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 21, 2023, 10:00 am ET.

PURPOSE

The purpose of the hearing was to address the increased rates of substance use disorder (SUD) and its impact on millions of Americans. The hearing agenda included 28 bills, and the discussion included legislative efforts to build upon the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act of 2018, the bipartisan, comprehensive effort to address SUD treatment, prevention and recovery. Committee members and witnesses evaluated the effectiveness of various legislative solutions in managing the SUD crisis, and sought to address issues such as the rise of dangerous street drugs, access to medication-assisted treatment (MAT), the need for increased prevention efforts, and the management of behavioral health needs of individuals transitioning in and out of the criminal justice system.

MEMBERS PRESENT

Subcommittee Chairman Guthrie, Subcommittee Ranking Member Eshoo, Full Committee Chair McMorris Rodgers, Full Committee Ranking Member Pallone, Representatives Burgess, Kuster, Latta, Cardenas, Dingell, Griffith, Ruiz, Carter, Barragan, Bucshon, Dunn, Blunt Rochester, Johnson, Schrier, Harshbarger, Kelly, Joyce, Sarbanes, Miller-Meeks, Trahan, Crenshaw, Bilirakis, Schakowsky, and Tonko

WITNESSES

Ms. Diana Espinosa, MPP, Principal Deputy Administrator of the Health Resources and Services Administration, Acting Deputy Assistant Secretary for Mental Health and Substance Use
Mr. Tom Coderre, Acting Deputy Assistant Secretary for Mental Health and Substance Use
Mr. Jonathan Blum, MPP, Principal Deputy Administrator and Chief Operating Officer for the Centers for Medicare and Medicaid Services
Dr. Christopher Jones, PharmD, DrPH, MPH, Director of the National Center for Injury Prevention and Control for the Centers for Disease Control and Prevention
Mr. Matthew Strait, Deputy Assistant Administrator, Office of Diversion Control for the Drug Enforcement Administration

LEGISLATION FOR DISCUSSION

H.R. 824, the Telehealth Benefit Expansion for Workers Act of 2023
H.R. 3892, the Improving Mental Health and Drug Treatment Act
H.R. 4091, the Combatting Substance Use Disorder Act
H.R. 3736, the Extending Access to Addiction Treatment Act
H.R. 4096, A bill to amend title XIX of the Social Security Act to expand the application of Medicaid State programs to monitor antipsychotic medications to all Medicaid beneficiaries.
H.R. 4056, the Ensuring Medicaid Continuity for Children in Foster Care Act of 2023
H.R. 3074, the Due Process Continuity of Care Act
H.R. 2400, the Reentry Act of 2023
H.R. 4089, the Safer Response Act
H.R. 4063, the FIND Fentanyl Act of 2023
H.R. 4079, the Substance Use Disorder Treatment and Recovery Loan Repayment Program Reauthorization Act of 2023
H.R. 4100, To amend the Public Health Service Act to reauthorize a monitoring and education program regarding infections associated with illicit drug use and other risk factors.
H.R. 4101, the Road to Recovery Act
H.R. 4099, the RECONNECTS Act of 2023
H.R. 4088, the CAREER Act
H.R. 1502, the Comprehensive Opioid Recovery Centers Reauthorization Act of 2023
H.R. 4098, the Communities of Recovery Reauthorization Act
H.R. 4095, the Save Children from Trauma Act
H.R. 4097, the Mental Health Improvement Act
H.R. 1839, the Combating Illicit Xylazine Act
H.R. 4053, the Studying Suboxone Act
H.R.__, To amend the 21st Century Cures Act to expressly authorize the use of certain grants to implement substance use disorder and overdose prevention activities with respect to fentanyl and xylazine test strips.
H.R. 4057, the Keeping Kids Safe Act
H.R. 4080, the Trauma-Informed Care Task Force Reauthorization Act of 2023
H.R. 4092, the Protecting Moms and Infants Reauthorization Act
H.R. 4054, the Trauma Support and Mental Health in Schools Reauthorization Act
H.R. 4093, the Remote Opioid Monitoring Act of 2023
H.R. 4007, the HEAL Act

KEY TAKEAWAYS

Prevention efforts and access to care are crucial in addressing the SUD crisis and reducing drug overdoses. Prevention measures and the need for accessible tools, such as fentanyl testing strips and overdose reversal medications, are essential.
There must be more care and treatment services for individuals struggling with addiction, including MAT and services for vulnerable populations, such as pregnant or postpartum women, foster care youth, and incarcerated individuals.
Collaboration and bipartisan support are key in addressing the opioid crisis. The testimonies from the witnesses demonstrated the collaborative efforts between various agencies and organizations to combat the crisis. Partnerships between federal agencies, state and local health departments, healthcare providers, and community organizations are essential to effectively prevent and respond to drug overdoses.

