Transcripts For CSPAN3 House Hearing On State Efforts To Combat The Opioid Epidemic 20200128

the subcommittee on oversight investigation will now come to order. today, the subcommittee on oversight and investigations is holding a hearing in titled, public health emergency, state efforts to curb the opioid crisis. the purpose of today's hearing is to examine states efforts and successes and addressing the opioid epidemic, as well as opportunities for future federal support, and just to let everyone know, doctor alexander scott the, reason why we are getting started a little bit late, the plane was delayed, but now the doctor is on her way. so, we will swear in the witnesses when we get to that point, and if we have to do that one later, we will. the chairman recognizes herself an open i using statement. as i, said the committee continues its bipartisan efforts to combat the opioid crisis. the country is in the midst of an opioid epidemic unlike any in history. according to the cdc, from 1999 to 2017, nearly 400,000 people died from opioid overdoses. in 2017, more than two thirds of drug overdose deaths and voiced evolved opioids. the crisis has continued to evolve, and the challenges we have faced have continued to evolve along. with it the first wave began in the 1990s with the overprescribed of pain medication, the second wave began in 2010 with increased death 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 fueled a huge increase in math and that i mean use, in 2018, there were more than twice as many deaths involving meth as 2015, and that is increasingly turning up an overdose death and drug busts across the country. given the complexity of the epidemic, and its ability to evolve, states in congress must remain vigilant. to that end, this committee has taken numerous steps to investigate the origins of drivers of the crisis, so we can learn from it, as we try to get ahead of the next wave. 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, we are 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, the past bipartisan efforts to help those impacted by substance use disorder. these legislative packages provided states billions of dollars in federal funding to assist in recovery efforts, and we have made some progress. cdc provisional data indicates that drug overdose deaths has fallen for the first time in decades, while the downward shift is welcome news, it is far from over. and we must continue to look for ways to bring relief to struggling cities and towns throughout the country. today's hearing continues those bipartisan efforts. day in and day out, states are on the front lines of this epidemic that killed more than 130 americans every single day. as the epidemic enters a new decade, and keeping with this commitment to finding solution to this nassau urgency, letters were sent 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 roles in treatment recovery and prevention efforts. we want to thank all of you for coming today. the states composed a large swath of the country, wilder demographics, they have all felt and they had the highest overdose deaths rates. the two them have taken a number of steps to carve the epidemic. pennsylvania could distribute 13,000 of naloxone kits in 2013, and again in 2019. thanks to a combination of state and federal funds. north carolina provided treatment 12,000 uninsured persons thanks to federal funding, and rhode island has been able to expand medication assisted treatment in the prison system, resulting in a 62% reduction an overdose path. this is how these states help communities. as congress considers action to address the crisis, all of our witnesses provide insights on how federal funds are used to come that the epidemic, what efforts are successful, and what we need to do further. and thank the witnesses for their service, for being here to testify on behalf of the state, and i look forward to hearing how we can all continue to work together to find the desperately needed solutions. with that, i am pleased to yield for purposes of an opening statement. there guess free, five minutes. >> thank you for holding this on state responses to the appellate epidemic. our local communities are suffering. on average, 130 americans die every day from an opioid overdose. and opioids were involved and 47,600 overdose deaths in 2017, which accounted for 67.1% of all deaths. there were -- reported deaths in 2017. energy and commerce committee have been steadfast in its efforts to combat the epidemic, with both investigations and legislation. whether there were investigations into the prescription drug and heroin epidemic, opioid distributors or the manger manufactures, 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 addiction recovery act. the support for patients and communities act, i was proud work on all three of these comprehensive laws, which were designed to combat the opioid crisis through prevention, advancing treatment and recovering initiatives, protecting communities and bolstering our efforts to find a synthetic drugs like fentanyl. this hearing is a critical opportunity for us 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 success they are having and 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 has seen a decrease in the overdose deaths. faiths sense 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, emergency departments, expanding and increasing the availability of naloxone and medicaid assisted treatment, increasing non emergency transportation options for those in rural areas. expanding neonatal abstinence syndrome treatment program for mothers, and workforce initiatives like a loan repayment program, and broadening the curriculum in medical schools. this hearing is a great platform for the states to share how the federal funding has made a difference in the programs. not only is it helpful for us and congress as we continue to conduct oversight and legislate, but also to the states as they learn from each other about new ideas or innovation approaches that could be implemented. well progress is being made, the director of national institute of drug abuse, doctor norah, declared this week that this country still has not controlled its addiction problems. some states are continuing to see a high number of -- overdose. states are facing many challenges, including a lack of qualified infrastructure, varying requirements and timelines and different federal funding streams, and restrictions on funding, including that some funds have been restricted to opioids, in pleading flexibility to address emerging challenges. in addition to the continuing threat of opioids, states are starting to see more instances of poly substance abuse, poly substance overdose deaths, with state specifically citing methods that i mean and cocaine as a growing concern. nationally, since last, year matt impediment has been detected in more deaths than oxygen. and 14 of the 35 states that report overdose deaths to the federal government, matt impediment is involved and more deaths than fentanyl. the threats are involving and the threat is not over. we will partner with state and local entities to combat the epidemic, as well as emerging threats, which is why it's important to not let our foot off the gas. congress needs to continue to support the states, and this committee needs to continue to conduct 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 and combatting the epidemic, but also have the threats have changed, what challenges remain, and what more we in congress can do with our partners, you, in this fight. and i yield back. >> i thank the gentleman, the chair recognizes the chairman of the full committee, mr. frank pallone jr. for five minutes. >> thank you. today's hearing continues the committees ongoing bipartisan efforts to combat the opioid epidemic, whether field by prescription drugs or illicit, synthetic opioids, this epidemic is a constantly evolving threat, putting families at grave risk. this is not a crisis that we can solve overnight it requires ongoing's detention. the states around the front lines of the national mercy regarding much of the support for those in need, they are eyes and ears on what's occurring on the ground, that's why this hearing is so, important it's the latest in a series of hearings it is held on the opioid crisis, and several states including rhode island about the epidemic, history the federal agencies about the urgent threat posed by fentanyl, and also directed to your bipartisan investigation into opioid distribution practices, then urgent commerce committee is also been on the four pointer passing critical legislation that gives our federal state and low will pop nerves the tools and resistance succeed including three pieces legislation all bipartisan. designed to give states funding and support 2016 the committee signed into law the comprehensive addiction ever covering acts and the 21st century cures act if you mention the chairwoman gets a major role in. that these two laws authorized over a billion dollars there in space state to suffolk grandson prevention recovery efforts. in 2018 the support act was passed and signed into law, realizing appeared specific funding opioid abuse and overdose production training and improving coordination and quality of care and then in -- there is ten billion dollars in additional opioid funding, this committee is committed to making sure communities receive funding the need to receive elites. we have requested information on how federal funds have this is to the states in this fight. and additional help and how it will affect future actions. much no sees or using federal opioid funds and find out how funds have helped transform systems. the federal money has allowed states to take important and innovative approaches to addressing opioid addiction or the most effective tools that is available is medicaid several states elaborated on that, a study released last week found it about 8000 lives have been saved from an opioid overdose thanks to the expansion of medicaid under the affordable care, act we want to hear about emerging trends and subjects abuse that are being seen, for example several states continue to fight the opioid epidemic, were also seeing an increase in methane feta mean and poly substance use, this of course is an alarming trend that threatens to be the next epidemic and i want to, thank the witnesses, we look forward to hearing about their, efforts thank you madam chair for continuing, your efforts on this i don't know if anyone wants my, time if not i'm going to yield back. >> thank you gentlemen we now recognize the ranking committee