U.S. GOVERNMENT PUBLISHING OFFICE

27–367 PDF WASHINGTON : 2018

CLOSE TO HOME: HOW OPIOIDS 

ARE IMPACTING COMMUNITIES 

JOINT HEARING 

BEFORE THE

SUBCOMMITTEE ON EARLY CHILDHOOD, 

ELEMENTARY, AND SECONDARY EDUCATION 

AND THE

SUBCOMMITTEE ON HIGHER EDUCATION AND 

WORKFORCE DEVELOPMENT 

OF THE

COMMITTEE ON EDUCATION 

AND THE WORKFORCE 

U.S. HOUSE OF REPRESENTATIVES 

ONE HUNDRED FIFTEENTH CONGRESS 

FIRST SESSION 

HEARING HELD IN WASHINGTON, DC, NOVEMBER 8, 2017 

Serial No. 115–28 

Printed for the use of the Committee on Education and the Workforce 

( 

Available via the World Wide Web: www.gpo.gov/fdsys/browse/ 

committee.action?chamber=house&committee=education 

or 

Committee address: http://edworkforce.house.gov 

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(II) 

COMMITTEE ON EDUCATION AND THE WORKFORCE 

VIRGINIA FOXX, North Carolina, Chairwoman 

Joe Wilson, South Carolina 

Duncan Hunter, California 

David P. Roe, Tennessee 

Glenn ‘‘GT’’ Thompson, Pennsylvania 

Tim Walberg, Michigan 

Brett Guthrie, Kentucky 

Todd Rokita, Indiana 

Lou Barletta, Pennsylvania 

Luke Messer, Indiana 

Bradley Byrne, Alabama 

David Brat, Virginia 

Glenn Grothman, Wisconsin 

Steve Russell, Oklahoma 

Elise Stefanik, New York 

Rick W. Allen, Georgia 

Jason Lewis, Minnesota 

Francis Rooney, Florida 

Paul Mitchell, Michigan 

Tom Garrett, Jr., Virginia 

Lloyd K. Smucker, Pennsylvania 

A. Drew Ferguson, IV, Georgia 

Ron Estes, Kansas 

Karen Handel, Georgia 

Robert C. ‘‘Bobby’’ Scott, Virginia 

Ranking Member 

Susan A. Davis, California 

Rau ́l M. Grijalva, Arizona 

Joe Courtney, Connecticut 

Marcia L. Fudge, Ohio 

Jared Polis, Colorado 

Gregorio Kilili Camacho Sablan, 

Northern Mariana Islands 

Frederica S. Wilson, Florida 

Suzanne Bonamici, Oregon 

Mark Takano, California 

Alma S. Adams, North Carolina 

Mark DeSaulnier, California 

Donald Norcross, New Jersey 

Lisa Blunt Rochester, Delaware 

Raja Krishnamoorthi, Illinois 

Carol Shea-Porter, New Hampshire 

Adriano Espaillat, New York 

Brandon Renz, Staff Director 

Denise Forte, Minority Staff Director 

SUBCOMMITTEE ON EARLY CHILDHOOD, ELEMENTARY, AND 

SECONDARY EDUCATION 

TODD ROKITA, Indiana, Chairman 

Duncan Hunter, California 

David P. Roe, Tennessee 

Glenn ‘‘GT’’ Thompson, Pennsylvania 

Luke Messer, Indiana 

David Brat, Virginia 

Tom Garrett, Jr., Virginia 

Karen Handel, Georgia 

Jared Polis, Colorado 

Ranking Member 

Rau ́l M. Grijalva, Arizona 

Marcia L. Fudge, Ohio 

Suzanne Bonamici, Oregon 

Susan A. Davis, California 

Frederica S. Wilson, Florida 

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(III) 

SUBCOMMITTEE ON HIGHER EDUCATION AND WORKFORCE 

DEVELOPMENT 

BRETT GUTHRIE, Kentucky, Chairman 

Glenn ‘‘GT’’ Thompson, Pennsylvania 

Lou Barletta, Pennsylvania 

Luke Messer, Indiana 

Bradley Byrne, Alabama 

Glenn Grothman, Wisconsin 

Elise Stefanik, New York 

Rick W. Allen, Georgia 

Jason Lewis, Minnesota 

Paul Mitchell, Michigan 

Tom Garrett, Jr., Virginia 

Lloyd K. Smucker, Pennsylvania 

Ron Estes, Kansas 

Susan A. Davis, California 

Ranking Member 

Joe Courtney, Connecticut 

Alma S. Adams, North Carolina 

Mark DeSaulnier, California 

Raja Krishnamoorthi, Illinois 

Jared Polis, Colorado 

Gregorio Kilili Camacho Sablan, 

Northern Mariana Islands 

Mark Takano, California 

Lisa Blunt Rochester, Delaware 

Adriano Espaillat, New York 

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C O N T E N T S 

Page 

Hearing held on November 8, 2017 ........................................................................ 1 

Statement of Members: 

Davis, Hon. Susan, A., Ranking Member, Subcommittee on Higher Education and Workforce Development ............................................................. 8 

Prepared statement of ............................................................................... 9 

Guthrie, Hon. Brett, Chairman, Subcommittee on Higher Education and 

Workforce Development ................................................................................ 6 

Prepared statement of ............................................................................... 7 

Polis, Hon. Jared, Ranking Member, Subcommittee on Early Childhood, 

Elementary, and Secondary Education ....................................................... 3 

Prepared statement of ............................................................................... 5 

Rokita, Hon. Todd, Chairman, Subcommittee on Early Childhood, Elementary, and Secondary Education ............................................................. 1 

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

Statement of Witnesses: 

Cox, Dr. David, Partner, Superintendent, Allegany County ......................... 41 

Prepared statement of ............................................................................... 43 

Miner, Ms. Toni, Family Support Partner ...................................................... 18 

Prepared statement of ............................................................................... 20 

Robinson, Mr. Tim, Founder and CEO, Addiction Recovery Care ............... 11 

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

Wen, Dr. Leana, Commissioner, Baltimore City Health Department ......... 27 

Prepared statement of ............................................................................... 29 

Additional Submissions: 

Adams, Hon. Alma, a Representative in Congress from the State of North 

Carolina: 

Article: President Trumps Says He Wants to Stop the Opioid Crisis, 

His Actions Don’t Match ....................................................................... 77 

Courtney, Hon. Joe, a Representative in Congress from the State of 

Connecticut: 

Graph ......................................................................................................... 80 

Ms. Davis: 

Article: Medicaid: States’ Most Powerful Tool to Combat the Opioid 

Crisis ....................................................................................................... 82 

Mr. Polis: 

Article: Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010 ................................................. 90 

Letter dated May 2, 2017, The American Health Care Act Vote .......... 97 

Questions submitted for the record by Fudge, Hon Marcia a Representive in Congress from the State of Ohio ......................................... 102 

Dr. Wen’s responses to questions submitted for the record ................... 104 

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CLOSE TO HOME: HOW OPIOIDS ARE 

IMPACTING COMMUNITIES 

Wednesday, November 8, 2017 

House of Representatives 

Committee on Education and the Workforce, 

Subcommittee on Early Childhood, Elementary, 

and Secondary Education 

joint with 

Subcommittee on Higher Education and Workforce Development 

Washington, D.C. 

The subcommittees met, pursuant to call, at 10:30 a.m., in Room 

2175, Rayburn House Office Building, Hon. Todd Rokita [chairman 

of the subcommittee on Early Childhood, Elementary, and Secondary Education] presiding. 

Present: Representatives Rokita, Guthrie, Barletta, Messer, 

Byrne, Brat, Grothman, Stefanik, Allen, Lewis, Mitchell, Smucker, 

Handel, Polis, Davis, Courtney, Fudge, Bonamici, Adams, 

DeSaulnier, Blunt Rochester, Krishmamoorthi, and Espaillat. 

Also Present: Representatives Foxx, Scott, and Shea-Porter. 

Staff Present: Courtney Butcher, Director of Member Services 

and Coalitions; Michael Comer, Press Secretary; Kathlyn Ehl, Professional Staff Member; Rob Green, Director of Workforce Policy; 

Amy Raaf Jones, Director of Education and Human Resources Policy; Jonas Linde, Professional Staff Member; Nancy Locke, Chief 

Clerk; Kelley McNabb, Communications Director; Jake 

Middlebrooks, Legislative Assistant; James Mullen, Director of Information Technology; Krisann Pearce, General Counsel; James 

Redstone, Professional Staff Member; Mandy Schaumburg, Education Deputy Director and Senior Counsel; Michael Woeste, Press 

Secretary; Tylease Alli, Minority Clerk/Intern and Fellow Coordinator; Jacque Chevalier, Minority Director of Education Policy; 

Mishawn Freeman, Minority Staff Assistant; Carolyn Hughes, Minority Director Health Policy/Senior Labor Policy Advisor; Stephanie Lalle, Minority Digital Press Secretary; Richard Miller, Minority Labor Policy Director, Udochi Onwubiko, Minority Labor Policy 

Counsel; and Veronique Pluviose, Minority Staff Director. 

Chairman ROKITA. A quorum being present the Subcommittee on 

Early Childhood, Elementary, and Secondary Education and the 

Subcommittee on Higher Education and Workforce Development 

will come to order. 

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2 

Today we will have opening statements from the chairman and 

the ranking members of our two subcommittees. And, with that, I 

recognize myself for an opening statement. 

Good morning and welcome to today’s joint subcommittee hearing with our colleagues from the Subcommittee on Higher Education and Workforce Development. I would like to thank our panel 

of witnesses and our members today for joining on this important 

discussion on opioid abuse and addiction that is taking a toll on the 

Nation as we see every night on our television sets, if not from 

other places. 

The opioid crisis is having a profound impact on families, jobs, 

communities, and the economy, and that is why we are here today. 

The issue of drug overdoses due to opioids is only getting worse as 

death related opioids have quadrupled since 1999. And we have 

some fast facts up on the screen detailing all of this. In fact, in 

2016 alone there were approximately 64,000 fatal drug overdoses. 

This means that the opioid crisis is claiming the lives of 175 Americans per day. These figures are horrifying and sad, not only for the 

country’s future, but for communities who are losing parents, husbands, wives, teachers, and, yes, students. 

Additionally, the opioid epidemic knows no age, gender, educational, credential, or class distinction. This crisis is touching all 

of us. Some of the most unfortunate stories have to do with children whose lives have been forever changed by this public health 

emergency. Between 2000 and 2014 the number of babies born 

drug-dependent increased by 500 percent. In my home State of Indiana a recent pilot program from the State Department of Health 

found that about one in five infants assessed at hospitals around 

the State tested positive for opioids, 20 percent of our babies in Indiana. 

More and more children are being placed into foster care or are 

cared for by another relative due to parental drug abuse. According 

to a recent analysis nearly a third of the children who entered foster care in the U.S. in 2015 alone did so at least partially because 

of parental drug abuse. 

It is one thing to read the statistics and accounts in the news 

about communities in the midst of an opioid crisis, but these accounts do not compare to the real voices we need to hear from in 

order to understand this crisis. 

I had the opportunity to host a school safety summit last week 

in my district. One of the two significant topics was the opioid crisis. I heard from Dustin Noonkester, one of the founders of Brady’s 

Hope. Dustin lost his son to opioid overdose. This organization is 

a resource to members of the community on how to spot abuse, how 

to address opioid misuse, and how families can help one another 

treat opioid addiction. Brady was a good student, he was off to a 

military career and he had 2 weeks to go before boot camp when 

his life was claimed by this. And it happened over the course of one 

summer. Started meeting with kids that he hadn’t before, and one 

thing led to another and he was 2 weeks short of getting to boot 

camp where his life would have been saved. 

The epidemic can no longer be ignored and it is important that 

we hear from those who are on the ground and facing tragic truths 

of this opioid crisis every day. The witnesses we have gathered 

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here today understand the opioid problem better than any of us 

here in Washington perhaps because they see it and they fight it 

in their communities nearly every hour of every day. So I am 

pleased this committee can come together to understand this true 

public health emergency and its impact on communities across the 

United States. 

And with that, it is now my pleasure to yield to the ranking 

member of the Subcommittee on Early Childhood, Elementary, and 

Secondary Education, and my friend, Congressman Polis for his 

opening remarks. 

[The information follows:] 

Prepared Statement of Hon. Todd Rokita, Chairman, Subcommittee on 

Early Childhood, Elementary, and Secondary Education 

Good morning, and welcome to today’s joint subcommittee hearing with our colleagues from the Subcommittee on Higher Education and Workforce Development. 

I’d like to thank our panel of witnesses and our members for joining today’s important discussion on opioid abuse and addiction that is taking a toll on the nation. 

The opioid crisis is having a profound impact on families, jobs, communities, and 

the economy, and that is why we’re here today. 

The issue of drug overdoses due to opioids is only getting worse as deaths related 

to opioids have quadrupled since 1999. In 2016 alone, there were approximately 

64,000 drug overdoses. This means that the opioid crisis is claiming the lives of 175 

Americans per day. 

These figures are horrifying and sad not only for the country’s future, but for communities who are losing parents, husbands, wives, teachers, and students. 

Additionally, the opioid epidemic knows no age, gender, educational credential, or 

class distinction. This crisis is touching all Americans. 

Some of the most unfortunate stories have to do with the children whose lives 

have been forever changed by this public health emergency. 

Between 2000 and 2014, the number of babies born drug-dependent increased by 

500 percent. In my home state of Indiana, a recent pilot program from the state 

Department of Health found that about 1 in 5 infants assessed at hospitals around 

the state tested positive for opiates. 

More and more children are being placed into foster care or are cared for by another relative due to parental drug abuse. According to a recent analysis, nearly a 

third of the children who entered foster care in the U.S. in 2015 did so at least partially because of parental drug abuse. 

It is one thing to read the statistics and accounts in the news about communities 

in the midst of the opioid crisis, but these accounts do not compare to the real voices 

we need to hear from in order to understand this crisis. 

I had the opportunity to host a school safety summit last week in my district. One 

of the two big topics was the opioid crisis. I heard from Dustin Noonkester, one of 

the founders of ‘‘Brady’s Hope.’’ Dustin lost his son to opioid overdose. This organization is a resource to members of the community on how to spot abuse, how to address opioid misuse, and how families can help one another treat opioid addiction. 

These are the stories that give me hope that this crisis can be overcome. 

This epidemic can no longer be ignored, and it is important that we hear from 

those who are on the ground and facing the tragic truths of the opioid crisis every 

day. 

The witnesses we have gathered here today understand the opioid problem better 

than any of us here in Washington, because they see it, and fight it, in their communities. 

I am pleased this committee can come together to understand this true public 

health emergency and its impact on communities across the United States. 

Mr. POLIS. Thank you, Chairman Rokita, for holding this very 

important hearing. As we know, the opioid crisis cuts across State 

lines, across party lines, it affects each of us in our congressional 

districts, and many of us in our neighborhoods and families. In my 

home State of Colorado the rate of drug overdose deaths since 2000 

has more than doubled. The impact of the opioid crisis needs to enCEWDOCROOM with DISTILLER

4 

gender a strong bipartisan response from Congress, and I am 

thankful that we are beginning to have an important discussion 

through our joint subcommittee this morning. 

Addressing the opioid crisis should be a top priority for the 

United States Congress, for our States, for our local governments. 

Last year Congress passed, and President Obama signed, a law 

with a new set of policies that helped restructure our prevention 

and treatment efforts to better respond to substance abuse problems. Unfortunately, it did not provide the funding necessary to effect change and this crisis. We need to match our rhetoric with action and with real resources. That means understanding the role 

that many programs fill in crafting a holistic approach to the crisis, 

programs within the jurisdiction of this committee and programs 

within the jurisdiction of other committees. For example, early 

learning programs, helping care for children who experienced a 

trauma of having addicted parents. 

Public schools are on the front line in the delivery and coordination of services for students impacted by addiction. Congress should 

fully fund programs authorized under ESSA to ensure that teachers and school leaders are equipped to be ready and willing partners in addressing the opioid addiction and opioid use disorder. 

We can’t overstate the importance of access to health coverage in 

this discussion. Medicaid and the Affordable Care Act have been 

improved and expanded to provide healthcare coverage to many 

who lacked it. In my home State alone 400,000 Coloradans have access to health insurance through the Medicaid expansion alone. 

Finally, as we address the opioid addiction crisis we have to remember that many communities were suffering from substance 

abuse disorders long before this current crisis. While the level and 

number of deaths has increased, addiction has always been a problem in our communities, in both rural communities, in urban and 

suburban communities, in every congressional district. 

We need to think critically about alternative options to addressing this crisis. For some communities, such as veterans, as we see 

in Colorado, cannabis should be considered as a replacement therapy for chronic pain management. Research suggests that implementing medical cannabis programs can reduce pain management 

medications associated with mortality, like opioid prescription 

drugs. It also can improve pain management and significantly reduce healthcare costs. In fact, a recent Journal of American Medical Association study analyzed all 50 States and found that those 

with medical marijuana laws had 25 percent fewer fatal opioid 

overdoses than States that did not have those laws between 1999 

and 2010. 

At this time I ask unanimous consent to place this study in the 

record. 

Chairman ROKITA. Without objection. 

Mr. POLIS. Recently I was honored to present a Purple Heart to 

a veteran who lives in my district. This 29-year-old man put his life 

on the line for our country and he told me he uses medical marijuana for all of his pain management and sleep issues and he has 

been able to successfully take himself off of the prescription opioids 

that the VA prescribed. His girlfriend also bore witness to the fact 

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that he is much better for it. And these are the kinds of stories and 

data that we need to look at in addressing the opioid crisis. 

It is encouraging that Congress is taking this time to discuss the 

issue, and it is important that this committee is staying involved 

in the Federal response to the opioid epidemic. I know that members on both sides of the aisle will have thoughtful questions and 

ideas both to address the under resourcing of programs and to 

make sure that we can address this issue in a comprehensive manner. 

I want to thank our panelists for taking the time to testify today. 

I look forward to hearing from everybody. 

And I yield back the balance of my time. 

[The information follows:] 

Prepared Statement of Hon. Jared Polis, Ranking Member, Subcommittee 

on Early Childhood, Elementary, and Secondary Education 

Thank you, Chairman Rokita, for holding this important hearing today. 

As each of us here knows, the opioid crisis is one that cuts across state lines and 

affects each of our congressional districts. In Colorado, the rate of drug overdose 

deaths since 2000 has more than doubled. The impact of the opioid crisis isn’t a partisan issue, and our response shouldn’t be either. I’m thankful we’re able to discuss 

this important issue at our joint subcommittee hearing this morning. 

Addressing the opioid crisis should be a top priority for Congress. Last year, Congress passed and President Obama signed into law a set of policies that helped restructure our prevention and treatment efforts to better respond to substance use 

disorder. It did not, however, provide the funding necessary to affect the change 

needed to address this crisis. 

To truly respond to this epidemic, we have to walk the walk, and without funding, 

we will not be doing enough for our constituents to move the needle. 

We must match our rhetoric with action and real money. That means understanding the role that many programs fill in crafting a holistic approach to this crisis – programs within the jurisdiction of this Committee. For example, early learning programs help care for children who experience the trauma of having addicted 

parents. Public schools are on the front line in the delivery and coordination of services for students impacted by addiction. Congress must fully fund programs authorized under ESSA to ensure that teachers and school leaders are equipped to be 

ready partners in addressing opioid addiction and opioid use disorder. 

We also cannot overstate the importance of access to health coverage in this discussion. Medicaid and the Affordable Care Act have dramatically improved and expanded access to health coverage, a vital part of responding to opioid use disorder 

and ensuring that Americans can get both needed preventive care and treatment. 

In my state alone, over 400,000 Coloradans have access to health insurance now 

through the Medicaid expansion. 

But for the last ten months and counting, we have wasted precious time trying 

to repeal the Affordable Care Act and Medicaid expansion. This is especially cruel 

because 1.6 million people with substance abuse disorders now have access to treatment precisely because 31 states expanded Medicaid as part of the ACA. 

Even last week, House Republicans advanced a bill that would cut billions from 

the Affordable Care Act’s Public Health and Prevention Fund, which helps states 

prevent and respond to the opioid epidemic. 

Finally, as we address the opioid addiction, we have to remember that many communities were suffering from substance use disorders long before Congress woke up 

to this issue. Addiction affects both rural and urban communities and every Congressional district. Efforts to address addiction through treatment, instead of incarceration and instead of punishment, should apply to all communities as well. 

We also need to think critically about alternative options to addressing this crisis. 

For some communities, such as veterans, cannabis should be considered as a replacement therapy for chronic pain treatment. Early research suggests implementing medical cannabis programs could reduce pain management medications associated mortality, improve pain management, and significantly reduce health care 

costs. In fact, a recent Journal of American Medical Association study analyzed all 

50 states and found that those with medical marijuana laws had 25% fewer fatal 

opioid overdoses than states that had no such laws between 1999 and 2010. 

At this time, I ask unanimous consent to place this study into the record. 

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6 

Recently, I was honored to present a Purple Heart to a veteran who lives in Boulder, Colorado. This 29 year old young man put his life on the line for our country. 

He told me that he uses medical marijuana for all his pain and sleep issues, and 

has been able to take himself off all opioids the VA had prescribed. His girlfriend 

testified to the fact that he’s so much better for it. These are the type of stories we 

need to listen to. 

It’s encouraging that Congress is taking time to discuss this issue and it is important that this Committee stay very involved in the federal response to the opioid 

epidemic. I am hopeful that we can address it through increased funding for effective, under-resourced programs and locally-driven state and federal initiatives that 

are built on evidence-based practices, not stigma or misperceptions about proven 

treatment strategies. 

I thank the panelists for taking the time to testify today. I look forward to hearing 

from you. 

Thank you, and I yield back the balance of my time. 

Chairman ROKITA. I thank the gentleman. I will now yield to the 

chairman of the Subcommittee on Higher Education and the Workforce for his opening remarks. 

Chairman GUTHRIE. Thank you, Chairman Rokita. I want to echo 

the chairman’s appreciation for the witnesses here today. 

The opioid crisis is having a profound impact on my constituents 

as well. And I am sure the stories we hear from the witnesses 

today resonate with many of the stories I have heard in Kentucky. 

The opioid crisis is a public health emergency and Congress must 

continue working to face the epidemic that has had an impact on 

all aspects of our society. Unfortunately, a problem as widespread 

as the opioid epidemic, which has already had an impact of 11.5 

million Americans has also taken a devastating toll on local economies and the national economy as a whole, and we are only beginning to see more clearly. As the opioid health emergency continues 

to worsen, the economy will continue to suffer. Data from CDC 

analyzing opioid overdose deaths by age groups in 1999 and 2015 

show that people most likely to die of an opioid overdose are between the ages of 25 and 39 years old. These are people who have 

entire lives, careers, and untold contributions to make to their communities and our country ahead of them. Numbers are important, 

but people with their own stories are at the heart of this crisis. 

To Americans who live in some of the areas hardest hit by the 

opioid crisis, including my home State of Kentucky, they are seeing 

their coworkers, bosses, friends, and family members suffer from 

this horrible affliction. The administration and Congress are coming together to identify community-based solutions to combat this 

crisis. But the day-to-day hard work fighting this outbreak is already being done on the ground by the people that face this issue 

every day. The witnesses we have gathered here today have seen 

the impact the opioid crisis is having on their communities every 

day and it is important we hear the stories of how it specifically 

impacted them as individuals, as well as their friends, families, 

and coworkers. 

When it comes to finding solutions for the workforce development 

needs and creating more good paying jobs, we look to State and 

local entities who are leading by example and the opioid crisis is 

no different. Our witnesses before us have learned a lot in their 

communities about how to spot opioid abuse and implement successful forms of treatment. It is important we hear about these exCEWDOCROOM with DISTILLER

7 

periences in order to inform the congressional response to this crisis. 

At this committee we talk a lot about how we are addressing the 

shortage of skilled workers across the country and how we want to 

empower people to build the lives they want for themselves. For 

many workers ensnared in this epidemic, it is critical that they receive the treatment they need to help them return to the workforce 

and to find a good job once they are drug free. We also have to acknowledge that the opioid crisis resulting in too many lives ending 

far too soon and we have to look at ways to stop it. 

I would like to welcome Tim Robinson here today from my home 

State of Kentucky. I know that Tim and I were discussing earlier 

Louisa, where he is from, is probably closer to this capital building 

than it is to my hometown of Bowling Green, but it just shows how 

broad and wide and diverse Kentucky is and the problem is pervasive through all economic groups, all people, and it is something 

that we are struggling with. I know that the dean of the Kentucky 

delegation, Hal Rogers, has been a strong supporter of what you do 

in Louisa and Martin County and all through Appalachia, and also 

across the Commonwealth. 

So I certainly appreciate you being here today and your testimony in a few minutes. I appreciate the witnesses for appearing 

and I look forward to hearing your testimony. 

And I yield back. 

[The information follows:] 

Prepared Statement of Hon. Brett Guthrie, Chairman, Subcommittee on 

Higher Education and Workforce Development 

Thank you Subcommittee Chairman Rokita, and I want to echo the Chairman’s 

appreciation for the witnesses joining us at today’s hearing. The opioid crisis is having a profound impact on my constituents as well, and I’m sure the stories we will 

hear from the witnesses today will resonate with many of the stories I have heard 

in Kentucky. 

The opioid crisis is a public health emergency and Congress must continue working to face the epidemic that has had an impact on all aspects of our society. 

Unfortunately, a problem as widespread as the opioid epidemic, which has already 

had an impact on over 11.5 million Americans, also has taken a devastating toll on 

local economies and the national economy as a whole, as we’re only beginning to 

see more clearly. 

As the opioid public health emergency continues to worsen, the economy will continue to suffer. 

Data from the CDC analyzing opioid overdose deaths by age groups in 1999 and 

2015 showed that the people most likely to die of an opioid overdose are between 

the ages of 25 and 39 years old. 

These are people who had entire lives, careers, and untold contributions to make 

to their communities and our country ahead of them. 

Numbers are important, but people with their own stories are at the heart of this 

crisis. 

To Americans who live in some of the areas hardest hit by the opioid crisis, including my home state of Kentucky, they are seeing their coworkers, bosses, friends, 

and family members suffer from this horrible affliction. 

The administration and Congress are coming together to identify communitybased solutions to combat this crisis, but the day-to-day hard work fighting this outbreak is already being done on the ground by the people that face this issue every 

day. 

The witnesses we have gathered here today have seen the impact the opioid crisis 

is having on their communities every day, and it’s important we hear their stories 

of how it has specifically impacted them as individuals, as well as their friends, families, and coworkers. 

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8 

When it comes to finding solutions for workforce development needs, and creating 

more good-paying jobs, we look to state and local entities who are leading by example, and the opioid crisis is no different. 

Our witnesses before us have learned a lot in their communities about how to spot 

opioid abuse and implement successful forms of treatment. It is important we hear 

about these experiences in order to inform the Congressional response to the crisis. 

At this Committee, we talk a lot about how we are addressing the shortage of 

skilled workers across the country, and how we want to empower people to build 

the lives they want for themselves. For many workers ensnared in this epidemic, 

it is critical that they receive the treatment they need to help them return to the 

workforce, and find a good job once they are drug-free. We also have to acknowledge 

that the opioid crisis is resulting in too many lives ending far too soon, and we have 

to look at ways to stop it. 

I’d like to welcome Tim Robinson from my home state of Kentucky who is testifying here today. Tim is the founder and CEO of Addiction Recovery Care in Louisa, 

Kentucky, which is a network of 13 addiction treatment centers. Thank you for the 

work you are doing to serve your community and the Commonwealth. I look forward 

to hearing your testimony today. 

I appreciate the witnesses for appearing before this committee, and look forward 

to hearing how they have responded in their own communities to combat this crisis. 

Chairman ROKITA. Thank you, Chairman Guthrie, and I yield to 

the ranking member of the Subcommittee on Higher Education & 

the Workforce, Congresswoman Davis, for her opening remarks. 

Ms. DAVIS. Thank you. Thank you, Mr. Chair. As my colleagues 

have said, and I want to point how much in sync I think that we 

are on many of these issues, the opioid crisis has greatly impacted 

our communities. In 2015, more than 33,000 Americans died of an 

opioid overdose and more than 2 million individuals had an opioid 

use disorder. 

In California, more people die from drug overdose each year than 

from auto accidents. And that is why it is so important to continue 

to invest in the Federal programs that promote addiction recovery 

and treatment. Across the country and in California Medicaid has 

been vital to addressing the opioid epidemic. Adults with Medicaid 

coverage are about three times more likely to have received treatment as inpatients and almost twice as likely to have received outpatient treatment than privately insured adults. As Ranking Member Polis has noted, in our efforts to combat this epidemic it is vital 

that we invest in the systems, systems and the programs that support healthy families in communities, and this means a strong 

workforce. And I am pleased that my colleague has also echoed 

that interest. 

As we have seen with past drug epidemics that have rocked our 

communities the opioid epidemic has a strong link to jobs. According to recent research an estimated 25 percent of the drop in women’s workforce participation between ’99 and 2015 can be attributed 

to the increase in opioid prescriptions, and for men that number is 

about 20 percent. And we know that when adults, particularly 

women, are not working it has significant impacts on the economic 

security of their families and communities. 

For example, job loss for a parent can mean lower wages and unemployment for their children later in life. It is particularly important to note the relationship between opioid abuse and unemployment. This means that individuals may fall out of the job force due 

to their dependence on opioids or it may be that they become addicted after job loss. We must help people remain employed and 

breakdown the barriers for individuals struggling with opioid abuse 

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9 

problems as they seek to reenter the workforce. And this means rethinking employer drug testing policies and using a more thoughtful approach for those in the criminal justice system. We must also 

leverage our workforce development systems to ensure that our 

workers, especially those in communities impacted by trade and 

technology, have access to the skills development that they need. 

Integrating job training into treatment efforts is also key. Linking 

these services can be crucial for helping people reenter the workforce and improve the probability of long-term recovery efforts. 

Now, we know that the Trump administration has declared a nationwide public health emergency to address the opioid crisis. And 

as part of this declaration the administration has directed the Department of Labor to use dislocated worker grants to, ‘‘Help workers who have been displaced from the workforce because of the 

opioid crisis subject to available funding.’’ Unfortunately, we will 

not be hearing from anyone from the administration today to get 

a better understanding of their plans. And that perspective would 

have been very helpful I believe for understanding why they would 

encourage the use of these grants but also, at the same time, call 

for a 40 percent cut to their funding. 

