[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
______
RESPONDING TO AMERICA'S OVERDOSE CRISIS: AN EXAMINATION OF LEGISLATION
TO BUILD UPON THE SUPPORT ACT
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
JUNE 21, 2023
__________
Serial No. 118-50
Published for the use of the Committee on Energy and Commerce
govinfo.gov/committee/house-energy
energycommerce.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
57-378 WASHINGTON : 2025
COMMITTEE ON ENERGY AND COMMERCE
CATHY McMORRIS RODGERS, Washington
Chair
MICHAEL C. BURGESS, Texas FRANK PALLONE, Jr., New Jersey
ROBERT E. LATTA, Ohio Ranking Member
BRETT GUTHRIE, Kentucky ANNA G. ESHOO, California
H. MORGAN GRIFFITH, Virginia DIANA DeGETTE, Colorado
GUS M. BILIRAKIS, Florida JAN SCHAKOWSKY, Illinois
BILL JOHNSON, Ohio DORIS O. MATSUI, California
LARRY BUCSHON, Indiana KATHY CASTOR, Florida
RICHARD HUDSON, North Carolina JOHN P. SARBANES, Maryland
TIM WALBERG, Michigan PAUL TONKO, New York
EARL L. ``BUDDY'' CARTER, Georgia YVETTE D. CLARKE, New York
JEFF DUNCAN, South Carolina TONY CARDENAS, California
GARY J. PALMER, Alabama RAUL RUIZ, California
NEAL P. DUNN, Florida SCOTT H. PETERS, California
JOHN R. CURTIS, Utah DEBBIE DINGELL, Michigan
DEBBBIE LESKO, Arizona MARC A. VEASEY, Texas
GREG PENCE, Indiana ANN M. KUSTER, New Hampshire
DAN CRENSHAW, Texas ROBIN L. KELLY, Illinois
JOHN JOYCE, Pennsylvania NANETTE DIAZ BARRAGAN, California
KELLY ARMSTRONG, North Dakota, Vice LISA BLUNT ROCHESTER, Delaware
Chair DARREN SOTO, Florida
RANDY K. WEBER, Sr., Texas ANGIE CRAIG, Minnesota
RICK W. ALLEN, Georgia KIM SCHRIER, Washington
TROY BALDERSON, Ohio LORI TRAHAN, Massachusetts
RUSS FULCHER, Idaho LIZZIE FLETCHER, Texas
AUGUST PFLUGER, Texas
DIANA HARSHBARGER, Tennessee
MARIANNETTE MILLER-MEEKS, Iowa
KAT CAMMACK, Florida
JAY OBERNOLTE, California
------
Professional Staff
NATE HODSON, Staff Director
SARAH BURKE, Deputy Staff Director
TIFFANY GUARASCIO, Minority Staff Director
Subcommittee on Health
BRETT GUTHRIE, Kentucky
Chairman
MICHAEL C. BURGESS, Texas ANNA G. ESHOO, California
ROBERT E. LATTA, Ohio Ranking Member
H. MORGAN GRIFFITH, Virginia JOHN P. SARBANES, Maryland
GUS M. BILIRAKIS, Florida TONY CARDENAS, California
BILL JOHNSON, Ohio RAUL RUIZ, California
LARRY BUCSHON, Indiana, Vice Chair DEBBIE DINGELL, Michigan
RICHARD HUDSON, North Carolina ANN M. KUSTER, New Hampshire
EARL L. ``BUDDY'' CARTER, Georgia ROBIN L. KELLY, Illinois
NEAL P. DUNN, Florida NANETTE DIAZ BARRAGAN, California
GREG PENCE, Indiana LISA BLUNT ROCHESTER, Delaware
DAN CRENSHAW, Texas ANGIE CRAIG, Minnesota
JOHN JOYCE, Pennsylvania KIM SCHRIER, Washington
DIANA HARSHBARGER, Tennessee LORI TRAHAN, Massachusetts
MARIANNETTE MILLER-MEEKS, Iowa FRANK PALLONE, Jr., New Jersey (ex
JAY OBERNOLTE, California officio)
CATHY McMORRIS RODGERS, Washington
(ex officio)
C O N T E N T S
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Page
Hon. Brett Guthrie, a Representative in Congress from the
Commonwealth of Kentucky, opening statement.................... 1
Prepared statement........................................... 4
Hon. Anna G. Eshoo, a Representative in Congress from the State
of California, opening statement............................... 6
Prepared statement........................................... 8
Hon. Cathy McMorris Rodgers, a Representative in Congress from
the State of Washington, opening statement..................... 10
Prepared statement........................................... 12
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 16
Prepared statement........................................... 18
Witnesses
Matthew Strait, Deputy Assistant Administrator, Diversion Control
Division, Drug Enforcement Administration, Department of
Justice........................................................ 20
Prepared statement........................................... 23
Submitted questions for the record \1\....................... 204
Christopher M. Jones, Phar.D., D.P.H., Director, National Center
for Injury Prevention and Control, Centers for Disease Control
and Prevention, Department of Health and Human Services........ 30
Prepared statement........................................... 32
Answers to submitted questions............................... 206
Tom Coderre, Acting Deputy Assistant Secretary for Mental Health
and Substance Use, Substance Abuse and Mental Health Services
Administration, Department of Health and Human Services........ 44
Prepared statement........................................... 46
Answers to submitted questions............................... 208
Diana Espinosa, Principal Deputy Administrator, Health Resources
and Services Administration, Department of Health and Human
Services....................................................... 69
Prepared statement........................................... 70
Answers to submitted questions............................... 213
Jonathan Blum, Principal Deputy Administrator and Chief Operating
Officer, Centers for Medicare & Medicaid Services, Department
of Health and Human Services................................... 69
Prepared statement........................................... 70
Answers to submitted questions............................... 217
----------
\1\ Mr. Strait did not answer submitted questions for the record by the
time of publication. Replies received after publication will be
retained in committee files and made available at https://
docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=116156.
Legislation \2\
H.R. 824, the Telehealth Benefit Expansion for Workers Act of
2023
H.R. 3892, the Improving Mental Health and Drug Treatment Act
H.R. 4091, the Combatting Substance Use Disorder Act
H.R. 3736, the Extending Access to Addiction Treatment Act
H.R. 4096, A bill to amend title XIX of the Social Security Act
to expand the application of Medicaid State programs to monitor
antipsychotic medications to all Medicaid beneficiaries
H.R. 4056, the Ensuring Medicaid Continuity for Children in
Foster Care Act of 2023
H.R. 3074, the Due Process Continuity of Care Act
H.R. 2400, the Reentry Act of 2023
H.R. 4089, the Safer Response Act
H.R. 4063, the FIND Fentanyl Act of 2023
H.R. 4079, the Substance Use Disorder Treatment and Recovery Loan
Repayment Program Reauthorization Act of 2023
H.R. 4100, To amend the Public Health Service Act to reauthorize
a monitoring and education program regarding infections
associated with illicit drug use and other risk factors
H.R. 4101, the Road to Recovery Act
H.R. 4099, the RECONNECTS Act of 2023
H.R. 4088, the CAREER Act
H.R. 1502, the Comprehensive Opioid Recovery Centers
Reauthorization Act of 2023
H.R. 4098, the Communities of Recovery Reauthorization Act
H.R. 4095, the Save Children from Trauma Act
H.R. 4097, the Mental Health Improvement Act
H.R. 1839, the Combating Illicit Xylazine Act
H.R. 4053, the Studying Suboxone Act
H.R. ___, To amend the 21st Century Cures Act to expressly
authorize the use of certain grants to implement substance use
disorder and overdose prevention activities with respect to
fentanyl and xylazine test strips
H.R. 4057, the Keeping Kids Safe Act
H.R. 4080, the Trauma-Informed Care Task Force Reauthorization
Act of 2023
H.R. 4092, the Protecting Moms and Infants Reauthorization Act
H.R. 4054, the Trauma Support and Mental Health in Schools
Reauthorization Act
H.R. 4093, the Remote Opioid Monitoring Act of 2023
H.R. 4007, the HEAL Act
Submitted Material
Inclusion of the following was approved by unanimous consent.
List of documents submitted for the record....................... 134
Letter of May 18, 2023, from the National Association of
Attorneys General, to Rep. Kevin McCarthy, et al............... 135
Letter of June 20, 2023, from Lori Teller, President, American
Veterinary Medical Association, et al., to Rep. Dick Durbin, et
al............................................................. 142
Letter of June 21, 2023, from National Association for Children's
Behavioral Health Board of Directors, Policy Committee, to Mr.
Bilirakis and Ms. Castor....................................... 146
Statement of Neely Frye, Director of Government Affairs,
Braeburn, June 21, 2023........................................ 148
Letter of June 20, 2023, from Elizabeth Hancq, Director of
Research, and Lisa Daily, Executive Director, Treatment
Advocacy Center, to Mr. Burgess and Rep. Ritchie Torres........ 152
Letter of June 20, 2023, from Andrew Hu, Director, Bipartisan
Policy Center Action, to Mrs. Rodgers, et al................... 153
Letter of June 15, 2023, from Brian M. Hepburn, Executive
Director, National Association of State Mental Health Program
Directors, to Mr. Burgess and Rep. Ritchie Torres.............. 157
----------
\2\ The bills have been retained in committee files and are available
at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=116156.
Letter of June 21, 2023, from Gordon Lavigne, Chief Executive
Officer, Schizophrenia & Psychosis Action Alliance, to Mr.
Burgess and Rep. Ritchie Torres................................ 158
Letter of June 20, 2023, from Jonathan Wolf, Chief Executive
Officer, Pyramid Healthcare, to Mrs. Rodgers, et al............ 160
Letter of May 31, 2023, from American Academy of Addiction
Psychiatry, et al., to Senator Bill Cassidy, et al............. 163
Letter of April 26, 2023, from Matthew D. Chase, Executive
Director and Chief Executive Officer, National Association of
Counties, et al., to Senator Charles Schumer, et al............ 167
Letter of June 21, 2023, from Sterling N. Ransone, Jr., Board
Chair, American Academy of Family Physicians, to Mr. Guthrie
and Ms. Eshoo.................................................. 169
Letter of June 20, 2023, from Edwin S. Jayne, Director of Federal
Government Affairs, AFSCME, to Mrs. Rodgers, et al............. 172
Letter of June 20, 2023, from Andrew Hu, Director, Bipartisan
Policy Center Action, to Mrs. Rodgers, et al................... 175
Letter of June 8, 2023, from A New PATH (Parents for Addiction
Treatment & Healing), et al., to Rep. Kevin McCarthy, et al.... 184
Letter of June 13, 2023, from Rep. David J. Trone, et al., to
Mrs. Rodgers and Mr. Pallone................................... 189
Letter of June 20, 2023, from Alsana, et al., to Mrs. Rodgers and
Mr. Pallone.................................................... 193
Letter of June 20, 2023, from Hannah Wesolowski, Chief Advocacy
Officer, National Alliance on Mental Illness, to Mr. Guthrie
and Ms. Eshoo.................................................. 196
Letter of June 21, 2023, from American Cancer Society Cancer
Action Network, et al., to Mrs. Rodgers and Mr. Pallone........ 198
Letter of June 20, 2023, from Matt Look, Chair, Anoka County
Board of Commissioners, to Mr. Guthrie, et al.................. 202
RESPONDING TO AMERICA'S OVERDOSE CRISIS: AN EXAMINATION OF LEGISLATION
TO BUILD UPON THE SUPPORT ACT
----------
WEDNESDAY, JUNE 21, 2023
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:00 a.m. in
room 2322, Rayburn House Office Building, Hon. Brett Guthrie
(chairman of the subcommittee) presiding.
Members present: Representatives Guthrie, Burgess, Latta,
Griffith, Bilirakis, Johnson, Bucshon, Carter, Dunn, Pence,
Crenshaw, Joyce, Harshbarger, Miller-Meeks, Rodgers (ex
officio), Eshoo (subcommittee ranking member), Sarbanes,
Cardenas, Ruiz, Dingell, Kuster, Kelly, Barragan, Craig,
Schrier, Trahan, and Pallone (ex officio).
Also present: Representatives Balderson, Schakowsky, and
Tonko.
Staff present: Sean Brebbia, Chief Counsel, Oversight and
Investigations; Jolie Brochin, Clerk, Health; Kristin Flukey,
Professional Staff Member, Health; Seth Gold, Professional
Staff Member, Health; Grace Graham, Chief Counsel, Health; Tara
Hupman, Chief Counsel; Emily King, Member Services Director;
Chris Krepich, Press Secretary; Molly Lolli, Counsel, Health;
Carla Rafael, Senior Staff Assistant; Michael Taggart, Policy
Director; Lydia Abma, Policy Analyst; Jacquelyn Bolen, Health
Counsel; Waverly Gordon, Deputy Staff Director and General
Counsel; Tiffany Guarascio, Staff Director; Saha Khaterzai,
Professional Staff Member; Una Lee, Chief Health Counsel; Andre
Rosario, Health Fellow; Tristen Tellman, Health Fellow; and
Rick Van Buren, Senior Health Counsel.
Mr. Guthrie. The subcommittee will come to order, and the
Chair recognizes himself for 5 minutes for an opening
statement.
OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF KENTUCKY
Today we are here to examine the SUPPORT Act and how its
implementation has helped increase access to prevention,
treatment, and recovery services. Since the passage of the
SUPPORT Act there have been several efforts to address issues
related to substance use disorder and drug overdoses, which
include Restoring Hope for Mental Health and Well-Being Act and
the HALT Fentanyl Act. This hearing will give us the
opportunity to see what legislation solutions have been working
and address any potential gaps.
Earlier this month we convened a field hearing in
Gettysburg, Pennsylvania, where we had the opportunity to hear
from addiction experts to learn about how policies from the
SUPPORT Act have helped in the fight against drug overdoses. We
heard heart-wrenching testimony from Michael Straley, who lost
his daughter Leah on Valentine's Day a few years ago to
fentanyl poisoning. Tragically, there are hundreds of thousands
of stories like Michael's.
In just the past 2 years, more than 200,000 Americans have
tragically lost their lives to drug overdoses driven by
synthetic opioids such as illicit fentanyl. In Kentucky, over
70 percent of all drug overdoses are caused by illicit
fentanyl. The evidence is clear that we have more work to do to
effectively curb historically high drug overdose rates, and it
is more important than ever that this committee recommit to
addressing this crisis.
Key to ensuring success will be a focus on prevention
efforts. One example of legislation we are considering today
would address the threat of xylazine, a tranquilizer routinely
used for animals that is quickly becoming one of the deadliest
street drugs. H.R. 1839, the Combat Illicit Xylazine Act, led
by Representative Pfluger, would subject individuals who
distribute these substances illegally to schedule III
penalties.
To supplement this work we are considering legislation to
allow Federal funding to be used for fentanyl and xylazine
testing strips in States where they are legal, and to help
ensure that all FDA-approved overdose reversal medications.
Prevention, however, must be coupled with policies that
promote access to care to help those who are currently
struggling with addiction. That is why we are considering
legislation today that will provide access to reliable care for
vulnerable populations, including providing for medication-
assisted treatment for Medicaid patients and treatment services
for foster care youth and for pregnant or postpartum women.
Of note, H.R. 3892, the Improving Mental Health and Drug
Treatment Act, will lift the IMD exclusion for residential and
inpatient services. The exclusion, which arbitrarily limits
access to residential care facilities with 16 or fewer beds,
has been a significant barrier to care for vulnerable
populations, including homeless populations and children that
are currently being boarded and treated in emergency
departments for severe mental illness and substance use
disorder, rather than able to get care in a clinically
appropriate setting. The legislation will ensure patients are
receiving the most appropriate and comprehensive care to
address their needs.
Thank you to Dr. Burgess for your historic leadership on
this important issue, and I look forward to moving this bill
forward.
We are also examining solutions that will promote long-term
recovery and wraparound services to support individuals'
journey to rehabilitate their lives. This includes my bill,
H.R. 1502, the Comprehensive Opioid Recovery Centers
Reauthorization Act, which reauthorizes the Comprehensive
Opioid Recovery Centers Program for 5 years. The CORCs Program
is responsible for providing wraparound treatment and recovery
support services, including workforce training, to individuals
living in communities with disproportionately drug overdose
rates.
I am proud of the early results of this program, and I
would like to thank Representatives Tonko, Bucshon, and Peters
for their partnership on this issue.
Before I close, I would like to touch on bills before us
that would attempt to support the behavioral health needs of
those moving in and out of the criminal justice system. There
is more we need to do to address access to the care for these
individuals so they can get the right care as they reenter the
communities. We are looking at two proposals before us today in
their current form. We need to make sure we don't do massive
cost-shifting from State spending to Federal spending without
first solving the problems at hand. So we need to look
carefully at the two bills before us today that do that.
I look forward to identifying long-term solutions that are
fiscally responsible and empower States to provide access for
care to incarcerated individuals. I look forward to continuing
the process to reauthorize the SUPPORT Act, and I thank my
colleagues for leading on these bipartisan policies.
[The prepared statement of Mr. Guthrie follows:]
Mr. Guthrie. And I yield back, and will recognize the
ranking member of the subcommittee, Ranking Member Eshoo, for 5
minutes for her opening statement.
OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Ms. Eshoo. Good morning, Mr. Chairman, and thank you for
yielding to me.
Good morning to our witnesses. Thank you for being here
today.
Over 1 million Americans died from COVID. Over 1 million
Americans have died from a drug overdose since 2000, including
nearly 110,000 overdose deaths in just the last year. About 300
Americans die every day from a drug overdose. These are jaw-
dropping figures.
Our country has had three waves of opioid deaths caused by
prescription opioids, heroin, and now illicit fentanyl.
According to the CDC, fentanyl poisoning caused 68 percent of
the overdose deaths in the past year.
Today our subcommittee considers 28 mostly bipartisan bills
to build on the 2018 SUPPORT Act to address the opioid crisis
by increasing access to treatment and improving overdose
prevention efforts.
To--I am sorry--a major contributing factor to overdoses is
difficulty finding treatment. According to SAMHSA, only 11
percent of people in our country with opioid use disorder
receive medication-assisted treatment. People in jails and
prisons are frequently denied treatment because of lack of
Medicaid coverage while incarcerated. People who are released
from jail and prisons are 12 times more likely to die of an
overdose than the general public. Bills by Representatives
Trone and Tonko address these inequities by expanding Medicaid
coverage during pretrial and the month before release.
Another barrier to accessing treatment is--are the
shortages of qualified health providers. According to HRSA,
more than 150 million Americans--150 million Americans, that is
almost half of our population--live in mental health provider
shortage areas, where the number of local providers cannot meet
the area's need for substance use treatment. To address these
shortages, we will consider legislation to continue grant
programs for opioid recovery centers, peer support workers, and
specialized treatment for pregnant and postpartum women with
substance use disorders, as well as for children recovering
from trauma.
We are also considering legislation to reform the
institutions for mental diseases exclusion, which restricts
Medicaid coverage for residential and inpatient behavioral
health services to facilities with fewer than 16 beds.
California, my home State, is currently benefiting from a
waiver to the IMD exclusion and is receiving Federal funding to
support quality inpatient treatment for substance use disorder.
Unintentional exposure to highly potent and fast-acting
fentanyl is driving overdose deaths. We know this. To help
prevent overdoses, we are considering the Test Strip Access Act
to provide access to strips that test drugs for deadly
chemicals like fentanyl and xylazine.
I look forward to hearing from each one of our witnesses
today from the CDC, CMS, HRSA--it is a real alphabet soup at
the table--CDC, CMS, HRSA, SAMHSA, and the DEA about their
whole-of-government effort to prevent overdose deaths, and your
recommendations for what else Congress should do to save lives.
It is really a tall order, but it must be addressed. These
statistics are really shameful. So thank you.
[The prepared statement of Ms. Eshoo follows:]
Ms. Eshoo. And I yield back, Mr. Chairman.
