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FRANK PALLONE, J, NEW JERSEY GREG WALDEN, OREGON CHAIRMAN RANKING MEMBER ONE HUNDRED SIXTEENTH CONGRESS Congress of the Anited States House of Representatives COMMITTEE ON ENERGY AND COMMERCE 2125 Raveurn House Orrice BuiLbinc Wastincton, DC 20515-6115 October 1, 2019 Substance Use Disorder Treatment Request for Informa The opioid epidemic in the United States (U.S.) is taking 130 American lives per day.! Just over two years ago, on July 13, 2017, the Committee on Energy and Commerce launched an investigation into allegations of patient brokering by sending a letter to the Secretary of the U.S. Department of Health and Human Services (HHS) regarding reports of patient brokers targeting individuals with substance use disorder, and treating them as a commodity.” On November 17, 2017, the Committee sought additional information from six states regarding how they regulate and oversee substance use disorder treatment facilities and recovery homes.* On December 12, 2017, the Subcommittee on Oversight and Investigations held a hearing examining concerns of patient brokering and addiction treatment fraud,* The Subeommittee heard testimony about problems that stem from the dramatic surge in the number of substance use disorder treatment facilities, detox centers, recovery homes, recovery residences, or halfway houses (hereinafter referred to as “facilities”) in states across the country. On May 29, 2018, the Committee sent letters to eight companies seeking information about their business structure and practices with respect to advertising and marketing in the substance use disorder treatment industry.* On July 24, 2018, the Subcommittee on Oversight and Investigations held a second " Centers for Disease Control and Prevention, Opioid Overdose, Understanding the Epidemic, available af hnips:/www ede. gov/drugoverdoseepidemic/index himl/ (last accessed Mar. 6, 2019) 2 Letter ftom Hon. Greg Walden, Chairman, and Hon, Frank Pallone, Jr, Ranking Member, H. Comm. on Energy & Commerce, etal, to Hon, Tom Price, Sec’y, U.S. Dept. of Health & Human Services, (July 13, 2017), available at hupsiffarchives- house.govifilesdocuments/20170713HHS.pd > Letters from Fon, Greg Walden, Chairman, and Hon, Frank Pallone, Jr.» Ranking Member, H. Comm. on Energy & Commerce, et a, to Mr. Thomas J. Betlach (AZ), Dr. Karen Baylor (CA), Dr, Robert Werthwein (CO), Ms. Ute Gazioch (FL), Ms. Allison Bauer (MA), and Ms, Jennifer Smith (PA) (Nov. 17, 2017), availabe at hps:!/republicans-energycommerce house. govinews/leter/letters-departments-six-stale-governments-patient- brokering-allegations! * Hearing before the Subcomm. on Oversight & Investigations, H. Comm, on Energy & Commeree, “Examining Concerns of Patient Brokering and Addiction Treatment Fraud,” Serial 115-87 (Dee. 12, 2017), available at https 'republicans-encreycommerce house. gov/hearings/examining-concerns-patient-brokering-addiction-treatment- fraud 5 Letters from Hon. Greg Walden, Chairman, and Hon. Frank Pallone, Jr, Ranking Member, H. Comm. on Energy & Commerce, etal, to Frik Epp, Robert Niznik, Michael T. Cartwright, Thomas Kearns, Carmine Thompson, Jason Brian, Dan Callahan, and Bryan Deering (May 29, 2018), avaiable a hitps:/iepublicans- Request for Information on Substance Use Disorder Treatment Page 2 hearing examining advertising and marketing practices within the substance use disorder treatment industry. The Subcommittee heard testimony about the various advertising and marketing practices in the industry, including various levels of transparency and disclosures, efforts made to promote ethical advertising and marketing, and how individuals sceking tweatment can identify quality treatment that will meet their needs, On October 24, 2018, LL. 6, the SUPPORT for Patients and Communities Act, was signed into law. The underlying text of H.R. 6 includes several Medicaid, Medicare, and public health reforms to help combat the