Transcripts For CSPAN3 House Hearing On State Efforts To Combat The Opioid Epidemic 20240713

Efforts to combat the Opioid Epidemic. Public Health Officials from five states testified on prescription take backs, needle exchanges, and access to opioid overdose drugs. Subcommittee of oversight investigations is holding a hearing entitled a Public Health emergency, state efforts to curb the Opioid Crisis. The purpose of todays hearing is to examine state efforts and successes addressing the Opioid Epidemic as well as opportunities for future support. Just to let everyone know, the reason were getting a little late, the plane was delayed but now dr. Scott is on her way. So, we will swear in the witnesses when we get to that point. If we have to do that one later, we will. The chairman will now recognize herself for an Opening Statement. As i said, today, the committee continues this bipartisan efforts to combat the Opioid Crisis. As we know, the countrys in the midst of an epidemic unlike any in recent history. According to the centers for Disease Control and prevention, from 1999 to 2017, nearly 400,000 people died from opioid overdoses. In 2017, more than twothirds of Drug Overdose deaths involved opioids. The crisis has 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 with the overprescribing of pain medications. The second wave began in 2010 with increased deaths due to heroin overdoses. Like the first two waves, the third wave marked by the rise of synthetic opioids like fentanyl have shattered lives, traumatized families, and devastated communities. Now unfortunately, it looks like a fourth wave of the crisis may have already arrived. The Opioid Epidemic has fuelled a huge increase in method am fete mean use. In 2018, there were more than twice as many deaths involves meth than 2015. Meth is turning up in deaths and drug busts in the country. Given the complexity of the ep Dominican Republic and i epidemic, states must remain vigilant. To that end, this committee has taken numerous steps to develop the origins and drivers of the crisis. Through Committee Hearings we have heard from states, federal agencies and drug distributors about their roles and responses. The groundbreaking work by the committee uncovered some of the failures that led to where we are today and looking forward were focused on identifying ways to stem this crisis and bring relief to the millions of americans who are suffering. As part of that effort, our committee has worked across the aisle to pass Bipartisan Legislation designed to give states the tools and resources needed to help those impacted by Substance Abuse disorder. These legislative packages provided states billions of dollars in federal funding to assist in opioid response treatment and recovery efforts. And weve made some progress. Cdc provisional data indicates that Drug Overdose deaths have fallen for the first time in decades. While this downward shift is welcomed news, the crisis is far from over and we must continue to look for ways to bring relief to struggling cities and towns throughout the country. Todays hearing continues those bipartisan efforts. Day in and day out, states are on the front lines of this epidemic that kills more than 130 americans every day. As the epidemic now enters a new decade, states face the challenge of keeping pace with evolving crisis. In keeping with this committees bipartisan commitment to finding solutions for this National Emergency, last september the committee sent letters to 16 states requesting information about on the ground efforts to curb the epidemic. The committee has sought to understand whether federal funds actually reach the hardest hit communities, how states use the funds provided by congress, and what strategies have proven to be successful. Today we have five key states that have each received a letter from this committee. These states represent the first line of defense against the crisis, and they each play pivotal rolls in Treatment Recovery and prevention efforts. I want to thank all of you for coming today. The states compose a large swath of the country. While their demographics, geography, and challenges vary, each has felt the effect of the epidemic and they all rank among the states with the highest overdose death rates. As such, each have taken a number of steps to curve the epidemic. For example, pennsylvania was able to distribute nearly 13,000 naloxone kits in 2018 and again in 2019 thanks to a combination of state and federal funding. North carolina provided treatment to 12,000 uninsured persons thanks again to federal funding. And rhode island has been able to expand medication treatment in the prison system resulting in a 62 reduction in Overdose Deaths. These are just a few examples of how the states are fighting this ep demic and 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 combat the epidemic, what efforts are proving successful, and what we feed had to do for further improvement. I thank the witnesses for their service, for being here to testify on behalf of their states, and i look forward to hearing how we can all continue to Work Together to find the desperately needed solutions. With that, im pleased to yield for purposes of an Opening Statement, mr. Guthrie, five minutes. Thank you. Thank you chair degette for holding this important hearing on state responses to the Opioid Crisis. Our local communities are suffering. On average 130 americans die every day from an opioid overdose, and opioids were involved in 47,600 over dose deaths in 2017 which accounted for 67. 8 of all Drug Overdose deaths n. Kentucky, there were 1,160 reported opioid involved deaths in 2017. The energy and Commerce Committee has been steadfast in its efforts to help combat the Opioid Epidemic with both investigations and legislation. Whether it was the committees investigations into the Prescription Drug and heroin epidemic, opioid patient brokering, or manufacturers, we have continued to ask questions and get answers for the american public. When it comes to legislation, this Committee Led the way on the passage of the 21st century cures act, the comprehensive reduction communities act. I was proud to work on these comprehensive laws which are designed to combat the Opioid Crisis to prevention, advancing treatment, and recovering initiatives protecting communities and bolstering efforts to fight synthetic drugs line of scrimmage fentanyl. This hearing is a critical opportunity to check in with the states. Those that are on the front lines battling the nations Opioid Epidemic to see how the federal Money Congress provided has been allocated and spent. What successes they are having in combatting the epidemic, but also what challenges they are still facing and what additional authorities and resources could be helpful. The good news is that each state testifying before us today has seen a decrease in their overdose death rates. Federal assistance is making a difference. In addition, states are creating and implementing innovative approaches to combatting the epidemic. Examples include expanding efforts to connect people to treatment through ems in Emergency Departments e panding and increase the availability of na loca naloxone, increasing transportation to areas, expanding neonatal Treatment Programs, and efforts to address work force issues through a Loan Repayment Program and broadening the curriculum in training and medical schools. This hearing is a great platform for the state to share how the federal funding has made a difference in what programs they are working. Not only is it helpful for us in congress as we continue to conduct oversight and legislate but also to the states as they learn from each other about new ideas or innovative approaches that can be implemented. While progress is being made in some of the overdose death rates are declining, the director of National Institute of drug abuse declared this week that this country still has not controlled its addiction problems. Some states are continuing to see a high number of First Responder Emergency Department encounters due to overdose. In addition, states are still facing many challenges including a lack of qualified work force in infrastructure, varying requirements in timelines, and different federal funding streams, and restrictions on funding including that some funds have been restricted to opioids impeding flexibility to address emerging challenges. In addition to the continuing threat of opioids, states are starting to see more instances of poliSubstance Abuse and polisubstance Overdose Deaths with states specifically citing meth methamphetamine and cocaine as a growing concern. Meth has been detected in more deaths than oxycodone and hyde coe done. Methamphetamine is involved in more deaths than fentanyl. The threats are evolving and the fight is not over. We want to continue partnering with state and local entities to combat the Opioid Epidemic as well as emerging threats which is why its important to not let our foot off the gas. Continue needs to continue supporting the states and this committee needs to continue conducting oversight of these issues. I want to thank all the witnesses for being here today. I look forward to hearing from you about all your successes we have had in combatting our nations Opioid Epidemic, also why the threat is changed, what we can do with our partners in this fight. I yield back. Thank the gentleman. The chairman recognizes the chairman of the full committee for five minutes. Thank you. Todays hearing continues the committees ongoing bipartisan efforts to combat the Opioid Epidemic fuelled by Prescription Drugs. This epidemic is a constantly evolving threat. This is not a crisis that we can solve over night and it requires ongoing federal and state attention. States are on the front lines of this National Emergency providing much of the support for those in need. Theyre our eyes and ears of whats occurring on the ground. Its the latest in a series of hearings weve held oon the Opioid Crisis. Weve heard from several states including rhode island about on the ground efforts to curve the epidemic. We heard from federal agencies about the urgent threat posed by fentanyl. The Committee Conducted legislation that gives our state and local departments tools and resources required to succeed in this fight including three pieces of legislation all bipartisan that were designed to give states funding and support n. 2016, the committee passed and president obama signed into law the comprehensive addiction and recovery act and the 21st century cures act. I have to mention that chairman degettes major role in that. These two laws authorized over a billion dollars in state specific grants and helped states bolster treatment, prevention, and recovery efforts. In 2018 the support act was passed and signed into law, authorizing opioid specific funding increasing opioid abuse and training, improving coordination and quality of care. In december, the house passed hr 3 which included 10 billion in additional opioid funding. This committee is committed to making sure communities are receiving the support they need to get relief from this crisis. Thats why we sent letters to 16 states last year requesting information on. We wanted to know how states are using federal opioid funds, whats being done to ensure the funds reach the hardest hit regions, and how funds have helped transform state treatment systems. Based on the responses, we heard that the federal money has allowed states to take important and innovative approaches to addressing opioid addiction. One of the most effective tools that is available to the states is medicaid. Several states elaborated on the Important Role of medicaid in stemming this crisis and the responses to the committee. A Study Released last week found that about 8,000 lives have been saved from an opioid overdose thanks to the expansion of medicaid under the Affordable Care act. We want to hear about any emerging trends in Substance Abuse theyre seeing. For example, several states informed the committee while they continue to fight the Opioid Epidemic, theyre also seeing increase of methamphetamine and poll li Substance Use. This of course is an alarming trend that threatens to become the next epidemic and i want to hear how congress can help states with this threat. Thank you to the witnesses, thank you madame chair for continuing your efforts on this. I dont know if anybody wants my time. If not, im going to yield back. Thank you. I thank the gentleman. Chair now recognizes the Ranking Member of the full committee, mr. Walden for five minutes. Good morning, thanks for holding this hearing. As i was preparing for this i noticed in my biggest county in my district they have a yellow alert up for opioids two, overdoses average per week in jackson county, oregon. Seven last week. No deaths. First responders tered naloxone five times last week. They believe its heroin with a heavy dose of fentanyl in it. For many years you heard the energy and Commerce Committee and this subcommittee in particular has been at the forefront to address the Opioid Crisis and Substance Abuse disorder issues weve done a lot of work on prevention. We know we have a lot more work to do. This hearing has held meetings from bringing in Purdue Pharma to our bipartisan investigations last congress about the rise in fentanyl, opioid manufacturing, opioid industry. These early hearings informed our legislative work including the comprehensive Addiction Recovery act, the 21st century care act, the Opioid Crisis grants, and billions more in federal appropriations to boost programs that fight, treat, and stop Substance Abuse and support access to Mental Health services. These efforts culminated in the sieping of the support act. Weve seen the results of 3. 