[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
COMBATING THE OPIOID CRISIS: BATTLES IN THE STATES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
JULY 12, 2017
__________
Serial No. 115-43
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Energy and Commerce
energycommerce.house.gov
__________
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COMMITTEE ON ENERGY AND COMMERCE
GREG WALDEN, Oregon
Chairman
JOE BARTON, Texas FRANK PALLONE, Jr., New Jersey
Vice Chairman Ranking Member
FRED UPTON, Michigan BOBBY L. RUSH, Illinois
JOHN SHIMKUS, Illinois ANNA G. ESHOO, California
TIM MURPHY, Pennsylvania ELIOT L. ENGEL, New York
MICHAEL C. BURGESS, Texas GENE GREEN, Texas
MARSHA BLACKBURN, Tennessee DIANA DeGETTE, Colorado
STEVE SCALISE, Louisiana MICHAEL F. DOYLE, Pennsylvania
ROBERT E. LATTA, Ohio JANICE D. SCHAKOWSKY, Illinois
CATHY McMORRIS RODGERS, Washington G.K. BUTTERFIELD, North Carolina
GREGG HARPER, Mississippi DORIS O. MATSUI, California
LEONARD LANCE, New Jersey KATHY CASTOR, Florida
BRETT GUTHRIE, Kentucky JOHN P. SARBANES, Maryland
PETE OLSON, Texas JERRY McNERNEY, California
DAVID B. McKINLEY, West Virginia PETER WELCH, Vermont
ADAM KINZINGER, Illinois BEN RAY LUJAN, New Mexico
H. MORGAN GRIFFITH, Virginia PAUL TONKO, New York
GUS M. BILIRAKIS, Florida YVETTE D. CLARKE, New York
BILL JOHNSON, Ohio DAVID LOEBSACK, Iowa
BILLY LONG, Missouri KURT SCHRADER, Oregon
LARRY BUCSHON, Indiana JOSEPH P. KENNEDY, III,
BILL FLORES, Texas Massachusetts
SUSAN W. BROOKS, Indiana TONY CARDENAS, California
MARKWAYNE MULLIN, Oklahoma RAUL RUIZ, California
RICHARD HUDSON, North Carolina SCOTT H. PETERS, California
CHRIS COLLINS, New York DEBBIE DINGELL, Michigan
KEVIN CRAMER, North Dakota
TIM WALBERG, Michigan
MIMI WALTERS, California
RYAN A. COSTELLO, Pennsylvania
EARL L. ``BUDDY'' CARTER, Georgia
Subcommittee on Oversight and Investigations
TIM MURPHY, Pennsylvania
Chairman
H. MORGAN GRIFFITH, Virginia DIANA DeGETTE, Colorado
Vice Chairman Ranking Member
JOE BARTON, Texas JANICE D. SCHAKOWSKY, Illinois
MICHAEL C. BURGESS, Texas KATHY CASTOR, Florida
SUSAN W. BROOKS, Indiana PAUL TONKO, New York
CHRIS COLLINS, New York YVETTE D. CLARKE, New York
TIM WALBERG, Michigan RAUL RUIZ, California
MIMI WALTERS, California SCOTT H. PETERS, California
RYAN A. COSTELLO, Pennsylvania FRANK PALLONE, Jr., New Jersey (ex
EARL L. ``BUDDY'' CARTER, Georgia officio)
GREG WALDEN, Oregon (ex officio)
C O N T E N T S
----------
Page
Hon. Tim Murphy, a Representative in Congress from the
Commonwealth of Pennsylvania, opening statement................ 1
Prepared statement........................................... 3
Hon. Diana DeGette, a Representative in Congress from the State
of Colorado, opening statement................................. 5
Hon. Greg Walden, a Representative in Congress from the State of
Oregon, opening statement...................................... 6
Prepared statement........................................... 8
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 9
Witnesses
Boyd K. Rutherford, Lieutenant Governor, State of Maryland....... 11
Prepared statement........................................... 14
Answers to submitted questions...............................
Brian J. Moran, Secretary of Public Safety and Homeland Security,
State of Virginia.............................................. 24
Prepared statement........................................... 26
Answers to submitted questions...............................
John Tilley, Secretary of The Justice and Public Safety Cabinet,
State of Kentucky.............................................. 45
Prepared statement........................................... 47
Answers to submitted questions...............................
Rebecca Boss, Director, Department of Behavioral Healthcare,
Developmental Disabilities and Hospitals, State of Rhode Island 50
Prepared statement........................................... 52
Answers to submitted questions...............................
Submitted Material
Statement of the National Association of Medicaid Directors Board
of Directors, submitted by Ms. Castor.......................... 95
Article entitled, ``Why taking morphine, oxycodone can sometimes
make pain worse,'' Science, May 30, 2016, submitted by Mr.
Murphy......................................................... 97
Article entitled, ``51 percent of opioid prescriptions go to
people with depression and other mood disorders,'' STAT, June
26, 2017, submitted by Mr. Murphy.............................. 100
Committe memorandum.............................................. 104
COMBATING THE OPIOID CRISIS: BATTLES IN THE STATES
----------
WEDNESDAY, JULY 12, 2017
House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:02 a.m., in
room 2123, Rayburn House Office Building, Hon. Tim Murphy
(chairman of the subcommittee) presiding.
Present: Representatives Murphy, Griffith, Barton, Brooks,
Collins, Walberg, Walters, Costello, Carter, Walden (ex
officio), DeGette, Schakowsky, Castor, Tonko, Ruiz, Peters, and
Pallone (ex officio).
Also Present: Representatives Guthrie, Bilirakis, Bucshon,
and Kennedy.
Staff Present: Elena Brennan, Legislative Clerk, Energy/
Environment; Zachary Dareshori, Staff Assistant; Paul Edattel,
Chief Counsel, Health; Ali Fulling, Professional Staff Member;
Brittany Havens, Professional Staff Member, Oversight and
Investigations; Katie McKeough, Press Assistant; John Ohly,
Professional Staff Member, Oversight and Investigations; Chris
Santini, Professional Staff Member; David Schaub, Detailee,
Oversight and Investigations; Kristen Shatynski, Professional
Staff Member, Health; Alan Slobodin, Chief Investigative
Counsel, Oversight and Investigations; Evan Viau, Staff
Assistant; Hamlin Wade, Special Advisor, External Affairs;
Christina Calce, Minority Counsel; Jeff Carroll, Minority Staff
Director; David Goldman, Minority Chief Counsel, Communications
and Technology; Chris Knauer, Minority Oversight Staff
Director; Miles Lichtman, Minority Policy Analyst; Kevin
McAloon, Minority Professional Staff Member; Dino
Papanastasiou, Minority GAO Detailee; Andrew Souvall, Minority
Director of Communications, Outreach and Member Services; and
C.J. Young, Minority Press Secretary.
OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA
Mr. Murphy. Good morning, everyone. Today, the Subcommittee
on Oversight and Investigation holds a hearing entitled
Combating the Opioid Crisis: Battles in the states. Make no
mistake, the term ``combating'' and ``battle'' are entirely
appropriate. Our nation is in the midst of a tremendous fight
against death and devastation affecting every corner of our
Nation.
In 2015, there were more than 52,000 deaths from drug
overdose in the U.S., with more than 33,000 deaths involving an
opioid, a 24 percent increase from the prior year. The overdose
death rate in 2015 was almost seven times the rate of deaths
from the heroin epidemic of the 1970s. For 2016, we have
learned from an analysis by The New York Times that we have
lost roughly 60,000 people to drug overdoses. That is more in 1
year than all the names on the Vietnam Veterans' Memorial Wall,
and likely, that number is underestimated because much of the
data will not be in until the end of this year, 2017. It is
staggering.
For every fatal overdose, it has been estimated there are
20 nonfatal overdoses. And for 2016, that could be near 1
million. More than 183,000 lives have been lost in the U.S.
from opioid overdoses between 1999 and 2015. That is about
500,000 that will be lost over the next decade. The roots of
this crisis began back in 1980 when a letter to the editor by
two doctors published in the New England Journal of Medicine
was misinterpreted as evidence. It was unlikely that someone
would become addicted. Out of 40,000 cases, they said there
were only four addictions.
Twenty years later, the Joint Commission on Accreditation
of Healthcare Organizations following the American Medical
Association recommendation that pain be assessed as the fifth
vital sign, and established standards for pain management
interpreted by many doctors as encouraging the prescribing of
opioids. Under the Affordable Care Act, prescribing pain
killers is incentivized by patient questionnaires where a
question specifically asked if their pain was adequately
addressed to their satisfaction. Based upon their answer, a
hospital may receive more or less money.
As we learned in our oversight hearing held in March, the
opioid epidemic is an urgent public health threat fueled by
fentanyl, a much more dangerous and potent synthetic opioid and
a clear and present danger to America.
Two states represented on today's panel, Rhode Island and
Maryland, were the first ones hit by the fentanyl wave, and
unfortunately, it seems certain that this wave will sweep the
Nation as low-cost, high-profit, hard-to-detect profile of
fentanyl is increasingly attracted to traffickers and easy to
manufacture, or obtain over the Internet.
This is an in extremis moment requiring all the experience,
resources, cooperation of our Federal, state, and local
governments, as well as all the different industries,
professionals, and experts to curb this terrible outbreak. With
this hearing, we will focus on the actions of our state
governments to find out what efforts are working, what is not
working, how we can work together to save lives. To the panel,
I say, we want to know the problems, and please be candid with
us, because as you know, there are millions of families being
torn apart by this.
As drug policy expert Sally Satel noted, ``It is at the
state and county levels that the real progress will be made. It
makes sense that the efforts to find inspired solutions would
be most concentrated there. We should invest in those solutions
and learn from them.''
Serving the front lines of the opioid epidemic, state
governments have been pursuing their own innovative
initiatives, such as more inventive use of incentives, more
structured medication-assisted treatment, more comprehensive
prescription drug monitoring.
States such as Maryland are making the best use of the
Center for Disease Control opioid prescribing guidelines to
help push back on the overprescribing. Kentucky's All Schedule
Prescription Electronic Reporting system, more known as KASPER,
a web-based monitoring system to help prescription use across
the state, is helping state regulators identify questionable
prescribing practices by physicians and abuse by patients.
Virginia has greatly expanded access to Naloxone, the drug
that can rapidly reverse an opioid overdose, but then again,
can have its own risk and its use. Some states are expanding
the availability of Naloxone by permitting third-party
prescribing by family and friends of individuals who are at
high risk of overdose. Rhode Island has developed the AnchorEd
Program that matches overdose victims with peer recovery
coaches to encourage treatment, who follow up with the patient
for the next 10 days after the overdose.
Much of the work of the states should help inform the
President's Commission on Combating Drug Addiction and the
Opioid Crisis. Two years ago, the subcommittee held a similar
hearing on what the state governments were doing to combat the
opioid abuse epidemic. Such oversight helped Congress enact
provisions in the Comprehensive Addiction Recovery Act, or
CARA, and it will help the administration.
We put $1 billion into grants over the next 2 years, but we
want to know if this money is being used wisely, and what is
working. We are eager to learn about those programs. But the
21st Century Cures state program is just the beginning. Our
state government witnesses can help this committee develop a
more effective and national strategy to combat the opioid
crisis in such areas as substance abuse prevention and
education, physician training, treatment of recovery, law
enforcement, expanded access to Vivitrol, while testing for
drugs in correctional facilities, data collection, examining
what reforms can be made to the 42 CFR Part 2, so there is
better coordination of care among physicians, and we can help
prevent relapses and overdose and improve patient safety.
We are in one of the worst medical tragedies of our time,
perhaps the worst. And although this subcommittee has given its
attention to many other problems in the past, we recognize this
is paramount among them. This is a national emergency. And we
look forward to hearing from the states and what you are doing
on the front lines of this.
[The prepared statement of Mr. Murphy follows:]
Prepared statement of Hon. Tim Murphy
Today, the Subcommittee holds a hearing entitled,
``Combating the Opioid Crisis: Battles in the States.'' Make no
mistake. The terms ``combating'' and ``battles'' are entirely
appropriate; our nation is in the midst of a tremendous fight
against death and devastation affecting every corner of our
nation.
In 2015, there were more than 52,000 deaths from drug
overdoses in the U.S., with more than 33,000 deaths involving
an opioid, a 24 percent increase from the prior year. The
opioid overdose death rate in 2015 was almost seven times the
rate of deaths from the heroin epidemic during the 1970's. For
2016, we have learned from an analysis by the New York Times--
not from the Federal government--that we have lost roughly
60,000 people to drug overdoses, more than all the Americans
who died in the Vietnam War. The staggering number of deaths is
only part of the picture. For every fatal opioid overdose, it
has been estimated that there are approximately 20 non-fatal
overdoses. For 2016, the number of overdoses could be nearing
one million.
More than 183,000 lives have been lost in the U.S. from
opioid overdoses between 1999 and 2015. A recent forecast from
STAT News projects that almost 500,000 lives will be lost from
opioid overdoses in the U.S. over the next decade.
The roots of this crisis began back in 1980, when a letter
to the editor from two doctors published in the New England
Journal of Medicine was misinterpreted as evidence of the
unlikelihood that patients given pain drugs would develop
addiction. About twenty years later, the Joint Commission on
Accreditation of Healthcare Organizations, following the
American Medical Association recommendation that pain be
assessed as the fifth vital sign, established standards for
pain management interpreted by many doctors as encouraging the
prescribing of opioids. Under the Affordable Care Act,
prescribing painkillers is incentivized because hospital
payments are tied to patient satisfaction surveys that reward
hospitals financially when patients give them high ratings.
As we learned in our oversight hearing held in March, the
opioid epidemic is an urgent public health threat fueled by
fentanyl, a much more dangerous and potent synthetic opioid and
a clear and present danger to America. Two states represented
on today's panel, Rhode Island and Maryland, were the first
ones hit by the fentanyl wave. Unfortunately, it seems certain
that this wave will sweep the nation as the low-cost, high-
profit, hard-to-detect profile of fentanyl is increasingly
attractive to traffickers and is relatively easy to manufacture
or obtain on the street or over the internet.
This is an in extremis moment requiring all the experience,
resources, and cooperation of our federal, state, and local
governments, as well as all the different industries,
professionals, and experts to curb this outbreak. With this
hearing, we will focus on the actions of our state governments
to find out what efforts are working, what is not working, and
how we can work together to save lives, restore communities,
and repair the millions of families torn apart by the deadliest
drug crisis in United states history. As drug policy expert
Sally Satel noted ``[it] is at the state and county levels that
the real progress will be made.It makes sense that the effort
to find inspired solutions would be most concentrated there; we
should invest in those solutions and learn from them.''
Serving on the front lines of the opioid epidemic, state
governments have been pursuing their own innovative
initiatives, such as more inventive use of incentives, more
structured medication assisted treatment and more comprehensive
prescription drug monitoring. states such as Maryland are
making the best use of the Centers for Disease Control Opioid
Prescribing Guidelines to help push back on the overprescribing
of opioids. Kentucky's All-Schedule Prescription Electronic
Reporting System, or KASPER--a web-based database to monitor
opioid prescription and use across the state--is helping state
regulators identify questionable prescription practices by
physicians and abuse by patients. Virginia has greatly expanded
access to Naloxone, the drug that can rapidly reverse an opioid
overdose.
Some states are expanding the availability of Naloxone by
permitting third party prescribing by family and friends of
individuals who are at high-risk of overdose. Rhode Island has
developed the AnchorED program that matches overdose victims
with peer recovery coaches to encourage treatment, who follow-
up with the patient for the next 10 days after the overdose.
Much of the work of the states should help inform the
President's Commission on Combating Drug Addiction and the
Opioid Crisis.
Two years ago, the Subcommittee held a similar hearing on
what the state governments were doing to combat the opioid
abuse epidemic. Such oversight helped Congress enact provisions
in the Comprehensive Addiction Recovery Act and 21st Century
Cures Act which authorized the Substance Abuse and Mental
Health Services Administration to administer nearly one billion
dollars in grants over the next two years to states and
territories for substance abuse prevention programs, treatment,
and training for health professionals. We are eager to learn
about how the states represented here today plan to use these
grants, to ensure the grants are reaching local communities in
need, and that the help provided is really working.
