Transcripts For CSPAN2 National Governors Association Winter Meeting - Opioid Epidemic 20180226

Do in their states to address the Opioid Epidemics. This is just over an hour. Good afternoon, everybody. Those of you whore Still Standing who plan to set, set it and those of you who stand can stand. My name is charlie baker, governor of the commonwealth of massachusetts and im the chair of the nba health and Human Services committee and i want to welcome you all to this conversation about an issue the nga has been engaged in in a big way for the past several years and i think it is fair to say that every governor of every state has made dealing with this particular issue is significant and important priority in their work and thats certainly been true in the commonwealth of massachusetts. I did run for governor to work on this issue, but upon me because wherever i campaigned, i ran into people who talk to me about it in their stories frankly broke my heart. Over the course of the past several years, working on a bipartisan basis with our legislature and others, we have made some progress in dealing with this terrible epidemic. In massachusetts, after years and years and years of doubledigit increases in opioid prescriptions and dads, literally for the first time in a very long time in 2017, we have a 30 reduction in prescriptions, overdoses leveled off and deaths dropped by 8 . Now, the way that was referred to by most people was sort of positive, but muted. The reason it was muted as because we have so far to go in so much more to do. Literally after bad news every single year for year after year after year, people did take some comfort in the fact that trend like this for a long time finally started to go like that. Theres a lot that went into that in todays conversation is to talk about what is working and where should we go next. Some of the things that i believe have worked does speak to others add to that as we go on to be the following. In massachusetts, we now required everybody graduates from medical school, dental school, nursing school, Pharmacy School and social work school to take and pass as part of their core curriculum for kosovo. Therapy and pain management. If youre a subscriber, as part of your continuing education for getting the license renewed, you have to take and pass a course about. Therapy and pain management. We are one of the first states on prescriptions. Over seven days. So far the states have followed since then and we dramatically upgraded and simplified or prescription monitoring program. As a result of that, we finally got to the point where the vast majority of prescribers who are working on that system and using it as a Search Engine every time they were prescriptions and in addition to that, finally got to the point where they can start giving them some pretty decent information on their own prescribing patterns relative to their peers. We also created programming to assess network in our middle schools and high schools for students and i Hope Department and also created as part of our sort of annual program for all athletes and their parents and coaches, and inclusion of a discussion about the positive and the negative along with discussions about hydration and health in concussions and all the rest. That is kind of the prevention Education Sector treatment and recovery we added 1100 treatment beds come increase state spending by 60 in a variety of addiction based programs that need medication assisted treatment a much larger part of our repertoire and portfolio than had been previously. One of the other elements that we pursued our pilot bases that turned out to be reasonably effective. We have embedded recovery coaches and some of our hospital ers around the commonwealth to engage in discussions with people who overdose to see if they couldnt talk them into moving into treatment. Most of the folks who played the recovery coaching role our people and recovery themselves and it turned out that their ability to reach out and speak to people who are just overdosed on were in the throes of this addiction is pretty powerful. In some cases besides much as 80 of those contacted and touched by this program find their way into treatment. That doesnt mean 80 got out of treatment. The bottom line is for the first time without a mechanism that help most people, many for the first time with treatment as a possible option for them. With respect to what is next, we filed legislation before legislature, the care act chosen number of elements to build on some of the things we had done previously. One of which is to take this whole nation of recovery coaching and turn it into a bona fide local program. But the process for it to really make it sort of a fundamental part of the way we deal with addiction, especially opioid addiction where recovery coach can be a big part of what helps somebody lower their medication assisted treatment or some other form of treatment, staying on the Positive Side of their Treatment Program that they battled their way out of this terrible addiction. The legislation also includes elements to experience some of our schoolbased assessment and Service Programming and also for the first time, well have us engage with the folks in the firm a community to see if we can create something that will look like a blister pack, which we have in many other parts of health care to provide the very small number of opioids that you might want to make available to somebody who had their wisdom teeth out or had minor gum surgery or sprained her ankle or Something Like that. The reason for that was the conversations is we write 30 days. Thats the thing we did. 30 days for a lot of this stuff is what weve been writing opiate prescriptions were for the better part of the past decade makes no sense at all and if we Credit Delivery model that makes it possible to give someone the two or three pills they might need to deal with whatever the particular