[Senate Hearing 117-392]
[From the U.S. Government Publishing Office]
S Hrg 117-392
STRENGTHENING FEDERAL MENTAL HEALTH
AND SUBSTANCE USE DISORDER PROGRAMS:
OPPORTUNITIES, CHALLENGES,
AND EMERGING ISSUES
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
SECOND SESSION
ON
EXAMINING STRENGTHENING FEDERAL MENTAL HEALTH AND SUBSTANCE USE
DISORDER PROGRAMS, FOCUSING ON OPPORTUNITIES, CHALLENGES, AND EMERGING
ISSUES
__________
MARCH 23, 2022
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Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
48-903 PDF WASHINGTON : 2023
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
PATTY MURRAY, Washington, Chair
BERNIE SANDERS (I), Vermont RICHARD BURR, North Carolina,
ROBERT P. CASEY, JR., Pennsylvania Ranking Member
TAMMY BALDWIN, Wisconsin RAND PAUL, M.D., Kentucky
CHRISTOPHER S. MURPHY, Connecticut SUSAN M. COLLINS, Maine
TIM KAINE, Virginia BILL CASSIDY, M.D., Louisiana
MAGGIE HASSAN, New Hampshire LISA MURKOWSKI, Alaska
TINA SMITH, Minnesota MIKE BRAUN, Indiana
JACKY ROSEN, Nevada ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico TIM SCOTT, South Carolina
JOHN HICKENLOOPER, Colorado MITT ROMNEY, Utah
TOMMY TUBERVILLE, Alabama
JERRY MORAN, Kansas
Evan T. Schatz, Staff Director
David P. Cleary, Republican Staff Director
John Righter, Deputy Staff Director
C O N T E N T S
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STATEMENTS
WEDNESDAY, MARCH 23, 2022
Page
Committee Members
Murray, Hon. Patty, Chair, Committee on Health, Education, Labor,
and Pensions, Opening statement................................ 1
Burr, Hon. Richard, Ranking Member, a U.S. Senator from the State
of North Carolina, Opening statement........................... 3
Witnesses
Delphin-Rittmon, Miriam E., Ph.D., Assistant Secretary for Mental
Health and Substance Use, Substance Abuse and Mental Health
Services Administration, Rockville, MD......................... 6
Prepared statement........................................... 7
Johnson, Carole, Administrator, Health Resources and Services
Administration, Rockville, MD.................................. 16
Prepared statement........................................... 17
Gordon, Joshua A., M.D., Ph.D., Director, National Institute of
Mental Health, National Institutes of Health, Bethesda, MD..... 24
Prepared statement........................................... 25
Volkow, Nora D., M.D., Director, National Institute on Drug
Abuse, National Institutes of Health, Bethesda, MD............. 28
Prepared statement........................................... 30
QUESTIONS AND ANSWERS
Response by Miriam E. Delphin-Rittmon to questions of:
Senator Casey................................................ 59
Senator Baldwin.............................................. 63
Senator Hickenlooper......................................... 65
Senator Murkowski............................................ 67
Senator Braun................................................ 74
Senator Tuberville........................................... 76
Response by Carole Johnson to questions of:
Senator Casey................................................ 78
Senator Rosen................................................ 80
Senator Hickenlooper......................................... 82
Senator Murkowski............................................ 85
Senator Braun................................................ 94
Senator Tuberville........................................... 95
Response by Joshua A. Gordon to questions of:
Senator Casey................................................ 96
Senator Rosen................................................ 97
Senator Hickenlooper......................................... 101
Senator Murkowski............................................ 102
Senator Scott................................................ 108
Senator Tuberville........................................... 111
Response by Nora D. Volkow to questions of:
Senator Casey................................................ 112
Senator Murkowski............................................ 114
Senator Tuberville........................................... 121
STRENGTHENING FEDERAL MENTAL HEALTH
AND SUBSTANCE USE DISORDER PROGRAMS:
OPPORTUNITIES, CHALLENGES,
AND EMERGING ISSUES
----------
Wednesday, March 23, 2022
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10:01 am, in room
430, Dirksen Senate Office Building, Hon. Patty Murray, Chair
of the Committee, presiding.
Present: Senators Murray [presiding], Baldwin, Murphy,
Kaine, Hassan, Smith, Rosen, Burr, Collins, Cassidy, Murkowski,
Braun, Marshall, Scott, and Tuberville.
OPENING STATEMENT OF SENATOR MURRAY
The Chair. Good morning. Senate Health, Education, Labor,
and Pensions Committee will please come to order. Today we are
holding a hearing on our Nation's growing mental health and
substance use disorder crisis. I will have an opening
statement, followed by Ranking Member Burr. We will then
introduce our witnesses. And after they give their testimony,
Senators will each have 5 minutes for a round of questions.
Again, we are unable to have the hearing fully opened to
the public or media for in-person attendance. As always, live
video is available on our Committee website at
help.senate.gov,. And if you are in need of accommodations,
including close captioning, you can reach out to the Committee
or to the Office of Congressional Accessibility Services.
I hope that everyone on this Committee found our hearing in
February with mental health and substance use disorder experts,
care providers, and advocates to be informative and compelling.
We are all hearing from families in our States about the need
for action.
Parents worried about their kids well-being after the
stress and trauma of this pandemic. People struggling with
depression and anxiety themselves and unsure where to go for
help. Communities fighting a rise in substance abuse, as well
as a surge in overdose deaths fueled by a deadly increase in
fentanyl use.
Mental health and substance use disorder professionals who
are feeling overworked, overwhelmed, and just burned out. We
all want to address these challenges, which is why Senator
Burr, and I are working in a bipartisan way on legislation to
support our communities and help people get the services for
mental health and substance use disorders that they need. We
continue to make progress on that effort, and our hearing today
represents another important step forward.
I spoke last time about the work that Lifeline Connections
and Neighborhood House and the Confederated Tribes and bands of
Yakama Nation and other local organizations are doing to
address the mental health needs of families in Washington
State. And I am glad to have this opportunity to discuss how
the Federal Government can better support frontline efforts to
screen and provide services for mental health challenges,
support people who are struggling with substance use disorder,
increase access to addiction treatment, prevent drug overdoses
and suicide, and more.
Because COVID-19 has made it clearer than ever that while
our communities are doing valuable, lifesaving work, we need to
do much more to help them. Youth health emergencies have
skyrocketed during this pandemic, with sharp increases in kids'
visits to the emergency room for mental health crises, thoughts
of suicide, suicide attempts, especially among girls, and as of
February, over 200,000 children have had their world shattered
after losing a parent or caregiver to COVID-19.
This pandemic has also set us back catastrophically when it
comes to substance use disorders. We saw an estimated 106,000
drug overdose deaths in a single year. That is a record high.
And fentanyl has been especially devastating for families in my
state. Fentanyl deaths in our largest county doubled last year.
But nationally we are also seeing a concerning rise in
methamphetamine and cocaine use.
Meanwhile, our mental health and substance use disorder
workforce, which was already stretched thin, is nearly
threadbare. I said this before, but it really stands out to me
that almost 130 million Americans live in areas with less than
one mental health provider per thousand people. And in my home
State of Washington, our mental health care workforce is only
able to meet 17 percent of our state's needs.
Meanwhile, nationwide, not even a tenth of people who need
treatment for substance use disorder actually get it. And these
problems are especially pronounced for rural areas, communities
of color, and people with disabilities. And it is important to
remember that the many people who are personally facing mental
health and substance use disorders or struggling to get the
support they need, aren't the only ones feeling this. We all
have friends and family who are, whether we realize it or not.
We all rely on first responders, health care providers, and
other frontline workers who are experiencing burnout and
trauma. We all have a stake in making sure people can get the
help they need. So let's make sure we act accordingly. Now we
are starting here on square one. We have a long, bipartisan
track record of addressing mental health and substance use
disorders in this Committee.
But we are also not close to where we need to be,
especially considering the ways this pandemic has worsened
preexisting challenges. We need to rise to this moment by
strengthening the tools that communities are already using
effectively to help people get care and providing new ones to
address the gaps and emerging issues this pandemic has made so
much worse.
That means putting together a bipartisan package that
supports suicide screening and prevention, help schools and
communities meet kids' mental health needs, reduces drug
overdose deaths and gives patients more options to get
substance use disorder treatment, addresses the mental health
needs of new mothers, tackles barriers that make it hard for
people to get the care they need, like stigma, health inequity,
and a strained workforce, and more.
I know Members on both sides of the aisle share these goals
and have ideas about how to make them a reality, and I look
forward to continuing to work with all of you on this. As
Ranking Member Burr and I have announced, it is our goal to
pull the Committee's mental health package together in early
summer so we can move legislation to the floor. We both hope to
have more to say on that in the days ahead and appreciate the
many ideas that Members on and off this Committee have for the
package as we work together to address this crisis.
This pandemic has done so much to damage our Nation's
mental well-being. There are so many people who are stressed
and anxious and traumatized, struggling with addiction, or who
are grieving over the loss of a loved one and don't know where
to turn. But there are also people in our communities who care
about them and who are working right now to get them help.
As this Committee works on bipartisan legislation to
reauthorize and improve Federal programs on mental health and
substance use disorder, I look forward to hearing from all of
our witnesses today about the steps that we can take to help
bolster the efforts of those on the front lines of our mental
health and substance use disorder crisis, and make sure that
every person who is struggling can get the care they need
without worrying about stigma or cost, without having to travel
for hours or wait for weeks, and without feeling like they are
all on their own.
With that, I will turn it over to Senator Burr for his
remarks.
OPENING STATEMENT OF SENATOR BURR
Senator Burr. Thank you, Madam Chair. Thank you for holding
this hearing. Even before the pandemic, we knew the need to
address mental health and substance use disorders were dire.
Opioids took hold and the result was a crisis, with families
and communities who had not dealt with that for some time. As
we look to reauthorize a number of these programs, we face
problems that have been compounded by the pandemic but can be
informed by our COVID response.
We learned that research, innovation, partnerships, and
real time data are the key to our success in overcoming an
unprecedented public health challenge. Today's hearing will
help us determine how to apply these lessons and those actions
to mental health and substance use challenges that continue to
devastate our communities.
The last time the Committee examined our mental health and
substance use programs, we heard from Sam Quinones, excuse me,
on opioids, who shared his belief that isolation and lack of
community was a driving factor in the substance use disorder
crisis facing America. Isolation only worsened when the
pandemic struck. Months on end of remote learning, time
separated from aunts, uncles, grandparents, friends, teachers,
families, were critical--with critically ill and dying loved
ones who could not say goodbye has taken a tremendous toll on
America, especially on children.
We are seeing the results of the past 2 years at an
alarming rate of people, particularly young children, arriving
in the emergency room in a state of mental health crisis. In
2020 alone, the number of young people seeking care for their
mental health in the emergency room increased by 31 percent.
Between 2016 and 2020, the number of children experienced
depression increased by 27 percent.
The number of children experiencing anxiety rose by 29
percent. Last year, more than 100,000 people lost their lives
to drug overdose, a nearly 30 percent increase from the year
before. Two-thirds of these adults were linked to synthetic
opioids such as fentanyl. But in the face of these tragedies,
we see strength and resilience, families turning tragedy into
action to bring awareness and understanding to help others.
In hearings over the past year, we have heard examples of
leaders in local communities ready to meet these challenges,
partnering to bring local solutions to address local
challenges. As we consider reauthorizing these programs, it
would serve us well to remind to remember this too. Since 2016,
we have authorized or reauthorized more than 40 different
Federal programs to address mental health and substance use
disorder.
In addition, the Fiscal Year 2022 omnibus appropriations
bill provided nearly $5 billion for mental health and substance
use disorder related programs. But at least nine of these
authorized programs did not receive funding. We have seen time
and time again that creating a new program that does not get
funded is a false promise. That creating new programs for the
press release of a markup isn't actually a solution.
We need to figure out what we can do with the tools that we
have and improve the current programs and fund the programs
that we do create. We should be honest with ourselves and the
country and terminate the programs that haven't received
funding in the last 5 years. If a program hasn't received
funding, it shouldn't stay on the books. We will have to
prioritize and answer key questions like how to better target
our programs to make sure that they are both meeting the needs
of today, but also have the flexibility to address the needs of
tomorrow.
To our witnesses, welcome. We need your expertise to ensure
we have the right performance measures in place to track
progress in the programs you oversee. GAO recently found that
many of our mental health and substance abuse programs lacked
the measures we need to know whether the programs work. You
only know what you can measure. If we cannot track programs in
a meaningful way, we will not know how to improve the programs
to better meet the needs of the people that are intended to be
served and reprioritize those that are underperforming.
Additionally, we need to make sure that we are using up to
date data to inform our response and addressing emerging
issues. States and local communities must be empowered to
address these issues, and they need accurate information to
identify the problems that they are facing, like emergence--or
emergence or reemergence of a new drug in an area or
identifying increased rates of suicide in certain populations.
Sometimes this requires thinking outside the box.
We saw communities pull together during the pandemic to
come up with solutions that worked, and we need the same spirit
and ingenuity with this challenge. One of the trends in that
success was partnerships with the private sector. Local public,
private partnerships are the foundation of many of our
successful Federal mental health and substance disorder
programs.
I look forward to hearing more about how SAMHSA is
encouraging partnerships and facilitating local engagement
through these programs, and how this can be improved going
forward. Leveraging innovation to help address our mental
health and substance use disorder crisis is another area I look
forward to focusing on and hearing more about. Critical to all
of this strong workforce, this Committee reauthorized a number
of health workforce programs in 2020, in addition to those
included in the pandemic package.
The health workforce, particularly our doctors, nurses,
counselors, and therapists, have been through a lot. They rose
to the challenge during this pandemic, and it has taken its
toll. Earlier this Congress, the Committee passed the Dr. Lorna
Breen Health Care Provider Protection Act, which was just
signed into law, to make sure that these providers get the
support and care they need for their own mental health and
substance use concerns, especially if they continue to care for
all of us.
Madam Chairman, I look forward to hearing more about how
HRSA is leveraging and prioritizing existing Federal health
workforce programs to fill gaps in the mental health and
substance use disorder workplace. I yield floor.
The Chair. Thank you very much. With that, I will introduce
today's witnesses. Our first witness is Dr. Miriam E. Delphin-
Rittmon. She is the Assistant Secretary for Mental Health and
Substance Use at the Department of Health and Human Services,
who leads the Substance Abuse and Mental Health Services
Administration. Welcome. Good to see you here today.
Our next witness is Ms. Carole Johnson. She is the
Administrator of the Health Resources and Services
Administration. Welcome to you. We are also joined today by Dr.
Joshua Gordon, the Director of the National Institute of Mental
Health. We appreciate you being here today.
Our final witness is Dr. Nora Volkow, Director of the
National Institute on Drug Abuse. Thank you for being with us
as well. With that, we will start with you, Assistant Secretary
Delphin-Rittmon.
STATEMENT OF MIRIAM E. DELPHIN-RITTMON, PH.D., ASSISTANT
SECRETARY FOR MENTAL HEALTH AND SUBSTANCE USE, SUBSTANCE ABUSE
AND MENTAL HEALTH SERVICES ADMINISTRATION, ROCKVILLE, MD
Ms. Delphin-Rittmon. Thank you, and good morning, Chair
Murray, Ranking Member Burr, and Members of the Committee for
inviting me here to testify today. I am the Assistant Secretary
for Mental Health and Substance Use at SAMHSA, the agency that
leads the public health efforts to advance the behavioral
health of the Nation and improve the lives of individuals
living with mental health and substance use disorders, as well
as their families. It is an honor to lead this agency, and I am
a proud product of one of its programs, the Minority Fellowship
Program.
I am pleased to be here with my colleagues from HHS, from
HRSA, NIH to discuss the growing mental health and substance
use challenges that we are facing as a country. As President
Biden noted, our Country faces an unprecedented mental health
crisis among people of all ages and backgrounds. Even before
the pandemic, rates of depression and anxiety were inching
higher. But grief, trauma, physical isolation of the last 2
years have driven Americans to a breaking point.
In addition, drug overdose deaths have reached a historic
high, devastating families and communities. More than 104,000
Americans died due to drug overdose in the 12 month period
ending in September 2021. For these reasons, the Biden-Harris
Administration has included addressing mental health and
addiction as two of the four pillars of the unity agenda that
was outlined in the President's State of the Union address.
SAMHSA is actively working to advance the unity agenda,
including helping to implement the National Mental Health
Strategy. This strategy includes strengthening capacity,
connecting more Americans to care, creating a continuum to
support--a continuum of support that aims to transform our
health infrastructure to address mental health holistically and
equitably. To help advance SAMHSA advance this mission, I have
identified five core near-term priorities for the agency.
The first is preventing overdose. Giving the escalating
overdose crisis and the negative impact of COVID-19 pandemic,
the HHS has created a new--created a new comprehensive overdose
prevention strategy meant to strengthen our primary prevention
efforts and increase access to a full continuum of care and
services for individuals with substance use disorder and their
families.
The second is enhancing access to suicide prevention and
crisis care. Preparing the National Suicide Lifeline for full
9-8-8 operational readiness requires a bold vision for a system
that provides direct lifesaving services to all in need and
links them to community based providers uniquely positioned to
deliver a full range of crisis care services.
SAMHSA sees 9-8-8 as a linchpin and a critical catalyst to
transform the behavioral health system of care. The third is
promoting children and youth behavioral health. To focus our
efforts on improving behavioral health wellness for our
Nation's youth, SAMHSA has developed the HOPE framework,
health, opportunity, potential, and equity for children, youth,
and families across the country.
The fourth is integrating primary care and behavioral
health. We know that individual's first interactions with
health system is typically through a primary care provider or
an emergency room. During the COVID-19 pandemic, while
providers were initially focused on acute medical concerns, we
heard that many were not adequately resourced to consider the
behavioral health effects of the pandemic.
The fifth is using performance measures, data, and
evaluation. For example, SAMHSA recently released the
Behavioral Health Equity Report 2021, drawing on data from our
national survey on drug use and health. My written testimony
also outlines four additional cross-cutting principles, several
SAMHSA programs that bolster our work to support these
priorities.
These principles are greater equity within the behavioral
health system, enhancing the behavioral health workforce,
promoting and supporting recovery practices, and working to
ensure financing of a robust behavioral health system of care.
I will close by echoing President Biden's call in his State of
the Union to support the millions of Americans who are in
recovery. Early on and throughout my career, I have been
inspired both personally and professionally by family members,
friends, colleagues, and acquaintances who with courage and
resilience have striven for wellness and recovery.
On behalf of my colleagues at SAMHSA, I want to thank you
for your interest and support for our programs, and for
supporting the Nation's behavioral health. I look forward to
answering any questions that you have.
[The prepared statement of Ms. Delphin-Rittmon follows:]
prepared statement of miriam e. delphin-rittmon
Good morning Thank you, Chair Murray, Ranking Member Burr, and
Members of the Committee for inviting me to testify during this hearing
focusing on mental health and substance use.
My name is Miriam Delphin-Rittmon, and I am the Assistant Secretary
for Mental Health and Substance Use at the U.S. Department of Health
and Human Services (HHS) In this role, I lead the Substance Abuse and
Mental Health Services Administration, also known as SAMHSA, SAMHSA is
the agency within HHS that leads public health efforts to advance the
behavioral health of the Nation and improve the lives of individuals
living with mental and substance use disorders, as well as their
families.
It is an honor to lead this agency In fact, I am a proud product of
one of SAMHSA's programs--the Minority Fellowship Program (MFP) The MFP
program provided me, and other mental health and substance use disorder
clinicians, an educational scholarship and training to more effectively
treat and serve people of different cultural and ethnic backgrounds.
I am pleased to be here, along with my HHS colleagues from the
Health Resources and Services Administration and the National
Institutes of Health to discuss the growing mental health and substance
use crisis.
As President Biden has noted, our Country faces an unprecedented
mental health crisis among people of all ages and backgrounds Two out
of five adults report symptoms of anxiety or depression and minoritized
communities are disproportionately undertreated Even before the
pandemic, rates of depression and anxiety were inching higher But the
grief, trauma, and physical isolation of the last 2 years have driven
Americans to a breaking point In addition, drug overdose deaths have
reached a historic high, devastating families and communities More than
104,000 Americans died due to a drug overdose in the 12-month period
ending in September 2021 For these reasons, President Biden included
addressing mental health and addiction as two of the four pillars of
the unity agenda he outlined in the State of the Union Address.
SAMHSA is actively working to advance the unity agenda and the
national mental health strategy, which includes strengthening system
capacity, connecting more Americans to care, and creating a continuum
of support that aims to transform our health and social services
infrastructure to address mental health holistically and equitably.
Though this testimony, I will expand on how SAMHSA is working to
achieve the goals of the President.
SAMHSA's Role, Priorities, and Principles
SAMHSA's mission of reducing the impact of substance use and mental
illness on American communities is more relevant than ever To help
advance our mission, I have identified five core near-term priorities
for the agency:
1. Preventing overdose;
2. Enhancing access to suicide prevention and crisis care;
3. Promoting child and youth behavioral health;
4. Integrating primary and behavioral healthcare; and
5. Using performance measures, data, and evaluation
I have also outlined four critical cross-cutting principles to
bolster SAMHSA's work on our near-term priorities These principles
include:
1. Greater equity within the behavioral health system;
2. Enhancing the behavioral health workforce;
3. Promoting and supporting recovery practices; and
4. Working to ensure financing of a robust array of
behavioral health services
These priorities and principles are aligned with the focus of the
HHS Behavioral Health Coordinating Council (BHCC), which I have the
honor of co-chairing with Admiral Rachel Levine, the Assistant
Secretary for Health The purpose of the BHCC is to more efficiently
identify and facilitate collaborative, innovative, transparent,
equitable, and action-oriented approaches to addressing HHS's
behavioral health agenda, priorities, and strategic planning.
RECENT SAMHSA DATA
2020 National Survey on Drug Use and Health
In October 2021, SAMHSA released findings from the 2020 National
Survey on Drug Use and Health (NSDUH) \1\, \2\ The data suggest that
the COVID-19 pandemic had a negative impact on the nation's well-being
Americans responding to the NSDUH survey reported that the coronavirus
outbreak adversely impacted their mental health, including by
exacerbating use of alcohol or drugs among people who had used drugs in
the past year.
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\1\ Substance Abuse and Mental Health Services Administration
(2021) Key substance use and mental health indicators in the United
States: Results from the 2020 National Survey on Drug Use and Health
(HHS Publication No PEP21-07-01-003, NSDUH Series H-56) Rockville, MD:
Center for Behavioral Health Statistics and Quality, Substance Abuse
and Mental Health Services Administration Retrieved from https://
wwwsamhsagov/data.
\2\ Several changes to the 2020 NSDUH prevent its findings from
being directly comparable to recent past-year surveys.
Based on data collected nationally from October to December 2020,
it is estimated that 259 million past-year users of alcohol and 109
million past-year users of drugs other than alcohol reported they were
using these substances ``a little more or much more'' than they did
before the COVID-19 pandemic began During that same time period, youth
ages 12 to 17 who had a past-year major depressive episode (MDE)
reported they were more likely than those without a past-year MDE to
feel that the COVID-19 pandemic negatively affected their mental health
``quite a bit or a lot'' Adults 18 or older who had any mental illness
(AMI) or serious mental illness (SMI) in the past year were more likely
than adults without mental illness to report that the pandemic
negatively affected their mental health ``quite a bit or a lot''.
SAMHSA PRIORITIES
Preventing Overdose:
Although overdose deaths involving heroin and prescription opioids
have decreased, the overdose crisis continues to be a challenge for
this country Synthetic opioids like illicitly manufactured fentanyl and
the use of other substances, like stimulants such as cocaine and
methamphetamine, and polydrug use, have led to significant increases in
overdose deaths. \3\
---------------------------------------------------------------------------
\3\ O'Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J Trends
in and Characteristics of Drug Overdose Deaths Involving Illicitly
Manufactured Fentanyls--United States, 2019--2020 MMWR Morb Mortal Wkly
Rep 2021;70:1740-1746 DOI: http://dxdoiorg/1015585/
mmwrmm7050e3external--icon.
Given the escalating overdose crisis and the negative impact of the
COVID-19 pandemic, HHS experts came together to create a new,
comprehensive Overdose Prevention Strategy (Strategy) meant to
strengthen our primary prevention efforts and increase access to the
full continuum of care and services for individuals with substance use
disorder (SUD) and their families \4\ I will discuss several SAMHSA
efforts that support this Strategy and the care continuum below.
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\4\ Haffajee, RL, Sherry, TB, Dubenitz, JM, White, JO, Schwartz,
D, Stoller, B, Swenson-O'Brien, AJ, Manocchio, TM, Creedon, TB,
Bagalman, E U.S. Department of Health and Human Services Overdose
Prevention Strategy (Issue Brief) Washington, DC: Office of the
Assistant Secretary for Planning and Evaluation, U.S. Department of
Health and Human Services October 27, 2021.
---------------------------------------------------------------------------
Establishing an Office of Recovery and Advancing Peer Supports
Recovery is a key pillar in our Overdose Prevention Strategy That
is why during Recovery Month last fall, SAMHSA announced it would be
establishing a new Office of Recovery This office will promote the
involvement of people with lived experience throughout agency and
stakeholder activities, foster relationships with internal and external
organizations in the mental health and addiction recovery fields, and
identify health disparities in high-risk and vulnerable populations to
ensure equity for support services across the Nation.
We know that recovery is enhanced by peer-delivered services These
services have proven to be effective as the support, outreach and
engagement with new networks help sustain recovery over the long term
Investing in peer services is critical, given the significant workforce
shortages in behavioral health That is why, as part of the President's
Strategy to Address Our National Mental Health Crisis, SAMHSA will
convene stakeholders to explore the benefits of national certified peer
specialist certification and how it could accelerate universal
adoption, recognition, and integration of the peer mental health
workforce across all elements of the health care system.
Substance Abuse Prevention and Treatment Block Grant
The Substance Abuse Prevention and Treatment Block Grant (SABG)
helps states in addressing substance use treatment and prevention needs
through support of prevention, treatment, and other services not
covered by commercial insurance and non-clinical activities and
services that address the critical needs of state substance use service
systems The SABG supports state prevention, treatment, and recovery
systems' infrastructure and capacity, thereby increasing availability
of services and development and implementation of evidence-based
practices.
The Administration supports the addition of a 10 percent set-aside
within the SABG for recovery support services aimed at significantly
expanding the continuum of care both upstream and downstream This
proposed set-aside would support the development of local recovery
community support institutions (ie, recovery community centers,
recovery homes, recovery schools); develop strategies and educational
campaigns, trainings, and events to reduce addiction/recovery-related
stigma and discrimination at the local level; provide addiction
recovery resources and support system navigation; make accessible peer
recovery support services that support diverse populations and are
inclusive of all pathways to recovery; and collaborate and coordinate
with local private and non-profit clinical health care providers, the
faith community, city, county, state, and Federal public health
agencies, and criminal justice response efforts.
State and Tribal Opioid Response Grants
The State Opioid Response (SOR) grant program aims to address the
overdose crisis by increasing access to FDA-approved medications for
the treatment of opioid use disorder (OUD), reducing unmet treatment
needs, and reducing opioid overdose related deaths through the
provision of prevention, treatment, and recovery activities for OUD.
States and communities across the country are also dealing with
rising rates of stimulant use and its negative health, social, and
economic consequences To address the growing rate of stimulant-involved
overdose deaths, Congress has allowed the use of State Opioid Response
grants to include methamphetamine and other stimulants to give states
and tribes flexibility to address their unique community needs.
Harm reduction is also an important pillar of the Strategy That is
why HHS announced, in April 2021, that grantees in certain programs
such as SOR may now purchase rapid fentanyl test strips to help curb
the dramatic spike in drug overdose deaths largely driven using strong
synthetic opioids, including illicitly manufactured fentanyl. \5\
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\5\ Centers for Disease Control and Prevention, ``Federal Grantees
May Now Use Funds to Purchase Fentanyl Test Strips'', (April 7, 2021).
Like the SOR program, the Tribal Opioid Response Grants program
also aims to address the overdose crisis, but directs funding to tribal
communities.
Pregnant and Postpartum Women Program
The Pregnant and Postpartum Women program (PPW) uses a family
centered approach to provide comprehensive residential substance use
disorder treatment, prevention, and recovery support services for
pregnant and postpartum individuals, their minor children, and for
other family members The family centered approach includes partnering
with others to leverage diverse funding streams, encouraging the use of
evidence-based practices, supporting innovation, and developing
workforce capacity to meet the needs of these families The PPW program
provides services not covered under most public and private insurance
SAMHSA continues to prioritize states that support best-practice
collaborative models for treatment, as well as provide support to
pregnant individuals with OUD The Comprehensive Addiction and Recovery
Act increased accessibility and availability of services for pregnant
individuals by expanding the authorized purposes of the program to
include the provision of outpatient and intensive outpatient services.
Harm Reduction Grants
This year, SAMHSA launched its first-ever Harm Reduction grant
program and expects to issue $30 million in grant awards This
opportunity, authorized by the American Rescue Plan Act, will help
increase access to a range of community harm reduction services and
support harm reduction service providers as they work to help prevent
overdose deaths and reduce health risks often associated with drug use
Providing funding and support for innovative harm reduction services is
a key pillar for the Strategy This funding will allow organizations to
expand their distribution of overdose-reversal medications and fentanyl
test strips, provide overdose education and counseling, and manage or
expand syringe services programs, which help control the spread of
infectious diseases like HIV and hepatitis C.
DATA Waiver, Treatment Capacity, and Buprenorphine Guidelines
In an effort to get evidenced-based treatment to more Americans
with OUD, last April SAMHSA and HHS announced buprenorphine practice
guidelines that remove certain training and certification requirements
which some practitioners have cited as a barrier to treating more
people \6\ The Practice Guidelines for the Administration of
Buprenorphine for Treating Opioid Use Disorder (Practice Guidelines)
provides an exemption from certain statutory certification requirements
for eligible physicians, physician assistants, nurse practitioners,
clinical nurse specialists, certified registered nurse anesthetists,
and certified nurse midwives, who are state licensed and registered by
the Drug Enforcement Administration to prescribe controlled substances
Specifically, the exemption allows these practitioners to treat up to
30 patients with OUD using buprenorphine without having to make certain
training-related certifications This exemption also allows
practitioners to treat patients with buprenorphine without certifying
as to their capacity to provide counseling and ancillary services As of
March 11, 2022, 12,005 providers have obtained a waiver through the
revised Practice Guidelines.
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\6\ Substance Abuse and Mental Health Services Administration,
``HHS Releases New Buprenorphine Practice Guidelines, Expanding Access
to Treatment for Opioid Use Disorder'' (April 27, 2021) https://
wwwsamhsagov/newsroom/press-announcements/202104270930.
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Enhancing Access to Suicide Prevention and Crisis Care:
Suicide rates increased 30 percent between 2000--2018 and declined
in 2019 and 2020 Suicide is a leading cause of death in the United
States, \7\ with 45,979 deaths in 2020 This is about one death every 11
minutes The number of people who think about or attempt suicide is even
higher In 2020, an estimated 122 million American adults had serious
thoughts of suicide in the past year, 32 million made a suicide plan,
and 12 million attempted suicide \8\ Among adolescents 12 to 17, 12
percent had serious thoughts of suicide, 53 percent made a suicide
plan, and 25 percent attempted suicide in the past year These findings
vary by race and ethnicity, with people of mixed ethnicity reporting
higher rates of serious thoughts of suicide Among people of mixed
ethnicity 18 or older, 11 percent had serious thoughts of suicide, 33
percent made a suicide plan and 12 percent attempted suicide in the
past year Among Hispanics or Latinos 18 or older, 42 percent had
serious thoughts of suicide, 12 percent made a suicide plan and 06
percent attempted suicide in the past year.
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\7\ CDC WONDER: Underlying cause of death, 1999--2019 Atlanta, GA:
U.S. Department of Health and Human Services, CDC; 2020 https://
wondercdcgov/Deaths-by-Underlying-Causehtml.
\8\ Substance Abuse and Mental Health Services Administration
(2021) Key substance use and mental health indicators in the United
States: Results from the 2020 National Survey on Drug Use and Health
(HHS Publication No PEP21-07-01-003, NSDUH Series H-56) Rockville, MD:
Center for Behavioral Health Statistics and Quality, Substance Abuse
and Mental Health Services Administration Retrieved from https://
wwwsamhsagov/data/.
Suicide is a complex public health problem There is no single cause
and no single solution As we work with our Federal agency partners to
improve suicide prevention efforts across the Nation, we are focused on
addressing upstream risk factors, expanding access to mental health and
substance use services, and improving the crisis services
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infrastructure.
SAMHSA has several programs aimed at supporting Americans in
crisis.
The National Suicide Prevention Lifeline and Transition to 988
The National Suicide Prevention Lifeline (Lifeline), currently 1-
800-273-TALK, is a network of more than 200 local, independent crisis
centers equipped to help people in mental health related distress or
experiencing a suicidal crisis via call, chat, or text The Lifeline
provides free and confidential support to people in suicidal crisis or
mental health related distress 24 hours a day, 7 days a week, across
the United States.
In 2020, the FCC and Congress designated the number 988 as the
nation's new, three-digit, national suicide prevention and mental
health crisis number On July 16, 2022, the U.S. will transition to
using the 988-dialing code The creation of 988 is a once-in-a-lifetime
opportunity to strengthen and expand the Lifeline and transform
America's behavioral health crisis care system to one that saves lives
by serving anyone, at any time, from anywhere across the Nation.
Preparing the Lifeline for full 988 operational readiness requires
a bold vision for a system that provides direct, life-saving services
to all in need and links them to community-based providers uniquely
positioned to deliver a full range of crisis care services SAMHSA sees
988 as the linchpin and catalyst for a transformed behavioral health
crisis system in much the same way that, over time, 911 spurred the
growth of emergency medical services in the United States.
Through the American Rescue Plan Act, the Administration has
provided $180 million to support local capacity to answer crisis calls
and establish more community-based mobile crisis response and crisis
stabilizing facilities to minimize unnecessary emergency department
visits.
Community Mental Health Services Block Grant
The Community Mental Health Services Block Grant (MHBG) continues
to serve as a safety net for mental health services for some of the
nation's most vulnerable populations By statute, MHBG funds must be
used to address the needs of adults with SMI and children with serious
emotional disturbances (SED) Ten percent of MHBG funds are set-aside
for evidence-based programs that address the needs of individuals with
early serious mental illness, including psychotic disorders The set-
aside helps reduce costs to society, as intervening early helps prevent
deterioration of functioning in individuals experiencing a first
episode of serious mental illness MHBG also includes a set-aside to
support state efforts to build much needed crisis systems to address
the needs of individuals in mental health crisis in a high quality,
expeditious manner The development of these services will promote 24/7
access to well-trained mental health professionals in the time of acute
mental health crisis.
Garrett Lee Smith Grant Program
The Garrett Lee Smith (GLS) Memorial Act authorizes SAMHSA to
manage two significant youth suicide prevention programs and one
resource center The GLS State/Tribal Youth Suicide.
Prevention and Early Intervention Grant Program supports
development and implementation of youth suicide prevention and early
intervention strategies involving public-private collaboration among
youth serving institutions The GLS Campus Suicide Prevention program
supports institutions of higher education, including tribal colleges
and universities, working to prevent suicide and suicide attempts A
peer reviewed research paper found that a sustained reduction in youth
suicide mortality rates was observed among youths in counties exposed
to GLS Memorial Youth Suicide Prevention Program programming compared
with matched control counties that were not exposed to GLS. \9\
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\9\ Garraza, Kuiper, Goldston, McKeon, Walrath Long-term impact of
the Garrett Lee Smith Youth Suicide Prevention Program on youth suicide
mortality, 2006--2015, Journal of Child Psychology and Psychiatry
(2019).
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Adult Suicide Prevention Grants
The 2012 National Strategy for Suicide Prevention (NSSP) seeks to
reduce the overall suicide rate and number of suicides in the U.S.
nationally. The NSSP grant program supports the efforts of states,
tribes, primary and behavioral healthcare organizations, public health
agencies, and emergency departments to implement the NSSP While the
NSSP addresses all age groups and populations with specific needs, the
goals and objectives of the NSSP grants focus on preventing suicide and
suicide attempts among adults over the age of 25.
The Zero Suicide model is a comprehensive, multi-setting approach
to suicide prevention in health systems The purpose of the Zero Suicide
program is to implement suicide prevention and intervention programs
for individuals who are 25 years of age or older by systematically
applying evidence-based approaches to screening and risk assessment,
developing care protocols, collaborating for safety planning, providing
evidence-based treatments, maintaining continuity of care during high
risk periods, and improving care and outcomes for such individuals who
are at risk for suicide being seen in health care systems.
Promoting Child and Youth Behavioral Health:
Even before the pandemic, our nation's children and youth were
struggling with mental health and substance use challenges, and during
the pandemic rates of anxiety and depression have skyrocketed, which is
why it is critical that we promote the behavioral health of young
people across the country To focus our efforts on improving behavioral
wellness for our nation's youth, SAMHSA has developed the ``Health,
Opportunity, Potential and Equity (HOPE) Framework for Children, Youth
and Families''.
SAMHSA wants to bring HOPE to children and families across the
country by creating and expanding programs and initiatives that provide
Health for every young person--and you can't have health without
mental, emotional, and behavioral health--improve Opportunity for youth
who may be at-risk through early identification and intervention, and
ensure that young people who experience serious emotional disturbances
or substance use disorders can reach their full Potential and we will
emphasize the need for Equity to deliver all our services and supports
in culturally and linguistically appropriate ways.
The HOPE Framework will guide efforts to expand access to proven
treatments, interventions, and other recovery supports, while
developing new and innovative solutions to strengthen behavioral health
services for America's children and young adults.
Project AWARE
Project AWARE (Advancing Wellness and Resiliency in Education) is
comprised of the Project AWARE grants, Resilience in Communities after
Stress and Trauma (ReCAST) grants, and the Mental Health Awareness
Training (MHAT) grants Project AWARE grants promote comprehensive,
coordinated, and integrated state efforts to make schools safer and
increase access to mental health services ReCAST assists high-risk
youth and families to promote resilience and equity in communities
struggling with civil unrest, trauma, and violence through
implementation of evidence-based violence prevention and community
youth engagement programs and linkages to trauma-informed mental health
services The MHAT grants train school personnel, emergency first
responders, law enforcement, veterans, armed services members, and
their families to recognize the signs and symptoms of mental disorders.
Project LAUNCH
Project LAUNCH (Linking Actions for Unmet Needs in Children's
Health) works to ensure that the systems that serve young children
(including childcare and education, home visiting, and primary care)
have the resources and knowledge to foster their social, emotional,
cognitive, and behavioral development The program also ensures that the
systems intervene to prevent, recognize early signs of, and address
mental, emotional, and behavioral disorders in early childhood and into
the early elementary grades.
Children's Mental Health Initiative
The Children's Mental Health Initiative (CMHI) supports ``systems
of care'' (SOC) for children and youth with SED and their families to
increase their access to evidence-based treatment and supports SOC is a
strategic approach to the delivery of services and supports that
incorporates family driven, youth-guided, strength-based, and
culturally and linguistically competent care to meet the physical,
intellectual, emotional, cultural, and social needs of children and
youth throughout the U.S. Services are delivered in the least
restrictive environment with evidence-supported treatments and
interventions Individualized care management ensures that planned
services and supports are delivered with an appropriate, effective,
family driven, and youth-guided approach This approach has demonstrated
improved outcomes for children at home, at school, and in their
communities For example, CMHI grantee data show that suicide attempt
rates significantly decreased within 12 months after children and youth
accessed CMHI-related services.
Infant and Early Childhood Mental Health
The purpose of the Infant and Early Childhood Mental Health program
is to improve outcomes for children, from birth to 12 years of age, who
are at risk for, show early signs of, or have been diagnosed with a
mental illness, including an SED Grantees improve outcomes for children
through training early childhood providers and clinicians to identify
and treat behavioral health disorders, including in children with a
history of in utero exposure to substances such as opioids, stimulants,
or other drugs that may impact development, and through the
implementation of evidence-based multigenerational treatment approaches
that strengthen caregiving relationships.
National Child Traumatic Stress Initiative and the National Child
Traumatic Stress Network
The National Child Traumatic Stress Initiative (NCTSI) aims to
improve behavioral health services and interventions for children and
adolescents exposed to traumatic events SAMHSA funds a national network
of grantees known as the National Child Traumatic Stress Network
(NCTSN) to develop and promote effective community practices for
children and adolescents exposed to a wide array of traumatic events
The NCTSN has grown to 116 funded and over 150 affiliate centers
located nationwide in universities, hospitals, and a range of diverse
community-based organizations with thousands of national and local
partners The NCTSN's mission is to raise the standard of care and
improve access to evidence-based services for children experiencing
trauma, their families, and communities A component of this work has
been the development of resources and delivery of training and
consultation to support the development of trauma informed child-
serving systems.
Center of Excellence on Social Media and Mental Wellness
While technology platforms have improved our lives in some ways,
there is mounting evidence that social media is harmful to many kids'
and teens' mental health, well-being, and development Therefore, over
the next year, SAMHSA will launch a National Center of Excellence on
Social Media and Mental Wellness, which will develop and disseminate
information, guidance, and training on the full impact of adolescent
social media use, especially the risks these services pose to their
mental health.
Integrating Primary and Behavioral Healthcare:
We know that an individual's first interaction with the health
system is typically through a primary care provider or the emergency
room During the COVID-19 pandemic, while providers were initially
focused on acute medical concerns, we heard that many were not
adequately resourced to consider the behavioral health effects of the
pandemic The following programs support efforts to integrate primary
and behavioral healthcare.