opioid crisis, which were advanced through and championed by the Committee on Energy and Commerce. The SUPPORT Aet will help improve.and expand access to treatmerit and recovery services; provide incentives for enhanced care, coordination, and innovation; establish comprehensive opioid recovery centers; and require HHS to issue best practices for entities operating recovery housing facilities. In addition, Section $122 of the SUPPORT Act made it illegal to knowingly and willingly pay or receive kickbacks in return for referring a patient to a recovery. home or clinical treatment facilities.” The provision also provides exceptions for legitimaite referrals, including ensuring logitimete entities can continue to zefer patients to reputable treatment providers, similar to those that are applicable in Medicare and Medicaid, The SUPPORT Act, which is the largest effort to combat a single drug, built upon the passage of the Comprehensive Addiction and Recovery Act and the 21st Century Cures Act in the 114th Congress, the $4 billion appropriated in the 2018-omaibus legislation to help combat the opioid crisis, as well as the $6.7 billion included in the Defense-Labor-HAS appropriations package, While these measures are critical steps in combating the opioid epidemic and the new fools arid resources provided are already being implemented, they are not silver bullets, More work needs to be done, ‘The need for quality substance use disorder treatment facilities is crucial. The Substance. Abuse and Mental Health Services Administration's (SAMHSA) 2016 National Survey on Drug Use and Health found that 11.5 million people over the age of 12 reported misusing prescription pain relievers in the past year-* Additionally, 2.1 million people over the age of 12-2re believed to have an opioid use disorder.° In 2017, overdoses involving opioids killed more than 47,000 people, and 36 percent of those deaths involved prescription opioids."® With more people now seeking treatment for substance use disorders involving opioids, the tzeatment industry is patient-brokeringy, * Hearing before the Subcomm oni Oversight & Investigations, A Comm. on Energy & Commerce, ‘Examining Advertising and Marketoig Practices within the Substance Use Treatment Industry, "Serial 115-155 (uly 24, 2018), available at bXtpslfrepublicans-enetgycommerce house, gev/hessings/examining-advertising-andl-marketing- ppractices-within-the-substanee-use-treatmentindusty H.R..6, SUPPORT for Patients and Commies Act, Phe Substance Use-Disorder Prevention thet Promotes Opioid Recovery and Treatment for Patients and Communities Aet, Section hy Section, available at thups:irepubtieans-energyeommerce-house.gav'wp-cortentupfoads!20 | /097HIR6_09.28.18-Einal-Opioid-See-by- Scc_BIPART-BICAM pal. ® Key Substance Use aad Mentat Health Indicators inthe United States: Results from the 2016 National Survey am Drug Use and Heal, SAMHSA, (HHS Publication No, SMA 17-5044, NSDUH Series #-52) available at tps 1-20 16/NSDUH-FFRI-261 6 hit. oth ™ Comers for Disease Control and Preventian, Opioid Overdose, available ot herpsy// html (last accessed ily-2, 2019). Newers-to-eight-call-agaregators-regaiding-their-practices-and-reporis-of2 ‘Request for Information on Substance Use Disorder Treatment Page 3 growing to meet the demand. In 2015, SAMHSA estimated that Americans spent $35 billion on substance use disorder treatmenit and projected that spending would rise to $42 billion by 2020."" ‘The number of substance use disorder treatment facilities across the nation has soared. And although prospective patients now have more treatment facilities to choose from, the array of new options has not directly translated to better care, Meiia reports and criminal investigations have identified serious concerns about the ‘quality of care provided at such facilities. Lapses in oversight within the substance use disorder treatment industry have leit patients vulnerable fo exploitation by unscrupulous business owners. As such, we are seeking information to understand better the business practices and the quality of care that various facilities provide, We believe this information can help identify problematic areas within the industry as well as best practices, ‘The substance use disorder treatment industry has been described as the “Wild West.” According to HHS, “(t]he federal government has oversight of opioid treatment prograins (OTPs) but does not have oversight authority over other levels of care ~ states are responsible.