Thank you for holding this hearing to discuss how the COVID-19 pandemic has exacerbated the existing substance use and overdose crises in America and to identify additional legislative action to provide Americans the help, treatment and care they need to recover from this difficult time and prevent further impacts. The National Safety Council (NSC) appreciates the opportunity to submit these comments for the record.
NSC is America’s leading nonprofit safety advocate and has been for over 100 years. As a mission- based organization, we work to eliminate the leading causes of preventable death and injury, focusing our efforts on the workplace, roadway and impairment. We create a culture of safety to keep people safer at work and beyond the workplace so they can live their fullest lives. Our more than 15,000 member companies, including federal agencies, represent seven million employees at nearly 50,000 U.S. worksites.
The COVID-19 pandemic has taken a serious toll on the mental health of Americans, with 40% of U.S. adults reporting that they struggled with mental health or substance use in June 2020.1 Studies show that from February to December 2020, the risk of having a general anxiety disorder increased by 80%, and the risk of having a depressive disorder has increased by 145%,2 with women showing the largest increases in stress and anxiety. Most recently, we learned that the percentage of adults who had anxiety or a depressive disorder symptoms during the past seven days, and those with unmet mental health needs during the past four weeks, increased significantly from August 2020 to February 2021. One in four adults who experienced such symptoms reported that they needed but did not receive counseling or therapy for their mental health.3
Mental distress and illness are closely linked with substance use and misuse. Recently released data show the 2018 decrease in both general and opioid-related overdose fatalities was reversed in 2019. The number of drug overdose fatalities topped 70,000 in 2019, and opioid overdose fatalities neared 50,000.4 The U.S. reached a tragic new high in the 12-month period ending in August 2020, with over 88,000 opioid overdose fatalities reported.5 Lastly, over 40 states are reporting an increase in opioid overdose fatalities since the beginning of the pandemic.6 These increases may be linked, in part, to increased feelings of stress, loss of control, and isolation in response to the pandemic and subsequent quarantine during stay-at-home orders, as well as impacts on varying socioeconomic factors that increase risk for substance use (e.g., financial and housing insecurity).7
To address the increased rate of substance use and mental health challenges, NSC supports creation of cooperative programs at the National Institute for Occupational Safety and Health (NIOSH) to provide employers with access to substance use mental health support resources. Multiple studies show that for people experiencing a mental illness during their lives, nearly half will also experience a substance use disorder and vice versa.8 Given that NIOSH has extensive workplace knowledge and makes “Mental Health in the Workplace” a priority area within the Total Worker Health program, NSC recommends NIOSH as the home for such a program.9
NSC encourages the Committee to focus on the following three areas in particular – the employer role in addressing the opioid crisis, expanding access to treatment and recovery services and supports, and addressing racial inequities.
The opioid crisis – the employer role
According to the Centers for Disease Control and Prevention (CDC), 95% of all opioid overdoses in the
U.S. strike working age adults.10 Over 70% of adults with a substance use disorder (SUD) are in the workforce,11 and 75% of employers have been impacted by employee opioids use in the workplace.12 Employers have an essential role to play in preventing opioid use and misuse and supporting employees through treatment and recovery. Research has demonstrated that providing wrap-around services enhances treatment retention and improves treatment outcomes.13 People in workplace- mandated treatment have better or similar outcomes on a variety of metrics, including employment stability at 1 and 5 years after treatment.14
The annual cost to employers of an untreated SUD ranges from an average of $8,255 – $14,000 per employee, depending on their industry and role, and workers with substance use disorders miss two more weeks of work annually than their peers, averaging nearly five working weeks (24.6 days) a year.15 However, workers in recovery, who have reported receiving substance use treatment in the past and have not had a substance use disorder within the last 12 months, miss the fewest days of any group – even the general workforce – at 10.9 days. Additionally, each employee who recovers from a SUD saves their company over $8,500 on average in turnover, replacement and healthcare costs.16 Given these numbers are dated through 2019, NSC expects to see these costs grow throughout 2020 and into 2021. NSC has a free, online tool for employers to estimate the cost of substance use in their workplace based on the size of the employee base, industry, and state at nsc.org/drugsatwork.
Workplaces are currently facing unprecedented challenges related to the COVID-19 pandemic with increased rates of substance use, and employers must be part of the solution. Employers will need resources, support and training to increase access to treatment, create recovery-ready workplaces, and take other steps necessary to combat the continued substance use and opioid crisis. Recovery-ready workplaces must not only focus on supporting recovery, but also providing a full spectrum of resources and support for employees and their families to address prevention and treatment needs, as well as reduce stigma.
