Transcripts For CSPAN3 State Officials Testify On Opioid Epidemic 20170713

Today the subcommittee holds a hearing entitled combatting the opoid crisis, battles in the states. Make no mistake, the term combatting and battles are entirely appropriate. Our nation is in the midst of a tremendous fight against death affecting every corner of our nation. There were more than 52,000 deaths in overdose. A 20 increase in the prior year. It was almost seven time it is rate of death from the heroin epidemic of the 1970s. We learned we have lost roughly 60,0 0 people to Drug Overdoses. That is more in one year than all the names on the vietnam veteran memorial wall. That is likely underestimated because much of the data will not be in until the end of next year. For every fatale overdose there is 20 nonfatale overdoses and for 2016 that could be near one million. More than 130,000 lives have been lost between 1999 and 2015. Thats about 50,000 oh 500,000 will be lost over the next decade. The roots began in 1980 when a letter was misinterpreted as evidence it was unlikely that someone would become addicted. About 20 years later the joint commission on accreditation of Health Care Organizations following the American Medical Association that pain h be assessed established standards for Pain Management interpreted by many doctors as encouraging the prescribing of opoids. A question specifically asked was their pain adequately addressed. Based on their answer, a hospital may receive more or less money. The opoid epidemic is an Urgent Public Health threat fueled by fentanyl and a clear and present danger to america. Who states represented on todays panel in rhode island and maryland were the first ones hit by the wave and it seems this wave will sweep the nation as it is increasingly attracted to manufacturers and easy to manufacture or obtain over the internet. This is an extreme moment requiring all the experience, resources, cooperation by federal, state and local governments as it was all the different industries, professionals and experts to curb this terrible outbreak. We will focus on the actions to find out what efforts are working, what is not working, how we could Work Together to save lives. We want to know the problems and please be candid with us. As drug industry as drug policy expert noted, quote, it is at the state and county levels that the Real Progress will be made. It makes sense to find inspired solutions be most concentrated there. Serving the front lines of the opoid epidemic, they have been more structured medication, assisted treatment, more comprehensive Prescription Drug monitoring. States such as maryland are making the best use of the guidelines to help push back on the overprescribing. Kentuckys reporting system, a web based Monitoring System is helping state legislature identify questionable prescribing practices by physicians. Virginia has greatly expanded access to the locks on the drug that could reverse an opoid overdose but could have its own risk in its use. Some states are expanding the use. Rhode island has developed the anchor ed program that matches overdose victims with peer recovery coaches. Much of the work of the states should help inform the president s commission on combatting drug addiction and the opoid crisis. Oversights have helped Congress Enact provisions. And it will help the administration. We put one billion collars into grants for the next two years, but we want to know if this money is being used wisely. Were eager to learn about those programs. But the 21st Century Program is just beginning. Our State Government witnesses can help this committee develop a National Strategy to combat the opoid crisis in substance prevention and education, physician training, treatment of recovery, Law Enforcement, expanded assets, Data Collection, examining what reforms could be made to the 42 cfr part two so there is better coordination of care and we could help prevent relapses and improve patient safety. We are in one of the worst medical tragedies of our time. Perhaps the worst. And although this committee that has given its attention to many other problems in the past, we recognize this is paramount among them. This is a National Emergency, and we look forward to hearing from the states on what you were doing on the front lines of this. I yield to my colleague for five minutes. Thank you so much, mr. Chairman. I appreciate this most recent hearing on opoid addiction. As you said so accurately, this crisis is really devastating america as all of us have seen it play out in our communities, urban and rural alike. Not a day passes without a report about children watching their parents overdose, about lie brians and School Nurses being trained to administer overdose victims or local and State Governments trying to respond to the issues surrounding addiction. All at the same time trying to stay within their budgets. There is some good news. The cdc reported that opoid prescriptions peeked in 2017 and have fallen by 41 . Thats the good news. The bad news is opoid prescribing remains untenably high and im hoping our future investigations will concentrate on this. In addition, as you pointed out, mr. Chairman, is the emergence of illegal fentanyl, which is an exceptionally potent opoid. It overtook heroin and prescription opioids as the leading cause of death in many places. Each of the state who is are here today, and i want to thank you all for coming, have faced alarming overdose outbreaks due to this drugs pervasive nations. This committee has done good work, investigating the seemingly voluminous amount of bills distributed in west virginia, and i know were planning to do more. As you see, a number of state attorneys general are investigating manufacturers and in some cases distributors. The attorney general in my home state of colorado has joined a Bipartisan Coalition looking into whether manufacture even gaged in illegal or deceptive practices when marketing opioids. Coming up with an effective solution to the opoid epidemic will require us to understand the actions of all actors. I hope to hear from some of the states today on what role they believe drug manufacturers and distributors may be adding to the crisis. Also i look forward to hearing from the panel about the impact of fentanyl on the towns and communities in which they work. States really are on the front lines of fighting this crisis. And i look forward to hearing from all of you. I know that rhode island, for example, has led the way in reconnecting people with in connecting people with Substance Abuse disorders to highlight trained coaches to guide them through recovery. Kentucky has established a program to provide medication assisted treatment to individuals in correctional facilities and to continue supporting them after their release. Maryland has just committed to establishing a 24 Hour Crisis Center in baltimore city. Mr. Chairman, i know these are all great state efforts. We have made some efforts here in congress. And i appreciate you referring to the 21st century legislation that congressman upton and i sponsored and that this whole committee Work Together on a bipartisan basis to pass. But as we move forward on this issue, we really need to Work Together to continue to address this. And thats why i kind of hate to be the fly in the ointment and talk about what these efforts to repeal the Affordable Care act will do to the fight against the opoid epidemic. As you know, the aca has helped nearly 20 million americans obtain health care coverage. In addition, its enabled governors to expand Medicaid Services that are critical tools in the fight. For example, studies that show that since 2014 1. 6 million uninsured americans gained access to Substance Abuse across the 31 states that expanded medicaid coverage. This is particularly true for states like kentucky where residents saw a 700 in medicaid beneficiaries seeking treatment for Substance Abuse. Many people think that the house passed bill that undermines the aca will threaten peoples ability to get opoid treatment. In its assessment, the nonpartisan cbo said the house bill will cost 23 million 22 million americans to lose Health Insurance. Now, there have been discussions, both in the house bill and the senate discussions, about adding some money for opoid treatment. But, for example, the most recent senate suggestion is an additional 45 million dollar, the governor said, quote, it is like spitting in the ocean. Its not enough. Weve got to get real and understand that access to Health Care Treatment is what is going to help with the health of all americans, including treatment of opoid addiction. And weve got to move forward to work on this together. I hope we can do that and with that ill yield back, mr. Chairman. And i recognize the chairman, mr. Wallden. Addiction is a crisis that does not pick people based on their age, race or status and does not pick them based on political parties. My round tables through oregon, it didnt matter if i was in a Rural Community or more populated, the stories are more similar. My state, more people now died from drug related overdoses than from automobile accidents and sadly that is not unique. According to preliminary data analysis, Drug Overdose deaths in 2016 exceeded 59,000 people. Thats the largest annual jump ever recorded in the United States. And whats worse, some of their preliminary numbers from the states indicate their numbers within the First Six Months of this year are already surpassing last years total numbers. And other the past seven years, opoid addiction diagnoses are up 500 according to a recent report. Despite a report released last week, which indicates the number of opoid prescriptions has decreased over the last five years, the rates are three times as high as they were back in 1999. The amount of opioids prescribed in 2015 was enough for every american to be medicated around the clock for three weeks. That report also found that counties in oregon have some of the highest levels of opoid prescriptions in the country. Of the top ten counties in my state for opioids prescription five of them are in my district. People aged 65 and older are being hospitalized at a far higher rate than any other state in the union. Sadly, Overdose Deaths continue to escalate, and this epidemic is simply getting worse and more severe. So challenges remain, and we need to get after it. First we need to improve Data Collection. In a few states are already requiring more specific information related to Overdose Deaths. Quite simply we cannot solve what we do not know. We need to be able to have more timely and reliable data, so we could better understand and address the full scope of the problem. There also needs to be an increase in Overdose Prevention efforts, improvement with respect to utilization and Prescription Drug Monitoring Programs and we need to increase access to evidence based treatment including medication assisted treatment. Combatting this epidemic requires an all hands on deck effort from federal, state and local officials and all of us spanning from Health Care Experts to our local Law Enforcement communities. It is why we are having this hearing today. Last Year Congress took action to combat this crisis by passing legislation, including the come pro hen sieve Addiction Recovery act and the 21st century cures act and states pursued programs to strength p our fight against this epidemic. Much more needs to be done. We need to Work Together to ensure the tools and Funding Congress has created are reaching our state and localities and being used effectively. We hope to hear from the state officials today so see how theyre utilizing these funds and whether these programs work or not. We appreciate the witness who is agreed to come before us today. We hope to have a dialogue about what the states are doing, what initiatives are working, what isnt working and how the federal government could be a better partner. I look forward to your testimony and working with all of you and our Community Leaders to help get our hands on this horrific crisis. With that, i know i have two members that want to introduce witnesses, so ill go first to mr. Guthrie. Thank you for letting me sit in. I want to introduce our secretary of justice in Public Safety in kentucky. Weve been friends for a long time. We served in the General Assembly together. He had a strong reputation, strong work in the houseworking with the senate to produce legislation that i think is landmark and was very important. And we have so much to do in kentucky. We have 1,404 people that died last year in opoid addiction. Were saying thank you for the work we have done. I can tell my colleagues on the committee here and my friends that i can think of nobody else in kentucky id rather have sitting where you are and leading this effort and i applaud the governor for making the choice and appreciate your willingness to do so. I yield back. Now i recognize the gentleman from virginia for the purpose of introduction. Thank you very much. Id like to introduce secretary ryan moran. He came to the Virginia House of delegates where we served together for a number of years. He was always a pleasure to work with and appreciated his work very, very much. And then he became the first director or secretary of ho Homeland Security and has oversight over 11 agencies. But he is generally well reasoned. Every now and then we would disagree on the floor of the house. But we worked together on a number of things. And i apologize. We have to run to another committee where we have two bills that are upstairs, so i wont be able to stay, but i will read with interest your testimony and learn from my colleagues the good words that you have to say and welcome you to our committee. And apologize that i cant be hear because im depending a bill upstairs. With that i will yield back the balance of my time. And unfortunately, i too must go to this subcommittee. Come on back. Secretary moran is a spitting image of his brother. I recognize mr. Cologne for five minutes. Thanks for holding this hearing on this critical issue. Our Committee Held several hearings on the ongoing opoid crisis. The opoid epidemic is not letting up and neither can our efforts to fight it. Since our last hearing, many more lives have been destroyed. There is no community that remains completely untouched by the opoids crisis. The cdc reported that the opoid prescribing rate has peaked, but remains far too high with enough opioids to keep every american medicated around the clock for three weeks. Id also like to hear from our witnesses about how the federal government can help. While it is important the state bs empowered to address the particular challenges of their communities, our response to this epidemic cannot be 51 separate efforts. But as we talk about a Public Health crisis of this magnitude, there is an elephant in the room that needs to be addressed. Coverage for Substance Abuse treatment is how an individual in society has a fighting chance to kick the opoid epidemic for good. Yet, republicans persist in their attempts to gut the Medicaid Program by capping it permanently and ending Medicaid Expansion as part of its efforts to repeal the Affordable Care act. Repealing the Affordable Care and replacing it with trump care would be devastating to 17 million americans who receive Health Care Services from the program. Half of all the babies born in this country are financed by medicaid and to the working poor, many of whom are hit hard by the opoids epidemic and eligible for medicaid for the first time through the ac as expansion, medicaid is the only Affordable Health Care Insurance available. And state Medicaid Programs are at the center of the opoids epidem epidemic. 23 million americans would lose coverage. The majority uncovered through medicaid with 834 billion in cuts to the program. The senators version of trump care is no better, cutting by 35 . These cuts could not come at a worst time for states and people who depend on the coverage medicaid provides. There is no substitute for coverage for our states or the people that need the care. As the Senate Continues to make cosmetic changes to its bill with only one goal in mind, passing any bill out of the senate, lets be clear, no one time amount of funds, whatever that amount may be will ever replace the certainty of comprehensive coverage. No cosmetic changes can offset the damage that could be used by repealing the aca and cutting hundreds of billions collars from the program. We must stay vigilant in this fight. I thank you for having this hearing. I believe there is no way this crisis can be solved with onetime infusions of resources and it will only get worse if medicaid thrdollars are removed from the fight. We must invest for the long term and medicaid is a critical pillar that should be strengthens. I fear if republicans are successful, well end up going in the opposite direction when it comes to fighting the drug problem that has devastated our communities. I thank you. I yield back. I dont think anybody from my side want it s the time, so i y back. I ask consent that the members Opening Statements be entered into the record. I also note the two former members of this committee are present. Thank you for being here and i believe you said mr. Stupek is around, too. This is an important issue. We heard some of the introductions. Let me introduce the rest of the panel. Lieutenant governor maryland, welcome here. As mentioned before, secretary moran. Secretary tilly and director the honorable rebecca boss from the state of rhode island. Thank you for being here today and providing testimony. We look forward for the continuing discussion. As i mentioned before, i really want to be brutality candid on what the problems are, what we need to do and what are the gaps. Youre all aware the committee is holding an investigative hearing and has had the practice of taking testimony under oath. Do any of you have any objection to testifying under oath . Seeing in objections, the chair that advised you that under the rules of the house and rules of the committee, youre entitled to be advised by counsel. Do any of you want to be advised by counsel . Seeing none, please rise. Raise your right hand. Ill swear you in. Do you swear the testimony you are about to give is the truth, the whole truth and nothing but the truth. Having answered affirmative, you are under oath and subject to the penalties set forward under the United States code. Well ask you each to give a finminute summary of your statement. You may begin. Make sure your microphone is turned. Thank you. Honorable members of the sub committee, thank you for the opportunity to join you today to discuss state of marylands response. Tackling this emergency necessitates a coordinated response from federal, state and local government and maryland looks forward to continuing the working together with our federal partners to address this challenge. Governor hogan and i first became aware of the level of this challenge while traveling throughout the state during our 2014 campaign. We quickly realized the epidemic had crept into every corner of our state, cutting across demographics. Maryland, like most states, has experienced an increase in the number of deaths related to opoids. In 2016, 2,089 marylanders died from alcohol or drug related intoxication. 66 increase over the deaths in 2015. And 89 of those deaths were related to opoids. Maryland has seen an increase in prescription opoid related deaths. And, so, we have we must address this particular element of the crisis. We must focus on reducing the inappropriate use of prescription opoids while ensuring patients have access to appropriate Pain Management. In maryland, there were over 8. 8 million total cds prescriptions dispensed in 2016. Now, this is 8. 8 million in a state with six million souls. Further, the challenge we face as evolved. As was mentioned, cheap, powerful and deadly synthetic opoids have burst on to the market, bringing a much higher overdose rate. Deaths related to fentanyl have increased from 29 in 2012 to over 1,100 in 2016 in maryland. Accordingly, as one of the governors first acts in 2015 was to establish the heroin and opoid Emergency Task force, which he asked me to chair, after nearly a year of stake holder meetings and expert testimony and research, the task force adopted 33 recommendations. Those recommendations range from prevention, access to treatment, alternatives to incarceration, enhanced Law Enforcement and more, and they form the foundation of our statewide strategy. Wi building on those recommendations, the task of the task force, they passed several comprehensive pieces of legislation. In 2016 we reformed our Prescription Drug Monitoring Program to require mandatory registration for all cds providers. What we set out to do was make a distinction between those who we are upset with and those who we are afraid of. This passed legislative session, we passed the opoid prevention effort, and the treatment act of 2017, which contains provisions to improve patient education, increased Treatment Services and provide greater access. The governor signed the Start Talking maryland act which will continue to base awareness efforts to bring attention to this crisis. Educating young people on the dangers of opoids as an earlier age was something our task force felt was extremely important. As i have said over and over again, virtually every third grader can tell you how bad it is to smoke cigarettes, but they cant tell you how dangerous it is to take someone elses prescription medications. With the deadly surge of synthetics on the scene, we saw the death toll continue to rise. Accordingly, in january of this year, Governor Hogan established the opoid Operational Command center, the Center Brings opoid response partners together to identify challenges and establish a systemwide priority and capitalize on opportunities for collaboration. It is a formal and a coordinated approach utilizing the National Incident Management System to develop both state and local Strategic Concepts for addressing the heroin and opoid crisis. Shortly after its creation, the governor declared a state of emergency in response to this crisis. But executive order, he dedicated delegated Emergency Powers to state and local Emergency Management officials tone able them to fast track coordination with state and local agencies. Thanks to your leadership and commitment, funding has greatly aided in this effort and these dollars will be used to build public awareness, improving treatment, expanding our Peer Recovery Specialist Program and increasing the availability of nooxon. What we would like to see from the federal government is to consider utilizing fema as an outline as outlined in the National Emergency frame work to centralize and coordinate the federal response to this crisis. The National Response frame work is a guide to how the nation responds to all types of disasters and emergencies and it would allow federal agencies to work more seamlessly with each other and with the agencies at the state level. We cant afford to have delays due to agency silos and burr rocksies. I appreciate this opportunity to talk to you and await any questions you may have. Thank you. Thank you, governor. Secretary, you are recognized for five minutes. It is a real honor. Still very much an honor to be with you this morning and to be able to discuss with you virginias response, as well as working with you to request assistance from the federal government to combat this epidemic. As has all been agreed and said this morning, america is in the midst of an opoid and heroin addiction. The epidemic does not discriminate. It is an equal opportunity killer. In virginia in 2016, 1,133 individuals died from opiate overdose. The sad truth is that virginia actually ranks 18th among the 50 states in opoid deaths. 17 states are doing worse than we are and in all likelihood, the other 32 states will be facing similar devastation if we dont take effective action now. As secretary of Public Safety, i am very proud of virginias sworn Law Enforcement officers who work 24 7 to keep us safe. What they tell me over and over and over again is we cannot arrest our way out of the heroin and opoid addiction crisis. And we cant simply tell those living with addiction to get over it. Why is that . Because addiction is a disease. Arrest and incourse nation of those adixed will no more cure this disease than it would cancer or diabetes. There are multiple causes of the rise. Overprescribing, failure to safely dispose, easy access and affordable. Over the last several years, we have seen a sharp rise in illegally manufactured synthetic opoids such as fentanyl and car fentanyl. They contribute to the increased numbers of opoid deaths. The number of fatale overdoses increased 175 and accounted for 618 of the 1,133 deaths in the commonwealth. Virginias response, virginias response to this epidemic began immediately upon the gov fortaking office in 2014. He convene add broad coaddition of Health Care Providers, criminal justice representatives and Community Stakeholders to participate in the Prescription Drug and heroin use task force. The secretary of health and Human Resources cochaired the committee with myself. The task force developed over 50 recommendations. I am proud to say we implemented the vast majority of those, the full list of which can be found in my written testimony. And of course the work continues in virginia. Our executive Leadership Team works across State Government and with regional and local agent sitzes and individuals to share best practices and work to overcome barriers to success. They organized a statewide approach to opoid crisis and provided leadership from the Virginia State police, department of health and from our local Community Service providers. Again, that is a theme that this is not just a Law Enforcement problem, but rather one that requires Health Care Providers to be at the table along with their community providers, Community Service providers. They support coordination among local organizations, task forces and other collaborations including that exist in designated areas that cover northern virginia. Let me highlight some of our establishments. Law enforcement officers and others working with potentially dangerous drugs are being trained in using this overdose reversal agent through the department of Behavioral Health and Development Services revive program. A commission of department of health issued a Standing Order for pharmacies to dispense it. We issued grants to pay for it to be used by Law Enforcement. The city of Virginia Beach has used it now and they have had over 60 deployments to save lives in that community. Now, our requests. I came into this job with a mandate for my 11 Public Safety agencies that we would rely on data driven decision makes. If we are going to wrap our arms around this epidemic and reverse the upward trends, we need to know what the problems are, where they are and what is working. To do that, we need good data. Here are some of the identified needs that congress and the administration can help us address. Craft limited exceptions to current regulatory and statutory barriers under hipaa, the Substance Abuse privacy protections. For example, we are prohibited from accessing any data from our methadone clinics. We need to know how they work and who they are providing care for and how it is working. Provide Technical Assistance or fund staff positions for states in localities in developing metrics sharing data and analyzing results. Support development of seas consistent metrics and mandate Data Collection as a requisite for federal funds. Increase support. Break down federal funding silos. Reduce demand. Support, train, incentivize Law Enforcement and currently insufficient to address this epidemic. Those with addictions shouldnt become Law Enforcements problems. They belong in the health care system. Examples of programs to further to explore further include assist localities, pilot, analyze and determine the efficacy of angel programs in police department, fully funded, utilization of naloxone or other overdose drugs. Apparently my time is up. You invited the request, mr. Chairman, but i will stop. It gets more interesting as we cover some of the questions, too. You are recognized for five minutes. Thank you for allowing me the chance to be here. I want to thank the governor from kentucky for that channels as well. He sends his regrets. He wanted to be here himself. He has been outspoken on this topic. I will share with you a quick story. When i first met Governor Bevin he was interviewing for this position, for this job. He walked into a room with dreamland under his arm and he said, have you read this book . Thankfully i had. So i said, yes, sir, i have read the book. Actually, im trying to reread it because it is, again, i think the best the best chronicling of this problem and how it began that i know. So that, again, illustrates to you our commitment and our shared understanding of this problem. I want to thank congressman guthrie for that fartookind introduction as well. Dreamland is relevant because the problem has it origins in kentucky and ohio. We lost 1404 kentuckians as the congressman said. Fentanyl is now the driving force behind these overdoses. We had 13,000 er visits, 13,000 er visits in a state with 4. 5 Million People. We lose in this country, as you heard in this country, nearly a commercial airplane a day. If it were a Communicable Disease we would bewaring hazmat suits to combat it. Again, i think overdoses and the visits only tell half of the story. This devastates communities. As soon as we got our arms around heroin, we began to see fentanyl. Our state police tell us in the last six years alone weve seen a 6,000 increase in fentanyl in our labs. 6,000 increase. I think all of us know the devastation it has had on our criminal justice community. Our jails and prisons are at capacity. We have no more room at the inn. The Public Health crisis is on full display in kentucky. We have a hepatitis c, a form of viral hepatitis, seven times the national average. Across the river in indiana they had an outbreak of hiv to rival that of sub saharan africa. We passed a comprehensive Syringe Exchange program, and in kentucky we have 30 programs passed by local option in our state. We know it increases the treatment capacity by five times. When someone walks over the doorstep of one of those programs and it battles back diseases like hepc and hiv. Sadly kentucky has a cdc report has 54 of 220 counties most susceptible to a rapid outbreak of hiv. So what has our response been in you kentucky to battle this . Again, taking a bold step on the Syringe Exchange program, passing legislation on prescription pills and pill mills, second state in the country to battle back, dealing with fentanyl, being first state to mandate using of our pdmp, our Prescription Drug Monitoring Program. Now we have become the first state in the country to require physicians when prescribing to limit or for acute pain to limit prescriptions for three days. Some have done seven, some have done ten. We limited to three days and i can promise our governor spent capital on that. It is how important it is to hichlt we doubled down on things like rocket dockets and help for those addicted through various forms of treatment. We have 1900 cases in kentucky, weve increased funding many times to combat and help with suffering of those adetectived there. We put it in our jails and prisons. Again, i mentioned rocket dockets with prosecutors again to try to make these cases, put them on a separate plane to deal with them in the most appropriate way possible. We increased treatment at the department of corrections by nearly 1,100 since 2004. We validate that treatment every year and our return on investment now is almost 5. Some of the innovative programs you may is heard about recently chronicled in the new york city times, is the way we use vivitrol as it is known in our jails, on the front lines. We dwigive, again, an injection prior to release and injection upon release and we try to link the returning individual to the services in the community to see if theyre medicaid eligible, to see what kind of resources they have to continue the treatment. I know a question will be do we link those folks up to counseling. We do our best to do that. It is not mandated. We do our best to do that. In kentucky, i will tell you validated and anecdotally we are seeing tremendous results from using mat and counseling together, but counseling in the form of cognitive behavioral therapy, like moral recognition therapy. We are seeing it used in jails and prisons and it is yielding tremendous results. We intend to emulate what is going on in rhode island. We visited there through an nga project and were doing peer recovery and bridge clinic sook. We will use a hotline to get folks linked up to treatment. We are educating our medical and dental schools. Overall as i close out and conclude at the end of my time, i think we have the most comprehensive effort i have seen in my 25 years in criminal justice with something called core, the kentucky ooiled and response objective. With that i will yield. Thank you. You are recognized for five minutes. [ inaudible ]. Thank you, chairman murphy. Ranking member, as the director for the department of Behavioral Health canned and disabilities in hospitals i oversee the states treatment prevention and recovery systems. Also a long standing member of the National Association of state alcohol and drug abuse directors. Thank you for the invitation to share with you rode islands work in combatting the Opioid Crisis. Our strategies to address this epidemic are clearly outlined on our website, preventoverdoseri. Org and i will be sharing slides from this website during the testimony. Our goal is to make the efforts open to the public with complete transparency on outcomes and available for application throughout the country. First and foremost i would like to thank congress for the action taken plas year passing the 21st century cures act with a billion dollars to help support prevention treatment and recovery. In a time of tight budgets we appreciate the significance of this action. Addiction and overdose are claiming lives, destroying families and undermining the quality of life across states in the United States and rhode island has been one of the hardest hit. In 2015 newlyelected governor recognized the need for the state to develop a prehencive strategy to prevent, address, evaluate and successfully intervene to reverse the overdose trends. Signed an executive order establishing the governors Overdose Prevention and Intervention Task force comprised of stakeholders from a broad array of sectors. It has one over arching goal, reduce Overdose Deaths by onethird in three years. The governors plan focuses on four specific strategies which i will briefly outline and focus on two specific areas. Others are scribbled fully in my written testimony. The first is prevention. We take aggressive measures to ensure appropriate prescribing of opioids, promote safely disposal of medication and encourage the use of alternative Pain Management services. Next is naloxone rescue. It is a standard of care for first response. It saves lives by reversing overdose and our plan supports increasing access to naloxone across various sectors of the state. Third, we believe every door is the right door for treatment and our goal is to increase access to evidencebased treatment. To do that rhode island developed centers of excellence which provide rapid access to treatment including induction on all fda approved medications for ooiled disorder. They provide thorough clinical assessments and sbenlsive Treatment Services with wraparound support. This program is designed, right opportunity for stabilization with referrals to Community Physicians for continued treatment, offering continued recovery through the centers of excellence. It is supported through private insurance add medicaid. In addition rhode island released the nations first statewide standards for treating overdose and opioid use in hospitals and emergency setting and the department of corrections is providing medicaid assisted treatment to the population most at risk for overdose. We have worked diligently to increase data wagered position in rode island, for example Brown University medical school is first in nation to incorporate data waiver training into its curriculum. Finally, recovery. We are looking to expand recovery support. Recovery is possible. To support successful recovery for more roeld islanders sorry. We are expanding peer recovery services, particularly when people are most at risk. The anchor pd program was started in june 2014 and now is a statewide 24 7 service that connects overdose survivors with peer recovery coaches and Hospital Emergency Department also. These coaches share their own stories of home and inspiration to engage those in crisis as well as providing continued service to follow connections. To date over 1600 individuals met with recovery coaches. As a result over 82 accepted a referral to treatment. The anchor more program exists as a statewide outreach effort to opioid hot spots identified through data, not waiting for someone to overdose. We are now facing a fentanyl crisis. As you can see in this slide, approximately twothirds of overdoses fentanyl related we must develop new strategies to address the changing face of this epidemic. As we speak the rhode island governor is signing an executive order to expand efforts to include more focus on primary prevention, engaging families and youth in the efforts, farm reduction strategies and access to treatment. I cannot state strongly enough Rhode Islands strategies rely on sustainable funding through medicaid and Health Insurance, held to standards of parity as an essential benefit. Any action taken on a federal level would weaken the plan. I would recommend any federal initiative would include involvement of state agency given their expertise in these matters. I would advocate for continued support of the Substance Abuse prevention treatment block grant as a foundation of comprehensive state system. I would encourage targeted funds to address these issue. Thank you for the opportunity to testify. I look forward to answering questions. Thank you all. I recognize myself now for five minutes starting with governor russert. Rarting the 42 cfr part two, it has a couple of effects. One as supported by secretary moran, if someone is using a pdmp, the data is not in there. A physician prescribing will not know what it is based on. Secondly, if a person shows up in an emergency room, a former colleague patrick kinlsy talks about it, shows up with an injury and when asked if the person has any allergies to any drugs and he says, please dont give me any opioids, they do it anyway. Theres nothing in the record thats prohibitive being in the record. We can list if a person has an allergy, but i consider this on opioid sensitivity should be in there as well. The law in place since the Nixon Administration does not allow that to be in there. So the person may leave that hospital with a vial of opioid and then saying, well, when i used to be addict i used to take 20 of these at a time. I will take 20 now, overdose and death, or they may take them and say, you know and they relapse, or they may be on other medication with bens owe dbenz die as peen. What do you recommend we do with that . It does have to be address. Secretary moran was correct in terms of that particular challenge. A person who goes in who may be receiving methadone treatment, they go in for knee replacement. Theres nothing to tell that doctor that this person is also receiving methadone when they prescribe oxycodone or oxycontin or something of that nature. It doesnt show up in our Prescription Drug Monitoring Systems as well, so it is a particular challenge. It needs to be addressed. There are some areas with regard to hipaa that also go to other areas of Behavioral Health and i know you have talked about that. When we talk about Mental Health and the challenges associated with getting assistance for an adult Family Member once that person goes from 17 to 18, you lose a lot of control where you can help this person. So, yes, if you can make some type of exceptions or clarification theres also a misunderstanding amongst some of the doctors as well. At least in the record to deal with it would be a start. Another quick question, a quick survey. Noting most people with addiction have a cooccurring Mental Health disorder, i wonder if any of you have taken a survey in your states. Do you have a sufficient number of psychologists, psychiatrists . I believe the National Numbers say half the counties in america have no psychiatrist, social worker, no licensed drug treatment counsellor. If you do know, do you have a sufficient number in your state to meet the need . I can only speak anecdotally. There are some counties in our state that have a substantial shortage of those times of professionals, including drug counsellors, thats a challenge we ask. Yes, quick. And it various by geology in southwest virginia. Congressman griffith represents a very insufficient shortage of counsellors. Urban areas yes. Rural areas, no. We have a community Mental Health network were proud of. Again, in the rural areas. Thank you. Director boss. Rhode island shares in the struggle with the number of psychiatrists to meet the demand. I would say there is a shortage. Thank you. The other issue is medication treatment, director boss, with regard to that in pennsylvania had some data that says that people who are on m. A. T. May be getting some box own or something. The question is are they getting treatment. I wonder if people actually review that. I have heard the treatment is no more than a nurse the waiting room saying, how are you doing today, and they call it group therapy, or a doc says is everything all right. 40 were not drug tested in year they received it, 30 had between two and five different prescribers and 24 didnt see a physician in the prior 30 days. Can you describe if you had the data in rhode island and other states, is that something to really find out if theyre getting real counseling . So in rhode island the Opioid Treatment Programs are required to provide counseling. Do you know if theyre really doing it . Yes, we actually do reviews of our program. So the state licenses the Opioid Treatment Programs and goes out to review records and to make sure theyre abiding by the counseling standards as well. I appreciate reviewing the records, im going to push on this because we need to know this. I have heard from people that go to centers that tell me in counseling they have no more than someone saying how are you doing. Really, im curious. Mr. Chairman, without me actually being able to sit in on sessions and times of sessions and make sure theyre happening, we have to rely on the validity of the record with which we review. And so, you know, unless people are willing to commit fraud and put their licenses on the line by documenting that something that didnt happen, i would have to say that i i believe that what i read in the record to be true. Okay. I think this committee has dealt with so much fraud we have to move on p you are recognized for five minutes. Mr. Chairman, it is cosmetic treatment and youre right. Counseling has to be and important part of that. So if theyre not giving the counseling, i would think they should. But i dont think we have any evidence that theres fraud being committed in rhode island. No, im not picking on rhode island. Thank you. I love rhode island. Yes, we do. My daughter went to Brown University and we love rhode island. So i want to talk to you a little bit, director boss, about about this issue of states being able to pay for treatment, and this is the full range of treatment. I think it applies in all of the other three states, too. I would assume that paying for treatment on this scale is really an ongoing challenge facing your state. Would that be a fair statement . Congressman, that would be a fair statement prior to 2014. We have seen significant increases in the number of people being able to access treatment post Medicaid Expansion. So the Medicaid Expansion has helped, and we have 21st century care has helped too but we know theres a lot more work that needs to be done. In fact, in your statement you said that medicaid has laid the foundation for treatment coverage, is that correct . That is correct. And so i wonder if you can tell me quite briefly how medicaid funds are helping roeld isla rhode island fight this epidemic. The funds cover all three forms of fda approved medication, methadone, inject after meltraxone, he support a comprehensive program to integrate health care with an individual receiving methadone treatment as well as all other forms of treatment and rhode island has a full treatment, from inpatient, outpatient to residential treatment. Thank you. Now, have you looked at these bills that House Republicans have passed and that the Senate Republicans are looking at which would severely reduce the well, would severely reduce the medicaid aid to the state . I have. How would those impact your state of rhode island . So any bill that would reduce access to medicaid and Medicaid Expansion or reduce access to Affordable Health insurance would have negative impact on rhode island as 77,000 lives are covered approximately by medicaid. Thats 77,000 of rhode island covered by the Medicaid Expansion . Correct. Now, secretary recently announced on a show the Medicaid Expansion accounted for more than 60 for the total medicaid spending on Substance Abuse treatment in kentucky. Between 2012 and 2014 theres been more than 700 increase in Substance Abuse treatment provided to residents due to Medicaid Expansion. I guess i want to ask you, it looks to me like medicaid has been particularly helpful in kentuckys help against the Opioid Crisis. Would you agree with that . Let me say this, i will tell you unequivocally of our governors commitment, again example willed by the 1115 waiver, and our effort to expand the Treatment Options under that waiver. Let me ask you my question. Would you agreed medicaid has been particularly helpful in kentuckys fight against the opioid. I would agree. Thank you. I would agree we increased up to 1100 let me ask you this. If the Medicaid Expansion went away would it impair your efforts to fund this in kentucky. Im secretary of the justice and Public Safety youre not going to answer my question so im going to ask secretary moran a question. Secretary moran, governor mcauliffe attempted to expand medicaid twice in virginia but the Republican Legislature rejected both of the attempts. I want to ask you. I know virginia is making the most out of the tools it has, but if you had had Medicaid Expansion, more money in virginia, would this have helped you be able to reach out to more people on this opioid issue . The point is yes, an emphatic yes. And why is that . More people would have access to treatment. Now, i will give credit to our department of health. Theyre using a very innovative art program, addiction, recovery and Treatment Services, to carve out a medicaid waiver to try to address these individuals addiction needs. With Medicaid Expansion 400,000 virginiaans would be covered and governor mcauliffe has attempted to do that every opportunity. Thank you. Thank you very much, mr. Chairman. I yield back. I recognize mr. Collins for five minutes. Thank you, mr. Chairman. I think maybe ill start this question with secretary moran. All of us all agree here that opioid addiction is a disease, it is an addiction, and weve all experienced the tragic death of many of our Young Children when it comes to the overdose and as was just pointed out we also have the fentanyl issues. My question really is surrounding naloxone or narcan as we know it. Could you help the committee to understand the issue on availability because we understand there may be some shortages, costs. Who is picking up the tab for this, is it patients, the state, is federal government, to give us an overview on how we are at least attempting to deal with that piece . And also if someone is obviously in an od, are they given narcan without really you dont know, or they od on opioids or fentanyl. Thank you very much for the question, congressman. We are attempting to expand the coverage of naloxone in every community with the Law Enforcement theres some resistance, particularly from the rural jurisdictions merely because theyre not first to respond typically in a large jurisdiction. Usually it is emergency medical services. Ems does carry it. The majority of our jurisdictions in Law Enforcement communities and certainly in urban areas now carry it. Now, as i mentioned Virginia Beach has a tremendous success rate. Theyre saving upwards of a life a wife with the use of naloxone. We appreciate the grants so that we can provide without cost to the local jurisdiction that naloxone. In terms of lay people, our department of Health Commissioner issued an order that anyone now can go into a pharmacy and receive a prescription for naloxone. So we are attempting to expand coverage in any way possible. It is obviously a life saver and the more people who will have it, more lives will be saved. Now, you know, obviously once you revive that individual there are consequences after that in terms of need for treatment, but the narcan itself is a life saver and more people that carry it and within our department of Forensic Science, for instance, one issue with respect to fentanyl because it is so dangerous and lethal, we have provided authority now for all of our Lab Technicians to carry it, that they may be subject to a lethal dose when theyre analyzing evidence in the criminal case. So, again, as many people can have it, it is a very significant piece in this entire puzzle. Now, weve heard that the fda is considering making narcan over the counter. You just mentioned anyone can go in and fill a prescription, but i guess that would certainly indicate they have to have a prescription to start with issued by a doctor, and i dont know if theres people sometimes do have different kinds of concerns in admitting that theyve got an issue. Could you expand on that a little bit, on what you may know of the fda making it over the counter and also how does someone get this prescription, which obviously theyve got to then fill. Congressman, thats what the Standing Order did, is that you do not need a prescription now. Okay. You actually can go in and obtain the narcan without a doctors written prescription. That was the Standing Order from our commission of health. So thats statewide . Thats correct. And thats what the fda is looking on to expand nationwide. Whats your experience with that . Are people are you tracking how many people, are these programs Family Members who know theyve got someone whos got this addiction and theyre being anticipatory to use that word and just be safe. That is certainly the intent to, if you have a loved one who is addicted you would say the proactive step of obtaining the narcan in case of an overdose. We have been trained, myself, the first allied of virginia, the governor of virginia, we received revised training, it is very simple, it truly is. We would encourage people to have access to narcan in case of an over doels. Thats a great example and im just thrilled you shared that with us. Maybe it is a message if the fda doesnt move that other states obviously could take the same steps. If we can save lives you should be able to go home and say, job well done. Thank you for sharing that. I reeled back. You are recognized, sir, for five minutes. Thank you, mr. Chair. Thank you to our witnesses for their Public Service and for the testimony that they shared today. Before i get to my questioning, i would be remiss if i didnt echo my colleagues remarks on the devastating impact that trump care in its iteration would have in the fight against the Opioid Epidemic. This mean and might i say very mean bill will rip hope away from people in communities across my district who depend on coverage from the Affordable Care act and Medicaid Expansion to help them recovery from this scourge of opioid addiction. Medicaid by far is the single largest payer for Behavioral Health services in our country. In rode island medicaid pays for nearly 50 of Addiction Treatment medication. In kentucky, 44 . Maryland, 39 . Virginia, 13 . It is still being considered in the senate. We cut 772 billion or 26 from medicaid over the next decade. Theres no way this highlyefficient Safety Net Program would sustain this kind of funding loss and continue to provide services for all that require it. Simply put, passing trump care would be the single bestest step for providing. That being said, i collaborated last year on legislation that expanded describing privileges to Nurse Practitioners and physician assistants. I would like to gather your feedback on how this law is being intimated in your state. Director boss, you mention in your testimony that rhode island is actively working to provide data 2000 training to interested practitioners. Have you seed Significant Interest in the Nurse Practitioners or physician assistance communities in becoming wavered practitioners. Congressman, im not sure that i have data on how many Nurse Practitioners and physicians assistants have applied to take training. I know were actively working with medical schools to get that interest and increase the training available but im not sure i would be able to answer that comprehensively. But as you are aware, there is interest in it. Absolutely. There is interest and theres active work with the decht of health and within my department to provide those trainings to any and all interested party. We have seen an increase number of data waivered physicians. We will be working with the Nurse Practitioners and pas pools to increase those as well. Are there any projections you have made in addition to this additional class of practitioners being able to predescribe m. A. T. S and increased success in rhode island . We track through our overdose website the number of people receiving treatment so were able to look at the increases, and through our Prescription Drug Monitoring Program track the number of waivered physicians that are actively prescribing. So we are seeing increases in the number of people receiving the treatment through these efforts. But i would assume that the further expansion of the data 2000 waiver, either in higher patient caps or additional classes of practitioners prescribing, would have a positive impact on access to treatment in rhode island. I would absolutely agree with that. Im not sure theres been enough time for us to document how much increase that will result in but, yes, i do agree and i thank you for your efforts with that legislation. Our pleasure. And to all of our panelists, what barriers do you face in trying to recruit practitioners to become waiver data 2000 practitioners . Start with the Lieutenant Governor, please. Well, we talked about in certain cases, in certain parts of the state there are limitations in terms of the number of practitioners in some of our more rural areas of the state. Also some of the anecdotal feedback, there is still in some cases, theres a stigma associated with treating individuals for Substance Abuse disorder and there are some doctors that just dont want those patients. But the lifting of the cap has helped us with regard to being able to provide the services for more individuals, but stigma is still a challenge. Secretary moran thank you, Lieutenant Governor. Secretary moran . I would agree most of that information would be within our secretary of health and Human Resources as opposed to me, but we have heard from the prak titig tigser tig practitioner. There is a shortage of people to address this issue. In their defense, it is an epidemic that has exploded over the last few years. Any assistance you can provide would be much appreciated by the commonwealth and state. Thank you. Secretary . I would reiterate what my colleagues stated with regard to it. We have a phenomenon, a number of physicians, nearly 700 prescribing, however, many of them did not apply to subscribe up to the 285 cap. Many of them we dont know whether they are requiring counseling. We do know we require counseling in our corrections settings in jails and prisons. We encourage it, we do urinalysises. We dont note thats one of the things we are doing now. We have to look at beyond why some of the physicians are not applying to do more in their communities. Again, we struggle with the same challenges with rural versus urban and getting those folks out to those areas largely, and appalachia is probably hit first there and more acute and it is a challenge for us. Director, could we have a quick response. Thank you. I agree with all of my colleagues but i would add in our discussions with physicians they want to do the right thing and be able to make sure people are receiving counseling and toxicology screens but lack the office staff to do that. They need increase support in the office to do the evidencebased practice needed to use it appropriately. Thank you. Thank you, mr. Chair, i lead back. Thank you. Mr. Wahlberg, youre recognized, sir. Thank you, mr. Chairman. Thanks to the panel for being here. Secretary moran, according to the centers for Disease Control and prevention approximately one in five deaths attributable to a Drug Overdose failed to list specific drug in the death certificate. Could you explain why this data gap is problematic and what efforts the commonwealth is taking to ensure that it has sufficient data to understand the true scope of the Opioid Epidemic . Sir, one theme of my remarks is the need for additional data. The state silos which we are trying to break down and then there are, of course, the privacy provisions with respect to some of the federal laws in hipaa. In a criminal investigation our department of Forensic Science will do the investigation. We have good data with respect to what drugs were involved because theyre collected. If it is an accidental death, it eventually goes to the oc office of chief medical examiner, but with respect to the data, it is challenging. You know, some individuals may not be anxious to reveal the cause of death under some circumstances. Family members may not, you know, choose to reveal that type of information. It is a challenge, one we are trying to get our arms around, because if we have better data we know how to respond better and what to do and what, if anything, is working with respect to addressing this epidemic. Is there anything that youre attempting to get your arms around that data that is working for you, at least with some families . Well, the prevalence of fentanyl, particularly fentanyl weve realized over the last that i have enjoyed the presentations because were night lone. You have seen a dramatic rise in the use of fentanyl over the last year. That helps inform not only Health Care Providers but our Law Enforcement. Where is the fentanyl coming from . And if it is located in a particular community, there can be a Rapid Response with respect to education and response and to interdict fentanyl because it is typically manufactured overseas and coming into the commonwealth, into the country. That type of information i think is critical to the interdiction of these drugs in addition to the health care in response to the individuals. So it is i think it is imperative that we collect more data and have access to more data because we can better respond to the crisis. Director boss, your written testimony notes that Rhode Islands multidisciplinary Overdose Prevention and task force making use of a data driven Strategic Plan to combat addiction and Substance Abuse. Could you tell us more how the state utilizes the data to develop its strategy to address this Opioid Crisis . That is a wonderful question and thank you for asking it. Specifically as you can. So we have two things that i will point to. We have something called mode, which is the multidisciplinary overdose drug response team. Basically we look at a number of specific overdoses. We look for trends and theres a Multidisciplinary Team that consists of individuals from Brown University, hospitals, department of health, my department, and we review cases in depth in terms of looking at where those individuals were, what kind of Treatment Services they were receiving, if any, and then develop the specific interventions as a response that we propose statewide. The others are surveillance response intervention team. We receive weekly reports on 48hour overdose reporting. All of our hospitals are required to report overdoses or suspected overdoses within 48 hours, and our medical examiner is able to determine whether or not fentanyl is a factor in those overdoses. As a result, we put out alerts to communities when overdoses, whether fatal or not, exceed a specific target in that particular area, and were able to notify Law Enforcement, First Responders, treatment providers and other individuals in the community that there is an increased overdose, fatal or nonfatal, in their communities. Okay. You mentioned that your state still lacks comprehensive data relating to fentanyl even with this approach that youre taking. If i understand it correctly, what are the obstacles preventing hospitals from developing comprehensive testing of fentanyl . How could they obtain more robust data . So i think the fentanyl question is regarding the drug supply. Our hospitals are now able to test for fentanyl as are our drug treatment providers, and so we are looking at how much fentanyl is in the drug supply. And as we see increases in hospital testing, in the testing thats done in our drug treatment providers are able to know what kind of fentanyl is out there, but not necessarily as quickly as we could if it were Law Enforcement, if we had more Rapid Response in Law Enforcement in looking at what is in the drug supply. Thank you. I yield back. Thank you. Ms. Kass, you are recognized for five minutes. Thank you, mr. Chairman. I would like to thank the witnesses here for your attention to this serious issue. I think at the outset it is important that america just cannot go backwards on this. This is a very costly, severe problem for families and all of us. And to watch what is happening with proposals from the gop on health care really would take us backwards, whether that ripping coverage away thats been provided under the Affordable Care act, under healthcare. Gov or serious assault on medicaid, the most serious retrenchment of medicaid in its 50year history, would be just disastrous for our ability to support families and address this crisis. If fact, i would like to ask unanimous consent to submit for the record a consensus statement from the National Association of medicaid directors on the Senate Version of the gop health bill. It states in part, medicaid is a successful, efficient and Cost Effective federal state partnership. It has a record of innovation and improvement of outcomes for the nations most vulnerable citizens, including comprehensive and effective treatment for individuals struggling with opioid dependency. No amount of administrative or regulatory flexibility can compensate for the federal spending reduck shans that would occur as a result of the bill. Medicaid or other forms of comprehensive accessible and Affordable Health coverage is the most comprehensive and effective way to address the Opioid Epidemic in this country. Earmarking funting for grants for exclusive purpose for treating addiction in the absence of preventative medical and Behavioral Health coverage is likely to be ineffective in solving the problem. Thats all. Ill ask unanimous consent that be admitted for the record. Were reviewing. We will get back to you before youre done. Okay. This is very important. Now, this committee to its credit, your head of the 21st century Cure Initiative that provided substantial funds from our state, and i heard from local experts back home in florida, held a number of round tables with Law Enforcement, treatment professionals, anesthesiologists, er docs, and they say the key is longterm coverage, to treat this as the chronic disease that it is. Thats why when you rip away coverage and instead say, in its place were going to have another fund, another opioid fund where maybe you have provided a few dollars to an er, thats not going to provide the longterm coverage that we need to treat this chronic disease. So i just had to get that off my chest here right off the bat. In fact, director boss, you have a lot of experience with this. Do you think we will be able to effectively address this crisis if the this retrenchment on medicaid and ripping coverage away from million also of americans were to succeed . So i believe that Rhode Islands efforts to address this crisis would not be able to be sustained if we were not able to continue to offer insurance through Medicaid Expansion to the number of Rhode Islanders that depend on it. And i thank you for your pointing out the fact that providing Substance Abuse Disorder Treatment alone is not enough. If we dedicate dollars towards that, thats wonderful. However, you know, oftentimes there are comorbid conditions interrelated with an individuals addiction, that if they dont have access to Affordable Health care for the rest of the body then were not going to be able to treat the person well enough to sustain any kind of recovery. So are you able right now to provide the type of longterm treatment that is needed for this, for an opioid addiction . Yes, we are. In fact, youve been to a program called anchor ed which connects individuals struggling with addiction to recovery coaches to help them navigate the treatment process. How successful has this program been to helping an individual recover . So, of the individuals that meet with recovery coaches in the emergency department, 82 are receiving referrals for treatment and engage in treatment and recovery services, which is pretty phenomenal actually. The actual anchor e. D. Program itself is not supported by medicaid, but the fact that were not required to use Substance Abuse prevention treatment block grant funds to fund the treatment itself new that individuals can access frees up that opportunity to use block Grant Funding to support recovery activities that may not be supported by medicaid or other insurance, although the program is so successful that many insurances including third party commercial insurances are paying for the recovery coaching program. Is that a requirement under rhode island law or something you found to be so Cost Effective theyre participating. It is not a lirmt. Just a follow up question. Recovery coaches have what kind of credentials . So we have a certification process for our recovery coaches. It requires training and a test and volunteer hours for certification to respond. Theyre not degreed. Okay. Not degreed. And do you have in Emergency Rooms then people who are themselves also licensed treatment providers . Not recovery coaches, not peers, people that actually this is their lies lecense, do we have in the er as a requirement . We do not. There was a study out of michigan and also i believe out of yale that when theres a licensed addictions counsellor in the er providing treatment, not referral providing treatment, they increase that the person will follow up by 50 . Im saying here is so people you can call 82 and know if theyll follow through. Thats my question. I would love to hear it from each state but i have to go to ms. Walters. Before you do, is ms. Unanimous consent . Yes, sorry about that. When i heard from a lot of persons, give them a card, they may not follow through. The 82 may not be available to us, but to know theyre getting treatment. You wouldnt send someone home and say, you broke your arm, make sure you see an ortho peeding surgeon next week. Thank you, mr. Chairman. We can acknowledge despite Government Resources that the Opioid Crisis continues to devastate our communities. In my home of orange county, california there were 361 Overdose Deaths in 2015. That accounts for a 50 increase in overdose Overdose Deaths since 2006. A majority of those deaths are attributed the heroin, prescription opioids or the two. One of the challenges in responding to the crisis is the sig ma tiesi stigmatizing which limites their response to outreach. These courts can help overcome the stigma and treat the underlying addiction as opposed to resulting on the criminal behavior. I became aware of a Drug Treatment Court in buffalo, new york focused on opioid enter veengs. My question is for everybody on the panel. Do you have an opinion whether some Drug Treatment Courts need to be specialized to handle opioid addiction . We have extensive drug courts in most of our jurisdictions across the state. They essentially are specific to opioid addiction, and good result from most of those courts. The one challenge that we have is that depending on how long some of our counties that period that youre involved with the drug court is maybe 18 months to two years. If you are someone who kmilcomme a crime at a local jail, that person will say i would rather do the six months rather than commit to the two years. I would rather sit in jail. We are big proponents of drug courts. Unfortunately, virginia is deficient in drug courts. We have about 37, yet we have over 200 courts. They are used for a variety of different specialties. Theres Mental Health court, veterans docket. The courts provide some diversion. The individual needs to want to address their addiction, and then the court can provide the coercive element. We have a tremendous success rate. We should expand. The one issue i could ask congress to help us with whoever is the medically assisted treatment. Some of our judges in the drug court are reluctant, and as of now it is required. So we would like we would request on behalf of those judges some flexibility with respect to mandating m. A. T. Again, i would concur. We have Mental Health courts, veterans courts and drug courts i think that do expand. We did lose our juvenile drug court. An offender sometimes chooses a shorter sentence than the two year strenuous program. We are addressing that. Oftentimes we find theyre cherry picking the best instead of focusing on the more high risk. We have a program that deals with high risk probationers, again, a modified drug court that specializes in opioid, at least one part does. It is being done at seven pilot sites, modelled after the judge in hawaii that many of you know about now. I would also add that what were finding is well, again, this combination of specializing in medically assisted treatment in the cognitive behavioral therapies. We are trying to integrate that model with some. We have a modified drug court that will be rolling out soon that will specialize in opioid addiction. I would agree with my colleagues as well, especially Lieutenant Governor rutherford in the fact that our drug courts have been addressing opioid use disorder for a very long time. In rhode island the drug court has been accepting of medicaid assisted treatment as appropriate treatment for individuals long before it was required to do so. Probably the Biggest Issue we have with drug court is that it is not able to reach enough people. While it is very successful and effective, the difficulty in getting the numbers through that system is challenging and we really would like to look at a broader perspective of diversion efforts than getting people connected to treatment prior to as our primary focus. I had an interesting thought here. We had a conference in kentucky that offered a legal opinion from one of our law firms there again, as secretary moran pointed out, if a judge denies someone medically assisted treatment which affects their liblt interest when they return to prison, that denial might invoke some ada moving forward. It is an interesting thing moving forward on our courts in kentucky that might be more accepting of the medical treatment. Dr. Reed, you are recognized for five minutes. Yes. Thank you for being here. It is an important topic. As an emergency medicine doctor i cannot emphasize enough the devastating effect it has on individuals, families, community. I have treated patients who have been blue, not breathing, dumped in front of our doors and we go into the Emergency Care mode. Theyre there unconscious about to die, and thankfully we saved many because we had the medication. We know one of the primary things of successful treatment is they get the medication, follow up and counseling. One of the factors for success is that they have Health Insurance that has guaranteed coverage for those medications, guaranteed coverage for meantal health. Thats why it is so devastating for me and my patients that were on the verge of repealing the Medicaid Expansion, repealing or some states that choose not to have the Mental Health and Prescription Drugs, guaranteed coverage that those people who need and want coverage wont be able to have it and it can be a situation of life and death as we know. In a report on addiction released last year, the u. S. Surgeon general found that Medicaid Expansion meant millions of americans with Substance Abuse disorders have access to treatment. In addition, because Substance Abuse treatment is a covered essential Health Benefit which is at risk of going away, individuals, Small Group Market participants gain access to lifesaving services. It is not just about coverage. You can have coverage like in some parts of my district, but if you dont have providers, if you dont have psychiatrists, if you dont have psychologists, if you dont have health care centers, Counseling Centers or programs in those communities that are underserved or in rural areas, then coverage does you know good. So you need to also think about making sure that we have more psychiatrists, more psychologists, more Mental Health providers in those areas, especially for the youth and gung adults. According to data from hhs, the number of children in foster care increased 8 between 2012 and 2015. Experts have suggested that this rides is due in large part to opioid abuse. Moreover, the Substance Abuse and Mental Health it Services Administration has estimated over eight million children have parents that need treatment for Substance Abuse disorder. The wall street journal, the Washington Post and the New York Times all recently reported on children who have experienced the impact of their parents opioid abuse and are being raced by grandparents or have been placed in foster care. Can you describe how children in your state have been impact by the Opioid Crisis and are there unique challenges facing children in this epidemic . I think it is an excellent question with a focus on correction. Sadly i can report in kentucky as it exists now, more children are living with an incarcerate willed parent than any other state in the country, in fact have or have had an incarcerated parent. I think that would be the first thing that comes to mind in our state, being driven by the epidemic. It puts an incredible string on our health and family services. We have a Record Number of children in foster care at the moment. That is certainly an issue. Beyond that, i think it puts tremendous strain on our Community Health centers as well. I think the absence of proper funding for community Mental Health is a huge issue. It is acute in kentucky as well. We rely on our 14 Mental Health centers throughout the state to provide the services to children. Weve seen an increase with a focus in recent years on addiction and proper treatment for children. So i think its been critical thank you. Let me just warn you that by turning medicaid into a per capita grant, the funding for new addicted folks is going to i should say the need for funding is going to increase. States have to make decisions. One, change their eligibility criteria, two, their reimbursement rates, and, three, the benefits they would cover. Unfortunately, oftentimes the Mental Health and these Community Center treatments are the first on the chopping block. So it is going to get worse if this bill is going to pass. Director boss, stated that families have a central role to play in treatment of individuals with Substance Abuse disorders. Can you discuss what efforts rhode island has taken to provide treatment that covers a persons entire family . All of our treatment providers are encouraged to engage families in treatment, and as part of effective treatment we know addiction is a family disease and engaging Family Members is critical in order to have success. One of the things that the state has done and engaged Family Members in the development over the [ inaudible ] plan, creating a family and parent task force as well as engaging youth to help us shape our efforts for the overdose crisis you found a positive result from those . Those efforts are just starting so i will be able to report back. Im very hopeful we can Work Together to help this situation get better. I appreciate that because there are things we need to be working on. I want to make sure secretary till has a chance to respond to what youre saying about Mental Health, Substance Abuse, money being first on the chopping block. Is that kentuckys intent . Do you know anything about that . That is not the intent. You asked, i want him to respond. No, im just saying historically Mental Health is one of the most under funded i understand. You made a claim and i want the secretary to have a chance to respond to that. I would only say that the absence of proper Mental Health funding is not a new phenomenon. I agree with. In my private like i happen to be soshlassociated with an M Health Center as counsel. I know since the 1990s we have not had an increase in reimbursement and we have not in sometime. I dont think it is a recent phenomenon. Thats what i want to amplify. When you look at Mental Health funding increases overall for health care. Mr. Carter, recognized for five minutes. Thank you, mr. Chairman. I want to thank you all for being here on an important subject. I want to express my dismay and my discouragement at some of my colleagues who have used this as a platform, if you will, for political messages about touching medicaid, et cetera. We all understand it is establish, this is an epidemic in this country. As a practicing firsthand props march everyone in here collectively has seen the impact this has had. At no time have i ever asked a patient or thought in any way, is this a republican or democrat or independent. It is someone who is struggling. It is a nonpartisan problem and i get frustrated by that. Governor rutherford you said something im confused about. You were talking about the Prescription Drug Monitoring Program in maryland. Did you say methadone was not on it . No, what i was saying is that if you are monitoring, if you go to the Prescription Drug Monitoring Program or the damt ah basdamt database, you will not see a person has been prescribed methadone, theyre in methadone treatment. Why is that . There are Privacy Restrictions associated with drug treatment. This was in place prior to our developing the Prescription Drug Monitoring Programs. There are different barriers to getting information. You get Mental Health fortunes or drug treatment, and in some cases is that something we can help you with legislatively here . Think thats what we talked about, that would be very helpful. Because a practitioner would not know that someone that theyre prescribing an opioid already has a problem associated with opioid. Okay. When i was in the state senate in georgia i sponsored legislation that created our Prescription Drug Monitoring Program. It has been improved since i left. July 1st of this year, just two weeks ago, in fact july fourth or excuse me, july 1st of this year, two weeks ago, we started 24hour reporting. Before that we were reporting every week. Now we are not in realtime yet but were getting there. We are making very Good Progress there. I want to know in the Prescription Drug Monitoring Programs within your states and secretary tilley, i tell you, i have worked closely with the kentucky board of pharmacy and association very strong, very strong programs there. I compliment you on that. But in your experiences with the Prescription Drug Monitoring Program, are you sharing information across state lines . We are. I think we have seven border states very unique in that regard. The only state that we dont at this moment is missouri. Theyve got to be a yeah, missouri struggled. They were the last one to add it on. The pdmp. We are working on that. Again i would be happy to supplement the record to confirm that answer for you. But i believe we are sharing with 6 of the 7 states bordering us. Senator moran . We have 21 states. And most of our neighbors. And and the state of georgia, we are sharing with south. Carolina, alabama, north dakota, and someone else way out west. I would tell you, in my over 30 years of practice of pharmacy, i never filled a prescription for north dakota. I know you find that hard to believe. But i mean, its useful but anyway. It would have been more useful if i could have seen it from florida. Being in that area in savannah where we are only two hours away, it would have been extremely useful for the state of florida and hopefully we can get to that point. I want to ask you, secretary tilley, about a program that was interesting, and that is peer recovery specialist and Emergency Departments in kentucky. Can you elaborate on that for just a minute. . The expert to my left, he had a chance, and i applaud the work in rhode island. We had a model that didnt meet the goals we wanted. It was not up to par from previous legislation. We looked at what rhode island was doing. We tried the same thing they did, we just didnt do it as well. I think we are fairly ambitious with trying to do both at once. Peer recovery coaches or specialists in our ers. And also bridge clinics as well to try to keep people there in treatment until we can get them to treatment maybe outpatient or some kind of other bed outside the hospital. So i think what they are doing in rhode island is certainly a model for the country. We are imlating them directly. I apologize i didnt get to you. I have 15 seconds. One thing from a pharmacists perspective, one thing we didnt cure is to allow states to implement laws on how much can be filled and whether pharmacist can fill partial quantities. That will help. We can throw money at this all day long, but we need to be smart. If were smart and do practical rational things, like limits. I got so many prescription for a dentist of a 30day supply of oxycontin. They take one or two and rest are in the medicine cabinet. That is not being smart. If we can have a states can do that as a result of 21st century, or result, that is something we need to look at implementing as well. And. Allowing the pharmacist to only give a partial fill at onset and then they can come back not that they are prescribing partially but that you have an option . That is an option that we are allowed to do. I would take it further. And my office is in talks with the ea about allowing maybe a refill on c2 for threeday supply. A lot of physician are concerned that the patient is going to run out over the weekend. They are going to be bothered. Or not be available and they will go without. Thats a real concern and i understand that. But at the same time, again, if we are just smart. Allow them to call in one refill over the phone. As long as it is limited to a shortday supply. Thank you. Recognized for five minutes. Thank you, mr. Chairman. Director boss, i just i want to go back to the issue of medicaid. Because as you know, the republicans are still trying to repeal the acas Medicaid Expansion in making a lot of changes to the program. So what role has medicaid played Rhode Islands effort to provide medicaid treatment in your state . Medicaid assisted treatment is both for the disabled and the expansion populations all medicaid coverage. Individuals. Are able to receive three forms of fda approved medications for opioid use disorders. The director of medicaid is a member of our Opioid Task Force and has been active in working with managed Care Organizations that manage the medicaid product to do things like remove prior authorizations for medicaid assisted treatment. It is fully funded through our Medicaid Program. And my colleagues on the other side of the aisle often characterize the Medicaid Program inflexible for states. We hear that a lot, that its inflexible. To the contrary, i think it is a great deal of innovation and how states respond to the Opioid Crisis. Would you please tell us about the Health Home Program in your state and how medicaid granted rhode island the flexibility to develop its own personcentered care Opioid Treatment Program . There are probably two innovations. And we work with the Medicaid Office for a period of 18 months to develop the comprehensive Care Management function for Opioid Treatment Programs to provide to their clients in addressing physical Health Issues as well as their addiction issues. And the process with medicaid was thorough but one