[Senate Hearing 118-206]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-206

                    UNDERSTANDING A GROWING CRISIS:
                          SUBSTANCE USE TRENDS
                           AMONG OLDER ADULTS

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS


                             FIRST SESSION
                               __________

                             WASHINGTON, DC
                               __________

                           DECEMBER 14, 2023
                               __________

                           Serial No. 118-12

         Printed for the use of the Special Committee on Aging
         
         
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         


        Available via the World Wide Web: http://www.govinfo.gov
        
                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
54-498 PDF                WASHINGTON : 2024


                       SPECIAL COMMITTEE ON AGING

              ROBERT P. CASEY, JR., Pennsylvania, Chairman

KIRSTEN E. GILLIBRAND, New York      MIKE BRAUN, Indiana
RICHARD BLUMENTHAL, Connecticut      TIM SCOTT, South Carolina
ELIZABETH WARREN, Massachusetts      MARCO RUBIO, Florida
MARK KELLY, Arizona                  RICK SCOTT, Florida
RAPHAEL WARNOCK, Georgia             J.D. VANCE, Ohio
JOHN FETTERMAN, Pennsylvania         PETE RICKETTS, Nebraska
                              ----------                              
               Elizabeth Letter, Majority Staff Director
                Matthew Sommer, Minority Staff Director


                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Robert P. Casey, Jr., Chairman......     1
Opening Statement of Senator Mike Braun, Ranking Member..........     3

                           PANEL OF WITNESSES

Keith Humphreys, Ph.D., Esther Ting Memorial Professor, 
  Psychiatry and Behavioral Sciences, Stanford School of 
  Medicine, Stanford, California.................................     4
Hon. James W. Carroll, JD, Former Director, White House Office of 
  National Drug Control Policy, Partner, Frost Brown Todd, LLP, 
  Washington, D.C................................................     6
Deborah Steinberg, JD, Senior Health Policy Attorney, Legal 
  Action Center, Washington, D.C.................................     7
William Stauffer, LSW, Executive Director, Pennsylvania Recovery 
  Organization Alliance, Harrisburg, Pennsylvania................     9

                                APPENDIX
                      Prepared Witness Statements

Keith Humphreys, Ph.D., Esther Ting Memorial Professor, 
  Psychiatry and Behavioral Sciences, Stanford School of 
  Medicine, Stanford, California.................................    33
Hon. James W. Carroll, JD, Former Director, White House Office of 
  National Drug Control Policy, Partner, Frost Brown Todd, LLP, 
  Washington, D.C................................................    38
Deborah Steinberg, JD, Senior Health Policy Attorney, Legal 
  Action Center, Washington, D.C.................................    42
William Stauffer, LSW, Executive Director, Pennsylvania Recovery 
  Organization Alliance, Harrisburg, Pennsylvania................    51

                        Questions for the Record

Keith Humphreys, Ph.D., Esther Ting Memorial Professor, 
  Psychiatry and Behavioral Sciences, Stanford School of 
  Medicine, Stanford, California.................................    59
Hon. James W. Carroll, JD, Former Director, White House Office of 
  National Drug Control Policy, Partner, Frost Brown Todd, LLP, 
  Washington, D.C................................................    62
Deborah Steinberg, JD, Senior Health Policy Attorney, Legal 
  Action Center, Washington, D.C.................................    65
William Stauffer, LSW, Executive Director, Pennsylvania Recovery 
  Organization Alliance, Harrisburg, Pennsylvania................    68

                       Statements for the Record

Statement of Overdose Prevention Initiative......................    73
Statement of R Street Institute..................................    79
.................................................................
.................................................................

 
                    UNDERSTANDING A GROWING CRISIS:
                          SUBSTANCE USE TRENDS
                           AMONG OLDER ADULTS

                              ----------                              


                      Thursday, December 14, 2023

                                        U.S. Senate
                                 Special Committee on Aging
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:30 a.m., Room 
106, Dirksen Senate Office Building, Hon. Robert P. Casey, Jr., 
Chairman of the Committee, presiding.
    Present: Senator Casey, Gillibrand, Kelly, Braun, Rick 
Scott, Vance, and Ricketts.

                 OPENING STATEMENT OF SENATOR 
                 ROBERT P. CASEY, JR., CHAIRMAN

    The Chairman. The Senate Special Committee on Aging will 
come to order. Thanks to our witnesses for being here and 
welcome to the Committee's 11th hearing of the 118th Congress 
about substance use disorder in older adults. In the five-years 
since the Committee held a hearing on this topic, we witnessed 
significant policy changes, but also gaps in data and coverage 
still remain.
    Although substance use disorders tend to be lower among 
older adults compared to other age groups, older adults are not 
immune to these issues, and this is an evolving and growing 
crisis in America. Recently, the National Survey of Drug Use 
and Health reported that nearly four million older adults have 
a substance use disorder in 2022.
    Of that, 1.8 million of the four million had a drug use 
disorder and 2.3 million of the four million had an alcohol use 
disorder. Mortality from drug overdoses among people aged 65 
and older has more than tripled, tripled between the year 2000 
and 2020.
    Alcohol related mortality among this population has also 
increased over the past several decades, including by more than 
18 percent just between 2019 and 2020 alone. The number of 
older adults needing substance use disorder treatment, as I 
mentioned, has tripled.
    Also, one in four older adults experience mental health 
issues, which often co-occur with substance use disorders. Even 
with these data points, the knowledge base regarding older 
adults with substance use disorders is limited.
    There is less data, less research, and far fewer resources 
than for other populations. Older adults tend to be overlooked 
for substance use disorders in typical screenings and 
prevention efforts, even though they are more susceptible to 
developing substance use disorders than other age groups, and 
there are higher risks--there are--they are at higher risk, I 
should say, of undiagnosed and untreated substance use 
disorders because of this lack of screening. One of our 
witnesses today will tell us that the people, the problems, and 
the solutions remain largely invisible to our society.
    While strong strides have been made in recent years to 
expand coverage and access to substance use disorders treatment 
across payer systems, gaps still remain. Another one of our 
witnesses will highlight these gaps within the Medicare and 
Medicaid programs, and what we can do to ensure that older 
adults receive the treatment and recovery supports that they 
need. There are also several significant barriers to accessing 
treatment, even if it is available and even if it is covered.
    Stigma, stigma, strongly inhibits the ability to seek and 
receive care. Stigma about substance use disorders. Stigma from 
society about older adults. Stigma from family members, and 
stigma from medical providers themselves further confounds the 
ability of older adults to receive accurate and timely 
diagnoses and treatments for their substance use disorders.
    Another barrier is a lack of substance use disorder 
providers or treatment programs to serve the population 
generally, and even fewer who will serve older adults 
specifically. As we will hear today, the substance use disorder 
crisis affects different age groups, demographic groups, and 
regions of the country differently. We are seeing devastating 
rates of overdose deaths of young people due to the ongoing 
fentanyl crisis.
    For example, in my home State of Pennsylvania, we have seen 
overdose deaths linked to fentanyl in the Eastern and Western 
parts of the State, but also in rural counties and in urban 
counties as well.
    We need to do more to stop the flow of fentanyl into 
America and into our communities, so I am fighting to pass the 
Fend Off Fentanyl Act, which will crack down on the chemical 
suppliers in China and the Mexican cartels that produce and 
bring fentanyl across the border.
    A family's tragedy with regard to fentanyl often begins 
with the chemical companies in China, which ship these lethal 
substances, often referred to as precursor chemicals, to Mexico 
where cartels produce fentanyl and traffic it to the United 
States. This bill, the Fend Off Fentanyl legislation, will make 
sure that we get tougher on these criminal organizations, 
sanctioning them and cutting off their source of income.
    Substance use disorders in the fentanyl crisis are complex 
topics that will not be fixed in one single solution, nor will 
we be able to cover every single facet of these topics at this 
hearing.
    Today, we intend to shine a light on these issues to gain a 
more comprehensive understanding of substance use disorder 
among older adults, and we look forward to policy solutions 
that can address some of these issues.
    I look forward to hearing from our witnesses today. I will 
now turn to Ranking Member Braun for his opening statement.

