Title: CARA 2.0 Act of 2018
Policy area: Health

Summary:
CARA 2.0 Act of 2018
This bill reauthorizes through FY2023 and revises several programs relating to opioid- and substance-use disorder prevention and treatment, including awareness campaigns and training programs for first responders; the bill also establishes several requirements relating to opioid prescribing practices, such as an initial three-day supply limit for certain opioids.

[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[S. 2456 Introduced in Senate (IS)]

<DOC>






115th CONGRESS
  2d Session
                                S. 2456

   A bill to reauthorize and expand the Comprehensive Addiction and 
                         Recovery Act of 2016.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           February 27, 2018

 Mr. Portman (for himself, Mr. Whitehouse, Mrs. Capito, Ms. Klobuchar, 
Mr. Sullivan, Ms. Hassan, Mr. Cassidy, and Ms. Cantwell) introduced the 
 following bill; which was read twice and referred to the Committee on 
                 Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL


 
   A bill to reauthorize and expand the Comprehensive Addiction and 
                         Recovery Act of 2016.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``CARA 2.0 Act of 2018''.

SEC. 2. NATIONAL EDUCATION CAMPAIGN.

    Section 102 of the Comprehensive Addiction and Recovery Act of 2016 
(42 U.S.C. 290bb-25g) is amended by adding at the end the following:
    ``(d) Authorization of Appropriations.--There is authorized to be 
appropriated to carry out this section, $10,000,000 for each of fiscal 
years 2019 through 2023.''.

SEC. 3. THREE-DAY LIMIT ON OPIOID PRESCRIPTIONS.

    Section 303 of the Controlled Substances Act (21 U.S.C. 823) is 
amended by adding at the end the following:
    ``(l) Three-Day Limit on Opioid Prescriptions.--
            ``(1) Definitions.--In this subsection--
                    ``(A) the term `acute pain'--
                            ``(i) means pain with abrupt onset and 
                        caused by an injury or other process that is 
                        not ongoing; and
                            ``(ii) does not include--
                                    ``(I) chronic pain;
                                    ``(II) pain being treated as part 
                                of cancer care;
                                    ``(III) hospice or other end-of-
                                life care; or
                                    ``(IV) pain being treated as part 
                                of palliative care; and
                    ``(B) the term `addiction treatment opioid 
                prescription' means a prescription--
                            ``(i) for an opioid drug in schedule II, 
                        III, or IV approved by the Food and Drug 
                        Administration for an indication for the 
                        treatment of addiction; and
                            ``(ii) that is for the treatment of 
                        addiction.
            ``(2) Three-day limit.--The Attorney General may not 
        register, or renew the registration of, a practitioner under 
        subsection (f) who is licensed under State law to prescribe 
        controlled substances in schedule II, III, or IV, unless the 
        practitioner submits to the Attorney General, for each such 
        registration or renewal request, a certification that the 
        practitioner, during the applicable registration period, will 
        not prescribe any opioid in schedule II, III, or IV, other than 
        an addiction treatment opioid prescription, for the initial 
        treatment of acute pain in an amount in excess of a 3-day 
        supply.''.

SEC. 4. FIRST RESPONDER TRAINING.

    Section 546 of the Public Health Service Act (42 U.S.C. 290ee-1) is 
amended--
            (1) in subsection (c)--
                    (A) in paragraph (2), by striking ``and'' at the 
                end;
                    (B) in paragraph (3), by striking the period and 
                inserting ``; and''; and
                    (C) by adding at the end the following:
            ``(4) train and provide resources for first responders and 
        members of other key community sectors on safety around 
        fentanyl and other dangerous illicit drugs to protect 
        themselves from exposure and respond appropriately when 
        exposure occurs.'';
            (2) in subsection (d), by inserting ``, and safety around 
        fentanyl and other dangerous illicit drugs'' before the period;
            (3) in subsection (f)--
                    (A) in paragraph (3), by striking ``and'' at the 
                end;
                    (B) in paragraph (4), by striking the period and 
                inserting a semicolon; and
                    (C) by adding at the end the following:
            ``(5) the number of first responders and members of other 
        key community sectors trained on safety around fentanyl and 
        other dangerous illicit drugs.''; and
            (4) in subsection (g), by inserting before the period the 
        following: ``, and $300,000,000 for each of fiscal years 2019 
        through 2023''.