Certified Community Behavioral Health Clinics Expansion Grants
The Certified Community Behavioral Health Clinics (CCBHC) Expansion
program is designed to increase access to and improve the quality of
community mental and substance use disorder treatment services CCBHCs
funded under this program must provide access to services for
individuals with SMI or SUD, including OUD; children and adolescents
with SED; and individuals with co-occurring mental and substance use
disorders This program improves the mental health of individuals by
providing comprehensive community-based mental and substance use
disorder services; treatment of co-occurring disorders; advancing the
integration of mental/substance use disorder treatment with physical
health care; utilizing evidence-based practices on a more consistent
basis and promoting improved access to high quality care.
Data from intake to most recent reassessment for individuals served
in the CCBHC program demonstrate that as of March 2022, clients have a
72 percent reduction in hospitalization and a 69 percent reduction in
Emergency Department visits, as well as a 25 percent increase in mental
health functioning in everyday life Additionally, the data demonstrates
that 12 percent had an increase in employment or started going to
school.
Primary and Behavioral Health Care Integration
The Primary and Behavioral Health Care Integration (PBHCI) program
addresses the intersection between primary care and treatment for
mental illness and co-occurring disorders This program awards grants to
community mental health centers and states to support coordination and
integration of primary care services and publicly funded community
behavioral health services for individuals with SMI and a co-occurring
substance use disorder served by the public mental health system The
PBHCI program encourages grantees to engage in necessary collaboration,
expand infrastructure, and increase the availability of primary
healthcare and wellness services.
Screening, Brief Intervention and Referral to Treatment Program
The Screening, Brief Intervention and Referral to Treatment (SBIRT)
program is intended to help primary care physicians identify
individuals who misuse substances and help them intervene early with
education, brief treatment, or referral to specialty treatment The
program's goal is to increase the number of individuals who receive
treatment and reduce the rate of substance misuse Studies have shown
that this approach is effective in helping reduce harmful alcohol
consumption \10\, \11\, \12\ A SAMHSA-funded cross-site evaluation
found that allied health professionals, rather than the physicians
themselves, were more likely to implement SBIRT with their patients The
SBIRT Student Training and Health Professionals Training grant programs
support SBIRT training efforts for medical students, medical residents,
nurses, social workers, psychologists, pharmacists, dentists, and
physician assistants These efforts aim to develop further the primary
healthcare workforce in substance use disorder services.
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\10\ 7 Bertholet, N, Daeppen, J-B, Wietlisbach, V, Fleming, M, &
Burnand, B (2005) Reduction of alcohol consumption by brief alcohol
intervention in primary care: systematic review and meta-analysis
Archives of Internal Medicine 165, 986--995.
\11\ Kahan, M, Wilson, L, & Becker, L (1995) Effectiveness of
physician-based interventions with problem drinkers: A review Canadian
Medical Association Journal, 152, 851--859.
\12\ Wilk, AI, Jensen, NM, and Havighurst, TC (1997) Meta-analysis
of randomized control trails addressing brief interventions in heavy
alcohol drinkers Journal of General Medicine, 12 (5), 274-283.
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Using Performance Measures, Data, and Evaluation:
Behavioral Health Equity Report
In October 2021, SAMHSA released its ``Behavioral Health Equity
Report 2021: Substance Use and Mental Health Indicators Measured from
the National Survey on Drug Use and Health (NSDUH), 2015--2019'' \13\
This report disaggregates the behavioral health indicators by selected
determinants of health: race and ethnicity (White, Black or African
American, Native Hawaiian or Other Pacific Islander, American Indian/
Alaska Native, Asian, Two or More Races, and Hispanic or Latino),
income level, county type, and health insurance status In this report,
the array of indicators presented across racial/ethnic groups and other
selected determinants of health provides a unique overview of
population-based variations in behavioral health at a point in time.
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\13\ Center for Behavioral Health Statistics and Quality (2021)
Behavioral health equity report 2021: Substance use and mental health
indicators measured from the National Survey on Drug Use and Health
(NSDUH), 2015--2019 (Publication No PEP21-07-01-004) Rockville, MD:
Substance Abuse and Mental Health Services Administration Retrieved
from https://wwwsamhsagov/data.
This effort--although a beginning step in addressing the complexity
of behavioral health issues and social determinants of health--provides
a mechanism for systematically tracking changes, trends, and
disparities over time.
Drug Abuse Warning Network
SAMHSA re-established the Drug Abuse Warning Network (DAWN) in 2018
as a nationwide public health surveillance system to monitor emergency
department visits related to recent substance use, including those
related to opioids Authorized by the 21st Century Cures Act, DAWN
provides necessary information such as patient demographic details and
substances used in order to respond effectively to the overdose crisis
in the United States and to better inform public health, clinicians,
policymakers, and other stakeholders to respond to emerging substance
use trends.
Updating SAMHSA's Government Performance and Results Act Tools
The Government Performance and Results Act (GPRA) requires agencies
to engage in performance management tasks such as setting goals,
measuring results, and reporting progress SAMHSA's discretionary grants
and block grants are required to collect and report GPRA data Based on
feedback from the field, SAMHSA is working to modify its existing
client-level GPRA tools with the goal to improve the agency's ability
to assess the impact of our programs on key outcomes of interest and to
gather vital information about clients served.
CONCLUSION
On behalf of my colleagues at SAMHSA, thank you for your interest
in, and support for, our programs, and for supporting the nation's
behavioral health I would be pleased to answer any questions you may
have.
______
The Chair. Thank you.
Administrator Johnson.
STATEMENT OF CAROLE JOHNSON, ADMINISTRATOR, HEALTH RESOURCES
AND SERVICES ADMINISTRATION, ROCKVILLE, MD
Ms. Johnson. Good morning Chair Murray, Ranking Member
Burr, and Members of the Committee. I am Carole Johnson,
Administrator of the Health Resources and Services
Administration. I appreciate the opportunity to speak with you
today about HRSA's programs that support the mental health and
well-being of our Nation.
As you know, HRSA supports health care services in
communities across the country, including, for example, for the
nearly 29 million people who receive care through HRSA funded
community health centers, the more than half a million people
diagnosed with HIV who receive care through the Ryan White HIV-
AIDS program, about 60 million pregnant individuals and
children who benefit from HRSA funded infant screenings,
preventive care visits, and other services, and individuals in
more than 1,500 rural counties who receive HRSA supported
substance use disorder services.
HRSA also plays an important role in supporting the health
care workforce. We provide scholarship and loan repayment
assistance to thousands of clinicians in return for them
practicing in underserved communities. This year marks our
largest scholarship and loan repayment cohort yet, with more
than 22,000 clinicians in these programs. We also invest in
recruiting, training, and retaining health professionals, from
community health workers to mental health professionals to
advanced practice nurses.
Like you, we recognize that mental health is essential to
overall health for people of all ages, including for parents
and children who have been affected by the pandemic. So today I
would like to highlight two HRSA maternal and child mental
health programs that are currently up for reauthorization, the
Screening and Treatment for Maternal Depression Program and the
Pediatric Mental Health Care Access Program.
The Screening and Treatment for a Maternal Depression
Program supports states in integrating mental health care into
maternal health care. There is tremendous demand for this
program, but to date we have only been able to fund about a
quarter of the applicants. Grantees provide training to help
maternal health care providers screen and treat their patients'
mental health conditions.
In a critical part of the program design, grantees give
maternal health care providers the opportunity to connect with
mental health care clinical experts through teleconsults to
help them treat their individual patient's mental health
conditions. As a result, more pregnant and postpartum women are
being screened for depression, and maternal care providers are
growing their capacity to support the mental health needs of
their patients. Of note, where those needs are more complex,
maternal care providers have the benefit of an expert
teleconsult to support them.
For example, through our program, a midwife in Montana and
her pregnant patient with emergent mental health needs got real
time mental health help from a perinatal psychiatrist through
teleconsultation. In the normal course of business, the midwife
would have had to refer the patient to a provider hours away
who likely would have had troubles easily squeezing the patient
in.
Similarly, the Pediatric Mental Health Care Access Program
promotes mental health care integration in pediatric primary
care. These grants provide teleconsultation, training, and care
coordination to help local pediatric primary care providers
diagnose, treat, and refer children for mental health care.
Similar to the Maternal Depression Program, our Pediatric
Program both provides training that is building the capacity of
pediatric primary care providers to respond to children's
immediate mental health care needs, while also giving them the
additional support of teleconsultation with a mental health
expert to ensure that they have backup and the resources they
need to serve their patients.
Funding from the American Rescue Plan allowed us to broaden
the program's reach from 21 to 45 states, territories, and
tribal areas, and we are currently taking additional
applications as well. There is considerable interest and demand
for these programs, and we look forward to working with the
Committee on their reauthorization.
In addition to our programs that support mental health
services, HRSA's workforce programs are training the behavioral
health workforce and creating incentives to encourage them to
practice in the communities where they are needed most. Our
Behavioral Health Workforce Education and Training Program
supports the training of psychologists, school and clinical
counselors, marriage and family therapists, as well as the
critical community connectors to mental health and substance
use disorder care, like community health workers and peers and
others.
Our scholarship and loan repayments are increasingly
supporting behavioral health care providers as well. We also
recently launched a new program with American Rescue Plan
funding to help support health care workers' mental health
resilience and reduce provider burnout. In closing, I want to
thank the Committee for your ongoing support for HRSA's
programs and your commitment to the mental health and well-
being of America's families. Thank you.
[The prepared statement of Ms. Johnson follows:]
prepared statement of carole johnson
Chair Murray, Ranking Member Burr, and Members of the Committee:
Thank you for the opportunity to speak with you about the Health
Resources and Services Administration's (HRSA) programs to support the
mental health and well-being of our Nation I am Carole Johnson,
Administrator of HRSA.
As you know, the Biden-Harris Administration is committed to
bipartisan solutions to address mental health challenges In his State
of the Union Address, the President announced a national strategy to
tackle the nation's mental health crisis as part of his Unity Agenda
This strategy centers on three pillars: strengthening system capacity,
connecting Americans to care; and, supporting Americans by creating
healthy environments Secretary Becerra has launched a national tour
focused on strengthening mental health and is hearing directly from
Americans across the country about the mental health challenges they
are facing and the opportunities to improve our mental health and
crisis care systems At HRSA, we recognize that mental health is
essential to overall health I appreciate the opportunity to speak with
you today about how HRSA is working to achieve the President and
Secretary's goals and how we are actively working to advance mental
health priorities through our programs.
HRSA supports health care services in communities across the
country, including for the nearly 29 million people who receive care
through HRSA-funded health centers; the more than a half a million
people diagnosed with HIV who receive care through the Ryan White HIV/
AIDS program; an estimated 60 million pregnant individuals and children
who benefit from HRSA-funded infant screenings, preventive care visits,
and other services; and individuals in more than 1,500 rural counties
who receive HRSA-supported substance use disorder services HRSA also
supports multiple programs to grow and sustain the health care
workforce, including providing scholarship and loan repayment
assistance to more than 22,700 clinicians in return for working in
underserved communities--the highest number ever for these programs--
and investing in recruiting, training, and retaining a wide range of
health professionals, from community health workers to psychiatrists to
advance practice nurses.
Two of HRSA's mental health programs are currently up for
reauthorization:
The Screening and Treatment for Maternal Depression
and Related Behavioral Disorders Program helps train maternal
health care providers on how to screen for, assess, treat, and,
as necessary, refer pregnant and postpartum individuals with
mental health conditions or substance use disorders as part of
routine maternal health care Maternal health care providers
also receive real-time psychiatric consultations for their
patients through telehealth services and care coordination
support.
The Pediatric Mental Health Care Access Program aims
to make early identification, diagnosis, treatment, and, as
needed, referral for behavioral health conditions a routine
part of children's health care services The program promotes
the integration of behavioral health services into pediatric
primary care through statewide and regional pediatric mental
health care telehealth programs These statewide or regional
networks provide tele-consultation, training, technical
assistance and care coordination to community-based pediatric
health care providers in order to expand the reach of critical
mental health services and support children's needs.
HRSA also received COVID-response funding to enhance our
investments in supporting the mental health needs of parents and
children, grow the mental health workforce, and reduce health care
provider burnout and promote resiliency HRSA has many other investments
that support behavioral health initiatives. \1\
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\1\ Behavioral health is inclusive of mental health and substance
use disorders.
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HRSA Health Workforce Programs that Support Behavioral Health.
HRSA programs play an important role in growing and training the
behavioral health workforce and creating supports and incentives to
help encourage providers to practice in the communities that need them
most Our programs include the Behavioral Health Workforce Education and
Training Program, which supports the training of social workers,
psychologists, school and clinical counselors, psychiatric nurse
practitioners, marriage and family therapists, community health
workers, outreach workers, social services aides, mental health
workers, substance use disorder workers, youth workers, and peers; the
Graduate Psychology Education Program, which supports innovative
doctoral level health psychology programs that foster a collaborative
approach to providing mental health and substance use disorder
prevention and treatment services in high need and high demand areas
through academic and community partnerships; the Children's Hospitals
Graduate Medical Education Program, which supports the training of
pediatric residents, including pediatric psychiatry residents, in
freestanding children's teaching hospitals; the Teaching Health Center
Graduate Medical Education Program, which supports residency training,
including for psychiatry, in community-based ambulatory care settings;
and the National Health Service Corps, which provides scholarships and
loan repayment for clinicians, including mental health and substance
use disorder providers, who commit to practice in underserved
communities we also launched new programs with American Rescue Plan
funding to address mental health and promote resilience in the health
care workforce through the Promoting Resilience and Mental Health Among
the Health Professional Workforce and the Health and Public Safety
Workforce Resiliency Training Program.
Our workforce programs also include initiatives specifically
focused on substance use disorder training, which is a vital component
of behavioral health training These programs include the Addiction
Medicine Fellowship Program, which focuses on increasing the number of
board certified addiction medicine and addiction psychiatry specialists
trained in providing behavioral health services, including prevention,
treatment, and recovery services in underserved, community-based
settings; the Integrated Substance Use Disorder Treatment Program,
which supports training and expansion of the number of nurse
practitioners, physician assistants, health service psychologists, and
social workers trained to provide mental health and substance use
disorder services in underserved community-based settings that
integrate primary care and mental health and substance use disorder
services; the Substance Use Disorder Treatment and Recovery Loan
Repayment Program, which focuses on recruiting and retaining medical,
nursing, and behavioral health clinicians and paraprofessionals who
provide direct treatment or recovery support of patients with or in
recovery from a substance use disorder through loan repayment in return
for providing services in high need areas; and the Opioid-Impacted
Family Support Program, which trains paraprofessionals to support
children and families living in underserved areas who are impacted by
opioid use disorder and other substance use disorders.
HRSA Health Care Services Programs that Support Behavioral Health
HRSA's health care services programs also play a key role in
providing mental health and substance use disorder services, with a
focus on delivering care and supports in underserved and rural
communities These programs include the Health Center Program, which
helps provide primary care in underserved communities across the
country and are increasingly focused on integrating behavioral health
into primary care services; the Health Care for the Homeless Program,
which supports coordinated, comprehensive, integrated primary care
including substance abuse and mental health services for individuals
experiencing homelessness; the Rural Communities Opioid Response
Program, which supports high need rural communities in establishing,
expanding, and sustaining prevention, treatment, and recovery services
for opioid use disorder; the Ryan White HIV/AIDS Program, which funds
and coordinates with cities, states, and local clinics/community-based
organizations to deliver HIV care, treatment, and support, including
mental health and substance use disorder services, to people with HIV
who have low incomes.
In addition to the two programs up for reauthorization, our
programs focused on maternal and child health include the Maternal,
Infant, and Early Childhood Home Visiting Program, which supports
voluntary, evidence-based home visiting services during pregnancy and
to parents with young children where trained professionals address
needs such as conducting screenings and providing referrals to address
caregiver depression, substance use, and family violence; the Maternal
and Child Health Block Grant, which supports states in improving access
to and the quality of health services for mothers, children, and their
families, including initiatives to address national or regional needs,
priorities, or emerging issues including mental health and substance
use disorder; and the Bright Futures Preventive Services Program, which
develops national guidelines to support children receiving high
quality, efficient, and comprehensive pediatric care, including
behavioral health services Bright Futures' recommended preventive
services are covered without cost-sharing by most health plans In 2022,
Bright Futures updates include adding universal screening for suicide
risk to the current depression screening category for individuals ages
12 to 21, and new guidance for behavioral, social and emotional
screening.
Mental Health is Essential to Maternal and Child Health
Last week, HRSA published a study in the American Medical
Association's journal JAMA Pediatrics based on our National Survey of
Children's Health that found significant increases in the number of
children diagnosed with mental health conditions between 2016 and 2020
During the study timeframe, the number of children ages 3-17 years old
diagnosed with anxiety grew by 29 percent and those with depression
grew by 27 percent The survey also showed declines in parental well-
being during this time: there was an 11 percent decrease in parents'
reported ability to cope with the demands of raising children and a 5
percent decrease in parents' mental and emotional well-being.
HRSA funds the National Survey of Children's Health, which is the
largest national and state-level annual survey of the health and health
care needs of children, their families, and their communities to
regularly assess the state of children' health Data from the 2020
national survey found that 149 percent of U.S. children ages 3-17
years--just over 9 million--had a current, diagnosed behavioral health
condition, and about one-third (347 percent) of these children had two
or more conditions Yet only half (505 percent) of those with a current
behavioral health condition received treatment or counseling from a
mental health professional in the past year This can have long-term
effects on health, well-being, and opportunity As noted in the 2021
Surgeon General's Advisory on Protecting Youth Mental Health, the
pandemic has compounded many of these adverse impacts by disrupting
educational, social, and service supports and opportunities upon which
so many vulnerable children, youth and families depend \2\ Children and
families have weathered the sudden interruption of in-person learning,
prolonged isolation during stay-at-home orders, loss of regular school-
based behavioral health services, family economic stressors like
housing instability and food insecurity, and the trauma and grief
associated with personal and family experiences and loss during the
COVID-19 pandemic.
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\2\ https://wwwhhsgov/sites/default/files/surgeon-general-youth-
mental-health-advisorypdf.
The Centers for Disease Control and Prevention reports that nearly
1 in 5 children \3\ have a mental, emotional, or behavioral disorder
and that suicide is the second leading cause of death for people ages
10 to 24 \4\ In 2019, 188 percent of high school students, ages 14-18
years, had seriously considered attempting suicide, and 89 percent had
attempted suicide one or more times, based on self-reporting \5\ Data
from the Substance Abuse and Mental Health Services Administration's
2016-2019 National Surveys of Drug Use and Health found that while
nearly half of White adolescents with a depressive episode (460
percent) received treatment in the past year, the same was true for
only one-third of their Black and Hispanic counterparts (363 and 356
percent, respectively) and one-quarter of Asian adolescents (262
percent) \6\ In 2017-2018, depression, anxiety, and behavioral
conditions were more prevalent among rural children ages 3-17 years
compared to urban children. \7\
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\3\ National Research Council and Institute of Medicine (2009)
Preventing Mental, Emotional, and Behavioral Disorders Among Young
People: Progress and Possibilities E O'Connell, T Boat, & K E Warner
Eds Washington, DC The National Academic Press.
\4\ https://wwwcdcgov/injury/wisqars/indexhtml.
\5\ https://wwwresearchgatenet/publication/343795548--Suicidal
Ideation and Behaviors Among High School Students-Youth Risk Behavior
Survey United States 2019.
\6\ Substance Abuse and Mental Health Services Administration
Report: Racial/Ethnic Differences in Mental Health Service Use among
Adults and Adolescents (2015-2019).
\7\ https://mchbhrsagov/sites/default/files/mchb/data-research/
rural-urban-differencespdf.
Research also shows that maternal mental health conditions are the
most common complications of pregnancy \8\ About 1 in 8 women
experience symptoms of postpartum depression \9\ Mental health
conditions, including suicides, drug overdoses or poisonings, and
unintentional injuries related to a mental health condition, are among
the leading underlying causes of pregnancy----related deaths \10\ As a
result of pandemic-related worries and stressors, pregnant and
postpartum people in the United States and internationally report
elevated symptoms of depression, anxiety, post-traumatic stress, and
loneliness \11\, \12\ Several empirical studies related to the pandemic
have reported higher prevalence of mental health problems among women
compared to men In this context, pregnant and new mothers could be more
vulnerable \13\ Yet, only 75 percent of mothers who need treatment are
finding and getting it \14\, \15\ Without treatment, mothers are at
increased risk for a range of poor outcomes In addition, substance use
during pregnancy can have serious consequences for maternal and infant
health, including preterm labor and complications related to delivery.
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\8\ Fawcett EJ, Fairbrother N, Cox ML, White IR, Fawcett JM The
Prevalence of Anxiety Disorders During Pregnancy and the Postpartum
Period: A Multivariate Bayesian Meta-Analysis J Clin Psychiatry 2019
Jul 23;80(4):18r12527 doi: 104088/JCP18r12527 PMID: 31347796; PMCID:
PMC6839961.
\9\ https://wwwcdcgov/mmwr/volumes/69/wr/mm6919a2htm's--
cid=mm6919a2--w.
\10\ Davis NL, Smoots AN, Goodman DG Pregnancy-Related Deaths:
Data from 14 U.S. Maternal Mortality Review Committees, 2008-2017
Atlanta, GA: Centers for Disease Control and Prevention, U.S.
Department of Health and Human Services; 2019.
\11\ Liu, CH et al ``Risk Factors for Depression, Anxiety, and
PTSD Symptoms in Perinatal Women during the COVID-19 Pandemic''
Psychiatry Review DOI: 101016/jpsychres2020113552.
\12\ Basu A, Kim HH, Basaldua R, Choi KW, Charron L, Kelsall N, et
al (2021) A cross-national study of factors associated with women's
perinatal mental health and well-being during the COVID-19 pandemic
PLoS ONE 16(4): e0249780 https://doiorg/101371/journalpone0249780.
\13\ Thapa SB, Mainali A, Schwank SE, Acharya G Maternal mental
health in the time of the COVID-19 pandemic Acta Obstet Gynecol Scand
2020 Jul;99(7):817-818 doi: 101111/aogs13894 PMID: 32374420; PMCID:
PMC7267371.
\14\ Byatt, Nancy et al ``Enhancing Participation in Depression
Care in Outpatient Perinatal Care Settings: A Systematic Review''
Obstetrics and gynecology vol 126,5 (2015): 1048-1058 doi:101097/
AOG0000000000001067.
\15\ Wright, TE, Terplan, M, Ondersma, SJ, Boyce, C, Yonkers, K,
et al (2016) The role of screening, brief intervention, and referral to
treatment in the perinatal period American Journal of Obstetrics &
Gynecology, 215(5), 539-547.
Access to mental health care is related to the volume and
distribution of maternal and child mental health and substance use
disorder providers In fact, ratios of child and adolescent
psychiatrists range by state from 1 to 60 per 100,000 children, with a
median of 11 child and adolescent psychiatrists per 100,000 children
\16\ As of December 2021, an estimated 136 million people in the United
States--over 40 percent of the total U.S. population--live in
designated ``Mental Health Professional Shortage Areas'' \17\ Only 28
percent of the need for mental health care in these Mental Health
Professional Shortage Areas has been met The need for prevention,
treatment, and recovery services to support children and families'
mental health are important drivers of the President's national
strategy to tackle the nation's mental health crisis and Secretary
Becerra's National Tour to Strengthen Mental Health.
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\16\ https://wwwaacaporg--AACAP--Press--Press--Releases/2018/
Severe--Shortage--of--Child--and--Adolescent--Psychiatrists--
Illustrated--in--AAACP--Workforce--mapsaspx.
\17\ Health Services and Resources Administration (2021) Fourth
Quarter of Fiscal Year 2021 Designated HPSA Quarterly Summary As of
December 31, 2021 Available at https://datahrsagov/Default/
GenerateHPSAQuarterlyReport.
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HRSA's Maternal and Child Behavioral Health Programs.
HRSA's maternal and child health work focuses directly on improving
the health and well-being of our nation's mothers, children and
families so they can thrive and reach their full potential Our program
investments in behavioral health have four primary aims:
First is to increase identification of behavioral health conditions
By that, we mean linking women and families to treatment and supports
through routine screening, referral, and direct service to prevent
mental health and substance use disorders whenever possible and treat
them appropriately when necessary.
The second aim is to improve access to quality services Patients
should be able to see care providers either in person in their local
communities or through telehealth This care should be high quality,
patient-centered, and culturally and linguistically appropriate.
The third aim is to advance equity we must eliminate health
disparities, including racial and geographic disparities that affect
far too many Our programs seek to address systemic and social
inequities and promote protective factors for families.
The fourth aim is to strengthen the maternal and child health
workforce to meet the behavioral health needs of families That includes
offering the training that our health care workers need to integrate
all best practices--including those that are culturally and
linguistically appropriate, equitable and trauma informed.
The two HRSA programs up for reauthorization, the Screening and
Treatment for Maternal Depression and Related Behavioral Disorders
Program and the Pediatric Mental Health Care Access Program, are key
investments that support primary care providers' ability to routinely
screen and treat behavioral health conditions.
Screening and Treatment for Maternal Depression and Related Behavioral
Disorders Program
HRSA's Screening and Treatment for Maternal Depression and Related
Behavioral Disorders Program supports states in integrating behavioral
health into maternal health care using telehealth The 21st Century
Cures Act (PL 114-255) authorized the program through fiscal year (FY)
2022 This program supports new or expanding state telehealth access
programs, including in rural and underserved areas The Screening and
Treatment for Maternal Depression program gives providers the tools to
integrate behavioral health care into routine maternal health care
through telehealth services that can help local providers bridge the
gap in access to psychiatrists, especially perinatal psychiatrists \18\
With telehealth support from the program, maternal health care
providers are able to receive real-time psychiatric consultations and
care coordination support Community-based maternal health providers
also are offered training on how to screen for, assess, treat, and
refer pregnant and postpartum individuals for mental health and
substance use disorders.
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\18\ https://bhwhrsagov/data-research/projecting-health-workforce-
supply--demand/behavioral--health.
The Screening and Treatment for Maternal Depression program is
implemented through 5-year cooperative agreements to states and funded
at approximately $45 million in total per year Each state health
department receives approximately $650,000 per year we are currently in
the fourth of 5 years of funding HRSA received tremendous interest in
the program--demonstrating the acute need for it--but is only able to
fund approximately a quarter of applicants The seven states that
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currently receive awards are Florida, Kansas, Louisiana.
Montana, North Carolina, Rhode Island and Vermont In fiscal year
2020, awardees trained 1,085 health care providers, participating
providers screened 24,500 pregnant and postpartum individuals for
depression, and providers sought and received expert mental health
consultation for nearly 7,500 pregnant and postpartum individuals, with
nearly half being from rural and underserved areas.
One example of the impact of the program is the story of a
pregnant, Native American woman from a Montana reservation who went to
a satellite site of a large hospital system to seek prenatal care Her
midwife noticed that the patient presented with symptoms of psychosis
and was not receiving medication or therapy The patient lived in a part
of the reservation that does not have cell service or internet, so the
only time the patient could seek telehealth services was when she was
at the satellite clinic The midwife called the Montana Screening and
Treatment for Maternal Depression program, which is called PRISM for
Moms, in order for the patient to be seen by the perinatal psychiatrist
The psychiatrist was able to see the patient that day and made
medication recommendations The psychiatrist also talked with the
midwife about options to get the patient to see a mental health
provider regularly If this midwife did not have access to Montana's
teleconsultation line, she likely would have referred the patient to a
prescribing provider in Billings (the largest city in the state), a 2-
hour drive from the reservation.
As another example, the Vermont awardee is helping to build a
statewide system of supports and services for expectant parents and
families with young children The program helps the perinatal population
in accessing perinatal mental health providers and other resources
Through this program, medical and mental health clinicians are able to
screen and provide culturally respectful and tailored services to
patients Over time, there has been an increase in the complexity of
calls from maternal health care providers to the program's mental
health expert consultation line, suggesting that the program's training
not only expands access to expertise, but also results in maternal
health providers addressing more and more of their patients' needs.
In short, the Screening and Treatment for Maternal Depression and
Related Behavioral Disorders Program has provided important tools to
support the mental health of pregnant and post-partum individuals The
fiscal year 2022 appropriation of $65 million, a $15 million increase,
will help us further address the maternal behavioral health needs we
are seeing in the Nation, and we look forward to working with the
Committee on its reauthorization.
Pediatric Mental Health Care Access Program
Just as the Screening and Treatment for Maternal Depression program
helps fill the gaps in behavioral health care for pregnant and
postpartum mothers, the Pediatric Mental Health Care Access program
helps do the same for pediatric care providers.
The 21st Century Cures Act (PL 114-255) authorized the Pediatric
Mental Health Care Access program through fiscal year 2022 The program
promotes behavioral health integration in pediatric primary care
through new or expanded statewide or regional pediatric mental health
care telehealth programs These statewide or regional networks of
pediatric mental health care teams provide tele-consultation, training,
technical assistance and care coordination With this support, pediatric
primary care providers can diagnose, treat and refer children to the
care they need for behavioral health concerns The telehealth
technologies promote long-distance clinical health care, clinical
consultation, and patient and provider education, helping to address
challenges in accessing psychiatrists, developmental-behavioral
pediatricians, and other behavioral health clinicians who treat
behavioral concerns in children and adolescents.
Beginning in fiscal year 2018, HRSA initially funded 18 awardees
for 5 years In fiscal year 2019, we funded 3 additional awardees for 4
years These awards are funded at $445,000 per year The American Rescue
Plan allowed HRSA to broaden the program's reach to 45 awards in 40
states, the District of Columbia, the U.S. Virgin Islands, the Republic
of Palau, and two Tribal areas--the Chickasaw Nation and the Red Lake
Band of the Chippewa Indians On January 5, 2022, HRSA released a Notice
of Funding Opportunity for a second round of American Rescue Plan
funding to further expand the Pediatric Mental Health Care Access
program This funding will support up to 10 awards at $445,000 each for
a 4-year period In addition, in the coming year, HRSA plans to
establish a technical assistance resource center for program grantees
The resource center will develop online resources accessible to all
states.
Grantee work in Alabama, particularly in rural areas, illustrates
the program's impact The Alabama Pediatric Access to Tele-Mental Health
Services (PATHS) program consultation team is composed of
psychiatrists, psychologists, psychiatric Nurse Practitioners, licensed
counselors and social workers An early childhood mental health
consultant on the PATHS consultation team enables team members to
address a broad range of questions during consultations before
providing a psychiatric diagnosis Through PATHS, pediatric providers
have access to consultation typically within an hour, and all
consultations are usually addressed the same day PATHS also offers
Project ECHO, a tele-mentoring program that links providers with the
PATHS team to review cases together as a group PATHS can provide
children and adolescents with specialty interventions not available in
the community through tele-therapy at Children's Hospital of Alabama
Care coordinators provide community-based resources to providers and
families The program reaches children and families across the state. As
one pediatric provider noted about the impact of the program:
``Participating in PATHS has improved my education to treat psychiatric
illnesses in patients PATHS has had a huge impact on my patient
population I can treat illnesses more immediately and not have my
patients waiting months for care''.
As the program expands to new states through funding provided
through the American Rescue Plan Act, we expect to see more providers
and children benefit from these services For example, the Washington
Partnership Access Line (PAL) received a HRSA Pediatric Mental Health
Care Access grant in September 2021 that will allow the program to
expand existing and offer new supports and services PAL has been in
operation since 2008, and currently delivers over 2,000 consultations a
year for primary care providers, four mental health training
conferences a year, and distributes thousands of copies of the
program's care manual for primary care mental health The service also
delivers a statewide mental health referral service for parents,
provides training and support to primary care clinic based mental
health therapists, and provides second opinion psychiatric medication
reviews for Washington State Medicaid.
With Pediatric Mental Health Care Access funding, PAL will expand
efforts to provide crisis support services for youth in rural
Washington In the remote, primarily rural counties of eastern
Washington State, the numbers of children and adolescents showing up in
primary care and at community hospitals with suicidal ideation and
psychological distress is of significant concern Through a partnership
with the Department of Health, Seattle Children's Hospital, and
Frontier Behavioral Health, the Supporting Adolescents and Families
Experiencing Suicidality (SAFES) project will address the behavioral
health patient surge due to the COVID pandemic, assist children in
crisis and their families, develop enhanced access to telehealth
behavioral services, provide access for primary care providers to
psychiatric consultation for children and adolescents, increase the
capacity of community therapists to safely care for suicidal youth in
outpatient settings, decrease the need for mental health emergency
department utilization, and address disparities in behavioral health
care in rural eastern Washington communities.
In short, the Pediatric Mental Health Care Access Program is
helping states fill critical needs for children's mental health The
fiscal year 2022 appropriation of $11 million will help us to continue
to address the pediatric behavioral health needs we are seeing across
the Nation, and we look forward to working with the Committee on
reauthorizing the program.
Conclusion
Thank you for the opportunity to discuss HRSA's key investments to
address the nation's behavioral health with you today we are looking
forward to working with the Committee on this critical issue and
reauthorizing the Screening and Treatment for Maternal Depression
Program and the Pediatric Mental Health Care Access Program.
______
The Chair. Thank you.
Director Gordon.
STATEMENT OF JOSHUA A. GORDON, M.D., PH.D., DIRECTOR, NATIONAL
INSTITUTE OF MENTAL HEALTH, NATIONAL INSTITUTES OF HEALTH,
BETHESDA, MD
Dr. Gordon. Chairman Murray, Ranking Member Burr, Members
of the Committee, the Biden Administration is committed to
addressing the unprecedented mental health crisis affecting
communities across the United States, using a strategy built on
a foundation of research carried out by the National Institute
of Mental Health, the lead Federal agency charged with setting
and supporting the national agenda for mental health research.
It is my privilege to represent NIMH before you today and to
discuss our ongoing collaborations with partner agencies to
support the President's strategy.
The NIMH is one of 27 institutes and centers of the
National Institutes of Health. NIMH's mission is to transform
the understanding and treatment of mental illnesses through
basic and clinical research, paving the way for prevention,
recovery, and cure. Guided by our strategic plan, NIMH supports
a research pipeline that includes basic efforts to understand
the brain and behavior, translational science focused on
developing transformative new therapies, and clinical research
aimed at maximizing the public health impacts of these
therapies.
The translational pathway is well illustrated by
considering one recent advance, in the treatment of postpartum
depression, a mental illness that impacts one in nine mothers
and can be life threatening. Working diligently over decades,
neuroscientists supported by NIMH discovered that a naturally
occurring brain chemical might have a role in postpartum
depression.
This led to the eventual FDA approval of brexanolone and
analog of that chemical as the first ever drug specifically for
postpartum depression. NIMH's role doesn't stop with the
development of transformative therapies like brexanolone. We
also collaborate extensively with other Federal agencies with
the goal of ensuring that effective treatments are accessible
to all who need them.
One such collaboration has transformed care for psychosis
in the United States. An ambitious NIMH supported research
program, the RAISE initiative, proved that coordinated
specialty care could cost effectively improve outcomes for
those experiencing their first episode of psychosis. Based on
these findings, our colleagues at SAMHSA used the Mental Health
Block Grant Program to fund first episode psychosis clinics
across the country.
Now, over 350 such clinics are providing this cutting edge
care to thousands of Americans each year. NIMH collaborations
are also making progress in preventing suicide. NIMH research
forms the backbone of the zero suicide approach, a systematic
framework for suicide prevention supported by SAHMSA, the
Department of Defense, the Indian Health Service, and numerous
others.
For example, NIMH research has demonstrated that emergency
room screening for suicidal thoughts, combined with brief
interventions and follow-up contacts, can reduce suicide
attempts by 33 percent. NIMH continues to work with public and
private partners to promote the use of zero suicide and other
evidence based approaches.
While it is too early to declare victory, we were gratified
to see rates of death by suicide decline for two consecutive
years following 2018, after two decades of inexorable
increases. The COVID-19 pandemic has brought additional
challenges to the mental health system.
The rates at which individuals note symptoms of depression,
anxiety, substance use, and suicidal thoughts have all gone up,
as has the demand for mental health services, especially among
children. These impacts have not been felt equally, with black,
latino, and other underserved communities, as well as care
practitioners and others on the front lines of the pandemic,
bearing the brunt of both the physical and mental health
impacts.
Yet even during the pandemic, research has offered hopeful
solutions, NIMH research so that mental health care can be as
effective as in-person mental health care, supporting the rapid
switch to remote care in early 2020.
NIMH research during the pandemic has also demonstrated
that social supports, such as providing meals to families
threatened by food insecurity, builds resilience to the mental
health impacts of the pandemic.
Additional challenges await solutions. The Surgeon General
has declared a crisis in youth mental health, noting the impact
of media and technology use and the rise in suicide rates among
black youth and other vulnerable groups.
We also face continuing challenges in caring for
individuals with serious mental illness and the equitable
delivery of mental health services. To address these
challenges, NIMH continues to collaborate with our Federal
partners, including those joining us today, to ensure that
evidence based solutions reach those in need.
In short, we stand ready to help. Thank you for your
opportunity to provide this testimony, and I would be pleased
to answer any questions you might have.
[The prepared statement of Dr. Gordon follows:]
prepared statement of joshua a. gordon
Chair Murray, Ranking Member Burr and Members of the Committee, The
Biden administration is committed to addressing the unprecedented
mental health and substance use disorder crisis that is affecting
adults and children of all races in urban and rural communities across
the United States During the State of the Union, President Biden
announced the strategy to address our national mental health crisis as
part of his Unity Agenda[1] The three pillars of the President's mental
health strategy are: (1) Strengthen System Capacity; (2) Connect
Americans to Care; and (3) Support Americans by Creating Healthy
Environments A These three pillars are built on a foundation of
research carried out by the National Institute of Mental Health (NIMH)
the lead Federal agency charged with setting and supporting the
national agenda for mental health research It is my privilege to
represent NIMH before you today, and to discuss our ongoing
collaborations with partner agencies to support the President's
strategy.
The NIMH is one of the 27 Institutes and Centers that make up the
National Institutes of Health (NIH), the largest biomedical research
agency in the world The NIMH mission is to transform the understanding
and treatment of mental illnesses through basic and clinical research,
paving the way for prevention, recovery, and cure The NIMH Strategic
Plan for Research guides the Institute's priorities for funding
research, from basic neuroscience aimed at understanding how the brain
produces behavior, to translational efforts to develop transformative
treatments, to clinical studies testing novel approaches in community
settings \1\ Indeed, research has driven significant progress in
several key areas of public health, providing hope that drives us
forward.
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\1\ https://wwwnimhnihgov/about/strategic-planning-reports.
This translational pathway from basic science to clinical
application is well illustrated by considering one recent advance in
the treatment of postpartum depression (PPD), a mental illness that
impacts 1 in 9 mothers and can be life-threatening \2\ Until recently,
there were no specific treatments for PPD But thanks to NIMH-supported
science, that is no longer the case This pathway to treatment
development started in the early 1990's, when scientists with NIMH and
the National Institute of Neurological Disorders and Stroke discovered
that naturally occurring brain chemicals called neurosteroids were
important for reducing the adverse effects of stress in laboratory
animals Subsequent work funded by NIMH showed that levels of one of
these chemicals, allopregnanolone, fluctuate through pregnancy and drop
rapidly at the time of birth, suggesting that low levels of
allopregnanolone might lead to PPD and that giving extra
allopregnanolone to women might treat PPD Subsequent clinical trials
published in 2018 confirmed this hypothesis, finding that brexanolone,
a synthetic version of the natural chemical, can rapidly reverse the
symptoms of PPD This decades-long scientific effort culminated in the
spring of 2019 with Food and Drug Administration (FDA) approval of
brexanolone as the first ever treatment specifically for PPD. \3\
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\2\ https://wwwnimhnihgov/about/director/messages/2019/a-bench-to-
bedside-story-the-development-of-a-treatment-for-postpartum-depression.
\3\ https://wwwfdagov/news-events/press-announcements/fda-
approves-first-treatment-post-partum-depression.
We are proud of NIMH research, and its role in developing
transformational new therapies like brexanolone and NIMH's role does
not stop there; we also collaborate extensively with other Federal
agencies, including the Substance Abuse and Mental Health Services
Administration (SAMHSA), the Health Resources and Services
Administration (HRSA), the Centers for Medicare & Medicaid Services
(CMS), and others, with the goal of achieving mental health equity by
ensuring that effective treatments are accessible to the people who
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need them.
One such collaboration has transformed care for psychosis in the
United States Maximizing the likelihood of recovery for individuals
with schizophrenia and other psychotic illnesses requires delivering
the very best care as early as possible in the course of their illness
But just what ``the very best care'' meant was unclear as recently as a
decade ago In the late 2000's and early 2010's, NIMH supported an
ambitious research program--the Recovery After an Initial Schizophrenia
Episode (RAISE) initiative--that tested the efficacy of Coordinated
Specialty Care for those experiencing their first episode of psychosis.
\4\ This research showed that individuals receiving this set of
wraparound services did significantly better than those who received
treatment as usual, particularly when interventions were offered early
on Perhaps even more importantly, the RAISE study showed that these
services can be effectively delivered in community settings and are
cost-effective when compared to usual care Based on these findings, our
colleagues at SAMHSA have used the Mental Health Block Grant program to
fund First Episode Psychosis clinics around the country that offer
Coordinated Specialty Care Now over 350 such clinics are providing
cutting-edge evidence-based care to thousands of Americans each year In
other interagency collaborations related to the treatment of early
psychosis, NIMH has partnered with SAMHSA in their efforts to establish
community treatment programs for those at clinical high risk for
psychosis, partnered with HRSA to implement psychosis screening in
primary care settings, and assisted the Department of Veterans Affairs
(VA) in assuring high-quality services for Veterans with early
psychosis.
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\4\ https://wwwnimhnihgov/health/topics/schizophrenia/raise.