1 reduction in opioid deaths based on recent statistics from the cdc. Im pleased weve continued to Work Together in this space. Its important. Including by continuing our work on fentanyl and with this important hearing today examining how the states are utilizing the funding and authorities provided by congress. But theres so much more we could do together. Earlier this year energy and commerce republicans published information about the Substance Abuse Disorder Treatment industry. The rfi built off the patient brokering 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 our rfi. With the billions of dollars were sending into the states for prevention and treatment, we need answers. Just yesterday, energy and commerce republicans sent a letter to the three opioid manufacturers. We began investigating together last Congress Asking them to complete production to our request. Its critical we fully understand the causes of the Opioid Epidemic in order to ensure that our solutions are the right ones and its important that they answer our questions. We should also hold a comprehensive series of hearings to conduct oversight in the implementation of the support act. For example, relevant to todays hearing, the support act included the info act which calls for the creation of a public and easily acceptable electronic dashboard linking to all the nationwide efforts and strategies to kocombat the cris. It was designed to meet a need of stakeholders telling us despite congress having to vote in record numbers, they had trouble finding what resources were available and where they were. Certainly an issue we heard a lot about from mr. Mckinley and others. This provisions absolutely critical in helping those on the front lines of the Opioid Crisis. Im really concerned about its slow implementation. In addition to oversight and support act we need to begin working on the next wave of legislation addressing the Opioid Crisis but also Substance Abuse disorders more broadly. We need to reauthorize the fentanyl ban which is set to expire in a matter of weeks. We authorize prohibitions as brought by partisan support, we should do that expeditiously. This is an important step to understand the impact grant dollars are having on states. I want to thank our witnesses for being here and being part of the equation and i look forward to hearing from you. With that i yield the balance of my time to the Ranking Member to the subcommittee on health. I thank the gentleman for yielding. It was under your leadership with the full committee that we worked in a bipartisan manner to produce legislation. Ultimately to sign into law by President Trump in october of 2018. And it really began in this subcommittee with a member we heard from over 50 members of not just the committee but throughout the congress. The problems they had in their districts and the ideas that they were bringing to the table that we could work on. The support act was written to help advance treatment and recovery initiatives for those affected by opiate habituation. I too want to thank our witnesses for being here today. Youll be helpful in understanding the challenges that we face continuing this fight against opiate addiction and death while ensuring that patients can manage their pain. It is important to congress to have hearings like this where we can haensure the effectiveness efforts and identify caps of where they exist. Madame chair i yield back with the notation that some of us have the subcommittee upstairs so well be coming and going between hearings. Thank you. I ask unanimous consent that the members Opening Statements be made part of the record. I want to introduce the witnesses for todays hearings. Mrs. Jennifer smith whos the secretary of department of drug and alcohol programs, commonwealth of pennsylvania, welcome. Dr. Monica bharel. Dr. Bharel is the department of massachusetts. I think they beamed you here from the airport so congratulations. Shes the director of the department of health at the state of rhode island. Mrs. Christina mullins, department of health and Human Services state of West Virginia, welcome. And mr. Kody kinsley, Deputy Department of health and Human Services state of North Carolina. Welcome to you. Thanks all of you for appearing in front of the subcommittee today. As you are aware, the committees holding an investigative hearing. When we do so we have the practice of taking the testimony under oath. Do any of you have objection to take testifying under oath today . Let the record reflect the witnesses responded no. The chair advises you under the rules of the house and committee, youre entitled to be accompanied by counsel. Does any of you wish to be accompanied by counsel. Let the record reflect the witnesses responded no. If you would, would you please rise and raise your right hand 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. Let the record reflect the witnesses responded affirmatively. And all of you are now under oath and subject to the penalty set forth in title 18 section 1001 of the u. S. Code. The share now recognizes our witnesses for five minute summaries of their written statements statements. In front of each of you theres a microphone, timer, and series of time. The red light comes on at the end of your five minutes. Ms smith, im speezpleased to recognize you for five minutes. My name is Jennifer Smith and i am secretary for Pennsylvania Drug and alcohol programs. As well as a member of the National Association of state, alcohol, and drug abuse directors. Thanks for your interest in how pennsylvania is using the state opioid response funding to promote prevention and Treatment Recovery efforts. Acting as the state single authority, my department coordinates efforts with federal and local entities as well as across state departments. Our ability to orchestrate resources and direct policy during the Opioid Crisis has been a crucial component in affecting long term change and maximizing Resources Available to our communities. We are grateful for these federal grant opportunities at a time of hopelessness and despair for families and communities. I can say with certainty that this funding has saved lives. With a population of 12. 8 million, pennsylvania is the fifth most populous state, consisting of 67 counties that range from large urban centers to rural counties. Our state is among those hardest hit by the nations prescription opioid and heroin epidemic. In 2014, we lost more than 2,700 pennsylvanians to drugrelated overdoses which equates to 7 deaths per day. By 2017, that number had tragically doubled to more than 5,400 lives lost for 13 deaths per day. As statistics rose year over year, our primary focus became simple, keep pennsylvanians alive. That meant infusing naloxone into communities, implementing hand off protocols to transition survivors from Emergency Departments into treatment, expand evidence in practices such as medication based treatment, and launching a 24 7 get help now hotline. Pennsylvania reported an 18 decrease in Overdose Deaths in 2018. While its not clear whether this promising trend will continue in 2019, it is clear that the more than 230 million in federal funding that the state has received is making a tremendous impact. We have used these resources and the momentum of the crisis to collaborate, modernize, and innovate using dollars across the full continuum. In prevention, we reduced opioid prescribing by 25 , developed prescribing guidelines, incorporated addiction content into medical School Curriculums, and established over 800 Prescription Drug take back boxes across the state. In treatment, we established naloxone Standing Order and distributed over 55,000 free kits, developed a warm handoff model thats been used over 6,400 times, expanded treatment capacity through 45 centers of excellence and 8 hub and spoke programs, increased our dea x waiver physicians to over 4,000, offered loan repayment, expanded support for pregnant women and women with children, and expand expanded m. A. T. , we developed a website to share recovery stories and spread hope, and awarded grant funds to build Recovery Housing supports. In coming months, pennsylvania will be focused on integrating quality into our four major goals of reducing stigma, intensifying primary prevention, strengthening the treatment system, and empowering sustained recovery. Without sustainable federal funding, the collaboration necessary to accomplish these goals will be greatly diminished. Although weve made significant strides, our work is not done 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 the block grant. As well as continued use of the Single State Authority as the central coordinating entity. Sustainability to allow for the continued relationship fostering, stigma reduction, and integration of services. Moving an entire system of care is a monumental task. Were working diligently, and weve made staggering progress. But please dont give up. The long term success of our programs and communities depends on sustained funding and support. Just two other quick considerations would be to address stigma in a more uniform way across the nation through language and action and to seek ways to address the dire Work Force Shortage challenges experienced by every state. Thank you again for allowing me to share what pennsylvania is doing and our suggestions for moving the system forward. I look forward to answering any questions you may have. Thank you so much. And dont worry. We dont intend to give up. Dr. Bharel, youre recognized now for five minutes. Chair degette, Ranking Member guthrie, and members of the subcommittee, thank you for the opportunity to speak with you today. In my role as commissioner of Public Health and as the states chief physician, im dedicated to addressing the Opioid Epidemic in masses ma. I commend wrong and federal agencies for funding those working tirelessly on the front lines every day. Our data indicates that in massachusetts our Public Health centered approach to the opiate 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, naloxone availability, medication treatment, Behavioral Health counseling, and sustained Recovery Supports. We have made progress, but its still unacceptable that nearly 2,000 individuals in massachusetts die from this preventable disease each year. In my clinical practice, i cared for people with this disease, and i never forget that behind these numbers which we will talk about today are real people, their families, and their communities. Since 2016, we have been awarded approximately 159 million in federal funding specific to opiate abuse disorder, prevention, treatment, and recovery and weve allocated approximately 111 million of those funds. Weve used federal funding to support expansion and enhancement of our treatment system through a datadriven approach that targets high risk, high need, priority populations and disparities with the goal of reducing opiate overdoses and deaths. In 2015, governor baker appointed a working group who developed an action plan emphasizing data to identify hotspots and deploy appropriate resources. Additionally, a law referred to as the Public Health Data Warehouse enabled us to link 28 different data sets across State Government and establish a Public Private partnership to maximize the use of data to study this major Public Health crisis. This was unprecedented in massachusetts. So, our approach started with Data Analytics and research allowing us to gain a deep understanding of who was dying, where, and why so that new investments could be strategic and impactful. Our data led us to quickly focus our efforts on five key populations that we saw were still suffering from overdoses and Overdose Deaths. Persons released from incarceration, communities of color, persons with cooccurring Mental Health and Substance Abuse disorders, people with a history of homelessness, and mothers are opiate abuse disorder. Our data showed that the rate of opiate deaths of mothers with opiate disorder was more than 300 times higher. In response one of the programs we set up was moms do care which is currently 100 federally funded. This innovative approach built a Seamless Integrated continuum of care for pregnant and parenting women. It provides access to medications, prenatal and postnatal care, maternity and behavioral care, and peer to peer supports and so much more. With federal friends, we are also supporting and expanding Prescription Drug Monitoring Program allowing all massachusetts prescribers enhanced access to this vital system. While we have had many successes, we do see opportunities for federal assistance so we can continue to make progress. This includes funding that is flexible. When funding requirements restrict us to addressing only opiates, states are limited in flexibility to address the changing landscape of Substance Abuse disorder. Flexibility would enable us to address other substances connected to this epidemic such adds cocaine and methamphetamines. Additionally, there are currently federal barriers to treatment such as methadone. These barriers should be removed. This would allow medication assisted treatment to be regulated more similarly to other chronic disease treatments and are available in Traditional Health care settings to increase access a access and reduce stigma. In conclusion, we are grateful to congress for the opportunity to address this epidemic. Much of our progress can be attributed to federal funding we received, and i encourage congress to continue these efforts. This crisis did not build overnight and it will take time to reverse. Addiction is not a choice. It is a disease. And with the continued support of our federal partners, we will build a solution to tackle this epidemic in massachusetts and in this country. Thank you. Thank you so much. Ms. Mullins, youre recognized now for five minutes. Thank you. Chairman degette, Ranking Members, and members of the subcommittee, my name is christina mullins, and im the commissioner for the bureau for West Virginia within the department of health and Human Resources and serve as a member of the National Association of state alcohol and drug abuse directors. I want to thank you for the commit tonight address