However, the 21st Century Cures state grant program is just
a beginning. Our state government witnesses can help this
Committee develop a more effective national strategy to combat
the opioid crisis in such areas as: substance abuse prevention
and education, physician training, treatment and recovery, law
enforcement, expanding access to Vivitrol while testing for
drugs in correctional facilities, data collection, and
examining what reforms can be made to 42 CFR Part 2 so that
there is better coordination of care among physicians.
We are honored to have our distinguished witnesses join us
this morning. We thank you for appearing today and look forward
to hearing your testimony.
Mr. Murphy. Now I yield to my colleague for 5 minutes, Ms.
DeGette of Colorado.
OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF COLORADO
Ms. DeGette. Thank you so much, Mr. Chairman. And I
appreciate this most recent hearing on opioid addiction. As you
said so accurately, this crisis is really devastating America,
as all of us on the dais have seen it play out in our
communities, urban and rural alike. Not a day passes without a
report about children watching their parents overdose, about
librarians and school nurses being trained to administer
Naloxone to overdose victims, or about local and state
governments trying to respond to the myriad of issues
surrounding addiction, all, at the same time, trying to stay
within their budgets.
There is some good news. Recently, the CDC reported that
opioid prescriptions peaked in 2010, and have since fallen by
41 percent. That is the good news. The bad news is, opioid
prescribing remains untenably high. And I am hoping our future
investigations will concentrate on this.
In addition, as you pointed out, Mr. Chairman, is the
emergence of illegal fentanyl, which is an exceptionally potent
opioid. In 2017, fentanyl overtook both heroin and prescription
opioids as the leading cause of death in many places. Each of
the states who are here today, and I want to thank you all for
coming, have faced alarming overdose outbreaks due to this
drug's pervasive dangerous nation.
This committee has done some good work, in particular,
investigating the seemingly voluminous amount of pills
distributed in West Virginia. And I know that we are planning
to do more. As you know, a number of state Attorneys General
are investigating manufacturers, and, in some cases,
distributors. The attorney general in my home State of
Colorado, for example, has joined a bipartisan coalition of
states nationwide, looking into whether manufacturers engaged
in illegal or deceptive practices when marketing opioids.
Coming up with an effective solution to the opioid epidemic
will require us to understand the actions of all actors. I hope
to hear from some of the states today on what role they believe
drug manufacturers and distributors may be adding to the
crisis. Also, I look forward to hearing from the panel about
the impact of fentanyl on the towns and communities in which
they work. states really are on the front lines of fighting
this crisis, and I look forward to hearing from all of you.
I know that Rhode Island, for example, has led the way in
connecting people with substance abuse disorders to highly
trained coaches to guide them through recovery. Virginia is
working to implement a similar peer recovery program. And
Kentucky has established a program to provide medication-
assisted treatment to individuals in correctional facilities
and to continue supporting them after they are released.
Maryland has just committed to establishing a 24-hour crisis
center in Baltimore City.
Mr. Chairman, I know these are all great state efforts. We
have made some efforts here in Congress, and I appreciate you
referring to the 21st Century Cures legislation that
Congressman Upton and I sponsored, and that this whole
committee worked together on a bipartisan basis to pass. But as
we move forward on this issue, we really need to work together
to continue to address this, and that is why I kind of hate to
be the fly in the ointment, and talk about what these efforts
to repeal the Affordable Care Act will do to the fight against
the opioid epidemic. As you know, the ACA has helped nearly 20
million Americans obtain healthcare coverage. In addition, it's
enabled governors to expand Medicaid services that are critical
tools in the fight.
For example, studies that show that since 2014, 1.6 million
uninsured Americans gained access to substance abuse treatment
across the 31 states that expanded Medicaid coverage. This is
particularly true for hard-hit states like Kentucky, where one
study reports that residents saw a 700 percent increase in
Medicaid beneficiaries seeking treatment for substance abuse.
Many people think that the House-passed bill that undermines
the ACA will threaten people's ability to get opioid treatment.
In its assessment, the non-partisan CBO said the House bill
would cost 23 million, or 22 million, Americans to lose health
insurance. A lot of these people need opioid treatment.
Now, there have been discussions, both in the House bill
and the Senate discussions, about adding some money for opioid
treatment. But, for example, the most recent Senate suggestion
of additional $45 billion to help combat opioid addiction,
Governor John Kasich said, ``It is like spitting in the ocean,
it is not enough.''
We have got to get real and understand that access to
healthcare treatment is what is going to help with the health
of all Americans, including treatment of opioid addiction. And
we have got to move forward to work on this together. I hope we
can do that. And with that, I will yield back, Mr. Chairman.
Mr. Murphy. The gentlewoman yields back. I now recognize
the chairman of the full committee, Mr. Walden.
OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF OREGON
Mr. Walden. Thank you very much, Mr. Chairman. Addiction is
an equal opportunity destroyer. It is a crisis that does not
pick people based on their age, race, or socioeconomic status,
and it most certainly does not pick them based on political
parties. From my roundtables throughout the Second District of
Oregon, it didn't matter if I were in a rural community or a
more populated city, the tragic stories were very similar. We
all know someone who has been impacted by this epidemic.
In my state, more people die from drug-related overdoses
than from automobile accidents, and sadly, that is not unique.
According to a preliminary data analysis, drug overdose deaths
in 2016 likely exceeded 59,000 people. That is the largest
annual jump ever recorded in the United states. And what's
worse, some of the preliminary numbers from the states indicate
that their numbers within the first 6 months of this year are
already surpassing last year's total numbers. And over the past
7 years, opioid addiction diagnoses are up nearly 500 percent,
according to a recent report.
Despite a report released by the Centers for Disease
Control last week, which indicates the number of opioid
prescriptions has decreased over the last 5 years. That's the
good news. The rates are still three times as high as they were
just back in 1999. And the amount of opioids prescribed in 2015
was enough for every American to be medicated around the clock
for 3 weeks. That report also found that counties in Oregon
have some of the highest levels of opioid prescriptions in the
country. Of the top 10 counties in my state for opioid
prescriptions, five of them are in my rural district.
Moreover, Oregonians, aged 65 and over, are being
hospitalized for opioid abuse, overdoses, and other
complications at a far higher rate than any other state in the
Union. Sadly, overdose deaths continue to escalate, and this
epidemic is simply getting worse and more severe. So challenges
remain and we need to get after it.
First, we need to improve data collection. In a few states,
we are already requiring more specific information related to
overdose deaths. Quite simply, we cannot solve what we do not
know. We need to be able to have more timely and reliable data
so we can better understand and address the full scope of the
problem. There also needs to be an increase in overdose
prevention efforts, improvement with respect to the utilization
and interoperability of prescription drug monitoring programs.
And we need to increase access to evidence-based treatment,
including medication-assisted treatment.
Combating this epidemic requires an all-hands-on-deck
effort from Federal, state and local officials, and all of us
spanning from healthcare experts to our local law enforcement
communities, that's precisely why we are having this hearing
today. Last year, Congress took action to combat this crisis by
passing legislation, including the Comprehensive Addiction
Recovery Act, and the 21st Century Cures Act, and states have
pursued programs to strengthen our fight against this epidemic.
But much more needs to be done. We need to work together to
ensure that the tools and funding Congress has created are
reaching our state and localities, and that they are being used
effectively.
We hope to hear from the state officials today to see how
they are utilizing these funds, and whether these programs work
or not. We greatly appreciate the witnesses who have agreed to
appear before us today. We hope to have a constructive dialogue
about what the states are doing, how we can improve data
collection, what initiatives are working, what isn't working,
and how the Federal Government can be a better partner in this
collective fight.
I look forward to your testimony and working with all of
you and our community leaders to help get our hands on this
horrific crisis. So thank you for being here. With that, I know
I have two members that want to introduce witnesses, so I will
go first to Mr. Guthrie, and then I'll go to Mr. Griffith.
[The prepared statement of Mr. Walden follows:]
Prepared statement of Hon. Greg Walden
Addiction is an equal opportunity destroyer. It is a crisis
that does not pick people based on their age, race, or
socioeconomic status. And it most certainly does not pick based
on political parties.
From my roundtables throughout the Second District of
Oregon, it didn't matter if I was in a rural community or a
more populated city; the tragic stories were similar. We all
know someone who has been impacted by this epidemic. In Oregon,
more people now die from drug-related overdoses than from
automobile accidents--and sadly, that is not unique to my home
state.
According to a preliminary data analysis, drug overdose
deaths in 2016 most likely exceeded 59,000--the largest annual
jump ever recorded in the United states. What's worse? Some of
the preliminary numbers from the states indicate that their
numbers within the first six months of this year are already
surpassing last year's total numbers. And over the past seven
years, opioid addiction diagnoses are up nearly 500 percent,
according to a recent report.
Despite a report released by the Centers for Disease
Control last week which indicates that the number of opioid
prescriptions has decreased over the past five years, the rates
are still three times as high as they were in 1999, and the
amount of opioids prescribed in 2015 was enough for every
American to be medicated around the clock for three weeks.
That report also found that counties in Oregon have some of
the highest levels of opioid prescriptions in the country. Of
the top 10 counties in Oregon for opioid prescriptions, five of
them are in my rural district. Moreover, Oregonians age 65 and
older are being hospitalized for opioid abuse, overdoses, and
other complications at a far higher rate than any other state
in our union.
Sadly, overdose deaths continue to escalate. This epidemic
is getting more severe. Challenges clearly remain.
First, we need to improve data collection, and a few states
are already requiring more specific information related to
overdose deaths. Quite simply, we can't solve what we don't
know.
We need to be able to have more timely and reliable data so
we can better understand and address the full scope of the
problem. There also needs to be an increase in overdose
prevention efforts, improvement with respect to the utilization
and interoperability of Prescription Drug Monitoring Programs,
and we need to increase access to evidence-based treatment,
including Medication-Assisted Treatment.
Combating this epidemic requires an all-hands-on-deck
effort from federal, state, and local officials--spanning from
health care experts to our law enforcement community. That is
precisely why we are having this hearing today.
Last year Congress took action to combat this crisis by
passing legislation, including the Comprehensive Addiction and
Recovery Act and the 21st Century Cures Act, and states have
pursued programs to strengthen our fight against this epidemic.
But much more needs to be done. We need to work together to
ensure that the tools and funding Congress has created are
reaching our state and localities, and that they are being used
effectively. We hope to hear from the State officials before us
today to see how they are utilizing these funds and what
programs have proven to be successful.
We greatly appreciate the witnesses who have agreed to
appear before us today. We hope to have a constructive dialogue
about what the states are doing; how we can improve data
collection; what initiatives are working, what isn't working;
and how the federal government can be a partner in this
collective fight. I look forward to your testimony, and working
with all of you to help our communities and solve this horrific
crisis.
Mr. Guthrie. Thank you, Mr. Chairman. Thank you, Mr.
Chairman, for letting me sit in for purposes of introduction. I
want to introduce our Secretary of Justice and Public Safety in
Kentucky, Secretary Tilley. We have been friends for a long
time. We served in the general assembly together. Secretary
Tilley had a strong reputation, strong work as fiduciary
chairman in the House, working with the Senate to produce
legislation that I think is landmark and was very important.
And we have so much to do in Kentucky. We have 1404 people that
passed away last year from opioid addiction.
There is so much to be done. So we are sitting here saying
thank you for the work that you have done. I know we have
enormous work to be done, and I tell my colleagues on the
committee here and my friends, I can think of nobody else in
Kentucky I'd rather have in sitting where you are and leading
this effort, and I applaud Governor Bevin for making the
choice, and asking you to serve in his cabinet, and appreciate
your willingness to do so. I think you will make a big impact.
And I yield back.
Mr. Walden. Now I recognize the gentleman from Virginia,
Mr. Griffith, for purpose of introduction.
Mr. Griffith. Thank you very much. I appreciate that. I
would like to introduce Secretary Brian Moran. Brian was a
prosecutor first, and then he came to the Virginia House of
Delegates, where he and I served together for a number of
years. He was a leader on the other side of the aisle, but he
was always a pleasure to work with, and appreciate his work
very, very much. And then he became the first Secretary of
Homeland Security in Virginia's history, and has oversight over
11 agencies. But he is generally well-reasoned; every now and
then we would disagree on the floor of the House, but not
always. But we worked together on a number of things. And I
apologize, both Mr. Guthrie and I have to run to another
committee where we have two bills that are upstairs, so I won't
be able to stay, but I will read with interest your testimony
and learn from my colleagues the good words that you have to
say. And I welcome you to our committee, and I apologize that I
can't be here because I'm defending a bill upstairs.
Mr. Walden. With that, I will yield back the balance of my
time. Unfortunately, I, too, must go to that subcommittee.
Mr. Murphy. Come on back. This is where it's going to be
exciting. I note Secretary Moran is a spitting image of his
brother. I now recognize the gentleman from New Jersey, Mr.
Pallone, for 5 minutes.
OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Mr. Chairman. Thanks for holding
this hearing on this critical issue. Our committee has held
several hearings on the ongoing opioid crisis, including one in
March. The opioid epidemic is not letting up, and neither can
our efforts to fight it. Since our last hearing many more lives
have been destroyed. There is no community that remains
completely untouched by the opioids crisis.
Recently, the CDC reported that the opioid prescribing rate
has peaked, but remains far too high, with enough opioids to
keep every American medicated around the clock for 3 weeks. I'm
glad we have the states here today so we can hear about what
they're seeing on the front lines, what successful approaches
they have found that deserve to be replicated, and what
challenges they still face.
I'd also like to hear from our witnesses about how the
Federal Government can help. While it is important the states
be empowered to address the particular challenges of their
communities, our response to this epidemic cannot be 51
separate efforts. We must harness our national resources data
in cooperation to get this crisis under control.
But as we talk about a public health crisis of this
magnitude, there is an elephant in the room that needs to be
addressed. Coverage for substance abuse treatment is how an
individual in society has a fighting chance to kick the opioids
epidemic for good. Health coverage is one of our strongest
weapons in the battles against opioids, the epidemic, and the
devastation it causes to our families.
Yet, Republicans persist in their attempts to gut the
Medicaid program by capping it permanently, and ending Medicaid
expansion as part of its efforts to repeal the Affordable Care
Act. Repealing the Affordable Care Act and replacing it with
TrumpCare would be devastating to 74 million Americans who
receive critical healthcare services from the program. Today, 1
in 5 Americans receive their health insurance from Medicaid.
Half of all the babies born in this country are financed by
Medicaid. And to the working poor, many of whom are hit hard by
the opioids epidemic, and are eligible for Medicaid for the
first time through the ACA's expansion. Medicaid is, quite
literally, the only affordable health insurance available. And
make no mistake, state Medicaid programs are at the center of
the opioids epidemic.
Yet, in the House-passed TrumpCare, the CBO determined that
23 million Americans would lose coverage, the majority of them
covered through Medicaid, with $834 billion in cuts to the
program. The Senate's version of TrumpCare is no better,
cutting Medicaid by a full 35 percent over the next two
decades. These cuts could not come at a worse time from the
perspective of the opioids crisis for states and for people who
depend on the coverage Medicaid provides. There's no substitute
for coverage for our states or for the people that need the
care.
As the Senate continues to make cosmetic changes to its
bill with only one goal in mind, passing any bill out of the
Senate. Let's be very clear, no one-time amount of funds,
whatever that amount may be, will ever replace the certainty of
comprehensive coverage. No cosmetic changes can effectively
offset the damage that could be caused by repealing the ACA and
cutting hundreds of billions of dollars from the Medicaid
program.
So, Mr. Chairman, we must stay vigilant in this fight and
remain open to any solution that shows promise. So I thank you
for having this hearing. But I believe that there is no way
that this crisis can be solved with one-time infusions of
resources, and it will only get worse if Medicaid dollars are
removed from the fight. We must invest in our healthcare system
and its critical public programs for the long term, and
Medicaid is clearly a critical pillar that should be
strengthened, not decimated.
And I fear that if Republicans are successful in passing
TrumpCare, we will end up going in the opposite direction when
it comes to fighting the drug problem that has so devastated
our communities. Thank you, and I yield back. I don't think
anybody on my side wants the time, so I yield back, Mr.
Chairman.
Mr. Murphy. Thank you for your comments. I ask unanimous
consent that the members' written opening statements be
introduced into the record, and without objection the documents
will be entered into the record. I also note that two former
members of this committee, Representative Mary Bono and Dr.
Phil Gingrey, are present. Thank you for being here. And I,
believe you said Mr. Stupak was around, too. Obviously, this is
an important issue to those who are alumni committee as well.
We heard so many introductions. Let me introduce the rest
of our panel for today's hearings, the Honorable Boyd
Rutherford, Lieutenant Governor of Maryland, welcome to the
hearing. As mentioned before, Secretary Moran, Secretary
Tilley; and the Honorable Rebecca Boss, Director of the
Department of Behavioral Healthcare, Developmental Disabilities
and Hospitals from the State of Rhode Island.
Thank you for being here today and providing testimony. We
look forward to our continued discussion on the opioid crisis
facing our nation. As I mentioned before, I really want you to
be brutally candid with us on what the problems are, what we
need to do, and what are the gaps. You are all aware the
committee is holding an investigative hearing, and when doing
so has had the practice of taking testimony under oath.
Do any of you have any objections to testifying under oath?
Seeing no objections, the chair then advises you that under the
rules of the House and rules of the committee, you're entitled
to be advised by counsel. Do any of you desire to be advised by
counsel during testimony today? Seeing none, then, in that
case, please rise, raise your right hand and I will swear you
in.
[Witnesses sworn.]
Mr. Murphy. Seeing all have answered in the affirmative,
you are now under oath and subject to the penalties set forth
in Title 18, Section 1001, United states Code. We'll ask you
each to give a 5 minute summary of your statement. Please pay
attention to the time here. We'll begin with you, Governor
Rutherford, you may begin.
TESTIMONIES OF HON. BOYD K. RUTHERFORD, LIEUTENANT GOVERNOR,
STATE OF MARYLAND; HON. BRIAN J. MORAN, SECRETARY OF PUBLIC
SAFETY AND HOMELAND SECURITY, STATE OF VIRGINIA; HON. JOHN
TILLEY, SECRETARY OF THE JUSTICE AND PUBLIC SAFETY CABINET,
STATE OF KENTUCKY; HON. REBECCA BOSS, DIRECTOR, DEPARTMENT OF
BEHAVIORAL HEALTHCARE, DEVELOPMENTAL DISABILITIES AND
HOSPITALS, STATE OF RHODE ISLAND
TESTIMONY OF HON. BOYD K. RUTHERFORD
Mr. Rutherford. Thank you, Chairman Murphy, Ranking Member
DeGette. Honorable members of the subcommittee, thank you for
the opportunity to join you today to discuss the State of
Maryland's response to heroin and opioid crisis. Tackling this
emergency necessitates a coordinated response from Federal,
state and local government. And Maryland looks forwards to
working together with our Federal partners to address this
challenge.
Governor Hogan and I first became aware of the level of
this challenge while traveling throughout the state during our
2014 gubernatorial campaign. We quickly realized the epidemic
had crept into every corner of our state, cutting across
demographics.
Maryland, like most states, has experienced an increase in
the number of deaths related to opioids. In 2016, 2089
Marylanders died from alcohol or drug-related intoxication; 66
percent increase over the deaths and 2015. And 89 percent of
those deaths were related to opioids. Maryland has seen an
increase in prescription opioid-related deaths, and so we must
address this particular element of the crisis. We must focus on
reducing the inappropriate use of prescription opioids, while
ensuring patients have access to appropriate pain management.
In Maryland, there were over 8.8 million total CDS
prescriptions dispensed in 2016. This is 8.8 million in a state
with 6 million souls. Further, the challenge we face has
evolved. As was mentioned, cheap, powerful, and deadly
synthetic opioids have burst onto the market, bringing a much
higher overdose rate. Deaths related to fentanyl have increased
from 29 in 2012 to over 1100 in 2016 in Maryland.
Accordingly, as one of the Governor's first acts in 2015,
was to establish the Heroin and Opioid Emergency Task Force,
which he asked me to chair. After nearly a year of stakeholder
meetings and expert testimony and research, the task force
adopted 33 recommendations. Those recommendations range from
prevention, access to treatment, alternatives to incarceration,
enhanced law enforcement, and more. And they form the
foundation of our statewide strategy. Building on those
recommendations of the task force, the Maryland General
Assembly passed several comprehensive pieces of legislation.
In 2016, we reformed our prescription drug monitoring
program to require mandatory registration for all CDS
providers. We passed the Justice Reinvestment Act to reform our
criminal justice system to shift from incarceration to
treatment for offenders who are struggling with addiction.
What we set out to do was make a distinction between those
who we are upset with, and those who we are afraid of. This
past legislative session, Maryland passed the Heroin and Opioid
Prevention Effort, or HOPE Act, and the Treatment Act of 2017,
which contains provisions to improve patient education,
increase treatment services, and provide greater access to
Naloxone.
The Governor signed the Start Talking Maryland Act, which
will continue to build school and community-based education and
awareness efforts to bring attention to this crisis. Educating
young people on the dangers of opioids at an earlier age was
something that our task force felt was extremely important. As
I have said over and over again, virtually every third grader
can tell you how bad it is to smoke cigarettes, but they can't
tell you how dangerous it is to take someone else's
prescription medications.
With the deadly surge of synthetics on the scene, we saw
the death toll continue to rise. Accordingly, in January of
this year, Governor Hogan established the Opioid Operational
Command Center. The Center brings opioid response partners
together to identify challenges and establish a systemwide
priority and capitalize on opportunities for collaboration. It
is a formal and a coordinated approach, utilizing the National
Incident Management System to develop both state and local
strategic operational and tactical level concepts for
addressing the heroin and opioid crisis.
Shortly after its creation, the Governor declared a state
of emergency in response to this crisis. By executive order, he
dedicated--delegated emergency powers to state and local
emergency management officials to enable them to fast track
coordination with state and local agencies. Thanks to your
leadership and commitment, funding of the 21st Century Cures
Act, has greatly aided in this effort. And these dollars will
be used in expanding educational efforts in the schools,
building public awareness, improving treatment, expanding our
peer recovery specialist program, and increasing the
availability of Naloxone.
The one thing that I would add that we would like to see
from the Federal Government is to consider utilizing FEMA as
outlined in the national emergency framework to centralize and
coordinate the Federal response to this crisis. The national
response framework is a guide to how the Nation responds to all
types of disasters and emergencies, and it would allow Federal
agencies to work more seamlessly with each other and with the
agencies at the state level. We can't afford to have delays due
to agency silos and bureaucracies. I appreciate this
opportunity to talk to you and await any questions you may
have.
[The prepared statement of Mr. Rutherford follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you. Thank you, Governor. Secretary
Moran, you're recognized for 5 minutes.
TESTIMONY OF HON. BRIAN J. MORAN
Mr. Moran. Mr. Chairman and members of the committee, it is
still very much an honor to be with you this morning, and to be
able to discuss with you Virginia's response, as well as
working with you to request assistance from the Federal
Government to combat this epidemic. As has all been agreed and
said this morning, America is in the midst of an opioid and
heroin addiction epidemic. The epidemic does not discriminate;
it is an equal opportunity killer.
In Virginia, in 2016, 1133 individuals died from opioid
overdose. The sad truth is that Virginia actually ranks 18th
among the 50 states in overdose deaths. Sadder than that, 17
states are doing worse than we are. And in all likelihood, the
other 32 states would be facing similar devastation if we don't
take effective action now.
As Secretary of Public Safety and Homeland Security, I am
very proud of Virginia sworn law enforcement officers who work
24/7, 365, to keep us safe. But what they tell me over and over
and over again is, we cannot arrest our way out of the heroin
and opioid addiction crisis. And we can't simply tell those
living with addiction to get over it. Why is that? Because
addiction is a disease.
Arrest and incarceration of those addicted will no more
cure this disease than it would cure cancer or diabetes. There
are a number of causes, multiple causes of this dramatic rise
in the deadly epidemic of overprescribing, failure to safely
dispose, easy access, and affordability. But over the last
several years, we have seen a sharp rise in illegally
manufactured synthetic opioids such as fentanyl and
Carfentanil. Lethal in even tiny amounts, they contribute
significantly to the increased numbers of heroin and opioid
deaths. From 2015 to 2016, the number of fatal overdoses
involving fentanyl increased to 175 percent, and accounted for
618 of the 1133 deaths in the Commonwealth.
Virginia's response to this epidemic began immediately upon
Governor McAuliffe taking office in 2014. He convened a broad
coalition of healthcare providers, criminal justice
representatives, and community stakeholders to participate in
the prescription drug and heroin use task force. The Secretary
of Health and Human Resources cochaired the committee with
myself. The task force developed over 50 recommendations. I am
proud to say we have implemented the vast majority of those
recommendations, the full list of which can be found in my
submitted written testimony. Of course, the work continues in
Virginia.
Our executive leadership team works across state government
and with regional and local agencies and individuals to
effectively align goals, share best practices, and work to
overcome barriers to success. The leadership team organized a
statewide approach to opioid crisis and provided leadership
from the Virginia state Police, Department of Health, and from
our local community service providers. Again, that is a theme
that this is not just a law enforcement problem, but, rather,
one that requires healthcare providers to be at the table along
with their community service providers.
They support coordination among local grassroots
organizations, task forces, and other collaborations, including
those that exist within Virginia's HIDTA designated areas,
which cover parts of Northern Virginia, Appalachia, and Hampton
Roads. So there is more work to be done. Let me highlight some
of our accomplishments. The General Assembly enacted
legislation expanding the deployment of Naloxone. Lay people,
law enforcement officers, state agencies like our Department of
Forensic Science and others working with potentially dangerous
drugs, are being trained in using this overdose reversal agent
through the Department of Behavioral Health and Developmental
Services Revive program. Our Commissioner of Department of
Health issued a standing order for pharmacies to dispense
Naloxone. The Department of Criminal Justice Services issued
grants to pay for increased Naloxone to be used by law
enforcement. In fact, the city of Virginia Beach has used
Naloxone now, and they have had over 60 deployments to save
lives in that community.
Now, our requests. I came into this job with a mandate from
my 11 public safety agencies that we would rely on data-driven
decision making. If we are going to effectively wrap our arms
around this epidemic and reverse the devastating upward trend
in deaths, overdoses, and related crime, we need to know what
the problems are, where they are, and what is working. To do
that, we need good data. Here are some of the identified needs
that Congress and the administration can help us address.
Craft limited exceptions to current regulatory and
statutory barriers under HIPAA, in 42 CFR, Part 2, which is the
substance abuse privacy protections. For example, our
prescription drug monitoring program is prohibited from
accessing any data from our methadone clinics. That is, we need
to know how they work and who they are providing care for, and
how it is working; provide technical assistance or fund staff
positions for states and localities in developing metric-
sharing data in analyzing results; support development of
consistent national metrics; incentivize private providers or
mandate data collection as a requisite for Federal funding;
change how the Federal agencies do business; increase support
for SAMHSA and HIDTA; break down Federal funding silos, reduce
demand; support, train, incentivize law enforcement to focus on
mid and high level dealers; and help us divert those who are
addicted into treatment programs. Our treatment programs are
currently insufficient to address this epidemic.
Those with addictions shouldn't become law enforcement's
problem, they belong in the healthcare system. Examples of
programs to explore further, include assist localities to
pilot, analyze, and determine the efficacy of Angel programs in
police departments, fully fund the dissemination and
utilization of Naloxone or other overdose drugs. My time is up.
There are a lot of requests, but you invited the requests, Mr.
Chairman, but I will stop if----
[The prepared statement of Mr. Moran follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. We will get more into that as we cover
questions. Thank you, Mr. Moran. Secretary Tilley, you are
recognized for 5 minutes.
TESTIMONY OF HON. JOHN TILLEY
Mr. Tilley. Mr. Chairman and members, thank you so much for
allowing me the chance to be here. I want to thank Governor
Matt Bevin from Kentucky for that chance as well. He sends his
regrets. He wanted to be here himself. He's been outspoken on
this topic. I will share with you a quick story. When I first
met Governor Bevin, he was interviewing for this position, for
this job, and he walked into a room with Dreamland under his
arm, and he said, have you read this book? And thankfully, I
had. So I said, yes, sir, I have read the book. And, actually,
I am trying to reread it because it is, again, I think the best
chronicling of this problem and how it began that I know of.
So that, again, illustrates to you our commitment and our
shared understanding of this problem. I want to thank
Congressman Guthrie for that far-too-kind introduction as well.
Dreamland, again, is relevant to us because, as you know, the
problem really has its origins in Kentucky and Ohio. We lost
1404 Kentuckians, as the Congressman said. Fentanyl is now the
driving force behind these overdoses. We had 13,000 ER visits,
13,000 ER visits in a state of 4 1A\1/2\ million people. We
lose, in this country, as you've heard those numbers, nearly a
commercial airplane a day. If this were a communicable disease,
we would be wearing hazmat suits to combat it.
But again, I think overdoses and those visits only tell
half the story. This devastates communities. As soon as we got
our arms around heroin, we began to see fentanyl. Our State
Police tells us that in the last 6 years alone, we have seen a
6,000 percent increase in fentanyl in our labs. 6,000 percent
increase. I think all of us know the devastation it's had on
our criminal justice community. Our jails and prisons are at
capacity. We have no more room at the inn.
The Public Health crisis is on full display. In Kentucky,
we have a Hep C rate, Hepatitis C, a form of viral hepatitis
that is seven times the national average. Right across the
river in Indiana, they had an outbreak of HIV that rivaled that
of Sub-Saharan, Africa. One of the first southern states to
pass a comprehensive--maybe the only comprehensive syringe
exchange program. Now in Kentucky, we have 30 programs all
passed by local option in our state. We know that that
increases the treatment capacity by five times. When someone
just walks over the doorstep of one of those programs, and it
battles back these diseases like Hep C and HIV.
Sadly, Kentucky, as the CDC reports, has 54 of 220 counties
most susceptible to a rapid outbreak of HIV. So what has our
response been in Kentucky to battle this? Again, taking a bold
step as a southern state on the syringe exchange program;
passing comprehensive legislation in consecutive years on
prescription pills and pill mills; the second state in the
country to battle back synthetics; dealing with heroin directly
and fentanyl; being the first state in the country to mandate
usage of what we call KASPER, our PDMP, our prescription drug
monitoring program.
Now we have become the first state in the country now to
require physicians, when prescribing, for acute pain, to limit
prescriptions to 3 days. Some have done 7, some have done 10.
We limited that to 3 days. And I could promise you, our
Governor has spent some capital on that. That's how important
it is to him.
We have doubled down on things like rocket dockets and
alternate sentencing worker programs, and help for those who
are addicted through various forms of treatment. Again, looking
at things like neonatal abstinence syndrome. We have 1900 cases
in Kentucky. We've increased funding many times to combat that
and to help for the suffering of those addicted there. We have
put it in our jails and our prisons. Again, I think I mentioned
rocket dockets with prosecutors, again, to try to make these
cases, put them on a separate plane, to deal with them in the
most appropriate way possible.
We have increased treatment at the Department of
Corrections by nearly 1100 percent since 2004. We validate that
treatment every year, and our return on investment now is
almost $5. Some of the innovative programs you may have heard
about, it was just recently chronicled in The New York Times,
is the way we use Naltrexone, or Vivitrol, as it's known, in
our jails, on the front lines. We give an injection prior to
release, and an injection upon release. And then we try to link
that offender, that returning individual, to those services in
the community to see if they are Medicaid-eligible, to see what
kind of resources they had to continue that particular
treatment. And I know a question will be, do we link those
folks up to counseling? We do our best to do it. It is not
mandated. We do our best to do that.
