[Senate Hearing 117-404]
[From the U.S. Government Publishing Office]
S. Hrg. 117-404
FIGHTING FENTANYL: THE FEDERAL
RESPONSE TO A GROWING CRISIS
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
SECOND SESSION
ON
EXAMINING FIGHTING FENTANYL, FOCUSING ON THE FEDERAL RESPONSE TO A
GROWING CRISIS
__________
JULY 26, 2022
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
_________
U.S. GOVERNMENT PUBLISHING OFFICE
48-915 PDF WASHINGTON : 2024
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont RICHARD BURR, North Carolina,
ROBERT P. CASEY, JR., Pennsylvania Ranking Member
TAMMY BALDWIN, Wisconsin RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut SUSAN M. COLLINS, Maine
TIM KAINE, Virginia BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota MIKE BRAUN, Indiana
JACKY ROSEN, Nevada ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado MITT ROMNEY, Utah
TOMMY TUBERVILLE, Alabama
JERRY MORAN, Kansas
Evan T. Schatz, Staff Director
David P. Cleary, Republican Staff Director
John Righter, Deputy Staff Director
C O N T E N T S
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STATEMENTS
TUESDAY, JULY 26, 2022
Page
Committee Members
Murray, Hon. Patty, Chair, Committee on Health, Education, Labor,
and Pensions, Opening statement................................ 1
Cassidy, Hon. Bill, a U.S. Senator from the State of Louisiana,
Opening statement.............................................. 4
Witnesses
Chester, Kemp, Senior Policy Advisor for Supply Reduction and
International Relations, Office of National Drug Control
Policy, The White House, Washington, DC........................ 6
Prepared statement........................................... 8
Summary statement............................................ 14
Delphin-Rittmon, Miriam, E., Ph.D., Assistant Secretary for
Mental Health and Substance Use, Substance Abuse and Mental
Health Services Administration, Rockville, MD.................. 14
Prepared statement........................................... 16
Johnson, Carole, Administrator, Health Resources and Services
Administration, Rockville, MD.................................. 21
Prepared statement........................................... 23
Jones, Christopher, Pharm.D, Dr.PH, MPH, Acting Director,
National Center for Injury Prevention and Control, United
States Centers for Disease Control and Prevention, Atlanta, GA. 28
Prepared statement........................................... 30
ADDITIONAL MATERIAL
Burr, Hon. Richard:
Statement for the Record..................................... 63
QUESTIONS AND ANSWERS
Response by Kemp Chester to questions of:
Senator Baldwin.............................................. 64
Senator Rosen................................................ 65
Senator Burr................................................. 65
Senator Collins.............................................. 66
Senator Murkowski............................................ 66
Senator Scott................................................ 68
Response by Miriam E. Delphin-Rittmon, to questions of:
Senator Baldwin.............................................. 69
Senator Lujan................................................ 70
Senator Burr................................................. 72
Senator Cassidy.............................................. 73
Senator Collins.............................................. 74
Senator Murkowski............................................ 74
Senator Scott................................................ 76
Response by Carole Johnson to questions of:
Senator Rosen................................................ 76
Senator Lujan................................................ 77
Senator Burr................................................. 78
Response by Christopher Jones to questions of:
Senator Casey................................................ 78
Senator Collins.............................................. 81
Senator Murkowski............................................ 81
FIGHTING FENTANYL: THE FEDERAL
RESPONSE TO A GROWING CRISIS
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Tuesday, July 26, 2022
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10 a.m., in room
216, Hart Senate Office Building, Hon. Patty Murray, Chair of
the Committee, presiding.
Present: Senators Murray [presiding], Casey, Baldwin,
Murphy, Kaine, Hassan, Lujan, Hickenlooper, Collins, Cassidy,
Braun, Marshall, Scott, and Moran.
OPENING STATEMENT OF SENATOR MURRAY
The Chair. Good morning. The Senate Health, Education,
Labor, and Pensions Committee will please come to order. Today
we are having a hearing on the fentanyl crisis that is
devastating our communities. I will have an opening statement
followed by Senator Cassidy. He will--and then we will
introduce our witnesses.
After they give their testimony, Senators will each have 5
minutes for a round of questions. And again, while we are
unable to have this hearing fully open to the public or media
for in-person attendance, live video is available on the
Committee website at help.senate.gov.
If you are in need of accommodations including closed
captioning, please reach out to the Committee or the Office of
Congressional Accessibility Services. Last week, back in
Washington State, King County declared fentanyl a public health
crisis and it is painfully obvious why. This year King County
alone has lost over 270 people to fentanyl overdoses. That is
an increase of nearly 50 percent from last year.
That is more than one fentanyl death every day, and that is
just one county in my state, one corner of our Country, which
lost over 100,000 people to drug overdoses last year. That is
an all-time high. And that number doesn't just represent a grim
record, it represents so many personal tragedies, so many
families that are shattered by the loss of a loved one,
parents, caregivers, and increasingly teenagers.
Now, there is no question we had a mental health and
substance use disorder crisis on our hands before the COVID
pandemic. But there is also no doubt things have gotten so much
worse due to the trauma of this pandemic and so much more
deadly with the sharp rise of illicit fentanyl in recent years.
That is because fentanyl is up to 50 times stronger than
heroin and 100 times stronger than morphine. Two milligrams can
be a lethal dose. From April 2020 to 2021, synthetic opioids,
mostly illicit fentanyl, were responsible for nearly two-thirds
of all overdose deaths. And the recent rise in fentanyl
overdose deaths has also reflected the painful, systemic health
inequities we still need to do so much to address.
Black communities as well as American Indian and Alaskan
Native communities have suffered a higher increase in overdose
deaths than other demographics. There has also been a deeply
alarming rise in young people dying from overdoses. In 2019,
over 250 teens died from illicit fentanyl. Last year, we lost
almost 900. Think about that. Fentanyl deaths for teenagers
more than tripled in 2 years.
My heart goes out to every family touched by this crisis,
and I have heard from many of them, people who lost a loved one
after a long, hard struggle with addiction and those who lost a
loved one suddenly to a counterfeit pill laced with a lethal
dose of fentanyl.
Our communities are doing everything they can to fight
this, but they need help from the Federal Government to stop
these dangerous drugs at the source, cutoff supply lines, and
importantly, get these kids and their families the help they
need. And the way we do that is to support families on the
ground through robust public health efforts and better access
to mental health and substance use disorder care.
When it comes to cutting off the supply of fentanyl, FDA
has been working to crack down on counterfeit drugs being sold
online. Something I want to see them continue making progress
on to protect our youth. And the DEA is working to seize
fentanyl laced pills before they can end up in our kids hands.
I have been pressing President Biden on this the same way I
pressed the Trump administration. And we are seizing more
fentanyl laced pills than ever before, and I appreciate the
hard work that is going into that.
Our law enforcement and first responders on the ground are
really working to rise to this challenge, to stop these deadly
pills and save lives, and ensure people can get the care they
need.
But when I talk to police officers or fire chiefs and first
responders back in Washington State, it is clear we have a lot
more to do to build on the progress that we are making, cutoff
the supply lines that produce these dangerous drugs, and
prevent them from ever reaching our communities.
Drug trafficking is a serious problem, and that is why
Democrats continue to work with Republicans to provide
significant funding for border security and drug interdiction.
But let's get one thing clear, we need to be taking this
seriously and having real conversations about how we address
the national threat of fentanyl use and supply, not playing
politics, not scapegoating, not fear mongering, not attacking
refugees and immigrants with proposals that are based more on
xenophobia than on what will actually work to keep people safe.
That is not to say we cannot talk about accountability,
especially for opioid manufacturers who fueled this crisis to
line their pockets.
There are enormous corporations that knew just how
dangerous and addictive these products were and yet decided to
ignore the risk for patients, market these pills aggressively,
and flood our communities with opioids. We absolutely must hold
these companies accountable for padding their profits at the
expense of countless lives.
Of course, stopping the supply of illicit fentanyl and
holding companies accountable, which fueled the opioid crisis,
is critical. But we really have to tackle this challenge from
every angle possible. And with that in mind, we have a lot more
work to do to help our communities get people the mental health
and substance use disorder care they need.
Right now, less than 10 percent of people who need
substance use disorder treatment can get it, and care is even
harder if you are Black, or Hispanic, or American Indian, or
Alaskan Native.
The painful reality is that most people who die by overdose
didn't get any substance use disorder treatment before they
passed away. That is unacceptable. We need to do better. A big
part of the problem is our mental health and substance use
disorder workforce has been woefully overstretched and
understaffed.
I said this before, but it is so important to understand if
we are going to get our arms around this. Almost 130 million
Americans live in areas with a mental health care provider
shortage. Essentially, they don't even have one mental health
care provider per thousand people--per 30,000 people.
In Washington, our mental health care workforce is only
able to meet 17 percent of our state's needs. If we are going
to turn the tide in the fight against fentanyl, that is going
to have to change. We cannot lose sight of the fact that a
strong public health system and easy access to treatment for
everyone are some of the most powerful tools in our arsenal.
We need to make sure every community has a robust public
health department with the data needed to track overdoses, stop
spikes, and the ability to raise public awareness about rising
threats like counterfeit drugs laced with fentanyl. And we need
to support programs on the front lines in our communities that
are focused on prevention, treatment, and recovery support.
I have fought hard to invest in our communities to expand
mental health and substance use disorder care through HRSA,
which is helping build our mental health and substance use
disorder workforce in our rural communities, through Federal
grants, which have helped set up dozens of new treatment
centers across our states, and in the American Rescue Plan,
which included critical funds for this work.
But to talk to anyone on the front lines of this for 2
seconds and you will understand we have a lot more to do. I
talked to the fire chief in Seattle who told me a few months
ago they respond to four overdoses every day.
I talked with a University of Washington researcher who
told me how 80 percent of people who could benefit from
services to keep them alive can't access them. Talked with a
nurse in Everett who told Secretary Becerra about how there are
just not enough beds to get people treatment.
The mom who told him about how she lost her job, her house,
and her child while she was struggling with fentanyl addiction.
Talked to Jason Cockburn at the Second Chance Foundation in
Everett, who is spoken about the challenge of trying to get
kids the treatment they need, or the many people who
desperately tried to help him find an open treatment bed for a
15 year old earlier this year, calling contacts, posting to
Facebook, no--all, to no avail.
It is so clear that leaders like Jason, who are on the
front lines of this crisis, need so much more from our Federal
agencies and from this Congress. More when it comes to getting
fentanyl off the streets and more when it comes to getting
people the health care they need.
Which is why I am as determined as ever to continue the
progress Senator Burr and I are making on a bipartisan package
on mental health and substance use disorder. We need to support
the programs on the ground in our communities that are already
doing lifesaving work to identify people who are at risk and
prevent substance use disorders in the first place, to get
people treatment, and to support people in recovery.
We need new programs, especially when it comes to
addressing the new challenges we are seeing with fentanyl and
with heart breaking increases in overdoses among young people.
So I am going to continue to press for us to advance as
expansive a package as possible, as quickly as possible.
I believe that we can do it because we have done it before.
In 2016 and again in 2018, Democrats and Republicans worked
together to pass some of the most comprehensive legislation to
respond to the opioid crisis in our Country's history. That has
made a big difference.
That legislation has undoubtedly saved lives. But I have
traveled to just about every part of Washington State to talk
about this crisis. From Everett, to Seattle, to Longview, to
the Tri-Cities, to Spokane, and more.
The challenges that we are dealing with today are not the
same challenges we faced in 2018. So now it is on all of us to
build on the bipartisan progress we have made. And it is
painfully clear our communities cannot wait.
They need us to meet this moment with serious action and
lifesaving support for families. With that, I will turn it over
to Senator Cassidy for his opening remarks.
OPENING STATEMENT OF SENATOR CASSIDY
Senator Cassidy. Thank you, Madam Chair. And I thank
Ranking Member Burr who allows me to lead this meeting. As a
physician, I took care of patients with addiction. But it
doesn't take a physician taking care of those with addiction to
know that we have a fentanyl crisis. Everyone here and everyone
watching knows of someone who has died or who has suffered from
addiction related to opioids.
If you read of the young person who dies, the teenager or
in college, most often it is related to a drug overdose. And
you think about the tragedy of that child whose whole future
was before she or he, and now it has ended, affecting not just
their life, but all those generations that would come after
them from that wonderful person. It is incumbent upon us to
address this issue.
Now the statistics. Fentanyl is killing over 200 Americans
a day. In 2021, we saw the largest annual increase in opioid
deaths in 50 years. In the 35 years between 1979 and 2016,
600,000 Americans died to overdose and a 100,000 died last
year.
I will speak of my own state. Louisiana's drug overdose
deaths hit a record high of 2,100 in the 12 months leading up
to March of 2021. Overdose mortality increased statewide by
over 56 percent through 2020 to 2021.
New Orleans was up 51 percent in 2020, with 365 overdose
deaths. Jefferson Parish up 69 percent. Saint Tammany up 35.
And Saint Bernard up 64 percent. And we know the cause of this,
it is fentanyl.
Illegal fentanyl and fentanyl related substances are
flooding into our market from our Southern border in
unprecedented amounts, with the bulk of this ultimately
originating from a handful of manufacturers in Wuhan, China.
Fentanyl accounted for 64 percent of the 100,000 overdose
deaths last year. Two out of every three people who die from
opioids it is from fentanyl or fentanyl like drugs. Now,
Congress has to continue to pass tools to fight this from
multiple fronts.
First, we need to make the classification of fentanyl
analogs as Schedule 1 drugs permanent. Several of my colleagues
and I introduced to Halt Lethal Traffic of Fentanyl Act last
year to do just that. Second, we need to educate Americans just
how deadly fentanyl is. Two milligrams is enough to kill
someone.
I was proud to join Senator Marshall and other doctors in
the Congress to record a PSA informing Americans about the risk
of fentanyl. Health experts and public officials need to
continue such efforts.
Third, the border. Last year, the DEA seized 20 million
fake pills and 50,000 pounds of fentanyl, enough for 440
million lethal doses. When I went to the border, I saw this big
cage of illegal drugs. I said, how much do you think you are
getting? They think, we probably think we are getting about a
third of it.
If we seize this much, that much more went through. We have
to recognize that a policy at the border which has been
feckless and ineffective as this Administration has had, not
just allows people to come here who are not--who are illegal,
illegal immigrants, it allows drugs to come across as well.
We have got to control that border. If there is a message I
wish the Administration to get, use your tools to control.
Fourth, we need to combat the drug cartels' ability to finance
the production and smuggling of illicit fentanyl into the
United States. Selling synthetic opioids laced with fentanyl is
a major source of revenue for cartels, drugs--excuse me, gangs,
criminal organizations, and for organizations such as
Hezbollah.
They use a financial process, including one known as trade
based money laundering, to disguise their activities and
illegally move in and out of the country. It is the use of
financial exchanges that look like legitimate trade to serve as
cover for illicit flows of money. If we can stop the financing
of the drug trade, we can stop the trade of drugs.
Finally, we need to look at loopholes in our customs
system. For example, cartels will ship Chinese made fentanyl
into our Country by mail, claiming the contents of the packages
worth less than $800, which is the threshold for paying
tariffs. Because it is declared as less than $800, Customs and
Border Protection does not inspect the package and it passes
through. It is a glaring loophole in our customs system.
I look forward to discussing these solutions and more in
todays hearing. Congress failing to address this crisis
threatens our national security and risks the safety of the
individual who does not know that one pill laced with fentanyl
can kill, which means that there will be one more obituary of
an 18 year old child whose life is gone forever. With that, I
yield.
The Chair. Thank you, Senator Cassidy. I will now introduce
today's witnesses. Mr. Kemp Chester is the Senior Policy
Adviser for Supply Reduction and International Relations at the
Office of National Drug Control Policy, ONDCP.
Dr. Miriam Dephin-Rittmon is the Assistant Secretary for
Mental Health and Substance Use and Head of the Substance Abuse
and Mental Health Service Administration, known as SAMHSA. Ms.
Carole Johnson is the Administrator of the Health Resources and
Services Administrator, HRSA.
Dr. Christopher Jones is Acting Director of the National
Center for Injury Prevention and Control at Centers for Disease
Control and Prevention. Thank you to all of you for joining us
today for this really urgent crisis--discussion on this really
urgent crisis.
I really do appreciate all of your sharing your time and
your expertise. We look forward to your testimony. And Mr.
Chester, we will begin with you.
STATEMENT OF KEMP CHESTER, SENIOR POLICY ADVISOR FOR SUPPLY
REDUCTION AND INTERNATIONAL RELATIONS, OFFICE OF NATIONAL DRUG
CONTROL POLICY, THE WHITE HOUSE, WASHINGTON, DC
Mr. Chester. Thank you, Chair Murray, Ranking Member
Cassidy, and Members of the Committee. Thank you for inviting
me to testify today on the dynamic, illicit drug environment we
face in the United States and the Administration's approach to
addressing it. Drug poisonings and overdoses claimed 108,809
lives in 2021 alone, which represents in American life lost
every 5 minutes around the clock.
Behind these fatal overdoses or millions of individuals
experiencing non-fatal overdoses that are overwhelming our
first responders and taxing our health care system. And while
these fatalities and non-fatal overdoses are the most visible
manifestations of our crisis, along with them are tens of
millions of Americans suffering from a substance use disorder.
Underlying these heartbreaking numbers is the impact on our
economic prosperity. The cost of this epidemic is estimated to
be $1 trillion a year, and up to 26 percent of the loss in our
labor force participation can be attributed to people suffering
from addiction.
The Administration is approaching this crisis with a keen
sense of urgency and with action that is bold, far reaching,
and innovative. The President's National Drug Control Strategy
is an evidence based blueprint designed to save as many lives
as possible in the near term, while building our capacity to
deal with untreated addiction and the profit driven trafficking
of illicit drugs in the long term.
The Director of National Drug Control Policy has further
identified four immediate priorities that cut across the
strategy's goals to achieve these outcomes. First is to have
naloxone, the opioid reversal medication, in the hands of
everyone who needs it, especially now when three out of every
four overdose deaths involve an opioid like fentanyl.
Second is tackling the enduring issue of Americans with
substance use disorder not getting the treatment they need.
Fewer than 1 out of 10 people in the United States who need
treatment are able to get it. We simply cannot accept that, and
we are committed to ensuring universal access to medication for
opioid use disorder by 2025.
Third, we must disrupt and dismantle the transnational
criminal organizations who produce and traffic illicit drugs
like fentanyl, by commercially disrupting the entire global
illicit business of drug production and trafficking, including
its illicit financial networks, supply chains, and a holistic
and coordinated fashion.
Finally, we need to close our existing gaps in data
collection and analysis we need to drive and evaluate drug
policy decisions, especially for non-fatal overdoses, which are
the most accurate predictors of a fatal overdose in the future.
Taken together, this represents a new era of drug policy that
is precisely what we need now to address an environment of drug
trafficking and use that is more dynamic than at any time in
history.
This is the first time the Federal Government is embracing
high impact harm reduction to reduce overdoses and deaths.
Commercial disruption is a new approach that brings together
our efforts in illicit finance, supply chain targeting, and
international engagement to target drug traffickers, their
operating capital, and their profits.
This strategy is the first in which we focused on improving
data to deliver lifesaving resources to the people who need it,
particularly those who interact with the criminal justice
system and those who are incarcerated. This is the first time
we have emphasized adverse childhood experiences and social
determinants of health as key elements of our prevention
efforts.
This is the first time we have called for making access to
substance use disorder treatment universal, removing outdated
barriers to prescribing medications for opioid use disorder,
and providing workforce opportunities for people in recovery.
In today's environment, dominated by opioids like illicit
fentanyl, we must reduce overdose deaths, ensure people can get
access to the help they need, and disrupt the flow of illicit
drugs across our borders and into our communities.
On behalf of Dr. Gupta and the men and women of the Office
of National Drug Control Policy, I want to thank this Committee
and your colleagues in Congress for your leadership on this
critical issue.
We look forward to working with you to address this complex
national security, law enforcement, and public health challenge
with the urgency that it so desperately demands. Thank you, and
I look forward to your questions.
[The prepared statement of Mr. Chester follows:]
prepared statement of kemp chester
Chair Murray, Ranking Member Burr, and Members of the Committee,
thank you for inviting me to testify today on the dynamic illicit drug
trafficking and use environment we face in the United States, and the
Administration's approach to addressing it with the urgency it demands.
Introduction
Since 2015, provisional data shows that annual overdose deaths in
America have more than doubled. \1\ Additionally, the COVID-19 pandemic
has increased the strain on our health care system and amplified the
existing difficulties in accessing treatment for substance use
disorder, which has exacerbated an overdose epidemic that was already
getting worse prior to the pandemic.
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\1\ Centers for Disease Control and Prevention, National Center
for Health Statistics. Multiple Cause of Death 1999-2020 on CDC WONDER
Online Data base, released in 2021. Available at http://wonder.cdc.gov/
mcd-icd10.html. Extracted by ONDCP on December 22, 2021.
The Centers for Disease Control and Prevention (CDC) estimates that
drug poisoning and overdoses claimed 108,809 lives in 2021 alone, which
represents an American life lost every 5 minutes around the clock.
These are our family members, co-workers, neighbors, and friends. Over
the past two decades, nearly a million Americans have lost their lives
to drug poisonings and overdoses, devastating their families, our
communities, and our Nation as a whole. Beyond these fatal overdoses
over the past two decades are millions of individuals experiencing
nonfatal overdoses that are overwhelming our first responders and
taxing our healthcare system. And while these fatalities and nonfatal
overdoses are the most visible manifestation of our crisis, underneath
them are tens of millions of Americans suffering from addiction to
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opioids.
While this crisis has been accelerating at an unprecedented rate
over the years, the impact on our economic prosperity goes even
further. Research estimates the economic costs of this epidemic to be a
staggering $1 trillion a year, \2\ and up to 26 percent of the loss in
U.S. labor force participation can be attributed to people suffering
from addiction. \3\
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\2\ Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug
overdose death counts. National Center for Health Statistics. 2022.
\3\ Federal Reserve Bank of Atlanta researcher Karen Kopecky,
Jeremy Greenwood of the University of Pennsylvania and Nezih Guner of
the Universitat Autonoma de Barcelona. National Bureau of Economic
Research Working Paper. https://www.nber.org/system/files/working--
papers/w29932/w29932.pdf.
This is a nonpartisan issue that touches everyone, regardless of
where they live or how they vote, and it is why ending the opioid
epidemic is a key part of President Biden's Unity Agenda for the
Nation, which he announced during his State of the Union address. The
strong support we see across our country, and across political parties,
for comprehensive and meaningful solutions to the overdose crisis
underscores the nonpartisan nature of this issue and the need for
immediate action.
The Administration's National Drug Control Strategy
The Administration is approaching this crisis with a keen sense of
urgency, prioritizing saving lives as our fundamental task. Our actions
must be bold, far-reaching, and innovative while also being evidence-
based, compassionate, equitable, safe, and effective. The President's
inaugural National Drug Control Strategy is an evidence-based blueprint
designed to save lives immediately, build the infrastructure our Nation
desperately needs to treat the enduring problem of addiction, and
disrupt drug trafficking and the illicit profits that fuel it,
enhancing public safety for us all. The implementation of President
Biden's Strategy will save as many lives as possible in the near term
while building our capacity to deal with untreated addiction and the
global production of illicit drugs in a long-term and sustainable
fashion.
As the Office of National Drug Control Policy developed this
Strategy, the Director focused on the two fundamental drivers of this
epidemic: untreated addiction, and the profit-driven production and
trafficking of illicit drugs.
In the SUPPORT Act of 2018, Congress laid out key requirements for
the President's National Drug Control Strategy that includes issuing a
comprehensive, evidence-based plan to reduce both the supply of, and
demand for, illicit drugs, and for illicit synthetic opioids more
specifically.
The Strategy does precisely this while outlining a bold and
innovative approach to reduce overdoses that includes measures at both
the strategic and program levels to hold government accountable under
the requirements of the SUPPORT Act.
The Director has identified four immediate priorities that cut
across the Strategy's goals, which if advanced will help us save lives
both in the short term while building our capacity to address this
challenge in the long term:
First, the most important action we can take right now is to have
naloxone, the opioid overdose reversal medication, in the hands of all
those who need it without fear or judgment--especially now when three
out of every four overdose deaths involve opioids. \4\ Harm reduction
interventions like fentanyl test strips, naloxone, and syringe services
programs that enable us to work with people who use drugs to build
trust, engagement, and, most importantly, keep them alive, are proven
to work and enjoy broad bipartisan support.
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\4\ Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug
overdose death counts. National Center for Health Statistics. 2022.
Expanding access to naloxone is a simple and cost-effective tool
supported by strong evidence: in addition to saving lives, every dollar
we spend on naloxone provides $2,769 in benefits according to one cost-
benefit analysis. \5\
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\5\ Naumann et al. Drug Alcohol Depend 2019;204:107536.
Second, the President's Strategy lays out actions to tackle a long-
standing issue: the majority of people with a substance use disorder
are not getting the treatment they need. Fewer than one out of ten
people in the United States who need treatment get it \6\ and we cannot
accept that.
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\6\ Substance Abuse and Mental Health Services Administration
(2021). Key substance use and mental health indicators in the United
States: Results from the 2020 National Survey on Drug Use and Health
Rockville, MD: Center for Behavioral Health Statistics and Quality.
When people lack the coverage and support they need for treating
and managing their substance use disorders they lose their jobs, their
families, they disengage from their communities, and far too often,
they lose their lives. Treatment saves lives, and everyone who needs
treatment should be able to access it. Through the President's
Strategy, we will ensure universal access to medications for opioid use
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disorder by 2025.
Third, the Director believes we must disrupt and dismantle the
Transnational Criminal Organizations (TCOs) who produce and traffic
illicit drugs by targeting their operations, illicit financial
networks, and supply chains in a comprehensive and sophisticated way.
The drug production and trafficking environment we see today is
vastly different than it was just a few years ago. The TCOs that
sustain and perpetuate the multi-billion-dollar illicit drug business
operate seamlessly across borders and cooperate with remarkable
efficiency to obtain raw materials, move and launder their proceeds,
and to ship their illicit products to the United States and
destinations around the world. Therefore, we must commercially disrupt
\7\ the global drug trafficking enterprise, first by raising a
sophisticated awareness of this environment, especially among private
sector entities, so we can focus our resources on the malign actors in
a more precise way. Moreover, we must expand the number of tools we
apply to include not only financial sanctions, but also a range of
other actions to disrupt and degrade drug production and trafficking
operations at best, or at the very least make it incredibly difficult
and much more costly.
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\7\ The 21st century global economy depends upon the constant
movement of money, ideas, people, and goods across international
borders with incredible speed and efficiency. Drug producers and
traffickers exploit this to sustain and enhance their illicit business:
the provision of precursor chemicals, some of which are unregulated
chemicals that can be shipped in plain sight; physically dislocated
payments that include the movement of funds across borders; the
internet-based sales of raw materials and finished drugs using both
fiat and cryptocurrency; and the physical movement of chemicals and
their finished products around the world. The vast majority of the
physical and virtual terrain on which drug producers and traffickers
operate such as the dark web, open social media platforms, eCommerce
sites, express consignment shippers and freight forwarders, banks,
cryptocurrency vendors, legitimate chemical suppliers, and pill press
and die mold manufacturers, are private sector entities who likely have
little to no idea they are a constituent part of an illicit business
enterprise. We must commercially disrupt what has become a global
illicit business enterprise that enjoys huge capital resources, routine
collaboration with raw material suppliers across international borders,
advanced technology to fund and conduct business, product innovation
and strategies to expand markets, and in many cases centralized control
and decision-making. Actions include: Raising a sophisticated awareness
of this environment with government and commercial sector partners
around the world, so we can sift out the unwitting from the
deliberately malignant; increasing the visibility of the legal goods
such as unregulated chemicals, high capacity pill presses, die molds,
and pill press replacement parts, that can be diverted for illicit use;
using financial tools such as sanctions to disrupt the flow of illicit
proceeds to drug producers and traffickers, and deny them the operating
capital they need to sustain their business; disrupt illicit drug
production capacity by focusing on the chemical precursors used to make
them; and expanding the tools we apply to the entire complex of drug
production and trafficking, to disrupt drug production and trafficking
or, at the very least, make it incredibly difficult and more costly. We
must also apply those tools in a sophisticated and surgical manner, and
make deliberate government-wide decisions about the long-term
consequences of our short-term actions, better synchronizing the full
range of tools to gain strategic results and avoid potentially negative
downstream effects.
It is also vitally important that we maintain close and cooperative
relationships with other countries where these illicit drugs and their
precursors are manufactured, and do so from a perspective of common and
shared responsibility. While the people of the United States see the
effects of global drug trafficking in the heartbreaking realities of
fatal and non-fatal overdoses, shattered families, and broken
communities, we must also bear in mind that many of the dollars used to
purchase those drugs--in addition from seeking to profit from harmful
and addictive psychoactive substances--often plays a role in
destabilizing that country, corrupting its officials, and victimizing
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its most vulnerable citizens.
Mexico has become the locus of illicit fentanyl production since
late 2019 and remains the country of origin for the majority of heroin
and methamphetamine found in the United States.
In September 2021, the United States marked a new era in security
cooperation with Mexico by establishing the U.S.-Mexico Bicentennial
Framework for Security, Public Health, and Safe Communities. This
comprehensive, long-term, and holistic approach to improve the safety
and security of both nations has three overarching goals: Protecting
Our People, Preventing Transborder Crime, and Pursuing the Criminal
Networks who threaten both countries. \8\ Earlier this month, the
Office of National Drug Control Policy and its partners from the
Department of State traveled to Mexico, where the United States and
Mexico formally committed to strengthening our work against the
manufacture, trafficking, distribution, and consumption of illicit
fentanyl and other synthetic drugs. Further, President Biden and
Mexican President Lopez Obrador met recently and the two heads of state
reemphasized the importance of our two nations working together to
address these challenges.
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\8\ https://www.whitehouse.gov/briefing-room/statements-releases/
2021/10/08/fact-sheet-u-s-mexico-high-level-security-dialog/.
The United States routinely engages with the People's Republic of
China to address shipments of PRC-origin precursor chemicals bound for
North America, as well as to cooperatively address the numerous money
laundering and illicit finance facilitators with ties to Chinese
---------------------------------------------------------------------------
criminal organizations that enable drug trafficking.
In the past, the PRC government has been responsive to the United
States' concerns about the shipment of fentanyl and its analogues
directly to the United States, and PRC's actions in that regard have
had a direct and positive impact. We must buildupon those actions, and
addressing illicit drugs precursor chemicals and associated money
laundering are areas where U.S. and PRC interests align. We look
forward to continuing our cooperation with the PRC government in
holding responsible those individuals, anywhere in the world, who
engage in this criminal enterprise.
India, another global producer and exporter of chemicals and
pharmaceuticals, similarly suffers from the presence of criminal
elements who traffic precursor chemicals for the manufacture of
synthetic opioids and other drugs, as well as finished opioids such as
tramadol and tapentadol. The United States has been working closely
with India over the last several years to develop a long-term
counternarcotics relationship, and earlier this month the Office of
National Drug Control Policy, along with the Departments of State and
Justice, headed the third, and first in-person, United States-India
Counternarcotics Working Group (CNWG) in New Delhi. The United States
made it clear it is in both countries' interest to establish and
maintain a relationship based upon mutual respect, shared interests,
and a common desire to partner as leaders on the global issue of
illicit drug production, trafficking, and use. During 2 days of
meetings both parties reached agreement on major issues to address
together and adopted a written framework to guide their collective work
going forward.
The Director firmly believes we must bring the international
community together to control fentanyl precursor chemicals. Earlier
this year, in response to a request by the United States, the United
Nations Commission on Narcotic Drugs (CND) voted to take international
action and internationally control the acquisition, production, and
export of three precursors used to illicitly manufacture illicit
fentanyl and its analogues: 4-anilinopiperidine (4-AP), 1-(tert-butoxy
carbonyl)-4-phenylaminopiperidine (boc-4-AP), and N-phenyl-N-
(piperidin-4-yl) propionamide (norfentanyl). The CND also voted to
schedule brorphine and metonitazene, two synthetic opioids, under
Schedule I of the 1961 Convention on Narcotic Drugs, and eutylone, a
synthetic stimulant, under Schedule II of the 1971 Convention on
Psychotropic Substances. This action obligates the signatories to these
conventions to establish national laws to control these substances. At
the same meeting, the CND also adopted a U.S.-sponsored resolution that
calls for greater cooperation among member states to prevent the
diversion of chemicals not subject to international control that are
diverted to illicit drug production, including so-called designer
precursor chemicals.
