June 18, RE: Policy Priority Areas to Combat the Opioid Epidemic. Dear Chairman Alexander and Ranking Member Murray:

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1 June 18, 2018 The Hnrable Lamar Alexander Chairman United States Senate Cmmittee n Health, Educatin, Labr, and Pensins 455 Dirksen Senate Office Building Washingtn, DC The Hnrable Patty Murray Ranking Member United States Senate Cmmittee n Health, Educatin, Labr, and Pensins 428 Dirksen Senate Office Building Washingtn, DC RE: Plicy Pririty Areas t Cmbat the Opiid Epidemic Dear Chairman Alexander and Ranking Member Murray: Thank yu fr yur leadership in intrducing and supprting measures t imprve the current health care system, particularly t address addictin in general and piid use disrders specifically. The undersigned rganizatins are members f the Natinal Health Care fr the Hmeless Cuncil and partner rganizatins wh are cncerned abut peple experiencing hmelessness and hw their needs are reflected in the current discussin abut the piid epidemic. While many prpsals have been intrduced fr cnsideratin, belw are ur pririties and recmmendatins in five key areas: increase capacity fr emergency verdse respnse, increase capacity fr harm reductin prgrams, expand access t evidence-based addictin treatment, expand wrkfrce pprtunities, and allcate additinal funding fr husing. We select these issues because they represent the mst tangible slutins at the patient and prvider level that will imprve health and stability amng thse struggling with addictin. 1. Increase capacity fr emergency verdse respnse. First and fremst, we must increase the capacity fr emergency verdse respnse in rder t stem the epidemic f deaths ccurring frm piid addictin. Decrease cst and expand access t the verdse antidte nalxne. Increasing numbers f verdses (especially thse invlving fentanyl) are requiring multiple units f nalxne, but at tremendus cst t state and lcal public health systems. Frntline prviders need greater access at lwer prices in rder t prvide effective first respnse t thse experiencing a life-threatening verdse. All cmmunities shuld have standing rders that allw members f the public t access nalxne as well. Natinal Health Care fr the Hmeless Cuncil P.O. Bx Nashville, TN (615)

2 Plicy Pririty Areas t Cmbat the Opiid Epidemic Page 2 Increase funding and training fr nalxne distributin amng first respnders. Law enfrcement, fire, EMT respnders, transit wrkers, and thers in a psitin t respnd t an verdse shuld be prvided training n hw t administer nalxne as well as have ready access t this life-saving antidte. Such trainings can als reduce stigma, and lead t mre effective cmmunity engagement practices. 2. Increase capacity fr harm reductin prgrams. Reducing the risks assciated with piid addictin must be a key cmpnent t stpping verdse deaths and reducing transmissin f cmmunicable disease. Including harm reductin as a principle f care thrughut the health care field wuld als help reduce stigma and engage a greater number f peple in treatment. Expand syringe exchange prgrams. Prviding access t clean needles reduces disease transmissin and ffers an pprtunity fr service prviders t cnduct utreach and engagement with peple struggling with injectin drug use disrders, leading t a greater willingness t cnsider treatment. Increasing funding and supprt fr syringe exchange prgrams will enable mre public health departments (r ther health care prviders) t reach vulnerable ppulatins and cnnect them t care. Establish pilt supervised cnsumptin sites (SCS). There are nw nearly 100 SCS prgrams (als called safe injectin facilities ) in 65 cities all ver the wrld, but nne in the United States. These prgrams have been demnstrated thrugh peer-reviewed, evidencebased research t reduce verdse deaths, facilitate entry int treatment, reduce disease transmissin, and save public health care csts (amng ther benefits). It is well past time that harm reductin prgrams such as SCSs can be tested as part f a public health apprach t vercming the piid epidemic. 3. Expand access t evidence-based addictin treatment. Primary care prviders are at the frefrnt f treating piid addictin but multiple barriers exist t accessing evidence-based treatment at all levels f care. Funding must be priritized fr treatment mdels that prvide lng-term clinical management f a chrnic disease such as addictin. Expand and strengthen Medicaid in all states t individuals earning at r belw 138% pverty. Nt nly des health insurance pay fr drug treatment, it als pays fr medical and mental health care, which are ften needed t address multiple health care cnditins. Relying n ad hc, grant-funded services des nt prvide the cntinuity f care and crdinatin needed t achieve gd medical and behaviral health utcmes. The 19 states that have yet t expand Medicaid t single adults leave their mst vulnerable citizens uninsured and unable t access needed cmprehensive care. We als encurage Cngress t incentivize greater use f 1115 waivers t add supprtive services such as care crdinatin, case management, and husing supprt services t blster the services needed t engage in care. Expand capacity fr drug treatment at all levels f care. Health care prviders wh are screening fr and treating substance use disrders need t be able t refer patients quickly and easily t prgrams that ffer an apprpriate level f treatment. Peple with private insurance generally have a wider range f treatment ptins than Medicaid participants. We must ensure equity in access t treatment, and we must be able t secure placement fr ur patients in prgrams that will deliver the apprpriate clinical level f evidence-based care. We recmmend remving the plicy barriers that prevent Medicaid beneficiaries frm accessing residential treatment, and we cannt emphasize mre strngly the need fr Natinal Health Care fr the Hmeless Cuncil P.O. Bx Nashville, TN (615)