SEC. 5. EVIDENCE-BASED PRESCRIPTION OPIOID AND HEROIN TREATMENT AND 
              INTERVENTION DEMONSTRATIONS.

    Section 514B of the Public Health Service Act (42 U.S.C. 290bb-10) 
is amended--
            (1) in subsection (d), by inserting ``, and Indian tribes 
        and tribal organizations (as defined in section 4 of the Indian 
        Self-Determination and Education Assistance Act)'' before the 
        first period; and
            (2) in subsection (f), by inserting before the period the 
        following: ``, and $300,000,000 for each of fiscal years 2019 
        through 2023''.

SEC. 6. BUILDING COMMUNITIES OF RECOVERY.

    Section 547 of the Public Health Service Act (42 U.S.C. 290ee-2) is 
amended--
            (1) by striking subsection (c);
            (2) by redesignating subsection (d) as subsection (c);
            (3) in subsection (c) (as so redesignated)--
                    (A) in paragraph (1), by striking ``and'' at the 
                end;
                    (B) in paragraph (2)(C)(iv), by striking the period 
                and inserting ``; and''; and
                    (C) by adding at the and the following:
            ``(3) may be used as provided for in subsection (d).'';
            (4) by inserting after subsection (c) (as so redesignated), 
        the following:
    ``(d) Establishment of Regional Technical Assistance Centers.--
            ``(1) In general.--Grants awarded under subsection (b) may 
        be used to provide for the establishment of regional technical 
        assistance centers to provide regional technical assistance for 
        the following:
                    ``(A) Implementation of regionally driven peer 
                delivered addiction recovery support services before, 
                during, after, or in lieu of addiction treatment.
                    ``(B) Establishment of recovery community 
                organizations.
                    ``(C) Establishment of recovery community centers.
                    ``(D) Naloxone training and dissemination.
            ``(2) Eligible entities.--To be eligible to receive a grant 
        under paragraph (1), an entity shall be--
                    ``(A) a national nonprofit entity with a network of 
                local affiliates and partners that are geographically 
                and organizationally diverse; or
                    ``(B) a national nonprofit organization established 
                by individuals in personal and family recovery, serving 
                prevention, treatment, recovery, payor, faith-based, 
                and criminal justice stakeholders in the implementation 
                of local addiction and recovery initiatives.''; and
            (5) in subsection (e), by inserting before the period the 
        following: ``, and $200,000,000 for each of fiscal years 2019 
        through 2023''.

SEC. 7. MEDICATION-ASSISTED TREATMENT FOR RECOVERY FROM ADDICTION.

    (a) Allowing States To Raise Patient Caps Under Certain Conditions; 
Making Nurse Practitioner and Physician Assistant Authority 
Permanent.--Section 303(g)(2) of the Controlled Substances Act (21 
U.S.C. 823(g)(2)) is amended--
            (1) in subparagraph (G)(iii)(II), by striking ``during the 
        period beginning on the date of enactment of the Comprehensive 
        Addiction and Recovery Act of 2016 and ending on October 1, 
        2021,''; and
            (2) in subparagraph (I)--
                    (A) in clause (i), by striking ``or'' at the end;
                    (B) by redesignating clause (ii) as clause (iii); 
                and
                    (C) by inserting after clause (i) the following:
                    ``(ii) permits a qualifying practitioner to 
                dispense drugs in schedule III, IV, or V, or 
                combinations of such drugs, for maintenance or 
                detoxification treatment in accordance with this 
                paragraph to a total number of patients that is more 
                than the total number applicable to the qualifying 
                practitioner under subparagraph (B)(ii)(II), including 
                an unlimited number, if the State--
                            ``(I) enacts a law authorizing such 
                        dispensing to that increased total number, or 
                        unlimited number, of patients;
                            ``(II) before the increased total number or 
                        elimination of a limit goes into effect in the 
                        State, directs the applicable State agency or 
                        regulatory board to adopt statewide regulations 
                        governing the use of medications approved by 
                        the Food and Drug Administration for the 
                        treatment of opioid dependence or for the 
                        prevention of relapse to opioid dependence, 
                        consistent with nationally recognized evidence-
                        based guidelines produced by a national or 
                        international medical professional association, 
                        public health entity, or governmental body with 
                        the aim of ensuring the appropriate use of 
                        evidence to guide individual diagnostic and 
                        therapeutic clinical decisions, including the 
                        National Practice Guidelines For the Use of 
                        Medications in the Treatment of Addiction 
                        Involving Opioid Use issued by the American 
                        Society of Addiction Medicine; and
                            ``(III) notifies the Attorney General of 
                        the increased total number or elimination of a 
                        limit; or''.
    (b) Repeal of Requirement To Update Regulations.--Section 303 of 
the Comprehensive Addiction and Recovery Act of 2016 (Public Law 114-
198; 130 Stat. 720) is amended by striking subsection (c).
    (c) Definition of Qualifying Other Practitioner.--Section 
303(g)(2)(G)(iv) of the Controlled Substances Act (21 U.S.C. 
823(g)(2)(G)(iv)) is amended by striking ``nurse practitioner or 
physician assistant'' each place that term appears and inserting 
``nurse practitioner, clinical nurse specialist, certified registered 
nurse anesthetist, certified nurse midwife, or physician assistant''.
    (d) Requirement To Offer Two Types of Medication-Assisted 
Treatment.--Any entity, including a prison or jail, that receives 
Federal funds for a program or activity offering medication-assisted 
treatment shall offer, or have an affiliation with a provider who can 
prescribe and discuss with patients the risks of, benefits of, and 
alternatives to--
            (1) not less than 1 opioid antagonist medication approved 
        by the Food and Drug Administration; and
            (2) not less than 1 opioid agonist (or partial agonist) 
        medication approved by the Food and Drug Administration to 
        treat addiction involving opioids.

