[Senate Hearing 118-200]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-200

                     A CRISIS IN MENTAL HEALTH AND
                      SUBSTANCE USE DISORDER CARE:
                   CLOSING GAPS IN ACCESS BY BRINGING
                   CARE AND PREVENTION TO COMMUNITIES

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

                                HEARING

                               BEFORE THE

         SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                                   ON

 EXAMINING A CRISIS IN MENTAL HEALTH AND SUBSTANCE USE DISORDER CARE, 
 FOCUSING ON CLOSING GAPS IN ACCESS BY BRINGING CARE AND PREVENTION TO 
                              COMMUNITIES

                               __________

                              MAY 17, 2023

                               __________

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

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
54-490 PDF                  WASHINGTON : 2024                    
          
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                 BERNIE SANDERS (I), Vermont, Chairman
PATTY MURRAY, Washington             BILL CASSIDY, M.D., Louisiana, 
ROBERT P. CASEY, JR., Pennsylvania       Ranking Member
TAMMY BALDWIN, Wisconsin             RAND PAUL, Kentucky
CHRISTOPHER S. MURPHY, Connecticut   SUSAN M. COLLINS, Maine
TIM KAINE, Virginia                  LISA MURKOWSKI, Alaska
MAGGIE HASSAN, New Hampshire         MIKE BRAUN, Indiana
TINA SMITH, Minnesota                ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico            MITT ROMNEY, Utah
JOHN HICKENLOOPER, Colorado          TOMMY TUBERVILLE, Alabama
ED MARKEY, Massachusetts             MARKWAYNE MULLIN, Oklahoma
                                     TED BUDD, North Carolina

                Warren Gunnels, Majority Staff Director
              Bill Dauster, Majority Deputy Staff Director
                Amanda Lincoln, Minority Staff Director
           Danielle Janowski, Minority Deputy Staff Director
                                 ------                                

         SUBCOMMITTEE ON PRIMARY HEALTH AND RETIREMENT SECURITY

                   ED MARKEY, Massachusetts, Chairman
PATTY MURRAY, Washington             ROGER MARSHALL, M.D., Kansas, 
TAMMY BALDWIN, Wisconsin                 Ranking Member
CHRISTOPHER S. MURPHY, Connecticut   RAND PAUL, M.D., Kentucky
MAGGIE HASSAN, New Hampshire         SUSAN M. COLLINS, Maine,
TINA SMITH, Minnesota                LISA MURKOWSKI, Alaska
BEN RAY LUJAN, New Mexico            MIKE BRAUN, Indiana
JOHN HICKENLOOPER, Colorado          MARKWAYNE MULLIN, Oklahoma
BERNIE SANDERS (I), Vermont, (ex     TED BUDD, North Carolina
    officio)                         BILL CASSIDY, M.D., Louisiana, (ex 
                                         officio)
                           
                           C O N T E N T S

                              ----------                              

                               STATEMENTS

                        WEDNESDAY, MAY 17, 2023

                                                                   Page

                           Committee Members

Markey, Hon. Ed, Chairman, Subcommittee on Primary Health and 
  Retirement Security, Opening statement.........................     1
Marshall, Hon. Roger, Ranking Member, a U.S. Senator from the 
  State of Kansas, Opening statement.............................     2

                               Witnesses

Celli, Maria, Psy.D., Deputy CEO, Brockton Neighborhood Health 
  Center, Brockton, MA...........................................     4
    Prepared statement...........................................     6
Denny, Steven, Deputy Director, Four County Mental Health Center, 
  Lawrence, KS...................................................    12
    Prepared statement...........................................    13
Taylor, Stephen, President Elect, American Society of Addiction 
  Medicine, Birmingham, AL.......................................    16
    Prepared statement...........................................    18
Ng, Warren, President, American Academy of Child and Adolescent 
  Psychiatry, New York, NY.......................................    25
    Prepared statement...........................................    27

                          ADDITIONAL MATERIAL

Markey, Hon. Edward:
    94 Organizations supporting expanding access to methadone 
      treatment for opiod use disorder...........................    42
    Clinicians supporting expanding access to methadone and to 
      pass the Modernizing Opioid Treatment Access Act...........    45
American Academy of Family Physicians, Statement for the Record..    64
American College of Emergency Physicians, Statement for the 
  Record.........................................................    68
American Therapeutic Recreation Association, Statement for the 
  Record.........................................................    74
Children's Hospital Association, Statement for the Record........    77

 
                     A CRISIS IN MENTAL HEALTH AND
                      SUBSTANCE USE DISORDER CARE:
                   CLOSING GAPS IN ACCESS BY BRINGING
                   CARE AND PREVENTION TO COMMUNITIES

                              ----------                              


                        Wednesday, May 17, 2023

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

    The Subcommittee met, pursuant to notice, at 10 a.m., in 
room 430, Dirksen Senate Office Building, Hon. Edward Markey, 
Chairman of the Subcommittee, presiding.

    Present: Senators Markey [presiding], Baldwin, 
Hickenlooper, Marshall, Murkowski, and Tuberville.

                  OPENING STATEMENT OF SENATOR MARKEY

    Senator Markey. Thank you all for joining us today for the 
first Primary Health and Retirement Subcommittee hearing on 
mental health and behavioral health for the 118th Congress.

    Thank you to Senator Marshall for your shared commitment to 
addressing the mental health and substance use crisis in the 
United States. There are many people at home who will watch 
this hearing and recognize the realities they face every day.

    They call for help and are met with long wait times or an 
hour-long commute to care. They have lost a friend, or a loved 
one, to mental illness or a substance use disorder. But support 
and services aren't accessible. They know when they need help, 
but they don't know where to go to get it.

    Let me start by saying, you are not alone. The reason we 
are here today is to identify those challenges and chart a path 
toward a future where help is there when you need it. On 
health--Senate Health, Education, Labor, and Pensions Committee 
it is our responsibility to take up the fight for a better 
mental health and substance use disorder care system that meets 
people where they are with dignity.

    But today we are losing that fight. Last year, over 106,000 
people died from an overdose. The CDC reported just last week 
that overdose deaths involving fentanyl had more than tripled 
in the last 5 years. Emergency department visits for opioid 
related overdoses increased by 41 percent for boys, and 10 
percent for girls age 12 to 17 in the fall of 2022, compared to 
the year before.

    Yet, 94 percent of people age 12 and older with substance 
use disorders did not receive treatment. The prospects for 
people facing mental health challenges are equally distressing. 
More than one in five adults in the United States has a mental 
health disability, yet over 10 million people report an unmet 
need for mental health services.

    One in five highschoolers have seriously considered 
attempting suicide. For LGBTQ youth, the number was closer to 
one in two. Yet over 2 million adolescents who needed care did 
not receive it.

    The cause is complex. Pharmaceutical companies supercharged 
an opioid pandemic by overprescribing oxycodone, ultimately 
hooking people on heroin and fentanyl. Big tech serves toxic 
content that grabs young people's attention, and fuels 
depression, anxiety, and eating disorders.

    Childhood trauma and toxic stress linked to violence, 
poverty, racism, and housing instability create invisible scars 
that weigh heavily on caregivers' children and seniors. And as 
a growing number experience mental health conditions, our 
health system has not been able to keep up. People are looking 
for an open door to care, and instead they are locked out.

    But these invisible scars continue to grow, and thousands 
of people find themselves in the emergency departments hoping 
for placement in treatment programs, or they leave, and without 
anywhere to go, we lose them to suicide and overdose.

    Yes, the challenges are complex, but the solution is 
simple, affordable, accessible, mental and substance use care 
for any and all that need it, when they need it, and where they 
need it. This is easier said than done, but there is hope to be 
found in the everyday heroes who have rolled up their sleeves, 
looked into people's eyes, and offered a helping hand.

    A few of those people are with us today, addiction medicine 
physicians, child psychiatrists, and providers from community 
health centers and certified community behavioral health 
clinics. They are the better angels of our health care system, 
and right now we need an army of angels.

    We can build a system that treats people with dignity and 
doesn't price patients out of the care. We can invest in 
community health providers. We can pass legislation to break 
down antiquated barriers to medication, treatment for opioid 
use disorder.

    We can support local communities, public health response to 
rising overdoses and mental health needs. And we can make sure 
that big pharma doesn't charge big bucks for life saving 
prescriptions. We can create a system that puts patients over 
profits.

    I am proud that so many of our fiercest advocates for these 
efforts are in this room today, and we thank you for all of 
your work. And with that, I turn to the Ranking Member, Senator 
Marshall, for his opening statement.

                 OPENING STATEMENT OF SENATOR MARSHALL

    Senator Marshall. Well, thank you, Mr. Chairman. I also 
want to appreciate your dedication to addressing the mental 
health crisis and for holding our first Subcommittee hearing. I 
know our colleagues on both sides of the aisle interested in 
reauthorizing several expiring programs.

    We also want to look for new ways to tackle this crisis. 
Our witnesses today will show us how they are using existing 
Federal programs and their own ingenuity to reshape their 
communities. It has been 5 years since Congress passed the 
Support for Patients and Community Act, the largest, most 
comprehensive legislative package that directs Federal 
resources and statutory changes toward prevention, treatment, 
and recovery.

    The Support Act encourages payers and providers to utilize 
alternative treatments for pain. It increased patient education 
and awareness across many markets. Modernizing prescribing to 
detect and prevent fraudulent prescriptions.

    The expanded safe disposal of unused prescription drugs, 
including at home deactivation packets. And finally, it helped 
people get on the road to recovery through various inpatient 
and outpatient services.

    Let's talk about prevention first, where we are seeing 
great progress. Notably, substance use disorder related deaths 
as a result of prescription opioids are decreasing because 
physicians and nurses are increasing patient awareness and 
utilizing other treatments for pain. However, Chairman Markey 
and I in this Committee, our aim is to prevent addiction by 
moving away from addictive medicines.

    The Support Act required the FDA to help address 
biopharmaceutical challenges in developing non-addictive pain 
therapies, but the agency has not successfully carried this 
out. We will hold the FDA accountable so patients can one day 
have access to innovative, non-addictive prescription drugs.

    On treatment, we will hear from our witnesses on the 
successes of expanded access to medication assisted treatment, 
telehealth, and novel coordinated care models, including 
certified community behavioral health clinics, or CCBHCs, which 
I am a very strong advocate for. We have all witnessed too many 
people experiencing mental health crises in the wrong setting 
and receiving the wrong type of care.

    While still new, the data looks promising. People who 
receive care at a CCBHC spend 60 less--60 percent less time in 
jail, 70 percent less time in the hospital, and are much 
likely--much more likely to have access to a primary care 
provider.

    CCBHCs also contributed to a 41 percent reduction in 
homelessness. Congratulations, and I will look forward to Mr. 
Denny's testimony to share some more of those stats again. For 
all the good the witnesses are providing,

    Congress must work to ensure that they can deliver timely 
access to care by addressing mental health parity issues. They 
need our help to eliminate unnecessary delays and denials from 
prior authorization, the No. 1 administrative burden across all 
clinicians and other health care providers.

    On recovery, the Support Act provided peer recovery support 
services and other programs that are helping people help 
themselves become independent, stable, and healthy. In addition 
to the Support Act, I hope this Committee will work with us on 
developing solutions to address some of the root causes of the 
mental health crises in America's youth. Do the lockdowns 
result in isolation?

    Kids increase their reliance on social media, shifting 
their habits beyond a casual pastime. In fact, experts have 
found that overuse of social media rewires their brains to 
constantly seek out immediate gratification. This leads to 
obsessive, compulsive, and addictive behaviors. Studies have 
linked heavy social media use increased risk for depression, 
anxiety, loneliness, self-harm, and even suicide ideation.

    This year, the CDC released a new survey finding that 
nearly 60 percent of young girls reported a mental health 
issue, with 30 percent seriously considering suicide, double 
the rate there was among boys and up to almost 60 percent from 
a decade ago. We know social media companies are aware of this 
based upon their own similar findings. There is no silver 
bullet in solving the mental crisis.

    We must continue to bolster efforts on prevention, 
treatment, and recovery. In doing so, we should value what we 
measure and measure what we value. As we consider reauthorizing 
expiring programs and exploring new ideas, they should be 
patient centered, outcome driven, cost effective.

    They must be backed by data. Mr. Chairman, thank you again 
for calling this hearing, and I yield back.

    Senator Markey. Thank you, Senator, so much. And we will 
turn to our first witness, Dr. Maria Celli, a Psychologist and 
Deputy CEO of Brockton Neighborhood Health Center in Brockton, 
Massachusetts.

    She has worked at the Brockton Neighborhood Health Center 
since 2016 and has worked in community health centers since 
2010. Dr. Celli launched the Brockton Behavioral Health Task 
Force to promote collaboration between behavioral health 
providers across the city's behavioral health and substance use 
services ecosystem.

    Welcome, doctor, whenever you are ready, please begin.

  STATEMENT OF MARIA CELLI, DEPUTY CEO, BROCKTON NEIGHBORHOOD 
                  HEALTH CENTER, BROCKTON, MA

    Dr. Celli. Good morning, Chairman Markey, Ranking Member 
Marshall, and Members of the Committee. Thank you for the 
opportunity to testify on the critical topic of mental health 
and substance use disorders and access to community-based 
prevention and services.

    As Senator Markey noted, my name is Maria Celli, and I am a 
Psychologist and the Deputy CEO at Brockton Neighborhood Health 
Center, a federally qualified health center located in 
Brockton, Massachusetts.

    In my role, I have witnessed the negative impact that the 
pandemic has had on the mental health of our patients and the 
community. The demand for behavioral health services is 
enormous, outstripping our community wide supply of resources. 
This morning, I am coming on behalf of our providers and 
patients I have the privilege to serve to propose four 
opportunities for support to improve community level access to 
behavioral health and substance use disorder services.

    Those four are, increasing support for integrated care team 
models, leveraging mobile medical units and continued use of 
telehealth services, including audio only services when 
appropriate, prioritizing pediatrics, and workforce development 
and wellness.

    Like many other community health centers across the 
country, Brockton Neighborhood Health Center employs 
integrated, multidisciplinary teams to serve patients 
holistically. That means we address everything from food 
insecurity and housing insecurity to disease management.

    Our patients are universally screened for health-related 
social needs, depression, and risky substance use. We make 
screening for mental health and substance use disorder a 
standard part of primary care.

    By doing so, we reduce stigma and create easy and seamless 
access to mental health and addiction services. Additionally, 
we have found that primary care behavioral health integrated 
teams can reduce costs to the medical system, and I will give 
one example.

    Recently, we had a 21-year-old male who was new to our 
adult medical department. This individual had significant 
medical complications and was in and out of the hospital 
frequently, very frequently, like seven times in a couple of 
weeks.

    Concerned about his mental status, the primary care 
provider at the NHC engaged one of the integrated behavioral 
health clinicians who was able to meet with this individual and 
begin to build trust.

    Since the team of the integrated primary care--the 
integrated clinician and the primary care provider has started 
to work with this patient, he has significantly reduced his 
emergency room visits and has begun to make good progress with 
his medical care addition.

    Additionally, in addition to primary care, behavioral 
health integrated models of care, I propose increasing access 
through mobile units and telehealth services. We have found at 
Brockton Neighborhood Health Center through our first mobile 
unit that this is an effective way to reach vulnerable 
populations, and I will highlight three in particular.

    In 2020, Brockton Neighborhood Health Center leveraged 
grant funding to launch our first mobile unit, which provides 
services specifically to those experiencing homelessness and 
people who use drugs. We have observed that overdose deaths 
have increased significantly in our town, and nationally that 
is the same.

    The services on this mobile unit have undoubtedly saved 
lives. However, we have also observed a rise in mental health 
needs in both pediatrics and seniors within our community. That 
is why Brockton Neighborhood Health Center is working hard to 
acquire mobile units that can be deployed to provide integrated 
care at schools, at senior housing sites, etcetera, to meet our 
patients in the community that has the need where they are.

    I am so appreciative that last year this Committee 
recognized the value of mobile care units when it passed the 
Mobile Health Care Act by unanimous consent to make it easier 
for health centers to finance mobile health units.

    Additional new access point funding will help health 
centers like ours take advantage of this opportunity to create 
easier access to patients who need it. In addition to launching 
the mobile clinical unit, leveraging strategic use of 
telehealth is essential to address this crisis, and I strongly 
support permanently extending the telehealth flexibilities 
implemented during the COVID-19 public health emergency.

    Of course, none of our work in addressing this crisis is 
possible without robust and well staffing. The NHC has designed 
and launched a number of grants funded professional pipeline 
projects, including one designed for the training, recruitment, 
and retention of behavioral health clinicians.

    We would love for this Committee to provide more flexible 
funding to support projects like ours. Another priority for our 
workforce is wellness programing to mitigate employment related 
stress. I appreciate that last year the HELP Committee passed 
the Lorna Breen Act, which authorized funding for provider 
burnout, and we genuinely appreciate any support that our staff 
can receive to remain well in these roles as they continue to 
work daily to save lives.

    Health centers like Brockton Neighborhood Health Center 
need long term, sustainable, and predictable funding to 
continue to address this behavioral health and substance use 
disorder crisis.

    Chairman Markey, Ranking Member Marshall, and Members of 
the Committee, thank you for allowing me to share some of the 
great work that my team at the NHC is doing to fight the mental 
health and substance use disorder crisis in this country.

    With this Committee's support, we will continue to find new 
ways to provide affordable, accessible, and high-quality care 
to the communities we serve. I look forward to your questions.

    [The prepared statement of Dr. Celli follows:]

                   prepared statement of maria celli
    Chairman Markey, Ranking Member Marshall, and Members of the 
Committee, thank you for the opportunity to testify on the critical 
topic of mental health and substance use disorders. My name is Maria 
Celli, and I am a psychologist and the Deputy CEO at Brockton 
Neighborhood Health Center, a federally qualified health center located 
in Brockton, MA, a city 24 miles south of Boston. BNHC serves over 
37,000 unique patients and conducted over 200,000 visits in 2022.

    While I am currently the Deputy CEO of BNHC, I have previously 
served as a COO and Director of Behavioral Health and Social Services 
at BNHC and as a Director of Behavioral Health at a Boston-based FQHC. 
As a psychologist, my areas of clinical work have focused on behavioral 
health-primary care integration and working with individuals who have 
experienced trauma. I have trained in early childhood mental health and 
perinatal care, and I continue to be attentive to the needs of our 
youngest patients because they are our future, and I am aware that the 
ills I see in our adult patients were, in many ways, impacted by their 
experiences as young children. I am eager to promote the well-being of 
children to reduce their risk of developing pathologies later in life.

    From my clinical care and administrative perspectives, I have 
observed the current state of behavioral health and substance use needs 
and care access from the patient level through to systems level. In 
Massachusetts, we are fortunate that the state's Executive Office of 
Health and Human Services has committed to improving access to 
behavioral health and substance use disorder services, through the 
development of a Behavioral Health Roadmap, which is a blueprint for 
creating accessible and equitable access to behavioral health and 
substance use disorder services across the state. Introduced in 2021 
and implemented in 2023, this roadmap included the design and launch of 
24 Community Behavioral Health Centers across the commonwealth. We, at 
BNHC, are thankful that one of the 24 CBHC's is located within the city 
of Brockton; and we leverage this and every other resource in 
Brockton's behavioral health ecosystem to try to address our patients' 
and community's needs. Despite these improvements in access, we are 
still witnessing a demand for services that exceed our supply of 
resources. We were concerned about our staff and community's mental 
health and wellness prior to COVID. However, the needs have risen 
throughout the pandemic and remain high.

    I have professionally witnessed the negative impact that the 
pandemic had on the mental health and well-being of our patient 
population. More specifically, the trauma of COVID has triggered 
exacerbations of what were once subthreshold mental health conditions. 
The demand for behavioral health services is enormous--outstripping our 
community-wide supply of resources. Unfortunately, the acuity of 
patient needs is also worse, meaning that patients who might have once 
sufficed with outpatient therapy, are now reporting symptoms requiring 
more intensive or even inpatient care due to imminent risk concerns.

    From my own professional experience, and as the representative on 
behalf of providers and patients whose voices are not here, I propose 
four opportunities for continued or additional support to improve 
community-level access to behavioral health and substance use disorder 
services:

          1. Increasing support for integrated care team models: 
        Integrated primary care team models co-locate and integrate 
        licensed behavioral health clinicians, Community Health 
        Workers, Peer Recovery Coaches, and sometimes other disciplines 
        to work alongside primary care providers so that health-related 
        social needs and behavioral health screenings and treatment are 
        universally available to any patient as part of their general 
        medical care. This model of care is foundational to how FQHCs' 
        practice and its expansion is essential to improving access.

          2. Leveraging Mobile Medical Units and continued use of 
        Telehealth Services: I propose support for care for hard-to-
        reach patients through support for unique and flexible models 
        of care, including mobile medical units that can strategically 
        deliver integrated primary care services to vulnerable 
        individuals who are not engaging in their primary health care 
        such as those struggling with homelessness, seniors and 
        individuals with transportation or mobility barriers. 
        Similarly, it is essential to continue to strategically use 
        telehealth services for otherwise hard-to-reach populations.

          3. Prioritizing Pediatrics: We must ensure that all pediatric 
        patients have universal access to behavioral health screenings, 
        assessments, and treatments throughout their development, 
        especially in their first 5 years of life.

          4. Workforce Development: Finally, we must continue to invest 
        in developing the healthcare workforce to serve these 
        behavioral health and substance use disorder needs, through 
        support for existing professional pipeline projects.

  Increasing Community Access through Primary Care-Behavioral Health 
                              Integration
    BNHC operates four clinical sites (including one in a homeless 
shelter and one mobile unit). BNHC provides the full spectrum of 
primary care services including adult medical, behavioral health, OB/
GYN, pediatrics, nutrition, oral health, optometry, cancer screenings, 
onsite pharmacy, radiology, diagnostic laboratory, infectious disease 
screening and care, substance use disorder screening and treatment. We 
serve patients with extraordinarily complex medical and social needs, 
including poverty, food insecurity, homelessness, trauma, and 
difficulty accessing transportation and employment. We serve all people 
regardless of their insurance status or ability to pay.

    Like many other Community Health Centers across the country, we 
serve our patients holistically, meaning that we provide healthcare 
that pays attention to and aims to address all aspects of a person's 
life, as they all impact their health. We screen, assess and address 
their care across multiple levels and domains of need addressing 
everything from food access to disease management. We practice this way 
because it is our mission to do so, and it is a way to promote wellness 
for individuals who might not otherwise engage in preventative 
services. This strategy is beneficial to the patients and restrains 
costs to the medical system, as the patient's engagement in our 
integrated primary care teams can reduce unnecessary utilization of 
higher levels of care.

    One recent example of this is the case of a 21-year-old male with 
multiple medical conditions, including seizure disorder, who was in and 
out of the hospital due to seizures. Unfortunately, he was not engaging 
in his medical treatment due to undiagnosed severe depression. After 
becoming aware of his medical disengagement and his frequent trips to 
the hospital, his primary care provider at BNHC engaged the integrated 
behavioral health clinician, who was able to begin to build trust with 
this traumatized young individual. Together, the primary care provider, 
behavioral health clinician, and patient began to make slow but steady 
progress in his participation with his healthcare. The patient has not 
visited the emergency room since the holistic treatment team has 
collectively engaged him. Now that he has built trust with this team, 
he is willing to meet with specialists who can stabilize his medical 
condition. Given his many needs, the behavioral health team is also 
working with his family and friends to know how to support his health 
and wellness. This is a person who was in a revolving door pattern of 
medical exacerbation to the emergency department--until he was engaged 
by his primary care provider and an integrated behavioral health 
clinician. Now, he is stabilized and moving toward illness management 
and an improved quality of life.

    At BNHC, like many other health centers, the integrated model of 
care is foundational to how we provide primary care services. Our 
patients are universally screened for health-related social needs (i.e. 
social drivers of health), as well as risky substance use and 
depression. Just as we measure vital signs such as blood pressure, 
temperature, and weight, we ask them about the social conditions that 
impact their health and wellness; and we have staff on the team who 
assist with addressing the issues that patients report. This universal 
screening and team-based approach to access is crucial because it 
communicates that health-related social needs, substance use and 
behavioral health concerns are all part of their primary care. It 
destigmatizes these issues and creates easy access to needed services 
that improve their health, well-being, and effective participation in 
their own treatment, in their own lives and in their communities.

    Another illustrative example of the benefits of Primary Care-
Behavioral Health Integration and universal screening for BH and SUD 
conditions is the story of Gloria, a 73-year-old woman who had recently 
moved to our service area and was a newer patient. She completed our 
standard, universal screening process and was found to have an elevated 
score on the depression screening tool. Her response on the screening 
indicated suicidal ideation, and the PCP was planning to complete a 
Section 12 for the patient, meaning sending her to the hospital for 
inpatient hospitalization. However, because of the integrated model of 
care, the PCP reported the result to the integrated BH clinician, who 
met with the patient and carefully assessed the patient's risk. Rather 
than hospitalizing the patient, the integrated clinician was able to 
make a referral to one of our in-house psychiatric providers, who 
consulted with the PCP to start psychotropic medications. The BHI 
clinician helped the patient to connect with other resources in the 
community because the patient had acknowledged that the primary drivers 
for her current state were loneliness and hopelessness due to multiple 
losses, including loss of employment.

    This patient did not need a hospital. She needed connection. The 
integrated care team model, which is a cornerstone for how BNHC and so 
many other CHCs around the country operate, made those connections 
possible. We strive, train, practice, commit and recommit to seeing the 
whole person. And in doing so, we are privileged to know the patients 
and support them through accessing what they need to cope more 
effectively with the many stressors associated with their lives. Access 
to effective behavioral health and substance use disorder screening and 
treatment within the community and through the primary care doorway is 
an essential strategy for maximizing access in this time of tremendous 
need.
     Increasing Access through Mobile Units and Telehealth Services
    Another fundamental way that Community Health Centers operate is 
that we are innovative and driven to meet the needs of our community. 
Additionally, we are committed to our communities' health and our 
patients' care, whether the patient is attending visits or not. We 
continuously track population health level data to monitor who is in or 
out of care, whose healthcare metrics (such as blood pressures or A1c's 
are out of control or have not been checked recently enough) etc. We 
launch population health text and mail campaigns to outreach and engage 
patients who are out of care. We mobilize community health and outreach 
workers to locate and reconnect these patients to their trusted medical 
home. However, many individuals remain disconnected, and it has 
worsened throughout the pandemic. We have observed that this has been 
particularly true for certain vulnerable populations, such as those 
experiencing homelessness, children, and seniors.

    BNHC was fortunate to be awarded a grant in 2020 that yielded our 
first mobile health unit. The ``Community Care in Reach'' mobile unit 
provides services specifically to those experiencing homelessness, as 
well as people who use drugs. Started in 2021, this mobile unit can 
provide primary care, some acute care services, peer recovery coaching, 
and referrals to specialty services--all occurring where the patients 
are located. According to the CDC, there were over 100,000 drug-related 
overdose deaths in 2021 alone, which has steadily increased over the 
last 5 years. The screening, education and interventions provided on 
this mobile unit have undoubtedly saved lives! Additionally, it offers 
a patient-centered approach to high-quality, evidence-based care while 
also serving to contain costs through the reduction of ED utilization 
for services that are offered on the unit.

    In addition to a mental health and substance use crisis in those 
who use drugs and in individuals experiencing homelessness, we have 
observed and measured an incredible increase in the behavioral health 
needs of our pediatric patients during and coming out of the pandemic. 
BNHC is actively seeking funding to acquire another mobile unit serve 
the pediatric populations of the city as a school-based service site. 
The integrated care team would include a full-time Nurse Practitioner, 
as well as a Behavioral Health Clinician, community health workers and 
Peer Recovery Coach. While not yet operational, this model (across any 
willing school system) can bring necessary and easily accessible 
resources to kids who are falling through the cracks, despite the 
school, parents' and health centers' best efforts.

    On the other end of the age spectrum, I have also professionally 
observed and have been informed by behavioral health providers across 
the city of Brockton and the state that there is great concern for the 
mental health and well-being of many seniors. Having been more socially 
isolated during COVID (in order to protect themselves), they are now 
struggling to re-emerge, including struggling to re-engage with their 
health care providers.

    I am privileged to treat a senior struggling with depression, who 
has said to me that she is deeply lonely, but is scared to leave her 
home without certain trusted individuals (her adult children). Despite 
the best efforts to coordinate transportation and engage her family, 
there are times when she simply does not feel well enough to leave the 
street on which she lives. She has missed appointments as a result. And 
like her, there are many others! BNHC is hoping to acquire a mobile 
unit that can visit senior centers, senior housing sites, the council 
on aging and potentially other locations (as determined by data) to 
bring integrated care, including screening and treatment for behavioral 
health and substance use disorder to their living space. Making care 
accessible reduces inefficiencies in the system, is cost-effective, 
and, most importantly, promotes patients' health and well-being.

    I am so appreciative that last year this Committee recognized the 
value of mobile care units when it passed the MOBILE Health Care Act by 
unanimous consent to make it easier for health centers to finance 
mobile health units. These mobile units can offer primary or dental 
care or provide behavioral health services to sparsely populated rural 
areas or underserved urban populations. While the MOBILE Health Care 
Act provided the necessary flexibility to health centers to use Federal 
funding for mobile units, it did not provide any additional New Access 
Point dollars to take advantage of this flexibility. Additional New 
Access Point funding is necessary for health centers to take advantage 
of this unique opportunity. With this funding, health centers, like 
BNHC, can provide easier access to patients who are not engaging in 
their integrated primary care homes. This prevents the worsening of 
their conditions, thus improving their health and well-being while 
being cost-effective.

    In addition to launching mobile clinical units to provide 
integrated care services to the homeless, at schools, and for seniors, 
I strongly support permanently extending the telehealth flexibilities, 
including audio only telehealth care, implemented during the COVID-19 
public health emergency. Telehealth has been particularly effective in 
creating and maintaining access to behavioral health and substance use 
disorder treatment. This should remain an option to maximize access to 
services so critically needed by so many. We are experiencing a mental 
health crisis, and our providers feel it. When 1 in 5 adults and 1 in 2 
adolescents live with a mental health illness, these nimble and 
flexible strategies can save lives, prevent the need for higher levels 
of care and promote well-being.
                        Prioritizing Pediatrics
    While I spoke about children generally, I would like to call out 
the critical importance of early childhood mental health. At BNHC, our 
experienced pediatric providers are deeply disturbed and overwhelmed by 
the number of children with symptoms of psychological distress. Senior 
pediatricians who have worked with our patient population for decades, 
are reporting a particular concern about seeing young children (0-5 
years old) exhibiting symptoms that are consistent with Autism Spectrum 
Disorder but having difficulty accessing diagnostic evaluations due to 
a limited supply of professionals (psychologists and psychiatrists) 
trained in these assessment protocols, particularly to serve patients 
who are uninsured or underinsured.

    Fortunately, at BNHC, we have had a robust primary care-behavioral 
health integration program for years, but we expanded in 2019 with the 
help of a private grant through the Transforming and Expanding Access 
to Mental Health Care in Urban Pediatrics (TEAM UP for children) 
program. TEAM UP is an initiative to build the capacity of 7 Community 
Health Centers in MA to deliver high-quality, evidence-based, 
integrated behavioral health care to children and families. The TEAM UP 
transformation model is rooted in three principles: transforming care, 
strengthening foundations, and creating a learning community. BNHC has 
been implementing the TEAM UP model since 2019 and continues to 
transform to meet the behavioral health needs of its early childhood, 
pediatric population through integration of behavioral health and 
social services into primary care. A study of the utilization of 
services for children who have engaged with TEAM UP sites showed an 
increase in access to behavioral health services for Medicaid-enrolled 
children. \1\ The mental health needs of our pediatric patients are 
enormous, and Community Health Centers have innovative and proven 
strategies to increase access to mental health services. I strongly 
support investments in health center service expansions, as health 
centers are well-positioned to meet the needs of our children, who 
continue to demonstrate the repercussions of the traumatic effects of 
the last 3 years.
---------------------------------------------------------------------------
    \1\  Association of Integrating Mental Health into Pediatric 
Primary Care at federally Qualified Health Centers with Utilization and 
Follow-Up Care. Jihye Kim, PhD1; R. Christopher Sheldrick, PhD2; Kerrin 
Gallagher, MPH2; et al
---------------------------------------------------------------------------
                         Workforce Development
    Nationally and locally, workforce recruitment and retention pose 
major barriers to maximizing access to services that can address this 
mental health crisis we are experiencing. According to HRSA estimates 
based on national benchmarks, nearly one-third of Americans live in a 
federally designated Mental Health Professional Shortage Area, 7.7 
million health center patients are currently going without needed 
mental health care, and 4.9 million health center patients are going 
without needed substance use disorder treatment. The models of care to 
maximize access exist and can be leveraged to meet these needs. 
However, staffing is critical to addressing this mental health crisis.

    In full awareness of our challenge, BNHC has designed and launched 
a number of grant-funded professional pipeline projects, including one 
designed for the training, recruitment, and retention of behavioral 
health clinicians. In this program, BNHC commits to accepting, 
training, supervising and paying stipends to a cohort of behavioral 
health students completing their Masters degrees. Additionally, BNHC 
will pay a recruitment bonus to new hires, and a retention bonus to 
Behavioral Health Clinicians who have been with the organization for 2 
years or more. Our intention is to incentivize training at and 
hopefully also working at BNHC, or another Community Health Center. We 
would love for this Committee to provide more flexible funding to 
support a project like ours. These projects encourage training and 
working at community health centers, thus increasing the supply of 
trained behavioral health clinicians to meet the needs of this mental 
health crisis.

