Transcripts For CSPAN3 State Officials Testify On Opioid Epidemic 20170714

Good morning everyone. Today the subcommittee of oversight and investigation holds a hearing entitled combatting the Opioid Crisis battles in the states. Now, make no mistake the term combatting and battled are entirely appropriate. Our nation is in the midst of devastation around every corner of the nation. In 2015 there were more than in the u. S. , more than 33,000 deaths involved in opioid. 24 increase from the prior year. Overdose death rate in 2015 was almost seven times the rate of deaths from the heroin epidemic of the 1970s. For 2016 weve already announced from New York Times weve lost roughly 60,000 people to Drug Overdose and that is more in one year than all the names on the Vietnam Veterans memorial wall. And likely that number is underestimated because much of the data will not be in until the end of this year 2017. Its staggering. For every fatal overdose its estimated there are 20 nonfatal overdoses and for 2016 that could be near 1 million. More than 183,000 lives have been lost in the u. S. From opioid overdose from 1999 and 2015. About 50,000 to be lost 500,000 will be lost over the next decade. The route to this crisis began in 1980 when a letter to the editor by two doctors was misinterpreted, it was unlikely that someone would become addicted out of 40,000 cases they said there was only four addictions. 20 years later the joint commission under credit dags following the American Medical Association that pain be assessed the fifth vital sign establish standard for Pain Management by many doctors as encouraging the prescribing of opioids. Under the Affordable Care act prescribing painkillers is incentivized by questionnaires where a patient is asked if their pain is answered to satisfaction. Based on their answer the hospital may receive more or less money. As we learned in hearing in march the Opioid Epidemic is Urgent Public Health threat fueled by fentanyl. Two states represented on todays panel, rhode island and maryland, were the first ones hit by the fentanyl wave and unfortunately seems certain this wave will sweep the nation as low cost high profit harder to detect profile fentanyl is easily attracted to manufacturers and easy to obtain over the internet. This is extreme moment recurring all the cooperation federal, state and local governments as it was all the different industries, professionals and experts to curb this terrible outbreak. With this hearing we will focus on the actions of our State Governments to find out what efforts are working, what is not working, how well Work Together to save lives. Panelists say we want to know the problems and please be candid with us. Because as you know theres millions of families being torn apart by this. As drug policy experts noted, quote, it is at the state and county levels that the Real Progress will be made. It makes sense inspired solutions most concentrated there, we should invest in those solutions and learn from them, unquote. Serving the front lines of the Opioid Epidemic own initiative such as more inventive use of incentives, more comprehensive Prescription Drug monitoring. States such as maryland are making the best use of the centers for Disease Control opioid prescribing guidelines to help push back on the overprescribing. Kentuckys all schedule prescription electronic reporting system, a web based Monitoring System to help prescription use across the state is helping state regulators identify personal prescribing practice by physicians and abuse by patients. Virginia has greatly expanded access to naloxone. Some states are expanding the availability by limiting third party prescribing of family and friends of individuals high risk of overdose. Rhode island has developed the program that matches overdose programs with peer recovery coaches to encourage treatment who follow up with the patient the next ten days after the overdose. Much of the work of the states should help inform the president s commission on combatting drug addiction and the Opioid Crisis. We held a similar hearing on what the State Government opioid abuse epidemic. Such oversight help Congress Enact vision it will help the administration. We put 1 billion into grants over the next two years, but we want being used widely and how well its working. Were eager to learn about those programs. With the 21st century cures program is just a beginning. Our State Government witnesses can help this committee develop a more Effective National strategy to combat the Opioid Crisis in such areas as Substance Abuse prevention and education, physician training, treatment of recovery, Law Enforcement, expanded access while testing for drugs in correctional facilities, Data Collection, examining what reforms need to be made to the 42 cfr 2, that theres better coordination among care physicians and we can help prevent relapses and overdose and improve patient safety. We are in one of the worst medical tragedies of our time, perhaps the worst. And although this committee has given this subcommittee has given 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 the states of what youre doing on the front lines of this. Thank you, mr. Chairman. And i appreciate this most recent hearing on opioid addiction. As you said so accurately, this crisis is really devastating america as all of us on the 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 librarians and School Nurses being trained to administer naloxone to overdose victims or about local and State Governments time trying to stay within their budgets. There is some good news. Recently the cdc reported that opioid prescriptions peaked in 2010 and have since fallen by 41 . Thats the good news. The bad news is opioid prescribing remains untenably high. I am hoping our future investigations will concentrate on this. In addition, as you pointed out, mr. Chairman, is the emergence of illegal fentanyl, an exceptionally potent opioid. In 2017 fentanyl overtook both heroin and prescription opioids as the leading cause of death in many places. Each of the states who are here today, and i want to thank you all for coming, have faced alarming overdose outbreaks. This committee has done some good work. In particular, investigating the seemingly voluminous amount of pills distributed in West Virginia and were planning to do more. The attorney general in my home state of colorado has joined a Bipartisan Coalition of states nationwide looking into whether manufacturers engaged in illegal or deceptive practices when marketing opioids. Coming up with an effective solution to the Opioid 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 or in connecting people with Substance Use disorders to highly trained coaches to guide them through recovery. Virginia is working to implement a similar Peer Recovery Program and kentucky established a program to provide medication assisted treatment to individuals in correctional facilities and to continue supporting them after theyre released. Maryland has committed to establishing a 24hour 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 cures legislation that mr. Upton and i sponsored and that this committee worked on a bipartisan basis to pass. As we move forward, we 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 Opioid Epidemic. As you know, the aca has helped since 2015, 1. 6 uninsured americans gained access to Substance Abuse treatment across the 31 states that expanded medicaid coverage. This is particularly true for states like kentucky where one report says that residents saw a 107 increase in beneficiaries seeking treatment for Substance Abuse. Many think that the housepassed bill that undermines the aca will threaten peoples ability to get opioid treatment. In its assessment, the nonpartisan cbo said the house bill will cause 23 million or 22 million americans to lose Health Insurance. A lot of these people, they need opioid treatment. There have been discussions, both in the house bill and the senate discussions, about adding some money for opioid treatment. But, for example, the most recent senate suggestion of additional 45 billion to help combat opioid addiction, Governor John Kasich said, quote, its 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 opioid addiction. And weve got to move forward to work on this together. I hope we can do that. With that ill yield back. Mr. Chairman. Ill recognize chairman of the full committee, mr. Walton. Addiction is an kwool opportunity destroyer. Its a destroyer that doesnt pick people based on age, race or socioeconomic status. It does not pick them based on political parties. My round tables throughout the Second District of oregon, it didnt matter if i was in a Rural Committee or a more populated city, the stories were similar. We all know someone who was impacted by this epidemic. In my state more people die from Drug Overdoses than from automobile accidents. Thats not unique. According to Data Analysis Drug Overdose deaths in 2016 likely exceeded 59,000 people. Thats the largest annual jump ever recorded in the United States. And whats worse, some of the preliminary numbers from the states indicate that their numbers within the First Six Months of this year are already surpassing last years total numbers, and over the past seven years opioid addiction diagnoses are up nearly 500 according to recent report. Despite a report released by the cdc last week which indicates the number of opioid prescriptions has decreased over the last five years, thats the good news, the rates are still three times as high as they were just back in 1999. And 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 opioid prescriptions in the country. Of the top ten counties in my state for opioid prescriptions, five of them are in my rural district. Moreover, oregonians aged 65 and older are being hospitalized for opioid abuse and overdoses at a higher rate than any state in the union. Opioid deaths continue to escalate, and this epidemic is simply getting worse and more severe. Challenges remain, and we need to get after it. We need to improve Data Collection. A few states are requiring more specific information related to Overdose Deaths. We cannot solve what we do not know. Overdose preconvention efforts, improvement with respect to the utilization and interoperability of Prescription Drug Monitoring Programs. We need to increase access to evidencebased 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. Its precisely why we are having this hearing today. Last Year Congress took action to combat this crisis by passing legislation including the comprehensive Addiction Recovery act and the 21st century cures act and states improved programs to strengthen the fight. Much more needs to be done. We need to Work Together to ensure the tools and Funding Congress created are reaching our states and localities and being used effectively. We hope to hear from state officials today to see how theyre utilizing these funds and whether these programs work or not. We greatly appreciate the witnesses who have agreed to appear before us today. We hope to have a constructive dialogue about what the states are doing, how to improve Data Collection, the initiatives that are working, what isnt working and how the federal government can be a better partner in the collective fight. 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. So thank you for being here. With that, i know i have two members that want to introduce witnesses. Ill go to mr. Guthrie and mr. Griffith. Thank you for letting me sit in for purposes of introduction. I want to introduce our secretary of justice and Public Safety in kentucky. Secretary tilley. We served in the General Assembly together. Secretary tilley had a strong reputation, strong work as judiciary chairman in the house working 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 1404 people that passed away last year from opioid addiction. It is so much to be done. We are saying thank you for the work that youve done. I know we have enormous work to be done. I can tell my colleagues on the committee and my friends, i can think of nobody else in kentucky id rather have sitting where you are leading this effort. I applaud Governor Bevin for making the choice and ask you to serve in his cabinet. Another committee where we have two bills that are upstairs. 