Hearings to examine combating the opioid epidemic.

1[Senate Hearing 119-57]2[From the U.S. Government Publishing Office]34                                                        S. Hrg. 119-5756                      COMBATING THE OPIOID EPIDEMIC78=======================================================================910                                HEARING1112                               BEFORE THE1314                       SPECIAL COMMITTEE ON AGING1516                          UNITED STATES SENATE1718                    ONE HUNDRED NINETEENTH CONGRESS1920                             FIRST SESSION2122                               __________2324                             WASHINGTON, DC2526                               __________2728                           FEBRUARY 26, 20252930                               __________3132                           Serial No. 119-043334         Printed for the use of the Special Committee on Aging3536[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]3738        Available via the World Wide Web: http://www.govinfo.gov3940                              __________4142                   U.S. GOVERNMENT PUBLISHING OFFICE4360-184 PDF                  WASHINGTON : 20254445-----------------------------------------------------------------------------------4647                       SPECIAL COMMITTEE ON AGING4849                     RICK SCOTT, Florida, Chairman5051DAVE McCORMICK, Pennsylvania         KIRSTEN E. GILLIBRAND, New York52JIM JUSTICE, West Virginia           ELIZABETH WARREN, Massachusetts53TOMMY TUBERVILLE, Alabama            MARK KELLY, Arizona54RON JOHNSON, Wisconsin               RAPHAEL WARNOCK, Georgia55ASHLEY MOODY, Florida                ANDY KIM, New Jersey56JON HUSTED, Ohio                     ANGELA ALSOBROOKS, Maryland57                              ----------58                McKinley Lewis, Majority Staff Director59                Claire Descamps, Minority Staff Director6061                         C  O  N  T  E  N  T  S6263                              ----------6465                                                                   Page6667Opening Statement of Senator Rick Scott, Chairman................     168Opening Statement of Senator Kirsten E. Gillibrand, Ranking69  Member.........................................................     37071                           PANEL OF WITNESSES7273Honorable Dennis Lemma, Sheriff, Seminole County Sheriff's74  Office, Sanford, Florida.......................................     475Honorable Gregory Duckworth, Commissioner, Raleigh County,76  Beckley, West Virginia.........................................     677Elizabeth Mateer, Grandparent Caregiver, Pittsburgh, Pennsylvania     878Dr. Malik Burnett, MD, MBA, MPH, Vice Chair, Public Policy79  Committee, American Society of Addiction Medicine, Baltimore,80  Maryland.......................................................    1081Bradley D. Stein, Director, Opioid Policy, Tools, and Information82  Center, RAND Corporation, Pittsburgh, Pennsylvania.............    128384                                APPENDIX85                      Prepared Witness Statements8687Honorable Dennis Lemma, Sheriff, Seminole County Sheriff's88  Office, Sanford, Florida.......................................    4089Honorable Gregory Duckworth, Commissioner, Raleigh County,90  Beckley, West Virginia.........................................    4291Elizabeth Mateer, Grandparent Caregiver, Pittsburgh, Pennsylvania    4492Dr. Malik Burnett, MD, MBA, MPH, Vice Chair, Public Policy93  Committee, American Society of Addiction Medicine, Baltimore,94  Maryland.......................................................    4695Bradley D. Stein, Director, Opioid Policy, Tools, and Information96  Center, RAND Corporation, Pittsburgh, Pennsylvania.............    509798                        Questions for the Record99100Dr. Malik Burnett, MD, MBA, MPH, Vice Chair, Public Policy101  Committee, American Society of Addiction Medicine, Baltimore,102  Maryland.......................................................    62103Bradley D. Stein, Director, Opioid Policy, Tools, and Information104  Center, RAND Corporation, Pittsburgh, Pennsylvania.............    63105106                       Statements for the Record107108Dr. Stacey McKenna Testimony.....................................    67109James Balda Testimony............................................    74110ASAM Criteria (Fourth Edition) Handout...........................    76111Moyo Dow and Francesca Beaudoin Testimony........................    77112Tim Clover Testimony.............................................    88113Dr. Jeffrey B. Reich Testimony...................................    89114115                     COMBATING THE OPIOID EPIDEMIC116117                              ----------118119                      Wednesday, February 26, 2025120121                                        U.S. Senate122                                 Special Committee on Aging123                                                    Washington, DC.124    The Committee met, pursuant to notice, at 3:30 p.m., Room125106, Dirksen Senate Office Building, Hon. Rick Scott, Chairman126of the Committee, presiding.127    Present: Senator Scott, McCormick, Justice, Tuberville,128Moody, Gillibrand, Warren, Kim, and Alsobrooks.129130                     OPENING STATEMENT OF131                  SENATOR RICK SCOTT, CHAIRMAN132133    The Chairman. The U.S. Senate Special Committee in Aging134will now come to order. Over the last decade, we have lost135hundreds of thousands of Americans lives to drug overdoses.136It's happening in every community across every state. None of137us have been spared from the carnage left by this crisis, and138we've all heard the heartbreaking stories of families who have139lost children, parents and siblings to fentanyl and other140opioids.141    Fighting the opioid crisis has been an incredible142challenge. The precursors of these drugs come from Communist143China and are bought by the evil drug cartels to make deadly144opioids like fentanyl. These cartels then traffic these drugs145over the border and into our communities where they poison and146kill tens of thousands of Americans every year.147    Thanks for the hard work of our Governors, our state148attorney generals, law enforcement advocates, our sheriff's149departments, police departments, from 2022 to 2023, we saw a150drop in overdose deaths from people aged 15 to 54. Now, that's151good news, but it shows we have more work to do.152    While overdose deaths in the U.S. dropped for people153between the ages of 15 and 54, we saw deaths increase from 22154to 23 for Americans who are age 55 and older, after seeing155increase in the 65 and older age group in 2022. In 2023, more156than 29,000 Americans aged 55 and older died from an opioid157overdose. That's 80 seniors dying from opioid overdoses every158single day. Think about it this way. In the two-hours we'll159spend together in this hearing today, six people aged 55 and160older will die. Every overdose is preventable.161    Every single one of those nearly 30,000 lives of older162Americans lost could have been saved. While we've all heard the163heart wrenching stories of the children and young people lost164to the opioid crisis, the stories that have been largely untold165are those about the devastating impact that this crisis is166having on American seniors. That includes not only the horrible167deaths I just talked about, but also the toll of being a168caretaker when parents are impacted by these drugs. I know that169we'll hear firsthand today about that from Ms. Mateer.170    I believe the Aging Committee must take this issue on, and171that's why we're having this hearing today. This isn't a172partisan issue, it's an American issue, and Congress must act173now. Last year, I was proud to have my bipartisan FEND Off174Fentanyl Act signed of the law, which fellow agent committee175member Mark Kelly co-sponsored.176    The END FENTANYL Act was a bipartisan success because it177exposed just how behind parts of the Federal Government were178when it came to fighting the opioid epidemic and stopping the179deadly fentanyl that is killing thousands of fellow Americans.180In 2019, a study from the government accounting office found181that drug interdiction guidance of the U.S. custom and border182patrol protection not been updated in 20 years. That's clearly183unacceptable.184    Now that the END FENTANYL Act is law, CBP is required to185update its policies at least once every three years to ensure186operational fuel manuals, including their drug interdiction187guidance are up to date. These are the kind of common-sense188policies we need to get done here in Washington. Seeing the END189FENTANYL Act become law makes me even more optimistic that we190can get things done, and I have more ideas with bipartisan191support to combat the opioid crisis.192    Last week, I reintroduced my OPIOIDS Act with Senator Welch193of Vermont. This bipartisan bill is one step we can take to194fight this epidemic here and now. It would provide better195insight into overdose deaths nationwide. Local law enforcement196agencies are on the front lines of this crisis, and this would197provide additional grants to support law enforcement and198communities with high rates of overdose.199    It would make Federal agencies collaborate on this problem,200and my OPIOIDS Act would stop the bad practice of stealing201money from the National Drug Control Strategy and Budget, and202this would provide additional grants to support law enforcement203and communities with high rates of overdoses. It would make204Federal agencies collaborate on this problem.205    Again, I'm also proud to lead a bipartisan awareness206resolution each year for the lifesaving drug naloxone. As our207witnesses know all too well, naloxone literally stops208overdosing its tracks. That's why each June 6th, we do a209National naloxone Awareness Day Resolution to raise awareness210and educate people on lifesaving drug capabilities is something211so simple to carry.212    In addition to those, I also have several other pieces of213legislation on this issue, including National Fentanyl214Awareness Week Resolution, Overdose RADAR Act, for better215health data on overdoses, and SOCIAL MEDIA Act to combat216illicit online sales of drugs. This is by no means all we can217do, but it has to start somewhere. Like I said earlier, I'm218optimistic. I know it may seem like there's not a clear path219forward, but if we keep fighting each and every single day, I220know we can make a change.221    I look forward to hearing your testimony and working with222my colleagues on the next step to fight this issue. I now want223to recognize Ranking Member Kirsten Gillibrand for her opening224statement.225226                 OPENING STATEMENT OF SENATOR227             KIRSTEN E. GILLIBRAND, RANKING MEMBER228229    Senator Gillibrand. Thank you, Chairman Scott, and thank230you for calling on today's hearing. There is no community in231this country that has escaped the impact of the opioid crisis.232Substance use disorders are growing at an alarming rate in the233United States. Broadly, 48.5 million people aged 12 or older234had substance use disorder in the past year. While older adults235tend to use substances at lower rates than other age groups,2364.6 million people aged 65 or older have or had a substance use237disorder.238    In the past year, fatal drug overdoses decreased239nationally, and while the numbers vary significantly between240states, we have the tools to continue reducing overdose deaths241to reverse the trend in states where this isn't the case. We242know that expanding the availability and affordability of243treatments and harm reduction policies like universal access to244naloxone are strategies that work. We need to make a245multifaceted approach that includes a law enforcement and246criminal justice element that places a larger emphasis on247public health and social policies.248    We can't fully address the opioid crisis if we are not also249addressing prevention and access to affordable treatment. It's250why protecting Medicaid is so critical. Medicaid is the primary251care for substance use disorder treatment, and any cuts to the252Medicaid program would devastate our ability to solve this253crisis.254    Another critical piece of the puzzle is the impact of drug255use on the whole family. More than 2.5 million children are256currently being raised by grandparents, or relatives, or a257close family friend. Over time, more grandparents are forced to258become family caregivers because of the opioid crisis. I co-259lead the bipartisan Supporting Families Through Addiction Act,260which would provide support to the families of people receiving261treatment for a substance use disorder.262    Congress must do a better job of tackling this crisis263holistically. I hope to work with my colleagues in the future264to develop policies that take every aspect of this crisis into265account from providing necessary public safety tools to making266sure those with substance use disorders have access to267affordable evidence-based treatments.268    I look forward to today's hearing, and I look forward to269hearing from our witnesses who can speak to the opioid270ecosystem and how we can truly combat the opioid crisis. Thank271you, Mr. Chairman.272    The Chairman. Thank you, Ranking Member Gillibrand. I'd273like to welcome our witnesses here today. Before I introduce274our first witness, I'd like to ask each of you to be mindful of275our limited time together and keep opening statements to five276minutes.277    First, I would like to welcome Seminole County Sheriff,278Dennis Lemma. Sheriff Lemma serves as the delegate chair on279Florida's statewide Council on Opioid Abatement created to280enhance the development and coordination of state and local281efforts to abate the opioid epidemic, and to support the282victims and families of this crisis.283    Sheriff has also served as a member of the Victoria's Voice284Foundation. Victoria's Voice Foundation does amazing life-285saving work to help prevent overdoses by raising awareness of286naloxone, a revolutionary drug to stop an opioid overdose in287its tracks, as well as educating students, parents, educators,288and communities about the dangers of illicit drugs.289    I've actually worked with Victoria's Foundation, now for290two years, to introduce the National Naloxone Awareness Day291Resolution, and was happy to see it pass to raise awareness of292this important opioid tool to combat the epidemic.293    I've also been honored to work with Victoria's Voice to294help get naloxone into more schools and help them partner with295school districts so these parents can come in and talk directly296to students about the dangers of fentanyl, and the pain and297losses the drug causes.298    I've also had the pleasure working with the Sheriff for299years on these important issues. Thank you for being here,300Sheriff Lemma.301302       STATEMENT OF THE HONORABLE DENNIS LEMMA, SHERIFF,303       SEMINOLE COUNTY SHERIFF'S OFFICE, SANFORD, FLORIDA304305    Mr. Lemma. Well, good afternoon, Chairman Scott, Ranking306Member Gillibrand, and distinguished members of this special307Committee. Thank you for the opportunity to testify on the308devastating crisis of overdoses and fentanyl poisonings in our309country. It is an honor to present a proven strategy from the310State of Florida, one that can be replicated nationwide.311    Chairman Scott, your leadership, starting with your time as312Florida's Governor, when you and Attorney General Bondi took313action to shut down pill mills served as a model for the314country. Senator Gillibrand, your efforts through the315legislative effort like FEND Off Fentanyl Act have been crucial316in this fight.317    I'd also like to recognize Senator Ashley Moody, who as318Florida's attorney general, provided invaluable leadership in319the fight against this epidemic. Her vision and dedication320inspired my own focus on this issue, which requires both law321enforcement and clinical understanding.322    I serve as the elected Sheriff of Seminole County, Florida,323located in the Orlando metropolitan area. Seminole County is324the fourth most densely populated county in the state. Despite325its affluence, we are not immune to the devastating effects of326this crisis. Simply stated, this epidemic does not327discriminate. It affects citizens from all backgrounds, and328demands comprehensive solutions.329    In my nearly 33 years of law enforcement, I've come to330believe that the greatest responsibility of any civilized331society is to protect and preserve human life. Overdose death332has tragically become a leading cause of death for individual333aged 18 to 45. In 2022, the average life expectancy of a U.S.334citizen decreased partially due to the rise in overdose deaths.335    To effectively combat this crisis, we need a holistic336approach that includes prevention, treatment, advocacy for337lifesaving interventions, and a strong emphasis on law338enforcement strategy that aggressively goes after the drug339dealers who are dealing deadly doses of narcotics in our340communities.341    Prevention remains a critical tool in the process. Through342focused education and awareness, we can equip individuals with343the knowledge to avoid addiction before it ever starts.344Prevention also requires ensuring the highest level of access345to opioid antagonists like, Narcan, a lifesaving medication346that can immediately reverse the effects of an opioid overdose.347In Florida, we've made great strides in expanding access to348these antagonists, and they have saved countless lives.349    Treatment is equally important in breaking the cycle of350addiction. Medication-assisted therapy combined with cognitive351behavioral therapy has proven to be effective in helping352individuals recover from substance use disorder in both353clinical and correctional settings.354    Data collection also plays a critical role in combating355this epidemic. We need to gather and analyze overdose data at356all levels. By understanding overdose trends, we can better357allocate resources and target enforcement efforts.358    However, accountability for drug dealers is absolutely359crucial if we're going to put an end to this epidemic. We must360ensure that those who distribute fentanyl and other illicit361substances like the emerging trend of street-level xylazine are362held fully responsible for their actions, whether there's an363associated death or not.364    Too often overdoses are treated as accidents when in365reality they are crimes. In Florida, we've passed legislation366with harsher penalties for those drug dealers whose actions367result in fatal overdoses, while at the same time we've created368criminal laws to hold drug dealers accountable for the369individual overdoses that we bring people back to life with an370antagonist.371    Drug dealers cannot be let off easily, and the law must372hold these individuals accountable to the fullest extent.373Additionally, we cannot ignore the illicit drug trade,374particularly from cartels like the Sinaloa and Jalisco New375Generation, which still pose a threat to our country. Securing376the border and preventing fentanyl from entering our country is377critical to minimizing its availability and reducing deaths.378This crisis must unite us all regardless of partisan lines,379because it impacts every community across the country.380    In conclusion, we must adopt a holistic strategy that381includes prevention, treatment, improved data collection, and382the strictest accountability for drug dealers. This strategy383works, builds safer communities, and ultimately, saves lives.384Utilizing this strategy in Seminole County, we've achieved a 29385percent reduction in overdoses and a 42 percent reduction in386fatalities in 2024 alone. While we have seen this reduction, we387know that the hard work still lies ahead.388    Thank you for having me here today and I look forward to389addressing your questions.390    The Chairman. Thank you, Sheriff. Now I'd like to recognize391Senator Jim Justice to introduce our next witness.392    Senator Justice. Well, first of all, let me just say this,393Greg Duckworth, you're an incredible man, and you've done394incredible work, and it's a real honor for me to be able to395introduce you, but I've got to say just this, I said this396earlier today, but can you just imagine West Virginia, how hard397West Virginia was hit? It was unbelievable, unimaginable in398every way. We had to have people that really stepped up, people399that were superstars. This man's a superstar. He's 27 years, I400think, a veteran of the state police, and absolutely a401superstar in every way.402    With all that being said, let me just tell you this story403very quickly. You know, baby dog and I go through a lot of404drive through windows, and maybe we shouldn't go through that405many, but just the other day we're going through the drive406through window at Arby's, and I looked up and the car right in407front of me had Amber and had a cross, and it had 1993, 2023.408    Well, we made it to the window to pay for our food, and the409car had left, and they paid for our food. Now, we tried to run410them down. We finally, through a lot of different ways through411the state police found them. Amber had played basketball for me412as a coach, so many situations to where all of a sudden, a drug413takes a life. It's happening all over the place.414    Greg, I mean this with all in me. It's an honor to415introduce you. You've done great work with our foundation in416West Virginia. You have absolutely been just what I've just417said. You've been a superstar, because you care, and I am418really proud to introduce you.419    Thank you so much, Mr. Chairman.420421         STATEMENT OF THE HONORABLE GREGORY DUCKWORTH,422      COMMISSIONER, RALEIGH COUNTY, BECKLEY, WEST VIRGINIA423424    Mr. Duckworth. Thank you very much. Chairman Scott, Ranking425Member Gillibrand, and my fellow West Virginian, Senator426Justice, and other members of the Committee, thanks so much for427having me here today. It's truly an honor.428    I spent my law enforcement career in the heart of the429opioid epidemic in an area once known as the coal fields.430Today, I want to share some firsthand experiences on how this431crisis has devastated families affected our aging population,432and where we must focus our efforts moving forward.433    In 2012, 17-year-old Cheyenne Martin reported to the police434that her father and two younger siblings were missing. She had435already lost her mother, Kerry Hendricks, who under the436influence of OxyContin, had wandered onto the highway and was437fatally struck by a truck. During the missing person438investigation, police found that her father Hendrix, was lured439into a trap by an OxyContin dealer named, Belknap, who owed him440money.441    Hendrix, his girlfriend, and the two youngest children,442ages six and four were ambushed and murdered, and their bodies443were discarded as if they were worthless. A decade later,444Cheyenne herself died of an opioid overdose leaving behind445three small children.446    Entire families are being erased by addiction. This is not447just a crisis of individuals, it's a crisis of generations.448Children lose parents, and grandparents are forced back into449parenting, and communities crumble.450    The second story involves a single mother in her early 30's451with four children: a nine-year-old, a seven-year-old, and452three-year-old twins. For years, she lived with her mother who453helped care for the children. Recently, she had moved into her454own place a single-wide trailer within walking distance of her455mother's home. At night after dinner, she would take the three-456year-old twins home while leaving the older children with their457grandmother who would ensure that they got to school the next458morning. The twins were described as full of life, radiating459joy, as most three-year-olds do.460    One night the mother put the twins to bed, and by the time461she checked back on them again, they were deceased. Autopsies462revealed multiple drugs in their systems, including lethal463amounts and fentanyl. The neglect was so severe that rigor464mortis had already set in before she even realized what had465happened.466    The children's grandmother had already lost her husband to467cancer, and she's fighting for custody of the remaining468children, but has been unsuccessful. She is, however, allowed469to see them with the help of the Child Protective Services. The470mother is currently in jail awaiting trial on two counts of471child neglect, resulting in death.472    The burden on our seniors in West Virginia. one in seven473children lose their parents to overdose or incarceration by the474age of 18 with the highest rate of neonatal abstinence475syndrome, many of these children have medical and developmental476challenges. Grandparents who thought they were retiring are now477primary caregivers. They face physical strain raising young478children at advanced age.479    Financial