Politics and Substance Use Disorder an Unexpected Vote Result for HR 4531

The Medication Access and Training Expansion (MATE) Act is a byproduct of the Consolidated Appropriations Act of 2023. Under the MATE Act, all DEA-registered practitioners must undergo a new requirement on the treatment and management of patients with opioid or other substance use disorders. This requirement applies to both new practitioners and those renewing their licensure [1]. The intended purpose of the MATE Act is twofold. First, it educates clinicians on their responsibility to prescribe potentially addictive drugs with caution. Second, it is meant to pave the way for a better understanding of how to fight back against the opioid crisis in America [1]. The eight-hour training prerequisite mandated by the MATE Act is surprisingly open-ended and gives practitioners a wide range of options for meeting this new compliance requirement. Because it is required for all DEA-registered practitioners, there are various ways to achieve compliance and a thorough list of accredited bodies that offer compliance training [1]. 

The MATE Act was originally introduced in the 117^th Congress [1]. The progress of the stand-alone bill stalled and was not expected to advance, and then it was included as a last-minute addition to the end-of-year omnibus bill as a proposed law that covered several diverse or unrelated topics passed late in December 2022. According to the American Podiatric Medicine Association (APMA), they did not have an opportunity to engage and address or clarify the oversight that the Council on Podiatric Medical Education (CPME) was not included in the list of approved accrediting organizations, as well as APMA’s own exclusion from the approved list of accredited groups that may provide training that meets the MATE requirements. APMA intended to correct these oversights. After several discussions with SAMSA and congressional members, HR Bill 4531, “The Support for Patients and Communities Reauthorization Act,” which modifies and reauthorizes key programs that expand access to substance use disorder prevention, treatment, and recovery, sponsored by Republican House Representative Brett Guthrie and cosponsored by a bipartisan group of 66 (Democratic and Republican) representatives, contained language resolving and correcting accreditation and oversite issues noted by the APMA. 

On December 12, 2023, HR 4531, “The Support for Patients and Communities Reauthorization Act,” passed by a two-thirds affirmation vote: 386 YEA votes (196 Democratic members and 190 Republican members) and 37 NAY votes (11 Democratic members and 26 Republican members). Historically, the 115^th Congress took significant steps to address the substance use disorder crisis by passing the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT ACT) as H.R.6-115^th Congress (2017-2018), which was passed by a two-thirds affirmation vote: 396 YEA votes (214 Republican members and 182 Democratic members) and 14 NAY votes (1 Democratic member and 13 Republican members). 

The purpose and importance of the HR 4531 bill was to reauthorize and expand the 2018 public law No. 115-271. While reviewing the comparative voting results of HR bills HR 6 and HR 4531, a paramount question is worth exploring: “What was the principal cause for the increase in bipartisan NAY votes for HR 4531?” Therefore, exploring the reasons for this increase in bipartisan NAY votes is warranted. To achieve this goal, the investigator first had to obtain a database of United States (US) congressional members who voted on both HR4531 and HR6 and, through analysis, develop a surveyable cohort. Then, they had to use a US postal service mail survey with only one question and a self-addressed return envelope to provoke a response from these bipartisan house representatives who voted NAY on HR 4531. The main objective of this mail survey was to determine if any bipartisan members would respond to the inquiry by acknowledging and returning the inquiry letter to the investigator. The secondary objective was to determine why each congressional member decided to vote NAY to HR 4531. The last objective was determining what changes to HR 4531 would have allowed these congressional members to change their NAY vote to a YEA vote.

