Good afternoon, everyone, or moving into evening. Hope you've had a wonderful day at the meeting so far. I'm going to get started with introductions. I am very excited to introduce our first keynote session this evening, titled Holding the Door Open, Building the Addiction Policy Workforce. Please welcome the winner of our Arts and Advocacy Award, Ms. Regina LaBelle. Ms. LaBelle is a distinguished scholar and director of the Addiction and Public Policy Initiative at the O'Neill Institute at Georgetown University Law Center. Additionally, she founded, directs, and is a professor at the Master of Science in Addiction Policy and Practice Program at Georgetown's Graduate School of Arts and Sciences. She brings decades of public service to her work and was most recently appointed by the Biden-Harris Administration to the position of Acting Director in the White House Office of National Drug Control Policy. There, Ms. LaBelle developed the Biden-Harris Administration's drug policy priorities, which included a historic focus on harm reduction services. She previously served in the Obama Administration as ONDCP Chief of Staff, where she oversaw the agency's overdose response and implementation of the National Drug Control Strategy. We are ecstatic to be presenting Ms. LaBelle with this award in recognition of her contributions as an unrelenting advocate in the field of substance use disorders and co-occurring psychiatric disorders. Your passion and activism through your tireless work has positively influenced how our nation addresses preventing and treating substance use disorders. We have this plaque for you. Congratulations. Thank you. Now we'll turn it over. Thank you so much. Thank you so much. I'm really honored to be here and thank you to folks for coming here this afternoon. So I want to talk about, I'll give you my, I have no personal or financial disclosures, no conflicts of interest. And what I want to talk about today are really three things. First, I'm going to go over what we're doing at Georgetown in terms of educating the new cadre of addiction policy, the addiction policy workforce. And it's really not just policy, it's also advocacy. And so go over what some of the gaps are between science and evidence. And then I want to do a deep dive into a couple of issues, policy issues. So methadone accessibility, availability, as well as medications for opioid use disorder for people who are incarcerated. And I look at those two issues specifically because they are tied to some of the highest rates of overdose death, a lack of access to addiction treatment, evidence-based addiction treatment, and people in correctional settings have high rates of suicide, withdrawal deaths related to alcohol and drugs. So I'm going to go over those three areas. So first I want to start by talking a little bit about the addiction and public policy initiative. So at Georgetown I split my time between the medical school, the law school where I'm in the O'Neill Institute, and then in the Graduate School of Arts and Sciences in the General University. And at the O'Neill Institute we work at the intersection of public health and the law. And we have, the O'Neill Institute has about 80 people. Most of the folks who work there work on international issues. Ours is one of three domestically focused issues. And we do a lot of policy research, but all of our work is really geared towards influencing public policy. And we also, my colleague Shelly Weissman is our associate director, is a person in long-term recovery. She's a young woman, but she's been in recovery for 25 years as of yesterday. And she leads our addiction policy capacity building efforts. So what she does and has set up this year is our Addiction Policy Scholars Program. Now the purpose of this program, there are five people in it from all across the country. And there are people who have been affected in some way by addiction. They either have suffered a loss of a loved one or they have, they're in recovery themselves. And so we brought them to DC this fall during Recovery Month. And theirs is a year-long scholars program. But we brought them for a boot camp because they may have known their own experience with addiction. They may know something about the science of addiction. They came from different, they came from harm reduction, treatment, et cetera. But they really didn't understand the basics and the nits that go into making policy and how you can influence policy making on the ground. So they came in for a week. We brought them to the White House where they met with the Office of National Drug Control Policy. They went to HHS. They met with the leader of the Substance Abuse and Mental Health Services Administration. And they met with members of Congress, but most especially and importantly, they met also with staff. Now I don't know how many of you have been to the Hill, but if you notice something, staff members are pretty young on the Hill. And we wanted to make sure that they understood that that doesn't matter, that those people are very influential. And so if you really want to get something done, you need to talk to the staff members. And in the absence of hearing from people like we brought together, they'll listen to lobbyists. They'll listen to industry people. But that's why it's so important to have their voices heard. So the Addiction Policy Scholars Program, as I said, is a year-long program. It'll end next September. But that's a piece, just a piece of what we're doing to build this policy capacity, addiction policy capacity. And then at the, and this is the folks on the capital steps. And then the second thing that we do is the Master of Science in Addiction Policy and Practice. So I'll tell you, we started this program two years ago. It was in, I started it out at Georgetown in 2018, and I started circulating this idea in 2019. Because I knew how little I knew about some of the important science and evidence when I started working on this issue, and how I had to learn it on the job, and how we thought there isn't time for people to learn this, for policy people to learn this on the job. There needs to be a place where they can go, where they're going to learn policy, evidence, science, and how to be an effective advocate. So that's what this program is. And I'm really so pleased, we had eight students last year who graduated. We have one part-time student who's going to graduate in a year. So the folks in the middle are the eight students who graduated last year in July. And