Similarly, in the area of suicide prevention, NIMH is collaborating
in science-to-service and service-to-science cycles of learning
healthcare NIMH research has shown that the majority of those who have
died by suicide were seen by their doctor or another healthcare
provider in the weeks or months prior to their death Accordingly, NIMH
has worked with numerous partners to improve suicide prevention efforts
in healthcare settings \5\ For example, findings from NIMH research
have been incorporated into the ``Zero Suicide'' model, a systematic
framework and multilevel approach to implementing evidence-based
practices; this framework is now supported by grants from SAMHSA, the
Department of Defense, and the Indian Health Service \6\ Initiated by
the National Action Alliance for Suicide Prevention--a public-private
partnership--the Zero Suicide model is based on systematic
implementation and continuous improvement of suicide reduction efforts,
resulting in fewer suicide events within healthcare systems.
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\5\ Gordon JA, Avenevoli A, Pearson JL Suicide Prevention Research
Priorities in Health Care JAMA Psychiatry 2020 Sep 1;77(9):885-886 doi:
101001/jamapsychiatry20201042 PMID: 32432690.
\6\ Hogan MF, Grumet JG Suicide Prevention: An Emerging Priority
For Health Care Health Aff (Millwood) 2016 Jun 1;35(6):1084-90 doi:
101377/hlthaff20151672 PMID: 27269026.
NIMH research has yielded relevant, practice-ready tools that form
the backbone of the Zero Suicide approach \7\ For example, NIMH funded
the Emergency Department Screen for Teens at Risk for Suicide (ED-
STARS) study, conducted in HRSA-supported pediatric emergency rooms, to
demonstrate the efficacy of screening for suicide prevention in these
settings A similar study in adults showed that emergency room screening
combined with brief interventions and follow-up contacts can reduce
suicide attempts by 33 percent NIMH research has also supported the
development of computational methods to identify suicide risk using
electronic health records, an approach that has already been
implemented in the Army, Veterans Affairs clinics, and many healthcare
systems around the United States \8\ Finally, NIMH research has
demonstrated the efficacy and cost-effectiveness of interventions that
can reduce suicide risk once detected, including Cognitive and
Dialectical behavioral therapies, safety planning, caring contacts, and
treating underlying mental illnesses.
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\7\ https://wwwnimhnihgov/archive/news/2016/nimh-funds-3-zero-
suicide-grants.
\8\ https://wwwnimhnihgov/news/science-news/2018/predicting-
suicide-attempts-and-suicide-deaths-using-electronic-health-records.
To ensure that these evidence-based approaches to identifying and
reducing suicide risk in individuals are being utilized, NIMH is
working with SAMHSA, HRSA, CMS, the Centers for Disease Control and
Prevention and other public and private partners to promote the use of
Zero Suicide and other suicide prevention approaches throughout the
United States and while it is too early to declare victory, we are
gratified to see rates of death by suicide decline for two consecutive
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years since 2018, after two decades of inexorable increases.
These and other efforts to improve mental health services through
evidence-based solutions have been confronted with another challenge;
the Coronavirus Disease 2019 (COVID-19) pandemic The impact of the
pandemic on mental health in the United States has been significant
Research supported by NIMH and others has confirmed much of what we
knew based on prior research on disasters and epidemics Through the
course of the pandemic, the rates at which individuals note symptoms of
depression, anxiety, substance use, and suicidal thoughts have all gone
up \9\ The demand for mental health services has also increased,
especially amongst children and the effects on our youth, though still
not fully quantified, are substantial These impacts have not been felt
equally across American communities, with Black, Latinx, and other
underserved communities as well as care practitioners and others on the
front lines bearing the brunt of both the physical and mental health
impacts of COVID-19 Suicide rates among Black youth, for example, have
been rising for the past 5 years, eclipsing rates among White youth for
the first time ever.
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\9\ Czeisler M, Lane RI, Petrosky E, et al Mental Health,
Substance Use, and Suicidal Ideation During the COVID-19 Pandemic--
United States, June 24--30, 2020 MMWR Morb Mortal Wkly Rep
2020;69:1049--1057 DOI: http://dxdoiorg/1015585/mmwrmm6932a1.
Yet even during the pandemic, research has offered hopeful
solutions Prior NIMH research conducted over the past two decades has
demonstrated that telemental health care can be as effective as in-
person mental health care when delivered appropriately; this research
supported the rapid switch to remote care delivery in early 2020 NIMH
research during the pandemic has demonstrated that social supports,
such as the provision of meals to families threatened by food
insecurity, help build resilience to the mental health impacts of the
pandemic and subsequent economic disruption and perhaps the most
optimistic finding is that despite the increased rates of mental
illness symptoms and increased demand for mental health services,
overall suicide rates in the United States continued to decline through
the first year of the pandemic. \10\
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\10\ Curtin SC, Hedegaard H, Ahmad FB Provisional numbers and
rates of suicide by month and demographic characteristics: United
States, 2020 Vital Statistics Rapid Release; no 16 Hyattsville, MD:
National Center for Health Statistics November 2021 DOI: https://
dxdoiorg/1015620/cdc:110369.
Of course, we must nonetheless strive to do better NIMH continues
to gather evidence and collaborate with Federal agencies and other
partners to widely disseminate evidence-based preventative and
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therapeutic interventions Some additional examples include:
Family Navigator Models, which provide assistance to
youth and families to navigate healthcare and social service
systems with the goal of improving outcomes and retaining more
people in care;
The Collaborative Care Model for integrated care,
which uses a team-based approach to incorporate mental health
care into primary care;
Learning Healthcare Networks, which utilize clinical
data to constantly improve and innovate in providing effective,
high-quality care to all patients; and,
School-based Mental Health programs, which provide
behavior management skills training and other interventions to
reduce symptoms of depression and other serious emotional
disturbances.
One quick fact to underscore this last example: NIMH-sponsored
research has shown that mental health care for school-aged children is
more readily accessed and more effective when delivered through school-
based programs, especially for Latinx and other children from
underserved communities. \11\
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\11\ Sanchez AL, Cornacchio D, Poznanski B, Golik AM, Chou T,
Comer JS The Effectiveness of School-Based Mental Health Services for
Elementary-Aged Children: A Meta-Analysis J Am Acad Child Adolesc
Psychiatry 2018 Mar;57(3):153-165 doi: 101016/jjaac201711022 Epub 2017
Dec 24 PMID: 29496124.
We are faced with numerous challenges to the mental health of
Americans, including the lingering effects of the COVID-19 pandemic,
the crisis in youth mental health, including the impacts of media and
technology use, challenges in caring for individuals with serious
mental illness, rising suicide rates among Black youth and other
vulnerable populations, and the limited efficacy of many existing
treatments for mental illnesses In this context, research to develop
novel, effective, and scalable preventive and therapeutic interventions
is more urgent than ever At the same time, recent advances--such as
novel technologies that are revolutionizing the understanding of the
human brain, discoveries in the genetics of mental illnesses, and the
successful development of novel, rapid-acting interventions for
depression--provide an unprecedented opportunity to capitalize on
mental health research and make significant progress for the future
Meanwhile, NIMH continues to collaborate with our Federal partners,
including those joining us here today, to ensure that evidence-based
solutions reach those in need now In short, we know what works, and we
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stand ready to help.
Thank you for the opportunity to provide this testimony, and I
would be pleased to answer any questions you might have.
______
The Chair. Thank you.
Director Volkow.
STATEMENT OF NORA D. VOLKOW, M.D., DIRECTOR, NATIONAL INSTITUTE
ON DRUG ABUSE, NATIONAL INSTITUTES OF HEALTH, BETHESDA, MD
The Chair. If you can turn your mic on.
Dr. Volkow. Can you hear me?
The Chair. Yes, yes.
Dr. Volkow. Good morning, I was saying, Chairwoman Murray,
Ranking Member Burr, and Members of the Committee. Thank you
for inviting me to speak to you today. The Biden Administration
is committed to addressing the unprecedented mental health and
substance use disorder crisis affecting our Country, and I
welcome the opportunity to discuss how research supported by
the National Institute on Drug Abuse is advancing this goal. We
are experiencing the worst drug overdose crisis in the Nation's
history.
Exacerbated by the COVID pandemic, overdose deaths have
escalated across states and demographics. Now, for the first
time ever, we are seeing fentanyl overdoses in adolescents
rising dramatically. Substance use disorders frequently co-
appear with other mental illnesses. Half of people with mental
illnesses will have a substance use disorder at some point in
their lives, and the reverse is also true.
These conditions share many common biological and
environmental risk factors, such as discrimination, trauma, and
economic deprivation. Since 2016, the rise in overdose
fatalities has been driven by potent synthetic opioids,
primarily fentanyl. In the meantime, social isolation and
stress during the pandemic have contributed to a rise in
emotional suffering and an increase in substance use and
overdoses.
This and twin public health crisis highlights the need to
implement prevention and treatment interventions. Preventions,
interventions work. They protect from the devastation of drug
use, and when delivered early in life, they can also help avert
adult mental illnesses. Prevention interventions aim to
decrease risk factors while enhancing resiliency and are
implemented through family, schools, communities, and health
care.
Evidence based prevention saves lives and money. And some
studies show these benefits even extend to future generations.
The Healthy Brain Study and the Child and the Adolescent Brain
Cognitive Development Study are two large longitudinal
investigations of human brain development. Together, they span
the prenatal period through young adulthood. And the findings
have already started to illuminate biological and environmental
influences on mental health and are expected to inform
prevention interventions.
The health care system can also play a key role in
prevention and treatment, through screening for substance use
and delivery of brief interventions or referral to specialty
treatment. Identification of drug use can also serve as a
sentinel symptom of a mental disorder that can then be treated.
When substance use disorders occur along with other mental
illnesses, both disorders must be treated.
Medications and behavioral therapies are effective in
treating substance use disorders with or without comorbidities.
However, less than 13 percent of people with substance use
disorders receive treatment. This percentage is even lower
among black Americans, among whom we are currently seeing the
fastest rate of growth in overdose deaths.
Even for individuals with substance use disorders and
psychiatric conditions, fewer than half received any treatment.
To address this gap, NIDA is prioritizing implementations and
services research. The NIDA clinical trial network or CTN has
shown that opioid use disorders can be successfully treated in
emergency departments and other health care settings. CTN is
now assessing new models of treatment delivery through
pharmacies and telehealth.
The NIDA Justice Community Opioid Innovation Network is
testing ways to expand addiction treatment in jails and other
justice settings. And are Healing Communities Study conducted
in conjunction with SAMHSA is investigating how evidence based
interventions can reduce opioid overdoses in some of the
hardest hit communities in our Country.
NIDA also helps biotech startups develop technologies that
connect people to care, provide or support treatment, help
people sustain their recovery, and even facilitate overdose
prevention. While there are effective medications for opioid,
alcohol, and tobacco use disorders, high relapse rates still
remain.
Critically, there are no medications for other drug use
disorders. Thus, NIDA is prioritizing the development of
addiction medications and treatment, including those that
address the intersection between substance use and other mental
illnesses.
The escalating loss of life due to drug addiction has made
evident the urgent need for interventions to prevent and treat
emotional distress and mental disorders as key strategies for
addressing the overdose crisis. Thanks for inviting me to
testify.
[The prepared statement of Dr. Volkow follows:]
prepared statement of nora d. volkow
Chair Murray, Ranking Member Burr, and Members of the Committee,
thank you for inviting the National Institute on Drug Abuse (NIDA), a
component of the National Institutes of Health (NIH), to participate in
this hearing NIDA's mission is to advance the science on the causes and
consequences of drug use and addiction and apply that knowledge to
improve individual and public health I am pleased to speak to you today
about the intersection of substance use and mental health.
The Administration is committed to addressing the unprecedented
mental health, and substance use disorder crisis that is affecting
adults and children of all races in urban and rural communities across
the United States During the State of the Union, President Biden
announced his Unity Agenda This includes a focus on fighting the
overdose epidemic as well as addressing our national mental health
crisis \1\ The three pillars of the President's mental health strategy
are: (1) Strengthen System Capacity; (2) Connect Americans to Care; and
(3) Support Americans by Creating Healthy Environments Today I will
detail for you how NIDA science is advancing these goals.
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\1\ FACT SHEET: President Biden to Announce Strategy to Address
Our National Mental Health Crisis, As Part of Unity Agenda in his First
State of the Union--The White House.
We are experiencing the worst drug overdose crisis in the nation's
history Exacerbated by the COVID-19 pandemic, overdose deaths exceeded
100,000 from September 2020 to September 2021, the highest number ever
recorded in a 12-month period and a staggering 50 percent increase over
the previous 2 years Large increases in many kinds of drug use have
been seen over the course of the pandemic: Several reports have
revealed increases in positive urine drug screens for fentanyl,
cocaine, heroin, and methamphetamine \2\, \3\, \4\ There have been
increases in cannabis and alcohol use, especially among people with
anxiety and depression and those experiencing COVID-19-related stress,
\5\, \6\, \7\ underscoring the close relationship between drug use and
mental health.
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\2\ Millennium Health's Signals Report to COVID-19 Special Edition
Reveals Significant Changes in Drug Use During the Pandemic
(prnewswirecom).
\3\ Analysis of Drug Test Results Before and After the U.S.
Declaration of a National Emergency Concerning the COVID-19 Outbreak--
Emergency Medicine--JAMA--JAMA Network.
\4\ The Opioid Epidemic Within the COVID-19 Pandemic: Drug Testing
in 2020--Population Health Management (liebertpubcom).
\5\ Alcohol Consumption during the COVID-19 Pandemic: A Cross-
Sectional Survey of U.S. Adults (nihgov).
\6\ Increased alcohol use during the COVID-19 pandemic: The effect
of mental health and age in a cross-sectional sample of social media
users in the U.S.--ScienceDirect.
\7\ Changes in Alcohol Consumption Among College Students Due to
COVID-19: Effects of Campus Closure and Residential Change: Journal of
Studies on Alcohol and Drugs: Vol 81, No 6 (jsadcom).
Substance use disorders (SUDs) are considered mental illnesses, and
these conditions frequently co-occur with other mental illnesses
including depression, anxiety, post-traumatic stress disorder (PTSD),
and others Half of people with mental illnesses will have an SUD at
some point in their lives, and the reverse is also true The reasons
that SUDs often co-occur with other mental illnesses are complex
Sometimes they arise independently as a result of shared risk factors
(common genetics, common environmental adverse factors) Their
development may also be intertwined, with one contributing to the other
Chronic, problematic drug use can disrupt the activity of the brain's
reward, stress, and executive-control systems, making it more difficult
for people to experience the pleasures associated with daily living and
contributing to negative emotional states, such as depression, stress,
and anxiety while impairing their capacity for self-regulation In other
cases, people use drugs to self-treat an underlying mental disorder
Over time, chronic drug use can lead to an SUD, which in turn can
worsen the original mental illness Genetics may also mediate the
relationship between drug use and mental illness For example, cannabis
use raises risk of psychosis in those who have an underlying genetic
vulnerability Research also points to a concordance between increases
in schizophrenia associated with cannabis use disorder and concurrent
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rises in cannabis use and cannabis potency over the past two decades.
Although genes play a role in some of the synergies between drug
use and mental illness, many of the common risk factors are social
determinants of health such as racial and other forms of
discrimination, adverse childhood experiences like abuse and neglect,
and economic deprivation including poverty and lack of access to
quality education and healthcare The stigma that attaches to both SUDs
and other mental illnesses is another important factor, which
contributes to and compounds adverse social determinants of health
including social isolation, job loss, incarceration, and reluctance to
seek care or difficulties accessing it.
Social isolation and stress have likely contributed to the rise in
substance use and overdose observed over the course of the pandemic
Social isolation can make people with SUDs more vulnerable to negative
outcomes because it interferes with many of the support systems that
can help them to reach and sustain recovery Although exposure to stress
is a common occurrence for many of us, it is also one of the most
powerful triggers for relapse to substance use for people with SUD,
even after long periods of abstinence and for the exacerbation of
depression and anxiety among with people with mental illnesses.
Notably, there are increased reports of mental distress since the
COVID-19 pandemic emerged, including among individuals with no history
of mental disorders and among younger adults, racial/ethnic minorities,
essential workers, and unpaid adult caregivers \8\, \9\, \10\, \11\
This increased mental distress is occurring in the context of a drug
supply that is dominated by potent synthetic opioids and
psychostimulants, underscoring the need for focused investment in
prevention and treatment to mitigate the impact of the pandemic on the
ongoing overdose epidemic Suicide is often linked to depression and
other mental illnesses including SUDs, and in the United States, and it
has significantly risen particularly among youth and, to a lesser
extent, the elderly Moreover, in a recent study, we found that although
suicide by overdose went down in most groups between 2015 to 2019 (the
most recent year available), it rose in young people aged 15-24, in
older adults aged 75-84, and in Black women The highest suicide-by-
overdose rate in all years studied was seen in women aged 45-64. \12\
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\8\ Mental Health--Household Pulse Survey--COVID-19 (cdcgov).
\9\ Early Release of Selected Mental Health Estimates Based on
Data from the January--June 2019 National Health Interview Survey
(cdcgov).
\10\ Mental distress during the COVID-19 pandemic among U.S.
adults without a pre-existing mental health condition: Findings from
American trend panel survey--ScienceDirect.
\11\ Mental Health, Substance Use, and Suicidal Ideation During
the COVID-19 Pandemic--United States, June 24--30, 2020--MMWR (cdcgov).
\12\ Intentional Drug Overdose Deaths in the United States
American Journal of Psychiatry 2022 179:2, 163-165.
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NIDA Is Advancing Research on SUDs and Other Mental Illnesses
NIDA-supported research has led to the development of effective
prevention and treatment interventions for SUD, providing hope for the
more than 20 million people in the United States with SUD and their
loved ones Although significant strides in establishing evidence-based
practices have been made, there is far more work to be done to develop
new prevention and treatment interventions and to deliver existing
effective interventions with fidelity, for diverse populations, and at
scale There is a particularly urgent need for interventions for
comorbid SUD and mental illness; just as SUD and other mental illnesses
may exacerbate one another, effective treatment for each of a person's
psychiatric condition improves overall outcomes.
Prevention
Two large NIH-funded longitudinal studies, the Adolescent Brain
Cognitive Development (ABCD) study and the HEALthy Brain and Child
Development (HBCD) study, will add greatly to our understanding of risk
and protective factors for SUDs and other mental illnesses Launched
last year, the HBCD study will examine, from the prenatal period
through age 9-10, both normal brain development and how environmental
factors, including social determinants of health, maternal drug
exposure, substance use, and COVID-19 influence brain development and
clinical outcomes ABCD is following nearly 12,000 children from age 9-
10 through the subsequent decade This study, too, has been examining
how childhood experiences affect brain development and social,
behavioral, academic, and health outcomes, including substance use and
COVID-19 Together, these studies will provide valuable information for
the development and implementation of prevention interventions.
It is already clear that interventions in early childhood or
adolescence can be beneficial for averting substance use and other
mental illnesses later in life Research has also provided evidence that
interventions for low-income families can ameliorate some of the
adverse neurobiological impacts of poverty \13\ Substance use and
behavioral disorders exact a monetary as well as a human cost, with
impacts felt across sectors of society including healthcare, the
justice system, education, and taxpayers in general Studies of
prevention's return on investment show that communities could not only
save lives but save money by investing in prevention programs A recent
analysis of one state's healthcare costs incurred by various risky
behaviors in pre-adolescents and adolescents pointed to great potential
cost savings from implementing relatively low-cost measures including
screening in primary care and referral to family based prevention. \14\
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\13\ Family centered prevention ameliorates the longitudinal
association between risky family processes and epigenetic aging--
Brody--2016--Journal of Child Psychology and Psychiatry--Wiley Online
Library.
\14\ Addressing Barriers to Primary Care Screening and Referral to
Prevention for Youth Risky Health Behaviors: Evidence Regarding
Potential Cost-Savings and Provider Concerns--SpringerLink.
Indeed, screening is crucial to better prevention of SUD and other
mental illnesses, and it is an important area to focus our efforts As
it now stands, within primary and ambulatory care settings, rates of
screening for depression are quite low \15\, \16\ Screening for
depression and other mental health conditions needs to become part of
standard practice along with asking about substance use Only when
providers screen for and diagnose all coexisting psychiatric conditions
can treatment plans be developed that address the patient's unique and
combined needs.
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\15\ National Rates and Patterns of Depression Screening in
Primary Care: Results From 2012 and 2013--PubMed (nihgov).
\16\ Depression Screening Patterns, Predictors, and Trends Among
Adults Without a Depression Diagnosis in Ambulatory Settings in the
United States--Psychiatric Services (psychiatryonlineorg).
Under the Helping to End Addiction Long-term or HEAL Initiative,
NIDA leads prevention research aimed at adolescent and young adult
populations that are at highest risk for opioid misuse and opioid use
disorder. (OUD) \17\ Ongoing studies are modifying an existing alcohol
and drug prevention intervention designed for American Indian/Alaska
Native (AI/AN) youth to be appropriate for opioid prevention in young
adults; preventing OUD among adolescents/young adults experiencing
homelessness; exploring whether providing housing in addition to risk
reduction services could improve outcomes; and leveraging technology
that is appealing to adolescents and young adults to facilitate
delivery of an emergency-department-based intervention via health
coaches Preventing harms related to substance use is another critical
priority and includes strategies to prevent overdose and other medical
consequences of substance use such as infectious diseases.
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\17\ Preventing At-Risk Adolescents from Developing Opioid Use
Disorder--NIH HEAL Initiative.
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Behavioral Treatments
Only 13 percent of people with drug use disorders receive any
treatment, and more than half of those with co-occurring conditions in
a given year will receive treatment for neither Behavioral therapies
can be effective for treating SUDs For example, contingency management,
a therapy that provides incentives for behavior change, is the most
effective treatment for stimulant use disorders, though it is
unfortunately not widely available to patients Other behavioral
treatments, like cognitive behavioral therapy, have been shown to be
effective in treating both SUDs and some other mental illnesses
together But by and large, treating SUDs and other mental illness will
require a combined approach and coordination of care among different
specialists In a person with OUD and depression, for instance, it could
mean a combination of buprenorphine and an antidepressant, ideally in
combination with some form of behavioral therapy Overall interventions
need to be personalized to the severity of the disorder and the
different needs of patients NIDA is supporting research to develop
behavioral treatments to reduce substance use by addressing symptoms of
anxiety and depression; to simultaneously intervene on substance use
and symptoms of PTSD in adolescents; and to develop SUD treatment
approaches that are tailored to the needs of people with schizophrenia
or symptoms of psychosis.
Medication Development
Developing effective medications for SUDs is one of NIDA's highest
priorities and is critical to improving treatment for people with
addiction While effective medications exist for OUD, these medications
are underutilized Suboptimal patient retention in treatment regimens,
policy barriers that limit opioid prescribing, and stigma around opioid
agonist medications all contribute to their underutilization More
options are needed to help people with OUD achieve long-term recovery
NIDA is supporting research on medication development for OUD and
overdose, including through funds provided by the NIH HEAL Initiative
The NIH HEAL Initiative has allowed investigators to file 21
Investigational New Drug Applications with the Food and Drug
Administration (FDA) in the past 25 years to initiate clinical trials
These studies focus on a variety of drug targets, as well as monoclonal
antibodies and vaccines that could prevent opioids from entering the
brain.
An increased focus on patient wants and needs, as well as a growing
understanding that SUD treatment needs to be personalized and
responsive to patients' unique changing sets of symptoms, is leading to
a broadened conception of treatment that can include addressing
multiple co-occurring symptoms of a disorder Sleep problems,
depression, and anxiety, for instance, are among SUD-associated
symptoms identified at patient-focused drug development meetings held
by the FDA in partnership with NIDA to solicit input from SUD patient
populations to help guide drug development Studies are underway to
investigate the possibility of repurposing existing medications for OUD
indications, such as the FDA-approved insomnia medication, suvorexant,
based on known overlaps between brain signaling systems involved in
sleep and addiction.
We are also prioritizing the development of medications to treat
stimulant use disorders for which there are currently no FDA-approved
medications Numerous compounds are being tested, and approaches span
identifying novel biological targets for new medications, developing
anti-cocaine and anti-methamphetamine vaccines, repurposing existing
FDA-approved medications, and testing the benefits from medication
combinations (ie, naltrexone buprenorphine for the treatment of
moderate to severe methamphetamine use disorder) NIDA's medication
development program is also supporting research on compounds that
specifically address intersecting substance use and psychiatric
symptoms, including potential treatments for mood disorder symptoms
associated with cocaine use and co-occurring bipolar and cannabis use
disorders.
More coordinated and targeted approaches to incentivize drug
development related to addiction are sorely needed The pharmaceutical
industry has historically underinvested in research and development of
substance use disorder treatments, due to the biological complexity of
these disorders, the stigma that surrounds them, and concerns around
the profit potential of substance use disorder medications.
Harm Reduction
Abundant research shows the value of interventions and services
aimed at reducing harms associated with drug use Overdose deaths are
significantly reduced in communities that distribute naloxone to people
who use drugs and to their families or other potential bystanders An
important part of NIDA's medication-development research involves
developing new and improved overdose reversal medications, particularly
formulations of naloxone that are effective for high-potency opioids
like fentanyl, as well as compounds that could reverse opioid overdoses
involving other drugs such as methamphetamine Syringe-services programs
are effective at reducing the spread of HIV and other infectious
diseases like hepatitis C, and they also help link people who inject
drugs to addiction and HIV screening and treatment NIDA continues to
support research on these and other harm reduction practices such as
drug checking technologies like fentanyl test strips.
Translating Research into Practice in Diverse Settings
Providing prevention and treatment services across health care,
justice, and community settings is key to addressing SUD and is the
most promising way to improve access to treatment Persistent challenges
continue to keep mental health care largely separate from general
medical care, and addiction care is often further sequestered to
specialized settings This leads to difficulty in providing patients
with coordinated, wholistic treatment In order to promote provision of
quality care, NIDA places a high priority on implementation research in
diverse settings, including through the NIDA Clinical Trials Network
(CTN), the Justice Community Opioid Innovation Network (JCOIN), and the
HEALing Communities Study (HCS).
Clinical Trials Network
The primary goal of CTN, which comprises 16 research nodes and more
than 240 community-anchored treatment programs across the country, is
to bridge the gap between the science of drug treatment and its
practice through the study of evidence-based interventions in real-
world settings NIDA's CTN allows medical and specialty treatment
providers, treatment researchers, patients, and NIDA to cooperatively
develop, validate, refine, and deliver new treatment options to
patients The CTN is conducting studies to evaluate strategies for
integrating OUD screening and treatment into emergency departments,
primary care clinics, infectious disease programs and rural and AI/AN
communities It also tests alternative models of care for SUD such as
the use of pharmacies for delivering medication for OUD and the
integration of telehealth for support of treatment The CTN supports
research based on data relevant to SUD by taking advantage of
electronic health record (EHR) systems It is currently developing and
testing a clinical decision support tool that integrates with EHR
systems to help doctors diagnose OUD and provide treatment or refer
patients to appropriate care The CTN also supports research to examine
the role of pharmacies in providing medications for OUD, an approach
that could be especially useful in rural communities located far away
from traditional treatment programs.
Justice Community Opioid Innovation Network
NIDA's JCOIN, which is funded though the NIH HEAL initiative, is
testing strategies to expand effective OUD treatment and care for
people in justice settings in partnership with local and state justice
systems and community-based treatment providers. \18\ JCOIN includes a
national survey of addiction treatment delivery services within the
justice system; studies on the effectiveness and adoption of new
medications, prevention and treatment interventions, and technologies;
and use of existing data sources in novel ways to understand care in
justice populations Together, these studies are generating real-world
evidence to address the unique needs of individuals with OUD in justice
settings JCOIN also responded in real time to the COVID-19 pandemic
with additional research to study COVID testing protocols in justice-
involved populations.
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\18\ Justice Community Opioid Innovation Network--NIH HEAL
Initiative.
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HEALing Communities Study
The HEALing Communities Study, also funded through the NIH HEAL
Initiative, is a multisite implementation research study investigating
coordinated approaches for deploying evidence-based strategies to
prevent and treat opioid misuse and OUD and prevent overdose deaths
that is tailored to the needs of local communities Research sites are
partnering with 67 communities highly affected by the opioid crisis
across four states (NY, MA, KY, and OH) to measure the impact of these
efforts. \19\ The ambitious goal of the study is to reduce opioid-
related overdose deaths by 40 percent over 3 years Despite the impacts
of COVID-19 on research and its severe exacerbation of the overdose
crisis, the HEALing Communities study was able to launch a key aspect
of its program, a diverse communications campaign to increase awareness
and demand for evidence-based practices and to reduce stigma against
people with OUD and those taking medications for OUD. \20\
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\19\ HEALing Communities Study--NIH HEAL Initiative.
\20\ Introduction to the special issue on the HEALing Communities
Study--ScienceDirect.
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Leveraging Telehealth, Digital Solutions, and Innovation to Expand
Access to Care
A component of translating research into practice is leveraging
existing opportunities and developing new ways to bring healthcare to
hard-to-reach populations The COVID-19 pandemic brought about
significant drug treatment policy changes that expanded telehealth and
facilitated access to medications for OUD--including by facilitating
remote prescribing of buprenorphine and take-home dosing of methadone
These flexibilities were rapidly implemented by providers, and evidence
to date suggests that they were not associated with an increase in
adverse outcomes NIDA is funding research on telehealth utilization and
the effects of recent changes in policy and practice.
NIDA is also leveraging the Small Business Innovation Research
(SBIR) and Small Business Technology Transfer (STTR) programs and other
funding mechanisms to help biotech startups develop technologies that
connect people with SUDs to care, provide or support treatment, help
individuals sustain their recovery, and even facilitate overdose
prevention For example, a smartphone app originally designed to connect
patients to open acute care beds has been adapted to facilitate
referrals to addiction treatment facilities and is currently being used
by several state governments and hospital systems NIDA has also helped
develop tools that put evidence-based psychosocial treatment for SUDs
right in the hands of anyone with a smartphone For example, reSET and
reSET-O are apps that deliver cognitive behavioral therapy in
conjunction with treatment that includes buprenorphine and contingency
management to people with non-opioid SUDs (reSET) and OUD (reSET-O),
and were the first prescription cognitive behavioral therapy mobile
apps to receive FDA clearance to help increase retention in an
outpatient treatment program A NIDA SBIR grant is now being used to
make these apps more accessible by converting them into a game Other
apps help doctors and patients monitor and maintain their OUD
medication, and connect individuals to behavioral therapies, peer
support groups, and community interventions Research is also ongoing to
develop automatic overdose detection devices that can inject naloxone
when a person overdoses, along with tools and methods to accurately
assess types of drugs detected in blood or urine for use in healthcare
or by medical examiners and coroners, among many other innovations
These and other innovative products demonstrate that pairing sound
science with biotechnology entrepreneurship has great potential to
expand the research of addiction treatments and support services.
Addressing Health Inequities and Disparities
Disparities by race, socioeconomic status, sex, and geography have
always created an inequitable landscape in care for SUDs and other
mental illnesses For example, Black people are much less likely to be
prescribed buprenorphine for OUD than white people and despite parity
laws, insurance coverage for SUD and other mental health treatment
remains limited, meaning that less advantaged populations have less
access to needed, potentially life-saving services The COVID pandemic
has illuminated and, in many ways, exacerbated many of these
disparities However, flexibilities in healthcare practice adopted
during the pandemic (eg, expanded telehealth) along with new tools to
facilitate telehealth may help overcome some of the existing barriers
to finding SUD treatment and psychiatric care, particularly for
currently underserved populations Ongoing research will help optimize
the most cost-effective interventions to mitigate the exacerbation of
health disparities due to COVID-19 Indeed, finding solutions to reduce
and ultimately eliminate health disparities, especially those related
to structural racism, is a NIDA research priority Racial disparities
also persist in the addiction science workforce NIDA's Racial Equity
Initiative is working to identify disparities and systemic barriers and
implement programs and funding opportunities to equitably enhance,
promote, and sustain engagement of people from diverse backgrounds,
including those from historically underrepresented groups, in addiction
science.
Substance use impacts women differently than men, conferring unique
challenges that warrant particular attention Women are more likely to
use substances to cope, progress more quickly from use to addiction,
and have greater co-occurrence of addiction with symptoms of mood
disorder. \21\, \22\ This increased vulnerability bears out in women
experiencing homelessness, who have higher rates of substance use than
their male counterparts and are a group more likely to have been victim
to physical and sexual abuse \23\, \24\ Worldwide, women are less
likely than men to receive treatment for their SUD. \25\ Negative
outcomes associated with substance use are also a serious concern among
women; women who use drugs experience gender-related violence at much
higher rates than those who do not, women have a greater likelihood
than men of contracting blood-borne infections from injection drug use,
and women are more likely than men to intentionally overdose. \26\,
\27\ These elevated risks not only impact women who use drugs, but
their children and family units as well It is imperative that the
specific needs of women are considered--from biological differences,
through childcare, personal safety, and transportation needs--to ensure
that addiction prevention and treatment are as effective as possible.
---------------------------------------------------------------------------
\21\ Full article: Women and Addiction: The Importance of Gender
Issues in Substance Abuse Research (tandfonlinecom).
\22\ Sex differences in vulnerability to addiction--ScienceDirect.
\23\ Women, Homelessness, and Substance Abuse: Moving Beyond the
Stereotypes--Lisa J Geissler, Carol A Bormann, Carol F Kwiatkowski, G
Nicholas Braucht, Charles S Reichardt, 1995 (sagepubcom).
\24\ Recognizing and responding to women experiencing homelessness
with gendered and trauma-informed care--BMC Public Health--Full Text
(biomedcentralcom).
\25\ WDR21--Booklet--2pdf (unodcorg).
\26\ Women who inject drugs more likely to be living with HIV--
UNAIDS.
\27\ Intentional Drug Overdose Deaths in the United States--
American Journal of Psychiatry (psychiatryonlineorg).
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Building Partnerships
Partnerships are critical to make a positive impact on public
health, and NIDA is engaged in productive collaborations at all levels
of government we value our partnerships with our sister agencies in
HHS, including the Substance Abuse and Mental Health Services
Administration (SAMHSA), the Health Resources and Services
Administration (HRSA), as well as the FDA, which is crucial to our
efforts to develop medications and devices for SUD medications NIDA
also partners closely with the Centers for Medicare & Medicaid Services
(CMS) to build the evidence base for healthcare funding decisions, with
the Office of National Drug Control Policy (ONDCP) to advance the far-
ranging goals of the National Drug Control Strategy, and with the
Department of Justice to improve addiction care in incarcerated
populations and promote research on controlled substances.
Collaborations also provide valuable and complementary perspectives
and infrastructures that NIDA leverages to advance research and
maximize its benefit for all people Some of the largest projects funded
under the NIH HEAL Initiative rely on such collaboration with our
Federal partners and others The HEALing Communities Study is led by
NIDA in close partnership with SAMHSA to ensure that this research is
poised to impact service delivery toward ameliorating the opioid crisis
in hard hit areas JCOIN fosters collaboration between investigators,
justice, and behavioral health stakeholders in search of creative ways
for improving the capacity of the justice system to respond to the
opioid crisis.
Conclusion
The issues of substance use and SUD are inseparable from the larger
landscape of mental health and mental illness Consequently, we cannot
hope to make headway against the drug overdose crisis unless we make
screening, preventing, and treating all mental illness, including SUDs,
one of our top priorities Continued research is also critical, and NIDA
is actively supporting research in each of these areas with a focus on
SUDs, their entwined psychiatric problems, and overcoming the various
infrastructural barriers and stigma that have historically impeded
these goals Thank you for the opportunity to address these critical
issues.
______
The Chair. Thank you very much to all of our witnesses. We
appreciate your being here today. We will now begin a round of
5 minute questions. And I again ask my colleagues to keep track
of your clock and stay within those 5 minutes. Assistant
Secretary Delphin-Rittmon, this pandemic, as I said, has been
especially difficult for children. They have dealt with major
disruptions in their daily lives.
Many have lost loved ones due to COVID-19. And meanwhile,
parents and caregivers are really stressed, making what has
been a really difficult time even harder for families and for
kids. I know as a mother and a grandmother and a former
preschool teacher, I am very committed to making sure we are
doing everything to meet the needs of our children and our
adolescents, and to address this real national emergency in
youth mental health.
Can you tell all of us why it is important to provide kids
with high quality mental health screening and prevention and
intervention and treatment services?
Ms. Delphin-Rittmon. Thank you so much again for convening
us, Chair Murray. You know, it is so critical to address the
mental health needs of young people. We know even before the
pandemic, young people were struggling with a range of mental
health challenges. And as a function of the pandemic, we have
seen those challenges increase.
Putting programs and strategies and training and technical
assistance in place to be able to address the needs of children
struggling with mental health challenges is a priority of
SAMHSA. For example, one program that we have is Project Aware,
that is promoting awareness and resiliency in schools.
It is a wonderful program that provides training and
technical assistance for school personnel to be able to
recognize children that are struggling, but then also connect
children who are struggling to care and to resources. And so
that is a program that we, in fact, have been able to scale up
through American Rescue Plan resources and one where we are
seeing significant impacts across the country.
We will also develop, as I mentioned, the HOPE framework.
So working to ensure that children and families are connected
to health, so healthy opportunities and opportunities to be
able to improve and advance health, again, opportunity to be
able to reach their full potential and be screened for any
risks.
Then equity, you know, certainly ensuring that those
services are equitable. And so that is a framework that
essentially encapsulates a range of programs and initiatives
across SAMHSA to be able to ensure that--and promote the mental
health and well-being of children. But this, especially now, is
an important time to address mental health. And again, we have
a range of programs.
To include mental health first aid, that is an additional
training program that provides training and support for
communities, again, for schools and individuals on request
really, faith communities as well, to be able to recognize the
needs of--and recognize when young children are struggling.
The Chair. Great. Okay, thank you. According to estimates
released actually just last week, more than a 105,000 Americans
died from drug overdoses from October 2020 to October 2021.
That is the highest annual total on record. In my home State of
Washington, we have seen a real drastic rise in synthetic
opioid use. Our largest county, King County, set a record high
of overdose deaths.
Those are really tragic and unacceptable numbers, and they
make clear that we really need to invest in treatment,
including medication assisted treatment, or MAT, and prevention
services for opioid use disorder. But right now, as I said,
just one in five Americans with opioid use disorder receive
MAT, and there are significant disparities in access to that
treatment.
Overdose rates are rising fastest among black people, we
also know black communities are less likely than white ones to
have access to those that they need. So as this Committee looks
at putting together legislation to combat substance use
disorders and overdose deaths, I really think we have to do
everything we can to expand access to prevention and treatment
services and reduce those disparities in care.
Director Volkow, I wanted to ask you, how would you improve
access to treatment, including medication assisted treatment,
help reduce those disparities?
Dr. Volkow. We know that the most effective intervention
that we have against overdoses is providing medication for
opioid use disorder. It increases your risk of overdosing by at
least 60 percent.
But unfortunately, as you mention, a very relatively small
percentage of people that can benefit are given access to
treatment, and the treatment also is not necessarily continued.
So we need to not only expand the number of individuals that
can be treated but ensure that we have the support systems that
will allow them to remain in treatment.
We have to take advantage of health care systems and
involve partnerships with justice settings so that we ensure
absolute equity in access to these treatments. The parity law
determines that you should be treating addiction as a medical
condition. And yet this has not been properly implemented, and
we need to ensure that the workforce is able to provide the
treatment, so.
The Chair. Okay, thank you. Thank you very much. And
Senator Burr, you are deferring to Senator Collins. Senator
Collins.
Senator Collins. Thank you. Thank you, Senator Burr. Dr.
Delphin-Rittmon, in Maine last year we had 636 deaths, a 23
percent increase, primarily as a result of fentanyl. This is
the highest level we have ever experienced. But what is equally
traveling is if you look at total overdoses in 2021, the number
exceeds 9,500.
What I am hearing from law enforcement and public health
officials is that they need data on non-fatal overdoses in
order to identify and investigate the sources of opioids and
fentanyl and other drugs in their communities, and to be able
to direct people to drug treatment programs.
I am working on a bill based on recent GAO recommendations,
which would require the Administration to improve the
timeliness, accuracy, and accessibility of both fatal and non-
fatal overdose data. During our meeting, prior to your
confirmation, you described yourself as a data person. Would
you support legislation to provide better information on non-
fatal overdoses? Because if we are just looking at the tragic
deaths we are missing the picture.
Ms. Delphin-Rittmon. Yes, you know, thank you so much for
that question. And, you know, I think it is right on. It is so
important that we have a good sense of both overdose data as
well as non-overdose data.
Would be definitely interested in talking with you further
about that. I think to the extent that we can understand some
of the non-overdose trends as well, it could help to inform
programs and services and interventions. So happy to have
further conversations about that. I do believe that will be an
important area of work.
Senator Collins. Thank you. The next question I want to ask
is for you also. Maine has the terrible distinction of having
the second highest rate of neonatal abstinence syndrome in our
Country, even though the number of babies born in our state
with neonatal abstinence syndrome has declined somewhat.
But still, in 2020, 901 babies were born drug affected. As
some Members of the Appropriations Committee, I have encouraged
the Administration to enhance efforts to screen, treat, and
support infants through the WIC program. USDA designates
neonatal abstinence syndrome as a nutrition risk, but WIC
programs do not currently have uniform, evidence based
nutrition educational materials.
Does SAMHSA coordinate with USDA on this issue?
Ms. Delphin-Rittmon. Yes, so the WIC program is, and thank
you for that question, is a USDA program, although we do have
coordination and collaborations with USDA and can certainly,
you know, develop additional work in this area. We currently
have collaborations related to rural technical assistance
related to opioid use but can certainly expand our work in
collaboration in terms of the WIC program as well which they
administer.
Senator Collins. I certainly hope that you will. It is
really a terrible problem. Ms. Johnson, my final question is
for you. It has to do with the STAR Loan Repayment Program that
is administered by HRSA. It offers loan repayment to eligible
substance abuse disorder professionals who agree to work in
areas that are located in the country with overdose races that
are greater than the national average or have mental health
professionals shortages.
