Transcripts For CSPAN2 House Hearing On State Efforts To Combat The Opioid Epidemic 20240713

Speemac. [background sounds] subcommittee on Oversight Committee will now here comes the order. It is hauling hearing in china and the public help emergencies, to curb the Opioid Crisis. The premise of todays hearing is to examine states efforts and successes and adjusting the Opioid Epidemics as well as opportunities for future federal support. And just to let everybody know, doctor alexander, the reason why we are Getting Started a little late. The plane was delayed. But now the dr. Is on our way. We will swear in the witnesses when we get to that. If we have to do that later we will. The. [cheering]. Will now recognize the suffering Opening Statement. As i said, today the committee contends his bipartisan efforts to combat the Opioid Crisis. As we know, the countries in the midst of an epidemic unlike any of recent history. According to the centers for Disease Control and prevention, from 1999, 2017, nearly 400,000 people died from opioid overdoses. In 2017, more than two thirds of Drug Overdose deaths involved opioids. The crisis, asked continued to evolve and the challenges that we face have continued to evolve along with it. The first wave of this crisis began in the 1990s, when they were prescribing him pain medication. The second way began in 2010 and it was increased as new to heroin overdoses. Unlike the first two waves, the third wave marked live the rise in synthetic opioids like fentanyl had shattered lives, traumatized families and devastated communities. Now, unfortunately it looks like a fourth wave of the crisis may have already arrived. It weighed epidemic asked fueled a huge increase in methamphetamines use and in 2018, no more than twice as many deaths involving deaths as many increasingly turning up the bus across the country. Given the complexity of the epidemic, and its ability to evolve, state federal and Government Agencies must remain vigilant. To that end, this committee asked taken numerous steps to escape the origins and drivers crisis. So we cant learn from it and try try to get ahead of the next wave. Through committee parents, we have are from state federal agencies and drug distributors about the roles and responses. In the groundbreaking work live the committee uncovered some of the failures led to where we are today. In looking forward we will focus on identifying ways to extend this crisis and bring relief to the millions of americans who are suffering. As part of that effort, our committee asked worked across the aisle to pass Bipartisan Legislation to finally give states the tools and resources needed to help those impacted live the disorder. These legislative packages provide the state millions of dollars in federal funding for response treatment and recovery efforts. And when we have made some progress. The provisional data indicates that the Drug Overdose deaths have fallen for the first time in decades. While the downward shift is welcomed, the crisis is far from over. We must continue to look for ways to bring relief to struggling cities and counties throughout the country. Jason continues on bipartisan efforts. David and day day out, since on the frontlines of this epidemic that kills more than hundred and 30 americans every day. As the epidemic now enters the new decade, they face the challenge of keeping pace of the evolving prices. In keeping with us, and his bipartisan commitment finding solutions for this National Emergency, last september the committee set letters to 16 states requesting information about on the ground efforts to the epidemic. Kemeny asked sought to understand the federal funds actually hit the hardest hit communities. How the use and what strategies have proven to be successful. Today we have five key states that each received a letter in this committee. He states represent the first line of defense against the prices and eat less pivotal roles in recovery efforts. I want to thank all of you for coming today. The states compose a large swath of the country. On the demographics and geography and challenges. , each asked felt the effect of this epidemic. And they all rank as among the highest overdose death rates. In fact each of them have taken a number of steps to curb the epidemic. For example, pennsylvania was able to distribute nearly 13000 get free of charge in 2018. And again in 2019. Thanks to a combination of state and federal funding. North carolina, provided treatment to 12000 uninsured persons things to again to federal funding and rhode island is unable to send medication in the present system resulting in a 62 percent reduction in Overdose Deaths. This is just a few examples of how the states are fighting this epidemic. In helping communities. As Congress Considers future action to address this crisis, all of our Witnesses Today provide important insights on how federal funds are being used to, the epidemic. When efforts are proving successful and what we need to do for further improvement. I think the witnesses for the service and for being here to testify and may have other states. I look forward to hearing how we cant all continue to Work Together to find the desperately needed solutions. With that i am pleased to yell purposes of an Opening Statement. Thank you for hauling this important hearing. Our local communities are suffering on average hundred and 30 americans die every day opioid overdose. There are involved in 47600 Overdose Deaths in 2017. Which accounted for 67. 8 percent of all Drug Overdose deaths. In kentucky, there were 1160 reported opioid involved deaths in 2017. The Commerce Committee asked been set out in its efforts to help combat the Opioid Epidemic. Mother was Committee News investigation for the Prescription Drug and heroin epidemic. The major opioid manufacturers, we have continued to ask questions and get the answers for the american public. When he comes to legislation, the Committee Led the way for the 21st century act. Comprehensive recovery act. , all of these laws which are designed to combat the Opioid Crisis to prevention, and is in treatment and recovery initiatives and protecting communities and bolstering our efforts to fight synthetic drugs what is known. This hearing is the critical opportunity for us to check in with states. Those of the our on the front lines, to see how the federal money on was asked been allocated and spent. While success is they are having, but that also what challenges they are still facing and what additional authorities and resources cant be helpful. Good news is that each state testifying before us today asked seen a decrease in their overdose death rates. Federal assistance is making a difference. In addition states are creating and implementing innovative approaches to combating the epidemic. Examples include expanding efforts to connect people to treatment through ambassador and Emergency Departments, expanding increasing availability of medication assisted treatment. Increasing nonemergency transportation treatment for those in rural areas. Expanding the neonatal treatment programs. In efforts to address workforce issues to the initiatives such as different programs running the curriculum. This hearing is the great platform. This is for the state to make a difference in what programs they are working. Not only is the helpful for us in congress as we continue to connect oversight and light display, but also to the state, they cant learn from each other. About new ideas and innovative approaches that cant be implemented. While progress is being made some of the overdose death rates are declining, the direction of National Institute of drug abu abuse, doctor and more, declared this week this country still asked not controlled this addiction problem. Some states, are continuing to see a high of First Responder Emergency Department encounter overdoses. In addition, states are still facing many challenges including a lack of qualified workforce and infrastructure printed and restrictions on funding including restricted to opioids and flexibility to address emerging challenges. In addition, our starting to see polySubstance Abuse and Overdose Deaths. This estate specifically stimulus such as an methamphetamine and cocaine. Thats a going concern printed is been detected in more deaths in opioids such as oxycodone and on cape cod on printed 14 of the 35 states, the report Overdose Deaths on with the bases, math is involved in more deaths than fentanyl. Can do with our partners n this fight. And i will yield back. The chair recognizes the chairman of the committee for five minutes. Todays hearing continues the ongoing bipartisan efforts to combat the Opioid Epidemic with a fuel by synthetic drugs putting people, families and communities at risk. It requires ongoing federal state attention. The states on the frontlines of the National Emergency providing much of the support for those in need. They are our eyes and ears the latest in a series of dreams held on the crisis and the occur from several states including rhode island on the ground efforts to the epidemic and we also hear from federal agencies about the urgent threat of fentanyl. The Committee Conducted bipartisan investigations of opioid distribution practices the energy and Commerce Committee has also been at the forefront passing the legislation that gives our federal state and local partners the tools and resources required to succeed in the fight including three pieces of legislation that would give the funding and support. In 2016 the committee passed the comprehensive addiction and recovery act and 21st century cures act which to mention its a major role in that. They authorize over a billion dollars of state specific grants and help the states bolster evidencebased treatment prevention and recovery efforts. In 2018 the support act was passed and signed into law reauthorizing of specific funding increasing the abusing overdose training and improving the coordination and quality of care. Then in december the house passed hr three that included 10 billion in additional opioid funding. The committee is committed to making sure the communities are receiving the support they need to get relief from the crisis and the states requesting information on how federal funds and put additional hope the congress can provide. Based on the responses theyve taken important innovative approaches to addressing opioid addiction and one of the most effective tools that is available to the states as medicaid. Several states elaborated on the Important Role demonstrating the crisis in response to the committee. The release last week found about 8,000 lives have been saved from an overdose thanks to the medicaid under the Affordable Care act. We want to hear about any emerging trends they are seeking for examples of all states informed the committee they also see an increase in methamphetamine and policy substance. This of course is an alarming trend for threats t of threats e next epidemic and i want to hear how congress can help the states come from this. Thanks to the witnesses in forward to hearing about their efforts. Thank you madam chair for continuing your efforts on this. I dont know if anybody wants my time, but im happy to yield back. The chair recognizes the Ranking Member of the full committee for five minutes. Thanks for holding this critically important hearing as i was preparing for this, i noticed in the county in my district they have a solo alert up for opioid. The two overdoses on average per week in jackson county. They had seven last week but fortunately no deaths. First responders administered in five times last week and they believe that its probably heroine with a pretty heavy dose of fentanyl. The deadly scourge continues. As he per the energy and Commerce Committee in this subcommittee in particular has been at the forefront of the efs to address the Opioid Crisis and Substance Use disorder issues, and weve done a lot of work on prevention and we know we have a lot more work to do. The committee has held hearings on the Opioid Epidemic for nearly two decades from reining in Perdue Pharma to testify in 2001 about the abuse of oxycontin to the bipartisan investigation into the rise of fentanyl, opioid manufacturing, distribution and Substance Use Disorder Treatment industry. They helped inform the legislative work including the comprehensive Addiction Recovery act 20 to authorize the state targeted response of the crisis grant and more in the federal appropriations to boost programs that fight, treat of use and access to Mental Health services. The signing into law in my home state of oregon we have seen the results of 3. 