Transcripts For CSPAN2 Opioid Epidemic 20180113

The Senate Committee on Health Education labor and Pensions Committee will come to order. Debbie talk about the Opioid Crisis the number one Public Health changes good out witness todays sam quinones. The author of dreamland, a true tale of americas Opioid Epidemic. Senator murray and i will each have an Opening Statement and then i will introduce the witness. Then we will hear from mr. Sam quinones and senators will each have five minutes of questions. This is the only witness i suggest if you want to take more than five minutes, to say whatever he has to say, we welcome that but there will be plenty of conversation back and forth for members of the committee. Mr. Sam quinones it is unusual to have a single witness at our hearings. But this is an unusual topic. One that you quote a professor is probably the worst manmade epidemic in history. The challenge this crisis presents has captured the attention of every member of this committee. Your research and writing has been a claim for their depth and breadth. This is what we call a bipartisan hearing. Most of them are. One in which democrats and republicans have agreed on the topic. On the importance and on the witness. It is my hope that we senators will restrain our habit of lecturing one another about Health Insurance and focus today on the topic. Which is the Opioid Crisis. This epidemic kills more americans every day than car accidents. Each of our states when reminded about almost every day. Yesterday i dropped by a meeting of the tenancy governors residence in nashville. Has about our state institutions involved in training doctors were planning how to discourage the over prescription of opioids. The governor told me that in our state, is. 6 Million People, it was 7. 6 million opioid prescriptions written in 2016. Even though the state has reduced the amount of opioids prescribed, the number of Overdose Deaths is up because of the abuse of fentanyl. A synthetic opioid. Rather than spend more time establishing the crisis i want to focus today on what we can do about it. There are two things im hoping to learn. First, when 100 million americans live with pain, 25 million of them with chronic or severe pain, why is it not a good idea to continue to find the socalled holy grail of medicine, a nonaddictive Pain Medicine . And stronger communities are the ultimate solution as he often suggest in your book, what can a Central Government in washington do that actually helps . Now my first question, you have a chapter in your book entitled searching for the holy grail. Finding a nonaddictive Pain Medicine. I have actually read your book. I think that there are a number of others here who have an even brought it with them. This search for the holy grail began you safe 75 years ago in 1928 with a committee on problems with drug dependence. That was the goal as you described it. Quote . The best scientists undulate extracting the painkilling attributes from the morphine molecule while discarding its miserable addictiveness . This effort to find a better way to treat pain you say, led to a revolution and attitudes toward pain treatment. First using opiates to relieve pain for dying patients. Then for patients with chronic pain. Then with a multitude of mexican gangsta pain clinics, overprescribing doctors and enterprising Drug Companies spiraling into the addiction and consequences that we find today. At least twice before this Conference Doctor Francis Collins, head of the National Institutes of health has predicted that the holy grail that was first sought 75 years ago is now within reach. Last month he said perhaps within five years. With our encouragement doctor collins has organized researchers in partnership with private companies to speed up the process. The food and drug and ministration commissioner was on board to fasttrack the effort within the bounds of safety and efficacy. I read at least some of your post to say that this holy grail may never be found. Some Scientists Say it should not be found. I hope you tell us what you think about this. Should we not continue to try to find nonaddictive penn medicine to relieve suffering without addiction . Is that not the obvious antidote to Opioid Epidemic . The second area i would hope to learn about is what we can do from washington dc. We have tried in important ways to adjust the ravages of this crisis. Which we have all experienced in our state. In 2016 Congress Passed the comprehensive addiction and recovery act. In the 21st century cures act to give states and communities those on the front lines, the tools and resources they need to combat this crisis. For example, a provision for sinners warren and treadwell was included that made it clear pharmacist could only fill parts on prescriptions like oxycodone, and opioid. That way a manipulative sons pain prescription after his wisdom teeth surgery can only ask for three days with the pills. Instead of 30 days he was prescribed. In addition to encourage the development of a nonaddictive Pain Medicine, cures including more than 1 billion in state grants. We are considering additional funding for treatment. And to discover alternative Pain Medicines. We have held hearings on wellness. Such as exercising, eating healthier and help people lead healthier lives. And what incentives would help people make those lifestyle changes. But you and i apparently have at least one thing in common. I am a skeptic of washingtons capacity to solve problems that are essentially problems of communities, families and lifestyle. You say that the uncured crisis is a problem of society. When we lose our sense of community, we become easy prey for quick external solutions for complex problems like opioids. In your words quote i believe more strongly than ever that the antidote to ireland is community. Make sure people in the neighborhood do things together. Break down those barriers that keep people isolated. In my own experience in public like a thing time as governor ive been increasingly convinced of the problemsolving ability of communities. With good jobs, good schools, Strong Families where everyone seems to be interested in the wellbeing of everyone else. Whenever i try to step in our center to solve a problem, in the end it was doctor creating an environment in which communities can themselves fix problems. Not sending in single shot solutions from a distance. For example, after spending years on state reforms in education as governor, i ended up traveling the state to create 143rd better Schools Community task force because i believe the communities who wanted good schools can have them and those who did not, would not. I held the same views as we have fixed no child left behind in 2015 when we restored more decisions to classroom teachers, School Boards and states. So, exactly what does congress do from washington d. C. About this Opioid Crisis . This committee has jurisdiction over a significant amount of what youve written about in dreamland. Not the spending of money. That belongs in the appropriations committee. We are eager to hear your testimony and your solutions. Senator murray. Thank you mr. Chairman. Im glad to be continuing our discussion on this important issue. I know our witness today has been following the epidemic crisis. Mr. Sam quinones, thank you for joining us. As we like to welcome your wife and daughter who i assume the city behind you. Im glad that they were able to be here with you today. I look forward to hearing your perspective on how we can better help our communities like this crisis and support all of those who have been impacted. I really appreciate the investigative work that you have done to help shed light on this challenge. Of course, im sure that you would agree the rise of the epidemic is broader in scope than any one book can tell. Their people from all backgrounds that have stories about the harm this is done. The arkansans lost children to an overdose. Children that have lost parents to an overdose. Veterans in chronic pain struggling with addictions, doctors treating babies born addicted to opioids and a lot more. I heard these heartbreaking stories firsthand traveling around my home state of washington. And meeting with doctors and families and communities fighting this disease. I was visiting a local hospital in longview. A community in my state and the staff told me almost 1 out of every two babies born, they have mothers that struggle with Substance Abuse. That was astonishing and heartbreaking. But it is unfortunately not the only evidence of this epidemic. Since 2000, no 10,000 people in Washington State alone have died of opioid overdose. This is not just happening in longview. This is happening in local hospitals across the nation. We are losing 91 people every day to opioid overdose. When i say this epidemic affects everyone, i do not just mean the individuals facing opioid addiction. There are other victims as well. The epidemic hurts families. It leaves children struggling to cope with the impact of their parents addictions. At least many of them in foster homes. Parents shattered with the heartbreak of the childrens illness. It leaves many struggling with the financial cost of good misuse and treatment and recovery as well. And this epidemic hurts our communities as a whole. It takes up resources, Public Health, hospitals and Law Enforcement dictates workers of the local economy. It takes a full on the morale of small towns and big cities alike with each new tragedy. We are behind the curve on fighting this endemic. One of the story gusted out to me in the book, was about a state employee for Washington Department of labor and industries. A woman named jamie may. Jamie was a pharmacist charged with overseeing the cases of workers who were receiving Prescription Drugs for injuries. After six months she noticed that some of these workers were dying from the same painkillers that they had been prescribed. The paper she published in 2005 about the uptick in high strength open prescriptions and deaths was one of the first papers in the country document the crisis we are facing today. She published the paper over a decade ago. And it shows we been fighting this battle for far too long. We have to do more. Im glad we have taken some necessary steps. In 2016 Congress Passed the 21st century cures act which included nearly 1 billion of funding for states to address the Opioid Crisis to prevent and treat and the recovery act. This sport specific outreach for veterans and pregnant and postpartum women. They extended access for treatment and much more. There is a lot more to do. Along with many of my colleagues i hope that we can move forward funding in the upcoming budget for appropriations agreements. First responders state and local officials Treatment Professionals and