Unfortunately, what we are finding in Maine is said some
clinicians have been denied loan repayment because HRSA does
not consider telehealth patient care unless both the
originating site where the provider is located and the distant
site where the patient is, meet the geographic criteria.
That is in conflict with the flexibilities that Congress
enacted to enable access to telehealth during the COVID public
health emergency. I have written to HRSA on this, and I am told
that you need a legislative fix. Would you support making such
a change to ensure that qualified substance abuse disorder
professionals are not disadvantaged because the care delivery
for vulnerable patients has shifted to telehealth during this
pandemic, particularly for rural areas and underserved
communities?
Ms. Johnson. Thank you so much, Senator, for the question.
As you know, HRSA is the home of the Federal Office of Rural
Health Policy. We are very dedicated to making sure that we are
doing everything we can to get services and supports to rural
communities. And increasingly, as you note, our loan repayment
programs are reaching into rural communities, and we are doing
everything we can to ensure those programs continue to grow in
rural areas.
We also have used a number of COVID flexibilities, as many
as we can, throughout the pandemic for our loan repayment
program, so I am very interested in having a follow-up
conversation with your staff about the opportunities here
because we want to support rural communities as much as
possible.
Senator Collins. Thank you.
The Chair. Thank you very much.
Senator Smith.
Senator Smith. Thank you, Madam Chair. Thank you to all of
you for being here today. Just following up on Senator Collins'
line of questioning. This issue of building out and expanding
the mental health care workforce is a crucially important
issue. I hear about this all the time.
People who finally kind of break through the stigma and the
systemic challenge is to say, okay yes, I am ready to get help,
and then they face long waiting lists, wait times that
sometimes that Minnesota will reach to months. And of course,
we would never put up with that kind of waiting time if
somebody was having a heart attack or had a broken limb. And so
I think addressing this workforce shortage, which is often the
cause of this waiting challenge, is really important.
Let me just ask Ms. Johnson a follow-up question. I mean, I
get from what you were saying that these loan repayment
programs work to build out the mental health care workforce
across the broad spectrum of providers. Because it is not just
psychiatrists. It could be a whole--you know, across a whole
range of providers. Is that right?
Ms. Johnson. That is correct. There are a whole range of
mental health professionals who are eligible to participate in
the National Health Service Corps. We also have a nurse corps,
a loan repayment program.
The advantage of these programs is that not only are we
helping those individuals with loan repayment in return for
service in underserved communities, but our data consistently
shows that people tend to stay in the communities in which they
originally practice. And so it is a long term investment in
those communities.
Senator Smith. Now, another issue that I hear about all the
time is that we have loan repayment programs that are getting
folks into--you know, that are getting people ready to go into
training but then we have a shortage of trainers. We have a
shortage of educators. This is a challenge in Minnesota around
nurses, not only in mental health training programs, but more
broadly. So could you just talk about what we need to do to
address that challenge of educators in the field?
Ms. Johnson. I just really appreciate you raising the
question, Senator, because before the pandemic, nurse faculty
was a challenge. The critical issues that our heroic frontline
nurses have dealt with throughout the pandemic has made it even
harder for us to recruit individuals who have the time and
resources and capacity to apply to function in nurse faculty
roles.
We have a loan repayment program to encourage people into
nurse faculty. We would love to continue to grow and expand
that work. But we also are--in my role in HRSA, I am
increasingly reaching out to health professions, leaders, and
health systems leaders who have a shared interest in ensuring
that we have a viable nursing workforce for the future.
Because I think this is, as Ranking Member Burr pointed to
earlier, a place for public, private partnership to encourage
individuals to work in nurse faculty is an important
partnership.
Senator Smith. Right. Because if you might have been a
practitioner, the thing you would like to see is practitioners
who then come into training and become an instructor. But often
that requires--I mean, you know, people are going to be hard
pressed to do that if they are taking a salary cut.
Ms. Johnson. That is right. I mean, what we can offer is
the loan repayment for you to be able to do the educational
piece. But given the current dynamics of where the workforce
is, it is a challenge on the salary side.
Senator Smith. I, so I think there is more work that we
should think about doing together on this because if we are--I
see in Minnesota pumping lots of resources, good resources into
loan repayment and scholarships, but then there aren't any
spots because of this issue that we are talking about.
Ms. Johnson. I would welcome the opportunity to work with
you on this. This is a huge priority for us as well.
Senator Smith. That is fantastic. That is great. Dr.
Delphin-Rittmon, I would like to ask you--would like take a bit
of time to talk about this question of how we integrate
behavioral health care better into primary care settings. We
know that this is a powerful way to expand our national mental
health treatment and behavioral and substance abuse treatment
capacity. And this strategy, of course, recognizes that it is
health, it is not mental health separate from physical health.
The better we integrate, the more we are going to undo the
barriers that we have up there to block access to mental health
care. So in just a few seconds I have left, can you just talk a
little bit about some of the models that are out there for
doing this kind of integration and where you see the greatest
opportunity?
Ms. Delphin-Rittmon. Yes, and thank you for that question.
So, absolutely. I mean, this is an area that is one of the
SAMHSA priorities as well. We have an initiative called PBHCI,
Primary Care Behavioral Health Integration, that is a grant
program that essentially integrates behavioral health screening
into primary care settings.
We know that is so important because often individuals will
go to a primary care setting first before they will contact or
connect with a behavioral health provider. So if screenings can
be done in that setting, it allows for the individual to be
connected to appropriate services and supports.
We also have a CCBHC model which integrates behavioral
health or primary care integration into behavioral health
settings, so Certified Community Behavioral Health Clinics,
provides that integration as well, which is critical.
Senator Smith. Madam Chair, I know there is lots of
interest in this topic. On the Committee, I am working with
Senator Moran, among others, to try to figure out how to
support this, and I want to just thank the Biden
Administration. I know that both of these issues I have raised
are part of their broad national strategy to address these
challenges, so appreciate it very much.
The Chair. Thank you. Senator Cassidy. And Senator Cassidy,
just let me say to you, we are all thinking of you and all the
people in New Orleans for the horrific tornadoes that we were
watching. Wish you all the best.
Senator Cassidy. Well, thank you. Thank you. Thank you,
Madam Chair. Thank you all for your service to our Country on
this issue. Ms. Volkow, you in your written testimony, and then
several years ago, mentioned the potential role of marijuana,
cannabis upon the adolescent brain as being a precipitate of
serious mental illness. Is that a correct statement of your
concern?
Dr. Volkow. Definitively, this is one of the areas that we
are most concerned off with the legalization of marijuana.
Senator Cassidy. So let me ask you, that would suggest that
states which have had a more liberal legalization of marijuana,
say Colorado, would have an increased incidence of serious
mental illness among adolescents and young adults than a state
with more restrictive laws and presumably less prevalence of
usage. Is that a finding that you have had?
Dr. Volkow. In the United States, there are no studies that
have documented that. In Europe and across the world, yes.
Senator Cassidy. Now, hang on. It is documented that more
relaxed legalization of marijuana is associated on a population
scale with increased incidence of serious mental illness, just
to be sure.
Dr. Volkow. Specifically, in the United States,
legalization by some states of marijuana has not been
associated with an increase in adolescents marijuana use. That
is something that has not happened.
Senator Cassidy. Well, that surprises me because
increased--if you relax blue laws for alcohol, there ends up
being more alcohol use by adolescents in that given county or
parish.
Dr. Volkow. We are seeing significant increases in adult
use of marijuana and young people, but not in adolescence,
which is different exactly from what you are saying with the
alcohol.
Senator Cassidy. Now what about the young adults? Because
the brain, as I recall, continues to develop maybe up to 30. If
you are a male, probably 35. So does that young 20, is there an
association with increased incidence?
Dr. Volkow. Yes, there is. There is--for example, there is
a significant increase in the risk for suicidal behaviors and
suicidality associated with marijuana use among young people.
Senator Cassidy. And that is when controlling for other
factors. And so that is just not a cause--that is just not an
association, but it is suspected that it is causal?
Dr. Volkow. It is an association after controlling for
factors like depression. But in order to establish causality,
you need to--you require prospective studies that we are
currently carrying on, on the ABCD.
Senator Cassidy. Now let me ask, and you may not have this
data, but we have worked hard to expand the ability of Medicaid
to address addiction disorder. Have you found that states with
Medicaid expansion and, or state regulations being more--
employing these tools Congress has given, have had better
outcomes for adolescent and adult addiction or not?
Dr. Volkow. There is evidence that some of the states that
have expanded Medicaid have been able to provide extended
access to medications for opioid use disorders among young
adults and adults. The data for adolescents is not as clear.
There is--because very--the sample sizes are much smaller.
Senator Cassidy. And are we seeing better outcomes or are
we just seeing greater utilization of drugs?
Dr. Volkow. We are seeing better outcomes.
Senator Cassidy. That is great. Dr. Delphin-Rittmon, Dr.
Gordon spoke about RAISE Grant, and Senator Murphy and I worked
in 2016 to expand access to these RAISE grants. Now in my
state, though, I just found out I got 30 people statewide
enrolled, 20 in New Orleans, 10 in Baton Rouge, and no other
city has these programs.
Now is that a function of inadequate funding or is that a
function of my state not completely employing, because
adolescent suicide we hear is a huge issue, serious mental
illness, and yet something that Murphy and Cassidy were
attempting to employ has not been widely deployed. What can we
learn from you about this?
Ms. Delphin-Rittmon. And thank you for that question. And
we can certainly have, you know, additional follow-up
conversations about this as well. I would have to look
specifically in terms of, you know, were there other
organizations that applied for the resources or applied for----
Senator Cassidy. Is there adequate money there for it?
Ms. Delphin-Rittmon. For the----
Senator Cassidy. RAISE Grant, for the coordinated specialty
care, I think it is called, the CSC. As a 10 percent set aside
within SAMHSA for mental illness, is that adequate or does
Congress need to look at that? Because from Dr. Gordon's
testimony and what I have learned before, this highly
effective. So I guess my question is, do we need to give you
more money for this or is it just get our states to apply for
it?
Ms. Delphin-Rittmon. Yes, I mean, it is definitely an
effective program, and if we are appropriated more money, we
will gladly receive it because it is a program that----
Senator Cassidy. I still not getting an answer to my
question, is more money needed or is a state just not applying?
Ms. Delphin-Rittmon. You know, I would have to go back and
look specifically in terms of the number of states that have
applied for that. I don't have that with me, but we certainly
could follow-up.
Senator Cassidy. Can I ask Dr. Gordon--Dr Gordon any
insight on that?
Dr. Gordon. In regards to the--I mean, whether additional
moneys would----
Senator Cassidy. No, no whether or not--what is the reason
why it is not more widely deployed?
Dr. Gordon. Well, I think we--it is a challenging program
to administer. You have to be willing to implement some changes
at a clinic level. But I can't speak to Louisiana's case, but
we--one of the things that the research project demonstrated is
that you can implement it in clinical settings, but you still
have to have the will at local level to do so. I can't speak to
the level of funding and whether it is adequate for the
situation.
I will say that while there are thousands of Americans
currently enrolled in these clinics, there are probably
thousands more who would benefit from it. And so expanding
access to coordinated specialty care for first episode
psychosis is a good thing.
Senator Cassidy. Got it. Thank you, Madam Chair.
The Chair. Thank you. I am going to call on Senator Baldwin
next. I am going to turn the gavel over to Senator Kaine while
I go and vote.
Senator Baldwin. Thank you, Madam Chair. Along with the
increase in overdose deaths that we have seen in the past few
years, I have been very alarmed to learn of really
heartbreaking reports of college students in my home state
dying from accidental fentanyl overdoses on campus.
Dr. Delphin-Rittmon, what can we do to bolster the efforts
of the residential colleges and universities to play a role in
preventing these tragic overdose deaths on campus, particularly
deaths as a result of fentanyl contamination?
Ms. Delphin-Rittmon. Thank you for that question. And it is
true, the patterns and trends are we are seeing as it relates
to the fentanyl related overdoses is truly troubling across the
country, on college campuses and communities, really across the
board.
In terms of college campuses and, you know, within each
state, there are prevention networks, really robust prevention
networks that we fund through our prevention, in part through
the prevention set aside as well as the SPF Rx Grant.
Those grants provide opportunities for community based
training related to the dangers of fentanyl. It allows for
dissemination, wide dissemination of naloxone and training
around naloxone Administration. As you know, naloxone is a
vital overdose reversal medication.
Continuing to scale up programs and initiatives like that
to blanket college campuses and you know, our strategy has
really been to work to disseminate naloxone far and wide across
the country as part of the--in fact, the HHS overdose
prevention strategy. But certainly some of the prevention work
that is happening at the community level, again funded by Block
Grant but also funded by SOR, the State Opioid Response Grant,
can be real valuable resources that states can use to provide
training, you know, and technical assistance to college
campuses and others about the dangers of fentanyl.
Senator Baldwin. Thank you. You actually anticipated my
second question, which is how can we get more naloxone
distributed on and available in community settings, at college
campuses, and the like. So I will move onto the implementation
of the 9-8-8 three digit suicide prevention hotline.
In 2019, I introduced that measure and it was signed into
law in 2020, converting from the ten digit numbers that are
available throughout the states to 9-8-8, to make it easier for
Americans to get the help they need. I am concerned that states
may not be ready to respond to calls when the new dialing code
becomes available in July of this year.
Dr. Delphin-Rittmon, how is SAMHSA working with states to
make sure they are prepared for the 9-8-8 launch this summer,
and how many states are ready right now for this transition?
Ms. Delphin-Rittmon. And thank you for that question. And I
have to say also, thank you for your leadership in terms of
helping this important piece of legislation come about. It is
significantly transformative for our Nation in terms of how we
approach crises responsiveness and addressing the needs of
individuals that are in crisis and experiencing suicidal
ideation. So I mean, there are many--states are in many
different places.
We have recently invested $282 million in the crisis
infrastructure within states. That is allowing them to shore
up, scale up, staff up the crisis call centers. That is an
integral part of the 9-8-8 transformation, as you know. But we
are thinking beyond that. It is not really just about the
crisis call center, it is also about the full continuum of
care.
States are getting ready, and we are watching their metrics
regularly and they are improving in terms of the influx of
calls and their responsiveness to the calls, texts, and chats,
in fact that they are getting.
In fact, later this week, we have a convening with states
as well as a number of other community providers and national
organizations around just this thing, operational readiness and
working to ensure that the 9-8-8 launch in July, that we are
ready to go.
Senator Baldwin. Yes. So right now, I am aware only four
states have taken action to approve additional funding needed
to support the 9-8-8 services, and my home State of Wisconsin
is not one of them, so I am very concerned that states will not
act to make this funding available.
I believe that we should be taking a look at additional
Federal funding opportunities for states to make sure that this
works across the country for people regardless of where they
live. Can you comment--is that your knowledge also that the
states are not accepting and implementing this additional
funding yet?
Ms. Delphin-Rittmon. You know, states are taking different
strategies. I mean, some states have put legislation in that
will that add in an additional tax that will help to support
the call center.
Other states and in fact, we had a convening in partnership
with CMS around thinking about Medicaid resources and funding
to be able to support the crisis care continuum. So states are
looking at a number of different strategies to include in some
instances state funding. Many--all states except for two
applied for, you know, the $282 million that I mentioned and
otherwise all states and in fact territories are engaged with
us on a regular basis, having discussions around operational
readiness, we will be doing resource materials and guides to
ensure that states have the materials that they need.
Senator Baldwin. Thank you.
Senator Kaine. Senator Tuberville.
Senator Tuberville. Good morning. Welcome. Thank you for
what you do. You are kind of on a boat that is taking on a lot
of water, and you got one cup trying to get it out. I have been
in a coach in preparation for 40 years. I felt like that every
day when it came to mental health addiction around kids. It is
tough. I just hope we start getting some answers to this. But
you know, I walk to work every day, not too far from here. And
the see 6 to 8, 10 people on drugs, passed out.
You can go within several blocks here and you probably find
one person a day that passed away from it. Seemed like we
just--we want to do something about it, but we really don't
know how, how to start from the bottom up. And again, I have
dealt with it all my life, and it is a sad situation. It is
something that if we don't get in control of it, we are going
to look at a huge--we have got an epidemic now, but we are
going to--we are looking at 400,000 that are going to start
dying from this.
Is there any work with any of you all with Homeland
Security that determines or gets any reports from what is
happening at the border from fentanyl? I am not getting into a
border wall--I am not getting into all this political stuff,
but I was down there not too long ago. I saw enough fentanyl in
the back of a truck to kill everybody in this country.
Most of us hadn't heard of fentanyl. Most people in here
hadn't heard of fentanyl until last year or so. And it is
getting bad. It is going--it is an epidemic. So anybody got any
thoughts on that?
Dr. Volkow. I guess definitively. I mean, what happens with
fentanyl, it is very lucrative for the illicit drug market. So
it started in 2016 and it just has grown increasingly.
Extraordinarily potent drug, so very few milligrams actually
can generate a very intense high, but it can also kill you.
It is much easier to transport across the border. You don't
need to cultivate. The synthesis of this compound is relatively
easy. So what we have seen was initially it was used to
contaminate heroin, and now we are seeing it contaminated
basically almost all illicit drugs. And that includes
prescriptions--illicit prescriptions.
This is probably one of the reasons why we are seeing
increases in deaths from overdoses among teenagers and young
people. Is being used to contaminate methamphetamine and
cocaine. And these accounts for the very steep rise in deaths.
So it is a lucrative drug, and it is much harder to contain.
Senator Tuberville. And it is synthetic.
Dr. Volkow. And it is synthetic.
Senator Tuberville. Chinese are making it, and a lot of it
has been made in Mexico and it is coming up to our border. And
hopefully sooner or later, you know, we wake up. You know, they
could put just a certain amount in our air duct system in this
building and either make all of us sick or kill us all. I mean,
that is how deadly this stuff is.
I don't--I really don't understand it. But I want to thank
all of you for your work. One problem that I ran into when I
was coaching is, I would bring in 25 kids a year that I would
sign, and a few years ago--it went over 10 years ago, one or
two of them would have insulin problems, you know, diabetics,
and not very many of them on drugs.
Recently, you can ask coaches now have two, three, four on
something, Adderall or Ritalin. Where is that taking us, Dr.
Gordon? Where are we headed with this?
Dr. Gordon. ADHD is an illness that strikes many young
people around the globe and in the United States.
Senator Tuberville. Is it a disease? Do you inherit it?
Dr. Gordon. It is a good question. There is a genetic
component, as well as likely environmental factors that
contribute to the risk for ADHD. The treatment of ADHD with
Adderall and other drugs can be very, very effective, but we
have both an undersupply and oversupply problem.
We have many, many children who could benefit from
treatment for ADHD who are not getting adequate treatment or
evidence based treatment. And then we probably also have
children who are getting it that maybe don't need it or
misusing it. And so you have both of those situations in the
United States.
I think what we try to urge at the NIMH is an adherence to
evidence based principles. So quantitative evaluation of
symptoms, appropriate treatment with medication for those
symptoms. And when that happens, children with ADHD can do very
well.
Senator Tuberville. Yes. Well, thank you. All this
symptom--is kind of like the--you can buy it anywhere, you
know, in colleges now. A lot of these kids, I don't know which
one of them they take, but they take it to stay up all night,
to absorb, you know, cramming for a test. Which one would that
be? Would it be Adderall?
Dr. Gordon. It could be. There are several different
versions.
Senator Tuberville. Yes, and you know, it is just--that is
another drug that we are going to have a huge problem with. But
I just hope we understand we are dipping water out by spoon in
a boat, and we are going to be in real deep trouble if we don't
get control of the substances coming in this country. We got
enough problems without those. But thank you for your help and
dedication in dealing with this because it is an ongoing
problem that is getting worse and worse. Thank you.
Senator Kaine. Senator Murphy.
Senator Murphy. Thank you very much. Thank you to all of
you for your tremendous work and for your time before the
Committee today. Senator Cassidy and I, along with Senator
Murray help and others, have been really focused on this issue
of mental health parity. We have passed several different
pieces of legislation through this Committee, got signed by the
President since 2016.
The latest piece of legislation we passed required the
Administration to do audits of insurance plans to see if they
were actually in compliance with Federal parity laws. What we
know is that, well your statement of benefits will often tell
you that you have access to mental health treatment. When you
go to get that treatment, you will face what we call non
quantitative treatment limitations, all sorts of
prioritization, bureaucracy, red tape that stands in the way of
you getting that treatment.
I forget the exact number that the Department surveyed, but
about 50 plans and the report we were given in January
essentially came to the conclusion that not a single one of
these plans was in compliance with parity laws. And
interestingly, when they notified the plans that they had set
up these burdensome barriers to mental health care that they
didn't have on the physical health side, the plans fixed those
issues, and all of a sudden thousands of people had access to
mental health that they didn't have.
Secretary Delphin-Rittmon, great to see you. I want to ask
you a question because I noticed that in the SAMHSA Joint Block
Grant application, there is some language in there that says
resources should be used to support, not supplant, services
that will be covered through the private--through private and
public insurance.
You kind of reference the fact that, you know it is
supposed to be insurance that is on the front lines here and
then we are going to come in on the back end. But that sentence
also sort of suggests a knowledge that insurance is not
actually providing the kind of reimbursement that it should.
Can you talk a little bit about how you approach this
issue? I mean, we don't want Federal dollars to essentially be
filling in what insurers should be covering. And this report we
got in January tells us that we just have massive noncompliance
in the insurance industry with existing parity laws.
Ms. Delphin-Rittmon. Yes, thank you, Senator Murphy, and it
is good to see you as well. And, you know, parity is such an
important issue for the American people in terms of health care
and ensuring that both primary care and behavioral health is
appropriately covered. I mean, as you know, SAMHSA has no
regulatory authority here, but we do see ourselves as a, in
some instances, a convener or we help to give states
information around how they can advocate and even families.
You know, we have been policy academies. We feel that it is
important for individuals as well states and communities to
know what the parity laws are. And so those policy academies
that we are looking to bring back, additional policy academies,
are one strategy for helping states have information around how
to, you know, how to work with providers and to promote
advocacy in this area.
We have resources as well for individuals and families, and
we feel that is important as well because people need to know
how to advocate if they are not having coverage for services
and support which they feel that they should be covered.
Senator Murphy. I think that is important but insufficient,
right. I mean, families ultimately are not going to be able to
enforce this right because the sort of details of obstruction
of care are so byzantine. Often it really is has to be
regulators that do this job, and we definitely have more
opportunity at the Federal level to enforce those laws. Just
one quick another topic for you, Ms. Johnson.
I want to talk to you about the state of pediatric mental
health. We talk about this problem we have with getting enough
practitioners, but we have got tens of thousands of
pediatricians who often frankly don't have a lot of background
in mental health.
It seems to me one of the easy things we could do is just
have a conversation with the profession to make sure that
either in the initial training or in some post-graduate
training opportunity, more pediatricians have a background in
mental health and substance abuse, but particularly in mental
health.
Ms. Johnson. Thank you for the question, Senator. I think
that is where we should be headed in pediatric and all clinical
training, that clinicians across the board need to have
training and exposure to mental health and substance use
disorder needs and conditions. We need, in my view, we need
primary care to be inclusive of mental health.
That is what we are working on at HRSA, and we are going to
continue to push forward, ongoing forward. Thank you for your
leadership on the Pediatric Mental Health Access Program. We
really see that as an exciting model for how we can continue to
help clinicians who are in practice now get the kind of mental
health support that they need, buildup their capacity.
What we are seeing anecdotally from that program is really
people being able, clinicians being able to handle more and
more mental health conditions and refer fewer. So we are
excited about continuing to grow that program.
Senator Murphy. And it is very clear, that program is a
mechanism by which pediatricians can get a phone or virtual
consult with a mental health practitioner. I agree that
program, which is included in the 2016 Mental Health Reform
Act, has already shown positive results, but that can be
partnered with the pediatricians themselves having a greater
level of expertise and something that hopefully this Committee
will work on. Thank you, Mr. Chairman.
Senator Kaine. Absolutely. At the request of Senator
Cassidy, we will introduce a statement for the record submitted
by the Children's Hospital Association. Senator Murkowski, you
are up next.
Senator Murkowski. Thank you, Mr. Chairman. And thank you
to the panel here. I just came from a meeting of a group of
Close Up Kids from Taylor, Alaska, pretty remote little
community north of Nome. And Close Up Kids have all kinds of
probing questions that they want to ask. But when I told them
that I was coming to a hearing on mental health and
particularly mental health as it may impact young people, all
of a sudden the chatter stopped because they knew that this
issue was something that was immediate, it was real.
I think they were somewhat relieved to know that the
grownups were talking about it. So I want to ask you, Dr.
Delphin-Rittmon, specific to these behavioral health issues
that we are seeing in younger kids and the number, the rising
number of suicide attempts. I have worked with Senator Rosen to
introduce the youth mental health and suicide prevention, which
would authorize SAMHSA to expand their work and services to
address mental health in K-12 schools.
I have got a letter that I would asked to be included as
part of the record, where we have a statement from the
President and CEO of the Mat-Su Health Foundation, and she
shares that they had a forum with all of them at Mat-Su Borough
School District nurses and the nurses were effectively
demanding that we change our conversation from access to health
care to access to behavioral health care.
What they did in the program there, they would launched
this back in 2017, they launched a behavioral health in schools
program. They then did a survey just recently. When schools
were asked whether they felt that the providers have helped
support students and whether they are satisfied with the
responsiveness of providers to meet the changing needs of
students and staff, 100 percent strongly, strongly agreed, 100
percent of the parents surveyed that they were satisfied, and
66 percent of those parents said that they made changes as
parents to better support their child.
I mean, when you have this level of, wow, we didn't know we
needed this, but I guess we needed this, and this is actually
something that makes us feel better or allows us to feel that
we have got a place to speak to this.
I would ask whether--I would ask you to speak to the
importance of authorizing SAMHSA to provide this kind of
support, direct funding to local schools, so that we can be in
the schools talking, raising this issue, not just talking about
health care, but talking about access to behavioral care. So if
you would speak to that, if you would.
Ms. Delphin-Rittmon. Yes, thank you for that question. And,
you know, we are in full support of something like that. I
mean, we have seen significant impacts and positive impacts
from our Project Aware grant, which is, you know, very much
what you are talking about. It is a program, a school based
program that is about increasing mental health awareness. It
provides training and education for school personnel.
It also provides components around linking students to
services and supports. And we see positive impacts there. We
see students being connected to care, being identified who are
struggling, who might not be connected otherwise. So I think
behavioral health with programs, initiatives within school
settings, are highly valuable. We know students are there, you
know, throughout the week.
If they are struggling, if teacher or school personnel, if
they are trained to be able to identify a student that is
struggling, can help to connect that student to services. So I
think those types of programs are very valuable.
Senator Murkowski. Well, I know that this is something that
we want to continue to push on. And let me then ask this next
question. Equally concerning in Alaska, but really around the
country, and that is military suicides.
We have seen really an alarming increase up North that has
caused a real focus to this from the top of the military
command as they are trying to do everything to improve quality
of life and just address everything from sleep deprivation,
because it is sunny most of the day in the summer and dark most
of the day in the wintertime, how you deal with all of this.
But we know there were still dealing with stigma.
We know that we are still dealing with concerns from those
that say that seeking care is going to harm their career
opportunities. I have been--I have worked over the years on the
Garrett Lee Smith Memorial Act and we are looking to
reauthorize that. It has proven itself, I think, to be
effective.
The law always authorizes the Suicide Prevention Resource
Center, which ensures that the grantees get appropriate
information training, technical assistance on suicide
prevention. So a question, again, to you, if I may, as to
whether or not you think there are opportunities for the
Suicide Prevention Resources Center to collaborate with DOD to
provide technical assistance?
I want to make sure that we are not just leaving DOD alone
in its own silo there to address suicide issues that
unfortunately are more broadly symptomatic of what is happening
across our society. So can you speak to whether or not there
might be some relationship there with these two programs?
Ms. Delphin-Rittmon. Yes. And thank you for that question.
You know, I think there are opportunities there. I in fact co-
chair the Interagency Task Force on Veterans Mental Health with
DOD and VA. And this is one of the very issues that we are
looking at, suicide. And so there are--it is an ongoing
collaboration.
There are a number of--it is a whole of Government
approach. So a number of different Federal agencies there. But
I think there certainly are opportunities here in terms of
collaboration and providing technical assistance, you know, for
VA as well and DOD as well.
Senator Murkowski. Thank you. Thank you, Madam Chair.
The Chair. Thank you. And Senator Murkowski asked unanimous
consent to introduce a letter. Without objection, so ordered.
The Chair. And I believe Senator Kaine introduced a
statement on behalf of Senator Cassidy that needs unanimous
consent. Without objection, so ordered on that.
The Chair. Senator Hassan.
Senator Hassan. Thank you, Madam Chair. I want to thank you
and the Ranking Member for holding this hearing and for your--
for the witnesses, for the work that you do and to be here
today to discuss what are incredibly important issues.
Dr. Delphin-Rittmon, the last time you testified before the
Committee, we discussed the State Opioid Response Grant
program. You spoke about the importance of reliable, consistent
funding and firmly committed to ensuring that states like New
Hampshire would avoid significant cliffs in state opioid
response grants.
I very much appreciate that commitment. I know that our
staff have been working together to develop a solution so we
can achieve the shared goal and I look forward to continuing
those efforts.
How do large swings in Federal funding to states from year
to year, particularly funding for programs that are responding
to the substance use disorder crisis, undermine those state's
public health infrastructures?
Ms. Delphin-Rittmon. Yes, you know, appreciate that
question, and you know, our staff did have a productive
conversation this week, and so we are looking to continue the
work that we discussed. You know, consistent, stable funding,
it is important.
As a former State Commissioner, I am aware of that, that
funding cliffs or swings or changes in funding can be
destabilizing for the system. So some of our work around
looking at the current SOR grant is around looking to sort of
mitigate or reduce any of those impacts. Some of our challenge
there though is that we receive significantly less than what
was proposed in the President's budget.
We are working with the resources we have to try to
minimize those cliffs that we discussed.
Senator Hassan. Thank you.
The Chair. Senator Hassan, let me just say that I agree
that we need consistent and reliable funding. It is really
critical to our state's efforts to respond and prevent those
drug overdoses. And it is important that Federal funding is
allocated in ways that don't result in usually large funding
restrictions--reductions between years, so I appreciate you
bringing that up.
Senator Hassan. Well, thank you. I appreciate that very
much. And I just wanted to note as well, I know there was a
discussion earlier about the importance of medication assisted
treatment as we deal with substance use disorder. And I want to
note that there are still barriers at the Federal level that
prevent more providers from prescribing medication assistant
treatment.
It is why I am so grateful to be working with Senator
Murkowski on this bipartisan Mainstreaming Addiction Treatment
Act to eliminate these outdated prescribing restrictions for
medication assisted treatment. So I look forward to working
with all of you and with my colleagues on the Committee to get
this done.
Following along the line of the substance use disorder
crisis, I want to ask you another question, Dr. Delphin-
Rittmon. Frontline workers in New Hampshire have shared with me
that they are seeing a resurgence in methamphetamine use, and
data show that deaths involving methamphetamines roughly
doubled between 2018 and 2021. How is HHS responding to that
trend?
Ms. Delphin-Rittmon. So one thing that we have done there,
because we are looking at that data and we see some of those
trends as well, is states are now able to use the state opioid
response grant to be able to address the patterns and trends
and needs that they are seeing related to methamphetamine usage
as well.
The saw resources can be used to address and put together
programs or initiatives, awareness campaigns to be able to
address the methamphetamine challenges as well.
Senator Hassan. Okay, thank you. That is an important step
forward. This is a question to the panel. Maternal mental
health conditions are among the most common complications of
pregnancy and childbirth. However, these conditions often go
undiscussed and untreated due to insufficient resources and
pervasive stigma.
I would like to ask the panel, what barriers have you seen
to a federally coordinated maternal mental health response? And
why don't we start with you, Dr. Volkow, and just work down on
the panel.
Dr. Volkow. Yes, thanks for the question. And for us, we
have focused very much on the challenges of ensuring that we
are able to screen and provide for treatment for women when
they are pregnant, ideally before they get pregnant, for any
substance use disorder. Because the data shows that without
treatment, the outcomes can be very negative for the mother
herself and also for the newborn infant.
The research shows that intervention is necessary not just
during pregnancy, but also the support that follows post-
pregnancy to ensure that the woman is able to stop taking drugs
or maintain--or stay in treatment. The data also shows that
pregnancy actually is a moment where women are much more likely
to be receptive for accessing treatment, and thus, is a lost
opportunity not to provide it.
Our research is ongoing to try to figure out which are the
models of care that are most effective and which medications we
can give to pregnant women safely, and how to monitor once the
baby is born to ensure that they will have the greatest
likelihood of success.
Senator Hassan. Thank you. And Dr. Gordon, if we can just
go down quickly because we are running out of time here and
then I can follow-up.
Dr. Gordon. Yes. One quick challenge I see is ensuring that
maternal health care providers have the expertise and
consultation necessary. So expanding collaborative care for
maternal health care providers is one potential solution to
that challenge.
Senator Hassan. Well, thank you because I have introduced
the bipartisan Plan for New Moms Act to improve this kind of
coordination. The bill would create a Federal task force, a
national strategy to expand mental health resources for new
mothers. So I look forward to working with my colleagues and
all of you, and I don't know, Madam Chair, if the last two
panelists can quickly answer--?
The Chair. If they could do it for the record, that would
be great.
Senator Hassan. Okay. We will do it for the record. Thank
you so much.
The Chair. Thank you. Senator Braun.
Senator Braun. Thank you, Madam Chair. Thank you all for
coming in today. It is obviously an important topic. The
question will be for Dr. Gordon and then one for all of you.
And after being subjected for so many--such a long time on
wearing masks and when the guidelines came out recently, most
Americans in the country can now be mask free. And of course,
it always comes back to kids.
That still seems that there is an err on the side of
masking when maybe they are in that group that is least prone
to significant impacts from it. So what is your feeling on, you
know, whether that is a good decision?
How has that impacted other developmental, emotional issues
that come along with, you know, being confined with a mask for
all this time?
Dr. Gordon. Data show that across a broad range of social,
behavioral, and emotional outcomes, allowing kids to attend
school in person is of the utmost importance. Accordingly, the
Biden Administration has prioritized that in their COVID
response plan. Now, mask wearing can be a crucial part of a
layered prevention strategy to allow children to remain in
school when the conditions of the pandemic merit it.
It has been shown to reduce closures of at least daycare
centers. The data for schools are not yet available. NIMH and
other institutes, including NICH, continue to study the impacts
of both the pandemic and mitigation strategies like mask
wearing on social, cognitive, and emotional development.
To date, there are no studies that reveal any significant
harms of mask wearing, but they have shown significant harms of
school closures. So we look forward to continuing that research
and making sure that we know for sure the effects of mask
wearing and other mitigation measures to the COVID pandemic on
children.
But so far, we have not seen any adverse consequences of
those particular ones.
Senator Braun. Thank you. And one of the tragic
consequences of trying to manage COVID from the mental health
side has been, you know, the overdoses that we have had to
contend with. I would like you to comment, particularly on
fentanyl, and is there anything else that has cropped up, you
know, or is contributing to that, and the other three panelists
as well. We have got about two and a half minutes left.
Dr. Volkow. Yes, there are two elements that are
contributing. One of them is the social isolation and the
uncertainty of stress can increase the risk of people to take
drugs, and those are more likely to be exposed to synthetic
drugs like fentanyl and others. And the second crucial element,
since the pandemic, the seizures of fentanyl has been
increasing quite dramatically, making it very available.
Also as I have mentioned before, it is increasingly used to
contaminate other drugs. So those two elements, people being
more vulnerable to taking drugs while at the same time access
to extremely dangerous drugs in the illicit drug market.
Ms. Johnson. I certainly defer to Dr. Volkow on the
fentanyl question. On the other, as an agency that focuses on
maternal and child health, let me just reinforce Dr. Gordon's
point about the critical importance of children being in
school, we have seen because we serve underserved communities,
how important it is for children to be in school to receive a
series of services, whether those are health care services or
whether that is cooking, nutritional support and the like.
In order to do that, we want to make sure that children are
following the appropriate public health mitigation guidance and
responding to that as CDC continues to update that.
Ms. Delphin-Rittmon. Yes. And I will just add that, you
know, in terms of the fentanyl, because of the patterns and
trends that we are seeing, it is increasingly more important
that we have naloxone disseminated far and wide. So again,
through our state opioid response grant, as well as block grant
dollars even, states and communities can purchase naloxone to
help reverse overdoses.
Senator Braun. Very good. And I think it is sad that most
of it gets produced somewhere else, comes through the Southern
border, and I think fixing that source would make a job a lot
easier for all of you that have to contend with it.
I just hope that we get our hands around it to stop it at
its source, and that looks like it is still to be accomplished.
So keep up in the meantime, all the good work to try to
remediate it. Thank you.
The Chair. Yes, Senator Rosen.
Senator Rosen. Thank you, Chair Murray. Thank you for
holding this hearing, for your commitment to a bipartisan
process to reauthorize, to improve, to expand these key Federal
mental health and substance abuse disorder programs. And I just
look forward to ensuring that Nevada's voices are heard
throughout the process.
I want to build a little bit about, Senator Murkowski and I
have been doing a lot of work together on this and so one
program that has been incredibly helpful in Nevada is SAMHSA's
Mental Health Awareness Training Grant Program, you alluded to
it earlier. We have a dire shortages of mental health care
providers, workforce training. That is a subsequent question we
have to address.
We can give all these dollars, but we need a workforce. But
this Federal program has been a critical lifeline, particularly
in rural parts of our state like Nye, Esmeralda, and Lincoln
Counties. They have used this grant funding to improve access
to evidence based mental and behavioral health training for
first responders, for parents, teachers, school staff,
community members, to first of all, better recognize and then
respond to unmet mental health needs of our communities and
help prevent mental and behavioral health issues from
escalating.
Dr. Delphin-Rittmon, as this Committee works to reauthorize
this important program, what has SAMHSA learn over the past 5
years about potential improvements we might make to make it
more accessible for everyone, particularly in our underserved
or rural communities? What should Congress be looking at to
help fix this?
Ms. Delphin-Rittmon. Yes. Thank you for that question and
for your leadership on this issue. This has been such a
critical program for us. Mental health first aid and the mental
health awareness training programs provide a wonderful
opportunity just to increase awareness about mental health
challenges.
These trainings are done across the board, in school
settings, in faith communities, within, you know, other
community centers. And what it does is it allows community
members to be able to recognize children that are struggling or
just anyone that is struggling. What we find is that people do
get connected to care. And I actually have some data on that I
would like to share.
Last year alone, so 2021, 38,000 individuals were trained
in mental health, mental health awareness training, and 125,000
individuals were connected to care as a function of those
trainings. So I think one thing we have learned is that it
makes a difference, it makes an impact. People are being
connected to care as a function of this increased awareness.
Senator Rosen. Well, I think it just increases our
compassion and empathy for others and allows us to reach out.
Sometimes that is maybe the most important first step, right.
But speaking of reaching out, I am working with Senator
Murkowski and being sure that we use these SAMHSA dollars down
at our K through 12 schools because Nevada's Clark County
School District were top of a list that no one wants to be top
of. We have lost 20 students in 2020 to suicide.
We have to do a lot more to be sure that our students are
just being taken care of, particularly through COVID. And so we
have to get that funding directly to the students. We need
workforce training. I know you have spoken about this about,
but Project Aware doesn't allow the funding to go directly to
local school districts, and you would think that is really
important.
I know you have already committed to working with Senator
Murkowski. We work together on this bill, so I won't ask you to
repeat your answer. I know you will be glad--I hope you will be
glad to work with all of us, and I am sure you will on that.
And to your point, what I really want to talk about in the
remaining time is address that workforce issue or training
issue, whether it is lay people or people who are going to be
put to the schools, because if we bring this money down, it is
no good if we don't have the counselors.
Can you talk to us about the workforce shortage, and how do
you think Congress can help provide--expand our provider
capacity for health, in the health professional area?
Ms. Delphin-Rittmon. Yes, thank you for that. I mean, we
certainly are seeing a workforce shortage. You know, programs
like Minority Fellowship Program make a difference or other
fellowship programs. Loan repayment programs make a difference
as well. And, you know, my colleague, HRSA, can share about
that as well. But you know, I think programs that essentially
create incentives for people going to--you know, entering the
behavioral health professions. For me, it made an impact.
As it came up earlier in this Committee, often individuals
will stay and continue to work in the communities where they do
their internships or where they do, you know, some of their
training programs. So those types of programs do make a
difference. And then also, certainly our loan repayment
programs make a difference as well.
Senator Rosen. Thank you. I appreciate that. I am out of
time. I just will ask Dr. Gordon for the record, you can submit
it offline, about seniors' mental health. We also have a lot of
issues there with social isolation and some of those
challenges. So we will submit that----
Dr. Gordon. Happy to do that.
Senator Rosen [continuing]. submit your response for the
record. Thank you. Thank you, Madam Chair.
The Chair. Thank you very much. And I will turn to Senator
Kaine for wrap up and thank you again for filling in for me.
Senator Kaine. Absolutely, Chair Murray. And thanks to the
witnesses. This has been a really good hearing. I want to stick
right where Senator Rosen was at the end of her questioning
about workforce issues, and particularly workforce in helping
folks with substance use disorders. My experience has been, and
I wonder if this is more than anecdotal, that some very
effective folks in this workforce are people who have had
substance use disorders themselves.
But I also find as I travel around Virginia and talk to
people, that they--and how legit this is, or whether it is a
perception, they still feel like if they have had a substance
use disorder, particularly that has led to any criminal
conviction, that they can be challenged in licensure and
regulations often get in their way in terms of being able to be
in the workforce.