1 reduction in the opioid deaths based on the recent statistics from the cdc. Im pleased we worked together in this space including by continuing work on fentanyl and with this important hearing today examining how states are utilizing the funding and authority provided by congress. But theres so much more we can do together earlier this year energy and commerce published request for information about the Substance Use Disorder Treatment industry. The buildup for the patient investigation that we conduct it in the last congress, and this investigation brought us to the question of what is good treatment, and conversely what is bad treatment which is the central question posed by the rfi. With the billions of dollars we need answers. Yesterday energy and commerce sent a letter to the opioid manufacturers we began investigating together last year in Congress Asking them to complete the reduction to the request. Its critical we fully understand the causes of the epidemic in order to ensure that solutions are the right ones and its important that the answer the questions. We should also hold a comprehensive series of earrings to conduct oversight and implementation of the act for example relevant to todays hearings the act include the info act sponsored that calls for the creation of the public and acceptable electronic dashboard linking to all the nationwide efforts and strategies to combat the Opioid Crisis. The act was designed to meet the specifispecific need of local stakeholders who were telling us despite congress having to vote on record numbers into trouble finding the resources that were available and where they were. Certainly an issue we heard a lot about from mr. Mckinley and others. Its critical in helping those on the frontlines of the crisis and we are concerned about the implementation. In concern fo conference of thet we need to be working on the next wave of this nation to address not only Opioid Crisis but Substance Use disorders and we need to reauthorize the fentanyl band set to expire a matter of weeks in the prohibitions on various forms as broad bipartisan support we should do that expeditiously. Todays hearing is a step to understand the impact of the dollars on the states and i want to thank the witnesses for being here and being part of the equation and i look forward to hearing from you. With i will yield the balance of my time to mr. Burgess. Of course it was under your leadership to the committee that last year we worked on a bipartisan manner to produce legislation that ultimately signed into law by President Trump in october of 2018. And theandy began in the subcome with hearing from over 50 members it was to help the advancement initiatives for those affected by the opiate. You will be helpful in understanding the challenges that we faced continuing the fight against the addiction while ensuring they can manage their pain is important to congress to have hearings like this where we can ensure the effectiveness of the efforts to identify accounts where they exist. I will yield back with a notation that we have to subcommittee upstairs so we will be coming and going between hearings. Jennifer smith is the secretary of the department of drug about the whole programs. Doctor monica, the commissioner and Alexander Scott, i think they deemed you hear from the airport, so congratulations. Shes the director of the department of health and the state of rhode island. The commissioner bureau for Behavioral Health, department of health and Human Services state in West Virginia, welcome, and the deputy secretary Behavioral Health and intellectual development of disabilitys department of health and Human Services in North Carolina, welcome to you. Thanks all of you for appearing in front of the subcommittee today. As you are aware of the the come is holding an investigative hearing and when we do so we have the practice of taking over testimony under oath. Do any of you have objections to testifying under oath today . Let the record reflect the witnesses responded no. We advise you under the rules of the house and the committee you are entitled to be accompanied. Do any of you wish to be accompanied by council . The witnesses of responded no. Iq. What would you please rise and raise your right hand so that you may be sworn in. Do you swear that the testimony you give today will be the truth, the whole truth and nothing but the truth . You may be seated. What the record reflectlet the e witnesses responded affirmatively at all if you are now under oath and subject to the penalties set forth in title 18. In front of each of you there is a microphone and a timer and series of flights. The timer counts down and the red light turns on at the end when youre five minutes have come to an end. Members of the subcommittee my name is Jennifer Smith and undersecretary for Pennsylvania Department of drug and Alcohol Program as well as a member of the National Association of state alcohol drug abuse directors. Thanks for your interest we are using the state opioid response funding to promote prevention, treatment and recovery efforts. Acting as the Single Authority for Substance Use disorder services, my department coordinates efforts with federal, local entities as well as the cross state department. Our ability to orchestrate resources and direct policy during the Opioid Crisis has been a crucial component in effecting longterm change maximizing Resources Available to the communities. We are grateful for the federal grant opportunities afederalgrae of hopelessness and despair for families and communities. I can say with certainty that this has saved lives. With a population of 12. 8 million, pennsylvania is the fifth most popular state consisting of 67 counties that range from large urban centers to the rural counties. The number tragically doubled to more than 5400 lives lost or 13 deaths per day. They keep the pennsylvanians alike and that meant infusing the molds them into the the communities come implementing handled particles to transfer using overdose survivors from Emergency Departments into treatment, expand access to medicaid practices for justification of assisted treatment and launching the 24 7 get help offline. What will it isnt clear it is clear the 230 million in federal funding that the state has received is making a tremendous impact. We have fused the resources and the momentum of the crisis to collaborate, modernizing innovate using dollars across the full continuum. In prevention week reduced opioid prescribing by 25 of developed prescribing guidelines unincorporated addiction content into medical School Curriculum and established over 800 Prescription Drug paperback boxes across the states. State. In treatment, we established a Standing Order and distributed over 55,000 free kids, developed a handled model and expanded treatment capacity through 45 centers of excellence. They offer loan repayments and awarded 3 million to expand we awarded 2. 1 million to expand Community Recovery services, developed a website to share recovery stories in desperate hope and awarded the grant funds to build Recovery Housing support. In the coming months, pennsylvania will be focused on integrating quality into our four major goals of reducing the stigma, intensifying primary prevention, strengthening the treatment system and empowering sustained recovery. Without the sustained federal funding the collaboration necessary to accomplish these goals will be greatly diminished. Although weve made significant strides in our work i, our worke and we need your help. In terms of funding, we need flexibility to address the system, not a substance. We need consistency with funding vehicles and reporting mechanisms where possible such as utilizing a block grant and continued use of the Single State Authority as the central coordinating entity. The continued relationship fostering stigma reduction and integration of services, the entire system of care is a monumental task. We are working diligently and we have made staggering progress. But please dont give up. The longterm success of the program and community depends on sustained funding and support. Two other quick considerations would be to address the stigma in a uniform way across the nation through language and action and seek ways to address the dire workforce challenges experienced by every state. Thank you again for allowing me to share with pennsylvania is having another suggestions for a moving the system forward. I look forward to answering any questions that you may have. Dont worry, we dont intend to give up. You are recognized now for five minutes. Ranking member and members of the subcommittee, thank you for the opportunity to speak with you today. In my role as the commissioner of Public Health and as the states chief physician, im dedicated to addressing the epidemic in massachusetts. I commend the congress and federal agencies for funding those working tirelessly on the front lines every day. Our data indicates that in indin massachusetts, our Public Health centric approach to the epidemic is working. Im heartened to let you know that from 2016 to 2018, our opiate Overdose Deaths have declined by 4 . We continue to focus on prevention and education, the availability, medication treatment, Behavioral Health counseling and assisting Recovery Support. We have made progress, but its still unacceptable tha but neary 2,000 individuals in massachusetts died from this preventable disease each year. In my clinical practice i care for people with this disease and i never forget that behind these numbers which we will talk about today are real people, their communities and their families. Since 2016, weve been awarded approximately 159 million in federal funding specifically for the opiate use disorder prevention treatment and recovery entries allocated 111 million of those fun. With the expansion and enhancement of the treatment system for datadriven approach that targets high risk, i need a priority population in the spirit of use with the goal of reducing opiate overdoses and deaths. In 2015, governor baker appointed a group that developed an action plan emphasizing the data to identify hotspots and deploy appropriate resources. Additionally the wall referred to as the Public Health Data Warehouse enabled us to link 28 different data sets across the State Government and establish a Publicprivate Partnership to maximize the use of the data to study this major Public Health crisis. This was unprecedented in massachusetts. So, the approach started with Data Analytics and research allowing us to get a deep understanding of who was dying when, where and why so that new investments could be stripped check and impactful. The data lead us to quickly focus our efforts on five key populations of peaceful were still suffering from overdoses and Overdose Deaths. Incarceration, communities of color, persons with Mental