Testimony from Christopher M. Jones, PharmD., M.P.H. on Opioids in Indian Country: Beyond the Crisis to Healing the Community before Committee on Indian Affairs

Chairman Hoeven, Vice Chairman Udall, and members of the Senate Committee on Indian Affairs, thank you for inviting me to testify at this important hearing. The Substance Abuse and Mental Health Services Administration (SAMHSA) has been actively engaged in the Administration’s effort to combat the opioid epidemic. SAMHSA works with our colleagues at the Department of Health and Human Services (HHS), state and local governments, tribal entities, and other key stakeholders.

Thank you for the opportunity to discuss the opioid crisis in the United States and the Federal response, particularly in relation to tribes and tribal entities. From the start of his Administration, President Trump has made addressing the opioid epidemic a top priority, and at SAMHSA we share the President’s commitment to bringing an end to this crisis, which is exacting a toll on individuals, families, and communities across the country. The Department, including SAMHSA, has made the crisis a top priority and is committed to using our full expertise and resources to combat the epidemic.

Over the past 15 years, communities across our Nation have been devastated by increasing prescription and illicit opioid abuse, addiction, and overdose. According to SAMHSA’s National Survey on Drug Use and Health (NSDUH), in 2016, over 11 million Americans misused prescription opioids, nearly 1 million used heroin, and 2.1 million had an opioid use disorder due to prescription opioids or heroin. The American Indian/Alaska Native (AI/AN) population is likewise affected by the opioid crisis. According to NSDUH, 5.2 percent (72,000) of AI/AN aged 18 and older reported misusing a prescription drug in the past year and 4.0 percent (56,000) of AI/ANs aged 18 and older reported misusing a prescription pain reliever in the past year. Over the past decade, the United States has experienced significant increases in rates of neonatal abstinence syndrome (NAS), hepatitis C infections, and opioid-related emergency department visits and hospitalizations. Most alarming are the continued increases in overdose deaths, especially the rapid increase since 2013 in deaths involving illicit fentanyl and other highly potent synthetic opioids. Since 2000, more than 300,000 Americans have died of an opioid overdose. Opioids were involved in 42,249 deaths in 2016, and opioid overdose deaths were five times higher in 2016 than 1999.

The opioid epidemic in the United States can be attributed to a variety of factors. For example, there was a significant rise in opioid analgesic prescriptions that began in the mid-to-late 1990s. Not only did the volume of opioids prescribed increase, but also well-intentioned healthcare providers began to prescribe opioids to treat pain in ways that we now know are high-risk and have been associated with opioid abuse, addiction, and overdose, such as prescribing at high doses and for longer durations. One additional factor is a lack of health system and healthcare provider capacity to identify and engage individuals, and provide them with high-quality, evidence-based opioid addiction treatment, in particular the full spectrum of medication-assisted treatment (MAT). It is well-documented that the majority of people with opioid addiction in the United States do not receive treatment, and even among those who do, many do not receive evidence-based care. Accounting for these factors is paramount to the development of a successful strategy to combat the opioid crisis. Further, there is a need for more rigorous research to better understand how existing programs or policies might be contributing to or mitigating the opioid epidemic.

HHS Five Point Strategy

In April 2017, HHS outlined its five-point Opioid Strategy, which provides the overarching framework to leverage the expertise and resources of HHS agencies in a strategic and coordinated manner. The comprehensive, evidence-based Opioid Strategy aims to:

• Improve access to prevention, treatment, and recovery support services to prevent the health, social, and economic consequences associated with opioid addiction and to enable individuals to achieve long-term recovery;

• Target the availability and distribution of overdose-reversing drugs to ensure the broad provision of these drugs to people likely to experience or respond to an overdose, with a particular focus on targeting high-risk populations;
• Strengthen public health data reporting and collection to improve the timeliness and specificity of data and to inform a real-time public health response as the epidemic evolves;
• Support cutting-edge research that advances our understanding of pain and addiction, leads to the development of new treatments, and identifies effective public health interventions to reduce opioid-related health harms; and
• Advance the practice of pain management to enable access to high-quality, evidence-based pain care that reduces the burden of pain for individuals, families, and society while also reducing the inappropriate use of opioids and opioid-related harms.

As HHS lead agency for behavioral health, SAMHSA’s core mission is to reduce the impact of substance abuse and mental illness on America’s communities. SAMHSA supports a portfolio of activities that address the HHS Opioid Strategy.

Today, I will address how SAMHSA is working with tribes and tribal organizations as that work relates to this strategy.