Mr. Guthrie. Thank you. The gentlelady yields back. I now
recognize the Chair of the full committee, Chair Rodgers, for 5
minutes for her opening statement.
OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON
Mrs. Rodgers. Thank you, Mr. Chairman.
Today we continue our work to address the opioid crisis, as
well as the despair addiction and increased suicides, as the
ranking member just said, to save lives.
This Congress, this committee has taken decisive actions to
keep Americans safe from the threats of illegal drugs. We held
two roundtables on the role that illicit fentanyl has played in
driving up overdoses and poisonings. We have had Biden
administration officials testify on the crisis at the first
Health Subcommittee hearing of this Congress. We held a field
hearing in Pennsylvania, where we heard from local law
enforcement and providers who are on the front lines of
responding to this crisis, and led on the HALT Fentanyl Act,
which passed the House with strong bipartisan vote.
And now it is time that we turn to strengthening the
SUPPORT Act, landmark legislation signed into law to bolster
treatment and recovery initiatives, improve prevention, and
fight fentanyl.
When this committee led the way on the SUPPORT Act 5 years
ago, there were about 70,000 overdose deaths per year, driven
by prescription opioids and other narcotics like heroin. Since
then, even though Congress has appropriated more than $20
billion to States for the substance use block grant and the
State Opioid Response block grant, the crisis has only gotten
worse. The Government enforced COVID-19 lockdowns, sent
millions of Americans who were on the road to recovery
backwards.
Additionally, the pandemic sent more people into despair
and isolation, driving them to take up illicit drugs for the
first time. We also saw a dramatic shift in the causes of
overdoses from prescription opioids to fentanyl poisonings, and
now other substances like tranqs. Together, these caused
overdose deaths to spike more than to 100,000 deaths per year,
more people than ever.
In my home State, overdose deaths have increased by 108
percent just since 2019. It is the second-largest increase in
the country.
To save lives and to give people hope, we must address the
root causes of this crisis. We need to cut off the supply of
illegal drugs and hold traffickers accountable. We need to
better warn Americans and young people that any drug could be
laced with fentanyl. We need to increase treatment options for
people in need, and we need to help those in recovery stay on
track and fully participate in their communities.
Many of our bills will build on what has worked to improve
access to care. This includes the Protecting Moms and Infants
Reauthorization Act, led by Representative Kim, to continue
support for residential substance use disorder treatment
services for pregnant and postpartum women.
The Safer Response Act, led by Representative D'Esposito,
would continue support for training related to fentanyl and
other illicit substances for first responders.
The Reconnect Act, led by Representative Griffith, would
continue support for the improvement of prescription drug
monitoring programs and other innovative projects related to
rapid response of controlled substance misuse and overdoses.
I also believe it is important to permanently lift
Medicaid's IMD exclusion so that we do not arbitrarily limit
access to care for those who need it most. Advocates from every
level of State and local government, as well as key
associations that represent people with substance use disorder
and mental health needs, support lifting the IMD exclusion as
well. These supporters recognize that when a patient needs help
and is ready to seek treatment, we should not be denying them
support at the level of care that works best for them. It is
time to end this prohibition once and for all.
Before I close, I would like to note my concerns on the
Reentry Act and the Due Process Continuity of Care Act. I
support the goal of ensuring people who are incarcerated have
the tools to safely reenter their communities and get the care
they need. This is why I have supported policies in the past,
like from Congressman Hudson, that helped children who are
incarcerated receive necessary treatments.
However, I have reservations about the bills in their
current forms, and believe that we need to know first what
barriers exist for States, localities, and the Bureau of
Prisons from providing care, which they are all required to do.
Overall, I want to thank you, thank all my colleagues who
are leading on solutions today. This crisis has hit every
community. We all know people and families who need to be
rescued from despair. And for them we must keep working
together to ensure these solutions provide the support and
tools that people need to find meaning, purpose, and the chance
for a better life. That is how we restore hope and bring
healing across America.
[The prepared statement of Mrs. Rodgers follows:]
Mrs. Rodgers. Thank you, I yield back.
Mr. Guthrie. Thank you. The Chair yields back. I now
recognize the ranking member of the full committee, Mr. Pallone
from New Jersey, for 5 minutes for an opening statement.
OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman.
In 2018 this committee came together in strong bipartisan
fashion to pass the SUPPORT Act to address the ongoing opioid
epidemic. Over the last 5 years, this law has expanded
treatment options in Medicare and Medicaid, allowed more
providers to prescribe medication-assisted treatment, and made
important investments in public health.
Today we are considering a number of bills to help further
address the ongoing opioid epidemic, including bills to
reauthorize critical programs included in the SUPPORT Act.
Ongoing action is necessary because, tragically, nearly 110,000
Americans died last year of drug overdoses. I am especially
hopeful that this will be the year that we are able to move
H.R. 2400, the Medicaid Reentry Act, out of the committee and
have it signed into law.
This bill would build on the bipartisan work we did last
Congress by enabling eligible individuals to enroll in Medicaid
30 days prior to their release from incarceration. Researchers
have found that people recently released from incarceration are
10 times more likely to overdose on opioids than the general
public. Many times, these individuals can struggle to access
care upon their release, making them more likely to delay
seeking treatment.
Allowing eligible people to enroll in Medicaid prior to
their release will help connect them to coverage upon their
discharge. This will help smooth their transition back into the
community because they are able to access the services they
need. I hope we can finally move this bill forward and give
States the tools they need to support incarcerated individuals
in recovery.
I am also pleased that we are considering bipartisan
legislation that would reauthorize several important provisions
from the SUPPORT Act that strengthen the ability of communities
to respond to the opioid epidemic. We will be discussing bills
to reauthorize programs to train first responders, support
recovery centers, and bolster the behavioral health workforce.
Other programs up for reauthorization would expand
treatment for pregnant and postpartum women, connect schools
with mental health services, and continue an important task
force on trauma care.
We will also consider legislation to expand access to
lifesaving resources such as fentanyl and xylazine test strips,
and to have HHS and DEA reexamine the evidence regarding the
important treatment options like Suboxone. I don't know if I am
pronouncing this correctly. Together, these bills will help us
combat the opioid epidemic.
I am hopeful that these bipartisan policies can move
through our committee process, but I am disappointed that the
majority has also chosen to include several bills that are
problematic. I am particularly concerned about proposals that
would create financial incentives to institutionalize
individuals with substance use disorders. Rather than simply
warehousing these individuals, Congress should provide States
with the resources to expand provider capacity and expand
access to services in home and community-based settings.
I am also--I also question why we are considering
legislation that would permanently extend the option for States
to cover short-term stays in an institution for mental disease,
or IMD. I was skeptical of this policy when it was passed 5
years ago. In the years since, the response from States has
been underwhelming. Currently, I am aware of only two States
that have taken up this option. We should acknowledge that this
policy has not lived up to the expectations of its supporters,
and not look to permanently extend it.
I have also concerns with H.R. 824, which would allow
employers to offer telehealth as a separate, standalone policy
exempt from the Affordable Care Act's critical consumer
protections. I believe this bill is a solution in search of a
problem. Employers already have the flexibility to offer
telehealth to their employees. I am concerned that this bill
would instead expand a form of insurance that is not subject to
the ACA's consumer protections.
These insurance plans are also not subject to mental health
parity, and can be deceptively marketed to Americans as
comprehensive coverage. I worry that if we expand these plans,
American families will be left with inadequate coverage and at
risk of surprise medical bills.
And finally, I am troubled by the inclusion of H.R. 1839,
the Combating Illicit Xylazine Act. I understand that xylazine
is a growing problem. Doing an end run around the interagency
process for scheduling controlled substances is not the answer.
I am concerned about the precedent of Congress attaching
criminal penalties to a drug that is not scheduled.
I understand that access to legitimate veterinary and
agricultural uses of xylazine needs to be preserved. But this
should not--this should be handled through the administrative
process, not by Congress picking and choosing drugs to apply
criminal penalties to--by statute.
Now, everyone in this room is far too familiar with the
tragic consequences of the opioid epidemic. While we have seen
some improvements, there is still a long way to go, and I am
hopeful that we will be able to find bipartisan solutions to
ensure that our States, cities, and first responders have the
resources they need.
Thank you, Mr. Chairman.
[The prepared statement of Mr. Pallone follows:]
Mr. Guthrie. Thank you. The gentleman yields back, and that
concludes opening statements. We will now move to our
witnesses' opening statements.
All of you have testified before. You have 5 minutes for
your opening statement, and there will be a yellow light, 1
minute, and so--kind of rounding up, and then after, red, it
means your time has expired.
I will introduce our witnesses together, and then I will go
back and call on each one of you individually to do your
testimony.
First we have Mr. Matthew Strait, Deputy Assistant
Administrator for the DEA Office of Diversion Control.
Dr. Christopher Jones, Director of the National Center for
Injury Prevention and Control for the CDC.
We have Mr. Tom Coderre, Acting Deputy Assistant Secretary
for Mental Health and Substance Abuse.
Ms. Diana Espinosa, a Principal Deputy Administrator of the
Health and Human Health Resources and Services Administration
and Acting Deputy Assistant Secretary for Mental Health and
Substance Abuse.
And Mr. Jonathan Blum, the Principal Deputy Administrator
and Chief Operating Officer for the Centers for Medicare &
Medicaid Services.
So thank you all for being here. We look forward to your
testimony.
And Mr. Strait, you are recognized for 5 minutes for your
opening statement.
STATEMENTS OF MATTHEW STRAIT, DEPUTY ASSISTANT ADMINISTRATOR,
DIVERSION CONTROL DIVISION, DRUG ENFORCEMENT ADMINISTRATION,
DEPARTMENT OF JUSTICE; CHRISTOPHER M. JONES, Phar.D., D.P.H.,
DIRECTOR, NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL,
CENTERS FOR DISEASE CONTROL AND PREVENTION, DEPARTMENT OF
HEALTH AND HUMAN SERVICES; TOM CODERRE, ACTING DEPUTY ASSISTANT
SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH
AND HUMAN SERVICES; DIANA ESPINOSA, PRINCIPAL DEPUTY
ADMINISTRATOR, HEALTH RESOURCES AND SERVICES ADMINISTRATION,
DEPARTMENT OF HEALTH AND HUMAN SERVICES; AND JONATHAN BLUM,
PRINCIPAL DEPUTY ADMINISTRATOR AND CHIEF OPERATING OFFICER FOR
THE CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF
HEALTH AND HUMAN SERVICES
STATEMENT OF MATTHEW STRAIT
Mr. Strait. Full committee Chairman McMorris Rodgers,
Chairman Guthrie, ranking member of the full committee Mr.
Pallone and Ranking Member Eshoo and distinguished members of
the committee, on behalf of DEA Administrator Anne Milgram and
the nearly 10,000 men and women of the Drug Enforcement
Administration, I am honored to be here today to discuss DEA's
efforts to implement important changes to the Controlled
Substances Act resulting from passage of the SUPPORT Act.
The latest provisional overdose death statistics from our
partners at CDC show that the U.S. lost an estimated 109,680
Americans for the 12-month period ending in December of 2022.
Fentanyl is involved in roughly two-thirds of those deaths, and
we refer to these deaths as poisonings because illicit fentanyl
is a poison. I am reminded of this every day as I pass through
the halls of DEA, where we have displayed the images of more
than 2,600 Americans lost. These individuals are the faces of
fentanyl.
These poisons are being produced primarily in the--by the
Sinaloa and Jalisco cartels in the form of fake pills.
According to DEA's forensic analysis of seized pills, 6 of 10
contain a lethal dose. The appearance of Xylazine, an animal
tranquilizer encountered in 48 States, adds complexity to our
response and increases harm to users.
While naloxone can reverse the respiratory depressive
effects of fentanyl, it will not reverse the same effects
produced by xylazine. Fentanyl mixed with xylazine is an
emerging threat in the United States and is the reason why we
must place schedule I controls on fentanyl-related substances
and improve regulations for xylazine.
The simple fact is that any pill which a person obtains
outside of a licensed pharmacy could contain a lethal dose of
fentanyl, could contain a lethal dose of methamphetamine,
cocaine, or a combination thereof. Teens who order a pill on a
smartphone, college students who take a pill from a friend,
elderly neighbors searching online for a painkiller, or
patients who develop the disease of addiction--these vulnerable
Americans are victims of predatory criminal drug networks.
Within the DEA, the Diversion Control Division, where I
have spent the majority of my 24-year career, is responsible
for preventing, detecting, and investigating the diversion of
controlled prescription medications from our more than 2
million registrants. Beyond this essential role of protecting
the safety of Americans from the improper prescribing and
misuse of prescription drugs.
And similar to the mission of the individuals sitting with
me today, I continue to dedicate my career towards efforts
aimed at addressing our equally important public health role.
That is to ensure that there is an adequate and uninterrupted
supply of controlled prescription medications to meet the
medical, scientific, and research needs of the U.S. It is that
mission, embodied by changes to the CSA resulting from passage
of the SUPPORT Act in 2018, where I hope to focus today's
discussion. I am happy to be here with my Federal partners to
explain the steps DEA is taking to ensure that patients in need
of vital medicines have safe and ready access.
On the top of this list is DEA's full support to improve
and expand access to important treatment drugs like
buprenorphine and methadone. This includes next week's
implementation of the MATE Act, as well as the repeal of the X
waiver for prescribing buprenorphine. It includes our efforts
to facilitate induction of new patients on buprenorphine, using
telemedicine and ongoing efforts to improve access to MOUD in
carceral settings.
We are also working to ensure Americans in underserved
areas have access to healthcare. We are considering changes to
regulations in response to the more than 38,000 comments we
received on two draft telemedicine rules published in March.
And we will establish clear and simplified rules with
guardrails for the prescribing of controlled substances.
We continue to work in close collaboration with the FDA,
manufacturers, and distributors to understand the causes for a
growing list of drug shortage reports from patients regarding
amphetamine-based pharmaceutical products, primarily generic
Adderall, used in the management of ADHD.
And finally, we have done tremendous work to ensure
schedule I controlled substances, including marijuana, MDMA,
and psilocybin are available to our 842 researchers from a
growing list of domestic sources.
Thank you for the opportunity to be here today, and I look
forward to your questions.
[The prepared statement of Mr. Strait follows:]
Mr. Guthrie. Thank you. Thank you for your testimony.
The Chair now recognizes Dr. Christopher Jones for your
opening statement.
STATEMENT OF CHRISTOPHER M. JONES, Phar.D., D.P.H.
Dr. Jones. Thank you, Chair, Chair Guthrie, Ranking Member
Eshoo, and distinguished members of the committee. Thank you
for the opportunity to be here today to discuss the CDC's
efforts authorized by the SUPPORT Act to address our Nation's
overdose crisis.
This crisis has profoundly impacted our Nation. CDC's most
recent data show that 300 Americans are dying each day from
overdose, and many millions more struggle with substance use.
The historic increases we have seen in overdose deaths in
recent years are facilitated by a rapidly changing and highly
lethal drug market saturated with illicitly made fentanyl and
the resurgence of stimulants like methamphetamine.
The ever-changing drug landscape continues to present
emerging and novel threats to the health of our Nation. And
behind these statistics are individuals, families, and
communities that have been deeply impacted. However, we remain
resolute in our belief that we can alter the trajectory of this
crisis. At CDC we are working urgently to save lives today,
while also building a strong foundation of prevention to
protect future generations.
CDC prioritizes five strategies that align with the HHS
overdose prevention strategy: monitoring, analyzing, and
communicating trends; building State, Tribal, local, and
Territorial capacity; supporting providers, health systems,
payers, and employers; partnering with public safety and
community organizations; raising public awareness and reducing
stigma.
CDC invests in communities across the country to the
national program Overdose Data to Action, or OD2A, that
supports the critical work being done by health departments in
our country. This program is improving fatal and nonfatal
overdose data collection, analysis, and dissemination,
advancing prescription drug monitoring programs and other
health system innovations, and driving targeted prevention
efforts tailored to individual community needs.
Building on knowledge gained from the OD2A program over the
past 4 years, CDC will fund 2 new programs this fall. Overdose
Data to Action in States will fund State health departments to
continue expanding innovative data efforts while implementing
prevention activities to decrease fatal and nonfatal overdoses
and related harms. And through a second program, OD2A: LOCAL,
CDC will provide direct funding to up to 40 city, county, and
Territorial health departments to directly advance their local
overdose prevention efforts.
In addition, CDC continues to advance innovative
partnerships through multiple public health and public safety
collaborations, partners with health systems to improve
upstream prescribing and pain care, enhance linkage to care and
services, and reduce stigma among clinicians.
CDC also strengthens national laboratory capacity by
developing tests and reference materials on synthetic opioids,
stimulants, and other drug threats for clinical and public
health labs.
We have also made great strides in improving the timeliness
and completeness of drug overdose death certificate data,
working closely with vital records offices and medical
examiners and coroners across the country. These activities are
complemented by other work at CDC, focusing on specific at-risk
populations. This includes efforts to prevent and respond to
infections commonly associated with illicit drug use like HIV
and viral hepatitis; preventing prenatal substance use and
related harms by improving data collection on neonatal
abstinence syndrome; establishing a data network to examine
outcomes associated with MOU receipt during pregnancy; and
connecting mothers and babies with needed services.
Moving forward, flexibility to address emerging threats and
new drug threats is paramount so CDC can quickly scale support
to jurisdictions and help health departments and communities
adapt strategies to meet their needs.
Finally, preventing substance use in the first place is a
core component of CDC's work and the long-term solution to
reversing the overdose crisis. Adverse Childhood Experiences,
or ACEs, are potentially traumatic events that occur in
childhood, such as witnessing or experiencing violence, growing
up in a family with substance use or mental health challenges,
or losing a parent to overdose. Research consistently shows
that ACEs are strongly linked to future risk for substance use
and addiction, mental health challenges, and suicide. And CDC
is working to strengthen ACEs data collection and supporting
efforts in communities to prevent ACEs and promote positive
childhood experiences. By addressing these root drivers, we
have a real opportunity to get ahead of the mental health and
substance use challenges facing our Nation.
For far too long, the tragic consequences of substance use
and overdose have devastated families and communities across
our country. As a person in long-term recovery, I know
firsthand the devastation and pain that addiction can inflict.
But I have also experienced the transformative power of
recovery. CDC is committed to continuing using data, science,
innovation, and collaboration as part of a whole-of-government
effort to save lives and bring it into our overdose crisis
Thank you for the opportunity to be here. I look forward to
your questions.
[The prepared statement of Dr. Jones follows:]
Mr. Guthrie. Thank you. I thank you for your testimony.
The Chair now recognizes Mr. Coderre for 5 minutes for your
opening statement.
STATEMENT OF TOM CODERRE
Mr. Coderre. Thank you, Mr. Chairman and Ranking Member
Eshoo, for inviting me to testify before you today. My name is
Tom Coderre, and I serve as the Acting Deputy Assistant
Secretary for Mental Health and Substance Abuse at the
Substance Abuse and Mental Health Services Administration.
I would like to start today by sharing a short story with
you. This story is about a man who came from a loving family
and had many friends. He was deeply involved in his community,
enjoyed politics and policy, and was elected to the State
senate at 25 years old. By 30 he had risen in his career to
become the executive director of a large nonprofit agency. On
the outside, everything about this man's life looked normal.
Some would even say ideal.
However, on the inside he was tortured. So he turned first
to alcohol and then to other drugs to cope with the stress in
his life. Underestimating the power of these substances and
unaware of the neurological consequences, he became addicted
and his life began to unravel. He started to lose the things
that were most important to him. When his family and friends
tried to help, he resisted their help and he pushed them away.
This caused him to lose them.
He lost his job and his position in the senate. His health
deteriorated. He lost his apartment and became homeless. He
lost his spirit. In the end, he lost everything, even his
desire to live. This man's life, which at one time was so full
of hope, became hopeless.