A questionnaire is a commonly used data collection method and a crucial part of research [2]. Medical research questionnaires, or surveys, are vital tools for gathering information on individual perspectives in a large cohort [3-5]. Moreover, two more aspects come into questionnaire design: aesthetics and question order. The questions should be arrayed logically, with questions on the same topic close together and with sensible sections if long enough to warrant them [3-5]. Only after a thorough reading of both HR 4531, “The Support for Patients and Communities Reauthorization,” [6] and HR-6, “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act [7] (the SUPPORT ACT),” by the 115^th Congress allowing for comparing and contrasting both legislative initiatives would serve as a bedrock foundation for the survey question [4]. The investigator decided that only one question would provoke a reply from the respondent. After a pilot review by a panel consisting of a podiatrist, pharmacist, nurse, paramedic, and an individual with substance use disorder, the following survey question was decided upon: “What provision(s) could have been added or made to HR 4531, the Support for Patients and Communities Reauthorization Act that modifies and reauthorizes key programs that expand access to substance use disorder prevention, treatment, and recovery to foster your support and change your vote from NAY to YEA?” Data from both Congressional Records Proceedings and Debates of the 118^th Congress, First Session Vol 169 No 203 December 11, 2023, [8] and Congressional Records Proceedings and Debates of the 118^th Congress, First Session Vol 169 No 204 December 12, 2023, [8] were read and analyzed before authoring a background, introduction, inquiry, survey question letter, double-spaced type, 2-page letter on 8½ by 11-inch white paper. All survey letters were mailed to each of the bipartisan congressional representatives’ Washington, D.C., office addresses obtained by research on the internet for each congressional member’s official site. With the contents of this letter, the investigator acknowledges the “franking privilege,” which is a personally pen-signed or printed facsimile signature of a person with a “franking privilege,” such as certain government officials (especially legislators) and others designated by law or postal regulations. The investigator decided to include in each of the thirty-seven bipartisan representatives’ survey letters a “Forever” stamped business envelope with a completed return address and the investigator’s destination address to facilitate a response. Then the investigator decided to not only certify each letter for signature using PS Form 3800, January 2023 PSN 7530-02-000-9047 but also attach a green domestic return receipt card, PS Form 3811, July 2020 PSN 7530-02-000-9053, to each certified letter. All thirty-seven bipartisan representative survey letters were mailed at a local US post office on the same date at $8.56 per letter, or a total cost of $316.72. The investigator chose this method of US mail delivery to track the delivery of the certified letter and the green domestic return receipt. An average eight-day delivery window was determined for the certified survey letters, while the green domestic return receipt cards were tracked for an average of 17 days for most cards. A response deadline of 35 days from when the survey letter was delivered to the representative, verified using US postal service tracking by the investigator, was decided upon. Lastly, data from the Congressional Records Proceedings and Debates of the 118^th Congress, First Session Vol. 169 No. 203, December 11, 2023, [8] and Congressional Records Proceedings and Debates of the 118^th Congress, First Session Vol. 169 No. 204, December 12, 2023, [9] as well as the previous house of representative members’ voting records on these bills will serve to provide insightful data for any response they offer to the investigator.

The demographics of congressional members who voted “NAY” on 4531 are presented in table 1. This table provides the names of the thirty-seven bipartisan NAY voters, their party affiliation (11 Democratic members and 26 Republican members), the house district they represent, and how they voted for HR 6 in 2018 if they were members of the House of Representatives at that time. Further, this table includes data from Drug Overdose Death Statistics (2023): Opioids, Fentanyl & More (drugabusestatistics.org) for each state that the 37 bipartisan NAY voters represent [10,11]. An interesting finding was that of the 37 bipartisan NAY voters, ten members who are also bipartisan had the opportunity to vote for HR 6 in 2018. Their votes are presented in table 1. The “NAY” votes accounted for five votes, all by Republican members, and the “YEA” vote accounted for five votes by one Democratic member and four Republican members. Finally, reviewing the state geographical distribution of the thirty-seven bipartisan NAY voters, the range of voters is between one house member representing one state and four house members representing one state. The thirty-seven bipartisan NAY voters represent twenty-four states. Numerically, the cohort was divided into three groupings; the first group was composed of fifteen states represented by one house representative. The second group comprised five states: Georgia, Indiana, Missouri, Pennsylvania, and Tennessee, with two state house representatives. While the last group described three state house representatives for four states: Arizona, Florida, New York, and Texas. Finally, only eight “NAY” voters indicated in their bibliographical information that they had veteran status from the armed services. 

Table 1: Demographics of congressional members who voted “NAY” on 4531 2023. 

REP-Republican

DEM-Democratic

ODD-Overdose Deaths 

A review of the data describing both the 14 bipartisan members who voted “NAY”-13 Republican and 1 Democratic member-and those 17 bipartisan members (7 Republicans and 10 Democrats) who did not vote in the 115^th Congress’s Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT ACT) [7] as H.R. bill 6 sponsored by Greg Walden (Republican) [7] provides some relative insightful information. A review of these members’ official websites revealed that only six (one Republican and five Democratic) members remained in office to vote on HR 4531. One democratic member and one republican member voted NAY on HR 6 and then, five years later, “YEA” for HR 4531. Three democratic house representatives who did not vote for HR 6 voted “YEA” on HR 4531, and one democratic member chose not to vote on either HR 6 or HR 4531. This data is presented in table 2. 

Table 2: Demographics of congressional members who voted "NAY" or did not vote HR 6 "Support Act". 