They can volunteer, they can be part of a support group,
but if they want to make it a profession and help others using
the experience that they have gone through, there can be
barriers in their way.
I wonder if you might talk about that because if we are
looking for a bigger workforce, we wouldn't want to keep out of
the workforce people who have had a life experience that would
make them particularly effective.
Ms. Delphin-Rittmon. Yes. I am happy to comment on that. I
mean, we have absolutely seen that individuals in recovery, so
peer support specialists, recovery support specialists make a
meaningful difference in terms of connecting people to care and
giving people hope. Often we find recovery coaches share their
own stories of lived experience and often are able to help
connect people to services and supports.
In fact, we have seen with our state opioid response grant,
many states now have programs where they have recovery coaches
connecting with emergency departments. So when an individual is
brought to an emergency department, they are linked up with a
recovery coach, and then the recovery coach helps with system
navigation, helps them get connected to care, or helps them
with whatever they need.
Often, they say their first question is, you know, how can
I help you in your recovery today? So those programs make a
difference. We have seen recovery coaches also in working in
methadone programs, working in supported employment programs.
And it is an area in terms of SAMHSA that is a priority for us
in terms of expanding our recovery work, and we recently
announced a recovery--Office of Recovery. Recovery is also one
of the pillars of the HHS Overdose Prevention Strategy as well.
Ms. Johnson. I would just add----
Senator Kaine. Ms. Johnson----
Ms. Johnson [continuing]. if you don't mind, sorry. Peers,
people with lived experience are part of the solution here, and
we are not going to succeed in the way that we want to in
combating the opioid epidemic, combating the substance use
disorder challenges, without engaging people who have lived
experience. They have a unique ability to connect people to
care, and we want to support that.
The licensure issue that you raise, I suspect, is a state
by state issue. Prior to this role, I was the Human Services
Commissioner in New Jersey. We didn't experience that issue
there. But I will commit to you, if you are seeing that in
other places, Miriam and I want to be vocal and help address
those issues because we want peers to be part of the solution.
Senator Kaine. Excellent. A related topic that I want to
ask about is folks who are incarcerated. So 2 million people in
the United States, 25,000 in Virginia. Of this population,
about two-thirds have a substance use disorder history, often a
current challenge, and about one-quarter of those have opioid
use disorders.
The data shows that folks who receive treatment, including
medication assisted treatment, are more likely to engage in
post-conviction--post-release treatment and to stay in
treatment longer.
There is challenges with medication assisted treatment in
prisons and jails. What might we do to enable people to get
this kind of treatment that is going to help them while they
are incarcerated, but more particularly when they are no longer
incarcerated?
Ms. Delphin-Rittmon. Yes, thank you for that question. And
such an important area that individuals who are connected to
the justice system get connected to services and supports. So
SAMHSA has a drug court initiative and grants which help to
divert individuals from further involvement in connection with
the justice system and into behavioral health treatment.
Individuals are then able to get connected to medication
assisted treatment or other services and supports that they
need. So that is one initiative. I think diversion programs
really make a difference in terms of connecting people to care.
But also In Reach Programs. So programs that connect people to
services and supports prerelease, and those programs can help
to ensure----
Senator Kaine. How about particularly the issue of
medication assisted treatment for those who are incarcerated?
Ms. Delphin-Rittmon. Yes. So we are supporting a number of
prisons and providing technical assistance around administering
buprenorphine or other forms of MAT within criminal justice
settings. So we have done some technical assistance there. And
so it is--that is an important area as well. So for individuals
that are in prison for them to get connected to MAT as well.
Senator Kaine. I have one last question that I want to
raise. The Committee was very helpful in getting a bill passed
that President Biden signed last week, called the Lorna Breen
Health Care Provider Protection Act, which was to try to
provide mental health assistance to our frontline health care
workers who have had a lot of challenges even before COVID and
in particularly since COVID.
I was thinking about that bill and talking with the Breen
family when we were at the bill signing last Friday, I started
to think about other parts of our workforce who have really had
challenges during COVID. And a friend of mine said, what about
last responders? And I said, I haven't heard that phrase, what
do you mean by that? And talking about people who work in
nursing homes and long term care facilities where the illness
and death tolls have been extremely high.
Often these workers are paid very little. These are some of
the, you know, lowest paid workers in our system, and yet they
have seen and experienced themselves, many of them have gotten
sick and died, too. What have you seen with our long term care
workforce in COVID, and how might we approach this issue of
mental health resources for them?
Ms. Johnson. I would say, thank you, Senator, for your
leadership on this issue and to the Chair as well. We were with
American Rescue Plan resources able to do $103 million in
awards to 45 grantees to support health care provider
resilience and help reduce burnout.
As part of that, one of those awardees is a Technical
Assistance Center, which we are hoping to leverage all the
learnings from this work so that it is not just the 44 grantees
and the Technical Assistance Center that get the benefit of
those resources, but that we can help health care providers
across the country in addressing this issue.
But you raise a very important point about frontline long
term care workers who have been heroes throughout the pandemic,
and I look forward to working with you on ways that we can
address their mental health needs going forward.
Senator Kaine. Great. Thank you. Thank you, Chair Murray.
The Chair. Thank you. Very, very good point. That concludes
our hearing today. And I want to thank all of our colleagues
and all of our witnesses, Assistant Secretary Delphin-Rittmon,
Administrator Johnson, Director Gordon, and Director Volkow.
Really important hearing and appreciate all of your thoughtful
input.
For any Senators who wish to ask additional questions,
questions for the record will be do in 10 business days, April
6th at 5 p.m.. And the Committee will next meet Tuesday, March
29th in 430 Dirksen for a hearing on how we can strengthen
families' finances and improve their retirement security. With
that, the Committee stands adjourned.
QUESTIONS AND ANSWERS
Response by Miriam E. Delphin-Rittmon to Questions From Senator Casey,
Senator Baldwin, Senator Hickenlooper, Senator Murkowski, Senator
Braun, and Senator Tuberville
SENATOR CASEY
Question 1. There are more than 26 million grandfamilies
and kinship families in the United States who are at a higher
risk of experiencing challenges related to mental health and
substance use disorder The pandemic has exacerbated the
difficulties that many of these families face, and more than
200,000 children have been orphaned by COVID-19, losing at
least one parent or primary caregiver to the disease The
Advisory Council to Support Grandparents Raising Grandchildren,
established by the Supporting Grandparents Raising
Grandchildren (SGRG) Act (Public Law 115-116), has emphasized
the importance of addressing the trauma experienced by
grandfamilies Page 3 of the SGRG Act Initial Report to Congress
notes that many children in need of homes have experienced
multiple adverse childhood experiences and require support
beyond what a kin or grandparent caregiver can provide Without
connections to publicly available assistance, grandfamilies and
kinship families may spend down their savings on services or go
without needed support The SGRG Act Initial Report to Congress
identifies awareness of and outreach to kin and grandparent
caregivers as a priority.
LQuestion 1(a). What, if any, systematic efforts have
been undertaken by the Biden administration to identify
(1) children who have been orphaned and now live with
multi-generational families and (2) the adults now
serving as caretakers?
LQuestion 1(b). What efforts are underway, or being
planned, to expand outreach to kinship families and
grandfamilies--including through schools and community
organizations--to connect them with information,
services, and supports? How can Congress support these
efforts?
Answer 1. SAMHSA is a member of the Administration for
Community Living's Recognize, Assistant, Include, Support, and
Engage (RAISE) Family Caregiving Advisory Council, which is
responsible for developing a national family caregiving
strategy The RAISE Family Caregiving Advisory Council delivered
its initial report to Congress on September 22, 2021 The report
outlines a review of the current state of family caregiving and
includes 26 recommendations on how the government and private
sector can better Recognize, Assist, Include, Support, and
Engage family caregivers, including grandparents.
LAnswer 1(a). SAMHSA also administers the Mental
Health Technology Transfer Center (MHTTC) Network and
National Child Traumatic Stress Network (NCTSN) These
entities have hosted webinars, developed resources, and
provided resources about trauma, grief, and loss
related to the pandemic.
LAnswer 1(b). MHTTC's training, technical assistance
products, and resources are all available online
(Responding to COVID-19 Grief, Loss, and Bereavement)
The site also includes a compilation of resources from
other reputable organizations.
The NCTSN has several resources to assist parents/
caregivers cope with trauma, guides for mental health providers
on family resilience, and other resources to promote
theoretical and practical perspectives on family resilience and
the clinical and research implications for children and
families who have experienced trauma The NCTSN has hosted and
issued the following webinars and fact sheets specifically
related to the COVID-19 pandemic:
LApplying Evidence-Based Treatments for Child
Traumatic Stress Reactions to COVID-19-Related Deaths
webinar and fact sheet.
LChild and Adolescent Traumatic Stress
Reactions to COVID-19-Related Deaths webinar and fact
sheet.
LGrief, Loss, and COVID-19 webinar.
LGrief, Loss, and COVID-19: Recommendations
for Supporting Children and Families webinar.
LHelping Children with Traumatic Separation or
Traumatic Grief Related to COVID-19 fact sheet:
LThe Power of Parenting During the COVID-19
Pandemic: Mourning the Death of a Loved One fact sheet.
LSchools and COVID-19: Recommendations for
Supporting Students, Families, Educators and Staff
webinar.
LTrauma-Informed School Strategies during
COVID-19 fact sheet.
LSuicide, Substance Use, and COVID-19:
Recommendations for Supporting Children and Families
webinar.
LUnderstanding The Impact of COVID-19 Through
the Lens of the Core Concepts webinar.
LWhere Do we Go from Here? A Call to Action in
Response to the Impact of COVID-19.
Finally, SAMHSA administers multiple school-based mental
health and early childhood grant programs, in which teachers,
healthcare professionals, families, and community members are
trained to identify, screen, and assess children and youth who
are experiencing distress (including grief and loss) and ensure
that they receive the services that they need These programs
include the Infant and Early Childhood Mental Health
Consultation, Project LAUNCH (Linking Actions to Unmet Needs of
Children), and Project AWARE (Advancing Wellness and Recovery)
SAMHSA's Mental Health Awareness Training program provides
mental health literacy to teachers, school personnel, first
responders, and other important community members so children
can be connected with needed supports and services, such as
when a child has experienced a familial loss.
All too often, when someone has a mental health crisis, 9-
1-1 is called and law enforcement arrives, putting both the
person having the crisis and police officers in situations they
should not be expected to be in My Human-services Emergency
Logistic Program (HELP) Act would divert non-criminal, non-
fire, and non-medical emergency calls from 9-1-1 to state and
regional 2-1-1 or 9-8-8 systems to address both immediate and
longer-term needs.
Question 2. What is being done or needs to happen to
support the 2-1-1 and 9-8-8 system in being able to handle
mental health and substance use crisis calls that do not
require law enforcement and would benefit from human service
professionals? How is SAMHSA working to coordinate the two
systems?
Answer 2. In most states, the 211 system provides health
and social service assistance information and referrals At the
same time, 988 crisis counselors will provide support for
people in suicidal crisis, mental health or substance use
crisis, or any other kind of emotional distress in the very
moments they need it most While generally being different in
scope, these systems need to be aligned, and in many cases,
local Lifeline centers also respond to 211 contacts That is
why, for example, SAMHSA partnered with the National
Association of State Mental Health Program Directors to publish
988 Playbooks, such as the playbook for Lifeline Contact
Centers, which provides examples of what a solidified
relationship between a contact center and 211 service may look
like Ultimately, we envision that 988 crisis centers will need
to continue to coordinate with 211 and other warmlines This
will help ensure an all-inclusive approach regardless of which
number a person may use first.
SAMHSA's Minority Fellowship Program (MFP) aims to reduce
health disparities and improve behavioral health outcomes for
racial and ethnic minority populations Grants through this
program increase the number of professionals who can support
patient-centered care for underserved populations with mental
health or substance use disorders.
Question 3. How has the Minority Fellowship Program (MFP)
worked to address child and adolescent mental health in
minority populations, and how many child and adolescent
psychiatrists or residents are currently supported through the
program?
Answer 3. Through national behavioral health professional
organizations (American Academy of Addiction Psychiatry;
American Association for Marriage and Family Therapy; American
Nurses Association; American Psychiatric Association; American
Psychological Association; Council on Social Work Education;
NAADAC: The Association for Addiction Professionals; and
National Board for Certified Counselors and Affiliates),
SAMHSA's Minority Fellowship Program (MFP) assists people who
seek doctoral-and master's-level degrees and plan to work to
improve behavioral health outcomes for minority communities The
program increases behavioral health practitioners' knowledge of
issues related to prevention, treatment, and recovery support
for mental illness and drug/alcohol addiction among racial and
ethnic minority populations, including children and adolescents
Each professional organization supports their fellows in
addressing youth mental health by providing networking
opportunities with mentors who specialize in that area, hosting
webinars, guest lectures, virtual simulations, additional
readings, and trainings One professional organization, the
American Association for Marriage and Family Therapy, has
developed its MFP-Master's program with a goal to increase the
number of culturally competent marriage and family therapists
whose specialty will be racial and ethnic minority youth and
adolescents as they transition into adulthood.
The program also seeks to encourage more racial and ethnic
minorities to join the behavioral health workforce, which in
turn will help address child and adolescent mental health in
minority populations Racial and ethnic minorities make up more
than 28 percent of the Nation's population, while less than 20
percent of the behavioral health workforce consists of racial
or ethnic minorities The relative scarcity of professionals who
are from culturally and linguistically diverse backgrounds
constitutes a workforce issue that contributes to the current
disparities in quality of care and access to behavioral health
treatment.
Currently, the MFP is supporting 26 psychiatric residents
(through the American Psychiatric Association) who plan to
pursue the child and adolescent psychiatric sub-specialty The
MFP is also supporting nearly 150 other healthcare
professionals (nurses, psychologists, counselors, social
workers, and therapists) who plan to pursue work in child and
adolescent mental health.
SENATOR BALDWIN
Question 1. 988 and State Fees:. In 2019, I introduced the
bipartisan National Suicide Hotline Designation Act, which was
signed into law in 2020 Converting from the existing ten-digit
number to 988 will make it easier for Americans to get the help
they need, but I'm concerned that states may not be ready to
respond to calls when the new dialing code becomes available.
LQuestion 1(a). How many states have enacted
service fees to provide the additional state funding
needed to support 988?
LQuestion 1(b). Given that many states will
not enact services fees, what information is SAMHSA
making available to states regarding additional options
for funding 988?
Answer 1. As you mention, the National Suicide Hotline
Designation Act gave states the ability to enact new
telecommunications fees to financially support 988 operations,
yet very few states have done this so far As of March 2022,
four states have passed legislation creating a 988-cell phone
fee.
Success of 988 will rest heavily upon state, territorial
and local leadership in leveraging the resources already
available, in addition to making new investments That is why
SAMHSA has awarded nearly $105 million in grant funding to 54
States and territories in advance of the transition of the
National Suicide Prevention Lifeline to help strengthen our
crisis care infrastructure.
We will continue to work in close partnership with them to
meet the crisis care needs of people across our Country For
example, there are several existing Federal resources that can
be leveraged to support 988 implementation Examples from SAMHSA
include the crisis set-aside through the Community Mental
Health Services Block Grant as well as funding through the
Certified Community Behavioral Health Clinic (CCBHC) program
Last, SAMHSA, in coordination with the National Association of
State Mental Health Program Directors and others, issued 988-
related playbooks for states and other entities to help states
transition to 988.
Question 2. Performance Metrics:. In order to make sure
that 988 works, we need goals and metrics in place to make sure
that calls and texts are answered, and answered quickly.
LQuestion 2(a). Right now, what percentage of
calls to the National Suicide Prevention Lifeline are
answered within 20 seconds? What is SAMHSA's goal for
the percentage of calls answered within 20 seconds once
988 goes live this summer?
LQuestion 2(b). What percentage of texts are
answered in less than 5 minutes? What is SAMHSA's goal
for the percentage of texts answered within 5 minutes
once 988 goes live this summer?
LQuestion 2(c). How is SAMHSA conducting
oversight of the administration of 988 and what tools
does SAMHSA have at its disposal in the event that
SAMHSA's established performance metrics are not met?
Answer 2(a),(b),(c). With almost 200 crisis call centers
across the U.S., the Lifeline has increased the size of its
network, expanded training, and improved response rates since
it began in 2005--yet demand continues to exceed capacity For
years, this network has been massively underfunded and under-
resourced In the past, this patchwork of local, state, and
private funding for the network has fallen way short of meeting
the need Despite the tireless work of crisis call centers
across the country, the network has not been able to keep pace
with demand.
Given the extent to which the Lifeline has been
historically under resourced, current demand significantly
exceeds available capacity The 988 Appropriations Report
highlighted that Lifeline capacity was only sufficient to
address 85 percent of calls, 56 percent of texts, and 30
percent of chats.
These deeply challenging statistics were one of the driving
forces for investing 10 times more in funding in fiscal year
2022 than fiscal year 2021 to support crisis call center
services across our Country we are hopeful that these
investments will play a meaningful role in driving higher
answer rates No call, text, or chat should ever go unanswered
That said, key metrics of success will include data around the
number of calls, chats, and text received and answered by the
Lifeline, and the average speed to answer, among other things.
In terms of specific answer rates, in February 2022, the
Lifeline answered 81 percent of incoming calls The average
speed to answer was 53 seconds In June 2022, the Lifeline
answered 83 percent of incoming calls The average speed to
answer was 45 seconds These statistics represent a roughly 13
percent increase in calls answered and a roughly 15 percent
improvement in average speed to answer in the last 4 months The
long-term aspirational targets for response are answering 95
percent of all contacts within 20 seconds, consistent with
standards for 911 and the Veterans Crisis Line While SAMHSA
expects recent investments to continue improving system
performance over the coming months, it will take time and
continued investments to reach these long-term targets Since
calls are first routed locally, overall network performance
will rest heavily on the pace of state crisis call center
capacity increases.
Additionally, in February 2022, the Lifeline answered 44
percent of incoming texts The average speed to answer for these
answered texts was 29 minutes and 43 seconds However, In June
2022, the Lifeline answered 96 percent of incoming texts The
average speed to answer for these answered texts was 6 minutes
and 47 seconds These statistics represent a roughly 200 percent
increase in texts answered and a roughly 400 percent
improvement in average speed to answer in the last 4 months
These significant improvements in system performance were
driven mainly by the influx in Federal funding, which began to
reach centralized chat/text centers in March 2022 The long-term
aspirational targets for response are answering 95 percent of
all contacts within 20 seconds, consistent with standards for
911 and the Veterans Crisis Line While SAMHSA expects recent
investments to continue improving system performance over the
coming months, it will take time and continued investments to
reach these long-term targets.
Over the course of several decades, 911 has developed
sufficient capacity to address 95 percent of calls within 20
seconds Robust and sustainable funding across all levels of
government will be essential in building toward this vision.
To help steer us toward these goals, SAMHSA has a number of
ways to oversee network performance, both through the
Cooperative Agreement with the Lifeline administrator and
directly with states and territories through the 988 state and
territory grant program There are regular reporting
requirements, and SAMHSA will engage in corrective action
planning processes in the event performance is off track or not
meeting expectations.
We are grateful for the support Congress provided for the
Lifeline so far However, the success of 988 will also rest
heavily upon state and local leaders, as well as local crisis
centers in the Lifeline network, as we work in concert with
them to meet the crisis care needs of people across our
Country.
SENATOR HICKENLOOPER
Suicide Prevention
When I was Governor of Colorado, we passed a suicide
prevention plan modeled on the Zero Suicide approach.
Studies have shown that about 45 percent of those who die
by suicide saw a primary care provider in the month before
their death.
The idea behind this approach is that no person slips
through the cracks.
The approach, which has been adopted in many communities
across the country, has shown significant reductions in
suicides among those receiving care.
Question 1. How can we incorporate on-the-ground examples
like these, to our national approach to the growing mental
health crisis?
Answer 1. SAMHSA oversees the Zero Suicide grant program,
which funds a comprehensive, multi-setting approach to suicide
prevention in health systems and tribes The purpose of this
program is to implement suicide prevention and intervention
programs for individuals who are 25 years of age or older by
systematically applying evidence-based approaches to screening
and risk assessment, developing care protocols, collaborating
for safety planning, providing evidence-based treatments,
maintaining continuity of care during high-risk periods, and
improving care and outcomes for such individuals who are at
risk for suicide being seen in health care systems.
Zero Suicide is an effective strategy in the national
approach to the growing mental health crisis The model
addresses goals 8 and 9 of the National Strategy for Suicide
Prevention (NSSP) goals: (8) for suicide prevention to become a
core component of health care, and (9) to promote and implement
effective clinical and professional practices for assessing and
treating those identified as being at risk for suicidal
behaviors.
In fiscal year 2021, SAMHSA supported the continuation of
30 Zero Suicide continuation grants and a new cohort of 10 Zero
Suicide grants The fiscal year 2023 President's Budget request
for the Zero Suicide program is $232 million This funding will
support 25 Zero Suicide continuation grants and 21 new Zero
Suicide grants Continuing the Zero Suicide program is an
important part of our Nation's mental health strategy and we
look forward to continuing to see promising results come from
more grantees.
988 Implementation and Staffing Issues.
988, the Suicide Prevention Lifeline, can be exactly that
for people in crisis, a lifeline.
We are looking forward to the official transition to the
three-digit 988 number this summer.
It is critical that as 988 is stood up, we support
increased staffing at the crisis centers that get the phone
calls we know these crisis centers have been stretched quite
thin as it is.
We passed critical investments in the recent Omnibus bill
to further support the transition to 988.
Question 2. How is SAMHSA prioritizing this investment to
support a robust and resilient workforce to adequately
implement the 988 Lifeline?
Answer 2. To support transition to 988, SAMHSA
significantly increased--by over 10 times--the Federal
Government's contribution to the Lifeline in fiscal year 2022.
SAMHSA announced a $282 million investment to support 988
efforts across the country to shore up, scale up and staff up
the lifeline Most of these funds are going to Lifeline crisis
centers around the country to ensure crisis centers that will
be answering 998 have the staff that they need, SAMHSA issued a
grant opportunity that will provide direct workforce support
for state, regional, territorial, and tribal call centers that
are part of the Lifeline 988 Network.
The President's Fiscal Year 2023 budget will build on this
investment with an additional nearly $700 million to staff up
and shore up local crisis centers while also building out the
broader crisis care continuum: someone to call, someone to
respond, and somewhere for every American in crisis to go.
Preparing for 988 is an imperative for SAMHSA and all of
HHS--we are steadfast in our planning efforts A smooth
transition to national access to the Lifeline via 988 in July
2022 is SAMHSA's top priority.
Upskilling
We are facing a constantly growing need for behavioral
health providers, particularly in rural and underserved areas.
During a recent Subcommittee hearing that I Chaired on the
health care workforce, we heard from Dr. Margaret Flinter with
the National Nurse Practitioner Residency and Fellowship
Training Consortium.
The Consortium is using innovative approaches to train
Nurse Practitioners in behavioral health.
Question 3. How can we further support the inclusion of
behavioral health within primary care settings?
Answer 3. SAMHSA administers the Promoting Integration of
Primary and Behavioral Health Care (PIPBHC) program The purpose
of the PIPBHC program is to promote full integration and
collaboration in clinical practice between primary and
behavioral healthcare; support the improvement of integrated
care models for primary care and behavioral health care to
improve the overall wellness and physical health status of
adults with a serious mental illness (SMI) or children with a
serious emotional disturbance (SED); and promote and offer
integrated care services related to screening, diagnosis,
prevention, and treatment of mental and substance use
disorders, and co-occurring physical health conditions and
chronic diseases In fiscal year 2021, the PIPBHC grant program
served over 12,028 consumers and provided training to over
9,000 individuals in the mental health and related workforce.
SAMHSA also funds a technical assistance center, the
National Center of Excellence for Integrated Health Solutions
(CIHS) CIHS offers technical assistance and training for
communities, individual practitioners, providers, and states on
evidence-based and effective strategies to address the
integration of primary and mental health care for individuals
with mental disorders or co-occurring mental and substance use
disorders In 2020, CIHS provided training to 23,880 individuals
in the mental health and related workforce.
Congress can further support the inclusion of behavioral
health within primary care settings by continuing to authorize
and fund the PIPBHC program and National Center of Excellence
for Integrated Health Solutions The President's fiscal year
2023 Budget request is $103 million The proposed funds increase
will fund a new cohort of 37 PIPBHC grants and continue to fund
the National Center of Excellence for Integrated Health
Solutions.
SENATOR MURKOWSKI
Question 1. Fentanyl Overdose Deaths: Overdose deaths from
fentanyl are on the rise, including in Alaska, which saw deaths
triple from 2019 to 2020 The loss of a loved one impacts
friends, families, and communities who continue to bear the
trauma of addiction long after someone passes I have heard
directly from Alaskans who have lost their children, and are
now dedicating their lives to prevent future overdose deaths
from fentanyl.
Unfortunately, this drug has a high lethality that can harm
both the user and responder I was horrified to learn about five
young men and women who overdosed on fentanyl-laced cocaine a
couple weeks ago while on spring break in Florida What is
particularly distributing, is that two of these young men
didn't consume the substance, but were performing CPR on their
friends when they went into respiratory arrest They were
exposed to fentanyl while they were performing mouth-to-mouth
resuscitation.
Congress needs to take action before fentanyl claims one
more American we need to start by educating people about the
lethality of fentanyl and the risk of contaminated drugs.
LQuestion 1(a). Dr. Delphin-Rittmon, I understand that
SAMHSA is broadly tasked with addressing substance use,
but what action is SAMHSA taking to educate Americans,
particularly at-risk youth, on the lethality of
fentanyl and the dangers of contaminated drugs?
Answer 1. On April 7, 2021, SAMHSA and CDC issued guidance
aimed at reducing drug overdose deaths, specifically that
certain Federal funding (eg, SAMHSA's State Opioid Response--
SOR grant) may be used to purchase rapid fentanyl test strips
(FTS) Providing tools to identify the presence of fentanyl
combined with referrals to evidence-based treatment options
complements SAMHSA's daily work to reduce the impact of
substance use disorders and mental illness on communities FTS
save lives by allowing individuals to rapidly determine the
presence of a lethal substance in their drug supply, while also
facilitating education on the harms of fentanyl and methods to
avoid it.
Additionally, the Drug Abuse Warning Network reports
fentanyl cases across various demographics and monitors trends
in the hospitals recruited SAMHSA is planning to use this
information to educate the public on fentanyl and the risks
associated with fentanyl use.
In December 2021, SAMHSA issued a Notice of Funding
Opportunity for a new Harm Reduction Grant Program, which will
help increase access to a range of community harm reduction
services and support harm reduction service providers as they
work to help prevent overdose deaths and reduce health risks
often associated with drug use Purchase of FTS for community
distribution are an allowable expense.
More broadly, SAMHSA has taken concrete steps to educate
providers and those who misuse substances on the harms of
fentanyl Through this, the treatment community and providers
receive education on the impact of fentanyl, empowering them to
educate individuals on the harms of synthetic opioids and to
provide evidence-based advice on avoiding exposure to this
substance This work is augmented through cross-agency
collaboration SAMHSA representatives regularly meet with other
agencies to foster synergy in the expansion or improvement of
SUD treatment, and how public education might be augmented.
SAMHSA also encourages the inclusion of robust curriculums
on substance misuse, addiction and treatment among all medical
and professional schools, and residency programs Robust
education on substance misuse is essential as it not only
normalizes discussions around substance misuse and treatment in
the provider's office, but it also reduces stigma and treatment
hesitancy A health workforce that is knowledgeable and skilled
in the treatment of SUDs means that there is no wrong door
through which an individual can seek treatment or information
about substance misuse.
Lastly, below are several training and technical assistance
resources on fentanyl which are available via the Prevention
Technology Transfer Centers and the Addiction Technology
Transfer Centers:
LFentanyl Test Strips: Fact Sheet--https://
pttcnetworkorg/centers/great-lakes-pttc/news/fentanyl-
test-strips-fact-sheet-now-available.
LFentanyl Test Strips: A Grassroots Harm
Reduction Strategy--https://pttcnetworkorg/centers/
great-lakes-pttc/product/fentanyl-test-strips-
grassroots-harm-reduction-strategy.
LCross-promotion of DEA press release--https:/
/pttcnetworkorg/centers/central-east-pttc/news/urgent-
press-release-and-public-safety-alert-issued-dea.
LDe-escalating the Opioid Crisis--An overview
of promising prevention strategies--https://
pttcnetworkorg/centers/northeast-caribbean-pttc/event/
de-escalating-opioid-crisis-overview-promising-
prevention.
LFentanyl Related Products and Events--https:/
/attcnetworkorg/centers/attc-network-coordinating-
office/fentanyl-resources.
Medication Assisted Treatment
Question 2. The Anchorage Daily News reported recently that
the U.S. has passed a ``never-before-seen milestone'' in losing
more than 100,000 Americans to drug overdoses in a year Sadly,
the CDC reports that the number of drug overdoses in Alaska
rose by more than 45 percent as of June 2021 That's more than
double the rate of increase for the United States.
One treatment that we know is critical to stemming the
overdose crisis is medication that prevent withdrawal symptoms
and stem opioid cravings These medications, like buprenorphine,
can cut the risk of overdose death in half when a person starts
taking them But, outdated Federal laws and stigma are
restricting access to these life-saving medications I have
introduced the Mainstreaming Addiction Treatment Act with my
colleague, Senator Hassan, to help more Americans have access
to life-saving medication and eliminate burdensome Federal red
tape.
LQuestion 2(a). How is the administration supporting
expanding access to medications to treat substance use
disorder so they reach all communities in need?
Answer 2. Medications for Opioid Use Disorder (MOUD) save
lives, and we have seen the importance of MOUD during the
COVID-19 Public Health Emergency (PHE) To expand and improve
access to MOUD, SAMHSA has approved 81 additional opioid
treatment programs (OTPs) since August 2021 and during the PHE,
it issued guidance related to flexibilities in the provision of
unsupervised doses of methadone, and in the provision of
buprenorphine through telehealth by OTPs The response from
SAMHSA's monthly meetings with the State Opioid Treatment
Authorities has been overwhelmingly positive These entities as
well as individual Opioid Treatment programs have reported
greater patient and provider satisfaction The lack of increased
reports of methadone overdoses or diversion further
demonstrates that these flexibilities are safe and that they
promote patient centered paradigms of care that enhance
engagement in treatment and promote recovery.
Moreover, HHS published new buprenorphine practice
guidelines that have expanded access to buprenorphine by
exempting certain practitioners from certification requirements
related to training, counseling, and other ancillary services
Indeed, implementation of these guidelines has seen the
addition of 12,822 waivered providers since April 28, 2021,
almost double the number of practitioners who were certified
during the same timeframe in the prior year In all, 22,561 more
providers were certified in the last year, bringing the total
number of waivered prescribers to 121,111 (as of March 2022)
This further expands access to buprenorphine with SAMHSA also
supporting prescribers through technical assistance programs
and continued production of evidence-based guides and
resources.
We further support access through the expansion of SAMHSA's
grant programs and the recent announcement that funds for the
State Opioid Response (SOR), Substance Abuse Block Grant
(SABG), and Medication Assisted Treatment for Prescription Drug
and Opioid Addiction (MAT-PDOA) could be used to purchase
mobile treatment units This reduces geographic disparity and
promotes innovation in the delivery of care Evaluation efforts
also allow for an understanding of what is working, and what
requires innovation SAMHSA is engaged in an HHS-wide evaluation
of the revision to the buprenorphine practice guidelines, and
this expansive undertaking will assess disparity in the
provision of treatment as well as factors that support the
provision of care to those with substance use disorders, or
hinder treatment activities Such information will allow for
data driven decision making that will facilitate SAMHSA's work
moving forward.
SAMHSA's grant programs such as the State Opioid Response
(SOR), Tribal Opioid Response (TOR) program, and Medication
Assisted Treatment for Prescription Drug and Opioid Addition
(MAT-PDOA) seek to address urgent, unmet, and emerging
substance use disorder treatment and recovery support service
capacity needs that remain a critical issue for the Nation The
SOR program provides resources to states, territories, and
tribes to continue to enhance the development of comprehensive
strategies focused upon preventing, intervening, and promoting
recovery from issues related to opioid misuse, and increasingly
stimulant misuse The TOR program provides dedicated resources
for this to Indian Tribes and Tribal organizations Both of
these programs aim to address the overdose crisis by increasing
access to the three FDA-approved medications for the treatment
of opioid use disorder, reducing unmet treatment need, and
reducing opioid-related overdose deaths through the provision
of prevention, harm reduction, treatment, and recovery
activities for OUD (including prescription opioids, heroin and
illicit fentanyl and fentanyl analogs) and stimulant use
disorder as so elected by states Since the SOR program began,
approximately 971,372 patients have received treatment
services, including 409,086 who have received an FDA-approved
MOUD Of that number, 166,091 received methadone, 218,518
received buprenorphine, and 24,477 received naltrexone Through
the SOR program, 686,998 patients received recovery support
services.
Similarly, the MAT-PDOA program for community-based
organizations addresses treatment needs of individuals who have
an OUD by expanding/enhancing treatment system capacity to
provide accessible, effective, comprehensive, coordinated/
integrated, and evidence-based MOUD and recovery support
services Medications are often combined with evidence-based
psychosocial interventions tailored to an individual's needs
This approach is a safe and effective strategy for decreasing
the frequency and quantity of opioid misuse and reducing the
risk of overdose and death Recovery support services include
linking patients and families to social, legal, housing, and
other supports to improve retention in care and increase the
probability of positive outcomes.
SAMHSA also subsidizes recovery housing as one component of
the SUD treatment and recovery continuum of care through
various grant programs Recovery houses are safe, healthy,
family like substance-free living environments that support
individuals in recovery from SUD SAMHSA supports recovery
houses that do not prohibit prescribed medications taken as
directed by a licensed practitioner, such as pharmacotherapies
specifically approved by the Food and Drug Administration (FDA)
for treatment of OUD as well as other medications with FDA-
approved indications for the treatment of co-occurring health
conditions Additionally, recovery housing facilities must have
mechanism(s) in place in their jurisdiction to assure that the
funding they receive supports and provides clients access to
evidence-based treatment, including all forms of medication for
opioid use disorders, in a safe and appropriate setting SAMHSA
funding recipients must also confirm how recovery housing
supports appropriate and legitimate facilities (eg, state or
other credentialing or certification or an established or
recognized model).
Last, in order to further the evidence base, the
administration supports the CDC to conduct a study of MOUD that
will examine how health and other patient outcomes vary across
the three types of medications used in MOUD and for patients
receiving counseling only treatment Patient, site, and provider
characteristics will also be examined to determine how they may
impact health and other outcomes
Infant and Early Childhood Mental Health
Question 3. The first years of life are an incredible
opportunity to promote positive mental health for babies, and
health and well-being during this time period affects future
learning, behavior and health.
LQuestion 3(a). Have you seen a marked impact by
Federal investment in infant and early childhood mental
health (IECMH)?
Answer 3. SAMHSA's Infant and Early Childhood Mental Health
Consultation (IECMH) program aims to improve outcomes for
children, from birth to 12 years of age, who are at risk for,
show early signs of, or have been diagnosed with a mental
illness, including a serious emotional disturbance IECMHC has
been shown to improve children's social skills and emotional
functioning, promote healthy relationships, reduce challenging
behaviors, reduce the number of suspensions and expulsions,
improve classroom quality, and reduce provider stress, burnout,
and turnover.
Grantees improve outcomes for children through service
provision to children and families, mental health consultation
to early childhood programs such as Head Start, and training
early childhood providers and clinicians to identify and treat
behavioral health disorders of early childhood, including in
children with a history of in utero exposure to substances such
as opioids, stimulants or other drugs that may impact
development, and through the implementation of evidence-based
multigenerational treatment approaches that strengthen
caregiving relationships.
In fiscal year 2021, grantees accomplished the following:
LTrained 4,003 clinicians and early childhood
providers on evidence-based mental health treatments
for infants and young children.
LScreened and assessed 9,883 young children
for developmental and behavioral disorders (including
screening parents for behavioral health issues such as
depression and substance misuse).
LReferred 3,551 children and parents for
treatment.
LProvided infant and early childhood mental
health treatment (including multigenerational
therapies) to 5,009 children and families
Suicide Screening in the Emergency Department
A recent CDC report on emergency department visits for
people age 12-25 found an over 50 percent increase visits for
suspected suicide attempts during early 2021 This underscores
the devastating mental health impact of the pandemic on our
youth and highlights yet another way that COVID-19 has strained
our hospitals and medical staff.
I introduced a bill, the Effective Suicide Screening and
Assessment in the Emergency Department Act, to improve the
screening and treatment of patients in hospital emergency
departments who are at high risk for suicide It will make sure
that we can better identify our most vulnerable mental health
patients so they do not slip through the cracks when they are
treated in hospitals, and make sure hospitals have the
resources they need to provide these critical services
LQuestion 4. What is the need for improved suicide
screening protocols in the Nation's emergency rooms?
LQuestion 4(a). Do you support efforts to bolster the
resources available to emergency rooms so they can
enhance their screening for high-risk suicide patients?
Answer 4. Screening is a key component in SAMHSA's Zero
Suicide grant program The Zero Suicide program funds a
comprehensive, multi-setting approach to suicide prevention in
health systems and tribes, including in emergency departments
The purpose of this program is to implement suicide prevention
and intervention programs for individuals who are 25 years of
age or older by systematically applying evidence-based
approaches to screening and risk assessment, developing care
protocols, collaborating for safety planning, providing
evidence-based treatments, maintaining continuity of care
during high-risk periods, and improving care and outcomes for
such individuals who are at risk for suicide being seen in
health care systems In fiscal year 2021, SAMHSA supported the
continuation of 30 Zero Suicide continuation grants and a new
cohort of 10 Zero Suicide grants.
As you correctly noted, suicide risk screening is
particularly important in emergency departments A multi-site
research study found that suicide risk screening, discharge
resources, and brief interventions resulted in a 5 percent
decrease in the proportion of patients who attempted suicide in
the year after the visit and a 30 percent decrease in the
number of suicide attempts in that period Screening tools
validated for use in emergency departments include the Ask
Suicide-Screening Questions screening tool and Patient Safety
Screener.
In addition to the Zero Suicide grant program, the Suicide
Prevention Resource Center (funded under a grant by SAMHSA) has
publicly available resources on suicide screening and
assessment.
The fiscal year 2023 President's Budget request for the
Zero Suicide program is $232 million This funding will support
25 Zero Suicide continuation grants and 21 new Zero Suicide
grants.
FASD
During COVID, we have seen a sharp rise in substance misuse
specifically alcohol, the most widely used and misused
substance Unfortunately, a landmark NIH study in 2018
established that 1 in 20 school-aged children are affected by
fetal alcohol spectrum disorders--FASD Due to its significance
and status as an overlooked disability that includes
debilitating stigma, I introduced S 2238, the FASD Respect Act
My legislation establishes common standards of care and
increases the capacity to manage FASD in medical and mental
health settings.
LQuestion 5. How can we address the social and
environmental factors that contribute to prenatal
alcohol exposure and reduce the traumas FASD creates
for individuals and families?
LQuestion 5(a). What steps are being taken by the
administration to provide more education and training
on FASD? How can stigma be lessened for individuals
living with behavioral health conditions, like FASD?
Answer 5. SAMHSA participates in the Federal Interagency
Coordinating Committee on FASD (ICCFASD) The mission of the
ICCFASD is to enhance and increase communication, cooperation,
collaboration, and partnerships among disciplines and Federal
agencies to address health, education, developmental
disabilities, alcohol research, health and social services and
justice issues that are relevant to disorders caused by
prenatal alcohol exposure This Committee fosters improved
communication, cooperation, and collaboration among disciplines
and Federal agencies that address issues related to prenatal
alcohol exposure The Committee also coordinates the activities
of all Federal agencies who seek to solve the challenges posed
by FASD, such as stigma.
Additionally, SAMHSA administers two programs that support
screening of pregnant and postpartum women, minor children of
the mothers, and other non-residential adults or family members
who are included in treatment planning, age 18 years or older,
for alcohol misuse or Fetal Alcohol Spectrum Disorders (FASD).
One program works to expand comprehensive treatment,
prevention and recovery support services for women and their
children in residential substance use treatment facilities,
provide services for non-residential family members of both the
women and children, and support evidence-based parenting and
treatment models including trauma-specific services in a
trauma--informed context.
The other pregnant and postpartum women program, which is a
pilot, is meant to support family based services for pregnant
and postpartum individuals with a primary diagnosis of a
substance use disorder, including opioid disorders, help state
substance abuse agencies address the continuum of care,
including services provided to individuals in nonresidential-
based settings, and promote a coordinated, effective and
efficient state system managed by state substance abuse
agencies encouraging new approaches and models of service
delivery.
SAMHSA also has a Screening, Brief Intervention and
Referral to Treatment (SBIRT) Program that aims to implement
screening, brief intervention, and referral to treatment
services for children, adolescents, and/or adults in primary
care and community health settings (eg, health centers,
hospital systems, health maintenance organizations, preferred-
provider organizations, federally Qualified Health Care
systems, behavioral health centers, pediatric health care
providers, Children's Hospitals, etc) with a focus on screening
for underage drinking, opioid use, and other substance use
There are several grantees focused on SBIRT with pregnant and
postpartum women and women of childbearing age The SBIRT
programs in this area are targeted at reducing the use of
alcohol and other drugs during pregnancy to reduce the
incidence of FASD and increase child and maternal health.
SENATOR BRAUN
In December 2020, a GAO report found that as of May 2020
only 6 percent of U.S. counties have all levels of substance
use disorder treatment available--that includes outpatient,
residential, and hospital inpatient services Even more
unsettling: nearly one-third of counties had no levels of
treatment available at all GAO concluded that SAMHSA's lack of
reliable reporting data contributes to these persistent gaps in
the treatment system.