I know this story well because it is mine. Fortunately, I
was able to get the help that I needed. And today I am a person
in long-term recovery--just look at my friend, Dr. Jones--
which, for me, means I haven't been able to use alcohol or
drugs since May 15 of 2003. During these 20 years in recovery,
my life has improved dramatically. Being in recovery has not
only enabled me to create a better life for myself, but it has
also enabled me to create a better life for my family and my
entire community.
With help, people can and do recover from substance use
disorders. I am here today not only representing SAMHSA, but I
am one of the more than 20 million Americans who have resolved
their issues with substances.
Unfortunately, too many people do not have stories as
hopeful as mine. In January SAMHSA released the latest National
Survey on Drug Use and Health, which estimates that 46.3
million people in this country had a substance use disorder.
SAMHSA's charge is to ensure that every one of them can get
evidence-based treatment to continue to support their success
once they enter recovery, and to work to prevent others from
starting down that dangerous path. That is why SAMHSA focuses
on the full range of the care continuum: prevention,
intervention, treatment, and recovery support.
My written testimony goes into more details than the time I
have today, so I just want to comment briefly on two programs
established or enhanced by the SUPPORT Act, the topic of
today's hearing. I am grateful to the Members of Congress who
have led this critical effort, to the members of this committee
for their support and their attention to this work today.
Among the many important programs authorizing the SUPPORT
Act, the law's enhanced funding for first responder training
for opioid overdose reversal drugs has provided resources to
rescue individuals at the brink of death by preventing opioid
overdoses. This program provides resources for first responders
and members of other key community sectors to administer FDA-
approved emergency treatment for known or suspected opioid
overdose.
During the program's recent grant period, grantees
distributed more than 340,000 naloxone kits with grant funds
and administered naloxone more than 157,000 times. By the end
of 2022, grantees had also conducted over 41,000 trainings and
trained more than 188,000 individuals on how to respond to
opioid-related incidents.
At the other end of the continuum, the Treatment Recovery
Workforce Support Program established by the SUPPORT Act
provides the resources so that people in recovery can find
stability, live independently, and participate in the
workforce. Grantees provide treatment or recovery services for
individuals with substance use disorders and partner with one
or more local or State entities to provide a broad range of
support services.
In fiscal year 2022, the modest program helped over 1,600
people stay in recovery, attend school and/or work, and achieve
permanent residence in their communities. These crucial SAMHSA
programs, along with many others in the SUPPORT Act, are up for
reauthorization. These programs are making a difference in
people's lives in States and communities across our Nation.
So thank you for the opportunity to appear before you today
and for your dedication to this issue.
[The prepared statement of Mr. Coderre follows:]
Mr. Guthrie. Thank you. Thank you for your testimony.
Ms. Espinosa, you are recognized for 5 minutes for your
opening statement.
STATEMENT OF DIANA ESPINOSA
Ms. Espinosa. Chairman Guthrie, Ranking Member Eshoo, and
members of the subcommittee, thank you for the opportunity to
discuss the Health Resources and Services Administration's
efforts to expand access to substance use disorder treatment
and prevention services and to grow the behavioral health
workforce.
My name is Diana Espinosa, and I serve as the Principal
Deputy Administrator of HRSA, the agency that supports
delivering healthcare in the Nation's highest-need communities,
building the health workforce, improving maternal and child
health, and meeting the healthcare needs of rural America.
I would like to begin by thanking the members of the
subcommittee. With your help we have made meaningful gains in
expanding behavioral health services and training more
providers. Through the SUPPORT Act, HRSA launched the Substance
Use Disorder, Treatment, and Recovery, or STAR, Loan Repayment
Program to recruit and retain clinicians and paraprofessionals
who provide direct treatment and recovery support for patients.
The program repays the educational loans of providers who
deliver 6 years of full-time service in communities with the
highest overdose rates in the country.
Today, across the United States, 445 clinicians and
community health workers are providing direct treatment and
recovery support to patients through this program. And by the
end of the fiscal year, that number will increase to over 600
providers.
The SUPPORT Act also provided authority for other critical
behavioral health workforce programs, which are training
providers in community-based settings. During the recent
academic year, these programs trained over 7,800 behavioral
health providers.
HRSA's National Health Service Corps also plays an
important role in combating the overdose epidemic by growing
and retaining a skilled workforce of behavioral health
professionals and increasing access to services in rural and
underserved communities. Currently, more than 9,600 mental
health and substance use disorder providers are practicing in
the highest need communities, thanks to the National Health
Service Corps.
Mandatory funding for the National Health Service Corps
expires at the end of this fiscal year. The President's budget
seeks to sustain the record level of clinicians in service and
provide a 3-year mandatory investment in the program.
HRSA created the Rural Communities Opioid Response Program,
the only targeted program focused specifically on addressing
substance use disorder in rural communities. HRSA has invested
over $500 million across more than 1,800 rural counties in
nearly every State via RCOR, and grantees have provided direct
services to nearly 4 million people living in these rural
counties.
The Health Center Program is also a tremendous resource for
increasing access to behavioral health services, given its
broad footprint and valuable role as a trusted provider in
communities across the country. Targeted investments have
helped health centers expand their capacity to deliver
behavioral health services, including increasing the number of
patients receiving mental health and substance use disorder
services.
Still today, health centers are only meeting about 27
percent of estimated demand for mental health services and
approximately 6 percent of estimated demand for substance use
disorder services among their patients. Mandatory funding for
the Health Center Program expires at the end of this fiscal
year, and the President's budget proposes a new $700 million
investment to expand behavioral health services in health
centers, along with a requirement that they provide mental
health and substance use disorder services.
HRSA continues to expand access to substance use disorder
services and grow the behavioral health workforce through its
SUPPORT Act programs and others.
I look forward to your questions about our programs. Thank
you.
[The prepared statement of Ms. Espinosa follows:]
Mr. Guthrie. Thank you for your testimony. The Chair now
recognizes Mr. Blum.
You have 5 minutes for your opening statement.
STATEMENT OF JONATHAN BLUM
Mr. Blum. Thank you, Mr. Chair, for the opportunity for CMS
to present today.
CMS deeply thanks this committee for authorizing the
SUPPORT Act. This law has provided new tools to CMS to address
the devastating toll substance use has taken on those covered
by CMS programs.
This toll has only worsened during the past 5 years. While
progress has been made, we agree that more must be done.
CMS works hand in hand with the other agencies here to
build system capacity, connect more people to care, and
integrate behavioral health services with primary care and
other social support services. For CMS, we have built a
comprehensive plan that coordinates work throughout the agency
and supports broader department and presidential strategies.
As the largest payer of care here in our country, CMS works
to ensure that our payment, coverage, and quality programs
promote person- and patient-centric behavioral healthcare.
As stated, the SUPPORT Act provided CMS new tools and
authorities to provide better care for patients. Medicare now
provides for treatment in more care settings. We have launched
new payment models to test value-based payment concepts. We
have worked closely with States to help their efforts to expand
Medicaid options that provide broader treatment options. We now
require CHIP programs to expand coverage for services. We have
provided planning grants to States to bolster their care
delivery systems, and we have expanded data monitoring for
prescribers.
So the SUPPORT Act only has 5 years--it is only 5 years
old. We are seeing positive change to our programs. But given
the demand for services, we must continue to find new ways to
improve our policies. The President's budget proposes many
policies to expand coverage and access to behavioral health
treatments. These include stronger mental health parity
provisions for the States, requiring Medicare and private
health insurance plans to cover three behavioral health visits
with no cost sharing, converting successful demonstration
programs to permanent programs.
I have personally traveled throughout the country to many
States and have seen firsthand the challenges that our care
systems now face. Healthcare providers and other stakeholders
tell us how much greater demand there is for behavioral
healthcare services today in both urban and rural settings. Our
programs are stronger today thanks to the SUPPORT Act, but we
know that more can be done and more must be done.
CMS stands ready to support this committee's work. Thank
you for the opportunity again. I look forward to your
questions.
[The prepared statement of Mr. Blum follows:]
Mr. Guthrie. Thank you. I appreciate your testimony. That
concludes all of our witnesses' testimony. And we will move to
questions, and I will begin the questioning by recognizing
myself for 5 minutes for questions.
So, Mr. Coderre, we are here today to examine what has
worked and what hasn't worked over the past several years. We
have also spent billions of dollars on treatment and recovery
programs. According to a December 2021 Government
Accountability Office report, SAMHSA spent 2.8 billion in State
opioid response grants, and there were over 2.2 billion in
unspent funds during fiscal year 2020.
I understand fiscal year 2020 is a difficult year to
benchmark because of all that was going on with COVID, and it
could have impacted funds. However, SAMHSA's data shows that
the base award for SOAR grants was 1.4 billion in 2020, and the
draw-down was 1.421 billion.
Why is there a discrepancy in the GAO's reporting and the
SAMHSA's website?
And for drawdowns, does that mean States spent all those
funds, or does that only mean they took the funding?
And how can we be more targeted with our funding?
Mr. Coderre. Thanks so much for that question, Mr.
Chairman.
The State Opioid Response Grant Program has been incredibly
important to States and local communities over the years, and
we at SAMHSA have worked very closely with States about how to
spend those resources effectively.
What we have heard from States is that they have had
difficulty spending those resources in the amount of time that
the grant period allows for. So we are working with States, and
we would be happy to work with the committee to address any of
those drawdown questions that you have.
Mr. Guthrie. OK. Is there opportunities to include other
things such as alcohol abuse?
I was on jury duty, I did my civic duty about 3 years ago,
and grand jury about--of 20 cases a day that came before us. It
was amazing to me how many were alcohol-related.
Mr. Coderre. Certainly, you know, alcohol becomes--it is a
major issue in this country. Alcohol use disorder is impacting
millions of Americans.
So we at SAMHSA are working as closely with States and
local communities as possible to make programming available to
them. The SOAR program itself is specific to opioids and
stimulant use disorder. However, we would be happy to work with
the committee on any of those, expanding that program in any
way that we can.
Mr. Guthrie. OK. Also, Mr. Coderre, the Comprehensive
Opioid Recovery Centers was an issue I championed. We need to
have access to all types of treatment and wraparound services.
Could you talk about that program, and what has been
successful?
Mr. Coderre. Certainly, Mr. Chairman. That program----
Mr. Guthrie. And improvements. What was successful in any
improvements? So that is what we are here to--what can we----
Mr. Coderre. Sure. Well, as you said, the Comprehensive
Opioid Recovery Center Program provides grants to nonprofit SUD
treatment organizations to operate those comprehensive centers
and provide that full spectrum of treatment and recovery
support for opioid use disorders.
Grantees are required to provide outreach and the full
continuum of treatment services, including medications for
opioid use disorder, counseling, treatment for mental
disorders, testing for infectious diseases. Very, very
comprehensive, as you pointed out.
And so, with that appropriation of $6 million, SAMHSA
funded 5 of these centers in fiscal year 2022. The grantees
utilized the funding to expand access to comprehensive service
in a variety of ways.
Mr. Guthrie. Would you view that as successful?
I am going to get to a couple other questions. Would you
view that as successful?
Mr. Coderre. Yes, we view that program as very successful.
Mr. Guthrie. And what do you think needs to be improved? Is
there----
Mr. Coderre. Improvements for it? Happy--I don't have any
suggestions for improvements today, Mr. Chairman, but I would
be happy to work with you and your staff.
Mr. Guthrie. Absolutely. We want to make sure we get this
right.
Mr. Coderre. Absolutely.
Mr. Guthrie. And we--after 5 years in all of your areas you
talk about, what things can we do better? That is what we want
to move forward.
So Mr. Strait, having you here today, I can't help but talk
about fentanyl analogs. And how simple is it to produce a
fentanyl analog?
And how many fentanyl analogs is DEA aware that you guys
believe are out there?
Mr. Strait. Yes, thank you for the question.
At present, since this threat has kind of really emerged,
we have scheduled a total of 36 individual analogs. Now, that
would be after we have developed enough evidence to represent
that they represent a risk to the public. That is when we would
then use our emergency scheduling authority to take permanent
action to control that substance. But there are hundreds of
substances out there, and the ability to actually make an
analog is slightly easy in that all you have to do is make a
slight modification to any portion of the----
Mr. Guthrie. So it really could almost be infinite, the
combinations out there.
Mr. Strait. There has been----
Mr. Guthrie. Could be.
Mr. Strait [continuing]. Questions about whether there is
an infinite number, and I think that is theoretical. I think it
is more likely that----
Mr. Guthrie. Have you seen fewer analogs since the
temporary scheduling took place?
And do you think permanent scheduling would--should be
continued, the temporary should be permanent?
Mr. Strait. We absolutely believe the temporary scheduling
should be permanent, and we have seen fentanyl analogs decrease
in terms of their prevalence.
Mr. Guthrie. OK, thank you. My time is expired. Thank you
for your answers. And I now recognize the ranking member for 5
minutes for her questions.
Ms. Eshoo. Thank you, Mr. Chairman, and thank you to each
of the witnesses for your testimony, which is your work.
Mr. Coderre, you are a source of inspiration to me, I think
to everyone in this room, that you would choose to tell a
story, and that it is your story. So thank you. Thank you.
Mr. Coderre. Thank you.
Ms. Eshoo. And thank God and everyone that helped you.
To Mr. Blum, over 50 million Americans live with chronic
pain, and this drives many individuals, you know, to seek
relief through opioids. The SUPPORT Act section 6086, the Dr.
Todd Graham Pain Management Study, required CMS to study and
report on nonopioid therapeutic services for pain management
for Medicare beneficiaries. The study was done in 2019.
What is CMS doing to--in the meantime--to improve access to
nonopioid treatment options to reduce pain?
CMS hasn't issued the report, so this is a while. This is--
how many years--2019 is, what, 4 years ago. So where is the
report, and what is CMS doing in the meantime?
Mr. Blum. Thank you for the question.
We believe that one of the greatest challenges that our CMS
programs have is not having sufficient access to those that
treat chronic pain. So we need to do more to expand CMS----
Ms. Eshoo. Yes, well, that is a given. That is a given.
Everyone, I think, would agree to that. But where is the
report? When do you think it is going to be issued? And in the
absence of it, what has been--what has CMS----
Mr. Blum. Sure.
Ms. Eshoo. What has CMS been doing?
Mr. Blum. I will get back to your office with a status
report for the status--for the report. But in the meantime, CMS
works tirelessly to expand physician networks to ensure that we
have a better coverage for pain management services.
Ms. Eshoo. Something is really wrong that a report is--it
seems, from where I sit, that this is just forgotten. So we
need to--the committee needs to get that information.
To CDC and DEA, in the past year deaths and severe medical
complications have soared due to xylazine. That is a drug that
is--currently has veterinary and agricultural uses--being mixed
into street drugs. It is just astounding to me what is taking
place.
And I would also like to know from both Mr. Jones and Mr.
Strait, do you have the data capabilities to track emerging
drug threats like xylazine?
And do you know where there are hotspots?
And can you identify the trends to prevent these overdoses?
I mean, people are using. And so it seems as if, you know,
there is constantly a new--something that is introduced. People
are just using. They don't--in terms of this scheduling
business, I don't think they check out to see what is
scheduled. They are using drugs, and those that are peddling
them are constantly introducing all these others.
So what is your capacity for, you know, for--as I said, do
you have the data capabilities to track these drug threats?
Dr. Jones. Thanks for the question. At CDC we put out our
first notes from the field on xylazine in September of 2021. So
almost 2 years ago, we started sounding the alarm that we were
seeing xylazine pop up in certain communities, and that was
consistent with data from DEA. And those data come from our
State Unintentional Drug Overdose Reporting System, which is a
system that we support----
Ms. Eshoo. So you do have the capability?
Dr. Jones. So we have--yes. That system captures very
granular toxicology information on deaths, and States have
access to those data through our Overdose Data to Action
program. We use that to raise awareness.
We recently also published through checking of drug
paraphernalia syringes in Maryland, sort of a novel approach to
trying to identify emerging threats, we also saw that xylazine
was very common in that area as well--again, consistent with
what information comes from DEA.
So we are continuing to try to raise awareness of those
data systems that do exist, but also continuing to look for
additional opportunities to get ahead of new emerging threats.
Ms. Eshoo. Thank you. My time is expired.
Thank you, Mr. Chairman.
Mr. Guthrie. Thank you. The gentlelady yields back. The
Chair now recognizes the Chair of the full committee, Chair
Rodgers, for 5 minutes for questions.
Mrs. Rodgers. CBO recently found that States that lifted
the IMD exclusion, whether through 1115 waiver or through the
SUPPORT Act's State plan option, saw reductions in emergency
room visits for overdoses. Nearly 40 States have chosen to lift
the IMD exclusion.
As we work to reauthorize the SUPPORT Act State plan
option, a key goal is ensuring that we increase uptake of these
options and reduce State burden. So, Mr. Blum, how long does it
take to approve an 1115 waiver from the start of the State's
process to the final CMS approval compared to a State plan
option to get approved in, and would you speak to the
difference in how long it takes?
Mr. Blum. For States, CMS works carefully to approve
waivers. Those timelines can vary. They can be dependent on the
complexity to the waiver. So there is no set rule of thumb that
we can provide that would say this is how long it takes to
approve a State waiver. They have to go through notice
requirements, they have to go through public requirements. But
in general, that--it takes longer for a State waiver than a
State plan.
Mrs. Rodgers. Can you give us a sense--is it months or
years?
Mr. Blum. I would say months.
Mrs. Rodgers. Months? The value of lifting the IMD
exclusion is clear. Now is the perfect chance to find a way to
reduce State burdens and find a more permanent solution to
lifting the IMD exclusion.
There has been a lot of discussion about how to lower
overdose rates and set individuals up for success upon leaving
jail or prison. Mr. Blum, the SUPPORT Act allows States to
suspend Medicaid coverage when an individual is incarcerated
rather than terminate their coverage, and the goal being that
suspending coverage would mean that an individual can more
easily resume Medicaid coverage upon their release from prison.
Would you speak to the technical assistance that CMS
provided to States to help clarify their ability to suspend
coverage for individuals, and do you see States doing this?
Mr. Blum. So CMS today is very excited to work with States
to help them build programs that ensure better continuity of
care. We recognize that those that are leaving prison often
times have tremendous breaks to their care, to their coverage.
So today CMS is eager to work with States to help to improve
those programs.
Mrs. Rodgers. How many States are doing this?
Mr. Blum. I will have to get back to you with that precise
number, but it is relatively small.
Mrs. Rodgers. OK. Thank you.
Mr. Strait, in your written testimony it discusses the work
DEA has done with Bureau of Prisons to enable them to provide
medication-assisted treatment. Have you seen more of this care
provided, especially prerelease?
Mr. Strait. Well, that action culminated in March of 2023,
so I would probably say it is a little early to know the
consequences of it, but we do think that was an important step.
We granted NTP, or opioid treatment program designation, to all
97 BOP facilities, greatly impacting access there.
Mrs. Rodgers. OK, thank you. I would like to quickly flag
my concerns with CMS's 1115 waivers to allow for Medicaid to
pay for care for inmates in jails and prisons. I questioned the
authority of the agency to do this. And these new waivers
appear to be far from budget neutral, a key 1115 waiver
requirement. The section of support you cite in your testimony
as rationale for this only required innovative strategies and
did not give authority to waive budget neutrality. And I hope
that we can find a way forward on these policies that are
ultimately authorized and actually authorized by Congress.
Mr. Coderre, your written testimony indicates that over 85
percent of SAMHSA's prevention resources are dedicated to
youth-focused primary prevention activities. Mr. Jones' written
testimony includes a tragic statistic: drug overdose deaths or,
more likely, poisonings among younger-aged people, 10 to 19,
have risen 65 percent from July 2019 to December 2021, even
though overall youth illicit substance use declined. How do you
measure the success of these primary intervention programs?
Mr. Coderre. Thanks so much for your question, Madam Chair.
SAMHSA's prevention programs are vital to providing mental
health and substance use services, and we are working closely
with our partners in the State and local communities to provide
resources to enact these programs. I would be happy to work
with you and your staff to get you some of the data from those
programs about the measures of success. We have lots of those
that we collect through our data systems, and we can--we are
happy to provide those to you.