families have made it clear continued federal funding is key to addressing the crisis. Unfortunately we have not had a lot of talk from administration on the spigot to see the president take the serious action that the emergency demands and he promised families on the campaign trail. The white house is on council of economic advisors released a report estimating the Economic Cost of the oakland crisis to be over 500 billion just for 2015. Adjusting the problem this will be taking an enormous investment of time energy and focus and robust funding. It is the Third Quarter paycheck of the president that will not cut it. Our communities are crying out for serous solutions. Not stunts. Im eager to see the committee continue the bipartisan approach and to take substantive action to address the epidemic over the next few months. Mr. Chairman, i look forward to working with you to have all of our members bring their ideas those we can work on moving policies to help our families and communities. Plan to do a lot more to find prevention efforts and Treatment Programs and builds on the gains we have made. This means immediately providing supplementing funding states need to implement evidencebased tools that can help turn the epidemic around. We need to ensure that local stakeholders and partners, the people on the ground we know what we are best in their communities, works best in their communities will respond to the spirit also means going beyond prevention and treatment and recovery. After work to support that only the individuals facing addiction but the families and communities were suffering as well. Im interested to hear your perspective on this today and how we do that. Im grateful for you coming here today to testify before us. Because if we are going to beat this opioid addiction we have to fund and enact solutions that are as comprehensive as the challenge. Thank you again very much for having this and i look forward to working with you in our members. Thank you, senator murray and thank you for working in his way to have such an important hearing. I am pleased to welcome sam and his family today. Thank you for taking the time to be here. Mr. Sam quinones has 30 Years Experience as a journalist and author. Written extensively on the oakland crisis and Drug Trafficking. The author of three acclaimed books. Most recent book dreamland, the true tale of americas Opioid Epidemic. It won the National Book critics circle award for general nonfiction. Early in his career mr. Sam quinones was the recipient of the Maria Moors Cabot prize. The International Award in journalism for his work covering latin america. It was also the recipient of a fellowship awarded to outstanding journalists who pursue stories and the Public Interest be welcome again mr. Sam quinones. You have 10 minutes to give your testimony and then the senate is a look at both to have a conversation with you. There we go. Clearly im a rookie here so a chairman, senator murray and honorable members of this committee. I would like to thank you for these hearings on our National Epidemic of opioid addiction. And for allowing the honor of addressing you. Im very happy to be here with my wife and daughter. For part of producing dreamland. And without him the book could never have been finished. This is the deadliest drug scourge lived on in this country. Hitting areas of the country that have never seen this kind of drug problem. It is the first in modern america to be spread not by mafias, not by street dealers but by doctors. Overprescribing pain pills convince they were doing right by their patients. Urged on by the pharmaceutical industry. By the medical establishment and indeed urged on by us. By American Health consumers who too often wanted to quit into tranquilizers could not have dreamed of inciting the kind of torment and death that we have visited upon ourselves to this overuse of opiates. These drugs are a symbol. For our era. For almost 4 decades, we have assaulted the private sector, the individuals. While we ridiculed government was inefficient, incompetent and wasteful. We admired wealthy Business People regardless of whether the way they made their money produce anything of value for our country and our communities. We have i believe a second gilded age. This epidemic of addiction to a class of drugs that thrives on isolation reflects all of that. This epidemic since cost has been borne by the public sector. All of its profits have been private. I believe that this is about issues far deeper than drug addiction. It is about the effects of this very cultural shift. It is also about isolation in areas rich and poor heard about the hollowing out the small town america and the middle class of that civilization our society. And it is about a culture that acts as a buying stuff is the path to happiness. I believe we got into this because we believe problems can be attacked in isolation. With one magical Silver Bullet. A pill for all of our pain. A jail cell for every addict. Results of the private and not the public in the communal. And in so doing we rid ourselves of things so central to us that they have no price. We have been invaded by cheap junk as a result. We dug up dreamland and replace it with a strip mall. Things like that requested america for years now. Heroin is what you get when you destroy dreamland. I believe isolation, the natural habitat, i believe this epidemic therefore is calling on us to revert these decades of isolation and come together as americans. I believe more strongly than ever that the antidote to heroin is not an officer it is not naloxone. No one is saving the world alone. The good news in all of this i believe is that there is no solution. There are Many Solutions. Each small, each must be tinkered with, improve. Some may be discarded. Each must be funded fully and for a long time. But the good news is that none of them is sexy. None will do the trick alone. I believe that across america today, communities are finding these solutions. The more they band together the more they leveraged all of that talent and energy, bring in ptas, pastors, artists and athletes. Recovering addicts and primary care doctors. Librarians and chamber of commerce. The more cops and Public Health nurses go out for a beer. Bridge that cultural chasm between them. And i believe is a thing that this is happening in counties across america. It is my opinion that supply has ignited all of this. We did not have this demand. This widespread addiction until we unleashed a large supply of powerful legal narcotics on the public for the last two decades. I believe it is essential that doctors reassess how and to home and in what quantities they prescribed these drugs. That does not mean just cutting people off for on high doses of these drugs and leaving them to fend for themselves. It does mean Insurance Companies to reimburse prepaid strategies that do not involve narcotics. Allowing doctors a wider array. Anymore education in both Pain Management and Addiction Treatment in med school. I have to say that i think it is delusional to spend time and money on yet another wall along the usmexico border hoping that this will somehow stop the supply. These are coming in through areas with walls already. I believe the wall will corrode the only thing that will truly stop these drugs from coming into the country. That is a deep respect both but also forthright, sometimes blunt, certainly honest, patient with mexico that will lead to it finally becoming a kind of neighbor and partner we can work with effectively. And in so doing, become the kind of neighbor the country needs a bus. Another wall to me seems is just like heroin. It feels good for the moment but it will leave us worse in the long run. Another Silver Bullet for a complicated adult problem. Sometimes the solutions are about the mundane mechanics of governing. We should find new ways of cutting Corners Office around the country and extend the National Forensic pathologist. Which is dangerously dwindling. This epidemic spread because so many of the offices are so poorly funded. I believe we must expand pretreatment options. One place to do this ironically, crucially i believe is jail. Consider how the country will be helped by transforming jail into a place of nurturing, and recovery. Instead of a place of tedium. It becomes an asset instead of a liability. And this is happening. Particularly i would note in the state of kentucky. I would also like to add all across america are families that are suffering due to the addition of a loved one or the loss of that loved one. I believe they are a raw material to be marshaled, harnessed in this fight. Many now want to be involved. Need to be involved. To help solve the last wounds that will last a lifetime. I believe that us centers can help this by recording them, recognizing them, giving them platforms from which to tell the stories. Maybe its because im a reporter but i believe that true stories, the awful stigma of addiction will be reduced. Im happy to elaborate on any of this. Before i do that though i want finally come to urge you to view this as an opportunity. View this as an opportunity to revive those regions hammered by globalization and free trade. The roots of our National Epidemic of narcotic addiction lie there. By the epidemic itself stands in the way of the revival. Many of these regions cannot revive until enough of their people can pass a drug test to fill new jobs. And this is not only a story of a drug addiction. It is a story of economic affliction. As politicians, i suspect a natural response for crisis like this is to look about for things that you can do quickly. To show constituents you are taking action and i believe it is entirely understandable. I would caution however, against believing in shortterm responses. Karen and joseph this is only a start. Everything about this issue has taught me the importance of longterm Community Responses and commitment. I believe American History offers us to templates for action. From what you might take guidance and inspiration. First is the Marshall Plan to rebuild europe after world war ii. Second is the Space Program. Each involved government on a private sector acting in concert over many years bringing money, brands, energy and of course longterm focus to bear. Each achieved and annihilated good for the country. Those were about doing things that seemed far beyond our own shortterm self interest. The Marshall Plan was about building up ravaged regions to allow them to function independently. While containing the viral spread of soviet communism. It allowed reborn countries to prosper and contribute to the world again. The Marshall Plan for american recovery, will focus on rebuilding reasons ive been part independence and ravaged by devastation to contain the viral