U.S. GOVERNMENT PUBLISHING OFFICE

26–839 WASHINGTON : 2018

COMBATING THE OPIOID CRISIS: BATTLES IN 

THE STATES 

HEARING 

BEFORE THE

SUBCOMMITTEE ON OVERSIGHT AND 

INVESTIGATIONS 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

JULY 12, 2017 

Serial No. 115–43 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 

(II) 

COMMITTEE ON ENERGY AND COMMERCE 

GREG WALDEN, Oregon 

Chairman 

JOE BARTON, Texas 

Vice Chairman 

FRED UPTON, Michigan 

JOHN SHIMKUS, Illinois 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

STEVE SCALISE, Louisiana 

ROBERT E. LATTA, Ohio 

CATHY MCMORRIS RODGERS, Washington 

GREGG HARPER, Mississippi 

LEONARD LANCE, New Jersey 

BRETT GUTHRIE, Kentucky 

PETE OLSON, Texas 

DAVID B. MCKINLEY, West Virginia 

ADAM KINZINGER, Illinois 

H. MORGAN GRIFFITH, Virginia 

GUS M. BILIRAKIS, Florida 

BILL JOHNSON, Ohio 

BILLY LONG, Missouri 

LARRY BUCSHON, Indiana 

BILL FLORES, Texas 

SUSAN W. BROOKS, Indiana 

MARKWAYNE MULLIN, Oklahoma 

RICHARD HUDSON, North Carolina 

CHRIS COLLINS, New York 

KEVIN CRAMER, North Dakota 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

FRANK PALLONE, JR., New Jersey 

Ranking Member 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

MICHAEL F. DOYLE, Pennsylvania 

JANICE D. SCHAKOWSKY, Illinois 

G.K. BUTTERFIELD, North Carolina 

DORIS O. MATSUI, California 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

JERRY MCNERNEY, California 

PETER WELCH, Vermont 

BEN RAY LUJA ́ N, New Mexico 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

DAVID LOEBSACK, Iowa 

KURT SCHRADER, Oregon 

JOSEPH P. KENNEDY, III, Massachusetts 

TONY CA ́ RDENAS, California 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

DEBBIE DINGELL, Michigan 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

TIM MURPHY, Pennsylvania 

Chairman 

H. MORGAN GRIFFITH, Virginia 

Vice Chairman 

JOE BARTON, Texas 

MICHAEL C. BURGESS, Texas 

SUSAN W. BROOKS, Indiana 

CHRIS COLLINS, New York 

TIM WALBERG, Michigan 

MIMI WALTERS, California 

RYAN A. COSTELLO, Pennsylvania 

EARL L. ‘‘BUDDY’’ CARTER, Georgia 

GREG WALDEN, Oregon (ex officio) 

DIANA DEGETTE, Colorado 

Ranking Member 

JANICE D. SCHAKOWSKY, Illinois 

KATHY CASTOR, Florida 

PAUL TONKO, New York 

YVETTE D. CLARKE, New York 

RAUL RUIZ, California 

SCOTT H. PETERS, California 

FRANK PALLONE, JR., New Jersey (ex 

officio) 

(III) 

C O N T E N T S 

Page 

Hon. Tim Murphy, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 1 

Prepared statement .......................................................................................... 3 

Hon. Diana DeGette, a Representative in Congress from the State of Colorado, opening statement ...................................................................................... 5 

Hon. Greg Walden, a Representative in Congress from the State of Oregon, 

opening statement ................................................................................................ 6 

Prepared statement .......................................................................................... 8 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 9 

WITNESSES

Boyd K. Rutherford, Lieutenant Governor, State of Maryland ........................... 11 

Prepared statement .......................................................................................... 14 

Answers to submitted questions ......................................................................

Brian J. Moran, Secretary of Public Safety and Homeland Security, State 

of Virginia ............................................................................................................. 24 

Prepared statement .......................................................................................... 26 

Answers to submitted questions ......................................................................

John Tilley, Secretary of The Justice and Public Safety Cabinet, State of 

Kentucky ............................................................................................................... 45 

Prepared statement .......................................................................................... 47 

Answers to submitted questions ......................................................................

Rebecca Boss, Director, Department of Behavioral Healthcare, Developmental 

Disabilities and Hospitals, State of Rhode Island ............................................. 50 

Prepared statement .......................................................................................... 52 

Answers to submitted questions ......................................................................

SUBMITTED MATERIAL

Statement of the National Association of Medicaid Directors Board of Directors, submitted by Ms. Castor ............................................................................. 95 

Article entitled, ‘‘Why taking morphine, oxycodone can sometimes make pain 

worse,’’ Science, May 30, 2016, submitted by Mr. Murphy .............................. 97 

Article entitled, ‘‘51 percent of opioid prescriptions go to people with depression and other mood disorders,’’ STAT, June 26, 2017, submitted by Mr. 

Murphy .................................................................................................................. 100 

Committe memorandum .......................................................................................... 104 

(1) 

COMBATING THE OPIOID CRISIS: BATTLES IN 

THE STATES 

WEDNESDAY, JULY 12, 2017 

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, COMMITTEE ON ENERGY AND COMMERCE, Washington, DC. 

The subcommittee met, pursuant to call, at 10:00 a.m., in room 

2123, Rayburn House Office Building, Hon. Tim Murphy (chairman 

of the subcommittee) presiding. 

Present: Representatives Murphy, Griffith, Barton, Brooks, Collins, Walberg, Walters, Costello, Carter, Walden (ex officio), 

DeGette, Schakowsky, Castor, Tonko, Ruiz, Peters, and Pallone (ex 

officio). 

Also Present: Representatives Guthrie, Bilirakis, Bucshon, and 

Kennedy. 

Staff Present: Elena Brennan, Legislative Clerk, Energy/Environment; Zachary Dareshori, Staff Assistant; Paul Edattel, Chief 

Counsel, Health; Ali Fulling, Professional Staff Member; Brittany 

Havens, Professional Staff Member, Oversight and Investigations; 

Katie McKeough, Press Assistant; John Ohly, Professional Staff 

Member, Oversight and Investigations; Chris Santini, Professional 

Staff Member; David Schaub, Detailee, Oversight and Investigations; Kristen Shatynski, Professional Staff Member, Health; Alan 

Slobodin, Chief Investigative Counsel, Oversight and Investigations; Evan Viau, Staff Assistant; Hamlin Wade, Special Advisor, 

External Affairs; Christina Calce, Minority Counsel; Jeff Carroll, 

Minority Staff Director; David Goldman, Minority Chief Counsel, 

Communications and Technology; Chris Knauer, Minority Oversight Staff Director; Miles Lichtman, Minority Policy Analyst; 

Kevin McAloon, Minority Professional Staff Member; Dino 

Papanastasiou, Minority GAO Detailee; Andrew Souvall, Minority 

Director of Communications, Outreach and Member Services; and 

C.J. Young, Minority Press Secretary. 

OPENING STATEMENT OF HON. TIM MURPHY, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA 

Mr. MURPHY. Good morning, everyone. Today, the Subcommittee 

on Oversight and Investigation holds a hearing entitled Combating 

the Opioid Crisis: Battles in the states. Make no mistake, the term 

‘‘combating’’ and ‘‘battle’’ are entirely appropriate. Our nation is in 

the midst of a tremendous fight against death and devastation affecting every corner of our Nation. 

2 

In 2015, there were more than 52,000 deaths from drug overdose 

in the U.S., with more than 33,000 deaths involving an opioid, a 

24 percent increase from the prior year. The overdose death rate 

in 2015 was almost seven times the rate of deaths from the heroin 

epidemic of the 1970s. For 2016, we have learned from an analysis 

by The New York Times that we have lost roughly 60,000 people 

to drug overdoses. That is more in 1 year than all the names on 

the Vietnam Veterans’ Memorial Wall, and likely, that number is 

underestimated because much of the data will not be in until the 

end of this year, 2017. It is staggering. 

For every fatal overdose, it has been estimated there are 20 

nonfatal overdoses. And for 2016, that could be near 1 million. 

More than 183,000 lives have been lost in the U.S. from opioid 

overdoses between 1999 and 2015. That is about 500,000 that will 

be lost over the next decade. The roots of this crisis began back in 

1980 when a letter to the editor by two doctors published in the 

New England Journal of Medicine was misinterpreted as evidence. 

It was unlikely that someone would become addicted. Out of 40,000 

cases, they said there were only four addictions. 

Twenty years later, the Joint Commission on Accreditation of 

Healthcare Organizations following the American Medical Association recommendation that pain be assessed as the fifth vital sign, 

and established standards for pain management interpreted by 

many doctors as encouraging the prescribing of opioids. Under the 

Affordable Care Act, prescribing pain killers is incentivized by patient questionnaires where a question specifically asked if their 

pain was adequately addressed to their satisfaction. Based upon 

their answer, a hospital may receive more or less money. 

As we learned in our oversight hearing held in March, the opioid 

epidemic is an urgent public health threat fueled by fentanyl, a 

much more dangerous and potent synthetic opioid and a clear and 

present danger to America. 

Two states represented on today’s panel, Rhode Island and Maryland, were the first ones hit by the fentanyl wave, and unfortunately, it seems certain that this wave will sweep the Nation as 

low-cost, high-profit, hard-to-detect profile of fentanyl is increasingly attracted to traffickers and easy to manufacture, or obtain 

over the Internet. 

This is an in extremis moment requiring all the experience, resources, cooperation of our Federal, state, and local governments, 

as well as all the different industries, professionals, and experts to 

curb this terrible outbreak. With this hearing, we will focus on the 

actions of our state governments to find out what efforts are working, what is not working, how we can work together to save lives. 

To the panel, I say, we want to know the problems, and please be 

candid with us, because as you know, there are millions of families 

being torn apart by this. 

As drug policy expert Sally Satel noted, ‘‘It is at the state and 

county levels that the real progress will be made. It makes sense 

that the efforts to find inspired solutions would be most concentrated there. We should invest in those solutions and learn from 

them.’’ 

Serving the front lines of the opioid epidemic, state governments 

have been pursuing their own innovative initiatives, such as more 

3 

inventive use of incentives, more structured medication-assisted 

treatment, more comprehensive prescription drug monitoring. 

States such as Maryland are making the best use of the Center 

for Disease Control opioid prescribing guidelines to help push back 

on the overprescribing. Kentucky’s All Schedule Prescription Electronic Reporting system, more known as KASPER, a web-based 

monitoring system to help prescription use across the state, is helping state regulators identify questionable prescribing practices by 

physicians and abuse by patients. 

Virginia has greatly expanded access to Naloxone, the drug that 

can rapidly reverse an opioid overdose, but then again, can have 

its own risk and its use. Some states are expanding the availability 

of Naloxone by permitting third-party prescribing by family and 

friends of individuals who are at high risk of overdose. Rhode Island has developed the AnchorEd Program that matches overdose 

victims with peer recovery coaches to encourage treatment, who follow up with the patient for the next 10 days after the overdose. 

Much of the work of the states should help inform the President’s 

Commission on Combating Drug Addiction and the Opioid Crisis. 

Two years ago, the subcommittee held a similar hearing on what 

the state governments were doing to combat the opioid abuse epidemic. Such oversight helped Congress enact provisions in the 

Comprehensive Addiction Recovery Act, or CARA, and it will help 

the administration. 

We put $1 billion into grants over the next 2 years, but we want 

to know if this money is being used wisely, and what is working. 

We are eager to learn about those programs. But the 21st Century 

Cures state program is just the beginning. Our state government 

witnesses can help this committee develop a more effective and national strategy to combat the opioid crisis in such areas as substance abuse prevention and education, physician training, treatment of recovery, law enforcement, expanded access to Vivitrol, 

while testing for drugs in correctional facilities, data collection, examining what reforms can be made to the 42 CFR Part 2, so there 

is better coordination of care among physicians, and we can help 

prevent relapses and overdose and improve patient safety. 

We are in one of the worst medical tragedies of our time, perhaps 

the worst. And although this subcommittee has given its attention 

to many other problems in the past, we recognize this is paramount 

among them. This is a national emergency. And we look forward 

to hearing from the states and what you are doing on the front 

lines of this. 

[The prepared statement of Mr. Murphy follows:] 

PREPARED STATEMENT OF HON. TIM MURPHY

Today, the Subcommittee holds a hearing entitled, ‘‘Combating the Opioid Crisis: 

Battles in the States.’’ Make no mistake. The terms ‘‘combating’’ and ‘‘battles’’ are 

entirely appropriate; our nation is in the midst of a tremendous fight against death 

and devastation affecting every corner of our nation. 

In 2015, there were more than 52,000 deaths from drug overdoses in the U.S., 

with more than 33,000 deaths involving an opioid, a 24 percent increase from the 

prior year. The opioid overdose death rate in 2015 was almost seven times the rate 

of deaths from the heroin epidemic during the 1970’s. For 2016, we have learned 

from an analysis by the New York Times—not from the Federal government—that 

we have lost roughly 60,000 people to drug overdoses, more than all the Americans 

who died in the Vietnam War. The staggering number of deaths is only part of the 

4 

picture. For every fatal opioid overdose, it has been estimated that there are approximately 20 non-fatal overdoses. For 2016, the number of overdoses could be 

nearing one million. 

More than 183,000 lives have been lost in the U.S. from opioid overdoses between 

1999 and 2015. A recent forecast from STAT News projects that almost 500,000 

lives will be lost from opioid overdoses in the U.S. over the next decade. 

The roots of this crisis began back in 1980, when a letter to the editor from two 

doctors published in the New England Journal of Medicine was misinterpreted as 

evidence of the unlikelihood that patients given pain drugs would develop addiction. 

About twenty years later, the Joint Commission on Accreditation of Healthcare Organizations, following the American Medical Association recommendation that pain 

be assessed as the fifth vital sign, established standards for pain management interpreted by many doctors as encouraging the prescribing of opioids. Under the Affordable Care Act, prescribing painkillers is incentivized because hospital payments are 

tied to patient satisfaction surveys that reward hospitals financially when patients 

give them high ratings. 

As we learned in our oversight hearing held in March, the opioid epidemic is an 

urgent public health threat fueled by fentanyl, a much more dangerous and potent 

synthetic opioid and a clear and present danger to America. Two states represented 

on today’s panel, Rhode Island and Maryland, were the first ones hit by the fentanyl 

wave. Unfortunately, it seems certain that this wave will sweep the nation as the 

low-cost, high-profit, hard-to-detect profile of fentanyl is increasingly attractive to 

traffickers and is relatively easy to manufacture or obtain on the street or over the 

internet. 

This is an in extremis moment requiring all the experience, resources, and cooperation of our federal, state, and local governments, as well as all the different 

industries, professionals, and experts to curb this outbreak. With this hearing, we 

will focus on the actions of our state governments to find out what efforts are working, what is not working, and how we can work together to save lives, restore communities, and repair the millions of families torn apart by the deadliest drug crisis 

in United states history. As drug policy expert Sally Satel noted ‘‘[it] is at the state 

and county levels that the real progress will be made.It makes sense that the effort 

to find inspired solutions would be most concentrated there; we should invest in 

those solutions and learn from them.’’ 

Serving on the front lines of the opioid epidemic, state governments have been 

pursuing their own innovative initiatives, such as more inventive use of incentives, 

more structured medication assisted treatment and more comprehensive prescription drug monitoring. states such as Maryland are making the best use of the Centers for Disease Control Opioid Prescribing Guidelines to help push back on the 

overprescribing of opioids. Kentucky’s All-Schedule Prescription Electronic Reporting System, or KASPER—a web-based database to monitor opioid prescription and 

use across the state—is helping state regulators identify questionable prescription 

practices by physicians and abuse by patients. Virginia has greatly expanded access 

to Naloxone, the drug that can rapidly reverse an opioid overdose. 

Some states are expanding the availability of Naloxone by permitting third party 

prescribing by family and friends of individuals who are at high-risk of overdose. 

Rhode Island has developed the AnchorED program that matches overdose victims 

with peer recovery coaches to encourage treatment, who follow-up with the patient 

for the next 10 days after the overdose. Much of the work of the states should help 

inform the President’s Commission on Combating Drug Addiction and the Opioid 

Crisis. 

Two years ago, the Subcommittee held a similar hearing on what the state governments were doing to combat the opioid abuse epidemic. Such oversight helped 

Congress enact provisions in the Comprehensive Addiction Recovery Act and 21st 

Century Cures Act which authorized the Substance Abuse and Mental Health Services Administration to administer nearly one billion dollars in grants over the next 

two years to states and territories for substance abuse prevention programs, treatment, and training for health professionals. We are eager to learn about how the 

states represented here today plan to use these grants, to ensure the grants are 

reaching local communities in need, and that the help provided is really working. 

However, the 21st Century Cures state grant program is just a beginning. Our 

state government witnesses can help this Committee develop a more effective national strategy to combat the opioid crisis in such areas as: substance abuse prevention and education, physician training, treatment and recovery, law enforcement, expanding access to Vivitrol while testing for drugs in correctional facilities, data collection, and examining what reforms can be made to 42 CFR Part 2 so that there 

is better coordination of care among physicians. 

5 

We are honored to have our distinguished witnesses join us this morning. We 

thank you for appearing today and look forward to hearing your testimony. 

Mr. MURPHY. Now I yield to my colleague for 5 minutes, Ms. 

DeGette of Colorado. 

OPENING STATEMENT OF HON. DIANA DEGETTE, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF COLORADO 

Ms. DEGETTE. Thank you so much, Mr. Chairman. And I appreciate this most recent hearing on opioid addiction. As you said so 

accurately, this crisis is really devastating America, as all of us on 

the dais have seen it play out in our communities, urban and rural 

alike. Not a day passes without a report about children watching 

their parents overdose, about librarians and school nurses being 

trained to administer Naloxone to overdose victims, or about local 

and state governments trying to respond to the myriad of issues 

surrounding addiction, all, at the same time, trying to stay within 

their budgets. 

There is some good news. Recently, the CDC reported that opioid 

prescriptions peaked in 2010, and have since fallen by 41 percent. 

That is the good news. The bad news is, opioid prescribing remains 

untenably high. And I am hoping our future investigations will concentrate on this. 

In addition, as you pointed out, Mr. Chairman, is the emergence 

of illegal fentanyl, which is an exceptionally potent opioid. In 2017, 

fentanyl overtook both heroin and prescription opioids as the leading cause of death in many places. Each of the states who are here 

today, and I want to thank you all for coming, have faced alarming 

overdose outbreaks due to this drug’s pervasive dangerous nation. 

This committee has done some good work, in particular, investigating the seemingly voluminous amount of pills distributed in 

West Virginia. And I know that we are planning to do more. As you 

know, a number of state Attorneys General are investigating manufacturers, and, in some cases, distributors. The attorney general 

in my home State of Colorado, for example, has joined a bipartisan 

coalition of states nationwide, looking into whether manufacturers 

engaged in illegal or deceptive practices when marketing opioids. 

Coming up with an effective solution to the opioid epidemic will 

require us to understand the actions of all actors. I hope to hear 

from some of the states today on what role they believe drug manufacturers and distributors may be adding to the crisis. Also, I look 

forward to hearing from the panel about the impact of fentanyl on 

the towns and communities in which they work. states really are 

on the front lines of fighting this crisis, and I look forward to hearing from all of you. 

I know that Rhode Island, for example, has led the way in connecting people with substance abuse disorders to highly trained 

coaches to guide them through recovery. Virginia is working to implement a similar peer recovery program. And Kentucky has established a program to provide medication-assisted treatment to individuals in correctional facilities and to continue supporting them 

after they are released. Maryland has just committed to establishing a 24-hour crisis center in Baltimore City. 

6 

Mr. Chairman, I know these are all great state efforts. We have 

made some efforts here in Congress, and I appreciate you referring 

to the 21st Century Cures legislation that Congressman Upton and 

I sponsored, and that this whole committee worked together on a 

bipartisan basis to pass. But as we move forward on this issue, we 

really need to work together to continue to address this, and that 

is why I kind of hate to be the fly in the ointment, and talk about 

what these efforts to repeal the Affordable Care Act will do to the 

fight against the opioid epidemic. As you know, the ACA has 

helped nearly 20 million Americans obtain healthcare coverage. In 

addition, it’s enabled governors to expand Medicaid services that 

are critical tools in the fight. 

For example, studies that show that since 2014, 1.6 million uninsured Americans gained access to substance abuse treatment 

across the 31 states that expanded Medicaid coverage. This is particularly true for hard-hit states like Kentucky, where one study reports that residents saw a 700 percent increase in Medicaid beneficiaries seeking treatment for substance abuse. Many people think 

that the House-passed bill that undermines the ACA will threaten 

people’s ability to get opioid treatment. In its assessment, the nonpartisan CBO said the House bill would cost 23 million, or 22 million, Americans to lose health insurance. A lot of these people need 

opioid treatment. 

Now, there have been discussions, both in the House bill and the 

Senate discussions, about adding some money for opioid treatment. 

But, for example, the most recent Senate suggestion of additional 

$45 billion to help combat opioid addiction, Governor John Kasich 

said, ‘‘It is like spitting in the ocean, it is not enough.’’ 

We have got to get real and understand that access to healthcare 

treatment is what is going to help with the health of all Americans, 

including treatment of opioid addiction. And we have got to move 

forward to work on this together. I hope we can do that. And with 

that, I will yield back, Mr. Chairman. 

Mr. MURPHY. The gentlewoman yields back. I now recognize the 

chairman of the full committee, Mr. Walden. 

OPENING STATEMENT OF HON. GREG WALDEN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF OREGON 

Mr. WALDEN. Thank you very much, Mr. Chairman. Addiction is 

an equal opportunity destroyer. It is a crisis that does not pick people based on their age, race, or socioeconomic status, and it most 

certainly does not pick them based on political parties. From my 

roundtables throughout the Second District of Oregon, it didn’t 

matter if I were in a rural community or a more populated city, the 

tragic stories were very similar. We all know someone who has 

been impacted by this epidemic. 

In my state, more people die from drug-related overdoses than 

from automobile accidents, and sadly, that is not unique. According 

to a preliminary data analysis, drug overdose deaths in 2016 likely 

exceeded 59,000 people. That is the largest annual jump ever recorded in the United states. And what’s worse, some of the preliminary numbers from the states indicate that their numbers within 

the first 6 months of this year are already surpassing last year’s 

7 

total numbers. And over the past 7 years, opioid addiction diagnoses are up nearly 500 percent, according to a recent report. 

Despite a report released by the Centers for Disease Control last 

week, which indicates the number of opioid prescriptions has decreased over the last 5 years. That’s the good news. The rates are 

still three times as high as they were just back in 1999. And the 

amount of opioids prescribed in 2015 was enough for every American to be medicated around the clock for 3 weeks. That report also 

found that counties in Oregon have some of the highest levels of 

opioid prescriptions in the country. Of the top 10 counties in my 

state for opioid prescriptions, five of them are in my rural district. 

Moreover, Oregonians, aged 65 and over, are being hospitalized 

for opioid abuse, overdoses, and other complications at a far higher 

rate than any other state in the Union. Sadly, overdose deaths continue to escalate, and this epidemic is simply getting worse and 

more severe. So challenges remain and we need to get after it. 

First, we need to improve data collection. In a few states, we are 

already requiring more specific information related to overdose 

deaths. Quite simply, we cannot solve what we do not know. We 

need to be able to have more timely and reliable data so we can 

better understand and address the full scope of the problem. There 

also needs to be an increase in overdose prevention efforts, improvement with respect to the utilization and interoperability of 

prescription drug monitoring programs. And we need to increase 

access to evidence-based treatment, including medication-assisted 

treatment. 

Combating this epidemic requires an all-hands-on-deck effort 

from Federal, state and local officials, and all of us spanning from 

healthcare experts to our local law enforcement communities, that’s 

precisely why we are having this hearing today. Last year, Congress took action to combat this crisis by passing legislation, including the Comprehensive Addiction Recovery Act, and the 21st 

Century Cures Act, and states have pursued programs to strengthen our fight against this epidemic. But much more needs to be 

done. We need to work together to ensure that the tools and funding Congress has created are reaching our state and localities, and 

that they are being used effectively. 

We hope to hear from the state officials today to see how they 

are utilizing these funds, and whether these programs work or not. 

We greatly appreciate the witnesses who have agreed to appear before us today. We hope to have a constructive dialogue about what 

the states are doing, how we can improve data collection, what initiatives are working, what isn’t working, and how the Federal Government can be a better partner in this collective fight. 

I look forward to your testimony and working with all of you and 

our community leaders to help get our hands on this horrific crisis. 

So thank you for being here. With that, I know I have two members that want to introduce witnesses, so I will go first to Mr. 

Guthrie, and then I’ll go to Mr. Griffith. 

[The prepared statement of Mr. Walden follows:] 

8 

PREPARED STATEMENT OF HON. GREG WALDEN

Addiction is an equal opportunity destroyer. It is a crisis that does not pick people 

based on their age, race, or socioeconomic status. And it most certainly does not pick 

based on political parties. 

From my roundtables throughout the Second District of Oregon, it didn’t matter 

if I was in a rural community or a more populated city; the tragic stories were similar. We all know someone who has been impacted by this epidemic. In Oregon, more 

people now die from drug-related overdoses than from automobile accidents—and 

sadly, that is not unique to my home state. 

According to a preliminary data analysis, drug overdose deaths in 2016 most likely exceeded 59,000—the largest annual jump ever recorded in the United states. 

What’s worse? Some of the preliminary numbers from the states indicate that their 

numbers within the first six months of this year are already surpassing last year’s 

total numbers. And over the past seven years, opioid addiction diagnoses are up 

nearly 500 percent, according to a recent report. 

Despite a report released by the Centers for Disease Control last week which indicates that the number of opioid prescriptions has decreased over the past five years, 

the rates are still three times as high as they were in 1999, and the amount of 

opioids prescribed in 2015 was enough for every American to be medicated around 

the clock for three weeks. 

That report also found that counties in Oregon have some of the highest levels 

of opioid prescriptions in the country. Of the top 10 counties in Oregon for opioid 

prescriptions, five of them are in my rural district. Moreover, Oregonians age 65 and 

older are being hospitalized for opioid abuse, overdoses, and other complications at 

a far higher rate than any other state in our union. 

Sadly, overdose deaths continue to escalate. This epidemic is getting more severe. 

Challenges clearly remain. 

First, we need to improve data collection, and a few states are already requiring 

more specific information related to overdose deaths. Quite simply, we can’t solve 

what we don’t know. 

We need to be able to have more timely and reliable data so we can better understand and address the full scope of the problem. There also needs to be an increase 

in overdose prevention efforts, improvement with respect to the utilization and 

interoperability of Prescription Drug Monitoring Programs, and we need to increase 

access to evidence-based treatment, including Medication-Assisted Treatment. 

Combating this epidemic requires an all-hands-on-deck effort from federal, state, 

and local officials—spanning from health care experts to our law enforcement community. That is precisely why we are having this hearing today. 

Last year Congress took action to combat this crisis by passing legislation, including the Comprehensive Addiction and Recovery Act and the 21st Century Cures Act, 

and states have pursued programs to strengthen our fight against this epidemic. 

But much more needs to be done. We need to work together to ensure that the tools 

and funding Congress has created are reaching our state and localities, and that 

they are being used effectively. We hope to hear from the State officials before us 

today to see how they are utilizing these funds and what programs have proven to 

be successful. 

We greatly appreciate the witnesses who have agreed to appear before us today. 

We hope to have a constructive dialogue about what the states are doing; how we 

can improve data collection; what initiatives are working, what isn’t working; and 

how the federal government can be a partner in this collective fight. I look forward 

to your testimony, and working with all of you to help our communities and solve 

this horrific crisis. 

Mr. GUTHRIE. Thank you, Mr. Chairman. Thank you, Mr. Chairman, for letting me sit in for purposes of introduction. I want to 

introduce our Secretary of Justice and Public Safety in Kentucky, 

Secretary Tilley. We have been friends for a long time. We served 

in the general assembly together. Secretary Tilley had a strong reputation, strong work as fiduciary chairman in the House, working 

with the Senate to produce legislation that I think is landmark and 

was very important. And we have so much to do in Kentucky. We 

have 1404 people that passed away last year from opioid addiction. 

There is so much to be done. So we are sitting here saying thank 

you for the work that you have done. I know we have enormous 

9 

work to be done, and I tell my colleagues on the committee here 

and my friends, I can think of nobody else in Kentucky I’d rather 

have in sitting where you are and leading this effort, and I applaud 

Governor Bevin for making the choice, and asking you to serve in 

his cabinet, and appreciate your willingness to do so. I think you 

will make a big impact. And I yield back. 

Mr. WALDEN. Now I recognize the gentleman from Virginia, Mr. 

Griffith, for purpose of introduction. 

Mr. GRIFFITH. Thank you very much. I appreciate that. I would 

like to introduce Secretary Brian Moran. Brian was a prosecutor 

first, and then he came to the Virginia House of Delegates, where 

he and I served together for a number of years. He was a leader 

on the other side of the aisle, but he was always a pleasure to work 

with, and appreciate his work very, very much. And then he became the first Secretary of Homeland Security in Virginia’s history, 

and has oversight over 11 agencies. But he is generally well-reasoned; every now and then we would disagree on the floor of the 

House, but not always. But we worked together on a number of 

things. And I apologize, both Mr. Guthrie and I have to run to another committee where we have two bills that are upstairs, so I 

won’t be able to stay, but I will read with interest your testimony 

and learn from my colleagues the good words that you have to say. 

And I welcome you to our committee, and I apologize that I can’t 

be here because I’m defending a bill upstairs. 

Mr. WALDEN. With that, I will yield back the balance of my time. 

Unfortunately, I, too, must go to that subcommittee. 

Mr. MURPHY. Come on back. This is where it’s going to be exciting. I note Secretary Moran is a spitting image of his brother. I 

now recognize the gentleman from New Jersey, Mr. Pallone, for 5 

minutes. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. Thank you, Mr. Chairman. Thanks for holding this 

hearing on this critical issue. Our committee has held several hearings on the ongoing opioid crisis, including one in March. The 

opioid epidemic is not letting up, and neither can our efforts to 

fight it. Since our last hearing many more lives have been destroyed. There is no community that remains completely untouched 

by the opioids crisis. 

Recently, the CDC reported that the opioid prescribing rate has 

peaked, but remains far too high, with enough opioids to keep 

every American medicated around the clock for 3 weeks. I’m glad 

we have the states here today so we can hear about what they’re 

seeing on the front lines, what successful approaches they have 

found that deserve to be replicated, and what challenges they still 

face. 

I’d also like to hear from our witnesses about how the Federal 

Government can help. While it is important the states be empowered to address the particular challenges of their communities, our 

response to this epidemic cannot be 51 separate efforts. We must 

harness our national resources data in cooperation to get this crisis 

under control. 

10 

But as we talk about a public health crisis of this magnitude, 

there is an elephant in the room that needs to be addressed. Coverage for substance abuse treatment is how an individual in society 

has a fighting chance to kick the opioids epidemic for good. Health 

coverage is one of our strongest weapons in the battles against 

opioids, the epidemic, and the devastation it causes to our families. 

Yet, Republicans persist in their attempts to gut the Medicaid 

program by capping it permanently, and ending Medicaid expansion as part of its efforts to repeal the Affordable Care Act. Repealing the Affordable Care Act and replacing it with TrumpCare 

would be devastating to 74 million Americans who receive critical 

healthcare services from the program. Today, 1 in 5 Americans receive their health insurance from Medicaid. Half of all the babies 

born in this country are financed by Medicaid. And to the working 

poor, many of whom are hit hard by the opioids epidemic, and are 

eligible for Medicaid for the first time through the ACA’s expansion. Medicaid is, quite literally, the only affordable health insurance available. And make no mistake, state Medicaid programs are 

at the center of the opioids epidemic. 

Yet, in the House-passed TrumpCare, the CBO determined that 

23 million Americans would lose coverage, the majority of them 

covered through Medicaid, with $834 billion in cuts to the program. 

The Senate’s version of TrumpCare is no better, cutting Medicaid 

by a full 35 percent over the next two decades. These cuts could 

not come at a worse time from the perspective of the opioids crisis 

for states and for people who depend on the coverage Medicaid provides. There’s no substitute for coverage for our states or for the 

people that need the care. 

As the Senate continues to make cosmetic changes to its bill with 

only one goal in mind, passing any bill out of the Senate. Let’s be 

very clear, no one-time amount of funds, whatever that amount 

may be, will ever replace the certainty of comprehensive coverage. 

No cosmetic changes can effectively offset the damage that could be 

caused by repealing the ACA and cutting hundreds of billions of 

dollars from the Medicaid program. 

So, Mr. Chairman, we must stay vigilant in this fight and remain 

open to any solution that shows promise. So I thank you for having 

this hearing. But I believe that there is no way that this crisis can 

be solved with one-time infusions of resources, and it will only get 

worse if Medicaid dollars are removed from the fight. We must invest in our healthcare system and its critical public programs for 

the long term, and Medicaid is clearly a critical pillar that should 

be strengthened, not decimated. 