                 OPENING STATEMENT OF SENATOR 
                   MIKE BRAUN, RANKING MEMBER

    Senator Braun. Thank you, Mr. Chairman. Today we are 
shining a light on older Americans who can easily be overlooked 
when it comes to substance use. Since the hearing in '18, a new 
threat has emerged, synthetics.
    The CDC has found a 53 percent increase in overdose deaths 
to synthetics like fentanyl among older Americans. It is a 
tragic statistic. One of our witnesses today, Dr. Humphreys, 
has research showing that overdose deaths among older Americans 
quadrupled over the last two decades, and synthetics like 
fentanyl are contributing in a big way.
    We have taken steps to support treatment services for older 
Americans struggling with addiction and opioids. On Tuesday 
this week, the HELP Committee marked up a bill I co-led with 
Senators Markey and Paul, the Modernizing Opioid Treatment 
Access Act.
    We are getting all kinds of attention to it through a 
variety of committees here, and it is about time. This bill 
will expand patients' access to methadone, a vital medication 
for treating opioid use disorder by scrapping outdated 
prescription rules. It will help individuals with opioid use 
disorder of all ages.
    In Indiana, Center Stone, a nonprofit treatment and service 
provider, is now finding synthetics are widespread among older 
Americans it serves. While these drugs don't kill older 
Americans at the same rate as younger ones, age isn't a shield 
against synthetics, and fentanyl seems to lead the pack. 
Synthetics are surging in counterfeit pills.
    Authorities have seized a record breaking 86 million 
fentanyl pills, 86 million in 2023. We need to sound the alarm 
about how synthetics like that known can poison older 
Americans' drugs. There are also many more grandparents raising 
their grandchildren because parents have died from synthetics 
overdoses.
    Fentanyl and other drugs have lowered Americans' life 
expectancy. They increasingly kill older Americans while 
limiting younger Americans' chances to grow old. We can't fight 
this crisis without reducing supply.
    That means countering China's chemical production of them 
and Mexican cartels distributing them. If we don't do that, we 
are going to be chasing our tail on this. It means finally 
getting serious about border security by stopping weak policies 
that invite chaos and turn every State into a border State.
    Last month, I joined the Indiana Sheriffs Association at 
the Southern border. I saw how easy it is for fentanyl to pour 
into our communities. The fact that we now are around 10,000 
illegal entries daily, something has got to give there because 
it is a crisis beyond just the humanitarian one and it is 
impacting every State.
    I have a new report, the silent epidemic, fentanyl and 
older Americans, that highlights this growing threat. You can 
get it on our website. I suggest all of you do. Look at it. It 
has got a lot more detail on what we are talking about.
    We got to reduce the supply of synthetic drugs, raise 
awareness among seniors, and improve data on synthetic drug use 
by seniors. I hope this hearing will raise awareness about the 
threat, reduce stigma, and rethink how and why older Americans 
are impacted by substance abuse. I yield back.
    The Chairman. Thank you, Ranking Member Braun. Now, we will 
turn to our witness introductions. I am pleased to introduce 
our first witness, Dr. Keith Humphreys, from Stanford, 
California.
    He is the Esther Ting Memorial Professor of Psychiatry and 
Behavioral Sciences at the Stanford School of Medicine. His 
research addresses addictive disorders and translation of 
science into public policy.
    Thank you, Dr. Humphreys, for being with us today and for 
sharing your expertise with the Committee. I will now turn to 
Ranking Member Braun to introduce our second witness.
    Senator Braun. My pleasure, Mr. Chairman, to introduce Jim 
Carroll. The Honorable James W. Carroll is a Former Director of 
the White House Office of National Drug Control Policy, also 
known as the Nation's drug czar. He focused on connecting 
people to treatment and countering the flow of illegal drugs. 
Thank you for being here today.
    The Chairman. Our third witness is Deborah Steinberg from 
Washington, D.C. Ms. Steinberg is senior health--is a Senior 
Health Policy Attorney at the Legal Action Center. She 
advocates for State and Federal policies to expand access to 
comprehensive and equitable substance use disorder and mental 
health care.
    Thank you, Ms. Steinberg, for being here with us and for 
sharing your expertise. Our fourth and final witness is Bill 
Stauffer. Bill is the Executive Director of the Pennsylvania 
Recovery Community Organizations Alliance. He has served in 
many capacities within the SUD treatment and service support 
system for well over three decades in Pennsylvania.
    He is an Adjunct Professor of Social Work at Misericordia 
University in Dallas, Pennsylvania, in the great Northeastern 
corner of our State. Thank you for sharing your expertise and 
for being with us today. We will start with our first witness, 
Dr. Humphreys.

              STATEMENT OF KEITH HUMPHREYS, PH.D.,

           ESTHER TING MEMORIAL PROFESSOR, PSYCHIATRY

               AND BEHAVIORAL SCIENCES, STANFORD

            SCHOOL OF MEDICINE, STANFORD, CALIFORNIA

    Dr. Humphreys. Chairman Casey, Ranking Member Braun, and 
your distinguished colleagues, thank you for the opportunity to 
speak with you today. My comments are informed by my 35 years 
studying addiction at Stanford University and my service as a 
White House drug policy adviser in the Administrations of 
Presidents Bush and Obama.
    Senator Braun was kind enough to mention our recent study 
that I did with Dr. Chelsea Shover of UCLA of the rise of 
overdose among older Americans. What we found is from 2002 to 
2021, they have quadrupled.
    Let me break down what they are so we can understand the 
challenge we are facing. About one in eight of those deaths was 
intentional in the judgment of the coroner, so these are 
suicides usually involving prescription medication. Now, it is 
tragic anybody gets to that point, and it is also worrisome 
that that type of death has increased 60 percent since the 
beginning of the study.
    That isn't the fundamental driver of what is making these 
numbers explode. Those are unintentional deaths in illicit 
markets. These are people who are consuming drugs like cocaine, 
methamphetamine, and particularly fentanyl. In 2021, about one 
in three hundred seventy deaths among older Americans were due 
to intentional or unintentional drug overdose.
    Now, on the one hand, that is thankfully lower than what we 
see in working age populations. On the other hand, quadrupling 
is worrisome, and I am glad you are showing leadership to 
intervene in this now before it spirals out of control.
    Just to add some concern on that score, CDC has released 
provisional 2022 overdose data, and that shows a 14 percent 
further increase in the most recent year. The problem seems to 
be getting worse.
    Now, fortunately, because older Americans are almost 
universally enrolled in Medicare, the Federal Government has 
multiple avenues available to prevent and treat substance use 
problems among older Americans. I will just highlight two of 
them.
    In 2018, Congress passed the Support Act, which, among 
other provisions allowed Medicare enrollees to have access to 
community-based clinics that provide methadone maintenance for 
opioid use disorder.
    Early evidence indicates that this change increased 
Medicare enrollees access to and utilization of this effective 
treatment for addiction. The Support Act is up for reauth now. 
One possibility would be to build on that success by including 
other community providers, for example, residential treatment 
programs as to make them Medicare eligible.
    The second option involves parity. As you know, parity is 
when insurance plans have to make the benefits for mental 
health and substance use disorder comparable to those for 
everything else in the plan.
    Over the last 15 years, parity has commanded wide 
bipartisan support, most notably the Wellstone Domenici Mental 
Health Parity and Addiction Equity Act, which was passed in 
2008. Since that time, multiple Congresses and multiple 
Presidential Administrations have expanded parity protections 
to employees of large, medium, and small companies, to people 
who purchase individual plans on the State exchanges, to most 
Medicaid recipients, to kids enrolled in CHIP, and to 
traditional Medicare enrollees who are using the Part B 
benefit.
    The parity protection does not apply to part A of Medicare, 
and more importantly, it doesn't apply to Medicare Advantage, 
which as you know, is a fast growing part of the Medicare 
program, giving everyone in Medicare the same parity 
protections that almost every other American enjoys, with 
increased access both to the care of substance use disorders, 
as well as the mental health problems that often co-occur with 
them.
    Thank you very much for the chance to submit evidence, and 
I look forward to your questions.
    The Chairman. Doctor, thanks very much. We will turn next 
to Mr. Carroll.

         STATEMENT OF HON. JAMES W. CARROLL, JD, FORMER

            DIRECTOR, WHITE HOUSE OFFICE OF NATIONAL

              DRUG CONTROL POLICY, PARTNER, FROST

               BROWN TODD, LLP, WASHINGTON, D.C.

