II 115th CONGRESS 2d Session S. 2456 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.

1. Short title This Act may be cited as the CARA 2.0 Act of 2018 . 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. . 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. . 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 . 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 . 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 . 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. 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. 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. 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 . 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. . 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). . 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 ). 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. .