Question 1. What concrete actions is SAMHSA taking to
address these issues?
Answer 1. SAMHSA has been focused on expanding access to
medication for opioid use disorder (MOUD) by promoting and
supporting opioid treatment programs (OTP) services and
increasing the number of practitioners able to address opioid
use disorder (OUD) in their practices Since March 2021, over
22, 500 practitioners were certified (as of the end of March
2022), and since August 2021, 81 more OTPs were added to the
treatment system To target these efforts, SAMHSA has been
mapping services and highest areas of need to enable greater
focus on local needs, using a regional approach to identify
needs and plan for support.
To help overcome geographic disparity in the provision of
comprehensive substance use disorder (SUD) treatment, since
November 2021 SAMHSA has allowed mobile treatment units to
provide OTP services, and it has been fostering telehealth
activities and assessing ways in which the COVID-19 Public
Health Emergency flexibilities might be made permanent ,
including work to review 42 CFR part 8 to make permanent some
regulatory flexibilities for opioid treatment programs to
provide extended take home doses of methadone SAMHSA also
promotes innovative models of care through the State Opioid
Response grant In addition, SAMHSA has been focusing on
expanding SUD education and supports for providers seeking to
treat OUD in their offices It has augmented provider education
through the Provider Clinical Support System, fostering the
development of a robust and responsive workforce that is
capable of providing compassionate and evidence-based care to
vulnerable individuals.
To further align services with areas of need, SAMHSA is
engaged in evaluation of the revised buprenorphine practice
guidelines This revision removed the education and attestation
requirements for those wishing to treat up to 30 patients with
buprenorphine As part of this evaluation effort, we will assess
geographic disparity, prescribing practices and prescriber
barriers and facilitators in the provision of MOUD The
information underlying this evaluation is obtained from
existing data sets as well as voluntary provider surveys Such
information provides detailed insight into the provision of SUD
treatment across America, while not imposing a reporting burden
on providers.
SAMHSA is also working to augment its data collection and
evaluation practices This undertaking recognizes the need to
collect data that provides insight into the provision of
comprehensive SUD treatment across America, the impact of such
treatment, and emerging practices that should be fostered
through grant funding or further assessment It is also
important to consider ways to collect this data so that it
provides detailed information without imposing a burden on
providers or institutions.
Question 2. Prior to the COVID-19 pandemic, patients
typically had to travel to an opioid treatment program on a
daily or near-daily basis Studies show that opioid treatment
programs that took advantage of the methadone take-home
flexibility have experienced significant increases in the
number of patients receiving take-home doses and the number of
take-home doses per patient, without increases in diversion or
overdose Importantly, patients indicate they've benefited from
reduced travel time to opioid treatment programs while still
feeling they are receiving the care they need.
LQuestion 2(a). Given SAMHSA has already announced it
will extend the methadone take-homes flexibilities for
1 year post the public health emergency declaration,
does the agency plan to make this change permanent?
Answer 2. The 1-year extension of this flexibility was
designed to allow SAMHSA the opportunity to engage in processes
that will make this flexibility permanent SAMHSA has indicated
in the HHS Unified Agenda that it intends to issue a notice of
proposed rulemaking for this purpose.
SENATOR TUBERVILLE
Question 1. we know that one in four Americans reports
having been a victim of crime in the past 10 years, and half of
those were victims of a violent crime Most report receiving no
help in the aftermath Police, corrections leaders, and the
courts agree that untreated mental health or co-occurring
substance abuse disorders are core drivers of the cycle of
crime and that they lack the infrastructure to respond
appropriately.
LQuestion 1(a). What do you see as the individual and
societal impacts of untreated trauma as it relates to
mental health and substance use disorder?
Answer 1. Trauma is a common experience for adults and
children SAMHSA describes individual trauma as resulting from
``an event, series of events, or set of circumstances that is
experienced by an individual as physically or emotionally
harmful or life threatening and that has lasting adverse
effects on the individual's functioning and mental, physical,
social, emotional, or spiritual well-being''.
The effects of traumatic events can place a heavy burden on
individuals, families, and communities Although many people who
experience a traumatic event will go on with their lives
without noticeable lasting negative effects, others may have
difficulties and experience traumatic stress reactions.
Research has shown that traumatic experiences are
associated with both behavioral health and chronic physical
health conditions, especially those traumatic events that occur
during childhood Substance use (such as smoking, excessive
alcohol use, and drug use), addiction, and mental health
conditions (including depression, anxiety, or PTSD) have been
linked with traumatic experiences, as have asthma, stroke, and
heart disease Because its symptoms appear as other health
conditions, trauma can be overlooked in medical and behavioral
health assessments.
Although experiencing trauma may contribute to developing
risk factors for violence, it is important to note that the
majority of individuals who experience trauma do not engage in
violent crime \1\ However, the behavioral health concerns
associated with trauma can present challenges in relationships,
careers, and other aspects of life For this reason, SAMHSA
believes addressing trauma is an important part of effective
behavioral health care and an integral part of the healing and
recovery process SAMHSA addresses the impact of trauma on
individuals, families, and communities by leading the
Interagency Task Force on Trauma-Informed Care and overseeing
programs such as National Child Traumatic Stress Initiative
(NCTSI) and ReCAST (Resiliency in Communities after Stress and
Trauma).
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\1\ Daniel J Neller PsyD & John Matthew Fabian PsyD (2006) Trauma
and its contribution to violent behavior, Criminal Justice Matters,
66:1, 6-7, DOI: 101080/09627250608553387.
Question 2. Federal data shows that 37 percent of people
sentenced to prison, and 44 percent of people arrested and
jailed, have experienced a mental health issue At the same
time, we know that an estimated 1 in 10 police service calls
are responding to an untreated mental health issue Across the
country, we've seen community-based programs that seek to
divert individuals experiencing mental health issues, direct
individuals to treatment and resources, and do so in a way so
---------------------------------------------------------------------------
the police department does not have to be involved.
LQuestion 2(a). What is the Federal Government doing
to ensure that mental health emergencies are being
responded to appropriately, early on, before a
treatable illness becomes a safety issue?
Answer 2. There is, unfortunately, an inaccurate perception
that mental illness is a cause of violent crime, wherein in
actuality, people with mental illness are more likely to be
victims of violent crime than perpetrators \2\ Most people who
have mental illness are never violent toward others and
research has found only 3-5 percent of violent acts in the
United States are attributable to mental illness alone \3\
---------------------------------------------------------------------------
\2\ Desmarais SL, Van Dorn RA, Johnson KL, Grimm KJ, Douglas KS,
Swartz MS Community violence perpetration and victimization among
adults with mental illnesses Am J Public Health 2014 Dec;104(12):2342-9
doi: 102105/AJPH2013301680 Epub 2014 Feb 13 PMID: 24524530; PMCID:
PMC4133297
\3\ Swanson JW Mental disorder, substance abuse, and community
violence: an epidemiological approach In: Monahan J, Steadman H,
editors Violence and mental disorder University of Chicago Press;
Chicago: 1994 pp 101--136.
This bias extends to the criminal justice system, where
people with mental illness are over incarcerated and often
experience worse outcomes compared to the general population
People with serious mental illness (SMI) are often booked into
jail for non-violent, minor offenses \4\ Once in jail, these
individuals are incarcerated twice as long, and few receive
needed treatment Many of these situations could be diverted if
there was more awareness and resources available. \5\
---------------------------------------------------------------------------
\4\ Swanson JW, Frisman LK, Robertson AG, et al Costs of criminal
justice involvement among persons with serious mental illness in
Connecticut Psychiatr Serv 2013;64:630--7
\5\ https://bjsojpgov/content/pub/pdf/imhprpji1112pdf.
SAMHSA supports community-based programs that seek to
divert individuals experiencing mental health issues, direct
individuals to treatment and resources, and do so in a way so
the police department does not have to be involved One such
programs is the Behavioral Health Partnerships for Early
Diversion (BHP-ED) This grant program supports grantees in
establishing or expanding programs that divert adults with
serious mental illness or co-occurring mental and substance use
disorder from the criminal justice system to community-based
services prior to arrest and booking Early diversion programs
establish collaborative partnerships between law enforcement
and community providers Special consideration is given to
---------------------------------------------------------------------------
programs that support early diversion services for veterans.
There are certain periods when a subset of individuals with
serious mental illness may be at elevated risk for violence,
such as the period around first episode psychosis To best
support these individuals, SAMHSA oversees the Assisted
Outpatient Treatment Grant Program for Individuals with Serious
Mental Illness (AOT) program and the Assertive Community
Treatment (ACT) program AOT aims to reduce the incidence and
duration of psychiatric hospitalization, homelessness,
incarcerations, and interactions with the criminal justice
system while improving the health and social outcomes of
individuals with a serious mental illness (SMI) AOT facilitates
the delivery of community-based outpatient mental health
treatment services to individuals with SMI that are under court
order as authorized by state mental health statute.
------
Response by Carole Johnson to Questions From Senator Casey, Senator
Rosen, Senator Hickenlooper, Senator Murkowski, Senator Braun, and
Senator Tuberville
SENATOR CASEY
The National Health Service Corps (NHSC) programs help
expand the health care workforce in underserved areas,
including the workforce for mental health care services
Currently, the NHSC Loan Repayment Program (LRP) offers
behavioral health care clinicians loan repayment in exchange
for serving communities with limited access to care Programs
require participants at approved sites to work full-time or
half-time.
Question 1. Has HRSA-NHSC considered program flexibilities
to encourage greater provider participation in its programs to
address urgent mental health workforce needs, such as a
reduction in the number of hours required?
Answer 1. HRSA's National Health Service Corps (NHSC)
offers a number of flexibilities to recruit, maintain and
support the health care workforce, including behavioral health
care providers NHSC awardees are able to select a half-time
service option over 2 years or a full-time service option over
2 years, at NHSC approved sites.
COVID-19 Flexibilities
Another flexibility is through the CARES Act (Section 3216)
which allows the Secretary to assign members of the NHSC to
provide health services as the Secretary determines necessary
to respond to the COVID-19 Emergency, which gives participants
more options as to where they can complete their service The
CARES Act COVID-19 flexibilities are not permanent.
HRSA also has provided COVID-19 flexibilities for NHSC
participants to adjust their commitment if their work is
impacted by the pandemic.
Unless an NHSC participant is eligible for a waiver as a
result of experiencing an ``extreme hardship'' under section
338E(d) of the Public Health Service Act, and implementing
regulations under 42 CFR 6212, 6228, the Secretary does not
have the statutory authority to shorten the length of a
participant's service requirement or cancel a participant's
obligation under a contract Section 338E(d)(2) states that the
Secretary may waive a participant's service obligation in whole
or in part whenever compliance is impossible or would involve
extreme hardship, and if enforcement of the obligation would be
unconscionable .
There are more than 26 million grandfamilies and kinship
families in the United States who are at a higher risk of
experiencing challenges related to mental health and substance
use disorder The pandemic has exacerbated the difficulties that
many of these families face, and more than 200,000 children
have been orphaned by COVID-19, losing at least one parent or
primary caregiver to the disease The Advisory Council to
Support Grandparents Raising Grandchildren, established by the
Supporting Grandparents Raising Grandchildren (SGRG) Act
(Public Law 115-116), has emphasized the importance of
addressing the trauma experienced by grand families Page 3 of
the SGRG Act Initial Report to Congress notes that many
children in need of homes have experienced multiple adverse
childhood experiences and require support beyond what a kin or
grandparent caregiver can provide Without connections to
publicly available assistance, grand families and kinship
families may spend down their savings on services or go without
needed support The SGRG Act Initial Report to Congress
identifies awareness of and outreach to kin and grandparent
caregivers as a priority.
Question 2. What efforts are underway, or being considered,
at HRSA and other relevant agencies to expand outreach to
kinship families and grand families to connect them with
information, services, and supports? How can Congress support
these efforts?
Answer 2. HRSA reaches families and caregivers, including
kinship and grand families, with information, services, and
other supports to address behavioral health needs.
For example, HRSA's Infant-Toddler Court Program (ITCP)
funds a National Resource Center (NRC) to improve the health,
well-being, and development of infants, toddlers, and families
in the child welfare system The program aims to improve direct
services, ensure community-level partnership-building, and
strengthen early childhood systems to serve families with
significant trauma and substance use histories ITCP provides
technical assistance and implementation supports to child
welfare judicial systems to educate judges, case workers, and
other professionals on the importance of kinship care and ways
to support young children and families in kinship placements As
part of direct support to families and caregivers, local court
teams also provide information, connection to services and care
coordination, and other supports for families, including
kindship and grand families ITCP received an increase of $3
million in the fiscal year 2022 annual appropriations for HRSA
to provide state grant awards which will support states to
build capacity for or expand implementation of the ITC approach
in local ITC sites.
The HRSA-funded School-Based Health Alliance maintains and
updates resources for families to learn about school-based
health, including behavioral health HRSA's Collaborative
Improvement and Innovation Network on School-Based Health
Services increases children's access to behavioral health care
by promoting evidence-based models of school-based health
services, including Comprehensive School Mental Health Systems
Additionally, HRSA, in collaboration with CDC, leads the
National Coordinating Committee on School Health & Safety
(NCCSHS), which is a partnership among Federal and non-
governmental organizations to coordinate communication and
support implementation at the state/local levels of school-
based approaches including expanding comprehensive, trauma-
informed mental health services in schools and the Whole
School, Whole Community, Whole Child Model.
The Family to-Family Health Information Center Program is
another investment that HRSA supports to assist families and
children Family to-Family information centers provide
information, education, and peer support to families with
children and youth with special health care needs, including
behavioral health needs--in addition to health professionals
who serve families Families served through the program can
include kinship and grand families.
SENATOR ROSEN
Question 1. As we talk about addressing the mental health
workforce shortage, we need to also think about the diverse
needs of children--especially those who have experienced
significant trauma Over the last 2 years, that number has
unfortunately grown It is estimated that in the U.S., 167,000
children have lost a parent or caregiver due to COVID-19, and
13,000 lost their only caregiver Others dealt with social
isolation and now struggle with the challenge of two lost years
The pandemic caused stress and anxiety for so many children,
only compounding the trauma that some children already faced
due to abuse, homelessness, or living in foster care These
children not only need mental health support, they need care
from a professional who has been specifically trained to
address their particular needs Ms. Johnson, what
recommendations do you have for Congress on how to expand our
provider capacity by helping mental health professionals become
further specialized?
Answer 1. Integrating behavioral health into primary care
and growing the behavioral health workforce, are two of HRSA's
strategies for expanding provider capacity to address the
mental health needs of children.
HRSA's Behavioral Health Workforce and Education Training
(BHWET) Professionals Program has a particular emphasis on the
integration of behavioral health into primary care, , and a
special focus in the BHWET Program is placed on the knowledge
and understanding of children, adolescents, and transitional-
aged youth at risk for behavioral health disorders The program
helps increase the supply of children's behavioral health
professionals as well as to increase access to children's
behavioral health services by funding institutions of higher
education and accredited professional training programs that
expand field placement programs in school social work, school
psychology, behavioral pediatrics, and school counseling The
program's emphasis on community-based partnerships promotes the
integration of behavioral health into primary care by
increasing the number of experiential training sites where such
training takes place In this way, the program emphasizes
interdisciplinary collaboration by utilizing team-based care in
integrated behavioral health and primary care settings By 2025,
the BHWET Professionals Program is projected to eliminate over
40 percent of the projected shortfall of behavioral health
providers Thanks to the American Rescue Plan, HRSA made 56
additional BHWET awards to behavioral health and training
programs in June 2021 In fiscal year 2022, HRSA is supporting
168 BHWET Program professional grantees, totaling $66 million
Continued funding for the BHWET Program allows HRSA to build on
this important work of integrating the behavioral health
workforce.
Continued investments in training and workforce development
that help providers prevent and treat diverse child health
conditions, including behavioral health, are key to expanding
provider capacity This includes integrating culturally and
linguistically appropriate, equitable, and trauma-informed best
practices HRSA supports several programs that are helping to
increase access to specialized mental health providers and
build provider capacity.
HRSA supports the Pediatric Mental Health Care Access
Program (PMHCA). This program promotes behavioral health
integration in pediatric primary care through new or expanded
statewide or regional pediatric mental health care telehealth
programs These statewide or regional networks of specialized
pediatric mental health care teams provide tele-consultation,
training, technical assistance, and care coordination to assist
pediatric primary care providers.
Through the Pediatric Mental Health Care Access Program,
pediatric primary care providers are able to diagnose, treat
and refer children to the care they need for behavioral health
concerns The telehealth technologies promote long-distance
clinical health care, clinical consultation, and patient and
provider education, helping to address challenges in accessing
psychiatrists, developmental-behavioral pediatricians, and
other behavioral health clinicians who treat behavioral
concerns in children and adolescents In fiscal year 2020,
approximately 3,000 children and adolescents benefited directly
from telehealth consultations through the PMHCA Program, (with
approximately 2/3 living in rural and underserved counties)
However, the reach of the program extends far beyond the
children for whom providers contact the consultation line.
L61 percent of participating providers report
screening more patients in their practices, extending
the impact of the program to more children and
adolescents.
L61 percent of participating providers also
report that they are now providing behavioral health
treatment in their practices, expanding the
availability of these services within our communities.
LThe number of primary care providers enrolled
in the PMHCA Program increased from 1,963 in fiscal
year 2019 to 4,511 in fiscal year 2020.
Authorization for the PMHCA program expires at the
conclusion of fiscal year 2022.
In addition, the Developmental Behavioral Pediatrics
Training Program (DBP). trains Fellows in developmental
behavioral pediatrics to address the broad range of behavioral,
psychosocial, and developmental concerns that present in
primary care pediatric practice The program also builds
capacity for practitioners to provide evidence-based
interventions to children's behavioral and developmental
concerns, including for individuals with autism spectrum
disorder and other developmental disabilities who may have co-
occurring behavioral health disorders In fiscal year 2020, the
DBP Training Program provided training to over 1,400 DBP
Fellows, medical students and pediatric residents DBP graduate
survey results indicate that 100 percent of DBP Fellows
demonstrated leadership, worked in an interdisciplinary manner,
and worked with maternal and child health populations,
including those considered to be underserved (5 years following
completion of the program).
HRSA's Leadership Education in Adolescent Health (LEAH)
Program prepares maternal and child health leaders in
adolescent and young adult health The program builds MCH
workforce capacity by preparing health professionals for
leadership roles in public health, health services, and
academic sectors to address the unique needs of adolescents,
including their behavioral health The program incorporates
evidence-based patient-centered, culturally relevant care to
build provider capacity and promote optimal mental health and
well-being for adolescents and young adults LEAH graduate
survey results show that 98 percent were engaged in work
related to MCH populations (5 years following completion of
program). \1\
---------------------------------------------------------------------------
\1\ Data from 2020 Discretionary Grants Information System.
While HRSA leads a number of programs to address mental
health care needs of children, there is so much more to do when
it comes to mental health care, especially considering the
impact the pandemic has had on the mental and emotional well-
being of people all ages HRSA looks forward to working with you
to build on these efforts as we carry out the President's
national strategy to tackle the Nation's mental health crisis.
SENATOR HICKENLOOPER
Behavioral Health Workforce
If we are serious about building the pipeline of behavioral
health workers, we need to make it easier for those without
college degrees, working parents, and those without previous
experience to break into early stage health care jobs According
to the Bureau of Labor Statistics, we will need more than
150,000 new mental health support staff over the coming decades
Even greater than the outstanding demand for psychologists.
Question 1. How can we more effectively recruit for these
jobs to address this growing need?
Answer 1. HRSA has multiple pathways to recruit, train and
place new behavioral health care providers in communities that
need them most Below are examples of HRSA programs that support
the priorities you have shared for building a pipeline of
behavioral health workers.
HRSA's Behavioral Health Workforce Education and Training
(BHWET) Program for Paraprofessionals develops and expands
community-based experiential training to increase the supply of
students preparing to become peer support specialists and other
mental health-related support workers while also improving
distribution of a quality behavioral health workforce In fiscal
year 2022, HRSA supported 44 paraprofessional grantee
organizations.
The Opioid-Impacted Family Support Program (OIFSP) trains
health support workers to support children and families
impacted by opioid use disorder (OUD) and other substance use
disorders (SUD) in underserved areas The Program also provides
professional development opportunities and educational support
to increase the number of paraprofessional trainees receiving a
certificate upon completion of the Program.
HRSA's Rural Public Health Workforce Training Network
Program expands public health capacity by supporting health
care job development, training and placement in rural
communities HRSA supports rural health networks (which may be
composed of, but are not limited to, minority-serving
institutions, community colleges, technical colleges, rural
hospitals, community health centers, nursing homes and
substance use providers) to address the critical need for more
trained health professionals, which has been amplified by the
COVID-19 pandemic.
HRSA also funds several pipeline programs to help people
prepare for and enter health professions The Health Careers
Opportunity Program (HCOP): National Academies provide
individuals from economically and educationally challenging
backgrounds opportunities to develop skills to help enter and
graduate from schools of health professions, including allied
health professions Program support includes tailored academic
counseling and highly focused mentoring services, scholarships
and stipends, financial planning resources, and health care
careers and training information.
Additionally, HRSA offers the Centers of Excellence (COE)
Program, which provides grants to health professions schools
and other public and nonprofit health or educational entities
to serve as innovative resource and education centers for the
recruitment, training, and retention of underrepresented
minority (URM) students and faculty.
Upskilling
We are facing a constantly growing need for behavioral
health providers, particularly in rural and underserved areas.
During a recent Subcommittee hearing that I Chaired on the
health care workforce, we heard from Dr. Margaret Flinter with
the National Nurse Practitioner Residency and Fellowship
Training Consortium The Consortium is using innovative
approaches to train Nurse Practitioners in behavioral health.
Question 1. How can upskilling opportunities, like these
training programs, help train more providers to increase access
to behavioral healthcare?
Answer 1. Upskilling increases the number of providers and
health support workers in the field with the skillset required
to treat mental and behavioral health issues One of the most
effective ways HRSA is growing the behavioral health workforce
is by integrating behavioral health into primary care training
while providing opportunities for providers across different
disciplines such as pediatricians and maternal care providers
to receive training in behavioral health care needs.
For example, HRSA funds two mental health programs that are
currently up for reauthorization The first program, the
Screening and Treatment for Maternal Depression and Related
Behavioral Disorders Program, helps train maternal health care
providers on how to screen for, assess, treat, and, as
necessary, refer pregnant and postpartum individuals with
mental health conditions or substance use disorders as part of
routine maternal health care Maternal health care providers
also receive real-time psychiatric consultations for their
patients through telehealth services and care coordination
support.
The second program, the Pediatric Mental Health Care Access
Program aims to make early identification, diagnosis,
treatment, and, as needed, referral for behavioral health
conditions a routine part of children's health care services
The program promotes the integration of behavioral health
services into pediatric primary care through statewide and
regional pediatric mental health care telehealth programs These
statewide or regional networks provide tele-consultation,
training, technical assistance and care coordination to
community-based pediatric health care providers in order to
expand the reach of critical mental health services and support
children's needs.
Additionally, HRSA funds a training program focused on
integration of primary care and behavioral health through the
Primary Care Training and Enhancement: Integrating Behavioral
Health and Primary Care Program, which aims to increase the
preparedness of primary care providers to identify and treat
mental health and substance use disorders In fiscal year 2021,
HRSA supported nine Primary Care Training and Enhancement:
Integrating Behavioral Health and Primary Care Program grants.
HRSA also has funded a new and innovative initiative to
train community health workers, through the Community Health
Worker and Health Support Worker Training Program This new
program will expand the public health workforce through the
training of CHWs and other health support workers These CHWs
will provide services, including behavioral health services in
underserved communities Training community health workers and
supporting job placement creates new opportunities to bring
people into the health professions and grow their career ladder
and upskilling opportunities over time.
HRSA's Rural Public Health Workforce Training Network
Program expands public health capacity by supporting health
care job development, training and placement in rural
communities HRSA supports rural health networks (which may be
composed of, but are not limited to, minority-serving
institutions, community colleges, technical colleges, rural
hospitals, community health centers, nursing homes and
substance use providers) to address the critical need for more
trained health professionals, which has been amplified by the
COVID-19 pandemic Similarly, HRSA's Regional Public Health
Teaching Center Program seeks to increase the number of
individuals in the public health workforce, enhance the quality
of such workforce, and improve the ability of this workforce to
meet national, state, and local health care needs Specifically,
this program aims to strengthen the public health workforce
through tailored training and technical assistance through
collaborative community-based projects.
Another way we are integrating behavioral health into
primary care is by growing the behavioral health provider
pipeline by promoting the inclusion of health support workers
as members of behavioral health treatment teams For example,
the Behavioral Health Workforce Education and Training Program
for Paraprofessionals develops and expands community-based
training for students preparing to become peer support
specialists and other behavioral health-related health support
workers
SENATOR MURKOWSKI
Mental Health Workforce
Question 1. I am deeply concerned by the worsening,
widespread shortage of mental health professionals, which has
only been exacerbated by the COVID-19 pandemic Over half of
Alaska's population--380,000 people--live in a designated
Mental Health Professional shortage area Workforce shortages
create another serious barrier to accessing mental health care
services, especially for those living in rural communities,
like many Alaskans Last May, I joined Senator Smith in
introducing the Mental Health Professionals Workforce Shortage
Loan Repayment Act This bill establishes a student loan
repayment program for mental health professionals who work in
these shortage areas My hope is that this legislation will help
expand the mental health workforce and incentivize
professionals to provide much-needed mental health care to
those living in rural communities and other underserved areas.
Question 1(a). What steps is the administration taking to
address mental health workforce shortages, specifically with
regard to the shortages facing Americans in underserved and
rural areas?
Answer 1. HRSA is investing in both growing the behavioral
health workforce in underserved and rural communities and in
integrating behavioral health training into primary care
training and practice to expand access to care.
HRSA's National Health Service Corps program provides
scholarships and loan repayment assistance to clinicians who
agree to work in health professional shortage areas Thanks to
American Rescue Plan funding, we now have a record number of
participants in this program, with over 9,000 participants
providing mental health services, and more than a third of
these providers are providing mental health services in rural
areas.
With American Rescue Plan funding, we also have expanded
our Behavioral Health Workforce and Education Training Program,
which has increased the number of behavioral health providers
entering and continuing practice.
To address workforce needs in rural areas, HRSA funds
several programs that either focus on workforce development in
rural communities or allow communities to propose a unique
workforce program to meet the needs of a community In fiscal
year 2021, HRSA funded the Rural Behavioral Health Workforce
Centers--Northern Border Region as part of the Rural
Communities Opioid Response Program (RCORP), a multi-year HRSA
initiative with the goal of reducing morbidity and mortality
resulting from substance use disorder (SUD) These centers are
improving behavioral health care services in rural areas
through educating and training health professionals and
community members to care for individuals with behavioral
health disorders, including SUD This program supports HRSA's
collaboration with the Northern Border Regional Commission
(NBRC) to provide career and workforce training activities that
assist individuals with behavioral health needs, particularly
SUD HRSA will continue funding for these centers in fiscal year
2022.
More broadly, through RCORP's other community-based grant
programs, award recipients serving over 1,500 rural communities
in 47 States and two territories have been able to leverage
grant funds to recruit, train, and retain interdisciplinary
teams of health and social service providers to support
behavioral health care interventions Since RCORP's inception in
2018, Alaska has received $22 million in RCORP funding.
In fiscal year 2022, HRSA will be awarding new grants under
the Rural Public Health Workforce Training Network Program to
expand the public health capacity by supporting health care job
development, including around behavioral health Additionally,
several of HRSA's rural community-based programs offer funding
opportunities that allow applicants in rural communities to
propose and build a program in response to an area of need HRSA
has funded many programs that focus on workforce development
through the Rural Health Network Development, Rural Health Care
Coordination, Rural Health Care Services Outreach, and Delta
States Rural Development Network grant programs.
Question 2. What can and should be done to grow the
employee pipeline in this field?
Answer 2. HRSA is regularly working to grow the pipeline
including through multiple pathways to recruit, train and place
new behavioral health care providers in the communities that
need them most One way we are growing the behavioral health
provider pipeline is by promoting the inclusion of health
support workers as members of behavioral health treatment teams
For example, the Behavioral Health Workforce Education and
Training Program for Paraprofessionals develops and expands
community-based training for students preparing to become peer
support specialists and other behavioral health-related support
workers HRSA will also support a new program this year to
expand the public health workforce through the training of
community health workers (CHWs) and other health support
workers and to extend the knowledge and skills of current CHWs
and other health support workers These CHW's will provide
services, including behavioral health services in underserved
communities.
Question 3. Provider Burnout: Throughout the pandemic, I
have been concerned about our health care workforce Now, with a
workforce shortage across the country, acute shortages in
workers as infected staff isolate, and mounting burnout as we
enter year three of this pandemic, I am more concerned than
ever about the future of our health workforce.
Question 3(a). In the mental health care sector, what steps
are you taking to help support the mental health needs of
health providers, and expand and improve retention in an
already-depleted workforce?
Answer 3. Supporting the mental health needs of health care
providers is a top priority for HRSA This past January, HRSA
announced $103 million in new grant awards to help support our
health professionals' resilience as they continue to face the
stress and challenges of responding to COVID-19 and other
health care needs These awards are funding evidence-informed
programs, practices and training, with a specific focus on
providers in underserved and rural communities.
Funding is allocated across the following programs:
LPromoting Resilience and Mental Health Among
Health Professional Workforce. HRSA awarded $286
million to 10 grantees to help health care
organizations establish, improve, or expand evidence-
informed programs and practices to promote mental
health and well-being among the health workforce,
including their employees.
LHealth and Public Safety Workforce Resiliency
Training Program. HRSA awarded $682 million to 34
grantees to support tailored evidence-informed training
development within health profession and nursing
training activities This curriculum will help reduce
burnout and promote resilience among health care
students, residents, health care professionals,
paraprofessionals, trainees and public safety officers,
such as firefighters, law enforcement officers, and
ambulance crew members.
LHealth and Public Safety Workforce Resiliency
Technical Assistance Center. HRSA awarded $6 million to
provide tailored training and technical assistance to
the awardees discussed above.
HRSA also has several programs under the Behavioral Health
Workforce Development Program that aim to expand and support
the behavioral and mental health workforce, including:
Y LBehavioral Health Workforce Education and Training
(BHWET) Programs: BWHET increases the number of
behavioral health providers entering and continuing
practice, with special emphasis on prevention and
clinical intervention and treatment for those at risk
of developing mental and substance use disorders, and
the involvement of families in the prevention and
treatment of behavioral health conditions BWHET
includes the activities described below.
Y LBWHET Program for Professionals: The BHWET Program
for Professionals aims to increase the supply of
behavioral health professionals while also improving
distribution of a quality behavioral health workforce
and thereby increasing access to behavioral health
services In fiscal year 2022, HRSA supported 168 BHWET
Professional grantee organizations.
Y LBHWET Program for Paraprofessionals: The BHWET
Program for Paraprofessionals develops and expands
community-based experiential training to increase the
supply of students preparing to become peer support
specialists and other behavioral health-related
paraprofessionals while also improving distribution of
a quality behavioral health workforce In fiscal year
2022, HRSA supported 44 paraprofessional grantee
organizations.
Other programs to expand the behavioral and mental health
care provider workforce include:
LSubstance Use Disorder Treatment and Recovery
Loan Repayment Program (STAR LRP): The STAR LRP
recruits and retains medical, nursing, behavioral/
mental health clinicians and paraprofessionals who
provide direct treatment or recovery support of
patients with or in recovery from a substance use
disorder STAR LRP participants must provide services in
either a county (or a municipality, if not contained
within any county) where the mean drug overdose death
rate per 100,000 people over the past 3 years exceeds
the national average, or in a Health Professional
Shortage Area (HPSA) designated for Mental Health.
LGraduate Psychology Education (GPE) Program:
This Program supports innovative doctoral-level health
psychology programs that foster an inter-professional
approach to providing behavioral health and substance
use prevention and treatment services in high-need and
high-demand areas through academic and community
partnerships.
LOIFSP: OIFSP trains paraprofessionals to
support children and families impacted by OUD and other
SUD in underserved areas The Program also provides
professional development opportunities and educational
support to increase the number of paraprofessional
trainees receiving a certificate upon completion of the
Program.
LAddiction Medicine Fellowship (AMF) Program:
The AMF Program seeks to increase the number of board-
certified addiction medicine and addiction psychiatry
specialists trained in providing inter-professional
behavioral health services, including OUD and SUD
prevention, treatment, and recovery services, in
underserved, community-based settings The AMF Program
is designed to foster robust community-based clinical
training of addiction medicine or addiction psychiatry
physicians in underserved, community-based settings who
see patients at various access points of care and
provide addiction prevention, treatment, and recovery
services across health care sectors.
Question 3(b). What more do you need from Congress to
support these efforts?.
Answer 3(b). HRSA continues to prioritize and grow our
provider resiliency efforts to retain and maintain a strong
health care workforce To ensure success in our efforts, we hope
to continue to have regular communication, collaboration and
support from Congress.
Question 4. Maternal Mental Health: Studies have found that
approximately 800,000 mothers are affected by maternal mental
health conditions each year, and yet 75 percent will go
entirely untreated In Alaska, only 1 in 4 pregnant and
postpartum women impacted by maternal mental health conditions
is diagnosed and receives the treatment needed I recently
worked with Senators Gillibrand, Capito, and Baldwin on a bill,
the Into the Light for Maternal Mental Health Act, that focuses
on supporting mothers mentally as well as physically, so that
they can better support their babies The bill would support
maternal mental health specific training and resources for
health care professionals to identify and treat patients at-
risk for or suffering from maternal mental health conditions.
Question 4(a). How is HRSA working to ensure pregnant and
postpartum mothers are screened, supported, and treated for
maternal mental health?
Answer 4(a). HRSA supports several programs that are
focused on maternal mental health The Screening and Treatment
for Maternal Depression and Related Behavioral Disorders
Program (MDRBD) gives providers the tools to integrate
behavioral health care into routine maternal health care
through teleconsultation services that help local providers
bridge the gap in access to psychiatrists, especially perinatal
psychiatrists With teleconsultation support, maternal health
care providers are able to receive real-time psychiatric
consultations and care coordination support In addition,
community-based maternal health providers are offered training
on how to screen for, assess, treat, and refer pregnant and
postpartum individuals for mental health and substance use
disorders.
HRSA has received tremendous interest in the MDRDB
program--demonstrating the acute need for it--but is only able,
with current resources, to fund approximately a quarter of
applicants The seven states that currently receive awards are
Florida, Kansas, Louisiana, Montana, North Carolina, Rhode
Island, and Vermont.
HRSA will also launch the National Maternal Mental Health
Hotline later this year The Hotline will be available 24/7 to
provide free, confidential support, resources and referrals to
any pregnant and postpartum mothers facing mental health
challenges and their loved ones Those in need can contact the
Hotline via phone or text and will receive culturally
appropriate support from counselors in English or Spanish;
interpreter services are also available in 60 languages Parents
and families who contact the Hotline will speak to licensed or
certified counselors The Hotline's counselors also are trained
in providing trauma-informed support.
HRSA additionally supports the Maternal, Infant, and Early
Childhood Home Visiting Program (MIECHV). This program supports
voluntary, evidence-based home visiting services for pregnant
people and parents with young children up to kindergarten entry
living in communities at risk for poor maternal and child
health outcomes Home visiting programs support maternal mental
health by screening for maternal depression and connecting
caregivers to needed treatment and services The MIECHV Program
also funds a Home Visiting Collaborative Improvement and
Innovation Network (HV CoIIN) that supports home visiting
programs to use quality improvement strategies to better screen
for and address maternal depression and intimate partner
violence, and disseminate best practices widely.
The Healthy Start Program supports community-based
strategies to reduce the rate of infant mortality, improve
perinatal outcomes, and address disparities in perinatal health
Healthy Start grantees provide screening and referral to
services for depression, substance use and interpersonal
violence Grantees support client and family behavioral health,
address toxic stress, and employ trauma-informed care Grantees
also address maternal depression through health education and
support groups to promote mental wellness for mothers
Currently, there are 35 States, the District of Columbia, and
Puerto Rico which have a Healthy Start site.
Finally, HRSA's Title V Maternal and Child Health Services
Block Grant (Title V) Program is a Federal-state partnership
that awards formula grants to 59 States and jurisdictions to
address the health needs of mothers, infants, and children,
including children with special health care needs The purpose
of the Maternal and Child Health Block Grant is to improve the
health of the Nation's mothers, children, and families through
Federal/state partnerships that provide each state with needed
flexibility to respond to its unique maternal and child
population needs An estimated 60 million pregnant women and
children benefited from a service supported by the Title V MCH
Block Grant in fiscal year 2020 While states have always used
their Block Grant to address mental and behavioral health
needs, there was a dramatic increase in the number of states
identifying it as a priority need in the past two reporting
years--from 36 States in 2015 to 51 States and territories in
2020 Access to behavioral health care, including integration of
behavioral health and primary care, is a major priority for
states and territories Title V strategies for women and
maternal health include promoting screening and referral for
mental health and substance use among pregnant women, training
providers on maternal mental health needs, and continuing work
to address opioid and other substance use and its impact on
women, infants, and families.
Question 5. Medication Assisted Treatment: The Anchorage
Daily News reported recently that the U.S. has passed a
``never-before-seen milestone'' in losing more than 100,000
Americans to drug overdoses in a year Sadly, the CDC reports
that the number of drug overdoses in Alaska rose by more than
45 percent as of June 2021 That's more than double the rate of
increase for the United States.
One treatment that we know is critical to stemming the
overdose crisis is medication that prevent withdrawal symptoms
and stem opioid cravings These medications, like buprenorphine,
can cut the risk of overdose death in half when a person starts
taking them But, outdated Federal laws and stigma are
restricting access to these life-saving medications I have
introduced the Mainstreaming Addiction Treatment Act with my
colleague, Senator Hassan, to help more Americans have access
to life-saving medication and eliminate burdensome Federal red
tape.
Question 5(a). How is the administration supporting
expanding access to medications to treat substance use disorder
so they reach all communities in need?
Answer 5. Health centers remain at the forefront in
addressing behavioral health issues nationwide, as many health
centers offer a wide range of integrated primary care, mental
health, and substance use disorder services including but not
limited to counseling and psychiatry, Screening, Brief
Intervention, and Referral to Treatment (SBIRT), medication-
assisted treatment, and recovery support HRSA provides all
health centers with access to technical assistance resources to
promote the integration of behavioral health/substance use
disorder services in primary care and support improvements in
access to SBIRT, MAT, and tele-behavioral health services
Nearly 8,400 health center providers were eligible to prescribe
MAT in 2020.
HRSA also provides payments to physicians and practitioners
to furnish opioid use disorder treatment services through its
implementation of Section 6083 of the SUPPORT for Patients and
Communities Act (SUPPORT Act), which authorizes payments to
federally Qualified Health Centers (FQHCs) and Rural Health
Clinics (RHCs) for completing training and obtaining a DATA
2000 waiver The payments were intended to increase the
availability of treatment by incentivizing FQHCs and RHCs to
have their providers receive the training that was originally
required to receive a waiver to prescribe medication assisted
treatment Though providers are no longer required to take the
training in order to prescribe medication assisted treatment,
HRSA has obligated the $6 million appropriated for FQHCs and
continues to promote the program for payments to Rural Health
Clinics.
HRSA has also increased the availability of substance use
disorder treatment through targeted health workforce programs
The National Health Service Corps (NHSC) Substance Use Disorder
Workforce Loan Repayment Program provides loan repayment
assistance to medical, nursing, and behavioral health
clinicians in exchange for a service commitment to provide
direct services at substance use treatment facilities in
underserved areas These sites include outpatient services at
opioid treatment programs and office-based opioid treatment
facilities Additionally, the NHSC Rural Community Loan
Repayment Program has made loan repayment awards in
coordination with the Rural Communities Opioid Response Program
initiative within the Federal Office of Rural Health Policy to
provide evidence-based substance use treatment, assist in
recovery, and to prevent overdose deaths across the Nation.
The Substance Use Disorder Treatment and Recovery Loan
Repayment Program (STAR LRP) recruits and retains medical,
nursing, behavioral/mental health clinicians and
paraprofessionals who provide direct treatment or recovery
support of patients with or in recovery from a substance use
disorder STAR LRP participants must provide services in either
a county (or a municipality, if not contained within any
county) where the mean drug overdose death rate per 100,000
people over the past 3 years exceeds the national average, or
in a Health Professional Shortage Area designated for Mental
Health.
HRSA's Primary Care Training and Enhancement Program
further supports efforts to expand access to medications for
SUD treatment Specifically, this program funds innovative
training programs that integrate behavioral health care into
primary care, particularly in rural and underserved settings
with a special emphasis on mental health and the treatment of
opioid use disorder Additionally, the Residency Training in
Primary Care Program requires that residents in the program are
provided with dedicated clinical experiences with at least one
provider with a DATA-2000 waiver who provides MAT services for
patients with opioid use disorder.
HRSA's Addiction Medicine Fellowship, Graduate Psychology
Education and Rural Communities Opioid Response Programs also
contribute to expanding access to SUD medications and
treatments across a variety of communities in need The
Addiction Medicine Fellowship Program supports the clinical
training of addiction medicine or addiction psychiatry
physicians in underserved, community-based settings The
Graduate Psychology Education Program supports innovative
doctoral-level health psychology programs that foster an inter-
professional approach to providing behavioral health and
substance use prevention and treatment services in high need
and high demand areas through academic and community
partnerships The Rural Communities Opioid Response Program aims
to reduce the morbidity and mortality associated with SUD,
including opioid use disorder, in high need rural communities
by establishing, expanding, and sustaining prevention,
treatment, and recovery services at the county, state, and/or
regional levels.
Question 6. Infant and Early Childhood Mental Health: The
first years of life are an incredible opportunity to promote
positive mental health for babies, and health and well-being
during this time period affects future learning, behavior and
health.