spread of addiction. There are Space Program we were inspired as a people. To spend years and dollars all to achieve something no previous generation ever thought possible. We ended up far beyond the moon. The spillover economic benefit increase of knowledge, and simple human inspiration is beyond calculation. Seems to me, that we might profitably apply these examples. The Marshall Plan and the Space Program to regions of forgotten americans with this problem began. Lets do it perhaps not because of it is easy but as jfk, he said because it is hard. Because that is what americans do and have always done at their greatest. Like our Space Program, i believe such an effort will have to last for years to be effective. To focus far beyond immediate goal of drug addiction and on the more profound problems of Community Destruction and the hollowing out of stretches of the country. Im here today to urge you to see this not only as the catastrophe that it is but also as a gift that can be. And also it offers opportunities to do something great. It is an opportunity to bridge the Political Polarization that is so annoying at the country. It is one of the few issues today that can do that. Do not miss this opportunity. It does not come around often. This calling i suspect is the very reason many of you got into public servicein the first place. And youre lucky i think you be here. You will be remembered for acting when acting was not easy to use. If you do, i believe your hometowns will thank you your counties will think. And we, your countrymen and women will thank you long after you are gone. With that, i am happy to talk about anything you want. Thank you. We will begin now have a fiveminute round of questions. I will say to the senators, ill try to stick to five minutes because we have lots of senators who want to ask questions. Ill be glad to stay for a second round of questions if anyone would like to. Senator paul. Mr. Sam quinones thank you for coming, the book was great. My pleasure. When you write about your nuptials will be different how much it will affect people i think have a best have read your book at least. With the Public Policy. So here. When i was a kid i used to visit my grandparents in pittsburgh. There is a big pool like dreamland. And it was in the 30s and an amazing pool. 100 yards along with the slide in the center. The community was surrounding the pool and activities. As a renter the book we tried to think what can we do better or change . The idea that big pharma lied and committed fraud is part of the book and part of the problem. They were punished but we need to make sure that people cannot lie and that is fraud and it is punished and it is preempted in some way. Some of that to be federal and simply state law. As a physician, i continue to become more and more alarmed by our profession being part of the problem. Try to fix this. In kentucky we monitor. You can type into that computer if patients need to find out if they are seeking different doctors. Have they gotten opioids somewhere else two days before . We have come to the bank doctors. The bed doctors south of portsmith. They are mostly gone. The pill mills are no longer in kentucky and yet, we have a concept of the mountains that has 21,000 people. Last year, said 2. 8 million doses of hydrocodone and oxycodone. This was after all of the stuff. So everyone knows this is a problem. Everyone knows more people are dying from car accident that is a horrible problem. And it was were strings county pieces Medicaid Expansion and has an 11 percent increase. When we look at we do we say lets have a plan. You have to think about how we spend the money and what we do because we want more people to help healthcare. To be extended medicaid. If you look at the expense of medicaid and to put the map overlying the United States, you have an overlay of the heroin problem and okay problem. It is related to poverty and expansion of healthcare. In your book you talk about you can get three dollars, you do not pay 200. You just pay three dollars a month and you can get it and trade it and all that. So we do have to figure out more rules on this. We have some new rules in kentucky on acute management. But i think the hard part is the chronic. If im your physician and you have been on it forever for low back pain, has i get off of it . Or how do i get you Something Else . Do you just choose another dr. . The question is, will know the knowledge. People have read your book. You know theres a problem out there. We have done changes and that we still have this enormous prescription opioid problem. And so, would you think that we do beyond that . I agree with the community more local and federal is probably better. We still, how do we fix the medical aspect of this . How did go a step beyond where we are . Well, i mean theres a lot here that is a massive question. I think they are smarter people than either contribute to it. I think one of the reasons that you find a correlation between heroin overdose in Medicaid Expansion is because more access to medical care needs more access to fills. And some doctors prescribed this as a solution. It seems to me the crucial in all of this is that we get back to what we were doing in the 1970s. That is, where Insurance Companies were reimbursing a wide array of strategies for pain. They have cut back significantly in some areas give one point it was all across the country. Some Insurance Companies are stepping up a little more. Tamia gets back to what the dr. Has available to him or her at the point of contact with the patient and to me that is, it feels like a crucial step. Every place i go, it is a speak on this topic. I run into doctors that tell me they just do not have much in the way of other options to provide. I guess the hard part of this is, i live in a county where we have four percent unemployment and the employers come to me and say we cannot find enough workers for work ethic and that are drugfree. I county with 30 percent of the people do not work and 30 percent of people are disabled. And in my county four percent of the people are disabled. The problem is will all have big hearts could be say lets help the disabled and unemployed. Yet we give them stuff but perhaps you become a nonworker, a permanent nonworker, beginning with this cycle where it is much more difficult. I agree. Map to find out how to do this with a heart and a brain we have work requirements and you are only temporarily disabled until you are back in the force. And so we do have to be careful about how we do it. So we do not have perverse incentives. Thank you senator. Mr. Sam quinones come because the time clock on the senators. Everybody will be very interested having long conversations with you. We are going to try and wrap each segment up in five minutes. Then well keep going as long as we can. Senator murray. Thank you very much for your very compelling testimony and thoughts. Specifically here i want to talk about the federal government to replay very Critical Role in preventing and tracking and solving this epidemic and in some areas, has truly unmatched capacity and reach to be able to affect broad change. One example is the centers for Disease Control and prevention. They provide funding today to 45 states and washington dc. They support Prescription Drug monitoring programs. They are invested in money muchneeded Public Awareness campaign. And they manage a Critical National Surveillance Program. Which is the only Surveillance Program to capture nonfatal overdoses as well as fatal overdoses. And he uses some innovative ways to get time layer data. That Public Awareness Program Actually started under the Obama Administration back in 2016 to raise awareness of the Opioid Crisis and the funding states actually personalize and disseminate the messaging. This administration has repeatedly requested cuts to cdc budgets. So wanted to ask you, you have mentioned in your writing that we need quality Data Collection and raising awareness and Community Spirit can you talk about programs like that in cdc . Yes. I suggest that is probably a good idea. I would also say that i think we need to greatly expand the amount of money we provide for research. Addiction and Pain Management. All of this is part of all of these Many Solutions and when i talked about the federal governments role in all of this, it is in no way to suggest that it has a dominant role or that i believe the important stuff is going on very often a local level. And the role of the federal government might well be to just simply facilitate. Make it easier their lives. And i think cdc has a number of proposals and programs that i think are extraordinarily effective. I would say that when i was doing this book, i found almost nobody wanted to talk about the success for government workers. This was the first line of defense in this when nobody really knew about this topic. In nobody really cared. I thought there was an enormous contract to write a book and put my family in jeopardy for story no one cared about the people who really did care. Were working on this from the beginning, cost, corners, cdc, dea, prosecutors, Public Health nurses, all of whom are gaining earning a government salary. Many of whom at the local level. But i believe the folks do a remarkable in fact i was a Crime Reporter. I am a crime report if its not right or the healthcare before i wrote this book. And my overall feeling is one of awe for these folks. They have done with gangs. You have written about the importance of Medicaid Expansion. To make sure that patients get medication assisted treatment. Katie responded to part of this very complex crisis. In fact, Medicaid Expansion about 1. 