And I fear that if Republicans are successful in passing 

TrumpCare, we will end up going in the opposite direction when 

it comes to fighting the drug problem that has so devastated our 

communities. Thank you, and I yield back. I don’t think anybody 

on my side wants the time, so I yield back, Mr. Chairman. 

Mr. MURPHY. Thank you for your comments. I ask unanimous 

consent that the members’ written opening statements be introduced into the record, and without objection the documents will be 

entered into the record. I also note that two former members of this 

committee, Representative Mary Bono and Dr. Phil Gingrey, are 

present. Thank you for being here. And I, believe you said Mr. StuVerDate Nov 24 2008 11:33 Nov 09, 2018 Jkt 037690 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-43 CHRIS
11 

pak was around, too. Obviously, this is an important issue to those 

who are alumni committee as well. 

We heard so many introductions. Let me introduce the rest of 

our panel for today’s hearings, the Honorable Boyd Rutherford, 

Lieutenant Governor of Maryland, welcome to the hearing. As mentioned before, Secretary Moran, Secretary Tilley; and the Honorable Rebecca Boss, Director of the Department of Behavioral 

Healthcare, Developmental Disabilities and Hospitals from the 

State of Rhode Island. 

Thank you for being here today and providing testimony. We look 

forward to our continued discussion on the opioid crisis facing our 

nation. As I mentioned before, I really want you to be brutally candid with us on what the problems are, what we need to do, and 

what are the gaps. You are all aware the committee is holding an 

investigative hearing, and when doing so has had the practice of 

taking testimony under oath. 

Do any of you have any objections to testifying under oath? Seeing no objections, the chair then advises you that under the rules 

of the House and rules of the committee, you’re entitled to be advised by counsel. Do any of you desire to be advised by counsel during testimony today? Seeing none, then, in that case, please rise, 

raise your right hand and I will swear you in. 

[Witnesses sworn.] 

Mr. MURPHY. Seeing all have answered in the affirmative, you 

are now under oath and subject to the penalties set forth in Title 

18, Section 1001, United states Code. We’ll ask you each to give a 

5 minute summary of your statement. Please pay attention to the 

time here. We’ll begin with you, Governor Rutherford, you may 

begin. 

TESTIMONIES OF HON. BOYD K. RUTHERFORD, LIEUTENANT 

GOVERNOR, STATE OF MARYLAND; HON. BRIAN J. MORAN, 

SECRETARY OF PUBLIC SAFETY AND HOMELAND SECURITY, 

STATE OF VIRGINIA; HON. JOHN TILLEY, SECRETARY OF 

THE JUSTICE AND PUBLIC SAFETY CABINET, STATE OF KENTUCKY; HON. REBECCA BOSS, DIRECTOR, DEPARTMENT OF 

BEHAVIORAL HEALTHCARE, DEVELOPMENTAL DISABILITIES AND HOSPITALS, STATE OF RHODE ISLAND 

TESTIMONY OF HON. BOYD K. RUTHERFORD 

Mr. RUTHERFORD. Thank you, Chairman Murphy, Ranking Member DeGette. Honorable members of the subcommittee, thank you 

for the opportunity to join you today to discuss the State of Maryland’s response to heroin and opioid crisis. Tackling this emergency 

necessitates a coordinated response from Federal, state and local 

government. And Maryland looks forwards to working together 

with our Federal partners to address this challenge. 

Governor Hogan and I first became aware of the level of this 

challenge while traveling throughout the state during our 2014 gubernatorial campaign. We quickly realized the epidemic had crept 

into every corner of our state, cutting across demographics. 

Maryland, like most states, has experienced an increase in the 

number of deaths related to opioids. In 2016, 2089 Marylanders 

died from alcohol or drug-related intoxication; 66 percent increase 

12 

over the deaths and 2015. And 89 percent of those deaths were related to opioids. Maryland has seen an increase in prescription 

opioid-related deaths, and so we must address this particular element of the crisis. We must focus on reducing the inappropriate 

use of prescription opioids, while ensuring patients have access to 

appropriate pain management. 

In Maryland, there were over 8.8 million total CDS prescriptions 

dispensed in 2016. This is 8.8 million in a state with 6 million 

souls. Further, the challenge we face has evolved. As was mentioned, cheap, powerful, and deadly synthetic opioids have burst 

onto the market, bringing a much higher overdose rate. Deaths related to fentanyl have increased from 29 in 2012 to over 1100 in 

2016 in Maryland. 

Accordingly, as one of the Governor’s first acts in 2015, was to 

establish the Heroin and Opioid Emergency Task Force, which he 

asked me to chair. After nearly a year of stakeholder meetings and 

expert testimony and research, the task force adopted 33 recommendations. Those recommendations range from prevention, access to treatment, alternatives to incarceration, enhanced law enforcement, and more. And they form the foundation of our statewide strategy. Building on those recommendations of the task 

force, the Maryland General Assembly passed several comprehensive pieces of legislation. 

In 2016, we reformed our prescription drug monitoring program 

to require mandatory registration for all CDS providers. We passed 

the Justice Reinvestment Act to reform our criminal justice system 

to shift from incarceration to treatment for offenders who are 

struggling with addiction. 

What we set out to do was make a distinction between those who 

we are upset with, and those who we are afraid of. This past legislative session, Maryland passed the Heroin and Opioid Prevention 

Effort, or HOPE Act, and the Treatment Act of 2017, which contains provisions to improve patient education, increase treatment 

services, and provide greater access to Naloxone. 

The Governor signed the Start Talking Maryland Act, which will 

continue to build school and community-based education and 

awareness efforts to bring attention to this crisis. Educating young 

people on the dangers of opioids at an earlier age was something 

that our task force felt was extremely important. As I have said 

over and over again, virtually every third grader can tell you how 

bad it is to smoke cigarettes, but they can’t tell you how dangerous 

it is to take someone else’s prescription medications. 

With the deadly surge of synthetics on the scene, we saw the 

death toll continue to rise. Accordingly, in January of this year, 

Governor Hogan established the Opioid Operational Command 

Center. The Center brings opioid response partners together to 

identify challenges and establish a systemwide priority and capitalize on opportunities for collaboration. It is a formal and a coordinated approach, utilizing the National Incident Management 

System to develop both state and local strategic operational and 

tactical level concepts for addressing the heroin and opioid crisis. 

Shortly after its creation, the Governor declared a state of emergency in response to this crisis. By executive order, he dedicated— 

delegated emergency powers to state and local emergency manageVerDate Nov 24 2008 11:33 Nov 09, 2018 Jkt 037690 PO 00000 Frm 00016 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-43 CHRIS
13 

ment officials to enable them to fast track coordination with state 

and local agencies. Thanks to your leadership and commitment, 

funding of the 21st Century Cures Act, has greatly aided in this 

effort. And these dollars will be used in expanding educational efforts in the schools, building public awareness, improving treatment, expanding our peer recovery specialist program, and increasing the availability of Naloxone. 

The one thing that I would add that we would like to see from 

the Federal Government is to consider utilizing FEMA as outlined 

in the national emergency framework to centralize and coordinate 

the Federal response to this crisis. The national response framework is a guide to how the Nation responds to all types of disasters 

and emergencies, and it would allow Federal agencies to work more 

seamlessly with each other and with the agencies at the state level. 

We can’t afford to have delays due to agency silos and bureaucracies. I appreciate this opportunity to talk to you and await any 

questions you may have. 

[The prepared statement of Mr. Rutherford follows:] 

14 


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STATE OF MARYLAND 

OFFICE OF THE LT. GOVERNOR 

BOYD K. RUTHERFORD 

LT GOVERNOR 

STATEHOUSE 

100STATECIRCLE 

ANNAPOUS, MARYLAND 21401-1925 

(410) 974-2804 (TOLLFREE}1-800-611·8335 

1TY USERS CALL vtA MD RELAY 

Testimony of Lieutenant Governor Boyd K. Rutherford 

Hearing before the Subcommittee on Oversight and Investigations of the House Energy & 

Commerce Committee 

July 12,2017 

Chainnan Murphy, Ranking Member DeGette, honorable members of the Subcommittee, thank 

you for the opportunity to join you today to discuss the State of Maryland's response to the 

heroin and opioid crisis ravaging the nation. Tackling this emergency necessitates a coordinated 

response from federal, state, and local government and Maryland looks forward to continuing to 

work together with our federal partners to address this challenge. 

As Governor Hogan and I traveled throughout Maryland during our 2014 gubernatorial 

campaign, we heard devastating stories from families and friends hurt from the destruction of 

heroin and opioid abuse. We quickly realized this epidemic had crept into every comer of our 

state and cut across all demographics. At the time, though the problem was well known to health 

and law enforcement personnel who confronted it every day, it received little media attention, 

and many families suffered in silence. 

Since taking office in 2015, we have worked aggressively to raise awareness of and take action 

to address the heroin and opioid crisis, combat the stigma associated with the disease of 

addiction, and increase and improve coordination among state and local agencies. Our approach 

has been multidisciplinary, and includes prevention, treatment, and enforcement strategies. But 

as this crisis continues to evolve, so must our response to it. Earlier this year, Maryland became 

the first state in the nation to declare an official State of Emergency in response to this epidemic, 

which in part allows for improved coordination among government entities at every level. It is 

only through a multi-pronged approach and intense collaboration by all stakeholders that we can 

begin to truly solve this problem. I appreciate the opportunity to share some of our strategies and 

lessons learned with you here today, and hope that we can work together to save the lives of our 

friends, families, and neighbors. 

I. The Opioid, Heroin, and Fentanyl Crisis in Maryland 

Mary land, like most of the nation, has experienced an increase in the number of deaths related to 

opioids. In 2016, 2,089 Marylanders died of alcohol- or drug-related intoxication, a 66% increase 
15 


26839.002

over the number of deaths in 2015. 1 89% of these deaths were opioid-related and substantial 

increases in the number of heroin and fentanyl-related deaths were largely responsible for the 

overall rise in opioid-related deaths? 

The state has also seen an increase in prescription opioid-related deaths, and so as we address 

this crisis, we must focus on reducing the inappropriate use of prescription opioids while 

ensuring patients have access to appropriate pain management. According to several nationwide 

studies, nearly 80% of heroin users reported using prescription opioids prior to heroin.3 In 

Maryland there were 8,847,085 total CDS prescriptions dispensed in 2016; this equates to more 

prescriptions dispensed than citizens who reside in the state. A little over 66% of the initial 

prescriptions last year were written for a supply of more than 7 days. 4 The number of 

prescription opioid-related deaths in Maryland has been rising since 2012, in large part as a result 

of the use of these drugs in combination with heroin and/or fentanyl. 5 

Further, the challenge we face has evolved. Cheap, powerful, and deadly synthetic opioids have 

burst onto the market, bringing with them higher overdose rates and even more devastation. 

Deaths related to fentanyl, a synthetic opioid 50 to 100 times more powerful than morphine, have 

increased from 29 in 2012 to 1,119 in 2016.6 Fifty-eight percent ofheroin-re1ated deaths in 2016 

occurred in combination with fentanyl.7 In Maryland, we have also begun to see deaths related to 

the synthetic opioid carfentanil, the clinical use of which is to sedate large animals. 

As the crisis evolves, so too must our response. Accordingly, Maryland has adopted a 

multi pronged approach, which includes addressing the epidemic from every possible angle. 

Education and prevention go hand-in-hand with treatment and enforcement, and all are essential 

components of the state's efforts to tum the tide against this crisis. 

II. Maryland's Response 

Maryland's Heroin and Opioid Emergency Task Force and Inter-Agency Heroin and Opioid 

Coordinating Council 

1 Maryland Department of Health and Mental Hygiene. 2017. Drug- and Alcohol-Related Intoxication Deaths in 

2016. Published June 2017. Accessed July 7, 2017. 

https:l/bha.health.maryland.gov/QVERDQSE PREVENTION/Dgcuments/Maryland%202016%200verdose%20An 

nual%20report.pdf 

2 Ibid. 

3 National Institute on Drug Abuse. Prescription opioid use is a risk factor for heroin use. 

https://www.drugabuse.gov/publicationsiresearch~reoorts/relationshiv-between-prescription·drugwheroin· 

abuselprescription-opioid-use-risk-factor-heroin-use Published December 2015. Accessed July 7, 2017. 4 Maryland Prescription Drug Monitoring Program; information provided by the Vital Statistics Administration. 5 Maryland Department of Health and Mental Hygiene. 2017. Drug- and Alcohol-Related Intoxication Deaths in 

2016. Published June 2017. Accessed July 7, 2017. 

https:l/bha.health.maryland.gov/OVERDOSE PREVENIIONIDocuments/Maryland%202016%200verdose%20An 

nual%20report.pdf 

6 Ibid. 

7 Ibid. 

Testimony of Lieutenant Governor Boyd K. Rutherford J July 12, 2017 2 
16 


26839.003

In February 2015, Governor Hogan issued Executive Order 01.01.2015.12, formally establishing 

the Heroin and Opioid Emergency Task Force and appointing me as chair.8 The task forcemade up of II members with expertise in substance abuse, treatment, and law enforcement, 

including a mother who lost her daughter to a heroin overdose-was established to advise and 

assist the governor in establishing a coordinated statewide and multi-jurisdictional effort to 

improve public awareness, access to treatment, quality of care, alternatives to incarceration for 

nonviolent drug abusers, and law enforcement coordination. 

In addition to creating the task force, Governor Hogan also issued an executive order 

establishing the Inter-Agency Heroin and Opioid Coordinating Counci!.9 The council is a subcabinet of the governor and consists of the heads of agencies and offices across all disciplines 

within the administration. The council was tasked with sharing data and information with one 

another and the Office of the Governor to support public health and public safety responses to 

the heroin and opioid epidemic. The council continues to meet in order to ensure fidelity to the 

task force recommendations and to share new information and developments. 

The task force held regional summits throughout the state to listen to the input of concerned 

Marylanders who had been affected first-hand by the disease of addiction and the opioid 

epidemic. We heard from more than 220 individuals on the frontlines of the crisis and dozens 

more submitted written testimony, suggestions, and comments to the task force through its web 

portal. 

The task force took swift action and issued an interim report including I 0 recommendations, 

which could be implemented by the relevant state agency within a few weeks: (I) earlier and 

broader incorporation of heroin and opioid prevention into the health curriculum; (2) infusion of 

heroin and opioid prevention into additional school disciplines; (3) heroin and opioid addiction 

integrated into school service learning projects; ( 4) student-based heroin and opioid prevention 

campaign; (5) video PSA campaigns; (6) Maryland emergency department opioid prescribing 

guidelines; (7) Maryland State Police training on the Good Samaritan Law; (8) Maryland State 

Police help cards and health care follow-up unit; (9) faith-based addiction treatment database; 

and (I 0) launching an Overdose Awareness Week. 10 

In addition to the recommendations, the report also included 10 funding announcements: seven 

Department of Health and Mental Hygiene allocations to improve access to treatment and quality 

of care, and three Governor's Office of Crime, Control, and Prevention grants to support law 

enforcement efforts. 

In December 2015, the task force issued its final report, containing 33 recommendations ranging 

from prevention and access to treatment to alternatives to incarceration and enhanced law 

8 Larry Hogan. 2015. Executive Order 01.01.2015.12 Heroin and Opioid Emergency Task Force. Available online at 

https:l/govemor marvland.govlwp-content/uploads/20 15103/EOO I 0120 1512.pdf 9 Larry Hogan. 2015. Executive Order 01.01.2015.13 Inter-Agency Heroin and Opioid Coordinating Council. 

Available online at httos:/lgovemor.marvland.govlwp-content/uploads/20 15103/EOO I 0120 !513.odf 10 Maryland Heroin and Opioid Emergency Task Force. 2015. Interim Report. August 24. Available online at 

https:l/governor.maryland.gov/ltgovernor!wp-contentfuploads/sites/2/2015/08/Draft-Heroin-Interim-ReportFINAL.pdf. 

Testimony of Lieutenant Governor Boyd K. Rutherford I July 12, 2017 3 
17 


26839.004

enforcement. 11 These recommendations fell into seven categories: expanding access to treatment; 

enhancing quality of care; boosting overdose prevention efforts; escalating law enforcement 

options; reentry and alternatives to incarceration; promoting education tools for youth, parents, 

and school officials; and improving state support services. Each recommendation was fully 

funded in the administration's proposed budget. 

These 33 recommendations, based on research, discussion, and expert and community feedback, 

built the foundation of our statewide strategy: 

Expanding Access to Treatment 

I. Implementing a Statewide Buprenorphine Access Expansion Plan 

2. Reviewing the Substance Use Disorder Reimbursement Rates Every Three Years 

3. Expanding Access to Treatment through Payments to Non-Contracting Specialists and 

to Non-Contracting Nonphysician Specialists 

4. Improving Provider Panel Lists 

5. Expanding Access to Training for Certified Peer Recovery Specialists 

6. Providing Recovery Support Specialists to Assist Pregnant Women with Substance 

Use Disorders 

7. Transitioning Inmates to Outpatient Addictions Aftercare and Community Providers 

8. lncentivizing Colleges and Universities to Start or Expand Collegiate Recovery 

Programs 

Enhancing Quality of Care 

I. Requiring Mandatory Registration and Querying of the Prescription Drug Monitoring 

Program 

2. Authorizing the Opioid-Associated Disease Prevention and Outreach Program 

3. Requiring and Publishing Performance Measures on Addiction Treatment Providers 

4. Requiring Continuing Professional Education on Opioid Prescribing for the Board of 

Podiatric Medical Examiners and Board of Nursing and on Opioid Dispensing for the 

Board of Pharmacy 

5. Requiring Drug Monitoring for Medicaid Enrollees Prescribed Certain Opioids 

Boosting Overdose Prevention Efforts 

I. Expanding Online Overdose Education and Naloxone Distribution 

2. Implementing a Good Samaritan Law Public Awareness Campaign 

Escalating Law Enforcement Options 

I. Enacting a Maryland Racketeer Influenced and Corrupt Organization Statute 

2. Creating a Criminal Penalty for Distribution of Heroin or Fentanyl Resulting in Fatal 

or Nonfatal Overdose 

3. Creating a Multi-Jurisdictional Maryland State Police Heroin Investigation Unit 

4. Designating HIDT A the Central Repository for Maryland Drug Intelligence 

5. Enhancing Interdiction of Drug-Laden Parcels 

11Maryland Heroin and Opioid Emergency Task Force. 2015. Interim Report. December 1. Available online at 

httns://govemor.mazyland.gov/ltgovernor/wp-content/uploads/sites/2/20 15/12fHeroin-Dnioid-Ernergency-TaskForce-Final-Reoort.pdf 

Testimony of Lieutenant Governor Boyd K. Rutherford I July J 2, 20 J 7 4 
18 


26839.005

6. Strengthening Counter-Smuggling Efforts in Correctional Facilities 

Reentry and Alternatives to Incarceration 

1. Establishing a Day Reporting Center Pilot Program to Integrate Treatment into 

Offender Supervision 

2. Expanding the Segregation Addictions Program in Correctional Facilities 

3. Implementing a Swift and Certain Sanctions Grid for Probation and Parole 

4. Institutionalizing a Substance Use Goal into the Maryland Safe Streets Initiative 

5. Establishing a Recovery Unit at Correctional Facilities 

6. Studying the Collateral Consequences of Maryland Laws and Regulations on 

Employment of Ex-Offenders 

Promoting Education Tools for Youth, Parents, and School Officials 

I. Creating a User-Friendly Educational Campaign on School Websites 

2. Training for School Faculty and Staff on Signs of Student Addiction 

3. Promoting Evidence-Based Prevention Strategies that Develop Refusal Skills 

4. Support Student-Based Film Festivals on Heroin and Opioid Abuse 

Improving State Support Services 

I. Implementing Comprehensive Heroin and Opioid Abuse Screening at the Department 

of Juvenile Services and the Department of Human Resources 

2. Establishing the Maryland Center of Excellence for Prevention and Treatment under 

the Behavioral Health Advisory Council 

The final report also recognized the need for treatment on demand and discussed the barriers to 

such a program. The key to improving access to high-quality treatment lies in creating a delivery 

system that provides a full continuum of substance use services and care. There are health care 

facilities in Maryland that are well suited to provide the necessary clinical care and support 

services for individuals on an urgent basis and assist in transitioning patients to the appropriately 

assessed level of care. Offering crisis services will relieve pressure on hospital acute-care 

systems. The $2 million of 21st Century Cures Act funding in support of a 24-hour stabilization 

center in Baltimore City will be an important step toward a system of treatment on demand. 

Key Legislative Actions 

Legislation based on several of the task force recommendations was then considered by the 

Maryland General Assembly, and Governor Hogan signed several key bills that encompass 

prevention, treatment, and enforcement strategies. 

A. Prescription Drug Monitoring Program (POMP) modifications 

A direct result of the Heroin and Opioid Emergency Task Force recommendations, House Bill 

437 (2016) requires mandatory registration with the POMP to all providers that have a license to 

prescribe or dispense controlled dangerous substances before obtaining a new or renewal 

controlled dangerous substance registration. Beginning July l, 2018, a prescriber must (I) 

request at least the prior four months of prescription monitoring data for a patient before 

initiating a course of treatment that includes prescribing or dispensing an opioid or a 

Testimony of Lieutenant Governor Boyd K. Rutherford I July 12, 2017 5 
19 


26839.006

benzodiazepine; (2) request prescription monitoring data for the patient at least every 90 days 

until the course of treatment has ended; and (3) assess prescription monitoring data before 

deciding whether to prescribe or dispense- or continue prescribing or dispensing- an opioid or 

a benzodiazepine. 

B. Increased penalty for knowing distribution offentanyl or its analogs 

Senate Bill 539 (2017), sponsored by the Administration, creates a new felony, punishable by up 

to I 0 consecutive years, for individuals who knowingly distribute fentanyl or a fentanyl analog. 12 

The legislation recognizes the deadly impact potent and cheap fentanyl has on our communities 

by providing law enforcement with more tools to hold drug traffickers accountable. 

C. The Prescriber Limits Act of2017 

House Bil11432 (2017), sponsored by the Administration, requires a health care provider, based 

on their clinical judgment, to prescribe the lowest effective dose of an opioid and a quantity no 

greater than the quantity needed for the expected duration of pain severe enough to require an 

opioid that is a controlled dangerous substance. 13 Certain exceptions are made for patients with 

chronic illness, receiving pain treatment associated with cancer or palliative care, or receiving 

medication assisted treatment for a substance use disorder. 

D. The Heroin and Opioid Prevention Effort (HOPE) and Treatment Act of2017 

Senate Bill 967/House Billl329 (2017), a bipartisan omnibus bill, contains provisions to 

improve patient education, increase treatment services, and includes the administration's 

Overdose Prevention Act, which enables all citizens to access life-saving naloxone without a 

prescription. 14 The legislation also requires an assessment of drug courts, the creation of a crisis 

stabilization center, enhancements to the existing state toll-free crisis hotline, the provision of 

information on all FDA-approved forms of medication assisted treatment, co-prescribing of 

naloxone with opioids for patients at an elevated risk of overdose, rate increases for behavioral 

health providers, and standardized hospital discharging protocols for patients treated for an 

overdose. 

E. Heroin and Opioid Education and Community Action Act of2017 (Start Talking 

Maryland Act) 

SB 1 060/House Bill I 082 increases school and community-based education and awareness 

efforts to continue to bring attention to the crisis and to equip our state's youth with knowledge 

about the deadly consequences of opioids. 15 Among other provisions, the legislation requires 

programming on heroin and opioid related addiction and prevention (including information on 

fentanyl) beginning in third grade, a county-level school policy on naloxone, the designation of a 

12 Senate Bill539. 2017. Criminal Law- Distribution of Controlled Dangerous Substances- Fentanyl. Available 

online at http://mgaleg.maryland.gov/2017RS1Chapters noln/CH 569 sb0539t.pdf 13 House Bill 1432. 2017. Health Care Providers- Prescription Opioids- Limits on Prescribing (The Prescriber 

Limits Act of 20 17). A vail able online at http://mgaleg.maryland.gov/20 17RS/Chaoters noln!CH 570 hbl432t.pdf 14 Senate Bill967/House Billl329. 2017. Heroin and Opioid Prevention Effort (HOPE) and Treatment Act of2017. 

Available online at http://mgaleg.maryland.gov/2017RS/Chapters noln!CH 572 sb0967e.pdf and 

http:llmgaleg.maryland.gov/2017RS/Chapters noln/CH 571 hbl329e.pdf 15 SB 1060/House Billl082. 2017. Heroin and Opioid Education and Commnnity Action Act of2017 (Start Talking 

Maryland Act). Available at http:l/mgaleg.marylaod.gov/2017RS/Chapters noln/CH 574 sbl060e.pdf and 

http://mgaleg.maryland.gov/20 l7RSIChapters noln!CH 573 hbl082e.odf 

Testimony of Lieutenant Governor Boyd K. Rutherford I July 12, 2017 6 
20 


26839.007

school health services coordinator, and community action officials to coordinate school-based 

community forums and public awareness efforts. 

State of Emergency and Opioid Operational Command Center 

As the death toll continued to rise, we recognized the need to treat the heroin and opioid crisis as 

we would treat any other life-threatening emergency. A formal, coordinated, multi-jurisdictional 

capacity did not exist among state and local health and human services, education, and public 

safety entities to address and respond to the crisis. The solution was to stand up a formal, 

coordinated approach utilizing the National Incident Management System to develop both state 

and local strategic, operational, and tactical-level concepts for addressing the heroin and opioid 

crisis to protect the residents of Maryland. 

In January 2017, Governor Hogan by executive order authorized the Inter-Agency Heroin and 

Opioid Coordinating Council to establish the Opioid Operational Command Center. 16 The 

Opioid Operational Command Center (OOCC) brings opioid response partners together to 

identify challenges, establish system-wide priorities, and capitalize on opportunities for 

collaboration. 

The OOCC is a collaborative effort working across all levels of state and local government. The 

OOCC is made up of partners representing a broad spectrum of state agencies and 

coordinating bodies, including: 

Department of Health 

Department of Human Resources 

Department of Juvenile Services 

Department of Public Safety and Correctional Services 

Governor's Office of Crime Control and Prevention 

Maryland Emergency Management Agency 

Maryland Higher Education Commission 

Maryland Institute for Emergency Medical Services Systems 

Maryland Insurance Administration 

Maryland State Police 

Maryland State Department of Education 

Office of the Attorney General 

High Intensity Drug Trafficking Area 

The goals of the OOCC include, but are not limited to, the following: 

Facilitate operational collaboration and coordination among state agencies and local 

partners working on heroin and opioid-related response initiatives 

Strengthen information management and sharing to partners and the public 

• Coordinate the development of stakeholder reports to document system-wide progress 

Develop cross-cutting, multi-disciplinary Opioid Intervention Teams based on local 

needs, to include training and subject matter expertise 

Coordinate training and resources available to state and local agencies 

16 Larry Hogan. 2017. Executive Order 01.01.20!7.0llnter-Agency Heroin and Opioid Coordinating Council. 

Available online at https:l/govemor.macyland.govlwp-content/uploads/20 17101/0 !99 00 !.pdf 

Testimony of Lieutenant Governor Boyd K. Rutherford I July I 2, 20 I 7 7 
21 


26839.008

On March 1, 2017, based on initial recommendations of the OOCC, Governor Hogan declared a 

State of Emergency in response to the heroin, opioid, and fentanyl crisis. This declaration 

activates the governor's emergency management authority and enables increased and more rapid 

coordination between the state and local jurisdictions. Maryland needed greater flexibility to 

activate emergency teams in jurisdictions across the state and engage local communities. The 

governor's executive order delegates emergency powers to state and local emergency 

management officials, enabling them to fast-track coordination among state and local agencies 

and community organizations, including private sector and nonprofit entities to ensure 

involvement of the entire community. 

As a result of the State of Emergency, the OOCC supported emergency managers and health 

officers in each jurisdiction as they formed Opioid Intervention Teams that serve as the multiagency coordinating bodies for the opioid response at the local level. Opioid Intervention Teams 

bring law enforcement, EMS, hospitals, schools, and other partners together with public health to 

address the opioid crisis. The OOCC provides ongoing support and coordination for the local 

jurisdiction Opioid Intervention Teams including funding, best practices guidance, legislative 

and policy support, and data sharing. 

Similar in declaring a state of emergency in Maryland, in order to better manage what we believe 

to be a national crisis, we request your consideration in using the Federal Emergency 

Management Agency (FEMA) as outlined in the National Emergency Framework to centralize 

and coordinate the federal response to this crisis in support of state and local 

efforts. The National Response Framework is a guide to how the Nation responds to all types of 

disasters and emergencies. It is built on scalable, flexible, and adaptable concepts identified in 

the National Incident Management System to align key roles and responsibilities across the 

Nation. 

Our federal, state, and local public health service continues to perform admirably. However, as 

with most crisis situations those sectors of government who are in the lead are often the last to 

know they need broader assistance in managing a crisis. The National Emergency Response 

Framework that provides guidance in crisis management and supports the great capability of the 

Federal Emergency Management System led by FEMA. 

In addition, Maryland launched Before It's Too Late, a statewide effort to bring awareness to the 

rapid escalation of the heroin, opioid, and fentanyl crisis in Maryland and to mobilize all 

available resources for effective prevention, treatment, and recovery. Those looking for help with 

their own addiction or help for a loved one can access information on treatment and recovery on 

one web portal, BeforeltsTooLateMD.org. 

IV. Funding Allocations 

21st Century Cures Act 

Testimony of Lieutenant Governor Boyd K. Rutherford I July 12, 2017 8 
22 


26839.009

Thanks to your leadership, Maryland has received $10,036,845 under the 21st Century Cures 

Act. In addition to state funding commitments, these dollars will allow Maryland to further our 

prevention and treatment strategies. 

Funding from the 21st Century Cures Act will expand our efforts to combat this epidemic. 

Notably, we will expand education efforts in schools to teach our students about the dangers of 

opioids, and we will build public awareness efforts to reduce stigma, increase patient-physician 

communication, and mobilize resources for effective prevention, treatment, and recovery. 

Resources will also bolster treatment efforts across the state. 21st Century Cures Act funding 

will expand treatment beds and adopt a tracking system for bed availability, help fund the 

establishment of a 24-hour stabilization center in Baltimore City, and expand peer recovery 

specialists. Additionally, funds will be used to expand access to medication assisted treatment. 

21st Century Cures Act funding, along with state funds, will also operationalize a proposal to 

bring naloxone, the lifesaving drug that can reverse an opioid overdose, to all jurisdictions 

through coordinated efforts and distribution to local health departments. 

State Funding 

In addition to fully funding the recommendations of the Heroin and Opioid Emergency Task 

Force, Governor Hogan's Fiscal Year 2018 budget included $159 million of non-Medicaid 

substance use disorder treatment programs and allocated $4 million in new funding to bolster the 

state's effort to help those struggling with opioid addiction. The Administration has also directed 

discretionary federal funding, such as the Byrne Justice Assistance Grants, to programs that 

support our strategy to confront the crisis. 

When Governor Hogan declared a State of Emergency in March, he concurrently announced an 

additional $50 million in new funding over a five year period to support the state's efforts. These 

state funds will supplement federal funds in expanding access to naloxone, building public 

awareness, and supporting the data and IT needs critical to this fight. The funds will also 

improve treatment through increasing medication assisted treatment availability; expand the use 

of Screening, Brieflntervention, and Referral to Treatment (SBIRT) in hospitals and parole, 

probation and correctional facilities, and improving the statewide 24/7 crisis hotline. 

The state will provide $4 million in grants up front to local jurisdictions to be used to address 

local prevention, treatment, and enforcement priorities. Funding was allocated to jurisdictions 

with a base amount supplemented by funding based on each jurisdiction's opioid-related deaths, 

and does not include other grants and additional funding distribution. 

In addition, state funds will reinforce Maryland's enforcement efforts to disrupt and dismantle 

drug trafficking organizations. We will continue that state's heroin coordinator program, which 

places heroin coordinators in local jurisdictions and promotes an integrated law enforcement and 

investigative strategy among all Maryland jurisdictions through extensive data-sharing. This, in 

tum, advances statewide investigations and prosecutions of drug traffickers, as well as referrals 

for treatment for individuals struggling with addiction. 

Testimony of Lieutenant Governor Boyd K. Rutherford I July 12, 2017 9 
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26839.010

V. Conclusion 

Our work with the Heroin and Opioid Emergency Task Force engendered a greater 

understanding of the gravity of the heroin and opioid epidemic and has informed our response 

since. What we heard from community members during our task force work varied, but the 

underlying message was the same: Maryland needs an all-hands-on-deck approach to confront 

this crisis. Working with our federal, local, and community partners across all disciplines, we 

will continue to address the heroin and opioid crisis from every angle. 

Testimony of Lieutenant Governor Boyd K. Rutherford I July 12,2017 10 
24 

Mr. MURPHY. Thank you. Thank you, Governor. Secretary 

Moran, you’re recognized for 5 minutes. 