Health and Substance Use disorders, people with a history of homelessness and mothers with soviet use disorder. The data showed a rate of Overdose Deaths of mothers with disorders was more than 300 times higher than those without. In response, one of the programs was moms didnt care which is currently an hundred federally funded. This innovative approach to a Seamless Integrated continuum of care for women with Substance Use disorders. It provides access to medication, prenatal and postnatal care, maternity and pediatric care, Behavioral Health counseling and peertopeer Recovery Support and so much more. We are supporting and expanding our Drug Monitoring Program allowing all of massachusetts prescribers enhanced access to this vital system. Why do we have had many successes, we do see opportunities for the federal assistance so we can continue to make progress. This includes funding that is flexible. When funding requires addressing only opiate, the states are limited in the flexibility to address the changing landscape of Substance Use disorder. It would enable others to this epidemic such as cocaine and methamphetamine. Additionally, there are currently several values to medication treatments such as methadone into these barriers should be removed. This would allow medication to be regulated or similarly to other chronic disease treatments and available in Traditional Health care settings with increased access and reduce the stigma. In conclusion we are grateful to the congress for the commitment to address the Opioid Epidemic. Much of the progress can be attributed to federal funding we have received and i encourage the congress to continue the federal funding efforts. This crisis do than to build overnight and it will take time to reverse. Addiction isnt a choice, it is a disease and with support of our federal partners we will build a solution to tackle this epidemic in massachusetts in this country. You are recognized now for five minutes. In the commissioner for the bureau of Behavioral Health and the department of health and human resources. And i also serve as a member of the National Association of state alcohol and drug abuse. I want to thank you for your commitment to address the crisis without the resources provided by the committee, West Virginia would be in a considerably less position. I want to thank you for the opportunity to discuss the importance of the initiative to address the Opioid Crisis and impact of the funding made available to promote treatment and recovery for Substance Use disorder. It is no secret that West Virginia had been ground zero of the crisis with the highest overdose rate. There are winning stories that describe what happened to the state and im sure these efforts have played a significant role draining the resources to West Virginia but today i would like to tell you a different story. With your help West Virginia has reduced the deficit for the first time in over ten years. With prescriptions and opioid doses have been reduced by 50 while the prescribing has increased by 208 . The capacity had been transformed into the number of people that can prescribe be the morphine have doubled from 243 to 584. Weve increased the number of treatment beds from 197 to 740 records indicate that they are about 85 full at all times. Additionally, nearly all facilities have access to integrated Substance Use Disorder Treatment in the communities. This extraordinary increase in infrastructure capacity is the result of this second Financial Investment of the federal, state and drug federal funds. To distribute the lifesaving and two the rigorous education on the prescribing increased evidencebased pension programs and stood up quickly response to followup on individuals with experience nonfatal overdoses. In addition to these efforts, the state also increased its infrastructure for surveillance and data analysts and this drives all of the decisionmaking. The state complimented the work the federal projects by using the funds and revenue to undertake the development of the projects that expanded the availability of the digital treatment including facilities that specialize in pregnant and postpartum women. The scope of the problem required a Financial Investment to respond to the crisis raiding the funds allowed them to balance the need for the interventions and services with the longterm needs to address the systemic issues that serve as an ongoing challenge to the states opiate response. While significant progress has been made, certain barriers and challenges remain. West virginia continues to experience substantial workforce shortages and the training related to the stimulants and Substance Use the lack of capacity to serve children impacted by the crisis and in addition to concern when utilizing timelimited grandfathers and sustainability of effort and thinking about a bigger and longer Term Investment of these are to have increasing availability and reducing Overdose Deaths. The predictable and sustained provision of resources is the key to allow the stated providers to play and rely on the commitments and it can be to plan and operate programs that providers are not confident resources will be available beyond the oneyear commitment. It would be difficult to believe West Virginia could have accomplished so much without the support of the committee. They have allowed them to have the resources needed to respond to this crisis that resulted in a decrease in Overdose Deaths that are down at this point and the records say by 10 to be the financia. The financial resourcee crucial to the continuing success and maintaining momentum ongoing funding for state alcohol and drug agencies to coordinate prevention Treatment Recovery services and continue progress while they remain West Virginia is a place to address the future challenges and continue its progress. In summary we continue to say thank you to the committee, thank you for your support and for the resources and for allowing us to share what is happening and what is working in West Virginia. I would like to recognize you for five minutes. Thank you Ranking Member and members of the subcommittee for the opportunity to testify on North Carolinas response to the epidemic. On behalf of the 10. 4 million approximately 26,000 have misused prescription orde or ilt opioids im allowed to express my deepest gratitude for your support of funding that has helped us turn the tide on the epidemic. It saved lives got transformed communities and has made the down payment on breaking the cycle of addiction and poverty in the state. Im also grateful to the committed staff of numerous federal agencies for the concerted strategy working across interconnected systems with healthcare, housing, employment and justice. North carolina was hit hard by the justice. In 2016, 1,407 died of an unintended overdose. We were one of the top eight states for deaths. Since the start of the epidemic nearly 100,000 workers have been kept out of the workforce because of opioid misuse alone. Today close to half of the children in North Carolina sponsored care systems have parental Substance Use as a factor in the out of home placement and of course the human cost for most of the communities and families is immeasurable. The scale of the problem underpins the magnitude for the accomplishment. The response is organized into three pillars. Prevention, Harm Reduction and connection to care. These encompass numerous strategies all made possible in the federal funding. Cutting the supply of the prescriptions making access to lifesaving, supporting exchange programs, making addiction medicine the core of the education, partnered with county and local communities, launching intervention at the start of the treatment the time of the reversal coming and blending together the broad efforts to support the housing employment and address the causes of the Substance Abuse disorder. With the separate North Carolina for the first decline of deaths in five years decreasing 9 between 2017 to 2018. Weve also seen the 24 decline in the prescribing and 20 increase in the number of uninsured individuals receiving treatment. 1 million north carolinians do not have Health Insurance and health of the visits to the emergency room are uninsured therefore the highest priority has been expanding evidencebased treatment for those without insurance. We focused on medication assisted treatment providing to an additional 12,000 people. The success is clear but with your help, theres much more wee can do. We can stretch further if its no longer required to obtain a waiver for addiction. Theres no additional waiver required to prescribe the exact same medication being prescribed for other conditions. We should strengthen the focus on just the population to study found exiting North Carolina prisons were leaving North Carolina prisons were 40 times likely to buy it in opioid overdose in the general population. We are grateful to have recently received the 6. 5 million grant from the department of justice to create these programs and expand the jail based treatments. But we have a long way to go. Most significant would be giving us more time. The same funding over longer windows of time or permanently would allow them to the next wave of the epidemic. That is already pressing as we start to see the rise of Overdose Deaths from methamphetamine. Before major federal funding in this epidemic became available, 12,000 people in North Carolina have already died. Meanwhile, North Carolina shared the Substance Abuse prevention treatment block grant hadnt changed in recent years when North Carolina was one of the Fastest Growing populations growing 9 between 2010 and 2018. Growing the block grant with inflationary cost updated allocation formula would allow the states to make better use of shortterm funding to prevent the next epidemic and save lives. Most of all, safeguarding the Affordable Care act is critical to the longterm success of the fightinoffighting the opioid ep. States with higher rates of coverage of more sustainable ways of providing treatment and are able to prioritize their precious federal block grant dollars on the system investments. This is why we are working hard everydaevery day to expand medin North Carolina. In closing, i want to applaud the flexibility of much of the federal funding we have received which has allowed each state to respond to its own pressing need. Our strategies are working with our eyes are on the horizon. We appreciate your leadership and i welcome your questions. Doctor Alexander Scott you are recognized for five minutes for your Opening Statement. Chairwoman, Ranking Member guthrie and distinguished members of the committee, thank you for inviting me to join you today to discuss Rhode Islands efforts to address the opioid overdose of epidemic. Collaboration between states, federal agencies and federal leaders such as yourselves is critical to our shared goal of preventing overdoses and saving lives. The fish you has taken a staggering toll on my state. Since i became the director of the Rhode Island Department of f health in 2015 and Overdose Deaths have occurred during this time, more rhode island have lost their lives to Drug Overdoses than two car crashes, firearms and fires combined. Almost immediately after coming into office in 2015, governor gina warren Overdose Prevention Intervention Task force to develop a centralized, strategic data driven comprehensive plan to prevent overdoses. The task force include stakeholders and experts in various fields including Public Health, law enforcement, Behavioral Health, communitybased support services, education, Veterans Affairs and recovery. As a cochair of the task force, ive helped steer the efforts into the four focus areas, prevention, treatment, recovery and rescue or reversal. Weve changed the culture of prescribing and have dramatically reduced our prescribing numbers. We now have a vast stairway to e Treatment Network in place. We have cultivated a group of certified peer Recovery Specialists that walk sidebyside with people in recovery. Weve put thousands of kids onto the street and most importantly wwe started to give people hope and we are focusing on the community level. Weve learned regardless of the resource, ethnicity, zip code, income or insurance status, every door for every person should make treatment and Recovery Services available. We believe that addiction is a disease in recovery as possible. One prime example is the story of jonathan from East Providence rhode island. Jonathan became dependent on opioid 16 years of age. At 25 come after more than 30 tries in after reaching depths many of us cant fathom how he was able to maintain a life in longterm recovery. He is now thriving as an expert adviser to the Governors Task force and he leads our states recovery workplace program. The opposite of addiction is connection. This is true for every community. We are trying to make the connection and the sense of the community that for jonathan and so many others back from the brink part of every overdose preventioprevention effort thatn place in rhode island. We have had some success. After the number of deaths increased each year in rhode island for the better part of a decade, the number decreased by 6. 