Briefly, what does the body of Scientific Evidence show regarding effect i haveness of met doen and buprenorphine in treatment of opioid abuse disorders . The research has shown, has shown it not just for methadone and buprenorphine, and naloxone, as part of a comprehensive program for treatment of opioid addiction are quite effective and significantly improve outcomes of individuals being able to stay on one hand ab stinent from the drug or to decrease likelihood of relapsing, also protects them against adverse outcome such as overdose. So in light of those studies you also said in your testimony that existing evidence based prevention and treatment strategies are highly underutilized across the United States, and last week we had an expert tell the panel that very few patients with opioid addiction today receive treatments that have been proven most effective. He was talking about the rapid detox, followed by abstinence based treatment. I wonder if you can help understand this. Why do we have a situation where people are not getting evidence based treatment . It is a complex problem. There are many reasons theyre not getting correct treatment, including the fact of education of proper management of Substance Abuse disorder including the health care system. Then you have an infrastructure because addiction is sigma advertised, therefore likelihood of people accessing that care is much lower, then of course theres a difference between states in the way they implement treatment, so all of these factors account for the current situation. Dr. Frank do you have anything to add to that . Yes i do. I think one thing thats very important to remember is that overall we treat 10 of the people with these disorders. So it is not surprising that people arent getting evidence based treatment because theyre not getting treatment period. Second part is why arent they getting evidence based treatment among those that do, and i think that there are insurance dynamics that hopefully we are fixing. There are access to trained professionals who are trained in these things and then in a sense trying to kind of get the systems and infrastructures aligned to support the best practices. And doctor, several of our witnesses, including you mentioned that role of the states in this. Can you talk about that for a minute . Absolutely. I think states have different populations, different issues, different Prescription Drug monitoring programs and so tailoring for states, so they can identify state Medicaid Program or other high risk patients, thats why the program at cdc is helpful, we are a higher level view to work across states. And do you think the states have work to do in terms of implementing these programs that are science based and that work . You know, i think we are starting to do that. Like our program itself has only been in existence for six months but we are seeing great progress. If you look at policies states are implementing we are seeing reductions in doctor shopping patients going to different doctors because of utilizing Prescription Drug monitoring program. Although it is early in the stage, i am optimistic we are making progress in the states. Doctor, i want to come back to you. Another expert last week said patients and their families need to know detox i have indication and drug free counseling are associated with a very high risk of relapse. I am wondering if you can tell us what the science shows. Is this type of treatment generally effective or less effect sniff what is does the Research Show . The research has shown that in general it is associated with increased mortality. This reflects the fact that addiction is a chronic disease, changes in the brain persist months, years after you stop taking the drug. What they do is remove the physical dependence and assume the addiction is cured and these are two independent processes. As a result, the patient feels theyre safe and then they relapse because theyre still addicted addicted. Thank you. Thank you very much, mr. Chairman. Recognize mr. Collins for five minutes. Thank you, mr. Chairman. This is truly a fascinating topic we are discussing and it is obvious theres no easy solution. We heard it is a chronic disease, 10 are seeking treatment. I guess my question for miss hyde and samhsa is certainly with pregnant women that may have young kids at home, inpatient treatment might be the preferred, we just cant let perfect be the enemy of good. What other options are you looking at for people that arent going to enter inpatient they may be part of 90 not getting treatment at all. Some treatment better than no treatment, as frustrating as that might be . What are your comments to the young mother thats got kids at home, shes pregnant and dependent and just cant go into an inpatient center. What do we do for that patient . Thank you for the question. The issue of pregnant and parenting women is a big one in our field. We have a Small Program to address your issue, but youre right, it is a residentially based program. We are increasingly looking for ways to take what we learned in the program about the best way to treat pregnant and parenting women and take it to other settings, whether it is opioid Treatment Programs or the training we do for physicians who are using medication assisted treatment to deal with pregnant and parenting women so we are trying in every way we can to make those Services Available to those women. So again, with pregnant women, looking at other treatments, whether thats buprenorphine or methadone, are there studies that show whether that has an impact on the fetus and baby . Youre right to be concerned about the child. What we see is that this prevents death it prevents addiction of the baby