    Mr. Carroll. Chairman Casey, Ranking Member Braun, and 
members of the Committee, thank you for holding this hearing 
about such a critically overlooked issue.
    As ONDCP Director from 2018 to 2021, I coordinated close to 
20 Federal departments and agencies and a $35 billion budget to 
address addiction. I want to thank the Senate for unanimously 
confirming me.
    I have the honor of saying that during my time in office, 
it was the first time in nearly 30 years that drug overdose 
deaths declined. While I am testifying today based on my 
professional experiences, I take this issue personally.
    With humility, I also speak today on behalf of my own child 
who is in recovery, thank God, from a dependance on opioids, 
and I will also respectfully try to testify on behalf of other 
impacted families. I will address five issues relevant for 
older adults. First, all Americans need to know that treatment 
is vital, and recovery is real.
    Nevertheless, there should be accountability and effective 
use of existing Medicare funding streams providing this help. 
We need to mandate that treatment centers be held accountable 
for positive results.
    I have had the pleasure of working with the country's 
leading treatment outcome tracking company. Chairman Casey, you 
might be pleased to know that this company is based in 
Pennsylvania. We shouldn't have to wait until someone relapses 
to see if a treatment center is any good.
    Also, critically, employers should support employees with 
substance use disorder as they get the help that they deserve. 
Second, overdose deaths are staggeringly high, with nearly 
110,000 American lives lost, driven almost entirely by 
synthetics, up almost 40,000 deaths from when I was in office.
    This equates to someone dying every five minutes. It is a 
major airliner going down every single day. It is 9/11 
happening every 10 days. This is just not acceptable, and as 
Dr. Humphreys has testified, older adults are not immune.
    This is why a bipartisan group of 18 Democrat and 
Republican State Attorney Generals have called for fentanyl as 
it is being smuggled into our country, as a weapon of mass 
destruction.
    Virtually none of the synthetics killing Americans are 
produced domestically. Nearly all fentanyl related deaths in 
the United States start in China. It is either sent here then 
as a finished product, or sent, as you noted, as a precursor 
chemical to Mexico, finished, and then smuggled across our 
Southern border.
    I led a White House delegation to China to end the shipping 
of fentanyl through the U.S. Postal Service. The percentage at 
that point dropped to nearly zero. Sadly, bad actors have now 
resumed and are shoveling it into the U.S. by exploiting 
weaknesses at our border, and specifically in our import roles.
    I am proud of Senator Vance for supporting the De Minimis 
Reciprocity Act, which would prevent untrustworthy packages 
from coming into the U.S. This is a rate of three million 
packages a day that are coming into the U.S. unchecked, 
unlabeled, with virtually no way to identify what is in there.
    The bottom line is we are not holding China and Mexico 
accountable. These cartels will do anything to make money. They 
will sell pills to anyone, and they do not care who they kill. 
I have seen counterfeit pills laced with fentanyl. I have seen 
fentanyl disguised as candy. Candy I love, such as Mentos, I 
have seen poisoned with fentanyl and being brought into our 
country.
    The cartels will even put a few kilos of marijuana in a car 
and send it in first as a distraction for our law enforcement 
authorities and then send a subsequent vehicle packed with 
fentanyl into the country. The cartels are exploiting migrants 
and U.S. citizens who are coming into our country.
    When the border is not secured, it invites chaos. We open 
the door to more poison. We need to return to common sense 
border security policies. I don't care about the immigration 
issue. I care about what is coming into our country. Third, the 
only synthetics education these days is for youth.
    Our seniors need to receive this message, too. One pill can 
kill. For Senator Rick Scott, thank you for all of your 
legislation on fentanyl awareness and more moving this. Fourth, 
if there is anything close to a silver bullet to combat this 
crisis, it is naloxone.
    I carry mine every day. I suspect most of my colleagues 
here at the table do as well. It saved countless Americans from 
death. I can't even fathom what this crisis and overdose death 
would be in the country without it.
    Senator Braun, thank you for your work to convince the Food 
and Drug Administration and in working in a bipartisan fashion 
to get the Food and Drug Administration to make it over the 
counter.
    In Georgia, Senator Warnock would be pleased to know that 
200 emergency wall mounted kits were just installed in college 
campuses down there. Finally, what we need to do also is 
provide the ability and the education for diversion at home by 
dispensing the ability to dissolve--render completely inert 
overdoses at home by having destruction of leftover 
medications.
    Finally, I plead with you to remember that behind all of 
these numbers are people being killed, children, teenagers, 
loved ones, the older Americans that we are talking about 
today. Normalizing these conversations will decrease stigma and 
save lives. Thank you.
    The Chairman. Thank you, Mr. Carroll, for your testimony, 
and we will turn next to Ms. Steinberg.

           STATEMENT OF DEBORAH STEINBERG, JD, SENIOR

                 HEALTH POLICY ATTORNEY, LEGAL

                ACTION CENTER, WASHINGTON, D.C.

    Ms. Steinberg. Thank you, Chairman Casey, Ranking Member 
Braun, and members of the Senate Special Committee on Aging.
    The Legal Action Center is a nonprofit law and policy 
organization that fights discrimination, builds health equity, 
and restores opportunities for people with substance use 
disorders, arrest and conviction records, and HIV-AIDS.
    Four million adults, ages 65 and older, had a substance use 
disorder in 2022, with escalating overdose deaths among older 
adults, particularly among black individuals. We commend 
Congress for expanding Medicare's coverage of addiction 
treatment in recent years to address this national problem.
    We applaud Congress for authorizing coverage of opioid 
treatment programs in Medicare and requiring substance use 
disorder screening in annual wellness visits in the 2018 
Support Act.
    We also commend Congress for authorizing coverage of mental 
health counselors and intensive outpatient treatment in the 
Consolidated Appropriations Act of 2023. CMS has affirmed in 
regulations that these expansions are intended to improve 
access to substance use disorder care by including addiction 
counselors under the definition of mental health counselors and 
opioid treatment programs as a setting for intensive outpatient 
treatment.
    CMS took additional steps this year to improve access to 
substance use disorder treatment for older adults. It created 
new codes that allow peer support specialists and community 
health workers to deliver services that address the social 
determinants of health of Medicare beneficiaries.
    To begin to address barriers to provider participation, CMS 
increased the Medicare reimbursement rates for a number of 
addiction and mental health services, including psychotherapy, 
behavioral health integration, and office based substance use 
disorder treatment.
    These improvements will certainly help save lives, but 
there is more that Congress must do to improve access to care 
for older adults. Our recommendations seek to first remove 
discriminatory standards in Medicare.
    Second, expand capacity to treat beneficiaries with 
substance use disorders and reduce unnecessary costs, and 
third, address barriers to care for vulnerable populations and 
reduce involvement with the criminal legal system. Our 
recommendations are detailed in the written testimony, and I 
will highlight several today.
    First, Congress must apply the Mental Health Parity and 
Addiction Equity Act to Medicare. Older adults and people with 
disabilities deserve nondiscriminatory coverage of substance 
use disorder and mental health treatment.
    Remarkably, the Medicare Program, the standard setter for 
other types of insurance, is not subject to this critical civil 
rights law, except for the outpatient cost sharing. As Congress 
and the Administration continue to improve Parity Act 
enforcement in commercial insurance, we urge you to ensure that 
Medicare beneficiaries do not continue to be left behind.
    Individual legislative and regulatory changes may be able 
to address the most glaring discriminatory barriers to care, 
but they cannot address the unwritten implementation practices 
that limit access, which the Parity Act also regulates.
    The lack of parity in Medicare merely shifts costs to 
beneficiaries, providers, and States, and often to the Medicare 
hospital trust fund when these conditions and co-morbid medical 
conditions go untreated. We recommend Congress apply the Parity 
Act to all parts of Medicare.
    We also urge Congress to require Medicare Advantage plans 
to remove inequitable barriers to addiction treatment, 
including cost sharing for medications for opioid use disorder 
and utilization management practices like prior authorization.
    Research has demonstrated that removing these barriers 
increases access to treatment and leads to cost savings. To 
make treatment more affordable across the board, we also 
recommend Congress pass the More Savings Act sponsored by 
Chairman Casey.
    Second, Congress must take additional steps to expand 
Medicare's capacity to treat beneficiaries consistent with all 
other health care financing and delivery systems. Although 
Medicare covers community mental health centers, it does not 
cover the comparable community-based facilities for substance 
use disorder treatment other than opioid treatment programs.
    OTPs can only serve Medicare beneficiaries with opioid use 
disorder, but the majority of beneficiaries with addiction have 
alcohol use disorders and cannot get community-based care. In 
Medicaid and commercial insurance, these missing settings 
already bill for services that are otherwise covered by 
Medicare, and we recommend Congress authorize Medicare coverage 
of these community-based facilities and the full continuum of 
addiction treatment in these settings, including residential 
treatment, to ensure that these reasonable and necessary 
services are meaningfully available to older adults.
    Third, we urge Congress to strengthen reentry for older 
adults who have previously been incarcerated as the high rate 
of overdose, and treatment needs are disproportionate for this 
population.
    We thank Ranking Member Braun for his leadership on the 
Reentry Act, which would promote continuous access to care for 
dually eligible individuals. We also urge this Committee to 
direct CMS to amend Medicare's custody definition to align with 
Medicaid and commercial insurance, since currently older adults 
who are on bail, parole, probation, or supervised release 
cannot enroll in Medicare even though they are no longer under 
confinement and that is not receiving their health care from 
the carceral setting.
    Finally, to reduce engagement with law enforcement, we 
recommend Congress authorize Medicare coverage of mobile crisis 
teams to ensure that trained mental health and substance use 
disorder professionals and peers can respond to substance use 
crises.
    Thank you again for the opportunity to testify and for 
highlighting this important issue. By adopting these 
recommendations, you can save lives and ensure that older 
adults have access to equitable and comprehensive substance use 
disorder treatment.
    The Chairman. Thanks, Ms. Steinberg. We will turn next to 
Mr. Stauffer.

         STATEMENT OF WILLIAM STAUFFER, LSW, EXECUTIVE

          DIRECTOR, PENNSYLVANIA RECOVERY ORGANIZATION

               ALLIANCE, HARRISBURG, PENNSYLVANIA

    Mr. Stauffer. Thank you, Chairman Casey, Ranking Member 
Braun, and all the esteemed members of this Committee for 
having this hearing and having me back to talk about this 
important issue.
    In 2018, I was here to speak about the impact of opioid use 
disorders on older adults. As my esteemed colleagues in the 
panel have talked about, these are issues that relate to the 
wider and broader range of substance use disorders as well. 
Perhaps one of the most important issues that we need to talk 
about is stigma, negative perceptions about people with 
substance use disorders.
    It is something that we are essentially swimming in as a 
society. Very recently in February 2023, my organization Pro-A 
and an organization called Elevyst released a study of a stigma 
in health care, the largest such survey done in the United 
States. What we found is that roughly one in three health care 
providers believe that people like me can and do recover.
    We have to think about this. Health care--our health care 
system is where people go for help, and if only roughly one in 
three health care providers think that we do recover, people 
get that message. They are not going to go for help. We found 
that same type of level of stigma across the rest of society.
    Until we understand what the truth is and what the research 
shows us, which is when people get what they need, the probable 
outcome is recovery. The key is that people need the treatment 
and recovery support that they need to recover, and when they 
do, just like in my life, people recover.
    Stigma is such a huge issue that it keeps our issues 
invisible. When someone around us, a loved one, a family 
member, or a neighbor, dies from an alcohol related fall, the 
underlying issue doesn't get recorded. When someone dies from a 
substance use related medical condition, the root cause doesn't 
get recorded, so as Chairman Casey identified in his opening 
statement, the people, the problems, and the solutions remain 
invisible to our society. I am honored that this Committee has 
moved this issue forward. It is so important. One of the 
reasons why this is so important is because there's going to be 
a whole lot more older adults in America.
    This year, the kids of 1968, the 20-year-old kids from 1968 
are going to turn 75. Their substance use over a lifetime was a 
greater rate than the generations that came before them, but 
consistent with the generations that have come after them. We 
have a whole lot more need coming at us.
    The median age in America in 1980 was 30. Last year, the 
median age for Americans was 38.9. In my home State of 
Pennsylvania, the median age last year was just under 41 years 
old, the oldest in the Nation.
    This is very important because there is going to be a whole 
lot more people in need and the work of this Committee is 
critically important to raise this issue and to continue to 
move things forward.
    We are going to have to think fairly critically about what 
we do. It is important that we think about the impacts of the 
pandemic and the relationship between things like loneliness, 
and make sure that we connect older adults in ways that we have 
not before.
    We have to understand that the issues of an older adult who 
needs services are complex. They often require highly 
structured care, and the same type of care is in competition 
because unfortunately, substance use itself has become more 
complex.
    Things like xylazine and fentanyl have created demand for 
highly structured care in ways that place competition on 
perhaps the level of care that has--that we have the least of 
in the United States, which is that type of hospital-based 
substance use treatment. Our workforce is--we have workforce 
shortages, because some of these centers require complex needs 
and highly trained staff, they are under a particular focus of 
needing people to staff them to conserve this population and 
many of those workers are still retiring--or are currently 
retiring as well, and we need to think about substance use 
disorders in a different way.
    You see, when I hit five years of recovery, I had about 85 
percent chance of staying in recovery for the rest of my life. 
We need to change the way that we think about substance use 
disorders and provide people care and support just like we 
would other chronic conditions like cancer where people get 
regular checkups.
    If we do that for older adults, we can see that they have 
value, and they can provide the kinds of things that they need 
to do for our community. Last, what we need to do is think 
about how we look at community.
    I would suggest that what we should do is create an older 
adult recovery community corp. You see, there is a lot of aging 
adults in recovery. They are looking for purpose. In fact, all 
of us across our society need purpose.
    We should be looking into our community and actually using 
the talents and skills of those in our community and harness 
them to support each other. Perhaps--well, I would say this to 
this Committee, the two most fundamental things that have 
changed my life, one was recovery.
    I got into recovery at age 21. I like to think of myself as 
a formerly young person still in recovery. That changed the 
course of my life. The other thing was that I spent much of my 
life talking to people about issues they experienced in their 
own lives. I have never met a person who didn't have talent and 
skills that they wanted to share with other people.
    What we should be doing in America, not just for older 
adults, but for everybody, is finding a way to harness the 
talents and skills of our people. We are reaching the point 
where roughly 25 percent--in 2060, there will be 98 million 
Americans, or one in four over the age of 65. One of the 
challenges that we have had in America is that we value youth 
and vitality.
    People spend their whole lives developing talents and 
skills and resources, and then they get to older adulthood, and 
they are looking for purpose. We can't afford to squander the 
talents of our older adults in the ways that we have.
    If we did something like created an older adult recovery 
community corp to pair older adults in recovery to others who 
need help, we will be saving a lot of lives, even those who are 
in the helping roles, because we all want hope, purpose, and 
connection.
    This is going to be very important for all of us to think 
about, and I am grateful for you and the work that you have 
done to do things like consider ways to support our 
infrastructure, develop the kinds of infrastructure that we 
need.
    We need to invest in our substance use workforce for older 
adults so that when people need help, it is there to help them. 
We need to fund the full continuum of care, as my colleagues 
have talked about so far here. If we don't fund it, it can't be 
provided. The time to do so is now.
    There has been great--great progress has been made, but as 
my colleague has noted, reimbursement rates are still too low. 
We have a long way to go, and most importantly, I would want to 
note in my home State of Pennsylvania, Governor Shapiro 
developed a 10 year strategic plan.
    In this plan, they are looking at the needs of our older 
adult communities in ways that focus all of the stakeholders on 
identifying the needs, barriers, and talents of our older 
adults. This is a model for how we should move forward.
    The Chairman. Mr. Stauffer, I just--we are way over in 
time.
    Mr. Stauffer. I am sorry. Thank you--this is the model that 
we should follow. Thank you.
    The Chairman. I will move to questions, and you will have 
the first question. I really appreciate you sharing your own 
personal story here, and I also appreciate the experience you 
have gained from that and the challenge we have on substance 
use disorder. You talked about in your testimony about stigma 
that I mentioned in my opening, that prevents older adults from 
reporting that they have a problem.
    Stigma also prevents providers from asking the right 
questions about substance use, and then finally, family members 
are often prevented from, due to stigma, from seeking help for 
a loved one. You also shared that the SUD treatment system is 
not built for older adults, and we need to move toward an age 
friendly service infrastructure.
    Please tell us about some of the unique stigma that older 
adults might face either receiving or accessing substance use 
disorder treatment, and how we can address these, and how age 
friendly care infrastructure can help?
    Mr. Stauffer. Thank you. I will keep my comments brief. By 
creating a plan to focus on the needs of older adults, we are 
creating a venue where we can talk about difficult issues. By 
talking about these difficult issues, I think that we are--
similar to how people, when they face difficult issues, the 
things that come out of that are the opportunities and our 
strengths.
    By focusing on this issue, what we are going to be able to 
get is we are going to find the talents and skills of our older 
adults. The thing that is keeping that--the barrier to that is 
the stigma that keeps us from doing that.
    Creating a place where we can talk about this in an open 
way is the way that we are going to be able to move beyond the 
stigma and treat older adults in the way that they should be. 
Thank you.
    The Chairman. Thanks very much. I will move next to Ms. 
Steinberg. In your testimony, you gave a helpful overview of 
recent improvements to the Medicare program, thanks to Congress 
and the Administration.
    I have long advocated for improving mental health services 
and supports for all Americans, and as you mentioned, I 
introduced the More Savings Act, which would require the 
Centers for Medicare and Medicaid innovation to test a model to 
offer opioid treatment and recovery services provided under 
Medicare without cost sharing, among other policies.
    We have got to do more to help older adults and families 
access mental health and substance use disorder care that they 
need. Could you speak to us about the remaining gaps in 
traditional Medicare for older adults trying to access 
treatment for substance use disorders?
    Ms. Steinberg. Thank you, Senator. Yes, the main remaining 
gaps in traditional Medicare are the lack of parity in parts A 
and B and the lack of coverage of specialty community-based 
substance use disorder treatment facilities that allow 
individuals to get the benefits that are otherwise covered 
under Medicare, like screening, outpatient services, intensive 
outpatient, and partial hospitalization.
    Residential treatment is still not covered in Medicare, 
although Representative Underwood will be introducing a bill 
that would expand coverage to this area, and then the 
reimbursement rates, as my colleague noted, are still a problem 
across the board, but especially for clinical social workers, 
mental health counselors, and marriage and family therapists 
who are still reimbursed at 75 percent of the physician fee 
schedule, even though non-medical physician--not non-medical 
physician practitioners--medical non-physician practitioners 
are reimbursed at 85 percent of that rate.
    In all, there are a lot of issues that need to be 
addressed. Parity would help to address all of them, although 
there are some individual legislative and regulatory changes 
that still need to happen.