I'm really pleased to say that all of them are working in addiction policy. Some are at the American Society of Addiction Medicine, actually two are. One is at the American Psychiatric Association. Several others are working in other federal agencies and on the state level. And they're prepared to hit the ground running when they go, because they're equipped with the science and the evidence, and they take the compassion that they have by themselves, that they've learned on the job, and they apply that to their current positions. Now of the about 20 students that we have in the program, and there are 11 right now, half of them have in some way been affected by addiction. Many are in long-term recovery. And they range in age from just recently undergraduates to some older, more senior people who are in their 40s and 50s, who have been involved in addiction policy for a while, but felt by coming here they could learn more. So they were better equipped to make a difference on this really important issue. And they, you know, we try to remain engaged in the D.C. community. We work with the medical school to distribute naloxone. Also go to the Hill for various activities. So they're seeing the totality of what addiction policymaking is like. And this is the year-long program. So it's, we wanted to make it one year, not two. It's a Master of Science. One year, not two, specifically because when students come out of here, we don't want them to be weighed down with a lot of debt. So that, and we gave a reduced amount for this year's tuition, for the last year and this year's tuition. And it looks like, you know, you would think this is a regular, perhaps a public health program. But it's very focused on addiction. And when we say addiction, we're looking also, we're looking at gambling, we're looking at alcohol use disorder, we're looking at drug use disorder. So the healthcare finance program, the healthcare finance class that they take is focused on, you know, how do we fund addiction treatment in this country? How do we fund addiction prevention? So they go, they look at the federal level, the SOAR grants, the SAMHSA grants. They understand what the Parity Act is. Actually Congressman Kennedy, who helped formulate the Parity Act, spoke to them last year about the Parity Act. And then they had data analysis and statistics and drug policy. That's taught by Dr. Chris Jones, who is with the Centers for Disease Control and Prevention and is a preeminent researcher on this issue. And then a U.S. addiction policy. So they understand where we, how do we get where we are? What are the laws that were put into place and passed that took us this somewhat dysfunctional place where we are now? So the first summer are the building blocks. And then in the fall, which we're in now, they have their last class with me tomorrow, they take a class in the fundamentals in neurobiology. And I have to say that the students are always really nervous about this, like, because a lot of them come from political science backgrounds, like me, and, you know, we have to kind of walk them through what this is going to look like. In some cases, we've suggested that they take kind of a starter class before this. But we feel it's important for them to understand this, if they're going to be making policy or influencing policy. And then foundations of addiction psychiatry one and two, taught by Dr. Wilson Compton, who's the deputy director of the National Institute on Drug Abuse. I'm sure many of you know him. I'm really pleased that he is giving up his time to teach. He's a great teacher. He's taught in the past, and it's a great program. And then I teach an integrative seminar. So the integrative seminar is intended to combine the science with the policymaking. And that's where we really look at what the gaps are. But it's also where I teach them about the levers of policymaking. Then they have an epidemiology elective that they take. And in the spring, they are going to, this is a new class on addiction and mental health law and policy, foundations of addiction again. And then they have a policy elective. And they finish it up in the summer with comparative addiction policy. What can we learn from Europe? What can we learn from other countries? What are they doing right? And how can we perhaps apply some of those principles to our own country? And they have the next data analytics and statistics. And lastly, the capstone. And the capstone, I want to just touch on that for a minute. One of the students that we had last year was, her brother died of an overdose. And what she discovered in her experience and her family's experience was that, and I've heard this repeatedly, but that there was really nowhere to go to process her grief for this specific issue. Because there's a lot of stigma attached. He died from an illegal substance. So she did a lot of research on it. Her capstone focused on the research, the lack of a body of research on this. And also, she has taken time to develop a nonprofit. But it's not a non, you see many nonprofits out there. She's going to combine a lot of nonprofits and take a lot of energy from other people who have experienced grief. So that they can have an organization to help people process their grief and put it into positive policies. To develop positive policies. So she's working on that now. But that's just one example of the incredible capstones that the students put together last year. So that's kind of the level set of what we're trying to accomplish. And now I want to talk a little bit more about why we're trying to accomplish this. Why we're trying to do this and why I think it's so important. We know that there are a lot of barriers. You face them every day in treating people with addiction. And I want to talk about the policy and the politics of these issues. And how building this trained and skilled addiction policy workforce is so important. So earlier in October, the U.S. Government Accountability Office put out this report. And the report focused on behavioral health providers. You all know this. You know the limits and the scarcity of providers that we have. And it's really, they identified three things that could be done. One is reimbursement rates. And CMS is always hearing about reimbursement rates. Always. And advocates are always telling them you need to look at your reimbursement rates. But this is something the Government Accountability Office identified. Second is the lack of diversity in the behavioral health