Testimony from Roselyn Tso on Fentanyl in Native Communities: Examining the Federal Response to the Growing Crisis before Committee on Indian Affairs

Good afternoon Chairman Schatz, Vice Chair Murkowski, and Members of the Committee.  I am Roselyn Tso, Director of the Indian Health Service (IHS).  Thank you for the opportunity to provide testimony on the IHS's efforts to combat and treat the opioid crisis – particularly synthetic opioids like illicitly manufactured fentanyl – in Native Communities.  As a comprehensive direct care and delivery provider, the IHS has been on the frontlines of the growing crisis, recognizing the profound toll the opioid epidemic has taken on American Indian and Alaskan Native people.  Together, we are not only confronting a medical challenge, but also standing against a threat to the very fabric of our communities.  The Biden Administration is addressing the devastating impact of the opioid epidemic on Tribal lands by dedicating millions of dollars to strengthen prevention, harm reduction, treatment, and recovery support services.  Close to 70 percent of overdose deaths in 2022 involved fentanyl.  In October of this year, the President requested $1.6 billion in supplemental funding for the Substance Abuse and Mental Health Service Administration's (SAMHSA) State Opioid Response program to address the opioid, fentanyl, and polysubstance use crisis in America.  Of this amount, $250 million or 16 percent, would be transferred to the IHS to address unmet needs regarding fentanyl and polysubstance misuse in Indian Country.  This request underscores the emergent nature of this crisis, and the work we still need to do 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.  Ultimately, this is about saving lives.

The IHS understands the cost of the converging overdose emergencies, pandemic recovery, continuing behavioral health crises, and the continued strain on our health care system and the communities we serve.  We live these realities daily to support the IHS mission.  We also recognize the overdose mortality data is rising and that American Indians and Alaska Natives (AI/ANs) overdose mortality rates increased by 39 percent between 2019 and 2020, with a sharp rise during the COVID-19 pandemic.  These mortality rates were the highest compared to other racial and ethnic groups.

We recognize that the impact of the fentanyl crisis is personal.  In August 2023, IHS joined many regional, state, and Tribal partners in a National Tribal Opioid Summit hosted by the Northwest Portland Area Indian Health Board to address the fentanyl crisis in American Indian and Alaska Native communities.  These partners used their time to underscore that approaches to this problem should center on collaboration, should support Tribal practices that are already in place and working, and should emphasize community approaches that strengthen resiliency.  IHS senior leadership also listened to the stories of both trauma and healing from community members, and we were reminded of the importance of centering ourselves in compassionate care models and ensuring policy decisions are guided by these lessons of lived experience.

Working Across the Department and Government

Just as we heard in the Portland Area, collaboration is a critical part of both the Department of Health and Human Services (HHS) and the Indian Health Service's approach to combat the opioid crisis.  IHS recognizes the importance of collaborating and consulting with Tribes to develop a comprehensive plan for addressing the opioid crisis in Indian Country.  This September, I joined Assistant Secretary Miriam Delphin-Rittmon from SAMHSA at the Secretary's Tribal Advisory Committee in South Dakota to consult with Tribal leaders and discuss our work in Indian Country.  Just last week, HHS principals, including the Assistant Secretary and myself met again with these Tribal leaders to continue our conversation.  As IHS combats the opioid crisis, we work hand in hand with our HHS colleagues at the Centers for Disease Control and Prevention (CDC), SAMHSA, Health Resources and Services Administration (HRSA), Administration for Children and Families (ACF), Centers for Medicare and Medicaid Services (CMS), and the Office of the Assistant Secretary for Health (OASH).  We have also partnered with other federal agencies beyond the Department, including the Department of Veterans Affairs (VA), Department of Agriculture (USDA), Department of Justice (DOJ), Office of National Drug Control Policy (ONDCP), and Bureau of Justice Assistance (BJA). IHS participates extensively on multiple interagency workgroups, providing valuable insight on the communities we serve.  In particular, IHS has collaborated with SAMHSA on the Indian Alcohol and Substance Abuse (IASA) Interdepartmental Coordinating Committee to build upon efforts in addressing alcohol and substance abuse in Indian Communities.  IHS also works closely with the Office of Tribal Affairs and Policy to identify resources and programs from each agency that would be relevant to combatting alcohol and substance abuse in Tribal communities.  This work and these partnerships demonstrate acutely that this problem is constantly evolving. It demands a whole of government approach.