Mrs. Rodgers. Well, we are moving in the wrong direction,
so we need to look at what is actually going to get results is
my point.
Mr. Coderre. Thank you.
Mrs. Rodgers. OK, thank you.
I yield back.
Mr. Guthrie. Thank you. The Chair yields back. The Chair
now recognizes the ranking member, Mr. Pallone, for 5 minutes
for----
Mr. Pallone. Thank you, Mr. Chairman. My questions are all
of Mr. Blum, and mainly about the IMD program.
I want to make sure that, in our rush to respond to the
opioid epidemic, we do not inadvertently create different
problems as the unintended consequences of our actions. And I
am particularly concerned that further weakening the
Institution for Mental Disease, or IMD, exclusion in Medicaid
could lead to an increase in institutionalization that would
further isolate individuals struggling with substance use
disorders.
So Mr. Blum, 5 years ago the SUPPORT Act authorized a
temporary Medicaid State plan amendment that created an
exception to the IMD exclusion for individuals with substance
use disorder. In the 5 years since, how many States have
adopted this option?
Mr. Blum. Two States, Congressman.
Mr. Pallone. Two. Only two. I mean, it sounds like this has
not been a very popular policy on the ground.
So I wanted to address the fact that States already have
options to receive Federal Medicaid funds for certain States in
an IMD. They can use the longstanding authority in Medicaid-
managed care known as in-lieu-of services to cover short-term
stays in IMDs of up to 15 days each month, and States can also
use 1-1-1-5--pronounced ``11 15''--waivers to cover longer
stays in IMDs, as long as the State average length of stay is
less than 30 days.
So again, Mr. Blum, how many States currently have these
1115 waivers to cover IMD stays for substance use disorder?
Mr. Blum. Thirty-four States, plus DC.
Mr. Pallone. OK. So, in other words, the overwhelming
majority of States have adopted the 1115 waivers to cover IMD
stays for beneficiaries with substance use disorder, and only 2
States have adopted the expiring State plan option. Is that
what you have basically said?
Mr. Blum. Yes, sir, that is correct.
Mr. Pallone. All right. Well, thank you.
I mean, again, it sounds to me like, for States that do not
want to cover IMD stays--that do want to cover the IMD stays, I
should say--the 115--or the 1115 waivers are a much more
popular approach than the State plan option that the
Republicans are attempting to extend. And I think we would be
far better off allowing States to cover IMD stays with 1115
waivers, which CMS does not need any additional statutory
authority to approve, rather than doubling down on the--what I
consider a failed approach of the State plan amendment.
Now, again, I mean, I am saying this because I wasn't--you
know, I am always very wary of IMDs and institutionalization.
And so, you know, I think we should just continue with the
1115s rather than trying to expand, you know, this State
amendment that allows for expanded IMD.
But I also wanted to ask you one more question unrelated to
IMDs. We have heard from a number--or I should say I have heard
from a number of advocates that, rather than investing more
Federal dollars towards institutional care, we should instead
focus on supporting treatment options that allow individuals to
stay in the community. Obviously, that is always my preference,
and I think most Members feel that way.
So, Mr. Blum, can you talk about the value of home and
community-based care for individuals in recovery?
Mr. Blum. Thank you for the question. One of the principles
that we feel very strongly about is that when helping to
support States to design their programs, that those programs
should provide the full spectrum to care options that best
serve the patient, given where they want to receive services.
We know that many patients want to receive services in
nonhospital settings. We have recently worked with States to
expand services, for example, in schools that really provide
services where people are. So our core principle is to work
with States carefully to ensure that services are provided with
the full spectrum that ensure that patients can receive
services where they are most comfortable.
Mr. Pallone. No, I appreciate that. And again, you know, I
know it is difficult because a lot of times when you talk about
community-based care, there are those in the community that--
you know, a not-in-my-back-yard type of thing, right?
But I just think that when we have resources--and they are
always limited--we are better putting them towards treatment
options that support community integration and keep people in
the community, rather than institutionalization. So that is my
view, and I appreciate your input, Mr. Blum.
Thank you, Mr. Chairman.
Mr. Guthrie. Thank you. The gentleman yields back. The
Chair recognizes Mr. Burgess for 5 minutes for questions.
Dr. Burgess.
Mr. Burgess. Thank you, Chairman.
Dr. Jones, from the perspective of the CDC, does this
country have a problem with homelessness?
Dr. Jones. Certainly, there are many communities that are
struggling with people experiencing homelessness, yes.
Mr. Burgess. So let me just ask you a question. Is one of
the root causes--people like to talk about root causes--is one
of the root causes of homelessness untreated mental disease and
untreated addiction?
Dr. Jones. We see certainly higher prevalence rates of
mental health and substance use disorders among people
experiencing----
Mr. Burgess. So, OK, let me just--let me boil it down for
you: What we are doing may not be working, and so we could do a
lot more of it and hurt people in the--as a consequence.
But, Mr. Blum, your comments and your back-and-forth with
the ranking member of the full committee, it seems logical that
you would try to help those people who have untreated mental
disease and who want help with addiction, who are not able to
receive it, and thereby not be subject to the degree of
homelessness and misery that they currently are. Is that not a
fair statement?
Mr. Blum. We believe strongly that we need to expand
services and do so in a way that provides the full spectrum of
care services.
Mr. Burgess. So I have a number of things, Mr. Chairman,
that I am going to ask inclusion in the record, and one of them
is a letter from the Schizophrenia and Psychosis Action
Alliance. And within their letter they talk about the IMD
exclusion is a manufactured and artificial scarcity of public
and private psychiatric hospital beds resulting in sky-high
utilization of hospital emergency departments among persons
with severe mental illnesses.
In fact, the American College of Emergency Physicians
reports a persistent boarding crisis in hospital emergency
rooms with individuals in psychiatric crisis. Is that a fair
statement from the Schizophrenia & Psychosis Association?
Mr. Blum. I haven't seen the letter, Congressman, but I can
tell you that, through personal travels, that we hear very
similar statements.
Mr. Burgess. Correct. Boarding in our emergency rooms is
literally at a crisis level. And one of the reasons for that is
trying to get a bed for someone who requires hospitalization.
And I just submit that the IMD exclusion is making this--well,
certainly not helping that problem. And that is why it is
important for us to be evaluating it.
So just in general, Mr. Blum, the United States, we have
got a significant mental health and substance abuse crisis,
increasingly difficult to manage.
Mr. Strait, I agree with you. The border issue is--man, oh,
man, that is front and center. And if you all take any
information back to your counterparts in the administration,
that is one that has to be fixed. But limited treatment options
for substance abuse and mental health and barriers to--access
to comprehensive care, especially for Medicaid beneficiaries,
that plays a role.
CBO, I do have a CBO estimate on this. It is high. And Mr.
Chairman, I would like to insert that for the record, as well.
But the cost of doing nothing is staggering. So yes, we can
look at the CBO, look at the CBO score and say, oh, that is so
big we really can't do anything about it, but we have to do
something about it. It is our obligation to do something about
it.
So, Mr. Blum, staying with you, how have States applied the
1115 waiver to lift the IMD exclusion to improve access to care
for substance abuse disorders?
Mr. Blum. There are 34 States that have moved forward with
that option.
Mr. Burgess. Yes. And just as an aside, it was extremely
difficult to get the 1115 waiver extended in the State of Texas
when the administration changed from the Trump administration
to the Biden administration. The Trump administration gave a
10-year extension of the 1115 waiver for the State of Texas.
The Biden administration came in and 4 months later said, ``No,
we are not going to extend. We have made a mistake. It is not
going to be extended at all.''
It took a full year--a full year--to get that extension of
the 1115 waiver. And that is why it is difficult using the 1115
waiver, because it is not necessarily assured that it is going
to continue, for political reasons, from one administration to
the next.
Mr. Chairman, I have got a number of questions that I am
going to submit for the record.
And I do have the CBO score and various letters that I
would also like to submit for the record, without objection.
Mr. Guthrie. I think we are going to do an action at the
end of all the letters on the record, so we will make sure
everybody has a chance to review those. But yes, those--we will
put those on our list for the end of the--unless you have any--
you would rather review.
No objection? If there is no objection, so they are so
ordered, yes.
[The information appears at the conclusion of the hearing.]
Mr. Guthrie. Now the Chair now--the gentleman yields back.
The Chair recognizes Ms. Kuster for 5 minutes for questions.
Ms. Kuster. Thank you, Mr. Chairman, and thank you to our
witnesses for your testimony. And I apologize when we are
scheduled for two hearings at once.
Your leadership highlights the importance of our Federal
agencies working together to address the addiction crisis. As
the founder and co-Chair of the bipartisan Mental Health and
Substance Use Disorder Task Force here in Congress, I am glad
we are dedicating time to discuss the issues posed by the co-
occurring mental health and substance use disorder illnesses.
We must do more to respond to these challenges. We all have
a role to play in reducing the stigma around mental health and
addiction. CDC data shows that around 300 Americans die every
day from drug overdoses--300 mothers, fathers, sisters,
brothers. We know the number of people suffering from mental
health challenges is even higher than that. And this hearing
comes at a critical time for this committee.
I would like to highlight some of the opportunities we have
to improve the SUPPORT Act during reauthorization. I am excited
that today's hearing includes two important bills that will
change the outdated Medicaid inmate exclusion policy: the
Medicaid Reentry Act, from my colleague, Representative Paul
Tonko; and the Due Process Continuity of Care Act from my
colleague, Representative David Trone. Letting people who are
incarcerated keep their Medicaid coverage will support healthy
communities and ultimately save State and taxpayer dollars.
My bill, the Humane Correctional Health Care Act, would
actually end the Medicaid exclusion--inmate exclusion policy
altogether, and I totally support the efforts of my colleagues
to chip away at this harmful policy.
I am also glad that today's hearing includes my bill with
Representative Buddy Carter, the Studying Suboxone Act, which
will increase accessibility to this important medication that
helps people with opioid use disorder.
The Star LRP reauthorization bill is an important tool that
we must support to expand our behavioral health workforce.
However, there are bills that we are not discussing today
that should be a part of this conversation. My bill with
Representative Lisa Blunt Rochester, Stop Fentanyl Overdoses,
is a comprehensive, bipartisan approach to reducing the harms
of the opioid crisis, leveraging many of the programs that have
been discussed today.
Additionally, expanding access to methadone for opioid use
disorder beyond the restrictive setting of opioid treatment
programs will enable more people to seek this treatment. And I
support Representative Norcross' bill.
I also worked with several of my E&C colleagues to reach
out to both DEA and SAMHSA to maintain telehealth prescribing
for buprenorphine, allowing for continued access to a critical
medication for people with opioid use disorder.
Mr. Blum, in your testimony you highlight research that the
expanded availability of telehealth services and medication
during the pandemic was associated with fewer fatal drug
overdoses for people on Medicare. Can you explain how
telehealth is specifically important in the prescribing of
medications for opioid use disorder?
Mr. Blum. Thank you for the question. We saw tremendous
growth in telehealth services throughout the country during the
pandemic, particularly for behavioral health services. And we
feel that we believe that maintaining access to these services
is crucially important for many patients, that it helps to
promote access.
There are still many questions that we have to better
understand for what is the right payment level, for what is the
right processes for us to ensure broad access to those
services. But in general, we are very supportive to
continuation for telehealth services for these services.
Ms. Kuster. Great. Thank you very much. I look forward to
hearing more from both DEA and SAMHSA before the November
expiration of this rule.
Today's hearing demonstrates that we must take an all-of-
government approach to addressing the mental health and
substance use disorder crisis that is affecting, literally,
every single community in our country.
I thank my colleagues for committing to a bipartisan
reauthorization that will meet the needs of our constituents.
And with that, I yield back.
Mr. Guthrie. Thank you. The gentlelady yields back. The
Chair now recognizes Mr. Griffith for 5 minutes for questions.
Mr. Griffith. Thank you very much, Mr. Chair.
Dr. Jones, I helped lead section 7161 of the SUPPORT Act in
2018 that would support and improve prescription drug
monitoring programs. My thought was the money authorized for
that was to start up the programs and increase collaboration
across State lines. The bill that reauthorizes this section is
in front of us today--authorizes an increase in funding.
So can you elaborate--so, one, can you elaborate how the
money in this program is being spent between agencies and
States?
And two, if the systems are already in place--we already
did the startup from the last bill--explain to us why there is
a need for an increase in the funding.
Dr. Jones. Thank you very much for the question. And
through our Overdose Data to Action program, that is how we
provide funding to States to support Prescription Drug
Monitoring Program work. The Bureau of Justice Assistance, who
is not here today, is the other Federal funder of PDMPs.
In our work, you are correct, the systems, you know, 4 or 5
years ago--or still getting started in some States--are moving
from paper-based systems to electronic-based systems. So we
have made great progress over the last several years in having
electronic systems that exist, having regular and very current
reporting from pharmacies to the PDMP, and improving interstate
data sharing across.
I think where there continue to be opportunities is to
integrate the PDMP data into electronic health records,
clinical decision support. It is an important piece of
information for clinicians to have, and we don't want them to
have to go to a separate system that disrupts their workflow.
So I think there is opportunity there, and better integration
in clinical workflow.
And then from a data analysis perspective, it is also an
important tool for health departments to understand what are
overall prescribing trends in a State, how are things changing,
where might they target educational resources.
So States have used our funding to not only have staff to
be able to analyze those data more regularly, but then also to
have academic detailers go out and say, ``Here is an area where
we are seeing some troubling trends. What might be driving
this? Can we help improve knowledge about appropriate
prescribing of opioids or other pain management options? Or are
we seeing a place where we might want to expand access to
buprenorphine?'' Because there is a desert for access to MOUD.
Mr. Griffith. And I appreciate that. And I am carrying the
bill again, but I wanted to make sure on the funding side that
I had a good defense for it. And you have presented that. Thank
you.
Mr. Strait, we were just talking about buprenorphine. With
DEA's proposed rule on March 1, 2023, that will ease in-person
requirements to be prescribed the controlled substance--a
controlled substance via telemedicine. And I am for
telemedicine.
That being said, in some parts of my district it is being
reported that buprenorphine, Suboxone, is being used as a
street drug, that they are taking some and not taking some. So
does the DEA track the prescription patterns or prescribing
patterns on buprenorphine so we can see if expanding the number
of patients any one doctor can have, and having telemedicine--
are we going to be prepared to keep an eye on that to make sure
this doesn't become a problem in and of itself?
Mr. Strait. Thank you for that question. It is a great
question.
And what I would tell you is that the best experience we
have is what happened during COVID, when telemedicine
flexibilities existed. And what I will say as a general matter
is we did not see a, you know, an increase in diversion or
misuse of buprenorphine.
I think the other piece is knowing that it is widely
dispensed in combination--as Suboxone, when it is in
combination with naloxone, tremendously helps toward that end
of ensuring that it is not going to be misused.
Mr. Griffith. So what you are telling me is you are, in
fact, tracking----
Mr. Strait. Absolutely.
Mr. Griffith [continuing]. It. OK, good. And in regard to
the three-day rule--and you amend the three-day rule for
dispensing medication for opioid use disorder--do you plan to
have a monitoring system in place for that, as well?
Mr. Strait. I am sorry. The three-day rule?
Mr. Griffith. Yes. There is going to be--apparently, the
Department of Justice is releasing an amendment to the three-
day rule for dispensing so that you can get a longer
prescription.
Mr. Strait. Yes.
Mr. Griffith. Do you plan to monitor that for abuse, as
well?
Mr. Strait. Absolutely. And in fact, we have been granting
exception letters in all 50 States to mostly hospitals. That
has been going on for about the last year and a half as well,
so that they can already--during the pendency of our
rulemaking, they can already do----
Mr. Griffith. All right.
Mr. Strait [continuing]. A three-day.
Mr. Griffith. And Dr. Jones, back to you, and I am running
out of time. Can you explain briefly how the CDC's high
resolution libraries function, and what research is being done
into fentanyl analogs on your end?
Dr. Jones. Yes, this is an active area for our National
Center for Environmental Health, where they have really been
leaders in developing new testing methods as well as sharing
reference materials to public health and clinical labs.
So we have expanded beyond fentanyl, fentanyl analogs to
synthetic stimulants, benzodiazepines, cannabinoids. We have
over 300 in the high reference lab at this point.
Mr. Griffith. All right. I would love a longer answer, but
my time is up and I must yield back.
Mr. Guthrie. Thank you. The gentleman yields back. The
Chair recognizes Mr. Cardenas for 5 minutes for questions.
Mr. Cardenas. Thank you very much, Chairman Guthrie, and
also Ranking Member Eshoo, for holding this hearing at this
very critical time in our country. As we navigate a worsening
substance use disorder crisis in this country, it is critical
we come together to fund a Federal response that matches the
severity of this emergency.
I am especially grateful to see the bill I am leading with
Rep. John James. It has been noticed. Thank you so much. The
Road to Recover Act will provide necessary resources to ensure
the National Peer-Run Training and Technical Assistance Center
for Addiction Recovery Support can assist individuals in need.
My first question is to Mr. Coderre.
Can you explain why the center is a helpful resource for
community organizations and peer support networks, and why is
peer support so critical to addressing those struggling with
substance use disorder?
Mr. Coderre. Well, thank you so much for that question,
Congressman.
For me personally, peer support was essential for my
recovery. Peer support taught me that I was not alone. Peer
support taught me that treatment is effective, that people do
recover. And so peer support workers are folks who have been
successful in the recovery process and are able to help others
who are in similar situations through understanding, respect,
mutual empowerment. And the workers help people become and stay
engaged in their recovery process.
So the peer support services definitely can effectively
expand the reach of treatment beyond that clinical setting that
you referred to into everyday environment of those who are
seeking sustained recovery.
Mr. Cardenas. Thank you very much.
I also want to take a moment to discuss institutions for
mental health disease exclusion, also known as IMD exclusion.
Medicaid's IMD exclusion limits Federal Medicaid dollars to
States for inpatient mental health services at facilities with
no more than 16 beds. And by the way, I am still trying to
figure out how we came up with the number 16. It is mind
boggling.
Unfortunately, while the intent of the restriction was
good, it has reduced the number of options for people who need
certain levels of mental healthcare. With fewer care
alternatives, more and more individuals end up in jail rather
than getting the mental health services they need. In fact,
half of the individuals in our jails across America today have
been diagnosed with some kind of mental illness, as compared to
about one-fifth of the broader U.S. population.
Now, I want to be clear. I am not saying that relaxing some
of those IMD restrictions should come at the expense of
community-based services, and I certainly think we need to take
a measured approach with safeguards in place. In fact, without
guardrails I would be hesitant to repeal existing restrictions.
That being said, we are trying to address a massive mental
health crisis, and we need to have a full set of care options.
There are some individuals who are struggling with substance
use disorder or other mental health issues who may need
inpatient care. I am worried that by maintaining a broad
exclusion, we are leaving out most middle-income and low-income
families across our country that need access to quality care
and necessary care.
Mr. Blum, I have heard from advocates who have concerns
about the treatment patients receive in IMD settings. It is
because of these conversations that I have been thinking
through ways to promote the highest quality care and ensure
accountability. One idea that comes to mind is creating certain
standards of care that must be met for reimbursement. Would
this be something CMS would be interested in working with us
on?
And if so, what types of considerations should we be sure
to keep in mind?
Mr. Blum. I am happy to work with you, Congressman, that
question. Today CMS maintains a robust criteria for all care
settings, be it behavioral health or just general healthcare
services. We are happy to work with you to find ways to define
services that are safe and high quality.
Mr. Cardenas. OK. Why is it important to ensure robust
funding for community-based services for people dealing with
mental health issues?
Mr. Blum. What we learned from States, working with States,
working with care systems--that patients prefer care in
different settings. And so we believe very strongly that, to
build the strongest possible systems, that patients need to
receive services that will best serve their needs. And so that
is one important principle that CMS works to maintain
throughout any conversation with the State.
Mr. Cardenas. Is the emergency room a good place for
somebody in a mental health crisis situation to be getting
care?