hardship. Many live on fixed incomes and struggle480to meet basic needs, emotional toll raising children while481still grieving the loss of their own, and many of these are off482the record to avoid the foster care system, so they don't483receive financial or legal support either.484    The West Virginia First Foundation is supporting grand485families and the aging population, and I'm proud to serve on486the board of the West Virginia First Foundation and to be part487of this organization that is making a real difference in our488communities. The Foundation is committed to addressing the full489impact of the opioid epidemic, including the burdens placed on490West Virginia's aging population, recognizing that addiction491does not just affect the individual, but entire families.492    The Foundation is dedicated to supporting grand families,493the grandparents raising grandchildren, by providing resources494and assistance to child advocacy and youth prevention programs.495We recognize that the crisis did not end with one generation.496It continues to ripple outwards, and by investing in solutions497that support full family systems the foundation is helping to498break the cycle of addiction, and ensuring the grandparents499raising grandchildren are not left to struggle alone.500    Where we must focus. Having served on the front lines of501the epidemic, I believe that our response must be502comprehensive, treatment, access prevention and education,503recovery support grand families and child advocacy, and of504course, economic recovery. We also must fix some of the505systemic failures as well. The under-reported overdose deaths,506the inconsistent Narcan use documentation and recovery home is507misclassifying overdoses.508    In closing, I believe we have to restore hope, and509substance use disorder is our enemy. It's destroying the very510core of the American way; God, family, and self. To win the511war, we must ensure the love of the church, reunite families,512and emphasize the importance of family values, and bring back513support systems that give people a sense of worth.514    The crisis is more than just statistics. These are real515people with names, faces, and stories. If there's one thing I516wanted you to take away from today, is that behind every517number, there's a human being. Thank you.518    The Chairman. Thank you, Commissioner. Thank you, Senator519Justice. Next, I'd like to recognize Ranking Member Gillibrand520to introduce the next witness.521    Senator Gillibrand. Thank you, Chairman Scott. I want to522introduce our next witness, Ms. Elizabeth Mateer. Ms. Mateer is523a grandparent who has been raising her grandson for more than a524decade due to his parents' opioid use disorder. Ms. Mateer,525thank you so much for sharing your story with us here today.526You may begin.527528          STATEMENT OF ELIZABETH MATEER, GRANDPARENT529              CAREGIVER, PITTSBURGH, PENNSYLVANIA530531    Ms. Mateer. Chairman Scott, Ranking Member Gillibrand, and532members of the Senate Aging Committee, thank you for holding533this important hearing and for inviting me to share my534perspective. My name is Elizabeth Mateer, I am a grandmother535raising my grandson due to the impact of opioids. I also536volunteer as a Generations United GRAND Voices caregiver537advocate.538    When my grandson was born, I had no idea that my life would539change forever. I did not know the baby was suffering with540neonatal abstinence syndrome. I also had no knowledge about541opioid use disorder. At first, I did not identify and542understand the harsh reality that both parents were addicted to543painkillers. When we learned of the mom's opioid use, my544husband and I intervened, and arranged for her to be admitted545to a treatment facility. Suddenly, we had a baby. Although we546were very relieved and hopeful for the future, we had no crib,547no diapers, no baby clothing, no formula, and no idea where to548start.549    Ten days later, I would receive a phone call that mom was550leaving treatment. We would not hand our infant grandson back551to parents who were using. Fear drove us to find an attorney552who obtained emergency custody, but a few weeks later, the553parents cheated a drug test, and we were ordered to return the554baby. Why do judges misunderstand opioid addiction and the risk555in placing children with parents who are inactive addiction?556    The cycle of staging interventions and arranging for557admissions to treatment continued early on. One interventionist558told me to be prepared to keep my grandson long-term because559this would go on for a long time. Each relapse was a crushing560blow, and each time the recommended length of inpatient561treatment increased. The staggering cost for some treatment562facilities included $30,000 deposits for admission, and $10,000563a month. I constantly battled with the insurance company.564    Opioid addiction is like none other. It takes a person's565soul and turns them into someone you don't even recognize. We566were desperate to save both mom and baby. The stress of living567in this opioid-created crisis landed me in the hospital with568pneumonia in both lungs. While we were trying to help our569grandson's mom get treatment, we were fighting a custody battle570with the father who was still in the throes of opioid571addiction.572    Our legal fees exceeded $85,000. The court was permitting573supervised visits that were actually not being supervised. We574worried every time we went to court. The court halted575visitation privileges when we learned that the father had been576charged with child endangerment of another child under his577supervision. Six months later, he died of a heroin overdose.578When I told my then four-and-a-half-year-old grandson that his579father died, the first question he asked was, "Will I still be580able to live with you?"581    I found that working and caring for a child was harder than582when I raised my own children. I had to leave my job. My583relationship slowly disappeared. Friends stopped inviting me to584social events since I didn't have childcare. I felt isolated as585my husband traveled for work. The stigma of addiction that the586child I raised could not raise their child made me feel587ashamed. No one knocks on your door with lasagna in hand to588comfort a family in this kind of crisis. My clergy never589called. Depression set in, and I wondered, "How would I go on?"590    By the grace of God, our grandson's mother has been clean591for a long time. Our relationship is challenging because her592son, now 13, wishes to remain in our home. During the years of593battling her addiction, he just grew up. This is his community,594his home where his pets live, where his school is, where his595friends are.596    My husband delayed retirement so we could provide for our597grandson, and it is nothing like we envisioned driving the598middle school carpool and hosting the baseball team picnic. We599hope to stay healthy so we can be there for our grandson.600    The staggering number of grandparents who care for their601grandchildren, often without any support, is one of the least602recognized populations impacted in the opioid crisis.603Grandparents and other relatives who step forward to keep604children out of foster care and safely with family save605taxpayers more than four billion a year. The child welfare606system would collapse if grandparents did not take in these607children.608    Any grandparent raising a grandchild could use financial609help. I urge you to consider these recommendations. Encourage610states to distribute opioid settlement money to help children611and caregivers promote peer support. Being part of Generation612United's GRAND Voices network has been a godsend to me.613    I was once told that opioid addiction in a family is like614pouring acid on it. Expand the number of mental health615providers with expertise in grandfamilies. When we enrolled in616Medicare, our grandson lost his health insurance. Expand617healthcare coverage options so grandparent caregivers on618Medicare have coverage for the children they are raising. Allow619grandchildren who are in the legal guardianship of their620grandparent to qualify for Social Security survivor benefits if621the grandparent dies.622    SNAP can be a lifesaver. I urge you to protect this623program. Continuing support for kinship navigator programs that624provide information about community-based services. I cannot625imagine what my grandson's life would've been like in foster626care with strangers. Grandparents are committed to protecting627the children under their care, but we need help.628    Thank you.629    Senator Gillibrand. Thank you, Ms. Mateer. Our next witness630is Dr. Malik Burnett. Dr. Burnett is an addiction medicine631provider and the medical director of several community opioid632treatment programs in Baltimore, Maryland. Dr. Burnett also633serves as the vice-chair of the Public Policy Committee for the634American Society of Addiction Medicine, and oversaw naloxone635distribution for the State of Maryland.636    Thank you for being here, Dr. Burnett. You may begin your637testimony.638639         STATEMENT OF DR. MALIK BURNETT, MD, MBA, MPH,640641              VICE CHAIR, PUBLIC POLICY COMMITTEE642643                 AMERICAN SOCIETY OF ADDICTION644645                 MEDICINE, BALTIMORE, MARYLAND646647    Dr. Burnett. Chairman Scott, Ranking Member Gillibrand,648esteemed members of the Senate Committee on Aging. I thank you649for inviting me to participate in this critically important650hearing. My name is Dr. Malik Burnett. I'm a board-certified651addiction specialist physician who takes care of patients with652addiction and co-occurring conditions in Baltimore, Maryland.653    Today, I'm testifying in my capacity as vice-chair of the654Public Policy Committee for the American Society of Addiction655Medicine, known as ASAM. ASAM is a national society656representing over 8,000 physicians and other clinicians who657specialize in the treatment and prevention of addiction.658    I want to begin today by talking about Baltimore and its659forgotten generation; older adults born between 1951 and 1970,660particularly older Black men. In my city, one in three drug661overdoses come from this demographic. Illicitly manufactured662synthetic opioids are among the deadliest health threats that663they face. Many of these men struggle with addiction or have664struggled with addiction for years, but today, there's no665margin for error. A single relapse can leave them at the mercy666of a lethal dose of fentanyl or other synthetic drugs.667    While addiction is a treatable chronic medical disease, it668is also one of the most complex in medicine. It involves669interactions among brain circuits, genetics, the environment,670and an individual's life experiences. As a result, solutions to671our Nation's addiction and overdose crisis can be equally672complex and interconnected.673    Supply side approaches are important to public safety, but674yield little net benefit. If demand-side interventions remain675inaccessible, underfunded, and undermined, drug cartels can676quickly replace confiscated synthetic drugs with little effort677and overhead, ensuring unbroken access to dangerous drugs for678fueling this overdose crisis.679    The good news, evidence-based addiction treatment works and680reduces the risk of overdose death by 80 percent. As a681physician, I've personally witnessed hundreds of patients'682lives transformed by addiction treatment. People in treatment683restore their marriages, rejoin the workforce, leave criminal684activity, improve their mental and physical well-being, reunite685with their children, and yes, escape the grasp of drug cartels.686    We are fortunate to live during a time when effective687evidence-based treatment exists for opiate use disorder, yet688tens of thousands of people in the U.S. continue to just die689from illicit opioids annually. How is this possible?690Unfortunately, the people who need these treatments the most691are not getting the life-saving care that they need when they692need it. In fact, it's this treatment gap that's barely budged693for the last decade. We will not end the opioid epidemic until694evidence-based addiction treatment is easier to get than695illicit opioids.696    For many Americans, especially in rural areas, evidence-697based addiction treatment is impossible to find Ease of698treatment access is critically important because people with699addiction often experience a brief window of time between700desiring treatment and experiencing painful withdrawal701symptoms.702    Symptoms that cheap Fentanyl, which is easier to get than703addiction medications temporarily stop in an instant, but704easier access to addiction treatment cannot happen without a705substantially larger addiction treatment workforce, including706more addiction specialists, physicians increasing Federal707funding for addiction medicine and addiction, psychiatry708fellowships and financial incentives to encourage more709physicians to enter. These training programs are solely needed710to ensure every community has high quality addiction treatment.711    In addition, federal law must be amended to allow these712addiction specialists to prescribe methadone for opiate use713disorder that can be dispensed from community pharmacies.714Today, only about 2,000 opioid treatment programs dispense715methadone for opiate use disorder. They're lacking in about 80716percent of U.S. counties. Methadone for opiate use disorder has717been caught in bureaucratic red tape for nearly 50 years.718Allowing states to regulate their methadone treatment without719undue Federal restriction could lead to the type of innovation720needed in opioid treatment in America.721    Yet, continuing individuals or connecting individuals to722treatment is not enough. They must also be able to afford their723care. Medicaid and Medicare are major insurers for people with724opioid addiction, making it essential that these fiscal725mechanisms facilitate rather than hinder access. Many726clinicians in opioid treatment programs do not accept Medicaid,727largely reflecting the program's administrative burdens and low728reimbursement rates. Congress should remove these burdens,729increase Medicaid rates to change this equation.730    Medicare and Medicaid must also cover the full continuum of731addiction care. Surprisingly, Medicare does not cover non-732hospital-based residential addiction treatment. This must733change furthermore, assurance of equal reimbursement for mental734health and addiction care must be strengthened by levying civil735penalties for parity violations and incentivizing state736regulators to be more robust in their enforcement.737    Stigma toward addiction is arguably the most difficult738barrier to address as it's so entrenched in society. Even when739people recognize that they have a problem with drugs or740alcohol, they're often too embarrassed or too scared to talk to741their physician about it. The Federal Government should stop742wasting money on incarcerating people for nonviolent drug743offenses, and must continue to emphasize that addiction is not744a disease, but a moral addiction is a disease and not a moral745failing.746    People already in the criminal legal system also need747better access to addiction treatment. Congress should eliminate748Medicaid's inmate exclusion requirements, and federal funding749for prisons and jails should be contingent upon providing750evidence-based addiction treatment to ensure that taxpayer751money is not wasted on a revolving door of incarceration.752    In closing, thank you for the opportunity to share my753perspective and expertise today. One thing is clear about754America's opioid ecosystem: whether it's funding, and training,755more addiction specialists, ensuring access to prescription756methadone, closing Medicare coverage gaps, avoiding harmful757cuts to Medicaid, or enforcing equal access to addiction758treatment in all healthcare settings. Congress owns this. Let's759work together to save lives.760    Thank you, and I look forward to answering your questions.761    The Chairman. Thank you, Dr. Burnett. Ms. Mateer, I've got762a 13-year-old grandson. I can't imagine trying to stay up with763him as a parent, as my daughter and my son-in-law have to do764so, but thank God, he's got you in his life.765    I'd like to introduce Dr. Bradley Stein. Dr. Stein is the766director of the RAND-USC Schaeffer Opioid Policy Center, and a767senior physician policy researcher at the RAND Corporation. Dr.768Stein has worked extensively, examining the effect of state769policies and community outcomes related to the opioid crisis.770    Thank you for being here.771772        STATEMENT OF BRADLEY D. STEIN, DIRECTOR, OPIOID773774          POLICY, TOOLS, AND INFORMATION CENTER, RAND775776             CORPORATION, PITTSBURGH, PENNSYLVANIA777778    Dr. Stein. Thank you. Good afternoon, Chairman Scott,779Ranking Member Gillibrand, and distinguished members of the780Committee. Thank you for inviting me to share insights on781combating the opioid crisis, which is increasingly impacting782older Americans. As the chairman said, I'm a senior physician783policy researcher at RAND, a direct and NIH-funded research784center devoted to better understanding the effectiveness of785opioid related policies. I'm also a practicing child786psychiatrist in Western Pennsylvania, where I see firsthand how787opioid addiction devastates families across generations.788    The toll of the crisis extends far beyond fatal overdoses.789It affects millions of Americans, not just older adults790fighting to maintain their own recovery, but also those791spending their life savings to pay for adult children's792addiction treatment or raising their children's children.793Today, I will focus on three topics, particularly relevant to794this Committee. What escalating rates of opioid use disorder795among older adults imply for healthcare. How upstream796strategies of better chronic pain management can help prevent797opioid misuse, and the social toll of grandparents raising798grandchildren due to parental addiction.799    Opioid use disorder rates have tripled among Medicare800beneficiaries over the last decade. The rapid increase poses801significant challenges to our healthcare system, which is not802adequately prepared to address the unique needs of this803population, who often have conditions that can complicate804diagnosing and treating opioid use disorders like dementia or805chronic pain.806    Primary care providers, the clinicians at the heart of807treating our older adults often lack training or confidence in808managing opioid use disorder. Meanwhile, few addiction809specialists are equipped to handle the complex medical needs of810older patients with conditions like dementia. This mismatch811leaves many older adults with opioid disorders without adequate812care, especially in rural areas experiencing acute clinician813shortages.814    The American population is aging, but currently most815clinicians treating chronic disorders in older adults don't816have expertise in substance use disorders, and substance abuse817experts treating older adults who have addiction usually have818little experience in treating chronic disorders in the elderly.819    Only with concentrated efforts in federal investments will820the clinical workforce caring for the elderly be prepared to821efficiently and effectively treat individuals with opioid use822disorder, and disorders like dementia, and chronic pain is even823more common than dementia, affecting 36 percent of those over824age 65. Efforts to reduce opioid prescribing have curbed825misuse, but many individuals with chronic pain don't receive826non-opioid treatments, leaving many with without adequate pain827management options.828    Some clinicians now avoid prescribing opioids altogether,829even when they're clinically appropriate, leaving patients to830suffer, or turn to elicit opioids for relief. In some831situations, expanding access to non-opioid pain management is832essential to address this gap and can help prevent new opioid833use disorder cases.834    Acupuncture, rehabilitative exercise, therapeutic massage835can all reduce reliance on opioids and improve quality of life836for individuals with chronic pain. However, insurance coverage837is often inconsistent or limited in scope, and high out-of-838pocket costs often make these non-medication therapies less839affordable than opioids, and provider shortages can make this840care very hard to find.841    Congress can help by considering incorporating non-opioid842therapies for chronic pain in value-based insurance designs to843enhance affordability and ensure that these services are fully844covered by Medicare. It can also possibly consider expanding845existing loan forgiveness programs such as rural health grants846or the National Health Services Corps to include providers847trained in these non-medication therapies to ensure we have an848adequate workforce in the future.849    Finally, as we've heard, the opioid crisis has far reached850social consequences for older Americans beyond their own health851needs. An estimated 2.6 million grandparents are raising852grandchildren, often becoming informal caregivers when parents853struggle with addiction or succumb to overdose. Doing so often854entails significant emotional and financial burdens as855grandparents working to keep their family together delay856retirement or take on new expenses like housing or childcare.857These older adults deserve better support.858    Better support systems; expanded access to respite care,859and kinship navigator programs, and information to help them860raise children affected by parental substance use and trauma.861Yet, informal caregivers commonly outside the child welfare862system often don't receive such support despite the vital role863these individuals play in providing stability for so many864children.865    Congress can help support these families by expanding866access to respite care and affordable childcare through867programs like Head Start or alongside the Child Abuse868Prevention and Treatment Act, CAPTA, reauthorization. It can869seek to ensure grandparent caregivers have access to benefits870such as health insurance for the children and kinship navigator871programs, whether they participate in the formal child welfare872system or not.873    It's important that we support the development of874educational resources tailored specifically for grandparents875stepping up to raise children affected by parental substance876use disorders. Supporting grandparent caregivers not only877strengthens families, but also reduces long-term social costs878associated with parental addiction.879    There's no single solution to the opioid crisis, but880healthcare reforms, improving non-opioid, chronic pain881management, and better supporting families affected by882addiction, like so many of the patients I treat, will help keep883families together, and ensure that our healthcare system is884better prepared to meet the diverse needs of older Americans.885    Thank you again for this opportunity and I look forward to886your questions.887    The Chairman. Thank you, Dr. Stein. Thanks for all of you888for being here. Now we'll start going to some questions. First,889we'll start with Senator Tuberville.890    Senator Tuberville. Thank you, Mr. Chairman. Dr. Stein, I891spent 40 years coaching, and all those 40 years, I saw the892correlation between family and some kind of addiction. There's893direct correlation, and if we don't figure out something to do894with family in this country and get back to mom and dad, and895discipline, and responsibility, we're going to have a tough896time and continue to have a tough time.897    Also, I saw over the years, I'd bring young men into my898football teams, and of course, with their mom and dad, you899know, for four years, and we'd bring doctors in, and for first900part of my career, you know, we had a few that was on insulin901for sugar diabetes or something, but my last 10 years, there902was very few that was not on Adderall or Ritalin for attention903deficit. Kids are overprescribed by doctors for some reason. Do904you see a direct correlation between over-the-counter drugs or905prescription drugs that lead to addiction?906    Dr. Stein. Thank you for your question, Senator. You know,907this is a question that scientists have been looking at, and so908far, the data really suggests that there isn't a direct909relationship between children receiving some of these910medications and later addiction.911    I also think it's important to recognize that we also do912recognize that there is a relationship between mental health913disorders in children generally, or in adults in substance use914disorders, and so, I think it's important that recognizing that915there is this relationship, and individuals may have both916mental health disorders and substance use disorders.917    I do think it's very important to make sure that not only918while we're here focused on opioid use disorders and substance919use disorders to try to address the opioid crisis