next to hearing on drug use, suicide risk, and solutions for a mental health treatment from the housemates means committee. next the hearing on drug use, committee. they also talk about rising overdose death due to fentanyl and illegal drugs crossing into u.s. borders. the ways and means committee will come to order. putting in a word of welcome, and delighted to see all of us back here. what i have always considered the best address on capitol hill, 1100 law worth. we are holding today's meetings in the hybrid format in compliance with rules and regulations -- pursuant to house regulation eight. before we begin i want to remind members of a few procedures to keep these procedings running will keep microphones muted to limit background noise. members are responsible for an meaning themselves when they seek recognition or when recognized for their five minutes. staff will mute members only in the event of inadvertent background noise. in addition, members present in the proceeding by a web acts they must have their cameras on. if you need to step way to attend another proceeding and please turn your camera and audio off as well, rather than logging out of the platform. now i would turn in the topic of today's hearing. substance use, suicide risk, and the american health care system. exactly one month ago we held the first hearing of the decade on examining americas mental health crisis. our discussion underscored the multidimensional nature of the issue. touching on factors including gaps in health care, coverage, stigma, workforce supply. covid-19 pandemic only complicated and exacerbated this long-standing crisis. causing increases in social isolation anxiety, and workforce burnout. all of this heightened existing mental health conditions. during today's hearing we will take a deeper look at the inter related mental health issues, substance abuse disorders, overdose deaths, and suicides. these are somber issues that affect each and every one of us in our communities. it is very pleased that we are able, as the 115th congress to pass bipartisan support legislation called the support act, which made progress in combatting the opioid crisis, including policies such as adding opioid crease programs to medicare providers. while the legislation was a step in the right direction data correctly shows that more work must be done to help those who are, indeed, suffering. in 2020, more than 40 million people over the age of 12 struggled with a substance use disorder. that same year, as the covid-19 pandemic cast its shadow over our nation, the united states set a record high 100,000 overdose deaths. sadly suicide rates also remain at historic levels. america remains the highest suicide rate of any wealthy nation, nearly double the rate of the united kingdom. during last night's hearing, we talked about the stigma regarding mental health issues. that is a conversation that we intend to continue this morning. the history of substance abuse disorders in the united states is one marked by again, stigma, criminalization, and a lack of recognition that these conditions are health issues requiring treatment in the same way that we treat diabetes and hypertension. without necessary support many americans face severe illnesses, addiction, incarceration, and death. a long-standing social and economic -- historically marginalized groups the united states, face particularly bleak outcomes. we must finally take on these issues in a serious, holistic manner. it will take all of us working together to address this often invisible suffering across many communities. fortunately, the white house also recognizes the need for urgent collective action. i am grateful, very pleased last night during the state of the union address that president biden announced strategy for addressing the nation's mental health challenge. together, we can build on the foundation we laid in the american rescue plan to ensure that everyone who needs mental health care is able to access it. >> today's hearing is an important step in tackling the problem. this will inform a legislative action committee will take this year to address some of the long-standing problems in the way that we deliver and access mental health services across our nation. with that, let me recognize the ranking member, mr. brady, for the purpose of the opening statement. >> thank you, mr. chairman for holding this important hearing. thank you to our witnesses. i am well i'm glad to see the committee back together, 1100, working on important issues. so the substance abuse is on the rise, among other risk factors, including social isolation, american families are facing a real mental health crisis. during today's hearing, we will hear about those real life challenges cross country are struggling. these problems can impact anyone. seniors, veterans suffering from post combat mental health practices. even our children, everyone is touched by these issues. to help the patients and families, we need to recognize the stock policies that worsen despair, disconnection, and get back to working together to strengthen american communities. i worry that the biden administration's mishandling of the pandemic, including tests, treatment, therapies and prolonged shutdowns of social isolation have only exacerbated the problems facing american families. half of all seniors reported during the pandemic, they were isolated, spending less time doing the things they enjoyed. without the routine and social environment provided by schools, sports, suicide attempt by teenage girls increased by 50%. two out of three patients of families with substance abuse disorder reported the pandemic had a negative impact on their recovery, with an increase in stress and isolation. critically, today, america is in the midst of a drug overdoses from fentanyl doubled epidemic, fueled by fentanyl, a deadly substance which is now the leading cause of death for americans aged 18 to 45. the in 30 states in the last two years, including my state of texas. these are real families, real communities that they devastate. we must do more together to reduce the prevalence of fentanyl, which must include solutions at the border. we see this firsthand in texas, where the open border policies the administration allows fentanyl to flow across the southern border, into our communities. just last, year the u.s. customs seized enough fentanyl to kill every american nearly seven times over. and in the fallout of president biden's open border policies, the administration deferred $850 million to support the nation's covid-19 testing capabilities, instead using the funds vowed in the vigils to cross america illegally. that's why i have the opportunity to talk to the sheriff in texas, anderson, who told me about the challenges that local law enforcement faces with the rise in fentanyl. he tells me more and more, about their drug procedures, including all kinds of fentanyl laced drugs, including marijuana, not being able to swap or slow the amount of these drugs getting into the country, american families and communities will continue to suffer. we can work together, to fight the use of opioid use and other forms of substance abuse that occurred during the pandemic. this is an important issue for republicans serving, and is the majority in the house and senate, we make a historic investment in combatting opioid crisis, and reducing substance abuse disorder throughout america by enacting the support act. we put in place many commonplace measures. reduce unnecessary prescriptions of opioids, and help those who have the addictive. i'm afraid we've taken our eye off of the ball. because of the pandemic, and the sluggish restart, the economy, the but -- drugs resulting from open border policies, it's clear that -- that the patients started to see hope as congress passed support, but they now feel neglected. it is critical that we renew our commitment to every american who is impacted it directly or indirectly by substance abuse disorder. we can build on and improve the support act, and look at new challenges combatting these issues. the committee could also work together, to make telehealth access permanent. first, through the first week of the pandemic, telehealth services jumped. from 13, 000, to 1. 7 million. tele-health was critical for maintaining health services. by increasing health services during that time, they saved countless lives of seniors, and those facing dire mental health issues. in 2020, congress will work together for something to stand many of the tele-health flexibilities for mental and behavioral health services. but we need to build on this more, and permanently extend further telehealth flexibilities that could help seniors. and finally, this committee should work together to get more americans off the sidelines, to ensure our economic recovery. >> we heard last night from president biden is something he wanted to work on, was to stop making things worse. but continue to urge the president to abandon his plans, crippling tax hikes on main street, lavish giveaways to special interests and more runaway spin. i will close here. on the heels of a raging pandemic, and a terrible pandemic, we know that the mental health crisis is real. i believe we have the tools to fight it. i believe together, taking a bipartisan approach, looking to the leadership of chairman neal, the republicans and democrats on this committee, i believe we can do that. so let's do this. >> thank you, mister brady. without objection, all opening statements will remain part of the official record. i want to thank our witnesses for taking the time to appear before us today. i am pleased we are able to welcome five very impressive guests to discuss this important issue. first of the honor of welcoming dr. jonathan mitchell, director of the department of medicine and health and society at vanderbilt university. next we have dr. edwin chapman, the private physician specializing in patient medicine. regina labelle, director of the addiction and public policy at the o'neil institute. next, we have dr. -- executive director of the national asian pacific american families against substance abuse organization. finally, we have jessica halsey, from the addiction forum. each other's statements will be made a part of the record in their entirety. i would ask that you summarize your testimony in five minutes or less. and to help you with that time, please keep an eye on the clock. it should be pinned to your screen. i will notify you when your time has expired. doctor metzl, please proceed. >> well, thank you very much, chairman neal, member brady and others in the committee, it's an honor to speak here today. and i'm so pleased we are having a testimony about this important topic. hopefully the next time we do this, i can open the room to everybody, in person, and not speak from the kitchen. but i hope my message will get through nonetheless. as you just heard, somebody who is on one hand a trained psychiatrist, and over the course of my career, i have seen close the devastating effects of the topics we are talking about today. depression, suicide, addiction. really, i agree with everything we just heard. the boundaries, the cut across geographic local, at the same time i am a social scientist. i directed the department of mental health and society. this studies have structure, infrastructure, things like that can contribute you and give resilience to what we are hearing, i think rightly described as a national emergency about the need to address mental illness issues broadly, and also the issues of addiction and suicide. certainly, as i will say in a minute here, we need more specific treatment. we need to reach out to people in communities and in ways that they understand and respond, to address, or the president called last night a national emergency. but i would also say in my testimony, i would try, as we set down to write some of my thoughts, i started thinking, think about everything we have all been through over the past three years. people would've imagined that even breathing somebody else's air, walking into a room, or thinking about whether or not somebody is carrying a virus or something like that, we have all been through this national trauma. we dealt with it in ways that i think highlight historical polarization's. but it's important to note that mental illness is the extreme point of a continuum, for if nothing else, this pandemic which has taught us we are all on this spectrum of vulnerability. and in a way, one of the things that i argue at the end of my statement, my opening statement, is i don't think we have a national conversation just about what mental health means after what we have all been through in the past three years. so something i suggest towards the end is we have a national referendum. if that seems kind of pie in the sky, but a non polar referendum on just what mental health means in this new world that we are all living in, and how to come together. because i will say, i completely agree with what i just heard there, so many groups are voicing despair right now, but it is my hope we could build mental health as a resource. i will also say as a psychiatrist, i can tell you, many of my colleagues have this panel, they will say that many important things we could do at the moment, and we have heard about the crisis of isolation, how that's happening. i know last that the president talked about technology, but it is now time to talk about how we can challenge people, create networks. how can we contact them, and dig the cycles of isolation? >> more insurance, more exchanged coverage, more treatment, i completely agree with the need for tele-health right now. i think it is an opportunity for us to use technology for the good. but my written testimony is not that of a sociologist. i think mental health with individual pathologies, larger structures and systems, the other part of my testimony, the other part of me today is the pandemic, exacerbated structural inequities, which underlie mental illness. i think chairman neal the it is really well in the opening statement. i think there's also a call to action to fix the underlying structural inequities we have, and conversely, i think there's a lot of evidence from history that societies that bonded together, and build what is called social capital versus social cohesion, and breaking the cycles of the spear. i don't go into it because a lot of it is in my written testimony. except i think we have the opportunity to build social structures that emphasize the importance of communal infrastructure for mental and biological well-being. i realized i'm out of time. thank you very much, i look forward to having this discussion later. >> thank you, doctor metzl. doctor chapman, would you please proceed? >> thank you, chairman neal and ranking member brady, and committee. thank you for allowing me to participate in today's hearing. for the past 42 years, i have been practicing internal medicine, in our nation's capital. 2003, a patient suffered from nowhere to use disorder as a medic medical record, one has three in the district of columbia. in 2005, we began using another fta proved medication, which is good at treating patients in my personal office. and over the past 17 years, i created a new approach, with 1100 patients. currently, i have 225 patients in my care. what we found is these patients had a bunch of problems, including 10% have spent at least ten years or more in jail. 50% initially tested positive for hepatitis c, and 12% for hiv. historically, we know that many epidemic outbreaks have hiv a. i. d. s., hepatitis c are related to untreated substance abuse. i have we have seen in scott candy -- scott county, indiana, massachusetts, west virginia, and the district of columbia. so i was appointed in 2019, into a yearlong team studying the integration of opioid abuse disorder treatment, and infectious diseases under the guidance of the national academy and science. we are now with nine major barriers, including state law. it has been talked about extensively. we also noted a prior authorization for the medications, are noted as the won't number one barrier by the medical association, the american society of medicine, so in the district of columbia, for example, one of the three had a six-page prior authorization form four doses, no more than 24 milligrams. so a lot of these are capital overdoses. this means it is far easier for a person to get fentanyl outside of my office thing get a prescription made secondly, is the lack of a national standard care for coordination and multiple plans would have different ways of doing this including medicare and medicare. but a lot of folks the same day seven it is or services for professional offer. saying we will reimburse the critical services with social social work, which will support thousands. since 2020, the federal register pointed out that it cost $42,000 untreated a patient, the cost was $42,000 it only cost $7,500 to see that patient. tunisia's $34, 500, for a patient that gets treated. so pre-sharing costs, plus additional, when i call rome pocket costs for every individual, you need $100,000 per patient, per year, even if that person happens to be single and homeless. so we envision a more simplified payment system, a bundle payments estimate, probably scaled, encapsulating all the statements described here in, and with a descriptive formula, a descriptive formula that would not only save taxpayer money, but we also provide participation we actually have that through the american society of medicine, and the american medical association. the treatment model, with this model which really put together in 2018 was never adopted by any state, or any insurance pine. we invite you to further explore this option this national innovation and building and incentivize network competency provides. i will stop there. >> thank you very much dr. chapman missed the bow, please proceed. >> thank you chairman neill, ranking member brady, and members of the committee. thank you for the opportunity to speak to you this morning. in 2021 i served as the acting director from national of drug control policy. and there i oversaw the development of the biden administration initial drug policy priorities currently i direct the -- georgetown law center where we use the law and policy to remote access to quality addiction treatment, harm rejection and recovery support services. i direct georgetown's master of science and policy program where we train future policy makers. i'm here today to discuss critical issues affecting the country. repeating from april 22 april 2021 over 1000 people died from drug overdose in our country. the situation calls from ian detention from policy makers and the public to provide both more resources and also acknowledge the need for tailored responses to the challenge of addiction. in 2021 on the biden harris administration publicist for a co drug your posse. from you heard last night. this is a comprehensive strategy based on scientific evidence that expands the entire continuum of care these priorities inspire a pathway to action that can cover any more routes bonds to today's issues. the health of those with substance disorders and the communities in which they live is often determined by social factors. policy requires not only tackling proximate factors but also comprehensive solutions to create greater stability in community -- especially important in this time of covid-19. i want to highlight three areas for actions. first is protecting children from harm we know the childhood trauma is linked to the later development of substance disorder. legislative initiatives like the child tax credit and expanding the availability of family centered approaches of treatment can provide services, keep families intact, and reduce adverse childhood experiences. also stigma towards people with substance use disorder also increases the harm associated with that condition, it can also prevent people from receiving needed services. to prevent risky substance use and limit harmful impact, we need to move aggressively to limit the stigmatization of people with addiction. strengthening house security, stable housing can improve health outcomes for those with addiction. there are a couple pieces of legislation that are being considered that might help in this area. the first is the affordable housing resident services act of 2022. this is to create grants to provide services for people with substance use disorder in affordable housing. the second lee the neighborhood home investment act. this is a bipartisan legislation that would incentivize the development of affordable housing by creating a federal tax credit that would build homes in distressed areas. another critical area for intervention is rid -- a greater focus on addressing substance use and mental health correction. the bureau of statistics in 2019, suicide with the leading cause of death and jail. jailed deaths are increasing year after year. from 2009 to 2019 the rate of jail deaths due to drug or alcohol intoxication more than quadrupled. research that we conducted in georgetown found that the majority of these deaths are preventable if correctional settings provide withdrawn management upon intake as well as longer addiction treatment. we simply using this research to develop a set of recommendations for preventing crimes from unsupervised withdrawal in jail. lack of treatment during incarceration and a lack of community based care place individuals at great risk. that is why the medicaid reentry act would ease reentry. enabling patients to reestablish medicaid benefits before they re-enter communities. in closing, too often we think about these issues as being resigned to their intractability. but these challenges do not have easy solutions. i really believe that there are concrete policy steps, often through bipartisan support, that can make a big difference and strengthen our communities. thank you for our time, i look forward to hearing from you. >> thank you miss labelle, we will now hear from doctor reataza, please proceed. >> ranking member brady, members of the ways and means committee it is an honor to testify today. i am doctor marielle reataza, director of the national asian pacific american families against substance abuse. we have served nation american who, i am for over 30 years. 