workforce. If we have unprecedented overdose death rates among the American Indian population and in black Americans, we don't have enough addiction practitioners who look like them. So the diversity of the workforce is critically important. And that's something the federal government can do something about. And then lastly, they identified rural areas. And the lack of treatment professionals in rural areas. Now telehealth helps some with that. But it's still not sufficient. So this GAO report came out in October. It didn't get a lot of play. Partly because this isn't news, right? We know this. But the more important thing is what are we going to do about it? But I would also contend that just as the clinical workforce, there's a shortage. The addiction policy workforce is also facing a shortage. Or at least with people who understand the evidence behind it. So as was mentioned, I served in the Obama administration. And there was a moment you could really feel there was a lot of momentum being built up. In 2014, 2015 is when there was a recovery rally on the National Mall. It was the first time ever. And it was a great moment for the recovery community. And there were many people, many highlighted a lot of stars, many of whom I don't know. You would probably know some of the names. So there were big names who went to the stage. It was a big project. And so it was like, okay, are we catching lightning in a bottle? Are we going to move on this finally? And it didn't peter out. But it was a bit of a moment, not necessarily a movement. But we also had the Surgeon General's report on facing addiction in America, which came out around the same time as this rally. And that was great, too. And that did move us a little bit further. It got Congress' attention. But I also have this research up here, which I found really interesting. And I always assign it to my students. And they argue for the need for addiction science advocacy. And I was thinking about this yesterday when we have a journal article that will be released in January on deaths in U.S. jails and the causes of deaths. And we looked at 2015 to 2020, all the reported cases of deaths in U.S. jails. And the findings were really, you know, pretty – they were what we expected, which is we saw, you know, suicide rates are up, et cetera. And the amount of money that counties, local jails have to pay out because of these deaths. But that piece isn't going to come out – it's 2015 to 2020. And our piece isn't going to come out until January. And right now as we sit here, Congress is making decisions about issues that would directly affect that population. So if I wait until January to give that to members of Congress, it's not going to make a difference. So yesterday we released a shorter policy document with recommendations. So certainly a lot of journal articles have those recommendations. But this – we specifically called out the recommendations. We sent it to the Hill. We gave the Hill a heads up that it was coming out. And while we can't practice specific advocacy, we can educate them about these issues. So this article, this journal piece, talks about how fear is – and we know this, right? You all are psychiatrists. You know it better than I. Fear is more of a motivator than science. But what we use to influence policy is fear, right? Marauding hordes at the border. I can get into the supply stuff. I'm happy to talk about that as well. But that fear motivator – fear as a motivator is often what drives our policies, not science. And what he argues for in this article, which I agree with, is that we need a little bit more of the science and scientists trying to influence the policy making. And there are ways that that can be done. Putting a face on the issue. You know, having a narrative. Those are all ways in which we can better influence policy as long as it's driven by science and evidence. So when we talk about the policy levers, you know, I often break them down into three areas. So the executive branch actions. So policy and regulation. Legislative actions. I think too often we just look at Congress or state legislatures. You know, there are other ways that we can influence policy. It's not just about legislation. But if you are going to try to get legislation passed, it needs to be bipartisan, particularly in this era. And at least at the federal level, you need to have a consensus among the agencies. So I'll give you a reason. And one of the reasons for that is, especially in drug policy, so you have Health and Human Services has a mission. SAMHSA has its mission. And then the Drug Enforcement Administration has its mission. And it has a lot of influence over policymaking. Now, whether you like that or not, that is a fact. So in order to get legislation passed, you have to have those two sides that have different missions. The Drug Enforcement Administration's mission is to reduce illegal substance availability and the diversion of controlled substances. That's its mission. But if you're on the health care side, and someone gets buprenorphine that may not have been prescribed to them, but it helps them reduce their risk of overdose, that's a different mission. But you have to bring these two sides together if you're going to have agency consensus before you can get legislative action done. And then lastly are enforcement actions as another policy lever. So the Department of Justice, I'm going to talk in a little bit about guidance they put out about the Americans with Disabilities Act recently. American Disabilities Act's been out since the 80s. But it had not been used until relatively recently in terms of making sure that people have access to medications for substance use disorder. So that's another tool that we can use. The other is litigation. I'm going to talk about that tool. That's a tool. Now, even as a lawyer, I'm not crazy about litigation as a policymaking tool. Because it's not always a great policymaking tool. But it can get people's attention. And it can drive a focus on an important issue. And then last but not least, parity enforcement. So making sure that this great law that we have, the Mental Health Parity Act, is actually enforced by the federal government, by the Department of Labor, as well as by states. So these three areas are all policy levers that can be used to drive effective evidence-based policies. So as was mentioned, I served in the Biden administration. But I also was on the transition team, which is basically for the Biden administration. So we started