President Biden's budget proposal includes substantial increased
investments for border security and supply reduction approaches. The
women and men who work every day to stop illicit drugs from coming into
our country perform extraordinary work protecting our public safety and
public health in challenging circumstances, and President Biden is
committed to ensuring they have the tools and technology they need to
get the job done.
This National Drug Control Strategy directs agencies to uncover
financial networks and obstruct and disrupt the illicit financial
activities that fund the TCOs that produce and traffic illicit drugs
into the United States by strengthening every available tool, seeking
new ones that will provide tangible results, and better synchronizing
our efforts across the Federal Government to commercially disrupt this
global illicit enterprise.
In support of this effort, this past December President Biden
issued two Executive Orders that provide the executive branch enhanced
architecture to better counter TCOs in this dynamic environment, and to
increase our ability to negatively impact foreign persons involved in
the global illicit drug trade from a financial perspective. When
issuing those executive orders, the President declared that
``international drug trafficking, including the illicit production,
global sale, and widespread distribution of illegal drugs; the rise of
extremely potent drugs such as fentanyl and other synthetic opioids; as
well as the growing role of Internet-based drug sales, constitutes an
unusual and extraordinary threat to the national security, foreign
policy, and economy of the United States.'' \9\ These carefully chosen
words not only speak to the high priority the President places upon
this issue, but also open doors to new authorities and capabilities for
the United States to address this threat in a comprehensive and
sustainable fashion.
---------------------------------------------------------------------------
\9\ https://www.whitehouse.gov/briefing-room/Presidential-actions/
2021/12/15/executive-order-on-imposing-sanctions-on-foreign-persons-
involved-in-the-global-illicit-drug-trade/.
Additionally, law enforcement task forces such as Organized Crime
Drug Enforcement Task Forces (OCDETF) and High Intensity Drug
Trafficking Areas programs (HIDTAs) work diligently with the Nation's
94 U.S. Attorney's Offices to disrupt and dismantle transnational
organized crime by prosecuting those individuals responsible for
manufacturing and distributing these deadly substances in our
---------------------------------------------------------------------------
communities.
Through this Strategy, the Director and ONDCP will continue to
work, both unilaterally and with other nations, to make it more
difficult and more costly, in every way, for drug trafficking
organizations to continue their business. This work is critical because
if it is easier to get illicit drugs in America than it is to get
treatment, we will never bend the curve on overdoses.
Finally, the Strategy ramps up our work on data and research at a
time when the Federal Government faces important gaps in data
collection and analysis related to drug policy.
We know that a past non-fatal overdose is one of the most accurate
predictors of whether someone will experience a fatal overdose in the
future. \10\ However, we currently lack consistent and timely measures
of non-fatal overdoses in all jurisdictions in the United States, and
this constrains our ability to identify emerging trends and act before
it is too late. Building on gains already made in the timeliness and
accuracy of our data will greatly increase our ability to drive and
evaluate policy decisions. With this Strategy, the Administration is
working to develop a near real-time national estimate for non-fatal
overdose occurrences, along with a system to rapidly surge substance
use prevention and treatment resources to those communities
experiencing the greatest burdens.
---------------------------------------------------------------------------
\10\ Krawczyk N, Eisenberg M, Schneider KE, et al. Predictors of
overdose death among high-risk emergency department patients with
substance-related encounters: A data linkage cohort study. Annal of
Emergency Medicine 2020;75(1):1-12.
In addition to these four areas, the President's Strategy also
directs Federal agencies to take actions to prevent youth substance
use, support people in recovery, and advance racial equity in our drug
policies across the board. The Strategy also expands the scope of our
work to address many of the factors that affect substance use disorder
including child poverty, employment, and economic opportunity, so
people can reach their full potential.
A New Era for Drug Policy
Taken together, these goals, priorities, and objectives usher in a
new era of drug policy that is evidence-based comprehensive, holistic,
and targeted at saving lives.
This is the first time the Federal Government is embracing high-
impact harm reduction as a tool to reduce overdoses and overdose
deaths, an effort that has broad bipartisan congressional support.
Commercial disruption is a new approach that brings together our
efforts in illicit finance, supply chain targeting, and international
engagement as a comprehensive and sophisticated means to target TCOs,
their operating capital, and their profits.
This Strategy is the first in which we have delivered extensive
chapters dedicated to data and criminal justice that will help us
better understand our environment and deliver life-saving resources to
people who interact with the criminal justice system, including
evidence-based treatment for people who are incarcerated, so we can
improve public health and public safety outcomes.
This is the first time we have emphasized Adverse Childhood
Experiences (ACEs) and the Social Determinants of Health (SDOH) as key
elements of our prevention efforts.
This is the first time we have called for making access to
substance use disorder treatment universal.
Finally, we are placing a new emphasis on getting naloxone to
everyone who needs it, removing outdated barriers to prescribing
medications for opioid use disorder, and providing workforce
opportunities for people in recovery.
This Strategy represents exactly what we need to do to reduce
overdose deaths, ensure people can access the help they need, and
disrupt the flow of illicit drugs across our borders and into our
communities.
Action Now
While we are taking action now to implement the President's
inaugural Strategy, since the beginning of this Administration, our
office has led a number of efforts designed to advance administration
priorities and deal with America's opioid and overdose epidemic head
on:
CDC and SAMHSA established a $3 million partnership
to leverage CDC's National Harm Reduction Technical Assistance
Center to support implementation of effective, evidence-based
harm reduction programs, practices, and policies in diverse
settings and decrease health disparities.
ONDCP announced the release of the Model Law
Enforcement and Other First Responders Deflection Act, a
resource for states that encourages the development and use of
deflection programs across the country. First responders,
including law enforcement, often do not have good options when
encountering people with substance use and mental health
disorders, and this Model Law deflects people with these
disorders away from traditional criminal justice programs when
appropriate and connects them to evidence-based treatment, harm
reduction, and recovery and prevention services, changing lives
and reducing a burden on first responders.
SAMHSA announced the extension of the methadone take-
home flexibilities for 1 year, effective upon the eventual
expiration of the COVID-19 Public Health Emergency. The
flexibility promotes individualized, recovery-oriented care by
allowing greater access for people who reside farther away from
an Opioid Treatment Program or who lack reliable
transportation, such as those in rural and tribal communities.
CDC has provided $300M+ per year through Overdose
Data to Action to support 47 states, Washington, DC, two
territories and 16 high burden cities and counties in
collecting high quality, comprehensive, and timely data on
nonfatal and fatal overdoses and in using those data to inform
prevention and response efforts, such as ensuring people are
connected with the care they need, supporting health care
providers and systems with overdose response efforts, and
developing partnerships with public safety and first responders
to improve data sharing and response.
CDC expanded its investment in Public Health Analysts
participating in the High Intensity Drug Trafficking Areas
(HIDTA) program's Overdose Response Strategy. This
collaboration is helping communities reduce fatal and non-fatal
drug overdoses by connecting public health and public safety
agencies, sharing information, and supporting evidence-based
interventions. CDC is funding public health analysts in all 50
states, the District of Columbia, the U.S. Virgin Islands, and
Puerto Rico.
The Department of Justice's Office of Justice
Programs (OJP) has provided more than $110.7 million to reduce
recidivism and support adults and youth returning to their
communities after confinement. OJP also awarded more than $300
million to help address the needs of individuals with substance
use disorders, including treatment and recovery services.
CDC and ONDCP invested in communities by expanding
our investment in the Combating Opioid Overdoses through
Community Level Intervention (COCLI) initiative to fund eight
new projects to implement innovative, evidence-based, and
scalable solutions--like the Merrimack Valley, Massachusetts
``Wheels of Hope'' program for persons with substance use
disorder to receive rides to treatment appointments.
Earlier this month ONDCP announced fiscal year 2022
Drug Free Communities (DFC) Continuation funds to 646
coalitions, representing an investment by the Biden-Harris
administration of approximately $81 million in youth substance
use prevention in communities across the country. Later this
summer, ONDCP anticipates awarding fiscal year 2022 DFC new
grant awards.
CONCLUSION
There is no doubt that the environment of illicit drug production,
trafficking, and use, particularly as it relates to synthetic opioids,
presents a daunting challenge. However, as difficult as it may be, it
is not insurmountable. The Biden-Harris administration is focused on
meeting this complex national security, public safety, and public
health challenge head on in a comprehensive and sophisticated way. This
will not only reduce the number of drug deaths and save American lives
in the short term, but also shape our approach to addressing the
broader and more enduring challenge of illicit drug use and its
consequences in the years to come.
The Administration's leadership on this critical issue, the close
collaboration among Federal departments and agencies, and the work the
members of this Committee and your colleagues in Congress have done to
keep this issue at the forefront of our national consciousness are
changing the trajectory of the challenge we face.
On behalf of Dr. Gupta and the men and women of the Office of
National Drug Control policy, I would like to thank the subcommittee
for your foresight and leadership on this critical issue, and on behalf
of the Administration, ONDCP looks forward to continuing to work with
you to reduce illicit drug availability, use, and the many harms they
bring to American families and their communities.
______
[summary statement of kemp chester]
The Centers for Disease Control and Prevention (CDC)
estimates that drug poisoning and overdoses claimed 108,809
lives in 2021, and research estimates the economic costs of
this epidemic to be $1 trillion a year. Up to 26 percent of the
loss in U.S. labor force participation can be attributed to
people suffering from addiction.
The National Drug Control Strategy's approach is
saving lives now while prioritizing innovative, evidence-based,
compassionate, and equitable actions. The Strategy focuses on
the two fundamental drivers of this epidemic: untreated
addiction and the profit-driven production and trafficking of
illicit drugs.
The Director identified four key priorities as
crucial components of the Strategy's goals:
Y Ensuring everyone can access naloxone. With 3 out of
4 overdose deaths involving opioids, access to this
overdose reversal medication will save lives
immediately.
Y Expanding access to substance use disorder treatment
and provide universal access to medication for opioid
use disorder by 2025.
Y Dismantling Transnational Criminal Organizations
(TCOs) by targeting their operations, illicit financial
networks, and supply chains.
Y Improving research and near-real time data,
particularly in tracking non-fatal overdoses, one of
the most accurate predictors of whether someone will
experience a fatal overdose in the future.
We maintain close and cooperative relationships with
countries where these illicit drugs are produced and
trafficked, and do so from this principal of shared
responsibility.
Y The 2021 the U.S.-Mexico Bicentennial Framework for
Security, Public Health, and Safe Communities is
designed to improve the safety and security of both
nations.
Y The United States routinely engages with the
People's Republic of China to address the ever-
increasing number of precursor chemical shipments
originating in China.
Y The United States is now working with India in a
long-term counternarcotics relationship to address the
shipment of precursor chemicals and drugs such as
tramadol and tapentadol.
The Administration's leadership on this critical
issue, the close collaboration among Federal departments and
agencies, and the work the Members of this Committee and your
colleagues in Congress have done to keep this issue at the
forefront of our national consciousness are changing the
trajectory of the challenge we face.
______
The Chair. Thank you.
Dr. Delphin-Rittmon.
STATEMENT OF MIRIAM E. DELPHIN-RITTMON, PH.D., ASSISTANT
SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION, ROCKVILLE, MD
Ms. Delphin-Rittmon. Good morning and thank you, Chair
Murray, Ranking Member Cassidy, and Members of the Committee
for inviting me to testify during this hearing focused on
fentanyl and its impact on the overdoses across the Nation.
I am pleased to be here, along with my colleagues from the
White House Office of Drug Control Policy, the Health Resources
and Services Administration, and the Center for Disease Control
and Prevention to discuss SAMHSA's efforts.
The overdose crisis continues to be a challenge across the
country. Synthetic opioids, like illicitly manufactured
fentanyl, and the use of other substances, particularly
stimulants such as cocaine and methamphetamines, have led to
significant increases in overdose deaths.
The COVID-19 pandemic exacerbated an already tragic
situation, with drug overdose deaths reaching a historic high,
devastating families and communities. Provisional data from CDC
reported that more than 107,000 Americans died due to drug
overdose in the 12 month period ending January 2022.
Moreover, preliminary findings from SAMHSA's analysis of
2021 data from the Drug Related Emergency Department visits
show that fentanyl related emergency department visits rose
throughout 2021. That is why addressing addiction and the
overdose epidemic is one of the four pillars of the unity
agenda the President outlined in the State of the Union
address.
Additionally, last year, Secretary Becerra released a
comprehensive HHS overdose prevention strategy, which is
designed to increase access to a full range of care and
services for individuals who use substances that cause
overdoses and their families. The strategy prioritizes four key
areas, primary prevention, harm reduction, evidence based
treatment, and recovery support.
SAMHSA has several efforts underway across this continuum.
For example, SAMHSA's First Responder Comprehensive Addiction
Recovery Act Program trains and equips first responders and
other volunteer organizations on how to respond to overdose
related incidents, including how to administer overdose
reversal medication, naloxone.
During the program's recent project period, each state
developed a strategic action plan for combating opioid misuse
and deaths related to heroin and illicit fentanyl. This year,
SAMHSA launched the first ever harm reduction grant program and
issued $30 million in grant awards.
This opportunity, authorized and funded by the American
Rescue Plan Act, is increasing access to a range of community
harm reduction services and supports harm reduction service
providers as they work to help to prevent overdose deaths and
reduce the health risks associated with drug use.
We are increasing access to evidence based treatments to
more Americans by allowing practitioners to treat more patients
with buprenorphine through the revised buprenorphine practice
guidelines. This policy has given over 17,000 more providers
the ability to provide this lifesaving treatment.
SAMHSA's programs like the Substance Abuse Prevention
Treatment Block Grant and the State Opioid Response Grant
Programs are critical resources for states to fight this
epidemic. States can use these funds to purchase fentanyl test
strips, which are disposable, single use tests to detect the
presence of fentanyl in a substance.
Finally, SAMHSA's Office of Recovery is promoting the
involvement of people with lived experience throughout the
agency and stakeholder activities and fostering relationships
with internal and external organizations with mental health and
addiction recovery field. On behalf of my colleagues at SAMHSA,
I want to thank you for your interest and support of our
programs and for supporting the Nation's behavioral health.
I would be pleased to answer any questions and look forward
to our discussion. Thank you.
[The prepared statement of Ms. Delphin-Rittmon follows:]
prepared statement of miriam e. delphin-rittmon
Good morning. Thank you, Chair Murray, Ranking Member Burr, and
Members of the Committee for inviting me to testify during this hearing
focused on fentanyl and its impact on overdoses across the Nation.
My name is Miriam Delphin-Rittmon, and I am the Assistant Secretary
for Mental Health and Substance Use at the U.S. Department of Health
and Human Services (HHS). In this role, I lead the Substance Abuse and
Mental Health Services Administration, also known as SAMHSA. SAMHSA
leads public health efforts to advance the behavioral health of the
Nation and improve the lives of individuals living with mental and
substance use disorders, as well as their families.
I am pleased to be here, along with my colleagues from the White
House Office of National Drug Control Policy, Health Resources and
Services Administration, and the Centers for Disease Control and
Prevention (CDC) to discuss SAMHSA's response to the overdose crisis.
The overdose crisis continues to be a challenge for this country.
Synthetic opioids like illicitly manufactured fentanyl and the use of
other substances, particularly stimulants such as cocaine and
methamphetamine, have led to significant increases in overdose deaths.
\1\
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\1\ O'Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J. Trends
in and Characteristics of Drug Overdose Deaths Involving Illicitly
Manufactured Fentanyls--United States, 2019-2020. MMWR Morb Mortal Wkly
Rep 2021;70:1740-1746. DOI: http://dx.doi.org/10.15585/mmwr.mm7050e3.
As President Biden has noted, our Country faces an unprecedented
crisis among people of all ages and backgrounds. The COVID-19 pandemic
exacerbated an already tragic situation, with drug overdose deaths
reaching a historic high, devastating families and communities. \2\
Provisional data from the CDC reported that more than 107,000 Americans
died due to a drug overdose in the 12-month period ending in January
2022. Moreover, preliminary findings from SAMHSA's analysis of 2021
data from drug-related emergency department visits show that fentanyl-
related emergency department visits rose throughout 2021. \3\
---------------------------------------------------------------------------
\2\ Substance Abuse and Mental Health Services Administration.
(2021). Key substance use and mental health indicators in the United
States: Results from the 2020 National Survey on Drug Use and Health
(HHS Publication No. PEP21-07-01-003, NSDUH Series H-56). Rockville,
MD: Center for Behavioral Health Statistics and Quality, Substance
Abuse and Mental Health Services Administration. Retrieved from https:/
/www.samhsa.gov/data.
\3\ Substance Abuse and Mental Health Services Administration.
(2022). Preliminary Findings from Drug-Related. Emergency Department
Visits, 2021; Drug Abuse Warning Network (HHS Publication No. PEP22-07-
03-001). Rockville, MD: Center for Behavioral Health Statistics and
Quality, Substance Abuse and Mental Health Services Administration.
Retrieved from https://www.samhsa.gov/data/.
That is why addressing addiction and the overdose epidemic is one
of the four pillars of the unity agenda the President outlined in the
---------------------------------------------------------------------------
State of the Union Address.
Last year Secretary Becerra released the comprehensive the HHS
Overdose Prevention Strategy (Strategy), which is designed to increase
access to the full range of care and services for individuals who use
substances that cause overdose, and their families. The Strategy
prioritizes four key areas: primary prevention, harm reduction,
evidence-based treatment, and recovery support.
Though this testimony, I will expand on how SAMHSA is working to
implement the Strategy and advancing the goals of the President.
SUPPORTING THE SUBSTANCE USE CARE CONTINUUM
Primary Prevention
Prevention is critical to reducing overdoses and overdose deaths.
SAMHSA's activities in this area are designed to invest in community
infrastructure necessary to prevent harms related to substance use.
Examples of SAMHSA's activities in support of the Strategy's primary
prevention goal are below.
First Responder Training for Opioid Overdose-Related Drugs
SAMHSA's First Responders--Comprehensive Addiction and Recovery Act
(FR-CARA) program is an important part of our response to the overdose
crisis. The FR-CARA program trains and equips firefighters, law
enforcement officers, paramedics, emergency medical technicians, and
volunteers in other organizations to respond to adverse overdose-
related incidents, including to administer naloxone. This program also
establishes processes, protocols, and mechanisms for referral to
appropriate treatment and recovery communities. FR-CARA's broader
eligibility and rural-set asides ensure that much needed services reach
rural and tribal areas. During the program's recent project period,
each state developed a strategic action plan for combating opioid
misuse and deaths related to heroin and illicit fentanyl.
Strategic Prevention Framework for Prescription Drugs Grant Program
The Strategic Prevention Framework for Prescription Drugs (SPF-Rx)
assists grantees in developing capacity and expertise in the use of
data from state run prescription drug monitoring programs (PDMP).
Grantees have also raised awareness about the dangers of sharing
medications and worked with pharmaceutical and medical communities on
the risks of overprescribing to young adults. SAMHSA's program focuses
on bringing prescription drug use prevention activities and education
to schools, communities, parents, prescribers, and their patients.
SAMHSA tracks reductions in opioid overdoses and the incorporation of
prescription drug monitoring data into needs assessments and strategic
plans as indicators of program success.
Harm Reduction
Evidence-based harm reduction strategies minimize the negative
consequences of drug use to both the individual and the community.
Therefore, providing funding and support for innovative harm reduction
services is a key pillar of the Strategy. The activities below
highlight the substantial strides that SAMHSA has made to advance the
adoption and use of evidence-based harm reduction approaches.
Harm Reduction Grant Programs
This year, SAMHSA launched its first-ever Harm Reduction grant
program and issued $30 million in grant awards. This opportunity,
authorized and funded by the American Rescue Plan Act, will help
increase access to a range of community harm reduction services and
support harm reduction service providers as they work to help prevent
overdose deaths and reduce health risks often associated with drug use.
This funding is allowing organizations to expand their distribution of
overdose-reversal medications and fentanyl test strips, provide
overdose education and counseling, and manage or expand syringe
services programs (SSP), which help control the spread of infectious
diseases like HIV and hepatitis C. For example, in Maine, ``Project
DHARMA (Distribution of Harm Reduction Access in Rural Maine Areas)''
will involve the delivery of evidence-based harm reduction strategies
across the state, with a focus on utilizing Peer Support Workers
embedded in SSPs to facilitate the distribution of harm reduction
supplies, such as naloxone and fentanyl test strips, and linkage to
care for infectious disease prevention and treatment, wound care, and
substance use.
Fentanyl Test Strips
HHS announced in April 2021 that grantees in certain programs, such
as State Opioid Response (SOR) grants and the Substance Abuse
Prevention and Treatment Block Grant program, may use grant funds to
purchase rapid fentanyl test strips to help curb the dramatic spike in
drug overdose deaths largely driven by strong synthetic opioids,
including illicitly manufactured fentanyl. \4\, \5\
---------------------------------------------------------------------------
\4\ Centers for Disease Control and Prevention, ``Federal Grantees
May Now Use Funds to Purchase Fentanyl Test Strips'', (April 7, 2021).
\5\ SAMHSA 2021 Report to Congress on the State Opioid Response
Grants (SOR). https://www.samhsa.gov/sites/default/files/2021-state-
opioid-response-grants-report.pdf.
Reports from states such as California, Arizona, Nevada, and Alaska
note that fentanyl test strips funded through SOR have become an
important component of syringe service programs; education and
awareness building toolkits; and innovative, low-threshold, on-demand
treatment programs. These 4 states report distributing approximately
15,000 fentanyl test strips collectively since April 2021.
Evidence-based Treatment
Evidence-based treatments for substance use disorder can reduce
substance use, related health harms, and overdose deaths, and increase
odds for long-term recovery. Below are examples of SAMHSA efforts and
programs that support evidence-based treatment.
Flexibilities to Increase Access to Medications for Opioid Use Disorder
In an effort to get evidenced-based treatment to more Americans
with opioid use disorder (OUD), in April 2021 SAMHSA and HHS announced
buprenorphine practice guidelines that remove certain training and
certification requirements which some practitioners have cited as a
barrier to treating more people. \6\ We know that treatment with
buprenorphine decreases opioid-related overdose mortality by over 50
percent. \7\, \8\ The Practice Guidelines for the Administration of
Buprenorphine for Treating Opioid Use Disorder (Practice Guidelines)
provides an exemption from certain statutory certification requirements
for eligible physicians, physician assistants, nurse practitioners,
clinical nurse specialists, certified registered nurse anesthetists,
and certified nurse midwives who are state licensed and registered by
the Drug Enforcement Administration to prescribe controlled substances.
Specifically, the exemption allows these practitioners to treat up to
30 patients with OUD using buprenorphine without taking the previously
required training so long as a practitioner submits a Notice of Intent.
This exemption also allows practitioners to treat patients with
buprenorphine without certifying to their capacity to provide
counseling and ancillary services. As of July 1, 2022, a total of
126,286 providers have obtained a waiver; of these, 17,633 were
specifically related to the revised Practice Guidelines.
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\6\ Substance Abuse and Mental Health Services Administration,
``HHS Releases New Buprenorphine Practice Guidelines, Expanding Access
to Treatment for Opioid Use Disorder'' (April 27, 2021). https://
www.samhsa.gov/newsroom/press-announcements/202104270930.
\7\ Substance Abuse and Mental Health Services Administration
Results From the 2018 National Survey on Drug Use and Health (2019)
https://www.samhsa.gov/data/.
\8\ Sordo, Barrio, Bravo, Indave, Degenhardt, Wiessing, Ferri,
Pastor-Barriuso, Mortality Risk During and After Opioid Substitution
Treatment: Systematic Review and Meta-analysis of Cohort Studies (Apr.
2017), available at: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC5421454/.
During the COVID-19 pandemic, we have seen how telehealth can
expand access to care, overcome geographic inequality in the provision
of services, and reduce stigma associated with accessing life-saving
medications such as buprenorphine. \9\ Providers and patients have
overwhelmingly supported integration of telehealth into the care of
those with OUD, since it offers: flexibility in delivery and receipt of
treatment; a means for those living in rural or remote areas to better
engage in care; improvement in the provider-client relationship through
flexible scheduling; greater care coordination activities; maximization
of workforce productivity; reduction in burnout; and a reduction in
service delivery costs by allowing remote work and care provision. \10\
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\9\ Guille, C., Simpson, A. N., Douglas, E., Boyars, L.,
Cristaldi, K., McElligott, J., Johnson, D., & Brady, K. (2020).
Treatment of opioid use disorder in pregnant women via telemedicine: A
nonrandomized controlled trial. JAMA Network Open, 3(1), e1920177-
e1920177.
\10\ King, V. L., Brooner, R. K., Peirce, J. M., Kolodner, K., &
Kidorf, M. S. (2014). A randomized trial of web-based videoconferencing
for substance abuse counseling. Journal of Substance Abuse Treatment,
46(1), 36-42.
The COVID pandemic also necessitated flexibilities in how patients
accessed methadone for unsupervised administration. SAMHSA's relaxation
of the strict regulations related to methadone take home medication has
been met with positive feedback and reports from patients, providers,
and researchers. Allowing patients to take home 14-28 days of methadone
medication as long as this has been deemed safe and appropriate by the
treating practitioner at the Opioid Treatment Program has proven safe
and effective. It has allowed patients to work, go to school, and take
care of their families without the restrictions previously imposed by
SAMHSA's regulations--many of which have been criticized for years as
being overly restrictive. Recent research has found that these
increases in methadone take home doses have not been associated with
increases in overdoses or other negative impacts. For these reasons,
SAMHSA has announced that it intends to propose making these
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flexibilities permanent through rulemaking.
In 2021, SAMHSA certified 113 new opioid treatment programs, new
brick and mortar medication units, as well as new mobile units to
expand treatment across the Nation. As of July 2021, there are 1,950
active opioid treatment programs (OTPs) with 65 brick and mortar
medication units, and 19 mobile locations. Additionally, SAMHSA
assisted the Federal Bureau of Prisons (BOP) with establishing OTPs for
its hub and spoke model for providing treatment across their system.
State and Tribal Opioid Response Grants
To assist states, territories, Tribes and Tribal Nations in
addressing the Nation's overdose crisis, SAMHSA manages the State
Opioid Response (SOR) and Tribal Opioid Response (TOR) grant programs.
Recognizing that illicitly manufactured fentanyl is driving overdose
deaths across much of the country, often in combination with
stimulants, both programs focus on opioids and as selected by grantees,
stimulants. As such, the core aims of SOR and TOR continue to involve
increasing access to the three FDA-approved medications for the
treatment of opioid use disorder, reducing unmet treatment need, and
reducing opioid-related overdose deaths by supporting the full
continuum of prevention, harm reduction, treatment, and recovery
support services. These programs also support the continuum of care for
those states and communities across the country who are dealing with
rising rates of stimulant use in addition to opioids and the associated
negative health, social, and economic consequences. Like the SOR
program, the Tribal Opioid Response TOR grants program provides
dedicated resources for these activities to Tribes and Tribal Nations.
As an example, in partnership with the Seattle Indian Health Board,
Washington State provided low barrier treatment with medications for
opioid use disorder and related services to urban American Indian and
Alaskan Native individuals who are experiencing homelessness with OUD.
In Alaska, in collaboration with the University of Alaska and with the
assistance of SAMHSA-funded opioid technical assistance and training
resources (i.e. Addiction Technology Transfer Center and the Opioid
Response Network), Alaska has provided co-occurring behavioral health,
opioid and stimulant use disorder trainings with SOR grant resources.
Substance Abuse Prevention and Treatment Block Grant
The Substance Abuse Prevention and Treatment Block Grant (SABG)
helps all 50 states, the District of Columbia, Puerto Rico, the U.S.
Virgin Islands, 6 Pacific jurisdictions, and 1 tribal entity in
addressing substance use disorder treatment and prevention needs
through support of prevention, treatment, and other services not
covered by public or private insurance and non-clinical activities and
services that address the critical needs of state substance use service
systems. The SABG supports state prevention, treatment, and recovery
systems' infrastructure and capacity, thereby increasing availability
of services and development and implementation of evidence-based
practices.
Medication-Assisted Treatment for Prescription Drug and Opioid
Addiction
The Medication-Assisted Treatment for Prescription Drug and Opioid
Addiction (MAT-PDOA) program addresses treatment needs of individuals
who have an OUD by expanding/enhancing treatment system capacity to
provide accessible, effective, comprehensive, coordinated/integrated,
and evidence-based Medications for Opioid Use Disorder (MOUD) and
recovery support services.
Comprehensive Opioid Recovery Centers
The Comprehensive Opioid Recovery Center (CORC) program provides
grants to nonprofit substance use disorder treatment organizations to
operate comprehensive centers which provide a full spectrum of
treatment and recovery support services for opioid use disorders.
Grantees are required to provide outreach and the full continuum of
treatment services including MOUD; counseling; treatment for mental
disorders; testing for infectious diseases, residential treatment, and
intensive outpatient services; recovery housing; peer recovery support
services; job training, job placement assistance, and continuing
education; and family support services such as childcare, family
counseling, and parenting interventions. The CORC Grantees have been
utilizing funding to expand access to comprehensive services in a
variety of ways, from improving the system of comprehensive MOUD care
at the county level; improving follow-up with clients who have
experienced overdose reversals; and removing barriers to MOUD in
residential treatment to engaging special populations, such as homeless
persons, people on probation, and LGBTQ+persons , and meeting the needs
of underserved areas.
Certified Community Behavioral Health Clinics Expansion Grants
The Certified Community Behavioral Health Clinics (CCBHC) Expansion
program is designed to increase access to and improve the quality of
community mental and substance use disorder treatment services. CCBHCs
funded under this program must provide access to services for
individuals with serious mental illness or SUD, including OUD; children
and adolescents with serious emotional disturbance; and individuals
with co-occurring mental and substance use disorders. This program
improves the mental health of individuals by providing comprehensive
community-based mental and substance use disorder services; improving
treatment of co-occurring disorders; advancing the integration of
mental/substance use disorder treatment with physical health care;
utilizing evidence-based practices on a more consistent basis; and
promoting improved access to high quality care.
Data from intake to most recent reassessment for individuals served
in the CCBHC program demonstrate that as of March 2022, enrollees have
achieved a 72 percent reduction in hospitalization and a 69 percent
reduction in Emergency Department visits, as well as a 25 percent
increase in mental health functioning in everyday life. Additionally,
the data demonstrated a 12 percent increase in employment or school
enrollment. SAMHSA appreciates Congress including support for CCBHC
planning grants and technical assistance in the Bipartisan Safer
Communities Act.
Pregnant and Postpartum Women Program
The Pregnant and Postpartum Women program (PPW) uses a family
centered approach to provide comprehensive residential substance use
disorder treatment, prevention, and recovery support services for
pregnant and postpartum individuals, their minor children, and for
other family members. The family centered approach includes partnering
with others to leverage diverse funding streams, encouraging the use of
evidence-based practices, supporting innovation, and developing
workforce capacity to meet the needs of these families. The PPW program
provides services not covered under most public and private insurance.
SAMHSA continues to prioritize states that support best-practice
collaborative models for treatment, as well as provide support to
pregnant individuals with OUD. The Comprehensive Addiction and Recovery
Act increased accessibility and availability of services for pregnant
individuals by expanding the authorized purposes of the program to
include the provision of outpatient and intensive outpatient services.
Recovery
SAMHSA has a long history of advancing recovery supports dating
back to the 1980's with the Community Support Program and the 1990's,
when the first Recovery Community Support Programs were funded. SAMHSA
defines recovery as a process of change through which individuals
improve their health and wellness, live self-directed lives, and strive
to reach their full potential.
Establishing an Office of Recovery and Advancing Peer Supports
Recovery is a key pillar of the HHS Overdose Prevention Strategy.