prevents a lot of other issues that come with allowing the young woman to continue with the Prescription Drug abuse or opioid misuse. Providing treatment helps both the woman and the child. Now, youve counselled these women. What kind of reaction are you getting . Are they recognizing, you would think genuine concern for the baby, very much a complicated balancing act going on here. What kind of reactions are you getting from the women acknowledging the problem and wanting to treat it . You know, most pregnant and parenting women really want to do the best thing for their babies and they want to do the best thing for themselves, but as youve heard addiction is a chronic disease, it is difficult. Changes the brain changes the ability to make decisions. The women in the programs we provide support for find it a helpful program with the kind of supports because we provide a range of programs and we have recently introduced medication assisted treatment into the programs as well. So are these women finding you on their own or are there physicians guiding them to you . The women that come to our programs come from a variety of places, some from correctional system, some from physicians some from family some from self referral. So they come from a number of places and we dont make a distinction between where they come from in terms of providing care. Now, something this committee is very concerned with, and again, mr. Chairman, thank you for holding this hearing and for all of your testimony. I wish there was an easy solution there just doesnt appear to be one. So this will have to be addressed on a lot of fronts. With that, i yield back. Thank you, mr. Chairman. Let me welcome the Connelly Family to the hearing and let me compliment michael bod which he ee for having the roots origins in the 20th Congressional District of new york. Welcome all. One of the biggest concerns i hear from families struggling with addiction is difficulty they have accessing treatment. With the Mental Health parody and addiction equity act as well as with the the Affordable Care act, millions more gained access to Mental Health and Substance Abuse services. However, recent reports lay bare the fact that these new treatments as options sometimes exist on paper only. So my question first to assistant director frank dr. Frank, what is hhs planning to do to increase Public Disclosure of the medicaid Management Practices insurers use both on the commercial side and on medicaid and chip so that consumers can truly evaluate their health plans to ensure theyre in compliance. Thank you for the question. We too, view the Mental Health parody act as an incredibly important opportunity to increase the use of Evidence Based Practice and access to treatment. We are doing a number of things. We work with both the department of labor on the erisa side of commercial Health Insurance side. We trained the erisa investigators in how to detect deviation from parody arrangements within insurance, and so theyre out there fully trained now working on these issues. We have a group within hhs who regularly provides Technical Assistance to state Insurance Commissioners and works with them to resolve complaints as they arise and weve done continuing series of forms and Technical Assistance around the country. We are working with stakeholders, some in the room today, to improve our ability to ask for disclosure and to offer up consumers the opportunity to really make that evaluation that you referred to. Thank you, assistant secretary. Director bod which he ee would like to talk about another barrier for treatment to patients. Press accounts suggest that some states are denying patients access to drug courts if theyre receiving medication assisted treatments or mats. I understand this is a problem in kentucky, according to some press accounts. So director can you explain whats going on here, given the important of mats, why are some attempting to cut patients off medicines that can help them recover . Thank you congressman. As many of my colleagues talked about today, increasing access to medication assisted treatment along with other behavioral therapies is the best course of treatment for people with opioid use disorders. One of the accesses we find in addition to issues around payment have been particularly lack of access within the criminal Justice System and we know that many people with opioid use disorders end up in our system. Some drug courts havent adapted policies that National Association of Drug Court Professionals endorse in terms of ensuring people who have an opioid use disorder get access to those medications as well as not predicating participation that they get off the medications. Part of what we have been doing on the federal level is using our federal contracting standards to ensure people with opioid use disorders, whether in drug court or Treatment Program or other venues are offered access to medication assisted treatment and are not denied participation based on the fact that they are on physician prescribed medication. Doctor volkow, on that issue do you agree with the ai assessment . I agree and developing opportunities that are more amenable, like prison and jail theres no reason they shouldnt get access to medication. Another barrier that patients face is lack of available treatment providers who can prescribe mats. Director, can you comment on this derth of providers that can prescribe buprenorphine, for example . What are the reasons for the shortage, what can we do to address it . One of the other opportunities we have is ensuring all of our Treatment Programs either low percentage of them incorporated medication assisted therapy into their programs. Some of this, congressman quite