[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
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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
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Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
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
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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
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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
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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.
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\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
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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\
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\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.
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\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\
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\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.
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\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\
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\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.
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\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.
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\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'').
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\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.
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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.
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\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.
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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.
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\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/.
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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\
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\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.
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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\
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\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\
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\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.
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\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).
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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\
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\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.
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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\
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\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.
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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.
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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\
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\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.
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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
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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\
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\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.
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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
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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\
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\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.
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\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
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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
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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.
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\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.
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\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\
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\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
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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\
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\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\
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\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.
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\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.]
[all]