That is why during Recovery Month last fall, SAMHSA announced it would
be establishing a new Office of Recovery. This office promotes the
involvement of people with lived experience throughout agency and
stakeholder activities, fosters relationships with internal and
external organizations in the mental health and addiction recovery
fields, and identifies health disparities in high-risk and vulnerable
populations to ensure equity for support services across the Nation.
We know that recovery is enhanced by peer-delivered support
services. These services have proven to be effective in sustaining
recovery over the long term. Investing in peer services is critical,
given the significant workforce shortages in behavioral health. That is
why, as part of the President's Strategy to Address Our National Mental
Health Crisis, SAMHSA is updating and expanding existing compendia \11\
of state-by-state peer specialist certifications and is convening
stakeholders to create a new set of model national standards for peer
specialist certification.
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\11\ Peer Recovery Center of Excellence, Comparative Analysis of
State Requirements for Peer Support Specialist Training and
Certification in the United States, January 2022 https://
www.peerrecoverynow.org/documents/Comparative%20Analysis-
Jan.31.2022520(003).pdf.
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SABG Recovery Set-Aside
The Administration supports the addition of a 10 percent set-aside
within the SABG for recovery support services aimed at significantly
expanding the continuum of care both upstream and downstream. This
proposed set-aside would support the development of local recovery
community support institutions (i.e., recovery community centers,
recovery homes, recovery schools); develop strategies and educational
campaigns, trainings, and events to reduce addiction/recovery-related
stigma and discrimination at the local level; provide addiction
recovery resources and support system navigation; make accessible peer
recovery support services that support diverse populations and are
inclusive of all pathways to recovery; and collaborate and coordinate
with local private and non-profit clinical health care providers, the
faith community, city, county, state, and Federal public health
agencies, and criminal justice response efforts.
CONCLUSION
On behalf of my colleagues at SAMHSA, thank you for your interest
in, and support for, our programs, and for supporting the Nation's
behavioral health. I would be pleased to answer any questions you may
have.
______
The Chair. Thank you.
Ms. Johnson.
STATEMENT OF CAROLE JOHNSON, ADMINISTRATOR, HEALTH RESOURCES
AND SERVICES ADMINISTRATION, ROCKVILLE, MD
Ms. Johnson. Chair Murray, Senator Cassidy, and Members of
the Committee, thank you for the opportunity to speak with you
today about the work of the Health Resources and Services
Administration to address the opioid crisis, which, as this
hearing demonstrates, is increasingly a fentanyl crisis.
I am Carole Johnson, Administrator of the Health Resources
and Services Administration, the agency in the Department of
Health and Human Services that is home to the Federal Office of
Rural Health Policy, community health centers, the Ryan White
HIV AIDS Program, Federal behavioral health workforce training
programs, and our Federal investments in maternal and child
health.
Across our work, we are seeing the impact of fentanyl use
in the historically underserved communities that we serve,
including urban, rural, and tribal communities. And we are
committed to improving access to mental health and substance
use disorder treatment and growing the behavioral health
workforce.
I want to focus my remarks today on three key issues
related to the crisis that HRSA's work aims to respond to.
First, as the Chair mentioned, our investments in training and
growing the mental health and substance use disorder workforce.
This includes psychiatrists and psychiatric nurses, social
workers, substance use disorder counselors, psychologists, and
peer support specialists with lived experience who are trained
and funded through programs like our Behavioral Health
Workforce Training Program that supports direct training and
stipends to build the next generation of mental health and
substance use disorder providers.
The National Health Service Corps, where we offer loan
repayment and scholarships to behavioral health students and
providers in return for practicing in high need areas. And our
other dedicated substance use disorder workforce programs like
the Substance Use Disorder Treatment and Recovery Loan
Repayment Program, our Addiction Medicine Fellowship Program,
and our Opioid Impacted Families Support Program.
We believe that is critical to expand our investment in
this training and deployment of a mental health and substance
use disorder workforce that can respond to the prevention,
treatment, and recovery needs of individuals struggling with
fentanyl use.
That is why the President's budget includes a nearly $400
million investment in growing the number of mental health and
substance use disorder providers. It is also why the American
Rescue Plan's unprecedented investment in the National Health
Service Corps has allowed us to see the largest cohort in the
program's 50 year history, including thousands of behavioral
health providers.
Second, I want to speak to our work to expand access to
substance use disorder services in rural communities across the
country. HRSA's Rural Communities Opioid Response Program
reaches over 1,500 rural communities in 47 states. And we are
funding what rural communities tell us they need, including
more access to treatment for individuals using fentanyl.
In fact, in June, we announced a new $10 million rural
investment to tackle synthetic opioid overdoses, including
fentanyl and fentanyl laced drug overdoses, with the goal of
creating new treatment access points in rural communities.
In June, we also announced a new $50 million rural
investment focused on stimulants like methamphetamine,
particularly as rural communities have reached out to us for
help with their critical needs as they see drugs like meth and
cocaine becoming even more dangerous due to contamination with
highly potent fentanyl.
We also fund other tailored support programs in rural
communities, such as grants to reduce the incidence and impact
of neonatal abstinence syndrome and our Rural Centers of
Excellence on Substance Use Disorder. And we are continuing,
and we are committed to continuing to help rural communities
respond to this crisis.
For a third and final point I want to emphasize HRSA's work
to help ensure that there is no wrong door for getting mental
health and substance use disorder help. And we want to do that
by integrating behavioral health into primary care. And with
this Committee's leadership, two important steps on that path
were included in the bipartisan Safer Communities Act.
The bill gave us new tools and resources to expand mental
health training of primary care providers, and the funding
needed to grow our pediatric mental health access program to
expand our work with pediatricians, as well as reach beyond
pediatricians' offices and into schools in emergency
departments.
We want there to be no wrong door for those seeking mental
health and substance use disorder care, which is why we aim to
expand the capacity of the primary care workforce to respond to
the mental health and substance use disorder needs of the
community, including family medicine, pediatrics, maternal
care, internal medicine, and others.
We are committed to building on the primary care footprint
of the 1,400 community health centers we fund in communities
across the country to help reach this goal. We know there is
much more work to do and are grateful to the Committee for the
opportunity to work with you on the next steps.
Thank you for the opportunity to discuss HRSA's work, and I
look forward to your questions.
[The prepared statement of Ms. Johnson follows:]
prepared statement of carole johnson
Chair Murray, Ranking Member Burr, and Members of the Committee:
Thank you for the opportunity to speak with you today about the
work of the Health Resources and Services Administration (HRSA) to
address the opioid crisis, which is increasingly a fentanyl crisis, in
communities across the country. I am Carole Johnson, Administrator of
HRSA, the agency of the Department of Health and Human Services that is
home to the Federal Office of Rural Health Policy, community health
centers, the Ryan White HIV/AIDS Program, Federal behavioral health
workforce training programs, and our Federal investments in maternal
and child health programs. Across our work, we are seeing the impact of
fentanyl use in the historically underserved and rural communities that
we serve, and are committed to improving access to services and growing
the behavioral health workforce to address these critical needs.
In October 2021, the Department of Health and Human Services
released the HHS Overdose Prevention Strategy (Strategy), which is
focused on saving lives, reducing risk, and removing barriers to
effective interventions. As the Strategy notes, the epidemiology of
drug overdose deaths has shifted from primarily involving prescription
opioids in the late 1990's and early 2000's to the current poly drug
landscape, where synthetic opioids like fentanyl and stimulants like
methamphetamine are the major drivers of overdose.
Also, in recent years, there have been marked increases in overdose
deaths among racial and ethnic minority populations, who are more
likely to face barriers in accessing equitable treatment and recovery
services. The rate of overdose deaths among non-Hispanic Black
Americans more than tripled between 2010 and 2019, but Black Americans
are still less likely to receive substance use disorder treatment than
White Americans. At the same time, research also has shown regional
variation in the types of drugs most commonly consumed and in access to
services, with rural areas experiencing more challenges in treatment
access compared to urban areas.
Today's testimony will review our work in rural and underserved
communities to expand access to services as well as our focus on
training and building the behavioral health workforce.
Overdose Prevention and Treatment in Rural Communities
Rural communities are on the frontline of the surge in synthetic
opioid overdoses, including fentanyl and fentanyl-laced drug overdoses.
HRSA funds the Rural Communities Opioid Response Program (RCORP), a
multi-year initiative aimed at reducing opioid use in rural communities
that reaches over 1,500 rural communities in 47 states and has
supported the provision of direct services to over two million rural
residents. The RCORP initiative is aimed at meeting community needs and
programs are designed through feedback received directly from rural
stakeholders. Through RCORP, HRSA funds five major lines of work in
rural communities addressing opioid use disorder, including:
Planning grants to help rural communities conduct
needs assessments, build partnerships, and develop workforce
plans and otherwise build their community framework for
prevention, treatment and recovery;
Implementation grants to support rural communities in
strengthening and expanding opioid use disorder prevention,
treatment, and recovery services in rural areas;
Medication-Assisted Treatment expansion grants to
support the establishment and/or expansion of medication-
assisted treatment in eligible rural hospitals, clinics, and
tribal organizations;
Neonatal Abstinence Syndrome grants to reduce the
incidence and impact of Neonatal Abstinence Syndrome in rural
communities by improving systems of care, family supports, and
social determinants of health; and
Psychostimulant Program grants to strengthen and
expand prevention, treatment, and recovery services for
individuals in rural areas who misuse psychostimulants and
enhance their ability to access treatment and move toward
recovery.
HRSA also supports three Rural Centers of Excellence on Substance
Use Disorders to identify and share evidence-based programs and best
practices for substance use disorder treatment, including as it relates
to fentanyl and prevention in rural communities. They are: (1) the
University of Rochester in New York, which focuses on addressing
synthetic opioid-related overdose mortality in the Appalachian region,
particularly high-need rural Appalachian counties in Kentucky, New
York, Ohio, and West Virginia; (2) the Center on Rural Addiction at the
University of Vermont, which focuses on treatment interventions and
supports in rural communities in Maine, New Hampshire, and Vermont; and
(3) the Fletcher Group in Stockbridge, Georgia in partnership with the
University of Kentucky, which focuses on recovery housing in rural
counties in Kentucky, Georgia, West Virginia, Ohio, Idaho, Montana,
Oregon, and Washington. In addition, in partnership with the Northern
Border Regional Commission, a Federal-state partnership to assist the
most distressed counties of Maine, New Hampshire, Vermont, and New
York, HRSA supports Rural Behavioral Health Workforce Centers to train
health workers and community members to support individuals with
substance use disorders. HRSA also supports an online technical
assistance portal to help our rural behavioral health grantees request
technical assistance, find nearby grantees or grantees with a similar
focus, and access a repository of resources tailored to support RCORP
grantees.
In fiscal year 2020, HRSA rural grantees trained over 44,000
providers, paraprofessional staff, and community members to administer
naloxone and between September 1, 2021 and February 28, 2022, over 60
percent of award recipients reported actively distributing fentanyl
test strips in their rural service area. \1\ Yet, with almost 30
percent of rural Americans compared to 2.2 percent of urban Americans
living in a county without a buprenorphine provider, HRSA believes it
is critical to continually focus on expanding access to the evidence-
based tools that we know work, including medication to treat opioid use
disorder. To that end, HRSA recently announced the availability of $10
million in grant funding through a new RCORP program called Medication-
Assisted Treatment Access. This funding will help rural communities
establish new treatment access points to connect individuals to
medication, counseling, and behavioral therapies to treat opioid use
disorder, with a particular emphasis on supporting new buprenorphine
providers to help reach more individuals in need.
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\1\ RCORP-awardee performance data.
Last month, HRSA announced nearly $15 million in funding to address
psychostimulant misuse and related overdose deaths in rural
communities. Psychostimulants include methamphetamine and other illegal
drugs, such as cocaine and ecstasy. The overdose crisis has evolved
over time and is now largely characterized by deaths involving
illicitly manufactured synthetic opioids, including fentanyl, and,
increasingly, psychostimulants. Overdose deaths involving
methamphetamine nearly tripled from 2015 to 2019 among people ages 18-
64 in the United States, according to a study by the National
Institutes of Health, which also noted that methamphetamine and cocaine
are becoming more dangerous due to contamination with highly potent
fentanyl, and increases in higher risk use patterns such as multiple
substance use and regular use. Rural communities have made their
concerns about what they are seeing with stimulant use known to us, and
given the flexibility of the RCORP program, we were able to respond
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with these timely investments.
Looking ahead, HRSA will continues to provide critical resources to
address the drug overdose crisis and remain responsive to rural
community needs. We anticipate awarding more than $90 million in
additional community-based funding to help rural communities address
substance use disorder and broader behavioral health care needs before
the end of this fiscal year. \2\ In fiscal year 2023, our proposed
budget focuses on expanding access to substance use prevention and
treatment across rural communities.
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\2\ RCORP-Implementation (HRSA-22-057); RCORP-Behavioral Health
Care Support (HRSA-22-061).
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Health Centers and Opioid Use Disorder
As you know, HRSA supports 1,400 community health centers in high
need, underserved communities across the country, where services are
available regardless of an individual's ability to pay. The Health
Center Program supports health centers that provide primary care in
underserved communities across the country and health centers are
increasingly focused on integrating behavioral health into primary care
services. We also fund the Health Care for the Homeless Program, which
supports coordinated, comprehensive, integrated primary care including
substance use and mental health services for individuals experiencing
homelessness. While many health centers offer a range of integrated
primary care services, HRSA is committed to increasing the capacity of
health centers to deliver mental health and substance use disorder
services. HRSA also provides all health centers with access to
technical assistance resources to promote the integration of behavioral
health and substance use disorder services in primary care.
To further improve access and raise the quality of substance use
disorder services, the availability of services onsite is essential.
HRSA is supporting this goal by training health center clinicians to
provide high quality and expanded services for those with substance use
disorders. Because many communities served by health centers have a
high need for substance use disorder treatment and services, many
health centers have chosen to co-locate and integrate substance use
disorder services reflecting efficient and effective approaches in
meeting patient needs. The integration of these services can include
the provision of enhanced services, such as medication-assisted
treatment by primary care clinicians. Going forward, HRSA is committed
to continuing to grow this footprint and expand access to opioid use
disorder treatment in high need communities across the country. Further
support is provided to clinicians through the Substance Use Warmline,
which provides free, real-time clinician-to-clinician telephone
consultation to health centers, focusing on substance use evaluation
and management for integrated primary care and behavioral health
clinicians.
HRSA also supports health centers to improve their care and
delivery of services by making a variety of technical assistance
available. The Health Center Program Care Integration of Behavioral
Health and Substance Use Disorder Services Technical Assistance focuses
on integrating behavioral health services through the dissemination of
evidence-based practices for health care delivery, as well as quality
improvement recommendations to improve access to health care for
medically underserved and vulnerable populations. Health centers
receive one-on-one support, directed to the health center's specific
needs and goals. Additionally, the National Training and Technical
Assistance Partners provides training and technical assistance to
existing and potential health center grantees and look-alikes.
Ryan White HIV/AIDS Program and Opioid Use Disorder
The Ryan White HIV/AIDS Program provides critical health care and
support services for people with HIV to help them get into and stay in
HIV care. This includes a range of behavioral health-focused services,
including mental health services, case management, inpatient and
outpatient substance use disorder treatment, and psychosocial support
services. The program plays a critical role in addressing the public
health crisis of opioid use disorder, including fentanyl, for people
with HIV, especially within rural communities. In consideration of the
opioid crisis, Ryan White HIV/AIDS Program grantees are facing the need
to redouble their efforts to provide a range of needed services to the
most vulnerable populations, including those who are uninsured or
underinsured, meeting clients where they are and working to improve
individual-level and overall public health.
HRSA supports Ryan White HIV/AIDS Program providers in addressing
opioid use disorder through training, technical assistance, and funding
innovative projects, including targeted projects to strengthen networks
of care to respond to the opioid epidemic and ensure people with HIV
and an opioid use disorder have access to behavioral health care,
treatment, and recovery services. Further, HRSA also funds an
initiative focused on implementing effective and culturally appropriate
evidence-informed interventions for integrating behavioral health in
primary care settings and identifying and addressing trauma among
people with HIV. Services include recently diagnosed patients being
screened for referrals to substance use treatment, mental health
supports, and other services, as well as facilitating rapid institution
of prophylactic medications when necessary; taking action to ensure
that mental health conditions, substance use, history of trauma, low
health literacy, and lack of support services among individuals living
with HIV can be addressed; and cognitive-behavioral group therapy
program designed to address co-occurring substance use and PTSD.
Health Workforce and Behavioral Health
HRSA programs play a critical role in growing and training the
behavioral health workforce, which are integral to building the
capacity to improve access to mental health and substance use disorder
treatment. HRSA funds:
Scholarships and loan repayment through the National
Health Services Corps where behavioral health providers receive
support for committing to practice in a high need community;
Training programs focused on recruiting and training
mental health and substance use disorder clinicians such as
psychiatrists, psychologists, psychiatric nurses, social
workers, and marriage and family therapists;
Training programs that help engage and retain people
in mental health and substance use disorder treatment,
including community health workers and peer support
specialists;
The Addiction Medicine Fellowship Program that
focuses on increasing the number of board certified addiction
medicine and addiction psychiatry specialists trained in
providing behavioral health services, including prevention,
treatment, and recovery services;
Graduate Medical Education, including the Children's
Hospitals Graduate Medical Education Program, which supports
the training of pediatric residents, including pediatric
psychiatry residents, in freestanding children's teaching
hospitals, and the Teaching Health Center Graduate Medical
Education Program, which supports primary care residency
training, including for psychiatry, in community-based
ambulatory patient care centers.
Thanks to the Bipartisan Safer Communities Act, HRSA is also
working to implement new funding to support integrating behavioral
health training in pediatric primary care training.
To strengthen the mental health and substance use disorder
workforce, the fiscal year 2023 budget proposes an investment of $397
million for HRSA's Behavioral Health Workforce Development Programs,
which is $235 million above fiscal year 2022 enacted level. This
funding will increase training of new behavioral health providers,
including a track for health support workers like peers and community
health workers, and place an emphasis on team-based care. To promote
inclusive and equitable behavioral health care for youth, this
investment will support a special focus on the knowledge and
understanding of children, adolescents, and youth at risk for a mental
health disorder, serious emotional disturbance, or substance use
disorder.
National Health Service Corps:
HRSA's largest workforce program is the National Health Service
Corps, which has also played a significant role in combatting the
overdose epidemic by growing and retaining a skilled workforce of
behavioral health professionals and increasing access to opioid and SUD
treatment and mental and behavioral health services in underserved
communities. Thousands of behavioral health clinicians have and are
serving in underserved communities through the support of the NHSC. The
NHSC provides scholarships and loan repayment for clinicians, including
mental health and substance use disorder providers, who commit to
practice in underserved communities. In 2021, thanks to the American
Rescue Plan Act of 2021, nearly 20,000 clinicians were practicing in
underserved communities through the National Health Service Corps, the
largest number in the 50-year history of the program.
The National Health Service Corps also received a dedicated
appropriation to expand and improve access to quality opioid and
substance use disorder treatment in rural and underserved areas in
settings such as opioid treatment programs, office-based opioid
treatment facilities, and non-opioid outpatient SUD facilities. Funding
for this National Health Service Corps Substance Use Disorder Workforce
Loan Repayment Program supports the recruitment and retention of health
professionals needed in underserved areas to provide evidence-based
substance use disorder treatment and to help prevent overdose deaths.
Providers receive loan repayment assistance to reduce their educational
financial debt in exchange for service at substance use disorder
treatment facilities. More than 3,000 clinicians are practicing in the
field thanks to the National Health Service Corps Substance Use
Disorder Workforce Loan Repayment Program.
HRSA also support the National Health Service Corps Rural Community
Loan Repayment Program, a program for providers working to combat the
opioid epidemic in the Nation's rural communities. This program has
made loan repayment awards in coordination with the Rural Communities
Opioid Response Program initiative to provide evidence-based substance
use treatment, assist in recovery, and to prevent overdose deaths in
rural communities. More than 1,200 clinicians are practicing in rural
communities thanks to the National Health Service Corps' Rural
Community Loan Repayment Program.
The Substance Use Disorder Treatment and Recovery (STAR) Loan
Repayment Program focuses on recruiting and retaining medical, nursing,
and behavioral health clinicians and paraprofessionals who provide
direct treatment or recovery support of patients with or in recovery
from a substance use disorder through loan repayment in return for
providing services in high need areas. Participation in this new
program is open to a number of provider disciplines and specialties,
including bachelor's-level SUD counselors, behavioral health
paraprofessionals, and clinical support staff, that previously have not
been eligible to participate in other HRSA-administered opioid-related
loan repayment programs. The STAR Loan Repayment Program's first
application cycle in fiscal year 2021 made 255 awards.
Behavioral Health Workforce Training Programs:
The Behavioral Health Workforce Education and Training Programs
(BHWET) for Professionals and Paraprofessionals are HRSA's primary
grant program to support the training of social workers, psychologists,
school and clinical counselors, psychiatric nurse practitioners,
marriage and family therapists, community health workers, outreach
workers, social services aides, mental health workers, substance use
disorder workers, youth workers, and peers. In Academic Year 2020-2021,
the BHWET Program supported training for nearly 6,500 individuals. The
program aims to increase the supply of behavioral health professionals
and paraprofessionals while also improving distribution of a quality
behavioral health workforce and thereby increasing access to behavioral
health services. The President's Budget for Fiscal Year 2023 would
significantly expand investment in this critical training program.
The HRSA Addiction Medicine Fellowship Program focuses on
increasing the number of board certified addiction medicine and
addiction psychiatry specialists trained in providing behavioral health
services, including prevention, treatment, and recovery services in
underserved, community-based settings. In Academic Year 2020-2021,
awardees trained 98 fellows in addiction medicine, including 63
graduates. Throughout the year, the fellows recorded over 61,000 hours
of training and nearly 80,000 patient encounters in medically
underserved communities. The HRSA Integrated Substance Use Disorder
Training Program supports training and expansion of the number of nurse
practitioners, physician assistants, health service psychologists, and
social workers trained to provide mental health and substance use
disorder services in underserved community-based settings that
integrate primary care and mental health and substance use disorder
services, and the HRSA Opioid-Impacted Family Support Program trains
paraprofessionals to support children and families living in
underserved areas who are impacted by opioid use disorder and other
substance use disorders. The HRSA Graduate Psychology Education Program
supports innovative doctoral level health psychology programs that
foster a collaborative approach to providing mental health and
substance use disorder prevention and treatment services in high need
and high demand areas through academic and community partnerships. In
addition, HRSA recently issued a funding opportunity announcement for
community health worker and other health support worker training,
including peer specialists, which aims to build the workforce
supporting community connections to care.
Additionally, HRSA supports the Children's Hospitals Graduate
Medical Education Program which supports the training of pediatric
residents, including pediatric psychiatry residents, in freestanding
children's teaching hospitals, and the Teaching Health Center Graduate
Medical Education Program, which supports primary care residency
training, including for psychiatry, in community-based ambulatory
patient care centers.
HRSA continues to take innovative steps to grow the behavioral
health workforce and support the recruitment and retention of health
professionals needed in underserved areas to expand access to substance
use disorder treatment and prevent overdose deaths, particularly given
the increasing challenges communities are facing as a result of
fentanyl.
Conclusion
Thank you for the opportunity to discuss HRSA's work on this
critical public health issue and our commitment to continuing to take
all steps that we can to combat is epidemic. We look forward to
continuing to work with the Committee on solutions to the Nation's
overdose crisis.
______
The Chair. Thank you.
Dr. Jones.
STATEMENT OF CHRISTOPHER JONES, PHARM.D, DR.PH, MPH, ACTING
DIRECTOR, NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL,
UNITED STATES CENTERS FOR DISEASE CONTROL AND PREVENTION
ATLANTA, GA
Dr. Jones. Chair Murray, Senator Cassidy, and distinguished
Members of the Committee, it is an honor to appear before you
today to discuss the Centers for Disease Control and
Prevention's efforts to address the overdose crisis. Thank you
to the Committee for your attention to this important public
health challenge.
This is a complex issue that requires a coordinated
approach, and I am pleased to be here with my colleagues from
SAMHSA, HRSA, and ONDCP. The overdose crisis continues to
escalate due to the proliferation of highly potent synthetic
opioids like illicit fentanyl and the resurgence of stimulants
like methamphetamine.
In fact, we have never seen an illicit drug supply that is
so potent, unpredictable, or lethal. According to the latest
CDC provisional data, of the more than 100,000 overdose deaths
in 2021, 75 percent involved at least one opioid, with 66
percent specifically involving synthetic opioids and 50 percent
involving stimulants, often in combination with synthetic
opioids.
These statistics reflect the urgent need for action, and
CDC is confronting this crisis through five key strategies that
complement the work of our sister agencies in HHS and across
the Federal Government. Our first strategy focuses on data
which are foundational to prevention efforts.
CDC uses data to stay on the leading edge of overdose
trends to ensure that communities have the information they
need to respond to the evolving crisis. Through our Overdose
Data to Action or OD2A program, CDC administers two key data
systems to improve the timeliness and comprehensiveness of both
nonfatal and fatal overdose data.
The drug overdose surveillance and epidemiology or DOSE
system collects near real time data on non-fatal overdoses in
emergency departments. States participating in DOSE have
immediate access to their data and can quickly mobilize a
community response to surges in overdose.
The State Unintentional Drug Overdose Reporting System, or
SUDORS, provides detailed contextual information on the
circumstances of overdose deaths and the specific substances
involved in deaths to inform prevention strategies. To make
these data more readily available for decision-making, we
recently launched public facing dashboards for both DOSE and
SUDORS.
Our second strategy is building state, tribal, local, and
territorial capacity. In addition to 47 states and DC, CDC's
OD2A program funds in 19 cities, counties, and territories, and
we fund 26 tribal entities through other cooperative
agreements.
Under these programs, funding is used to build public
health capacity, leverage data to drive action, and support the
implementation of evidence based strategies to reduce overdose.
Our third strategy is supporting providers, health systems,
payers, and employers.
Under this strategy, CDC supports efforts to increase safer
prescribing and improve pain care, maximize the use of
prescription drug monitoring programs, advance insurer and
health system interventions, and link people to care and
services across health care, community, and criminal justice
settings.
Our fourth strategy focuses on partnering with public
safety and community organizations. For example, the Overdose
Response Strategy, a unique collaboration between CDC and
ONDCP's HIDTA program helps communities reduce overdose by
connecting public health and public safety agencies in all 50
states.
CDC also partners with ONDCP on the Drug-Free Communities
Program to provide grants and supports to hundreds of community
coalitions across the country to advance youth substance use
prevention. Our fifth strategy is raising public awareness and
reducing stigma.
To advance this strategy, we recently launched a campaign
called Stop Overdose, which focuses on raising awareness about
fentanyl, naloxone, polysubstance use, and decreasing stigma.
To date, Stop Overdose has reached over 1 billion views.
Finally, CDC recognizes the importance of preventing
adverse childhood experiences or ACEs as a key part of the
prevention strategy. ACEs are potentially traumatic events that
happen during childhood, and decades of research show ACEs are
strongly linked to risk for substance use addiction and
overdose, as well as risk for mental health challenges and
suicide, among other leading causes of death.
By focusing on upstream ACEs prevention, we can make
substantial progress in preventing substance use and overdose
and addressing the behavioral health challenges facing our
Nation. As a person in long term recovery, I know firsthand the
pain and devastation that addiction can inflict on individuals,
families, and communities. But I have also seen the
transformative power of recovery.
I am grateful to be one of the millions of Americans in
recovery that can serve as a beacon of hope to others
struggling with substance use. This work is very personal to
me, and at CDC, we are committed to advancing a comprehensive,
community driven approach to save lives today, get ahead of the
crisis by identifying emerging threats, and supporting upstream
prevention so the next generation doesn't have to experience
this overdose crisis.
Thank you for the opportunity to be here. I look forward to
your questions.
[The prepared statement of Dr. Jones follows:]
prepared statement of christopher jones
Introduction
Chair Murray, Ranking Member Burr, and distinguished Members of the
Committee, thank you for the opportunity to be here today to discuss
the Centers for Disease Control and Prevention's efforts to address of
our Nation's drug overdose crisis. I appreciate the Committee's
dedicated support and attention to this pressing public health issue
and we at CDC are committed to continuing our work to tackle the
growing crisis.
Over the past two decades, drug overdose deaths have claimed far
too many lives, with more than 250 Americans now dying each day from an
overdose. \1\ These sobering statistics represent individuals,
families, and communities that have been deeply and forever impacted by
this crisis. However, there is hope in knowing that we can alter this
trajectory. Drug overdoses can be prevented and people with substance
use disorders can recover. At CDC, we are working tirelessly to prevent
overdose and substance-use related harms so that we can save lives and
all people can achieve optimal health and well-being.
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\1\ Wide-ranging online data for epidemiologic research (WONDER).
Atlanta, GA: CDC, National Center for Health Statistics; 2021.
Available at http://wonder.cdc.gov.
The drug overdose crisis is complex and requires a multi-sector,
multi-pronged response. That is why I am pleased and privileged to be
joined by colleagues from the Office of National Drug Control Policy
(ONDCP), the Substance Abuse and Mental Health Services Administration
(SAMHSA), and the Health Resources and Services Administration (HRSA)
to discuss the Federal Government's comprehensive response to curtail
substance use and overdose, particularly from illicitly made fentanyl.
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Together we can stop drug overdoses and save lives.
The latest provisional mortality data from CDC indicate that more
than 107,000 Americans died from a drug overdose in the 12-months
ending in January 2022. Of these deaths, it is estimated that 80,590 of
these deaths, or 75 percent, involved at least one opioid, with 71,450
(66.5 percent) involving synthetic opioids, primarily illicitly
manufactured fentanyl or fentanyl analogs. \2\ Stimulant overdose
deaths are also on the rise, with approximately 33,128 (30.8 percent)
deaths involving methamphetamine and 24,751 (23 percent) involving
cocaine. \3\ The increases in overdose deaths have been experienced
across the nation. The overdose crisis cuts across socioeconomics,
demographics, political and religious affiliation, and geography. This
is a crisis that impacts both large cities and rural communities.
Particularly noteworthy are the recent unprecedented increases in
overdoses among communities of color, including Black persons and
American Indian and Alaska Native persons, with disparities in overdose
deaths among these populations compared to White persons worsening
during the COVID-19 pandemic. \4\
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\2\ Centers for Disease Control and Prevention. State
Unintentional Drug Overdose Reporting System (SUDORS). Atlanta, GA: US
Department of Health and Human Services, CDC; [2022, July, 11]. Access
at: https://www.cdc.gov/drugoverdose/fatal/dashboard.
\3\ Centers for Disease Control and Prevention. State Unintentional
Drug Overdose Reporting System (SUDORS). Atlanta, GA: US Department of
Health and Human Services, CDC; [2022, July, 11]. Access at: https://
www.cdc.gov/drugoverdose/fatal/dashboard.
\4\ Vital Signs: Drug Overdose Deaths, by Selected Sociodemographic
and Social Determinants of Health Characteristics--25 States and the
District of Columbia, 2019--20Mbabazi Kariisa, PhD1; Nicole L. Davis,
PhD1; Sagar Kumar, MPH1; Puja Seth, PhD1; Christine L. Mattson, PhD1;
Farnaz Chowdhury; Christopher M. Jones, PharmD, DrPH3 Vital Signs: Drug
Overdose Deaths, by Selected Sociodemographic and Social Determinants
of Health Characteristics--25 States and the District of Columbia,
2019-2020 MMWR (cdc.gov).
Driving the historic increases in overdose deaths, particularly
since 2013, is the continued proliferation of a highly potent and
unpredictable illicit drug market saturated with synthetic opioids,
especially illicitly manufactured fentanyl and fentanyl analogs (IMFs),
which are easier and less costly to make, distribute, and sell.
Introduced primarily as adulterants in, or replacements for white
powder heroin in drug markets east of the Mississippi River, IMFs are
now widespread in these white powder heroin markets, increasingly
expanding into drug markets in the western United States, and readily
available as pressed counterfeit pills that resemble commonly misused
prescription drugs such as oxycodone and alprazolam throughout the U.S.