this crisis. Without the resources provided by this committee, West Virginia would be in a considerably worse condition. I want to thank you for the opportunity to address the Opioid Crisis and the impact of the funding made available to this committee to promote prevention, treatment, and recovery. It is no secret that West Virginia has been ground zero for the Opioid Crisis with the highest overdose rate in the nation. There are Award Winning documentaries and stories that describe what happened to our state. I am sure these efforts played a significant role in bringing muchneeded resources to virginia but today i would like to tell you a different story. With your help, West Virginia has reduced Overdose Deaths for the first time in over ten years. Both opioid prescriptions and opioid doses have decreased by about 50 while naloxone prescribing as increased. We have distributed over 10,000 doses of naloxone to local health departments. Treatment capacity has been transformed. The number of people that can prescribe buprenorphine has doubled to 584 since 217. We have increased the number of residential treatment beds from 197 to 740 and our records indicate that those beds are about 85 full at about all times. Additionally nearly all birthing facilities have access to integrative Substance Abuse Disorder Treatment in their community. This is the result of the significant Financial Investment of federal, state, and drug settlement funds. West virginia leveraged federal investments to increase outpatient treatment capacity, increase the number of the work force, provide education on opioid prescribing, increase evidence based prevention programs and stood up Quick Response teams. In addition to these efforts, the state also increased its infrastructure for surveillance and Data Analysis and this work drives all of our programattic decision making. The state complemented the work to undertake the development of Construction Products that expanded the availability of residential treatment. The scope of this problem required historic Financial Investment to respond to this crisis. Funding sources allowed West Virginia to balance the need for immediate interventions and services with the long term need to address the systemic issues that serve as an ongoing challenge to the states opioid response. While significant progress has been made, certain barriers and challenges remain. West virginia continues to experience substantial Work Force Shortages. Gaps in training related to psychostimulates, lack of capacity to serve children impacted by this crisis. In addition, a key concern when utilizing time limited grant dollars is sustainability of efforts n. Thinking about a bigger investment if the endeavors are to have an impact in treatment availability and reducing overdose death. The predictability and sustained provision of resource Social Security key to allow states and providers to plan and allow future commitments. It can be tough to plan and operate programs if providers are not confident resources will be available. It would be difficult to believe that West Virginia could have accomplished so much without the suppo support of this committee. These funds have allowed West Virginia to have resources it needed to respond the the crisis and result in Overdose Deaths and transformed the system of care. Our over dose deaths are down at this point by 10 . The Financial Resources are crucial to our continuing success and maintaining momentum. Ongoing funding for state agencies will ensure continued progress. While barriers remain, West Virginia is poise for future challenges. West virginia wishes to say thank you to this committee, sam sa, and cdc. Thank you for your support. Thank you for the resources. And thank you for allowing us to share what is happening and what is working in West Virginia. Thank you. Now mr. Kinsley, i would like to recognize you for five minutes. Good morning. Thank you chair degette, Ranking Member guthrie, and the honorable members of the subcommittee to testify on North Carolinas response to the Opioid Epidemic. On behalf of the 10. 4 million north carolinians, approximately 126,000 of whom misuse prescription opioids, i want to express my deepest gratitude of your funding that has helped us turn the tide on the epidemic. This investment has saved lives, transformed communities, and made the down payment on breaking the cycle of addiction, trauma, and poverty in our state. Im also grateful to the committed staff of numerous federal agencies that worked quickly to support a concerted strategy working across interconnected systems of health care, housing, employment, and justice. North carolina was hit hard by the skries. In 2016, for each death, there were 6 overdose hospitalizations. And we were one of the top eight states for the fentanyl Overdose Deaths. Since the start of the epidemic, nearly 100,000 workers have been kept out of the work force because of opioid misuse alone. Today close to half of the children in North Carolinas foster care system have parental Substance Abuse as a factor in their out of home placement. And of course the human cost, the loss to communities and families is immeasurable. The scale of the problem underpins our magnitude for accomplishment. Our states comprehensive response, the North Carolina opioid action plan, is organized into three pillars, prevention, Harm Reduction, and connections to care. These pillars encompass numerous strategies all made possible because of federal funding, cutting the supply of inappropriate opioid prescriptions, making access to life saving naloxone ubiquitous, supporting exchange programs, making addiction medicine a core, partnering with county and local communities, launching interventions that start treatment at the time of overdose reversal, and blending together broader efforts that support recovery into housing, employment, and address the root cases of Substance Abuse disorder. With these efforts North Carolina saw the first decline in deaths in five years, decreasing 9 between 2017 and 2018. Weve seen a 24 decline in opioid prescribing and 20 increase in the number of uninsured individuals receiving treatment. 1 million north carolinians do not have Health Insurance and half of the visits to the emergency room are uninsured. We have focused on medication assisted treatment as the Gold Standard of care providing treatment to an additional 12,000 people. Our success is clear, but with your help there is much more we can do. We could stretch grant dollars further if doctors were no longer required to obtain a separate dea waiver to prescribe buprenorphine for addiction. We should strengthen our focus on justice involved populations. A recent study found that exiting North Carolina prison prisoners leaving North Carolina prisons were 40 times more likely to die of an opioid overdose than the general population. We are grateful to receive a grant to expand jail based treatment in our state. With 56 prisons and 96 jails we have a long way to go. The most significant of all would be giving us more time. Sustaining funding over longer windows of time would allow states to ready states for the next wave of the epidemic. That wave is cresting as were starting to see rising rates of overdose death for method methamphetamine and benz die yaz peen. Meanwhile, North Carolinas share of the Substance Abuse prevention and treatment block grant had not changed in recent years while North Carolina was one of the Fastest Growing populations in the country growing 9 between 2010 and 2018. Growing the block grant at pace with population and inflationary costs in an updated allocation formula would allow states to make better use of short term funding, prevent the next epidemic, and save lives. Most of all the Affordable Care act is critical to our long term success. States with higher rates of Insurance Coverage have more Sustainable Way of providing treatment and able to prioritize investment dollars. This is why we are working hard every day to expand medicaid in 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 pressing needs. Our strategies are working but our eyes are on the horizon. We appreciate your leadership. Thank you. Dr. Alexander scott you are recognized for five minutes. Thank you. Chairwoman degette, Ranking Member guthrie, and distinguished members of the committee, thank you for inviting me to join you to address the opioid overdose epidemic. Collaboration between states, federal agencies, and federal leaders such as yourselves is critical to our shared goals of preventing overdoses and saving lives. This issue has taken a staggering toll on my state. Since i became the director of the Rhode Island Department of health in 2015, an overdose death has occurred in every city and town in rhode island. During this time, more Rhode Islanders have lost their lives to Drug Overdoses than to car crashes, firearms, and fires combined. Almost immediately after coming into office in 2015, governor gi gina rahmon doe formed a strategic data driven comprehensive plan to prevent overdoses. The Task Force Includes stakeholders and experts in various fields including Public Health, law enforcement, Behavioral Health, Community Based support services, education, Veterans Affairs and recovery. As a cochair of this task force, i have helped steer our efforts into our four focused areas, prevention, treatment, recovery, and rescue or reversal. We have changed the culture of prescribing in rhode island and have dramatically reduced our prescribing numbers. We now have a vast statewide Treatment Network in place. We have cultivated a group of certified peer Recovery Specialists who walk side by side with people in recovery. We have put thousands of naloxone kits on to the streets. And most importantly, we have started to give people hope, and were focusing at the Community Level. We have learned that regardless of your race or ethnicity, regardless of your 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 and recovery is possible. One prime example is the story of jonathan goier from east providence, rhode island. Jonathan from east providence, rhode island. Jonathan became dependent on opioid at 16 years of age. At 25, after more than 30 tries and after reaching depths that many of us could not 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 recoveryfriendly workplace program. Jonathan says the opposite of addiction is not sobriety, but 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 Prevention effort that we put in 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, that number decreased by 6. 5 between 2016 and 2018. However, significant challenges remain. Fantanylrelated Overdose Deaths continue to increase and the opioid conversation must be considered within the larger context of an addiction epidemic that has alcoholism, tobacco use, cocaine use and other substances involved. We can broaden the scope even further to talk about the Health Implications of social and emotional isolation and the need to address the root causes of these challenges in our communities. All of this requires us to look beyond what many believe to be our traditional focus areas in Public Health. We need to look at the socioeconomic and environmental determinants of health, which determine roughly 80 of what makes you healthy and what makes me healthy. These are 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, supported and loved, 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 that ive outlined today wouldnt have been possible without the tremendous contributions of congress and federal agencies you fund. I thank you for that sincerely and i look forward to partnering with you to address what lies ahead and on behalf rhode island 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 really been focusing on the Opioid Epidemic for quite some number of years and this subcommittee in particular in the last few congresses i was the ranking democray 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 upton and i sponsored, we provided toprovided to states with a 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 miss smith, i believe you said 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 with cocaine and methamphetamine 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 . That people are moving from opioids . Absolutely. Youre shaking your head yes, are you seeing that as well . The Substance Abuse is the only sustainable tool that we havehave to build the workforce and develop the treatment resources for those individuals to go to to get ahead of the problem. Doctor alexanderscott, 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 . Certainly the increase in the percentage with Overdose Deaths. We are seeing also an increase in poly substances, multiple substances involved with Overdose Deaths 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 Use. Do you think the federal the language with some of the federal funds is restricted to address those issues . There is opportunity to be more deliberate in allowing the flexibility 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 that prescribing. And dr. Bharel, 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 had more flexibility . Absolutely. Thank you for your leadership in this area. So, what weve been doing in our Public Health approach to this opiate epidemic is focusing on of course prevention and intervention but really enhancing the treatment system, but as 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 were trying to build up systems of care so 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 within our system to over 1,200 including increasing training and availability of space to treatments and enhancing availability of methadone through Treatment Programs. 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 maximum flexibility. Id remind you in the recent federal 2020 federal government funding bill, Congress Continues to invest 1. 