OPENING STATEMENTS

Subcommittee Chairman Guthrie (R-KY) opened the hearing by discussing the impact of the SUPPORT Act in addressing the SUD crisis. He mentioned that the purpose of the hearing was to evaluate the effectiveness of various legislative solutions and identify any gaps that Congress must address. He emphasized the importance of prevention efforts in curbing the high rates of drug overdoses. He highlighted the need for tools such as fentanyl testing strips and overdose reversal medications to be accessible nationwide. He also mentioned specific legislation under consideration, such as the Combating Illicit Xylazine Act, which aims to combat the rise of dangerous street drugs. He discussed the importance of access to care for individuals struggling with addiction. He stressed proposed legislation providing MAT for Medicaid patients, treatment services for foster care youth, and pregnant or postpartum women. He also mentioned the Improving Mental Health and Drug Treatment Act, which seeks to lift barriers to residential care for vulnerable populations. He discussed the Comprehensive Opioid Recovery Centers Reauthorization Act of 2023, which aims to support long-term recovery and wrap-around services for individuals. He addressed the need to manage the behavioral health needs of individuals transitioning in and out of the criminal justice system. He emphasized the importance of finding fiscally responsible solutions and empowering states to provide access to care for incarcerated individuals. He concluded by expressing his commitment to reauthorizing the SUPPORT Act and thanked his colleagues for their bipartisan efforts on these policies.

Subcommittee Ranking Member Eshoo (D-CA) emphasized the crucial need to reduce the impact of drug overdoses and the opioid crisis. She highlighted the alarming increase in the death toll caused by the epidemic. She pointed out that a significant contributing factor to opioid use disorder is the limited availability of treatment options, such as MAT. She emphasized the considerable lack of access to care, particularly affecting incarcerated individuals and low-income populations. She expressed her support for legislation extending Medicaid coverage to incarcerated individuals for thirty days before their release. Another concern raised was the shortage of mental health providers in the United States. She emphasized that local providers cannot meet the needs of their communities, especially in the context of SUD. She stated support for bills would expand care provided to mothers and children struggling with SUD. Regarding unintentional exposure to fentanyl, she highlighted its role in the rising number of deaths. She expressed her interest in learning about the government's actions and recommendations to address SUD, seeking guidance for Congress.

Full Committee Chair Rodgers (R-WA) provided an update on the committee's efforts to combat the opioid crisis. She highlighted key actions taken by the committee, such as organizing roundtables on illicit fentanyl, inviting Biden Administration officials to testify, conducting a field hearing, and leading the successful passage of the HALT Fentanyl Act with bipartisan support. Despite Congress allocating over $20 billion to states for substance use and opioid response grants, the chair acknowledged that the crisis has worsened. The COVID-19 pandemic and associated lockdowns disrupted recovery efforts, leading to an increase in despair and illicit drug use. Overdose deaths have surpassed 100,000 annually, driven by fentanyl poisonings and other substances. She emphasized the importance of addressing the underlying causes of the crisis, including cutting off the supply of illegal drugs, holding traffickers accountable, raising awareness about the presence of fentanyl in all drugs, expanding treatment options, and supporting the reintegration of individuals in recovery into their communities. While expressing support for reentry programs, the chair expressed reservations about the Reentry Act and the Due Process Continuity of Care Act, suggesting a need to understand existing barriers before expanding Medicaid or shifting costs to the federal government. She highlighted the committee's commitment to addressing the opioid crisis and urged the committee to strengthen and reauthorize the SUPPORT Act. She emphasized the changing landscape of opioid addiction, particularly the shift from prescription drugs to fentanyl as the primary cause of overdoses. She voiced support for removing Medicaid IMD exclusions to ensure individuals receive care where and when they need it. Finally, she expressed support for policies benefiting incarcerated individuals but expressed concerns about the current forms of certain bills.