Mr. Blum. What we hear from clinicians is those settings
tend to be chaotic. They tend to be noisy. They tend to be not
the best care setting for patients.
Mr. Cardenas. Well, that is where too much care is being
handled, and we need to make sure we have the infrastructure to
do otherwise. So thank you very much, I appreciate it very
much.
Mr. Chairman, my time is expired. I yield back.
Mr. Bucshon [presiding]. The gentleman yields back. I now
recognize myself for 5 minutes.
Never mind. Mr. Latta.
[Laughter.]
Mr. Bucshon. Mr. Latta, I recognize Mr. Latta for 5 minutes
for his line of questioning.
Mr. Latta. Well, I thank the chairman. And also, I
appreciate the witnesses being here today.
It probably was announced a little bit earlier we have two
hearings running today, and I am chairing the one downstairs
right now. But we really appreciate your testimony today, and
this is really an important hearing.
The United States has continued to fight an endless battle
against the faceless enemy that knows no boundaries, and that
enemy is the decades-long fight against substance abuse and
addiction.
I want to start by saying addiction can happen to anyone.
I am saddened, after all the great work this committee has
accomplished at fighting addiction, we are still having these
discussions. However, I am optimistic that, with improvements
that are offered today in the SUPPORT Act reauthorization, we
will have a--be better positioned to provide access to care
resources to those suffering and save lives.
[Chart shown.]
Mr. Latta. And this is important because, you know, one of
the little graphs that was handed out earlier today in our
binders, it just shows--the graph here just shows the number of
deaths from overdoses, and this only goes through 2021. But we
also know that was 106,000, almost 107,000 in 2021. We know it
is up to 109,000. It is not going down, it is going up.
And the other thing about these is, you know, if we look at
a graph, we just see statistics. These are humans. And so I
think this is why it is important that we are having this
discussion today.
And again, I am proud that you are all--that I am leading
legislation with my friend, the gentleman from California's
25th district who was included in today's hearing. It is a step
in the right direction.
In addition, I am also proud that the House passed the HALT
Fentanyl Act earlier this year that I co-led with my friend and
colleague, the gentleman from Virginia.
If I could start with Mr. Strait, tragically, the United
States, you know, passed the second year in a row of over
100,000--109,000, to be more accurate--overdose deaths, of
which one county sheriff told us we shouldn't really be talking
about overdoses. In a lot of cases we should be talking about
these are poisonings, not an overdose. And in some cases it is
outright murder, and especially when we saw that, with
fentanyl-related, that we went up to over 73,000 people passing
because of it. Do you see--are there any other legislative
proposals now brought before this committee today that would be
a game changer in fighting addiction?
Mr. Strait. Well, from DEA's perspective, the single most
important aspect of our ability to infiltrate and to prevent
these controlled substances from--or these substances from
crossing our borders and being distributed by violent street
gangs is through its control under the CSA. That gives law
enforcement--not only ourselves, but our law enforcement
counterparts at the border, our folks that are interdicting
mail packages and mail parcels--with authority to seize.
And then, obviously, it gives us to work--the authority to
work backwards and arrest individuals for trafficking those
substances. So schedule I control is, by far, the biggest
single thing that can be done to help us.
Mr. Latta. Well, I think that is absolutely correct, and I
know that--the Chair earlier had talked about that, permanently
scheduling fentanyl-related substances. But it is also
important that, you know, again, we just have to get this thing
done, and it has got to be a schedule I.
And let me just ask, you know, just yes or no, do you
believe that permanently scheduling fentanyl-related substances
as schedule I is needed, no matter what the mandatory
requirements are out there?
Mr. Strait. Yes.
Mr. Latta. Yes, and I think just real briefly on that, on
the mandatories--because I think, when you look at it, it is
100 grams of fentanyl. That is--if you take that out to what it
turns out to be, that is 50,000 lethal doses that someone--that
you could kill somebody with. And I think that is really
absolutely important.
Dr. Jones, do we anticipate any more aggressive substances
that could be more deadly than fentanyl to enter the illegal
drug market?
Dr. Jones. We certainly see the proliferation of a variety
of synthetic drugs coming in. And as was discussed earlier, it
is fairly straightforward to modify the chemical structures.
So we have seen nonfentanyl-based synthetic opioids like
nitazenes emerge in the U.S. drug market. So it is very
possible that other substances could be created and trafficked
into the U.S. Whether they are opioids or synthetic
benzodiazepines, cannabinoids, or synthetic stimulants, we see
sort of a constellation of synthetic drugs that are fairly
straightforward and easy to produce in labs.
Mr. Latta. Well, I appreciate that.
And Mr. Chairman, my time has expired and I yield back.
Mr. Bucshon. The gentleman yields back. I now recognize Ms.
Kelly for her 5 minutes for questions.
Ms. Kelly. Thank you, Chair Guthrie and Ranking Member
Eshoo, for holding today's critically important hearing.
In Illinois, the leading cause of pregnancy-related deaths
is due to mental health conditions, including substance use
disorders, which comprise 40 percent of pregnancy-related
deaths. This aligns with the national trend of substance use
being a leading contributing factor of maternal death.
Pregnant and postpartum women who misuse opioids are at a
high risk for poor maternal outcomes, including preterm labor
and complications related to delivery, problems frequently
exacerbated by malnourishment, interpersonal violence, and
other health-related social needs.
Infants exposed to opioids before birth also face negative
outcomes, with a higher risk of being born preterm, having a
low birth weight, and experiencing the effects of neonatal
abstinence syndrome, where babies go through drug withdrawals
after birth.
I am pleased to hear about all the investments from the
different agencies to address substance use disorder and
pregnant women.
Mr. Blum, in your testimony you speak about the maternal
opioid misuse model that has been established in seven States.
I am elated that there are 983 women participating in the
model. But how do we expand this program to increase
participation, and what efforts are there to increase the
diversity in the participation pool?
Mr. Blum. Thank you for the question. This model is
relatively new for CMS, and so we are still learning the
overall data impacts. Participation has been relatively small,
just about 900 or so beneficiaries. We want to expand that
work. We want to really learn from what can be learned so far.
But we agree that, for us to improve safety, to improve lives,
to save mothers, to save babies, we have to better integrate
services together.
Ms. Kelly. And I would be interested in hearing, as you
progress, how that is going. So thank you for your response.
Surgery is among the most common indication for opioid
initiative, as opioids are routinely described for preoperative
pain management. Data suggests that there has been an increase
in the amount of opioids dispensed following minor surgical
procedures, and that many U.S. patients receive more opioids
than necessary to treat their short-term pain. This is why I am
happy to work with my partner, Rep. Balderson, to introduce
H.R. 4093, the Remote Opioid Monitoring Act of 2023, which
requires a GAO study on the use of remote monitoring for
patients who are prescribed opioids to better understand the
efficacy, individual outcomes, and potential cost savings from
this tool.
I am also married to an anesthesiologist, so we talk a lot
about this.
Dr. Coderre, thank you for sharing your story. Thank you so
much. With so many individuals having access to opioids due to
outpatient procedures, is there a standardized process to
ensure a safe monitoring of patients prescribed opioids once
they are discharged home, and what additional support should be
provided?
Mr. Coderre. Well, thanks so much for that question,
Congresswoman.
At SAMHSA, you know, we fund the full continuum of programs
related to prevention, intervention, treatment, and recovery
support. And so, as it relates to safe monitoring of opioids,
that is not my area of expertise, but I would be happy to have
our staff work with your staff to get you some data and some of
the resources from some of our programs to respond to you.
Ms. Kelly. That would be great. Also, is alcohol use
disorder an allowable use of funds for other grant programs
such as the Substance Use Prevention Treatment and Recovery
Support Services Block Grant?
Mr. Coderre. Thanks so much for that question. Yes,
certainly, alcohol is an allowable use of State substance use
block grant dollars. The Chair asked me earlier about the SOAR
program, and I neglected to mention that, while SOAR is for
opioids and stimulants, if somebody has a co-occurring alcohol
use disorder, SOAR funds can also be used in that program.
Ms. Kelly. So let me ask. Would adding alcohol use disorder
as an allowable use for the State opioid response grant
program--would that take away funds from the existing opioids
response program?
Mr. Coderre. Well, certainly, Congresswoman, it is a zero
sum game. So if you add something to the program, there will be
less resources available for the other parts. But as you point
out, the substance use block grant is a vehicle that States are
currently using to fund these programs, and we have a few other
programs at SAMHSA that they are using, as well.
Ms. Kelly. So I will just let you know I would support an
increase in funding for a new program.
Mr. Coderre. Thank you so much.
Ms. Kelly. With that, I will yield back.
Mr. Bucshon. The gentlelady yields back. I now recognize
Mr. Bilirakis for his 5 minutes.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
I would like to ask for unanimous consent to insert into
the record two letters, one from the American Veterinary
Medical Association and key animal health and medicine
stakeholder groups, and the other from 39 State attorneys
general, both letters urging passage of the bipartisan bill I
colead with Representatives Panetta and Representative Pfluger,
the Combating Illicit Xylazine Act, H.R. 1839.
Mr. Bucshon. Without objection.
[The information appears at the conclusion of the hearing.]
Mr. Bilirakis. Thank you.
Mr. Bucshon. So ordered.
Mr. Bilirakis. I would also--thank you--I would like to ask
for unanimous consent to insert into the record a letter from
the National Association for Children's Behavioral Health in
strong support of my bipartisan bill, the Ensuring Medicaid
Continuity for Children on Foster Care Act, which I lead with
Representative Castor.
Mr. Bucshon. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Bilirakis. Thank you. So my first question is my bill
will ensure that Qualified Residential Treatment Programs are
exempt from being considered as institutions for mental
disease, which are prohibited from drawing down Medicaid funds
for medical services. QRTPs are one of the few residential
settings that have strong oversight and accountability due to
the Federal qualification accreditation requirements, improving
outcomes for children with acute mental health needs.
Unfortunately, QRTPs have been inadvertently--I really
believe this--inadvertently considered as IMDs under the law,
which could prevent additional options for foster children in
need of care. I was glad to see CMS supports this change, since
it allows States to lift the IMD exclusion for QRTPs under the
1115 waiver. I do believe--I do not believe that QRTPs were
ever intended to be considered IMDs.
And while I strongly support the goal to ensure all foster
children get placed in family home settings, unfortunately the
reality is there is a shortage of licensed foster homes
available for children in need of care--unfortunately, again,
it is very sad--and reports have recently revealed some States
have resorted to, believe it or not--and I have the article
here--putting foster kids up in casino hotels and juvenile
detention centers and other desperate settings since, sadly,
they have nowhere else to go. We have got to rectify this.
QRTPs can help fill this clear continuity of care, again,
with the Medicaid program by providing qualified care on a
temporary basis. So Mr. Blum, will you commit to working with
us to ensure that foster children have the appropriate Medicaid
coverage for medical services in appropriate settings that can
provide care for their mental and behavioral health needs? If
you could answer that, I would appreciate it.
Mr. Blum. Yes, sir. We would be very happy to work with
your office.
Mr. Bilirakis. All right, very good. Next question. I don't
have a lot of time. Next question.
Dr. Jones, you spoke to CDC's Drug Overdose Surveillance
and Epidemiology system and the work that is being done to
collect and analyze data to better understand the opioid
overdose epidemic. It seems to me that electronic health
records and hospital discharge records may only provide a
narrow scope of information, since many struggling may not
officially use the healthcare system or seek care.
As the substance abuse epidemic shifts, I believe we must
also shift our data collection mechanisms. What role could
wastewater surveillance, which is appealing because it protects
individual privacy, play--so what role will it play in
identifying clusters of drug utilization and changes in trends
in suspected drug overdoses at the local, State, and regional
levels? What role can that play, the wastewater surveillance,
please, sir?
Dr. Jones. Thank you for the question. Certainly, we have
seen the value of wastewater in response to COVID. We have used
that same approach for Mpox and other infectious diseases.
There are ongoing discussions about how do we best utilize
the potential for wastewater surveillance in the overdose
crisis. We have prioritized DOSE, which you mentioned, as a
syndromic surveillance system, toxicology data, emergency
medical services data, other data that can connect the
substances being used with the outcomes we are trying to
prevent.
But there is an interagency group that is really thinking
through what are the ethical resource needs, what are the
community acceptability levels for drug-related wastewater
testing. So it is an active area of discussion. I am certainly
happy to come back to the committee and work with the committee
as we continue to explore how best to use wastewater within the
context of the systems we already have.
Mr. Bilirakis. Please, I appreciate that. I think we are on
to something.
Thank you very much, and I yield back.
Mr. Guthrie [presiding]. Thank you, the gentleman yields
back. The Chair now recognizes Dr. Schrier for 5 minutes for
questions.
Ms. Schrier. Thank you, Chair Guthrie, and thank you very
much to the witnesses who are here today.
In my State of Washington, like every other State that you
have heard, substance use continues to rise, and overdeaths--
overuse deaths and overdoses have increased. And in fact,
opioid drug overdose deaths in the State nearly doubled in just
2 years, from 827 in 2019 to over 1,600 in 2021. And that
number is continuing to rise, as we are seeing in every State.
Fentanyl has dramatically added to this picture with
profound and devastating impacts, including in people who have
never used any drug before.
In Chelan County, a rural county in the eastern part of my
district, the coroner recently reported that the number of
deaths adjusted for population is actually 10 times higher than
the rest of the State. And I don't believe this is unique for
rural America. The numbers and absolute numbers were from 6 to
20, but when you look at that as a percentage of population, it
is quite high.
So the people in my district and all over this country are
concerned. I have talked with parent groups about the hard
conversations that they need to have with their children--I am
also a pediatrician--so how to talk with your tweens and teens
early about never accepting any pill from anyone other than a
pharmacist. I have held multiple roundtables in my district to
bring families together with local officials, law enforcement,
behavioral health providers, schools to talk about the impact
of opioids and fentanyl use. And I have had conversations with
mayors and Homeland Security just about how we can prevent harm
and stop this from flooding into our communities.
I wanted to first focus on this epidemic in rural America
because it seems to be hitting there even harder, despite what
many might expect. As I mentioned, Commissioner Overbay told me
about these increasing numbers. One of the worries in rural
America, like with all other healthcare, is do we have the
workforce and do we have the resources to treat substance use
disorder there?
And so, Administrator Espinosa, this question is for you.
You talked about several programs specifically directed at
rural populations. And I was wondering if you could just expand
on those and how reauthorizing the SUPPORT Act will help in
rural communities.
Ms. Espinosa. Sure, thank you for the question. As I
mentioned, you know, HRSA has a strong focus on supporting
rural communities. As you note, there are unique issues there,
particularly in the workforce.
The Public Health Service Act Section 756 Program, which
is--which the committee helped reauthorize in the omnibus, is a
valuable tool for us. We are training professionals, clinical
social workers, psychologists, and others. And a key factor is
that we train them in community-based settings in rural and
underserved areas. And the importance there is that people who
train in areas are more likely to go on and practice there. In
addition, while they are training, they are providing services
in the community.
We have also, through that program, supported families. So
we have a family support program that focuses on community
health workers, peer support professionals, because, as many
have remarked, the substance use disorder issue impacts not
just the individual, but their whole family and their
community. And so those supports are particularly important for
prevention, and also for making--helping people stay retained
in care.
And then----
Ms. Schrier. Can I ask another--just a tangential question?
Because you talked about mental health support, which is so
important. But we also know that we just don't have the number
of practitioners. Many of these substance use disorders began
with an injury and with a need for good pain management. And so
another thing I have heard in rural communities is, ``We don't
have a pain medicine specialist anywhere near here who can help
address that.'' Is that at all included, or is that one of the
things you are focusing on?
Ms. Espinosa. We have included pain management as a
component in the programs that we have authorized. For example,
we have an addiction medicine fellowship program. So in that
training, pain management is a component there.
Similarly for the graduate psychology program, where
doctoral-level psychologists--so where we can, we are including
that as a component of the training.
Ms. Schrier. Thank you. It sounds like a great use of
telemedicine.
I only have 14 seconds left, so I am just going to
highlight the importance of addressing adverse childhood
experiences and ACEs in the risk for teens and children to, you
know, become victims of substance use disorders.
And I want to thank you, Dr. Jones. I was going to direct a
question to you. I just want to thank you for focusing on
children.
Thank you, I yield back.
Mr. Guthrie. Thank you. The gentlelady yields back. The
Chair recognizes Mr. Johnson for 5 minutes for questions.
Mr. Johnson. Well, thank you, Chairman Guthrie. You know,
in 2021, according to the CDC, Ohio had the fourth-highest
number of overdose deaths of any State in the Nation. Every day
when I am back home in Ohio's 6th Congressional District I am
told heart-wrenching stories about this plague that has swept
across Appalachia and that has ended so many young lives. It is
no secret that eastern Ohio, where I call home, has been hit
particularly hard by the opioid crisis.
As a member of the bipartisan Fentanyl Prevention Caucus
and the bipartisan Mental Health and Substance Use Disorder
Task Force, I have witnessed firsthand the power of bipartisan
work in addressing the epidemic.
Opioid addiction does not discriminate based on gender,
age, race, social status, or political view. It takes no
prisoners.
The work that our committee, frequently recognized as the
most bipartisan committee in Congress--the work that we have
done to combat this scourge is one that I commend. Whether it
be the SUPPORT Act, the largest, most comprehensive legislative
response to the opioid crisis, or our continued work
eliminating barriers to mental healthcare and telehealth
services, these efforts are making a difference.
So my first question goes to Dr. Jones.
In your testimony you mentioned the CDC's Overdose Data to
Action prevention program and how it is used to understand the
drivers of overdoses. You specifically referenced my home State
of Ohio. And in fact, the Stark County Health Department in my
district is using a geographic information system to pinpoint
areas in the county that are being hit hardest by opioids and
then share that data online.
Stark County, home to Canton and the Pro Football Hall of
Fame, alone has seen over 500 overdose deaths since 2012. Could
you explain the real-world life-and-death impacts that these
types of data-sharing software and mapping has on communities?
Are they helping bend this devastating curve in the other
direction?
Dr. Jones. Thank you for your question.
I mean, I think data are really foundational to
understanding what is happening in a community, who is at risk,
and how is risk changing, and where should we deploy resources.
And that is really the goal of our support to health
departments, is to use the near-real-time syndromic data, use
emergency medical services data, use mortality data to really
tell that story for a community.
There might be assumptions that a community has that this
area is more impacted than this area, but really using data to
say, in fact, it is here where we need to be deploying
resources--and so, especially with quick response teams, spikes
in overdose with a toxic drug market, these near-real-time data
allow communities to rush in resources to connect people
postoverdose to care, so that they can receive lifesaving
care----
Mr. Johnson. In other words, follow the facts, follow the
science, right, and you make better decisions.
A key component to combating opioid abuse is addressing
pain care and ensuring patients and providers are informed of
the continuum of nonopioid pain therapies. In 2019 HHS released
its Best Practices for Pain Management Task Force
recommendations with the goal of improving safe, effective,
evidence-based pain care in America. Unfortunately, the
recommendations of this task force have not reached wide--
widely reached clinicians.
So Mr. Blum--have I got that right? ``Bloom'' or ``Blum''?
Mr. Blum. ``Blum,'' sir.
Mr. Johnson. ``Blum''? I am sorry. What has HHS done to
distribute the task force recommendations?
And will you commit to developing and implementing a
strategic plan to widely disseminate those recommendations to
clinicians?
Mr. Blum. Thank you for the question, Congressman. We agree
that CMS programs certainly need to do more to expand----
Mr. Johnson. What has HHS done?
Mr. Blum. We continue to work with care systems to identify
better pathways for pain management services, but I am happy to
work with you to find ways for us to improve.
Mr. Johnson. OK, all right. Well, I had another question,
but my time has expired and--or close to it. But thank you
folks for being with us today. Obviously, we have got a lot of
work to do to wrestle this scourge to the ground. And I
appreciate all that you are doing to help us get there. Thank
you for being here today.