After allowing the 35 days to pass, only one typed congressional response letter was received from a congressional member on why they voted “NAY” on HR 4531, Dr. Paul Gozar, representing Arizona’s district 9, whose biographical description notes him as a dentist [10]. Two other healthcare providers were among the 37 bipartisan “NAY” voters who chose not to respond to the survey letter: Dr. Andy Harris, representing Maryland’s district 1, who was described as a physician, and Ms. Cory Bush, representing Missouri’s district 1. Interestingly, Dr. Andy Harris did vote “YEA” for the 2018 HR 6 Support Act. Dr. Gozar’s return letter fulfills the investigator’s main objective. Would any bipartisan member respond to the survey by acknowledging and returning the inquiry letter to the investigator? Granted, this one return letter out of thirty-seven was calculated as a 2.7% response rate, lower than the 9% response rate for mailed surveys reported in the literature [12]. Moreover, the secondary objective of determining the reason for each congressional member’s decision to vote NAY to HR 4531 was also achieved. Dr. Gosar acknowledges that the bill reauthorizes several programs and makes changes to some of them. His letter stated: “He had concerns about expanding any government program, which puts us deeper into our debt, which is over $34 trillion, and expands government power, which is already out of control” [10]. Unfortunately, the last objective could not be achieved through Dr. Gosar’s response letter because that question was not addressed. 

To determine if the survey letters were appropriately delivered to all thirty-seven bipartisan members of Congress at their Washington, D.C., office destination, an actual physical count was conducted of the received green domestic return receipt card, PS Form 3811, July 2020 PSN 7530-20-000-9053, for each certified letter. There were thirty green domestic return receipt cards, PS Form 3811, July 2020, PSN 7530-20-000-9053, leaving seven green domestic return receipt cards unaccounted for. Next, to determine who these seven green domestic return receipt cards belong to, the investigator matched the certified receipt with the corresponding USPS tracking numbers for the certified mailed envelopes and the green domestic return receipt cards. Upon review of the remaining seven unaccounted-for green domestic return receipt cards, they were matched with their respective certified tracking numbers and each respected bipartisan representative of Congress. Further, after reviewing each of the seven certified mail tracking numbers electronically, six USPS tracking numbers indicated that they were received at each addressee’s Washington, D.C., address with the notation “time and date: Washington, D.C., United States. Delivered, left with the individual.” An interview with a USPS delivery supervisor at the local post office where all thirty-seven mailed surveys were processed revealed that all seven remaining certified mailed surveys were signed by one person during the process known as bulk signing firm book, and the seven green domestic return receipt cards were discarded.

In order to explore a thorough discussion, the reader is encouraged to read the entire text, all 44 pages of H.R. 4531: Support for Patients and Communities Reauthorization Act, to appreciate the intent and purpose of the passed congressional bill.6 A highlighted summary as well as specific text of HR 4531 that gives podiatric physicians with a DEA registration number the autonomy they need to fulfill their 8-hour DEA-MATE required training1 is offered below: 

Summary of H.R. 4531: Support for Patients and Communities Reauthorization Act [6] 

• This bill reauthorizes through FY2028 and modifies various grants, programs, and activities that address substance use and misuse [6]
• This includes reauthorizing (1) data collection, education, and surveillance activities; (2) grants and other support for substance use disorder prevention, treatment, and recovery; (3) student loan repayment and other programs for the substance use disorder workforce; and (4) programs for addressing trauma, particularly for children, youth, and their families. These modifications expand programs [6]
• Additionally, the bill modifies provisions related to the scheduling of controlled substances, including incorporating illicit Xylazine (a compound used in veterinary medicine as a nonopioid tranquilizer) into Schedule III of the Controlled Substances Act [6]
• Further, the bill makes it a permanent requirement that Medicaid programs cover medication-assisted treatment for individuals with substance use disorders [6] 

Title II-controlled substances in sec. 205. required training for prescribers of controlled substances [6]. 

Section 303 of the Controlled Substances Act (21 U.S.C. 823) is amended- 

(1) by redesignating the second subsection (l) (added by section 1263 of division FF of Public Law 117-328) as subsection (m) and

(2) in subsection (m), as redesignated-

(A) in paragraph (1)(A)(iv)-

(i) in subclause (I), by striking “or the Commission for Continuing Education Provider Recognition (CCEPR)” and inserting “the Commission for Continuing Education Provider Recognition (CCEPR), the American Podiatric Medical Association, the Council on Podiatric Medical Education (CPME), or the Academy of General Dentistry.”