Question 6(a). Have you seen a marked impact by Federal
investment in infant and early childhood mental health (IECMH)?
Answer 6. The Maternal, Infant, and Early Childhood Home
Visiting Program (MIECHV) supports voluntary, evidence-based
home visiting services for pregnant people and parents with
young children up to kindergarten entry living in communities
at risk for poor maternal and child health outcomes The program
is built on decades of scientific research, which shows that
home visits by a nurse, social worker, or early childhood
educator during pregnancy and in the first years of life,
improve child and family outcomes like maternal and newborn
health MIECHV programs support Infant and Early Childhood
Mental Health (IECMH) Consultation, which pairs a mental health
specialist with a home visitor to help them strengthen and
support the healthy social and emotional development of
children ages 0--5 HRSA provides technical assistance to state
awardees and local programs to expand use of IECMH in home
visiting Federal investment in IECMH improves the capacity of
home visiting programs to meet families' needs and promote
healthy child development Authorization and funding for the
MIECHV program expires at the conclusion of fiscal year 2022
without further legislative action.
Suicide Screening in the Emergency Department
Question 7. A recent CDC report on emergency department
visits for people aged 12-25 found an over 50 percent increase
visits for suspected suicide attempts during early 2021 This
underscores the devastating mental health impact of the
pandemic on our youth and highlights yet another way that
COVID-19 has strained our hospitals and medical staff.
I introduced a bill, the Effective Suicide Screening and
Assessment in the Emergency Department Act, to improve the
screening and treatment of patients in hospital emergency
departments who are at high risk for suicide It will make sure
that we can better identify our most vulnerable mental health
patients so they do not slip through the cracks when they are
treated in hospitals, and make sure hospitals have the
resources they need to provide these critical services.
Question 7(a). What is the need for improved suicide
screening protocols in the Nation's emergency rooms?
Question 7(b). Do you support efforts to bolster the
resources available to emergency rooms so they can enhance
their screening for high-risk suicide patients?
Answer 7. The HRSA Emergency Medical Services for Children
(EMSC) Program's Pediatric Emergency Care Applied Research
Network (PECARN) examined suicide among adolescents to help
identify those most at-risk Although the second leading cause
of death among youth, only a fraction of adolescents who die of
suicide have ever been treated for a mental or behavioral
health problem \2\ As many at-risk adolescents remain
unidentified, emergency departments are particularly suited for
suicide risk screening PECARN investigators implemented an
observational study to validate the Computerized Adaptive
Screen for Suicidal Youth (CASSY) survey which predicts
adolescent suicidality using a 1-2 minute screening strategy
Investigators found that the CASSY correctly identified 824
percent of youth who went on to attempt suicide in the 3-months
following screening The results suggest this screener could
serve as an easy-to-use way for providers to detect youth
suicide risk in emergency department settings \3\ Though this
looks to be a promising screening tool for use in emergency
departments, the study suggests that it needs further testing
for validity and reliability HRSA continues to support efforts
to improve suicide screening protocols and bolster the
resources available in emergency departments to prevent youth
suicide.
---------------------------------------------------------------------------
\2\ King CA, Brent D, Grupp-Phelan J, Gibbons R, etal (2021)
Prospective Development and Validation of the Computerized Adaptive
Screen for Suicidal Youth Pediatric Emergency Care Applied Research
Network JAMA Psychiatry 2021 May 1;78(5):540-549
\3\ King CA, Grupp-Phelan J, Brent D, etal (2019) Predicting 3-
month risk for adolescent suicide attempts among pediatric emergency
department patients J Child Psychol Psychiatry 2019 Oct;60(10):1055-
1064 doi: 101111/jcpp13087 Epub 2019 Jul 21.
FASD
Question 8. During COVID, we have seen a sharp rise in
substance misuse specifically alcohol, the most widely used and
misused substance Unfortunately, a landmark NIH study in 2018
established that 1 in 20 school-aged children are affected by
fetal alcohol spectrum disorders--FASD Due to its significance
and status as an overlooked disability that includes
debilitating stigma, I introduced S 2238, the FASD Respect Act
My legislation establishes common standards of care and
increases the capacity to manage FASD in medical and mental
health settings How can we address the social and environmental
factors that contribute to prenatal alcohol exposure and reduce
the traumas FASD creates for individuals and families?
Question 8(a). What steps are being taken by the
administration to provide more education and training on FASD?
How can stigma be lessened for individuals living with
behavioral health conditions, like FASD?
Answer 8. HRSA supports the Supporting Fetal Alcohol
Spectrum Disorders (FASD) Screening & Intervention Program,
called the SAFEST Choice Learning Collaborative This program
trains primary care providers with the aim to reduce the
incidence of prenatal alcohol exposure, and improve
developmental outcomes in children with suspected or diagnosed
FASDs This program reaches providers in states, territories,
tribes, or communities that have high rates of binge drinking
among pregnant women, especially in rural areas The SAFEST
Choice program successfully recruited providers from community
health centers to participate in the first cohort, including 10
maternal health practices and 12 pediatric practices from seven
states: IA, MA, ME, MI, MN, RI, SD Five of the 22 practices are
in tribal health clinics and several other practices serve
tribal communities SAFEST Choice offers a range of technical
assistance to providers such as strategies to improve practice,
change systems including quality improvement approaches, and
identify and access community resources Provider trainings
include a focus on reducing stigma and bias
SENATOR BRAUN
Senior caregivers working across assisted living and memory
care have been instrumental in successfully mitigating the
spread of COVID-19 among the most vulnerable populations, even
without Federal relief Nearly half of the 30,000 seniors in
assisted living in Indiana have Alzheimer's or dementia, which
created complex challenges for their caregivers during the
pandemic Assisted living and memory care communities continue
to be proven effective in addressing the social determinants of
senior health: proper nutrition, housing, and most importantly,
social interaction.
Question 1. Administrator Johnson, how does HRSA plan to
engage assisted living and memory care communities as important
stakeholders as alarming data finds the need for 14 million
additional senior caregivers to keep pace with America's
rapidly aging population, which shows 10,000 individuals
turning 65 every day?
Answer 1. HRSA's Geriatrics Workforce Enhancement Program
improves health care for older adults by developing a health
care workforce to provide value-based care that improves health
outcomes for older adults by integrating geriatrics and primary
care delivery sites/systems The Program maximizes patient and
family engagement in health care decisions and provides
training focusing on inter-professional and team-based care
across the educational continuum (students, faculty, providers,
direct service workers, patients, families, and lay and family
caregivers).
An essential component of the program is developing
academic-primary care-community-based partnerships to address
gaps in health care for older adults and transforming clinical
training environments into integrated geriatrics and primary
care sites/systems to become age-friendly health systems and
dementia-friendly communities
SENATOR TUBERVILLE
Question 1. we know that one in four Americans reports
having been a victim of crime in the past 10 years, and half of
those were victims of a violent crime Most report receiving no
help in the aftermath Police, corrections leaders, and the
courts agree that untreated mental health or co-occurring
substance abuse disorders are core drivers of the cycle of
crime and that they lack the infrastructure to respond
appropriately.
Question 1(a). What do you see as the individual and
societal impacts of untreated trauma as it relates to mental
health and substance use disorder?
Answer 1. Untreated trauma can result in an individual or a
community experiencing emotional challenges including suicidal
ideation, depression, anxiety, increased substance use, an
inability to thrive in interpersonal relationships and more The
impact of trauma can be subtle, insidious, and destructive \4\
There is, unfortunately, an inaccurate perception that mental
illness is a cause of violent crime, wherein actuality, people
with mental illness are more likely to be victims of violent
crime than perpetrators \5\ Data implies there is a benefit of
trauma informed care regardless of an individual's mental
health status
---------------------------------------------------------------------------
\4\ Understanding the Impact of Trauma--Trauma-Informed Care in
Behavioral Health Services--NCBI Bookshelf (nihgov)
\5\ Desmarais SL, Van Dorn RA, Johnson KL, Grimm KJ, Douglas KS,
Swartz MS Community violence perpetration and victimization among
adults with mental illnesses Am J Public Health 2014 Dec;104(12):2342-9
doi: 102105/AJPH2013301680 Epub 2014 Feb 13 PMID: 24524530; PMCID:
PMC4133297.
HRSA is working to increase not only the pipeline of mental
and behavioral health care professionals but also to increase
the access and touch points for mental and behavioral health
services in the community through community health workers, and
---------------------------------------------------------------------------
other professionals.
Question 2. Federal data shows that 37 percent of people
sentenced to prison, and 44 percent of people arrested and
jailed, have experienced a mental health issue At the same
time, we know that an estimated 1 in 10 police service calls
are responding to an untreated mental health issue Across the
country, we've seen community-based programs that seek to
divert individuals experiencing mental health issues, direct
individuals to treatment and resources, and do so in a way so
the police department does not have to be involved.
Question 2(a). What is the Federal Government doing to
ensure that mental health emergencies are being responded to
appropriately, early on, before a treatable illness becomes a
safety issue?
Answer 2. The HRSA Health Center Program supports mental
health and substance use disorder services in primary care
settings These investments support health centers to integrate
mental health/substance use disorder services into the primary
care setting to better address the significant unmet need for
these services in their communities.
------
Response by Joshua A. Gordon to Questions From Senator Casey, Senator
Rosen, Senator Hickenlooper, Senator Murkowski, Senator Scott, and
Senator Tuberville
SENATOR CASEY
Question 1. Postsecondary age youth are often in need of
greater access to mental health resources than the general
population With 2 years of the pandemic causing social
isolation and greater levels of stress and anxiety, their needs
are likely even greater Prior to the pandemic, the number of
postsecondary students using their college counseling centers
increased by 30-40 percent, whereas enrollment had only
increased by 5 percent How the pandemic has affected the need
for additional mental health services has yet to be determined
as we do not yet have systematic, quality data on the mental
health impacts of the pandemic on postsecondary students My
Higher Education Mental Health Act would establish a national
Commission to study the mental health concerns facing students
at institutes of higher education and report on services
available to students with mental health disabilities The bill
also charges the Commission to provide detailed recommendations
to improve the mental health services available to students at
institutes of higher education.
Question 1(a). If passed, what data would you recommend be
collected by the Commission and do you have preliminary
recommendations the Commission should consider to assist
institutes of higher education to better serve the mental
health needs of young adults entering postsecondary education?
Answer 1. The National Institute of Mental Health (NIMH)
supports research aiming to develop and test sustainable
approaches to college-based mental health interventions and
services NIMH-supported researchers are evaluating the use of a
mobile prevention and intervention platform that includes
population-level screening for college students and tailored
services to address common mental disorders (clinical anxiety,
depression, eating disorders) Additional NIMH-funded
investigators are testing the effectiveness and implementation
of two separate prevention and early intervention strategies
for eating disorders among college populations, and other NIMH-
funded researchers are aiming to test the effectiveness of
sequential suicide prevention interventions for college
students Another team of NIMH-supported researchers are
examining changes in mental health over the course of the
undergraduate experience through a longitudinal study.
The neurodiversity of young adults entering postsecondary
education, including the diversity of needs experienced by
adolescents and young adults with autism spectrum disorder
(ASD), is also important to consider NIMH recently supported
researchers examining the Stepped Transition in Education
Program for Students with ASD (STEPS), a multipronged approach
to prepare students with autism for the transition to post-
secondary education The study demonstrated that STEPS helped to
increase participants' college readiness and decrease
depressive symptoms over the transition period. \1\, \2\
---------------------------------------------------------------------------
\1\ White et al (2021), pubmedncbinlmnihgov/31609666/
\2\ Capriola-Hall et al (2021), pubmedncbinlmnihgov/32468396/.
Youth mental health is a priority for the National
Institutes of Health (NIH) Both NIMH and the Eunice Kennedy
Shriver National Institute of Child Health and Human
Development (NICHD) prioritize research focused on social
determinants of health and the impact of health disparities on
intervention efforts during adolescence NIMH prioritizes
research to understand the mechanisms by which social
determinants of health drive risk of, and resilience to, the
development of mental illnesses NICHD supports research to
determine how exposure to social and environmental factors such
as diet and nutrition, technology and digital media use, sleep
habits, and physical activity affect neurodevelopment and
health outcomes Advances in our understanding of the mechanisms
by which these social and environmental factors impact mental
health could lead to improved interventions for youth with, or
at high risk for, mental illnesses--including interventions
delivered through non-specialty settings such as colleges and
universities.
SENATOR ROSEN
Question 1. Over the last 2 years, we saw the devastating
impact of social isolation on seniors' mental health As we look
back at measures taken to protect the physical health of the
most vulnerable during the pandemic, we also must take to heart
the lessons learned for how to do better in the future One area
of particular concern is how many seniors were not allowed a
family member or caregiver to be with them during inpatient
hospital stays--even when dealing with anxiety, depression,
temporary psychosis, or delirium--regardless of whether their
caregiver was vaccinated or willing to use protective gear AARP
also has noted how critical it is to find a balance between
protecting patient health and how the absence of caregivers
puts additional pressure on clinical staff.
Question 1(a). Dr. Gordon, how would you recommend Federal
guidance be adjusted in the future to best protect both the
physical and mental health of seniors, especially when they are
particularly vulnerable during hospital stays?
Answer 1. NIH continuously strives to build a strong
foundation of evidence to inform Federal guidance, including
through research on evidence-based practices to optimally
protect the physical and mental health of older adults across
multiple care settings To this end, the NIMH supports
interdisciplinary research to improve diagnosis, treatment, and
prevention of mental illnesses in older adults NIMH recognizes
the ongoing need for research to develop and test strategies
that speed dissemination, adoption, and implementation of
evidence-based interventions, and the importance of sustaining
these practices over time For example, universal screening for
suicidal thoughts and behaviors in older adults is shown to
double the rate of suicide risk detection \3\ While effective
evidence-based practices like these could improve diagnosis,
treatment, and prevention of mental illnesses in older adults,
more NIH research is needed to inform broader Federal guidance.
---------------------------------------------------------------------------
\3\ Betz et al (2016), pubmedncbinlmnihgov/27596110/.
NIMH supports the Partnership for the Implementation
Science in Geriatric Mental Health (PRISM) Hub, which aims to
establish a collaborative network of institutions and
individuals to carry out and utilize research that answers
policy-relevant questions related to reducing the treatment gap
for older adults with mental health problems Recently, and
historically, NIMH has supported studies related to reducing
suicidal ideation in older adults with depression, including
research on person-centered approaches for understanding
suicidal ideation and behaviors among nursing home residents
and research on reducing suicidal ideation and depressive
symptoms in depressed older primary care patients \4\, \5\, \6\
---------------------------------------------------------------------------
\4\ reporternihgov/project-details/10163269
\5\ Bruce et al (2004), pubmedncbinlmnihgov/14996777/
\6\ Untzer et al (2006), pubmedncbinlmnihgov/17038073/.
NIMH Director Dr. Joshua Gordon has highlighted the need to
further examine the impact of social isolation and loneliness
among older adults and the impact the COVID-19 pandemic might
have on this vulnerable population \7\ NIMH also encourages
research that examines novel treatment delivery paradigms that
might reach underserved populations, more innovative approaches
to the ways in which care is delivered, and improved
understanding of the negative impact of social isolation and
loneliness on the mental health of older adults relatedly, in
December 2021, NIMH issued a pair of calls for applications to
examine the role of social disconnection and risk of suicide in
late life. \8\, \9\
---------------------------------------------------------------------------
\7\ Gordon and Evans (2021), pubmedncbinlmnihgov/35132392/
\8\ grantsnihgov/grants/guide/rfa-files/RFA-MH-22-135html
\9\ grantsnihgov/grants/guide/rfa-files/RFA-MH-22-136html.
NIMH has also supported research to examine the impact of
telehealth approaches to the provision of treatment for
isolated and homebound elders Further, NIMH highlights a
commentary discussing potential mechanisms of risk and
resilience among older adults at risk for the development of
prolonged grief disorder. \10\
---------------------------------------------------------------------------
\10\ Goveas and Shear (2020), pubmedncbinlmnihgov/32709542/.
In addition, other NIH Institutes and Centers, including
the National Institute on Aging (NIA), directly support
research which informs policies related to older adults' health
and well-being, particularly in the context of the COVID-19
pandemic and associated social isolation and loneliness NIA has
a robust history of promoting research to help understand how
we can reduce loneliness and enhance social connection among
older adults to improve physical and mental health outcomes The
pandemic underscored that rigorous research on the health
effects of social isolation and loneliness--and the development
of interventions to prevent or address these conditions--are
needed now more than ever \11\ To this end, NIA supports the
following:
---------------------------------------------------------------------------
\11\ Necka (2021), wwwnianihgov/research/blog/2021/06/after-covid-
research-social-isolation-and-loneliness-needed-more-ever
LStudies examining how COVID-19-associated
social isolation and loneliness impact the health and
well-being of midlife and older adult populations. \12\
---------------------------------------------------------------------------
\12\ grantsnihgov/grants/guide/notice-files/NOT-AG-21-015html.
LResearch on the biopsychosocial aspects of
social connectedness and isolation and their
association with health, well-being, illness, and
recovery, via two funding opportunity announcements.
\13\, \14\
---------------------------------------------------------------------------
\13\ grantsnihgov/grants/guide/pa-files/PAR-21-144html
\14\ grantsnihgov/grants/guide/pa-files/PAR-21-145html.
LObservational studies as well as intervention
research to identify quality of life and health
outcomes for people with dementia, with particular
interest in those who are socially isolated. \15\
---------------------------------------------------------------------------
\15\ grantsnihgov/grants/guide/notice-files/NOT-AG-18-056html.
LAn NIA-hosted Facebook Live Q&A event on
social isolation and loneliness, \16\ in which NIA
experts shared insights on how social isolation and
loneliness affect health, and how to stay connected
during and after the COVID-19 pandemic.
---------------------------------------------------------------------------
\16\ youtube/WBJclABlg--U.
LA Focus on Aging: Federal Partners' Webinar
on social isolation and loneliness, \17\ conducted by
NIA in partnership with the Administration for
Community Living, the Centers for Disease Control and
Prevention, and the Health Resources and Services
Administration.
---------------------------------------------------------------------------
\17\ youtube/tKOAO09PsFU
In concert with the efforts above, NIA supports research to
understand the effect of the COVID-19 pandemic on older adults'
health and well-being, particularly as a result of shifting
patterns of social contact Researchers found that greater
levels of concern about becoming infected with SARS-CoV-2, the
virus which causes COVID-19, were associated with greater
loneliness in older adults \18\ Researchers showed that weekly
in-person contact fell substantially during the pandemic among
older adults in both residential care and community settings
This effect was particularly pronounced among older adults
living in residential care facilities and was not
counterbalanced by an increase in video contact for these
individuals \19\ In addition, older adults with cognitive
impairment living alone during the pandemic reported
significant distress, including isolation, fear, confusion, and
variable access to essential services \20\ In addition to
experiencing these effects, older adults may also be relatively
resilient to the negative psychosocial effects of the COVID-19
pandemic, showing lower levels of stress, better psychosocial
functioning, and more effective coping behavior than younger
adults. \21\
---------------------------------------------------------------------------
\18\ Polenick et al (2021), pubmedncbinlmnihgov/33641513/
\19\ Freedman et al (2021), pubmedncbinlmnihgov/34529083/
\20\ Portacolone et al (2021), pubmedncbinlmnihgov/33404634/
\21\ Minahan et al (2021), pubmedncbinlmnihgov/33320191/.
Question 1(b). Dr. Gordon, can you please speak to how the
presence of a trusted caregiver impacts the well-being of
---------------------------------------------------------------------------
vulnerable seniors when they are in an unfamiliar setting?
Answer 1(b). NIA conducts research to better understand the
pivotal role that caregivers play in providing support to older
adults Older adults, particularly those living with chronic
disease, disability, or cognitive impairment or dementia, may
be vulnerable in unfamiliar settings and especially reliant
upon a caregiver Below are several examples of NIA-and other
NIH-supported research which indicate the potential
significance of these trusted caregivers.
In the context of COVID-19, the presence of a trusted
caregiver may be indispensable given what is known about the
presentation of COVID-19 in older adults For example, NIA-
funded researchers showed that older adults may present with
COVID-19 in an atypical manner, showing altered mental status
or functional decline, and that an atypical presentation may
lead to less aggressive care \22\ Similarly, NIA-funded
researchers showed that 28 percent of older adults with COVID-
19 present with delirium, and 37 percent of these older adults
with delirium did not show typical COVID-19 symptoms, such as
fever or cough \23\ Delirium in this context was also
associated with an increased risk of death In such situations,
the presence of a trusted caregiver might enhance recognition
of these atypical COVID-19 symptoms (eg, altered mental status/
delirium, functional decline) in an older patient, particularly
in an emergency room, hospital, or other potentially novel and
unfamiliar setting, and could enhance the likelihood of
appropriate intervention.
---------------------------------------------------------------------------
\22\ Marziliano et al (2022), pubmedncbinlmnihgov/34279628/
\23\ Kennedy et al (2020), pubmedncbinlmnihgov/33211114/.
In addition, the COVID-19 pandemic led to restrictions
regarding in-person visits in residential care settings,
thereby limiting interactions between older adults and their
families and trusted caregivers NIA-supported researchers
examined communication methods which replaced face-to-face
visits with the onset of the COVID-19 crisis and their impact
on the emotional well-being of long-term care residents These
researchers showed that the ability to communicate through
familiar and synchronous modes of communication (eg, phone
calls, email) improved residents' emotional well-being, whereas
less familiar and asynchronous methods of communication (eg,
letters delivered by a staff member) negatively affected their
emotional well-being. \24\
---------------------------------------------------------------------------
\24\ Monin et al (2020), pubmedncbinlmnihgov/33004262/.
NIH's Inclusion Across the Lifespan initiative, \25\ which
seeks to increase the recruitment and retention of older adults
and children in NIH research, has identified a need to engage
caregivers in older adults' care and well-being This
recommendation stems from the NIA-supported ``5Ts'' framework,
\26\ in which a team-based approach, incorporating geriatric
care professionals, as well as family members, caregivers, and
community partners, is posited to support the needs and well-
being of older adults in clinical research settings, including
those related to studies of COVID-19.
---------------------------------------------------------------------------
\25\ grantsnihgov/policy/inclusion/lifespanhtm
\26\ Bowling et al (2019), pubmedncbinlmnihgov/30693952/
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SENATOR HICKENLOOPER
Across the Nation, suicide is the second leading cause of
death for children and young adults In Colorado, it is number
1.
The pandemic has exacerbated mental health challenges for
kids, including increased isolation and distance from social
and emotional support.
I was proud to vote for the Omnibus bill, which included
more than $100 million for the Department of Education to
increase mental health services in schools.
Question 1. What does the data indicate about the benefit
of school interventions and support for students struggling
with mental health needs?
Answer 1. Youth have been disproportionately impacted by
the pandemic; globally, in the first year of the pandemic one
in four children reported elevated depression and one in five
reported elevated anxiety \27\ Numerous causes likely
contributed to these mental health impacts, including loss of
caregivers and family members, fear of being infected, loss of
family income, and social isolation.
---------------------------------------------------------------------------
\27\ Racine et al (2021), pubmedncbinlmnihgov/34369987/.
For more than one in three adolescents, schools provide
their primary access to mental health care \28\ School-based
health centers (SBHCs) have been recommended by the American
Academy of Pediatrics as a safety net care delivery model for
youth who do not have access to a consistent source of health
care \29\ However, more research is needed to investigate the
effectiveness of SBHCs To this end, NIMH issued a funding
opportunity announcement to support research on the delivery,
implementation, and sustainability of evidence-based mental
health interventions provided by SBHCs that also addresses
health disparities and advances health equity among underserved
populations. \30\
---------------------------------------------------------------------------
\28\ Hertz and Barrios (2021), pubmedncbinlmnihgov/33172840/
\29\ Kjolhede et al (2021), pubmedncbinlmnihgov/34544844/
\30\ grantsnihgov/grants/guide/pa-files/PAR-21-287html.
School settings also present a critical opportunity for
identifying risk and preventing youth suicide NIMH recently
hosted a webinar, titled ``School-based Suicide Prevention:
Promising Approaches and Opportunities for Research,'' in which
presenters discussed preliminary research efforts and
challenges, as well as ways to overcome common barriers to
implementing suicide prevention in schools, including data
collection and evaluation \31\ NIMH-supported investigators are
testing a universal school-based suicide prevention program,
and other NIMH-supported researchers are examining school-based
interventions to prevent depression in adolescents with
attention-deficit hyperactivity disorder (ADHD).
---------------------------------------------------------------------------
\31\ wwwnimhnihgov/news/events/2022/school-based-suicide-
prevention-promising-approaches-and-opportunities-for-research
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SENATOR MURKOWSKI
Medication Assisted Treatment
Question 1. The Anchorage Daily News reported recently that
the U.S. has passed a ``never-before-seen milestone'' in losing
more than 100,000 Americans to drug overdoses in a year Sadly,
the CDC reports that the number of drug overdoses in Alaska
rose by more than 45 percent as of June 2021 That's more than
double the rate of increase for the United States.
One treatment that we know is critical to stemming the
overdose crisis is medication that prevent withdrawal symptoms
and stem opioid cravings These medications, like buprenorphine,
can cut the risk of overdose death in half when a person starts
taking them But, outdated Federal laws and stigma are
restricting access to these life-saving medications I have
introduced the Mainstreaming Addiction Treatment Act with my
colleague, Senator Hassan, to help more Americans have access
to life-saving medication and eliminate burdensome Federal red
tape.
Question 1(a). How is the administration supporting
expanding access to medications to treat substance use disorder
so they reach all communities in need?
Answer 1(a). Methadone, buprenorphine, and naltrexone are
effective for the treatment of opioid use disorder (OUD) and
the prevention of overdose deaths, but they are highly
underutilized The Department of Health and Human Services (HHS)
released the Overdose Prevention Strategy (OPS) in October 2021
to expand access to substance use prevention, treatment, harm
reduction, and recovery support services. \32\
---------------------------------------------------------------------------
\32\ wwwhhsgov/overdose-prevention/.
To identify best approaches to expand access to and speed
the uptake of medications for OUD (MOUD) in diverse settings
and diverse populations, the National Institute on Drug Abuse
(NIDA) funds implementation research in healthcare settings,
justice settings, and community settings through the Clinical
Trials Network, \33\ the Justice Community Opioid Innovation
Network (JCOIN), \34\ and the HEALing Communities StudySM \35\
These studies are evaluating strategies for expanding OUD
screening and treatment into emergency departments, primary
care clinics, infectious disease programs, rural and American
Indian/Alaska Native communities, and criminal justice
settings.
---------------------------------------------------------------------------
\33\ nidanihgov/about-nida/organization/cctn/clinical-trials-
network-ctn
\34\ healnihgov/research/research-to-practice/jcoin
\35\ healnihgov/research/research-to-practice/healing-communities.
NIDA also funds research on the provider-and systems-level
barriers and facilitators to adoption of MOUD, particularly
among people experiencing homelessness, women, and racial/
ethnic minority groups, as well as testing new strategies to
expand MOUD access to pregnant people, rural areas, and
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justice-involved populations.
During the COVID-19 pandemic, people with OUD can now
obtain a 14-28 days' take-home supply of methadone, which may
particularly benefit people who live in rural areas or who
otherwise have had trouble accessing treatment in the past
NIDA-funded research is examining clinicians' and patients'
experiences with telehealth services for the treatment of OUD
and studying the implementation and outcomes of changes in OUD
health services delivery policies This research will be
critical for determining how to optimize access to effective
MOUD through flexibilities in the provision of MOUD.
Question 2. Infant and Early Childhood Mental Health: The
first years of life are an incredible opportunity to promote
positive mental health for babies, and health and well-being
during this time period affects future learning, behavior and
health.
Question 2(a). Have you seen a marked impact by Federal
investment in infant and early childhood mental health (IECMH)?
Answer 2. NIMH supports biomedical research to understand
the mechanisms that underlie neurodevelopment, and how typical
and atypical development affects future learning, behavior, and
mental health Novel biomarkers and behavioral indicators hold
promise for identifying at the earliest possible point who is
at risk, when development or aging is going off course, or
which preventive and treatment interventions will produce the
best outcomes for which individuals To identify promising
targets for new interventions, studies of risk factors--
including those related to genetics, experience, and the
environment--help provide clues to how mental disorders and
developmental disorders emerge.
NIMH-supported investigators found that early life stress,
for example, can cause alterations in neural circuitry and
impair social interactions later in life \36\ Other NIH-funded
studies are examining measurements of sleep and brain activity
related to mental health in children In addition, as a result
of the growing focus on mental health during the COVID-19
pandemic, NIMH is supporting research on COVID-19 mother and
baby outcomes for brain and behavior function, as well as
neurobehavioral consequences of COVID-19-related stressors on
maternal mental health and infant and child neurodevelopment
\37\, \38\
---------------------------------------------------------------------------
\36\ Opendak et al (2021), pubmedncbinlmnihgov/34706218/
\37\ Shuffrey et al (2022), pubmedncbinlmnihgov/34982107/
\38\ reporternihgov/project-details/10414939.
NIMH is committed to supporting research to identify autism
spectrum disorder (ASD) at the earliest age possible to enable
early intervention and better long-term outcomes NIMH-funded
researchers have demonstrated that differences in brain
development and function (eg, eye gaze patterns, brain growth,
and how different parts of the brain develop connections), as
well as some subtle behavioral differences, emerge in the first
months of life, before ASD symptoms begin to appear \39\, \40\
Building on these findings, NIMH is partnering with other NIH
Institutes to support researchers developing and validating new
screening methods for ASD that can be used in the first year of
life \41\ For example, NIMH and the NICHD supported researchers
developed an eye-tracking app that successfully distinguished
toddlers diagnosed with ASD from typically developing toddlers
\42\ Study results indicate that an app-based approach could be
used to screen infants and toddlers for ASD and refer them for
early intervention when likelihood for treatment success is
greatest (ie, at younger ages) In addition, a network of NIMH-
funded researchers has tested different models of service
engagement and coordination to determine how best to eliminate
disparities in diagnosis, and how to diagnose children within
underserved populations at earlier ages \43\, \44\
---------------------------------------------------------------------------
\39\ Hazlett et al (2017), pubmedncbinlmnihgov/28202961/
\40\ Stallworthy et al (2022), pubmedncbinlmnihgov/33965519/
\41\ wwwnimhnihgov/news/science-news/2019/nih-awards-funding-for-
early autism-screening
\42\ wwwnimhnihgov/news/science-news/2021/media-advisory-
prototype-app-for-mobile-devices-could-screen-children-at-risk-for-
autism-spectrum-disorder
\43\ Sheldrick et al (2022), pubmedncbinlmnihgov/34982099/
\44\ Pierce et al (2019), pubmedncbinlmnihgov/31034004/.
In addition, NICHD is committed to supporting research to
identify and examine the psychological and behavioral factors
and processes that influence social/emotional development and
expression in individuals with intellectual and developmental
disabilities NICHD-funded researchers recently examined the
role of behavioral and mindfulness-based interventions in
promoting parent and child well-being in families with children
demonstrating intellectual and developmental disabilities. \45\
---------------------------------------------------------------------------
\45\ McIntyre (2020), pubmedncbinlmnihgov/32936889/.
Question 3. Suicide Screening in the Emergency Department:
A recent CDC report on emergency department visits for people
age 12-25 found an over 50 percent increase visits for
suspected suicide attempts during early 2021 This underscores
the devastating mental health impact of the pandemic on our
youth and highlights yet another way that COVID-19 has strained
---------------------------------------------------------------------------
our hospitals and medical staff.
I introduced a bill, the Effective Suicide Screening and
Assessment in the Emergency Department Act, to improve the
screening and treatment of patients in hospital emergency
departments who are at high risk for suicide It will make sure
that we can better identify our most vulnerable mental health
patients so they do not slip through the cracks when they are
treated in hospitals, and make sure hospitals have the
resources they need to provide these critical services.
Question 3(a). What is the need for improved suicide
screening protocols in the Nation's emergency rooms?
Answer 3. Developing suicide risk screening tools and
testing their effectiveness in real-world settings such as
emergency departments (EDs) remains a high-priority research
area for NIMH Approximately 80 percent of U.S. suicide
decedents accessed health care services in the 12 months
preceding their death, and nearly 30 percent had a health care
visit in the week before suicide, demonstrating that health
care systems can play a vital role in identifying individuals
at risk and preventing suicide attempts. \46\
---------------------------------------------------------------------------
\46\ Gordon, Avenevoli, and Pearson (2020), pubmedncbinlmnihgov/
32432690/.
NIMH-funded researchers demonstrated that the use of brief
screening tools in EDs can improve providers' ability to
identify individuals at risk for suicidal behavior and refer
them to treatment \47\ As one example, the NIMH-funded ED
Safety Assessment & Follow-up Evaluation (ED-SAFE) study found
that universal screening of ED patients doubled the rate of
risk detection (from 3 percent to 6 percent), and that ED-
initiated interventions reduced subsequent suicidal behavior by
30 percent \48\ Additionally, NIMH-funded researchers developed
the Ask Suicide-Screening Questions tool--a very brief (four-
question) screening instrument that was shown to identify risk
for suicide in pediatric emergency departments and has now been
adapted for use across multiple other settings and populations.
\49\, \50\
---------------------------------------------------------------------------
\47\ wwwnimhnihgov/news/science-news/2021/adaptive-screener-may-
help-identify-youth-at-risk-of-suicide
\48\ Boudreaux et al (2016), pubmedncbinlmnihgov/26654691/
\49\ Horowitz et al (2012), pubmedncbinlmnihgov/23027429/
\50\ wwwnimhnihgov/research/research-conducted-at-nimh/asq-
toolkit-materials.
Question 3(b). Do you support efforts to bolster the
resources available to emergency rooms so they can enhance
---------------------------------------------------------------------------
their screening for high-risk suicide patients?
Answer 3(b). Since emergency departments and other health
care settings have a critical role in identifying and providing
preventive interventions for individuals at risk of suicide, it
is important that these settings have the resources they need
to implement effective screening tools and evidence-based
preventive interventions NIMH remains committed to supporting
research on developing and validating tools and interventions
for use in such settings, and also on identifying innovative
and sustainable service delivery models to ensure that such
tools and interventions are widely available.
Question 4. FASD: During COVID, we have seen a sharp rise
in substance misuse specifically alcohol, the most widely used
and misused substance Unfortunately, a landmark NIH study in
2018 established that 1 in 20 school-aged children are affected
by fetal alcohol spectrum disorders--FASD Due to its
significance and status as an overlooked disability that
includes debilitating stigma, I introduced S 2238, the FASD
Respect Act My legislation establishes common standards of care
and increases the capacity to manage FASD in medical and mental
health settings.
Question 4(a). How can we address the social and
environmental factors that contribute to prenatal alcohol
exposure and reduce the traumas FASD creates for individuals
and families?
Answer 4. The risk for use of alcohol during pregnancy is
influenced by a range of environmental and social factors such
as social isolation, living in environments where alcohol
misuse is common and accepted, and having limited resources for
prenatal care Stigma can serve as a barrier to pursuing and
receiving care for alcohol misuse or an alcohol use disorder as
part of prenatal care This is particularly concerning given
recent research indicating that during 2018--2020, 135 percent
of pregnant adults in the United States reported current
drinking, 52 percent reported binge drinking, and those with no
routine health care provider or with frequent mental distress
were more likely to consume alcohol The risk of an individual
being born with a fetal alcohol spectrum disorder (FASD) is
influenced by factors such as the level and frequency of
alcohol exposure during prenatal development and when during
prenatal development alcohol exposure occurs Maternal factors
that can also influence this risk include inadequate nutrition
and smoking or other substance use, among other factors In
addition to the physical, cognitive, and other challenges
individuals with FASD may face, stigma can be a barrier to
seeking and receiving the health, educational, and professional
care and support they need.
Evidence-based prevention and treatment interventions,
improved access to care, and substance misuse and mental health
services integrated into routine health care are among the
strategies needed to prevent and reduce prenatal alcohol
exposure For children who are prenatally exposed to alcohol,
widespread screening (including when screening for
developmental disabilities), accurate diagnosis, early
intervention, and access to support services are needed to
improve the health and quality of life for individuals with
FASD and their families.
The National Institute on Alcohol Abuse and Alcoholism
(NIAAA), part of the NIH, supports a broad research portfolio
on the etiology, prevention, diagnosis, and treatment of FASD A
major research program funded by NIAAA is the Collaborative
Initiative on Fetal Alcohol Spectrum Disorders (CIFASD) with
the goal to improve prevention of FASD, diagnosis of the full
range of birth defects associated with prenatal alcohol
exposure, and interventions for affected individuals One recent
study includes the development and evaluation of mobile apps to
give caregivers of children with FASD to help them learn new
skills to manage their children's behavior and to provide
adults with FASD tools to promote their own self-management and
health advocacy goals.
To facilitate widespread screening and early diagnosis of
FASD, CIFASD researchers have developed three-dimensional
photography and computerized image analysis that can enhance
the detection of a broad range of alcohol-induced facial
characteristics in children with prenatal alcohol exposure This
approach is being refined and could improve access to FASD
diagnosis in underserved regions Other projects are developing
screening tools that distinguish neurobehavioral features
associated with FASD from other neurodevelopmental conditions
NIAAA-supported studies also focus on the use of novel
methodologies such as 3D fetal ultrasound, blood-based
biomarkers, and physiological measures to improve earlier
identification of prenatal alcohol exposure and risk of
neurodevelopmental delay among neonates, infants, or young
children.
Developing culturally appropriate approaches for the
prevention of alcohol-exposed pregnancies also continues to be
an important focus of NIAAA research For example, an ongoing
study is conducting a randomized clinical trial of a culturally
appropriate prevention program delivered via a smartphone app
for urban American Indian and Alaska Native women ages 16-20
This study is also examining the impact of the COVID-19
pandemic on risk of alcohol-exposed pregnancy NIAAA-supported
research is also evaluating the effectiveness of nutritional
supplementation, administered prenatally and during childhood,
to mitigate the adverse impact of prenatal alcohol exposure
Studies have shown that screening, brief intervention, and
referral to treatment (SBIRT) approaches are a significant tool
for addressing alcohol and other substance use in primary and
prenatal care settings NIAAA will continue to encourage alcohol
SBIRT in these settings and provide resources to assist health
care providers in improving care for patients with alcohol
misuse, such as our Alcohol Treatment Navigator and soon-to-be
launched Healthcare Professional's Core Resource on Alcohol.
Moving forward, NIAAA will continue to encourage research
on prevention and intervention approaches for FASD through
funding opportunities \51\, \52\ Among the research topics of
interest is advancing strategies to reduce stigmatization of
biological mothers of children with FASD and individuals with
FASD NIAAA will continue its overall effort in reducing
alcohol-related stigma by promoting the use of non-stigmatizing
language when describing alcohol-related issues and the people
who experience them. \53\
---------------------------------------------------------------------------
\51\ grantsnihgov/grants/guide/pa-files/PAR-21-097html
\52\ grantsnihgov/grants/guide/pa-files/PAR-21-098html
\53\ wwwniaaanihgov/alcohols-effects-health/reducing-alcohol-
related-stigma.
Question 4(b). What steps are being taken by the
administration to provide more education and training on FASD?
How can stigma be lessened for individuals living with
---------------------------------------------------------------------------
behavioral health conditions, like FASD?
Answer 4(b). NIAAA sponsors and chairs the Interagency
Coordinating Committee on FASD (ICCFASD) to foster improved
communication, cooperation, and collaboration among Federal
agencies that address issues related to prenatal alcohol
exposure \54\ Several member agencies of ICCFASD have ongoing
efforts aimed at improving education and training on FASD and
reducing stigma for people living with FASD These agencies can
be contacted for more information Examples of their educational
efforts are:
---------------------------------------------------------------------------
\54\ wwwniaaanihgov/interagency-coordinating-committee-fetal-
alcohol-spectrum-disorders
LThrough its Collaborative for Alcohol-Free
Pregnancy, the Centers for Disease Control and
Prevention (CDC) works with multiple partner
organizations to educate healthcare professionals on
the risks of alcohol use during pregnancy and to equip
them to help their patients in preventing prenatal
alcohol use and identifying and caring for individuals
and families living with FASDs Disciplines represented
are family medicine, medical assisting, nursing,
obstetrics-gynecology, pediatrics, and social work CDC
and partners involved in the Collaborative have
developed and disseminated a wide range of online
courses on alcohol use during pregnancy and FASDs for
healthcare providers These free courses offer
continuing education and are available at wwwcdcgov/
FASDtraining \55\
---------------------------------------------------------------------------
\55\ nccdcdcgov/FASD/.
LThe Administration for Children and Families
Children's Bureau in collaboration with the CDC support
the Prenatal Alcohol and Other Drug Exposures in Child
Welfare Study which explores the current knowledge,
attitudes, policies, practices, and needs of child
welfare agencies for identifying and caring for
children who were exposed to alcohol and other drugs
during pregnancy Findings from this study can be found
at https://wwwacfhhsgov/cb/report/prenatal-alcohol-
drug-exposures-final-report and are being used to
inform the development of resources and tools for
professionals serving child welfare populations. \56\
---------------------------------------------------------------------------
\56\ wwwacfhhsgov/cb/report/prenatal-alcohol-drug-exposures-final-
report.
LCDC, in collaboration with March of Dimes,
developed the Beyond Labels Stigma Reduction
interactive website Designed for people who work in
health-related fields, this site helps users learn how
stigma can impact the healthcare and support women
need, seek, and receive during pregnancy The site
provides information on why stigma happens, stories
about the impact of stigma, and specific ways users can
become a change agent to reduce stigma in their
workplace or community This resource also offers a
specific module on stigma around substance use during
---------------------------------------------------------------------------
pregnancy.