Full Committee Ranking Member Pallone (D-NJ) supported the SUPPORT Act and the initiatives that it created. He stated that ongoing action was needed due to the increasing number of deaths caused by overdose. He expressed his support for removing barriers to supporting incarcerated individuals in their recovery and reauthorizing the programs outlined in the legislation. He stated that Congress should provide states with the resources to expand provider capacity and care in home and community-based settings. He expressed concerns about IMD exclusions, noting that only two states had opted into this provision. He voiced his concerns with H.R. 824, the telehealth excepted benefits bill. He believed that the bill was a solution in search of a problem and argued that consumers already had the flexibility to offer telehealth to their employees. He worried that the bill would expand a form of insurance not subject to the Affordable Care Act’s consumer protections and mental health parity, potentially leading to deceptively marketed plans and inadequate coverage for families, exposing them to surprise medical bills. He also expressed his concern with H.R. 1839, stating that he did not believe that Congress should be able to apply criminal penalties that had not been scheduled by the Administration. He hoped that the committee could work together to provide bipartisan solutions to address the SUD and opioid epidemic.

TESTIMONY

Ms. Espinosa testified about HRSA programs authorized under the SUPPORT Act and their efforts to expand access to substance use disorder treatment and prevention services, as well as strengthen the substance use disorder workforce. She expressed gratitude for the Subcommittee's bipartisan support for HRSA's programs. She highlighted the progress in expanding behavioral health services and training more mental health and SUD treatment providers. She discussed the HRSA Substance Use Disorder Treatment and Recovery (STAR) Loan Repayment Program, which aims to recruit and retain medical, nursing, and behavioral health clinicians providing direct treatment and recovery support for patients with substance use disorder. She mentioned the various provider disciplines and specialties eligible for participation in the program. She also said the reauthorization of HRSA's behavioral health workforce training programs under the SUPPORT Act supports the training of various professionals in the behavioral health field. She highlighted HRSA's National Health Service Corps, which offers scholarships and loan repayment for clinicians, including mental health and substance use disorder providers, who commit to practice in underserved communities. She mentioned the programs focused on substance use disorder providers, including the Substance Use Disorder Workforce Loan Repayment Program and the Rural Community Loan Repayment Program. She discussed the HRSA Rural Communities Opioid Response Program (RCORP) aimed at reducing the morbidity and mortality of substance use disorders in rural communities. She emphasized the importance of expanding behavioral health services in health centers, which are crucial in increasing access to mental health and substance use disorder treatment. She mentioned the proposed behavioral health service investment in health centers and the requirement for all health centers to provide mental health and substance use disorder services. She said HRSA's efforts to address substance use disorders through telehealth, licensure compacts, and collaborations with other programs such as the Ryan White HIV/AIDS Program and the Screening and Treatment for Maternal Mental Health and Substance Use Disorder Program. Her testimony highlighted HRSA's programs and initiatives to expand access to substance use disorder treatment and prevention services, strengthen the workforce, and integrate behavioral health services into primary care settings.

Mr. Coderre's testimony focused on the SUPPORT Act, its impact on addressing substance misuse, and the progress made by SAMHSA in implementing its provisions. He highlights the ongoing challenge of drug overdoses in the country, with synthetic and illicitly manufactured opioids causing significant increases in overdose deaths. Mr. Coderre emphasized the importance of a comprehensive approach to addressing the overdose crisis, including primary prevention, harm reduction, evidence-based treatment, and recovery support. He mentioned the comprehensive Overdose Prevention Strategy released by HHS at the beginning of the Biden Administration, which prioritizes these key areas. He also acknowledges the bipartisan efforts and collaborations between Congress and the Administration in addressing the overdose epidemic, including the Bipartisan Safer Communities Act and reauthorizations of SAMHSA programs. He discussed the Substance Use Prevention, Treatment, and Recovery Services Block Grant program administered by SAMHSA, which received an unprecedented $2 billion appropriation for FY 2023. He proposed updates to the program, such as including a 10 percent set aside for recovery services and using HIV cases instead of AIDS cases to calculate the HIV set aside. The testimony highlighted several SAMHSA programs and initiatives created or expanded by the SUPPORT Act. The SUPPORT Act included provisions for the First Responder Training for Opioid Overdose-Related Drugs (FR-CARA) program, which trains and equips first responders to respond to overdose incidents and administer naloxone. It provides comprehensive substance use disorder treatment, prevention, and recovery support services for pregnant and postpartum individuals, their children, and their families. Another program mentioned is the Comprehensive Opioid Recovery Center (CORC), which funds nonprofit organizations to provide a full spectrum of treatment and recovery support services for opioid use disorders. His testimony emphasized the importance of prevention, evidence-based treatment, and comprehensive support services in addressing the substance misuse crisis and the progress made by SAMHSA in implementing these initiatives.