The IHS has strengthened and prioritized efforts to address the opioid crisis in Tribal communities through dedicated funding.  In fiscal year (FY) 2023, the IHS provided over $266 million in funding to support alcohol and substance abuse programs, with the majority distributed directly to Tribally operated programs via compacts or contracts.  These programs provide services at all stages of recovery from detoxification, behavioral counseling, outpatient and residential treatment, and long-term follow-up to prevent relapse.  The IHS also administers several grant programs that impact prevention, treatment, and aftercare and support harm reduction services.

IHS developed the Community Opioid Intervention Pilot Project (COIPP) in coordination with SAMHSA colleagues.  The IHS COIPP is a three-year pilot program and aligns with HHS' Overdose Strategy to respond to the national overdose crisis.  The COIPP integrates culturally appropriate care as grantees create comprehensive support teams to strengthen and empower families confronting the opioid crisis.  Developing and implementing a trauma-informed approach, including addressing historical trauma, is necessary to comprehensively address the root causes of SUDs. As a direct result of COIPP funding, there are now over 800 staff and community members trained in trauma-informed care.  Finally, the COIPP grantees continue to prioritize efforts to reduce unmet needs and opioid overdose deaths through education, partnerships, and increased access to treatment for persons with opioid use disorder.

It is also important to note that SAMHSA provides Tribal Opioid Response (TOR) grants, a critical piece of the puzzle.  These grants address the public health crisis of escalating opioid misuse and overdose in Tribal communities.  In FY 2022, SAMHSA awarded $55 million in TOR grants.  Since 2018, Tribes and Tribal organizations have provided TOR-funded treatment and recovery support services to 7,700 clients.  Tribes have also purchased and distributed 16,955 naloxone kits and 7,045 fentanyl testing strips and trained 3,357 community members on the use of lifesaving naloxone using TOR funding.

Federal Healthcare Operation Efforts

In addition to dedicated funding to support overdose prevention efforts for IHS and Tribally operated programs as well as urban Indian organizations, the IHS provides administrative support and technical assistance for health care operations for direct service Tribes when requested.  The IHS understands the importance of primary care and works through its Integrating Primary Care model to support integrated services.  These efforts can be seen through the collaborative work championed by the IHS National Committee on Heroin, Opioids, and Pain Efforts.

The IHS chartered a National Committee on Heroin, Opioids, and Pain Efforts (HOPE) in 2017 to promote appropriate and effective pain management, reduce overdose deaths, and improve access to culturally appropriate treatment.  The HOPE Committee Treatment and Recovery work plan emphasizes two primary aims: (1) increasing access to treatment and (2) increasing patient engagement with recovery services.  The strategy and work plan recognize the impact of health disparities resulting from historical structural determinants of health and align with critical concepts in the National Tribal Behavioral Health Agenda.

The work plan addresses system-level barriers to support enhanced screening and patient assessment, early identification and diagnosis of SUD, improved care coordination, and access to high-quality integrated treatment services where needed.  The IHS accomplishes these aims through policy, identification of clinical recommendations to support evidence-based care, and workforce development strategies.  The IHS is proud of the work of its front-line staff throughout the pandemic – the same people managing the opioid overdose response also supported COVID-19 pandemic response activities with limited additional resources.