As I am sure many of my colleagues today will underscore, substance abuse and its impacts on communities is nothing new. And 

if there is anything that we have learned from past failures in addressing this problem it is that resources do matter. In addition to 

investing in treatment and recovery programs at the back end, we 

must also address the poverty, the violence, poor healthcare, and 

inadequate education that can be contributing factors to unhealthy 

communities. 

I look forward to hearing about what investments are needed to 

address a crisis of this magnitude without robbing other vital programs, such as family support services and job training that support families and communities. 

I want to thank the witnesses for being here today. And I certainly want to congratulate Dr. Leana Wen on her newest addition 

to her family. I look forward to your testimony and hearing more 

about how we can address and help communities impacted by the 

opioid abuse exist its crisis. 

Thank you very much for being here. 

[The information follows:] 

Prepared Statement of Hon. Susan A. Davis, Ranking Member, 

Subcommittee on Higher Education and Workforce Development 

As my colleagues have said, the opioid crisis has greatly impacted our communities. In 2015, more than 33,000 Americans died of an opioid overdose, and more 

than 2 million individuals had an opioid use disorder. In California, more people die 

from drug overdose each year than from auto-accidents. 

That’s why it’s so important to continue to invest in the federal programs that 

promote addiction recovery and treatment. 

Across the country and in California, Medicaid has been vital to addressing the 

opioid epidemic. Adults with Medicaid coverage are about three times more likely 

to have received treatment as inpatients, and almost twice as likely to have received 

outpatient treatment, than privately insured adults. 

As Ranking Member Polis noted, in our efforts to combat this epidemic, it’s vital 

that we invest in the systems and programs that support healthy families and communities. This means a strong workforce. As we’ve seen with past drug epidemics 

that have rocked our communities, the opioid epidemic has a strong link to jobs. According to recent research, an estimated 25 percent of the drop in women’s workCEWDOCROOM with DISTILLER

10 

force participation between 1999 and 2015 can be attributed to the increase in 

opioid prescriptions. For men, that number is about 20 percent. 

And we know that when adults, particularly women, aren’t working, it has significant impacts on the economic security of families and communities beyond the immediate loss of income. For example, job loss for a parent can translate into lower 

wages and difficulty remaining in the labor market for their children later in life. 

It’s particularly important to note the relationship between opioid abuse and unemployment. This means that individuals may fall out of or have difficulty staying 

in the job force due to their dependence on opioids or may become addicted after 

job loss. 

We must help individuals remain employed and break down barriers to individuals with substance use disorders re-entering the workforce. This means rethinking 

employer drug testing policies and using a more thoughtful approach to employment 

for those with involvement in the criminal justice system. We must also leverage 

our workforce development system to ensure our nation’s workers, especially those 

in communities or industries impacted by trade and technology, have access to the 

jobs and skills development they need. 

Integrating job training into recovery and treatment efforts is also key. Linking 

these services can be crucial for helping people re-enter the workforce and improve 

the probability of recovery efforts long term. 

So I look forward to hearing about how our current system can be improved, including ideas on providing key services in the same location, or best practices for 

partnerships between the workforce development and health systems. 

Now, we know that the Trump Administration has declared a Nationwide Public 

Health Emergency to address the opioids crisis. As part of this declaration, the administration has directed the Department 

of Labor to use Dislocated Worker Grants ‘‘to help workers who have been displaced from the workforce because of the opioid crisis, subject to available funding.’’ 

Unfortunately, we will not be hearing from anyone from the administration today 

to get a better understanding of their plans. That perspective would have been key 

in understanding why they would encourage the use of these grants while calling 

for a 40 percent cut to this funding. 

As I’m sure many of my colleagues today will underscore, substance abuse and 

its impacts on communities is nothing new. And if there’s anything we’ve learned 

from our nation’s past failures in addressing substance abuse issues and supporting 

impacted communities, it is that resources matter. 

So I look forward to hearing about what investments are needed to address a crisis of this magnitude without robbing other vital programs, such as family support 

services and job training, that support healthy families and communities, 

I would like to thank the witnesses for being here today. I also want to congratulate Dr. Leana Wen on the newest addition to her family. 

I look forward to your testimony and hearing more about the how we can help 

communities impacted by the opioid abuse crisis. 

Thank you. 

Chairman ROKITA. And the gentlelady yields back. Pursuant to 

committee rule 7C all members of the subcommittees will be permitted to submit written statements to be included in the permanent hearing record. And without objection the hearing record will 

remain open for 14 days to allow statements, questions for the 

record, and other extraneous material reference during the hearing 

to be submitted for the official record. 

We will now turn to the introduction of our distinguished panel 

of witnesses, and I yield to Chairman Guthrie to introduce our first 

witness. 

Chairman GUTHRIE. First I would like to introduce Mr. Tim Robinson as the founder and CEO of Addiction Recovery Care, and it 

has 13 organizations that are networked through eastern and central Kentucky, and I talked about him in my previous remarks. So 

welcome, and I look forward to your testimony. 

I yield back to the chairman. 

Chairman ROKITA. Thank the gentleman. I yield to Ranking 

Member Polis for the introduction of the second witness. 

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11 

Mr. POLIS. Thank you. I am honored to introduce Toni Miner. 

Miss Miner is a fellow Coloradan from Jefferson County, Colorado, 

which I have the honor of representing much of. She is currently 

working as a family support partner with the Jefferson County 

Child and Youth Leadership Commission. Prior to this position 

Toni Miner served as a family advocate with the Child and Youth 

Leadership Commission. She also worked as a parent partner for 

5 years. In addition to mentoring families she also provides training to caseworkers on the ground. Court-appointed special advocate 

volunteers, she helps train as well. Miss Miner has been active in 

the Child Welfare System team decision-making meetings and 

serves on the Domestic Violence and Child Protection Services Coordinating Council. Welcome to our committee. 

Chairman ROKITA. Thank you. I thank the gentleman and I will 

resume introducing our witnesses. Dr. Leana Wen is the commissioner of health for the city of Baltimore, Maryland. And Dr. David 

Cox is the superintendent of schools in Allegany County, Maryland. 

Welcome to all the witnesses. 

[Witnesses sworn] 

Chairman ROKITA. And let the record reflect that all witnesses 

answered in the affirmative. 

Before I recognize each of you to provide your testimony let me 

briefly explain our lighting system, and it is a reminder for us up 

here as much as it is for you. You will each have 5 minutes to 

present your testimony. And when you begin the light in front of 

you will be turned green, when 1 minute is left it will be yellow, 

and when the time is expired the light will turn red. At that point 

I will ask you to wrap up your remarks. After everyone has testified members up here will each have 5 minutes to ask questions 

of each of you. 

And so with that, let me recognize Mr. Robinson for 5 minutes. 

Thank you, sir. 

TESTIMONY OF TIM ROBINSON, FOUNDER AND CEO, 

ADDICTION RECOVERY CARE 

Mr. ROBINSON. Good morning. My name is Tim Robinson. I’m the 

founder and CEO of Addiction Recovery Care. As already mentioned, there were more deaths due to overdoses than car accidents 

last year, making addiction a public health crisis. The addiction 

epidemic is not just costing us thousands of lives, it is also threatening our economic security as employers struggle to find and retain employees who can pass the drug screen. In September, our 

Kentucky Chamber of Commerce CEO wrote an op-editorial that 

called addiction the number one economic concern in our State. 

Everyone is looking for a silver bullet to the addiction crisis and 

there is no single intervention that alone is a silver bullet. Addiction recovery requires a whole person approach which starts with 

identifying those in addiction, intervening with treatment, investing in their economic future through education and workforce development, and inspiring them to join the effort to do for others 

what was done for me, help another person discover their destiny 

and work out their recovery. 

I am thankful for the opportunity to speak to you because recovery is personal to me. I started drinking in my first year of law 

CEWDOCROOM with DISTILLER

12 

school at the University of Kentucky to cope with my mom passing 

away from terminal lung cancer during finals. For the next 8 years 

I almost drank myself to death. Ten years ago, while I was a prosecuting attorney in Lawrence County, Kentucky, a court bailiff who 

was a recovering alcoholic and a pastor led me to a spiritual awakening at my desk. He became my sponsor, but he also became my 

pastor. And he carried me for a while and he walked with me and 

poured his recovery and his faith into me. Addiction recovery is 

personal to me because I am a survivor. 

Two years later, I resigned as prosecutor, gave my law practice 

to my law partner, and in 2010, opened Karen’s Place, a recovery 

center for women in eastern Kentucky. Since opening our first center we’ve realized that addiction is a disease that devastates all aspects of a person’s life and that a holistic approach is crucial for 

long-term recovery. Addiction impacts someone’s mind, body, spirit, 

and their purpose. And we’ve been determined to treat addiction 

medically, clinically, spiritually, and vocationally. And though our 

centers are led by an addictionologist and are nationally accredited, 

Alcoholics Anonymous has taught us that a spiritual awakening is 

the foundation of lasting recovery. In that tradition we’ve developed a spirituality program that inspires hope and offers those 

coming out of an addiction an opportunity to understand that God 

is the source to find hope, forgiveness, and redemption. Much like 

hospice care centers and Catholic healthcare systems we employ 

chaplains and pastoral counselors who work alongside our clinical 

staff. And though we consider the faith-based aspect of our centers 

to be the heart of our success, our spirituality program does not replace medical and evidence-based clinical practices. It’s in addition 

to them and makes our care more comprehensive. 

Treating the whole person has led to great success. Our clients 

stay in treatment for 60 to 70 days, compared to a national average 

of 25 to 30 days. This objective measure shows our residential centers to be twice as effective as the national average. 

Readmission is another objective measure. Those in addiction 

who relapse most often return to the same center 40 percent of the 

time. Less than 10 percent of our clients readmit. 

As we have built our treatment network we have had a great 

need for addiction treatment workers and we have created an internship program and issued a challenge. Clients who intern with 

us until their 1-year clean mark would be guaranteed a job. Today 

70 of Addiction Recovery Care’s 200 employees are graduates of our 

program. We formalized their internship program, becoming a 

State-certified peer support specialist training program. A peer 

support specialist is a recovering addict who has at least 1 year of 

sobriety. After a 40-hour class they become a Medicaid billable behavioral health practitioner and can provide those in addiction 

with peer support. 

SOAR, an economic initiative in Kentucky’s Fifth Congressional 

District, connected us with the Workforce Board Eastern Kentucky 

Concentrated Employment Program and their executive director, 

Jeff Whitehead. With the Workforce Board providing funding we 

partnered with Sullivan University to transform our internship 

program into a workforce development opportunity. Our program 

graduates become State-certified and earn a college certificate. 

CEWDOCROOM with DISTILLER

13 

There’s also soft skills development and professionalism in workplace ethics. They receive other skills such as CPR, first aid, and 

using a medical record, electronic medical record. 

In 2016, we started our first class and 16 peer support specialists 

graduated in May of 2017. Out of the 16 graduates, 14 of them 

were at least 8 months clean and sober today, working full-time, 

paying taxes, and transitioning off of public assistance. These 14 

people now have great purpose and meaningful careers. We now 

have more than 50 others in the academy today. 

Prior to the academy 40 percent of our clients moved to our transitional program. After starting the academy, now 70 percent of our 

clients now choose to continue treatment, which means treatment—— 

[The statement of Mr. Robinson follows:] 

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14 

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Insert offset folio 1 here 27367.001

Good morning. My name is Tim Robinson, Founder and CEO of Addiction Recovery Care. 

There were more deaths due to overdoses than to car accidents last year making addiction a 

public health crisis. The addiction epidemic is not just costing us thousands of lives, it is also 

threatening our economic security as employers struggle to find and retain employees who can 

pass a drug screen. In September, our Kentucky Chamber of Commerce CEO wrote an Op 

Editorial that called addiction the number one economic concern in our state. 

Everyone is looking for a silver bullet to our addiction crisis. There is no single intervention that 

alone is a silver bullet. Addiction recovery requires a whole person approach which starts with 

identifying those in addiction, intervening with treatment, investing in their economic future 

through education and workforce development, and inspiring them to join the effort to do for 

others what was done for me: help another person discover their destiny and walk out their own 

recovery. 

I am thankful for the opportunity to speak to you because recovery is personal to me. I started 

drinking in my first year of law school at the University of Kentucky to cope with my mom 

passing away from terminal lung cancer during finals. For the next eight years, I almost drank 

myself to death. Ten years ago, while I was a prosecuting attorney in Lawrence County, 

Kentucky, a court bailiff who was a recovering alcoholic and pastor, led me to a spiritual 

awakening at my desk. He became my sponsor and my pastor. He carried me for a while; He 

walked with me and poured his recovery and his faith into me. Addiction recovery is personal to 

me because I am a survivor. 

Two years later, I resigned as prosecutor, gave my practice to my law partner, and in 2010 

opened Karen's Place, a recovery center for women in Eastern Kentucky. Since opening our 

first center, we have realized that addiction is a disease that devastates all aspects of a 
15 

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Insert offset folio 2 here 27367.002

person's life, and that a holistic approach is crucial for long-term recovery. Addiction impacts 

someone's mind, body, spirit, and purpose. We have been determined to treat addiction 

medically, clinically, spiritually, and vocationally. 

Though our treatment centers are led by an addictionologist and are nationally accredited, 

Alcoholics Anonymous has taught us that a spiritual awakening is the foundation of lasting 

recovery. In that tradition, we have developed a spirituality program that inspires hope and 

offers those coming out of addiction an opportunity to understand that God is the source to find 

hope, forgiveness and redemption. Much like hospice care centers and Catholic healthcare 

systems, we employ chaplains and pastoral counselors who work alongside of our clinical staff. 

Though we consider the faith-based aspect of our centers to be the heart of our success our 

spirituality program does not replace medical and evidence-based clinical practices - it is an 

addition to them and makes our care more comprehensive. 

Treating the whole person has led to great success. Our clients stay in treatment for 60-70 days 

compared to a national average of 25-30 days. This objective measure shows our residential 

centers to be twice as effective as the national average. Readmission is another objective 

measure. Those in addiction who relapse most often return to the same center 40% of the time. 

Less than 10% of our clients readmit. 

As we built our treatment network we have had a great need for addiction treatment workers. 

We created an internship program and issued a challenge: clients who interned with us until 

their 1 year clean and sober mark would be guaranteed a job. Today, seventy of Addiction 

Recovery Care's two hundred employees are graduates of our centers and products of our 

internship program. 
16 

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We formalized our internship program by becoming a state certified Peer Support Specialist 

(PSS) training program. A Peer Support Specialist is a recovering addict who has at least one 

year of sobriety. After a forty-hour class, they become a Medicaid billable behavioral health 

practitioner and can provide those in addiction with peer support. 

SOAR, an economic development initiative in Kentucky's 5th Congressional District, connected 

us with the workforce board Eastern Kentucky Concentrated Employment Program, and their 

Executive Director, Jeff Whitehead. With the workforce board providing funding, we partnered 

with Sullivan University to transform our internship and peer support program into a workforce 

development opportunity. Our program graduates become state certified and earn a college 

certificate. There is also soft skills development in professionalism and workplace ethics. They 

receive other skills such as CPR, first aid, using an electronic medical record, and HIPAA 

compliance that are transferable to other career paths especially in the medical field. In just one 

year, a person in addiction can go from an IV needle heroin user to employed and earning a 

living helping others follow their path of recovery. 

In October 2016, we started our first class, and sixteen Peer Support Specialists graduated in 

May 2017. Out of the sixteen graduates, fourteen of them are at least eighteen months clean 

and sober, working full time, paying taxes and are transitioning off of public assistance. These 

fourteen people now have great purpose and meaningful careers. We now have over fifty more 

recovering addicts in the academy today. Some of the graduates have even been promoted to 

middle management, and others are continuing their education for careers such as counseling. 

Prior to the Academy, 40% of our clients moved on to our transitional program. After starting the 

Academy, 70% of our clients now choose to continue treatment, which means treatment 

motivation has almost doubled for those who have been given a meaningful career opportunity. 

It has exponentially multiplied the success of our treatment outcomes as 85% of our first 
17 

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academy class are at least 18 months clean and sober and employed as productive citizens 

today. 

Vocational education as a part of the continuum of care for addiction treatment drives greater 

levels of success due to three major reasons: 1 ). When someone enters treatment and knows 

there is a second chance career path it inspires hope and increases treatment motivation, 2). 

The 12th step of AA informs us that sharing our recovery is one of the foundations of long-term 

sobriety. This concept suggests that finding purpose in helping others strengthens your recovery 

and helps you to continue to heal from addiction; and Finally, 3). Experiencing the dignity of 

work gives recovering addicts who have reentered the workforce a positive self-image, 

confidence and helps them to establish career goals and plan for their future. A great example 

of this is Vanessa Keeton. She was an IV-needle user who entered one of our residential 

centers and completed our internship program. She became a treatment center director while 

earning a college degree and purchasing her first home. Recently, she resigned as our HR 

director to focus on the business she started that now supports her family. 

We are also seeing success in other vocational education programs such as our maintenance 

internship. We are in the process of adding automotive, culinary arts and welding certificate and 

apprentice programs. 

The hope of America is not merely surviving. The hope of America is an opportunity to flourish. 

That is what our brothers and sisters in addiction need; an opportunity. An opportunity for 

treatment and vocational skill building that leads to a meaningful career path, and when the 

opportunity is given ... ! have seen us not just survive, but thrive. 
18 

Chairman ROKITA. Thank you, Mr. Robinson. I appreciate that 

very much. Miss Miner, you are recognized for 5 minutes. 

TESTIMONY OF TONI MINER, FAMILY SUPPORT PARTNER 

Ms. MINER. Good morning. I wish to thank the Committee on 

Education and Workforce for providing me with this opportunity to 

share my perspectives with you today. 

My name is Toni Miner and I am a birth mother of three children, Mercedes, Jonell, and Spencer, and the legal guardian for my 

two grandchildren, Angel and Tavin. And we live in Jefferson 

County, Colorado. 

My story is that of a mother who was heavily ruled by her addiction to methamphetamine. My meth use became daily in 1996 and 

continued until 2002. Unfortunately, my two beautiful daughters 

had to live through my active meth addiction. I didn’t think my 

meth use really had an effect on my girls as I was providing a roof 

over their head, food on the table, and clothes on their backs. But 

what my daughters wanted and needed more than anything in this 

world was a clean and protective parent. 

Now, during this time of my meth use I received many criminal 

charges that were due to my use. I had burned all my bridges and 

had no support and I really didn’t see any way out of my addiction. 

Then I found out that I was pregnant. I had no idea what I was 

going to do or how to get clean, but knew that I had to. I had hit 

my rock bottom. Because I was finally ready to get clean I was able 

to take the first steps and stop my meth use with the support of 

my amazing caseworker and probation officer, who did not judge 

me, but encouraged me. My daughters returned to my care the day 

that I was released with the understanding that I would comply 

with the probation requirements and complete intensive outpatient 

treatment. 

Today, almost 16 years later, I am still clean and actively involved in a recovery program. I have rebuilt relationships with 

family, made many new friends, and have many supports in my 

life. Unfortunately, my poor choices did take a toll on my two 

daughters who eventually became addicted to drugs. Today as a 

kinship care provider, I can make sure that my grandchildren are 

safe from any future harm. 

Besides working to ensure that my own family is strong and safe, 

I also work to help families who are impacted via child welfare and 

struggling with addiction. Working as a family support partner in 

Jefferson County, Colorado, and also working in our Problem-Solving Court, which is our family drug court in Jefferson County, I am 

able to educate and empower struggling families with the skills 

and knowledge to navigate multiple systems and advocate for their 

own supports and connections within the community. I also work 

with families through facilitating a circle of parents and recovery 

group, which are specialized parent support groups designed to 

build protective factors in families, addressing substance abuse and 

the impact of trauma. 

Through my personal experience and my work with families I am 

able to provide you with recommendations that I believe will help 

strengthen families, especially during the opioid crisis. 

CEWDOCROOM with DISTILLER

19 

One, collaboration across agencies is a must to ensure that children and families are getting the right service they need efficiently. 

Families interact with multiple systems with their own requirements, processes, and it is essential that these systems work together to ensure families get the help they need. Law enforcement, 

child welfare, schools, mental health, housing, courts, hospitals, 

employers, substance abuse programs, and methadone clinics 

should all be part of the process to help strengthen families struggling with addiction. 

Two, focus on the whole family. Addiction is a family disease. 

And if the whole family is not treated and provided the right supports history will continue to repeat itself, as it did within my own 

family. Families at risk respond best to supportive and strengthsbased approaches. Both my child welfare caseworker and probation 

officer believed that I could change and become the strong, resilient, and healthy parent that I am today. 

Three, educate our communities and families regarding substance abuse. Public service announcements must talk about link 

between substance abuse and mental health and include available 

resources for treatment. Children must be educated, especially prevention education of the children of adult addicts. 

Four, partner with parents to work with other families before, 

during, or after involvement with the child welfare and court systems. We need to partner with parents like me who have learned 

from their own experiences and can help other families navigate 

complex systems and access services. Many States and local jurisdictions are implementing parent partner programs and finding 

this can be a very useful strategy to effectively engage parents in 

their child welfare cases and treatment. These voices are also important as they educate policymakers, administrators, frontline 

workers, and others interacting with families. 

If we implement these recommendations and invest in families, 

the sky is the limit in what we can achieve together. 

Thank you for your time. 

[The statement of Ms. Miner follows:] 

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20 

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Testimony for 

u.s. House of Representatives Committee on Education and the Workforce 

Joint Subcommittee on Early Childhood, Elementary, and Secondary 

Education and Higher Education and Workforce Development 

Washington D. C., November 8, 2017 

Submitted by Toni Miner, Family Support Partner 

Introductory Remarks 

• My name is Toni Miner and I am a birth mother of three children and the legal 

guardian for my two grandchildren. I reside in Jefferson County, Colorado. I am 

pleased to be here today as a strong parent advocate who believes that families 

must be supported. 

• I wish to thank the Committee on Education and Workforce and the Subcommittees 

on Early Childhood, Elementary, and Secondary Education and Higher Education and 

Workforce Development for providing me with this opportunity to share my 

perspectives with you today. Thank you to Chairmen Rokita, Guthrie, and to Ranking 

Members Polis and Davis. 

• I am here to talk with you about some insights that I have gained from my own life 

experiences with addiction and the child welfare system and my work as a family 

support partner and facilitator for Circle of Parents in recovery group. 

• I want to briefly share my story and my work as a family support partner. I am 

making four recommendations that I believe will help to create strength in families. 

1. Collaboration across agencies. 

2. Focus on the family as a whole. 

3. Educate our communities and families regarding substance abuse. 

4. Partner with parents to work with other families before, during or after 

involvement with the child welfare and court systems. 

Background- My Story 

As I share a little of my story, you will see why I am urging you to act on these 

recommendations. 

• I grew up in a home with violence and alcohol. To cope with this during my early 

years, I also got involved in using drugs and alcohol. I continued to use off and on 

throughout my twenties. Fall of 1996 is when everything changed for me and my 

daughters. We had suffered a traumatic event in our life and I went to meth to 

solve how I was feeling, or to not feel. My meth use became daily for me that year. 

Now I didn't see how it was affecting my daughters because I still took them to 

1 
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school, provided a roof over their head, food on the table and clothes on their back. 

My disease convinced me that I was being a great Mom by providing for them. The 

one thing that they needed more than anything else in their life was a sober and 

protective parent. I couldn't give that to them. As time went on and my addiction 

grew deeper, I was no longer getting them to school like I should have been. Even 

when I was there, I wasn't there emotionally. Meth was giving me what I needed, 

(so I thought) but in turn it was taking everything away from my daughters, and 

from me. I loved them so very much and wanted to be better, but I couldn't, I was 

stuck in my disease. There wasn't a day that went by that I didn't love my 

daughters, as a matter of fact, on most days I used more to not feel the guilt and 

the pain of what my addiction (disease) had done to my family. 

• Unfortunately, my two daughters had to live through my problems with substance 

abuse. As I struggled with my drug addiction issues my daughters were frequently 

moved in and out of placements with relatives and friends. 

• Then I got raided by the police for possession and went to jail. I was devastated 

and didn't know how to get clean. I continued to make bad choices until I found out 

I was pregnant. So there I was - pregnant, scared, dealing with social services and 

facing a prison term of more than 30 years. By this time my daughters were eight 

years old and 14 years old. Thankfully I could plan in advance for my daughters to 

go into kinship care while I served my jail sentence. 

• That's when I met a child welfare case worker who truly changed my life. Instead of 

telling me what a loser I was, he asked how he could help, how he could partner 

with me to get my children back and to stay out of prison! I looked at him in 

disbelief and I doubted he meant a word of what he said. But when he showed up 

in court to beg the judge to give me a chance, I looked at him and cried! Here was 

someone who truly cared about what happened to me! 

• The judge was lenient and only sentenced me to 90 days in jail and six years of 

probation. Due to my good behavior, I only had to serve 60 days. My daughters 

were returned to my care the day that I was released with the understanding that I 

would comply with the probation requirements and complete intensive outpatient 

treatment. Along with continued work and support from my caseworker. 

• This case worker became an amazing source of strength for me. He encouraged me 

to re-establish my relationship with my mom. I needed my mom to help me get 

clean. I believe that we all need our Mom in our life. I didn't have mine at the time 

due to my addiction and the pain that I had caused her. I had hurt her emotionally 

and financially. I needed my Mom to believe in me again, to help me with my girls, 

for moral support and help with transportation. To my surprise, my mom was there 

for me and still loved me very much and continues to do so to this very day. 

• Getting clean was one of the hardest things that I have ever had to do. I had to 

attend different classes, complete regular drug screening and participate in many 

2 
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appointments. I was given an opportunity to heal and knew that I would lose my 

children for good if I did not comply with all the requirements. Even though I was 

receiving the supports that I needed, my daughters were not. My daughters had 

suffered very severe trauma due to my addiction. I believe this contributed to their 

own addictions, as their trauma was never dealt with. 

• Today, almost 16 years later, I am still clean and actively involved in a recovery 

program. I have rebuilt relationships with family. I have made many new friends. I 

have lots of supports in my life - church, my children's school, my neighbors and of 

course, my family. Each one helps me stay strong and determined to never again 

go where I once was. Not every day is perfect for me. Some days are very hard but 

I know now that I can make it. 

• As I look back on the life I led then and the one I lead now, I realize that coming in 

contact with the judicial and child welfare system was not as bad as I thought it was 

at the time. I have learned a lot. My case worker and probation officer were so 

supportive and empowering. I doubt I would have survived as well without them. 

They showed me that creating and supporting strong parent partnerships was a 

critical part of their work in helping families be successful. They trusted me. They 

believed that I could change that I could grow and that I could be a strong, 

resilient and healthy parent. 

• Unfortunately, my poor choices did take a toll on my two daughters. Both girls 

followed in my footsteps and became addicted to drugs. My oldest daughter 

continues to abuse drugs and also has major mental health issues. When they were 

younger they didn't get services or education about how to understand their parents 

addiction (a disease) and strategies and steps to take to prevent their own 

addiction. They also didn't get the appropriate mental health services they needed 

after experiencing traumatic events. 

• When I learned that my oldest daughter was unable to properly care for her two 

children, I brought them into our home and became a permanent kinship care 

provider for them. Today I am actively parenting my son Spencer together with my 

two grandchildren, Angel and Tavin. As a kinship care provider, I can make sure 

that my grandchildren are safe from any future harm. Part of my decision to be a 

kinship caregiver is because I wanted to avoid my grandchildren going into foster 

care. 

• Kinship care providers are such an important piece to the opioid epidemic that we 

are facing. We open our homes and our hearts to the children of the addicts. By 

doing so children can still have the family connection that is so important to their 

success. Kinship care providers also need support from the community such as 

mental health centers, social services, financial, schools, respite care and any other 

systems that may be involved with the family. It is a lot for kin to take responsibility 

of children, but it can be successful if given the supports needed to ensure these 

placements are stable and supported. It's not easy being a kinship caregiver. With 

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the opioid epidemic, states and counties are seeing an enormous rise in the number 

of kinship caregivers, many of whom are much older than I am who are raising 

young children, and they need help to care for these children. 

My Work as a Family Support Partner, Family Advocate, Educator and 

Collaborator on Systems Change for families with addiction and child welfare 

involvement 

My life experiences have provided me with some amazing opportunities to help other 

families in various ways such as: 

• Working as a Family Support Partner in Jefferson County, Colorado to educate 

families and help them advocate for themselves on how to get their needs met .. A 

Family Support Partner is a parent or caregiver who has faced and overcome many 

barriers. Because of their unique perspectives and personal experiences, they are in 

a position to assist other families facing similar challenges in navigating multiple 

systems and locating community resources. The goal of the family support partners 

is to empower each family with the skills and knowledge to advocate for their own 

supports and connections within the community, and identify the best ways to 

ensure their voice is heard by the professionals they work with. 

• A Family Support Partner empowers families by providing 

impartial support during meetings (e.g. family engagement meetings, team decision 

meetings, school, court, therapy, etc.); assistance in identifying community and 

natural supports; and support planning to prepare for future crisis and emotional 

support. 

I worked with a family who suffered from opioid addiction and helped them to find 

the light within themselves and navigate these systems. I attended court regularly 

with the mother and attended school meetings for the children. The mother 

expressed her gratitude to me for how I was supporting not just her but also her 

family, as addiction is a family disease. 

Facilitating a Circle of Parents in Recovery Group: 

o The model is based on the following network standards to guide group 

implementation: 

o The groups utilize the mutual self-help support model. 

o An educated group facilitator and parent leader facilitate the support groups. 

o Open groups meet regularly and are offered at no cost to any participant. 

o Children's Program or Childcare Available 

o The group facilitator, parent leader and other group members are available to 

one another between group meetings. 

o Group members are assured of confidentiality in a non-judgmental 

environment within the limits of the law. 

o Community resource information that supports healthy family development is 

available to all group members. 

o Builds positive peer support networks 

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o Prevents relapse and sustains recovery 

o Prevents future child abuse or neglect. 

We have partnered with Betty Fords Children's Center to educate our children group 

facilitators on their curriculum. This curriculum really helps children aged 6 to 14 

years old learn that their parent's addiction and recovery is not their responsibility. 

The also learn about addiction itself. They learn about their feelings in regard to 

their parents addiction and how to heal and work through them. The children learn 

how to share their feelings, and that they are not alone. 

• Facilitating Family Leadership Training Institute (FLTI) to help families become 

engaged in civics, and identify their leadership skills in their communities. 