\5\ Data from the Drug Enforcement Administration and other law
enforcement partners also indicate that IMFs are found in some illicit
supplies of other drugs such as methamphetamine and cocaine, adding an
additional concern about unintentional exposure to these highly potent
drugs among individuals who may have little prior exposure to opioids--
exponentially raising their risk for overdose. Illicitly manufactured
fentanyl is highly potent, and CDC data shows that over half of
decedents with an IMF-related overdose had no pulse when first
responders arrived at the scene. \6\, \7\
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\5\ Shover CL, Falasinnu TO, Dwyer CL, et al. Steep increases in
fentanyl-related mortality west of the Mississippi River: recent
evidence from county and state surveillance. Drug Alcohol Depend
2020;216:108314. https://doi.org/10.1016/j.drugalcdep.2020.108314.
\6\ O'Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J. Trends
in and Characteristics of Drug Overdose Deaths Involving Illicitly
Manufactured Fentanyls--United States, 2019-2020. MMWR Morb Mortal Wkly
Rep 2021;70:1740-1746. DOI: http://dx.doi.org/10.15585/mmwr.mm7050e3.
\7\ Gill H, Kelly E, Henderson G. How the complex pharmacology of
the fentanyls contributes to their lethality. Addiction 2019;114:1524-
5. https://doi.org/10.1111/add.14614.
The recent increases in overdose deaths highlight the need to
ensure people most at risk of overdose can access care, as well as the
urgent need to expand prevention and response activities with a focus
on health equity. As the nation's public health and prevention agency,
CDC is leading the public health approach in collaboration with our
state, local, territorial, and tribal partners. Our top priority is to
address the overdose crisis by rapidly tracking the evolving epidemic
and using this information to equip people on the ground to save lives
in their community. We work to ensure that data is driving decision
making and planning so that the response to the overdose crisis meets
local needs, particularly in communities hardest hit by IMFs.
Communities use this information to inform where they should focus
their efforts including activities such as providing naloxone,
decreasing stigma, increasing linkage to care, and improving bystander
---------------------------------------------------------------------------
education and response.
CDC prioritizes five key strategies that align with the HHS-wide
Overdose Prevention Strategy to address the evolving drug overdose
crisis and reduce substance use related harms: (1) monitoring,
analyzing, and communicating trends; (2) building state, tribal, local,
and territorial capacity; (3) supporting providers, health systems,
payors, and employers; (4) partnering with public safety and community
organizations; and (5) raising public awareness and reducing stigma.
CDC's mission is to end this crisis by using data to drive innovation,
tailoring prevention in local communities, partnering broadly, and
addressing underlying factors, including a central focus on health
inequities, and preventing or reducing adverse childhood experiences,
which are key risk factors for substance use and overdose.
CDC's Efforts to Use Data for Overdose Prevention
Data are essential for informing a public health response to the
overdose crisis. CDC uses data to understand drivers of both nonfatal
and fatal overdose, including its scope and magnitude, who is most
impacted, and to track trends over time to inform prevention and
response efforts. CDC's National Center for Health Statistics (NCHS)
maintains strong working relationships with state vital records offices
and has made great strides in improving the timeliness and completeness
of drug overdose death certificates in recent years. In fact, the
improvements in the timeliness of these data have now made it possible
to provide provisional drug overdose death data on a monthly basis,
allowing for the identification of trends in overdose counts by drug
class within 4-5 months as opposed to within 2 years. NCHS has also now
released provisional drug overdose death data on CDC's online analysis
system WONDER, enabling for the first time, detailed analyses of
overdose death counts and rates by demographic and geographic
characteristics. These improvements allow us to assess overdose death
trends at a national level and adjust our use of resources in a
timelier manner. In addition, the completeness of drug overdose death
certificates has greatly improved in recent years, with approximately
95 percent of drug overdose death certificates listing specific drugs
contributing to the overdose, up from approximately 75 percent a decade
ago. To continue to advance improvements in the death certification
process, CDC has recently established a Coordinating Office for Medical
Examiners and Coroners that will continue to seek improvements in the
speed, accuracy, and completeness of data received.
CDC's National Center for Injury Prevention and Control has
developed two key data systems to improve the timeliness and
comprehensiveness of both nonfatal and fatal overdose data as part of
the Overdose Data to Action (OD2A) cooperative agreement. These two
systems provide more information about substances contributing to
nonfatal overdoses and contextual information about what led to an
overdose death. CDC's Drug Overdose Surveillance and Epidemiology
(DOSE) System was developed to analyze data from electronic health
records to rapidly identify outbreaks and provide situational awareness
of changes in suspected drug overdose-related emergency department
visits at the local, state, and regional levels ensuring consistent and
accurate reporting across all entities that make it easier to compare
data across states. DOSE captures timely data on emergency department
visits involving all suspected drug overdoses, including demographic
characteristics of those who overdose such as sex, age, and county of
patient residence. Since 2019, forty-one states and the District of
Columbia have provided data to CDC on a monthly basis which is publicly
accessible through an Interactive dashboard. This data improves
coordination and strategic planning for intervention and response
efforts among health departments, community members, healthcare
providers, public health, law enforcement, and government agencies.
CDC's State Unintentional Drug Overdose Reporting System (SUDORS)
collects comprehensive information on drug overdose deaths in 47 states
and the District of Columbia. The data are collected from death
certificates and medical examiner/coroner reports (including scene
findings, autopsy reports, and full postmortem toxicology findings) to
help inform overdose prevention and response efforts by (1) lending a
better understanding of the circumstances that surround overdose
deaths, (2) identifying specific substances causing or contributing to
overdose deaths as well as emerging and polysubstance overdose trends,
and (3) improving the timeliness and accuracy of overdose data. In
2016, SUDORS began as part of CDC's Enhanced State Opioid Overdose
Surveillance (ESOOS) program, to provide comprehensive data on opioid-
involved overdose deaths. In 2019, SUDORS expanded to collect data on
all unintentional and undetermined intent drug overdose deaths. Through
this data, we have gleaned integral information that can help inform
prevention in communities. For example, recent SUDORS data indicated
that more than 3 in 5 people who died from a drug overdose had an
identified opportunity for linkage to care or life-saving actions. \8\
In addition, 40 percent of overdose deaths occurred while a bystander
was present. \9\ CDC disseminates both DOSE and SUDORS data through
interactive data dashboards accessible via CDC's website.
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\8\ O'Donnell J, Gladden RM, Mattson CL, Hunter CT, Davis NL.
Vital Signs: Characteristics of Drug Overdose Deaths Involving Opioids
and Stimulants--24 States and the District of Columbia, January--June
2019. MMWR Morb Mortal Wkly Rep 2020;69:1189-1197. DOI: http://
dx.doi.org/10.15585/mmwr.mm6935a1.
\9\ O'Donnell J, Gladden RM, Mattson CL, Hunter CT, Davis NL.
Vital Signs: Characteristics of Drug Overdose Deaths Involving Opioids
and Stimulants--24 States and the District of Columbia, January--June
2019. MMWR Morb Mortal Wkly Rep 2020;69:1189-1197. DOI: http://
dx.doi.org/10.15585/mmwr.mm6935a1.
In addition to DOSE and SUDORS investments in states, localities,
and territories, CDC continues to use other proprietary data sets to
gain a holistic understanding of the factors that contribute to drug
overdose and substance use related harms so communities know what
interventions to choose and when to make adjustments based on the
evolving crisis. This includes leveraging data sets within CDC and from
our Federal partners, including data related to substance use disorder
and treatment, prescribing data, and using innovative data science
tools, methods, and techniques, and advance modeling efforts to help
communities allocate resources and interventions. CDC is also
supporting medical examiners and coroners with increased toxicology
testing as well as supporting labs to identify synthetic opioids
through the provision of Traceable Opioid Material Kits that provide
reference materials for fentanyl compounds and other synthetic opioids.
In coming months, CDC will expand this portfolio to include stimulant
reference materials. Finally, CDC works collaboratively with other
Federal partners to conduct research and leverage available data
sources that help identify key information about emerging substance use
patterns, prevalence, treatment availability, and the changing drug
supply.
CDC's Comprehensive Public Health Approach to Preventing Overdose and
Substance Use Related Harms
CDC's National Center for Injury Prevention and Control has funded
state health departments for overdose prevention activities since 2015,
beginning with a small subset of high-burden states. This program has
since scaled to a national program that has not only provided support
to every state that applies for funding but adapted as the overdose
crisis evolved. Under the Overdose Data to Action (OD2A) program, CDC
now funds 47 states, Washington DC, and 16 city and county health
departments to advance surveillance efforts, which allows the
departments to tailor the implementation of prevention efforts with a
menu of strategies that support jurisdictions in addressing the primary
drivers of overdose in their states and communities.
As the overdose crisis has broadened, CDC has expanded the initial
scope of its overdose prevention activities to address new challenges
along with opioids misuse and overdose. This flexibility allows funded
jurisdictions to meet the needs of today's crisis, including investing
in populations with a high percentage of individuals using stimulants
like methamphetamine and cocaine, which we know are increasingly
intertwined with illicit fentanyl and opioid overdose. CDC has also
scaled investments in activities to link people to care and treatment
across health care, community, and criminal justice settings. These
activities include peer navigation, quick response teams, and harm
reduction and represent an important compliment to the work of other
agencies focused on funding substance use treatment and service
delivery. The insights we have gained from OD2A have informed two new
funding opportunities that were recently announced, including an
announcement specifically to support state and territorial health
departments (OD2A-S) and another to support local health departments
(OD2A-Local). CDC is also partnering with other Federal agencies to
coordinate and leverage all resources to increase uptake of these
important strategies. For example, The National Harm Reduction
Technical Assistance Center (NHRTAC) is a joint project funded by CDC
and SAMHSA. This program provides critical technical assistance to harm
reduction programs, including syringe services programs (SSPs) to
prevent the spread of infectious diseases, and other community-based
programs and organizations that provide treatment, prevention,
recovery, and harm reduction services including increasing access to
fentanyl test strips (FTS) by allowing Federal funds to be used to
purchase FTS in an effort to curb the spike in drug overdose deaths.
In addition to the Overdose Data to Action program, CDC, in
partnership with the National Association of City and County Health
Officials, supports local county health departments through the
Implementing Overdose Prevention Strategies at the Local Level (IOPSLL)
program. This program focuses on establishing linkages to care;
supporting providers and health systems; enhancing surveillance and
data sharing capabilities; improving partnerships with public safety
and first responders; implementing harm reduction activities such as
providing fentanyl test strips and educating about the use of naloxone;
developing communications campaigns; and implementing innovative
prevention projects. This program enables the implementation of
innovations and promising strategies at the local level and is an
essential source of funding for capacity-building that can increase
readiness to participate in future funding opportunities aimed at local
health departments.
CDC also funds 11 Tribal Epidemiology Centers and 15 tribes or
tribal-serving organizations for overdose prevention activities. These
collaborations support efforts to improve data quality, completeness,
accuracy, and timeliness among a high-risk population. Funding also
supports regional strategic planning to address opioid overdose
prevention so that strategies appropriate to tribal communities are
developed by the communities impacted and the strengths inherent to
tribal organizations are built upon and scaled across the country.
In addition to supporting states, localities, territories, and
tribes, CDC continues to advance partnerships through multiple public
health and public safety collaborations that aim to strengthen and
improve efforts to reduce drug overdoses. These partnerships allow for
effective implementation of programs and help advance promising
strategies that address rising overdoses in communities. The Overdose
Response Strategy (ORS) is a unique collaboration between CDC and the
High Intensity Drug Trafficking Areas (HIDTA) program at ONDCP designed
to enhance public health and public safety partnerships. The mission of
the ORS is to help communities reduce fatal and non-fatal drug
overdoses by connecting public health and public safety agencies,
sharing information, and supporting evidence-based interventions. More
specifically, under the program, drug intelligence officers and public
health analysts collaborate and leverage supply and overdose data to
problem-solve and address local and regional issues, including spikes
in overdoses related to illicit fentanyl. Given the potential impact of
this program, CDC has expanded its investment in this partnership to
support the public health component in all 50 states, Puerto Rico and
the U.S. Virgin Islands.
The ORS also supports the Combatting Overdose through Community-
level Intervention program, to implement innovative strategies within a
targeted geographic area to build the evidence base for response
activities that other communities can employ. Projects include efforts
on post-overdose strategies to link people to care using patient
navigators and recovery coaches; justice-involved populations and
access to medications for opioid use disorder (MOUD); buprenorphine
induction in emergency departments; and training and provision of
trauma-informed care.
One example from the program is the Martinsburg Initiative in West
Virginia. The Initiative is an innovative, police-school-community
partnership focused on opioid overdose prevention that can act as a
model for other communities. Through a partnership between the
Martinsburg Police Department, Berkeley County Schools, and Shepherd
University, this project expands community resources and links law
enforcement, schools, communities, and families in a dynamic
partnership that assesses participants' ACE scores and subsequently
links them to necessary resources and supports. Through a strategic
focus that targets at-risk children and families experiencing
challenges, this initiative aims to assess, identify, and reduce the
root cause families experiencing challenges, this initiative aims to
assess, identify, and reduce the root cause of substance use through a
trauma-informed and collaborative approach.
CDC also partners with the Office of Justice Programs, Bureau of
Justice Assistance's Comprehensive Opioid, Stimulant, and Substance
Abuse Program (COSSAP) to support effective state, local, and tribal
responses to illicit substance use. These demonstration projects
promote public safety, and support access to treatment and recovery
services in the criminal justice system in order to reduce overdose
deaths. This partnership has focused on rural responses, expanding use
of the Overdose Detection Mapping Application Program (ODMAP) in states
and tribes, harm reduction education and training for law enforcement,
building bridges between jail and community-based treatment, and
overdose fatality review (OFR) implementation.
In an epidemic of this scale, public education and empowerment to
combat stigma has never been more important. This is true not only for
individuals who use drugs, but also anyone--friend, parent, caregiver,
or community member--who may encounter someone experiencing an
overdose. CDC's public messages and campaigns have evolved along with
the epidemic. For example, CDC's Rx Awareness campaign initially
focused on increasing awareness of the risks associated with
prescription opioids when prescription opioids were the primary driver
of overdose deaths. As the crisis evolved, the campaign shifted to
focus on messages of hope in recovery with a focus on equity and
inclusion. Most recently, CDC's latest messaging includes four mini-
campaigns, entitled ``Stop Overdose,'' and focuses on raising awareness
of fentanyl, naloxone, polysubstance use, and decreasing stigma with a
particular focus on 18-34 year olds--a group experiencing some of the
highest rates of overdose in recent years. Launched in late 2021, these
new mini campaigns have reached over 1 billion views, showing not only
the importance of these messages, but the need for messages in reaching
all populations, especially young adults.
We cannot reverse current trends without a holistic effort that
fully leverages the health system and health care providers to address
substance use disorder and overdose. Recent research shows that touch
points with the health system present an important opportunity to
engage at-risk patients in care for substance use-related challenges
and overdose prevention. This includes advancing efforts for
prevention, screening, linkage to care, and retention in treatment
toward long-term recovery. In particular, CDC's work in health systems
and funding to jurisdictions a focus on improving upstream prescribing
and pain care, enhancing linkage to care and treatment across various
health care settings, from primary care to emergency departments,
utilizing peer navigators to help individuals seek and connect to
recovery options, and reducing stigma among clinicians and providers so
that people feel safe seeking the care they need. Pain, particularly
chronic pain, can lead to impaired physical functioning, poor mental
health, and a reduced quality of life. A key aim of pain management is
the provision of individualized, patient-centered care that focuses on
optimizing function and supporting activities of daily living. CDC
provides guidance to clinicians, as well as tools and resources for
patients and clinicians, to help advance comprehensive pain care. One
important way CDC promotes patient-centered pain care is through
recommendations in its 2016 CDC Guideline for Prescribing Opioids for
Chronic Pain and accompanying training and ancillary resources.
Since release of the Guideline in 2016, CDC has stayed at the
forefront of new research and collaborated with the Agency for
Healthcare Research and Quality to conduct five formal systematic
reviews of new available evidence on noninvasive, nonpharmacological
treatment and nonopioid pharmacological treatment of chronic pain. As a
result of these reviews and the new scientific evidence that has
accrued since 2016, CDC determined that an update of the Guideline, and
an expansion to certain acute conditions, was warranted. The draft 2022
CDC Clinical Practice Guideline for Prescribing Opioids was posted for
a 60-day public comment period from February 10, 2022, to April 11,
2022. Release of a final updated Guideline is anticipated in late 2022,
along with a suite of translation and communication resources to
facilitate effective implementation.
Finally, focusing on preventing substance use in the first place is
a core component of CDC's work and the long-term solution to reversing
the decades-long overdose crisis. A key element of this work is
advancing upstream prevention strategies to prevent Adverse Childhood
Experiences, or ACEs--potential traumatic events like experiencing
abuse or neglect, witnessing violence in the home or community, and
growing up in a household with mental health or substance use problems.
Research shows that ACEs are strongly linked to increased risk for
substance use, including increased risk for prescription opioid misuse,
opioid injection, cocaine and amphetamine use and use disorder, and
earlier age of initiation for these substances. Additionally, losing a
loved one to overdose or suicide are themselves ACEs that can increase
the risk of overdose or suicide in the future. Thus, preventing
exposure to these early adversities is an important step in reducing
the risk for overdose and suicide, and many other health risk behaviors
and health outcomes throughout the lifespan. Focusing on shared risk
and protective factors at the individual, family, and community levels
helps to create safe, supportive, and nurturing relationships and
environments and reduces these risks. Upstream prevention of ACEs and
other violence and adversity among children and youth can have a
profound impact on the trajectory of substance use, overdose, and
mental health in the United States. CDC appreciates the support of
Congress to address these intertwined crises through an integrated
public health approach.
CDC also partners with ONDCP on youth prevention efforts through
the Drug Free Communities (DFC) Support Program. DFC, the Nation's
leading effort to mobilize communities to prevent and reduce substance
use among youth is administered by ONDCP and managed by CDC. The DFC
Program funds community-based coalitions to strengthen the
infrastructure among local partners to create and sustain a reduction
in local youth substance use. The DFC coalitions focus efforts on youth
and in many instances, promote health equity and aim to reduce
disparities that impact youth substance use, and address the risk and
protective factors that negatively impact health outcomes in
communities. More than 700 community coalitions across the country
receive funding of up to $125,000 per year to strengthen collaboration
among local partners and create an infrastructure that reduces youth
substance use.
Closing
The drug overdose crisis continues to evolve, and our response must
be nimble and flexible to the changing situations in communities
throughout our country. We know that public health thrives when the
approach is comprehensive, coordinated, and can quickly adapt and
respond to current and emerging needs. Data are foundational to this
effort. This is especially true with an overdose crisis driven by an
extremely potent illicit substance, like fentanyl. CDC is continuously
using data to drive prevention action in states, territories, tribes,
and local communities. We are continuing to make vital strides in
accelerating data collection, analysis, and dissemination of nonfatal
and fatal overdoses and increasing the use of innovative data science
and modeling efforts to fight the current crisis and predict where it
will go next.
For far too long the tragic consequences of overdose have devasted
families and communities across the country, and the continued
proliferation of illicitly made fentanyl has only exacerbated the
challenges we face. CDC is committed to using data, science,
innovation, and collaboration as part of a whole-of-government approach
to save lives and bring an end to our Nation's overdose crisis.
______
The Chair. Thank you very much to all of our witnesses
today and for sharing your expertise. We will now have opening
rounds of questions from Senators. Please again, if you can
keep your remarks to, or your questioning to 5 minutes.
Mr. Chester, let me start with you. As you know, fentanyl
has been devastating for all of our communities, including in
my home State of Washington. Over 2,000 people died from a drug
overdose in Washington State in 2021.
That is an increase of nearly 70 percent over 2019. And
half of those deaths involve fentanyl. So those numbers are
really heartbreaking. And in King County, we saw record high
fentanyl deaths in 2021.
Spokane County reported out 186 percent increase in
fentanyl overdose. That is devastating. And because of the
transnational criminal networks that traffic fentanyl, it is
only becoming more prevalent. The Drug Enforcement
Administration recently reported a 264 percent increase in
counterfeit pill seizures in Washington State alone.
Law enforcement officials and first responders are working
hard to intercept and seize fentanyl before it reaches our
communities and respond to the increased use, but the Federal
Government really has to do more.
Mr. Chester, share with us what steps ONDCP is taking to
coordinate the activities of the Federal law enforcement
agencies, Department of Justice, DEA to make sure that our
efforts to disrupt fentanyl trafficking is as effective as
possible.
Mr. Chester. Thank you for the question, Senator. And in
your question was a great deal of the answer, and that is going
after the transnational criminal organizations before the drugs
can even get across our borders and into our communities. And
it is what we refer to as commercial disruption.
What we are dealing with is a global illicit business that
has all of the hallmarks of a transnational business
organization. They have access to resources. They do product
development. They have the ability to move money, products, raw
materials across borders with incredible efficiency. They are
free riders on the back of the legitimate commercial network
that keeps the international economy alive.
But it has critical vulnerabilities. And so what we are
focused on, and this is across the interagency and across the
Federal Government, is focusing our efforts on those critical
vulnerabilities where we can get the greatest amount of effect.
And one of them, obviously, as was discussed before, is illicit
finance.
That is their operating capital and that is their profits.
And another one is the precursor chemicals that are used in
order to manufacture these drugs. And in many cases now, the
technology is at the point where precursor chemicals are no
longer regulated and some of them are so legitimate that they
can't be regulated. The third one is going after the commercial
shipping that moves these things around the country.
Then the fourth thing is the pill presses and the dye molds
that are used to make them. And so what we are doing at the
Office of National Drug Control Policy is not only working
across the Federal Government, but working bilaterally with key
countries like China, like Mexico, and like India in order to
be able to disrupt the production of these drugs at their
source and to prevent them from getting to our borders and into
our communities in the first place.
That is truly an interagency effort, and it is where the
bulk of our efforts lie right now.
The Chair. Okay. Thank you. Thank you very much. Let me
turn to Dr. Delphin-Rittmon. For a lot of parents, it is really
hard to help their kids navigate teenage years anyway,
especially when it comes to drug and alcohol. And the fentanyl
crisis has made keeping our kids safer a lot harder.
I am a mom. I am a grandma. I understand exactly how scary
this is for parents today. Counterfeit pills with fentanyl are
extremely dangerous and extremely easy for teens to find, often
accidentally, on social media platforms. The stories from
parents and family members and loved ones are heartbreaking.
Kids buy what they think are prescription opioids online,
only to get lethal fentanyl laced pills instead. And in fact,
the problem is so widespread that the Drug Enforcement
Administration issued its first public safety alert in 6 years,
warning about the dangers of those pills.
We have got to protect our communities, especially our
kids, from fentanyl. It is vital that we invest in substance
use disorder prevention, treatment, and recovery for youth.
Talk to us about how this Committee can support the efforts,
especially in our upcoming reauthorization package.
Ms. Delphin-Rittmon. Yes. So, thank you, Chair Murray, for
that question. And you are right. I mean, this is such a
challenging area. And I also want to thank you for your
bipartisan work to reauthorize our programs.
We do have a specific program, the Strategic Prevention
Framework for Prescription Drugs, that is geared toward helping
to increase awareness of the dangers of sharing substances or
substance use. It is geared toward raising awareness among
youth and families and communities.
This program also does include information and training in
technical assistance related to the dangers of buying
substances, period, but also through the web, and particularly
focuses on youth. So some of the goal is to raise awareness and
to change youth behaviors through that awareness raising.
The Chair. Well, thank you. I am out of time. Dr. Jones, I
wanted to ask you, your--what efforts CDC is doing and how we
can support that. If you can give that to me in writing or if I
can get a back around for a second round of questions, I will
ask you that question.
Senator Cassidy.
Senator Cassidy. Thank you, Madam Chair. Mr. Chester, you.
[Technical problems]--thank you. I am still getting
feedback. Still getting feedback. Oh, well. It is irritating
me, so it is probably--let's try that.
Mr. Chester, I am struck that I can speak about chemical
providers in Wuhan sending chemicals here that are precursors
for fentanyl that are used by Mexican cartels that are all
shipped directly--you can acknowledge it in your testimony.
Now, we think of China as an area where they have
surveillance cameras on every corner in which at any point
someone may be arbitrarily imprisoned. I could go on, but we
know what the go on would be.
How much collaboration are we getting from the Chinese in
terms of this? Because some have suggested this is a form of
bioterrorism.
Mr. Chester. Yes, Senator. No, thank you very much for the
question. I can tell you that we engage regularly with the
People's Republic of China on this specific issue.
Although, as you know, we have a very complicated
relationship with China, this is an area where U.S. and PRC
interests align, and we have made progress in the past. The
most notable was our work up until May 2009----
Senator Cassidy. Let me stop you though. I am sorry.
Mr. Chester. Yes, sir.
Senator Cassidy. But if we know who those chemical
manufacturers are, the Chinese know who they are. So, yes,
there may be collaboration----
Mr. Chester. Right.
Senator Cassidy [continuing]. But there is a fundamental
breakdown there, right?
Mr. Chester. Yes, sir. And the first thing is ensuring we
have open lines of communication so the information that we
have, that we understand about seizures in the Western
Hemisphere can be sent to the Chinese so that they can take
action on it.
The second part of that is, and something that we have
clearly communicated to the Chinese--and you mentioned it in
your opening statement. I think you brought up a very good
point when you talk about the mislabeling. We have asked the
Chinese Government to do three very simple things.
The first one is agree with us on the list of unregulated
chemicals that are used to create precursor chemicals that bear
increased scrutiny. That is the first thing. The second thing
is to properly label their chemical and equipment shipments in
accordance with the World Trade Organization. And the third one
is that they know their customer and put--know your customer
procedures into place.
Those are the things we should expect of any responsible
country. We have asked other countries to do this as well, and
we look forward to working with the Chinese for them to
implement these procedures to reduce the flow of these
precursor chemicals into the Western Hemisphere.
Senator Cassidy. Now, we have been raising this issue of
the Chinese for several years now. So I guess what I am after,
which I am not sure I am getting, is a level of collaboration
and true collaboration as opposed to, hey, we are with you, as
opposed to no, we are knocking on doors, and we are shutting
down people and we are throwing them in jail.
Mr. Chester. Right. I would tell you that in--the
relationship that we have with Chinese, with the PRC, has given
us uneven progress. I wouldn't disagree with you on that. I
think that there are areas where the Chinese Government has
taken quick and decisive action at a request of the United
States and has had good results.
I think there are other times that we have differences with
the Government of China procedurally on certain things that we
ask them to do, and we have to ensure that we continue to
communicate with them and impress to them how incredibly
important this is, not just to the United States, but to the
rest of the world.
Other countries, and Secretary Blinken brought this up in
his speech about China, other countries should expect two great
countries like the United States in the PRC to work together on
this global issue and they understand that.
Senator Cassidy. Now, looking at Mexico, I know you have a
sense that Mexico is always teetering on whether or not it is
in control or not, and several states apparently are not in
control of the central Government.
But to what degree has the Mexican Government collaborated
with us if these cartels are bringing these drugs from China to
then bring across our border? To what degree are we getting
collaboration there?
Mr. Chester. We have a good and long standing relationship
with the Government of Mexico, which was solidified in the
bicentennial framework for security that was signed just a few
months ago that replaces the previous Merida Initiative that is
a little bit more holistic and takes in more of the
contributing factors within Mexico, not just the security side
of the house.
We have, on the ground, we have a large embassy down there.
We have deep law enforcement relationships with the Government
of Mexico. And we have had cooperation in the past. And most
recently, obviously, the apprehension of Rafael Caro Quintero
is a good example of cooperation with the Government of Mexico
that actually bears--that bears fruit.
Senator Cassidy. Now, but I had a sense that recently there
were some--a back, like increased liability for some of our
agents who might be down there if something goes wrong. And
also had a sense that President, or I will just call him AMLO,
the President of Mexico, has less affection for the U.S. than
perhaps some of his predecessors. Any comment on that?
Mr. Chester. What you are referring to is the national
security law that was put in place in January of last year,
that created a bunch of increased procedures for collaboration
between Mexican and U.S. law enforcement agencies.
I think on the ground, that has been worked out in
practical terms, that it has not had a devastating effect on
law enforcement cooperation in Mexico. That is not uniform
across all agencies, but I think in general terms, the national
security law isn't a barrier from us working with Mexico, but I
think it is clear that President Lopez Obrador sees really two
things.
The first one is he wants to go after the root causes of
criminality. And the second thing is he continually looks at
the U.S., Mexico relationship in terms of Mexico's interests as
much as United States' interests.
This has caused a recasting of our relationship with
Mexico. But we have made some progress on this particular
problem when working with the Government of Mexico.
Senator Cassidy. I yield.
The Chair. Thank you.
Senator Murphy.
Senator Murphy. Thank you very much, Madam Chair. Thanks
for this hearing. You are all doing super important work. We
appreciate the testimony. Dr. Delphin-Rittmon, I wanted to talk
to you about the genesis of the opioid crisis, which, of
course, at first is rooted in America's penchant to prescribe
opioids and addictive pain medication at a rate that is
unparalleled in the rest of the world.
We have made a lot of progress when it comes to the overall
number of opioids that are prescribed in this country. And
there is a direct line between individuals who become addicted
to these pain medications and then those that end up seeking
illicit drugs in black markets that often end up having
fentanyl attached to them.
We have seen this drop in the number of opioids that have
been prescribed, and we have sort of pat ourselves on the back.
And yet when you look at our numbers, even with this drop
compared to the rest of the world, we are still a crazy
outlier, right.
We are still 5 percent of the world's population and
somewhere between 70 and 80 percent of the world is opioid
prescriptions, even with a 40 percent drop in the overall
number of prescriptions that are being made.
Just talk for a second about, as we are as we are talking
about the fentanyl crisis here, the work that we still have to
do to alter prescribing patterns as a means to stop people from
getting on this pathway to fentanyl.
Ms. Delphin-Rittmon. Yes. Thank you for that question,
Senator. And, the prescribing patterns and, ultimately ensuring
that people have access to evidence based services and supports
is so critical.
We have seen that over time, and we know that the evidence
based practices and treatment such as medication assisted
treatment, whether it be buprenorphine or methadone, can help
people who are struggling with opioid related substance
challenges.
In terms of prescribing patterns, I mean, one thing that we
are working on is to increase that access for individuals that
may be struggling, is to allow individual prescribers that is,
prescribers to treat up to 30 individuals with buprenorphine.
We have revised the buprenorphine practice guidelines such
that those individuals can control individuals struggling with
opioid addiction with buprenorphine.
Senator Murphy. But I guess what I am talking about, right,
pain management. I am talking about the fact that we still are
prescribing far more pain medication, addictive pain medication
than the rest of the world.
That we have got to--from your perspective, right, you have
got to focus on trying to find alternative ways to manage pain
so that people never get in the position of being addicted to
pain medication that then becomes an addiction to heroin,
fentanyl, etcetera.
Ms. Delphin-Rittmon. Yes. And we do have grants actually
that do that type of training. So for example, our state opioid
response grant does train providers on alternatives to pain
management such that prescription medications aren't the first
course. And so other strategies to manage pain and that can
help to alter and change some of the prescribing practices that
we are seeing.
Senator Murphy. Mr. Chester, I want to talk to you a little
bit about how fentanyl and other illicit substances come into
the United States through the Southern border. It is still
true, correct, that the lions share, the vast majority, not
all, but almost all of the products coming into the United
States comes through our ports of entry.
We have made through the Appropriations Committee, I chair
the subcommittee that writes the budget for DHS, some
significant investments in technology at those ports of entry.
But there is sometimes there is an impression here that a lot
of this product is being, moved across in the dead of the night
through the desert.
But the reality is we still don't catch as much as we
should that is walking straight through public ports of entry.
And there is additional investments that we can make to try to
catch more of it and ultimately deter more of that activity.
Mr. Chester. Yes, Senator. No, you are correct. So the
preponderance of the drugs do come through the existing ports
of entry. The technology that they have available is very
impressive. And the men and women of Customs and Border
Protection, those are our most experienced folks on the ground.
It is the most efficient way to be able to move them across
and then have access on the other side to an available network
to get them quickly across the country. So they do come through
most of the ports of entry, but there is obviously more that we
can do.