    The Chairman. Thanks very much. I will move to Ranking 
Member Braun.
    Senator Braun. Thank you, Mr. Chairman. You know, when you 
look at what we are talking about here, it would be a moot 
point if you didn't have China producing all the precursors and 
Mexican cartels being a distributor of them.
    The fact that I think all Americans need to realize that 
fentanyl seizures at our Southern border have gone up five 
times, five times from 2020 to the present. Mr. Carroll, I want 
to focus on a few things so we understand better how this can 
happen when you have got a geopolitical competitor like China.
    You hear about precursors. Explain to us precursors. Are 
they used for a variety of legal drugs, or is the market 
primarily precursors being shipped to the main customer, 
Mexican cartels?
    Mr. Carroll. The problem is both precursors and pre-
precursors. At the precursor level, there is the ability to 
understand exactly where they are going, and for the most part, 
the precursor chemicals that are coming from China to Mexico 
are completely unchecked, unregulated. The Mexican government 
is not following through to see where those precursors are 
going. Are they going to a legitimate facility for some purpose 
that is legitimate?
    Senator Braun. In like what percentage of precursors would 
be across the world being used as part of legal drug 
formulations? Just to get a feeling for how much of what the 
Chinese are doing, you know, is aimed at an illicit use.
    Mr. Carroll. I would submit that there is very little 
legitimate use of the immediate precursors to making for--
making fentanyl.
    Senator Braun. That then is a blatant kind of trafficking 
of something that is essential, and the fact that that has gone 
up five times in just three years, that is where it all begins, 
correct?
    Mr. Carroll. That is where it begins. That is the blatant 
problem that we are not holding Mexico accountable for keeping 
track of the precursor chemicals coming in.
    Senator Braun. What about China's responsibility, the 
Chinese Communist Party, for being in an enterprise where they 
would know that this is going to end up on American streets? I 
can see why the cartels are interested in it, because they have 
had a track record of doing stuff over many years that would be 
illicit in many different ways, but China would have to know as 
well that these precursors, when they go to Mexico, are nearly 
100 percent being used to produce fentanyl.
    Mr. Carroll. I have no doubt that they know that the 
precursors are being sent from their country to Mexico.
    Senator Braun. That is a tragedy, and it is also, when you 
look at the fact that it has gone up five times in three years, 
that ought to be an eye opener to Americans across the country 
about what open borders have done in terms of creating 
something where we are losing 100,000 Americans annually.
    I just want to make sure that connection is clear, and it 
is not confusing. The Chinese Communist Party knows what it is 
doing. The cartels lap it up because they know how much money 
they have been making off of it. It is basically a two-entity 
enterprise, China making it and the cartels distributing it.
    Mr. Carroll. China is not a democracy. They ended the--
shipment of fentanyl to the U.S. when I led the White House 
delegation there. It ended almost overnight. They could end it 
if they wanted to, the shipment of precursors to Mexico, but 
they are not.
    Senator Braun. It begs another question. Any other 
countries making fentanyl precursors?
    Mr. Carroll. We, in an unclassified setting, the answer is 
yes, but only to a very small degree at this point.
    Senator Braun. That is what I thought. They are a monopoly 
on the fentanyl precursor market, and it is aimed at us. 
Another point. Recently, illegal crossings have gone up to 
roughly 200,000 a month.
    There is a new category called got-aways that we never even 
talked about back, pre--during the Trump Administration. The 
border policies that we have had, is there any way you can say 
that it hasn't been part and parcel, the third factor that has 
taken the crisis to where it is?
    Mr. Carroll. God bless the men and women of CBP on our 
border who are trying to do everything that they can. The patch 
on their sleeve says border protection and that is what they 
want to do.
    Sadly, they are being exploited. They are sending family 
units over, children over. They are being distracted and a mile 
down the, you know, the cartels are sending drugs over----
    Senator Braun. One other quick question with as quick an 
answer as you can give. I am slightly over my time.
    Is there any other dynamic in the world that has got a 
State being a drug trafficker like Mexico would be with China, 
evidently has got the market cornered on fentanyl precursors. 
In your awareness, does any other country suffer from what we 
do that has this same type of problem?
    Mr. Carroll. Not to the extent. China is the drug dealer of 
the world.
    Senator Braun. It ought to be clear in both cases then, the 
Chinese Communist Party using Mexican cartels, and we are the 
brunt of it. Something has got to give. Thank you.
    The Chairman. Thank you, Ranking Member Braun. We will turn 
next to Senator Scott.
    Senator Rick Scott. I want to thank Chairman Casey for 
holding this hearing. I want to thank Ranking Member Braun for 
his efforts in this regard. I want to thank each of you for 
being here. This is an unbelievable crisis.
    The broken U.S. border unfettered criminal networks thanks 
to a lawless Administration that ignores our immigration 
policies and a system failing Americans, American families has 
created a crisis claiming more than 100,000 lives last year.
    I think everyone of us has a--somebody we know that has had 
an addiction problem in our lifetime, and it just seems like it 
is getting worse. In February, I held a roundtable in Florida 
to discuss the fentanyl prices--this one was up here, discuss 
the fentanyl crisis with families, law enforcement, and policy 
experts to help find solutions to this crisis.
    I am a proud sponsor, co-sponsor of 19 bills that directly 
touch issues we addressed at the roundtable in February. The 
first is the My End Fentanyl Act will help our brave Border 
Patrol officers have the most up to date information when 
performing interdiction at the border.
    I would thank Senators Braun and Kelly who are both co-
sponsors of that legislation. My Social Media Act will help 
combat the sale of illicit drugs online. My updated USPS Act 
will help close the loopholes in our U.S. mail system to stop 
packages containing illicit drugs from being shipped to the 
U.S. from places like communist China and Mexico.
    Naloxone is a safe and effective tool to prevent opioid 
related overdose and death. As I have said before, everyone 
should know how to use it and be prepared in the event someone 
you know or around you experience an overdose.
    The list goes on and on. There is a lot of things that I 
know our colleagues--my colleagues here care about this. There 
is a lot to be done. Mr. Carroll, how can Federal agencies 
collaborate more effectively to implement comprehensive 
strategies for preventing and treating substance abuse 
disorders in older populations?
    Mr. Carroll. I think being able to work together on using 
the convening authority of the White House to bring together 
these agencies that are trying to help, but right now, there is 
a lot of disjointed work going on.
    My colleagues here have talked about it, about some of the 
gaps in parity. I submit that it is not only the gaps in 
written regulations on parity. It is also the gaps in actually 
applying it. That treatment centers are not being held 
accountable, that insurance companies are not being held 
accountable for a lack of parity.
    Coming together as a government would address those issues. 
Coming together with the intel agencies, with all of our law 
enforcement agencies to address the border problem, looking at 
some of the fundamental problems and taking the problem off our 
shore, stopping it before it gets here, I believe, is one of 
those ways that the Government can work together.
    Senator Rick Scott. Do you think if we made the ONDCP 
Director to be a cabinet level position it will help coordinate 
the Federal agencies?
    Mr. Carroll. I fully support that position more than you 
can say to elevate Dr. Gupta and his successors to that 
position of being in the Cabinet.
    Senator Rick Scott. How do you think we should make seniors 
more aware of naloxone?
    Mr. Carroll. I think there is two issues to make them more 
aware.
    One, is working with the health care providers to make sure 
at the time they are prescribing an opioid, to tell the 
patients, make sure that you have naloxone. It is like having a 
fire extinguisher at home.
    God forbid that you need it, but just in case, it is there. 
The other is actually co-dispensing it and looking at that when 
a prescription is given for an opioid, and then finally, there 
is also just the basic education, the ability for seniors to 
hear this message. There is a lot of money being spent on 
educating youth using social media. That is their form.
    I don't think too many people in my generation that are 
part of the population of this community are using TikTok or 
using some of the, you know, the other social media.
    We have to find relevant means to go to them, to talk about 
naloxone, to talk about alternatives to treatment as well. 
There is some great technology, some great health care that is 
in the contrary. That is actually in addition to or in lieu of 
opioids.
    Senator Rick Scott. Can you give us an everyday example of 
how bad actors use Section 321 to export deadly fentanyl 
directly to American consumers?
    Mr. Carroll. Absolutely. Three million packages a day are 
coming into this country because of the 321 loophole----
    Senator Rick Scott. That is a billion--is that a billion--
that is a billion a year then, right?
    Mr. Carroll. That is a billion a year, three million a day, 
and it is completely unchecked. I actually, when I was kind 
enough to be invited by Chairman Casey to come here, actually 
went online and ordered something less than $800 from China.
    I admit that it was a rock specimen that looked kind of 
cool, and it was sealed when I got here. Two weeks later, it 
was sealed perfectly. It was clear it had never been opened, 
never been inspected, no ability to really know what is in it. 
Right now, the best technology we have to detect fentanyl is 
our canines.
    I should also mention that the end of this month, Keith 
Barker, who is really--at CBP, is retiring. He is the one that 
led the ability to have dogs sniff for fentanyl undetected. 
That is really some of the best technology we have out there. 
That is a shame.
    There is some wonderful technology to look for anomalies in 
packages, but at a billion a year, it is--they are not being 
checked and we are not holding the originating company--60 
percent of that billion is coming from China.
    Senator Rick Scott. Can I ask one more question, Mr. 
Chairman?
    The Chairman. Sure.
    Senator Rick Scott. What percentage of the fentanyl coming 
into this country do you think is coming in because of this de 
minimis test versus what they are bringing up across the 
border? Do you have any idea?
    Mr. Carroll. We have no idea, but we look at the number of 
deaths that are happening and you have to believe that it is 
because of the dramatic rise of 321. It is sort of like looking 