I yield back.
Mr. Guthrie. Thank you. The gentleman yields back. The
Chair recognizes Mr. Sarbanes for 5 minutes for questions.
Mr. Sarbanes. Thanks very much, Mr. Chairman. Thanks to all
of you for being here.
We know it is a theme here today, and it is a persistent
one in many hearings, that our communities are facing a mental
and behavioral health crisis, and no community has been left
untouched. We know that because every Member of Congress is
stepping into this conversation in a meaningful way.
I am pleased that the subcommittee is holding this hearing
today to discuss the reauthorization of so many important
programs that work to address these challenges.
I do have to note that this week, unfortunately, however,
the House will consider legislation to continue the
Republicans' attempts at undoing the Affordable Care Act, to
undercut the accessibility of comprehensive and quality
healthcare coverage for millions of Americans across the
country, including many with substance use disorders.
The committee is also considering some legislation today
that gives me some pause because I worry about it having
potentially similar impacts. We all know that telehealth has
been vital to improving timely access to care, particularly in
underserved and rural communities, and there has been some real
advances over the last few years--a lot of that forced by the
pandemic--on the telehealth front. But I do have concerns with
H.R. 824, the Telehealth Benefit Expansion for Workers Act.
Contrary to what the title suggests, I think the bill could
actually put workers at risk of losing their access to the
comprehensive kind of health coverage that they should have. By
expanding accepted benefits--that is a phrase we have come to
know, accepted benefits programs, which is sort of a form of
these junk plans that we worry about that aren't subject to the
ACA's consumer protections--the proposal would allow more
employers to offer these plans, these sort of less-than-
comprehensive and, really, in some cases, shoddy plans, instead
of ensuring all eligible workers are able to enroll in
comprehensive group health coverage.
Accepted benefits are not subject to the ACA's protections
for people with preexisting conditions or subject to the ACA's
mental health parity requirements, and they aren't subject to
the ACA's out-of-pocket spending limits, bans on annual or
lifetime limits or the requirement that insurers spend at least
80 percent of their premiums on actual healthcare, as opposed
to CEO pay and profit.
Mr. Blum, am I accurately characterizing what these
accepted benefit plans are missing?
Mr. Blum. I believe so, yes, sir.
Mr. Sarbanes. Thank you very much. So a proposal like this
would put vulnerable Americans, including those with mental and
behavioral health challenges, at risk and without reason. Mr.
Blum, is there any reason that employers who already have
significant flexibility to offer telehealth coverage--I mean,
you can do that as part of a plan--would they be prevented from
doing so as part of their comprehensive coverage approach?
Mr. Blum. No, sir.
Mr. Sarbanes. Thank you. When we weaken consumer and parity
protections, we are undercutting our response to the ongoing
mental and behavioral healthcare crises and raising healthcare
costs for everyone. Instead, we should be focusing our energy
on building up programs that are proven to help address these
challenges.
I will switch gears here now and talk about one such
program that is doing that. It is the Substance Use Disorder
Treatment and Recovery, or STAR, Loan Repayment Program. I was
pleased to be able to play a role in developing this program in
2018, along with Chairman Guthrie, because I knew it was
critical to create these kinds of incentives for individuals to
serve their communities as behavioral healthcare providers.
Ms. Espinosa, can you comment on the impact that this
program has had in strengthening our behavioral healthcare
workforce pipeline since its inception, and the resources that
are necessary now to ensure that it can reach the most
providers and ultimately promote access to care for the most
patients?
Ms. Espinosa. Thank you for the question, sir.
The STAR LRP program has--is currently supporting 445
people that are in the field providing direct patient care
right now. We are going to make some additional awards this
year by the end of the fiscal year, and that will be over 600.
It has a tremendous impact in expanding the types of sites that
can receive this type of support. Loan repayment is critical in
some places in being able to attract the workforce that you
need. It provides the providers--the employers an additional
incentive that they can offer folks.
And so we have also been able to greatly expand the types
of providers. And so we are--these are people that are now
working in both inpatient and outpatient, paraprofessionals
that are working as peer support counselors and throughout the
community. So it has had a significant impact in targeting that
particular gap in supporting the workforce.
Mr. Sarbanes. That is terrific. We look forward to hearing
about how it continues to scale up.
With that, I yield back, Mr. Chairman.
Mr. Guthrie. Thank you. The gentleman yields back. The
Chair now recognizes Dr. Bucshon for 5 minutes for questions.
Mr. Bucshon. Thank you, Chairman Guthrie, and thank you to
the witnesses for being here today.
We have people in ERs, in jails, and on the street with
substance abuse disorder. We are doing them a disservice, and
we all have to do better.
The SUPPORT Act contains several critical policies to
reduce opioid-related harms by improving pain management and
patient awareness of and access to nonopioid treatments,
including FDA-approved medical devices, nonopioid medicines,
and other therapies.
Unfortunately, 5 years after passage, there are several
provisions of the SUPPORT Act where the executive branch has
failed to fully implement policies or to meet required
deadlines.
Mr. Blum, I have been a big proponent of breaking down
reimbursement barriers to increased adoption of nonopioid
alternatives. Congress has worked in a bipartisan fashion to
unbundle nonopioid payments from the ambulatory surgery center
and hospital outpatient setting to spur adoption of new and
innovative nonopioid treatments. However, I am concerned with
inconsistent coverage policies that are harming patient access.
I do believe we are in a critical phase concerning how CMS
makes or doesn't make national coverage decisions for
innovative medical therapies in a timely and appropriate
manner. More specifically--and this is related to Medicare
Administrative Contractors--I have heard from physician
organizations that they have implemented far more restrictive
policies for nonopioids in the face of an existing National
Coverage Decision which, by law, they are not allowed to do.
Can you tell me what CMS is doing to enforce NCDs?
Should Congress look to clarify that MACs are not allowed
to have more restrictive coverage policies, particularly for
nonopioid alternatives?
Mr. Blum. Thank you for the question, Congressman.
By statute, we have a Medicare coverage framework that
delegates much decision making for coverage to MACs. That is
one fundamental tenet to our statute.
CMS works hard to oversee that process. And whenever we
hear concerns that MACs aren't following the law, aren't
following processes, aren't following notice and comment, that
we are comfortable to step in to ensure strong oversight.
Mr. Bucshon. That is great, because it is not working, just
so you know. I am hearing that from not--I am not directing
this at you personally, I am directing this at the agency.
And why is that? Well, let me see. Opioids cost almost
nothing, and nonopioid alternatives are expensive in many
cases. Makes sense, right? So you have administrative
contractors limiting access to nonopioid alternatives. It is
unacceptable. CMS needs to do better.
Question number two, continuing with the issue of
reimbursement for nonopioid alternatives, as was mentioned by
Ranking Member Eshoo, CMS has yet to release the Todd Graham
Pain Management Study, section 6086 of the SUPPORT Act, 5 years
later, which directs CMS to revise payment and coverage of
nonopioid pain treatment options. We need the data. It seems
CMS is dragging their feet. I don't know why. It seems CMS
has--drags their feet a lot. I work with them a lot, and it has
taken years sometimes to get innovative treatments covered that
are approved by the FDA, by private insurers, by the VA. We
have to do better. We need this data so we can move forward.
And on the topic of implementation, the CMS Opioid Action
Plan, section 6032 of the SUPPORT Act, was released in 2021.
How has CMS adopted the action plan to revise payment and
improve coverage of devices, nonopioid medicines, and other
therapies?
Mr. Blum. Thank you for the question. The CMS has worked
hard to implement all of the SUPPORT Act provisions. We are
happy to follow up with any specific concerns of areas that we
are falling short.
Mr. Bucshon. Time is of the essence. And Mr. Chairman, as I
said and I implied, CMS should not be the limiting factor
related to access to FDA-approved medical therapies or devices.
This needs to end. CMS needs, in my opinion, top-to-bottom
reform. It is overly bureaucratic, and it takes years to get
approval and access to devices and medical therapies to
patients. I have personal experience with this. I have been in
Congress--this is my 13th year.
So I implore us to do something about these unnecessary
delays that are limiting the access to alternatives to opioids,
because opioids are very, very cheap, and nonopioid
alternatives may not be, and so funding and paying for these
things is limiting access, I think, based on finances. And that
is just unacceptable.
I yield back.
Mr. Guthrie. Dr. Bucshon yields back. The Chair recognizes
Mrs. Dingell from Michigan for 5 minutes for questions.
Mrs. Dingell. Thank you, Mr. Chairman, and to you and
Ranking Member for convening this really important hearing.
Many if not all of us have deeply personal stories of
losing loved ones, friends, and constituents to opioids and
addictions and the fentanyl. With the growing opioid and
fentanyl crisis, these stories are becoming distressingly
common. So it is important that this subcommittee is taking
action to address this crisis with the urgency it requires,
including expanding upon the important progress we have made
through the enactment of the SUPPORT Act in 2018.
As we work to continue responding to this crisis--and I
agree with my other colleagues who say we are not going fast
enough; someday we are going to get something that somebody
will prescribe that is not addictive like opioids for pain
relief--it is critical that we authorize key provisions that
are set to expire at the end of this year.
The SUPPORT Act authorized a pilot program to improve
coordination between public health laboratories and those
operated by law enforcement to better detect fentanyl and other
synthetic opioids. Dr. Jones, you mentioned that the CDC is
strengthening public health testing by developing advanced
laboratory tests for fentanyl. How can lab testing improve our
understanding of opioid trends and new, emerging threats?
Dr. Jones. Thank you for the question. I think it is a
really important point that we are in a very dynamic, illicit
drug market where new, emerging substances need to be
identified as quickly as possible so that communities can
respond to those threats.
That provision in the Public Health Act, unfortunately, has
not been appropriated, but we have used funding through our
overdose line to support our public health lab work, developing
reference materials, traceable opioid material kits, as well as
other reference standards that public health as well as
clinical labs can use to try to stay on the cutting edge of
what is emerging in communities.
And I think the components of that section are also
important about public health and public safety working
together. We are here together with DEA. We share information.
We work closely together at the Federal level, but we are also
supporting that work at the State and local level as well.
Through our overdose response strategy, we pair up drug
intelligence officers and public health officials to share
data, to share information, to have a common operating picture
of what is going on, what is emerging, and what do we need to
do together to advance solutions to the crisis.
So having that data is absolutely critical so that
communities can understand how is it changing, how do we need
to change tactics to address emerging threats.
Mrs. Dingell. Thank you, I agree with that. I am going to
do a question for the record on the--working with the other
labs, but I want to move to another question. Last week I
introduced the FIND Fentanyl Act with Representative Bilirakis
to reauthorize the SUPPORT Act's lab pilot program through
fiscal year 2028. And I am grateful that this bill is included
as part of today's hearing. And thank you to Rep. Gus Bilirakis
for his partnership on this important effort. So we are going
to work it.
Now I want to shift our focus a bit and talk about the
importance of ensuring people in recovery can access the care
they need, surrounded by their families and friends. As many of
you know, I have worked very hard to ensure--not getting there
yet--that folks can access care in home and community-based
settings, or HCBS. We know that, given the choice, most people
would prefer to remain in their homes and communities while
they receive treatment, rather than being sent off to an
institution. And that is why I am concerned about policies that
could lead to an increase in people being in institutions.
Mr. Blum, there are two bills before us today that would
further weaken the Institution for Mental Disease, or IMD,
exclusion. Other than the State plan amendment that Republicans
would like to extend, are there other options for State
Medicaid programs to cover IMD stays?
Mr. Blum. Thank you for the question. Today CMS works with
States to help design comprehensive systems that provide
coverage for the full spectrum of care services that can best
meet patients where they want to receive those services.
Mrs. Dingell. So that is what I thought. So for the record,
so a State that wants to cover IMD stays in Medicaid has
options, even if this option were to expire.
I also want to ask about the waivers you mentioned. It is
my understanding that a condition of those waivers is that
States must support a continuum of care. Mr. Blum, can you talk
about why it is important that individuals seeking treatment
have access to care in more integrated settings in their homes
and communities and not just care in IMDs?
Mr. Blum. Well, we know that patients prefer to receive
services in different care settings. And we also know that one
size doesn't fit all. And so work today that CMS does is to
work in close partnership with States to ensure that we can
help support programs that best meet those needs. And one
principle that we believe is vital is that we provide--help
support States to provide services to that full spectrum.
Mrs. Dingell. I know I am out of time, Mr. Chair. I yield
back.
Mr. Guthrie. Thank you. The gentlelady yields back. The
Chair recognizes Mr. Carter for 5 minutes for questions.
Mr. Carter. Thank you, Mr. Chairman, for holding this
hearing, and thank all of you for being here.
Dr. Jones, it is always good to see you. I appreciate you
all being here.
Mr. Strait, I want to ask you, the DEA released two
proposed rules back in March that would govern the prescribing
of controlled substances via telemedicine following the COVID-
19 public health emergency, of course. And there were many,
many comments from stakeholders on this.
And in May the agency and SAMHSA released a temporary
extension of COVID-19 health emergency waiver authorities that
allowed for some controlled substances, anyway, to continue to
be prescribed via telemedicine without an in-person visit
through November 11th of this year. It is my understanding that
this temporary extension will give DEA and other agencies the--
more time to review and respond to these comments as part of
the rulemaking.
You well understand it is critical for patients across the
country that the DEA process the final rules in a way that is
going to balance patient access with concerns about diversion.
I mean, we are concerned about diversion. There is no question
about that. But we also need access, especially--especially--
for those patients that are utilizing buprenorphine as a
medication to treat opioid use disorder.
If the DEA has not completed the rulemaking process by the
November deadline, can you assure and commit to issuing another
temporary extension so that patients can retain access to this
care that they need?
Mr. Strait. Thank you for the question, Congressman.
First of all, I want to say, from DEA's perspective, we
believe that telemedicine is medicine. Telemedicine is here to
stay.
Mr. Carter. Right.
Mr. Strait. But with that we also want to acknowledge the
fact, you know, that this rule impacts the delivery of
healthcare for every American, and we want to make sure we get
it right.
So we, obviously, did get a robust response to our proposed
rules, 38,000 comments, as has been noted previously. And we
want to make sure we are giving a thoughtful review, again, to
make sure that we are getting it right, because we know how
important this is.
Mr. Carter. OK. So can you commit that you will extend the
date if you don't have it done by then?
Mr. Strait. Well, we definitely believe that the 6 months
is going to be sufficient to do an adequate review of the
comments, but we are not going to let these vital services
lapse.
Mr. Carter. OK, good. All right. Very quickly, I want to
turn to another piece of legislation that I am leading, along
with Congresswoman Schakowsky, who is waiving onto this
subcommittee today. It is H.R. 4096, and it is pending before
the committee today. It is legislation that standardizes the
oversight and reporting of antipsychotic medications prescribed
to Medicaid recipients.
I was really alarmed at a GAO report that found
extraordinarily high rates of schizophrenia diagnoses and other
psychotic disorders among Georgia Medicaid recipients. It
looked like an outlier to me. I was just taken aback by that.
But this is very important. It is important to note and it
is disturbing to note that GAO also found a high antipsychotic
use in Georgia, over 90 percent--over 90 percent--of the
beneficiaries with intellectual or developmental disabilities
in Georgia with schizophrenia had used antipsychotic
medications. And this suggests that there might be an
overprescribing problem, especially in Georgia.
Mr. Blum, what actions can CMS take to monitor the
prescribing of antipsychotics?
Mr. Blum. Thank you for the question, Congressman. We, too,
are very concerned, alarmed at those same numbers. We have
taken strong steps to better collect information from nursing
homes that serve Medicare and Medicaid patients, and we are
prepared to take strong steps when we see prescribing that
doesn't meet clinical standards.
Mr. Carter. OK. All right.
At this time, Mr. Chairman, I am going to yield to
Congresswoman Schakowsky, if she--she is leading this
legislation with me.
Ms. Schakowsky. Thank you, Representative Carter. I just
want to say how happy I am to join this. For a long time I have
been very concerned about the overuse of antipsychotics for the
purpose, really, of restraint.
And I, too, I just wanted to ask Mr. Blum, are you--do you
have any estimation of how--I am assuming lives would be saved
if legislation like this would be--would be passed, and I
wondered if you could comment on that, because the FDA has said
that these drugs can kill up to 15,000 nursing home residents
every year.
Mr. Blum. We share the view that lives will be saved. We
share the view that quality of care will improve. We know from
clinicians there are legitimate uses for prescribing, but we
also know that we have seen spikes that can't be explained. So
we share the goal that you have, and I am happy to work with
you to ensure that we can move forward better.
Ms. Schakowsky. Thank you.
Thank you, Mr.----
Mr. Carter. And reclaiming my time real quickly, I was a
consultant pharmacist in nursing homes for many years, and I
have seen chemical restraints like this. And this is a big
problem. So I hope that CMS is looking at this diligently and
very closely.
Mr. Blum. I can assure you that we are, Congressman. I can
also assure you that we are hearing very strong pushback. But
CMS will stand strong, and we share the goal that you have.
Mr. Carter. Great. Thank you, and I yield back. Thank you.
Mr. Guthrie. Thanks. The gentleman yields back. The Chair
recognizes Dr. Dunn for 5 minutes.
Mr. Dunn. Thank you very much, Mr. Chairman.
Mr. Strait, we know that we have shifted from a
prescription opioid crisis to a new crisis now surrounding
illicit fentanyl. But we have also seen xylazine being used as
an adulterant to the fentanyl and its analogs. This is the
reason I cosponsored the Combating Illicit Xylazine Act, which
we think will help law enforcement better track the information
and enforce the law against traffickers distributing it
illegally.
Now, this is a delicate policy because I recognize that
this drug, you know, represents the unique challenges of a
regularly utilized FDA-approved drug in veterinary uses, and it
is safe in animals. But it is, obviously, quite deadly in human
beings, so we want to make sure we strike the right balance.
Can you briefly speak to the importance of the policy, and
perhaps how we could do that best, how we can empower the DEA
to address xylazine as an illegal adulterant but yet a legal
drug in veterinary medicine?
Mr. Strait. Sure. Thank you for that question. And it is
the same kind of delicate balance that we are talking about at
DEA, as well, and you described it perfectly.
On the one end, we know it is being encountered with
fentanyl and creating potentially devastating consequences on
people who would unsuspectingly use it. But at the same point,
we also know that it has got widespread veterinary
applications, specifically in large animals. So we too want to
strike the appropriate balance on what makes best to protect
public safety, while also ensuring that it is available for
public health. And we are kind of not ruling any options out.
As Congressman Pallone mentioned at the outset, we know
that there is an interagency process and some executive branch
procedures underway, but we also welcome the opportunity to
work toward a legislative solution as well.
Mr. Dunn. Well, we would love to work with you, would love
to see--I don't think the people who are out of the medical
practice--out in the medical world actually appreciate the
difference between this and fentanyl. When we say fentanyl, we
mean the analogs of fentanyl, which are clearly not legal
drugs. And now we are talking about an illegal drug being used
as an adulterant in an off-label way--way the hell off-label,
out-of-the-species-label way.
So it is, it is a little bit of a different problem for us.
But I think--I trust that we can do this, and do it with
alacrity. So I look forward to working with you. Thank you very
much.
Mr. Chairman, I yield back.
Mr. Guthrie. The gentleman yields back. The Chair now
recognizes Ms. Barragan from California for 5 minutes of
questions.
Ms. Barragan. Well, thank you. Thank you, Mr. Chairman.
Mr. Blum, thank you for CMS's steadfast work to encourage
States to apply for the new Medicaid reentry waiver program.
On January 26, 2023, CMS approved California's section 1115
waiver request, which is a first in the Nation to include a
partial waiver of the Medicaid inmate exclusion policy for
justice-involved individuals for up to 90 days prior to
release.
In December 2023, Congress passed bipartisan changes to the
Medicaid law to require State Medicaid programs to start
covering services for young people in juvenile detention 30
days prior to their release to help them transition back to
their communities.