TESTIMONY OF HON. BRIAN J. MORAN 

Mr. MORAN. Mr. Chairman and members of the committee, it is 

still very much an honor to be with you this morning, and to be 

able to discuss with you Virginia’s response, as well as working 

with you to request assistance from the Federal Government to 

combat this epidemic. As has all been agreed and said this morning, America is in the midst of an opioid and heroin addiction epidemic. The epidemic does not discriminate; it is an equal opportunity killer. 

In Virginia, in 2016, 1133 individuals died from opioid overdose. 

The sad truth is that Virginia actually ranks 18th among the 50 

states in overdose deaths. Sadder than that, 17 states are doing 

worse than we are. And in all likelihood, the other 32 states would 

be facing similar devastation if we don’t take effective action now. 

As Secretary of Public Safety and Homeland Security, I am very 

proud of Virginia sworn law enforcement officers who work 24/7, 

365, to keep us safe. But what they tell me over and over and over 

again is, we cannot arrest our way out of the heroin and opioid addiction crisis. And we can’t simply tell those living with addiction 

to get over it. Why is that? Because addiction is a disease. 

Arrest and incarceration of those addicted will no more cure this 

disease than it would cure cancer or diabetes. There are a number 

of causes, multiple causes of this dramatic rise in the deadly epidemic of overprescribing, failure to safely dispose, easy access, and 

affordability. But over the last several years, we have seen a sharp 

rise in illegally manufactured synthetic opioids such as fentanyl 

and Carfentanil. Lethal in even tiny amounts, they contribute significantly to the increased numbers of heroin and opioid deaths. 

From 2015 to 2016, the number of fatal overdoses involving 

fentanyl increased to 175 percent, and accounted for 618 of the 

1133 deaths in the Commonwealth. 

Virginia’s response to this epidemic began immediately upon 

Governor McAuliffe taking office in 2014. He convened a broad coalition of healthcare providers, criminal justice representatives, and 

community stakeholders to participate in the prescription drug and 

heroin use task force. The Secretary of Health and Human Resources cochaired the committee with myself. The task force developed over 50 recommendations. I am proud to say we have implemented the vast majority of those recommendations, the full list of 

which can be found in my submitted written testimony. Of course, 

the work continues in Virginia. 

Our executive leadership team works across state government 

and with regional and local agencies and individuals to effectively 

align goals, share best practices, and work to overcome barriers to 

success. The leadership team organized a statewide approach to 

opioid crisis and provided leadership from the Virginia state Police, 

Department of Health, and from our local community service providers. Again, that is a theme that this is not just a law enforcement problem, but, rather, one that requires healthcare providers 

to be at the table along with their community service providers. 

25 

They support coordination among local grassroots organizations, 

task forces, and other collaborations, including those that exist 

within Virginia’s HIDTA designated areas, which cover parts of 

Northern Virginia, Appalachia, and Hampton Roads. So there is 

more work to be done. Let me highlight some of our accomplishments. The General Assembly enacted legislation expanding the 

deployment of Naloxone. Lay people, law enforcement officers, state 

agencies like our Department of Forensic Science and others working with potentially dangerous drugs, are being trained in using 

this overdose reversal agent through the Department of Behavioral 

Health and Developmental Services Revive program. Our Commissioner of Department of Health issued a standing order for pharmacies to dispense Naloxone. The Department of Criminal Justice 

Services issued grants to pay for increased Naloxone to be used by 

law enforcement. In fact, the city of Virginia Beach has used 

Naloxone now, and they have had over 60 deployments to save 

lives in that community. 

Now, our requests. I came into this job with a mandate from my 

11 public safety agencies that we would rely on data-driven decision making. If we are going to effectively wrap our arms around 

this epidemic and reverse the devastating upward trend in deaths, 

overdoses, and related crime, we need to know what the problems 

are, where they are, and what is working. To do that, we need good 

data. Here are some of the identified needs that Congress and the 

administration can help us address. 

Craft limited exceptions to current regulatory and statutory barriers under HIPAA, in 42 CFR, Part 2, which is the substance 

abuse privacy protections. For example, our prescription drug monitoring program is prohibited from accessing any data from our 

methadone clinics. That is, we need to know how they work and 

who they are providing care for, and how it is working; provide 

technical assistance or fund staff positions for states and localities 

in developing metric-sharing data in analyzing results; support development of consistent national metrics; incentivize private providers or mandate data collection as a requisite for Federal funding; change how the Federal agencies do business; increase support 

for SAMHSA and HIDTA; break down Federal funding silos, reduce demand; support, train, incentivize law enforcement to focus 

on mid and high level dealers; and help us divert those who are 

addicted into treatment programs. Our treatment programs are 

currently insufficient to address this epidemic. 

Those with addictions shouldn’t become law enforcement’s problem, they belong in the healthcare system. Examples of programs 

to explore further, include assist localities to pilot, analyze, and determine the efficacy of Angel programs in police departments, fully 

fund the dissemination and utilization of Naloxone or other overdose drugs. My time is up. There are a lot of requests, but you invited the requests, Mr. Chairman, but I will stop if—— 

[The prepared statement of Mr. Moran follows:] 

26 


26839.011

Cover Sheet I Written Testimony 

Hearing Title: "Combatting the Opioid Crisis: Battles in the States" 

July 12,2017 

Attribute statement to: Brian Moran, Secretary of Homeland Security and Public Safety 

for the Commonwealth of Virginia 

Submitted by: 

Brian Moran, Secretary of Homeland Security and Public Safety for the Commonwealth of 

Virginia 

Patrick Henry Building 

1111 Broad Street I Richmond, VA 23219 

804-692-2569 

Brian.Moran@govemor.virginia.gov 
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26839.012

Executive Summary 

America is in the midst a national crisis. The opioid and heroin addiction epidemic led to the 

deaths of nearly 310,000 individuals between 1999 and 2015. The number of deaths annually 

has quadrupled since 1999. More people in America died of opioid overdose in 2014 and 2015 

than were killed in Viet Nam. In addition to the personal devastation this epidemic wreaks upon 

individuals and families across our great nation, this crisis is overwhelming current health care 

resources and challenging our criminal justice system to respond in a way that provides for 

individual and public health needs as well as the safety of our citizens and communities. 

Virginia ranks I gth among the 50 states in opioid deaths; in 2016, I, 133 people died from opioid 

overdose in Virginia. We must work collaboratively across Federal, state and local governments, 

across traditionally silo-ed systems and alongside private providers, faith communities and nonprofit organizations to stern the tide of this devastating disease. 

The causes of the epidemic are complex- from the prevalence of cash and carry pill mills and 

overprescribing prescription medications which are then illicitly diverted to the sharp rise in 

illegally manufactured synthetic opioids such as Fentanyl and Carfcntanil- lethal in even 

infinitesimal amounts. 2016 saw a 175% increase in fentanyl related deaths (616 of 1,133 opioid 

deaths in Virginia). But it is not only the deaths which must concern us: It is the increasing 

numbers of non-fatal overdoses, the resource and access challenges to providing evidence based 

treatment and recovery supports. It is also the nexus between addiction and crime- from the 

property crimes often committed by those trying to support their illicit habit to the lucrative drug 

trafficking trade aided by the advent of the "dark web.' 

In Virginia our Governor convened a statewide Prescription Drug and Heroin Use Task Force, 

for which I served as co-chair, along with Secretary of Health and Human Resources, Dr. Bill 

Hazel. The Task Force membership reflected the necessary breadth of input and developed over 

50 recommendations from which have been or are being implemented by the follow up 

Executive Leadership Team. The goal of these collaborations is to effectively align goals, share 

best practices, work to overcome barriers to success across Virginia's localities. 

The challenges to effectively combat this epidemic are many. We must remove statutory and 

resource barriers to data collection, sharing and analytics; increase support for ONDCP, HIDTA 

and the National Guard's Counterdrug program; breaking down funding and programmatic silos 

is imperative; and consistent, flexible and long term funding for evidence based drug treatment 

programs and interdiction efforts must be undertaken in lieu of sporadic grant based funding. 

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26839.013

Statement 

Brian Moran, Secretary of Public Safety and Homeland Security for the Commonwealth of 

Virginia 

Written Testimony Provided to the Subcommittee on Health of the House Energy and 

Commerce Committee 

Overview 

July 12,2017 

Virginia Response to the Heroin, Opioid and Addiction Epidemic 

I. National Perspective 

a. America is in the midst of an opioid and heroin addiction epidemic 

that is killing our children and loved ones, devastating families, overwhelming 

health care resources and challenging our criminal justice system. Between 2006 

and 2015 the number of annual deaths from opioid overdoses nearly doubled from 

17,545 to 33,091. It quadruples from 1999 to 2015. These numbers are 

unacceptable. Law enforcement officers, first responders and medical 

professionals are encountering untold numbers of non-fatal overdose victims on 

the streets of our towns, cities and counties. This epidemic does not respect social, 

economic, racial, religious or political divides. It is an equal opportunity killer. 

b. Addiction is a devastating disease, and its causes are many. For 

example, the quantity of opioids prescribed in 2015 would be enough to provide 

every American with around-the-clock painkillers for three weeks. In the 1960's, 

nearly 80% of opioid addicts, started out on heroin. By the 2000's those numbers 

were reversed: according to some sources, nearly 80% of those addicted started 

out using prescription opioids. 

c. However, it isn't just prescribers, the prevalence of prescription 

drugs or improper storage of legal medications that are to blame. Over the last 

several years, the rise in illegally manufactured, highly lethal synthetic opioids 

such as Fentanyl and Carfentanil has contributed significantly to the impact of 

these drugs, both nationally and in Virginia. 

II. Virginia Perspective 

a. Our own Commonwealth's disheartening statistics bear this out: 

According to Virginia's Chief Medical Examiner (OCME), since 2014, more 

people are dying from drug overdose (I 028) than from motor vehicle crashes 

(879) or gunshots (940). In 2016, I ,420 Virginians died from drug overdoses, and 

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26839.014

I, 133 of those lives (80%) were lost because of opioids. 

ALL OPIOIDS 

b. The problem is more acute now than ever. With the rise of illicitly 

produced fentanyl in Virginia, the total number of fatal fentanyl-related drug 

overdoses has sharply increased since 2012; which coincides with the dramatic 

increase in fatal heroin overdoses. Prior to 2013, most fentanyl-related deaths in 

Virginia were due to illicit use of pharmaceutically produced fentanyl. However, 

in early 2014, law enforcement investigations and toxicology testing 

demonstrated an increase in illicitly produced fentanyl. By 2016, most fatal 

fentanyl-related overdoses were due to illicitly produced fentanyl and fentanyl 

analogs, and not pharmaceutically produced fentanyl. The number of fatal 

fentanyl overdoses increased 175% from 2015 to 2016, and now accounts for 618 

of 1133 opioid deaths. 

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c. 

Ill. Regional Differences 

a. Virginia, like the rest of the nation, sees differences based on 

geography. There is a much higher prevalence of prescription opioids in the 

Southwest portion of the state (Virginia's Appalachian and historic coal 

producing region), and a much greater reliance on heroin in Northern and Eastern 

areas. We are dedicated to gathering and sharing data across Virginia to analyze 

relevant drug trends in the Commonwealth. While challenged by limited 

resources to provide analysis in a more timely way, we are able to coordinate data 

from a number of sources, including the Virginia Department of Health, the 

Office of the Chief Medical Examiner, the Department of Forensic Science and 

the Virginia State Police Fusion Center, among others. We organize and analyze 

data by Virginia State Police Divisions to determine how the opioid and heroin 

epidemic is manifested differently across the state, and seek to modify our health 

and public safety responses to address region-specific problems. 

b. While we can create monthly, quarterly and annual reports that aid 

us in coping with this epidemic, we are severely limited in our capacity to share 

real time data. Further in this testimony are some suggestions for Federal action 

which might alleviate some of this backlog. 

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26839.016

Virginia State Poiice Divisions 

c. 

d. The rate of prescription opioid submissions from far Southwest Virginia (Division 

IV) is three times higher than any other part of the state. 

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26839.017

e. 

f. In Regions II and V, which include Richmond, Northern Virginia, and Hampton 

Roads. the amount of heroin cases is 2x hi~her than any other re~ions. 

g. 

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26839.018

h. 

i. A heartbreaking result of this epidemic of addiction is the number of babies who 

are born addicted. In 2016, 1334 babies were reported to Child Protective 

Services to have been exposed to substances, a 21% increase from the 1,099 

babies in 2015. The prevalence ofNeonatal Abstinence Syndrome (NAS) in 

Virginia has risen steadily over the past 10 years, and in 2015 there were 6.1 NAS 

discharges for every 1,000 live births. In some localities in Southwest Virginia, up 

to 58.8 babies for every I ,000 live births are born with NAS. 

Virginia's Collaborative Approach to Treating the Epidemic 

I. We cannot expect law enforcement to arrest our way out of this epidemic; we 

cannot expect health care providers to treat our way out of it; and we cannot expect 

people with serious addictions to just "get over it". This is a multifaceted problem that 

requires a multifaceted solution. 

II. Task force 

a. Understanding the necessity for cross system collaboration and the 

importance of a holistic response to this multifaceted crisis, Governor Terry 

McAuliffe issued an executive order in April, 2014, convening a Task Force on 

Prescription Drug and Heroin Abuse. The Governor recognized how deeply 

connected health and public safety are when responding to this issue, so he 

appointed Secretary Moran of Public Safety and Homeland Security and Secretary 

Hazel of Health and Human Resources to co-chair the Task Force. This group 

brought together parents, people in various stages of recovery from drug 

addiction, legislators, health professionals, educators, corrections and law 

enforcement to craft policy recommendations addressing the growing opioid and 

heroin overdose epidemic. The Task Force established five working groups 

comprised of subject matter experts who developed recommendations in the 

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following areas: Education, Treatment, Data and Monitoring, Storage and 

Disposal, and Enforcement. 

b. The Task Force issued over 50 policy recommendations in an 

interim report in April of 2015, and updated that report in October of 2015 (see 

attached). 

c. In December, 2016, the Governor issued Executive Directive No. 

9, establishing an Executive Leadership Team (EL T), again led by the Secretaries 

of Public Safety and Homeland Security and of Health and Human Resources, to 

oversee continuing implementation of the Task Force recommendations and 

coordination of ongoing efforts to address the heroin and opioid addiction crisis in 

the Commonwealth. 

i. The Executive Leadership Team is comprised oftop 

management from each of the relevant state agencies with responsibilities 

for or interaction with individuals affected by the issue. Staffing is 

provided by the two secretaries' Deputy and Policy Advisor, as well as 

representatives of key agencies: Virginia State Police, Departments of 

Criminal Justice Services, Corrections, Health Professions, Health, 

Behavioral Health and Developmental Services, and Social Services. 

ii. The ELT meets twice a year with stakeholders, 

holds quarterly executive leadership meetings, and the staff group meets 

monthly. 

iii. The staff group oversees coordination of data and 

resources across state agencies and provides regional leadership to 

coordinate with regional 'grassroots' coalitions across the Commonwealth. 

The goal is to make sure that from the grassroots to the tree tops, 

Virginia's efforts to combat the epidemic arc aligned, that communication 

is open, data and information is easily shared, needs and gaps ascertained 

and potential resources identified and leveraged to the greatest extent 

possible. 

iv. Through these efforts, we are able to share 

information on the successes and challenges we are experiencing across 

the Commonwealth. Our ELT and grassroots coalitions exchange best 

practices across localities and develop innovative approaches to 

addressing the heroin and opioid addiction epidemic. 

III. Law Enforcement 

a. With the invaluable assistance of the Virginia State Police, 

Virginia's Public Safety and Homeland Security Secretariat continues to 

emphasize the importance of viewing addiction as a disease rather than a criminal 

activity, and promote a culture change in law enforcement and across the criminal 

justice system. With a(l understanding that we cannot arrest or prosecute our way 

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26839.020

out of this problem, Virginia is emphasizing rehabilitation instead of incarceration 

for those individuals struggling with opioid addiction. Law enforcement can help 

addicted individuals access treatment, through "angel programs" and other 

criminal justice diversion approaches. However, we must also have the resources 

to limit the supply of illegal opioids into our state, target those pill mills and 

dealers whose actions are creating the addiction cycle, and interdict the influx of 

precursors and internet predators from countries such as China. 

i. An example of our local law enforcement's 

leadership on this issue has been the Chesterfield County Sheriffs 

Department. Sheriff Karl Leonard and his staff started the Heroin 

Addiction Recovery Program (HARP) for incarcerated men in March, 

2016, and a corresponding program for incarcerated women in September, 

2016. HARP treats addiction as a disease rather than a crime and offers 

peer-to-peer counseling, group recovery sessions and family participation 

in the recovery process. Inmates in the HARP program hear interviews 

from potential participants and have the ability to remove participants who 

arc not fully committed to the program. Additionally, individuals can 

continue to use HARP as a support network after they are released, and 

can return to the HARP unit at any time if they are tempted to relapse. 

This program has a success rate of over 90% for 250 participants since its 

inception. 

ii. In 2014, the city of Winchester and Frederick and 

Clarke Counties formed the Northern Shenandoah Valley Substance 

Abuse Coalition. The Coalition brought together over I 00 stakeholders, 

including law enforcement, health personnel, social workers and nonprofit organizations, to launch a community model for responding to the 

opioid epidemic. The three localities initiated education programs, drug 

take-back and drop-box programs and encouraged participation in the 

Prescription Monitoring Program to reduce opioid overdoses. These 

localities show how constant collaboration can lead to community-based 

solutions. 

iii. One way to address the influx of illegal opioids to 

Virginia is through increased availability and flexibility of funds through 

Virginia's two High Intensity Drug Trafficking Area designations and 

from Department of Justice grant programs funded through the Byrne 

Justice Assistance Grants and others. 

b. High Intensity Drug Trafficking Area (HIDTA) 

i. HIDT A provides support for interstate and 

interagency collaboration, intelligence and information sharing, and 

specialized training for law enforcement and treatment agencies in areas 

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26839.021

characterized by high amounts of drug trafficking. The extra support and 

resources HIDT A offers increases local law enforcement's capacity to 

limit the supply of illegal opiates within the region. 

ii. Virginia participates in two HIDTA regions, the 

Washington-Baltimore region and Appalachia region, which includes 

counties in SW Virginia, Kentucky, West Virginia, and Tennessee. The 

mission of Appalachia HIDTA is to use a multi-disciplinary approach to 

deal with ongoing threats to public health and safety, particularly 

regarding prescription drug diversion and the emerging threat of heroin. 

The Appalachia region is arguably the epicenter of this crisis, and will 

require unprecedented multi-disciplined cooperation to effectively address 

the many health and public safety problems that result from this threat. 

iii. Virginia has 22 counties participating in HIDTA 

efforts (Washington-Baltimore and Appalachia). Our state police are 

involved in 32 multi-jurisdictional drug task forces, encompassing 144 

local jurisdictions, the DEA, and FBI. We appreciate our federal partners 

at HIDT A for providing resources to Frederick, Pulaski, and Wythe 

counties; this expansion increases Virginians' ability to share data and 

collaborate across localities. 

c. Interstate collaboration 

II 
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26839.022

i. As HIDT A demonstrates, the epidemic of opioid 

addiction does not recognize borders, so interstate collaboration is a 

necessary piece in addressing this crisis. In October 2016, Governor 

McAuliffe, Governor Hogan of Maryland, and Mayor Muriel Bowser of 

D.C. signed the National Capital Region Compact to Combat Opioid 

Addiction. On May 91

h, 2017, Maryland, the District of Columbia, and 

Virginia came together at the Regional Opioid and Substance Abuse 

Summit for a day-long conference focused on curtailing this ongoing 

public health and safety crisis. We hope to continue exchanging best 

practices and engaging in initiatives with surrounding states, knowing that 

another state's progress is progress for all of us. 

ii. We have also had the opportunity to collaborate 

with other states through NGA's learning labs on opioids. Virginia has 

participated in two NGA learning labs regarding the opioid epidemic. 

From October, 2016 to February, 2017, Virginia was part of a learning lab 

that addressed the unique problem of fentanyl. In June, 2017, Virginia 

began another learning lab on expanding opioid treatment options for 

offenders. 

Successful Implementation: Task Force Recommendations 

I. Based on the recommendations of the Task Force, the Governor's office 

advocated for and passed 14 pieces of bipartisan legislation addressing the opioid 

epidemic. These bills were passed in the legislative sessions of2015 through 2017. Some 

bills adapted existing regulations in response to the opioid crisis and others created new 

initiatives (see Appendix A for a complete list of bills). 

II. Three significant pieces oflegislation include: 

a. Reducing dispensing reporting time to the Prescription Monitoring 

Program from 7 days to 24 hours when physicians and healthcare providers 

prescribe opiates (SB287, 2016). 

b. Making Naloxone and Naloxone training available to first 

responders throughout Virginia (HB 1458, 20 15). 

c. Allowing for the registration of peer recovery specialists to assist 

addicts in recovering from addiction (SB 1020, 20 17). 

Ill. The Prescription Monitoring Program (PMP) 

a. The Prescription Monitoring Program has been an essential tool in 

tracking opiate distribution and holding prescribers accountable. Currently, over 

64,000 prescribers and 14,500 physicians in Virginia are registered to use the 

PMP, and the program is interoperable with 21 states. As of January I, 2016, all 

newly licensed physicians are automatically registered to participate in this 

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26839.023

program. The PMP allows us to see in real time exactly where and how often 

doctors are prescribing opiates as pain management. 

b. At the task force's recommendation, Governor McAuliffe made 

the PMP a more robust and responsive program. Dispensers formerly were 

required to submit opioid prescriptions to the PMP within 7 days, but now must 

do so within 24 hours. Virginia also put procedures in place for reporting 

egregious prescribing to agency enforcement and for prescribers to request patient 

information when prescribing a course of opiates longer than 14 days (previously 

90 days). These adaptations have already increased awareness of and control over 

opiate prescriptions. 

c. In 2016, Virginia passed a law mandating Continuing Medical 

Education for medical care providers regarding proper prescription, addiction and 

treatment. By 2020, all prescriptions containing opiates will be registered 

electronically. Both of these measures will ensure that our agencies can monitor 

opioid prescriptions and be poised to respond to future outbreaks. 

IV. Addiction and Recovery Treatment Services (ARTS) Program 

a. The Department of Medical Assistance Services administers 

Medicaid in Virginia. In 2016, Virginia passed the Addiction and Recovery 

Treatment Services (ARTS) program. The ARTS program went live in April, 

2017, and offers evidence-based addiction treatment to Medicaid users in 

Virginia. The continuum of treatment includes every level of treatment from 

inpatient detox to intensive outpatient treatment to office based opioid treatment. 

Though the ARTS benefit is limited without comprehensive Medicaid expansion, 

it does expand the menu of options available to those seeking treatment. The 

ARTS benefit created new treatment types and expanded services in every 

existing treatment category to provide a more comprehensive response to opioid 

and heroin addiction. For example, before the ARTS benefit only four providers 

offered Residential Treatment programs; after the ARTS benefit, 65 did. No 

providers offered Office-Based (remote) Opioid Treatment before the ARTS 

benefit; after, 24 did. 

V. Medically Assisted Treatment (MAT) 

a. Additionally, we have expanded Medically Assisted Treatment for 

those struggling with addiction. MAT is a combined medication and counseling 

treatment that is successful for 40 to 60% of its users. With MAT, healthcare 

providers have flexible options to treat the addicted population that uses 

Medicaid. Providers now can bill all Medicaid plans for substance abuse care and 

can bill for Certified Peer Recovery specialists under MAT. 

b. While MAT is an important component of treating addiction, 

medication must be combined with peer support services and other wraparound 

services in order to be effective. Under the MAT model, assessing individuals' 

13 
39 


26839.024

psychosocial needs, linking them to family or peer support networks and referring 

them to community-based services are as important as providing monitored 

medication for addicts. 

VI. Peer Support Services 

a. A critical component of treatment is the Peer Support Services 

program, effective July 1, 2017. Individuals can be trained and registered as Peer 

Recovery Specialists to offer support and assistance to those in the recovery 

process. Peer Recovery Specialists allow individuals to undergo treatment within 

their communities rather than in a hospital or other intensive care option. 

VII. Through the Public Health Emergency declaration in 2014, the 

Commissioner of the Virginia Department of Health was able to create a standing order 

that allowed any person to go to a pharmacy and obtain a prescription for Naloxone 

(commercial name Narcan). 

a. In 2015, Virginia expanded Naloxone use and training to first 

responders in Virginia. EMS and law enforcement personnel are being trained to 

use Naloxone to respond to overdoses at the scene. 

i. In June, 2017, non-profit EMS agencies began 

applying for Rescue Squad Assistance Fund grants to obtain Naloxone 

free of charge. 

ii. Local law enforcement agencies have been 

administering Naloxone with great success. In 2016, Fauquier county 

sheriff's deputies and Warrenton police officers administered Naloxone 22 

times. In Virginia Beach, officers began carrying Naloxone in the spring 

of 2016 and were saving lives at the pace of one per week. 

iii. We hope to continue to expand EMS, physician and 

law enforcement use of Naloxone so that the medication is accessible 

statewide. 

VIII. The passing of HB2317 in the 2017 General Assembly Session initiated 

Virginia's Comprehensive Harm Reduction with Syringe Services program. In 

response to this legislation, the Virginia Department of Health drafted standards and 

protocols which will be used by authorized Comprehensive Harm Reduction (CHR) 

programs including but not be limited to the Syringe Services Program (SSP). 

Localities must demonstrate both a need for the CHR and SSP programs, as well as a 

readiness for implementation, to ensure all stakeholders are invested in the programs' 

success. Additionally, localities must demonstrate an ability to sustain the program in 

the long term and a plan for engaging the communities they serve. 

Opportunities for Federal Partnership 

14 
40 


26839.025

I. Data sharing Health Insurance Portability and Accountability Act (HIPAA) and 

42 CFR Part 2 

a. HIP AA regulations particularly protect privacy in substance abuse 

cases pursuant to federal law (42 U.S.C. § 290dd-2) and regulations (42 CFR Part 

2). These restrictions limit law enforcement, health professionals and community 

stakeholders' data sharing ability. 

b. Because of the epidemic proportions of the current heroin and 

opioid addiction crisis, it may be time to reexamine states abilities to access and 

share information whether the data is 'de-identified' or individually identifiable 

lives can be saved through creation of issue specific strategies for sharing 

information pertaining to opioid use. 

c. Improved data sharing between state and local agencies will better 

aim the efforts in treatment and prevention that could be measured in several 

areas, such as the analysis of narcotic related arrests, property crimes and 

overdoses and types of drugs involved. Treatment and prevention partners can 

thus better target community needs and adjust law enforcement strategies 

accordingly. 

d. While these regulations protect the privacy of individuals' medical 

information, they also cause an inability to have real-time data on the number of 

overdoses, concentration of prescriptions, how drugs are being distributed at the 

local level, and other key data. Specific relaxation of certain aspects of HIP AA 

and associated regulations would lead to easier data sharing and better informed 

efforts in combatting this epidemic. 

e. One initiative that could be immediately implemented as a 

reasonable response to the opioid epidemic is nationwide mandatory reporting of 

heroin and opioid overdoses. Mandatory reporting would allow hospitals, labs and 

law enforcement to pinpoint the source of the problem. Additionally, having 

accurate statistical information on drug overdoses is crucial for federal and state 

grant applications. 

II. II. Medicaid expansion 

a. Virginia's Medicaid program spent $26 million on opioid use and 

misuse in 2013, with $10 million of this spending occurring in Southwest 

Virginia. More broadly, at least 40,000 adults in Virginia's Medicaid program 

have a substance abuse disorder, and over 50% of Medicaid members with serious 

mental illness also have a substance use disorder. The Joint Legislative Audit and 

Review Commission estimates that untreated substance abuse costs Virginia state 

and local governments $613 million per year in public safety and health care 

services alone. 

b. In order to address this epidemic, treatment must be available 

through Medicaid for Virginia's underserved population. Any reduction to 

15 
41 


26839.026

Medicaid funding or services would severely harm our ability to combat this 

ongoing public health crisis. Expanding opportunities for treatment is one of the 

most fundamental ways to address this epidemic. 

Ill. The Importance of Drug Courts 

a. The success of drug courts is indisputable, but Virginia state 

legislators have been reluctant to support widespread use of this option. 

b. The most rigorous and conservative scientific "meta-analyses" 

have all concluded that Drug Courts significantly reduce crime as much as 45% 

more than other sentencing options. Nationwide, 75% of Drug Court graduates 

remain arrest-free at least two years after leaving the program. For every $1.00 

invested in Drug Court, federal taxpayers save as much as $3.36 in avoided 

criminal justice costs alone. Drug Courts produce cost savings ranging from 

$3,000 to $13,000 per client. These cost savings reflect reduced prison costs, 

reduced revolving-door arrests and trials, and reduced victimization. 

c. It is essential that public servants in Congress adopt a supportive 

attitude towards the drug court system and communicate the importance of 

implementing this system to local legislators. 

IV. Supporting local coalitions through grant funding and data expansion 

a. In the mid late 90's the Department of Justice offered several 

grants to state/local agencies to slow the distribution and manufacturing of 

Methamphetamine in this country. These dollars ultimately resulted in the 

decrease of sales and manufacturing of Methamphetamine. Today, heroin and 

opioids require a similar response. Using federal Byrne Justice Assistance Grant 

funds, the Department of Criminal Justice Services (DCJS) in Virginia are 

providing grants to local law enforcement agencies to purchase naloxone. In 

Virginia, DCJS developed a program to train law enforcement officers in the 

delivery of Naloxone as a treatment to overdose cases. Enhanced federal support 

for the expansion ofthis program would equip first responders to save lives of 

more Virginians. 

b. Increased federal support for the HIDT A Program would be 

critical at the state, federal, and local level to allow coordination at all levels 

designed to stop the flow of drug production and trafficking. 

16 
42 


26839.027

Appendix A: Opioid Legislation in Virginia, 2015-2017 

Opioid Task Force Recommendations: Passed Legislation 

Year Bill Number Description 

SB1230 Mandates e-prescribing for prescriptions containing opiates beginning 

July, 2020 

Allows authorized persons to train emergency services and law 

SB848 enforcement personnel to administer Naloxone in the case of an opioid 

overdose 

SB1020 Authorizes the registration of peer recovery specialists by the Board of 

Counseling 

2017 Directs department of social services to collect information on in utero SB1086 

exposures to controlled substances 

HB2317 Authorizes pilot programs for the provision of sterile and the disposal of 

used hypodermic syringes and needles 

Extends requirement for PMP prescribers to request patient information 

HB1885 when prescribing opiates for longer than 14 consecutive days to 2022 (see 

SB513) 

HB829 Mandates Continuing Medical Education for opiate providers regarding 

proper prescribing, addiction and treatment 

SB827 Reduces opiate dispenser reporting time from 7 days to 24 hours 

HB657 Authorizes the Director of the Department of Health Professions to send 

2016 reports on unusual prescribing/dispensing behavior to agency enforcement 

SB5l3 Requires PMP prescribers to request patient information when prescribing 

opiates for longer than 14 consecutive days 

HB583 Provides certification for substance abuse peer support 

HBI458 Allows trained first responders to administer Naloxone; allows pharmacists 

to dispense Naloxone under proper protocols 

2015 HB184l Requires every licensed opiate dispenser to register with the Prescription 

Monitoring Program 

HB1738 Requires hospices to notify pharmacies of the death of a patient 

Source: V1rgmw's Leg1slat1ve Information System 

17 
43 


26839.028

Appendix B: Relevant Links 

Drug Cases Submitted to the Virginia Department of Forensic Science, CY 2015 

http://www .dfs. virginia.gov /wp-content/uploads/20 16/09/CY 15DfsDataReportSiides.pdf 

**Note: updated report for 2016 to be released soon 

Executive Directive 9, Establishing the Governor's Executive Leadership Team on Opioids, 

2016: 

http :II governor. virginia. gov I m edia/8166/ ed-09-estab I ish i ng-the-gov ernor-s-executi ve-l eadershipteam-on-opioid-abuse-and-addiction.pdf 

Executive Order 29, Establishing the Governor's Task Force on Prescription Drugs and Heroin 

Abuse, September, 2014: 

https :/I govern or. virginia. gov !tned ia/3 34 2/ eo-2 9-establ ish in g -the-governors-task-force-onprescription-drug-and-heroin-abuseada.pdf 

OCME Fatal Drug Overdose Report, April, 2017: 

http://www. vdh. virginia. gov /content/uploads/sites/18/20 16/04/F ata1-Drug-Overdose-QuarterlyReport-1.pdf 

Overview of ARTS benefit 

http://www.dmas.virginia.gov/content atchs/bh/Medicaid%20Addiction%20Recovery%20and% 

20Treatment%20Services%20Update%20-%20April%205%2020 17 .... pdf 

Prescription Drug Spending Report 

http:/ /1eg2.state. va.us/dls/h&sdocs.nsf/By+ Y ear/RD56320 16/$file/RD563 .pdf 

Task Force Recommendation Report: Implementation Plan (June 2015) 

https:/ /www .dhp. virginia.gov/taskforce/minutes/20 15 0630/T askF orceimplementationPlan.pdf 

Task Force Recommendation Report: Implementation Plan Update (October 2015) 

https:/ /www .dhp. virginia.gov/taskforce/minutes/20 150630/TaskF orcelmplementationPlan.pdf 

18 
44 


26839.029

Appendix C: HIDTA Map 

HIDTA Task Force Areas 

c:::::J HIDTA Designated Area. 

c:::::J !'ending HIDTA Designation 

19 
45 

Mr. MURPHY. We will get more into that as we cover questions. 

Thank you, Mr. Moran. Secretary Tilley, you are recognized for 5 

minutes. 

TESTIMONY OF HON. JOHN TILLEY 

Mr. TILLEY. Mr. Chairman and members, thank you so much for 

allowing me the chance to be here. I want to thank Governor Matt 

Bevin from Kentucky for that chance as well. He sends his regrets. 

He wanted to be here himself. He’s been outspoken on this topic. 

I will share with you a quick story. When I first met Governor 

Bevin, he was interviewing for this position, for this job, and he 

walked into a room with Dreamland under his arm, and he said, 

have you read this book? And thankfully, I had. So I said, yes, sir, 

I have read the book. And, actually, I am trying to reread it because it is, again, I think the best chronicling of this problem and 

how it began that I know of. 

So that, again, illustrates to you our commitment and our shared 

understanding of this problem. I want to thank Congressman 

Guthrie for that far-too-kind introduction as well. Dreamland, 

again, is relevant to us because, as you know, the problem really 

has its origins in Kentucky and Ohio. We lost 1404 Kentuckians, 

as the Congressman said. Fentanyl is now the driving force behind 

these overdoses. We had 13,000 ER visits, 13,000 ER visits in a 

state of 4 1A1⁄2 million people. We lose, in this country, as you’ve 

heard those numbers, nearly a commercial airplane a day. If this 

were a communicable disease, we would be wearing hazmat suits 

to combat it. 

But again, I think overdoses and those visits only tell half the 

story. This devastates communities. As soon as we got our arms 

around heroin, we began to see fentanyl. Our State Police tells us 

that in the last 6 years alone, we have seen a 6,000 percent increase in fentanyl in our labs. 6,000 percent increase. I think all 

of us know the devastation it’s had on our criminal justice community. Our jails and prisons are at capacity. We have no more room 

at the inn. 

The Public Health crisis is on full display. In Kentucky, we have 

a Hep C rate, Hepatitis C, a form of viral hepatitis that is seven 

times the national average. Right across the river in Indiana, they 

had an outbreak of HIV that rivaled that of Sub-Saharan, Africa. 

One of the first southern states to pass a comprehensive—maybe 

the only comprehensive syringe exchange program. Now in Kentucky, we have 30 programs all passed by local option in our state. 

We know that that increases the treatment capacity by five times. 

When someone just walks over the doorstep of one of those programs, and it battles back these diseases like Hep C and HIV. 

Sadly, Kentucky, as the CDC reports, has 54 of 220 counties 

most susceptible to a rapid outbreak of HIV. So what has our response been in Kentucky to battle this? Again, taking a bold step 

as a southern state on the syringe exchange program; passing comprehensive legislation in consecutive years on prescription pills and 

pill mills; the second state in the country to battle back synthetics; 

dealing with heroin directly and fentanyl; being the first state in 

the country to mandate usage of what we call KASPER, our PDMP, 

our prescription drug monitoring program. 

46 

Now we have become the first state in the country now to require 

physicians, when prescribing, for acute pain, to limit prescriptions 

to 3 days. Some have done 7, some have done 10. We limited that 

to 3 days. And I could promise you, our Governor has spent some 

capital on that. That’s how important it is to him. 

We have doubled down on things like rocket dockets and alternate sentencing worker programs, and help for those who are addicted through various forms of treatment. Again, looking at things 

like neonatal abstinence syndrome. We have 1900 cases in Kentucky. We’ve increased funding many times to combat that and to 

help for the suffering of those addicted there. We have put it in our 

jails and our prisons. Again, I think I mentioned rocket dockets 

with prosecutors, again, to try to make these cases, put them on 

a separate plane, to deal with them in the most appropriate way 

possible. 

We have increased treatment at the Department of Corrections 

by nearly 1100 percent since 2004. We validate that treatment 

every year, and our return on investment now is almost $5. Some 

of the innovative programs you may have heard about, it was just 

recently chronicled in The New York Times, is the way we use 

Naltrexone, or Vivitrol, as it’s known, in our jails, on the front 

lines. We give an injection prior to release, and an injection upon 

release. And then we try to link that offender, that returning individual, to those services in the community to see if they are Medicaid-eligible, to see what kind of resources they had to continue 

that particular treatment. And I know a question will be, do we 

link those folks up to counseling? We do our best to do it. It is not 

mandated. We do our best to do that. 

In fact, in Kentucky, I will tell you both, validated and 

anecdotally, we are seeing tremendous results from using MAT and 

counseling together, but counseling in the form of cognitive behavioral therapy, like moral reconation therapy. We are seeing that 

used in both our jails and prisons, and that is yielding some tremendous results. We intend to emulate what’s been going on in 

Rhode Island with the AnchorED program. We visited there with 

Director Boss some time ago through an NGA project. And I can 

promise you, we are doing peer recovery and bridge clinic soon. 

We’ll do some innovative awareness. We’ll use a hotline to get folks 

linked up to treatment. We’re even educating our medical and dental schools. And overall, as I close out and conclude at the end of 

my time, I will tell you that I think we have the most comprehensive effort I’ve seen in my 25 years in criminal justice with something called KORE, the Kentucky Opioid and Response Effort. 

So with that, I will look forward to questioning. Thank you, 

Chairman. 

[The prepared statement of Mr. Tilley follows:] 

47 


26839.030

Kentucky's Crisis 

John Tilley 

Secretary, Kentucky Justice and Public Safety Cabinet 

July 12,2017 

Committee on Energy and Commerce 

Subcommittee on Oversight and Investigations 

"Combating the Opioid Crisis: Battles in the States" 

2016 proved to be a deadly year for the citizens of the Commonwealth ofKentuckywho saw 1,404 

of their family members, friends, and neighbors die from drug overdoses. Since 2012, drug 

overdoses have accounted for more accidental Kentucky deaths than motor vehicle crashes. The 

leading culprit, Fentanyl, a potent synthetic opioid, was detected in 47% of overdose deaths, up 

from 34% in 2015. According to the Kentucky State Police, there was a 6,000% increase in 

laboratory samples submitted to the Central Forensic Laboratory testing positive for fentanyl from 

20 I 0 to 2016. Last year, in addition to fentanyl, the Kentucky State Police reported samples from 

I 0 different counties testing positive for carfentanil, a fentanyl derivative which is I 00 times more 

potent than fentanyl itself. Fentanyl continues to engulf Kentucky as the Kentucky State Police 

report that the number of submissions testing positive for fentanyl in the first two quarters of 2017 

has already exceeded the 2016 total. The 2017 samples also included cyclopentylfentanyl, 

acetylfentanyl, butyrylfentanyl, acrylfentanyl, furanylfentanyl, and carfcntanil. According to 

Appalachia HIDT A's 2018 Threat Assessment, Kentucky remains particularly vulnerable to drug 

trafficking organizations because of its central geographical location and many interstate 

highways. 

In addition to increased rates of substance usc disorders and overdose deaths, the opioid epidemic 

has also brought the threat of blood borne pathogens such as viral hepatitis and human 

immunodeficiency virus (HIV). According to the Centers for Disease Control and Prevention, 54 

of the top 220 counties most vulnerable to a rapid outbreak of HIV are located in Kentucky. In 

response to the devastating HIV outbreak just over the Ohio River in Austin, Indiana in 2014, the 

2015 Kentucky General Assembly became the first Southern state to authorize the creation of 

syringe exchange programs designed to reduce the incidence of needle sharing and prevent the 

spread viral hepatitis and IllY. Over 30 Kentucky counties have authorized syringe exchange 

programs since the General Assembly granted county officials the power to do so. Aside from 

HIV, forms of viral hepatitis such as hepatitis C also pose a large threat to the residents of 

Kentucky. From 2008 to 2015, Kentucky had the highest rate of acute hepatitis C infections. 
48 


26839.031

Department of Corrections Response 

The Kentucky Department of Corrections remains the single largest treatment provider in the 

Commonwealth. In 2004, the Kentucky Department of Corrections had 475 substance abuse 

treatment slots available. Today, the Kentucky Department of Corrections has 5,901 treatment 

slots which represents a 1, I 00% increase in substance abuse treatment slots available to Kentucky 

inmates since 2004. The Kentucky Department of Correction's substance abuse treatment 

programs utilize evidence-based cognitive behavioral therapy and therapeutic community models. 

According to a recent study by University of Kentucky professors, the Kentucky Department of 

Corrections' Substance Abuse Treatment program resulted in a $4.29 return on investment in terms 

of cost avoidance for every $1.00 spent on the program itself in FY 2015. During the 12 months 

following release, 70% of participants were notre-incarcerated, 85% maintained housing, and 68% 

were employed at least part-time. The study participants also reported decreased illicit drug use, 

decreased feelings of serious depression and anxiety, and decreased instances of suicidal ideation. 

In 2015, the Kentucky Department of Corrections began a pilot project aimed at reducing fatal 

overdoses among inmates released on parole. The Kentucky Department of Corrections uses a 

validated risk and needs assessment to target those inmates most vulnerable to overdoses and offer 

them the chance to voluntarily receive injections of naltrcxone, a long-acting opioid receptor 

antagonist, before they leave prison. Within 24 hours of being paroled, participating inmates meet 

with social service clinicians at their local Probation and Parole offices who assist the inmates in 

detennining healthcare coverage eligibility and setting up an appointment for the inmate's next 

naltrexone injection. The initial results from the pilot project have been so promising that 

representatives from five other states, tribal authorities from Montana, and the U.S. Virgin Islands 

have observed the program. 

21st Century Cures Act Programming 

The Kentucky Office of Drug Control Policy worked closely with representatives from the 

Kentucky Cabinet for Health and Family Services to develop a comprehensive strategy to utilize 

funds from the 21" Century Cures Act to bolster evidence-based treatment interventions aimed at 

reducing the impact and prevalence of opioid use disorder among non-fatal drug overdose 

survivors, pregnant and parenting women, and state and county inmates. 

Initiatives aimed at survivors of non-fatal overdoses include the creation of specialized 

medication-assisted treatment bridge clinic programs and the placement of peer recovery 

specialists in emergency departments. The specialized bridge clinics would initiate a medicationassisted treatment protocol with overdose victims while they are still in hospital in order to stabilize 

them long enough to obtain treatment in the community. The peer recovery specialist initiative, 

which was modeled after Rhode Island's Anchor ED program, would incentivize Kentucky 

hospitals to contract with certified peer recovery specialists who could counsel recent drug 
49 


26839.032

overdose survivors while they are still in the emergency department and help them enroll in a 

treatment program if the survivor chooses treatment in that instance. Some additional funds will 

be used to distribute naloxone at community awareness events, emergency departments, and 

syringe exchange programs 

The initiative aimed at pregnant and parenting women would create an integrated continuum of 

care model, which breaks down silos between obstetrics care, primary care, medication-assisted 

treatment provider care, and case management. Once the model is perfected, a training program 

will be developed and offered to healtheare and treatment providers. 

Finally, part of the 21st Century Cures Act funding will be used to create a targeted employment 

pilot program for state and county inmates reentering into society with a history of opioid use 

disorder. The program will hire employment specialists to assist former inmates in finding and 

maintaining employment in Northern and Eastern Kentucky, which are two regions that have been 

most affected by the opioid epidemic. 
50 

Mr. MURPHY. Thank you, Mr. Secretary. Director Boss, you are 

recognized for 5 minutes. 

TESTIMONY OF HON. REBECCA BOSS 

Ms. BOSS. Thank you, Chairman Murphy. Thank you, Chairman 

Murphy and Ranking Member DeGette. As the director of Rhode 

Island’s Department of Behavioral Healthcare, Developments, Disabilities and Hospitals, I oversee the state’s treatment, prevention 

and recovery system. I am also a longstanding member of the National Association of State Alcohol and Drug Abuse Directors, and 

currently serve on their board. 

Thank you for the invitation to appear before you today to share 

Rhode Island’s work in combating the opioid crisis, an effort that 

has been proposed as a national model. Our strategies to address 

this epidemic are clearly outlined on our Web site: 

preventoverdoseri.org. And I will be sharing slides from this Web 

site during this testimony. 

Our goal is to make these efforts open to the public with complete transparency on outcomes and available for replication 

throughout the country. First and foremost, I would like to thank 

Congress for the action taken last year passing the 21st Century 

Cures Act with $1 billion to help support prevention, treatment, 

and recovery. In a time of tight budgets, we fully appreciate the 

significance of this action. 

Addiction and overdose are claiming lives, destroying families, 

and undermining the quality of life across states in the United 

states, and Rhode Island has been one of the hardest hit. In 2015, 

newly elected Governor Gina Raimondo recognized the need for 

this state to develop a comprehensive strategy to prevent, address, 

evaluate, and successfully intervene to reverse the overdose trends. 

She signed an executive order establishing the Governor’s Overdose 

Prevention and Intervention Task Force, which is comprised of 

stakeholders and experts from a broad array of sectors. The resulting plan has one overarching goal: reduce overdose deaths by onethird in 3 years. Governor Raimondo’s plan focuses on four specific 

strategies, which I will briefly outline and focus on two specific 

areas, others are described fully in my written testimony. 

The first is prevention. We take aggressive measures to ensure 

appropriate prescribing of opioids, promote safe disposal of medication, and encourage the use of alternative pain management services. 

Next is Naloxone, rescue. Naloxone is a standard of care for first 

response. Naloxone saves lives by reversing overdose. And our plan 

supports increasing access to Naloxone across various sectors of the 

state. 

Third, we believe that every door is the right door for treatment, 

and our goal is to increase access to evidence-based treatment. To 

do this, Rhode Island developed Centers of Excellence, which provide rapid access to treatment, including induction on all FDA-approved medications for opioid use disorder. These specialized programs provide thorough clinical assessments and intensive treatment services with wraparound support. This program is designed 

to provide opportunities for stabilization with referrals to community physicians for continued treatment, offering continued clinical 

51 

and recovery support through the Centers of Excellence. This program is supported through private insurance and Medicaid. 

In addition, Rhode Island released the Nation’s first statewide 

standards for treating overdose and opioid use in hospitals and 

emergency settings. And the Rhode Island Department of Corrections is providing medication-assisted treatment to the population 

most at risk for overdose. We have worked diligently to increase 

data-waivered physicians in Rhode Island. For example, Brown 

University Medical School is the first in the Nation to incorporate 

data-waivered training into its curriculum. 

Finally, recovery. We are looking to expand recovery supports. 

Recovery is possible. To support successful recovery from more 

Rhode Islanders, we are expanding peer recovery services, particularly at moments when people are most at risk. The AnchorED program was started in June of 2014, and is now a statewide, 24/7 

service. It connects overdose survivors with peer recovery coaches 

in hospital emergency departments. These coaches share their own 

stories of hope and inspiration to engage those in crisis, as well as 

providing continued services, and follow up in connection. To date, 

over 1600 individuals have met with recovery coaches; and as a result, over 82 percent have accepted a referral to treatment. 

The Anchor MORE Program exists as a statewide peer outreach 

effort to opioid hotspots that are identified through data, not waiting for someone to overdose to be seen. We are now facing a 

fentanyl crisis. As you can see in this slide, with approximately 

two-thirds of overdoses, fentanyl-related, we must develop new 

strategies to address the changing face of this epidemic. 

As we speak, the Rhode Island Governor is signing an executive 

order expanding our efforts to include more focus on primary prevention, engaging families and youths in these efforts, harm reduction strategies, and access to treatment. I cannot state strongly 

enough that Rhode Island’s strategies rely on sustainable funding 

through Medicaid and health insurance held to standards of parity 

with SUD treatment as an essential benefit. Any action taken on 

a Federal level which would threaten this funding would weaken 

this plan substantially. 

I would also recommend that any Federal initiatives specifically 

include involvement of state agencies given their expertise in these 

matters. I would advocate for continued support of the Substance 

Abuse Prevention Treatment block grant as the foundation of comprehensive state systems. And finally, I would encourage continued 

consideration of targeted funds to address these issues. 

Thank you for this opportunity to testify. I look forward to answering questions. 

[The prepared statement of Ms. Boss follows:] 

52 


26839.033

STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS 

Department of Behavioral Healthcare, Developmental Disabilities & Hospitals 

OFFICE OF THE DIRECTOR TEL: (401) 462-3201 

14 Harrington Road FAX: (401) 462-3204 

Cranston, Rl 02920-3080 TDD: ( 401) 462-6087 

Written Testimony of 

Rebecca L. Boss, M.A., Director 

Rhode Island Department of Behavioral Healthcare, Developmental Disabilities & Hospitals 

Before the 

House Subcommittee on Oversight and Investigations 

The Energy and Commerce Committee 

2123 Rayburn House Office Building 

Wednesday, July 12, 2017 at 10:00 a.m. 

Chairman Murphy, Vice Chairman Griffith, Ranking Member DeGette and Distinguished 

Subcommittee Members, my name is Rebecca Boss. I am the Director of the Department of 

Behavioral Healthcare, Developmental Disabilities & Hospitals (BHDDH) and oversee Rhode Island's 

substance use disorder division. 

It is a privilege to serve my home state of Rhode Island under the leadership of Governor Gina 

Raimondo and Secretary of Health and Human Services Eric Beane. 

With more than 2S year's experience in both state government and the provider community in 

substance use disorders, and as a long-standing member of the National Association of State Alcohol 

and Drug Abuse Directors, also known as NASADAD, I feel that I am uniquely positioned to testify on 

this crucial matter. 

Thank you for the invitation to appear before you to allow me to describe how our state is 

addressing the critical issue of the opioid overdose epidemic. First and foremost, I wish to thank 

Congress for the federal funding that is essential to state agencies like BHDDH that comes to us 

through the Substance Abuse and Mental Health Services Administration (SAMHSA), CDC and HRSA. 

Furthermore, we are very appreciative of the action Congress took last year through CURES with $1 

billion to help support prevention, treatment and recovery throughout the country. We are grateful 

for the funds, which enabled us to carry out our much-needed work with Congressional support. 
53 


26839.034

Addiction and overdose are claiming lives, destroying families, and undermining the quality of life 

Kross Rhode Island. For over a decade, opioid dependence and accidental drug overdose have been 

~rowing problems across the United States, and Rhode Island has been one of the hardest hit. In 

2013, Rhode Island had the highest rates of illicit drug use in the nation, as well as the highest rate 

>f drug overdose in New England, and in 2015 had the fifth highest rate of overdose deaths in the 

1ation. 

1\s the numbers indicate, this problem is not going away. Soon after her election in 2015, Rl 

Governor Gina Raimondo recognized the state did not have a comprehensive statewide strategy to 

evaluate, prevent, and successfully intervene to reverse the overdose trends. She knew that it was 

not enough to treat a single overdose; recovery support services needed to expand to embrace the 

full scope and depth of treatment. Clearly a new strategy had to be implemented. 

In August 2015, Governor Raimondo signed an Executive Order establishing the Governor's 

Overdose Prevention and Intervention Task Force naming the Directors of BHDDH and the 

Department of Health (DOH) as Co-Chairs. The Task Force included stakeholders and experts in fields 

ranging from public health and law enforcement to healthcare, community-based support services, 

insurance, academia, business, government and more. Also included were family members of those 

who lost loved ones, and have added an invaluable perspective that we in government and the 

private sector sometimes miss. 

The Task Force created a Strategic Plan for Addiction and Overdose and recommended numerous 

strategies within four areas: prevention, rescue, treatment and recovery. The data-driven plan was 

created and soon after, with the help of Brown University a website was created 

(www.preventoverdoseri.orgl where all efforts are tracked in a public and transparent fashion. 

The distinguishing factor of the multi-disciplinary Task Force was that the members brought the Plan 

back to the sectors they represented. For instance, the Medicaid Director worked with her team to 

cut red tape that was identified and work with the insurers. The community providers, with their 

boots on the ground, were nimble enough to put plans in action after our meetings. 

Each of the four areas has moved forward with numerous initiatives: 

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Prevention 

Safer Prescribing: To achieve safer opioid prescribing, it is important to weigh the benefits of 

medication access for patients living with acute and chronic pain with those of the risks of diversion, 

addiction, overdose, and premature death. Unsafe combinations of prescribed medications are 

linked to addiction and many overdoses are preventable. To support these efforts, the Rhode Island 

Legislature passed the following bills: (2016-H8224A, 52823Aaa): Sets out limits for most initial 

opioid prescriptions. Requires pharmacies to upload dispensing data within 24 hours. (52822A): 

Allows patients to synchronize certain drug refills for chronic conditions by requesting a limited 

supply (less than 30 days), with pro-rata cost sharing applied by the insurer 

The key strategy to reduce dangerous prescribing is to use the Prescription Drug Monitoring 

Program (PDMP) and system-level efforts to reduce co-prescription of benzodiazepines with opioids 

(for pain or opioid use disorder). Before DOH launched its Prescription Drug Monitoring Program 

Enrollment Enforcement Plan in 2016, more than 30 percent of Rhode Island prescribers had failed 

to enroll in the PDMP, and fewer than 40 percent were using it. As of July 2016, legislation had 

passed that all such practitioners shall be automatically registered with the Prescription Drug 

Monitoring Program maintained by the Department of Health. As of today, 100 percent of 

practitioners are enrolled. To support these efforts, the Rhode Island Legislature passed the 

following bills: (2016-H7847, 52897): Allows the Prescription Drug Monitoring Program to be 

electronically connected to electronic medical records systems. {H7849, 52874}: Adds Schedule V 

prescriptions to the Prescription Drug Monitoring Program. (H8326, 52946A): Requires DOH to look 

for federal funding opportunities to improve the POMP, such as by adding additional analytical 

functions and incorporating data from similar programs in other states. 

Additionally, DOH Director, Dr. Alexander-Scott co-led a successful national petition drive calling on 

the FDA to require "black box" labels on opioids and benzodiazepines warning that concurrent use 

of these medications increases the risk of fatal overdose. 

Reducing the Supply of Prescribed Opiates (Rx): Rhode Island has developed regulations that limit 

most opioid dosing for acute pain management to a contained period of time (with exceptions for 

specifically-determined patients) and supports existing hospital policy to restrict opioid prescriptions 

from emergency rooms to three days or less. 

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The promotion of non-opioid therapies for chronic pain, such as chiropractic services, massage 

therapy, physical therapy, and acupuncture as important alternatives to opioid pain relief is another 

successful effort in Rhode Island. Access to comprehensive health care coverage, including 

Medicaid, is a crucial component of these non-opioid alternatives. 

Reducing Demand (Illicit): We cannot arrest our way out of this crisis, but we must build on 

partnerships with community organizations and law enforcement to reduce demand for heroin and 

other illicit drugs. Deaths associated with illicit drug use and fentanyl have increased exponentially 

in recent years. To address the illicit drug crisis, the Rhode Island Department of Health is working 

with the Rhode Island State Fusion Center and participating in the New England High Intensity Drug 

Trafficking Area (NEHIDTA) multi-state Heroin Response Strategy. This program, funded through the 

Office of National Drug Control Policy, currently maintains a 20-state partnership to address heroin 

and opioid abuse and trafficking. In fact, Rhode Island has designated a Heroin Response Strategy 

Drug Intelligence Officer and Public Health Analyst who are positioned at the Rhode Island State 

Fusion Center. 

There is no current data on all fentanyl drug seizures from Rl law enforcement since many 

investigations are ongoing. However, the NFLIS data has shown steady fentanyl seizures in powder 

form with sporadic counterfeit pill seizures (most recently pills containing furanyl fentanyl). Heroin 

seizures have declined. 

The supply chain enters Rl via sources in NY and MA as well as from China via US mail and common 

carrier services (UPS) etc. Cartels are not prominent in Rl but their use of secondary drug trafficking 

organizations to ship the product is the most common source of transport. We remain concerned 

about the strong potential for the production of counterfeit A-215, M-30 and V-48/12 pills in our 

area. 

Hospital Testing for Fentanyl: Some hospital systems are testing for fentanyl, but we do not yet 

know the frequency of testing or how many tests are returning positive for fentanyl. DOH is hoping 

to develop a data feed to include fentanyl test results. 

With regards to fentanyl testing in the Emergency Departments, there is some preliminary data 

from one of the largest hospital systems. Between March 1st and May 31st, just under 3,600 

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toxicology screens were conducted, of which 11.6% were positive for fentanyl. About 40% of 

discharges coded as overdose (and which a toxicology screen was conducted) were positive for 

fentanyl. 

In February, Rhode Island started testing all inductees in the Opiate Treatment Program (OTP) 

system (13 locations throughout Rl) and have met regularly with the OTP MD's to analyze findings. 

Initial results indicate that a large percentage of individuals being admitted to treatment are testing 

positive for either heroin or fentanyl, or fentanyl alone. 

MODE Team: Rhode Island has implemented a Multidisciplinary Review of Drug Overdose Death 

Evaluation (MODE) Team which combines strategies of "rapid response" with "community 

intervention." The Team is modeled after the multidisciplinary review processes for child deaths. 

The purpose of the MODE Team is to gain insight into emerging overdose trends, identify gaps in or 

opportunities for policy development and prevention programming and inform the distribution of 

mini-grants to Rhode Island communities for prevention efforts. The MODE Team is comprised of 

individuals from varying agencies and organizations, including the Rhode Island Department of 

Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH); Rhode Island 

Department of Health (RIDOH); Boston Medical Center's Injury Prevention Center; Rhode Island 

Department of Corrections (RIDOC); and Brown University. Data sources come from RIDOH (Medical 

Examiner reports, Prescription Drug Monitoring Program (POMP)), BHDDH (substance abuse and 

mental health treatment episodes), and RIDOC (incarceration history and medical records from 

incarceration). The MODE Team has met three times quarterly to review this data on 11 cases. 

Twenty-five MODE Team recommendations have been developed, with nine community-based drug 

overdose prevention mini-grants distributed. 

Surveillance, Response, and Interventions (SRI): This workgroup made up of staff from DOH and 

BHDDH review overdose information on a weekly basis. When overdoses exceed a certain threshold, 

alerts are issued to the community, law enforcement, and health providers. 

Naloxone as Standard of Care: Naloxone saves lives by reversing the severe respiratory depression 

caused by opioids. Its use by laypeople trained to identify and respond to overdose has been linked 

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to reductions in overdose death rates. People who use opioids are at greatest risk of overdose, and 

are motivated to protect themselves and others around them to save a life with naloxone. law 

enforcement being equipped with naloxone is critical in the fight against opioid overdoses. In fact, in 

Rhode Island two police departments {East Providence and North Providence) have offered to 

purchase naloxone for those departments who may not have the funds to purchase it themselves. 

Further, Rhode Island has promulgated regulations requiring all inpatient substance use disorder 

providers to offer naloxone to at-risk clients, Emergency Departments are dispensing naloxone to 

individuals who have overdosed, peers distribute on the street, and inmates with substance use 

disorders are given naloxone upon release. Fortunately, Medicaid funds pay for Naloxone and 

allows BHDDH to use other federal funds for additional prevention and intervention activities. 

Rhode Island's DOH Director, Dr. Alexander-Scott sent a letter to Rhode Island prescribers 

encouraging the co-prescription of naloxone and a letter to Rhode Island pharmacists encouraging 

them to stock naloxone. To support these efforts, the Rhode Island Legislature passed the following 

bill: (2016-H7710A, S2460Aaa): Requires all insurers to cover naloxone and related devices, including 

in cases where the medication is intended for patients ather than the insured. 

Naloxone in the Community: Rhode Island State Police invested $40,000 in Google settlement funds 

in February 2016 to distribute more than 1,000 naloxone kits to law enforcement agencies. BHDDH 

has secured $40,000 from the Substance Abuse Prevention and Treatment block grant to purchase 

1,000 units of naloxone in 2016. Kits were distributed at the Department of Corrections and through 

targeted street outreach by peer recovery coaches. This effort will be sustainable for three 

additional years. 

Good Samaritan Law: "The Good Samaritan Overdose Prevention Act of 2016" was strongly 

advocated by the Task Force, after the previous Good Samaritan law had expired. The new law also 

expanded immunity to people at risk of violating probation or parole and protects from liability 

those who use life-saving medical treatments such as naloxone that can prevent an overdose. To 

support these efforts, the Rhode Island Legislature passed the following bill: (2016-H7003}(S-2002) 

No liability to any person who administers an opioid antagonist to another person to prevent a drug 

overdose and provides immunity for violations of probation and/or parole for those persons who in 

good faith, seek medical assistance for a person experiencing a drug overdose. 

Treatment 

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Medication Assisted Treatment: Evidence indicates that medication-assisted treatment 

(methadone, buprenorphine or depotnaltrexone* injection) has profound effects on people with an 

opioid use disorder. It reduces their risk of death, relapse, chance of going to prison, and greatly 

improves their quality of life. 

Rhode Island supports a model of shared decision making between the individual and their provider. 

We support the use of FDA-approved medications for the treatment of opioid use disorder including 

methadone, buprenorphine products, and injectable naltrexone, always in the context of recovery 

support services. These supports vary based on patient need, but include drug and alcohol 

counseling, screening and treatment of co-occurring mental and physical health issues, checking of 

the state prescription drug monitoring database, toxicology screening, individual and group 

therapies, peer support services, vocational and educational assistance. These supports must 

include the development of a treatment agreement with every person receiving care. Governor 

Raimondo, RIDOH, and BHDDH, along with expert advisors to the Task Force began working with 

primary care practice leaders across the state to overcome barriers to expanding buprenorphine 

prescribing among primary care providers. 

Rhode Island has developed the Centers of Excellence for the Treatment of Opioid Use Disorder 

which are being established throughout the state. This model provides a means of rapid access to 

treatment for opioid use disorder, provides all of the above-mentioned services and works 

collaboratively with community providers of ongoing treatment for the opioid use disorder once 

stabilized in the Center of Excellence. This model also provides additional support to community 

providers-be they physicians or other allied providers, or community treatment programs that may 

not be equipped to assist a person who experiences relapse to opioid use by re-admitting the 

person to the Center for any additional stabilization needed. These Centers also serve to assist with 

the workforce development needs of our state in that these centers provide practical educational 

experiences in opioid use disorder treatment to community providers and trainees alike. Centers of 

Excellence are funded through private third party insurers as well as Medicaid. With Medicaid 

expansion, many more people are able to access Medication Assisted Treatment for opioid 

addiction. 

Rhode Island offers medication-assisted treatment through the Department of Corrections. The 

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Governor proposed $2.5 million in the FY17 budget for medication-assisted treatment in the state 

prisons and the General Assembly approved $2 million in the final budget. The Governor requested 

repeat-funding in her FY18 budget. Individuals who are awaiting trial are no longer withdrawn from 

MAT, and those who are opioid dependent and not in treatment are able to be inducted on 

medication as appropriate. Incarcerated individuals with histories of opioid use disorder are at a 

significantly increased risk of overdose upon release, so these individuals are also being offered 

induction on MAT. The Department of Corrections has worked closely with the Rhode Island 

Medicaid Office to ensure that these individuals are connected to coverage so that there is not 

treatment disruption upon release. 

Centers of Excellence: As described above, the Centers of Excellence for the Treatment of Opioid 

Use Disorders was created and provides comprehensive evaluation, including mental health 

evaluation and treatment or referral, induction and stabilization services, as well as support to 

providers in the community. It is envisioned that such Centers would refer stabilized patients to 

other providers and receive back patients if they destabilize and require more intensive services. 

Rhode Island's first Center of Excellence opened in November 2016 at CODAC Behavioral 

Healthcare. CODAC has six sites with a COE at each site; a seventh will open soon in the state 

hospital known as the Eleanor Slater Hospital System. Additionally, two community providers are 

opening new COEs this month. 

Waiver Training: Rhode Island has sought to address the issues of access to care and workforce 

development by building a program of physician and practitioner Drug Abuse Treatment Act of 2000 

(DATA 2000) trainings which are necessary to obtain the waiver to prescribe buprenorphine to 

individuals with opioid use disorder from office-based practice. These trainings also offer education 

on the epidemiology of opioid use disorder in the United States, appropriate assessment and 

treatment of opioid use disorder, an overview of all FDA-approved medication assisted treatment 

and evidence-based psychosocial interventions, confidentiality issues related to 42 CFR Part 2, and 

an overview of special populations that may be affected by opioid use disorder. As such, the course 

is an excellent overview of current approaches to management of substance use disorders. We have 

trained over 300 practitioners since January of 2016 and we have established a system where 

institutions can request trainings as needed. This dovetails well with our practical experience 

available in Centers of Excellence and which we hope will encourage prescribers to engage in officebased treatment of opioid use disorder. 