14 years of experience of working closely with communities and i currently serve on the samhsa harm collection committee as more specifically in american and a filipino immigrant. my concern and -- first it is worth noting that they a upi represent people from approximately 50 ethnic groups, and over 100 spoken languages. this has resulted in the misunderstanding of and pei's in regards to mental health services unfortunately there is already an ongoing stigma in our communities when it comes to seeking care. the stigma can be so strong that there is a delay in skincare, or worse, we did not see care at all. sometimes individuals must also seek services in private, that can help when -- which can be challenging when we often live in multigenerational households. and tint tele-health is not always feasible in specially when language access and technology are already barriers. not gaining a complex a confusing system of insurance providers are already difficult for most, the a really hard for anpi's. an estimated 40% have limited english proficiency and finding appropriate language care can be difficult. a two thirds of anpi them's being born outside of the united states understanding cultural differences is critical to serving us. thus, it is not surprising that upi demonstrate the lowest health seeking rate of any racial or healthy can group, creating the illusion that we do not need them. many have called for the covid-19 pandemic to be redefined as endemic acknowledging that is different throughout different communities. a committee led team of native hawaiians and pacific islanders experience the highest per capita rate in the u.s.. which has been contributed to health and socioeconomic inequity prior to covid-19. notably many asian americans, in spite of living in cities who boast a robust asian american, have provided no information in their native american. while filipino americans make up only 4% of registered nurses in the u.s., they make up nearly one third of all covid related deaths among our ends. the -- significant rise of anti asian health crimes. between the march of 2021 10,370 hate incidents have been reported against anpi's have been reported. have been found to displaying psychological emotional harm caused by racism, showing heightened systems of depression, anxiety, stress and post-traumatic stress disorder. without appropriate care, substance use disorder among api's is also believed to be on the rise. some locality saw a 196. 1% increase in accidental overdose deaths amongst asians during the first five months of this pandemic. lastly, suicide is also reported as the leading cause of death among api and young adults aged 15 to 24, despite it being the tenth leading cause of death in the u.s.. this cause of death is for 33% of our young adults. knowing that reluctance that we already demonstrated skincare, combined with a lack of to segregated data among api's i have much reason to believe that cases go under reported and require much more investigation to be well understood. >> one way in which this could be improved is by increasing capacity for community light research. frankly, we are under represented in these studies. this is further complicated by the fact that there is a large percent of us, again, which are immigrants. sometimes, undocumented. additionally, i urge the committee to build capacity for culturally responsible -- and language access. secondly, our community to grow a capacity for collection and reporting, because api's also represent diverse socioeconomic status is, i recommended it also be stratified for additional demographic factors. third, i urge the committee to proceed with armored auction principles and practices. this could look like a number of things, such as pure driven support networks, community support through education, meal education programs, safe kits, medically assisted treatment and safe consumption services. harm or doctrine is comprehensive, wellness centered, reduces disease transmission and saves lives. harm reduction is also science based and community vetted. with mental and behavioral health providers already integrated him and then we can feel the need, i worry about the long term impact on this endemic with mental health. i acknowledge the challenge and speaking to a group as large and efforts of ours also knows we need help. i think the committee for inviting me to testify. >> thank you doctor marielle reataza. miss hulsey, will you please proceed? >> thank you chairman neal, member brady, and members of the committee for having me here today. my name is jessica hulsey, founder of the addiction policy forum, a nonprofit, working in states and communities across the country to end the stigma around addiction, to help families in crisis, and to translate the science. over the last two years, as our country has grappled with the pandemic, if addiction is worsened at historic rates. obstructions to the pandemic, or in too many cases catastrophic for our patients. we conducted an atf surge, and interviews with our patients. one shared, living through recovery in this time, of being able to be active in meetings has been disappointing. when they keep liquor stores and weed shops open, this society is so twisted. also, later this month, we are releasing a patient journey map which also understand the recovering process, and input from our patients. the project has so many findings. but, one to share with the committee, is one of the most difficult points in the entire process, highlighted by our patients themselves is how hard it is to find help, how difficult it is. one of our patients shared, and this is a direct quote. in my experience, i was not able to get help when i needed it. when i asked for it, or when i beg for it. to make matters worse, the introduction of fentanyl into our drug supply has significantly increased mortality rates. fentanyl is 100 times more potent than morphine, 15 more times than heroin, and the mass production of fake pills marketed as legitimate prescription pills has devastated our communities. the results is 104,000 drug overdose deaths in one year's. that is 285 deaths in one day. that is, like a plane crash every single day in america. like, losing a high school class of seniors in one day, every day in this country. i know firsthand this devastation, as i lost both of my parents to opioid use disorder, but my story is just one of millions, repeated daily across our nation. to put a different lens on 104,000 deaths in just one year, i would like to take a moment to share letters from our families who are part of the addiction policy forms to stop opioid use campaign. we have hundreds of these letters, i only have five minutes, so i will only introduce you to a few of our families. christina lost her son jha have been to a fentanyl overdose. she writes, he was my oldest son. he made me a mother. people need to know this is a disease, not a choice. jim's son, scott. this is jim and his beautiful son scott. he struggles with mental health and opioid uses. after three years in recovery, he relapsed, which led to his suicide, two days before his 21st birthday. he left a letter to his family which read, i have not found one person who could help me. i love you mom dad and ashley so much, this nothing that you could have done better. i just can't stand being in my own mind. it is torture, it hurts, and i have tried for years to get help but nothing works. and denise, one of our moms, denise. she lost both of her beautiful sons, matthew and dylan. this is matthew and deal into an opioid overdose. she shares, my boys had a bright future ahead of them. but because of their illness and lack of adequate treatment and medical coverage, their lives were cut tragically short. had they suffer from diabetes or cancer, they would have been provided the medical care and attention necessary to live a full life. what is so frustrating to me is that we have most of the tools we need to address the crisis, yet we do not systematically implement these for those in need. for example, medications to treat opioid use disorder or mat, reduced opioid deaths, criminal activity and infectious disease transmission. >> research says individuals cheated with morphine or methadone after a lot of fatal overdose had a 40 to 60% reduction of mortality, yet less than 50% of our privately funded addiction treatment author 90, and only a few patients there will actually receive it. you imagine if less than half of all oncology centers provide chemotherapy? and in that half, only one in three patients received the medications that were needed? if you feel shock and horror even at the thought of this, then why is it the case for addiction treatment. we are considering expanding critical services, like distribution, they're -- used to sort, or a poly is disorder, not a single drug issue in this country, we need to have more submissions for stimulant treatments. syringe service programs and medication for addiction treatment. number two is build the addiction workforce by addressing lack of coverage for any providers in the field, reimbursement rates, create incentives for this pipeline of workers that we need, and finally, addiction is a pediatric brain disorder, and evidence based strategies are utilized to prevent children and adults from developing this in the first place. thank you so much for your focus on this important issue and for having me today. >> thank you, miss hulsey. without objection, each member will be recognized for five minutes to question our witnesses. in this hybrid setting, we will go in the order of seniority, switching between majority and minority members. before questioning our witnesses, without objection, i like to enter into the record is statement of a physician and rapper, sir robert rice halt the second, nonprofessionally as logic. in 2017, he raised a song which is the current phone number of the national suicide prevention lifeline. the song drew much attention to the suicide helpline and helped many who needed help. the national suicide hotline is 18002731855 anyone can call for help. this past december, the biden administration announced two point $8 million to strengthen and expand the lifeline. and in july, will change the ten digit number two a three digit code, which will accept calls. texts, and chats. i encourage every member of the committee to work to publicize this court number and the new one, which goes online. with that, let me turn to our questions for our witnesses. let me begin by recognizing again, edwin c. chapman. i want to thank you for your testimony. thank you for sharing the struggles with the patients and seeking the care that they need. d. c. is lucky to have you as a provider. as part of our bipartisan work in this committee with the support act of 2018, particularly in my bill, added opioid treatment care for providers. that was a big deal. while the step was important, it is clear that this was just a first step in ensuring medicare beneficiaries have access to a full continuum of services for all types of substance use disorders. doctor chapman, can you talk about the challenges that americans face in getting necessary substance abuse disorder care. whether it is a result of a gaps and health care coverage or other social and structural factors intervening? >> thank you mister chairman for this very probing, and insightful question. we have tremendous gaps in care. in the district, however, 98% of our patients are covered. i was on a panel at the bookings institute about three years ago, -- is it money, why is it structure? i think the consensus was it was both. the fact that we have these structural barriers to care, and i mentioned prior authorizations but there are many other variables. for instance, if it patient comes to see me in my office we set up telemedicine six years ago. anticipating the need for psychiatric services, social workers, support services. most insurance companies do not pay for multiple services on the same day. under the old system a patient came in and they saw me for primary care or wanted to see a psychiatrist, one of us was not getting paid. the idea of value based treatment means that we are challenged with patients who have limited resources. we want to do everything we can while we have that patient in front of us. when we set my office up. that patient came in needing to see a social worker and didn't have telephone to put them in an examination room and connect them with a social worker. we called the reversed telehealth. we have been doing this for six years very successfully, but there is no payment structure to support that. we are really looking for a consistent payment structure for medicare, medicaid, across the board, that will support these very necessary services. there are other issues such as transportation, housing, of course is a major issue. anywhere from 25 to 50% of our patients in the district of columbia are homeless, depending on how you define homelessness. they may not be on the street but they may be housed with a friend or family member. again the puts those patients in dangerous situations whether or not they can be controlling their environment. how building, as far as i'm concerned, is medicine. without housing we are not creating or allowing for treatment of patients when they come into the office of the hospital. we are not really discharging them back to the same dangerous environment. >> thank you dr. chapman. i want to reference a follow-up question in my congressional district, the hampton county sheriff's office none a number of programs that intersect the mental health, drug use, and justice system. the -- pretty significant conduit to employment, stable housing opportunities, with intensive wraparound services education, support for individuals, entering the community. the former sheriff and current sheriff of hampton county both very good public servants and find people. they have pointed out to me in conversation that, different intervals up to 90% of the inmates either have alcohol, drug, or mental health issues. would you talk a bit about what programs are needed to address these issues, inside of these institutions? >>. absolutely, less than 5% of jails and prisons across the country use medication assisted treatment. as a matter of fact, they would take patients off of turn orphan or methadone if they were incarcerated. which means that if you can imagine a diabetic being incarcerated and being taken off of their insulin. it is unheard of. again it boils down to stigma. without education, without understanding when these medications are you for, our criminal justice system considers this replacing one dog with another. we have to start with professional education. both in the medical field as well as the criminal justice field. so there is better understanding of what these medications do. as i alluded to in our national academy of science report, untreated the worst place to put a patient who is using drugs is in jail. that is going to be the highest rate of transmission of infectious diseases. in maryland, a number of years ago, the prohibition of even orphan because it was being smuggled into the leaves of books and understands and so forth. it means that it created a black market within jail the easiest way to stop that black market is to just provide those medications in jail and just have those criminals trying to transition from jail back into the. -- we can stop these black markets in these gaps by simply providing these services and making many need insurance, that can be access when you talk to regina labelle and her work in georgetown university you will see that they have these policies really nailed down to the and degree, in terms of what needs to be -- all we need to do is following these policies. >> thank you for testifying today in for the work you are doing to heal the american people during these times of heightened stress. it is certainly invaluable and we want to continue that conversation. in may 2020 this committee held -- to the disproportionate effect of covid-19 on people of color. it was clear that that probe was highlighting -- this and equitable system effects and exacerbates effects for depression and suicide. what do you think that congress can do to more structurally address these issues? >> thank you so much, really wonderful question. i would say first of all that we are not, it is not reinventing the wheel. there is a great deal of sociological, medical literature. some of which i have cited in my written report. that is just the tip of the eight berg. talking about how in moments of society being challenged by wars, famines, pandemics, ways that highlight structural inequities. if you kind of create what's sociologist call, social capital, or social cohesion. you actually move not to talk about people identities but here are the fault lines that are being exposed. in this moment of crisis and what we are going to do is have a national effort to actually fix these fault lines, to help those who are most vulnerable in our society and i can get just a few examples of this. it is pretty remarkable for example that one of the pieces i cite in my recent testimony is the effects of writing health care networks in low income communities, people of course are able to access all kinds of care. mental health care, physical care. they unintended effects of broadening health care networks as one example have all of the -- people kind of feel like they are part of a network you can see less things like optimism go out, civic participation, participation in community rebuilding efforts. parks, and all that kind of things. point ember one that i make in my report is that i think that we really need to think about infrastructure as not just let's fix some bridges are roads that are broken or something like that, but how can we fix infrastructure in a way that actually enhances people sense of connectedness, and the feelings of mental health. the other part of course is that, those early stages of the pandemic that you mentioned really did highlight weak points and our society. people have been living in multigenerational homes. they have jobs where they couldn't possibly social distance. they had an equal access to information from the internet, for example. and so they didn't really know the up-to-date safety information. >> in a way, these structural inequities or really brought into focus during the first moments of the pandemic. we did not have a choice, as a society to either say, they are dying, those less fortunate than us. or it to say, we are dying, our fellow citizens, our country, and try to fix that. so the language that we use at vanderbilt's called structural competency. basically, what we advocate for is training health professionals, both to understand individual systems, but also to see the weak points in structures, the upstream factors that might lead to downstream mental health issues, and to inequities. hopefully, what we are doing is training legions of mental health practitioners, health practitioners who are really versed in individual treatments, but also, in these upstream factors about who do you need to partner with to help people pay their heating bill, give them internet access, how can we reimagine medical clinics in that way? >> thank you, doctor reataza, your testimony was superb again with the others this morning. and we acknowledge that the mental health crisis, its impact on asian american, native hawaiian and pacific islander communities is clear. we certainly have much more to do. you highlight ways in which we can overcome some of these challenges to ensure that everyone has access to the care, both structurally and culturally competent. >> thank you, chairman neal. i appreciate the question and agree with a law that is already been said by our colleagues. today, a lot of things we have to understand as health care practitioners, or the mental behavior space, and other spaces of care, is that oftentimes, we don't really understand how this system has worked for different communities. so, i really advocated for better understanding, what is going on on the community level structurally. i would also argue that identity is also impacted in which the way that people interact with the health system, whether it is mental health, health care in general. there are a lot of gaps that everybody is already identifying. whether it is lack of access which we see time and time again. there is difficulty and challenge in navigating the system. and even when folks have access to insurance, often they are under insured, and access to the services are expensive and really challenging to navigate. what we often see is if somebody has to go and see a provider, that means as well they need to take the day off. in fact, they might even get a sick day. do they have to look for childcare? there are so many issues which are complicated by just trying to get well. so i think that ultimately, the system is challenging. we have to find ways to help people access it, navigate it. it must be affordable, equitable. and a lot of that would also involve learning how different cultures interact with the system, and how to better address them appropriately, with research as well and better understanding on those ends, really prioritizing community driven research as well. >> thank you, doctor reataza. now let me recognize the ranking member, mr. brady for five minutes. >> thank you, chairman. you mentioned the national suicide lifeline has transitioned to a simple 988, which i think sounds terrific. but i did not catch what the timetable was? when does that happen? >> shortly, within the next couple of months or so. >> okay, soon. we ought to do our best to get that word out, thank you for that. i know our law enforcement community deals with mental health issues every day, i am pleased to see our former colleague from his committee, and former sheriff, dave reiter from washington state has