(ii) by redesignating subclauses (II), (III), and (IV) as subclauses (III), (IV), and (V), respectively; and

(iii) by inserting after subclause (I) the following:

“(II) the American Academy of Family Physicians or any organization whose continuing medical education activity has been approved or accredited by the American Academy of Family Physicians;” and

(iv) in subclause (V), as redesignated, by striking “any organization approved by the Assistant Secretary for Mental Health and Substance Use, the ACCME, or the CCEPR” and inserting “any organization approved by the ACCME or the CCEPR.”

(B) in paragraph (1)(A)(v)-

(i) by inserting “podiatric medicine” after “allopathic medicine, osteopathic medicine” and

(ii) by striking “allopathic or osteopathic medicine curriculum” and inserting “allopathic, osteopathic, or podiatric medicine curriculum.”

(C) in paragraph (1)(B)(i), by striking “or any other organization approved or accredited by the Assistant Secretary for Mental Health and Substance Use or the Accreditation Council for Continuing Medical Education” and inserting “the American Podiatric Medical Association, the Council on Podiatric Medical Education (CPME), the American Pharmacists Association, the Accreditation Council for Pharmacy Education, the American Optometric Association, the Academy of General Dentistry, the American Psychiatric Nurses Association, the American Academy of Nursing, the American Academy of Family Physicians, or any other organization approved or accredited by the American Academy of Family Physicians or the Accreditation Council for Continuing Medical Education;” and

(D) in paragraph (1)(B)(ii), by striking “from an accredited physician assistant school or accredited school of advanced practice nursing” and inserting “from an accredited physician assistant school, an accredited school of advanced practice nursing, or an accredited school of pharmacy.” 

It is acknowledged that the only response letter cites “the need to enact legislation that secures our border to stop the flood of fentanyl from killing Americans [10]. However, when HR 4531 came to the House floor, I voted no. I have concerns about expanding government programs, as that puts us deeper into our debt, which is $34 trillion, and expands government power, which is already out of control” [10]. Given political party ideology, this reason may be applied to the five Republican “NAY” voters who voted “NAY” and even the four Republican “NAY” voters who voted “YEA” on HB 6 when serving in the 115^th Congress 2^nd Session [7]. The lone Democratic New York Representative who voted “YEA” on HR 6 and “NAY” on HB 4531 remains a question that cannot be answered. 

To engage in a relative narrative discussion of the reasons for thirty-seven bipartisan “NAY” voters’ choice when reading and examining HR 4531, pertinent elements grounded in facts and scientific clinical evidence need to be presented and explored. It must be acknowledged that each of the thirty-seven bipartisan NAY voters was allowed to debate HR 4531 on the congressional floor before the roll call vote. A review of the Congressional Records Proceedings and Debates of the 118^th Congress, First Session Vol. 169 No. 203, December 11, 2023, [8] reveals none of these “NAY” voters took this opportunity. 

The first is that the effect of Substance Use Disorder (SUD) persistence varies by race or ethnicity, and the nature of these relationships is different by gender. Moreover, as related by Evans et al., persistence rates at three-year follow-up differed for SUD type by gender by race/ethnicity sub-group and ranged from 31% to 81% [13]. Given that persistence rates were consistently higher among poly-substance users, patterns were mixed concerning gender and race/ethnicity. Among women, alcohol-disordered Hispanics were less likely to persist than Whites [13]. Lastly, among men, drug-disordered Hispanics were less likely to persist than Whites [12]. Also, Black men with an alcohol or drug use disorder were less likely to persist than Whites, but Black men with a poly-substance use disorder were more likely to persist than Hispanics [13]. 

According to Clemans-Cope et al.,’s investigation, in the year before and after delivery, 2.2 percent of their study sample had an Opioid Use Disorder (OUD) diagnosis, and 5.9 percent had a substance use disorder diagnosis [14]. Of the women with OUD, 72.8% had treatment for a SUD in the year before and after delivery, but most had none in an average enrolled month, and only 8.8% received any methadone treatment in each month [14]. Further, pregnant women with OUD had delayed and lower rates of prenatal care compared to women with other Substance Use Disorders (SUD) [14]. Also, they concluded that healthcare costs for women with an OUD were higher than those with other SUDs. They emphasize an urgent need for comprehensive, evidence-based OUD treatment integrated with maternity care to fill critical gaps in care. Workforce and infrastructure innovations can facilitate the delivery of preventive and treatment services coordinated across settings [14]. Finally, Ndanga et al., assert that the current trends necessitate a further assessment and implementation of comprehensive community-based treatment programs tailored to the most frequent regional SUD presentations, which could aid in mitigating drug use during pregnancy [15]. HR 4531 Title 1: Public Health Section 101, titled “Prenatal and Postnatal Health,” [6] allows for concern for the 11 democratic “NAY” voters. Given the political rhetoric centered on women’s health and reproductive rights, healthcare disparities based on gender, race, economics, and affordable healthcare are among the highest priorities asserted by political advocates. However, given that the remaining thirty-six bipartisan “NAY” voters chose to ignore and disregard participation in the one-question mail survey, one can only speculate on the representative’s political motives and agenda for not supporting HR 4531. 