meeting even before Election Day. And this is typically how it's done. You start meeting before Election Day, both sides, just to make sure you're ready when Inauguration Day comes. So we had to develop plans for the Office of National Drug Control Policy. And in doing that, we met with organizations, lots of organizations. I'm pretty sure we met with AAAP at some point, as well. And we asked folks, tell us what your input is. What should we do? And we did use this term, what's the low-hanging fruit? What should we be done? What should we be doing? But I think we define low-hanging fruit a little bit differently, because people came to us and gave us ideas that should be done, as opposed to what could be done. And my job in policymaking is not to tell people what we can't do. It's really to figure out a way to get it done. But some things are easier done than others. So we asked people to tell us what the low-hanging fruit were. And this is what was identified. Barriers to methadone access. Eliminating possession charges. That's federal, as well as state and local. Reducing family separation brought about by drug use. Access to medications during incarceration. Expanding syringe services programs. Removing the X waiver. And then lastly, and this is little, investing in the social determinants of health. So all these things people brought to us. So what we had to do was kind of shift through these and figure out when. So I started on the afternoon of the inauguration. And by April 1, Congress required us to come up with seven policy priorities. And we based some of them on the policy reforms that we identified, that people identified for us during the transition period. And those seven policy priorities were expand access to evidence-based treatment. Expand access to prevention, evidence-based prevention. But that includes the social determinants of health. Providing recovery support. So what are we going to do in a policy basis to make sure that we are supporting people in their recovery through housing, employment, and all those recovery support services that are essential? And then two other pieces, facing the equity issues that we know exist in our current drug policy. And then lastly, harm reduction. So in last year's policy priorities, it was the first time the administration had ever put those words in an Office of National Drug Control Policy document. And we said it had to be in there. It had kind of danced around it for a long time. But we said those words have to be in there. Because when you have over 100,000 people dying a year, and you have 12% or 13% of those people are getting treatment, you've got to do something about reducing the harms associated with drug use. So we put harm reduction in. And we got some criticism for it. But it was essential that it be in that policy platform. So I don't know if Twitter still exists as of now. But it did when I did this. And I put this in because I love working in policy. It really gives me a lot of joy. Even though these are tough issues, even though I'm not always fun at parties when I talk about what I do. But it's really important. And I think, you know, and I tweet on occasion. I write, I tweet like a lawyer, which doesn't mean I have a lot of tons of followers because I always have caveats. But Twitter is not policy reform, right? And what I want to talk about is how do we go from should, because there's a lot of shoulds on Twitter, right? And I wish I could write like this on Twitter. I just don't. There's a lot of shoulds. But how do we move from should to how to get it done, right? And I often talk to my students also about activist tourism. And what activist tourism is marked by is when you're trying to reform policy. And that's really well-meaning. And it's important. But policy reform takes a really long time. Sometimes you can do it quickly. But usually it takes a long time. You've got to be in it for the long haul to see the change that can come about. And it's a ship. It's a ship that moves slowly. But I can see from the time I started even in the Obama administration, we had our first director of national drug control policy who was in recovery, openly in recovery. And that made a difference for people. And I think he helped move policy reform just by his very being. First of all, he's a great guy. But Michael Botticelli made a great difference just by his identifying as a person in long-term recovery. And we have now the first doctor as a director of Office of National Drug Control Policy. That also makes a big difference. But those are things that don't come. A lot of the stuff that's done, it's really like, I spent six months working part-time and that transition team preparing for that one day of coming into office and making sure we hit the ground running. And then it's the behind-the-scenes stuff that isn't, it doesn't give you the same satisfaction as a really great tweet. But over the time, over a long period of time, it's going to make more of a difference. So why do we do what we do? It's because of, and I'm sure you see this repeatedly, I think it bears repeating because we cannot numb ourselves to this figure. Of over 100,000 people a year, we can't numb ourselves. We have to keep this in front of us at all times. And I remember when I started at the Office of National Drug Control Policy in 2009, it was 20,000 deaths. And that was horrible. And now look at where we are. And that doesn't even include alcohol-related deaths of 144,000. So keeping this front and center and central in our minds is a galvanizing force to making the change that we need to make. And the other piece of this is the reality of our life expectancy. Life expectancy in the United States is currently at the lowest it was since 1996. Now, yes, that's due to COVID primarily. But it's also, as you can see here, unintentional injuries, which are drug deaths, and chronic liver disease, which is directly related to alcohol use. And it's even worse in other communities, black and American Indian populations. The black population life expectancy fell from 75 to 71. And again, these are deaths of despair that are driving these numbers. And it's important that we keep these things front and center at all time and that we constantly remind people of the urgency of this issue. So given these urgent issues and the policy reforms before us, I want to take a dive into a couple of them and a few that we've worked on quite a bit at the O'Neill Institute and that I worked on last year when I was