acute pain is coming out of a minor procedure, we might be able to take a lot of this stuff off the street to begin with. The final thing i will speak to the sentinel. In 2014, sentinel was present in about 30 of the overdosed deaths announced she says. In 2017, and it is over 80 of the deaths in massachusetts. If it wasnt for sentinel, the success we have had a reducing overdose Overdose Deaths wouldve dropped dramatically more. But the sense of truth is we can do a lot of things in prevention education and i believe we are. We can do a lot of things on treatment and i believe we are. But we have got to come together state, local, federal with a lot harder than we are now if we truly want to protect and preserve the opportunity for treatment to be successful as many people on our states. So we are going to hear shortly from the newly confirmed health and Human Services secretary, alex azar and have an opportunity to engage in a roundtable discussion led by the los Angeles Times. But before we get there, i did want to give the vice chair of the health and Human Services committee at nga the chance to offer some of her thoughts on what has worked. Governor brown. [applause] tonight, governor baker for that in your leadership on this issue. Also thank you to nga for its continued focus on is critically important issue. Im looking forward to hearing from secretary azar in a few moments and from all of you. I am eager to hear how other states have made progress toward implementing Creative Solutions and what struggles our state share in common. There are too Many Americans who feel the impact of the Opioid Crisis every single day. We cant ever look at opioid abuse in isolation. The effects of addiction were pulling to family members, friends, colleagues and our communities. Oregon, 60 of foster children have parents who struggle with addiction in general. 25 of abuse to opioids. And each year with this dozens upon dozens to death by overdose. This is tragedy demand inaction. Part of the reason the opioid addiction is so insidious is that it still carries too much stigma. To face this crisis, we need to let people know that its okay to come out of the shadows and that they have a Supportive Community on their side. We must focus on prevention, treatment and recovery to turn the tide on this epidemic. Right now, the federal government recognizes the problem, but from my perspective is overly focused on punishment. That leaves us, the state, to address the issues that drive this Health Crisis while prisons in foster care system are filled to capacity with this problem. We must do to what this by increasing access to treatment and doing away with failed first policy. We must be creative in bringing forward alternatives that work. We know that reduce the chance of relapse or overdose, we can make sure treatment support is immediately available. The governor baker, were pushing forward on legislation that includes a Pilot Program that would dispatch recovery mentors, highly trained people in recovery themselves to Emergency Rooms, to connect with the patient immediately and act as a peer, friend and navigator in the next steps on the road to recovery. Im pleased to say we have so many people testifying in legislation. We didnt have time to hear from all of them. A past that is committee unanimously. I look forward to our conversations today, the hearings from you on what innovative strides you have made in your own states. Thank you. [applause] is very much, governor. A coasttocoast overview. We are very pleased today to be joined by the newly confirmed secretary of health and Human Services, alex azar and i know many of us have had a chance to speak to him about this issue during the brief time he spent on the job. The best part is this is not somebody whos new to this issue. He comes to with a wealth of knowledge and information about what it means to all of us and what it means to the people we serve and represent in our communities and he is bringing what i would describe as not just enthusiasm, but a ton of knowledge and experience to this and as someone who is no stranger to the role of hhs and the federal government. Were certainly looking forward to working with him and serve on the administrations opioid task force. Looking for to have a chance to see the recommendations that we may pursue on a grand scale on a National Level. Thank you undersecretary for being with us today. We really appreciated. [applause] thank you, governor baker and Governor Brown. Id like to express my gratitude to both of you into all of the governors who have gathered here today on this vital issue. Todays turnout reflects the level of commitment to this crisis that weve seen from governors across the country and from both parties. Your involvement and input are deeply valued at the federal level. We applaud your work on the many different runs where you have thought this crisis from establishing and improving Prescription Drug monitoring programs and expanding Treatment Options teasing Community Resources like fire and police stations to connect people to treatment. State governments and local communities have taken late. Im grateful to be here today to share how we see our role in complementing and empowering this great work that youve already been doing. As many of you know, President Trump has made the Opioid Crisis a top priority. Hhs has occurred in historic nationwide Public Health emergency last year, bringing a level of experience across the federal government. President trump in this administration recognize that its not the federal government on the front lines of this battle. It is all of you and your Law Enforcement officers, teachers, school counselors, committee leaders, doctors, emts and nurses in your faithbased partners. We are dedicated to empowering you and your allies on this site. That is what undergirds the comprehensive strategy for fighting the Opioid Crisis that hhs introduced