LThe Health Resources and Services
Administration's Maternal and Child Health Bureau
established the SAFEST Choice Learning Collaborative, a
primary care provider education and practice
improvement effort to reduce prenatal alcohol exposure
and improve outcomes in children with suspected or
diagnosed FASD. \57\
---------------------------------------------------------------------------
\57\ wwwbmcorg/addiction/training-education/safest-choice
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SENATOR SCOTT
School closures have failed America's children,
particularly students in marginalized communities whose
families are living paycheck-to-paycheck From learning loss to
mental health crises, the damaging effects of school closures
on our Nation's children are undeniable.
Because of this, I introduced the Kids in Classes Act,
which would allow families with children in Title I schools to
put unused Federal education funds toward in-person education,
should their school close due to COVID-19 or a teachers union
strike.
You noted yourself in your testimony before this Committee
that ``the effects on our youth, though still not full
quantified, are substantial'' Based on your remarks, I think
you would agree with me when I say that if we want to move
forward, we must examine the long-term repercussions of COVID-
19 on students' academic and health outcomes.
As such, I joined my colleagues on both sides of the aisle
to introduce the Assessing Children's Academic Development and
the Emotional and Mental Health Implications of COVID-19
(ACADEMIC Act), which would help to better assess the impact of
the pandemic on student outcomes and well-being I am hopeful
this legislation will pass and am eager to see the results, but
I am also interested in what the National Institute of Mental
Health has found in its preliminary research.
Question 1. Dr. Gordon, what impact do you think school
closures have had on the youth mental health crisis we are
facing?
Answer 1. The COVID-19 pandemic has been challenging for
many children, due to the fear of being infected, loss of
economic, food, caregiver, or housing security, in addition to
over 140,000 children losing at least one parent or caregiver
to COVID-19 as of June 2021 \58\ Children are also facing
challenges due to the cumulative social effects of hybrid and
remote schooling and the need for physical distancing, which
may leave some feeling less connected with their peers and
teachers While early data indicate that school closures and
other mitigation efforts were effective at significantly
reducing the spread and mortality of COVID-19, \59\, \60\
school closures have also been associated with increased mental
health symptoms among children \61\ It is currently unknown
whether the benefits of school closures outweigh the drawbacks,
\62\ and it will likely take years to fully understand the
long-term effects of the COVID-19 pandemic and mitigation
efforts.
---------------------------------------------------------------------------
\58\ Hillis et al (2021), pubmedncbinlmnihgov/34620728/
\59\ Liu et al (2021), pubmedncbinlmnihgov/34020613/
\60\ Liyaghatdar et al (2021), pubmedncbinlmnihgov/34849394/
\61\ Verlenden et al (2021), pubmedncbinlmnihgov/33735164/
\62\ Mulligan (2021), pubmedncbinlmnihgov/34334835/.
For more than one in three adolescents, schools provide
primary access to mental health care \63\ Pandemic-related
school closures and remote schooling may cutoff or limit access
to these resources, leaving many youths disconnected from their
primary sources of social support and mental health treatment
As schools continue to navigate in-person and remote schooling,
it will be important to consider ways to ensure that youth with
or at risk for mental illnesses have access to the supports
they need.
---------------------------------------------------------------------------
\63\ Ali et al (2019), pubmedncbinlmnihgov/30883761/.
NIH is funding research investigating evidence-based
approaches for children to safely remain in school during the
COVID-19 pandemic For example, NICHD manages the Safe Return to
School Diagnostic Testing Initiative, launched in 2021 as part
of the NIH Rapid Acceleration of Diagnostics-Underserved
Populations (RADxSM-UP) program \64\ This initiative addresses
the needs of children with unequal access to COVID-19 testing
and who face barriers to attending school remotely, including
those who do not have adequate equipment, internet access, or
adult supervision at home The RADx-UP Return to School projects
combine frequent COVID-19 testing with evidence-based safety
measures to reduce the spread of SARS-CoV-2 \65\ Early results
indicate that COVID-19 testing is feasible and acceptable in
the school setting across a range of populations Furthermore,
these community-engaged projects will aid in our understanding
of the social, behavioral, and ethical implications of COVID-19
testing implementation within underserved and vulnerable school
communities.
---------------------------------------------------------------------------
\64\ wwwnihgov/research-training/medical-research-initiatives/
radx/funding--radx-up-funded
\65\ D'Agostino et al (2022), pubmedncbinlmnihgov/34737180/.
Findings from a nationwide study of 1,290 parents of
children aged 5-12 years conducted during October and November
2020, suggest children not receiving full-time, in-person
instruction and their parents ``might experience increased risk
for negative mental/emotional and physical health outcomes''
\66\ Specifically----
---------------------------------------------------------------------------
\66\ Verlenden et al (2021), https://pubmedncbinlmnihgov/33735164/
LParents of children receiving virtual-only or
combined instruction more frequently reported that
their child's mental/emotional health worsened during
the pandemic and that their time outside, time in-
---------------------------------------------------------------------------
person with friends, and physical activity decreased.
LParents of children receiving virtual-only
instruction more frequently reported their own
distress, difficulty sleeping, loss of work, concern
about job stability, conflict between work and
providing childcare, and childcare challenges than did
parents whose children were receiving in-person only
instruction.
LChildren receiving in-person instruction and
their parents reported the lowest prevalence of
negative indicators of child and parent well-being.
LParents whose children attended school in-
person only were less likely to report challenges with
employment and childcare.
Moreover, findings from a similar nationwide survey of 567
adolescents aged 13-19 years, conducted during October--
November 2020, suggested similar results: \67\
---------------------------------------------------------------------------
\67\ Hertz et al (2022), https://pubmedncbinlmnihgov/34930571/
LStudents attending school virtually reported
---------------------------------------------------------------------------
poorer mental health than students attending in-person.
LRacial/ethnic disparities related to mode of
school instruction were noted, with virtual instruction
only more prevalent among Black (68 percent) and
Hispanic students (69 percent) compared to White
students (48 percent).
LAdolescents receiving virtual instruction
reported more mentally unhealthy days, more persistent
symptoms of depression, and a greater likelihood of
seriously considering attempting suicide than students
in other modes (in-person or hybrid) of instruction.
LAfter demographic adjustments, school and
family connectedness each reduced the strength of the
association between virtual versus in-person
instruction for all of the examined mental health
indicators
SENATOR TUBERVILLE
Question 1. we know that one in four Americans reports
having been a victim of crime in the past 10 years, and half of
those were victims of a violent crime Most report receiving no
help in the aftermath Police, corrections leaders, and the
courts agree that untreated mental health or co-occurring
substance abuse disorders are core drivers of the cycle of
crime and that they lack the infrastructure to respond
appropriately.
Question 1(a). What do you see as the individual and
societal impacts of untreated trauma as it relates to mental
health and substance use disorder?
Answer 1. Traumatic events include any shocking, scary, or
dangerous event in which someone experienced, or was threatened
with, death or serious injury, or witnessed the death or threat
to the physical safety of others Without professional
intervention, trauma is likely to result in negative mental and
behavioral health consequences, including post-traumatic stress
disorder, substance use, and substance use disorders (SUDs).
Among people diagnosed with SUDs, a history of exposure to
violence or other traumatic experiences is common, as are
experiences of mental illnesses such as post-traumatic stress
disorder SUDs also exacerbate the impacts of trauma exposure,
with downstream effects on individuals, families, and society,
including job loss, housing instability, fractured
relationships, and legal system involvement Despite the known
bidirectional, deleterious relationship between trauma and
SUDs, a major gap exists in understanding how trauma history
affects treatment seeking, treatment retention, and recovery
from SUDs.
NIMH supports clinical research focused on developing a
deeper, more complete understanding of how exposure to
traumatic stress affects individuals' mental health, with
particular emphasis on youth and U.S. military service members,
as these groups are disproportionately impacted by trauma As an
example of NIMH-supported research in this area, a study of
over 9,000 youths between the ages of 8 and 21 found that low
socioeconomic status and the experience of traumatic stressful
events were associated with alterations in neurodevelopment and
cognition, as well as greater severity of psychiatric symptoms
such as anxiety, depression, fear, externalizing behavior, and
psychosis. \68\
---------------------------------------------------------------------------
\68\ Gur et al (2019), pubmedncbinlmnihgov/31141099/.
Similarly, NIDA continues to support studies at the
intersection of substance use and trauma Current studies aim to
adapt evidence-based interventions and test novel approaches
tailored to individuals at the highest risk for comorbid SUDs
and trauma-related stress, including people who have
experienced interpersonal violence, multiple adverse childhood
experiences, or racial trauma In addition, the HEALthy Brain
and Child Development Study and the Adolescent Brain Cognitive
Development (ABCD) Study, which NIDA respectively leads and co-
leads with other NIH Institutes, will substantially contribute
to our understanding of healthy development and the impact of
adverse childhood experiences on outcomes like substance use
and post-traumatic stress, paving the way for new prevention
---------------------------------------------------------------------------
and treatment interventions.
Question 2. Federal data shows that 37 percent of people
sentenced to prison, and 44 percent of people arrested and
jailed, have experienced a mental health issue At the same
time, we know that an estimated 1 in 10 police service calls
are responding to an untreated mental health issue Across the
country, we've seen community-based programs that seek to
divert individuals experiencing mental health issues, direct
individuals to treatment and resources, and do so in a way so
the police department does not have to be involved.
Question 2(a). What is the Federal Government doing to
ensure that mental health emergencies are being responded to
appropriately, early on, before a treatable illness becomes a
safety issue?
Answer 2. As noted by the Substance Abuse and Mental Health
Services Administration, ``preventing mental and substance use
disorders or co-occurring disorders and related problems is
critical to behavioral and physical health'' \69\ NIMH shares
this sense of urgency for ensuring that individuals
experiencing or at high risk for a mental health emergency are
able to receive effective, evidence-based interventions as
early as possible NIMH aims to build the evidence base for
effective interventions through research For example, NIMH
recently supported a study designed to examine the
effectiveness of a new police-to-mental-health linkage system
that would provide opportunities for officers to involve a
mental health professional immediately and directly during
encounters with individuals with serious mental illness NIMH
also supported a study aiming to evaluate alternative mental
health crisis services that seek to reduce the incarceration of
individuals with serious mental illnesses and provide
alternatives to law enforcement in responding to mental health
crises.
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\69\ wwwsamhsagov/find-help/prevention.
As well, NIMH supports research focused on identifying
individuals and populations most at risk for suicide,
understanding the causes of suicide risk, developing suicide
prevention interventions, and testing the effectiveness of
these interventions and services in real-world settings Because
many suicide decedents in the United States access health care
services in the 12 months before their death by suicide, \70\
NIMH is prioritizing research on practices within health care
settings that may identify individuals at risk for suicide.
\71\
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\70\ Hedegaard et al (2021), wwwcdcgov/nchs/products/databriefs/
db398htm.
\71\ wwwnimhnihgov/news/science-news/2020/nimh-leadership-
describes-suicide-prevention-research-priorities.
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------
Response by Nora D. Volkow to Questions From Senator Casey, Senator
Murkowski, and Senator Tuberville
SENATE CASEY
Without a robust mental health and substance use disorder
system of care, we are unfortunately asking law enforcement
officers to be on the frontlines of addressing mental health
and substance use crises In response, some communities have
been developing programs like Crisis Assistance Helping Out on
the Streets (or CAHOOTS) that divert mental health calls to
mobile crisis teams staffed by a mental health professional
along with an EMT or nurse.
Question 1. What models of non-law enforcement mental
health and substance use crisis interventions are effective and
which would you want to see made available to communities
across the country?
Answer 1. When someone with a substance use disorder (SUD)
or other mental health condition is in crisis--potentially at
risk of suicide or overdose--and does not pose a threat to
public safety, a response aimed at connecting the person to
treatment should be available CAHOOTS and similar programs
deploy mental health crisis teams to redirect the person toward
essential healthcare and away from law enforcement resources in
appropriate circumstances Given promising results to date, the
White House Office of National Drug Control Policy has
commissioned a model law, the Law Enforcement and Other First
Responder Deflection Act, \1\ to make it easier for states to
establish deflection programs Existing legislation in this area
includes the National Suicide Hotline Designation Act of 2020
which designates ``9-8-8'' as the universal telephone number in
the United States for the national suicide prevention and
mental health and substance use crisis hotline system; and new
funding authorized under President Biden's American Rescue Plan
to support community-based mobile crisis intervention services
for persons with Medicaid \2\ In February 2020, NIH issued a
Notice of Special Interest encouraging research on the full
continuum of crisis service systems.
---------------------------------------------------------------------------
\1\ legislativeanalysisorg/model-law-enforcement-and-other-first-
responder-deflection-act/
\2\ https://wwwCongressgov/bill/116th-congress/senate-bill/2661/
text--overview--closed.
In addition to crisis response, it is important to invest
in preventive health programs to reduce the risk of crisis from
occurring in the first place For this reason, NIH funds
research to develop and test methods of delivering preventive
care to people at high risk from substance use and other mental
health issues For example, to reduce the risk of opioid
overdose, the HEALing Communities StudySM aims to integrate SUD
prevention and treatment across primary care, behavioral
health, justice, and other community-based settings in
communities hit hard by the opioid overdose epidemic This study
is part of the NIH Helping to End Addiction Long-term (HEAL)
Initiative and is funded by the National Institute on Drug
Abuse (NIDA) and the Substance Abuse and Mental Health Services
---------------------------------------------------------------------------
Administration (SAMHSA).
Because individuals involved in the justice system are at
particularly high risk of suicide and overdose, NIH supports
research into interventions to reduce these risks For example,
NIDA's Justice Community Opioid Innovation Network (JCOIN),
funded by the HEAL Initiative, is testing strategies to expand
treatment for opioid use disorder (OUD) in justice settings The
National Institute of Mental Health (NIMH) is supporting
research on interventions to reduce suicide risk among
incarcerated youth as they transition to residential placement
and probation, and among incarcerated adults as they re-enter
their communities NIMH, the NIH Office of Behavioral and Social
Sciences Research (OBSSR), and the National Institute of
Justice (NIJ) are also funding a study to test whether a safety
plan developed for and by at-risk adults during jail detention
can reduce their suicide risk after release from jail.
In addition to efforts to prevent and reduce drug use, NIDA
supports research into harm reduction, which involves
strategies to prevent overdose and infectious disease among
people who use drugs One such strategy is to increase
availability and use of naloxone, a medication that can rapidly
reverse opioid overdose Through funds from the HEAL Initiative,
NIDA plans to establish a Harm Reduction Network that aims to
increase our understanding of the effectiveness,
implementation, and impact of existing and new harm reduction
strategies Projects are expected to begin as early as September
2022.
SENATOR MURKOWSKI
Fentanyl Overdose Deaths
Question 1. Overdose deaths from fentanyl are on the rise,
including in Alaska, which saw deaths triple from 2019 to 2020
The loss of a loved one impacts friends, families, and
communities who continue to bear the trauma of addiction long
after someone passes I have heard directly from Alaskans who
have lost their children and are now dedicating their lives to
prevent future overdose deaths from fentanyl.
Unfortunately, this drug has a high lethality that can harm
both the user and responder I was horrified to learn about five
young men and women who overdosed on fentanyl-laced cocaine a
couple weeks ago while on spring break in Florida What is
particularly distributing, is that two of these young men
didn't consume the substance, but were performing CPR on their
friends when they went into respiratory arrest They were
exposed to fentanyl while they were performing mouth-to-mouth
resuscitation.
Congress needs to take action before fentanyl claims one
more American we need to start by educating people about the
lethality of fentanyl and the risk of contaminated drugs.
Question 1(a). Dr. Volkow, how can we raise awareness to
ensure no good Samaritans are harmed when responding to a
fentanyl overdose?
Answer 1. Despite media reports alleging first responder
exposures to fentanyl, the risks for secondhand fentanyl
toxicity when rendering aid to a person who is experiencing
overdose are very low Unfortunately, research shows that
misinformation about risk from accidentally coming in contact
with fentanyl is abundant among first responders The good news
is that this study also shows that education shows greats
promise in correcting these false beliefs \3\ ``Second-hand''
fentanyl exposure--eg, through mouth-to-mouth cardiopulmonary
resuscitation (CPR)--has not been documented and is unlikely,
given that once consumed, fentanyl is rapidly absorbed across
mucous membranes into the blood \4\ Common preparations of
fentanyl include liquid, pills, and powder that can be
injected, ingested, or inhaled Inadvertent consumption of
fentanyl by these routes, at a dose required for toxicity,
would occur only in exceptional cases where a significant
volume of drug powder, liquid, or aerosol becomes airborne \5\
For example, a 2010 medical report describes a veterinarian who
became drowsy after accidentally splashing himself in the mouth
and eyes with an animal tranquilizer that contained fentanyl
\6\ and in 2017, the American College of Medical Toxicology
(ACMT) and the American Academy of Clinical Toxicology (AACT)
concluded that a person would have to breathe fentanyl at its
highest airborne concentrations for 200 minutes to ingest a
therapeutic does, which still would not be potentially fatal.
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\3\ del Pozo, et al Can touch this: training to correct police
officer beliefs about overdose from incidental contact with fentanyl
Health Justice 9, 34 (2021) https://doiorg/101186/s40352-021-00163-5
\4\ Lhtsch, Walter, Parnham, et al (2012) Pharmacokinetics of Non-
Intravenous Formulations of Fentanyl Clin Pharmacokinet 52, 23--36
\5\ Moss, Warrick, Nelson, et al (2017) ACMT and AACT Position
Statement: Preventing Occupational Fentanyl and Fentanyl Analog
Exposure to Emergency Responders J Med Toxicol 13(4): 347--351
\6\ George, Lu, Pisano, et al (2010) Carfentanil--an ultra potent
opioid Am J Emerg Med 28(4):530-532.
Transdermal patches have become a familiar means of
fentanyl delivery and unfortunately have been linked to
accidental poisonings Yet these patches are designed to be
firmly pressed to the skin and worn for many hours, with the
fentanyl contained in a liquid or gel that aids absorption By
contrast, accidental skin contact with fentanyl pills or powder
is exceedingly unlikely to cause harm For instance, a study
demonstrated that an extreme example of covering both palms of
a person with fentanyl patches, each specifically designed to
transmit high doses through skin (unlike powders or tablets),
would take 14 minutes to reach clinically significant levels,
\7\ leading the ACMT and AACT to conclude that it ``is very
unlikely that small, unintentional skin exposures to tablets or
powder would cause significant opioid toxicity, and if toxicity
were to occur, it would not develop rapidly, allowing time for
removal''.
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\7\ Rhodes & Phillips (2013) The surface area of the hand and the
palm for estimating percentage of total body surface area: results of a
meta-analysis Br J Dermatol 169(1):76-84.
Despite the low probability of actual opioid toxicity,
there are other reasons that responders at the scene of an
overdose might report symptoms of possible exposure Responding
to an overdose can be a stressful experience, even for
emergency personnel, and observing known or suspected opioids
at the scene can cause anxiety about exposure Indeed, analyses
of responders who report potential exposure to opioids
typically find no conclusive route of exposure and symptoms
that are more consistent with anxiety (eg, dizziness, nausea,
palpitations) than with opioid toxicity (eg, slowed breathing).
\8\
---------------------------------------------------------------------------
\8\ https://wwwcdcgov/niosh/topics/opioids/
fieldinvestigationshtml.
Given the potency of synthetic opioids such as fentanyl and
their increasing presence in the illicit drug supply, concerns
about accidental exposure are understandable However, a person
rendering standard aid to an overdose victim--including CPR or
naloxone--has little danger of opioid toxicity More dangerous
is the possibility that the person might decline to render aid
based on fears about fentanyl exposure.
Medication Assisted Treatment
Question 2. The Anchorage Daily News reported recently that
the U.S. has passed a ``never-before-seen milestone'' in losing
more than 100,000 Americans to drug overdoses in a year Sadly,
the CDC reports that the number of drug overdoses in Alaska
rose by more than 45 percent as of June 2021 That's more than
double the rate of increase for the United States.
One treatment that we know is critical to stemming the
overdose crisis is medication that prevent withdrawal symptoms
and stem opioid cravings These medications, like buprenorphine,
can cut the risk of overdose death in half when a person starts
taking them But, outdated Federal laws and stigma are
restricting access to these life-saving medications I have
introduced the Mainstreaming Addiction Treatment Act with my
colleague, Senator Hassan, to help more Americans have access
to life-saving medication and eliminate burdensome Federal red
tape.
Question 2(a). How is the administration supporting
expanding access to medications to treat substance use disorder
so they reach all communities in need?
Answer 2. Methadone, buprenorphine, and naltrexone are
effective for the treatment of OUD and the prevention of
overdose deaths, but they are highly underutilized The
Department of Health and Human Services (HHS) released the
Overdose Prevention Strategy (OPS) in October 2021 to expand
access to substance use prevention, treatment, harm reduction,
and recovery support services.
To identify best approaches to expand access to and speed
the uptake of medications for OUD (MOUD) in diverse settings
and diverse populations, NIDA funds implementation research in
healthcare settings, justice settings, and community settings
through the JCOIN, and the HEALing Communities Study These
studies are evaluating strategies for expanding OUD screening
and treatment into emergency departments, primary care clinics,
infectious disease programs, rural and American Indian/Alaska
Native communities, and criminal justice settings.
NIDA also funds research on the provider-and systems-level
barriers and facilitators to adoption of MOUD, particularly
among people experiencing homelessness, women, and racial/
ethnic minority groups, as well as testing new strategies to
expand MOUD access to pregnant people, rural areas, and
justice-involved populations.
Policy changes made at the beginning of the COVID-19
pandemic have allowed people with OUD to obtain a 14-28 days'
take-home supply of methadone, which particularly benefits
people in rural areas or those who otherwise had trouble
accessing treatment in the past NIDA-funded research is
examining clinicians' and patients' experiences with telehealth
services for the treatment of OUD and studying the
implementation and outcomes of changes in OUD health services
delivery policies This research will be critical for
determining how to optimize access to effective MOUD through
flexibilities in the provision of MOUD.
Question 3. Infant and Early Childhood Mental Health: The
first years of life are an incredible opportunity to promote
positive mental health for babies, and health and well-being
during this time period affects future learning, behavior and
health.
Question 3(a). Have you seen a marked impact by Federal
investment in infant and early childhood mental health (IECMH)?
Answer 3. NIMH supports biomedical research to understand
the mechanisms that underlie neurodevelopment, and how typical
and atypical development affects future learning, behavior, and
mental health Novel biomarkers and behavioral indicators hold
promise for identifying at the earliest possible point who is
at risk, when development or aging is going off course, or
which preventive and treatment interventions will produce the
best outcomes for which individuals To identify promising
targets for new interventions, studies of risk factors--
including those related to genetics, experience, and the
environment--help provide clues to how mental disorders and
developmental disorders emerge.
NIMH-supported investigators found that early life stress,
for example, can cause alterations in neural circuitry and
impair social interactions later in life Other NIH-funded
studies are examining measurements of sleep and brain activity
related to mental health in children In addition, as a result
of the growing focus on mental health during the COVID-19
pandemic, NIMH is supporting research on COVID-19 mother and
baby outcomes for brain and behavior function, as well as
neurobehavioral consequences of COVID-19-related stressors on
maternal mental health and infant and child neurodevelopment.
NIMH is committed to supporting research to identify autism
spectrum disorder (ASD) at the earliest age possible to enable
early intervention and better long-term outcomes NIMH-funded
researchers have demonstrated that differences in brain
development and function (eg, eye gaze patterns, brain growth,
and how different parts of the brain develop connections), as
well as some subtle behavioral differences, emerge in the first
months of life, before ASD symptoms begin to appear Building on
these findings, NIMH is partnering with other NIH Institutes to
support researchers developing and validating new screening
methods for ASD that can be used in the first year of life For
example, NIMH and the Eunice Kennedy Shriver National Institute
of Child Health and Human Development (NICHD) supported
researchers developed an eye-tracking app that successfully
distinguished toddlers diagnosed with ASD from typically
developing toddlers Study results indicate that an app-based
approach could be used to screen infants and toddlers for ASD
and refer them for early intervention when likelihood for
treatment success is greatest (ie, at younger ages) In
addition, a network of NIMH-funded researchers has tested
different models of service engagement and coordination to
determine how best to eliminate disparities in diagnosis, and
how to diagnose children within underserved populations at
earlier ages.
In addition, NICHD is committed to supporting research to
identify and examine the psychological and behavioral factors
and processes that influence social/emotional development and
expression in individuals with intellectual and developmental
disabilities NICHD-funded researchers recently examined the
role of behavioral and mindfulness-based interventions in
promoting parent and child well-being in families with children
demonstrating intellectual and developmental disabilities.
Question 4. Suicide Screening in the Emergency Department:
A recent CDC report on emergency department visits for people
age 12-25 found an over 50 percent increase visits for
suspected suicide attempts during early 2021 This underscores
the devastating mental health impact of the pandemic on our
youth and highlights yet another way that COVID-19 has strained
our hospitals and medical staff.
I introduced a bill, the Effective Suicide Screening and
Assessment in the Emergency Department Act, to improve the
screening and treatment of patients in hospital emergency
departments who are at high risk for suicide It will make sure
that we can better identify our most vulnerable mental health
patients so they do not slip through the cracks when they are
treated in hospitals, and make sure hospitals have the
resources they need to provide these critical services.
Question 4(a). What is the need for improved suicide
screening protocols in the Nation's emergency rooms?
Answer 4. Developing suicide risk screening tools and
testing their effectiveness in real-world settings such as
emergency departments (EDs) remains a high-priority research
area for NIMH Approximately 80 percent of U.S. suicide
decedents accessed health care services in the 12 months
preceding their death, and nearly 30 percent had a health care
visit in the week before suicide, demonstrating that health
care systems can play a vital role in identifying individuals
at risk and preventing suicide attempts. \9\
---------------------------------------------------------------------------
\9\ Gordon, Avenevoli, and Pearson (2020) Suicide Prevention
Research Priorities in Health Care JAMA Psychiatry 1;77(9):885-886.
NIMH-funded researchers demonstrated that the use of brief
screening tools in EDs can improve providers' ability to
identify individuals at risk for suicidal behavior and refer
them to treatment As one example, the NIMH-funded ED Safety
Assessment & Follow-up Evaluation (ED-SAFE) study found that
universal screening of ED patients doubled the rate of risk
detection (from 3 percent to 6 percent), and that ED-initiated
interventions reduced subsequent suicidal behavior by 30
percent Additionally, NIMH-funded researchers developed the Ask
Suicide-Screening Questions tool--a very brief (four-question)
screening instrument that was shown to identify risk for
suicide in pediatric emergency departments and has now been
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adapted for use across multiple other settings and populations.
Question 4(b). Do you support efforts to bolster the
resources available to emergency rooms so they can enhance
their screening for high-risk suicide patients?
Answer 4(b). Since emergency departments and other health
care settings have a critical role in identifying and providing
preventive interventions for individuals at risk of suicide, it
is important that these settings have the resources they need
to implement effective screening tools and evidence-based
preventive interventions NIMH remains committed to supporting
research on developing and validating tools and interventions
for use in such settings, and also on identifying innovative
and sustainable service delivery models to ensure that such
tools and interventions are widely available.
Question 5. FASD: During COVID, we have seen a sharp rise
in substance misuse specifically alcohol, the most widely used
and misused substance Unfortunately, a landmark NIH study in
2018 established that 1 in 20 school-aged children are affected
by fetal alcohol spectrum disorders--FASD Due to its
significance and status as an overlooked disability that
includes debilitating stigma, I introduced S 2238, the FASD
Respect Act My legislation establishes common standards of care
and increases the capacity to manage FASD in medical and mental
health settings.
Question 5(a). How can we address the social and
environmental factors that contribute to prenatal alcohol
exposure and reduce the traumas FASD creates for individuals
and families?
Answer 5. The risk for use of alcohol during pregnancy is
influenced by a range of environmental and social factors such
as social isolation, living in environments where alcohol
misuse is common and accepted, and having limited resources for
prenatal care Stigma can serve as a barrier to pursuing and
receiving care for alcohol misuse or an alcohol use disorder as
part of prenatal care This is particularly concerning given
recent research indicating that during 2018--2020, 135 percent
of pregnant adults in the United States reported current
drinking, 52 percent reported binge drinking, and those with no
routine health care provider or with frequent mental distress
were more likely to consume alcohol The risk of an individual
being born with a fetal alcohol spectrum disorder (FASD) is
influenced by factors such as the level and frequency of
alcohol exposure during prenatal development and when during
prenatal development alcohol exposure occurs Maternal factors
that can also influence this risk include inadequate nutrition
and smoking or other substance use, among other factors In
addition to the physical, cognitive, and other challenges
individuals with FASD may face, stigma can be a barrier to
seeking and receiving the health, educational, and professional
care and support they need.
Evidence-based prevention and treatment interventions,
improved access to care, and substance misuse and mental health
services integrated into routine health care are among the
strategies needed to prevent and reduce prenatal alcohol
exposure For children who are prenatally exposed to alcohol,
widespread screening (including when screening for
developmental disabilities), accurate diagnosis, early
intervention, and access to support services are needed to
improve the health and quality of life for individuals with
FASD and their families.
The National Institute on Alcohol Abuse and Alcoholism
(NIAAA), part of the NIH, supports a broad research portfolio
on the etiology, prevention, diagnosis, and treatment of FASD A
major research program funded by NIAAA is the Collaborative
Initiative on Fetal Alcohol Spectrum Disorders (CIFASD) with
the goal to improve prevention of FASD, diagnosis of the full
range of birth defects associated with prenatal alcohol
exposure, and interventions for affected individuals One recent
study includes the development and evaluation of mobile apps to
give caregivers of children with FASD to help them learn new
skills to manage their children's behavior and to provide
adults with FASD tools to promote their own self-management and
health advocacy goals.
To facilitate widespread screening and early diagnosis of
FASD, CIFASD researchers have developed three-dimensional
photography and computerized image analysis that can enhance
the detection of a broad range of alcohol-induced facial
characteristics in children with prenatal alcohol exposure This
approach is being refined and could improve access to FASD
diagnosis in underserved regions Other projects are developing
screening tools that distinguish neurobehavioral features
associated with FASD from other neurodevelopmental conditions
NIAAA-supported studies also focus on the use of novel
methodologies such as 3D fetal ultrasound, blood-based
biomarkers, and physiological measures to improve earlier
identification of prenatal alcohol exposure and risk of
neurodevelopmental delay among neonates, infants, or young
children.
Developing culturally appropriate approaches for the
prevention of alcohol-exposed pregnancies also continues to be
an important focus of NIAAA research For example, an ongoing
study is conducting a randomized clinical trial of a culturally
appropriate prevention program delivered via a smartphone app
for urban American Indian and Alaska Native women ages 16-20
This study is also examining the impact of the COVID-19
pandemic on risk of alcohol-exposed pregnancy NIAAA-supported
research is also evaluating the effectiveness of nutritional
supplementation, administered prenatally and during childhood,
to mitigate the adverse impact of prenatal alcohol exposure
Studies have shown that screening, brief intervention, and
referral to treatment (SBIRT) approaches are a significant tool
for addressing alcohol and other substance use in primary and
prenatal care settings NIAAA will continue to encourage alcohol
SBIRT in these settings and provide resources to assist health
care providers in improving care for patients with alcohol
misuse, such as our Alcohol Treatment Navigator and soon-to-be
launched Healthcare Professional's Core Resource on Alcohol.
Moving forward, NIAAA will continue to encourage research
on prevention and intervention approaches for FASD through
funding opportunities Among the research topics of interest is
advancing strategies to reduce stigmatization of biological
mothers of children with FASD and individuals with FASD NIAAA
will continue its overall effort in reducing alcohol-related
stigma by promoting the use of non-stigmatizing language when
describing alcohol-related issues and the people who experience
them.
Question 5(b). What steps are being taken by the
administration to provide more education and training on FASD?
How can stigma be lessened for individuals living with
behavioral health conditions, like FASD?
Answer 5(b). NIAAA sponsors and chairs the Interagency
Coordinating Committee on FASD (ICCFASD) to foster improved
communication, cooperation, and collaboration among Federal
agencies that address issues related to prenatal alcohol
exposure Several member agencies of ICCFASD have ongoing
efforts aimed at improving education and training on FASD and
reducing stigma for people living with FASD These agencies can
be contacted for more information Examples of their educational
efforts are:
LThrough its Collaborative for Alcohol-Free
Pregnancy, the Centers for Disease Control and
Prevention (CDC) works with multiple partner
organizations to educate healthcare professionals on
the risks of alcohol use during pregnancy and to equip
them to help their patients in preventing prenatal
alcohol use and identifying and caring for individuals
and families living with FASDs Disciplines represented
are family medicine, medical assisting, nursing,
obstetrics-gynecology, pediatrics, and social work CDC
and partners involved in the Collaborative have
developed and disseminated a wide range of online
courses on alcohol use during pregnancy and FASDs for
healthcare providers These free courses offer
continuing education and are available at wwwcdcgov/
FASDtraining.
LThe Administration for Children and Families
Children's Bureau in collaboration with the CDC support
the Prenatal Alcohol and Other Drug Exposures in Child
Welfare Study which explores the current knowledge,
attitudes, policies, practices, and needs of child
welfare agencies for identifying and caring for
children who were exposed to alcohol and other drugs
during pregnancy Findings from this study can be found
at https://wwwacfhhsgov/cb/report/prenatal-alcohol-
drug-exposures-final-report and are being used to
inform the development of resources and tools for
professionals serving child welfare populations.
LCDC, in collaboration with March of Dimes,
developed the Beyond Labels Stigma Reduction
interactive website Designed for people who work in
health-related fields, this site helps users learn how
stigma can impact the healthcare and support women
need, seek, and receive during pregnancy The site
provides information on why stigma happens, stories
about the impact of stigma, and specific ways users can
become a change agent to reduce stigma in their
workplace or community This resource also offers a
specific module on stigma around substance use during
pregnancy.
LThe Health Resources and Services
Administration's Maternal and Child Health Bureau
established the SAFEST Choice Learning Collaborative, a
primary care provider education and practice
improvement effort to reduce prenatal alcohol exposure
and improve outcomes in children with suspected or
diagnosed FASD.
SENATOR TUBERVILLE
Question 1. In July 2017, you and Dr. Collins co-authored a
paper entitled: ``The Role of Science in Addressing the Opioid
Crisis'' That report states, ``The NIH will now work with
private partners to develop stronger, longer-acting
formulations of antagonists, including naloxone, to counteract
the very-high-potency synthetic opioids that are now claiming
thousands of lives each year''.
Question 1(a). What innovation is still needed regarding
these lifesaving medications given that at present, over 80
percent of opioid overdose deaths have been linked to
synthetics?
Answer 1. Deaths involving synthetic opioids (like
illicitly manufactured fentanyl), cocaine, and
methamphetamine--as well as combinations of these drugs--have
increased sharply in recent years Opioid overdose reversal
agents may not be as effective when opioids, stimulants,
alcohol or other substances are used in combination NIH and
NIDA are supporting numerous studies across the therapeutics
development pipeline to advance treatments for OUD and
stimulant use disorder, and to develop novel therapeutics to
treat co-intoxication with stimulants and opioids.
The opioid overdose reversal medication, naloxone, still
remains the most effective available agent to save the life of
someone who is overdosing on opioids, but a recent study found
that naloxone was not administered in 77 percent of 33,084
opioid-involved overdose deaths in 2019 \10\ NIDA funds
research to identify innovative ways to expand access to
naloxone and promote its use, for example by identifying
barriers and facilitators to naloxone access through pharmacies
by testing the effectiveness of overdose education and naloxone
distribution through churches in Black communities, and using
simulation models to determine the best local strategies to
distribute naloxone.
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\10\ Quinn, Kumar, Hunter et al (2022) Naloxone administration
among opioid-involved overdose deaths in 38 United States jurisdictions
in the State Unintentional Drug Overdose Reporting System, 2019 Drug
and Alcohol Dependence Volume 235, 1 June 2022, 109467.
Fifty-six percent of individuals who died from a fentanyl-
involved overdose had no pulse when first responders arrived
\11\ Timely naloxone administration is critical, particularly
for overdoses involving highly potent synthetic opioids, and
because of naloxone's short duration of action, repeat doses
may need to be administered in some cases NIDA-supported
research led to FDA approval of KLOXXADO, a higher dose
naloxone nasal spray formulation NIDA funds research on longer-
acting reversal agents, including methocinnamox (MCAM) and
implants and injections containing nalmefene, which prevents
opioid overdose during relapse Other NIDA-funded researchers
have developed a small molecule intended to act like a sponge
and clear drugs from the body; they are testing its ability to
clear either fentanyl or methamphetamine NIDA is also funding
research to develop antibodies against fentanyl that could be
used to treat and prevent overdoses.
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\11\ O'Donnell, Tanz, Gladden, et al Trends in and Characteristics
of Drug Overdose Deaths Involving Illicitly Manufactured Fentanyls--
United States, 2019--2020 MMWR Morb Mortal Wkly Rep 2021;70:1740-1746.
One-third of fentanyl-involved overdose deaths occurred
when a potential bystander was present who did not respond to
the overdose (eg, person who overdosed was in a separate room
of the same house, underscoring the need for innovative
overdose reversal agents that can detect overdose and quickly
administer reversal medication when individuals are alone or
friends and family are unaware NIDA is funding the development
of wearable devices and smartphone sensors that detect opioid-
induced respiratory depression and administer naloxone or
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summon help.
NIDA plans to fund more research to develop new medications
to prevent and treat OUD and opioid overdose, elucidate
mechanisms of action of synthetic opioids, and understand the
complexities, public health impacts, clinical characteristics,
and treatment of opioid and polydrug use disorders involving
fentanyl.
Question 2. we know that one in four Americans reports
having been a victim of crime in the past 10 years, and half of
those were victims of a violent crime Most report receiving no
help in the aftermath Police, corrections leaders, and the
courts agree that untreated mental health or co-occurring
substance abuse disorders are core drivers of the cycle of
crime and that they lack the infrastructure to respond
appropriately.
Question 2(a). What do you see as the individual and
societal impacts of untreated trauma as it relates to mental
health and substance use disorder?
Answer 2. Traumatic events include any shocking, scary, or
dangerous event in which someone experienced, or was threatened
with, death or serious injury, or witnessed death or a threat
to the physical safety of others Without professional
intervention, trauma is likely to result in negative behavioral
health consequences, including post-traumatic stress disorder,
substance use, and SUDs.
Among people diagnosed with SUDs, a history of exposure to
violence or other traumatic experiences is common, as are
experiences of mental illnesses such as post-traumatic stress
disorder SUDs also exacerbate the impacts of trauma exposure,
with downstream effects on individuals, families, and society,
including job loss, housing instability, fractured
relationships, and legal system involvement Despite the known
bidirectional, deleterious relationship between trauma and
SUDs, a major gap exists in understanding how trauma history
affects treatment seeking, treatment retention, and recovery
from SUDs.
NIMH supports clinical research focused on developing a
deeper, more complete understanding of how exposure to
traumatic stress affects individuals' mental health, with
particular emphasis on youth and U.S. military service members,
as these groups are disproportionately impacted by trauma As an
example of NIMH-supported research in this area, a study of
over 9,000 youths between the ages of 8 and 21 found that low
socioeconomic status and the experience of traumatic stressful
events were associated with alterations in neurodevelopment and
cognition, as well as greater severity of psychiatric symptoms
such as anxiety, depression, fear, externalizing behavior, and
psychosis.
Similarly, NIDA continues to support studies at the
intersection of substance use and trauma Current studies aim to
adapt evidence-based interventions and test novel approaches
tailored to individuals at the highest risk for comorbid SUDs
and trauma-related stress, including people who have
experienced interpersonal violence, multiple adverse childhood
experiences, or racial trauma In addition, the HEALthy Brain
and Child Development Study and the Adolescent Brain Cognitive
Development (ABCD) Study, which NIDA respectively leads and co-
leads with other NIH Institutes, will substantially contribute
to our understanding of healthy development and the impact of
adverse childhood experiences on outcomes like substance use
and post-traumatic stress, paving the way for new prevention
and treatment interventions.
Question 3. Federal data shows that 37 percent of people
sentenced to prison, and 44 percent of people arrested and
jailed, have experienced a mental health issue At the same
time, we know that an estimated 1 in 10 police service calls
are responding to an untreated mental health issue Across the
country, we've seen community-based programs that seek to
divert individuals experiencing mental health issues, direct
individuals to treatment and resources, and do so in a way so
the police department does not have to be involved.
Question 3(a). What is the Federal Government doing to
ensure that mental health emergencies are being responded to
appropriately, early on, before a treatable illness becomes a
safety issue?
Answer 3. As noted by the Substance Abuse and Mental Health
Services Administration, ``preventing mental and/or substance
use disorders or co-occurring disorders and related problems is
critical to behavioral and physical health'' NIMH shares this
sense of urgency for ensuring that individuals experiencing or
at high risk for a mental health emergency are able to receive
effective, evidence-based interventions as early as possible
NIMH aims to build the evidence base for effective
interventions through research For example, NIMH recently
supported a study designed to examine the effectiveness of a
new police-to-mental-health linkage system that would provide
opportunities for officers to involve a mental health
professional immediately and directly during encounters with
individuals with serious mental illness in appropriate
circumstances NIMH also supported a study aiming to evaluate
alternative mental health crisis services that seek to reduce
the incarceration of individuals with serious mental illnesses
and provide alternatives to law enforcement when appropriate in
responding to mental health crises.
As well, NIMH supports research focused on identifying
individuals and populations most at risk for suicide,
understanding the causes of suicide risk, developing suicide
prevention interventions, and testing the effectiveness of
these interventions and services in real-world settings Because
many suicide decedents in the United States access health care
services in the 12 months before their death by suicide, NIMH
is prioritizing research on practices within health care
settings that may identify individuals at risk for suicide.
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[Whereupon, at 11:50 am, the hearing was adjourned].
[all]