Improving Access to Prevention, Treatment, and Recovery Support Services

SAMHSA administers the State Targeted Response to the Opioid Crisis Grants, a two-year program authorized by the 21st Century Cures Act (P.L. 114-255). By providing $485 million to states and U.S. territories in fiscal year (FY) 2017, this program allows states to focus on areas of greatest need, including increasing access to treatment, and reducing opioid overdose related deaths through the provision of the full range of prevention, treatment, and recovery services for opioid use disorder. Specific areas in which states and tribes collaborate on prevention activities include: Prescription Drug Monitoring Program (PDMP) data-sharing; State Epidemiological Outcome Workgroups; overdose education on naloxone distribution; and media campaigns. In Minnesota, the state is supporting five Native American communities to service high-risk pregnant women with opioid use disorder (OUD) in order to strengthen and enhance peer recovery support services. In Montana, the state is working with the Rocky Mountain Tribal Leaders Council to develop culturally tailored versions of the current peer monitoring trainings and peer supervisor trainings.

Tribes receive SAMHSA prevention grant funds to address opioid misuse and abuse.

Prevention programs include a focus on change at the community level that will, over time, lead to measurable changes at the state and tribal levels. Under the Strategic Prevention Framework-Partnerships for Success (SPF-PFS) grant program, First Nations Community HealthSource in New Mexico serves four tribes: Pueblo de Cochiti; Pueblo of Laguna; Native American Community Academy; and Zuni Pueblo. First Nations Community HealthSource has developed prevention strategies based on research and tribal traditions, culture, language, and values that reduce prescription drug abuse and misuse; improve the capacity of tribal leadership to understand and support prevention strategies designed to decrease prescription drug abuse and misuse; and develops a tribal strengths based method to decrease prescription drug abuse and misuse.

Other tribes are developing capacity and expertise in the use of data from state-run PDMPs. Under the Strategic Prevention Framework for Prescription Drugs (SPF Rx) grant program, four tribes (Cherokee Nation, Southern Plains inter-tribal, Nooksack, and Little Traverse Bay Band of Odawa Indians) currently work with their states to bring tribal data into the system and decrease prescription drug misuse in their communities. For example, in Oklahoma, the Cherokee Nation has used the PDMP data to develop a tribal-wide media campaign, “Think SMART,” that is educating community members on the responsible use of opioids and the risks associated with overprescribing.

Since coming to SAMHSA, the Assistant Secretary for Mental Health and Substance Use, Dr. Elinore McCance-Katz, has reviewed all of our discretionary funding announcements and has looked for opportunities to improve tribal access to SAMHSA’s discretionary grant funds. For example, tribal leaders informed her they have a great concern about the vulnerability of tribal youth to developing mental and substance use disorders. With clarity that tribal youth are a priority, Assistant Secretary McCance-Katz was able to ensure that a funding opportunity announcement (FOA) that SAMHSA recently released entitled “Enhancement and Expansion of Treatment and Recovery Services for Adolescents, Transitional Aged Youth, and their Families” included at least a $5 million set-aside for tribes, tribal organizations, urban Indian health programs, and consortia of tribes or tribal organizations. This amount is approximately 34 percent of the total anticipated $14.6 million available for this program.

Targeting Overdose-Reversing Drugs

SAMHSA has been a leader in efforts to reduce overdose deaths by increasing, through funding and technical assistance, the availability and use of naloxone to reverse overdose. SAMHSA’s “Opioid Overdose Prevention Toolkit,” first released in 2013, is one of SAMHSA’s most downloaded resources. The Toolkit provides information on risks for opioid overdose, recognition of overdose, and how to provide emergency care in an overdose situation. The Toolkit is intended for community members, first responders, prescribers, people who have recovered from an opioid overdose, and family members, as well as communities and local governments.

SAMHSA provides a number of funding streams that can be used to expand access to naloxone. In September 2017, SAMHSA awarded funding for the First Responders-Comprehensive Addiction and Recovery Act (FR-CARA) grant program, which includes grants to four tribes: White Earth Band of Chippewa Indians; Cherokee Nation; Choctaw Nation of Oklahoma; and Lac Du Flambeau Band of Lake Superior Chippewa Indians. The First Responders grant program provides resources to first responders and treatment providers who work directly with the populations at highest risk for opioid overdose. For the White Earth Band of Chippewa Indians in Minnesota, prescription opiate and heroin admissions for American Indians on the Reservation totaled almost 30 percent of the treatment admissions. SAMHSA’s grant helps support the tribe’s collaborative approach to addressing the crisis throughout its community, including partnerships with public health, law enforcement, behavioral health, first responders, public relations, and cultural representatives.