The foremost realization is that Xylazine is not currently a controlled substance under the United States Controlled Substances Act (CSA). Xylazine has harmful physical effects on the respiratory and circulatory systems, as well as muscle and soft tissue injuries that can turn necrotic or result in amputations. Xylazine is geographically spread throughout the United States, indicative of its wide incorporation into the illicit drug supply. The most common routine substances detected with Xylazine were fentanyl, buprenorphine, naloxone, cocaine, d-methamphetamine, and delta-9-tetrahydrocannabinol. Xylazine is increasingly reported in street drugs and fatal overdoses in the United States. According to the publicly available data compiled in this study, at least 43 states reported at least one Xylazine-related overdose death from 2019 to 2022, yet yearly totals of Xylazine-related deaths were available for only 21 states [16-19]. The CDC analyzed unintentional and undetermined intent overdose death data from the State Unintentional Drug Overdose Reporting System (SUDORS) in 38 states and the District of Columbia (DC). SUDORS cases in which Xylazine is listed on the death certificate as a contributing cause of death by the medical examiner or coroner were defined as Xylazine-involved [16-19]. Xylazine was listed as a cause of death in 64.3% of deaths in which it was detected. Xylazine-involved deaths were among males (73.1%), non-Hispanic White persons (75.4%), and from states in the Northeast Census region (67.0%). Among all Xylazine-involved deaths, one or more other drugs, particularly illicit drugs, were also listed as a cause of death, and 98.7% of Xylazine-positive deaths and 99.1% of Xylazine-involved deaths had fentanyl (including analogs) listed as a cause of death [16-19]. Cocaine and heroin were listed as causes of death in 32.1% and 26.0% of Xylazine-positive deaths, respectively, and in 29.6% and 28.4% of Xylazine-involved deaths, respectively [16-19]. Overall, the study findings underscore the need for more state-level (and community-level) data on Xylazine-related overdoses to inform local overdose response initiatives [19]. The last point is that the NFLIS 2022 Xylazine Top Ten State Count presents eight states: Ohio, Maryland, Florida, Tennessee, Pennsylvania, New York, and Indiana, which are among the 24 states represented by the 37 bipartisan NAY voters [20]. This should have been a paramount consideration for all 37 bipartisan “NAY” voters, but the growing Xylazine was ignored by these representatives. 

In closing it is acknowledged that receiving only one mail response during the investigation time is a limitation. However, receiving any response from any congressional representative is considered a victory as the written response received answers and fulfills the first and second objectives as objective three can be gleaned answered by the respondent’s letter. There needs to be more investigation into the motives and intention of legislative members of our government when voting on important bills to become law. In this case it is suggested that national medical societies, the free press, and constituents request answers from political officials especially the thirty-seven “NAY” voters on HR 4531.

Fortunately, HR Bill 4531, “The Support for Patients and Communities Reauthorization Act,” modifies and reauthorizes key programs that expand access to substance use disorder prevention, treatment, and recovery sponsored by Republican House Representative Brett Guthrie and cosponsored by a bipartisan group of 66 (Democratic and Republican) representatives passed by 386 “YEA” votes (Democratic 196 votes and Republican 190 votes) on December 12, 2023. Humbly, HR 4531 should have passed with a greater margin than Support ACT HR 6 by the 115^th Congress, 2^nd session, June 22, 2018. A “NAY” vote allows for several inferences: (1) Podiatric physicians are disenfranchised and are not viewed with the same respect as their allopathic, osteopaths, nurses, and dental colleagues; (2) fostering of apathy for the continuation of substance use disorder stigmatization affecting women, children, minorities, and the elderly; and (3) tolerance to the inevitable adverse economic impact to communities suffering from the impact of the opioid crisis, fentanyl contaminate poisoning, and substance use disorder.

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7. Public law No. 115-271 (2024) Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT ACT)” H.R.6 - 115th Congress (2017-2018): SUPPORT for Patients and Communities Act. Library of Congress, Washington, D.C., USA.
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9. Congressional Records Proceedings and Debates of the 118th Congress, First Session Vol 169 No 204 December 12, 2023.
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20. DEA (2024) State and Territory Report and Enduring and Emerging Threats (STREET). DEA, Virginia, USA.