in the Biden administration. So first, eliminating barriers to methadone access, and then access to medications for opioid use disorder during incarceration and on reentry. And I want to talk about how we move from the should to the how. So this isn't the best slide, but the point is that there are a lot of things we can do with methadone. And unfortunately, methadone is, you know, I've said this before because in all the time that I've focused on it, have been to opioid treatment programs, it's like a punishment, right? It's like we're treating these patients. We're punishing them. And the way we punish them is by making them show up every day until they're stable and making all these rules. So this chart just shows all the rules, some of the rules anyway. The rules are voluminous, but some of the rules around methadone that were written by people like me, by lawyers, about how to make sure it's not diverted. Yes, it's a dangerous substance, but there are things that we can do. So the George Washington University Regulatory Center did a great study called the discretionary regime. They put this out earlier this year. And it identifies what, without Congress, without congressional action, what can we do to increase access to methadone so we're not just punishing people and making it more and more difficult for them to get the treatment that they need. And there are a couple of things I want to point out. Well, first, and this is a congressional action, there are a couple other ways it could be done. But Congress is considering legislation right now that would allow addiction doctors to prescribe and then patients to pick up methadone at pharmacies. And one of the reasons that this legislation is being considered is to expand access, because there are 30,000 pharmacies in the United States, and there are 1,900 opioid treatment programs, 90% of which are in urban areas. In West Virginia, there's a ban on methadone treatment facility, on opioid treatment facilities, a ban. They call it a moratorium. It's a ban. But there are things that we can do short of Congress acting. One is methadone, there's a regulation that could be revised, because right now you have to have one year of, show that you have one year of an opioid use disorder before you can get methadone and an OTP. That can be revised. It doesn't have to go through Congress. It can be revised. Secondly, patients who are less than 18, you have to have evidence that the person has tried an abstinence-based effort at treatment before they can access what could be a lifesaving substance for them. Those two things can be changed by the administrative branch right now. And so this report did a great job of identifying low-hanging fruit, what can be done. And then third, I think the third piece of this, the third reform that could be done and is being done, which is good. So during COVID, actually, it was very, very good that during the first year of COVID, changes were made so that people could get take-home methadone, even if they were in early stages of treatment. Now, that was set to sunset when the emergency declaration went away for COVID. However, SAMHSA has provided, has sent out guidance that they would extend that for a year. And then they'll start working on rulemaking for that so that people can have better access to take-home methadone. And there are many reasons why that's important. But one of the reasons, we know from the last couple of years, we didn't see an increase in diversion of methadone. And we didn't see an increase in people overdosing from diverted methadone. So we had a natural experiment where we could kind of show with science and evidence, not scary, this can be done. So those are three ways in which methadone access can be expanded so it is, and there are many other ways, and they're identified in this report. But those are three things that can be done right away. And one thing that we started with when I was on the transition team, one of the things we put into our planning was having the National Academies of Science, Engineering, and Medicine do a workshop on methadone access. And when I was at the Office of National Drug Control Policy, we pulled together some money to fund that. So they have put out a report on that. And they had the voices of people with lived experience also included in that discussion. So the workshop paper, again, it's all those little things. It's not one thing. It's little things, little things that add up to policy change. And I'm really hopeful that we'll see action on methadone in the next year. And then the second piece is medication for opioid use disorder and corrections. And it's not as compelling a group of people that we're talking about, right? But when I served in the federal government, I would tell staff, if we don't do this, literally no one else is going to care. We're the ones that have to care about this. And we know they're more likely to die. When they get out, they're going to die, right? They are more likely to die of an overdose upon reentry because they're not getting the treatment that they need when they're incarcerated. It is not a panacea. And people who have a substance use disorder or a mental health condition should be diverted away from jails and prisons. However, there are people today in jails and prisons, 60% of whom have a mental health issue or a substance use disorder. And we have to treat them. There are basically three tools that have been used to move the ball forward on this. Litigation, legislation, and executive branch leadership. So the first piece, oops, sorry. Sorry, I'm, OK, litigation. There have been cases brought around the country. Washington State has seen a SOG case. Maine saw a case. The ACLU has been bringing these cases on behalf of individuals who are told that in order to go into a jail, they have to withdraw from buprenorphine or methadone. They don't require people to get off of Vivitrol, naltrexone, but they do require for buprenorphine and methadone. So these cases were brought because some really good lawyers said, well, this seems to be contrary to the Americans with Disabilities Act, because the Americans with Disabilities Act covers people in recovery from a drug use disorder. It is an incredibly important tool that was really unused. So they use it in these cases. The Maine case went to trial. Whatcom County, Washington, they settled. And they are working, they have worked, the ACLU has worked closely with the sheriff in that county to establish a program