We actually have office of Tribal Affairs we have ongoing meetings with tribal leadership. When i came, i learned one of the Addiction Technology transfer centers that was specifically put in place to it assist tribal nations was going to end it. That has now been funded with a funding announcement out and we will choose a grantee, who will work with tribes and meet their cultural needs as well as their Substance Abuse needs. We also work as i mentioned with Indian Health service. We have our chief medical officers meeting with theirs and working with them around what kinds of Technical Assistance and Training Needs it do they recognize and can help them with. I wont take a lot of time, but we have Training Programs that are quite good. Think you because i am out of time and before the hearing i spoke to you about Supportive Housing and i want to continue the conversation with you even as i leave this body. I think thats very important that people with Mental Health disorders and with addiction get Supportive Housing and Wraparound Services, so thank you for engaging my conversation before the hearing. Senator whitehouse. Thank you chairman. Appreciate it. Welcome, good to see you again before the committee. We in the negotiations got a commitment bipartisan commitment for an extra Million Dollars to be spent on opioid treatment. Of the first half of that was already distributed and we hope and expect the second half will come through at the end of this year funding measure, whatever that ends up looking like. We are counting on that. In the last one the measure by which the funding was distributed to states didnt correlate to the rate of the Opioid Epidemic, intensity and severity in that state nor did it connect to the recently passed tariff bill. Im hoping as we move forward on this you will be in a position to structure the grant process for that second half billion in such a way that it more accurately addresses the highimpact state and that it better connected to the terra bill. I think you can probably do that in the terms of the Grant Application request you structure from samsung. I just want to hear where you plan to go with that because highimpact states kind of got not treated so well. So, my understanding of this situation is that if we make any kind of changes to the previous funding announcement, then all states would have to reapply for the money. I can tell you we have been hearing from lots of states about their concern and having to reapply for the money and the decision was made to not have any substantive changes in the second year funding for that billion dollar, 500 million each year. For the sake of the process convenience for all the high intensity states pay the price . I would say couple of thinks. One when that decision was made i did go back and we looked very hard and did find money and put a new funding announcement out that does prioritize those states that have been hardest hit by the Opioid Epidemic. I will continue to do that. In addition, the other thing ive been able to do is to reallocate funding so that we are building a new Technical Assistance program that will be individualized to every state, so those states hardest hit who have certain types of special needs we will have local Technical Assistance available to them that we think will be important to helping them implement as efficiently and effectively as possible. Going forward from that two years of funding whatever congress and the president decide upon we will look at that and be very much aware of the kinds of issues you have just raised. Please also be an advocate for additional spending in this area. I think we were able to get 170 million in the last funding measure. That is 2 of the 8. 6 billion that the pharmaceutical industry makes selling just the prescribed opioid products, setting aside the illicit stuff that comes over the border, so 2 up against the devastation we see in the context of a multibilliondollar industry i would consider a beachhead, not a victory. I hope you agree. Yes, sir. Last quick thing. The Health Insurance commissioner is you know in rhode island is looking at the parity compliance of the Insurance Companies in rhode island and i know youre looking at that at the national level. Can i make sure you have someone on your staff coordinating to make sure you support their work if everyone is pulling smoothly together on parity disclosure it enforcement . 23 next. One, a parity tool kit for Insurance Commissioners we have made available to all of the states and we have an Office AroundHealth Care Reform issues and we have a person who works individually with the states and the Insurance Commissioners within the state so we will make sure that happens. Appreciate it. Chairman alexander. Thank you. Welcome. I want to follow up, senator whitehouse is question because if i remember right it was his language we put in to try to make sure the money distributed took into account highimpact state. Mi not correct about that . The problem is that it was based, as i understand it, on the number of opioid deaths. Right, but obviously the big number, but not a big impact. So our intention was to recognize the importance was to distribute money to highimpact state was our intention. That was not accomplished. So, what do we need to do to accomplish our intention . You are saying it would be impractical to cause the states to reapply again. I can see that, but there will be more