Mr. Blum testified about CMS efforts to implement the SUPPORT Act and combat the opioid crisis. He emphasized the impact of the opioid crisis on millions of Americans and the need for comprehensive actions to address the situation. He discussed CMS's Behavioral Health Strategy, which aims to increase access to equitable and high-quality behavioral health services, including prevention and treatment services for substance use disorders, mental health services, crisis intervention, and pain care. CMS has implemented various initiatives and programs to improve access to substance use disorder prevention, treatment, and recovery services. One key initiative is expanding Medicare coverage for specific items and services provided by Opioid Treatment Programs (OTPs), including MAT with methadone. Medicare now pays for MAT services at OTPs through bundled payments, which has increased access to treatment for beneficiaries with opioid use disorder. CMS has also expanded access to treatment at OTPs, such as increasing bundled payments to account for the severity of patients' needs and allowing billing for services furnished via mobile units. CMS has supported state Medicaid agencies in expanding MAT options for Medicaid beneficiaries and has conducted a demonstration project to increase the number of Medicaid providers delivering SUD treatment or recovery services. CMS has also launched the Maternal Opioid Misuse (MOM) Model and the Integrated Care for Kids (InCK) Model to improve care for pregnant and postpartum Medicaid beneficiaries with OUD and children with physical and behavioral health needs, respectively. He highlighted the importance of telehealth in expanding access to behavioral health services, particularly during the COVID-19 pandemic. The SUPPORT Act removed geographic and site of service limitations for telehealth services for individuals with substance use disorders. CMS has expanded telehealth policies for mental health services in Medicare. CMS has also been working to increase access to crisis services in Medicare and Medicaid, including enhanced payment for crisis services in specific settings, implementing mobile crisis intervention services, and facilitating Medicaid reimbursement for school-based mental health professionals. His testimony highlighted CMS's efforts to address the opioid crisis through various initiatives, including expanding access to treatment, supporting state programs, promoting telehealth, and improving crisis services.

Dr. Jones discussed the CDC's efforts to address substance use, drug overdose, and mental health crisis in the United States. He highlighted the impact of the substance use and overdose crisis, with over a million Americans dying from a drug overdose since 2000. He mentioned that the proliferation of synthetic opioids, especially illicitly manufactured fentanyl, has increased overdose deaths since 2013. He discussed CDC's comprehensive public health approach to preventing overdose and substance use-related harms, which includes monitoring and analyzing trends, building capacity at the state and local level, supporting healthcare providers and employers, partnering with public safety and community organizations, and raising public awareness while reducing stigma. He mentioned the CDC's Overdose Data to Action (OD2A) program, which funds states and local health departments to implement data collection, analysis, and prevention efforts. He highlighted the importance of data systems such as the Drug Overdose Surveillance and Epidemiology (DOSE) System and the State Unintentional Drug Overdose Reporting System (SUDORS) in tracking and understanding overdose trends. He mentioned the CDC's efforts to improve the timeliness and completeness of drug overdose data collection and the development of advanced laboratory tests to identify synthetic opioids and other drugs of abuse. He addressed the importance of harm reduction strategies, such as fentanyl test strips and syringe services programs, in reducing the negative consequences associated with drug use. He also discussed CDC's efforts to understand and prevent drug-related harms among children and youth. He emphasized the importance of partnerships between federal agencies, national partners, public health, and public safety sectors to address and prevent drug overdose. He mentions the collaboration between the CDC and the High-Intensity Drug Trafficking Areas (HIDTA) program at the Office of National Drug Control Policy (ONDCP) through the Overdose Response Strategy (ORS) to reduce fatal and non-fatal drug overdoses.