6 million previously uninsured people with Substance Use disorder to get the health care and the treatment for Mental Health substance that they need to fix this. He talked about the importance of medicaid . Medicaid expansion provided drug treatment for people did not have it. Hundreds of thousands of people in different states. It is extraordinarily important i think. I know people are in different communities and enormously helped by this. I do not want to downplay what senator paul was talking about. Which is that we do have increases in overdose when that happens. And i think one of the reason for that, my hunch is that in too many communities, pills are still the only drug or medical treatment. Important part of that is also the, to support Mental Health and everything else. Of course. And when you get more access to healthcare, there are other things that come along with it. I think one thing that does come along with it is that reliance still to this day,. We have dropped prescribing but it is still at about 2006 levels and almost triple what it was in late 1990s. To me that means, that we probably still relied far too much on these. That said of course, i do not understand the impulse to strip away Medicaid Expansion. Particularly in areas where this problem is so intensely felt and to me it feels like these are regions that desperately need the services that they have been provided through Medicaid Expansion. For drug treatment being primary. Thank you senator murray. Senator collins. Thank you. First of all, let me thank you for writing such an important book. Thank you. The possibilities, what has been discouraging to me is despite much greater Public Awareness and much more money, and much greater intentions that the problem does not seem to be getting much better. One possible communitybased approach was described in the morning sentinel. This was an waterville, maine. It struck a chord with me because Law Enforcement officials in my state tell me that their jail intake rooms resemble hospital emergency rooms. What some police and prior police in maine including in waterville, scarborough, and other areas. They are telling addicts if they come in with the drugs, and turn them in, they will place them in treatment facilities. And this is a whole different approach for Law Enforcement to take. Rather than locking people up, helping them to get the help that they need. And it is also very communitybased that you have suggested in your book. In your experience, have you seen that type of program work better than the traditional approach . A couple of things and i would say. First of all, in reference to the first point senator, i think we need to keep in mind that this problem has been festering for 20 years. 20 years. People come small time and say why is this . And i say has been going on for 20 years. Weve been at this for a year and and a half or two years. It seems to me as a culture we need to learn patience. And not believing Silver Bullet answers. Like the mysteries of human pain. It is a complicated thing. Weve not solve this problem in the air and half or two years i would say of course not. We just need to keep working at it. These things exist because they took a long time for these things to exist. And Law Enforcement i would say, in general, some of the most innovative folks and innovative things i have seen come from Law Enforcement. We think not. Think Law Enforcement will be holding onto the old ways. No. Ive been amazed to see remarkably innovative ideas that come out of Law Enforcement. The one that you mentioned is one of them. One that i mentioned in my written testimony is about the transformation of jail. I believe if we come out of this with a new kind of jail, the new way that jail is run as you see actually in the state of kentucky, 2000 jails during the spring that would be an enormous advance. What is more jail would then be a asset again. Not a liability. Today jail is a liability. As a place we take people who, was a detox, want to see clearly the records of their own lives and want to change. Then we put them in a place that is tedious, predatory, ganged up, sexual stuff going on. All of that kind of spell only. And the pods that i have seen in seven jails and and one in particular in kentucky, a remarkable. A change of nurturing. One of time together. It is where youre working on recovery from the moment that you get up at eight in the morning and make your bed military style. Until 11 oclock or whenever lights go out. That kind of change in jail would be enormous. As a sediment testimony try to highlight things i thought would not just be beneficial to this problem but for the next drug problem as well. So its like playing whackamole with this stuff. I believe that jail in fact is one of the great places of effervescence you might say when it comes to the epidemic and the way new ideas are being tried. It is in jail and ive never spent but i think it what you are highlighting is one of those. I do believe it is an essential part of this. If we come out with jail the way we always have used it, then we will not really have advanced. And that is the problem that we will hit and we will wonder why we are not making greater advances. My feeling is changing jail is the way it is happening. Not just the revolutionary idea. You can find this in various examples around the country. It is very invigorating to see. Thank you. Thank you, senator collins. Senator casey. Thank you, mr. Chairman. Mr. Sam quinones, thank you for your testimony and i would like to start with some of the realities in a state like pennsylvania. We have had last year, 4624 Overdose Deaths. That is up 37 percent from the prior 2015. And rural areas are higher. Almost 10 Percentage Points higher byway percentage. Of an increase. And that is Overdose Deaths overall. Obviously love that being driven by the Opioid Crisis epidemic really. What i see and i miss some of the testimony going back and forth between hearings but what i see in pennsylvania is a tremendous resource. When we went across pennsylvania last year, especially this last summer, we would have meetings with county officials. Often in small Rural Counties. Smalltown counties where you have a group of people coming together. The mayor of a small town in the police chief in the corner. And any medical professionals that Treatment Professionals. All around the table meeting all the time every week. Because of the dead bodies that keep coming in. One county, a very small county said to us, maybe the most graphic metric was they did not have enough places to put bodies. That is how bad it was. It is everywhere but what i keep hearing from folks at the local level is we need more resources. We are getting our arms around this. We are dealing with this is a local community but we need more resources. They needed for Community Health workers, social workers, Law Enforcement. They obviously are bearing a lot of the third. I guess the first question i would ask is what recommendations we have for closing the resource gap which i think is a, in the federal government has made some strides as you know, with cures and what is your sense of the way the federal government can provide resources. Counties and the level of government most affected, corners, gels, libraries, Public Health, cherif, etc. I have been struck particularly in the last year year and and a half to watch the very organic taskforces, committees or what you have you. Sprout up in county after county. In pennsylvania, i was in i spoke with those folks at some length. Yes. These folks are coming together in very healthy ways. They are leveraging, theres a whole bunch of people on the committee. Our recovering addict, primary care doctors. I spoke with the president that recently she said one of the problems is we can find medical programming. For naloxone and whatever. But we cannot find money for the nuts and bolts that make it work. Like office space and you know that kind of stuff that as essential is not as sexy as the other stuff. To me, i think the federal government needs to step up. And the are wonderful but i do not think that we have been doing this for 20 years over prescribing and creating addiction unintentionally 20 years. One year, 1 billion is a lot of money. But in comparison to what the country needs comets in every state. It is an unprecedented problem because its in every state in america. Coasttocoast. This is, what i am suggesting is that this evidence shows that there is a need for sustained, i am talking years worth, sustained investment in i think, thinking in terms of for example, there is more mundane idea of how to, that their job easier. On telephones. That kind of thing. And we can talk later if you like about the issue of corners. But to me the crucial part of this as well. I think i know it feels like a lot of money, 1 billion is a lot of money. But not compared to the lack of depth and length of time that this problem aof this problem. It seems to me it needs to go. Thank you for that. I know we are out of time. I have done to commit for now billion a year. If the idea from the republican version of the repeal of aca where they were setting up a separate fund. So i just took what he thought was a good idea and made into a different bill. We are hoping that we can get support that will be bipartisan. We appreciate your testimony and your commitment to these issues. My pleasure. If you have any. Thank you can senator casey. Senator young. Mr. Sam quinones, thank you for being here and thank you for writing this book. You came to indiana to visit with us last week. I would like to discuss our children. Thousands of children across my state and really around the country are having our lives turned upside down. On account of this epidemic. Not because theyre addicts per se. But because they are being removed from their home. Their parents have become addicted. They are overwhelmed in an already overwhelmed foster care system. If identified in his book the need for more services for families. Can you elaborate on what specifically, what sort of needs there are for families or resources in your experience that might help mitigate this crisis. Well, i think honestly, as a reporter i like to say that probably the best to talk to people that work in that field. One of the areas that has been devastating is foster care. My goodness, theres so much need now. The word for grandparents in america today, it would be just, mind boggling to think with the needed b. Searcy, so many kids are living with their grandparents not because the mother and father are gone or in prison or what have you. So, my feeling on a very blunt basic kind of macrolevel that we need to look at, and how to fund more foster care. How to do foster care better is most likely another great question. But not one that i feel like i can answer. You know you are, your larger point about the solution, if you will to this order epidemic is, hundreds, thousands of individual solutions and collectively, many of them fall under the banner of community. Absolutely. If we can persuade individuals that a fellow human beings plight, a fellow childs hard luck is actually their own plight. Then we can entice more people to be foster parents. To care for these children. To lobby on their behalf and so forth. I think is a good overall message. Taking that away from your book. Weve already discussed the jails. In your book you have highlighted some gels that offer rehabilitation services. And particularly, in those areas, you have people putting themselves into the criminal Justice System just so they can get assistance. Or you have relatives or friends doing so. And i like to, i would like to sort of discuss a different sort of setting. I visited with jails. I used to represent the house of representatives, austin, indiana. You know that name because we have a huge hiv operation out there on account of the