joined us. >> and i want to say, a nice guy. >> a terrific guy. >> although, i think he enjoys sitting over there, rather than over here at the moment, mister chairman. it is good to see you, dave. >> [laughs] >> [laughs] >> there are criminals who would argue with us over there. so, like the chairman said, i would like to thank all of the witnesses. i want to, if i may, direct this question to miss hulsey. thank you so much to be here, sharing those heartbreaking stories, your testimony stories. like jonathan scott, matthew billings, they are powerful reminders of the devastating effect on mental health problems, substance use disorder, have all communities across the country today. i would wager every member of this committee has a story as well. a friend, a colleague, a loved one who we have lost to these issues. >> i remember when we first worked on the support act in 2018, the dangers of fentanyl which is coming into view for us in congress. now, a few years later, fentanyl is the number one killer of young adults in america. so just think about this. if you have a child between 18 and 45, your biggest fear about losing them does not come from cancer, car accidents or crime. it comes from fentanyl. it comes from fentanyl. it is a shocking change how quickly this occurs in our country. so, miss hulsey, how has, since we passed the support act, how his fentanyl changed the substance abuse landscape? how do we catch up to these challenges? >> i think fentanyl is driving overdose deaths and mortalities, not just in patients from opioid use disorder, but stimulant abuse disorder, using methamphetamine, cocaine as well as prescription stimulates, like adderall as well as sedative use disorder, with so many counterfeit pills, countenance xanax which is out there, laced with fentanyl. we need to have ways to address this, to intervene sooner, to have more prevention. law enforcement strategies to disrupt fentanyl coming into our country, and making its way into so many communities with devastating effects. one of our moms wrote in, her name is angela. she lost her beautiful daughter emily to a fentanyl overdose. she had six times where the therapeutic dose would be of fentanyl, when she lost her daughter, with very little warning. there is so much we can do, but this takes a collaborative effort with both line forsman and policy makers, like yourselves, treatment providers, families, making it easier to get the care that we need. >> let me ask you this, miss hulsey. you are in the trenches, you run a terrific program. you deal with this every day, you see successes, or the shortcomings. what is, for congress, what is the most important thing that we could do to help you succeed, obviously in prevention, providing services in having that. what is the number one thing congress could do it to help you? >> i think the number one thing that we need is to actually implement that scale, all of the things we have learned and have proven worked. it is very frustrating to be in this space, you know, our families are at the epicenter of this, there is so much loss which we are experiencing. yet, the science tells us all of these things we need. medications for opioid use disorder, alcohol use disorder. we would like medications for stimulant use disorder, we need more tools. but the tools we have our decades of research, that they work. yet, they are not implemented to scale. we have early intervention programs, like esper which works, programs for kids, kids like me impacted by parental substance use disorder. on one end, the essex county, massachusetts is amazing. yet, we don't take them to scale, we don't implement them systematically or make all of these resources, these findings from sciences available in all of our counties. and if we could substitute that, i think they would be a way for us to turn the tide around. >> thank you so much, miss hulsey. thank you again to all of the witnesses. i yield, mister chairman. >> thank, you mr. brady. let me recognize the gentleman from california, mr. thompson to inquire. >> thank you, mister chairman. thank you for holding this important hearing. thank you to all of the witnesses for your fantastic presentation. i just want to go back and comment on one thing which was said earlier, i think was incorrect. president biden has handled this pandemic quite well. first of all, he did not deny that it was real, he encouraged people to get vaccinations and to be careful. he provided critical funding for shots, tests and to get kids back in school. as a matter of fact, when he became president, 48% of our schools were opened. today, 98% of our schools are open. i think that is an important thing to mention. also, as we talk about drug addiction and mental health, i think that it is critically important to note 25% of our world population is impacted by a mental health issue. and at least one mental health event in their life. at the same time, around 70% of people with mental health issues do not have access, nor do they receive treatment. >> we can talk about this all day, but unless we make some investment in neurological research, we are never going to get ahead of this curve. i think that it is important to point these things out. i think that it is a bipartisan issue. we should all be concerned with this, and figure out how we conduct that research, fund that research in order to deal with this problem which affects every one of us and every one of our families, somehow or another. doctor chapman, i have a question for you. i have been working on telemedicine since my time in the state legislator in california in the 1990s. and i am convinced that it is not only important, but it is critical that we make advances in this area. i want to thank ranking member brady for voicing his support for tele-health in his opening statement. this is something we all need to work on to make sure that we make the advances necessary. but doctor chapman, you also mentioned tele-health. and you mentioned a key barrier for treatment to those struggling with addiction and mental health. and that is the stigma of both. so now, do you believe that by using telemedicine more generously, that we could help deal with the stigma issues that surround addiction and mental health? >> thank you for that, a pleasure, it has been an absolute -- i am not a psychiatrist. and in 2013, i went back to howard university. i went back because, i needed the support of the psychiatrists and so forth. and the psychologists. so when we designed this telehealth platform for an urban population, we looked at the profile of our patients. whether it is homelessness, the statistics that talked about, homelessness, you know that the patients don't have internet connections. if they had cell phones, they are very limited. so we had to design a process for a practitioner like myself, in the city, not connected to a hospital, how will i get those services to a patient who walked into the office, and the number one issue is that someone very close to them died, they lost their housing last night? these are the types of things that make providers not want to treat them, because they don't have access to those services. by bringing tele-health into my office, i am no able to access, simply by putting a patient in one of the exam rooms, and connecting him to a social worker, connecting them to a psychiatrist or, if they have legal problems with a parole officer, i can connect them to a pure navigator. this takes the burden off of me. that reduces provider burnout. and provider burnout is the number one reason why providers like myself will not treat these patients. many providers who have been certified and have an excellent number to provide people, but because of these other support services, if they are not able to institute these easily, it scares them off, they back off of treatment. >> thank you, doctor chapman. my time is expired, i go back. >> let me now recognize the gentleman from florida, mr. buchanan to inquire. >> thank, you mister chairman. i can't imagine anything more important than mental health, especially today. i also want to thank all of our witnesses, miss hulsey, i want to ask you, all of us, those stories were so powerful. you know, i have a nephew, struggling a semipro, a very competitive hockey player and got addicted on drugs. unfortunately, they have been battling, my sister and him for 20 years. it is an incredible struggle. it seems once they get addicted, many of them go through that door, if you don't get to them early, as with prescription drugs, there's a good chance you lose most of them. >> i don't know what you find, but what more could we do about the front, in terms of prevention? it seems to me, whether it is kids or anybody, if we catch them early, it makes a big difference. because where i have seen over the years anyways, many of them, even if they figure out a way to manage it, it is brutal trying to manage the process. i know people who have been successful, who have been addicted to cocaine, alcohol, and they went to rehab for one month, a year, every year if they have to or they will lose everything. but, you touched on prevention. what is your thought? i guess this is two questions. one is once they go through the door, what are the chances of coming back based on what you have seen with all of your stories? the bigger question for me is, how do we do more in terms of the prevention on the front and? because otherwise, the cost, the pain and suffering is brutal for the family and communities. >> thank you for that. i am so sorry that your family has struggled with this as well. you know, going upstream as we say, both in preventing addiction and intervening early is so critical in this. in no other illness would we wait for it to get worse before we intervene. we would never wait for stage four cancer before we engaged patients in care. the same is true for addiction. i think everybody can recover, recovery is possible, recovery is beautiful. we have had so many positive, inspiring stories of those who are in stable recovery and how they got their, even putting out a patient journey map later this month to detail that. but you are right, the quicker we intervene when someone has developed a substance abuse disorder, the better the outcome is. and most addiction begins in adolescence, or young adulthood. so, making sure that we intervene at the time of onset. most of our treatment is set up for adults. yet, onset is in adolescence, which is something we really need to address. there are programs. we all know what eaps our, employee assistance programs. there are also really important student assistant programs in middle and high school -- >> let me ask you one more question, before we run out of time. as a family member, no one wants to get the call i got last week, we probably all got the call. as a family, they found their son, three tours in afghanistan, committed suicide in the area that i represent. you know, it seems like it is 50% greater than the general population in terms of suicide deaths amongst our veterans. what are your thoughts and ideas about where we are at, and what more we need to do? i can tell you, one of the things that i have left says, we do a good job bringing the kids in, as a marine, in the boot camp. we don't do a good job in his opinion, when they come out of the service, also having a boot camp. that was his term for on the way out. and his son struggled for quite awhile, he finally took his life last week. >> i am so sorry to hear that. i think that we do have treatments and interventions for those who have co-occurring disorders, struggling with mental health and substance use disorders, and those services really need to be available to our veterans. we have interventions and programs that work, which started a treatment court, so successful which combines wraparound services which we need for our veterans. but we don't apply those solutions at scale to all those that need it. i do think that it should be a huge priority area that we focus our time and resources on to make sure there is a safety net there. >> thank you, i yield back, mister chairman. >> thank you, gentlemen. let me recognize the gentleman from connecticut, mr. morrison to inquire. >> thank you, mister chairman. thank you for holding this important hearing. i want to commend president biden, last night as well, for underscoring the need for us to come together around issues that i think everybody here in this committee agrees, are nonpartisan and deserve our direct attention. miss regina labelle, in your you spoke about mental health, which impacts substance use. in my district, in our community, which has deep poverty levels, it accounts for over 25% of accidental overdoses. what policies do we need to pursue, to address this addiction holistically? >> thank you, congressman. i am very familiar, from connecticut, familiar with hartford. i was actually there last year, with the office of national drug control policy. and i think that there are a couple of things. first of all, there are good harm reduction programs which exist in hartford. they get people who might not be receiving services elsewhere. they get vulnerable populations the help that they need. they get them the deluxe own if they inject drugs, they get them syringe's by can prevent them from having infectious disease. that's one piece. i think they prevention is examples of good prevention programs that work to build communities of care, that have wraparound services for families. finally, i mentioned my testimony, you know, i am a strong believer in the child tax credit, to help families experiencing poverty, and to lift children out of poverty. also, to address some of the adverse childhood experiences and trauma which are often accompanying poverty. those are three things i believe could help in that area. >> thank you for your answer and your clarity. with that, mister chairman, i yield back. >> i thank the gentleman. let me recognize the gentleman from nebraska, mr. smith, to inquire. >> thank, you mr. gentlemen. thank you for the panelist as well for this timely discussion but i think is needed across our country and i appreciate the opportunity to continue this conversation we began exactly one month ago with the last full committee hearing, on help mental health care has been impacted by the pandemic. as i said then, the events of the last few years have made clear just how important the mental health component is to our health care system. especially when dealing with trauma and tragedy. whether our constituents are impacted directly or indirectly, natural disasters like flooding and hurricanes, novel infectious diseases like ebola and covid, or barbaric words like what is occurring in ukraine can impact mental health and develop problems with substance abuse. we have seen this risk during the early days of the pandemic as alcohol sales shot up, just as in person support group meetings were banned. now, we are finally seeing covid related restrictions relax, and other people crazy normal, social interactions but long lasting damage has been done, nothing can bring back those who died of suicide or overdose, while isolated from society, for their own protection. appropriate treatment for substance abuse or related behavioral health issues is more complicated to manage other conditions, or a simple prescription can manage a health concern for months, or even years. instead, a major component is interacting with a therapist, or other human being. but especially in rural areas, access to these is-limited, by virtue of distance and population density. rule areas like mine have experience shortages of all kinds in skilled health care providers but especially those who work in mental health. addressing these requires innovation and creative approaches, often leveraging modern technology. one option to expand the number of mental and behavioral health care options and in underserved communities, which i have been working on with a representative is the pure act, initiatives to enact for peer support to be included in behavioral health and medicare coverage. these trained peer support coverage leverage their own experiences with mental health, and make substance of these challenges, experience with those already in our communities to provide an inexpensive and effective resource, helping to address the provider shortfall. another important opportunity is to address access to care if you use for mental health, as it continues to grow, tele-health capacity as mentioned earlier. in rural areas, we lack a lot of these opportunities. there is widespread, high speed broadband demand which is not currently available. it is impossible to appropriate the use of audio only engagement. in areas of my district where he can't even get a strong enough signal to make a call on a cell phone, you are likely many miles away from the nearest mental health professional. people in these communities, the high resolution video connection in order to access telehealth care, it is just not a realistic option. for this reason, last year, i introduced the protecting world telehealth access act, which in addition to permanently removing barriers to rural tele-health, would also allow for audio only provision for behavioral health services, essential to those with mental health or substance abuse disorders. i hope these rare and underserved access will be considered and incorporated into a long term telehealth package, which we need to chart a viable post covid course into the future. miss hulsey, i'm wondering, what do you think are the most effective opportunities for us to use tele-health, and new technologies to improve treatment in support for those with substance abuse disorders, especially in rural and underserved areas. and then also, do you think that the audio only options for behavioral health, telehealth, can be used to effectively expand access and provide support to rural and underserved areas, without creating too much vulnerability for fraud and abuse? >> absolutely. i think expanding and making permanent some of the changes to telehealth which we saw during the pandemic will be helpful to increase access moving forward, including the audio only options for after just since, it can be tricky to turn on that video component, and we need to make sure we have better access, better connections to provide clinicians to all of our -- we still struggle with the right reimbursement rates for its services, and the addiction treatment fields. we will of congress to be able to work on that so we can keep and retain our clinicians that we have in the addiction field. there are other solutions. and i think that both telehealth and digital therapeutics to have applications, particularly for rural communities, where he might have more gaps in access to care, not enough variation of the types of care plans of some of our patients are looking for. digital therapeutics enable us to use our smartphones to help with pure services, recovery support, connections to clinicians, a very important part of recovery is building a brand-new social network, getting a positive pure network, and digital therapeutics can be very helpful with that. there's a lot of potential over here. there are red tape pieces which must be removed. i think congress could help us with those next steps. >> very good. thank you, gentlemen. i recognize the gentleman from new jersey, to inquire. >> thanks, mister chairman. i do appreciate the comments, and the words of members of both sides of the aisle. there are obviously things we can work on together, and we should because that is part of our mental problems over here. there is a democratic way, and a republican way. yet, when i was mayor of one of the largest cities in new jersey, i knew there was no democratic way to pick up the garbage. we look at those tangible things very differently than we look at problems that each one of us have. no one is totally free from those problems. the last few years made as painfully aware, our witnesses were excellent, each one of them. the testimony today removed all doubt that mental health and addiction are the crises we face. tens of millions of americans are suffering from social isolation, fear of infection, job loss, burn out. the statistics, some of these things are easier to talk about than others. the reduction and use of fentanyl is easier to talk about then it is transgender. and what those folks have had to go through for the last few years, from remarks from people in our own group, our own congressman, were not only hurtful, not only hurtful but very, very divisive. so during the pandemic, more than one in ten adults reported using alcohol or drugs to cope with stress. drug overdose deaths goes by 40%, between 2019 and 2021. an increase of 29,000 people. but access to treatment is inadequate. medicare is not subject to requirements. often, one must be hospitalized to even access to treatment. congressman chu and i are finally making legislation to legislate medicare. our fix requires mental health and substance abuse treatment across the continuum of services in settings. it will take us a long time to break away from stigma. a long time. this will improve access to essential mental health services. i would also like to point out that 25 to 50% of all people served by the mental health system have a lifetime history of brain injury. a loss of consciousness, many of our soldiers, those individuals often have longer and more severe histories of substance abuse, more behavioral health issues. we must support the individuals with suffer through these disorders to access and navigate treatment. i have been to too many weeks for friends and neighbors who are mental health systems failed. i have attended too many funerals for young people who could not overcome their valiant struggles with addiction. we cannot fail to help tens of millions of americans get access to care. if we do, more americans will suffer and more americans will die. doctor chapman, thank you for your great testimony and has to each of the witnesses provided. doctor chapman, your testimony highlighted the gaps in substance use