SEC. 8. NATIONAL YOUTH RECOVERY INITIATIVE.

    (a) Definitions.--In this section:
            (1) Eligible entity.--The term ``eligible entity'' means--
                    (A) a high school that has been accredited as a 
                substance use recovery high school or that is seeking 
                to establish or expand substance use recovery support 
                services;
                    (B) an institution of higher education;
                    (C) a recovery program at an institution of higher 
                education;
                    (D) a nonprofit organization; or
                    (E) a technical assistance center that can help 
                grantees install recovery support service programs 
                aimed at youth and young adults which include recovery 
                coaching, job training, transportation, linkages to 
                community-based services and supports, regularly 
                scheduled alternative peer group activities, life-
                skills education, and leadership development.
            (2) High school.--The term ``high school'' has the meaning 
        given the term in section 8101 of the Elementary and Secondary 
        Education Act of 1965 (20 U.S.C. 7801).
            (3) Institution of higher education.--The term 
        ``institution of higher education'' has the meaning given the 
        term in section 101 of the Higher Education Act of 1965 (20 
        U.S.C. 1001).
            (4) Recovery program.--The term ``recovery program'' means 
        a program--
                    (A) to help youth or young adults who are 
                recovering from substance use disorders to initiate, 
                stabilize, and maintain healthy and productive lives in 
                the community; and
                    (B) that includes peer-to-peer support delivered by 
                individuals with lived experience in recovery, and 
                communal activities to build recovery skills and 
                supportive social networks.
    (b) Grants Authorized.--The Assistant Secretary for Mental Health 
and Substance Use, in consultation with the Secretary of Education, 
shall award grants, on a competitive basis, to eligible entities to 
enable the eligible entities to--
            (1) provide substance use recovery support services to 
        youth and young adults enrolled in high school or an 
        institution of higher education;
            (2) help build communities of support for youth and young 
        adults in substance use recovery through a spectrum of 
        activities such as counseling, job training, recovery coaching, 
        alternative peer groups, life-skills workshops, family support 
        groups, and healthy and wellness-oriented social activities; 
        and
            (3) encourage initiatives designed to help youth and young 
        adults achieve and sustain recovery from substance use 
        disorders.
    (c) Application.--An eligible entity desiring a grant under this 
section shall submit to the Assistant Secretary for Mental Health and 
Substance Use an application at such time, in such manner, and 
containing such information as the Assistant Secretary may require.
    (d) Use of Funds.--Grants awarded under subsection (b) may be used 
for activities to develop, support, or maintain substance use recovery 
support services for youth or young adults, including--
            (1) the development and maintenance of a dedicated physical 
        space for recovery programs;
            (2) hiring dedicated staff for the provision of recovery 
        programs;
            (3) providing health and wellness-oriented social 
        activities and community engagement;
            (4) the establishment of a substance use recovery high 
        school;
            (5) the coordination of a peer delivered substance use 
        recovery program with--
                    (A) substance use disorder treatment programs and 
                systems;
                    (B) providers of mental health services;
                    (C) primary care providers;
                    (D) the criminal justice system, including the 
                juvenile justice system;
                    (E) employers;
                    (F) recovery housing services;
                    (G) child welfare services;
                    (H) high schools; and
                    (I) institutions of higher education;
            (6) the development of peer-to-peer support programs or 
        services delivered by individuals with lived experience in 
        addiction recovery; and
            (7) any additional activity that helps youth or young 
        adults achieve recovery from substance use disorders.
    (e) Resource Center.--The Assistant Secretary for Mental Health and 
Substance Use shall establish a resource center to provide technical 
support to recipients of grants under this section.
    (f) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out this section $10,000,000 for fiscal year 2019 
and each of the 4 succeeding fiscal years.

