the American Association of Colleges of Osteopathic Medicine

This analysis was prepared by McDermott+ Consulting, on behalf of AACOM.

This hearing took place on June 9, 2023, 9:30am ET .

PURPOSE

This hearing focused on recommendations for improving the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act. It also discussed success and challenges in opioid and substance use disorder treatment, including barriers to accessing care, especially for rural populations.

MEMBERS PRESENT

Chairman Guthrie, Representatives Joyce, Tonko, Obernolte, Griffith, Bucshon

WITNESS

Ms. Emily Keller, Special Secretary of Opioid Response, Opioid Operational Command Center, Office of Governor Wes Moore
Mr. Mike Straley, Founder, Leah’s Legacy Foundation
Dr. Mitchell Crawford, D.O., Medical Director, Specialized Treatment and Recovery, WellSpan Health, Director, Addiction Services, WellSpan Health
Chief William Ceravola, Reading Township Police Department

KEY TAKEAWAYS

There is bipartisan support for addressing the opioid crisis.
There was support from witnesses and representatives for expanding telehealth access to mental health and substance use disorder treatment.
There was discussion on how to increase access to care for rural populations and those who are incarcerated.
Suggestions on how to improve the SUPPORT Act focused on increasing access to care through expanding providers and facilities, especially in rural areas.

OPENING STATEMENTS

Chairman Guthrie (R-KY) thanked the National Park Service for hosting them in Gettysburg and noted the bipartisan support for addressing opioid and addiction recovery.

Representative Joyce (R-PA) drew parallels between the battles of addiction and the battle at Gettysburg and highlighted the importance of learning from communities on ways to improve the SUPPORT Act as it comes up for reauthorization this year. He highlighted the work that is done by law enforcement, communities and families when dealing with addiction. He also noted the challenge in balancing policies to support those with chronic pain.

Representative Tonko (D-NY) began by noting the magnitude of the overdose crisis and the barriers people face in accessing addiction treatment. He highlighted several bipartisan bills aimed at addressing this including the CARA Act, SUPPORT Act and recent mental health legislation, and called on his colleagues to come together to pass the Reentry Act. Additionally, he expressed a need to expand access to medicines to reverse and prevent overdoses and treat addiction.

TESTIMONY

Ms. Emily Keller began her testimony by noting her personal experience of having a friend dying to overdose, which shaped her commitment to public service. She noted the extent of overdoses deaths across the country and praised the increased access enabled by the SUPPORT ACT. She highlighted the challenges and barriers that those in rural areas face, and the importance of telehealth. She also noted the impact on the incarcerated population and the steps taken in Maryland to provide medical assistance to those with substance use disorder (SUD) in carceral settings. She praised the new guidance on Section 1115 waivers to provide SUD treatment. She highlighted the positive impact and pathways to treatment that harm reduction programs enable.

Mr. Mike Straley began by sharing his experience having a daughter who battled addiction and premature death by fentanyl poisoning. He described his daughter going into a detox center, which was not covered by insurance that they had to pay out of pocket, and how he later changed jobs so insurance would cover the detox centers and sober living homes. He detailed her journey from age 16-26, 12 detox centers and eight sober living homes, thriving in sober living communities. At age 26 she needed state insurance and the new sober living home she entered was in terrible condition. He described his final unknowing goodbye to his daughter, and its impact on his family. Leading him and his wife to start a nonprofit to help women in recovery and in sober living to honor their daughter.

Dr. Mitchell Crawford, D.O. began his remarks by noting the extent of the addiction crisis and his connection to it through his sister’s death. He thanked Congress for the SUPPORT Act, but noted the growing nature of the crisis and the need to match the response to the need. He noted the Medicaid institutions for mental disease (IMD) exclusion and recent temporary telehealth flexibilities and encouraged congress to make them permanent and pass the Modernizing Opioid Treatment Act.

Chief William Ceravola began by highlighting his path into law enforcement and experience as a crime scene investigator. He noted the stigma of addiction but that it can happen to anyone. He described how drugs personally impacted his brother and the subsequent impact on their mother. He noted that since starting to carry Narcan he has seen a decrease in overdose deaths over the past ten years in Pennsylvania. He concluded stating that saving people does not just impact the user, but also their families.

QUESTIONS AND ANSWERS

Chairman Guthrie (R-KY) asked Chief Ceravola to comment on the prevalence of alcohol use and other addictions. Chief Ceravola confirmed that it plays a role, but also noted the role that mental health plays and shared a story about his mother overcoming alcohol addiction. Mr. Straley shared examples of what treatments worked for his daughter. He highlighted her experience in a group sober living setting and the importance of peers additional opportunities. The biggest challenge was being back in old surroundings that compounded existing mental health challenges. Dr. Crawford thought increasing access to low barrier treatment and to change culture around stigma were important steps. Ms. Keller confirmed the importance of low barrier treatment and added the importance of wrap around services and insurance coverage.