• Educating caseworkers, Court Appointed Special Advocate (CASA) volunteers and 

kinship care providers by sharing my story to help them understand that even with 

some of the toughest families that they come across there is indeed hope. We have 

conversations about partnering with the families that they are working with, to get 

to know the families so they can work collaboratively and to help them understand 

that there is not only one way to work with families, because every family is unique. 

• Serving on various state and local committees such as: 

o Collaborative Management State Steering Committee 

o Child and Youth Leadership Commission, Juvenile Justice Subcommittee 

o Child and Youth Leadership Commission, Human Trafficking Subcommittee 

o Child and Youth Leadership Commission, Education Subcommittee 

• Collaborating with numerous advisory groups such as the Casey Family Programs 

Birth Parent Advisory Committee (BPAC) and the Birth Parent National Network 

(BPNN) to help make system reform and support families. 

Recommendations. 

Based on my own experiences with my family and now as a Family Support Partner, I 

am recommending the following: 

1. Collaboration across agencies is a must to ensure that children and 

families are getting the right services they need efficiently. 

• Families interact with multiple systems with their own requirements, processes and 

it is essential that these systems work together to ensure families get the help they 

need. Law enforcement, child welfare, schools, mental health, housing, courts, 

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hospitals, employers, substance abuse programs and methadone clinics should all be 

part of the process to help strengthen families struggling with addiction. 

2. Focus on the whole family 

• Provide support groups for the whole family. Addiction is a family disease and if 

the whole family is not treated history will continue to repeat itself, as it did 

within my own family 

• Circle of Parents are specialized parent support groups designed to build 

protective factors in families. Examples of current focus areas include: Recovery 

Support, Parents and Families affected by Substance Use, and Parents and 

Families Impacted by Trauma. 

• For example, parents need to hear that everyone has frustrations and problems 

and that it's okay for them to reach out for help without it creating more 

problems for them. Parents get isolated and think they are the only ones feeling 

overwhelmed or too ashamed to ask for help. 

• Speaking from my own experiences, families at risk respond best to supportive 

and strengths-based approaches. I really appreciated the support and the trust 

that I received from my child welfare case worker and probation officer. They 

both believed that I could change and become the strong, resilient and healthy 

parent that I am today. 

3. Educate our communities and families regarding substance abuse. 

• Public Service Announcements that talk about substance abuse and mental 

health and how they often go together, including available resources for 

treatment. 

• Share success stories of the families that are successful. 

• We must educate our children of their own risk of being addicted. I talk with 

my children about it often, because it is not something that they think about 

every day. We need to have a prevention education for the children of adult 

addicts. 

4. Partner with parents to work with other families before, during or after 

involvement with the child welfare and court systems. 

• We need to partner with parents like me who have learned from their own 

experiences and can help other families navigate effectively access services and 

complex systems. Many states and local jurisdictions are implementing parent 

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partner programs and finding that this can be a very useful strategy to effectively 

engage parents in their child welfare cases and treatment. 

• I would have benefitted greatly from having a parent partner who could have 

talked with me and provided me with support and assistance to navigate these 

systems. 

• The perspectives of parents like me are important if we are to truly achieve 

better outcomes for children, families and communities. Policymakers, 

administrators, front line workers, and others interacting with families need to 

listen and understand the experiences and needs of families directly as they 

make decisions that will impact lives. 

If we implement these recommendations and invest in families, the sky's the limit in 

what we can achieve together. I strongly urge you to implement these 

recommendations. 

Thank you for your time and I welcome any questions that you may have. 

7 
27 

Chairman ROKITA. Thank you, Ms. Miner. Dr. Wen, you are recognized for 5 minutes. 

TESTIMONY OF LEANA WEN, COMMISSIONER, BALTIMORE 

CITY HEALTH DEPARTMENT 

Dr. WEN. Chairmen Rokita and Guthrie, Ranking Members Polis 

and Davis, thank you for calling this hearing. I am here as an 

emergency physician and the Health Commissioner of Baltimore 

where overdose claims the lives of two residents a day and where 

addiction affects every aspect, from the workforce to our youngest 

children. 

Baltimore has a three pillar approach. First, we focus on saving 

lives by making the opioid antidote, naloxone, or Narcan, available 

to everyone. Not only have we equipped paramedics and the police, 

I issued a blanket prescription to all 620,000 of our residents. Since 

2015, every day individuals have saved the lives of 1,500 people. 

But we have a problem. Our city is out of funds to purchase 

naloxone, forcing us to ration and make decisions every day about 

who can receive the antidote. At a time of a public health crisis it 

is unconscionable that we are being limited in our ability to save 

lives. 

Our second pillar is to increase on-demand addiction treatment. 

The science is clear: addiction is a disease, treatment exists, and 

recovery is possible. Nationwide only 11 percent of patients with 

addiction get treatment. Imagine if only 1 in 10 people with cancer 

can get chemotherapy. Yet, my patients come to the ER asking for 

help and I tell them they must wait weeks or months. I have had 

patients overdose and die while they are waiting because our system failed them. 

In Baltimore, we started a 24/7 phone hotline that includes immediate access to a social worker or addiction specialist. We receive 

1,000 calls a week. We are starting a 24/7 ER for addiction and 

mental health. 

We believe that treating addiction as a crime is unscientific, inhumane, and ineffective. That’s why we have programs like LEAD, 

Law Enforcement Assisted Diversion, where individuals caught 

with small amounts of drugs will be offered treatment instead of 

incarceration. 

Law enforcement to stop the trafficking of drugs is important as 

is more judicious prescribing by doctors. However, reducing the 

supply of drugs will not work unless there is equal attention to 

curbing demand through providing treatment. That means the Federal Government should do everything possible to expand insurance coverage. One in three patients with addiction depend on 

Medicaid. If Medicaid were gutted and they were to lose coverage 

many more would overdose and die. Other patients on private insurance could find themselves without access to treatment if addiction is no longer required to be part of their health plan. 

Essential health benefits are called essential for a reason, and all 

insurance plans should cover preventive care and evidence-based 

addiction services, including the gold standard, which is medication-assisted treatment. Block grants should not replace insurance 

coverage because no disease can be treated through grants alone. 

CEWDOCROOM with DISTILLER

28 

We on the front lines know what works. We have done a lot with 

very little, but this is a national emergency. We desperately need 

new resources, not repurposed funding that will divert from other 

critical priorities. These funds should be given directly to communities of greatest need. Cities and counties have been fighting the 

epidemic for years and we should not have to jump through additional hoops, like competing for grants and having funding pass 

from the States to cities. That will cost time and more lives. 

Our third approach is to reduce stigma and prevent addiction. 

We have trained all of our nurses in our 180 public schools to save 

lives with naloxone and we now have addiction and mental health 

services in 120 of our schools. Opioid addiction affects those even 

younger. More than half of children who die in Baltimore have a 

parent or a caregiver with addiction and mental health concerns. 

Home visiting for pregnant women helps to identify families in 

need of treatment and support. This is a key component of our citywide strategy, B’more for Healthy Babies, which has successfully 

reduced infant mortality by nearly 40 percent in 7 years. The 

opioid crisis requires proven public health approaches spanning the 

entire life course. 

In closing, we know what works. We need support from the Federal Government with three actions. First, protecting and expanding insurance coverage to get to on-demand treatment for the disease of addiction. Second, allocating additional funding to areas 

hardest hit by the opioid epidemic directly to local jurisdictions. 

And third, supporting early interventions for women, children, and 

families. By the time this hearing is over at least 10 more people 

will have died from overdose. I urge Congress to commit the additional resources needed to save lives and reclaim our communities. 

I thank you for calling this hearing. 

[The statement of Dr. Wen follows:] 

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CITY OF BALTIMORE 

CATHERINE E. PUGH, Mayor 

HEALTH DEPARTMENT 

Leana S. Wen, M.D., M.Sc., FAAEM 

Commissioner of Health 

1001 E. Fayette St. 

TO: 

FROM: 

RE: 

Baltimore, MD 21202 

ll.c.ill.t:b..commissjoner@baltimorecity gov 

Tel: 410-396-4387 

November g<h, 2017 

Committee on Education and the Workforce: Joint Subcommittee on Early 

Childhood, Elementary. and Secondary Education and Higher Education and 

Workforce Development 

Dr. Leana Wen, Baltimore City Health Commissioner 

Testimony: "Close to Home: How Opioids are Impacting Communities" 

Subcommittee Chairmen Rokita and Guthrie, Subcommittee Ranking Members Polis and Davis, 

Chairwoman Foxx, Ranking Member Scott, and Distinguished Members of the Committee and 

Subcommittees: 

Thank you for inviting me to testify on the epidemic of opioid abuse that is sweeping across our 

country. Opioid abuse is a public health emergency that is claiming the lives and livelihoods of 

our citizens. It affects the entire life course, and touches upon every aspect of our communities, 

from public safety to the workforce to children and families. 

As an emergency physician, I have witnessed firsthand the effects of substance addiction, 

including treating hundreds of patients who have overdosed on opioids. I remember well my 

patient, a 24-year old mother of two who came to the emergency room (ER) nearly every week 

requesting addiction treatment. She would be told there was nowhere for her to go that day or the 

next, and would be otlered an appointment in three weeks' time. Because she lacked housing and 

other supportive services. she would relapse. One day, her family found her unresponsive and 

not breathing. By the time she arrived in the ER, it was too late for us to save her, and she died. 

I always think back to my patient now: she had come to us requesting help, not once, not twice, 

but over and over again. dozens of times. Because we do not have the treatment capacity, people 

looking to us for help fall through the cracks, overdose, and die. Why has our system failed her, 

just as it is failing so many others who wish to get help for their addictions? How does our 

system continue to fail her family? Nationwide, 2.5 million children are raised by grandparents 

and other relatives, with parents missing-and that number is rising, in part because of the 

epidemic of opioid addiction. After a long period of decline, the number of children in foster care 

is rising f{Jr the same reason. 

My colleagues and I frequently felt fi·ustrated by the limitations of clinical practice; by the time 

patients made their way to us, society had missed significant opportunities to intervene further 

upstream in that individual's life. We treat addiction ditTerently than we treat any other illness. 

Would we ever tell someone who has had a heart attack to wait three weeks to get treatment? 

Despite scientific studies showing that addiction is a disease and that recovery is possible, many 
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still question why people "choose" a lifestyle of using drugs. Would we impose such stigma on 

any other disease? How can we intervene early-not just when someone is dying from an 

overdose, but much earlier, to prevent addiction in the first place and to provide treatment for 

people the moment they need it? These are the experiences that drove me to public health: a 

desire to tackle the epidemic of addiction at a community-level, and in doing so, save lives while 

also redefining our societal approach to the treatment of addiction. 

As the Health Commissioner of Baltimore City, I work every day with my dedicated staff at the 

Health Department and partners across our city to prevent overdose and stem the tide of 

addiction. These partners include our local behavioral health authority, Behavioral Health 

System Baltimore, whose board I serve on as the Chair. I am encouraged that the approach to the 

opioid epidemic is shifting away from the rhetoric of the "war on drugs" and instead focusing on 

treating addiction as a disease. But while our rhetoric is changing, fimding for treatment lags 

behind. Of the more than 25 million people who abuse some form of drug, only about I in I 0 is 

able to receive treatment. Ensuring those struggling with addiction can access treatment ondemand requires urgent funding and support from the federal government. 

The Opioid Problem in Baltimore 

With over 21,000 active heroin users in Baltimore and far more who misuse and abuse 

prescription opioid medications, opioid addiction and overdose is a critical health priority in our 

city. In 2016, 694 people died from drug and alcohol overdose, which is more than twice the 

number of people who died from homicide. Drug addiction impacts our entire community and 

ties into nearly every issue facing our city including crime, unemployment, poverty, and poor 

health. It claims lives every day and affects those closest to us-our neighbors, our friends, and 

our family. 

Baltimore's Response to Addiction and Overdose 

Our work in Baltimore is built on three pillars: 

• First, we have to prevent deaths from overdose and save the lives of people suffering 

from addiction. 

• Second, we must increase access to quality and effective on-demand treatment and 

provide long-term recovery support. 

Third, we need to increase education and awareness in order to reduce stigma and 

encourage prevention and treatment. 

l. Preventing deaths from overdose 

In 2015, I declared opioid overdose a public health emergency and led the charge in one of the 

most aggressive opioid overdose prevention campaigns across the country. 

a. The most critical part of the opioid overdose prevention campaign is expanding access to 

naloxone- the lifesaving drug that reverses the effect of an opioid drug overdose. 

Naloxone is sate, easily administered, not addictive, and nearly 100% effective at 

reversing an overdose. In my clinical practice as an emergency physician, I have 

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administered naloxone to hundreds of patients and have seen how someone who is 

unresponsive and about to die will be walking and talking within seconds. 

Since 2003, Baltimore City has been training drug users on using naloxone through our 

Staying Alive Program. In 2015, we successfully advocated for a change in State law so 

that we can train not only individuals who use drugs, but also their tiunily and friends, 

and anyone who wishes to learn how to save a life. This is critical because someone who 

is overdosing will be unresponsive and friends and family members are most likely to 

help. 

In 2017, we further amended the state law to eliminate the training requirement for 

obtaining naloxone. Today, naloxone is now essentially available over the counter in 

Baltimore. Anyone can walk into any pharmacy and obtain naloxone under my blanket 

prescription. 

Our naloxone education efforts are extensive. Since 2015, we trained nearly 30.000 

people to use naloxone: in jails, public housing, bus shelters, street corners. and markets. 

We work with businesses, libraries, restaurants, and other entities to conduct outreach 

and education, and go to where people are. 

We were one of the first jurisdictions to require naloxone training as part of courtmandated time in Drug Treatment Court. We have trained federaL state and city 

legislators so that they can not only save lives, but also serve as ambassadors and 

champions to their constituents. 

b. We use up-to-date epidemiological data to target our training to "hotspots," taking 

naloxone directly into the most at-risk communities and putting it in the hands of those 

most in need. This was put into effect in 2015, when 39 people died from overdose of the 

opioid Fentanyl between January and March of20 15. In 2016 we lost 419 people to a 

Fentanyl overdose; the numbers continue to escalate, and there are now 50 times the 

number of people dying from Fentanyl than there were in 2013. Fentanyl is many times 

stronger than heroin, and individuals using heroin were not aware that the heroin had 

been laced with Fentanyl. These data led us to target our messaging so that we could save 

the lives of those who were at immediate risk. Through our citywide Fentanyl Taskforce, 

we coordinate our data with agencies across the city, including the police department, tire 

department, and hospitals, to ensure our information is complete and our efforts are 

unified. 

c. In order to train even more people in the usc of naloxone, we have launched an online 

platform that now allows residents to get trained online and immediately receive a 

prescription for naloxone. This online platform, which is the first-ot:its-kind around the 

country and the world, is the next step to reduce barriers to the use of naloxone. 

d. Already, our naloxone outreach and trainings are changing the way our frontline officials 

approach addiction treatment, with a focus on assessment and action. In addition to 

training paramedics, we have also started to train police officers who have since saved 

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182 lives. The initial trainings were met with resistance from the officers who were 

hesitant to apply medical interventions that some did not see as part of their job 

description. However, in the first month of carrying naloxone, four police officers used it 

to save the lives of four citizens. After those involved acclimated to the change, I 

attended a training where I asked the officers what they would look for if they were 

called to the scene for an overdose. In the past, I would have received answers about 

looking for drug paraphernalia and other evidence. This time, officers answered that their 

job was to find out what drugs the person might have taken, call an ambulance, and 

administer naloxone, because their duty is to save a life. By no means is naloxone 

training the panacea for repairing police and community relations. However, it is one step 

in the right direction as we make clear that addiction is a disease and overdose can be 

deadly. We are changing the conversation so that all of our partners can join in 

encouraging prevention, education, and treatment. 

e. We successfully advocated for Good Samaritan legislation, which expanded protections 

for those who assist in the event of an overdose, and malpractice protection for doctors 

who prescribe naloxone. 

f. Our state Medicaid program has agreed to set the co-pav for naloxone at $1. While we 

still struggle with the pricing for naloxone (see below), this has allowed us to provide 

prescriptions to patients and others at a greatly reduced cost. We have to get naloxone 

into the hands of everyone who can save a life-which we believe is each and every one 

of us. 

Some people have the misconception that providing naloxone will only encourage a drug user by 

providing a safety net. This dangerous myth is not rooted in science but in stigma. Would we 

ever say to someone whose throat is closing from an allergic reaction, that they shouldn't get 

epinephrine because it might encourage them to eat peanuts or shellfish? An Epi-Pen saves lives; 

so does naloxone, and it should be just as readily available. Our mantra is that we must save a 

life today in order for there to be a better tomorrow. 

2. Increasing access to on-demand treatment and long-term recovery support 

Stopping overdose is only the first step in addressing addiction. To treat people with substance 

addiction. we must ensure there is adequate access to on-demand treatment. Nationwide, only 

I 0% of patients with addiction get the treatment they need. There is no physical ailment for 

which this would be acceptable-imagine if only I 0% of cancer patients or I 0% of patients with 

diabetes were being treated. If we do not increase access to quality treatment options we are 

merely treading water, waiting for the person who has overdosed to use drugs and overdose 

again. 

The evidence is clear: addiction treatment requires a combination of medication-assisted 

treatment, psychosocial support, and wrap-around services including supportive housing. All of 

these must be in place for individuals suffering from addiction to recover, and they must be 

available at the time the individual is seeking these services-the same as for any medical 

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condition. There are three FDA-approved medications (methadone, buprenorphine, and 

naltrexone). All three should be available and covered by insurance equally in all places where 

people are seeking treatment. 

a. In Baltimore, we have started a 24/7 "crisis, information, and referral" phone hotlinc that 

connects people in need to a variety of services including: immediate consultation with a 

social worker or addiction counselor; connection with outreach workers who provide 

emergency services and will visit people in crisis at homes; information about any 

question relating to mental health and substance addiction; and scheduling of treatment 

services and information. This hotline is not just for addiction but for mental health 

issues; behavioral health issues arc so closely related, and there is a high degree of cooccurrence. Those who are seeking treatment for behavioral health should be able to 

easily access the services they need, at any time of day. This 24/7 line receives 

approximately I ,000 phone calls every week. It is being used not only by individuals 

seeking assistance, but by schoolteachers and family members seeking resources, and 

police and providers looking to connect their patients to treatment. 

b. We have implemented the Screening, Brief Intervention, and Referral to Treatment 

(SBIRT) approach, which provides universal screening of patients presenting to ERs and 

primary care offices. SBIRT is now being implemented in nine of our eleven hospitals 

and in our city clinics to ensure delivery of early intervention and treatment services for 

those with or at-risk for substance use disorders. 

c. We have piloted a real-time treatment dashboard to obtain data on the number of people 

with substance use disorders, near-fatal and fatal overdoses, and capacity for treatment. 

This enables us to map the availability of our inpatient and outpatient treatment slots and 

ensure that treatment availability meets the demand. The dashboard is being connected to 

our 24/7 hot line that will immediately connect people to the level of treatment that they 

require-on demand, at the time that they need it. 

d. We have secured $3.6 million in capital funds and $2 million in operating funds for a 

"stabilization centcr"-also known as a sobering center-for those in need of temporary 

service related to intoxication. This is the first step in our efforts to start a 24/7 ''Urgent 

Care'' for addiction and mental health disorders-a comprehensive, community-based 

'·ER" dedicated to patients presenting with substance abuse and mental health complaints. 

Just as a patient with a physical complaint can go into an ER any time of the day for 

treatment, a person suffering from addiction must also be able to seek treatment ondemand. This center will enable patients to self-refer or be brought by families, police, or 

EMS-a "no wrong door" policy ensures that nobody would be turned away. The center 

would provide full capacity treatment in both intensive inpatient and low-intensity 

outpatient settings, and connect patients to case management and other necessary services 

such as housing and job training. 

e. We arc expanding and promoting medication-assisted treatment, which is an evidencebased and highly effective method to help people recover from opioid addiction. This 

combines behavioral therapy with FDA-approved medications. Taking medication for 

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opioid addiction is like taking medication to control heart disease or diabetes. When 

prescribed properly, medication does not create a new addiction. Rather, it manages a 

patient's addiction so that they can successfully achieve recovery. Baltimore has been at 

the cutting edge of innovation for incorporating medication-assisted treatment, including 

providing medications in structured clinical settings. Last year, we expanded access to 

buprenorphine treatment by offering services in low-barrier settings, such as recovery 

centers, emergency shelters, and mental health facilities. This year, we are looking to 

double the number of physicians who are able to prescribe buprenorphine, and to begin 

buprenorphine induction in other settings including our city clinics and ERs. Providing 

access to buprenorphine services allows us to engage more people into much needed 

treatment. 

f. We arc expanding our capacity to treat overdose in the community by hiring communitybased peer recoverv specialists. To build trust, these individuals have been recruited from 

the same neighborhoods as individuals with addiction, and are trained as overdose 

interrupters who can administer overdose treatment and connect patients to treatment and 

other necessary services. To date, eight of eleven hospitals participate in our Overdose 

Survivors Outreach Program, in which overdose survivors in the emergency room are 

linked with peer recovery coaches in the community. These peers work with patients after 

they are discharged to provide a "warm hand-off' into treatment and other support 

services. 

g. We are working to expand case management and diversion programs across the city so 

that those who need help get the medical treatment they need. In our city of 620,000, 

more than 75,000 people are arrested each year. The majority ofthese arrests are due to 

drug offenses. Of the individuals in our jails and prisons, 8 out of 10 use illegal 

substances and 4 out of l 0 have a diagnosed mental illness. Addiction and mental illness 

are diseases, and we should be providing medical treatment rather than incarcerating 

those who have an addiction. 

Baltimore already has highly-effective diversion efforts such as Drug Treatment Courts 

and Mental Health Treatment Courts. At the start of2017, we began implementing a Law 

Enforcement Assisted Diversion Program CLEAD), a pilot model that has been adopted 

by a select group of cities. LEAD establishes criteria for police officers to identify 

eligible users and take them to an intake facility that connects them to necessary services 

such as drug treatment, peer supports, and housing- rather than to central booking for 

arrest. Cross agency partnerships will be key in making these programs successful. 

LEAD implementation in Baltimore involves not only the Health Department and our 

behavioral health providers but the Police Department, State's Attorney's Office, Public 

Detender's Otlice, and many more entities that together recognize the importance of 

addiction treatment. 

h. We are increasing our capability for case management services for every individual 

leaving jails and prisons. These individuals arc in a highly vulnerable state, and must be 

linked to appropriate physical and behavioral health care, social and supportive services, 

employment, mentoring and housing. Our outreach workers already target a subset of this 

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population; we need to expand capacity to every one of these individuals. Additionally, 

we are deploying community health workers who are individuals in recovery themselves. 

Based in the communities in which they work, they are "credible messengers" who reach 

people where they are. In deploying this tactic, we are also excited to bring jobs and 

opportunities to vulnerable individuals and neighborhoods that otherwise have limited 

employment opportunities. 

3. Providing education to reduce stigma and prevent addiction 

In addition to treating patients, we must also change the dialogue around the nature of substance 

usc disorders while we work towards preventing addiction. This effort has multiple components, 

including educating doctors and the public, and providing prevention and early intervention 

services throughout the life course. 

a. We have been at the forefront of changing public perception of addiction so those in need 

arc not ashamed to seek treatment. We have launched a public education campaign. 

"DontDie.org," to educate citizens that addiction is a chronic disease and to encourage 

individuals to seek treatment. This was launched with bus ads, billboard ads, a new 

website, and a targeted door-to-door outreach campaign in churches, all coordinated with 

neighborhood leaders. We work with restaurants and bar owners to post "Don't Die" 

posters in their establishments. "DontDie.org" has also become our portal for online 

trainings and for the dispensing of naloxone through the Standing Order mentioned 

above. Any resident can watch a short (I 0 minute) video, take a four-question quiz, and 

have completed the training. 

b. We have established permanent prescription drug drop boxes at all nine of the city's 

police stations and have conducted educational awareness campaigns around not using 

prescriptions that were given to anyone else. Anyone can drop-off their unused, 

unwanted, or unnecessary prescription drugs-no questions asked. Drugs left in the home 

can end up in the wrong hands-spouses, elderly family members, or even our children. 

More than half of 12 to 17 year-olds who misuse prescription opioids say they got them 

rrom a friend or family member. Despite this, half of all patients prescribed opioids report 

receiving no instructions about safe storage and disposal. 

c. We are targeting our educational efforts to phvsicians and other prescribers of opioid 

medications. Nationwide, over-prescribing and inconsistent monitoring of opioid pain 

medications is a major contributing factor to the overdose epidemic. According to the 

Centers for Disease Control and Prevention (CDC), there were 259 million prescriptions 

written for opioids in 2014. That is enough for one opioid bottle for every adult 

American. Every day, people overdose or become addicted to their prescription opioids. 

To address this, I have sent ·'best practice" letters to evcrv doctor in the city. These letters 

addressed the importance of the Prescription Drug Monitoring Program and judicious 

prescribing of opioids, including not using narcotics as the first-line medication for acute 

pain, and emphasizing the risk of addiction and overdose with opioids. We emphasize 

adherence to CDC guidelines. Importantly, this best practice requires co-prescribing of 

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naloxone for any individual taking opioids or at-risk for opioid overdose. Hospitals keep 

naloxone on hand if patients receive too much intravenous morphine or fentanyl. Patients 

must also receive a prescription for naloxone if they are to be discharged with opioid 

medications that can result in overdose. 

These best practices were developed through convening ER doctors, hospital CEOs, and 

other medical professionals in the city. To reach practicing doctors, we have been 

presenting at Grand Rounds, medical society conlerences, and have also launched 

physician "detailing," where we deploy teams of public health outreach workers and 

people in recovery to visit doctors to talk about best practices for opioid prescribing. We 

are working on a convening for pharmacists to set pharmacy best practices, and have 

supported statewide legislation to require the use of Prescription Drug Monitoring 

Programs by physicians and pharmacists. All of us-as providers, patients, and family 

members-must play our part to prevent addiction and overdose. 

d. We recognize that education must begin as early as possible, and that our schools are a 

critical part of our efforts. We launched a concerted effort to target prevention among our 

teens and youth through a campaign called "BMore in Control." We are also 

incorporating prevention into the public school curriculum. As of2017, Maryland state 

law requires schools to teach on addiction. We are working with our school district to 

implement evidence-based educational curricula. 

e. We have trained all of our nurses in our 180 public schools to save lives with naloxone. 

We now have addiction and mental health services in 120 of our schools. These efforts 

are a good start, but are limited for two reasons. First is the issue of billing: certain 

critical services such as case management and care coordination are not reimbursable, yet 

these are key to identifying children in need. Second is that there must be a focus on a 

true prevention intervention model. Substance use is often not the problem but a response 

to trauma, and there must be a more comprehensive approach to social and emotional 

learning and to addressing intersecting issues such as poverty, violence, racism, and 

trauma. 

f. A guiding principle in public health is to intervene as early-and as "upstream"-as 

possible. This is particularly salient given the statistics that show that the number of 

babies born addicted to drugs has tripled between 1999 and 2013. In some places, up to 

40% ofNICU costs are from babies with neonatal abstinence syndrome. In Baltimore, 

more than half of children >vho die have a parent or caregiver with addiction and mental 

health concerns. 

Home visiting for pregnant women helps to identify families in need of treatment and 

support. Becoming a parent is one oflife's most rewarding experiences-and also one of 

its most difficult. I am a new mother to an 11-week old baby. My son and I are healthy, 

and I am privileged to have many resources available to me, including excellent health 

insurance and many social supports. Even so, learning to care for a newborn has been 

very hard. Many new mothers face significant obstacles, including stress, poverty, 

trauma, and social isolation, and physical and mental health issues. Home visiting has 

been shown to be an evidence-based, effective method of supporting families. 

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In our experience, home visitation identifies issues ranging from lack of resources to 

purchase cribs (in which case, we help to supply them); to homes with peeling paint and 

allergy- and asthma-inducing molds (in which case, we work with other city agencies to 

remediate homes to prevent lead poisoning and asthma exacerbations); to other social 

issues that could have otherwise resulted in serious harm such as domestic violence and 

substance use disorders. 

Home visitation is a key component of our citywide strategy, B'More for Healthy Babies, 

which has successfully reduced infant mortality citywide by nearly 40% and sleep-related 

infant deaths by 70% in 7 years. B'Morc tor Healthy Babies has more than 150 partners 

around the city who work to provide support and resources for women, children, and 

families. These supports include identification and connections to behavioral health 

treatment and housing assistance. 

Despite the success of strategies like B'Morc for Healthy Babies, this and other programs 

that focus on upstream, early interventions are chronically underfunded. Such programs 

are evidence-based and cost-effective. They are necessary to break the cycle of 

intergenerational poverty and addiction. Studies have shown that children who grow up 

with family members who have substance use disorder are themselves much more likely 

to develop substance use disorder. 

Critical to programs like these are care coordination services to identify and conduct 

outreach to women and families and need. Home visitation is most effective when it is 

combined with a continuum of care services such as child development and other fiunily 

services in the community. These programs and the connections to care must also be 

significantly expanded. 

g. In August 2017, the Baltimore City Health Department was informed that our grant from 

the Department of Health and Human Services' Office of Adolescent Health was to end 

early. This grant funds sexual health education and outreach programming, promoted 

through our "U Choose, Know What U Want" campaign. With a total cut of$3.5 million, 

this will affect 20,000 youth in our city. 

This program is much more than about sex education in schools. It is an integrated effort 

to reduce the city's teen pregnancy rate and to empower girls and women. It provides 

needed education, connection and services, including to behavioral health providers. It 

helps to break intergenerational poverty and trauma. Programs like these must be 

recognized as a key component to reducing and preventing addiction, and should be 

funded and expanded. 

Working with the Federal Government: 

The Baltimore City Health Department, together with our partners across the city and state, has 

made significant progress in tackling the opioid epidemic. However, there are some areas where 

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we face continued challenges. Though there is much that can be done on the city- and statelevels, the federal government also plays a critical role. 

Congress has shown clear concern for this pressing tragedy, including through the passage last 

year of the Comprehensive Addiction and Recovery Act. There is also increased recent attention 

to the crisis by President Trump's declaration of a limited public health emergency. 

There are three specific areas that we urge for this Committee to consider: 

l. Congress must protect and expand insurance coverage for on-demand addiction 

treatment. 

One in three patients with substance use disorders depend on Medicaid. If Medicaid were gutted 

and they were to lose coverage, there is no margin of error: the only option for millions might be 

to use drugs, and potentially overdose and die. Other patients on private insurance could find 

themselves without access to treatment too if addiction is no longer required to be part of their 

health plan. 