3 Plicy Pririty Areas t Cmbat the Opiid Epidemic Page 3 stable husing as a critical part f effective treatment (see related recmmendatins belw). Eliminate Medicatin Assisted Treatment (MAT) barriers like patient caps and additinal paperwrk requirements. Clinical prviders are currently able t prescribe much mre harmful medicatins than buprenrphine, yet this drug is regulated mre than any ther. Remving current limits n the number f patients allwed t be treated by an individual prvider will allw mre peple t access care. Remving the requirement t keep patient lgs will reduce regulatry burdens withut decreasing quality f care. Eliminating bth these measures will increase the number f prviders willing t prescribe MATs. Imprve MAT prvider training t be mre effective. Prviders need supprt and training t effectively treat patients with addictin disrders; hwever, many prviders in the field questin the utility and efficacy f the current 8- and 24-hur trainings specifically required fr prescribing buprenrphine. As larger changes t training in addictin medicine are being cnsidered fr primary care prviders, MAT trainings shuld evlve t include mre infrmatin abut addictin treatment, pain management, and integratin f care. This is especially true f the 24-hur training required f physician s assistants and nurse practitiners the additinal hurs are a barrier t getting a waiver and thus reduce the number f prviders authrized t prescribe buprenrphine. Expand MAT access and imprve cntinuity f care fr bth rural and incarcerated ppulatins. Allwing payments fr telemedicine wuld enhance access t MATs, especially fr peple living in rural r underserved areas where transprtatin is limited and/r prviders may nt be accessible. Jails and detentin centers shuld be required t prvide MAT as part f health care services fr thse wh are incarcerated, and shuld nt be permitted t discntinue treatment already initiated by cmmunity prviders. Require Medicare and Medicaid t cver at least ne frm f buprenrphine and eliminate prir authrizatins fr prescribing any frm f MAT. Buprenrphine is n lnger an experimental interventin. Its use ver the last 20 years has demnstrated it is an effective treatment withut adverse cnsequences, yet many insurance plans cntinue t require prir authrizatins. Limited frmularies and delays caused by administrative prcesses such as these nly impede entry int treatment and raise the chances f an verdse. It s past time t make buprenrphine an integrated part f primary care, especially in the midst f an piid crisis. Cntinue expanding funding fr SAMHSA and HRSA. Safety net prviders, especially in states that have nt expandedf Medicaid, need additinal resurces t care fr peple wh remain uninsured. Even in Medicaid expansin states, nt all services are reimbursed thrugh Medicaid. Funding frm previus legislatin (e.g., the Cmprehensive Addictin and Recvery Act) was a gd start, but will nt meet the extensive need fr treatment and supprt in ur cmmunities. We urge nging investments in these prgrams. 4. Expand wrkfrce pprtunities. As demand fr treatment cntinues t grw, we need t ensure we have a highly trained wrkfrce ready and able t meet thse needs particularly fr peple with unique needs such as thse wh are hmeless and battling addictin. Natinal Health Care fr the Hmeless Cuncil P.O. Bx Nashville, TN (615)