Strengthening Public Health Data and Reporting

NSDUH provides key national and state level data on a variety of substance use and mental health topics, including opioid misuse. NSDUH is a vital part of the surveillance effort related to opioids, and the data from NSDUH has been used to track historical and emerging trends in opioid misuse, including geographic and demographic variability.

According to the 2016 NSDUH, 5.2 percent (72,000) of AI/AN aged 18 and older reported misusing a prescription drug in the past year and 4.0 percent (56,000) of AI/ANs aged 18 and older reported misusing a prescription pain reliever in the past year, compared to national averages of 7.1 percent and 4.3 percent respectively. The 2016 NSDUH also found that 4.1 percent (63,000) of AI/ANs aged 12 and older reported opioid misuse in the past year, in line with the national average of 4.4 percent. The 2016 NSDUH found that 1.1 percent (16,000) of AI/ANs aged 12 and older reported having an opioid use disorder in the past year.

Working with Tribes and Tribal Organizations to Reduce Opioid Misuse and Abuse

Assistant Secretary McCance-Katz reinstated SAMHSA’s Addiction Technology Transfer Center (ATTC): American Indian and Alaska Native Support Center Cooperative Agreement (AI/AN ATTC). The purpose of this program is to provide support for the ATTC Network, AI/AN, tribal organizations, urban Indian programs, state and local governments, and other organizations to develop and strengthen the specialized behavioral healthcare and primary healthcare workforce that provides substance use disorder (SUD) treatment and recovery support services to tribal communities. The University of Iowa, the grantee, works directly with SAMHSA and in collaboration with the FY 2017 ATTC National Coordinating Center and the 10 Regional ATTC Centers. The Centers focus on activities aimed at improving the quality and effectiveness of treatment and recovery, as well as working directly with providers of clinical and recovery support services, and others that influence the delivery of services, to improve the quality of workforce training and service delivery to tribal communities.

SAMHSA also funds the Tribal Training and Technical Assistance Center, which actively engages and serves tribes across the Nation. Through onsite and virtual training, targeted resources, learning communities, assistance with Tribal Action Plans, and intensive community engagement, our technical assistance guides tribal communities and organizations in using cultural knowledge and strengths to support wellness, including addressing the opioid crisis. For example, today, this Center is conducting the first of two webinars targeting opioids in Indian Country. SAMHSA is in the process of assessing the technical assistance provided to assure that the funding is appropriate to the need and that the tribal entities get the support they need while maximizing grant funds to communities.

SAMHSA received input from our Tribal Technical Advisory Committee (TTAC) and shared TTAC’s recommendations with the Secretary’s Tribal Advisory Committee. Based on input from these tribal leaders, SAMHSA is partnering with the Centers for Disease Control and Prevention, Indian Health Service, Centers for Medicare & Medicaid Services, and National Institutes of Health to host a Joint Tribal Advisory Committee (JTAC) meeting. The JTAC will bring together tribal leaders from the tribal advisory committees for these operating divisions to discuss related priorities. Our plan is to host the joint meeting immediately preceding the National American Indian and Alaska Native Behavioral Health Conference this summer.

We have heard from tribal leaders that SAMHSA also has a responsibility to improve tribal-state relationships. In response, the Agency is hosting a Tribal-State Policy Academy (TSPA) to advance tribal behavioral health planning. The TSPA will have a particular emphasis on improving current efforts to address the impact of the opioid epidemic in Indian Country but will also include an opportunity for tribes and states to work together on other primary substances of abuse affecting local tribal communities. Beyond supporting improved working relationships and planning, proposed outcomes include joint tribal-state plans for combating drug use in tribal communities and collaborative models that may be replicated by other states and tribes. Up to ten tribal-state teams will be able to participate in the Academy that is targeted for this summer. Additionally, Assistant Secretary McCance-Katz recently sent a letter to governors urging them to assess the behavioral health needs of AI/ANs in their states and to equitably distribute federal funds directed to states to address the opioid crisis and mental health needs.

Finally, SAMHSA has had discussions with tribal leaders about the importance of recognizing and elevating tribal behavioral health as a critical step toward collaborative improvements. SAMHSA is in the process of engaging Federal and tribal organization partners to host a national town hall on combatting substance use in tribal communities. The town hall will bring together senior government officials and tribal leaders to explicitly address opportunities, and identify a clearer path forward, for combatting substance use in AI/AN communities.

Thank you again for inviting me to testify today. I look forward to answering your questions.