5 billion in the state opioid response grants and so in response to the changing drug abuse landscape we allowed grantees 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 mr. Guthrie for five minutes of questioning. Thank you i appreciated and all of you being here to tell your stories. Talking of bipartisan, youve asked questions i woulve and one thing i want to when we did the markup, our colleagues on the committee they dont know if hedidnt know if he had an amendment or made a point that different communities have different issues involve opioids in different communities 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 somebody on another substance that helps to build the infrastructure that has the same kind moving forward and we do need 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 that experienced that and they talked about the patient brokering and walked away appalling that there didnt seem to be any states which you represent, 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 Recovery Housing and started this 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 . Yes, thank you. I would be happy to provide Additional Information to support this. Our Sister Agency recognized 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 that 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 this Sister Agency in rhode island oversees the certifications to help establish those standards. I can get back to you on the official number that we have on recovery 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. That receives federal funding. Can you talk about why you needed to do this and the effect of it and when it goes into effect . Absolutely. It was passed by the legislature and our governor for the same reasons that it was in other states like rhode island. We were niing sues both through parents, through advocacy groups, through individuals who were attending Recovery Housing offense and noticing that there seemed to be some inconsistencies in the practices, and so we felt it was critical to pass some kind of legislation that enables us to have some oversight of these entities. What is interesting is that in pennsylvania, 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 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 recovery 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 have some level of Quality Services and maybe it will reduce business that some of the more scrupulous entities. I have a cousin who is a neonatologist and we talk a lot about this, i know that i only have a few seconds, so maybe one of you have you used federal dollars for that and has have it reduced it in your state if anyone wants to go first, anybody working with that specifically . West virginia to working 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. Ank you. I will yield back. Thank you, madam chair. As congress and the commitee consider furhter action on the crisis, 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 the as a 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 Carolina saw its first decline in opioid Overdose Deaths in five years decreasing 9 from 2017 to 2018 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 specialist and 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 treatment then and theres a group of folks that come out and see the to see the individuals after the fact. There has been a lot of very strategic focused interventions like that that have moved people into recovery and treatmentthat have been important for us in North Carolina. Ms. Smith, i was encouraged to hear pennsylvania has witnessed an 18 increase from 2017 to 2, 018th of what factors do you attribute the reduction to and what are a few key areas pennsylvania should focus on the continued trend . The key is not all that different actually. The focus on getting naloxone 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 then being quickly released back onto the streets to overdose again a repeated time so i think 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 needing naloxone 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 do we improve our prevention efforts. Thank you. Let me go to alexanderscott with regards to Rhode Islands response to the committee. You noted that 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 in those areas . 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 to 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 localrealtime at the local level which is 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 our 55 counties able to receive mat and we have prescribers in most counties. Thats the success we have experienced with the federal funds. Thank you madam chair. I recognize the gentleman from oregon for five minutes. I want to start with a question of transportation issues, 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, washington, 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 thank you for the question north 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. As you know, in the act expanded. When minister other treatments. Anyone else want to weigh in on this . Id be happy to very quickly. So pennsylvania is really fortunate in that we have a large number of Opioid Treatment Centers in the state. That is an advantage for us, but beyond that to assist Rural Communities, we have in particular a ramp grant that we call, will access to medication where we are expanding in rural areas thanks to grants from the federal government. As well as weve offered a Loan Repayment Program for practitioners in areas that are hard hit by the Opioid Epidemic. But also have Workforce Shortages which you can imagine is mostly rural areas. The commitment for that Loan Repayment Program is that you have to have two years of experience treating suv patients and you have to commit to an additional two years. Treating in that area. Up i want to move on to this 40 to see if our part to issue. The confidentiality of alcohol and drug abuse patient records. I heard a lot from providers about how this impacts negatively the exchange of information regarding individual Substance Abuses and treatment. Up there other health issues. We passed legislation in the house overwhelmingly to try to address this, protect patient privacy but allow the right flow of information to other medical providers. Tragically it went up on the rocks in the senate. Id like to see us renew our efforts here. Can you all tell me briefly, are you seeing patients impacted by this . I heard it from providers in my district. Y yes doctor. Y and massachusetts it we provided related to 40 to see a far and the obstacles that that produces. As we have started to think about what is the next step about what needs to happen to fight the epidemic. One of the issues is around appropriate Behavioural Health integration, both with Mental Health issues and Substance Abuse issues as well as how to connect that to the medical care that an individual needs, and many aspects that are four to 42 c four that are an obstacle. Have others run into . This dr. . You have a place to be aware, where it may be considered, within the school system. Making sure that it School Nurses and psychologists are able to Exchange Information needed to care for children who have Mental Health or even Substance Abuse challenges. Okay. Others want to comment on this . Mr. Kingsley. North carolina is fully supportive of modernizing 42 cfo are in an attempt to both maintain privacy but also move west integrated care. I think what is important is that, we have to systematically address stigma to help reduce systematic exclusion of individuals from housing, employment, and Everything Else the experiences. Well exactly. Anyone else . Miss smith. He said exactly what i was going to say. That really addressing eye you are looking at you notes. It has to be the primary concern here. I think its important to protect those individuals who suffer from this disease. 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 as someone who has hard disease or diabetes, but except their medical records. I think we need to change that conversation. That is just led to deaths. We need to fix this. I think we, manage share, can renew this effort to pass reform here. I know the administration has done some things, they could within the existing law, but i dont think that goes far left. Youve been generous with time. This is an issue we have worked on for a long time. We need to find a resolution. Thank you madam chair. Thank you to everyone. Share now recognizes general lady which housekeep. Thank you madam chair. In 2018, the overall rate of opioid Overdose Deaths in illinois felt for the first time in five years. The decrease was likely impacted by the efforts of this committee and congress to combat the Opioid Epidemic. But, this trend was primarily driven by the decline in deaths among white residents. Today, in illinois, opioid Overdose Deaths among blacks and latinos continue to rise. In fact, my hometown of chicago experienced more opioid Overdose Deaths then homicides. Up in 2017. Y of the 796 people who died from opioid Overdose Deaths that year, 400 were african american. And as a up, a recent study from the american journal of Public Health found that black and hispanic residents of cook county illinois were more likely to experience offense overdose than whites. That does not square with the sort of Public Perception of the Opioid Crisis as a white suburban and rural issue. Up i want to ask you, doctor alexanderscott, i know you have experience not only in your state but, as the president , former president of the association of state and territorial Health Officials. Can you tell us how the congress, how we, can help states to address the overlooked Racial Disparities in the Opioid Epidemic . Thank you so much for this question. It is such a chris critical issue for us. We in rhode island are also starting to take a more deliberate approach at addressing this by really making sure that we have the Health Equity lens in terms of how we are implementing our Overdose Prevention and intervention efforts. We have to make sure that every community that is impacted by this has the opportunity to have access to the Treatment Services as well as continue to look upstream to address the root causes that exist. We cannot overlook the social economic and environmental determinants that are occurring in various communities. I appreciate that congressman guthrie raised this question to some extent as well. So go ahead. It to be able to tackle this. The start is with what you have done, which is really expose the fact that different races and ethnicities are impacted by this epidemic in different ways and we have to make sure that we are taking into account the cultural and social economic environmental influences up that are contributing to why we have these different outcomes. And really focus on the root causes and making sure the funding that era you appropriate is able to take place at the Community Level and be driven by what the Community Needs to make the difference. Thank you very much. Doctor, it bharel is that right. Your testimony mentioned, in your testimony you mentioned that you are focusing on top in your state and so, what does that look like . Yes, thanks for bringing up this important issues. One of our five areas where we found we have seen an increase in overdoses and overdosed at city in our communities of color, so, youve been using federal funds to assist us in those efforts. To give you an example, as weve all noted, as our opioid Overdose Deaths thankfully begun to decline for 16 to 2017, we broke down our debt data by race and ethnicity. We found the only group still with an increasing rate of opioid Overdose Deaths was black men, so, we have, we routed some of our efforts to be able to focus on communities of color. Just to give you a few examples, we did some of our campaigns, including prevention campaigns to address different communities and provide them indifferent languages. Additionally and other example is, we have a license addiction counselor program, we have focused on latino and african members of our communities some more individuals can be trained and then go back to their communities to provide services. Thank you, i think this, the statistics are completely unacceptable, and chicago and a lot of metropolitan areas. Especially among communities of color theme. It would be a terrible mistake to go with just this overall data and not look at the particular communities, thank you for responding to this question. I yield back. Up thank you gentlelady, we now recognize the gentleman. inaudible im wondering if i could offer something, for the record as well, i forgot. Y what is it . Okay. If i could put in the study that i mentioned. The geographic distribution of fentanyl involved Overdose Deaths in cook county illinois and u. S. News and world report article titledy. Separate, unequal, and overlooked. Both items will be entered into the record. We recognize the gentleman from texas. I thank the chair for the recognition. Doctor, just briefly, mr. Guthrie had talked a little bit about patient brokering. I will share with you some of the most troubling testimony that we have had in this committee. Up on this issue. Was from your assistant attorney general up. I think his name was eric gould. Who came and testified to one of our oversight investigation subcommittees up about homes that were relocated in other states. Y his massachusetts residents would be lured two other locations, to have their treatment and of course, all covered by insurance, with no real identifiable metrics assist them to whether or not anyone was getting better. In fact, i think he share data with us up but he had a number of deaths of massachusetts residents that happened as a result of being farmed out to a sober home. Up as a followup to his testimony, is there anything up from a state chief medical officer, is there anything else that you can share about us about what he told