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 here because i am defending a bill upstairs. With that ill yield back the balance of my time. Unfortunately i too must go to that subcommittee. Come on back. Its going to be exciting. Secretary moran is the spit and image of his brother. Recognize the gentleman from new jersey, mr. Pallone for five minutes. Thank you. Thank you for holding this hearing. Our committee has held several hearings on the ongoing crisis including one in march. Since our last hearing many more lives have been destroyed. There is no community that remains completely untouched by the Opioid Crisis. Recently the cdc reported that the opioid prescribing rate has peaked but remains far too high with enough opioids to keep every american medicated around the clock for three weeks. I am glad we have the states here today to hear about what theyre seeing on the front lines, what successful approaches they have found that deserve to be replicated and what challenges they still face. I would also like to hear from our witnesses about how the federal government can help epidemic. In the house passed trumpcare cbo determined 23 million americans would lose coverage, the majority covered through medicaid, with 834 million billion dollars in cuts to the program. The senates version cuts medicaid by a full 35 over the next two decades. The cuts could not come at a worse time from the perspective of the opioids crisis, for states and people who depend on the coverage medicaid provides. There is no substitute for coverage for our states or for people that need the care. As the Senate Continues to make cosmetic changes to its bill with one goal in mind, passing any bill out of the senate, lets be clear. No one time amount of funds, whatever the amount may be, whether replace the sernlt of comprehensive coverage. No cosmetic changes can offset the damage caused by repealing the acc a and putting hundreds of billions of dollars from the program. We must stay vigilant in the priet and remain open to any solution that shows promise. I believe there is no way the crisis can be solved with onetime infusions of resources and it will only get worse if medicaid dollars are removed from the fight. We must invest in the Health Care System and the critical programs for the long term and medicaid should be strengthened, not decimated. I fear that if the republicans are successful in passing trumpcare well end up going in the opposite direction when it comes to fighting the drug problem thats devastating our communities. I thank you and i yield back. I dont think anybody on my side wants the time so ill yield back, mr. Chairman. Thank you for your comments. I ask unanimous consent that the members written Opening Statements be introduced in the record. Without objection the documents will be entered. Two former members of the committee are present. Thank you for being here. I believe you said mr. Stupak was around yesterday too. This is an important issue to those who are alumna of the committee as well. Ill introduce the rest of the panel. Boyd rutherford, Lieutenant Governor of maryland. Welcome. As mentioned before, secretary moran. Secretary tilley, and director honorable rebecca boss. Department of Behavioral Health care, Development Disabilities and hospitals state of rhode island. We look forward to our continued discussion to the Opioid Crisis facing our nation. As i mentioned, i want you to be brutally candid about what the problems are, what we need to do and what are the gaps. The committee is holding an investigative hearing and when doing so has had the practice of taking testimony under oath. Do any of you have objection to testifying under oath . Seeing no objections, under the rules of the house and the committee you are entitled to be advised by counsel. Do any of you so desire . Seeing none, please rise, raise your right hand and ill swear you in. [ oath administrated ] seeing all have answered affirmative you are under oath and subject to the penalties in the United States code. Well ask you each to give a fiveminute summary of your statement. Please Pay Attention to the timing here. Beginning with you, governor rutherford, you may begin. Make sure your microphone is turned on. Thank you, chairman. Mayor murphy, Ranking Member degette, honorable members of the subcommittee. Thank you for the opportunity to join you today to discuss the state of maryland response to heroin and Opioid Crisis. Tackling the emergency requires a combined response from local federal and State Government. Maryland looks forward to continue to Work Together with our federal partners to address the challenge. Governor hogan and i first became aware of the level of this challenge while traveling throughout the state during our 2014 gubernatorial 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 opioids. In 2016, 2,089 marylanders died from alcohol or drug related intoxication. 66 increase over the deaths in 2015. 89 of the deaths were related to opioids. Maryland has seen an increase in prescription opioid 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 opioids 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 6 million souls. Further, the challenge we face has evolved. As was mentioned, cheap, powerful and deadly synthetic opiates burst onto the market, bringing a much higher overdose rate. Deaths related to fentanyl have increased from 29 in 2012 to over 1100 in 2016. In maryland. Accordingly, as one of the governors first acts in 2015 was to establish the heroin and Opioid Emergency Task force, which he asked me to chair. After nearly a year of stakeholder meetings and expert testimony and research, the task force adopted 33 recommendations. Those recommendations ranged from prevention, access to treatment, alternative to incarceration, enhanced Law Enforcement and more. Our statewide strategy. Building on those recommendations of the task force, the maryland General Assembly passed several comprehensive pieces of legislation. In 2016 we reformed our Prescription Drug Monitoring Program to require mandatory registration for all cds providers. We passed the justice reinvestment act to reform our criminal Justice System to shift from incarceration to treatment for offenders struggling with addiction. 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 past legislative session maryland passed the heroin and opioid prevention act and the treatment act of 2017 which contains provisions to improve patient education, increase Treatment Services and provide greater access to naloxone. The governor signed the Start Talking maryland act to continue to build school and Community Based education efforts to bring awareness to this crisis. Educating young people on the dangers of opioids at 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 opioid Operational Command center, the Center Brings opioid 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 Operational tacticallevel concepts for addressing the heroin and Opioid Crisis. Shortly after its creation the governor declared a state of emergency in response to this crisis. By executive order he dedicated delegated Emergency Powers to state and local Emergency Management officials to enable them to fasttrack coordination with state and local agencies. Thanks to your leadership and commitment, funding of the 21st century cure act has greatly aided in this effort. These dollars will be used in expanding educational efforts in the schools, Building Public awareness, improving treatment, expanding Peer Recovery Specialist Program and increasing the availability of naloxone. The one thing that i would add that we would like to see from the federal government is to consider utilizing fema as an outline of the as outlined in the National Emergency framework to centralize and coordinate the federal response to this crisis. The National Response framework is a guide to how the nation responds to all types of disasters and emergencies. And it would allow federal agencies to work for seamlessly with each other and with the agencies at the state level. We cant afford to have delays due to agency silos and bureaucracies. I appreciate this opportunity to talk to you and await any questions you may have. Thank you. Thank you, governor. Secretary moran, you are recognized for five minutes. Mr. Chairman, members of the committee, its 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 opioid and heroin addiction epidemic. The epidemic does not discriminate. It is an equal opportunity killer. In virginia in 2016 1133 individuals died from opioid overdose. The sad truth is that virginia actually ranks 18th among the 50 states in opioid deaths. Sadder still, 17 states are doing worse than we are and in all likelihood the other 32 states will face similar devastation if we dont take effective action now. As secretary of Public Safety and Homeland Security i am proud of virginias sworn Law Enforcement officers who work 24 7, 365, 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 opioid 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 incarceration of those addicted will no more cure this disease that it would cure cancer or diabetes. There are a number of causes, multiple causes, of this dramatic rise in the deadly epidemic. Overprescribing. Fairly to safely dispose. Easy access and affordability. Over the last several years we have seen a sharp rise in illegally manufactured synthetic opioids such as fentanyl and car fentanyl. They contribute significantly to the numbers of death. From 2015 to 2016, the number of fatal overdoses involving fentanyl accounted for 618 of the 1133 deaths in the commonwealth. Virginias response. The response began immediately upon governor mcauliffe taking office in 2014. He convened a Broad Coalition of Health Care Providers, criminal justice representatives and Community Stakeholders to participate in the Prescription Drug and heroin use task force. Secretary of health and Human Resources cochaired the committee with myself. The task force developed over 50 recommendations. I am proud to say we have implemented the vast majority of those recommendations. The full list of which can be found in my submitted written testimony. Of course, the work continues in virginia. Our executive Leadership Team works across State Government and with regional and local agencies and individuals to effectively align goals, share best practices and work to overcome barriers to success. The Leadership Team organized a statewide approach to Opioid 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 grass roots organizations, task forces and other collaborations in designated areas by cover parts of northern virginia. Appalachia and northern roads. Let me highlight some of our accomplishments. We expanded the deployment of naloxone. People are being trained in using the overdose reversal agent through the department of Behavioral Health and Developmental Services revive program. Commissioner of the department of health issued a Standing Order for pharmacies to dispense naloxone. The department of criminal Justice Services issued grants to pay for increased naloxone to be used by Law Enforcement. In fact the city of Virginia Beach has used naloxone 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 from my 11 Public Safety agencies that we would rely on datadriven and is decision making. If were going to wrap our arms around this epidemic and reverse the devastating trend in deaths and related crime, 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 address. Our