money coming for opioids we dont know when or where or how much, but is it the language about the difference between highimpact states them in the number of total deaths, per capita death is at the issue were what kind of language would you recommend that we include in any new funding so we direct money with a particular sensitivity to highimpact states . I was not here in the Previous Administration when the decision was made. However, my guess would be they were trying to implement as congress directed and i dont know. What would be a better way . Im not trying to criticize. Im just saying if you are doing it today how would you do it . For the new funding announcement that we just put out, what we said was we were looking at the rate of opioid Overdose Deaths within the state in the rate of increase yearoveryear. Of that tells you how hard a state is being hit. Will that affect the second round of the funding . When the second round of funding comes forward that doesnt require reapplication . If its a new source of funding, no. Everyone would have to apply for that funding. The second round the second half billion dollars that you just described. So, no. But, you would recommend what you just said would apply to any new money . Exactly. Would you work with our staff so if we write that properly and our intention is to recognize highimpact states that we do it in a correct way so we are not surprised. Absolutely, yes. In 2014, congress required i remember the discussion with senator whitehouse and i wanted to see we try to implement his intention and we can keep working on the. I am so grateful you followed up that way, chairman. In 2014 congress required states to set aside 5 of community Mental Health block grant funds for Mental Illness. This increase the requirement to 10. That sounds good, but reduces the flexibility the states had to address what my be different in rhode island and california. What is your opinion about the increased from five to make 10 . Does that help or hurt the ability of states to respond . The vast majority of payment of services delivered is not from samsara. The block grant having an increase of 10 has is it causes a focus on early identification of First Episode psychosis. We know the longer a person goes without having their psychotic thinking detected and treated the more refractory their illness comes over time and so that 10 in the block grant does a tremendous amount of good in terms of raising awareness of this important issue. Out is that encourage early prevention . The language just looks is serious Mental Illness or does it say about early . It talks about early identification of the serious early identification of serious Mental Illness. Yes. Not just serious, but early as the key really too effective and frequent. We consider psychosis to be indicative of serious Mental Illness. You think the 10 helps. I absolutely do. Because they pushed towards early identification of serious Mental Illness. Yes and we know the onset of most psychotic disorders is an outlet it adolescents and transitional age youth, so its important to the lies these folks will live going forward. Thank you, mr. Chairman. Thank you very much senator cassidy and mr. Chairman, thank you for holding this hearing and doctor, thank you so much for being here in the work you do. I want to follow up on a conversation we were just having about funding for those of us from states who have been incredibly disproportionately impacted by a horrible epidemic taking lives obviously across our country, but in New Hampshire heroine and Opioid Epidemics is that no killing people in my state at one of the highest per capita death rates in the country and we have been targeted by dealers. I was at a funeral saturday were eight family buried their second daughter from an overdose. A woman had been in recovery and working really hard and this disease is taking all of our efforts and im very grateful to everyone on the committee, but i will add my concerns and frustrations to what you heard from senator whitehouse. I have expressed record to the secretary and i think the fact that states are uncomfortable about reapplying is not an excuse in terms of the decision made for the second round of this funding and towards that end a senator capita kunz, myself and senator mansion have a bill called the targeted Opioid Funding act to change the funding to make clear what kind of priorities we should give to per capita death the states and i would love the committees attention and collaboration on the bill, but even if we fix this formula under the act, we know the money right now is only for two years and we know theres no quick fix for this epidemic. We desperately need funds to fight this epidemic. We need the administration to tell us what supplemental resources is proposing to turn the tide and i was appreciative of the doubt the white house in october when the president s declared this a Public Health emergency, but so far weve not seen followup to the declaration we have seen no proposal from the administration for the funds we need to tackle this epidemic everywhere in our country, and epidemic not only taking lives, but in New Hampshire cost us over 2 billion in our economy, so have you had conversations about the need for additional funding with hh s of the white house . Why hasnt this administration called for additional funding or proposed additional funding so we can get the dollars and resources