Recommendations:
- NSC supports the first year priorities set by the Biden-Harris Administration Office of National Drug Control Policy (ONDCP).17 In particular, NSC encourages the Committee to focus on the actions underpinning Priority 6: Advancing recovery-ready workplaces and expanding the addiction workforce.
- Support funding for NIOSH workplace supported recovery programs (WSRP).18 WSRPs use a variety of tactics to prevent exposure to workplace factors that could cause or perpetuate a substance use disorder and lowers barriers to seeking and receiving care and maintaining recovery.
- Provide funding and support for training and re-entry programs focusing on:
- Helping people with a substance use disorder re-enter the workforce (job / skills training). The SAMHSA Treatment, Recovery, and Workforce Support Grant19 is an excellent example of providing funding for these programs.
- Ensuring the workplace is prepared (training supervisors and managers, creating supportive policies). For example, the Opioids & Substance Use: Workplace Prevention & Response Worker Training Program from the National Institute of Environmental Health Sciences (NIEHS) at the National Institutes of Health (NIH).20
- Providing funding and incentives to workplaces who become recovery-friendly and/or focus on hiring workers in treatment/recovery.
- Expand and enhance research and development of evidence-based and promising recovery services and programs, such as peer-to-peer support programming.
- Increase employment programs for people in recovery to ensure employees can return to work after successful completion of a treatment program.
- Expand access to transitional housing, job training, and social services for people in recovery.
Expanding and increasing access to evidence-based treatment and recovery supports
Treatment for mental health and SUD is effective, but access to treatment, which was a significant barrier before the COVID-19 pandemic, has been strained further. Only 10.3% of people with an SUD in 2019 received any treatment, and only 18% of people with an opioid use disorder (OUD) received medications for addiction treatment (MAT).21 Additional disruptions have occurred in recovery support systems which are critical given that social exclusion and the inability to find employment are associated with relapse and exacerbated struggles with substance use.22 Of note, both of these experiences have become more common during of the pandemic. Given the clear need for increased access to treatment, there are a variety of tactics the federal government should consider, as well as actions to support individuals in recovery.
Recommendations:
- Expand and enhance research and development of evidence-based treatment programs and other programming to treat and manage SUDs.
- Increase insurance coverage of medications for addiction treatment and other behavioral health services, including via employer-sponsored insurance plans.
- Expand and enhance research and development of specialized evidence-based treatment programs for vulnerable populations.
- Support community-based programs – such as housing services, job training and other initiatives that assist individuals in treatment.
- Expand and enhance the public reporting of quality measures for all addiction treatment programs to guide individuals in locating evidence-based treatment.
- Increase appropriations for treatment and recovery programs.
- Increase access to MAT for OUD – methadone, buprenorphine and other opioid agonist therapies; Vivitrol and other opioid antagonist therapies.
- Evaluate the X-Waiver training requirement (the training requirement stemming from the Drug Addiction Treatment Act of 2000):
- Update or remove requirements as /necessary,
- Incentivize providers to get the DATA 2000 waiver to prescribe buprenorphine for OUD, and
- Eliminate the cap on the number of patients whom providers with the DATA 2000 waiver can treat with buprenorphine.
- NSC supports the Mainstreaming Addiction Treatment (MAT) Act (H.R.1384/S.445) which would eliminate the training and X-waiver requirements for physicians who want to prescribe buprenorphine.
- NSC supports the Medication Access and Training Expansion (MATE) Act (H.R.2067) to expand the number of practitioners educated about screening patients with SUDs and enable them to use evidence-based approaches.
Supporting EEOC Actions and Clarifications to Increase Access to Treatment
The Equal Employment Opportunity Commission (EEOC) issued two new guidance documents23 addressing the opioid epidemic and its impact on the workplace in August 2020, providing clarity on opioid use disorder and its relation to the Americans with Disabilities Act (ADA). This guidance is critically important for workplaces as they support employees with an opioid use disorder.
Recommendation:
- Clearly state support for the recent EEOC clarification to ensure employers are aware of and abide by the guidance stating that individuals on medications for addiction treatment (MAT) are protected from disability discrimination.