    According to a survey by the National Association of Community 
Health Centers, behavioral health staff are in the top three categories 
for the highest rate of job loss for health centers. Competition from 
other employers and burnout from the pandemic are the most common 
reasons for staff departure. Additional Federal funding would help 
recruitment and retention. Another top priority impacting retention of 
staff are wellness programs and other interventions for employees to 
mitigate employment-related stress. I appreciate that last year, the 
HELP Committee passed the Lorna Breen Act by unanimous consent, which 
authorized funding for provider burnout. These programs are valuable 
because our staff are extraordinarily burnt out. As the Deputy CEO of 
BNHC, and a psychologist, I have the privilege and responsibility of 
listening to a lot of staff, and many of them have reported that they 
have ``never felt worse''.

    We genuinely appreciate any support that our staff can receive to 
remain well in their roles as they continue to work daily to save lives 
and serve as the healthcare heroes who have been heralded throughout 
the pandemic. While not fighting COVID, they are fighting to address 
the effects of COVID including increased overdose deaths and substance 
use as well as serious mental health concerns.
                               Conclusion
    Health centers like Brockton Neighborhood Health Center need long-
term, sustainable, and predictable funding to meet our patients' 
behavioral health and substance use disorder needs. I recognize the 
difficult decisions Congress must make to balance funding levels with 
the need to maintain our Nation's fiscal health. Still, medical 
inflation has outpaced health centers' funding increases since 2015, 
leading to a 9.3 percent decrease in actual funding levels. Decades of 
research show that Federal investments in health centers reduce overall 
health spending by expanding access to efficient and effective primary 
care. Patients who access primary care at health centers show positive 
health outcomes and reduced use of emergency departments and hospital 
stays.

    I appreciate that this budget environment makes additional 
investments challenging. Still, millions of patients could benefit by 
expanding access to mental health and substance use disorder care at 
the health centers where they are already receiving primary care. For 
example, the National Association of Community Health Centers estimates 
that an additional investment of $500 million over 5 years would allow 
health centers to hire more than 2,500 behavioral health specialists 
and reach more than 5 million additional patients. This level of 
commitment by Congress would leverage the existing network of care and 
build on a proven model that saves the health system billions of 
dollars.

    Chairman Markey, Ranking Member Marshall, and Members of the 
Committee, thank you for allowing me to share the great work my team at 
BNHC is doing to fight the mental health and substance use disorder 
crisis in our Country. With this Committee's support, we will continue 
to find new ways to provide affordable, accessible, and high-quality 
care to the communities we serve. I look forward to your questions.
                                 ______
                                 
    Senator Markey. Thank you, Dr. Celli, so much. Now, Senator 
Marshall will introduce our next witness.

    Senator Marshall. Well, thank you, Mr. Chairman. I am 
certainly honored to introduce our second witness, Mr. Steven 
Denny, a fellow Jayhawk and a multi-generational Kansan. Mr. 
Denny is the deputy director of the Four County Mental Health 
Center. Their main office is in Independence, Kansas, and they 
proudly serve five counties now across Southeastern Kansas, 
including Montgomery County, Wilson, Elk, and Chautauqua.

    As I think about that, that is probably an area of about 
100 miles by 70 miles, very sparsely populated, and probably--
it is the most economically challenged portion of Kansas. In 
addition to serving the mental health center, Mr. Denny is also 
the project director of Four Counties Certified Community 
Behavioral Health Clinic Expansion Grant, provided by the U.S. 
Substance Abuse and Mental Health Services Administration.

    Under this role, Mr. Denny oversees clinical crises and 
substance use treatment services, as well as seeing patients 
every day. Thank you so much for agreeing to testify in person 
to discuss the work being done at Four County.

    Mr. Denny, the floor is yours, thank you.

STATEMENT OF STEVEN DENNY, DEPUTY DIRECTOR, FOUR COUNTY MENTAL 
                HEALTH CENTER, INDEPENDENCE, KS

    Mr. Denny. Chairman Markey and Senator Marshall, thank you 
so much for this opportunity to testify before the Senate HELP 
Committee this morning. As I mentioned, my name is Steve Denny.

    I serve as Deputy Director at Four County Mental Health 
Center, serving five counties in Southeast Kansas. You will 
hear me refer to our organization as Four County throughout 
this testimony. As I mentioned, I am also the Certified 
Community Behavioral Health Clinic Project Director, also known 
as CCBHC.

    We were the first Kansas organization awarded a SAMHSA 
CCBHC expansion grant in May 2020. Since then, six additional 
centers have followed suit in 2021, and by July 1st of 2024, 
all Kansas community mental health centers will have the same 
opportunity to become CCBHCs after the passage of Kansas House 
Bill 2208.

    It is a true honor today to speak to you about this 
exciting opportunity and what it has done for our state and our 
Nation. The second C in CCBHC stands for community. My 
community is Montgomery County, Kansas. It is a rural Kansas 
county located on the Oklahoma border. It contains both 
industry and agriculture.

    My hometown is a place that I swore I would never return to 
when I went away to college, and I have been back now for 18 
years. My father was a lifelong rancher. My children are the 
sixth generation to live on our family property, our small 
farm. My community matters to me.

    The CCBHC model requires nine core services that are 
oriented around the unique needs of each community served by 
CCBHCs. Those nine services are included in my written 
testimony for further review. This community focus, combined 
with the comprehensive care, data driven measures, and a 
continuous focus on quality improvement, is what makes the 
CCBHC model such a game changer.

    I have worked in this field since 2002 as a therapist and a 
supervisor of multiple populations. During this time, our field 
has experienced funding cuts, reduction of inpatient resources, 
and a state hospital crisis that has brought our system to a 
breaking point.

    Many of my colleagues have left the field for less 
demanding jobs that often pay more. Meanwhile, the needs of our 
communities continue to grow, leading to this crisis. CCBHCs 
have served as a lifeline for our system.

    Kansas House Bill 2208 provided foundation for our state to 
apply for the recent CCBHC planning grant to expand this model, 
with the support of Senator Marshall, for which we are 
immensely thankful. One shining example of an expanded program 
into our model is our Veterans Services Program. This provides 
specialized care coordination for veterans, service members, 
and their families.

    We have seen a 51 percent increase from baseline of 
veterans served each quarter since project implementation. This 
crisis also involves our youth. The pandemic was mentioned as a 
creator of isolation. We found that 36 percent of our 
adolescent admissions are identified as at risk for suicide or 
self-harm. 35 percent from the same demographic report that 
social media is a negative factor in relationship to their 
mental wellness.

    In response, we have started a robust school-based program 
that serves ten different districts in our area so that we can 
move our staff beyond the walls of our clinic. We anticipate 
continued growth in our youth services. In addition, we have 
created a special program targeting at risk adults for both 
legal place or legal issues and homelessness.

    This program is known as the ACT, or a sort of community 
treatment program. It provided a crucial relief valve to law 
enforcement and emergency services. Initial outcome shows that 
80 percent of the population has avoided homelessness and 76 
percent have avoided new legal incidents based on quarterly 
tracking data.

    In addition, we have developed a special program in 
partnership with law enforcement. We have four co-responders 
and 25 iPad devices deployed to our law enforcement partners to 
increase connection to law enforcement and emergency services. 
The CCBHC model increases access to care.

    Since implementation, our Four County provides 70 percent 
of the admissions on the same day that individuals seek 
services. For those who elect to wait, the average wait time is 
3 days compared to the national average of 48 days.

    They also receive enhanced care coordination and 
involvement with primary care. If they don't have a primary 
care provider, we work hard to get them connected. The next big 
thing in our field is mobile crisis services, which we will 
need to develop in partnership with a new 9-8-8 crisis hotline.

    National data indicates that this CCBHC model reduces ER 
visits by 68 percent. It also emphasizes care coordination and 
improved partnership with our local emergency hospitals. In 
conclusion, I just want to express my sincere support that we 
should move this model beyond a demonstration project and have 
it become a staple of our health care system.

    Thank you for the opportunity to testify here today on 
behalf of the people we serve, and for the incredible 
workforce. Senator Markey, you said, heroes will go--there are 
so many unsung heroes that do this work, and I am thankful to 
be in this field. Thank you.

    [The prepared statement of Mr. Denny follows:]

                   prepared statement of steven denny
    Chairman Markey and Senator Marshall, thank you for the opportunity 
to testify before the Senate HELP Committee this morning. My name is 
Steve Denny, and I serve as Deputy Director of Four County Mental 
Health Center, Inc. (FCMHC) located in Southeast Kansas, where I also 
serve as the Certified Community Behavioral Health Clinic (CCBHC) 
project director. FCMHC was the first Kansas organization awarded a 
SAMHSA CCBHC expansion grant in May 20. Six additional 
Community Mental Health Centers followed suit and were awarded 
expansion grants in 2021. I have had the privilege of bearing witness 
to the milestones that created the rapid development of CCBHCs in 
Kansas. These milestones include the passage of the Kansas House Bill 
2208 which established CCBHCs in Kansas and led to the eventual 
development of a State Plan Amendment to fund these clinics. By July 
1st, 2024, our goal is to have all Kansas Community Mental Health 
Centers become CCBHCs. It is my honor today to speak to the exciting 
opportunity that the CCBHC model has brought to Kansas and to our 
Nation.

    The second ``C'' in ``CCBHC'' represents the word ``community.'' My 
community is Montgomery County, Kansas. It is a rural Kansas county 
located on the Oklahoma border that contains both industry and 
agriculture and where CCBHCs have saved lives. The CCBHC model requires 
9 core services based on the unique needs assessment of the communities 
served by each clinic. These services include (1) crisis services, 
screening, (2) diagnosis and risk assessment, (3) psychiatric 
rehabilitation services, (4) outpatient primary care screening and 
monitoring, (5) targeted case management, (6) outpatient mental health 
and substance use services, (7) person and family centered treatment 
planning, (8) community based mental health care for veterans and (9) 
peer and family support services. This community focus combined with 
comprehensive care, data-driven approaches, and a continuous focus on 
quality is what makes the CCBHC model such a game changer.

    I have worked in the field of behavioral health since 2002 as a 
therapist and supervisor for services to adults diagnosed with severe 
mental illness, crisis services, substance use treatment services, and 
adult and child outpatient therapy services. During this time, our 
field has experienced funding cuts, reduction of inpatient resources 
that brought us to the breaking point. Many colleagues have left the 
field for less demanding jobs that pay more. Meanwhile, the behavioral 
health needs of our communities continue to rise, leading us to a 
mental health and substance use crisis. Both personally and 
professionally, I've experienced the impact of suicide involving a 
variety of demographics, including adults, older adults, veterans and 
adolescents. One out of every five of FCMHC's crisis assessments are in 
response to a suicide attempt. In addition, we are facing an 
unparalleled mental health and substance use provider workforce 
shortage that has been growing for years and now is at a tipping point.

    CCBHCs serve as a lifeline to the people of Kansas. Legislative 
efforts in Kansas established CCBHCs and provided the foundation for us 
to apply for the recent CCBHC planning grant to expand this model, with 
the tremendous support from Senator Marshall, for which we are 
immensely thankful. CCBHC implementation meant our organization could 
start and bolster mental health and substance use services based on the 
community needs. One shining example is FCMHC's Veterans Services 
program, which provides specialized care coordination for Veterans, 
service members, and their families. As a result, our organization 
serves an average of 140 unduplicated veterans each quarter which is a 
51 percent increase from baseline all while improving our working 
relationship with two Veterans Administration facilities with the 
support of Senator Moran.

    Part of the nationwide mental health and substance uses crisis 
involves our youth. Our children have been isolated with nothing but 
screens and devices, left alone at times to try and survive without the 
support of a community that teaches them to not just survive but to 
thrive. Youth suicide rates in Kansas increased by 63.8 percent in the 
most recent 15 year period (Kansas Health Institute) Outpacing the 
national

    average, which is also rising.. 36 percent of adolescent admissions 
at FCMHC are identified as at risk for suicide or self-harm and 35 
percent of the same demographic report that social media is a negative 
factor in relationship to their mental wellness. In response, we 
started a robust school-based program along with long standing programs 
that offer rehabilitation services to youth with more intensive needs. 
We are currently serving 9 school districts with CCBHC staff embedded 
in schools. We anticipate that opportunities to serve our youth will 
increase under the CCBHC model.

    In addition, we have created special programs to work with the most 
``at risk'' adults who have been diagnosed with mental health and 
substance use challenges and are often homeless and/or involved with 
the legal system. This program is known as the Assertive Community 
Treatment (ACT) model and has provided a crucial relief valve to law 
enforcement. The initial outcome data shows 80 percent of the 
population has avoided homeless incidents and 76 percent have avoided 
new legal incidents. Nationally, 96 percent of CCBHCs are actively 
engaged in one or more innovative activities in partnership with 
criminal justice agencies, including 77 percent who--like us--have used 
their CCBHC status to launch intensive outreach and engagement services 
to divert people at high risk from further involvement with the 
criminal justice system.

    Of equal importance is the increased access to services in a timely 
manner while improving care coordination. Since CCBHC implementation, 
our organization provides 70 percent of admissions on the same day that 
they seek services. For those who do have to wait, the average wait 
time is 3 days compared to the national average of 48 days. Individuals 
in our care receive enhanced care coordination with primary care. 74 
percent of our active population has an active primary care provider. 
When individuals do not have a primary care provider or require 
additional referrals, care coordinators work hard to close the referral 
loop. Through data collection, we identified the need to develop a 
tobacco cessation program. FCMHC currently provides tobacco cessation 
services to 72 individuals with 47 percent successfully quitting or 
reducing usage by more than half after starting the program. This is 
especially encouraging for the long-term cost implications for 
populations that have co-occurring chronic health conditions.

    As we look ahead to CCBHC implementation in Kansas, we need to 
develop more mobile crisis services in partnership with the national 
988 crisis hotline. Mobile crisis services reduce the number of 
emergency room visits. National data indicates that the CCBHC model 
reduces emergency room admission percentages by 68 percent. In 
addition, the CCBHC model emphasizes care coordination agreements 
between the CCBHC and the hospital. This improves partnerships and 
helps individuals from falling through the cracks upon discharge to the 
community.

    In conclusion, I wish to express my support that the CCBHC model 
should move beyond ``demonstration'' status and become a staple of our 
healthcare system. As Daniel Tsai, the Director of Center for Medicaid 
and CHIP services at the Center for Medicare and Medicaid Services 
(CMS) and past Medicaid Director for the State of Massachusetts 
articulated during the national meeting for the National Council for 
Mental Well-being just a few weeks ago, the CCBHC model represents a 
crucial part to the pyramid of health care that we need to ensure high 
quality access to care for all people across our Nation. We have 
clearly seen this to be true for Kansas. Thank you for the opportunity 
to testify on behalf of the countless individuals that the CCBHC system 
serves and the incredible workforce that provides this care.
                                 ______
                                 
    Senator Markey. Thank you, Mr. Denny, so much. I am going 
to recognize Senator Tuberville for an introduction of Dr. 
Taylor. Dr. Taylor is President Elect of the American Society 
of Addiction Medicine, a triple board certified in general 
child, adolescent addiction and sports psychiatry. Dr. Taylor 
also serves as the Medical Director of the NBA.

    Senator Tuberville.

    Senator Tuberville. Thank you. Thank you, Senator Markey 
and Senator Marshall, for having this. Just a quick statement, 
and I note, I am not a Member of this Committee, but I will say 
this is--the importance of this Committee. I dealt with 
hundreds of families every year in my former job, and there 
weren't many families that I would ever run into that didn't 
have some type of mental health problem in their family.

    This is not a crisis. This is a national emergency. I don't 
think we really understand the problems that we have now. We 
are going to continue to have it. It is going to get worse if 
we don't address it, and it is by having hearings like this. I 
tell people all the time, they say, wait, we can't afford to 
attack mental health problems. It is too big.

    My comment to that is we can't afford not to fund mental 
health in this country. We have to attack mental health in this 
country, and we have got to fund it no matter what it takes. 
So, tough times requires tough leaders. Dr. Taylor, it is my 
privilege to introduce Stephen Taylor from Birmingham, Alabama.

    He is completing his 13th season as the Medical Director of 
the Player Assistance Anti-Drug Program with the NBA, the 
National Basketball Players Association. He also serves as the 
Chief Medical Officer of the Behavioral Health Division of 
Pathway Health Care, a company that operates 17 outpatient 
addiction treatment offices spread throughout the South. 
Additionally, Dr. Taylor is President Elect of the American 
Society of Addiction Medicine.

    Dr. Taylor is uniquely positioned to understand the scope 
and the extent of the mental health crisis and emergency we are 
experiencing in this country. This crisis affects children and 
adults of all ages and all walks of life. He is a perfect 
witness for today's hearing, a crisis in mental health and 
emergency substance use disorder care.

    He will discuss the work that needs to be done to fix our 
broken mental health care infrastructure in this country. I am 
incredibly proud to have someone like Dr. Taylor working on 
these issues in the great State of Alabama, and I look forward 
to partnering with him, moving forward, to help keep up these 
efforts. I am also pleased that this Subcommittee is focusing 
on this today and hope that the entire HELP Committee can 
understand the importance of this.

    Dr. Taylor, welcome and thank you, Mr. Chair.

    Senator Markey. Thank you, Senator. You are recognized, 
whenever you are comfortable, Dr. Taylor. Please begin.

STATEMENT OF STEPHEN TAYLOR, PRESIDENT ELECT, AMERICAN SOCIETY 
             OF ADDICTION MEDICINE, BIRMINGHAM, AL

    Dr. Taylor. Thank you for that kind introduction, Senator 
Tuberville. Chairman Markey, Ranking Member Marshall, and 
esteemed Members of this Subcommittee, thank you for inviting 
me to participate in today's hearing on closing gaps in access 
to mental health and substance use disorder care by bringing 
that care into communities across this Nation.

    Today, I am testifying in my capacity as President elect of 
the American Society of Addiction Medicine, known as ASAM. ASAM 
is a National Medical Society representing over 7,000 
physicians and other clinicians who specialize in the 
prevention and treatment of addiction and co-occurring 
conditions.

    I would like to begin by recognizing the bipartisan work 
that Congress has done over the years to help address what is 
turning out to be the deadliest addiction and overdose crisis 
in American history. Thank you for your efforts.

    Still, at a time of elevated death rates and medical 
complications associated with synthetic opioids like fentanyl, 
psycho stimulants like methamphetamine, and the non-opioid 
veterinary tranquilizer Xylazine, much more work needs to be 
done to create a sustainable and robust addiction care 
infrastructure, one that addresses addiction as a preventable 
and treatable chronic medical disease.

    Accordingly, ASAM asks this Subcommittee to focus on three 
areas that are ripe for policy intervention. First, the 
addiction specialist physician workforce. ASAM estimates that 
there are only about 7,000 addiction specialist physicians 
defined as physicians who are board certified in addiction 
medicine or addiction psychiatry in this country.

    While addiction treatment in the United States is often 
delivered to patients by multidisciplinary health care teams 
that work to address patients bio-psychosocial needs, the 
distinct clinical knowledge and skill set of addiction 
specialist physicians best situates us to lead those teams.

    Addiction specialist physicians can increase our health 
care team's capacity to prevent and treat more complicated 
medical cases involving substance use disorder. Addiction 
specialist led care teams also lead to the greater integration 
of addiction care into general medical and mental health 
treatment settings.

    Even more importantly, such care models can enable our 
health care system to increase its capacity to provide 
addiction treatment in primary care settings, which is 
especially important in areas where there is a dearth of 
specialty addiction treatment facilities.

    For this and other reasons, Congress created the 
groundbreaking Substance Use Disorder Treatment and Recovery 
Loan Repayment Program, or STAR-LRP, in the Support Act of 
2018. When individuals pursue a full-time job to provide 
addiction treatment in high need geographic areas, HRSA's STAR-
LRP can help them repay up to $250,000 in their student loans. 
Demand for this program has been overwhelming.

    Therefore, ASAM strongly supports the Substance Use 
Disorder Treatment and Recovery Loan Repayment Program 
Reauthorization Act of 2023, which was introduced yesterday in 
the House on a bipartisan basis and would further strengthen 
the program while preserving its focus on addiction care 
workforce.

    Additionally, ASAM urges this Congress to pass legislation 
to encourage teaching health center graduate medical education 
program applicants to sponsor addiction medicine fellowship 
programs, and to require all HRSA funded health centers to 
offer addiction and mental health services.

    Second, decriminalization of the prescribing of methadone 
for the treatment of OUD by addiction specialist physicians for 
dispensing at pharmacies. While ASAM is grateful for SAMHSA's 
ongoing efforts to update Federal regulations governing opioid 
treatment programs known as OTPs, continuing to restrict 
patient access to methadone for OUD to OTP settings is a public 
health threat that unnecessarily limits access to this 
lifesaving medication for those who need it.

    Therefore, ASAM strongly supports passage of the 
bipartisan, bicameral, Modernizing Opioid Treatment Access Act, 
which would responsibly expand access to methadone treatment 
for all OUDs by decriminalizing its prescribing by addiction 
specialist physicians for dispensing at pharmacies.

    Third, enforcement of Federal mental health and addiction 
parity law. It has been well documented that we need better 
enforcement of Federal mental health and addiction parity law 
in this country. Under current law, the U.S. Department of 
Labor lacks the authority to assess civil monetary penalties 
for violations of Federal parity law already on the books.

    This prevents DOL from effectively ending parity violations 
with respect to group health plans. That is why ASAM strongly 
supports the soon to be introduced Parity Enforcement Act, 
which would finally add civil monetary penalty authority to the 
DOL's oversight.

    In conclusion, these policies and resources are imperative 
to bringing addiction care into communities across this Nation 
and to saving more lives. Thank you, and I look forward to 
answering your questions.

    [The prepared statement of Dr. Taylor follows:]

                  prepared statement of stephen taylor
    Chairman Markey, Ranking Member Marshall, and esteemed Members of 
this Subcommittee, thank you for inviting me to participate in today's 
critically important hearing on closing gaps in access to mental health 
and substance use disorder (SUD) care by bringing that care into 
communities across this Nation. My name is Dr. Stephen Taylor. I am 
board-certified in addiction medicine, addiction psychiatry, child and 
adolescent psychiatry, and general psychiatry. I take care of patients 
with addiction and co-occurring conditions in Birmingham, Alabama where 
I serve as the Chief Medical Officer of Pathway Healthcare--a company 
operating 17 outpatient mental health and addiction treatment offices 
in five southern states. I am also the Medical Director of the Player 
Assistance and Anti-Drug Program of the National Basketball Association 
(NBA) and the National Basketball Players Association (NBPA) . Today, I 
am testifying in my capacity as President-Elect of the American Society 
of Addiction Medicine, known as ASAM. ASAM is a national medical 
society representing over 7,000 physicians and other clinicians who 
specialize in the prevention and treatment of addiction and co-
occurring conditions.

    I would like to begin by recognizing the bipartisan work that 
Congress has done over the years to help address--what is turning out 
to be--the deadliest addiction and overdose crisis in American history. 
Your efforts have made a positive difference. Thank you.

    Still, at a time of elevated death rates and medical complications 
associated with synthetic opioids like fentanyl, psychostimulants like 
methamphetamine, and the non-opioid veterinary tranquilizer xylazine, 
much more work needs to be done to create a sustainable and robust 
addiction care infrastructure--one that addresses addiction as a 
preventable and treatable chronic medical disease.

    Accordingly, ASAM asks this Subcommittee to focus on the following 
three areas that are ripe for policy intervention:

          1. Prioritization of the recruitment, training, and retention 
        of addiction specialist physicians--defined as physicians who 
        are board certified in addiction medicine or addiction 
        psychiatry; \1\
---------------------------------------------------------------------------
    \1\  ASAM. Public Policy Statement on Recognition and Role of 
Addiction Specialist Physicians in Health Care in the United States. 
https://www.asam.org/advocacy/public-policy-statements/details/public-
policy-statements/2022/01/28/public-policy-statement-on-the-
recognition-and-role-of-addiction-specialist-physicians-in-health-care-
in-the-united-states (describing the four medical subspecialty 
certifications that demonstrate and define physician expertise in 
addiction treatment).

          2. Decriminalization of the prescribing of methadone for the 
        treatment of opioid use disorder (OUD) by addiction specialist 
        physicians (and OTP (defined below) clinicians) for dispensing 
        at pharmacies; methadone is the only full opioid agonist 
        medication that is approved by the Food and Drug Administration 
---------------------------------------------------------------------------
        (FDA) for the treatment of OUD; and

          3. Enforcement of Federal mental health and addiction parity 
        law that is already on the books.
     Prioritization of the Addiction Specialist Physician Workforce
    Addiction is a chronic medical disease involving complex 
interactions among brain circuits, genetics, the environment, and an 
individual's life experiences. People with addiction use substances or 
engage in behaviors that become compulsive and often continue despite 
harmful consequences. A lack of knowledge and misinformation about 
addiction within the medical community has been a longstanding problem. 
Therefore, the fact that there remains far too few physicians and other 
clinicians who specialize in the assessment of substance use disorder 
(SUD) and the prevention and treatment of the disease of addiction is 
of grave concern. According to the Substance Abuse and Mental Health 
Services Administration (SAMHSA), in 2021, well over 40 million 
Americans had SUD in the past year. \2\ For purposes of comparison, the 
State of California has nearly 40 million residents. At the same time, 
deaths continue to persist at record levels from drug overdoses, 
according to the Centers for Disease Control and Prevention. \3\
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    \2\  Substance Abuse and Mental Health Administration. ``Key 
Substance Use and Mental Health Indicators in the United States: 
Results from the 2021 National Survey on Drug Use and Health.'' U.S. 
Department of Health and Human Services Substance Abuse and Mental 
Health Services Administration, Center for Behavioral Health Statistics 
and Quality, Populations Survey Branch, no. PEP22-07-01-005 (December 
2022). https://www.samhsa.gov/data/sites/default/files/reports/
rpt39443/2021NSDUHFFRRev010323.pdf.
    \3\  Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug 
overdose death counts. National Center for Health Statistics. 2023. 
Designed by LM Rossen, A Lipphardt, FB Ahmad, JM Keralis, and Y Chong: 
National Center for Health Statistics.

    Shortfalls exist at all levels of the addiction care workforce, but 
one of the most grievous is among addiction specialist physicians. ASAM 
estimates that there are only about 7,000 \4\ of said physicians in 
this country--defined as physicians holding board certification in the 
medical subspecialty of addiction medicine or addiction psychiatry. As 
of March 2023, there were only 96 ACGME-accredited addiction medicine 
fellowship programs in the nation \5\5--far below the recommended goal 
of 125 fellowships by 2022 set by the President's Commission on 
Combating Drug Abuse and the Opioid Epidemic over 5 years ago. \6\ Our 
failure to meet this goal should be unacceptable.
---------------------------------------------------------------------------
    \4\  According to an email that ASAM received from the Executive 
Director of the American Board of Preventive Medicine (ABPM), as of 
January 2023, there were 4,347 Addiction Medicine Diplomates through 
ABPM with active status. According to an email that ASAM received from 
the Executive Director of the American College of Academic Addiction 
Medicine (ACAAM), as of January 2023, there were 1,312 addiction 
medicine physicians through the American Board of Addiction Medicine 
(ABAM). (According to ACAAM's Executive Director, there may be small 
overlap of people who remain both certified by ABAM and ABPM, but it 
would not be a significant number.) According to the 2021--2022 ABMS 
Board Certification Report, as of June 30, 2022, there were 1,398 
board-certified addiction psychiatrists in the U.S. (some of whom may 
be retired). ASAM was unable to confirm the number of AOA board-
certified addiction medicine physicians as of the date of this hearing, 
but estimates a few hundred physicians holding such board 
certification.
    \5\  American College of Academic Addiction Medicine. https://
www.acaam.org/fellowship-training
    \6\  THE PRESIDENT'S COMMISSION ON COMBATING DRUG ADDICTION AND THE 
OPIOID CRISIS. https://trumpwhitehouse.archives.gov/sites/
whitehouse.gov/files/images/Final--Report--Draft--11-15-2017.pdf

    While addiction treatment in the U.S. is often delivered to 
patients by multidisciplinary healthcare teams that work to address 
patients' biopsychosocial needs, \7\ the distinct clinical knowledge 
and skill set of addiction specialist physicians best situate them to 
lead those teams. Addiction specialist physicians can increase a 
healthcare team's capacity to prevent and treat more complex medical 
cases involving substance use disorder. Addiction specialist-led care 
teams can also lead to the greater integration of addiction care into 
general medical and mental health treatment settings. Even more 
importantly, such care models can enable our healthcare system to 
increase its capacity to provide addiction treatment in primary care 
settings--which is especially important in areas where there is a 
dearth of specialty addiction treatment facilities.
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    \7\  Examples of multidisciplinary team models include specialized 
addiction treatment programs, the Patient Centered Medical Home (PCMH), 
the ``hub-and-spoke'' model, the nurse care management model, and the 
Collaborative Care Model, which exist on a spectrum of integration with 
general medical treatment.

    Indeed, Congress acknowledged just how severe the overall SUD 
workforce shortage is--including its addiction specialist shortage--
when it created a groundbreaking loan repayment program, known as the 
Substance Use Disorder Treatment and Recovery Loan Repayment Program, 
or STAR-LRP, in the SUPPORT for Patients and Communities Act of 2018. 
When individuals pursue a full-time job to provide SUD treatment in 
high-need geographic areas, the Health Resources and Services 
Administration (HRSA)'s STAR-LRP can help them repay up to $250,000 in 
their student loans. Unsurprisingly, demand for this program has been 
overwhelming. In Fiscal Year 2021, alone, over 3,000 people applied for 
the program, but HRSA only had enough funding to serve 8 percent--or 
255 of them--at an average award amount of a little over $100,000, 
which is far below the maximum award amount allowed. Reauthorizing and 
strengthening STAR-LRP this year, while retaining its laser focus on 
the SUD workforce, is a top priority for ASAM. That is why ASAM 
strongly supports passage of the Substance Use Disorder Treatment and 
Recovery Loan Repayment Program Reauthorization Act of 2023, which is 
bipartisan legislation in the House that would further strengthen the 
---------------------------------------------------------------------------
program while preserving its focus on the addiction care workforce.