The President has asked for $300 million in enhancements
for Customs and Border Protection for that very reason that
this is an evolving threat. But there are other places,
obviously, through the mail system, through maritime
conveyances, that these drugs get into the country as well.
Senator Murphy. I just make that point, Madam Chair,
because a lot of our colleagues think that by putting up this
wall on the border you are going to stop fentanyl from coming
into the country.
The reality is that fentanyl is coming in through the
ports. And so we can make investments, but the idea that it is
the one wall portions of the border where the fentanyl is
pouring in is just not what the facts bear out. Thank you,
Madam Chair.
The Chair. Thank you.
Senator Marshall.
Senator Marshall. Thank you, Madam Chair. Dr. Jones, do you
consider the fentanyl crisis to be a public health emergency?
Dr. Jones. Yes. And there is currently a public health
emergency declared for the opioid crisis.
Senator Marshall. Okay. Thank you. Like every state, my
home State of Kansas is now a border state. That is right, as
you can see from this map behind me, Kansas is literally at the
crossroads of fentanyl trafficking.
With three major arteries coming out of Mexico piercing the
heart of our great state, and all three bisecting the Nation is
busiest East-West byway, we are now at ground zero. In fact,
just recently, officers in Kansas City, Kansas, seized nearly
15,000, 15,000 fake pills laced with fentanyl during a 2-day
bust. Fentanyl is now killing a Kansan and almost every day is
killing over 250 Americans every day.
Sadly, fentanyl is now the No. 1 killer of young adults,
poisoning deaths. And I mention and I stress these are
poisoning deaths from synthetic opioids, particularly fentanyl,
have increased by more than 600 percent. So where does it come
from and why is it so cheap? As we all know, the fentanyl
precursors are made in China.
You could call this China's revenge on the West for the
opium war. In Mexico, Chinese chemists and their cartels
convert these precursors into fentanyl, and they lace fake
pills like Adderall or Xanax or Percocet, they mix them with
illicit drugs like meth and cocaine, or simply they sell it in
various pure forms.
Unfortunately, this is one supply chain from China that is
not broken. It goes without saying, with an open, porous
Southern border, the supply is abundant, driving the street
price down. For where oxycodone tablets maybe cost $60, you can
pay $2 to $6 for a fentanyl tablet.
One final point I want to go back to, returning to this
fake pills concept. Dying from fentanyl is poisoning. It is not
an overdose. That is poisoning. If a non-suspecting student
takes a fake Adderall pill they purchased online or wherever
they purchased and dies, that is poisoning, and the criminals
should be tried for murder.
At least that is how I see it. Mr. Chester, would securing
borders and decreasing smuggling impact the fentanyl crisis?
Mr. Chester. Yes, Senator. I mean, as I said in response to
Senator Murphy as well, the men and women that we have at our
Southern border are the finest we have.
Senator Marshall. We understand, but you agree it would
have a significant impact. Dr. Jones, same question. Would
securing our borders and decreasing the smuggling and the easy
access to fentanyl impact the crisis?
Dr. Jones. I would reiterate Mr. Chester's points about the
efforts in the National Drug Control Strategy to address----
Senator Marshall. But they are not working. You can rewrite
the points, but obviously with a 600 percent increase in
deaths, whatever we are trying to do, reiterating the points,
forming committees, talking to people, something is not
working. Dr. Jones, do you believe we should apply Title 42 to
drug smuggling across the Southern border?
Dr. Jones. Well, Title 42 is rooted in protecting public
health from communicable diseases. So while there is a declared
319 public health emergency for the opioid crisis, it falls
outside of the scope of Title 42.
Senator Marshall. Okay. Mr. Chester, you stated that first,
the most important action we can do right now is to get more
naloxone out. As a physician, that is like telling me to give
people with brain tumors, Tylenol, to say that is the most
important thing. Do you really feel that giving out naloxone
would have a bigger impact than securing our borders?
Mr. Chester. Senator, by most important thing, what I meant
was most important thing in saving lives now because it can
reduce an opioid overdose. But that is not exclusive of all the
work that is being done at the Southern border and with other
countries and with the Postal Inspection Service and all of the
other means that we do to keep the drugs out of our
communities. The Naloxone is designed to reduce an overdose
death and save a life immediately.
Senator Marshall. What we are doing now is we are putting a
finger in the dike and the entire dike is giving away. If we
don't secure our borders, this epidemic is only going to get
worse. Mr. Chester, you also stated that the U.S. routinely
engages with the People's Republic of China to address
shipments.
You go on to say the PRC actions in that regard have a
direct and positive impact. How can you objectively,
quantitatively substantiate your statement when we are seeing a
600 percent increase in deaths?
I know you are talking to them. I know there is
collaboration. But what is your objective evidence that says
that China is doing anything to slow this machine down?
Mr. Chester. The best example I can give you is the work
that we did with China prior to May 2019, when China class
scheduled all fentanyl related substances, and as a result, the
direct shipment of fentanyl and fentanyl related substances
from China to the United States went down to almost zero. Now--
--
Senator Marshall. That was in 2019?
Mr. Chester. That was in 2019. Yes, sir. And now, the
traffickers moved from producing finished fentanyl into
precursor chemicals, which they supplied to Mexican suppliers
and that went up, but that speaks to the dynamic and
interactive nature of a very determined, profit driven----
Senator Marshall. But quantitatively, what have you done
that can show me that we have impacted that? What--is there any
objective evidence that we have impacted China's supply? I
mean, they are sending it to us like we send wheat to them.
Mr. Chester. The number of seizures of precursor chemicals
and pre-precursor chemicals in the Western Hemisphere has been
consistently high. And in many of those cases, that was due to
cooperation with Chinese officials, or subsequent to the
seizure, the information was sent to the Chinese officials so
that they could take action and hold the individuals
responsible.
Senator Marshall. Thank you, Madam Chair. I yield back. But
the point is, the seizures are going up because objectively,
China is not doing--is not stopping the supply of these
precursors. Thank you. I yield back.
The Chair. Senator Hassan.
Senator Hassan. Thank you, Madam Chair. And thank you to
all of our witnesses for being here today. I want to start with
a question to you, Mr. Chester. Deaths from fentanyl among
teenagers more than tripled between 2019 and 2021.
As Chair Murray mentioned, many of these teens were not
seeking fentanyl. They purchased what they thought was
Percocet, Oxycodone or Adderall, only to take a fatal dose of
fentanyl. And the stories are truly heartbreaking. How are
young people getting exposed to these fentanyl laced drugs?
Mr. Chester. Thank you for the question, Senator. And I
think the distinction was made between poisonings and overdose
deaths. And I think it is an important one because you bring it
up in your question. Unfortunately, they are being exposed to
these drugs in a greater variety of means than they ever were
before.
In many cases, and Dr. Gupta has said this several times,
getting access to these drugs is as simple as in the palm of
your hand, through a social media app. And so when you are
dealing with global drug traffickers who want to reduce their
risk and reduce their overhead and increase their customer base
and increase their profits, it is in their interest to make it
available through a variety of means.
The first thing is to have access to them through social
media apps, through the dark web, sometimes through the clear
web, sometimes through their own personal interactions. The
second thing is how those drugs move across our borders and
into the United States. And in some cases it is the Southwest
border, but in some cases it is through our mail and express
consignment.
The work we have done with the Postal Inspection Service,
where the number of seizures in the mail has increased, I think
has been admirable in being able to disrupt that vector coming
into the country.
Senator Hassan. Thank you. Another question for you. Last
year's National Defense Authorization Act included a bipartisan
bill that Senator Toomey and I authored, the Blocking Deadly
Fentanyl Imports Act.
This law requires the Government to publicly identify
countries that are major producers or traffickers of illicit
fentanyl and cutoff foreign aid to those countries if they fail
to increase efforts to fight drug trafficking.
Mr. Chester, what steps has the Administration taken to
evaluate whether we should cutoff foreign aid to countries due
to the production or trafficking of fentanyl and fentanyl
analogs within their borders?
Mr. Chester. Thank you for the question. I am sure you
understand, I can't take a position on pending legislation.
What I can tell you is that the current process that we have,
that we apply under the majors list process for plant based
drug producing countries, has been effective over the years.
And we welcome any tool that gives us the ability--[technical
problems]----
Senator Hassan. Thank you. I appreciate that. How is our
audio here? Is there--Okay. We are good.
The Chair. I can hear you. I am not sure we can hear the
witness. Is it off?
Senator Hassan. I think we are all right now. I want to
turn to Ms. Johnson with another question, and I appreciate Mr.
Chester's response to the last one.
Ms. Johnson, according to the Department of Health and
Human Services, the country must add more than 100,000 general
psychiatrists and 43,000 addiction psychiatrists to meet the
current need. This shortage impacts States like New Hampshire,
where patients may have to drive hours to find treatment for a
substance use disorder.
As part of funding I helped advocate for, the Department of
Health and Human Services awarded a $1.4 million grant to
Dartmouth-Hitchcock in January to train behavioral health
clinicians, paraprofessionals, and other residents of rural New
Hampshire communities to address the substance use disorder
needs of residents.
Ms. Johnson, how will these grant programs help build the
behavioral health workforce over the long term? How will they
help rural areas in particular?
Ms. Johnson. Thank you, Senator. And thank you for your
leadership in supporting and developing these critical programs
that are really part of what it is going to take for us to
confront this crisis, for us to be able to build critical
programs that my colleagues across the table have identified.
We need a workforce to be able to deliver on that. And it
is the types of programs that you have helped create that give
us the tools to be able to recruit people into the field, to
get them the training that they need, and then to deploy them
into the communities where they are needed most.
We are looking forward to the work that will happen at
Dartmouth under the grant program.
Senator Hassan. Well, thank you for that. Quickly, I have a
question for Dr. Delphin-Rittmon. While we know that medication
assisted treatment, like buprenorphine, is the gold standard
for opioid use disorders, access to treatment is limited by the
requirement that providers obtain a special DEA waiver known as
the X-waiver in order to prescribe buprenorphine.
About 40 percent of counties across the United States in
2018 lacked even a single waiver practitioner who was able to
provide this treatment. Dr. Delphin-Rittmon, if the X-waiver
continues, how will the lack of treatment providers offering
medication assisted treatment impact fentanyl overdose rates?
Ms. Delphin-Rittmon. Yes. Thank you for that question,
Senator, and for all of your work in this critical area. We
know that it is just vital that people have access to
medication assisted treatment when they are struggling with
opioid use disorder.
Data shows that. It can help people move into long term
recovery along with other services and supports. In terms of
increasing the number of providers, we have removed some of the
barriers and we are in full support of removing barriers to
such that additional providers can be--can prescribe
buprenorphine.
That is why we changed some of the training requirements
along with the buprenorphine guidelines. And so that did bring
an additional 17,000 prescribers into the field since we put
that in place.
Senator Hassan. Well, that is important, but I think we
have more to do. So I have introduced the Bipartisan
Mainstreaming Addiction Treatment Act, which would eliminate
the X-waiver and expand access to treatments that we know will
save lives. Thank you so much, Madam Chair.
The Chair. Thank you. Senators know that a vote has been
called. I am going to call on Senator Moran and Senator Lujan.
I will go vote and come back. Senator Casey will hold the gavel
while I am gone.
Senator Moran. Chair, thank you. Thank you very much for
your presence today. Let me start with Administrator Johnson.
In your testimony, you mentioned that HRSA is working on better
connecting substance abuse disorder treatment with access to
mental health care.
I come from a state, but I also come from a nation in which
access to mental health care is limited in--for a number of
reasons, but particularly the rural parts of our state, the
inability to attract and retain health care professionals is a
huge issue. I see this in my Veterans Affairs Committee where
we are trying to take steps necessary to prevent veteran
suicide.
The services, if they exist, are a distance away. Senator
Smith and I recently introduced a bill authorizing a grant
program under HRSA to help primary care practices integrate
behavioral health care services into their offices. Designed to
take those circumstances in which you do have a hometown
physician, a family practice doctor, and bring mental health
care services to that practice.
Do you think better integrating behavioral health services
into primary care settings for adults and children makes sense?
And would that help address the substance abuse crisis that our
Country is facing?
Ms. Johnson. Thank you, Senator. I thank you so much for
your leadership on this issue. I think integrating behavioral
health, mental health and substance use disorder services in
primary care is essential for us to confront this crisis.
We are not going to be able to solve this problem unless
people can get the care and services they need, and that means
we have to deploy all available assets to the problem. And that
means there needs to be no wrong door for getting in to get
mental health and substance use disorder services.
That is why we are really focused on trying to leverage the
programs that HRSA and are grateful for the support of this
Committee to identify ways that we can continue to help the
primary care workforce understand and treat and identify mental
health and substance use disorders.
Senator Moran. Thank you. I intend to use your endorsement
in our efforts to get the legislation passed. Dr. Delfin-
Rittmon, in addition to serving on this Committee, I am also
the lead Republican on the Appropriations subcommittee that
funds the Department of Justice.
What--in your testimony you touched on the First Responders
Comprehensive Addiction and Recovery Act grant program, which
helps to train and equip first responders to respond to
overdose related incidents. This grant program, as you note--
noted, includes a rural set aside.
For many rural departments, the loss of man or woman power
while an officer or deputy is off training is almost as
prohibitive as the lack of funding. What is your department
doing to make training and other resources more accessible,
such as through online training courses to small and
understaffed departments?
Ms. Delphin-Rittmon. Thank you for that question, Senator.
You are right. I mean, it is so important to be able to have
multiple modalities, to be able to offer training. And so we do
have a number of training and technical assistance centers.
We have addiction training and technical assistance center,
as well as the provider clinical support system that provides a
range of technical assistance, training, and education for
prescribers as well as other behavioral health providers in the
field.
Those include both in-person as well as remotely through
webinars and online strategies and means as well.
Senator Moran. I might suggest to you that, at least in our
state, we have a number of law enforcement training centers
across the state geographically. You may want to integrate your
program or share the opportunity for training in those settings
and utilize the services that generally the law enforcement
community has already created for ongoing training for members
of law enforcement.
I also appreciate your attention to ensuring that rural
communities have the resources needed to fight fentanyl and
substance abuse. There are two issues--these two issues are
often associated with urban areas. I can assure you, it is not
a urban, suburban issue. It is, it is not solely that.
Rural America is battling the epidemic, and we do--are
doing so with, as I indicated earlier, a more strained health
care delivery system and limited workforce. One particular
program, you talk about in your testimony, that Kansas is
utilizing well is a certified community behavioral health
clinic programs.
In 2021, Kansas became the first state to establish the
model at the state level, and by 2024, we have 26 state
certified CCBHCs. Would you speak further to the role of
localized care like these community mental health centers have
in fighting substance abuse that we are talking about today?
Ms. Delphin-Rittmon. Yes, absolutely. And I want to commend
Kansas for having that number of CCBHCs. It is a wonderful
model. It provides both mental health, substance use services,
as well as coordination and connection and linkage to primary
care services as well. It is a model that also provides
wraparound prevention treatment and recovery services and
supports.
It is critical in terms of being able to connect people
that are struggling with opioid use disorders, as well as other
substance use disorders to services and supports, to include
recovery services and supports as well.
Senator Moran. Thank you both for responding to my
questions.
Senator Casey. Senator Lujan.
Senator Lujan. There we go. Thank you very much, Madam
Chair, for this important hearing. I do want to start by
echoing something from my colleague from Connecticut and
bringing attention to our ports of entry. Somehow this keeps
getting politicized.
If, in fact, the United States wants to be serious about
stopping the flow of illicit substances into the United States,
we must remember there is a Southern border and a Northern
border, and there is two water borders, and then you go down
and you remember the Gulf of Mexico with our water ports.
Don't forget about our airports. The screening or lack
thereof that is done at our ports should alarm all of us. 5 or
6 percent just improve to 10 percent with passenger screening
into the Southern border is embarrassing.
The United States must adopt 100 percent screening into the
United States with commercial goods and with passenger traffic
at all of our ports of entry. Only then will we start to
understand how these cartels and other entities are throwing
product at the problem.
I hope that we can at least come together there and work
together to get something done. By the way, one of the last
pieces of legislation that was signed by President Trump was a
bipartisan initiative challenging the Department of Homeland
Security to tell Congress how to get to 100 percent screening
of our ports.
Let's find a way to work together. Second, Mr. Chester, I
appreciate the attention to the illicit financial markets. The
United States should be embarrassed by the lack there of
process that we have with prosecuting against illicit financial
markets. And it is not just Democrat or Republican
Administrations. It is both.
When major financial institutions in the United States are
found to be laundering money for cartels, and the outcome is no
one goes to jail, someone gets a fine, well that is just a new
cost of doing business. If someone can make that much money and
only get fined, it is going to continue.
If there is one thing that all these bad people have in
common in what is happening here is that they are making money.
And until you stop the flow of that money, you are not going to
stop any of this.
I am hopeful that these are some areas, I know we are not
in the committee of jurisdiction, but some areas that we can
find some common ground to go after these entities that are not
politicized.
Now, the questions that I have, I want to echo a statement
made earlier, pushing on buprenorphine or improving screening
at ports of entry in America. Dr. Delphin-Rittmon, does the
United States need to adopt both, access to treatments as well
as trying to stop these movements of these illicit substances
from around the world in the United States?
Ms. Delphin-Rittmon. Thank you for that question, Senator.
I can certainly speak to the work of SAMHSA. I know Mr. Chester
has comments in terms of the movement. It does seem that we are
taking a multi-level approach, and so certainly there are is
quite a bit of work underway to increase access to medication
assisted treatment, as well as other vital prevention and
recovery services and supports as well.
It does sound like there is quite a bit of work in terms of
border--work at the border as well. But in terms of SAMHSA's,
the programs and initiatives that we have in place, both
through the source of state opioid response grant, as well as
the substance abuse treatment block grant, there are a range of
services and supports available across the country to help
individuals that are struggling with opioids, to include the
dissemination of fentanyl test strips, which allow for the
testing of substances and allow for the testing of the presence
of fentanyl.
Senator Lujan. Dr. Delphin-Rittmon, would access to
fentanyl testing strips save more lives?
Ms. Delphin-Rittmon. What we are seeing is that fentanyl
test strips do allow for the identification of fentanyl and
substances. That is helpful for individuals that are not
interested--that don't want to take fentanyl. Often what we
find is that harm reduction programs also disseminate
information about how to access services.
Often people are connected with a recovery coach or
recovery programing. So the harm reduction offers an
opportunity to sort of disseminate the fentanyl test strips,
but also to disseminate information about how to navigate and
access services and supports as well.
Senator Lujan. I believe access to those strips will save
lives. It alarms me that in some states those strips are
treated as illegal use or treated in a way where people can't
use them. I hope that one thing we can do is come together to
ensure that access to meds, to strips, things of that nature is
something that can be accessible across the United States.
I do have other questions for the record that I will
submit. The one point that I wanted to raise, though, is,
according to the CDC, only about one in every ten American
Indian, Alaska Native, and Hispanic people with substance use
disorder reported receiving treatment.
The numbers are about 70 percent of the 2 million folks
across the country that are not getting any treatment,
predominantly in rural and Native American communities, and in
Hispanic communities, Black communities, other communities of
color as well.
I appreciate that there is more attention being brought to
these, but again, what has been happening? The data shows where
this is occurring and there is still no response. Madam Chair,
I am certainly hopeful that as we have this conversation and we
are moving to move legislation to encourage more and demand
more access to meds, but that we understand where the data is
based on the number of folks that we are losing, while we also
stop these illicit financial markets, and we improve
dramatically and require present screening at our borders to
begin to make the drastic steps necessary to be able to get our
hands around this. Thank you. I yield back.
Senator Casey. Senator Collins.
Senator Collins. Thank you, Chair, Members of the panel, I
say this with grave respect for each of you. I know that you
care deeply and that the policy and programs that you are
implementing are well-intentioned, but I think we have to face
the very unpleasant truth that what we are doing is not
working.
The data overwhelmingly demonstrate that, whether you look
at national data or data from the State of Maine. Maine's
leading drug overdose, drug death researcher, Dr. Marci Sorg
from the University of Maine recently called Maine's overdose
epidemic, ``the worst it has ever been.''
Tragically, we lost a record high 627 Mainers in 2021. And
the data from the first part of this year shows a 9 percent
increase over a comparable period of last year. The number of
total overdoses in Maine exceeded 9,500 last year.
Fentanyl was involved in 77 percent of deadly overdoses in
Maine. That is a dramatic increase. So I want to talk to you
about two issues. One is enforcement and interdiction, and the
second is prevention and education.
In 2021, the Maine Drug Enforcement Agency seized more than
10,000 grams of fentanyl. That is a 67 percent increase. But
they tell me they cannot possibly keep up. They are
overwhelmed. And that Maine's overdose crisis is primarily
driven by the increased supply of illicit fentanyl originating
in China and smuggled through Mexico into our Country.
I have been to the border with Mexico. I have seen the
cartels who are smuggling people across the border. I talked
with the Border Patrol officers out on their midnight shift,
and they have expressed such frustration that they have had to
divert their resources to handling the tremendous influx of
people crossing the border, rather than focusing on illicit
drug interdiction.
Like my colleagues, I cannot help but conclude that our
inability to secure the Southern border has an adverse impact
and contributes directly to our inability to stop the flow of
drugs into this country. I have also talked to the Coast Guard
and their efforts and how frustrated they feel.
My first question, Mr. Chester, is, do you agree that the
unprecedented surge of people illegally entering the United
States has diverted limited Government resources away from drug
interdiction?
Mr. Chester. Thank you for your question, Senator. And I
know Marcy Sorg and I have worked with her for the past several
years, and she is an incredible professional.
Senator Collins. She is.
Mr. Chester. She understands this issue better than just
about anybody, so I appreciate that. There is no doubt that
there are a number of challenges at the Southwest border of the
United States. But what I would ask that we all bear in mind is
a couple of things.
The first one is, these are very determined drug
traffickers who are going to find any means to get these drugs
into our Country, whether it is the Southwest border, whether
it is the mail, express consignment, maritime, or air
conveyances. I think that is the first thing.
I think the second thing is our focus that we have not only
in commercial disruption, but going after the illicit finance,
not only the profits that are the motivation for doing this,
but the operating capital that allows it to happen, is an
overarching way to be able to deal with this very frustrating
problem.
The last thing I would tell you, ma'am, is this is a very
dynamic problem in a very dynamic situation. And when you say
that what we are doing is not working, it would be easy to say,
well, what we have done is not working.
What we have to do is very quickly identify when we have
new vulnerabilities, when the traffickers have changed the ways
that they do business and close those gaps and vulnerabilities
as quickly as we possibly can. And that is what we are in the
process of doing right now.
Senator Collins. Thank you. I am going to submit my next
question for the record, because my time has expired. But Dr.
Delphin-Rittmon, it is for you. I just want to tell you about
Hannah Flaherty, a 14 year old girl from Portland.
A straight-A student with no history of drug abuse who died
from a suspected fentanyl poisoning last month. And my question
for you is going to be, for the record, given the time, what
more can we do to reach young people?
I am not talking just about high school. I am talking about
middle school students, to educate them about the dangers of
drug abuse so that they don't think a pill is harmless, it is
injecting yourself which is dangerous, which I think is
common--a common misperception.
I would like to follow-up and talk with you about that,
because I remember very well when I was growing up in Cariboo
in Northern Maine, that we had a recovered heroin addict come
in and talk to us and it was so powerful.
It was incredibly powerful. So I am wondering what more we
can do to educate students at a young age about the dangers.
And I know I am out of time but thank you.
The Chair. Thank you, Senator Collins. Critical question,
and I think we all would look forward to your answering that in
the response.
Senator Baldwin.
Senator Baldwin. Thank you, Madam Chair. I am listening to
my colleagues as well as the responses and there is sort of a
pattern that I have observed over time.
When we were talking in this Committee about the opioid
epidemic just several years ago, it was much more, the
conversation was much more focused on prescribers and
overprescribing and, 30 day supply after dental surgery rather
than something that would be much more appropriate to avoid
substance abuse.
Now we are talking a lot about accidental overdose and
getting--folks who have gotten fentanyl laced pills, etcetera.
Like my colleagues, I want to share the stories of several
Wisconsin families that I have gotten to know this year because
they have gone through this crisis themselves.
Cade Reddington was a graduate of Waunakee Community High
School, a student at UW Milwaukee, and a kid who was full of
life and energy and excitement. On November 4th of last year,
Cade died in his dorm room after taking what he thought was a
Percocet pill. That pill contained fentanyl.
Combating fentanyl is a critical task for this Committee
and this entire Administration, but I am concerned we are not
doing enough to warn our Nation's young people about the
dangers of counterfeit pills.
But Dr. Jones, I wanted to just draw your attention to the
work that, and I am sure you know about it, the work that the
DEA has been doing to spread the word that, ``one pill can
kill.'' This message, in my mind, has not yet been shared
widely enough. And so I wonder how the CDC is working with the
DEA to elevate this particular message and make sure that this
information is being shared with young people.
Dr. Jones. Great. Thanks so much for the question. And we
worked closely with DEA before that campaign was launched
because we have experience over the last several years multiple
campaigns that we have done at CDC around prescription opioids,
transitioning to recovery, and now the illicit fentanyl market.
We have learned lessons along the way about how to
communicate and wanted to make sure that we could assist DEA in
their messages. So we worked with them prior to the launch, and
we certainly worked across agencies here with DEA to help
disseminate those messages.
I think that campaign is an important one because it is
very catchy. One pill can kill. That makes sense. And that is
something that is not lost on people. And it does reflect the
toxicity of the illicit drug market, as many Senators here have
mentioned today, the issue of poisoning versus overdose.
I recently participated in a DEA event that brought
families together who have lost individuals through those exact
scenarios, taking counterfeit pills that they thought was Xanax
or Percocet and was actually pressed fentanyl. But I think I
will highlight two things at CDC that I think complement the
work of DEA and how we can continue to spread these messages.
The first is our Stop Overdose campaign, which I mentioned
in my opening statement, which focuses specifically on fentanyl
and the toxicity of the illicit drug market, the availability
of naloxone, possibly substance use, which is also contributing
to overdose, as well as unintentional exposure, people thinking
they are using something else and they are actually getting
fentanyl, and then decreasing stigma, which we know is a
barrier for people to seek help.
That campaign was formally tested among young adults, 18 to
34 year olds. And so that is something that is freely
available. People can take what we have done and use it and
apply it in their communities. So that is, I think, a new asset
that is available to help spread the message about the toxicity
of the drug market.
The last thing I will say is that there is a real
opportunity to focus on upstream primary prevention. We need to
get messages out about the toxicity of the drug market. But
fundamentally, as a long run strategy to addressing this issue,
we need to help instill resilience, life skills, problem
solving, conflict resolution, focus on root causes like adverse
childhood experiences that really set the trajectory for
someone to have risk for substance use.
We know that people with ACEs initiate substance use
earlier, which increases your risk of having a substance use
disorder. So there are really powerful opportunities for public
health prevention in that space.
Senator Baldwin. Thank you, Dr. Jones. And I didn't want to
cut you off because this is very responsive to my question. I
did--I will do as Senator Collins did and submit some questions
for the record.
But I did want to indicate that both Cade, who I just told
you about, and Nickolas Barrett Graves of Beloit, were--have
passed away of fentanyl poisoning. Nicholas of Beloit,
Wisconsin could have been saved by naloxone, as could have
Cade.
That is why I have been pressing manufacturers to make
their products available over the counter and working on
legislation to reauthorize the opioid overdose reversal
medication access and education grant programs.
For Dr. Delphin-Rittmon, again, for the record, I will be
inquiring what SAMHSA needs to make sure that naloxone is more
readily available to first responders and in key locations such
as school dormitories and community centers. And that will be
submitted for the record.
The Chair. Thank you.
Senator Braun.
Senator Braun. Thank you, Madam Chair. My question is going
to be for Mr. Chester. Want to cite a few things that I think
most Americans would be appalled at what is happening. Since
2021, January, 3.2 million migrants have crossed the border
illegally. We have intercepted 1.2 million pounds of illegal
drugs, over 16,000 pounds of fentanyl.
That is approximately 3.7 billion lethal doses coming into
the country to kill the population ten times over. Also, we
have got 100,000 per year overdose deaths nationally and 2,000
opioid overdose deaths every year in my State of Indiana.
I don't know that we need to dispute the facts. I think
mostly what I am interested--and look at your background. It is
impressive in that it has kind of been your job to figure out
how to disrupt the supply chain. Of course, now the main
manufacturer is China. The main distributor is Mexico.
When I was down there in March, I think of 2021, illegal
crossings were 40,000, 50,000 going up to 60,000 or 70,000. Now
they exceed 200,000. We all remember the vivid interception
recently of I don't know how many pounds of fentanyl.
Are you confident that what we are doing is aggravating the
problem, just encouraging more proportionately from what it was
pre-Biden administration? And are we making any headway?
Dr. Jones. Thank you very much. It is a very comprehensive
question and I want to hit all of it. The first thing is, I
would ask that we all bear in mind that there has absolutely
been an increase in the number of drugs seized at our Southwest
border.
Those are drugs that are not in our communities, and that
is money that will not go to drug traffickers for their
benefits. And I think that is the first thing. I think the
second thing is, and I think I have mentioned this before, what
you described very accurately is the results of a global
business enterprise that is driven by profits and is focused on
finding vulnerabilities in order to expand their customer base
and make as much money as they can with the decreased amount of
risk.
Synthetic drugs like fentanyl and synthetic opioids can be
produced at much lower overhead and sold for much more money.
And so that is the second thing. And then the third thing is
that this is not confined, the problem doesn't begin or end at
the Southwest border, but rather it is deep in a country where
those drugs are produced.
It is the conveyances that move them and their raw
materials around the world, and they are shipped through
multiple means into the United States and into our communities.
And so what we cannot do is take individual pieces of that
complex and focus our efforts on it and ignore the others.
We have to look at it in its totality. We have to determine
when there are changes in that environment and focus our
efforts against those changes for the ultimate goal, and you
use the exact right word, I think, in disrupting over time
their ability to be able to move these drugs into our Country.
Snapshots in time, I absolutely understand that they give
certain numbers in certain indicators, but I can tell you is we
are approaching this in a holistic fashion, which is what it
deserves, because that is the complex of issues that we are
dealing with under this particular drug trafficking----
Senator Braun. Let me follow-up with this, because that
sounds like a good approach in terms of how you are analyzing
it. But we had 40,000 to 60,000 illegal crossings about a year
and a quarter ago. Now it is up to over 200,000.
Can--and what they told us then was that the wall, which I
don't think ever was talked about being from sea to shining
sea, where it was, it was our most important tool along was the
stay in Mexico policy.
How do you explain why it is gone from 40,000 to 60,000
illegal crossings to what could be approaching 300,000 and how
we could be doing a better job at intercepting all the illicit
material that comes along with the illegal crossings?
Dr. Jones. Yes, Senator, thank you. And please understand,
I am going to limit my comments and my answers to the issue of
illicit drug trafficking.
But what I can tell you is, that is precisely why in the
Presidents Fiscal Year 2023 budget, we have asked for $300
million to enhance the capability of CBP to be able to deal
with illicit drug trafficking across our borders, and another
$300 million for the Drug Enforcement Administration to be able
to do its work within the United States at being able to seize
drugs as well.
As I mentioned before, these are very determined drug
traffickers that are going to find a way to get the drugs into
the country. We have the greatest professionals on the face of
the earth, but we can always do more in order to give them the
tools that they need in order to be most effective against this
problem----
Senator Braun. I think I am out of time, and I won't go for
another round of questions. But I think carefully about that
relationship between how many people are coming across and what
is underlying the fact that you are going to be intercepting a
lot more illicit materials as well. Thank you.
The Chair. Thank you.
Senator Hickenlooper.
Senator Hickenlooper. Thank you, Madam Chair. Mr. Chester,
I wanted to ask a question about pyral, because even as
fentanyl devastates our communities, more is coming and in
Colorado we are just starting to see pyral, a drug that appears
to be ten times stronger than fentanyl.
I know, Mr. Chester, you have made disrupting the supply of
illicit drugs a major focus of your career. And how do illicit
drugs like pyral, where do they come from? How does it end up
in Colorado, and what is the Administration going to try to
intercept supply routes?