to the frontline . I think there are many conversations going out about what the needs are and lots of efforts to look at the Data Available and Information Available its my understanding that the administrations interest in working with congress on developing those that both the president and congress can agree upon to bring more resources to bear. This congress had made clear we support additional funding that we need a partner in the administration to stop talking and start funding. I look for to continuing conversations. I also wanted to followup with another another question because we know how complex the opioid use disorder is. Its often accompanied by a variety of Mental Health disorders including post dramatic stress disorder leading to complex and sometimes dangerous outcomes. Veterans in other populations with ptsd are often prescribed higher doses of opioid putting them at a greater risk for accidental overdose at best are treating one disorder does not address symptoms of the other. Is imperative we work to ensure patients have access to comprehensive treatment to address both Substance Abuse disorder and Mental Health needs has it helped sam thought enhance availability from dual diagnosis to Mental Health disorder . I believe they have and specifically i can speak speak to the issue around department of defense and veterans affairs, which has developed into a very strong relationship where samsara works collaboratively in an ongoing way and we specifically address the issues of mental disorders and Opioid Epidemic as well as suicide. Those are the big issues we are working on right now and we also can use the information that we learn from the va which actually does a lot of research of its own and we share this and we promulgated to communities. I thank you for that in the vision of the integrated healthcare in this area. Im most concerned we are delaying some of our work that would be made possible with xo funding because of the stigma attached as some other senators have referenced and i appreciate your efforts. Doctor, good to see you. I read a book some months ago by sebastian younger, small little book called tribe he discusses the challenges our veterans face as they reintegrate back into Society Makes a point from an evolutionary standpoint we are more comfortable in Tribal Society like military platoons embedded in a military structure then we are in the Current Society where people tend to feel lonely so there are challenges of reintegration and adaptation so we turn it on its head the challenges our veterans are facing, not per se with the veteran, but maybe broader society. Its an interesting read and when i lay that line of argument, that analysis on top of the study, the depth of despair study that indicates we see increasing rates of morbidity among middleaged men, white men in this country and the reason for the death and heightened suicide, alcohol use and so forth start to think loneliness is driving so many of the Mental Health issues in our country. Can you give me your assessments of that perhaps popular reading of the literature . I do think that those are important points and i actually think theres Research Data that says people who are isolated who will endorse loneliness and feeling ostracized within their communities died at much younger ages, so thats important. Is a driver is what im hearing, a driver of some for Mental Health challenges what interventions work . Senator young, i think its a topic and evolution. I think there is some accumulating evidence for the value of recovery supports as they relate not only to Substance Abuse disorders, but mental disorders and so one of the things im working on and at this is one of my priorities, actually is to bring psychiatric medicine into closer contact in collaboration with Community Recovery support. Its not enough to just provide medical care and psychiatric medical care. People need those recovery supports in their communities. They can be a veteran based, faithbased, so you get where im going and i think that it will go a long way towards assisting people to live the fullest life to think it seems consistent with common sense that theres more needed in medicating these problems away. People need genuine human contact, relationships that are meaningful to them. They need to feel like they are part of broader community. So, i just have a couple of minutes left. If we could turn to how the federal government incorporates or fails to incorporate feedback loops in terms of addressing Mental Health and the policies we have. Theres a recent governing Magazine Article on this written by Health Economic professional at Harvard Med School and former Obama Administration official and authors advocate for he peered evidence approach to allow scaling up of evidence based approaches while supporting fuel generated innovations. Have you considered including evidence approach and some of your programs say the national Mental HealthSubstance Abuse policy lab . Thank you for that question and i think we spoke a bit about this when i was going through the confirmation process. I want to publicly speak about it. The answer to your question is yes, we are and im happy to tell you that the policy lab is stood up now. We have hired a director who i think is very experienced and knowledgeable who will do exactly that kind of work. I continue to have great interest in this and we will followup with you to see how it m