SEC. 9. NATIONAL RECOVERY RESIDENCE STANDARDS.

    (a) Best Practices for Operating Recovery Housing.--The Secretary 
of Health and Human Services, acting through the Director of the Center 
for Substance Abuse Treatment of the Substance Abuse and Mental Health 
Services Administration--
            (1) shall publish best practices for operating recovery 
        housing, based on--
                    (A) the applicable domains, core principles, and 
                standards of the National Alliance for Recovery 
                Residences; and
                    (B) input from other nationally accredited recovery 
                housing entities and from stakeholders;
            (2) shall disseminate such best practices to each State;
            (3) may provide technical assistance to States seeking to 
        adopt or implement such best practices;
            (4) shall identify barriers with respect to recovery 
        housing, State licensure, zoning restrictions, and 
        discrimination against individuals receiving medication 
        assisted treatment for the treatment of opioid abuse; and
            (5) shall develop strategies to address the barriers 
        identified under paragraph (4).
    (b) Definitions.--In this section:
            (1) The term ``recovery housing'' means a family-like, 
        shared living environment free from alcohol and illicit drug 
        use and centered on peer support and connection to services 
        that promote sustained recovery from substance use disorders.
            (2) The term ``State'' includes any of the several States, 
        the District of Columbia, and any territory or possession of 
        the United States.

SEC. 10. IMPROVING TREATMENT FOR PREGNANT AND POSTPARTUM WOMEN.

    Section 508(s) of the Public Health Service Act (42 U.S.C. 290bb-
1(s)) is amended in the first sentence by inserting before the period 
the following: ``, and $100,000,000 for each of fiscal years 2019 
through 2023''.

SEC. 11. VETERANS TREATMENT COURTS.

    Section 2991(o)(3) of title I of the Omnibus Crime Control and Safe 
Streets Act of 1968 (34 U.S.C. 10651(o)(3)) is amended--
            (1) by striking ``Limitation'' and inserting ``Veterans'';
            (2) by striking ``Not more than'' and inserting the 
        following:
                    ``(A) Limitation.--Not more than'';
            (3) in subparagraph (A), as so designated, by striking 
        ``this section'' and inserting ``paragraph (1)''; and
            (4) by adding at the end the following:
                    ``(B) Additional funding.--In addition to the 
                amounts authorized under paragraph (1), there are 
                authorized to be appropriated to the Department of 
                Justice to carry out subsection (i) $20,000,000 for 
                each of fiscal years 2019 through 2023.''.

SEC. 12. INFANT PLAN OF SAFE CARE.

    Section 112 of the Child Abuse Prevention and Treatment Act (42 
U.S.C. 5106h) is amended by adding at the end the following:
    ``(c) Infant Plan of Safe Care.--In addition to amounts otherwise 
appropriated to carry out this title, there is authorized to be 
appropriated $60,000,000 for each of fiscal years 2019 through 2023, to 
provide funds for States to collaboratively develop policies and 
procedures concerning implementing and developing systems to monitor 
plans of safe care under section 106(b)(2)(B)(iii).''.

SEC. 13. REQUIRE THE USE OF PRESCRIPTION DRUG MONITORING PROGRAMS.