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Rhode Island is leading the way with the training of medical students, the first of its kind in the 

country. The 2018 Class of the Warren Alpert Medical School of Brown University, which will 

graduate next May, will be the first class to participate in a new program to complete the training 

necessary to qualify for a Drug Abuse Treatment Act of 2000 (DATA 2000) waiver prior to 

graduation. The waiver is necessary to prescribe FDA-approved medications for the treatment of 

opioid use disorders. Once the new graduates receive their full medical license and DEA 

registration, they can apply for the DATA 2000 waiver. 

Emergency Department Standards: leadership from hospitals and emergency departments 

throughout Rhode Island joined Governor Raimondo's Overdose Prevention and Intervention Task 

Force. They will release a first-in-the-nation set of statewide guidelines to save lives by ensuring 

consistent, comprehensive care for opioid-use disorder in emergency and hospital settings. Released 

in March 2017, it established a common foundation for treating opioid-use disorder and overdose in 

Rhode Island hospitals and emergency departments, the standards establish a three-level system of 

categorization that defines each hospital and emergency department's current capacity to treat 

opioid-use disorder. All emergency departments and hospitals in Rhode Island will be required to 

meet the criteria for level 3 facilities. As a facility's capacity to treat opioid-use disorder develops, 

that facility can apply for a higher designation. 

Recovery: 

Expand Recovery Supports: The growing need and capacity for peer recovery services mirrors the 

pace of the epidemic. Successful recovery nurtures the individual's health, home, community and 

purpose. New opportunities are envisioned that support peer recovery services and medicationassisted recovery. Medicaid coverage for treatment of substance use disorders and parity has 

allowed Rhode Island to maximize block grant fund and state general revenues to fund these 

important supports as well as prevention activities. 

Recovery Coaches: It is important to cultivate a recovery coach pipeline, with a plan to double the 

number of recovery coaches for statewide and extended coverage, supporting in-prison recovery 

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coaching and certification, and ensuring proper support and supervision of recovery coaches at this 

scale. Every effort is being made to expand and create consistency in reimbursement for delivery of 

certified peer recovery coach services. Since Rl developed a certification process in 2014, 98 peer 

recovery coaches have been certified in Rl, nearly double in 2016 than in 2015. A related aspect of 

this strategy is to standardize help-seeking and recovery supports through standardization of 

employee assistance programs (EAP) for the workforce and by mandating that all drug treatment 

programs develop recovery planning (including training programs and referrals, establish 

certification for recovery housing, and support case management to help people access resources) 

or coordinate such supports with an outside entity. 

DOH has a contract with Anchor Recovery through 2019 to provide peer recovery coaches to 

inmates upon release from the Department of Corrections and through targeted street outreach to 

state hotspots. 

Recovery Coaches in Emergency Departments (AnchorED): In May of 2014, Rhode Island started a 

pilot program using recovery coaches to respond to overdose survivors while they were receiving 

treatment in hospital Emergency Departments. On-call coaches respond to overdose survivors and 

offer support, referrals, resources, family support and training on naloxone. This success of this pilot 

project supported its expansion to be offered statewide twenty-four hours per day, seven days per 

week. These coaches have had great success at engaging clients with an 85% follow up rate with 

treatment and/or recovery support services. This service has provided the state with a wealth of 

information on the experience of individuals with the healthcare system as well as the addiction 

treatment system. While engaging with recovery coaches at a crucial point in their addiction, many 

individuals make the decision that they are ready for treatment - seeing the hope of recovery 

through shared experience and recognizing their desperate state makes people ready for change. 

The number of contacts that the Peers have made in the ED has been steadily increasing from 

around 85 contacts in the first month to 165 contacts in the most recent month. The majority of 

patients seen in this program (67%) are not currently receiving treatment for substance use 

disorders (SUD), but more than 85% of them agree to get a referral to SUD treatment. 

Anchor MORE: The success of AnchorED spurned the development of AnchorMORE, recognizing 

that successful consumer engagement does not have to wait for an individual to show up at and ED 

with an overdose. The Anchor MORE is a community outreach program, placing recovery coaches 

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on the streets to connect with and engage individuals. Anchor MORE currently dispatches these 

teams of recovery coaches to areas in which individuals are using substances in public places. 

Anchor MORE teams are also proactively dispatched to certain areas in the state by looking at 

overdose data and emergency services pick-up data. Both programs connect individuals with 

recovery coaches - trained peers with lived experience of addiction. Recovery coaches stay actively 

engaged with individuals after an encounter and connect them to treatment and recovery support 

services, including integrated health home teams, homeless assistance programs, employment 

assistance programs, primary care, and case management services, once the individual is 

comfortable. 

Recovery Houses: Safe, drug-free living environments are crucial to support recovery. Rhode Island 

has identified a funding source to begin the certification process for a network of recovery houses 

across the state. Legislation passed that requires recovery houses to meet a set of standards to 

receive state certification. The National Alliance for Recovery Residences (NARR) will be tasked with 

certifying recovery houses and will receive verified training to become a certifying entity. Recovery 

housing will include on-site staff and resources in addition to housing. Rhode Island Communities for 

Addiction Recovery Efforts (RICARES) will be tasked with stakeholder oversight. To support these 

efforts, the Rhode Island Legislature passed the following bill: (2016-H8056A, 525798): Authorizes 

BHDDH to develop a process to certify recovery housing facilities for residential substance abuse 

treatment. 

Discharge and Recovery Plan: Through the work done by the Task Force, state health agencies 

developed a model discharge and recovery plan to promote recovery services for patients with 

substance use disorder. Known as the Perry and Goldner Bill, the legislation is designed to improve 

emergency room treatment for those with substance use disorders and ensures patients receive a 

discharge and recovery plan. To support these efforts, the Rhode Island Legislature passed the 

following bill: (2016-H7616A, S2356Aaa: The Alexander Perry & Brandon Goldner Act): Requires 

comprehensive discharge planning for patients with substance use disorders and requires insurers ta 

cover expanded medication-assisted treatment. 

Rhode Island's Future Plans: Today, Governor Gina Raimondo is issuing an Executive Order 

declaring that the alarming rate of deaths caused by opioid overdose constitutes a public health 

crisis. The Executive Order outlines new initiatives in the four areas recommended in the Task 

Force's Strategic Plan: Prevention, Rescue, Treatment and Recovery. Included in the Order are 

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educational components, the promotion of existing systems, and the expansion of partnerships. The 

Governor also incorporated a coordinated public outreach campaign into the Order to engage 

parents and youth to prevent opioid abuse through the establishment of a Parental Task Force. This 

Task Force will collaborate with schools to expand access to prevention programming for high-risk 

youth and the expansion of family support groups throughout the state. The Executive Order 

asserts that all state agencies, with coordination and support from the Task Force, shall take all 

necessary actions to reduce opioid overdose deaths. The Departments of Health and Behavioral 

Healthcare, Developmental Disabilities, and Hospitals will ensure implementation of the Executive 

Order initiatives and report back to the Governor on a semi-annual basis. 

Executive Order 17-07 issued on July 12,2017. 

Recommendations: I humbly submit a few recommendations-

• Any federal initiatives include the involvement of the state agencies. Between the expertise 

and authority our staffs have within the substance use disorder system, our agencies can 

help to chart the right course. 

• The importance of the Substance Abuse Prevention and Treatment Block Grant cannot be 

understated. It is a critical component in our efforts to engage our communities in primary 

prevention. We hope the strong support you have shown continues. As Medicaid has laid 

the foundation for treatment coverage, the block grant has been critical in providing 

coverage for recovery support services and prevention efforts. 

Targeted funds to address the many issues I have discussed today would be helpful. 

Congress has shown generous support to substance use disorder agencies and we certainly 

hope there is consideration for continued support. 

Treatment for substance use disorders leads to recovery. Access to the treatment has been 

advanced by Medicaid expansion. Continuing to support funding for Medicaid expansion to 

single adults with low incomes is essential to helping more people recover from substance 

use disorders. 

Many individuals living with substance use disorders do not have access to transportation. 

Permitting mobile methadone or buprenorphine provisions would eliminate that barrier and 

make treatment more accessible. 

Workforce development in the field of substance use disorders is crucial with a standardized 

certification program to license workers across all states. If this were coupled with a loan 

forgiveness program, the workforce could grow to the numbers needed. 

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With elder opioid addiction on the rise, parity for Medicare clients would be welcomed by 

all. 

Repealing the Institution for Mental Disease (IMD) exclusion would allow for meaningful 

behavioral health care to those who present with a substance use disorder, truly allowing 

every door to be the right door. 

Conclusion: I appreciate the opportunity to present testimony before the Subcommittee. Over the 

last 5 years we have lost more than 1,200 people to drug overdoses, coming from every community 

in the state. Our work is focused on saving lives. I encourage the Subcommittee and Congress to 

work with the NGA, NASADAD and ASTHO as well as other partners to leverage the collective 

knowledge and expertise of State alcohol and drug agency directors and public health departments 

across the country to help end this epidemic. 

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Mr. MURPHY. Thank you all. I recognize myself now for 5 minutes. Starting with Governor Rutherford, regarding the 42 CFR, 

Part 2, a couple of effects. One is, as also as pointed by Secretary 

Moran and others, if someone is using a PDMP, the data is simply 

not in there. A physician prescribing will not know if that patient 

is on methadone, suboxone or some other synthetic opioid. 

Secondly, if a person shows up in an emergency room—our 

former colleague, Patrick Kennedy, talks about this incident— 

shows up there with an injury, and when asked if that person has 

any allergies or any drugs, and he says, ‘‘Please don’t give me any 

opioids.’’ They do it anyway, because there’s nothing in the record 

that’s prohibitive of being in the record. We can list if a person has 

an allergy, but an opioid sensitivity should be in there as well. But 

the law in place since the Nixon administration does not allow that 

to be in there. So the person then may leave that hospital with a 

vial of opioids, and then saying, ‘‘Well, when I used to be addicted, 

I used to take 20 of these at a time, I’ll take 20 now.’’ Overdose 

and death. Or they may take them and then they relapse, or they 

may be on other medications, such as benzadine, the PNN, a bad 

drug interaction. 

What do you recommend we do with that 42 CFR Part 2? 

Mr. RUTHERFORD. Well, that does have to be addressed. You’re 

exactly right. And Secretary Moran was correct in terms of that 

particular challenge. A person who goes in who may be receiving 

methadone treatment, they go in for a knee replacement. There’s 

nothing to tell that doctor that this person is also receiving methadone, when they prescribe oxycodone or OxyContin or something of 

that nature. It doesn’t show up in our prescription drug monitoring 

system as well. 

So it is a particular challenge. It needs to be addressed. There 

are some areas with regard to HIPAA that also go to other areas 

of behavioral health, and I know you talked about that. When we 

talk about mental health and the challenges associated with getting assistance for an adult family member, once that person goes 

from 17 to 18, you lose a lot of control when you can help this person. So, yes, if you can make some type of exceptions or clarification—— 

Mr. MURPHY. At least in the—— 

Mr. RUTHERFORD. That is also a misunderstanding among some 

of the doctors as well. 

Mr. MURPHY. At least in the medical record to be able to do a 

42 CFR—— 

Mr. RUTHERFORD. Yes, that would be a start. 

Mr. MURPHY. Let me ask another quick survey. Noting that most 

people with an addiction disorder have a co-occurring mental 

health disorder. I was just wondering if any of you have taken a 

survey in your states? Do you have a sufficient number of psychiatrists, psychologists? I believe the national numbers say that half 

the counties in America have no psychiatrists, no psychologists, no 

clinical social worker, no licensed drug treatment counselor. 

If you know? If you don’t know, tell me. But if you do know, do 

you have ever a sufficient number in your state to meet the need? 

Mr. RUTHERFORD. I can only speak anecdotally. There are some 

counties in our state that have a substantial shortage of those 

66 

types of professionals, including drug counselors. That is the challenge that we have. 

Mr. MURPHY. Secretary Moran, real quick, yes or no. 

Mr. MORAN. Yes. And it varies by geography in southwest Virginia, Congressman Griffith represents a very insufficient shortage 

of such counseling. 

Mr. MURPHY. Secretary Tilley. 

Mr. TILLEY. Urban areas, yes; rural areas, no. We do have a community mental health network we’re proud of. But, again, in the 

rural areas, they are still struggling to find the qualified professionals. 

Mr. MURPHY. Thank you. Director Boss? 

Ms. BOSS. Rhode Island shares in the Nation’s struggle with the 

number of psychiatrists needed to meet the demands. So I would 

say, yes, there is a psychiatrist shortage. 

Mr. MURPHY. Thank you. The other issue is medication-assisted 

treatment, Director Boss, with regard to that. In Pennsylvania, we 

had some data that says that people who are in an MAT and may 

be getting suboxone or something. The question is, are they getting 

treatment? And I’m wondering if your state and other states, too, 

if people have actually reviewed that? I heard in some cases, the 

treatment is no more than a nurse in the waiting room, saying, ‘‘So 

how are you doing today?’’ And they call that group therapy if a 

doc says, ‘‘Is everything all right?’’ 

But in Pennsylvania, 59 percent had no counseling in the year 

that they received buprenorphine, 40 percent were not drug tested 

in the year they received it, 33 percent have between two and five 

different prescribers, and 24 percent of them didn’t see a physician 

in the prior 30 days. 

Can you describe if you have the data in Rhode Island and other 

states? Is that something to really find out if they are getting real 

counseling? 

Ms. BOSS. No. In Rhode Island, our opioid treatment programs 

are required to provide counseling, and they are—— 

Mr. MURPHY. But do you know if they are really doing it? 

Ms. BOSS. Yes. We actually do reviews of our programs. So the 

state licenses the opioid treatment programs, and goes out to review records and to make sure that they are abiding by the counseling standards as well—— 

Mr. MURPHY. I appreciate reviewing the records. I am going to 

push on this, because we need to know this. I have heard from people who go to centers who tell me that they are listed in the records 

as having counseling, and they have no more than someone saying, 

How are you doing? I’m just curious. Not Rhode Island. I have 

heard other states. 

Ms. BOSS. Mr. Chairman, without actually being able to sit in on 

sessions and time the sessions and make sure that they are happening, we have to rely on the validity of the record with which we 

review. And so, unless people are willing to commit fraud and put 

their licenses on the line by documenting something that didn’t 

happen, I would have to say that I believe that what I read in the 

record to be true. 

67 

Mr. MURPHY. OK. I think this committee has dealt with so much 

fraud. We have to move on. Ms. DeGette, you’re recognized for 5 

minutes. 

Ms. DEGETTE. Mr. Chairman, it’s called medically assisted treatment, and you’re right, counseling has to be an important part of 

that. So if they are not giving the counseling, I would think they 

should. But I don’t think we have any evidence that there’s fraud 

being committed in Rhode Island. 

Mr. MURPHY. No, I’m not picking on Rhode Island. We love 

Rhode Island. 

Ms. DEGETTE. Yes, we do. My daughter went to Brown University, and we love Rhode Island. So I want to talk to you a little 

bit, Director Boss, about this issue of states being able to pay for 

treatment. And this is—the full range of treatment—and I think it 

applies in all the other three states, too. I would assume that paying for treatment on this scale is really an ongoing challenge facing 

your state. Would that be a fair statement? 

Ms. BOSS. Congresswoman, that would be a fair statement prior 

to 2014. But we have seen significant increases in the number of 

people being able to access treatment, post Medicaid expansion. 

Ms. DEGETTE. And so the Medicaid expansion has helped. And 

we hope 21st Century Cures helped, too, but we know that there’s 

a lot more work that needs to be done. In fact, in your statement, 

you said Medicaid has laid the foundation for treatment coverage. 

Is that correct? 

Ms. BOSS. That is correct. 

Ms. DEGETTE. So I wonder if you can just tell me, quite briefly, 

how Medicaid funds are helping Rhode Island fight this epidemic? 

Ms. BOSS. So Medicaid funds in Rhode Island cover medicationassisted treatment, all three forms of FDA approved medications, 

methadone, buprenorphine, and injectable Naltrexone. They support something known as OTP health homes, and that’s a comprehensive program to integrate healthcare with individuals who 

are receiving methadone treatment, as well as all other forms of 

treatment. And Rhode Island has a full continuum of treatment 

from inpatient detoxification to outpatient treatment to residential 

treatment to the use of medication and assistant treatment as well. 

Ms. DEGETTE. Now, have you looked at these bills that House 

Republicans have passed, and that the Senate Republicans are 

looking at, which would severely reduce the Medicaid aid to the 

states? 

Ms. BOSS. I have. 

Ms. DEGETTE. How would those impact your State of Rhode Island? 

Ms. BOSS. So any bill that would reduce access to Medicaid and 

Medicaid expansion, or reduce access to affordable health insurance 

would have negative impact on Rhode Island, as 77,000 lives are 

covered, approximately, by Medicaid. 

Ms. DEGETTE. You have 77,000 people in Rhode Island covered 

by the Medicaid expansion? 

Ms. BOSS. Correct. 

Ms. DEGETTE. Now, Secretary Tilley, a recent AP analysis 

showed that the Medicaid expansion accounted for more than 60 

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ment in Kentucky. Between 2012 and 2014, there’s been a more 

than 700 percent increase in substance abuse treatment provided 

to Kentucky residents due to Medicaid’s expansion. 

So, I guess I want to ask you, it looks to me like Medicaid has 

been particularly helpful in Kentucky’s fight against the opioid crisis. Would you agree with that? 

Mr. TILLEY. Let me say this: I will tell you unequivocally of our 

Governor’s commitment, and again, exampled by the 1115 waiver, 

and our effort at this very moment to expand our treatment options 

under that—— 

Ms. DEGETTE. Let me ask you my question. Would you agree 

that Medicaid has been particularly helpful in Kentucky’s fight 

against the opioid crisis? 

Mr. TILLEY. I would agree—— 

Ms. DEGETTE. Thank you. 

Mr. TILLEY. I would agree. Yes. I would agree that through a 

number of sources of funding, we have increased treatment dating 

back to 2014 by 1100 percent dating to today. 

Ms. DEGETTE. Let me ask you this: Let me ask you this. If the 

Medicaid expansion went away, would that impair your efforts to 

fund this in Kentucky? 

Mr. TILLEY. Ma’am, I’m the Secretary of the Justice and Public 

Safety cabinet, and I do have five major—— 

Ms. DEGETTE. You’re not going to answer my question, so I am 

going to ask Secretary Moran a question. Secretary Moran, Governor McAuliffe attempted to expand Medicaid twice in Virginia, 

but the Republican legislature rejected both of the attempts. So I 

want to ask you, I know Virginia is making the most out of the 

tools it has, but if you had had Medicaid expansion, more money 

in Virginia, would this have helped you be able to reach out to 

more people on this opioid issue? 

Mr. MORAN. Simple answer is yes. That’s an emphatic yes. 

Ms. DEGETTE. Why is that? 

Mr. MORAN. More people would have access to treatment. Now, 

I will give credit to our Department of Health, they are using a 

very innovative ARTS program, addiction, recovery and treatment 

services, to carve out a Medicaid waiver to try to address these individuals’ addiction needs. But with Medicaid expansion, 400,000 

Virginians would be covered, and Governor McAuliffe has attempted to do that at every opportunity. 

Ms. DEGETTE. Thank you very much, Mr. Chairman. I yield 

back. 

Mr. MURPHY. I recognize Mr. Collins for 5 minutes. 

Mr. COLLINS. Thank you, Mr. Chairman. I think maybe I’ll start 

this question with Secretary Moran. 

All of us all agree here that opioid addiction is a disease, it is 

an addiction, and we all experienced the tragic deaths of many of 

our young children when it comes to the overdose. And as was just 

pointed out, we also have the fentanyl issue. 

So my question really is surrounding Naloxone, or Narcan, as we 

know it. And could you help the committee understand some of the 

key issues on availability—because we do hear there may be some 

shortages, cost. Who is picking up the tab for this? Is it patients? 

Is it the state? Is it the Federal Government—to maybe give us a 

69 

little bit of an overview on how we are at least attempting to deal 

with that piece. 

And, also if someone is obviously in an OD, are they given 

Narcan without really—you don’t know. Are they OD on opioids or 

fentanyl? 

Mr. MORAN. Thank you very much for the question, Congressman. We are attempting to expand the coverage of Naloxone in 

every community. With the law enforcement community, there is 

some resistance, particularly from our rural jurisdictions because— 

merely because they are not the first to respond typically in a large 

jurisdiction. Usually it is the emergency medical services. EMS 

does carry it. The majority of our jurisdictions in law enforcement 

communities, and certainly in urban areas, now carry it. And as I 

mentioned, Virginia Beach has a tremendous success rate. They 

are saving up towards of a life a week with the use of Naloxone. 

Now, that’s law enforcement. That’s EMS. We appreciate the 

Federal grants through the Department of Criminal Justice Services so that we can provide, without any cost to the local jurisdiction that uses Naloxone. Now, in terms of lay people, our Department of Health commissioner issued an order so that anyone now 

can go into a pharmacy and receive the prescription for Naloxone. 

So we are attempting to expand coverage in any way possible. It 

is obviously a lifesaver, and the more people who will have it, more 

lives will be saved. 

Now, obviously then once you revive that individual, there are 

consequences after that in terms of needs for treatment. But the 

Narcan itself is truly a lifesaver, and more people that carry it— 

within our Department of Forensic Science, for instance, one issue 

with respect to the carfentanil and fentanyl, because it is so dangerous and lethal, we are provided authority now for all of our lab 

technicians to carry it, that they may be subject to a lethal dose 

when they’re analyzing evidence in the criminal case. And so, 

again, as many people can have it, it is a very significant piece in 

this entire puzzle. 

Mr. COLLINS. Now, we have heard that the FDA is considering 

making Narcan over-the-counter. Now, you just mentioned anyone 

could go in and fill a prescription. But that, I guess, would certainly indicate they have to have a prescription to start with issued 

by a doctor. And I don’t know if there is—people sometimes do 

have different kinds of concerns in admitting that they’ve got an 

issue. Could you expand on that a little bit on what you may know 

of the FDA making over-the-counter and, also, how does someone 

get this prescription, which obviously they would then fill. 

Mr. MORAN. Congressman, that’s what the standing order did is 

that you do not need a prescription now. You can actually go in and 

obtain the Narcan without a doctor’s written prescription. And that 

was the standing order from our commission of health. 

Mr. COLLINS. So that’s statewide. 

Mr. MORAN. That is correct. 

Mr. COLLINS. And that’s what the FDA is actually looking to expand nationwide. And what’s your experience with that? Are you 

tracking how many people—are these, perhaps, family members 

who know that someone that’s got this addiction and they’re being 

anticipatory, to use that word, just in case? 

70 

Mr. MORAN. That is certainly the intent to—if you have a loved 

one who is addicted, you would take the proactive step of obtaining 

the Narcan in case of an overdose. And we have been trained—myself, the first lady of Virginia, the Governor the Virginia. We received revived training. It is very simple. It truly is. And we would 

encourage people to have access to Narcan in case of an overdose. 

Mr. COLLINS. That’s a great example, and I’m just thrilled you 

have shared that with us. Maybe that’s a message, if the FDA 

doesn’t move, that other states obviously could take those same 

steps, because if we can save lives, then you should be able to go 

home and say job well done. 

Thank you for sharing that. And I yield back. 

Mr. MURPHY. Mr. Tonko, you are recognized for 5 minutes. 

Mr.TONKO. Thank you, Mr. Chair, and thank you, chair witnesses, for their public service and for the testimony that they 

shared today. 

Before I get to my questions, I would be remiss if I didn’t echo 

my colleagues’ remarks on the devastating impact that TrumpCare, 

in its iterations, would have in the fight against the opioid epidemic. This mean, and might I say very mean, bill will rip hope 

away from people in communities across my district who depend on 

coverage from the Affordable Care Act and Medicaid expansion to 

help them recover from the scourge of opioid addiction. Medicaid by 

far is the single largest payer for behavioral health services in our 

country. In Rhode Island, Medicaid pays for nearly 50 percent addiction treatment medication. In Kentucky, it’s 44 percent; Maryland, 39 percent; Virginia, 13 percent. The bill being considered in the Senate would cut $772 billion, 

or 26 percent, from Medicaid over the next decade. There is no way 

this highly efficient safety net program could sustain this type of 

funding loss and continue to provide services for all that require it. 

Simply put, passing TrumpCare would be the single biggest step 

backward in providing treatment for substance use and mental 

health services in our Nation’s history. That being said, last year 

I collaborated with my friend Dr. Bucshon on legislation that expanded buprenorphine prescribing privileges to nurse practitioners 

and physician assistants. And I would like to gather your feedback 

on how this law is being implemented in your states? 

Director Boss, you mentioned in your testimony that Rhode Island is actively working to provide DATA 2000 training to interested practitioners. Have you seen significant interest from the 

nurse practitioners or physician assistants communities in becoming waivered practitioners? 

Ms. BOSS. Congressman Tonko, I’m not sure that I have data on 

how many nurse practitioners and physicians assistants have applied to take data-waiver training. I know that we are actively 

working with medical schools to get that interest and to increase 

the training available, but I’m not sure that I would be able to answer that comprehensively. 

Mr. TONKO. But as you are aware, there is interest in it? 

Ms. BOSS. Absolutely. There is interest, and there is active work 

with the Department of Health and within my department to provide those trainings to any and all interested parties. And we’ve 

seen increased number of data-waivered physicians. We will be 

71 

working with the nurse practitioners in PA schools to increase 

those as well. 

Mr. TONKO. Are there any projections you’ve made in terms of 

these additional classes of practitioners being able to prescribe 

MAT’s improved addiction treatment access in Rhode Island? 

Ms. BOSS. We track through our overdose Web site and our regular performance management meetings the number of people receiving buprenorphine treatments. So we’re able to look at the increases and, through our prescription drug monitoring program, 

track the number of waivered physicians that are actively prescribing. And so we are seeing increases in the number of people 

receiving buprenorphine treatment through these efforts. 

Mr. TONKO. But I would assume that the further expansion of 

the DATA 2000 waiver, either in higher patient caps or additional 

classes of practitioners prescribing would have a positive impact on 

access to treatment in Rhode Island? 

Ms. BOSS. I would absolutely agree with that. I’m not sure that 

there has been enough time for us to document how much increase 

that will result in. But yes, I do agree. And I thank you for your 

efforts with that legislation. 

Mr. TONKO. Our pleasure. 

And to all of our panelists, what barriers do you face in trying 

to recruit practitioners to become waivered DATA 2000 practitioners? 

Start with the lieutenant governor, please. 

Mr. RUTHERFORD. Well, we talked about, in certain cases, in certain parts of the state, there are limitations in terms of the number 

of practitioners in some of our more rural areas of the state. Also, 

some of the anecdotal feedback, in some cases, there is a stigma 

associated with treating individuals of substance use disorder, and 

there are some doctors that just don’t want those patients. But the 

lifting of the cap has helped us with regard to being able to provide 

the services for more individuals, but stigma is still a challenge. 

Mr. TONKO. Thank you, Lieutenant Governor. Secretary Moran. 

Mr. MORAN. I would agree, though, most of that information 

would be within our secretary of health and human resources as 

opposed to me. But we have heard from the practitioner. There is 

a shortage of personnel to address this issue. And in their defense, 

it’s an epidemic that has really exploded over the last several 

years. Any assistance you can provide for additional funding in 

flexibility would be much appreciated by the Commonwealth and 

other states. 

Mr. TONKO. Thank you. And Secretary Tilley. 

Mr. TILLEY. Yes. I would reiterate my colleagues, we have a 

number of physicians, I think nearly 700, who are prescribing. 

However, many of them have not applied to prescribe over that 100 

up to the 285 cap. And in many of them, we don’t know, as has 

been stated earlier, whether they are requiring counseling. We do 

know we require counseling in our correction settings and jails and 

prisons. We encourage it. We do urinalysis. But we don’t know— 

that’s one of the things we have to get our arms around. We are 

doing that now. 

We have to look beyond why some of these physicians are not applying to do more in their communities. Again, we struggle with 

72 

the same challenges with rural versus urban in getting those folks 

out to those areas largely. In Appalachian, this problem hit first 

there, and it’s more acute there in many ways. So that’s a challenge for us. 

Mr. TONKO. Thank you. 

Director Boss, we were going across the board. Can we just have 

a quick response, Director? 

Mr. MURPHY. Real quick. 

Ms. BOSS. All right. Thank you. 

So I would agree with all of my colleagues. But I would add, in 

our discussions with physicians, they want to do the right thing, 

and they want to be able to make sure that people are receiving 

counseling and toxicology screen but lack the office staff and the 

management to do that. So they need increased supports in the offices to do the kind of evidence-based practice that’s needed to use 

buprenorphine appropriately. 

Mr. TONKO. Thank you. 

Thank you, Mr. Chair. I yield back. 

Mr. MURPHY. The committee likes those words, evidence-based 

practices. Thank you. 

Mr. Walberg, you’re recognized for 5 minutes. 

Mr. WALBERG. Thank you, Mr. Chairman. And thanks to the 

panel for being here. 

Secretary Moran, according to the Centers for Disease Control 

and Prevention, approximately one in five deaths that are attributable to a drug overdose failed to list specific drug in the death 

certificate. Could you explain why this data gap is problematic and 

what efforts the Commonwealth is taking to ensure that it has sufficient data to understand the true scope of the opioid epidemic? 

Mr. MORAN. Thank you, sir. The theme of my remarks is the 

need for additional data, the state silos, which are we trying to 

break down, and then there are, of course, the privacy provisions 

with respect to some of the Federal laws and HIPAA. 

In a criminal investigation, our Department of Forensic Science 

will do the investigation. We have good data with respect to what 

drugs were involved, because they are collected. If it is an accidental death, it eventually goes to the OCME, Office of Chief Medical Examiner. But with respect to the data, it is challenging. And 

some individuals may not be anxious to reveal the cause of death 

under some circumstances. Family members may not choose to reveal that type of source. So it is a challenge. It’s one we’re trying 

to get our arms around, because if we have better data, we know 

how to respond better and what to do and what, if anything, is 

working with respect to addressing this epidemic. 

Mr. WALBERG. Is there anything that you’re attempting to get 

your arms around that data that is working for you, at least with 

some families? 

Mr. MORAN. Well, you’ve seen a dramatic rise in the use of 

fentanyl over the last year. That helps inform not only our 

healthcare providers but our law enforcement. 

Where is the fentanyl coming from? And if it is located in a particular community, there can be a rapid response with respect to 

education and response and to interdict the fentanyl, because it’s 

73 

typically being manufactured overseas and coming into in the commonwealth and the country. 

So that type of information I think is critical to the interdiction 

of these drugs in addition to the healthcare in response to the individual. So I think it’s imperative that we collect more data and 

have more access to data because we can better respond to the crisis. 

Mr. WALBERG. Director Boss, your written testimony notes that 

Rhode Island’s multiple disciplinary overdose prevention and intervention task force makes use of a date-driven strategic plan to combat addiction and substance abuse. Could you tell us more about 

how the state utilizes data to develop its strategy to address this 

opioid crisis? 

Ms. BOSS. That is a wonderful question. And thank you for asking it, because—— 

Mr. WALBERG. As specifically as you can. 

Ms. BOSS. So we have two things that I will point to. We have 

something called MODE, which is the multidisciplinary overdose 

drug response team. Basically, we look at a number of specific 

overdoses to look for trends, and there is a multidisciplinary team 

that consists of individuals from Brown University, hospitals, Department of Health, my department. And we review cases in depth 

in terms of looking at where those individuals were, what kind of 

treatment services they were receiving, if any, and then develop 

specific interventions as a response that we propose statewide. 

The others are surveillance response intervention team. We receive weekly reports on 48-hour overdose reporting. All of our hospitals are required to report overdoses or suspected overdoses within 48 hours, and our medical examiner is able to determine whether or not fentanyl is a factor in those overdoses. As a result, we 

put out alerts to communities when overdoses, whether fatal or 

not, exceed a specific target in that particular area. And we’re able 

to notify law enforcement, first responders, treatment providers, 

and other individuals in the community that there is an increased 

overdose—fatal or nonfatal, in their communities. 

Mr. WALBERG. OK. You mentioned that your state still lacks 

comprehensive data relating to fentanyl even with this approach 

that you’re taking. If I understand it correctly, what are the obstacles preventing hospitals from developing comprehensive testing of 

fentanyl and how could they obtain more robust data? 

Ms. BOSS. So I think the fentanyl question is regarding the drug 

supply. Our hospitals are now able to test for fentanyl as are our 

drug treatment providers. And so we are looking at how much 

fentanyl is in the drug supply. And as we see increases in hospital 

testing, in the testing that’s done in our drug treatment providers, 

we’re able to know what kind of fentanyl is out there, but not necessarily as quickly as we could if we had more rapid response in 

law enforcement in looking at what’s in the drug supply. 