intravenous issues and nlp are named opana. Many communities like that around indiana have a strong suspicion because ive spoken with them. That their inmates have either hiv or hepatitis c or Something Else. That they might typically test for. They have a moral dilemma. There on the horns of a dilemma because if they test these individuals, there legally on the health to provide medical services to them. And in a place like scott county, indiana, that we deplete the entire Law Enforcement budget for a year if many of them tested positive. Look, im not asking you to be a magician here but, number one, have you encountered this dilemma and if yes, do you have any thoughts about how check request honestly senator, i have not. I do not doubt it exists. I mean nothing surprises me anymore about this topic i have to say. But i do not, and sandra do not you know, all i can say is that this is, it seems to be the nature of this problem that we are asking in one case, foster care. In another case that you just mentioned, a jailer to be the again, the magicians. To figure out this deep social problem and i do not think they have an answer for. They do not have an answer for this nor do they have the funding. What they go about doing sometimes, im a reporter. Sometimes i just have to say i mean, i dont know. Honestly, sometimes against the program overwhelmed by all of the ways that this problem manifests itself. There is a it is, i do believe locally, it is the place where we find the solutions. But that you all have an absolute role in facilitating. Making sure that they have the resources they need because on the ground i have to say, it the county, the people in the counties that i have been to our working hard and working imaginatively. And helping those solutions and facilitating the solutions. I agree. Senator bennett. I very much appreciate you having this hearing. One of the most compelling pieces of nonfiction ive read in a long, long time, and its very, very depressing. Something we havent really talked about which is the heroin epidemic that rode on the back of the Prescription Drug. Utility for lee and he. My reaction reading it is this was happening all in place but somehow we missed it. And today 42,000 people a year are dying from this. White house estimated that its costing the United States economy 504 billion a year comes wit, soa billion is a lott its. 2 of what its costing the economy. It isnt just about the Rural Counties anymore. The sheriff tells you a 92 of the people hes admitting our testing positive for heroin. The jailer that opens up and take us you back and opens up the window and says look what are you showing me . There are women in my jail. Ive never had women in my jail and we are spending. 2 on treatment, targeted treatment. So as a former local perso persm all about people in the local community but they cant do it without resources. If anything, they have less access today than they did ten years ago so it is striking we are moving in the wrong direction and i wonder whether you want to comment on that. One of the problems is with the overprescribing of the pills we created legions of addicts and that a weekend the vast logistics potential of the mexican Drug Trafficking culture which i know fairly well and that is when most never really cared to traffic heroine. Its viewed as a pretty disgusting drug and people are far more enamored with meth and coke and stuff, so they didnt really tragic heroine or they didnt really want to get involved in it too much until we began to explore and now the prophet motivation is at a very highlevel and thehigh level ant involved in that and it exploded on the numbers of people who are trafficking from mexico and so forth, so that is one thing. As i said before, i believe that the Community Solution is where it seems to me i have seen people working hard and coming up with solutions appropriate to their counties and their regions. I do not believe they can continue longterm without more help and sustained as ive seen a longterm focus from the federal government. I believe a lot of folks are looking to the federal Government Republican and democrat, rightwing and leftwing in this fight for the sustained health and not one off. You mentioned very briefly earlier about the ways in which healthinsurance reimbursement are creating challenges for the work level. Initially in Pain Management for many years Pain Management was to take one individual and design over a period of time ind close connection to the patient and doctor together a menu of strategies. Marital counseling, diet, acupuncture, things like that, physical therapy etc. As we began to believe that one kind of drug would be the solution to all the Insurance Companies dropped a lot of that and you couldnt design the full panoply. Because the were no longer getting reimbursed for a lot of that. To me i think it is fundamental in this whole problem. Doctors need to be more educated that when they get educated they need the tools and doctors were not told that there is a pain epidemic in the country and they were left with one tool. The reason we got into this. Ibb strongly and this comes from talking with lots of doctors about their dilemma is to find that they need more solutions in that moment when they are meeting in some places. Now they can get to the acupuncture etc. They are absolutely useful. It seems to me the reimbursement for printing strategies. Senator murkowski. Thank you for your leadership on this issue and really raising the level of awareness. As you pointed out, this has been out there for a while but i think my colleague just mentioned that its been growing in plain sight and thank you for acknowledging there is no one Silver Bullet. It is a complicated problem and yet we all know and have been mentioned its not just an adult problem. This is a problem that consumes all ages and spectrums and classes. Im interested in your suggestion that we need to look at this from a very Broad Perspective and really strive high on the Marshall Plan to follow the same lines of the Space Program. The problem i see with that is we are still suffocated and strangled by the stigma is attached. But is attached. It seems like it has just been recently that you will see in the obituary that there is an acknowledgment this young person, this individual died of an overdose. But we have very good because there is this sense of wide field as a parent if my kid died of a drug overdose. Until you can get beyond the stigma i think there are still so many like those are the ones who just couldnt take it. Those are failures, losers, which is a horrible thing to say and i even hate to say it in front of a microphone but there is the stigma that is out there. So how do we get people galvanized to help and to be inspired to do something as big as i agree with you that this needs to be in order to make the difference. That difference. Are we making headway in reducing the stigma . Guest crate question, thank you for asking. I think definitely we are. I was writing this book and i had a conversation with my wife i said we are going to write this book and put it out and fulfill a contract, but the truth is that is going to die when it comes out because nobody cares about this problem. I couldnt find anybody would want to talk about it except the occasional narcotics officer or judge. The reason was common one of the main reason most parents or families were mortified, and barest. This is a different kind of problem and people were mortified at what had happened to their children. You never saw an obituary that told the truth. It was like he issue. In this case it was he died at home of a heart attack at age 25. Now, i believe that what is hoping to change that i think similar to say the marriage issue it is getting to know people that are affected. I know youve heard a lot about how you need to provide more funding but i do believe we have a public profile role. If you go to the communities and find those parents, talk to them, meet with the county groups that are sprouting up all over the country. Its amazing to see this and when your own high public profile meets with parents and say thank you, tell us your story and helped recruit them. I think that theres a lot of folks who would go along and do that if they were asked. If they were flooded with, please do this. And as i said maybe it is because i am a reporter but i agree with the power of the story teaching peoples minds. As human beings from the prehistoric times to today weve always needed stories to help us understand and the reason this wasnt very wellpublicized is because the people who could best tell the story didnt and now increasingly they want to talk and its so important to embrace them and bring them out of the shadows they wanted many of them not yet but others someday soon and with that my feeling is theres a horrible stigma exactly as you say and one of the main ways we defeat that is through stories and i believe as Public Officials, you all have a magnificent old whenever you go home or go to some public event that may deal with this, find those parents com,bring them out, have them tk about it, and recruit them to give them a phone call saying i heard this happen and we would love to hear your story. We just want them to know we are here because so many of them also on. They made bad mistakes because they thought that there was nobody nearby and that they were all alone in this. Defeating that isolation is part of the solutions of things that have to be tried. As they make a great reminder its not just all resources. Thinks senator murkowski. We have several senators remaining so im going to try to stick to the five minutes if i may just so we have time for everybody to be involved. Senator murphy is next. Thank you mr. Chairman. If one of us were to go down to the senate floor and give a speech on loneliness, we would worry that it would come off feeling or looking silly. If you look at a map of the suicide epidemic in this country, it is the worst and if you read the great book about the Mental Health crisis in this country, he comes to the conclusion that in the end the only effective Treatment Program is the one that builds connectivity between people and you did entitle your blog the Great American heroine epidemic, you titled it dreamland. You made your case in the opening comment. The story is a complicated one. It was a private lowcost Community Pool that closed in part because of factors that were outside of the governments control. Peoplesoft war going on in their house, had more pools, tv channels, kid had lots of reasons to stay inside, and yet you are sort of hinting at being critical about the decision by the government to let the pool close because theoretically there were other options. They could have spent