Prescription Drug Monitoring Program is 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 and localities and developing metrics, sharing data and analyzing results. Support development of consistent national metrics. Incentivize providers and mandate Data Collection as a requisite for federal funding. Change how federal agencies do business. Increase support for sa msa and hida. Break down funding silos, reduce demand. Train Law Enforcement to focus on mid and highlevel dealers and help divert those who are addicted into treatment programs. Treatment programs are 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 to pilot, analyze and determine the efficacy of angel programs in police departments, fully Fund Dissemination of naloxone or other drugs. My time is up. There are a lot of requests. You invited the requests, mr. Chairman. I will stop if well get into that as we cover questions too. Thank you. Secretary tilley, you are recognized for five minutes. Mr. Chairman and members. Thank you so much for allowing me to be here. I thank governor matt bevin for the chance as well. He sends his regrets. He has been outspoken on this topic. I will share a quick story. When i first met Governor Bevin it was interviewing for this job. He walked into a room with dreamland under his arm and he said have you read this book . Thankfully i had. And i said i am trying to reread it because it is, i think, the best chronicling of this problem and how it began that i know of. So that, again, illustrates our commitment and our shared understanding of this problem. I want to thank congressman guthrie for the kind introduction. Dreamland is relevant to us because the problems has its origins in kentucky and ohio. Fentanyl is now the driving force behind the overdoses. We have 13,000 e. R. Visits. 13,000 e. R. Visits in a state with 4. 5 Million People. We lose in this country as you have heard the numbers nearly a commercial airline a day. If this were a Communicable Disease we would be wearing hazmat suits to combat it. I think overdoses and the visits only tell half the story. It devastates community. Our state police tells us in the last six years alone we have seen a 6,000 increase in fentanyl in our labs. 6,000 increase. I think all of us know the devastation its 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 right, a form of viral hepatitis, seven times the national average. Right across the river in indiana they had an outbreak of hiv that rivalled that of sub saharan africa. So we passed one of the First Southern states to pass a comprehensive Syringe Exchange program. Now in kentucky we have 30 programs all passed by local option in our state. We know that that increases the treatment capacity by five times. When someone just walks over the doorstep of one of the programs and it battles back the diseases like hep c and hiv. Sadly kentucky, as the cdc reports, has 54 of 220 counties most susceptible to a rapid outbreak of hiv. What has our response been in kentucky to battle this . Taking a bold step as a Southern State on a Syringe Exchange program. Passing comprehensive legislation on consecutive years on prescription pills and pill mills. Second state to battle back synthetics. Dealing with heroin directly and fentanyl. Being the first state in the country to mandate usage of what we call casper. Prescription Drug Monitoring Program. Weve become the first state in the country now to require physicians, when prescribing, to limit for a cute pain to limit acute pain to limit prescriptions to three days. Some have done seven, some ten. We limit it to three days. Our governor spent some capital on that. We doubled down on rocket dockets and sentencing programs and help for those who are addicted through various forms of treatment. Neonatal abstinence syndrome. We have increased funding many times to combat that and help the suffering of those addicted there. We put it in our jails and prisons. I mentioned rocket dockets with prosecutors to 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 1100 since 2004. We validate the treatment every year and our return on investment now is almost 5. Some of the Innovative Programs, most recently chronicled in the New York Times is the way we use next atroen in our jails. We give an injection prior to release and upon release and try to link the returning individual to the services in the community to see if theyre medicaid eligible, to see what resources they have to continue that particular treatment. I know a question will be do we link them to counseling . Its not mandated but we do our best to do that. In kentucky validated and anecdotally we are seeing tremendous results from using m. A. T. And counseling together. But counseling in the form of cognitive behavioral therapy. Like moral recognition therapy. Its being used in our jails and prisons and its yielding tremendous results. We intend to emulate whats going on in rhode island. Were doing peer recovery and bridge clinic soon. We will do innovative awareness, use a hotline. Were educating our medical and dental schools. Overall as i close out and conclude at the end of my time ill tell you that i think we have the most comprehensive effort i have seen in my 25 years in criminal justice with the kentucky opioid and response effort, core. Director boss youre recognized for five minutes. Thank you, chairman murphy. Is it on . Thank you, chairman murphy, Ranking Member degette. I oversee the states treatment, preconvention and recovery systems. I am a long member of the drug abuse directors and currently serve on the board. Thank you for the invitation to appear to share Rhode Islands work in combatting the Opioid Crisis, an effort thats been proposed as a national model. Our strategies to address this epidemic are clearly outlined on our website, preventoverdoser. Org. Ill be sharing slides from this website during this testimony. Our goal is to make these efforts open to the public with complete transparency on outcomes and available for replication throughout the country. First and foremost, i would like to thank congress for the action taken last year, passing the 21st century cures act with 1 billion to help support prevention, treatment and recovery. We fully appreciate the significance of this action. Addiction and overdose are climbing 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 newly elected governor recognized the need for the state to develop a comprehensive strategy to prevent, address, evaluate and successfully intervene to reverse the overdose trends. She signed an executive order establishing the governors Overdose Prevention and Intervention Task force comprised of stakeholders and experts from a broad array of sectors. The resulting plan has one overarching goal, reduce Overdose Deaths by one third in three years. The governors plan focuses on four strategies which ill briefly outline and focus on two specific areas. Others are described fully in my written testimony. The first is prevention. We take aggressive measures to ensure appropriate prescribing of opioids, promote safe disposal of medication and encourage the use of alternative Pain Management services. Naloxone, rescue. As a standard of care for first response. It saves lives by reversing overdose. 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 this, rhode island developed centers of excellence which provide rapid access to treatment including induction on all fda approved medications for opioid abuse disorder. Programs provide thorough assessments and intensive Treatment Services with wraparound supports. The program is designed to provide opportunity for stabilization with referrals to Community Physicians for continued treatment, offering continued clinical and recovery supports through the centers of excellence. The program is supported through private insurance and medicaid. In addition, rhode island released the nations first statewide standards for treating overdose and opioid use in hospitals and emergency settings. And the Rhode Island Department of corrections is providing medication assisted treatment to the population most at risk for overdose. We have worked diligently to increase data waivered physicians in rhode island, for example, Brown University medical school is the first in the nation to incorporate data waiver training into its curriculum. Finally, recovery. We are looking to expand recovery supports. Recovery is possible. To support successful recovery for more Rhode Islanders we are expanding Peer Recovery Services particularly at moments when people are most at risk. The anchor ed program was started in june of 2014 and is now a statewide 24 7 service. It connects survivors with peer coaches in hospital and emergency environments. They provide continued services and follow up and connection. To date over 1600 individuals have met with recovery coaches and as a result over 82 have accepted a referral to treatment. The anchor more programs exists as a suicide peer outreach effort to hot spots, not waiting for someone to overdose to be seen. We are now facing a fentanyl crisis. As you can see in this slide, with 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 expanding our efforts to include more focus on primary prevention, engaging families and youth in these efforts. Harm reduction strategies and access to treatment. I cannot state strongly enough that Rhode Islands strategies rely on sustainable funding through medicaid with parity and treatment with essential benefit. Any action on a federal level that threatens that plan weakens it substantially. I would advocate for continued support of the Substance Abuse preconvention treatment block grant as the foundation of comprehensive state systems. And finally i encourage continued consideration of targeted funds to address these issues. Thank you for the opportunity to testify. I look forward to answering questions. Thank you all. I recognize myself for five minutes starting with governor rutherford. Regarding the 42 cfr part 2, a couple effects. One, as was pointed out by secretary moran and others. If someone is using a pdmp. D based on methadone or some other synthetic opioid. Secondly if someone shows up in an emergency room, shows up there with an injury and when asked if that person has allergies or drugs, says please dont give me any opioids, they do it anyway. We can live if a person has an allergy, but i can consider this an opioid sensitivity should be placed in there as well. So the person may leave the hospital with a vial of opiates, and saying well when i used to be addicted, i would take 20, so ill take 20, and overdose and die, or relapse then may be on other medications. What do you think we recommend we do with the 42 cfr. Secretary moran was correct in terms of that particular challenge. A person who may be receiving methadone treatment, they go in for a knee replacement. Theres nothing to tell that doctor that this person is also receiving methadone when they prescribe oxycodone it doesnt show newspaper our prescription Monitoring Systems as well. It needs to be addressed. Theres areas with regard to hipaa, that go to other areas of Behavioral Health. When we talk about Mental Health and the challenges, for adult family members. Once the person goes from 17 to 18, you lose a lot of control. So if you can make some type of exception or clarification. Theres misunderstanding amongst some of the doctors as well. In the medical record to deal with 42 cfr. We have another quick question, noting that most people with addiction have a cooccurring mental disorder. Do you have a number have a sufficient number of psychiatri psychiatrists. Half of the counties in america have no psychiatrists, no psychologists, no licensed drug treatment counsellor, if you know if you dont know, tell me. But if you do know, do you have enough to meet the need . There are counties in our state that have a substantial shortage of those types of professionals including drug counsellors. That is a challenge we have. Yes or no, real quick. It changes in south carolina. There is an insufficient shortage. Thank you. Secretary tilley . Urban areas, yes. Rural areas, no. We have a Community Network were proud of. But in the rural areas, they still are finding quality professionals. I would say yes there is a psychiatrist shortage. Shortage for all of the psychic. With regard to that in pennsylvania, data that says that people who are on an matt be mat, the question is, are they getting treatment. And in your state too, people reviewing that, and ive heard the treatment is no more than a nurse in the waiting room saying, how are you doing today . They call that Group Therapy if the doctor says, is everything all right . 40 were not drug tisted in the year they received it. 30 have between 2 and 5 different prescribers. Some didnt see a physician in prior days. Can you describe if you have the data in rhode island to find out if theyre getting real counseling. In rhode island open yoit treatment is needed to provide counseling are they really doing . Excuse me . Do you know if they are really doing it . Yes. We do we reviews of our licenses. The opioid treatment programs review records and make sure they are abiding by the counseling standards i appreciate reviewing records but i will push on this. I have heard from people who go to centers who tell me their list in records of counseling and have no more than someone saying how are you doing . Im just curious. Mr. Chairman without actually sitting in on sessions and timing sessions and making sure they are happening we have to rely on the validity of the record with which we review. So unless people are willing to today commit fraud and document something that didnt happen, i have to say that i believe what i read in the record to be true. Okay. This committee has dealt with so much fraud. Youre right, counseling has to be an important part of that. So if they are not giving counseling, i think they should. There is no evidence of fraud in rhode island. My daughter went to Brown University and i love rhode island. So i want to talk to you a little bit, director boss, about this issue. Of states being able to pay for treatment. And this is, the full range of treatment. And 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 . That would be fair statement prior to 2014. But weve seen significant increases in the number of people being able to access treatment post Medicaid Expansion. So the Medicaid Expansion has helped and we helped 21st century too but we know that theres a lot more work that needs to be done. And in fact, in your statement you said, medicaid has laid the foundation for treatment coverage. Is that correct . That is correct. And so i wonder if you can just tell me quite briefly how medicaid funds are helping rhode island fight this epidemic. So medicaid funds in rhode island cover medicaid assisted treatment. All approved medications. And injectable and support opt health homes and thats a comprehensive program to integrate health care within individuals receiving methadone treatment as well as all other forms of treatment. There is full treatment from inpatient treatment to outpatient treatment to residential treatment to the use of medication assisted treatment as well. Thank you. 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 states . 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 77,000 in rhode island covered by the Medicaid Expansion . Correct. Secretary tilley, recent ap announcements show that Medicaid Expansion accounted for more than 60 of 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 kentucky residents due to medicaids expansion. So i guess i want to ask you, it looks to me like medicaid has been particularly helpful in kentuckys fight against the Opioid Crisis. Would you agree with that . Let me say this. I will tell you unequivocally of our governors commitment and again examples by the 1115 waiver and our effort at this very moment to expand our Treatment Options there that let me ask you my question. Would you agree that medicaid has been particularly helpful in kentuckys fight against the Opioid Crisis . I would agree thank you im sorry. I would agree that through a number of sources of funding we would increase treatment dating back to 2004, 1100 . Let me ask you this. Let me ask you this. If the Medicaid Expansion went away, would that impair your efforts to fund this in kentucky . Maam, i have five major youre not going to answer my question. So im going to ask secretary moran a question. Governor mccallive tried to expand medicaid twice in virginia. But the Republicanled Legislature rejected twice that the attempts. I know virginia is making the most out of 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 . Simple answer is yes. An emphatic yes. Why is that . More people would have access to treatment. I will give credit to our department of health, using very innovative arts program Addiction Recovery and Treatment Services to carve out a medicaid waiver to address individual addiction needs. But with Medicaid Expansion, 400,000 virginians would be covered and governor mcauliffe attempted to do that at every opportunity. Thank you very much, mr. Chairman. I yield back. I recognize mr. Collins for five minutes. Thank you, mr. Chairman. I think maybe i will start this question with secretary moran. All of us agree here that opioid addiction is a disease. It is an addiction. And were all experienced the tragic deaths of many of our Young Children when it comes to overdose and it was just pointed out we also have the fentanyl issue. So my question really is surrounding narcan, as we know it. And can you help the committee understand some key issues on availability because we do hear there may be shortages. Cost, who is picking up the tab for this. Is it patients . The state . The 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. Are they oding on opioids or fentanyl . Thank you. We are expanding the coverage on narcan in every community. There is some resistance. Particularly from a rural jurisdiction meefrly because they are not the first to respond under a large jurisdiction. It is usually emergency medical services. Ems does carry it. The majority of our jurisdictions in Law Enforcement communities and certainly in urban areas now carry it. As i mentioned, Virginia Beach has a tremendous success rate. They are saving in upwards after life week with the use. Thats ems. We appreciate the grants, so we can provide without any cost of the local jurisdiction. Now in terms of lay people, our department of health commissionerish you eed an order so someone can go into the pharmacy and receive a prescription for nalaxon. 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 now there are consequences of that in terms of needs for treatment but the narcan itself is truly a life saver and more people that carry it, within the department of Forensic Science, with addition 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 they are analyzing evidence in the criminal case. So again as many people can have it, it is a very significant piece in this entire puzzle. We have heard that the fda is considering making narcan overthecounter. Now you just mentioned anyone could go in and fill a prescription but that i guess with 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 concerns with an issue. Can you expand on that a little bit . Or what you may now know of the fda making over counter and also how does someone get this prescription, which obviously theyve got to then fill . Congressman, thats what Standing Order did is that you do not need a prescription now. You can only obtain the narcan without a doctors written prescription. Thats the Standing Order from our commissioner of health. Thats statewide. Correct. Thats what the fda is looking ton expand nationwide and whats your experience with that . Are you attracting how many people are these perhaps family members who know that theyve got someone thats got this addiction and they are being anticipatory to use that word . That is certainly the intent. If you have a loved one who is who is addicted, you would take the proactive step of obtaining the narcan in case of an overdose. We have been trained, myself, first lady of virginia, governor of virginia, we received revived training, it is very simple. It truly is. And we would encourage people to have access to narcan in case of an overdose. Thats a great example. Im just thrilled you shared it with us. Maybe thats a message if the fda doesnt move that other states obviously could take those same steps because if we can save lives, then you should be able to go home and say job well done. Thank you for saying that. I yield back. Thank you, mr. Claire. Thank you chair witnesses for their Public Service and for the testimony that they share today. Before i get to my questions, i would be remiss if i didnt echo my colleagues remarks on the devastating impact that trump care in consideration 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 commune its cross my district who depend on coverage from the Affordable Care act and Medicaid Expansion to help them recover from this opioid addiction. Medicaid by far is the single largest payer for Behavioral Health services under our country. In rhode island, medicaid pays for nearly 50 of Addiction Treatment medication. In kentucky, 44 . Maryland, 39 . Virginia, 13 . The bill considered in the senate would cut 772 billion or 26 frers medicaid over the next decade. Theres no way this highly efficient Safety Net Program has the same type of funding loss and continue to provide services for all this require it. Simply put, passing trumpcare would be the singest biggest step back for Mental Health services in our nations history. That being said, last year i collaborated with my friend on legislation that expanded, prescribing privileges to Nurse Practitioners and physician assistants. I would like to thank i would like to gather your feedback on how this law is being implemented in your states. Director boss, you mentioned in your testimony that rhode island is actively working to provide data 2,000 training to practitioners. Have you seen Significant Interest from Nurse Practitioners or physician assistants communities in becoming wavered practitioners . Congressman tonko, im not sure i have data on how many Nurse Practitioners and nurses assistants have taken data wavered training. I know we are actively working with medical schools to get that interest and to increase the training available but im not sure i would be able to answer that comprehensively. As you areware, there is interest in it . Absolutely. There is interest and active work with the department of health and within my department to provide those trainings to any and all interested parties. And weve seen an interest in data wavered physicians. We will be working with the Nurse Practitioners and schools as well. We track through our overdose website and our regular Performance Management meetings. Number of people receiving the treatment so we are able to look at the increases and through our Prescription Drug Monitoring Program, track the number of wavered physicians actively prescribing. So we are seeing increases in the number of people receiving the treatment through these efforts. I would assume that further expansion of data 2,000 waiver even 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 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 wavered data 2,000 practitioners . Start with the Lieutenant Governor, please. Well, we talked about in certain cases and 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 feedback, there is still in some cases, theres a stigma associated with the Substance Abuse disorder and there is some doctors that just dont want those patients. But the lifting of the cap has helped us with regard to