honestly, has been by myth and misunderstanding and this divide between abstinence based care and medication assisted treatment which i think is really unfortunate that we have here. We really want to make sure if a client is entering a Treatment Program that has particularly federal funding, needs to offer by way of its own offering or through referral medication assisted treatment. All right. Thank you very much. And thank you to the entire panel for guiding us on this. I want to ask as clarification for the question on drug courts and use of medication assisted treatment, youre recommending medication assisted treatment as part of an option package, although you say obviously we want to get people free from drugs all together. Does it require recommended practice from your agencies to get drug courts to do that . Does it require regulatory changes from one of the agencies or legislative solution from us to do that . We have been doing that as condition of their federal drug court language. You know again we want this to be decided by an expert in Addiction Services in consultation with the patient, but didnt want categorical denial. Are you adding to that . I did mention in consultation with ondcp and with department of justice we changed the language in request for applications for drug courts so that they cant require someone get off of or not be on medication assisted treatment, if it is prescribed appropriately by physician or certified program. So i just wanted to add though, what you can do you can make federal funding contingent on full programs but we cant force the states or whatever Regulatory Agency setting up the drug courts to offer this, they just cant get federal money if they dont offer it. Going to be talking at state level as former state administrator, states play a crucial role. There are many many programs out there that dont receive federal funding or drug courts that dont receive federal funding. We hope our policies and procedures are adopted by those nonfederally funded programs, but states play a key role in licensing Treatment Programs. Thank you. And they i think can look at the opportunities of increasing or ensuring that state license of Treatment Programs also have the same kind of language. Thank you. Speaking of states, the gentleman from West Virginia. Thank you very much, mr. Chairman, and thank you for the hearings on this topic. As an engineer, i need to see things in perspective. So been following this the last four years in congress and on this committee, trying to look at this issue. I think one of the last meetings we just had, i tried to put it in perspective by saying you said there were 44,000 Overdose Deaths. I want people to understand, thats more than died in vietnam in combat. I dont know that the American Public understands that and every day on the news nbc or whatever, they had body counts and had that and people were outraged over that. I am not getting the sense of outrage over every year we are lose as many to Drug Overdose as in a ten year war in vietnam. I am concerned when i had affirmed in West Virginia one in five babies born in West Virginia and may be 1 in 4 in other states, but 1 in 5 have been effected with drugs. I keep things in perspective saying in europe overdose rate is 21 per million. In america it is 7 to 10 times that amount. I get on the verge of outrage, father of four, grandfather of six. These are what we are giving our kids, this is what the future is. I hear this testimony from this panel of seven and seven before that and seven before that. Quite frankly, i get confused. I dont know what the priority is. For the Business Community and you all here in washington everyone loves to plan. But they dont carry out. That may be insulting, and i dont mean it in insulting fashion, but we have 44000 more people that will die between now and next year. I would like to think we could come up with one way at least one, prioritize it, whats one thing, and then put everything we have into it. That Manhattan Project go after that one solution and see if that doesnt start the ball rolling in the right way. Then we can do two, three, four with it. But a focus. I dont see a focus. I didnt see a focus from you. I heard seven or eight ways we might be able to approach this problem because the Plan Everyone loves the plan but implementation falls short. So since youre meeting on a regular basis couldnt you come up with one idea to where we ought to begin . Trics, the optics, we can dig into that and then we can have plan b, c and d, but lets achieve one instead of continuing to meltdown like this. I dont want to see another statistic of 44,000 more people died of overdose. I hesitate to ask, can you come up with an idea today in the time frame . Is there one, just one idea we should focus on . Whats the best way . Is that in the drug use is that in real time, on purchasing Prescription Drugs that it is a National Database . Is that the number one thing we should do . My god the federal government just changed sentencing guidelines for her oh in. If youre caught with 50 hits of heroin you get probation. What are we doing . Are we fighting heroin or not . I am really frustrated with this. Give me more guidance on plan one. I appreciate your attention to this and you know myself and many of our colleagues have been doing this work a long time, i think are filled with a sense of tragedy in terms of where we are and know that we can do better and work with congress. You asked for one. I think there are three areas in the secretarys plan that we have to do. We have to change prescribing patterns, we are prescribing way too much medication. And thats starting the trajectory. We need to increase capacity to treat t