What progress is CMS making to implement the changes, and
how would the implementation of this legislation interact with
California's 1115 waiver?
Mr. Blum. Thank you for the question. We were very happy to
work with California to put in place this new waiver. CMS wants
to--would welcome working with other States. We share the goal
that California has to ensure that whatever we can do to
continue coverage for services keeps going forward. CMS today
welcomes but also encourages more States to follow California's
lead.
Ms. Barragan. OK, thank you.
In the 5 years since the SUPPORT Act was first passed, the
opioid epidemic has evolved, and some challenges have continued
to grow. One of these challenges is how the opioid crisis
continues to fuel increases in deaths for people who are
experiencing homelessness.
According to the Los Angeles County Department of Public
Health, between 2017 to 2019, people experiencing homelessness
in LA County were more than 36 times more likely to die of a
drug overdose compared to the general LA County population.
Mr. Blum, can you discuss the innovative strategies CMS is
testing to address homelessness and other housing stability
needs for individuals with substance use disorders?
Mr. Blum. Thank you for the question. We have started to
work with States, California being one, to test ways for us to
expand services that help to support better healthcare
outcomes.
One of those services that we are--very early testing of is
limited, but carefully designed housing programs. These
programs are new, are just starting, but we see further
interest from other States for similar care models.
Ms. Barragan. OK. Well, this is an issue that I think is
going to be very important on addressing homelessness. It is, I
think, one of many of the factors into going--why, you know, we
are seeing the numbers go up, and making sure we are providing
assistance to folks.
Now, substance use disorder can be both a cause and a
consequence of homelessness and a significant barrier to
exiting homelessness. Stable housing plays a vital role in the
recovery process for individuals who are experiencing or at
risk of experiencing homelessness. And so States are
increasingly testing, evaluating, and advancing best practices
around providing housing-related and recovery services and
supports for Medicaid-eligible individuals.
Mr. Blum, what are some of the lessons learned by CMS or
States regarding the Medicaid waivers approved under section
1115 or 1915, and how Congress can use these lessons to improve
upon existing CMS authorities or maybe create new ones to
ensure that Medicaid resources for housing-related services are
coordinated and easily accessed by the people in need?
Mr. Blum. Thank you for the question. These services are
new. They are relatively new. I don't think we have sufficient
data to come back to this committee to say how permanent policy
can be best designed.
But what I can say, we are happy to stay in touch. We are
happy to report progress as California but other States move
forward with these new innovations.
Ms. Barragan. Great, thank you.
Ms. Espinosa, healthcare centers have identified behavioral
health as the highest priority for service expansion, and they
continue to play a critical role in reducing overdose deaths
and improving mental health. Could you please explain how HRSA-
supported Community Health Centers collaborate with community-
based organizations to increase access to behavioral health
services?
Ms. Espinosa. Sure, thank you. Our health centers have
partners throughout the community that they use for referrals,
bidirectional referrals. Health centers have significantly
expanded the behavioral health services they have provided
since they started making targeted investments, increasing
behavioral health--mental health by about 50 percent and
substance use disorder by doubling it.
So they have been able to leverage these, but they are
still not meeting all the need, and that is why we think it is
very important to continue the funding for health centers, so
that we don't lose ground on this important service venue.
Ms. Barragan. Well, thank you, Ms. Espinosa, for that
excellent explanation.
You know, Community Health Centers provide comprehensive
healthcare services, regardless of a patient's ability to pay,
and a lifeline for so many individuals and families across the
Nation. I, for one, as a kid, we used Community Health Centers,
yet they are only able to meet about 25 percent of the demand
for mental health services. So that is one of the reasons me
and my colleagues, Representatives Blunt Rochester and Kuster,
have introduced a bill called the Health Center Service
Expansion and Provider Shortage Reduction Act to provide
funding in behavioral health service investments to support and
expand behavioral health services in about 1,400 health centers
across the country.
So thank you all for your work, and for being here today.
And with that, Mr. Chairman, I yield back.
Mr. Guthrie. Thanks. The lady's time has expired. So I note
the clock didn't start exactly right, so we didn't give you an
extra 4 or 5 minutes. You had your full 5, I know, you are
good. You are good.
So now the Chair recognizes Dr. Joyce for 5 minutes for
questions.
Mr. Joyce. Thank you for yielding, Mr. Chairman, and to our
witnesses for appearing here today at this critical legislative
hearing.
This marks another important step in the legislative
process as we work as a committee to reauthorize the SUPPORT
Act, a process that--Chairman Guthrie brought the subcommittee
to Gettysburg, Pennsylvania, where we heard powerful and
important testimony from my constituents. And I would like to
thank Mike Straley, Police Chief Bill Saravala, and addiction
specialist Dr. Mitch Crawford again for their input and for
sharing their firsthand experience with the opioid and
addiction crisis that we are currently facing. We were able to
examine crucial questions, particularly access to recovery
services and how we can improve upon the SUPPORT Act as we move
forward.
I would also like to thank the committee for including H.R.
4097, the Mental Health Improvement Act, which I cointroduce
with Representative Sykes here today. This bill reauthorizes
756(f) of the Public Health Service Act, which provides
important grant funding for our behavioral health workforce.
Deputy Administrator Espinosa, can you please elaborate on
your testimony on how this funding is used, particularly in
rural areas like mine, to train healthcare workers and expand
access to behavioral and mental health services?
Ms. Espinosa. Yes, thank you for the question.
Our behavioral health workforce programs emphasize the
importance of clinical training in those underserved
communities and rural communities. So we are training
professionals and giving them that experiential learning in
those most underserved communities that has implications for
where they go on to practice, since people who have experience
in those areas are more likely to go practice there, and it
also expands services in those communities by having them as
training sites.
We have also been supporting the paraprofessional workforce
to support communities in the broader sense. Those are
community health workers, peer support specialists, those key
positions that help with prevention and help make sure that
people in rural communities are retained in care, and then can
help them overcome some of the obstacles for staying in care.
Mr. Joyce. Thank you.
Ms. Espinosa. So----
Mr. Joyce. I continue to be very concerned about the
increase in fentanyl poisonings that we are seeing across the
country. And fortunately, the House recently passed the HALT
Fentanyl Act to permanently place fentanyl-related substances
into schedule I of CSA and work toward getting these weapon-
grade poisons off of our streets.
Mr. Coderre, in your written testimony you mentioned that
the prevalence of synthetic and illicitly manufactured opioids
have led to a significant increase in overdose deaths. How has
the increase in synthetic opioids, including illicit fentanyl,
impacted the way that SAMHSA communicates with treatment
providers and disseminates what best practices are and what are
available?
Mr. Coderre. Thank you so much for that question,
Congressman.
At SAMHSA, as you know, we are concerned with the full
continuum of care for substance use disorders: prevention,
treatment, recovery support, as well as intervention. And so we
use our programs to communicate with States and local
providers. We have a variety of centers of excellence that work
with our folks on the ground to alert them of these dangers,
provide them with the best practices for treatment and recovery
support in these instances. But we would be happy to work with
you and your team to identify ways we could do better.
Mr. Joyce. Thank you. I look forward to that collaboration.
At the recent SUPPORT Act reauthorization field hearing
that I mentioned in Gettysburg, I highlighted that improving
pain management for the 50 million Americans in chronic pain is
a critical component in helping to combat our country's
substance misuse crisis. Both the SUPPORT Act and its
predecessor, CARA, had numerous policies to improve pain
management, including the creation of the Pain Management Best
Practices Task Force to make recommendations to improve pain
care and to reduce opioid-related harms. The task force called
for individualized, multimodal care, improved access to
nonopioid therapies, and increased education on pain management
best practices.
Director Jones, did the CDC's updated opioid prescribing
guidelines incorporate task force recommendations?
And what educational tools has the CDC developed, and how
are they used to promote nonopioid options?
Dr. Jones. Thank you for the question, and I certainly will
underscore that the Pain Management Task Force was a very
important piece of the SUPPORT Act in bringing people together
to really elevate the conversation not just about opioids and
what role they might play in pain, but also how we might look
at pain more holistically.
The CDC guideline, which came out last year, repeatedly
references the Best Practices Task Force document and has good
consistency with those recommendations for how we approach pain
care and prioritizes nonopioid medications or nonopioid--
nonpharmacological treatments for pain, recognizing there is a
role for opioids but in many cases nonopioid treatments may
actually be the better option for patients to actually achieve
their pain-related goals.
Mr. Joyce. And I think all of those options need to be
evaluated and continue to be evaluated.
Chairman, my time has expired, but again I thank you for
bringing the Health Subcommittee on the important issue of the
SUPPORT Act to Gettysburg, Pennsylvania, and I yield.
Mr. Guthrie. Thank you. That was a wonderful trip. The
gentleman yields back, and the Chair recognizes Ms. Craig for 5
minutes for questions.
Ms. Craig. Thank you so much, Mr. Chairman, and thank you
to all of the witnesses for being here today. I am so heartened
by the number of good, bipartisan bills that we are discussing
here today.
But I want to be clear. We are in an American crisis. Over
the course of this hearing, approximately 21 people will die of
a fentanyl overdose. That is why my bipartisan bill with Mr.
Griffith, the RECONNECTS Act, is so critical. It will provide
Federal resources to our public health agencies to head off
overdoses before they occur. This is an important issue, and I
am glad--really, really heartened--that it is so bipartisan.
To start I want to focus my first question on the
importance of this legislation in the continued fight against
the opioid epidemic. Dr. Jones, can you talk a little bit about
the function of prescription drug monitoring programs and how
they serve as a public health tool?
Dr. Jones. Thank you for the question.
So prescription drug monitoring programs are State-based
programs that capture information from pharmacies on controlled
substances that are dispensed in that jurisdiction. They can be
used as a clinical tool. So pharmacists, physicians, nurse
practitioners, other prescribers can go into the system if they
are treating a patient to see has that patient been prescribed
other medications by other providers, where there might be an
interaction or there is some pattern of potential misuse so
they can provide information to make those clinical decisions.
But they also can be used as a data tool to help States
understand what are the prescribing trends that are happening
in a State, how might they vary across communities in their
State, where might they deploy resources to support, whether it
is addiction or better access to pain care?
Ms. Craig. Thank you so much, Dr. Jones.
I want to note that the RECONNECTS Act explicitly
designates the fentanyl crisis as a new and emerging public
health crisis. To me this is a critical addition to current
law.
Next I would like to touch on another new and emerging
threat that our country is facing. Mr. Strait, earlier this
year DEA issued a public safety warning of a sharp increase in
the trafficking of fentanyl mixed with--sorry, I can't see here
today--xylazine. How has the introduction of xylazine into the
illicit drug market complicated DEA's efforts to combat the
fentanyl crisis?
What do you need from Congress to better address the
emerging threat of xylazine?
Mr. Strait. Thank you for that question. I didn't get a
chance to say this earlier, but in this current fiscal year
about 25 percent thus far of our powder samples of fentanyl are
containing xylazine. And that, obviously, complicates kind of
what you were talking about earlier with your previous--with
your legislation with trying to reduce the number of overdose
deaths, because that is a complicating factor to how a patient
may present, and the ability of Narcan to actually impact a
positive outcome there.
So at DEA we are kind of taking a look at and seeing what
options are available to us to have better data to understand
where this xylazine is coming from, and so that we can go back
and try to, you know, try to address the threat where it
begins.
Ms. Craig. Well, I just want to say that we really
appreciate all of your efforts in my district and across the
country. There is absolutely no time to waste. Lives depend on
whether we have the political will to act. I am ready to work
with anyone to address these problems head on, and I am really
grateful to my colleagues across the aisle who are doing the
same.
With that, Mr. Chair, I again, recognizing the urgency of
this issue and the fact that we have no time to waste, I yield
back.
Mr. Guthrie. Thank you. The gentlelady yields back. The
Chair recognizes Mr. Crenshaw for 5 minutes for questions.
Mr. Crenshaw. Thank you, Chair and Ranking Member. Thank
you to the witnesses for being here today.
As we consider the SUPPORT Act, I want us to think of 21st
century solutions to substance abuse. PTSD and substance abuse
disorders often happen together. Forty-six percent of those
with lifetime PTSD will also have substance abuse disorder.
One of the solutions I am working on is getting clinical
trial guidance for psychedelic therapies, a guidance from the
FDA, of course. And this therapy will be Earth shattering. It
already has been. It has already changed dozens of lives. I
have dozens of testimonies from veterans and service members
who have suffered severe traumatic brain injuries and severe
PTSD--they were on the brink of suicide--whose lives were
changed by these therapies.
It is not just veterans, it is also people living with
PTSD, whatever kind of trauma they have gone through. Civilians
struggling with addiction have benefited massively as well. The
testimonies from each and every person who goes through these
therapies is they no longer drink and they no longer do drugs.
They have no need for it after one day of a therapy with a drug
called ibogaine, for instance. And this is not--again, not just
veterans, people like John Costa, who, after participating in a
clinical trial at NYU, was cured of his alcoholism.
We are not talking about 1960s LSD trips. This therapy is
supervised by a medical practitioner, often occurs with repeat
treatments in a controlled setting.
And when it comes to the efficacy of this therapy, the
proof is in the data, in the testimonies. But we need the FDA
to issue clinical trial guidance for psychedelic-assisted
therapy so that the industry can actually invest in this. Right
now it is difficult for researchers to pursue these trials
without any direction at all from FDA. Without that direction,
it is even more difficult for us to conduct the research to tap
into this breakthrough treatment option.
Unfortunately, I was told we could not get this bipartisan
bill noticed in today's hearing, but I would appreciate the
chairman's commitment to put it in future markups.
Mr. Guthrie. I will work with you.
Mr. Crenshaw. Now I want to shift gears to the fentanyl
issue.
Everyone on this committee should know that one of my top
priorities is confronting the cartels head on. They are
poisoning tens of thousands of Americans per year with
fentanyl, and this is particularly true for communities in my
district, like Harris County, where fentanyl and fentanyl
derivatives kill at least one person every day. The cartels
facilitate and take advantage of our open borders so that they
can push deadly fentanyl into our country while Border Patrol
resources are diverted to deal with mass influxes of migrants.
The cartels and their Chinese Communist Party allies are
constantly changing the chemical composition to evade law
enforcement. The new emerging threat is illicit xylazine, which
the cartels are mixing into fentanyl. It is cheaper to produce,
easier to sell, produces a different high, severe side effects.
I am supporting Representative Pfluger's legislation to
permanently schedule illicit xylazine so that we can actually
prosecute traffickers with the penalty they deserve.
Mr. Strait, can you explain why you are unable to schedule
drugs through the administrative process and need congressional
action, and what type of congressional action?
Mr. Strait. Well, thank you, Congressman Crenshaw. And I
think you summarized the issue as well as my previous colleague
who was here in February talking about this threat.
So the short answer to your question is that there is an
administrative process that we are currently pursuing. We are
taking an all-options approach at this point, and we are going
to be considering our executive branch procedures for
considering potential control under the CSA, as well as
opportunities to work with Congress in the event that that
could be potentially quicker.
Mr. Crenshaw. Can we just talk in general about the
fentanyl poisoning problem? And that is your description of it,
that is my description of it as well. It is a poisoning
problem. What is preventing us from stopping this?
Is it lack of resources? Do you just not have enough agents
on the ground?
Or is it lack of authorities? Can you not prosecute people
effectively when they are caught dealing fentanyl?
Or is the only way--is the only solution to target the
actual source, the cartels in Mexico producing it?
Mr. Strait. I think the targeting piece is certainly one of
the most important aspects of this administration's approach to
addressing the problem.
Mr. Crenshaw. Targeting of cartels----
Mr. Strait. Yes.
Mr. Crenshaw [continuing]. Specifically within Mexico.
Mr. Strait. Yes, sir.
Mr. Crenshaw. Yes, and how successful are we? I mean, do
we--how is the DEA's relationship with the Mexican Government?
Are they being cooperative?
Mr. Strait. Well, on that one I will probably pivot, just
because of my role within DEA. I am part of the 20 percent of
the organization that has that regulatory role on domestic----
Mr. Crenshaw. OK, fine.
Mr. Strait [continuing]. On the domestic supply chain. But
I do want to make one important point, and it is something that
Dr. Jones made earlier.
You know, I think the biggest threat that we have noticed
with opioid misuse has been this constantly evolving landscape,
where we have gone from prescription drugs to heroin to
synthetic drugs, which have included opioids and now nitazenes
and other substances. And that will continue to be a problem.
It has been the situation for my----
Mr. Crenshaw. Excuse me, if I can go over time just 1
second. So I listed three things, right: lack of resources,
lack of authorities, target the cartels directly. You chose
target the cartels directly, as, I think, the number-one
missing element in being able to stop this. Is that----
Mr. Strait. No, sir.
Mr. Crenshaw. OK. The other two are important also?
Mr. Strait. I apologize. I apologize. I am telling you that
that is the number-one priority for our Administrator at this
point.
Mr. Crenshaw. OK.
Mr. Strait. That is what we are focused on.
Mr. Crenshaw. OK. Well, that tells me something. Thank you.
And I yield back.
Mr. Guthrie. The gentleman yields back. And Mrs. Trahan,
you are ready?
OK, Mrs. Trahan, you are recognized for 5 minutes for
questions.
Mrs. Trahan. Thank you, Mr. Chair.
Time and again, this committee has come together in a
bipartisan manner to pass critical policies to address the
addiction overdose crisis that has been plaguing our
communities for far too long. At the end of last year we passed
policies that break down barriers to buprenorphine access as
well as increased knowledge on how providers can help their
patients who may be suffering with substance use disorder.
Now we must take this unique opportunity to hold--to build
on that progress, to strengthen our response to the ongoing
addiction crisis, including increasing equitable access to all
FDA-approved MATs, like methadone. The hearing today includes a
bipartisan bill I introduced with Representative Lori Chavez-
DeRemer that authorizes a monitoring and education program
regarding infections associated with illicit drug use.
Dr. Jones, can you please state the importance of this
program and how a program like this can help to break down the
stigma associated with opioid use disorder?
Dr. Jones. Thank you very much for the question.
We have seen over the last decade, certainly, increases in
hepatitis C, hepatitis B virus, as well as outbreaks of HIV in
communities across the country associated with injection drug
use. And so the authorization and investment in expanding
access to services not only to increase testing for viral
hepatitis or HIV, expand vaccination for A and B, as well as
referral to treatment services for, you know, antivirals that
can cure hepatitis C or treat HIV or HIV prep, those are really
critical services for people who inject drugs.
And oftentimes that population is highly stigmatized and
marginalized. And our work in this space is supporting health
departments and community organizations to really meet the
moment where those individuals are through syringe services
programs, through other programs in communities that can
approach individuals with compassion and empathy who have often
not wanted to engage with the health system because of stigma
in the way that they have been treated.
So it is a really critical investment in reaching a very
high-risk population not only for overdose, but also infectious
disease transmission.
Mrs. Trahan. I appreciate all of that, and it is something
this committee will take into account.
So in early 2000, a company in my home State of
Massachusetts paused its wastewater epidemiology work in
opioids to focus on the COVID-19 pandemic, making the
Commonwealth a pioneer in measuring SARS-CoV-2 community
infections in wastewater. Now this same company is expanding
its wastewater platform as it shifts back to the opioid space
to help communities better understand and respond to high-risk
substance use at all community levels.
So, Dr. Jones, to you again, in your testimony you state
that CDC works with State and local communities to ensure
funded programs and resources are identifying and addressing
trends in the overdose landscape that are evident through data
systems. I understand the CDC utilizes wastewater epidemiology
data analysis to identify emerging infections within
communities. How can wastewater epidemiology help to identify
emerging substances related to illicit opioid use like
fentanyl, and now xylazine?
Dr. Jones. Thank you for the question. It is certainly an
active area of discussion within CDC, but also more broadly
within the interagency and the executive branch about what is
the role, how do we apply what we have learned through COVID
and Mpox and other infectious disease outbreaks that might be
useful in helping communities tap into wastewater surveillance
as a component of the overdose crisis response?