of the committee mr. walden. >> thank you for holding this green the important meeting, us as i was preparing for this i know is the biggest county in my district they have a two overdoses per average for week, and seven last week and fortunately no deaths. . they believe that it's probably heroin with a pretty heavy dose of fentanyl in it, the deadly scourge continues, for many years that urgent commerce committee this subcommittee has been at the forefront of the efforts to address the opioid crisis, and substance use disorder issues, we've done a lot of work on prevention, we know we have a lot more work to do this committees held hearings we've conducted investigations on opioids an opioid epidemic for nearly two decades bringing in new pharma to testify about the abuse of oxycontin to our bipartisan vacillation into the rise of fentanyl opioid manufacturing, opioid distribution, substance use disorder treatment industry, these early hearings help informed or legislative work, including the comprehensive addiction recovery act, kara, 21st country cures, act which authorizes see tarred decked -- billions more in federal appropriations, to fight treat and stop substance abuse and support access to mental health these efforts, culminated to signing the support act. the most recent statistics to the cdc. i'm pleased we have contained who are together on the space. it's important including by continuing our work on fentanyl. and with this important hearing today examining how the states are utilizing the funding. and the authorities provided by congress. there are so much more we can do together earlier this year. and harvey and commerce and republicans publishing request for information, about the substance use disorder, treatment industry, the builds off the patient brokering investigation that we conduct in the last conference, in this investigation brought us to the question, what is good treatment, and conversely, what is a bad treatment, which is a question posed by rfi the billions of dollars we are sending into the states for prevention treatment we need answers yesterday and urging commerce, sent a letter to three operated manufactures we began investigating last congress, asking tingly production, is critical we fully understand the causes of the opioid epidemic in order to ensure our solution to the right ones in support that they answer a questions. we also hold a comprehensive series of hearings to, relevant today's hearings, to support act included the nfl acts, sponsored by mr. latta, which called for the creation of a public electronic dashboard, linking to all the nationwide effort and strategies to combat the opioid crisis. the infill act was described to meet the local meet of state holders that were telling us, despite congress voting to combat the opioid crisis, they had trouble finding the resources, and where they were. this was certainly an issue we heard a lot about from mr. mckinley and others. these provisions are critical in helping those on the front lines of the opioid crisis, and i'm really concerned about it slow implementation. in addition to oversight, we need to begin to work on not only opioid crisis, but also substance use disorder's more broadly, was urgently we need to reauthorize the fentanyl ban, which is set to expire in a matter of weeks. we authorize the prohibitions on various forms of fentanyl by prohibitions support, should do that expeditiously. and i want to thank all our witnesses for being here and being part of this equation. and i look forward to hearing from you. with that, i yield a balance of my time to the ranking member on the subcommittee on health, mister bridges. >> thank you for yielding. it was under your leadership that we worked on a bipartisan manner to produce legislation. and ultimately decided to law by president trump in october of 2018. and it really began in the subcommittee with the members we heard from, and we heard from over 50 members, not just the committee, but throughout the congress, the probably had in their districts in the ideas that they were bringing to the tables that we could work on. the support act was written to help the initiatives for those affected by opioid habituation. i still want to thank our witnesses for being here today it will be helpful understanding the challenges that we face continuing this fight against opioid addiction and death, while ensuring that patients can't manage their pain. it is important to congress to have hearings like this where we can ensure the effectiveness a legislative efforts and identify gaps where they exist. i want to thank the chairman. >> madam chair, i yield back with the notation that other members will be coming and going. >> i ask unanimous consent that the members running opening statements be made part of the record. without objection, so ordered. i now want to introduce the witnesses for today's hearings. miss jennifer smith, the secretary of the department of drug and alcohol programs, commonwealth of pennsylvania. welcome. doctor monica bharel, the commissioner of the commonwealth of michigan. doctor nicole alexander-scott, i think they banned you hear from the airport, so congratulations. he's the director of the department of health for rhode island. miss christina mullins, commissioner bureau for behavior health, health of human services, state of virginia. welcome. and mister kody kinsley, director of intellectual disabilities, department of health and human services. state of north carolina. welcome to you. thanks to all of you for appearing before in front of the subcommittee today. as you are, aware the committee is holding an investigative hearing, and when we do so we have the practice of taking all of our testimony under oath. do any of you have objection to taking testimony under oath today? >> let the records reflect that the witnesses responded. no under the rules of the house and committee, you are entitled to be accompanied by counsel. it doesn't if you wish that? let the record reflect the witnesses have responded. no so if you would, would you please rise and raise your right hand that you may be sworn in. you swear 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 the penalties set forth in title 18, section 1001 of the u.s. code. we now recognize the witnesses for five minutes summaries of the written statements. in front of you, there's a microphone, a timer, and a series of lights. the timer counts down your time, and the red light turns on when your five minutes have come to an end. and, so, miss smith, i'm pleased to recommend recognized for five minutes. >> thank you. chairman, ranking member, and members of the subcommittee. my name is jennifer smith, and i am a secretary for pennsylvania drug and alcohol programs, as well as a member of the national association of state alcohol and drug abuse directors. thank you for your interest and how pennsylvania is using the state opioid response funding to promote food prevention, treatment, and recovery efforts. acting as the states single authority for substance use disorder services, 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 effecting 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 2700 pennsylvanian's to drug related overdoses, which equates to seven deaths per day. by 2017, that number had tragically doubled to more than 54 lives lost, with 13 deaths per day. as such as six raised every year, our primary focus is simple, key pennsylvania is alive. that meant infusing the lock zone into communities, and learning more handoff, from emergency treatments into treatment. and evidence based treatment, such as launching a 24/7 get help now hotline. i'm proud to say that in 2018, pennsylvania reported 18% decrease in overdose thefts, while it's not clear whether this promising trend will continue in 2019, it is clear that the more than 230 million dollars 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 curriculum's, and established over 18 prescription drug take back boxes over the state. we established a naloxone standing order and distributed over 55,000 free kids, developed a warm handoff model that has been used over 6400 times, expanded treatment capacities through 45 centers of excellence and eight programs. it increased our, offered a loan repayment, awarded 3.5 million to expand support for pregnant women and women with children, and expanded him 80 into our state correctional institutions, in terms of recovery support we awarded 2.1 million to expand community recovery services, developed a website to share recovery stories, and spread hope, and awarded grant funds to build recovery housing support. in coming months the pennsylvania will integrate quality into our four major goals of reducing stigma, intensifying primary prevention, strengthening the treatments system and empowering state recovery. without sustainable federal funding, the collaboration necessary to accomplish these goals will be greatly diminished. although we 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 were possible. such as utilizing the block grant, as well as continue use of the single state authority as essential 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, are working diligently, and we have made staggering process. the police don't give up. long term success of our programs, and communities, depends on sustained funding and support. just to other quick considerations, would be to address stigma in a more uniform way across the nation, through language and action. to seek ways to address the dire workforce shortage challenges. experienced by every state. thank you again for allowing me to share what pennsylvania is doing, and our suggestions removing this system forward. up for it answering you your questions you may have. >> thank you so much and don't worry we don't intend to give up. doctor you are recognized now for five minutes. >> chair, the 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, and dedicated to addressing the opioid epidemic in massachusetts, i commend congress and our federal agencies for funding, those working tirelessly on the front lines every day. >> her data indicates that in massachusetts, are public centered approach, the opioid epidemic is working. i'm heartened to let you know that from 2016 to 2018. our opioid overdose deaths have declined by 4%. we continue to focus on prevention and education. availability, medication treatment. behavioural health counseling. and sustained recovering supports. we've made progress, still unacceptable, the 2000 individuals in massachusetts dive 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, in their