*"* Other than for OFPs, there ate no federal regulations af substance use disorder weaiment facilities, and there is wide variability in terms of how facilities are regulated at the state level, The National Association of State Alcohol and Drug Abuse Directors (NASADAD) compiled information on state licensure bodies and regulations in 2012,}° bat this survey is more than six years old and, given the continued efforts to update regulations in this space, needs to be updated. According to HHS, SAMHSA hes engaged NASADAD to update this document as soon as passible.!® Regulations vary dramatically by state. In some states, no license is necessary to open & substance use disorder treatment facility for adults unless the facility receives goverament Din Munro, Inside tie $35 Billion Addiction Treatment Indusiry, FORBES (Apr, 27, 2015), available at buipev/ |SI04/27 fside-the-35-biilion-addiction-trestment- industry'¥617faa9. 7409; Teri Sforze et al., How some Southern California drug rehab ceniers exploit addiction, ORANGE COUNTY REGISTER (May'2f, 2017), avaiable at httpsvws,ocregister-com/2017/05/2 fow-some- southern-zalfoigrug-rehab-centers-explott-iddietion © Mandy Staitmiller, Js she 835 Billion Rehab Incusiey Ready for a Disruption?. TH DAILY BEAST (Nov. 19, 2017), available at hispsifiwwwttedailybeast.cotwis-the-dollar35-billion-rehab- indusiry-reedy-for-a-disruption, © Teri Sforza etal., How sorne Southern California drug rehab centers exploit addietion, ORANGE COUNTY RecasteR (May 24, 2017), available’ at htp:/Avww. octegister.con/ 2017/05/21 /how-some-southern-california-drug= rehab-centers-exploit-addiction/; Mandy Stadimtlley, Is the $35 Billion Reheb {ndustry Ready for'a Disruption?, ‘TAEDAILY BEAS? (Nov. 19, 2017), avartable at bitps:// wav hedsilybeast convis-the-dollar35-billion-rebab- indusry-feady-for-a-disruption; David Seanl, fn Pursuit of Liquid Gold, NEW YOR Times (Dec, 27, 2017), available at atps:iwwow.nysimes.convinteractive/201 7/12/27 business/urine-tes-cost ita, "ULS, Dept. of Health & Human Services Réspanse to H. Comm, on Energy & Commerce Letter (Sept. 12,2017), lvalable at htiys:/ ontenl/uploads/2017/07/2017092HHS. Response pdf, "The National Association of State Alcohol and Drug Abuse Directors (NASADAD), State Regulations Substance Use Disorder Programs and Counselors: An Overview (Dec. 2012), avaitable at bitpsffrepublicans- ‘energycotninerce louse. gov/wp-contentfupioad’/2017/07/201709128HS_Response_Enelosure,pa. "© U,S, Dept. oF Health & Hurman Services Response to H. Comm. on Energy & Commerce Leiter (Sept. 12,2017), vaitable at bttps:srepublicans-enoreycommerce house, gov"wp- contenvuplonds/2017/07/201709(21THS_Response.pdt Request for Information on Substance. Use Disorder Treatment Pages funding." In others, no special training or education is ieeded to obtain a license,'* and facilities may be exempt from licensing requirements if they are described as [2-step programs.!® While several states have established certification or licensing programs to provide better oversight of substance use disorder treatment facilities, some of the state-rust programs do not require certification; rather, they merely incentivize-certification.”” Further, there is no mandatory national certification exam to become a substance use disorder counselor.”