The federal government needs to protect and expand Medicaid and require that all insurance 

plans cover evidence-based addiction treatment. Essential health benefits are called essential for 

a reason, and all insurance plans should cover preventive care and addiction and mental health 

services. There should also be coverage for wraparound services that are critical for treating 

addiction, such as connections to treatment, coverage for supportive housing, and reimbursement 

for peer recovery specialists. 

Block grants should not replace insurance coverage, because no disease can be treated through 

grants alone. 

2. Congress should urgently allocate new funding directly to local jurisdictions hardest hit 

by the opioid epidemic. 

While states have traditionally received block grants from the federal government, local 

jurisdictions are the closest to the ground in service delivery, and understand the needs of 

residents the best. We urge Congress to consider direct support for local jurisdictions, 

particularly those in areas of greatest need, by providing cities and counties with the autonomy to 

innovate and provide real-time care for our residents. 

Baltimore is in dire need for more funding to purchase the opioid antidote, naloxone. Naloxone 

is part of the World Health Organization's (WHO) list of essential medications. It is available as 

a generic, yet both the generic version as well as brand-name versions are too expensive for local 

jurisdictions to afford with their limited budgets. 

In Baltimore, not only have we equipped paramedics, EMTs, and the police with naloxone, my 

blanket prescription equips every resident in our city to carry naloxone. Since 2015, we have 

trained 30,000 people, and everyday people have saved the lives of nearly 1,500 of their fellow 

residents. 

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But we have a problem: our city is out of funds to purchase naloxone, forcing us to ration and 

make decisions every day about who can receive this antidote. This issue is particularly acute 

because of Fentanyl. The number of people dying from Fentanyl has increased 50-times since 

20 !3, and because of how strong Fentanyl is, we need more naloxone to revive individuals who 

are overdosing. 

Last month, Representative Elijah Cummings led a coalition of 51 members to call for the 

President to negotiate directly with manufacturers of naloxone. We urge for these negotiations to 

occur-imagine how many more lives we can save if we had the resources to do so. In the shortterm, we need many more resources to purchase this life-saving medication. If our city receives 

funding today, we can immediately translate it into saving lives through purcha'iing naloxone and 

through expanding treatment access. 

For years, we on the front lines have been able to do a lot with very little. We need resources 

from the federal government to help us-new resources, not repurposcd funding that will divert 

from other critical health priorities. These funds should be directly given to communities of 

greatest need. Cities and counties know what works, and local officials should not have to jump 

through additional hoops to obtain the resources we need. Issuing grants and having local 

jurisdictions compete for them will cause months if not years of delay, as would funding that 

passes through the states before getting to cities and counties. 

3. Congress should support and fund early interventions for women, children, and families. 

Upstream. early interventions such as home visitation and school-based supports are evidencebased and cost-effective. A recognition of substance use as not the cause but as a response to 

trauma, poverty, and violence calls for early investments in our women, children, and families. 

To mitigate the impact of addiction on families and to prevent future addictions from occurring, 

educational campaigns are not enough. They must be combined with social support 

interventions, including horne visitation and care coordination programs. 

Congress should immediately reauthorize funding for the Children's Health Insurance Program, 

as well as tully fund and expand evidence-based horne visitation funding for programs such as 

Healthy Start, Healthy Families America, and Nurse Family Partnerships. Additional support 

should be given to expand whole-family, multi-generational approaches such as Early Head 

Start. Congress should also urge the Department of Health and Human Services to restore 

funding for teen pregnancy prevention and expand similar holistic approaches that empower 

girls, women, and families. 

Conclusion 

While some of the challenges facing Baltimore arc unique, we join our counterparts around the 

country in addressing the epidemic of opioid abuse and addiction. According to the CDC, the 

number of people dying from overdose has quadrupled from 15 years ago. In many states, there 

arc more people dying from overdose than from car accidents or suicide. This crisis extends far 

] 
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beyond the individual suffering from addiction; it ties into the very fabric of society and has 

impacts across the life course and for generations to come. 

There are some who say the opioid problem is too big and too complicated-that it cannot be 

solved. It is true that treating the opioid epidemic requires many approaches. However, this is a 

problem with a solution-if only we have the will and commit the resources. Treating addiction 

is not only the humane thing to do, it is also cost-effective. According to theN IH, treating opioid 

addiction saves society $12 for every $1 spent on treatment. Treatment also impacts communities 

by reducing excess healthcare utilization, increasing productivity and employment rates, and 

decreasing poverty and unnecessary cost to the criminal justice system. Furthermore, treating 

addiction is a moral imperative and a matter of life and death. 

I'd like to end with one final plea: imagine if a natural disaster like a hurricane were claiming 

142 lives a day. No one would question the resources required to repair houses and rebuild 

infrastructure, and billions of dollars would immediately be appropriated. The opioid epidemic 

can be solved if we commit a similar level of resources with urgency, compassion, and action. I 

urge Congress to put the full weight of the federal government to stem the tide of this epidemic, 

and to join those of us on the frontlines to commit the necessary resources to save lives and 

reclaim our communities. 

I want to thank you for calling this important hearing. I look forward to working with you to stop 

the epidemic of heroin and opioid addiction in the United States. 

:t 
41 

Chairman ROKITA. Thank you, Doctor. Dr. Cox, you are recognized for 5 minutes. 

TESTIMONY OF DAVID COX, SUPERINTENDENT, ALLEGANY 

COUNTY 

Dr. COX. Good morning, Chairmen Rokita and Guthrie, and 

Ranking Members Polis and Davis. Thank you for the invitation to 

be here today to share the very deep impact of a real struggle affecting our district, students, and our community. As stated, I am 

the superintendent of schools in Allegany County, which is located 

in western Maryland, where it’s been my honor to serve as its superintendent since 2009. 

Just a few quick facts about Allegany County. The median in- come is just over $40,000. The population there is about 72,000. 

Our current student enrollment is 8,700. Our free and reduced 

meal population in the school system is 55 percent. Countywide, 

our special education population is 16 percent. And according to 

our sheriff this year to date there have been 27 overdose deaths in 

our county. Last year there were 59. 

Today I want to share the impact of opioid abuse that affects my 

students each day and the dramatic change that I’ve witnessed in 

just the past 5 years, and with each successive year getting progressively worse. 

One of the first was a decline in our attendance and parental involvement in the child’s schools. We work very hard as a priority 

of our local board to provide every child in our county with a highquality preschool experience in our district and to identify the 

learning needs of children as early as possible. In doing so, we’ve 

experienced a sharp increase in the number of children who require 

special services due to the opioid issues. 

Eighteen percent of all newborns in Allegany County are born 

drug affected. And this statistic does not include those children 

who may have prolonged prenatal exposure to alcohol. Last year we 

experienced multiple occasions where parents overdosed and died 

in their homes while their young children were present. On two different occasions during the preschool home visits our staff encountered young children who answered the door, and each of those 

times when asked where their mother is the child said she’s asleep. 

And when further investigated one of the mothers was deceased 

and the other was brought back through the use of Narcan. 

In one particularly sad and impactful occasion last school year 

we had a kindergarten student who came to school on a Monday 

morning after staying with her father over the weekend. When she 

got to school she was sick and she had a fever. The school nurse 

tried to call the mother since the custody schedule indicated that 

the mother was the Monday caregiver. When the mother did not 

answer the phone, the school’s secondary emergency contact was 

her grandfather who was contacted and he picked her up for medical attention. No one could have imagined that this child’s mother 

and the mother’s boyfriend had overdosed in the mother’s home, at 

which time the boyfriend’s also 5-year-old son was in the home and 

not in school. When the little boy ran out of food in his home he 

went to neighbors’ houses and knocked on doors for food, which led 

to the discovery then that the little girl’s mother and the boyfriend 

CEWDOCROOM with DISTILLER

42 

were dead from an overdose of fentanyl. It was estimated by our 

authorities that the mother and boyfriend had been dead for 2 

days. 

My elementary principals have shared with me this year that 

they’re experiencing more and more incidents of children who have 

severe behavioral issues when they enter school. Some of our preschool age and kindergarten students require full-time adult support just to manage their behavioral issues as they work with individual behavioral support plans and often there is limited parental 

support. 

The good news in all of this is that for many of our children who 

have been so impacted their public school is the place that they are 

the most loved, the best cared for, and where they receive the best 

nutrition, they’re the warmest, and where they’re shown the most 

kindness. And for this I am grateful to our caring teachers and 

schools and staff members, where they can grow and learn. 

Allegany County Public Schools has revised its health curriculum 

to include specific information for students regarding substance 

abuse at all grade levels. We have particularly focused on the high 

school level on the prevention of opioids where we have enlisted the 

help of two recovering opioid addicts who give presentations to students in high school health classes. All schools are now stocked 

with naloxone and staff members know how to administer the 

opioid antidote to persons who are believed to have overdosed. 

While I do appreciate that President Trump has recently recognized opioids as a national crisis, it is my hope and plea that our 

Federal Government will allow flexibility in use of Federal funds 

to allow school districts to utilize resources to help with our efforts 

to combat this crisis and to tend to the many unmet needs of our 

children. There is a good opportunity that Title IV funds in the 

new ESSA regulations could provide some of those flexibilities. 

I have great difficulty in finding the words to describe the magnitude of the unmet mental health issues and the health issues of 

my students and families. Many are self-medicating their depression and anxiety and many suffer from generational addiction. Others have become addicted to prescription pain medicine and migrated to opioid addictions. Others, our children, are left with deep 

emotional scars when they lose the parents due to overdoses and 

there aren’t enough resources to provide all the needs for counseling, therapy, and treatment. Keeping options open for children’s 

health insurance programs is a critical need. 

I want to express my sincere appreciation and opportunity to be 

here today. And if there is anything that I can do or AASA, we 

would certainly be glad to have you contact us. 

[The statement of Dr. Cox follows:] 

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Draft Testimony to the House Committee on Education and Workforce 

David A. Cox, Ed. D., Superintendent, Allegany County Public Schools 

November 8, 2017 

I. Introduction of myself and Allegany County and ACPS 

Good morning, Chairmen Rokita and Guthrie and Ranking Members Polis and Davis. Thank you for the 

invitation to be here today to share the deep impacts of a very real struggle affecting our district's 

students and our community. My name is Dr. David Cox, and I am the Superintendent of Schools in 

Allegany County, Maryland, which is about 2 and a half hours Northwest of Washington, DC. It has been 

my honor to serve as Superintendent since 2009, now in my 9'h year in that role. 

At one time, Cumberland was the second largest city in Maryland, second only to Baltimore, and at our 

largest in 1971, we had a student enrollment of about 19,000 students. Today, our enrollment is about 

8,700 students. The decline in enrollment is largely attributed to the departure of large manufacturing 

companies such as Kelly Springfield Tires, AFG Glass, Bayliner, and many more large scale 

manufacturers. 

According to the US Census Bureau, the median income in Allegany County is just over $40,000 per year, 

and in 2016 the population was estimated to be about 72, 000, which is down from about 75,000 in 

2010. Our county is about 425 square miles and is nestled in the Appalachian Mountains. From 

Cumberland on the Potomac River traveling west to Frostburg, in just about 12 miles, the elevation 

climbs about 1200 feet, creating another climate zone. 

With the shuttering of so many manufacturers, we have also had to close and consolidate many schools 

over the years. Likewise, the real estate market has a surplus of available housing, and there is an 

abundant supply of affordable housing on the rental market. 

Cumberland and Allegany County is primarily accessed via Interstate 68, from the east, connecting to 

Interstate 70, west of Hagerstown, Maryland, and we are about an hour east of Morgantown, West 

Virginia, on Interstate 68. 

Today, our Free and Reduced meal population is about 55% countywide, with schools in the City of 

Cumberland having over 90%. Our Special Education population is about 16% of our total enrollment. 

II. Summary of the Opioid Crisis in Allegany County and impacts to our students and their 

families, and our school communities 

Cumberland and Allegany County is testament to the fact that the devastation of the opioid crisis is not 

contained in America's large cities. It also devastates suburban and rural America. 

According to Allegany County Sheriff, Craig Robertson, so far this year there have been 27 overdose 

deaths in our county. 
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Today, I wanted to tell you how impactful this crisis is to my children who attend Allegany County Public 

Schools. As I indicated earlier, I have been the superintendent since 2009, but have seen a dramatic 

change within the past 5 years, with each successive year getting progressively worse. Among the first 

impacts we noticed was that our usually strong elementary attendance began to decline. When I talked 

with our principals about this a few years ago, they told me that they attributed much of the decline in 

attendance to parents not getting up and getting their kids to school because of drug use, and how 

difficult it was to make contact with parents to talk about attendance, achievement, and grades. Also, 

we have seen a progressive decline in attendance at parent-teacher conferences at the elementary 

level. 

We work hard to provide every child in our county with a high quality pre-school experience in our 

district. This remains a top priority of our local board of education, and we have two Maryland Judy 

Centers (pre-school initiative named after Maryland Congressman Stenny Hoyer's late wife). We 

collaborate with our Special Education Department to identify the special learning needs of our children 

as early as possible through our Infants and Toddlers program. In doing this work, I can tell you that we 

have experienced a sharp increase in the number and percentage of our children who require special 

services due to the opioid crisis. Our local health department shared that this year 18% of all newborns 

in Allegany County are born drug affected, and this statistic does not include those children who may 

have been exposed to alcohol during their pre-natal development. That is one in 5 of all children born 

here. 

last school year, we experienced several occasions where parents overdosed and died in their homes 

while their young children were present. On two different occasions, staff from our County's Head Start 

Program made home visits only to encounter a young child who answered the door. Each oft hose times 

when asked "Where is your mommy?" the child responded, "She is asleep", and when further 

investigated, the mothers were deceased. In both cases, the cause of their death was overdose. 

On another sad occasion last school year, we had a Kindergarten student who came to school on a 

Monday morning after staying with her father over the weekend. When she got to school, she was sick 

and had a fever. The School nurse tried to contact the mother, since the custody schedule indicated 

that the mother was the Monday care giver. When the mother did not answer her phone, the school's 

secondary emergency contact was a grandfather and he was reached to come to pick up the little girl to 

take her for medical attention. 

Unbeknownst to anyone else that day, the little girl's mother and her boyfriend had overdosed in the 

mother's home, at which time the boyfriend's 5 year old son, who attended another elementary school, 

was also in the home. When the boy ran out of food that he could readily eat, he went to neighbors' 

houses and knocked on doors to ask for food, and this lead to the investigation and the discovery that 

the little girl's mother and her boyfriend were dead from an overdose of Fentanyl. It was estimated by 

the authorities that the mother and boyfriend had been dead for about 2 days. If the little girl had not 

been sick at school on Monday, or if the boyfriend's son had not sought food from neighbors, the little 5 

year old girl would have gone to her mother's home on the bus and would have encountered the dead 

bodies of her mother and the mother's boyfriend. 

Imagine, if you will, the long term impacts of these two innocent children who have become victims of 

this crisis. 
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Also last year, a Kindergarten student was attempting to ride his tiny bicycle to school on a busy street in 

Cumberland after having missed his bus. A Good Samaritan woman stopped her vehicle and took him 

and his bicycle to his school just before he would have crossed 4 lanes of traffic on Industrial Boulevard 

in Cumberland. The mother of this child had not overdosed, but was drug affected to the point that the 

child could not awaken her to take him to school after he missed the bus. When the school finally did 

get to speak with the mother, she was unaware as to where her child was. 

I, or many of my superintendent colleagues, could provide more accounts of similar instances, but I 

think this provides you with an idea of how devastating this crisis is to too many of my children in 

Allegany County Public Schools. Imagine the long term mental health implications of these situations, 

and also imagine insufficient resources to deal with the mental health needs of my children and their 

families. 

My elementary principals have reported to me that they are experiencing more children who have 

severe behavioral issues as they enter school. We have, in fact, some pre-school and Kindergarten 

students who require full time adult support just to manage their behavioral issues as they work on 

individual behavior plans; and much of the time, there is limited parental support. 

The good news is that for many of our children, their public school is the place that they are the most 

loved, best cared for, where they receive the best nutrition, and are the warmest. Just like the little boy 

who was trying to ride his bike to school with all the dangers of traffic unknown to him, he knew that his 

school was a place where he would be taken care of. His principal described him as a "rounder," but 

also as a sweet child who had many, many needs. I am proud of his principal, his teachers, and his 

school for being a safe place for him, but I know that he has many more needs that go beyond the 

resources available. 

111. Community/State and State Efforts Underway to Educate Citizens 

Our county sheriff has hosted a series of town hall meetings for the community for the past 2 years and 

is beginning a new series this week. Our county partners have collaborated in many efforts to educate 

the larger community. A partial list of the community efforts include: 

The Greater Cumberland Committee Education Subgroup 

The Opioid and Heroin Prevention Taskforce 

The Opioid and Heroin Fatality Review Board 

The Drug and Alcohol Abuse Council 

The Western Maryland Health System Opioid Summit and its policy subcommittee 

Allegany County Public Schools has revised its Health Curriculum to include specific information for 

students for substance abuse at all grade levels, but is particularly focused at the high school level on 

prevention of the use of opioids. We have two recovering opioid addicts who give presentations to 

students in high school health classes, as a part of their curricular experience. 

Maryland has been a leader on this issue through the General Assembly and the Maryland Department 

of Education (MSDE). This year, MSDE has developed and shared the "Heroin and Opioid Awareness and 

Prevention Toolkit" as a resource guide for schools. As well the General Assembly, during the 2017 

session passed the Heroin and Opioid Education and Community Action Act of 2017 (Senate Bill1060). 
46 

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All schools have stock of Naloxone (Narcan) and staff members who can administer the opioid antidote 

to persons who are believed to have overdosed. 

Our lieutenant Governor, Boyd Rutherford, asked to meet with all of Maryland's 24 Superintendents 

earlier this year to discuss this epidemic. He attended a meeting ofthe Public School Superintendents 

Association of Maryland {PSSAM) and listened attentively to the concerns of Maryland Superintendents 

representing the nearly one million public school students in the state, and he also discussed Governor 

Hogan's commitment to work on this issue, and to provide additional funding to local school districts. 

IV. Challenges that are yet unmet with effective solutions 

As indicated earlier in my testimony, this crisis has challenged our public schools and has stretched our 

staff and financial resources well beyond anyone's expectations. I do appreciate that President Trump 

has recently recognized this as a national crisis, just as has Governor Hogan. It is my hope and plea that 

our Federal Government will allow flexibility of the use of Federal Funds to allow local school districts to 

utilize resources to help with our efforts to combat this crisis and attend to the many unmet needs of 

our children. There is a good opportunity that Title IV funds in the new ESSA regulations could provide 

some additional flexibility to school districts. 

I have great difficulty in finding the words to describe the magnitude of the unmet mental health needs 

of my students and families. The opioid crisis is connected to this issue on the front end, in that many 

are self-medicating their depression and anxiety, and many come from families with histories of 

addiction issues. Children are left with mental health scars when they lose parents to overdose deaths, 

and quite simply, there aren't enough resources to provide all the needs for counseling, therapy, and 

treatment. Keeping options for Children's Health Insurance Programs is a critical need. 

We also need help to quell the supply of illegal drugs including opioids into this country, and particularly 

Fentanyl. There are yet too many physicians who over prescribe opioids, and in my inquiries, I have not 

been able to understand who holds those accountable who are sworn to "first cause no harm," when 

some physicians knowingly keep those addicted in supply of prescribed opioids. 

v. Expression of Appreciation for the opportunity to share 

I want to express my most sincere appreciation for this opportunity to share this information and 

perspective to this committee. Thank you for the work you do for all of America's Public School children 

each and every day. My kids count on you, just like they count on me. If there is anything that I can do 

or that AASA can do to provide additional perspectives or information, please contact us. 
47 

Chairman ROKITA. Thank you, Dr. Cox. I appreciate all the witnesses’ testimony. 

I would like to recognize the chairwoman of the full committee, 

Dr. Foxx, for 5 minutes. 

Chairwoman FOXX. Thank you, Mr. Chairman, and thank you 

for convening this hearing. It is a very, very painful topic to be 

talking about, but it is one that I know we need to discuss. 

Mr. Robinson, in your testimony you talked about workforce preparedness and helping to educate people. How does preparing and 

educating individuals to reenter the workforce increase their motivation for treatment? 

Mr. ROBINSON. Vocational education is a part of a continuum of 

care for addiction treatment. It drives greater levels of success for 

really three reasons. One, when someone enters treatment and 

knows there is a second chance career path it inspires hope and increases treatment motivation. Number two, the twelfth of AA informs us that sharing our recovery is one of the foundations of 

long-term sobriety. So this concept suggests that finding purpose in 

helping others strengthens your own recovery. And then, finally, 

and I think most importantly, experiencing the dignity of work 

gives recovering addicts who have reentered the workforce a positive self-image, confidence, and helps them to establish career goals 

and a plan for their future. 

A great example of this is Vanessa Keeton, who was an IV heroin 

needle user who entered one of our residential treatment centers 

and completed our internship program. She later became a treatment center director while earning a college degree and purchasing 

her first home. And recently she resigned as our HR director and 

now started a business that is supporting her family. 

Chairwoman FOXX. Thank you very much. And thank you, particularly, for mentioning the dignity of work. I don’t think we do 

that often enough in our conversations. 

Ms. Miner, you discuss how families need to be part of their own 

solution. Can you elaborate on what this means? And my assumption is it is different for different families, but you might want to 

give examples of that. 

Ms. MINER. Absolutely. Families are different, they are unique in 

their own ways. Really, in my position in Colorado, I sit down with 

the families and discuss with them what it looked like for them 

when things were going well for them, before their addiction had 

taken its toll, what their children looked like, what kind of supports they had in their family. Because all too often we find that 

when someone is in active addiction that they have really severed 

their ties with all of their good supports in their life. And they really believe that this is severed for life. I share my story with them 

and tell them about how bad I had hurt my own mother through 

my addiction and she is now my best friend again and my biggest 

support. And really we have got to get these families to believe that 

they have the power within themselves to do it. 

Chairwoman FOXX. Thank you very much. Dr. Cox, I represent 

Alleghany County in North Carolina but we spell it just slightly 

differently, we put an ‘‘H’’ in it there. And our county is not as 

large as yours and I don’t think it has quite the same problems, 

but I love representing Alleghany County in North Carolina. 

CEWDOCROOM with DISTILLER

48 

You discussed the need for flexibility for the use of Federal funds 

to allow schools districts to utilize available resources to help meet 

the needs of the students. How would additional ESSA Title IV 

fund flexibility help you as you respond to this problem? 

Dr. COX. Well, let me give you a very specific example. And I go 

back to a meeting I was in yesterday with my elementary principals. It was our regularly scheduled time and we talked about 

some of these issues and the presentation of kids with lots of 

needs. In our district we have one behavioral specialist that serves 

the needs for all of my 13 elementary schools. While I am grateful 

that we have the Title IV funds, you basically have to write your 

plan to fulfill three different areas. And in our county we get 

$70,000. And it would be helpful if I could pool all of that money 

to be able to hire another behavior specialist to help with my elementary principals and the counselors and the nurses in the school 

to design plans to deal with the behavioral issues. I mean, that is 

one example. 

And I think, you know, in all of our public schools in Maryland, 

across the country, having greater flexibility within the Federal entitlement programs to meet the specific needs in each of our jurisdictions would be very helpful to all of us. 

Chairwoman FOXX. Thank you. And thanks to the panelists, 

again, and thank you, Mr. Chairman, for indulging me. I yield 

back. 

Chairman ROKITA. I thank the chairlady. I recognize Ranking 

Member Scott for 5 minutes. 

Mr. SCOTT. Thank you. Thank you, Mr. Chairman. Mr. Chairman, it seems to be a consensus that we should treat the opioid addiction through a public health strategy rather than a criminal justice strategy, which means primary prevention before people get in 

trouble and then responding afterwards. 

Dr. Wen, you mentioned in your closing statement a need to support early intervention for women, infants, and children. What does 

that mean and what can be achieved? 

Dr. WEN. Thank you for that question. We need to have early 

intervention and detection. That would include things like home 

visiting services, which have been found to have profound longterm effects on improving children’s health and also the health and 

wellbeing of their families, too. We know that there is a cycle that 

exists, this cycle of poverty, trauma, addiction, that addiction often 

begets addiction. And we need to do everything we can to break 

that cycle, to have early intervention where possible, to have prevention services, but also critically, when people are seeking treatment we need to be there for them. We should not have to tell 

them to wait weeks or months, but we should make every interaction the opportunity for intervention. 

Mr. SCOTT. Well, if you are going to have a public health response as a cost after they get addicted, to paying for the services, 

can you repeat what you said about the effect of cuts in Medicaid 

and removal of behavioral health coverage as an essential benefit 

in health policies? 

Dr. WEN. Absolutely. In Maryland alone there are 250,000 people 

who gained insurance because of expanded Medicaid. All these individuals could stand to be without access to treatment if Medicaid 

CEWDOCROOM with DISTILLER

49 

were cut. Essential health benefits, too. One out of every three individuals who now are newly insured through ACA plans might not 

have gotten coverage before because essential health benefits did 

not include addiction services. For all these individuals there is no 

margin of error. So an individual who is in treatment now, if they 

don’t have treatment tomorrow their only option may be to overdose and die. And at a time of a public health epidemic the last 

thing that we can afford to do is to deprive people of the coverage 

they have instead of providing access to treatment for the more 

than 1 in 10 who cannot access it now. 

Mr. SCOTT. You made a comment about dealing with the supply. 

Can you say why investments in cutting supply are inherently unsuccessful? 

Dr. WEN. Well, currently substance abuse already costs society 

$600 billion annually in medical costs and incarceration costs. So 

we need to invest much earlier. And cutting supply alone is not 

going to work unless we also address demand, because currently 

we have millions of people who have the disease of addiction. If we 

are not able to get them treatment, that demand is going to continue to fuel supply and that is why a public health approach combined with a law enforcement approach are what we need. That is 

the humane thing to do, the ethical thing to do, and it saves society 

money. 

Mr. SCOTT. Thank you. Dr. Cox, you indicated that superintendents need flexibility with the funding. Isn’t it true that superintendents have also been asking for significant increases in funding, particularly Title II–A funding, and other funding that can 

help address this? Not just flexibility, but more resources? 

Dr. COX. We have a lot of needs and certainly additional funding 

would be helpful. One of the greatest needs is that for treatment, 

that we have children whose mental health needs are not being attended to because there aren’t enough resources to do that. 

Mr. SCOTT. And so you need more resources, not just flexibility? 

Dr. COX. Yes. 

Mr. SCOTT. Thank you. And, Mr. Chairman, I yield back. 

Chairman ROKITA. I thank the ranking member. I recognize myself for 5 minutes. I thank the witnesses again. 

Mr. Robinson, you mentioned Alcoholics Anonymous, and pardon 

my ignorance, does it receive Federal funding? 

Mr. ROBINSON. No, it does not. 

Chairman ROKITA. So that allows you to explore the spiritual element of the recovery process? 

Mr. ROBINSON. Yes, absolutely. And, again, you know, in our 

treatment centers we still have an addictionologist leading our 

medical programs. We are nationally accredited by CARF, so we 

are recognized as a center for clinical excellence. 

But we have added two things to our programs that maybe not 

all programs have, and one is a spirituality program, which is very, 

very important, especially when you start looking at pastoral care 

and chaplains. And that is very consistent with other faith-based 

health systems that we have across the country. 

And then, finally, as I said in my comments, we have added vocational workforce development as a key part. And so you really have 

to treat the whole person and spirituality is a piece of that. 

CEWDOCROOM with DISTILLER

50 

Chairman ROKITA. And funding source aside, and regardless of 

it, you recommend spirituality and vocational for every program? 

Mr. ROBINSON. Absolutely. I think we should be investing in programs that are holistic, that are treating the whole person. Addiction devastates every aspect of someone’s life. 

Chairman ROKITA. Thank you, Mr. Robinson. And then you mentioned Medicaid-eligible healthcare providers. Can you unpack that 

a little bit? 

Mr. ROBINSON. Yes. I mentioned the peer support specialists in 

our State is a Medicaid billable professional, which is incredible 

public policy because it creates employment for people recovering 

from addiction. And it puts them to work in a field that is the best 

thing for them to do, which is to share their recovery with other 

people. And so in our State, for some billing codes, a peer support 

specialist, who is someone who has been clean and sober for a year, 

that has either got a high school diploma or GED, that goes 

through a 40-hour course, they become a behavioral health practitioner. And organizations like ours hire those individuals to lead 

group, to do individuals, to go to needle exchanges, to go to 

ERs—— 

Chairman ROKITA. And what is the cost to get them trained—or 

educated, excuse me, so that they are Medicaid billing eligible? 

Roughly. 

Mr. ROBINSON. So it is a 40-hour cost and our academy has 

added lots of other skills. Our Workforce Development Board provides us approximately about $10,000 for each one that we train. 

But we are training super peer support specialists that are certified 

in CPR, first aid. 

And one of the other things about peer support specialists is it 

prepares them—when they start getting this medical training they 

can go into other careers other than peer support, enter the nursing field or other healthcare professions, like medical assistants. 

Chairman ROKITA. Thank you, Mr. Robinson. Let me skip over 

to Dr Cox here. You mentioned, I believe, if not in your oral testimony, your written testimony, community task forces? 

Dr. COX. Yes. 

Chairman ROKITA. Can you unpack that a little bit? 

Dr. COX. Sure. We have several—— 

Chairman ROKITA. How do you organize them? Who is involved? 

What is the cost associated with it? What is your funding source 

if there is a cost to the county? 

Dr. COX. We have several actually. The Western Maryland 

Health System sponsors one and they are called actually The Summit. And they are the recipient of some State grant funding. 

Chairman ROKITA. Summit? 

Dr. COX. The Summit, right. 

Chairman ROKITA. Okay. 

Dr. COX. I am a member of the Greater Cumberland Committee 

Education Workforce. They also had an EVANA forum. And then 

we have staff members who participate in various committees with 

the health department. We have a lot of efforts underway. Our 

sheriff, as a matter of fact, this evening will kick off another series 

of town hall meetings all over the county. So we have done a really 

good effort of educating the population about what addiction is. 

CEWDOCROOM with DISTILLER

51 

Chairman ROKITA. What is the effect so far? Can you tell? 