Mr. Chester. Yes, thank you for the question, Senator.
I know in particular, I-75 is a major corridor for you and
the amount of concerns that are involved with the physical
movement of drugs throughout your state and really throughout
the region on that corridor. That particular drug and others
like it--and I want to be clear kind of in our characterization
here.
You have fentanyl itself and then you have fentanyl
analogs, which are alterations, additions, or substitutions to
the base fentanyl molecule, an entire class of substances. And
then you have other non-fentanyl synthetic opioids. And that is
the nitazenes family and those are others that come up.
The reason we see them is for two reasons. No. 1, one of
the best accelerants for the production of a new drug is action
taken against an existing one. These are profit seeking
enterprises that have very smart chemists who want to market
new substances, post them on the internet or on social media
for availability, and get people to be early adopters to them.
That is the first time that is the first way that you see
them. And then the second way that you see them is, it is
generally product placement. They have the available precursor
chemicals, they have a chemical formulation they can get on,
and they advertise it is having a certain qualitative effect on
the body.
All of them are illicit. All of them are dangerous. And all
of them are available on the internet and on the dark web, and
to be shipped in either physically into the United States or
across our borders through mail and express consignment. The
last thing I will tell you is, and I know the Rocky Mountain
HIDTA did very well.
We are very proud of the High Intensity Drug Trafficking
Areas Program that we administer and manage here in ONDCP. It
is organized--and we have extended the overdose response
strategy for the HIDTA program to all 50 states, the Virgin
Islands, Puerto Rico, and DC.
That brings together drug intelligence officers and public
health individuals in order to be able to better understand the
environment, identify those new and emerging threats like the
one that you just mentioned, to be able to take action on them,
and they do very good work.
Senator Hickenlooper. All right. And thank you for this,
for the HIDTA. It has been very effective and remarkably
effective. Dr. Delphin-Rittmon, fentanyl has killed 1,600
Coloradans in the last almost 3 years.
Just a few months ago, we had a high school sophomore from
Durango, Colorado, who died from an accidental fentanyl
overdose. We received $23 million, maybe a little more than
point $23 million for the substance abuse prevention treatment
block grants as part of the Rescue Plan, the American Rescue
Plan.
As this help goes out across Colorado, do you see, or let
me be--what specifically do you see as the most effective
utilizations of that funding? What are the best investments we
can use to try and go after the fentanyl overdose rates, and
how is SAMHSA working with states to provide that real time
information and data and technical assistance to get there.
Ms. Delphin-Rittmon. Yes. So often what we find is states
will use the strategic prevention framework approach to be able
to identify approaches and strategies that will work most
effectively within their context.
Many of the community coalitions will do focus groups, meet
with schools, meet with students to be able to develop
messaging that is going to resonate with students and resonate
with schools.
In some instances, the coalitions will work with schools
and students to develop some of that messaging so that it is
really coming from students. So I think that is one thing that
is helpful, developing messaging that students can take in and
that raises awareness about the dangers of fentanyl, to include
social media access of fentanyl, as well as just the dangers of
fentanyl use.
I think another strategy that can help is working with
schools to raise awareness about and being able to identify
students that may be struggling with substances or that may be
having trouble. And ultimately being able to connect those
students to services and supports.
Senator Hickenlooper. All right. Thank you. And I think
that--I think we are making progress in actually identifying
the types of kids that might, would be likely to experiment.
Often with fentanyl, it seems like so often that it is
somebody who has almost no experience in drug use. Not always,
obviously, but too often. Anyway, I am out of time. I have got
a couple other questions, but I will file them in written form.
Thank you.
The Chair. Thank you.
Senator Casey.
Senator Casey. Thank you, Chair Murray. And I want to thank
you for calling this hearing, and I want to thank our witnesses
for their testimony and for the expertise they bring to bear on
this awful, awful fentanyl crisis that has consumed the
country.
Pennsylvania is third in a category we don't want to be
third in, third in overdose deaths. Pennsylvania had 5,438
deaths in 2021 alone. That is around one death every 2 hours.
And of course, just like in so many other places, fentanyl is
the dominant, the dominant opioid. So it has consumed so many
families, so many communities.
Like Chair Murray, I am very concerned about the rise in
fentanyl related overdose deaths in adolescents who, because of
their stage of development, are more vulnerable to opioid use
disorder.
This is particularly the case when a young person has a
mental health condition like ADHD, depression, or anxiety,
which too often goes undiagnosed and untreated. So I will start
with Dr. Delphin-Rittmon. Can you speak to two things, No. 1,
the relationship between opioid use disorder and other mental
health conditions?
No. 2, how timely mental health care for young people can
help prevent opioid misuse.
Ms. Delphin-Rittmon. Yes. Thank you for that question,
Senator, and for all your work and advocacy in this area. We
know that for some youth as well as adults, use of opioids or
other substances is connected to, for some individuals, mental
health challenges.
To the extent that services and supports are, and we talk a
lot about this, that we are able to take a co-occurring
approach, that services and supports are able to address both
mental health and substance use challenges. But that is
important also in terms of identification.
We do have a program called, for short it is, the youth
family tree. And what that program is about is early
identification of youth that may be struggling, youth, as well
as transition age individuals, and other members of families.
It is a grant that takes a community based approach, a
family based approach, and really uses multi-system approach to
be able to identify, do early identification, but also early
connection to services and supports such that the addiction
doesn't progress.
I think that is one area that is an important area of work.
In fact, that grant is up for authorization so certainly
appreciate this Committee's commitment to that area of work.
There is also work in terms of being able to ensure access.
You mentioned the piece around ensuring that there is
timely access to services and supports. And so I think that is
an important part of the system of care work as well, ensuring
that whether it is a school system or whether family members,
that there is awareness around how to access and connect
students or families to services and supports.
Senator Casey. Thank you very much, doctor. And I wanted to
turn to Carole Johnson, with whom I worked on the Aging
Committee.
It is great to see you again, I guess twice in a week. But
Carole, wanted to make a reference to both the screening and
access to medications for opioid use disorder, which, of
course, are not yet meeting demand.
We know there are wide gaps in the workforce that are
caring for adolescents. I have a bill with Senator Cassidy to
support cross training of the pediatric health care workforce
to address mental health and substance use disorders.
Given the serious threat of fentanyl to young people, we
can't afford to miss any opportunity to screen adolescents for
these disorders. How do we increase opioid use disorder
competency in the pediatric health care workforce?
Ms. Johnson. Thank you so much, Senator Casey, and thank
you for your leadership on this issue. We think this is
critically important, making sure that we create sort of norms
and standards in the health care workforce.
That primary care sites, pediatrics offices, primary care
physicians, our community health centers are places where our
clinical workforce is trained to identify mental health and
substance use disorders and, where appropriate, be able to help
begin treatment. And so that is why we are committed to this
work.
We appreciate the progress that we have made with the
Pediatric Mental Health Access Program, which has helped us be
able to bring mental health expertise directly into
pediatricians' offices. But we want to continue to look for
ways to grow the capacity of the primary care workforce and
pediatricians to address substance use disorder directly.
Senator Casey. Thanks very much. Thanks, Chair Murray.
The Chair. Senator Rosen.
Senator Rosen. Thank you, Chair Murray. I really appreciate
holding this very important hearing today, and of course, the
witnesses for all of your work in this area. And so, like so
many of us, we are just so worried about our communities and
the overdose disparities, especially in Nevada in our Latino
communities.
The synthetic fentanyl crisis has gotten worse in recent
years in Nevada. It has unfortunately disproportionately
impacted our growing latino population. In fact, between 2019
and 2020, drug overdose deaths among Latinos in Nevada
increased 120 percent, and the proportion of those involving
fentanyl increased 135 percent, the highest among any
demographic group.
Compounding this problem is a lack of awareness in our
Latino community about resources, including harm reduction
strategies, as well as a shortage of substance abuse disorder
providers, particularly culturally competent Spanish speaking
providers.
Dr. Delphin-Rittmon, what kind of targeted community
outreach is SAMHSA doing to ensure Latino communities not just
in Nevada but across the country, have access to evidence based
substance use disorder resources to help curb addiction,
including those harm reduction strategies?
Ms. Delphin-Rittmon. Yes, thank you for that question,
Senator Rosen. And so this is an area that is a priority for
SAMHSA. It is certainly a priority as well within the
Secretary's overdose prevention strategy, or it is one of the
cross-cutting areas that is equity.
One of the things that we do is we fund the Hispanic and
Latino Addiction Technology Transfer Center. What that center
does is it provides a broad range of training and technical
assistance to providers across the Country.
That helps to ensure that those providers are able to
implement culturally responsive services, services that meet
the needs of Latino individuals and diverse groups. And so that
training is available across the Country.
Another area of work we have through our Office of
Behavioral Health Equity for our new grantees and actually
previous grantees as well that we have strengthened this
program. We now do disparity impact statements. And so grantees
have to identify disparity populations that may be serving
within their region or area, and then identify how that grant
will be used to address disparities among those individuals or
groups that--where disparities exist.
Then what we have increased, we have now increased, or will
be increasing, the technical assistance to grantees to ensure
that they have the resources and support that they need in
terms of addressing the needs of diverse groups.
We are excited about that program. We think that will make
a real difference in terms of working across our grant programs
to help them to be able to identify disparity populations, but
also address those disparities as well to include among Latino
individuals.
Senator Rosen. Well, that is great that you are doing that,
but we know that you need the resources and that means the
workforce.
While SAMHSA's minority fellowship program, you have made
strides in increasing provider diversity and boosting cultural
competency and behavioral health, data suggests that people of
color still only constitute a significant minority of the
substance abuse disorder workforce.
Again, Dr. Delphin-Rittmon, as the Committee seeks to
reauthorize and enhance SAMHSA programs this year, I really
want to see how we can expand and improve on these minority
fellowship programs to bring people into the workforce to
ensure we are attracting and retaining these providers,
mentoring the next gen of them, and they can better serve the
trust of Latinos, of course, all of our minority populations,
underserved populations across the Nation.
Ms. Delphin-Rittmon. Yes. Thank you for that. And that is a
program, well, for one I can say it is near and dear to my
heart. I went through the fellowship program 1992 to 1993.
One thing we are doing to expand that program is to
increase the number of individuals that can go through at the
master's level. Either they are doctoral level fellowships that
are provided.
I went through the doctoral program, but now we are
increasing that to the master's level. That will help to
increase the numbers of individuals that are able to begin
practicing and begin working in the field sooner.
We are real excited about that. And we know the programs
coming up for authorization. That is some of what we will use
those resources for. Other programs we have are around working
with HBCUs and Hispanic serving institutions as well around
attracting individuals to the behavioral health professions who
may be considering behavioral health or may be interested in
behavioral health.
That is an additional program that works to increase the
numbers of individuals from diverse populations that are
entering the behavioral health fields or individuals interested
in working with diverse populations as well.
Senator Rosen. Thank you. I think my time has expired.
Thank you, Madam Chair.
The Chair. Thank you.
Senator Kaine.
Senator Kaine. Thank you, Chair Murray. And thank you to
our witnesses for being here today and for your important
testimony. So my state is like others, I have heard each
Senator talk about the tragedy of this in their states.
There were 2,656 overdose deaths in Virginia in 2021. It
was a 15 percent increase from 2020, and fentanyl was
responsible for 77 percent of those fatal overdoses. So we are
all grappling with this, and I appreciate the testimony, and
colleagues of mine have asked many questions that I was going
to.
I wanted to ask you a question about a strategy to deal
with this issue, Dr. Delphin-Rittmon, that we have talked about
before. The last time you were here, I asked a question about
connecting incarcerated individuals to treatment services and
in particular about drug courts.
You shared information from SAMHSA's drug court program,
and those are programs most of us have in our states. Work to
divert individuals from further involvement with the justice
system into behavioral health treatment that is more likely to
lead to a successful outcome.
When I meet with sheriffs in Virginia, I always ask them
this as the opening question, what percentage of people in your
jail shouldn't be there? I don't have to describe my terms. I
don't have to define what I mean. They know what I mean.
They know that I am asking what percentage of people in
jail aren't really bad people, are not really crooks, they are
not criminals, but they are people with substance use issues
that have either been diagnosed and not treated or not
effectively treated, or in some instances never diagnosed.
I have never had a sheriff give me a number less than 40
percent. And often sheriffs give me numbers 50, 60, 65 percent.
Since 2017, Virginia has received four SAMHSA supported grants
for drug courts, one in Lynchburg, Harrisonburg, Richmond, and
Abingdon in far Southwest Virginia.
I have been to some of the drug courts to talk to them
about what they do. I have been to some graduations. In fact, I
have been to two graduations in the last couple of years. In
one, the drug court program was started by a local circuit
court judge whose child had died of a drug overdose and that
led her to spur the effort to start it.
Then the other one that I went to, one of the probation
officers who works with the drug court program came up to me
and said, and this is my second graduation this week, and I
said, I thought this county only had one program going on at
any one time. He said, we do, but my first graduation was my
son graduated from a drug court program in another county and
here is the one that where I am the probation officer and I am
here for--because I am proud of my graduates.
Talk a little bit about the effectiveness of the drug court
programs in SAMHSA. There is funding issues. Do we have enough
funding to operate them? I happen to believe the moneys we
invest in these are some of the best investments we make. But
if you, Dr. Delphin-Rittmon, talk about drug court programs.
Ms. Delphin-Rittmon. Yes. Thank you for that question, and
just for all your work in this area. I mean, what we find and
what we know is that drug court programs, they make a
difference. They make a meaningful impact in people is lives.
That it is an opportunity to reduce further penetration
into the justice system for individuals that are struggling
with substance use challenges. It is an opportunity to connect
people to evidence based services and supports, to include
medication assisted treatment, and to really change the
trajectory of an individual's life because they are able to get
that treatment that is critical.
As you know, we also do enriched programing. And so the
enriched programing is for individuals that are connected, are
further along, and maybe before release, whether it is from
jail or prison, we work to connect them to services and
supports to include buprenorphine if necessary.
In fact, right after this hearing I will be flying to the
national annual meeting of drug court professionals and will be
doing a series of meetings with different court groups related
to their work. This is vital lifesaving work, and this program
is coming up for reauthorization as well. So, I certainly
appreciate the Committee's commitment and interest in this
area.
Senator Kaine. Please pass on, as you go out and talk to
drug court professionals, the respect that we have for the work
that they do. Here is a question dealing with fentanyl coming
into the United States from abroad.
What can you tell us, particularly those with the National
Drug Control Office, what can you tell us if there is a pie
chart, some come by mail, some people smuggle over the border,
some maybe come around the borders, but I understand that huge
percentages of the fentanyl that come in the United States come
in across our ports of entry in vehicles.
Because we only inspect one out of every however many
vehicles, cartels figure they can play the odds and they can
actually just smuggle it right across the border through ports
of entry. Can you share what the data is about that?
Mr. Chester. Yes, Senator. And it is an understandable
question, but I am afraid it is an unknowable question, because
the only thing that we can calculate is what we see and what we
find, right. But your characterization of vehicles is correct,
but I think for a different reason. Our Customs and Border
Protection do have the ability to be able to do non-intrusive
detection that is very impressive.
I was down last fall in El Paso, and the non-intrusive
detection capability that they have is very good. But more
importantly are those ports are manned with incredibly
experienced agents who can pull a vehicle into secondary just
based upon, I have seen this before, just based upon intuition.
They also have heuristic models and algorithms that can
determine the right time to pull folks into secondary. So there
are a lot of reasons why someone get pulled in the secondary.
But your characterization of drug traffickers is absolutely
correct, because a drug trafficker can send ten vehicles across
knowing that two may get pulled aside, but that is just built
into the business model and the amount of profit and knowing
that the remainder are going to be able to get through.
That is the challenge that we have. And even if we were
able to reduce that number to C7 and only three get through,
drug traffickers in pursuit of profits are going to find other
ways in order to be able to circumvent that and get the drugs
into the Country.
What we do by looking at it really in a more holistic
fashion is to determine when we see changes in the environment
and how quickly we can surge in order to address that change as
well. And that is why we would describe it as a dynamic
environment. That is what we mean by that.
Senator Kaine. Well, I am over time. But Madam Chair, to
me, what that suggests is if any of our efforts on the
enforcement side just lead creative people who want to make
profits to figure out another way to do it, then ultimately you
have got to tackle this on the demand side. And so that is
prevention, and that is the kind of things you have been
testifying to. And if we don't talk about--[technical
problems]----
The Chair. Thank you. That will conclude our hearing today.
And I want to thank all of my colleagues, and especially I want
to thank our witnesses today, Mr. Kemp, Dr. Delphin-Rittmon,
Ms. Johnson, and Dr. Jones.
Thank you for a very thoughtful conversation on such an
urgent crisis for all of our communities. If there is one thing
we take away from today's conversation, I hope it is that our
communities can't wait.
They need urgent action from the Administration and from us
in Congress to disrupt the supply of dangerous illicit
fentanyl, to support those on the front lines of this crisis in
our communities, and especially to connect people with the
prevention, the treatment, and recovery support services that
we know saves lives.
That is why it is really important to me, as--more
important to me as ever that we can advance a bipartisan
package that makes meaningful progress on these issues.
I hope that all of my Republican colleagues agree and that
we can continue our process negotiating a very robust mental
health and substance use disorder bill that will support the
programs we have seen make such a difference and provide
additional tools and resources to tackle the new threats and
emerging challenges in this space.
For any Senators who wish to ask additional questions,
questions for the record will be due in ten business days,
August 9th at 5.00 p.m. And the Committee stands adjourned.
ADDITIONAL MATERIAL
prepared statement of ranking member richard burr
The rise in overdose deaths is being driven by illicit fentanyl and
has affected every corner of our communities. My home State of North
Carolina has not been spared, and too many individuals and families in
my state have dealt with tragedy as a result of fentanyl. In order to
address the fentanyl problem in the United States, we need strong
leadership and an effective, multi-sectoral strategy that addresses
both the source of the drugs and also the substance use disorder
prevention and treatment needs of the response.
I had hoped to have Customs and Border Protection here to discuss
with the Committee what they are seeing, particularly at the border,
with respect to drug trafficking. Just last week, two men in Washington
State were charged with smuggling 91,000 fentanyl pills inside potato
chip containers in connection with a transnational criminal
organization. Or the Drug Enforcement Administration, which just
earlier this month, announced the seizure of 100,000 fake oxycodone
pills containing fentanyl and could provide us with a clear picture of
the criminal networks that are mass-producing illicit fentanyl and fake
pills in clandestine laboratories. But Chair Murray did not want to
invite those agencies to this hearing, despite requests, so that we
might gain a better understanding of the complexity behind the illicit
fentanyl and fentanyl analogues problem in the United States and their
sources.
Every day, illicit drugs are entering the country from China,
Mexico, and India. The recent news from Washington State is just one
example of this problem. And it's driving overdose deaths. According to
DEA, the agency's lab testing demonstrated that 4 out of every 10 pills
with fentanyl contain a potentially lethal dose. Permanently scheduling
fentanyl analogues, which drug traffickers use to skirt trafficking
laws, as Schedule I under the Controlled Substances Act would play a
significant role in reducing the supply of illicit fentanyl smuggled
into the United States. I urge my colleagues to consider the HALT
Fentanyl Act, a bill that Senator Cassidy and I worked on together that
would permanently schedule fentanyl analogues as Schedule I under the
Controlled Substances Act.
We also need to continue to support and improve public health
programs charged with responding to the substance use disorder
prevention, treatment and recovery needs of communities that were hit
hard by the opioid crisis and now are grappling with high overdose
rates driven by illicit fentanyl. With the passage of the Comprehensive
Addiction and Recovery Act of 2016, the 21st Century Cures Act, and the
SUPPORT for Patients and Communities Act, Congress has demonstrated its
commitment to supporting substance use disorder needs. We need to make
sure our programs are effectively utilizing data, leveraging innovative
medical products for treatment and overdose reversal, and partnering
with different sectors to promote effective solutions on the ground. I
am thankful for Senator Bill Cassidy's expertise and willingness to
serve as Ranking Member for the Senate HELP Committee hearing today,
and look forward to continuing to work on this issue.
______
QUESTIONS AND ANSWERS
Response by Kemp Chester to Questions of Senator Baldwin, Senator
Rosen, Senator Burr, Senator Collins, Senator Murkowski, and Senator
Scott
senator baldwin
Question 1. Steven Welnetz's mother recently shared his story with
me. She described him as a person with a heart of gold. On November 6,
2021, he took what he thought was a Xanax. It had been pressed with
fentanyl, and he died shortly thereafter.
Fentanyl is being brought in to the United States in large
quantities, including through International Mail Facilities.
How is ONDCP working with other agencies to combat the importation
of fentanyl, including fentanyl that is entering the country through
the mail?
Answer 1. Illegal substances enter the United States through a
variety of means. They can be marketed and sold on the dark web using
cryptocurrency and delivered to the purchaser through the mail and
commercial carriers, or can be brought across the Nation's geographic
borders by multiple conveyances; from body carries, to containers on
cargo ships, through commercial and private vehicles, or purpose-built
watercraft. The Biden-Harris administration is committed to exploring
and using every means available to reduce the supply of illicit
substances in America's communities. This includes ensuring our law
enforcement agencies have the resources they need to disrupt the sale
of these drugs on the internet and the flow of drugs across our borders
and working with our international partners to halt drug production
outside the United States. Those international efforts include
controlling the chemicals used to produce both plant-based and
synthetic drugs, and ensuring those involved in any aspect of the
global drug trade, including their illicit proceeds, are held
accountable.
There are a number of robust and ongoing interagency efforts
investigating drug sales on the internet and shipped through the mail
system. As you can imagine, we do not make a lot of that information
public so that drug traffickers cannot adapt their tactics based upon
knowledge the extent of our activities. Discussing law enforcement
activities in detail could compromise ongoing investigations, but
successful initiatives are underway, such as the FBI Joint Criminal
Opioid and Darknet Enforcement (JCODE) program which pursues
traffickers who exploit the dark web to market and sell opioids, as
well as other drugs.
We also know that transnational criminal organizations (TCOs) are
poly-crime, and that their illicit revenues come from a variety of
criminal activities in addition to illicit drugs. Organizations like
Homeland Security Investigations' (HSI) Cyber Crimes Center (C3) is
dedicated to the criminal investigation of transborder internet-related
crimes, including the sale and distribution of illicit drugs, as well
as other criminal activities such as money laundering, illegal arms
trafficking, child exploitation, and human trafficking.
The United States Postal Inspection Service is at the forefront of
both domestic and international efforts to stem the flow of illicit
drugs through the mail. For example, The United States and Canada
agreed to a bilateral Joint Action Plan on Opioids to strengthen cross-
border cooperation and develop effective approaches to addressing the
opioid crisis. Within this bilateral agreement, The U.S.-Canada Postal
Security Action Plan was created, which directly supports the bilateral
priorities between the two Governments to address the ongoing opioid
crisis and the emergence of dangerous synthetic drugs in the supply
chain within the mail system.
Over the last 3 years, the Postal Inspection Service has witnessed
a dramatic decrease in international seizures of opioids, especially
from China, while domestic seizures are increasing. Since 2019, the
Inspection Service has not had a direct seizure of fentanyl from China.
Ninety-nine percent of Postal Inspection Service seizures in fiscal
year 2021 and fiscal year 2022 were from domestic mail, most originated
from southwest border states. Overall, the Postal Inspection Service
has greatly increased seizures of illicit synthetic opioids from the
mailstream in terms of both the number of seizures and weight. In the
past few years, the Postal Inspection Service has seen an increase in
the weight of synthetic opioids per seizure. Nonetheless, China remains
one of the top global suppliers of precursor chemicals for fentanyl
production and continues to supply Mexico with these essential
ingredients to the drug trade.
The United States will pursue TCOs through all appropriate means,
whether those are investigations into illicit drug trafficking, or any
of their numerous other criminal activities.
If you would like a more in-depth discussion on engagements by
individual departments and agencies, I refer you to my colleagues in
the Departments of Justice and Homeland Security, and the U.S. Postal
Inspection Service.
senator rosen
Question 1. SUPPORTING LAW ENFORCEMENT EFFORTS TO COMBAT FENTANYL
IN NORTHERN NEVADA: While synthetic fentanyl took hold quickly in other
parts of the country, it had been slower to reach Northern Nevada,
which includes many rural communities. However, according to the Washoe
County Sheriff's Office, as the amount of fentanyl in Northern Nevada
has spiked in the last year and a half, fentanyl is now the second-
deadliest drug in Washoe County, behind only methamphetamine. Synthetic
fentanyl is increasingly being pressed into pills to look like
prescription drugs. As so many of my colleagues have pointed out, this
is a public health crisis, and we must do more do support both law
enforcement and the public alike to combat it.
Mr. Chester, is ONDCP witnessing similar trends among other
smaller, rural counties across the country, and what more can Congress
and the Administration do to help support our local law enforcement
agencies like the Washoe County Sheriff's Office in further disrupting
fentanyl trafficking and production?
Answer 1. ONDCP works to coordinate the efforts of Federal, state,
Tribal, and local law enforcement to reduce the supply of fentanyl and
other dangerous drugs through multijurisdictional task forces, such as
those funded through ONDCP's High Intensity Drug Trafficking Areas
(HIDTA) Program. HIDTA currently augments efforts in Washoe County
through the Nevada HIDTA. In addition, Congress should pass the Biden-
Harris administration's approach to reduce the supply and availability
of illicitly manufactured fentanyl-related substances (FRS) by
permanently scheduling FRS, while safeguarding against racial
disparities in prosecution and sentencing and reducing barriers to
scientific research for all Schedule I substances.
senator burr
Question 1. In years' past, and as recently as 2020, the National
Drug Control Strategy (NDCS) has highlighted the beneficial role that
Prescription Drug Monitoring Programs (PDMPs) play in combating
prescription drug abuse and saving lives, going as far as to call for
an increase in the utilization of PDMPs and their integration into
Electronic Health Records (EHRs) to increase utilization. However, in
the recently released 2022 NDCS, there is no mention of PDMPs the role
they can play in helping to prevent the use and abuse of medications
and the fact that 47 PDMPs have successfully integrated their PDMP into
EHRs and Pharmacy Dispensation Systems. Why did the ONDCP decide to no
longer highlight the positive role that PDMPs are playing in reducing
access to, and abuse of, controlled prescription medications?
Answer 1. ONDCP's response to overprescribing and the diversion of
prescription opioids through prescribing guidelines, PDMPs, and
provider training has been successful but more can be done to save
lives. Overprescribing and ``pill mills'' still cause harm but the
nature of the overdose crisis shifted from prescription opioid
overprescribing to illicitly manufactured fentanyl, and our strategies
for responding have shifted to address this new reality. The National
Drug Control Strategy is a forward-looking document that identifies key
drug policy priorities for the Federal Government and lays out a plan
for addressing the most urgent work ahead. It is imperative that we
focus our supply and demand reduction efforts on the key driver of
overdose deaths today: illicitly manufactured fentanyl.
Question 2. As the ONDCP has stated in previous years' National
Drug Control Strategy that a barrier to the increased utilization of
Prescription Drug Monitoring Programs (PDMPs) is due to a lack of
integration into providers' Electronic Health Records (EHRs) and a lack
of interstate data sharing capabilities. Technology underlying the
PDMPs has made great strides in recent years to alleviate these issues,
improving integration into EHRs, providing prescribers with complete
and interstate data and improving the usability and ease to increase
uptake and utilization of the PDMP services in all geographies.
However, there are still impediments to fully realizing the PDMPs
capabilities due to certain Federal entities discouraging states from
using their preferred vendor and significantly obstructing progress in
the market. Will you commit to ensuring that the ONDCP works with PDMP
service providers and other Federal agencies to ensure that the PDMP
market is fair and capable of offering the best services available for
both patients and providers? Will you commit to ONDCP ensuring that
Federal agencies do not impose any unnecessary conditions that could
jeopardize the success of these programs by adversely impacting
patients, providers, states, and/or the public health?
Answer 2. ONDCP recognizes that PDMPs are a helpful tool for
monitoring care. ONDCP is supportive of Centers for Disease Control's
and Prevention and the Bureau of Justice Assistance's work related to
developing PDMP infrastructure within States and fostering
bidirectional capacity for data-sharing within and across States that
enhances and maximizes bidirectional connectivity. ONDCP is embracing a
combined public health and public safety approach to reduce demand and
supply which will complement provider use of the PDMPs.
senator collins
Question 1. Actionable Overdose Data (Mr. Chester and Dr. Jones).
Mr. Chester, I appreciate that the National Drug Control Strategy
prioritizes the need for more actionable data to track nonfatal
overdoses, which you recognize in your testimony as ``one of the most
accurate predictors of whether someone will experience a fatal overdose
in the future.'' I was also encouraged to hear Director Gupta recently
met with officials in Maine to see firsthand how Maine collects
detailed overdose data. This data is critical for law enforcement and
health care providers to appropriately gauge the scope of the crisis in
their local communities and target resources where they are needed. I
understand the Administration has recently created a Drug Data
Interagency Working Group that will assist with the development of a
new national plan for obtaining data in near real-time. However, this
is expected to take 1 year to develop fully.
Mr. Chester, can you provide an update on the status of this
overdue data effort, including how the 1-year timeline was determined?
Answer 1. The SUPPORT Act of 2018 mandated that ONDCP develop a
``systematic plan for increasing data collection to enable real time
surveillance of drug control threats, developing analysis and
monitoring capabilities, and identifying and addressing policy
questions related to the National Drug Control Strategy and Program.''
In order to develop a comprehensive Data Plan that meets these
statutory requirements, it was critical for ONDCP to obtain and
incorporate input from Federal agencies engaged in drug-related
activities, since much of the data collection and analytical activities
occur within these entities. In order to facilitate discussion and
obtain feedback from each of the National Drug Control Program
Agencies, ONDCP reconstituted the Drug Data Interagency Working Group
in December 2021. The working group has convened four times in total
with approximately 60 participants from 25 different Federal agencies.
Through these communications, the working group identified data needs,
discussed methods, analytical approaches, and challenges to developing
evidence to support policymaking, and identified steps to be taken to
implement the plan.
The 2022 National Drug Control Strategy (pages 123-125) summarized
the background and process for developing the Data Plan, and proposed
an approximately 1-year timeline to develop a more comprehensive plan.
Question 2. Mr. Chester and Dr. Jones, how is ONDCP utilizing
partners like the CDC who have expertise in data collection and
partnerships across state and local public health agencies?
Answer 2. ONDCP routinely meets and collaborates with organizations
who have expertise in data collection and analysis. We have convened
the Drug Data Interagency Working Group four times since December 2021
to discuss data-related topics with the National Drug Control Program
Agencies. We also meet periodically with CDC and other agencies on a
regular basis to coordinate and discuss when new data has become
available (such as the CDC's monthly releases of provisional estimates
on drug overdose deaths), and to review and provide feedback on new
data products and deliverables (such as the CDC's State Unintentional
Drug Overdose Reporting System (SUDORS) and Drug Overdose Surveillance
and Epidemiology (DOSE) Dashboards). ONDCP also hosts a monthly webinar
which allows state and local governments to showcase their opioid and
synthetic drug data. We also engage in stakeholder meetings with non-
profit organizations, private sector companies, and academic
institutions to learn about innovative data sources and analytic
approaches (such as wastewater-based epidemiology).
senator murkowski
Question 1. I am concerned about the transportation of illicit
fentanyl and other substances through the southern border and ports of
entry. Throughout the U.S., many of the hardest-hit and most at-risk
communities of the fentanyl and opioid crisis are often remote and
rural areas. In Alaska, for example, many towns and villages are
unconnected to major roadways and have limited access to land, air, and
sea travel, and yet, continue to suffer from the inflow of fentanyl and
fentanyl analogs into their communities.
How is illicit fentanyl making inroads into the U.S. and Alaska's
most rural communities, and what measures are being taken to address
the trafficking that occurs within our own borders?
Answer 1. The Biden-Harris administration is exploring and using
every means available to reduce the supply of illicit substances in
America's communities. This includes working with our international
partners to halt drug production outside the United States, which
includes monitoring and controlling the chemicals used to produce both
plant-based and synthetic drugs; facilitating international law
enforcement cooperation, ensuring our law enforcement agencies have the
resources they need to disrupt the sale of these drugs on the internet
and the flow of drugs across our borders; and ensuring those involved
in any aspect of the global drug trade, including those that benefit
from their illicit proceeds, are held accountable.
