Transcripts For CSPAN2 State Officials Testify On Opioid Epidemic 20170712

The 2016 we learned from the New York Times weve lost roughly 60,000 people to Drug Overdoses. That is more in one year that all the names on the Vietnam Veterans Memorial Wall and likely, that number is underestimated because much of the data will not be in until the end of this year, 2017. Its staggering. For every fatal overdose its estimated there are 20 nonfatal overdoses and for 2016 that could mean your 1 million. 183,000 lives have been lost in the us from overdoses between 2015. Thats about 50,000 we lost over the last, 500,000 we lost over the next decade. The roots of this crisis began in 1980 when a letter to the editor in the journal of medicine was misinterpreted as evidence. It was unlikely someone become addicted out of 4000 cases a center was only four connections. Years later the joint Commission Following the american medical associations recommendation assessment established standards for Pain Management interpreted by many doctors as encouraging the prescription of opioids. Under the Affordable Care act, prescribing opioids is incentivized where that pain was adequately addressed. Based on their answer, they may receive more or less money. As we learned in our oversight hearing held in march the Opioid Epidemic is an Urgent Public Health threat fueled by a much more synthetic open opioid and a clear and present danger. Stage represented on todays panel, were the first ones hit by the fentanil wave and it seems certain this way will sweep the nation as hard to detect profile of fentanil is increasingly attracted to traffickers and easy to manufacture over the internet. This is an in extremist moments requiring all the experience, resources, cooperation of our federal, state and local governments as well as Different Industries to curb this terrible outbreak. His hearing we will focus on the actions of our State Governments to find out what efforts are working, not working and how we can Work Together to save lives. We want to know the problem and please be candid with us. As you know, there are families being torn apart by this. The drug industry, as one policy experts, sally petrone noted it is at the state and local level that the progress will be made. It makes sense that efforts to find solutions the most concentrated there and we should invest in those solutions and learn from them. State governments have been pursuing a innovative initiatives as well as inventive use of incentives, structured medication and more comprehensive Prescription Drug monitoring. States such as maryland are making the best use of the opioid prescribing guidelines to prevent overprescribing. Kentuckys electronic reporting system known as casper where they had Monitoring Systems to help your prescriptions lose use across the state helping regulators identify questionable prescribing practices by physicians and abused by patients. Virginia has expanded access to the lots owned, the drug that can reverse an overdose that can have its own risk in its use. Some states are expanding the availability of naloxone by prescribing family and friends and individuals who are susceptible to overdose. Rhode island has developed a program that matches overdose victims with your recovery to encourage treatment for the next 10 days after the overdose. Much of the work of the states should help inform the president Opioid Crisis. Three years ago the subCommittee Held a hearing on what State Governments were doing to combat the opioid abuse epidemic. The oversight helped congress and asked kera and help that will help the administration put 1 million of grant for the next two years but we want to know if this money is being used wisely and whether its working. We are eager to learn about those programs. The Security State program is just the beginning. Our State Government assistance can help these cities develop a more Effective National strategy to combat the Opioid Crisis in areas of Substance Abuse prevention and education, training, treatment and recovery, Law Enforcement expanded access while testing for drugs in correctional facilities, Data Collection and determining what reforms can men be made to the cfr and better coordination among care among physicians and we can prevent relapses and improve patient safety. We are in one of the worst medical tragedies of our time , perhaps the worst. Although this committee has given the subcommittees attention to many other problems in the past, we recognize this is paramount among them. This is a National Emergency and we look forward to hearing from the states and what you are doing on the frontline and i yield to my colleague. Thank you so much mister chairman and i appreciate this most recent hearing on opioid addiction. As you said, so accurately, this crisis is really devastating america as all of us in our community. Urban and rural alike, not a day passes without a report about children watching their parents overdose, about librarians and School Nurses being trained to administer naloxone to overdose victims, about local and State Governments trying to respond to the issues surrounding addiction. All of the same time trying to stay within their budgets. There is some good news, recently the cdc reported that opioid prescriptions in 2010 peaked and has since fallen by 41 percent. Thats the good news. The bad news is opioid prescribing remains uncannily high and im hoping our future investigations will concentrate on that. In addition as you pointed out mister chairman, as the emergence of illegal fentanil which is an exceptionally potent opioid. In 2017 fentanil undertook heroin and prescription opioids as the leading cause of death in many places. Each of the state who are here today and i want to thank you all for coming out these alarming overdose outbreaks rate due to this drugpervasive used in this nation. This committee has done good work , in particular investigating the seemingly voluminous amount of coke distributed in West Virginia and i know we are planning to do more. As you know, a number of secretarygeneral are investigating manufacturers and in some cases distributors. The attorney general in my home state of colorado for example has joined a Bipartisan Coalition of states nationwide looking into whether manufacturers engaged in illegal or deceptive practices when marketing opioids. Coming up with an effective solution to the Opioid Epidemic will require us to understand the actions of all actors. I hope to hear from from the sum of the states today on what role they believe drug manufacturers and distributors maybe adding to the crisis. Also, i look forward to hearing from the panel about the impact of fentanil on the towns and communities in which they work. States really are on the frontline of fighting this crisis and i look forward to hearing from all of you. I know rhode island for example has led the way in reconnecting people with Substance Abuse disorders to highly trained coaches to guide them through recovery. Virginia isworking to implement a similar pure Recovery Program and kentucky has established a program to provide medication , assistant treatment to individuals in correctional facilities and to continue supporting them after their release. Maryland has committed to establishing 24 hour Crisis Centers in Baltimore City. Mister chairman, i know these are all great state efforts, weve made some efforts here in congress and i appreciate you referring to the 21st century care legislation that congressman absent and i sponsored and that this whole community Work Together on a bipartisan basis to pass but as we work to move forward on this issue, we need to Work Together to continue to address this and thats why i kind of hate to be the fly in the ointment and talk about what these effort to repeal the Affordable Care act will do to the fight against the Opioid Epidemic. As you know, the aca has helped nearly 20 million americans obtain health care coverage. In addition, its enable governors to expand Medicaid Services critical to the fight. For example, studies show that since 2014, 1. 6 million americans gained access to Substance Abuse treatment across the 31 states that expanded medicaid coverage. This is particularly true for hardhit states like kentucky where one Study Reports that residents saw a 700 percent increase in medicaid beneficiaries facing treatment for Substance Abuse. Many people think that the house passed bill that undermines the aca will threaten peoples ability to get opioid treatment. And its assessment, the nonpartisan cbo said the house bill would cost 3 million or 22 million americans to lose Health Insurance. A lot of these people, they need opioid treatment. There have been discussions both in the house bill and send discussions about adding some money for opioid treatment but for example, the most recent senate suggestion of an additional 45 billion to help combat opioid addiction, Governor John Kasich said its like spitting in the ocean, its not enough. We have to understand access to healthcare treatment is what is going to help with the health of all americans including the opioid addiction andweve got to move forward to work on this together. I hope we can do that and with that i will yield back. Vice chairman and full committee, mister walden. Addiction is an equal opportunity destroyer. Its a crisis that is not attack people based on their race, age or socioeconomic status and does not pick them based on political parties. My own table through origami, it didnt matter if i was in a Rural Community or more popular city, the stories were similar and i we all know someone weve been impacted. In my state, more people die from drugrelated overdoses and automobile accidents and sadly thats not unique. According to preliminary data, Drug Overdose death in 2016 exceeded 59,000 people. Thats the largest annual jump ever recorded in the United States and whats worse, some of the preliminary numbers from the state indicate there are numbers within the First Six Months of this year are already surpassing last years total numbers and over the past seven years, opioid addiction diagnoses were up 500 percent according to a recent report. The bible report released by the centers for Disease Control indicate the number of opioid prescriptions has decreased over the last five years, thats the good news. The rates are still three times as high as they were in 1999 and the amount of opioids prescribed in 2015 was enough for every american to be medicated around the clock for three weeks. That report also found the counties in oregon on how some of the highest levels of opioid prescriptions in the country, of top 10 counties in my state for opioid prescriptions, five of them are in my rural districts. Organizes the five and older are being hospitalized for overdoses and other complications and a far higher rate than any other state in the union. Sadly, Overdose Deaths in this epidemic are simply getting worse and more severe. So challenges remain and we need to get accurate. First we need to improve Data Collection and a few states are requiring more specific information related to Overdose Deaths by simply, we cannot solve what we do not know. We need to be able to have more reliable data so we can better understand or address the full scope of the problem. There also needs to be an increase in Overdose Prevention efforts, improvement with respect to the utilization and operability of Prescription Drug Monitoring Programs and we need to increase access to programs including medication assisted frequent. And this epidemic requires an all hands on deck effort from federal, state and local officials and all of us standing from healthcare efforts to local Law Enforcement community. Its precisely why we are having this hearing today. Action to combat the spices by passing legislation including the comprehensive Addiction Recovery act and the 21st century jurors act and state to pursue programs that strengthen our fight against his academic. But much more needs to be done. We need to Work Together to ensure the tools and Funding Congress has created are reaching our state counties and they are being used effectively. We will hear from state officials today and see how they are utilizing these funds and whether these programs work or not. We greatly appreciate the witnesses who have agreed to appear before us today. We hope to have a constructive dialogue about what the states are doing, how we can improve Data Collection, initiatives are working and how the federal government can be a better partner. We look forward to your testimony and working with all of you and our Community Leaders to help get our hands on this or crisis so thank you for being here. With that i have to members that want to introduce witnesses to allow the first to mister buckley. 