5 between 2016 and 2018. However, significant challenges remain. Send them all related Overdose Deaths continue to increase and opioid conversations must be considered within the larger context of an addiction epidemic that has alcoholism, tobacco use, cocaine and other substances involved. We can broaden the scope even further to talk about the Health Implications of the social and emotional isolation and the need to address the root causes of the challenges in our communities. All of this requires us to look beyond what many believe to be our traditional focus areas and Public Health. We need to look at the socioeconomic and environmental determinants of health which determine luckily 80 of what makes you healthy and what makes me healthy. These were factors like access to quality education, access to fresh fruits and vegetables and reliable transportation. We need to ensure all children grow up in homes and go to schools where they feel safe, supportive and flipped to ensure people have houses that are healthy, safe and affordable and to ensure people have jobs that offer fair pay. This is part of our response. The efforts and progress i dont find today wouldnt have been possible without the tremendous contributions of congress and federal agencies you find. Thank you for that sincerely and i look forward to partnering with you to address what lies ahead and on behalf of the association of state and Territorial Health officials where i serve as the immediate president. The chair will recognize herself for five minutes. As i mentioned in the Opening Statement in as many of you mentioned, and thank you, the committee has been focusing on the Opioid Epidemic for quite a number of years. This Committee Last few congresses i was the ranking democrat and now i am the chair and its been a bipartisan effort over the years to help address this crisis. Over a number of pieces of legislation into the 21st century act which congress and opt in and i sponsored, we provided tprovided to states wia considerable amount of funding to address Substance Abuse and so we are happy to see some of them have been used as a part of your efforts. Several of you mentioned that the we need to give more flexibility to the states to address the system and not the substance and i wonder if some of you can talk about what we need to do to get the flexibility of some of the substances to shift. Would you want to expand on that a little bit . I would be happy to. You mentioned the poly Substance Use and increase in particular in many states across the nation are seeing. One of the challenges has been the focus being on opioids. Its been a little bit challenging depending on the type of programs that we wanted to establish in making sure that we were appropriately tidying up to opioid the same time recognizing folks can benefit from the program may not identify the opioids as their primary substance or even identify them at all. Do you think that that is getting more noticeable . Absolutely. Youre shaking your head yes, are you seeing that as well ask the Substance Abuse is the only sustainable tool that we havhave to build the workforce d develop the treatment resources for those individuals to go to to get ahead of the problem. Doctor Alexander Scott, you talk a lot about what rhode island is trying to do. Without this crisis now that you were not able to see a couple of years ago, are there some new things are seeing now . The increase in the percentage with Overdose Deaths. We are seeing also an increase in poly substances, multiple substances and we recognize the importance of going upstream more to get at the root causes of what is driving many of the challenges associated with Mental Health and substance. Do you think the federal, the language with some of the federal funds is restricted to address those issues . There is opportunity so we can look more upstream and engage in the community level. What would you say the key challenge that you are facing right now with addiction . We could open more for the prescribers but we do not have the therapists to be able to support the prescribing. And i want to ask you in your written testimony you said that massachusetts utilize federal funding to support expansion enhancement of the Treatment Systems. Can you tell me specifically about how the federal funds enabled you to do that and what could be done more if you have more flexibility . Absolutely. Thank you for your leadership in this area. What we have been doing in our Public Health approach in the Opioid Epidemic is focusing on of course prevention and intervention but really enhancing the treatment system as it has been said before, what we are dealing with now for many of us is trying to build a system in a place that for many decades he has been underfunded so we are trying to build systems that individuals can get the treatment that they needed. We have used some of our federal funding to enhance the treatment opportunities including increasing our treatment beds to over 1200 including increasing training and availability of space to treatments and enhancing availability of methadone. I just want to again thank you for your efforts and what you know this committee and the committee is committed to help make the most flexibility. I would remind you in the recent federal 2020 federal government funding bill, Congress Continues to invest 1. 5 billion in the opioid response grant and so in response to the changing drug abuse landscape we allow them to use the funding to address stimulant use but if theres more we can do please let us know because we want you to consider us to be your partners with that and i will recognize iyou for five minutes of questioning. Thank you i appreciated and all of you being here to tell your stories. Youve answered questions well and one thing i want to when we did the markup, our colleagues on the committee they dont know if hdidnt know if hn amendment or made a point that different communities have different issues involve opioids i remember the discussion being the amount of resources we are focusing on. I hope this as you bring more workers using the money you cant always use the opioid money for another substance that helps to build the infrastructure that has the same kind moving forward and we do need to open up to look at that. That is something we absolutely need to look at. Something that was interesting to me as we were having a hearing because some families thafamilieshave experienced thid about the patient brokering and walked away appalling that there didnt seem to be any but he was in a state which is from one brokerage to another and a couple of you have looked at that. Its my understanding rhode island certifies the Recovery Housing and started the certification two years ago. Can you talk about the certification process and why rhode island started it and about how many recovery homes you have certified . I would be happy to provide Additional Information to support this. Since the hospitals recognize the importance of having social determinants of health addressed such as housing and Recovery Housing is a critical tool for supporting those living the lives of recovery like jonathan i mentioned earlier. We wanted to make sure that there was a level of quality and standards across all of the recovery houses that were available and the Sister Agency in rhode island oversees the certification to help establish those standards. I can get back to you on the numbers that we have a three country houses that are available, but this has been a quality data driven program that we have felt to be critical to supporting this Opioid Epidemic. Also it is my understanding that in the last year pennsylvania passed legislation that enables the department of drug and Alcohol Programs to regulate and license Recovery Housing. It receives federal funding. Can you talk about why you need to do this and be effective if and when it goes into effect . It was passed by the legislature and our governor for the same reasons that it was in other states like rhode island. We were definitely identifying ish news as parents and advocacy groups through individuals who were attending Recovery Housing offense and noticing that there seemed to be some inconsistencies in the practices. So we felt it was critical to pass some kind of legislation that enabled us to have oversight of these entities. What is interesting is that we dont know the exact number of current recovery houses operating. We know that it is in the thousands so what this with this legislation will enable us to do is create cool legislations of any Health Receives referrals or funding from state or federal entities with us to be licensed by our department so it wont require every house in pennsylvania be licensed, but the hope is folks are utilizing the website that contains the Licensing Information to utilize those licensed entities that they know has a level of Quality Services and maybe it will reduce business that some of the more scrupulous entities. The issue in general when we talk a lot about this, i know that [inaudible] i only have a few seconds, so maybe one of you. Ihave you reduce federal coffers for this and ha have it reducedt in your state if anyone wants to go first, anybody working with that specifically . To provide treatment to women affected by the Substance Abuse disorder. It doesnt come sometimes it can increase with the use of medication but our babies are being born over year and the outcomes are better. So we are optimistic with continued effort we can make more progress. Thank you. I will yield back. Thank you, madam chair. As congress and the commit or consider action on this, i would like to hear more about how the federal been used to make a difference in based on the states submissions to the committee that i mentioned in my opening it appears that several have successfully used federal funds to respond to the crisis is what we see how many i can give to hear. In your testimony to federal funding has enabled North Carolina to provide used to thea treatment for 12,000 people and in the same testimony you mentioned and i quote since 2015 was the first of the federal branch received North Carolinas first decline in opioid Overdose Deaths in five years decreasing 9 from 2017 to 2,018th so