Mr. Strait addressed the devastating drug crisis in the United States caused by illicit fentanyl. He highlighted the role of two Mexican drug cartels in driving the drug poisoning epidemic and emphasized the need to target and dismantle these criminal organizations. He stated that DEA's top operational priority is to defeat these cartels through various initiatives. He discussed the implementation of the SUPPORT Act, a comprehensive law aimed at combating the opioid crisis. Regarding data, DEA established a Suspicious Orders Database to improve information sharing and prevent the diversion of controlled substances. DEA is actively implementing several provisions of the SUPPORT Act. DEA has also made progress in expanding access to treatment services through mobile narcotic treatment programs and is working on regulations related to telemedicine prescribing of controlled substances. DEA is committed to increasing access to medications for opioid use disorder (MOUD). They have obtained certifications and registrations to provide MOUD in federal prisons. They are working on expanding immediate and emergency access to narcotic medications for individuals suffering from acute withdrawal symptoms. The recent elimination of the DATA-waiver registration requirement will further increase access to buprenorphine for those in need. He expressed DEA's dedication to combating the drug poisoning epidemic and willingness to work with Congress to find practical solutions to this crisis.

KEY QUESTIONS AND ANSWERS

Ranking Member Eshoo (D-CA) raised concerns about chronic pain and people turning to opioids for relief. She inquired about what CMS is doing to enhance access to non-opioid treatment options for pain management. Mr. Blum replied that CMS needs to expand chronic pain treatment and mentioned efforts to broaden physician networks addressing pain management.

Rep. Schrier (D-WA) asked if rural areas have the workforce and the resources to treat SUD. She mentioned that a pain management specialist is not accessible in rural communities and asked what HRSA is doing to solve it. Ms. Espinosa answered that HRSA has programs that help train clinicians in rural areas, which leads them to stay in that more rural community. She stated that fellowships are available in these areas for pain management and drug utilization, but Congress could partner with HRSA to expand this.

Rep. Johnson (R-OH) asked about what HHS has done to distribute the recommendations of the federal pain management task force. Mr. Blum answered that HHS works with states to ensure that providers and prescriptions appropriately use care models and medication to treat pain.

Rep. Sarbanes (D-MD) asked about the STAR-LRP program. Ms. Espinosa responded that the STAR-LRP program has tremendously impacted the types of places that provide care and receive reimbursement. The act has allowed for the expansion of the types of providers giving care.

Rep. Carter (R-GA) asked if the DEA would issue another temporary extension to the rule that allows the buprenorphine to be prescribed via telemedicine. Mr. Strait stated that the DEA will not let vital services lapse and is doing everything in their power to ensure that the final rulemaking has been well thought out.

Rep. Barragan (D-CA) asked how HRSA supports community health centers in improving access to behavioral health services. Ms. Espinosa responded that community health centers have been able to leverage partnerships to expand access to behavioral health services, but they need more funding to make even more progress.

Rep. Joyce (R-PA) inquired about the allocation of funding in rural areas to support providers and enhance access to behavior and mental health services. In response, Ms. Espinosa explained that training providers in rural regions would attract more clinicians who are willing to stay in those areas. Additionally, having a greater number of individuals receiving training can contribute to providing some level of care. Rep. Joyce further inquired about the prevalence of synthetic opioids, specifically illicit fentanyl, and its impact on SAMSHA's communication with providers. Ms. Espinosa clarified that SAMSHA employs its programs to furnish centers with best practices and facilitate data communication to address the challenges associated with synthetic opioids. Rep. Joyce then shifted the focus to the implementation of recommendations by CDC from the pain management taskforce and their role in promoting non-opioid options. Dr. Jones responded that the CDC guidelines align well with the pain management taskforce and acknowledge the significance of opioids. However, the CDC has found that non-opioid alternatives are sometimes more suitable for patients.

Rep. Miller-Meeks (R-IA) asked about what CMS is doing to support policies for and increase access to and availability of non-addictive pain management options and that patients have access to these options. Mr. Blum answered that CMS is working hard to ensure that Medicare beneficiaries receive the full spectrum of coverage and that these programs are appropriate.

CLOSING STATEMENTS

Chairman Guthrie (R-KY) concluded by thanking the witnesses for their testimonies and adjourned the committee.