    In addition, while ASAM urges Congress to ensure that addiction 
specialist physicians are included across all HRSA Behavioral Health 
Workforce Development Programs, I also want to highlight that addiction 
specialist physicians often hold primary board certifications in the 
primary care specialties recognized by HRSA's Teaching Health Center 
Graduate Medical Education (THCGME) program. Those primary care 
specialties include family medicine, internal medicine, pediatrics, and 
general psychiatry. This multispecialty characteristic of addiction 
medicine is, therefore, why ASAM recommends that Congress pass 
legislation that would prioritize (or otherwise incentivize) THCGME 
program applicants that sponsor addiction medicine fellowship programs. 
ASAM also strongly supports the President's Budget proposals to (1) 
make additional investments in addiction and mental health services at 
health centers and (2) amend section 330 of the Public Health Service 
Act to require all HRSA-funded health centers to offer addiction and 
mental health services. \8\
---------------------------------------------------------------------------
    \8\  Johnson, Carole. HRSA Administrator. Testimony before the U.S. 
House of Representatives Committee on Energy and Commerce Subcommittee 
on Health on ``Examining Existing Federal Programs to Build a Stronger 
Health Workforce and Improve Primary Care.'' https://
d1dth6e84htgma.cloudfront.net/Witness--Testimony--Carole--Johnson--HE--
Hearing--04--19--23--e3abe98943.pdf'updated--at=2023--04--
17T20:18:01.021Z. Published April 19, 2023. Accessed April 24, 2023.
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Decriminalization of the Prescribing of Methadone for OUD by Addiction 
             Specialist Physicians for Pharmacy Dispensing
    Second, we all know that the long U.S. history of treating 
addiction in siloed settings separate from the rest of medicine 
exacerbates the addiction care workforce shortage. SAMHSA estimates 
that less than four in ten patients with OUD--who are primarily 
admitted for OUD to publicly funded SUD treatment--receive treatment 
with medications for OUD. \9\ Other studies have shown even worse rates 
of appropriate medication usage for alcohol use disorder. \10\, \11\ We 
no longer accept this in other parts of American medicine, and it is 
not acceptable for caring individuals with addiction.
---------------------------------------------------------------------------
    \9\  Substance Abuse and Mental Health Services Administration, 
Center for Behavioral Health Statistics and Quality. Treatment Episode 
Data Set (TEDS): 2020. Admissions to and Discharges from Publicly 
Funded Substance Use Treatment Facilities. Rockville, MD: Substance 
Abuse and Mental Health Services Administration, 2022.
    \10\  Arms L, Johl H, DeMartini J. Improving the utilization of 
medication-assisted treatment for alcohol use disorder at discharge. 
BMJ Open Quality 2022;11:e001899. doi: 10.1136/bmjoq--2022--001899
    \11\  Policymaker Summary: Pharmacotherapy for Adults With Alcohol 
Use Disorder in Outpatient Settings. Content last reviewed January 
2021. Effective Health Care Program, Agency for Healthcare Research and 
Quality, Rockville, MD. https://effectivehealthcare.ahrq.gov/products/
alcohol-misuse-drug-therapy/policymaker

    In 2019, a national report noted that the fragmentation that has 
occurred as a result of separating OUD treatment settings from other 
medical care not only creates significant access barriers, but is not 
supported by evidence. \12\ More specifically, while models of 
integrated methadone treatment of OUD with primary and other medical 
care sometimes exist in the U.S., they are much more common 
internationally. A 2017 international meta-analysis showed a 
significant reduction in all-cause mortality among people treated with 
methadone for OUD, both by general practitioners and specialty clinics. 
\13\, \14\ Randomized controlled trials--the gold standard--have 
demonstrated the safety and efficacy of methadone treatment of stable 
patients in primary care. \15\, \16\ Safety has also been shown in 
multiple non-randomized studies, some with 9 to 15 years of follow-up. 
\17\, \18\, \19\ Methadone has been available by prescription in 
Australia since 1970, and in Great Britain since 1968. \20\ Moreover, 
office-based prescribing and pharmacy dispensing of methadone increase 
the number of individuals with OUD with access to methadone treatment, 
as occurred in Canada following its 1996 implementation of such 
practices. \21\
---------------------------------------------------------------------------
    \12\  National Academies of Sciences, Engineering, and Medicine. 
2019. Medications for opioid use disorder save lives. Washington, DC: 
The National Academies Press. doi: https://doi.org/10.17226/25310.
    \13\  Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and 
after opioid substitution treatment: systematic review and meta-
analysis of cohort studies. BMJ. 2017;357:j1550
    \14\  Samet JH, Botticelli M, Bharel M. Methadone in Primary Care--
One Small Step for Congress, One Giant Leap for Addiction Treatment. N 
Engl J Med. 2018;379(1):7-8. doi:10.1056/NEJMp1803982
    \15\  Fiellin DA, O'Connor PG, Chawarski M, Pakes JP, Pantalon MV, 
Schottenfeld RS. Methadone maintenance in primary care: a randomized 
controlled trial. JAMA. 2001 Oct 10;286(14):1724-31. doi: 10.1001/
jama.286.14.1724. PMID: 11594897.
    \16\  Carrieri PM, Michel L, Lions C, et al. Methadone induction in 
primary care for opioid dependence: a pragmatic randomized trial (ANRS 
Methaville). PLoS One. 2014;9(11):e112328. Published 2014 Nov 13. 
doi:10.1371/journal.pone.0112328.
    \17\  Novick DM, Joseph H, Salsitz EA, et al. Outcomes of treatment 
of socially rehabilitated methadone maintenance patients in physicians' 
offices (medical maintenance): follow-up at three and a half to nine 
and a fourth years. J Gen Intern Med. 1994;9(3):127-130. doi:10.1007/
BF02600025.
    \18\  Salsitz EA, Joseph H, Frank B, et al. Methadone medical 
maintenance (MMM): treating chronic opioid dependence in private 
medical practice--a summary report (1983-1998). Mt Sinai J Med. 
2000;67(5-6):388-397.
    \19\  Schwartz RP, Brooner RK, Montoya ID, Currens M, Hayes M. A 
12-year follow-up of a methadone medical maintenance program. Am J 
Addict. 1999;8(4):293-299. doi:10.1080/105504999305695.
    \20\  Samet JH, Botticelli M, Bharel M. Methadone in Primary Care--
One Small Step for Congress, One Giant Leap for Addiction Treatment. N 
Engl J Med. 2018;379(1):7-8. doi:10.1056/NEJMp1803982
    \21\  Nosyk B, Anglin MD, Brissette S, et al. A Call For Evidence-
Based Medical Treatment Of Opioid Dependence In The United States And 
Canada. Health Affairs. 2013;32(8): 1462--1469. https://doi.org/
10.1377/hlthaff.2012.0846

    Here, in the U.S., methadone was first used for OUD treatment in 
the 1960's under Investigational New Drug applications issued by the 
FDA, at a time when providing opioid medications for OUD remained 
illegal otherwise. \22\ In 1972, the FDA determined and approved 
methadone as safe and effective for treatment of OUD. \23\ At the same 
time, erroneous beliefs that methadone replaced one addiction for 
another, reports of methadone-related deaths and diversion, \24\ and 
concerns over increasing crime rates \25\ created a climate of 
skepticism and hostility toward methadone-based OUD care. In 1974, 
Congress granted additional jurisdiction over methadone to the Drug 
Enforcement Administration (DEA). \26\ Both FDA, and subsequently 
SAMHSA, replaced the usual practice of physician autonomy with strict 
rules governing the provision of methadone for OUD treatment that--to 
this day-do not apply when methadone is prescribed for pain and 
dispensed from a community pharmacy.
---------------------------------------------------------------------------
    \22\  Jaffe JH, O'Keeffe C. From morphine clinics to buprenorphine: 
regulating opioid agonist treatment of addiction in the United States. 
Drug Alcohol Depend. 2003 May 21;70(2 Suppl):S3-11. doi: 10.1016/s0376-
8716(03)00055-3. PMID: 12738346.
    \23\  Institute of Medicine (US) Committee on Federal Regulation of 
Methadone Treatment; Rettig RA, Yarmolinsky A, editors. Federal 
Regulation of Methadone Treatment. Washington (DC): National Academies 
Press (US); 1995. Executive Summary. Available from: https://
www.ncbi.nlm.nih.gov/books/NBK232111/.
    \24\  Jaffe JH, O'Keeffe C. From morphine clinics to buprenorphine: 
regulating opioid agonist treatment of addiction in the United States. 
Drug Alcohol Depend. 2003 May 21;70(2 Suppl):S3-11. doi: 10.1016/s0376-
8716(03)00055-3. PMID: 12738346.
    \25\  Kleber, Herbert D. Methadone Maintenance 4 Decades Later. 
JAMA. 2008;300(19):2303-2305. free: https://jamanetwork.com/journals/
jama/fullarticle/182898.
    \26\  Jaffe JH, O'Keeffe C. From morphine clinics to buprenorphine: 
regulating opioid agonist treatment of addiction in the United States. 
Drug Alcohol Depend. 2003 May 21;70(2 Suppl):S3-11. doi: 10.1016/s0376-
8716(03)00055-3. PMID: 12738346.

    These exceptional Federal regulations specified criteria on 
eligibility, initial methadone dosages, required counseling services, 
supervised dosing, and restricted methadone treatment to provision 
within a closed system of regulated clinics, then known as narcotic 
treatment programs, now known as opioid treatment programs or OTPs. 
\27\ Such detailed regulations surrounding a specific medical practice 
have led into an orientation toward regulatory compliance, to the 
detriment of incentivizing innovation, quality, or individualized 
patient care. The detailed regulations also have carried along with 
them a misguided conception of abstinence defined as cessation of 
methadone pharmacotherapy. \28\ Experts have written about how such a 
highly regulated system of methadone-specific clinics in the U.S. 
reflects structural racism and contributes to health disparities among 
people with OUD. \29\
---------------------------------------------------------------------------
    \27\  Jaffe JH, O'Keeffe C. From morphine clinics to buprenorphine: 
regulating opioid agonist treatment of addiction in the United States. 
Drug Alcohol Depend. 2003 May 21;70(2 Suppl):S3-11. doi: 10.1016/s0376-
8716(03)00055-3. PMID: 12738346.
    \28\  White WL, Mojer-Torres L. Recovery-Oriented Methadone 
Maintenance. 2010. http://www.williamwhitepapers.com/pr/dlm--uploads/
2010Recovery--orientedMethadoneMaintenance.pdf. Accessed April 22, 
2023.
    \29\  Miller, NS. Racial disparities in opioid addiction treatment: 
a primer and research roundup. The Journalist's Resource. 2021. https:/
/journalistsresource.org/home/systemic-racism-opioid-addiction-
treatment/. Accessed April 22, 2023.

    It is progress and good news that outdated Federal OTP regulations 
will be updated soon to address OUD treatment standards in that 
setting. Drawing on research, evidence, and experience from the past 
two decades, thankfully, SAMHSA has indicated forthcoming regulatory 
updates when it issued a notice of proposed rulemaking in December 
2022. \30\ However, by continuing to largely restrict access to 
methadone for OUD to OTPs, the potential for expanded access to 
methadone treatment for OUD remains severely limited. Despite an 
expansion of OTPs in the U.S. in certain sectors in recent years, the 
prevalence of OUD has grown more quickly. \31\ Most U.S. counties do 
not even have an OTP. \32\ OTPs have established only a limited number 
of ``mobile components,'' known as medication vans, \33\ and a limited 
number of satellite medication units in locations such as pharmacies, 
jails, prisons, federally qualified health centers (FQHCs), and 
residential treatment facilities, resulting in limited geographic 
reach, \34\ and complex demographic inequities in access to treatment. 
\35\
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    \30\  SAMHSA. SAMHSA Proposes Update to Federal Rules to Expand 
Access to Opioid Use Disorder Treatment and Help Close Gap in Care. 
https://www.samhsa.gov/newsroom/press-announcements/20221213/update-
Federal-rules-expand-access-opioid-use-disorder-treatment. Published 
December 13, 2023. Accessed April 24, 2023. In addition, in April 2023, 
SAMHSA issued newly revised April 2023 Guidance extending methadone 
take-home flexibilities--effective upon the expiration of the COVID-19 
public health emergency and remaining in effect for the period of 1 
year from the end of the COVID-19 public health emergency, or until 
such time that the final rules revising 42 CFR part 8 are published. 
https://www.samhsa.gov/medications-substance-use-disorders/statutes-
regulations-guidelines/methadone-guidance.
    \31\  Substance Abuse and Mental Health Services Administration, 
National Survey of Substance Abuse Treatment Services (N-SSATS): 2020. 
Data on Substance Abuse Treatment Facilities. Rockville, MD: Substance 
Abuse and Mental Health Services Administration, 2021.
    \32\  Joudrey PJ, Chadi N, Roy P, Morford KL, Bach P, Kimmel S, 
Wang EA, Calcaterra SL. Pharmacy-based methadone dispensing and drive 
time to methadone treatment in five states within the United States: A 
cross-sectional study. Drug Alcohol Depend. 2020 Mar 27;211:107968. 
doi: 10.1016/j.drugalcdep.2020.107968. Epub ahead of print. PMID: 
32268248; PMCID: PMC7529685.
    \33\  Biden-Harris Administration Expands Treatment to Underserved 
Communities with Mobile Methadone Van Rule. https://www.whitehouse.gov/
ondcp/briefing-room/2021/06/29/biden-harris-administration-expands-
treatmentto-underserved-communities-with-mobile-methadone-van-rule--
2021/. Published June 29, 2021. Accessed April 22, 2023.
    \34\  ``Methadone Barriers Persist, Despite Decades Of Evidence, `` 
Health Affairs Blog, September 23, 2019. DOI: 10.1377/
hblog20190920.981503.
    \35\  Joudrey, Paul, Gavin Bart, Robert Brooner, Lawrence Brown, 
Julia Dickson-Gomez, Adam Gordon, Sarah Kawasaki, et al. ``Research 
Priorities for Expanding Access to Methadone Treatment for Opioid Use 
Disorder in the United States: A National Institute on Drug Abuse 
Center for Clinical Trials Network Task Force Report.'' Substance Abuse 
42 (July 3, 2021): 245--54. https://doi.org/10.1080/
08897077.2021.1975344.

    For these reasons, ASAM strongly supports passage of the bipartisan 
and bicameral Modernizing Opioid Treatment Access Act (M-OTAA) (S. 644/
H.R. 1359). M-OTAA would responsibly expand the capacity for lifesaving 
methadone treatment for individuals with OUD through our existing 
medical infrastructure. Specifically, it would decriminalize \36\ OTP 
clinicians and addiction specialist physicians--the latter representing 
some of the most educated and experienced physicians using 
pharmacotherapies for OUD in the nation \37\--who prescribe methadone 
for OUD that can be dispensed from a community pharmacy. Among other 
safeguards contained in M-OTAA, these separately registered prescribers 
would remain subject to SAMHSA's continued regulation and guidance on 
supply of methadone for unsupervised use.
---------------------------------------------------------------------------
    \36\  Lampe, J.R. (2023). The Controlled Substances Act (CSA): A 
legal overview for the 118th Congress (CRS Report No. R45948). 
Congressional Research Service, 9. https://crsreports.Congress.gov/
product/pdf/R/R45948 (stating that a violation of the Controlled 
Substances Act's registration requirements is a criminal offense if the 
violation is committed knowingly, and the Department of Justice may 
bring criminal charges against individual registrants; for example, a 
first criminal violation of the registration requirements by an 
individual is punishable by a fine or up to a year in prison).
    \37\  The American College of Graduate Medical Education (ACGME) 
sets the program requirements for graduate medical education in 
addiction medicine and addiction psychiatry. ACGME common core program 
requirements for addiction medicine fellowships include: 
pharmacotherapy and psychosocial interventions for SUDs across the age 
spectrum, (IV.B.1.c.).(1).(k)); the mechanisms of action and effects of 
use and abuse of alcohol, sedatives, opioids, and other drugs, and the 
pharmacotherapies and other modalities used to treat these 
(IV.B.1.c).(1).(m)); the safe prescribing and monitoring of controlled 
medications to patients with or without SUDs (IV.B.1.c).(1).(n)); at 
least 3 months of structured inpatient rotations, including inpatient 
addiction treatment programs, hospital-based rehabilitation programs, 
medically managed residential programs where the fellow is directly 
involved with patient assessment and treatment planning, and/or general 
medical facilities or teaching hospitals where the fellow provides 
consultation services to other physicians in the Emergency Department 
for patients admitted with a primary medical, surgical, obstetrical, or 
psychiatric diagnosis; (IV.C.3.a).(1)); at least 3 months of outpatient 
experience, including intensive outpatient treatment or ``day 
treatment'' programs, addiction medicine consult services in an 
ambulatory care setting, pharmacotherapy, and/or other medical services 
where the fellow is directly involved with patient assessment, 
counseling, treatment planning, and coordination with outpatient 
services (IV.C.3.a).(2)). https://www.acgme.org/globalassets/pfassets/
programrequirements/404--addictionmedicine--2022--tcc.pdf

    While it is true there is widespread stakeholder support for 
SAMHSA's proposals for greater OTP clinician discretion in determining 
take-home methadone doses for OUD, \38\ certain OTP stakeholders have 
expressed concerns with M-OTAA's provisions that would allow addiction 
specialist physicians practicing outside of OTPs to prescribe methadone 
for OUD. These critics often cite the risks of methadone overdose and 
diversion as the primary reasons for this concern. However, when more 
closely examined, the totality of that opposition puts more patients 
with OUD at risk for overdose in a time of an alarming death toll.
---------------------------------------------------------------------------
    \38\  Two studies published in January 2023 raise questions about 
the role of Federal regulatory OTP flexibilities during the COVID 
public health emergency in increases in methadone-involved overdoses 
deaths. However, both studies' authors identify significant limitations 
of their study in demonstrating direct causality. While there remains 
no direct evidence of causality, ASAM recognizes that granting more 
flexibilities within the OTP setting must be carried out with caution 
and with Federal agencies' continual, longitudinal regulations and 
monitoring for unintended consequences, notwithstanding the widespread 
support of making such Federal take home policy changes permanent, 
including among OTP stakeholders. OTP medical directors are not 
required to be addiction specialist physicians, and not all OTP 
clinicians are physicians. See Kleinman, Robert A., and Marcos Sanches. 
``Methadone-Involved Overdose Deaths in the United States before and 
during the COVID-19 Pandemic.'' Drug and Alcohol Dependence 242 
(January 1, 2023): 109703. https://doi.org/10.1016/
j.drugalcdep.2022.109703. See also Kaufman, Daniel E., Amy L. 
Kennalley, Kenneth L. McCall, and Brian J. Piper. ``Examination of 
Methadone Involved Overdoses during the COVID-19 Pandemic.'' Forensic 
Science International 344 (January 31, 2023): 111579. https://doi.org/
10.1016/j.forsciint.2023.111579.

    For starters, any analysis of M-OTAA must be situated in a 
contemporary framework for the current crisis. The adulteration of the 
illegal drug supply with illicitly manufactured fentanyl, fentanyl 
analogs, and xylazine has created an unprecedented and catastrophic 
moment in U.S. history. Today, it is a more dangerous time than it has 
ever been to be an American with OUD. However, patients with OUD who 
are engaged in addiction treatment are less likely to die than those 
who remain untreated, and for some patients, methadone is essential to 
a successful recovery. \39\ Methadone can facilitate abstinence from 
illegal substance use, support recovery, and prevent overdose deaths. 
\40\ Thus, restrictions that continue to limit methadone treatment for 
OUD to OTPs are a well-recognized vulnerability in the response to the 
nation's addiction and overdose crisis. \41\
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    \39\  National Academies of Sciences, Board on Health Sciences 
Policy, Committee on Medication Assisted Treatment for Opioid Use 
Disorder. The Effectiveness of Medication-Based Treatment for Opioid 
Use Disorder. National Academies Press (US); 2019. Accessed March 31, 
2022. http://www.ncbi.nlm.nih.gov/books/NBK541393/
    \40\  Stone AC, Carroll JJ, Rich JD, Green TC. Methadone 
maintenance treatment among patients exposed to illicit fentanyl in 
Rhode Island: Safety, dose, retention, and relapse at 6 months. Drug 
Alcohol Depend. 2018;192:94-97. doi:10.1016/j.drugalcdep.2018.07.019
    \41\  NASEM. Methadone Treatment for Opioid Use Disorder Examining 
Federal Regulations and Laws A Workshop National Academies. Published 
2021. Accessed December 6, 2021. https://www.nationalacademies.org/
event/03--03--2022/methadone-treatment-for-opioid-usedisorder-
examining-Federal-regulations-and-laws-a-workshop

    Furthermore, there are underlying complexities in the early trends 
of diversion of methadone and related overdoses, which were, in large 
part, associated with historical trends in the acceleration of 
prescribing opioids for chronic, non-cancer pain. \42\, 1A\43\, \44\ 
Methadone is unusual among opioid agonists in that the slow 
accumulation of serum levels during initial dose adjustment may 
contribute to the risk of fatal methadone overdose, \45\ especially if 
healthcare professionals overestimate a patient's degree of opioid 
tolerance. \46\ And, when methadone is used to treat chronic pain--
especially by prescribers lacking training in pain medicine, the 
frequent dosing regimens tend to play into methadone's pharmacological 
risks. \47\ M-OTAA, however, does not increase methadone prescribing 
for chronic pain (which happens to remain available through 
prescription and pharmacy dispensing today). Indeed, historical and 
contemporary research support a responsible expansion in access to 
methadone treatment for OUD, including through office-based practices. 
\48\, 1A\49\, \50\
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    \42\  Paulozzi L, Mack K, Jones CM. Vital Signs: Risk for Overdose 
from Methadone Used for Pain Relief--United States, 1999--2010. 
Published July 6, 2012. Accessed December 11, 2021. https://
www.cdc.gov/mmwr/preview/mmwrhtml/mm6126a5.htm
    \43\  Jones CM. Trends in Methadone Distribution for Pain 
Treatment, Methadone Diversion, and Overdose Deaths--United States, 
2002--2014. MMWR Morb Mortal Wkly Rep. 2016;65. doi:10.15585/
mmwr.mm6526a2
    \44\  DEA. Methadone Diversion, Abuse, and Misuse: Deaths 
Increasing at Alarming Rate. Published October 16, 2007. Accessed April 
22, 2023. https://www.justice.gov/archive/ndic/pubs25/25930/index.htm--
Diversion
    \45\  Clark JD; Understanding Methadone Metabolism: A Foundation 
for Safer Use. Anesthesiology 2008; 108:351-- 352 doi: https://doi.org/
10.1097/ALN.0b013e318164937c
    \46\  Center for Substance Abuse Treatment, Methadone-Associated 
Mortality: Report of a National Assessment, May 8-9, 2003. SAMHSA 
Publication No. 04-3904. Rockville, MD: Center for Substance Abuse 
Treatment, Substance Abuse and Mental Health Services Administration, 
2004.
    \47\  FDA. Highlights of Prescribing Information--Methadone
    \48\  Salsitz EA, Joseph H, Frank B, et al. Methadone medical 
maintenance (MMM): treating chronic opioid dependence in private 
medical practice--a summary report (1983-1998). Mt Sinai J Med N Y. 
2000;67(5-6):388-397.
    \49\  McCarty D, Bougatsos C, Chan B, et al. Office-Based Methadone 
Treatment for Opioid Use Disorder and Pharmacy Dispensing: A Scoping 
Review. Am J Psychiatry. 2021;178(9):804-817. doi:10.1176/
appi.ajp.2021.20101548
    \50\  Novick DM, Salsitz EA, Joseph H, Kreek MJ. Methadone Medical 
Maintenance: An Early 21stCentury Perspective. J Addict Dis. 2015;34(2-
3):226-237. doi:10.1080/10550887.2015.1059225

    To be clear, M-OTAA is not methadone for everyone, prescribed by 
anyone. It represents a responsible expansion in methadone access for 
OUD, including through a highly trained, modern-day workforce of expert 
physicians who can manage this essential treatment for Americans who 
need it. Inaction on M-OTAA is the risk that this country cannot 
continue to take.
 Enforcement of Existing Federal Mental Health and Addiction Parity Law
    Last, despite over a decade since the passage of the Paul Wellstone 
and Pete Domenici Mental Health Parity and Addiction Equity Act of 
2008, such parity of coverage for care remains elusive for millions of 
Americans suffering with mental health and substance use disorders. A 
wide disparity in network use and provider payment rates between mental 
health and addiction treatment, on the one hand, and general medical 
care on the other, have been well-documented. \51\ A recent report to 
Congress, issued by the U.S. Departments of Labor, Health and Human 
Services, and the Treasury, suggests that health plans and issuers are 
not always delivering parity for mental health and substance use 
disorder benefits to their beneficiaries. \52\
---------------------------------------------------------------------------
    \51\  Davenport S, Gray T, Melek SP. Addiction and mental health 
vs. physical health: Widening disparities in network use and provider 
reimbursement. https://www.milliman.com/en/insight/addiction-and-
mental-health-vs-physical-health-widening-disparities-in-network-use-
and-p. Published November 20, 2019. Accessed May 14, 2023.
    \52\  USDOL. US DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, 
TREASURY ISSUE 2022 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 
REPORT TO CONGRESS. https://www.dol.gov/newsroom/releases/ebsa/
ebsa20220125. Published January 25, 2022. Accessed May 6, 2023.

    While the reasons for parity elusiveness are many, one sits 
squarely within your jurisdiction. Under current law, the U.S. 
Department of Labor (DOL) lacks the authority to assess civil monetary 
penalties for violations of Federal parity law already on the books. 
Without this power, DOL cannot effectively end parity violations with 
respect to group health plans. That is why ASAM strongly supports 
passage of the Parity Enforcement Act, \53\ which would finally add 
civil monetary penalty authority to the DOL's oversight, by amending 
the Employee Retirement Income Security Act (ERISA) to allow the DOL to 
levy Federal parity violation penalties against covered health 
insurance issuers, plan sponsors, and plan administrators. According to 
the same report to Congress noted above, the Employee Benefits Security 
Administration (EBSA) ``believes that authority for DOL to assess civil 
monetary penalties for parity violations has the potential to greatly 
strengthen the protections of MHPAEA [the Paul Wellstone and Pete 
Domenici Mental Health Parity and Addiction Equity Act of 2008].'' \54\
---------------------------------------------------------------------------
    \53\  The Parity Enforcement Act was introduced by Senator 
Christopher Murphy during the 117th Congress. https://www.Congress.gov/
bill/117th-congress/senate-bill/4804--qpercent7B percent22search 
percent22 percent3A percent5B percent22parity+enforcement+act percent22 
percent5D--percent7D&s=1&r=41. It is expected to be reintroduced during 
the 118th Congress.
    \54\  USDOL. US DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, 
TREASURY ISSUE 2022 MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT 
REPORT TO CONGRESS. https://www.dol.gov/newsroom/releases/ebsa/
ebsa20220125. Published January 25, 2022. Accessed May 6, 2023.
---------------------------------------------------------------------------
                               Conclusion
    In conclusion, ASAM is actively designing, implementing, and 
advocating for the policies and resources that will secure a stronger 
foundation for addiction prevention, treatment, harm reduction, and 
recovery in this country. The policies and resources I have mentioned 
today are not inconsequential; they are imperative to saving lives.

    We know what to do to treat addiction. We also know that systemic 
change--a disruption of the status quo, which is currently falling 
short of our Country's full potential--is exceptionally difficult. But, 
working together, we must effect change, nonetheless. It is a matter of 
life or death.

    Thank you, and I look forward to answering your questions.
                                 ______
                                 
    Senator Markey. Thank you, doctor, so much. And our final 
witness is Dr. Warren Ng. Dr. Ng is the President of the 
American Academy of Child and Adolescent Psychiatry, and a 
Professor of Psychiatry at Columbia University Medical Center 
in New York City.

    At the American Psychiatric Association, he served on the 
Council for Children, Adolescents and their Families. Dr. Ng, 
welcome. Whenever you are ready, please begin.

 STATEMENT OF WARREN NG, PRESIDENT, AMERICAN ACADEMY OF CHILD 
            AND ADOLESCENT PSYCHIATRY, NEW YORK, NY

    Dr. Ng. Good morning. Thank you, Chairman Markey and 
Ranking Member Marshall, as well as Members of the Senate HELP 
Subcommittee.

    The members of the American Academy of Child and Adolescent 
Psychiatry, or AACAP, thanks you for hosting this hearing, as 
well as your opportunity to share our thoughts on how to bridge 
the gap to access to care, particularly for the pediatric 
mental health and substance use treatment.

    AACAP represents over 10,000 child and adolescent 
psychiatrist and trainees, all of whom grasp the gravity of the 
current situation in the pediatric mental health crisis. Our 
members work in every child facing system of care in rural and 
urban communities, as well as hospitals, schools, to families 
and communities across our Country.

    No one in our Nation has been spared the impact of the 
COVID-19 pandemic. Child and adolescent psychiatrists with 
their teams have been on the front lines. That is the reason 
why in October 2021, the American Academy of Child Analysis and 
Psychiatry with the American Academy of Pediatrics and the 
Children's Hospital Association officially declared a national 
state of emergency for children's mental health.

    While there are many factors that contribute to poor access 
to pediatric mental health care, my testimony today will focus 
on the impact of the insufficient behavioral health workforce 
on access to care, as well as some potential solutions.

    There has been a silent pandemic of pediatric mental health 
building for decades. This has largely impacted minoritized 
groups, including racial, ethnic, as well as gender diverse 
youth, as well as those who are still living in poverty.

    The social disruptions, fear and grief caused by COVID-19 
has turned the world upside down for all children, especially 
those most vulnerable. The escalating rates of pediatric 
suicide, as well as mental illnesses, compounded by the chronic 
workforce shortages are well-documented.

    We, in collaboration with the Federal and state 
policymakers, must support immediate, short, and long term 
strategies. In the short term, to increase access. We can 
extend the reach of child and adolescent psychiatry workforce 
by supporting primary care and school-based providers in their 
settings.

    Pediatric mental health care access programs, as well as 
school based mental health programs, integrated behavioral 
health, as well as primary care partnership, and tele-
psychiatry have all increased access to care.

    AACAP is grateful for the recent congressional investments 
in these models and urges Congress to promote state financing 
innovations, provider adoption to ensure these models are 
sustainable. We must meet children where they are at and reduce 
the barriers to care.

    We can also supplement our physician supply by recognizing 
the invaluable contributions of our international medical 
graduates. These American trained physician experts are an 
important part of the mental health care teams, particularly in 
underserved areas.

    Long term strategies to address access counts must include 
building a strong pipeline of pediatric mental health 
providers. There are significant workforce shortages even 
before the pandemic. This was especially true for child and 
adolescent psychiatrists, whose educational requirements as 
physician subspecialists are expensive and costly.

    Targeted student loan repayment programs and programs set 
to first student loan payments interest free while training 
make a difference. Research has shown that these solutions 
directly influence physician practice choices. The good 
behavioral health will not attract qualified, highly trained 
providers, reduce stigma, nor accommodate the growing demand 
until it is on equal footing with physical health and surgical 
care.

    Poor reimbursement is a disincentive to recruiting medical 
students into psychiatry and building robust behavioral health 
services. This contributes to limited in-network psychiatry 
access, longer wait times, higher expenses for patients who are 
forced to go out of network to find any care.

    Full parity for insurance coverage and reimbursement rates 
for mental health substance use treatment are critical. AACAP 
also recommends the Centers for Medicare and Medicaid Services, 
and other insurance regulators require health plans to use 
nationally recognized service intensity tools to making medical 
necessity determinations.

    These standardized assessment tools determine the 
appropriate level of service intensity needed for a particular 
patient and could assist payers in making appropriate coverage 
determinations.

    Last, we must acknowledge that America is becoming more 
racially and ethnically diverse and requires a pediatric mental 
health care system that reflects the communities being served.

    The COVID-19 pandemic and preexisting disparities for 
minoritized youth, including gaps in access to high quality 
care, truly to bridge this gap in all access to care, we need a 
workforce that reflects the patients' experiences, language, 
and background. This leads to better outcomes overcoming 
stigma, as well as addressing inequities.

    We can do this by investing in recruitment, training, and 
broader distribution of a more diverse representative 
workforce. AACAP encourages Congress to support programs and 
improve health equity by providing support for training to 
racially, ethnically diverse pediatric behavioral health 
professionals, to scholarship tuition assistance, as well as 
professional development opportunities.

    Thank you again for this opportunity to testify. AACAP is 
grateful for this opportunity give input into closing the gap 
in access for lifesaving behavioral health care for children 
and all Americans. Thank you for taking care of our--being our 
heroes, as well as our angels in terms of taking care of our 
children. Thank you.

    [The prepared statement of Dr. Ng follows:]

                    prepared statement of warren ng
    Chairman Markey, Ranking Member Marshall, and Members of the Senate 
HELP Subcommittee on Primary Health and Retirement Security, the 
members of the American Academy of Child and Adolescent Psychiatry, 
AACAP, thank you for hosting this hearing and for the opportunity to 
share our thoughts on how to bridge the gap in access to pediatric 
mental health and substance use disorder care. I am Warren Ng, AACAP 
President, and Director of Outpatient Behavioral Health for New York 
Presbyterian Hospital in New York City.

    AACAP represents over 10,000 child and adolescent psychiatrists and 
trainees all of whom grasp the gravity of our Nation's pediatric mental 
health crisis and have been responding. Our members work in every 
child-facing system of care, in urban and rural communities, from 
hospitals to schools, and across the lifespan. No one in our Nation has 
been spared the impact of the COVID-19 pandemic, and child and 
adolescent psychiatrists and their teams have been on the frontlines. 
In fact, in October 2021, AACAP along with the American Academy of 
Pediatrics and the Childrens' Hospital Association, declared a national 
state of emergency in children's mental health. \1\1 While there are 
many factors that contribute to poor access to pediatric behavioral 
health care, my testimony today will focus on the impact the 
insufficient behavioral health workforce has on access to care and 
potential solutions.
---------------------------------------------------------------------------
    \1\  Pediatricians, CAPs, and Children's Hospitals Declare National 
Emergency (aacap.org)

    There has been a silent pediatric mental health pandemic building 
for decades, disproportionately impacting minoritized groups including 
racial, ethnic, and gender diverse youth, and those living in poverty. 
The social disruptions, fear and grief caused by the COVID-19 pandemic 
turned the world upside down for all children, especially those 
vulnerable to mental illness and substance use disorders. The 
escalating rates of suicide and mental illness-related morbidity and 
mortality are well documented. Behavioral health workforce shortages 
are also chronic and well documented, especially for children. We, in 
collaboration with our Federal and state policymakers, must support 
---------------------------------------------------------------------------
immediate short and long-term strategies.

    In the short-term to increase access, we can extend the reach of 
the child and adolescent psychiatry workforce by supporting primary 
care and school-based providers in identifying, assessing, and 
stabilizing pediatric behavioral health disorders and in escalating to 
specialty behavioral healthcare when the patient's needs require a 
higher level of care. Pediatric Mental Healthcare Access (PMHCA) 
consultation programs, school based mental health care, integrated 
behavioral health and primary care models, and telepsychiatry have all 
proven to be effective means of connecting patients to behavioral 
health care. AACAP is grateful for recent congressional investments in 
these models and urges Congress to promote state financing innovation 
and provider adoption to ensure these models are sustainable. We must 
meet children where they are and eliminate additional barriers.

    We can also supplement our physician supply by recognizing the 
invaluable contributions of our international medical graduate (IMG) 
colleagues. These American trained physician experts are an important 
part of our mental health care teams, particularly in rural and 
underserved areas. In fact, recent data shows that 31 percent of child 
and adolescent psychiatrists are IMGs. \2\ We encourage Congress to 
reauthorize the Conrad 30 Waiver and extend for another 3 years.
---------------------------------------------------------------------------
    \2\  Active Physicians Who Are International Medical Graduates 
(IMGs) by Specialty, 2021--AAMC

    Long-term strategies to address access gaps must include building a 
strong pipeline of pediatric mental health providers, including child 
and adolescent psychiatrists. Long before the COVID-19 pandemic, the 
workforce shortages of pediatric mental health providers were 
significant. This is especially true for child and adolescent 
psychiatrists, whose educational requirements as physician 
subspecialists are extensive and costly. Targeted student loan 
repayment programs that support pediatric mental health professionals 
and programs that defer student loan payments, interest-free, while 
training, help mitigate the barrier of student debt. Research has shown 
---------------------------------------------------------------------------
that these solutions directly influence physician practice choices.