what factors do you attribute this success in reducing the Overdose Deaths in providing treatment to people who really needed . Our focus has been 100 of medication assisted treatment and the distribution and communities. The distribution has been directly tied to the definite reduction but we have seen. And after that, they move individuals and to recovery and goes like pure support specialistspecialist sweetness d Emergency Departments and weve worked with our local providers to conduct people into treatment so that an individual because the reversal does not want to go to the hospital they can begin their judgment to plan and theres a group of folks that come out and see th to see the s after the fact. That is the name of the very strategic focused interventions like that that have moved people into recovery and treatmentthat have been important for us. I was encouraged to hear pennsylvania has witnessed an 18 increase from 2017 to 2,018th of what factors do you attribute and one of a few key areas pennsylvania should focus on the continued trend . The key is not all that different actually. The focus on getting it into the communities and big focus on what we call the one hand off process which is getting overdose survivors from the hospital into treatment. We had a major issue in our systems with individuals overdosing and being quickly released back onto the streets to overdose again so those have been key for us and moving forward we would like to spend a little more time and energy in the prevention space before we get to worrying about it and needing to activate the hand off process but our primary focus is really keeping people alive now that weve started to get a handle on that and expanding treatment i think we can spend some time and energy thinking about looking upstream and how w do we improve our prevention efforts. Thank you. Let me go to Alexander Scott with regards to Rhode Islands response to the committee. The federal funds have enabled the states to improve the data surveillance treatment capacity and support innovation and delivery of treatment. Can you give some specific examples of how the federal funds have helped rhode island . Multiple examples similar to what has been mentioned. Since you asked about data specifically, we use the data as realtime as possible. We obtained 48 hour reporting from our Emergency Departments for any suspected or actual overdose that have occurred. In all the weekly basis we have a Cross Agency Team that assesses where they are. They mapped across the state and we released the advisories through municipalities, the Key Stakeholders and providers to focus on areas when the Overdose Deaths have increased beyond a certain threshold. That allows us to drive out the need of the resources that we have based on the data in realtime at the locarealtime as one example. We continue to expand treatment and Recovery Service with the intention of meeting people where they are. So reaching folks through the mobile recovery treatment vehicle is another example if i can get West Virginia in, the treatment system has overhauled the response of the crisis and much of the work has occurred as a direct result of the federal funds awarded since 2016. Do you want to give us briefly some examples of how the federal have provided these Recovery Services to the disadvantaged parts of the state . We now have people in all of the counties able to receive thats when the number one success we have experience with the federal funds. Thank you madam chair. I recognize the gentleman from oregon for five minutes. Its a big problem in districts like mine from the atlantic to ohio. At my roundtable in districts in oregon, 2017, i heard from a woman that had to travel from five hours to another state to find a provider to get her off of her addiction. For each, what is your state doing to address access where there is no local health . Thank you for the question. North carolina has 100 counties. We have about 20,000 people a day in our Opioid Treatment Program into the largest strategies to address the access has been first and foremost moving as much care into the office based outpatient treatment as programs that is how we would like to see the data act waiver requirements moved to try to make that easier. Weve doubled the number in North Carolina and have a long way to go. We are not going to get the largescale providers there. We have been investing in the project eecho which is a leveraging ability to try to get the providers to provide the support they need to take on the patients. Theyve administer these other treatments. Does anybody else want to weigh in on this . Pennsylvania is fortunate in that we have a large number of opioid treatment providers already in that state, so that is an advantage for us but to assist communities, we have a particular grant grant where we are expanding access to medication assisted treatment in the rural areas thanks to the grants from the federal government for those in areas hardhit bhard hit by the opioic that commitment for that program is that you have to have two years of experience treating patients and commi cometh to an additional two years treating in that area. I want to move onto the authority to issue. The confidentiality. I heard a lot from providers about how this impacts negatively the exchange of information regarding individual Substance Abuse Disorder Treatments and other health issues. We passed legislation overwhelmingly to try to address this, protect privacy and allow the right flow of information to other medical providers. It went up in the rocks in the senate and i would like to see us renew our efforts here. Can you also may briefly are you seeing patients infected by this . Ive heard from providers in my district. Yes. In massachusetts we provided comments related to this and the obstacle that the producers as we have started to think about the next step of what needs to happen to fight this epidemic. One of the issues is around appropriate Behavioral Health integration, both with Mental Health issues and Substance Use issues as well as how to connect back to the medical care that individual needs and the obstacles they are. Are. Of others run into this . There is a place to be aware of where it may be considered is within the school system, making sure the School Nurses and psychologists are able to exchange the information needed to care for children who have mental call for even Substance Use challenges. Do othertwo others want to cn this . North carolina is fully supportive of modernizing an attempt to both maintain privacy but also to move us to integrated care. I think what is important as wee also have to systematically address the stigma to help the systematic exclusion of individuals from housing and everything else. Exactly. You said above i was going to say. It has to be the primary concern here. I think its important to protect those individuals, but at the same time, i dont know how we move to a truly integrated system of care when we treat their records differently. We keep talking about treat them the same as everyone else, treat them the same as someone with Heart Disease or diabetes. But i think we need to change the conversation. Which has led to deaths and we need to fix this. I hope we can renew this effort to pass the reform. I know the administration has done some things they could in the existing law its an issue that we have been working on for a long time, and we do need to find a resolution. The chair recognizes the gentle lady is a schakowsky for five minutes. In 2018, the overall rate of opioid Overdose Deaths in illinois so for the first time in five years. The decrease was likely impacted by the efforts of this committee and the congress to combat the Opioid Epidemic. But this trend was primarily driven by the decline among the white residents. Today in illinois, opioid overdose of blacks and latinos continue to rise. In fact, my hometown of chicago experienced more Overdose Deaths in homicides in 2017. Of the 796 who died from the opioid Overdose Deaths that year, 400 were africanamerican. In a recent study from the american journal of Public Health found that black and hispanic residents were more likely to experience fentanyl deaths. That doesnt square with the perception of the Opioid Crisis as a white suburban and rural issue. Thank you so much for this question and it is such a critical issue for us. We in rhode island are starting to take a more deliberate approach to have a Health Equity lens to prevent intervention to make sure every community is impacted has the opportunity to have access to the treatments as well as continuing to the upstream root causes. And with that environmental determinants that are occurring in various communities. I appreciate this question has been raised to some extent as well. The start what you have done to expose the fact different races and ethnicities are impacted we have to make sure we are taking into account our influences that are contributing to these outcomes. And what you are appropriate and what the Community Needs to make a difference. Doctor your testimony you mentioned that you are focusing on communities of color in your state. What does that look like quick. One of our five areas we have an increase of overdoses so we have been using federal funds so to give you an example thankfully those overdoses has begun to decline from when we broke down with an increasing rate with the death of black men. So we alluded those efforts to focus on communities of color. We did some campaign as well as different communities and languages but a different example focusing on those in the community. The statistics are completely unacceptable here in chicago and metropolitan areas especially among communities of color. It would be a terrible mistake to go with overall data and not the particular communities thank you for responding to this question. I want to offer something for the record again. If i can put in the study that i mentioned, the geographic distribution of fentanyl with overt all loan over the one Overdose Deaths in cook county and u. S. News world report titled separate and unequal and overlooked. It shall be entered into the record. Thank you for the recognition. Just briefly Mister Guthrie had talked about some of the most troubling testimony on this issue was the assistant attorney general who came to testify to one of our oversight investigations subcommittees the silver homes that were located in other states so that they would be leeward to other locations of course with no real identifiable metrics whether anyone was Getting Better and i think he shared with us today not only did they not get better but the deaths of massachusetts residents as a result so as a followup to his testimony. The quality of care is absolutely critical it reaches the highest standards to a very vulnerable population. We take very seriously our responsibility all of the Substance Addiction Services we provide to the department of Public Health. And through that authority you are able to set the criteria and respond to complaints and at any time to go into inspector but now in massachusetts we have a Certification Program which must meet certain criteria standards and we have seen improvement with over 2000 beds to make just to be clear he wasnt talking about silver homes in the state of massachusetts that those that may be im sure massachusetts in january anytime to be favorable. [laughter] but thats the deal that people are leeward to come spend your winter in a sunny location and then to lose control of the situation. When you lose a resident to addiction is there a followup done on that quick. I dont have any specific examples to give you but i could have the Attorneys Generals Office