In fact, in Kentucky, I will tell you both, validated and
anecdotally, we are seeing tremendous results from using MAT
and counseling together, but counseling in the form of
cognitive behavioral therapy, like moral reconation therapy. We
are seeing that used in both our jails and prisons, and that is
yielding some tremendous results. We intend to emulate what's
been going on in Rhode Island with the AnchorED program. We
visited there with Director Boss some time ago through an NGA
project. And I can promise you, we are doing peer recovery and
bridge clinic soon. We'll do some innovative awareness. We'll
use a hotline to get folks linked up to treatment. We're even
educating our medical and dental schools. And overall, as I
close out and conclude at the end of my time, I will tell you
that I think we have the most comprehensive effort I've seen in
my 25 years in criminal justice with something called KORE, the
Kentucky Opioid and Response Effort.
So with that, I will look forward to questioning. Thank
you, Chairman.
[The prepared statement of Mr. Tilley follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you, Mr. Secretary. Director Boss, you
are recognized for 5 minutes.
TESTIMONY OF HON. REBECCA BOSS
Ms. Boss. Thank you, Chairman Murphy. Thank you, Chairman
Murphy and Ranking Member DeGette. As the director of Rhode
Island's Department of Behavioral Healthcare, Developments,
Disabilities and Hospitals, I oversee the state's treatment,
prevention and recovery system. I am also a longstanding member
of the National Association of State Alcohol and Drug Abuse
Directors, and currently serve on their board.
Thank you for the invitation to appear before you today to
share Rhode Island's work in combating the opioid crisis, an
effort that has been proposed as a national model. Our
strategies to address this epidemic are clearly outlined on our
Web site: preventoverdoseri.org. And I will be sharing slides
from this Web site during this testimony.
Our goal is to make these efforts open to the public with
complete transparency on outcomes and available for replication
throughout the country. First and foremost, I would like to
thank Congress for the action taken last year passing the 21st
Century Cures Act with $1 billion to help support prevention,
treatment, and recovery. In a time of tight budgets, we fully
appreciate the significance of this action.
Addiction and overdose are claiming lives, destroying
families, and undermining the quality of life across states in
the United states, and Rhode Island has been one of the hardest
hit. In 2015, newly elected Governor Gina Raimondo recognized
the need for this state to develop a comprehensive strategy to
prevent, address, evaluate, and successfully intervene to
reverse the overdose trends. She signed an executive order
establishing the Governor's Overdose Prevention and
Intervention Task Force, which is comprised of stakeholders and
experts from a broad array of sectors. The resulting plan has
one overarching goal: reduce overdose deaths by one-third in 3
years. Governor Raimondo's plan focuses on four specific
strategies, which I will briefly outline and focus on two
specific areas, others are described fully in my written
testimony.
The first is prevention. We take aggressive measures to
ensure appropriate prescribing of opioids, promote safe
disposal of medication, and encourage the use of alternative
pain management services.
Next is Naloxone, rescue. Naloxone is a standard of care
for first response. Naloxone saves lives by reversing overdose.
And our plan supports increasing access to Naloxone across
various sectors of the state.
Third, we believe that every door is the right door for
treatment, and our goal is to increase access to evidence-based
treatment. To do this, Rhode Island developed Centers of
Excellence, which provide rapid access to treatment, including
induction on all FDA-approved medications for opioid use
disorder. These specialized programs provide thorough clinical
assessments and intensive treatment services with wraparound
support. This program is designed to provide opportunities for
stabilization with referrals to community physicians for
continued treatment, offering continued clinical and recovery
support through the Centers of Excellence. This program is
supported through private insurance and Medicaid.
In addition, Rhode Island released the Nation's first
statewide standards for treating overdose and opioid use in
hospitals and emergency settings. And the Rhode Island
Department of Corrections is providing medication-assisted
treatment to the population most at risk for overdose. We have
worked diligently to increase data-waivered physicians in Rhode
Island. For example, Brown University Medical School is the
first in the Nation to incorporate data-waivered training into
its curriculum.
Finally, recovery. We are looking to expand recovery
supports. Recovery is possible. To support successful recovery
from more Rhode Islanders, we are expanding peer recovery
services, particularly at moments when people are most at risk.
The AnchorED program was started in June of 2014, and is now a
statewide, 24/7 service. It connects overdose survivors with
peer recovery coaches in hospital emergency departments. These
coaches share their own stories of hope and inspiration to
engage those in crisis, as well as providing continued
services, and follow up in connection. To date, over 1600
individuals have met with recovery coaches; and as a result,
over 82 percent have accepted a referral to treatment.
The Anchor MORE Program exists as a statewide peer outreach
effort to opioid hotspots that are identified through data, not
waiting for someone to overdose to be seen. We are now facing a
fentanyl crisis. As you can see in this slide, with
approximately two-thirds of overdoses, fentanyl-related, we
must develop new strategies to address the changing face of
this epidemic.
As we speak, the Rhode Island Governor is signing an
executive order expanding our efforts to include more focus on
primary prevention, engaging families and youths in these
efforts, harm reduction strategies, and access to treatment. I
cannot state strongly enough that Rhode Island's strategies
rely on sustainable funding through Medicaid and health
insurance held to standards of parity with SUD treatment as an
essential benefit. Any action taken on a Federal level which
would threaten this funding would weaken this plan
substantially.
I would also recommend that any Federal initiatives
specifically include involvement of state agencies given their
expertise in these matters. I would advocate for continued
support of the Substance Abuse Prevention Treatment block grant
as the foundation of comprehensive state systems. And finally,
I would encourage continued consideration of targeted funds to
address these issues.
Thank you for this opportunity to testify. I look forward
to answering questions.
[The prepared statement of Ms. Boss follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Mr. Murphy. Thank you all. I recognize myself now for 5
minutes. Starting with Governor Rutherford, regarding the 42
CFR, Part 2, a couple of effects. One is, as also as pointed by
Secretary Moran and others, if someone is using a PDMP, the
data is simply not in there. A physician prescribing will not
know if that patient is on methadone, suboxone or some other
synthetic opioid.
Secondly, if a person shows up in an emergency room--our
former colleague, Patrick Kennedy, talks about this incident--
shows up there with an injury, and when asked if that person
has any allergies or any drugs, and he says, ``Please don't
give me any opioids.'' They do it anyway, because there's
nothing in the record that's prohibitive of being in the
record. We can list if a person has an allergy, but an opioid
sensitivity should be in there as well. But the law in place
since the Nixon administration does not allow that to be in
there. So the person then may leave that hospital with a vial
of opioids, and then saying, ``Well, when I used to be
addicted, I used to take 20 of these at a time, I'll take 20
now.'' Overdose and death. Or they may take them and then they
relapse, or they may be on other medications, such as
benzadine, the PNN, a bad drug interaction.
What do you recommend we do with that 42 CFR Part 2?
Mr. Rutherford. Well, that does have to be addressed.
You're exactly right. And Secretary Moran was correct in terms
of that particular challenge. A person who goes in who may be
receiving methadone treatment, they go in for a knee
replacement. There's nothing to tell that doctor that this
person is also receiving methadone, when they prescribe
oxycodone or OxyContin or something of that nature. It doesn't
show up in our prescription drug monitoring system as well.
So it is a particular challenge. It needs to be addressed.
There are some areas with regard to HIPAA that also go to other
areas of behavioral health, and I know you talked about that.
When we talk about mental health and the challenges associated
with getting assistance for an adult family member, once that
person goes from 17 to 18, you lose a lot of control when you
can help this person. So, yes, if you can make some type of
exceptions or clarification----
Mr. Murphy. At least in the----
Mr. Rutherford. That is also a misunderstanding among some
of the doctors as well.
Mr. Murphy. At least in the medical record to be able to do
a 42 CFR----
Mr. Rutherford. Yes, that would be a start.
Mr. Murphy. Let me ask another quick survey. Noting that
most people with an addiction disorder have a co-occurring
mental health disorder. I was just wondering if any of you have
taken a survey in your states? Do you have a sufficient number
of psychiatrists, psychologists? I believe the national numbers
say that half the counties in America have no psychiatrists, no
psychologists, no clinical social worker, no licensed drug
treatment counselor.
If you know? If you don't know, tell me. But if you do
know, do you have ever a sufficient number in your state to
meet the need?
Mr. Rutherford. I can only speak anecdotally. There are
some counties in our state that have a substantial shortage of
those types of professionals, including drug counselors. That
is the challenge that we have.
Mr. Murphy. Secretary Moran, real quick, yes or no.
Mr. Moran. Yes. And it varies by geography in southwest
Virginia, Congressman Griffith represents a very insufficient
shortage of such counseling.
Mr. Murphy. Secretary Tilley.
Mr. Tilley. Urban areas, yes; rural areas, no. We do have a
community mental health network we're proud of. But, again, in
the rural areas, they are still struggling to find the
qualified professionals.
Mr. Murphy. Thank you. Director Boss?
Ms. Boss. Rhode Island shares in the Nation's struggle with
the number of psychiatrists needed to meet the demands. So I
would say, yes, there is a psychiatrist shortage.
Mr. Murphy. Thank you. The other issue is medication-
assisted treatment, Director Boss, with regard to that. In
Pennsylvania, we had some data that says that people who are in
an MAT and may be getting suboxone or something. The question
is, are they getting treatment? And I'm wondering if your state
and other states, too, if people have actually reviewed that? I
heard in some cases, the treatment is no more than a nurse in
the waiting room, saying, ``So how are you doing today?'' And
they call that group therapy if a doc says, ``Is everything all
right?''
But in Pennsylvania, 59 percent had no counseling in the
year that they received buprenorphine, 40 percent were not drug
tested in the year they received it, 33 percent have between
two and five different prescribers, and 24 percent of them
didn't see a physician in the prior 30 days.
Can you describe if you have the data in Rhode Island and
other states? Is that something to really find out if they are
getting real counseling?
Ms. Boss. No. In Rhode Island, our opioid treatment
programs are required to provide counseling, and they are----
Mr. Murphy. But do you know if they are really doing it?
Ms. Boss. Yes. We actually do reviews of our programs. So
the state licenses the opioid treatment programs, and goes out
to review records and to make sure that they are abiding by the
counseling standards as well----
Mr. Murphy. I appreciate reviewing the records. I am going
to push on this, because we need to know this. I have heard
from people who go to centers who tell me that they are listed
in the records as having counseling, and they have no more than
someone saying, How are you doing? I'm just curious. Not Rhode
Island. I have heard other states.
Ms. Boss. Mr. Chairman, without actually being able to sit
in on sessions and time the sessions and make sure that they
are happening, we have to rely on the validity of the record
with which we review. And so, unless people are willing to
commit fraud and put their licenses on the line by documenting
something that didn't happen, I would have to say that I
believe that what I read in the record to be true.
Mr. Murphy. OK. I think this committee has dealt with so
much fraud. We have to move on. Ms. DeGette, you're recognized
for 5 minutes.
Ms. DeGette. Mr. Chairman, it's called medically assisted
treatment, and you're right, counseling has to be an important
part of that. So if they are not giving the counseling, I would
think they should. But I don't think we have any evidence that
there's fraud being committed in Rhode Island.
Mr. Murphy. No, I'm not picking on Rhode Island. We love
Rhode Island.
Ms. DeGette. Yes, we do. My daughter went to Brown
University, and we love Rhode Island. So I want to talk to you
a little bit, Director Boss, about this issue of states being
able to pay for treatment. And this is--the full range of
treatment--and I think it applies in all the other three
states, too. I would assume that paying for treatment on this
scale is really an ongoing challenge facing your state. Would
that be a fair statement?
Ms. Boss. Congresswoman, that would be a fair statement
prior to 2014. But we have seen significant increases in the
number of people being able to access treatment, post Medicaid
expansion.
Ms. DeGette. And so the Medicaid expansion has helped. And
we hope 21st Century Cures helped, too, but we know that
there's a lot more work that needs to be done. In fact, in your
statement, you said Medicaid has laid the foundation for
treatment coverage. Is that correct?
Ms. Boss. That is correct.
Ms. DeGette. So I wonder if you can just tell me, quite
briefly, how Medicaid funds are helping Rhode Island fight this
epidemic?
Ms. Boss. So Medicaid funds in Rhode Island cover
medication-assisted treatment, all three forms of FDA approved
medications, methadone, buprenorphine, and injectable
Naltrexone. They support something known as OTP health homes,
and that's a comprehensive program to integrate healthcare with
individuals who are receiving methadone treatment, as well as
all other forms of treatment. And Rhode Island has a full
continuum of treatment from inpatient detoxification to
outpatient treatment to residential treatment to the use of
medication and assistant treatment as well.
Ms. DeGette. Now, have you looked at these bills that House
Republicans have passed, and that the Senate Republicans are
looking at, which would severely reduce the Medicaid aid to the
states?
Ms. Boss. I have.
Ms. DeGette. How would those impact your State of Rhode
Island?
Ms. Boss. So any bill that would reduce access to Medicaid
and Medicaid expansion, or reduce access to affordable health
insurance would have negative impact on Rhode Island, as 77,000
lives are covered, approximately, by Medicaid.
Ms. DeGette. You have 77,000 people in Rhode Island covered
by the Medicaid expansion?
Ms. Boss. Correct.
Ms. DeGette. Now, Secretary Tilley, a recent AP analysis
showed that the Medicaid expansion accounted for more than 60
percent of the total Medicaid spending on substance abuse
treatment in Kentucky. Between 2012 and 2014, there's been a
more than 700 percent increase in substance abuse treatment
provided to Kentucky residents due to Medicaid's expansion.
So, I guess I want to ask you, it looks to me like Medicaid
has been particularly helpful in Kentucky's fight against the
opioid crisis. Would you agree with that?
Mr. Tilley. Let me say this: I will tell you unequivocally
of our Governor's commitment, and again, exampled by the 1115
waiver, and our effort at this very moment to expand our
treatment options under that----
Ms. DeGette. Let me ask you my question. Would you agree
that Medicaid has been particularly helpful in Kentucky's fight
against the opioid crisis?
Mr. Tilley. I would agree----
Ms. DeGette. Thank you.
Mr. Tilley. I would agree. Yes. I would agree that through
a number of sources of funding, we have increased treatment
dating back to 2014 by 1100 percent dating to today.
Ms. DeGette. Let me ask you this: Let me ask you this. If
the Medicaid expansion went away, would that impair your
efforts to fund this in Kentucky?
Mr. Tilley. Ma'am, I'm the Secretary of the Justice and
Public Safety cabinet, and I do have five major----
Ms. DeGette. You're not going to answer my question, so I
am going to ask Secretary Moran a question. Secretary Moran,
Governor McAuliffe attempted to expand Medicaid twice in
Virginia, but the Republican legislature rejected both of the
attempts. So I want to ask you, I know Virginia is making the
most out of the tools it has, but if you had had Medicaid
expansion, more money in Virginia, would this have helped you
be able to reach out to more people on this opioid issue?
Mr. Moran. Simple answer is yes. That's an emphatic yes.
Ms. DeGette. Why is that?
Mr. Moran. More people would have access to treatment. Now,
I will give credit to our Department of Health, they are using
a very innovative ARTS program, addiction, recovery and
treatment services, to carve out a Medicaid waiver to try to
address these individuals' addiction needs. But with Medicaid
expansion, 400,000 Virginians would be covered, and Governor
McAuliffe has attempted to do that at every opportunity.
Ms. DeGette. Thank you very much, Mr. Chairman. I yield
back.
Mr. Murphy. I recognize Mr. Collins for 5 minutes.
Mr. Collins. Thank you, Mr. Chairman. I think maybe I'll
start this question with Secretary Moran.
All of us all agree here that opioid addiction is a
disease, it is an addiction, and we all experienced the tragic
deaths of many of our young children when it comes to the
overdose. And as was just pointed out, we also have the
fentanyl issue.