Representative Tonko (D-NY) noted the issue of SUD in incarceration, and the current statutes preventing federal health insurance coverage when incarcerated leading to a coverage gap when released. Ms. Keller described the impact the lack of access to care upon release had. She noted that the two weeks following release are the most dangerous time and reiterated the importance of returning citizens having access to medical care immediately to reduce recidivism rates. She confirmed that people incarcerated cannot access opioid use disorder treatment while incarcerated. Representative Tonko noted a demonstration program that allows people to access care 90 days prior to release, and called on his colleagues to pass the Reentry Act and highlighted the number of lives that would be saved by allowing them to access healthcare services. Ms. Keller confirmed that this is a beneficial use of federal funds. Representative Tonko entered into the record a letter from several law enforcement groups supporting the Reentry Act. Chief Ceravola’s advice to colleagues about carrying Narcan is that they are not just saving the person, but their family.

Representative Griffith (R-VA) discussed with the panel the issue of diversion of suboxone. Mr. Straley and Chief Ceravola had not encountered this. Dr. Crawford had and would then not continue that treatment path for those patients. He stated that those who do not divert are sometimes able to slowly taper off, while others continue throughout their life. He stated that his approach is to do what is best for that patient at that moment. Ms. Keller confirmed that her community had success with the Drug Monitoring section of the SUPPORT Act.

Representative Bucshon (R-IN) asked Dr. Crawford what one thing Congress should do. Dr. Crawford thought that because the disease is multifactorial there is not one thing, but to keep having evidence-based conversations to be a healthier community rather than being reactive. Representative Bucshon asked Chief Ceravola about where the drugs are coming from in rural areas. Chief Ceravola thought they were coming from Baltimore, and confirmed that there was still a methamphetamine problem, but the most prevalent was heroin. Representative Bucshon noted that methamphetamine is the biggest problem in his rural district. He asked Dr. Crawford about methamphetamine impact on the brain and if this chronic brain change was seen in other drugs. Dr. Crawford noted the current addiction and behavioral health epidemic, noting that in some regions there is more stimulant misuse and opioid use in others. But also noted the lack of treatment options for stimulant misuse. Representative Bucshon concluded by noting the importance of addressing stigma and finding medical solutions to addressing this.

Representative Joyce (R-PA) commended Mr. Straley for the work he has done, and confirmed with him that access to care was insufficient in rural areas and should be included in the SUPPORT Act. Chief Ceravola confirmed the importance of first responders having access to naloxone. Dr. Crawford confirmed that physicians should not have a limit on the number of people they can prescribe suboxone to.

Representative Obernolte (R- CA) described his districts a problem with fentanyl, fentanyl poisoning and the new problem of xylazine that has no reversal method. He asked about strategies to get the drugs off the street. Chief Ceravola recommended more enforcement and sentence enhancement for dealing and the incorporation of fentanyl into pills. Representative Obernolte noted that often local dealers do not know that what they have as fentanyl.

Chairman Guthrie (R-KY) highlighted the importance of collaboration in addressing this crisis. He encouraged States to take more responsibility in ending the crisis and mentioned the bill that would allow justice involved juveniles to access to mental health services, which passed last year.

Representative Tonko (D-NY) asked Ms. Keller to describe evidence-based harm reduction. She highlighted the importance of linkage to care and peer support specialists and syringe service program. She also noted that people in harm reduction programs are more likely to enter treatment. Mr. Straley confirmed that having more people who can prescribe treatment would be helpful. Dr. Crawford thought the best way to encourage people to enter into a service provider role emphasized the importance of systems and providers meeting people where they are at, reducing stigma and viewing it as a medical disease, and to continue to raise awareness and reduce barriers.

Representative Griffith (R-VA) asked about the problem of treating fentanyl analogs. Dr. Crawford stated that it was more difficult because it is more potent and old strategies do not work. He noted that fentanyl and xylazine cause additional issues such as necrotic wounds. He recommends that first responders do what they can with what they have to keep people alive so they can get to the next step in treatment and recovery.

Representative Bucshon (R-IN) stated that fentanyl is coming to the US from China through Mexico. At the federal level they are working on both reducing demand and supply by scheduling all fentanyl analogs as schedule one. Dr. Crawford confirmed this a chronic disease and refers to people as being in recovery not cured. He noted that wrap around therapy is important for those in recovery. He noted the gold standard is medication assisted treatment and recommended that Congress not withhold parts of treatment just because someone in need of the other aspects. He also confirmed that people are in some form of treatment for forever, and this is the importance of low barrier entry to treatment.

Representative Joyce (R-PA) stated that this is a battle that everyone continues to fight across America, and asked the panel how the SUPPORT Act can be improved. Ms. Keller suggested extending care to loved ones, providing resources for families, and investing in adolescent care to respond to the increase in adolescents with SUD. Mr. Straley suggested more funding for more treatment centers and sober living homes to support people looking for help. Dr. Crawford highlighted the need for ongoing long-term therapy to respond to the behavioral health epidemic. And to continue to expand treatment of SUDs beyond opioids, because more people are lost to alcohol and tobacco. Chief Ceravola suggested improving the drug take back programs, making more mental health beds available, and increasing early education and outreach.

Representative Obernolte (R-CA) asked what can be done to reduce the cycle of people being in and out of treatment. Dr. Crawford highlighted the importance of harm reduction and personalized care approaches to meet people where they are. Ms. Keller discussed expanded telehealth and virtual health services being the way of future. However, it is important that insurance and Medicaid will cover these services so everyone can have access.

CLOSING STATEMENTS

Chairman Guthrie (R-KY) thanked the witnesses and the national park for hosting them and added several documents to the record.