[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]



              COMBATING AN EPIDEMIC: LEGISLATION TO HELP  
                PATIENTS WITH SUBSTANCE USE DISORDERS

=======================================================================

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                        COMMITTEE ON ENERGY AND 
                                COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             SECOND SESSION

                               ----------                              

                             MARCH 3, 2020

                               ----------                              

                           Serial No. 116-106 
                           
                           
                           
                           
                           
                [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] 
                
                
                           


      Printed for the use of the Committee on Energy and Commerce

                   govinfo.gov/committee/house-energy
                        energycommerce.house.gov






                                -------
                                
                   U.S. GOVERNMENT PUBLISHING OFFICE 

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                    COMMITTEE ON ENERGY AND COMMERCE

                     FRANK PALLONE, Jr., New Jersey
                                 Chairman
BOBBY L. RUSH, Illinois              GREG WALDEN, Oregon
ANNA G. ESHOO, California              Ranking Member
ELIOT L. ENGEL, New York             FRED UPTON, Michigan
DIANA DeGETTE, Colorado              JOHN SHIMKUS, Illinois
MIKE DOYLE, Pennsylvania             MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois             STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina    ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California          CATHY McMORRIS RODGERS, Washington
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, Vice     BILL JOHNSON, Ohio
  Chair                              BILLY LONG, Missouri
DAVID LOEBSACK, Iowa                 LARRY BUCSHON, Indiana
KURT SCHRADER, Oregon                BILL FLORES, Texas
JOSEPH P. KENNEDY III,               SUSAN W. BROOKS, Indiana
  Massachusetts                      MARKWAYNE MULLIN, Oklahoma
TONY CARDENAS, California            RICHARD HUDSON, North Carolina
RAUL RUIZ, California                TIM WALBERG, Michigan
SCOTT H. PETERS, California          EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             JEFF DUNCAN, South Carolina
MARC A. VEASEY, Texas                GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
A. DONALD McEACHIN, Virginia
LISA BLUNT ROCHESTER, Delaware
DARREN SOTO, Florida
TOM O'HALLERAN, Arizona
                                 ------                                

                           Professional Staff

                   JEFFREY C. CARROLL, Staff Director
                TIFFANY GUARASCIO, Deputy Staff Director
                MIKE BLOOMQUIST, Minority Staff Director 
                
                
                
                
                
                



                
                
                         Subcommittee on Health

                       ANNA G. ESHOO, California
                                Chairwoman
ELIOT L. ENGEL, New York             MICHAEL C. BURGESS, Texas
G. K. BUTTERFIELD, North Carolina,     Ranking Member
  Vice Chair                         FRED UPTON, Michigan
DORIS O. MATSUI, California          JOHN SHIMKUS, Illinois
KATHY CASTOR, Florida                BRETT GUTHRIE, Kentucky
JOHN P. SARBANES, Maryland           H. MORGAN GRIFFITH, Virginia
BEN RAY LUJAN, New Mexico            GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon                BILLY LONG, Missouri
JOSEPH P. KENNEDY III,               LARRY BUCSHON, Indiana
  Massachusetts                      SUSAN W. BROOKS, Indiana
TONY CARDENAS, California            MARKWAYNE MULLIN, Oklahoma
PETER WELCH, Vermont                 RICHARD HUDSON, North Carolina
RAUL RUIZ, California                EARL L. ``BUDDY'' CARTER, Georgia
DEBBIE DINGELL, Michigan             GREG GIANFORTE, Montana
ANN M. KUSTER, New Hampshire         GREG WALDEN, Oregon (ex officio)
ROBIN L. KELLY, Illinois
NANETTE DIAZ BARRAGAN, California
LISA BLUNT ROCHESTER, Delaware
BOBBY L. RUSH, Illinois
FRANK PALLONE, Jr., New Jersey (ex 
  officio) 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
                            C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................     1
    Prepared statement...........................................     3
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................     4
    Prepared statement...........................................     5
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     7
    Prepared statement...........................................     8
Hon. Greg Walden, a Representative in Congress from the State of 
  Oregon, prepared statement.....................................   157

                               Witnesses

ADM Brett P. Giroir, M.D., Assistant Secretary for Health, 
  Department of Health and Human Services and Senior Advisor to 
  the Secretary for Opioid Policy................................    10
    Answers to submitted questions...............................   305
Kimberly Brandt, Principal Deputy Administrator for Operations 
  and Policy Centers for Medicare & Medicaid Services............    12
    Joint statement..............................................    14
    Answers to submitted questions...............................   317
Thomas W. Prevoznik, Deputy Assistant Administrator, Diversion 
  Control Division, Drug Enforcement Administration..............    28
    Prepared statement...........................................    30
    Answers to submitted questions \1\
Michael Botticelli, Executive Director, Grayken Center for 
  Addiction, Boston Medical Center...............................    84
    Prepared statement...........................................    87
    Answers to submitted questions...............................   330
Smita Das, M.D., Ph.D., American Psychiatric Association.........    91
    Prepared statement...........................................    93
    Answers to submitted questions...............................   334
Patty McCarthy, Chief Executive Officer, Faces and Voices of 
  Recovery.......................................................   100
    Prepared statement...........................................   102
    Answers to submitted questions...............................   337
Robert I. L. Morrison, Executive Director, National Association 
  of State Alcohol and Drug Abuse Directors......................   107
    Prepared statement...........................................   109
    Answers to submitted questions...............................   339
Margaret Rizzo, Executive Director/CEO, American Association 
  Treatment of Opioid Dependence (NJ Board Member), JSAS 
  Healthcare, Inc................................................   125
    Prepared statement...........................................   127
Shawn Ryan, M.D., MBA, Chair, Legislative Advocacy Committee, 
  American Society of Addiction Medicine.........................   131
    Prepared statement...........................................   133
    Answers to submitted questions...............................   342

                           Submitted Material

H.R. 1329, Medicaid Reentry Act, submitted by Mr. Tonko..........   159
H.R. 2281, Easy Medication Access and Treatment for Opioid 
  Addiction Act, submitted by Mr. Ruiz...........................   161
H.R. 2466, State Opioid Response Grant Authorization Act, 
  submitted by Mr. Trone.........................................   163
H.R. 2482, Mainstreaming Addiction Treatment Act of 2019, 
  submitted by Mr Tonko..........................................   165
H.R. 2922, Respond to the Needs in the Opioid War Act, submitted 
  by Ms. Kuster..................................................   171
H.R. 3414, Opioid Workforce Act of 2019, submitted by Mr. 
  Schneider......................................................   188
H.R. 3878, Block, Report, And Suspend Suspicious Shipments Act of 
  2019, submitted by Mr. McKinley and Ms. Dingell................   198
H.R. 4141, Humane Correctional Health Care Act, submitted by Ms. 
  Kuster.........................................................   201
H.R. 4793, Budgeting for Opioid Addiction Treatment Act, 
  submitted by Mr. Norcross......................................   205
H.R. 4812, Ensuring Compliance Against Drug Diversion Act of 
  2019, submitted by Mr. Griffith................................   213
H.R. 4814, Suspicious Order Identification Act of 2019, submitted 
  by Ms. Matsui and Mr. Johnson..................................   216
H.R. 4974, Medication Access and Training Expansion Act of 2019, 
  submitted by Ms. Trahan........................................   227
H.R. 5572, Family Support Services for Addiction Act of 2020, 
  submitted by Mr. Trone.........................................   239
H.R. 5631, Solutions Not Stigmas Act of 2019, submitted by Mr. 
  Kim............................................................   245
Statement of Young People in Recovery, by Danielle Tarino, 
  President and CEO, submitted by Mr. Eshoo......................   250
Statement of March 3, 2020, from National Association of Chain 
  Drug Stores, submitted by Ms. Eshoo............................   251
Statement of March 3, 2020, by Mark W. Parrino, President, 
  American Association Treatment Opioid Dependence, submitted by 
  Ms. Eshoo......................................................   257
Graphics ``Huge Surge in Clinicians Taking MAT Waiver Training'', 
  from Providers Clinical Support System, submitted by Ms. Eshoo.   265
Statement of March 3, 2020, from National Safety Council, 
  submitted by Ms. Eshoo.........................................   266
Letter of March 3, 2020, to Ms. Eshoo, and Mr. Burgess, from 
  Medication Assisted Treatment Leadership Council, submitted by 
  Ms. Eshoo......................................................   278
Letter of March 3, 2020, to Ms. Eshoo and Mr. Burgess, from David 
  Houghton, M.D., System Chair, Telemedicine, Vice Chair, Ochsner 
  Health System, submitted by Ms. Eshoo..........................   284
Letter of March 3, 2020, to Ms Eshoo and Mr. Burgess, by Joel 
  White, Executive Director, Opioid Safety Alliance, submitted by 
  Ms. Eshoo......................................................   287
Letter of March 3, 2020, to Ms. Kuster and Mr. Booker, by Paul 
  Earley, M.D., President, American Society of Addiction 
  Medicine, submitted by Ms. Kuster..............................   292
Letter of March 3, 2020, to Mr. Bilirakis, by Saul Levin, M.D., 
  CEO and Medical Director, American Psychiatric Association, 
  submitted by Ms. Eshoo.........................................   294
Letter of March 3, 2020, to Ms. Eshoo, by Mr. Greer, President, 
  SMART Recovery, submitted by Ms. Kuster........................   297
Letter of March 3, 2020, to Ms. Eshoo and Mr. Burgess, by Mary 
  Dale Peterson, M.D., President, American Society of 
  Anesthesiologists, submitted by Ms. Eshoo......................   302
List of Supporting Organizations, submitted by Ms. Kuster........   304

 
                 COMBATING AN EPIDEMIC:  LEGISLATION  TO 
                   HELP PATIENTS WITH SUBSTANCE USE DIS- 
                   SORDERS

                              ----------                              

                         TUESDAY, MARCH 3, 2020

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:00 a.m., in 
the John D. Dingell Room 2123, Rayburn House Office Building, 
Hon. Anna G. Eshoo (chairwoman of the subcommittee) presiding.
    Members present: Representatives Eshoo, Engel, Butterfield, 
Matsui, Castor, Sarbanes, Lujan, Schrader, Kennedy, Cardenas, 
Welch, Ruiz, Dingell, Kuster, Kelly, Blunt Rochester, Pallone 
(ex officio), Burgess (subcommittee ranking member), Shimkus, 
Guthrie, Griffith, Bilirakis, Long, Bucshon, Brooks, Mullin, 
Hudson, Carter, Gianforte, and Walden (ex officio).
     Also present: Representatives Tonko, Johnson, and Soto.
    Staff present: Joe Banez, Professional Staff Member; 
Jeffrey C. Carroll, Staff Director; Waverly Gordon, Deputy 
Chief Counsel; Una Lee, Chief Health Counsel; Meghan Mullon, 
Policy Analyst; Joe Orlando, Staff Assistant; Rebecca 
Tomilchik, Staff Assistant; Kimberlee Trzeciak, Senior Health 
Policy Advisor; Rick Van Buren, Health Counsel; Madison 
Wendell, Intern; C. J. Young, Press Secretary; S. K. Bowen, 
Minority Press Secretary; William Clutterbuck, Minority Staff 
Assistant; Caleb Graff, Minority Professional Staff Member, 
Health; Tyler Greenberg, Minority Staff Assistant; Peter 
Kielty, Minority General Counsel; James Paluskiewicz, Minority 
Chief Counsel, Health; Kristin Seum, Minority Counsel, Health; 
and Kristen Shatynski, Minority Professional Staff Member, 
Health.
    Ms. Eshoo. Good morning, everyone. The Subcommittee on 
Health will now come to order.
    The Chair now recognizes herself for 5 minutes for an 
opening statement.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN     
           CONGRESS FROM THE STATE OF CALIFORNIA

    According to recently reported CDC data, in 2018, 67,000 
Americans died of a drug overdose. Overdoses in 2018 killed 
more Americans than those lost in the Vietnam War.
    So this is a national crisis. In 2016, Congress passed the 
21st Century Cures Act and CARA, and in 2018, the SUPPORT Act 
was signed into law to stem the tide of addiction and 
devastation that the opioid crisis has created.
    Yet, despite our legislative efforts to give Medicaid more 
flexibility and increase access to medication-assisted 
treatment, or MAT, according to a 2019 National Academies of 
Science report, more than 80 percent of the two million people 
with opioid use disorder are not receiving MAT and families and 
children affected by the opioids crisis also are not receiving 
the care they need. We will learn more about why during our 
questions and answers.
    I think it is painfully clear that much more work needs to 
be done. But we also need to know how the administration is 
carrying out responsibilities that the Congress gave to them in 
carrying out the laws that we created. We will learn about 
where and why previous efforts have fallen short. We will 
grapple with what is needed to truly end these overdoses. Our 
next steps will require overcoming stigma and they will require 
spending money.
    From 1999 to 2018, more than 750,000 Americans died from an 
overdose and we all have to ask ourselves the question: are we 
willing to do what is needed to be done to avoid another near 
million deaths?
    Among the 14 bills we will discuss today, Representative 
David Trone and Representative Annie Kuster propose providing 
$1 billion annually to states and $5 billion annually to 
federal programs already in place that provide treatment and 
support prevention activities.
    Another part of the solution requires investing in a 
healthcare workforce to treat underserved areas. 
Representatives Tonko, Ruiz, Schneider, Brooks, Trahan, who---
Lori Trahan who I understand--where is Lori? She is in the 
audience today. There you are. Thank you very much.
    And Andy Kim have bills to create a brand-new healthcare 
workforce trained to recognize substance use disorder and are 
able to prescribe the medication-assisted treatment that we 
know saves lives.
    And it will require spending federal dollars to address the 
stigma against people in jails and prisons who, despite their 
sentences, deserve healthcare. People who are released from 
prisons and jail are 12 times more likely to die of an overdose 
than the general public.
    Currently, federal law bars Medicaid recipients from 
accessing their federal health benefits while incarcerated, so 
state and local governments face challenges to provide needed 
medication-assisted treatment to people that are incarcerated.
    Bills by Representatives Tonko and Kuster address these 
inequities by expanding Medicaid coverage during and after 
incarceration.
    And lastly, we will be considering bills from 
Representative Matsui, McKinley, and Griffith to fight back 
against suspicious drug orders and diversion to stop the 
illicit flow of opioids into our communities.
    So I look forward to discussing the impact of these 14 
bills and the effect they can have and hearing from the federal 
agencies in charge of implementing our past legislation, which 
are now the laws.
    [The prepared statement of Ms. Eshoo follows:]

                Prepared Statement of Hon. Anna G. Eshoo

    According to recently reported CDC data in 2018, 67,000 
Americans died of a drug overdose. Overdoses in 2018 alone 
killed more Americans than the Vietnam War. This is a national 
crisis.
    In 2016 Congress passed the 21st Century Cures Act and 
CARA, and in 2018 the SUPPORT Act was signed into law to stem 
the tide of addiction and devastation that the opioid crisis 
has created.
    Yet, despite our legislative efforts to give Medicaid more 
flexibility and increase access to medication-assisted 
treatment or MAT, according to a 2019 National Academies of 
Science report, more than 80 percent of the 2 million people 
with opioid use disorder are not receiving MAT and families and 
children affected by the opioids crisis also are not receiving 
the care they need.
    It's clear much more work needs to be done.
    Today we will hear from Administration officials 
responsible for carrying out these laws.
    We'll learn about where and why previous efforts have 
fallen short.
    And we will grapple with what is needed to truly end these 
overdoses.
    Our next steps will require overcoming stigma. And they 
will require spending money.From 1999 to 2018 more than 750,000 
Americans died from an overdose. What are we willing to spend 
to avoid another million deaths?
    Among the 14 bills we'll discuss today, Representative 
David Trone and Representative Annie Kuster propose providing 
$1 billion annually to states and $5 billion annually to 
federal programs already in place that provide treatment and 
support prevention activities.Another part of the solution 
requires investing in a healthcare workforce to treat 
underserved areas. Representatives Paul Tonko, Raul Ruiz, Brad 
Schneider, Susan Brooks, Lori Trahan (who is in the audience 
today), and Andy Kim, have bills to create a brand-new 
healthcare workforce trained to recognize substance use 
disorder and are able to prescribe the medication-assisted 
treatment that we know saves lives.
    And it means spending federal dollars to address the stigma 
against people in jails and prisons who, despite their 
sentences, deserve healthcare. People who are release from 
prisons and jail are 12 times more likely to die of an overdose 
than the general public.
    Currently federal law bars Medicaid recipients from 
accessing their federal health benefits while incarcerated, so 
state and local governments face challenges to providing needed 
medication assisted treatment to people incarcerated. And when 
an individual leaves jail or prison, they are often left 
without coverage and can't continue treatment.
    Bills by Representatives Tonko and Kuster address these 
inequities by expanding Medicaid coverage during and after 
incarceration.
    And lastly, we're considering bills from Representative 
Doris Matsui, David McKinley, and Morgan Griffith to fight back 
against suspicious drug orders and diversion to stop the 
illicit flow of opioids into our communities.
    I look forward to discussing the impact these 14 bills can 
have and hearing from the federal agencies in charge of 
implementing our past legislation.
    I yield the rest of my time to a leader on addressing the 
opioid epidemic, Representative Annie Kuster.

    It is a pleasure now for me to yield my remaining time to 
Representative Annie Kuster, who has just been a superb leader 
relative to the opioid epidemic.
    Ms. Kuster. Thank you so much, Chairwoman Eshoo, and thank 
you for scheduling these bills for a hearing.
    As founder and co-chair of the bipartisan Congressional 
Opioid Task Force, now a hundred members of Congress, this 
issue is one that impacts Republicans and Democratic districts 
across this country.
    Every community no matter race, region, intergenerational--
in short, this crisis knows no bounds. The complexity of the 
crisis is urgent and it has devastated communities across my 
district, and one thing we recognize the solution must be 
comprehensive. There is no silver bullet. It is a silver 
buckshot approach.
    So that is why I am so pleased to see my bill with 
Representative McKinley, the Humane Correctional Health Care 
Act, be included. We need to bring treatment to every part of 
our community and I look forward to working with you all. It 
saves lives and I would be shocked for anyone to speak out 
against innovative solutions to address the root cause of this 
incredibly high recidivism rates in this country.
    Thank you, Chairwoman Eshoo, and I yield back.
    Ms. Eshoo. And the gentlewoman yields back.
    The Chair now recognizes Mr. Burgess, the ranking member of 
our subcommittee, for his 5 minutes for an opening statement.

OPENING STATEMENT OF HON. MICHAEL C. BURGESS, A REPRESENTATIVE 
              IN CONGRESS FROM THE STATE OF TEXAS

    Mr. Burgess. And I thank the Chair and I appreciate that we 
are holding this hearing to continue this subcommittee's 
important work on addressing the opioid epidemic in our nation.
    Last Congress, we conducted a member-driven process that 
began in October of 2017 with an Energy and Commerce Committee 
Member Day and concluded with President Trump signing the 
SUPPORT Act one year later.
    Throughout that process we held four subcommittee hearings, 
a subcommittee markup, two full committee markups. This process 
allowed members to hear from relevant stakeholders, offer 
amendments to improve the legislation under consideration and, 
perhaps most importantly, allow the public a window into the 
process.
    While I am grateful that we are continuing our work on 
opioids I still believe it is critical that we have a 
standalone SUPPORT Act implementation hearing. This committee 
does important work. We have passed many landmark laws over the 
last five or ten years.
    But one thing I have learned our job does not stop at the 
signing ceremony. We must monitor the implementation as it goes 
through the agency process and be sure that the agencies are 
implementing the law as Congress intended and we can accomplish 
that through oversight hearings and implementation hearings.
    We need to monitor what is or what is not working, what 
deadlines the agencies might have missed. I appreciate that we 
have agency witnesses here today and I promise I will take full 
advantage of that.
    But I hope we will have a separate implementation hearing 
soon. I also hope that any future legislative hearings will 
include some of the outstanding issues such as aligning 42 CFR 
Part 2 with HIPAA, a bipartisan effort that Representatives 
Mullin and Blumenauer have championed and passed the House by a 
vote of 357 to 57 in the last Congress.
    The 14 bills before us today cover a broad range of ways to 
address substance use disorder, from solving problems with 
suspicious orders to requiring increased levels of education 
and training.
    A number of these have the potential to provide quality 
assistance to individuals with substance use disorders and to 
prevent future addiction. As we look at these bills we must be 
mindful of what we did in the SUPPORT Act to ensure that there 
are not duplicative provisions or policies that will complicate 
the implementation of the SUPPORT Act.
    I especially appreciate the inclusion of Representative 
Griffith's H.R. 4812, the Ensuring Compliance Against Drug 
Diversion Act of 2019, and Representative McKinley's H.R. 3878, 
the Block, Report, and Suspend Suspicious Shipments Act of 
2019.
    H.R. 4812, Mr. Griffith's bill, requires that the DEA 
registrants must obtain written consent from the DEA to assign 
or transfer a registration. This is a common sense step to 
prevent fraud and maintain up-to-date DEA records.
    Mr. Griffith's bill, H.R. 3878, builds off the Oversight 
and Investigations' important work last Congress on opiate pill 
dumping, particularly in the state of West Virginia. The 
sharing and reporting of suspicious order data is critical in 
ensuring we can prevent similar situations in the future.
    While I appreciate that the attention of H.R. 2483, the 
Mainstreaming Addiction Treatment Act of 2019, which is to 
increase the availability of medication-assisted treatment. We 
still do not have the reports that were mandated in the last 
legislation that we passed in the SUPPORT Act as to whether 
expanding prescribing power under the data waivers has made a 
meaningful difference.
    I understand that access to buprenorphine is important, 
sometimes limited, especially in rural areas. But we need to 
make certain that the policies for which we are advocating are 
effective and we should allow our current laws to be enacted 
and examined.
    I do have concerns with H.R. 3414, the Opiate Workforce 
Act, as it would require the secretary of the Department of 
Health and Human Services to establish an additional 1,000 
residency positions paid for by the Medicare program for the 
purpose of combating the opiate epidemic.
    Ensuring an adequate workforce can certainly be part of 
this discussion. But we need to keep in mind the danger of 
having a centralized government dictate how many healthcare 
professionals we need practicing which specialties. We already 
have health professional shortages and establishing this new 
requirement could create shortages in other areas.
    While I am grateful we are having the conversation today, 
the crisis continues to ravage communities across our nation. 
We have all heard from our constituents who have been affected 
in one way or another.
    I hope we will be able to soon have a standalone SUPPORT 
Act implementation hearing to do our due diligence in ensuring 
that the law is having a positive impact on our communities.
    Thank you, and I will yield back my time.
    [The prepared statement of Mr. Burgess follows:]

             Prepared Statement of Hon. Michael C. Burgess

    Thank you, Madam Chair. I appreciate that we are holding a 
hearing to continue this subcommittee's important work on 
addressing the opioid epidemic in our nation. Last Congress, we 
conducted a Member-driven process that began with an Energy and 
Commerce Committee Member day and concluded with President 
Trump signing the SUPPORT for Patients and Communities Act into 
law. Throughout that process, we held four Health Subcommittee 
hearings, one subcommittee markup, and two full committee 
markups. This process allowed Members to hear from relevant 
stakeholders, ask questions, and offer amendments to improve 
the legislation under consideration.
    While I am grateful we are continuing our work on opioids, 
I do still believe it is critical we have a standalone SUPPORT 
Act implementation hearing. Our job does not end at the signing 
ceremony.
    We must continue to ensure that the agencies are 
implementing our laws as Congress intended through oversight. 
We need to monitor what is or is not working or what deadlines 
the agencies have missed. I appreciate that we have some agency 
witnesses here today and will take advantage of that, but I 
hope we will have a separate implementation hearing soon.
    I also hope that any future legislative hearings will 
include outstanding issues, such as aligning 42 CFR Part 2 with 
HIPAA--a bipartisan effort Reps. Mullin and Blumenauer have 
championed, and which passed the House by a vote of 357-57 last 
Congress.
    The 14 bills before us today cover a broad range of ways to 
address substance use disorder, from solving problems with 
suspicious orders to requiring increased levels of education 
and training.
    A number of these have the potential to provide quality 
assistance to individuals with substance use disorders and to 
prevent future addiction. As we look at these bills, we should 
be mindful of what we did include in the SUPPORT Act to ensure 
that there are not duplicative provisions or policies that will 
complicate implementation of SUPPORT Act.
    I especially appreciate the inclusion of Rep. Griffith's 
H.R. 4812, the Ensuring Compliance Against Drug Diversion Act 
of 2019, and Rep. McKinley's H.R. 3878, the Block, Report, and 
Suspend Suspicious Shipments Act of 2019. H.R. 4812 requires 
that DEA registrants must obtain written consent from DEA to 
assign or transfer a registration. This is a commonsense step 
to prevent fraud and maintain up-to-date DEA records.
    H.R. 3878 builds off the Oversight and Investigation's 
important work last Congress on opioid pill dumping, 
particularly in West Virginia. The sharing and reporting of 
suspicious order data is critical in ensuring we can prevent 
similar situations in the future. This bill will also hold 
manufacturers and distributors accountable in that effort.
    While I appreciate the intention of H.R. 2483, the 
Mainstreaming Addiction Treatment Act of 2019, which is to 
increase the availability of medication assisted treatment, we 
still do not have the reports mandated by the SUPPORT Act as to 
whether expanding prescribing power under the DATA waivers has 
made a meaningful difference. I understand that access to 
buprenorphine is limited, especially in rural areas, but we 
should make sure that the policies for which we are advocating 
are effective and should allow our current laws to play out.
    I do have concerns with H.R. 3414, the Opioid Workforce 
Act, as it would require the Secretary of the Department of 
Health and Human Services to establish an additional 1,000 
residency positions, paid for by the Medicare program, for the 
purpose of combating the opioid epidemic. Ensuring an adequate 
workforce can certainly be part of this discussion, but we need 
to keep in mind the dangers of having the government dictate 
how many healthcare professionals we need practicing certain 
specialties. We already have healthcare professional shortages 
and establishing this new requirement could create new 
shortages in other areas.
    I am grateful we are having this conversation today because 
the opioid crisis continues to ravage communities across our 
nation. We have all heard from constituents who have been 
affected in one way or another by this epidemic, and it 
deserves our attention.
    I hope that we will be able to have a standalone SUPPORT 
Act implementation hearing to do our due diligence in ensuring 
that the law is having a positive impact on communities, and to 
address any other issues as they evolve.
    Thank you, Madam Chair. I yield back.

    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the chairman of the full 
committee, Mr. Pallone, for his 5 minutes for his opening 
statement.

OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. Thank you, Madam Chair.
    Today, the subcommittee will continue its bipartisan work 
to combat an ongoing and devastating epidemic involving opioids 
and substance use.
    We all know the statistics. In 2018, over 67,000 Americans 
died from a drug overdose. Well over half of these deaths 
involved opioids. There are approximately 20 million Americans 
living with a substance use disorder while only a fraction are 
receiving treatment.
    This committee has taken action to reverse this trend. We 
advanced major pieces of legislation through the committee in 
recent years, including the Comprehensive Addiction and 
Recovery Act, the 21st Century Cures Act, and the SUPPORT for 
Patients and Communities Act.
    These were important legislative achievements that invested 
in critical treatment and I look forward to hearing from our 
witnesses about the implementation of these laws, and what gaps 
remain to be addressed.
    Nationwide, opioid prescribing rates and overdose deaths 
are decreasing but our work in fighting this epidemic is far 
from over. There are still a lot of people and communities 
struggling and we must continue to do more.
    We must also address the emergence of synthetic opioids 
like illicit fentanyl, and the rise in deaths attributed to 
stimulants like cocaine and methamphetamine.
    Our first panel of witnesses includes officials from both 
the Department of Health and Human Services and the Drug 
Enforcement Administration. I look forward to hearing more 
about the progress the administration has made in implementing 
the SUPPORT Act.
    Among some of the key provisions of this law, HHS was 
charged with providing grant support and guidance to states and 
other stakeholders, while DEA was charged with issuing 
telemedicine regulations aimed at helping more patients in 
areas with doctor shortages, and I hope to drill down on these 
provisions and many others.
    I am concerned that the administration may be falling 
behind on some of the deadlines in the SUPPORT Act and I want 
to understand why that is happening.
    Our second panel includes experts on the ground of this 
epidemic, all of which are working to turn the tide for 
Americans across this country.
    I look forward to hearing testimony about the impact that 
recent federal funding and policy changes are having and what 
more we can do. I thank all of our witnesses for their ongoing 
dedication.
    As I said, when all the prior substance use packages passed 
out of this committee, we have made progress, but our work is 
far from complete. So today, we will be considering 14 pieces 
of legislation aimed at providing more help and more resources 
to those still struggling across the country.
    Some of these policies were Democratic priorities that were 
not included in the SUPPORT Act but that we continue to feel 
are critical to effectively responding to this national 
epidemic. Others are new ideas to address new and emerging 
problems that my colleagues on both sides of the aisle have 
identified.
    The unique jurisdiction of this subcommittee spans the work 
of both HHS and DEA, which allows us to approach this problem 
from multiple angles. That said, it is critical that we look at 
substance use disorder as a complex but treatable disease of 
the brain.
    Whether an individual has a substance use disorder in a 
hospital or within a criminal justice setting, they are a 
patient and we must address this epidemic as the true public 
health crisis that it is.
    Many of the bipartisan bills we will be discussing today 
take this public health approach. This includes proposals to 
address the need for more addiction medicine providers, to 
dismantle barriers to treatment, and to bolster public health 
and recovery programs in the states.
    And I thank all my colleagues for your continued dedication 
to combating this devastating epidemic.
    [The prepared statement of Mr. Pallone follows:]

             Prepared Statement of Hon. Frank Pallone, Jr.