So my question really is surrounding Naloxone, or Narcan,
as we know it. And could you help the committee understand some
of the key issues on availability--because we do hear there may
be some shortages, cost. Who is picking up the tab for this? Is
it patients? Is it the state? Is it the Federal Government--to
maybe give us a little bit of an overview on how we are at
least attempting to deal with that piece.
And, also if someone is obviously in an OD, are they given
Narcan without really--you don't know. Are they OD on opioids
or fentanyl?
Mr. Moran. Thank you very much for the question,
Congressman. We are attempting to expand the coverage of
Naloxone in every community. With the law enforcement
community, there is some resistance, particularly from our
rural jurisdictions because--merely because they are not the
first to respond typically in a large jurisdiction. Usually it
is the emergency medical services. EMS does carry it. The
majority of our jurisdictions in law enforcement communities,
and certainly in urban areas, now carry it. And as I mentioned,
Virginia Beach has a tremendous success rate. They are saving
up towards of a life a week with the use of Naloxone.
Now, that's law enforcement. That's EMS. We appreciate the
Federal grants through the Department of Criminal Justice
Services so that we can provide, without any cost to the local
jurisdiction that uses Naloxone. Now, in terms of lay people,
our Department of Health commissioner issued an order so that
anyone now can go into a pharmacy and receive the prescription
for Naloxone.
So we are attempting to expand coverage in any way
possible. It is obviously a lifesaver, and the more people who
will have it, more lives will be saved.
Now, obviously then once you revive that individual, there
are consequences after that in terms of needs for treatment.
But the Narcan itself is truly a lifesaver, and more people
that carry it--within our Department of Forensic Science, for
instance, one issue with respect to the carfentanil and
fentanyl, because it is so dangerous and lethal, we are
provided authority now for all of our lab technicians to carry
it, that they may be subject to a lethal dose when they're
analyzing evidence in the criminal case. And so, again, as many
people can have it, it is a very significant piece in this
entire puzzle.
Mr. Collins. Now, we have heard that the FDA is considering
making Narcan over-the-counter. Now, you just mentioned anyone
could go in and fill a prescription. But that, I guess, would
certainly indicate they have to have a prescription to start
with issued by a doctor. And I don't know if there is--people
sometimes do have different kinds of concerns in admitting that
they've got an issue. Could you expand on that a little bit on
what you may know of the FDA making over-the-counter and, also,
how does someone get this prescription, which obviously they
would then fill.
Mr. Moran. Congressman, that's what the standing order did
is that you do not need a prescription now. You can actually go
in and obtain the Narcan without a doctor's written
prescription. And that was the standing order from our
commission of health.
Mr. Collins. So that's statewide.
Mr. Moran. That is correct.
Mr. Collins. And that's what the FDA is actually looking to
expand nationwide. And what's your experience with that? Are
you tracking how many people--are these, perhaps, family
members who know that someone that's got this addiction and
they're being anticipatory, to use that word, just in case?
Mr. Moran. That is certainly the intent to--if you have a
loved one who is addicted, you would take the proactive step of
obtaining the Narcan in case of an overdose. And we have been
trained--myself, the first lady of Virginia, the Governor the
Virginia. We received revived training. It is very simple. It
truly is. And we would encourage people to have access to
Narcan in case of an overdose.
Mr. Collins. That's a great example, and I'm just thrilled
you have shared that with us. Maybe that's a message, if the
FDA doesn't move, that other states obviously could take those
same steps, because if we can save lives, then you should be
able to go home and say job well done.
Thank you for sharing that. And I yield back.
Mr. Murphy. Mr. Tonko, you are recognized for 5 minutes.
Mr.Tonko. Thank you, Mr. Chair, and thank you, chair
witnesses, for their public service and for the testimony that
they shared today.
Before I get to my questions, I would be remiss if I didn't
echo my colleagues' remarks on the devastating impact that
TrumpCare, in its iterations, would have in the fight against
the opioid epidemic. This mean, and might I say very mean, bill
will rip hope away from people in communities across my
district who depend on coverage from the Affordable Care Act
and Medicaid expansion to help them recover from the scourge of
opioid addiction. Medicaid by far is the single largest payer
for behavioral health services in our country. In Rhode Island,
Medicaid pays for nearly 50 percent addiction treatment
medication. In Kentucky, it's 44 percent; Maryland, 39 percent;
Virginia, 13 percent.
The bill being considered in the Senate would cut $772
billion, or 26 percent, from Medicaid over the next decade.
There is no way this highly efficient safety net program could
sustain this type of funding loss and continue to provide
services for all that require it.
Simply put, passing TrumpCare would be the single biggest
step backward in providing treatment for substance use and
mental health services in our Nation's history. That being
said, last year I collaborated with my friend Dr. Bucshon on
legislation that expanded buprenorphine prescribing privileges
to nurse practitioners and physician assistants. And I would
like to gather your feedback on how this law is being
implemented in your states?
Director Boss, you mentioned in your testimony that Rhode
Island is actively working to provide DATA 2000 training to
interested practitioners. Have you seen significant interest
from the nurse practitioners or physician assistants
communities in becoming waivered practitioners?
Ms. Boss. Congressman Tonko, I'm not sure that I have data
on how many nurse practitioners and physicians assistants have
applied to take data-waiver training. I know that we are
actively working with medical schools to get that interest and
to increase the training available, but I'm not sure that I
would be able to answer that comprehensively.
Mr. Tonko. But as you are aware, there is interest in it?
Ms. Boss. Absolutely. There is interest, and there is
active work with the Department of Health and within my
department to provide those trainings to any and all interested
parties. And we've seen increased number of data-waivered
physicians. We will be working with the nurse practitioners in
PA schools to increase those as well.
Mr. Tonko. Are there any projections you've made in terms
of these additional classes of practitioners being able to
prescribe MAT's improved addiction treatment access in Rhode
Island?
Ms. Boss. We track through our overdose Web site and our
regular performance management meetings the number of people
receiving buprenorphine treatments. So we're able to look at
the increases and, through our prescription drug monitoring
program, track the number of waivered physicians that are
actively prescribing. And so we are seeing increases in the
number of people receiving buprenorphine treatment through
these efforts.
Mr. Tonko. But I would assume that the further expansion of
the DATA 2000 waiver, either in higher patient caps or
additional classes of practitioners prescribing would have a
positive impact on access to treatment in Rhode Island?
Ms. Boss. I would absolutely agree with that. I'm not sure
that there has been enough time for us to document how much
increase that will result in. But yes, I do agree. And I thank
you for your efforts with that legislation.
Mr. Tonko. Our pleasure.
And to all of our panelists, what barriers do you face in
trying to recruit practitioners to become waivered DATA 2000
practitioners?
Start with the lieutenant governor, please.
Mr. Rutherford. Well, we talked about, in certain cases, in
certain parts of the state, there are limitations in terms of
the number of practitioners in some of our more rural areas of
the state. Also, some of the anecdotal feedback, in some cases,
there is a stigma associated with treating individuals of
substance use disorder, and there are some doctors that just
don't want those patients. But the lifting of the cap has
helped us with regard to being able to provide the services for
more individuals, but stigma is still a challenge.
Mr. Tonko. Thank you, Lieutenant Governor. Secretary Moran.
Mr. Moran. I would agree, though, most of that information
would be within our secretary of health and human resources as
opposed to me. But we have heard from the practitioner. There
is a shortage of personnel to address this issue. And in their
defense, it's an epidemic that has really exploded over the
last several years. Any assistance you can provide for
additional funding in flexibility would be much appreciated by
the Commonwealth and other states.
Mr. Tonko. Thank you. And Secretary Tilley.
Mr. Tilley. Yes. I would reiterate my colleagues, we have a
number of physicians, I think nearly 700, who are prescribing.
However, many of them have not applied to prescribe over that
100 up to the 285 cap. And in many of them, we don't know, as
has been stated earlier, whether they are requiring counseling.
We do know we require counseling in our correction settings and
jails and prisons. We encourage it. We do urinalysis. But we
don't know--that's one of the things we have to get our arms
around. We are doing that now.
We have to look beyond why some of these physicians are not
applying to do more in their communities. Again, we struggle
with the same challenges with rural versus urban in getting
those folks out to those areas largely. In Appalachian, this
problem hit first there, and it's more acute there in many
ways. So that's a challenge for us.
Mr. Tonko. Thank you.
Director Boss, we were going across the board. Can we just
have a quick response, Director?
Mr. Murphy. Real quick.
Ms. Boss. All right. Thank you.
So I would agree with all of my colleagues. But I would
add, in our discussions with physicians, they want to do the
right thing, and they want to be able to make sure that people
are receiving counseling and toxicology screen but lack the
office staff and the management to do that. So they need
increased supports in the offices to do the kind of evidence-
based practice that's needed to use buprenorphine
appropriately.
Mr. Tonko. Thank you.
Thank you, Mr. Chair. I yield back.
Mr. Murphy. The committee likes those words, evidence-based
practices. Thank you.
Mr. Walberg, you're recognized for 5 minutes.
Mr. Walberg. Thank you, Mr. Chairman. And thanks to the
panel for being here.
Secretary Moran, according to the Centers for Disease
Control and Prevention, approximately one in five deaths that
are attributable to a drug overdose failed to list specific
drug in the death certificate. Could you explain why this data
gap is problematic and what efforts the Commonwealth is taking
to ensure that it has sufficient data to understand the true
scope of the opioid epidemic?
Mr. Moran. Thank you, sir. The theme of my remarks is the
need for additional data, the state silos, which are we trying
to break down, and then there are, of course, the privacy
provisions with respect to some of the Federal laws and HIPAA.
In a criminal investigation, our Department of Forensic
Science will do the investigation. We have good data with
respect to what drugs were involved, because they are
collected. If it is an accidental death, it eventually goes to
the OCME, Office of Chief Medical Examiner. But with respect to
the data, it is challenging. And some individuals may not be
anxious to reveal the cause of death under some circumstances.
Family members may not choose to reveal that type of source. So
it is a challenge. It's one we're trying to get our arms
around, because if we have better data, we know how to respond
better and what to do and what, if anything, is working with
respect to addressing this epidemic.
Mr. Walberg. Is there anything that you're attempting to
get your arms around that data that is working for you, at
least with some families?
Mr. Moran. Well, you've seen a dramatic rise in the use of
fentanyl over the last year. That helps inform not only our
healthcare providers but our law enforcement.
Where is the fentanyl coming from? And if it is located in
a particular community, there can be a rapid response with
respect to education and response and to interdict the
fentanyl, because it's typically being manufactured overseas
and coming into in the commonwealth and the country.
So that type of information I think is critical to the
interdiction of these drugs in addition to the healthcare in
response to the individual. So I think it's imperative that we
collect more data and have more access to data because we can
better respond to the crisis.
Mr. Walberg. Director Boss, your written testimony notes
that Rhode Island's multiple disciplinary overdose prevention
and intervention task force makes use of a date-driven
strategic plan to combat addiction and substance abuse. Could
you tell us more about how the state utilizes data to develop
its strategy to address this opioid crisis?
Ms. Boss. That is a wonderful question. And thank you for
asking it, because----
Mr. Walberg. As specifically as you can.
Ms. Boss. So we have two things that I will point to. We
have something called MODE, which is the multidisciplinary
overdose drug response team. Basically, we look at a number of
specific overdoses to look for trends, and there is a
multidisciplinary team that consists of individuals from Brown
University, hospitals, Department of Health, my department. And
we review cases in depth in terms of looking at where those
individuals were, what kind of treatment services they were
receiving, if any, and then develop specific interventions as a
response that we propose statewide.
The others are surveillance response intervention team. We
receive weekly reports on 48-hour overdose reporting. All of
our hospitals are required to report overdoses or suspected
overdoses within 48 hours, and our medical examiner is able to
determine whether or not fentanyl is a factor in those
overdoses. As a result, we put out alerts to communities when
overdoses, whether fatal or not, exceed a specific target in
that particular area. And we're able to notify law enforcement,
first responders, treatment providers, and other individuals in
the community that there is an increased overdose--fatal or
nonfatal, in their communities.
Mr. Walberg. OK. You mentioned that your state still lacks
comprehensive data relating to fentanyl even with this approach
that you're taking. If I understand it correctly, what are the
obstacles preventing hospitals from developing comprehensive
testing of fentanyl and how could they obtain more robust data?
Ms. Boss. So I think the fentanyl question is regarding the
drug supply. Our hospitals are now able to test for fentanyl as
are our drug treatment providers. And so we are looking at how
much fentanyl is in the drug supply. And as we see increases in
hospital testing, in the testing that's done in our drug
treatment providers, we're able to know what kind of fentanyl
is out there, but not necessarily as quickly as we could if we
had more rapid response in law enforcement in looking at what's
in the drug supply.
Mr. Walberg. Thank you.
I yield back.
Mr. Murphy. Thank you. Mrs. Castor, you're recognized for 5
minutes.
Ms. Castor. Well, thank you, Mr. Chairman. I'd like to
thank all of the witnesses here for your attention to this very
serious issue. And I think at the outset it's important that
America just cannot go backwards on this.
This is a very costly, severe problem for families and all
of us. And to watch what is happening with proposals from the
GOP on healthcare really would take us backwards, whether
that's ripping coverage away that's been provided under the
Affordable Care Act, under healthcare.gov, or the very serious
assault on Medicaid. The most serious retrenchment of Medicaid
in its 50-year history would be just disastrous for our ability
to support families and address this crisis.
In fact, I'd like to ask unanimous consent to submit, for
the record, a consensus statement from the National Association
of Medicaid Directors on the Senate version of the GOP health
bill.
It states, in part, Medicaid is a successful, efficient,
and cost-effective Federal-state partnership. It has a record
of innovation and improvement of outcomes for the Nation's most
vulnerable citizens including comprehensive and effective
treatment for individuals struggling with opioid dependency.
No amount of administrative or regulatory flexibility can
compensate for the Federal spending reductions that would occur
as a result of the bill. Medicaid or other forms of
comprehensive, accessible, and affordable health coverage in
coordination with public health and law enforcement entities is
the most comprehensive and effective way to address the opioid
epidemic in this country.
Earmarking funding for grants for exclusive purpose for
treating addiction in the absence of preventative medical and
behavioral health coverage is likely to be ineffective in
solving the problem.
So I'll ask unanimous consent that that be admitted for the
record, Mr. Chairman.
Mr. Murphy. We're reviewing. We'll get back to you before
you're done.
Ms. Castor. OK.
Mr. Murphy. Thank you.
Ms. Castor. Because this is very important. Now, this
committee, to its credit, spearheaded the 21st century cures
initiative that did provide substantial funds to our states.
And I've heard from local experts back home in Florida, held a
number of roundtables with law enforcement, treatment
professionals, anesthesiologists, ER docs--the panoply. And
they say the key is long-term coverage to treat this as the
chronic disease that it is. And that's why, when you rip away
coverage and instead say, in its place, we're going to have
another fund, an opioid fund, where maybe you provide a few
dollars to an ER, that's not going to provide that long-term
coverage that we need to treat this chronic disease. So I just
had to get that off my chest here right off the bat.
In fact, Director Boss you have a lot of experience with
this. Do you think we'll be able to effectively address this
crisis if this retrenchment on Medicaid and ripping coverage
away for millions of Americans were to succeed?
Ms. Boss. So I believe that Rhode Island's efforts to
address this crisis would not be able to be sustained if we
were not able to continue to offer insurance through Medicaid
expansion to the number of Rhode Islanders that depend on it.
And I thank you for your pointing out the fact that providing
substance use disorder treatment alone is not enough. If we
dedicate dollars toward that, that's wonderful. However,
oftentimes there are comorbid conditions that are interrelated
with an individual's addiction, that if we don't have access to
affordable health care for the rest of the body, then we're not
going to be able to treat the person well enough to sustain any
kind of recovery.
Ms. Castor. So are you able right now to provide the type
of long-term treatment that is needed for an opioid appointed
addiction?