Mr. WALBERG. Thank you. 

I yield back. 

Mr. MURPHY. Thank you. Mrs. Castor, you’re recognized for 5 

minutes. 

Ms. CASTOR. Well, thank you, Mr. Chairman. I’d like to thank all 

of the witnesses here for your attention to this very serious issue. 

74 

And I think at the outset it’s important that America just cannot 

go backwards on this. 

This is a very costly, severe problem for families and all of us. 

And to watch what is happening with proposals from the GOP on 

healthcare really would take us backwards, whether that’s ripping 

coverage away that’s been provided under the Affordable Care Act, 

under healthcare.gov, or the very serious assault on Medicaid. The 

most serious retrenchment of Medicaid in its 50-year history would 

be just disastrous for our ability to support families and address 

this crisis. 

In fact, I’d like to ask unanimous consent to submit, for the 

record, a consensus statement from the National Association of 

Medicaid Directors on the Senate version of the GOP health bill. 

It states, in part, Medicaid is a successful, efficient, and cost-effective Federal-state partnership. It has a record of innovation and 

improvement of outcomes for the Nation’s most vulnerable citizens 

including comprehensive and effective treatment for individuals 

struggling with opioid dependency. 

No amount of administrative or regulatory flexibility can compensate for the Federal spending reductions that would occur as a 

result of the bill. Medicaid or other forms of comprehensive, accessible, and affordable health coverage in coordination with public 

health and law enforcement entities is the most comprehensive and 

effective way to address the opioid epidemic in this country. 

Earmarking funding for grants for exclusive purpose for treating 

addiction in the absence of preventative medical and behavioral 

health coverage is likely to be ineffective in solving the problem. 

So I’ll ask unanimous consent that that be admitted for the 

record, Mr. Chairman. 

Mr. MURPHY. We’re reviewing. We’ll get back to you before you’re 

done. 

Ms. CASTOR. OK. 

Mr. MURPHY. Thank you. 

Ms. CASTOR. Because this is very important. Now, this committee, to its credit, spearheaded the 21st century cures initiative 

that did provide substantial funds to our states. And I’ve heard 

from local experts back home in Florida, held a number of 

roundtables with law enforcement, treatment professionals, anesthesiologists, ER docs—the panoply. And they say the key is longterm coverage to treat this as the chronic disease that it is. And 

that’s why, when you rip away coverage and instead say, in its 

place, we’re going to have another fund, an opioid fund, where 

maybe you provide a few dollars to an ER, that’s not going to provide that long-term coverage that we need to treat this chronic disease. So I just had to get that off my chest here right off the bat. 

In fact, Director Boss you have a lot of experience with this. Do 

you think we’ll be able to effectively address this crisis if this retrenchment on Medicaid and ripping coverage away for millions of 

Americans were to succeed? 

Ms. BOSS. So I believe that Rhode Island’s efforts to address this 

crisis would not be able to be sustained if we were not able to continue to offer insurance through Medicaid expansion to the number 

of Rhode Islanders that depend on it. And I thank you for your 

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ment alone is not enough. If we dedicate dollars toward that, that’s 

wonderful. However, oftentimes there are comorbid conditions that 

are interrelated with an individual’s addiction, that if we don’t 

have access to affordable health care for the rest of the body, then 

we’re not going to be able to treat the person well enough to sustain any kind of recovery. 

Ms. CASTOR. So are you able right now to provide the type of 

long-term treatment that is needed for an opioid appointed addiction? 

Ms. BOSS. Yes, we are. 

Ms. CASTOR. In fact, you’ve instituted a program called AnchorED which connects individuals struggling with addiction to recovery coaches who help them navigate the treatment process. How 

successful has this program been to helping an individual recover? 

Ms. BOSS. So of the individuals that meet with recovery coaches 

in the emergency department, 82 percent are receiving referrals to 

treatment and engage in treatment and recovery services, which is 

pretty phenomenal, actually. And the actual AnchorED program 

itself is not supported by Medicaid. 

But the fact that we are not required to use substance abuse prevention treatment block grant funds to fund treatment itself, now 

that individuals can access, it frees up that opportunity to use 

block grant funding to support recovery activities that may not be 

supported by Medicaid or other insurance, although the program is 

so successful that many insurances, including third-party commercial insurances, are paying for the recovery coaching program. 

Ms. CASTOR. Is that a requirement under Rhode Island law, or 

is that something that you found to be so cost-effective that they 

are participating? 

Ms. BOSS. It is not a requirement. 

Ms. CASTOR. OK. Thank you very much. 

Mr. MURPHY. Can I just ask a follow-up question, what you’re 

saying? Recovery coaches have what kind of credentials? 

Ms. BOSS. So we have a certification process for our recovery 

coaches that are standardized and involves training and a test and 

voluntary hours for certification in order to respond. They are not 

degree—— 

Mr. MURPHY. OK. No degree. 

And do you have, in emergency rooms, then, people who are 

themselves licensed treatment providers? Not recovery coaches, not 

peers, but people who are actually—this is their licensing. Do you 

have them in the ERs as a requirement? 

Ms. BOSS. We do not. 

Mr. MURPHY. Let me just ask: Does Kentucky have them? Or 

Virginia? Maryland? 

There was a study done out of Michigan, and I believe also one 

done at Yale, that when there is a licensed addiction’s counselor in 

the ER providing treatment, not referral, providing treatment, they 

increase the chance that person is going to follow up by 50 percent. 

So just saying here’s some place you can call, 82 percent—do you 

know if they actually follow through in the event—that’s my question that I have now. I’d love to hear that from each state, but I 

next have to go to Ms. Walters. 

76 

Ms. DEGETTE. Before you do, are—is Ms. Castor’s unanimous 

consent request? 

Mr. MURPHY. Yes. We’re fine with that. Yes. Thank you. Sorry 

about that. 

[The information appears at the conclusion of the hearing.] 

Mr. MURPHY. But I was saying that information is critically important. And I’ve heard from a lot of places, give them a card, they 

may not follow through. So 80 percent may not be valuable to us. 

But to know they’re actually getting treatment, just like you 

wouldn’t send someone home and say, ‘‘You broke your arm. Could 

you, please, make sure you see an orthopedic surgeon next week,’’ 

but to make sure it’s being done. 

Mrs. Walters, You’re recognized for 5 minutes. 

Mrs. WALTERS. Thank you, Mr. Chairman. 

We can all acknowledge that, despite increased societal awareness and government resources, the opioid crisis continues to devastate our communities. In my home of Orange County, California, 

there were 361 overdose deaths in 2015. That accounts for a 50 

percent increase in overdose deaths since 2006. A majority of those 

deaths are attributed to heroine, prescription opioids, or a combination of the two. 

One of the challenges in responding to the crisis is the stigmatizing of the victims which limits their responsiveness to treatment 

outreach. 

There has been discussion today of the importance of drug 

courts. And these courts can help overcome the stigma and treat 

the underlying addiction as opposed to focusing on the resulting 

criminal behavior I recently became aware of a specialized drug 

treatment court in Buffalo, New York, that is focused solely on 

opioid interventions. 

My question is for everybody on the panel. Do you have an opinion whether some drug treatment courts need to be specialized to 

handle opioid addiction? 

Mr. RUTHERFORD. We have extensive drug courts in most of our 

jurisdictions across the state. They essentially are specific to opioid 

addiction. And there’s been good results from most of those courts. 

The one challenge that we have is that, depending on how long 

that period that you’re involved with the drug court is maybe 18 

months to 2 years. And if you’re someone who commits a crime at 

a local jail and you’re not ready for treatment, that person will say, 

‘‘I’d rather do the 6 to 8 months than to have to commit to 2 years. 

Even though I’m outside the fence, I’d rather sit in jail.’’ 

Mr. MORAN. We’re big proponents of drug courts. Unfortunately, 

Virginia is deficient in drug courts. We have about 37 yet we have 

over 200 courts. They are used for a variety of different specialities. 

There’s mental health courts; there’s veterans dockets. The drug 

courts, however, provide some coercion. I mean, the individual 

needs to want to address their addiction, and then the court can 

provide that coercive element. And we have a tremendous success 

rate. I mean, we should expand. 

The one issue I would ask Congress to help us with, however, is 

the medically-assisted treatment. Some of our judges in the drug 

courts are reluctant, and as of now, it is required. And so we would 

77 

request, on behalf of those judges, some flexibility with respect to 

mandating MAT. 

Mr. TILLEY. And again, I would concur. We have mental health 

courts, veterans courts, and drug courts I think that do expand. We 

did lose our juvenile drug courts due to a funding issue. We’re trying to rebuild that program now. Some of the same issues exist. Oftentimes that offender chooses a shorter prison sentence and that 

2-year, again, very strenuous program. But we’re addressing that 

as well. 

I would say that oftentimes too we find that there are cherry 

picking the best instead of focusing on the more high-risk folks. We 

do have a program called SMART that deals with high-risk probationers keeping them—again, a modified drug court that does specialize in opioid, at least one part of it does. And that’s being done 

at seven pilot sites. It’s modelled after the HOPE program that 

began with Judge Steven Alm in Hawaii that many of you know 

about now. 

And I would also add that what we’re finding as well is, again, 

this combination of specializing in medically assisted treatment 

and the cognitive behavioral therapies that, again, we’re trying to 

integrate that model with some of our existing. And we also have 

passage of recent legislation in Kentucky, through the Department 

of Corrections, a modified drug court through a reentry program 

that we’ll be rolling out soon that will specialize in the opioid addictions. 

Ms. BOSS. I would agree with my colleagues as well, especially 

Lieutenant Governor Rutherford in the fact that our drug courts 

have been addressing opioid use disorder for a very long time. In 

Rhode Island, the drug court has been accepting of medication assisted treatment as appropriate treatment for individuals long before it was required to do so. 

Probably the biggest issue that we have with drug court is that 

it’s not able to reach enough people. And while it’s very successful 

and effective, the difficulty in getting the numbers through that 

system is challenging, and we really would like to look at a broader 

perspective of diversion efforts and getting people connected to 

treatment prior to arrest as our primary focus. 

Mrs. WALTERS. Thank you. 

Mr. TILLEY. Mrs. Walters, may I add an interesting thought 

here? We had, again, a conference recently in Kentucky that offered a legal opinion from one of our law firms that there—and, 

again, as Secretary Moran pointed out, if a judge denies someone 

medically assisted treatment which then affects the liberty interest 

if they return to prison, that denial might invoke some protection 

of the Americans with Disabilities Act. And I think that’s an interesting thought moving forward. And I think it’s a little bit of a 

chilling effect on our judiciary in Kentucky to be—again, might be 

more accepting of medically assisted treatment. 

Mrs. WALTERS. Thank you. Thank you all. I yield back my time. 

Mr. MURPHY. Mr. Ruiz, you’re recognized for 5 minutes. 

Mr. RUIZ. Yes. Thank you, Mr. Chairman. Thank you all for 

being here. It’s such a very important topic. And as an emergency 

medicine doctor, I cannot emphasize enough the devastating effect 

it has on individuals, families, communities. 

78 

I’ve treated patients who have been dumped, blue, not breathing, 

in front of our doors, and we go into the emergency care mode providing Naloxone and the other cocktails for somebody who you 

don’t know anything about, and they’re there unconscious right 

about to die. And thankfully we’ve saved many of them because 

we’ve had the medication. 

We know that one of the primary determinants of successful 

treatment is that they get medication, follow-up, and counseling. 

And one of the factors for success is that they have health insurance that has guaranteed coverage for those medications, guaranteed coverage for mental health, and that’s why it’s so devastating 

for me and for my patients that we’re on the verge of repealing the 

Medicaid expansion, repealing for some states who choose not to 

have the mental health and prescription drug guaranteed coverage, 

that those people who need coverage and want coverage won’t be 

able to have it. And it can be a situation of life and death, as we 

know. 

In a report on addiction released last year, the U.S. Surgeon 

General found that Medicaid expansion meant that millions of 

Americans with substance-use disorders now have access to health 

coverage and, subsequently, substance abuse treatment. And additionally, because substance-use treatment is now a covered essential health benefit, which is at risk of going away, individuals, a 

small group market participants also gain access to those lifesaving 

services. 

But it’s not just about coverage. OK. I’ve seen some parts in my 

district but if you don’t have providers, if you don’t have psychiatrists, if you don’t have psychologists, if you don’t have healthcare 

centers or counseling centers or programs in those communities 

that are underserved or in rural areas, then coverage does you no 

good. 

So you need to also think about making sure that we have more 

psychiatrists, more psychologists, more mental health providers in 

those areas, especially for the youth and young adults. 

According to data from HHS, the number of children in foster 

care increased 8 percent between 2012. Experts have suggested 

that this rise is due in large part to increased opioid abuse. Moreover, the substance abuse and Mental Health Services Administration, SAMHSA, has estimated that over 8 million children of parents who need treatment for substance abuse disorder. 

The Wall Street Journal, the Washington Post, and the New 

York Times have all recently reported on children who have experienced the impact of their parents’ opioid abuse and are being 

raised by grandparents who have been placed into foster care as a 

result. 

Secretary Tilley, can you please describe how children in your 

state have been impacted by the opioid crisis, and are there unique 

challenges facing children in these epidemics? 

Mr. TILLEY. I think it’s an excellent question. With a focus on 

correction, sadly I can report that, in Kentucky, as it exists now, 

more children are living with an incarcerated parent than any 

other state in the country. In fact, have had or have an incarcerated parent. And, again, our prison population largely being driven 

79 

by the epidemic, I think that would be the first thing that comes 

to mind. 

I also believe that it puts an incredible strain on our cabinet for 

health and family services. We have a record number of children 

in foster care at the moment. So that certainly is an issue. 

And beyond that, I think it just puts a tremendous strain on our 

community mental health centers as well. I think, again, the absence of proper funding for community mental health in this country is a huge issue. It exists all over. It certainly is acute in Kentucky as well. We rely on our 14 community mental health centers 

that fan out through our state to provide those services to children. 

We have seen an increase with the focus in recent years on addiction issues that increase and proper treatment for children, and 

so I think that’s been critical for some of our—— 

Mr. RUIZ. So Secretary Tilley, let me just warn you that, by turning Medicaid into per-capita grant, the funding for new addicted 

folks are—I should say the need for funding is going to increase. 

States are going to have to make decisions: One, change their eligibility criteria; two, their reimbursement rates; and three, the benefits that they would cover. And oftentimes, unfortunately, the mental health and these community center treatments are the first on 

the chopping block. So it’s going to get worse if this bill is going 

to pass. 

Director Boss, SAMHSA stated that families have a central role 

to pay in the treatment of individuals with substance abuse disorders. Can you discuss what efforts Rhode Island has taken to 

provide treatment that covers a person’s entire family? 

Ms. BOSS. All of our treatment providers are encouraged to engage families in treatment and—as part of effective treatment. We 

know that addiction is a family disease, and engaging family members is critical in order to have success. 

One of the things that the state has done is engage family members in the development overdose task force and plan, and we’re 

creating a family and parent task force as well as engaging youth 

to help us shape our efforts for the overdose crisis in—— 

Mr. RUIZ. Have you found positive results on those? 

Ms. BOSS. Those efforts are just starting. So I will be able to report back hopefully. 

Mr. RUIZ. Well, I’m very hopeful that we can work together to 

help this situation get better. 

Mr. MURPHY. I appreciate that, because there’s some things we 

need to be working on out there. But I want to make sure Secretary Tilley has a chance to respond to what you’re saying about 

mental health substance abuse, money being first on the chopping 

block. Is that Kentucky’s intent? Do you know anything about that? 

Mr. RUIZ. That was not the intent, I don’t agree—— 

Mr. MURPHY. No. I didn’t know—but you had asked. I want him 

to respond. 

Mr. RUIZ. No. No. I’m just saying that, historically, mental 

health is one of the most underfunded—— 

Mr. MURPHY. I understand. But you made a claim, and I want 

Secretary Tilley to have a chance to the respond to that, find out 

if it’s—— 

80 

Mr. TILLEY. I would only say that the absence of proper mental 

health funding is not a new phenomenon. I happen to—— 

Mr. RUIZ. I agree with that. 

Mr. TILLEY [continuing]. In my private life, be associated with a 

mental health center as as general counsel. And I happen to know 

that since the late 1990s we haven’t had an increase in those reimbursement rates. And that is an issue, and that has existed for 

some time. And so I don’t think that’s a recent phenomenon. That’s 

all I would add. 

Mr. MURPHY. No. And that’s why I want to amplify what he’s 

saying, that when everybody looks at mental health funding gets 

cut or doesn’t get increased, if actually increases costs overall for 

healthcare. So—— 

Mr. Carter, you’re recognized for 5 minutes. 

Mr. CARTER. Thank you, Mr. Chairman. I want to thank all of 

you for being here on such an important subject. And I want to express my dismay and my discouragement at some of my colleagues 

who have used this as a platform, if you will, for political messages 

about cuts in Medicaid, et cetera. I mean, we all understand. It is 

established this is an epidemic in this country. 

As a practicing pharmacist for over 30 years, I have seen firsthand, perhaps more than everyone in here collectively, has seen 

the impact that this has had. At no time have I ever asked a patient or thought in any way is this a Republican or a Democrat or 

Independent. It’s someone who’s struggling. That’s all there is to it. 

This is a nonpartisan problem, and I just frustrated by that. 

Governor Rutherford, you said something earlier that I’m a little 

bit confused about. You were talking about the prescription drug 

monitoring program in the State of Maryland. Did you say that 

methadone is not on it? 

Mr. RUTHERFORD. Well, no. What I was saying is that if you go 

to the prescription drug monitoring program, or the database, you 

will not see that a person has been prescribed methadone, that 

they’re in methadone treatment. So—— 

Mr. CARTER. Why is that? 

Mr. RUTHERFORD. There are privacy restrictions associated with 

drug treatment. And so this was in place prior to our developing 

these prescription drug monitoring programs. There are different 

barriers to getting information, be it mental health information or 

drug treatment and, in some cases, healthcare, that there are 

walls—— 

Mr. CARTER. Is that something we can help you with, legislatively, here? 

Mr. RUTHERFORD. I think that’s what we talked about, that that 

would be very helpful, because a practitioner would not know that 

someone that they’re prescribing an opioid already has a problem 

associated with opioids. 

Mr. CARTER. OK. When I was in the state senate in Georgia, I 

sponsored legislation that created our prescription monitoring program. And I can tell you, it has been improved since I left. In fact, 

July 1st of this year, 2 weeks ago, we started 24-hour reporting. 

Before that, we were reporting every week. Now, we’re not in 

realtime yet, but we’re getting there. We’re making very good 

progress there. 

81 

I want to know, in the prescription drug monitoring programs 

within your states—and, Secretary Tilley, I’ll tell you. I’ve worked 

closely with the Kentucky Board of Pharmacy and with the Kentucky Pharmacists Association—very strong. Very strong programs 

there. And I compliment you on that. 

But in your experiences with the prescription drug monitoring 

program, are you sharing information across state lines? 

Mr. TILLEY. We are. I think we have 7 border states. Very unique 

in that regard. I think the only state in which we don’t at this moment is Missouri. I think that be to the case now. 

Mr. CARTER. Yes. Missouri struggled. They were the last one to 

add it on, the PDMP. 

Mr. TILLEY. We are working on that. And again, I’d be happy to 

supplement the record to confirm that answer for you. But I do believe we are sharing with six of those seven states that board us. 

Mr. CARTER. OK. Secretary Moran, what about Virginia? What 

are you all doing? 

Mr. MORAN. Thank you. And I think this is an area where Congress could investigate. We have 21 states. And our neighbor to the 

South, North Carolina, we do not share information. We would request some help to better share data across state lines. 

Mr. CARTER. Right. 

Mr. MORAN. Most of our neighbors are not North Carolina. So we 

would look for some more relief there. 

Mr. CARTER. Yes. In the State of Georgia, we’re sharing with 

South Carolina, Alabama, North Dakota, and someone else way out 

West. I will tell you, in my over 30 years of practicing pharmacy, 

I never filled a prescription for North Dakota, for a C2 prescription. 

I know you find that hard to believe. It would have been more useful if I could have seen it from Florida. Being in that area, in Savannah, where we’re only 2 hours away, it would have been extremely useful for the State of Florida, and hopefully we can get 

to that point. 

I want to ask you, Secretary Tilley, about a program that I 

thought was pretty interesting that was a result of 21st century 

cures, and that was the peer recovery specialist and emergency departments in Kentucky. Can you elaborate on that just a minute? 

Mr. TILLEY. The expert is sitting to my left. We actually had a 

chance. 

Mr. CARTER. Right. 

Mr. TILLEY. And again, I, applaud the work in Rhode Island. We 

actually had sort of a model that didn’t really meet the goals that 

we wanted. It was not up to par from previous legislation. We 

looked at what Rhode Island was doing. We had tried the same 

thing they did. We just didn’t do it as well. I think we’re on the 

path to doing it now. And I think we’re fairly ambitious with trying 

to do both at once. 

The peer recovery coaches or specialists in our ERs and also 

doing the bridge clinics as well to try to keep people there in treatment until we can get them to treatment, maybe outpatient or 

some kind of other bed outside that hospital. And so I think what 

they’re doing in Rhode Island is certainly a model for the country. 

And we’re emulating them directly. 

82 

Mr. CARTER. Great. And I know you are doing great work, Director Boss. And I apologize. I didn’t get to you. I have 15 seconds. 

I just want to add one thing from a pharmacist’s perspective. One 

of the things that we didn’t cure was to allow states to implement 

laws on C2 prescriptions on how much can be filled and whether 

pharmacists can fill partial quantities. That will help. 

We can throw money at this all day long. But we need to be 

smart. If we’re smart and we do practical, rational things, like limiting—I got so many prescriptions from a dentist for a 30-day supply of OxyContin. They take one or two, and then the rest of them 

are in the medicine cabinet. That is not being smart. If we can 

have a partial refill, if states can do that as a result of 21st Century, or as a result of CARA, that’s something we need to look at 

implementing as well. 

Thank you, all. My time is out, and I yield back. 

Mr. MURPHY. Mr. Carter, will you yield for a question? 

Mr. CARTER. Yes. 

Mr. MURPHY. When you refer to partial refill, you mean allowing 

the pharmacist to only give a partial fill at the onset, and then the 

person could come back and get the rest? Is that what you’re referring to? 

Mr. CARTER. That is exactly right. 

Mr. MURPHY. So not the position for prescribing partially, but 

you would have that option? 

Mr. CARTER. That is one of the options that CARA allowed us to 

do. I would take it even further. And I’ve been in talks. My office 

has been in talks with the DEA about allowing maybe a refill on 

a C2 for a three-day supply. Because a lot of physicians are concerned that the patient’s going to run out over the weekend, they’re 

going to be bothered, or they’re not going to be available and 

they’re going to go without. And that’s a real concern. And I understand that. 

But at the same time, again, if we’ll just be smart, if allowing 

them to maybe call in one refill over the phone as long as it’s limited to a short-day display. 

Mr. MURPHY. Thank you. 

Mr. CARTER. Thank you, Mr. Chairman. 

Mr. MURPHY. Mr. Pallone, you’re recognized for 5 minutes. 

Mr. PALLONE. Thank you, Mr. Chairman. 

Director Boss, I wanted to ask you the questions. And I want to 

go back to the issue of Medicaid, because, as you know, the Republicans are still trying to repeal the ACA’s Medicaid expansion and 

making a lot of changes to the program. 

So what role has Medicaid played in Rhode Island’s effort to provide medication-assisted treatment in your state? 

Ms. BOSS. Medication-assisted treatment is covered by Medicaid 

for both the disabled and the expansion populations. All Medicaidcovered individuals are able to receive all three forms of FDA-approved medications for opioid use disorders. The director of Medicaid is a member of our opioid task force and has been active in 

working with the managed care organizations that manage our 

Medicaid product to do things like remove prior authorizations for 

medication-assisted treatment. It is fully funded through our Medicaid program. 

83 

Mr. PALLONE. All right. Now, my colleagues on the other side of 

the aisle often characterize the Medicaid program as inflexible for 

states. We hear that a lot, that it’s inflexible. To the contrary, 

though, I think Medicaid has provided for a great deal of innovation in how states have responded to the opioid crisis. So could you 

please tell us about the health home program in your state and 

how Medicaid granted Rhode Island the flexibility to develop its 

own person-centered care opioid treatment program? 

Ms. BOSS. So there are probably two innovations, and the OTP 

health home would be one of them where we worked with the Medicaid office for a period of 18 months to develop the comprehensive 

care management function for opioid treatment programs to provide to their clients in addressing physical health issues as well as 

their addiction issues. And the process with Medicaid was thorough, but it was one that allowed us to use a monthly rate to support the work that was really improving the health care of individuals in opioid use disorder. 

And we know that people who have opioid use disorders often 

have comorbid conditions, don’t necessarily have the greatest access to care in the community. And the health homes allow those 

programs, which have the greatest access to individuals, to provide 

nursing support. They’re overseen by physicians. They have case 

management that help them get to the needed appointments, dental appointments. And Medicaid has been supporting those efforts 

with an understanding that improving those outcomes will improve 

outcomes overall and reduce cost. 

The Centers of Excellence are also a Medicaid innovation where 

we allow people to be seen very quickly. And it’s the issue. You 

need to have that access to treatment, which was noted. A person 

seen in the emergency room needs to be able to follow through and 

get access to treatment in order for anything to be effective. 

Centers of Excellence exist as a Medicaid innovation allowing 

people access to treatment, all FDA-approved medications, again, 

within 72 hours, and have intensive services provided in the 6 

months of treatment supported by a Medicaid rate with as much 

treatment in case management and recovery supports as the individual needs with the intention to move that individual into the 

community once stabilized and continue to provide the clinical and 

recovery supports needed again through a Medicaid-supported invasion. 

Mr. PALLONE. Obviously, my concern is that, in states most heavily impacted by the opioid epidemic, if you have cuts to Medicaid 

that that may lead to cuts in addiction treatment and exacerbate 

the process. 

I have a minute left. Let me ask you: Would you agree that deep 

cuts to addiction services that might result from the Senate 

TrumpCare bill, for example, that if states decided because of the 

cuts in the Senate TrumpCare bill, that those kinds of cuts to addiction treatment would have a drastic impact on our ability to 

fight this epidemic? 

Ms. BOSS. Our overdose strategy engages 4 different components, 

and three of the four would be effected if Medicaid were not available to support. The access to Naloxone, again, is supported by 

Medicaid. Medicaid covers Naloxone for individuals. The treatment 

84 

component is, again, supported by Medicaid, our Centers of Excellence—all of the treatment components have that as well. 

And the ability for recovery coaches to be funded if not for the 

treatment being covered by Medicaid, our substance abuse block 

grant dollars would have to be redirected from those recovery efforts to support individuals in treatment. 

Mr. PALLONE. All right. Thank you so much. 

Thank you, Mr. Chairman. 

Mr. MURPHY. Mrs. Brooks, you’re recognized for 5 minutes. 

Mrs. BROOKS. Thank you. 

Director Boss, I want to clarify something that my colleague, 

Congressman Walberg, asked you previously. You talked about a 

data gap with respect to fentanyl in law enforcement data. In your 

written testimony, you’ve talked about hospital systems are testing 

for fentanyl, but we do not yet know the frequency of testing or 

how many tests are returning positive for fentanyl. 

And so I just want to clarify and make sure. So the gap in collection on data for fentanyl exists in law enforcement and hospitals 

as well. Is that correct? 

Ms. BOSS. So the testing for fentanyl in the hospitals is fairly 

new, and we are not sure how complete the data is. They do have 

the ability. And whether or not all the hospitals are testing or not, 

I’m not exactly sure. And I think it’s really, for the most part, an 

issue of timeliness. 

To be able to respond effectively, we need to have access to timely data and making sure that, if testing occurs, that we’re able to 

get the results quickly and in enough time to respond to a community that may be seeing an increase in fentanyl. 

Mrs. BROOKS. And I guess I’d ask the others on the panel whether or not you know if your hospitals are gathering data on fentanyl 

specifically and the frequency and so forth. 

Yes, Lieutenant Governor. 

Mr. RUTHERFORD. I can’t speak directly for the hospitals. I know 

that, through our medical examiner’s office, through our emergency 

first responders, that they get information with regard to fentanyl 

usage. A little more than 60 percent of our fatalities, overdose fatalities, on opiates, are related to fentanyl. In most cases, it’s a 

mixture with something else, cocaine or heroine. But we’re getting 

most of our information from the law enforcement and emergency 

responders. 

Mrs. BROOKS. I want to just talk a little bit more specifically 

about the criminal justice system and would like to ask you, Secretary Tilley, the CORE program that you mentioned, that is specific to the criminal justice system in Kentucky, isn’t it? 

Mr. TILLEY. Actually, it brings in all stakeholders, even education. 

Mrs. BROOKS. OK. 

Mr. TILLEY. The Cabinet for Health and Family Services, our 

CORE system, certainly many—all elements of the criminal justice 

system but any element affected by the opioid scourge is present 

on that particular effort. 

Mrs. BROOKS. I’d like to find out from you, and briefly, your 

states’ efforts, because, obviously, when a person is incarcerated, 

which many family members said that saves their lives. It’s sad 

85 

and we want them to be diverted, and we obviously do want to 

focus on high level. I’m a former U.S. Attorney. So we want to focus 

on the mid and high level dealers and those who were exposing 

people with addictions. However, at times we have a captive audience of participants in treatment. 

And can you talk a bit more about medication-assisted treatment 

in your facilities and then counseling? Is there drug testing that is 

part of your incarcerated population, juveniles and adults? 

Mr. TILLEY. I’ll start with adults. Again, counseling is required 

with any medically assisted treatment we do. Again, I described 

earlier in my testimony I think a pretty innovative program where 

we assessed, through a risk needs assessment, those who would 

need an injection of naltrexone, or more commonly called Vivitrol, 

prior to their release as a stabilization mechanism. Upon release, 

they get another injection, and then they are matched with a counselor and a peer recovery coach to try to find the necessary resources to continue that treatment, whatever it may be and whatever source it may come from. 

In our juvenile setting, we do not have medically assisted treatment at this time. However, we in Kentucky thankfully have a 

record low in terms of our juvenile detention population at the moment. And that doesn’t seem to be near the issue in our facilities, 

although we do offer that treatment in the facilities, just not medically assisted at this time. And the same way you would see it in 

the corrections setting. 

One thing that’s very unique about Kentucky, and one thing that 

was not maybe reflected in the New York Times article about that 

treatment is that Kentucky houses roughly half of its state inmate 

population in county jails. We have 83 full-service county jails that 

do that. And that presents some challenges. But we are expanding 

and incentivizing that kind of treatment, that kind of medically assisted treatment, like you may have read about in Kenton County, 

which is part of the Greater Cincinnati, Northern Kentucky area 

there. I would also add the piece about incarceration. 

We are trying to use elements like involuntary commitment—we 

call it Casey’s law in Kentucky—to try to bypass the need for incarceration for those individuals, again, who stand out to their family 

as someone who needs a forceful hand, maybe a judge’s contempt 

power to keep them in treatment. 

Mrs. BROOKS. I will be submitting questions for the record for 

each of your states, because I’m interested in knowing more, and 

my time is up, on medically assisted treatment as well as counseling and what you’re doing with your inmate population. And I 

know you’re each doing something but would love to learn more 

about it. 

And I want to thank you all for cooperating with each other and 

learning from each other. Critically important. 

I yield back. 

Mr. MURPHY. The gentlelady yields back. I recognize Mr. Costello 

for 5 minutes. 

Mr. COSTELLO. Thank you, Mr. Chairman. 

Some of you may know the chairman and I both hail from Pennsylvania. The chairman from the Western part of the state. Myself 

from the Eastern part of the state. And sometimes people think 

86 

they’re two different states. But having said that, in Pennsylvania, 

the epidemic is particularly acute. And just a few brief comments 

about what we’re doing in Pennsylvania. And then Lieutenant Governor Rutherford, I had a couple of questions for you. 

With the enactment of the 21st Century Cures Act, Pennsylvania 

received $26.5 million dollars in Federal funding to address the epidemic: $3.5 million for drug courts, $23 million being funded to expand access to medication-assisted treatment, increase training opportunities to better connect individuals with additional treatment 

when they visit an emergency room as a result of an overdose and 

also to improve access to opioid use disorder treatment for uninsured individuals. 

And Lieutenant Governor Rutherford, you spoke about establishing a 24-hour stabilization center in Baltimore city. I wanted to 

ask you about that. What services will be provided at the facility? 

Why do you think it is better suited to have such a facility to treat 

substance abuse issues rather than in emergency departments? 

And then, maybe depending upon your answer, I’ll have some follow-up questions off that. 

Mr. RUTHERFORD. Well, the concept of the stabilization center is 

a place where both first responders support as well as law enforcement or family members can take a person who is suffering from 

substance abuse disorder and they may be ready for some type of 

treatment. And the idea is to bring them into a locale, not necessarily an emergency room because that is a very high cost approach to addressing this challenge where they can be stabilized 

and get them into longer-term treatment. 