disorder treatment across various pairs. can you talk about some of the barriers that medicare beneficiaries face, what are the solutions that we may be able to apply to the medicare program? >> thank you for your question. absolutely. support services that i mentioned before including social workers, here is support staff, it is critical. they saved me so much time. the system that we have set up allow people to introduce my patients to a social worker while they are in the office. the social worker is in a remote site. once those connections are made, then they are able to give 24/7 access to that same patient. they can call me if they have a problem, they can call the social worker, or they can call it pure support specialists that they have been introduced to. this model has has been fantastic, in terms of closing some of those gaps. when we look at the savings, i think one of the problems as you know folks worry about how can we pay for these new services, but look at the savings! look at the federal register and what's it cost the system not to treat a patient. $42,000. treatment, comprehensive treatment spread across the population. i have a population of 225 patients. you spread those costs across that population. and it may come to about 1 million and a half dollars but every patient does not need that service every day. when you spread across that population, you end up saving money through the criminal justice system because they are not going to jail. you save money because they are not overdosing in going to emergency room. you are also able to re-engage patients, especially if they have children, so that the children are not going into foster chair. >> thank you, so much. >> thank you dr. chapman. >> let me recognize the gentleman from new york, mr. reed. >> thank you mister chairman. first i wanted to recognize miss hulsey, it is my understanding that you have family members who are you are associated with that you are tuning in today. i just want to recognize angela, jim, watching him tuning into this here. obviously thinking about their loved ones who have been lost to addiction in opioids and fentanyl, all of the issues that we are talking about today. my thoughts in prayers go to you each. angela, jim, we appreciate you using that horrific situation in such a positive way by participating today. mister chairman, i will open my remarks by confronting the issue of stigma. as someone who surrendered to his higher power almost five years ago, dealing with the demons that we are talking about here today, i have to tell you it is time for us to come out of the darkness. it is time for us to celebrate, as has been indicated by each one of those witnesses, recovery. the best decision i ever made my life with that decision i made when i went to my knees and turned my higher power in the program that was associated with. wrestling that demon under control. my life has improved so drastically, in a positive way. i'm here to be a message to all those who are in the darkness still. all those who are facing addiction, all those when they reach out for help and or denied, because i know exactly what that experience is, i will tell you do not give up hope. do not turn back to the demon. don't give up! if you embrace recovery, if you have the strength to ask for help, i can assure you there are millions of us around this globe who are pulling for you, standing with you, and will do whatever it takes to get you out of that dark place and into the light of recovery. with that being said, one of the things i experienced, and i think alex rivlin talked about it directly correct, it is a question of money and a question of structure. i want to focus on the structure side of this conversation. what i have seen is that we have a silo effect of substance abuse counselors, and mental health counselors, they are not reimbursed in a way that makes any sense to me under our federal health care system. that needs to change in my humble opinion. i hope every witness on this panel will agree with that. i have also seen, when we talk about a 12 step program when it calls for you to surrender to a higher power, often our treatment providers will not talk about those spirituality issues. we'll not talk about the power of religion, because somehow that is something that is not to be discussed in our public system. i've got to tell you, if you do not have a spiritual reawakening as part of recovery, it is very difficult to succeed. i am going to ask you, miss hooks lee -- how or is there a structural barrier into incorporating, documented successful treatment programs based on a 12 step spiritual based type of recovery program that prevents you from treating or giving your patients mr. chapman, i will ask you the same question. the best opportunity to get into recovery and succeed in life? another barriers that you face in new treatment model that we need to change to encourage that peace of the treatment protocol to be there for those suffering through addiction and mental health? >> absolutely, congratulations on your many years and recovery. and for sharing your story, this is some of the pieces that we need to do more of to tackle stigma around addiction, telling our stories. 12 step programs, all of the different variation of support group, mutual aid support groups that are out there are really the foundation, it beautiful part of our recovery system in america. it has been proven by science, we have the data that it works, it is helpful. in our research and our work of network of patients and recovery in addiction, 64% of them rely on support groups for the long term. this is what we need to stay well and keep healthy. if you look at sort of the scientific components of it you are attaching to community, you are dealing with shame and self stigma, you are creating positive pure connections. there is sea p t into the program there is training in how to manage the chronic condition. it really is one of our most important resources. some of the barriers can be misinformation and not understanding that you need to choose a brand of mutual support. there are so many different ones. a secular program, a religious program, some that are focused on certain substances. i think if we have more education for our providers and practitioners in the field to let them know how important it is of being aware of the resources available in their community. >> miss hulsey, i know my time is expiring we can talk about this for hours. i just want to thank the chairman for highlighting this. to know that there are solutions here. especially with a program such as 12 step, 64% plus success rate. we should be embracing that, and embracing -- removing all barriers so people can get the help they need. thank, you i appreciate the tenants courage are stepping forward in a public arena. with that, we will recognize the gentleman from chicago. mr. davies to inquire. >> thank you mister chairman. let me thank you for this very important hearing. let me just thank you for your testimony, and all of the witnesses, and also your interaction with my office. as chairman of the subcommittee, with your distinction over child welfare i am deeply concerned about 40% of the youth coming into foster care due to parental substance abuse, including about 20% of infants. this committee has bipartisanly invested in policies to strengthen these family so that children can grow up safely at home. policies like federal reimbursement for inpatient family substance beuse treatment, and outpatient services for parents to keep children from entering care, and the regional partnership -- like that received by kentucky stark, as well as through various tax credits for children in moderate and low income families. miss labelle, can you speak about how family centered approaches to treatment that provide wraparound care for families and can limit adverse childhood experiences and childhood entering care. >> thank you congressman for that important question, i think if we separated into three stages of child life, taking into account the pregnant woman. so first of all we need to make sure that pregnant women get the prenatal care that they need. particularly if they have a substance use disorder. the women with substance use disorder often keep them from getting very necessary prenatal care. that is one piece. the second piece is once that child is born, too often women no longer, postpartum women are no longer eligible for medicaid which often causes, again, women not to get the type of treatment they may need if they have a substance use disorder. lastly those wraparound services, that family centered care that takes into account that a child is not separate from the parents, the parents and the child all need services. the parent navy treatment but the parent may need other services such as housing, such as parenting skills. again to prevent foster care placements. the family prevention act that passed a couple years ago, the renewal of captain which is happening right now, all of these things can take into account family reunification go that we have. thank you, congressman. >> thank you very much. i have been told that drug addiction is a complex brain disease that is characterized as an uncontrollable desire to continue taking drugs with the tendency to increase overtime. this results in a physical and psychological dependence with at risk youth there are many factors involved with drug addiction. early stresses, use of dogged by a family member, peers or friends who use drugs, financial crisis, academic pressures, all kinds of things! what's seems to work best, one of the best practices with preventing and successfully treating youth using drugs? >> is that for me again, thanks. i think, you know, first of all pediatricians for many people play a really important role for young people and identifying risky substance use. they may not be at the point where they have a substance use disorder, but that is why that early intervention by a pediatrician or primary care doctor is really important. the second thing, i think, is the role of parents. many of us are parents a lot of kids don't listen to us, and certainly feel that way with my son, but they do. if you talk to kids about how. risky early substance use is, make sure that they know that if you are using substances they can talk to you. they can get the kind of early intervention that they need. i think the goal of the parent, as well as certainly schools playing an important role, parents and communities -- also the substance abuse and mental health service administration at h h s, has really good tools for parents on how to talk to their kids. it is called you talk, they listen. it is about, talking to kids about alcohol use, marijuana use, two of which are the most commonly used substances by young people >> thank you very much. and i yield back. >> i thank the gentleman. let me recognize the gentleman from pennsylvania, mr. kelly, to inquire. >> thank, you chairman. great hearing. mr. reed and i are good friends, i know what he has gone through. really good to put it out there, so people know. i had a similar situation with a family member, that started, at age of 14, it really hit home with me. i have been going through this for 28 years. i have to tell you, most people who have this problem wish they were the only person, the only family that had it. but this is not true. i am just trying to -- get my eyes and brain around this. because the size and scope of this problem goes far beyond anything. so everyone on the panel, thank you for what you do. it is like the rock of sisyphus. you push that rock up the hill, as soon as you do, you have to do it again. i can tell you that i've been through so many starts, sat through graduations, combinations, it felt so good coming out of that only to find out, that disease was waiting for this person out in the parking lot as soon as they left whatever it was that they were. but i was looking at this thinking, maybe you can help me with this because i do not know where this ends. this is my understanding, there are about 14,000 addiction rehab centers in the u.s., serving a total of 3. 7 million individuals. this industry, and you talk about a big business, right now in 2020, it was worth about 42 billion dollars. billion, with a b. flip it to go to 53 billion by 2025, driven largely by private equity investments. but a criticism, just an understanding. this is a big business. in total, there are 11,000 pounds of fentanyl risks sleeved at the border last year, enough to kill every american seven times over. and according to the border patrol, in texas alone, 8670 pounds of narcotics, including 588 pounds of fentanyl were received from mexican cartels. the street value of the seized drugs is 786 million. why do i bring this up? i can remember president trump talking very clearly about what he told his kids. don't get started on alcohol or drugs, because then you won't have to stop. i look at, this illustrates there are no secrets, but a lot of things we don't talk about. the stigma of having this happen in your family, and reflected on me that somehow i was not aware, i did not do enough going in. i should have done something more, we all have these wonderful pieces of legislation we are telling people about, to say this is where ice sponsored, when i cosponsored, this kind of stuff. it is not made a difference. we are spending money like there is no tomorrow. in the rate of recidivism on this, i want to ask you miss hulsey, but the cure rate. we are very optimistic that it will be okay. i just went through another and she program, but started 28 years ago, with the same person. i am trying to figure out, is there something out there we don't know? the idea is, if we start, you won't have to stop? easy to say, is there anything you can think of right now? i know we are aware, you guys are dedicating your whole life to it. but we are only chipping away at an iceberg. i don't know how to change it, i wish we could have more meetings, mr. chairman. you have done a wonderful job on this. but let's stop talking about it and find it where to direct the money. we are throwing money at a problem, throwing it, throwing it, and not getting a good return on that. maybe we are throwing it in the wrong places at the wrong time, to the the wrong folks. so miss hulsey, if you can, we are almost out of time on this, but i'm with you and all of this, all of you have done a wonderful job, thank you for being here today. it's no longer but republicans or democrats, but americans facing the greatest threat to the generations that have come after us that we have right now. so miss hulsey, i know you don't have much time to follow up on, it will stay in touch with you. any other ideas? because you've got to get these kids, the destruction of our nuclear family is really one of those things that we worry about. so i think miss halsey, that you could help with, that could be positive, and do this today now. a couple things, you're right about when you don't start this, without going down that road, that's easier, most people with an addiction are struggling with an alcohol use disorder, and delaying the age of onset, it's so vulnerable, prevention is really about pushing back when you're about to use anything. we just put out an awareness campaign about this call protector brain. the other part of this is just addressing the myths and misinformation that exist, from waiting to rock-bottom, this is an acute issue and a chronic condition that we need to manage for years these are things that we need to change. congress can play an important role in getting information out. >> thank you all for being with us today -- thank the gentlemen. thank you mister chairman for your leadership on this issue -- i want to thank all of the witnesses -- over the last decade our country has seen an increase in addiction and suicide. and other mental health needs, has determined has determined the -- to access the support that we need, and the consequences have been deadly. in 2020 alone, nearly 150,000 lives were lost due to suicide, and thousands more were impacted by the loss of family members. we have in my family in my family, -- my heart really goes across the nation for those that have lost the loved ones, either due to overdose covid, or any of the stressors caused by that pandemic. as our witnesses shared, there is an urgent need, because americans from youngest to oldest, where they need it. i have an opportunity to follow evidence based strategies, which will help all americans with care. that's why i am deeply troubled to learn that despite rising suicide rates, stateside florida and texas are advancing policies that place lgbtq youth at increased risk of suicide with youths of color fading grace or greater risk than those their counterparts. specifically, texas is having state agency workers who are paid through your taxpayer dollars, to investigate parents who support their children for expressing who they are. now, i am a mom. i firmly believe that no child part of a loving and informing community, should fear be taken away from them. doctor, giving your expertise on the structural, social and environmental factors that impact mental health, could you say more about the influx of these forms discrimination, and raise themselves on the individual's well-being? >> thank you so much for your question. you are right, that is exactly what our research focuses on. i am an addiction specialist, but i just wrote a book on suicide in america iowa working on the suicide component of this. and certainly, there are several forms of discrimination which have happened here, feeling like there is xenophobia, hatred directed towards someone's own group, or even their group not being recognized by their own government, state, leaders or things like that, it could lead to a sense of despair. this also goes hand in hand with a lot of the social economic disparities that accompany the stigma. so one of the sources that i cited in my report says, basically depression of course is two out of ten adults during the pandemic, but five or six out of ten adults who have less than $5,000 of savings in their account. so, this despair goes hand in hand with social economic factors, defaced disadvantaged groups as well so there's a real imperative to address economic inequity in a way that feels like people have that. also, there are stress factors, risk factors on issues like suicide, the last book that led to an in-depth gun suicide, i know it's a very hot, contested topic. i am not coming at this as a pro or anti gun person. i was born on a military base. i grew up in missouri, have been around guns my entire life. but i would also say in moments of despair, having fire arms around the home, giving firearms to people who might be at risk, in tense moments, it also has particular negative outcomes. so i have worried about what has happened with firearms in the kinds of isolation, people particularly in the age of 18 to 21 each gap, also the economic factors, economic stress can lead to that despair. but when you start to look at issues of disparity, what you start to see is, they look not just to societal attitudes for particular groups, but what are called intersectional. they intersect with all of these other issues about social economic class, factors. there is a vital part of this story. >> thank you. doctor reataza, like you, i grew up in a tight-knit community. and then fortunately, that does not always mean it is easier to openly talk about the mental health issues. what do you do about the role for community driven, culturally responsible mentally behavioral services and helping communities access the support that they need? >> thank you, representative sanchez for the question. i think that ultimately, the role that we play is organizations, we hope to direct services and provide access to services that i think are otherwise inaccessible to communities such as ours and, you know, i am also it native resident of california, i am in los angeles. so we grew up with a large number of other minorities and communities. we see this time and time again, the models that work really, they really prioritize our own community members, our own community leaders, our own researchers to go into the communities to be able to ask questions which would otherwise not be able to talk about. they are also great models that help us with the latinx community, as far as being able to engage with community members and helping them find direct services. this goes along with health care and mental health, behavioral health services. this is similar to what we are seeing in the hp community. people trust members of their own communities, a lot more than others. so i believe that one of the ways in which we could really strengthen how we address stigma in our communities as well as all communities is to really be able to talk to each other better. and this involves access to communities that will be accessible. >> thank you so much. >> thank you, young lady. the gentleman from missouri, mr. smith is recognized to inquire. >> thank you, mister chairman. substance use disorder is an issue, plaguing our nation, that republicans take very seriously. and we have the record to prove it. in 2016, republicans passed the comprehensive addiction and recovery act into law, making the first major federal legislation devoted to combatting substance abuse disorder in 48 years. but we did not stop there. in 2018, with president trump's leadership, we passed the support for communities act into law. this legislation included several important provisions including one that i personally worked on and wrote. it was designed to monitor the use of opioids, during surgery, to reduce the risk that patient suffers from addiction later. washington democrats have destroyed all the momentum, making a bad problem worse. addiction is a disease of isolation. during the pandemic washington democrats and joe biden promoted isolation, and mandated lockdowns and mask requirements. it is hard to believe that they suddenly believe about substance use disorder today, after keeping