! The vast majority of states do not require substance ise disorder counselors to have-a bachelor degree; and 14 states do not require substance use disorder counselors to have any formalized training at all.2? There are even fewer battiers to establish a recovery home because they do not provide formal treatment services, so genevally no state license is requited 2° According to a 2012 report by the Center on Addiction, very few people seeking substance tise disorder treatment receive evidence-based treatment, such as medication-assisted treatment (MAT)."" In March 2019, the National Academies of Sciences, Engineering, and ‘Medicine released a report on Medications for Opioid Use Disorder. The report states that “[mjost residential treatment facilities do not offer medications, and if they do, they rarely offer all three medications."”* Less than half of privately-funded substance use disorder treatment programs offer MAT and only one third of patients with opioid dependence at these programs actually receive it.2* Of even greater concern, the quality of care offeréd in many substance use 1 The National Association of State Alcohol and Drug Abuse Ditestors (NASADAD), Skate Reguutions on Suéstance Use Disorder Programs and Counselors: An Overview (Dee. 2012), available at hpsiH/energyoommerce house. gov/wp-content/uplosds/2017/07/20170912HHS. Response_Fuelosare pdf. tei Sforza etal, How some Southern California drug rehab centers explolt addietion, ORANGE COUNTY REGISTIR (May 21,2017), available at lttpe/ww.octegister,com/2017/0572 lihow-some-southern-califomia-drug- tehab-centers-exploit-eddiction’; The National Associstion of State Alcohol and Drug Abuse Directors (NASADAD), State Regulations on Substaitce Use Disorder Programs ond Counselors: dn Overview (Dec. 2012), ‘available at zoviv- ‘contenvuploads/2017/07/26170912HHS_ Response Enclosure pd P Amy Julia Harris ad Shoshana Waller, Hove a Reliab Boss Exploited the Drug Epidemie ~ With Impuaity, US. News (May 24, 2018), avifable ar htps:/ ‘Lithow-a-eeha-boss-cxploited-the-drag-epidemic-with-impunity * US. Government Accountability Offic, lnformation on Recovery Honsing, Prevalence, Selected Sates" Oversight, and Funding (Mar. 2018), avaiable ar ntps:vwww.ga0 goviassets/700/69083 1 pd? | Gabrielle Glaser, The drrationality of Alcoholics Anonymous, THE ATLANTIC (Apr. 2015), available at ‘tpsi~9ww healantie com mayvine/archive/2015/O4Ahesirsinality-oFakehotic-anonymous/386255/ td. ® Sec interne CRS riemo on fle with the Commitee on Energy and Commerce, Republican Staff, ™ dudliction Medicine: Clasing the Gup Between Seienoe and Practice (ime 2012), available at Itpsy/vanw cenreronaddietion ors/adeiction-rescarch/reports/addction-medicine-closing-gap-between-science-and- practice, See aiso Dan Munro, /uside the $35 Billion Addhction Treatment Indust available at bntpstwww.forbes.comvsitesfdarimunr6/201 5104/9 /inside-tne-35-billion-adciction-tealiment- industry46171e017de9; Christopher Moral, Why Drug Rehab is Outdated, Expensive, and Deadly, He DALY BEAST (May 9, 2016), nvaitable a htp//worw.thedailybeast.conv why See, eg, Paloma Esquivel, Mirder Charges igainst Rehab Center area First in California, Los ANGELES TIM (Geb. 28, 2086), available at intythwwyw-Fatimes.convlocel/crié/ta-me-rehab-enurder-charge-20 160228-story. html; Amy Julia Harts ard Shoshana Wallet, Drug wsors got exploited. Disabled patients got hurt. One wonian benefitted fromin all, THe CHARLOTIE OaseRVER (May 2!, 2018), available a http:/'wivw chai lostegbserver.comd/atest- nevesfartile 211600538 hin; Cat Ferguson, Searching far Help, Tie VERGE (Sept. 7,2017), availabe af bbipsif/wwwtheverge.con’2017/9/7/162574 | 24tehabs-near-m-goosgle-search-scam-Nlorida-treatinent-centers, * See, e, Paloma Esquivel, Marder Charges Against Rehab Cemer are a First in California, LOS ANGELES TIMES (eb. 28,2019), available a hisp:www lalimes.convlocalerimeria-me-rehab-raurdér-charge-20160228-story. html, ‘Teri Sforza etal, How some Southern California drag rehub centers explo diction, ORANGE COUNTY REGISTER (May 21, 2017), available