    The field of behavioral health care will not attract qualified, 
highly trained providers, reduce stigma, nor accommodate the growing 
demand for such services until it is on equal footing with physical 
health and surgical care. In addition to extensive time in training and 
student debt, poor reimbursement is a disincentive to recruiting 
medical students into psychiatry and building robust psychiatric 
services. This contributes to limited in-network psychiatry access, 
longer wait times, and higher expenses for patients--who are often 
forced to go out of their insurance networks to find any care. Full 
parity in insurance coverage and reimbursement rates for mental health 
and substance use treatment in Medicare and Medicaid would support 
children's access to high quality and timely mental health care by 
covering the full range of evidence-based behavioral health care 
services.

    AACAP recommends that the Centers for Medicare & Medicaid Services 
(CMS) and other insurance regulators require health plans to use 
nationally recognized service intensity tools developed by professional 
organizations in making medical necessity determinations. These 
standardized assessment tools provide determinations of the appropriate 
level of service intensity needed by a particular patient and could 
assist payers in making appropriate coverage determinations relating to 
mental health and substance use services.

    Last, we must acknowledge that America is becoming more racially 
and ethnically diverse and that the current pediatric mental health 
care system does not sufficiently serve the needs of our communities. 
The COVID-19 pandemic amplified pre-existing mental health disparities 
in minoritized children and adolescents, including gaps in access to 
high quality mental health care. To truly bridge the gap in all 
children's access to mental health and substance use disorder care, we 
need a behavioral health workforce that understands and identifies with 
their patient's experiences, language, and background. We can do this 
by investing in the recruitment, training, and broader distribution of 
a more diverse and representative workforce. Physicians who understand, 
speak the language, and identify with their patient's life experiences 
lead to better outcomes and are better equipped to overcome stigma and 
address inequities. AACAP encourage Congress to support programs that 
improve health equity by supporting the training of racial and 
ethnically diverse pediatric behavioral health professionals through 
scholarship, tuition assistance, and professional development 
opportunities.

    Thank you, again, for the opportunity to testify on this important 
topic. AACAP appreciates the opportunity to provide input as the Senate 
HELP Subcommittee on Primary Health and Retirement Security works to 
close gaps in access to life-saving behavioral healthcare for all 
Americans who need it, including those who hold our promise for the 
future, our children.
                                 ______
                                 
    Senator Markey. Thank you. Thank you, Dr. Ng, very much. 
Now we will turn to questions from the Senators. Dr. Taylor, 
thank you for raising the Modernizing Opioid Treatment Access 
Act. Methadone for chronic pain can be prescribed by doctors 
and picked up at a pharmacy.

    But methadone for opioid use disorder, it has a stigma. It 
is restricted. You talked about SAMHSA and ensuring that we 
decriminalize methadone as a treatment. Can you talk about why 
that is such an important step for our Country to take?

    Dr. Taylor. Absolutely, Senator. As you know that methadone 
is the only full agonist opioid treatment for opioid medication 
that is FDA approved for treatment of patients with opioid use 
disorder.

    It seems strange, to say the least, to put it mildly, that 
I, as an addiction specialist physician, board certified in 
addiction medicine and addiction psychiatry, would be 
committing a crime to prescribe a patient methadone in my 
office who needs methadone for treatment and stabilization of 
their opioid use disorder.

    But someone who has no training in addiction treatment, a 
doctor who is maybe a general family medicine physician or 
someone in some other specialty, as long as they have a DEA 
registration, can prescribe methadone in their office for pain, 
and can do so and have that patient go pick up that medication 
in a pharmacy.

    That does not make sense, to be honest. And that is a 
remnant of a really stigmatizing approach to the treatment of 
people with opioid use disorder. That is really the only way to 
understand how that came about.

    What we are trying to advocate for, and what we hope 
Congress will pass with the Modernizing Opioid Treatment Access 
Act, is to make it so that we can be very thoughtful and very 
careful in our approach to prescribing methadone for treatment 
of patients with OUD.

    That it is addiction specialist physicians, defined as 
someone who is board certified in addiction medicine or 
addiction psychiatry, who can prescribe the medication in a 
patient, in our office, or in one of the other various settings 
in which addiction specialist physicians work.

    Some of those settings are actually even more carefully 
monitored than OTPs, so called methadone clinics. But can 
prescribe it to patients and then have those patients pick up 
that medication in a pharmacy.

    It just increases access to care at a time when, as was 
mentioned, 106,000 patients died, people died last year from 
overdoses. We have to increase access to care.

    Senator Markey. Thank you, Dr. Taylor. I wanted unanimous 
consent to enter into the record two letters from 94 supporting 
organizations and other clinicians supporting expanding access 
to methadone and to pass the Modernizing Opioid Treatment 
Access Act.

    Without objection, so ordered.

    [The following information can be found on page 42 in 
Additional Material.]

    Senator Markey. Social media, its role in creating this 
teenage, young people mental health crisis in our Country. I 
would love to hear any of you step up and speak about this, and 
what you believe the correlation is. Dr. Celli, would you like 
to take that on?

    Dr. Celli. Sure. This one hits close to home as I have two 
teenagers and a preteen at home. But I think what we have 
observed is that social media is--distracts children. It is 
extraordinarily appealing and gives instant gratification for 
the desire to connect with somebody.

    Now, this was happening prior to the pandemic, but of 
course, during the pandemic, in a time where children were 
isolated, had to remain at home in many cases, were not in 
their school settings, they were not practicing social skills.

    It is much the anecdotes that I will hear in the office or 
from behavioral health clinicians who are seeing teens where I 
work is that it takes 1 second for a child to put in a friend 
into some sort of a platform where they can connect with other 
peers, and instantly your friends come up and they begin to 
connect.

    But these are not actual practiced social skills sort of 
relationships. And what I think is appealing is that it is so 
instant, and it can be very engrossing. What is--as a result, 
the adolescents and children are feeling more isolated.

    In fact, I mean, we call these social skills because they 
are skills they need to be practiced. I think this is impacting 
how our children are--whether or not they are connecting with 
their peers and how they are feeling about themselves.

    Senator Markey. Thank you, doctor, so much. It is 
unbelievable. One in three teenage girls contemplated suicide 
last year. One in ten teenage girls attempted suicide last 
year. One in five LGBTQ youth attempted suicide last year.

    Social media is implicated. It is an accessory to this 
tragedy that we are seeing in our Country, and we have to do 
something. We need a teenage privacy bill of rights online. We 
just have to pass one this year. It is urgent. Thank you.

    Senator Marshall.

    Senator Marshall. Thank you again, Chairman. Mr. Denny, I 
want you to talk just a second about your mobile crisis center. 
As I travel around the State of Kansas, I think I have been in 
every hospital, the emergency room is the epicenter of the 
crisis, and the mental health epidemic has definitely impacted 
that.

    The National Nurses Organization in my office 2 weeks ago, 
concerned about the violence in the emergency room. There is a 
right place, there is a tough place to take care of folks with 
mental health crisis going on, but it is tough in the emergency 
room.

    ER docs are leaving the field. We are not getting new year 
docs to go into to the field. How have you interacted with your 
emergency room, and what does your mobile crisis center do?

    Mr. Denny. Well, our mobile crisis services to degree have 
always been mobile. We are now taking it to 2.0 in terms of 
being able to respond to anywhere in the community. One 
strategy is to divert crisis in someone's home or a school or 
another location, so they do not end up in the emergency room.

    That is one of the big strategies that we will employ. 
Stabilization during a wait for a placement in inpatient 
hospitalization is an adaptive challenge. And what I mean by 
that is that there is no technical fix that is going to 
immediately resolve this issue.

    But what we have found, first of all, is partnership on the 
front end with our emergency rooms, and we serve rural areas, 
so getting to know and having plans on how we deal with 
emergency situations are important.

    Training for emergency room staff is important, at least 
some base level behavioral health response training. There are 
different options out there. And last, one of the things we 
have developed in Kansas, or are still developing, are the 
regional crisis centers, which would provide an alternative for 
someone to go and wait, and be assessed and stabilized, versus 
an emergency room.

    Anytime we can find a different setting to accomplish that 
purpose that is not as triggering or as difficult as an 
emergency room, I think the more of that we can do, that is a 
state program with Federal support, but the more of that we can 
do, the less of those incidents we will see over time.

    But it is a challenge. It is a frustration. It takes 
partnership between both of our systems to work through those 
issues.

    Senator Marshall. Certainly, a patient waiting days in an 
isolated room in the emergency room is not the solution. And it 
takes one on one nursing staff, so it takes away resources.

    We literally just have a shortage of those inpatient 
opportunities. Maybe, kind of turn to Dr. Ng, tell us, what is 
working and what is not working out there in your world? Just 
take like 1 minute to tell me what you think is cutting edge, 
and what do you think we have been doing that is not working?

    Dr. Ng. Thank you very much, Senator Marshall. I think that 
what is working and what is not working is also acknowledging, 
I think what Mr. Denny mentioned, is really creating that 
better continuum of care that goes from community to more 
intensive treatment, whether or not that is emergency 
department or inpatient psychiatric units.

    I think what is really important to hold center is the fact 
that person who is experiencing that mental health or emotional 
crisis is probably scared and frightened and overwhelmed as 
well.

    Being able to center our experience with that person is 
also understanding that emergency departments are never the 
place to be when you are in that situation. And how do we 
humanize that environment, whether or not this an adult or as a 
child, or a family member.

    I think that creating that continuum of care, of escalating 
intensity of outpatient and community services, that are 
embedded within communities, partnering with communities to 
provide the most culturally competent, as well as responsive 
care is really important.

    I think that means that we have to create some innovative 
programs that are funded and sustainable so that we can provide 
wraparound care for young people, and their families, and 
adults within communities.

    I think that we are thinking about these intensive 
outpatient programs, partial hospitalization, wraparound, as 
well as some of the critical time intervention programs that 
can sometimes be helpful, but I think the important thing is 
that they are networked toward a system of care that is a 
continuum, so that people who are experiencing that care don't 
have to jump through hoops, but experience it as being 
surrounded by people who can provide the care they need.

    Senator Marshall. Yes. Thank you so much. Mr. Chairman, I 
yield back and maybe we can get some follow-up questions after 
our colleagues finish.

    Senator Markey. Absolutely.

    Senator Baldwin.

    Senator Baldwin. Thank you, Mr. Chairman, Ranking Member, 
for holding this important Subcommittee hearing, and thank you 
to all of our witnesses today. I will never forget meeting with 
three moms in my office who all lost their children to fentanyl 
overdoses.

    Poisonings is the word they used, I think, in part because 
they believe their children perhaps didn't know that there was 
fentanyl lacing the illegal pill that they had taken. It is so 
clear that we have to do more to stop fentanyl from coming into 
our Country and our communities, and increase prevention and 
treatment efforts, and make overdose reversal drugs much more 
widely available.

    To do so, we have to use every tool we have to combat this 
epidemic. I know as Chair of the LHHS Subcommittee of 
Appropriations, I am committed to fighting for sufficient 
resources. I am also proud to co-sponsor Bruce's law with my 
colleague, Senator Murkowski, who has led that important 
measure.

    It would bolster Federal prevention and education efforts 
surrounding fentanyl. I look at how the opioid epidemic has 
changed and evolved, if that is the word you want to use, but 
changed fundamentally just in the last decade or so.

    Dr. Taylor, maybe you can describe why the fentanyl phase 
of this crisis has proven to be so especially challenging for 
health care providers. How have you experienced this 
transformation or evolution in our opioid epidemic and in the 
country?

    Dr. Taylor. Thank you for that question, Senator Baldwin. 
So, you hit something right on the head, which is fentanyl 
represents a third phase of this opioid crisis. Sort of the 
first phase was the prescription opioid proliferation and the 
overdose--the overdose death and the addiction epidemic that 
resulted from that.

    Second phase being heroin, as prescription opioids were 
made more difficult to access and much more expensive, and 
heroin came in and was much cheaper and much more readily 
accessible. One of the challenges is that fentanyl is even 
cheaper than heroin.

    As people developed ongoing addiction, marked, of course, 
with particularly with opioids, with the development of 
tolerance to whatever dose of drug that they were taking, and 
withdrawal, which is incredibly unpleasant when someone 
attempts to abruptly stop using opioids, then the person is 
driven to find something else that they can take.

    Of course, with fentanyl being less expensive and more 
readily available, it was predictable, if you think about it, 
that people would then turn to fentanyl. The problem is that it 
wasn't just pharmaceutical fentanyl.

    When you think of fentanyl, it is important to recognize 
there is pharmaceutical fentanyl, and then there is the 
illicitly manufactured synthetic product. And then beyond that, 
there is a number of different synthetic fentanyl analogs that 
are even more potent than fentanyl.

    People are familiar with the word carfentanyl, which is an 
analog, a synthetic analog of fentanyl that is--has been used 
to put down elephants. And that is how potent that drug is, and 
that is the drug that you hear people first responders showing 
up in situations and just by casual contact with it, ending up 
with significant levels of it in their system.

    Part of the challenge is that as people have continued on 
with addiction, that may have started from the time they were 
on prescription opioids, they now are at a point where they are 
addicted to fentanyl. The other part of the challenge for us as 
addiction treatment professionals is that because fentanyl and 
its analogs are so incredibly potent, it is actually much 
harder to provide treatment for someone who is addicted to 
fentanyl.

    We literally now are scrambling. ASAM just had our annual 
meeting a couple of weeks back, actually about a month ago in--
right here in the D.C. area. And we literally had several 
conferences with people on the front lines sharing with our 
general membership what are the strategies for taking someone 
who is addicted to fentanyl, or even one of the more potent 
fentanyl analogs, and trying to get that person inducted on to 
buprenorphine or even methadone.

    Because the challenge is that the withdrawal syndrome is so 
severe when we try to transition a person, that very often 
people end up not continuing with the treatment and going back 
out to use fentanyl. And so, we have had to figure out, and we 
are actively working on, strategies that work to address the 
severe withdrawal that people go through long enough so that 
they can transition smoothly to a medication like buprenorphine 
or methadone.

    Which is why we are pushing to make it possible for us to 
be able to prescribe methadone and have people get it from 
pharmacies, because for many patients, buprenorphine isn't the 
medicine that they are going to need for that transition--it is 
methadone.

    That is--and we need to have every tool available in the 
toolbox to be able to take care of people, particularly because 
of this extremely complicated, potent drug to which so many 
people are addicted.

    Senator Baldwin. Thank you.

    Senator Markey. Senator Murkowski.

    Senator Murkowski. Thank you, Mr. Chairman. I want to thank 
my colleague for your support on Bruce's law. I think, Dr. 
Taylor, this goes exactly to what you are talking about is the 
intensity of the addiction for those that have been using, 
whether it was prescription drugs or heroin.

    The intensity of the addiction is such that I think people 
need to understand that we are dealing--we are dealing with 
something at a higher, more intense level, and what that 
actually means. And the intensity of fentanyl itself and the 
lethality.

    As we work to educate people, to try to explain that this 
is not something that you can engage in lightly--you will be 
poisoned, and you will die. And part of what I am hearing with 
fentanyl is that the treatment, as you have indicated, is very, 
very challenged. But, that the likelihood of being poisoned as 
Sandy Snodgrass' son Bruce was, is out there as a very real 
reality.

    The lethality of fentanyl is something that scares the 
living daylights out of me. I want to ask, and I am not 
entirely sure who to address this to, but this week in our 
largest newspaper in the state was a front-page article about 
traumatic brain injury and how Alaska has the highest rates of 
TBI deaths, related deaths in the country.

    One out of every four deaths in Alaska under the age of 30 
is related to TBI. So, we know that we do a lot of rock 
climbing and some things that are inherently dangerous, four-
wheeling, snow machining. We get all that.

    But the reality is, of those deaths, 43 percent were due to 
suicide. Suicide attempts are more common in individuals that 
have sustained a brain injury. Almost half of brain injury 
survivors reporting symptoms of depression.

    The question to you all is, what protocols are in place to 
ensure that those who have sustained a TBI get the mental 
health that they need, that they get it on the front end? We 
recognize that this is--this is a pretty tight correlation 
here.

    Are we doing anything with regards to that? If you have 
got--if you have had a traumatic brain injury, is there follow-
up then to help on the mental health side? Dr. Ng.

    Dr. Ng. Thank you, Senator Murkowski. I think that this is 
a really incredibly important question to ask around how are we 
integrating mental health, and behavioral health, and suicide 
screening throughout all of our health care systems.

    It is really understanding that there is no health without 
mental health, and it is being able to ask those questions, but 
also work collaboratively with teams.

    When we integrate mental health and behavioral health 
services within medical settings and primary care settings, in 
specialty pediatric settings, it is really important. It allows 
us to have that conversation, to ask those questions.

    But also, when there are issues related to suicide, that we 
are able to address it directly and we are not having to refer 
to someone else. But when you are talking within your trusted 
medical care team and you are able to provide that level of 
identification, screening assessment, and referral to 
treatment, I think that is really key.

    Senator Murkowski. Dr. Ng, let me ask about that, because 
part of our big challenge in Alaska is lack of access to the 
providers, and particularly pediatric health providers who 
would be encouraged to practice in rural and medically 
underserved communities.

    Senator Smith and I have a bill, the Mental Health 
Professionals Workforce Shortage Loan Repayment Act, again, 
designed to get professionals out into rural areas. But it is a 
challenge for us in Alaska, I know, but I know that it is also 
equally challenging in other parts of rural America.

    I don't know that we can do enough fast enough, and 
particularly when we are looking at suicide statistics for 
young people who are struggling and are just simply not able to 
get the mental health treatment that they need.

    In Alaska, unfortunately, if a young person has been told 
that we don't have any services that we can provide to you, the 
care that they receive is outside. And when I say outside, it 
is not outside of a building, it is outside of the State of 
Alaska. So, they have to fly to Seattle, if they are lucky. A 
lot of times the medical help is available in Utah. You are 
separated from your family, from your support systems. This is 
not a tenable situation.

    I look at what we need to do to grow this workforce, but I 
also think that--Dr. Ng, you talk about this continuum of care 
and wraparound services, what more we can do to help parents 
and families and educators and local community leaders to help 
be that support in these smaller communities until you can get 
to the medical professional. I don't know if there is a 
question in there, but we are really struggling with this at 
home. Dr. Ng.

    Dr. Ng. Thank you, Senator. I think that--thank you very 
much for your leadership and support for S. 462, because I 
think the workforce shortage issues are really key. But also, 
being able to fund and support providers to be able to provide 
those mental health services within the medical setting and 
within communities is also really key.

    Being able to finance some of those strategies, the 
pediatric mental health care access programs that provides 
consultation to medical providers, particularly pediatric 
providers in urgent settings. The other thing is tele-
psychiatry has been really important to be able to bridge some 
of those gaps.

    I think that partnership with families within communities 
is key so that we can also encourage tele-psychiatry to be able 
to be helpful, to bring in key members of the community, as 
well as family members, to be a partner to that care.

    I totally agree that there isn't a quick fix to this 
because this problem existed well before, but at the same time, 
the loan repayment, as well as trying to finance integrated 
behavioral health interventions, as well as leveraging tele-
psychiatry and continuing to fund those innovations that have 
been helpful during the pandemic would be key.

    Senator Markey. Thank you. Thank you.

    Senator from Colorado.

    Senator Hickenlooper. Thank you, Mr. Chair. And thank all 
of you for being here today, but also for your ongoing work. 
Clearly, very, very important time to address some of these 
issues. Peer to peer mental health programs are taking off 
across school districts around the country.

    These programs where trained students offer a listening ear 
to their peers, they look for concerning signs, help connect 
students with professional resources appear to add real value. 
Students often feel more comfortable asking for help from a 
peer than from an adult, and this step alone can help break the 
stigma, especially for young people, around going forward and 
seeking care.

    Dr. Ng, why don't I start with you and just say, why do you 
think so many schools are gravitating--I mean, beyond that 
trying to work around the stigma, why are they gravitating 
toward these peer-to-peer programs, and what more can we do to 
support them?

    Dr. Ng. Thank you, Senator Hickenlooper. I think that is 
really a key perspective, is really bringing in the youth 
voice, as well as the youth involvement, and the youth 
solutions.

    I think that they are incredibly creative, and they are 
also an incredible resourced for us to continue to partner 
with, and that is partnering with them at a level that respects 
the information that they are giving us.

    I think it is really important that we honor that and also 
the diversity among the youth perspectives. And as you heard, 
the number of adolescent females that are experiencing 
helplessness and the rates of suicide with regards to the LGBTQ 
and gender diverse youth, as well as racial or ethnic diversity 
youth as well.

    I think that having the youth voice, and the youth is 
definitely--they will connect with each other in a way that we 
are not easily connected to them, and we can also gain from 
them that wisdom. But the important thing is, is that is not 
where we stop, that is where we start.

    Where we need to end up is actually connecting those youth 
peers, as well as support services, with other additional help 
and services along a larger continuum. So being able to 
reinforce the school based mental health programs embedded 
within those, as well as crisis response, so that those young 
people who need more urgent and critical care can be 
coordinated through that system, through their youth advocates.

    Senator Hickenlooper. Great. Appreciate it. Mr. Denny, you 
are from--your approach is from a different ecosystem. Would 
you agree with that?

    Mr. Denny. Yes, especially in relation to the development 
of peer services. That is one of the nine required services 
under CCBHC, person, peer and family support services 
organization. We have hired our first peer services supervisor 
and our hope is to continue to develop those services.

    One of the exciting things in Kansas too is we have just 
recently passed a code that would allow us to provide parent 
peer support services for parents of youth in our services, and 
I am really excited to see those develop. But it is as it was 
addressed earlier, there is not always a provider nearby.

    Our need to identify across multiple areas, whether it be 
schools, hospitals, there is a lot of different community-based 
trainings to help identify people in need and not always rely 
on a service provider to be there. Because a lot of times when 
the crisis happens, a behavioral health professional is right 
around the corner.

    Programs for us, such as mental health first aid, 
psychological first aid, question--for QPR training. There is a 
lot of different models that help train the community and 
engage around suicide, particularly in rural areas where we 
don't always have someone readily available.

    We don't have to go to Seattle, but we are two and a half 
hours away sometimes from a hospital. I totally get the 
isolation. And what do we do when we are here--kind of out here 
on our own.

    Senator Hickenlooper. Great. Thank you. Dr. Celli, I was 
going to--Colorado hospitals often don't have the resources to 
provide the care for kids, just as Mr. Denny was describing. 
Hospital staff are trying to do too much with too little, and 
again, especially in rural areas.

    Your testimony highlighted the outsized importance of 
community health centers, I think, in this community health 
programs, but not just--centers and programs.

    What do community health centers and certified community 
behavioral health clinics do to help address these gaps in the 
behavioral health care system? And how do we--how can we do 
more, since there are still so many people struggling to access 
care?

    Dr. Celli. Thank you so much, Senator Hickenlooper, for the 
question. So, one of the cornerstones of community health 
centers is that all of the service--all of the services are 
within the same team.

    That team can be very large thousands of staff, but they 
are all within the same team. And that makes coordination of 
care, as Dr. Ng was referring to, much easier. You don't have 
to go through--to another institution. It is one of your 
colleagues.

    That makes access to care much faster, more seamless, and 
feel like a standard part of your health care, once again, 
reducing stigma. So, addiction services, mental health 
services, help for health-related social needs.

    Many times, a person is subthreshold diagnostic depression, 
but then food insecurity or housing insecurity is that one 
stressor that takes them to a level of being quiet quite ill.

    I think that is one of--again, one of the cornerstones of 
community health centers, that integrated model, and the 
ability to have all of those services within the same system 
helps with coordination of care. I did want to highlight for a 
moment around pediatrics, in particular.

    At Brockton Neighborhood Health Center, we have the good 
fortune of having a program that is called--a grant funded 
initiative that trains not only the behavioral health 
providers.

    You could have a behavioral health provider who maybe had 
worked more with adults but is able to get trained in working 
with children because there is such a gap in services for 
pediatrics of trained professionals.

    This program trains providers on the medical side, medical 
assistance, nurses, behavioral health clinicians, clinical 
secretaries, everybody who is on the team, on how to create 
that space that really engages both the child and the family, 
and in some cases, other community members as well.

    Senator Hickenlooper. Yes, I love that approach. I think 
that is very useful. Thank you all. Dr. Taylor, I have got 
questions for you as well, and we will put them into the 
written. I am out of time. I apologize. I yield back to the 
Chair.

    Senator Markey. Thank you, Senator, so much. I would just 
like to follow-up, if I could, on Senator Murkowski's line of 
questioning of, with so few practitioners, how can telehealth 
help deliver services?

    What is necessary to be able to bridge this gap between 
Anchorage and Seattle, or Salt Lake City? What are the 
reimbursement issues? What are the licensing issues so that 
people can practice across state lines virtually?

    What are those new licensing opportunities that are going 
to have to be put in place if we are going to ensure that we 
get the resources to where the problem is? Yes, Dr. Ng.

    Dr. Ng. I will give it a try. I think that there are 
multiple strategies. I think one of that is the state compacts 
and being able to provide regional support.

    I think that familiarity for the child and adolescent 
psychiatrist consultant, to know that system of care, to 
understand that community being served is really key, until the 
time that you can develop in resources. So, specialists who are 
actually embedded within, for Senator Murkowski, within the 
State of Alaska.

    Really being able to partner with the local resources, with 
the community health centers, with the CCBHCs, with that 
network of care and the educational system is key. Also being 
able to finance appropriate consultation.

    When we are providing that expertise, as child and 
adolescent psychiatrists and physician experts in mental 
health, one of the things that we do, we are able to integrate 
is the health, as well as the mental health, as well as the 
psychosocial issues.

    Being able to integrate all of those in terms a 
comprehensive treatment plan involving all members, as well as 
the youth, the family, the community, and the school resources, 
is really key.

    Senator Markey. How will that help Senator Murkowski's 
problem in Alaska? Do you have a recommendation in terms of 
ensuring that somebody doesn't have to leave Anchorage, can get 
a top-notch psychiatrist in another state online, so that it 
can be integrated with perhaps the physical care in Anchorage? 
What is your recommendation?

    Dr. Ng. Those wonderful programs, the pediatric mental 
health care access programs, which really helps to partner 
child and adolescent psychiatrists with pediatricians, if we 
are talking about that population.

    It is really helping them talk through the care of that 
young person to develop and acquire some of the skills and the 
tools necessary to providing that care onsite. And it is really 
building that capacity for the care.

    There are other models, such as the Echo models, that can 
help extend the clinical expertise locally, whether or not it 
is with a primary care provider or if it is a provider within 
the CCBHC, or a community health center, or a private practice 
provider as well. I think that is the most rapid way of 
expanding your current short-term strategy, in addition to 
building some long-term strategies.

    Senator Markey. Dr. Taylor, I would like to come back to 
you one more time, and that is on this suboxone, methadone 
issue, in terms of the help which people need. Can you just put 
an exclamation point on the need for that law to change?

    Dr. Taylor. Senator, I have--about a few months ago, I got 
a message on LinkedIn from a gentleman who was the father of a 
young man who had been a patient of mine.

    The message was thanking me for helping his son and letting 
me know that his son was just about to graduate from law 
school. His son had been a patient of mine with a severe opioid 
use disorder, and I took care of him in my office for several 
years when he had flunked out of college and was--had gone 
through the progression, very much like I described previously, 
of addiction to prescription opioids, and then had moved on to 
snorting heroin and then injecting heroin, and had really 
severe addiction to opioids.

    I worked with him in the office, and I treated him with 
buprenorphine, and he did well for periods of time, and then 
would have a recurrence of his illness. And then I, at one 
point, had to refer him to a methadone program, an OTP, because 
I was not able to provide that for him in my office.

    During that period of time, I stayed in touch with him, and 
I tried to liaison with the doctor at the methadone program, 
who was not necessarily an addiction specialist, but we made 
the best of it. And then at other periods of time, we then 
transitioned him back to buprenorphine and I was able to then 
be the one prescribing and monitoring his medication.

    It was a torturous process taking care of that young man 
because of the fact that he wasn't able to just have me work 
with him on a consistent basis, prescribing whatever it was 
that he needed, that I, as an addiction specialist, was more 
than qualified to prescribe him.

    The bottom line--and so he had to come and see me for a 
while, and then go to the OTP for a while, and then come back 
into my office for a while, and it was a very difficult 
treatment course.

    I can't guarantee that he would have had a shorter or 
easier time of it if we had been--if I had been able to 
prescribe him the methadone the same way I was able to 
prescribe him buprenorphine, but it certainly would have made 
more sense for him, and it would have been more convenient for 
his family.

    Thankfully, he is in recovery now. He is doing great. He 
just graduated from law school. But it shouldn't be necessary 
for him to go through all of that, and not everyone has the 
kind of outcome he had.

    Senator Markey. Senator Marshall.

    Senator Marshall. Thank you again, Mr. Chairman. Mr. Denny, 
you have led this prototype of the Certified Community 
Behavioral Health Clinics. What are the three most important 
lessons that you would pass on, if we are going to set up 
something like this up in Alaska or other parts of Kansas? What 
is the secret recipe, in your opinion--lessons learned?

    Mr. Denny. From the National Council was just letting me 
know there are two clinics being piloted in Alaska currently, 
two CCBHC clinics. So that is--the model is off the ground 
there.

    Senator Marshall. That is great. And we should ask the 
Senator Murkowski's staff to follow-up with you and the 
clinics, and share some lessons learned.

    Mr. Denny. Yes. In terms of setting, it up, it is so 
important to have an effective community needs assessment and 
make sure that you are really assessing the needs of each 
community served. You know, the accessibility conversation, 
particularly as it relates to telehealth, I always think about 
rural frontier areas, right.

    A lot of our areas that we serve don't necessarily have 
connectivity. So, making sure that whenever--wherever we offer, 
those services have the tools and resources, that the right 
people are at the table. So, an effective needs assessment that 
truly identifies the unique needs of each community.

    The second thing is really developing providers' skill sets 
and practices that are going to have outcomes. So, the models 
you choose need to be applicable to the populations you are 
serving. I think Kansas has done a really good job of choosing 
evidence-based practices that are really relevant to the needs 
of Kansans we are serving.

    The third thing is, and this is a practical thing, but 
there is a lot of talented CCBHC clinics throughout our 
Country. When we were starting, I had people from all over the 
country reaching out to me saying, try this, try that, consider 
this, consider that. Here is how you get started on your data.

    But the thinking of a data collection strategy that is 
practical, meaning that you can get started with meaningful 
outcomes that are going to tell your story, but at the same 
time, having a plan to how to build and grow that.

    You know, in Kansas, in the next 6 months to a year, we 
will have a data warehouse that will allow us to track outcomes 
across our entire state population. That will be a really 
unique opportunity just to begin observing how we are using 
these clinics to truly impact change.

    Senator Marshall. Thank you. Dr. Taylor, I know you are a 
treatment specialist, but I want to go to the prevention side 
for a second. You know, as a physician, we take family 
histories.

    You say, oh, my goodness, you are at risk for colon cancer, 
so therefore you need to start your screening at an earlier 
age. Or you are at risk for diabetes, and your weight is up a 
little bit this year, and your blood pressure is up we have--
how are we doing identifying at risk people, and what other 
ounces of prevention would you be recommending out there from 
your experiences?

    Dr. Taylor. Thanks for that question, Senator Marshall. I 
am actually also a big-time prevention hawk. Our organization, 
ASAM, is very much concerned about prevention as well as 
treatment. We know what the risk factors are for a young person 
to develop an addiction disorder. We know that addiction is a 
disease of pediatric onset, in fact.

    We know that effective interventions--and when I say--just 
want to say pediatric onset, we know most of the time when 
someone develops an addiction disorder, the onset of use and 
the onset of the disorder is actually in adolescence. So that 
is what I mean by pediatric onset.

    But we know that there are effective evidence-based 
interventions, prevention and prevention interventions that 
work at the community-based level. They often involve building 
social skills, teaching adolescents social skills, and many of 
these are school based programs. We know that if--the No. 1 
risk factor for a young person to develop an addiction is to 
have a parent who has or has had an addiction disorder.

    One of the most effective things you can do is to provide 
effective treatment for parents who have an addiction disorder, 
get them stabilized, so that their children are not subject to 
the ACES, the adverse childhood experiences, that a child of a 
person with an addiction is at risk for, and then target those 
young people, knowing that they are at increased risk, with 
early intervention.

    I have done that on the individual level in my office, but 
also organizations can do that. And I am involved in community-
based organizations in Birmingham, one specifically called the 
Addiction Prevention Coalition that actually does a lot of 
programing in and around Birmingham, specifically designed to 
target young people in schools with mental health first aid, 
with peer programs like Senator Hickenlooper had described.

    That is something that is doable. We at ASAM support the 
implementation of those programs. The key is to fund ones that 
are evidence based and to actually de-emphasize and not 
continue to fund those that have been shown to not be 
effective.

    Senator Marshall. Well, thanks so much. Again, I want to 
thank all the witnesses. I think you can tell this is a very 
thoughtful Subcommittee, and your testimony is very valuable, 
and we hope that there is follow-up at the staff level. And you 
all certainly made us think about several issues, and I 
appreciate you being here. Thank you.

    Senator Markey. Thank you, Senator Marshall. Thanks to our 
great panel here today. This is obviously a period where there 
is a devastating behavioral health crisis that threatens every 
community in this country, and disproportionately impact 
communities of color and low income and other marginalized 
communities.