90 mister chairman for letting me sit in for purposes of introduction. I went to introduce our secretary in kentucky, secretary tilly. Been friends for a long time and served in the General Assembly together. Secretary tilly had a strong reputation as judiciary chairman working with the senate to produce legislation that i think is landmark and was very important. And we have so much to do in kentucky, 1404 people that passed away last year from opioid addiction. Theres so much to be done were saying thank you for the work youve done, i know we have enormous work to be done and i can tell my colleagues in the committee and my friends that i can think of nobody else in kentucky id rather have leading this effort and i applaud the governor for making the choice and asked to serve in his cabinet and appreciate your willingness to do so and i think you will make again. I recognize the gentleman from virginia mister gifford. I appreciate that. Id like to introduce secretary brian moran. Brian was prosecutor first when he came to the Virginia House of delegates where he and i served, he was a leader on the other side of the island but he was always a pleasure to work with and i appreciated his work very much and he became the first secretary of Homeland Security in virginia sensory and has oversight over 11 agencies but is generally well reasoned. Every now and again we would disagree on the floor of the house but we Work Together on a number of things and i apologize, Mister Guthrie and i have to run to another committee where we have two bills that are upstairs so i wont be able to stay but i will read with interest your testimony and learn from my colleagues the good work that you have to say and welcome you to our committee and apologize that i cant be here because im defending a bill upstairs. With that i will yield back the balance of my time andunfortunately i too must go to that subcommittee. Secretary moran is the spitting image of his brother and i recognize the chairman for five c minutes. Thank you mister chairman thank you for holding this hearing on this critical issue. Our Committee Held several meetings on the Opioid Crisis including one in march, the Opioid Epidemic is not letting up and neither can our efforts to fight. Our last year and many more lives have been destroyed and theres no community that remains untouched by the Opioid Crisis. Recently the cdc reported the opioid prescribing rates as the butt remains far too high with enough opioid every american medicated around the clock for three weeks and im glad we have the states here today so we can hear about what they are seeing on the front lines and what successful approaches have found that deserve to be replicated and what challenges they face. Id like to hear from our witnesses about how the federal government can help support in this case and the power to address the challenges of the community, our response to this epidemic cannot be 51 separate efforts. We must harness our Resources Data in cooperation to get this crisis under control but as we talk about a Public Health crisis of this magnitude there is an elephant in the room that needs to be addressed. Coverage for Substance Abuse treatment is how an individual in society as a fighting chance to kick the Opioid Epidemic. Healthcare is one of our strongest weapons in the battle against opioid and the devastation it causes to our families yet republicans persist in their attempts to the Medicaid Program by tapping it permanently and ending Medicaid Expansion as part of its efforts to repeal the Affordable Care act. Revealing the Affordable Care act and replacing it with from care would be devastating to 74 million americans who receive Healthcare Services from the program. One in five americans receive their Health Insurance from medicaid, half of all the babies born in this country are financed by medicaid and to the working poor, many of whom are hard by the Opioid Epidemic and are eligible for care through the aca expansion, medicaid is literally the only affordable Health Insurance available and make no mistake , state Medicaid Programs are at the center of the Opioid Epidemic area yet in the house passed from care, ceo determined 23 million americans would lose coverage, a number of them covered through medicaid with 834 billion in cuts to the program. The Senate Version of trumpcare is no better, cutting medicaid by a full 35 percent over the next two decades. These cuts could not come at a worse time from the perspective of the Opioid Crisis for states and people who depend on the coverage medicaid provides. Theres no substitute for coverage for our state for people who need to care. As the Senate Continues to make cosmetic changes to its bill with one goal in mind, passing any bill out of the senate, lets be clear. No onetime amount of funds, whatever that amount will be will ever replace the certainty of comprehensive coverage. No cosmetic changes can offset the damage that could because by repealing the aca and cutting billions of dollars to the Medicaid Program so we must stay vigilant in this fight and remain open to any solution that shows promise. I thank you for having this hearing but i believe there is no way this crisis can be sold with onetime infusions of resources and will only get worse if medicaid dollars are removed from the fight. Lets invest in our Healthcare System and its programs for the longterm and medicaid is still a critical pillar that should be strengthened, not decimated and i fear that if republicans are successful in passing trumpcare, we will go the opposite direction when it comes to fighting the drug problem that hasdevastated our communities. Thank you and i yelled back, i dont think anybody on my side once the time i will yield back. That you for your comments. I ask unanimous consent that the members be introduced into the record and i also know that two former members of the committee, mary bodo and philip angry are present and i believe that was around yesterday too, obviously this is an important issue to those who are alumnus in this committee. We heard introductions and im going to introduce the rest of our panel, the honorable boyd rutherford, governor of maryland this year and as mentioned before, secretary moran, secretary kelly and director rebecca bost, director of the department of Behavioral Health and Developmental Disabilities for the state of rhode island. Thank you for providing testimony, we look forward to our discussion of the Opioid Crisis in our nation and as i mentioned, i want you to be brutally candid with us on what the problems are, what we need to do and what are the gaps. You are all aware the committee isholding a hearing and when doing so has the practice of test taking testimony under oath. Do any of you objecting to testify under oath . We would advise you under the rules of the house and committee youre entitled to be advised by counsel. Do any of you desire to be advised by counsel during testimony today . In that case, rise and i will swear you in. Views where the testimony you are about to give is the truth, whole truth and nothing but the truth . You are now under oath and subject to these set forth in title 18 01 of the United States code. We ask that you receive a five minute summary of your statements, please Pay Attention to the timing and we go to government for, you may begin. Make sure your microphone is turned on. Thank you chairman murphy, Ranking Member duquette, honorable members of the subcommittee, thank you for the opportunity to join you to discuss the state of maryland response to the heroine and Opioid Crisis. Back when this emergency in the states a coordinated response from federal, state and local governments and maryland looks forward to continuing working together with our federal partners to address this challenge. Governor hogan and i first became aware of the level of this challenge while traveling throughout the state during our 2014 rhetorical campaign. We quickly realized the epidemic had crept into every corner of our state, cutting across demographics. Maryland, like most state has experienced an increase in the number of deaths related to opioids. In 2016 through 2089, marylanders died from alcohol or drug related intoxication. 66 percent increase over the deaths in 2015. An 89 percent of those deaths were related to opioids. Maryland has seen an increase in prescription opioid related deaths so we have, we must address this particular element of the crisis. We must focus on reducing the inappropriate use of prescription opioids while ensuring patients have access to appropriate Pain Management. In maryland there were over 8. 8 million total cds prescriptions dispensed in 2016. This is 8. 8 million in a state with 6 million souls. Further, the challenge we face has evolved. As was mentioned, chief honorable and deadly synthetic opioids have burst onto the market, bringing a much higher overdose rate. Deaths related to fentanil have increased from 29 in 2012 2 1100 in 2016 in maryland. Accordingly as one of the governors first asked in 2015 was to establish the heroine and Opioid Emergency Task force which he asked me to chair. After nearly a year of stakeholder meetings and expert testimony and research, the task force adopted 33 recommendations those recommendations range from prevention , access to treatment, alternatives to incarceration, enhanced Law Enforcement and more and they form the foundation of our statewide strategy. Building on those recommendations , the maryland General Assembly passed several contents and pieces of legislation. In 2016 we report our Prescription Drug Monitoring Program to require mandatory registration for all cds providers and passed reinvestment act to perform our criminal Justice System to shift from incarceration to treatment for offenders who are struggling with addiction. What we set out to do was make a distinction between those who we are upset with and those who we are afraid of. This past legislative session, maryland past the heroine and opioid prevention effort or hope act and the treatment act of 2017 which contains provisions to improve patient education, increase Treatment Services and provide greater access to naloxone. The governor stop sign the Start Talking maryland act which will continue to build pool and communitybased education and awareness efforts to bring attention to this crisis. Educating young people on the dangers of opioids and an earlier age was something our task force felt was extremely important. As i said over and over again, excuse me, virtually every thirdgrader can tell you how bad it is to smoke cigarettes, but they cant tell you how dangerous it is to take someone elses prescription medications. With the deadly sturgis index on the scene, we saw the death toll continue to rise. Accordingly in january of this year, Governor Hogan established the opioid Operational Command center, the Center Brings opioid response partners together to identify challenges that establish a systemwide priority and capitalize on opportunities for collaboration. There is a formal and a coordinated approach utilizing the National Incident Management System to develop both state and local Strategic Operational tactical level concepts for addressing the heroine and Opioid Crisis. After its creation the governor declared a state of emergency in response to this crisis. By executive order e dedicated, delegated Emergency Powers to state and local Emergency Management officials to enable them to fasttrack ordination with state and local agencies. Ask your leadership and commitment, the funding of the 21st century cure act as greatly aided in his effort and these dollars will be used in expanding educational efforts in the schools, Building Public awareness and improving treatment , expanding rp a recovery specialist programs and increasing the ability of naloxone. The one thing that i would add that we would like to see from the federal government is to consider utilizing fema as an outline of outlined in the National Emergency framework to centralize and coordinate the response to this crisis. The National Response framework is a guide to how the nation responds to all types of disasters and emergencies and would allow federal agencies to work more seamlessly with each other and with the agencies at the state level. We cant afford to have delays due to