us that day . Absolutely. The quality of care that our patient received in the system is absolutely critical that we make sure it reaches the High Standard for this vulnerable population. There are several things we do at the state level, we take very responsibly responsibly licensing and contract. All the services we provide to the department of Public Health. For that licensing and contracting authority, which has recently been enhanced through massachusetts law. We are able to set the criteria and have a feedback loop. We also respond to complaints, to rely sensing every two years, and anytime go into inspect the site. I will add in terms of sober homes. We now have in massachusetts a voluntary sober home certification program, which must meet certain criteria and standards. Weve seen improvements and have over 2000 beds in that system as well. Very good about that. Just to be clear when mr. Gold came and testified to us. He was not talking about sober homes within the state, or within the commonwealth of massachusetts, he was talking about sober homes that up there might be in a more agreeable southern climate. Not that there is a more agreeable climate than massachusetts in january im sure. Having never experienced that, up that was the deal that people would be, again lured, is that okay you can come spend, and a sunny location up. And you all sort of lose control of the situation when that happens. I guess what i am asking, are we doing any better as far as being able to communicate between states about when this type of activity happens, when you lose a resident up to addiction in another state . Is there some type of followup that is down on that . I do not have any specific example of a patient brokering, i can have the Attorney Generals Office followup to see what they can provide. I will say one of the things we need to do in our state, people are leaving, is make sure that people have the facilities and appropriate access to care in the state. We have been working really hard in that, one important success that many of us have in terms of crossed a communication, is the prescription Monitoring Programs. Ours in massachusetts, providers up party need to use before prescribing opioids, it was connected to 37 states including washington d. C. Up the whole program was a product of this community, many years ago i remember we worked on it, as well as on project echo. Over in the Senate Finance committee, thank you for mentioning project echo. Mr. Kingsley let me ask you if i could, she already addressed up for you to see a for par to issue. It do you feel that within your state, your programs are able to share the appropriate addiction medical records so that they can coordinate care with people undergoing treatment for Substance Use disorder . The simple answer is no. We have invested a lot of resources through peer support and other tools to try and support the coordination of care. Care management etc. There is still a huge limitation and even doctors within the same systems can easily talk to each other to coordinate care around their patients. Again up, an agreement with mr. Walden, i think we should redouble our efforts. Weve got 42 c for par to reform done on the house floor. In 2018, we were not able up, it did not survive the senate, so when President Trump signed a big bill into law, that part was removed. We need to continue to work on that because it is critically important. Thank you managerial back. Up the gentleman from massachusetts for five minutes. Thank you madam chair i want to thank the witnesses for being here today, to your testimony, i want to thank our colleagues on the committee for this attention. Up your welcome to boston anytime and winter dr. , the weather might not be the warmest, up we have our share of those. And hopefully it might be something that you guys experience sometime soon, we will move right along with october. He said on the massachusetts harm rejection up. In 2019 exploring the use of evidence based safe injection facilities it. The sites are shown to reduce the risk of infection, increase Public Health outcomes, and increased outreach to services. They are supported by the medical society massachusetts, the implementation of the site is currently being explored by the massachusetts state legislature. Doctor can you elaborate a little bit how the Harm Reduction commission came to recommend piloting evidence based safe injection spaces, as address briefly in the report, could you explain why the state operated facilities do not violate federal law . Up thank you congressman, thank you for your support of the work happening in massachusetts and around the country. Talking broadly about the harm induction commission, first to address the safe injection facilities, these were reviewed in the rebel dense was reviewed and the recommendation was to look at this further through our legislative process. I understand there are legal barriers both of the state and federal level. Talking about harm addiction broadly, what we currently have the capacity to do in Public Health. We have really been focusing our effort on the high risk populations i have mentioned and one of the important armored accent pieces including Syringe Service programs, we have expanded those in massachusetts from several years ago from less than ten, to over 30 now. Up we have good Response Rates not only collectings ranges but also providing Harm Reduction services, decreasing infections and connecting people to care. One statistic that has been very helpful for individuals is for every hundred surrenders that are handed out, 120 are returned, cleaning out neighborhoods and communities as well. Weve had a focused effort on that as well as our reach to communities at highest risk. Other evidence based treatment strategies such as fda approved drugs it methadone and our trucks own are considered the Gold Standard for treating those who suffer from opioid use disorder. Doctors it response to the committee is that the state has increased access to medication assisted treatment to those who have been incarcerated and reentering communities. Can you describe the types of treatments massachusetts is providing the incarcerated population in the state and if there is any disconnect, seeing up as individuals who are incarcerated lose medicaid once they are incarcerated, any roadblocks that come from that bureaucratic disconnect . Im proud to say one of the areas we have a lot of improvement is in treating individuals who are incarcerated. I mentioned in my testimony, one of our five high risk groups, in fact from our data we see that when individuals are released from incarceration, the risk of opioid death death is 120 times higher than other individuals, especially two to four weeks after release. That data and information really helped us open dialog in new ways with our criminal justice colleagues. And now the department of corrections is offering fda approved medication for opioid use disorder as well as a pilot happening in seven of our jail systems. We are also expanding our program of post release assistance as that has been mentioned earlier, individuals not only need to be connected to medications when they leave but also employment and housing opportunities. Thank you dr. Mr. Kingsley, a Study Released found that states that expanded medicaid had a 6 overall lower rate of up opioid Overdose Deaths than states they did not expand medicaid. Three specific opioids this rate was as high as 11 lower mortality. Unlike the other four states represented today, North Carolina decided not to expand medicaid, up has that diminished the of states ability to provide longterm Treatment Options . Thank you for the question congressman, absolutely. 426,000 people have an opioid prescription misuse up, we have been able to provide treatment to 12,000 uninsured folks, half of everyone coming into in the room with an opioid overdose are uninsured. We are digging out of this hole with a teaspoon, we are proud of our progress, we have so much further to go based after recent report came out from jama we estimate, many your carolinians would be alive today had the expanding medicaid 2014. Thank, you for your back. Gentleman from West Virginia is now recognized for five minutes. Thank, you madam chairman. I would like to enter into the record this letter from the voices it deals with the union opioid options, and with unanimous consent. Without objection. Thank you. I guess maybe the focus back on this mueller, on some of your testimony, i want to congratulate you for West Virginia the work youve done, and like you say, we have been the epicenter of this problem, going from 50 to 57 deaths per hundred thousand. And its just its incredible to see what is happening. My concern has been from the day one on this, that weve never really understood the contributing factors that lead to abuse. Weve had people in here from nih and cdc, it talk about associate Economic Issues and weve been able to go back and forth about whether states like New Hampshire that has absolute opposite social economic contributing factors as compared to West Virginia and three years they were the number two in the country, so id like, id like to understand more but what were doing about prevention rather than the treatment. And then i during perspective, what we have a building collapsed or building failure, we go back to front what caused it and then we can it, doesnt happen again so my question back to you, what do you think if youre getting factors are . Because i look at for example, and i agree with dr. Scott, service about productivity. I want to see how that goes together, because texas, texas has a rate of only 10. 5 two hour 57 whatever they do right in texas that we in West Virginia or maybe around the country could learn but what theyre doing their . Theres been other drugs are coming across. Its not like you dont have access to these illegal drugs. We know where theyre coming from. What can we learn from that, prevent people from abusing drugs. So, i think in terms of contributing factors, West Virginia experience a perfect storm but we had prescribed was trying to treat pain, we have individuals in high injury occupations, coal mining and some of the other industries that we have in West Virginia are prone to accidents so then, we had influxes appeals coming into the state, that easy availability and those things were how the perfect storm, if you will, get started with low incomes and people, the recession and the Different Things that were happening, people coming frustrated but in my opinion, you have to go further back and, we have to start with our, kids we have kids an absolute crisis. They are not living with their parents, many of them are living in foster care. Let me interrupt, id like to have more of a dialog with you about, this or referencing all the time, i am concerned if we dont stop the prevention, well get into the prevention, we will see even more of a neonatal a problem with our children, will see the impact it has on foster, families foster children in our foster homes as a result of this, so im really curious about how we stop in the first place, and i would mitigate the problem in the future. So let me go to the last comment. Id like to hear from you, and if you on the panel urges, we know Tobacco Settlement occurred years ago, 97 , 97 theyve administer these of the money it came in from tobacco payments he forgot to tell you there you fixing potholes. They were fixing ballots balanced eight budgets. Should we do the same thing . Because i would imagine that we are going to see quite a bit of litigation over the opioid, and there will be some federal settlement on this. Is there a role for us, for the federal government to try to step in to make sure that money doesnt go for potholes and balanced budgets . Is there some way that we can assure it will go for things like prevention or foster care or neonatal, to assure longterm funding from people that are making investments in treatment . How would you react to the federal involvement in the settlements . Any of you . Thank you for the question, congressman. We would welcome the opportunity to have sustainable funding that allows us to really focus on this epidemic comprehensively and over the long term. Many of us have referenced the importance of stability funding, particularly when you look at making sure the funding currently implemented at the Community Level. Communities that were great with you know the president is available for them to address the principle and you address a contractor system will be in place for a long time for there to be an impact, and the improvement we want to see. So, the assistance it is welcome to help us do that, across the board, is certainly to be well received. The gentleman from california is recognized for five minutes. Thank you very much thank you for being here for the incredible work that youre doing in your state. This committee has worked before partisan manner of the last several years pass legislation to help states implement programs to help the Opioid Crisis within our nation but more can and must be done. Remember. While members on both sides of the aisle are committed to addressing this issue, at the same, time directed effort to expand medicaid in some states, and even to make access to medicaid more difficult overall. Despite the fact that increased access to care means increased access to lifesaving treatment interpreter interpreter . In fact, just last, week a new study was published in a journal, the association of america medical association, jama, founded expanding medicaid under the Affordable Care act may have saved as many as 8000 people from fatal opioid overdose. I would like to ask unanimous consent to search for the record. Without objection. And according to the Kaiser Family foundation, another study 2017, medicaid covered 54 of people who received true treatment for opioid use disorder. So, despite the words about wanting to increase