Recent Accomplishments

I would like to bring your attention to some recent achievements by IHS in its battle against fentanyl.  The IHS Opioid Surveillance Dashboard was initially released in 2022 and was recently enhanced to include an additional 19 measures, which deliver additional data visualizations for safe opioid prescribing, naloxone saturation, co-prescribing, and harm reduction activities.  Prescription level drill-down is enhanced to support targeted population health strategies.  The Opioid Surveillance Dashboard data indicates initial positive increases in overall buprenorphine prescriptions, with an increase in the number of patients receiving buprenorphine and increases in naloxone prescribing.  The dashboard also shows that prescribing of opioids in the IHS agency has been reduced from 261,813 opioid prescriptions in 2014 to 63,340 opioid prescriptions in 2023, a decrease of 75 percent.  This indicates that our training is working.

In September 2023, the IHS released a new Essential Training on Pain and Addiction (ETPA) initial and refresher course.  This on-demand, web-based course delivers evidence-based updates to clinical practice guidelines for pain management and includes a focus on patient-centered assessments and treatment planning.  It also includes important content essential to support health equity for pain management conditions and opioid use disorders.  This new training meets the Medication Access and Training Expansion Act requirements for new or renewing Drug Enforcement Administration licenses (provides 3 hours).  The training is required for federal IHS prescribers, contractors (that spend 50 percent or more of their clinical time under contract with the Federal Government), clinical residents, and trainees.  The training is also available for Tribal and urban prescribers.

The IHS has also developed an Educational Outreach Program pilot project.  Three IHS sites were identified to create tailored peer-to-peer interventions to enhance opioid stewardship activities, increase access to treatment services, and promote quality of care.

The IHS is continuing to work to modernize its electronic health record to include integration of Prescription Drug Monitoring Program data.  This software enhancement will streamline provider access to prescribing data and will inform clinical practice and care-planning decisions to increase the safety of opioid prescribing activities.

The IHS collaborates with the NPAIHB to support the National Clinician Consultation Center Warmline access. This service offers on-demand Clinician-To-Clinician support for IHS, Tribal and Urban Organization (I/T/U) providers managing substance use disorders, recommendations to support local policy and procedure development, and on-going site implementation. From July – September 2023, the call-center experienced a 48 percent increase in /I/TU consultation requests (compared to the same period in 2022).  Word is getting out that these resources are now here to help.

Care for specialized populations

The IHS is also partnering with the Bureau of Indian Affairs (BIA) Corrections to develop a Memorandum of Agreement to improve access to care and care coordination for justice-involved populations. The collaboration aims to mitigate the impact of chronic diseases – including substance use disorders and other behavioral health conditions, reduce morbidity related to secondary complications (including persons who inject drugs), reduce disease transmission rates and treat infectious diseases for justice involved populations.  The IHS has also developed a provider guide and patient resources to support a comprehensive approach to supporting pregnant and parenting persons using substances.

Harm Reduction

The IHS Pain and Addiction Care in the Emergency Department pilot project resulted in American College of Emergency Physicians (ACEP) Pain and Addiction Care in the Emergency Department accreditation of five direct-service Emergency Departments.  The programs promote access to naloxone, evidence-based treatment, and enhanced care coordination.  The second annual convening was hosted in September 2023 and included didactic presentations from the ACEP.  There is no wrong door for treatment as this program aims to enhance screening for SUD and supports establishment of a treatment bridge and referral pathways.

The Indian Health Service supports expanded harm reduction activities and continues to support community response.  Health promotion and educational materials as well as direct naloxone distribution are key strategies.  Recently, syringe service materials, drug checking strips, and, more broadly, infectious disease treatments have expanded as IHS works to address secondary complications of substance use.

Expanded access to naloxone to prevent unintentional opioid overdose.

In September 2023, the IHS completed updates to IHM 3:35 Dispensing of Naloxone to First Responders and Community Representatives.  These policy revisions expanded first responder definitions and reduced administrative burdens to naloxone access.  As part of the expanded policy scope, the IHS collaborated with Bureau of Indian Education (BIE) Schools to develop and release a Naloxone in Schools toolkit to support school systems with expanding access to naloxone and overdose prevention efforts.  The toolkit provides an example of training plans and materials that may be used to support school implementation.  This toolkit is available on the IHS website.