liquor stores and marijuana stores open as essential services while shutting down addiction support groups. after just last month, they proposed distributing free crack pipes. to propose aid to those suffering from the disease. -- democrats continue to hurt americans. my district alone suffered 350 overdose deaths in the calendar year during the pandemic. in the state of missouri we suffered over 2000 over dead of death while our nation suffered over 100,000 overdose deaths this may 2021 the deadliest overdose year for any country ever in history! this increase in overdose death is directly tied to the emergence of fentanyl, which is shipped from china to mexico and then smuggled into our country through the gaping hole in our southern border. fentanyl is deadly with 50 to 100 times the potency of morphine, and that cartels are mixing it with other drugs to make them even more addictive and dangerous. worst yet, cartels are also producing lethal counterfeit prescription medications laced with fentanyl. even without control in congress, republicans won't stop fighting to protect americans from the threat of fentanyl. we tried to pat legislation a month ago that would've made it illegal to use fentanyl and similar drugs outside of research purposes. washington democrats blocked that legislation, even though the biden administration recommended a similar strategy last september. we must empower our nations law enforcement to stop fentanyl from for more families have to bury their loved ones. miss hulsey, could you elaborate on the harms of these counterfeit fentanyl pills and would restricting the supply of fentanyl coming into our nation save lives? >> absolutely. anything we can do as a country to prevent fentanyl from being so prevalent would save lives, immediately. we have fentanyl that we are finding in methamphetamine's, in cocaine, in counterfeit xanax, counterfeit adderall, counterfeit opioids. the effects are devastating. we have so many of our families who share stories of someone taking what they thought was a prescription medication, maybe not from the right source but to have a substance use disorder and in effect it is poisoned. we need more resources, more tools, all hands on deck to help us with the issue. there is a really good awareness campaign that the d e a put out called one pill can kill. each and every one of us on committee just to talk about this to make sure that people in your districts are aware of the prevalence of fentanyl, all subsystems and three drugs, counterfeit prescriptions right now, it would be a very helpful awareness piece. >> thank you mister chairman, i yield back. >> thank you gentlemen, let me recognize the gentleman from new york, mr. hagan's to inquire. >> thank you mister chairman. substance abuse disorder continue to be a public health crisis as we have heard. it affects millions of americans, it is disheartening with these numbers. but it is important to remember as we heard from our colleague mr. reed, his compelling testimony that there are good people in organizations that strive every day to help those recovering from substance abuse disorder. my district in buffalo new york saved the michaels of the world is a nonprofit to help educate communities about substance abuse disorder and provide support and resources for individuals. substance abuse disorder suffers and their family. save the michaels was founded by abe and julie israel after their son michael died by suicide, after struggling with opioid addiction. when it comes to treatment, and to treating substance use disorder in particular opioid use disorder, we know a great deal about what works and what does not. medication assisted therapy, of which 1. 4 million americans now seeking, in conjunction with therapy and community support off tours the best chance for folks recovering from opioid abuse disorder. medication assisted treatment are controlled substances, and we should be thoughtful and deliberate with how we regulate, providers wishing to offer medication assisted treatment face a complicated web of reimbursement and regulatory guidelines that can be difficult to navigate. they can make medication assisted treatment financially unsustainable. diversion and abuse of medication assisted treatment is a real concern. evidence strongly suggest that if you want to reduce diversion and inappropriate use of medication assisted treatment, the solution is to make them more accessible and to get more patients into treatment. doctor chapman, can you speak more about your experience in navigating the rules of administering and being reimbursed for medication assisted treatments. how can we increase access to them, responsibly, and make the progress of administering paying for it and disposing of them less confusing for providers. doctor chapman? >> thank you for that question. from my perspective, expanding medication assisted treatment is going to be the key to curbing this epidemic. we know that opioids, unlike any other addiction, has a 90% relapse, without treatment. the problem is it is so closely mirroring our own endogenous dopamine system, our feel-good system. and we know now that there is a genetic component to it. a person may, a young person break an arm or sprain ankle, go to the emergency room and with that first dose feel different, feel that this is the greatest thing that ever happened. on the other hand, i am allergic to morphine. we can see that there is this wide spectrum to how each of us responds to this medication. medication assisted treatment needs to be available to anyone and everyone in the country. we know from our experience that, if we leave pockets of patients untreated that drug suppliers and patients will find each other. we cannot leave any community untreated, any person untreated. i think free access, similar to france and portugal, where they had similar problems 20 years ago at the same time that we did, they turned to medication assisted treatment with methadone and if it nor friend. there was a dramatic decrease in crime there is a dramatic decrease in aids and hepatitis c of course there was a dramatic decrease and overdose death. we know from international studies, because of our system the fact that we do not have universal health care makes it very difficult for us to penetrate and replicate what we know works in other countries where they do have universal health care. >> mr. rice to inquire. >> thank you mister chairman for calling this right important hearing. thank you shoot the witnesses for sharing their stories. this is certainly a topic where we need to do everything we can to tackle the rise in drug overdose deaths it is shocking by any measure. if you it look at it i have been in congress for nine years i think every year we have adopted at least one or two or three bills. to adopt new programs, to find supporting act is certainly a milestone. i'm sure all of them have helped at the edges. i agree with mr. kelly. it seems that we are attacking an iceberg with an ice pick. we are just chipping around the edges. it almost seems helpless if you look at the numbers. 1999 until today i mean, the graph just goes like this. i mean, almost straight up! it starts out with cocaine type drugs and then harrowing kicks in and makes it rise further. finally, synthetic opioids, fentanyl. the reason for that is because fentanyl is so extremely cheap and extremely available. a street dose cost less than $5. it shouldn't cost less for $5. supply and demand but there's so much of it on the street is it is so widely available to everyone and it results in this straight-up graph. it mostly affects, while everybody but it inordinately affects african americans and people in poor communities. last year fentanyl, or excuse me opioid deaths were 100,000 people in the united states. this is a time south carolina last year, opioid deaths increased by 50%. 50%! the primary driver is that, cheat, available drugs. have a chart here from the national vital statistics system that tracks these death, i would like to enter for the record mr. chairman. >> to order. >> if you look at this chart, interesting thing where it goes up almost every single year, it actually does go up every single year from 1999 until this year. except for one year, that year was from 2017 until 2018. in 2019 goes up but not that much, with covid starts going up radically again. what was different from 2017 to 2018? where can we learn from that? if we look at our southern border 90% of the hair when that kills people in the united states comes from the southern border. cocaine, 90%. fentanyl we had 2600 pounds in 2019. 94% of the fentanyl seized in the entire country was at the southern border. 21 it was 10,589 pounds. 95% of the fentanyl seized in the entire country was seized at the southern border. that way is enough to kill every person in the united states six times over with the single dose. homicide, if you just don't look at the drug desk and you look at the homicide deaths in the united states. 24,000 people were killed in homicides. i would venture to say that two thirds of that was related to the drug trade, drugs coming over our southern border. homicides have increased dramatically over the last two years as a result of the defund police campaign, increased violence, and the increased drive flow at the southern border. these homicides obviously mostly affect poor communities. african americans are eight times more lightly in a homicide death. if you don't to look at our homicides, look at mexican homicides. 36,000 people died in mexico. this is six times the regular of the united states. i would venture to say 90% of those were related to the drug trade, cartels, and things. resulting in 36,000 deaths. so folks, this isn't rocket science. if you look at what happened when president trump came in and we clamp down on the southern border, for the first time in 30 years the number of drug does actually decreased, for the first time in 30 years. the policy of the biden administration to encourage people to the southern border number one, and number two to relax restrictions on the southern border is killing people. it is absolutely killing people. this is not a question, it's a fact. just look at the graph. i would say that, you know, so many of these programs so many of these additional dollars are chipping at the edges. if we really, really, want to make a difference to the people who need it the most. and we really want to save tens of thousands of lives, we have got to increase our presence at the southern border. we have got to have a real southern border, we have to seal it up. mister chairman, i yield back. >> thank you chairman, we recognize the gentlelady from california miss shoe to inquire. >> i would like to thank the chair for holding today's important hearing and for continuing our focus on mental health issues. i was so glad to hear president biden address mental health last night. i look forward to soon introducing legislation with representative pass corral to close many of the gaps in medicare coverage for substance abuse. including for intermediate levels of care, expanding the list of eligible providers, and improving reimbursement. i welcome the support of my colleagues on both sides of the aisle on this legislation and as we develop common sense motions that treat some of the most vulnerable medicare beneficiaries. doctor reataza, thank you so much for being here. thank you for your testimony, for highlighting the impact of the past two years of increased violence, abuse of asian americans has had on the mental health of our communities. can you expand on how the rise in anti asian hate during the pandemic has influenced substance you in the ap api population. has your organization seen more used and need and drug use since the pandemic began? >> -- especially during this time where there has been, as you mentioned, as we discussed earlier, and increased rise of anti asian hate or violence directed towards asian during this time. yes, we have seen an increase in stress and anxiety. you know, as well as altogether mental behavior many health challenges and concerns that our community are facing. ultimately people are afraid, they are afraid for their lives, they're afraid for their loved ones, especially our elderly and our girls. ultimately that has resulted in and increase use of substances. there is a lot we have seen. a lot of increased use in tobacco, things that can be smoked or inhaled. we also have seen some increase use in alcohol, ultimately we have seen a rise as i mentioned and overdose, accidental overdose related deaths. this is something that has been highlighted by a number of individuals throughout this discussion. we have seen substance use rise altogether. even when it comes to stimulus and opioids, i believe it was miss hushed lee who said a lot of stimulant are even laced with opioids. there have been a lot of death related with those. in that capacity i do want to remind a lot of us here that opioid disorder was also driven by industry. you know, that is something that i know is tricky to tackle but we have seen it time and time. and we see going through the api community as well. the short answer is yes, absolutely. >> doctor reataza i also want to touch on a statement that the api community has suffered from stigma in accessing health care. -- because of this barrier, that is in addition to the linguistic and cultural differences that you noted in your written testimony. can you discuss how bills like the stop stigma in our communities act can help increase access to care for minorities struggling with substance use disorder, especially in the aapi community. and also how immigration status could prevent aapi's from seeking the help that they need. >> thank you again for this very important question. everyone on this discussion address statement today. i believe stigma is a huge barrier to addressing mental health behavior, substance use. any kind of addiction, including problem gambling, which is a big part of our community. when we are not able to talk about issues either, you know, openly admitting them with a close family or friends. these things do not get addressed. they don't get addressed and when you can't address them, how can we know what's the needs are? how do we know how to serve our community in the ways that everyone on the panel is really striving to do. i think, you know, the bill such as this one is an important one. i think this is important for api communities. i think it is important for directing a model for how do we address traditionally modulus and represented communities -- on issues that are already really difficult to talk about and to address systemically. >> thank the gentlelady, let me recognize the gentlelady miss go are ski to inquire. >> the open border policy of joe biden continue to wreak havoc in my district. the complete disregard of our border security a spirited plate of illicit drugs, including fentanyl, heroin, methamphetamine and even found a lace marijuana that's being trafficked and local communities. there's open border approaches burning everyone in my district. >> i threw in that immigration thing because i thought that it was hopeless. >> first responders and our first work and child welfare system it is costing lives. the previous administration took meaningful steps to secure the southern border and reduce drug smuggling. all of that work has been lost. it is obvious that president biden like the fortitude to stand up to the left wing extremist in his party. instead he is stepping aside to allow a wicked drug cartels to pray on americans. the scourge of these illicit drugs had a real effect on indiana. recently a local fire captain of mine district pointed out a warning that ventilate marijuana has caused a string endangered overdoses in our district. a local tv station in my district put together three part series called addiction and indiana's youngest victim. they told the story of an infant brutally murdered by an adult interested to babysit her. every murder case has multiple layers. a major issue underpinning the eventual murder of this child seems to be masks and drug abuse by those responsible for her care. the baby's grandmother also believed the 11 month old was suffering from withdrawals to exposure to matt. this woman alleges that a sibling is also suffering from ramifications of her parents addiction. that is just one example, another high profile case in my district a four-year-old was tortured and beaten to death by his father. the murder of the child has also many layered there still a common seem. there was drug use in the home. in an interview the child and who was fighting for custody often worried about the child while being told a news, quote, because of the drug use in the way their relationship was it was very toxic. the way they live was filthy. children in indiana and across the country are suffering from the ravages of drug addiction. we need to take a strong bipartisan approach to protect children and help individuals to get on the road to recovery. however we will not be able to get to that point until we stop the flow of drugs coming in across that border and into our own communities. miss hulsey you mentioned the ace intervention programs in the stock program in your written territory. both are trying to address the substance abuse disorders in the child welfare system. do you have recommendations on how you can move coordinated intervention upstream? how can we protect children from obesity parents with substance abuse issues while also helping to get those parents into recovery programs? >> thank you so much for highlighting this. this is such a critical part of our solution. i am a grown-up napa i was a kid impacted by parental substance use disorder. i have seen firsthand the difficulties that chemical addiction can create. there are some amazing programs and innovations out there. can sticky start is a child welfare intervention. it is also in ohio and several other jurisdictions now. teams work with both the parent as well as the children to increase, keeping the kids at home but also addressing recovery, evidence-based treatment, and supports for children. kids who have experience childhood trauma, due to parental substance use disorder also a high priority. there is a program in essex county, massachusetts, that works with the school system, the middle school, and kids who have addiction at home. it has social emotional learning curriculum, connection to counselors and behavioral health care, the result of this program are tremendous. higher graduation rates, lower substance use, the kids are headed off to college. district attorney jonathan blob to lead that program 70 or to go. we have solutions, we know that this is one of the most important populations to work with. we can implement things that address this really critical time when someone in a family is involved in child protective services due to an suv. we can also have better screening for all screening with adverse childhood experiences to get them the care they need. >> can i ask you one more question miss hulsey before i run out of time? homeless youth is another problem i'm sure we are all in countering. are there any programs that connect homeless youth with substance abuse services offered a federally qualified health centers? >> i am not aware of any specific programs. we are healthy to help with our network and report back. >> i appreciate that, thank you mister chairman. >> thank the gentlelady. let me recognize the gentlelady from wisconsin, miss moore to inquire. >> thank you so much mister chairman. i want to thank all of our witnesses who are participating in this very important hearing today. i want to thank mr. reed for sharing his very personal story. really helping us move to a point where the stigma of substance abuse is no longer there, something we can work on this systemically. mr. kelly talked about us dealing with this program, like chipping away at an iceberg. i say that, similarly, it is like trying to grab a problem that is sort of like jell-o. i really appreciate the fact that most of our witnesses have at least appreciated that we have to start young. we have to deal with delaying the onset of use of substances. we need to be careful with our brain injured athletes, foster youth, and others. this has been very informative. doctor chapman, i appreciate your bringing up the importance of having social workers involved. every year i've been here i put in a bill to try to put social workers in our schools so we can identify the problems early on. that being said let me direct my first question to dr. metzl. you talked about structural competency. but you also talked about how there is no magic bullet. there is a myriad of factors that contribute to this. we have the poorest of the poor who are subject to it and then you have the rich kid on the hill. i fear that we are all about the southern border if we can just fix that then we will no longer have substance abuse. i'm wondering, i was curious about your truth and reconciliation provision under structural competency. how do you see truth and reconciliation as really helping us prioritize where to put the resources that we have. also, i think that we heard doctor reataza saying we need to bring stuff up to scale. what should we bring up to scale? i would ask doctor metzl, and then doctor reataza, to talk about what we can bring up to scale to help us with this problem. i will yield now to dr. metzl for his answer. >> thank you so much, wonderful question. as these all are, i would say that i wish there was an easy answer. i wish it was this one policy, this one moment in time. unfortunately when we look at substance of these issues, depression, suicide what we see are these over result not of something that happen in a particular year because of a particular decision but because of long-standing neglect about support systems, about infrastructures, factors like that. i am all for doing anything that will help here but especially when you look at the impact on communities of color, but you are seeing is really there is long term neglect of all kinds of infrastructure. health infrastructure, support infrastructure, substance abuse, treatment, things that go hand in hand with economic inequity. >> let me make an intervention here. are you saying that these poverty indicators make you more at risk than say the rich get on the hill or say, prints, or michael jackson? would you say that poverty and inequality is more indicative of risk? >> i directly yes, i cite several references in my written testimony that support that point. this cuts across many different avenues. i certainly would say that economic despair is one part of it. you referenced a paper that -- from the beginning of the pandemic. first what we did was we called for an open honest conversation about the structural upstream drivers that aren't producing despair and on equality. one of the comments we had before we also cause for reimagining health care clinics. not just telemedicine but actual health care clinics. people can go to that clinic and people would not just treat that medical condition or other substance abuse issues there would also be resources within particular clinics to address issues that caused the kind of structural vulnerability. you can have a clinic with an internet provider. you can have a clinic to help people pay their heat bill. >> thank you sir. >> doctor reataza, what should >> doctor reataza, what should we bring up to scale that you we bring up to scale that you think would be most helpful? think would be most helpful? >> i appreciate this question. i think what we really have to understand is why the people support -- why do they get addicted to substances? there are a number of issues that we are not addressing as far as safety net, really caring for our communities. people do not have appropriate access to health care, to childcare, to job training. a lot of people do not have a livable wage, stable housing, we really need to address all of these issues that impact people social economically. when we are looking at ethnic and racial disparities and we know, we have seen, these are also issues that combined together as far as what we are seeing in trends on a local and also national scale with substance use and other addictive behaviors. >> thank you so much. my time has expired, i yield back. >> thank you gentlelady, let me recognize the gentleman from ohio doctor windstorm from ohio to inquire. >> thank you mister chairman, thank you all for being here today. this is a very important issue i'm glad that we are discussing substance abuse, mental health. the pandemic actually exacerbated these conditions in my mind. the last hearing we had here at ways and means, i touched on a couple of stories. one about a veteran, a double amputee. his last facebook post was an empty refrigerator and a couple bottles of water. then he took his life, i shared a story about a gentleman from my district who was scheduled for his painful hernia to be operated on, then canceled his surgery and he took his life. the isolation, the pain, the lack of treatment. a lot of lessons learned i would say through this pandemic. one of the other things that bother me through this pandemic was when we told people some people that they weren't essential. i think that had a big impact on other people weigh say that some people are central but other people or not we essentially don't need them. i have made a lot of mistakes, addition to the pandemic, the current border free-for-all is a part of this that empowered the cartels to go ahead to continue to exacerbate and grow their business human trafficking, drug trafficking. if you have read the book dream land, i imagine most of you have, that is my district on the cover. i know firsthand all of the effects of what has been taking place. in america what has been happening it's a problem that goes from our border all the way to work or purpose >> you have a problem with drugs coming across the border, the supply chain is great, we should do it we can to stop that. everything that we can to stop that. and then, stop the dealers who are running around our country. then, we have to take with our youth, and prevent, prevent people from ever getting in that situation. i am a doctor, a surgeon. i never thought that those drugs were not addictive. i always felt that they were. i never prescribed oxycontin for my patients. as a surgeon, i managed pain in a lot of other ways, with a limited use of opioids. there is an onus on the medical community to do this. i think the medical community has responded to this. we need to do more than catch and release. when somebody goes into rehab, that is a good thing but there must be something on the other end, a purpose, a job. or else they will end up right where they are. so it is all encompassing of what we need to do to address these problems. and i'm grateful for the hard work, some of the folks in my district like the learners center of hope, the county addiction response coalition, they have done great work. in 2018, i passed bipartisan support act, the alto bill, which is the alternative to open goods in the emergency department. and really throughout medicine, this is what we should be approaching. i think by the end of the day, we need to always address the events and issues in somebody's life that led to the thoughts and feelings that led to the behavior. if we don't do that, we never resolve these issues. as we try to be supportive of trying to solve these issues, one question i would ask to miss hulsey, are there provisions in the support act that do not apply to fentanyl, for example, that we could update, or other things within that act that we could update to address some of the heightened challenges that we have today? >> well, absolutely. i think that both the care and support act are important, so legislation with the policy changes and resources to improve treatment. and, looking at treatment options, to make sure we have medication for opioid use disorder. making it permanent, the health or wraparound services that are needed. it is not just one thing, recovery from opioid use disorder, it's managing of a chronic health condition, but i think it's important for our population. >> i appreciate that as you heard me go through all of those components that lead to the situation that we are in to think that the patient is in, we do need more wraparound services. i yield back. >> thank you, gentlemen. let me recognize the gentleman from michigan to inquire. >> well, thank you mister chairman for holding this really important hearing, and for the focus on this issue. like others, i want to share a bit of a personal story. last year, i publicly shared that i began receiving treatment to help with traumatic stress. i and a number of us have experienced's attack on the u. s. capital, with a few other members who are trapped when, the insurrection occurred, we were in a violent situation, it had an effect on me. i did not expect it to, but it did. i was lucky, i got access to a great professional, doctor jim gordon, who gave me technique and skills that i need to address. i went public with it because i felt like it was a small opportunity for me to help reduce the stigma of mental health care. we have improvements in mental health and mental health care, but the stigma still persists and they can manifest in stereotypes, prejudice, other aspects, some of which i have heard, and we expect the sorts of attacks in my business. but for someone who is dealing with a mental health issue, privately, quietly, painfully, that stigma can keep them from making the choice to get help. we know, a lot of people struggle with issues and never get help. we sadly no sometimes with the result of that will be. access to health care is a huge factor, but the stigma plays a role as well. so i am wondering, i know this has been addressed, but dr. metzl, if you might, talk about how u.s. policies may have stigmatized care for mental health or substance use, and help us understand from your point of view, what we should and can be doing to reduce stigma associated with mental health among communities, among health care providers in particular, but just in general, a population. >> thank you so much, what a wonderful question. i will make two points in response. first of course it talks about traumatic stress. it's important to note that traumatic stress results when people feel like their lives are in danger. the initial ptsd studies were done with fighter pilots in vietnam. if you flew ten hours, you had a 10% chance of getting ptsd. if you thought, you flew 40 hours yet a 40% chance. so think about it, we have all gone through this pandemic, where just something outside the door, breathing air that other people breathe, put us all at risk. i think even some people, although like yourself, or involved in direct conflicts, i feel like there is a national moment of stress where we really had to rethink our own being, our own vulnerability. we really had to ask, what is a safe space? number one, as i was mentioning before, create a national conversation about what mental health means, where we can have an open, honest bipartisan conversation about the trauma we have all been through over the past three years. and think about ways to come together. i really think this is vital, to reimagine what mental health means in this context. and the other part of course is, that fighting stigma is an ongoing battle. i wrote a book called the protest psychosis, about michigan, actually that came out a couple of years ago. and it looked at how the diagnosis of schizophrenia in the 1960s was reflecting cultural attitudes about political protests, incarceration, all of these factors. doctors thought they were healthy people. they were in certain ways, but just the idea of what mental illness was reflected cultural attitudes about politics, race, factors like that. the second point i would make is that fighting stigma is an ongoing battle. it is not just like, here is one thing we have to think about. as much as we impact it, and continue to engage with our own reflections, and have a national debate about this, i think it will be an awful day in the wrong rotten. >> thank you. if i may quickly pivot, i represent to communities, flint and saginaw, both majority minority communities. both historically marginalized communities. in flint especially, having now gone through this pandemic and also the trauma, the spate of violent crime that has gone back decades. and in flint, the water crisis. i wonder if either miss regina labelle or edwin c. chapman could come together with community issues, and sort of how we deal with these historically marginalized communities, really as a community, maybe dealing with community trauma, impacting illness as a result? >> thank you for that question. about two or three years ago, the lancet magazine put out an article, evaluating communities, actually automobile assembly plants. they found that five years after an assembly plant quote, there was a dramatic increase in opioid disuse disorder and alcoholism. we know that there is a close association with economics, on not having a job, it's sarah. the same thing happened in cecil county, maryland. an automobile assembly plant in delaware, five years later there was a dramatic increase in foster care. this was noticed by a state trooper, who happened to be evaluating some of the schools. he looked and realized, there was a 30% increase in foster care. the fact was that the parents had overdosed and died. so, all of these things directly impact. >> thank you. i love to hear more information, mister chairman, if you allow me to go beyond my time. i appreciate that, and you'll back. >> thank you, let me recognize the gentleman from texas, mr. arrington to inquire. >> thank, you mister chairman. let me dive right in on the drug addiction and the drug, illicit drug epidemic that we have in our country right now. it boggles the mind what is happening, and what our nation, but the peoples government is doing or not doing to stop a major contributing factor to this epidemic in our country. we have over 100,000 americans lost to drug overdose last year. the leading cause of death aged 18 to 45 is a drug overdose. mainly fentanyl, which is two thirds of the contributing drug to the overdose. and 100% of those drugs are coming from across the border. the 100,000 people who lost their lives in our country, our fellow americans, is at a 50% increase over the last year. the fentanyl seized at the border was at over 130%. we are losing a generation of americans to this epidemic. we are seeing record volumes, increasing, exponential volumes of drugs continuing to flow into our neighborhoods and to kill our fellow americans and our family members. and we are seeing nothing stopping the drug cartels to control the border from pushing this product on to our citizens. i will ask every witness to answer this directly and succinctly, with a yes or no. is this dynamic? he's a dynamic of drug cartels in control of our border, pushing record amounts of drugs, is it a major factor in the drug epidemic and the overdoses which are at record highs in the united states of america? so i will start from the very top, i would like to hear from these experts, as to whether or not it concerns them. so does it concern you? is it a contributing factor on the supply side, at minimum, yes or no? yes or no. >> that is not a yes or no question. >> okay, thank you dr. metzl it is a yes or no question. i'm not saying it's not other factors. i'm not saying it's not a more complicated and nuance discussion to have. but is the border, wide open, pouring drugs that are killing americans at rates that defy logic because of our ability to stop it concern you. yes or no? is it a concern? >> certainly a supply side is a major aspect of addiction, i will certainly agree with that. >> not to be rude, thank you. we are going to move on. doctor edwin c. chapman, you are a physician. is it a concern what is happening at our southern border? it's one factor, but is it a big ones, are you concerned, yes or no? indiana in the 1960's and we did not have this problem until the ste >> i grew up in gary, indiana. in the 60s and we didn't have this problem. until the steel mills closed. and then -- >> are you concerned, mr. chapman -- does the open border concern you. the drugs flowing across the border via the drug cartels that are in control of the border. does that concern you? >> we have new synthetics now. >> the synthetics are coming from china. >> they are coming from china, mister chairman. they are part of the input to making this manufactured product. it is being laced, with the marijuana that the kids are taking up in the northeast, killing teenagers. this is a big deal! the fact that, i respect these witnesses and i know they care about this. but the fact that they can't just say yes, what is happening at the border, all of the volume of drugs that are coming across the border by the cartels, with aiding and abetting by chinese synthetic materials, is, is -- i just can't believe it. i can't believe i'm sitting here with nobody to bang the table and say, you're right! we can talk about other issues but you're right. >> i don't intend to speak for the witnesses but i think we are all concerned. i think the witnesses have suggested that there may be additional answers. but i think everyone would preface their comments by saying we are all concerned by it. >> mister chairman i know my time is expired. but as a person who lives in a state on the border, at ground zero, i'm telling you we have got to do something about that. i know that there are other complicating factors. >> they are enough. >> i'm very frustrated that we haven't. >> thank the gentleman. let me recognize the gentleman from virginia. thank you so much for having this meeting today on suicide risk and substance abuse disorder. i'm so proud we are having a hearing where suicide is actually the headline. suicide rates in the u.s. have increased by 35% over the last decade. they remained high over the pandemic. nearly 46,000 people dying by suicide in 2020. more than the total of car crashes, and gun fatalities combined. i entered congress in 2015, suicide wasn't talked about by members in stepped in reaction to the veteran suicide crisis. folks knew we had a veteran issue. we also had an active suicide crisis in the broader population. even then we were seeing a 30% surge and no one was talking about it. i chatted with representative republican katko, and democrat grace--. john i started the suicide prevention task force, in graces mental health caucus. we hope to improve suicide prevention on the civilian side. we focused on restoring the suicide line at the cdc, tackling the glaring issues we knew we could help with. like the suicide lifeline which was under resourced and couldn't keep up with demand. we restored the suicide account at cdc, we have slowly been able to work out allocating more funding to the lifeline. we helped representative chris stewart, republican and seth moulton, democrat. to change the lifeline number to the easy number which goes live this summer on july 16th to be exact. i hope everyone will remember that. during may mental health month, members of congress advancing mental health package that included a great number of suicide prevention bills. including the campaign to prevent suicide. this is a bill that republican adam kinzinger and i put together two bipartisan effort to educate the public about the 988 number but also to change the culture around suicides and people know how to engage and connect individuals in crisis. the fortunately the house is taking suicide prevention much more seriously than the senate. much of that bipartisan legislation is stalled in the senate today. i just want to put a little bit of time to draw attention to the fact that the senate cannot, should not delay. we have to advances the house legislation as soon as possible. doctor metzl, i was fascinated in the written stuff that you talked about the polarization as a national health crisis. you said divisiveness is a vector that weakens nation in moments of crisis. eminent bodies like congress can -- they replace them with structures that model unity in value of cooperation over competition. i just looked at the difference in the opening statements. the tone and content of our chair and ranking members today. i don't want to blame all divisiveness republicans, that wouldn't be fair, but can you talk about how our divisiveness is affecting the american people in their mental health? >> sure. there is so much research from other points in times, other historical presidents to talk about when you are facing a crisis, a pandemic, an epidemic, one of the most important currencies is you can have is social capital, or social cohesion. this notion that we are all in it together. i realized that our political system is sort of a zero sum formulation. it is winner take all election system. we compromise is very difficult lee. what happens a lot is issues where we should all agree, things like mental health like we are talking about today. they become polarized, and identity issues in a way that might make sense in a political arena. but when they filter down they really become moments of discord and despair. these can directly lead to poor mental health. people feel like they are literally fighting with their neighbors. i think that president biden was right with what he said last night that is fomented by some of the algorithms of social media. when i was writing my written statement i just thought, one of the ways in which we can think about polarization in itself as being almost a crisis moment. i thought mental health was one of the areas where we might actually figure out where we might come to some common agreement. i have much more to say about suicide, that in my research but i can say that for later. >> doctor metzl i have a couple of seconds left. more than half of suicides are gun related. two thirds of gun deaths are suicides. yet my republican friends have an aversion to recognize the realities on the ground, how easy it is for a person with suicidal ideation to have access to again. this will be a great place to start to overcome that divisiveness. any idea on how to move forward? >> absolutely. much to say about this. that is the focus of a lot of my research. what is important to know about gun suicide is we have 25 to 27,000 gun suicides a year. it is very often an impulsive act. not someone who has been seeing their history 25 years. it was i was drunk, i lost my job, i found out something happen in my family and within 59 minutes or less email ability of a firearm is there. that leads to gun suicides very often. having urgent resources, a hotline in that moment. some access to help in that moment, that passing moment of crisis is vital. gun suicide is a different type of suicide, that is what i argue in my work. we need urgent suicide prevention in that moment of crisis. >> thank you gentlemen. let me recognize the gentleman from georgia, doctor ferguson to inquire. >> thank you chairman, i want to go back to the topic that my friend from texas mr. arrington touched on. first let me say, addiction is an incredibly difficult disease. i have been involved in that as a health care provider stamp way, and just as a general member of a community. it is devastating. one of the key components is the supply of drugs. i think my colleague around texas asked a really important question, can we all agree, can we objectively say that the drugs flowing across another border are a major problem here? this is devastating. i'm going to continue down, ask mrs. labelle, do you agree that this is a major problem at the border? can you objectively say that drugs flowing across our southern border is a major problem. >> thank you sir for that question, because i think illicit drug trafficking is an international problem. i think going after illicit finance as well as making sure that we have protection at the border is a way to approach it, a comprehensive approach. >> going down, again, this is a major problem. we have got to objectively look at where it is coming from. we have to look at the problem, we have got to secure our southern border for a lot of reasons. human trafficking, you know, illegal immigration, but this drug issue is so serious in our communities. i want to change gears, i want to talk a little bit about, you know, the mental health issues that our school children are seeing. not just in k-12 but also in college. miss hulsey i, know that you have been able to dive into this. i introduced a bill last year called the big act. an early intervention bill helping universities and schools put together best practices on how to engage, early on, with students. can you talk a little bit more about what we should be doing in that arena. also, can you touch on the importance of telehealth, also, not only providing more in these areas but the resources that we need to be giving those in our education community. in order for them to recognize the problems at an early time. >> thank you so much, absolutely. early intervention, all programs research back solutions that we can dedicate to middle school, high school, college age, young adults. these are the ages when typically it coincides with the onset of the substance use disorder. the fact that we delay, and do not have proper early intervention mechanisms in place is a huge gap in our system. we have them, we just need to implement them. things like screening, grief intervention, student assistance programs, programs that steel with aces, children impacted by addiction. primary and universal prevention to help us delay the onset of substance use. all of these are critically important. i think your second question is about telehealth. absolutely! the more access we can open up the better, to all types of providers. psychiatrist, psychologist, counselors, peter navigators, they only more access. we would love at some point to tackle some of the less insured issues and we have across state lines. we could really open up the amount of workforce we had available if we looked at from a different lens. on the provider side maintaining in training of the pipeline looking into the addiction workforce, that is incredibly important. our workforce was paid less than other health care profession than same training in education. we need to dedicate resources and time to figuring out how we have a plan for the clinicians that we will need long term. >> thank you ms. hulsey, going back to the topic in dealing with early intervention in schools, i just feel like this is so important. we focus on this that we get the early signs, we get the children and the young adults the help they need very early on. i realize as a multi faceted event social media influences, we are dealing with the isolation that has occurred during covid. i have a high school senior, i can tell you the impact on him have been very rare. i see that with not only him but with his friends. a truly believe that we can solve this issue in rural america if we do not have access to broadband, and we do not have access to telehealth services. that is something that we have got to get right in all of this. mister chairman, i yield back. >> thank the gentlemen, let me recognize the gentleman from illinois, mr. schneider to inquire. >> thank you mister chairman. i want to thank you in the ranking member for having this hearing. witnesses joining us today. and for your commitment to patient care. your perspectives the you brought with you. one thing for the committee has continued discussion, dr. metzl, i think you made a very important point in your testimony. addiction, depression, suicidality did not discriminate. as you know, and we have discussed today, there are groups with particular concentrations and in particular veterans and young people. we all know the pandemic has led to a spike in stressed, depression, addiction, and tragically suicide. i'm sure each of us here today have many personal in autumn tragic stories, we have heard some of them today. just last month a dear friend of mine got a call every parent fears. or leash fe was a vibrant, smart, beautiful 19-year-old. her name means my light and it beautifully describes her. no one, not her friends or teachers understood her anguish. if we did we all would've done what we could to try to help. everyone's challenges and experience with mental health are unique. sometimes there are clear signs that people need help. they may lack confidence to seek it out, or even know where to find. it in other times there are no flares or warning signs that any of us can see. sadly in illinois and around the country too many people or unable to find the help they need longer for this pandemic, we faced shortages of the resources needed to care for those who are struggling. in the united states we have seen an increase in suicide rate by 35% over the last decade. nearly 46,000 americans died by suicide in 2020 >> that's an average of nearly 300 people a day in the united states, who die every day of a drug overdose or other struggles. to me, these statistics need we need to deal with these crises. during last month's hearing on the mental health crisis, i emphasize the need for more mental health resources, better education, increased awareness, remove the stigma for asking for help. and smarter reimbursement policies for mental health providers and services. i reintroduced my substance use disorder workforce to increase the number of medicare positions, eligible at hospitals to have addiction, psychiatry or pain medication programs. this is one real way to help deal with the behavioral health services and the staff problem, we must do more to expand these services. while we can't always recognize the signs, we must empower adolescents and adults to feel brave enough, confident enough to reach out for help. and when people do, we need to ensure that there are mental health services, and trusted, prevention hotline. which reliable resources waiting on thankfully, soon, will be a the other end with a suicide prevention hotline. which three digit crisis 988 number this summer. we must also recognize the challenge but certain face, like african american men who have a risk of overdose, and white american men who have 99. 2% of all gun suicides. now, i'll turn it over to dr. reataza. last year, i received a letter from high school senior outlining her findings on the disparities of mental health resources at her school. she highlighted the value placed on new gym flooring and scoreboards, but a lack of investment in mental health counselors. she shared a lot to classmate earlier this year to suicide. i also became more aware of a so-called suicide websites, social media influencers, impacting children's mental health. could you please explain out stigma and chronic mental health systems could lead some children to turn to these websites, and what we can do to better understand or support mental health for these school aged children? >> thank you, and i appreciate this very, very important question. you know, this is something i constantly worried about when teaching high school. it is also something that personally impacted me when i was in high school. one of my friends, classmate, also committed suicide during spring break. it impacted all of us. i think overall, when we think about what is happening in schools, our children spend the most time at schools. and if we do not have services, that students feel safe accessing, and i can come in a lot of ways. yes, we need more counselors, but we also need to work with our teachers, educators. and the entire workforce at schools to be able to address at risk youth. if there's any kind of suspicious behavior. not suspicious behavior, but potentially dangerous behavior, which involves the self. with regard to access to social media, i think that social media is a big concern, because i think that it paints a picture that can be damaging. and if we do not have the appropriate awareness or regulations on damaging social media, and access to that, if we are accessing this then, we are not addressing those in a way -- let me come back to my words over here. the issue is that when we have websites like these that go on monitored, and we do not actually have a way to discuss with our youth what the issue is, these issues continue to be stigmas. they will continue to be stigmas, we will continue to fail addressing them and,. we will continue to see these deaths come together. and unfortunately, sorry, i am struggling to find the words over here. this is my first hearing. >> you are doing great, let me assure you. you have done great! >> so, i think overall, we are not having the conversation, we are not having the conversation of what is happening, what students are seeing at home, at schools, while they are talking about with their friends, seeing on social media. if we can't talk about these things overall, the stigma will persist. it will continue to hit all of our communities, especially our youth. >> thank you, thank you gentlemen. i am glad that our witness mentioned social media, that's a very important consideration here. let me recognize this gentleman from kansas to inquire. >> well, thank you mister chairman for holding this very important hearing. and thank you to each of our witnesses for joining us today. as we talk about the tragic rise in mental health issues including cases of severe anxiety and depression, in the rise of substance abuse disorders, and suicide, i hope we can address the underlying causes behind the rapid decline in our nation's mental health. also, if we can address so many of these dangerous drugs, why they're becoming so widely available over so much of our communities. in kansas, the first half of 2021 showed methamphetamine accounting for 44% of overdoses. the white dispersal of this and other dangerous drugs like fentanyl is destroying families and whole communities across kansas and across the country. no matter how much some of us may want to ignore the crisis we are facing on the border, the fact remains that illegal drugs are pouring in. the number of fentanyl deaths has doubled in 30 states in the last two years. five of which saw a five fold increase. the dea has confirmed that mexico is one of the primary sources for the flow of fentanyl into the united states. just this past week, border patrol officers seized close to $3 million worth of math, disguised as onions. i am proud to say that our border patrol caught this shipment, but too much is being missed. without proper enforcement of americas laws at the border, with this administration, the substance of these crisis and many other associated crises will only get worse. in kansas, our law enforcement have sounded alarm bells over the rising crime linked with drugs, especially with matt. institute county, kansas, my home county, it is report that 70% of all drug crimes involve matt. there is assisted treatment for those addicted to opioids, researches for those with methamphetamine struggles are scarce. as we talk about the horrible rise in drug overdoses and suicide, it is time to recognize the fact that many of the major issues must be addressed. miss hulsey, in your testimony, you mentioned the importance of increasing the availability of medically assisted treatment, mat. unfortunately mat does not exist for meth addiction. is this something that needs to be further explored in research? >> absolutely. top of my wish list every year's medications to treat stimulant use disorder. my dad struggled with both opioid use disorder and stimulant use disorder. crack cocaine, it is a devastating illness. we need more tools in our tool box is. but yes, we do have contingency management, which is behavioral therapy, proven to work for stimulant use disorder, for cocaine and methamphetamine's, vastly underutilized in all of our communities across the country. so yes we need more tools, yes we need to actually use the tools that our researchers, clinicians and scientists have already built for us. >> so you talk about contingency management. what are the barriers, to use those? is it crossed primitive, is there too great a demand? are there too few individuals trained in these services? >> that it's a great question. we could use your help with eliminating some of the barriers, for our contingency management. it is beautiful because it uses sort of incentives. the scales are, pardon your brain, affecting this, using this against the disease. you are incentivizing positive behaviors through rewards, through a gift card, incentives that keep someone retained in the program, participating in the behaviors that we need to see. there are prohibitions on using federal money for contingency management, that we would love your help to address. we have a lot of stigma around these programs. and it should not be there. we can incentivize, build these programs and this behavioral therapy, so all of our treatment, you could even use contingency management through digital therapeutics now, i believe. we can improve, layer interventions that work. let's say, even someone who is on mat, contingency management could still be used in concert, along with cognitive behavioral therapy, counseling, other supports. so yes there are some barriers. we would love your help eliminating those, particularly with an increase in cocaine and methamphetamine overdoses. we should be doubling down on the availability of c am. >> thank you. mister chairman, thank you again for holding your support. there are too many americans who are suffering right now, and we can't continue to rely on our jails and hospitals as a place of last resort for folks who need help. i yield back. >> great point, great point. thank you, gentlemen. let me recognize the gentleman from california to inquire. >> great, thank you mister chairman. thank you to all of our witnesses. i think that beyond this hearing, i think all of us have seen over the last three years what the pandemic has done, the toll that it has taken on our nation's mental health. but obviously, for many people including many in my community, on the central coast of california, it has exacerbated long-standing problems. for the past three years, basically, it has been laid bare to the challenges facing our health care system, our first responders, and many of our most vulnerable and under represented communities. so obviously, thanks to all of the witnesses today for sharing their time, and also their expertise. i am hopeful that this hearing will help us better serve our diverse communities, and younger constituents are often the victims of the substance abuse epidemic. doctor reataza, you are doing so well in this hearing, i will continue to ask you a couple of questions if that is all right. obviously in your testimony, you mentioned that suicide is the leading cause of death among asian americans aged 15 to 24. absolutely alarming, if you ask me. and california, as you probably know, three and ten asian americans reside there, that's 70% of my great state. now these communities face unique stigmas, stressors that really increase the rate of youth suicide and make mental health outreach much harder. so now in your testimony, you also point out some barriers to care that are common across the aapi population. you make it clear how much diversity there is between aapi communities and cultures. so my first question is, can you disaggregate some of the cultural barriers to care, in different aapi communities? and are there any communities in particular that we have to do a better job reaching out to? and if so, how do we do it? >> thank you, representative. thank you for being gracious on my fumbling my words, i really appreciate that so much. yes, i think that it is very clear, even within the aapi communities that there are a number of ethnic groups and sub communities that are constantly, consistently marginalized. so for instance, i mentioned native hawaiians and pacific islanders, the pacific islander community as a whole are generally a smaller proportion of the larger asian american hawaiian pacific islander umbrella. and because of that, a lot of their needs and priorities actually do not get met, because the data is not done, not collected properly. and then because it is not there, we do not have the accurate report to reflect what is happening. other things that impact the communities very much, i know this is an issue that does not just impact aapi's's immigration. a lot of us also come as immigrants over here, and as far as immigration is concerned, specifically, a lot of southeast asians have undergone tremendous amounts of trauma. this involves war, authoritarian rule, poverty. famine. and a lot of these issues are very specific to our communities. in those instances, with those ethnic groups specifically, i am talking about the cambodians, by, now, meng, vietnamese there are a lot of issues we are not seeing, personally in my opinion, as filipino americans, colonialism is something that we have really still been trying to heal from as well. so, i come that to the question of desegregation. how do better address these committees? well in part, we have to do a better job of addressing actually what is going on. we have to be very intentional in how we are collecting data, in how we are doing this with communities, partnerships with communities, and also reporting back. what happens oftentimes is this data does not actually come back to communities or, there's a long, long stretch of time before it's actually published. and then what happens is time changes, needs become different and, those populations that were already marginalized or not reported upon, they have already had different needs. so i think there is an urgency we are trying to address it with data disaggregation which must be done gently, and thoroughly. thank you, are standing articulation and an outstanding answer. thank you mister chairman, i yield back. >> thank you mister chairman, let me recognize the gentleman from oklahoma. >> thank you mister chairman, thank you ranking committee to hold this meeting on substance abuse, she was at risk, and the american health system. as i explained at the screen he's hearing a few weeks ago this country is facing multiple crises. we must work and what has worked with the covid-19 pandemic and face the challenges that remain. we have data that prove that shut down, social isolation, have judgmental long term effects on mental health and overall well-being. from backseat mandates on their fragile workforce to a growing work crisis that have -- thousands of pounds of fentanyl to our community. the biden administration seems only create one crisis after another, and the american families are hurting. given the current crisis in ukraine it have never been more clear that we must protect our country and its borders from the dangers abroad. in 2019 china fulfilled a pledge to the united states placed all forms of fentanyl and it's in a locks on a regulatory schedule. nevertheless china remains the primary country origin for illicit fentanyl and fentanyl related substances trafficked into the united states. when you introduce an influx of deadly drugs into a vulnerable communities of isolated and depressed individuals you create a substance abuse crisis, economic crisis, and suicide crisis. as leaders we must come together as how to focus how we can save our fellow americans from this fate. on the national level of the southwest border crisis is creating opportunities for cartels and other criminal organizations to increase the flow of drugs, including fentanyl, into the united states. the border crisis devastates families and places americans out of jobs. the oklahoma bureau of narcotics said that fentanyl related overdose increased by 157% from 2019 to 2020. they say this spike will only continue. in addition to the drug crisis at our southern border, our nation is also facing an unemployment crisis. unfortunately psychiatric reports tell us that over the last 23 years economic hardship increases substance abuse, based on state annual administrative data. showing a correlation between welfare recipients and substance abuse issues. this is something, unfortunately, that i can connect to personally. growing up in poverty, on welfare, i witnessed firsthand the brutal cycle of poverty in substance abuse. addiction traps people and makes a very difficult to break free. it's about time we reform our welfare system to also provide support for americans facing economic hardship. whether it is support through our community or faith leaders. allocating money towards more expensive public health programs not with this country needs right now. the last thing americans needs are higher prices at the gas pump and the grocery store. one major tool that overcomes accessibility and -- mental health treatment is tele-health, or as i prefer to call it, virtual health. as the covid-19 public health crisis limits public treatment options, tele-health shows that it has helped over half of our nation. data shows that nearly 80% of americans showed covid-19 showed that more tele-treatment health meant options are needed. as i reiterate before it is time to make these options permanent. we need to figure out how to pay health providers virtual visits. come up with a plan to pay for those benefits without bankrupting the already financial abused medicare trust fund. substance abuse, mental health disorder and suicide can be prevented in our country if americans have access to the care they need. not only during the pandemic, but during all times of need. miss hulsey, thank you for your testimony. you mentioned something through the programs that mentioned parents of children on welfare, can you tell us if there are any states or local communities leading similar mental health programs for people who are unemployment programs? >> that's a great question. i am not aware of any state or communities that connect behavioral health services with unemployment recipients. i can check on that and get back to you. i do agree though that any of our vulnerable communities, and when you have financial hardship, this can increase the stress and anxiety as well as our reliance on alcohol and other substances as a coping mechanism. it is unfortunately pretty consistent throughout the counties in the country. i think having safety net services for anyone who is one-able is a really important part of the solution. >> miss hulsey thank you for your work in this area, thank you for your comments. mister chairman, i yield back. >> i thank the gentlemen, let me check mr. horsford from nevada to inquire. >> thank you very much mister chairman. i appreciate you holding this critically important hearing as a continuation of last month's hearing on america's mental health crisis. i want to thank our witnesses for reiterating for how dire our nation's mental health and substance abuse crisis really is and for sharing their expertise. many people across america are facing unprecedented challenges, whether it is the onset or exacerbation of depression and anxiety, or hurdles to access health care services that address the problems. rates of mental illness, such as depression and anxiety disorders have skyrocketed since the beginning of the pandemic. as we all know, drug overdoses hit an all-time high in the united states between may of 2020 and april of 2021. while congress has made behavioral health services more accessible during the covid-19 pandemic, some of these provisions have expired. such as the cares act provision, which allowed high deductible health plans to cover telehealth their buses. i worry what's impact the laps of coverage will mean for those who have relied on those health care services over the last two years. i look forward to working with you mister chairman, and this committee, to make sure we provide that coverage in future legislation. i have been listening to some of my colleagues on the other side, i do want to make one thing perfectly clear. there may be a correlation between economic conditions, such as poverty, but that is not the cause. if we really want to help our fellow neighbors, and family members, who suffer from substance abuse and mental illness, we should avoid placing blame, particularly on efforts that are trying to eradicate those challenges. one example would be, support the child tax credit that is actually lifted 50% of children out of poverty, for example. more than 100,000 americans died of an overdose in the last year the tragedy of this enormous loss of life is compounded by the fact that it is almost entirely preventable. according to the cdc the state of nevada experienced a 30. 