access to Mental Health and Addiction Treatment, you are also efforts to roll back the Affordable Care act which would limit coverage of the essential Health Benefits like Mental Health services and Addiction Treatment and repeal the Medicaid Expansion. If we truly want to address this crisis in a meaningful way, need to work to increase coverage, expand medicaid, not take it away. Time after time appeared for creation it was overdosing Emergency Department. Usually come unresponsive and lose and in the Emergency Department, we treat everybody with a life threatening illness regardless of their ability to pay, but once they are stabilized and leave the Emergency Department, to the hospital, they need to find treatment you help them with their addiction. They need to go to the facilities that offer the programs that receive the grant money. Those facilities often benefit if they have the medicaid, and if they dont have medicaid, they will go, because the Opioid Epidemic is an unprecedented crisis, they need to make fundamental treatment change the treatment system to combat opioid Substance Used disorders, so i would like to hear happening has played a role in the system. It is about, West Virginias response to the committee those statements infrastructure was initially not capable of the demand for over three minutes services. Including the rededicate is played. Medicaid has been a key component. We have used medicaid. We were approved for an 11 50 as 50 waivers reviews status part of our backbone to pay for Treatment Services with 11 15 waiver does not enable us to train our providers, it does not enable us to build our infrastructure, so we used the reference to wrap around that waiver and build infrastructure as well as cover people with no insurance or who are underinsured. That is been our strategy, greatest parts to gather and i dont think we couldve done one without the other. And according to a recent study, opioid treatment is much more widely access to the states have expanded medicare, go down that West Virginia, to medicaid expanded states both noted in their response to the committee, the importance of federal medicaid dollars in their ability to address the Opioid Crisis. Mr. Cohens hundred carolina, correct . You raised, injury, medicare it is, for, the most important tool in a sustainable response to the Opioid Epidemic. It will bring an additional four billion dollars into North Carolina for health care. How would expanding medicaid further develop its current approach of your crisis . The question. The interaction with the Substance Use disorder and employment and the fact that most get their colleges to republican or be overlooked. Iran or my people every day there potentially one driest away from losing their Health Insurance coming up in a way where they have no way to pay for the trip to the need to recover and get back into the employment. North carolina we are 5000 additional people would have charged with Medicaid Expansion, our duty to then shift as individuals to get treatment through medicaid through the 11 15 waver, and then use our resources to invest in the surpassing before scaled labrador resolve. I see, youve done to good work here that we take a step forward and come back the Opioid Epidemic but if we made it harder for people to withdraw in medicaid, such as biography overmedicate the spaniard from the Affordable Care act, including the essential Health Benefits that may determine the Health Coverage by making it difficult let me first answer a question that mr. Mckinley asked of you all and that was how do we treat this money, we had the Tobacco Settlement and a lot of many states want for not. In virginia they created a separate commission that handled the Tobacco Commission money for Economic Development purposes. Whatever purpose your individual states might want, i recommend that model. Because then you can take that lump sum of money and have it stretch out to assist in this case it would be with whatever issues you all had with Substance Abuse that virginia model has worked well for Economic Development in the former tobacco producing areas of the public. My district is the area stretch between West Virginia and North Carolina and kentucky and tennessee and virginias numbers look better than West Virginia, my district does not, have both marksville on the North Carolina side it is heavily impacted, and then all areas equal country and look very much like West Virginia when it comes to the Opioid Crisis. So im very concerned about a lot of these issues and we all are moved testimony from time to time it earlier you had a discussion related to privacy forces integrated medical care, testimony i remember is a man who came to testify for his brother who could not testify because he had died. He had looked the opioid problem and then was it a major car accident, because the doctors had no idea that he had an opioid problem because he was unconscious he could not tell anybody, you dont get the opioids, to give me opioids. He survived the injuries from the accident. He did not survive the reintroduction of opioids to the system so, we have to work on that problem and i appreciate all the testimony in that regard. Foster care. Restrictions like, you said half of the children in foster care, their parents had some form of drug addiction . But you i didnt see in the written testimony how many that was. In can give you the exact number. We have about 12000 individuals in the foster care system. So roughly 6000. I thought it was interesting 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 then adopted children from households where the parents were addicted to various drugs in particular opioids with significant behavior problems. What can we do to help our School Systems 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. Youth. Including behavior problems that are a result of being around folks who were using drugs at the time, those first couple of years. Is that also be included . It does address the Mental Health as well as behavioural challenges that you often face. I appreciate that thank you very much. Miss smith, i really want to learn more about what pennsylvania is doing more with its doctor, real Loan Repayment Program. Representing an area that has both significant as both pennsylvania and West Virginia do, in the appalachians together. We need more Health Care Providers out in our most affected areas. The rural areas particularly the coal counties that have been affected by this, tell me about that program some more. Sure. Plug this was an Innovative Program that we decided to use our federal funding for. We are a Medicaid Expansion state. For treatment dollar purposes, a lot of our patients are medically patients. The federal granddaughters we are getting we can used to be innovative. We have done some housing things. In this case we decided how do we address the workforce issue. Because it is an issue across the nation. We decided that you had to be practicing in an area with high opioid use. You had to have at least two years of experience treating patients with Substance Use disorder. And you had to commit to an additional two years. In order to make good on that loan repayment. Have you had the program long enough to know if the doctors or Health Care Providers they after their two years, there additional two years . Two years has not elapsed since the beginning. I look forward to getting that information in the future. My time is up unfortunately. Ill help you to share Additional Information about how much were granted. And i yield back. Thank you gentlemen, we recognize general lady from New Hampshire for five minutes. Thank you madam chair. I just want to say thank you to you for your leadership in my seven years in congress, this is one of the best most productive hearings i have been at. Its an honor to be on this committee. I am the founder and cochair of the Bipartisan Opioid Task force that has close to 100 members. Just to give you a sense of the scope, New Hampshire is my colleague mr. Mckinley suggested, was hit very hard along with West Virginia. A perfect storm situation. Up what i am proud of is that New Hampshire has some innovative models coming out of the Opioid Epidemic, and yes indeed we need to include meth amphetamines and cocaine and the rest. Up i want to focus in on a particulary vulnerable population and expensive population for the taxpayers, our communities and for individuals personal lives. Up the incarcerated population. We know that at least 65 , in some of our countries some as high as 85 , of our incarcerated population have cooccurring Mental Health and Substance Use issues. One of my big moments in the last seven years was to discover that something that past Congress Many years ago, at the inception of medicaid, called the medicaid inmate exclusion. It caused people to lose coverage and lose the funding for health care namely, Mental Health treatment, Substance Abuse treatment, during that period of incarceration. New hampshire is a Medicaid Expansion state, thank goodness, given the discussion today, but literally the day you go in, you lose your coverage. And to me, if we were to design a system that would faily american taxpayers, communities, it would be this system many. What happens is, people live with very high recidivism rates and we all do. We are the taxpayers. We have people, in incarceration, for drug related crimes, getting no treatment for their Mental Health or Substance Use disorder, and when they come out we all act shot the shocked they go back to their addiction. We are not shocked that they go back to their diabetes, and we should not be shocked if they go back to their addiction. So, i have introduced legislation that we call the Humane Correctional Health Care act. What this would do is continue medicaid coverage during and carson ration so that we can ensure treatment for Substance Use disorder and mental illness. What happens is that we have already demonstrated in New Hampshire is a dramatic drop in the recidivism rate. From the upwards of 50 or 60 down to 18 . I dont care if you are republican or democrat, left, right or center that is saving lives and saving taxpayer dollars. Im very pleased that mr. Mckinley agreed to join today as the doctor ruiz. So quickly moving on to questions, doctor scott, 2016, i know rhode island implemented a statewide Treatment Program for opioid addiction within your corrections. I would love to get the studies for the record and share with my colleagues, can you just explain the overall decrease an Overdose Deaths and what the outcome so far of that program has been . Thank you for that question the key to the program has been making that we have all three fda approved medications from medication assisted treatment available to those who are incarcerated. We also allow for screening of all incarcerated inmates for Substance Use disorder. So if they were not previously on an mma tee option, that was made available to them. The final key is making sure that prior to incarceration release from incarceration, they are connected to one of our Community Based behavioural agencies, they are a client in advance, make sure that once they are released they are able to have a warm handoff directly to continuing to receive recovery and Treatment Services at the Community Level. That is one of the one of the key components for our programs as well. So as i continue to build bipartisan support for this legislation, i would love to work with you and others, i know miss smith you mentioned housing. Or maybe it was the doctor, but i would like to work on what those supports are to illuminate the barriers to recovery. So that people can be successful in their lives, get back to raising their children, get back to work, get back to paying taxes. So thank you i yield back and i appreciate this hearing. Thank the gentlelady from indiana is recognized. Thank you chair, so much for you and the Ranking Member to holding this really important hearing. I am very pleased that we are focusing once again on opioids. It is some of the most important work that i have done and my time here in congress, i want to thank each of you, and particularly all the states that responded to the committees questions. It is really wonderful to see all of the progress and all of the efforts that each of your states are making. I think that while its not getting much Media Attention anymore, there was a period of time the last few years where, opioid issues were on the front pages, on tv all the time. Its not anymore. It has fallen off of the radar sadly. Of the american people, except for those families and those professionals, and the people who are dealing with this day in and day out. I really want to thank you for your work. I want to focus, go back to the workforce issues. Because all of this whether its prevention, whether its treatment, whether its the work that you are all doing. If we do not have the workforce, and i say workforce even beyond physiciansy and addictions, we need to stay focused. My friend across the oil aisle Brad Schneider from illinois, introduced the opioid workforce act, it is meant to try to raise the cap on graduate medical education residency slots, by thousand more residencies across the country. Y in addiction medicine. I know that i have spoken to mid school in indiana, i represent indiana,y with its grand challenge tried to put emphasis on addiction medicine, and at all levels. Whether its a nursing, prescribing practices, whether its addiction medicine. I want to go back just briefly to start on your Loan Repayment Program and learn if any other states are doing that. Miss smith, building on what my colleague said, he wanted to say a little bit more about loan repayment and then i want to do lightning rounds to find out if you are states are doing it and if not why not . Yes so very quickly i want to add, i can find the data here in my notes. We made 91 awards two individuals from 23 different counties the total 4. 