some taxpayer money in order to keep it open and probably would have been criticized for throwing away money in a money losing effort, but the result might have been that the Community Assets stayed open, so i guess lets me sort of take you from where you left off in your testimony. You focus your book on this question of Building Community and we are really awkward when we try to address the ways in which the government can build the community and attack loneliness because it sounds like something we are not supposed to do and yet at the heart this is a critique that we should be thinking about those things so share with us your thoughts on how we can change may be the way we spend money and do Public Policy to try to build communities rather than tear them down. The best idea that i can come up with is to consult the people that are already working on that and i think all across the country that is what is happening and that has changed that we have nobut we have now d lots of people working on this in a variety of ways. My feeling as a reporter is always to go there and ask questions but also understand that the government has a convening role by providing the infrastructure that does bring people together, that includes stop signs and good roads by the way that kind of thing, but also funding to provide Community Centers and this kind of thing. We would all be inspired if it did, seriously, my feeling anyway. I am a reporter. Im not sure if i know all the ways. My impulse as a journalist is to go to those areas and talk to as many people as you can and highlight them. Find people working hard and those coalitions and task forc forces. Will it be will it be a pr even, who cares. These are the folks working and from that thats how innovation works. Youve got the factory floor, factory worker, the supervisor, Computer Software guy, they are all putting their brains together and finding little incremental ways to make the product better and that is i think cities and towns work in the same way no magic bullet, sulfur magic wand, just slow incremental work. If we are going to spend an awful lot on this epidemic thank you senator murphy bed is a good description on the way we feel. I want to ask about the holy grail. What do you think about that, you dont pretend to be a medical expert but why is it not a good idea to try to find nonaddictive Pain Medicine . Its a strange thing. As i got into this story for the first time in my life i began reading philosophy about how we create happiness as human beings, how we achieve, what is happiness, because it seems like all these people across the country are looking to this substance, one form or another to be happy at least for a few hours and it seems they talked about working hard toward something more fulfilled by god you are excited by and about you love to do and along the way comes a fulfillment. First it was to help people dying who were in horrible pain. Then it appeared they might not be edited as revolutionary as you describe it way of making pain a vital sign came about but just because opioids turned out to be edited, is that a reason not to try to find other strategies that are nonaddictive . To me this is a hunch. Im not saying ten years from now or five years if i have to come up from the bill that reduces all to negligible amounts and does not they would be thrilled and happy for those that benefit and i would be one of them. It sounds lik like you would sut it could be possible. We need friction and tension in our lives to be productive and be happy and back. I believe there are other things that need to happen. When i was writing this book i stopped drinking and wanted to be the change i wanted to see in the country so i stopped eating food i saw advertised on tv. I felt that it was important to do things that wil would reducee chance that i would have pain. I just have a skepticism that in the long run he would be able to handle it, that we behave very poorly when they have no other friction in their lives and public accountability. He had a meeting of all of the people in the state and universities who were in charge of training with the goal of changing their attitudes towards prescribing them of opioids. One of the Health Officials said to me when i told him i would be hearing from you today, hes asked him about fentanyl. So in 50 seconds can you tell us about that . Its transforme transformed e market completely. It has democratized. It used to be when heroine was in the country we knew it came from mexican states and what can come from hungary, nebraska, canada. It has made heroine dealer is far more willing to kill people. Used to be for many years you ht it by overdosing clients when somebody overdosed that was not a warning, that was an advertisement on the street. And heroine trafficking what you want to do is reduce the number because it gives you more volume so you cut it into two or three at a south that theres less chance of being people saw what he has donit has done is its mr cheaper to b go to the people ad then therefore create bugs around your product. Its a diabolical thing to it scribed leakages cried that is in the nature of which seem. Also, it has allowed many more people to get involved in this and by the dark where thats coming from mexico but its also being sold. Prevalently and that has allowed a lot of people not to get involved in selling its probably never would have before. Thank you for being here and for your work. Just at the outset, i would say some of the things youve touched on today about Community Also seems that the author a sociologist Robert Putnam has touched on and i think that your book and his together are really important. I want to start by laying a little bit of groundwork. Starting in january 13 i was also a governor that worked with my Republican Legislature to implement Medicaid Expansion which was implemented in the middle of 2014 in august. In 2013, we had 192 Overdose Deaths in new hampshire. In 2014, 326. We were on an upward trajectory even before Medicaid Expansion. And in fact one of the reasons this all came together to implement if hed expansion is because we had the crisis in the Interval Health and drug Overdose Deaths in our state and we knew Medicaid Expansion would get more treatment to people and my own anecdotal sense is that it did not in fact cause an increase in opioid deaths slide just want folks to have a sense of that. I think that there may be a correlation here, but to suggest there is a causation is very troubling to me and i also think its the sum of the stigma issues that youve talked about. I do also want to thank you for your consistent that this is a problem that was decades in the making. Its going to be decades in the fixing and it requires subtle approaches that can evolve in the way the epidemic is evolving to the chairmans point. In our state it has changed a lot in the way Law Enforcement and the Community Addresses this, so thank you for your advocacy. I want to spend a lot of time on the issues i dont think weve touched on as much right now as it deserves. The new england journal of medicine was completely misinterpreted and used to claim that their products are virtually nonaddictive. Doctors only rely on the letter as Scientific Evidence that it is rare when an opioids. Its astounding that one paragraph jotted down in 1980 helped fuel the horrible epidemic that we are seeing today. Your book outlines how Drug Companies played a big role in how some of them have misled patients, providers and Public Officials about the addictive nature of their products. Can you give us a brief overview of the role of the pharmaceutical industry and creating the misconceptions . Brief . You have one minute and 45 seconds. Well, it would be pivotal in all of this. It starts really with specialists believing we purportedly treating pain, and we were. This is the story of a lot of people doing what they thought was the right thing but doing too much of it maybe. I dont believe they would have had to megaphone that they came to have were it not for a lot of the money and funding and selected use of their information by pharmaceutical companies. I think that their money and influence is whats changed thee tide and then of course they were joined by certain institutions like the va and other possible accreditation agents with a vital sign and all that kind of stuff that i think they saw early on that they tried a time released opioid and thats costing only for cancer patients. Had they just kind of stuck right there, we would have been applauding them. Instead, what baseball is a dying cancer patient market was pretty small and there was a much, much larger one called chronic pain which was normal pain of america basically and they got on board. This was also by the way what the industry went through was a arms race where every company was hiring more and more and more sales reps and these were not the order sales reps its my impression talking with the doctors they knew what they were doing and it went from 35,000 to 100,000. It was also part of this story and i have to say that this is a complicated tale and i want to not blink at the complications. I believe also we as americans play a huge role in this. Our desire to not be accountab accountable. I think that is fair and i thank you for this. I also just won wont have thee for second round of questions that i will say that in my state, the need for funding to support the Grassroots Efforts and some of the things that Law Enforcement is doing is critical and i would look forward to talking with you more about that. Thank you. I think these are the best works of reporting ive read in the past 25 years. Tremendous work. I want to ask two questions if i can get to the two. We have had witnesses here and ive asked them the questions could we set the gold Addiction Free by 2030 im mindful of your point that there is no Silver Bullet but im also mindful if you dont have a target to organize around. We will rebuild these economies and enable them to protect themselves. If you dont set the target, then you dont marginalize your resources around meeting the target so if you were to advise us about the target would be, again i pose the question to these folks could we set the target by 2030 and Francis Collins they said yes, that is doable if you define it the right way it is doable within the current scientific knowledge and technological likely future but if you were to give us a target, what would you tell us. We would all be in trouble. I would say that a target is good and my hunch as an american is i that is something to strive towards and its always good to have a deadline and a goal on what that year should be and whether or not humans can ever beat Addiction Free is a debatable point in my opinion. As i said in