being able to provide services for more individuals. The stigma is still a challenge. Secretary moran, thank you. Secretary moran . I would agree, most of that information would be within our Secretary Health of Human Resources as opposed to me. But we have heard from the practitioner. There is a shortage of personnel to address this issue. Me, but wd from the practitioner. I mean, there is a shortage of personnel to address this issue and you know, in their defense it is an epidemic that has exploded over the last several years and any assistance you can provide for additional funding and flexibility would be much appreciated in the commonwealth and other states. Thank you. Secretary . I would reiterate my colleagues, what they stated with regard to i would also add that we have a phenomenon, we have a number of physicians, i think, nearly 700 who are prescribing, however many of them are not prescribed up to the 100 up to the 285 cap and many of them, we dont know as has been stated earlier, and we do know we require counseling in the correction settings and jails and prisons and we encourage it and we do urine analysis, and we have to look at why some of these physicians are not applying to do more in their communities and we have to struggle with the same challenges with rural versus urban in getting the folks out to those areas largely in appalachia that say challenge for us. Thank you. Director . We are going across the board. We just have a quick response. Thank you. So i agree with all of my colleagues and i would add in our discussions with physicians. They want to do the right thing and they want to make sure people are receiving counseling and lack the office staff and the management to do that, so they need increased supports in the offices to do the kind of evidencebased practice in order to do it appropriately. Thank you, mr. Chair. I like those words, evidencebased practices. You are recognized for five minutes. Thanks to the chairman and the panel for being here. Secretary moran, according to the centers for Disease Control and prevention, the Drug Overdose failed to list a 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, the theme of my remarks is the need for additional data, and 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 and we have good data with respect to what drugs are involved because they are collected. If it is an accidental death, it eventually goes to the office of chief medical examiner, but with respect to the data, it is challenging and, you know, some individuals may not be anxious to reveal the cause of death under some circumstances. Family members may not choose to reveal that type of source. So it is a challenge. Its one were 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, will work in responding to this epidemic. Is there anything that youre attempting to get your arms around that data that is working with you, at least with some families . Well, the prevalence of fentanyl and carfentanil, weve realized that were not alone. Youve seen a dramatic rise in the use of fentanyl. That informs not only our 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 the fentanyl because its typically being manufactured overseas and coming into the commonwealth and the country. So that type of information, i think, is critical to the interdiction of these drugs in addition to the healthcare and response to the individual. So 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 interaction task force to combat addiction and Substance Abuse. Could you tell us more about how the state utilizes data to develop its strategy to address this Opioid Crisis . That is a wonderful question and thank you for asking it. As 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 to look for trends and there is a Multidisciplinary Team that consists of individuals from Ground 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 there were if any and then develop specific interventions as a response that we propose statewide. The others are surveillance response intervention team. We receive weekly reports on 48hour overdose and suspected overdoses within 48 hours and our medical examiner is able to determine whether or not fentanyl is active in those overdoses. As a result, we put out alerts with communities, with overdoses whether fatal or not exceed a specific tag net 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 youre taking. If ti understand it correctly, what are the obstacles preventing hospitals developing testing of fentanyl and how can they obtain more robust data. I think its regarding the drug supply. Our hospitals are able to test for fentanyl as are our drug treatment providers. So we are looking at how much fentanyl is in the drug supply and as we see increases in hospital testing and the testing thats done and the drug treatment providers, we are able to know what kind of fentanyl is out there and not necessarily as quickly as we could if it was a Law Enforcement and if we had more Rapid Response and Law Enforcement in looking at what is in the drug supply. Mr. Cass, youre recognized for five minutes. I would like to thank the witnesses here for your attention to this very serious issue, and i think at the outset its important that we can america just cannot go backward 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 thats ripping coverage away thats been provided under the Affordable Care act, under health care. Gov or the very assault on medicaid and the most serious retrenchment of medicaid in its 50year history, would be just disastrous for our ability to support families and address this crisis. In fact, id 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 it has a federal state partnership and it has a record of innovation 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 spending reductions that would occur as a result of the bill. Medicaid or other forms of comprehensive, accessible and Affordable Health coverage in coordination with Public Health and Law Enforcement entities is the most comprehensive and effective way to address the Opioid Epidemic in this country. Earmarking funding for grants for treating addiction and the absence of behavior and medical Health Coverage is likely to be ineffective in solving the problem. Ill ask unanimous consent that that be admitted for the record, mr. Chairman. Were reviewing. Back to you before youre done. Thank you. Because this is very important. Now this committee, to its credit, spearheaded the 21st Century Cures Initiative that did provide substantial funds to our states, and ive heard from local experts back home in florida held a number of roundtables with Law Enforcement, treatment professionals, anesthesiologists and e. R. Docs and they say the key is longterm coverage to treat this as the chronic disease that it is, and thats why when you rip away coverage and instead say in its place were going to have another fund, an opioid fund where maybe you provide a few dollars to an e. R. , thats not going to provide that 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 well be able to effectively address this crisis if this retrenchment on medicaid and ripping coverage away from millions of americans were to succeed . I believe Rhode Islands efforts to address this crisis would not be able to be sustained if we were not able to continue to offer insurance to a number of Rhode Islanders who 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, often times conditions interrelated to an individuals condition that if they dont have access to Affordable Health care for the rest of the body and were not going to be able to treat the person well enough to sustain any kind of recovery. So how are you able to provide the longterm treatment that is needed for an opioid addiction . Yes, we are. In fact, youve instituteded a program called anchor ed which connects individuals struggling with addiction to recovery koches who help them navigate the treatment process. How successful has this program been to help an individual recover . Of individuals who meet recovery coaches in the emergency department, 82 are receiving referrals to treatment and engage in treatment Recovery Services which is pretty phenomenal, actually. And the actual anchor e. D. Program itself is not supported by medicaid, but the fact that we are not required to use Substance Abuse block grant funds to Fund Treatment itself, it frees up that opportunity to use block Grant Funding to support recovery activitieses that may not be supported by medicaid and other insurance, although the program is so successful that many insurances including thirdparty commercial srnses are paying for the Recovery Coaching Program . Is that a requirement under rhode island law or is that something that you found to be so Cost Effective that theyre participating . It is not a requirement. Can i ask a followup question. Recovery coaches have what kind of credentials . We have a certification process for our recovery coaches that are standardized and involves training and a test and voluntary hours for them to respond. Theyre not degree okay. Not degree. Do you have in Emergency Rooms then people who are themselves licensed treatment providers, not recovery coaches, not peer, but people that this is their licensed field . Do you have them in the e. R. S as a requirement . We do not. Let me ask, does kentucky have them or virginia or maryland . There was a study done out of michigan and i believe also down in yale that when there is a licensed addictions counselor in the e. R. Providing treatment, not referral, providing treatment it increases the person will follow up by 50 . So just saying heres some place you can call, the 82 , do you know if they follow through . Thats my question, i love to hear that from each state, but i next have to go to miss walters. Before you do, is ms. Casters unanimous consent yes, we are. Sorry about that, but i was saying that information is very important. Just give them a card and they may not follow through so 82 may not be valuable to us, but to know theyre actually getting treatment just like you wouldnt send someone home, you broke your arm, you have have to make sure being done. Thank you, mr. Chairman. We can decide that despite societial awareness that the Opioid Crisis continues to devastate our communities. In my home of orange county, california, there were 261 Overdose Deaths in 2015 that accounts for a 50 increase in Overdose Deaths since 2006. A majority of those deaths are attributed to heroin, prescription opioids or a combination of the two. One of the challenges in responding to the crisis is the stigmatizing of the victims which limits their responsiveness to treatment outreach. There has been discussion today of the importance of drug courts and these courts can help overcome the stigma and treat the underlying addiction as opposed to focusing on the resulting criminal behavior. I became aware of a Drug Treatment Court in buffalo, new york, that is focused solely on own yoid interventions and 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 the jurisdictions across the state. They essentially are specific to opioid addiction and theres been good results from most of those courts. The one challenge that we have is that depending on how long, some of the counties and the period that youre involved with the drug court is 18 months to two years and if youre someone who commits a crime at a local jail and youre not ready for treatment, that person will say i would rather do the six to eight months than to have to commit to two years even though im outside the fence, id rather sit in jail. Were big proponents of drug court. Unfortunately, virginias 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 courts, theres veterans dockets. The drug courts however provide some coercion. The individual needs to want to address their addiction and then the court can provide that coercive element, and we have a