communities. since 2016 we have been awarded approximately 159 million dollars, in federal funding specific to opioid use disorder, prevention treatment and recovery. we've allocated approximately 111 million of those funds. we've used federal funding to support expansion and in hadn't spent of our treatment system, to a data driven approach, the targets high risk, high need, priority populations and disparities, with the goal of reducing opioid overdoses and deaths. in 2015, governor baker pointed out working group who developed an action plan, emphasizing data, to identify hotspots. a ploy 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 is unprecedented in massachusetts. allowing us to have a deep understanding so the new investments can be strategic and i'm impactful. our efforts are focused on five key populations, still suffering from overdoses, persons released from incarceration, communities of, color persons with coworker image a health and substance use disorder,'s history of homelessness, and mothers with opioid use disorder, or data showed that the rate of opiate overdose right death for mothers, was more than 300 times, higher. mothers without it. in response, one of the programs we set up was moms you care. which is currently 100 percent federally funded. it's innovative approach built a seamless, integrated, continuum of care for pregnant and parenting women. with substance use disorder, and provide access to medication, prenatal and postnatal care, maternity and pediatric care. behavioural health counseling, and peer to peer recovery supports and so much more. with federal friends we are also supporting and pre-spending our prescription drug monitoring program, allowing all massachusetts prescribe, arrears enhanced access to this vital system. while we have had many successes, we do see opportunities for federal existence, so we can continue to make progress. this includes funding that is flexible. and funding requirements restricted to addressing only our period, states are limited in our flexibility to address the changing landscape of substance use disorder, flexibility would enable us to address other substances connected to this epidemic, such as container matt impediments. there are currently federal barriers to treatment. these barriers should be removed. this would allow medication assisted treatment to be regulated more similarly to other chronic disease treatments. and available in traditional health care settings, to access and reduce system. stigma, in conclusion we are grateful for the commitment to address the opiate epidemic, watch for progress can be attributed to federal funding we received, and i encourage congress to continue these critical funding, efforts this crisis did not build, overnight it will take time to reverse, addiction is not a, choice is a, disease with a continuous supporter our federal partners we will build a solution to tackle this epidemic, in massachusetts and in this, country thank. you >> thank you so much, miss mantra recognize now for five minutes. >> thank you, chairwoman ranking members, and members of the subcommittee, my name is christine imbalance, i'm the commissioner for the bureau behavioural health within the west virginia department of human resources, and they also serve as a member of the national association of state alcohol and drug abuse directors, first and want to thank you for your commitment to address this crisis, but at the resources provided by this committee west virginia would be in a considerably worse position, also want to thank you for the opportunity to discuss the important of the initiatives in west virginia to address the or pr crisis in the impact of the funding made available through this committee to promote recovery and treatment. it is no secret that west virginia has been ground zero the appeared crisis with the highest overdose rate in the nation there are more getting documented support surprising stories that describe will happen to our state, i'm sure these efforts that played a significant role in bringing much needed resources to west virginia. today i would like to tell you a different story, with your help west virginia has reduced i'm decrease by about 50% while prescribing has increased by 208%, additionally we have distributed over 10,000 doses in the political health departments, treatment capacity has been transformed, number of people that could prove fry has more than doubled, to 584 since 2017, we've increased a number of residential treatment beds from 197, to 700 and, 40 and i records indicate those beds are about 85%, fall at about all times. additionally, nearly all urban facilities have access to integrated substance use disorder committee, this extraordinary increase in infrastructure and capacity as a result of the significant financial investment, the federal state a drug summit fans. west virginia leverage federal investment, increase the number and quality of its, workforce distribute life-saving a lock zone, production rigorous provide of education on opioid describing increase evidence based prevention programs, and stood up quick response seems to follow up on individuals that experience non fatal overdoses in addition to these efforts it also increases infrastructure for surveillance and data analysis, is what drives all of our decision-making, estate complemented the work of his federal project by using settlement funds in general revenue to undertake the development of construction projects. that expands specialize in treatment of pregnant post pardon women. writing funding sources allowed west virginia to violence the need for immediate interventions, with the long term need to event the systemic issues, that serve is an ongoing challenge in the states opioid response, significant progress has been made certain barriers and challenges remain, west virginia continues to work you, -- lack of passages are children impacted by this, crisis in addition to keep concerned of tine, granddaughters and sustainability of, everest and thinking about a bigger longer term investment, that these endeavors are going to have a continuing at, packed increasing treatment availability of reducing overdose deaths, predictable and sustain provision reserves is key to allow states and providers to plan a reliant virtual recommends, it can be tough to successfully plan and operate programs a providers, are not confident resources will be available be on the one-year commitment, it would be difficult to believe that west virginia could've accomplished so much without the support of this committee. these funds have allowed west virginia to have the resources that it needs to respond to this crisis, and resulted in a decrease of overdose deaths, and transformed our system of care, are overdose deaths are down at this point, or records say by 10%. financial resources are crucial to ongoing funding for prevention treatment recovery services at the state, level to ensure continued, progress will barriers remain west virginia is better police to address future challenges and continue challenges. they wish to say thank you to this committee, to, d.c. 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. can say i like to recognize you for five minutes. >> thank you, chair there are game remember guthrie, and honor all members of the subcommittee for this opportunity to testify on north carolina's response to the opioid epidemic, on behalf of the 10.4 billion north carolinians, 26, 000, want to express my deepest prostitute for this supportive funding that is helped us turn the tide on the epidemic, this investment has save lives, transformed communities, and has made the down payment on breaking the cycle of addiction, trauma and poverty interstate, i'm also grateful to the committed staff it is help to support a strategy working across interjected systems, health, care, housing employment, injustice, north carolina was hit hard by the crisis. 2016, 1407 north carolinians di of an unintended opioid overdose, for each death there were six overdose obsolescence a, shuns and we were one of the top eight states for fentanyl overdose, deaths since the start of the epidemic nearly 100,000 workers have been kept out of the workforce because of opioid misuse alone today close to half of the children in north carolina's foster care system have parental substance uses factor in their out of home, placement of course the human cost, loss to community and, families skill the problem underpins are magnitude for accomplishment, isis comprehensive response, opioid action plan, is organized into three, pillars prevention, harm, addiction in connection to care, these pillars and compass numerous strategies, all made possible because of federal funding. how did supply vein appropriate opener predictions, making access to like saving a lock zone, ubiquitous, supporting syringe exchange programs, making addiction, medicine a core medical at acacia, partnering with county and local communities, washing interventions at the start of treatment. the star treatment at the time of overdose reversal a budding together broader efforts to support recovery housing, employment, and address the recalls of substance use disorder, with these efforts north carolina's saw the first planted death of five. here is decreasing 9% between 2017 in 2018. we've also seen a 24% you ... 1 million north carolinians do not have health insurance. over half of visits to the emergency room are uninsured. our highest priority has been expanding evidence based treatment, to those without insurance. we focused on medication assistant treatment as the gold standard of care. providing treatment to an additional 12,000 people. our success is critical with your health there is much more we can do. we can stretch grant dollars further if doctors have no longer required to obtain a separate dea waiver to prescribe up an effort for addiction there's no additional with your car to prescribe the exact same medication was being subscribed for other addictions. it was a study found that axing north carolina prisoners were leaving 40 times more likely to die from opioid overdose in the general population. we are grateful devilishly received a six napoli dark man from the department of justice, to create progress diversion programs and expand she'll based put on an interstate. 