agency silos and bureaucracies. We appreciate this opportunity to talk to you and await any questions you may have, thank you. Kamran, youre recognized for five minutes. Im still very much an honor to be with you and to be able to discuss with you virginias response as well as working with you to request assistance of the federal government to combat this epidemic. As has all been agreed and said this morning, america is in the midst of an opioid and heroine epidemic , the epidemic does not discriminate, it is an equal opportunity killer. In virginia in 2016, 1133 individuals died from opioid overdose. The sad truth is that virginia lawrence 18 among the 50 states in opioid deaths, sadder than that 17 states are doing worse than we are and in all likelihood the other two states will be facing similar devastation if we dont take effective action now. These as secretary of Public Safety and Homeland Security i am proud of virginias officers to work 24 seven, 365 to keep us safe. But they tell me over and over again is we cannot arrest our way out of the heroine and opioid addiction crisis. We cant simply tell those living with addiction to get over it. Why is that . Because addiction is a disease, arrest and incarceration of those addiction will know more to reduce disease and cancer or diabetes. There are a number of causes, multiple causes ofthis rise in the deadly epidemic , overprescribing, or to dispose, easy access and affordability. But over the past several years weve seen a sharp rise in illegally manufactured synthetic opioids such as fentanil and carfentanil, legal and even tiny amounts. They contribute significantly to the increase number of heroine and opioid deaths from 2015 to 2016, fatal in overdoses involving fentanil increase hundred 75 percent and accounted for 300 percent of the deaths in the commonwealth. Virginias response, virginias response to this epidemic began immediately upon mcauliffe taking office in 2014. He convened a Broad Coalition of Healthcare Providers, criminal justice representatives and Community Stakeholders to participate in the Prescription Drug and heroin use task force. Secretary of health and Human Resources cochaired the committee with myself. Task force developed a 50 recommendations, im proud to say we have implemented the vast majority of those recommendations, a full list of which can be found in my submitted written testimony. The work continues in virginia. Our team works across State Government and with agencies and individuals to effectively align goals, share best practices and work to overcome barriers to success. Readership team organizers statewide approach to the Opioid Crisis and provide leadership for the Virginia State police, department of health, and from our local Community Service providers. That is the theme that this is not just a Law Enforcement problem but rather one that requires Healthcare Providers to be at the table along with their community providers, Community Service providers. They support task forces and other collaborations including those that exist within virginias highly designated areas which cover parts of northern virginia, appalachia and the roads so theres more work to be done, lets highlight some of our punishments and end legislation expanding the deployment of naloxone, ole state agencies like our department of forensic scientists and others working with dangerous drugs of being trained in using this overdose reversal agent through the department of Behavioral Health and Developmental Services revise program. Our commission of department of health issued a Standing Order or pharmacies to dispense naloxone. The department of criminal Justice Services issue grants to pay for increased naloxone to be used by Law Enforcement, the city of Virginia Beach has used naloxone now and they had over 60 deployments to save lives in the community. Now, our requests. I came into this job with a mandate from my 11 Public Safety agency that we would rely on datadriven decisionmaking. If we had gone to effectively wrap our arms around this epidemic and released the devastating upper trend in deaths, overdoses and related crime, we need to know what the problems are, where they are and what works. To do that we need good data. Here are some of the identified needs that congress and the administration can help us address. Limited exceptions to current regulatory and statutory barriers under in 42 cfr part two which is the Substance Abuse protections. Our Prescription Drug Monitoring Program is prohibited from accessing any data from our methadone clinics. We need to know how they work and who they are providing care for. Provide Technical Assistance or fun staff positions for states, localities in developing metrics, sharing data and analyzing results. Support development of consistent National Metrics , incentivize private providers and mandate collection as a requisite for federal funding. Increased support with santa and heine, breakdown federal funding silos, reduce command. Incentivize Law Enforcement to focus on highlevel dealers and help us for those who are addicted into treatment programs with our treatment programs are currently insufficient to address this epidemic. Those with addictions should become Law Enforcement problems. They belong in the Healthcare System. Examples of programs to further explore include assisting localities to pilots, analyze and determine the efforts of angel programs and police departments, only fund the dissemination of naloxone or other overdose drugs and my time is up, theres a lot of requests but youve invited the requests mister chairman but ill stop. We have more incentive as we cover questions to thank you, secretary tilly, you are recognized for five minutes. Thank you so much for allowing me the chance to be here, i want to thank matt benton or that chance as well, he sends his regrets. You want to be here, hes been outspoken and i will share with you a quick story, when i first met governor better than it was interviewing for this job. He walked in to a room with dreamland under his arm and said have you read this book to market and thankfully i had, i said yes ive read the book and im trying to reread it because it is again the best chronicling of this problem and how it began that i know of. So that again illustrates to you our commitment and our shared understanding of this problem. I want tothank congressman guthrie for that kind introduction as well. Dreamland is relevant to us because the problem really has its origins in kentucky and ohio. We lost 1404 kentuckians at the congressman said. Fentanil is now the driving force behind these overdoses, we had 13,000 er visits, 13,000 er visits in a state of 4 and a half million people. Nearly a commercial airplane a day. Just for a communicable disease, we be wearing hazmat suits to combat it. But overdoses and those visits only tell half the stories, this designates communities. As soon as we got our arms around heroine we began to see fentanil. The police tells us in the last years alone weve seen a 6000 percent increase in fentanil in our labs. 6000 percent increase. I think all of us know the devastation it had on our criminal justice commute community, our jails and prisons are at capacity, no more room at the end. The Public Health crisis is on full display in kentucky, we had hepatitis c, a former while at seven times the national average. Across the river in indiana had an outbreak of hiv rivaled that of Subsaharan Africa that we passed one of the First Southern states to pass a comprehensive Syringe Exchange program and now in kentucky we have 30 programs all passed by a local option in our state. We know that increases the treatment capacity by five times. When someone walks over the doorstep and it battled back these diseases like hep c and hiv, kentucky has the cdc report at 54 of 220 counties, most susceptible to a rapid outbreak of hiv. What is our response in kentucky to battle this . Taking a bold step as a Southern State on a Syringe Exchange program, enacting legislation in consecutive years on prescription pills, the second state in the country to battle back synthetics, dealing with heroine directly and fentanil, being the first date to mandate usage of what we call casper, our Prescription Drug Monitoring Program. We become the first state to require physicians when prescribing to limit or limit prescriptions to three days. Some are done seven, some have done 10. I can promise you our governor spent some capital on that, thats how important it is to him. Double down on things like rocket docket and programs and help for those who are addicted through various forms of treatment in looking at things like neonatal abstinence syndrome, 1900 cases in kentucky, we increase funding to combat that and help with the suffering of those addicted. We put it in our jails and prisons and i think i mentioned rocket dockets or prosecutors to make these cases and put them on a separate claim to deal with them in the most appropriate way possible. Weve increased treatment by nearly 1100 percent since 2004. We validate treatment every year and i return on investment is almost 5 dollars. Some of the Innovative Programs you may have heard about as recently chronicled in the New York Times as well we use naltrexone or video trawl in our jails on the front line. We get again an injection prior to relief and an injection upon release and we link that returning individual to the services in the community to see if they are medicaid eligible and see what resources they have to continue that treatment and i know the question will be do we link those folks to counseling . We go there best to do that and in fact in kentucky i will tell you both validated and anecdotally we are seeing tremendous results from using an 80 and counseling together but counseling in the form of cognitive behavioral therapy. Were seeing that used in both our jails and prisons and that is yielding tremendous results. We intend to emulate whats been going on in rhode island with the anchor the program. We visited there with director ball for an project and we are doing here recovery bridge clinics soon so this is an innovative awareness, we will use our lives to get folks linked up to treatment and are educating our dental school and overall as i close out and conclude i will tell you that i think we have the most comprehensive effort ive seen in my 25 years with something called core, the kentucky opioid response effort with that i will look forward to questioning, thank you. You are recognized for five minutes. Thank you chairman murphy. Thank you chairman murphy. Thank you member duquette. I oversee the states treatment prevention and Recovery Systems and am also a longstanding member of the National Association of state alcohol and drug abuse directors and serve on their board. You for the invitation to appear today to share Rhode Islands work in combating the opioid prices, and efforts thats been proposed as a national model. Our strategies to address this epidemic are outlined on the website, overdose ri. Com and i will be sharing slides. From this website during the testimony. Our goal is to make these efforts open to the public with complete transparency on outcomes available for replication through the country. First and foremost i would like to thank congress for the action taken last year passing the 21st century cures act with 1 billion to support prevention, treatment and recovery. At a time of tight budgets, we appreciate the significance of this action. Addiction and overdose are claiming lives, destroying families and undermining the quality of life across state in the United States and rhode island as been one of the hardest hit. In 2015, newly elected governor gina romano recognized the need for the state to develop a comprehensive strategy to prevent, evaluate and successfully intervene to reduce the overdose trend. He signed an executive order establishing the governors Overdose Prevention and Intervention Task force comprised of stakeholders and experts from a broad array of sectors. The resulting plan as one over our jingle to produce Overdose Deaths by one third in three years. Governor romanos plan focuses on four specific strategies which i will briefly outline and focus on specific areas. Other described fully in my testimony. The first is prevention. We take aggressive measures to ensure prescribing opioids from a safe disposal of medication and encourage the use of alternative Pain Management services. Next is naloxone. Naloxone as a standard of care for first response. Naloxone saves lives by reducing