7 Million Dollars for that program. It was a combination of both mental and Behavioral Health practitioners. So more of the clinician level, and then 1. 8 million of it was for medical professionals which includes see our mps, physician assistants, and positions. We tried to capture the full range of professionals as part of that program. The second round of awards is currently out, but applications are being submitted for us for a second round of a warning for that program. Do you believe if we increase the number of residency slots and addiction medication would that be helpful . I do believe it would be helpful. Doctor bharel your statement . Thank you for the important attention to the professional training. And massachusetts we were the first state to develop voluntarily at all four of our medical schools. Core competencies that were standardized for all medical students. That was quickly taken up by all of our three dental schools as well as our advanced near vance nursing programs. In a standardized way so that it could balance the needs of Pain Management with the potential for opioid misuse. Additionally, our social work schools have taken up their training as well as physical therapists. It is enhancing the capacity for individuals to treat this medical illness. I know one of the challenges with mid schools, in the past, they have given very little time to addiction medicine and pain issues. Are they starting at the first year now . And you met schools . The trick with our Core Competencies is we allow each individual medical school to create the curriculum the way they needed to based on what the curriculum is. They have been posted in multiple different ways. But that allows, usually curriculum changes takes two to three years, this we did it in a matter of weeks because the competencies were brought enough for them to incorporate. We know from graduating medical students, they see the difference and feel more prepared. Miss moments . We are very excited, we just did a Loan Repayment Program this year, we had over 100 applicants, i think 102. We funded 22 of those applications in this first round with a twoyear requirement. To practice within the state. That was focused on their therapists becausey it was for the existence it existed program focuses on the medical physician, we want it something to focus on the therapy level. But in addition to that, we also provided about 154 scholarships wish with the same type of requirements, eliminated the front and investment and some of the Student Loan Debt as well. Mr. Mckinley. We have a Loan Repayment Program for both doctors and mid levels. We have trained over 900 residents in North Carolina, currently in four of our five medical schools have built the curriculum into their built it into the recurrent. Can get rhode island to answer . Our Loan Repayment Program has also expanded to include Behavioural Health providers. Our medical school does now incorporate the data waiver training into our medical School Curriculum so students graduate, they automatically have the data waiver to be able to prescribey. Thank you for working so hard with youre Higher Education institutions. Itll make a difference. I yield back general lady from florida is recognized for five minutes. Thank you chair, i want to thank you for calling this hearing on the Public Health epidemic that is the Opioid Crisis. Thanks to all of you, all of our expert witnesses for everything you are doing to help families deal with the dire consequences. Back in florida, the past few years, we have lost well over 5000 of our neighbors per year. Y while i am really proud of the work of this community passing 21st century cures and the comprehensive addiction and recovery act, the support act, up there is one glaring problem often it has been highlighted by a few. Of my colleagues here today. It is the lack of continuity of care and resources in the minority estates they have not expanded medicaid. Unfortunately, the state of florida is one of those. Back mr. Kingsley, North Carolina has not expanded medicaid, i know i believe all the other states have here today. Pennsylvania, massachusetts, through West Virginia rhode island. Up in your testimony you said, for every person is brought to the Emergency Department, nearly half has no Health Insurance at all. Further you stated, that expanding medicaid would quote bring an additional four billion dollars into North Carolina for health care all of the democratic members of the florida congressional delegation yesterday sent a letter back home. Its the opening day of the Florida Legislature and our message to the governor and members back in florida was that you are not doing right by our citizens. One recent study said that if florida expanded medicaid we would down almost 14 billion over the next five years alone. 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 Use disorder. Talk to us again about how expanding medicaid in North Carolina would allow the state to better use the grant 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 but 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 Medicaid Expansion. The North Carolina state legislature reopened 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, too, hope that we are able to expand and increase access for North Carolina. Other recent counties have showed now that other states have expanded, other states have not. We are sending our dollars to subsidize the budget in health care of other states, but congressman customer wants to take me to lunch or something. Miss smith, how many lives have you saved in pennsylvania because pennsylvania expanded medicaid . In pennsylvania, as a result of Medicaid Expansion weve been able to treat about 125,000 additional patients, so for us, thats 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 a Loan Repayment Program, about housing and expanding corrections or about any of those things because the reality is that we would be sending off those dollars just on plain old treatment. So, as a result of Medicaid Expansion, we have been able to repurpose those dollars in ways that allow us to modernize the system, to integrate with physical health, Mental Health, Behavioral Health, altogether in one system moving forward, so i really cant stress enough the importance of having participated in Medicaid Expansion and i certainly hope it continues for years to come. How about you in massachusetts . In massachusetts, the foundation of our treatment is having access to the medical treatment that is proving an evidencebased because we have to, that, we have been able to tackle the very challenging and complex issues related to 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. Miss mullins, West Virginia has the highest share of population served through medicaid. You talked about the importance of predictability. How important has Medicaid Expansion to the opioid Substance Use treatment . You talked about the predictability of care. 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 West Virginians receiving medicationassisted treatment in our state. Thank you very much. The gentleman from maryland. Thank for the very compelling testimony and i think you all for coming. Weve learned of course that one causes inappropriate prescribing practices and a number of outspoken that today we know that many states such as virginia, maine, and rhode island have set prescribe agreements for opioids. Doctor alexanderscott, you highlighted a part of your response to the addiction crisis, your state enacted regulations in 2017, that limited the initial prescription of an opioid for a new patient to know more than 30, what are called morphine milligram equivalents, four emmys, per day. Could you describe a little bit more for us the danger to some patients of exceeding that limit and you think the policy has helped drivers make better discrepancies for their patients . Thank, you congressman. We had data that said the higher the morphine milligram equivalents of patient is on for a longer period of time, to hire their risk is of becoming addicted to opioids over time and thus their risk of an overdose. We want to make sure that there was flexibility for the provider in determining what was needed for the patient, and we also thought it was important to disagree critic you painting chronic pain limiting the opioids prescribed, so by cutting off the enemy at 30, four a key reason for pain, we have seen a substantial decrease in the number of opioids prescribed for an initial use of pain, particularly for acute pain scenarios. We have chosen to handle chronic pain needs separately, because oftentimes people already have an addiction or a tolerance to opioids that require a more and multidisciplinary approach to addressing that. But we drill down on that a little bit more. Because i know the cdc in their recommendations has indicated that providers should avoid prescribing over 90 emmys a day and many states have put that in the code, i think nevada and South Carolina have limited, in most patient cases. There are a lot of product on the market, especially extended release and long acting opioid products that do exceed even 90 m. M. E. A day limit, and some of them even double or triple that limit so i understand that the product are intended for patient who have become opioid resistant, as you, mentioned to these lower those products but do these high dosage opioids pose enough of an overdose risk . That we should at least we can to explore mothers to limit the rocket availability your judgment . We have certainly consider that now regulations approach for acute Pain Management, condition to the 30 morphine milligram equivalents limitation, we have also required that long acting opioids are not used for acute pain in those scenarios as well, because of the challenge that can occur and again, distinguishing from those patients that are already dealing with chronic pain and we need to be handled separately, and thank, you i know at the has taken previous action to limit the use of these high those products and they have imposed a risk evaluation Strategy Program on providers who prescribe these products and i also know there was a recently released gem a steady on this topic that failed to find any evidence that the program was successful in achieving its goals in reducing inappropriate prescribing, given the cdc recommendations, state precedent on prescribing limit, the lack of existing action, it may be time for the fta or congress or both of us to explore options for limiting the market availability of high those opioid products that are currently on the market, and limiting these new hires products, restraining them from entering the market in the future, so i think thats something i want to look out and i look forward to exploring a wide array of solution to come back to the Opioid Crisis and making sure the states have the funding in flexibility support these effective communities and thank you again for your testimony. I yield back. General from new york is recognized for five minutes. Thank you, madam chair, and that you do our panel for a very interesting unhelpful conversation. In your testimony, many of you head up our topic that was near inured to my heart and that is a limit your crowd can unnecessary barriers to Substance Use treatment. Research has shown that individuals who are being actively treated with no open up front, limit their use of roe v. Wade overdosed for people to pretend even when we provided without corresponding comprehensive Psychosocial Support for services. With any other medications that lowered mortality by 50 we would be rightfully healing this as a miracle drug and doing everything in our power to get it out to anyone who could possibly need it. Unfortunately here in the United States we continue to make it harder to obtain these medications the powerful obviously carson was probably the first place. So, secretary smith i was pleased to see that in your testimony you called to the elimination of the requirement for providers to obtain a waiver from the da in order to prescribe for creating opioid dependence. I have introduced bipartisan mainstreaming Addiction Treatment act, with over 100 cosponsors, to do exactly that. He described to the committee why this is such an important step to take in expanding access to Addiction Treatment . Absolutely, thank you so much for sponsoring that legislation that we are fully supportive of. So, i mentioned earlier in my opening that we have expanded our gis waiver positions to over 4000 and we are near the top of the list when you look at state in terms of a number of ex wavered positions, but looks can be deceiving. So when you take a look at those 4000 waiver doctors and you look at what are their prescribing capacities, and then whether or not they are actually prescribing up to their capacity or not, its pretty staggering, so we have a very large percentage that are still at that 30 patient capacity level and most of them are not even prescribing up to 30 patients and so weve worked with an Organization Called vital strategies to design a survey thats going to go out to all 4000 of our ex waiver position in the state to ask some very specific questions about why they are treating more patients. Are they willing to treat corporations . Is it an education issue . Is it a barrier because of additional oversight . And so anecdotally weve definitely heard that efforts to overregulate, doctors who are trained to administer any and all medication but specifically the call of this kind of medication and to say you need a special waiver to administer this, they dont want to be bothered with that and so pennsylvania believes that any steps we can take to eliminate those barriers, to change the conversation around the idea that treating addiction is a clinical necessity and we rely on trained physicians to be able to provide that treatment. If i could have the rest of the panel respond yes or no, do you agree with the