So it’s an opportunity to get that person, as I mentioned, stabilized. They could reside there for a few days before—if there’s a 

bed available to get them into treatment. 

Mr. COSTELLO. Any similar facilities that you might be modeling 

this off of? 

Mr. RUTHERFORD. I believe San Antonio has something similar. 

I’d have to get more information and talk to my staff. I believe it 

was San Antonio that I believe was doing something very similar 

to this. 

Mr. COSTELLO. Once stabilized, will the patients then be moved 

into evidence-based treatment and counseling? 

Mr. RUTHERFORD. That is the objective. We haven’t stood this up 

as yet, and we’re working with the city of Baltimore in terms of the 

parameters and how this is going to actually operate and what the 

state’s oversight role will be with this. 

Mr. COSTELLO. Is the hope that the funding that you will be utilizing for the facility itself, will that funding extend to the treatment and counseling, or are you looking at the facility to just be 

sort of on the front end? 

Mr. RUTHERFORD. The facility is on the front end. We will look 

to the other funding sources, be it through the Cures Act, through 

state revenue, through insurance, through Medicaid to pick up the 

treatment aspects of the challenge. 

Mr. COSTELLO. Can you describe some of the challenges that your 

state currently faces to provide beds in a timely manner for individuals seeking treatment for substance abuse? 

87 

Mr. RUTHERFORD. Well, the lifting of the restriction with regard 

to Medicaid reimbursement on the number of beds in a facility has 

helped that particular challenge, because we did have situations 

where we had individuals who would receive treatment through 

Medicaid, and we have beds available in some of our facilities, but 

we could not utilize those. That has helped. 

We are working to expand the capabilities, particularly for some 

of the nonprofits that have services and are providing services and 

seeing what we can do to assist them in expanding their access. We 

have close to 800 facilities around the state. There is always a discussion about getting additional beds and capacity, and so we’re 

working on those things as well. 

Mr. COSTELLO. Thank you. 

My general comment on this epidemic is oriented towards the following. I think there are a lot of variables that contribute to this. 

I think everyone knows that. I get concerned when we point to one 

particular actor in this ecosystem and say that’s the problem, because it is manifold. It is complex. And I think what concerns me 

more than anything is that the life cycle of treatment is much 

longer than the infrastructure that has been set up to deal with it. 

And as a consequence of that, no matter how good we might be 

in the first six innings of this, if we’re not good in innings seven, 

eight, and nine, it’s not going to ultimately matter. And we’re really just embedding more cost into the system by front-loading some 

of the cost without really acknowledging that, on the back end, if 

we don’t finish it off with the right kinds of treatment and the 

right type of counseling and the right kind of follow-up off that, we 

will not ultimately be able to drive down the epidemic. 

I think all can identify what some of the front-end issues are 

here, but that would be something I’d just like to submit to the 

record. 

And, Mr. Chairman, I see I’m well over my time. 

Mr. MURPHY. Thank you. 

Mr. RUTHERFORD. Can I respond just very briefly. 

Mr. MURPHY. Yes. 

Mr. RUTHERFORD. You’re absolutely right. And some of the 

thought process behind the crisis center is it’s a front end. You’re 

right. It’s a front end of where the person comes in the door, they’re 

in distress at that point, stabilizing them, getting them into treatment. But even after the treatment, one of the things we’ve heard 

over and over again from people who have relapsed is they come 

out of treatment and they go back into the same community, the 

same stimuli, the same issues that they had before. 

And one of the areas that we’re focusing on going forward, including utilizing the Cures Act funding and state funding, is transitional housing. For lack of a better word, you can call it a halfway 

house—but transitional housing where a person can go and continue to get treatment in terms of the counseling aspects of it. But 

during the day, they can go to work, they can do the things that 

they need to do, but they have to report back to this facility. And 

people have said that that is something they need before they go 

back into the unrestricted society, because all the stimuli is still 

there. 

Mr. COSTELLO. Yes. Thank you much. 

88 

Thank you, Mr. Costello. 

It’s the policy of this committee to let other members of Energy 

and Commerce who are not on this subcommittee to ask questions. 

Mr. Bilirakis, you’re recognized for 5 minutes. 

Mr. BILIRAKIS. Thank you so very much. And thank you for allowing me to sit in on the hearing. I appreciate it, Mr. Chairman. 

Well, I have some prepared questions. But does anyone else want 

to elaborate on that? Any other suggestions as far as a long-term, 

the back end? Is there anyone on the panel that would like to talk 

about that? You mentioned the transitional housing. And cooperation, obviously, is so very important. The patient needs to cooperate 

and voluntarily, in most cases. Is there anyone that wants to make 

another comment before I get started? 

Ms. BOSS. If I could, I would add—— 

Mr. BILIRAKIS. Yes. 

Ms. BOSS. The front door is very important, because access to 

care—oftentimes, you’ll hear families saying, ‘‘I don’t know where 

to turn for help.’’ And we’re looking at a crisis center model as well. 

And I think that’s critically important. You don’t know which number to call. You’ve got a family or loved one, and you’re not sure 

how to connect them. 

But then the connection to treatment is critically important as 

well. It’s like someone with hypertension going to the emergency 

room and getting a pill but not getting a prescription. It’s not going 

to help. 

And so without the access to care and the kind of supports needed—so recovery housing is critical as well. And in part of our Cures 

Act funding, we are looking to establish that kind of transitional 

housing for individuals who are not able to return to their communities. We really need to look at the long-term and treating addiction as a chronic disease, not through acute episodes. 

So I think that the approach to long-term and looking at the 

long-term needed supports are critically important as well. 

Mr. BILIRAKIS. Thank you. 

With regard to Florida, in 2010, in response to the opioid crisis 

in Florida, the pill mill problem—I think you probably know about 

that. Florida’s legislature enacted a statewide tracking of painkiller 

prescription coupled with law enforcement using drug-trafficking 

laws to prosecute providers caught overprescribing. Within 3 years, 

Florida saw a decrease of more than 20 percent in overdose deaths, 

and I want to give Pam Bondi, the attorney general, and others 

credit for this. 

But now the rise in the fentanyl and its various derivatives have 

presented new challenges to the State of Florida and other states 

as well. However, we remain optimistic with recent legislative initiatives in Florida. 

These include requiring doctors to log prescriptions in a statewide painkiller database by the end of the next day. I think that’s 

important, to curb the so-called doctor shopping and setting aside 

state-sponsored medication that can help reduce opioid dependency. 

So we’re working on it. 

But during the August recess, I want to meet with stakeholders—and conduct roundtables with regard to this issue. 

89 

Do you have any suggestions for me? What has succeeded? Obviously, sir, you talked about the Baltimore model, and I think that’s 

very important. Are there any other innovative ideas or legislative 

initiatives that you would recommend for my State of Florida? Anyone on the panel, please. 

Mr. TILLEY. I just might start by adding that one thing I wanted 

to convey to the panel, and I know you’re very well aware of the 

STOP Act and this issue of keeping fentanyl and carfentanil out of 

our country where it’s manufactured legally, sometimes illegally, 

and still shipped in and mailed into our country. 

The DEA recently informed us that the profit margin for these cartels that bring fentanyl in, for a $6,000 investment, to make 

that more of a heroin-type substance, is about a $1.6 million profit. 

To do it in pill form, just to press it into a pill, is a $6 million profit. And so with that kind of profit margin out there for their taking, 

it’s very difficult to combat this if we’re flooded with it with impunity. We’ve got to figure out ways to stop it from coming into our 

country in the first place. 

And I think that would be—again, that’s not necessarily Florida 

specific, but I think this idea that’s contained in the STOP Act— 

and I won’t comment on the specifics, but I understand that would 

again curtail some of that. 

Mr. BILIRAKIS. Does anyone else? Please. 

Ms. BOSS. If I could, fentanyl is changing the face of this epidemic, and we need to respond in our interventions. And one of the 

things that I would comment on is that this is a marathon, not a 

sprint. And we really need to take a look at prevention efforts as 

critical to changing the face of this epidemic and not cutting our 

efforts in prevention. Primary prevention, working with transitional-aged youth. If we can stop their use before they use, we’re 

not going to have them dying with fentanyl. 

I think we need more research. Recently, we haven’t had any 

new medications. We haven’t had any new treatment models necessarily proposed for opioid-use disorders. And I’m not sure enough 

effort has been placed into the research needs of this epidemic. And 

we need to start looking at this as we would, the focus on cancer. 

This is an epidemic. We need research that’s going to support the 

most evidence-based models that are effective in treating this. 

Mr. BILIRAKIS. Thank you very much. I agree. 

I yield back, Mr. Chairman. Thank you for allowing me to ask 

questions. 

Mr. MURPHY. Thank you Mr. Bilirakis. 

I recognize Ms. DeGette for follow-up. 

Ms. DEGETTE. I just really want to commend all of your states 

for leaning in, for moving forward on this, and for trying to find 

robust solutions. It’s really important that we do that. And I know 

almost all the states are doing this. My State of Colorado has also 

started really paying attention. It’s the kind of thing where it crept 

up on us collectively as a society, and so people have had to move 

really fast. And I just want to commend you. 

And I also want to reiterate that we’re very flattered. I, personally, am very flattered that you’re taking this 21st Century Cures 

money and really making something with it and developing some 

programs that are uniquely and appropriately tailored to your 

90 

states. Sometimes when we’re in Congress, we wonder if anything 

we do actually impacts people’s lives? And when I hear what you’re 

doing, it’s really gratifying and I think it will save lives. 

I hate to sound like a downer, though, but to say that this 21st 

Century Cures money, which was $2 billion, it’s really well used I 

think by the states with these grants to develop programs, but $2 

billion is nothing. As Governor Kasich said, $45 billion. If you’re 

trying to substitute the Medicaid expansion money and other treatment monies that are coming, you can’t use the money for that. 

We have to make opioid treatment and prevention part of our 

overall mental and physical healthcare in this country. And what 

that does take, and I’m sorry that Mr. Carter left, because we’re 

not trying to politicize this. What we’re trying to say is, if you really want to give treatment to people, you have to develop the programs, which is what something like the Cures money is good for. 

But then you have to be able to implement them. 

You have to be able to give the counseling to people. You have 

to be able to give the MAT treatment to people. You have to be able 

to build and maintain these housing options that people were just 

talking about. You don’t do that with just fairy dust. You have to 

do that with resources. And some of the resources can come from 

the states, but the states are jammed. And so that’s why the Medicaid expansion has helped so many millions of Americans be able 

to get access to the treatment that they need, and that’s why we 

need to be able to keep that for these populations. 

So I want you to know that—and it’s not that we really disagree 

on that either. Mr. Murphy and I agree on a lot of these issues, 

he just can’t say it as forcefully as I can sometimes. But we know 

that we need to make sure that all Americans can get this treatment. And we will commit to you that we are going to continue to 

work with the states to make that happen. 

Thank you. 

Mr. MURPHY. Thank you. 

I have a few questions I want to follow up on. This goes in the 

category of coverage without access is a problem. Coverage without 

access and access without coverage are both problems. To this extent, I want to make a note or put in the record, and ask unanimous consent. 

One is an article why taking morphine and OxyContin can sometimes make pain worse from Science Magazine. And another one is 

an article that 51 percent of opioid prescriptions go to people with 

depression and other mood disorders, from Stanton News. I’ll let 

you see that if—— 

Ms. DEGETTE. I don’t have an objection. 

Mr. MURPHY. There’s no objection, it will go in the record. 

[The information appears at the conclusion of the hearing.] 

Mr. MURPHY. But I want to make reference to a couple of those 

things. There are about 50 million Americans with lower back pain, 

25 million of those take an opioid. When a person has pain and depression, about 40 percent of them are 300 to 400 percent, the risk 

of abuse, misuse or addiction, noting that when we’re dealing with 

people with addiction disorders and 80 percent of them begin with 

a prescription for pain, but mood disorders are a big, big part of 

91 

this. Fifty-one percent of people on opioids have a mood disorder, 

anxiety, depression or something else. 

And I don’t know if any of your states ask physicians to screen 

for that when they are prescribing. I would imagine not, because 

I think in most states they don’t. Do any of you know if your state’s 

medical society or hospitals ask to screen? When you’re prescribing 

a medication for pain, do you also screen for depression, anxiety, 

anything like that? Do any of your states—if you don’t know, just 

tell me you don’t know. 

Mr. RUTHERFORD. I don’t know, but I believe that it’s not available in the prescription drug monitoring program either. 

Mr. MURPHY. Oh, OK. Secretary Moran, do you know if you do 

that in Virginia? 

Mr. MORAN. My counterpart, he’s a doctor, and the medical community was using the chart, and say, 0 to 10, smiley face. We were 

addressing pain and we overprescribed. I’m not aware, to answer 

your particular question, I’m not aware of whether or not we—— 

Mr. MURPHY. Yes. Those emojis are not to do with mood, they’re 

to do with pain. I find it amazing that the other vital signs, blood 

pressure we measure. Temperature, we have an instrument for 

that. Respiration. All these are measured, but when it comes to 

pain, 1 to 10 or an emoji is pretty primitive. 

Mr. MORAN. We are mandating now 2 hours of continuing education in the medical community to address pain. It starts in the 

medical community with better education around how we manage 

pain. 

Mr. MURPHY. As far as you know, it doesn’t also include assessing a mood disorders. I’ve seen this take place where they actually 

assess it, and there’s a big difference. Secretary Tilley, do you 

know, or Director Boss, do you know if in your states there’s any 

requirement to also concurrently assess patients for mood disorders 

when prescribing these? 

Mr. TILLEY. Not specifically, but I did mention the limit to the 

3-day supply for acute pain, which again, I think presents a bit of 

a pause for the physician before that prescription. Also, I did not 

get a chance to mention the University of Kentucky is piloting a 

program, our flagship institution piloting a program there, to start 

with everything but an opioid in the course of treatment and try 

to taper—instead of starting with and tapering down, starting 

without and maybe moving toward it if it’s absolutely necessary. 

And then, lastly, I would say we are embarking to your question. 

We actually are embarking on that very thing potentially with a 

statewide mental health approach as to a number of best practices 

across there, and that’s one of the things we’ve discussed. 

Mr. MURPHY. Thank you. Director Boss do you know if you evaluate—— 

Ms. BOSS. I can’t speak as to whether or not it’s required. I can 

say that the state has had major efforts toward behavioral health 

integration and primary care. And I know that a lot of our 

collaboratives and a lot of our—asking primary care settings, and 

most large primary care settings are screening for mood disorders 

as well as anxiety. 

Mr. MURPHY. I would bet during the time when someone is in 

the emergency room, the chance of someone actually getting a 

92 

screen for that is probably pretty close to zero. And just as we have 

the problems of 42 CFR, a doctor doesn’t know if they are on methadone with a prescription or monitoring program. They don’t know 

if they are on these medications. It’s usually patch them up, get 

them out. 

I know when I was prescribed a lot of fentanyl and other opiates 

when I had an injury in Iraq, nobody ever asked me about any 

other questions, just, take these, take these, take these. And I 

ended up with my own issues there, which I didn’t get an addiction, but my body developed a dependency upon those. And when 

I finally said enough is enough, and I had the fun on my own, a 

mild withdrawal reaction. It was not pleasant at all. But going 

with—— 

Director Boss, you mentioned 82 percent of people get a referral 

in the emergency room by talking with, I guess, the peers support 

or a counselor there. Do you know how many of that 82 percent actually follow up and follow up consistently in an evidence based 

program? 

Ms. BOSS. We are not able to measure where the 82 percent go. 

And so 82 percent, not just are referred, but are connected and do 

follow through with treatment and recovery supports. 

Mr. MURPHY. We don’t know what the follow up is afterward? 

Ms. BOSS. Right. 

Mr. MURPHY. That’s important to me. So we’ve identified a few 

things here such as we have a crisis shortage of providers. We all 

agree with that, across the Nation, especially in rural areas. Quite 

frankly, in urban areas, too, if you assess providers and say, how 

many of you actually have openings in your schedule, you’ll see 

that they don’t. I know in my areas, for example, child and adolescent providers are even more rare, and some say, I just don’t have 

any appointments open for months. And when you’re dealing with 

a substance abuse disorder, I need treatment now. Now is the best 

time for treatment. Giving them a waiting list is not helpful at all. 

So even when we do refer people over, the statistic I see is of the 

27 million people in this county with an addiction disorder, 1 percent get evidence-based care. So if you look at this, about 90 percent of the people with a substance abuse disorder don’t seek attention. So out of every 1000, 900 don’t seek attention. 

Out of the 100 that do seek attention, 37.5 can’t find it, it’s not 

available. Of those who do get it, get attention, 90 percent of those 

don’t get evidence based care. So we have a crisis that’s getting 

worse. And I might add, too, I think, Virginia, you’re the only state 

that doesn’t have Medicaid expansion right? 

Mr. MORAN. We do not. 

Mr. MURPHY. You do not. But in this time period of which it was 

available, I would assume that your addiction rate, your overdose 

and death rates have climbed, correct? 

Mr. MORAN. They have. 

Mr. MURPHY. And in the states that do have Medicaid expansion, 

Maryland, Kentucky, Rhode Island, has your overdose and death 

rates also climbed? 

Mr. RUTHERFORD. Oh, yes. Yes, sir. 

Ms. BOSS. Ours have raised but not as significantly as other 

states have experienced in these last few years. 

93 

Mr. MURPHY. Yes, I want to help, but we need honest data here. 

Look, we don’t even have information on if those numbers are accurate, because if your medical examiners and coroners are not doing 

toxicology tests, and if we don’t even have data for 2016, and we 

won’t have it until the end of this year. We just don’t know. 

And what this committee likes to do is identify. We need the absolute, honest, bare bone problems. And if you tell us, look, we 

don’t know, this is probably much worse. We don’t have enough 

providers. We had legislation, some of it was reduced down and I 

want to see it reenacted, where we could do more to get more psychiatrists, psychologists, clinical social workers, and licensed addiction counselors out there. 

We’re probably going to have to do things with the states and 

Federal Government providing scholarships or pay for their internships or something to get them out there, because who would want 

to go into a field that pays so little and the frustration is so high. 

You’re 24/7 on call. You’re probably going to get called into court 

and testimony, a lot of different problems. And that itself could be, 

it only requires the best who have true altruism in their blood to 

help fight that. But we’ve got to do it. 

I also want to ask a question, too, with regard to getting drugs 

back to someone who is not using. I know even realtors now say 

when you’re putting a home up for sale the first thing you should 

do is go to your medicine cabinet and clean it out. I know there are 

some products, even in rural areas, some places will have drug recovery programs, you take it to the pharmacist or you take it to 

the police. There are some products—one product called Deterra, 

which actually—a drug deactivation system where you can use in 

your home and then throw it away. Virginia, you have programs 

where you do drug recovery at home? 

Mr. MORAN. We do, sir. And we are using those. And I would 

congratulate our private sector partners pharmacies have collection 

boxes now. And I will tell you, DEA does a terrific job. In fact, they 

were going to suspend their take-back program, and now they continue their robust take-back program. Tons of drugs, it’s amazing, 

I’ve witnessed it myself, how much. And improper disposal in the 

medicine cabinets. 

As the father of 2 children, teenagers, it’s imperative that we 

keep the drugs out of that medicine cabinet because we’ve heard 

from anecdotal stories, that’s where the addiction begins. Kids 

using it out of their medicine cabinets. 

Mr. MURPHY. They go into homes for a party and the next thing 

you know—— 

Mr. MORAN. Exactly, sir. 

Mr. MURPHY. I want to thank this panel. We have a long way 

to go. And, unfortunately, at this point we’re seeing the battles in 

the states to combat, but I think we have to be honest and say we 

have a long way to go in this war, it’s still quite a crisis here. 

This committee will continue to take this up on lots of different 

ways, because it isn’t just a matter of funding. What good is funding if you haven’t got a provider? What good is some of the jail 

treatment programs if a person is discharged from jail and they’re 

now back on Medicaid, so they go right back to the streets, right 

back to somewhere where they had problems before. I hear someVerDate Nov 24 2008 11:33 Nov 09, 2018 Jkt 037690 PO 00000 Frm 00097 Fmt 6633 Sfmt 6633 I:\MY DOCS\HEARINGS 115\HEARINGS\115-43 CHRIS
94 

one will work in certain professions where everybody—a lot of the 

people in the back rooms also have addiction problems and get reexposed. We have an awful, awful mess in this country, and the 

outcome is a death rate that is mortifying. 

So I thank the panel here and I thank the members for being in 

today’s hearing. And I remind members, they have 10 business 

days to submit questions for the record, and ask the witnesses to 

all agree to respond promptly to the questions. 

Thank you for your honest approaches. Keep fighting the good 

fight. Thank you. 

Mr. MORAN. Thank you, Chairman. 

Ms. BOSS. Thank you. 

[Whereupon, at 12:16 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 

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26839.046

FOR IMMEDIATE RELEASE 

June 26, 2017 Contact: matt.salo@medicaiddirectors.org 

Consensus Statement from the National Association of Medicaid 

Directors (NAMD) Board of Directors on the Better Care Reconciliation 

Act of 2017 

This statement represents the overwhelming consensus of the NAMD Board of Directors, but 

is not intended to communicate the unanimous position of all 56 members. 

Washington, DC- Medicaid is a successful, efficient, and cost-effective federal-state 

partnership. It has a record of innovation and improvement of outcomes for the nation's most 

vulnerable citizens. 

Medicaid plays a prominent role in the provision of long-term services and supports for the 

nation's elderly and disabled populations, as well as behavioral health services, including 

comprehensive and effective treatment for individuals struggling with opioid dependency. 

Medicaid is complex and therefore demands thoughtful and deliberate discussion about how to 

improve it. 

Medicaid Directors have long advocated for meaningful reform of the program. States continue 

to innovate with the tools they have, but federal changes are necessary to improve effectiveness 

and efficiency of the program. However, these changes must be made thoughtfully and 

deliberately to ensure the continued provision of quality, cost-effective care. 

Medicaid Directors have asked for, and are appreciative of, improved working relationships 

with HHS and are working hard to streamline and improve the administration of the program. 

The Senate bill does formalize several critical administrative and regulatory improvements, 

such as giving Medicaid Directors a seat at the table in the development of regulations that 

impact how the program is run, and the pathway to permanency for certain waiver programs. 

444 North Capitol Street. Suite 524 • Washington, DC 20001 • Phone: 202.403.8620 • www.medicaiddirectors.org 
96 


26839.047

NAMD 

However, no amount of administrative or regulatory flexibility can compensate for the federal 

spending reductions that would occur as a result of this bill. 

Changes in the federal responsibility for financing the program must be accompanied by clearly 

articulated statutory changes to Medicaid to enable states to operate effectively under a cap. The 

Senate bill does not accomplish that. It would be a transfer of risk, responsibility, and cost to the 

states of historic proportions. 

While NAMD does not have consensus on the mandatory conversion of Medicaid financing to a 

per capita cap or block grant, the per capita cap growth rates for Medicaid in the Senate bill are 

insufficient and unworkable. 

Medicaid - or other forms of comprehensive, accessible and affordable health coverage - in 

coordination with public health and law enforcement entities, is the most comprehensive and 

effective way address the opioid epidemic in this country. Earmarking funding for grants for 

the exclusive purpose of treating addiction, in the absence of preventative medical and 

behavioral health coverage, is likely to be ineffective in solving the problem and would divert 

critical resources away from what we know is working today. 

Medicaid Directors recommend prioritizing the stabilization of marketplace coverage. Medicaid 

reform should be undertaken when it can be accomplished thoughtfully and deliberately. 

### 

The National Association of Medicaid Directors (NAMD) is a bipartisan, nonprofit, professional 

organization representing leaders of state Medicaid agencies across the country. NAMD members 

drive major innovations in health care while overseeing Medicaid, the nation's most important health 

care program. NAMD serves as the voice for state Medicaid directors in national policy discussions, 

supports state-driven policies and practices that strengthen the efficiency and effectiveness of 

Medicaid and actively monitors emerging issues in Medicaid and health care policy. Learn more at 

http://www.medicaiddirectors.org and follow NAMD on Twitter@statemedicaid. 

Page 2 of2 
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Why taking morphine, oxycodone can sometimes make pain worse I Science! AAAS 

Long-term use of opioid painkillers such as oxycodone (above} may increase a person's sensitivity to pain. 

Why taking morphine, oxycodone can sometimes 

make pain worse 

By Kelly Servick May. 30, 2016, 3:00PM 

There's an unfortunate irony for people who rely on morphine, oxycodone, and other opioid painkillers: The 

drug that's supposed to offer you relief can actually make you more sensitive to pain over time. That effect, 

known as hyperalgesia, could render these medications gradually less effective for chronic pain, leading 

people to rely on higher and higher doses. A new study in rats-the first to look at the interaction between 

opioids and nerve injury for months after the painkilling treatment was stopped-paints an especially grim 

http:!/v.·ww.scienccmag.org/news/20 16/05/why-taking-morphine-oxycodone-can-sometimes-make-pain-worse[?/12/20 17 4:39:22 PM] 
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Why taking morphine, oxycodone can sometimes make pain worse i Science I AAAS 

picture. An opioid sets off a chain of immune signals in the spinal cord that amplifies pain rather than 

dulling it, even after the drug leaves the body, the researchers found. Yet drugs already under development 

might be able to reverse the effect. 

It's no secret that powerful painkillers have a dark side. Overdose deaths from prescription opioids have 

roughly quadrupled over 2 decades, in near lockstep with increased prescribing. And many researchers 

see hyperalgesia as a part of that equation-a force that compels people to take more and more 

medication, while prolonging exposure to sometimes addictive drugs known to dangerously slow breathing 

at high doses. Separate from their pain-blocking interaction with receptors in the brain, opioids seem to 

reshape the nervous system to amplify pain signals, even after the original illness or injury subsides. 

Animals given opioids become more sensitive to pain, and people already taking opioids before a surgery 

tend to report more pain afterward. 

But how opioids actually interact with pre-existing pain has been poorly studied, says Peter Grace, a 

neuroscientist at the University of Colorado (CU), Boulder. His team has been trying to trace hyperalgesia 

to the way opioids affect the immune system. In the new study, he and his collaborators used a rat model 

meant to mimic chronic nerve pain in people-the kind many might feel from traumatic nerve injury, stroke, 

or nerve damage caused by diabetes. They sliced into the rats' thighs and tied a fine thread around a major 

nerve. The thread swelled over time, causing the nerve to painfully constrict, and then dissolved after about 

6 weeks. 

Ten days after that injury, half the rats received a 5-day treatment of morphine. Then over about 3 months, 

the researchers periodically measured the rodents' threshold of pain by poking their hind paws with stiff 

nylon hairs of varying thicknesses. (The finer the hair that causes the rat to withdraw its paw, the logic 

goes, the more sensitive it is to pain.) After 6 weeks, injured rats that had received no morphine withdrew 

from the same kind of pokes as uninjured control rats. But morphine-treated rats remained sensitive to 

pokes with much finer hairs. It took them 12 weeks to return to the same pain sensitivity as the control rats, 

the team reports today in the Proceedings of the National Academy of Sciences. Even after the physical 

injury had presumably healed, they were in pain. 

"Just the primary observation itself, I think, is amazing," says Vania Apkarian, a neuroscientist 

at Northwestern University, Chicago, in Illinois, who was not involved in the study. The result "should have 

a wake-up impact on the field." 

Control rats with no injury also saw their pain tolerance dip if they got morphine, but they returned to their 

original threshold after about a week. So what made pain sensitivity jump so much more dramatically in the 

rats with an injury? 

The authors propose that the nerve damage and the morphine delivered a kind of one-two punch to cells in 

the spinal cord called microglia-sentinels of the nervous system that scout for infection. Microglia release 

inflammatory signaling molecules into the spinal cord, which activate neurons that shoot pain signals up to 

the brain. Previous studies have shown that opioids make microglia more sensitive to activation. In the new 

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Why taking morphine, oxycodonc can sometimes make pain worse I Science i AAAS 

study, the authors found that morphine activates a specific group of signaling proteins in microglia, 

collectively known as an inflammasome. 

That's not likely to be the only mechanism behind hyperalgesia, Apkarian notes. But in the study, inhibiting 

microglia-by inserting a gene for a receptor that makes them susceptible to a deactivating drug-reversed 

the pain-prolonging effect in morphine treated-rats, as did blocking certain proteins in the inflammasome. 

Researchers are already exploring drugs that interrupt this pathway to treat pain or improve the 

performance of opioids. A clinical trial recently launched at Yale University, for example, will test whether 

an antibiotic that inhibits glial cells prevents the inflammatory effects of opioids. And Linda Watkins, a 

CU Boulder neuroscientist and senior author on the new study, co-founded a company to develop a 

chronic pain treatment that blocks one of the signaling proteins in the inflammasome, called toll-like 

receptor 4. 

In the meantime, the finding certainly shouldn't be the basis for withholding opioids from people in pain, 

says Catherine Cahill, a neuroscientist at the University of California, Irvine. These drugs also work to block 

the emotional component of pain in the brain, she notes-a form of relief this study doesn't account for. 

And opioids might not prolong pain in humans the way they did in these rats, she says, because the dosing 

of morphine and its quick cessation likely caused repeated withdrawal that can increase stress and 

inflammation. Humans usually don't experience the same withdrawal because they take sustained-release 

formulations and taper off opioids gradually. 

Grace says the field badly needs a human study that systematically tests pain thresholds over time in 

opioid users. His team is working to confirm the animal findings with pain from other kinds of injury, and in 

female rats, which weren't included in this study. In the meantime, he says, "I hope that it'll get people to 

really question what the benefit of long-term opioid therapy might be." 

Posted in: Brain & Behavior, Health 

DOl: 1 0.1126/science.aag0579 

Kelly Servick 

Kelly is a staff writer at Science. 

Email Kelly 

Twitter 

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51 percent of opioid prescriptions go to people with depression and anxiety 

HEALTH 

51 percent of opioid prescriptions go to people with 

depression and other mood disorders 

By CATHERINE CARUSO @cat_caruso I JUNE 26, 2017 

https://www.statnews.com/20 17/06/26/opioiUs-depression-anxiety/[7112/20 17 4:37:53 PM] 
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5! percent of opioid prescriptions go to people with depression and anxiety 

i>()J\i,Rl 

M 

Y/ \I' 

ore than half of all opioid prescriptions in the United States arc written for people with 

anxiety, depression, and other mood disorders, according to a new study that questions 

how pain is tteated in this vulnerable population. 

People with mood disorders arc at increased risk of abusing opioids, and yet they received many 

more prescriptions than the general population, according to an analysis of data from 2011 and 2013. 

https://www.statnews.com/20 17 /06/26/opioids-depression-anxiety/! 7/12/2017 4:37:53 PM j 
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51 percent of opioid prescriptions go to people with depression and anxiety 

"We're handing this stuff out like candy," said Dr. Brian Sites, of Dartmouth-Hitchcock Medical 

Center, the senior author of the study. Opioid prescribing in the U.S. quadrupled between 1999 and 

2Q15, and during that time over 183,000 people died from overdoses related to prescription opioids, 

according to the CDC. 

Sites said more research is needed to understand whether opioids are being overprescribed to adults 

with mood disorders. 

READ MORE 

Treating patients with opioid disorders is not just about treating addiction. Here's why 

"If you want to come up with social policy to address the need to decrease our out-of-control opioid 

prescribing, this would be the population you want to study, because they're getting the bulk of the 

opioids, and then they are known to be at higher risk for the bad stuff," he said. 

The study, published Monday in the Journal of the American Board of Family Medicine, tapped a 

U.S. health survey that gathered data from providers and facilities on prescription medications, health 

status, and basic demographics for about 51,000 adults. It found that 19 percent of the 38.6 million 

Americans with mood disorders use prescription opioids, compared to 5 percent of the general 

population a difference that remained even when the researchers controlled for factors such as 

physical health, level of pain, age, sex and race. 

The analysis showed that adults with mood disorders receive 51 percent of the opioid prescriptions 

distributed in the U.S., some 60 million prescriptions a year. 

It's unclear why such a discrepancy exists. Sites said it's possible that patients with mood disorders 

respond to pain differently, spurring physicians to write more opioid prescriptions; previous research 

has shown that patients with a history of depression are at increased risk of developing chronic pain. 

Or physicians might be more sympathetic to patients with preexisting conditions, making them more 

likely to prescribe opioids. Sites also said that opioids might have a short-term antidepressant effect, 

which could motivate patients with mood disorders to seck prescriptions. 

For Sites, the bottom line is that while opioid prescriptions can be appropriate for individual patients 

with mood disorders, the study raises concerns about overprescribing on a population scale. 

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51 percent of opio[d prescriptions go to people with depression and anxiety 

"We need to understand if this massive prescribing level is appropriate in actually providing benefit 

commensurate with the risk," said Sites, who collaborated with researchers at the University of 

Michigan. 