last year. He brings a unique powers and resources of the federal government to bare empowering those on the frontlines. Many of you may already be familiar with the strategy, but the five points but as briefly as possible our data, research, pain, overdose reversers and access. After running through the strategy, i want to highlight a couple pieces of news for the food and Drug Administration that underscore commitment to advancing particular access to effective Addiction Treatment. The first one is better data on the epidemic. We have to understand this crisis in order to stop it, which is why hhs is working with state and other stakeholders to support parttime a specific Public Health data and reporting. The center for Disease Control and prevention for instance works with your state Health Offices and local corners and monitoring overdose data. The second point of the strategy is Better Research on pain and addiction. We clearly need more tools to help us win this, which is why we support cuttingedge research on pain and addiction in part through the National Institutes of health. The potential advances we see at nih in the air like nonaddictive painkillers and new methods of Addiction Treatment are credible. As they get closer to reality, we look forward to partnering with states and private partners to understand how these can best be put into this. The third is pain management. We need to do a better job of addressing the real problem of pain in america, which is quite hhs wants to ensure everything we do. Payments, prescribing guidelines, best practices and more to promote healthy evidencebased methods of pain management. We look forward to continuing to work with you on disseminating best practices including the work of the federal Interagency Pain Management Task force that were standing up before this better targeting of overdose router seem drugs. People in communities across america and our own cities and towns are alive today because of the progress made in making drugs like malloc sound available when and where they are needed. We are committed to working with you to ensure communities have access to lifesaving drugs are hhs grants, research and Technical Assistance. At this point of the strategy is better prevention, treatment and recovery services. We know directly providing these services often falls on state and local governments and community groups. But we can help by issuing grants that support access, expanded coverage theyre hhs programs and providing guidance and Technical Assistance. The budget includes a range of different investments. 74 million to improve targeted distribution of naloxone, for instance, and 150 150 millior rural Substance Abuse treatment. It takes a state target response grants to 1 billion a year, twice what we had under 21st century cures act we look forward to building a base of experience from these grants, hearing from you about how you have used this money. One particular point want to emphasize to the 2018 grants is that states of a wide range of options for using them. This includes treatment vouchers which allow for the use of funds for evidencebased services from faithbased providers. Americans affect the taken a leading role in the compassion approach we need to take, we have to take to this crisis and were were eager to support their work, however we can. On top of the grants we have released guidelines to accelerate the approval of Substance Use disorder waivers within the medicaid program, three of which weve already granted this year for indiana, kentucky and louisiana. I would just what your note for our governors that if you have waiver requests with us and you have particular waivers of this kind we can also streamline holdings is out and working directly with cms for approval around those concrete waivers so it doesnt have to be caught up in broader waiver discussions that we have to have. So what works . Medicationassisted treatment. One particular piece of artwork on treatment is supporting access medicationassisted treatment. Part of the title of todays session is whats working. As i said hhs is always dedicated dancing our understanding of what does work when it comes to Public Health challenges like opioids. But we already know some important facts. One of them is this. Medicationassisted treatment works. The evidence on this is voluminous and evergrowing. One study from governor baker state massachusetts sound footing survivors of overdoses on medicationassisted treatment along with the appropriate therapy and social supports reduced further future chances of death by more than 50 . That is a remarkable number of lives saved, and speaks to the number of lives we can be sitting by expanding access to treatments that work. Eight sf on the dedicated to promoting access to an awareness of medicationassisted treatment, or matt. We still have a long way to go. According to samhsa date at just third of specialty Substance Abuse Treatment Programs across the country offer medicationassisted treatment. Many People Struggle with addiction, failing to offer mat is like trying to treat an infection without antibiotics. Given what we know and given the scale of this epidemic, having just onethird of Treatment Programs offer the most effective intervention for opioid addiction is simply unacceptable. Under this administration we want to race that onethird number. In fact, it will be not impossible to turn the tide with that doing so. We know that there is sometimes stigma associate with mat, especially longterm therapy. But somewhat on medically assisted therapy, even one who requires longterm treatment, is not an addict. They need medicine to return to work. Reengage with the families, and regained the dignity that comes with being in control of their lives. These outcomes are literally the opposite of how we define addiction. Our fellow citizens to commit to treatment should not be treated as pariahs. They are