followup. But one of the things we need to do is make sure we have the facilities and appropriate access to care. One really important success that many of us have is a prescription Monitoring Program and that is required from prescribing opioids connected to 37 other states and washington dc that understands the care they may receive in other states as well. And in the Senate Finance committee. So let me ask if i could but do you feel within your state the programs can share the appropriate medical records to coordinate care with Substance Use disorders quick. The simple answer is no we have invested resources through peer support to have that coordination of care but there is still a huge limitation even and doctors can talk to one another to coordinate care around the patients. I am in agreement with mister walden we should redouble our efforts. We have reform done on the house floor in 2018 we were not able to survive the senate. So when President Trump signed the big bill into law that part was removed. We need to continue to work on that because its critical and important. Thank you to the witnesses for being here today and our colleagues for their attention. You are welcome to boston any time in the winter. It may not be the warmest but super bowl rings warm you up. [laughter] event something you can experience what we are moving right along. [laughter] so the Commission March 2019 recommended the use of evidencebased injection use facilities. And to increase outreach to services so supported by the Massachusetts Medical Society and by the state legislature so can you elaborate how Harm Reduction commission with those facilities as it is explained in the report and why it does not violate federal law quick. Thank you congressman for your support around the country. So talking about the Harm Reduction of the safe injection facilities due to the recommendation to look at this further through the legislative process both at the state and federal level. Talk about Harm Reduction broadly we have the capacity to do in Public Health we have been focusing her effort on the populations that i mentioned in one of the harm pieces on reduction pieces we have expanded those two less than ten to now over 30 with markedly good Response Rates from providing Harm Reduction services to care. One statistic but all those that were handed out so to clean out neighborhoods and communities. And with those fda approved drugs and hitting the Gold Standard for opioid use disorder. So as the committee indicated there was increased medicated assisted treatment and those that are reentering the community. And if there is any disconnect to lose medicaid once they are incarcerated. I am proud to say the individuals with incarceration. And when we see when individuals are read one released they are 120 times higher that helps to and now the department of correction offers fda approved medication for opioid use disorder as well as seven of the jail systems and also expanding our program as that has been mentioned earlier. Individuals not only to be connected but also employment and housing opportunities. So states that expanded medicaid have a 6 percent over all than those that did not. And then does that have longterm evidencebased quick. Absolutely thank you for the question. And to provide treatment to 12000 uninsured half coming into the emergency room or uninsured. Lee are proud of our progress. We have so much further to go. We estimated 415 north carolinians would be alive today had we expanded medicaid 2014. I would just like to enter into the record the letter from voices of non opioid choices. I ask unanimous consent to be entered into the record. To put the focus on your testimony and i want to congratulate you. We have been at the epicenter of this problem going from 52 through 57 deaths per thousand and it is incredible. My concern has been and we never really understood the contributing factors and people here from nih and cdc and the Economic Issues and to quibble back and forth that were states like New Hampshire that is compared to West Virginia but they were the number two in the country. So talk about prevention rather than treatment when we have a Building Collapse we find out what caused it then we can fix it. But lets make sure it doesnt happen again. So what are the contributing factors clicks for example, it is conductivity. Texas has a rate of ten. Five out of 57. What are we doing right in texas or West Virginia around the country can learn what they are doing clicks we know where they are coming from. And then to prevent people from abusing drugs quick. And those contributing factors is the perfect storm prescribers trying to treat pain with individuals and high injury occupation like coal mining and those kind of accidents and we have an influx of pill with the availability to find out how they got started with low income and the recession that was happening people were becoming frustrated but then we have to go further back stream downstream they are not living with their parents. I would like to have more of a dialogue with you about this the sin of taking all the time because if we dont get into the prevention we will see more neonatal impact with our children in foster families and foster homes as a result of this. So how do we stop this in the first place in the future correct so let me go to the last comment on the panel. We know that tobacco settlemen settlement, 97 percent 97 percent of the money came from the Tobacco Settlement and then to balance the state budgets. And then to imagine quite a bit of litigation. And some federal settlements on this. Is there a role for us to step into make sure that money doesnt go to balance budgets and potholes to ensure that it will go to things like prevention or foster care or neonatal and with the settlements any of you . And then to have sustainable funding to allow us to focus on this epidemic comprehensively and over the long term. Many of us have referenced the importance of the funding. And those that the funding that that will be in place for a long enough time and that assistance across the board is certainly to be well received. And this Committee Works in a bipartisan manner to pass legislation to implement programs to curb the Opioid Crisis that more can and must be done wet members on both sides are committed at the same time there are continued efforts not to expand medicaid and instant crease care is to treatment but in fact last week, and a new study was published in the journal of the association to expand medicaid under the Affordable Care act to have as many as 8000 people from opioid overdose. I would like to submit for the record. Without objections mimic the Kaiser Family Foundation Medicaid covered 54 percent and with the Affordable Care act of the essential Health Benefits and to increase coverage and expand medicaid if i have cared for a patient overdosing in the Emergency Department. And then to leave the hospital and those that receive the grant money in the Opioid Epidemic is the unprecedented crisis to make fundamental changes to combat opioid addiction and Substance Abuse disorder. So to play a role to support these Treatment Systems so the West Virginias response to the committee knows that the infrastructure with a demand for opioid Treatment Services. Medicaid has been a key component. And with the waiver we have had to use that as part of our backbone to pay for Treatment Services. And doesnt enable us to train our providers or infrastructure but then they use that to wrap around to build infrastructure as well as cover people with no insurance or underinsured. That is our strategy to bring those funds together. Opioid treatment is much more widely access that expanded medicaid. Both noted in their responses to the committee of federal medicaid dollars to address the Opioid Crisis. You raise that medicaid is the most important tool of the Opioid Epidemic to bring an additional 4 billion into North Carolina for healthcare. How is expanding medicaid further develop the treatment infrastructure to address the Opioid Crisis quick. Thank you for the question. And those vast majority of individuals get insurance through employment cannot be overlooked. One drug test away from losing Health Insurance or ending up with a place they have no way to pay to get back into the workforce. In North Carolina we estimate 500,000 additional people would have expansion and then to get treatment through medicaid and use our resources to build a system capacity. And to combat the Opioid Epidemic but if we make it harder for people to enroll with medicaid from the Affordable Care act and essential Health Benefits, by making it difficult to enroll like work requirements and then we take five steps back its important to take that big picture. Let me first answer a question. How do we treat this money with the Tobacco Settlement . In virginia they created a separate commission for Economic Development purposes and whatever your individual states might want to recommend that model because then you can take that money and have it stretch with ever one with whatever issues of Substance Abuse but the virginia model has worked well for Economic Development in tobacco producing areas. Especially between West Virginia and North Carolina and while virginias numbers look bette better, mine does not. And to be heavily impacted in all the areas of cool country that looks like West Virginia with the Opioid Crisis. We are all moved by testimony from time to time with privacy versus testimony and then to testify for her brother who could not testify because he died. He licked the problem and then was in a major car accident but because the doctors had no idea and he was unconscious and could not tell anybody , they gave him and he survived the injuries he did not survive the reintroduction of opioids into his system. We have to work on that problem. Foster care. You said half of the children in foster care their parents had some form of drug addiction . But you didnt see in the written testimony how many that was. We have about 12000 individuals in the foster care system. So roughly 6000 i thought it was that your answer to another question you mentioned the School Systems to make sure there was money there. Several families that have first gone through foster care and the parents were addicted to various drugs in particular opioids with significant behavior problems. What can we do to deal with the next generation . They may not have drug problems themselves but there are behavior problems. In rhode island we have the student loan student Assistive Services program to allow for peer recovery in support of their families and the ability to have that be integrated with the physical health that will allow for a comprehensive approach to address the needs of our youth. Including those that are using drugs at the time. The first couple years is that included quick. It does address Mental Health as well as behavioral challenges that you often face. I really want to learn more what pennsylvania is doing with the doctor Loan Repayment Program to represent an area and we are all right there in the appellation mountains together we need more Healthcare Providers in the most affected areas. Ale decided to you had to be practicing in an area with high opioid use and have beast two years of experience treating patients with Substance Abuse disorder and commit to an additional two years in order to make good on that repayment. Two years has not elapsed. I look forward to getting that in the future. Im happy to share some Additional Information. And i would yield back. The chair recognizes the gentle lady from New Hampshire. Thank you madam chair. I would say thank you for your leadership in my seven years in