    Thanks to these experts here today and so many people 
across the country, we have the opportunity to build on what 
has already been done to create a society where everyone has a 
fair and just opportunity to attain their highest level of 
health, and I look forward to continuing to work with each of 
you to do that.

    We have to discuss how we can get more resources into the 
hands of all of the practitioners, all the families out there. 
A vision without funding is a hallucination. You need--if you 
get the tools, you will be able to help families.

    I ask unanimous consent to enter into the record statements 
from various stakeholders outlining priorities for closing the 
gaps in access to mental health and substance use disorder 
care.

    [The following information can be found on pages 64 through 
77 in Additional Material.]

    Senator Markey. For any Senators who wish to ask additional 
questions for the record, they will be due in 10 business days, 
on June 1st at 5.00 p.m.

    The Committee stands adjourned.

                          ADDITIONAL MATERIAL

                                                       May 16, 2023
Hon. Kevin McCarthy, Speaker,
Hon. Hakeem Jeffries, Minority Leader
Hon. Chuck Schumer, Majority Leader,
Hon. Mitch McConnell, Minority Leader,
Hon. McMorris Rodgers, Chair,
Hon. Frank Pallone, Ranking Member,
Hon. Jim Jordan, Chair,
Hon. Jerrold Nadler, Ranking Member,
U.S. House of Representatives House of Representative
Washington, D.C. 20515.
Hon. Bernie Sanders, Chair,
Hon. Bill Cassidy, Ranking Member,
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Washington, DC. 20510.

    Dear Speaker McCarthy, Majority Leader Schumer, Minority Leader 
Jeffries, Minority Leader McConnell, Chair McMorris Rodgers, Ranking 
Member Pallone, Chair Jordan, Ranking Member Nadler, Chair Sanders, and 
Ranking Member Cassidy:

    The undersigned organizations, representing a broad base of 
stakeholders, write today to endorse S. 644/H.R. 1359--the Modernizing 
Opioid Treatment Access Act (the ``M-OTAA''). This bipartisan, 
bicameral legislation would responsibly expand access to methadone 
treatment for opioid use disorder (OUD) in medical settings and areas 
where it is not available now. There is a shortage of methadone 
treatment for OUD that contributes to racial, gender, and geographic 
inequities in access to such treatment in the U.S.--especially in rural 
areas--despite an increasing number of opioid treatment programs (OTPs) 
in the for-profit sector in recent years. \1\ Therefore, imminent 
passage of the M-OTAA is critical to saving lives, helping families, 
and strengthening American communities.
---------------------------------------------------------------------------
    \1\  Joudrey, Paul, Gavin Bart, Robert Brooner, Lawrence Brown, 
Julia Dickson-Gomez, Adam Gordon, Sarah Kawasaki, et al. ``Research 
Priorities for Expanding Access to Methadone Treatment for Opioid Use 
Disorder in the United States: A National Institute on Drug Abuse 
Center for Clinical Trials Network Task Force Report.'' Substance Abuse 
42 (July 3, 2021): 245--54. https://doi.org/10.1080/
08897077.2021.1975344.

    Only three medications have been approved by the Food and Drug 
Administration to treat OUD: methadone, buprenorphine, and naltrexone. 
OUD is associated with a 20fold greater risk of early death due to 
overdose, infectious disease, trauma, and suicide. \2\ Methadone is the 
most well-studied pharmacotherapy for OUD, with the longest track 
record. \3\ According to myriad experts, methadone is safe and 
effective for patients when indicated, dispensed, and consumed 
properly. \4\ But federal law largely limits its availability for OUD 
to OTPs and prevents the broader use of this medication to address 
fentanyl's deadly role in driving the rise of, and disparities in, drug 
overdose deaths in America.
---------------------------------------------------------------------------
    \2\  Schuckit MA. Treatment of Opioid-Use Disorders. N Engl J Med. 
2016;375(4):357-368. doi:10.1056/NEJMra1604339
    \3\  Substance Abuse and Mental Health Administration. Medications 
for Opioid Use Disorder: For Healthcare and Addiction Professionals, 
Policymakers, Patients, and Families. Treatment Improvement Protocol 
(TIP) Series, No. 63. Chapter 3B: Methadone.; 2018. Accessed March 31, 
2022. http://www.ncbi.nlm.nih.gov/books/NBK535269/
    \4\  Baxter LES, Campbell A, DeShields M, et al. Safe Methadone 
Induction and Stabilization: Report of an Expert Panel. J Addict Med. 
2013;7(6):377-386. doi:10.1097/01.ADM.0000435321.39251.d7
---------------------------------------------------------------------------
    The M-OTAA would allow OTP clinicians and board-certified 
physicians in addiction medicine or addiction psychiatry to prescribe 
methadone for OUD treatment that can be picked up from pharmacies, 
subject to the Substance Abuse and Mental Health Services 
Administration rules or guidance on supply of methadone for 
unsupervised use. This legislation would capitalize on the existing 
addiction expert workforce and pharmacy infrastructure to integrate 
methadone treatment for OUD with the rest of general healthcare. In 
doing so, the M-OTAA would help increase innovation in the OTP industry 
and narrow gaps in access to methadone for OUD for those who need it.

    Our organizations are unified in our support of the M-OTAA and our 
strong belief that it will help turn the tide on the addiction crisis 
facing our Nation.

            Sincerely,
                  1. American Society of Addiction Medicine
         2. American Association of Psychiatric Pharmacists
         3. American College of Academic Addiction Medicine
    4. American College of Osteopathic Emergency Physicians
                  5. American College of Medical Toxicology
                          6. American College of Physicians
7. American for Multidisciplinary Education and Research in 
                 Substance Use and Addiction, Inc. (AMERSA)
                            8. American Medical Association
      9. American Osteopathic Academy of Addiction Medicine
                       10. American Pharmacists Association
                     11. American Psychological Association
                          12. AIDS Foundation Chicago (AFC)
                                            13. AIDS United
                  14. Alabama Society of Addiction Medicine
 15. A New PATH (Parents for Addiction Treatment & Healing)
          16. Anxiety and Depression Association of America
                              17. Any Positive Change, Inc.
                 18. Arkansas Society of Addiction Medicine
         19. Association for Behavioral Health and Wellness
                                            20. Being Alive
                            21. Big Cities Health Coalition
                                         22. Broken No More
                            23. CADA of Northwest Louisiana
               24. California Society of Addiction Medicine
     25. Center for Adolescent Behavioral Health Research, 
                                 Boston Children's Hospital
                            26. Center for Housing & Health
                       27. Clinical Social Work Association
            28. Collaborative Family Healthcare Association
    29. Community Outreach Prevention and Education Network
                                    30. Coolidge Consulting
                                             31. DAP Health
                                   32. Drug Policy Alliance
                             33. Faces & Voices of Recovery
                  34. Florida Society of Addiction Medicine
                           35. The Grand Rapids Red Project
  36. Grayken Center for Addiction at Boston Medical Center
                           37. Harm Reduction Action Center
                 38. Hawai'i Health & Harm Reduction Center
                  39. Hawai'i Society of Addiction Medicine
                                       40. Hep Free Hawai'i
          41. Honoring Individual Power and Strength (HIPS)
                 42. Illinois Society of Addiction Medicine
                              43. Indiana Recovery Alliance
                                            44. Inseparable
           45. International Society for Psychiatric Nurses
                                      46. The Kennedy Forum
                                      47. Landmark Recovery
                                    48. Legal Action Center
                49. Louisiana Society of Addiction Medicine
 50. Massachusetts Association of Behavioral Health Systems
      51. Massachusetts Association for Mental Health, Inc.
            52. Massachusetts Society of Addiction Medicine
                                  53. Mental Health America
                 54. Michigan Society of Addiction Medicine
                  55. Midwest Society of Addiction Medicine
                56. Minnesota Society of Addiction Medicine
    57. National Alliance for Medication Assisted Recovery 
                                            (NAMA Recovery)
  58. National Association of Pediatric Nurse Practitioners
                    59. National Alliance on Mental Illness
  60. National Association of Addiction Treatment Providers
                 61. National Association of Social Workers
                62. National Board for Certified Counselors
     63. National Council on Alcoholism and Drug Dependence
                      64. National Harm Reduction Coalition
          65. National Health Care for the Homeless Council
                            66. National League for Nursing
                          67. National Safety Council (NSC)
                               68. National Survivors Union
                           69. New Bedford Community Health
                 70. New York Society of Addiction Medicine
     71. Northern New England Society of Addiction Medicine
                 72. Oklahoma Society of Addiction Medicine
                   73. Oregon Society of Addiction Medicine
                          74. Overdose Crisis Response Fund
                           75. Partnership to End Addiction
                    76. Pennsylvania Harm Reduction Network
                          77. The Porchlight Collective SAP
                                  78. Public Justice Center
                                       79. RI International
                                       80. Rural Organizing
                          81. San Francisco AIDS Foundation
                                           82. Shatterproof
      83. The Sheet Metal and Air Conditioning Contractors 
                              National Association (SMACNA)
                                         84. SMART Recovery
                                     85. South Shore Health
                            86. Southwest Recovery Alliance
                      87. Students for Sensible Drug Policy
                               88. Tennessee Justice Center
                89. Tennessee Society of Addiction Medicine
                                   90. Today I Matter, Inc.
                                       91. Vital Strategies
               92. Washington Society of Addiction Medicine
                93. Wisconsin Society of Addiction Medicine
                               94. Young People in Recovery
                                 ______
                                 
                                                     March 30, 2023
U.S. Committee on Energy and Commerce,
2125 Rayburn House Office Building,
Washington, DC 20515.
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Primary Health and Retirement Security,
428 Dirksen Senate Office Building,
Washington, DC. 20510.

    Dear United States Senators and Representatives:

    We write from the frontlines of our Nation's addiction and overdose 
crisis, as board-certified physicians in addiction medicine or 
addiction psychiatry, some of whom work in opioid treatment programs 
(OTPs). As you help lead us out of this public health emergency, we 
humbly ask that you consider this message with the seriousness it 
deserves. Our aim is to inform recent discourse on the delivery of 
high-quality and effective treatment for people with opioid use 
disorder (OUD) with methadone, and provide critical clarifications to 
complex issues that have arisen in the context of that discussion on 
Capitol Hill.

    Currently, Federal law limits the availability of methadone for OUD 
to heavily regulated OTPs at both the Federal and state level, a 
structure that has implications for access to, and quality of, care. 
During the COVID-19 pandemic, public health recommendations for social 
distancing compelled the Federal Government to reform Federal 
regulations governing methadone treatment for OUD at OTPs. As a result, 
a natural experiment occurred, \1\ and our Nation learned that the 
Federal Government could move quickly and responsibly to protect 
patients' health and safety, while ensuring that they receive the 
addiction care they need. Thus, as you consider next steps to tackle 
our Nation's addiction and overdose crisis, we urge you to support 
swift passage of the bipartisan and bicameral Modernizing Opioid 
Treatment Access Act (S. 644/H.R. 1359) (the ``M-OTAA'').
---------------------------------------------------------------------------
    \1\  Krawczyk, Noa, Bianca D. Rivera, Emily Levin, and Bridget C. 
E. Dooling. ``Synthesising Evidence of the Effects of COVID-19 
Regulatory Changes on Methadone Treatment for Opioid Use Disorder: 
Implications for Policy.'' The Lancet Public Health 8, no. 3 (March 1, 
2023): e238--46. https://doi.org/10.1016/S2468-2667(23)00023-3.
---------------------------------------------------------------------------
              The Modernizing Opioid Treatment Access Act
    The M-OTAA would modernize Federal law governing the delivery of 
OUD treatment with methadone--law which has largely remained unchanged 
since 1974, despite the scientific and medical consensus, dating as far 
back as 1995, calling for the Federal Government to regulate methadone 
for OUD more in alignment with other Schedule II Food and Drug 
Administration (FDA)-approved medications. \2\ Notably, existing 
Federal law predates the establishment and recognition by the American 
Board of Medical Specialties of the medical subspecialties of addiction 
medicine and addiction psychiatry. This explains one reason for the 
prescriptive Federal laws enacted in the 1970's that were to govern 
methadone treatment for OUD in a practice environment without 
recognized addiction specialist physicians. In brief, the M-OTAA would 
authorize the Drug Enforcement Administration (DEA) to issue special 
registrations for physicians who are board-certified in addiction 
medicine and/or addiction psychiatry, as well as OTP prescribing 
clinicians, who could then use their clinical expertise in prescribing 
methadone for OUD treatment that could be dispensed by community 
pharmacies, subject to SAMHSA rules or guidance on supply of methadone 
for unsupervised use.
---------------------------------------------------------------------------
    \2\  In 1995, experts at the Institute of Medicine (IOM) wrote, 
``In light of these considerations, the committee urges reassessment of 
the appropriate balance between the risks of methadone and its 
benefits. The current regulations foster situations where addicts 
cannot obtain a treatment program tailored to their individual 
circumstances, physicians are unable to exercise professional judgment 
in treating individual patients, programs are isolated from mainstream 
medical care (thus depriving patients of important ancillary services), 
and significant economic costs are incurred in assuring compliance with 
regulatory requirements--costs that are shared by programs, insurers, 
patients, and taxpayers. We have concluded that there is no compelling 
medical reason for regulating methadone differently from all other 
medications approved by FDA, including schedule II controlled 
substances. Nevertheless, the committee is not recommending abolition 
of the methadone regulations. The regulations serve important 
functions, not the least of which is to maintain community support for 
methadone treatment programs by assuring that the programs maintain 
standards and are subject to outside review.'' See Institute of 
Medicine (US) Committee on Federal Regulation of Methadone Treatment; 
Rettig RA, Yarmolinsky A, editors. Federal Regulation of Methadone 
Treatment. Washington (DC): National Academies Press (US); 1995. 
Available from: https://www.ncbi.nlm.nih.gov/books/NBK232108/--doi--
10.17226/4899.
---------------------------------------------------------------------------
 Areas of Concern: Patient and Public Safety, the Current Quandary in 
Outpatient Treatment with Buprenorphine, and High-Quality and Effective 
                  OUD Treatment and Persistent Stigma
    Methadone is a lifesaving medication that also has risks that we 
take very seriously. It can be a challenge to balance the risk of 
adverse individual and community-related impacts associated with the 
inappropriate provision, and diversion, of the medication against the 
well-established individual and public health benefits of properly 
treating certain patients with OUD with methadone. Our aim with this 
letter is to provide salient information on three relevant areas of 
concern: 1) the safety of patients with OUD who may be treated with 
methadone, and more broadly, of the public, 2) the current quandary in 
outpatient treatment with buprenorphine (a partial agonist) for 
patients with OUD who are increasingly using fentanyl or other high 
potency synthetic opioids, and 3) what constitutes high-quality and 
effective treatment for patients with OUD and the persistent stigma 
that surrounds those patients.
                       Patient and Public Safety
    Evidence gathered over the last several decades illustrates that, 
for many people with OUD, treatment with methadone is critical to 
preventing overdose and promoting remission and recovery. \3\ In 
addition, because methadone is also a very effective analgesic and has 
a long half-life, it is also sometimes used to treat chronic pain in 
pain management practice.
---------------------------------------------------------------------------
    \3\  National Academies of Sciences, Engineering, Health and 
Medicine Division, Board on Health Sciences Policy, Committee on 
Medication-Assisted Treatment for Opioid Use Disorder, Michelle 
Mancher, and Alan I. Leshner. The Effectiveness of Medication-Based 
Treatment for Opioid Use Disorder. Medications for Opioid Use Disorder 
Save Lives. National Academies Press (US), 2019. https://
www.ncbi.nlm.nih.gov/books/NBK541393/.
---------------------------------------------------------------------------
 Decades Ago, Methadone-Involved Overdoses Correlated With Its Use in 
                         the Treatment of Pain
    As an opioid analgesic for pain, methadone was swept up in the 
confluence of factors that lead to the inappropriate prescribing of 
opioids for pain treatment in the 1990's and 2000's. \4\ The scientific 
and medical consensus after examining these trends concluded that there 
was a strong, positive correlation between rates of methadone 
prescription for use in pain treatment and methadone diversion and 
overdose deaths. \5\ Methadone for use in pain treatment and its 
involvement in overdoses, however, drastically declined as public 
health and law enforcement agencies took measured steps to limit its 
injudicious use for pain, while still making it available via 
prescription and pharmacy dispensing when clinically appropriate for 
pain treatment. \6\
---------------------------------------------------------------------------
    \4\  Paulozzi, Leonard, Karen Mack, and Christopher M. Jones. 
``Vital Signs: Risk for Overdose from Methadone Used for Pain Relief--
United States, 1999--2010,'' July 6, 2012. https://www.cdc.gov/mmwr/
preview/mmwrhtml/mm6126a5.htm.
    \5\  Jones, Christopher M., Grant T. Baldwin, Teresa Manocchio, 
Jessica O. White, and Karin A. Mack. ``Trends in Methadone Distribution 
for Pain Treatment, Methadone Diversion, and Overdose Deaths--United 
States, 2002--2014.'' Morbidity and Mortality Weekly Report 65, no. 26 
(2016): 667--71.
    \6\  Id.
---------------------------------------------------------------------------
 New Studies Have Been Used Opportunistically, And Their Nuances Have 
                           Not Been Explained
    With that said, we share concerns expressed by others of methadone 
becoming a potential contributor of more overdoses and deaths if 
careful policy changes are not enacted. For example, there was an 
increase in methadone-involved overdose deaths in 2020; however, 
evidence shows such increase was likely associated with the synthetic 
opioid-driven spike in drug overdose deaths that year. \7\ 
Unfortunately, some advocates use that increase opportunistically to 
convey a fatalistic approach that risks paralyzing lawmakers and 
preventing any progress. Further, those same advocates may even mention 
two other studies published in January 2023 that raise questions about 
the role of Federal regulatory OTP flexibilities during the COVID PHE--
which allowed for more unsupervised use of methadone in the treatment 
of OUD within OTP settings--to increases in methadone-involved 
overdoses deaths. Specifically, one such study found an increase in 
methadone-involved overdose deaths in the year after March 2020 
compared with prior trends, both with and without co-involvement of 
synthetic opioids; \8\ the other found an increase of methadone-
involved overdose deaths by 48.1 percent in 2020 relative to 2019. \9\
---------------------------------------------------------------------------
    \7\  Jones, Christopher M., Wilson M. Compton, Beth Han, Grant 
Baldwin, and Nora D. Volkow. ``Methadone-Involved Overdose Deaths in 
the US Before and After Federal Policy Changes Expanding Take-Home 
Methadone Doses From Opioid Treatment Programs.'' JAMA Psychiatry 79, 
no. 9 (September 1, 2022): 932--34. https://doi.org/10.1001/
jamapsychiatry.2022.1776.
    \8\  This study examines absolute counts rather than relative rate 
increases in methadone-involved overdose deaths. Relative rates are in 
proportion to the whole, while absolute counts are not, and the use of 
absolute counts rather than relative rates limits the usefulness of 
this analysis. See Kleinman, Robert A., and Marcos Sanches. 
``Methadone-Involved Overdose Deaths in the United States before and 
during the COVID-19 Pandemic.'' Drug and Alcohol Dependence 242 
(January 1, 2023): 109703. https://doi.org/10.1016/
j.drugalcdep.2022.109703
    \9\  This study points out that the rate of methadone-involved 
overdose deaths in 2020 was much lower than its peak in 2006-2008, and 
that these methadone-involved overdose deaths have been largely 
attributed to methadone prescribed for pain. See Kaufman, Daniel E., 
Amy L. Kennalley, Kenneth L. McCall, and Brian J. Piper. ``Examination 
of Methadone Involved Overdoses during the COVID-19 Pandemic.'' 
Forensic Science International 344 (January 31, 2023): 111579. https://
doi.org/10.1016/j.forsciint.2023.111579

    Neither of those two studies, however, includes or examines 
additional, provisional overdose death data after March 2021, when the 
rate of methadone-involved overdose deaths stabilized and declined. The 
authors' failure to include this data may bias the models in their 
studies. Indeed, the relative rate of methadone-involved overdose 
deaths has declined by 9.5 percent between August 2021 and August 2022, 
\10\ while overdose deaths related to a lack of access to medications 
for OUD increased in the same period. \11\
---------------------------------------------------------------------------
    \10\  See statistical examination of provisional overdose death 
data from the CDC's National Center for Health Statistics Vital 
Statistics System. Volkow, Nora, D. Presentation to the American 
Society of Addiction Medicine Advocacy Conference, ``National Institute 
of Drug Abuse: What Radical Change Means,'' March 6, 2023.
    \11\  Kariisa, Mbabazi. ``Vital Signs: Drug Overdose Deaths, by 
Selected Sociodemographic and Social Determinants of Health 
Characteristics--25 States and the District of Columbia, 2019--2020.'' 
MMWR. Morbidity and Mortality Weekly Report 71 (2022). https://doi.org/
10.15585/mmwr.mm7129e2.

    In addition, there is no direct evidence of causality that links 
any change in Federal OTP take-home policies to an increase in 
methadone-involved overdose deaths, as is noted in one study. \12\ Nor 
do the authors in the other study wish to add to misconceptions about 
the safety of methadone for OUD, as stated by those authors themselves. 
\13\ If anything, these two studies demonstrate that modernizing 
treatment with methadone for OUD--within the OTP setting--must be 
carried out with caution and with Federal agencies' continual, 
longitudinal regulations and monitoring for unintended consequences, 
notwithstanding the widespread support of making such Federal take home 
policy changes permanent by OTP organizations and associations. By way 
of contrast, our experience and training as addiction specialist 
physicians, coupled with the thoughtful guardrails in the M-OTAA, 
enables us to lead models of methadone treatment for OUD responsibly 
and safely, while we manage risks to patient and public health. In the 
absence of continued DEA and SAMHSA Federal regulations, oversight, and 
monitoring of OTPs on several fronts, however, these two studies do 
illustrate why we cannot say the same yet for all clinicians within the 
OTP setting. While some OTP medical directors are board-certified 
addiction specialist physicians, the Federal Government does not 
require them to be so credentialed; thus, some are not.
---------------------------------------------------------------------------
    \12\  ``This study is observational and does not allow for a causal 
attribution of the increase in methadone-involved overdose deaths to 
any specific factor,'' and ``this study cannot distinguish whether 
individuals who die from methadone-involved overdoses receive methadone 
through OTPs, as prescriptions for pain, or through other sources, 
including diverted methadone.'' See Kaufman, et al., (2023).
    \13\  ``We hope that these findings will not add to further 
misconceptions about the safety of methadone relative to other less 
widely prescribed Schedule II opioids,'' see Kleinman, et al., (2023).
---------------------------------------------------------------------------
    Recently Published Systematic Review Finds No Increased Risk of 
 Methadone Overdose From Federal Regulatory Flexibilities That Allowed 
                 For More Unsupervised Use of Methadone
    We also draw your attention to a review that synthesized peer-
reviewed research between March 2020 and September 2022 on the effect 
of the Federal regulatory flexibilities on OTPs' operations, the 
perspectives of patients and providers, and health outcomes of patients 
at OTPs, including for methadone-involved overdoses, which found no 
evidence of increased risk of methadone overdose. \14\ We do understand 
from this review, on the other hand, that many OTPs limited their 
uptake of the Federal regulatory flexibilities and did not universally 
provide the maximum ceiling of doses allowed for take home methadone, 
driven in part due potential consequences to patients, concerns about 
reduced OTP revenue, and uncertainty about when this temporary 
regulatory flexibility would end. \15\
---------------------------------------------------------------------------
    \14\  The systematic review of 29 peer-reviewed studies published 
between March 1, 2020, and September 6, 2022, includes six studies that 
assessed the association between pandemic flexibilities and overdose 
risk, which used OTP records or state-level mortality data, national 
poison-control or mortality data, or qualitative data. See Krawczyk, 
Noa,
    \15\  Findings include three studies of OTP providers, three 
surveys of OTP patients, and one multi-State survey of 170 OTP 
providers. Krawczyk, Noa, Bianca D. Rivera, Emily Levin, and Bridget C. 
E. Dooling. ``Synthesising Evidence of the Effects of COVID-19 
Regulatory Changes on Methadone Treatment for Opioid Use Disorder: 
Implications for Policy.'' The Lancet Public Health 8, no. 3 (March 1, 
2023): e238--46. https://doi.org/10.1016/S2468-2667(23)00023-3.
---------------------------------------------------------------------------
 One Explanation for the Spike in Methadone-Involved Overdoses Is The 
  Increase of Synthetic Opioids in the Non-Pharmaceutical Drug Supply
    As previously noted, a plausible explanation for changes in trends 
in methadone-involved overdose deaths in 2020 is the dominating role 
that fentanyl and other high potency synthetic opioids have been 
playing in our non-pharmaceutical drug supply. For example, another 
recent analysis found an increase in overdose deaths, with and without 
methadone, in March 2020. Then, overdose deaths not involving methadone 
continued to increase by approximately 69 deaths per month, while 
methadone-involved overdose deaths remained stable. In terms of the 
implementation of the Federal regulatory flexibilities for unsupervised 
use of methadone at OTPs, in the period before this policy change, and 
after it, there were similar rates of decline in the percentage of 
methadone-involved overdose deaths. \16\ This study therefore suggests, 
in light of this data, that in the early months of the COVID-19 
pandemic, the spike in drug overdose deaths overall in March 2020 was 
associated with the increase in synthetic opioids in the drug supply 
among people who were being treated with methadone from an OTP, not due 
to methadone risks associated with Federal regulatory flexibilities for 
OTPs.
---------------------------------------------------------------------------
    \16\  In January 2019, 4.5 percent of overdose deaths involved 
methadone, and 3.2 percent of overdose deaths involved methadone by 
August 2021. See Jones, et al., (2023).
---------------------------------------------------------------------------
   Multiple Factors Explain Methadone Being Preferentially Listed on 
                      Overdose Death Certificates
    Finally, it is important for lawmakers to understand that 
methadone's long half-life is an additional, confounding variable that 
can result in the preferential listing of methadone on death 
certificates, during a period when overdose deaths frequently involve 
multiple substances. Novel psychoactive substances permeate the non-
pharmaceutical drug supply as well, for which drug overdose deaths are 
not routinely assessed. Moreover, the decentralization of authority in 
death certification policy and procedure also creates substantial 
differences in how overdose deaths are characterized and reported, and 
there is a high error rate in death certificates for overdose deaths. 
\17\
---------------------------------------------------------------------------
    \17\  Peppin, John F., John J. Coleman, Antonella Paladini, 
Giustino Varrassi, John F. Peppin, John J. Coleman, Antonella Paladini, 
and Giustino Varrassi. ``What Your Death Certificate Says About You May 
Be Wrong: A Narrative Review on CDC's Efforts to Quantify Prescription 
Opioid Overdose Deaths.'' Cureus 13, no. 9 (September 16, 2021). 
https://doi.org/10.7759/cureus.18012.
---------------------------------------------------------------------------
  The Current Quandary in Outpatient Treatment with Buprenorphine for 
 Patients with OUD Involving Fentanyl or Other High Potency Synthetic 
                                Opioids
    Under the Code of Federal Regulations Title 21 1306.07(b), the DEA 
permits an exception to methadone dispensing requirements for DEA-
registered physicians outside of OTPs to provide emergency treatment 
for patients with methadone for OUD for 1 day, and to carry out such 
treatment for no more than 3 days, while planning for the patients' 
referral to treatment. \18\ Last March 2022, the DEA started allowing 
certain DEA-registered physicians to dispense a 3-day supply of 
methadone at one time, so long as the exception is requested. \19\ 
While this change is theoretically helpful, it does not help us face a 
terrible quandary when we attempt to initiate buprenorphine treatment 
with patients with OUD involving illegal fentanyl or other high potency 
synthetic opioids.
---------------------------------------------------------------------------
    \18\  ``21 CFR 1306.07--Administering or Dispensing of Narcotic 
Drugs.'' Accessed March 16, 2023. https://www.ecfr.gov/current/title-
21/chapter-II/part-1306/subject-group-ECFR1eb5bb3a23fddd0/section-
1306.07.
    \19\  ``DEA's Commitment to Expanding Access to Medication-Assisted 
Treatment.'' Accessed March 16, 2023. https://www.dea.gov/press-
releases/2022/03/23/deas-commitment-expanding-access-medication-
assisted-treatment.
---------------------------------------------------------------------------
 Federal Law Currently Prevents the Use of Methadone for the Treatment 
 of Patients Via a ``Low Dose Buprenorphine with Opioid Continuation'' 
                           Initiation Process
    Patients who use fentanyl in the unregulated drug supply, which 
increasingly has unpredictable and hazardous novel contaminants, have 
significant challenges with initiation of buprenorphine (a partial 
agonist), another highly effective medication for OUD treatment. Under 
current law, however, it is illegal to prescribe full opioid agonists 
such as hydromorphone, oxycodone, or morphine for OUD during 
buprenorphine initiation and titration. Thus, we are sometimes left 
with a dangerous alternative, which is to advise patients that use of 
opioids from the unregulated supply should be continued while 
undergoing buprenorphine initiation via a low dose buprenorphine with 
opioid continuation initiation process. Access to methadone would be a 
safe full agonist alternative to use for individuals who are undergoing 
a low dose buprenorphine with opioid continuation initiation process, 
and the M-OTAA could allow this to be safely done under expert 
physician guidance.
Restrictions on Methadone for OUD Limit Treatment Options for Patients 
             with OUD Who Do Not Stabilize on Buprenorphine
    In addition, methadone is an excellent alternative medication 
treatment recommended for patients with OUD who do not stabilize on 
buprenorphine. However, unless it's being dispensed from an OTP, we can 
only dispense methadone to those patients for up to 3 days. This 
limitation restricts our being able to offer this critically important 
medication to those patients, even when they face insurmountable 
geographical, financial, transportation, or other barriers to continue 
their treatment at OTPs. In these medical scenarios, the absurdity of 
antiquated Federal laws that govern methadone for OUD treatment is 
extremely clear. When the laws are applied to an ever and rapidly 
changing unregulated drug supply, the laws' out-of-date nature is 
obvious and distressing.
     High-Quality and Effective OUD Treatment and Persistent Stigma
 High-Quality and Effective Treatment for OUD Does Not Make Engagement 
     in Psychosocial Counseling a Condition of Receiving Medication
    Patients with OUD who are treated with medications for OUD have 
over 50 percent lower overdose rates. \20\ For this reason and to 
fulfill our medical mission to save lives, our first, most immediate 
goal is to reach more people with moderate to severe OUD with this 
life-saving medication. \21\ Patients who receive medication for OUD, 
including methadone, have better rates of retention in treatment; 
behavioral therapies, alone, do not increase patient retention in 
treatment. \22\ While psychosocial treatment and other services are an 
important component of quality care and beneficial to many people with 
OUD, \23\ the scientific and medical consensus is that psychosocial 
treatment should be made available to patients in treatment for OUD, 
but a patient's willingness to engage in such treatment should not be a 
condition of the patient receiving medication. \24\
---------------------------------------------------------------------------
    \20\  National Academies of Sciences, Engineering, Health and 
Medicine Division, Board on Health Sciences Policy, Committee on 
Medication-Assisted Treatment for Opioid Use Disorder, Michelle 
Mancher, and Alan I. Leshner. The Effectiveness of Medication-Based 
Treatment for Opioid Use Disorder. Medications for Opioid Use Disorder 
Save Lives. National Academies Press (US), 2019. https://
www.ncbi.nlm.nih.gov/books/NBK541393/.
    \21\  NYU Langone News. ``Almost 90 Percent of People with Opioid 
Use Disorder Not Receiving Lifesaving Medication.'' Accessed March 10, 
2023. https://nyulangone.org/news/almost-90-percent-people-opioid-use-
disorder-not-receiving-lifesaving-medication.
    \22\  Timko, Christine, Nicole R Schultz, Michael A Cucciare, Lisa 
Vittorio, and Christina Garrison-Diehn. ``Retention in Medication-
Assisted Treatment for Opiate Dependence: A Systematic Review.'' 
Journal of Addictive Diseases 35, no. 1 (2016): 22--35. https://
doi.org/10.1080/10550887.2016.1100960.
    \23\  Dugosh, Karen, Amanda Abraham, Brittany Seymour, Keli McLoyd, 
Mady Chalk, and David Festinger. ``A Systematic Review on the Use of 
Psychosocial Interventions in Conjunction With Medications for the 
Treatment of Opioid Addiction.'' Journal of Addiction Medicine 10, no. 
2 (March 2016): 91--101. https://doi.org/10.1097/ADM.0000000000000193.
    \24\  See National Academies of Sciences, Engineering, Health and 
Medicine Division, Board on Health Sciences Policy, Committee on 
Medication-Assisted Treatment for Opioid Use Disorder, Michelle 
Mancher, and Alan I. Leshner. The Effectiveness of Medication-Based 
Treatment for Opioid Use Disorder. Medications for Opioid Use Disorder 
Save Lives. National Academies Press (US), 2019. https://
www.ncbi.nlm.nih.gov/books/NBK541393/, and see American Society of 
Addiction Medicine. ``National Practice Guideline for the Treatment of 
Opioid Use Disorder: 2020 Focused Update,'' 2020. https://
sitefinitystorage.blob.core.windows.net/sitefinity-production-blobs/
docs/default-source/guidelines/npg-jam-supplement.pdf'sfvrsn=a00a52c2--
2.
---------------------------------------------------------------------------
    High-Quality and Effective Treatment for OUD Is Patient-Centered
    In an office-based practice of addiction medicine or addiction 
psychiatry, an expert physician may counsel patients with OUD who are 
willing to engage in psychosocial treatment as part of the physician's 
medical management; a multidisciplinary team member in the practice may 
provide more intensive counseling for patients with OUD, or the 
practice may refer some of those patients to another practice for even 
more psychosocial treatment. While we are grateful for SAMHSA's 
recently proposed modifications to 42 CFR Part 8 which, if finalized, 
should significantly improve the quality of treatment services at OTPs, 
by making it less ``program centered'' and more ``patient centered''--
like expert-led office-based practices--patients with OUD need more 
options for their care, and more OTPs need to face high-quality 
competition as an incentive to continue to improve their services.
 Existing Stereotypes Lend Themselves to Prescriptive, Rigid Models of 
                      Methadone Treatment for OUD
    Finally, we know that patients with OUD face persistent stigma, 
including stereotypes that they are non-compliant, out-of-control, 
unwilling to change risk behaviors, and do not have strong communities. 
\25\ We are extremely concerned that these stereotypes lend themselves 
to prescriptive, rigid approaches to methadone treatment for OUD. The 
existing, siloed infrastructure for methadone treatment for OUD in the 
U.S. has compounded such stigma, and despite methadone's strong 
evidence as a life-saving medication, there is neither broad acceptance 
of methadone as a treatment intervention by the public, nor by 
healthcare providers, including some addiction providers. \26\
---------------------------------------------------------------------------
    \25\  Earnshaw, Valerie, Laramie Smith, and Michael Copenhaver. 
``Drug Addiction Stigma in the Context of Methadone Maintenance 
Therapy: An Investigation into Understudied Sources of Stigma.'' 
International Journal of Mental Health and Addiction 11, no. 1 
(February 1, 2013): 110--22. https://doi.org/10.1007/s11469-012-9402-5.
    \26\  Madden, Erin Fanning. ``Intervention Stigma: How Medication-
Assisted Treatment Marginalizes Patients and Providers.'' Social 
Science & Medicine (1982) 232 (July 2019): 324--31. https://doi.org/
10.1016/j.socscimed.2019.05.027.
---------------------------------------------------------------------------
  The Integration of Methadone Treatment with Other Medical Care Will 
                    Improve the Quality of OUD Care
    The separateness of methadone treatment for OUD--which results in 
methadone dispensed from OTPs, rather than pharmacies, being nearly 
universally excluded from prescription drug monitoring programs--has 
rather served to focus OTP services on the administration of one 
medication for one medical indication. \27\ In contrast, the 
modernization of methadone treatment for OUD, as contemplated by the M-
OTAA, will give Americans with addiction involving polysubstance use 
more conveniently located, comprehensive treatment options that can 
treat and manage their uncontrolled use of any substance, as well as 
other chronic, often comorbid diseases with OUD, such as depression, 
diabetes, bipolar disorder, and hypertension. \28\ These additional 
options are urgently needed, so that we may safely integrate treatment 
with methadone for OUD with the rest of general healthcare, and 
continue to improve the treatment of OUD with methadone in this 
country.
---------------------------------------------------------------------------
    \27\  See Olsen, Yngvild, and Joshua M. Sharfstein. ``Confronting 
the Stigma of Opioid Use Disorder--and Its Treatment.'' JAMA 311, no. 
14 (April 9, 2014): 1393--94. https://doi.org/10.1001/jama.2014.2147, 
and National Association of State Alcohol and Drug Abuse Directors, and 
American Association for the Treatment of Opioid Dependence. 
``TECHNICAL BRIEF: CENSUS OF OPIOID TREATMENT PROGRAMS--NASADAD,'' 
December 5, 2022. ttps://nasadad.org/2022/12/technical-brief-census-of-
opioid-treatment-programs/.
    \28\  Olsen, Yngvild, and Joshua M. Sharfstein. ``Confronting the 
Stigma of Opioid Use Disorder--and Its Treatment.'' JAMA 311, no. 14 
(April 9, 2014): 1393--94. https://doi.org/10.1001/jama.2014.2147.