tremendous success rate. We should expand. The one issue i could ask congress to help us with, however, is the medically assisted treatment. Some of the uj jjudges in the d courts are reluctant and as of now it is required and 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 court, veterans courts and drug courts that do expand. We did lose our juvenile drug court due to a funding issue and were trying to rebuild that program now. Some of the same issues exist, often times that chooses a shorter prison sentence and that is again, a very strenuous program and were addressing that, as well. Oftentimes, too, we find theyre cherry picking the best instead of focusing on the highrisk folks. We have a program called s. M. A. R. T. With probationers that does specialize in opioid, at least one part of it does and thats being done at seven pilot sites and its modeled after the hope program that many of you know about now, and i would also add that what were finding, as well is again, this combination of specializing and medically assisted treatment and the cognitive behavior that were trying to have the model, and we have the passage of recent legislation in kentucky through the department of corrections, a modified drug court through an Entry Program that well be rolling out soon that will specialize in the opioid addictions. I would agree with my colleagues, as well, especially Lieutenant Governor rutherford and the fact that the drug courts have been addressing use disorder for a long time. In long island, the drug court has been accepting the medically assisted treatment long before it was required to do so. Probably the Biggest Issue that we have with drug court is that its not able to reach enough people and 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 and getting people connected to treatment prior to arrest as our primary focus. Ms. Walter, may i add an interesting thought here . We had a conference in kentucky that offered a legal opinion from one of the law firms there as secretary moran pointed out, if a judge denies someone medically assisted treatment which affects their liberty interest, that might invoke the americans with disabilities act and i think its a bit of a Chilling Effect on the judiciary in ken tuck they might be more accepting of treatment. Thank you. I yield back my time. You are recognized for five minutes. Thank you all for being here on such a very important topic, and as an emergency medicine doctor i cant emphasize enough on the effect it has on individuals, families and communities. Ive treated patients that have been dumped blue and not breathing in front of our doors and we go into the Emergency Care mode and provide the cocktails for someone that you dont know anything about and theyre there unconscious right about to die and thankfully weve saved many of them because we have the medication. One of the successful treatments is they get medication, followup and counseling and one of the factors for success is that they have Health Insurance that has guaranteed coverage for those medications and guaranteed coverage for Mental Health and thats why it is so devastating for me and for my patientses that were on the verge of repealing the Medicaid Expansion and repealing for some states who dont have the Mental Health and Prescription Drug guarantee coverage that those people who need coverage and want coverage wont be able to have it, and it can be a situation of life and death as we know, and the report on addiction released last year, the u. S. Surgeon general found that medicare expansion meant that millions of americans with Substance Abuse disorders now have access to Health Coverage and Substance Abuse treatment. It is now a covered essential Health Benefit which is at risk of going away. Individuals and the Small Group Market participants also gain access to those lifesaving services. But its not just about coverage, okay . You can have coverage in some part was my district, but if you dont have providers and you dont have psychiatrists and you dont have psychologists and Health Care Centers and counselling centers and programs in those communities that are underserved or in rural areas then coverage does you no good, so you also need to think about making sure that we have more psychiatrists and more psychologists and more Mental Health providers in those areas especially for the youth, and young adults. According to data from hhs, the number of children in foster care increased 8 between 2012 and 2015. Experts suggest this rise is due in large part to increased opioid abuse. Moreover, the Substance Abuse, and samhsa estimate that over 8 million and the wall street journal and the Washington Post and New York Times have reported on children who have impacted the impact of the opioid abuse and are taken care of by grandparents as a result. Can you please describe how children in your state have been impacted by the Opioid Crisis and are there unique challenges facing children with these epidemics . I think its an excellent question. With a focus corrections, sadly, i can report that in kentucky as it exists now where children are living with an incarcerated parent than anywhere else in the country have had or have an incarcerated parent. Our prison population driven by the epidemic, that would be the first thing that comes to mind. I also believe that it puts an incredible strain on the health and Family Services and a Record Number of children in foster care and thats an issue. It puts a tremendous strain on health centers, as well. The absence of proper funding is a huge issue and it exists all over and it is acute in kentucky, as well. We rely on 14 the Mental Health services to provide those services to children. We have seen an increase with the focus in recent years on addiction issues and increase and proper treatment for children and so i think thats been critical. Let me just warn you that by turning medicaid into a percapita grant, the funding for new, addicted folks is going to is, i should say the need for fundings going to have to increase. States will have to make decisions. Change of Eligibility Criteria and two, their reimbursement rates and three, the benefits that they would cover and oftentimes the Mental Health and these Community Center treatments are the first on the chopping block. It will get worse if this bill is going to pass. Director boss, samhsa stated that families have a central role to play in the 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 that 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 is engaged family members in the development over the task force and plan and were creating a family and a parent task force as wrel as engaging youth to help us shape the efforts. Maybe finding positive results on those . Those efforts are just starting so i will be able to report back, hopefully. Thank you. I am very hopeful that we can Work Together to help the situation get better. I appreciate that, because there are things that we need to be working on. He has a chance to respond to what youre saying about Mental Health Substance Abuse, is that kentuckys intent . That was not the intent. I want him to respond. No. Im just saying that historically Mental Health is one of the most underfunded i understand. You made a claim and i would like him to respond. I would say the absence of Mental Health funding is not a new phenomenon. I agree with that. To be associated with the general counsel, and i know that since the late 1990s we havent had an increase in the reimbursement rates and that is an issue that has existeded for some time and i dont think thats a recent phenomenon. Thats all i would add. Thats why i want to amplify what youre saying and when Mental Health doesnt get funding it increases cost for Overall Health care. Mr. Carter, you are recognized for five minutes. Thank you, mr. Chairman. I want to thank all of you for being here on such an important subject. About cuts and medicaid, et cetera. We all understand it is established this is an epidemic in this country. As a practicing pharmacist for over 30 years, i have seen first hand probably more than anyone 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, democrat or independent . Its someone who is struggling. Thats all there is to it. This is a nonpartisan problem, and i just get frustrated by that. Governor rutherford, you said something earlier that im a little bit confused about. You are talking about the drug Prescription Program in the state of maryland. Did you say methadone was not on it . No. What i was saying is if youre monitoring, and if you go to the Prescription Drug Monitoring Program or the database you will not see that a person has been prescribed methadone treatment. Why is that . The Privacy Association with drug treatment and so this was in place prior to our developing these Prescription Drug Monitoring Programs and they are different barriers to getting information, be it Mental Health information or drug treatment and in some cases health care. Is that something we can help you with legislatively here . I think thats what we talked about that that would be very helpful because a practitioner would not know that someone that they are prescribing an opioid already has a problem associated with opioids. Okay. When i was in the state senate in georgia i sponsored legislation that created our Prescription Drug Monitoring Program, and i can tell you, it has been improved since i left. 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. We are not in real time yet, but were getting there and making very Good Progress there. I want to know in the Prescription Drug Monitoring Programs within your states and secretary tilly, ill tell you, i worked closely with the kentucky board of pharmacy and the kentucky pharmacists association, very strong, very strong programs there, and i compliment you on that, but your experience in the Prescription Drug Monitoring Program, are you sharing information across state lines . We are. We have seven border states that are unique in that regard. And the only state which we dont is missouri. And missouri struggled. They were the last one to add it on, the pdmp. We are working on that and i would be happy to supplement the record to confirm that answer for you, but i do believe we are sharing with six of the seven states that border us. Secretary moran, what about virginia, what are you doing . This is abarea where congress could investigate. We have 21 states in our neighbor to the south and north carolina, we do not share information so we would request some help, and our neighbors are not in north carolina. In the state of georgia, we are sharing with south carolina, alabama, north dakota and someone else, way out i will tell you in over my 30 years of pharmacy, i never filled a prescription for north dakota, i know you would find that hard to believe. If would be more useful if i could have seen it from florida and savannah, where we are only two hour 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 tilly, about a program that i thought was pretty interesting that was the result of 21stcentury cures and that was the peer Recovery Specialists and emergency in kentucky. Can you elaborate on that. The expert is sitting to my left. Right. We had a chance and i applaud the work in rhode island. We had sort of a model that didnt really meet the goals that we wanted and it was not up to par from previous legislation. We looked at what rhode island was doing and we had tried the same thing they did, and we didnt do it as well and were on the path to doing it and were fairly ambitious to doing it more than once and the peer Recovery Specialists in the e. R. S and doing the bridge clinics to keep people there in treatment until we can get them to outpatient or another bed outside that hospital. And so i think what theyre doing in rhode island is certainly a model for the country and thats where were emulating you