at 7405/2 how.some-southern-californiarugerchal ‘efters-exploitaddiction/, Amy Julia Harts and Shoshana Walter, Drug users got explotted. Disabled patients got Juurt, Onw worrdn borfited rom i all, THE CHARLOTTE OBSHRVER (May 21, 2018), available at btp:/rvwrw.charlotteabsorver.comfatest-nevrs/article21 1600539.itm. Request for Information on Substance Use Disorder Treatment Page 6 failed to refill the patient's oxygen tank, and employees with inadequate medical training Gispensed drugs that inhibited the patients breathing, * In another case, a facility employee with inadequate training dispensed the swxong medication to a patient, leading the pationt to become ill. In other cases, patients died of drug overdoses while in the care of a treatment facility or recovery home,"” In 2017, in California alone, the average number of patient deaths in licensed substance use disorder treatment facilities was one death every: 16 days.** ‘The success rates touted in marketing or promotional materials also merit scrutiny, given the‘concems raised over the quality of care provided at substance use disorder treatment facilities. Some reports suggest that thie high success rates that many programs promote may be exaggerated or entirely fabricated.”? The snccess rates at many facilities are based on self reporting by patients, and facilities may make little or no effoit to verify or define what qualifies as “success.” Seléinflated claims about program success rates coupled with ineffective ‘treatment can further endanger patients or lead io death. At Some facilities, patients ate seen as a money-making opportunity and conduit for insurance reimbursement. Some facilities have been known to engage in the practice of patient brokering; through which brokers are paid by the facilities to find and recruit individuals 10 enroll in their substance use disorder treatment programs, The patient brokers are predominantly paid in one of two ways, a per-head fee that can range from $500 to $5,000 for each patient who successfully enters a treatment facility, or monthly treaiment Facility fees that ace based on the broker mecting a quote of patients and can result in earnings in the lens of thousands of dollars."! According to some reports, in an effort to lure patients to these facilities, perks are sometimes offered, such as free plane tickets," “scholarships” to go into treatment, free housing, discounted * Paloma Esquivel, Murder Charges Against Rehab Center are a First in California, LOS ANGELES TIMES (Feb. 28, 2016), available ar hutpt/www-latimes.convlacal‘erimella-me-rebab-murder-charge-20 1 60228-story hin. Amy Julia Harris and Shoshana Walter, Drug users got exploited. Disabled patlats got hurt. One woman benefited from if all, THe CHARLOTTE OBSERVER (May 21, 2018), available at http://www 1600539.htmI, 5 Pauls MeMshon, Sober Homes Fraudter who gave Drugs to Adicts Sentenced to 2? % years in prison, SUN SENTINEL, (May 17, 2017), available at htp/wwwsun-sentine) comvnass/crimeltlreg-kennsth-chatman-sentenced- ‘sober-harnes-201 70516 story ht * Teri Sforza.ct al., How sone Southern California drug rehab centers explott addiction, Of ANGE COUNTY: Rectsrer (May 21, 2017), available at hitp/Averw.oeregistercom20)740S/21Viow-some-southern-ealifornia-drug- rehab-centers-oxplait-addiction!. » Lipi Roy, 4 ‘Beautiful Boy's’ Struggle: What You Need To Know About Afethamphetanine Addicsion, BORIS (Dee, 28, 2018), avaifeble af hiips(fwww. forbes, comsites/ipiroy/201 8/12/28/a-beautiful-boys-strugete-whst-you- inece-to-Know-about-methamphetamine-addiction/i2d9e3b635i5e; Jennifer Miller, Finding « Rehab Facllity Shouldht Be-Tais Nard, B.OOMMERG BUSINESSWEEK (Oct. 17,2018), available at hitps:/Snww bloomberg. com/news/features/2018-10- 1 7éwierceaver-aims-t0-disript-the-predatory-rehab-system. Christopher Moraff, Whp Drug Rehab is Outdated, Expensive, and Deadly, THE DALY BEAST (May 9, 2016), avaitable at hitips:fwww lbnedailybeast comn/why-