that allowed us to use a monthly rate to support the work that was really improving the health care of individuals in opioid use disorder. And we know that people who have opioid use disorders that have conditions dont have the greatest access to care in the community. And the health homes allow those programs which have the greatest access to individuals to provide nursing support, overseen by physicians, case management, to help them get to the needed appointments, dental appointments and medicaid is supporting those efforts with an understanding that improving those outcomes will improve outcomes overall and reduce cost. Centers of excellence are also a Medicaid Innovation. Where we allow people to be seen very quickly. And it is the issue. You need have that access to treatment which was noted. A person seen in the emergency room needs to follow through and get access to treatment and in order for anything to be effective. Centers of excellence exist as Medicaid Innovation allowing people access to treatment all fda approved medications again within 72 hours and have intensive services supported with a medicaid rate and recovery supports as individual needs with the intention to move that individual into the community once stabilized and continue to provide the clinical and recovery supports needed again through medicaid supported innovation. Obviously my concern is that in states most heavily impacted by the Opioid Epidemic if you have cuts to medicaid then cuts to treatment and exacerbate the process. So i have a minute left. Let me ask you, would you agree that deep cuts to addiction services, that might result from the Senate Trump Care bill for example, that if, you know, if states decided because of the cuts in Senate Trump Care bill, that those kinds of cuts to Addiction Treatment would have addressed an impact on the ability to fight this epidemic. Our recovery, our overdose strategy engages four different component and three of the four would be effected if medicaid were not available to support the access to naloxone. Medicaid covers naloxone for individuals. The treatment component is, again, supported by medicaid, our centers of excellence as well as treatment components of that as well. And the ability for recovery coaches to be funded, if not for the treatment covered by medicaid, our Substance Abuse block grant dollars would have to be recovered from those efforts to support individuals in treatment. Thank you so much. Thank you, mr. Chairman. Ms. Brooks, recognized for five minutes. Thank you. Director boss, i want to clarify something that my colleague, congressman wahlberg asked you previously. You talked about a data gap with respect no fentanyl in Law Enforcement. With respect to Law Enforcement data. In your written taemt you talked about hospitals testing for fentanyl but we dont know how many are testing positive for fentanyl. So the gap in collection on data for fentanyl exists in Law Enforcement, and hospitals as well. Is that correct . So the testing for fentanyl in the hospitals is fairly new. And so were not sure how complete the data is. They do have ability and whether or not all of the hospitals are testing or not, im not exactly sure. And i think for the most part it is an issue of timeliness. We need to have access to timely data and making sure that if testing occurs, that were able to get the results quickly and in enough time to respond to a community that may be seeing an increase in fentanyl. I guess i have asked others on the panel whether or not you know if your hospitals are gathering data on fentanyl specifically and the frequency and so forth. Yes . I cant speak directly for the hospitals. I know through our medical examiners office, through our emergency First Responders, they get information with regard to fentanyl usage a little more than 60 of fatalities, overdose fatalities are opioids are related to fentanyl. It is a mixture with something else, cocaine or heroin. But most of our information is from emergency responders. I want to talk more specifically about the criminal Justice System and would like to ask you, secretary tilley, the core program you mentioned, that is specific to the criminal Justice System in kentucky, isnt it . Actually, it brings in all stake holders. Even education. Cabinet for Family Health and family services. Many elements of the criminal Justice System. I cant speak directly for the hospitals. I know that through our medical examiners office, a little more than 60 of fatalities are related to fentanyl. In most cases its a mixture with something else, cocaine or heroin. But were get most of our information from the Law Enforcement and emergency responders. I want to just talk a little bit more specifically about the criminal Justice System and would like to ask you, secretary tilley, the c. O. R. E. Program. It brings in all and then they are matched with a counselor and appear recovery coach and try to find the necessary resource to continue that treatment, whatever it may be and whatever source it may come from. In our juvenile setting, we do not have medically assisted treatment at this time. However we at kentucky have a record low in terms of our juvenile detention population at the moment and that doesnt seem to be near the issue in our facilities. We do offer the treatment in the facilities just not medically assisted in the same way that you would see anytime the corrections setting. One thing thats unique about kentucky and wung thing not reflected in the the New York Times article about that treatment is kentucky houses half of its state population in its jails. Were expanding that medically assisted treatment like you may have read about in kenton county, part of the greater cincinnati, Northern Kentucky area. I would also add the piece about incarceration, were trying to use elements like involuntary commitment to try to bypass the need for incarceration for those individuals, again, who stand out to their families as someone who needs a forceful hand, maybe a judges contempt power, to keep them in treatment. Well be submitting questions for the record for each of your states, because im interested in knowing more and my time is up, on medically assisted treatment as well as counseling and what youre doing with your inmate population. And i know youre each doing something. But i would love to learn more about it. I want to thank you all for cooperating with each other and learning from each other. Critically important. I yield back. I recognize mr. Costello for five minutes. Thank you, mr. Chairman. Some of you may know that the chairman and i both hail from pennsylvania, the chairman from the western part of the state, myself from the eastern part of the state. Sometimes people think theyre two different states. But having said that, in pennsylvania, the epidemic is particularly acute. And just a few brief comments about what were doing in pennsylvania. Then Lieutenant Governor rutherford, with the enactment of the cures act, pennsylvania received federal funding to address the epidemic 3. 5 million for drug courts, 23 million being funded to expand access to medication assisted treatment, increase training opportunities to Better Connect individuals with additional treatment when they visit an emergency room as a result of an overdose, and also to improve access to opioid use Disorder Treatment for uninsured individuals. And Lieutenant Governor rutherford, you spoke about establishing a 24hour Stabilization Center in baltimore city. I wanted to ask you about that. What services will be provided at the facility, why do you think it is better suited to have such a facility to treat Substance Abuse issues rather than in Emergency Departments, and maybe depending on your answer, ill have some questions following on that. The concept at the Stabilization Center is a place where both First Responders as well as Law Enforcement or Family Members can take a person suffering from Substance Abuse disorder, and they may be ready for some type of treatment. The idea is to bring them into a locale, not necessarily in the emergency room, because that is a very high cost approach to addressing this challenge, where they can be stabilized and get them into longer term treatment. So its an opportunity to get that person, as i mentioned, stabilized. They can reside there for a few days before we if theres a bed available to get them into treatment. Any similar facilities that you might be modelling this off of . I believe san antonio has something similar. I would have to get more information and talk to my staff. I believe it was san antonio that i believe was doing something very similar to this. Once stabilized, will the patients then be moved into evidencebased treatment and counseling . Thats the objective. We havent stood this up as yet, and were working with the city of baltimore in terms of the parameters and how this is actually going to operate and what the states oversight role will be with this. Is the hope that the treatment and counseling, and you said thats your hope, that the funding that you would be utilizing for the facility itself, would that funding extend to the treatment and counseling, or are you looking at the facility to just be sort on the front end . The facility is on the front end. We will look to the other funding sources, be it through the cure act, through state revenue, through insurance, through medicaid, to pick up the treatment aspects of the challenge. Can you describe some of the challenges that your state currently faces to provide beds in a timely manner for individuals seeking treatment for Substance Abuse . Well, the lifting of the restriction with regard to medicaid reimbursement on the number of beds in the facility has helped that particular challenge, because we did have situations where we had individuals who would receive treatment through medicaid, and we had beds available in some of our facilities, but we could not utilize those. That has helped. We are working to expand the capabilities, particularly for some of the nonprofits that have services and are providing services, and seeing what we can do to assist them in expanding their access. We have close to 800 facilities around the state. There is always a discussion about getting additional beds and capacity. And so were working on those things as well. Thank you. My general comment on this epidemic is oriented towards the following. I think there are a lot of variables that contribute to this. I think everyone knows that. I get concerned when we point to one particular actor in this ecosystem and say, thats the problem, because it is manifold, it is complex. And i think what concerns me more than anything is that the life cycle of treatment is much longer than the infrastructure that has been set up to deal with it. And as a consequence of that, no matter how good we might be in the first six innings of this, if were not good in innings seven, eight, or nine, it ultimately wont matter. And were just embedding cost into the system without front loading the cost, without acknowledging that on the back end, if we dont finish it off with the right types of treatment and the right types of counseling and the right followup off that, we wont be able to drive down the epidemic. I think weve all tried to identify what some of the front end issues are here. But that would be something i would like to submit for the record. Mr. Chairman, i see im well over my time. May i respond briefly . Youre absolutely right. And some of the thought processes behind the Crisis Center is, its a front end, right, its a front end where the person comes in the door. Theyre in distress at that point, stabilizing. Getting them into treatment, but even after the treatment, one of the things weve heard over and over again from people who have relapsed is they go out of treatment, go back to the same community, the same stimuli, the same issues that they had before. One of the areas were focusing on going forward, including utilizing cure act funding and state funding, is transitional housing, for lack of a better word you can call it a halfway house, where a person can go and continue to get treatment in terms of the counseling aspects of it, but during the day they can go to work, do the things they need to do, but they have to report back to this facility. People have said that is something they need before they go back into the unrestricted society. Because all the stimuli is still there. Thank you very much. Thank you, mr. Costello. Its the policy of this committee to let other members of the full committee ask questions. Mr. Bilirakis . Thank you so much for allowing me to sit in on the hearing, i appreciate it, mr. Chairman. I have some prepared questions. Does anyone else want to elaborate on that, any suggestions as far as the long term, the back end . Is there anyone on the panel who would like to talk about that . You mentioned, and youre so correct, transitional housing, and cooperation, obviously, is so very important. The patient needs to cooperate, and voluntarily, in most cases. Is there anyone who wants to make another comment before i get started . If i could, i would add that the front door is very important, because access to care, oftentimes youll hear families say, i dont know where to turn for help. Were looking at a Crisis Center model as well. I think thats critically important. You dont know which number to call, youve got a Family Member, a loved one, and youre not sure how to connect them. Its like someone with hypertension going to the emergency room and getting a pill but not getting a prescription. Its not going to help. Without access to care and the kind of supports needed. Recovery housing is needed as well. As part of our cures act funding, were looking at establishing that housing for individuals not able to turn to their communities. We need to treat addiction as a chronic disease and not acute episodes. I think the approach to longer term and looking at the long term needed supports are critically important as well. Thank you. With regard to florida in 2010, in response to the Opioid Crisis in florida, the pill mill problem, i think you probably know about that, floridas legislature enacted a statewide tracking of painkiller prescriptions coupled with Law Enforcement, using Drug Trafficking laws to prosecute prescribers caught overprescribing. Within three years florida saw a decrease of 20 in Overdose Deaths. I want to give pam bond, the attorney general, and others credit for this. But now the rise in fentanyl and its various derivatives have presented new challenges to the state of florida and other states as well. However, we remain optimistic with recent legislative initiatives in florida, these include requires doctors to log prescriptions in a statewide painkiller database by the end of the next day. I think thats important, to curb the socalled doctor shopping, and setting aside state funds for medication that can help reduce opioid dependency. So were working on it. During the august recess, i want to meet with stakeholders and conduct round tables with regard to this issue. Do you have any suggestions for me, what has succeeded . Obviously, sir, i talked about the baltimore model, and i think thats very important. Are there any other innovative ideas or legislative initiatives that you would recommend for my state of florida . Anyone on the panel. I know youre very aware of the stop act and this issue of keeping fentanyl and carfentanil out of our country, where its manufactured legally, sometimes illegally, shipped in, mailed into our country. The dea informed us that for a 6,000 investment, its about a 1. 