Dr. COX. Well, I think we are a lot better educated as a community about the aspects. I mean, for example, just educating people 

who have no experience with addiction, that people use to feel normal. That is one of the hardest things I think for people to understand is that a person doesn’t use necessarily to get high, but just 

to feel normal so that they can carry on and function. So that is 

one of the things that we have—— 

Chairman ROKITA. Thank you. Thank you, Dr Cox. Coming back 

to Ms. Miner now. You indicated in your testimony—and thank you 

for sharing your tragic story as well. I appreciate the courage that 

must take. You mentioned that you thought you weren’t affecting 

your kids, perhaps they didn’t even know, and then obviously you 

say you now have children that are or were drug addicts. So they 

did see your behavior? What do you think the cause is? Is it just 

more than observation? Or what is your instinct as a mother there? 

Ms. MINER. They did see. They saw that I was not present. They 

saw that when they needed me to wake up in the morning to take 

them to school that I could not do it. They saw that when they 

were clinging on my leg wanting mommy time that I could not be 

present because—— 

Chairman ROKITA. Why does that make them become a drug addict in your mind? 

Ms. MINER. You know, I really believe—and after talking to both 

of my daughters, that because they witnessed so much tragedy in 

their life and because there was so much trauma that was never 

dealt with them. When I first got clean everyone swooped around 

me because I was pregnant with my son, but nobody helped my 

daughters who had suffered significant trauma. And trauma is a 

leading cause to substance abuse. 

Chairman ROKITA. Thank you. At the risk of breaking my own 

rules I need to stop. I apologize. Thank you very much for your responses. 

I now recognize the ranking member of the K–12 Subcommittee, 

Mr. Polis, for 5 minutes. 

Mr. POLIS. Mr. Robinson, can you confirm if your centers accept 

Medicaid and receive Medicaid reimbursement for services? 

Mr. ROBINSON. We do. 

Mr. POLIS. Okay. I just wanted to be clear to point that out as 

a Federal funding stream. 

Ms. Miner, you know, I think the power of your personal narrative is very strong. Do you have any suggestions about what we 

can do either officially as a committee or unofficially as individuals 

to encourage more people like yourself to be open and share their 

own stories and narratives and help educate others? 

Ms. MINER. I really believe that people like myself can help to 

build the power of people in recovery up to want to come and talk. 

It is a very frightening thing to go out and share your story because you never know the reaction that you are going to get from 

people. We are our own worst critics and we tend to think that everybody that we go and talk to is just going to look down on us. 

It is really about educating us and really helping us to get our 

voices out there and for you to really want to listen, and for us to 

know that you want to hear what we have to say. 

CEWDOCROOM with DISTILLER

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Mr. POLIS. And, you know, I have also appreciated the movement 

that many families who have lost children or family members to 

the opioid epidemic have been more forthcoming in their obituaries 

to mention the true cause rather than sweep it under the rug. The 

more visibility and awareness I think the more empowered we are 

to counter this deadly epidemic. 

Dr. Cox, I want to thank you for being here today and sharing 

some data about the opioid crisis. In your testimony you talked 

about the funding struggles that your district is facing. In Colorado, when I meet with superintendents and school board members, often funding is one of the first issues they bring up. Still, 

school districts are being asked to do more with less. And we have 

never met through this body our full commitment to special education funding. 

Most recently there is significant scale-backs in funding for 

ESSA. For instance, eliminating Title II has been proposed and 

cutbacks in Title IV Part A. Can you share the importance of fully 

funding Federal education programs, specifically Title IV, and how 

this could benefit Allegany County Public Schools in your efforts to 

support students and families impacted by the opioid epidemic? 

Dr. COX. Sure. You are correct. I mean, we have so many needs 

and this opioid crisis has only contributed to that. And we are 

funded by a combination—and every State is a little bit different, 

but most of our funds come from the State of Maryland. Second is 

going to be our local county government, and then the third pool 

is the Federal funds. So we use a combination of all those funding 

sources to meet the needs. And, as you mentioned, with IDEA not 

being fully funded it really imposes some hardships. And this issue 

impacts the IDEA needs that children have. So it is only going to 

create more need for children. So, you know, whether it is additional funding for IDEA or Title IV flexibilities or additional Title 

IV funds, we just need more resources to deal with the issues. 

Mr. POLIS. And, Dr. Wen, I want to thank you for being here this 

morning. I am fortunate to represent a district with several research universities, University of Colorado at Boulder and Colorado 

State University, both of which are leading research universities 

doing great work to help better understand the opioid epidemic. In 

a recent study from CU in partnership with the VA in Colorado 

they found that patients almost universally cited emotional support 

from family members and healthcare providers as essential to recovery. 

Can you speak to the emotional support for family members and 

healthcare providers, and specifically what Baltimore is doing to 

help provide emotional support services for patients? 

Dr. WEN. It is critical to remember that when people are recovering from the disease of addiction they need not only the medication assistive treatment, which is also the gold standard, they also 

need psychosocial counseling and wraparound service, social services. And also that people who are addicted to opioids are not only 

treating physical pain, they are potentially treating some other 

type of pain as well that might include emotional pain and trauma. 

And so in Baltimore, we provide services for healthcare workers. 

We provide services also to assist with our most vulnerable, including our children in our schools. 

CEWDOCROOM with DISTILLER

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Mr. POLIS. And are those models—do you think they can be expanded or scaled, included in rural areas? 

Dr. WEN. Absolutely. We have many evidence-based pilots and 

evidence-based programs in Baltimore. We know what works. We 

just need the resources to scale them up in our jurisdiction and 

across the country. 

Mr. POLIS. And I will finally go back to Ms. Miner. Can you 

share a little bit about your personal experience as an advocate 

working across different systems and different jurisdictions that 

are all trying to work on this issue and how you have been able 

to try to bring people together through your own personal narrative 

and advocacy? 

Ms. MINER. Absolutely. We are still very siloed, I am finding out, 

across the country, but I am finding more and more, at least in 

Colorado, that people are wanting to work together. They are wanting to talk so that we can help eliminate the trauma to the family 

from the family having to tell their story over and over again because every time they have to repeat it is more traumatizing to 

them and to their children. And with me working so closely with 

the executives that we have in Jefferson County, it makes it that 

much easier for me to help them partner with each other and with 

the families. And they really want to listen to what the families 

have to say. 

Mr. POLIS. Thank you. And I yield back. 

Chairman ROKITA. The gentleman’s time has expired; the gentleman yields back. Chairman from Kentucky is recognized for 5 

minutes. 

Chairman GUTHRIE. Thank you very much. It is great to be here. 

And I just want to say that this is something that is not going to 

be solved solely in Washington. Certainly you guys are on the front 

line at the local level. I just want to point out for the witness testimony earlier, joining us was Kim Ozer from northern Kentucky, 

which is not just the north part of our State, northern Kentucky 

is how we define our Cincinnati suburbs. So if you live in northern 

Kentucky, you are closer to a Reds game than if you live in north 

Cincinnati. 

And though hearing opioids has been statewide, we call the I– 

74 corridor in Appalachia, where you are, has been really the brunt 

of it and all the work moving forward. And there are so many 

issues and there are so many committees here looking at this crisis 

together. But on the Higher Ed Committee that I chair, we are 

really looking at how the opioid crisis is affecting the workforce. 

So I did my 21 town halls in August. Everywhere I went most 

were talking about healthcare, but there was not one that people 

were not talking about the heroin problem and opioid. They say 

heroin back home, but we are talking opioids in general. And so it 

is everybody who is focused on it want to move forward, but every 

employer that I would talk to who were looking at—I think every 

employer I talked to in Kentucky—you will probably find some 

rural areas, but probably in your area that is not—are looking for 

people to hire and the biggest problem they are seeing is passing 

the drug test, a lot of people who show up to work. So there are 

a lot of issues that we just can’t look at the criminal justice problem, we have got to look at it holistically. I don’t want to dismiss 

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that part of it. I have changed my attitude on that, too, is that we 

have got to look at people are in trouble because they are addicts, 

not the other way around. 

So the big thing is, as you said, I think you hit it, the dignity 

to get them to work. And I know your program does that. And so 

what are you hearing from local businesses? And I know that you 

tailor some of your programs from what local businesses have told 

you they need to get certificate programs. Could you address that? 

Mr. Robinson? I am sorry, I am talking to you. 

Mr. ROBINSON. Our first training was to provide peer support 

specialists for the addiction treatment field. And those folks are 

going to work not only for us, but for other providers, community 

mental health centers, hospitals, health departments. 

One of the things that has recently happened to us is we had an 

executive with a major industrial maintenance company approach 

me. I was actually just eating in a restaurant in our town and he 

said we are needing to hire people. We can’t get enough folks to 

pass the drug screen, and especially we need welders. So we are 

right now in the process of adding a welding program to what we 

are already doing and that is going to allow us to create a flow not 

only of an opportunity to allow someone that is recovering from addiction to maybe start a job at $40,000 or $50,000 a year, but it 

is going to provide a flow of employees who are in some ways kind 

of drug-proof because they have been through treatment, they have 

got the support. 

And, again, that dignity of work, the confidence that comes. One 

of the most compelling stories I heard was one of our graduates 

came by my office, it was such a big deal, to tell me that he had 

just been to the social services office and told the worker there to 

take his kids of Medicaid because he had private health insurance. 

And that worker said it is the first time they had ever seen that. 

But I could see in his eyes just tears welling up when he was able 

to come and share that with me and came to my office to tell me 

that. 

Chairman GUTHRIE. That is great. And I know Sullivan University out of Louisville is partnering with you so people can also earn 

credentials, academic credentials, with your training program. How 

does that work? 

Mr. ROBINSON. Sullivan has been a great partner. And they are 

just one of our most outstanding private universities in the State, 

including having a pharmacy school. And so they just came along 

and said, look, we have got a responsibility as an education provider to be involved in this issue in our State. And they came to 

us and said how can we be involved? And so they stepped forward, 

and at their own cost are awarding college credit for our peer support academy. Those folks are not having to pay any tuition dollars. They are awarding equivalency credit, which is fantastic. 

And now we have got other educational groups, like our community college system, who is coming to us and saying we want to do 

the same thing Sullivan is doing. And, again, this idea of putting 

vocational workforce skill-building as a part of the treatment continuum, we have never seen anything increase the outcomes of our 

treatment programs better than this. 

CEWDOCROOM with DISTILLER

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And, like I said, the first graduating class of our peer support 

specialist academy we graduated 16; 14 of them today are full-time 

employed, they are sober, and they are 18 months at least clean 

and sober, so that is 85 percent. That is an incredible return. And 

I think we can do that in all kinds of different professions. 

Chairman GUTHRIE. Well, thank you. I appreciate that very 

much. And I don’t have enough time to ask another question, but 

I was going to ask Ms. Miner just about working with families. But 

I just want to say when you guys share your stories that has got 

to be extremely difficult to do and put your family out here as you 

have already done earlier today. But it means a lot. I think it adds 

to what we are trying to do and it certainly encourages other people and I appreciate you doing that, all of you who shared your personal stories and the work you do. 

And my time has expired. I yield back. 

Chairman ROKITA. The gentleman yields back. Ranking Member 

Davis recognized for 5 minutes. 

Ms. DAVIS. Thank you so much, Mr. Chairman. And for the 

record, I wanted to put in this State Health Reform Assistance 

Network article, ‘‘Medicaid States: The Most Powerful Tool to Combat the Opioid Crisis.’’ If I can put that for the record. 

Chairman ROKITA. Without objection. 

Ms. DAVIS. Thank you very much. You know, I don’t think any 

of us could sit here with your very compelling testimony and not 

be moved, not be concerned, and on some levels a little outraged 

as well that we are not finding our way to provide the resources 

that are needed to spot—you know, with all the compelling good 

work that is being done in our local communities. Because I think 

the local communities are the foundation of how we respond. But 

we can’t do that if we don’t have the resources. And so it is very 

important. We are doing that in the context of contemplating trillions of dollars’ worth of debt that we are taking on right now, 

knowing that as the years go by into 2025, 2026, the families who 

could be hurt the most are those today that are really the most vulnerable when it comes to the use of Medicaid and health and support that is out there. 

So, you know, I can’t help but say that because I think that we 

have to put this in some context. And it is wonderful to have the 

sympathy, the empathy, the drive to change things, but it is not 

going to happen if we don’t recognize that we are making choices 

every day here in the Congress. And the choices that we are making today, unfortunately, I don’t think are in line with what we see 

as an emergency in our country. 

And thank you very much for your being here because you represent really the issue that we are facing today. 

It was interesting to me, Mr. Robinson, as you were speaking I 

could not help, but think of some of the issues that we look at 

when it comes to the transition of our military into civilian 

workforces. And some of the issues and the need that we have had 

to have companies acknowledge and know more about what they 

are bringing to the job, all the wonderful benefits they bring in 

terms of knowing how to conduct themselves at work, but also 

some of the trauma, in fact, that has been experienced. I wonder 

whether you see that there is a link, some relevance to that, and 

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whether or not we could be looking at some of those models as 

well? Does that align for you? 

Mr. ROBINSON. Yes. As a grandson of a World War II veteran 

this is something that is near and dear to my heart. I still remember my grandpa wearing his DAV hat. And so he taught us to take 

care of our military, whatever we can do. 

So we have had several veterans come to us for treatment because there still is a lack of access for those that are coming back. 

And one of the big success stories, one of the favorite stories I 

love to tell, is Brandon Leslie, who was an Afghanistan and Iraq 

veteran that came to us. He was an IV needle user suffering from 

PTSD, went through our program, did our internship program, became a residential staff, then a center director, and now he is the 

assistant director over nine residential centers, and he has only 

been clean and sober for 3 years. And so one of the things that I 

noticed were his leadership skills that were just inherent in who 

he is that he learned in the military. 

And so we need more of our veterans that are struggling active 

duty to get into recovery because he can talk to them in a different 

way than anybody else can. 

Ms. DAVIS. Mm-hmm. And I think that goes for Ms. Miner as 

well. I mean, as someone who has been clean, as you noted, for 

many years, you have that special gift to be able to communicate 

that as well. 

Dr. Wen, so within these discussions I think it is clear that there 

needs to be a Federal response with the help of our local communities. Can you say why is that important? Why can’t all of this 

just happen if communities did the right thing? 

Dr. WEN. We are already doing what we can with extremely limited resources, but I will give you an example. Because we are out 

of money for Narcan, if we were to get money to purchase 10,000 

units of Narcan today I can distribute all 10,000 units by the weekend. Think about how many more thousands of lives we would be 

able to save every day in our local communities if we had the resources and the will to do so. 

The opioid epidemic is a solvable problem. This is what frustrates me every day. We know what works, we know the science 

is there, we just have to do the right things, including protecting 

existing insurance coverage, but also expanding coverage and increasing the resources to allow us to do what we already know 

based on evidence works. 

Ms. DAVIS. Thank you. Thank you, Mr. Chairman. 

Chairman ROKITA. Thank the gentlelady. Congressman Allen, 

you are recognized for 5 minutes. 

Mr. ALLEN. Thank you, Mr. Chairman. Appreciate you all coming 

and sharing with us about this difficult, really difficult problem 

that we have. 

In this country it really dates back to the 10th century if you 

read about the problems in China. I do not know how many male 

citizens of the United States are on drugs, but in China in the late 

1800s over 25 percent of the male citizens of that country were 

opioid users. And, of course, they went to great lengths to deal with 

it there. 

CEWDOCROOM with DISTILLER

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You know, when I am out and talking with educators, it is difficult because a lot of our educators tell me their biggest challenge, 

not only in elementary schools but also in colleges, is emotional 

health of the student body. And, you know, I look at my days in 

college and I thought that was a great time to be—you know, I had 

a great time in college, it was a wonderful experience. So I don’t 

know what has happened since I was in college. I know that I was 

fortunate in that drugs really did not come on the scene until I was 

out of college, at least at my particular college. But I saw it as soon 

as I got home after college with a lot of my friends who I went to 

high school with that became drug users. 

I will tell you this, we have got 6–1/2 million jobs open in this 

country right now. I did a 19 county tour in August and I met with 

our chambers and our county commissioners and our mayors, and 

economic activity is at its highest level. I met with a company that 

is going to add 100 jobs in one county. They had 400 applicants 

and only 40 could pass the drug test. Folks, we have got a serious, 

serious problem. 

I talked to law enforcement. In most of my counties my sheriffs 

say that if we didn’t have a drug problem they wouldn’t have anybody in prison. And maybe there would be something else going on, 

I don’t know. And a lot of it is people have entirely too much idle 

time. 

And so, you know, with that, Mr. Robinson, obviously treatment 

is critical, but, you know, somehow—how do we stop the supply? 

Because, like I said, if you read the history of China when they cut 

off supply, the price, you know, increased dramatically which 

stopped a lot of the use. Because right now, as I understand it, 

opioids are very inexpensive. The street stuff is very inexpensive to 

get. Do you have any comments on that? 

Mr. ROBINSON. I mean, I think we always have to be diligent 

when it comes to attacking supply. One of the problems that has 

happened with the prescription drug problem is that it is hard to 

stop the supply when you have grandmas and people who in their 

medicine cabinets have a 90-day prescription or a 30-day prescription for oxycodone. And the opiates we looked at, you know, 20 to 

25 years ago are nowhere near as potent as it is today. When you 

take a pill such as an Oxycontin table that has—is supposed to release the morphine, the opiate, over time and then you crush it and 

it gives you the full potency of that, the addictive nature of that 

is just so much more than maybe just the heroin that was available 

in the ’50s and ’60s. 

The other thing is now we are getting these synthetic versions, 

like carfentanyl and fentanyl, which are 100 and 1,000 more times 

more potent. 

Mr. ALLEN. But again, that is a business decision by the pushers 

to get more people addicted. I mean, you have got to go to the 

source here and stop this. 

Mr. ROBINSON. Yes, absolutely on the pharmaceutical companies. 

Mr. ALLEN. If we get serious we can stop it. I mean, the country 

I think has got to get serious about stopping this problem. I mean, 

you can’t just say laissez-faire, we are going to prescribe some byproduct. Now, obviously we have got to do something with those 

folks who are on drugs, but until this country decides we are going 

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to deal with this and we are going to deal with this in a way that 

we are going to stop it, I don’t know how we stop it. I mean, is 

there any disagreement? 

You know, in other words, we have a very, very serious problem 

here. And, you know, I am hearing, well, treatment and throwing 

more money at it and this sort of thing, we have got to stop—it is 

always the money. You know, in China, you know who it was? It 

was the British that were making all the money off the drugs. And 

so, you know, I wish you all the luck in the world and I am thankful for what you are doing. Thank you so much for what you are 

trying to do. 

I yield back. 

Chairman BRAT. Thank you. I recognize Mr. Courtney for 5 minutes. 

Mr. COURTNEY. Thank you, Mr. Chairman. I want to thank the 

witnesses for your thoughtful testimony today. Again, and the topic 

of the hearing which is to sort of even get beyond the emergency, 

you know, first responder healthcare, but the ripple effect that is 

happening in communities, which is true in New England as well. 

A couple of weeks ago, I was with the school superintendent up in 

Enfield, Connecticut, which is a suburban town in Hartford County. It’s about 50,000 population which again in 12 days this year 

they had 13 overdoses, you know, show up at the police and volunteer fire department. But the school superintendent actually pulled 

out some data which was actually pretty—it was even another 

layer of alarm because he was describing what they are seeing in 

kindergarten in the schools where, again, behavior is just totally 

unprecedented in terms of what teachers and staff are seeing. 

So, for example, they have the data, physical assaults in kindergarten in the school year of 2013–2014 were 1 for the whole district, there were 14 in 2016, last year’s school year. The emergency 

protective holds in kindergarten in 2013 were four. There were 114 

in 2016. And, again, the kids with emotional disturbance—and I 

am going to submit this data for the record, Mr. Chairman—but 

what it is doing to teachers is that—you know, these are veteran 

kindergarten teachers who are like at the end of the school day in 

tears because they are just so overwhelmed with kids. 

They have a term for some of the kids, they are called runners, 

where they just literally bolt from the classroom out the building, 

chasing them in the streets. And so, you know, this has created a 

challenge that aside from everything else that school superintendents have to deal with in terms of State budgets and local property 

taxes, about how do you get some, you know, stability under the 

roof of a school district. 

So one of the things we did in this committee with the ESSA, 

which was a great bipartisan achievement when signed by President Obama, but a lot of the Republican members were there at 

the White House, that updated the Elementary and Secondary 

Education Act. We again really bolstered the Title II, Title I, and 

Title IV funding that directed money to help schools, and teachers 

in particular, to sort of get trained up to deal with these behavioral 

health problems, which again didn’t really exist even as recent as 

4 or 5 years ago. 

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And, Dr. Cox, I mean you have really talked about this challenge 

that you are seeing with your staff. The Title II–A funding that 

came out of this year’s budget from the White House and the majority is zero. And, I mean, that is the exact opposite direction we 

ought to be going right now in terms of what we are seeing because 

obviously we are talking about kids in kindergarten. I mean, this 

is just the bow wave. This problem is going to get worse as kids, 

you know, obviously come in waves, you know, upcoming years as 

well as what their behavior is going to look like as they go through 

the other grades in the school system. 

So, again, can you describe what you are seeing? I mean, are you 

seeing teachers who are overwhelmed with trying to deal with behavior problems that again are just unprecedented? 

Dr. COX. Absolutely. And, you know, I refer back to my testimony. In meeting with my principals yesterday at our monthly 

meeting, every time I meet with them and when I visit schools that 

is what I hear. And just as an example of that I hear stories, today 

we had this issue, and sometimes kids do run. But the number of 

very serious discipline issues that kids have just increased. And I 

will benchmark it in 5 years that I have seen the sharp increase. 

And we have to hire additional people just to be with the kids. We 

don’t have the funding for that. I mean, we have to take it from 

somewhere else. And so, I mean, we have higher class sizes than 

we would like to because you have got to do what you have got to 

do and we don’t have enough resources to do it. 

Mr. COURTNEY. Well, what you just said is exactly what Superintendent Drezek in Enfield described, which is that they need social workers, they need help, but they are already running into 

staffing challenges just in terms of having people in the classroom. 

And so, Mr. Chairman, I would like to introduce this data from 

the town of Enfield for the record. And, again, I want to thank the 

witnesses for really raising the alarm about the fact that we are 

just dealing with the beginning of this problem, not the end of it. 

Thank you. 

Chairman BRAT. Thank you. I will recognize myself for 5 minutes 

and I will start with Ms. Miner and others can weigh in. 

Ms. Miner, do you have any experience or have children in your 

programs who have experience with recovery high schools and colleges? 

Ms. MINER. Not in my experience, no, I do not. 

Chairman BRAT. Well, I will fire away and maybe you have recommendations based on your work, and others can weigh in as 

well. 

The President’s Commission on Opioids calls for better educating 

middle school, high school, and college students with the help of 

trained professionals, such as nurses, counselors, who can assess 

at-risk kids. As you know, this epidemic does not just affect older 

working Americans, it is affecting high school and college kids as 

well. The President’s commission also calls for supporting collegiate 

recovery and changing the culture on campuses, which I think is 

great. There is a recovery high school in my district called McShin 

Academy, where they are seeing great success just 1 year into their 

program. 

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And so my question is, how can we focus on supporting recovery 

high schools and colleges where those kids are having great success? And, Ms. Miner, if you want to weigh in based on what you 

may have heard about them, and others if you want to weigh in 

as well. 

Ms. MINER. Thank you. I really have not heard a lot about them. 

I mean, it sounds like it would be something amazing because 

opioid abuse is very prevalent in high schools, in middle schools. 

I know my middle daughter, when she first got into abusing substances it was prescription pills. And she was in high school and 

then she had someone come up to her and say, hey, try this heroin. 

It is going to get you higher, keep you higher for longer, and it is 

more easily accessible and it is cheaper. And then she went to that. 

And we need to educate our kids. It is a must. They have got to 

know the effects that the drugs are going to have on them, not just 

that day, but long-term, and to be real with them. I actually go and 

talk in different schools and I am not going into the schools to tell 

the kids don’t do drugs because drugs are bad. I am real with them 

and I tell them this is why you should not do the drugs, because 

you could wind up liking them way too much. 

Chairman BRAT. Thank you. Any others want to weigh in on that 

one? Mr. Robinson? 

Mr. ROBINSON. I think one of the reasons that works so well is 

because addiction is a disease and it requires treatment and requires support. And so for kids in high school who go to a recovery 

high school, that gives them that support they need, to have a peer 

support specialist, the counselor. Same thing on the college level. 

With all the temptations that are on typical college campuses it 

would be a very hard place for somebody in addiction to go and be 

successful. And not just in high schools and colleges, but I think 

what we are doing, in taking vocational workforce development to 

get people in addiction straight out of treatment and then give 

them that vocational rehabilitation and then prepare them for a job 

to go right to work then, to produce people who can just reenter 

the workforce instead of going back and selling drugs. 

Chairman BRAT. Right. Thank you very much. I am going to ask 

a question for my colleague, Jason Lewis, from Minnesota. And if 

any of you want to weigh in on this one. Question, it is aimed at 

Ms. Miner again. Each of you has mentioned the importance of coordinating with other entities and services in the community. As 

part of the committee’s work to reform the Juvenile Justice and Delinquency Prevention Act we specifically included renewed focus on 

community coordination of services to prevent and address juvenile 

delinquency through the local delinquency prevention grant program. 

Ms. Miner, can you discuss why coordination of services at the 

community as well as identifying and addressing any gaps in services is critical to success for at-risk youth? 

Ms. MINER. I believe that is really addressing the family as a 

whole, not just the youth. Like we have said before, addiction is a 

disease and it affects the entire family. So when you are going in 

and you are working with these youth more times than not what 

I have seen is that the addiction goes back to the parents, back to 

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the grandparents. So we are not just dealing with this youth who 

is now getting in trouble. 

Collaboration is a must. We have got to talk to each other so that 

these families do not slip through the cracks so that we can actually better educate them on how they can help their whole family. 

Chairman BRAT. Okay. I would like to recognize Ms. Blunt Rochester for 5 minutes. 

Ms. BLUNT ROCHESTER. Thank you, Mr. Chairman. I first want 

to really thank the panel, Mr. Robinson and Ms. Miner, for your 

personal stories. You deeply touched me and I want to thank you 

for that and also for the work that you are doing; Dr. Wen and Dr. 

Cox for being on the front lines. I am a new member of Congress 

and so to hear you reminds me again why we are here. So I want 

to thank you all for that. 

A few weeks ago, I had an opportunity to meet with neonatal 

nurses in the State of Delaware, and we talked about neonatal abstinence syndrome. And I wanted to go back to something in your 

testimony, Dr. Wen. You said that you—in the testimony you said 

the number of babies born addicted to drugs has tripled between 

1999 and 2013. Can you talk a little bit about the long-term effects 

of neonatal abstinence syndrome on children in their academic performance? And, also, has there been enough funding or research in 

these areas to help us understand the effects of NAS on children 

as they mature? And Dr. Cox, you could also join in on that as well. 

Dr. WEN. We are seeing a skyrocketing of the number of babies 

who are born addicted to opioids. Many of these children, many of 

these babies end up having severe problems from the very beginning, including seizures and other withdrawal symptoms that could 

be fatal. And many of them end up having long-term effects as 

well, including reduced academic performance. Again, emphasizing 

why it is that we have to intervene as early as possible. And as 

early as possible means that we need to provide treatment to 

women, we need to provide treatment to pregnant women, and also 

to women before they get pregnant, and in general to people because otherwise we are going to be perpetuating the cycle where 

poverty and trauma and violence and addiction ends up in another 

generation as well. 

And I think this illustrates the necessity of early investment of 

treatment of early detection and also of reducing stigma. It is critical that we talk about addiction as a disease, as everyone here has 

been talking about, because there is treatment available, because 

we know that recovery is possible. And unless we fight that stigma 

then people are going to continue to have a disease that otherwise 

would be preventable and treatable. 

Ms. BLUNT ROCHESTER. Dr. Cox? 

Dr. COX. Sure. Dr. Wen certainly is in a better position to address the medical aspects. And, again, we have about one in five 

of our children born in our hospital who are drug affected. And so 

we make an effort to reach out to them, but we are only able to 

service about 11 percent of those identified because it is voluntary. 

And some of the things that are reported to me, the lack of executive function that the children have and just creating very difficult 

issues that gets to the learning, you have to approach that in such 

different ways and that is one of the things that we struggle with. 

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Ms. BLUNT ROCHESTER. You know, the reason why I really wanted to focus on that as particularly Ed and Workforce, we are talking about not just high school and college students or those who 

are older, but we are talking about babies and then middle school, 

as you mentioned. And so it is sort of the continuum. And I want 

us to think about how that impacts our workforce, how that impacts the quality of life, healthcare. It is all connected. 

I wanted to ask, also, Dr. Wen, is there a national standard of 

care for screening or treating NAS and how would creating one 

help improve treatment for newborns? 

Dr. WEN. We need to do a lot more when it comes to addressing 

this issue, including with a national standard. But I want to bring 

us back to how can we prevent neonatal abstinence syndrome to 

begin with, which involves early detection for pregnant women that 

includes increasing our home visiting services so that we are able 

to bring women into treatment and critically expanding treatment 

overall so that everyone has access to live saving services. 

Ms. BLUNT ROCHESTER. Thank you. Thank you, also, for mentioning home visiting. I think that is one of the most important 

programs and one that has been in jeopardy of many cuts. And so 

again, I thank each of the panelists for your testimony and I yield 

back. 

Chairman ROKITA. Thank the gentlelady. The gentleman from 

Alabama is recognized for 5 minutes. 

Mr. BYRNE. Thank you. Dr. Cox, I have a question for you. I am 

a former State school board member in Alabama and sort of keep 

up with things. And I have heard, and it is very disturbing to me, 

that a lot of our young athletes in high schools get injured in practice or in a game, they go to get treatment and their physician prescribes a painkiller, an opioid, for them and they get hooked. And 

so I am hearing a large number of our young people are hooked on 

opioids are actually starting out getting a legitimate prescription 

for pain drugs because of a sports injury, but then it just gets carried away. I mean, either they don’t understand what they are on, 

then they get hooked and they start doing inappropriate things to 

get more opioids. I don’t know if you have had any experience with 

that, if you have any views of what we can do about that. 

Dr. COX. Sure. I think it is not just student athletes, but any 

time someone presents at an ER or, you know, has a pain issue, 

part of that according to—well, our western Maryland health system has developed ER protocols and has tried to educate ER physicians about pain management, and that certainly is a problem. We 

have had students, unfortunately, that have been prescribed 

opioids and it has become a problem. But it is not limited to just 

our students. And that is an area that I think is ripe for growth, 

too. We have in my opinion too many prescriptions being written 

for opioids. 

Mr. BYRNE. I agree with you, it is bigger than athletes, but high 

schools—athletes are playing on our sports teams, et cetera, so I 

sort of feel like we have a little extra obligation to be looking out 

for them. What can we do for with our student athletes? 

Dr. COX. Well, I think it is an education effort. Maryland has 

taken a lead in this. We actually have legislation that was passed 

this year that addressed education efforts in high schools. And we 

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have—this is actually a copy of the opioid awareness and prevention kit. So it is a good resource from the Maryland State Department of Education. It is a part of our health curriculum where we 

teach our children, you know, the dangers of taking opioids when 

they are not absolutely necessary. 

So I think it is a two part. I think it is educating physicians and 

folks as they present in ER plus educating our kids through our 

curriculum and efforts to let them know ahead of time the dangers, 

that when you take substances like these they can be addictive. So 

we are addressing that way. 

Mr. BYRNE. Dr. Wen, you know, when young people, whether student athletes or not, when they come to an emergency room or 

come to a physician with a problem, they are young people, they 

don’t necessarily have the same judgment as an adult does and 

they don’t necessarily have the same knowledge of what an adult 

does. What extra do we need to be doing working with young people to help them understand, hey, this painkiller is not for you to 

take forever? And you need to be careful that you find yourself becoming too used to it and wanting to have it all the time, describing to them. What is the obligation of the medical profession with 

regard to this? 

Dr. WEN. We know that there is an overprescribing of opioids 

that is fueling this epidemic. And the CDC has put out excellent 

guidelines for urging more careful prescribing and we in Baltimore 

have been working with all of our doctors to ensure that those 

guidelines are followed. Doctors also need better tools as well. If 

opioids are the only tools that we have for pain management, that 

is what we end up turning to. But actually there are many other 

alternatives that we need to be exploring. But I think you bring up 

a very important point about what we do for young people because 

we know that what works for children is not just teaching about 

saying no, we also have to ensure that young people’s lives are not 

ones that they want to escape from. And that is why the early investment and nutrition and family literacy and housing, all of 

these other services are critical as well to prevent drug use. 

Mr. BYRNE. Now, I will just make this observation, and this is 

not in any way an indictment of the medical profession, but we 

come to you, we the nonmedical profession public come to you when 

we have a health problem. We put ourselves in your hands. Parents, we put our children in your hands. We have an injured young 

person, you know that they are going to have a lot of pain from 

whatever you are doing, you are using your professional judgment 

as to what they should be taking to deal with that pain. Maybe 

there is also an obligation on behalf of the medical profession to 

spend a little more time with the family and the young person saying, now wait a minute, this is a very serious pain pill you are taking here. This is not something for you to take lightly. Let us go 

over what you should be doing and not doing with it. 

So I just offer that observation, not in any way as an indictment 

of your profession. But I think if we all work together I think we 

can do something about this epidemic. 

With that, I yield back, Mr. Chairman. 

Chairman ROKITA. The gentleman yields back. Ms. Adams, you 

are recognized for 5 minutes. 

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Ms. ADAMS. Thank you, Mr. Chairman. And thank you all very 

much for being here and for your testimony today. Mr. Chairman, 

I want to enter into the record if we can a Time’smagazine article 

regarding the President’s desire to stop the opioid crisis and the actions that don’t match. 

Chairman ROKITA. Without objection. 

Ms. ADAMS. Thank you very much. Let me direct this first question to Dr. Wen. Do home visiting services like Head Start and 

other early learning programs make an impact on the outcomes for 

children in difficult situations? For example, when a child suffers 

from trauma due to a parent’s struggle? 

Dr. WEN. Home visiting programs make a profound difference in 

children’s lives and in the future of their families. Home visiting, 

for example, has been shown to reduce infant mortality, to improve 

health for children. Home visitors might, for example, find that 

there is paint that is peeling, that there may be lead poisoning hazards in the home. Home visiting also has been shown to increase 

educational outcomes for that child as well as for the mother. 

There can also be detection of other issues that come up during 

home visiting, for example, on domestic violence, on smoking in 

homes, on other traumatic instances for which there are interventions that are possible. For home visiting to be effective it must be 

fully funded. And not only is home visiting itself important, care 

coordination is important, too, because we also have to identify 

those families that are at greatest risk in order for the home visiting to even occur in the first place. 

Ms. ADAMS. Thank you. Are there other ways and opportunities 

to leverage early learning and early supports to respond to the 

opioid crisis? 

Dr. WEN. We need to be doing everything we can to invest in our 

children in support for their family, recognizing that things like 

housing are part of healthcare. Food and nutritional support are 

critical to education and to health. And recognizing this life course 

approach is important, too. If a child is experiencing trauma because of substance addiction in their families, what we have to do 

is to treat their families and make sure that treatment is available 

at the time that people are requesting. It just is not appropriate 

that only 1 in 10 people who have the disease of addiction are able 

to get treatment. We have to invest in treatment now because that 

is also key to preventing the cycle of addiction from fostering. 

Ms. ADAMS. Thank you. Dr. Cox, the School Superintendants Association, along with the Save Medicaid in Schools Coalition, expressed a concern about how the American Health Care Act, also 

known as the Trumpcare bill, would jeopardize healthcare for the 

Nation’s most vulnerable children. And the coalition sent a letter 

urging Congress to avert the harmful and unnecessary impacts 

that AHCA would impose on Medicaid. 

So can you discuss the role of Medicaid in providing the schoolbased health services in your county? And are you concerned about 

efforts to cut Medicaid there? 

Dr. COX. Sure. In my district alone part of our funding structure is we get about $2.5 million a year in reimbursables for the medical 

services that are delivered to our children while at school to meet 

their learning needs, and a lot of that is through their IEPs. We 

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have children that are medically fragile, all kinds of different 

things. And AASA has taken a position on that as well. I would 

just reference that about 50 percent of my children in my district 

do qualify for services for the children’s insurance healthcare, or 

CHIP. And so we are concerned about that as well. 

Ms. ADAMS. Thank you very much. Ms. Miner, thank you for 

being here, thank you for sharing your story. And I appreciate your 

comments on focusing on the whole family, which is the approach 

that we need to take to address this addiction. We have the jurisdiction over programs in this committee that serve pregnant mothers all the way to programs that serve the elderly. So we have that 

opportunity right here in our committee to address those things. 

Can you discuss why this holistic approach is absolutely needed? 

Ms. MINER. Sure. Addiction is a family disease. It does not just 

affect the addict. We have got to serve the entire family. We have 

got to go in and we have got to educate teen moms, we have got 

to educate them when they are young. I have conversations with 

my teenager and with my 8-year-old that are in my home all the 

time about drugs and alcohol and cigarettes and why they should 

not use them. And they carry this with them. They go into school 

and they talk about it. They have deep discussions with their peers 

at school. They go out in the community and talk about it as well. 

It is really about prevention and intervention with the families. 

Ms. ADAMS. Thank you very much. And, Mr. Chair, I yield back. 

I am out of time. 

Chairman ROKITA. I thank the gentlelady. Mr. Mitchell, you are 

recognized. No, no, no, Ms. Stefanik, you are recognized for 5 minutes. Excuse me. 

Ms. STEFANIK. Thank you, Mr. Chairman, and thank you to the 

committee for having this hearing today to highlight such an important issue. As we know, the opioid epidemic has wreaked havoc 

across this Nation. I represent the North Country, which is a district in upstate New York, and we have seen an exponential increase in deaths related to the heroin opioid crisis. And many of 

my local law enforcement, many of my counties, many local advocacy groups have come together to really foster these types of conversations in the local communities. 

My question, and I want to direct it to Ms. Miner to start with, 

I have met with so many families impacted, whether it is a recovering addict themselves, whether it is a parent who has lost an 

adult child, whether it is healthcare professionals, or whether it is 

principals and teachers. My question to you is, yes, it is important 

to educate our youth about risks associated with drug abuse, but 

I also think it is important that parents, teacher, guidance counselors, employers, managers, have resources and understand what 

the best practices are so they can identify this early, early enough 

to help an individual seek care. 

Can you talk about what resources you wish you had and what 

best practices there are out there? 

Ms. MINER. I wish that we had more beds available. When Dr. 

Wen had mentioned earlier about when a parent is ready and they 

say that they are ready to quit, it takes a lot for a parent to be 

able to come forth and say I can’t do this anymore, I need help. 

And then for them to be told we have nothing for you, you are 

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going to have to wait weeks or sometimes you have to wait months, 

I have seen way too many overdoses because of the parents that 

are waiting. They go back to what they know, and that is the substance use to make them feel better. 

We absolutely have to educate everyone that is involved with this 

person’s life, whether that be the schools, the employers, the community resource centers, anyone who comes in contact with this 

family, we have got to educate them and really talk about what it 

might look like, you know, if little Johnny is getting to school later 

and later, or he is missing more and more school, could there be 

a problem. And how the schools or whoever is coming in contact 

with this family can approach that child without it feeling like it 

is an interrogation or feeling like they have done something wrong 

or that they are too afraid to tell on their parents. 

Ms. STEFANIK. Let me ask you about the flip side for a parent 

being able to identify in their child, let us say a high school age 

child—I met with a recovering addict who was a nationally recognized athlete and had an injury. She went through an operation 

and was prescribed pain medication. That led to a downward spiral 

of addiction, in and out of jail. And she was a very powerful advocate about how her—she was very good at hiding it, she said. And 

her parents didn’t know, her coaches weren’t aware of this issue. 

How do we educate the parent in that situation, when the parent 

is not the addict, but they are the parent of a child who is the addict? 

Ms. MINER. I would say just we have got to break the stigma 

about addiction. Everybody looks at addiction as a really bad, dirty, 

ugly thing and they don’t look at that it could be something that 

is being prescribed, especially to our children by our doctor, because we trust these doctors with our children and they sometimes 

are the ones who are overprescribing our youth. And it is really 

about educating the parents and sitting down and talking to the 

parents about differences in what their attitudes or their behaviors 

might be like, how they are reacting to things. I know that in my 

own experience that when my daughters had started in their active 

addiction their behavior toward me changed. They became more aggressive toward me and wanted to argue with me about a lot more 

things than what they did prior to that. 

Ms. STEFANIK. And, Dr. Cox, if you could follow up from a 

school’s perspective, how do principals, teachers, coaches, guidance 

counselors, how do we arm them with the resources and the education they need to identify when a student is going down the path 

towards addiction? 

Dr. COX. Well, again, it is part of a comprehensive education effort and that is a part of our total health curriculum that starts 

in elementary school where we talk about this. And we have the 

DARE program at fifth and eighth grade, but also it really gets intense in our high school health class where we have actually recovering addicts who speak to our students. Our sheriff comes in and 

talks about all the things that he has seen. So we try to give them 

the best information that we can so that they can at least be forewarned. 

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Ms. STEFANIK. So the students are forewarned, but how about 

teachers? Not the health teacher, but the average teacher in the 

school, do they have the resources and the education they need? 

Dr. COX. Well, let me give an example of that. You know, we 

have made it part of our professional development. This year at the 

beginning of school we convened an opioid panel of community experts and we actually recorded that. So it has been made available 

for our schools to use to show our teachers. It gives them the facts 

and information. And then also—— 

Ms. STEFANIK. Thank you. My time has expired. I am sorry about 

that. 

Dr. COX. Sure. 

Chairman ROKITA. I thank the gentlelady. Time has expired. Mr. 

DeSaulnier, you are recognized for 5 minutes. 

Mr. DESAULNIER. Thank you, Mr. Chairman. And as someone 

who has spent some time on this issue in the course of my public 

service, I just want to remind folks some startling numbers. The 

United States has 4 percent of the world’s population, but we consume 80 percent of the opioids in the world. Since 2000, over 

200,000 Americans have lost their lives to opioid addiction. Four 

out of five heroin users started with the opioids. In 1995, when 

OxyContin started, the abuse of opioids was nonexistent. Quickly 

thereafter it became a catastrophe for this country. 

Ms. Miner, first to you. As the son of a parent who had addiction 

problems, whose struggle was stigma and shame, I just want to tell 

you how proud I am of your testimony and your life testimony. In 

getting over stigma and shame in my relationship with my dad, 

who was not as successful as you, he ultimately lost his life to addiction, we have come a long way. But you telling your story, but 

tell me what would have happened, do you think, as you reflect 

back, if that child welfare worker or public employee hadn’t 

interceded the way he did, when he did? Where do you think your 

life might be right now? 

Ms. MINER. I think that I would probably be dead or in prison. 

I really don’t believe that I stood much of a chance had I not had 

that one person that truly believed me and saw something in me 

that I was not able to see in myself at that time and to offer the 

supports to me for me to remain clean. 

Mr. DESAULNIER. So to take something that is very emotional 

and put it in that sort of actuarial perspective, and this goes to cost 

and responsibility and prevention, intervention is what we should 

be doing, but ultimately, Dr. Wen, as a physician we want to get 

to prevention and root cause. 

So there is a recent story, very troubling, in The New Yorker, if 

it is true, it is titled ‘‘The Family That Built an Empire on Pain.’’ 

It is about Purdue Pharma. My experience when then-Attorney 

General Kamala Harris and I were working on simply upgrading 

the prescription monitoring system in California, which came to us 

by a software engineer who was a constituent who lost two children 

who were hit by someone who was abusing and doctor shopping, 

all we wanted to do was have real-time information, so the Department of Justice, the pharmacist, the doctor, could see if anyone is 

abusing. It has been in effect now and it has worked. But it was 

obvious to me that the pharmaceutical industry and the lobbyists 

CEWDOCROOM with DISTILLER

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in Sacramento did not want that to happen. And I intuitively 

thought that it was because they were making money on the lack 

of our knowledge. 

So in this article they talk about their senior medical advisor, 

once publicly likening addiction of Oxycontin to celery, where he 

said if you take celery—he said this at an event at Columbia, talking about addiction and opioids—it is healthy for you, but if you 

blend it and put it in your arteries, inject it, it is bad for you. So 

in that article it also talks about the response from Purdue Pharma 

is that clients don’t abuse it, drug users abuse it, which, Ms. Miner, 

strikes me as throwing it right back on the addict. And personal 

responsibility is also the people who sell this. 

So could you talk to me a little bit about addiction, prevention, 

root cause, and what the ultimate cause is, and who pays for that? 

Dr. WEN. We did not get to this problem of the opioid epidemic 

overnight. There are a lot of people who have to take responsibility, 

including me as a physician. I know that I overprescribed opioids 

because that is what I learned in my medical training to do. That 

is the culture in medicine that we have to work to change. Big 

Pharma, though, plays a big role in this as well. They had misleading advertising and perpetuated this pill for every pain culture. 

If you fall down and you bruise your knee, it is okay to have pain, 

you don’t have to take it away with opioids. There is a risk, there 

is a side effect. That is something that we can all work to change 

today. 

We have been talking a lot about education in schools. And if you 

ask a student do you think heroin is good or bad, probably they 

will know that heroin is bad. But when they see their parent or 

their caregiver taking pills for back pain, for dental pain, that is 

a culture that we also have to work to change. 

Mr. DESAULNIER. So, Dr. Cox, you talked about generational addiction. So unlike tobacco, opioids we now know have addicted future generations, and people have benefitted, just like the tobacco 

industry, off of this addiction; not to ascribe blame, but trying to 

identify responsibility to get at prevention. 

Dr. Wen, back to you as a public health official. Unlike tobacco, 

we need to go back upstream. If there was a settlement agreement 

some years down the road, and I know that there is litigation 

around the country from attorney generals, the cost seems so out 

of proportion to the public cost of healthcare around secondhand 

smoke. 

Dr. WEN. We need much more investment and perhaps Big 

Pharma can help us to pay for the effects of addiction that they 

have helped to create. 

Mr. DESAULNIER. Maybe they should be held responsible. 

Thank you, Mr. Chairman. 

Chairman ROKITA. I thank the gentleman. The gentleman from 

Wisconsin is recognized for 5 minutes. 

Mr. GROTHMAN. Yes, a couple of questions. As has been mentioned, I don’t know any child out there who gets through school 

without knowing that opiates are bad for you. Nevertheless, I 

would like—Dr. Cox said something before and I would like follow 

up. You mentioned you had DARE and other programs in your 

school system. Could you or anybody else be a little more animated 

CEWDOCROOM with DISTILLER

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about what doesn’t work? What are we wasting money on so we 

can stop wasting money on it and genuinely get people not involved 

in these opioids? Could you give me examples of things that don’t, 

so you can—anybody have ideas of things that aren’t working? 

Dr. COX. I think that is a hard question to answer. I mean, you 

are talking about messaging to kids. And we don’t really have 

mechanisms to know how the messages have been effective or not. 

It admittedly is a shotgun kind of approach. 

Mr. GROTHMAN. It is a little shocking. It is shocking. You don’t 

have any opinions on things that aren’t working? I mean, I have 

read articles on things that aren’t working. None of you up here 

knows things that are not working so we can stay away from them? 

Dr. COX. Well, I will say I don’t feel that anything we are currently doing is not working. You know, specifically from our DARE 

program we get lots of parental feedback on that, it creates a great 

relationship with our law enforcement community. 

Mr. GROTHMAN. You might want to Google DARE a little bit and 

dig a little bit deeper. 

Dr. COX. I am aware of what you are speaking about. 

Mr. GROTHMAN. Okay. Next thing, I wonder if anybody could 

comment on the criminal end of this? I know in my area, at least 

in more liberal counties where a lot of the drug dealing is going on, 

it is sometimes amazing how little the penalties are and how people are getting off with very little. Does anybody want to comment 

on what we could do on the criminal justice side to maybe persuade 

people not to become dealers? Anybody have any comments on 

that? 

Mr. ROBINSON. I think one of the things to get people not to be 

drug dealers, a lot of those—you know, if we have got somebody 

that is part of a criminal syndicate, we need to prosecute them and 

put them in jail. But most of the dealers that we see are people 

that are dealing to support their habit. So the best way to get those 

dealers not dealing is to put them into a treatment program, give 

them a job skills course to allow them to go back to work and have 

a different way to support themselves than dealing drugs. And we 

have a lot of petty drug dealers that are just supporting their 

habit. 

Mr. GROTHMAN. I am talking about Milwaukee because I am 

from Wisconsin and obviously very, you know, ‘‘liberalish’’ and 

maybe ‘‘liberalish’’ judges, ‘‘liberalish’’ DA. I wonder whether 

around the country there is also a concern that there are areas of 

high drug dealing in which people are not receiving appropriate 

sentences. Given the huge number of people who are dying does 

anybody feel that you have seen not enough people being thrown 

in prison for, as a practical matter, killing people? 

Mr. ROBINSON. In Kentucky, we have broke our corrections budget in most of our counties. The county executives, their biggest cost 

that they are paying out is their jail budgets. I toured a jail a couple of weeks ago that had twice as many inmates as it was set up 

for because we have tried to incarcerate ourselves out of this. And 

we have to treat and then vocationally prepare people out of this 

problem. 

Mr. GROTHMAN. Okay. I will give you one more question, because 

we are running out of time here. Are any of you aware of any studCEWDOCROOM with DISTILLER

70 

ies of people who go through this? I know it can happen from any 

family, horrible things can happen in any family. But on the family 

background of both the dealers and the people who are, you know, 

arrested for possession, that sort of thing, do we have any studies 

on that? Any indications on, you know, where this disproportionately affects people? 

Dr. WEN. We know that 8 out of 10 people who are in our jails 

in Maryland use illegal substances. Four out of 10 have mental 

health issues—— 

Mr. GROTHMAN. No—okay. Mental health is a big issue and what 

mental health issues are those? 

Dr. WEN. It could be a combination of things, depression, schizophrenia, anxiety. They are often coexisting with substance abuse. 

And it is important for us to treat these diseases as the diseases 

that they are because an investment in public health is an investment in public safety. For every $1 invested in treatment, it saves 

society $12, including of criminal justice and incarceration costs. 

Mr. GROTHMAN. Does anybody know any different on background 

of these people? 

Mr. ROBINSON. When it comes to IV needle users, which are 

some of the folks that are most addicted, 80 percent of IV needle 

users today had a childhood trauma that is linked to their current 

issues. And so those early childhood traumas and not dealing with 

that is a major—— 

Mr. GROTHMAN. Can you describe trauma? Nobody knows what 

that means? What is a childhood trauma? 

Chairman ROKITA. I think the gentleman’s time has expired. 

Mr. GROTHMAN. Yes. Could you—— 

Chairman ROKITA. The gentleman’s time has expired. The 

gentlelady from Oregon is recognized for 5 minutes. 

Ms. BONAMICI. Thank you, Mr. Chairman. Thank you to the witnesses, value all of your testimonies but, Ms. Miner, Mr. Robinson, 

thank you so much for being here and sharing your very personal 

stories. It takes courage to do that in such a public forum, but it 

really does make a difference. 

I am from Oregon where, of course, this is affecting every community, not just urban, but also rural communities as well. In 

2015, 180 people died from just prescription opioids in Oregon. 

That doesn’t include the nonprescription. I just had a community 

discussion on opioids in Clatsop County, Oregon, which is a pretty 

rural coastal community. My constituent, Kerry Strickland, who I 

had met before, she created Jordan’s Hope for Recovery. She lost 

her son Jordan—it started with a sports injury, following up on 

what my colleagues already mentioned—after a 7-year struggle 

with addiction and relapse. And her family’s loss is just a reminder 

that we are talking about, you know real people and how this affects people in communities. 

But there were some very common themes here about the inability—and we had this roundtable—the inability when people are 

ready, the inability to get them into treatment. And there are just 

too many barriers. Like you said, we know what to do, we just 

don’t have the resources in many cases. 

This crisis is tearing our families and communities apart, but it 

is not the first time. We went through this back; it was about 30 

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years ago, when the crack cocaine epidemic that disproportionately 

affected marginalized minority communities and, unfortunately, 

our country tended to respond with increased criminalization of 

abuse and addiction. 

And, Dr. Wen, thank you for recognizing, as others have, that addiction is a disease, we should treat it as a disease. We know that 

our response then affected an entire generation of people and led 

to some pretty severe disadvantages and stalled educational 

progress and poor academic, employment, and life outcomes. So 

this is key, the conversation that we are having today. 

You know, the President just declared that the opioid crisis is a 

public health emergency, but he didn’t provide the financial resources that we need to fight the epidemic. So we don’t just need 

a declaration. We need resources and we know where they need to 

go: prevention, recovery, treatment. And by bolstering the Affordable Care Act, for example, Medicaid, fully funding the Every Student Succeeds Act, programs that provide for health services for 

our students who are in schools - this is all really important. 

I just visited a school-based health clinic in a high school in my 

district, and what a difference it makes for those students to have 

somewhere right there on campus where they can go, whether it 

be to talk to a counselor, get a vaccination, get healthcare right 

there on campus. It really makes a difference. 

Dr. Cox and Dr. Wen, according to the original Adverse Childhood Experience, ACE, study by the CDC, individuals with 4 or 

more traumas were 12 times more likely to have attempted suicide, 

7 times more likely to have alcoholism, and 10 times at greater risk 

for intravenous drug use. And we know that childhood traumas affect child brain development, children living in households, as we 

heard from Ms. Miner, with addiction are living in environments 

of chronic toxic stress. 

So Warrenton-Hammond, which is a school district again in 

Clatsop County, in my district, is helping students by their incorporating trauma-informed practices into their school system. They 

have shifted from a punitive to a compassionate approach to school 

discipline, suspensions have gone down, attendance has improved. 

So, Dr. Cox and Dr. Wen, you know that teachers and our school 

staff are oftentimes the first responders to the opioid epidemic. So 

are there tools and resources that teachers need to build around 

our knowledge of childhood trauma in order to be good first responders? And I want time for other questions. 

Dr. WEN. In Baltimore City, we have started trauma-informed 

care trainings, including for all of our frontline city workers, such 

as our teachers. We have done now trainings for over 2,000 of our 

staff so far. It is important to shift the mentality, not look at someone as the perpetrator of violence, but rather as the victim of deep 

trauma. And that will help us to break the cycle that we talked 

about. 

We also have to increase mental health services and substance 

abuse services in our schools, too. We have to provide services exactly where they are. In addition to recovery high schools, also increase services and screening right in our schools. 

Ms. BONAMICI. Thank you. And, Dr. Cox, I want you to respond 

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gress authorized Title IV–A at $1.65 billion because members on 

both sides of the aisle understand the importance of these programs. Title IV–A is currently funded at $400 million. Now, we 

have worked very closely with AASA, the School Superintendents 

Association, of which you are a member, to try to increase that 

funding. Isn’t it important that Congress uphold its promise to get 

that funding so we can get these programs into schools? 

Dr. COX. Absolutely. It is the position of AASA that we need the 

complete funding. 

Ms. BONAMICI. Thank you. It is not just the flexibility, it is the 

funding. 

And finally, I just want to close with a follow-up to the DARE 

program. I certainly hope it has been updated from its early ’80s 

days because it was woefully ineffective. And I am hoping that it 

is—— 

Dr. COX. It has. 

Ms. BONAMICI. To an evidence-based program. Because there are 

ways to figure out what works and what doesn’t. And if it is evidence-based that would be useful. 

I yield back. Thank you, Mr. Chairman. 

Chairman ROKITA. The gentlelady’s time has expired. The gentleman from Indiana is recognized for 5 minutes. 

Mr. MESSER. Thank you, Chairman Rokita. I want to thank the 

panel for your testimony today and for your stamina as we get toward the end of today’s hearing. 

You know, in Indiana, opioids are wrecking communities and 

breaking hearts all across our State. President Trump was right to 

call this a public health emergency. And despite the hard work of 

our police, first responders, public health officials, and our schools, 

leadership all across these communities, the epidemic seems to 

have only gotten worse. I think we all can agree today that more 

needs to be done. 

In Indiana, drug overdose fatalities have increased by more than 

500 percent since 1999. And estimates of the total annual cost of 

overdoses exceeds $1 billion just in my home State of Indiana 

alone. This crisis is crippling generations of Hoosiers and ripping 

apart their families and their communities. 

In Indiana, I applaud recent steps by our Governor, Eric Holcomb, who in partnership with the Hoosier healthcare providers 

are working to tackle this public health crisis. Their approach is 

designed to decrease opioid deaths, increase awareness, and decrease the number of babies born with neonatal abstinence syndrome by devoting $50 million over the next 5 years to this problem in our State. 

A couple of quick questions. First, I wanted to start just with Dr. 

Cox. You gave testimony about some of the efforts in and around 

your school. How do you train teachers to counsel students who are 

coping with addiction themselves or who may have a family member dealing with the disease? 

Dr. COX. Well, it is difficult. You know, I think part of it is developing initial understanding of what it is because there is so much 

misunderstanding about addiction. And so that is what we have 

tried to do. And we don’t have enough time resource for professional development. That is an issue as well. So it is not just the 

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money issue in terms of the professional development experience. 

But to answer your question, you know, we need to help our teachers understand what addiction is before they begin to help students 

and then refer them to counselors. 

Mr. MESSER. And do you have family based programs, trying to 

get parents more engaged as well? 

Dr. COX. We do. Again, our sheriff has done a really remarkable 

job in the community holding town hall meetings across the whole 

county. In fact, there is one this evening. And they have been well 

attended. 

Mr. MESSER. Dr. Wen, I was hoping to just get any further recommendations. I mentioned in my introduction Indiana is working 

on a program to tackle these challenges. And I wonder if you had 

any further recommendations as we get to the end of this hearing 

for States who are looking to implement programs to prevent 

deaths and increase awareness? 

Dr. WEN. The first thing that we have to do is get naloxone, the 

antidote, into the hands of every single individual, not only first responders, but we should all be able to carry it in our medicine cabinet, in our first aid kit, in our schools, in our libraries, similar to 

how we have defibrillators available at all these public places. But 

we also have to have funding so that we can get this lifesaving 

medication into the hands of everyone. 

The second is we need to have treatment for people at the time 

that they need, all types of treatment that are evidence-based, 

which includes medication-assisted treatment that has been shown 

to reduce illness and prevent overdose deaths. 

And the third is we critically have to fight stigma and encourage 

people to seek treatment. That also includes the prevention that we 

all talked about. 

We were speaking about schools and what we can do at our 

schools. The Just Say No and programs such as that are not going 

to be enough. The education for teachers will not be enough unless 

we also promote wellbeing overall, so that we provide children and 

families the support that they need in terms of food and housing 

and other critical services. 

Mr. MESSER. I do have to say to that, quickly, that I grew up in 

1980s. I am a child of the 1980s and I remember the Just Say No 

program. Frankly, I think it mattered. I mean, the 1980s were a 

time when it wasn’t cool to do drugs. Before that it was cool to do 

drugs, After that, you know, some said it was cool to do drugs. It 

wasn’t cool then and I think it is part of the answer, not the only 

answer. And I appreciate the rest of the your testimony. 

In the little limited time I have left, Mr. Robinson, I would just 

ask you to maybe comment a little further on the economic crisis 

that is being created by this opioid epidemic as well. I have talked 

to so many employers in my home State who are saying they are 

having a hard time finding the workforce they need because drugs 

is epidemic in their community. 

Mr. ROBINSON. It is happening everywhere. And as I mentioned 

in my comments, our State chamber CEO says the number one economic concern in our State—and our State is moving forward with 

economic development, but one of the big concerns is are we going 

to, as jobs come, as companies expand, are we going to be able to 

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provide enough employees that can pass drug screens? And that is 

why I think one of the places that we need to look for workforce 

is people that are in addiction today. If we can treat them, then 

put them through vocational rehabilitation, and then get them a 

work ready program to put them back to work, then we can provide 

those employees that have been treated to those employers and 

meet this need. 

Mr. MESSER. Yes. Thanks again. Thanks for your testimony. And 

thank you all for being here. 

Chairman ROKITA. Thank you, gentlemen. The gentleman’s time 

has expired. 

Mr. Barletta, the gentleman from Pennsylvania, is recognized for 

5 minutes. 

Mr. BARLETTA. Thank you. Mr. Robinson, you hit on exactly what 

I am going to talk about right now. Whenever I sit down with 

Pennsylvania business owners they tell me that a major roadblock 

in job growth in recent years has been directly connected to the 

opioid crisis. These employers have good paying jobs that they desperately need to fill, but they can’t find people who can pass a drug 

test for hiring. 

Now, Pennsylvania is not alone in this crisis. Economist Alan 

Krueger identified national labor force participation for men aged 

24–54 has fallen more in counties across America where more 

opioid pain medicine is prescribed. Chair of the Federal Reserve, 

Janet Yellen, has also acknowledged the opioid epidemic’s tragic 

and devastating effects on the workforce. Now, clearly there needs 

to be a plan of action to treat these folks so that they could work 

again. 

