies against fentanyl that could be 
used to treat and prevent overdoses.
---------------------------------------------------------------------------
    \11\  O'Donnell, Tanz, Gladden, et al Trends in and Characteristics 
of Drug Overdose Deaths Involving Illicitly Manufactured Fentanyls--
United States, 2019--2020 MMWR Morb Mortal Wkly Rep 2021;70:1740-1746.

    One-third of fentanyl-involved overdose deaths occurred 
when a potential bystander was present who did not respond to 
the overdose (eg, person who overdosed was in a separate room 
of the same house, underscoring the need for innovative 
overdose reversal agents that can detect overdose and quickly 
administer reversal medication when individuals are alone or 
friends and family are unaware NIDA is funding the development 
of wearable devices and smartphone sensors that detect opioid-
induced respiratory depression and administer naloxone or 
---------------------------------------------------------------------------
summon help.

    NIDA plans to fund more research to develop new medications 
to prevent and treat OUD and opioid overdose, elucidate 
mechanisms of action of synthetic opioids, and understand the 
complexities, public health impacts, clinical characteristics, 
and treatment of opioid and polydrug use disorders involving 
fentanyl.

    Question 2. we know that one in four Americans reports 
having been a victim of crime in the past 10 years, and half of 
those were victims of a violent crime Most report receiving no 
help in the aftermath Police, corrections leaders, and the 
courts agree that untreated mental health or co-occurring 
substance abuse disorders are core drivers of the cycle of 
crime and that they lack the infrastructure to respond 
appropriately.

    Question 2(a). What do you see as the individual and 
societal impacts of untreated trauma as it relates to mental 
health and substance use disorder?

    Answer 2. Traumatic events include any shocking, scary, or 
dangerous event in which someone experienced, or was threatened 
with, death or serious injury, or witnessed death or a threat 
to the physical safety of others Without professional 
intervention, trauma is likely to result in negative behavioral 
health consequences, including post-traumatic stress disorder, 
substance use, and SUDs.

    Among people diagnosed with SUDs, a history of exposure to 
violence or other traumatic experiences is common, as are 
experiences of mental illnesses such as post-traumatic stress 
disorder SUDs also exacerbate the impacts of trauma exposure, 
with downstream effects on individuals, families, and society, 
including job loss, housing instability, fractured 
relationships, and legal system involvement Despite the known 
bidirectional, deleterious relationship between trauma and 
SUDs, a major gap exists in understanding how trauma history 
affects treatment seeking, treatment retention, and recovery 
from SUDs.

    NIMH supports clinical research focused on developing a 
deeper, more complete understanding of how exposure to 
traumatic stress affects individuals' mental health, with 
particular emphasis on youth and U.S. military service members, 
as these groups are disproportionately impacted by trauma As an 
example of NIMH-supported research in this area, a study of 
over 9,000 youths between the ages of 8 and 21 found that low 
socioeconomic status and the experience of traumatic stressful 
events were associated with alterations in neurodevelopment and 
cognition, as well as greater severity of psychiatric symptoms 
such as anxiety, depression, fear, externalizing behavior, and 
psychosis.

    Similarly, NIDA continues to support studies at the 
intersection of substance use and trauma Current studies aim to 
adapt evidence-based interventions and test novel approaches 
tailored to individuals at the highest risk for comorbid SUDs 
and trauma-related stress, including people who have 
experienced interpersonal violence, multiple adverse childhood 
experiences, or racial trauma In addition, the HEALthy Brain 
and Child Development Study and the Adolescent Brain Cognitive 
Development (ABCD) Study, which NIDA respectively leads and co-
leads with other NIH Institutes, will substantially contribute 
to our understanding of healthy development and the impact of 
adverse childhood experiences on outcomes like substance use 
and post-traumatic stress, paving the way for new prevention 
and treatment interventions.

    Question 3. Federal data shows that 37 percent of people 
sentenced to prison, and 44 percent of people arrested and 
jailed, have experienced a mental health issue At the same 
time, we know that an estimated 1 in 10 police service calls 
are responding to an untreated mental health issue Across the 
country, we've seen community-based programs that seek to 
divert individuals experiencing mental health issues, direct 
individuals to treatment and resources, and do so in a way so 
the police department does not have to be involved.

    Question 3(a). What is the Federal Government doing to 
ensure that mental health emergencies are being responded to 
appropriately, early on, before a treatable illness becomes a 
safety issue?

    Answer 3. As noted by the Substance Abuse and Mental Health 
Services Administration, ``preventing mental and/or substance 
use disorders or co-occurring disorders and related problems is 
critical to behavioral and physical health'' NIMH shares this 
sense of urgency for ensuring that individuals experiencing or 
at high risk for a mental health emergency are able to receive 
effective, evidence-based interventions as early as possible 
NIMH aims to build the evidence base for effective 
interventions through research For example, NIMH recently 
supported a study designed to examine the effectiveness of a 
new police-to-mental-health linkage system that would provide 
opportunities for officers to involve a mental health 
professional immediately and directly during encounters with 
individuals with serious mental illness in appropriate 
circumstances NIMH also supported a study aiming to evaluate 
alternative mental health crisis services that seek to reduce 
the incarceration of individuals with serious mental illnesses 
and provide alternatives to law enforcement when appropriate in 
responding to mental health crises.

    As well, NIMH supports research focused on identifying 
individuals and populations most at risk for suicide, 
understanding the causes of suicide risk, developing suicide 
prevention interventions, and testing the effectiveness of 
these interventions and services in real-world settings Because 
many suicide decedents in the United States access health care 
services in the 12 months before their death by suicide, NIMH 
is prioritizing research on practices within health care 
settings that may identify individuals at risk for suicide.
                                ------                                


    [Whereupon, at 11:50 am, the hearing was adjourned].

                                 [all]