    Today, the Subcommittee will continue its bipartisan work 
to combat an ongoing and devastating epidemic involving opioids 
and substance use.
    We all know the statistics. In 2018, over 67,000 Americans 
died from a drug overdose--well over half of these deaths 
involved opioids. And there are approximately 20 million 
Americans living with a substance use disorder--while only a 
fraction are receiving treatment.
    This Committee has taken action to reverse this trend. We 
advanced major pieces of legislation through the Committee in 
recentyears--including the Comprehensive Addiction and Recovery 
Act, the 21st Century Cures Act, and the SUPPORT for Patients 
and Communities Act. These were important legislative 
achievements that invested in critical treatment. I look 
forward to hearing from our witnesses about the implementation 
of these laws, and what gaps remain to be addressed.
    Nationwide, opioid prescribing rates and overdose deaths 
are decreasing, but our work in fighting this epidemic is far 
from done. There are still a lot of people and communities 
struggling and we must continue to do more. We must also 
address the emergence of synthetic opioids like illicit 
fentanyl and the rise in deaths attributed to stimulants like 
cocaine and methamphetamine.
    Our first panel of witnesses includes officials from both 
the Department of Health and Human Services (HHS) and the Drug 
Enforcement Administration (DEA). I look forward to hearing 
more about the progress the Administration has made in 
implementing the SUPPORT Act. Among some of the key provisions 
of this law, HHS was charged with providing grant support and 
guidance to states and other stakeholders, while DEA was 
charged with issuing telemedicine regulations aimed at helping 
more patients in areas with doctor shortages. I hope to drill 
down on these provisions and many others. I am concerned that 
the Administration may be falling behind on some of the 
deadlines in the SUPPORT Act, and I want to understand why this 
is happening.
    Our second panel of witnesses includes experts on the 
ground of this epidemic--all of which are working to turn the 
tide for Americans across this country. I look forward to 
hearing testimony about the impact that recent federal funding 
and policy changes are having, and what more we can do. I thank 
all of our witnesses for their ongoing dedication to the 
communities they serve.
    As I said when all the prior substance use packages passed 
out of this Committee--we have made progress, but our work is 
far from complete. So today, we will be considering 14 pieces 
of legislation aimed at providing more help and more resources 
to those still struggling across the country. Some of these 
policies were Democratic priorities that were not included in 
the SUPPORT Act, but that we continue to feel are critical to 
effectively responding to this national epidemic. Others are 
new ideas to address new and emerging problems that my 
colleagues on both sides of the aisle have identified.
    The unique jurisdiction of this Subcommittee spans the work 
of both HHS and DEA, which allows us to approach this problem 
from multiple angles. That said, it is critical that we look at 
substance use disorder as a complex but treatable disease of 
the brain. Whether an individual has a substance use disorder 
in a hospital or within a criminal justice setting--they are a 
patient. We must address this epidemic as the true public 
health crisis it is.
    Many of the bipartisan bills we will be discussing today 
take this public health approach. This includes proposals to 
address the need for more addiction medicine providers, to 
dismantle barriers to treatment, and to bolster public health 
and recovery programs in the states.
    I thank all my colleagues for your continued dedication to 
combating this devastating epidemic.
    Thank you, I yield the remainder of my time.

    And I yield the remaining time to my colleague from New 
Mexico, Mr. Lujan
    Mr. Lujan Thank you, Chairman Pallone, and I am proud to 
have Lauren Reichelt, the Health and Human Services director 
for Rio Arriba County in New Mexico here with us in DC Rio 
Arriba County is a state-funded behavioral health investment 
zone.
    In the past five years, they have made incredible progress 
in reducing overdoses and overdose deaths with intensive case 
management to connect patients to services. We should learn 
from their success.
    Coordinating only works when there is treatment available. 
One way we can ensure more patients have access to the 
treatment they need is by eliminating outdated requirements for 
providers who are qualified and willing to provide medication-
assisted treatment. That is why Congressman Tonko and I 
introduced the Mainstreaming Addiction Treatment Act. In states 
where there are high rates of substance use disorder and a 
shortage of healthcare providers, removing these hurdles is an 
easy step that will immediately improve access to treatment.
    I would also like to highlight Project ECHO, a 
telementoring program for health professionals developed at the 
University of New Mexico by Dr. Sanjeev Arora. ECHO has a 
curriculum to support rural primary care providers who want to 
start or expand medication-assisted treatment in their 
communities.
    Nearly 90 programs in 40 states are using ECHO to treat or 
prevent substance use disorder. I urge my colleagues to yet 
again come together and work together on this issue as we have 
in the past.
    And I thank the chairman. I yield back.
    Ms. Eshoo. The gentleman yields back. Is there anyone on 
the Republican side that would like to claim the time since Mr. 
Walden is not here?
    If not, we will go directly to our witnesses.
    So I would like to introduce our first panel and thank them 
for being here with us today. Admiral Brett Giroir--beautiful 
name. Thank you, and welcome to you. He is the assistant 
secretary for health and senior advisor to the secretary on 
opioid policy, U.S. Department of Health and Human Services.
    Ms. Kimberly Brandt, principal deputy administrator for 
policy and operations, Centers for Medicare and Medicaid 
Services. Welcome to you.
    And Mr. Thomas Prevoznik, welcome to you, sir. Deputy 
assistant administrator, diversion control.
    So we look forward to your testimony. I think you are 
probably familiar with the lights. Green is go, yellow is a 
warning, and everyone knows what a red light is, right? Stop 
sign, so and you have a minute remaining when the light turns 
yellow.
    So Dr. Giroir, you can begin your testimony. You have 5 
minutes. Make sure your microphone is on, and we look forward 
to hearing you.

 STATEMENTS OF ADM BRETT P. GIROIR, M.D., ASSISTANT SECRETARY 
   FOR HEALTH AND SENIOR ADVISOR TO THE SECRETARY ON OPIOID 
POLICY, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES; KIMBERLY 
     BRANDT, PRINCIPAL DEPUTY ADMINISTRATOR FOR POLICY AND 
OPERATIONS, CENTERS FOR MEDICARE & MEDICAID SERVICES; THOMAS W. 
 PREVOZNIK, DEPUTY ASSISTANT ADMINISTRATOR, DIVERSION CONTROL 
           DIVISION, DRUG ENFORCEMENT ADMINISTRATION

              STATEMENT OF BRETT P. GIROIR, M. D.

    Dr. Giroir. Thank you, Chair Eshoo, Ranking Member Burgess, 
and distinguished members of the committee. Thank you for the 
opportunity to update you on the status of America's overdose 
epidemic, HHS's implementation of the SUPPORT Act, and how the 
SUPPORT Act has catalyzed our efforts to address America's 
evolving substance use crisis.
    Because of the SUPPORT Act, we have enhanced the scale and 
effectiveness of HHS's substance use-related programs within 
the HHS strategy designed to achieve the following five 
objectives.
    One, improve the access to prevention, treatment, and 
recovery services.
    Two, strengthen public health data reporting and collection 
to inform real-time public health responses.
    Three, advance the practice of pain management.
    Four, enhance the availability of overdose reversing 
medications, namely, naloxone.
    And five, support cutting-edge research that improves our 
understanding of pain and use disorders, leads to new 
treatments, and identifies effective public health 
interventions.
    In my opening statement, I will provide just a few examples 
of how the SUPPORT Act has directly benefitted and enabled HHS 
programs.
    First, MAT, or medication-assisted treatment, is a standard 
of care essential component of evidence-based treatment. 
Section 3201 of the SUPPORT Act broadened eligibility to allow 
other qualified practitioners like nurse-midwives and clinical 
nurse specialists to become trained and prescribe 
buprenorphine.
    Section 3201 has contributed significantly to the now over 
110,000 providers currently approved to prescribe buprenorphine 
and that translates into over 1.3 million Americans now 
receiving MAT.
    Similarly, Section 3202 decreases the burden on physicians 
who have received appropriate training in medical school to 
obtain a waiver to prescribe MAT. SAMHSA has already provided 
48 grants to universities to train providers to became data 
waived immediately upon graduation and we will continue this 
program in fiscal year 2020.
    To further strengthen public health data reporting and 
collection, Section 7162 authorizes the CDC's support for 
states to improve their prescription drug monitoring programs, 
or PDMPs.
    To implement this provision, in 2019 CDC awarded $301 
million in cooperative agreements through the Overdose Data to 
Action program, which will enable providers to make better 
clinical decisions.
    And very important to me as a physician, the program funds 
the effort to assure PDMPs are easy to use and do not interrupt 
the physician-patient relationship.
    Section 7041 of the SUPPORT Act recognizes the critical 
importance of cutting--edge research. In fiscal year 2019, NIH 
awarded $945 million through their HEAL initiative for such 
topics as basic and applied research on pain, new approaches in 
medications to treat addiction, treatment of infants with NAS, 
and perhaps most immediately impactful, the $350 million 
Healing Communities Study aimed at reducing overdose mortality 
by 40 percent within three years in communities in Kentucky, 
Massachusetts, New York, and Ohio.
    So where are we now? Since 1999, over 810,000 Americans 
died of drug overdoses, the majority of which were caused by 
opioids, and the latest data from our National Survey on Drug 
Use and Health showed that approximately two million Americans 
currently have an opioid use disorder.
    But we are making progress. Over 1.1 million fewer 
Americans misused opioids last years compared to the year 
before. The total amount of opioids prescribed to Americans 
decreased 32 percent since January 2017 and naloxone 
prescriptions have increased by 405 percent in addition to the 
literally millions of doses that have been directly distributed 
to those at risk, first responders and family members.
    As a result of these and other whole of society programs, 
drug overdose deaths fell by 4.1 percent in 2018 compared to 
2017, the first year to year decrease in deaths in almost three 
decades.
    But we have a long way to go and we should not believe for 
one moment that the crisis is over or even substantially 
abating. While deaths from prescription opioids continue to 
decrease, deaths associated with synthetic opioids like 
fentanyl continue to rise at approximately ten percent 
annually.
    Even more concerting, data indicate that we have now 
entered the fourth wave of the crisis, characterized by a 
shocking increase in deaths from methamphetamine.
    From 2012 to 2018, the rate of drug overdose deaths 
involving methamphetamine increased by nearly 500 percent and 
our most recent data demonstrate that that continues to 
increase 25 to 30 percent annually.
    Certainly, as the assistant secretary for health but also 
as a physician, parent, and grandparent, I want to thank you 
all, all the members of Congress, for your visionary work on 
the SUPPORT Act. I am absolutely certain that working together 
we can provide Americans with not only hope but the lifesaving 
results they deserve.
    Ms. Eshoo. Thank you very much, Admiral.
    I now would like to recognize Ms. Brandt. You have 5 
minutes for your testimony and thank you again for being with 
us.

                  STATEMENT OF KIMBERLY BRANDT

    Ms. Brandt. Thank you.
    Chairwoman Eshoo, Ranking Member Burgess, and distinguished 
members of the subcommittee, thank you for inviting me to 
discuss the Centers for Medicare and Medicaid Services' work to 
combat the opioid epidemic.
    CMS is committed to a comprehensive strategy to address 
this public health crisis and we appreciate Congress's 
leadership in passing the SUPPORT Act, which has given us 
important new tools to use in this fight.
    Over 140 million people receive health coverage through CMS 
programs and the opioid epidemic affects every one of them as a 
patient, family member, caregiver, or community member.
    The SUPPORT Act was a historic step in helping us address 
the opioid epidemic. CMS has implemented 18 of its 49 
provisions to date and is hard at work to build on that 
progress.
    Just yesterday we completed a provision with the issuance 
with a state health official letter that provides guidance to 
states on enhanced behavioral health coverage for separate 
children's health insurance programs as required by Section 
5022 of the SUPPORT Act.
    This, and all of our opioid work, is focused on three 
goals: improving prevention, expanding treatment, and using 
data.
    Key components of any strategy to combat this crisis 
include insuring that opioid prescriptions are limited to those 
patients who have a clinical need and prescriptions follow 
appropriate safeguards.
    CMS expects all our Part D sponsors to limit initial opioid 
prescriptions for acute pain to no more than a seven-day 
supply, which is consistent with guidelines issued by the 
Centers for Disease Control and Prevention.
    We have seen progress in this area. The number of those 
receiving opioids for the first time who were prescribed 
opioids of seven days or less increased from 68 percent in 2017 
to 75 percent in 2018.
    Also in 2018 the percentage of Part D beneficiaries who 
were prescribed opioids fell to 29 percent, down from 35 
percent in 2013. As a payer for opioid use disorder, or OUD 
treatment, CMS plays an important role by incentivizing 
clinicians to provide the right services to the right patients 
at the right time while at the same time working to expand the 
services that are available to our beneficiaries.
    Beginning this January, for the first time CMS is now 
covering OUD treatment services furnished by opioid treatment 
programs in Medicare Part B. As of mid-February, 334 out of 
about 1,500 opioid treatment programs have already enrolled in 
Medicare with another 400- plus in the application queue.
    As part of our prevention efforts, we are also reviewing 
coverage and payment barriers for non-opioid pain relief. As of 
January, Medicare now covers acupuncture for Medicare patients 
with chronic lower back pain. This is a significant expansion 
of our non-opioid treatment options.
    We are building on important lessons learned from the 
private sector in this critical aspect of patient care. Over-
reliance on opioids for people with chronic pain is one of the 
factors that led to this crisis. So it is vital that we offer a 
range of treatment options for our beneficiaries.
    The opioid epidemic has had a significant on some of our 
most vulnerable beneficiaries and the surge in substance use 
related illness and deaths in recent years has particularly 
affected pregnant women.
    In response, CMS had developed the maternal opioid misuse, 
or MOM, model. The model addresses fragmentation in the care of 
pregnant and post-partum Medicaid beneficiaries with OUD 
through state-driven transformation of the delivery system 
surrounding this vulnerable population.
    But supporting the coordination of clinical care and the 
integration of other services critical for health, well-being 
and recovery, the MOM model has the potential to improve 
quality of care and reduce costs for mothers and infants. CMS 
has ordered ten states a total of $64.5 million for this five-
year model.
    We have also worked collaboratively with our state partners 
to provide the flexibility they need to meet the unique needs 
of their populations through Medicaid Section 1115 
demonstrations targeting substance use disorder treatment.
    In November of 2017, we announced a streamline process for 
states interested in covering the continuum of OUD services 
including inpatient care, and to date, we have approved 27 SUD 
treatment waivers and we are starting to see results from 
those.
    Virginia has experienced a four percent decrease in acute 
inpatient SUD admissions during the first ten months of 
implementation, along with a six percent decrease in opioid use 
disorder inpatient admissions.
    Finally, responding quickly and effectively to the changing 
nature of the crisis requires easily accessible data and CMS 
has leveraged our wealth of data to confront the crisis.
    In November of 2019, we released the Substance Use Disorder 
Data Book, the first nationwide analysis using data from 
Medicaid's new data system that transformed Medicaid's 
Statistical Information System, or T-MSIS.
    As required by Section 1015 of the SUPPORT Act, the Data 
Book details Medicaid beneficiaries' SUD diagnosis, enrollment 
type and service utilization by state to help CMS, researchers, 
and policymakers better understand where to focus their 
efforts.
    Along with the SUD Data Book, we released the underlying 
data that we used to develop the report so that the states and 
policymakers can understand their challenges in facing the 
crisis.
    With the SUPPORT Act, Congress has equipped CMS with 
important tools to combat this emergency and we look forward to 
continuing working toward our shared goals.
    Thank you for your interest in our efforts and I look 
forward to answering your questions.
    [The prepared statements of Dr. Giroir and Ms. Brandt 
follows:]

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Ms. Eshoo. Thank you, Ms. Brandt.
    Mr. Prevoznik, you have 5 minutes for your testimony. Thank 
you again for being here with us today.
    Put your microphone on, please.
    Mr. Prevoznik. I am sorry.
    Ms. Eshoo. That is all right. Get it close. Thank you.

                STATEMENT OF THOMAS W. PREVOZNIK

    Mr. Prevoznik. Chairwoman Eshoo, Ranking Member Burgess, 
and distinguished members of the committee, on behalf of Acting 
Administrator Dhillon and the Drug Enforcement Administration, 
I appreciate the opportunity to update you on the actions of 
DEA as well as our future intentions to combat the opioid 
epidemic and protect public health and safety.
    My name is Tom Prevoznik. I am the deputy assistant 
administrator of the Policy Office in the DEA's Diversion 
Control Division. I am a diversion investigator by training and 
have been with the DEA since 1991.
    As you know, on October 24th, 2018, President Trump signed 
H.R. 6, the SUPPORT Act, into law. This legislation is a 
comprehensive government-wide approach to reduce the national 
opioid epidemic.
    DEA was one of many entities charged to implement policies 
and expand existing programs to obtain this goal. Although work 
remains to be completed for DEA to fully execute the 
requirements of this law, DEA has successfully implemented key 
provisions to its enactment.
    In October of 2019, DEA made available to all DEA 
registrants the newly-created centralized database for 
reporting suspicious orders. Specifically, this database was 
created to better track suspicious orders and prevent the 
diversion of controlled substances.
    Also, in October of 2019, the DEA published a notice of 
proposed rulemaking in the Federal Register to change 
regulations that improved DEA's ability to oversee the 
aggregate production quotas for Schedule One and Two controlled 
substances.
    The goal of these changes is to further limit excess 
quantities of medications that might be diverted. The SUPPORT 
Act also requires DEA to provide additional information from 
the existing Automation Reports and Consolidated Order System, 
or ARCOS, to monitor controlled substances.
    In February of 2019, DEA enhanced the ARCOS Buyer Lookup 
Tool. It now includes the total number of distributors and 
total quantity and type of ARCOS reportable drugs, including 
opioids, sold by each distributor to a pharmacy or 
practitioner.
    The SUPPORT Act also requires DEA to provide state law 
enforcement and other entities standardized reports containing 
analytical information on ARCOS distribution patterns.
    DEA is currently providing these reports on a biannual 
basis. DEA was also tasked with promulgating regulations that 
will expand access to treatment and availability of controlled 
substances in rural areas.
    DEA is resolute in enacting regulatory obligations all in 
the final step of the review process. An area of great interest 
for DEA is the data contained in prescription drug monitoring 
programs, or PDMPs.
    PDMPs are state-run data collection programs that, when 
used properly, could help prescribers, pharmacists, and law 
enforcement prevent and identify over prescribing and 
indiscriminate dispensing controlled substance prescriptions.
    Currently, there are over 1.7 million practitioners 
registered with the DEA, 71,000 pharmacies, and 18,000 
hospitals. These registrants constitute 99.1 percent of the DEA 
registrant population. Manufacturers and distributors, the 
entities that report ARCOS reportable transactions, constitute 
only .06 percent of registrants.
    It is important to note that ARCOS data represents what is 
received by a pharmacy, whereas PDMP data represents what is 
dispensed by a pharmacy. At present, DEA's access to PDMP data 
is limited to information relating to the ongoing investigative 
matter. The means by which DEA obtains this information varies 
from state to state with approximately half of the states 
requiring some kind of court or grand jury process.
    However, without PDMP data from every state, DEA faces 
challenging knowledge gaps that hinder its ability to fight 
prescription drug diversion, protect public health and safety. 
Additionally, since the SUPPORT Act requires DEA to estimate 
diversion and reduce manufacturers' quotas based on those 
estimates, DEA requires access to state PDMP data to assist in 
fulfilling its statutory obligation to calculate diversion.
    I would like to thank our federal partners here at the 
table today for our continued work together to address the 
opioid crisis. The department and DEA thank Admiral Giroir for 
his support and guidance in the collaborative efforts of the 
department, DEA, CDC, HHS, OIG, and the Commission Corps to 
address patient continuity and treatment for patients impacted 
by enforcement actions taken on healthcare providers.
    This is a collaborative effort in conjunction with state 
departments of health contacts. The goal is to ensure that 
persons suffering from addiction to opioids are provided 
treatment resources.
    Finally, I would be remiss if I didn't extend DEA's sincere 
gratitude to the members of this subcommittee and Congress at 
large for extending DEA's emergency order controlling fentanyl-
related substances.
    However, this order will expire in May 2021 so a permanent 
solution to a controlled fentanyl-related substances remains a 
necessity for DEA and the department. We look forward to 
working with this committee and others in the coming weeks and 
months to find that permanent solution.
    [The prepared statement of Mr. Prevoznik follows:]
    
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
   
    
    Ms. Eshoo. Thank you very much. We have now concluded the 
opening statements of our witnesses. We thank you again. We 
will now move to members and I will recognize myself for 5 
minutes.
    First, I would like to enter into the record Inside Health 
Policy report dated February 24th, 2020, titled 
``Administration's Delays in Implementing Major Opioid Law 
Hinder Efforts to Curb Crisis.''
    Are there any objections?
    Certainly. OK. I will move to my questions. But I just want 
to comment. This report found that CMS has not published six 
guidance documents required under the SUPPORT Act within the 
statutory time frame.
    So I want to begin with Ms. Brandt. I am going to describe 
each guidance document and ask you to give me the date you 
expect it to be published. The first document is about 
reimbursement options for substance use disorder treatments, 
including medication-assisted treatment than can be delivered 
via telehealth. When do you expect this to be published?
    Ms. Brandt. We expect to publish that----
    Ms. Eshoo. Turn your microphone on.
    Ms. Brandt. Apologies, Chairwoman. We expect to issue that 
yet this spring. It is currently being in final----
    Ms. Eshoo. Let us just keep it short. Spring means what----
    Ms. Brandt. OK. Spring.
    Ms. Eshoo. --April? May?
    Ms. Brandt. Hopefully, no later than May.
    Ms. Eshoo. All right. The first day of summer is June 21st 
so----
    Ms. Brandt. Duly noted.
    Ms. Eshoo. The next document is about opportunities to 
finance and improve family-focused residential treatment 
programs. When do you expect that to be published?
    Ms. Brandt. That is also one for this spring. May.
    Ms. Eshoo. May. The next are recommendations for improving 
care for infants with neonatal abstinence syndrome and their 
families. When do you expect that to be published?
    Ms. Brandt. We hope to have that one also this spring. 
Hopefully, no later than May.
    Ms. Eshoo. You are also behind on publishing a best 
practices for ensuring Medicaid coverage of former foster 
youth. When do you expect that to be published?
    Ms. Brandt. That one we are currently working on. We hope 
to have that by April.
    Ms. Eshoo. Got a lot of work to do before spring. You are 
also behind on publishing best practices for prescription drug 
monitoring programs and privacy protections for Medicaid 
beneficiaries. When do you expect that to be published?
    Ms. Brandt. That is one we are working with our federal 
partners on and we also expect that by the end of the spring.
    Ms. Eshoo. By the end of spring. All right. Well, you have 
a full portfolio there and we will track with you and to make 
sure that they actually take place.
    To the admiral, I would like to ask you what is the status 
of your efforts in coordinating with NIH and FDA to support 
research and development for nonopioid pain management?
    Dr. Giroir. Thank you for that. There are efforts nearly 
every day to do that. We are coordinating with all the 
speciality societies to make sure that nonopioid uses are being 
done. We have issued guidance on the appropriate tapering of 
opioids. That was in the fall in substitution of other 
activities.
    The HEAL initiative, as you know, has applied research, 
meaning not just in the, you know, in a laboratory and a mouse 
but, really, applied research on pain management. That is, you 
know, coordinated----
    Ms. Eshoo. What is your--let me ask you this. What is your 
assessment of a near outcome relative to the R&D?
    Dr. Giroir. I am sorry, ma'am. I didn't----
    Ms. Eshoo. The outcome of the R&D between NIH and FDA.
    Dr. Giroir. Well, the research and development is ongoing. 
Again, the HEAL initiative just started. There are----
    Ms. Eshoo. It just began?
    Dr. Giroir. Well, the funding for the HEAL initiative--
there was $945 million last year and there is ongoing research 
with I think there is going to be very near-term deliverables.
    It is really defined--you know there is some basic research 
that will take years or a decade to go but there are near-term 
deliverables with actual clinical trials, including neonatal 
abstinence syndrome, including----
    Ms. Eshoo. And when do you expect those clinical trials to 
begin?
    Dr. Giroir. Oh, most of these have already begun. We expect 
new--you know, new data, new results, on an ongoing basis.
    Ms. Eshoo. But where are they? I mean, the first trial is 
the easy one. Second phase is longer, more expensive. I still 
don't have a sense of exactly where we are and when--I mean, 
are deliverables three years off? Two years off? Four years 
off?
    Dr. Giroir. So deliverables are being done now. As we said, 
opioid prescribing is down almost 34 percent even in the last 
two years. Substitution of ibuprofen, multi-modal management--
that is all going on now with existing technologies that we 
use.
    Ms. Eshoo. Those are the easy things.
    Dr. Giroir. But they are also effective. They are also very 
effective. There are trials--
    Ms. Eshoo. Oh, I am not--I am not diminishing that. I am 
just saying those are the easy things.
    Well, I think that my time has expired and I now recognize 
the ranking member for his 5 minutes of questions.
    Mr. Burgess. Just before we start my time, my initial 
perusal of this, since I am quoted accurately, I will not 
object to its inclusion.
    Ms. Eshoo. So ordered.
    [The information appears at the conclusion of the hearing.]
    Ms. Eshoo. I wouldn't think of putting something in the 
record where you are misquoted, Doctor.
    Mr. Burgess. Mr. Prevoznik, let me just ask you a couple of 
questions about the PDMP because, of course, that is something 
this committee worked on, really, since my first term in this 
committee so many, many years ago and with the several time 
reauthorization of NASPER, to the extent that you are able to 
utilize it in your investigative activity, has that been 
helpful?
    Mr. Prevoznik. Absolutely.
    Mr. Burgess. So what extent are you utilizing PDMP data? Is 
that something that happens frequently or just occasionally?
    Mr. Prevoznik. It is typically used in investigative 
matters so the current investigations that we are doing it we 
will--the access is through each state. So it varies state by 
state how we gain access to that data. But it is case specific.
    Mr. Burgess. And just to refresh everyone's memory is 
there--may a physician or other practitioner query the PDMP 
before issuing a prescription to a patient?
    Mr. Prevoznik. That, again, varies by state by state, 
whether the state requires the prescribers or the pharmacist. 
DEA fully encourages all prescribers, all pharmacists, to look 
at the PDMP data either prior to or at whatever point that they 
feel that they need to look at to assess the patient that is in 
front of them.
    Mr. Burgess. So yes, that is the aspect I was going to 
get--if we want it to be effective; preventative medicine 
probably works best. Query before writing the prescription. I 
think that is something that maybe some of our follow-up can 
look at as to how that is working, what are the best practices 
of various states--other ways we can extend that best practice 
to other participants.
    On the--Admiral Giroir and Ms. Brandt, on the--in Section 
5052 of the SUPPORT Act there's an option for state Medicaid 
programs to cover care for 21 to 64-year-olds in certain 
institutions for mental disease--the so-called IMD exclusion--
which otherwise would not have been federally reimbursement--
federally--eligible for federal reimbursement because of the 
IMD exclusion. So how many states have utilized or expressed 
interest in utilizing this option?
    Ms. Brandt. Sir, we issued guidance to states in November 
of last year on this and we are working with states and, as of 
yet, we are still working to assess their interest.
    Mr. Burgess. That is really too soon to tell because last 
November was--this is--you know, we all see the problems, the 
news stories about the numbers of homeless in various cities 
and I think it was Dr. Drew who correctly identified it is one 
thing to put someone in an apartment or a room but you are not 
going to fix their homelessness.
    The cause of their homelessness if you don't address the 
underlying mental health disorder and so oftentimes that is a 
substance use disorder. So to the extent--and I do want to 
continue to work with you. I know there are other pieces of 
legislation out there--the IMD exclusion, I recognize it is 
expensive when you get the Congressional Budget Office 
involved.
    But it does seem to me that we are being penny-wise and 
pound-foolish in not making the investment in the actual fixing 
the problem for someone rather than just continuing to respond 
to their symptoms.
    Are there any other tools that you think would be helpful 
for the states or the Center for Medicare and Medicaid Services 
to increase utilization of this option?
    Ms. Brandt. I think continuing to have a dialogue with 
members such as yourself and continuing to talk to the states 
about this option and the flexibilities they need is really 
what we think would be most helpful so that we can understand 
exactly where the issues are and how we can best used our 
levers to help with them.
    Mr. Burgess. And, Dr. Giroir, do you have anything to add?
    Dr. Giroir. I don't have--I don't have anything to add to 
that.
    Mr. Burgess. Well, I do hope that is one of the things that 
we, as a committee--as a subcommittee--can explore because I 
think it is terribly important.
    One of the things, and Admiral, you mentioned in your five-
point strategy the alternative pain treatments for alternative 
management of pain. So how are we doing? What actions is HHS 
taking to address the alternative pain treatments?
    Dr. Giroir. Thank you for that. There are both informal 
mechanisms and formal mechanisms. The formal mechanisms often 
come through CMS issuing a number of guides and guidelines to 
all practitioners about the use of alternative pain medications 
including, most recently, acupuncture but also the normal 
things that we do, and as you understand, most of this is 
driven by our interactions with medical societies.
    Mr. Burgess. Yes. I would be interested to know what the 
discussion was about the coverage determination for 
acupuncture. Were commercial insurance companies covering that 
and CMS was late to the table or was CMS on the vanguard here?
    Ms. Brandt. There are some private insurers which were 
covering it. We did, certainly, consulted with the private 
insurers. But this was a groundbreaking and very aggressive 
move on our part to cover this particularly in a broad base, 
not just in a clinical capacity.
    Mr. Burgess. OK. Thank you. I yield back.
    Ms. Eshoo. The gentleman yields back. It is a pleasure to 
recognize the gentlewoman from California, Ms. Matsui, for her 
5 minutes of questions.
    Ms. Matsui. Thank you very much, Madam Chair.
    Addiction is a devastating disease that knows no bounds and 
we must provide solutions in a comprehensive manner. This 
includes extending and expanding community- based behavior 
health clinics, improving enforcement of mental health parity 
laws, putting greater transparency on the drug supply chain, 
and addressing outstanding barriers to using telehealth to 
expand access to care.
    Telemedicine is a critical tool that should be leveraged to 
expand the ways a patient can receive medication-assisted 
treatment, especially in rural areas. That is why I 
reintroduced the Improving Access to Remote Behavioral Health 
Treatment with several of my colleagues on this committee.
    The Ryan Haight Act of 2008 allowed for legitimate entities 
to register with DEA to use telemedicine to remotely prescribe 
controlled substances in a regulated way. However, these 
guidelines were never issued.
    As such, Congress included in H.R. 6, the SUPPORT Act, a 
provision requiring DEA to issue regulations around the special 
registration process within one year of enactment of the law. 
SUPPORT was passed into law in October 2018. As of today, DEA 
still has not set the ground rules for providers with a special 
registration to prescribe controlled substances.
    Mr. Prevoznik, can you provide an update on the agency's 
work on the special registration rule? When can we expect the 
proposal to be published?
    Mr. Prevoznik. Thank you for that question. Telemedicine is 
being practiced today, being done now. The regs are in the 
review process. As I said, we are in the final stages of the 
review process. It is very much an interagency process in that 
it is not just DEA equities that are involved in this.
    This is a lot of different equities that are involved from 
various agencies and we want to ensure that patients are truly 
getting legitimate care and that we do not reopen this up to 
the Wild West, which required the passing of the Ryan Haight 
Act. So we are working very closely with our interagency 
partners on this. We are working diligently and very hard to 
get it done.
    Ms. Matsui. Well, thank you. It has been 11 years since the 
Ryan Haight Act originally called for this process and amid 
this addiction epidemic, we have to expand access to treatment, 
particularly through legitimate community addiction and mental 
health centers that are regulated in a way that does not 
currently comply with the DEA registration process, and I urge 
the agency to issue a proposal as soon as possible.
    Current regulations require all DEA-registered 
manufacturers, distributors, and dispensers of controlled 
substances report suspicious orders to DEA. These suspicious 
orders may include orders of unusual size, orders deviating 
substantially from a normal pattern, and orders of unusual 
frequency, which could indicate that controlled substances are 
being diverted out of legitimate use.
    Among other things, the SUPPORT Act tasks DEA with 
evaluating the utility of real-time reporting of suspicious 
orders.
    Mr. Prevoznik, to what extent has the DEA engaged in 
capabilities to develop a system to identify real-time reports 
and how does the DEA propose to share this data with suppliers 
before orders are filled?
    Mr. Prevoznik. I appreciate that question as well. As you 
know, in October, we--October 23rd we released the newly-
created centralized database to report suspicious orders. This 
requires all registrants that distribute amongst registrants to 
report suspicious orders.
    Currently right now, we are getting data that is inputted. 
Prior to that, we did not have that data into that newly- 
created centralized database system. We want to ensure that the 
data that is in there is it valid and correct because garbage 
in is garbage out. So we are working with the industry as well 
to ensure that the data that is going in there is correct and 
valid, and then that data will be shared with the state 
attorney generals. We are working on a portal system now to 
share that data with the state attorney generals law 
enforcement.
    Ms. Matsui. Well, thank you. We just want to make sure that 
we do this in a timely manner because it does hinder the 
ability of manufacturers and distributors to identify 
suspicious activity and that is why Representative Johnson and 
I have introduced the Suspicious Order Identification Act of 
2019, legislation that sets up a workable real-time reporting 
system through DEA to help us prevent diversion and maintain 
integrity in the supply chain.
    We would like this going--I understand what you mean 
about--you know, garbage in--But, you know, we really need to 
do this in an expeditious manner and I believe you can handle 
this. So, please, we have this law--this bill going through the 
process right now, bipartisan. We would like to have it done.
    Thank you. Yield back.
    Ms. Eshoo. The gentlewoman yields back. A pleasure to 
recognize Dr. Bucshon for his 5 minutes of questions.
    Mr. Bucshon. Well, thank you very much.
    There is one of the bills that we are talking about today 
that I want to express some concerns about. It is H.R. 2482, 
Mainstreaming Addiction Treatment Act of 2019. This would--it 
eliminate the separate registration requirement for dispensing 
narcotic drugs in Schedule III, IV, or V such as buprenorphine 
for maintenance or detoxification treatment and for other 
purposes.
    My concerns are that buprenorphine can be effective if 
administered by properly educated and trained providers who 
counsel and educate the patient. However, the vast majority of 
individuals currently receive--are receiving no counselling.
    Medication-assisted treatment may not be effective unless 
there is a more comprehensive treatment plan in place, and so 
my concern of waiving a DEA requirement is significant.
    I have been working in this--in Congress to implement 
prescribing limits and increase prescribers education for 
buprenorphine to mitigate the practices that led to the current 
opioid epidemic.
    However, some of my friends in Congress continue to want to 
expand the scope of practice to allow almost anyone regardless 
of their qualifications and/or training to prescribe 
buprenorphine, and there are other medication-assisted 
treatments but we seem to be focusing on this one.
    In my opinion, that is exactly what H.R. 2482, the 
Mainstream Addiction Treatment Act does. It removes education 
requirements and limits making it easier to prescribe a 
medication known to be highly diverted and misused.
    The bill may only expand access to the medication but not 
real and effective treatment for individuals with substance 
abuse disorder.
    The last thing Congress should be doing, in my view as a 
physician, is limit and relax requirements for prescribing and 
dispensing narcotic drugs like buprenorphine, even when there 
is political pressure and sometimes social pressure to do so.
    With that said, I have a few questions. Pain management is 
real and we must all look to find nonopioid alternatives to use 
to help individuals that suffer from pain daily.
    Admiral, I want to thank you for making improving pain 
management a key component of the HHS opioid strategic plan and 
for your leadership of the Pain Best Practices Task Force.
    Can you tell us specifically what HHS is doing to promote 
pain best practices and improve patient and provider education 
about nonopioid alternatives?
    Dr. Giroir. Yes, sir. Thank you for that.
    There are both formal and informal mechanisms. Again, we 
tend to use CMS as a formal mechanism to reach all prescribers 
with their guidelines and guidances about nonopioid treatment 
and, again, we are not just talking about acupuncture but we 
are talking about the things that you and I know to do--anti-
inflammatory agents, multi-modal behavioral therapy. All those 
things are there.
    Mr. Bucshon. And there may--and there is devices, medical 
devices that can be useful.
    Dr. Giroir. And devices. We are in really a 
transformational period of understanding how medical devices in 
and of themselves can control or modify pain to a great degree. 
And, again, this is an interagency process. As you also know, 
the medical societies have really taken this up on their own 
with individual guidelines for dental procedures, for 
outpatient surgery, for knees, hips--all the issues. So we are 
working with them actively and on a weekly basis.
    Mr. Bucshon. Great. And Ms. Brandt, the HHS pain management 
report calls for breaking down barriers, improving patient 
access, and expanding coverage to nonopioid treatment options 
for pain. Will the task force recommendations be reflected in 
the forthcoming CMS Opioid Action Plan?
    Ms. Brandt. Yes. We plan on using that as well as 
information we got from a request for information that we 
issued last fall where we specifically asked for input on 
things that have enhanced or impeded access to nonopioid 
treatment so that we can take that into account as well.
    Mr. Bucshon. Great. That is important. I just want to say 
as a physician I do think that the physician community is 
becoming more and more aware of their prescribing habits. I 
will speak specifically for Indiana.
    That is based on a lot of factors, both state and federal--
the federal government but also on the media and the society at 
large, and I think our physicians are trying to do their part 
to help mitigate this opioid crisis.
    I do, again, want to reiterate my concerns about lifting 
regulatory requirements on qualifications required to prescribe 
these medications for MAT and I think that they are there for a 
reason. Although I am for expanding treatment but in--but, 
again, as a physician, I have serious concerns about expanding 
the treatment in that way.
    So with that, and I also want to thank the chairwoman for 
this hearing, for all of these opioid-related bills as it is a 
critical problem that our nation needs to continue to address.
    I yield back.
    Ms. Eshoo. The gentleman yields back and I appreciate the 
good words. Let us see who is next.
    The gentleman from California, Dr. Ruiz, is recognized for 
5 minutes.
    Mr. Ruiz. Thank you very much for holding this hearing.
    We passed comprehensive legislation that was signed into 
law last Congress and the Congress before that to address the 
opioid crisis that has swept our nation. But the crisis is far 
from over and it is important that we look back at our past 
work on this issue to assess the results and see what we can 
further do to make a positive impact on this public health 
epidemic.
    When we passed the SUPPORT Act last Congress, one of my 
bills was included in that package and that is what I want to 
focus on today. As we all know, seniors are at heightened risk 
for opioid use disorder and the severe consequences of the 
respiratory depression that they may cause.
    The purpose of the Advancing High-Quality Treatment for 
Opioid Use Disorders in Medicare Act is to help ensure our 
seniors have access to high quality evidence-based opioid 
misuse disorder treatment.
    Specifically, this voluntary demonstration project will 
create an alternative payment model through Medicare for 
comprehensive treatment and care programs for opioid misuse 
disorder.
    Participating providers or institutions will receive a case 
management fee to enable them to provide wraparound services to 
Medicare beneficiaries and receive a higher fee if the 
coordinated care team includes an additional specialist.
    For Medicare beneficiaries participating in this program in 
addition to medication-assisted treatment, they will receive 
psycho social support such as psychotherapy, treatment 
planning, and appropriate social services to treat substance 
use disorder.
    This coordinated care approach is considered the gold 
standard of care and if we want to successfully address this 
crisis we need to ensure that individuals have access to 
treatments that will result in successful outcomes. I have seen 
firsthand the importance of this with my patients and beginning 
medication-assisted treatment is important.
    But the success of that treatment is enhanced if the 
patient is also participating in psychotherapy and receiving 
the appropriate social services. It is of the utmost importance 
that all Americans, regardless of their age or how much money 
they make, have access to high-quality comprehensive treatment.
    Our entire healthcare system is moving towards a more 
coordinated care and incentive programs for performance 
outcomes and our seniors should not be left behind. This 
demonstration project is slated to begin in January of 2021.
    So Ms. Brandt, can you tell me where you are in the 
development process at this time including which specialists 
you have consulted with?
    Ms. Brandt. Thank you, Dr. Ruiz. We are actually very 
actively working on this and hope to meet the implementation 
deadline. Thus far, because this is a very hands-on 
demonstration, we have been working very closely with 
stakeholders, including clinicians in the primary care 
community and those in the field of addiction medicine to help 
us with designing the demonstration.
    We did a series of listening sessions in April and May of 
last year with both stakeholders and beneficiaries to help us 
better be able to understand the issues and design the 
demonstration, and we are hopeful that within the next month 
that we will start to be able to work on the application 
process and start moving forward.
    Mr. Ruiz. So what are steps that still need to be taken to 
roll out this program?
    Ms. Brandt. We need to finish designing the demonstration, 
finish the cost estimates, and begin with the applications.
    Mr. Ruiz. OK. And are you on schedule for the demo to be up 
and running in January as required?
    Ms. Brandt. As of right now we are on track and we are 
pushing hard to remain on track.
    Mr. Ruiz. Good. Well, that is important for our seniors. We 
need to address all the other social determinants of health and 
that could be as simple as do they have transportation to their 
treatment and psychotherapy. That can be as simple as looking 
at some of their addiction behaviors and start creating 
psychotherapy for them to understand their own physiology. 
Seniors in particular are more at risk to have pain issues 
because of the musculoskeletal wear and tear throughout their 
lifetime.
    At the same time, they are more sensitive to opioids. They 
are more at risk of getting addicted and an opioid of the same 
dose can cause respiratory depression, severe drowsiness to a 
point where they can fall, where they can regurgitate from 
their food, which can cause pneumonia more so than somebody who 
is, let us say, in their 30s. So that is why we need to pay 
special attention to our seniors and we need to ensure that 
this program is ready, up, and running by the due date this 
January.
    Thank you very much. I yield back.
    Ms. Eshoo. The gentleman yields back.
    A pleasure to recognize Mr. Long, our good friend.
    Mr. Long. Thank you, Madam Chairwoman.
    And Ms. Brandt, the opioid epidemic continues to devastate 
families and communities in my district and across the country, 
as you know, and I myself have some personal experience with 
opioids over about a four or five day period when I was in the 
hospital for eight days right before Christmas after I was 
trying to get a four-pound poodle out of the middle of the 
street.
    That wasn't a very good idea, and I shattered my shoulder. 
So that led to a long stay and a few days of opioids in there, 
which--the hallucinations, the bugs and things crawling on the 
wall. I saw pain relief I did not get. So I am not sure how 
people get addicted to these but I know that it is a very, very 
serious issue.
    One thing we can do at the federal level is to ensure 
Medicare patients have access to safe and effective 
alternatives to opioids to manage their pain. Unfortunately, 
Medicare payment policies can keep these alternatives out of 
the reach of many of our nation's seniors by failing to 
adequately reimburse hospitals for the cost of the therapy.
    I was proud of the work Congress did in the SUPPORT Act to 
provide CMS with new authorities to adjust payment for 
evidence-based nonopioid therapies under Section 6082 and I was 
very disappointed to learn that the agency declined to make 
payment adjustments for any alternative therapies in its 2020 
payment rule.
    What more do you need from Congress to make payment 
adjustments necessary to ensure seniors can access these safe 
alternatives that reduce opioid use?
    Ms. Brandt. Well, first of all, I hope you are recovered 
from your experience, sir, and I am sorry to hear about that.
    But from our perspective at CMS, we are really open to 
working with you all to get feedback on how we are implementing 
this section and what else we can do.
    I, personally, have met with dozens of stakeholders on 
this. We have been taking into account additional research and 
additional information that we have gotten from them about we 
can better look at how we are adjusting our payment policies to 
reflect this, and right now we are working with an interagency 
task force to look into this issue and see how we can continue 
to evolve on this.
    Mr. Long. OK. How do we ensure that the reimbursement 
policies don't create a disincentive, I guess you would say, 
for prescribing opioid alternatives?
    Ms. Brandt. Well, one of the things that has been most 
helpful to us is continuing to have the dialogue not only with 
you all but with the stakeholder community about the evidence 
showing the impact of those costs and what we can do to be able 
to adjust our payment policies to reflect that.
    Mr. Long. OK. Thank you.
    And, Admiral Giroir, you briefly mentioned in your 
testimony that you are witnessing new and highly dangerous 
patterns of use, including a combination of polysubstance 
methamphetamines and illicit fentanyl?
    And I might add that I toured a drug facility. It wasn't 
really a drug facility but in the Kansas City, area they have 
a--if the police pick you up instead of taking you to jail, 
they will take you to this facility for 24 to 48 hours. The 
first thing they do is drug test you and they got a guy in 
there and they said, what are you on, and he said, oh man, I am 
on opioids.
    They tested him and they said, sir, you don't have one 
opioid in your system. They said, you have fentanyl. He said, 
what is fentanyl. He said, I bought opioids. So I know what an 
issue is it. Can you explain what is going on here? Can you 
discuss how the opioid crisis is evolving and how that 
substances like these can threaten the overall progress being 
made against opioids and heroin?
    Dr. Giroir. Yes. Yes, sir. Thank you.
    Overall, the numbers looked good. Prescription opioid 
deaths are down 10, 12, 14 percent. Heroin deaths are 
decreasing. Fentanyl deaths are still going up at ten percent 
but they were going up 30 and 40 percent. So we are starting to 
make headway into this.
    You have characterized it. Really, the fourth wave is 
methamphetamines and methamphetamines combined with drugs like 
fentanyl that are really a deadly potion. In many parts of the 
country, particularly in the West, methamphetamines absolutely 
dominate over opioids now as the cause of death and despair.
    A very important thing that Congress did on the State 
Opioid Response Grants for this year allowed flexibility so 
states could use the money not just for opioids but 
predominantly for methamphetamine if that is an issue, and in 
that regard, the Tribal Opioid Response Grants for this year 
will be announced today at $50 million to get relief to the 
tribes on methamphetamines.
    So, again, sir, all the investments that you are making--
workforce, training, incentive payments--these will all go 
across the board to help methamphetamine but we do need the 
flexibility and there are some specifics about methamphetamine 
that are critical.
    And, again, there are cartels manufacturing hundreds of 
thousands of pounds of pure methamphetamine. This is not 
someone cooking it in the kitchen next door anymore. This is 
industrial-scale methamphetamine that is an all out for DEA, 
DOJ----
    Mr. Long. How about you down the table? I was going to ask 
Mr. Prevoznik, would you care to comment? What is the DEA 
seeing in terms of new patterns of use?
    Mr. Prevoznik. The biggest thing that we are seeing is the 
counterfeiting--the counterfeiting of these very--fentanyl, 
methamphetamine, they are being pressed into pills so that the 
public does not know what they are getting. This is a very 
scary time.
    As the admiral pointed out, that it is highly 
industrialized. We have the pill press issue of where they are 
coming from, who is getting them, who is using them. We are 
attacking it. We have just started Operation Crystal Shield, 
which we are targeting eight distribution hubs for 
methamphetamine and we are doing a full court press on that 
right now.
    Mr. Long. OK. And I yield back. Thank you all.
    Ms. Eshoo. The gentleman yields back.
    Pleasure to recognize the gentleman from Massachusetts, Mr. 
Kennedy, for 5 minutes.
    Mr. Kennedy. Thank you, Madam Chair, and I want to thank 
Ranking Member Burgess for convening this hearing today and for 
taking proactive steps to combat the Opioid epidemic.
    To our witnesses, thank you for being here. Thank you for 
your service. A few minutes ago, I left a roundtable discussion 
with mental health and substance use disorder experts and 
dozens of healthcare leaders from providers to insurers to 
researchers and advocates.
    All of them are intimately familiar with our past failure 
to prevent this crisis from taking root and all of them have 
seen how our efforts to confront it today far too often fall 
short.
    Because it simply is not enough to try to smooth out the 
edges of what ends up being a completely hollow system for far 
too many Americans. As long as there are Americans out there 
without healthcare coverage or who are underinsured or covered 
by junk insurance plans or have plans that simply do not 
provide adequate coverage for mental and behavioral health 
services because they do not consider them to be a priority, we 
will not be able to overcome an opioid epidemic.
    Even worse, as long as this administration continues to cut 
holes into the very safety net system and programs that are 
meant to catch those who fall through the cracks, we will fail 
without a doubt.
    Ms. Brandt, do you know what program is the largest payer 
of substance use disorder treatment in the country?
    Ms. Brandt. Medicaid.
    Mr. Kennedy. Do you know, roughly, how much Medicaid pays 
annually for that treatment?
    Ms. Brandt. I do not know that exact amount.
    Mr. Kennedy. Well, about $7 billion or so.
    Admiral Giroir, is that--did I pronounce your name anywhere 
close to correct? I am sorry, sir.
    Dr. Giroir. Anything close is fine, sir.
    Mr. Kennedy. Apologies, sir.
    Dr. Giroir. Cajun names are a problem.
    [Laughter.]
    Mr. Kennedy. Forgive me. Would you agree that Medicaid is 
the largest payer of mental behavioral services in the country?
    Dr. Giroir. Yes, that is correct.
    Mr. Kennedy. And so, Ms. Brandt, are you familiar with the 
statistics showing that the percentage of people hospitalized 
with a substance use disorder who did not have health insurance 
dropped from 20 percent to just five percent in states that 
expanded Medicaid coverage in just two years?
    Ms. Brandt. I have heard those statistics.
    Mr. Kennedy. And, Admiral, does that sound familiar to you 
as well?
    Dr. Giroir. Yes, sir.
    Mr. Kennedy. So, Admiral, have you seen studies showing 
that Medicaid work requirements or Medicaid block grants would 
increase access to addiction treatment options?
    Dr. Giroir. Have I seen studies that block grants will 
increase the access?
    Mr. Kennedy. Yes.
    Dr. Giroir. No, sir. I have not seen those.
    Mr. Kennedy. How about work requirements? Would they 
increase access to treatment options?
    Dr. Giroir. I have not seen studies either way on that, 
sir.
    Mr. Kennedy. Ms. Brandt?
    Dr. Giroir. I have not either.
    Mr. Kennedy. So, Ms. Brandt, in your experience, does 
cutting a program by, roughly, $1 trillion usually make it more 
or less effective in treating a population that is already 
horrifically under-served and under-treated?
    Ms. Brandt. Our efforts are to try and keep the program 
sustainable at all costs for all of our vulnerable 
beneficiaries.
    Mr. Kennedy. And cutting a trillion dollars make that 
easier to do or harder to do?
    Ms. Brandt. It will make it so that the program hopefully 
will be able to be sustainable in the long term to be able to 
cover those people that need those services.
    Mr. Kennedy. And so when you cut a trillion dollars out of 
it, who gets--who feels the basis of that cut?
    Ms. Brandt. The cut is in the growth of spending, not the 
actual spending itself and it is to help to sustain the program 
over the long term.
    Mr. Kennedy. So your position then is that cutting a 
trillion dollars out of Medicaid will not actually harm the 
beneficiaries from being able to access their care?
    Ms. Brandt. It is to help be able to make the program more 
long-term sustainable.
    Mr. Kennedy. I understand that is the hope. What do you 
think the reality is of cutting a trillion dollars out of the 
healthcare program?
    Ms. Brandt. That is the genesis behind our budget proposal 
is to go ahead and keep the program sustainable in the long 
term.
    Mr. Kennedy. And, Admiral, are you familiar with the ten 
essential health benefits mandated by the Affordable Care Act?
    Dr. Giroir. Yes, generally.
    Mr. Kennedy. Yes. I won't quiz you on all of them. But one 
of those essential health benefits, again, mandated by the ACA 
is mental health and substance use disorder services.
    Yet, this administration will be arguing before the Supreme 
Court in just a few months that the entire Affordable Care Act 
should be struck down.
    Admiral, if the ACA is struck down in its entirety and 
substance use disorder services are no longer considered an 
essential health benefit, would that be good or bad for 
patients in need of addiction treatment?
    Dr. Giroir. So, as you know, the last thing I am would be 
to pretend to be a lawyer. But, clearly, having access to 
substance use and mental health services is absolutely key to 
eliminating the crisis and also preventing the next one.
    Mr. Kennedy. Thank you.
    And is there a possibility that health insurers will see 
mental and behavioral health conditions as preexisting 
conditions if the ACA is struck down?
    Dr. Giroir. If you are asking me, I am sorry, I don't 
really have expertise to comment.
    Mr. Kennedy. The idea being that if it was in fact, the 
Affordable Care Act that mandated coverage for substance use 
disorder and mental behavioral health coverage, that if somehow 
those protections were taken away that insurance companies 
would step into that void voluntarily. They never did in the 
past. Is there any reason to believe they would now?
    Dr. Giroir. Again, you know, I am sorry. I can't predict 
insurance coverers' behavior. But it is absolutely vital that 
everyone with substance use disorder, the potential for it and 
mental illness, get the care they need as soon as possible 
because the spiral goes very badly over the decades as they--as 
they progress.
    Mr. Kennedy. Agree, sir. Thank you very much.
    Yield back.
    Ms. Eshoo. The gentleman yields back.
    A pleasure to recognize the ranking member of the full 
committee, the gentleman from Oregon, Mr. Walden, for 5 
minutes.
    Mr. Walden. Good morning, Madam Chair, and I want to thank 
our panellists. We got another subcommittee going on, so some 
of us are bouncing back and forth between the two.
    Admiral, I want to ask you about 42 CFR Part 2. Are you 
familiar with that regulation and the impact it has on sharing 
critical medical information back and forth among providers?
    Dr. Giroir. Yes, sir. Of course, I am. Dr. McCance-Katz 
really is the expert in our department on that, but I am 
certainly familiar with it.
    Mr. Walden. In the last Congress, when I had the great 
honor to chair the committee, we moved legislation as part of 
our opioids package dealing with--to provide some reforms to 42 
CFR Part 2. We had instances where there had been loss of life 
because that information had not been shared.
    I know the Trump administration has attempted to do what we 
failed to do legislatively. Not in the House. We passed it in 
the House.
    Can you speak to the importance of making these changes and 
what other legislation might be helpful in this area? Or Ms. 
Brandt, if you are involved in this?
    Dr. Giroir. I think we could probably all speak. But it is 
clear that the administration believes, and I do as well, and 
certainly all the experts that I know that we need reform in 42 
CFR. It is really meant for a time that is 40 or 50 years ago 
and does not address the crisis as we have today and, thus, we 
proposed regulations, as you know, to do as much as we can 
without legislation. That is still limited in what can be done.
    But, clearly, to be able to have information for one 
provider to know that the patient is in an opioid treatment 
program and has a long-term substance use issue can be 
lifesaving and I think there are many examples when it is.
    Mr. Walden. That is right.
    Dr. Giroir. I think there is a balance that we can protect 
patients' privacy like through HIPAA but still get lifesaving 
information to providers.
    Mr. Walden. Ms. Brandt, do you have any additional comments 
on this matter?
    Ms. Brandt. Well, in our meetings with stakeholders, this 
is one of the issues that has come up that is very important.
    Mr. Walden. You know, I did a lot of roundtables in my 
district and this almost above any other with the provider 
community, was the top issue, and we protected patients' 
privacy rights. I think the bill we passed in the House was 
stronger than existing HIPAA requirements.
    We don't want this information used against them in any 
way--their, you know, employment or anything else. But failure 
to share in a modern environment is deadly and so we worked 
together on that, and I know it was an issue for Mr. Kennedy as 
well.
    Unfortunately, I have to confess, my dear friend, the 
chairman of the committee now was the lead opposition to this 
and we had a problem in the Senate. We got it passed through 
the House but not in the Senate. So, regretfully, I doubt we 
will see any forward motion on this, going forward, with those 
that are in charge right now.
    Admiral, how is HHS monitoring the use and determining the 
success of the Opioids Dashboard? That is something else that 
my colleague, Mr. Latta, was lead on, and the National Help 
Line and findtreatment.gov. Mr. McKinley was big on this as 
well. Are you getting that dashboard up and running?
    Dr. Giroir. Yes, sir. The dashboard is up and running at 
hhs.gov/opioids, and we tried to certainly highlight and 
prioritize the things that could be lifesaving like 
findtreatment.gov, which was completely redone to make sure 
that people who are in need or need a hotline have that right 
there.
    But as you look down it gives the up-to-date statistics. 
There is a quick link to make sure that everybody who wants a 
grant--that is one thing we heard, is there a quick way to just 
click to it.
    Mr. Walden. That is right.
    Dr. Giroir. And also, although you can tell it is made by 
accountants and not by some of the digital folks, but there is 
a basic, easy-to-use map about where the money has gone and who 
it has gone to----
    Mr. Walden. Oh, good.
    Dr. Giroir [continue].To be transparent. Again, it is not 
beautiful but it is easily seen----
    Mr. Walden. Right.
    Dr. Giroir [continue]. And downloadable so Congress or the 
private can have some sunlight on that and see how we are 
doing.
    Mr. Walden. Ms. Brandt, do you have a comment on that?
    Ms. Brandt. I would just add that in addition to the 
dashboard that the Admiral mentioned, we at CMS have our own 
opioid heat map that is available using our CMS data that 
allows you to see down to the zip code level trends in 
utilization and prescribing.
    Mr. Walden. One of the things that--great joys of serving 
in the Congress people from different districts and different 
issues and I will never forget the moment Bobby Rush from 
Chicago made it clear to me it is more than just opioids, and 
we changed the legislative intent to include all substance use 
disorder.
    In my district, meth is still a huge issue, probably bigger 
than opioids. Can you speak in the last 20 seconds to what we 
are doing in methamphetamine and what you see?
    Dr. Giroir. Dr. McCance-Katz and I formed a task force last 
March actually when we saw this really rolling across the 
states. One of the major issues is we provided technical 
assistance so the State Opioid Response Grants could be used 
because----
    Mr. Walden. Right.
    Dr. Giroir. California, Oregon, Washington----
    Mr. Walden. It is meth.
    Dr. Giroir [continue]. New Mexico, Arizona, it is really 
meth, meth, meth, and you were--you were hand tied. SAMHSA has 
also opened up a completely nationwide technical assistance 
programs because there is not MAT for methamphetamine.
    Mr. Walden. Right.
    Dr. Giroir. And just to be sure, the NIH and FDA are 
working together to try to develop the MAT but also open the 
doors to industry to let them know that every power of the FDA, 
priority reviews, all those kinds of things will be used 
because we really need to focus on that, and methamphetamine, 
as you know, is devastating. And, again, more deaths from 
methamphetamine now than prescription opioids or heroin and it 
will overtake cocaine within the next month or two.
    Mr. Walden. Yes. I know Bobby talked about crack cocaine 
and the impact in his community, and we want to be on all of 
these. We don't want to just isolate to specific drugs.
    So thank you, Madam Chair. You have been most generous with 
the time.
    Ms. Eshoo. For you, Mr. Chairman.
    It is now a pleasure to recognize the gentlewoman from 
Michigan, Mrs. Dingell.
    Mrs. Dingell. Thank you, Madam Chair and to Ranking Member 
Burgess for holding this hearing and--to evaluate the impact of 
opioid legislation passed last Congress and to examine 
bipartisan legislation to continue to address this epidemic, 
and I do want to associate myself with the comments that were 
just made that it is not just opioids but it is a number of 
other drugs, and I thank all of the witnesses for being here.
    As we all keep saying, the Opioid epidemic is one of the 
defining public health challenges of our time. It was good that 
we witnessed in 2018 a reduction in drug overdose deaths for 
the first time in years.
    There were still 67,000 people that lost their lives and, 
you know, I am one of those families that lost a sister and 
whose father--he lived with it but it impacted his whole life. 
So I know firsthand what a challenge we are dealing with.
    And there is not a member on this committee or in the 