overdose and our plan supports written increasing access to naloxone across sectors of the state. We believe that every door is the right door for treatment and our goal is to increase access to evidencebased treatment. To do this rhode island developed centers of excellence with rapid access to treatment including induction on all approved medications for opioid disorder. These specialized programs provide clinical assessment and intensive Treatment Services through the wraparound support. This program is designed to provide opportunity for stabilization with referrals to Community Physicians for treatment offering continued critical and Recovery Support through the centers of excellence. This program is supported through private insurance and medicaid. In addition rhode island release the nations first statewide standards for treating overdose and opioid use in hospitals and emergency settings and the Rhode Island Department of corrections is providing medication assisted treatment to the population most at risk for overdose. We work diligently to increase data wavered physicians in rhode island, for example and Brown University medical school is the first to incorporate data wavered training into his curriculum. Finally, recovery. We are looking to expand Recovery Support, recovery is possible. Supports successful recovery for moreRhode Islanders , we are expanding repair and Recovery Services particularly at moments when people are most at risk and the program was started in june 2014 and is now a statewide when 47 service that can ask overdose survivors would be recovery coaches. These coaches share their own stories of hope and inspiration to engage those in crisis as well as providing continued services and follow in connection to with data with 600 individuals have met with coaches and as a result 82 percent have accepted a referral to treatment. The anchor more programexists as a statewide outreach effort to opioid hotspots that are identified through data, not waiting for someone to overdose. Were now facing in fentanil prices as you can see in the slide with two thirds of overdoses fentanil related, we must develop new strategies to address the changing face of this epidemic. The rhode island governor is signing an executive order expanding our efforts to include more focus on prevention, engaging families and use in these efforts, reduction strategies and access to treatment. I cannot state strongly enough that Rhode Islands strategies lie in sustainable funding, medicated Health Insurance, standards of parity and suv treatment as an essential benefit. Any action taken on the federal level which would threaten this funding would weaken the plan substantially. I would also recommend that any federal initiative specifically include involvement of state agencies given their expertise in these matters. I would advocate for support of the Substance Abuse prevention treatment block grant as the foundation of state systems and finally i would encourage continued consideration of targeted funds to address these issues. Thank you for this opportunity to testify, i look forward to answering questions. Recognize myself for five minutes darting with governor rutherford. According to the cfr part two theres a couple of facts, one is as was pointed out by secretary moran, if someone is using add mp, the data is not in there. A physician prescribing will not know if that patient on methadone is boxed on some other opioid. Only if the person shows up in the emergency room or a former colleague talk about this shows up here with an injury, and when asked if that person has any allergies or drugs and he says please dont give me any opioids, they do it anyway. Because theres nothing in the record because we can list in a person has a allergy, and i consider this and opioid sensitivity should be in there as well but the law in places for the Nixon Administration does not allow that to be in there so the person then they leave the hospital with a file of opioids and then say well, i used to be addicted to 20 visa time, ill take 20 down, overdose and die. Or they may take in and say that they relaxed or a navy on other medications and they put a bad drug interaction. What do you recommend we do with that 48 cfr part two . Does have to be addressed. Youre exactly right and secretary more and was correct in that particular challenge. A person who goes into maybe receiving methadone treatment, they go in for a knee replacement, theres nothing to tell the doctor that this person is also receiving methadone. When they prescribe oxycodone or oxycontin or something of that nature. It doesnt show up in our Prescription Drug Monitoring Systems as well so it is particularly challenging. It needs to be addressed. There are areas with regard to hit the go to other areas of Behavioral Health and i know you talk about that when we talk about Mental Health and the challenges associated with getting the systems or an adult family member. Whats that person goes from 17 to 18, you lose a lot of control when you can help this person so yes, if you can make some type of exceptions or clarification. Theres also a misunderstanding on some of the doctors as well i think at least in the medical records to do for a few sheep are. We had a quick question or survey, knowing that most people with addiction to have a cooccurring Mental Health disorder, im wondering if any of you have taken a survey in your state, you have a sufficient number of psychologist, i believe the National Numbers a half counties in america have no psychologist, no critical social worker, no license drug treatment counselor. If you dont know, tell me but if you know, do you have a sufficient number to meet the need . I can only speak accurately, there are counties in our state that have a substantial shortage of those types of professionals including drug counselors. That is the challenge that we have. And it varies by geography itself, West Virginia was congressman griffiths represents a very insufficient shortage. Urban areas, yes, rural areas no, we had a network we are proud of but in the rural areas theyre hoping to find qualified professionals. The nation struggles with the number of psychiatrists needed to meet the demand so yes, there is a psychiatrist shortage. Thank you. Theother issue is medication assisted treatment, with regard to that, in pennsylvania we have data that says that people who are in , on and 80 may be getting suboxone because getting treatment . Im wondering if in your state people review that. Ive heard in some cases the treatment is no more than a nurse saying how are you doing today. Is everything all right. But in pennsylvania, 59 percent have no counseling in the year, 49 percent were not going to, 33 percent have between two and five different prescribers and 24 percent see a physician prior 30 days. Can you describe if you have the data in rhode island, can we find out if theyre getting real counseling . I know in rhode island are treatment programs are required to find some point. You know theyre really doing it . You know if they are really doing. We do refuse our program so thestate licenses , and Opioid Treatment Program then goes out to review records and to make sure they are abiding by Counseling Centers as well. I appreciate reviewing the records but we need to know this, i heard from people who go to centers who tell me that they are listed in the records havingcounseling and they have no more than someone saying how are you doing. Im just curious. Not in rhode island but other state. Without actually being able to sit in on sessions and time the questions and make sure theyre running we have to rely on the validity of the records which we review and so unless people are willing to commit fraud and put their licenses on the line by documenting that something that didnt happen, i would have to say that i believe that what i read in the records to be true. I think, this committee has dealt with so much fraud. But i will let you be recognized for five minutes. Mister chairman, its cosmetically assisted treatment, that has to be an important part of that so if theyre not getting the council, i would think they should but i dont think we have any evidence that theres fraud being committed in rhode island. You. We love rhode island. Yes we do, my daughter went to Brown University and we love rhode island. So i want to talk to you a little bit, director boss, about this issue of state being able to pay for treatment and this is for a range of treatments and i think it applies in all the other three states. I would assume that paying for treatment on this scale is really an ongoing challenge facing our state, without be a fair statement . That would be a fair statement, prior to 2014 weve seen significant increases in the number of people being able to access treatment post Medicaid Expansion. So the Medicaid Expansion has helped. 21stcentury cures help to but we know theres a lot more work that needs to be done. In your statement you said medicaid has laid the foundation for treatment coverage, is that correct . And so i wonder if you could just tell me quite briefly how that medicaid funds are helping rhode island fightthis epidemic . Medicaid funds in rhode island cover medicaid assisted treatment, all three forms of fda approved medication, dedication, morphine and the locks own, they support something known as otb telephones and that a comprehensive program to integrate healthcare within individuals receiving methadone treatment as well as all other forms of treatment, rhode island has a full continuum of treatments to detoxification for treatment residential treatment through the use of medication and assisted treatment as well. Have you look at these bills that House Republicans have passed and that the Senate Republicans are looking at which would severely reduce, would severely reduce the medicaid aid to the states . I have and how would those impacts your state of rhode island. 811 reduce access to medicaid and Medicaid Expansion or reduce excess to affordable Health Insurance would have negative impacts on rhode island as 77,000 lives are counted approximately by Medicaid Expansion. 77,000 covered by the Medicaid Expansion. Secretary kelly, a recent ap analysis showed that the Medicaid Expansion accounted for more than 60 percent of the total medicaid spending on Substance Abuse treatment in kentucky. Between 2012 and 2014 there been a more than 700 percent increase in Substance Abuse treatment provided to kentucky residents due to Medicaid Expansion. So i guess i want to ask you, it looks to me like medicaid has been particularly helpful inkentuckys fight against the Opioid Crisis , would you agree with that . Let me say this, i will tell you unequivocally, our governors commitment again, example by the 1115 waiver and our effort at this very moment to expand our treatment options. My question, would you agree that medicaid has been particularly helpful in kentuckys fight against the Opioid Crisis . I would agree. Im sorry, i would agree that the number of sources of funding, weve increased treatment always dating back to 2004 1100 percent. Let me ask you this, if the Medicaid Expansion went away, would that impair your efforts to fund this in kentucky. I the secretary of the justice and Public Safety cabinet and i do have five major. Youre not going to answer my question so im going to ask secretary more and question. Secretary moran, governor mcauliffe attempted to expand medicaid twice in virginia but the republican legislation ruth rejected both the attacks. So i want to ask you, i know virginia is making the most out of the tools it has but if you had had Medicaid Expansion, more money in virginia, with this and help you be able to reach out to more people on this opioid issue . The answer is emphatic yes. More people would have access to treatment. We have, i will give credit to our department of health using a very innovative arts program Addiction Recovery and Treatment Services and give a medicaid waiver to address these individuals addiction needs but with Medicaid Expansion, 400,000 virginians would be covered and governor mcauliffe has attempted to do that at every opportunity. You very much mister chairman, i feel that. I recognize mister colin for five minutes. Thank you mister chairman, i think maybe ill start this question with secretary moran. All of us all agree here that opioid addiction is a disease, it is an addiction and we are all experienced the tragic deaths of many of our young Young Children when it comes to the overdose and as was pointed out, we also have