The IHS developed and released its "Naloxone Keeps the Circle Strong" campaign, which includes educational materials and additional IHS resources, including a new naloxone training to be used by and for community members, and a naloxone conversation starter guide for front-line clinicians.  All IHS Employees will receive opioid overdose and naloxone use training beginning in 2024.

Increase understanding of and access to drug checking equipment.

In August 2023, the IHS started a fentanyl test strip pilot program, including sample policies and procedures, product labeling materials, educational documents, and procurement pathways.  A total of four points of distribution have been identified with positive preliminary feedback.  The IHS also created education materials on the use of fentanyl test strips for health care providers, community workers, and patients.

Workforce development and support

IHS continues to support new strategies to leverage advanced practice providers and paraprofessionals to support opioid crisis response activities.  In September 2022, the IHS renewed the IHS Advancing Pharmacist Roles in Substance Use Disorder Treatment and Recovery Teams Extension for Community Healthcare Outcomes for a second year.  This community of practice increases participant knowledge surrounding patient screening, assessments, evidence-based practices for managing Substance Use Disorders, and trauma-informed care principles.  A new clinician mentorship program is set to launch later in December that includes opportunities for staffing patient cases and peer review to support new advanced practice pharmacists expanding services to include SUD treatment.

The IHS will launch a community navigator program training community health representatives, community health aides, and public health aides in 2024.  The training will include training in behavioral health navigation and whole-health approaches.

The IHS is creating position descriptions for Peer Recovery Support Specialist staff to support recovery.  The Peer Recovery specialists will reduce recidivism and assist the patient in re-integration into their family and community.  Enhanced IHS collaboration with CMS and states to explore opportunities to leverage reimbursement parity between state Medicaid plans for outreach work provided by peer workers and community navigators is ongoing.

Treatment and Recovery

The updated IHS Purchased Referred Care clinical priorities include acute detoxification and inpatient Alcohol/Substance Use Disorder as part of our priorities to more appropriately connect persons to treatment.  This prioritized availability of referral to an appropriate program will provide access to immediate treatment for substance abuse disorders.

Challenges

IHS appreciates the work of the Biden Administration to prioritize this crisis, and the work of Congress to secure additional resources to address urgent needs and remove barriers to care.  The removal of the Drug Addiction Treatment Act waiver and other Federal efforts have helped, but more needs to be done. For example, there remains a lack of research and data related to effective SUD prevention and treatment interventions for American Indians and Alaskan Natives. We are still unable to quantify the extent of the disparity due to racial misclassification.

The IHS supports the policy recommendations from the National Tribal Opioid Strategy to support "housing first" initiatives that include transitional housing/supportive housing and dedicated funding to establish pilot programs.  Evaluation findings from the IHS COIPP grant reported homeless persons doubled since Year 1 (April 1, 2021 to March 31, 2022).  Reports of the increase in housing insecurity could be linked to an increase in street outreach systems and an increase in opioid trafficking.

Additionally, feedback from the field states there is a lack of resources for detoxification services for opioids for those contemplating entering treatment.  Detoxification from opioids is challenging, and medically complex.  There is often a requirement to enter residential treatment, and the current lack of services creates a barrier to treatment.  It is crucial to have specific funding allocated to support detoxification services.  This can act as an entry point to treatment and is essential for those struggling with addiction.

The IHS values the ongoing support of federal partners to continue the critical work happening in tribal communities.  We welcome additional opportunities to work together across government and with Congress to enhance programs, further support communities, and find solutions to resource challenges to address this scourge across Indian Country and the rest of our nation.  Thank you for your commitment and dedication to improving health care for American Indians and Alaska Natives.  I will be happy to answer any questions the Committee may have.