by which you don't have to withdraw in order to go to that jail. You don't have to withdraw from buprenorphine or methadone. So that was because of litigation and because of the Department of Justice used the tool of the Americans with Disabilities Act to enforce this. Now, Department of Justice put out guidance not too long ago about the Americans with Disabilities Act, which has been around. The ADA has been around since 88. But it hadn't been used in this arena very often. So DOJ put out guidance that said, yep, that's what the ADA says. You cannot have a blanket rule requiring people to withdraw from a medication. So they put out that guidance. And we spend a lot of time working with people to try to get them to understand what the guidance says and what are the policy implications of that. Because while I like litigation, it doesn't always result in the best policy results. Because these cases are good for telling people that they don't have to withdraw from methadone or buprenorphine, but the induction piece still isn't there. So the second piece of what is important is looking at legislation. So 24 bills were introduced in 18 states. And we also, at O'Neill, we developed model legislation that has been implemented in some of these states. and the legislation basically mandates that jails and prisons set up these medication programs. Now the one thing, you know, again, legislation important, but the money is also important. And in Congress, make sure that if, you know, you hear about a piece of legislation being passed, the second question is always, is there money appropriated to implement that? And as Hal Rogers, who was the chair of the Appropriations Committee in the Obama administration for a few years, said, an authorization without an appropriation is a hallucination. Because it's really just a political tool that they can use to say I've gotten something done, but they really don't. Until the money's there, it's not done. So the legislation is important, but really what matters is how much money they're putting in, how much money the state legislature is putting forward. Primarily because, as you probably know, there is the inmate exclusion. The inmate exclusion means that if you are incarcerated and you're eligible for Medicaid, otherwise eligible for Medicaid, once you enter incarceration, regardless if you're pretrial or not, regardless of whether or not you've had a trial, you're no longer on Medicaid. So if you're a county, say you're a small rural county and someone comes to you on methadone or buprenorphine and you've been required, you've been mandated to provide that, now those drugs in and of themselves don't cost a lot of money, but setting up programs can cost money. But you're not getting money from the state. You're not getting money from the federal government. That's on the county to pay. So that inmate exclusion prohibits the federal government from spending a penny on Medicaid for otherwise eligible people who are incarcerated. There's legislation right now before Congress that would change that. It would cost more money. There are a lot of issues involved in that, but it's a very important legislative issue that is coming up that I'm hopeful they'll pass perhaps next year. But you have to build the case for it. At the time that law was passed, it's the 1965 Social Security Act was passed. There were 200,000 people in the United States who were incarcerated. Now there are more than 2.2 million people in the United States who are incarcerated. And although many of those people, certainly all of them need healthcare, many of those people would have relied, otherwise relied on Medicaid. So executive leadership is another way in which states are getting funding. Now executive orders, executive leadership come and go with the executive. So not always reliable sources of long-term funding, of long-term action. California and Maine have executive orders. And in Colorado, by July of 2023, all of the jails in the state have to provide access to medication for opioid use disorder for induction as well as continued treatment, and New York as well. So what's the future state? I mean, these are the things that we kind of aspire to in the policy space. That we stop treating methadone as if it's a punishment for people. That people are not incarcerated for substance use alone. That we have community-based treatment for them that we can divert them to. We're not there yet. But child welfare is equated with family welfare. And whenever we talk about child welfare, I always try to, you know, put it in the framework of the family because children come in families. And if you support the families, you're supporting the child. So one way, one piece of legislation, not legislation, but one act that happened last year is the child tax credit, which basically was a prepayment of tax credits for people. It cut child poverty in half. And we know that child poverty is connected with adverse childhood experiences, which can put people, put young people at risk for substance use disorder. So that child tax credit, child welfare, family welfare, very interconnected. Expanding syringe services programs and harm reduction services in that they're seen as part of the continuum of care. So prevention, treatment, harm reduction, recovery, all of those are places where people can go to get the help that they may need. Buprenorphine prescribing is normalized. And then lastly, that the social determinants of health, the social determinants of addiction, housing, employment, that those are all seen as parts of a holistic approach to addiction policy. So I want to end with this acknowledgement that is not showing up, I apologize. Because I want to acknowledge the people who have passed, many of whom you know, I know, and their families. And those people are, you know, members of our community. And everything that I do at Georgetown is dedicated to them. And so I just always want to end any talk with an acknowledgment of the people who we've lost. So this is my contact information. I'm happy to answer any questions. If you want to hear more about the Master of Science Program, this is the website. And with that, I'm happy to take any questions that you may have. Hi, Regina. Thank you very much. First, I want to thank you for, while you were in ONDCP, it was the first time, AAAP, since I've been here for 18 years, we're invited to come and have a discussion prior to the transition. So I want to personally thank you for that, because that was