    (a) Definitions.--In this section:
            (1) Controlled substance.--The term ``controlled 
        substance'' has the meaning given the term in section 102 of 
        the Controlled Substances Act (21 U.S.C. 802).
            (2) Covered state.--The term ``covered State'' means a 
        State that receives funding under the Harold Rogers 
        Prescription Drug Monitoring Program established under the 
        Departments of Commerce, Justice, and State, the Judiciary, and 
        Related Agencies Appropriations Act, 2002 (Public Law 107-77; 
        115 Stat. 748), under this Act (or an amendment made by this 
        Act), or under the controlled substance monitoring program 
        under section 399O of the Public Health Service Act (42 U.S.C. 
        280g-3).
            (3) Dispenser.--The term ``dispenser''--
                    (A) means a person licensed or otherwise authorized 
                by a State to deliver a prescription drug product to a 
                patient or an agent of the patient; and
                    (B) does not include a person involved in oversight 
                or payment for prescription drugs.
            (4) PDMP.--The term ``PDMP'' means a prescription drug 
        monitoring program.
            (5) Practitioner.--The term ``practitioner'' means a 
        practitioner registered under section 303(f) of the Controlled 
        Substances Act (21 U.S.C. 823(f)) to prescribe, administer, or 
        dispense controlled substances.
            (6) State.--The term ``State'' means each of the several 
        States and the District of Columbia.
    (b) In General.--Beginning 1 year after the date of enactment of 
this Act, each covered State shall require--
            (1) each prescribing practitioner within the covered State 
        or their designee, who shall be licensed or registered 
        healthcare professionals or other employees who report directly 
        to the practitioner, to consult the PDMP of the covered State 
        before initiating treatment with a prescription for a 
        controlled substance listed in schedule II, III, or IV of 
        section 202(c) of the Controlled Substances Act (21 U.S.C. 
        812(c)), and every 3 months thereafter as long as the treatment 
        continues;
            (2) the PDMP of the covered State to provide proactive 
        notification to a practitioner when patterns indicative of 
        controlled substance misuse, including opioid misuse, are 
        detected;
            (3) each dispenser within the covered State to report each 
        prescription for a controlled substance dispensed by the 
        dispenser to the PDMP not later than 24 hours after the 
        controlled substance is dispensed to the patient;
            (4) that the PDMP make available a quarterly de-identified 
        data set and an annual report for public and private use, 
        including use by healthcare providers, health plans and health 
        benefits administrators, State agencies, and researchers, which 
        shall, at a minimum, meet requirements established by the 
        Attorney General, in coordination with the Secretary of Health 
        and Human Services;
            (5) each State agency that administers the PDMP to--
                    (A) proactively analyze data available through the 
                PDMP; and
                    (B) provide reports to law enforcement agencies and 
                prescriber licensing boards describing any prescribing 
                practitioner that repeatedly fall outside of expected 
                norms or standard practices for the prescribing 
                practitioner's field; and
            (6) that the data contained in the PDMP of the covered 
        State be made available to other States.
    (c) Noncompliance.--If a covered State fails to comply with 
subsection (a), the Attorney General or the Secretary of Health and 
Human Services may withhold grant funds from being awarded to the 
covered State under the Harold Rogers Prescription Drug Monitoring 
Program established under the Departments of Commerce, Justice, and 
State, the Judiciary, and Related Agencies Appropriations Act, 2002 
(Public Law 107-77; 115 Stat. 748), under this Act (or an amendment 
made by this Act), or under the controlled substance monitoring program 
under section 399O of the Public Health Service Act (42 U.S.C. 280g-3).

SEC. 14. INCREASING CIVIL AND CRIMINAL PENALTIES FOR OPIOID 
              MANUFACTURERS.

    Section 402(c) of the Controlled Substances Act (21 U.S.C. 842(c)) 
is amended--
            (1) in paragraph (1)(B), by striking ``shall not exceed 
        $10,000.'' and inserting the following: ``shall not exceed--
            ``(i) except as provided in clause (ii), $10,000; and
            ``(ii) if the violation is committed by a manufacturer of 
        opioids and relates to the reporting of suspicious orders for 
        opioids or failing to maintain effective controls against 
        diversion of opioids, $100,000.''; and
            (2) in paragraph (2)--
                    (A) in subparagraph (A), by inserting ``or (D)'' 
                after ``subparagraph (B)''; and
                    (B) by adding at the end the following:
    ``(D) In the case of a violation referred to in subparagraph (A) 
that was a violation of paragraph (5) or (10) of subsection (a) 
committed by a manufacturer of opioids that relates to the reporting of 
suspicious orders for opioids or failing to maintain effective controls 
against diversion of opioids, the criminal fine under title 18, United 
States Code, shall not exceed $500,000.''.
                                 <all>