Enforcing and Supporting Parity
Mental health parity and addiction equity is a critical component of combatting the opioid crisis, so that coverage, payment and treatment for mental health conditions and substance use disorders are equal to that of other chronic and acute health conditions. Mental health parity, as designated by the Mental Health Parity and Addiction Equity Act (MHPAE), makes effective care available to those suffering from mental illness and/or substance use disorder. Work needs to be done to ensure that those in need of mental health and substance use treatment receive it to prevent tens of thousands of unnecessary deaths.
Recommendation:
- Support the following recommendations for employers from President Obama’s Mental Health and Substance Use Disorder Parity Task Force final report from October 2016:24
- Supporting consumers and providing parity education and awareness,
- Clarifying parity requirements and improving implementation, and
- Improving and enhancing compliance and monitoring.
Medicaid
Medicaid is a critical tool to reduce overdose deaths, help individuals receive treatment, receive recovery support and mitigate impacts of mental illnesses and increase treatment. There are several points where Medicaid and substance use intersect, including:
- Currently, nearly 17% of Medicaid beneficiaries have a SUD.25
- Evidence demonstrates that Medicaid expansion states have seen improvements in access to medications and SUD treatment services following expansion.
- Medicaid expansion is associated with increases in overall prescriptions for Medicaid-covered prescriptions, including medications to treat OUD and opioid overdose.26
- Medicaid is one of the largest sources of federal funding of health care services for individuals with OUD, including medications for addiction treatment (MAT).27
Recommendation:
- Medicaid expansion without work requirements to qualify should be prioritized for SUD and mental health treatment.
- NSC supports the Medicaid Reentry Act of 2021 (H.R.955) to restore Medicaid access to addiction treatment for incarcerated individuals up to 30 days before their release and encourages this Committee to advance this legislation. Releasing individuals who are incarcerated without connections to healthcare providers, medical coverage, safe and stable housing, or a support system can greatly increase their risk of relapse, overdose and death.28,29
Addressing Racial Inequities
NSC recognizes the need to confront racial and other equity issues related to existing drug policies throughout this process, especially given the disproportionate impact that the COVID-19 pandemic has had on communities of color and other vulnerable populations, and encourages Congress to do the same. Collaboration among community leaders, associations, advocates and the general population with policymakers, government agencies, educators, prevention specialists, employers and workplaces, and treatment and recovery providers is urgently needed, given the intertwining and exacerbating nature of substance use, the COVID-19 pandemic, and the impacts on Black, Indigenous, and People of Color (BIPOC).
The COVID-19 pandemic has disproportionately impacted BIPOC, which can be seen by cumulative infection, hospitalization and death rates that are higher among minority racial/ethnic groups than whites.30 Certain social determinants of health and other risk factors for increased substance use may contribute to this increased risk including social stressors (e.g., discrimination, stigma, profiling), access to and utilization of healthcare, socioeconomic disparities (e.g., employment, housing, factors relating to school and education31) and access to transportation.32 People of color are more likely to work in jobs that require a physical presence in the workplace and are more likely to use public transportation, which puts them at increased risk for exposure to COVID-19.33 Furthermore, early data points to racial disparities in COVID-19 vaccinations, underscoring the importance of focusing on equity both regarding the vaccine rollout and its impact on the workplace.34
Access to treatment is critical, and is even more limited for BIPOC with SUDs. White Americans are 17% more likely to receive mental health treatment than Black or Hispanic people, and 20% more likely than Asian Americans.35 Regardless of socioeconomic status, data shows that Black individuals enter addiction treatment four to five years later than white individuals.36 Individuals in Latino communities who need treatment for an SUD are also less likely to access care.37 Addressing these discrepancies is made even more critical with rates of overdose increasing for some communities of color during the pandemic.38,39 In 2019, CDC reported although African Americans and Hispanics experience similar rates of opioid misuse when compared to the general population, they experienced the greatest increase in overdose death rates from synthetic opioids (such as fentanyl) from 2014 to 2017.
Substance use and SUDs impact all population groups in the U.S. and strategies to address them must be tailored to the diversity of targeted communities. Promoting a one-size-fits-all strategy inhibits access to appropriate, quality prevention and treatment for culturally diverse populations, as well as the efficacy of those interventions. An interdisciplinary, multi-level team approach including community leaders, associations, advocates and the general population working with policymakers, government agencies, educators, prevention specialists, employers and workplaces, and treatment and recovery providers is critical to understand the related issues and treatment barriers, as well as successful community-informed strategies.