Ms. Boss. Yes, we are.
Ms. Castor. In fact, you've instituted a program called
AnchorED which connects individuals struggling with addiction
to recovery coaches who help them navigate the treatment
process. How successful has this program been to helping an
individual recover?
Ms. Boss. So of the individuals that meet with recovery
coaches in the emergency department, 82 percent are receiving
referrals to treatment and engage in treatment and recovery
services, which is pretty phenomenal, actually. And the actual
AnchorED program itself is not supported by Medicaid.
But the fact that we are not required to use substance
abuse prevention treatment block grant funds to fund treatment
itself, now that individuals can access, it frees up that
opportunity to use block grant funding to support recovery
activities that may not be supported by Medicaid or other
insurance, although the program is so successful that many
insurances, including third-party commercial insurances, are
paying for the recovery coaching program.
Ms. Castor. Is that a requirement under Rhode Island law,
or is that something that you found to be so cost-effective
that they are participating?
Ms. Boss. It is not a requirement.
Ms. Castor. OK. Thank you very much.
Mr. Murphy. Can I just ask a follow-up question, what
you're saying? Recovery coaches have what kind of credentials?
Ms. Boss. So we have a certification process for our
recovery coaches that are standardized and involves training
and a test and voluntary hours for certification in order to
respond. They are not degree----
Mr. Murphy. OK. No degree.
And do you have, in emergency rooms, then, people who are
themselves licensed treatment providers? Not recovery coaches,
not peers, but people who are actually--this is their
licensing. Do you have them in the ERs as a requirement?
Ms. Boss. We do not.
Mr. Murphy. Let me just ask: Does Kentucky have them? Or
Virginia? Maryland?
There was a study done out of Michigan, and I believe also
one done at Yale, that when there is a licensed addiction's
counselor in the ER providing treatment, not referral,
providing treatment, they increase the chance that person is
going to follow up by 50 percent.
So just saying here's some place you can call, 82 percent--
do you know if they actually follow through in the event--
that's my question that I have now. I'd love to hear that from
each state, but I next have to go to Ms. Walters.
Ms. DeGette. Before you do, are--is Ms. Castor's unanimous
consent request?
Mr. Murphy. Yes. We're fine with that. Yes. Thank you.
Sorry about that.
[The information appears at the conclusion of the hearing.]
Mr. Murphy. But I was saying that information is critically
important. And I've heard from a lot of places, give them a
card, they may not follow through. So 80 percent may not be
valuable to us. But to know they're actually getting treatment,
just like you wouldn't send someone home and say, ``You broke
your arm. Could you, please, make sure you see an orthopedic
surgeon next week,'' but to make sure it's being done.
Mrs. Walters, You're recognized for 5 minutes.
Mrs. Walters. Thank you, Mr. Chairman.
We can all acknowledge that, despite increased societal
awareness and government resources, the opioid crisis continues
to devastate our communities. In my home of Orange County,
California, there were 361 overdose deaths in 2015. That
accounts for a 50 percent increase in overdose deaths since
2006. A majority of those deaths are attributed to heroine,
prescription opioids, or a combination of the two.
One of the challenges in responding to the crisis is the
stigmatizing of the victims which limits their responsiveness
to treatment outreach.
There has been discussion today of the importance of drug
courts. And these courts can help overcome the stigma and treat
the underlying addiction as opposed to focusing on the
resulting criminal behavior I recently became aware of a
specialized drug treatment court in Buffalo, New York, that is
focused solely on opioid interventions.
My question is for everybody on the panel. Do you have an
opinion whether some drug treatment courts need to be
specialized to handle opioid addiction?
Mr. Rutherford. We have extensive drug courts in most of
our jurisdictions across the state. They essentially are
specific to opioid addiction. And there's been good results
from most of those courts.
The one challenge that we have is that, depending on how
long that period that you're involved with the drug court is
maybe 18 months to 2 years. And if you're someone who commits a
crime at a local jail and you're not ready for treatment, that
person will say, ``I'd rather do the 6 to 8 months than to have
to commit to 2 years. Even though I'm outside the fence, I'd
rather sit in jail.''
Mr. Moran. We're big proponents of drug courts.
Unfortunately, Virginia is deficient in drug courts. We have
about 37 yet we have over 200 courts. They are used for a
variety of different specialities. There's mental health
courts; there's veterans dockets. The drug courts, however,
provide some coercion. I mean, the individual needs to want to
address their addiction, and then the court can provide that
coercive element. And we have a tremendous success rate. I
mean, we should expand.
The one issue I would ask Congress to help us with,
however, is the medically-assisted treatment. Some of our
judges in the drug courts are reluctant, and as of now, it is
required. And so we would request, on behalf of those judges,
some flexibility with respect to mandating MAT.
Mr. Tilley. And again, I would concur. We have mental
health courts, veterans courts, and drug courts I think that do
expand. We did lose our juvenile drug courts due to a funding
issue. We're trying to rebuild that program now. Some of the
same issues exist. Oftentimes that offender chooses a shorter
prison sentence and that 2-year, again, very strenuous program.
But we're addressing that as well.
I would say that oftentimes too we find that there are
cherry picking the best instead of focusing on the more high-
risk folks. We do have a program called SMART that deals with
high-risk probationers keeping them--again, a modified drug
court that does specialize in opioid, at least one part of it
does. And that's being done at seven pilot sites. It's modelled
after the HOPE program that began with Judge Steven Alm in
Hawaii that many of you know about now.
And I would also add that what we're finding as well is,
again, this combination of specializing in medically assisted
treatment and the cognitive behavioral therapies that, again,
we're trying to integrate that model with some of our existing.
And we also have passage of recent legislation in Kentucky,
through the Department of Corrections, a modified drug court
through a reentry program that we'll be rolling out soon that
will specialize in the opioid addictions.
Ms. Boss. I would agree with my colleagues as well,
especially Lieutenant Governor Rutherford in the fact that our
drug courts have been addressing opioid use disorder for a very
long time. In Rhode Island, the drug court has been accepting
of medication assisted treatment as appropriate treatment for
individuals long before it was required to do so.
Probably the biggest issue that we have with drug court is
that it's not able to reach enough people. And while it's very
successful and effective, the difficulty in getting the numbers
through that system is challenging, and we really would like to
look at a broader perspective of diversion efforts and getting
people connected to treatment prior to arrest as our primary
focus.
Mrs. Walters. Thank you.
Mr. Tilley. Mrs. Walters, may I add an interesting thought
here? We had, again, a conference recently in Kentucky that
offered a legal opinion from one of our law firms that there--
and, again, as Secretary Moran pointed out, if a judge denies
someone medically assisted treatment which then affects the
liberty interest if they return to prison, that denial might
invoke some protection of the Americans with Disabilities Act.
And I think that's an interesting thought moving forward. And I
think it's a little bit of a chilling effect on our judiciary
in Kentucky to be--again, might be more accepting of medically
assisted treatment.
Mrs. Walters. Thank you. Thank you all. I yield back my
time.
Mr. Murphy. Mr. Ruiz, you're recognized for 5 minutes.
Mr. Ruiz. Yes. Thank you, Mr. Chairman. Thank you all for
being here. It's such a very important topic. And as an
emergency medicine doctor, I cannot emphasize enough the
devastating effect it has on individuals, families,
communities.
I've treated patients who have been dumped, blue, not
breathing, in front of our doors, and we go into the emergency
care mode providing Naloxone and the other cocktails for
somebody who you don't know anything about, and they're there
unconscious right about to die. And thankfully we've saved many
of them because we've had the medication.
We know that one of the primary determinants of successful
treatment is that they get medication, follow-up, and
counseling. And one of the factors for success is that they
have health insurance that has guaranteed coverage for those
medications, guaranteed coverage for mental health, and that's
why it's so devastating for me and for my patients that we're
on the verge of repealing the Medicaid expansion, repealing for
some states who choose not to have the mental health and
prescription drug guaranteed coverage, that those people who
need coverage and want coverage won't be able to have it. And
it can be a situation of life and death, as we know.
In a report on addiction released last year, the U.S.
Surgeon General found that Medicaid expansion meant that
millions of Americans with substance-use disorders now have
access to health coverage and, subsequently, substance abuse
treatment. And additionally, because substance-use treatment is
now a covered essential health benefit, which is at risk of
going away, individuals, a small group market participants also
gain access to those lifesaving services.
But it's not just about coverage. OK. I've seen some parts
in my district but if you don't have providers, if you don't
have psychiatrists, if you don't have psychologists, if you
don't have healthcare centers or counseling centers or programs
in those communities that are underserved or in rural areas,
then coverage does you no good.
So you need to also think about making sure that we have
more psychiatrists, more psychologists, more mental health
providers in those areas, especially for the youth and young
adults.
According to data from HHS, the number of children in
foster care increased 8 percent between 2012. Experts have
suggested that this rise is due in large part to increased
opioid abuse. Moreover, the substance abuse and Mental Health
Services Administration, SAMHSA, has estimated that over 8
million children of parents who need treatment for substance
abuse disorder.
The Wall Street Journal, the Washington Post, and the New
York Times have all recently reported on children who have
experienced the impact of their parents' opioid abuse and are
being raised by grandparents who have been placed into foster
care as a result.
Secretary Tilley, can you please describe how children in
your state have been impacted by the opioid crisis, and are
there unique challenges facing children in these epidemics?
Mr. Tilley. I think it's an excellent question. With a
focus on correction, sadly I can report that, in Kentucky, as
it exists now, more children are living with an incarcerated
parent than any other state in the country. In fact, have had
or have an incarcerated parent. And, again, our prison
population largely being driven by the epidemic, I think that
would be the first thing that comes to mind.
I also believe that it puts an incredible strain on our
cabinet for health and family services. We have a record number
of children in foster care at the moment. So that certainly is
an issue.
And beyond that, I think it just puts a tremendous strain
on our community mental health centers as well. I think, again,
the absence of proper funding for community mental health in
this country is a huge issue. It exists all over. It certainly
is acute in Kentucky as well. We rely on our 14 community
mental health centers that fan out through our state to provide
those services to children.
We have seen an increase with the focus in recent years on
addiction issues that increase and proper treatment for
children, and so I think that's been critical for some of our--
--
Mr. Ruiz. So Secretary Tilley, let me just warn you that,
by turning Medicaid into per-capita grant, the funding for new
addicted folks are--I should say the need for funding is going
to increase. States are going to have to make decisions: One,
change their eligibility criteria; two, their reimbursement
rates; and three, the benefits that they would cover. And
oftentimes, unfortunately, the mental health and these
community center treatments are the first on the chopping
block. So it's going to get worse if this bill is going to
pass.
Director Boss, SAMHSA stated that families have a central
role to pay in the treatment of individuals with substance
abuse disorders. Can you discuss what efforts Rhode Island has
taken to provide treatment that covers a person's entire
family?
Ms. Boss. All of our treatment providers are encouraged to
engage families in treatment and--as part of effective
treatment. We know that addiction is a family disease, and
engaging family members is critical in order to have success.
One of the things that the state has done is engage family
members in the development overdose task force and plan, and
we're creating a family and parent task force as well as
engaging youth to help us shape our efforts for the overdose
crisis in----
Mr. Ruiz. Have you found positive results on those?
Ms. Boss. Those efforts are just starting. So I will be
able to report back hopefully.
Mr. Ruiz. Well, I'm very hopeful that we can work together
to help this situation get better.
Mr. Murphy. I appreciate that, because there's some things
we need to be working on out there. But I want to make sure
Secretary Tilley has a chance to respond to what you're saying
about mental health substance abuse, money being first on the
chopping block. Is that Kentucky's intent? Do you know anything
about that?
Mr. Ruiz. That was not the intent, I don't agree----
Mr. Murphy. No. I didn't know--but you had asked. I want
him to respond.
Mr. Ruiz. No. No. I'm just saying that, historically,
mental health is one of the most underfunded----
Mr. Murphy. I understand. But you made a claim, and I want
Secretary Tilley to have a chance to the respond to that, find
out if it's----
Mr. Tilley. I would only say that the absence of proper
mental health funding is not a new phenomenon. I happen to----
Mr. Ruiz. I agree with that.
Mr. Tilley [continuing]. In my private life, be associated
with a mental health center as as general counsel. And I happen
to know that since the late 1990s we haven't had an increase in
those reimbursement rates. And that is an issue, and that has
existed for some time. And so I don't think that's a recent
phenomenon. That's all I would add.
Mr. Murphy. No. And that's why I want to amplify what he's
saying, that when everybody looks at mental health funding gets
cut or doesn't get increased, if actually increases costs
overall for healthcare. So----
Mr. Carter, you're recognized for 5 minutes.
Mr. Carter. Thank you, Mr. Chairman. I want to thank all of
you for being here on such an important subject. And I want to
express my dismay and my discouragement at some of my
colleagues who have used this as a platform, if you will, for
political messages about cuts in Medicaid, et cetera. I mean,
we all understand. It is established this is an epidemic in
this country.
As a practicing pharmacist for over 30 years, I have seen
firsthand, perhaps more than everyone in here collectively, has
seen the impact that this has had. At no time have I ever asked
a patient or thought in any way is this a Republican or a
Democrat or Independent. It's someone who's struggling. That's
all there is to it. This is a nonpartisan problem, and I just
frustrated by that.
Governor Rutherford, you said something earlier that I'm a
little bit confused about. You were talking about the
prescription drug monitoring program in the State of Maryland.
Did you say that methadone is not on it?
Mr. Rutherford. Well, no. What I was saying is that if you
go to the prescription drug monitoring program, or the
database, you will not see that a person has been prescribed
methadone, that they're in methadone treatment. So----
Mr. Carter. Why is that?
Mr. Rutherford. There are privacy restrictions associated
with drug treatment. And so this was in place prior to our
developing these prescription drug monitoring programs. There
are different barriers to getting information, be it mental
health information or drug treatment and, in some cases,
healthcare, that there are walls----
Mr. Carter. Is that something we can help you with,
legislatively, here?
Mr. Rutherford. I think that's what we talked about, that
that would be very helpful, because a practitioner would not
know that someone that they're prescribing an opioid already
has a problem associated with opioids.
Mr. Carter. OK. When I was in the state senate in Georgia,
I sponsored legislation that created our prescription
monitoring program. And I can tell you, it has been improved
since I left. In fact, July 1st of this year, 2 weeks ago, we
started 24-hour reporting. Before that, we were reporting every
week. Now, we're not in realtime yet, but we're getting there.
We're making very good progress there.
I want to know, in the prescription drug monitoring
programs within your states--and, Secretary Tilley, I'll tell
you. I've worked closely with the Kentucky Board of Pharmacy
and with the Kentucky Pharmacists Association--very strong.
Very strong programs there. And I compliment you on that.
But in your experiences with the prescription drug
monitoring program, are you sharing information across state
lines?
Mr. Tilley. We are. I think we have 7 border states. Very
unique in that regard. I think the only state in which we don't
at this moment is Missouri. I think that be to the case now.
Mr. Carter. Yes. Missouri struggled. They were the last one
to add it on, the PDMP.
Mr. Tilley. We are working on that. And again, I'd be happy
to supplement the record to confirm that answer for you. But I
do believe we are sharing with six of those seven states that
board us.
Mr. Carter. OK. Secretary Moran, what about Virginia? What
are you all doing?
Mr. Moran. Thank you. And I think this is an area where
Congress could investigate. We have 21 states. And our neighbor
to the South, North Carolina, we do not share information. We
would request some help to better share data across state
lines.
Mr. Carter. Right.
Mr. Moran. Most of our neighbors are not North Carolina. So
we would look for some more relief there.
Mr. Carter. Yes. In the State of Georgia, we're sharing
with South Carolina, Alabama, North Dakota, and someone else
way out West. I will tell you, in my over 30 years of
practicing pharmacy, I never filled a prescription for North
Dakota, for a C2 prescription. I know you find that hard to
believe. It would have been more useful if I could have seen it
from Florida. Being in that area, in Savannah, where we're only
2 hours away, it would have been extremely useful for the State
of Florida, and hopefully we can get to that point.