the fentanil issue so my question is surrounding naloxone for narcan and could you help the committee understand some of the key issues onavailability because we do here , there may be shortages, who is picking up the tab for this and is it the patients, is it the state, is it the federal government to maybe give us an overview on how we are at least attempting to deal with that piece and also, if someone is obviously in an od, are they given narcan, without really, you dont know are they toadying on opioids or fentanil . Thank you for the question and we are attempting to expand the coverage of fentanil and every community, there some resistance, particularly from rural jurisdictions because they are not the first to respond typically. Usually it is emergency medical services. Tnf does carry it. , a majority of our jurisdictions in Law Enforcement communities and certainly in urban areas now. As i mentioned, Virginia Beach has a tremendous success rate, they are serving up towards a life week with the use of. Thats cms, we appreciate the federal grants through the department of criminal and Investigative Services so that would provide any cost to the local jurisdiction. That naloxone. Now, in terms of laypeople, our department of Health Commissioner issued an order that anyone can go into a pharmacy and received the prescription for naloxone so we are attemptingto expand coverage in any way possible. Issued by a dot there. I dont know if theres people sometimes do have different kinds of concerns and admitting theyve got an issue. Could you expand on that a little bit on what you may know and also how does someone get this prescription, which obviously theyve got to then fill. Congressman, that is at the Standing Order did. You actually use narcan without a doctors written prescription and that was from the commission of health. That a statewide in what the fda is looking to expand nationwide. What is your experience with that . Are you tracking how many people, family members who know that theyve got someone thats got this addiction and they are being anticipatory. If you have a loved one whos dead, you take the proactive step of an overdose. We have been trained myself to the first lady virginia, governor virginia with training that is very simple. It truly is. We would encourage people to have access to narcan. Thats a great example. Im just thrilled you shared it with us. Maybe thats the message the fda doesnt know that the other state can save lives. Then you should build to go home. Thank you for sharing that. I yield back. Mr. Tomko coming to recognize for five minutes. Thank you, mr. Chairman. Thank you chair witnesses for their Public Service in the testimony they share today. Before i get to my questions, id be remiss if i didnt trump care would have been the fight against the Opioid Epidemic. This mean, and might i say very mean bill will rip hope away from people in communities across my district to depend on coverage from the Affordable Care act and Medicaid Expansions to help them recover the opioid addiction. Medicaid by far is the single largest payer for Behavioral Health services in our country. In rhode island, medicaid pays for nearly 50 of Addiction Treatment and medication. In kentucky, at 44 . Maryland 39 good virginia 13 . The bill being considered in the senate cut 772 billion or 26 from medicaid over the next decade. There is no way this highly efficient Safety Net Program with the type of funding hamas would continue to provide services for all that requirement. Simply put, passing trump care would be the single biggest step backward in providing treatment for Substance Use and Mental Health services in our nations history. That being said, last year i collaborated with my friend on legislation that expanded prescribing privileges to Nurse Practitioners and physician assistants. I would like to think i would like to gather your feedback on how this law is implemented in your states. You mentioned in your testimony that rhode island is actively working to provide data to interested practitioners. Have you seen Significant Interest from the Nurse Practitioners or physician assistant communities and becoming labored practitioners . Congressmen jason, im not sure i have data on how to Nurse Practitioners and physicians assistant for to take data waiver trading. I know we are actively working with medical schools to get that interest into increase the training available, but im not sure i would be able to answer that comprehensively. As youre aware, there is interest in it . Absolutely. In fact it work with the department of health to provide those trainings to any and all interested parties. Weve seen an increased number of data waiver positions. We will be working at the Nurse Practitioner to increase those as well. Are there any projections youve made in classes of practitioners being able to prescribe improved addiction in rhode island . We track for overdose website and a regular performance meetings the number of people receiving norepinephrine treatments and we are looking at the number of waiver positions actually prescribing. We are seeing increases in the number of people receiving treatment through these efforts. I would assume the further expansion. The additional classes of practitioners prescribing. We have a positive impact on access to treatment in rhode island. I would absolutely agree with that. Im not sure theres been enough time to document how much increase that will result in. But yes, i do agree in a thank you for your efforts without legislation. Our pleasure. To all of our panelists, what barriers to face trying to recruit practitioners to become waiver data practitioners . We talk about in certain cases in certain parts of the state they were limitations in terms of the number of practitioners in some of our more rural areas. Also, some of the anecdotal feedback there is still in some cases a stigma associated with treating individuals of Substance Abuse disorder and they send doctors they just dont want those patients. But the lifting of the cap has helped us with regard to being able to provide services for more individuals. Secretary moran. Thank you. Secretary moran. I would agree most of that information would be with our health and Human Services close to me. We have heard there was a shortage of personnel to address this issue. Its an epidemic that is lowered over the last several years. Any assistance you can provide for funding the flexibility would be much appreciated. Thank you. Secretary tilly. I would reiterate my colleagues that they said and i would also add that we have a phenomenon we have a number of positions in the nearly 700 prescribing. Many if not applied up to the 285 cap. Many of them we dont know as they say earlier whether they are requiring counseling. We do know we require counseling in our correction settings in jail and prisons. We encourage it, do your analysis. Thats one of the things we have to get our arms around. We have to look beyond the positions that are not applying to do more in their communities and again we struggle at the same challenges with rural versus urban and getting out of the area is largely an appalachia is a problem at first there and its more cheaper in many ways, so thats a challenge for us. We are going across the board. Thank you. Agree with all my colleagues that i would add they want to do the right thing and they want to be able to make sure people are receiving counseling and toxicology screens and the management to do that. They need increase supports in the office is to do the kind of evidencebased practice that is needed in order to use appropriately. Thank you, mr. Chair. I yield back. Mr. Walberg, you are recognized for five minutes. Thank you, mr. Chairman. Thank you to the panel for being here. Secretary moran, according to the centers for Disease Control and prevention, practically one in five deaths that are attributable to a Drug Overdose failed to list specific drugs in the death certificates. Could you explain why this data gap is problematic and what efforts the commonwealth is taking to ensure that it has sufficient data to understand the true scope of the Opioid Epidemic. The need for additional data, the state silos which we are trying to break down the privacy provisions with respect to some of the federal laws. In the investigation we have good data with respect to what drugs were involved because they were collected. If it was an accidental death, it eventually goes to the chief medical examiner. But with respect to the data, it is challenging. Some individuals may not be anxious to reveal the cause of death under some circumstances. Family members may not choose to reveal that type of source. It is a challenge, one we are trying to get our arms around because if we have better data, we know how to respond better and what to do and what if anything is working with respect to addressing this epidemic. Is there anything youre attempting to get around the data that is working for you at least had some families . Well, particularly sent to knock weve realized over the last presentations because we are not alone. We seen a dramatic rise in the use of ethanol. That affects not only are health care, but Law Enforcement. Bursa fentanyl coming from and if it is located in a particular community, there can be a Rapid Response to education and to interdict because it is typically being manufactured overseas coming into the commonwealth in the country. That type of information is critical to the addiction of these drugs and the health care in response to the individuals. I think it is imperative that we collect more data and have access to more data because we can better respond to the crisis. Director boss. Your written testimony notes that Rhode Islands Overdose Prevention and Intervention Task force makes use of the datadriven Strategic Plan to combat addiction and Substance Abuse. Could you tell us more about how the state utilizes data to develop a strategy to address this Opioid Crisis . That is a wonderful question. Thank you for asking. So we have two things that i will point to. We have something called mode, which is the multidisciplinary overdose drug response team. Basically, we look at a number of specific overdose trends and there is a Multidisciplinary Team that consists of the university, hospitals, department of health and we review cases and deaths in terms of looking out where those individuals were, what kind of Treatment Services they were receiving if any and then develop specific interventions as a response that we propose statewide. The others are surveillance response intervention team. We receive weekly reports on all of our hospitals required to report overdoses or suspected overdoses within 48 hours and i medical examiner is able to determine whether or not fentanyl is a factor in those overdoses. As a result, we put out alerts to communities and overdoses, whether fatal or not exceed a specific target in that particular area and we are able to notify Law Enforcement, first with unders, treatment providers and other individuals in the community that there is an increased overdose, fatal or nonfatal in their communities. You mentioned that your state still . Comprehensive data related to fentanyl. Even with this approach you are taking. If i understand it correctly, what are the obstacles preventing hospitals with comprehensive testing firm fence and all . How could they obtain more robust data . Defense and all question are now able to test out our drug. So we are looking at how much is in the drug supply and as we see increases in hospital test aimed that is done in our drug treatment providers, youll know what kind of fentanyl is out there, but not as quickly as they could if they were a Law Enforcement, if we had more Rapid Response and Law Enforcement looking at what is in the drug supply. Thank you. I yield back. Ms. Cassidy come youre recognized for five minutes. Thank you very much. I think at the outset, it is important that we cannot go backwards en masse. This is a costly severe problem for families and allah bless. What is happening with proposals from the gop on health care really would take us backwards, whether that gripping coverage of a has been provided under the Affordable Care act, under health care. Gov, or very serious assaults on medicaid, the most serious retrenchment of medicaid in mississippi history would be just disastrous for our ability to support families and address this crisis. In fact, i would like to ask unanimous consent to submit for the record a consensus statement for the National