congress, this is one of the most productive i have been added and it is an honor to be on the committee. Im the founder and cochair of the Bipartisan Opioid Task force that has close to 100 members to give you a sense of the scope, New Hampshire as my colleague suggested was hit very hard along with West Virginia, perfect storm situation. But what i am proud of is the model coming out of the Opioid Epidemic and is indeed we need to include methamphetamine, cocaine and the rest and im a very vulnerable population in an extensive population for taxpayers and communities and that is the population where we know at least 65 in some of our counties as high as 85 of our incarcerated populations have Mental Health and Substance Use issues and one of my moments of the last seven years was to discover something passed Congress Many years ago at medicaid called the exclusion caused people to lose mainly Mental Health treatment, Substance Use treatment during the period of incarceration. But the day that you go in you lose your coverage if we were to design a system that would fail american taxpayers, families and communities, it would b be the system because what happens is people. Getting no treatment. And they go back to their addiction. We are not shocked they go back to their diabetes and we shouldnt be shocked they go back to their addiction. I have legislation that we call the humane Prefectural Health care act, and what this would do is continue medicaid coverage during incarceration so we can ensure treatment for Substance Use disorder and mental illness. What happens that we have already demonstrated in New Hampshire is a dramatic drop in the recidivism rate from the upward of 50 to 60 down to 18 and i dont care if you are republican, left right or center is saving lives and taxpayer dollars and im very pleased mr. Mckinley agreed to join today. So, quickly moving on. In 2016, i know the rhode island implemented a program for opioid addiction within your department of corrections. I would like to get to study for the record and to show with my colleagues. But can you explain the Overdose Deaths and what the outcome so far of that program has been. Its been making sure that we have all three approved Communications Available to those incarcerated. Making sure that prior to the release from incarceration they are connected to one of our communitybased Behavioral Health agencies to do this for the programs as well, so as i continued to build. Id like to work on those supports to eliminate the barriers they can be successful in their lives and get back to raising their children thank you for holding this really important hearing im pleased we are focusing once again on the opioid. Some of the most important work that ive done particularly all the states that responded to the questions its wonderful to see all of the progress in all of the efforts of states are making the issues were in the front pages on tv all the time and the people who were dealing with it day in and day out if we dont have the workforce, and i say workforce even beyond physicians and addiction it is meant to try to raise the cap on the residency by a thousand more residencies across the country to an addiction medicine. I know that ive spoken to a school in indiana and i represented anna and with the grand challenge tried to put a lot more emphasis on the addiction medicine on all levels, whether it is nursing, prescribing practices, addiction medicine. I want to go back briefly to start on the Loan Repayment Program and learned any other states are doing that. You wanted to say a little bit more about the loan repayment and then i want to do a lightning round to find out if the states are doing and if not, why not. I was able to find the data here in my notes. We made it 91 awards to individuals from 23 different counties that totaled 4. 7 million in that program and it was a combination of both mental and behavioral practitioners some more of the clinician level and then 1. 8 million. And the second round of the words that are currently out are being committed to the second round of the warning from the program. I do believe it would be helpful. Thank you for this important attention to the professional training. In massachusetts we were the first state to develop voluntarily of all of our medical schools the Core Competencies that would standardize all medical students and if it was taken up by all of our mental schools and advanced practicing training over 8,000 individuals in a standardized way so that they could balance the needs of the Pain Management with a potential for the misuse. The social work schools have taken up the training as well as the physical therapists with enhancing the capacity for individual to treat this medical various i know one of the challenges in the past, theyve given very little time to do with addiction medicine and pain issues. Are they starting in the first year now . The trick is they allowed each individual medical school to create the curriculum the way they needed to based on what they had in multiple different ways. They were broad enough for them to incorporate and we know from graduating they are seeing the difference in feel more prepared. We are very excited we did a program this year and we had over 100 applicants i think 102 we funded the 22 of the applications in the first round to process within the state that was focused on therapists because some of the existing Loan Repayment Programs focused on the medical, so we really wanted something to focus on the fate of the level but in addition to that, we also provided about 154 scholarships which would be the same type of requirement that eliminated the front end of the investment in some ointosome of the students s well. Very briefly. We have a lot of programs for the doctors and midlevel and we work to train over 9,000 in North Carolina and four of the five medical schools have both the training and the core curriculum. With the chairs indulgence if we could get rhode island to answer. The Loan Repayment Program has also expanded to include Behavioral Health providers and or medical school does now incorporate the data waiver training into the medical School Curriculum so that as the students graduate they automatically have the data waiver to gentle lady from florida is recognized various think you and i want to thank you as well for calling the hearing thank you for everything youre doing tyou are doing to e families deal with weve lost over 5,000 of our neighbors per year and while im proud of the work passing into the comprehensive addiction and recovery act and the support act there is one glaring problem. Theres the continuity of care and resources in the minority of states that have not expanded medicaid your written testimony to noted that for every Single Person that has been brought to the Emergency Department, nearly half as no Health Insurance at all for the expanding medicaid and bringing the additional 4 billion into North Carolina for healthcare. All of the democratic members of the florida congressional delegation yesterday had a letter back home to the opening day of the Florida Legislature and our message to the governor and the members back in florida was the you are not giving right by our citizens. One recent study said that the florida expanding medicaid we withdraw down almost 14 billion over the next five years alone and it would improve Peoples Health and improve peoples access to health, healthcare and it would do so much for families that suffer the consequences of Substance Abuse disorder. Talk to us again about how this would allow the state to better use the grand office to address the Opioid Epidemic. Thank you for the question, congresswoman. At present, more than two thirds of the response is just going for treatment or expanding the individuals that are uninsured and that is a laudable and notable purpose for the dollars that we do not have those available to build the workforce to training and increasing the way the system works together to coordinate care to expand treatment because we do not have expansion. The nort North Carolina state legislature reopen and reconvene today around a budget that hasnt been able to be passed primarily in the debate of Medicaid Expansion in North Carolina and i hope that we are able to expand and increase access for North Carolina. Weve expanded into the other states havent. They are sending our dollars in subsidizing the budgets and healthcare to other states. Weve been able to trade at 125,000 additional addictions. So, for us but its a huge. I can tell you with a large amount of funding over 230 million coming to the state, if we did not have Medicaid Expansion, you wouldnt be hearing me talking about the Loan Repayment Program and about housing and expanding corrections were about any of those things because the reality is that we would be sending off those dollars just on plain treatment. So come as a result of Medicaid Expansion, we have been able to repurpose those dollars in ways that allow us to modernize the system and to integrate with physical health, mentalhealth, Behavioral Health, altogether in one system moving forward so i cant stress enough the importance of having participated in Medicaid Expansion and i certainly hope it continues in the years to come. How about you . In massachusetts, the foundation of our treatment is having access to the medical treatment that is proving an evidencebased because we have tothat, we have been able to tackle the very challenging complex issues getting individuals to the care making sure that individuals that are the highest risk not only obtain but stay in touch with recovery coaching which is covered by the medicaid waiver. Just the highest share of population served through medicaid. You talked about the importance of predictability. How important is Medicaid Expansion to the opioid Substance Use treatment, you talked about the predictability of care to talk about the infrastructure that weve been building without medicaid paying for the residential treatment. There is no way to sustain those valuable services and according to my notes, we have over 21,000 receiving medication assisted treatment in our state. Thank you very much. The gentleman from maryland. Very compelling testimony and i think you all for coming. We have learned of course one of the root causes and a member you havnumber ofyou have spoken to. We know many states such as virginia, maine, rhode island have set limits. You highlighted as part of the response your state enacted regulations in 2017 that went into the initial prescription of an opioid patient at no more than what are called morphine milligram equivalents. Can you describe a little bit more for us the danger of patients exceeding the limit and do you think that the policies and success to make the better position to veto decisions. We had data tha but said the higher the milligram equivalents a patient is on for the longer period of time, the higher the risk of becoming addicted to the opioid overtime at the risk of an overdose. We wanted to make sure there was flexibly for the provider in limiting the opioids prescribed by cutting off at 30 and the reason for paying we have seen a substantial decrease in the number of opioids prescribed for an initial use of pain particularly for the scenarios. We have chosen to handle chronic pain needs separately because often times people already have an addiction or tolerance that require the multidisciplinary approach to addressing that. Let me drill down on that a little bit more. Because i know that the cdc in the recommendations indicated the provider should avoid prescribing over 90 and many states have put that recommendation into the code some of them even double or triple that