    We stand ready to discuss this information further with you at any 
time. We are hopeful that we can work together to save as many lives as 
---------------------------------------------------------------------------
possible. We look forward to hearing from you.

            Sincerely,
                                             Ruth A. Potee,
                                                     M.D., FASAM**,
                                                  Medical Director,
                              Franklin County House of Corrections,
         Director of Addiction Services, Behavioral Health Network.

    The views expressed are those of the authors and do not necessarily 
represent the views of their institutions.

    One asterisk (*) indicates an individual has past work experience 
at an opioid treatment program (OTP); two asterisks (**) indicates the 
individual currently works at an OTP.

                            Melissa Weimer, DO, MCR, DFASAM
                           Yale New Haven Hospital, Yale University
                                 Jessica R. Gray, MD, FASAM
                                     Massachusetts General Hospital
                 William F. Haning, III, M.D., FASAM, DFAPA
                  President, American Society of Addiction Medicine
        Professor of Psychiatry, John A. Burns School of Medicine, 
                                              University of Hawai'i
                                                Nina Vidmer
     Executive Director, American Osteopathic Academy of Addiction 
                                                           Medicine
                              Brian Hurley, MD, MBA, DFASAM
            President-Elect, American Society of Addiction Medicine
   Medical Director, Substance Abuse Prevention and Control at Los 
                         Angeles County Department of Public Health
                  Stephen M. Taylor, MD, MPH, DFAPA, DFASAM
   Vice-Chair, Legislative Advocacy Committee, American Society of 
                                                 Addiction Medicine
                                            Pathway Healthcare, LLC
                                    Suneel M. Agerwala, MD*
                                            Yale School of Medicine
                                       Dinah Applewhite, MD
                                     Massachusetts General Hospital
                          Michael S. Argenyi, MD, MPH, MSW*
                             University of Iowa Hospitals & Clinics
                                    Mahreen Arshad, MD, MPH
            Addiction Medicine, Obesity Medicine, Internal Medicine
                                          Julia Arnsten, MD
                                          Montefiore Medical Center
                                    Lance Austein, MD, FACP
                                               Monogram Medical, PC
                                        Sarah Axelrath, MD*
                                         Stout Street Health Center
                                Colorado Coalition for the Homeless
                                      Sarah Bagley, MD, MSc
                   Addiction Consult Service, Boston Medical Center
                                 Jessica Barnes Calihan, MD
   Adolescent Substance Use & Addiction Program, Boston Children's 
                                                           Hospital
                                        Raymond Bertino, MD
                  President, Illinois Society of Addiction Medicine
Clinical Professor of Radiology and Surgery, University of Illinois 
                                        College of Medicine, Peoria
                           Benjamin Bearnot, MD, MPH, FASAM
          Charlestown Health Center, Massachusetts General Hospital
                       Annemarie Bonawitz-Dodi, MD, FASAM**
                                      Lexington Center for Recovery
                                       Joseph F. Boyle, MD*
      Addiction Consult Service, Faster Paths To Treatment, Boston 
                                                     Medical Center
                                     Jeffrey Brent, MD, PhD
                         University of Colorado, School of Medicine
                                  Emily Brunner, MD, DFASAM
                                            Gateway Recovery Center
                                Bradley M. Buchheit, MD, MS
                                Oregon Health & Sciences University
                                   Michael A Carnevale, DO*
                                          Peacehealth Medical Group
                                          Carolyn Chan, MD*
          Yale Hospital and Cornell Scott Hill Health Center (FQHC)
                                            Yale School of Medicine
                               Edwin C. Chapman, MD, FASAM*
                                           Edwin C. Chapman, MD, PC
                                   Avik Chatterjee, MD, MPH
                   Addiction Consult Service, Boston Medical Center
                          Cynthia Chatterjee, MD, MA, FASAM
                                  San Mateo County Health (Retired)
                          Paul Cheng, MD, MPH, MROCC, FASAM
                                                         The Clinic
                                        Judy S. Chertok, MD
                       Penn Family Care, University of Pennsylvania
                                  Samantha Chirunomula, MD*
            Department of Medicine, Division of Infectious Diseases
                                     University of Illinois-Chicago
                            Seth A. Clark, MD, MPH, FASAM**
          Addiction Medicine Consult Service, Rhode Island Hospital
                                           Lifespan Recovery Center
                                           Shawn Cohen, MD*
                                            Yale School of Medicine
                                   D. Tyler Coyle, MD, MS**
                          University of Colorado School of Medicine
                                   Paul Christine, MD, PhD*
                                              Boston Medical Center
                                Fabiola A. Arbelo Cruz, MD*
          Connecticut Mental Health Center, Yale School of Medicine
                                           Paula Cook, MD**
                                             Moab Regional Recovery
                                       Ashley Coughlin, MD*
       Addiction Psychiatrist and Director of Intensive Outpatient 
                                               Psychiatric Services
                                     Lawrence and Memorial Hospital
                                            Northeast Medical Group
                                              Yale New Haven Health
                                     Phoebe Cushman, MD, MS
                          Boston University School of Public Health
                                     Catherine DeGood, DO**
              CODAC Behavioral Healthcare, Butler Behavioral Health
                   Michael Delman, MD, FACP, FACG, DFASAM**
                                  Medical Director, Seafield Center
                              Regina DiGiovanna, MD, FASAM*
                                               Wellness Center-AMEX
                                           Dora Dixie, MD**
   Family Guidance; The Women's Treatment Center; Symetria Recovery
                           Frank Dowling, MD, FASAM, DLFAPA
                                Long Island Behavioral Medicine, PC
                                       Honora Englander, MD
Principal Investigator and Director, Improving Addiction Care Team 
                                                           (IMPACT)
                                 Oregon Health & Science University
                                         Mark Eisenberg, MD
                                     Massachusetts General Hospital
                                Boston Health Care for the Homeless
                                   Caitlin Farrell, DO, MPH
                                              Boston Medical Center
                                      Allen Fein, MD, FASAM
                                 Stonybrook Community Medical Group
                                        Casey Ferguson, MD*
                                                         CODA, Inc.
                                               Central City Concern
                                          Bridget Foley, DO
  Director, Office-Based Addiction Treatment (OBAT), Tufts Medical 
                                                             Center
                                     Martin Fried, MD, FACP
                       Wexner Medical Center, Ohio State University
                  Peter D. Friedmann, MD, MPH, DFASAM, FACP
                            Chief Research Officer, Baystate Health
      Office of Research, University of Massachusetts Chan Medical 
                                                    School-Baystate
                                    Jennifer Frush, MD, MTS
                         Boston Medical Center Emergency Department
                                    Jennifer L. Fyler, MD**
Greenfield Opioid Treatment Program, New View Residential Treatment 
                                   Program, Behavioral Health Group
                                      Hiroko Furo, MD, PhD*
              University of Texas Health Science Center-San Antonio
                                              Evan Gale, MD
                 Associate Medical Director, Addiction Consult Team
                                     Massachusetts General Hospital
                               Joseph Garbely, DO, DFASAM**
                               Brookdale Premier Addiction Recovery
                                  Heidi Ginter, MD, FASAM**
                                        Recovery Centers of America
                              Melody Glenn, MD, MFA, FASAM*
                          Director, Addiction Medicine Consult Team
           Banner--University Medical Center, University of Arizona
                              David Goodman-Meza, MD, MAS**
 Division of Infectious Diseases, David Geffen School of Medicine, 
                                                               UCLA
                     Andrea Gough-Goldman, MD, MPH, FASAM**
                                 Oregon Health & Science University
                                          Paul Grekin, MD**
                                       Evergreen Treatment Services
                                     Lucinda Grovenburg, MD
                          Scott Hadland, MD, MPH, MS, FASAM
             Massachusetts General Hospital; Harvard Medical School
                                      John Hardy, MD, FASAM
   John Hardy MD LLC, AMG Physicians LLC, Transformations Wellness 
                                                             Center
                                   Miriam Harris, MD, MSc**
                                              Boston Medical Center
   Health Care Resource Centers, Boston Methadone Treatment Program
                                 Nzinga Harrison, MD, FASAM
                              Chief Medical Officer, Eleanor Health
                                       Leah Harvey, MD, MPH
Infectious Disease and Addiction Medicine Physician, Boston Medical 
                                                             Center
                                Benjamin Hayes, MD, MS, MPH
                                          Montefiore Medical Center
                                      Andrew A. Herring, MD
    Systemwide Medical Director, Substance Use Disorder Treatment, 
                                              Alameda Health System
                                Janet J. Ho, MD, MPH, FASAM
  Addiction Consult Service, University of California-San Francisco
            Lynda Karig Hohmann, MD, PhD, MBA, FAAFP, FASAM
                                                          (Retired)
                             Randolph P. Holmes, MD, DFASAM
            Los Angeles Centers for Alcohol and Drug Abuse (LACADA)
                               Stephen Holtsford, MD, FASAM
Recovery Centers of America; Lighthouse Recovery, Inc.; BrightHeart 
                                                             Health
                               Stanley T. Hoover, MD, FASAM
                                             Dan Hoover, MD
       Oregon Health & Sciences University Addiction Medicine ECHO 
                                                           Director
                                         Connie Hsaio, MD**
                   APT Foundation; Connecticut Mental Health Center
 Cornell Scott--Hill Health Center, Yale School of Medicine
                                        Ilana Hull, MD, MSc
                            University of Pittsburgh Medical Center
                                     Michael Incze, MD, MEd
  Department of Internal Medicine, Primary Care, University of Utah
                             Christina E. Jones, MD, FASAM*
                     Behavioral Health Group; Community Connections
                                     Ayana Jordan, MD, PhD*
                                Sunset Terrace Family Health Center
                    New York University Grossman School of Medicine
                                    Joseph Joyner, MD, MPH*
         Chelsea Health Care Center, Massachusetts General Hospital
                        Kimberly A. Kabernagel, DO, FASAM**
      Medical Director, Marworth Treatment Center, Geisinger Health
                                     David Kan, MD, DFASAM*
                                                      Bright Health
        Volunteer Clinical Professor, University of California-San 
                                                          Francisco
                                  Peter Kassis, MD, FASAM**
                              BayMark, Health Care Resource Centers
                                     Ghulam Karim Khan, MD*
        Clinical Research Fellow, Infectious Disease and Addiction 
                                    Medicine, Boston Medical Center
                                    Laura Gaeta Kehoe, MD**
                                     Massachusetts General Hospital
                                       Andrea Kermack, MD**
            Wellness Center--Port Morris, Montefiore Medical Center
                                 Stefan G. Kertesz, MD, MSc
             Professor of Medicine, Heersink UAB School of Medicine
                                      Laila Khalid, MD, MPH
                                          Montefiore Medical Center
                                     Simeon Kimmel, MD, MA*
 Assistant Professor of Medicine at Chobanian and Avedisian School 
                                                        of Medicine
     Attending Physician, General Internal Medicine and Infectious 
                                    Diseases; Boston Medical Center
                                           Rachel King, MD*
                                  South End Community Health Center
                                              Boston Medical Center
                                     Miriam S. Komaromy, MD
    Medical Director, Grayken Center for Addiction, Boston Medical 
                                                             Center
                   Juleigh Kowinski Konchak, MD, MPH, FASAM
  Attending Physician, Behavioral Health, Department of Family and 
                                                 Community Medicine
                                                 Cook County Health
                                   Jared W. Klein, MD, MPH*
     Harborview Medical Center, University of Washington School of 
                                                           Medicine
                                Elizabeth E. Krans, MD, MSc
                            University of Pittsburgh Medical Center
                                  Ari Kriegsman, MD, FASAM*
  Medical Director, Addiction Consult Service, Mercy Medical Center
                                             Sunny Kung, MD
                                     Merrimack Valley Bridge Clinic
                                     Jordana Laks, MD, MPH*
                                              Boston Medical Center
                            James R. Latronica, DO, FASAM**
 University of Pittsburgh Medical Center; University of Pittsburgh 
                                                 School of Medicine
                                David Lawrence, MD, FASAM**
     Medical Director, Veterans Affairs Greater Los Angeles Health 
                                                             System
                                             Diana Lee, MD*
Addiction Medicine and Primary Care Physician, New York University 
                                        Grossman School of Medicine
                                        Sky Lee, MD, AAHIVS
                     Board Certified in Family & Addiction Medicine
                               Ximena A. Levander, MD, MCR*
                        Addiction Medicine Clinician and Researcher
                                 Oregon Health & Science University
                                Sharon Levy, MD, MPH, FASAM
  Director, Adolescent Substance Use and Addiction Program, Boston 
                                                Children's Hospital
          Associate Professor in Pediatrics, Harvard Medical School
                           Moxie Loeffler, DO, MPH, FASAM**
                                       Lane County Treatment Center
                               Oregon Society of Addiction Medicine
                                     Sara Lorenz Taki, MD**
 Medical Director, Greenwich House Methadone Maintenance Treatment 
                                                            Program
                             Margaret Lowenstein, MD, MSHP*
                                         University of Pennsylvania
                                 Tiffany Lu, MD, MS, FASAM*
                                          Montefiore Medical Center
                                   Cynthia Sue Marske, DO**
                                      Benton County Health Services
                                         Marlene Martin, MD
     University of California-San Francisco; San Francisco General 
                                                           Hospital
                      Stephen Martin, MD, EdM, FASAM, FAAFP
  Barre Family Health Center, University of Massachusetts Memorial 
                                                             Health
                                                       Boulder Care
                                   Mariya Masyukova, MD, MS
         Attending Physician, Montefiore Medical Center; Assistant 
                     Professor, Albert Einstein College of Medicine
                             Mary G. McMasters, MD, DFASAM*
                                    Nicky Mehtani, MD, MPH*
                          San Francisco Department of Public Health
                             University of California-San Francisco
                                         Sarah Messmer, MD*
     Mobile MAR Program, University of Illinois-Chicago College of 
                                                           Medicine
                                      Jennifer Michaels, MD
                         The Brien Center, Berkshire Medical Center
                               Kenneth Morford, MD, FASAM**
   APT Foundation, Yale New Haven Hospital, Yale School of Medicine
                             Katherine Mullins, MD, AAHIVS*
                                New York University--Langone Health
                                           Rayek Nafiz, MD*
                                                      Penn Medicine
              Anne N. Nafziger, MD, PhD, FASAM, FCP, FACP**
                                                 Conifer Park, Inc.
                                Christine Neeb, MD, FASAM**
University of Illinois Health Mile Square Health Center; Stonybrook 
                                                             Center
                                   Aaron Newcomb, DO, FASAM
                                            Shawnee Health Services
                           Mark X. Norleans, MD, PhD, FASAM
                                       Addiction Care of Excellence
                                         Sherry Nykiel, MD*
          Justus Mental Health; Key Recovery and Life Skills Center
               Delaware Division of Medicaid and Medical Assistance
                                        Nicole O'Connor, MD
                               Beth Israel Deaconess Medical Center
                                            Linda Peng, MD*
      Hillsboro Medical Center, Oregon Health & Sciences University
                                        Alyssa Peterkin, MD
          Hospital, Outpatient Bridge Clinic, Boston Medical Center
                                     Charles Peterson, MD**
              Medical Director, New Season Opioid Treatment Program
                                  Arwen Podesta, MD, DFASAM
                                              Podesta Wellness, LLC
                         Cara Poland, MD, MEd, FACP, DFASAM
                                          Michigan State University
                          Smita Prasad, MD, MBA, MPH, FASAM
                                              Longbranch Healthcare
                        Tulane Addition Medicine Fellowship Program
                                   Josiah D. Rich, MD, MPH*
           Professor of Medicine and Epidemiology, Brown University
 The Miriam and Rhode Island Hospitals, Rhode Island Department of 
                                                        Corrections
                                Elise K. Richman, MD, FASAM
                                Montefiore Behavioral Health Center
                                Eowyn Rieke, MD, MPH, FASAM
                                                        Fora Health
                                          Daniel Rosa, MD**
                            Senior Medical Director, Acacia Network
                                  A. Kenison Roy, III, MD**
                               Behavioral Health Group, New Orleans
                                   Lipi Roy, MD, MPH, FASAM
                                                      Housing Works
                                 Kenneth Saffier, MD, FASAM
                                       Contra Costa Health Services
                           Kelley Saia, MD, F-ACOG, D-ABAM*
    Project RESPECT, Substance Use Disorder in Pregnancy Treatment 
                                                             Center
                                              Boston Medical Center
    Elizabeth M. Salisbury-Afshar, MD, MPH, FAAFP, DFASAM, 
                                                      FACPM
  Associate Professor, Department of Family Medicine and Community 
                                                             Health
                                    University of Wisconsin-Madison
                            Jasleen Salwan, MD, MPH, FASAM*
                              Montgomery Family Medicine Associates
                       Jeffrey H. Samet, MD, MA, MPH, FASAM
  John Noble Professor of Medicine and Professor of Public Health, 
                                                  Boston University
   Primary Care, Inpatient Medicine Service, and Addiction Consult 
                                     Service, Boston Medical Center
                   Mario San Bartolome, MD, MBA, MRO, FASAM
                                                  KCS Health Center
                     Randy Seewald, MBBS, MD, FASAM, HMDC**
                                      Lexington Center for Recovery
                         Jeffrey Selzer, MD, DFASM, DLFAPA*
                  Medical Director, Committee for Physicians Health
            Christopher W. Shanahan, MD, MPH, FASAM, FACP**
    Frontage Road Methadone Clinic, Boston Public Health Commission
                                    Dean Singer, DO, FASAM*
                 Bridge Primary, Clinical and Support Options (CSO)
                                  Deepika E. Slawek, MD, MS
                                          Montefiore Medical Center
                                   Marcela Smid, MD, MA, MS
                              University of Utah School of Medicine
                                       Eleasa Sokolski, MD*
                                 Oregon Health & Science University
                Mia D. Sorcinelli Smith, MD, FASAM, FAAFP**
                              Greater Lawrence Family Health Center
                                            Spectrum Health Systems
                        Massachusetts Behavioral Health Partnership
                                       Peter Smith, MD, MSc
                                              Boston Medical Center
                                    Natalie Stahl, MD, MPH*
                              Greater Lawrence Family Health Center
                        Paul J. Steier, D.O., FASAM, FAOAAM
G Street Integrated Health; Serenity Lane; Centro Latino Americano; 
                                           South Lane Mental Health
                  Stephanie Stewart, MD, MPHS, FASAM, MRO**
                          University of Colorado School of Medicine
                          Joshua St. Louis, MD, MPH, FASAM*
                              Greater Lawrence Family Health Center
                                  Sarah Bronwyn Stuart, MD*
                                                  Syracuse Recovery
                                      Leslie Suen, MD, MAS*
                                     San Francisco General Hospital
                             University of California-San Francisco
                                            Mohsin Syed, MD
                                       Slocum-Dickson Medical Group
                                        Ashish Thakrar, MD*
                           University of Pennsylvania Health System
                                      Philadelphia Veterans Affairs
                                      Jessica L. Taylor, MD
                        Medical Director, Faster Paths to Treatment
                                              Boston Medical Center
                                 Carlos F. Tirado, MD, MPH*
                      Travis County Integral Care, CARMAHealth PLLC
                       Kristine Torres-Lockhart, MD, FASAM*
               Port Morris Wellness Center--Opioid Treatment Center
                                          Montefiore Medical Center
                            Joseph M. Valdez MD, MPH, FASAM
         Outpatient Addiction Medicine Clinic, Geisinger Center of 
                                                         Excellence
                                Sarah E. Wakeman, MD, FASAM
    Medical Director, Massachusetts General Hospital Substance Use 
                                                Disorder Initiative
                                             Harvard Medical School
                              William Joseph Walsh, III, MD
                                              Weber Recovery Center
                                    Nalan Ward, MD, FASAM**
             Massachusetts General Hospital; Harvard Medical School
               Carolyn Warner-Greer, MS, MD, FACOG, FASAM**
                                                   The Bowen Center
                         Andrea Weber, MD, MME, FACP, FASAM
            University of Iowa Addiction and Recovery Collaborative
                                     John Weems, MD, FASAM*
                   CommunityCare federally Qualified Health Centers
                                   Daniel Weiner, DO, FASAM
                                             Rogue Community Health
                          Zoe M. Weinstein, MD, MS, FASAM**
                                              Boston Medical Center
                                          Annalee Wells, DO
                                       Lynn Community Health Center
                            Arthur Robin Williams, MD, MBE*
    Assistant Professor of Clinical Psychiatry, Columbia University
   Director, American Academy of Addiction Psychiatry Area II (New 
                                                              York)
                      Jan Widerman, DO, FAAP, FASAM, FAOAAM
                           Medically Assisted Recovery Services, PC
                       Tricia Wright, MD, FS, FACOG, DFASAM
                                     San Francisco General Hospital
                             University of California-San Francisco
                                Jeffery T. Young, MD, FASAM
                                     Hazelden Betty Ford Foundation
                                              Amy Yule, MD*
          Medical Director, Addiction Recovery Management Service, 
                                     Massachusetts General Hospital
                                Psychiatrist, Boston Medical Center
                        Additional Signatories:
                                Rohit Abraham, MD, MPH, MAT
                                              Boston Medical Center
                                  Marielle Baldwin, MD, MPH
   Assistant Professor of Family Medicine, Chobanian and Avedisian 
                              School of Medicine, Boston University
                                    Rebecca Barron, MD, MPH
     Emergency Medicine, University of Massachusetts Chan--Baystate
                                  Angela R. Bazzi, PhD, MPH
                                   Corinne A. Beaugard, MSW
  Grayken Center for Addiction, Boston University School of Social 
                                                               Work
                                 Robert S. Beil, MD, AAHIVM
                                          Montefiore Medical Center
                                   Judana Bennett, PMHNP-BC
                                     Massachusetts General Hospital
                                  Cari Benbasset-Miller, MD
                                  Cambridge Health Alliance--Revere
                                       Edward Bernstein, MD
      Professor Emeritus, Department of Emergency Medicine, Boston 
                                      University School of Medicine
                                       Anne Berrigan, LICSW
                                              Boston Medical Center
                                Alexandra Bessaoud, BSN, RN
               Center for Infectious Disease, Boston Medical Center
                                    Samantha Blakemore, MPH
                                              Boston Medical Center
                                        James Blum, MD, MPP
                                              Boston Medical Center
                               Kimberly Brandt, MS, FNP-BC*
                                                         CODA, Inc.
                                           Bari Brodsky, MD
            North Shore Community Health, Cambridge Health Alliance
                                  Ebony Caldwell, MD, MPH**
                   APT Foundation; Cornell Scott Hill Health Center
                                           Sandra Cagle, NP
                                  Ascension Macomb Oakland Hospital
                          Mordechai Caplan, Medical Student
                              Brittney Carney, DNP, FNP-BC*
                                         Boston Children's Hospital
                                             Layla Cavitt**
                           Comprehensive Psychiatric Centers--Miami
                                      Deborah Chassler, MSW
                      Senior Academic Researcher, Boston University
                                     Benjamin J. Church, DO
                                Emergency Medicine, Baystate Health
                                      Kaitlyn Clausell, MS4
                                Albert Einstein College of Medicine
                                           Camille Clifford
 Massachusetts HEALing Communities Study, School of Public Health, 
                                                  Boston University
                                  Alex Close, MD, EM, PGY-2
                                        Bridget Coffey, MSN
   Missouri Institute of Mental Health, University of Missouri-St. 
                                                              Louis
                                           Gerald Coste, MD
                                          Cambridge Health Alliance
                         Patricia Cremins, MA, PA-C, AAHIVS
                                     Chanelle Diaz, MD, MPH
                                          Montefiore Medical Center
                                          Frank DiRenno, MD
                                          Montefiore Medical Center
                                Catherine Donlon, MD, PGY-1
                                          Cambridge Health Alliance
                         Ashley Deutsch, MD, FACEP, FAAEM**
    Emergency Medicine, University of Massachusetts Chan School of 
                                                           Medicine
                                              Tala Elia, MD
    Emergency Medicine, University of Massachusetts Chan School of 
                                                           Medicine
                                      Anthony English, PA-C
            Springfield and Holyoke OTPs, Behavioral Health Network
                                             Liz Evans, PhD
                                           Public Health Researcher
Health Promotion and Policy Department, University of Massachusetts
                                         Patrick Felton, MD
                                            Baystate Medical Center
                                            Sean Fogler, MD
                                                            Elevyst
                   Nicole Fordey, LCSW, LISAC, LICSW, CCTP*
                                                           Monument
            Eduardo Garza, MD Pgy-5 Chief Resident FM/Psych
                                              Boston Medical Center
                       Angela G. Giovanniello, PharmD, L.Ac
               Amanda Gebel, Overdose Prevention Specialist
   Missouri Institute of Mental Health, University of Missouri-St. 
                                                              Louis
                                        Mat Goebel, MD, MAS
                   Baystate Medical Center, Baystate Noble Hospital
                                          Andrea Gordon, MD
                                          Cambridge Health Alliance
                                    Robert M. Grossberg, MD
                                          Montefiore Medical Center
                                        Valerie Gruber, PhD
                         Clinical Psychologist, Addiction Counselor
                                   Jonathan Hanson, MD, MPH
                          Resident Physician, Boston Medical Center
                                    Jacqueline Harris, PA-C
                                            Baystate Springfield ED
                                        Iman Hassan, MD, MS
                                Albert Einstein College of Medicine
                                     Erica Heiman, MD, MS**
                                  Yale Fellow in Addiction Medicine
                                       Kevin T. Hinchey, MD
                                                   Matthew Holm, MD
                                          Montefiore Medical Center
                                           Jamie Lee Horton
                                            Baystate Medical Center
                              Sandra Honter-Williams, MBM**
Rapid Access Program, Grayken Center for Addiction, Boston Medical 
                                                             Center
                                         Beth Hribar, MPP**
                                           Andrew Hyatt, MD
                                          Cambridge Health Alliance
                                         Fazeelah Ibrahim**
                                          Addiction Medicine Fellow
                                      J. Aaron Johnson, PhD
  Professor and Director, Institute of Public and Preventive Health
                                                 Augusta University
                                    Michelle R. Johnson, MD
                                          Cambridge Health Alliance
                                         Jennifer Jones, MD
                                     Paul Joudrey, MD, MPH*
    University of Pittsburgh Medical Center--Shadyside, Mercy IMREP
                                       Darline Justal, NP**
                                              Boston Medical Center
                                       Matthew Kahari, MD**
                                           Geisinger Medical Center
                                   Carol B. Kelly, MD, FACP
                        Montefiore Comprehensive Family Care Center
                                       Mark E. Klee, PharmD
                           Baystate Medical Center, Baystate Health
                                     Sarah Kleinschmidt, MD
                                               Emergency Department
                                      Sarah Kosakowski, MPH
                                              Boston Medical Center
                       Colleen T. LaBelle, MSN, RN-BC, CARN
                                                  Boston University
                                                 Shilpa Lad
                            Moses Campus, Montefiore Medical Center
                                   Hung Le, SPRM, CARN-AP**
                                              Boston Medical Center
                                                Hansel Lugo
                              Recovery Coach, Boston Medical Center
   Casa Esperanza, Bridgewell, Lynn Community Health Center
                                               YinPhyu Lwin
                 Interfaith Methadone Maintenance Treatment Program
                               Kirsten Meisinger, MD, MHCDS
       Union Square Family Health Center, Cambridge Health Alliance
                                    Harvard Center for Primary Care
                              Carla Merlos, MSN, PMHNP-BC**
                                              Boston Medical Center
                                           Dave Morgan, RPh
                                   Stephen Murray, MPH, NRP
                                              Boston Medical Center
                                        Nicole O'Connor, MD
                               Beth Israel Deaconess Medical Center
                                     Adele Ojeda, RN, CARN*
             University of Massachusetts Barre Family Health Center
                                           Chiedozie Ojimba
                                        Montefiore Methadone Clinic
                         Interfaith Medical Center Methadone Clinic
                                                Donald Otis
   Missouri Institute of Mental Health, University of Missouri-St. 
                                                              Louis
                                     Danielle C. Ompad, PhD
                     Drug Use Researcher, Professor of Epidemiology
                 New York University School of Global Public Health
                                          Linda Neville, BS
                                              Boston Medical Center
                                       Viraj Patel, MD, MPH
                                          Montefiore Medical Center
                     Lisa Peterson, LMHC, LCDP, LCDS, MAC**
                                     Chief Operating Officer, VICTA
                                          Sriya Podila, MS1
                University of Massachusetts Chan School of Medicine
                            Daniel Pomerantz, MD, MPH, FACP
                                          Montefiore Medical Center
                                  Talia Puzantian, PharmD**
     Keck Graduate Institute School of Pharmacy and Health Sciences
                                     San Francisco General Hospital
                                          Heidi Quist, PA-C
                     Chronic Pain Wellness Center at the Phoenix VA
                                          Gabriela Reed, MD
                   Addiction Medicine Fellow, Boston Medical Center
                              Daniel Resnick, MBA, OMS-III*
                                       Dawn Rice BSN, RN2**
                                  Montefiore's Family Health Center
                                  John Roberts, DNP, ANP-BC
                          Gavin Foundation Acute Treatment Services
                                      Jonathan Ross, MD, MS
                 Community Health Center, Montefiore Medical Center
                                                Victor Roy*
               National Clinician Scholars Program, Yale University
                              VA Homeless Patient Aligned Care Team
                                                 Jay Schiff
                       Co-Founder & CEO, Addinex Technologies, Inc.
                               Elizabeth Schoenfeld, MD, MS
  Vice Chair for Research, Department of Emergency Medicine, UMass 
                                                      Chan-Baystate
                                     Gail Groves Scott, MPH
      Director of Research and Advocacy, Health Policy Network, LLC
                                             Ruchi Shah, DO
Family Medicine Residency, Grayken Addiction Medicine Fellow, 2023, 
                                              Boston Medical Center
                                         Lauren Shapiro, MD
                      Montefiore Medical Center; Family Care Center
                                       Anjali Sharma MD, MS
                                          Montefiore Medical Center
                           Jennifer Sharpe Potter, PhD, MPH
                             University of Texas Health-San Antonio
                                       Marc Shi, MD, AAHIVS
                                          Montefiore Medical Center
                                           Joseph Sills, MD
    Emergency Medicine, University of Massachusetts Chan School of 
                                                           Medicine
           Rosemary E. Smentkowski, MSN, RN, PMHNP-BC, CARN
                         New Hope Integrated Behavioral Health Care
                                           Rachel Smith, BS
                                 Medical Student, Boston University
                                           Mark Spencer, MD
                                  Kathleen Sylvester, FNP**
                         Greenfield OTP, Behavioral Health Services
                                        Mary Tomanovich, MA
                Grayken Center for Addiction, Boston Medical Center
                               Sheila P. Vakharia, PhD, MSW
                                               Drug Policy Alliance
                                                 Kyle Vance
   Missouri Institute of Mental Health, University of Missouri-St. 
                                                              Louis
                                     Alicia S. Ventura, MPH
                                              Boston Medical Center
                                       Nadia Villarroel, MD
                                          Durane Walker, MD
                                            Baystate Medical Center
                                       Ryan Walker, MD, MPH
                              Greater Lawrence Family Health Center
                                                Kris Warren
                Grayken Center for Addiction, Boston Medical Center
                                      Karrin Weisenthal, MD
                   Addiction Medicine Fellow, Boston Medical Center
                                         Libby Wetterer, MD
                              American Academy of Family Physicians
                                          Alexa Wilder, MPH
                Grayken Center for Addiction, Boston Medical Center
                Dawn Williamson RN, DNP, PMHCNS-BC, CARN-AP
                                     Massachusetts General Hospital
                                      Rachel Winograd, PhD*
                      Clinical Psychologist and Associate Professor
   Missouri Institute of Mental Health, University of Missouri-St. 
                                                              Louis
                                         Emily Zametkin, MD
                                            Baystate Medical Center
                                 ______
                                 
             American Academy of Family Physicians,
                                                      May 17, 2023.
Senator Ed Markey, Chairman
Senator Roger Marshall, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Primary Health and Retirement Security,
428 Dirksen Senate Office Building,
Washington, DC. 20510.