Association of medicaid directors on the Senate Version of the gop house bill. It states in part medicaid is a successful Cost Effective federal state partnership. It has a record of innovation and improvement of outcomes for the nations most vulnerable citizens, including comprehensive and effective treatment for individuals struggling with opioid dependency. No amount of administrative regulatory flexibility can compensate for the federal spending reductions that would encourage result of the bill. Medicaid or other forms of comprehensive accessible and Affordable Health coverage and coordination of Public Health and Law Enforcement is the most comprehensive and a way to address the Opioid Epidemic in this country. Earmarking funding for exclusive service for treating addiction in the absence of preventative medical and Behavioral Health coverage is likely to be ineffective in solving the problem. Ill ask unanimous consent that be in the record, mr. Chairman. Well get back back to you before you are done. Because this is very important. This committee to its credit, head of the Cure Initiative that did provide financial funds to her state, not local experts here in florida all the number of roundtables with Law Enforcement, treatment professionals, anesthesiologist, er doctors and they say the key is longterm coverage to treat this as the chronic disease that it is. That is why when you rip away coverage and instead say in its place we will have another fun, where maybe you provide a few dollars to a dr, that is not going to provide the longterm coverage we need to treat this chronic disease. I just had to get that off my chest here right off the bat. In fact, you have a lot of experience with this. Do you think we will be able to effectively address this crisis if this retrenchment on medicaid and gripping coverage of a for millions of americans were to succeed . I believe rhode island effort to address this crisis would not be able to be sustained if we were not able to continue to offer the number of Rhode Islanders that depend on it. I thank you and you are pointing out the fact that providing Substance Abuse alone is not enough if we dedicate dollars for that, that is wonderful. However, the comorbid conditions are interrelated with an individual addiction that if they dont have access to Affordable Health care, then we are not going to be able to treat the person well enough to sustain any kind of recovery. So are you able right now to provide the type of longterm treatment that is needed for opioid addiction . Yes, we are. The program called anchor at which connects individuals struggling with addiction to recovery coaches who help them navigate the treatment process. How successful has the program then to helping an individual recover . The individual recovery coaches in the emergency department, 82 are receiving referrals to treatment and engage in treatment and Recovery Services, which is pretty phenomenal actually. The actual anchor ed program itself is not supported by medicaid, but the fact we are not required to Substance Abuse block grant funds to fund in treatment golf now that individuals can access frees up the opportunity to use block Grant Funding to support recovery activities that may not be supported by medicaid or other insurance. Although many insurances including thirdparty commercial insurance are paying for the recovery coaching program. Is that something effective they are participating. Just a followup question. Recoveries have what kind of credentials . We have a certification process that is standardized and involved in the past involuntary hours for certification in order to respond. And do you have an Emergency Rooms the people that are themselves licensed treatment providers, not recovery, not here. This is a licensing. Do you have the requirement . We do not. There was a study done out of michigan and also yield that when there is a life sentence addictions counselor providing treatment, not referral, providing treatment that increase the chance the person will follow up by 50 . Here is some place to call. The 82 , do you know if they actually follow through . I would love to hear that, but nx have to go go to ms. Walters. Before you do, with unanimous consent request. We are fine with that. Anyways, the information is important. What ive heard from a lot of places, they dont need that to follow through. 80 may not be valuable, but to know if theyre getting treatment just like if you broke your arm, make sure you see an Orthopedic Surgeon next week. Recognized for five minutes. Thank you, mr. Chairman. We cannot knowledge despite increased societal awareness and Government Resources that the Opioid Crisis continues to devastate our communities here to my home of orange county, california there were 361 Overdose Deaths in 2015. That accounts for a 50 increase in Overdose Deaths since 2006. The majority of those deaths are attributed to heroin prescription opioid or a combination of the two. One of the challenges in responding to the crisis is the stigmatizing of the guns, which limits their response to the treatment outreach. There has been discussion today of the importance of drug courts and the escorts can overcome the stigma and treat the underlying addiction as opposed to focusing on the resulting criminal behavior. I recently became aware of a Specialized Drug treatment in buffalo, new york the focus solely on opioid intervention. My question is for everybody on the panel. Do you have an opinion whether some drug treatment courts need to be specialized to handle opioid addiction . We have extension drug courts in most of our jurisdictions across the state. They essentially are specific to opioid addiction and theres been good result for most of those courts. The one challenge that we have is that depending on how long some of our counties, and appeared that the drug court is coming 18 months to two years. If youre someone who commits a crime at a local jail and you are not ready for treatment, the personal fad rather do the six to eight months and have to commit to two years, even though im outside the fence, i would rather sit in jail. We are big proponents of drug courts. We have yet over 200 courts. They are used for a variety of different specialties. Mental health court, dockets. The drug courts however provide some coercion. The individual needs to want to address their addiction in the court can provide the coercive element. We have a tremendous success rate and we should expand. I should ask congress to help us with however the medically assisted treatment. Some on the drug courts are reluctant. As of now it is requires. We would like to request on behalf of those judges some flexibility with respect to mandating. Again, i would incur we have the veteran scored 10 drug court they do expand. We did lose to an issue we are trying to rebuild the program now. Oftentimes they choose a shorter prison sentence. But we are addressing that as well. Oftentimes we find they are cherrypicking the best instead of focusing on the more high risk folks. We do have a program called smart tags keeps them a modified drug court that does specialize in opioid, at least one part of it does. Its modeled after the whole program. In hawaii many of you know about now. I would also add to what we are finding as well is again this combination of specializing medically assisted treatment of cognitive behavior that we are trying to integrate the model. We also have passage of recent legislation in kentucky through the department of corrections, a modified drug court for a Reentry Program double specialize in opioid depictions. I would agree with my colleagues as well, especially Lieutenant Governor rutherford and the fact that her drug courts have been addressing opioid cases for a very long time. Rhode Island Drug Court has been accepting the treatment one before it was required to do so. The issue we have a drug court is its not able to reach enough people. By its very successful and effective, the difficulty in getting the numbers through the system is challenging and we really would like to look at a broader perspective of diversion efforts in getting people connect it to treatment prior to our primary focus. One interesting thought. We had a conference recently in kentucky that offered a legal opinion from one of our law firms they are in the guinness secretary moran pointed out, if the judge denies in medically assisted treatment, which if they returned to prison, that denial might invoke protection of the americans with disabilities act and that is an interesting thought moving forward with a Chilling Effect on our judiciary that might be more accepting. Thank you. I yield my time. Youre recognized for five minutes. Thank you, mr. Chairman. Thank you for being here. Such an important topic and as an emergency medicine doctor, i cannot emphasize enough the devastating effect it has on individuals, families, communities where they have been blue, not breathing in front of our doors in waco to Emergency Care mode for somebody who you dont know anything about and they are there unconscious about to die. Thankfully weve saved many of them because weve had the medication. We know that one of the primary determinants of successful treatment is that they get the medication and follow up with counseling. One of the factors for success is that they have Health Insurance that has guaranteed coverage for those medications, guarantee coverage for Mental Health. That is why it is so devastating for me and my patient that we are on the verge of repealing the Medicaid Expansion, for some states who choose not to have the Mental Health and Prescription Drug guaranteed coverage that those people who need coverage in one coverage wont be able to have it and it can be a situation of life and death as we know it. In the report on addiction released last year, the u. S. Surgeon general said that millions of americans for Substance Abuse disorders now have access to Health Coverage and subsequently abusive treatment. Since its not only covered essential help renovate, which is at risk of going away come the Small Group Market participants also gain access to those with lifesaving services. But its not just about coverage. You cannot coverage like some parts of my district. If you dont have providers come if you dont have psychiatrists, psychologists, Health Care Centers and Counseling Centers or programs in those communities that are underserved and rural areas, then coverage does you no good. You need to also think about making sure that we have more psychiatrists, more psychologists, more Mental Health providers in those areas. Especially for the youths and young adults. According to data from hhs, the number of children foster care increased 8 between 2012 and 2015. Experts suggest this is due in large part to increased opioid abuse. Moreover, Substance Abuse of Mental Health Service Administration has over 8 million children assessing the use disorder. The washington journal, Washington Post and New York Times of all recently reported on children who have experienced the impact of their parents opioid abuse and are being raised by grandparents who have been placed into foster care as a result. Secretary tilley commented can you please describe how children your states have been impacted by the Opioid Crisis and are there unique challenges facing children in these epidemics . So that certainly is an issue. And beyond that i think it just puts tremendous strain on our Community Health centers as well. Again the absence of proper funding for community Mental Health in this country is a huge issue. It exists all over. It is acute in contact as well. We rely on r14 Community Health centers to provide those services to children. With seen an increase with the focus in recent years on addiction issues an increase in the proper treatment for children and such think thats been critical for let me just warn you that by treating medicaid into per capita grant, tiffany for new addicted folks is going, i should say the need for funding is going to increase. States are going to have to make decisions, one, change their eligibility criteria, two, the reimbursement rates, and three, the benefits that they would cover. And oftentimes, unfortunately, the Mental Health and these Community Centers treatments are the first on the chopping block. Its going to get worse if this bill is going to pass. Director boss, families have a central role to play in treatment with Substance Abuse disorders. Can you discuss what efforts rhode island has taken to provide treatment that covers a