a first for us. Too often, I find we're not at the table in discussions. And I think the people in this room are the very people that are kind of the dream team, if you will. I'm curious about the part about the elimination of ex-waiver. I'm not going to get into a debate about it, but I'm just curious because I think most people here would agree getting rid of a lot of the things related to the ex-waiver is a great thing. I think the biggest challenge is eliminating education. And I think my concern is that a big part of what's happening, it's not people getting the waiver or not. We've got enough people that are waivered that don't prescribe. We had, after the elimination of the waiver last year, April 2021, in one year, we trained and completed training 30,000 health professionals. So there's obviously, that's not the thing that's deterring people from getting the education, but still the decision was made to throw it all out. My fear is, is that the more we say we're going to do that, not require any type of training or education, we're doing the very same thing that we did to how we got to part of this problem. Health professionals or doctors don't know how to treat pain effectively, so they go this way. So I'm just curious from your perspective, where do you see that going if we are getting rid of something without having the data to really show us, is that the deterrence? Because a lot of what we're seeing out in the community through our grants for providers clinical support system, opioid response, it's about implementation. It's about not being able to find a behavioral health specialist to connect with. It's about basic human needs. So I'm just curious of your perspective of that. Yeah, thanks for raising that. And actually, when I was acting, I said that I was really queasy about this because, not because I think the X waiver is great, but because what are we going to do in lieu of that when we have so little education as it is? So I don't disagree. And I do think that medical schools, and we need more professional development. Like what you do to educate your colleagues around the country so that they feel more comfortable treating people with addiction. Because as you know, the reason people aren't treating people with addiction isn't because an eight hour, it's not because of eight hours. And the 30, we waived the requirement if you're treating 30 or fewer patients last year. And again, that's not why people aren't. It's the whole stigma. It's got to be a much broader approach. I'm not sure. I mean, we've only got a couple days left in the legislative session in Congress. I'm not sure. There's 350 people who've signed on. I don't know if the MADAC is going to pass this year. I do hope we can underscore the role of mental health because more times than not, it's either mental health or substance use disorder. And that's really what the elephant in the room. People don't talk about mental health. And I think that's another thing these people really want to have come from the forefront. Thank you. Yeah. Thanks. Hi. I'm Ramaswamy Viswanathan from State University of New York in Brooklyn. I want to commend you for, you know, the extraordinary work you are doing and also bring home the message that we have to engage in advocacy, not only in legislation, but also implementation. And one of the examples of that is sometimes, you know, local communities undo, even if you pass state law, you know, like in terms of legal exchange program, for example, in New Jersey, even though it allowed it, you know, Atlantic City Council disallowed it. And luckily in New Jersey, then they gave the responsibility to the state government as opposed to local. So can you comment on that? You know, the local communities undoing whatever advances we make in the legislative front. Local community not complying with... Exactly. Yeah. You know, some of the extends which don't allow, for example, you know, some kinds of treatments. Oh, you mean like zoning and using those like NIMBY things, keeping people out? Yeah. So certainly, you know, that's often part of the problem and it shows the, you know, the depth of the extent of the issue and the depth of stigma that we face. So that's why every level of government is part of the solution and we need to bring people in. I used to do some work on how to expand, for example, syringe services programs in rural areas. And so finding partners who can, like, who are part of the community, who can act as your advocate with that community, so you're not, you know, telling them what to do. You're not the state government telling them what to do. But looking for allies in the local community, it's kind of basic community organizing. But yes, it's a big problem and we see it repeatedly. And there's no simple solution for that, but it's really trying to find advocates in the local community. Thank you so much for a great presentation. It's so nice to know that people are working on very important issues. I have three questions. One is that you mentioned about methadone being prescribed and then picked up at the, you know, Walgreens or all the pharmacies. One concern is that physicians have to do the physical exam at the initiation. And I think it's very important because methadone can kill the person unless, you know, we make sure that the patient is healthy enough to take the methadone. And also, you know, in the first two weeks are the most dangerous time. They tend to have overdose. So I believe the first two weeks, they go there and then, you know, monitored taking the medication is great. But once they were stabilized, then, you know, they can go and pick up the medication at the pharmacy. So my recommendation is more like a hybrid as opposed to, you know, going there versus, you know, going to pick up at the pharmacy. That's the first question. And the second question is that two of my patient did abortion because they cannot raise children when they are engaged in the opioid treatment. Currently, there is the Supreme Court. I'm sorry. Can you repeat what you just said? Yeah. I want to make sure I'm understanding what you just said. Yeah, sure. So two of my patient had an abortion because they were engaged in opioid treatment and they can't raise their kid. So were they told by child services that they couldn't or who said that? So they voluntarily aborted the children when I was, you know, so I asked them, how's the baby doing? And I mean, do you go to OBGYN? And they said, oh, I'm sorry, Dr. Huro, I aborted