or substance920use disorder crisis more generally without recognizing how many921of those individuals suffer from mental health problems. Really922makes us suggest we're trying to fight that battle with one923hand tied behind our back.924    Senator Tuberville. Do you think we need to roll back the925prescription of childhood drugs, of what I was just talking926about a few minutes earlier?927    Dr. Stein. Sir, I----928    Senator Tuberville. Are we over drugged, is what I'm929asking, at a young age?930    Dr. Stein. That's well beyond the sort of research that I'm931currently involved in. As a clinician, I can say it's important932that we need to make sure that we're using medications and933other therapies appropriately, and that means making sure that934individuals who are not being treated and may benefit from935medications do receive them, and also making sure that we're936not providing medications to children or adults who may not937benefit from them.938    Senator Tuberville. Thank you. Mr. Duckworth, how have939states like West Virginia used opioid settlement funds to fight940back against epidemics?941    Mr. Duckworth. That's a great question. The West Virginia942First Foundation's brand new, it's in its infancy, so, May94324th, was when----944    Senator Tuberville. How is it funded, by the way?945    Mr. Duckworth. It's the opioid settlement money, so, the946executive director actually wasn't hired until May 24th, so,947between May and September it took a lot to get the homework948done, the policies, procedures, the staff hired. We put an949initial opportunity grant together that went out for950application, receiving applications in September.951    By the end of December, we've committed over $20 million,952and most of it at this point has went to youth prevention and953child advocacy, and I think we'd all agree that the, the hidden954epidemic of our seniors isn't really so hidden anymore. I can955anticipate in the future having a lot more funding going toward956the grandparents raising grants because of the seniors, that's957the direction we want to go in West Virginia.958    On to answer your question on the short-term child advocacy959and prevention education, things like that is where it went960recently.961    Senator Tuberville. Yes. Do you think there's anything that962you use that we could do on a federal level to help more from963this program?964    Mr. Duckworth. I think Senator Scott's on a data sharing,965education. The data sharing, the support for law enforcement I966think is so, it's so important, and I love the mission that967you're on there, and hope we can see that come together.968    Senator Tuberville. Thank you. Sheriff, we've heard a lot969about how children are now able to purchase drugs, which are970awful, often laced with fentanyl, and there's this godawful971stuff that you can go into one of these convenience stores and972buy that all of it's made in China, that's for some reason973we're allowed to be sold here in this country.974    What can we do here in Washington to curb practices and975raise awareness to parents about the things that the kids are976able to buy?977    Mr. Lemma. Well, thank you for the question, Senator, and978you're spot on. I mean, Chinese really created this epidemic,979illicit substances. Now we've seen the most recent number is980actually 50 percent of the pills that are made in clandestine981labs or somebody's dirty bathroom, in many cases, contain a982lethal dose of fentanyl. That's down from 70 percent, seven out983of ten people that were taking it for the first time were984likely to die with a pill that was manufactured illicit listed985environment.986    We see these things, these trends. It was just yesterday987where we were talking about methylenedioxy, methamphetamine,988MDMA, flunitrazepam, Rohypnol, where roofies were available,989and then things got confusing for Americans with designer drugs990where they would walk in and illicit chemists would stay one991step ahead of what the DEA would approve as illegal, and we992would clean the shelves off.993    I think we have that under control now. There's no longer a994problem in this country of over-prescribing. Clearly, you have995to have your head in the sand to not realize that we have a996problem that's down at our southern border with Mexican997chemists now picking up precursor chemicals from China and998learning how to process this.999    Education is so incredibly important. That's why when we1000talk about greater access to opioid antagonists, the most1001significant thing that we can do to prevent people from having1002a drug overdose is never starting. Many of us remember Nancy1003Reagan saying, "Just say no." Well, just say no - works1004incredibly well if you've never started, so, when people have1005started on a regimen, we have to give them access to science-1006based, medical-based treatment therapy combined with cognitive1007therapy.1008    Not just do that for the person on the journey. Make sure1009that the family members, and the loved ones, and partnership1010with businesses and corporations, and the private companies1011have a big role to play in that, because many people who are on1012this journey are actually going into an environment, whether1013they're going to a public school system, or that type of1014environment, or they're going to work, somebody is formally1015supervising them, and when they first see the first signs of1016it, it's important to not only say something, but know what1017resources are available and stay current with the current1018trends.1019    Last, we all remember the program, DARE, which was an1020incredibly successful program across the country, but DARE had1021nothing to do with what the challenges are of our kids today.1022Sexting, texting, cyber bullying, vaping. All of these other1023things have to be incorporated in educational curriculums, K1024through 12.1025    The Chairman. Thanks, Senator Tuberville. Senator1026Gillibrand.1027    Senator Gillibrand. Senator Kim, would you like to take the1028time?1029    Senator Kim. Sure.1030    Senator Gillibrand. Go ahead.1031    Senator Kim. Thank you. I appreciate it, Ranking Member.1032Ms. Mateer, I wanted to just start by just saying how grateful1033I am that you took the time to come up here and share your1034personal story. It's so important that we talk about the1035difficulties that are faced, and I'll be honest with you, I've1036heard a lot of stories about the opioid crisis but I haven't1037heard as much about the challenges that it puts upon1038grandparents, and I thought that was very powerful.1039    I wanted to ask you, I don't know if you have this off1040hand, but you were talking about numbers and figures in terms1041of how much, in some ways, is being saved by grandparents1042stepping up, but is there an actual figure in terms of the1043number, the estimated number of grandparents who are in this1044situation right now, like you?1045    Ms. Mateer. Thank you for the question, and to my1046knowledge, according to what Generations United has at their1047fingertips, the grandparents save taking care of their1048grandchildren, save $4 billion a year.1049    Senator Kim. Do we have a sense of how many grandparents1050are in this situation?1051    Ms. Mateer. Yes, we do. There are probably--I know there1052are around 2.6 million children in our country being raised by1053caregivers other than their parent, and of those, the majority1054of them are being raised by grandparents. There is a website1055that has statistics for every state, and I think it's1056grandfamilies.org.1057    If you look at that, where I'm from in Pennsylvania, I know1058there are over 250,000 grandparents or children in Pennsylvania1059being raised by other caregivers. It does show you the1060grandparent statistics. The problem is a lot of these1061situations stay under the radar because they're unreported and1062they're not part of the system, so, there are probably many1063more than we know about.1064    Senator Kim. Yes, and I think that that stands to be1065something that this Committee can try to look into. Because1066kind of as Dr. Stein was saying, we want to make sure that that1067support is available to all that are struggling. We don't want1068to have bureaucracy getting in the way or regulations in that1069specific way, getting in the way of getting support out to1070those that need it, so, thank you for illuminating me on this,1071and I certainly promise to continue to followup with you and1072others to figure out how we can move this needle forward, both1073in terms of the caregivers.1074    Dr. Burnett, you know, what I've come to understand is just1075not just the challenges it is to the caregivers, but that we as1076a nation right now are not resourced in terms of the workforce1077needed to be able to address it, both from a practitioner1078standpoint, and more broadly, against other types of addiction-1079related specialists.1080    I guess I wanted to ask you, what can we do at the Federal1081level to try to increase that sense of workforce to make sure1082we can rise up to the magnitude of this challenge that we face?1083    Dr. Burnett. Sure. Thanks for the question. One thing I1084would say that we can do is reauthorize a couple of different1085programs. One called the Substance Use Disorder Treatment and1086Recovery Act Loan Repayment Program, which is the STAR LRP1087Program, is a great program that provides loan reimbursement1088for providers and clinicians up to $250,000 to work in mental1089health professional shortage areas, or in places where the1090overdose rate is greater than three times the national average.1091    Also, there's another HRSA program that currently exists1092that could be reauthorized that provides fellowship support for1093addiction medicine and addiction psychiatric fellowship1094programs to be able to increase the number of these types of1095providers. Because, currently, we're about at half the capacity1096that is estimated to be needed to be able to address and treat1097the current substance use disorder need for the country.1098    Senator Kim. One thing you raised as well was just the1099challenge sometimes getting providers to be able to engage with1100Medicaid, for instance, and you were actually suggesting maybe1101increasing the rates to be able to try and get more providers1102on board.1103    I guess I just want to end here. We're having a debate here1104in Congress, in the Senate, about Medicaid right now, and I1105just want to hear from you just what you think would happen if1106we saw cuts to Medicaid. What would happen to our ability as a1107nation to respond to the opioid crisis?1108    Dr. Burnett. Sure. I think Medicaid is vital to the ability1109for us to be able to take care of our patients with substance1110use disorder. I'd say about 80 percent of the patients in my1111clinic utilize Medicaid as the financing mechanism for their1112care. If we were to cut Medicaid funding, it would1113significantly reduce our capacity to be able to fight the1114addiction crisis, fundamentally.1115    Senator Kim. Thank you, and with that, I yield back.1116    The Chairman. Senator Justice.1117    Senator Justice. Thank you so much, Mr. Chairman. I'm going1118to be very official. I'm going to call Greg, Mr. Duckworth, but1119I have two questions. I really do. You know, the first question1120is about our aging, but of course you've seen the crisis on1121both sides. You've seen it from the law enforcement side, and1122you've seen it from the community advocacy side. How does this1123particularly affect the aging population in West Virginia?1124    Mr. Duckworth. Thank you Senator. It starts with the1125grandparents raising their grandchildren, so, if a grandparent1126is raising a grandchild, we've lost a generation out of their1127family tree, so, the senior is mourning the loss of their child1128and raising their grandchildren.1129    It's not just grandparents. It's great grandparents, and1130there's great aunts and great uncles that are also raising, so,1131it's like the floods and fires; everything that it touches, it1132destroys, and it starts with the babies being born with1133addicted to opioids, or in West Virginia, we have a large1134amount of babies being born addicted to Suboxone, so, we're1135dealing with the neonatal abstinence issues, and the seniors1136who are mourning the loss and raising their grandkids. It's a1137huge impact. 40 to 50 percent of West Virginia grandparents are1138raising their grandchildren.1139    Senator Justice. I hope everyone heard that. You know, the1140magnitude of the percentage in West Virginia of grandparents1141that are raising the grand babies. It's terrible. It's all1142there is to it, and I've said this over, and over, and over,1143but I said this when I was a Governor, I said, if we don't1144really get a handle on this, it will cannibalize all of us, and1145we better absolutely get a handle on. You know, there's so much1146more we can do.1147    I've got one more question, and this is I'd like you to1148talk about the ways we can see hope restored. You know, when it1149really boils down to this level of crisis, what really keeps1150our West Virginia families even going? You know, Greg, we1151started with Jim's Dream, and then we went to Jobs and Hope,1152and we made a dent, but there's got to be a lot more dents1153that's just all risk to it.1154    You know, I've said so many times in life that you'll never1155get out of the hole till, you know, really where you are in the1156hole, and the hole in this situation is bad. That's all there1157is to it, so, I just think that we have got to give people all1158across this land, if not all, across the globe, hope. I mean,1159optimism, a chance to be better. This situation has got to have1160every single one of us arm in arm pulling the rope together. We1161can do it, but that's exactly what we've got to do.1162    Tell me your thoughts real quickly on how do we address1163this terrible crisis and give hope to our West Virginia1164families?1165    Mr. Duckworth. Yes, thank you. In my mind, the treatment1166centers, and the detox centers, the doctors, they do a fine job1167for those 30 days, and then, our addict gets released from1168either jail or a recovery home, and there's nowhere to go1169except back where they came from, so, there's a piece of this1170in the economic development part of creating jobs, so that when1171these folks get detoxed or they get out, they have hope for a1172job, something they can support their family in.1173    That's where we lack sometimes, is a place for them to go,1174either when they get out of jail--the overdose rates are1175highest when someone first gets out of jail or out of a1176treatment program, and they don't have a place to go to a1177recovery center or somewhere different than where they came1178from, and they just go back to the community they were in to1179start with.1180    Senator Justice. Isn't that exactly what we tried to do1181with Jobs and Hope? I would tell everyone just this, you know,1182we have to have treatment. We know we have to have treatment,1183and we know we have to have sympathy to bring people back, but1184these people got to have a job. They have to have training.1185They can't be trained on a pickup truck, how to drive a dump1186truck. Absolutely. They got to have real life training, and we1187got to spend dollars to be able to do that.1188    I thank you all so much for being here, so, thank you,1189Greg.1190    The Chairman. Thank you. Senator Alsobrooks.1191    Senator Alsobrooks. Thank you so much, Mr. Chair, for1192hosting this important hearing today. Thank you so much as well1193to each of our witnesses.1194    Baltimoreans are dying from overdose at a rate never seen1195before in a major American city, with the number of deaths1196quadrupling over the last 10 years. The frequency of overdose1197deaths in senior homes has likewise increased. More than 3401198people have died in Baltimore senior housing complexes in1199recent years. Black men aged 55 to 74 lead drug fatalities over1200all other demographic groups in the city, a death rate that is120120 times that of the rest of the country.1202    Yet, this administration is working to slash funding for1203research treatment, and our public health workforce, nearly one1204in ten employees at the Substance Abuse and Mental Health1205Services Administration known as SAMHSA, were just recently1206summarily fired by this administration as a part of DOGE's1207governmentwide cuts. Cuts at SAMHSA threaten continued access1208to essential mental health and substance use services,1209including crisis support and suicide prevention, and as you1210know, SAMHSA is yet another Federal agency that is based in1211Maryland.1212    I'd like to start with Dr. Burnett. First of all, to thank1213you so much for the work that you have done every day on the1214front lines of the opioid crisis in Baltimore, and just want to1215ask you, how will public health efforts be impacted by this1216administration's slashing of the Federal workforce at SAMHSA,1217and will leaving SAMHSA with a skeleton staff worsen the1218situation on the ground in Baltimore?1219    Dr. Burnett. Thank you, Senator Alsobrooks. I can answer1220definitively, and talk about a little bit about my experience1221working for the Maryland Department of Health and how SAMHSA1222funding was integral to not only ensuring that prevention and1223public health efforts around opioid overdose were implemented.1224    The SAMHSA funding supported a large percentage of our1225efforts toward naloxone distribution statewide, and so, any1226cuts to SAMHSA funding would significantly curtail our ability1227to be able to provide naloxone across the State of Maryland,1228and I'm sure that that's true for many other states here, and1229it's particularly true in states that have not expanded1230Medicaid.1231    SAMHSA funding provides integral not only prevention1232support, but treatment support in places where patients don't1233have access to Medicaid. You can provide the funding from1234SAMHSA to be able to get into community health programs so that1235people can get access to medications, opiate use disorder, so,1236it's very, very critical funding.1237    Senator Alsobrooks. Thank you. You know, also, it's really1238shocking, but the New York Times recently reported that dealers1239are targeting senior apartments in Baltimore, yet health1240officials have done little targeted outreach to older people.1241We're seeing that this is an epidemic that is affecting them.1242    What more can be done on the ground to help address the1243pattern of deaths among low-income seniors and to stop1244vulnerable communities from being preyed upon.1245    Dr. Burnett. I see that every day in Baltimore where I1246work. We have a senior living facility just down the street1247from our opioid treatment program, and we've taken steps toward1248partnering with the senior community to be able to talk about1249treatment and recovery.1250    You know, the population of seniors experienced opioid1251treatment in the years before major reforms to opioid treatment1252took place, and so, they have a very negative perception of1253opioid treatment, very strong stigma toward medications for1254opioid use disorder, and so, there's got to be a significant1255amount of education to be able to bring those individuals back1256into treatment.1257    It requires partnerships and peer recovery support services1258going into these senior homes to be able to talk about what1259recovery looks like and being able to access medications and1260really reducing the stigma associated with opiate use disorder1261because it's very pervasive within the community.1262    Senator Alsobrooks. I think there was a question that1263addressed at least a part of this, but also would you speak to1264the importance of supports for seniors who are caring for1265children impacted by the opioid crisis, and how does keeping1266families together reduce the trauma experienced by these1267children?1268    Dr. Burnett. Just to clarify, was that question from you?1269    Senator Alsobrooks. That's for anyone who might want it,1270who can answer.1271    Dr. Burnett. I'm happy to take the question. In my clinic,1272one of the things that we really look for in terms of people's1273capacity to recover is their connection to community and having1274family support. Sometimes, people come into treatment and they1275are by themselves, they don't have any social support systems,1276and so, it's critical toward your recovery process if you1277actually have people that can help you through the process.1278It's a long one. It's much more than the 30-day timeframe that1279most treatment access provides.1280    It's really critical that you have family members,1281especially if you're in an older generation and you're caring1282for younger individuals. That support and that community-based1283experience is critical to being able to help people get into1284recovery. Because a lot large percentage of people who suffer1285from opiate use disorder are wholly disconnected, right?1286They're suffering from trauma, they don't have any resources or1287any places to turn to, and so, they use drugs to cope with1288their isolation.1289    Being able to bring them back into the community, whether1290through faith-based organizations, community partnerships and1291relationships, non-profit organizations, all of that is1292critical to their recovery.1293    Senator Alsobrooks. Thank you.1294    The Chairman. Thank you. Senator McCormick.1295    Senator McCormick. Mr. Chairman, thanks for hosting this1296important meeting on such an important topic. Good to see some1297fellow Pennsylvanians on the panel, so, thank you for being1298here today to talk about such an important issue for the1299Commonwealth of Pennsylvania and the country.1300    4,000 Pennsylvanians died last year from fentanyl, about1301100,000 nationally. This is a crisis of sort of historic1302proportion. You know, I see it all the time in Pennsylvania. I1303was in Cambria County, a couple years ago, and I talked to a1304woman, and she was describing a family member who died of1305fentanyl poisoning and the devastating effect on her family,1306so, I started to make these campaign visits. I'd ask people,1307who among you has been affected by fentanyl? Almost half the1308people in the audience would put their hands up. Either their1309immediate family or their friend's group affected by fentanyl.1310    We've got to get our hands around this, and of course, it's1311a problem that begins at the southern border, primarily with1312the precursors from China, comes across our border, and then1313goes out into a network of drug dealers and cartels in the1314United States.1315    My first question is for you, Sheriff Lemma, about the1316coordination among law enforcement, and is there any gaps you1317see in the way the federal, state, and various law enforcement1318bodies coordinate, and any insights you can give us on what we1319might do better?1320    Mr. Lemma. Yes. Thank you for the question, Senator, and I1321think that first there were gaps. I think that we're reigning1322those gaps in right now. I think that there is potentially some1323confusion and need for deconfliction in the past between the1324law enforcement agencies that worked under the Department of a1325Homeland Security Secretary, and those that worked for Main1326Justice. I suspect now those problems are going to be cleaned1327up pretty quickly.1328    I do think deconfliction is incredibly important, not only1329between Federal agencies, but local, state, and there's1330platforms, and relationships, and task forces that are a huge1331benefit to the country, so, what we can do better, I think more1332of what we're witnessing right now. We're witnessing a1333bipartisan effort to focus on things that move beyond politics1334and find a way to at least tackle what we agree on, and I think1335that through that process should build chemistry and comradery.1336    When we look at what works we cannot lose focus treatment,1337and access to prevention programs, and access to lifesaving1338opioid antagonists like Narcan Kloxxado, and generic versions.1339All of those things are incredibly important, but the bad guys1340have to go to jail. The cartels are a big part of this. They1341are a threat to this country, particularly the Sinaloa and the1342Jalisco New Generation Cartels. We have to be incredibly1343aggressive about that.1344    Unfortunately, many overdoses or poisonings across the1345country are still being treated as accidental, tragic events.1346Every person who's dealt from those dealers is likely to1347experience similar fate, so, I've recently had some1348conversations with incoming Attorney General, Pam Bondi, our1349association, Major County Sheriffs of America, have had the1350same conversations, and I think that we're going to see a lot1351of great progress, so, more of this is good.1352    Senator McCormick. Thank you, and, Ms. Mateer, fellow1353Pittsburgher, I want to say, I think your grandson is extremely1354blessed to have your support. It must be emotionally taxing and1355financially challenging, but it sounds like you're making it1356work. Unfortunately, as Senator Justice was saying, many1357grandparents, hundreds of thousands of grandparents across our1358country suffer through.1359    Any advice that you would offer to families going through a1360similar situation, and particularly grandparents faced with a1361similar set of challenges?1362    Ms. Mateer. The best advice I can offer is to join some1363sort of a peer-to-peer support group. That has been my1364lifesaver. Because of my advocacy with GRAND Voices, I connect1365with grandparents raising grandchildren across the country, in1366the tribal nation, and everywhere, and that's where I get my1367mojo, because we support one another and we understand one1368another.1369    Senator McCormick. Good. Thanks Mojo, and Sheriff Lemma,1370back to you. Just one final question. You talked about1371collaboration and, of course, common data, referring to your1372testimony. Common data is an important part of a unified1373effort. Any commentary on the quality of the data, and anything1374in particular Congress could do to ensure common data standards1375and availability to combat this horrible fentanyl crisis.1376    Mr. Lemma. Yes. I think that we have a lot of great things1377that are going on, and Congress has really been, you know,1378responsible for those things. The elimination of the X-Waiver I1379really think that really we should take on permanently1380scheduling xylazine. Many states have already moved down that1381path. We're seeing the deadly substance xylazine end up in,1382again, mixed in substances and a growing problem across this1383country, but yet still is not scheduled at the Federal level.1384    What's incredibly frightening about xylazine, it's an1385animal tranquilizer. It really eats the skin away and is non-1386responsive to opioid antagonists, so, these success numbers1387that were presented across the country in various areas would1388absolutely decline, or the drug dealer would kind of move down1389the path to move into that business if we don't kind of tighten1390up on that.1391    One last thing, is kind of looking at that scheduling of1392that, and then making sure that we have programs that work.1393Operation Overdrive is a DEA program that has shown great1394success, great data tracking. Last report, I think it was in 371395cities across the country. Those should spread out, not to new1396cities necessarily, but into the unincorporated counties that1397those major municipalities are in, and I think that data1398collection, OD Maps, is another great effort to expand research1399data collection and allow us to kind of let science move the1400path.1401    Senator McCormick. Thank you.1402    The Chairman. Thank you, Senator McCormick. Senator Warren.1403    Senator Warren. Thank you, Mr. Chairman, and thank you and1404Ranking Member Gillibrand for holding this hearing today. It's1405a really important topic, and I appreciate the care with which1406you treat this issue.1407    Since 2017, the opioid epidemic has taken the lives of1408nearly half a million Americans. Their families, and so many1409more people around this country need Congress to come up with1410some real solutions. For example, I know that Chairman Scott1411and I agree on the need to close a trade loophole that lets1412China ship fentanyl precursors into the country uninspected,1413and it's time to put a stop to that.1414    As we sit here today, President Trump and congressional1415Republicans are working hard to advance budget legislation that1416would make the opioid epidemic worse and not better. They have1417proposals to cut over $800 billion from Medicaid, which is the1418largest single payer of substance use disorder services in the1419entire country, and why? That they can fund tax cuts for1420billionaires.1421    Let's be clear about this. Slashing Medicaid funding,1422either through per capita caps or backdoor cuts, like work1423requirements in an area that already have work requirements,1424would mean ripping away healthcare from millions of vulnerable1425Americans, including about a million people right now who are1426getting treatment for their opioid addiction.1427    Dr. Burnett, you've worked on the front lines of the opioid1428crisis. You have helped countless people overcome addiction. I1429want to thank you for your work and express my admiration for1430that, but tell me, in this budget space, what percentage of1431your patients rely on Medicaid for their treatment?1432    Dr. Burnett. I would say, currently, about 80 percent of my1433patients rely on Medicaid for treatment.1434    Senator Warren. Wow. In other words, Medicaid, as I1435understand it, is not just one option for how people get1436treatment, it is the backbone of the entire system for treating1437opioid addiction. Is that fair?1438    Dr. Burnett. That's a fair comment.1439    Senator Warren. All right, and yet, Republicans are talking1440about gutting that system to the tune of nearly $1 trillion1441dollars, so, I'd like to look at just a little deeper level1442about what those cuts would actually mean for our country's1443battle against the opioid crisis. Two of the policies proposed1444by House Republicans are capping Medicaid payments to states,1445and imposing red tape like additional work requirements.1446    Dr. Burnett, can you just talk for a minute about how those1447changes would affect access to treatment if they were put into1448law?1449    Dr. Burnett. Absolutely. I think there was a recent Kaiser1450Family Foundation study that talks about the work requirements1451issue, and that actually almost 92 percent of people on1452Medicaid already are either working or involved in some sort of1453part-time or full-time work, so, the work requirements1454situation would just really add a lot of administrative1455burdens, ultimately resulting people getting kicked off of1456Medicaid.1457    Senator Warren. I just want to make sure we say that again.1458What proportion of people are now already subject to work1459requirements?1460    Dr. Burnett. There are 92 percent.1461    Senator Warren. Ninety-two percent. All right, so, adding1462more work requirements on top of this has what impact?1463    Dr. Burnett. It would certainly increase the administrative1464burdens of keeping people on Medicaid.1465    Senator Warren. That's right, and what's the consequence of1466increasing those administrative burdens?1467    Dr. Burnett. They would lose access to their addiction1468care.1469    Senator Warren. That's right. People just can't get the1470paperwork filled out. More people fall by the wayside. I think1471that was the Arkansas experiment, as I recall.1472    Dr. Burnett. That's correct.1473    Senator Warren. Yes, but there's another part to this as1474well. What about capping the funding?1475    Dr. Burnett. Yes. Capping the funding would create two1476problems. One, it would definitely curtail the amount of choice1477that patients have relative to the types of addiction treatment1478that they would have, and then capping the funding would also1479create a network advocacy problem because more providers would1480disenroll from accepting patients on Medicaid, so, patients1481would not have the ability to access treatment close to where1482they live.1483    Senator Warren. Yes. In fact, we don't have to speculate on1484what the consequences would be. In states expanding Medicaid,1485treatment for opioid addiction increased over four times faster1486than in states that refuse the expansion. Meanwhile, Republican1487states that imposed so-called work requirements did not1488actually increase employment because that was never the point.1489Instead, opioid overdoses went up and access to treatment1490actually went down, so, look, there is no denying the critical1491role that Medicaid plays in fighting the opioid epidemic.1492Cutting that program is not just cruel, it's totally backward1493in what we're trying to accomplish.1494    Might I ask one more question, Mr. Chairman? Thank you, so,1495Dr. Burnett, I want to ask about something you've done some1496scholarly work on and you've published. You've written1497extensively about the positive effects of investing in1498treatment, and how that ultimately lowers costs down the line1499so that if you cut the investments for treatment, like cutting1500Medicaid. The question is, is that really going to save any1501money?1502    Dr. Burnett. No. I think it as I said in my testimony1503people who experience treatment are much faster to return to1504work, be productive members of society, and ultimately not be a1505burden on the social safety net, so, it would actually be more1506detrimental to cut Medicaid funding in terms of the amount of1507expenditure that states and public dollars would be needing to1508use to be able to,1509    Senator Warren. This treatment gets people back to work,1510fewer trips to the emergency room----1511    Dr. Burnett. Correct.1512    Senator Warren. Long-term cost----1513    Dr. Burnett. Totally.1514    Senator Warren [continuing]. is that we save money by1515making these investments. One study found that for every1516patient treated with medication for opioid addiction, the1517government saves up to $100,000 over the course of that1518person's lifetime.1519    Let's be clear, the budget cuts the Republicans are1520proposing are not about saving money. If Republicans really1521wanted to save money, they'd be expanding treatment to folks1522that they claim they want to represent here, rather than1523ripping it away so that we can bankroll tax cuts for1524billionaires.1525    Families and communities across this country are counting1526on us to deliver real solutions to the opioid epidemic, not1527play politics, and I won't stop fighting for that. Thank you1528very much. Thank you all for being here. Thank you, Mr.1529Chairman.1530    The Chairman. Thanks, Senator Warren. Senator Moody.1531    Senator Moody. Thank you, Senator Scott, and I've always1532been impressed, Senator Scott, and as a former Governor as1533well, of the great State of Florida, you have always dug into1534the details and cared about things that were harming1535Floridians, and this Committee hearing is a perfect example of1536that.1537    You saw how it was affecting seniors, and I don't know how1538that isn't abundantly clear, and I love that you are the one1539that highlighted this and brought it as the chairman. When we1540say working and fighting age Americans are dying at a faster1541rate than anyone else, the largest bulk of the number of people1542we lose to overdose death, those are often our parents. They1543are our parents, in this country.1544    I'm so grateful Ms. Mateer, that you were here and willing1545to share your story and your experience. I think it certainly1546informs everyone and raises awareness that those parents when1547they fall victim to addiction and that affects not only the1548children, but the generation before them, and I really1549appreciate you being here.1550    Much of what we did in Florida addressed really aiding many1551levels, and some of that went to helping caregivers and family1552members of those addicted. I think it is a false narrative and1553very shortsighted to say that we have to stop incarcerating1554drug traffickers. In fact, Sheriff Lemma is a leader in our1555State. I have proudly supported him to numerous boards to1556oversee not only how we are tackling this problem, but how we1557are expending the resources that our office recovered going1558after pharmaceutical companies, distributors, pharmacies for1559the opioid epidemic itself. He now helps oversee responsible1560spending.1561    We broke it down into, No. 1, you have to put the peddlers1562of this poison, the traffickers of opioid, synthetic opioids1563like fentanyl behind bars, because they will do violence to our1564communities by selling them lethal doses of opioids or1565synthetic opioids, and to call that nonviolent, I think, is1566shortsighted, and I think if we do not take them out of the1567communities, they will continue to create daughter after son,1568after mother after father falling prey to this, and that is1569step one.1570    I'm so proud of law enforcement efforts in Florida. We led1571the Nation at one point in fentanyl seizures. We are focused on1572that. We have dedicated resources to that funding, pushing into1573law enforcement, making sure that they were focused on that and1574had the resources to go after those traffickers.1575    You can say, honestly, we cannot arrest our way out of this1576crisis. That is true, but we cannot stop going after the people1577who pedal poison indiscriminately that our children, and our1578mothers, and fathers are taking. That has to be our first step,1579and going after the cartels and everyone that's helping them1580spread this is No. 1.1581    After that, we broke it down into how do we; one, make sure1582that Narcan is available to family members, caregivers? Readily1583available, and we pushed it to our first responders. Because of1584that, we are leading the national rate in decreasing the number1585of deaths that we are seeing every year, and I'm so proud of1586that statistic. We're going to keep doing better.1587    Past that, we want to make sure that people can receive1588treatment, good treatment, treatment that's proven successful1589with few rebounds, and that's done so with science-based1590methods. I agree that that is the case. The problem is, I think1591a lot of money is getting shoved because this is such a problem1592and we're trying to fix it, and, tragically, we often try to1593fix things by just shoving money at the problem and not doing a1594very efficient and intelligent way of distributing that or1595accounting for that.1596    What would you say, Sheriff Lemma, is the independent body1597that rates these substance abuse providers?1598    Mr. Lemma. Well, first, Senator, I want to thank you for1599your leadership. It was your work that inspired many of us to1600go down the path, in the first place, and I think it's so1601incredibly important.1602    I also think that for the first time in recent history, the1603stars have aligned and funds have been made available because1604of work of attorney generals in various states, and Big Pharma1605settlement money, and, federally, candidly, I think that if you1606cannot explain what you did last week, you probably don't have1607that important of a job.1608    I think when we talk about healthcare, it is incredibly1609important, and these programs are incredibly important. We said1610medical-based treatment therapy is the gold standard for1611treatment, greater access to naloxone, but when it comes to the1612drug enforcement, connecting the dots, making all of these1613things work together, I think that there has to be a sensible1614strategy because many of the cartel members that are in here,1615they're selling drugs. Some of them are not even legal citizens1616anyway. It creates an incredibly challenging dilemma.1617    We have boards, we have committees in the State of Florida.1618We have an opioid abatement settlement team that you led when1619you were attorney general, and it has these checks and balances1620for 20 qualified counties out of the 67 in the State of Florida1621that have populations of over 300,000 people, and a1622comprehensive strategy to make sure that all of the checks and1623balances are in place, followed by organizations like the1624Department of Children and Families in the various states that1625work through the managing entities that are, again, adhering to1626the gold standard, to making sure that there's checks and1627balances, and people who are, who are responsible for the money1628at a local level, are held accountable to make sure that1629they're doing the right thing.1630    We don't want patrol cars, and fire trucks, and water1631treatment plants, because as Big Pharma who created this by1632saying proper use of OxyContin, the patient was less than one1633percent likely to become addicted, and the world said, no, no,1634no, that's simply not true. Well, the money should go to enrich1635programs that help those individuals and those families.1636    Senator Moody. Thank you, Chairman Scott, I appreciate it.1637Dr. Stein, I'll direct my attention to you. One of the things,1638as Attorney General, and I dug into this, it was heartbreaking1639to see so many people in Florida and across our Nation dying.1640    I was very hands-on on this, and I was shocked to know that1641there wasn't a directory of sorts that people could go to in1642the moment when they were ready to get help that had reputable,1643proven, quality-assured treatment with beds available right1644then. I ultimately ended up speaking with--and, thankfully,1645Florida was supportive, and we contracted with a group called1646Shatterproof Treatment, atlas.org.1647    I think I was one of the first states, certainly Republican1648states, that was pushing something like Treatment Atlas.1649Because as you know, as a mother, as a parent, a family member,1650when somebody's ready for treatment, you want it then, right1651now, when the bed is available, but you don't want to put it1652somewhere where they're just going to take your money and turn1653them out.1654    This is what I want to get to; is there an independent body1655that is ranking the success of these treatment services that1656are grasping all the grants and the funding from federal, or1657state government, or even recovery settlements?1658    Dr. Stein. Senator, thank you for the question. I think1659it's an incredibly important issue. This is a topic that has1660come up over a long period of time in terms of helping people1661find the places they can offer them the best treatment, right?1662    As you point out, when someone needs treatment, you need to1663connect them. Now you have a window of opportunity.1664Unfortunately, I am not aware of any organization that does1665this routinely and standardly in the type of way that I think1666many families look for. I think you're supportive of1667Shatterproof in naming them. There's certainly an organization1668that has done tremendous work in this area, and I think has1669been a leader in many people look to and support the work1670they've done, and that certainly is helpful.1671    I want to pick up on your comment and sort of point out two1672things, though. I think one is sort of identifying places that1673are providing good evidence-based care, medication treatment1674for opioid use disorder, cognitive behavioral treatment.1675    Senator Moody. I don't want you to get it off-track.1676    Dr. Stein. Yes.1677    Senator Moody. To your knowledge, is there an independent1678organization that rates the quality of these drug treatment1679facilities?1680    Dr. Stein. To my knowledge, the organization that comes1681closest right now is Shatterproof, but I am not aware of1682anything beyond that.1683    Senator Moody. There's probably very limited attention or1684resources being given to something like that before we're1685handing out billions, and billions, and billions of dollars.1686    Dr. Stein. I certainly think that that is one area that1687absolutely does need attention. Yes, Senator1688    Senator Moody. Would necessarily be a helpful filter. Thank1689you. Thank you, Chairman Scott.1690    The Chairman. Thank you, Senator Moody. Thanks for what you1691did as attorney general. Senator Kelly.1692    Senator Kelly. Thank you, Mr. Chairman. Dr. Stein, and1693everyone who is appearing here today, thank you. Thank you for1694being here. It's a very important topic.1695    Dr. Stein, we know, well, based on the conversation with1696Senator Moody, seniors are rather vulnerable, a vulnerable1697population when it comes to opioid use disorder. The number of1698adults who need treatment for this have tripled between 2020, I1699think is what the statistics on this say, and a study from the1700Moran Company recently found that opioid use disorder costs1701$4.3 billion each year for newly diagnosed Medicare1702beneficiaries.1703    If you think about not just newly diagnosed beneficiaries,1704but if you think about all Medicare beneficiaries, and you1705extrapolate that $4.3 billion each year to the size of the1706Medicare population, it looks like the treatment for this could1707be in the tens of billions of dollars.1708    Dr. Stein, I believe, you know, I think we can stop1709addiction before it starts for many of these individuals that1710wind up in treatment, and I have a bill that would improve1711access to non-opioid pain medication for seniors who are on1712Medicare. Now, my bill would make sure that seniors aren't1713paying more for a non-opioid pain reliever than they would pay1714for an opioid.1715    Dr. Stein, do you think addressing that financial barrier1716is important to ensuring folks have alternatives and aren't put1717on the pathway to addiction?1718    Dr. Stein. Senator, thank you very much for the question. I1719think multiple steps such as making sure that there are not1720financial barriers to allow adults who could benefit from non-1721opioid management of their pain and decrease use of opioids1722would help to decrease the risk for opioid use disorder in that1723population. I absolutely believe the financial benefit is one1724barrier that's important to address.1725    I also believe that we need to have a sufficient workforce1726providing these treatments that are available. We need to, to1727make sure that Medicare,1728    Senator Kelly. What would that workforce look like? Because1729isn't it just a decision for a doctor to say, "Hey, I've got1730these two options. I've got this non-opioid pain reliever. It1731costs X out of your pocket. I got the opioid. I'd prefer you1732take the non-opioid. I understand you got financial issues, you1733might be on a fixed income as a senior. This is a choice we're1734going to have to make here." But what is the workforce beyond1735that?1736    Dr. Stein. Absolutely, I think non-opioid medications is1737one option, but there are also non-medication options that can1738very much help people: therapeutic massage and acupuncture.1739Does it work for everyone? No, but it certainly works for a lot1740of people, and has been shown to reduce the amount of opioids1741they need.1742    We need to make sure that we have sufficient individuals,1743so, that's an option for the doctor you're talking about that1744it's not just opioid or non-opioid, but I've got three options.1745What works best for you and your family? Making sure that1746Medicare reimburses those services.1747    For example, right now, non-pain management for1748chiropractors is limited to back pain, but there are other1749things within their scope of practice that might be useful: an1750acupuncturist, so, I think the financial barrier is one. It's1751critically important, but there are others to make sure that1752our older adults get the care they need for the pain to reduce1753the risk of opioid use.1754    Senator Kelly. The financial barrier extends beyond just1755the cost of the medication, I think is, you know, one of what1756you're referring to. Do you have a sense for how many folks1757wind up on opioids because they can't afford a non-opioid pain1758medication?1759    Dr. Stein. I do not.1760    Senator Kelly. Does anybody know of any studies that's been1761done. I'm trying to get this sense for my legislation, and if1762we were to implement this, how big of an impact it would have.1763Do you think reducing the price of the non-opioid pain reliever1764would result in less people addicted to opioids?1765    Dr. Stein. I think options that allow the elderly non-1766opioid medication treatment to better control their pain are1767all things the less elderly exposed to opioids and potentially1768more opioids than they need, the more likely we're going to be1769reducing.1770    Senator Kelly. Dr. Burnett, it seemed like you wanted to1771comment?1772    Dr. Burnett. Yes. I would just say that when we're talking1773about chronic pain management, a multimodal approach that Dr.1774Stein is talking about is critical, and this is something that1775I see regularly in my clinic, and Dr. Stein highlights this1776point in that you're actually only limited to pharmaceutical1777options a lot of the time relative to your pain management.1778    Coverage for the physical and occupational therapy, being1779able to get into people's homes to be able to improve their1780living environments, and having people go in and make those1781evaluations and those changes in addition to aqua therapy,1782acupuncture, all these alternative and complimentary strategies1783would be instrumental to improving the overall quality of life1784for people with pain and making their pain much more manageable1785so that we don't have to turn to the pharmaceutical options and1786avoid people getting addicted.1787    Senator Kelly. All right. Thank you. Thank you, Mr.1788Chairman.1789    The Chairman. Thank you, Senator Kelly, so, you know, I ran1790a large hospital company for a long time, and then I was1791Governor