56 persons 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 permanently we allow states to ready systems for the next wave of the epidemic, that wave is already cresting, we're starting to see rising rates of overdose death from nothing fell to mean and eyes appeared, before major federal funding became available 12,000 people in north carolina have already died, meanwhile, north carolina share the substance abuse prevention and treatment brought have not changed in recent years while north carolina was one of the fastest-growing populations in the country. growing 9% between 2010 in 2018. growing the block ran at a pace with population and inflationary costs in updated allocation formula would allow states make better use of force short-term funding to prevent the next epidemic and save lives, most of all safeguarding medicaid expansion the affordable care act is critical to our long term success in fighting the epidemic states with more ensures insurance dollars have more of a chance. that's what we are working hard every day to have medicaid in north carolina. in closing i want to applaud the flexibility of much of the federal funding we have received, which is allowed each day to respond to his own pressing needs our strategies are working, their eyes are on the horizon we appreciate your leadership, and i welcome your questions. >> thank, you doctor alexander, you are not recognized for five minutes. >> chairwoman ranking member guthrie and distinguished members of the committee thank you for inviting me to join you today to discuss rhode island's efforts 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, and overdose death has occurred in every city and town in rhode island, during this time more road islanders have lost their lives to drug overdoses that two car crashes fire arms and fires combined. almost immediately after coming into office in 2015, governor gina rwanda formed an overdose prevention and intervention tacked forced to develop a centralized strategic data driven comprehensive plan, to prevent overdoses, the task force include stakeholders and experts in various fields including public health, law enforcement, behavioural health. community based support services, education veterans affairs, and recovery. as a culture of this task force i've helped steer our efforts into our for focus areas, prevention, treatment, recovery, and rescue or reversal. we have changed the culture of prescribing rhode island and dramatically reduce prescribing numbers, we now have a vast statewide treatment network in place, we have cultivated a group of certified pure recovery specialists who walk side by side with people. recovery we have put thousands of naloxone kits onto the, streets and most importantly we have started to keep people hope and we are focusing at the community level. >> we have we have learned that regardless of your race and committee regardless of your zip comb income or insurance status every door for every person should make treatments and recovery services available. we believe that addiction is a disease and recovery is possible. one prime example was a story of jonathan gore from east providence rhode island. jonathan became dependent on opioids that 16 years of age at 25, after more than 30 tries, and after reaching depths that many of us could not fathom, he was finally able to find, stain sane, and maintain a life in long term recovery. he is now thriving as an expert adviser to governor rondos tax forced, and he leads our states recovery friendly workplace program. when you talk to jonathan about his journey he says the opposite of addiction is not sobriety the opposite of addiction is connection. this is true for every community we are trying to make the connection and the sense of community that brought jonathan and so many others back from the brink, a part of every overdose prevention effort we put in place and rhode island, we have had some success. after the number of drug overdose 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, a significant challenge remains, fentanyl -related overdose deaths continue to increase and the opioid conversation must be considered within a 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 they need to address the root causes of these challenges in our communities. all of this requires us to look beyond what many believed to be our traditional focus areas in public health, we need to look at the social economic 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 that all children grew up in homes, and go to schools where they feel safe supported and loved, to ensure that people have the houses that are helping safe and affordable and torture that people have jobs that offer fair pay, this is a part of our response, the efforts and the progress that i've outlined today would not have been possible without the tremendous contributions of congress and the federal agencies you fund i thank you for that sincerely, and i look forward to partnering with you to address what lies ahead. on behalf of rhode island and on behalf of the association of state and territorial health officials. where i served as immediate past presidents. thank you. >> thank you so, much it's now time for members to ask questions, and the chair will recognize herself for five. minutes as i mentioned in my opening statement, and as many of you mentioned, and thank, you the committee has really been focusing on the opioid epidemic for quite some number of years, this subcommittee in particular in the last few congress is i was the ranking democrat, now i'm the chair. it's been a real bipartisan effort over the years. to help address this crisis. and ultimately under of course a number of pieces of legislation. at the 21st century cures act which congressman up to deny sponsored. we provided the states with a considerable amount of funds to address substance abuse and so we are happy to see the some of those funds have been used as part of your efforts but several of you mentioned that we need to give more flexibility to the states to address i believe miss smith you said to address the system not the substance and i'm wondering if some of you can talk about what we need to do to give that flexibility as some of the substances shift miss mitt do you want to expand on that a little bit >> i will be happy, to thank you for asking that question. this goes to. in many of you are opening remarks you mentions on the poly substance use and the increase in particularly meth impediment and cocaine that many cities across the nation are seeing and i think one of the challenges has been for us with the funding being so focused on opioids it's been a little bit challenging depending on the types of programs that we wanted to establish in making sure that we are appropriately tying it to opioids while the same time recognizing that some folks who benefit from the program may not identify opened isis or primary substance or even identify them at all as a substance. >> do you think that is getting more noticeable that people are moving? >> absolutely. >> you're shaking your head are you seeing that is? well. >> absolutely we are seeing it in north carolina and of course the substance abuse blockers only tool we have to build the truman sources for those individuals to go to to get out of the problem. >> doctor alexander scott you talked a lot about what rhode island is trying to do, what about this crisis that you are dealing with now that you weren't able to see a couple of years ago. are there some new things that you are seeing now? >> certainly the increase in the percent of fentanyl with overdose deaths is occurring we are seeing also an increase in policy substances multiple substances involved with overdose deaths and we recognize the importance of going upstream more to really get at the root cause of what is driving many of the challenges. in both mental health and substance abuse. >> do you think that the federal language with some of the federal funds you are getting is too restrictive? . >> i think that there is opportunity to be more deliberate and engage more at the community level. >> what would you say is the key challenge you're facing in your state with addiction? . >> right now my key challenges the work force i do not have enough people to deliver the treatment that is needed for the state. we could open up more days for prescribe earth but we do not have the therapists to be able to support that prescribing. >> i wanted to ask you doctor in your written testimony said the massachusetts realized federal funding to support expansion enhanced mid of the treatment system 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. what we have been doing in our public health approach, to this opiate epidemic is focusing on of course prevention interventions but really enhancing our treatment system. has been said before what we are dealing with now, many of, us is trying to build a system in a place that, warfare behavioural health issues in general, for many many decades have been underfunded, we are really trying to build up systems of care, so the individuals can get the treatment that they need, reviews some of our federal funding to enhance, treatment opportunities including increasing our treatment beds within our systems over 12, hundred including a increasing the availability of opiate, and enhancing the availability of methadone. >> pursuant to again thank all of you for your. efforts and let you know that the committee in the full energy and commerce committee is committed to helping, make the maximum flexibility, i will remind you that in the recent federal, 2020 government, funding congress continues to invest 1.5 billion dollars in the state opioid response grants and so in response to the changing geography's landscape we allowed granted to use his funding to address stimulant, use but if there's more we can use please that is snow, because we want you to consider ourselves to be partners with. that i will recognize mr. guthrie for five minutes. >> thank you very, much i appreciate, it appreciate you being here and telling your stories, about bipartisan u.s. a lot of questions that i had originally i was going to look forward to you all have answered i guess one thing i want to get a flexibility and emigrated the markup on this is the our colleague on the committee, i do know if he had an amendment or a just made a point, different committees have different issues and all opioids are never community amara the discussion being on there is eczema ana resources focusing on here, i guess my hope is as you bring more workers using the money you can't always use the open yard money for somebody on another substance but it helps you build the infrastructure that has the same kind of moving forward and we do need to open up to look at that. that's something we absolutely need to look at. as we had sometimes interesting to me is that as we were having a hearing is hearing around channel we had some things that have passed away weaving experience they talk about the patient brokering and it just walked away that there seem to be not any sense that you represent but he was in a state and winston several brokers to another and no a couple of the states have looked at that and i think rhode island has looked at patient brokering rhode island certifies recovering started the certification two years ago, he talked about the certification process, why rhode island started it? and about how many homes were certified. >> i'll be happy to provide additional information, to support, this or sister agency, the department of behavioural health care disabilities, recognize the importance of, having recovery housing is a critical tool for supporting those, living the lives of recovering 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. in this sister agency in rhode island. overseas the certifications to help establish those standards. i can get back to you on the official number that we have of recovery houses that are available. but this has been a quality and data different program we have felt to be critical to supporting this opioid epidemic. >> i think you, also i think pennsylvania, is my understanding then the last year pennsylvania passed legislation that enables the part mint of drug and alcohol programs to regulate license recovery housing can you talk about why you need to do this, and the effect of it, and when it goes into effect? >> absolutely. i think it was passed by the legislature, and our governor for the first reasons that was and other states like rhode island. we were definitely identifying issues the apparent. through advocacy. groups or individuals who are attending recovery housing events and noticing that there seem to be some in consistencies in practices. he felt it was really critical to pass some kind of legislation that enables us to have some kind of oversight of these entities. one disgusting is in pennsylvania we don't really know the exact number of current recovery houses operating we know within the thousands. and so what this legislation will enable us to do is create regulations so that any palace that receives referrals or funding from state or federal entities will have to be licensed fire department. it won't require that every recovery houston pennsylvania be licensed but the help is that folks are utilizing the website that contains the licensing information. to utilize there was licensed entities that they know have some level of quality services. it maybe it will reduce business that some of the more scrupulous entity. >> thank you i have a cousin never talks about any individual patient i know that on for the opioid neonatal absent syndrome. and i only have a few seconds so maybe one of you. if any of you use federal dollars for neonatal absences from has that introduced it? anybody working with that specifically? >> west virginia is working very specifically to provide treatment to women affected by substance use disorder. the treatment itself sometimes can increase syndrome with the use of cnn -- their birth outcomes are better we are--. >> thank you madam, chair is congress in the committee consider further action the opioid, crisis and would be more about how federal funds have been used to make a, difference based on the state submissions to the committee, which i mentioned in my opening, it appears several states have successfully use federal funds to respond to the crisis, let me see how many i can get through here. >> mr. can sleep, in your testimony you noted the federal funding has enabled north carolina to provide a va used to search treatment for 12,000 uninsured, people in the same testimony you mention that, and unquote since 2016 when the first initial federal, grasses received north carolina so this person kind in a period overdose deaths in five, years increasing 9% from 2000 1718, so what factors you attribute north carolina success, in providing treatment you people really need it? >> our focus has been 100% on medication assistant treatment, until oxide distribution communities, believe knocks in distribution it's been directly tied to the hold and deaths in the reduction index that we have seen, and after that, important programs linked individuals into care have been able to sustain that treatment it move individuals in recovery, programs like pure support specialist, individuals who are in cover, themselves or milk with local ems providers actually induct people into, treatment individual with an operator versus thrown ems visit, does not want to go to the hospital they can actually begin the treatment, then there's a follow-up group of folks that come out and see those individuals after the, fact there's been a lot of very scaled, very strategic focus interventions like, that that have moved people into recovery, and into the treatment pipeline that have been really important for us in north carolina. >> thanks, notes encouraged here from your testimony that pennsylvania so it is an 18% decrease an overdose deaths, of 2017 dating, what factors your tribute to reduction, what are the few key areas the pennsylvania should focus on, to continue that trend of possible? >> i think the key for us is not all that different actually, a big focus on getting the oxygen into communities, we focused on what we call warm handoff process which is getting overdose survivors from the hospital into treatment, a major issue in our hospitals in the house systems, of the individuals open i think and then quickly being released out into the streets. to overdose again. repeated times i think those two things happen before us. i think moving forward what we would like to do is spend a little bit more time and energy in the prevention space trying to prevent before we get to worrying about needing the lock so. are needing to activate that process but our primary focus is really keeping people alive and now that we have started to get a handle on that through naloxone and more handoff and expanding treatment now i think we can spend some time and energy really thinking about looking upstream and how do we improve our prevention efforts. >> thank you let me go to doctor alexander scott with regard to rhode island's response to the committee you noted the federal funds have enabled the state to approve data and surveillance and treatment capacity in support innovations in delivering treatment can you give us some specific examples of how federal funds have helped rhode island in those areas? >> there multiple examples similar to what has been mentioned, since you asked about data specifically, we use data in as realtime as possible, we have chain 48 hour reporting from our merge and see departments or any suspected or actual overdose has occurred. and on a weekly basis, we have across agency team that assesses where overdoses, our gis mats across the state, and we release advisories to municipalities key, stakeholders and providers. to focus their areas when the overdose deaths have increased beyond a certain threshold. that allows us to drive out the resources and services that we have. based on data in realtime. at the local level. which is one example, we continue to expand treatments. and recovery services with the intention of meeting people where they are. so going out to reach folks through a mobile recovery and treatment vehicle. it's another example. >> i don't know if i can get west virginia and must balance noted that the states treatment has glue overhauled in response to the crisis. much of the positive work today is made possible as a direct result. i want to give some brief examples of how federal funds had provide treatment recovery services. to rural and financially disadvantaged parts of the state. >> specifically it has given us the ability to expand our clinical providers who can provide and made she. we now have people on all of our 55 counties able to receive mit. and then we have prescribe or's located physically most counties. it's when the number one success we've really experienced for the federal. funds >> thank you madam chair. >> we recognize the gentleman from oregon for five minutes. >> thanks for your participation as well i want to start with a question about transportation issues. it's a big problem to put into perspective it's bigger it's almost a east to mississippi my round tables in the second district. 2017 i've heard from a woman in her mustn't. she had to travel five hours into another state just to find a provider and helper treatment to get her off of her addiction. awe there's no local help can be kind of brief on that. if anybody wants to weigh in on that. . you >> north carolina has about 20,000 people today nor opioid treatment programs. i think our largest two strategies to address role access. it's been first and foremost moving as much care in the office based out treatment programs as possible. that's why we love to see the data ex waiver requirement removed to try to make that easier. we've doubled a number of physicians in north carolina. we have a long day to go were not going to get large-scale tb providers we've been heavily investing a project. echo which is ledges or ability to try to train providers to give them support they need to take on these missions. >> as we know the support act of expanded minister other treatments. does anyone else want to weigh in >> i can quickly. pennsylvania is really fortunate that we have a large number of opioid treatment providers already in the state. it's destined vantage for. us but beyond us to assist rural communities we have a particular ramp cramped we call it. earl access to medication. where we are expanding access to medication assisted treatment in rural areas. thanks to grant from the federal government. as well as we offered a loan repayment program for practitioners in areas that are hard hit by the opioid academic. but also have workforce shortages. which you can imagine is mostly a areas. and the commitment for that lumpy repay program as you have to have two years of experience treating. an additional two years. >> i want to move on to this 40 to the confidentiality of alcohol and drug use patient records. i heard a lot from providers and how this impacts negatively the effect of the exchange of information regarding individual substance use treatment. and then there other health issues we pass legislation to protect pre-existing privacy. it went up on the rocks in the senate i would like to see us renew our efforts can you all tell me briefly, are you seeing patients impacted by this? >> yes. >> in massachusetts we provided comments related for ucl for some of the obstacles that, produces as we have started to think about what is the next step, of what needs to happen to fight this opioid epidemic, one of the issues is around appropriate behavioural health integration. with mental health issues and substance use emissions, as well as how to connect that to the medical care that individual needs, and the obstacle. started >> others run into this? >> we have a place to be aware of where may be considered within the school system, making sure that school nurses, and psychologists, are able to exchange the information needed to care, for children who have mental health or even substance use challenges. >> >> travelers want to comment on this? >> north carolina's support of modernizing 40 to see if, our to maintain privacy but also move to integrated care, i think what's important is we have to systematically addresses ma, and it is systematic exclusion from individuals from employment housing, as well. >> even? else. >> he said exactly what i was going to, say that really addressing. >> he was looking at your notes. >> housing has to be a primary concern, to think it's important to protect those individuals who suffer from this disease, but at the same time i don't know how we move to a truly integrated, system of care, when we treat their records differently we keep saying, treat them the same as every all, street them the same, but except their medical records, i think we need to change that conversation. >> which has led to deaths, we need to fix this. >> we like to renew the effort to pass reform, here we know the damage which has done some things, they couldn't noticing law i don't think it was far enough in the right direction. >> this is an issue been working on for a long time and we do need to find a resolution. >> thank you madam, chair thank you. >> shared now recognizes gentlelady for five. minutes >> in 2018 the overall rate of opioid overdose deaths in illinois, fell for the first time in five years. the decrease was likely impacted by the efforts on this committee, and congress, to combat the fbi it epidemic. but, this trend was primarily driven by the decline in deaths among white residents, today, in illinois appetite overdose deaths among black and latino's continue to rise. in fact my hometown of chicago here's more opioid overdose deaths, then homicides, in 2017, of the 796 people who died of opioid deaths that year 400 were african american. as 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 a fentanyl, evolved overdose then whites. that doesn't square with the perception of the opioid crisis as a white suburban and rural issue i want to ask you doctor alexander scott, i know you have experience not only in your state, but as the 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 upper epidemic? >> >> thank you so much for this question and it is such a critical issue for us. we in rhode island are starting to take a more deliberate approach to have a health equity lens to prevent intervention to make sure every community is impacted has the opportunity to have access to the treatments as well as continuing to the upstream root causes. and with that environmental determinants that are occurring in various communities. >> i appreciate this question has been raised to some extent as well. >> the start what you have done to expose the fact different races and ethnicities are impacted we have to make sure we are taking into account our influences that are contributing to these outcomes. and >> what you are appropriate and what the community needs to make a difference. >> doctor your testimony you, >> mentioned that you are focusing on communities of color in your state. what does that look like quick. >> one of our five areas we have an increase of overdoses so we have been using federal funds so to give you an example thankfully those overdoses has begun to decline from when we broke down with an increasing rate with the death of black men. so we alluded those efforts to focus on communities of color. we did some campaign as well as different communities and languages but a different >> example focusing on those in the community. >> the statistics are completely unacceptable here in chicago and metropolitan areas especially among communities of color. it would be a terrible mistake to go with overall data and not the particular communities thank you for responding to this question. i want to offer something for the record again. if i can put in the study that i mentioned, the geographic distribution of fentanyl with overt all loan - - over the one - - overdose deaths in cook county and u.s. news & world report titled separate and unequal and >> overlooked. >> it shall be entered into the record. >> thank you for the recognition. just briefly mister guthrie had talked about some of the most troubling testimony on this issue was the assistant attorney general who came to testify to one of our oversight investigations subcommittees the silver homes that were located in other states so that they would be leeward to other locations of course with no real identifiable metrics whether anyone was getting better and i think he shared with us today not only did they not get better but the deaths of massachusetts residents as a result so as >> a follow-up to his testimony. >> the quality of care is absolutely critical it reaches the highest standards to a very vulnerable population. we take very seriously our responsibility all of the substance addiction services we provide to the department of public health. and through that authority you are able to set the criteria and respond to complaints and at any time to go into inspector but now in massachusetts we have a certification program which must meet certain criteria standards and we have seen improvement with over 2000 beds to make just to be clear he wasn't talking about silver homes in the state of massachusetts that those that may be i'm sure massachusetts in january anytime to be favorable. but that's the deal that people are leeward to come spend your winter in a sunny location and then to lose control of the situation. when you lose a resident to addiction is there a follow-up done on that quick. >> i don't have any specific examples to give you but i could have the attorneys general's office follow-up. but one of the things we need to do is make sure we have the facilities and appropriate access to care. one really important success that many of us have is a prescription monitoring program and that >> is required from prescribing opioids connected to 37 other states and washington dc that understands the care they may receive in other states as well. >>. >> and in the senate finance committee. so let me ask if i could but do you >> feel within your state the programs can share the appropriate medical records to coordinate care with substance use disorders quick. >> the simple answer is no we have invested resources through peer support to have that coordination >> of care but there is still a huge limitation even and doctors can talk to one another to coordinate care around the patient's. >> i am in agreement with mister walden we should redouble our efforts. we have reform done on the house floor in 2018 we were not able to survive the senate. so when president trump signed the big bill into law that part was removed. we need to continue to work on that because it's critical and >> important. >> thank you to the witnesses for being here today and our colleagues for their attention. you are welcome to boston any time in the winter. it may not be the warmest but super bowl rings warm you up. event something you can experience what we are moving right along. so the commission march 2019 recommended the use of evidence-based injection use facilities. and to increase outreach to services so supported by the massachusetts medical society and by the state legislature so can you elaborate how harm reduction commission >> with those facilities as it is explained in the report and why it does not violate federal law quick. >> thank you congressman for your support around the country. so talking about the harm reduction of the safe injection facilities due to the recommendation to look at this further through the legislative process both at the state and federal level. talk about harm reduction broadly we have the capacity to do in public health we have been focusing her effort on the populations that i mentioned in one of the harm pieces on - - reduction pieces we have expanded those two less than ten to now over 30 with markedly good response rates from providing harm reduction services to care. one statistic but all those that were handed out so to clean out neighborhoods and communities. >> and with those fda approved drugs and hitting the gold standard for opioid use disorder. so as the committee indicated there was increased medicated assisted treatment and those that are reentering the community. and if there is any disconnect to lose medicaid once they are incarcerated. >> i am proud to say the individuals with incarceration. and when we see when individuals are read one - - released they are 120 times higher that helps to and now the department of correction offers fda approved medication for opioid use disorder as well as seven of the jail systems and also expanding our >> program as that has been mentioned earlier. individuals not only to be connected but also employment and housing opportunities. >> so states that expanded medicaid have a 6 percent over all than those that did >> not. and then does that have long-term evidence-based quick. >> absolutely thank you for the question. and to provide treatment to 12000 uninsured half coming into the emergency room or uninsured. lee are proud of our progress. we have so much further to go. we estimated 415 north carolinians would be alive today had we expanded >> medicaid 2014. >> i would just like to enter into the record the letter from voices of non-opioid choices. i ask unanimous consent to be entered into the record. >> to put the focus on your testimony and i want to congratulate you. we have been at the epicenter of this problem going from 52 through 57 deaths per thousand and it is incredible. my concern has been and we never really understood the contributing factors and people here from nih and cdc and the economic issues and to quibble back and forth that were states like new hampshire that is compared to west virginia but they were the number two in the country. so talk about prevention rather than treatment when we have a building collapse we find out what caused