the baby. That happened twice. And I believe the abortion rate is a little bit higher compared to, you know, the opioid use disorder patient compared to the regular general population. And there is a Supreme Court abortion, you know, decision and stuff. Is there anyone working on the, you know, the abortion in opioid use disorder patient? That's the second question. And the third question is that cannabis role, those in regulation, I know they are working on it. Currently, the federal, it's the control one, schedule one. And then I'm sure they are working on it, but I was late, so you might have mentioned about it. But if you can, if you haven't mentioned it, if you can mention about the scheduling of cannabis schedule one, is there any changes you can foresee? So those are the three questions I have. Okay. So scheduling cannabis was the last question. So I'll answer that quickly. That has to go through an eight-factor analysis basically done by HHS. HHS has to determine what's called an eight-factor analysis. They send it back to the Drug Enforcement Administration. They will make the determination on scheduling of cannabis. The second question about, I mean, there's a lot of issues there. But what I will say is we wrote a piece last summer on the increased rates of unintended pregnancies among the population of people with substance use disorder and the importance of accessing, you know, treatment. There are, you know, and as well as birth control, there's a lot of ADA issues involved in what you just said. So I am not going to comment on a particular case because I'd have to know a lot more facts, but that's a little disturbing. But yes, there are more, there's more unintended pregnancies. And then your first question, see, I think this, what you raised is why, you know, again, a lot of the methadone rules were written by lawyers, not practitioners and clinicians. And so that's why it's so important that we have clinicians inform that type of policymaking. The law before, the bill before Congress allows for that to occur. It doesn't mandate it. And it's not, you, the pharmacy wouldn't be prescribing it. That's a different piece of it. But anyway, this is the opening discussion on it and, you know, clinicians need to get engaged in that debate. Thank you so much for your presentation. My name is Tanya Sorrell. I'm the director of Rush University Medical Center's Substance Use Disorder Center of Excellence. And Illinois is actually shooting for the higher fruit on the tree in this legislative section, actually answering one of her questions, CAPTA, which is the Child Abuse Prevention Services at the federal level. They have actually stated that you can remove a positive drug screen from pregnancy testing. But unfortunately the states, only New Mexico has actually done a, had a law, a state law that says that they can do that. Illinois is another, is the second state that's trying to do that this year so that women will feel more comfortable voicing their substance use and having a positive test and not having DCSF or child protection notified. But my question is for that highest hanging fruit. We actually have a bill this term for an overdose prevention site. And despite the one year of success that OnPoint New York has had in saving prevention of overdoses, actually preventing the medical cost of overdoses and the other 14 countries, several hundred OPCs, the DOJ has still just the other day decided to push a couple more months before they report on that. What are some of the issues besides what we all know, stigma, racial issues, and the actual recognition of use as part of harm reduction, are our policy makers seeing as the deterrent to that? And what movement is happening toward being able to recognize either if the Philly side or other sites or us, we in Illinois move for these to be able to release the bill that's refusing people to be persons to have a facility where consumption of substances are used. I know that's one of the biggest deterrents. Thank you so much. Thanks. So overdose prevention sites, as you mentioned, it's their litigation in Pennsylvania because the previous administration pointed out that it violated the RAVE Act, the crack house statute. So DOJ was supposed to come out with a decision the other day and they didn't. They punted it, but you could potentially have like a research exception to allow those to occur. The issue is scalability, you know, and how much, how many you would have. So those are, you know, just some of the thoughts on that. So we have 37 seconds. Okay. So quickly. I'm Rick Rosenthal. I'm head of the public policy section for the academy. In the 2000s, we had three separate office of a narcotic and drug control policy summits, White House executive office of the president sponsored on medical education, substance use disorders. Everybody, AAMC, Federation of State Medical Boards, everybody was at the table. Everybody bowed, you know, bounced their heads up and down. Oh, this is really great. You know, learn about pain, learn about addiction, blah, blah, blah. We continue to pump out doctors from medical schools that don't know anything about pain prescribing or substance use disorders. I'm wondering at the federal level, what can be done policy-wide? Obviously we've got a lot of private not-for-profit, you know, institutions, but I'm wondering if like pressure can be brought to bear on AAMC and some of the other big, big guys to see what we can do policy-wise to stop this. This is just stupid at this point. So I agree with you. So one thing that could be done, and this is pretty risky, is to say that you would, they would hinge your federal funding on providing medical education on- Well, look, Medicare did it with pain. Yes. So but it hasn't been done because it hasn't been done and because it's like, oh boy. But as someone said to me who presented me with this said, you just like, you know, you perfume the air with that before you go in and you make them think you might do it. So again, gets their attention. So just the thought to get with your colleagues to perhaps perfume the air. Yeah. Thank you so much. And thank you for all the great work you're doing. Thanks very much, everyone.

Regina LaBelle

Addiction policy workforce

Science and evidence gaps

Methadone accessibility

Medications for opioid use disorder

Correctional settings

Overdose death rates

Evidence-based addiction treatment

Addiction and Public Policy Initiative

Master of Science in Addiction Policy and Practice