of Florida, and then one of the frustrating things1792about any issue, this is an example, but I think all of us have1793stories that we believe that some sort of treatment, some sort1794of something is going to save money down the road, and if you1795believe that, man, you jump at it, right? Nobody comes with1796comes with an analysis and nobody ever wants to take the risk.1797    I had at times I had hundreds of thousands of employees in1798some of my companies and people come and say, oh, if you'll do1799this test, it'll cost you X dollars. You'll save multiples of1800that in healthcare. I mean, who wouldn't do that? I said, "I'll1801tell you what, I'll do it. I'm going to double what I'll pay1802you, but you take the risk that I'm going to save the money."1803"No, wait a minute. We're not in that business. We're not going1804to take the risk."1805    That's the issue you have on all these programs. Nobody1806wants to go through what Ms. Mateer's going through. Everybody1807wants to do what all of you have talked, you know, almost1808everybody's talked about is some program. Nobody, nobody,1809nobody comes with data. Nobody comes with data, and nobody's1810willing to take the risk, I mean, on any program whether it's a1811Medicare program, Medicaid program, and so, it makes it so1812difficult to say, "Oh man, I am all in for doing that because1813there's no data, there's nothing." Nobody was willing to take1814the financial risk.1815    Like, I've never been in the insurance business, but you1816would think, right, if you were in the insurance business, and1817somebody came to you and you could really prove that they could1818save money by providing this service, or this drug, or this1819blah, blah, whatever it is, they would jump at it, but for1820whatever reason it doesn't happen.1821    I always ask, you know, the biggest thing I always ask1822everybody is, are you willing to take the risk? I mean, it's a1823great story. Are you willing to take the risk that it's going1824to save money? If you are, then, man, you people should jump at1825that, but nobody does.1826    Sheriff Lemma, can you just talk about your community for a1827second? You're not in a big downtown area, you're more of a1828suburban and a little bit rural area. How is an area like that1829that most people think of this country? Oh, you don't have1830drugs in that area. I mean, this is sort of the heartland of1831America and it never happens, so, how does it happen in an area1832like yours?1833    Mr. Lemma. Yes. Thanks so much, Chairman. You know,1834Seminole County is, again, the fourth most densely populated1835per square mile, but we're a small county. We have a population1836of about 500,000 people, and a little more than 300 square1837miles. Very affluent county has the highest level of education1838per capita that does not host home to a major university, and1839great quality of life. One of the top school systems in the1840entire state.1841    When we look at the significance of the reduction, we're1842proud about that. I talked about a 29 percent reduction in1843overdoses or poisonings, and a 42 percent reduction in1844fatalities, but when you look at the volume of numbers even of1845a community like that, the overdoses last year representing the184629 percent decrease is 427, and the fatalities are 66.1847    If we had a community meeting just there in Seminole1848County, and laid 66 body bags and the tragic effects that they1849have on the entire family, it would be devastating, and it1850would be a topic of conversation that everybody would like lean1851in and talk about tremendously, and, again, this is one of the1852most successful counties in the State of Florida based on1853recent data.1854    Palm Beach County is another county that had a remarkable1855reduction. Forty percent or more reduction in fatalities. I1856think this is a testament to the strategy that absolutely1857works, and in addition to that, and I hadn't mentioned it yet,1858but in Seminole County alone, we've charged 39 drug dealers1859with first degree murder for dealing deadly doses of narcotics,1860and at the same time, we worked with the Florida legislature to1861change the burden of proximate cause of death to substantial1862factor.1863    Another key success point there is in areas across the1864country, the most important thing is to protect and preserve1865human life. Greater access to opioid antagonists and reversing1866the effects of the overdose, or bringing people back to life1867literally with medicine on gun belts, and in back of patrol1868cars, and in private citizens' pockets, but we created a new1869law in the State of Florida that allows us to charge every drug1870dealer with second degree felony culpable negligence if we can1871prove that they dealt a deadly dose of drugs and we've revived1872them with the use of naloxone.1873    This is creating momentum. It's something that people are1874talking about, not only in the State of Florida and in our1875community, but across the country, and we would be happy to1876share it, and I think that it really saves lives.1877    The Chairman. Thank you. Ranking Member Gillibrand.1878    Senator Gillibrand. Thank you, Mr. Chairman. Thank you to1879each of you for your testimony. I was very moved by everyone's1880perspective and the work that you're doing on the ground every1881day to save lives, and what's happened to your practice, and1882what's happened to your community, it really does matter.1883    Ms. Mateer, thank you so much for sharing your story about1884your grandson. He sounds like he's a wonderful boy, and you1885gave some very persuasive recommendations at the end of your1886testimony. I thought they were excellent. Can you give us a1887little more guidance on what types of services or supports1888would make a difference?1889    I have a piece of legislation called Supporting Families1890Through Addiction Act, which would provide $25 million to1891community programs so they can provide families with the1892resources they need to support loved ones battling addiction,1893so, that grant money is pretty flexible, but I'd love to hear1894directly from you at different stages in your life raising your1895grandson, what types of supports could have made a difference1896for you and your family?1897    Ms. Mateer. Thank you for the opportunity to speak and for1898your reinforcement. It means so much. I think from my1899standpoint, when I first was showing up at the pediatrician's1900office with an infant child, and I wasn't the parent right then1901and there, it would've been so helpful for that community to1902provide me with at least some basic information where to go for1903things, what to do, a pamphlet on what kind of crib to buy,1904what kind of car seat to buy. Because a generation later, all1905of these things change; how to feed a baby, everything's1906different.1907    I think wherever we touch, it would be good to have some1908sort of supportive measure in place that at least would provide1909information and maybe a list of where to go for resources, what1910community groups are there, where you could get baby clothing,1911things like that. I think those things would really be helpful.1912    Senator Gillibrand. Maybe services through pediatrician's1913offices, at a minimum?1914    Ms. Mateer. Yes. It just seems to me that they don't see1915the issue, they don't recognize it. I know there are so many of1916us out there, but it's just not on the radar. It's just quiet.1917    Senator Gillibrand. Very helpful. Thank you.1918    Ms. Mateer. Thank You.1919    Senator Gillibrand. Dr. Burnett, thank you for testifying1920about what you're doing to help older adults access these1921critical addiction services in your community. In your1922testimony, you discuss the challenge of accessing evidence-1923based addiction treatments for those who need it. You also1924discuss the impact on older adults who are struggling with1925their addiction.1926    Can you expand on some of the challenges that older adults1927face with regard to substance use disorder treatment, and are1928there policy changes that you would, that you would recommend1929that could address some of those barriers?1930    Dr. Burnett. Yes, sure. You know, I think Dr. Stein also1931highlighted this very eloquently in so far as older adults have1932a multitude of chronic disease issues that you have to manage1933in addition to their substance use disorder care. They've got1934issues related to transportation, polypharmacy. Being able to1935connect your substance use disorder care to their general1936medical care in and of itself is a challenge, and so, it1937requires a team-based effort between the nurses on the team,1938the peers on the team, and collaboration with other physicians1939that might be taking care of this patient population.1940    There's definitely lots of different strategies and policy1941solutions that we can come up with largely focusing on1942Medicare. We could certainly expand the Mental Health Parity1943and Addiction Equity Act to Medicare so that reimbursement for1944these services could be paid at an equal rate within the1945Medicare population, because currently, that's excluded. We1946could authorize Medicare coverage of non-hospital-based1947residential treatment. Currently it is difficult for1948individuals to be able to participate in community-based IOP1949and PHP programs because they don't have--Medicare doesn't1950cover that. The Medicare SUD bundled payments provisions could1951be in increased.1952    There's lots of different ways that we could ensure that1953more providers are able to take Medicare and take care of those1954patients with substance use disorder.1955    Senator Gillibrand. Thank you. Dr. Stein, you also1956discussed some of the challenges with treating an older1957population with substance use disorder, and you mentioned one1958of the challenges is being the acute shortage of the workforce1959and the lack of preparedness among the workforce to treat older1960adults with co-occurring substance use disorder and dementia.1961Can you elaborate on this issue and what we can do to help?1962    Dr. Stein. Sure. Senator, thank you very much for the1963question. It's a challenge, right? Because as we've heard many1964of the individuals providing treatment under the addiction1965specialists, and they don't necessarily have this expertise.1966    I think one solution that has come up, as I've talked to1967colleagues, is either to enhance training in geriatrics for1968those individuals, or find ways to support those systems in1969bringing in physicians' assistants or people who may have more1970basic medical training in geriatrics to partner within the care1971system so they don't have to move back and forth.1972    I think the other one that we really need to focus on,1973though, is primary care, because that honestly is where the1974majority of elderly are going to continue to get care, and1975despite so many of our efforts, many of them still don't1976provide medication treatment for opioid use disorder with1977buprenorphine that we know to be effective.1978    One of our recent studies actually showed that there are1979probably only about 1,200 clinicians in the country that treat1980over a third of the older adults receiving buprenorphine. It's1981highly concentrated, and so, I think one of the things we1982really need to think about is in that group of primary care1983clinicians treating the elderly, so much of our focus has been1984trying to get a new clinician to prescribe buprenorphine.1985    Maybe we need to start focusing on the types of supports,1986whether it be additional supports within the office, better1987connections with non-physician substance abuse treatment1988services to make those clinicians more likely not to just1989prescribe one buprenorphine, but one patient, one elderly1990patient with buprenorphine, but more of those physicians and1991physician's assistants, nurse practitioners to treat more1992elderly with buprenorphine. Let's try to build a greater a1993workforce of somewhat higher volume prescribers toward the1994elderly that can merge this expertise.1995    Senator Gillibrand. Got it. Thank you so much. Thank you,1996Mr. Chairman.1997    The Chairman. Thank you. Commissioner Duckworth, what's1998some examples of success that you think we ought to try to do1999at the federal level?2000    Mr. Duckworth. Thank you very much for the question. Some2001of the issues in West Virginia, and to the sheriff's point, his2002county of 500,000 would represent about one-third of our whole2003state, so, we're very rural and very family oriented.2004    Going back to the seniors and what I came prepared with2005today was the grandparents raising their grandchildren, so,2006helping those folks and getting programs in place that helps2007the seniors. That, I think, is key. I think we're missing a2008whole generation of people. We're missing workforce. Like I2009said earlier, the whole generation of the family tree is2010missing.2011    You know, to Senator's point of non-opioid medications.2012Like, 50 and every 1,000 of the babies born in West Virginia2013are addicted to Suboxone. You know, curbing those things,2014getting into to some of the non-opioid treatments, I think2015would be a huge success for what West Virginia needs anyway,2016and where my space is.2017    The Chairman. Yes, I think we have over 50 million2018Americans, working age, I think like 16 or 15, something like2019that, to 64 that don't have a job. That didn't help, so, Dr.2020Stein, your research at RAND has highlighted unintended2021consequences of past opioid policies. We know that increased2022access to naloxone, for example, works. What are some of the2023lessons learned from past missteps that we should keep in mind2024in designing future policy.2025    Dr. Stein. I think the awareness that there are sometimes2026unintended consequences for well-meaning policies is critically2027important, and so, one area that we've certainly seen this and2028learned about it goes back to actually 2010 and the2029reformulation of OxyContin, which was approved by the FDA and2030it was well intended. It took OxyContin, at that point, was2031subject to being abused and misused and reformulated it to make2032much more that much more difficult, and about three years2033later, that old formulation was taken off.2034    What we've learned in terms of unintended consequences2035there, though, is subsequently that reformulation led to higher2036rates of heroin use, higher rates of over overdoses from2037opioids, and the consequences still stay with us. The2038communities that were subject to more subject to the effects of2039that reformulation continue to have higher rates of fentanyl2040overdoses, cocaine problems, and recent research from a2041colleague actually shows higher rates of child suicide.2042    I think as we're putting in place these policies, one of2043the things that becomes critical that we've learned from that2044is to continue to monitor and evaluate. It's not one and done.2045We can't do these things and turn away. We have to continue to2046learn because the crisis is going to continue to evolve, and2047our ability to understand how to respond to the changing2048landscape requires us to continue to pay attention.2049    The Chairman. Thanks. Sheriff, are there any different law2050enforcement issues dealing with seniors? Is there anything that2051makes it more challenging?2052    Mr. Lemma. Yes, Chairman. I think when we look at the baby2053boomers particularly--you know, their name, baby boomers, for a2054reason, and we saw a significant population growth in that2055time, and we find many of that generation are evolving into2056really some dependency.2057    What I think the unintended consequences of Covid was, a2058senior population was thrusted into having a greater online2059presence that they weren't necessarily prepared for. A clue is2060if you're still paying $25 for an AOL account, you're probably2061victim, prime target for a victim of some online scamming.2062We're seeing an increase in white collar crimes and2063victimization of seniors.2064    When it comes to substance use and all of that, I think2065that we've always tried to balance the need for really reliable2066services and opioids have its place in certain environments and2067making sure that people who need the medicine are not getting2068it--not living in pain as a result of it.2069    I think that back when you were Governor, we saw that occur2070in the State of Florida with prescribing three and seven days2071and for acute pain. Then, prolonged issues, whether it's cancer2072or other type of items, seniors are able to get access to that.2073Again, the greatest increase that we're seeing is victimization2074because many of our senior population were thrusted into this2075online presence, and because of that, they become more2076vulnerable.2077    The Chairman. Well, I just want to thank each of you for2078being here. Thank you for caring so much about this issue. It's2079impacted--I don't know, actually, of a family that's not been2080impacted either by alcohol abuse or drug abuse. I mean,2081everybody has. I lost my brother last spring. He started out,2082used some marijuana, eventually used all the drugs, and he2083impacted his life, and so, it screwed up. It doesn't just2084impact him, impacts my whole family. Just I feel sorry for2085everybody that does that, goes through this.2086    Thank each of you for being here, and I want to thank the2087ranking member for her hard work.2088    Senator Gillibrand. Thank you.2089    The Chairman. Thanks.2090    [Whereupon, at 5:20 p.m., the hearing was adjourned.]20912092=======================================================================20932094                                APPENDIX20952096=======================================================================20972098                      Prepared Witness Statements20992100=======================================================================21012102                 U.S. Senate Special Committee on Aging21032104                    "Combatting the Opioid Epidemic"21052106                           February 26, 202521072108                      Prepared Witness Statements21092110                         Honorable Dennis Lemma21112112    Good afternoon, Chairman Scott, Ranking Member Gillibrand,2113and distinguished members of the Special Committee. Thank you2114for the opportunity to testify on the devastating crisis of2115overdoses and fentanyl poisonings. It is an honor to present a2116proven strategy from Florida-one that can be replicated in2117communities nationwide.2118    Chairman Scott, your leadership, starting with your time as2119Florida's Governor when you and Attorney General Bondi took2120action to shut down pill mills, served as a model for the2121country. Senator Gillibrand, your efforts through legislation2122like the FEND Off Fentanyl Act have been crucial in this fight.2123I would also like to recognize Senator Moody, who, as Florida's2124Attorney General, provided invaluable leadership in the fight2125against this epidemic. Your vision and dedication inspired my2126own focus on this issue, which requires both law enforcement2127and clinical understanding.2128    I serve as the elected Sheriff of Seminole County, Florida,2129located in the Orlando Metropolitan area. Seminole County is2130the fourth most densely populated county in Florida, and2131despite its affluence, we are not immune to the devastating2132effects of this crisis. Simply stated, this epidemic does not2133discriminate-it affects citizens from all backgrounds and2134demands comprehensive solutions.2135    In my nearly 33 years of law enforcement, I've come to2136believe that the greatest responsibility of a civilized society2137is to protect and preserve human life. Overdose deaths have2138tragically become the leading cause of death for individuals2139aged 18 to 45. In 2022, the average life expectancy in the2140United States decreased, partially due to the rise in2141overdoses.2142    To effectively combat this crisis, we need a holistic2143approach that includes prevention, treatment, advocacy for2144life-saving interventions, and a strong emphasis on a law2145enforcement strategy that aggressively goes after drug dealers2146who are dealing deadly doses of narcotics in our2147communities.Prevention remains an incredibly powerful tool.2148Through focused education and awareness, we can equip2149individuals with the knowledge to avoid addiction before it2150starts. Prevention also requires ensuring the highest levels of2151access to opioid antagonists, like Narcan, a life-saving2152medication that can immediately reverse opioid overdoses. In2153Florida, we've made great strides in expanding access to these2154antagonists, and they have saved countless lives.2155    Treatment is equally important in breaking the cycle of2156addiction. Medication-assisted therapy, combined with cognitive2157behavioral therapy, has proven effective in helping individuals2158recover from substance use disorder in both clinical and2159correctional settings.2160    Data collection also plays a critical role in combating2161this epidemic. We need to gather and analyze overdose data at2162all levels. By understanding overdose trends, we can better2163allocate resources and target enforcement efforts.2164    However, accountability for drug dealers is absolutely2165crucial if we are going to put an end to this epidemic. We must2166make sure that those who distribute fentanyl and other illicit2167substances, like the emerging trend of street-level Xylazine,2168are held fully responsible for their actions, whether there is2169an associated death or not. Too often, overdoses are treated as2170accidents when, in reality, they are crimes. In Florida, we've2171passed legislation with harsher penalties for drug dealers2172whose actions result in fatal overdoses, while at the same2173time, we have created laws that criminally charge dealers if an2174individual overdoses and is brought back to life with an opioid2175antagonist. Drug dealers cannot be let off easily, and the law2176must hold these individuals accountable to the fullest extent.2177    Additionally, we cannot ignore the illicit drug trade,2178particularly from cartels like the Sinaloa and Jalisco New2179Generation, which still pose a threat to our country. Securing2180the border and preventing fentanyl from entering our country is2181critical to minimizing its availability and reducing deaths.2182    This crisis must unite us all, regardless of partisan2183lines, because it impacts every community across the country.2184    In conclusion, we must adopt a holistic strategy that2185integrates prevention, treatment, improved data collection, and2186the strictest accountability for drug dealers. This strategy2187works, builds safer communities, and ultimately saves lives.2188Utilizing this strategy in Seminole County, we've achieved a218929% reduction in overdoses and a 42% reduction in fatalities in21902024. While we have seen a reduction, we know the hard work2191still lies ahead.2192    Thank you for having me here today. I look forward to2193addressing any questions you may have.21942195                 U.S. Senate Special Committee on Aging21962197                    "Combatting the Opioid Epidemic"21982199                           February 26, 202522002201                      Prepared Witness Statements22022203                      Honorable Gregory Duckworth22042205                                 "HOPE"22062207Introduction22082209    My name is Greg Duckworth. I am a County Commissioner in2210Southern West Virginia, a board member of the West Virginia2211First Foundation (WVFF), and a 26-year retired veteran of the2212West Virginia State Police.2213    I spent my law enforcement career in the heart of the2214opioid epidemic, an area once known as "The Coal Fields."2215Today, I want to share some firsthand experiences on how this2216crisis has devastated families, affected our aging population,2217and where we must focus our efforts moving forward.22182219State Trooper Experience 1: 201222202221    In 2012, 17-year-old Cheyenne Martin reported to police2222that her father and two younger siblings were missing. She had2223already lost her mother, Kerri Hendrix, who-under the influence2224of OxyContin-wandered into a highway and was fatally struck by2225a truck.2226    During the investigation, police found that her father,2227Hendrix, was lured into a trap by a drug dealer named Belknap,2228who owed him money. Hendrix, his girlfriend, and his two2229youngest children were ambushed and murdered. Their bodies were2230discarded as if they were worthless.2231    A decade later, Cheyenne herself died of an opioid2232overdose, leaving behind three small children. Entire families2233are being erased by addiction.2234    This is not just a crisis of individuals-it's a crisis of2235generations. Children lose parents. Grandparents are forced2236back into parenting. Communities crumble.22372238State Trooper Experience 2: 202322392240    The second story involves a single mother in her early 30s2241with four children: a nine-year-old, a seven-year-old, and2242three-year-old twins.2243    For years, she lived with her mother, who helped care for2244the children. Recently, she had moved into her own place-a2245single-wide trailer within walking distance of her mother's2246home.2247    At night, after dinner, she would take the three-year-old2248twins home while leaving the older children with their2249grandmother, who ensured they got to school each morning. The2250twins were described as full of life, radiating joy, as most2251three-year-olds do.2252    One night, the mother put the twins to bed. By the time she2253checked on them again, they were deceased. Autopsies revealed2254multiple drugs in their systems, including lethal amounts of2255fentanyl. The neglect was so severe that rigor mortis had2256already set in before she realized what had happened.2257    The children's grandmother had already lost her husband to2258cancer. She fought for custody of her remaining grandchildren2259but was unsuccessful. She is, however, allowed to see them with2260the help of Child Protective Services.2261    The mother is currently in jail, awaiting trial for two2262counts of child neglect resulting in death.22632264The Burden on Our Seniors22652266    In West Virginia, one in seven children loses a parent to2267overdose or incarceration by age 18. With the highest rate of2268neonatal abstinence syndrome (NAS), many of these children have2269medical and developmental challenges.2270    Grandparents-who thought they were retiring-are now primary2271caregivers. They face:22722273    Physical Strain - Raising young children at an advanced2274age.2275    Financial Hardship - Many live on fixed incomes and2276struggle to meet basic needs.2277    Emotional Toll - Raising children while grieving the loss2278of their own.22792280    Many do this off the record to avoid the foster care2281system, meaning they receive no financial or legal support.2282    West Virginia First Foundation: Supporting Grandfamilies2283and the Aging PopulationI'm proud to serve as a board member2284for the West Virginia First Foundation (WVFF) and to be part of2285an organization that is making a real difference in our2286communities.2287    WVFF is committed to addressing the full impact of the2288opioid epidemic, including the burdens placed on West2289Virginia's aging population. Recognizing that addiction does2290not just affect the individual but entire families, WVFF is2291dedicated to supporting grandfamilies-grandparents raising2292grandchildren-by providing the resources and assistance to2293child advocacy and youth prevention programs.2294    We recognize that this crisis does not end with one2295generation-it continues to ripple outward. By investing in2296solutions that support the full family system, WVFF is helping2297to break the cycle of addiction, ensuring that grandparents2298raising grandchildren are not left to struggle alone.22992300The Fight Against Addiction: Where We Must Focus23012302    Having served on the front lines of this epidemic, I2303believe that our response must be comprehensive. This includes:23042305    Treatment Access - Making detox and rehab services more2306available.2307    Prevention & Education - Stopping addiction before it2308starts.2309    Recovery Support - Ensuring people have pathways to long-2310term sobriety.2311    Grandfamilies & Child Advocacy - Protecting children and2312supporting caregivers.2313    Economic Recovery - People in recovery need jobs,2314stability, and hope.23152316    We must also fix systemic failures, such as:23172318    Underreported overdose deaths.2319    Inconsistent Narcan use documentation.2320    Recovery homes misclassifying overdoses.23212322Closing Statement: Restoring Hope23232324    I believe that hope can be restored.2325    Substance use disorder is our enemy. It is destroying the2326very core of the American way-God, family, and self.2327    To win this war, we must:23282329    Ensure the love and support of the church.2330    Reunite families and emphasize the importance of family2331values.2332    Bring back support systems that give people a sense of2333self-worth.23342335    This crisis is more than just statistics. These are real2336people with names, faces, and stories. If there is one thing I2337want you to take away from today, it is this: behind every2338number, there is a human being.2339    We must act. We must restore hope.2340    Thank you.23412342                 U.S. Senate Special Committee on Aging23432344                    "Combatting the Opioid Epidemic"23452346                           February 26, 202523472348                      Prepared Witness Statements23492350                            Elizabeth Mateer23512352    Chairman Scott, Ranking Member Gillibrand, and members of2353the Senate Aging Committee, thank you for holding this2354important hearing, and for inviting me to share my perspective.2355My name is Elizabeth Mateer. I am a grandmother raising my2356grandson due to the impact of opioids on our family. I also2357volunteer as a Generations United GRAND Voice caregiver2358advocate.2359    When my grandson was born, I had no idea that my life as I2360knew it would soon be forever changed. I did not know that the2361baby was suffering from Neonatal Abstinence Syndrome (NAS). I2362also had no knowledge about Opioid Use Disorder and this made2363it difficult to identify and understand the harsh reality that2364both parents were addicted to painkillers.2365    A few months later my husband and I intervened. We arranged2366for the mom to be admitted to a treatment facility and suddenly2367we had a baby! Although we were very relieved and hopeful for2368the future, we had no crib, no diapers, no baby clothing, no2369formula and no idea where to start.2370    Ten days later I received a phone call that the mom was2371leaving treatment. What were we to do? How could we hand our2372infant grandson back to parents who were using? Fear drove us2373to contact an attorney who obtained emergency custody and we2374were relieved to have the baby safe in our care. However, a few2375weeks later the parents cheated a drug test and we were ordered2376to return the baby. Why do judges appear to misunderstand2377opioid addiction and the risk in placing children with parents2378who are struggling with it?2379    For years we lived an endless cycle of staging2380interventions and arranging for admissions to treatment. Early2381on, one interventionist told me to be prepared to keep my2382grandchild long term because this would go on for a long time.2383Each relapse was a crushing blow and each time the recommended2384length of inpatient treatment increased.2385    The cost for all these treatment facilities was staggering.2386We paid $30,000.00 deposits for admission and $10,000.00/month.2387I constantly battled with the insurance company. If you have2388ever known a person to be caught up in opioid addiction, it is2389like none other. It takes a person's soul and turns them into2390someone you don't even recognize. We were desperate to save2391both mom and baby. The stress of living this opioid-created2392crisis landed me in the hospital with pneumonia in both lungs.2393    Usually, when your loved one heads to treatment you are2394relieved that they are safe, and you have a break from the2395crisis mode. Unfortunately, we did not have that break and were2396instead slapped with a custody case from our grandson's father2397and had to obtain legal counsel. Our legal fees mounted over2398more than two years of custody proceedings and exceeded2399$85,000.00. The court permitted "supervised" visits that were2400not actually being supervised. We were treated like bad people2401who had stolen a baby. Every time we went to court, we worried.2402We requested that the court stop the father's visitation2403privileges when we learned that the father was charged with2404child endangerment when another child of his was under his2405supervision. Six months later, he died of a heroin overdose.2406When I told my then four-and-a half-year-old grandson that his2407father died the First question he asked was "Will I still be2408able to live with you?".2409    I found that working and caring for a child was harder than2410when I raised my own children. I tried to stay in the workforce2411but managing the daycare requirements of drop off, packing2412lunches, pickup on time and all the preparation that goes along2413with it while getting to the office on time was overwhelming. I2414resigned from my position.2415    My relationships slowly disappeared. There were no more co-2416workers. Friends stopped inviting me to social events since I2417did not have childcare, and social outings at my age are not2418typically conducive to bringing children along. I felt isolated2419at home while my husband traveled for work. The stigma of2420addiction, that the child I raised could not raise their child,2421made me feel ashamed. No one knocked on my door with a lasagna2422in hand to comfort our family in crisis. The clergy where I was2423ordained an elder and served twenty-four years never called.2424Depression set in and I wondered, how could I go on?2425    By the grace of God our grandson's mother has been clean2426for a long time. Our relationship is challenging because her2427son, now age 13, wishes to remain in our home. During the years2428of battling her addiction he just grew up. This is his2429community, his home where his pets live, where his school is,2430where his friends are. If this is where he wants to be we will2431support his choice.2432    Though the years were difficult in many ways, there is2433great joy knowing that our grandchild is thriving and happy. We2434are now both retired, my husband delayed retirement so we could2435provide for our grandson. Our retirement is nothing like we2436thought it would be, driving the middle school carpool and2437hosting the baseball team picnic. We hope to stay healthy so2438that we can be there for our grandson.2439    The staggering number of grandparents who care for their2440grandchildren, often without any support from the child welfare2441system, appears to be one of the least recognized populations2442impacted by the opioid crisis. According to Generations United,2443grandparents and other relatives who step forward to keep2444children out of foster care and safely with family, save2445taxpayers more than $4 billion each year. The child welfare2446system would collapse if grandparents did not take in all these2447children. Any grandparent raising a grandchild could use2448financial help.2449    I urge you to consider the following recommendations:2450    Encourage states to support grandfamilies with opioid2451settlement funds. Why is there hardly any consideration to2452distribute opioid settlement money to help the children and2453caregivers in grandfamilies that have formed out of the opioid2454crisis? Anything would help. Seniors on fixed incomes struggle2455to pay for school supplies, activities, clothing, camps, and2456orthodontic treatment among many other things for a child they2457did not plan to raise.2458    Peer Support for grandparents raising grandchildren. Peer2459support from Generation United's GRAND Voices Network has been2460an important way for me to engage with others in my situation2461and share ideas. It has eliminated my feelings of isolation.2462There is a great need for grandparents to connect and support2463one another.2464    Increase availability of knowledgeable mental health2465providers who work with the whole family. There are few mental2466health providers who are qualified to provide care to2467grandfamilies. How can the number of these providers be2468expanded? The dynamics in the family are difficult to navigate2469when the parent loses custody. I was once told that opioid2470addiction in a family is like pouring acid on it. None of the2471treatment facilities provided any support to our family, the2472only focus was on the inpatient and yet our whole family was2473suffering.2474    Ensure access to health care and social security for2475grandfamilies. When we enrolled in Medicare, our grandson lost2476his health insurance. The Affordable Care Act ensures coverage2477of children up to age 26, but we had to purchase private health2478insurance for our grandchild in addition to paying for Medicare2479and a supplemental policy for us. Why are grandchildren not2480included in the Affordable Care Act? Allow grandchildren who2481are in the legal guardianship of their grandparent to qualify2482for survivor benefits if their grandparent dies. Social2483Security requires a grandchild to be legally adopted if they2484are to receive any benefit should the grandparent die. Legal2485fees for adoption can be $30,000.00 on top of initial custody2486proceedings.2487    Protect SNAP. SNAP can be a lifesaver when a grandparent2488suddenly takes in a child. I urge you to protect this critical2489program from cuts.2490    Continue federal support for kinship navigator programs.2491When grandparents step in suddenly to raise children they often2492do not know where to turn for help. Kinship Navigator Programs2493offer important information, referral and support to help2494families connect to community-based services and supports.2495    Children in the care of grandparents are loved and thrive.2496I cannot imagine what my grandson's life would have been in2497foster care with strangers. Grandparents feel a connection and2498commitment to protecting the children in their care, but we2499need help. Any grandparent raising a grandchild could use2500support regardless of their station in life. Please, do what2501you can to help us.25022503                 U.S. Senate Special Committee on Aging25042505                    "Combatting the Opioid Epidemic"25062507                           February 26, 202525082509                      Prepared Witness Statements25102511                           Dr. Malik Burnett25122513    Chairman Scott, Ranking Member Gillibrand, and esteemed2514Members of the Special Committee on Aging, thank you for2515inviting me to participate in today's critically important2516hearing.2517    My name is Dr. Malik Burnett. I am a board-certified2518addiction specialist physician who takes care of patients with2519addiction and co-occurring conditions in Baltimore, Maryland. I2520serve as the medical director of several community opioid2521treatment programs, an Adjunct Assistant Professor at the2522University of Maryland, and a consultant for the Maryland2523Addiction Consultation Service.2524    Today, I am testifying in my capacity as Vice Chair of the2525Public Policy Committee of the American Society of Addiction2526Medicine, known as ASAM. ASAM is a national medical society2527representing over 8,000 physicians and other clinicians who2528specialize in the prevention and treatment of addiction.2529    I want to begin by talking about Baltimore and its2530forgotten generation - older adults born between 1951 and 1970,2531particularly older Black men.1 In my city, almost one in three2532drug overdose deaths come from this demographic.1 Indeed,2533illicitly manufactured synthetic opioids are among the2534deadliest health threats they face. Many of these men have2535struggled with addiction for years, but today, there is no2536margin for error. A single relapse can leave them at the mercy2537of a lethal dose of fentanyl and other synthetic drugs.2538    While addiction is a treatable, chronic medical disease, it2539is also one of the most complex in medicine. It involves2540interactions among brain circuits, genetics, the environment,2541and an individual's life experiences. As a result, solutions to2542our nation's addiction and overdose crisis can be equally2543complex and interconnected.2544    Supply-side approaches - like the DEA's record seizure of2545fentanyl pills in 20232 - are important to public safety, but2546yield little net benefit if demand-side interventions remain2547inaccessible, underfunded, or undermined. Drug cartels can2548quickly replace confiscated synthetic drugs - no crops,2549farmland, or irrigation required - just some precursor2550chemicals, a few chemists, and hundreds of traffickers, all2551making more money than most of us will see in a lifetime.2552    The good news? Evidence-based addiction treatment works,2553and it as effective as treatments for other chronic diseases.32554    As a physician, I have personally witnessed hundreds of2555patients' lives transformed by addiction treatment. Practicing2556addiction medicine is an immensely satisfying profession,2557because I get to see people get really well - they restore2558their marriages, rejoin the workforce, leave criminal activity,2559improve their mental and physical wellbeing, reunite with their2560children, and yes - escape the grasp of drugs cartels.2561Addiction treatment not only improves their lives, but the2562lives of those around them.2563    We are fortunate to live during a time when effective,2564evidence-based treatments exist for opioid use disorder. These2565treatments cut the risk of death, decrease or eliminate drug2566use, and facilitate transitions into healthy, productive roles2567in society.4,5 Yet, tens of thousands of people in the US2568continue to die from illicit opioids annually.2569    How is this possible?2570    Unfortunately, the people who need these treatments the2571most - people with opioid use disorder - are not getting the2572lifesaving care they need, when they need it. In fact, this2573treatment gap has barely budged over the last decade.6 We will2574not end this opioid epidemic until evidence-based addiction2575treatment is easier to get than illicit opioids.2576    For many Americans, especially in rural areas, evidence-2577based addiction treatment can be impossible to find.7,8 Ease of2578treatment access is critically important, because people with2579addiction often experience a brief window of time between2580desiring treatment and experiencing painful withdrawal symptoms2581- symptoms that cheap fentanyl, which can be easier to get than2582addiction medications, can temporarily stop in an instant.2583    Easier access to addiction treatment cannot happen without2584a substantially larger addiction treatment workforce,92585including more addiction specialist physicians. Specialist2586physicians like me are critical for helping patients with2587complex, interconnected health conditions, for leading2588interdisciplinary care teams, and for serving as mentors to2589primary care clinicians who would like to integrate addiction2590treatment into their practices but need greater guidance to do2591so. Increased federal funding for addiction medicine and2592addiction psychiatry fellowships and financial incentives to2593encourage more physicians to enter these training programs are2594sorely needed to ensure every community has access to high-2595quality addiction treatment.2596    In addition, federal law must be amended to allow these2597addiction specialist physicians to prescribe methadone for2598opioid use disorder that can be dispensed from community2599pharmacies. Today, only about 2,000 clinics dispense methadone2600for opioid use disorder, and they are lacking in 80% of US2601counties.10 Methadone for opioid use disorder (but not for2602pain) has more federal restrictions than just about any other2603FDA-approved medication. It has been caught in bureaucratic red2604tape for nearly fifty years - despite an opioid epidemic that2605has continued to worsen. Allowing states to regulate their2606methadone treatment, without undue federal restrictions, could2607lead to the type of innovation needed in opioid addiction2608treatment in America.2609    Yet, connecting individuals to treatment is not enough -2610they must also be able to afford their care. Medicaid and2611Medicare are major insurers for many people with opioid2612addiction, making it essential that their policies facilitate,2613rather than hinder, access. For example, if states are expected2614to implement Medicaid work requirements, then they also should2615have the ability to exempt beneficiaries with substance use2616disorders that make it difficult for them to meet those2617requirements. While completing addiction treatment can increase2618the likelihood of employment,11 beneficiaries struggling with2619severe, unmanaged substance use disorders and associated2620criminal records may not be able to obtain or maintain2621employment. Without such an exemption, our nation could face an2622unnecessary increase in expensive emergency room visits, as2623well as in overdose deaths.122624    Many mental health therapists,13 opioid treatment2625programs,14 and buprenorphine prescribers15 do not accept2626Medicaid, largely reflecting the program's administrative2627burdens and low reimbursement rates.13 Congress should remove2628these burdens and increase Medicaid rates to change this2629equation. In the meantime, addiction treatment providers who do2630not accept Medicaid are essentially unavailable to the2631approximately 40% of nonelderly adults with opioid use disorder2632who rely on Medicaid.162633    Medicare and Medicaid must also cover the full continuum of2634addiction care. (See the enclosed handout on The ASAM2635Criteria). Surprisingly, Medicare does not cover non-hospital-2636based residential addiction treatment,17 even though the rate2637of drug overdose death rates quadrupled among older Americans2638between 2002 and 2021.18 This must change. Further, enforcement2639of mental health and addiction parity must be strengthened by2640requiring robust data collection and evaluation, levying civil2641penalties for parity violations, and incentivizing state2642regulators to be more robust in their enforcement.19 Consumers2643should not have the burden of initiating investigations into2644insurance practices that may violate parity, especially as many2645addiction treatment patients lack financial resources or legal2646knowledge.2647    Additionally, countless studies indicate that the stigma of2648addiction prevents treatment access. Even when people recognize2649they have a problem with drugs or alcohol, they are too2650embarrassed or scared to talk to their physician about it.202651Stigma is arguably the most difficult barrier to address, as it2652is so entrenched in society.21 The federal government should2653stop wasting money on incarcerating people for non-violent drug2654offenses and must continue to emphasize that addiction is a2655disease, not a moral failing. When government resources are2656spent on incarcerating people with addiction for non-violent2657drug offenses, this message gets muddled, and society continues2658to view addiction as a moral failing, disincentivizing people2659from seeking help.21 Incarcerating people for low-level drug2660crimes is also incredibly fiscally irresponsible. Every dollar2661spent on addiction treatment saves $7 of justice system2662resources.22 Research continues to show that treatment can2663reduce illicit drug use and associated criminal activity.232664    People already in the criminal legal system also need2665better addiction treatment. Congress should eliminate2666Medicaid's inmate exclusion, and federal funding for prisons2667and jails should be contingent on providing evidence-based2668addiction treatment - to ensure that taxpayer money is not2669wasted on a revolving door of incarceration.24 The Department2670of Justice should continue investigating criminal legal2671institutions that refuse to offer or permit use of methadone2672and buprenorphine.25 There is a high risk of overdose death for2673people leaving jail or prison,26 as they lose opioids tolerance2674but may return to drug use without a connection to community-2675based treatment. Prisons and jails should be incentivized to2676hire professionals, like social workers, to connect people who2677are reentering the community to continued addiction treatment,2678housing, and employment services - critical services that2679reduce the chances of returning to environments that involved2680drug use.272681    In closing, thank you for the opportunity to share my2682perspective and expertise today. Prior to this hearing, I had2683the privilege of reading RAND's report on America's Opioid2684Ecosystem and related policy ideas.28 Throughout it, there is2685one fundamental question: Who owns this?2686    Whether it is funding the training of more addiction2687specialists; ensuring that they can legally prescribe2688methadone; closing the dangerous Medicare coverage gap for2689residential addiction treatment; equipping the criminal legal2690system to provide evidence-based addiction care; enforcing2691mental health and addiction parity, or avoiding harmful cuts to2692Medicaid, the answer is the same: Congress owns this.2693    Let us work together to save lives.2694    Thank you, and I look forward to answering your questions.26952696REFERENCES269726981.Thieme N, Zhu A, Gallagher J. Seniors in Baltimore Are Being2699Devastated by Drugs: five Takeaways. The New York Times. June27003, 2024. https://www.nytimes.com/2024/06/03/us/baltimore-2701opioid-epidemic-seniors-takeaways.html270227032.Operation Engage Seattle-Top Local Drug Threat:Fentanyl.2704Accessed February 20, 2025.www.dea.gov/engage/operation-engage-2705seattle#:text=In20calendar20year202320DEA,enough20to20kill20ever2706y20American270727083.McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug2709dependence, a chronic medical illness: implications for2710treatment, insurance, and outcomes evaluation. Jama. Oct 427112000;284(13):1689-95. doi:10.1001/jama.284.13.1689271227134.Santo T, Jr., Clark B, Hickman M, et al. Association of2714Opioid Agonist Treatment With All-Cause Mortality and Specific2715Causes of Death Among People With Opioid Dependence: A2716Systematic Review and Meta-analysis. JAMA Psychiatry.27172021;78(9):979-993. doi:10.1001/jamapsychiatry.2021.0976271827195.Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and2720after opioid substitution treatment: Systematic review and2721meta-analysis of cohort studies. BMJ. 2017;357:j1550.2722doi:10.1136/bmj.j1550272327246.Krawczyk N, Rivera BD, Jent V, Keyes KM, Jones CM, Cerd  M.2725Has the treatment gap for opioid use disorder narrowed in the2726U.S.?: A yearly assessment from 2010 to 2019". Int J Drug2727Policy. Jul 19 2022:103786. doi:10.1016/j.drugpo.2022.103786272827297.Andrilla CHA, Patterson DG. Tracking the geographic2730distribution and growth of clinicians with a DEA waiver to2731prescribe buprenorphine to treat opioid use disorder. The2732Journal of Rural Health. Mar 18 2021;doi:10.1111/jrh.12569273327348.Stopka TJ, Estadt AT, Leichtling G, et al. Barriers to opioid2735use disorder treatment among people who use drugs in the rural2736United States: A qualitative, multi-site study. Soc Sci Med.2737Feb 13 2024;346:116660. doi:10.1016/j.socscimed.2024.116660273827399.Jones CM, Campopiano M, Baldwin G, McCance-Katz E. National2740and state treatment need and capacity for opioid agonist2741medication-assisted treatment. Am J Public Health.27422015;105:e55-e63. doi:10.2105/AJPH.2015.3026642743274410.J.H. Duff and J.A. Carter, "Location of Medication-Assisted2745Treatment for Opioid Addiction: In Brief" (Congressional2746Research Service, 2019),tps://www.everycrsreport.com/files/274720190624--R45782--ed39091fadf888655ebd69729c3180c3f7e550f6.pdf2748274911. Zarkin GA, Dunlap LJ, Bray JW, Wechsberg WM. The effect of2750treatment completion and length of stay on employment and crime2751in outpatient drug-free treatment. Journal of Substance Abuse2752Treatment. 2002;23(4):261-271. doi:10.1016/S0740-5472(02)00273-275382754275512.Andrews CM, Humphreys K, Grogan CM. How Medicaid work2756requirements could exacerbate the opioid epidemic. Am J Drug2757Alcohol Abuse. 2020;46(1):1-3. doi:10.1080/275800952990.2019.16867602759276013.Zhu JM, Huntington A, Haeder S, Wolk C, McConnell KJ.2761Insurance acceptance and cash pay rates for psychotherapy in2762the US. Health Aff Sch. Sep 2024;2(9):qxae110. doi:10.1093/2763haschl/qxae1102764276514.Substance Abuse and Mental Health Services Administration.2766(2023). National Substance Use and Mental Health Services2767Survey (N-SUMHSS) 2022: Data on Substance Use and Mental Health2768Treatment Facilities (SAMHSA Publication No. PEP23-07-00-002).2769Rockville, MD: Center for Behavioral Health Statistics and2770Quality, Substance Abuse and Mental Health Services2771Administration. Retrieved from https://www.samhsa.gov/data/2772sites/default/files/reports/rpt42714/NSUMHSS-Annual-Detailed-2773Tables-22.pdf2774277515.Saunders H, Britton E, Cunningham P, Saxe Walker L, Harrell2776A, Scialli A, Lowe J. Medicaid participation among2777practitioners authorized to prescribe buprenorphine. J Subst2778Abuse Treat. 2022 Feb;133:108513. doi: 10.1016/2779j.jsat.2021.108513. Epub 2021 Jun 1. PMID: 34148758.2780278116.Orgera K, Tolbert J. The opioid epidemic and medicaid's role2782in facilitating access to treatment. Kaiser Family Foundation.2783http://files.kff.org/attachment/Issue-Brief-The-Opioid-2784Epidemic-and-Medicaids-Role-in-Facilitating-Access-to-Treatment2785278617.Legal Action Center. Medicare's Expanded Coverage of2787Substance Use Disorder Treatment:Important Progress and2788Recommendations to Fill Remaining Gaps. 2024.2789279018.Humphreys K, Shover CL. Twenty-Year Trends in Drug Overdose2791Fatalities Among Older Adults in the US. JAMA Psychiatry. May 127922023;80(5):518-520. doi:10.1001/jamapsychiatry.2022.51592793279419.Ard JP. An Unfulfilled Promise: Ineffective Enforcement of2795Mental Health Parity. Annals of Health Law. 2017;26 70-85.2796279720.Farhoudian, A., Razaghi, E., Hooshyari, Z., Noroozi, A.,2798Pilevari, A., Mokri, A., Mohammadi, M. R., & Malekinejad, M.2799(2022). Barriers and Facilitators to Substance Use Disorder2800Treatment: An Overview of Systematic Reviews. Substance abuse :2801research and treatment, 16, 11782218221118462. https://doi.org/280210.1177/117822182211184622803280421.Tsai AC, Kiang MV, Barnett ML, et al. Stigma as a2805fundamental hindrance to the United States opioid overdose2806crisis response. PLoS Med. Nov 2019;16(11):e1002969.2807doi:10.1371/journal.pmed.10029692808280922.Fardone, E., Montoya, I. D., Schackman, B. R., &2810McCollister, K. E. (2023). Economic benefits of substance use2811disorder treatment: A systematic literature review of economic2812evaluation studies from 2003 to 2021. Journal of substance use2813and addiction treatment, 152, 209084. https://doi.org/10.1016/2814j.josat.2023.2090842815281623.Chandler, R. K., Fletcher, B. W., & Volkow, N. D. (2009).2817Treating drug abuse and addiction in the criminal justice2818system: improving public health and safety.MA,01(2), 183-190.2819https://doi.org/10.1001/jama.2008.9762820282124.Daley M, Love CT, Shepard DS, Petersen CB, White KL, Hall2822FB. Cost-Effectiveness of Connecticut's In-Prison Substance2823Abuse Treatment. Journal of Offender Rehabilitation. 2004/10/0728242004;39(3):69-92. doi:10.1300/J076v39n03--042825282625.The Americans with Disabilities Act and the Opioid Crisis:2827Combating Discrimination Against People in Treatment or2828Recovery 2022. Accessed June 2, 2023. https://archive.ada.gov/2829opioid--guidance.pdf2830283126.Binswanger IA, Blatchford PJ, Mueller SR, Stern MF.2832Mortality After Prison Release: Opioid Overdose and Other2833Causes of Death, Risk Factors, and Time Trends From 1999 to28342009. Ann Intern Med. 2013;159:592-600. doi:10.7326/0003-4819-2835159-9-201311050-000052836283727.Hoffman KA, Thompson E, Gaeta Gazzola M, et al. "Just2838fighting for my life to stay alive": a qualitative2839investigation of barriers and facilitators to community re-2840entry among people with opioid use disorder and incarceration2841histories. Addict Sci Clin Pract. Mar 21 2023;18(1):16.2842doi:10.1186/s13722-023-00377-y2843284428.America's Opioid Ecosystem: How Leveraging System2845Interactions Can Help Curb Addiction,Overdose, and Other Harms.2846The Ecosystem Approach to Opioid Policy.RAND Corporation; 2023.2847https://www.rand.org/pubs/visualizations/DVA604-1/ecosystem-2848approach-to-opioid-policy.html28492850                 U.S. Senate Special Committee on Aging28512852                    "Combatting the Opioid Epidemic"28532854                           February 26, 202528552856                      Prepared Witness Statements28572858                            Bradley D. Stein28592860[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]28612862=======================================================================28632864                        Questions for the Record28652866=======================================================================28672868                 U.S. Senate Special Committee on Aging28692870                    "Combatting the Opioid Epidemic"28712872                           February 26, 202528732874                        Questions for the Record28752876                           Dr. Malik Burnett28772878                        Senator Raphael Warnock28792880    Question:28812882    Medicaid is the largest payer of behavioral health care2883services in the United States, providing access to mental2884health and substance use disorders.\1\ Additionally, Medicaid2885expansion plays a significant role in access to treatment for2886opioid use disorder (OUD) across the U.S. For example, research2887shows that Medicaid expansion leads to an increase in access to2888treatment for individuals with OUD.\2\2889---------------------------------------------------------------------------2890    \1\ Behavioral Health Services, Centers for Medicare and Medicaid2891Services, https://www.medicaid.gov/medicaid/benefits/behavioral-health-2892services/index.html.2893    \2\ Richard G. Frank, The Role of Medicaid in Addressing the Opioid2894Epidemic, Brookings Institution (Feb. 25, 2025), https://2895www.brookings.edu/articles/the-role-of-medicaid-in-addressing-the-2896opioid-epidemic/ .2897---------------------------------------------------------------------------2898    Can you describe the barriers in access to treatment for2899OUD for people in non-expansion states like Georgia?29002901    Response:29022903    Senator Warnock, states that have not expanded access to2904Medicaid have populations that face significant barriers to2905affording SUD treatment. Lack of access to programs like2906Medicaid means that individuals with an SUD would be required2907to pay with cash for treatment. Furthermore in non-expansion2908states individuals would be required to travel farther to2909access treatment given these states have smaller provider2910networks due to the limitations on reimbursement for services.2911Ultimately, these individuals either delay or forgo treatment2912entirely, and if they do end up in the hospital for medical2913complications associated with the SUD, these complications are2914much worse than the otherwise would have been if they were able2915to be treated sooner. This reality is particularly concerning2916given that in non-expansion states 60 percent of people in the2917coverage gap are people of color, closing the gap would also2918advance more equitable access to behavioral health care and2919reduce overdose rates in these communities which are some of2920the highest in the country. The research demonstrated that2921Medicaid expansion increases coverage for patients, expanded2922behavioral health care provider capacity, increases the2923likelihood that substance use disorders are identified and2924treated. This reduces the likelihood of hospitalization and2925ensures individual are more likely to participate in the labor2926force and be value added to the community.29272928    Question:29292930    How would proposed cuts to Medicaid exacerbate these2931existing barriers to treatment?29322933    Response:29342935    Senator Warnock as of October 2024, there were over 70M2936people Medicaid enrollees, with approximately 14 million2937enrollees having a mental health or substance use disorder2938(SUD). ASAM is extremely concerned about the potential harmful2939cuts to the Medicaid program which are being discussed by some2940lawmakers, as the program provides lifesaving care to Americans2941living with SUD. Proposals that would impose burdensome work2942requirements on people with SUD are just unnecessary2943administrative burdens considering 92% of adults on Medicaid in29442023 were reported to be working full or part time, or unable2945to work due to illness, caregiving obligations, or schooling.2946America is in the middle of an addiction and overdose crisis.2947We have evidence-based treatments for addiction, but if2948patients can't afford or access them, their lives are at risk.29492950                 U.S. Senate Special Committee on Aging29512952                    "Combatting the Opioid Epidemic"29532954                           February 26, 202529552956                        Questions for the Record29572958                          Bradley D. Stein\1\2959---------------------------------------------------------------------------29602961    \1\ The opinions and conclusions expressed in this addendum are the2962author's alone and should not be interpreted as representing those of2963RAND or any of the sponsors of its research.2964---------------------------------------------------------------------------29652966                                RAND\2\2967---------------------------------------------------------------------------29682969    \2\AND is a research organization that develops solutions2970to public policy challenges to help make communities throughout the2971world safer and more secure, healthier and more prosperous. RAND is2972nonprofit, nonpartisan, and committed to the public interest. RAND's2973mission is enabled through its core values of quality and objectivity2974and its commitment to integrity and ethical behavior. RAND subjects its2975research publications to a robust and exacting quality-assurance2976process; avoids financial and other conflicts of interest through staff2977training, project screening, and a policy of mandatory disclosure; and2978pursues transparency through the open publication of research findings2979and recommendations, disclosure of the source of funding of published2980research, and policies to ensure intellectual independence. This2981testimony is not a research publication, but witnesses affiliated with2982RAND routinely draw on relevant research conducted in the organization.29832984---------------------------------------------------------------------------2985                        Senator Raphael Warnock29862987    Question:29882989    According to the Centers for Disease Control and2990Prevention, non-opioid treatments are effective in managing2991chronic pain.\3\ However, barriers like step therapy2992requirements and prior authorization create unnecessary burdens2993on a patient's access to non-opioid pain management treatment.2994---------------------------------------------------------------------------2995    \3\ Centers for Disease Control and Prevention, "Nonopioid2996Therapies for Pain Management," webpage, January 31, 2025, https://2997www.cdc.gov/overdose-prevention/hcp/clinical-care/nonopioid-therapies-2998for-pain-management.html.2999---------------------------------------------------------------------------3000    How can increasing access to non-opioid pain medications,3001like through the Alternatives to Prevent Addiction in the3002Nation Act, help address the opioid epidemic in the United3003States?\4\3004---------------------------------------------------------------------------3005    \4\ The question is presented verbatim as it was submitted to RAND.30063007---------------------------------------------------------------------------3008    Response:30093010    Thank you for the question, Senator. With approximately one3011in four Americans experiencing chronic pain,\5\ there is an3012urgent need to develop comprehensive solutions that will3013effectively meet the diverse needs and preferences of chronic3014pain patients across the nation.3015---------------------------------------------------------------------------3016    \5\ J. Lucas and I. Sohi, "Chronic Pain and High-Impact Chronic3017Pain in U.S. Adults, 2023," Centers for Disease Control and Prevention,3018November 2024, https://www.cdc.gov/nchs/data/databriefs/db518.pdf.3019---------------------------------------------------------------------------3020    Recent clinical practice guidelines from leading health3021organizations-including the Centers for Disease Control and3022Prevention, Department of Veterans Affairs, and World Health3023Organization-have aligned in recommending non-opioid treatments3024for the majority of chronic pain conditions.\6\3025---------------------------------------------------------------------------3026    \6\ World Health Organization, WHO Guideline for Non-Surgical3027Management of Chronic Primary Low Back Pain in Adults in Primary and3028Community Care Settings, December 7, 2023; Use of Opioids in the3029Management of Chronic Pain Work Group, VA/DoD Clinical Practice3030Guideline for the Use of Opioids in the Management of Chronic Pain,3031U.S. Department of Veterans Affairs and U.S. Department of Defense, May30322022, https://www.healthquality.va.gov/guidelines/pain/cot/; Centers3033for Disease Control and Prevention, "2022 CDC Clinical Practice3034Guideline at a Glance," webpage, May 7, 2024, https://www.cdc.gov/3035overdose-prevention/hcp/clinical-guidance/index.html.3036---------------------------------------------------------------------------3037    These guidelines include both non-opioid pain medications3038and non-pharmacological therapies. Despite this robust evidence3039foundation, a variety of policies continue to impede3040implementation in routine clinical practice.3041    When evaluated solely on direct costs to patients and3042insurers, generic opioids appear relatively inexpensive.\7\ In3043contrast, non-opioid analgesics face barriers, including tiered3044formulary placement, elevated cost-sharing, prior3045authorization, and step therapy protocols that mandate3046treatment failure with cheaper alternatives (often opioids)3047before covering preferred non-opioid options. These obstacles3048rarely apply to generic opioid medications, creating a3049situation in which the clinically preferred options face a3050broader range of cost and non-cost barriers compared with the3051less clinically preferred and higher-risk opioid analgesic3052alternative.3053---------------------------------------------------------------------------3054    \7\ Hilary Aroke, Ashley Buchanan, Xuerong Wen, Peter Ragosta,3055Jennifer Koziol, and Stephen Kogut, "Estimating the Direct Costs of3056Outpatient Opioid Prescriptions: A Retrospective Analysis of Data from3057the Rhode Island Prescription Drug Monitoring Program," Journal of3058Managed Care & Specialty Pharmacy, Vol. 24, No. 3, 2018.3059---------------------------------------------------------------------------3060    Administrative and reimbursement policies also restrict3061access to evidence-based non-pharmacological interventions for3062pain. For example, although the Centers for Medicare & Medicaid3063Services began covering acupuncture for chronic low back pain3064in 2020,\8\ reimbursement is limited to select providers. This3065restriction disproportionately affects patients in medically3066underserved areas and excludes those with other chronic pain3067conditions. Similarly, Medicare's coverage of chiropractic care3068is restricted to spinal manipulation,\9\ requiring3069beneficiaries to pay out of pocket for essential services, such3070as physical examinations or rehabilitative exercises.3071---------------------------------------------------------------------------3072    \8\ Medicare.gov, "Acupuncture," webpage, undated, https://3073www.medicare.gov/coverage/acupuncture.3074    \9\ Medicare.gov, "Chiropractic Services," webpage, undated,3075https://www.medicare.gov/coverage/chiropractic-services.3076---------------------------------------------------------------------------3077    Approaches to addressing these barriers and expanding3078access to non-opioid pain medications that Congress could3079consider include3080    limiting patient cost-sharing for non-opioid pain3081management medications3082    limiting prior-authorization requirements and step therapy3083protocols for non-opioid pain management medications3084    enhancing shared-decisionmaking approaches with patients3085regarding pain management preferences.3086    These possible policy changes would enable meaningful3087shared decisionmaking regarding non-opioid versus opioid3088medications, which can decrease opioid misuse.\10\ It is likely3089that these changes would reduce opioid prescriptions as3090patients gain access to alternatives. Additional policy reforms3091that Congress could consider to reduce barriers to non-3092pharmacological interventions include the following:3093---------------------------------------------------------------------------3094    \10\ Vanessa C. Somohano, Crystal L. Smith, Somnath Saha, Sterling3095McPherson, Benjamin J. Morasco, Sarah S. Ono, Belle Zaccari, Jennette3096Lovejoy, and Travis Lovejoy, "Patient-Provider Shared Decision-Making,3097Trust, and Opioid Misuse Among US Veterans Prescribed Long-Term Opioid3098Therapy for Chronic Pain," Journal of General Internal Medicine, Vol.309938, September 2023.3100---------------------------------------------------------------------------3101    Cover nonpharmacological therapies-for example, expand3102coverage for licensed acupuncture for more than chronic low3103back pain and to any trained provider and add coverage of3104chiropractic services within Medicare to align with scope of3105practice.3106    Generate a larger workforce and a more robust provider3107network by including providers of non-pharmacological therapies3108in existing loan forgiveness programs, such as rural health3109grants or the National Health Service Corps.3110    Provide funding for integrative training opportunities to3111complementary and integrative health providers, similar to3112those available through Centers for Medicare & Medicaid3113Services-funded graduate medical education residency programs.3114    In conclusion, the policy options presented above could3115help align payment and administrative policies with evidence-3116based guidelines for non-opioid pain medications while helping3117to address additional barriers that exist in accessing non-3118pharmacological therapies.31193120=======================================================================31213122                       Statements for the Record31233124=======================================================================31253126                 U.S. Senate Special Committee on Aging31273128                    "Combatting the Opioid Epidemic"31293130                           February 26, 202531313132                       Statements for the Record31333134                      Dr. Stacey McKenna Testimony31353136[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]31373138                 U.S. Senate Special Committee on Aging31393140                    "Combatting the Opioid Epidemic"31413142                           February 26, 202531433144                       Statements for the Record31453146                         James Balda Testimony31473148    On behalf of Argentum, the leading national association3149representing assisted living and memory care communities and3150the older adults and families they serve, I want to commend you3151for holding today's hearing: "Combating the Opioid Epidemic."3152We appreciate the opportunity to share insights on the3153importance of supervised medication management, especially for3154seniors who struggle with physical limitations and/or various3155forms and levels of dementia. Medication management is often3156confusing and daunting to seniors and can lead to misuse, abuse3157and addiction, especially with opiates. Our communities offer3158residents medication management to both control chronic3159conditions as well as effectively mitigate pain.3160    The members of Argentum operate senior living communities3161offering independent living, assisted living, memory care, and3162continuing care. The members of Argentum and our state partners3163represent approximately 75 percent of the professionally3164managed communities in the senior living industry-an industry3165with an annual national economic impact of nearly a quarter of3166a trillion dollars and responsible for providing more than 1.63167million jobs. These communities are home to nearly two million3168seniors, offering choice, dignity, security, and an enhanced3169quality of life.3170    The American population is aging rapidly. According to data3171just released by the U.S. Census Bureau, the median population3172age reached 39.2 years in 2022-the highest on record. Every3173day, 10,000 Americans turn age 65, and the U.S. population age317465 and older grew from 2010 to 2020 at the fastest rate since3175the 1800's and reached 55.8 million-a 38.6 percent increase in3176just 10 years. The data also showed that for the first time in3177a century the number of adults over 60 in the U.S. is greater3178than the number of children under 10 years of age.3179    Senior living providers start their support of residents3180and families with an evaluation or assessment of a resident's3181condition, which helps identify and establish the level and3182types of care needed. This assessment is conducted by a trained3183and qualified professional, such as the resident's primary care3184physician, and takes place at or around the time of move-in for3185new residents, periodically (e.g., annually), and upon changes3186in a resident's condition. Senior living community staff3187participate in this assessment to ensure the community is3188capable of providing the level of support the resident needs.3189    Individuals who require assistance with activities of daily3190living - the type of care provided by family members in the3191home, such as bathing, walking, dressing, and dining - are3192recommended for assisted living. Residents living with low to3193moderate cognitive disability may receive care in an assisted3194living community, whereas more pronounced levels of cognitive3195disability typically require higher levels of care offered by3196memory care or continuing care communities.3197    A resident's current medications are typically reviewed as3198part of the resident assessment, with medication optimization3199being a primary goal. Medications are reviewed for whether or3200not they're (still) needed, effectiveness, and potential3201harmful interaction with other medications taken by the3202resident. Residents are also assessed to determine whether3203they're able to self-administer their medications, or if this3204is a service that should be provided by trained staff. Best3205practice is for a consultant pharmacist to be part of the3206medication review process.3207    Senior living residents typically also suffer from multiple3208chronic conditions. As reported in NCHS Data Brief No. 506, the320910 most frequently observed chronic conditions among senior3210living residents include high blood pressure (58%), Alzheimer's3211disease or other dementias (44%), heart disease (33%),3212depression (26%), arthritis (18%), chronic obstructive3213pulmonary disease (16%), diabetes (16%, osteoporosis (12%),3214stroke (7%), and cancer (6%). Further, the Data Brief states3215that 55% of residents were diagnosed with two to three chronic3216conditions and 18% of residents with between four and 103217chronic conditions. As reported in Senior Housing News, a3218September 2020 study conducted by NORC at the University of3219Chicago showed that assisted living residents specifically3220manage 14 chronic conditions, on average. Memory care residents3221are comparable, at just under 13 chronic conditions.3222    These chronic conditions are often accompanied by chronic3223pain. Assisted living providers collaborate with each3224residents' physician and with a consultant pharmacist to3225explore options for deprescribing, replacement with non-opioid3226medications, and implementing non-medicinal interventions such3227as physical therapy, strength conditioning, walking clubs, and3228heat and ice treatments, to name a few. All of these options3229are preferable due to the side effects of opioids in the3230elderly, such as increased falls, changes in cognition,3231constipation, and other well-known issues.3232    Although pharmaceutical developments have increased the3233availability of nonopioid options in recent decades, many3234geriatric patients have comorbidities that preclude the use of3235many other classes of medications. Millions of Americans are3236treated with opioids each year, and many of these patients are3237elderly. According to the CDC, 17.4% of the U.S. population, or323856,935,332 persons, filled at least one opioid prescription in32392017, and opioid prescribing was highest at 26.8% in adults3240aged 65 and up. (See Mayo Clinic Proceedings, Volume 95, Issue32414, April 2020, Opioids in Older Adults: Indications,3242Prescribing, Complications, and Alternative Therapies for3243Primary Care.) Due to the multitude of chronic conditions they3244face, some residents need and benefit from opioid therapy.3245    According to the Kaiser Family Foundation, more than half3246of adults 65 and older report taking four or more prescription3247drugs compared to one third of adults 50-64 years old (32%) and3248about one in 10 adults 30-49 years old. Medication management3249is an important support provided in assisted living3250communities, with up to 85% of residents wanting or needing3251assistance with taking medications.3252    This dispensing of medication by trained community staff3253generally makes it safer for residents, providing a structured3254system for managing medications, including reminders to take3255medications as prescribed and reducing the risk of missed3256doses. Community personnel maintain detailed records of each3257medication administration, allowing for tracking and3258communication with healthcare providers. Staff also help3259monitor for potential interactions or side effects. All of3260these factors help to significantly reduce the risk of3261medication errors compared to self-administration by3262individuals with memory issues or declining cognitive3263abilities. Medication administration is governed by state3264regulation.3265    It is important to note that senior living residents3266typically retain their own primary care physician - the people3267who know residents well - when moving into a senior living3268community.3269    Senior living community personnel spend a lot of time3270supporting and getting to know residents and as a result, are3271in a unique position to advocate for residents. The following3272statement was provided by Kim Butrum, RN, MS, GNP-BC, Senior3273Vice President, Clinical for Silverado - a senior living3274provider operating 27 standalone memory care communities.3275    The average length of stay in assisted living communities3276is two to three years. Susan Mitchell's seminal work on those3277with advanced dementia, found that people living with dementia3278have a similar degree of pain and suffering in the last 183279months of life as those living with terminal cancer; yet3280unfortunately many times a behavioral expression in dementia is3281seen as a psychiatric symptom rather than that the resident3282with difficulties with language and perception is demonstrating3283that they are having discomfort.3284    Despite more than 20 years of regulatory guidance and3285research showing that pain and behavioral expressions in3286dementia are correlated, it can be very difficult to get3287adequate analgesic treatment for residents with moderate to3288advanced dementia. Pain medications are limited... non-3289steroidals usually can't be used due to renal impairment, which3290is common in the elderly, and many prescribers, unfortunately3291are fearful of prescribing adequate analgesia. Opiates, while3292dangerous when used inappropriately, are also very effective3293analgesics when used appropriately. Even the 2022 CDC guidance3294on chronic opiate use stated that those on palliative care, at3295end of life, and those with cognitive impairment are at high3296risk of inadequate treatment for pain.3297    I hope if further regulations are added that there will be3298a carve-out around opiate use for those on palliative care,3299those living with dementia, and on hospice.3300    Please do not hesitate to contact my office with any3301questions or requests for additional information.33023303    Sincerely,33043305    James Balda3306    President & CEO3307    Argentum33083309                 U.S. Senate Special Committee on Aging33103311                    "Combatting the Opioid Epidemic"33123313                           February 26, 202533143315                       Statements for the Record33163317               The ASAM Criteria (Fourth Edition) Handout33183319[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]33203321                 U.S. Senate Special Committee on Aging33223323                    "Combatting the Opioid Epidemic"33243325                           February 26, 202533263327                       Statements for the Record33283329               Moyo Dow and Francesca Beaudoin Testimony33303331[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]33323333                 U.S. Senate Special Committee on Aging33343335                    "Combatting the Opioid Epidemic"33363337                           February 26, 202533383339                       Statements for the Record33403341                          Tim Clover Testimony33423343    Thank you, Chairman Scott, Ranking Member Gillibrand, and3344distinguished members of the Senate Special Committee on Aging,3345for holding this critically important hearing, "Combating the3346Opioid Epidemic," to examine addiction and abuse in older3347Americans. As President and CEO, Rayner Global, I appreciate3348the opportunity to highlight new laws that have taken effect3349this year to help combat the opioid crisis, and the shared3350commitment we have in fighting addiction and curbing the opioid3351crisis. Rayner is a global ophthalmic company that operates3352across the United States and is one of the few companies who3353has developed a non-opioid alternative for use during cataract3354surgery, the most commonly performed surgery in the USA with3355nearly five million surgeries per year.\1\ Our non-opioid3356pharmaceutical product, OMIDRIA (phenylephrine and ketorolac3357intraocular solution) 1%/ 0.3% is the only FDA-approved3358intracameral Non-Steroidal Anti-Inflammatory Drug (NSAID).3359OMIDRIAr is indicated for maintaining pupil size by preventing3360intraoperative miosis and reducing post-operative pain after3361cataract surgery.3362---------------------------------------------------------------------------3363    \1\ Market Scope, Forecast for the Global IOL Market, 2024, p. 1993364---------------------------------------------------------------------------3365    Substance abuse and overdose deaths are rapidly growing in3366Americans who are 65 years and older. The most common3367substances abused are alcohol, prescription drugs such as3368opiates and benzodiazepines (BZD), and over-the-counter (OTC)3369medications. Due to the highly addictive nature of opioids,3370many ophthalmologists want to avoid opioid use in cataract3371surgery, and therefore, having alternative pain management3372strategies is critical. Sadly, drug-related deaths have3373skyrocketed since the COVID-19 pandemic and are increasing in3374seniors. In 2020 alone, over 5000 American seniors died by3375overdose.\2\ For any individual, and especially one who has3376struggled with addiction or is predisposed to addiction, being3377prescribed opioids during or after surgery is highly3378problematic.3379---------------------------------------------------------------------------3380    \2\ https://www.cdc.gov/nchs/data/databriefs/db455.pdf3381---------------------------------------------------------------------------3382    There is not one magic bullet solution to the opioid3383epidemic, it will take a multipronged approach. To that end, at3384Rayner, we are focused on legislation intended to incentivize3385development of non-opioid pain treatments, such as the Non-3386Opioids Prevent Addiction in the Nation (NO PAIN) Act, which3387passed as part of the Consolidated Appropriations Act (CAA) in3388December 2022. NO PAIN was created to reduce financial barriers3389in prescribing innovative non-opioid therapies to Medicare3390patients for improved management of postsurgical pain. The law3391was a bipartisan effort led by Senator Shelley Moore-Capito (R-3392WV) and co-sponsored by several members of this committee,3393including Chairman Scott (R-FL), Senator Mark Kelly (D-AZ), and3394Senator Raphael Warnock (D-GA). The law directs the Centers for3395Medicare and Medicaid Services (CMS) to make a separate payment3396for certain non-opioid pain relief treatments in the hospital3397outpatient department (OPD) setting between January 2025 and3398December 2027. These products may not be bundled into the3399underlying procedure payment, and CMS may not reduce the3400payment level of the underlying procedure to offset the3401separate payment.3402    For any senior, and especially one who has struggled with3403addiction or is predisposed to addiction, being prescribed3404opioids during or after surgery is highly problematic. With the3405passage of the NO PAIN Act, doctors and surgeons can now3406provide innovative, non-opioid alternatives -like OMIDRIA-to3407Medicare patients without facing financial barriers. Policies3408that promote new, innovative non-opioid treatments and options3409are a critical component to combating this terrible epidemic3410with a straightforward solution - prevent addiction before it3411starts. We want to work with the Committee to ensure that this3412law and others remain in place to curb the epidemic.3413    I applaud all the work that the Committee is doing to3414highlight the issues around opioid abuse in older Americans and3415look forward to working with you on this law and our shared3416goal of preventing abuse.34173418    Tim Clover3419    President and CEO of Rayner Global34203421                 U.S. Senate Special Committee on Aging34223423                    "Combatting the Opioid Epidemic"34243425                           February 26, 202534263427                       Statements for the Record34283429                     Dr. Jeffrey B. Reich Testimony34303431Overview34323433    Sparian Biosciences is grateful for the opportunity to3434submit a statement for the record for the Special Committee on3435Aging hearing on February 26, 2025, entitled, "Combatting the3436Opioid Epidemic." This timely hearing brought a much-needed3437spotlight to the challenges and issues engendered by the3438ongoing opioid and drug use epidemic, which collectively3439claimed an estimated 105,000 American lives in 2023, according3440to the Centers for Disease Control and Prevention (CDC).\1\3441---------------------------------------------------------------------------3442    \1\ Garnett, M. F., & Minino, A. M. (2024). Drug overdose deaths in3443the United States, 2003-2023. (NCHS Data Brief No. 522). National3444Center for Health Statistics. www.cdc.gov/nchs/products/databriefs/3445db52234463447---------------------------------------------------------------------------3448About Sparian Biosciences34493450    Sparian Biosciences is a clinical stage biopharmaceutical3451company headquartered in Ranking Member Gillibrand's home state3452of New York. Sparian Biosciences is developing innovative3453medications to combat substance use disorders (SUDs), a public3454health crisis that the congressional Joint Economic Committee3455estimates costs the United States nearly $1.5 trillion3456annually.\2\ Despite recent advances in addiction medicine,3457there are still significant unmet medical needs as noted by the3458CDC and other federal health agencies.\3\ To address this gap,3459Sparian is developing four novel medications. Sparian's AEAr3460agonists (SBS-1000 and SBS-147) are first-in-class novel3461analgesics that hold the promise of offering a non-opioid3462treatment for patients requiring both acute and chronic pain3463management. In November 2024, Sparian completed a Phase 1 trial3464that SBS-1000 was safe and well tolerated in healthy3465volunteers.\4\ The company's second program (SBS-226) is a pre-3466clinical drug candidate that has potential to treat opioid use3467disorders, which if successful, would provide clinicians with a3468new pharmacological treatment and an incremental advance over3469current therapies such as buprenorphine and methadone. Sparian3470is also developing a third drug candidate (SBS-371) that could3471vastly improve how first responders reverse drug overdoses from3472fentanyl and other powerful synthetic opioids. Lastly, Sparian3473is developing a new therapeutic (SBS-518) for stimulant use3474disorders. Currently, there are no FDA approved treatments for3475methamphetamine and cocaine. Sparian is proud that it has built3476this impressive and innovative pipeline with nearly $60 million3477in NIH/NIDA grant funding. Sparian Biosciences is a prime3478example of a successful public-private partnership.3479---------------------------------------------------------------------------3480    \2\ The Economic Toll of the Opioid Crisis Reached Nearly $1.53481Trillion in 2020 - The Economic Toll of the Opioid Crisis Reached3482Nearly $1.5 Trillion in 2020 - United States Joint Economic Committee3483(senate.gov)3484    \3\ Dasgupta, S., Tie, Y., Beer, L., Broz, D., & Vu, Q. (2021).3485Unmet needs and barriers to services among people who inject drugs with3486HIV in the United States. Journal of HIV/AIDS & social services, 20(4),3487271-284.3488    \4\ Sparian Biosciences. (2024, November 12). Sparian Biosciences3489announces results from the Phase 1 clinical trial of first in class3490novel arylepoxamide receptor (AEAr) agonist analgesic SBS-1000. https:/3491/www.sparianbiosciences.com/news/sparian-biosciences-announces-results-3492from-the-phase-1-clinical-trial-of-first-in-class-novel-arylepoxamide-3493receptor-aear-agonist-analgesic-sbs-100034943495---------------------------------------------------------------------------3496Introduction34973498    The SUD epidemic in all of its manifestations, including3499opioid use disorders, has affected all corners of the United3500States or as Ranking Member Gillibrand noted in her opening3501statement, "There is no community in this country that has3502escaped the impact of the opioid crisis."\5\ Sparian3503Biosciences strongly supports Ranking Member Gillibrand's call3504for a "multi-faceted approach"\6\ to end this public health3505crisis. In that spirit, Sparian Biosciences recommends building3506a coalition of multi-disciplinary stakeholders ranging from law3507enforcement to healthcare professionals. Sparian Biosciences3508appreciates Chairman Scott's efforts to recognize that "local3509law enforcement agencies are on the frontlines of this3510crisis"\7\ and their need for additional resources.3511---------------------------------------------------------------------------3512    \5\ U.S. Senate Special Committee on Aging. (2025, February 26).3513Combating the opioid epidemic [Video]. U.S. Senate. https://3514www.aging.senate.gov/hearings/combatting-the-opioid-epidemic3515    \6\ U.S. Senate Special Committee on Aging. (2025, February 26).3516Combating the opioid epidemic [Video]. U.S. Senate. https://3517www.aging.senate.gov/hearings/combatting-the-opioid-epidemic3518    \7\ Scott, R. (2025, February 26). Combating the opioid epidemic:3519Opening statement. U.S. Senate Special Committee on Aging. https://3520www.aging.senate.gov/imo/media/doc/31cc37f1-dfa0-063e-8205-35210b4c3645bfd5/Opening20Statement--Scott2002.26.25.pdf35223523---------------------------------------------------------------------------3524Legislative Accomplishments35253526    Sparian Biosciences commends Chairman Scott and Ranking3527Member Gillibrand for their leadership to address all facets of3528the SUD epidemic and its disproportionate impact on seniors.3529Chairman Scott's leadership was instrumental in the enactment3530of the End Fentanyl Act (S.206) last Congress; this bipartisan3531law modernizes Customs and Border Protection's procedures and3532tools to interdict as well as seize illicit opioids. Sparian3533Biosciences is also grateful for Senator Gillibrand's3534authorship of the bipartisan Supporting Families Through3535Addiction Act (S.1810) that provides resources to help3536individuals and their loved ones through the experience of3537recovery. Sparian Biosciences urges the committee to continue3538its tradition of bipartisan leadership to finally end the SUD3539crisis.35403541Recommendations35423543    As the Special Committee on Aging considers its next3544iteration of bipartisan efforts, Sparian Biosciences3545respectfully submits the following proposals for the3546committee's review:3547    1. Empower the National Institutes of Health (NIH) to3548catalyze the biomedical innovation ecosystem: The committee has3549a bipartisan record of supporting policy mechanisms to drive3550research and innovation to better care for aging Americans. On3551February 12, 2025, the committee brought this to the forefront3552by holding a hearing on strengthening research around longevity3553and aging.\8\ To continue this legacy, the committee should3554push for additional resources for NIH's Helping to End3555Addiction Long-term (HEAL) Initiative. This initiative3556represents NIH's largest commitment to combatting SUDs and3557currently supports more than 1,800 projects in all 50 states.3558Some of these projects are aimed at addressing the nexus of3559SUDs and aging. For example, the HEAL Initiative funded a study3560in 2023 to explore non-opioid based treatment options for older3561Americans suffering from chronic pain.\9\ Another funded study3562in 2022 assessed how regulatory changes around opioids might3563affect care in older lung cancer patients.\10\ The HEAL3564Initiative has a demonstrated track record of success and3565should receive additional resources to combat the SUD epidemic.3566---------------------------------------------------------------------------3567    \8\ U.S. Senate Special Committee on Aging. (2025, February 12).3568Optimizing longevity: From research to action [Hearing]. U.S. Senate.3569https://www.aging.senate.gov/hearings/optimizing-longevity-from-3570research-to-action3571    \9\ National Institute on Aging. (2025) Addressing the chronic pain3572epidemic among older adults in underserved community center. National3573Institutes of Health. https://reporter.nih.gov/project-details/107890613574    \10\ National Cancer Institute. (2025). The effects of hydrocodone3575rescheduling on pain management of older lung cancer patients. National3576Institutes of Health. https://reporter.nih.gov/project-details/105993853577---------------------------------------------------------------------------3578    2. Support a whole-of-government initiative to combat SUDs:3579Republican and Democratic presidential administrations have3580both recognized SUDs are a pressing public health and national3581security challenge that require a coordinated and disciplined3582response. To that end, presidents from both parties have3583consistently declared SUDs a public health emergency.\11\ While3584these declarations have helped marshal additional resources,3585they have failed to materialize in a whole-of-government effort3586analogous to Operation Warp Speed, a public-private partnership3587that delivered lifesaving COVID-19 vaccines in record time.3588Given the rising toll of SUDs, Sparian would urge the committee3589to take a leadership role in developing and implementing a3590whole-of-government SUD initiative. Sparian Biosciences would3591also encourage committee Members to convey to their3592congressional colleagues, FDA, the White House, and other3593relevant stakeholders on the pressing need for such a program.3594---------------------------------------------------------------------------3595    \11\ https://aspr.hhs.gov/legal/PHE/Pages/default.aspx3596---------------------------------------------------------------------------3597    3. Strengthen the SUD workforce to improve access to care:3598Multiple hearing witnesses spoke about the need to improve3599access to SUD care and treatment. Dr. Bradley Stein, who3600testified on behalf of the RAND Corporation, contextualized3601this in the case of older Americans, "Despite widespread3602federal efforts to increase access to such treatment, few older3603adults with OUD receive medication treatment. Only 15 percent3604of Medicare beneficiaries with OUD received medication3605treatment in 2022, lower rates than among younger cohorts."\12\3606Patients with SUDs also face numerous hurdles in accessing3607care, one of which is a shortage of qualified physicians3608certified in addiction medicine, a trend that Dr. Malik3609Burnett, who testified on behalf of the American Society of3610Addiction Medicine (ASAM), reiterated, "Easier access to3611addiction treatment cannot happen without a substantially3612larger addiction treatment workforce, including more addiction3613specialist physicians."\13\ ASAM reports the U.S. needs an3614additional 1,600 physicians to adequately meets its current3615demand for SUD care. To address this workforce shortfall,3616Sparian Biosciences urges committee members to consider3617proposals such as the Substance Use Disorder Workforce Act3618(H.R. 7050), which would add 1,000 residency slots for pain and3619addiction medicine over five years.\14\3620---------------------------------------------------------------------------3621    \12\ Stein, B. D. (2025, February 26). Addressing the opioid crisis3622among older Americans: Strategies for prevention, treatment, and3623supporting families affected by addiction. RAND Corporation. Testimony3624presented before the U.S. Senate Special Committee on Aging. https://3625www.aging.senate.gov/imo/media/doc/31cc37f1-dfa0-063e-8205-36260b4c3645bfd5/Testimony--Stein%2002.26.25.pdf3627    \13\ Burnett, M. (2025, February 26). Combating the opioid3628epidemic. Testimony presented before the U.S. Senate Special Committee3629on Aging. https://www.aging.senate.gov/imo/media/doc/31cc37f1-dfa0-3630063e-8205-0b4c3645bfd5/Testimony--Burnett2002.26.25.pdf3631    \14\ Schneider, B. S. (2024, January 18). H.R.7050 - Substance Use3632Disorder Workforce Act. 118th Congress (2023-2024). Congress.gov.3633https://www.congress.gov/bill/118th-congress/house-bill/70503634---------------------------------------------------------------------------3635    Thank you for the opportunity to share Sparian's3636perspective. Sparian Biosciences shares the committee's mission3637of improving care for aging Americans. If Sparian can serve as3638a resource on these matters, please do not hesitate to reach3639out to Sahil Chaudhary at sahil@sparianbiosciences.com.36403641    Thank you,36423643    /s/3644    Jeffrey B. Reich, MD3645    CEO, Sparian Biosciences, Inc.