    Dear Chairman Markey and Ranking Member Marshall:

    On behalf of the American Academy of Family Physicians (AAFP), 
representing more than 129,600 family physicians and medical students 
across the country, I write to applaud the Subcommittee's focus on 
mental health and substance use disorder with today's hearing titled 
``A Crisis in Mental Health and Substance Use Disorder Care: Closing 
Gaps in Access by Bringing Care and Prevention to Communities.''

    Family physicians provide comprehensive mental health services and 
are a major source for mental health care in the U.S. Nearly 40 percent 
of all visits for depression, anxiety, or cases defined as ``any mental 
illness'' were with primary care physicians, and primary care 
physicians are more likely to be the source of physical and mental 
health care for patients with lower socioeconomic status and for those 
with comorbidities. \1\ Family physicians also play a crucial role in 
safe pain management prescribing practices, screening patients for 
opioid use disorder (OUD), and prescribing and maintaining treatment of 
medications for OUD (MOUD). Primary care physicians are often the first 
point of care for patients and can provide necessary referrals or 
coordinate care with psychiatric and other mental health professionals 
when needed.
---------------------------------------------------------------------------
    \1\  Jetty, A., Petterson, S., Westfall, J. M., & Jabbarpour, Y. 
(2021). Assessing Primary Care Contributions to Behavioral Health: A 
Cross-sectional Study Using Medical Expenditure Panel Survey: https://
Doi.Org/10.1177/21501327211023871

    Unfortunately, access to mental health care and substance use 
disorder (SUD) treatment remains a significant challenge for many 
patients across the country, particularly those from underserved 
communities or marginalized populations. A study published this month 
found that Black patients lacked equal access to OUD treatment and were 
far less likely to be prescribed buprenorphine, to live near a 
prescriber, and to remain in treatment 6 months after first being 
prescribed it when compared to white patients. \2\
---------------------------------------------------------------------------
    \2\  Black patients with opioid addiction lack equal access to 
treatment (statnews.com)

    The AAFP shares your commitment to advancing policies that will 
improve access to mental health and SUD care for all communities across 
the country. We long advocated for elimination of the X-waiver and 
applaud Congress for doing so as part of the Consolidated 
Appropriations Act of 2023. Removing these burdensome requirements for 
physicians to prescribe MOUD will greatly improve patient access to 
evidence-based, lifesaving treatment. To build upon this momentum, we 
urge Congress to consider the following policy recommendations.
       Support Integration of Behavioral Health and Primary Care
    Given the dire shortage of behavioral health clinicians, especially 
in many rural and underserved communities, equipping primary care 
clinicians to provide frontline mental health and substance abuse 
disorder treatment is essential for ensuring patients have timely 
access to care. Integrated behavioral health has shown significant 
cost-savings for payers and physicians, as well as more equitable 
access to mental health services for traditionally underserved 
populations. \3\ Unfortunately, while many primary care physicians want 
to integrate behavioral health services in their practices, they face 
burdensome startup costs and payment and reporting challenges that 
prevent integration.
---------------------------------------------------------------------------
    \3\  SY, L.-T., J, E., D, C., & PY, C. (2018). A Systematic Review 
of Interventions to Improve Initiation of Mental Health Care Among 
Racial-Ethnic Minority Groups. Psychiatric Services (Washington, DC.), 
69(6), 628--647. https://doi.org/10.1176/APPI.PS.--201700382

    The AAFP has continuously advocated for additional Federal 
investments to initiate and sustain BHI in primary care practices. We 
applaud Congress for including a provision in the most recent year-end 
omnibus to authorize grants to support the uptake and adoption of 
integrated care services, including the Collaborative Care Model 
(CoCM). We strongly encourage Congress to build upon this by 
---------------------------------------------------------------------------
implementing additional legislation to support BHI.

    Specifically, the AAFP urges the reintroduction and passage of the 
bipartisan Improving Access to Behavioral Health Integration Act. This 
bill makes necessary changes to existing Federal programs to ensure 
primary care practices can integrate behavioral health care services by 
providing grant funding that covers the steep startup costs. This 
initial financial support is critical to improving access to integrated 
services and ensuring patients and payers can achieve the long-term 
cost savings that behavioral health integration often provides.

    We also urge Congress to pass the Better Mental Health Care for 
Americans Act (S. 923), which would establish a Medicare add-on code 
for office visits provided by primary care physicians who have 
integrated behavioral health into their practice. This enhanced payment 
recognizes the unaccounted resources required to provide integrated 
behavioral health care and ensures that primary care practices can 
sustain it. Additionally, it would establish a Medicaid demonstration 
program to ensure that all children covered by Medicaid have access to 
integrated behavioral health care in primary care, schools, or other 
critical settings. This program would provide infrastructure, technical 
assistance, and sustainable financing to support expanding access to 
integrated mental health care for children.

    Additionally, to improve access to integrated tele-mental and 
behavioral health care in primary care settings, the AAFP encourages 
Congress to establish a new program for adults that mirrors HRSA's 
Pediatric Mental Health Care Access Program (PMHCA). This program, 
recently reauthorized in 2022, promotes behavioral health integration 
into pediatric primary care by using telehealth, and has a proven track 
record of increasing mental and behavioral health needs despite ongoing 
workforce shortages by meeting children and adolescents where they are. 
Given the well-documented shortage of mental and behavioral health 
clinicians and the growing demand for specialized care, a HRSA-funded 
program that provides primary care clinicians with virtual access to 
specialists could increase timely access to care for adult patients.
                               Telehealth
    The COVID-19 public health emergency (PHE) transformed access to 
mental and behavioral health care via telehealth, making it possible 
for many patients to be connected to appropriate clinicians and 
treatment that had otherwise been unavailable to them due to financial, 
geographic, coverage, or other barriers. As PHE flexibilities end, we 
strongly urge that Congress implements policies to minimize disruptions 
in access to tele-mental and behavioral health care.

    The AAFP has consistently advocated to Congress to permanently 
remove the in-person requirement for tele-mental health services for 
Medicare beneficiaries. Evidence has shown that telehealth is an 
effective modality for providing mental and behavioral health services. 
\4\ Meanwhile, family physicians report that persistent behavioral 
health workforce shortages create significant barriers to care for 
their patients. Arbitrarily requiring an in-person visit prior to 
coverage of tele-mental health services will unnecessarily restrict 
access to behavioral health care.
---------------------------------------------------------------------------
    \4\  Pew Trust. (2021, December 14). State Policy Changes Could 
Increase Access to Opioid Treatment via Telehealth--The Pew Charitable 
Trusts. https://www.pewtrusts.org/en/research-andanalysis/issuebriefs/
2021/12/state-policy-changes-could-increase-access-to-opioid-treatment-
via-telehealth

    As acknowledged in the AAFP's recent comments to the Drug 
Enforcement Administration (DEA), the in-person connection between a 
physician and patient can provide a valuable touchpoint for patients 
receiving MOUD and other OUD treatment services. However, existing 
shortages of clinicians prescribing buprenorphine for OUD, as well as 
numerous other barriers faced by patients with OUD, will prevent many 
patients from being able to obtain an in-person visit, particularly 
within the DEA's proposed 30-day timeframe. To that end, we strongly 
urge against requiring an in-person exam for prescribers of 
buprenorphine for treatment of OUD, given evidence in support of 
telehealth, limited access to OUD treatment prescribers, and relatively 
---------------------------------------------------------------------------
lower rates of buprenorphine diversion.

    While an in-person evaluation may be necessary for other primary 
care treatment, data shows that buprenorphine prescribing is 
particularly well-suited for virtual-only visits. Telehealth initiation 
of and continued treatment with buprenorphine has shown greater 
treatment retention, reduced illicit opioid use, improved access to 
treatment, greater patient satisfaction, and reduced healthcare costs. 
\5\
---------------------------------------------------------------------------
    \5\  Vakkalanka, J.P., Lund, B.C., Ward, M.M. et al. Telehealth 
Utilization Is Associated with Lower Risk of Discontinuation of 
Buprenorphine: a Retrospective Cohort Study of US Veterans. J GEN 
INTERN MED 37, 1610--1618 (2022). https://doi.org/10.1007/s11606--021--
06969--1

    Nearly 160 million individuals live in a mental health professional 
shortage area, and many more have mental health professionals in their 
area that do not accept the patient's insurance or require unfeasible 
cost sharing. \6\ Nearly 99 million individuals live in a primary care 
health professional shortage area and would be unable or challenged to 
receive MOUD without telehealth and audio-only visits. \7\ This 
difficulty in access to care for patients is compounded by 
transportation, time, and child-care challenges, as well as trauma and 
stigmatization from past experiences with the health care system. All 
of which makes virtual visits critically important for initiating and 
maintaining OUD treatment.
---------------------------------------------------------------------------
    \6\  Bureau of Health Workforce, Health Resources and Services 
Administration (HRSA), U.S. Department of Health & Human Services, 
Designated Health Professional Shortage Areas Statistics: Designated 
HPSA Quarterly Summary, as of September 30, 2022 available at https://
data.hrsa.gov/topics/healthworkforce/shortage-areas.
    \7\  Ibid.
---------------------------------------------------------------------------
                    Close the Medicaid Coverage Gap
    The AAFP supports efforts to provide coverage for low-income 
individuals in states that decided to forgo the Affordable Care Act's 
Medicaid Expansion. Closing the Medicaid expansion coverage gap would 
grant over 2 million uninsured Americans access to health coverage and 
would be a critical step in improving access to mental and behavioral 
health care, as well as addressing existing disparities in access. Data 
has shown that 60 percent of those in the Medicaid coverage gap are 
people of color, and more than 1 in 4 are estimated to have a 
behavioral health condition. \8\ Family physicians have repeatedly 
called upon states to expand Medicaid to avoid coverage gaps, and in 
the absence of state action, we support alternative options to cover 
individuals who would otherwise be eligible.
---------------------------------------------------------------------------
    \8\  Sullivan J, Pearsall M, and A Bailey. ``To Improve Behavioral 
Health, Start by Closing the Medicaid Coverage Gap,'' Center on Budget 
and Policy Priorities. October 4, 2021. Accessed online: https://
www.cbpp.org/research/health/to-improve-behavioral-health-start-by-
closing-the-Medicaid-coverage-gap#--ftn3
---------------------------------------------------------------------------
            Improved Access for Justice-Involved Populations
    Individuals who have been incarcerated have significant health care 
needs and face multiple barriers to obtaining health insurance and 
access to care. These challenges affect not only the formerly 
incarcerated individuals, but also their families and communities, many 
of which are disadvantaged, and experience health inequities born out 
of complex social determinants of health.

    It is estimated that nearly half (47 percent) of individuals who 
are incarcerated meet the Diagnostic and Statistical Manual (DSM)-IV 
criteria for substance use disorder in the 12 months prior to admission 
to prison. \9\ Unfortunately, only 12 to 15 percent of individuals who 
have a substance use disorder receive drug treatment while 
incarcerated. \10\ For this reason, individuals who have chronic 
addictions have a higher risk of going through withdrawal while in 
custody and then overdosing when they return to the community. \11\, 
\12\
---------------------------------------------------------------------------
    \9\  Maruschak L, Bronson J, and M Apler. ``Survey of Prison 
Inmates, 2016: Alcohol and Drug Use and Treatment Reported by 
Prisoners,'' U.S. Department of Justice Office of Justice Programs 
Bureau of Justice Statistics. July 2021. Accessed online: https://
bjs.ojp.gov/sites/g/files/xyckuh236/files/media/document/
adutrpspi16st.pdf
    \10\  Ibid.
    \11\  Fu JJ, Zaller ND, Yokell MA, et al. Forced withdrawal from 
methadone maintenance therapy in criminal justice settings: a critical 
treatment barrier in the United States. J Subst Abuse Treat. 
2013;44(5):502-505.
    \12\  Magura S, Lee JD, Hershberger J, et al. Buprenorphine and 
methadone maintenance in jail and post-release: a randomized clinical 
trial. Drug Alcohol Depend. 2009;99(1-3):222-230.

    The AAFP advocates for individuals who are incarcerated or detained 
to have access to comprehensive medical services, including mental 
health care and substance use disorder treatment. We support the 
funding and implementation of successful re-entry models and other 
evidence-based programs to assist those who have recently been 
incarcerated. Access to evidence-based treatments for SUD should be 
provided by correctional health facilities while individuals are still 
incarcerated, and connections to housing, employment, comprehensive 
primary care, and substance use and mental health support should be 
made to best support their health outcomes and transition back into the 
---------------------------------------------------------------------------
community.

    To that end, the AAFP urges Congress to pass the Reentry Act (S. 
1165 / H.R. 2400), which allows Medicaid coverage for incarcerated 
individuals to automatically begin 30 days prior to their release. This 
will facilitate better care continuity as part of community reentry, 
including for those with SUD and mental health needs.

    Thank you for the opportunity to offer these recommendations. The 
AAFP looks forward to continuing to work with you to advance policies 
that improve patient access to mental health and substance use disorder 
care. Should you have any questions, please contact Natalie Williams, 
Senior Manager of Legislative Affairs at [email protected].

            Sincerely,
                                  Sterling N. Ransone, Jr.,
                                                       Board Chair,
                             American Academy of Family Physicians.
                                 ______
                                 
          American College of Emergency Physicians,
                                                      May 17, 2023.
Senator Ed Markey, Chairman
Senator Roger Marshall, Ranking Member
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Primary Health and Retirement Security,
428 Dirksen Senate Office Building,
Washington, DC. 20510.

    Dear Chairman Markey and Ranking Member Marshall:

    On behalf of the American College of Emergency Physicians (ACEP) 
and our nearly 40,000 members, thank you for holding today's hearing, 
entitled, ``A Crisis in Mental Health and Substance Use Disorder Care: 
Closing Gaps in Access by Bringing Care and Prevention to 
Communities.'' We appreciate the opportunity to share some of our 
experiences on the frontlines of our Nation's mental health and 
substance use disorder (SUD) crises, and we look forward to continuing 
to work with you to improve access to the lifesaving care and treatment 
that our patients need and deserve.

    As the health care safety net, the emergency department (ED) is 
often the first--and sometimes only--point of contact for individuals 
experiencing mental health crises or other behavioral health 
challenges, such as substance use disorder (SUD) or overdose. While the 
ED is the critical frontline safety net and the most appropriate 
setting for acute unscheduled care for individuals suffering from a 
mental health crisis, it is not ideal for long-term treatment of mental 
and behavioral health needs. However, due to the fragmented nature of 
the mental health care infrastructure in the U.S., persistent lack of 
sufficient resources, and longstanding shortages of mental and 
behavioral health professionals, far too many Americans have limited 
options for the longer-term follow-up treatment they need and deserve. 
These challenges contribute to long ED wait times and aggravate 
``boarding'' issues, a scenario where patients are kept in the ED for 
extended periods of time due to a lack of available inpatient beds or 
space in other facilities where they could be transferred. Overcrowding 
and boarding are not failures of the ED; rather, they are symptoms of 
larger systemic issues that must be addressed to eliminate bottlenecks 
in health care delivery and reduce the burden on the already-strained 
health care safety net.

    Once again, ACEP is grateful for the Committee's attention to the 
mental and behavioral health challenges affecting millions of 
Americans. As you continue to examine this pressing public health 
issue, we urge you to consider several key issues. These include 
strengthening the mental/behavioral health workforce; increasing 
integration, coordination, and access to care; ensuring parity; 
furthering the use of telehealth; and improving access to behavioral 
health care for children and young people. We also continue strongly 
urge the Committee to include physician and provider mental health and 
burnout as necessary considerations in comprehensive mental health 
policy initiatives, especially in light of the significant mental 
health toll the COVID-19 pandemic and its lingering effects have taken 
on frontline health care providers. Improving and providing for the 
mental health and well-being of the health care workforce is a unique 
challenge, but one that is absolutely essential to ensure that patients 
have access to the full continuum of high-quality health care. 
Additionally, we hope you will examine the many innovative solutions 
that emergency physicians throughout the country have developed and 
successfully implemented to reduce emergency psychiatric patient 
boarding.
                     Emergency Department Boarding
    Patient ``boarding'' occurs when a patient continues to occupy an 
ED bed even after being seen and treated by a physician, while waiting 
to be admitted to an inpatient bed in the hospital, or transferred to 
psychiatric, skilled nursing, or other specialty facility. As our 
health care system becomes increasingly strained, these patients must 
stay in the ED for days or even weeks on end waiting for a bed to 
become available so they can be admitted or transferred. Patients being 
boarded in the ED limits the ability of ED staff to provide timely and 
quality care to all patients, forcing other newly arriving patients 
with equally important emergency conditions to wait in the ED waiting 
room for care, with wait times as long as eight or even 12 hours 
rapidly becoming a new norm, and patients even dying during these waits 
as staff struggle to keep up with an unsupportable volume of sick 
patients to care for.

    Boarding has become its own public health emergency. Our nation's 
safety net is on the verge of breaking beyond repair; EDs are 
gridlocked and overwhelmed with patients waiting--waiting to be seen, 
waiting for admission into an inpatient bed in the hospital, waiting to 
be transferred to psychiatric, skilled nursing, or other specialized 
facilities that have little to no available beds, or, waiting to simply 
return to their nursing home. And this breaking point is entirely 
outside of the control of highly skilled emergency physicians, nurses, 
and other ED staff doing their best to keep everyone attended to and 
alive.

    Any emergency patient can find themselves boarded, regardless of 
their condition, age, insurance coverage, income, or geographic area. 
Even patients sick enough to need intensive care may board for hours in 
ED stretchers not set up for the extra monitoring they need. Those in 
mental health crises, often children or adolescents, board for months 
in chaotic EDs while waiting for a psychiatric inpatient bed to open 
anywhere. But boarding does not just affect those waiting to receive 
care elsewhere. When ED beds are already filled with boarded patients, 
other patients are decompensating and, in some cases, dying while in ED 
waiting rooms during their tenth, eleventh, or even twelfth hour of 
waiting to be seen by a physician.

          ``At peak times which occur up to 5 days per week we have 
        more patients boarding than we have staffed beds. High numbers 
        have include last week when our 22 bed emergency department had 
        35 boarders and an additional 20 patients in the waiting room. 
        In addition, we have patients who unfortunately have died in 
        our waiting room while awaiting treatment. These deaths were 
        entirely due to boarding. Our boarding numbers have 
        unfortunately skyrocketed in the wake of COVID as a consequence 
        of increasing surgical volumes and decreasing inpatient nurse 
        staffing.''----anonymous emergency physician

    To illustrate the stark reality of this crisis, ACEP asked its 
members to share examples of the life-threatening impacts of ED 
boarding. The stories paint a picture of an emergency care system 
already near collapse. While the causes of ED boarding are 
multifactorial, unprecedented and rising staffing shortages throughout 
the health care system have recently brought this issue to a crisis 
point, further spiraling the stress and burnout driving the current 
exodus of excellent physicians, nurses, paramedics, and other health 
care professionals.

    We need a health care system that can accurately track available 
beds and other relevant data in real-time, appropriate metrics to 
measure ED throughput and boarding, contingency plans and ``load 
balancing'' plans for boarding/crowding scenarios, and fewer regulatory 
or other ``red tape'' burdens that delay necessary care. Recognizing 
all EDs are different and there is no one-size-fits-all solution to 
this multifactorial problem, ACEP is in the process of developing a 
broad range of potential legislative and regulatory solutions that will 
alleviate the burdens and overall strain on EDs caused by patient 
boarding. As we finalize these recommendations and policy solutions, we 
will share more broadly with you and your staff in the coming weeks. 
Further, we strongly urge Congress to direct its attention to this 
critical issue and work with us and other stakeholders through 
roundtables, hearings, and legislation to provide both short-and long-
term solutions to this public health crisis.
     Violence Against Emergency Physicians and Health Care Workers
    Violence in the emergency department is a serious and growing 
concern, causing significant stress to emergency department staff and 
to patients who seek treatment in the emergency department (ED). 
According to a survey conducted by ACEP in 2022, two-thirds of 
emergency physicians report being assaulted in the past year alone, 
while more than one-third of respondents say they have been assaulted 
more than once. Nearly 85 percent of emergency physicians say the rate 
of ED violence has increased within the last year.

    Beyond the immediate physical impacts and injuries, the risk of 
violence increases the difficulty of recruiting and retaining qualified 
health care professionals and contributes to greater levels of 
physician burnout. In fact, 87 percent of emergency physicians report a 
loss of productivity from the physician or staff as a result, and 85 
percent of emergency physicians report emotional trauma and an increase 
in anxiety because of ED violence. Most importantly, patients with 
medical emergencies deserve high-quality care in a place free of 
physical dangers from other patients or individuals, and care from 
staff that is not distracted by individuals with behavioral or 
substance-induced violent behavior.

    And unlike the significantly more visible violence against airline 
employees and other travelers that has become more ubiquitous over the 
last several years, violence against health care workers often is not 
seen or addressed because of inadequate reporting and tracking of 
violent incidents, and other systemic barriers that do not hold violent 
individuals accountable for their actions. As a result of the inability 
to prosecute those who are arrested, many health care workers are 
discouraged from even pressing charges and being forced to accept that 
it's ``just part of the job.'' Violence is not accepted in any other 
workplace, and it must not be accepted especially in a setting focused 
on improving the health and well-being of individuals.

    There are many factors contributing to the increase in ED and 
hospital violence, we recognize there is no one-size-fits-all solution 
to this issue either. In fact, one of the challenges is that the types 
of violence one ED typically experiences can be significantly different 
from another ED, even in the same town. Therefore, ensuring there are 
adequate resources to help identify best practices and outfitting 
facilities with resources appropriate to their specific needs is 
imperative. Overall, employers and hospitals should develop workplace 
violence prevention and response procedures that address the needs of 
their particular facilities, staff, contractors, and communities, as 
those needs and resources may vary significantly.

    ACEP supports multi-pronged legislative efforts to address various 
aspects of health care workplace violence prevention, including the 
``Workplace Violence Prevention for Health Care and Social Service 
Workers Act,'' (H.R. 2663/S. 1176), introduced by Sen. Tammy Baldwin 
(D-WI) (and by Reps. Joe Courtney (D-CT), Don Bacon (R-NE), and others 
in the House); as well as the ``Safety From Violence for Healthcare 
Employees (SAVE) Act,'' (H.R. 2584) introduced by Reps. Larry Bucshon 
(R-IN) and Madeline Dean (D-PA). The Workplace Violence Prevention for 
Health Care and Social Service Workers Act would ensure that health 
care workplaces implement violence prevention plans and techniques and 
are prepared to respond to acts of violence, while the SAVE Act would 
establish Federal legal penalties for individuals who knowingly and 
intentionally assault or intimidate health care workers and provide 
grants to help hospitals and medical facilities establish and improve 
workplace safety, security, and violence prevention efforts.
                      Access to Mental Health Care
    The emergency department is not only a safety net for those with 
physical care needs, but also for individuals suffering from a mental 
health crisis or acute psychiatric emergency. However, it is not ideal 
for long-term treatment of mental and behavioral health needs. Due to 
the fragmented nature of the mental health care infrastructure in the 
U.S., persistent lack of sufficient resources, and longstanding 
shortages of mental and behavioral health professionals, far too many 
Americans have limited options for the longer-term follow-up treatment 
they need and deserve. These challenges also contribute to the long ED 
wait times and aggravate ED boarding issues detailed above. In fact, ED 
boarding challenges disproportionately affect patients with behavioral 
health needs who wait on average three times longer than medical 
patients because of these significant gaps in our health care system.

    Improving coordination of care across the health care continuum 
must be one of the highest priorities for any mental health reform 
effort. The ED serves as the critical health care safety net not only 
for acute injuries, but for psychiatric emergencies as well. However, 
most EDs are not ideal facilities to provide longer-term care for 
patients experiencing a mental health crisis--they are often hectic, 
noisy, and particularly disruptive for behavioral health patients.

    Across the country, communities have adopted innovative alternative 
models to improve emergency psychiatric care and reduce psychiatric 
patient boarding. These include Behavioral Health Emergency Rooms 
(BHERs), separate areas of the ED that specialize in caring for 
patients experiencing a behavioral health crisis; Emergency Psychiatric 
Assessment Treatment and Healing (EmPath) Units, a separate, hospital-
based setting solely for psychiatric emergencies with the safe, 
calming, homelike environment of a community mental health crisis 
clinic but with the ED's ability to care for any patient presenting for 
treatment; and Psychiatric Emergency Service (PES) models, a ``hub-and-
spoke'' model with a dedicated psychiatric ED serving as a central hub 
with bidirectional spokes going out to a wide variety of mental, 
behavioral, and physical care, as well as social services.

          Behavioral Health Emergency Rooms (BHERs). BHERs are 
        separate areas of the ED that specialize in proactive rapid-
        assessment, stabilization, and treatment of patients in 
        experiencing a behavioral health crisis. Care is delivered via 
        a multidisciplinary team of emergency physicians, 
        psychiatrists, psychiatric nurses, and social workers. This 
        service is operational 24 hours a day, 7 days a week, 365 days 
        a year. These dedicated spaces provide patients with a safer, 
        private, and more peaceful setting in which to deescalate and 
        receive specialized care.

          By initiating proactive assessments in a BHER, 40-50 percent 
        of patients can be safely discharged home, reducing ED boarding 
        time. Additionally, optimizing transition of care through 
        Integrated Outpatient Care clinics ensures ongoing high-quality 
        medical and behavioral health care follow-up with convenient 
        and comprehensive treatment options for patients.

          EmPath (Emergency Psychiatric Assessment Treatment 
        and Healing) Units. The EmPath unit is a separate, hospital-
        based setting solely for psychiatric emergencies with the safe, 
        calming, homelike environment of a community mental health 
        crisis clinic with the ED's ability to take care of any patient 
        who presents for treatment. This unit accepts all suitable 
        patients regardless of the severity of their illness, legal 
        status, dangerousness, substance use intoxication or 
        withdrawal, or co-morbid medical problems, as these patients 
        are typically excluded from community programs and thus would 
        likely experience boarding in an ED in the traditional medical 
        system.

          EmPath units provide immediate access to individualized care 
        from a comprehensive mental health care team of psychiatrists, 
        psychologists, mental health nurses, social workers, and other 
        licensed mental health care professionals. This team partners 
        directly with patients and their families to address the 
        immediate mental crisis and to develop a longer-term care plan 
        through appropriate follow-up services. In some instances, 
        EmPath Units have reduced regional ED boarding by 80 percent, 
        and have also reduced the need for--and incidence of--coercive 
        measures (such as physical restraints), episodes of agitation, 
        and psychiatric hospitalization.

          Psychiatric Emergency Service (PES). The PES model is 
        a multipronged approach for emergency psychiatric patients 
        treated in the ED based on increased availability of 
        psychiatrists and dedicated case managers who focus on 
        psychiatric patients. This model is referred to as a ``hub-and-
        spoke'' model with a dedicated psychiatric ED serving as a 
        central hub with bidirectional spokes going out to a wide 
        variety of mental, behavioral, and physical care, as well as 
        social services. Recognizing that psychiatric patients have 
        vastly different needs and circumstances affecting their 
        overall health, this model helps address the patient's 
        immediate mental health needs and swiftly directs them to the 
        most appropriate follow-up services, which helps alleviate the 
        overall load on the mental health care system. These two-way 
        spokes may also serve to reconnect patients with the 
        psychiatric ED should they require acute stabilization while 
        receiving follow-up services, potentially avoiding an inpatient 
        hospitalization and ensuring the patient receives the most 
        appropriate care and treatment throughout the mental health 
        care continuum.

    These innovative approaches have helped communities improve 
coordination of emergency psychiatric care and they can serve as models 
for other communities to implement and build upon. However, what is 
clear from experience is that the ultimate success of any model hinges 
on the availability of resources, whether monetary, staffing, or access 
to follow-up services and patient access to long-term mental and 
behavioral health care. One of the persistent challenges in emergency 
medicine is that ``one emergency department is one emergency 
department''--i.e., the needs of each community and the resources 
available to local EDs, hospitals, and other facilities vary widely, 
and a model that is successful in one community may not be the best fit 
for another community.

    For example, in 2017, Oregon implemented a dedicated psychiatric ED 
model in Portland based closely on the Alameda Model (California), but 
the transition has been marked by challenges for both the dedicated 
psychiatric ED and surrounding facilities. The dedicated psychiatric ED 
that was intended to reduce the burden on individual EDs is frequently 
at capacity or overcrowded, but emergency physicians at other 
facilities have noted that they are still seeing the same number of 
acute psychiatric patients in their own EDs. Additionally, the 
dedicated psychiatric ED has struggled to transfer patients to long-
term follow-up treatment at Oregon State Hospital, contributing to long 
wait times, crowding, and poor outcomes for patients. Despite these 
challenges, stakeholders have been working to address the shortcomings 
of the system and adapt the model to better meet the needs of the 
Portland community, but the experience has highlighted that new care 
models are not necessarily ``plug-and-play'' and do not guarantee 
immediate results.

    To ensure that communities can implement models that best fit their 
needs, ACEP supports the bipartisan ``Improving Mental Health Access 
from the Emergency Department Act'' (S. 1346), led by Senators Shelley 
Moore Capito (R-WV) and Maggie Hassan (D-NH). This legislation would 
provide critical funding to help communities implement and expand 
programs to expedite transition to post-emergency care through expanded 
coordination with regional service providers, assessment, peer 
navigators, bed availability tracking and management, transfer protocol 
development, networking infrastructure development, and transportation 
services; increase the supply of inpatient psychiatric beds and 
alternative care settings; and, expand approaches to providing 
psychiatric care in the ED, including telepsychiatry, peak period 
crisis clinics, or dedicated psychiatric emergency service units. 
During the 117th Congress, this legislation (H.R. 1205) was passed by 
the House of Representatives in a voice vote but was not considered by 
the Senate. We urge Congress to consider and pass this important 
legislation.

    Another longstanding barrier to providing adequate mental health 
treatment services is the Medicaid Institutions for Mental Disease 
(IMD) exclusion that prohibits the Federal Government from providing 
Medicaid reimbursement to states for care provided to most patients in 
an inpatient psychiatric or SUD facility with more than 16 beds. Though 
this longstanding policy was intended to reduce the number of people 
committed to long-term psychiatric treatment facilities without 
receiving appropriate care, it has perpetuated the problem of disparate 
treatment of mental health and has stood as a major barrier in the 
effort to provide necessary non-hospital inpatient psychiatric care 
options.

    As a limited workaround, states have been able to apply for Section 
1115 Medicaid waivers to receive matching Federal funds for short-term 
residential treatment services in an IMD. Congress also recently took 
steps to address some of the challenges posed by the IMD exclusion in 
the Substance Use-Disorder Prevention that Promotes Opioid Recovery and 
Treatment for Patients and Communities (SUPPORT) Act (P.L. 115-271), 
creating a limited new exception to allow states to provide Medicaid 
coverage for beneficiaries with at least one SUD in certain IMDs.