READ MORE 

Your mind can be trained to control chronic pain. But it will cost you 

He added that physicians need viable alternatives for treating pain, including cognitive behavioral 

therapy, acupuncture and acupressure, physical therapy, and massage. 

''\'Ve don't have the ability to refer and recommend those things easily," he said, "So the easiest thing 

right now is to prescribe a pill." 

Jeffrey Scherrer, a professor and epidemiologist at Saint Louis University not involved in the study, 

was not particularly surprised by the results. ";\ lot of pain patients attribute their depression to their 

pain, but there's a lot of evidence that depression is playing a role in both the experience of pain and 

the odds of getting an opioid," he said. 

!'or Dr. Mark Edlund, a senior public health analyst at RTI International who was also not involved 

in the study, it adds to a growing and worrisome body of evidence that people with mental health 

disorders who are at higher risk for abusing opioids are also more likely to receive opioid 

prescriptions. 

"There's an emphasis now on cutting back opioid prescribing," he said. "Probably just as important is 

assuring that we're prescribing the opioids to the right populations, and that we're doing our riskbenefit analysis on each patient." 

Contact the Author 

Catherine Caruso can be reached at ~D.li<lHI!l.!l@.'llatn~ 

Follow Catherine on Twitter @cat caruso 

https://www.statnews.com/20 17/06/26/opioids-deprcssion-anxiety/[7/12/20 17 4:37:53 PM] 
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U.S. HOUSE OF REPRESENTATIVES 

COMMITTEE ON ENERGY AND COMMERCE 

July 10,2017 

TO: Members, Subcommittee on Oversight and Investigations 

FROM: Committee Majority Staff 

RE: Hearing entitled "Combating the Opioid Crisis: Battles in the States" 

The Subcommittee on Oversight and Investigations will hold a hearing on Wednesday, 

July I2, 2017, at 10:00 a.m. in 2123 Rayburn House Office Building, entitled "Combating the 

Opioid Crisis: Battles in the States." The United States is experiencing an epidemic of opioid 

abuse and addiction, with drug overdose deaths increasing dramatically over the last two decades 

and becoming the leading cause of injury death in the U.S. In the early 21st century, overdose 

deaths primarily involved prescription opioids and then later, around 2005, heroin. Increasingly 

since 2013, the apparent next wave of the opioid epidemic includes fentanyl, a synthetic opioid 

I 00 times more powerful than morphine. 

This hearing will examine how a few states with particular challenges are battling the 

opioid crisis, what responses show evidence of effectiveness or great promise, where the federal 

government can assist with such responses, and any state policies that could help improve the 

federal response to this growing epidemic. This hearing follows up on a series of hearings that 

the Subcommittee has held over the past two Congresses. In particular, on May 21, 2015, the 

Subcommittee held a hearing entitled, "What Are the State Governments Doing to Combat the 

Opioid Abuse Epidemic?" 

Pursuant to the 21st Century Cures Act enacted in December 2016, the Substance Abuse 

and Mental Health Services Administration (SAMHSA) is administering nearly one billion 

dollars in grants over the next two years to states and territories for substance abuse prevention 

programs, treatment, and training for health professionals. This hearing is also an opportunity 

for the Subcommittee to learn how some of these grants are being spent. 

I. WITNESSES 

• The Honorable Boyd K. Rutherford, Lt. Governor of Maryland; 

• The Honorable Brian J. Moran, the Virginia Secretary of Public Safety and Homeland 

Security; 

• The Honorable Rebecca Boss, Director, Rhode Island Department of Behavioral 

Hcalthcare, Developmental Disabilities & Hospitals; and 

• The Honorable John Tilley, Kentucky Secretary of the Justice and Public Safety Cabinet. 
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Majority Memorandum for July 12, 2017, Subcommittee on Oversight and Investigations Hearing 

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II. BACKGROUND 

a. Committee activity on the opioid epidemic 

I 13th and ]14th Congresses. The Subcommittee held a series of hearings, beginning in 

April 2014 and continuing into early 2015, that examined the growing problem of prescription 

drug and heroin abuse nationwide and evaluated solutions to address the crisis. In the course of 

these hearings, the Subcommittee heard testimony from federal, state, and local levels, and 

developed a record demonstrating not only the various factors contributing to the opioid abuse 

epidemic, but also a number of possible solutions. Solutions presented at these Subcommittee 

hearings helped inform the Committee's legislative efforts ultimately enacted into law as part of 

the Comprehensive Addiction and Recovery Act (CARA), followed by authorized funding 

included in the 21st Century Cures Act. 

I 15th Congress. Earlier this year the Committee began focusing on the synthetic opioid, 

fentanyl, which "has spawned a deadly drug crisis in the United States." 1 On February 23, 2017, 

the bipartisan leaders of the full Committee and the Subcommittee sent a letter to the Acting 

Director of the Office ofNational Drug Control Policy (ONDCP) seeking details about the 

fentanyl problem, actions taken, and any strategic plan to address the fentanyl threat.2 On March 

21,2017, the Subcommittee held a hearing on "Fentanyl: The Next Wave of the Opioid Crisis." 

This hearing examined the unique threat that fentanyl has started to pose in communities across 

the country and what more we need to do at the federal, state, and local level to tackle fentanyl as 

part of the opioid epidemic. 

On May 9, 2017, the Committee launched an investigation into the distribution of 

prescription opioids in West Virginia. The Committee sent letters to distributors as well as the 

Drug Enforcement Administration (DEA) inquiring about how so many prescription opioids 

have been distributed in such high quantities to such small communities, especially in a state that 

has the highest opioid overdose death rate in the nation.3 There needs to be a comprehensive 

approach to combat this growing epidemic that includes all components of the health care and 

law enforcement community. 

1 Press Release, U.S. Drug Enforcement Admin., DEA Warning to Police and Public: Fentanyl Exposure Kills, June 

I 0, 20 16, available at https://www.dea.gov/divisionslhq/20 16/hq061 0 16.shtml. 2 Letter from Hon. Greg Walden, Chairman, H. Comm. on Energy & Commerce, Hon. Frank Pallone, Jr., Ranking 

Member, H. Comm. on Energy & Commerce, Hon. Tim Murphy, Chairman, Subcomm. on Oversight and 

Investigations, & Hon. Diana DeGette, Ranking Member, Subeomm. on Oversight and Investigations, to Mr. Kemp 

Chester, Acting Director, ONDCP, February 23, 2017, available at 

https://energyeommeree.house.gov/sites/republicans.energycommerce.house.gov/files/documents/20 1702230NDCP 

.pdf. 

3 Letters from Hon. Greg Walden, Chairman, H. Comm. on Energy & Commerce, Hon. Frank Pallone, Jr., Ranking 

Member, H. Comm. on Energy & Commerce, lion. Tim Murphy, Chairman, Subcomm. on Oversight and 

Investigations, & Hon. Diana DeGette, Ranking Member, Subcomm. on Oversight and Investigations, to 

Distributors and DEA, May 8, 2017, available at https://energycommerce.house.gov/news-center/letters/lettersdistributors-and-dea-regarding-alleged-pill-dumping-west-virginia. 
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Majority Memorandum for July 12,2017, Subcommittee on Oversight and Investigations Hearing 

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b. Scope of the opioid crisis 

Drug overdose trends. Drug-poisoning (overdose) is now the leading cause of death 

from injury in the U.S., surpassing motor vehicle accidents, suicide, firearms, and homicide. 

More than 183,000 people have died from overdoses of prescription narcotics between 1999 and 

2015, with more than 15,000 deaths in 2015 alone.4 Drug overdose deaths in 2016 most likely 

exceeded 59,000, the largest annual jump ever recorded in the U.S., according to preliminary 

data collected by the New York Times.5 Drug overdoses are now the leading cause of death 

among Americans under 50.6 

Opioid-use disorders are surging. An analysis of millions of Americans' medical claims 

showed diagnoses of opioid-use disorder surged roughly 500 percent over the past seven years, 

according to a review by the Blue Cross Blue Shield Association.7 As the opioid crisis 

accelerates, one forecast projected that almost 500,000 Americans will die from opioids over the 

next decade. 8 

c. State policies and issues 

While opioid abuse is a nationwide epidemic,9 state activities vary depending on 

circumstances in the particular state. For example, beginning in late 2013, there were sudden 

and large increases in the number of deaths involving fentanyl in a number of states throughout 

the country, with the increase seen particularly in states on the East Coast. 10 Fentanyl is a 

narcotic pain reliever used to manage moderate to severe chronic pain. 11 The majority of 

4 Centers for Disease Control and Prevention, Prescription Opioid Overdose Data, updated December 16, 2016, for 

2015 alone, the estimate could be as high as 33,000 Americans dying of opioid overdoses, available at 

https://www.cdc.gov/drugoverdose/data/overdose.html. 

5 Josh Katz, Drug Deaths in America Are Rising Faster than Ever, N.Y. TIMES, June 5, 2017, available at 

https ://www .nytimes.com/i nteractive/20 17/06/05/upshot/opioid -epidemic-drug -overdose-deaths-are-rising-fasterthan-ever.html. 

6 !d. 

' Anne Steele, Opioid Addiction Climbs by 500%, WALL ST. J ., June 30, 2017, available at 

https://www.wsj.com/articles/opioid-addiction-diagnoses-up-nearly-500-in-past-seven-years-study-shows1498737603. 

8 Max Blau, STAT forecast: Opioids could kill nearly 500,000 Americans in the next decade, STAT News, June 27, 

2017, available at https://www.statnews.com/20 17/06/27/opioid-deaths-forecast/. 9 Drug poisoning is the leading cause of death from injury in 30 states, according to CDC in 2011. In addition, 

opioid analgesics were involved in more than 40 percent of drug poisoning deaths in 2008. According to a 2014 

National Association of State Alcohol and Drug Abuse Directors (NASADAD) survey, roughly 40 states 

consistently say that prescription drug abuse is either "most" or "very" important (slide 17), with 34 states reporting 

that they have an active prescription drug task force, an increase from 29 reported in 2012. (slide 19). 35 States 

reported that their strategic plan explicitly addresses prescription drug abuse, and 12 of these states reported that 

their plan explicitly addresses heroin abuse. 37 states said that heroin abuse is either "most" or "very important" 

(slide 36), with 15 states reporting that they have an active task force for heroin abuse (slide 40). National 

Association of State Alcohol and Drug Abuse Directors, Inc. (NASADAD), "State Substance Abuse Agencies, 

Prescription Drugs, and Heroin Abuse: Results from a NASADAD Member Inquiry," 2014 update, available at 

http://nasadad.org/wp-contentluploads/20 14/05/NASAD AD-Prescription-Drug -and-Heroin-Abuse-Inquiry-FullReport-Final.pdf. 

10 Maryland Department of Health and Mental Hygiene, "Deaths Related to Fentanyl-Laced Heroin and Other Illicit 

Drugs," July 2014, available at https://health.maryland.gov/data!Documents/fentanyl%20brief_draft.pdf. 

II /d. 
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Majority Memorandum for July 12, 2017, Subcommittee on Oversight and Investigations Hearing 

Page4 

fentanyl-related deaths do not result from overdoses of pharmaceutical fentanyl, but instead 

involved an illicit, powdered form of fentanyl that was mixed with, or substituted for, heroin or 

other illicit substances. 12 In response to this problem, for example, the state of Maryland took 

the following actions to reduce fentanyl-related overdoses throughout the state: sharing data with 

law enforcement, expanding access to naloxone (a medication designed to rapidly reverse an 

opioid overdose) 13, and launching a public awareness campaign. 14 

Despite differences in circumstances, prevention plans, and strategies, the states have 

identified certain overarching challenges. 15 The challenges have included: a lack of or 

incomplete data, stigma, the need for increased and interoperable POMP (Prescription Drug 

Monitoring Program) utilization, overdose prevention, increasing access to MAT (medicationassisted treatment); and evidence and research on effectiveness of strategies. 

Data Needs. Concerns have been raised about real-time data/measurement, data quality, 

and data utilization. As noted by the National Governors Association, to develop an effective 

response to prescription drug abuse, states need accurate and timely information about the 

incidence and scope of the problem. It can be 6 to 12 months before the medical examiner's 

information becomes available, long after an OTP [ opioid treatment programs] has reported the 

death to the state. 16 States have reported that CDC data is slow to be released and cannot capture 

real-time changes in drug use that are occurring. 17 For example, a CDC expert told bipartisan 

Committee staff that time lags in reporting, for example, would mean that CDC would not have 

2016 overdose death data until the end of2017. Moreover, CDC noted they primarily rely on 

death certificates which sometimes only note a "drug overdose" and do not always list the 

specific drug(s). 

Serious challenges exist concerning state data on the cause of death regarding drug 

overdose deaths. State death certificates often do not specify the type of drug related to drug 

overdose deaths. 18 Lethality issues can be hard to separate when multiple drugs are involved, 

especially with benzodiazepines. 19 Additionally, defining the cause of death in patients receiving 

MAT is inherently complex, since, regardless of the cause of death, these patients may have a 

high level of methadone in their blood. Medical examiners often do not know that the individual 

is receiving methadone treatment. 2

° Further, many states do not conduct the full medical review 

"Jd 

13 National institute on Drug Abuse, Opioid Overdose Reversal with Naloxone (Narcan, Evzio ), September 2016, 

available at https:l/www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio. 

14 /d. 15 The Substance Abuse and Mental Health Services Administration, Successful Strategies in Addressing Opioid 

Overdose Deaths, White Paper developed for the Center for Substance Abuse Treatment, March 2010, available at 

https://www .michigan.gov I documents/mdch/SAMHSA _Overdose .. Report_ 34523 8 _7. pdf. 16 /d. at 11. 17 National Association of State Alcohol and Drug Abuse Directors, Inc. (NASADAD), "State Substance Abuse 

Agencies, Prescription Drugs, and Heroin Abuse: Results from a NASADAD Member Inquiry," slide 14, 2014 

update, available at http://nasadad.org/wp-contcntiuploads/20 14/05/NASAD AD-Prescription-Drug-and-HeroinAbuse-Inquiry-Fuii-Report-Final.pdf. 

18 A CDC expert in a briefing with Committee Staff estimated that 25 percent of death certificates listing overdose 

as a cause did not specifY the drug. 19 Successful strategies, Supra note 15 at I 0. 

00 !d. 
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Majority Memorandum for July 12, 2017, Subcommittee on Oversight and Investigations Hearing 

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for determining the cause of death. 21 For example, Colorado noted that from 2004 to 2013, 2.4 

percent of Colorado death certificates had an unknown cause of death. 22 

CDC believes information collected in Will County, Illinois that tracks "accidental 

overdoses" by date of death, cause of death, and personal demographics would be extremely 

helpful if it were collected on all death certificates of drug overdose deaths in the U.SY This 

information is useful to public health, medical, and legal entities as it helps researchers, 

investigators, health care providers, and public health practitioners understand and identify drug 

use risks, appropriate clinical and behavioral care, and possible public health interventions.24 

CDC reported to the Subcommittee that there are multiple national and state efforts underway to 

address these issues that align with the effort in Will County.25 Currently, CDC is partnering 

with the Association of State and Territorial Health Officials (ASTHO) on a project to improve 

drug specificity on death certificates.26 

In a response to a Question for the Record that was submitted following the 2015 

Subcommittee hearing, one state government witness noted that it had become clear that her 

state's ability to address the underlying health issues and social determinants that are driving this 

epidemic ''is dependent on the state's ability to successfully leverage data and measure results."27 

This witness wrote that her state had more "than 300 different internal data sources that have 

been developed by individual programs using a variety of different formats for a variety of 

different purposes. They arc managed by different staff, reside on different servers, and don't 

talk to each other."28 

Stigma. The stigma associated with seeking treatment was reported by states in 2014 as 

one of the top remaining challcngcs.29 In addition to the underlying stigma against addiction, 

stigma and bias against MAT exists even after research has proved its value for treating opioid 

dependence. The stigma underlies a score of issues that states confront in developing their 

strategies. Such issues include: state moratoriums on establishing new opioid treatment 

programs (OTPs) despite large, unmet treatment needs for the opioid-dependent population, 

unwillingness of the criminal justice system to set up MAT in correctional facilities, and the 

requirement of some drug court judges that people must abandon the usage of MAT to 

participate in the program and of some family court judges who mandate that individuals must 

21 /d. 22 Colorado Department of Public Health & Environment, Special Emphasis report: Drug Overdose Deaths, 1999-

2013, October 2014, page 196-197, available at 

https://www.colorado.gov/pacific/sites/default/files/LPH _ MCH _ N A-RepOit-Appendix-only _20 l6-2020.pdf. 23 Dr. Debra Houry, Director, National Center for Injury Prevention and Control, CDC, Responses to Questions for 

the Record, Subcomm. hearing on "Fentanyl: The Next Wave of the Opioid Crisis," March 21,2017, available at 

http://docs.house.gov/meetings/IF/1F02/20 170321/l 05739/HHRG-115-IF02-Wstate-HouryD-20 170321-SD026.pdf. 

24 !d. 

25 !d. 

26 !d. 

27 Commissioner Monica Bharel, MD, MPH, Massachusetts Department of Public Health, Responses to Questions 

for the Record, "What are the State Governments Doing to Combat the Opioid Epidemic?", Serial No. 114-46, 102, 

May 21, 2015, available at http://docs.house.gov/meetings/IF/IF02/20150521/1 035011HHRG-114-1F02-WstateBhare!M-20 150521-SD003 .pdf. 

28 !d. 29 NASADAD, 2014 update, Supra note 9, at slide 34. 
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stop MAT before receiving custody of their children. 30 State initiatives to reduce the stigma of 

treatment for opioid use disorders are: increasing access to a full range of evidence-based 

therapies, facilitating access to recovery support services, and expanding access to effective 

therapies in the criminal justice system. 31 

Need.for PDMP improvement. PDMPs are state-run electronic databases of prescriptions 

for controlled substances. PDMPs can provide a prescriber or pharmacist with information 

regarding a patient's prescription history, allowing prescribers to identify patients who are 

potentially abusing medications. With Missouri adopting a POMP in April 2017, all 50 states, 

the District of Columbia, and Guam have legislation authorizing the creation and operation of a 

POMP, and all but the District ofCo1umbia program are operational. 32 While there is evidence 

indicating the potential of PDMPs to identify high-risk patients and impact prescribing 

behaviors, the effectiveness of PDMPs is constrained by the lack of consistent utilization, timely 

data in some states, and limited interoperability with other PDMPs. Witnesses at the March 26, 

2015, Subcommittee hearing also testified about their concerns over methadone clinics not being 

required to report methadone dispensing to PDMPs. One witness said it was "a very serious 

situation" because if these patients do not disclose their methadone treatment to their primary 

care providers and the providers do not know about it from accessing the PDMP, other opioids or 

benzodiazepines could be prescribed leading to an increased risk of an overdose death. 33 

Another concern that was expressed at the hearing related to neonatal doctors not knowing about 

methadone treatment for pregnant women, which poses potential problems for the mother and 

the life of the fetus if the methadone is being increased while the mother and baby are receiving 

MAT to treat the addiction.34 

States have noted that it is critical to an effective statewide strategy for combatting opioid 

abuse to improve the effectiveness and use of PDMPs. While 50 states and the District of 

Columbia have legislation authorizing the creation and operation of a PDMP, they vary in their 

degree of use and overall effectiveness depending on who is registered to use them, whether data 

is current or real-time, whether there are limitations on authorized users, and whether processes 

30 Successful strategies, Supra note 15 at 9. 31 NASADAD 2014 update, Supra note 9, slide 48. 32 Summer Ballentine, Missouri House Passes Prescription Drug Tracking Program, ASSOC. PRESS, April 3, 

2017, available at https://www.usnews.com/news/best-states/missouri/articles/20 17 -04-03/missouri-house-passesprescription-drug-tracking-program. PDMP Training and Technical Assistance center, PDMP Frequently Asked 

Questions, available at http://www.pdmpassist.org/content/prescription-drug-monitoring-frequently-askedquestions-faq, 

33 Examining the Growing Problems of Prescription Drug and Heroin Abuse: State and Local Perspectives Before 

the H. Comm. on Energy & Commerce Subcomm. on Oversight and Investigations, 114th CONG, Unofficial hearing 

transcript, 40, Testimony of Fred Wells Brason II, Executive Director, Project Lazarus, Moravian Falls, North 

Carolina, March 26,2015, available at http://docs.house.gov/meetings/JF/IF02/20150326/103254/HHRG-114-IF02-

Transcript-20 150326.pdf. 34 Examining the Growing Problems of Prescription Drug and Heroin Abuse: State and Local Perspectives Before 

the H. Comm. on Energy & Commerce Subcomm. on Oversight and Investigations, !14th CONG, Unofficial 

hearing transcript, 90, Testimony of Stefan R. Maxwell, MD, Chair, West Virginia Perinatal Partnership, MEDNAX 

Medical Group, Director NICU, Charleston Area Medical Center, Charleston, West Virginia, March 26, 2015, 

available at http://docs.housc.gov/meetings/IF/IP02/20 150326/1 03254/HHRG-114-IP02-Transcript-20 150326.pdf. 
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for accessing the databases integrate easily into clinical workflows.35 Another major component 

of these PDMPs is their interoperability with other states, particularly neighboring states. The 

level of interoperability with other states varies greatly and currently lacks uniformity. This is a 

weakness among the programs because the lack of data sharing allows patients to doctor shop 

across state Jines. Thus, a White House report issued in 2011 declared that "[a] major effort 

must be undertaken to improve the functioning of state PDMPs, especially regarding real-time 

data access by clinicians, and to increase the inter-state operability and communication."36 In 

addition, in many states, privacy concerns may limit the extent to which PDMP data can be used 

for law enforcement, public health, and research purposes. 

Some states arc providing out-of-state access to their PDMPs. For example, prescribers 

in states bordering Maryland (Delaware, the District of Columbia, West Virginia, northern 

Virginia, and southern Pennsylvania) can have access to the Maryland PDMP. Maryland 

currently shares with limited states, but will continue adding new connections. 37 In addition, 

pharmacists employed outside of Maryland, but who possess a Maryland pharmacist's license 

and dispense to Maryland residents are allowed to have access to the PDMP. 38 

States also vary with respect to their continuing medical education (CME) requirements 

for physicians. Some state licensing boards have established more robust CME requirements to 

improve prescribing practices among doctors in their state. California is an example of a state 

that has implemented stricter CME for prescribing doctors while other states may have very little 

required CME of their doctors. With the release of the CDC guidelines for primary care 

providers prescribing opioids for chronic non-cancer pain, states are looking to these guidelines 

as an important tool for curbing overprescribing of opioids. 39 

CDC experts have found that a few states have been able to change prescribing patterns 

by increasing prescriber use of their PDMPs.40 New York and Tennessee, for example, 

mandated prescriber use of the state PDMP in 2012.41 They subsequently used their PDMPs to 

document declines of75 percent and 36 percent, respectively, in their inappropriate use of 

multiple prescribers by patients.42 Other actions taken by states affecting prescribers that CDC 

experts believe are promising interventions are: developing or adopting existing guidelines for 

prescribing opioid pain relievers that can establish local standards of care that might bring 

35 National Governors Association (NGA), "Six Strategies for Reducing Prescription Drug Abuse," Issue Brief, 

September 2012, available at https://www.nga.orglcmslhome/nga-center-for-best-practices/centerpublications/page-hsps-publications/six-strategies-for-reducing-pres.html. 

36 Executive Office of the President of the United States, "Epidemic: Responding to America's Prescription Drug 

Abuse Crisis," Page 6, 2011, available at https://www.ncjrs.gov/pdffilesl/ondcp/rx_abuse_plan.pdf. 37 Maryland Department ofllealth and Mental Hygiene, PDMP FAQ, May 22,2017, available at 

https :1/www .crisphealth.org/wp-content/uploads/20 I 7/05/PDMP -FA Q-v3. pdf. 

38 !d. 39 National Governors Association, Governors' Priorities for Addressing the Nation's Opioid Crisis, February 18, 

20 16, available at https://www .nga.org/cmslhome/special/ coil-content/ governors-priorities-opioid.html. 40 L. Paulozzi, et al, 63 CDC Morbidity and Mortality Weekly Report (MMWR), "Vital Signs: Variation Among 

States in Prescribing ofOpioid Pain Relievers and Benzodiazepines- United States, 2012," 563, July 4, 2014, 

available at https:/lwww.cdc.gov/mmwr/preview/mmwrhtml/mm6326a2.htm. 

"Id. 

42 /d., citing Prescription Drug Monitoring Program Center of Excellence at Brandeis University. Mandating PDMP 

participation by medical providers: current status and experience in selected states. 
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prescribing rates more in line with current best practices, state Medicaid programs managing 

pharmacy benefits to promote cautious, consistent use of opioids, and enacting law to address the 

most egregious prescribing incidents.43 

The National Institute of Drug Abuse (NIDA) recently reported to the Subcommittee that 

in states with the most comprehensive initiatives to reduce opioid overprescribing, "the results 

have been encouraging."44 The state of Washington's implementation of evidence-based dosing 

and best-practice guidelines, as well as enhanced funding for the state's PDMP, helped reduce 

opioid deaths by 27 percent between 2008 and 2012.45 In Florida, new restrictions were imposed 

on pain clinics, new policies were implemented requiring more consistent use of the state PDMP, 

and the DEA worked with state law enforcement to conduct widespread raids on pill mills, which 

resulted in a dramatic decrease in opioid prescribing and in overdose death between 2010 and 

2012.46 A recent analysis by the CDC found that while the rate of prescribing has decreased 

since 2010, the prescribing rate in 2015 is still three times as high as it was in 1999 and the 

amount of opioids prescribed in 2015 was enough for every American to be medicated around 

the clock for three weeks.47 

It should be noted that methadone clinics are not covered by PDMPs; thus, physicians 

treating patients for pain cannot find out if the patient is on methadone, a potentially dangerous 

situation if an opioid medication is prescribed. 

Overdose prevention. State efforts to combat heroin abuse have varied from state to 

state. For example, several states have passed laws that generally provide immunity for victims 

and witnesses who act in good faith and seek medical assistance for an overdose; these laws are 

commonly referred to as "Good Samaritan Laws."48 States have also taken different approaches 

to expanding access to naloxone, with some states permitting third party prescribing by family 

and friends of individuals who are at high-risk of overdose, and others providing a standing order 

for community organizations who distribute naloxone to those who meet certain criteria.49 

Liability protection for prescribers who administer naloxone, as well as the nature of naloxone 

distribution programs may differ from one state to the other. 5° In addition, many states have 

established task forces, or have initiated new law enforcement efforts to combat heroin and 

prescription opioids. 51 

43 I d. For example, Florida enacted pain clinic legislation in 2010 and prohibited dispensing by prescribers in 2011. 44 Dr. Wilson Compton, Deputy Director, NIDA, responses to Questions for the Record, "Fentanyl: The Next Wave 

of the Opioid Crisis," March 21, 2017, available at 

http://docs.house.gov/meetings/IF/IF02/20 17032111 05739/HHRG-115-IFOZ-W state-Compton W -20170321-

SD028.pdf. 

45 Jd. citing G. Franklin eta/, A Comprehensive Approach to Address the Prescription Opioid Epidemic in 

Washington State: Milestones and Lessons Learned, 105 American Journal of Public Health 463 (2015). 46 /d. citing H. Johnson eta/, Decline in drug overdose death after state policy changes- Florida, 2010-2012,63 

MMWR 569 (2014). 47 Centers for Disease Control and Prevention, Vital Signs, Opioid Prescribing, July 6, 2017, available at 

https://www.cdc.gov/vitalsigns/opioids/index.html. 

48 NGA. Supra note 35. 49 !d. 

50 !d. 

5I !d. 
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Naloxone is still a prescription in all 50 states and the District of Columbia, although 

states are taking steps to make naloxone available to their communities. Forty states and the 

District of Columbia have passed laws that in some way expand the availability of naloxone. 5

2 

This is a dramatic increase compared to the 17 states that had such laws in 2013.53 

States' efforts in this area have also targeted the proper disposal of prescription drugs. 

The majority of people who abuse or misuse prescription drugs get them from friends and 

family; many of those drugs are leftover because a patient did not take the full amount of pills 

prescribed to them. These efforts have included public education on proper disposal and takeback activities, such as designating times and places where the public can safely dispose of 

unused prescription medication. 5

4 

The AnchorED program, developed in Rhode Island, matches overdose victims with peer 

recovery coaches to encourage treatment. 55 Michelle Harter, Manager of Operations for Anchor 

Recovery Community Centers, described how the program works: 

When a person is brought to a hospital emergency department with an opioid overdose, a 

member of the hospital staff calls the AnchorED hotline, which is available 24 hours a 

day, 7 days a week. The hotline connects the caller with a peer recovery coach, who is 

then dispatched to the hospital. Prior to the patient's release from the hospital, the 

recovery coach meets with the patient to discuss available recovery supports and 

resources in the community. Coaches can also provide education on overdose prevention, 

including information on how to obtain Narcan or Naloxone, a medication used to reverse 

an opioid overdose, and may provide additional resources and support to family members 

with the patient's approval. Upon the patient's release from the hospital, AnchorED staff 

follow-up with the patient for the next I 0 days, encouraging him or her to engage in 

recovery support services. 56 

Increasing access to MAT. In 2015, 8.4 million people needed treatment for drug 

addiction, yet four out of five did not receive it. 57 Forty-nine states and the District of Columbia 

have opioid treatment programs. All 50 states and the District of Columbia have physicians with 

waivers to prescribe buprenorphine. All three FDA-approved opioid treatment medications 

(methadone, buprenorphine, and naltrexone) are covered under the Medicaid Drug Rebate 

Program. The associated co-pays and authorization requirements vary from state to state. 

Twenty-six states reported in 2014 that they have expanded or made plans to expand MAT in the 

52 NASADAD, Overview of State Legislation to Increase Access to Treatment for Opioid Overdose, September 8, 

20 15, available at http://nasadad,org/20 l5/09/ovcrview-of-state-1egislation-to-increase-access-to-treatment-foropioid-overdose-3/. 53 Id 

54 ld 

55 Addiction Policy Forum, AnchorED Rhode Island, February 2, 2017, available at 

http://www .addictionpolicy .org/si ngle-post/20 17/02/02/ AnchorED-Rhode-Island, 56 Jd. quoting Michelle Harter, Manager of Operations, Anchor Recovery Community Centers. 57 Statement of Richard Baum, Acting Director of the Office of National Drug Control Policy (ONDCP) cited in A. 

Knopt; Report from NASADAD ONDCP to State Director: Increase Access to Treatment, June 2, 2017, available 

at http://atforum.com/20 I 7/06/report -nasadad-ondcp-state-directors-increase-access-treatment!. 
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two years prior. 5

8 Although the opioid addiction field recognizes addiction as a chronic, 

relapsing disease, some substance abuse counselors and administrators have been reluctant to 

embrace new technologies for its treatment. 59 At the same time, most physicians and other 

health care professionals receive little or no training in the treatment of addiction.60 As a result, 

adoption of MAT has been slow in some areas. 61 

Evidence and research on effectiveness of strategies. Very little evidence-based research 

exists on the most cost-effective and efficacious strategies for states to use in order to reduce 

opioid-related overdoses, however states are seeking guidance.62 Massachusetts, when 

developing its comprehensive state overdose prevention plan, turned to international sources to 

identify successful strategies.63 States have also been frustrated from not knowing the outcomes 

of their actions.64 Potential outcomes include: (1) Did physicians change their opioid prescribing 

practices after receiving webinars and other training; (2) Why do so many physicians train to 

become registered providers of buprenorphine for addiction, and then not treat any patients; and 

(3) When informed by letter that a patient has shown up on the PDMP with multiple opioid 

prescriptions, does the prescribing doctor take action, and, if so, what action?65 State 

representatives particularly requested studies that would look at overdose outcomes for opioiddependent patients who receive drug-free treatment compared to those receiving MA T.66 

III. ISSUES 

The following issues may be examined at the hearing: 

• What are the most critical data gaps facing state governments combating the opioid 

crisis? 

• How can data collection and reporting in the states be improved for responding to the 

opioid epidemic? 

• How could the federal response help bolster state PDMP programs? 

• How can states improve surveillance of the fentanyl epidemic? 

What initiatives and programs are the states utilizing that have been successful? 

• What barriers exist to enacting successful programs? 

58 NASADAD, 2014 update, Supra note 9, slide 45. 59 Statement of Mark G. Stringer, Director of Division of Behavioral Health, Missouri Department ofMental Health, 

available at http://dmh.mo.gov/ada/provider/medicationassistedtreatment.html. 

60 ld 

61 Jd 62 Successful strategies, Supra note 15, at 9. 63 Id 64 ld 

65 !d. 

66 /d. at 10. 
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What additional burdens is the opioid crisis putting on society, the healthcare system, the 

criminal justice system, the emergency response system, and state budgets? 

IV. STAFFCONTACTS 

If you have any questions regarding the hearing, please contact Alan Slobodin, Brittany 

Havens, or David Schaub of the Committee staff at (202) 225-2927,