I think we are still trying to work through what are the
ethical and legal constraints, community acceptability,
resources to do that work, and then how does it fit within the
other data collection systems that we have. And we have
prioritized, under our Overdose Data to Action program,
emergency department data, mortality data, EMS data, which
links the substances that are being used with the outcomes that
we are trying to prevent. So it does provide very actionable
information for communities to understand what drugs are
circulating, what harms are happening.
So we are trying to figure out, if we move in that
direction with wastewater, how do we do it in the most optimal
way that really gives communities information for action that
they don't currently have.
Mrs. Trahan. Sure. And given the example that, you know,
you just raised related to wastewater epidemiology, how should
we think about bolstering public-private partnerships to
utilize data infrastructure that was put in place through COVID
to improve our community responses to the ongoing addiction
crisis?
What tools do you think we can leverage private investment
in?
Dr. Jones. I think it is an area for further discussion.
I mean, we certainly work with companies that have
different data sources to help us understand and help
communities understand the full mosaic of what is going on with
substance use in communities. So data that looks at prescribing
trends for buprenorphine, data that looks at emergency medical
services, ambulance runs in communities.
So I think we are trying to build out those public health
and private-sector partnerships to help tell the story and not
recreate the wheel with new surveillance systems, but to
leverage systems that already exist.
Mrs. Trahan. Great. Well, thank you all for being here
today. I really appreciate your responses.
And I yield back my time.
Mr. Guthrie. Thank you. The gentlelady yields back. The
Chair recognizes Mrs. Harshbarger for 5 minutes for questions.
Mrs. Harshbarger. OK. Thank you, Mr. Chair. Thank you all
for being here today.
Mr. Blum, my first question goes to you. It is a common
practice among some insurance plans to use closed pharmacy
networks, which only permits patients to get their medication
from a specific pharmacy, and that is selected from a pharmacy
benefit manager. This practice can result in patients with a
substance use disorder not getting their required treatment
because the pharmacy can be difficult to access, or--especially
in instances when the medications are distributed through
specialty pharmacies. And this gap to a prescribed medication
could lead patients to relapsing, or even worse.
And I know that some States are advancing policies that
would require the PBMs to utilize any--willing provider status
is what it is called, and that is for serious mental health
illnesses and substance use disorder medications to address the
problem.
My question is, is this delay in timely fulfillment of
substance use disorder medication something CMS is aware of, or
have you looked into that?
Mr. Blum. Thank you for the question.
We have certainly heard very similar concerns, and see very
little evidence that by having closed pharmacy networks there's
better clinical outcomes, there's more savings.
We are happy to work with you on ways for us to improve
Medicare policies, Medicaid policies, but haven't seen data
that suggests that we get better outcomes by having more narrow
pharmacy networks.
Mrs. Harshbarger. OK, OK, we will try to help in any way we
can on that.
Mr. Strait, the SUPPORT Act provided resources and
authorities to prevent illegal drug products from entering the
U.S. supply chain via mail. However, you know, consumers are--
they are going to rely on the Internet to purchase various
products, and that includes prescription medications. And the
emergence of these illegitimate online pharmacies has really
become a concerning issue. And I have been a pharmacist 36
years, so this is right up my alley.
These bad actors deceive these unsuspecting customers by
selling counterfeit pills. Sometimes they are laced with
fentanyl. And I know, Dr. Jones, when I was at CDC they were
looking at opioid deaths, going back to see if there was
fentanyl involved when I talked to the CDC Director.
You know, it really--it poses significant risks to people's
health and safety. And to address the evolving challenge of
corner drug stores shifting to online platforms, how do you
suggest we effectively shut these digital drug dealers down?
And we know that they are dealing through Snapchat and
TikTok. And, you know, being on Homeland Security, I know that
that is how they recruit these drug dealers, basically.
Mr. Strait. Congresswoman, I thank you for that question,
because that is an important piece of the puzzle that we need
to also solve.
Mrs. Harshbarger. Yes.
Mr. Strait. You know, what we have been saying at DEA is
that social media actually represents the superhighway----
Mrs. Harshbarger. Absolutely.
Mr. Strait [continuing]. For connecting a drug dealer with
an unsuspecting American.
Mrs. Harshbarger. Yes.
Mr. Strait. And unfortunately, we see that happening every
day. And I would say that we not only see it on the illicit
side of our house, but then, to your point about some of these
online intermediaries, we can also see how social media is
being used to get new patients to seek controlled substances
pursuant to a prescription that may not be being issued in the
legitimate course of practice.
Mrs. Harshbarger. Well, of course. That is why they are
online trying to get it.
Mr. Strait. So we are very, very concerned about that
issue.
Mrs. Harshbarger. Yes, I would like to see numbers on that
too, you know, data.
Well, I have got a minute left. Mr. Coderre, SAMHSA has
awarded billions of dollars in grants to treat opioid use
disorders under the State opioid response grants. To my
knowledge--and you correct me if I am wrong--SAMHSA is not
tracking clinical outcomes like treatment retention rates or
whether patients stop using the illicit opioids or whether or
not those patients are getting back to work.
So I would like to ensure that the funds authorized and
appropriated by Congress are used wisely, especially given we
already have a broad network of effective programs for treating
these opioid disorders. And I believe we need a greater focus
on the effectiveness of these programs. You know, you have to
measure outcomes, especially when they receive funding from us.
And without tracking clinical outcomes, how can we assure that
money is going to providers with the best clinical outcomes and
highest likelihood by helping their patients achieve recovery?
Mr. Coderre. Thanks so much for that question,
Congresswoman.
The State opioid response grants are critically important.
The States rely on these resources to really expand treatment,
prevention, and recovery support services. We do track outcomes
through that program. I would be happy to get you the
outcomes----
Mrs. Harshbarger. OK.
Mr. Coderre [continuing]. That we do track, and then work
with the committee----
Mrs. Harshbarger. Yes, that would be very----
Mr. Coderre [continuing]. To track things that we may not
be tracking that you think we should be.
Mrs. Harshbarger. Yes, fantastic. Because we need to know
who is doing it right and who is not doing it right.
Mr. Coderre. Absolutely.
Mrs. Harshbarger. OK. I think my time has expired, and I
yield back, sir.
Mr. Guthrie. The gentlelady yields back. The Chair
recognizes Dr. Ruiz for 5 minutes for questions.
Mr. Ruiz. Thank you for holding this important hearing
today as we are considering these programs that were originally
included in the SUPPORT Act in 2018, which built on the work
done in the Comprehensive Addiction and Recovery Act before
that.
It is sobering to note how long we have been working to
tackle this crisis, which continues to evolve. And while I know
we have made great strides to tackle this epidemic, the COVID
pandemic and the surge of fentanyl have pushed us into another
wave of the crisis, with fentanyl remaining the leading cause
of death for U.S. adults ages 18 to 45. That is why it is
critical to examine these programs and extend the ones that are
working.
Substance use disorders don't just affect the person with
the disorder. Entire families feel the ripple effects, often
suffering trauma as a result of their experiences. That is why,
in the SUPPORT Act, we created the Interagency Task Force on
Trauma Informed Care. We need to make sure that we are taking a
holistic approach and treating the entire family appropriately
in order to properly address the effects of this disease.
The purpose of this task force is to solicit input from on-
the-ground experts and then provide recommendations, including
evidence-based best practices and a national strategy, to help
children and youth who have experienced or are at risk of
experiencing trauma resulting from substance use disorder.
As a doctor who came to Washington to advocate for and
write policy to improve the health and lives of the communities
that I serve, I can say firsthand that it is critical to
include experts in the policymaking process. And by experts I
mean people on the ground with lived experiences carrying out
those policies every single day. Many things that we consider
here in Congress sound like a good idea, and intentions are
good, but there's nothing that can replace the value of real-
life experiences in the policymaking process, real life
experience to know what actually works, what actually doesn't
work.
That is why this task force is so important. It includes
input from the very people that need to be at the table as
these decisions are being made: frontline providers; educators;
mental health professionals; researchers; experts in infant,
child, and youth trauma; and child welfare professionals. These
are the people who should be helping to shape the best practice
recommendations.
And the work of the task force is not done, which is why it
is important to extend their authority past its current
expiration in September. That is why I introduced H.R. 4080,
the Trauma Informed Care Task Force Reauthorization Act, with
my colleague Mr. Latta to ensure the successful completion of
this important work.
I understand that next month the task force is holding a
meeting with stakeholders to present the status of their work
on phase one of the operating plan of the National Strategy for
Trauma Informed Care and solicit their feedback and input to
help inform their work, moving forward. The importance of
stakeholder input cannot be overstated, and giving the task
force more time to complete their mission is essential so that
the process is not rushed and the final product is
comprehensive and effective.
Mr. Coderre, what is the current status of the task force,
and why is it necessary or beneficial to extend it?
Mr. Coderre. Thanks so much, Dr. Ruiz.
You know, the SUPPORT Act really represented a huge step
forward in integrating trauma-informed care throughout the
Department of Health and Human Services public health
activities. As you pointed out, the task force has been meeting
regularly and has been doing really important work creating an
operating plan for the national strategy that exists on four
pillars: best practices, research, data, and Federal
coordination.
And so at the July meeting we expect to have the findings
presented from phase one, the environmental scan, and so we are
really looking forward to having the task force----
Mr. Ruiz. And what is the goal of that meeting? Like,
what--how will it influence the work of the task force, moving
forward?
So you have a presentation, but what do you want to do with
it?
Mr. Coderre. Well, the--as I mentioned, they will present
the findings from the environmental scan, which will be a
roadmap for the task force going forward.
Mr. Ruiz. OK. And so there's a plan.
Mr. Coderre. Correct.
Mr. Ruiz. You are going to create--OK. And what can
Congress do to assist the task force to help ensure its
success?
Mr. Coderre. Well, I think reauthorizing the task force
would be the first step, and then working with us, as we find
the recommendations from the task force, to help implement
them.
Mr. Ruiz. Thank you.
I yield back my time.
Mr. Guthrie. The gentleman yields back. The Chair
recognizes Dr. Miller-Meeks for 5 minutes.
Mrs. Miller-Meeks. Thank you, Mr. Chair.
We are here today talking about reauthorizing the SUPPORT
Act amid an opioid crisis that is now worse than ever.
According to the latest CDC data, we have lost more than
110,000 Americans due to drug overdose deaths in 2022. It is
estimated that 75 percent of these deaths involved opioids, and
many of them fentanyl or fentanyl analogs, meaning that we lost
226 Americans every day to opioids.
To put this in context, 5 years ago, when Congress
considered this legislation, we lost just over 53,000
Americans, or 146 a day, to opioid-related drug overdoses. This
means that rates of opioid-related drug overdoses have
increased by 55 percent.
We need to approach our opioid crisis differently. The
SUPPORT Act included important, well-intentioned efforts to
help individuals and families in crisis. However, more needs to
be done to prevent addiction, including minimizing unnecessary
exposure to opioids.
Ninety percent of the acute pain patients receive opioids
to manage their pain, whether they need them or not. Between
2011 and 2019, opioid prescriptions decreased by 40 percent,
which is a good thing, from approximately 250 million to 150
million prescriptions dispensed. This is true across most payer
audiences: Medicaid, private, and cash payments. However, among
Medicare patients, opioid prescribing actually increased
nominally.
Furthermore, Medicare's share of opioid prescribing during
this time increased substantially, from approximately 20
percent of the country's opioid prescriptions in 2011 to 35
percent in 2019. This represents a 75 percent increase in just
under a decade. We clearly have some work to do in Medicare to
make sure that patients have access to effective pain relief
agents while also not unnecessarily exposing them to narcotic
painkillers.
One opportunity to do this would be to enhance access to
and use of nonopioid pain relief agents and also other things
that look at presurgical treatment, whether or not someone
should be nothing by mouth for an entire time, adequate
hydration. And I have seen that through places within my
district.
Mr. Blum, can you detail CMS's support for policies to
increase access to and availability of nonaddictive pain
management options?
How can my office work with you to make sure that patients
have robust access to these approaches?
Mr. Blum. Thank you for the question, Congresswoman. We too
support the goal to ensure that Medicare beneficiaries have the
full spectrum of treatment.
The Part D Medicare program today monitors use very
carefully to ensure that we don't have inappropriate use. That
program today works very well. We are happy to follow up to
learn more how CMS programs can do better.
Mrs. Miller-Meeks. Thank you, and I will also keep you
apprised of what is happening within my district and the unique
approaches they are taking as well.
Deputy Administrator Blum, H.R. 824, the Telehealth Benefit
Expansion Act, would increase the ability of employers to offer
telehealth-only coverage by accepting it from various laws that
apply specifically to health insurance. During the pandemic,
employers did this to increase access to care for employees
that did not have access to major medical insurance, like
seasonal and part-time workers. I have a technical question on
the bill.
Employer health plans are regulated through several
different statutes, some of which have different requirements
that are applied and enforced differently. For example, the
Public Health Service Act includes requirements onto fully
insured employer plans, small employer plans, and individuals
that purchase major medical insurance directly from the
exchanges.
The ERISA statute includes requirements onto self- and
fully insured plans, some of which are different than the
Public Health Service Act's requirement. If the bill were only
to amend the ERISA statute, would fully insured employers and
small employers for purchase through the exchanges be able to
offer telehealth-only plans as an accepted benefit?
Mr. Blum. I don't believe so, but I am happy to follow up
to better understand your question.
Mrs. Miller-Meeks. We would certainly appreciate the
follow-up, and you can do that written to the subcommittee.
Thank you, Mr. Chair. I yield back.
Mr. Guthrie. Thank you. The gentlelady yields back. That
completes all the Members for questions.
We do have--I would have thought you are a Member--you are
very participatory in this, I know, this issue because you have
worked hard and traveled to Gettysburg and did everything.
So it gives me joy to recognize my good friend, Mr. Tonko,
for 5 minutes.
Mr. Tonko. Thank you, Chair Guthrie, and thank you, Ranking
Member Anna Eshoo, for your work with me on this topic and for
waiving me on for today's hearing, and I thank my friend and
colleague Representative Armstrong for working with me on
several of the bills before us today. And thank you for our
experts at the table as witnesses for joining us.
Our country has a mental health crisis, a substance use
crisis, and a fentanyl crisis. And so it requires us--I think
the presence of everyone in this room today speaks to that
concern, and want to have a resolve. So my reentry bill needs
to be done. It is a very, very impactful audience that is
affected by that legislation, and we need to save their lives.
So when I hear of IMD exclusion, not requiring any kind of
adjustment of a funding stream, but I hear it for the reentry
bill, I get concerned. When I hear suspension versus
termination discussion--I didn't pull 30 days out of the air.
They need at least 30 days to get themselves tethered to a
system and to be strong enough as they leave that incarcerated
system--incarceration system to be able to survive and beat the
statistics.
And when I joined my colleagues in Gettysburg, I
appreciated that it was an honorable offering they made to join
them at the hearing. And we heard from the law enforcement
community that this is a very important tool.
So thanks to the bipartisan work this committee has done
over the years, 5 years ago, with the SUPPORT Act, States can
now apply for a demonstration program to use Medicaid for
eligible services for justice-involved individuals returning to
their communities 90 days prerelease.
Currently, Federal statute, as we know, prohibits any form
of Federal health coverage for incarcerated individuals, except
under very limited circumstances. In many States, Medicaid
coverage is immediately terminated when someone is sent to a
correctional setting. And in the rest, coverage is suspended,
and it takes various lengths of time to restart it. This
creates a serious coverage gap when individuals are released,
as they often have no access to healthcare or addiction
treatment during a stressful and dangerous time.
Mr. Blum, I applaud CMS for moving forward with the
demonstration program, which was a result of this concern. And
through my Reentry Act I hope to codify reentry policy.
I also am proud to champion the Due Process Continuity of
Care Act with my friends, Representatives Trone, Turner, and
Rutherford, who also lead Reentry with me. Due Process would
make certain that pretrial detainees are not kicked off
Medicaid prior to ever being found guilty of a crime.
So CMS has said extending Medicaid eligibility prior to
release can improve connections to community-based providers.
Can you talk about why that is important?
And additionally, why does CMS believe that the period
postincarceration is such a critical time to receive treatment
and coordination of care?
Mr. Blum. Thank you for the question. We hear from States,
we hear from experts that one of the best ways that we can
prevent relapse is to ensure continuity of coverage. And so we
are very supportive to the work that you have put forth. We are
very excited to work with more States to figure out ways for us
to continue coverage.
Mr. Tonko. Thank you. And with the recent passage of my
Mainstreaming Addiction Treatment Act, or MAT Act, we have had
a dramatic expansion of the United States' healthcare system's
ability to treat opioid use disorder with buprenorphine,
increasing the number of medical professionals who can
prescribe buprenorphine for opioid use disorder from 130,000 to
1.8-plus million with the removal of the X waiver. That is a
lot of hope, a lot of lives saved.
I sent the DEA Administrator a bipartisan letter with 20-
plus Members in March of this year asking several questions
about increased access to buprenorphine, and specifically asked
for the DEA to issue additional guidance to all registrants to
ensure patients get access to this lifesaving medication. To
date, I have not received a response.
I also requested a meeting to follow up on this, and so far
nothing has been set up.
I am hearing repeatedly from emergency physicians that when
they write prescriptions for buprenorphine, patients are
getting told at pharmacies that it is not available. In many
cases, the pharmacies are saying they are cut off for the month
and are too close to their limit. In some cases, patients give
up after going to multiple pharmacies. This is simply
unacceptable, that someone would get so close to accessing
addiction treatment and then, at one of the last steps, be
turned away. I believe that DEA must play a role in clearing up
this confusion.
So when will the DEA be responding to my letter?
Mr. Strait. I am going to take that back to our leadership
team and get you an answer to that question, sir.
But I do want to also----
Mr. Tonko. Well----
Mr. Strait [continuing]. Just give a quick shout-out to our
folks at SAMHSA. We have been dealing with the buprenorphine
access issue at the pharmacy level for over a year and a half
now.
Mr. Tonko. And Mr. Chair, if you will indulge me, when will
DEA issue additional guidance that sends a strong message to
the community that DEA wants access to addiction medication in
every community?
Mr. Strait. I would argue that we have already sent that
message out, and we will repeat that message again and again.
Mr. Tonko. And will you----
Mr. Strait [continuing]. A year ago.
Mr. Tonko. And will you provide additional clarification to
distributors, pharmacists, providers so they better embrace
their role to expand access to addiction treatment? We want
that 1.83 million achieved.
Mr. Strait. You are 100 percent correct. So do we. And
actually, we have been working with our manufacturing and
distributor communications, and communicating just those
points.
Mr. Tonko. Well, thank you. I think this is a time for us
to come together, not deal with politics but with facts to come
together, to make certain we respond to the needs of those that
are incarcerated, struggling with the illness of addiction.
Let's not start negotiating other terms around this issue that
deals with the most vulnerable audience. And I would hope today
we would hear a go-forward-and-get-it-done attitude. We need to
address the reentry bill.
And with that, Mr. Chair, I yield back.
Mr. Guthrie. Thanks. The gentleman yields back. All
questions have been asked, and the time has expired for asking
questions.
So I will move to--I will ask unanimous consent to insert
in the record the documents included on the staff hearing
documents lists, including both minority and--minority
information.
Ms. Eshoo. So moved, Mr. Chairman.
Mr. Guthrie. Without objection, so ordered.
[The information appears at the conclusion of the hearing.]
Mr. Guthrie. And I will remind the Members that they have
10 days to submit questions for the record--so you could
receive further questions--and ask the witnesses to respond
promptly. Members should submit their questions by the close of
business July the 5th.
Yes?
Mr. Tonko. Mr. Chair, if I might, I thank you for allowing
me to waive on, and you and the ranking member have been most
helpful. Let's get this reentry done, and let's solve the
crisis nationally.
Mr. Guthrie. Thank you. Thank you for your kind words.
So Members will submit their questions by close of business
on July 5.
So without objection, the subcommittee is adjourned.
[Whereupon, at 1:10 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]