some of my testimony, to me this is a supply story. I lived in mexico for ten years and when i was in mexico, i grew up having thought about very deeplit verydeeply i adopted tht all of the American Drug problems were demand driven and theres a lot of evidence for that when you arrest a Street Corner dealer another one pops up but the demand is going to keep producing. I agree, but the thing that starts it i believe is supply, and i came to believe that after living in mexico because it absorbs them of responsibility and our drug problem which isnt just our drug problem, it needs to be addressed as such, us and them, thats when i start doing the book and began that is not exactly what happened. We had no real problem with this before the overprescribing. The difference in this story is that the supply didnt come from colombian dealers and mexican cartel, it came from doctors buying into sincere, wellmeaning, and welltrained doctors buying into this idea that they could help their patients by just massively prescribing these pills. So the goal is in my way of thinking the supply is the issue and therefore to get there i believe it requires. The reason why all those guys in vietnam came back addicted first of all no longer worked for them but now in rural tennessee and there was no supply so they found the more that you separate the addict from the supply, the better chance they have of success and thats what youre finding. Let me ask a second question. I have a brotherinlaw. I know him well. A u. S. Attorney in portland who then decided he would be the ceo of a Substance Abuse organization and he says if there was a social movement for the recovery, it would become the most powerful Political Movement in the United States each grappling with how you get over the stigma and the democrats and republicans, red d state and redstates and blue sts Recovery Movement would be massive and help us meet the target so i am curious what you think about that. The more stories you tell, the more we start to get talking about the book i just wrote and told them they will start looking around like this and say my cousin is doing five years in prison and i think the more those stories come out the more we all know how many around us have this issue and you dont have to lower your voice anymore. It becomes natural well, you know, recovering from, and i think thats why its very important for recovering addicts who mentioned that i want. Just because it normalizes it and makes us all understand this is something that is going on all around us and it is an amazing thing to have written a book like this and then go on the road and hav have encountern airports and places like that. So in the power of the story as i said. Im over my time, but id appreciate you being here today. Mr. Chairman, and thank you for being here. Thank you for your research. I want to followup o follow upr point about supply. In your book you write about a hospital in columbus where a doctor in the adolescent Medicine Department helping heroine addicts get detox talks about the kids he was seeing started with prescription painkillers and he says it was all of them. Thats how all of them have gotten started with superstition painkillers. A story that was true i take for far too many americans. According to the cdc, people that are addicted to prescription painkillers are 40 times more likely to be addicted than to hear when and many people who misuse prescription opioids take the pills that started out as legally prescribed whether to them or a friend with a bulleted and i know youve written about your own personal experience with opioid prescriptions when your appendix was removed. Do you mind saying a bit more about that experience about how many painkillers and you can keep it short, how many you were prescribed and how many you think you actually needed . Sure and i think my story is multiplied by millions every year for 20 years. I had an appendix rupture at work when i was at the la times might shift one night and i didnt realize it, went home, went to the hospital later and they said i appendix ruptured. I spent two days in the hospital and was a perfect example of what to do and what not to do. Each of the two days i was in the hospital they gave me to vicodin, very good idea, i just had been cut open, good idea. And then when i left, they gave me a bottle of 60 instead take as needed. Again i am a Crime Reporter and ive done work on games and stuff like that and id never written about health care. I didnt know, not really paying attention to this issue at all i didnt know what vicodin was, i thought it was a glorified aspirin because they told me as i left, take as needed. Okay that sounds like aspirin to me. I dont like taking pills, so i took two of them. Thethe remained of my medicine cabinet for four years and i said i think i still have that. I knew what it was and sure enough, we found it and disposed of it. But again, a couple things. That is a perfect example of the supply that we have unleashed on the company. Multiply my case by millions of people and you get to where we are. There is actually some data on this but found that between two thirds to 92 of patients who underwent various procedures like you did reported that they end up with unused opioids afterwards and just like you a lot of them stood out in the medicine cabinet and can then fall into the wrong hands. Very easily. As senator alexander noted earlier, last congress senator capito and i passed a bill to try to tackle this problem by letting the patients request only a fraction, only a day or two worth of their opioid prescription to be filled at the pharmacy and if they are still in pain a few days later they can get a few more pills if thats what they want to do. I know its not coming you talked about how complex this problem is but i want to talk about it one little part. I think thats exactly the kind of thing im talking about, the Small Solutions, many Small Solutions one of them is to take that kind of slide off out of the medicine cabinet of america basically and i think also to get doctorgive doctors in the hf questioning i think it was routine for years in this country to just prescribed 60 or 90 of these pills and give doctors out of it. Think of the windfall by the way a Pharmaceutical Company when a doctor in a white coat prescribes you ten times more than the pills that you need and you like i did say okay. Or in your case, 30 times more. And theres refills and so on. Again, i get back to the basic dichotomy here. Its a story built on bbc in a magic bullet solution. I think that theres lots of Little Things and what youre outlining sounds like to me one of those Little Things. I just want to say on this, we got the law passed here but that doesnt make it a reality, so we have sent letters, senator capito and i come to every governor in the country com, the different medical organizations asking them to back us on the implementation of the partial fill. And also, here we are more than a year after the wall has changed and the Drug Enforcement Administration Still has definition on partial fill that is out of date, not in compliance suggest a couple of weeks ago senator capito and i along with senator grassley and senator feinstein sent a letter to the dea to ask them to update these regulations, so as you said a complex problem. Weve done our part and we need to get if you proceed in line with this. Thank you senator warren. Senator baldwin. I really appreciate you being here today. Its my pleasure. What an opportunity to have a conversation and so you chronicled this epidemic as having its roots to decades ago at least and yes, we find ourselves still scrambling and losing ground. I represent wisconsin and the new front of this battle. In a Community Like Milwaukee County, fentanyl was the cause of deaths combined with other opioid overdose is about 420 in that county last year. Its just one example in the state of wisconsin. And at this point, there is no sense that 2018 is going to be a turnaround. Despite the fact that Milwaukee County has a very committed here when task force and leaders from the local Law Enforcement and leaders from Health Providers have been collaborating to address this. I wanted to sort of dovetail on your conversation with chairman about synthetics like this sort of changing this epidemic in some way. We need to be prepared for a next generation of synthetic opioid and what is the federal role in assisting communities . That is a huge question i think and im not sure i have all the answers. I have a couple more huge questions for you. [laughter] theres nothing but huge questions on this topic seems to me. Yes, fentanyl has been remarkable and transformative. Its like the third stage, pills, heroine and fentanyl. It is my belief strongly having lived in mexico that it is calling on us to understand that the only way we are going to talk any kind of an effect is by working with mexico, not at odds with mexico. There is no way you can stop the smuggling, but we a alone can stop the smuggling into the United States because of his so small. A sugar packet worth could kill everybody in this room, so and probably on this whole floor. So my feeling is one thing that seems to be extraordinarily counterproductive in my opinion having lived in the country for a long time is the rhetoric im not saying it is put on rosecolored glasses. Ive lived there and they know the issues and the corruption and depth of the problems that they have but never the less, in a persontoperson connection which we never have achieved as government to government from what i can see, that is how you advance. They just shut down. It was an interesting case in july. They shut down the marketplaces in july of last year and they did with the fbi an it with thee others i think. It was a classic example of how you make a huge dent in the supply by working with these governments, Global Economy copy only groups that dont Work Together in the governments and that was one example i thought was fascinating is how you move forward, and to me those are the ways that you help local Law Enforcement. Being in local Law Enforcement today feels like you are standing in the ocean trying to take back the tide. Im going to ask a question but i dont think there will be time for an answer. Maybe we can follow up. I have held a lot of roundtables with stakeholders from recovering addicts, family members whove lost loved ones, Law Enforcement health etc. Around the state you talk so much about solving this through the ending isolation and having stronger communities. I do find some significant variation between what i hear in urban centers in wisconsin and what i hear in rural areas come everything from the availability of resources to help people who want to get treatment even to what