I want to ask you, Secretary Tilley, about a program that I
thought was pretty interesting that was a result of 21st
century cures, and that was the peer recovery specialist and
emergency departments in Kentucky. Can you elaborate on that
just a minute?
Mr. Tilley. The expert is sitting to my left. We actually
had a chance.
Mr. Carter. Right.
Mr. Tilley. And again, I, applaud the work in Rhode Island.
We actually had sort of a model that didn't really meet the
goals that we wanted. It was not up to par from previous
legislation. We looked at what Rhode Island was doing. We had
tried the same thing they did. We just didn't do it as well. I
think we're on the path to doing it now. And I think we're
fairly ambitious with trying to do both at once.
The peer recovery coaches or specialists in our ERs and
also doing the bridge clinics as well to try to keep people
there in treatment until we can get them to treatment, maybe
outpatient or some kind of other bed outside that hospital. And
so I think what they're doing in Rhode Island is certainly a
model for the country. And we're emulating them directly.
Mr. Carter. Great. And I know you are doing great work,
Director Boss. And I apologize. I didn't get to you. I have 15
seconds. I just want to add one thing from a pharmacist's
perspective. One of the things that we didn't cure was to allow
states to implement laws on C2 prescriptions on how much can be
filled and whether pharmacists can fill partial quantities.
That will help.
We can throw money at this all day long. But we need to be
smart. If we're smart and we do practical, rational things,
like limiting--I got so many prescriptions from a dentist for a
30-day supply of OxyContin. They take one or two, and then the
rest of them are in the medicine cabinet. That is not being
smart. If we can have a partial refill, if states can do that
as a result of 21st Century, or as a result of CARA, that's
something we need to look at implementing as well.
Thank you, all. My time is out, and I yield back.
Mr. Murphy. Mr. Carter, will you yield for a question?
Mr. Carter. Yes.
Mr. Murphy. When you refer to partial refill, you mean
allowing the pharmacist to only give a partial fill at the
onset, and then the person could come back and get the rest? Is
that what you're referring to?
Mr. Carter. That is exactly right.
Mr. Murphy. So not the position for prescribing partially,
but you would have that option?
Mr. Carter. That is one of the options that CARA allowed us
to do. I would take it even further. And I've been in talks. My
office has been in talks with the DEA about allowing maybe a
refill on a C2 for a three-day supply. Because a lot of
physicians are concerned that the patient's going to run out
over the weekend, they're going to be bothered, or they're not
going to be available and they're going to go without. And
that's a real concern. And I understand that.
But at the same time, again, if we'll just be smart, if
allowing them to maybe call in one refill over the phone as
long as it's limited to a short-day display.
Mr. Murphy. Thank you.
Mr. Carter. Thank you, Mr. Chairman.
Mr. Murphy. Mr. Pallone, you're recognized for 5 minutes.
Mr. Pallone. Thank you, Mr. Chairman.
Director Boss, I wanted to ask you the questions. And I
want to go back to the issue of Medicaid, because, as you know,
the Republicans are still trying to repeal the ACA's Medicaid
expansion and making a lot of changes to the program.
So what role has Medicaid played in Rhode Island's effort
to provide medication-assisted treatment in your state?
Ms. Boss. Medication-assisted treatment is covered by
Medicaid for both the disabled and the expansion populations.
All Medicaid-covered individuals are able to receive all three
forms of FDA-approved medications for opioid use disorders. The
director of Medicaid is a member of our opioid task force and
has been active in working with the managed care organizations
that manage our Medicaid product to do things like remove prior
authorizations for medication-assisted treatment. It is fully
funded through our Medicaid program.
Mr. Pallone. All right. Now, my colleagues on the other
side of the aisle often characterize the Medicaid program as
inflexible for states. We hear that a lot, that it's
inflexible. To the contrary, though, I think Medicaid has
provided for a great deal of innovation in how states have
responded to the opioid crisis. So could you please tell us
about the health home program in your state and how Medicaid
granted Rhode Island the flexibility to develop its own person-
centered care opioid treatment program?
Ms. Boss. So there are probably two innovations, and the
OTP health home would be one of them where we worked with the
Medicaid office for a period of 18 months to develop the
comprehensive care management function for opioid treatment
programs to provide to their clients in addressing physical
health issues as well as their addiction issues. And the
process with Medicaid was thorough, but it was one that allowed
us to use a monthly rate to support the work that was really
improving the health care of individuals in opioid use
disorder.
And we know that people who have opioid use disorders often
have comorbid conditions, don't necessarily have the greatest
access to care in the community. And the health homes allow
those programs, which have the greatest access to individuals,
to provide nursing support. They're overseen by physicians.
They have case management that help them get to the needed
appointments, dental appointments. And Medicaid has been
supporting those efforts with an understanding that improving
those outcomes will improve outcomes overall and reduce cost.
The Centers of Excellence are also a Medicaid innovation
where we allow people to be seen very quickly. And it's the
issue. You need to have that access to treatment, which was
noted. A person seen in the emergency room needs to be able to
follow through and get access to treatment in order for
anything to be effective.
Centers of Excellence exist as a Medicaid innovation
allowing people access to treatment, all FDA-approved
medications, again, within 72 hours, and have intensive
services provided in the 6 months of treatment supported by a
Medicaid rate with as much treatment in case management and
recovery supports as the individual needs with the intention to
move that individual into the community once stabilized and
continue to provide the clinical and recovery supports needed
again through a Medicaid-supported invasion.
Mr. Pallone. Obviously, my concern is that, in states most
heavily impacted by the opioid epidemic, if you have cuts to
Medicaid that that may lead to cuts in addiction treatment and
exacerbate the process.
I have a minute left. Let me ask you: Would you agree that
deep cuts to addiction services that might result from the
Senate TrumpCare bill, for example, that if states decided
because of the cuts in the Senate TrumpCare bill, that those
kinds of cuts to addiction treatment would have a drastic
impact on our ability to fight this epidemic?
Ms. Boss. Our overdose strategy engages 4 different
components, and three of the four would be effected if Medicaid
were not available to support. The access to Naloxone, again,
is supported by Medicaid. Medicaid covers Naloxone for
individuals. The treatment component is, again, supported by
Medicaid, our Centers of Excellence--all of the treatment
components have that as well.
And the ability for recovery coaches to be funded if not
for the treatment being covered by Medicaid, our substance
abuse block grant dollars would have to be redirected from
those recovery efforts to support individuals in treatment.
Mr. Pallone. All right. Thank you so much.
Thank you, Mr. Chairman.
Mr. Murphy. Mrs. Brooks, you're recognized for 5 minutes.
Mrs. Brooks. Thank you.
Director Boss, I want to clarify something that my
colleague, Congressman Walberg, asked you previously. You
talked about a data gap with respect to fentanyl in law
enforcement data. In your written testimony, you've talked
about hospital systems are testing for fentanyl, but we do not
yet know the frequency of testing or how many tests are
returning positive for fentanyl.
And so I just want to clarify and make sure. So the gap in
collection on data for fentanyl exists in law enforcement and
hospitals as well. Is that correct?
Ms. Boss. So the testing for fentanyl in the hospitals is
fairly new, and we are not sure how complete the data is. They
do have the ability. And whether or not all the hospitals are
testing or not, I'm not exactly sure. And I think it's really,
for the most part, an issue of timeliness.
To be able to respond effectively, we need to have access
to timely data and making sure that, if testing occurs, that
we're able to get the results quickly and in enough time to
respond to a community that may be seeing an increase in
fentanyl.
Mrs. Brooks. And I guess I'd ask the others on the panel
whether or not you know if your hospitals are gathering data on
fentanyl specifically and the frequency and so forth.
Yes, Lieutenant Governor.
Mr. Rutherford. I can't speak directly for the hospitals. I
know that, through our medical examiner's office, through our
emergency first responders, that they get information with
regard to fentanyl usage. A little more than 60 percent of our
fatalities, overdose fatalities, on opiates, are related to
fentanyl. In most cases, it's a mixture with something else,
cocaine or heroine. But we're getting most of our information
from the law enforcement and emergency responders.
Mrs. Brooks. I want to just talk a little bit more
specifically about the criminal justice system and would like
to ask you, Secretary Tilley, the CORE program that you
mentioned, that is specific to the criminal justice system in
Kentucky, isn't it?
Mr. Tilley. Actually, it brings in all stakeholders, even
education.
Mrs. Brooks. OK.
Mr. Tilley. The Cabinet for Health and Family Services, our
CORE system, certainly many--all elements of the criminal
justice system but any element affected by the opioid scourge
is present on that particular effort.
Mrs. Brooks. I'd like to find out from you, and briefly,
your states' efforts, because, obviously, when a person is
incarcerated, which many family members said that saves their
lives. It's sad and we want them to be diverted, and we
obviously do want to focus on high level. I'm a former U.S.
Attorney. So we want to focus on the mid and high level dealers
and those who were exposing people with addictions. However, at
times we have a captive audience of participants in treatment.
And can you talk a bit more about medication-assisted
treatment in your facilities and then counseling? Is there drug
testing that is part of your incarcerated population, juveniles
and adults?
Mr. Tilley. I'll start with adults. Again, counseling is
required with any medically assisted treatment we do. Again, I
described earlier in my testimony I think a pretty innovative
program where we assessed, through a risk needs assessment,
those who would need an injection of naltrexone, or more
commonly called Vivitrol, prior to their release as a
stabilization mechanism. Upon release, they get another
injection, and then they are matched with a counselor and a
peer recovery coach to try to find the necessary resources to
continue that treatment, whatever it may be and whatever source
it may come from.
In our juvenile setting, we do not have medically assisted
treatment at this time. However, we in Kentucky thankfully have
a record low in terms of our juvenile detention population at
the moment. And that doesn't seem to be near the issue in our
facilities, although we do offer that treatment in the
facilities, just not medically assisted at this time. And the
same way you would see it in the corrections setting.
One thing that's very unique about Kentucky, and one thing
that was not maybe reflected in the New York Times article
about that treatment is that Kentucky houses roughly half of
its state inmate population in county jails. We have 83 full-
service county jails that do that. And that presents some
challenges. But we are expanding and incentivizing that kind of
treatment, that kind of medically assisted treatment, like you
may have read about in Kenton County, which is part of the
Greater Cincinnati, Northern Kentucky area there. I would also
add the piece about incarceration.
We are trying to use elements like involuntary commitment--
we call it Casey's law in Kentucky--to try to bypass the need
for incarceration for those individuals, again, who stand out
to their family as someone who needs a forceful hand, maybe a
judge's contempt power to keep them in treatment.
Mrs. Brooks. I will be submitting questions for the record
for each of your states, because I'm interested in knowing
more, and my time is up, on medically assisted treatment as
well as counseling and what you're doing with your inmate
population. And I know you're each doing something but would
love to learn more about it.
And I want to thank you all for cooperating with each other
and learning from each other. Critically important.
I yield back.
Mr. Murphy. The gentlelady yields back. I recognize Mr.
Costello for 5 minutes.
Mr. Costello. Thank you, Mr. Chairman.
Some of you may know the chairman and I both hail from
Pennsylvania. The chairman from the Western part of the state.
Myself from the Eastern part of the state. And sometimes people
think they're two different states. But having said that, in
Pennsylvania, the epidemic is particularly acute. And just a
few brief comments about what we're doing in Pennsylvania. And
then Lieutenant Governor Rutherford, I had a couple of
questions for you.
With the enactment of the 21st Century Cures Act,
Pennsylvania received $26.5 million dollars in Federal funding
to address the epidemic: $3.5 million for drug courts, $23
million being funded to expand access to medication-assisted
treatment, increase training opportunities to better connect
individuals with additional treatment when they visit an
emergency room as a result of an overdose and also to improve
access to opioid use disorder treatment for uninsured
individuals.
And Lieutenant Governor Rutherford, you spoke about
establishing a 24-hour stabilization center in Baltimore city.
I wanted to ask you about that. What services will be provided
at the facility? Why do you think it is better suited to have
such a facility to treat substance abuse issues rather than in
emergency departments? And then, maybe depending upon your
answer, I'll have some follow-up questions off that.
Mr. Rutherford. Well, the concept of the stabilization
center is a place where both first responders support as well
as law enforcement or family members can take a person who is
suffering from substance abuse disorder and they may be ready
for some type of treatment. And the idea is to bring them into
a locale, not necessarily an emergency room because that is a
very high cost approach to addressing this challenge where they
can be stabilized and get them into longer-term treatment.
So it's an opportunity to get that person, as I mentioned,
stabilized. They could reside there for a few days before--if
there's a bed available to get them into treatment.
Mr. Costello. Any similar facilities that you might be
modeling this off of?
Mr. Rutherford. I believe San Antonio has something
similar. I'd have to get more information and talk to my staff.
I believe it was San Antonio that I believe was doing something
very similar to this.
Mr. Costello. Once stabilized, will the patients then be
moved into evidence-based treatment and counseling?
Mr. Rutherford. That is the objective. We haven't stood
this up as yet, and we're working with the city of Baltimore in
terms of the parameters and how this is going to actually
operate and what the state's oversight role will be with this.
Mr. Costello. Is the hope that the funding that you will be
utilizing for the facility itself, will that funding extend to
the treatment and counseling, or are you looking at the
facility to just be sort of on the front end?
Mr. Rutherford. The facility is on the front end. We will
look to the other funding sources, be it through the Cures Act,
through state revenue, through insurance, through Medicaid to
pick up the treatment aspects of the challenge.
Mr. Costello. Can you describe some of the challenges that
your state currently faces to provide beds in a timely manner
for individuals seeking treatment for substance abuse?
Mr. Rutherford. Well, the lifting of the restriction with
regard to Medicaid reimbursement on the number of beds in a
facility has helped that particular challenge, because we did
have situations where we had individuals who would receive
treatment through Medicaid, and we have beds available in some
of our facilities, but we could not utilize those. That has
helped.
We are working to expand the capabilities, particularly for
some of the nonprofits that have services and are providing
services and seeing what we can do to assist them in expanding
their access. We have close to 800 facilities around the state.
There is always a discussion about getting additional beds and
capacity, and so we're working on those things as well.
Mr. Costello. Thank you.
My general comment on this epidemic is oriented towards the
following. I think there are a lot of variables that contribute
to this. I think everyone knows that. I get concerned when we
point to one particular actor in this ecosystem and say that's
the problem, because it is manifold. It is complex. And I think
what concerns me more than anything is that the life cycle of
treatment is much longer than the infrastructure that has been
set up to deal with it.
And as a consequence of that, no matter how good we might
be in the first six innings of this, if we're not good in
innings seven, eight, and nine, it's not going to ultimately
matter. And we're really just embedding more cost into the
system by front-loading some of the cost without really
acknowledging that, on the back end, if we don't finish it off
with the right kinds of treatment and the right type of
counseling and the right kind of follow-up off that, we will
not ultimately be able to drive down the epidemic.
I think all can identify what some of the front-end issues
are here, but that would be something I'd just like to submit
to the record.
And, Mr. Chairman, I see I'm well over my time.
Mr. Murphy. Thank you.
Mr. Rutherford. Can I respond just very briefly.
Mr. Murphy. Yes.
Mr. Rutherford. You're absolutely right. And some of the
thought process behind the crisis center is it's a front end.
You're right. It's a front end of where the person comes in the
door, they're in distress at that point, stabilizing them,
getting them into treatment. But even after the treatment, one
of the things we've heard over and over again from people who
have relapsed is they come out of treatment and they go back
into the same community, the same stimuli, the same issues that
they had before.
And one of the areas that we're focusing on going forward,
including utilizing the Cures Act funding and state funding, is
transitional housing. For lack of a better word, you can call
it a halfway house--but transitional housing where a person can
go and continue to get treatment in terms of the counseling
aspects of it. But during the day, they can go to work, they
can do the things that they need to do, but they have to report
back to this facility. And people have said that that is
something they need before they go back into the unrestricted
society, because all the stimuli is still there.