directly. I apologize i didnt get to you. I just want to ask one thing from a pharmacists prescription. One thing we didnt allow states on how much can be filled and whether pharmacists 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 we do practical, rationale things like limits. I mean, ive got so many prescriptions from a dentist for a 30day supply of oxycontin. They take one or two and the rest are in the medicine cabinet. That is not smart. If we can have a partial refill and if states can do that as a result of cara, thats something that we need to look at implementing, as well. Thank you all. My time is up and i yield back. When you refer to partial refilling, you mean allowing the pharmacist to only give a partial fill at the onset and the person can come back and get the rest . Not the physician prescribing, but that option . That is one of the options that they would allow us to do. I would take it further and my office has been in talks with dea about allowing maybe a refill on a c2 for a threeday supply because a lot of physicians are concerned that the patients going to run out over the weekend and theyre going to be bothered or theyre not going to be available and theyre going to go without and thats a real concern, and i understand that, but at the same time, again, if well just be smart. Allowing them to call in one refill over the phone as long as its limited to a shortday supply. Thank you. You are recognized if are five minutes. Thank you, mr. Chairman. Director boss, i wanted to ask you the questions, and 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 and making a lot of changes to the program so what role has medicaid played for medicareassisted treatment in your state . Medicaid assisted treatment is covered for both the disable and the the expansion population and all medicaid coverage individuals are able to receive all three forms of fdaapproved medications for opioid use disorders and the director of medicaid is a member of our Opioid Task Force and has been active in working with the managed Care Organizations that manage our medicaid product to do things like remove prior authorization for assisted treatment and it is fully funded through the Medicaid Program. My colleagues on the other side of the aisle often has the Medicaid Program as inflexible for states and we hear that a lot and that its inflexible. To the country, i think medicaid is provided for a great deal of innovation in how states have responded to the Opioid Crisis. Can you please tell us about the Home Health Program and the flexibility to develop its own personcentered care opioid treatment program. There are two innovations and the otp health home would be one of them where we work with the Medicaid Office for a period of 18 months to develop the comprehensive Care Management function to provide for their clients in addressing physical Health Issues as well as their addiction issues and the process with medicaid was thorough, but it was one that allowed us to use a monthly rate to support the work that improved the health care of opioid use disorder, and we know that people who have opioid use disorders often have comorbid conditions and dont necessarily have the greatest access to care and the community and the health homes allow those programs which have the greatest access to individuals to provide nursing support and overseen by physicians and they have Case Management that help them get to the needed appointments and dental appointments and medicaid has been supporting those efforts with the understanding that improving those outcomes will improve outcomes overall and reduce cost. The centers of excellence are also a Medicaid Innovation where we allow people to be seen very quickly and its the issue. You need to have that access to treatment which was noted. A person seen in the emergency room needs to be able to follow through and get access to treatment in order for anything to be effective. The centers of excellence exists as a Medicaid Innovation, and all fdaapproved medications again within 72 hours and have intensive Services Provided in the six months of treatment supported by a medicaid rate with as much treatment and Case Management and recovery supports as the 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 a medicaidsupported innovation. Obviously, my concern is in states most heavily impacted by the Opioid Epidemic if you have cuts to medicaid that that may lead to cuts in Addiction Treatment and exacerbate the process. So i have a minute left, but 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 that if states decided because of the cuts in the Senate Trump Care bill that those kinds of cuts to Addiction Treatment would have a drastic impact on our ability to fight this epidemic . Our recovery our overdose strategy engages four different components and three of the four would be affected if medicaid were not available to support the access to the zone again, as supported by medicaid. Medicate covers naloxone and the centers of excellence as well as the treatment components have that, as well and the ability for recovery coaches to be funded, if not for the treatment being covered by medicaid our Substance Abuse block grant dollars would have to be redirected from those recovery, forts to support individual in treatment. Thank you so much. Thank you, mr. Chairman. Ms. Brooks is ridiculoused for five minutes. Director boss, i want to clarify something thated for fi minutes. Director boss, i want to clarify something thcd for five minutes. Director boss, i want to clarify something thd for five minutes. Director boss, i want to clarify something thgd for five minutes. Director boss, i want to clarify something thnd for five minutes. Director boss, i want to clarify something thid for five minutes. Director boss, i want to clarify something thzd for five minutes. Director boss, i want to clarify something thed for colleague asked you previous. You talked about fentanyl with Law Enforcement with respect to Law Enforcement data. In your written testimony youve talked about Hospital Systems are testing for fentanyl, but we do not yet know the frequency of testing or how many tests are returning positive for fentanyl, and i want to clarify so the gap in collection on data for fentanyl exists in Law Enforcement and hospitals, as well, is that correct . The testing for fentanyl in the hospitals is fairly new so were not sure how complete the data is. They do have the ability and whether or not the hospitals are testing or not, im not exactly sure and its for the most part an issue of timeliness. To be able to respond effectively, we need to have access to timely data and making sure that testing occurs and they we are able to get it quickly and enough time to respond with an increase in fentanyl. I guess i would ask the 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. Governor . I cant speak directly for the hospitals, and i know through our medical examiners office, through our emergency First Responders, that they get information with regard to fentanyl usage, a little more than 60 of our fatalities and overdose fatalities on opiates are related to fentanyl. Its a mixture of cocaine and heroin and were getting most of the information from the Law Enforcement and emergency responders. I want to talk just more specifically about the criminal Justice System and would like to ask you, secretary tilly, the core program that you mentioned, that is specific to the criminal Justice System in kentucky, isnt it . Actually, it brings in all stakeholders and even education and the health and Family Services and our court system, certainly and many and all elements of the criminal Justice System and the element is present on that particular effort. I would like to find out from you and briefly your states efforts and obviously when a person is incarcerated which many family members says that saves their lives and its sad and we want them to be diverted and we want to focus high level and u. S. Attorneys and we want to focus the highlevel dealers and those exposing to people with a dicks, however, at times we have a captive audience of participants in treatment and can you talk a bit more about medicationassisted treatment in your facilities and then counseling. Is there drug testing that is part of your incarcerated population, juveniles and adults . Well start with adults. Again, counseling is required with any medically assisted treatment we do. Again, i described earlier in my testimony, i think a pretty Innovative Program where we assess through a risk of Needs Assessment those who would need an injection of maltrexone or vivitrol. They also get a release excuse me, upon release get another injection and then they are matched with a counselor and appear recovery coach to try to find the necessary resources to continue that treatment and 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 thankfully have a record low in terms of the juvenile detection at the moment and that doesnt seem to be near the issue in the facilities and we do offer the treatment in the facilities and just not medically assisted at this time and the same way you would see it in the corrections setting. One thing thats very unique about kentucky and one thing that was not reflected in the New York Times article is that the state inmate population in county jails. We have 83 fullservice county jails and that presents some judges and we are incentivizing the medically assisted treatment, which is not part of the since natty and Northern Kentucky area, and i would add the piece of the incarceration and wield use elements like the involuntary commitment and like caseys law in kentucky to bypass it for those individuals who stand out to their families as someone who needs a forceful hand and maybe a judges contempt power. Well be submitting questions for the record for each of the states because im interested in knowing more. My time is up, on medication medically assisted treatment as well as counseling and what youre doing with your inmate population, and i know youre each doing something and 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 chairman and i both hail from pennsylvania, the chairman from the western part of the state and myself from the eastern part of the state and 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 and the Lieutenant Governor rutherford, i have a couple of questions for you with the enactment of the 21st century cures act, pennsylvania received 26. 5 million in federal funding to address the epidemic 3. 5 million for drug courts. 