Mr. Robinson, in your testimony you shared how the CEO of the 

Kentucky Chamber of Commerce identified addiction as Kentucky’s 

number one economic concern. What kind of partnerships has the 

Addiction Recovery Center formed with Kentucky workforce development boards to connect individuals who can pass a drug test 

with employers? And do you have any suggestions for how business 

owners in Pennsylvania and across the country can find qualified 

individuals to fill their open positions? 

Mr. ROBINSON. I think our workforce development boards need to 

be as involved in this opioid issue as the healthcare side of this because treatment is essential. We can’t get somebody back to work 

without treating them, but we also have to be able to give them 

an economic opportunity. And so I think the workforce boards is 

the logical place for us to put funding that allows them to work not 

only with treatment providers like us and those that are doing 

workforce programs, but also to work with those employers and to 

help us in this change in the culture because there are a lot of employers that have zero tolerance programs. Those zero tolerance 

programs are not going to work in the current reality moving forward. 

And so we need to get those employers to start hiring some recovering addicts because then they will see what I have seen. A 

third of my workforce is recovering addicts and they are my best 

employees. 

And so by getting those employers engaged—and we get them to 

the table by saying, look, if you will give second chances, we will 

CEWDOCROOM with DISTILLER

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help you with the programs, the workforce programs, that you need 

to provide you with welders and truck drivers and some of these 

high-demand fields, healthcare, that they are suffering to fill those 

jobs. 

Mr. BARLETTA. Yes, and I agree. And I think the first step is getting help for people. So the public and employers and our country 

as a Nation understand that it is a disease and an illness. These 

are not people who are losers and decide they want to wreck their 

lives with drugs. This is an illness, and as a country we need to 

understand that. Get people help, treatment, and then give them 

another shot at life. 

Mr. ROBINSON. And we found as we have had people come into 

treatment, stick around and do our workforce program, it is not 1 

in 5 or 1 in 10. There is a significant number of people coming into 

our residential centers. If given a career path at the time of treatment and knowing that they are going to be able to make a living 

on the other side of it, it increases treatment motivation. And those 

become some of the most successful people that we have in our 

communities. 

Mr. BARLETTA. Well, the worst thing we can do as a Nation is 

help people and get them treatment and then slam a door in their 

face after they have gone through that when they are looking for 

another chance. 

Thank you. 

Mr. ROBINSON. Absolutely. 

Chairman ROKITA. I thank the gentleman. The gentleman yields 

back. 

I would like to again thank our witnesses for taking the time to 

be here with our subcommittees today. 

I recognize Mr. Polis for closing remarks. 

Mr. POLIS. I want to thank our witnesses for being here today 

and your compelling testimony, which will also appear in the official congressional record for the benefit of members who don’t serve 

on this committee and members who were unable to attend. Each 

of you shared stories and data about your work and about the individuals that are impacted by the opioid crisis. 

In my own community, like for so many of us, the opioid crisis 

has become very personal. For instance, my constituent Carlos 

Santos. When Carlos was in high school he was severely injured 

while playing in Summit County High School’s homecoming football game. During his recovery process, he was prescribed habitforming pain medications that later became an addiction. For years 

Carlos kept finding the pills to continue his habit until his entire 

life and health revolved around his addiction. It took a serious 

drunk driving accident to finally give Carlos a wake-up call that he 

needed to change his life. Now, years later, Carlos has successfully 

battled his addiction. But we all know that many others aren’t as 

lucky and many pay the ultimate price. 

As policymakers it is important to hear and share these stories, 

but we also have a responsibility to take these words and turn 

them into action. Throughout this hearing we have heard about 

how critical funding programs are for tackling this national crisis. 

To truly defeat this epidemic we need to fully fund programs that 

include the educational programs we have authorized in ESSA that 

CEWDOCROOM with DISTILLER

76 

we have talked about today, mental health and treatment programs; research to study pain management alternatives like cannabis and others; and, of course, fully fund and support Medicaid, 

which, of course, provides funding to organizations like Mr. Robinson’s. 

I look forward to continuing to work with my Democratic and Republican colleagues towards the goal of ending the scourge of opioid 

and substance abuse across the country. 

And I yield back the balance of my time. 

Chairman ROKITA. I thank the gentleman. Let me also add my 

comments and close out this hearing. Again, thank each of you for 

your leadership, your courage for coming here today and helping 

not only these subcommittees and this committee as a whole and 

this Congress learn more about this crisis, this emergency, but 

your help to the entire Nation. You are, as has been said in this 

hearing, on the front lines. And funding and all that surely will 

continue to be discussed and debated. 

But one thing is for sure that I learned in this hearing, is that 

you are the solutions, we are the solutions as a community. That 

one-size-fits-all approach certainly won’t be helpful to this coming 

from Washington alone. So thank you again for your leadership. 

Thank you for sharing your experiences with us. As my colleague, who sat in the chair here for a while, Mr. Brat, mentioned 

one of the bills we have been working to update—and apologies we 

did not speak more about it in terms of how it could help—is the 

Juvenile Justice and Delinquency Prevention Act. Your testimony 

today highlights the need for reforms that encourage community 

collaboration and engagement. And we have done this in H.R. 

1809. So this is just one example of how Congress can be supportive, as the gentleman mentions, to communities in responding 

to unique local needs. 

Again, your testimony has been invaluable as we learn more 

about how communities are coming together at the local level to 

address this epidemic, and it informs our discussions as we consider the next steps, including any legislation to help you do your 

jobs better, be the leaders that you are. 

So thank you again for everything that each of you do and all 

the people that you represent who are doing very similar work. 

Hearing no other business before us—— 

Mr. POLIS. Mr. Chairman, I do have a unanimous consent request. I ask unanimous consent to insert in the record a letter discussing the importance of the Medicaid expansion signed by numerous health and education organizations. 

Chairman ROKITA. I thank the gentleman. Without objection, so 

admitted. 

And having no other business before the committee we are adjourned for the day. Thank you very much. 

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[Additional submission by Ms. Adams follows:] 

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Insert offset folio 28 here 27367.028

TIME 

President Trump's Says He Wants to Stop the Opioid Crisis. 

His Actions Don't Match 

By Dr. Mary T. Bassett, Dr. Julie Morita and Dr. Barbara Ferrer November 2, 2017 

Dr. Mary T. Bassett is the Commissioner of Health for New York City, a 

position she assumed in February 2014. With more than 30 years of 

experience in public health, Dr. Bassett has dedicated her career to 

advancing health equity. 

Dr. Julie Morita was appointed as commissioner of the Chicago Department 

of Public Health (CDPH) in early 2015; under Dr. Morita's leadership, CDPH 

IDEAS developed and launched Healthy Chicago 2.0, a four-year plan to assure 

health equity by addressing the social determinants of health. 

Dr. Barbara Ferrer leads the Los Angeles County Department of Public 

Health which protects and promotes health and prevents disease among 

L.A. County's more than 10 miJJion residents. Dr. Ferrer has over three 

decades of experience as a philanthropic strategist, public health director, 

researcher, and community advocate. 

President Trump's declaration of opioids as a public health emergency left 

jurisdictions across the country- including New York City, Los Angeles and Chicago, 

the cities and county we serve as health commissioners and director- scrambling to 

understand the actual impact that this legal action will have on our response to an 

alarming increas<> in drug overdose deaths. In our cities, 2,650 people died last year 

of a drug overdose, the largest number on record. 
78 

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Insert offset folio 29 here 27367.029

Given the public health emergency designation, answers to three basic questions will 

determine the significance of this action: How much funding for public health 

responses will states and cities actually be able to access to support a long-term 

response to this deadly epidemic; how those dollars can be used; and for how long 

new funds will be available. 

To be clear, the President's declaration of a public health emergency is an overdue 

recognition of the reality of the opioid epidemic in our cities and across the country. 

But it is definitely short from the much anticipated declaration of national 

emergency the President had promised, and without much-needed resources to 

expand effective interventions it will be largely symbolic. 

The President's commission on combating the opioicl epidemic has reportedly 

finalized a 53-page recommendation document that will guide the implementation 

of this plan. While we wait for official details, we remain very concerned about the 

future of another crucial piece in our nation's response to the alarming increase in 

overdose deaths: Medicaid- perhaps the most significant source of funds to treat 

opioid addiction. 

In his speech last week, the President prompted Americans to know that the federal 

government "is aggressively fighting the opioid epidemic on all fronts." As we assess 

the President's announcement, we must remember that the true test of how seriously 

our country takes the opioid crisis will come down to our commitment to preserve 

our public insurance program for low-income people. 

Ironically, just as President Trump hypes his announcement, at the same time - in a 

position drastically at odds with a plan to combat the opioid crisis - he is still 

pressuring Congress to make extensive cuts to Medicaid. His tax plan, now being 

debated by Congress, includes a substantial $1 trillion cut to the program by 2026. 

His Administration has also overtly advocated for including cuts to Medicaid in a 

new health care bill. While not in the headlines at the moment, the legislative push 

for repealing the Affordable Care Act is far from over. In his announcement of an 

executive order on health care two weeks ago, the President promised a new bill "in 

the coming months" that will have broad support from the GOP; if the two failed 
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health care bills are any indication of what is to come, an ACA repeal will slash 

Medicaid by hundreds of billions of dollars. 

If the President succeeds at dismantling Medicaid, the emergency declaration will do 

little to reverse America's upward trend of overdose deaths. 

Medicaid has given millions of Americans access to substance use disorder 

treatment, providing health care coverage to some 3 in 10 people with opioid 

addiction in 2015. The program covers addiction treatment services, including 

reimbursement for the life-saving medications buprenorphine, methadone and 

naloxone. It also helps fund other approaches that we know work- including raising 

awareness and reducing stigma about drug use and distributing naloxone, an 

emergency medication to reverse overdose. Currently, over half of the states have 

increased access for Medicaid enrollees to naloxone. This is not just about the urban 

centers we serve; a cut to Medicaid is going to be felt in other parts of the country 

where the epidemic is acute, from New Mexico to New Hampshire. 

For a full and honest response to the opioid crisis, we urge President Trump to 

support the bipartisan health care bill currently before the Senate, which would not 

change the number of people with Medicaid or private health insurance coverage. 

The President's support of this bill, along with the emergency declaration, will 

protect access to health insurance for people with drug addiction and at risk of an 

overdose. We cannot risk their lives. Our leaders in Washington must continue to 

give Americans the resources they need to get effective care to prevent overdose and 

treat addiction. Without a true commitment to reverse this deadly trend, these 

entirely preventable deaths will continue to soar. 

TIME Ideas hosts the world's leading voices, providing commentary on events in news, society, and 

IDEAS culture. We welcome outside contributions. Opinions expressed do not necessarily reflect the views of 

TIME editors. 
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Comparison Data by Year 

DESCRIPTION 

Physical 

Assaults (others) 

Kindergarten 

2013·14 

14 

Comparison Data by Year 

DE;SCRIPTION 

emergency Protective 

Holds (others) 

Kindergarten 

20i3c14 

15 

4 

Comparison Data by Year 

DESCRIPTION 

Students with ED 

Classification 

2013-14 

96 

201'6-F'RES 

6 

14 

114 

2016-PRES 

104 

200 

150 

100 

50 

120 

90 

60 

30 

20 

15 

10 

Ill 

Ill 

Physical Assaults 

2016-pres 

Assaults{others) 

Emergency Prot-e-ctive Holds 

2013~14 2016·pres 

Students with ED Classification 

2013-14 2016-pres 

Ill Students with ED C!as:siflca!ion 
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Memorial 

DESCRIPTION 

Total # of Students 

10/19/2016-

1/12/2017 

288 

542 

Enfield Street School 

DESCRIPTION 

Total # of Students 

12/7/2016-1/11/2017 

292 

60 

Henry Barnard School 

DESCRIPTION 

Total # of Students 

52 DAYS 

Nathan Hale School 

DESCRIPTION 

Total # of Students 

11/9/16 - 1/13/17 

371 

312 

230 

198 

Student R~sponse Teams 

600 

450 

300 

150 

TOTAL # OF TOTAL # OF 

STUDENTS RESPONSES 

Crisis Intervention Teams 

300 

150 

75 

TOTAL # OF TOTAL # OF 

STUDENTS RESPONSES 

Crisis Intervention Teams 

380 

190 

TOTAL # OF TOTAL# OF 

STUDENTS RESPONSES 

Crisis Intervention Teams 

:100 

250 

?00 

150 

100 

so 

TOTAL # OF TOTAL# OF 

SoUDENTS RESPONSES 
82 

[Additional submission by Ms. Davis follows:] 

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ISSUE BRIEF 

July 2016 

Medicaid: States' Most Powerful Tool to 

Combat the Opioid Crisis 

Prepared by Oebl)r<th Bachrach, Patricia Boozang, and Mindy Lipson, Manaft Health 

Introduction 

Background 

on limited state genera! 

addillon, prior to 

~.Cxpan:-:.ion, u m.mbcr of ~tatcs limited SUD coverage tl) prcgnanl womc11- By 
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contrasL ~1dults rcct.':iYe the alternative b¢nefit plan or ABPwhich 

covers the !0 ;;;sscntial health bcnclits. SUD services. And 

expansion states arc tapping into !'cdcra! Medicaid to cover SUD 

prevention and treatm;;;nt as well as th~ full range Gf comorhid physical and 

mental health conditions that come v.ith substance use. 11 

State plan strategies 

Through the straightf(w\vard mechanism or State Plan Amendments (SPA). state Medicaid agencies can design and pay tOr a 

wide range of programs to address the opioid epidemic and other SUDs. 

COVERAGE AND BENEFITS 

l !ndcr J\ikdkaid law. states have the opportunity to tailor their hl:tlC!it packages 1o improve SUD pr.::vcntion and treatment. 

Spc,:ifkally. stmcs may: 

• Implement prior ~uthorization requirements, institute (JUantity limits, and strengthen utilization re,,iew criteria for opioid 

pn:s1.:riptions. 17 

• Expand i\1edicaid's access to and US(> of the state's Prescription Drug Monitoring Program (POMP), a state database containin~ 

information about prescrijltions for controlled substances, to identif)' Medicaid enrolled indh·iduals who may be atwrisk of opioid 

abuse and providers with lcnhmt prescribing practices.:X Washington st<1te's Medicaid is using its PDMP to identif~ 

bcnclkiarics w'ith controlled :>ubstan..::c as well as providers an above average number of 

i1sPDMP, 

• Improve timet~· access to medications used in medication-assisted treatment (MAT) by eliminatin~ or modifying prior 

authorization requirements, and n•viel\in~ prescription drug policies to ensure that they are cvidcnct-"-based and do not impose 

lifctimt\ duration, or quantity limits for :\1AT drugs that are not .clinically indicated.>' To f<t~..:-ilitate usc of MA'L Medicaid 

programs in Ohio and Texas h~wc also issued detailed provider guidan(:C on MAT billing proccdurcsJl 

• Add all forms of naloxone, a drug that can reverse an opioid owrdosc, and other evidence-based medications tOr opioid overdose 

to their preferred drug lists.:: Multiple forms of na!o"Xonc arc on the preferred drug list in California and Nt:w York, among 

other statcs.c• 
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HEALTH HOMES 

Under the ACA. state Medicaid 

Rhode Island, 

providing the fol!mving: servic,;-s: 

• lnh.>Jlsiw care mana~emcnt and care coordination for individuals \vith opioid usc disorders. These services include 

individualized care plans; helping patierHs navigate rare ;:~eross providers, behavioral health 

to benefit from 

• Provider and worktOrce education on evidence-based treatment 

induding health literacy, motivational interviev,1ing, 

LEVERAGING MEDICAID'S PURCHASING POWER 

also cmkavor to expand 

Medicaid payment rates, as 

proposes a increase in Mt::dicaid rates for 

with the stated purpose of to substance use treatment.r States can go further in SlJD delivery 

payment rmcs for providers that meet core SlJD prevention and treatment best 

meeting pati-ent-centered medical home {PCMH) standard~.~~ Notably, new 

states with the authority to health plans to contract with certain 

meet certain metrlcs, 2

') States may 

to enrollees v·.:ith SUDs. 

snm-:: strategies require using \\'aivcr authority, not just an SPA. 

for individuals with serious 

need:; or these complex 

noted that depending on the 

Demonstration waiver strategies 

payment and delivery system. 
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States arc using lll5 waivl~rs to Jhcus their St ·n and delivery systt:m reform efforts, draw down additional federal 

reform cfT~)rtS, and hold 

• Establishing integrat<.'ll delh·ery networks of physical heatthj behaYioral health, 

and social senice Through its. Delivery Reform Incentive 

New Hampshire 

networks to impnwc the continuum of care for ~"'lcdicaid 

Thcst' ndvvorks will induJc 

to create intcrdi:-;dplinary care teams 

health, s.Qcial sl.'rvicc, and long-term services 

providers. ln addition, nc~v tvkdicaid accountable care onwnlzal.wrlS 

under lVI assachusctts \waiver will be to haw memoranda of 

un<kn<llHldill£ \\itb ''B;.;havinral 

Health Home, 

• Implementing targeted dinical programs for bene1iciari<'s with SUDs. States 

of models. for 1 he 

peer 

based mental substance abuse screening and intervention, 

and mental health conditions, integration of primar) care and 

\Vithdrawrll management, 's 

quality and performance measures 

:-.Jew is implementing a !vlcdic<ltion Assisted Treatment initiative, which makes. 

with incom\!s up to 150 percent of the fPL who would otherwise have int::omc above Medicaid limits.~~ 

• Increasing access to care management and care coordination services. Under its DSRlP waiver, California 

counties, the entitic:\ overseeing structured to cocrrdination 

cnsmv that bencfkiarics successfully (i.e .. 

dismptions to services.'''~:: Massadmsctts is 

s-.~rviccs across its SUD delivery system as part of its wrmcom"'" 

Conclusion 
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End notes 

2015. Accessed May 23. 2016. 

AOrnrnrrtratron. "Mental and Substance Use Disorders.~ 

7 Substance Abuse and Mental Health Services Administration. ''Substance Use Disorders.' October 27, 2015. Accessed May 23, 2016. 

http:J/www.samhsa.govJdisorders/substance-use. 

Condltton. 

h!tp.l/vvww.samhsa.govidata/sitesidefault!fiJesireport_2073!ShortReport-2073.pdf. 

Since November 2015, Montana has implemented its Medicaid expansion. 

http://www.samhsa.gov/data!sites/defau!ttflles/report_2073/ShortReport-2073.pdf. 

Medicaid Services. 2016. Accessed June 7, 2016. 

https:!!www.medrcaid.gov/medicaid-chrp-program-informalion/prograrn-information/downtoads/march-2016-enrolhnent~report.pdf. 

23,2016. htlp:f/www~samhsa.gov/data!sites/defau!tlh!esfreport_20731ShortReport·2073.pdf. 

http ·//content hea!thaffairs. org/contenlf35/611 058. full#ref-1 B. 
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'

4 Rhode Island Executive Office of Health and Human Services_ Health Home State Plan Amendment: Rl Opioid Treatment Program Health Home 

Servtces. Baltimore: Centers for Medicare and 

/o Centers for Medicare and Medtcaid Services. Ca/iforma Med1HCal 2020 Demonstratton Specie/ Terms and Conditions. Baltimore: Centers for Medicare 

and Medicaid Serv1ces. 2015. Accessed 2016. 

April 7, 2016. Accessed June 20. 

Centers for Medicare and Medicaid Services. Califorme Medi-Cal 2020 Demonstration Special Terms and Conditions. Baltimore: Centers for Medicare 

and Medicaid Services, 2015. Accessed 2016. 
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Commonwealth of Massachusetts, Executive Office of Health and Human Services, Office of Medicaid. Section 1115 Demonstration Project Amendment 

and Extension Request Boston: Commonwealth of Massachusetts, Executive Office of Health and Human Services, Office of Medicaid, 2016. Accessed 

June 20, 2016, http:!/www. mass.gov/eohlls/docs/eohhs/cms-waiver/06·1 5-16-sectlon-1115-demonstration-extension-requestpdf. 

:w. New Hampshire Department of Health and Human Services. New Hampshire Budding Capacity for Transformation Section 1115(a) Medicaid 

Demonstration· Attachment C" DSR/P P!annmg Protocol. Concord: New Hampshire Department of Health and Human Services. 2016. Accessed May 23. 

2016, http:l!www.dhhs.nh.gov/section-1115-waiver/docurnents!nh-dsrlp-p!an-protocol-attach-c-draft-20160229.pdf: New York State Department of Health. 

New York State Del1vety System Reform lncentrve Payment Program,· Project Toolkit Albany: New York State Department of Health, 2014. Accessed 

June 5, 2016. http:l!www.health.ny.gov/health_care/medlcaid/redesign/docs/dsrip_project_too!kit.pdf. 

~ Centers for Medicare and Medicaid Services. California Medr-Caf 2020 Demonstration Special Terms and Conditions. Baltimore: Centers for Medicare 

4

' Centers for Medicare and Medicaid Services. Cal!fomm Medi-Ca! 2020 Demonstration Special Terms and Conditions. Ba!tlmore: Centers for Medicare 

4

:

1 Commonwealth of Massachusetts. Executive Office of Health and Human Services, Office of Medicaid. Section 1115 Demonstration Project Amendment 

andExt,,n.,,on Fleq<<'eSI, Boston: Commonwealth of Massachusetts, Executive Office of Health and Human Services. Office of Medicaid, 2016. Accessed 
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Appendix A 

CMS GUIDANCE ON MEDICAID COVERAGE FOR ANO PAYMENT OF SUO SERVICES 

related to 1vfcdicaid coverage and payment of SUD 

Notes 

CMCS =Center for MediCaid and CHIP Serv1ces 

SAMHSA :::: Substance Abuse and Mental Health Services Administration 

NIH :::: National Institutes of Health 
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11/7/2017 Medtcal Cannabis Laws and Op10id Mortahly l Law and Medicine I JAMA Internal Medicine! The JAMA Network 

Original Investigation 

October 2014 

Medical Cannabis Laws and Opioid Analgesic 

Overdose Mortality in the United States, 1999-2010 

Marcus A Bachhuber, MD1·

2·

3; Brendan Saloner, Ph03·4; Ch!nazo 0. Cunningham, MD, MS5; M 

t\utho1· Affdi<it!ons/\rt!de tnf0rmm1on 

JAMA Intern Med.2014;174(1 0):1668-1673. doi:10.10011jamainternmed.2014.4005 

Abstract 

Importance Opioid analgesic overdose mortality continues to rise in the United States, driven by increases 

in prescribing for chronic pain. Because chronic pain is a major incication for medical cannabis, laws that 

establish access to medical cannabis may change overdose mortality related to opioid analgesics in states 

that have enacted them. 

Objective To determine the association between the presence of state medical cannabis laws and opioid 

analgesic overdose mortality. 

Design, Setting, and Participants A time-series analysis was conducted of medical cannabis laws and 

state-level death certificate data in the United States from 1999 to 201 0; all 50 states were included. 

Exposures Presence of a law establishing a medical cannabis program in the state. 

Main Outcomes and Measures Age-adjusted opioid analgesic overdose death rate per 100 000 population 

in each state. Regression models were developed including state and year fixed effects, the presence of 3 

different policies regarding opioid analgesics, and the state-specific unemployment rate. 

Results Three states (California, Oregon, and Washington) had medical cannabis laws effective prior to 

1999. Ten states (Alaska, Colorado, Hawaii, Maine. Michigan, Montana, Nevada, New Mexico. Rhode Island, 

and Vermont) enacted medical cannabis laws between 1999 and 2010. States with medical cannabis laws 

had a 24.8% lower mean annual opioid overdose mortality rate (95% Cl, -37.5% to -9.5%; P= .003) 

compared with states without medical cannabis laws. Examination of the association between medical 

cannabis laws and opioid analgesic overdose mortality in each year after implementation of the law showed 

that such laws were associated with a lower rate of overdose mortality that generally strengthened over time: 

year 1 (-19.9%; 95% Cl, -30.6% to -7.7%; P= .002), year 2 (-25.2%; 95% Cl, -40.6% to -5.9%; P= .01), 

year 3 (-23 6%; 95% Cl, -41.1% to -1.0%; P= .04), year 4 (-20.2%; 95% Cl, -33.6% to -4.0%; P= .02), 

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111712017 Med1cal Cannabis Laws and Opiold Mortality! Law and Med1cine! JAMA Internal Medicine 1 The JAMA Network 

year 5 (-33.7%; 95% Cl, -50.9% to -10.4%; P= .008), and year 6 (-33.3%; 95% Cl, -44.7% to -19.6%; P 

< .001 ). In secondary analyses, the findings remained similar. 

Conclusions and Relevance Medical cannabis laws are associated with significantly lower state-level 

opioid overdose mortality rates. Further investigation is required to determine how medical cannabis laws 

may interact with policies aimed at preventing opioid analgesic overdose. 

Introduction 

Chronic noncancer pain is common in the United States, 1 and the proportion of patients with noncancer pain 

who receive prescriptions for opioids has almost doubled over the past decade2 1n parallel to this increase in 

prescriptions, rates of opioid use disorders and overdose deaths have risen dramatically.3ApoHcies such as 

prescription drug monitoring programs, increased scrutiny of patients and providers, and enhanced access to 

substance abuse treatment have been advocated to reduce the risk of opioid analgesics5; however, relatively 

less attention has focused on how the availability of alternative nonopioid treatments may affect overdose 

rates. 

As of July 2014, a total of 23 states have enacted laws establishing medical cannabis programs6and chronic 

or severe pain is the primary indication in most stalesT· 10Medical cannabis laws are associated with 

increased cannabis use among adults. 11This increased access to medical cannabis may reduce opioid 

analgesic use by patients with chronic pain, and therefore reduce opioid analgesic overdoses. Alternatively, if 

cannabis adversely alters the pharmacokinetics of opioids or serves as a "gateway" or "stepping stone" 

leading to further substance use, 12· 14medical cannabis laws may increase opioid analgesic overdoses. 

Given these potential effects, we examined the relationship between implementation of state medical 

cannabis laws and opioid analgesic overdose deaths in the United States between 1999 and 2010. 

Methods 

The opioid analgesic overdose mortality rate in each state from 1999 to 2010 was abstracted using the Wideranging Online Data for Epidemiologic Research interface to multiple cause-of-death data from the Centers 

for Disease Control and Prevention.' 0We defined opioid analgesic overdose deaths as fatal drug overdoses 

of any intent (International Statistical Classification of Diseases, 10th revision[ICD-10],codes X40-X44, X60-

X64, and Y10-Y14) where an opioid analgesic was also coded (T40.2-T40.4). This captures all overdose 

deaths where an opioid analgesic was involved including those involving polypharmacy or Illicit drug use (eg, 

heroin). Analysis of publicly available secondary data is considered exempt by the University of Pennsylvania 

Institutional Review Board. 

Three states (California, Oregon, and Washington) had medical cannabis laws effective prior to 19996 Ten 

states (Alaska, Colorado, Hawaii, Maine, Michigan, Montana, Nevada, New Mexico, Rhode Island, and 

Vermont) implemented medical cannabis laws between 1999 and 2010. Nine states (Arizona, Connecticut, 

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11{{12017 Medical Cannabis Laws arid Opioid Mortality j law and Medicine I JAMA Internal Medicine l The JAMA Network 

Delaware, Illinois, Maryland, Massachusetts, Minnesota, New Hampshire, and New York) had medical 

cannabis laws effective after 2010, which is beyond the study period. New Jersey's medical cannabis law 

went into effect in the last quarter of 2010 and was counted as effective after the study period. In each year, 

we first plotted the mean age-adjusted opioid analgesic overdose mortality rate in states that had a medical 

cannabis law vs states that did not. 

Next, we determined the association between medical cannabis laws and opioid analgesic-related deaths 

using linear time-series regression models. For the dependent variable, we used the logarithm of the yearand state-specific age-adjusted opioid analgesic overdose mortality rate. Our main independent variable of 

interest was the presence of medical cannabis laws, which we modeled in 2 ways. 

In our first regression model, we included an indicator for the presence of a medical cannabis law in the state 

and year. All years prior to a medical cannabis law were coded as 0 and all years after the year of passage 

were coded as 1. Because laws could be implemented at various points in the year, we coded the law as a 

fraction for years of implementation (eg, 0.5 for a law that was implemented on July 1 ). The coefficient on this 

variable therefore represents the mean difference, expressed as a percentage, in the annual opioid analgesic 

overdose mortality rate associated with the implementation of medical cannabis laws. To estimate the 

absolute difference in mortality associated with medical cannabis laws in 2010, we calculaled the expected 

number of opioid analgesic overdose deaths in medical cannabis states had laws not been present and 

subtracted the actual number of overdose deaths recorded. 

In our second model, we allowed the effect of medical cannabis laws to vary depending on the time elapsed 

since enactment, because states may have experienced delays in patient registration, distribution of 

identification cards, and establishment of dispensaries, if applicable. Accordingly, we coded years with no law 

present as 0, but included separate coefficients to measure each year since implementation of the medical 

cannabis law for states that adopted such laws. States that implemented medical cannabis laws before the 

study period were coded similarly (eg, in 1999, California was coded as 3 because the law was implemented 

in 1996). This model provides separate estimates for 1 year afier implementation, 2 years after 

implementation, and so forth. 

Each model adjusted for state and year (fixed effects). We also included 4 time-varying state-level factors: (1) 

the presence of a state-level prescription drug monitoring program (a state-level registry containing 

information on controlled substances prescribed in a state), 16(2} the presence of a law requiring or allowing a 

pharmacist to request patient identification before dispensing medications, 17 (3) the presence of regulations 

establishing increased state oversight of pain management clinics, 18and (4) state- and year-specific 

unemployment rates to adjust for the economic climate. 19Colinearity among independent variables was 

assessed by examining variance inflation factors; no evidence of colinearity was found. For all models, 

robust standard errors were calculated using procedures to account for correlation within states over time. 

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To assess the robustness of our results, we performed several further analyses. First, we excluded 

intentional opioid analgesic overdose deaths from the age-adjusted overdose mortality rate to focus 

exclusively on nonsuicide deaths. Second, because heroin and prescription opioid use are interrelated for 

some individuals.20- 23we included overdose deaths related to heroin, even if no opioid analgesic was coded. 