Mr. Costello. Yes. Thank you much.
Thank you, Mr. Costello.
It's the policy of this committee to let other members of
Energy and Commerce who are not on this subcommittee to ask
questions. Mr. Bilirakis, you're recognized for 5 minutes.
Mr. Bilirakis. Thank you so very much. And thank you for
allowing me to sit in on the hearing. I appreciate it, Mr.
Chairman.
Well, I have some prepared questions. But does anyone else
want to elaborate on that? Any other suggestions as far as a
long-term, the back end? Is there anyone on the panel that
would like to talk about that? You mentioned the transitional
housing. And cooperation, obviously, is so very important. The
patient needs to cooperate and voluntarily, in most cases. Is
there anyone that wants to make another comment before I get
started?
Ms. Boss. If I could, I would add----
Mr. Bilirakis. Yes.
Ms. Boss. The front door is very important, because access
to care--oftentimes, you'll hear families saying, ``I don't
know where to turn for help.'' And we're looking at a crisis
center model as well. And I think that's critically important.
You don't know which number to call. You've got a family or
loved one, and you're not sure how to connect them.
But then the connection to treatment is critically
important as well. It's like someone with hypertension going to
the emergency room and getting a pill but not getting a
prescription. It's not going to help.
And so without the access to care and the kind of supports
needed--so recovery housing is critical as well. And in part of
our Cures Act funding, we are looking to establish that kind of
transitional housing for individuals who are not able to return
to their communities. We really need to look at the long-term
and treating addiction as a chronic disease, not through acute
episodes.
So I think that the approach to long-term and looking at
the long-term needed supports are critically important as well.
Mr. Bilirakis. Thank you.
With regard to Florida, in 2010, in response to the opioid
crisis in Florida, the pill mill problem--I think you probably
know about that. Florida's legislature enacted a statewide
tracking of painkiller prescription coupled with law
enforcement using drug-trafficking laws to prosecute providers
caught overprescribing. Within 3 years, Florida saw a decrease
of more than 20 percent in overdose deaths, and I want to give
Pam Bondi, the attorney general, and others credit for this.
But now the rise in the fentanyl and its various
derivatives have presented new challenges to the State of
Florida and other states as well. However, we remain optimistic
with recent legislative initiatives in Florida.
These include requiring doctors to log prescriptions in a
statewide painkiller database by the end of the next day. I
think that's important, to curb the so-called doctor shopping
and setting aside state-sponsored medication that can help
reduce opioid dependency. So we're working on it.
But during the August recess, I want to meet with
stakeholders--and conduct roundtables with regard to this
issue.
Do you have any suggestions for me? What has succeeded?
Obviously, sir, you talked about the Baltimore model, and I
think that's very important. Are there any other innovative
ideas or legislative initiatives that you would recommend for
my State of Florida? Anyone on the panel, please.
Mr. Tilley. I just might start by adding that one thing I
wanted to convey to the panel, and I know you're very well
aware of the STOP Act and this issue of keeping fentanyl and
carfentanil out of our country where it's manufactured legally,
sometimes illegally, and still shipped in and mailed into our
country.
The DEA recently informed us that the profit margin for
these cartels that bring fentanyl in, for a $6,000 investment,
to make that more of a heroin-type substance, is about a $1.6
million profit. To do it in pill form, just to press it into a
pill, is a $6 million profit. And so with that kind of profit
margin out there for their taking, it's very difficult to
combat this if we're flooded with it with impunity. We've got
to figure out ways to stop it from coming into our country in
the first place.
And I think that would be--again, that's not necessarily
Florida specific, but I think this idea that's contained in the
STOP Act--and I won't comment on the specifics, but I
understand that would again curtail some of that.
Mr. Bilirakis. Does anyone else? Please.
Ms. Boss. If I could, fentanyl is changing the face of this
epidemic, and we need to respond in our interventions. And one
of the things that I would comment on is that this is a
marathon, not a sprint. And we really need to take a look at
prevention efforts as critical to changing the face of this
epidemic and not cutting our efforts in prevention. Primary
prevention, working with transitional-aged youth. If we can
stop their use before they use, we're not going to have them
dying with fentanyl.
I think we need more research. Recently, we haven't had any
new medications. We haven't had any new treatment models
necessarily proposed for opioid-use disorders. And I'm not sure
enough effort has been placed into the research needs of this
epidemic. And we need to start looking at this as we would, the
focus on cancer.
This is an epidemic. We need research that's going to
support the most evidence-based models that are effective in
treating this.
Mr. Bilirakis. Thank you very much. I agree.
I yield back, Mr. Chairman. Thank you for allowing me to
ask questions.
Mr. Murphy. Thank you Mr. Bilirakis.
I recognize Ms. DeGette for follow-up.
Ms. DeGette. I just really want to commend all of your
states for leaning in, for moving forward on this, and for
trying to find robust solutions. It's really important that we
do that. And I know almost all the states are doing this. My
State of Colorado has also started really paying attention.
It's the kind of thing where it crept up on us collectively as
a society, and so people have had to move really fast. And I
just want to commend you.
And I also want to reiterate that we're very flattered. I,
personally, am very flattered that you're taking this 21st
Century Cures money and really making something with it and
developing some programs that are uniquely and appropriately
tailored to your states. Sometimes when we're in Congress, we
wonder if anything we do actually impacts people's lives? And
when I hear what you're doing, it's really gratifying and I
think it will save lives.
I hate to sound like a downer, though, but to say that this
21st Century Cures money, which was $2 billion, it's really
well used I think by the states with these grants to develop
programs, but $2 billion is nothing. As Governor Kasich said,
$45 billion. If you're trying to substitute the Medicaid
expansion money and other treatment monies that are coming, you
can't use the money for that.
We have to make opioid treatment and prevention part of our
overall mental and physical healthcare in this country. And
what that does take, and I'm sorry that Mr. Carter left,
because we're not trying to politicize this. What we're trying
to say is, if you really want to give treatment to people, you
have to develop the programs, which is what something like the
Cures money is good for. But then you have to be able to
implement them.
You have to be able to give the counseling to people. You
have to be able to give the MAT treatment to people. You have
to be able to build and maintain these housing options that
people were just talking about. You don't do that with just
fairy dust. You have to do that with resources. And some of the
resources can come from the states, but the states are jammed.
And so that's why the Medicaid expansion has helped so many
millions of Americans be able to get access to the treatment
that they need, and that's why we need to be able to keep that
for these populations.
So I want you to know that--and it's not that we really
disagree on that either. Mr. Murphy and I agree on a lot of
these issues, he just can't say it as forcefully as I can
sometimes. But we know that we need to make sure that all
Americans can get this treatment. And we will commit to you
that we are going to continue to work with the states to make
that happen.
Thank you.
Mr. Murphy. Thank you.
I have a few questions I want to follow up on. This goes in
the category of coverage without access is a problem. Coverage
without access and access without coverage are both problems.
To this extent, I want to make a note or put in the record, and
ask unanimous consent.
One is an article why taking morphine and OxyContin can
sometimes make pain worse from Science Magazine. And another
one is an article that 51 percent of opioid prescriptions go to
people with depression and other mood disorders, from Stanton
News. I'll let you see that if----
Ms. DeGette. I don't have an objection.
Mr. Murphy. There's no objection, it will go in the record.
[The information appears at the conclusion of the hearing.]
Mr. Murphy. But I want to make reference to a couple of
those things. There are about 50 million Americans with lower
back pain, 25 million of those take an opioid. When a person
has pain and depression, about 40 percent of them are 300 to
400 percent, the risk of abuse, misuse or addiction, noting
that when we're dealing with people with addiction disorders
and 80 percent of them begin with a prescription for pain, but
mood disorders are a big, big part of this. Fifty-one percent
of people on opioids have a mood disorder, anxiety, depression
or something else.
And I don't know if any of your states ask physicians to
screen for that when they are prescribing. I would imagine not,
because I think in most states they don't. Do any of you know
if your state's medical society or hospitals ask to screen?
When you're prescribing a medication for pain, do you also
screen for depression, anxiety, anything like that? Do any of
your states--if you don't know, just tell me you don't know.
Mr. Rutherford. I don't know, but I believe that it's not
available in the prescription drug monitoring program either.
Mr. Murphy. Oh, OK. Secretary Moran, do you know if you do
that in Virginia?
Mr. Moran. My counterpart, he's a doctor, and the medical
community was using the chart, and say, 0 to 10, smiley face.
We were addressing pain and we overprescribed. I'm not aware,
to answer your particular question, I'm not aware of whether or
not we----
Mr. Murphy. Yes. Those emojis are not to do with mood,
they're to do with pain. I find it amazing that the other vital
signs, blood pressure we measure. Temperature, we have an
instrument for that. Respiration. All these are measured, but
when it comes to pain, 1 to 10 or an emoji is pretty primitive.
Mr. Moran. We are mandating now 2 hours of continuing
education in the medical community to address pain. It starts
in the medical community with better education around how we
manage pain.
Mr. Murphy. As far as you know, it doesn't also include
assessing a mood disorders. I've seen this take place where
they actually assess it, and there's a big difference.
Secretary Tilley, do you know, or Director Boss, do you know if
in your states there's any requirement to also concurrently
assess patients for mood disorders when prescribing these?
Mr. Tilley. Not specifically, but I did mention the limit
to the 3-day supply for acute pain, which again, I think
presents a bit of a pause for the physician before that
prescription. Also, I did not get a chance to mention the
University of Kentucky is piloting a program, our flagship
institution piloting a program there, to start with everything
but an opioid in the course of treatment and try to taper--
instead of starting with and tapering down, starting without
and maybe moving toward it if it's absolutely necessary.
And then, lastly, I would say we are embarking to your
question. We actually are embarking on that very thing
potentially with a statewide mental health approach as to a
number of best practices across there, and that's one of the
things we've discussed.
Mr. Murphy. Thank you. Director Boss do you know if you
evaluate----
Ms. Boss. I can't speak as to whether or not it's required.
I can say that the state has had major efforts toward
behavioral health integration and primary care. And I know that
a lot of our collaboratives and a lot of our--asking primary
care settings, and most large primary care settings are
screening for mood disorders as well as anxiety.
Mr. Murphy. I would bet during the time when someone is in
the emergency room, the chance of someone actually getting a
screen for that is probably pretty close to zero. And just as
we have the problems of 42 CFR, a doctor doesn't know if they
are on methadone with a prescription or monitoring program.
They don't know if they are on these medications. It's usually
patch them up, get them out.
I know when I was prescribed a lot of fentanyl and other
opiates when I had an injury in Iraq, nobody ever asked me
about any other questions, just, take these, take these, take
these. And I ended up with my own issues there, which I didn't
get an addiction, but my body developed a dependency upon
those. And when I finally said enough is enough, and I had the
fun on my own, a mild withdrawal reaction. It was not pleasant
at all. But going with----
Director Boss, you mentioned 82 percent of people get a
referral in the emergency room by talking with, I guess, the
peers support or a counselor there. Do you know how many of
that 82 percent actually follow up and follow up consistently
in an evidence based program?
Ms. Boss. We are not able to measure where the 82 percent
go. And so 82 percent, not just are referred, but are connected
and do follow through with treatment and recovery supports.
Mr. Murphy. We don't know what the follow up is afterward?
Ms. Boss. Right.
Mr. Murphy. That's important to me. So we've identified a
few things here such as we have a crisis shortage of providers.
We all agree with that, across the Nation, especially in rural
areas. Quite frankly, in urban areas, too, if you assess
providers and say, how many of you actually have openings in
your schedule, you'll see that they don't. I know in my areas,
for example, child and adolescent providers are even more rare,
and some say, I just don't have any appointments open for
months. And when you're dealing with a substance abuse
disorder, I need treatment now. Now is the best time for
treatment. Giving them a waiting list is not helpful at all.
So even when we do refer people over, the statistic I see
is of the 27 million people in this county with an addiction
disorder, 1 percent get evidence-based care. So if you look at
this, about 90 percent of the people with a substance abuse
disorder don't seek attention. So out of every 1000, 900 don't
seek attention.
Out of the 100 that do seek attention, 37.5 can't find it,
it's not available. Of those who do get it, get attention, 90
percent of those don't get evidence based care. So we have a
crisis that's getting worse. And I might add, too, I think,
Virginia, you're the only state that doesn't have Medicaid
expansion right?
Mr. Moran. We do not.
Mr. Murphy. You do not. But in this time period of which it
was available, I would assume that your addiction rate, your
overdose and death rates have climbed, correct?
Mr. Moran. They have.
Mr. Murphy. And in the states that do have Medicaid
expansion, Maryland, Kentucky, Rhode Island, has your overdose
and death rates also climbed?
Mr. Rutherford. Oh, yes. Yes, sir.
Ms. Boss. Ours have raised but not as significantly as
other states have experienced in these last few years.
Mr. Murphy. Yes, I want to help, but we need honest data
here. Look, we don't even have information on if those numbers
are accurate, because if your medical examiners and coroners
are not doing toxicology tests, and if we don't even have data
for 2016, and we won't have it until the end of this year. We
just don't know.
And what this committee likes to do is identify. We need
the absolute, honest, bare bone problems. And if you tell us,
look, we don't know, this is probably much worse. We don't have
enough providers. We had legislation, some of it was reduced
down and I want to see it reenacted, where we could do more to
get more psychiatrists, psychologists, clinical social workers,
and licensed addiction counselors out there.
We're probably going to have to do things with the states
and Federal Government providing scholarships or pay for their
internships or something to get them out there, because who
would want to go into a field that pays so little and the
frustration is so high. You're 24/7 on call. You're probably
going to get called into court and testimony, a lot of
different problems. And that itself could be, it only requires
the best who have true altruism in their blood to help fight
that. But we've got to do it.
I also want to ask a question, too, with regard to getting
drugs back to someone who is not using. I know even realtors
now say when you're putting a home up for sale the first thing
you should do is go to your medicine cabinet and clean it out.
I know there are some products, even in rural areas, some
places will have drug recovery programs, you take it to the
pharmacist or you take it to the police. There are some
products--one product called Deterra, which actually--a drug
deactivation system where you can use in your home and then
throw it away. Virginia, you have programs where you do drug
recovery at home?
Mr. Moran. We do, sir. And we are using those. And I would
congratulate our private sector partners pharmacies have
collection boxes now. And I will tell you, DEA does a terrific
job. In fact, they were going to suspend their take-back
program, and now they continue their robust take-back program.
Tons of drugs, it's amazing, I've witnessed it myself, how
much. And improper disposal in the medicine cabinets.
As the father of 2 children, teenagers, it's imperative
that we keep the drugs out of that medicine cabinet because
we've heard from anecdotal stories, that's where the addiction
begins. Kids using it out of their medicine cabinets.
Mr. Murphy. They go into homes for a party and the next
thing you know----
Mr. Moran. Exactly, sir.
Mr. Murphy. I want to thank this panel. We have a long way
to go. And, unfortunately, at this point we're seeing the
battles in the states to combat, but I think we have to be
honest and say we have a long way to go in this war, it's still
quite a crisis here.
This committee will continue to take this up on lots of
different ways, because it isn't just a matter of funding. What
good is funding if you haven't got a provider? What good is
some of the jail treatment programs if a person is discharged
from jail and they're now back on Medicaid, so they go right
back to the streets, right back to somewhere where they had
problems before. I hear someone will work in certain
professions where everybody--a lot of the people in the back
rooms also have addiction problems and get reexposed. We have
an awful, awful mess in this country, and the outcome is a
death rate that is mortifying.
So I thank the panel here and I thank the members for being
in today's hearing. And I remind members, they have 10 business
days to submit questions for the record, and ask the witnesses
to all agree to respond promptly to the questions.
Thank you for your honest approaches. Keep fighting the
good fight. Thank you.
Mr. Moran. Thank you, Chairman.
Ms. Boss. Thank you.
[Whereupon, at 12:16 p.m., the subcommittee was adjourned.]
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