at, you know, we don't know how many drugs are coming across 
the Southwest border.
    All we know is what we are catching. The same is true, all 
we know is what we are intercepting, and it is, you know, less 
than five percent--I think less than one percent, candidly--is 
actually being checked. We don't know what we don't know.
    Senator Rick Scott. Thank you. Thank you, Chairman.
    The Chairman. Thank you, Senator Scott. Because of the day 
this is, we have got a lot of hearings and activities planned, 
so members are coming at different times. I will ask some other 
questions before--as we wait on another Senator from the 
Committee. I want to turn next to Dr. Humphreys.
    Doctor, compared to the knowledge base regarding substance 
use disorders in younger populations, as we made reference to 
earlier, there is far less research and data on the older adult 
population. In your testimony, you note that from what we do 
know, there is an increased prevalence, prevalence of substance 
use disorders among older adults.
    The research shows that recent cohorts of individuals ages 
65 and older tend to have higher prevalence of lifetime 
substance use than seen in prior generations. Specifically, the 
rates at which older adults use alcohol, prescription drugs, 
and cannabis are increasing fast. We also have seen rates of 
substance use among older adults rise through the COVID-19 
pandemic, so here is the question. Doctor, can you speak to how 
the gaps in data and research of substance use disorder in 
older adults negatively impacts our understanding of the issue?
    Dr. Humphreys. Yes, sir. We do not know how many Americans, 
older or not, for example, use fentanyl or are addicted to 
heroin or use cocaine.
    We try to assess that with surveys which are increasingly 
less reliable, partly because Americans are just less 
interested in doing surveys, but also because those surveys do 
not cover jails and they do not cover people living in 
encampments or on the street.
    Most importantly, they rely on people telling a surveyor, 
yes, I have a substance use disorder, which is a deeply 
stigmatized thing to have, perhaps particularly for older 
Americans. As scary as those numbers are that you quoted in 
there, they are scary about the number of older Americans who 
have some use disorder, that is almost surely an underestimate, 
so, we need different kinds of technologies. I think the most 
promising things we have in development are one, wastewater 
technology. We built that during COVID. We can use that for 
drugs. Europe, Australia use it very extensively.
    We would know in a community, you know, if fentanyl has 
arrived before--no one would have to tell us. We would be able 
to detect it from the--because people excrete the molecule into 
the water. The other thing is that the internet is a remarkable 
source of evidence.
    All the social media sites, there are people working, 
including at Stanford University, on scraping sites. When there 
is a new drug that comes in or a new problem, it is very often 
discussed on all those social media forums which you can grab 
with AI and detect trends that way. Those are the 
possibilities, I think, for improvement.
    The Chairman. Well, I appreciate that. I know that we--one 
of the things we are trying to do by putting a spotlight on 
this is to focus on those gaps in data and in research. As I 
said, we are--we have a busy Thursday, so we are joined by 
another member of the Committee, Senator Vance.
    Senator Vance. Thank you, Mr. Chairman, and to you and the 
ranking member for doing the hearing. Especially excited to see 
Mr. Humphreys, an old friend of mine. Good to see you, Keith, 
and glad you are here.
    I know, Mr. Carroll, you made an observation just in your 
opening remarks, I appreciated, about the importance of closing 
the de minimis loophole for drug imports. Could you speak just 
to that for a little bit longer because I think it is such an 
important thing to get on the record.
    Mr. Carroll. Thank you for your leadership and moving 
forward with legislation to close that gap.
    What really concerns me on the 321 is how it is being used 
and how it is being exploited, including for seniors who might 
not understand that when they think they are buying a 
prescription online, that they are actually buying an 
illegitimate pill that is going to be able to be, you know, 
snuck into our country unchecked.
    They will think it is a legitimate prescription, a 
legitimate pill. They don't have--one of the things that we 
have talked about is they don't get the education and 
prevention necessarily that our young people do.
    They might be ordering something, and they will have no 
idea that, in fact, the prescription that is--they think is 
being filled by an online pharmacy is in fact a complete 
loophole of 321, and they are losing their life for it.
    Senator Vance. Yes. I appreciate that. Appreciate that 
further explanation. Mr. Humphreys--I guess I should say, Dr. 
Humphrey, but I--you know, you and I spent a lot of time 
talking in private about the ways in which we sort of 
misunderstand very often the pipeline from opioid prescription 
to opioid addiction.
    Obviously, the world has changed a lot in the last few 
years on this account, but you know, just to sort of, to repeat 
and correct this if I am wrong, but we have this perception, I 
think that the way that a lot of young people, middle aged 
people, get addicted to heroin and then go into fentanyl from 
there is, you know, they hurt their shoulder or they break a 
leg, they get a prescription for opioids, and the prescription 
is far too generous.
    Eventually they take too much. They get hooked on it. When 
in reality, that is the perception we have. The reality is that 
very often you have a lot of opioid pills in the community 
because of this overprescribing problem, and then that can 
become a pipeline. Maybe the grandkids get into it, maybe a 
friend gets into it, and that is sort of the first step down 
the path to opioid addiction.
    You know, I am just curious, given the, you know, the way 
and the access that our elderly Americans have to opioids is 
going to be much different on that first step. If you could 
just talk a little bit about what, you know--like, how does a 
65 or a 70-year-old American get addicted and then eventually 
get on the pathway to taking fentanyl?
    I imagine it is much different than for our younger people, 
but I would like you to sort of explain what that looks like.
    Dr. Humphreys. Yes. Thanks for that question, Senator. You 
know, the overprescribing, we had the 400 percent increase in 
per capita prescribing started in the mid-90's and went up to 
about 2010.
    We have improved a lot on that, so we are much more 
careful, right, but that did generate new markets. Markets, 
illicit markets evolved to serve people who were addicted to 
opioids, which let people go directly to opioids. Younger 
people, particularly, that couldn't do it before because, you 
know, doctors are not going to believe a 20-year-old is in 
serious pain.
    As you note, you know, seniors have full access and 90 
percent of people on Medicare take a medication. Half of them 
take four or more, and quite a few of those are opioids, as 
well as drugs that have addictive potential like the 
benzodiazepines, tranquilizers, and things of that sort.
    In what we see in the death data, there is a mix of how 
people are suffering. We do see in the intentional population 
taking their own lives, very commonly that is with the opioid 
prescribed to them, or benzodiazepines prescribed to them.
    On the illicit side, the deaths we are seeing are for 
people who have actually been in touch with illicit markets for 
a long time and cannot handle the new drugs that are out there. 
We have a dramatic overrepresentation of African Americans 
among the deaths of older Americans that started in 2014, which 
is about when fentanyl started to show up in Eastern markets.
    Now, those were folks who were probably already in touch 
with--using drugs, using illicit drugs, but could not tolerate 
when heroin turned into fentanyl, or Vicodin diverted and 
turned into fentanyl, or cocaine became laced with fentanyl, 
and that has caused a just epic, you know, destruction, sadly.
    Senator Vance. Have you done any research, Mr. Humphreys, 
or anybody else on, you know, the sort of problem Mr. Carroll 
talked about, right, where you have obviously illicit 
substances coming in through mail order pharmacies, but that 
obviously there is sort of the street level fentanyl problem, 
too.
    Like, do you have a sense of what the breakdown is? How 
much of this is coming in through mail order pharmacies, how 
much of this is coming through traditional street methods? Like 
what is really going on here?
    Dr. Humphreys. Yes. We don't have--as you know, Mr. Carroll 
said, we don't have precise estimates of the exact sourcing of 
all this fentanyl but say the most important thing to remember 
is RAND Corporation estimates that annual illicit consumption 
of fentanyl for the entire country is single digit metric tons 
a year.
    That fits literally on one truck. You can put it all on 
there. That underscores what incredibly difficult problem this 
is. You know, you stop one route--let's say we could keep it 
out of the mail system, which of course, we would all like to 
do, only have to get, you know, five or ten tons a year as all 
the traffickers have to do, and so, this, you know, switching 
to another option is almost a certainty.
    Senator Vance. Yes. I am mindful of time. I yield back. 
Thanks to all of you for being here.
    The Chairman. Thank you, Senator Vance. We will turn next 
to Senator Kelly.
    Senator Kelly. Thank you, Mr. Chairman, and thank you for 
having this hearing today. Ms. Steinberg--and to the rest of 
you, thank you for attending. I know, Ms. Steinberg, my staff 
appreciates working with you. You have emphasized Medicare's 
traditional approach to covering substance use disorder 
treatment at the polls.
    Historically, beneficiaries have had to either wait till 
their situation becomes rather severe before they can access 
covered treatment, and when it is time to wind down, the 
challenge--there is a challenge because the continuum of care 
isn't there. Medicaid, however, is required to cover medication 
assisted treatment, and that has been key for many Medicare 
beneficiaries able to access treatment, and it is because they 
are also eligible for Medicaid, and Medicaid is the largest 
payer for behavioral health services in the country, and 
unfortunately, jails are sometimes a community's largest 
provider of behavioral health services. Too often, we see 
people struggling to maintain their treatment.
    They end up in jail, and the jail is sort of the substitute 
for behavioral--for a behavioral health facility. In Coconino 
County, which is where Flagstaff is in Northern Arizona, 65 
percent of pretrial detainees have a diagnosed mental health 
condition, and more than 50 percent of the inmate population 
have both a mental illness and a substance abuse disorder.
    Once you enter that facility for pretrial detention, your 
Federal benefits get cutoff. I have heard this from sheriffs' 
multiple times, and they are still required to treat them, and 
this is placing a huge burden on our counties in Arizona who 
have to pick up the costs and the continuity of care for these 
individuals once they are released.
    We have got some incredible local organizations and 