limit. So, i understand that the products are intended for patients have become opioid resistant as you mentioned to the lower dose products. There was enough of a risk that we should at least begin to explore the methods to limit the market availability. We certainly considered that in the regulations approach or the acute Pain Management in addition to the equivalents we have also required they are not used because of the challenge that can occur. They would need to be handled separately. I know theyve taken previous action to limit the use of the products for the Strategy Program on the providers to describe these products i also know there was a recently released study that failed to find any evidence of the program that was successful at achieving the goals of producing the appropriate prescribing the lack of existing action it may be time for the fda where congress or both of us to explore options with limiting the market availability. Limiting these new highdose products restraining them from entering the market into the future, so i think that is what we are going to look at and explore a wide array of solutions to combating the crisis for the funding and flexibility to support these objective communities. Think you begin to the testimony. I yield back. Thank you, madam chair and the panel for the helpful conversation. Many of you hit on a topic that is very near and dear to my heart, and that is eliminating the bureaucratic unnecessary barriers to the Substance Abuse treatment. Individuals began actively treated with be the marketing lower their risk of opioid overdose by up to 50 in a way that is provided without corresponding comprehensive Psychosocial Support or services. With any other medication that lowers by 50 , we would be hailing this as a drug doing everything in our power to possibly needed and unfortunately here in the United States would continue to make it harder the policies got us into this problem in the first place, so secretary smith, i was pleased to see that in your testimony you called for the elimination of the requirement for the providers to obtain a waiver in order to prescribe for treating dependence. Over 100 cosponsors do exactly that. Can you describe for the committee why it is an important step to take and expanding access to Addiction Treatment . Thank you so much for sponsoring the legislation we are fully supportive. I mentioned earlier in my opening we have expanded our waiver positions to over 4,000 we are near the top of the list when you look at states in the number of the positions but looks can be deceiving. When you take a look at the 4,000 doctors and look at what are their prescribing this debate go capacities its pretty staggering so we have a large percentage that are still at the 30 patient capacity and are not prescribing up to 30 patients so we worked with an Organization Called vital strategies to design a survey that is going to go out to all 4,000 of our physicians in the state and asked very specific questions about why they are not treating patients and are they willing to treat more. Is it an education issue, is it a barrier because of the oversight . Goes to overregulate and doctors are trained to administer any and all kinds of medication but specifically to call out this kind of medication and say you need a special waiver to administer this, they just dont want to be bothered with that. Pennsylvania believes any steps we can take to eliminate the barriers to change the conversation around to the idea as a clinical necessity and we rely on the trained physicians to be able to provide the treatment. We spoke about it in our testimony. We dont have a therapist to really support the physicians once they are able to prescribe. Its impact on thits impacted os and counseling side. The service is available as well. You mentioned individuals released from incarceration particularly vulnerable to the overdose with the commissioner noting the justice involved population and i heard your exchange so while the federal grant opportunities for the treatment Reentry Initiative for helping for a strategy as required there for the medicaid reentry act which would allow the states to have benefits for incarcerated individuals in 30 days prior to the release providing a sustainable stream for the medication treatment Case Management Recovery Support Services Including the seamless transition. But allowing states the flexibility to restart the benefits for the eligible incarcerated individuals 30 days prior to the release help reduce the Overdose Deaths . The continuity of care is critical to medicare and the other support mechanisms that you stated. Ive exhausted questions and with that i will yield back. The gentle lady from new york is recognized for five minutes. Thank you madam chair and i would think the Ranking Member. We heard a lot of encouraging stories today about how they can put federal funds to make progress. Its also clear the challenges the states face as they work to address the ongoing crisis. Id like to explore some of the remaining challenges as they consider support. In your testimony, you noted a result challenges building the treatment workforce including people to work in areas across the state. Can you describe what additional hurdles remain . So to me that it is a fundamental thing. So we have really been focusing on the Scholarship Program to increase our pipeline but also the ongoing education and we find the individuals entering recovery with a strong interest to provide services to pay particular attention even to persons who might to be in recovery wishing to take the steps. So anything you think would be helpful to on earth individuals quick. I think the flexibility to use the funds in the best creative way would be beneficial. With the treatment workforce to be noted it is increasing as a move toward treatment and recovery. s explain how it has provided services to vulnerable populations and how it addresses the problem. Our workforce challenges particularly in urban centers like philadelphia and pittsburgh have inhibited for the vulnerable populations to access treatment. We have a an Advisory Council that advises a Department One member happens to tree adolescence but is part of his practice is so overwhelmed with patients he is working well into the night beyond office hours because they have nowhere else to go. So part of the challenges we hear to build a workforce where you dont have communication barriers and those that really understand them and communicate with them a lot of the challenges come down to education and training requirements and those that exist to meet those requirement requirements. In North Carolina the states note in many communities with the Opioid Epidemic it is difficult to build access because it lacks basic infrastructure including broadband. So can you describe how Broadband Services are important to help address the Opioid Epidemic quex and what can congress do to overcome these challenges quick. Thank you for the question telehealth access is a key strategy to expand access to treatment but many cannot sustain more than a four g signal or have access to broadband and without those we cannot sustain the services that is built on the fact it is a sustainable approach for education to be at parity with all of the colleagues. Madam chair i would like to ask for this letter from new york state Addiction Services and support to be added to the record. Without objection. Thank you for letting me be here today it is a very relative topic. This is one of the major newspapers in the state of ohio had an article that came out but we know in 2009 we had 1423 people die of overdose in the state of ohio the number went up in 2017 and the trend right now think heavens it is going down that these are all deaths from overdose. In my district its very important when i talk to my Health Care Providers one of the things they were telling me for several years as we cannot find help. Everything to finding where they can get services so in the last congress to establish his dashboard for communities to go find help. I would like to ask you today and if i could ask everyone maybe be brief on your answers but those public facing dashboards what information do you have in them quicks go right down the line. Pennsylvania does have a an Interactive Data dashboard. It contains information like Prescription Drug monitoring distributions treatment statistics and it goes on and on. Im happy for you to check that out if you have questions let me know. It was established about two years ago. Since 2015 massachusetts put out a quarterly dashboard that has the same information related to the number of deaths with that predictive model as well as towns and cities all hundred 351 report on the number of deaths in their communities as well as ems and healthcare data and 2015 to put together for the first time data across State Government so this is the First Time Health data relates to criminal justice. The last couple of years we have been using reports updated quarterly that highlight things Prescription Drug monitoring and those data points to focus on. Then we do that quarterly. That than to upload and make public dashboard with non fatal overdose and stay tuned we are looking forward to that this week. North carolina launch the dashboard in 2017 it not only has key data points updated consistently around the up Opioid Epidemic but other aspects of abuse disorder to have others drill down what you have seen to be incredibly powerful with the same strategies giving foundations and nongovernmental entities and those that see their dollars as a way we need to focus all these indicators relate back to our strategy to help us measure success in this effort. Similar to what has been heard in rhode island with the Intervention Task force we understood having a dashboard would be critical and that was activated in the 2015 timeframe the dashboard does serve as a metric for each Strategic Initiative reversal and treatment to allow for the public to access where Treatment Services are as well as access to other Recovery Services that are needed. Has the community had a problem with that help getting it out quick. Yes and no. Mostly know because of our procurement system. I would go with the answer yes and no many people have no trouble but those that are struggling to find that information. Over 50 local communities we dont have enough funds. We use a data driven process and given that its rhode island to make sure every town and city has access to services needed. Thank you very much madame chair. Thank you to all of our witnesses this is one of the best we have had its excellent with very good information we look forward to our next step stand in response to the september 18 letter receiving responses from 16 states how the estates addresses the crisis with federal funding and i moved to enter all those responses into the record and in addition from florida and indiana new york, North Carolina, ohio, rhode island, tennessee, West Virginia and and wisconsin those will be ordered and in continuation of our bipartisan work in treatment issues today we are sending a bipartisan letter signed by the Ranking Member and other others, letters to the dea and hhs about the emergence of what this panel is talking about with polySubstance Abuse and what it is doing i would ask unanimous consent to put those into the record and the chair would like to remind members pursuant to the Committee Rule there are ten Business Days to submit additional questions to the record to be answered several members did ask witnesses to answer additional questions please respond promptly if you received those questions with that we are adjourned. 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