Congress that has not heard about it from their constituents, 
hasn't seen it firsthand. So that is why we have got to 
redouble our efforts to understand what is working and what 
else we need to be doing to help you.
    So, Admiral, I want to ask you the first question. The 
SUPPORT Act included the ACE Research Act, which I introduced 
with my colleague, Fred Upton, to encourage the development of 
nonaddictive pain medications. We have talked about 
alternatives but we have really not talked about what the 
status is in developing new drugs that aren't addictive.
    Earlier this year, Dr. Volkow, the director of the National 
Institute of Drug Abuse, stated that it would likely take years 
before new pain medicines could replace today's opioids and 
reach the market.
    Can you discuss some of the challenges that remain with 
developing these new treatments and what action we can take 
further to develop these new medicines in a faster way?
    Dr. Giroir. So I am going to answer your question but I 
just want to be clear that we have a number of nonaddictive 
medications that are highly effective when used in a multi-
modal service. And, again----
    Mrs. Dingell. So what--so talk about that because the anti-
inflammatory drugs or the other ones you talk about can't be 
taken by many older people. They get bleeding in their stomach. 
They have side effects that causes increased high blood 
pressure. For many, especially older people, who have kidney 
disease, et cetera, opioids are the only thing they can take.
    Dr. Giroir. So there are always going to be exceptions to 
all pain categories and part of the Pain Management Task Force 
is we have said like anyone knows, you need a patient-centered 
approach. You can't just make a rule and have it apply to 
everyone----
    Mrs. Dingell. Right.
    Dr. Giroir [continue]. And we actually go through many 
special populations, including women, including patients with 
sickle cell disease exactly to work on that. But for many 
patients, in fact, most patients, it has been--it has been 
shown that high dose ibuprofen can be as good as opioids coming 
out of the emergency room. That multi-modal----
    Mrs. Dingell. But not for long term.
    Dr. Giroir. Not for long term. Not for long term at all. So 
there are a variety of devices--physical therapy, all the kinds 
of things that you know about and I know you know about that. 
On the----
    Mrs. Dingell. I have spent a lot of time--I am not a 
doctor, but--and that is what I am worried about. We really do 
need nonaddictive----
    Dr. Giroir. So we do have a lot that we can do now. But 
your point is correct. Unfortunately, it takes a long time to 
develop new drugs. Fortunately, the incentives are there.
    Congress has provided the money to support NIH very 
dramatically and there are very exciting--I mean, extremely 
exciting things on the horizon. But it will take years for a 
nonaddictive opioid-like substance or antibody to come onto the 
market.
    Mrs. Dingell. We are not doing it quick enough. This is the 
real world for me. I have lived with it on both sides, as you 
know.
    I am going to do, quickly--additionally, Rep. Walberg and I 
worked on legislation, Jesse's Law, which included as a 
provision--it was included as well in the SUPPORT Act. It 
ensures that doctors have access to a consenting patient's 
prior history of addiction in order to make fully informed care 
and treatment decisions--my colleague, Mr. Walden, was talking 
about this--because we want to protect people's privacy but we 
also need to make sure people who are addicted--Jesse was a 
young woman in our district that died of a drug overdose 
because her doctor didn't know.
    Ms. Brandt, can you discuss the additional steps that 
providers are now taking as a result of the SUPPORT Act to 
ensure that those with a history of addiction are not receiving 
opioids as pain treatment and the impact that this has had on 
opioid misuse?
    Ms. Brandt. So one of the things that we have done is to 
have it as part of the visits that Medicare beneficiaries do 
with their doctors to encourage the doctors to discuss with 
them issues of opioid addiction and to help them understand----
    Mrs. Dingell. OK. But Medicare is someone that is over 65 
or is disabled. Jesse was just out of college.
    Ms. Brandt. Right. And, in general, we also have been 
giving issuance guidance to states to encourage states to work 
with their providers.
    A lot of this is especially for people who are like Jesse--
younger adults--are not necessarily people that are covered 
directly by Medicare or Medicaid. They might, you know, be just 
on their own. So part of this----
    Mrs. Dingell. Like a lot of young people in this country.
    Ms. Brandt. Correct. And so as a result we have done all we 
can within our programs to make sure that we are spreading the 
word to providers.
    Mrs. Dingell. So do we need to do more in this area?
    Ms. Brandt. I think we can all work together to do more in 
this area.
    Mrs. Dingell. I would like to do that. My time is up so I 
have to yield back.
    Ms. Eshoo. The gentlewoman yields back.
    Pleasure to recognize the gentleman from--oh, from 
Kentucky, Mr. Guthrie, for 5 minutes.
    Mr. Guthrie. Thank you, Madam Chair. I appreciate the--I 
appreciate that, and I am glad we are here to discuss the 
implementation of the SUPPORT Act in the ongoing opioid 
epidemic.
    My home state is Kentucky and it has been hard hit by the 
this tragic epidemic, and I believe implementation of the 
bipartisan SUPPORT Act deserves our full attention in addition 
to examining where the gaps remain in policy.
    And I also want to mention, and I know Dr. Giroir--Admiral 
Giroir--I went to Army so it is hard to say admiral. I am 
kidding.
    [Laughter.]
    Mr. Guthrie. So I really appreciate the Navy, actually. So 
but I want to--you mention the NIH Healing Communities grant 
and it will help--and what it will do to help communities 
affected by the opioid epidemic. I was very pleased that the 
University of Kentucky was awarded one of the community grants 
and I look forward to seeing them and other awardees reducing 
opioid-related overdose deaths by 40 percent over the course of 
three years.
    Well, my question is, Ms. Brandt, in your testimony, you 
mentioned Section 1003 of the SUPPORT Act, which authorized CMS 
to increase the capacity of Medicaid providers to deliver SUD 
treatment to recovery--recovery service in a two-phase 
demonstration. Kentucky was included in the 15 states for phase 
one. Can you please explain the current progress of the 15 
states and what are next steps through translation to phase 
two?
    Ms. Brandt. Sure. Thank you, sir. I am happy to talk about 
that. We were excited last September to issue $48.5 million to 
15 states including, Kentucky for an 18-month demonstration 
project to be able to have them look at, you know, the benefits 
of additional types of flexibilities for SUD treatment.
    We are currently monitoring the demonstration. We look 
forward to evaluating the results. The program will end in 
March of 2021 at the end of the period. At that point we will 
select no more than five of the 15 states to participate in the 
final 36 months of the demonstration and there will be an 
additional $5 million that will go to those states at that 
point.
    Mr. Guthrie. So, next, to Ms. Brandt and to Admiral, how 
does HHS ensure that opioid federal grant funds are not 
diverted for unauthorized purposes and do you periodic--do you 
do periodic check-ins or are these done annually?
    I just want to make sure the money and resources are 
getting to those who need the resources the most. So how do you 
do oversight of the funding?
    Dr. Giroir. Well, I think we can all take a bit of that. It 
depends on the--it really depends specifically on what grant 
category it is. The State Opioid Response Grants from SAMHSA, 
as you know, by design provide great flexibility to the states 
because we want the states to be able to use the funds that are 
needed for the states but there is, clearly, reporting 
requirements about what category there are clear stipulations 
about it has to be evidence-based therapy, right.
    So you can't do things that are not supported by science 
and medicine, and in other programs, they are much more, you 
know, specifically managed. It just depends on the programs. 
But, obviously, we are--we are getting into a phase right now--
not that we haven't been there before but we are really getting 
to a phase that there is a lot of money on the streets and we 
have at least four different groups right now doing modelling 
and simulation to determine where is the best bang for the 
buck.
    In other words, so we can advise you if you put a dollar 
here it will be better than putting a dollar there right now. 
It's a very complex system but we are getting to the point of 
being able to do that.
    Mr. Guthrie. OK. Thank you.
    Ms. Brandt?
    Ms. Brandt. So for ours because there are demonstrations 
where we give federal moneys to the states directly or we have 
models where we give money directly to entities, we track those 
very closely. That is part of the demonstration agreement is 
that we look at their spending. We look at how it is being 
spent.
    In particular, with the demonstration you mentioned we have 
reports to Congress that we are required to give, the first of 
which I believe we are going to be issuing in October of this 
year and that would continue to have it so that we would be 
able to say how the money is being spent and holding them 
accountable.
    Dr. Giroir. And, for example, some are very easy to monitor 
like the CDC grants to improve data reporting. So we now know 
there has been astronomical progress in being able to report 
data on deaths and on real-time in the emergency rooms.
    This was an exercise in history a couple of years ago where 
you were always two years behind. Now for fatalities within six 
months we have 99.8 percent done down to the level of fentanyl 
or the analogs. So there are some very specific things that are 
easy to monitor and we see those results.
    Mr. Guthrie. Thank you. My time has expired and I yield 
back.
    Ms. Eshoo. The gentleman yields back.
    A pleasure to recognize the gentleman from California, Mr. 
Cardenas, for 5 minutes.
    Mr. Cardenas. Thank you, Madam Chair, and also the ranking 
member for having this important committee.
    I am happy that this committee is continuing its work on 
the opioid epidemic and also looking forward to talking about 
how we can help patients with other substance use disorders. 
This is a public hearing and I just want to read off some of 
the legislation that had been introduced by my Republican 
colleagues and Democrat colleagues in Congress.
    The Medicaid Reentry Act. Another one is Easy Medication 
Access and Treatment for Opioid Addiction Act. Another one is 
State Opioid Response Grant Authorization Act. Another one is 
the Mainstreaming Addiction Treatment Act of 2019.
    Another one is Respond to the Needs in Opioid War Act. 
Another one is Opioid Workforce Act of 2019. Another one is 
Block, Report, and Suspend Suspicious Shipments Act. And the 
list goes on.
    The reason why I wanted to point that out is because I 
think the people who have gathered in this room they are all 
familiar with these bills but the issue that I think that we 
need to convey to the American people is that we have too many 
people saying that Congress is doing nothing, and the fact of 
the matter is we are trying to tackle issues in Congress.
    That is why my colleagues on both sides of the aisle, 
Republican and Democrat, are introducing bills so that we can 
have legislative hearings like this so that we can actually 
hear from the experts and try to figure out how do we make life 
better for the American people on a day-to-day basis, and much 
of it has to do with making sure that we take the resources 
that come to the United States Congress, the taxpayer dollars, 
and make sure that we put it to good, good use.
    So I first want to thank my colleagues for the attention 
that many of my colleagues are putting on this issue but also 
the experts who are in fact working with the various 
departments at the federal level, working with our state and 
local governments to make sure that American lives are in fact 
being addressed when it comes to issues of opioid addiction and 
other issues.
    I would also like to point out that data from the agencies 
testifying today tell us that while we are seeing positive 
signs with the opioid epidemic, our work is far from over.
    Adding to the need to continue work on substance use 
disorders in this country is the rise in availability and use 
of stimulants like methamphetamine and cocaine. The Drug 
Enforcement Administration's 2019 National Drug Threat 
Assessment states that methamphetamine remains widely available 
and the DEA field divisions are reporting an increasing 
availability of the drug compared to the previous year.
    Mr. Prevoznik, is there a difference between the 
methamphetamine use we saw in the early 2000s compared to what 
we are seeing now and how is your agency working to reduce its 
availability?
    Mr. Prevoznik. I can address the latter part of your 
question in that we are currently working Operation Crystal 
Shield that we just launched that we are targeting the eight 
districts--eight city hubs where we have the transport hubs of 
methamphetamine, which we have seized. Over 75 percent of the 
methamphetamine that we have had are in these eight different 
cities. So we are full-court press in those cities. I believe 
what you--I am not the expert on--the whole expert on the 
methamphetamine of the 2000s compared to that. But if----
    Mr. Cardenas. OK. Please.
    Dr. Giroir. So the methamphetamines we are seeing now are 
essentially--they are industrial scale. So it is 100 percent 
pure. It is cheap, very cheap. Much less expensive than it was 
before and it is being intentionally put in other supplies like 
fentanyl and heroin to create mixed addictions. So this is a 
whole different ball game. Not that it wasn't severe before but 
this is really a true national security issue with hundreds of 
thousands of pounds of industrialized methamphetamine coming 
in.
    Mr. Cardenas. So the intensity that we are seeing on the 
streets of America today is higher and then also the activity 
is more?
    Dr. Giroir. Yes, sir. And methamphetamine is, by itself, an 
extraordinarily addictive drug that you know is toxic to--it is 
really toxic to the brain and if you have seen individuals who 
are on methamphetamines for a period of time you understand the 
devastation it has to the person and to the community.
    Mr. Prevoznik. And if I could add to that. The 
counterfeiting of the pills themselves is huge because the 
public just does not know what they are getting. It looks like 
Adderall but it's not, and we don't know what it is mixed with.
    Mr. Cardenas. OK. Doctor, HHS has a five-point opioid 
strategy. Is your agency considering a five-point stimulant 
strategy?
    Dr. Giroir. We have a much larger strategy than--the five 
points is a good overriding and, in general, access to 
treatment and prevention that really works, right. There are so 
many things that work with that.
    But, again, we have an intra-agency methamphetamine task 
force of the leaders of every single one of our divisions that 
have moved forward with a number of actions specific for 
methamphetamines and also working with DOJ and ONDCP. Director 
Carroll has been really on top of this coordinating across the 
agencies as well.
    Mr. Cardenas. So you do have a stimulant strategy as well? 
And many others?
    Dr. Giroir. Yes, sir.
    Mr. Prevoznik. Yes.
    Dr. Giroir. And we briefed--I think we just briefed your 
staff on this very recently, maybe a few weeks ago. Is that 
right? On our methamphetamine approaches. Yes, sir.
    Mr. Cardenas. Thank you so much.
    I yield back.
    Ms. Eshoo. The gentleman yields back. Excuse me.
    Pleasure to recognize the gentleman from Florida, Mr. 
Bilirakis, for 5 minutes.
    Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so 
much.
    I am going to yield to Representative Brooks my 5 minutes. 
If she doesn't take the entire 5 minutes I will take whatever 
is left. Appreciate it.
    Ms. Eshoo. Well, we can recognize you as well.
    Mr. Bilirakis. OK. That would be great. I was going to----
    Ms. Eshoo. I know that Congresswoman Brooks has another----
    Mr. Bilirakis. She has another----
    Ms. Eshoo. Exactly. So you are recognized for 5 minutes.
    Mrs. Brooks. Thank you so much, Madam Chairwoman. I thank 
my colleague for yielding to me, and I want to thank each of 
our witnesses for your incredibly important work.
    I must say that given how bipartisan our work has been for 
quite some time, I do have one concern about one of the bills 
that is being put forth, the H.R. 2466, the State Opioid 
Response Grant Authorization Act.
    This committee worked so hard on CARA, 21st Century Cures, 
and the SUPPORT Act, and we, in 21st Century Cures, passed--I 
am sorry, with the SUPPORT Act we actually already have put 
forth state and local grant programs. And so I am very 
concerned that H.R. 2466 might undermine the State Opioid 
Response Grants that the states are already very much working 
hard on. And so I would be--I would like to see us remain 
focused on the grant programs we have already initiated rather 
than create a whole new set of grant programs.
    With that, I would also like to focus on Section 101 of the 
CARA Act, which I was involved--the Pain Management Best 
Practices Task Force. And we know that that is one of the great 
challenges in this opioid crisis is trying to figure out ways 
to treat real chronic and the need for implementation of best 
practices has never been greater.
    In fact, a Harris poll found that 80 percent of primary 
care physicians believe that the opioid crisis has made it 
actually more difficult to treat pain patients and they need 
more information on nonopioid options. Many of the front-line 
providers have actually stopped seeing pain patients because 
they are concerned about what they can do for pain patients.
    Admiral Giroir, you mentioned already in your testimony the 
Pain Management Best Practices Task Force and, Madam 
Chairwoman, this report, which was--which was the product of 
really our legislation that we worked on so hard together was 
issued May 9th. With unanimous consent, I would like for this 
to be entered into the record.
    Ms. Eshoo. So ordered.
    [The information appears at the conclusion of the hearing.]
    Mrs. Brooks. And I also would ask us to consider 
potentially even having a future hearing relative to these are 
incredible recommendations that dozens of providers worked very 
hard on for an entire year.
    But I am very concerned as to what Health and Human 
Services is doing to ensure that these pain best practices are 
disseminated. It is a lot for providers. How is this being 
disseminated to our nation's primary care physicians?
    Admiral Giroir, if you know.
    Dr. Giroir. Well, it--first of all, it is being 
disseminated through the mechanisms that we normally 
disseminate--having it posted, speaking about it, having the 
Surgeon General amplify it.
    But we are picking out specific pieces of it and amplifying 
it on a regular basis. For example, one of the largest issues 
we are facing is that, as you pointed out, because of all the 
issues, physicians and other providers are too rapidly tapering 
people from opioids or taking them off of them acutely. This is 
really one of the most urgent issues that we face and we have 
put out sequential guidance for that. The CDC--I put out 
guidance from my office in the fall of 2018 with opioid 
tapering guidelines. So we are doing it generally but our 
strategy is also to take small buckets of it and to disseminate 
that as the priorities exist and that is just--that is just one 
example of them. Another one and, again, that I am, as a 
pediatric ICU doctor, sickle cell patients is one of those 
categories who have tremendous needs for pain. Not only have we 
worked with the national program with prescribers through our 
Office of Minority Health, but even CMS has put out letters 
that said that you need to exempt these kinds of individuals 
from their regs.
    Mrs. Brooks. So is there a strategic plan, though, to 
implement these task force reports? As I look at the content--
table of contents--medications, restorative therapies, and 
interventional procedures--there are--I mean, that is just to 
name the first half of the----
    Dr. Giroir. Yes.
    Mrs. Brooks [continue]. Special populations there is--this 
report is actually I think chock full of incredible 
information. So is there a strategic plan rather than each of 
the different agencies taking small buckets at a time?
    Dr. Giroir. Yes. So there is an overall--we--part of my job 
is to coordinate across the agencies and you will see in that 
report almost every section has an individual recommendation 
associated with that and not every one of those recommendations 
is being implemented.
     But they are sort of being parsed out. For example, some 
of the pain research that went directly into the HEAL program. 
So research on special populations, on women's pain, on pain in 
special needs populations went directly into the HEAL program. 
So there is no independent strategic plan to implement that. 
But it is coordinated through our normal activities.
    Mrs. Brooks. Well, thank you.
    Dr. Giroir. But I hear what you are saying.
    Mrs. Brooks. Very proud of this work and all of the work 
that all the providers and patients put into this, and so would 
strongly urge that somehow, Madam Chairwoman, we get if not 
either part of the hearing or that we get more information out 
about all of this good work that has been done.
    With that, I yield back.
    Dr. Giroir. And I do think it is one of the best documents 
and it was incredible. The people who worked on the committee 
and the thousands of people who provided input makes it a 
really special contribution and thank you for making that 
requirement. It was great to do that.
    Mrs. Brooks. Thank you, and I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    Pleasure to recognize the gentlewoman from New Hampshire 
who once again I want to say has exhibited terrific, very 
important leadership on the issue of opioids, Ms. Kuster, 5 
minutes of questions.
    Ms. Kuster. Thank you so much, Chairwoman Eshoo, and thank 
you again for including H.R. 2922, the Respond NOW Act, and 
H.R. 4141, the Humane Correctional Health Care Act, as part of 
today's hearing.
    I am also grateful to see our discussion include the 
Opioids Workforce Act, which I introduced with Congressman 
Schneider. This important bill would increase the number of 
physicians trained in pain medicine, addiction medicine, and 
addiction psychiatry.
    I have heard from treatment and recovery providers, law 
enforcement and first responders all across New Hampshire about 
the need for additional resources to support their efforts on 
the front line and that is why I introduced the Respond NOW 
Act, which creates a $25 billion opioid epidemic response fund.
    This bill provides those tangible sustained resources of $5 
billion a year over five years to our front line. This funding 
spans across agencies to fund programs like the State Opioid 
Response Grants and the Child Abuse Prevention and Treatment 
Act.
    This epidemic is complex and what we have learned in New 
Hampshire is there is no silver bullet approach. I call it a 
silver buckshot approach with all hands on deck, and because I 
have heard what many others can attest to, we will not arrest 
our way out of this epidemic. So that is why I introduced H.R. 
4141, the Humane Correctional Health Care Act, bipartisan 
legislation to repeal the Medicaid inmate exclusion and allow 
justice-involved individuals to access quality healthcare, 
including mental health and substance use treatment.
    Across New Hampshire we have seen the difference it can 
make to have appropriate healthcare in our criminal justice 
system. In Sullivan County in my district beginning in 2010 at 
the beginning of this crisis the jail superintendent had a 
choice to make to deal with an incredibly high recidivism rate. 
He could build a new jail for $42 million or bring treatment 
in- house for $7 million, and thankfully, he chose the latter. 
As a result, we saw recidivism in that country drop from 54 
percent down to just 18 percent, and even those a substantial 
number were parole violations. It was only six percent new 
crimes.
    That is the difference that appropriate healthcare can make 
for our most vulnerable population. We can build off of the 
success that we have seen in New Hampshire by bringing this 
model to correctional facilities across the country. I am 
pleased to see that Michigan is implementing a similar program.
    So my bill will do just that, improve access to treatment 
for justice-involved populations by allowing healthcare to 
follow the person into incarceration. We have heard in this 
committee that Rhode Island has opioid addiction treatment for 
justice-involved populations that reduced post-incarceration 
death by 61 percent. These aren't just statistics.
    These are real lives of people in our communities. If we 
are serious out overcoming addiction we must treat this as a 
disease, not a moral failing, and because let me tell you, if 
we were to design a system to fail this would be it. A system 
that strips healthcare from a person at their most vulnerable 
point. A system that leaves the crippling disease of addiction 
untreated and a system that perpetuates recidivism instead of 
prioritizing rehabilitation.
    So it is time to look at the evidence, listen to our 
communities on the front line, and end this outdated policy. I 
want to thank Chairwoman Eshoo and Chairman Pallone for 
including this bill in today's discussion. This bill presents 
our committee with the opportunity to turn the tide. I have 
seen how it works in our state.
    I would love to hear your comments on how it could work 
across this country if we eliminated the Medicaid exclusion for 
justice-involved individuals, if you have any comment.
    Ms. Brandt. I will address that, at least from the Medicaid 
perspective. We are in the process right now of finalizing 
implementation of support at Section 1001, which requires 
states to suspend, not terminate, Medicaid enrollment for 
juveniles and that is going to be finalized within the next few 
months.
    And then we also have two budget proposals, one which 
would, again, suspend, not terminate, Medicaid enrollment for 
not only all incarcerated individuals but for those covered 
under CHIP, the Children's Health Insurance Program, as well. 
Both of those would be for six months.
    Ms. Kuster. And what I am hoping is that you would consider 
supporting our bill that would take it a further step. I 
appreciate the efforts you are doing but your hands are tied. 
We need to go a further step and actually have the Medicaid 
coverage follow the individual during their incarceration so 
that they can get access for their co-occurring mental health 
and substance use.
    And so my time is up, but I do want to submit for the 
record the wonderful letters of support from all of the great 
organizations that will be on our next panel that support this 
approach.
    And I thank you and I yield back.
    Ms. Eshoo. And so ordered, and we thank the gentlewoman.
    [The information appears at the conclusion of the hearing.]
    Ms. Eshoo. Those are dramatic figures that you cited. 
Excellent. The gentlewoman yields back.
    Pleasure to recognize Mr. Griffith for 5 minutes.
    Mr. Griffith. Thank you very much, Madam Chair, and I 
appreciate having this hearing and considering one of my bills.
    Before we get to that, I do want to address some of the 
comments that were just made. And Ms. Brandt, I really 
appreciate the fact that you are working on the juvenile issue 
and suspending, because it is one of the concerns that we have 
had back home.
    When a juvenile goes into custody and then has to reapply 
when they get out, and so suspending instead of terminating 
will make a huge difference so that when that juvenile gets 
back out, we don't start the process all over again and take 
60, 90, or more days to get them back into the system to make 
sure they have their healthcare. So I appreciate that, and you 
mentioned CHIP as well. Is there anything else you wanted to 
say on that?
    Ms. Brandt. No. We do think these are important 
flexibilities that will, to your point, be able to allow these 
individuals to have that much needed coverage.
    Mr. Griffith. I am concerned about going that extra step 
and I think it is probably a good bill that Representative 
Tonko has that says we will start--for adult prisoners we will 
start the process 30 days before they are released so that if 
they are eligible for Medicaid they can--they can receive it 
but not while they are in prison.
    How much would the bill that Ms. Kuster was talking about a 
minute ago, her H.R. 4141, what would that cost if we suddenly 
took on the responsibility for all the prisoners, whether they 
be local--and most of them would be local and the state because 
we are already responsible, maybe not through Medicaid but 
through other federal coffers, to pay for medical care for 
those in federal prisons. But how much would it cost if we 
suddenly took on all the state and territory, local and state 
folks who are incarcerated and in jail for some reason?
    Ms. Brandt. That would be something, sir, where I would 
have to get back to you. But we would be happy to work with you 
all to be able to provide estimates based on our information.
    Mr. Griffith. I would assume it would be billions and 
billions of dollars. Isthat a fair assessment?
    Ms. Brandt. It would be substantial, yes.
    Mr. Griffith. Yes, ma'am. I thought so.
    Now, we are also--you know, we have been talking about a 
lot of different things and I want to make sure I get in a plug 
for a bill that I am carrying and that is--and that we are 
considering today, the Ensuring Compliance Against Drug 
Diversion Act.
    H.R. 4812 would terminate controlled substance registration 
belonging to someone who dies, ceases to legally exist, or 
discontinues business or professional practice. It would also 
require registrants to obtain written consent from the DEA to 
assign or transfer their registration.
    Can you tell us a little bit about the process of 
registering to manufacture, distribute and dispense controlled 
substances and remind us of why it is important for DEA to be 
involved in these changes to controlled substance 
registrations?
    Mr. Prevoznik?
    Mr. Prevoznik. Yes, sir. Thank you for that question.
    The current way that it works is that we work with each 
registrant to assess are they terminating, how they are 
terminating, where are they being sold, how are they being 
sold. So we work with each individual to assess that particular 
situation.
    It would be helpful to engage them more on that because 
what we do see is we are seeing some transactions in which it 
is just the actual shares are being sold. So it kind of makes 
it convoluted on who actually is owning it. So we would 
certainly work with you on that to discuss that.
    Mr. Griffith. Well, whatever you--if you have got 
suggestions now is the time to make them because I think it is 
something that is a good idea and we are going to go forward. 
But if there is something we need to tweak, let me know.
    Mr. Prevoznik. Absolutely.
    Mr. Griffith. Absolutely. We brought up--one of the members 
on the other side brought up methamphetamine. It is a serious 
problem.
    Mr. Prevoznik, I will continue with you for just a second. 
You indicated that there were counterfeits that were looking 
just like Adderall. Adderall is a prescription drug. Are we 
seeing any problems in our drug supply chain or is it just on 
the street--in the street market for Adderall?
    Mr. Prevoznik. On the street market.
    Mr. Griffith. On the street market. And are there some 
people who--we talked about how cheap it was to get these meth 
products. Is this a lot cheaper than they can get through their 
prescription--regular supply chain--the Adderall? If you 
actually had a prescription but is it a lot cheaper on the 
street?
    Mr. Prevoznik. It would depend on the supply.
    Mr. Griffith. Depend on the supply.
    Mr. Prevoznik. Yes.
    Mr. Griffith. And, Admiral, you indicated that we had a big 
supply of this--of meth coming in. I remember, you know, when 
we had a previous spike, we had what was known as shake and 
bake. People were making it themselves. Is that what we are 
seeing today with this higher quantity or higher intensity 
meth?
    Dr. Giroir. Because of the law enforcement efforts, there 
is essentially negligible production in the United States. This 
is transnational Mexican cartels that are making it on an 
industrialized basis at the hundreds of thousands of pounds per 
factory and every cartel has a number of factories and they are 
pouring into our country.
    Mr. Griffith. And what is the main way of bringing that in? 
Is it over the border or are they flying it in?
    Mr. Prevoznik. It comes from all different ways.
    Mr. Griffith. But isn't it true that most of it would be 
coming across the border in the South?
    Dr. Giroir. Yes.
    Mr. Prevoznik. That is true.
    Mr. Griffith. Thank you very much. I yield back.
    Ms. Eshoo. The gentleman yields back.
    And now I would like to recognize the gentlewoman from--oh, 
no, the gentleman from New Mexico, Mr. Lujan, for 5 minutes.
    Mr. Lujan Thank you, Madam Chair. I want to thank 
Chairwoman Eshoo, Ranking Member Burgess, Chairman Pallone, and 
Ranking Member Walden.
    I mentioned earlier that I have Lauren Reichelt, the Health 
and Human Services director for Rio Arriba County, New Mexico, 
here with us today. Lauren, thank you for your work and thank 
you for what you do.
    Five years ago, Rio Arriba County received funding from the 
state of New Mexico to establish a behavioral health investment 
zone. As part of the investment zone, her department leads an 
Opiate Use Reduction Network, which allows the various 
healthcare agencies and providers to work collaboratively to 
manage individual cases and connect patients to services.
    The network had an immediate impact in 2015 when it made 
overdose reversal drugs available throughout the county. Right 
away they saw a 30 percent drop in overdose deaths. Over the 
past few years, overdose deaths in the county have continued to 
decline.
    While ER visits for overdose initially increased because 
people's lives were saved and they were able to receive 
treatment, those numbers are now being driven down as well with 
better prevention in the community.
    Rio Arriba County was selected for this project because it 
was a national leader in overdose deaths. Now they are a leader 
in showing the rest of the nation how to address substance use 
disorder head on with a network of community supporters.
    So, Lauren, again, I want to recognize your work and that 
of your team.
    Mr. Prevoznik, you mentioned in your testimony that there 
are just over 75,000 D-A-T-A, DATA-waived practitioners who are 
authorized to provide medication-assisted treatment with 
buprenorphine. Is that correct?
    Mr. Prevoznik. Correct.
    Mr. Lujan And how does that number compare to the number of 
practitioners who are registered to prescribe controlled 
substances?
    Mr. Prevoznik. It is a much smaller percentage.
    Mr. Lujan How much smaller? A little bit? A lot?
    Mr. Prevoznik. Quite a lot.
    Mr. Lujan According to the Diversion Control Division's 
website, there are over 1,756,677 practitioner registrants, 
including over 1.3 million doctors, over 400,000 mid-level 
practitioners. We have nearly 12--and just to compare that 
number, so 75,000 on the other side, 1.7 million on the other.
    In New Mexico, we have nearly 12,000 practitioners who are 
registered with the DEA to prescribe controlled substances 
including opioids. Yet, only 1,200 who can prescribe 
buprenorphine for medication-assisted treatment. Isn't that 
something that we should fix?
    Mr. Prevoznik. Yes. I mean, it is a requirement by SAMHSA 
that they have certification for the treatment so they have to 
take the training in order to get--to be DATA-waived.
    Mr. Lujan So if there is the ability to prescribe the 
opioid, shouldn't those practitioners or others be able to also 
help treat people to prevent overdose?
    Mr. Prevoznik. Those that--those that are certified, yes.
    Mr. Lujan Well, how do we close the gap for 1.7 million to 
75,000? How do we close that gap?
    Mr. Prevoznik. Well, I mean, one of--one of the things that 
we did do that was part of the SUPPORT Act is we just passed a 
notice of proposed rulemaking for mobile NTPs so that NTPs--
that brick and mortars can now have mobile units that can go 
out to the rural areas or those areas of need so that we have 
proposed that and it is out and looking forward to comments 
from the industry on that. So that should help out some.
    Mr. Lujan And there is another piece of legislation that 
Senator Tonko and I have introduced called the Mainstreaming 
Addiction Treatment Act to eliminate the outdated requirements 
for providers to go through additional hurdles to provide the 
treatment that patients need and which are qualified to 
provide, and I hope that is an area that we can work on 
together and that the committee is willing to be supportive of 
as well.
    I urge my colleagues to support this legislation and I am 
proud to support several of the other proposals that we are 
considering here today including the State Opioid Response 
Authorization Act to make sure these crucial grants make it to 
states and the Opioid Workforce Act to create more residency 
slots for physicians to enter the field of addiction medicine.
    And lastly, just because it was mentioned, the importance 
of Project ECHO, which has been highlighted by the Office of 
National Drug Control Policy in their new action guide for 
drug-free rural communities.
    ECHO provides a telemonitoring program to train and support 
primary care providers who want to start or expand medication-
assisted treatment in their communities. It is proven to be a 
cost saver and a lifesaver. It has been expanded to the VA as 
well and I am certainly hopeful that we can continue to be 
supportive of this.
    Admiral, I see you nodding in agreement there. So anything 
you might want to add there on Project ECHO?
    Dr. Giroir. I just think Project ECHO and Dr. Sanjeev Arora 
at University of New Mexico has been transformational and a 
game changer, whether it is opioids, whether it is sickle cell 
or now they are doing ECHOs on coronavirus, it really is a gift 
from New Mexico and the University of New Mexico to the world. 
I could not be more impressed with that program.
    Mr. Lujan Glad to hear you say that. Dr. Sanjeev Arora is a 
real hero of mine and someone that I appreciate very much, sir.
    Thank you so much. I yield back.
    Ms. Eshoo. The gentleman yields back.
    A pleasure to recognize the gentleman from Florida, Mr. 
Bilirakis, whose father was chair of this Health Subcommittee 
when he served in the Congress.
    Mr. Bilirakis. Thank you.
    Ms. Eshoo. Another true gentleman. Five minutes.
    Mr. Bilirakis. Yes, he is a good man. Thank you. Thank you 
very much.
    Ms. Eshoo. Sure.
    Mr. Bilirakis. I appreciate it, Madam Chair. Thank you so 
much.
    The first question is for Mr. Prevoznik. I hope I got that 
right.
    Mr. Prevoznik. It is OK.
    Mr. Bilirakis. I will get it right the next time.
    One of the bills we are considering would eliminate the 
separate DEA registration requirement for providers prescribing 
buprenorphine for SUD treatment.
    Why does a patient limit exist today for buprenorphine and 
what is its extent post-SUPPORT Act?
    Mr. Prevoznik. So it is buprenorphine and----
    Mr. Bilirakis. Yes. Sorry.
    Mr. Prevoznik. That is OK. The requirement is actually an 
HHS SAMHSA requirement.
    Dr. Giroir. It is statutory.
    Mr. Prevoznik. Statutory as well.
    Mr. Bilirakis. OK. Very good.
    Admiral, Congress commissioned an HHS study due later this 
year in the SUPPORT Act that will include recommendations on 
where patient limits should be set.
    Does the HHS have any concerns with Congress removing this 
limit without this study idea? The data, in other words. The 
study data idea.
    Dr. Giroir. So two points, sir. The main problem we have 
are not with people bumping up against their limit but people 
not even prescribing even close to their limit. So we are 
trying to work on that set of barriers that are--that are there 
that keep people prescribing for five or ten people instead of 
120 or 130 people.
    The general concern and it is not an overwhelming concern, 
but the concern is, as all of you have pointed out, people in 
my generation or even younger do not get appropriate training 
for addiction medicine in medical schools.
    So there needs to be a gradual process as people get 
trained under a DATA waiver that eventually--now it is moving 
very quickly, that people are getting more and more training, 
there is funds to do that.
    But right now, we are sort of in that unstable period where 
we don't want to just give people the ability--it is not just 
give a pill. These are people with a chronic brain disease and 
there needs to be some training.
    It is only eight hours training, right? It is only eight 
hours of training for a physician. So we would, of course, like 
to do the study and work with you on that.
    But again, we have been focused on the main problem of 
people--only 110,000 prescribers by our data, or 70,000, have 
waivers, and they are prescribing only at a small fraction of 
their prescribing ability.
    Mr. Bilirakis. So you are saying it is mandated now in the 
medical schools that they get the training. How many hours you 
said?
    Dr. Giroir. So the DATA waiver, it is only eight hours or 
physicians----
    Mr. Bilirakis. Eight hours.
    Dr. Giroir [continue]. And, you know, that is not a big 
burden. Most states you have to do 20 or 30 hours of continuing 
education a year, and for nonphysician prescribers in general 
it is 24 hours of training.
    Mr. Bilirakis. All right. Thank you very much.
    Next question is for Ms. Brandt. What can CMS do to 
encourage or utilize nonopioid-related quality initiative 
programs to incentivize providers to use less opioids during 
pain management to decrease the long-term opioid addiction 
risk? This is a question--I mean, this affects all our 
communities, as you know. So if you could answer that I would 
appreciate it.
    Ms. Brandt. Sure. As I mentioned in my opening statement, 
one of the things we have recently done is expand coverage to 
things like acupuncture. So we are really looking to, you know, 
expand our use of nontraditional opioid alternatives.
    We also did the RFI, or request for information, in 
September of last year where we basically sought feedback on 
ways that we, as an agency, could help address the crisis and 
look particularly at, you know, what are the Medicare and 
Medicaid payment and coverage policies that have enhanced or 
impeded nonopioid treatments--where are the barriers that we 
have that we can potentially change.
    We have really been working very closely with the 
department and taking the recommendations that were discussed 
earlier from the interagency pain task force to really look at 
how we can pull our levers to try and expand our coverage as 
much as possible for these nonopioid alternatives.
    Dr. Giroir. And maybe I will just----
    Mr. Bilirakis. Yes, sir?
    Dr. Giroir [continue]. Mention that we have many ongoing 
work streams. So under CDC but being done by AHRQ, the Agency 
for Health Research and Quality, there is a report that is 
going to be published in April on nonopioid pharmacologic 
treatments to chronic pain that reviews the entire world's 
literature as well as one that talks about noninvasive 
nonpharmaceutical treatments coming in April.
    So there is going to be a whole lot more guidance coming 
out that we want to be evidence-based, right? We got into this 
problem because we didn't look at the evidence and opioids got 
over-prescribed.
    So we are trying to be very careful through CDC and AHRQ to 
make sure the best evidence is considered as we roll this out, 
again, in the spring. The spring is going to be a busy time.
    Ms. Brandt. Busy.
    Mr. Bilirakis. Very good. I am on the VA Committee as well 
and, you know, we have been exploring these alternative 
therapies for PTS and TBI but also for opioids, whether they 
are alternative or complementary, to reduce the dosage of the 
opioids.
    So we all have to work together and think outside the box 
because this is a true epidemic in this country.
    Thank you very much, and I yield back, Madam Chair.
    Ms. Eshoo. The gentleman yields back.
    It is a pleasure to recognize the gentlewoman from 
Illinois, Ms. Kelly, for 5 minutes.
    Ms. Kelly. Thank you, Madam Chair, and I thank the 
committee for holding this hearing for all the witnesses for 
being here today.
    We have all heard the statistics about the opioid epidemic 
and how it is impacting Americans. As chair of the 
Congressional Black Caucus Health Brain Trust, I have worked 
with my colleagues to create legislative and policy solutions 
to reduce health disparities and promote good health outcomes 
in all communities.
    I also think it is important to have a conversation about 
how we are making sure minority individuals with substance use 
disorder are receiving equal treatment opportunities.
    I understand that there is a number of barriers that exist 
for patient show seek to receive treatment. However, I was 
concerned to hear that some of the barriers have also 
heightened racial inequities.
    An article written last year in JAMA Psychiatry found that 
although opioid use disorder rates are similar for white 