6 million profit to press it into a pill is a 6 million profit. Again, the cartels, that kind of profit margin out there for their taking, its very difficult to combat this, if were flooded with it with impunity. We have to figure out ways to stop it from coming into our country in the first place. Again, thats not necessarily floridaspecific, but i think this idea that its contained in the stop act, i wont comment on the specifics, but i understand that would, again, curtail some of that. Anyone else, please . If i could, fentanyl is changing the face of this epidemic and we need to respond in our interventions. One of the things i would comment on is this is a marathon, not a sprint. We really need to take a look at prevention efforts as critical to changing the face of this epidemic, and not cutting our efforts in prevention, primary prevention, working with transitional aged youth. If he can stop their use in youth, we wont have them dying of fentanyl. Recently we havent had any new medications, we havent had any new treatment models necessarily proposed for opioid use disorders. And im not sure enough effort has been placed into the Research Needs of this epidemic. We need to start looking at this as we would the focus on cancer. This is an epidemic. We need research thats going to support the most evidencebased models that are effective in treating this. Thank you very much. I agree. I yield back, mr. Chairman. I recognize the gentlewoman for followup. I want to commend all of your states for leaning in, for moving forward on this, and for trying to find robust solutions. Its really important that we do that. I know almost all the states are doing this. My state of colorado has also started really paying attention. Its the kind of thing where it crept up on us collectively as a society, and so people have had to move really fast. And i just want to commend you. And i also want to reiterate that were very flattered, i personally am very flattered that youre taking this 21st industry cures money and really making something with it, and developing some programs that are uniquely and appropriately tailored to your states. Sometimes when were in congress, we wonder if anything we do actually impacts peoples lives. And when i hear what youre doing, its really gratifying. And i think it will save lives. You do i hate to sound like a downer, though, but to say that this 21st century cures money which was 2 billion, its really wellused i think by the states with these grants to develop programs. But 2 billion is, as governor kasich said, not 45 billion. If youre trying to substitute the Medicaid Expansion money and other treatment monies that are coming, you cant use the money for that. We have to make opioid treatment and prevention part of our overall mental and physical health care in this country. And what that does take, im sorry that mr. Carter left, were not trying to politicize this. What were trying to say is, if you really want to give treatment to people, you have to develop the programs, which is what Something Like the cures money is good for. But then you have to be able to implement them. You have to be able to give the counseling to people. You have to be able to give the mat treatment to people. You have to be able to build and maintain these Housing Options that people were just talking about. You dont do that just with fairy dust. You have to do that with resources. And some of the resources can come from the states, but the states are jammed. And so thats why the Medicaid Expansion has helped so many millions of americans be able to get access to the treatment that they need. And thats why we need to be able to keep that for these populations. So i want you to know that and, you know, interthat we really disagree on that either. Mr. Murphy and i agree on a lot of these issues. He just cant say it as forcefully as i can sometimes. But we know that we need to make sure that all americans can get this treatment. And we will commit to you that we were going to continue to work with the state to make that happen. Thank you. Thank you. Some questions i want to follow up on. This goes in the category of coverage without access is a problem, as is access without excuse me, coverage without access and access without coverage are both problems. To this extent i want to put in the record, i ask unanimous consent, why oxycontin can make pain worse, and another is an article, depression and other mood disorders. Ill let you see that. No objection. No objection, it will go in the record. I want to reference a couple of those things. Theres about 50 million americans with low back pain. 25 million of those take an opioid. When a person has pain and depression, about 40 of them are 300 to 400 times percent, 300 to 400 abuse, misuse or addiction. Noting that when were dealing with people with addiction disorders, and 80 begin with a prescription for pain, but mood disorders are a big part of this. 51 of people on opioids have mood disorders, anxiety, depression, something else. I dont know if any of your states ask physicians to screen for that, i would imagine not, most states they dont. Do any of you know if your states, medical societies or hospitals ask them to screen when youre prescribing a medication for pain, you also screen for depression, anxiety . If you dont know, just tell me i dont know. I dont know. But i believe that is not available in the precipitation Drug Monitoring Program either. Do you know if you do that in virginia . My counterpart, a doctor in the medical community was using the chart, zero to ten, smiley face. We were addressing pain. And we overprescribed. Im not aware, to answer your particular question, im not aware whether or not those emojis are not to do with mood, theyre to do with pain. I find it amazing that the other vital signs, Blood Pressure we measure, temperature we have an instrument for that, respiration, all these are measured. But when it comes to pain, one to ten or an emoji is pretty primitive. We are mandating two hours in the medical community to address pain. This starts in the medical community with better characterization around how you manage pain. As far as you know, it doesnt also include assessing mood disorders. Secretary tilly, do you know, director, do you know if theres any Movement Towards assessing prescribing these . I think it presents a bit of a pause for the prescription, i did not get a chance to mention the university of kentucky is piloting a program, our flagship institution, piloting a program there to start with everything but an opioid in the course of treatment and try to taper, instead of starting with it, tapering down, starting without and maybe moving toward it if its absolutely necessarily. Lastly, to your question, we actually are embarking on that very thing potentially with a statewide Mental Health approach, a number of best practices across the there. Thats one of the things weve discussed. Thank you. Dr. Boss . I cant speak to whether or not its required. I can say the state has had major efforts towards Behavioral Health integration and primary care. I know a lot of our collaboratives are screening for mood disorders and anxiety. The chance for somebody getting a screen for that is probably pretty close to zero. Just as we had the problems with 42 cfr, a doctor doesnt know if a person is on methadone, they dont know if theyre on these medications. Its usually patch em up, get em out. I know when i was prescribed a lot of fentanyl and other opioids when i had an injury in iraq, nobody never asked me any questions, take these, take these, take these. I ended up with my own issues there, which i didnt get an addiction but my body developed a dependency. I finally said enough is enough, and i had my own mild withdrawal reaction, it wasnt pleasant at all. You said people get referrals in the emergency room. Do you know how many of that 82 follow up and follow up consistently and in an evidencebased program . We are not able to measure where the 82 go. So 82 not just are referred to but are connected to and follow through with treatment and recovery supports. We dont know what the followup is. Right. Thats important to me. Look, weve identified a few things here, such as we have a crisis shortage of providers. We all agree with that across the nation, especially in rural areas, quite frankly in urban areas too. If you assess providers and say, how many openings do you have in your schedule, theyll say they dont. Some providers say i just dont have appointments open for months. Someone with Substance Abuse needs treatment now, giving them a waiting list is not helpful at all. Even when we do refer people over, the statistic i see is of the 27 Million People in this country with an addiction disorder, 1 get evidencebased care. 90 people with Substance Abuse disorder dont seek attention. Out of 1,000, 900 dont seek attention. 37 1 2 cant find it, its not available. Of those that do get it, get attention, 90 of those or dont get evidencebased care. So we have a crisis thats getting worse. And i might add too, i think virginia, youre the only state that doesnt have Medicaid Expansion, right . So we do not. In this time period in which it was available, i would assume that your addiction rate, your overdose death rates have climbed, correct . And in the state that do have Medicaid Expansion, maryland, kentucky, rhode island, has your overdose and death rates also climbed . Oh, yes, yes, sir. Ours have raised but not as significantly as other states have experienced in these last few years. Yeah, but look, i want to help, but we need honest data here. Look, we dont even have information on if those numbers are accurate, because if your medical examiners and coroners are not doing toxicology tests and we dont have data for 2016 until the end of this year, we just dont know. What this committee likes to do is identify. We need the absolute honest bare bone problems. If you tell us, look, we dont know, this is probably much worse, we dont have enough providers. We had legislation, some of it was reduced down and i want to see it reenacted, to get more psychologists, psychiatrists. Were probably going to have to do things with states and the federal government providing scholarships or paying for their internships. Who would want to do that . Youre on 24 7, probably going to get called into court to testify. It only requires the best who have true altruism in their blood to fight that. Weve got to do it. I want to ask a question with regard to getting drugs back to someone who is not using. Even realtors say when you have a home up for sale, go to your medicine cabinet and clear it out. Some places will have recovery programs to take you to the pharmacy or take it to the police. Theres a product called detera, a drug deactivation system you can use in your home and then throw it away. Virginia, you have some programs like that where you do Drug Recovery at home . We do, sir. We are using those. I would congratulate our private sector partners, pharmacies have collection boxes now. I will tell you, dea does a terrific job. They were going to suspend their takeback program. We included dea on the Governors Task force and now they continue their robust takeback program, tons of drugs, its amazing, ive witnessed this myself. Improper disposal in the medicine cabinets, as a father of two children, teenagers, its imperative that we keep the drugs out of that medicine cabinet, because weve heard anecdotal stories, thats where the addiction begins. Kids using it out of the medicine cabinet. They go to homes for a party. Exactly, sir. I want to thank this panel too. We have a long way to go. Unfortunately i think at this point, were seeing the battles in the states, but we have to be honest and say we have a long way to go in this war, its still quite a crisis here. And this committee will continue to take this up in lots of different ways. It is just a matter of funding. What good is funding if you havent got a provider . What good is a jail Treatment Program if the person discharged from jail arent on medicaid so they go right back to the streets or wherever they had a problem before. Weve heard problems in certain professions were people in the back rooms have addiction problems and theyre getting exposed. We have an awful problem in this country and the problem is a death rate that is mortifying. I thank the panel here and i thank the members for being at todays hearing and remind them they have ten Business Days to submit questions for the record. Thank you for your honest approaches. Keep fighting the good fight. Thank you. Thank you, chairman. Nate republicans released their updated Health Care Replacement bill today. Were expecting it to hit the floor for debate next week. Ahead of that we talked to a reporter on capitol hill for the late