it then we can fix it. but let's make sure it doesn't happen again. so what are the contributing factors clicks for example, it is conductivity. texas has a rate of ten.five out of 57. what are we doing right in texas or west virginia around the country can learn what they are doing clicks we know where they are coming >> from. and then to prevent people from abusing drugs quick. >> and those contributing factors is the perfect storm prescribers trying to treat pain with individuals and high injury occupation like coal mining and those kind of accidents and we have an influx of pill with the availability to find out how they got started with low income and the recession that was happening people were becoming >> frustrated but then we have to go further back stream downstream they are not living with their parents. >> i would like to have more of a dialogue with you about this the sin of taking all the time because if we don't get into the prevention we will see more neonatal impact with our children in foster families and foster homes as a result of this. so how do we stop this in the first place in the future correct so let me go to the last comment on the panel. we know that tobacco settlement settlement, 97 percent 97 percent of the money came from the tobacco settlement and then to balance the state budgets. and then to imagine quite a bit of litigation. and some federal settlements on this. is there a role for us to step into make sure that money doesn't go to balance budgets and potholes to ensure that it will go to things like prevention or foster care or >> neonatal and with the settlements any of you? and then to have sustainable funding to allow us to focus on this epidemic comprehensively and over the long term. many of us have referenced the importance of the funding. and those that the funding that that will be in place for a long enough time and that assistance across the board is certainly to be well >> received. >>. >> and this committee works in a bipartisan manner to pass legislation to implement programs to curb the opioid crisis that more can and must be done wet members on both sides are committed at the same time there are continued efforts not to expand medicaid and instant crease care is to treatment but in fact last week, and a new study was published in the journal of the association to expand medicaid under the affordable care act to have as many as 8000 people from opioid overdose. i would like to submit for the record. >> without objections mimic the kaiser family foundation medicaid covered 54 percent and with the affordable care act of the essential health benefits and to increase coverage and expand medicaid if i have cared for a patient overdosing in the emergency department. and then to leave the hospital and those that receive the grant money in the opioid epidemic is the unprecedented crisis to make fundamental changes to combat opioid addiction and substance abuse disorder. so to play a role to support these treatment systems so the west virginia's response to the committee knows that the infrastructure with a demand for opioid treatment >> services. >> medicaid has been a key component. and with the waiver we have had to use that as part of our backbone to pay for treatment services. and doesn't enable us to train our providers or infrastructure but then they use that to wrap around to build infrastructure as well as cover >> people with no insurance or underinsured. that is our strategy to bring those funds together. >> opioid treatment is much more widely access that expanded medicaid. both noted in their responses to the committee of federal medicaid dollars to address the opioid crisis. you raise that medicaid is the most important tool of the opioid epidemic to bring an additional $4 billion into north carolina for >> healthcare. how is expanding medicaid further develop the treatment infrastructure to address the opioid crisis quick. >> thank you for the question. and those vast majority of individuals get insurance through employment cannot be overlooked. one drug test away from losing health insurance or ending up with a place they have no way to pay to get back into the workforce. in north carolina we estimate 500,000 additional people would have expansion and then >> to get treatment through medicaid and use our resources to build a system capacity. and to combat the opioid epidemic but if we make it harder for people to enroll with medicaid from the affordable care act and essential health benefits, by making it difficult to enroll like work requirements and then we take five steps back it's important to take that big >> picture. >> let me first answer a question. how do we treat this money with the tobacco settlement? in virginia they created a separate commission for economic development purposes and whatever your individual states might want to recommend that model because then you can take that money and have it stretch with ever one - - with whatever issues of substance abuse but the virginia model has worked well for economic development in tobacco producing areas. especially between west virginia and north carolina and while virginia's numbers look better better, mine does not. and to be heavily impacted in all the areas of cool country that looks like west virginia with the opioid crisis. we are all moved by testimony from time to time with privacy versus testimony and then to testify for her brother who could not testify because he died. he licked the problem and then was in a major car accident but because the doctors had no idea and he was unconscious and could not tell anybody, they gave him and he survived the injuries he did not survive the reintroduction of opioids into his system. we have to work on that problem. foster care. you said half of the children in foster care their >> parents had some form of drug addiction? but you didn't see in the written testimony how many that, >> was. >> we have about 12000 individuals in the foster care system. >> so roughly 6000 i thought it was that your answer to another question you mentioned the school systems to make sure there was money there. several families that have first gone through foster care and the parents were addicted to various drugs in particular opioids with significant behavior >> problems. what can we do to deal with the next generation? they may not have drug problems themselves but there are behavior problems. >> in rhode island we have the student loan - - student assistive services program to allow for peer recovery in support of their families and the ability to have that be integrated with the physical health that will allow for a comprehensive approach to address the needs of our youth. >> including those that are using drugs at the time. the first couple >> years is that included quick. >> it does address mental health as well as behavioral challenges that you often face. >> i really want to learn more what pennsylvania is doing with the doctor loan repayment program to represent an area and we are all right there in the appellation mountains together we need more healthcare >> providers in the most affected areas..... all across the nation, so we decided to you had to be practicing in an area with high opioid use and have beast two years of experience treating patients with substance abuse disorder and commit to an additional two >> is medicaid expansion to the opioid substance use treatment, you talked about the predictability of care to talk about the infrastructure that we've been building without medicaid paying for the residential treatment. there is no way to sustain those valuable services and according to my notes, we have over 21,000 receiving medication assisted treatment in our state. >> thank you very >> much. >> the gentleman from maryland. >> very compelling testimony and i think you all for coming. we have learned of course one of the root causes and a member you havenumber ofyou have spoken to that today. we know many states such as virginia, maine, rhode island have set limits. you highlighted as part of the response your state enacted regulations in 2017 that went into the initial prescription of an opioid patient at no more than what are called morphine milligram equivalents. can you describe a little bit more for us the danger of patients exceeding the limit and do you think that the >> policies and success to make the better position to veto decisions. >> we had data that but said the higher the milligram equivalents a patient is on for the longer period of time, the higher the risk of becoming addicted to the opioid overtime at the risk of an overdose. we wanted to make sure there was flexibly for the provider in limiting the opioids prescribed by cutting off at 30 and the reason for paying we have seen a substantial decrease in the number of opioids prescribed for an initial use of pain particularly for the scenarios. we have chosen to handle chronic pain needs separately because often times people already have an addiction or tolerance that require the multidisciplinary approach to addressing that. >> let me drill down on that a little bit more. because i know that the cdc in the recommendations indicated the provider should avoid prescribing over 90 and many states have put that recommendation into the code some of them even double or triple that limit. so, i understand that the products are intended for patients have become opioid resistant as you mentioned to the lower dose products. there was enough of a risk that we should at least begin to explore the methods to limit the market availability. >> we certainly considered that in the regulations approach or the acute pain management in addition to the equivalents we have also required they are not used because of the challenge >> that can occur. they would need to be handled separately. >> i know they've taken previous action to limit the use of the products for the strategy program on the providers to describe these products i also know there was a recently released study that failed to find any evidence of the program that was successful at achieving the goals of producing the appropriate prescribing the lack of existing action it may be time for the fda where congress or both of us to explore options with limiting the market availability. limiting these new high-dose products restraining them from entering the market into the future, so i think that is what we are going to look at and explore a wide array of solutions to combating the crisis for the funding and flexibility to support these objective communities. think you begin >> to the testimony. i yield back. >> thank you, madam chair