person entire family . All of our treatment providers are encouraged to engage families in treatment. And as part of effective treatment we know that addiction is a family disease and engaging family members is critical in order to have success. One of the things that state has done in engaged family members in the development over the plan and where creating a family and parent task force as well as engaging youth to appreciate our efforts for the overdose crisis. Have you found positive results . Those efforts are just starting, so i will be able to report back, hopefully. Im very hopeful that we can Work Together. I appreciate that. I want to make sure secretary tilley has a response to say about Mental Health, Substance Abuse, money being first on the chopping block. That was not the intent. I dont agree i didnt know, i asked if you want to respond. Addressing a stroke with mentalhealth is one of the most underfunded i understand. I want secretary tilley have a chance respond about that. I would oversee the absence of proper Mental Health funding is not a new phenomenon. I happen to be a soso with a Mental Health center as general counsel. I happen to know since the late 1990s we havent had an increase in those reimbursement rates. That is an issue that has existed for some time periods ii dont think thats a recent phenomenon. Thats why want to emphasize what okay. Doesnt get increased come it increases costs overall for healthcare. Mr. Carter come here recognized for five minutes. Thank you, mr. Chairman. I want to thank all of you for being here on such an important subject. I want to express my dismay and my discouragement at similar colleagues who have used this as a platform if you will for political messages about cuts in medicaid, et cetera. We all understand it is established of this is an epidemic in this country. As a practicing pharmacist for over 30 years i have seen firsthand reps more than everyone in your collectively has seen the impact that this has said. At no time have i ever asked the patient or thought anyway is this a republican or democrat were independent . Its someone who struggling. Thats all there is to it. This is a nonpartisan problem. I just get frustrated by that. Governor rutherford come you said something earlier im confused about turkey were talked about Prescription Drug Monitoring Program in the state of maryland. Did you save methadone is not on it . No. What i was saying is that if youre monitoring, if you go to Prescription Drug Monitoring Program, or the database, you will not see that a person has been prescribed methadone. That there in methadone treatment. Why is that . There are Privacy Restrictions associated with drug treatment, and so this was in place prior to our developing these Prescription Drug Monitoring Programs. There are different barriers to getting information, be it Mental Health information or drug treatment and in some cases healthcare, that there are walls is a something we can help you with a legislatively . Thats a we talked about that i would be very helpful because the practitioner would not know that someone that they are prescribing an opioid already has a problem associated with opioid. Okay. When i was in the state senate in georgia i sponsored legislation that could Prescription Drug Monitoring Program. It has been improved essentialist. July 4th, july 1 of this year just last week or two weeks ago we started 24 hour reporting. Before that we were reporting every week. We are not realtime yet but were getting there. We are making good progress. I want to know in the Prescription Drug Monitoring Programs within your state, and secretary tilley, ive worked closely with the kentucky board of pharmacy and with Kentucky Pharmacist Association very strong, very strong programs there and i complement you on that. But in your experiences with the Prescription Drug Monitoring Programs are you sharing information across state lines . We are. I think with seven border states, unique in that regard. The only state in which we dont at this moment is misery. I think that missouri struggle. There with the last one to add it on. Were working on that and again i gathers up at the record to confirm that answer for you buddy to believe we are sharing with six o of the seven states that border us. Secretary moran, what about virginia, what are you all doing . Thank you. This is everywhere congress could investigate. With 21 states and our neighbor to the southnorth carolina we do not share information. So if theres can we would request some help to better share data across state lines. Most of our neighbors, not north carolina. We would work with more really. In georgia we are sharing with south carolina, alabama, north dakota, and someone else way out i will tell you in my over 30 years of practicing pharmacy i never filled a prescription for north dakota. I know you find that hard to believe, but, i mean, its useful but anyway. Wouldve been more useful if i couldve seen it from florida. Being in that area, incident where we are only two hours away it wouldve been extremely useful for the state of florida and hopefully we can get to that point. I want to ask you, secretary tilley, about a program that i thought was pretty interesting that was a result of 20 for since he cares, that was a pure recovery specialist and Emergency Departments in kentucky. Can you elaborate on that just a minute . The expert is sitting to my left. We had a chance at again i applaud the work in rhode island. We had sort of a model that didnt really meet the goals that we wanted. It was not up to par from previous legislation trip we looked at what rhode island was doing. We tried the same thing they did. We just dont we just didnt do as well and i think were fairly ambitious with trying to do both at once. The pure recovery coaches are specialists and also doing bridge clinics as well to try to keep people there in treatment until we can get into treatment may be outpatient or some kind of other bed outside the hospital. I think whether doing it rhode island is a model for the country and thats come we are emailing them directly. I know youre doing great work, director boss. I have 15 seconds. I want to add one thing for me pharmacist perspective. One of the things we did there was to allow states impotent laws on c2 prescriptions on how much can be filled an in with te pharmacist can fill partial quantities. That will help. We can throw money at this all day long that we need to be smart. If we are smart and we do irrational things like limiting, ive got some prescription from a dentist for 30s life oxycontin. They take one or two in the rest of them are in the medicine cabinet. That is not being smart. If we can have a partial refill, it states ca into as result of 21st century, as result of care that some 20 to look at the many as well. Thank you all. My time is that you back. Would you for a question . When you refer to partial refill in do you mean allowing the pharmacist to really get a partial fill of the onset and then the person can can i . You would have that option . That is one of the options. I would take it even further and i been in talks, my office has been in talks with dea about allowing maybe refill on a c2 for a threeday supply. Because a lot of physicians are concerned that the patient will run out over the weekend, they will be bothered or dont not be available until go without. Thats a real concern and i understand that but at the same time again if we would just be smart. Allowing him to make the call in the phone, as long as its limited to a short day supply. Thank you. Thank you, mr. Chairman. Director boss, i wanted to ask you questions but i want to go back to the issue of medicaid because as you know the republicans are still trying to repeal the aca Medicaid Expansion, and making a lot of changes to the program. So what role has medicaid played in Rhode Islands effort to provide medicationassisted treatment in your state . Medicationassisted treatment is covered by medicaid for both the disabled and the expansion populations, all medicaid coverage individuals are able to receive all three forms of fda approved medication for opioid use disorders. The director of medicaid is a member of our Opioid Task Force and has been active in working with the managed Care Organizations that manage our medicaid product to do things like remove prior authorization for medication assisted treatment. It is fully funded through our Medicaid Program. My colleagues on the other side of the i often characterize the Medicaid Program as inflexible for states. We heard that a lot, that it is inflexible. To the contrary though i think medicaid has provided for a great deal of innovation in a state that responded to the Opioid Crisis. Could you please tell us about the Health Home Program in your state and how medicaid granted rhode island the flexibility to develop its own person centered care Opioid Treatment Program . That are probably two innovations and home health will be one of them where we worked with the Medicaid Office for a period of 18 months to develop comprehensive Data Management functions for Opioid Treatment Programs to provide to their clients. In addressing physical Health Issues as well as their addiction issues. And the process with medicaid was one that allowed us to use a monthly rate to support the work that was really improving the health care of individuals and all. Abuse disorder. We know that people who have opioid use disorder often have comorbid conditions dont necessarily have the greatest access to care in the community, and the health homes allow those programs which of the greatest access to individuals to provide nursing support that are overseen by physicians, Case Management that helps them get to the need appointment, dental appointments. Medicaid has been supporting those efforts within understanding that improving those tha outcomes will improve outcomes overall, reduce costs. The centers of excellence are also a Medicaid Innovation where we allow people to be seen very quickly, and its the issue. You need at that access to treatment which was noted. A person seen in the emergency room needs to be able to follow through and get access to treatment in order for anything to be effective. Centers of excellence exist as a Medicaid Innovation allowing people access to treatment, all fda approved medications again within 72 hours that have intensive Services Provided in six months of treatment supported by a medicaid rate with as much treatment and Case Management and Recovery Supports as the individual needs. We intention to move the individual into the community once stabilize and continue to provide the clinical and Recovery Supports needed, again, through a medicaid supported innovation. Obviously my concern is in states most heavily impacted by the Opioid Epidemic, if you have cuts to medicaid that then may lead to cuts in Addiction Treatment and exacerbate the process. I have one minute left. Would you agree that deep cuts to addiction services, that might result from the Senate Trumpcare bill, for example, that if states decide because of this, cuts in the Senate Trumpcare bill, that those kinds of cuts to Addiction Treatment would have a drastic impact on our ability to fight this epidemic . Our recovery, our overdose strategy engages for different components. And three of the four would be affected if medicaid were not available to support. The access to naloxone is supported by medicaid. Medicaid covers naloxone for individuals to the treatment component is again supported by medicaid. Our centers of excellence as well as all of the treatment components have that as well, and the ability for recovery coaches to be funded if not for the treatment being covered by medicaid, our Substance Abuse block grant dollars would have to be redirected from this Recovery Efforts to support individuals in treatment. Thank you so much. Thank you, mr. Chairman. Ms. Brooks is recognized for five minutes. Thank you. Director boss, i want to clarify something that my colleague congressman walz, walberg asked you previously. You talked about a data gap with respect to fit in all in Law Enforcement come with respect to Law Enforcement data. In your written testimony to talk about Hospital Systems are testing for fentanyl but we do not yet know the frequency of testing or how many tests on returning positive for fentanyl. And so i just want to clarify and make sure so the gap, the gap in collection on data for fentanyl exist in Law Enforcement, and hospitals as well, is that correct . So the testing for