4 Plicy Pririty Areas t Cmbat the Opiid Epidemic Page 4 Increase funding fr peer specialists, case managers, care crdinatrs, utreach wrkers, cmmunity health wrkers, and ther scial supprt rles. Successful treatment requires crdinated care and supprt beynd the exam rm and therapy sessins. These health care disciplines are critical parts f interdisciplinary teams that engage clients in care, and help supprt them in recvery. Many f these rles can be filled by peple wh are themselves in recvery, thereby creating additinal emplyment pprtunities. Expand the Natinal Health Service Crps. Every state needs a greater number f primary care and behaviral health specialists wrking in underserved areas. The lans and schlarships available thrugh the NHSC are vital fr grwing a wrkfrce that is dedicated t vulnerable ppulatins in safety net settings. 5. Expand funding fr husing. Husing must be a part f the package f slutins in rder t make treatment effective and reduce the verall levels f piid addictin. Hmelessness makes entering treatment mre difficult and presents nearly impssible dds f staying in recvery. High rates f relapse are understandable when ne is living n the street r in emergency shelters. Expanding access t treatment must be accmpanied by addressing husing needs. Dedicate mre funding fr stable husing. Federal husing prgrams administered by HUD are chrnically underfunded and the need fr husing cntinues t grw. Only 1 in 4 peple wh qualify fr husing assistance currently receive it, and thse with addictin are at a much higher risk fr husing instability and hmelessness. Husing is a crucial cmpnent t enabling individuals t enter treatment, and be successful in recvery. Prviding drug treatment nly t discharge int hmelessness is nt helpful fr individuals with addictin (and may serve as a disincentive t enter treatment), and is nt an effective use f health care resurces. Cngress must increase investments in husing s that vulnerable peple have a stable, affrdable, and accessible place t live. Ensure a brad range f husing ptins are available. Recvery husing, transitinal husing, supprtive husing, and ther husing mdels are all needed in the cntinuum f treatment. Each mdel has its advantages and disadvantages, but fr thse with the greatest addictin prblems, prgrams need t be nn-time limited, lw-barrier and prvide the supprts needed fr individuals and families t live in an envirnment that supprts their recvery. Finally, current prpsals t restrict access and reduce federal funding fr Medicaid, fd assistance (SNAP), and husing nly undermine the gals related t preventing and treating piid addictin, and facilitating successful recvery. We are encuraged by the attentin being given t the wide range f changes needed t address the piid crisis that has claimed far t many lives, but limiting access t basic human needs thrugh the implementatin f wrk requirements, time limits, and ther barriers is entirely cunterprductive. While sme exemptins are being made fr thse in treatment, we emphasize that nly 1 in 10 peple with an addictin disrder are receiving treatment. As lawmakers cnsider slutins t the piid crisis, these issues shuld nt be cnsidered in islatin frm ne anther. Sincerely, Natinal Health Care fr the Hmeless Cuncil Natinal Health Care fr the Hmeless Cuncil P.O. Bx Nashville, TN (615)

5 Plicy Pririty Areas t Cmbat the Opiid Epidemic Page 5 Endrsing Organizatins Lcal rganizatins: AIDs Fundatin f Chicag, IL Alabama Reginal Medical Services, AL Albuquerque Health Care fr the Hmeless, NM Ascending t Health Respite Care, CO Bstn Health Care fr the Hmeless Prgram, MA Califrnia Cnsrtium f Addictin Prgrams & Prfessinals, CA Care fr the Hmeless, NY Central City Cncern, OR Central Outreach Wellness Center, PA Circle the City, AZ Clrad Calitin fr the Hmeless, CO Daily Planet Health Services, VA Duffy Health Center, MA Elit Cmmunity Human Services, Inc. MA Greater Light Ministries, LA Healthcare fr the Hmeless- Baltimre, MD Health Care fr the Hmeless - Hustn, TX Health Care Center fr the Hmeless, FL Heartland Alliance fr Human Needs & Human Rights, IL Hmeless Health Care Ls Angeles, CA Hmeless Unin f Greensbr, NC Illuminatin Fundatin, CA Mercy Care, GA Nassn Health Care, ME Neighbrhd Health, TN New Hrizn Family Health Services, INC, SC Pathways t Husing, DC Petaluma Health Center, CA Peak Vista Cmmunity Health Centers, CO The Manners Husing Fundatin, FL URAM Cmmunity Health Center, NY Unity Health Care, DC Yakima Neighbrhd Health Services, WA YIMBY Actin, CA Natinal rganizatins: A New PATH American Medical Student Assciatin Crpratin fr Supprtive Husing Faces & Vices f Recvery Harm Reductin Calitin HerStry Ensemble HIV Alliance Natinal Alliance t End Hmelessness Natinal Assciatin f Clinical Nurse Specialists Natinal Calitin fr the Hmeless Natinal Law Center n Hmelessness & Pverty Natinal Lw Incme Husing Calitin NETWORK Lbby fr Cathlic Scial Justice Rights and Demcracy Educatin Fund Bard Treatment Cmmunities f America Trinity Health Western Reginal Advcacy Prject Yung Peple in Recvery Fr mre infrmatin n the Natinal Health Care fr the Hmeless Cuncil s piid plicy agenda please cntact Regina Reed, MPH, Plicy Organizer, at rreed@nhchc.rg r Natinal Health Care fr the Hmeless Cuncil P.O. Bx Nashville, TN (615)