Third, we assessed the robustness of our findings to the inclusion of state-specific linear time trends that can 

be used to adjust for differential factors that changed linearly over the study period (eg, hard-to-measure 

attitudes or cultural changes). Fourth, we tested whether trends in opioid analgesic overdose mortality 

predated the implementation of medical cannabis laws by including indicator variables in a separate 

regression model for the 2 years before the passage of the law. 24Finally, to test the specificity of any 

association found between medical cannabis laws and opioid analgesic overdose mortality, we examined the 

association between state medical cannabis laws and age-adjusted death rates of other medical conditions 

without strong links to cannabis use: heart disease (ICD-10codes 100-109, 111, 113, and 120-151f5and 

septicemia (A40-A41 ). All analyses were performed using SAS, version 9.3 (SAS Institute Inc). 

F~esults 

The mean age-adjusted opioid analgesic overdose mortality rate increased in states with and without medical 

cannabis laws during the study period (Figure 1 ). Throughout the study period, states with medical cannabis 

laws had a higher opioid analgesic overdose mortality rate and the rates rose for both groups; however, 

between 2009 and 2010 the rate in states with medical cannabis laws appeared to plateau. 

In the adjusted model, medical cannabis laws were associated with a mean 24.8% lower annual rate of 

opioid analgesic overdose deaths (95% Cl, -37.5% to -9.5%; P= .003) (Table), compared with states without 

laws. In 2010, this translated to an estimated 1729 (95% Cl, 549 to 3151) fewer deaths than expected. 

Medical cannabis laws were associated with lower rates of opioid analgesic overdose mortality, which 

generally strengthened in the years after passage (F1guro 2): year 1 (-19.9%; 95% Cl, -30.6% to -7.7%; P 

= .002), year 2 (-25.2%; 95% Cl, -40.6% to -5.9%; P= .01), year 3 (-23.6%; 95% Cl, -41.1% to -1.0%; P 

= .04), year 4 (-20.2%; 95% Cl, -33.6% to -4.0%; P= .02), year 5 (-33.7%; 95% Cl, -50.9% to -10.4%; P 

= .008), and year 6 (-33.3%; 95% Cl, -44.7% to -19.6%; P < .001 ). The other opioid analgesic policies, as 

well as state unemployment rates, were not significantly associated with opioid analgesic mortality rates. 

In additional analyses, the association between medical cannabis laws and opioid analgesic mortality rates 

was similar after excluding intentional deaths (ie, suicide) and when including all heroin overdose deaths, 

even if an opioid analgesic was not involved (Table). Including state-specific linear time trends in the model 

resulted in a borderline significant association between laws and opioid analgesic overdose mortality 

(-17.9%; 95% Cl, -32.7% to 0.3%; P= .054). When examining the years prior to law implementation, we did 

not find an association between medical cannabis laws and opioid analgesic overdose mortality 2 years prior 

to law implementation (-13.1%; 95% Cl, -45.5% to 38.6%; P= .56) or 1 year prior (1.2%; 95% Cl, -41.2% to 

74.0%; P= .97). Finally, we did not find significant associations between medical cannabis laws and mortality 

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associated with heart disease (1.4%; 95% Cl, -0.2% to 2.9%; P= .09) or septicemia (-1 .8%; 95% Cl, -7.6% 

to 4.3%; P= .55). 

Discussion 

In an analysis of death certificate data from 1999 to 2010, we found that states with medical cannabis laws 

had lower mean opioid analgesic overdose mortality rates compared with states without such laws. This 

finding persisted when excluding intentional overdose deaths (ie, suicide), suggesting that medical cannabis 

laws are associated with lower opioid analgesic overdose mortality among individuals using opioid 

analgesics for medical indications. Similarly, the association between medical cannabis laws and lower 

opioid analgesic overdose mortality rates persisted when including all deaths related to heroin, even if no 

opioid analgesic was present, indicating that lower rates of opioid analgesic overdose mortality were not 

offset by higher rates of heroin overdose mortality. Although the exact mechanism is unclear, our results 

suggest a link between medical cannabis laws and lower opioid analgesic overdose mortality. 

Approximately 60% of all opioid analgesic overdoses occur among patients who have legitimate prescriptions 

from a single provider-"6This group may be sensitive to medical cannabis laws; patients with chronic 

noncancer pain who would have otherwise initiated opioid analgesics may choose medical cannabis instead. 

Although evidence for the analgesic properties of cannabis is limited, it may provide analgesia for some 

individuals.n,?Bin addition, patients already receiving opioid analgesics who start medical cannabis 

treatment may experience improved analgesia and decrease their opioid dose.Z9·:10thus potentially 

decreasing their dose-dependent risk of overdose. 31 ·

32Finally, if medical cannabis laws lead to decreases in 

polypharmacy-particularly with benzodiazepines-in people taking opioid analgesics, overdose risk would 

be decreased. Further analyses examining the association between medical cannabis laws and patterns of 

opioid analgesic use and polypharmacy in the population as a whole and across different groups are needed. 

A connection between medical cannabis laws and opioid analgesic overdose mortality among individuals 

who misuse or abuse opioids is less clear. Previous laboratory work has shown that cannabinoids act at least 

in part through an opioid receptor mechanism33·

34and that they increase dopamine concentrations in the 

nucleus accumbens in a fashion similar to that of heroin and several other drugs with abuse 

potential. 33·

35Ciinically, cannabis use is associated with modest reductions in opioid withdrawal symptoms 

for some people, :'"·37 and therefore may reduce opioid use. In contrast, cannabis use has been linked with 

increased use of other drugs, including opioids 14•

38- 40; however, a causal relationship has not been 

establishedH·41 1ncreased access to cannabis through medical cannabis laws could influence opioid misuse 

in either direction, and further study is required. 

Although the mean annual opioid analgesic overdose mortality rate was lower in states with medical 

cannabis laws compared with states without such laws, the findings of our secondary analyses deserve 

further consideration. State-specific characteristics, such as trends in attitudes or health behaviors, may 

explain variation in medical cannabis laws and opioid analgesic overdose mortality, and we found some 

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evidence that differences in these characteristics contributed to our findings. When including state-specific 

linear time trends in regression models, which are used to adjust for hard-to-measure confounders that 

change over time, the association between laws and opioid analgesic overdose mortality weakened. In 

contrast, we did not find evidence that states that passed medical cannabis laws had different overdose 

mortality rates in years prior to law passage, providing a temporal link between laws and changes in opioid 

analgesic overdose mortality. In addition, we did not find evidence that laws were associated with differences 

in mortality rates for unrelated conditions (heart disease and septicemia), suggesting that differences in 

opioid analgesic overdose mortality cannot be explained by broader changes in health. In summary, although 

we found a lower mean annual rate of opioid analgesic mortality in states with medical cannabis laws, a 

direct causal link cannot be established. 

This study has several limitations. First, this analysis is ecologic and cannot adjust for characteristics of 

individuals within the states, such as socioeconomic status, race/ethnicity, or medical and psychiatric 

diagnoses. Although we found that the association between medical cannabis laws and lower opioid 

overdose mortality strengthened in the years after implementation, this could represent heterogeneity 

between states that passed laws earlier in the study period vs those that passed the laws later. Second, 

death certificate data may not correctly classify cases of opioid analgesic overdose deaths, and reporting of 

opioid analgesics on death certificates may differ among states; misclassification could bias our results in 

either direction. Third, although fixed-effects models can adjust for time-invariant characteristics of each state 

and state-invariant time effects, there may be important time- and state-varying confounders not included in 

our models. Finally, our findings apply to states that passed medical cannabis laws during the study period 

and the association between future laws and opioid analgesic overdose mortality may differ. 

Conclusions 

Although the present study provides evidence that medical cannabis laws are associated with reductions in 

opioid analgesic overdose mortality on a population level, proposed mechanisms for this association are 

speculative and rely on indirect evidence. Further rigorous evaluation of medical cannabis policies, including 

provisions that vary among states, 14 •

42is required before their wide adoption can be recommended. If the 

relationship between medical cannabis laws and opioid analgesic overdose mortality is substantiated in 

further work, enactment of laws to allow for use of medical cannabis may be advocated as part of a 

comprehensive package of policies to reduce the population risk of opioid analgesics. 

Article Information Back to top 

Accepted for Publication:May 2, 2014. 

Corresponding Author: Marcus A. Bachhuber, MD, Center for Health Equity Research and Promotion, 

Philadelphia Veterans Affairs Medical Center, 423 Guardian Dr, 1303-A Blockley Hall, Philadelphia, PA 

19104 (marcus.!Jachhuber@gmail. corn). 

https.l/jamanetwork.comfjourna!s/jamalntemalmedicioe/fu!lartic!e/1898878 618 
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11[712017 Medical Cannabis Laws and Opioid Mortallty 1 Law and Medicine 1 JAMA Internal Medicine jl he JAMA Netwo~k 

Published Online:August 25,2014. doi:10.10011jamainternmed.2014.4005. 

Author Contributions: Dr Bachhuber had full access to all the data in the study and takes responsibility for 

the integrity of the data and the accuracy of the data analysis. 

Study concept and design:Bachhuber, Saloner, Barry. 

Acquisition, analysis, or interpretation of dala:Bachhuber, Cunningham, Barry. 

Drafting of the manuscript:Bachhuber, Sa loner. 

Critical revision of the manuscript for important intellectual content: All authors. 

Statistical analysls:Bachhuber, Saloner, Barry. 

Study supervision.·Cunningham, Barry. 

Conflict of Interest Disclosures: Dr Cunningham's husband was recently employed by Pfizer 

Pharmaceuticals and is currently employed by Quest Diagnostics. No other disclosures are reported. 

Funding/Support: This work was funded by National Institutes of Health (NIH) grants R01 DA032110 and 

R25DA023021 and the Center for AIDS Research at the Albert Einstein College of Medicine andMontefiore 

Medical Center grant NIH Al-51519. Dr Sa loner received funding support from the Robert Wood Johnson 

Foundation Health and Society Scholars Program. Dr Bachhuber received funding support from the 

Philadelphia Veterans Affairs Medical Center and the Robert Wood Johnson Foundation Clinical Scholars 

Program. 

Role of the Sponsor: The sponsors had no role in the design and conduct of the study; collection, 

management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and 

decision to submit the manuscript for publication. 

Disclaimer: The findings and conclusions of this article are those of the authors and do not necessarily 

reflect the position or policy of the Department of Veterans Affairs or the US government. 

Corrections:This article was corrected on August 27, 2014, to fix a typographical error in Figure 1 and on 

September 10, 2014, to fix an incorrect term in the Discussion. 

References 

1. 

2. 

3. 

4. 

5. 

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May 2, 2017 

Re: The American Health Care Act Vote 

The Honorable Mitch McConnell 

Majority Leader 

U.S. Senate 

Washington, DC 20510 

The Honorable Paul Ryan 

Speaker 

U.S. House of Representatives 

Washington, DC 20515 

The Honorable Chuck Schumer 

Minority Leader 

U.S. Senate 

Washington, DC 20510 

The Honorable Nancy Pelosi 

Minority Leader 

U.S. House of Representatives 

Washington, DC 20515 

Dear Majority Leader McConnell, Speaker Ryan, Minority Leader Schumer, and Minority 

Leader Pelosi: 

The undersigned member organizations of the Save Medicaid in the Schools Coalition are 

concerned that the American Health Care Act (AHCA) jeopardizes healthcare for the 

nation's most vulnerable children: students with disabilities and students in poverty. 

Specifically, the AHCA reneges on Medicaid's 50+ year commitment to provide America's 

children with access to vital healthcare services that ensure they have adequate 

educational opportunities and can contribute to society by imposing a per-capita cap and 

shifting current and future costs to taxpayers in every state and Congressional district. 

While children currently comprise almost half of all Medicaid beneficiaries, less than one in 

five dollars is spent by Medicaid on children. Accordingly, a per-capita cap, even one that is 

based on different groups of beneficiaries, will disproportionally harm children's access to 

care, including services received at school. Considering these unintended 

consequences, we urge a 'no" vote on The American Health Care Act (AHCA). 

Medicaid is a cost-effective and efficient provider of essential health care services for 

children. School-based Medicaid programs serve as a lifeline to children who can't access 

critical health care and health services outside of their school. Under this bill, the bulk of 

the mandated costs of providing health care coverage would be shifted to the States even 

though health needs and costs of care for children will remain the same or increase. Most 

analyses of the AHCA project that the Medicaid funding shortfall in support of these 

mandated services will increase, placing states at greater risk year after year. The federal 

disinvestment in Medicaid imposed by the AHCA will force States and local communities to 

increase taxes and reduce or eliminate various programs and services, including other nonMedicaid services. The unintended consequences of the AHCA will force states to cut 

eligibility, services, and benefits for children. 

The projected loss of $880 billion in federal Medicaid dollars will compel States to ration 

health care for children. Under the per-capita caps included in the AHCA, health care will 

be rationed and schools will be forced to compete with other critical health care providershospitals, physicians, and clinics- that serve Medicaid-eligible children. School-based 

health services are mandated on the States and those mandates do not cease simply 
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because Medicaid funds are capped by the AHCA. As with many other unfunded mandates, 

capping Medicaid merely shifts the financial burden of providing services to the States. 

Medicaid Enables Schools to Provide Critical Health Care for Students 

A school's primary responsibility is to provide students with a high-quality education. 

However, children cannot learn to their fullest potential with unmet health needs. As such, 

school district personnel regularly provide critical health services to ensure that all 

children are ready to learn and able to thrive alongside their peers. Schools deliver health 

services effectively and efficiently since school is where children spend most of their days. 

Increasing access to health care services through Medicaid improves health care and 

educational outcomes for students. Providing health and wellness services for students in 

poverty and services that benefit students with disabilities ultimately enables more 

children to become employable and attend higher-education. 

Since 1988, Medicaid has permitted payment to schools for certain medically-necessary 

services provided to children under the Individuals with Disabilities Education Act (IDEA) 

through an individualized education program (IEP) or individualized family service 

program (IFSP). Schools are thus eligible to be reimbursed for direct medical services to 

Medicaid-eligible students with an IEP or IFSP. In addition, districts can receive Medicaid 

reimbursements for providing Early Periodic Screening Diagnostic and Treatment Benefits 

(EPSDT), which provide Medicaid-eligible children under age 21 with a broad array of 

diagnosis and treatment services. The goal of EPSDT is to assure that health problems are 

diagnosed and treated as early as possible before the problems become complex and 

treatment is more expensive. 

School districts use their Medicaid reimbursement funds in a variety of ways to help 

support the learning and development of the children they serve. In a 2017 survey of school 

districts, district officials reported that two-thirds of Medicaid dollars are used to support 

the work of health professionals and other specialized instructional support personnel (e.g., 

speech-language pathologists, audiologists, occupational therapists, school psychologists, 

school social workers, and school nurses) who provide comprehensive health and mental 

health services to students. Districts also use these funds to expand the availability of a 

wide range of health and mental health services available to students in poverty, who are 

more likely to lack consistent access to healthcare professionals. Further, some districts 

depend on Medicaid reimbursements to purchase and update specialized equipment (e.g., 

walkers, wheelchairs, exercise equipment, special playground equipment, and equipment to 

assist with hearing and seeing) as well as assistive technology for students with disabilities 

to help them learn alongside their peers. 

School districts would stand to lose much of their funding for Medicaid under the AHCA. 

Schools currently receive roughly $4 billion in Medicaid reimbursements each year. Yet 

under this proposal, states would no longer have to consider schools as eligible Medicaid 

providers, which would mean that districts would have the same obligation to provide 

services for students with disabilities under IDEA, but no Medicaid dollars to provide 

medically-necessary services. Schools would be unable to provide EPSDT to students, which 

would mean screenings and treatment that take place in school settings would have to be 
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moved to physician offices or hospital emergency rooms, where some families may not visit 

regularly or where costs are much higher. 

In addition, basic health screenings for vision, hearing, and mental health problems for 

students would no longer be possible, making these problems more difficult to address and 

expensive to treat. Moving health screenings out of schools also reduces access to early 

identification and treatment, which also leads to more costly treatment down the road. 

Efforts by schools to enroll eligible students in Medicaid, as required, would also decline. 

The Consequences of Medicaid Per Capita Caps Will Potentially Be Devastating 

for Children 

Significant reductions to Medicaid spending could have devastating effects on our nation's 

children, especially those with disabilities. Due to the underfunding ofiDEA, districts rely 

on Medicaid reimbursements to ensure students with disabilities have access to the 

supports and services they need to access a Free and Appropriate Public Education (FAPE) 

and Early Intervention services. Potential consequences of this critical loss offunds include: 

Fewer health services: Providing comprehensive physical and mental health services 

in schools improves accessibility for many children and youth, particularly in highneeds and hard-to-serve areas, such as rural and urban communities. In a 2017 

survey of school district leaders, half of them indicated they recently took steps to 

increase Medicaid enrollment in their districts. Reduced funding for Medicaid would 

result in decreased access to critical health care for many children. 

Cuts to general education: Cuts in Medicaid funding would require districts to divert 

funds from other educational programs to provide the services as mandated under 

IDEA. These funding reductions could result in an elimination of program cuts of 

equivalent cost in "non-mandated" areas of regular education. 

Higher taxes: Many districts rely on Medicaid reimbursements to cover personnel 

costs for their special education programs. A loss in Medicaid dollars could lead to 

deficits in districts that require increases in property taxes or new levies to cover the 

costs of the special education programs. 

Job loss: Districts use Medicaid reimbursement to support the salaries and benefits 

of the staff performing eligible services. Sixty-eight percent of districts use Medicaid 

funding to pay for direct salaries for health professionals who provide services for 

students. Cuts to Medicaid funding would impact districts' ability to maintain 

employment for school nurses, physical and occupational therapists, speechlanguage pathologists, school social workers, school psychologists, and many other 

critical school personnel who ensure students with disabilities and those with a 

variety of educational needs are able to learn. 

Fewer critical supplies: Districts use Medicaid reimbursement for critical supplies 

such as wheelchairs, therapeutic bicycles, hydraulic changing tables, walkers, 

weighted vests, lifts, and student-specific items that are necessary for each child to 

access curriculum as closely as possible to their non-disabled peers. Replacing this 
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equipment would be difficult if not impossible without Medicaid reimbursements. 

Fewer mental health supports: Seven out often students receiving mental health 

services receive these services at schooL Cuts to Medicaid would further marginalize 

these critical services and leave students without access to care. 

Noncompliance with IDEA: Given the failure to commit federal resources to fully 

fund IDEA, Medicaid reimbursements serve as a critical funding stream to help 

schools provide the specialized instructional supports that students with disabilities 

need to be educated alongside their peers. 

We urge you to carefully consider the important benefits that Medicaid provides to our 

nation's most vulnerable children. Schools are often the hub of the community, and 

converting Medicaid's financing structure to per-capita caps threatens to significantly 

reduce access to comprehensive health and mental and behavioral health care for children 

with disabilities and those living in poverty. We look forward to working with you to avert 

the harmful and unnecessary impacts the AHCA would impose on Medicaid, which has 

proven to benefit children in a highly effective and cost-effective manner. 

If you have questions about the letter or wish to meet to discuss this issue further, please 

do not hesitate to reach out to the coalition co-chairs via email: John Hill 

(john.hill@medicaidforeducation.org), Sasha Pudelski (spudelski@aasa.org), and Kelly 

Vaillancourt Strobach (kvaillancourt@naspweb.org). 

Sincerely, 

AASA, The School Superintendents Association 

AccelifY 

American Civil Liberties Union 

American Dance Therapy Association 

American Federation of Teachers 

American Foundation for the Blind 

American Occupational Therapy Association 

American Psychological Association 

Association of Assistive Technology Act Programs 

Association of Educational Service Agencies 

Association of School Business Officials International (ASBO) 

Association of University Centers on Disabilities 

Autistic Self Advocacy Network 

Center for American Progress 

Center for Public Representation 

Clearinghouse on Women's Issues 

Colorado School Medicaid Consortium 

Conference of Educational Administrators of Schools and Programs for the Deaf 

Council for Exceptional Children 

Council of Administrators of Special Education 

Council of Parent Attorneys and Advocates 

Disability Rights Education & Defense Fund 
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Division for Early Childhood of the Council for Exceptional Children (DEC) 

Health and Education Alliance of Louisiana 

Healthy Schools Campaign 

Healthmaster Holdings LLC 

Higher Education Consortium for Special Education 

Judge David L. Bazelon Center for Mental Health Law 

LEAnet, a national coalition of local education agencies 

Learning Disabilities Association of America 

Lutheran Services in America Disability Network 

Michigan Association of Intermediate School Administrators 

Michigan Association of School Administrators 

National Association of Pediatric Nurse Practitioners 

National Association of School Nurses 

National Association of School Psychologists 

National Association of Social Workers 

National Association of State Directors of Special Education (NASDSE) 

National Association of State Head Injury Administrators 

National Black Justice Coalition 

National Black Justice Coalition 

National Center for Learning Disabilities 

National Association of Councils on Developmental Disabilities 

National Disability Rights Network 

National Down Syndrome Congress 

National Education Association 

National Health Law Program 

National Respite Coalition 

National Rural Education Advocacy Collaborative 

National Rural Education Association 

National School Boards Association 

Paradigm Healthcare Services 

School Social Work Association of America 

School-Based Health Alliance 

Share Our Strength 

Society for Public Health Education 

Teacher Education Division of the Council for Exceptional Children 

The Arc of the United States 

United Way Worldwide 
102 

[Questions submitted for the record and their responses follow:] 

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December 19, 201 7 

r-nuAn~T·rcr:: ON EDUCATION 

AND THE WORKFORCE 

WASHINGTON, DC 20515-6100 

Leana S. Wen, M.D., MSc., FAAEM 

Commissioner of Health for the City of Baltimore 

Baltimore City Health Department 

1001 E. Street 

Baltimore, 21202 

Dear Dr. Wen: 

Thank you, 

hearing 

for testifying before the Committee on Education and the Workforce at the 

to Home: How Opioids are Impacting Conununities" on Wednesday, 

November 8, 2017. 

As a to your testimony, please find enclosed additional questions submitted by a 

member of the for inclusion in the final hearing record. Please provide your written 

Sincerely, 

Jake Middlebrooks no later than January 3, 2017. 

should you have any questions about this request 
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Dr. Wen 

December 19. 2017 

Pe1gc 2 

Rep. Marcia Fudge (D-OH) 

1. Dr. Wen, the President declared the opioid epidemic a Public Health Emergency in 

October. What does that mean for you as the head of a local public health agency? 

Without funding to go with the declaration, does a federal declaration make any real 

irnpact0 

2. In your testimony you mention Baltimore's diversion eiiorts such as Drug Treatment 

Courts. We have also had drug courts in Cleveland since 1998, with hundreds 

successfully completing the program and realizing thousands of dollars in savings per 

participant for treatment and diversion over that of incarceration. Could you speak more 

about the outcomes you have seen from these diversion programs? What impact does 

having treatment placement immediately available have on participation? 

3. I have beard tl·Oin several stakeholders that the Institution for Mental Disease (IMD) 

exclusion presents a barrier to treatment for Medicaid recipients. Can you discuss how 

this exclusion, affects your ability to get people who need the help, access to substance 

abuse treatment? 
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CITY OF BALTIMORE 

CATHERINE E. PUGH, Mayor 

HEALTH DEPARTMENT 

Leana S. Wen, M.D., M.Sc., FAAEM 

Commissioner of Health 

1001 E. Fayette St. 

TO: 

FROM: 

RE: 

Baltimore, MD 21202 

health commissioner@baltimorecjtygoy 

Tel: 410-396-4387 

January 2, 2018 

Members of the Subcommittee on Early Childhood, Elementary, and Secondary 

Education and the Subcommittee on Higher Education and Workforce 

Development 

Dr. Leana Wen, Baltimore City Health Commissioner 

Answers for the record 

Dr. Leana Wen 

"Close to Home: How Opioids are Impacting Communities" 

November 8, 20 17 

1. Dr. Wen, the President declared the opioid epidemic a Public Health Emergency in 

October. What does that mean for you as the head of a local public health agency? Without 

funding to go with the declaration, does a federal declaration make anv real impact? 

a. While l commend the President for raising awareness about the opioid epidemic through 

his Public Health Emergency declaration. his announcement did not come with a 

commitment for additional federal funding that is so desperately needed to save lives. 

National state of emergency declarations come with commitments for funding-new 

funding, not funding that is diverted from other critical priorities. When hurricanes 

devastate communities, it's understood that billions of dollars are required to rebuild 

homes and repair infrastructure. The same understanding applies for stopping an 

epidemic. In Baltimore and across the country, we desperately need these resources. 

Studies show that only I in I 0 people with addiction receive the treatment that they 

need-a statistic we would not find acceptable for any other disease. 

b. We look to the President and to Congress to announce a specific dollar amount for new 

funding, not repurposed dollars that take away from other key health priorities. Without 

such a commitment, the Declaration will not be etlectivc on the frontlines of this 

epidemic. 

c. If funding were to be allocated, we urge that Congress allocate new funding directly to 

local jurisdictions hardest hit by the opioid epidemic. While states have traditionally 

received block grants from the federal government, local jurisdictions are closest to the 

ground in service delivery, and understand the needs of residents the best. We urge 

Congress to consider direct support for local jurisdictions, particularly those in areas of 

greatest need, by providing cities and counties with the autonomy to innovate and provide 

real-time care tor our residents. Cities and counties have been fighting this epidemic for 
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years. We know what works, and local officials should not have to jump through 

additional hoops to obtain the resources we need. In Baltimore, we have saved 1,500 

lives in just two years with very limited resources. Imagine how many tens of thousands 

of lives can be saved around the country, if only we had the willpower to do so in the 

form of a real state of emergency declaration. 

2. In vour testimony you mention Baltimore's diversion efforts such as Drug Treatment 

Courts. We have also had drug courts in Cleveland since 1998, with hundreds successfully 

completing the program and realizing thousands of dollars in savings per participant for 

treatment and diversion over that of incarceration. Could you speak more about the 

outcomes you have seen from these diversion programs? What impact does having 

treatment placement immediately available have on participation'! 

a. Baltimore Citv has a Drug Treatment program that has produced many anecdotal positive 

outcomes, with graduates reentering the workforce and reclaiming their families and 

lives. There is currently no longitudinal data due to funding and personnel constraints. 

We are seeking additional funding to track outcomes and formally evaluate the program. 

This and many other behavioral health programs are extremely underfunded, a problem 

that exists around the country. 

b. Based on anecdotal observations, numerous participants are completing Drug Treatment 

Court and getting connected with a recovery residence when necessary. A number of 

these participants are obtaining employment once they enter into Phase III of the Drug 

Treatment Court program. Some individuals are hired by their treatment programs (e.g., 

as house managers of their residential program) after they have been in recovery for a 

certain period of time (usually one year). These individuals often express how important 

it is for them to "give back" to the treatment facilities that helped them. 

c. It is important to mention that Drug Treatment Court is entirely grant funded. Thus, the 

development of a system to track the outcomes of participants would have to be paid for 

through additional grant funding. At the moment, the program has a database that 

captures participants' demographics, education levels, employment statuses, referral 

services, and other relevant information when they enter Drug Treatment Court. 

However, that database does not capture outcomes or drug testing results from parole or 

probation. Anecdotally, we have observed that some Drug Treatment Court graduates 

enroll in vocational/job training programs. For those who were employed when they 

enrolled in Drug Treatment Court, Court staff work with individuals' employers to help 

them keep their jobs, but have had varying levels of success. Therefore, while eliminating 

the !MD exclusion is important (as noted in Question #3), additional, sustained funding is 

critical to ensuring that Drug Treatment Court programs can afford the necessary 

personnel and develop the systems needed to properly assess their outcomes. 

d. It is unclear whether having treatment placement immediately has an impact on Drug 

Treatment Court participation. Again, anecdotally speaking, the result is mixed: For some 

individuals, treatment placement matters tremendously, and they are eager for the 

opportunity to plea to Drug Treatment Court. Others may see Drug Treatment Court as a 

2 
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way to avoid jail time, or they may not fully comprehend the commitment-level and 

various requirements involved with Drug Treatment Court. On the other hand, some 

individuals are aware of the commitments involved or believe they might receive 

probation, and consequently, may decide not to plea into Drug Treatment Court. 

e. If Drug Treatment Courts divert individuals from the criminal justice system to treatment, 

local governments need additional funds to ensure that the treatment programs they enter 

are available and of good quality. Thus, increased funding would not only help Drug 

Treatment Courts develop a system to track program outcomes, but would also ensure 

that the intended benefits of program participation are being achieved. 

3. [ have heard from several stakeholders that the Institution for Mental Disease (IMD) 

exclusion presents a barrier for Medicaid recipients. Can you discuss how this exclusion 

affects your ability to get people who need the help, access to substance abuse treatment? 

a. In addition to treating patients, we must also change the dialogue around the nature of 

substance use disorders while we work towards preventing addiction. This effort has 

multiple components, including educating doctors and the public, and providing 

prevention and early intervention services throughout the life course. 

b. The IMD exclusion is a needless constraint on the country's ability to offer treatment to 

individuals with opioid use disorder. Maryland is fortunate to have recently been partially 

exempted from this exclusion as part of its Medicaid waiver, and we can thus speak from 

experience about the importance of eliminating it. The exclusion means that public 

funding for substance use disorder treatment is not adequately sensitive to need. 

c. Since treatment facilities with more than 16 beds cannot be funded through Medicaid, 

states must instead use block grants, allocating each facility some portion of whatever 

funding is available. This typically means that a facility will contract with a state or local 

agency to make a specific number of beds available over the course of a set amount of 

time (say, a year). This requires predicting how many beds will be needed-but of course 

such a prediction is impossible. If a treatment facility finds that demand exceeds the 

capacity for which it has contracted, there is often no recourse; it cannot expand services 

in response to increased demand. 

d. Eliminating the !MD exclusion and allowing Medicaid to fund these treatment centers 

allows them to shift to a fee-for-service model, where services can to some extent expand 

and contract in response to demand. And eliminating the exclusion would not just mean 

that individual treatment centers no longer need to worry about hitting an artificial 

funding cap. The same would be true for states themselves. Since Medicaid is an 

entitlement program, Medicaid funding for the treatment of opioid use disorder can 

expand as needed over time; if states could leverage those dollars, they would not be held 

hostage to finite block grants (the sizes of which cannot help but be somewhat arbitrary). 

e. It is important to clarify the following: While directing Medicaid funding to treating 

opioid use disorder is important, there are essential services for which Medicaid does not 

3 
107 

[Whereupon, at 12:47 p.m., the Subcommittees were adjourned.] 

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