    The IMD exclusion may also threaten the ability of communities to 
provide a continuum of crisis stabilization services that includes call 
centers, mobile crisis units, and crisis stabilization programs. Crisis 
stabilization programs are a resource distinct from traditional 
residential treatment facilities for mental health and SUD treatment. 
These provide individuals with additional immediate-access treatment 
options, helping them avoid settings detrimental to their condition 
such as jails, homeless shelters, or the streets. Unfortunately, the 
IMD exclusion was established before crisis stabilization beds were 
developed, and the 16-bed limitation for facilities severely restricts 
the ability of these services to meet the needs of communities with 
vulnerable Medicaid populations and high demand for such services. We 
agree with legislators' bipartisan efforts urging CMS to ensure 
Medicaid reimbursement for crisis stabilization beds and to ensure 
these programs are not adversely affected by the IMD exclusion.

    ACEP has long advocated for full repeal of the IMD exclusion and 
strongly urges Congress to rescind this harmful policy either as a 
standalone effort or as a cornerstone of any comprehensive mental 
health reform legislation.
      Ensuring Parity Between Behavioral and Physical Health Care
    Limited access to appropriate coverage, narrow provider networks, 
lack of Federal enforcement mechanisms for parity law violations, and 
low reimbursement for mental health services remain barriers to 
achieving parity between mental and physical health care.

    In recent years, Congress has taken important steps to improve 
parity between mental and physical health care by requiring insurers to 
provide the same level of coverage for mental health and substance use 
disorder treatment as they do for physical care. But despite Federal 
law, there is no mechanism for the Federal Government to enforce 
compliance against plans that continue to violate parity requirements 
and discriminate against patients with mental health conditions or SUD. 
ACEP supports providing the Department of Labor (DOL) with the ability 
to issue civil monetary penalties (CMPs) for violations of the ``Mental 
Health Parity and Addiction Equity Act'' (MHPAEA; P.L. 110-343) by 
group health plan sponsors, plan administrators, or issuers. ACEP 
supports legislative efforts to give the DOL the authority to issue 
CMPs.

    Without enforcement penalties and more explicit parity 
requirements, we will continue to see insurers attempting to find their 
way around the law and limit the coverage available to beneficiaries 
experiencing mental health crisis. As a recent example, Optum in 
Maryland issued a policy several years ago establishing that only 
certain provider types (specialty mental health providers) are eligible 
to bill when the only diagnosis is a psychiatric issue, including 
homicidal ideation and suicidal ideation, precluding payment for an ED 
physician's evaluation and management services. This policy ignores the 
significant challenges emergency physicians are experiencing in seeing 
and treating mental health needs in the ED and has disproportionate 
impacts on hospitals with high Medicaid populations. Though Optum 
ultimately issued an updated provider alert that resolved this matter, 
it was not without significant confusion and substantial delays that 
affected patient care.

    We also believe this is yet another example of insurers attempting 
to disregard the Prudent Layperson Standard (PLP), a longstanding and 
critical policy that protects patients from retroactive denials of 
insurance coverage for emergency department visits that are ultimately 
determined to be non-emergent. Patients who believe they are 
experiencing a medical emergency should not be discouraged from seeking 
treatment out of fear that their ED visit will not be covered by their 
insurer.

    Ensuring parity for behavioral health care also requires 
appropriate treatment of substance use and opioid use disorders (SUD/
OUD). Individuals with SUD/OUD often seek care in the emergency 
department, and one of the most effective means emergency physicians 
have to aid these patients is by using buprenorphine as part of a 
medications for opioid use disorder (MOUD) protocol. As one of three 
drugs approved by the U.S. Food & Drug Administration (FDA) for the 
treatment of opioid dependence, buprenorphine is a very safe and 
efficacious medication. Strong enough to reduce withdrawal symptoms and 
cravings but not enough to cause euphoria, it can allow individuals 
with OUD to more effectively engage in treatment as they pursue 
recovery. But despite the passage of the MAT Act and subsequent removal 
of the X-waiver, significant barriers to the use of buprenorphine 
persist, including limited access to the treatment due to Drug 
Enforcement Administration (DEA) set quantity limits, which flag 
pharmacy and hospital purchases of these required SUD/OUD treatments as 
suspicious orders. In fact, both prescribers and patients across the 
Nation are still experiencing difficulty in obtaining buprenorphine 
prescriptions. According to a recent study that surveyed more than 
5,000 pharmacies, less than half stocked buprenorphine. \1\ 
Additionally, a separate survey found that one-fifth of pharmacies were 
not willing to fill buprenorphine prescriptions. \2\ A survey of 
addiction treatment providers also revealed that 84 percent of their 
patients experienced a delay in accessing their buprenorphine, which 
can be life-threatening for those undergoing treatment for opioid use 
disorder. \3\ We urge Congress to ensure that health insurance plans 
appropriately cover SUD/OUD treatments, and further to ensure that 
patients are not are not hindered by unnecessary Federal barriers on 
their path to recovery through arbitrary limitations on the medications 
they need.
---------------------------------------------------------------------------
    \1\  Hill, L. G., Loera, L. J., Torrez, S. B., Puzantian, T., Evoy, 
K. E., Ventricelli, D. J., Eukel, H. N., Peckham, A. M., Chen, C., 
Ganetsky, V. S., Yeung, M. S., Zagorski, C. M., & Reveles, K. R. 
(2022). Availability of buprenorphine/naloxone films and naloxone nasal 
spray in community pharmacies in 11 U.S. states. Drug and alcohol 
dependence, 237, 109518. https://doi.org/10.1016/
j.drugalcdep.2022.109518
    \2\  Kazerouni, N. J., Irwin, A. N., Levander, X. A., Geddes, J., 
Johnston, K., Gostanian, C. J., Mayfield, B. S., Montgomery, B. T., 
Graalum, D. C., &; Hartung, D. M. (2021). Pharmacy-related 
buprenorphine access barriers: An audit of pharmacies in counties with 
a high opioid overdose burden. Drug and Alcohol Dependence, 224. 
https://doi.org/10.1016/j.drugalcdep.2021.108729
    \3\  American Society of Addiction Medicine. (2022).Reducing 
Barriers to Lifesaving Treatment: Report on the Findings from ASAM's 
Pharmacy Access Survey. https://
sitefinitystorage.blob.core.windows.net/sitefinity-production-blobs/
docs/default-source/advocacy/reports/asam-pharmacy-access-survey-
report-final 11.7.22.pdf'sfvrsn=6da97680--3
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   Improving Access to Behavioral Health Care for Children and Young 
                                 People
    The full effects of the COVID-19 pandemic are not limited to the 
staggering toll on American lives or the long-term physical health 
challenges from which many recovering patients still suffer. We are 
still collectively struggling to comprehend the true scope of the 
pandemic's impact on the mental health and well-being of millions of 
Americans, particularly on children and younger Americans.

    As the recent U.S. Department of Education report, ``Supporting 
Child and Student Social, Emotional, Behavioral, and Mental Health 
Needs'' notes, children have experienced isolation, bereavement, 
depression, worry, and other issues throughout the pandemic, leading to 
reports of anxiety, mood, and eating disorders, as well as increased 
self-harm behavior and suicidal ideation at nearly twice the rate of 
adults. Pediatric ED visits related to mental health significantly 
increased during the pandemic--a 24 percent increase for children 5-11 
years of age, and 31 percent for children 12-17. These stressors affect 
children's development and ability to learn in both the immediate and 
long-term with lasting consequences should their mental health needs 
not be adequately addressed.

    Adding to these long-term considerations are the mental health 
stresses associated with the loss of a caregiver. According to a recent 
pre-publication study in the October 2021 issue of the American Academy 
of Pediatrics journal, Pediatrics, more than 140,000 U.S. children 
under the age of 18 lost a primary or secondary caregiver due to COVID-
19 between April 1, 2020 and June 30, 2021. \4\ The consequences of the 
pandemic's disproportionate impact on racial and ethnic minorities, 
exacerbated by longstanding systemic inequalities, manifest here as 
well given that children of racial and ethnic minorities account for 65 
percent of children who lost a primary caregiver (compared to 39 
percent of the total population). The authors note the significant 
long-term impacts that orphanhood and caregiver loss have on the health 
and well-being of children, ranging from mental health problems and 
increased risks of suicide violence, sexual abuse, and exploitation, to 
disruptions in family circumstances such as housing instability and 
lack of nurturing support. Especially given the Committee's 
considerable attention to gaps in equity and longstanding disparities 
in health care, we urge you to examine the far-reaching effects of 
pandemic on historically underserved populations and we stand ready to 
work with you to provide the perspective and experience of emergency 
physicians to help develop effective and durable policy solutions.
---------------------------------------------------------------------------
    \4\  COVID-19-Associated Orphanhood and Caregiver Death in the 
United States (aappublications.org)

    Our health care system is not currently well-equipped to address 
the long-term effects of the significant trauma so many young Americans 
have experienced over the course of the last year. Given the 
substantial strains on the health care and social safety nets that 
existed long before the pandemic hit, it is clear that EDs, child 
welfare systems, the child and adolescent mental health workforce, and 
other related services will need considerable investments and 
significantly expanded resources in order to appropriately address this 
unprecedented challenge. As policymakers and stakeholders evaluate 
suggestions to improve mental and behavioral health access, these 
proposals and any new treatment models must be considered through the 
lens of pediatric care in order to prioritize the most vulnerable of 
---------------------------------------------------------------------------
the vulnerable.

    Once again, thank you for the opportunity to provide our comments 
and suggestions on how to improve access to mental health and substance 
use disorder care for our patients and their families. We look forward 
to working with you on these important efforts. Should you have any 
questions or require any further information, please do not hesitate to 
contact Ryan McBride, ACEP's Congressional Affairs Director, at 
[email protected].

            Sincerely,
                                       Christopher S. Kang,
                                                       M.D., FACEP,
                                                    ACEP President.
                                 ______
                                 
       American Therapeutic Recreation Association,
                                                      May 17, 2023.
Senator Ed Markey, Chairman,
Senator Roger Marshall, Ranking Member,
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Primary Health and Retirement Security,
428 Dirksen Senate Office Building,
Washington, DC. 20510.

    Dear Chairman Markey and Ranking Member Marshall:

    On behalf of the American Therapeutic Recreation Association 
(ATRA), we appreciate the opportunity to submit this testimony for the 
record regarding the Committee's hearing on A Crisis in Mental Health 
and Substance Use Disorder Care: Closing Gaps in Access by Bringing 
Care and Prevention to Communities. As providers that comprise a part 
of the mental healthcare workforce with a particular focus on community 
response, we look forward to working with you to develop solutions to 
address America's mental health and substance use crisis.

    ATRA is committed to advancing access to recreational therapy and 
ensuring that individuals are able to receive care that suits their 
interests and needs and supports the development of functional skills 
for daily living and stress release. ATRA is the largest professional 
association representing recreational therapy. Recreational therapists 
are nationally certified, and where applicable, state-licensed to 
provide evidence-based treatment services for individuals with a range 
of disabling conditions across the lifespan. Recreational therapy is 
active treatment, medically necessary, and can be prescribed by a 
physician as part of a client's plan of care. \1\
---------------------------------------------------------------------------
    \1\  Kemeny B, Fawber H, Finegan J, Marcinko D. Recreational 
therapy: Implications for life care planning. J life care Plan. 
2020;18(4):35-58.

    ATRA has watched with interest and concern as new data has 
highlighted the mental health crisis that America is currently 
experiencing. As recreational therapists, we are trained to use a 
variety of interventions to help clients address mental health 
challenges, as well as other areas like physical health and emotional/
social well-being. Therefore, we recognize the critical need to ensure 
that resources are in place to address this mental health emergency to 
ensure that people are able to successfully manage the stress and 
---------------------------------------------------------------------------
anxiety of everyday life.

    In mental health care, recreational therapists support clients with 
cognitive, social, leisure, and physical interventions, as well as 
stress management techniques, to improve a client's overall health. 
Recreation therapy (RT) for mental health incorporates activities 
including music, sports, dance, art, and outdoor activities to help a 
client find strategies that work for them to manage stress and ensure 
they have a healthy outcome for managing their mental health. RT also 
uses meaningful engagement in life activities or leisure as a means to 
increase coping and therefore reduce depression and anxiety. This type 
of therapy can be particularly helpful and attractive to individuals, 
including adolescents, as an alternative, non-pharmacological outlet.

    RT's focus their work on community engagement and specifically work 
with individuals in their communities and homes to provide 
opportunities to participate in life activities including leisure, 
recreation, and play. The primary purpose of recreational therapy is to 
establish and maintain tools and skills to be successful in their 
community and home environment.
          The Important Role that Recreational Therapists Play
    Recreational Therapy (RT) embraces a definition of ``health'' which 
includes not only the absence of ``illness,'' but extends to the 
enhancement of physical, cognitive, emotional, social, and leisure 
development so individuals may participate fully and independently in 
chosen life pursuits. Recreational therapists address assessed client 
needs related to behavior, cognition, function, pain management, 
physical activity level, socialization, recreation, and leisure. \2\ 
Recreational therapists have the competencies to assess and implement 
interventions necessary to promote improved mental health, quality of 
life, and prevent secondary conditions \3\, \4\ by reducing depression, 
stress, and anxiety in their clients and helping build confidence to 
socialize in their community. Recreational therapists work in a variety 
of settings that promote youth and adolescent mental health including 
community mental health centers, public and alternative schools, co-
occurring disorder programs, day hospitals for outpatient treatment, 
inpatient psychiatric hospitals, inclusive recreation programs, 
residential living facilities, nature-based recreation programs, and 
addiction recovery centers.
---------------------------------------------------------------------------
    \2\  Commission on Accreditation of Rehabilitation Facilities. 2020 
Medical Rehabilitation Standards Manual. 2020.
    \3\  Hawkins B, Kemeny B, Porter H. Recreational therapy 
competencies, Part 2: Findings from the ATRA competencies study. Ther 
Recreation J. 2020;54(4). doi:10.18666/trj-2020-v54-i4-10238
    \4\  Kinney J. Analysis of services performed by recreational 
therapists. Ther Recreation J. 2020;54(3):227-243. doi:10.18666/trj-
2020-v54-i3-10248

    In the United States, recreational therapists at a minimum must 
have a bachelor's degree in recreational therapy or a related field. 
\5\ Anatomy and physiology, assessment, salient characteristics of 
illness and disabilities, medical terminology, the therapeutic process, 
and 560 hours of fieldwork are required courses. \6\ The Certified 
Therapeutic Recreation Specialist (CTRS) is the required certification 
for recreational therapists by NCTRC and shows that the recreational 
therapist has passed an all-encompassing national certification exam 
demonstrating extensive knowledge and skill-based training in core 
therapy skills (assessment, planning, implementation, documentation, 
and evaluation), a team-oriented approach to care delivery, and 
training in group processes.5 The CTRS credential is required for 
practice as a recreational therapist in Veterans Affairs \7\ and 
designated as the accepted certification for recreational therapists by 
the Centers for Medicare and Medicaid Services Federal guidelines for 
skilled nursing facilities. Ethical conduct is mandated by the 
professional organization, the American Therapeutic Recreation 
Association (ATRA)'s code of ethics, and quality indicators of RT 
practice are supported by the ATRA Standards of Practice.
---------------------------------------------------------------------------
    \5\  National Council for Therapeutic Recreation Certification. The 
CTRS is the qualified provider of Recreational Therapy Services. 2020.
    \6\  Bureau of Labor Statistics U.S. Department of Labor. 
Occupational Outlook Handbook, Recreational Therapists. 2020.
    \7\  U.S. Department of Veterans Affairs. VA Handbook 5005, Part 
II, Appendix G60. The Recreation and Creative Arts Therapist.

    Research has shown the effectiveness of recreational therapy 
services for mental health outcomes. Through recreational therapy 
interventions, youth with mental health challenges saw increases in 
health-related quality of life \8\, positive changes in their perceived 
self-esteem \9\, and decreases in feelings of social isolation and 
loneliness. \10\ Through outdoor adventure interventions, recreational 
therapists also helped some young people with substance abuse disorder 
and post-traumatic stress disorder to learn effective strategies for 
their personal recovery. \11\
---------------------------------------------------------------------------
    \8\  Bennett JR, Negley SK, Wells MS, Connolly P. Addressing well-
being in early and middle childhood: recreation therapy interventions 
aimed to develop skills that create a healthy life. Spec Issue 
Strengths-based Pract--Part 1. 2016;50(1):unpaginated. http://
js.sagamorepub.com/trj/article/view/6782.
    \9\  Concepcion H. Video game therapy as an intervention for 
children With disabilities. Ther Recreation J. 2017;(3):221-228.
    \10\  Luchies LB, Barbour AL, Anderson SR. Children's Healing 
Center involvement reduces social isolation and loneliness among 
immunocompromised children and their family members. Am J Recreat Ther. 
2019;18(3):37-47.
    \11\  Leighton J, Lopez KJ, Johnson CW. `` There is Always Progress 
to Be Made'': Reflective Narratives on Outdoor Therapeutic Recreation 
for Mental Health Support. Ther Recreation J. 2021;55(2):185-203.

    To better explain the role of RT, we have provided some examples of 
recreational therapy services specific to adolescents with mental 
---------------------------------------------------------------------------
health conditions:

          A recreational therapist in Virginia works at a 
        residential treatment center for adolescents with mental health 
        diagnoses. Utilizing stress management interventions like 
        guided imagery, progressive muscle relaxation, Tai Chi, and 
        yoga, recreational therapy services help adolescents reach 
        goals like decreasing symptoms of depression and anxiety while 
        increasing self-confidence and personal grounding.

          Another recreational therapist works in a school in 
        New Mexico with high school students with intellectual and 
        developmental disabilities (IDD) who are experiencing increased 
        anxiety during COVID-19. Recreational therapy services help the 
        students cope with feelings of fear, worry, and hopelessness 
        through after-school, group therapy sessions for teaching 
        emotional identification, coping skills, and adjustment 
        strategies to navigate their ever-changing daily schedules.

          Last, a recreation therapist in Colorado utilizes 
        nature-based, adventure therapy interventions for adolescents 
        with mental health diagnoses. Goals of improving adolescents' 
        self-confidence, problem-solving skills, and sense of community 
        are achieved through outcomes-based, recreational therapy 
        modalities that include kayaking, rock climbing, high and low 
        ropes courses, and wilderness hiking.
                               Conclusion
    ATRA is supportive of Congress' work to address the mental health 
crisis and appreciates the opportunity to provide written testimony. As 
Congress continues to consider legislative opportunities to address the 
mental health crisis, we ask that recreational therapists be included 
in any legislative language to support efforts to reduce stress, 
anxiety, and depression among youth, adolescents and adults. We welcome 
the opportunity to speak with you more about what RT is, and how it can 
help in responding to the mental health emergency. Please do not 
hesitate to contact the American Therapeutic Recreation Association 
(ATRA) directly Brent Wolfe, ATRA Executive Director, at brent@atra-
online.com.

            Sincerely,
                                               Brent Wolfe,
                                                 on behalf of ATRA.
                                 ______
                                 
                   Children's Hospital Association,
                                                      May 17, 2023.
Senator Ed Markey, Chairman,
Senator Roger Marshall, Ranking Member,
U.S. Senate Committee on Health, Education, Labor, and Pensions,
Subcommittee on Primary Health and Retirement Security,
428 Dirksen Senate Office Building,
Washington, DC. 20510.

    Dear Chairman Markey and Ranking Member Marshall:

    On behalf of the nation's children's hospitals and the children and 
families we serve, thank you for holding this hearing, ``A Crisis in 
Mental Health and Substance Abuse Disorder Care: Closing Gaps in Access 
by Bringing Care and Prevention to Communities.'' We appreciate your 
leadership on this issue and look forward to working together to ensure 
that Federal programs are tailored to meet the unique needs of 
children, adolescents and the pediatric provider community proudly 
committed to serving them. We appreciate the work Congress has done to 
date to address the national children's mental health crisis; however, 
more Federal support and attention is urgently needed to meaningfully 
impact the troubling trajectory for our Nation's children.

    Children's Hospital Association represents more than 220 children's 
hospitals nationwide, dedicated to the health and well-being of our 
Nation's children through innovations in the quality, cost, and 
delivery of care. Children's hospitals serve as a vital safety net for 
all children across the country regardless of insurance status, 
including those that are uninsured, underinsured and enrolled in 
Medicaid, the single largest payer of mental health services for 
children. As essential providers dedicated to providing the highest 
quality pediatric care, children's hospitals look forward to working 
with you to address the crisis in mental health facing America's 
children.

    Prior to the pandemic, trends in child and adolescent mental health 
were worrying, as mental health symptoms increased among children, and 
many did not receive needed care. The stressors of the pandemic on 
families and children have worsened these trends significantly. 
Concerning evidence of the crisis:

          1 in 5 children and adolescents experience a mental 
        health condition in a given year. \1\
---------------------------------------------------------------------------
    \1\  ``What is Children's Mental Health?,'' Centers for Disease 
Control and Prevention, April 2019

          In 2021, 29 percent of teens reported experiencing 
        poor mental health, while 4 in 10 reported feeling persistent 
        sadness or hopelessness. Teen girls were twice as likely (57 
        percent) to report persistent sadness. \2\
---------------------------------------------------------------------------
    \2\  ``Youth Risk Behavior Survey Data Summary & Trends Report,'' 
Centers for Disease Control and Prevention, February 2023.

          1 in 5 high school students contemplated suicide and 
        1 in 10 attempted suicide one or more times. \3\
---------------------------------------------------------------------------
    \3\  ``Youth Risk Behavior Survey Data Summary & Trends Report,'' 
Centers for Disease Control and Prevention, February 2023.

          Suicide is the second leading cause of death for 
        youth and young adults between the ages of 10 and 24. \4\
---------------------------------------------------------------------------
    \4\  ``Facts about Suicide,'' Centers for Disease Control and 
Prevention

    An increased demand for mental health services across the continuum 
of care for children, but particularly for children in crisis, has 
stressed already inadequate and under-resourced systems, leaving far 
too many children waiting for needed mental and behavioral health care, 
frequently ``boarding'' in emergency departments until an appropriate 
placement becomes available. As compared to pre-pandemic, 84 percent of 
hospitals report boarding more children and youth and 75 percent report 
longer boarding stays. \5\ As we emerge from the public health 
emergency, the troubling trends continue with large numbers of children 
and youth languishing in hospital emergency departments waiting for 
access to needed care.
---------------------------------------------------------------------------
    \5\  Leyenaar J, Freyleue S, Bordonga A, et al., ``Frequency and 
Duration of Boarding for Pediatric Mental Health Conditions at Acute 
Care Hospitals in the US,'' JAMA: Vol 326, No. 22, 2021.

    This crisis in boarding is also reflection of inadequacies within 
our Nation's pediatric mental health system, which is fragmented and 
insufficiently supported, too often resulting in delayed care. For many 
children, their mental health conditions can be managed with less 
intensive treatment, such as outpatient therapy and medication 
management through primary care, yet children's mental health 
conditions often go unidentified and untreated. Nearly 60 percent of 
children and youth with major depression are not receiving care and it 
is common for several years to pass between when symptoms first appear 
and treatment begins. \6\ To prevent the children's mental health 
crisis from continuing we need to do a better job of providing access 
to needed services across the continuum of care, beginning as early as 
possible and ideally before children reach a point of crisis.
---------------------------------------------------------------------------
    \6\  ``The State of Mental Health In America,'' Mental Health 
America, 2023.

    As you consider changes to existing programs and contemplate new 
initiatives, it is critical to examine how these changes affect the 
pediatric population. The importance of investing in services and 
supports that promote timely access to necessary pediatric mental 
health care cannot be overstated. Current Federal programs are 
essential and yet remain insufficient to meet the severity of this 
compounding national crisis in children's mental health. We look 
forward to partnering with you as you work to implement programmatic 
improvements and address the continued mental, emotional, and 
---------------------------------------------------------------------------
behavioral health needs of children across the country.

    As the Senate HELP Committee moves forward, we urge you to 
prioritize:

          Creating new programs and investments meeting the 
        needs of children and youth.

          Refining existing programs and increasing support to 
        ensure that they are intentionally designed to meet the unique 
        needs of children and adolescents and ensure access to services 
        as early as possible.

          Increasing and targeting investments to support the 
        recruitment, training, retention, and professional development 
        of a diverse clinical and non-clinical pediatric workforce.

      New Tailored Investments to Meaningfully Address the Crisis
    Within HHS, there are several programs that focus on mental health 
broadly and some that focus on children specifically. These are 
important programs that play a role in meeting children's needs, but 
more is desperately needed. There are a number of programs that aim to 
improve children's access to evidence-based treatment for mental health 
conditions, yet they do not go far enough to address the widespread and 
unmet needs of children. Both the creation of new initiatives and 
enhancements to existing programs will be needed to adequately address 
the growing crisis in child and adolescent mental health.

    At the core of a strong pediatric mental health care delivery 
system is a strong, interconnected network of pediatric health 
providers and supportive services that are available to deliver high-
quality, developmentally appropriate mental and behavioral health care. 
Building a strong system of care starts with ensuring that children are 
able to access services in the settings where they are such as: early 
learning and childcare settings, schools, their pediatrician's office, 
community settings and emergency departments. A truly comprehensive 
approach must include the full continuum of clinical and non-clinical 
health services and supports that encompass promotion and prevention, 
early intervention and treatment. In too many communities, there are 
few local options for children in need of mental health treatment and 
investment is urgently needed to scale up services and support for the 
pediatric population.

    Given the workforce shortages within pediatric mental health 
professions, the importance of innovative approaches to utilizing our 
current workforce, such as through integrated care, and support for 
enhanced care coordination are paramount. When children's and 
adolescents' mental health needs are significant enough to require 
services outside of schools and community-based outpatient settings, it 
is critical that they are delivered in appropriate settings designed 
for them and staffed by professionals with pediatric expertise. 
Children's hospitals have seen a growing demand for inpatient 
psychiatric care, as well as step down levels of care including partial 
hospitalization, day hospitals and intensive outpatient services. 
Unfortunately, there are too few of these services designed 
specifically for children, adolescents, and young adults, which results 
in significant delays in care and contributes to mental health 
boarding.

    While investing in upstream mental health promotion, prevention, 
early identification and intervention for children is critical, 
including to prevent conditions from worsening to the point of crisis, 
we also need to ensure that there are appropriate treatment options 
across the full continuum of care for children and adolescents who need 
them. We urge Congress to provide resources to support efforts to scale 
up inpatient care capacity, including costs associated with the 
conversion of general beds to accommodate mental health patients, as 
well as to support the development of intermediate levels of care such 
as partial hospitalization, day programs, intensive outpatient services 
and crisis response and stabilization services which are designed to 
support families and divert children from emergency departments.

    To better support the continuum of care, we strongly support 
legislation introduced last year by Sens. Casey and Cassidy entitled, 
Health Care Capacity for Pediatric Mental Health Act of 2022. The bill 
focused on children and would improve access to community-based 
services and supports, support training to enhance the workforce and 
invest in mental health infrastructure. Similar bipartisan legislation 
has been introduced in the House this year, H.R. 2412, the Helping 
Children Cope Act, which would provide grants to children's hospitals 
and other providers to increase their capacity to provide pediatric 
mental health services such as those described above. We would like to 
see policies like these enacted this year to address the serious gaps 
children and youth experience when attempting to access mental health 
services. We understand it is challenging to create new programs and 
dedicate spending but the level of the crisis and longstanding impacts 
for children and families and our Nation warrant the new dedicated 
investments.
    Refining Existing Programs to Better Work for Children and Youth
    The Community Mental Health Services Block Grant. The Community 
Mental Health Services Block Grant, frequently called the Mental Health 
Block Grant, supports state mental health agencies to provide 
comprehensive community mental health services and investments in 
evidence-based prevention for adults with severe mental illness or 
children with serious emotional disturbances (SED). The parameters of 
the funding as currently written focus on children with SED, making it 
difficult to spread funds to broader activities, such as evidence-based 
prevention efforts or mental health services for children whose needs 
do not reach the threshold of a serious emotional disturbance or have 
not yet been diagnosed. We strongly support a set-aside within this 
block grant for prevention and early intervention, to ensure that these 
Federal dollars can be used by states to expand early intervention and 
prevention services, especially with children and teens. A similar 
provision was included in the Mental Health Reform Reauthorization Act 
of 2022, led by Senators Cassidy and Murphy last Congress, and received 
bipartisan support.

    Support for Children's Mental Health Workforce. Congress must 
address the urgent need to relieve pressure on the existing pediatric 
mental health workforce, as well as invest in its long-term expansion 
across disciplines to meet the ongoing and growing mental health needs 
of our children. Pediatric mental health workforce shortages are 
persistent and projected to increase over time. Nationally, there are 
approximately 10,500 \7\ practicing child and adolescent psychiatrists 
and only 5.4 clinical child and adolescent psychologists per 100,000 
children 18 years of age and younger, far fewer than needed to meet the 
existing and increasing demand. \8\ Shortages also exist for other 
vital pediatric mental health specialties critical to improving early 
identification and intervention for children with mental health needs. 
Additionally, racial and ethnic minority providers are under-
represented across many mental health professions, which can be an 
added burden on racial and ethnic minority communities who already face 
inequitable access to care. More dedicated support for a larger and 
more diverse pediatric workforce is critical to addressing children's 
mental health needs now and into the future.
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    \7\  Workforce Maps by State (aacap.org), American Academy of Child 
and Adolescent Psychiatry.
    \8\  ``Supply of Child and Adolescent Behavioral Health 
Providers.'' University of Michigan Behavioral Health Workforce 
Research Center. July, 2020.

    Congress can take several immediate steps to address the current 
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and ongoing mental health workforce shortage.

    Loan forgiveness for pediatric mental health providers. Existing 
loan forgiveness programs can be difficult for pediatric specialty 
providers to access. We support robust funding for the Pediatric 
Subspecialty Loan Repayment Program, which would provide loan 
forgiveness for pediatric subspecialists, including mental health 
providers practicing in underserved areas. While we were glad to see 
the program received increased funding in fiscal year 2023, we strongly 
encourage a larger investment of at least $30 million, to support the 
pediatric subspecialty workforce and improve longstanding shortages. 
Additionally, we support S. 462, the Mental Health Professionals 
Workforce Shortage Loan Repayment Program Act, a bipartisan bill which 
would extend loan repayment to mental health providers across a wider 
array of mental health professional fields, who serve in areas with 
shortages of mental health professionals. We look forward to working 
with you to identify realistic and effective immediate solutions to 
support and retain a diverse national pediatric mental health 
workforce.

    Children's Hospitals Graduate Medical Education (CHGME) program. 
Pediatricians build strong relationships with families and can play a 
critical role in identifying children with mental and behavioral health 
needs earlier, before more serious issues emerge. The CHGME program 
supports the training of more than half of the nation's pediatric 
physician workforce and is essential to the continued access of 
children to needed pediatric specialists, including developmental 
pediatricians and child adolescent psychiatrists. However, CHGME 
represents only 2 percent of the total Federal spending on GME. These 
funding shortfalls must be financed by children's hospitals' child-
patient care operations and are a key contributor to the overall 
pediatric workforce shortage. We appreciated the fiscal year 2023 
funding level but would encourage Congress to consider a higher overall 
appropriations level for fiscal year 2024 to reduce the growing and 
unsustainable gap between other federally funded training programs and 
CHGME and a bipartisan reauthorization of the program this year 
supporting the existing goals to secure the future pediatric physician 
workforce.

    Project AWARE. SAMHSA's Project AWARE--Advancing Wellness and 
Resiliency in Education, supports partnerships between State Mental 
Health Agencies and State Educational Agencies to expand programs which 
improve mental wellness and mental health awareness in schools. The 
program provides funding to develop school-based mental health programs 
and training for school-based professionals. Given the increased need 
for early intervention services, and the effectiveness of the existing 
program we support the Mental Health Services for Students Act, led by 
Senator Tina Smith and Rep. Grace Napolitano in the 117th Congress. 
This legislation would provide competitive grants for local education 
agencies to bring in onsite mental health professionals, improving 
children's access to mental health services at schools across the 
country. School partnerships with local mental health providers, 
including children's hospitals, facilitate early identification and 
intervention to improve mental health outcomes for school-aged children 
and teens.

    Pediatric Mental Health Care Access Grants. The Pediatric Mental 
Health Care Access program is administered through HRSA with the goal 
of improving access to quality health care services through supporting 
the development of pediatric mental health care telehealth access 
programs or support existing programs. We were pleased to see the 
program reauthorized in the Bipartisan Safer Communities Act last year 
and we look forward to seeing how the program's expansion into more 
sites, including emergency departments and schools, progresses. 
Integrated care, including through telehealth consultation supported by 
this program, can improve identification of mental and behavioral 
health needs in children and streamline connections to care. While this 
program provides critical support to pediatricians, enabling them to 
treat some mental health conditions within primary care, we know that 
greater investment is needed in pediatric care integration. Integrating 
mental health with primary care, including through colocation of mental 
health providers, has been shown to substantially expand access to 
mental health professionals and increase children's utilization of 
behavioral health services.

    Thank you again for your commitment to improving the mental and 
behavioral health care delivery system for children and adults. 
Children's hospitals and their affiliated providers stand ready to 
partner with you as you continue your work. Children need your help 
now.

    With questions or for more information on Children's Hospital 
Association's mental health policy recommendations, please contact Vice 
President of Policy, Aimee Ossman, or Director of Federal Affairs, 
Cynthia Whitney.
                                 ______
                                 
    [Whereupon, at 11:17 a.m., the hearing was adjourned.]

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