assessment by secretary smith . Yes, hello, thank you for your question. The access to emerati and decreasing the barriers is critical, and we also spoke about it in our testimony. Do you agree with the waiver . Yes. I want to use my time here wisely so yes, and miss williams . This melons . Im sorry. Yes, but we dont have a therapist, but we dont have a therapist who really support those physicians once they can prescribe. For us, the Workforce Shortage is way more impacted on the therapy and counseling side. Guess, we are supportive. And doctor . Yes, we support and also look to expand Services Available as well. Even if you also mention individuals release from incarceration as a particularly volatile population to opioid overdose, and we noticed that the justice involved population has a death rate of 120 times hour higher than the clinical population, heard your changed my colleague from New Hampshire, so, while federal grant opportunities such as the Reentry Initiative are helping to fill in the, gossip a little more comprehensive and sustainable strategy is required in there for a champion the medicaid reentry act which would allow states to start medical benefits for incarcerated individuals, prior to, release with a sustainable funding streams, medication assisted treatment, case management, and Recovery Support services, and creating a more seamless transition back into community care. Commissioner barrel, but allowing states the flexibility you have benefits for eligible incorporated individuals 30 days prior to release help to reduce Overdose Deaths for that population . Making sure there is a continuity of care is critical for continuity of care and the other support mechanisms you stated. I was asked my, questions i have several other questions i was submitted somebody with that i yield. I thank the gentleman. Gentlelady from new york is recognized for five minutes. Thank you very much madam chair and i think our Ranking Member. We have heard a lot of encouraging stories today about how they would be able to put federal funds to use to make progress, but its also clear there are still unmet needs and unresolved challenges as they work to address the ongoing crisis. I would like to explore some of the remaining challenges as we consider further support. Small and, in your testimony you noted unresolved challenges around the building a robust Addiction Treatment workforce. Including attracting people to work in rural areas throughout the state. Can you describe what steps the state is taken to address this challenge of an additional hurdles remained . So, there is multiple challenges for this. There is pervasive work for shortage and in all areas implement West Virginia, we do not have enough people to fill our vacancies. And it also is about parity in terms of what we pay our Mental Health and addictions workforce. It is not the same so when students graduate with debt, they are graduating with levels of debt that we cannot really expect to earn salaries that are commensurate with a levels of education so to me, that is a fundamental thing that we must address and the Student Loan Debt to go with it so we have really been focusing on those Loan Repayment Program, scholarship programs, anything that would really increase, a, our pipeline but then also to provide ongoing education that we can, and we are finding that our individuals that are katie recovery have a really strong interest in providing services so we are paying particular attention in our Loan Repayment Programs even if the person who might be in recovery and wishing to take those next steps to enter the workforce. So is up the state level . Is there something at the federal level that you think could be helpful in sort of undergirding and helping to unearth individuals who were moving to that line of work . I think that the flexibility to use the funds in those creative ways would really be very beneficial. Very well. Secretary summit, in your written testimony submitted to the committee you also referenced the lack of additional treatment, excuse me, Addiction Treatment workforce i noted that quote, demands on Addiction Treatment workforce will increase as more people moved toward Treatment Recovery, and quote, so can you describe for the lack of Addiction Treatment workforce has inhibited pennsylvanias ability to provide services to vulnerable populations, and what steps have your stay taken to address this problem given and more people are moving toward treatment and recovery . Yes, certainly, our workforce challenges, particularly in urban centers like philadelphia and pittsburgh have really inhibited the ability for some of those more vulnerable populations to access treatment. Give you an example, we have an Advisory Council that advises my department and one of the members of that council is a practicing addiction medicine physician who happens to also treat adolescent, but he is part of the Latino Community and his practice is so overwhelmed with patients that he is working well into the night, beyond his Office Closure hours because those individuals have nowhere else to go and so part of the challenges that we hear in building a workforce where you dont have communication barriers, so where you have doctors who are treating patients that really understand im a communicate with them, a lot of the challenges come down to the education and training requirements and some of those language barriers that exist in being able to meet those requirements. So you have ided cultural competence, essentially. Yes. Very well. Mr. Kingsley, in North Carolinas response letter to the committee, state notes to quote, in many of North Carolinas communities hardest hit by the Opioid Epidemic it is difficult to implement programs that build Treatment Recovery access because the community lacks basic infrastructure including broadband and cell phone service, and quote so, can you describe how broadband itself and services are important to helping North Carolina address the Opioid Epidemic in these communities . And what can congress do to overcome these challenges . Thank you for the question. Tell a Health Access in our Rural Communities key strategy for our efforts to expand access to treatment, yet there are many parts of North Carolina that cannot sustain more than a 4g signal digitally or have access to broadband and so without, those we are not able to sustain those services. That of course is built on the fact that it is a sustainable approach for education, for all these providers, for parity, i agree with what all of my colleagues have said. Well, ive been a fan, we got discarded have a question for you but i will submit it for your response at a later time. I am chair, id like to ask for this letter from new york, state the office of Addiction Services and support the added to the record. No objection, its entered. I yield back, madam chair. The chair now recognizes the very patient mister letter for five minutes, i love the subcommittee. Thank, you madam, chair and first, i want to thank you very much, i really appreciate, this is a very important and relevant topic. One of the major newspapers in the state of ohio yesterday had an article that just came out i something we had heard coming but we know that in 2009 we had 1423 people dive overdose in the state of ohio. That number went up in 2017 to 4854 and the trend right now, thank, heavens going, down it was 3764 last year but these are all deaths that we dont want to see it all, these over the stats, and i know what i have gone in my district it is very important isnt talking to my Health Care Providers and other folks out there, one of the things they were telling me for several years is, we cannot find help and so it is everything from finding the dollars to finding where they can get services and so in the last congress, but what we do have the impact, we established a dashboard through hhs, states and communities go out there and find a health and what i would like to ask you all today is to some questions as to what is going on in your state, and if i could ask everyone, i know i dont have a lot of time if you could maybe be brief on your answers but some of your states have developed public facing dashboard. When were these dashboards created and what information you having them . Just go right down the line. Sure, i will be as big as possible. Pennsylvania does have an Interactive Data dashboard. If you go to a double slash opioids you are able to access that. It contains information like Prescription Drug monitoring information, Overdose Deaths, locked in distributions, and a, mass behind, treatment statistics and the number goes on and on so, happy for you to check that out and if you have questions let me know. I was there a second partner question . Just, the information you have contained in them. It was established two years ago. Thank you. Thank you for the question. Since 2015 massachusetts has put out a quarterly dashboard that contains much of the same information related to a number of deaths reported unpredictable using a predictive model as well as town by city so, appreciative one towns and cities get a report on the number of deaths in their communities so they can do a local base planning as well as ems and health care data. We also, since 2015 it together for the first time it across the State Government so were looking at the first time and health data as it relates to Public Health but also criminal justice, etc. So, for West Virginia, over the last couple of years weve been using reports uploaded quarterly that highlight things like Overdose Deaths, Prescription Drug monitoring and different data points that weve been focusing on through our grants with a centers for Disease Control surveillance. We do that quarterly what this week actually we expect to upload and make public a dashboard, that tracks non fatal death non fatal overdoses, and stay tuned. We are really looking forward to releasing that. North carolina launched its opioid action plan dashboard in 2017. This dashboard not only has key data points and adopted consistently around the Opioid Epidemic but it also broadens other aspects of Substance Use disorder it allows counties in local communities to drill down into the information there community which we see is being incredibly powerful and aligning us all the same strategies and also getting foundations, non governmental entities, private Public Partnerships on board with focusing their dollars in the same way that we need to focus on the other thing is that all of these indicators relate back to our strategies as Key Performance indicators that help us measure our success in this effort. Similar to what has been heard, in rhode island, when the governor activated the Overdose Prevention Intervention Task force, we understood that having a dashboard would be critical to that and that was activated in the 2015 timeframe, our dashboard does serve as a metric for each of our strategic initiatives, on prevention recovery, reversal and treatment and also allows for the public to be able to access where Treatment Services, are naloxone is available as well as access to other Recovery Services that are needed. In my last 15 seconds, packages do this real quick, i just ask real quick maybe with a yes or no, have your communities had a problem finding those federal dollars out there to get that help . I mean, just yes or no, down the line. Yes and no. Mostly know, because of the way our procurement system has worked and the capacity to put data into the community so they know what problems they are seeing in the past history the appropriate funding. It is targeted. I would go with, the deputy secretary smith answer, yes and no, many people have no trouble but there are still some folks out there struggling to find that information. Thank you. Weve been able to deploy funds to more than 50 local communities. Our issue is primarily that we dont have enough funds because there are going to augment treatment. Heres a data driven process to target which communities need it most and are really looking given that it is rhode island make sure that every town and city has access to those services needed. Thank you very, much madam, chair again, i want to thank you very much. I thank the gentleman. But i want to thank all of our witnesses, one of the members said this was one of the best hearings weve had this session, it might be very good information as we move forward to see what our next steps, are and in response to the committee september 18th letter, the Committee Received responses from 16 states garden they address the Opioid Crisis in support of federal funding and i moved to enter all of those responses into the record and in addition, lets, see were going to enter them all from florida, indiana, kentucky, maine, maryland, massachusetts, mexico, new york, North Carolina, ohio, oregon, pennsylvania, rhode island, tennessee, West Virginia, wisconsin, without objection. Those will be ordered and in addition, the continuation of our bipartisan work looking at addiction and treatment issues today, the committee is sending a bipartisan letter signed by the Ranking Member, myself and others, letters to the dea, dhs and a about the emergence of what is panel was talking about, memphis ivan and police Substance Use and what the administration is doing about this, and i would ask unanimous consent to enter those, them into the record, without objection that will be ordered as well and i would like to remind members of pursuant to the Committee Rules they have ten Business Days to submit additional questions for the record, created by the witnesses him, several members today asked the witnesses to additional questions and i will ask you to respond properly if you received any evidence questions and with that, the subcommittees adjourned. [laughter] [inaudible conversations] [inaudible conversations] [inaudible conversations]govern. Washington journal continues. Host back at the table, congresswoman gwen