and the panel for the helpful conversation. many of you hit on a topic that is very near and dear to my heart, and that is eliminating the bureaucratic unnecessary barriers to the substance abuse treatment. individuals began actively treated with be the marketing lower their risk of opioid overdose by up to 50% in a way that is provided without corresponding comprehensive psychosocial support or services. with any other medication that lowers by 50%, we would be hailing this as a drug doing everything in our power to possibly needed and unfortunately here in the united states would continue to make it harder the policies got us into this problem in the first place, so secretary smith, i was pleased to see that in your testimony you called for the elimination of the requirement for the providers to obtain a waiver in order to prescribe for treating dependence. over 100 cosponsors >> do exactly that. can you describe for the committee why it is an important step to take and expanding access to addiction treatment? >> thank you so much for sponsoring the legislation we are fully supportive. i mentioned earlier in my opening we have expanded our waiver positions to over 4,000 we are near the top of the list when you look at states in the number of the positions but looks can be deceiving. when you take a look at the 4,000 doctors and look at what are their prescribing this debate go capacities it's pretty staggering so we have a large percentage that are still at the 30 patient capacity and are not prescribing up to 30 patients so we worked with an organization called vital strategies to design a survey that is going to go out to all 4,000 of our physicians in the state and asked very specific questions about why they are not treating patients and are they willing to treat more. is it an education issue, is it a barrier because of the oversight? goes to overregulate and doctors are trained to administer any and all kinds of medication but specifically to call out this kind of medication and say you need a special waiver to administer this, they just don't want to be bothered with that. pennsylvania believes any steps we can take to eliminate the barriers to change the conversation around to the idea as a clinical necessity and we rely on the trained physicians to be able to provide the treatment. we spoke about it in our >> testimony. >> we don't have a therapist to really support the physicians once they are able to prescribe. its impact on theit's impacted on the therapies >> counseling, >> side. >> the service is available as well. >> you mentioned individuals released from incarceration particularly vulnerable to the overdose with the commissioner noting the justice involved population and i heard your exchange so while the federal grant opportunities for the treatment reentry initiative for helping for a strategy as required there for the medicaid reentry act which would allow the states to have benefits for incarcerated individuals in 30 days prior to the release providing a sustainable stream for the medication treatment case management recovery support services including the seamless transition. but allowing states the >> flexibility to restart the benefits for the eligible incarcerated individuals 30 days prior to the release help reduce the overdose deaths? >> the continuity of care is critical to medicare and the other support mechanisms that you stated. >> i've exhausted questions >> and with that i will yield back. >> the gentle lady from new york is recognized for five minutes. >> thank you madam chair and i would think the ranking member. we heard a lot of encouraging stories today about how they can put federal funds to make progress. it's also clear the challenges the state's face as they work to address the ongoing crisis. i'd like to explore some of the remaining challenges as they consider support. in your testimony, you noted a result challenges building the treatment workforce including people to work in areas across the state. can you describe >> what additional hurdles remain? .. >> so to me that it is a fundamental thing. so we have really been focusing on the scholarship program to increase our pipeline but also the ongoing education and we find the individuals entering recovery with a strong interest to provide services to pay particular attention even to persons who might to be in recovery wishing to take the steps. >> so anything you think would be helpful to on earth >> individuals quick. >> i think the flexibility to use the funds in the best creative way would be beneficial. >> with the treatment workforce to be noted it is increasing as a move toward treatment and recovery.'s explain how it has provided services to vulnerable >> populations and how it addresses the problem. >> our workforce challenges particularly in urban centers like philadelphia and pittsburgh have inhibited for the vulnerable populations to access treatment. we have a an advisory council that advises a department one member happens to tree adolescence but is part of his practice is so overwhelmed with patients he is working well into the night beyond office hours because they have nowhere else to go. so part of the challenges we hear to build a workforce where you don't have communication barriers and those that really understand them and communicate with them a lot of the challenges come down to education and training >> requirements and those that exist to meet those requirements requirements. >> in north carolina the states note in many communities with the opioid epidemic it is difficult to build access because it lacks basic infrastructure including broadband. >> so can you describe how broadband services are important to help address the opioid epidemic quex and what can congress do to overcome these challenges quick. >> thank you for the question telehealth access is a key strategy to expand access to treatment but many cannot sustain more than a four g signal or have access to broadband and without >> those we cannot sustain the services that is built on the fact it is a sustainable approach for education to be at parity with all of the colleagues. >> madam chair i would like to ask for this letter from new york state addiction services and support to be added to the record. >> >> without objection. >> thank you for letting me be here today it is a very relative topic. this is one of the major newspapers in the state of ohio had an article that came out but we know in 2009 we had 1423 people die of overdose in the state of ohio the number went up in 2017 and the trend right now think heavens it is going down that these are all deaths from overdose. in my district it's very important when i talk to my health care providers one of the things they were telling me for several years as we cannot find help. everything to finding where they can get services so in the last congress to establish his dashboard for communities to go find help. i would like to ask you today and if i could ask everyone maybe be brief on your answers but those public >> facing dashboards what information do you have in them quick's go right down the line. >> pennsylvania does have a an interactive data dashboard. it contains information like prescription drug monitoring distributions treatment statistics and it goes on and on. i'm happy for you to check that out if you have questions let me know. >> it was established about two >> years ago. >> since 2015 massachusetts put out a quarterly dashboard that has the same information related to the number of deaths with that predictive model as well as towns and cities all hundred 351 report on the and healthcara and 2015 to put together for the first time data across state government so this is the first time health data relates >> to criminal justice. >> the last couple of years we have been using reports updated quarterly that highlight things prescription drug monitoring and those data points to focus on. then we do that quarterly. that than to upload and make public dashboard with non-fatal overdose and >> stay tuned we are looking forward to that this week. >> north carolina launch the dashboard in 2017 it not only has key data points updated consistently around the up - - opioid epidemic but other aspects of abuse disorder to have others drill down what you have seen to be incredibly powerful with the same strategies giving foundations and nongovernmental entities and those that see their dollars as a way we need to focus all these indicators relate back to our strategy >> to help us measure success in this effort. >> similar to what has been heard in rhode island with the intervention task force we understood having a dashboard would be critical and that was activated in the 2015 timeframe the dashboard does serve as a metric for each strategic initiative reversal and treatment to allow for >> the public to access where treatment services are as well as access to other recovery services that are needed. >> has the community had a problem with that help getting it out quick. >> yes and no. >> mostly >> know because of our procurement system. >> i would go with the answer yes and no many people have, >> no trouble but those that are struggling to find that information. >>, >> over 50 local communities we don't have enough funds. >> we use a data driven process and given that it's, >> rhode island to make sure every town and city has access to services needed. >>, >> thank you very much madame chair. >> thank you to all of our witnesses this is one of the best we have had it's excellent with very good information we look forward to our next step stand in response to the september 18 letter receiving responses from 16 states how the estates addresses the crisis with federal funding and i moved to enter all those responses into the record and in addition from florida and indiana new york, north carolina, ohio, rhode island, tennessee, west virginia and and wisconsin those will be ordered and in continuation of our bipartisan work in treatment issues today we are sending a bipartisan letter signed by the ranking member and others others, letters to the dea and hhs about the emergence of what this panel is talking about with polysubstance abuse and what it is doing i would ask unanimous consent to put those into the record and the chair would like to remind members pursuant to the committee rule there are ten business days to submit additional questions to the record to be answered several members did ask witnesses to answer additional questions please respond promptly if you received those questions with that we are adjourned.

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