Recommendation:
- NSC encourages the Committee to focus on the Advancing racial equity in our approach to drug policy (Priority 2) set by the Office of National Drug Control Policy (ONDCP).40
Conclusion
The COVID-19 pandemic has undoubtedly increased risk factors for developing a SUD or OUD. The long-term effects of these risk factors may not been seen for some time, but warrant an increased focus on prevention and mental wellbeing. NSC looks forward to working with you to address these
priorities and enhance evidence-based prevention efforts in the future. Working together, we can enable people to live their fullest lives.
1 Czeisler MÉ , Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049–1057. https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm
2https://connect.nationalalliancehealth.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=1b159a27-931e-6069-03b2-
30e0ce570e32&forceDialog=0
3 https://www.cdc.gov/mmwr/volumes/70/wr/mm7013e2.htm?s_cid=mm7013e2_e&ACSTrackingID=USCDC_921- DM53115&ACSTrackingLabel=MMWR%20Early%20Release%20-
%20Vol.%2070%2C%20March%2026%2C%202021&deliveryName=USCDC_921-DM53115
4 https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
5 https://emergency.cdc.gov/han/2020/han00438.asp
6 https://www.ama-assn.org/system/files/2020-09/issue-brief-increases-in-opioid-related-overdose.pdf
7 https://tools.niehs.nih.gov/wetp/public/hasl_get_blob.cfm?ID=12121
8 https://www.drugabuse.gov/publications/research-reports/common-comorbidities-substance-use-disorders/part-1-connection-between- substance-use-disorders-mental-illness
9 https://www.cdc.gov/niosh/twh/priority.html
10 https://www.cdc.gov/niosh/topics/opioids/data.html
11 https://www.samhsa.gov/data/sites/default/files/cbhsq- reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf 12 NSC Employer Survey, 2019
13 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711315/
14 https://ps.psychiatryonline.org/doi/full/10.1176/ps.2009.60.5.646
15 https://www.nsc.org/getmedia/9dc908e1-041a-41c5-a607-c4cef2390973/Substance-Use-Disorders-by-Occupation.pdf
16 Ibid
17 See: https://www.whitehouse.gov/wp-content/uploads/2021/03/BidenHarris-Statement-of-Drug-Policy-Priorities-April-1.pdf
18 See: https://www.cdc.gov/niosh/topics/opioids/wsrp/default.html
19 See: https://www.samhsa.gov/grants/grant-announcements/ti-20-013
20 See: https://tools.niehs.nih.gov/wetp/index.cfm?id=2587 21https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR1PDFW090120.pdf 22 https://www.sciencedirect.com/science/article/pii/S0955395917300877
23 https://www.eeoc.gov/newsroom/eeoc-releases-technical-assistance-documents-opioid-addiction-and-employment
24 https://www.hhs.gov/sites/default/files/mental-health-substance-use-disorder-parity-task-force-final-report.pdf
25 https://www.kff.org/report-section/medicaids-role-in-financing-behavioral-health-services-for-low-income-individuals-issue- brief/#endnote_link_223575-4
26 http://files.kff.org/attachment/Report-The-Effects-of-Medicaid-Expansion-under-the-ACA-Updated-Findings-from-a-Literature-Review.pdf
27 https://www.gao.gov/assets/710/704043.pdf
28 https://www.drugabuse.gov/publications/drugfacts/criminal-justice
29 https://www.fiercehealthcare.com/hospitals/industry-voices-incarcerated-people-need-health-coverage-to-help-stop-drug-overdose-and
30 https://pubmed.ncbi.nlm.nih.gov/33231496/
31 https://www.cdc.gov/healthyyouth/substance-use/index.htm
32 https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
33 https://synergist.aiha.org/202101-confronting-two-crises
34 https://www.kff.org/racial-equity-and-health-policy/issue-brief/how-are-states-addressing-racial-equity-in-covid-19-vaccine-efforts/
35 https://synergist.aiha.org/202101-confronting-two-crises
36 https://www.tandfonline.com/doi/full/10.1080/15332640.2017.1336959
37 https://www.samhsa.gov/data/sites/default/files/NSDUH117/NSDUH117/NSDUHSR117HispanicTreatmentNeeds2012.pdf
38 Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple Cause of Death 1999- 2019 on CDC WONDER Online Database, released December, 2020. Data are from the Multiple Cause of Death Files, 1999-2019, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. Accessed at http://wonder.cdc.gov/mcd-icd10.html
39 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2775360
40 See: https://www.whitehouse.gov/wp-content/uploads/2021/03/BidenHarris-Statement-of-Drug-Policy-Priorities-April-1.pdf