partnerships that have stepped up to do this, but many of the 
Arizona sheriffs that I mentioned, they have asked for Congress 
to fix this policy through the Due Process Continuity of Care 
Act, and that is why I am a co-sponsor of this bipartisan bill 
and eager to get it move forward.
    Ms. Steinberg, could you speak to the benefit of ending 
this exclusion policy? How would this help older adults and all 
individuals who suffer from substance abuse?
    Ms. Steinberg. Thank you, Senator, and thank you for your 
work on such an important bill. As you have noted, the costs of 
health care services just get shifted to jails and to taxpayers 
when Medicaid does not cover the health care services for 
pretrial detainees, and these are people who are presumed 
innocent at that time.
    It is absolutely absurd that we are not paying for their 
care at that point, and health care is disrupted when this 
happens. People lose access to their substance use disorder 
treatment, their medications, and their treatment team, their 
providers, who they trust, who they have been working with.
    It is absolutely imperative that we end the exclusion to 
ensure access to those services and to save the counties and 
communities billions of dollars.
    Senator Kelly. The Coconino County sheriff told me of a 
couple of cases. They get somebody that comes through the door, 
and then while they are there in detention, they are able to 
access some fentanyl. They wind up overdosing. They wind up 
going to the emergency room and getting treated in the 
hospital, and then who gets the bill? The sheriff gets the bill 
because they are no longer covered. How would this--that is one 
example. How would this help the finances of counties and local 
communities?
    Ms. Steinberg. If Medicaid were to pay for these services, 
it is a split between the Federal Government and the State, 
rather than that shift to the counties, to the sheriffs, and 
again, to the taxpayers, so this would--it is estimated that 
about $3.34 billion are spent on pretrial detainees every year, 
so that cost would get shifted back to the Federal Government, 
and to again, work with the treating providers that are 
providing the most comprehensive and equitable services that we 
know are the lifesaving, evidence based medications and 
services, and we want to be encouraging that as much as 
possible.
    Senator Kelly. I imagine you are in favor of the Due 
Process Continuity of Care Act?
    Ms. Steinberg. Yes, sir. I am in favor of the Due Process 
Continuity of Care Act.
    Senator Kelly. I invite my colleagues, if you haven't co-
sponsored it, to take a look. Thank you. Thank you, Mr. 
Chairman.
    The Chairman. Thanks, Senator Kelly. Senator Ricketts.
    Senator Ricketts. Thank you, Mr. Chairman, and thanks to 
all of our witnesses coming here today for this hearing.
    The National Institute of Drug Abuse reported in 2019 that 
rates of substance abuse had climbed in adults between 50 and 
64 years old, and those 65 year old and older in previous--from 
a previous decade. It has been called an invisible epidemic. 
Opioids are the second most commonly reported substance abuse 
by seniors.
    The number of fatal opioid overdoses among seniors has 
risen dramatically over the last decade. U.S. Customs and 
Border Protection seized nearly 549,000 pounds of illicit 
drugs--illicit substances nationwide in Fiscal Year 2023.
    Fentanyl seizures at the Southern border increased by 480 
percent in 2023, compared to 2020. Fentanyl seizures amounted 
to 220--sorry, 27,000 pounds, surpassing fentanyl seizures in 
the previous three years.
    While the drug situation on our Nation's Southern border 
has gone from crisis to catastrophe, the Nebraska State Patrol 
has stepped up. In my last year as Governor, troopers 
confiscated two times as much methamphetamine, three times as 
much fentanyl, and ten times as much cocaine as they had just 
two years prior.
    In 2019, Nebraska law enforcement, this is statewide law 
enforcement, had confiscated just 46 pills that were laced with 
fentanyl. In the first six months of 2021, that number had 
grown to 151,000, so let me just emphasize that again, it went 
from 46 pills in 2019 to 151,000 in just the first six months 
of 2021.
    Last year, around 1.5 million potentially lethal doses of 
fentanyl were distributed in Nebraska. Mr. Carroll, as you 
know, drug overdose deaths have been climbing and fentanyl has 
been an overwhelming driver of the record breaking number of 
overdose deaths we have experienced in 2021.
    How important is it that fentanyl related substances are 
permanently schedule one--and, you know, listed permanent 
schedule one drug in the Controlled Substances Act?
    Mr. Carroll. I think it is critical. I started my career as 
a drug prosecutor, and the ability to have the permanent 
scheduling means that we would actually be able to more easily 
prosecute fentanyl traffickers for this, but recognizing that, 
in fact, it is the analogs that are coming through in a variety 
of different ways.
    Senator Ricketts, and this is actually true for Ranking 
Member and for Chairman Casey, all three of you are in States 
where actually over the last from June to June of this year, 
you are actually in States where there has been a slight 
decrease in the number of fatalities--all three of your States.
    Senator Ricketts, I think you lead the country in Nebraska 
with a drop of about 16 percent because of the work that is 
going on in Nebraska. I commend you, all three of you, for the 
work that you are doing there, because these fentanyl and its 
analogs and the synthetics, the latest wave of the xylazines 
and things like that will continue to be produced and continue 
to be formulated in different ways to try to avoid prosecution 
whenever possible, or at least make it more difficult.
    Senator Ricketts. Yes, and that is certainly part of what 
we have to do is the law enforcement, prosecution part. One of 
the other things we have done in Nebraska is we work with our 
prescription drug monitoring program as well to be very 
proactive with regard to looking at doctors who are maybe 
overprescribing or patients who are doctor shopping so that we 
can spot those ahead of time for people who may be abusing 
opioids through that channel.
    Then, of course, working with our law enforcement to make 
sure that they have got, you know, the appropriate tools to be 
able to combat some--to combat when somebody gets an overdose 
and that sort of thing.
    It is a multi--it is not just one thing we have to do. It 
is really working with all levels of people who are interacting 
to be able to stop it from a drug side, prosecution side, from 
a mental health side, all that sort of stuff.
    Mr. Carroll. Our law enforcement officers are truly the 
first responders.
    Senator Ricketts. Front line.
    Mr. Carroll. They are--at that point, that is where they 
are most susceptible, I think, to entering treatment, if the 
law enforcement officers are sufficiently trained to divert 
someone who is just suffering from an addiction, instead of 
going to jail, to get treatment. There is a lot of great 
communities. I have been to all three of the States numerous 
times, and there is a lot of work being done.
    Senator Ricketts. Great. Also, Mr. Carroll, you know, the 
Biden Administration has demonstrated they are really not doing 
anything on the Southern border as part of our negotiations 
right now to try and get this, because not only is it about the 
humanitarian crisis, national security crisis, but the amount 
of drugs that are coming across.
    Actually, we did see some progress with meeting with 
President Biden and Xi Jinping to start cracking down on some 
of the precursors there, but as I gave some stats for 2021 
earlier this year, the Nebraska State Patrol seized 50,000 
fentanyl pills that were suspected to have illegally come 
through the southern border and made their way up to Interstate 
80, which runs East to West through our State.
    How are we leveraging technology? We were talking earlier 
about how it is hard to track this, but how are we leveraging 
technology to improve our intelligence gathering of tracking 
the fentanyl to prevent it from reaching our neighborhoods once 
it is in the country?
    Do you have any suggestions for improvement on how we can 
do that tracking of the trafficking of these drugs that is 
coming through?
    Mr. Carroll. You know, there is some great programs 
happening right now in terms of tracking it in the country, but 
they don't receive the support that they should have. Quite 
frankly, I think this entire issue, whether we are looking at 
it from a prevention, treatment, or law enforcement 
perspective, we are not looking at this as the incredible 
crisis that it is with over 100,000 deaths.
    Being able to track this through such things as wastewater 
treatment, looking at treatment centers, talking to individuals 
is really the best way that we have this--there is some great 
technology out there law enforcement is using. It is scattered. 
There is also some great technology, as far as I know and my 
sources are telling me, at CBP that are sitting in boxes that 
have the ability to actually detect the anomalies.
    They have been paid for by the Government, but they haven't 
been installed. We need to be able to do this as quickly as 
possible, and thank goodness there are some great American 
companies that have this. That we are not just deploying it in 
the way that we should for any of these issues of treatment, 
prevention, or, as I said, God bless our law enforcement.
    Senator Ricketts. Mr. Chairman, I notice I am out of time, 
but I have one more quick followup question, if you are okay 
with that.
    The Chairman. Sure.
    Senator Ricketts. Mr. Carroll, and I don't know how much of 
the background you have on this, but obviously a lot of 
things--one of the things that has been talked about is 
artificial intelligence as a way to be able to spot patterns 
and, you know, obviously leverage the potential there.
    What role do you see AI having for detection and 
intelligence with regard to how we can intervene in some of 
these drug cases? Are there safeguards being put in place to 
prevent AI from being used to elude the current counter-
trafficking techniques?
    Mr. Carroll. Maybe because I am in the demographic of the 
Committee. AI scares me----as much as--you know, as much as it 
might provide helpful. Certainly, there are some anomalies that 
we can look for that AI will detect, and that is true, I think 
also if we look at the de minimis rule and look at all these 
packages that are coming in, can we use technology and a and 
AI, so instead of an individual looking for an anomaly and 
hoping to detect it, that the machine through machine learning 
will be able to do it.
    I do have to say, overall, if you look at the AI issue, I 
need some better education to make sure that we are applying it 
in a safe and realistic manner and we are not too aggressively 
going to the other extreme.
    There is also, technology also to look for people who have 
an addiction to use, like the PDMPs, to use early detection and 
early screening when seniors are, you know, getting their 
checkups, or going to a physician and health care emergency 
room to help detect it.
    There is a lot of technology that can work. AI is an 
interesting one.
    Senator Ricketts. Right. Well, thank you, Mr. Carroll, and 
thank you, Mr. Chairman, for allowing me to go over my time.