23 million being funded to expand access to medicationassisted treatment and increased training opportunities to Better Connect individuals with better treatment when they visit an emergency room as a result of an overdose and also to improve access to opioid use Disorder Treatment under 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 the facility . Why do you think it is better suiteded to have such a facility to treat Substance Abuse issues rather than in Emergency Departments and depending upon your answer ill have followup questions off that. Well, the concept of the Stabilization Center is a place where both First Responders as well as Law Enforcement or family members can take a person who is suffering from Substance Abuse disorder and they may be ready for some type of treatment, and the idea is to bring them into a local and not necessarily an emergency room because thats a highcost 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 stabilized and they can reside there for a few days if there say bed available to get them into treatment. Any similar facilities that you might bed modeling 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 was doing something similar to this. Once stabilized, will the patients then be moved into evidencebased treatment and counselling . That is the objective. It hasnt been we havent stood this up as yet and were working with the city of baltimore in terms of the parameters and how this is going to actually 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 will be utilizing for the facility itself, would that funding extend to the treatment and counseling or are you looking at the facility to sort of be on the front end . The facility is on the front end. We will look to the other Funding Sources be it through the care act, through the 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 a facility has helped. Right. That particular challenge because we hadition swas where we had individuals that would receive treatment through medicaid and we had beds available in some of the facilities, but we could not utilize those and 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 let 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 and nine, its not going to ultimately matter and were really just embedding more cost into the system by front loading some of the costs without really acknowledging that on the back end, if we dont finish it off with the right kinds of treatment and the right type of counseling and the right kind of follow up off that we will not ult patly ultimately drive down the epidemic. We can identify what are the issues on the front end, and mr. Chairman, i see i am well over my time. Respond very briefly. You are absolutely right. And some of the thought process behind the Crisis Center is a front end. Youre right. Its a front end where the person comes in the door and theyre in distress at that point and stabilizing them and 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 theyve come out of treatment and they go back into the same community and the same stimuli and the same issues theyve had before and one of the areas that were focusing on Going Forward including the utilizing the cure act, state funding is transitional housing, for lack of a about thdditionalg and during the day, they can go to work and they can continue to do the things they need to do, but they have to report back to this facility and people have said that that is something they need before they go back into the unrestricted society because all of the stimuli is still there. Thank you very much. Its the policy of the committee for letting the sub commity a commity to ask questions. Thank you for letting me sit in on the hearing, mr. Chairman. I have prepared questioned and does anyone else want to elaborate on that as far as the long term and the back end . Is there anyone on the panel that would like to talk about that, and you mentioned and you are so correct with transitional housing and cooperation, obviously, is so very important. The patient needs to cooperate and voluntarily in most cases, is there anyone that 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 you will hear families saying i dont know where to turn for help and we are lookinging at a Crisis Center model, as well, and i think thats critically important. You dont know which number to call and you have a family or loved one and youre not sure how to connect them and then the connection to treatment is critically important, as well. Its like someone with hypertension getting a pill and not getting a prescription. Its not going to help. So without the access to care and the kind of supports needed and its critical, as well, and in part of the cares act funding we are looking to salvage that kind of transitional housing for individuals who are not able to return to their communities and we are looking at the long term and treating addiction as a chronic disease not through acute episodes. I do think the approach to long term and looking at the longterm needed support are critically important, as well. Thank you. With regard to florida in 2010 in response to the Opioid Crisis, the pill mill problem, i think you know about that. Floridas legislature enacted painkiller prescriptions coupled with Law Enforcement using Drug Trafficking laws to prosecute providers caught overprescribing, within three years florida saw a decrease of more than 20 in Overdose Deaths and i want to give pam bond, the attorney general and others credit for this, but now the rise in the fentanyl and the derivatives have presented new challenges to the state of florida and other states, as well. However, we remain optimistic with recent initiatives in florida and this requires doctors to log prescriptions and the statewide database by the end of the next day. I think thats important to curb the socalled doctor shopping and setting aside states funds for medication that can help reduce opioid dependency. So were working on it, but during the august recess, i want to meet with stakeholders and conduct roundtables with regard to this issue. Do you have any suggestions for me . What has succeeded, obviously, sir, you talked about the baltimore 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, please. I just might start by adding that one thing i wanted to convey to the panel and i know you are very well aware of the stop act and this issue of keeping fentanyl and carfentanil out of the country and manufactured illegally and sometimes shipped in and mailed into our country. The dea recently informed us that the from Profit Margins for the cartel is a 6,000 investment and to make it a herointype substance is a 1. 4 million profit is to press it into a pill is a 6 million profit. So with that kind of, again, the cartels, that kind of profit margin out there for their taking its very difficult to combat this, if we are flooded with impunity. Weve got to figure out ways to stop it in the first place and thats not necessarily florida specific, but i think this idea that its contained in the stop act and 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 to the interventions and one thing i would comment on is this is a marathon and not a sprint and we need to take a look at prevention effort as critical in changing the face of the epidemic and not cutting our efforts and prevention, primary prevention and working with transitionalaged youth if we can stop before theyre used and were not going have them dieing with fentanyl. I think we need more research. Recently, we havent had any new medications and we havent had any new treatment models nsly proposed for opioid use disorders and im not sure enough effort has been placed into the Research Needs of this epidemic, and we need to start looking at this as we would the focus on cancer. This is an epidemic and we need research that will support the most evidencebased models that are effective in treating this. Thank you very much. I agree. I yield back, mr. Chairman. Follow up . I just really want to commend all of your states for leaning in and moving forward on this and for trying to find robust solutions. Its really important that we do that, and i know almost all of 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 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 and taking this 21st century cure and making something with it and developing programs that is 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 gratifying and i think it will save lives. I hate to sound like a downer, though, but to say that this 21stcentury cures money which was 2 billion, it its really well used, i think, by the states with these grants to develop programs, but 2 billion is nothing as governor kasich says 4 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 and im sorry that mr. Carter left because were not trying to politicize this, and if you want to give treatment to people you have to develop the programs which is what Something Like the cures money is good for and then you have to be able to implement them and you have to be able to give counselling to people and you have to be able to give the mat treatment to people and 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 yet 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, its not that 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 you will continue to work with the states to make that happen. Thank you. I have a few questions i want to follow up on. And this goes to the category of coverage without access is a problem as with access coverage without access and access without coverage are both problems. To this extent, i want to make note and put in the record and ask unanimous consent, why taking morphine and oxycontin can make pain worse and another one is an article that 51 of opioids go to people with depression and other mood disorders. No objection. It will go in the record. I want to make reference to a couple of those things. There are about 50 million americans with low back pain and 25 million of those take an opioid. When a person has pain and depression about 40 of them are 300 to 400 times percent with the risk of abuse, misuse or addiction noting that when were dealing with people with addiction disorders and 80 its for pain, but mood disorders are a big, big part of this. 51 of people on opioids have anxiety, depression or Something Else and i dont know if any of your states ask physicians to screen for that when they are prescribing i would imagine not. Most states dont. Do any of you know if in your states hospitals 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 education 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 . Not specifically. Although i did mention the acute pain which i think 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. Director boss, do you know if you evaluated that . 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 82 of people get a referral 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 have openings do you have in your schedule, theyll say they dont. Some providers say i just dont have appointments open for months. When youre dealing with 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. So if you look at this, about 90 people with Substance Abuse disorder dont seek attention. Out of 1,000, 900 dont seek attention. Out of the 100 that do 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 states 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 if 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. Clinical social workers and counselors out there. 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 to lots of different problems. 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. I know there is some products even in rural areas. 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. In fact, they were going to suspend their takeback program. We included i heard that 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. Next thing you know 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 of combat, 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. I hear someone who work in professors where 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. Cspans interview with Linda Mcmahon airs tonight. She was a member of president trumps cabinet. She was ceo of World Wrestling entertainment. Join us tonight at 8 00 p. M. Or on the free cspan radio app. And on sunday, new york congressman elliot engel discusses russia, north korea and iran. Thats on news makers sunday morning at 10 00 and later th thatvenitha thatvening at 6 00. Starting at 9 30 a. M. Eastern, governors talk about computer coding and the importance of Computer Science in school with girls who code ceo, former microsoft ceo and tesla ceo who will speak at the governors closing session. Watch the National Governors Association Summer meeting live on the cspan networks, cspan. Org and listen live on the cspan radio app. Cspan, where history unfolds daily. In 1979, cspan was created as a Public Service by americas Cable Television companies and is brought to you today by your cable or satellite provider. Next Energy Secretary rick perry testifies before the Senate Energy and Natural Resources committee on president trumps proposed fiscal year 2018 budget for his agency. This is an hour and 40 minutes