fentanyl in hospital is fairly new and so were not sure how complete the date is. They do have the ability whether or not all the hospitals are testing or not, im not exactly sure. I think its for the most part an issue of timeliness, to be able to respond effectively we need to have access to timely data and making sure that if testing occurs, that were able to get the results quickly and it enough time to respond to a community that may be seeing an increase in fentanyl. I guess i would ask the others on the panel whether or not you know if your hospitals are gathering data on fentanyl specifically, and the frequency and so forth . I cant speak directly for the hospitals. I know that there are medical examiners office, through our emergency First Responders, if the information with regard to fentanyl usage, little more tn 6 of our foot ou fatalities, oe fatalities on opiates are related to fentanyl. In most cases its a mixture with something else, cocaine or heroin, but were getting most of her information from the Law Enforcement and emergency responders. I want to talk a little bit more specific about the criminal Justice System and would like to ask you, secretary tilley, the core program that you mention, that is specific to criminal Justice System in kentucky, isnt it . Actually it brings it all stakeholders even education, cabinet for health and family services, our court system, all elements of the criminal Justice System but any element affected by the opioid scrooge is present on that particular effort. I like to find out from you briefly your state efforts because of his and what is incarcerated, which many family members said that saves their lies. Its had every want them to be diverted and we do want to focus on highlevel and former u. S. Attorneys we want to focus on the mid and high level deals dealers and those exposing people with addictions. However at times we have a captive audience a participant in treatment. And can you talk a bit more about medicationassisted treatment in your facilities and then counseling . Is their drug testing that is part of your incarcerated population, juveniles and adults . Start with adults. Again, counseling is required with any medically assisted treatment we do. Again, i described earlier in my testimony i think a pretty Innovative Program where we assess to risk and Needs Assessment those would need an injection of the patrol, prior to their release as a stabilization mechanism. They also get our release, excuse me, upon release get another injection and then they are matched with a counselor and if you recovery coach to try to find the necessary resources to continue that treatment whether it may be a what other sources may come from. In our juvenile setting we did not have medically assisted treatment this time. However, we acted like a faithful have a record low in terms of juvenile detention population at the moment and that doesnt seem to be nearly the issue in our facilities although we do offer that treatment in the facility is, just a medically assisted at this time. In the same we receive in the corrections setting. One thing that unique about kentucky and one thing that was not maybe reflected in the newark times article about that treatment is the kentucky houses roughly half of its state inmate population New York Times. We have 83 fullservice county just a do that that that presents challenges but we are expanding and incentivizing that kind of treatment come back on a medically assisted treatment like you may read about. I think i would also add that the piece about incarceration, we are trying to use elements like involuntary commitment. We called caseys law in kentucky, to try to maybe bypass the need for incarceration for those individuals, again, who stand up to the families as someone who needs a forceful hand, maybe a judges content power power to keep them in treatment. We will be submitting questions for the record for each address its because im interested in knowing more and my time is up, on medication, medically assisted treatment as well as counseling and what you are doing with her inmate population. I know you each doing something but would love to learn more about peer i want to thank you all for cooperating with each other and learning from each other medically important. I yield back. Recognize mr. Costello for five minutes. Thank you, mr. Chairman. Some of you may know that the chairman and i both hail from pennsylvania. The chairman from the western wn park, myself on the eastern part state. Sometimes people thanks they are to devastates. But having said that in pennsylvania the epidemic is particularly acute think they are two different states. Just a few brief comments about what were doing in pennsylvania and then Lieutenant Governor rutherford, i had a couple of questions for you. With the enactment of the 20 teachers act pennsylvania received 26. 5 million in federal funding to address the epidemic, 3. 5 million for drug courts, 23 million being funded to expand Access Communication assisted treatment, increase training opportunities to Better Connect individuals with additional treatment when it is an emergency room as result of an overdose and also to improve access to opioid use Disorder Treatment under, for uninsured individuals. Lieutenant governor rutherford, you spoke about establishing a 24 hour Stabilization Center in Baltimore City i wanted to ask you about that. What services will be provided the facility . Why do you think it is better suited to such a facility to treat Substance Abuse issues rather than in Emergency Departments . And they may be keeping up on your answer i will have some followup questions. Well, the concept of a Stabilization Center is a place where both First Responders as well as Law Enforcement or family members can take a person who is suffering from Substance Abuse disorder, and they need ready for some type of treatment. And the ideas to bring them into an locale, not necessarily an emergency room because that is a very high cost approach to addressing this challenge where they can be stabilized and get them into longerterm treatment. So its an opportunity to get the person, as i mentioned, stabilized. They can reside there for a few days before, if theres a bed available to get them into treatment. Any similar facilities you might be modeling is often . I believe san antonio has something similar. Id have to get more information and talk to my staff. I believe it was san antonio that apple he was doing something very similar to this. Once stabilized will the patient can be moved into evidencebased treatment and counseling . That is the objective. It hasnt been, we havent stood this up as yet and were working with the city of baltimore in terms of the parameters and how this is going to actually operate, and but the states over several will be with this. Is the hope that treatment and counseling and you said that is your hope, that the funding that you will be utilizing for the facility itself, would that funding extend to the treatment and counseling, or are you looking at the facility to just be sort of on the front and . Facility is on the front end. We will look to the other funding sources, the future act, through state revenue, insurance, through medicaid, to pick up the treatment aspects of the challenge. Can you describe some of the challenges that you stay currently faces to provide beds in a timely manner for individuals seeking treatment for Substance Abuse . Well, the lifting of the restriction with regard to medicaid reimbursement on the number of beds in the facility has helped that particular challenge because we did have situations where we had individuals who would receive treatment through medicaid, and we had beds available in some of our facilities but we could not utilize of those. That has helped. We are working to expand the capabilities, particularly for some of the nonprofits that have services and or providing services and seeing what we can do to assist them and expanding their access. We have close to 800 facilities around the state. Theres always discussion about getting additional beds and capacity, and so were working on those things as well. Thank you. My general comment on this epidemic is oriented towards the following. I think there are a lot of variables that contribute to this peer i think everyone knows that. I get concerned when we point to one particular actor in this ecosystem and say thats the problem. Because it is manifold. It is complex, and i think what concerns me more than anything is that the lifecycle of treatment is much longer than the infrastructure that has been setup to deal with it. And as a consequence of that, no matter how good we might be in the first six innings of this, if were not good in innings seven, eight and nine it will not ultimately matter and we really just embedding more cost into the system by frontloading some of the costs without really acknowledging that on the back in if we dont finish it off with the right kinds of treatment at the right type of counseling and the right kind of follow up on that, we will not ultimately be able to drive down the epidemic. I think we all can identify what some of the front end is you are here, but that would be something i would just like to sit for the record. Mr. Chairman, i see i am well my time. May i respond . Yes. Very briefly. You are absolutely right. Some of the thought process behind the process it is its a front end, youre right come is a front end with a person comes in the door. They are in distress at that point, stabilizing did. Them into treatment, but even after the treatment one of the things we were over and over again from people who have relapsed is a come out of treatment and the go back into the sink unity, the same stimuli, the same issues that they had before. One of the areas where focusing on going forward, including utilizing picture act funding in state funding is transitional housing cures act the Halfway House but transitional housing where a person can go and continue to get treatment in terms of the counseling aspects of it but during the day they can go to work, they can do the things they need to do a have to report back to this facility, people said that is something they need people to go back into the unrestricted society. Because all the stimuli is still there. Thank you very much. Its a policy of this committee to let other members are not on the subcommittee ask questions. Mr. Bilirakis, you recognize for five minutes. Thank you so very much and thank you for allowing me to sit in on the hearing. Appreciate it, mr. Chairman. I have some prepared questions but does anyone else want to elaborate on that come any other suggestions as far as longterm, the backend . Is or anyone on the panel that would like to talk about that . You mentioned, and you are so correct, transitional housing. Cooperation obviously is so very important, the patient needs to cooperate and voluntarily in most cases. User anyone who who wants to make another comment before i get started . If i could i would add the front end is very important because access to care oftentimes you have family saying i dont know where to turn for help. We are looking at a Crisis Center model as well. I think thats critically important. You dont know which number to call. You have a family or loved one and youre not sure how to connect them. But in the connection to treatment is critically important as well. Its like someone with hypertension going to the emergency room and Getting Better but not getting a prescription. Its not going to help. So without access to care and the support needed, so Recovery Housing is critical as well, and part of our cures act funny were looking to establish that kind transitional housing for individuals who are not able to return to their communities. We really need to look at the longterm and treating addiction as a chronic disease not to acute episodes. So i think the approach to longterm advocate the longterm you can continue watching this hearing at cspan. Org. The Senate Begins its session voting at 12 30 p. M. To confirm confirm a judicial nomination at a second vote to advance the nomination for ambassador to japan. Reports today said Senate Republican leaders plan to unveil tomorrow a new version of their healthcare replacement plan. We may hear more details about that today. This is live coverage on cspan2. The president pro tempore the senate will come to order. The chaplain, dr. Barry black, will lead the senate in prayer. The chaplain let us pray. 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