    The Chairman. Senator Ricketts, that won't come out of your 
next hearing time----because of your faithful attendance. 
Senator Braun.
    Senator Braun. Thank you. I got one final question. It will 
be for Dr. Humphreys and Ms. Steinberg. When you look at what 
an ounce of prevention would do here in terms of cutting off 
the supply, you know, to me, it exceeds the pound of cure in 
terms of the value.
    Dr. Humphreys, you list over prescription, decreased 
tolerance, baby boomers' permissive drug habits, and synthetic 
drugs like fentanyl, and there was a normal kind of paradigm to 
all this before fentanyl came onto the scene, which in the same 
quantity is 50 times more powerful than its counterpart prior 
to it.
    In the business of remediation and when you and Ms. 
Steinberg were talking about how do you deal with it all and a 
lot of other related issues, I would like to hear your opinion 
on the relative importance of all of these factors and what 
would happen if we just had China quit sending precursors to 
Mexico, and Mexico was doing its job of not letting cartels 
enrich themselves by being the distributor. You know, give some 
sense of proportionality.
    Dr. Humphreys. Fentanyl has been a public health disaster 
and has caused more deaths more quickly than any drug in my 
career. The synthetization makes it far more potent. It is also 
far more compact, so it is much harder to interdict. It is 
highly addictive. It is hard for people to stop using it.
    Absolutely, you know, if fentanyl did not exist, you know, 
we would clearly have many fewer deaths. Challenge is, it does 
take--it is so compact, as I said, it probably takes five or 
ten metric tons to supply our entire country. Let's say China 
did the right thing, as they should, and this business, it 
could be just moved to another country. You know, India has a 
very large pharmaceutical industry, not super tightly 
regulated. They have chemists who would like to make a little 
extra money, too, so that would be the challenge. We have to 
work with China, but we also have to work with essentially 
every other nation that has this technology.
    Senator Braun. Ms. Steinberg.
    Ms. Steinberg. Well, I am not even an armchair foreign 
policy expert, but what I can say is that while fentanyl has 
been contributing substantially to the overdose death rate, we 
are still talking about millions of older adults that have a 
substance use disorder.
    Preventing those deaths is very significant but allowing 
these individuals to recover and live their lives with dignity, 
reconnect with their families, reengage with their friends, 
that is something that is fundamentally important for all the 
people who are suffering from substance use disorders, but also 
alcohol use disorders, the growing rate of methamphetamine use 
disorders, and stimulant use disorders.
    There are a lot of people that we are missing if we are 
focusing so narrowly on fentanyl and providing that treatment 
and that full range of evidence based treatment for those 
individuals is critically important.
    I have heard a lot of talk today about a lot of the medical 
symptoms and side effects of fentanyl, like seizures, which are 
serious, and to me, that is pointing again to this issue of 
parity, that we are focusing so much on the medical side and 
not on the substance use disorder treatment needs.
    I urge us, as a group here, to remember that these people 
deserve substance use disorder treatment as well, and to do 
that in a comprehensive and equitable way.
    Senator Braun. Well, thank you for that. I think if there 
is one clear thing from these hearings, and Dr. Humphreys, I am 
glad you accentuated it, the Chinese Communist Party ought to 
do the world a favor and pull their production, and I think it 
would set the stage for making it difficult for other countries 
to pick it up if they led by example.
    That is probably a pipe dream to even expect that to occur, 
but the fact that we have been accommodating this with an open 
border policy, shame on us because that is doubling down on 
what we know is going to be a difficult thing to solve. Thank 
you all for your opinions today. Appreciate it.
    The Chairman. Thank you, Ranking Member Braun. I have only 
one more question. We have lots more if we had more time. One 
more question, but just one comment on some of the fentanyl 
discussion.
    We have before us, it is really the last remaining thing we 
will do in the Senate this year, or I should say the most 
important remaining thing we will do in the Senate this year, 
and we are hoping that negotiators have made some progress on 
border policy, but at the same time, that same bill has an 
awful lot of money in it for emergency funding for the border 
that would directly affect this issue.
    For example, I was looking at the data here or the numbers, 
I should say, in the bill. This bill, the supplemental 
legislation we are hoping to vote on soon, provides more than 
$5.3 billion for Customs and Border Patrol. $5.3 billion extra 
over the appropriations for the year. It also provides more 
than $2.3 billion for ICE, Immigration and Customs Enforcement. 
That is just kind of a sampling of it.
    The bill also provides, and this has been lost in all the 
coverage, this Fend Off Fentanyl legislation that I mentioned 
earlier. It is overwhelmingly bipartisan. It started in the 
Banking Committee. Senator Brown, the chairman, and Senator Tim 
Scott, the ranking member, they got out of that Committee. It 
was supposed to be on the national defense bill, but that got 
knocked out by the House.
    The Fend Off Fentanyl bill now is attached to the 
supplemental, and that is a tough, tough bill on these bad 
actors in China and Mexico. It will hit them hard with 
sanctions and it has a lot of anti-money laundering provision.
    It is a very tough bill. You can make a good argument 
because of the dollars in this bill, the dollars that are 
proposed, in addition to the policy that is trying to be--folks 
are trying to work out now, and then you have the third element 
would be the Fend Off Fentanyl legislation, you could make a 
pretty good argument this is the most important fentanyl bill 
that any of us will ever vote for coming up in the 
supplemental.
    It is a bonanza of support to stop fentanyl, so I am just 
hoping we can get it done, but I wanted to move to the last 
question, and not just simply because he has got such good 
roots in Pennsylvania, but, Mr. Stauffer, I wanted to give you 
the final word, so to speak.
    You mentioned earlier about some efforts in Pennsylvania 
that were creative strategies to address coverage issues at the 
State level have taken place, and that the State is leading the 
way as one of the handful of States to develop what is known as 
multisector or master plan for aging. Can you tell us more 
about these positive advances in the state?
    Mr. Stauffer. Thank you, Chairman Casey. The plan is--it is 
a 10-year-plan, and the focus of is, it is important to 
understand that it comes from a place of not having 
preconceived notions, objectives, or initiatives.
    It creates a space to have difficult conversations about 
the needs of our seniors, but also to acknowledge their talents 
and skills. By having a 10-year-plan of this type, what we are 
going to be able to do is look at access to services in a 
transparent way, include all populations. As my colleagues have 
talked about, marginalized communities have been impacted more 
greatly by substance use disorders.
    This is going to create a framework and a space to talk 
about how these communities are impacted so that we can move to 
solution. I, as a person in recovery, a generation ago, Dr. 
Clark, who--of SAMHSA, created an environment as a leader to 
bring people in recovery to the table, and by bringing people 
in recovery to the table really changed the way that America 
thought about recovery. It became more common to talk about it.
    The services that were provided to people expanded, and we 
changed the language in how we talk about recovery. This kind 
of a plan and creating an environment where we can do these 
kinds of things sets the table to move toward--away from, just 
not just looking at the barriers but the opportunities.
    It is great to be from the State of Pennsylvania and 
exciting to be part of this plan here in Pennsylvania. I hope 
that other States do it, and it could be a model nationally.
    The Chairman. That is great. Thank you very much. Thanks 
for your testimony. I want to thank all of our witnesses. I 
have a brief closing statement. I will turn to Ranking Member 
Braun after my close. As we heard today, substance use 
disorders among older adults represents a growing crisis 
nationwide, and that might be an understatement, as our aging 
population is growing, and at the rate that several of our 
witnesses made reference to.
    We heard from many of our witnesses today that Congress 
must build on the recent legislative success of the Support Act 
of 2018 and the Consolidated Appropriations Act of 2023 to 
truly make parity a reality for everyone, including individuals 
with Medicare or Medicaid--Medicare and Medicaid coverage.
    I note for the record the Support Act was just reauthorized 
by way of committee activity in the HELP Committee that Ranking 
Member Braun and I are a member of. I voted to reauthorize, as 
did virtually the whole Committee, I think, and to strengthen--
reauthorize and strengthen the Support Act.
    I am committed to ensuring that older adults are able to 
access the treatment and recovery services they need, and we 
have a lot more work to do on this, but we are grateful for the 
bipartisan support for not just the Support Act itself, but for 
other measures as well.
    I now turn to Ranking Member Braun for his closing remarks.
    Senator Braun. Thank you, Mr. Chairman, and thanks to all 
the witnesses for being here today. This is a unique Committee 
because we are able to delve into a lot of subjects that just 
don't get covered elsewhere across the many other committees.
    It is sad when you have to have the focal point being older 
Americans on a topic like this, and that just shows you that 
when you have got something so insidious, so harmful, that it 
can reach anyone, and when you look at how we confront it, I 
think it is clear, we have got to prevent it.
    We have got to be tough on the enablers, and until China 
accepts the responsibility that it is in a lethal business and 
gets rid of it, the cartels will still try to probably get it 
from somewhere else, but I think that is where it starts.
    We need to keep exposing light on the situation, doing 
research on it to make it clear for all Americans to see how 
big a problem it is, and I am glad that we are on a Committee 
that we will keep this in the limelight until something 
substantive occurs. Thank you.
    The Chairman. Thanks, Ranking Member Braun, for your work 
on the hearing and for your comments just now. I want to once 
again reiterate our thanks to each of our witnesses for taking 
the time to be here out of your busy schedules and to bring the 
benefit of both your experience and your expertise to bear on 
these issues.
    If any Senators have additional questions for the witnesses 
or statements to be added, the hearing record will be open for 
seven days until next Thursday, December 21st. Thanks, 
everyone, for joining us today. We are adjourned.
    [Whereupon, at 10:56 a.m., the hearing was adjourned.]

   
      
      
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