4% increase and overdose deaths between september 2020, and september 2021. this is almost double the nationwide increase. medications for opioid use disorder reduce mortality from drug overdose by as much as 50% yet, because of outdated federal regulations only about 11% of americans with opioid use disorder receive these medications. miss labelle, what specific actions can congress take to expand access to this lifesaving treatment? >> thank you congressman, i think there are a couple things before you to know. there is the mad act as well as the maid act. the math act would eliminate that requirement for someone to go through, a provider to go through an eight hour or a 24-hour training before they can provide the medication. the maid act would increase the training that would need to be done so that more health care professionals, nurse practitioners, doctors, understand addiction treatment. we have a real problem not only with medical schools not teaching about addiction but we also have a number of health care professionals who are not only not sure how to identify if someone has a substance use disorder, but they also don't really know where to refer them for treatment. that is two pieces of illusion that could be done. >> thank you, thank you for that response. i will have my staff look into those options. quickly on the topic of preventing suicide, america has the highest suicide rate of any wealthy nation, nearly doubled out of the uk. it is the second leading cause of death in the united states for individuals ages 15 to 24. the risk of suicide increases significantly after 65. doctor metzl, your research touches on social instructor determinants of health, mental health, and suicide. what are some of the ways we can rebuild our mental health system to ensure those in crisis have access to key resource and treatment? >> very quickly i realize the time is short first of all again suicide is a, what other resources available to someone who's contemplating suicide, at that moment? it is something like a national suicide hotline is a brilliant idea. how can we expand those immediate resources for people who are in moments of despair? also, as we have been saying, how can we not defund but really fun things that build social capital. things like education, the ability to create social networks, job training, all of these factors. these kinds of things make people feel connected and it gives them a pathway out of the kind of despair that leads to suicide. >> thank you so much. i yield back. >> thank you gentlemen, let me recognize the gentlelady from virginia, miss miller to inquire. >> thank you chairman, ranking member brady, thank you for all of our witnesses for being here today. the topic before our committee today is devastating. i have seen firsthand in my home state of west virginia, how the opioid epidemic deeply impacted our families, our children, and our communities. i must also point out that mr. arrington, dr. ferguson, mr. estes and mr. hern all alluded to the difficulty we all have with drugs coming over our border, how important it is that we secure our border. in the face of the immense sadness and despair that i have seen in my community, coming together in amazing and inspiring ways, we have so many facilities, programs, and individuals who have risen up to a direct the epidemic and to help find healing for patients, and their families. one of these places is the lotus recovery center located in boone county, in my district. they utilize and evidence based approach where they provide a wide variety of services, including cognitive behavioral therapy. they also have a case management program where they focus on the social determinants such as housing insecurity, food insecurity, workforce issues, and educational development. they ensure that patients not only he'll while they are in their center but also that they have the tools to remain sober once they leave. i am thankful for all of the work that they do. we are two years into this pandemic and as a result we have seen an increase in the drug overdoses. thanks to historic investment from congress and the support act, i hope as we emerge from this pandemic we get right back on track in addressing the substance abuse disorders. miss hulsey, first i want to thank you for sharing your story. i'm so sorry about the loss of your parents. in your testimony you discussed the dangers of fentanyl. as we all know, west virginia had the largest number of fentanyl deaths per capita in 2020. can you discuss the changes in how fentanyl is presenting itself in the country? for example, we are now seeing it in counterfeit pills and even in marijuana. >> thank you so much for your kind words. fentanyl are changing a lot of this space is so many individuals with different types of substance use disorder are now finding fentanyl in their supplies. you have individuals using sedative's or stimulant's who are not expecting to take an opioid. who have very high doses and can have fatal doses of fentanyl there. it is high-risk it is scary for patients in families. we need to be able to address this and keep our patients safe. things like fentanyl test rips, we need intervention efforts to help us reduce the amount of fentanyl in our supply. we also need to make sure that we have treatment and safety net services we might need multiple doses in narcan to reverse a fentanyl overdose. because of the potency you might need to have modifications to a treatment plan. ensuring that we engage people with medications who are struggling in opioid disorder because of fentanyl. i think it is affecting every aspect of addiction crisis. i think we need to double down the loss of life is, the numbers and what is happening in the community are just really hard >> you mentioned that 78% of the patients have a history of substance use disorder. and as we all know, rates of substance abuse grew in the pandemic. children whose parents have substance abuse disorder are at greater risk in the home. as congress looks to address this issue, what effective methods can congress consider to provide support for the children and adolescents who is caregivers are struggling with addiction? >> absolutely. the risk, the risk of genetic factors add to your risk of developing, but it's not just one gene, but i constantly changing constellation of genetic factors. we need to make sure that we are supporting families who are struggling. we need to look at all sud types, of the 20 million people struggling with addiction, 50 million have an alcohol use disorder. so while we are experiencing overdoses, so much difficulty in the opioid space, we must look at the big picture. there are amazing programs that work with child welfare services, but help keep families together and help give families the treatment that they need. i would have loved to have something available i got to my family before i went into foster care. so, how do we take what we know works, and then take it to scale? that is really our challenge right now. >> thank you so much. i know i have already used up my time. i yield back. >> thank the gentlelady. let me recognize the gentlelady from the virgin islands to inquire. >> thank you so much, mister chairman. thank you for this hearing. i think the quickness has been absolutely incredible. i want to thank you for the staff, for putting this together. it has been absolutely informative. i have been so grateful to members on both sides of the aisle, who asked some tremendous questions, on the information we have been able to glean from this. we will focus on substance abuse disorders, overdose deaths and suicides, which are in fact, a huge epidemic in this country. and taking a deep dive in these issues, looking at how the rates have increased exponentially over the last decade and the work which is being done to try and stem the tide of something which seems to be absolutely overwhelming. the need for greater awareness, how federal policies have long stigmatized and marginalized treatment for those people struggling with substance abuse disorders and suicide ideation into shadows. i am so grateful for you, mister chairman, and the other members of the committee for shining a light on this throughout the country, even within our own lives. you know, i have a couple of questions here. one of the things i noted, however, and they do not mean to throw any cold water on the care and concern, but many of the members have expressed in this discussion, there has been a stark, glaring absence in some of the discussions i have been hearing. i know that one of my colleagues, earlier in the discussion talk about the support for patients and communities that was passed in 2018. he also mentioned the comprehensive addiction recovery act of 2016. so much of this legislation is related, and is focused squarely on opioids. squarely on prescription drug addiction, which is absolutely necessary. it is something that is going out of control within this country. but i cannot not notice the fact that we have not given the same kind of discussion, and the need, the ability to call individuals who are addicted to prescription drugs as having a mental disease and those who are addicted to crack cocaine, or heroin, in communities of color as being criminals and drug addicts. my colleagues and i are willing to expand prescription drug and support for individuals who are addicted to crack cocaine, addicted to heroin and the ravage that is doing in those communities as well. i have had several cousins, early in the beginning of the crack cocaine epidemic, early on during the aids epidemic, die of either crack cocaine or heroin addiction, that precipitated them dying in the early 80s from aids. so i wanted to ask these practitioners, what do you think has transpired over the last 30 years, that is now allowing us to call prescription drugs addiction as a mental health addiction, a disease? and those individuals who are addicted to crack cocaine, heroin and other drugs which are predominantly in african american and people of color communities, still as criminals? >> thank you. this is doctor chapman, i would like to answer that. my presentation for the office of minorities and mental health years ago, i emphasized the historical difference of africans in america. we started from slavery, we went through the post slavery era, reconstruction, and then the jim crow era, with hangings, segregation's. i showed slides that show this is a continuum. it really has not changed. and then, in the post civil rights era. so our community has always suffered from post traumatic stress disorder. it has been intergenerational, and was just ignored. >> sorry, i have so little time. if anybody else wanted to offer any thoughts on this? >> my research shows that when you called something an addiction versus criminalizing it, it leads to different outcomes. so an addiction leads to support networks, which are so important, where is the criminalization of something will lead to the prison pipeline, basically. things like that. this has real consequences. and so, we really need to broaden the definition of addiction, and also the alternatives. >> so, in closing, i would just like to ask my colleagues across the aisle, if they could show the same empathy that they have for prescription drugs and opioids, to the ravages that are occurring in my community from crack cocaine, heroin and other drugs which you are insisting on criminalizing. i yield back, and thank you so much mister chairman. >> thank the gentlelady. thank you. let me recognize the gentleman from north carolina, mr. murphy, to inquire. >> thank you, mister chairman. thank you to all of the witnesses who have come out today. i appreciate all of the hard work you do in a very, very difficult environment. this is personal for me. i have treated patients for 30 years, many of them have substance disorders, and it makes them frequent for cancers, and everything else, exceedingly more difficult. it's personal for me, i have known nine young men, kids that were in my kids school, church, scout troops who have died from an overdose. so this is a very, very personal issue for me. obviously, the pandemic presented many disturbing societal challenges and implications to public health, but i believe deserve some retrospective analysis. in as many instances with the biden administration, many of these prices have been self inflicted, and worsened by politically motivated decision. the unnecessarily prolonged lockdowns brought stress, uncertainty and isolation, which serves catalysts to suicidal ideation and substance abuse. public health, economic and mental health deterioration, driven by the isolation and depression of subsequent substance abuse, have regrettably led it to make committing suicide, or accidentally overdosing. one witness pointed out that building societal structures is a good thing. i believe in that. i believe that it is beneficial. but i will submit, this problem with societal structures will be traced back now, to 1965 with the creation of the great society programs, and the destruction of the nuclear family as started. we close businesses during the pandemic, schools, clinics, churches, people sunk into a very, very dark place. sadly, political science overtook medical science, and heavily exacerbated what was already a bad mental health crisis. suicide attempts among girls aged 12 to 17 rose to more than 50%. you can see the despair on the youth. look at the walls of the kids who painted pictures for us, and you see what was normally a happy picture, oftentimes now is turned very, very sad. we need to move away from this, we need to play our parts as parents and leaders of the community. we as physicians took leadership in the opioid epidemic, and we stopped prescribing opioids. we took a great lead in this, 5 to 8 years ago. sadly enough now, the addiction now is with illicit fentanyl's. we know that 80% of those come across our very, very porous southern border. how do we know that? seizures are up 134% from 2021, totaling to 11,000 plus pounds, which is enough to kill every american, seven times over. how do we know that is not enough? we know it is not because 100,000 americans died in a 12 month period, even further, the price of sentinel in the streets have dropped 50%. so the southern border has a very, very large part in exacerbating this crisis. >> now, fentanyl is the largest killer in age 18 to 45, as many of my colleagues have said. overdose deaths have increased 25% in north carolina in this past year. we need to do something about this. and i appreciate the work that you are doing. miss hulsey, my deepest, deepest condolences to you, and sympathy to the loss of your parents. tragic. let me ask a question of this. you spoke of the need to enhance the substance abuse use disorder treatment workforce in your testimony, in section 70 71 of the support act, which was a loan repayment program to incentivize students to enter the profession. are there any avenues that you feel could enhance movement to this program to provide personalized care to different geographic regions, which require a diverse set of needs? >> thank you so much for highlighting that. i do think that there are enhancements, whether it is more loan payments, incentivizing more bachelors and masters degree positions, kind of going upstream in the work form place, how do we get more people entering the addiction workforce, engaging high school and college students to talk about this as a priority. and even as we incentivize and bring people into the space, if we don't pay them the same as other health care specialties, how can we retain our workforce? there is an amazing provider in illinois. you know, he was showing the reimbursement rate for the case match, and the counselors he works with's minimum wage, $15 an hour. so you are working with clients, in a manufacturing position at $30 an hour, when you are making half of that. so, we need to address the pay disparities, and make sure we can keep our workforce focused on this growing health condition that needs to have a whole host of clinicians ready to treat our patients. >> all right, thank you. again, i will go back to the fact that we do need all of the armaments ready to help us in this. but i will go back again and again, to talk about the destruction of the nuclear family and how it is led to so many societal ills that we now have today. i would end, because i agree with my colleague across the aisle but the criminalization of the addiction, different forms of addiction. it is a disease, it changes your brain chemistry. very point blank, i don't care if it is prescription opioids, heroin or crack cocaine. it changes your brain. and i do agree that incarceration for individuals, yes it should be done for people pushing, but i believe that in our prisons, we need much more of a mental health intervention on those individuals because the recidivism rate for individuals who have mental health disorders, and an addictive addiction to opioids, and other substances is tremendously high. intervention is really within our criminal justice program, to necessitate at this point in time. thank you, mister chairman. i will yield back. >> thank you, doctor murphy. so as we conclude this very informative session, we have heard a great deal of talk about the southern border. we all acknowledge, based on the testimony, the commentary that was offered here today, that this is a supply and demand issue. it has to be treated as such. but i think that as dr. murphy just indicated, we don't want to miss the point that substance abuse is a mental health disorder, a disease. it is a disease that existed before drugs came across the border, and will persist, even if we are successful in closing down the border. we need to stop the flow of dangerous drugs, and everybody acknowledges that. the biden administration is taking steps to do so. i want to enter into the record, it list of actions taken over the last year. in 2021, customs and border controls seized twice as much fentanyl as they did in 2020. four times as much as they did in 2019. this issue has spanned many presidents, democrat and republican administration's. it is a very complex issue. but we learned a lot because the witnesses were superb today. the best way to fight substance abuse disorders is to work to illuminate the risk factors that cause addiction in the first place. poverty, instability, race, criminalization among many others. preventing addiction is the first and most ensuring, robust access that we need to evidence based treatment, to support our priorities. i stand committed, as we heard some pretty good, encouraging terms today to pursue this objective. millions of americans and their families know of what we speak. everybody in this room today knows somebody, has a family member or an acquaintance, a neighbor down the street who has had this issue. i think the best way to address it is to continue to understand that we need to treat the disease. while obviously addressing the supply issue simultaneously. witnesses were terrific. please be advised that members have two weeks to submit written questions to be answered later in writing. those questions and answers will remain part of the official record. with that, the committee stays adjourned. how months curate he secretary. alejandro mayorkas joined others council from europe and australia, to join cybersecurity issues from the security council. this is from the atlantic council. >> hello to our audience all around the world and in particularly, to our australian audience in the wee hours of the morning. i am fred kemp, president and ceo of the atlanticnc

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