drugs are being taken and abused. I would love to hear your thoughts. Im not going to be able to stay for the second round, but perhaps a followup in helping strengthen communities and all those different settings as they respond to sometimes unique and sometimes common challenges. Thank you, senator. Thank you mr. Chairman. I wanted to explore further with you the link between economic affliction and drug addiction that you refer to. Many of the communities like portsmouth ohio have been devastated by ease closures for example. You said heroine is what you get when you destroy dreamland and use that isolation is the natural habitat. In the state of maine, the Opioid Crisis appears to have started decades ago in Washington County that borders canada and it is an economically disadvantaged counties very high rates of unemployment and a lot of isolated communities. It then spreads everywhere in name including our most prosperous towns and cities. The Portland Press herald last summer ran a ten part series on the Opioid Epidemic and it focused one story on the lobster industry highlighting the high entry rate in that industry and also the logistical challenges of securing treatment in the rural communities. Its a great story. Ive read it. They will be interested to know that. In your investigation, did you find that drug dealers tend to target communities that are economically devastated, are they more Fertile Ground for addiction fax i did notice that. I dont think drug dealers are deep sociologists. I think they are following the money coming into the first place this begins his economically devastated because teepain treatment and resortingo doctors was part of how you navigate economic disaster. You get disabilities as we were talking about earlier. You have people who are trying to navigate and to get that, you need a doctor and again, this seemed as time went on the it became something to result to a substance. You get pills and you can solve them and people figure that out. Some of the first dealers were seniors, they were not young people at all, they were seniors that figured out that kids will buy this stuff and so the rest. I do believe as you said that this is it starts in areas with deep economic affliction and in the areas that are viewed as kind of the losers and the great freetrade we had over the last 30 or 40 years perhaps. Now of course that made me change my view of the story Charlotte North Carolina, banking center, very wealthy country clubs and mansions, they have the problem a that problemi think that it is into some larger questions of the as americans how we view pane and what we want to deal with. I want to followup on your comment about the horrific role that is played by grandparents. I held a hearing in the committee to look at this issue and grandparents raising their grandkids due to the Opioid Crisis. Just as an important statistic i will tell you that in my state, between 2010 to 2015, the number of grandparents taking care of their grandchildren and being solely responsible for their care soared by 24 and its because of the Opioid Epidemic. I think that is what is happening. I think that story is repeated in many states in the country. Thank you for your good work. Senator murray, do you have additional questions . I just want to thank the witness for being here today. Your name has been pronounced a lot of different ways. [laughter] can you pronounce it. Quinoes. [laughter] [laughter] its been pronounced to me in numerous different ways through my life. Thank you for your excellent work and i look forward to working with you and all of the committee members. Thank you senator murkowski has questions and then we will wrap up the hearing. So many statistics you have cited in your book but one that floored me was the reference to the volume goes in the United States consume when it comes to narcotics and you state that the United States consumes and they are writing 83 of the votes oxycodone and 99 of the worlds hydrocodone. Gram for gram a group of specialists wrote in 2012 people in the United States consume more narcotic medication than any other nation worldwide. Okay, so people can become addicted whether you are a u. S. Citizen or some place in south america, what is it about this country that has us at only 99 of the worlds hydrocodone and vicodin . What is it that has happened here . That is a terrific question and one that began to hit me as i got into this book and realized it wasnt just a story about a drug addiction but who weve become as americans. Two generations ago or so, about a Million People joined the army and the whole country participated in defeating the nazis and now we cant get our wisdom teeth out without getting massive doses of opioids. I mean, i sought the answer to that. What is the common denominator between words of ohio, a town battered by almost every Economic Force the last 30 years in Charlotte North Carolina which is a very wealthy town, Salt Lake City and these towns have done very well. What is the overriding common denominator . It isnt economics obviously. You have two very different economic situations. By way of feeling is that it is a combination of isolation and also frankly maybe this was an essay on the dangers of prosperity that too much stuff given to freely people are not expecting. Everybody fearing that its scanning thei their anemia due o keeping them outside for keeping them indoors and all across the country. But is it interesting to you that those that were doing the deliveries didnt use the stuff. They were addicted to Something Else. They were addicted to the resources that came back. But you look at that and say what is it about americans that has pushed us in this direction in such an extreme direction . You have other countries that have the same issues that we have. They have economic decline, isolationism, the same things that we have come and get me have turned to opioids to done numb it all. We focused on the individual and great ideals of american kind of experiments that have become twisted and the pursuit of convenience and be entertained us with selfreliance ifor selfreliancs isolation. Accountability becomes tantrums whenever any political official oor cough call for doctor doesnt exactly what we say it seems these are things behind of whatf this but maybe we have had too much. Weve become pampered in some sense. I dont pretend to know at all. These are questions that im fascinated by and i would love to talk about them but i make no claim to know all the answers to these questions you are posing. So, this statement was made back in 2012 in the journal of pain physicians. What do you assumwould you assue numbers have continued to increase . Part of it bears noting part of that is because a lot of the countries dont use enough of these drugs. People die in horrible agony from cancer when they shouldnt be. There is a proper role for these drugs and inhuman medicine and distrust the debate over what that role is is a very, very important one and up to now in the last 20, 25 years in the country, the proper role would appear to be a bottle in every medicine cabinet and that is where he got into trouble. Thank you. Thank you mr. Chairman. Mr. Quinoes, if i need to make a couple of quick observations about her testimony had been one of your space shot Marshall Plans ideas. Listening to this, one thought i had is with your family here especially as i mentioned before, you should be glad you were not nominated for some think were some senator would have kissed you under the table and confused using the process. We thoroughly benefited from your testimony. It strikes me that with your book and with her testimony you may be helping to lead a revolution in a different direction than the one you describe in your book. One of the leading states for this problem. Working together with the governor is change the way they teach doctors on what to do about opioids. You have many prescriptions of three days worth instead of 60. There are some steps that we can take and i congratulate you for that. On your testimony, he wanted to demonstrate humility and you dont claim to know everything. We find around here thats a very useful attribute because we dont know everything either. Helps hear from you and second you are wonderful storyteller. He reminds me of my friend alex haley who wrote roots and he told me after he made his speech he said men make a suggestion when you begin you would say may i tell you a story instead of making a speech . Someone might ask and listen to what you have to say so because of your storytelling we listen to what you have to say. Finally on the Marshall Plan and the space shot i think senator murray and murkowski worked together fixed no child left behind a couple of years ago. One of the things no child left behind in education is have as a goal 100 of children would be proficient in reading and math by the year 2014 and i remember when that was set i was not in the senate and i thought i guess thats all right. We say all people are created equal and Samuel Huntington a professor at harvard said most of our politics is about setting high goals for ourselves so we never reach in dealing with the consequences so not having reach them a sort is sort of what we do as a country. Then i was thinking about a created a lot of problems for us and the consequences that were attached to that. On the Marshall Plan and this they shot i think it might be more like the Marshall Plan. As they shot was a high goal and inspired everybody but it was done from washington. He was essentially organized single shot efforts and the Marshall Plan actually was a request of European Countries to come up with their own plan. It wasnt marshalls plan or president trumans plan. Those countries came up with a plan and we funded it but then they implemented it and some succeeded more than others. Its probably what will happen here. Some sort of hide whole but i think the better example may be the Marshall Plan. And you are right to cause each of the states are different and i like the fact that you talk about parts of the country that are ravaged by a globalization and on line purchasing and leaving main streets empty and people without things to do but then we have charlotte and nashville. The complex problem and youve helped us understand it. Thank you for your leadership and we appreciate your family coming as well all the way from los angeles. Senator murray anything else . The hearing record will remain open for 10 days. Members may submit Additional Information to the record within that time if they would like. The Committee Meeting on thursday january 11 for the executive session on nominations, thank you for being here. The committee will stand adjourned. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations]