“Combating the Opioid Crisis: Prevention and Public Health Solutions” (Part One), including H.R.449, the “Synthetic Drug Awareness Act”; H.R.5002, the “Advancing Cutting Edge Research Act”; H.R.5009, “Jessie’s Law”; H.R.5102, the “Substance Use Disorder Workforce Loan Repayment Act”; H.R.5140, the “Tribal Addiction and Recovery Act”; H.R.5176, the “Preventing Overdoses While in Emergency Rooms Act”; H.R.5197, the “Alternatives to Opioids in the Emergency Department Act”; H.R.5261, the “Treatment, Education, and Community Help to Combat Addiction Act”; H.R.5272, the “Reinforcing Evidence-Based Standards Under Law in Treating Substance Abuse Act”; the “Poison Center Network Enhancement Act”; a bill to authorize the HHS secretary to conduct programs to address the usage of illicit drugs, particularly fentanyl; the “Eliminating Opioid-Related Infectious Diseases Act”; the “Comprehensive Opioid Recovery Centers Act”; a bill to amend the Public Health Service Act to authorize the Centers for Disease Control and Prevention director to carry out certain activities to prevent controlled substances overdoses; a bill to support the peer support specialist workforce; a bill to amend the Federal Food, Drug, and Cosmetic Act to require the HHS secretary to issue guidance with respect to the accelerated approval of certain drugs; a bill to amend the Federal Food, Drug, and Cosmetic Act with respect to the importation of certain drugs; a bill to direct the HHS secretary to update or issue guidance addressing alternative methods for data collection on opioid sparing and inclusion of such data in product labeling; a bill to amend the Federal Food, Drug, and Cosmetic Act to require improved packaging and disposal methods with respect to certain drugs; a bill to amend the Federal Food, Drug, and Cosmetic Act with respect to post-approval study requirements for certain controlled substances; and a bill to amend the Federal Food, Drug, and Cosmetic Act to authorize the HHS secretary to consider the potential for misuse and abuse when determining whether to approve certain drugs.
Introduction
Chairman Burgess, Ranking Member Green and Members of the Subcommittee, the
Since 1972,
Trust Responsibility
The federal promise to provide Indian health services was made long ago. Since the earliest days of the Republic, all branches of the federal government have acknowledged the nation's obligations to the Tribes and the unique trust relationship between
The
Today the Indian healthcare system includes 46 Indian hospitals (1/3 of which are Tribally operated) and nearly 630 Indian health centers, clinics, and health stations (80 percent of which are Tribally operated). When specialized services are not available at these sites, health services are purchased from public and private providers through the IHS-funded purchased/referred care (PRC) program. Additionally, 34 urban programs offer services ranging from community health to comprehensive primary care. To ensure accountability and provide greater access for Tribal input, IHS is divided into 12 geographic Service Areas, each serving the Tribes within the Area. It is important to note that
Overview of the Opioid Epidemic in Indian Country
The national opioid epidemic represents one of the great public health challenges of the modern era. The
Regional data trends further demonstrate the high burden of the opioid epidemic within Tribal communities. According to the State of Alaska Epidemiology Center, AI/ANs had the highest overdose death rate by race from 2009-2014 at 20.2 deaths per 100,000 population. Similarly, the
While Tribal communities are certainly in need of expanded treatment resources, public health prevention must not be forgotten. This includes upstream prevention activities such as comprehensive substance use education in youth, expanded substance and alcohol use education and training for our providers, prevention of adverse childhood experiences, healing from historical and intergenerational trauma, and investment in culturally appropriate and Tribally-driven programming.
Bolstering Tribal public health surveillance infrastructure is also a major need. The
Tribes also remain behind many other communities in their public health infrastructure, capacity, and workforce capabilities as a result of being largely left behind when
At IHS, and indeed even at many Tribal facilities, deferral of care due to funding and workforce shortages has pushed more and more Tribal members towards prescription opioids to treat health conditions that would otherwise successfully be treated with non-opioid therapies. For instance, limited funding resulted in nearly 80,000 Purchased/Referred Care (PRC) services (an estimated total of
The
Tribes throughout the country are finding that lack of adequate funding for the IHS exacerbates some of the systemic challenges currently afflicting the Indian health system and is further restricting their ability to confront the opioid crisis.
Policy Solutions
A) Access to Federal Opioid Resources
Addressing the opioid epidemic is a nationwide priority; however, access to critical opioid prevention and treatment dollars are not reaching many of the Tribal communities that are in serious need of these funds. As the federal, state, and local governments are working together to ensure a coordinated, comprehensive response, Tribal Nations are frequently excluded from these efforts. Failure to include Tribal Nations when seeking solutions to the opioid epidemic will result in major gaps in the ability of
H.R. 5140 - Tribal Addition Recovery Act (TARA)
The CURES Act provided
Forcing Tribes to go to states diminishes the federal trust relationship for health and means that little, if any, funding reaches the Tribal communities. It also erodes Tribal sovereignty and the constitutional relationship set up between the Tribes and the federal government. Tribes are not subservient to the state governments, but exist as equal, sovereign partners with the federal government, and H.R. 5140 would correct an error in the law that erroneously left Tribes of the direct funding pool.
An example of the current funding structures can be seen in Ho-Chunk Nation in
In
H.R. 5140 would also help get resources to Tribal communities in a more efficient way. Forcing Tribes to go to states diminishes the federal trust relationship for health and means that little, if any, funding reaches the Tribal communities. Tribes should be put in charge of their own funding because they will know the strategies that will help challenges in their own communities. Time and again, we have seen that when Tribes are given funding directly outcomes are better and funds are used more efficiently. When state priorities are driving the programming decisions, the unique needs of Tribal communities are often left out.
We are also encouraged to see that TARA includes an extra
In short, H.R. 5140 is a critical piece of legislation that will be an important first-step in getting funding to Tribal communities.
Discussion Draft of a Bill to Improve Fentanyl Testing and Surveillance
The Committee's consideration of the bill to improve fentanyl testing and surveillance would provide grants to federal, state, and local agencies for the establishment or operation of public health laboratories to detect fentanyl, its analogs, and other synthetic opioids.
Discussion Draft of a Bill to Enhance and Improve State-run Prescription Drug Monitoring Programs
Prescription Drug monitoring programs (PDMPs) can be an important tool in tracking opioid abuse or misuse. However, integration between IHS and Tribal health providers with state-level PDMPs has been mixed at best. In order to fully overcome this crisis, it is critical that Tribes be included in the development and implementation of state PDMPs. Therefore, we request that the legislation statutorily require states to conduct meaningful consultation with the Tribes on the implementation of any PDMP in the state about how to better track, report and assess Tribally-specific prescriber and dispenser practices.
Additionally, the draft bill would authorize "Evidence-Based Prevention Grants" and "Enhanced Surveillance of Controlled Substances grants." In both of these cases, Tribes and Tribal organizations should be allowed to receive this funding. Tribal public health systems, including Tribal Epidemiology Centers (TECs), are at the frontlines of treating and preventing the opioid crisis, but, as discussed above, are often not included in state-level initiatives. Therefore, direct funding will enable this important work to reach Tribal communities.
The Eliminating Opioid-Related Infectious Diseases Act
The Eliminating Opioid-Related Infectious Diseases Act will authorize the
In addition, we call upon
* Establish Tribally-specific funding streams such as a
* Ensure parity between states and Tribes in any new opioid-related legislation advanced in
* Establish trauma-informed interventions in coordination with Tribes to reduce the burden of substance use disorders including those involving opioids.
* Include set asides for Tribes within the
FY 2019 Budget Proposal
B) Supporting Traditional Healing Initiatives
Tribal communities have been healing their people for thousands of years, and these strategies are highly effective in the communities where they are employed and engaged. Yet, it is often the case that traditional healing practices are not do not meet mainstream criteria for data collection under federal grants, which puts Tribes at a disadvantage when applying for and administering federal programs. It is critical that
H.R.5272, the Reinforcing Evidence-Based Standards under Law in Treating Substance Abuse (RESULTS) Act
H.R.5272, the Reinforcing Evidence-Based Standards under Law in Treating Substance Abuse Act, requires entities applying for federal grants and cooperative agreements for mental health or substance use disorder (SUD) treatment to demonstrate how their program is evidence-based.
Tribal Healing to Wellness Courts
In addition to traditional healing practices, we urge
For example, the Penobscot Nation, has operated a Healing to Wellness Court (HTWC) since 2011. Any individual Penobscot Nation citizen who is charged with a non-violent crime can petition to participate in the HTWC program. Once accepted into the program, the individual must agree to enter a guilty plea for the crime charged against him/her, but his/her sentence is "deferred" to allow the individual to go through the program. Then, a comprehensive, holistic plan is developed in collaboration between 10 Tribal government departments to address the individual's treatment needs in four phases:
* Phase I: Introduction/Education. This phase is focused on detoxification and beginning treatment and generally lasts 180 days.