patients and black patients, white patients received a 
prescription for medication-assisted treatment at much higher 
rates than black patients.
    Admiral, were you aware of this study when it was published 
last May and these statistics?
    Dr. Giroir. Yes, ma'am. I don't remember what date it was 
published by we are acutely aware of that, and it, clearly, is 
our position and it should be our position that this is a 
chronic brain disease.
    It doesn't matter what color you are. Everybody deserves 
medication-assisted treatment for opioids as the cornerstone of 
therapy along with all the psychosocial and other issues.
    Stigma is an issue no matter where you go and we are trying 
to work through those issues specifically not only with racial 
and ethnic minorities but also for women.
    So in my office, the Office of Women's Health and the 
Office of Minority Health, focuses on disparities across the 
board but specific efforts throughout the regions to make sure 
that MAT and other evidenced, based treatments are provided.
    I will also say that Dr. McCance-Katz, who we are all a fan 
of, is absolutely adamant that the State Opioid Response Grants 
will only support evidence-based treatment. So if you are in a 
program that doesn't offer MAT or doesn't offer meaningful MAT, 
you are not going to get funded by that.
    So anything we can do, and I would love to work with you to 
enhance those treatments for everyone.
    Ms. Kelly. A morbidity and mortality report issued last 
year by the Center for Disease Control and Prevention reported 
that opioid overdose rates for African Americans increased more 
than any other group from 2016 to 2017.
    Admiral, what do you believe are the barriers or challenges 
facing African Americans with opioid use disorder and accessing 
treatment?
     Dr. Giroir. So it is very complicated and my office tried 
to do studies as well because it is very interesting. I don't 
mean interesting in an academic way. It is really challenging 
because it is not even across the board for African Americans.
    It is really segmented into certain age groups that are 
seeing the higher rates and whether they are urban or rural, 
and all of those have different--you know, all of those have 
different challenges.
    On the urban side, particularly recognizing that many 
minorities are socioeconomically in a challenged position, we 
have been working very closely with HRSA and the community 
health center program, which I love. Now takes care of 30 
million Americans and one out of three in poverty, and they 
have made a full-court effort to integrate SUD behavioral 
health and physical all within the same environment.
    In many cases, I think they are a model for how the U.S. 
healthcare system should go forward. You know, that is one 
example on the urban side and we have been--really been 
focusing with FQHCs and, you know, rural is a whole another 
topic but happy to get into that with you as well.
    Ms. Kelly. And how do you think Congress can help HHS 
agencies manage inequities and treatment access? What more can 
we do?
    Dr. Giroir. So, you know, that is a--that is a big 
question. Number one, we need to--we need to take care of 
treatment across the board, right--across the board.
    We are also--so number one. Number two, we do need a 
workforce and that is critically important, and as you know, 
the workforce tends to be disproportionately not in areas where 
minorities are in rural.
    So, for example, funding the Addiction Medicine Fellowships 
that are proposed, we think that is very important. And I just 
want to make the point is it is not--it is OK to train 
addiction psychiatrists. We need that. But we need a lot of 
primary care practitioners who work in rural, just internists, 
OB/Gyns, to get that one year of addiction training, because 
they are really on the front lines and we are trying to incent 
that with the National Health Service Corps, with HRSA loan 
repayments, a $5,000 incentive if you get your DATA waiver--all 
those kinds of things.
    So I would say that still workforce is a real issue as well 
as parity and reimbursement through systems like Ms. Brandt's. 
I mean, that is very important. If you have the workforce but 
you don't have the appropriate reimbursement for care, you are 
not going to have a long-term solution.
    Ms. Kelly. And through the Brain Trust we try to make sure 
that we are pushing for a diverse workforce. And lastly, I just 
want to say to Ms. Brandt I totally believe in acupuncture. I 
had a pinched nerve and that is the only thing that worked. So 
good luck.
    Ms. Brandt. Thank you. My mother was also very happy about 
that.
    Dr. Giroir. You can now be covered under Medicare for that 
once you get to that age. Yes.
    Ms. Kelly. I am not far away.
    [Laughter.]
    Ms. Eshoo. Well, thank God you are feeling terrific. We 
need you.
    The gentlewoman yields back, and now I will recognize the 
gentleman from North Carolina, Mr. Hudson, for his 5 minutes.
    Mr. Hudson. Thank you, Madam Chair. Thank you for holding 
this important hearing and thank you to our panel for the great 
work you do every day. Thank you for your time being here with 
us.
    Congress took strong bipartisan action in 2018 to combat 
opioids epidemic but I have always believed that that was the 
first step. In North Carolina, we have four of the top 25 worst 
cities for abuse in the country, one of which is in my 
district, the city of Fayetteville.
    This issue is personal for me. It is personal for my 
constituents, just as I know it is personal for everyone in 
this room. I believe this hearing gives us a good opportunity 
to examine what we have done and what the next steps are.
    Admiral Giroir, I understand that as a senior advisor for 
opioid policy at HHS you are responsible for coordinating the 
department's response to the opioid epidemic. I know the 
primary focus of today's hearing is on treatment and recovery, 
but I have had many providers in my office tell me that 
prevention is often the best treatment.
    As we discussed in this committee before and you and I have 
discussed, most addictions start in the medicine cabinet. 
Getting unused medications out of the home in a safe and timely 
manner is critical, particularly if a household has teenagers 
or other susceptible family members.
    Unfortunately, federal disposal recommendations are 
inconsistent, ineffective, and out of date. Let me just go over 
a few points that have been a concern to me.
    First, we need consistent messaging out of HHS. For 
example, FDA includes a list of drugs that could be flushed 
down the toilet, including fentanyl. SAMHSA discourages this 
practice altogether.
    Second, we need someone to review the adequacy of the 
current federal recommendations. I understand GAO put out a 
report in September highlighting that very few people actually 
follow the federal recommendations.
    And third, it has been over a decade since these federal 
recommendations have been updated. And so given all those 
issues, I do believe it is appropriate to advise people to 
mix--I don't believe it is appropriate to advise people to mix 
their pills with kitty litter, as it says on one of the 
websites, or coffee grounds, and I know there are better 
options for in-home disposal that we could--that we could talk 
about instead.
    Can you commit to me to look in these issues and get back 
to me on sort of the next steps on trying to address these 
disparities?
    Dr. Giroir. Yes, sir. I absolutely do. It is an area that 
we really do need to work on. We focused on take back days and 
other things that we know have been highly effective.
    But it is not just in HHS. There is DEA and many agencies 
involved with this. And yes, sir, I will do that and I think 
that is a really good direction for us to move in the next 
level.
    Mr. Hudson. I appreciate that and, sir, from DEA's 
perspective do you--interested in commenting?
    Mr. Prevoznik. Absolutely. We would certainly work with 
you, yes.
    Mr. Hudson. OK.
    Mr. Prevoznik. And we want to make April 25th as the next 
Take Back Day. So----
    Mr. Hudson. April 25th?
    Mr. Prevoznik. -- Get it out of the cabinets.
    Mr. Hudson. Absolutely. Well, thank you. I appreciate that.
    Ms. Eshoo. Mr. Prevoznik, I can't--I am losing some of your 
words and I think they are important for everyone to hear. Can 
you just answer the gentleman's question again?
    Mr. Prevoznik. Yes. The next--I just want to put a plug in 
there that the next National Take Back Day is April 25th.
    Ms. Eshoo. I see.
    Mr. Prevoznik. So please get that medicine out of your 
cabinets.
    Mr. Hudson. That is great. Madam Chair, I think it is 
important we continue to promote that. But I think it is also 
important that we look at these federal recommendations and 
make sure they make sense. Make sure that different agencies 
don't have, you know, guidance that contradicts other agencies' 
guidance and that we are giving the best information to folks.
    Ms. Eshoo. Well, it is wonderful that you are pointing out. 
I wasn't even aware of it. So thank you.
    Mr. Hudson. With that, I will be happy to yield back.
    Ms. Eshoo. You still have some time. Do you want to yield 
time to someone?
    Mr. Hudson. If anyone would be interested in the time I 
would be happy to yield.
    Ms. Eshoo. Can I take 10 seconds?
    Mr. Hudson. Please.
    Ms. Eshoo. Does anyone on the panel know--Medicare has been 
referenced more than once in our hearing this morning. Do you 
know what the addicted population of Medicare beneficiaries is 
in our country?
    Ms. Brandt. We can get back to you with an exact number on 
that, ma'am. But of our Medicare Part D or our drug coverage 
beneficiaries it is a fairly small but meaningful percentage 
that we definitely focus on.
    Ms. Eshoo. That we what?
    Ms. Brandt. It is a--it is a small percentage of our Part D 
beneficiaries. But I will get you the exact number. I would be 
happy to get back to you with that exact----
    Ms. Eshoo. Because there was a lot of emphasis about 
benefits and what they need in the Medicare population, and, I 
mean, I think Medicaid is the main player in this. But I would 
appreciate getting that information.
    The gentleman yields back. Thank you.
    The Chair is pleased to recognize the gentleman from 
Maryland, Mr. Sarbanes, for 5 minutes.
    Mr. Sarbanes. I thank--thank you, Madame Chair, and thank 
you too to the panel.
    Admiral, you started to speak a moment ago. I want to pick 
up on this topic of the workforce because I think it is really 
critical and, you know, we can put resources behind expanding 
our capacity in terms of the general delivery framework that we 
have to address this crisis.
    But if we don't have the professionals in place to actually 
deliver the care then that, obviously, is going to impede 
progress on our efforts.
    Two years ago, and this is--the workforce issue is 
something I have brought some special attention to in my time 
here in Congress, even going back to the passage of the ACA and 
pushing the idea of developing a national healthcare workforce 
commission to kind of look at where the shortages are.
    But two years ago, I joined my colleagues, Katherine Clark 
and Hal Rogers in introducing the Substance Use Disorder 
Workforce Loan Repayment Act. So that is a bipartisan bill that 
would help increase a number of healthcare professionals 
working in addiction treatment in substance use disorder 
programs around the country by offering student loan 
forgiveness when they provide direct patient care at opioid 
treatment programs, and then that bill was included in the 
SUPPORT Act, I am glad to say.
    I am also a co-sponsor of one of the bills that we are 
looking at today, which is H.R. 3414, the Opioid Workforce Act. 
We know many communities across the country are facing 
shortages of these kinds. Professionals lack access to the 
services they need as a result.
    This is especially true, as you know when it comes to 
mental health and substance use disorder providers, and in 
addition to the affordability the provider capacity is clearly 
a barrier to treatment.
    H.R. 3414 would help expand treatment by growing the 
provider workforce. It would make a thousand new graduate 
medical education slots available under Medicare. Those slots 
would be targeted towards training providers in addiction 
medicine, addiction psychiatry, pain medicine, or prerequisites 
of those programs.
    So I will just give you the opportunity maybe just to speak 
broadly about the importance of meeting these workforce needs, 
where you seen the bottlenecks. Another kind of iteration of 
this, a kind of second-degree issue relates to you can put 
money in programs in place to train providers but then finding 
the folks that can deliver the training sometimes also can be a 
challenge.
    So how do we make sure that we fill these gaps in terms of 
the workforce and to the extent you would kind of prioritize or 
triage that effort, can you speak to that as well?
    Dr. Giroir. So thank you, sir, and this is--this is a 
critically important long-term issue. This is not a put a Band-
Aid on it but this is how we sustainably begin to fix the 
system.
    There are shortages of psychiatrists for mental illness and 
shortages of addiction psychiatrists. There are also shortages 
across the board. Being a physician, I can say don't just focus 
on physician training.
    It is social workers. It is community health workers. It is 
peer counsellors and peer coaches, all the--all the different 
aspects that you need. What we have done is a couple of things, 
number one, and you will be seeing this coming out this year.
    We have asked, and HRSA has been working very much on not 
just, like, drawing the line. Like, so many psychiatrists die 
this year and we will draw a line on how many need to come. But 
what is the impact of the new models of care and what is the 
impact of things like telemedicine on changing the entire model 
and how do we move the workforce to that--just to park that.
    Secondly, we have focused on ancillary providers through 
the National Health Service Corps, you know, nurses, you know, 
all the healthcare providers that are non-physician.
    But, again, I do want to say that the addiction medicine 
fellowships, we are very excited about that because it brings 
people--like, if you want to decrease neonatal abstinence 
syndrome, let us train obstetricians to have a year of 
addiction medicine so they can provide the treatment that is 
right there.
    Pediatrics--you know, a lot of this starts in--I am a 
pediatric ICU doctor in 14, 15, of 16 years of age. So we are 
very bullish and I think there is broad support in the 
community to supply these kinds of one-year fellowships and you 
could imagine a family practice group that may have eight 
physicians and two are trained in addiction medicine. It really 
changes the way how we deliver care.
    So but you can really say all of the above, sir. We really 
need all of the above types of professionals because they will 
help not only in opioids but in methamphetamine, in alcohol 
addiction, in marijuana addiction, all the kinds of things that 
our society faces. This truly--if we get the workforce right 
and we get the model right and we get the incentive payments 
right, this will work out in the long term.
    Mr. Sarbanes. Thanks very much.
    Yield back.
    Ms. Eshoo. The gentleman yields back.
    Please to recognize the gentleman from Georgia, Mr. Carter, 
for 5 minutes.
    Mr. Carter. Thank you very much. I thank all of you for 
being here.
    Ms. Brandt, I am going to start with you. I need to 
understand exactly the rule proposals, the rule changes that 
you are proposing. If someone is incarcerated, their Medicaid 
would be suspended for 60 days and then reinstated?
    Ms. Brandt. Six months, sir.
    Mr. Carter. Six months?
    Ms. Brandt. It would be for six months.
    Mr. Carter. OK. How do you--is it six months or less or is 
it--I mean, how do you determine how long somebody--is that he 
usual sentence or what?
    Ms. Brandt. So it's a great question and we came up with 
six months because there were a number of people whose 
sentences were less than the six-month period of time. Usually, 
it's much more serious types of things that would incarcerate 
them for longer than that.
    Mr. Carter. If they are less than six months and they get 
out after three months, they got to wait three months before it 
kicks back in?
    Ms. Brandt. No, it's up to six months.
    Mr. Carter. Up to?
    Ms. Brandt. Up to six months.
    Mr. Carter. OK.
    Ms. Brandt. So that way, we give them that flexibility.
    Mr. Carter. OK. All right. And let me--let me say that I 
know what a big problem this is. I have been to the jails 
visiting them. I know what a struggle they are having paying 
for these anti- psychotics, paying--and I can see the value 
that this would have.
    However, I wanted to ask you specifically about 4141, the 
Humane Correctional Health Care Act. Do we--and you have been 
asked this in this hearing--do we have any idea how much that 
would cost?
    Ms. Brandt. You know, that particular provision actually 
would not impact us at CMS but we don't have--I don't have a 
good number----
    Mr. Carter. It is going to impact somebody in the--I don't 
need to hear that it is not going to impact me so I am washing 
my hands of it.
    Ms. Brandt. No, absolutely. No, and we would be happy to 
work with you to give us any data we have----
    Mr. Carter. Well, as I understand it, the bill has got--
part of the bill in there is to do a study to see how much it 
would cost. But it seems to me like that is after the fact.
    I mean, if we were to implement this and then find out how 
much it costs, this is going to be billions upon billions of 
dollars that we are looking at here. And what about the impact 
on the state? The states is going to--the states are going to 
have to take up their part of it as well. This could bankrupt 
some of these states.
    Ms. Brandt. Again, we share your concern. That is why our 
budget proposals are up to six months and happy to work with 
you to provide whatever information and data we can.
    Mr. Carter. OK. Good. If I could switch over to Mr. 
Prevoznik.
    Mr. Prevoznik, I was a practicing pharmacist for over 30 
years and while I was serving in the Georgia state Senate I 
sponsored the legislation that led to the establishment of the 
Prescription Drug Monitoring Act. I have seen what a problem 
this is.
    But I have also been a frustrated pharmacist because, over 
the years, I have reported physicians whose practices--whose 
prescribing habits in their practices have been questionable. 
Reported it to the DEA as a number of pharmacists have only to 
get no response whatsoever.
    I just want to ask you has that changed any? Are you 
helping pharmacists now to identify those physicians that are 
out of control and to try to get them under control?
    Mr. Prevoznik. That is a great question and I appreciate 
that. As a diversion investigator, when I heard from a 
healthcare professional such as a pharmacist, that 
unequivocally sent all the tentacles up on the back of my neck 
that this is very important because this is a pharmacist who 
knows the community, he knows the practice of medicine. When 
they say, what are you doing about Dr. Candyman--the candyman--
what are you going to do about this, you have our undivided 
attention on that.
    As a law enforcement agency we--well, sometimes we cannot 
come back to you to talk about the investigation because we are 
investigating the candyman or whoever you are presenting as a 
person who is diverting.
    I can't overemphasize how important your voice is and that 
the pharmacists do need to speak up and let us know what is 
going on because you do have the pulse of that community.
    Mr. Carter. And you see what a difficult position--and I 
can appreciate the fact that you can't always communicate with 
us what is going on. You are, obviously, building a case.
    But at the same time it puts us in a precarious position as 
well because we don't know whether to fill the prescriptions or 
not fill the prescriptions and, you know, I have always said 
the only thing worse than filling a prescription for someone 
who doesn't need it is not filling a prescription for someone 
who does need it.
    Now, having said that, I want to ask you this. I am 
continuing to get calls now at home, I get them in my office, I 
get them from constituents, I get them from people who know 
that I am the only pharmacist currently serving in Congress.
    But they want to know, there is a problem here with some of 
these people who do need this medication getting this 
medication. I think it was mentioned earlier that we are trying 
to help soften that blow, if you will.
    But we get calls. It was always my fear and I tried to 
communicate this and articulate it to my colleagues, we got to 
be careful how far we swing that pendulum. Now we have got 
people out there who truly need these medications who can't get 
them and that is creating a big problem.
    Admiral, are we addressing that?
    Dr. Giroir. Yes, sir. It is one of our biggest concerns. We 
have heard from, you know, hundreds of patients if not 
thousands about patient abandonment or too abrupt 
discontinuation of opioids and when you have an opioid use 
disorder and your opioids get taken away what do you do? You go 
to the streets because if I can ask you to stop breathing for 
ten minutes you can ask them to stop cold turkey.
    So we put out--the CDC and my office put out guidance. We 
published it in the literature. We are referencing that all the 
time in order to make sure that, you know, if you do this do 
this very slow and in a patient- centric noncoercive way, and I 
just want to echo how important--we can swing the pendulum to 
the other direction and I think we have kind of gone too far, 
at least for many patients in a significant way.
    Mr. Carter. Absolutely. Well, again, I want to thank all 
three of you for what you are doing. This is extremely 
important. I witnessed this firsthand when we were at the 
epitome of this and I have seen improvements and it is 
encouraging.
    So thank you, and I yield back.
    Ms. Eshoo. Gentleman yields back.
    Pleasure to recognize the gentlewoman from Delaware, Ms. 
Blunt Rochester, for 5 minutes.
    Ms. Blunt Rochester. Thank you, Madam Chairwoman, and thank 
you so much to the witnesses for this very important hearing 
today.
    Our nation's ongoing overdose crises isn't represented by 
one community, one region, or one socioeconomic class. We are 
all being touched.
    I am proud to have worked with my colleagues to address the 
rise of overdose deaths by passing the 21st Century Cures Act 
and the Support for Patients and Communities Act.
    Despite these efforts, Delaware continues to be in the 
middle of a public health crisis. As our nation's overdose 
death rate dropped for the first time in two decades, my state 
remained fifth in the nation due to higher rates in 2018 and 
2017.
    Looking at the highest age- adjusted drug overdose death 
rates in 2018, Delaware is second in the nation. Those aren't 
just numbers. It means we are losing someone every 22 hours to 
an overdose.
    The rise in synthetic opioids is playing an increasing role 
in overdose deaths. In 2009, almost all of Delaware's overdose 
deaths were due to prescription opioids like oxycodone. 
However, in 2017, synthetic opioids contributed to 72 percent 
of our 400 overdose deaths.
    As our committee continues to combat the opioid epidemic, I 
look forward to working with my colleagues on a comprehensive 
public health response to the proliferation of synthetic 
opioids.
    My first question is to you, Admiral, and I just want to 
follow up on Ms. Kelly's line of questioning. You got a chance 
to talk about the urban area. Delaware is urban, suburban, and 
rural, and I was hoping that you could speak specifically to 
the unique challenges and solutions for rural communities.
    Dr. Giroir. Yes, ma'am. So rural communities have a whole 
plethora of issues. Some are the same and some are different. 
If you look at many of the rural areas they have higher 
prescribing but many people are also--have jobs that take a 
toll on your bodies, right, so you are in chronic pain.
    So it really goes that way. So they have that problem. We 
find that in rural areas actually the economic issues are more 
important than provider issues for neonatal abstinence 
syndrome.
    Urbanly, it is providers. Rurally, it is actually the 
socioeconomic issues and opportunity. But I think we all know 
that provider shortages in the rural area is really the 800-
pound gorilla in the room and the way to solve that is, of 
course, increasing providers, National Health Service core 
issues like that and trying to bring people to under-served 
areas. And I can't--I can't overestimate--I can't over 
emphasize the importance of things like telemedicine.
    Telemedicine for MAT is really a game changer because it 
allows people who may not have a DATA-waived provider to gain 
access to that provider remotely and I would personally like to 
see as many efforts as possible to enhance telemedicine--
telemedicine reimbursement across the board.
    Ms. Blunt Rochester. Thank you. I appreciate that CMS has 
also taken steps to increase the capacity of Medicaid providers 
to deliver substance use disorder treatment through funding 
grants authorized by the SUPPORT Act.
    Delaware was fortunate to be one of the 15 states to 
receive a planning grant. Sixty percent of Delawareans who died 
from an overdose in 2017 were Medicaid eligible the previous 
year.
    We know that the Agency for Healthcare Research and Quality 
will consult with CMS to report back to Congress on the 
experiences of states who were awarded planning grants.
    Ms. Brandt, I would like to ask if you would just pay 
particular attention to how states dealt with one of the 
greatest barriers that has been discussed here today, which is 
providers' lack of willingness to treat SUD because of stigma 
and also knowledge gaps. If I could just have you confirm that 
that will be a focus.
    Ms. Brandt. We will certainly take that into account, 
ma'am.
    Ms. Blunt Rochester. And, Ms. Brandt, also additional 
statutorily-required reports in these will CMS track or measure 
whether physicians who receive a waiver through the grant are 
actively prescribing or treating at the patient capacity they 
are currently allowed.
    Ms. Brandt. I will have to get back to you to confirm that. 
But I will certainly take it back to make sure whether or not 
that will be our requirement.
    Ms. Blunt Rochester. I only have about ten seconds, and one 
of the things that I did want to ask about and I will follow up 
on is the ability for physician assistants and nurse 
practitioners to prescribe buprenorphine and I want to make 
sure that states don't have laws that are preventing us from 
this expanded opportunity. So we will follow up with you 
afterwards. But thank you so much and I yield back the balance 
of my time.
    Ms. Eshoo. The gentlewoman yields back. It is a pleasure to 
recognize the gentleman from Montana, Mr. Gianforte, for 5 
minutes.
    Mr. Gianforte. Thank you, Chairwoman Eshoo and Ranking 
Member Burgess, for holding this hearing today. This is a very 
important topic, and thank you for the witnesses for being here 
for this ongoing discussion of the opioid and substance abuse 
issues that are facing--crisis that is facing our country.
    This committee has a successful history of working together 
to respond to this issue. In 2016, we passed the CARE Act and 
the 21st Century Cures Act. In 2018, the committee followed 
that with the SUPPORT Act.
    These laws expanded substance abuse disorder treatment 
funding for treatment recovery and prevention, the expanded 
Medicaid and Medicare coverage for medication-assisted 
treatment, and Congress has continued to fund these treatment 
and prevention programs with billions of dollars.
    The funding was also made available for stimulant treatment 
programs like those that treat meth addiction. Meth is the 
largest substance abuse issue in Montana, accounting for a 
majority of our substance--our addiction cases.
    I am glad that we have this panel here today to discuss the 
ongoing implementation and outcomes of these efforts. I think 
we need more of that and I wish we could have a full committee 
hearing on this effort.
    I am somewhat less excited about some of the new 
legislation that is also the topic of this hearing. H.R. 2292 
creates a new $5 billion mandatory grant program. It also 
permanently extends what was meant to be a temporary waiver of 
authority to prescribe opioid treatment medication. That may be 
useful and we should certainly consider it. But the current 
waiver does not expire until 2023. So we might best focus our 
efforts elsewhere.
    I can appreciate also the desire to ensure that our state 
and tribal health agencies have the resources they need. I saw 
this firsthand.
    Last month I spoke to a group of students in Montana at a 
trade school. There were about 50 of them. Many, if not most, 
had experienced the heartbreak of substance abuse addiction 
either directly or in a family member.
    I heard their stories. They included family separations, 
incarceration, and the death of loved ones. It was in their 
eyes. The pain in the room was palpable.
    One gal told me that it was easier for her to get meth on 
the street than it was to get treatment, even when she was 
looking for treatment. Another young man recounted being 
permanently separated from his brother due to the addiction of 
his parents and even as a young man now has not been reunited. 
Doesn't know the whereabouts of his brother.
    Drugs are ripping our communities and families apart and we 
must make sure we get this right.
    Admiral, a question for you. You are currently senior 
advisor for the opioid policy at HHS and I appreciate that HHS 
has a website dashboard to track the stats on the funding, 
treatment providers, overdose deaths and other metrics, 
tracking results as a basis for evaluating success or failure 
of these programs. Where do you feel the department has been 
most successful in working to deal with the opioid crisis?
    Dr. Giroir. For the opioid crisis specifically, I do think 
the overall--the overall approach to approaching it as a public 
health issue, that is the underlying philosophy that people 
need treatment and you are not going to get well unless you get 
treatment. That is the number-one issue.
    Number two, emphasizing medication-assisted treatment as 
well as other evidence-based forms of treatment. But we still 
have a long way to go. There is absolutely no question about 
that.
    One point three million on MAT is good but we still have a 
long way to go and, as you know, for methamphetamine, our 
treatment is--can be effective but it is just behavioral. We 
don't have any medications to support that treatment right now.
    So we really are on a full-out dash with FDA and NIH trying 
to develop adjuncts to therapy that could be as useful as 
buprenorphine is for opioids.
    Mr. Gianforte. OK. My colleague just asked you about rural 
substance abuse and that is, certainly, an issue in Montana. I 
want to ask you to spend a minute just talking about the unique 
challenges in Native American tribal environments.
    We have about seven percent of our population is Native 
American and the substance abuse issues there are chronic and I 
am just interested in what you--what you have learned and what 
resources you are applying to that problem.
    Dr. Giroir. So today we are releasing $50 million in tribal 
opioid response grants which are going to be flexible because 
of the Congress's action to use on methamphetamines. So that is 
going to give a very good boost to the tribes to be able to use 
that money flexibly.
    I met with the secretary's Tribal Advisory Committee maybe 
two or three weeks ago and we spoke specifically about some of 
the issues, and some of the--you know, we have to meet people 
where they are and understand what the best solutions are.
    One thing that we are, clearly, doing is trying to--and 
there's a program out of my office--using community health 
workers in tribal settings, right, because often you need to 
bring the care to the people instead of the people to the care, 
and our preliminary evidence is that is really very successful.
    But we are trying to work--you know, a tribe in Alaska is 
very different than a tribe in Montana, trying to be, you know, 
very specifically geared to the solutions that they need and we 
have an ongoing dialogue. I meet with Admiral Weahkee at least 
every couple of weeks trying to----
    Mr. Gianforte. Admiral, I would just ask that if you could 
follow up with my office on any specific substance abuse 
programs for rural or tribal. We would like to stay in touch on 
that.
    Dr. Giroir. Absolutely, yes.
    Mr. Gianforte. And with that, Madam Chair, I yield back.
    Ms. Eshoo. Gentleman yields back.
    A pleasure to recognize the gentleman from New York, Mr. 
Engel, for 5 minutes.
    Mr. Engel. Thank you, Madam Chairwoman, for holding today's 
hearing on the drug epidemic plaguing our communities. In my 
home state of New York, opioids alone claimed 3,000 lives in 
2017.
    Last Congress, this subcommittee led the efforts to deal--
to draft the legislative response to this ongoing public crisis 
which culminated in the enactment of the Support for Patients 
and Communities Act.
    This package included my bipartisan Results Act, which 
directs the National Mental Health and Substance Use Policy 
Laboratory to issue new guidance to applicants seeking federal 
funding to treat and prevent mental health and substance abuse 
disorders.
    Support For Patients and Communities Act was an important 
step forward. It lacked the federal funding necessary to expand 
access to treatment. To that end, I am a co-sponsor of the 
comprehensive Addiction Resources Emergency Act, which would 
provide $100 billion to combat the drug epidemic. This epidemic 
also disproportionately affects communities of color, which 
face additional barriers and challenges in accessing treatment.
    I am working on legislation which would direct the 
Department of Health and Human Services to commission a study 
that would look at ways to expand access to substance use 
disorder treatments in minority and under served communities. I 
look forward to hearing from our witnesses on the federal 
government's ongoing response to this crisis and ways that we 
could strengthen it.
    My home state of New York is one of the leading states for 
training physicians. Training hospitals in my state constantly 
tell me we need additional residency training slots in the 
field of addiction medicine to promote access to substance use 
disorder treatments.
    The Opioid Workforce Act, which I have co-sponsored and is 
under consideration today would increase the number of 
federally-supported residency slots in addiction medicine, 
addiction psychiatry, and pain medicine by a thousand over five 
years.
    Admiral Giroir, I hope I am not ruining your name too much. 
I apologize.
    Dr. Giroir. It is all good. I respond to anything. It is 
great, sir.
    Mr. Engel. I know before you spoke about Cajun accents. So 
I figured when it gets to be my turn am I going to blow it. Do 
you agree, sir, that we need additional providers in these 
specialties?
    Dr. Giroir. Absolutely.
    Mr. Engel. Thank you. The ongoing drug epidemic has had a 
tremendous impact on children, whether it is witnessing their 
parents overdose on opioids or being torn away from their 
families and put into foster care.
    Admiral, let me ask you again and let me also ask Ms. 
Brandt. What efforts have your respective agencies take--are 
your respective agencies taking to ensure that children who 
have experienced trauma as a result of this crisis are getting 
access to the services and supports they need?
    Ms. Brandt. So, sir, Admiral Giroir has deferred to me to 
answer at least a couple of these. So one of the things that we 
have done is I mentioned in my opening testimony about our MOM, 
Maternal Opioid Misuse model, where we are looking to allow for 
more coordinated care and support for mothers, particularly 
post-partum, when their children have neonatal abstinence and 
when they themselves have addiction problems.
    We also, and accompanying with that, gave grants to a 
number of states for what we call Integrated Care for Kids, or 
InCK model, where it actually allows for things like 
occupational, behavioral, and physical health services to be 
covered. So the full suite of wraparound services to really be 
able to treat children with those addiction issues.
    Dr. Giroir. I wanted her to highlight that because I am 
very, very positive about those programs. We are also trying--
and think it is an important point. As a pediatrician, I would 
be remiss to say that a child with neonatal abstinence syndrome 
is not well once they become nondependent.
    We now have good data that over the long term they will 
have continuing issues and it is really the responsibility of 
our society to nurture them through their childhood, make sure 
they get the interventions they need. So we have a very 
specific program trying to create the long-term data that we 
can have to support these children so they can overcome that 
neonatal experience that we know stays with them for many 
years.
    Mr. Engel. Well, thank you both for the good work you are 
doing. And thank you, Madam Chair. Since you have been chair of 
this subcommittee you have done so many important and wonderful 
things and, of course, this ranks with them as well. So thank 
you.
    Ms. Eshoo. I thank the comments of the gentleman. We are 
all here to give and do for our country and this subcommittee 
has--is front and center with some of the really challenging 
public health issues. So we have to keep the pedal to the 
metal.
    And now, not seeing any other members, the gentleman from 
New York, Mr. Tonko, is here. He is waiving on to our 
subcommittee and we are very--I am really pleased that he is 
here. He has been very important in this--in this battle to 
address opioids in our country. So welcome to our committee and 
you have 5 minutes to question.
    Mr. Tonko. Thank you, Madam Chair, for your focus. Thank 
you for allowing me to waive on.
    Admiral Giroir, I championed a provision in the SUPPORT Act 
based on my Medicaid Reentry Act which we are considering today 
that aimed to improve care coordination for Medicaid-eligible 
individuals who are reentering the community post-incarceration 
as this group is particularly vulnerable to opioid overdose, 
dying at a rate of 120 times that of the general population in 
the first two weeks post-release.
    Section 5032 of the SUPPORT Act required HHS to convene a 
stakeholder group with a deadline of April 2019 to develop best 
practices on smoothing healthcare transitions including best 
practices for ensuring continuity of health insurance coverage 
or coverage under the state Medicaid plan for individuals 
reentering the community post-incarceration.
    Has HHS convened this stakeholder panel?
    Dr. Giroir. The answer is it is in process but we received 
guidance from our Office of General Counsel that this is a 
FACA. So we have to go through all the FACA processes to what 
delayed it. But I want to get back to your point. We actively 
need to work with this population because we recognize that 
they are at high risk and there is specific guidance that we 
have already delivered. But yes, sir, that is not up and 
running. It is in the FACA process.
    Mr. Tonko. OK. And let me just make the point that it is 
pretty concerning that you have missed a deadline by almost a 
year at this point. Can you commit to when we might see 
additional action on this? Quickly, so I can move on.
    Dr. Giroir. I am going to have--we will--we will--I will 
get back to you on that.
    Mr. Tonko. Thank you. Thank you.
    Administrator Brandt, similar to the provision described to 
Admiral Giroir, Section 5032 of the SUPPORT Act also required 
CMS to publish by October 2019 guidance to state Medicaid 
directors on how they can pursue 1115 waivers to provide 
coverage to Medicaid-eligible individuals 30 days prior to 
release from a public institution.
    My home state of New York is currently applying for a 
Medicaid waiver in this space and because this guidance hasn't 
been issued by CMS I am concerned that they don't have a 
roadmap for how CMS will ultimately evaluate their request.
    Despite the missed deadline, do you have a time line for 
when this guidance is expected to be published?
    Ms. Brandt. Thank you, sir, and appreciate your concern. We 
are working closely with the department because the stakeholder 
group that the Admiral mentioned is critical for the feedback 
for us to be able to use that to be able to have the data 
needed to issue the letter.
    Mr. Tonko. Well, these are critical deadlines that have 
been missed, and so I strongly encourage that we meet them 
quickly. Thank you.
    Let us--moving on to another issue, one of my top 
priorities in this epidemic has been to move to a system of 
treatment on-demand for the disease of addiction, ensuring that 
when an individual has that moment of clarity and is ready to 
seek help that we have a medical system ready to meet the need.
    One of the limiting factors holding us back for treatment 
on demand is that we have institutionalized through law this 
concept that medications for addiction should somehow be 
treated differently than those for other chronic diseases, even 
when there isn't any underlying safety profile to medications 
like buprenorphine that merits this special treatment.
    We can see this legal stigma clearly through a medication 
like buprenorphine, which provides--which providers can freely 
prescribe without jumping through additional hoops for the 
treatment of pain. But for some reason, when it comes to the 
treatment of addiction, providers have to seek a special waiver 
from the DEA and complete onerous training and paperwork 
requirements.
    If there were any other medication for any other disease 
that reduced mortality by up to 50 percent we would be doing 
everything in our power to make certain that it was an easy to 
access--was as easy to access as possible.
    Admiral Giroir, are you familiar with the report from the 
National Academies of Science, Engineering, and Medicine from 
March of 2019 entitled, ``Medications for Opioid Use Disorders 
Save Lives?''
    Dr. Giroir. Absolutely.
    Mr. Tonko. So, as you know, some the major conclusions of 
the report were there, and I will repeat, opioid use disorder, 
is a treatable chronic brain disease. FDA-approved medications 
to treat opioid use disorder are effective and save lives.
    A lack of availability or utilization of behavioral 
interventions is not a sufficient justification to withhold 
medications to treat opioid use disorder. Most people who could 
benefit from medication-based treatment for opioid use disorder 
do not receive it and access is inequitable across subgroups of 
the population, and confronting the major barriers including 
existing laws and regulations for the use of medications to 
treat opioid use disorder is critical to addressing the opioid 
crisis.
    So, Admiral, do you have any reason to disagree with the 
principal conclusions of the National Academies study?
    Dr. Giroir. Those conclusions I not only generally agree 
with but use. The only thing I don't agree with is the fact 
that we have made so much progress. About 1.3 million people 
are now on MAT, about two million people--with opioid use 
disorder.
    So some of the statistics are older. But in general, of 
course, MAT is important and we support it. It needs to be 
available to everyone who had opioid use disorder.
    Mr. Tonko. So you do agree with the principal conclusions?
    Dr. Giroir. From what you just said, yes. I am not 
commenting on the data waiver and whether that should be 
waived. That is a very complicated and important issue. But 
those conclusions I do agree with.
    Mr. Tonko. Well, thank you very much, and let us move on 
and fight this illness of addiction.
    With that, I yield back.
    Ms. Eshoo. I thank the gentleman for the work that he has 
done. I want to thank the witnesses for not only being here 
today, answering our questions, your willingness to answer 
written questions that will be submitted to you by members and 
answering them in a timely way.
    This concludes the first panel and I want to ask the staff 
to ready the table for the second panel of witnesses, and I am 
going to step out to a meeting and Congresswoman Annie Kuster--
no, women are in charge, Doctor.
    [Laughter.]
    Ms. Eshoo. Congresswoman Kuster is going to chair until I 
return and I want to thank her in advance for her willingness 
to do that. Thank you again to you.
    Ms. Brandt. Thank you.
    Ms. Eshoo. Keep the pedal to the metal.
    [Whereupon, the above-entitled matter went off the record 
at 12:52 p.m. and resumed at 12:57 p.m.]
    Ms. Kuster [presiding]. Good afternoon. We will now hear 
from our second panel of witnesses on this critically important 
issue.
    I would like to introduce Mr. Michael Botticelli, executive 
director, Grayken Center for Addiction from Boston Medical 
Center; Dr. Smita Das, clinical associate--assistant professor, 
psychiatry and behavioral sciences, Stanford University School 
of Medicine; Ms. Patty McCarthy, chief executive officer, Faces 
and Voices of Recovery; Mr. Robert Morrison, director of 
legislative affairs, National Association of State Alcohol and 
Drug Abuse Directors; Ms. Margaret Rizzo, executive director, 
ISAS Health Care, Inc.--JS, excuse me. I am so sorry. JSAS 
Health Care Inc. And Dr. Shawn Ryan, president and chief 
medical officer of Brightview.
    Thank you to our witnesses for joining us today on the 
second panel and we look forward to our testimony--to your 
testimony.
    Mr. Botticelli, you are recognized for 5 minutes.