The National Drug Control Strategy addresses both domestic and
international priorities to reduce the supply of illicit substances
coming into the United States. Domestically, we prioritize improving
information sharing and cooperation; disrupting domestic production,
trafficking, and distribution; improving efficiency and effectiveness
of resource allocation, and protecting individuals and the environment
from criminal exploitation.
A key domestic partnership between Federal, state, local and Tribal
law enforcement which is key to our supply reduction efforts in
communities across the United States is the High Intensity Drug
Trafficking Area (HIDTA) Program. HIDTA task forces work to disrupt and
dismantle drug trafficking organization (DTO) networks that traffic
Mexican sourced fentanyl into and throughout the United States. The
HIDTA Program's continued efforts to address fentanyl trafficking
played a significant role in the response to this threat. In 2021, in
Alaska, in particular, the Alaska HIDTA has disrupted drug trafficking
organizations operating in the region, and seized thousands of dosage
units of fentanyl throughout the state.
Question 2. According to preliminary data from the CDC, the U.S.
experienced a 15 percent increase in overdose deaths from 2020 to 2021.
Meanwhile, in Alaska, that increase was a staggering 75 percent,
roughly five times the national average. Due to historical trauma other
inequities, our Alaska Native population have experience high rates of
substance use and alcoholism. I am concerned about the impact of the
fentanyl epidemic on our rural Alaska Native communities, who are
already experiencing significant increases in overdose deaths. How will
you ensure the Federal efforts to address the rise of fentanyl overdose
deaths will address the needs of those in rural areas, specifically
American Indians and Alaska Natives?
Answer 2. ONDCP continues to work closely with the Health Resources
and Services Administration to ensure the fentanyl overdose prevention
and opioid use disorder treatment needs of rural areas are being met.
This includes expanding access to medication for opioid use disorder,
naloxone to reverse overdoses, and fentanyl test strips where
applicable under the law. In addition, ONDCP supports the Alaska HIDTAs
in their efforts to reduce the supply of illicit fentanyl in the state.
Question 3. In Alaska and around the country, drug addiction and
substance use disorders are ending the lives of far too many youths.
This past June, I, along with my colleagues Senator Feinstein, Senator
Sullivan, and Senator Hassan, introduced S. 4358, Bruce's Law. This
bill authorizes funding for the Department of Health and Human Services
(HHS) to conduct a public awareness campaign targeted toward school-
aged children and youth on the dangers of fentanyl, establish an
interagency working group on fentanyl contamination, and authorizes an
expansion of grants for community coalitions to engage school-aged
children and youth in outreach and prevention efforts.
What type of outreach and prevention efforts are the CDC and SAMHSA
currently supporting to educate youth and school-aged children on the
dangers of counterfeit drugs laced with fentanyl? What inter-agency
coordination takes place between the CDC, SAMHSA, and ONDCP on these
efforts?
Answer 3. ONDCP, CDC, and SAMHSA regularly amplify prevention
efforts, new resources and training opportunities among the youth
substance use prevention field. The most recent example of
collaboration amongst ONDCP, CDC, and SAMHSA Center for Substance Abuse
Prevention is the sharing of a monthly resource document to ensure
Federal staff supporting prevention efforts are aware of the resources
available amongst the three agencies. The sharing of this monthly
resource will ensure the Federal Government continues to be well
equipped to support the evolving needs of communities.
In addition, the Drug-Free Communities (DFC) Support Program is the
Nation's leading effort to mobilize communities to prevent and reduce
substance use among youth. Created in 1997 by the Drug-Free Communities
Act, administered by the White House Office of National Drug Control
Policy (ONDCP), and managed through a partnership between ONDCP and
CDC, the DFC program provides grants to community coalitions to
strengthen the infrastructure among local partners to create and
sustain a reduction in local youth substance use.
The Drug Enforcement Administration (DEA) also issued its first
national public safety alert in 6 years and launched the ``One Pill Can
Kill'' public awareness campaign to raise awareness of the dangers of
fake prescription pills laced with fentanyl.
Question 4. How does ONDCP believe that Bruce's Law, if enacted,
would enhance their prevention efforts?
Answer 4. While the Administration has not yet taken a position on
the legislation, ONDCP supports evidence-based prevention and reduction
of youth substance use and evidence-based overdose prevention.
senator scott
Question 1. The Drug Enforcement Agency has referred to Mexican
drug cartels as the ``greatest drug trafficking threat to the United
States.'' According to the U.S. Customs and Border Patrol Agency,
fentanyl seizures at our ports of entry increased 1,066 percent in
2021. This came at a time when the Biden administration was moving to
end the previous Administration's ``zero tolerance'' border policy.
Mr. Chester--In your testimony, you describe routine engagements
between the U.S. and China regarding shipments of precursor chemicals
and illicit financing schemes with ties to Chinese criminal
organizations.
How confident is the Biden administration in its Chinese Communist
Party counterparts to cutoff the flow and finance of illicit Chinese
fentanyl into North America, given the lack of cooperation on
investigations into the origins of COVID-19 and recent provocations by
the Chinese Communist Party in the Taiwanese region?
Answer 1. The Chinese government must do more to hold accountable
the individuals and entities within its borders who supply synthetic
opioids and drug precursors to drug trafficking organizations. Dr.
Gupta made this point recently in a Wall Street Journal opinion piece
urging The People's Republic of China (PRC) to join the United States'
efforts to stop the flow of illicit precursor chemicals and substances.
He wrote that ``Unless other countries, including the PRC, join the
U.S. and act, drugs such as fentanyl and methamphetamine synthesized
with precursors made in the PRC will continue to flood the world.''
Question 2. What specific actions has the Biden administration
taken to not just address the deficit of trust but to also hold the
Chinese Communist Party accountable in the international fight against
illicit fentanyl flows and financing?
Answer 2. There are practical and common-sense steps nations can
take to disrupt the global trafficking of synthetic opioids and their
precursors. They include implementing ``know your customer'' standards
to prevent the diversion of chemicals to illicit drug manufacturing;
proper labeling of chemical shipments from host countries through
enforcement of World Customs Organization standards; and monitoring for
the diversion of uncontrolled chemicals and equipment in international
flows.
Dr. Gupta recently expressed the need for the Chinese government to
reengage in the international arena. Without the Chinese government's
engagement, shipments of precursor chemicals to illicit drug producers
in Mexico will continue, and traffickers will keep moving these drugs
into America. The Chinese government's decision to suspend full
cooperation on this issue will result in more American deaths and more
deaths worldwide. The U.S. will continue to work domestically and with
its partners around the world to disrupt criminal organizations, get
people the care they need and save lives. The Biden administration is
turning partnerships it has renewed and strengthened, such as the
Bicentennial Framework with Mexico and the Opioid Action Plan with
Canada, into action. The Biden administration will continue to make
action against the synthetic-drug supply chain a priority in order to
save lives.
Question 3. Mr. Chester--Are the relaxed border policies of the
Biden administration coupled with rouge district attorneys and
prosecutors who fail to prosecute criminals contributing to, in whole
or part, America's opioid crisis?
Answer 3. There are record amounts of illicitly manufactured
fentanyl being seized at our borders thanks to the brave men and women
on the front lines. Dr. Gupta has been to the border and seen first-
hand the great work being done there.
For example, in fiscal year 2022 through July, CBP seized 231,186
pounds of drugs along the southwest border, 68 percent of which were
seized at southwest border Ports of Entry (POE). When you look at
fentanyl and methamphetamine, the percentage of drugs seized at POEs is
even higher. POE seizures account for 85 percent of the weight of
fentanyl and 88 percent of the weight of methamphetamine seized along
the southwest border.
The good news is that those drugs won't make their ways into our
communities. But we must also ensure that the men and women on the
front lines have the resources they need to ramp up their efforts to
address the immense influx of supply they face at our borders. That's
why the President called for more than an $18 billion investment to
reduce the supply of illicit substances in the United States in his
fiscal year 23 budget. This includes $747.5 million in increases for
efforts to reduce the availability of drugs, including efforts to
interdict illicit drugs at ports of entry and disrupt drug trafficking
networks, support domestic law enforcement efforts to reduce drug-
related violence and property crime, and availability of illicit
substances and work with international partners to reduce drug
production.
However, the challenge of drugs like illicit fentanyl making its
way into our communities does not begin or end at the border, so we
must also counter the criminal networks who produce and traffic them;
disrupt every aspect of their commercial enterprise; target drug
transportation routes and modalities; and aggressively reduce the
production of illicit drugs in the countries where they are created.
Effectively bolstering border security and reducing drug trafficking
require effort and coordination both domestically and abroad.
Domestically, our nationwide drug interdiction efforts are focused
on the most prolific drug trafficking routes and modalities, and we
seek to fully leverage drug interdictions to help illuminate and
dismantle the criminal organizations responsible for manufacturing and
trafficking illicit drugs. Information sharing between agencies is
vitally important to this end.
One of the things ONDCP does is provide funds directly to our state
and local partners through the national HIDTA program to disrupt drug
trafficking organizations. For fiscal year 2023, ONDCP requested $293.5
million for the national HIDTA program.
Abroad, we work with our key partners in the Western Hemisphere,
like Mexico, to shape collective and comprehensive responses to illicit
drug production and trafficking. We also engage with nations like the
PRC and India to disrupt the global flow of synthetic drugs and the
precursor chemicals used to produce them to nations, like Mexico, where
illicit synthetic drugs are produced in large quantities.
______
Response by Dr. Miriam E. Delphin-Rittmon to Questions of Senator
Baldwin, Senator Lujan, Senator Burr, Senator Cassidy, Senator Collins,
Senator Murkowski and Senator Scott
senator baldwin
Question 1. Nikolas Barrett Graves of Beloit, Wisconsin had plans
to go to culinary school. He was active and outgoing. On December 22,
2018, he died after trying heroin that contained fentanyl. Cade
Reddington was a graduate of Waunekee Community High School, a student
at UW-Milwaukee, and a kid who was full of life, energy and excitement.
On November 4th, 2021, Cade died in his dorm room after taking what he
thought was a Percocet pill. That pill contained fentanyl.
Nikolas and Cade could have been saved by naloxone.
What does SAMHSA need to make sure that naloxone is more readily
available to first-responders and in key locations, such as schools and
community centers?
Answer 1. The promotion and distribution of naloxone and fentanyl
test strips represent an opportunity to not only promote life-saving
interventions, but to also provide education on drug potency and
mortality. However, some grantees are faced with challenges in the
distribution of fentanyl test strips due to state laws that classify
fentanyl test strips as illegal paraphernalia.
SAMHSA has focused on promoting education about synthetic opioids
through its grantees and education networks such as the Addiction
Technology Transfer Centers. We have also produced evidence-based
guides on addressing polysubstance misuse in order to overcome the
growing incidence of concurrent substance use disorders.
Through SAMHSA's State Opioid Response (SOR) program, grantees are
required to implement prevention and education services including:
training of peers, first responders, and other key community sectors on
recognition of opioid overdose and appropriate use of the opioid
overdose antidote naloxone; developing evidence-based community
prevention efforts such as strategic messaging on the consequences of
opioid and stimulant misuse; implementing school-based prevention
programs and outreach; and distributing the opioid overdose antidote
reversal naloxone. Naloxone is an important tool in preventing overdose
deaths and many studies have demonstrated the value of naloxone
distribution \1\ and that increased saturation in communities reduces
overdose deaths. \2\ Therefore, SAMHSA has required that all SOR
grantees submit a naloxone distribution and saturation plan
particularly focused on areas with high rates of overdose mortality.
With SAMHSA funds, states have the flexibility to purchase and
distribute naloxone in areas they deem most appropriate based on the
needs of the state. SAMHSA will continue working with states on the
implementation of these plans.
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\1\ Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M,
Sorensen-Alawad A, Ruiz S, Ozonoff A. Opioid overdose rates and
implementation of overdose education and nasal naloxone distribution in
Massachusetts: interrupted time series analysis. BMJ. 2013 Jan 30; 346:
f174.
\2\ Irvine MA, Oller D, Boggis J, Bishop B, Coombs D, Wheeler E,
Doe-Simkins M, Walley AY, Marshall BDL, Bratberg J, Green TC.
Estimating naloxone need in the USA across fentanyl, heroin, and
prescription opioid epidemics: a modelling study. Lancet Public Health.
2022 Feb 10: S2468-2667(21)00304-2. doi: 10.1016/S2468-2667(21)00304-2.
Epub ahead of print. PMID: 35151372.
The SOR grant program has supported local educational campaigns on
naloxone for younger Americans. For example, through an agreement with
Morgan State University (MSU), MSU created three digital ads on stigma,
the dangers of fentanyl, and how to use naloxone. These ads were
displayed on digital advertising boards at three local shopping malls
over a 90-day period. MSU also created augmented reality spots for the
social media platform, TikTok, using the Maryland Helpline: Call 211,
press one campaign. These were all geared for the younger demographic
as a way to provide lifesaving information through an interactive app
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on their cell phones.
SAMHSA's Substance Abuse Prevention and Treatment Block Grant
(SABG) program is another resource for states to use to combat the
overdose crisis. Through the SABG, states are able to promote education
about naloxone through a wide variety of school, community, and faith-
based organizations. States also have the option to use block grant
funds for the purchase and distribution of naloxone. A particularly
critical area of focus is through substance use prevention, harm
reduction, and treatment programs. These actions through the SABG can
assure more ready access to and rapid use of naloxone by members of the
broader community, including prevention, harm reduction, and treatment
professionals and affiliates, community centers, educational
institutions, the medical community, clients and potential clients,
family members, and persons in the larger recovery community.
SAMHSA's First Responders--Comprehensive Addition and Recovery
Support Services Act (FR-CARA) grant program provides resources to
first responders (such as firefighters, law enforcement officers,
paramedics, emergency medical technicians, mobile crisis providers,
Tribes or Tribal organizations that respond to adverse opioid related
incidents) to train, carry and administer naloxone and other drugs and
devices for emergency reversal of known or suspected opioid overdose.
The FR-CARA grant program specifically targets populations which are
especially vulnerable to overdose, including communities with an
incidence of individuals with opioid use disorder that is above the
national average and communities with a shortage of prevention and
treatment services.
senator lujan
Question 1. According to the CDC, only about 1 in every 10 American
Indian, Alaska Native, and Hispanic people with substance use disorder
reported receiving treatment. \3\ In fact, more than 70 percent of the
over 2 million Americans struggling with opioid addiction are not
getting treatment. \4\ Will improving access to medication assisted
treatment for opioid use disorder save lives?
---------------------------------------------------------------------------
\3\ https://www.cdc.gov/media/releases/2022/s0719-overdose-rates-
vs.html.
\4\ Center for Behavioral Health Statistics and Quality, 2017
National Survey on Drug Use And Health: Detailed Tables, Rockville,
Md,: Substance Abuse and Mental Health Services Administration, 2018.
Question 2. Despite an expansion in access to medication assisted
treatment for opioid use disorder in some areas, rates of overdose
remain high for American Indian and Alaska Native communities. \5\ How
important is the availability of culturally competent treatment for
historically marginalized communities?
---------------------------------------------------------------------------
\5\ Higher availability of treatment services does not mean
improved access to care. Opioid overdose rates in 2020 were higher in
areas with higher availability of opioid treatment programs compared
with areas with lower treatment availability, particularly among Black
(34 vs. 17) and AI/AN (33 vs. 16) people per 100,000. The known
differences in access, barriers to care, and healthcare mistrust could
play a role in exacerbating inequities even when treatment is available
in the community.
Question 3. Does increasing access and reducing barriers to proven
---------------------------------------------------------------------------
recovery support services reduce future overdose deaths?
Question 4. What are the primary barriers for those seeking
recovery services?
Question 5.Harm reduction tools are critical to saving lives. New
Mexico recently passed legislation to decriminalize the possession of
fentanyl test strips. How have harm reduction measures, like fentanyl
test strips, impacted people's behavior?
Answers 1-5. Evidence-based treatments for substance use disorder
reduce substance use, related health harms, overdose deaths, and
increase odds for long-term recovery. Medications for opioid use
disorder (MOUD) in particular have been shown to significantly reduce
the risk of opioid-related overdose. \6\ However, these medications
continue to be underutilized, in part due to the stigmatization
associated to them compounded by other barriers to treatment access.
---------------------------------------------------------------------------
\6\ Krawczyk, N., Mojtabai, R., Stuart, E. A., Fingerhood, M.,
Agus, D., Lyons, B. C., Weiner, J. P., and Saloner, B. (2020) Opioid
agonist treatment and fatal overdose risk in a state-wide US population
receiving opioid use disorder services. Addiction, 115: 1683-1694.
https://doi.org/10.1111/add.14991.
Addressing this stigmatization and expanding access to MOUD is a
significant focus for SAMHSA. Part of this work is ensuring that MOUD
and other substance use disorder services and policies are culturally
responsive, evidence-based and in the best interest of those receiving
services. For instance, SAMHSA's Tribal Opioid Response program is
specifically focused on providing Tribal Nations resources to address
opioid use disorder and stimulant use disorder in their communities.
Another of SAMHSA's grant programs, the Tribal Behavioral Health grant
program, also known as Native Connections, is intended to prevent
suicide and substance misuse, reduce the impact of trauma, and promote
mental health among American Indian/Alaska Native (AI/AN) youth. This
program fosters culturally responsive models that reduce and respond to
the impact of trauma and involve AI/AN community members (including
---------------------------------------------------------------------------
youth, tribal leaders, and spiritual advisors) in all grant activities.
SAMHSA also has a long history of advancing recovery supports.
SAMHSA defines recovery as a process of change through which
individuals improve their health and wellness, live self-directed
lives, and strive to reach their full potential. Recovery support
services make up a crucial component of the continuum of care for
people with substance use disorders given the long-term nature of these
conditions. With the non-clinical nature of these services, other
funding sources often do not cover them, even when they are evidence-
based, validated recovery services that are integrated into treatment
settings. The Administration supports the addition of a 10 percent set-
aside within the Substance Abuse Prevention and Treatment Block Grant
(SABG) for recovery support services. This 10 percent recovery set-
aside will ensure that each state is supporting:
the further development of local recovery community
organizations and centers, recovery and resiliency focused
strategies and educational campaigns, trainings, and events to
combat stigma;
addiction recovery resources and support system
navigation;
the recovery of diverse populations; and
collaboration and coordination with local private
and non-profit clinical health care providers, the faith
community, city, county, and Federal public health agencies,
and criminal justice response efforts.
Moreover, the increase in SABG harm reduction and treatment
activities will help to fortify efforts to reduce drug overdose deaths.
Additionally, the increased emphasis on the widespread implementation
of MOUD treatment services can begin to help eliminate community and
provider barriers to effective engagement in MOUD treatment, and
encourage clinical, administrative, and fiscal policies and practices
that incentivize the continued long-term involvement of clients in both
MOUD treatment and recovery support services.
Evidence-based harm reduction strategies are also key to minimizing
the negative consequences of drug use to both the individual and the
community. That is a key reason why the Department of Health and Human
Services (HHS) announced in April 2021 that grantees in certain
programs, such as State Opioid Response (SOR) grants and the SABG
program, may use grant funds to purchase rapid fentanyl test strips to
help curb the dramatic spike in drug overdose deaths largely driven by
strong synthetic opioids, including illicitly manufactured fentanyl.
Reports from states such as California, Arizona, Nevada, and Alaska
note that fentanyl test strips funded through SOR have become an
important component of syringe service programs; education and
awareness building toolkits; and innovative, low-threshold, on-demand
treatment programs. From the start of the reporting period on April 1,
2022 to June 30, 2022, grantees reported distributing 259,025 fentanyl
test strips.
Additionally, SAMHSA has awarded 25 grants for the first-ever
SAMHSA Harm Reduction grant program. The Harm Reduction grant program
supports community-based overdose prevention programs, syringe services
programs, and other harm reduction services including test strips for
fentanyl and other synthetic drugs. In adherence with Federal, state,
and local laws, regulations, and other requirements, Harm Reduction
grant recipients enhance overdose and other types of prevention
activities to help control the spread of infectious diseases, support
distribution of FDA-approved overdose reversal medication, build
connections for individuals at risk for, or with, a SUD to overdose
education, counseling, and health education, and to encourage
individuals to take steps to reduce the negative personal and public
health impacts of substance use or misuse.
senator burr
Question 1. In 2018, Congress passed the SUPPORT Act with broad
bipartisan support, which included Section 6082 directing CMS to review
its existing packaging policies for the outpatient and Ambulatory
Surgical Center (ASC) settings, ``with a goal of ensuring that there
are not financial incentives to use opioids instead of non-opioid
alternatives.'' Yet, even with this directive from Congress, CMS has
made no changes to packaging policies in the outpatient setting, and
only limited changes in the ASC setting.
For 2022, CMS adopted a policy in the ASC setting that would pay
for non-opioid pain alternatives separately, but only those costing
over $130/day separately. Non-opioid pain alternatives with lower
prices, but still with a meaningful differential compared to less
costly generic opioids, continue to be bundled in single payment.
Potentially incentivizing providers to choose opioids over non-opioid
options that cost under $130. Despite this potential, CMS has proposed
to keep the $130/day unbundling threshold for 2023 in the Outpatient
Prospective Payment System proposed rule.
Though CMS, CDC, HRSA, and SAMHSA are all under HHS, there seems to
be a lack of comprehensive strategy to combat the opioid epidemic.
While CDC, HRSA, and SAMHSA are working to put out the fires caused by
illicit fentanyl, CMS is implementing policy through the Outpatient
Prospective Payment System that may misalign incentives for the
prescribing of opioids over non-opioid alternatives.
Ms. Johnson, Dr. Delphin-Rittmon, and Dr. Jones, can you please
provide:
1. The number of times your agencies have reached out to CMS to
share information or expertise to inform their rulemaking
regarding opioids policies
2. The number of times CMS has reached out to your agencies for
information or expertise to inform their rulemaking regarding
opioids policies
3. The number of times your agency has met with CMS over the
past year (by phone, video, or in person) to discuss opioid
addiction, abuse, and deaths
4. The extent to which aggregated data and information
collected by your agencies is shared with CMS to inform
rulemaking
Answer 1. SAMHSA and CMS staff coordinate regularly on multiple
levels. One example of that is through the Behavioral Health
Coordinating Council (BHCC), a group I co-chair along with the
Assistant Secretary for Health, that convenes to inform and improve the
various mental health and substance use-related projects and programs
that HHS Operating Divisions, like CMS and SAMHSA, are managing an d
leading. In particular, the BHCC has an Overdose Prevention
Subcommittee which coordinates programs and policies across HHS in
terms of implementing the HHS Overdose Prevention Strategy. The BHCC
also has a Performance Measures, Data and Evaluation Subcommittee at
which data collected by HHS operating divisions is shared.
Additionally, since May 2021, CMS, AHRQ, SAMSHA touch base every
other month on the 1003 project concerning a demonstration grant
expanding OTP treatment across 11 states. In December 2021 and January,
SAMHSA engaged with Medicare and Medicaid to confirm SAMHSA's upcoming
rulemaking to make telehealth flexibilities permanent would be
compliant with Medicare and Medicaid regulations. Last, SAMHSA met with
CMS throughout May and June to discuss evidence-based treatment models
for opioid use disorder, including models for individuals who also have
other complex medical conditions.
senator cassidy
Question 1. Dr. Delphin-Rittmon, Congress provided the
Administration discretionary spending of more than $6 billion per year
from fiscal year 2018 through 2020 for opioid-related programs. This
was further increased by $2.5 billion via COVID-relief funds. In 2019,
SAMHSA received $3.7 billion for substance use-related activities.
Despite these resources, overdose deaths have increased to more than
100,000 Americans in the 12-month period ending February 2022. What
metrics does SAMHSA use to determine whether opioid-related funding is
being used efficiently and effectively?
Answer 1. Through the Government Performance and Results Act (GPRA)
of 1993 and the Modernization Act of 2010, SAMHSA's Center for
Substance Abuse Treatment (CSAT) evaluates program performance and
effectiveness through six National Outcome Measures, which include:
Abstinence
Crime and Criminal Justice
Employment/Education
Health/Behavioral/Social Consequences
Social Connectedness
Stability in Housing
In fiscal year 2021, 1,559,592 clients were served by the Substance
Abuse Prevention and Treatment Block Grant (SABG), State Opioid
Response (SOR), and Medication-Assisted Treatment for Prescription Drug
and Opioid Addiction programs. Across the three programs, participating
clients reported positive rates of change for each outcome measure. The
fiscal year 2021 performance measures for CSAT's programs are available
in SAMHSA's Fiscal Year 2023 Justification of Estimates for
Appropriations. \7\
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\7\ https://www.samhsa.gov/sites/default/files/samhsa-fy-2023-
cj.pdf.
Question 2. Dr. Delphin-Rittmon, the Bipartisan Policy Center has
estimated that in 2019, mandatory spending on Medicaid beneficiaries
with opioid use disorder (OUD) exceeded $23 billion. This is a nearly
150 percent increase in Medicaid spending compared to 2013 when
spending on OUD was estimated by the Kaiser Family Foundation to be
about $9.4 billion. From 2013 to 2019, the number of Medicaid
beneficiaries getting treatment for OUD increased by 150 percent, and
from 2010 to 2019, the number of Medicaid covered OUD medication
prescriptions increased by 550 percent. However, overdose deaths kept
increasing during that timeframe, not decreasing or even plateauing.
Which SAMHSA-developed or SAMHSA-recommended outcome measures should
CMS and State Medicaid agencies use to ensure accountability in opioid-
---------------------------------------------------------------------------
related Medicaid spending?
Answer 2. SAMHSA plans to continue collaboration with CMS and State
Medicaid agencies to support outcome improvements for individuals with
Substance Use Disorder (SUD including Opioid Use Disorder (OUD) ). For
Medicaid 1115(a) demonstrations, CMS continues to develop tools to
assist states and provide them with CMS's expectations and guidance to
support rigorous evaluation activities as well as to improve access to
and quality of treatment to Medicaid beneficiaries as part of a
Department-wide effort to combat the ongoing opioid crisis. States can
utilize a flexible, streamlined approach to respond to the national
opioid crisis while enhancing states' monitoring and reporting of the
impact of any changes implemented through these demonstrations. \8\
---------------------------------------------------------------------------
\8\ https://www.Medicaid.gov/sites/default/files/federal-policy-
guidance/downloads/smd17003.pdf.
---------------------------------------------------------------------------
Additionally, CMS has provided tools and guidance to support state
approaches to monitoring and evaluation of SUD and tools to meet the
requirements in special terms and conditions for SUD section 1115
demonstrations. These tools include templates and guidance for
implementation, monitoring protocol and reporting, and evaluation
design. CMS also provides mid-point technical assistance to support
states with planning and executing the assessment. \9\
---------------------------------------------------------------------------
\9\ https://www.Medicaid.gov/Medicaid/section-1115-demonstrations/
1115-demonstration-monitoring-evaluation/1115-demonstration-state-
monitoring-evaluation-resources/index.html.
---------------------------------------------------------------------------
senator collins
Question 1. Increase in Teen Overdoses (Dr. Delphin-Rittmon). Last
month, Hannah Flaherty, a 14-year-old girl from Portland, died from a
suspected fentanyl overdose 1 day after her middle school graduation.
According to her friends and family, she was a straight A student with
no history of drug use. Sadly, Hannah's death is not an outlier.
According to a new study from UCLA researchers, after staying flat for
a decade, the overdose death rate among adolescents in the United
States nearly doubled from 2019 to 2020, and then increased again by 20
percent in the first 6 months of 2021. This is the first time in
recorded history that the teen drug death rate has seen an exponential
rise, which researchers attribute to drug use ``becoming more
dangerous, not more common.'' Dr. Delphin-Rittmon, we are not
prioritizing primary prevention enough. What more can be done to
educate teens and young adults about the dangers of fentanyl and
counterfeit pills in particular, so we can prevent them from turning to
drugs in the first place?
Answer 1. Education is the cornerstone of prevention, however, in
order to ensure that education works, it must be population specific,
culturally conscious and easily understood.
SAMHSA's Substance Abuse Prevention and Treatment Block Grant
(SABG) program provides funds to all 50 states, the District of
Columbia, Puerto Rico, the U.S. Virgin Islands, 6 Pacific
jurisdictions, and 1 tribal entity to prevent and treat substance
abuse. SAMHSA requires that grantees spend no less than 20 percent of
their SABG allotment on substance abuse primary prevention strategies.
These strategies are directed at individuals not identified to be in
need of treatment. SABG grantees develop a comprehensive primary
prevention program that targets both the general population and sub-
groups that are at high risk for substance abuse. Grantees use a
variety of primary prevention strategies, including but not limited to
education, healthy alternatives, and community-based process, to target
the populations at greatest risk for substance use in their community.
The prevention set-aside is one of SAMHSA's main vehicles aimed at
preventing substance misuse and allows states to develop prevention
infrastructure and capacity.
SAMHSA's Strategic Prevention Framework for Prescription Drugs
(SPF-Rx) grant program provides resources to help prevent and address
prescription drug misuse within a state or locality. The SPF-Rx program
is designed to raise awareness about the dangers of sharing medications
and to highlight the risks of fake or counterfeit pills purchased over
social media or through other sources.
Finally, the SABG and State Opioid Response Grant (SOR) programs
are funds that states can also use to support youth SUD prevention
efforts. The SOR grant program, for example, funds state strategies
that focus on the prevention of substance use for at-risk youth. SOR
grantees also use funds to support interventions through Teen Courts,
Recovery High Schools, and Peer Mentor Programs.
senator murkowski
Question 1. According to preliminary data from the CDC, the U.S.
experienced a 15 percent increase in overdose deaths from 2020 to 2021.
Meanwhile, in Alaska, that increase was a staggering 75 percent,
roughly five times the national average. Due to historical trauma other
inequities, our Alaska Native population have experience high rates of
substance use and alcoholism. I am concerned about the impact of the
fentanyl epidemic on our rural Alaska Native communities, who are
already experiencing significant increases in overdose deaths. How will
you ensure the Federal efforts to address the rise of fentanyl overdose
deaths will address the needs of those in rural areas, specifically
American Indians and Alaska Natives?
In Alaska and around the country, drug addiction and substance use
disorders are ending the lives of far too many youth. This past June,
I, along with my colleagues Senator Feinstein, Senator Sullivan, and
Senator Hassan, introduced S. 4358, Bruce's Law. This bill authorizes
funding for the Department of Health and Human Services (HHS) to
conduct a public awareness campaign targeted toward school-aged
children and youth on the dangers of fentanyl, establish an interagency
working group on fentanyl contamination, and authorizes an expansion of
grants for community coalitions to engage school-aged children and
youth in outreach and prevention efforts.
Question 2. What type of outreach and prevention efforts are the
CDC and SAMHSA currently supporting to educate youth and school-aged
children on the dangers of counterfeit drugs laced with fentanyl? What
inter-agency coordination takes place between the CDC, SAMHSA, and
ONDCP on these efforts?
Question 3. How does ONDCP believe that Bruce's Law, if enacted,
would enhance their prevention efforts?
Answer 1-3. One of the key cross-collaboration principles that
drives SAMHSA's work is promoting greater equity within the behavioral
health system. This includes addressing the longstanding inequities
faced by Tribal citizens.
The Tribal Opioid Response grant (TOR) program assists in
addressing the public health crisis caused by escalating opioid and
stimulant misuse and use disorders across tribal communities. The
purpose of the program is to prevent overdoses in Tribal communities by
increasing access to FDA approved medications for the treatment of
opioid use disorder and to support culturally appropriate prevention,
harm reduction, treatment, and recovery support services.
SAMHSA's Tribal Behavioral Health grant program, also known as
Native Connections, is intended to prevent suicide and substance
misuse, reduce the impact of trauma, and promote mental health among
American Indian/Alaska Native (AI/AN) youth. This program fosters
culturally responsive models that reduce and respond to the impact of
trauma and involve AI/AN community members (including youth, tribal
leaders, and spiritual advisors) in all grant activities.
The SAMHSA Tribal Training and Technical Assistance Center and the
National American Indian and Alaska Native Technology Transfer Centers
for addiction, prevention and mental health provide training and
technical assistance specific to working with tribes and tribal
citizens in the behavioral health arena. These Centers work with
organizations and treatment practitioners involved in the delivery of
behavioral health services to American Indian and Alaska Native
individuals, families, and tribal and urban Indian communities to
develop and strengthen the specialized behavioral healthcare workforce
and the primary healthcare workforce that provide these services.
Furthermore, SAMHSA works closely with the State Opioid Treatment
Authorities (SOTA) assigned in each state to support MOUD by overseeing
Opioid Treatment Programs, providing guidance regarding MOUD, and
facilitating MOUD services within the state. Specific to Alaska, SAMHSA
has been working with the SOTA to identify ways in which state funds
and the current Opioid Treatment Programs (OTP) can utilize medication
unit guidance, issued in November 2021, to establish additional sites
in Alaska, expanding the reach of current OTPs. Three new OTPs have
opened in the last year and at least one mobile medication unit is
planned. In addition, as of July 31, 2022, 792 practitioners in Alaska
had received a waiver to prescribe buprenorphine.
The drastic increase in overdoses contributed to fentanyl is of
pressing concern to Substance Abuse Prevention and Treatment Block
Grant (SABG) Program and Strategic Prevention Framework--Partnership
for Success (SPF-PFS) grant recipients. Grant recipients utilize a
range of evidence-based and culturally informed strategies to educate
youth and school-aged children on the dangers of counterfeit drugs
laced with fentanyl. By conducting a local needs assessment, grantees
are able to target the populations and communities that are most at
risk for substance use. SAMHSA's Strategic Prevention Framework for
Prevention Drugs (SPF Rx) grant program provides resources to help
prevent and address prescription drug misuse within a State or
locality. The program was established in 2016 to raise awareness about
the dangers of sharing medications as well as the risks of fake or
counterfeit pills purchased over social media or other unknown sources,
and work with pharmaceutical and medical communities on the risks of
overprescribing. Grant recipients are required to track reductions in
opioid related overdoses and incorporate relevant prescription and
overdose data into strategic planning and future programming.
Recipients are expected to leverage knowledge gained through
participation in the SPF process to more effectively address targeted
community needs.
The HHS Behavioral Health Coordinating Council (BHCC) is tasked
with coordinating all Federal Government resources to address
inequities and gaps within the mental health and substance use disorder
system. The BHCC's chief goals are to share information about the
various mental health and substance use projects and programs that HHS
Operating Divisions and Staff Divisions are managing and leading, as
well as ensure that all behavioral health issues are being handled
collaboratively and without duplication of effort across the
department. HHS's BHCC has five areas of focus: Children and Youth
Behavioral Health, Performance Measures, Data and Evaluation,
Behavioral and Physical Health Integration, Suicide Prevention and
Crisis Care, and Overdose Prevention.
senator scott
Question 1. Dr. Delphin-Rittmon--Faith-based organizations provide
vital community supports and can play a critical role in addressing
this crisis. Can you discuss how your Agency is currently working with
faith-based organizations to address this public health emergency and
your vison for partnership growth?
Answer 1. SAMHSA engages with faith-based organizations in several
ways. Through the STOP Act Program and Partnership for Success program,
we have maintained strong faith-based sector support in the development
of anti-drug strategies impacting youth. The faith-based community has
integrated numerous youth programs as a strong addition to community
coalition efforts in several funded communities over the years. Faith-
based leaders have provided important perspectives which contribute to
the collaborative sprit of successful anti-drug community level
campaigns.
In addition, SAMHSA's Substance Abuse Prevention and Treatment
Block Grant (SABG) grantees effectively engage with faith-based
organizations using SABG funds to address the fentanyl overdose crisis.
These efforts include the active involvement of faith-based communities
in statewide needs assessments of recovery support services that are
aimed at addressing specific issues related to the staggering increases
in fentanyl overdoses. Grantees are expanding recovery support services
and developing targeted initiatives with faith-based groups, recovery
community organizations, recovery community centers, and peer advocates
to support individuals in long-term recovery. Grantees are also
engaging substance use disorder treatment providers in developing
culturally appropriate faith-based models to focus on the
disproportionate overdose rates among African Americans.
Moreover, through the Medication Assisted Treatment-Prescription
Drug Opioid and Opioid Addiction (MAT-PDOA) program, some grantees
provide outreach to faith-based communities through radio programming.
Utilizing community outreach teams, these grantees connect with faith-
based leaders to ensure that they are supported and that information
regarding treatment and recovery services are appropriately
communicated to congregations. They also provide recommendations to
pastors on effective methods of conveying information to congregants on
the array of services that are available for persons with an opioid use
disorder either virtually (during COVID) or through the distribution of
flyers and pamphlets (provided by the grantee) to their parishioners
and members of their local communities.
In addition, SAMHSA's discretionary grants work in collaboration
with the Health and Human Services (HHS) Partnership Center for Faith-
based and Neighborhood Partnerships to extend the reach and impact all
of HHS related programs into communities. This includes those related
to mental well-being and recovery from substance use disorders and
encourages and supports faith-based community organizations in their
work to the individuals they serve.
______
Response by Carole Johnson to Questions of Senator Rosen, Senator
Lujan, and Senator Burr
senator rosen
INCREASING ACCESS TO FENTANYL TEST STRIPS: We know that fentanyl
test strips are relatively easy to use, accurate, and can help prevent
overdoses. That's why I'm glad the Nevada state legislature recently
voted--nearly unanimously--to legalize fentanyl test strips in our
state. I'm also proud of the work that community partners like Northern
Nevada Hopes--a federally Qualified Health Center (FQHC) in Reno--and
the Southern Nevada Health District in Las Vegas are doing to
distribute them to some of our most vulnerable patients.
Question 1. Ms. Johnson, how is HRSA partnering with federally
Qualified Health Centers across Nevada and the country to increase
awareness of and access to fentanyl test strips for those who may need
them, and how can Congress help you improve this outreach?
Answer 1. Health Centers that are funded and designated by HRSA
under section 330 of the Public Health Service Act (which are among the
types of federally Qualified Health Centers as defined under the Social
Security Act for purposes of Medicare and Medicaid reimbursement) play
a key role in providing substance use disorder and mental health
services. Aligned with the Biden-Harris administration's 2022 National
Drug Control Strategy, which identified expanding substance use
disorder services in federally qualified health centers as a strategy
to increase access to treatment services, HRSA's Health Center Program
funding supports health centers in implementing and advancing evidence-
based strategies to expand access to quality integrated substance use
disorder prevention and treatment services, including those addressing
opioid use disorder and other emerging substance use disorder issues.
In addition to this health center work, HRSA supports a range of
prevention, treatment and recovery services and supports through other
programs, such as the Rural Communities Opioid Response Program
(RCORP). Between September 1, 2021, and February 28, 2022,
approximately 40 percent of HRSA's RCORP awardees reported actively
distributing fentanyl test strips in their rural service area.
HRSA looks forward to working with you to ensure these important
programs continue to be successful and reach the populations in need of
substance use disorder and mental health services.
senator lujan
Question 1. Would incorporating MAT training in primary care and
emergency department residency programs increase access to this
lifesaving treatment? What would this additional expertise mean for
those in rural areas?
Answer 1. One of HRSA's top priorities is integrating behavioral
health into primary care, including medications for opioid use disorder
training, to increase access to evidence-based treatment for opioid use
disorder. The integration will help to ensure that opioid use disorder
can be addressed and treated by more providers along the continuum of
care, including those practicing in rural areas.
For example, to support these goals, HRSA's Rural Communities
Opioid Response Program is funding a $10 million in grant awards to
expand access to MAT in rural communities in fiscal year 2022.
Additionally, HRSA's Teaching Health Center Graduate Medical
Education Program also helps support opioid use disorder training in
primary care settings, many of which are in rural areas. HRSA will
continue to support strategies to expand access to MAT by training
additional providers.
Question 2. How does targeted training for health care providers
alleviate the stigma associated with treating individuals for opioid
use disorder?
Answer 2. HRSA programs aim to increase access to treatment for
substance use disorder, including opioid use disorder, and educate
health care providers and the communities they serve on the need for
providing treatment across patient populations. HRSA's training
highlights the various touch points at which health care providers may
encounter individuals with opioid use disorder or substance use
disorder and provide potentially lifesaving treatments and
interventions. HRSA programs train health care professionals to provide
mental health and substance use disorder services, as well as focus on
training to integrate behavioral health care into primary care.
Furthermore, these programs focus on training and maintaining workforce
in rural and underserved communities.
Question 3. COVID has caused rapid burnout across all health care
providers. Behavioral health workers face the same challenges. How
would sustained and coordinated retention efforts help sustain a robust
behavioral health care workforce?
Answeer 3. To improve the retention of health care workers, reduce
burnout and promote mental health and wellness among the health care
workforce, the American Rescue Plan Act authorized new HRSA grant
programs to support evidence-informed training on burnout reduction and
promotion of resilience for providers and help health care
organizations establish, improve, or expand evidence-informed programs
and practices to promote mental health and well-being within the health
care workforce.
In Fiscal Year 2023, the President's Budget proposes $50 million
for the Promoting Resilience and Mental Health Among Health
Professional Workforce program. These funds would support strategies to
help the health care workforce better prepare for and respond to
workplace stressors, while fostering healthy workplace environments
that promote mental health and resilience by improving the quality of
training and increasing access to care through partnerships and
linkages. The program is authorized by the Dr. Lorna Breen Health Care
Provider Protection Act (P.L. 117-105). HRSA looks forward to
continuing to work with Congress on this important issue.
senator burr
In 2018, Congress passed the SUPPORT Act with broad bipartisan
support, which included Section 6082 directing CMS to review its
existing packaging policies for the outpatient and Ambulatory Surgical
Center (ASC) settings, ``with a goal of ensuring that there are not
financial incentives to use opioids instead of non-opioid
alternatives.'' Yet, even with this directive from Congress, CMS has
made no changes to packaging policies in the outpatient setting, and
only limited changes in the ASC setting.
For 2022, CMS adopted a policy in the ASC setting that would pay
for non-opioid pain alternatives separately, but only those costing
over $130/day separately. Non-opioid pain alternatives with lower
prices, but still with a meaningful differential compared to less
costly generic opioids, continue to be bundled in single payment.
Potentially incentivizing providers to choose opioids over non-opioid
options that cost under $130. Despite this potential, CMS has proposed
to keep the $130/day unbundling threshold for 2023 in the Outpatient
Prospective Payment System proposed rule.
Though CMS, CDC, HRSA, and SAMHSA are all under HHS, there seems to
be a lack of comprehensive strategy to combat the opioid epidemic.
While CDC, HRSA, and SAMHSA are working to put out the fires caused by
illicit fentanyl, CMS is implementing policy through the Outpatient
Prospective Payment System that may misalign incentives for the
prescribing of opioids over non-opioid alternatives.
Ms. Johnson, Dr. Delphin-Rittmon, and Dr. Jones, can you please
provide:
Question 1. The number of times your agencies have reached out to
CMS to share information or expertise to inform their rulemaking
regarding opioids policies
Question 2. The number of times CMS has reached out to your
agencies for information or expertise to inform their rulemaking
regarding opioids policies
Question 3. The number of times your agency has met with CMS over
the past year (by phone, video, or in person) to discuss opioid
addiction, abuse, and deaths
Question 4. The extent to which aggregated data and information
collected by your agencies is shared with CMS to inform rulemaking
Answer 1-4. As a part of interagency clearance on the OPPS/ASC
rule, HRSA reviews and provides input, as appropriate, on Section 6082
policies, HRSA works in close collaboration with CMS and other HHS
operating divisions to combat the opioid epidemic, including through
Secretary Becerra's Behavioral Health Coordinating Council (BHCC). The
BHCC is a significant mechanism for HRSA to coordinate existing efforts
and future initiatives with other HHS operating divisions, including
CMS, CDC, and SAMHSA. For example, HRSA collaborated with other HHS
agencies through the BHCC to implement the HHS Overdose Prevention
Strategy. We will continue to collaborate with our colleagues across
HHS to combat the opioid epidemic.
______
Response by Christopher Jones to Questions of Senator Casey, Senator
Collins, and Senator Murkowski
senator casey
I hear from Pennsylvanians who have suffered tragic losses from the
scourge of fentanyl and opioid overdose gripping our Nation. I also
hear from Pennsylvanians who suffer from debilitating chronic pain and
depend on medically appropriate use of opioids to lead meaningful
lives. As our country has taken steps to address the opioid epidemic,
some of these patients have faced barriers to the care they need.
In 2016, CDC published its Guideline for Prescribing Opioids for
Chronic Pain, and subsequently issued a statement in 2019 advising
against misapplication of the Guideline. In that statement, CDC
acknowledged that ``some policies and practices that cite the Guideline
are inconsistent with, and go beyond, its recommendations,'' and noted
that these issues ``could put patients at risk.'' CDC is now working on
its successor, the 2022 CDC Clinical Practice Guideline for Prescribing
Opioids.
Question 1. As CDC revises the 2022 draft based on feedback and
prepares to release the updated Guideline, how will CDC work with
Federal, state, and local agencies, as well as clinicians, to clarify
acceptable and unacceptable practices for prescribing physicians?
Question 2. How will CDC ensure that the latest guidelines are not
misapplied, restricting access for patients with a legitimate medical
need for opioids, and encourage application consistent with CDC's
position that ``patients with pain deserve safe and effective pain
management''?
Answer 1-2 CDC is working to ensure effective communication about
the 2022 Clinical Practice Guideline for Prescribing Opioids for Pain.
CDC is carefully reviewing how recommendations are written to ensure
they are properly applied and not misinterpreted.
The 2022 Clinical Practice Guideline addresses these critical
issues by emphasizing that the 2022 Guideline is a clinical tool to
improve communication between clinicians and patients and empower them
to make informed, person-centered decisions related to pain care
together. The 2022 Clinical Practice Guideline includes call out boxes
and language throughout the document that clearly states the purpose of
the Guideline, what it is intended for, and what it is NOT intended
for. For example:
The Clinical Practice Guideline IS a clinical tool to
improve communication between clinicians and patients and
empower them to make informed, person-centered decisions
related to pain care together.
The Clinical Practice Guideline IS NOT intended to be
applied as inflexible standards of care across patients, and/or
patient populations by healthcare professionals, health
systems, pharmacies, third-party payers, or governmental
jurisdictions or to lead to the rapid tapering or abrupt
discontinuation of opioids for patients.
CDC will also release a suite of translation and communication
materials with the 2022 Guideline that will emphasize these critical
messages and provide resources to clinicians providing pain care to
patients. These materials will help achieve the goal of providing
flexible, patient-centered care that is tailored to the needs and
circumstances of the patient.
CDC also will work with public and private payers as well as other
decisionmakers and share evidence that can be used to inform decisions
regarding coverage for a broader range of pain therapies. To assist in
uptake and understanding of the 2022 Guideline, CDC will update and
develop tools and resources for clinicians, health systems, and
patients. In September 2019, CDC launched the multiyear Overdose Data
to Action (OD2A) cooperative agreement with 66 recipients (referred to
as jurisdictions) comprised of state, territorial, county, and city
health departments in which dissemination and TA on the Guideline will
also go out through these funded partners. CDC is also working with
ASTHO to develop tools and resources for state agencies and
policymakers to support implementation of the Guideline.
Question 2. In your testimony, you discuss CDC's efforts to use
data for overdose prevention and the essential role of data in
informing a public health response to the overdose crisis. I appreciate
that ``CDC is committed to using data . . . as part of a whole-of-
government approach to save lives and bring an end to our Nation's
overdose crisis,'' and encouraged by your collection of data which you
report ``improves coordination and strategic planning for intervention
and response efforts among health departments, community members,
healthcare providers, public health, law enforcement, and government
agencies.''
In what ways are the CDC data being used to ``improve coordination
and strategic planning''?
Question 3. What barriers exist to CDC collaborating and sharing
data with other government agencies to help ensure the government's
approach to combatting the crisis is informed by the best available
clinical evidence and health statistics?
Answer 2-3. CDC partners across Federal Government agencies to
leverage data sources to inform prevention, treatment, and harm
reduction efforts. For example, CDC participates in a number of Federal
interagency workgroups focused on the improvement of data systems and
data sharing, including the White House ONDCP Drug Data Interagency
Workgroup, the HHS Behavioral Health Coordinating Council subcommittee
on data and metrics, and the Federal Interagency Medicolegal Death
Investigation Working Group. In addition, CDC regularly partners with
other HHS agencies, such as SAMHSA, CMS, NIDA, and FDA to collaborate
and leverage data sources focused on substance use, overdose, and
prescribing and patient behaviors to help inform translation and
dissemination of data to the public. Two recent examples of data
sharing and collaboration from these interagency efforts include
research papers in JAMA Psychiatry examining COVID-19 related emergency
policy changes for methadone take-home doses from opioid treatment
programs opioid treatment programs \1\ and use of telehealth in the
treatment of opioid use disorder among Medicare beneficiaries. \2\
Findings from these papers are informing ongoing discussions related to
potential permanent adoption of these COVID-19 flexibilities.
---------------------------------------------------------------------------
\1\ Jones CM, Compton WM, Han B, Baldwin G, Volkow ND. Methadone-
involved overdose deaths in the US before and after Federal policy
changes expanding take-home methadone doses from opioid treatment
programs. JAMA Psychiatry. 2022;79(9):932-934.
\2\ Jones CM, Shoff C, Hodges K, Blanco C, Losby JL, Ling SM,
Compton WM. Receipt of telehealth services, receipt and retention of
medications for opioid use disorder, and medically treated overdose
among Medicare beneficiaries before and during the COVID-19 pandemic.
JAMA Psychiatry. 2022;Aug 31. Doi:10.1001/jamapsychiatry.2022.2284.
CDC also partners with Federal agencies, such as the Department of
Justice and High Intensity Drug Trafficking Programs, to leverage drug
supply data that can help inform prevention efforts. For example, the
Overdose Response Strategy is funded by the Centers for Disease Control
and Prevention (CDC) and the White House Office of National Drug
Control and Policy (ONDCP). The CDC Foundation and 33 High Intensity
Drug Trafficking Areas (HIDTAs) are working together to support this
unique and unprecedented collaboration between public health and public
safety, which allows agencies to share timely data, pertinent
intelligence and innovative strategies to address overdoses. Through
the project, ORS teams made up of drug intelligence officers (DIO) and
public health analysts (PHA) work together on drug overdose issues
within and across sectors. In addition to these efforts, CDC's Overdose
Data to Action (OD2A) program is designed to facilitate data sharing
and use data to inform prevention efforts at the state and local
levels, and CDC works closely with funded jurisdictions to optimize
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their data to action strategic frameworks.
Question 3. What more can be done to encourage proactive use of
CDC-provided resources to develop data-driven approaches to combating
fentanyl and reducing overdose deaths across public health, law
enforcement, and other elements of the Federal response?
Answer 3. CDC's funding to state, local, and territorial entities
has evolved and expanded with the overdose crisis. CDC data have been
integral to informing this evolution and the response across
jurisdictions. CDC's Overdose Data to Action program is forecasted to
expand support for local communities through a new 5-year funding
opportunity, Overdose Data to Action: Limiting Overdose through
Collaborative Actions in Localities (OD2A: LOCAL). Additionally, CDC's
new forecasted 5-year funding opportunity for states, Overdose Data to
Action in States (OD2A-S), will build off the work and gains made
through previous overdose surveillance and prevention investments
supporting state health departments through the promotion of overdose
surveillance strategies and evidence-based and promising interventions
that have an immediate impact on reducing morbidity and mortality
associated with overdoses, with a primary focus on opioids, stimulants,
and polysubstance use. OD2A-S will emphasize health equity, and
strategies will be underpinned by a data-to-action framework that aims
to expand and strengthen fatal and non-fatal overdose surveillance
efforts of State Health Departments and their use of these and other
data to drive prevention strategies and policies. Data-driven
strategies within each of these funding opportunities aim to enhance
partnerships and collaborations across public health, public safety,
law enforcement, and the medical community, among others, and to
promote evidence-based prevention strategies, interventions, and care.
CDC also provides extensive technical assistance (TA) to OD2A
funded recipients. The OD2A TA Hub centralizes and standardizes TA
provides to recipients across 13 domains using a tech-based portal and
5 step prioritization process. This portal facilitates access to a
coordinated network of TA and training services in surveillance and
prevention activities. It also focuses on:
systematic amplification and dissemination of CDC
scientific and programmatic technical assistance to OD2A funded
recipients to better equip them to address the overdose
epidemic
assessment and enhancement of capacity of recipients
to successfully implement and evaluate surveillance and
prevention activities of OD2A in coordination and collaboration
with CDC and as elaborated in the Overdose Prevention Capacity
Assessment Tool (OPCAT)
translation and dissemination of data to inform
action as well as best practices and resources; and
development and maintenance of an electronic resource
library.
In addition, CDC is partnering with SAMHSA to provide technical
assistance on harm reduction strategies. The Harm Reduction Technical
Assistance Center is designed to strengthen the capacity and improve
the performance of Syringe Services Programs (SSPs) throughout the
United States by supporting enhanced technical assistance (TA) to
ensure the provision of high-quality, comprehensive harm reduction
services.
senator collins
Question 1. Actionable Overdose Data (Mr. Chester and Dr. Jones).
Mr. Chester, I appreciate that the National Drug Control Strategy
prioritizes the need for more actionable data to track nonfatal
overdoses, which you recognize in your testimony as ``one of the most
accurate predictors of whether someone will experience a fatal overdose
in the future.'' I was also encouraged to hear Director Gupta recently
met with officials in Maine to see firsthand how Maine collects
detailed overdose data. This data is critical for law enforcement and
health care providers to appropriately gauge the scope of the crisis in
their local communities and target resources where they are needed. I
understand the Administration has recently created a Drug Data
Interagency Working Group that will assist with the development of a
new national plan for obtaining data in near real-time. However, this
is expected to take 1 year to develop fully. Mr. Chester and Dr. Jones,
how is ONDCP utilizing partners like the CDC who have expertise in data
collection and partnerships across state and local public health
agencies?
Answer 1. CDC actively participates in the ONDCP Drug Data
Interagency Working Group, sharing lessons learned from implementing
our nonfatal and fatal overdose surveillance efforts in funded
jurisdictions. CDC contributes to the overall development of working
group outputs related to drug overdose mortality and morbidity efforts,
focused on improving the timeliness and comprehensiveness of data
related to drug overdose and related harms, including ongoing
discussions on how to continue to leverage CDC data systems like the
Drug Overdose Surveillance and Epidemiology (DOSE) syndromic
surveillance system to improve awareness about overdoses seen in
Emergency Departments across the U.S.
With support from the Office of National Drug Control Policy
(ONDCP) the Overdose Response Strategy (ORS) is a unique collaboration
between CDC and the High Intensity Drug Trafficking Areas (HIDTA)
program designed to enhance public health and public safety
partnerships. The mission of the ORS is to help communities reduce
fatal and non-fatal drug overdoses by connecting public health and
public safety agencies, sharing information, and supporting evidence-
based interventions. This program offers evidence-based intervention
strategies that can be implemented at the local, regional, and state
level. CDC has expanded its investment in this partnership to support
the public health component in all 50 states, Puerto Rico and the U.S.
Virgin Islands. Drug intelligence officers and public health analysts
collaborate and leverage supply and overdose data to problem-solve and
address local and regional issues, including spikes in overdoses
related to illicit fentanyl.
senator murkowski
In Alaska and around the country, drug addiction and substance use
disorders are ending the lives of far too many youth. This past June,
I, along with my colleagues Senator Feinstein, Senator Sullivan, and
Senator Hassan, introduced S. 4358, Bruce's Law. This bill authorizes
funding for the Department of Health and Human Services (HHS) to
conduct a public awareness campaign targeted toward school-aged
children and youth on the dangers of fentanyl, establish an interagency
working group on fentanyl contamination, and authorizes an expansion of
grants for community coalitions to engage school-aged children and
youth in outreach and prevention efforts.
Question 1. What type of outreach and prevention efforts are the
CDC and SAMHSA currently supporting to educate youth and school-aged
children on the dangers of counterfeit drugs laced with fentanyl? What
inter-agency coordination takes place between the CDC, SAMHSA, and
ONDCP on these efforts?
Answer 1. The Drug Free Communities (DFC) Support Program is the
Nation's leading effort to mobilize communities to prevent and reduce
substance use among youth. Administered by ONDCP and managed by CDC,
the DFC Program funds community-based coalitions to identify and
respond to the drug problems unique to their community and change local
community environmental conditions tied to substance use. The DFC
coalitions focus efforts on youth and in many instances, promote health
equity and aim to reduce disparities that impact youth substance use,
and address the risk and protective factors that negatively impact
health outcomes in communities. As the overdose crisis has evolved to a
crisis driven by illicit fentanyl and fentanyl analogs, DFC coalitions
have responded by increasing their focus on this threat to youth.
Examples of their work include collaboration with CDC's Overdose
Response Strategy include:
DFC coalitions in the state of CT collaborate on a
fentanyl awareness campaign targeting teens, young adults, and
caregivers on the dangers of counterfeit pills. The campaign,
which is available through social media, billboards, TV
coverage, newspaper ads, banners, and postcards, aims to
educate not only how young people are accessing counterfeit
medications, but also why they are using them and to provide
families with tools and resources that they can use to offer
support.
Westbrook Partners for Prevention (ME): Updated
Westbrook School District medication dispensing policy to
include naloxone administration. Training will be provided to
interested staff, coaches, and others in overdose recognition
and response protocols in the 2022/2023 school year. Coalition
staff worked to update the Westbrook School District medication
dispensing policy to allow for school staff to dispense
naloxone if necessary. Staff provided education to school
nurses about the policy and new protocols. A plan was made to
provide training to teachers, staff, and coaches in the
upcoming school year as well.
Griswold PRIDE (CT): In January, CT had the first
youth overdose on fentanyl while at school . . . a middle
school. This prompted many discussions, education
opportunities, and policy changes among school districts. In
April, all 500 high school students watched Natural High's Dead
on Arrival documentary, which was followed up with lessons and
discussion using their Fentanyl Toolkit. Parents were also
provided information on the lessons and a link to the
documentary to follow-up at home. Also stemming from that
overdose student death, came Narcan/naloxone training for
support staff from each of the schools, Griswold Elementary,
Middle, High, and Alternative. Before this, only the high
school was trained and carried naloxone onsite. Now after a
district policy, all of their schools have staff trained, and
have naloxone on site.
CDC recognizes the historical increases in drug overdose deaths
associated with illicit fentanyl and the risks posed by an increasingly
changing illicit drug supply. In addition to leveraging data and
working with public safety to address emerging drug threats and co-
involvement of fentanyl in the illicit drug supply, CDC is also raising
awareness of the risks of fentanyl and polysubstance use. Our Stop
Overdose campaign focuses on the risks associated with illicit fentanyl
and polysubstance use as well as the importance of naloxone as a life-
saving antidote for overdose. The intended audience for these campaigns
is people who use drugs between the ages of 18-34 and there has been
widespread pick-up of this campaign, which has received over 2 billion
impressions over the past year.
Question 2. How does ONDCP believe that Bruce's Law, if enacted,
would enhance their prevention efforts?
Question 3. According to preliminary data from the CDC, the U.S.
experienced a 15 percent increase in overdose deaths from 2020 to 2021.
Meanwhile, in Alaska, that increase was a staggering 75 percent,
roughly five times the national average. Due to historical trauma other
inequities, our Alaska Native population have experience high rates of
substance use and alcoholism. I am concerned about the impact of the
fentanyl epidemic on our rural Alaska Native communities, who are
already experiencing significant increases in overdose deaths.
How will you ensure the Federal efforts to address the rise of
fentanyl overdose deaths will address the needs of those in rural
areas, specifically American Indians and Alaska Natives?
Answers 1-3. The increases in overdose deaths among American Indian
and Alaska Native persons is very concerning, and CDC recently called
attention to this issue in our July Vital Signs on drug overdose.
Efforts specific to the needs of the AI/AN population are underway
across the Federal Government to address this crisis. CDC is working to
ensure that multiple programmatic efforts are reaching tribal
populations.
Targeted AI/AN Funding
CDC ensures that American Indian and Alaska Native communities are
reached through many of our national and local programs that are
represented below, but also provides targeted, tailored funding and
support that goes directly to tribal and Alaska Native communities and
tribal serving organizations. AI/AN specific funding includes:
Capacity building funding to tribal epidemiological
centers to provide actionable data on opioid use disorder
(OUD), stimulant use disorders (StUD), and polysubstance use.
Funding to address strategic plan priority areas such
as epidemiologic surveillance and public health data
infrastructure; implementation of evidence-based health systems
interventions; or innovative community-based strategies.
Funding the National Indian Health Board (NIHB) to
produce an opioid conference track at a national conference
annually.
Funding tribal serving organizations to provide
training and technical assistance to tribes related to opioid
overdose prevention and to develop resources such as a toolkit
that translates Indigenous evaluation approaches into
actionable guidance for tribal public health & opioid overdose
prevention programs.
Drug Free Communities (DFC)
During the application process of the DFC program, CDC and ONDCP
encourage coalitions to pay particular attention to communities or
populations disproportionately affected by substance use including but
not limited to those with reduced economic stability; limited
educational attainment, access or quality, limited healthcare access or
quality, people from non-English populations, tribal populations, rural
communities and other geographically underserved areas, racial/ethnic
minority groups, and sexual and gender minority groups. Currently, the
DFC program funds the Healing Our People and Environment (HOPE)
Coalition and the Ketchikan Wellness Coalition in Alaska.
Partnership with BJA
CDC partners with the Bureau of Justice Assistance's Comprehensive
Opioid, Stimulant, and Substance Abuse Program on multiple projects to
support effective state, local, and tribal responses to illicit
substance use. These projects promote public safety, and support access
to treatment and recovery services in the criminal justice system in
order to reduce overdose deaths. This partnership has focused on rural
responses, expanding use of the Overdose Detection Mapping Application
Program (ODMAP) in states and tribes, harm reduction education and
training for law enforcement, building bridges between jail and
community-based treatment, and overdose fatality review (OFR)
implementation. The ODMAP Initiative, co-funded by the Bureau of
Justice Assistance and the Centers for Disease Control and Prevention,
supports the implementation of the ODMAP in four tribal communities.
The project strengthens the ability of the selected tribes to assess
information gathered from public safety, public health, and behavioral
health responses. This initiative also strives to enhance the ability
of the selected tribes to implement tailored prevention and
intervention activities to reduce overdose deaths and facilitate access
to treatment and recovery services to survivors of nonfatal overdoses.
Sites include:
Eastern Band of Cherokee Indians
Oneida Nation Behavioral Health
Tulalip Tribes of Washington
White Earth Band of Chippewa Indians through its
Behavioral Health Division
Health IT
In January 2020, CDC and ONC successfully completed an integration
of the Utah Navajo Health System Electronic Health Records (EHRs)
through RxCheck, a system that allows healthcare providers within
clinical settings to access patient prescription history within their
EHR workflow. CDC and ONC successfully launched a PDMP-EHR pilot with
the Ponca Health Services in Nebraska and with Blue Mountain Health in
Utah, which serves both the Ute and Navajo tribes. NCIPC and the Office
of the National Coordinator for Health Information Technology (ONC)
have collaborated on this CDC-ONC project to advance and scale
sustainable pathways to PDMP integration within health IT systems
(e.g., EHR). CDC and ONC are piloting this work in at least six health
systems across multiple states. This project also included two
additional systems that will pilot CDC Guideline-concordant electronic
clinical decision support.
CDC also provided funds to the National Indian Health Board to
support the implementation of evidence-based health interventions to
prevent substance use disorder and drug overdose in American Indian and
Alaska Native populations. These interventions include addressing
challenges in accessing state PDMPs and increasing their use, linking
people to opioid use disorder treatment services, creating translation
materials, evaluating the effectiveness of implemented interventions,
and adapting current CDC factsheets or other materials for clinics that
serve American Indian and Alaska Native populations.
______
[Whereupon, at 12 p.m., the hearing was adjourned.]
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