* Phase II: Personal Responsibility. This phase is focused on stabilization and treatment and generally lasts 120 days.
* Phase III: Cooperation/Accountability. This phase is focused on maintenance and treatment and generally lasts 120 days.
* Phase IV: Completion/Continuing Wellness. This phase is focused on graduation and aftercare and generally lasts 120 days.
Successful completion of the program results in a dismissal of the participant's guilty plea. Over two dozen individuals have gone into the program since 2011. Recidivism is extremely low. The biggest problem that the Penobscot Nation has is that they do not have sufficient resources to accommodate all the individuals who are interested in participating in the program. While, the program is funded mainly through the
C) Health Information Technology (IT) within the
The federal government has not met its trust responsibility as it relates to updating and modernizing the physical and technological infrastructure within IHS and Tribal health facilities and health IT systems. The current primary Electronic Health Record (EHR) system IHS uses is the Resource and Patient Management System (RPMS), an integrated public health information system based on the
* Many Tribes utilize different EHR systems instead of RPMS;
* Smaller Tribal health facilities do not have the bandwidth to fully operationalize RPMS, and would benefit from the ability to share new components such as files that contain all available drugs instead of just some;
* Some smaller Tribal health clinics are in need of greater training and technical assistance on how to utilize the system most efficiently;
* There is a need to further streamline the system and align it with other EHRs utilized by Tribes;
* Robust and timely IT support is not routinely available;
* Interoperability is incomplete, meaning that if a patient is referred to another clinic that utilizes a different system, the patient records are more than likely not cross-referenced which leads to inconsistencies in patient records.
Issues also exist in terms of RPMS interactions with Prescription Drug Monitoring Programs (PDMPs). PDMPs are state-run electronic databases that track controlled substance prescriptions. Across the board, utilization of PDMPs is inadequate. A national survey of primary care physicians found that 86% of the time, physicians did not check their statewide PDMP prior to prescribing an opioid, despite the fact that 72% of primary care physicians are aware of their state's PDMP. n5
It is important to note the limitations of the PDMP system, both generally and in its usefulness for IHS and Tribal providers, pharmacists and public health practitioners. One, PDMP laws and regulations differ by state. In other words, whereas one state may require providers to update the system within a 24 hour period, other states only require updating the system every few days, or even over a longer period of time. Further, interstate sharing of PDMP data is not streamlined, which creates gaps in monitoring especially for individuals living in border towns, or for reservations that traverse multiple state boundaries. Additionally, to
Due to budgetary constraints, IHS has not been able to support operations and maintenance for the certified RPMS site. Other federal agencies, like the
Telehealth is a much-needed and successful innovation in rural areas. For example, the
To ensure Tribes are able to utilize Health IT to the greatest extent possible in confronting Indian Country's opioid epidemic,
* Provide adequate support, funding, and oversight as IHS moves away from the RPMS system toward a more integrated platform that can better interact with E-prescriptions and EHRs.
* Provide oversite to IHS to implement a Tribally-specific PDMP system than can interact with state PDMPs.
* Review and support IHS's list of Tribal broadband projects, and also include direct funding to Tribes to improve their broadband and telehealth infrastructure.
* Mandate State-Tribal consultation on changes to state PDMPs.
* Incentivize providers to adopt E-prescription as a way to reduce the needless and harmful spread of opioids.
* Eliminate the requirement for Tribal providers to obtain the Secretary's authorization to be designated as an Internet Eligible Controlled Substances Provider, as it imposes an undue burden that delays the delivery of much-needed treatment resources, especially given that no other providers are subject to this requirement. n6
Tribal Response to Opioids
Despite these challenges, Tribes across Indian Country have engaged in multifaceted response efforts that traverse the prevention, treatment and interdiction landscape. For instance, after declaring a state of emergency on the opioid epidemic in
In
In
Conclusion
Again,
n1
n2
n3 Mack KA, Jones CM, Ballesteros MF. Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas --
n4
n5
n6 (21. U.S.C. 829) Section 311(g)(2)
Read this original document at: http://docs.house.gov/meetings/IF/IF14/20180321/108049/HHRG-115-IF14-Wstate-CookB-20180321.pdf
Senator Collins: Congress Must Take Action Now to Significantly Reduce the Cost of Health Insurance for Millions of Americans
“Implementation of MACRA’s (Medicare Access and CHIP Reauthorization Act) Physician Payment Policies.”
Advisor News
Annuity News
Health/Employee Benefits News
Life Insurance News