 STATEMENTS OF MICHAEL BOTTICELLI, EXECUTIVE DIRECTOR, GRAYKEN 
  CENTER FOR ADDICTION, BOSTON MEDICAL CENTER; SMITA DAS, MD, 
   PHD, MPH, ADDICTION PSYCHIATRIST, DUAL DIAGNOSIS CLINIC, 
    CLINICAL ASSISTANT PROFESSOR, PSYCHIATRY AND BEHAVIORAL 
    SCIENCES, STANFORD UNIVERSITY SCHOOL OF MEDICINE; PATTY 
MCCARTHY, CHIEF EXECUTIVE OFFICER, FACES & VOICES OF RECOVERY; 
     ROBERT I. L. MORRISON, EXECUTIVE DIRECTOR/DIRECTOR OF 
LEGISLATIVE AFFAIRS, NATIONAL ASSOCIATION OF STATE ALCOHOL AND 
DRUG ABUSE DIRECTORS; MARGARET RIZZO, EXECUTIVE DIRECTOR, JSAS 
   HEALTHCARE, INC.; SHAWN RYAN, MD, MBA, CHAIR, LEGISLATIVE 
   ADVOCACY COMMITTEE, AMERICAN SOCIETY OF ADDICTION MEDICINE

                STATEMENT OF MICHAEL BOTTICELLI

    Mr. Botticelli. Thank you, Congresswoman Kuster, Ranking 
Member Burgess, and members of the committee for the 
opportunity to speak with you today about legislation to help 
patients with substance use disorders including continued 
efforts against the national opioid crisis.
    My name is Botticelli. I am the executive director of the 
Grayken Center for Addiction at Boston Medical Center. BMC is 
the largest safety net provider and busiest trauma and 
emergency service center in New England.
    Our patient population has the highest public payer mix of 
any acute care hospital in Massachusetts. For decades, BMC has 
been a leader in substance use disorder treatment and research.
    Many of our programs have been replicated across 
Massachusetts and nationally. The Grayken Center for Addiction 
encompasses over 18 clinical programs for substance use 
disorders and serves as an umbrella for all of BMC's work, 
including addiction treatment, research, medical education, and 
training.
    I offer my perspective not only as an executive director 
but insights gained from my over 30-year career in the 
addiction field, formerly serving as the director of the White 
House Office of National Drug Control Policy, the director of 
the Massachusetts Bureau of Addiction Services, and I am also a 
person in long-term recovery.
    In previous sessions of Congress this committee has taken 
the lead on and leadership on passing landmark legislation to 
improve addiction treatment and prevention through the 21st 
Century Cures Act, CARA, and, most recently, the Support for 
Patients and Communities Act of 2018. These laws have gone a 
long way to bring much-needed funding and comprehensive reforms 
to how our system treats and supports people with substance use 
disorders.
    That said, still over 67,000 people have died from a drug 
overdose in 2018 and the death rate from fentanyl and other 
analogs has increased by ten percent.
    This epidemic continues to evolve as polysubstance use, 
namely, mixing opioids or stimulants like cocaine and 
methamphetamine has increased and disparities have widened 
within certain segments of the population including racial and 
ethnic minorities, youth and young adults, members of the LGBTQ 
community and incarcerated individuals who are 
disproportionately burdened by addiction and lack sufficient 
access to culturally competent care.
    The epidemic target challenges our treatment system and 
providers with other notable longstanding challenges. Notably, 
in the 2019 report on addressing the opioid crisis that was 
discussed earlier, the National Academies of Sciences, 
Engineering, and Medicine recognized opioid use disorder as a 
chronic and treatable brain disease while underscoring, and I 
quote, inadequate professional education and training as a key 
barrier to addressing the addiction epidemic. The bills before 
the committee today for consideration in many ways rise to meet 
those challenges and I would like to discuss a few of those 
areas that I think are most pressing for action.
    The 100,000--I wish it was 100,000--the 1,000 additional 
addiction residency slots funded through the Opioid Workforce 
Act of 2019 would significantly accelerate our ability to fight 
the mounting burden of addiction faced by individuals and 
communities nationwide.
    BMC was among the first institutions in the country to 
establish a credited fellowship program in addiction psychiatry 
and addiction medicine. Graduates of an addiction program like 
ours go on to hold faculty and clinical leadership roles in 
medical centers and treatment programs across the country.
    Under the direction of BMC--under the Grayken Center BMC 
has taken initiative to provide comprehensive education and 
training to staff on safe opioid prescribing and over the last 
several years we have systemically reduced opioid prescribing 
across both inpatient and outpatient settings.
    Notably, we require all of our physicians across our system 
to receive waiver training as part of their commitment to 
dramatically expand our workforce license to prescribe 
medication for opioid use disorder treatment and we readily 
offer addiction training to other staff members.
    We also know that addiction affects more than individuals. 
It impacts families as well. Families struggle with knowing how 
best to be supportive of their loved ones and avoid doing harm. 
We also know that getting evidence-based guidance into the 
hands of family and community support systems can dramatically 
influence the trajectory of individuals' care and treatment.
    We are, therefore, highly supportive of the Family Support 
Services Act and appreciate the committee's attention to this 
often overlooked aspect of addiction.
    Two years ago, in testimony before this committee I shared 
the disparity insights gleaned from overdose data in 
Massachusetts that we heard today, that individuals recently 
released from incarceration overdosed at 120 times the rate of 
the general population.
    Nationally, there remains much to be done to improve 
treatment for individuals while incarcerated and upon release 
into the community and I am, therefore, pleased that several of 
these bills under review by the committee intend to make 
substantial progress in those areas.
    While we are seeing modest progress against this epidemic, 
I think we all agree that we can and should do more.
    This will require continued leadership at the federal, 
state, and local levels, additional resources, particularly the 
reauthorization of SOR funding that can continue to make sure 
that we have constant surveillance as this epidemic evolves.
    As I have said many times before and I will say it again, 
addiction is a disease and recovery should be the expected 
outcome. The work lies in getting our systems to a place where 
patients with addiction are treated in a way that affects this 
reality.
    Thank you for your time and I look forward to your 
questions.
    [The prepared statement of Mr. Botticelli follows:]
    
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    Ms. Kuster. Thank you, Mr. Botticelli. And I do recall my 
experience working with you when you were in the White House, 
and thank you for your expertise.
    Dr. Das, you are recognized for 5 minutes.

                 STATEMENT OF SMITA DAS, M. D.

    Dr. Das. Thank you.
    Congresswoman Kuster, Ranking Member Burgess, and 
distinguished members of the Energy and Commerce Health 
Subcommittee, thank you for allowing me the opportunity to 
serve on today's panel.
    My name is Smita Das. I am a clinical assistant professor 
of psychiatry and behavioral sciences at Stanford. In addition 
to being a medical doctor, I have completed a Master's of 
public health and a Ph.D. in community health. I am also board 
certified in psychiatry, addiction psychiatry, and addiction 
medicine.
    My testimony today is on behalf of the American Psychiatric 
Association, an organization representing over 38,000 
psychiatrists, including addiction psychiatrists.
    With help from federal grants, the APA provides thousands 
of psychiatrists ongoing education and training to improve the 
diagnosis and care of patients with all substance use 
disorders.
    With your help, we have made strides in reversing the 
upward trend of opioid overdose deaths and reducing stigma 
surrounding addiction over the past few years and these efforts 
must continue.
    Given this committee's history on focusing on opioids, I am 
not going to use my time today to recite statistics aloud or 
tell you how real the opioid crisis is. Each of you already 
know this.
    We also know that addiction is a chronic brain disease, a 
chronic medical illness that can be effectively treated. 
However, we cannot treat addiction without investing in several 
areas.
    We need to increase workforce capacity, increase provider 
literacy on addiction treatment, and alleviate fragmentation 
and barriers to care like cost and stigma. On workforce, 
psychiatrists are uniquely positioned to treat the substance 
use disorders with the ability to diagnose and treat co-
occurring psychiatric disorders and recognize suicide risk.
    However, the shortage of psychiatrists and trained in 
addiction medicine, addiction psychiatry, or pain management 
has created a longstanding acute treatment gap for those with 
or at risk of substance use disorders.
    Funding new residency positions, expanding loan repayment 
and forgiveness, and offering incentives to work in under-
served areas can help mitigate the effects of the overall 
physician shortage.
    As we invest in our workforce, we also need to ensure that 
clinicians have the support, education, and training that is 
essential to treating patients with substance use disorders and 
co-occurring illnesses.
    We have been working to improve education while 
acknowledging that the complexity of substance use disorders 
requires thoughtful integration of training across the 
continuum from medical school to residency fellowship and 
continuing education.
    Turning to the issue of fragmentation, people with 
substance use disorders are more likely to have physical co-
morbidities like chronic pain, cancer, heart, and liver 
disease. We need more integrated care and for all physicians to 
be aware of the risk and impact of substance use disorders.
    Despite the progress we have made, mental health and 
addiction treatments are still often siloed. Breaks in 
continuity of care leave patients at higher risk for relapse 
and overdose.
    Though not the focus of today's hearing, I would be remiss 
not to mention how lack of compliance with the 2008 Mental 
Health Parity and Addiction Equity Act has aggravated the lack 
of access to substance use treatment.
    Stigma in seeking help is already an enormous obstacle for 
our patients. But forcing both the patients and the providers 
to engage in bureaucracy to get coverage makes treatment that 
much more inaccessible.
    We need to ensure that the intent of the law is enforced 
appropriately and that patients receive seamless and timely 
care to lifesaving treatment.
    We want to thank the committee for working with us on this 
critically important issue. Also, as fears spread about the 
impact of coronavirus, we urge the committee to consider how to 
reduce barriers to telemedicine including telepsychiatry while 
also eliminating originating site restrictions.
    Lastly, ensuring that incarcerated individuals have 
continuity of care so that they can get treatment for substance 
use disorders and mental illness to prevent recidivism when 
they are released from custody is vitally important.
    Using evidence-based common sense policy like allowing 
incarcerated individuals to enroll in Medicaid prior to 
discharge defragment care and coordinates support to allow 
patients to successfully reenter their communities.
    Though I am encouraged that the committee has chosen to 
continue its focus on the opioid epidemic, I want to make one 
last point, that it is not just opioid misuse that is 
problematic.
    We must treat substance use disorders as the chronic 
diseases they are and pursue solutions that address all 
substances including opioids, methamphetamine, alcohol, and 
tobacco.
    I encourage the committee to look beyond opioids and ensure 
consideration of all substance use disorders as it considers 
legislation. While we discuss the 67,000 deaths related to drug 
overdose, let us not forget the impacts of alcohol, responsible 
for 88,000 deaths, or tobacco, responsible for nearly 500,000 
deaths annually in the United States.
    Solutions to close the gap must focus on increasing access 
and literacy, decreasing stigma, coordinating care, and working 
together to help our patients and communities recover from the 
impact that this crisis has had on our country.
    Thank you again for inviting us here today. The APA and I 
look forward to working with members of the subcommittee on 
substance use disorders and health, more broadly.
    I am happy to answer any questions. Thank you.
    [The prepared statement of Dr. Das follows:]
    
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    Ms. Kuster. Thank you very much, Dr. Das, for your insights 
and for your passionate advocacy. We appreciate it.
    Ms. McCarthy, you are recognized for 5 minutes.

                  STATEMENT OF PATTY McCARTHY

    Ms. McCarthy. Thank you, Congresswoman Kuster and members 
of the subcommittee for this opportunity to testify today on 
behalf of Faces and Voices of Recovery. We are a national 
recovery advocacy organization based in Washington, DC, with 
members and affiliates nationwide. Our mission is to organize 
and mobilize the over 23 million Americans in recovery.
    I have had the honor of being the chief executive officer 
for five years and I have been in recovery from substance use 
disorder since 1989. Over the past 30 years of my recovery, I 
have seen firsthand the impact of addiction and have 
experienced the loss of friends and colleagues to alcohol and 
other drug-related fatalities.
    However, over my 20-year career in the addiction field I 
have also witnessed the healing power of recovery for tens of 
thousands of individuals who courageously overcome addiction to 
go on to rebuild their lives.
    So several of the bills being considered here by this 
committee are of particular importance to the recovery 
community. The first pertains to the State Opioid Response 
Grant Authorization Act.
    While medications play an important role in addiction 
treatment, medication alone is not a complete solution. In 
fact, the success of medication often depends on additional 
recovery support services in the community and millions of 
Americans find recovery from addiction without the use of 
medication.
    The 2018 Surgeon General's report states that individuals 
who participate in substance use disorder treatment and 
recovery support services typically have better long-term 
recovery outcomes than individuals who receive either alone.
    The 2017 President's Commission report recommends that the 
government partner with appropriate hospital and recovery 
organizations to expand the use of recovery coaches, especially 
in hard-hit areas.
    Federal funding for medication-assisted treatment can be 
measured in the hundreds of millions while federal funding for 
recovery support services is still only a fraction of all 
funding for the opioid crisis.
    Recovery community organizations, recovery housing, 
recovery high schools, collegiate recovery communities and harm 
reduction, all of which are evidence-based models, have no 
reliable and sustainable funding sources.
    There is, clearly, an issue of scale here and substantial 
investment in recovery support is needed. In my written 
testimony, I have included a more detailed plan to make this 
significant investment by reauthorizing the State Opioid 
Response Grants, moving that funding into the block grant for 
long-term, setting aside 20 percent of the block grant funding 
for recovery support services, and increasing the funding for 
the BCOR, Building Communities of Recovery, grant program to 
$25 million. Treatment is short-term. Recovery is long term and 
investments must reflect that.
    The second bill we strongly support is the Family Support 
Services for Addiction Act. Parents, children, and other family 
members including those who have lost loved ones need support 
groups and they need help navigating the complexity of the 
treatment system.
    However, $5 million per year is not nearly enough to 
establish this new grant program. Not only do we need funds, we 
need an entire paradigm shift on how we view the importance of 
the family's role in recovery.
    We must be bold in this pursuit and we must send a signal 
to families and the recovery community that we are truly vested 
in their continued well-being.
    That being said, increasing the authorization to $25 
million is warranted.
    Third, we strongly support the Medicaid Reentry Act, which 
would allow medical assistance for incarcerated individuals 30 
days prior to release. This new policy will make it easier for 
states to provide effective treatment and recovery support 
services, allowing for smoother transitions to care in the 
community and reducing the risks of preventable overdose 
deaths.
    If we are truly serious not only about treating addiction 
but also moving individuals out of incarceration and into long-
term recovery, we must take this legislation seriously and see 
to its passage.
    I will conclude by thanking you on behalf of the recovery 
community for all the work that Congress has done to address 
the addiction crisis in America. There is much more to be done 
and we want you to know that we are fighting this battle on the 
ground every day in communities across the nation.
    We focus on providing effective recovery support services, 
eliminating the stigma of addiction, and celebrating the 
successes of individuals and families who have found their 
chosen pathway of recovery, and will continue to be vocal, 
visible, and valuable part of the solution working with 
Congress to save lives.
    And with that, I conclude my remarks. Thank you.
    [The prepared statement of Ms. McCarthy follows:]
    
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    Ms. Kuster. Thank you, Ms. McCarthy, and I can certainly 
say as a sister of a brother in recovery, I am very grateful 
for your organization and for bringing Voices of Recovery here 
to us in Washington. So thank you.
    Mr. Morrison, you are recognized for 5 minutes.

               STATEMENT OF ROBERT I. L. MORRISON

    Mr. Morrison. Thank you, Congresswoman Kuster, Ranking 
Member Burgess, and members of the subcommittee. I appreciate 
you providing us the opportunity to testify. It is a privilege.
    I am Rob Morrison. I serve as executive director of the 
National Association of State Alcohol and Drug Abuse Directors, 
or NASADAD. We are a nonprofit serving state alcohol and drug 
agencies directors across the country.
    Our board is led by our president, Cassandra Price. She is 
from the state of Georgia, and our members are very grateful 
for the program funding authorized by this very committee. 
These programs are housed in HHS agencies such as SAMHSA, CDC, 
HRSA, and NIH, and I would like to thank you for your work to 
pass the Comprehensive Addiction Recovery Act, or CARA, the 
21st Century Cures Act, and the SUPPORT Act.
    We note our particular appreciation for what is now known 
as the State Opioid Response Grant, or SOR, which is authorized 
by this very subcommittee and is being managed by SAMHSA.
    SAMHSA is directing $1.5 billion in SOR funding to our 
members' state alcohol and drug agencies. These resources are 
supporting evidence-based, innovative, and lifesaving programs 
at the local level. In short, this program has been a game 
changer.
    In written testimony, we have outlined some SOR-funded 
activities for a handful of states, those on the subcommittee, 
our webpage. We have profiles for all states regarding SOR-
funded activities for your review.
    And it is a privilege to offer some following principles 
for your consideration as you examine the legislation before 
you regarding substance use disorders in general and the opioid 
crisis in particular.
    First, ensure provisions work through and coordinate with 
the State Alcohol and Drug Agency. This approach promotes 
efficiency, avoids creating parallel systems and duplicative 
systems of care.
    Second, ensure consistent, predicable, and sustained 
federal resources to avoid creating a fiscal cliff. We 
recommend extending the duration of federal grants beyond the 
typical one- or two- year funding cycle and affording states 
three year, even five years time frame to allocate funding.
    Third, continue to address the opioid crisis but also 
elevate efforts to address all substance use disorders. This 
can be achieved in part through a gradual transition from 
directing funds to opioid-specific grants to the substance 
abuse prevention treatment block grant.
    Fourth, maintain investments in SAMHSA as the lead agency 
within HHS, focus on substance use disorders program and 
service delivery.
    Finally, work to ensure new legislation complements and 
builds from the current system. In the process, consider 
provisions affording state and federal agencies adequate 
resources to effectively administer these programs, both the 
previous programs and new ones.
    Added people power will be required to additionally manage 
addictional programs. I would like to focus on the benefits of 
working through the State Alcohol and Drug Agency for a minute.
    Our members draft and implement coordinated statewide plans 
for program and service delivery. These plans are 
comprehensive, work across state agencies, and span the 
continuum of prevention and treatment recovery.
    State Alcohol and Drug Agencies ensure oversight of 
providers through tools such as performance management and 
reporting, contract monitoring, corrective action planning, 
onsite technical reviews, licensure and certification.
    Members also work to promote quality through state-
established standards of care, evidence-based practices, 
collecting and analyzing data, and using these tools to drive 
management decisions.
    The foundation of this work is the Substance Abuse 
Prevention Treatment Block Grant. This program is designed to 
be flexible to meet the unique needs of states and to address 
all substances in its backyard.
    Twenty percent of the SAPT block grant by statute is 
dedicated to much needed primary prevention programming. In 
fact, of the budgets our members manage for primary prevention, 
on average approximately 70 percent comes from the SAPT block 
grant.
    So we look forward to a continued dialogue regarding the 
different proposals before this committee. Again, we appreciate 
the opportunity.
    [The prepared statement of Mr. Morrison follows:]
    
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    Ms. Kuster. Thank you, Mr. Morrison. I appreciate your 
remarks as well.
    Ms. Rizzo, you are recognized for 5 minutes.

                  STATEMENT OF MARGARET RIZZO

    Ms. Rizzo. Good afternoon. My name is Margaret Rizzo. I am 
the executive director and CEO of JSAS Health Care. We are 
currently treating 700 patients with opioid use disorder. Our 
agency has been treating this population since 1973 and this is 
my twenty-ninth year in the field.
    I am here to testify on the views of the American 
Association of the Treatment of Opioid Dependence, ATOD, of 
which are a New Jersey member.
    ATOD represents over 1,000 OTPs throughout the United 
States. All OTPs are under the regulatory oversight of SAMHSA, 
the DEA, as well as the individual states' opioid treatment 
authorities.
    We also are required to be accredited every three years 
through a rigorous process from our SAMHSA-approved 
accreditation bodies. Only OTPs are authorized to use all three 
federally approved medications to treat OUD.
    At the outset, our association members want to express our 
appreciation to this committee for authorizing the development 
of the first ever Medicare reimbursement rate for OTPs in the 
United States. It will make a profound difference in the lives 
of Medicare-eligible patients entering and remaining in 
treatment.
    As you discuss the various legislative proposals before you 
today, we urge you to consider the following. When DATA 2000 
was passed, Congress wisely imposed reporting requirements in 
order to properly evaluate the quality and integrity of this 
new expanded program and identify any unintended consequences.
    However, we have not seen any publications from SAMHSA 
reporting the quality of care provided, the effectiveness of 
the services nor the degree of compliance with current federal 
regulations.
    Thus, any changes being considered today would be in the 
absence of data. Such policymaking is dangerous and we 
recommend SAMHSA publish and analyze this data before any 
changes are made to existing caps, training, or oversight.
    We are concerned that proposed legislation would increase 
buprenorphine diversion. The data clearly shows that opioids 
are most frequently diverted from private physician offices.
    In 2011, the radar surveillance system reported 45.5 
percent of individuals presented in a treatment facility used 
buprenorphine intravenously and 16.3 percent of individuals 
reported misuse of the buprenorphine naloxone combination 
medication.
    Also, the assertion that training is a barrier to providers 
using buprenorphine in their practices is not supported by the 
evidence. In a survey of MAT waiver prescribers who have taken 
the waiver course, 83 percent indicated they needed to know 
more about the topic. There are currently more than 113,000 
waiver prescribers who under the current system have collective 
capacity to prescribe buprenorphine to more than 6.3 million 
patients.
    This nearly triple the estimated 2.5 million people in the 
United States with OUD. Clearly, this suggests adequate 
capacity in our current system. Instead of eliminating 
oversight that will result in greater diversion and abuse, we 
suggest solutions to expand access to areas where there are 
limited treatment options.
    We are still in the midst of a changing opioid use epidemic 
which has shifted from prescription opioid misuse to heroin use 
and, more currently, fentanyl combined with methamphetamine 
use.
    This is not a time to be removing clinical training 
requirements which are, at best, quite simple. For all of these 
reasons, we oppose the passage of H.R. 2482.
    Regarding H.R. 4141 and 1329, there is a greater interest 
for correctional facilities and other parts of the criminal 
justice system including drug courts to increase the use of MAT 
for opioid use disorder.
    Model programs in Connecticut, Rhode Island, Philadelphia, 
Baltimore prison systems and Rikers Island in New York City are 
certainly moving the right direction.
    Accordingly, there has been a 55 percent decrease in post-
release recidivism as reported in Rhode Island in addition to a 
60 percent reduction in post-release mortality as inmates are 
transitioned from correctional facilities into outpatient 
treatment settings.
    Furthermore, ensuring the newly released inmates have 
Medicaid coverage in place prior to the release as proposed in 
H.R. 1329, Improve Access to OUD Treatment.
    This is all very encouraging news and we encourage the 
House to support such measures. This is why we are supporting 
the passage of H.R. 4141 introduced by Congresswoman Kuster, 
and H.R. 1329 introduced by Congressman Tonko.
    Other bills under consideration today have our strong 
support. H.R. 5631 would provide funding for addiction 
education in medical and nursing schools. H.R. 2466 extends the 
SOR grants. H.R. 2922 provides opioid funding of $5 billion.
    H.R. 3414 proposes additional residency positions in 
hospitals and H.R. 4974 proposes training and education 
requirements which we support. However, such requirements 
cannot replace the current oversight and patient limits which 
are critical to preventing medication diversion and abuse.
    Thank you for accepting this testimony. I am happy to 
answer any questions that you may have.
    [The prepared statement of Ms. Rizzo follows:]
    
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    Ms. Kuster. Thank you, Ms. Rizzo. That was very helpful and 
I appreciate it. I would love to follow up with you after.
    Dr. Ryan, you are recognized for 5 minutes.

                 STATEMENT OF SHAWN RYAN, M. D.

    Dr. Ryan. Thank you. Congresswoman Kuster, Ranking Member 
Burgess, and esteemed subcommittee members, thank you for 
inviting me to participate in this important meeting.
    My name is Dr. Shawn Ryan. I am a board certified addiction 
specialist and an emergency physician. I take care of patients 
in Ohio. I am also the chair of the Legislative Advocacy 
Committee of the American Society of Addiction Medicine, known 
as ASAM, a medical society representing over 6,000 clinicians 
who specialized in the prevention and treatment of addiction.
    I would like to begin by recognizing the phenomenal work 
Congress has done to advance crucial pieces of legislation and 
funding to address this crisis. It has made a life or death 
difference for many.
    However, we must do more to create a sustainable and robust 
treatment infrastructure, one that addresses addiction as the 
treatable chronic medical disease that it is.
    To realize this addition, we must focus on three primary 
issues: strengthening the addiction treatment workforce, 
standardizing the delivery of individualized addiction care by 
rethinking our largest federal grant programs, and reforming 
payment policies and strongly enforcing mental health and 
addiction parity.
    Focusing first on our workforce needs, there are only about 
3,000 board certified addiction specialist physicians, 
according to ABMS, and in a recent survey in Massachusetts only 
one in four healthcare providers report receiving on addiction 
during medical education. I know that I did not.
    For a country that prides itself on the medical care 
available to its citizens, this is simply unacceptable. That is 
why ASAM supports the Opioid Workforce Act legislation that 
will provide additional GME slots to hospitals with programs in 
addiction medicine and addiction psychiatry.
    To ensure more healthcare providers receive basic training 
in addiction, ASAM supports the MATE Act, legislation that 
would require all DEA-controlled medication prescribers to have 
at least a baseline knowledge about addiction.
    Dr. James Baker, who is with us here today and behind me, 
has been a determined champion of the MATE Act, in honor of his 
son, Max, whose life was, unfortunately, cut short in part 
because the medical community has yet to reckon fully with 
addiction.
    After or concurrent with the passage of the MATE Act, ASAM 
supports the passage of the MAT Act, legislation that would 
eliminate what would then be a redundant separate waiver to 
prescribe buprenorphine for addiction along with the waiver of 
patient limits and regulations.
    Secondly, this workforce shortage is exacerbated by a long 
history of treating addiction in silos, as has been stated many 
times today, and available treatment is, largely, determined by 
local culture rather than nationally recognized standards of 
care.
    This must change. To that end, ASAM supports the State 
Opioid Response Grant Authorization Act with certain technical 
amendments and the addition of a new provision. This would 
strengthen the program by applying a Medicaid provider 
requirement included in both the bipartisan Ryan White Care Act 
and in the late Elijah Cummings CARE Act.
    Such a provision would require certain grantees to enroll 
in Medicaid, ensure that they can meet--ensuring that they can 
meet minimum standards and grant funds are used as they are 
intended to pay for crucial services that cannot be billed to 
Medicaid.
    Investments above this foundation, however, need to be used 
efficiently and effectively and they should drive sustainable 
change. For example, Congress should--could establish a new 
supplemental grant program with conditions that require states 
and localities to adopt certain strategic policies.
    To qualify for this supplemental funding, states could be 
required to adopt nationally recognized levels of care 
standards for the regulation of the addiction treatment 
programs. This would make oversight and payment more efficient 
and set baseline expectations for care as we have with the rest 
of American medicine.
    States could be incentivized to require health plans to use 
medical necessity criteria for addiction treatment as defined 
by national medical societies and certain grantees could be 
required to offer all medication for addiction treatment.
    Over time, the largest federal grant programs in this space 
could be combined with a common set of modernized requirements. 
But let us be clear. We need these sizeable grants because to 
this day mental health an addiction parity is not a reality.
    Payers continue to discriminate and there is wide disparity 
in network use in provider payment rates. That brings us to the 
bills being considered that will improve insurance coverage 
specifically to those in the criminal justice system, the 
Medicaid Reentry Act, and Humane Correctional Health Care Act.
    Continuation of Medicare and Medicaid coverage during 
detention and incarceration or reinstatement immediately prior 
to release will facilitate treatment continuity, retention, and 
save lives. ASAM is proud to support these bills.
    In conclusion, ASAM is actively building, implementing, and 
advocating for the tools and resources to secure a solid and 
sustainable foundation for addiction treatment in this country.
    While change won't be easy, it is both necessary and worth 
it to end the suffering being experienced across our nation and 
our communities and by American families.
    Thank you, and I look forward to your questions.
    [The prepared statement of Dr. Ryan follows:]
   
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    Ms. Kuster. Thank you, Dr. Ryan.
    I need to inform all of you that we are about to be called 
for votes and so we are going to take a recess to go vote but 
we will come back, and we will proceed with the questions for 
the second panel.
    So thank you so much for all of you being with us, and 
patience.
    [Pause.]
    Ms. Kuster. Actually, it turns out that our votes were not 
quite called. They are about to be called. So we are going to 
go ahead, Representative Brooks and I, and get started on our 
round of questions, and use your time wisely and then we have 
15 minutes to get to the floor once they are called. There they 
are.
    So I want to just take a minute for my own questions and 
then I will turn it over to Mrs. Brooks.
    It is our job to continue to bring attention to this opioid 
crisis and, as you have all pointed out, other drugs as well 
and to find solutions that will save lives, and that is why I 
founded the bipartisan Opioid Task Force and it is why I waited 
and worked for six years to get on this committee. So I am 
delighted to be with you today.
    For folks in New Hampshire and families across the United 
States, this hearing is one of the most important that we will 
hold. These issues that we are discussing are critical and we 
need to end the stigma of addiction.
    Many of you mentioned that, in my view, stigma is just 
another word for bias and discrimination. When it comes to 
physical health, we as a society are quite understanding and 
the same should be said for mental health and addiction 
treatment.
    So I would like to focus my remarks on my bill, H.R. 4141, 
the Humane Correctional Health Care Act. In New Hampshire, we 
saw again and again incredibly high rates of recidivism 
directly related to substance use disorder and mental health 
issues.
    As it turns out, there are many jails and prisons that are 
not providing adequate healthcare, especially when it comes to 
these co-occurring illnesses. I have said it before. I will 
continue to say it. If we wanted to design a system the fail, 
this would be it.
    This bill is a game changer. It ensures that the justice-
involved population gets access to the treatment that they 
need. It is co-sponsored by many of my friends on both sides of 
the aisle here on the Energy and Commerce Committee and I am 
proud to have introduced this bipartisan legislation.
    I am particularly appreciative of the many organizations, 
some of whom are with us today, that have supported this bill, 
the American Society of Addiction Medication--Medicine Smart 
Recovery, the American Corrections Association, the American 
Psychological Association, the National Council for Behavioral 
Health, and Faces and Voices of Recovery, among many others.
    So let me jump into the questions. Mr. Botticelli, could 
you please describe the Grayken Center's direct experience in 
treating individuals upon release and the importance of 
seamless care in reducing overdose risk and recidivism?
    Mr. Botticelli. So Boston Medical Center we have the 
largest office space addiction treatment program in New 
England. We have about 800 active clients.
    Directly across the street from us is the Suffolk County 
House of Correction and literally our job is to get them 
seamlessly from the County House of Correction into our office-
based addiction treatment program without any interruption in 
care and continuity of providers.
    You know, so it is very clearly important. Besides all of 
the incredible salient points that you already raised about, 
you know, being able to not just move beyond suspending their 
Medicaid but actually enrolling them in Medicaid while they are 
behind the walls so that there is absolutely no interruption in 
care while people are coming out.
    I do want to address the issue of payment because I do 
think it might not be Medicaid funding but we are paying for 
those services anyway.
    Whether it is State Opioid Response money or state 
appropriation dollars or moneys that the sheriffs are paying to 
implement medications behind the wall. So whether it is 
Medicaid funding or another funding source we are already 
paying for those services.
    Ms. Kuster. I appreciate that, and I hope the CBO is 
listening when they take that into consideration.
    Mr. Ryan, are you aware of any estimates on the percentage 
of those who suffer from substance use disorder that become 
involved with the criminal justice system at some point and 
with either mental health or substance use disorder?
    Dr. Ryan. Absolutely. Thank you for the important question.
    So statistics show as high as 50 to 70 percent of 
individuals in the incarcerated population in any way, shape, 
or form have mental health and addiction, and in many locations 
where opioid use disorder is the most pervasive, there are 
places seeing as high as 75 to 80 percent of their justice 
population involved.
    So I have actually worked a fair bit with an institution 
that does jail healthcare across the state of Ohio and other 
areas. Because I recognize that in this country we are not 
disconnecting criminal justice involved and substance use 
disorder probably ever. And so it is really important that we 
do--speak these transitions and I can tell you first hand in 
taking patients on in our treatment centers right out of, you 
know, criminal justice settings, the transition is quite hard 
and we do really need to work to improve that.
    Ms. Kuster. So are there any estimates suggesting how many 
more could receive MAT and jails and prisons if such treatment 
was widely available?
    Dr. Ryan. I cannot say that I have seen an estimate in 
regards to what this particular or these particular bills 
would--how much it would increase the access to medication 
assisted treatment.
    I will tell you in those localities where I have been 
involved and the sheriffs have been very supporting in doing 
this and we have seen the estimates and you described in Rhode 
Island, if we put a pervasive and sustained effort to deliver 
the absolutely necessary and evidence-based treatments such as 
MAT to these justice-involved individuals, they will do better.
    Ms. Kuster. Thank you very much. I appreciate it.
    And that has certainly been our experience in Sullivan 
County and now in Merrimac County in New Hampshire where the 
recidivism rate dropped from as high as in the high 50 percent, 
58 percent, all the way down to 18 percent.
    So I don't care if you are left, right, or center, that is 
a savings of tax dollars, if we can get people back to the 
community, going to work taking care of their families and 
living in recovery.
    So thank you, and I guess I say, Madam Chair, I want to 
recognize my good friend and colleague, Representative Susan 
Brooks.
    Mrs. Brooks. Thank you, Madam Chairwoman, and thank you so 
much to all of our witnesses and for your important work. I 
just want to spend a few minutes talking about H.R. 3414, the 
Opioid Workforce Act.
    As I stated earlier, the crisis continues to plague so many 
of our communities. That is not to say we haven't made 
progress. In fact, yesterday an Indiana state public health 
official shared with our office that Indiana has--my home 
state--has seen a 13 percent reduction of opioid overdoses last 
year.
    But we also increased by 75 percent the number of available 
inpatient treatment beds. Pretty significant increase. But 
despite these improvements, one thing that continues to be 
clear is we have to have more care providers in order to staff 
and in order to take care of the beds.
    Doesn't matter how many beds we have in the hospitals if we 
don't have the doctors and the professionals to treat those 
patients, and so that is why I introduced with you, Madam 
Chairwoman, along with Representative Schneider and 
Representative Stefanik the Opioid Workforce Act, providing a 
thousand Medicare-funded residency slots to hospitals.
    So I just have a couple of questions, briefly, before we 
have to probably take a break to vote.
    Mr. Botticelli, in your written testimony, you talked about 
the additional thousand addiction residency slots. How 
specifically do you believe those additional slots would 
improve our ability to help these patients?
    And if you could--your mic, please.
    Mr. Botticelli. You think I would know after all these 
years.
    One of the things that the opioid epidemic has laid bare 
the lack of trained professionals that we have to provide 
treatment. So we can put out all the funding dollars that we 
want without a prepared workforce in terms of implementing it.
    I think this act has the potential to dramatically expand 
access to treatment by having a trained pool of professionals, 
of physicians who are able to understand and treat addiction.
    I think it is really important for us to ensure that while 
we are doing other activities such as integrating addiction 
treatment into medical residency training that having a trained 
workforce both of addiction medicine and addiction 
psychiatrists are really critical. I think this is a critical 
piece of legislation. We have known this since the beginning of 
the epidemic that this is one of the prime areas in terms of if 
we are going to make an impact.
    Mrs. Brooks. Thank you, and thank you for your long decades 
of work.
    Dr. Ryan, in your written testimony you too, emphasized 
just how under served individuals struggling with substance 
disorder are and, in fact, there are only about 3,000 board-
certified specialists in the country really highlights for me 
how short staffed our treatment facilities might be.
    How do you think the addiction specialists would best be 
used if we were to improve and increase fairly dramatically the 
number of addiction specialists which, as we have said, would 
also be trained not just on substance--I mean, whether it is 
alcohol, whether it is drug, whether it might be other 
addictions, you know, addiction just generally, can you just 
share with us how you believe it would make a meaningful impact 
on this significant challenge?
    Dr. Ryan. Absolutely. A couple of points. So I am board 
certified in addiction medicine as those of us who are. Not in 
opioid medicine.
    So we are broadly trained in all of the substance use 
disorders. Understanding that alcohol still had huge impact on 
our society and we have to understand how to address that and 
every other substance so that drug use transitions to 
methamphetamine, et cetera, that theworkforce is trained to 
manage any substance use disorder it becomes the topic of most 
importance at that time. So I just want to make that point.
    Also we do have a system of care in this country for 
specialists and primary care to interact through different 
mechanisms.
     So as I would--the way that I would probably put it, 
Representative, is that a specialist like myself should be 
taking care of the sickest patients. Not all opioid-use 
disorder patients need the highest level of care or the highest 
trained specialists but many do.
    And so we have these systems of care in place for chronic 
disease management. We should simply reflect back to those as 
so for diabetes so that we, again, diabetes best managed the 
same way in a whole holistic model for patients. We should 
really parallel those types of systems of care and use those 
trained addiction specialists in that.
    Mrs. Brooks. Besides residencies, do you believe that our 
med schools and the education higher ed institutions are doing 
enough relative to addictions?
    Dr. Ryan. Enough is a loaded question, I guess, a little 
bit. But no, I don't believe so. Actually, in my personal 
opinion I feel like there is more to be done. I have spent 
thousands of hours myself educating, you know, medical 
students, residents, and I am sure that others on the panel 
have done the same. I do believe we are behind the eight ball 
on that and I would say with the workforce at hand we are also 
under educated in relation to the disease of addiction.
    Mrs. Brooks. Thank you, and with that I yield back. Thank 
you for your work.
    Ms. Kuster. With that, I recognize Dr. Raul Ruiz from 
California.
    Mr. Ruiz. Thank you all for being here.
    Congress has passed multiple pieces of legislation to 
address the opioid misuse public health crisis and more still 
needs to be done.
    That is why I introduced the H.R. 2281, the Easy Medication 
Access and Treatment for Opioid Addiction Act, or EASY MAT Act. 
This bill will remove a rule that restricts doctors from giving 
a patient more than one day's worth of buprenorphine or other 
medication assisted treatment at a time.
    Under current DEA regulation, physicians are authorized to 
give a patient one day's worth of MAT for three consecutive 
days while the patient is secure long-term treatment.
    However, they can only give the patient the MAT one day at 
a time. Meaning, the patient has to go back to the doctor, back 
to the emergency department, every 24 hours for three days 
which, as you can imagine, is huge barrier to a patient who may 
not have access to their provider.
    Under this bill, physicians will be allowed to provide 
three days worth of MAT at one time so that patients don't have 
to come back every 24 hours to be seen by a doctor while they 
are waiting to get into long-term treatment.
    This will increase the chances that a patient will remain 
on medication-assisted treatment and off of illegal and illicit 
drugs.
    It will save money for the healthcare system by requiring 
fewer visits and it will maintain all of the other safeguards 
currently in place under DEA regulation. Most importantly, it 
will save lives.
    As an emergency department physician, I know that once a 
patient walks out of the door of the hospital, the fewer 
barriers there are to get someone in treatment, the higher the 
chances of success, and I believe that this bill will remove 
one of those barriers.
    Dr. Ryan, I understand that you, too, are an emergency 
physician and you are also an addiction specialist, correct?
    Dr. Ryan. Correct.
    Mr. Ruiz. When there isn't long-term treatment on demand, 
how important is it to have this bridge of care in the interim?
    Dr. Ryan. It is very important, and thank you for the good 
question. I would say two things.
    One of which we worked very hard in the state of Ohio where 
I practiced to develop treatment on demand with ready access to 
medication-assisted treatment, and in some areas of the state, 
we are there. But in most parts of the country, we are not.
    And so I said, you know, I would say that the second point 
is given the safety profile of buprenorphine that what you are 
proposing makes sense to me and I would support it, as was 
already said.
    Mr. Ruiz. Thank you. And as an emergency physician, what is 
the practical implication of this current restriction?
    Dr. Ryan. Well, the practical implication, as you know, 
emergency departments are very busy across the country. By and 
large, it is more common than not that they are overwhelmed.
    And so when you add this increased burden of a patient 
having to come back, not only is transportation for that 
patient an issue it is almost a big issue for patients with 
opiate disorder.
    But you burden the emergency department with more 
unnecessary visits for the simple administration of a very safe 
medication.
    Mr. Ruiz. What would you say the return rate would be if 
you are in a rural area and your emergency department is quite 
far from your area?
    Dr. Ryan. I would say it would be very poor. I cannot quote 
a specific statistic. I am not sure if anyone else on the panel 
is aware. I have not seen such a study.
    But knowing the return rates we have on the second day of 
admission for outpatient programs it would be----
    Mr. Ruiz. So they would be lost to follow up. They might 
receive the first dose but then take an incomplete three-day 
course?
    Dr. Ryan. It would seem that that would be fairly common, 
yes.
    Mr. Ruiz. OK. So what are the implications of reversing 
this restriction for the provider and, in your experience, 
would this lead to greater rates of success for patients trying 
to access long-term treatment programs?
    Dr. Ryan. We do note, from some studies, that emergency 
department initiation medication-assisted treatment with the 
appropriate transition to care can lead to substantially better 
retention rates in treatment and recovery and lower rates of 
relapse.
    Mr. Ruiz. So is there is--this is evidence-based programs 
that actually work to improve success in compliance as a bridge 
into long-term treatment with successful treatment for opioid 
misuse disorders, correct?
    Dr. Ryan. Correct.
    Mr. Ruiz. Thank you. I yield back my time.
    Ms. Kuster. Thank you, Dr. Ruiz. You have convinced me and 
I will co-sponsor your bill.
    Thank you very much. Now I will ask for your patience. The 
subcommittee will stand in recess for 20 minutes while we go 
vote and then we will come back to resume questions.
    [Whereupon, the above-entitled matter went off the record 
at 1:46 p.m. and resumed at 2:14 p.m.]
    Ms. Eshoo [presiding]. The Subcommittee on Health will come 
back to order. Thank you to our witnesses. I know I had to go 
out to have a meeting. I want to thank Congresswoman Kuster, 
who held the fort down. And I understand that you have all 
testified and that those of us that are still here can ask our 
questions.
    I am going to recognize myself for some questions. Let me 
start with the following. A federal court in northern 
California recently found that United Behavioral Health 
rejected the insurance claims of tens of thousands of people 
seeking mental health and substance use disorder treatment 
based on defective medical review criteria.
    I have heard from many constituents about this and how 
harmful these denials, obviously, are to their recovery. To the 
practicing clinicians and, Dr. Das, I mean, you are all 
wonderful and brilliant and we are all so grateful to you but a 
special welcome to you, my constituent from Stanford. Very 
proud. Very proud to represent Stanford and who is there and 
what you do.
    So to the practicing clinicians--Dr. Das, Dr. Ryan, and to 
Mr. Botticelli--what a beautiful name. What a beautiful name. 
Have you encountered burdensome prior authorization processes 
or denials from private insurance when you try to get your 
patients the mental health and substance abuse care both 
medication and services that they need?
    Mr. Botticelli. I think it is probably most appropriate. At 
Boston Medical Center we, largely, serve Medicaid clientele, 
and actually I think we know that generally Medicaid and access 
to benefits under Medicaid has been better, quite honestly, 
than under most commercial plans. That may vary by state. But I 
think my colleagues on the panel probably have more experience 
with commercial insurance.
    Ms. Eshoo. That is wonderful what you just shared with us. 
That is very good to hear. There are so many on the committee 
that have worked so hard over the years to bolster, make 
stronger and better Medicaid. So I appreciate what you said.
    Dr. Das?
    Dr. Das. I will add that before Medi-Cal covered 
buprenorphine I would sometimes spend more time on the phone 
trying to get buprenorphine approved than compared to how much 
time I was able to spend with a patient. It is one of the most 
frustrating things when we have evidence-based treatments that 
work and there are hoops that we need to jump through to get 
our patients connected with that care.
    And as recently as last week, I was ordering nicotine 
replacement therapies for a patient wanting to quit smoking. 
Really severely needed to quit smoking, and that wasn't covered 
by the insurance. And I was just blown away and the reasoning 
was that it is over-the-counter.
    But, again, another barrier for somebody who is already 
disadvantaged who is already struggling to get the treatments 
that they need. It is frustrating as a psychiatrist.
    Ms. Eshoo. Thank you.
    Dr. Ryan?
    Dr. Ryan. I thank you for the question. So I was actually 
the chair of Peer Relations in my past tenure at the American 
Society of Addiction Medicine. So a lot of insurance 
interaction.
    I would say that there are substantial utilization 
management techniques such as the one you described of 
prioritization and other efforts to block access to care. That 
can be inadequate networks, it could be inadequate payments in 
many cases whether it be commercial or Medicaid.
    And so there are many obstacles to accessing appropriate 
reimbursement for good mental health and addiction care. There 
is also a lack of following science or national standards.
    So they will often have their own criteria. It may or may 
not be something that is nationally recognized as a standard. 
And so the--in finality I would say the need to hold insurers 
accountable to the science and the evidence is----
    Ms. Eshoo. Is Medicare or Medicaid different with regards 
to a prior authorization for these types of claims?
    Dr. Ryan. It is state-by-state in my experience with 
Medicaid specifically, obviously. Medicare, you know, coverage, 
for opioid use disorder is a new thing, as was talked about 
earlier. And so I readily don't know that we have an answer to 
that last part yet. But for Medicaid it is state-by-state 
variance.
    Ms. Eshoo. Yeah. So for those who are in recovery from 
substance use disorder or work directly with patients, and we 
have some of you here with us, have you had trouble getting 
your care covered by insurance? I mean, you just touched on 
some of it. Is it--you all agree that you have trouble? Any 
smooth sailing anywhere?
    Ms. Rizzo. Yes, as Dr. Ryan said, it's state by state. New 
Jersey did away with prior authorizations for Medicaid. So we 
don't have that barrier anymore, which was a big help.
    Ms. Eshoo. That is a--that is big.
    I don't have any other questions. You were all here 
listening this morning. Is there something that if you were up 
here you would have asked that we didn't, of the first panel?
    Dr. Ryan. I would say actually how to better enforce parity 
is probably the number one thing that we deal with because that 
would actually answer some of the questions you just asked. We 
were actually performing oversight and regulation and adherence 
to parity. We wouldn't be having a conversation about a safe 
and fairly cheap medication and prior authorizations.
    Ms. Eshoo. Yes?
    Mr. Botticelli. I would add to this, you know, while we 
simultaneously build up our treatment system, we know there are 
considerable number of people who are not ready for treatment 
but who are also getting infected with HIV. They are getting 
hepatitis C.
     So having access to things like sterile syringes, access 
to naloxone I think become really important priorities. So I 
think that part of what I didn't hear as part of kind of the 
larger federal strategy is how do we significantly expand what 
we kind of commonly term harm reduction services.
    I think it is particularly important priority for those 
folks who are not ready to enter treatment. We know it's a 
glide path for people to get into treatment. We know it reduces 
overdose and infectious disease rates.
    You know, I think we have seen outbreaks in other parts of 
the country that were caused by lack of access to things like 
sterile syringes. So part of what I think we really have to 
focus on is not just how do we build up our treatment system 
but also how do we create those glide paths and those harm 
reduction services for folks who are not ready to enter care.
    Ms. Eshoo. Thank you very, very much. My time has expired.
    And is there anyone that hasn't been called on that I need 
to recognize? Dr. Burgess?
    Mr. Burgess. Thank you. I thought you would never ask.
    Ms. Rizzo, actually my questions are along the same lines 
as the discussion that has just been going on on the prior 
authorization. In fact, I was rather startled in your testimony 
that hey, the eight-hour educational requirement is not a 
barrier--it is prior authorization and utilization review, I 
guess, by inferences is more of a barrier.
    Prior authorization, something that we live with at a lot 
of different levels. As someone who has sat in the prescriber's 
chair, I hated prior authorization; how dare you second guess 
my intuition and medical knowledge. I guess it is something 
that we just have to live with but at the same time there ought 
to be a way to streamline so it's not--it's not the barrier 
that certainly you have encountered.
    I was also intrigued your testimony that we forget 
buprenorphine is not always a benign drug. There are some times 
that it can be misused. It can be diverted. In fact, there is 
actual harm that can occur with buprenorphine.
    So that is I think something that is important for us to 
bear in mind as we do things that, yes, we want to get more 
treatment in the hands of more people but at the same time 
there are--there are controls because there is a reason to have 
the control and if we just remove all of that, we may 
inadvertently be causing harm.
    I guess, Dr. Ryan and Dr. Das, both of you, been through 
training programs, you know what they are like. So the--I will 
just--I am conflicted because we have a bill that says we need 
a thousand new residency slots. So I presume these are 
psychiatric residencies that are three years in duration. Is 
that correct?
    Dr. Das. I believe the bill is for residency slots where 
there could be addiction treatment provided at the end of it so 
it would be psychiatry which is four years as well as other 
programs that support addiction medicine and addiction 
psychiatry training.
    Mr. Burgess. So but it would be in conjunction with an 
established training program training program that may be 
several years in length. In other words, a significant 
investment of time that someone is going to undergo, correct?
    Dr. Das. It could be a significant investment in time. 
However, an addiction psychiatry or an addiction medicine 
fellowship could be just one year of additional training in 
addition to the residency.
    Mr. Burgess. Right. You are starting with somebody who has 
already been through your rigorous four-year program that is 
not everyone can do it, right?
    How about you, Dr. Ryan? Are you a psychiatrist by 
background?
    Dr. Ryan. No, sir. Emergency medicine originally and then 
went back through and trained in addiction. So to the doctor's 
point, I think that fellowships are a good route to educate 
folks.
    I will tell you that we over the past ten years have 
definitely increased our availability of those folks. But they 
are few and far between still. And the recruiting of them is 
challenging. You know, we live out of Cincinnati, basically.
    It is not exactly Denver or Miami or San Diego. It is not a 
particularly great place to recruit folks. It is a little 
challenging and in the rural areas in tri-state where I work is 
even more so. So anything we can do to improve and increase the 
education of folks and so funding and support for that is 
greatly appreciated.
    Mr. Burgess. So what I am hearing is actually fellowships 
might be a wiser course of action than actually creating 
residency programs de novo. Is that a fair assessment?
    Dr. Ryan. I would say it is part of the overall plan.
    Dr. Das. I would also add that only a handful, 5 to 7 
percent of U.S. medical graduates go into psychiatry residency 
training programs and so----
    Mr. Burgess. There is a reason for that.
    Dr. Das. Residencies are important. But it is not just 
about residency. I think having an additional thousand spots 
would emphasize the importance of this problem in our country 
and that we need to make changes, not just at residency but 
through medical education all the way up to continuing 
education.
    Mr. Burgess. So going back to Ms. Rizzo's point about prior 
authorization, it was my opinion back in the early '90s, late 
'80s that managed care wasn't doing a thing for the practice of 
psychiatry and in fact probably was a barrier for young people 
considering that as a speciality.
    Then on the other hand we have the bill that is--well, 
during the SUPPORT Act we said you don't really even need any 
special training. If you are a nurse practitioner with no 
additional credentials, if you are a nurse anaesthetist who may 
not have ever practiced clinical medicine in a clinic, if you 
are a nurse midwife who may have never practiced outside labor 
and delivery, you can also prescribe buprenorphine.
    So it seemed like on the one hand we are making additional 
requirements and training. On the other hand, we are loosening 
the requirements. So how do you resolve that discrepancy or 
that dilemma?
    Is more training good or is more training just superfluous 
and it doesn't matter--we need to push more stuff out and get 
it out there, even though Ms. Rizzo has testified that there is 
harm that is potential from some of these medication?
    Dr. Ryan. So I would come into the--I think it was the 
previous section when you were out, which is basically we have 
parallel paradigms of this type of training, meaning as an 
emergency physician I went through a very rigorous, you know, 
training program in emergency medicine at the University of 
Cincinnati and had wonderful NPs and PAs who came on board with 
me that had been trained in family medicine. But because I had 
the, you know, upper level of training was capable of bringing 
those folks along and educating them.
    So I would draw that parallel and saying that I think we 
need, you know, education at all levels. In fact, that is why 
ASAM supports the MATE and the MAT Act together in order to 
increase the education.
    Mr. Burgess. Right. But in some states, as you know, there 
is not--in Texas there is. There is supervisory requirement.
    Dr. Ryan. Same in Ohio.
    Mr. Burgess. I don't know about Ohio. But as some states 
there is not.
    Dr. Ryan. Understood.
    Mr. Burgess. And that is what I know Dr. Bucshon when we 
had those hearings he was concerned about, as a cardiothoracic 
surgeon. I think it is something that we need to bear in mind 
that we are being asked now to extend the program before its 
expiration. We have a report due. I just think we ought to 
evaluate the report before we make a new decision.
    So thank you and I will yield back.
    Dr. Ryan. Thank you.
    Ms. Eshoo. The gentleman yields back.
    You know, when we hear these numbers, a thousand--a 
thousand new physicians--when you divide that by 50 states it 
is a handful of people and the needs in our country are great. 
I think this discussion about residencies and all of that are 
really important.
    I think that what we approve we want to make sure that it 
truly is the tip of the spear and that we don't miss the mark 
because of the demands of human beings across the country. We 
have to meet these demands.
    This is--I mean, that statistic I gave that more people 
have lost their lives to this public health challenge than all 
of the lives that were lost in Vietnam. It's a huge number. 
It's a huge number.
    So, collectively, we have our work cut out for us but this 
is the first place where the table is set and we thank you for 
travelling across the country to come here to testify.
    Oh, we still have Doris. I am sorry. I thought you had 
already been recognized. There you are. I would never leave her 
out.
    The gentlewoman from California, Ms. Matsui, 5 minutes. I 
am sorry. I apologize.
    Ms. Matsui. Thank you very much, Madam Chair, for 
acknowledging me. I know you would never forget me.
    And I want to thank the witnesses for being here today on 
this very important topic. And before I get into my questions, 
I want to take a quick moment to recognize the important role 
hospitals are playing in the substance abuse fight.
    In building upon our work here, I believe we should look 
for ways to streamline funding for these entities to improve 
care coordination efforts, reduce emergency room use and scale 
abuse prevention initiatives.
    Now, the availability and use of stimulants like meth and 
cocaine are definitely on the rise, according to the DEA 2019 
National Drug Threat Assessment and it remains widely available 
and the DEA field divisions are reporting an increasing 
availability of drug compared to the previous years and I do 
have to say that I hear it from my healthcare providers all the 
time. It is a cheap drug, easy to make, and the people who get 
it are the ones who are basically on the streets, a lot of 
them.
    Mr. Morrison, your organization convenes stakeholders who 
play a key role in ushering federal dollars into communities 
that need it the most. In your testimony, you mentioned that 
state directors are observing increases in stimulant use. Is 
that correct?
    Mr. Morrison. Yes, it is. In certain states there are 
increases in admissions to treatment that they are reporting.
    Ms. Matsui. Right. I would like to note that when we passed 
the fiscal year 2020 funding package we continued our 
investment in State Opioid Response Grants while also allowing 
grantees to use this funding to address stimulant use.
    Dr. Ryan and Dr. Das, can you describe the differences in 
how we treat a patient with meth use disorder?
    Dr. Das?
    Dr. Das. For psychiatrists and addiction psychiatrists 
generally we would take the same overall approach where we 
assess for things that may be occurring along with that primary 
diagnosis.
    The difference with stimulant use disorder is that we don't 
have a medication in place for us to utilize. However, 
oftentimes with most substance use disorders, they don't occur 
by themselves. They are going to occur with some co-occurring 
disorder, either physical co-morbidities or generally more 
often other mental illnesses.
    And so taking a comprehensive approach to treating all of 
the patients needs gives them the best options and chance for 
recovery.
    Ms. Matsui. Sure. Dr. Ryan, like to make a comment?
    Dr. Ryan. I concur with Dr. Das.
    Approaching the patient in that holistic biosocial model is 
exactly how we should address this. It is unfortunate that we 
do not have medications developed for stimulant use disorder 
and probably was a failure of, you know, 20 or 30 years ago of 
the last stimulant crisis that we had.
    So it is my hope and I am working with the different folks 
and I know that the FDA and other entities are working on 
developing and approving a medication so that we would have the 
full biopsychosocial model.
    Ms. Matsui. Absolutely, because I mean, as sad and as 
severe as the opioid crisis we do have something there and we 
have no pharmacological way to help these people.
    Currently, no law enforcement agency or private party has 
the ability to provide real-time nationwide oversight of all 
orders for controlled substances, which is a major contributing 
factor to disproportionate prescription opioid shipments to 
certain pharmacies across the country.
    Distributors especially lack any visibility into the total 
volume of opioids that customers purchase from other suppliers, 
severely hindering their ability to make fully informed 
assessments of an order that could potentially be suspicious.
    Mr. Botticelli, given your experience would you agree that 
the identification of patterns and trends in detecting real 
time drug diversion would be an important step in addressing 
this country's opioid epidemic?
    Mr. Botticelli. Incredibly helpful. You know, one of the 
things that I felt hamstrung by during my time in Washington, 
both on the law enforcement side and the public health side is 
lack of access to real time data, and I always felt it was hard 
to see where you are going if the only tool you have is a rear 
view mirror. And I really felt hampered by our ability to 
understand things like where parts of the country--hot spots in 
parts of the country or where we were seeing--where we needed 
to plow additional public health resources.
    And, unfortunately, it was only until people died that we 
actually had that information. So I think anything that the 
committee can do to really strengthen both our law enforcement 
and public health data in a real timely way.
    Ms. Matsui. Right. And I agree with you. I believe creating 
a DEA program that collects and shares in real time data of 
every sale, delivery, or disposal of controlled substances is 
essential.
    So I ask my colleagues to support my bill with 
Representative Johnson, the Suspicious Order Identification Act 
of 2019, to achieve this goal. You need as much information as 
possible and we would like to get there.
    So thank you very much. I yield back.
    Ms. Eshoo. The gentlewoman yields back.
    Anyone--no, Mr. Tonko is not here. I thought he was coming 
back to waive on.
    Timing is everything. Mr. Welch of the great state of 
Vermont, you are recognized for 5 minutes.
    Mr. Welch. Thank you very much.
    Some of you might have been here for the first panel. 
Incredible challenge. But the big challenge for a lot of us is 
the workforce. It is unbelievable, as you know, I mean, 
especially in a state like Vermont.
    But Vermont is not at all atypical. I mean, the number of 
nurses we had, LPNs, among others, doctors, regular physicians, 
it is really declining precipitously just in the last 15 years.
    And, first of all, I would just ask Mr. Morrison, that 
dynamic that I am talking about, is it your awareness that that 
is very typical of a lot of communities across the country?
    Mr. Morrison. In terms of struggles with workforce and 
workforce development, absolutely. I would say it is consistent 
across our members across the country.
    Mr. Welch. Yes. Dr. Das?
    Dr. Das. In California, yes, we are also facing workforce 
shortages and with the APA we are wanting to increase the 
number of psychiatrists that there are and the amount of 
training that psychiatrists would get in substance use 
disorders.
    Mr. Welch. So we are looking for solutions and one of the 
proposals is to have more GME residency options. Anybody want 
to comment on whether that would be helpful or not?
    Go ahead.
    Mr. Botticelli. I will start. I think it is incredibly 
helpful. You know, we do a significant amount of medical 
residency training and fellowships for addiction medicine.
    But we don't have enough slots to meet demand for it and I 
think having more trained professionals, quite honestly, you 
know, we need a trained workforce at all levels of the 
organization. Not only at the physician and psychiatrist level 
but at the nurse level, at the licensed counselor level and 
even with people with experience.
    Mr. Welch. Right. And is it the case--I don't know what the 
stats are--that if you get your degree at a local institution 
the likelihood is that you will--there is a higher likelihood 
you will stay rather than leave?
    Mr. Botticelli?
    Mr. Botticelli. I think that anything that we can do to 
kind of recruit and retain a workforce is incredibly important. 
I will tell you that as states have expanded services, we are 
poaching from each for a trained workforce, which is not what 
we want to be doing here.
    Mr. Welch. Right. And then a lot of hospitals are having 
travellers, right. Ms. Rizzo, do you want to comment on that?
    You know, it makes me nervous. I had a relative in a 
hospital and we had great nursing care. But then we had a lot 
of people who were coming and going.
    Ms. Rizzo. Yes, it is difficult. In New Jersey medical 
directors and physicians are very hard to come by. We are 
required to have an opioid treatment program. We have to have a 
medical director and a medical director designee who has the 
same certifications as the medical director.
    But, again, counselling is another area that is greatly 
lacking. Again, we have to have 50 percent--50/50 ratio of 
licensed counselors to counsel interns, and as programs are 
opening, broadly, throughout the state we are all scrambling to 
build up the workforce so it is very difficult.
    Mr. Welch. So what are the impediments to having a 
workforce?
    Ms. Rizzo. Well, I think one of the things, and I think it 
was in the SUPPORT Act about the loan forgiveness, I think that 
is really important.
    But it is just enticing people to come into the field. So 
it is just--it is a battle that we all face.
    Mr. Welch. But the pay is reasonably good, right? I mean, 
it is not like----
    Ms. Rizzo. No.
    [Laughter.]
    Mr. Welch. All right. We want a raise.
    Ms. Rizzo. You know, it is getting better. With Medicaid 
reimbursements and now Medicare we have definitely been able to 
grow with our census and we have been able to lift the salaries 
of our staff.
    But it is difficult to compete and especially, you know, we 
are a private nonprofit and we are competing against some of 
the larger for profit programs and it is difficult.
    Mr. Welch. Yes. OK. Well, I just want to thank you all, and 
I will yield back. Thank you very much.
    Mr. Burgess. Will the gentleman yield his last 46 seconds?
    Ms. Eshoo. Yes.
    Mr. Welch. I will. Thank you.
    Mr. Burgess. Just before this panel, it is such a smart 
panel and before you leave and I think, particularly, Dr. Das, 
I wanted to ask you--you might have heard me ask our agency 
group about the IMD exclusion, and I thought we had dealt with 
that in the SUPPORT Act.
    Perhaps we didn't deal with it as effectively as we might 
have. Do you have any thoughts on the IND exclusion and how it 
is contributing to the ongoing problems that we are having?
    Dr. Das. Continued exclusions further silo the access to 
care problem that we have and so I would say that while there 
are many things that were part of the SUPPORT Act enforcement 
and having those carried out properly still are panning out.
    Mr. Burgess. Well, Medicaid has been held up to us as 
perhaps one of the better providers but with the Institute of 
Mental Disease exclusion, you can only have 16 beds with 
Medicaid patients who are hospitalized. It just seems to me to 
be an impediment as to way the world is now. It is different 
from what it was in 1960.
    I think--maybe we can have a hearing on that at some point. 
I think that will be a good idea. I will yield back to the 
gentleman.
    Ms. Eshoo. The gentleman from Vermont yields back and I see 
that Mr. Bilirakis has returned. The gentleman from Florida--
you are recognized for 5 minutes.
    Mr. Bilirakis. Thank you, Madam Chair. I appreciate it so 
very much. Thanks for holding this hearing. I thank the ranking 
member as well and, of course, the presenters.
    Dr. Das, is telepsychiatry an effective--an evidence-based 
method for improving access to mental health and substance use 
disorder treatment?
    Dr. Das. During my time at the VA as the director of 
addiction treatment services, I had the honor of using 
telepsychiatry to reach veterans in remote areas, veterans who 
not only were in remote areas but also oftentimes as a result 
of their co-occurring mental illnesses or PTSD, for example, 
couldn't get to our clinic sometimes 40 miles, 80 miles away.
    In using telepsychiatry I was able to assess them 
oftentimes in person when there was something acute but then 
continue to treat them through telepsychiatry very effectively 
with them going to the local community-based outpatient clinic.
    These folks felt and told me more than once throughout 
their treatment that they felt like this was a lifesaver, that 
had they not learned about this option, they wouldn't be around 
and that having the ability to see me through the video was 
life changing for them.
    Mr. Bilirakis. OK. So needless to say--suffice it to say 
that you endorse it?
    Dr. Das. Yes.
    Mr. Bilirakis. OK. Are there patient populations like 
patients with autism spectrum diagnosis, severe anxiety 
disorders, or geriatric patients with physical limitations who 
may prefer and benefit from telepsychiatry compared to its in-
person counterpart?
    So, again, elaborate on how effective it is but let me ask 
one more question here because it is related. How can 
telepsychiatry lead to improved overall patient outcomes 
including shorter hospitalizations and improved medication 
adherence? What barriers still exist to telepsychiatry, in your 
opinion?
    Dr. Das. I think one of the----
    Mr. Bilirakis. What barriers still exist?
    Dr. Das. So the care is available and we have been able to 
do it--for example, at the VA we have been able to use 
telepsychiatry. Telemedicine is available across the VA across 
all disciplines and we use it, for example, in wound care so 
that somebody doesn't--somebody who may be an older patient who 
is limited physically may not be able to come in for wound care 
post-surgery and so they are able to do wound care even through 
telemedicine.
    And so the same sort of things apply for telepsychiatry, 
that we would be able to have continuity of care, easier access 
to care. I think the--you asked about barriers, I think, and 
kind of--I have been speaking about the VA because that is 
where I have done most of my telepsychiatry work. But the 
barriers to care in the general public are reimbursement for 
telepsychiatry.
    Mr. Bilirakis. Reimbursements. OK. Thank you.
    And in your opinion across the board in the medical 
community, particularly in the psychiatric community, 
professionals endorse this form of therapy, correct? Across the 
board.
    Dr. Das. Well, the APA has----
    Mr. Bilirakis. In general.
    Dr. Das [continue]. A telepsychiatry initiative. They have 
resources available for telepsychiatry and information on the 
evidence base for telepsychiatry across the board, across all 
physicians. I wouldn't be able to speak for all physicians but 
I think there is a movement towards getting people quicker 
access to care and removing barriers.
    Mr. Bilirakis. Absolutely. Access is definitely the key.
    Madam Chair, I recently co-sponsored a bipartisan bill with 
Congressman Soto called the Enhanced Access to Support 
Essential, or EASE for short, Act--Behavioral Health Services 
Act and it is H.R. 5473. H.R. 5473 builds upon the SUPPORT Act 
to connect patients without a primary diagnosis of an SUD to 
the Behavioral providers they need via telehealth.
    My bill enables Medicare reimbursements, to your point--
Medicare reimbursements for behavioral health services 
delivered via telehealth while also supporting school-based 
behavioral health services delivered via telehealth--so very 
important as well.
    I ask for unanimous consent to include a letter of support 
of H.R. 5473, the EASE Behavior Health Services Act, from the 
American Psychiatric Association, and I have the letter here 
somewhere, Madam Chair.
    Ms. Eshoo. Well, you find it and we will put it in the 
record.
    [The information appears at the conclusion of the hearing.]
    Mr. Bilirakis. Thank you. I appreciate that. Thank you. I 
am going to yield back, Madam Chair. Thank you very much for 
giving me the time.
    Ms. Eshoo. The gentleman yields back.
    We have been joined by the gentleman from New York, Mr. 
Tonko, and we are glad that you are back and waiving on.
    Mr. Tonko. Thank you.
    Ms. Eshoo. It is really nice to see you here. You have 5 
minutes.
    Mr. Tonko. Thank you, Madam Chair. Thank you for allowing 
me to waive on and welcome to our panellists.
    Ms. Rizzo, let us start with you. I would like to begin by 
asking you some questions that require a simple yes or no. Does 
a medical provider need to obtain a special waiver from the DEA 
in order to prescribe fentanyl?
    Ms. Rizzo. No.
    Mr. Tonko. Does a medical provider need to obtain a special 
waiver from the DEA in order to prescribe codeine?
    Ms. Rizzo. No.
    Mr. Tonko. How about morphine?
    Ms. Rizzo. No.
    Mr. Tonko. How about hydrocodone?
    Ms. Rizzo. No.
    Mr. Tonko. I think you see what I am getting at here. Now, 
let us talk about buprenorphine for a moment. Wouldn't you 
agree that buprenorphine has a much stronger safety profile 
than the drugs I just mentioned, specifically in that it has a 
ceiling effect that doesn't increase with dosage and that the 
risk of respiratory depression leading to overdose is much 
lower with buprenorphine compared to the other medications that 
I just mentioned? Yes or no?
    Ms. Rizzo. Yes. Can I follow up?
    Mr. Tonko. Thank you, Ms. Rizzo. What I am trying to make 
clear here is that buprenorphine doesn't have a safety profile 
that distinguishes it from other medications that providers can 
freely prescribe.
    So I am trying to rationalize why we continue to make this 
medicine, which has been shown to reduce mortality associated 
with overdose by up to 50 percent, again, reduces mortality by 
up to 50 percent and has a safety profile that is much more 
benign than the powerful opioids that got us into this crisis 
so difficult to obtain. Perhaps it is because there is 
something unique about the practice of addiction medicine.
    So let me ask you, Ms. Rizzo, do you need a special DEA 
waiver to prescribe naltrexone, one of the three FDA-approved 
medications to treat opioid use disorder?
    Ms. Rizzo. No.
    Mr. Tonko. But, Ms. Rizzo, without a special waiver for 
naltrexone how are we going to ensure the quality of care that 
patients are receiving? How are we going to impose the 
reporting requirements that you find so essential for 
buprenorphine? And that is, largely, a rhetorical question but 
let me ask you this.
    Because you seem to think that addiction medicine uniquely 
needs these bureaucratic safeguards in place do you believe 
Congress should require all providers who want to prescribe 
naltrexone have a special DEA waiver?
    Ms. Rizzo. No.
    Mr. Tonko. And the answer is no because it would be 
ridiculous for Congress to impose such barriers to lifesaving 
medicine in the middle of an epidemic. So just to recap here, 
we have an overdose crisis that is killing 67,000 to 70,000 
individuals a year.
    We have a medication that will treat the vast majority of 
these individuals and reduce their chance of death by up to 50 
percent. This medication has a strong safety profile, 
especially when compared to other controlled substances that 
don't require jumping through special hoops.
    Other addiction medications can be freely prescribed 
without a waiver and yet we have set up a system where 
somewhere less than ten percent of our medical professionals 
can offer this lifesaving medication.
    Does anyone actually have any rational defense of this ex-
waiver system that is causing people to die on our streets 
other than it is simply the status quo? Would any of you 
honestly set up a system like this from scratch today? Anyone?
    Ms. Rizzo. Can I respond to that?
    Mr. Tonko. Would you set up a system like that?
    Ms. Rizzo. I wouldn't set up a system like that but our 
concern is the diversion potential for buprenorphine on the 
street and----
    Mr. Tonko. Diversion on the streets when you have a better 
established system for treatment--I don't think it is an 
appropriate argument that there were be a diversion.
    You know what I think? I think this is simply stigma 
written into our laws. It is right there and crystal clear in 
the fact that you don't need a special waiver to prescribe this 
exact same medication for pain.
    But once you want to help someone struggling with the 
disease of despair that is substance use disorder, all of a 
sudden, we throw up all kinds of barriers to a literal miracle 
drug because we simply don't trust the people we are 
prescribing them to.
    Shame on us. We can fix this by passing the Mainstreaming 
Addiction Treatment Act. We can't afford to wait and I thank 
those witnesses and organizations who have offered support for 
this critical legislation.
    Now, Dr. Ryan, can you explain briefly how the current 
waiver system limits access to care, particularly for the one-
third of Americans largely in rural counties who don't have 
access to a single waivered provider?
    Dr. Ryan. Thank you, sir. So I would--I guess I would 
summarize by saying there are many barriers to access to care 
for medication-assisted treatment, specifically buprenorphine, 
and that this is one of them. There are also stigma, 
reimbursement challenges, et cetera, but in--kind of in 
totality it creates quite a barrier for folks to access 
treatment.
    Mr. Tonko. Well, thank you, and let me be clear before I 
wrap up. I agree with many aspects of your testimony, Ms. 
Rizzo, including that there are numerous other barriers we need 
to address like prior authorizations, clinical support for 
providers and better access for our incarcerated populations.
    But the idea that just because other barriers exist that we 
shouldn't knock down the one that is staring us in the face is 
tough to swallow.
    With that, I thank you and I yield back the balance of my 
time, Madam Chair.
    Ms. Eshoo. The gentleman yields back. Seeing no one else, I 
think that our hearing is coming to an end.
    Thank you to each one of you again for travelling across 
the country and, most importantly, for what you do day in and 
day out. This is a huge challenge for all of us and your 
knowledge, your considerable knowledge, is not only a source of 
inspiration to me, I think to all of the members. But it also 
gives me confidence that what you have testified to and the 
answers that you have given will help us to shape legislation 
that is really going to make a difference for people in our 
country and that is what we are here for. So I consider you all 
healers.
    I would also like to submit the following statements for 
the record and request unanimous consent to do so.
    Testimony from Danielle Tarino, president and CEO of Young 
People in Recovery; a statement from the National Association 
of Chain Drug Stores; a statement from Mark Parrino, president 
of the American Association for Treatment of Opioid Dependence; 
a graphic on MAT waiver training produced by Providers Clinical 
Support System; a statement from the National Safety Council; a 
statement from the Medication-Assisted Treatment Leadership 
Council. Never ceases to amaze me all of the organizations we 
have in our country.
    A letter from Ochsner Health System--I think I am 
pronouncing it correctly; a letter from the Opioid Safety 
Alliance; a letter from the American Society of Addiction 
Medicine; a letter from Bill Greer, president of SMART 
Recovery; a letter from the American Society of 
Anaesthesiologists; a letter from the American Psychiatric 
Association.
    I don't hear any objection so I will say so ordered.
    Ms. Eshoo. And I know that each one of the witnesses will 
on a timely basis, respond to any written questions that are 
submitted to you and I want to thank you in advance for that.
    Bless you in your work, and with that the subcommittee will 
now adjourn. Thank you, everyone.
    [Whereupon, at 2:53 p.m., the committee was adjourned.]
    [Material submitted for inclusion in the record follows:]

                 Prepared Statement of Hon. Greg Walden

    The United States remains in the midst of an opioid crisis 
that is a national emergency. Under my leadership in the last 
Congress, the Energy and Commerce Committee took the lead in 
addressing this crisis head on. We took input from Members on 
both sides of the aisle, from both on and off the committee, at 
our Member Day before this subcommittee. We then held numerous 
bipartisan hearings, briefings, and roundtables with experts, 
stakeholders, law enforcement, individuals in recovery, and 
family members of opioid abuse victims in order to build off 
the prior work of both the Comprehensive Addiction and Recovery 
Act and the 21st Century Cures Act in the previous Congress. 
Our efforts culminated into one of the most significant 
congressional efforts against a single drug crisis in history: 
the Substance Use-Disorder Prevention that Promotes Opioid 
Recovery and Treatment, or SUPPORT for Patients and Communities 
Act, which was signed into law by President Trump on October 
24, 2018.
    Yet, we made clear that the SUPPORT Act would not our last 
effort to address this crisis. Careful and thorough evaluation 
of the law's implementation is necessary even as we continue to 
explore additional needs for new legislation. I know that our 
side will have questions about the SUPPORT Act's 
implementation. We want to be sure deadlines are being met, and 
Congress' intent is being fulfilled by the Administration. I 
hope that today's testimony will allow us all to learn more 
about the Federal Government's shared efforts and to drill 
deeper to learn what's working and what's not working.
    However, I'm disappointed at the rushed nature of today's 
hearing, and that the majority has seemingly combined a SUPPORT 
Act implementation hearing with a legislative hearing. While 
both are necessary, this feels more like an exercise to "check 
the box" instead of a meaningful discussion of next steps.
    On the legislative front, I am pleased that we are 
reviewing H.R. 2281, the Easy MAT for Opioid Addiction Act, 
along with H.R. 3878, the Block, Report, And Suspend Suspicious 
Shipments Act, H.R. 4812, the Ensuring Compliance Against 
Opioid Diversion Act, and H.R. 4814, the Suspicious Order 
Identification Act.
    These bills address policy issues that were identified in 
the committee's 2018 report summarizing the committee's 
bipartisan investigation into the distribution of prescription 
opioids by wholesale drug distributors, and enforcement 
practices by the Drug Enforcement Administration (DEA).
    However, I am disappointed that H.R. 2062, the Overdose 
Prevention and Patient Safety Act, a bipartisan bill that would 
make meaningful changes to 42 CFR Part 2, was not included in 
today's hearing. This bill passed the House in the last 
Congress 357-57 and has been identified numerous times as a 
potential game-changer in addressing the crisis.
    Also worth noting is the absence of H.R. 4963, the Stop the 
Importation and Manufacturing of Synthetic Analogues (SIMSA) 
Act, bipartisan legislation introduced today by Reps. John 
Katko (R-NY) and Kathleen Rice (D-NY) to combat illicit 
fentanyl. Fentanyl and other synthetic drugs are devastating 
our communities at a rapid pace and SIMSA would provide law 
enforcement with the tools they need to stopthese deadly drugs 
from entering our country, without compromising important 
public health and research protections.
    These bills and others today represent additional 
bipartisan steps Congress could take-right now-to continue to 
combat this crisis.
    Some of the bills included in today's hearing are 
problematic for our side. Two bills, H.R. 2922 and H.R. 2482, 
make significant changes to the waiver requirements for the 
administration of medication-assisted treatment, or MAT. These 
initiatives are extremely costly and premature, given we just 
made changes to the waiver process as part of the SUPPORT Act. 
The SUPPORT Act also commissioned a report to access the care 
provided by qualifying practitioners who are providing MAT to 
high numbers of patients. We need to see the data and 
recommendations of that report to make the appropriate next 
steps in this area.
    Finally, H.R. 4141 would repeal the Medicaid Inmate 
Exclusion in its entirety. This bill is a non-starter. Instead, 
we have H.R. 1329, a bill that would allow Medicaid coverage 30 
days before leaving the Jail or Prison. This "warm hand-off" 
approach is something I think merits further consideration and 
I am happy it is included here today.
    One additional item we could explore having the Medicaid 
Inmate Exclusion not apply until a person is convicted of a 
crime. About 60 percent of people in jail have not been 
convicted. This approach could alleviate the burden jails face 
of providing care for people who are still considered innocent. 
That, in conjunction with Mr. Tonko's 30 day prior to release, 
seems like an area ripe for bipartisanship.
    We have a lot of ground to cover today and it is my hope 
that we can work with the majority to address our concerns so 
that we have bipartisan consensus before any markup. To our 
witnesses today, I thank you for providing your feedback as we 
need your help to continue to address this critical issue.

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