role models. That is why i am pleased to announce today that the fda will soon release two new draft guidance is up improve the quality of and expand access medicationassisted treatment across america. The first is a draft guidance to inform manufacturers that are trying to develop new formulations of you for morphine that may be more effective for particular populations. As some of you may know several months ago at the april the first ever monthly injection of buprenorphine using whats known as the depot injection method thats long been used in psychiatric treatments. Depot injections make it easier to go need the shot once a month rather than going to get it every day. But they also can be more feasible in rural settings for the opiate crisis has hit especially hard and get Treatment Options can be especially sparse. Fdas guidance will help clarify what can what kind of evidence for new people forums of buprenorphine such as data regarding how quickly the drug is distributed in the bloodstream the second draft guidance were pleased to announce that it will encourage more flexible and Creative Designs of medically assisted therapy studies. Ask just one example of the guidance will correct a misconception that patients must achieve total abstinence in order for m. A. T. To be considered effective. Research is be invited to develop new measures for evaluating the effects of m. A. T. Formulations rather than just patterns of drug use, for instance. They might look at emergency room visits are overdoses. These fda guidances can make a material difference and accelerating efforts to develop new forms of m. A. T. And they will complement work elsewhere at hhs to deepen our understanding of how m. A. T. Works and access can be expanded. As just one example samhsa announced an effort this past fall to update how it provides Technical Assistance for the grants are moving towards a a e personalized model but we support states access to local expertise when and where its needed. On all elements of a work to address the Opioid Crisis, not just treatment access, close collaboration with all of you is key. This crisis requires new levels of coordination across all levels of government and sectors of our society. We are always listening closely to you. In fact, im pleased to say that many of the recommendations in in jays recently released report as it pertained your hhs reflect much of the thinking going on at our department, our action plans and look forward to engaging with you further. A final thought i want to leave you with is that i chose to highlight efforts on medicationassisted treatment today because this is a particular aspect of the epidemic that demand leadership. Leadership is willing to work to overcome any stigma associated with addiction and Addiction Treatment and to treat the Opioid Epidemic not as a moral failing but as a moral child for every single american. We had that kind of leadership in this room, and we had the kind of leadership in the white house. Together we can recognize the challenge of opioid addiction for what it is, and work to empower and heal our fellow citizens. Thank you all very much for the opportunity to be with you today on this critical issue. [applause] thank you very much, secretary. I want to thank you again for joining us and for your remarks. I went down like to turn the mic over to a reporter for the loss Angeles Times has done a ton of coverage work in healthcare and as i i said to him earlier, asa colleague of many people including sam who wrote dreamland which i consider to be sort of the best and most comprehensive overview of how we got into this terrible place in the first place. I want to thank you for me with us and what to thank you for your participation today. Thank you, governor baker, and thank you very much for the invitation to participate today. Its an honor to be with all of you. I should say for now that ive some trepidation about accepting the job of moderating this discussion. I have twosexual twosexual dd im sure they would tell you i do a triple jump of soliciting their opinions. I hope come hope you will not comment a dummy if i dont let you voice your opinion. As the title of todays discussion indicates the focus really here is on specifics, and on specific strategies, lessons learned. I know many of you are doing Amazing Things to take on the many challenges that are inherent in this public Health Crisis. I have a few questions to get us started, and ensure there will be many, many comments from you so want to get out of the way, but just let me say from housekeeping perspective ill make a plea that our time is limited. So please try to keep your comments to saint so we can hear from as many as governors as possible. I thought maybe we would start by looking a little bit, digging a little bit into an issue that governor baker race in his opening remarks, and that is the effort to get at the supply of prescription opioids which obviously have been linked conclusively i think its fair to say to the development of this epidemic. Many states, many of you have been working on the subject for some time and have i think its fair to say had a good amount of success in trying to control how these prescription painkillers are being distributed. I thought maybe we could talk about some of the things you all are doing on the front and the success that you had, lessons youve learned and you want to share with your colleagues. I dont know if we should do this by a raise of hands. Raise your hand i i suppose ifu like to share something. Governor wolf, would you like to start . Sure. First of all i think governor baker, Governor Brown, thank you so much what you are doing. This is a big, important problem in pennsylvania. Its an epidemic. I like the fact are looking at this for what it really is, medical crisis, not moral failing. Part of what gets to the issue of the statement is that were not looking at it as a medical issue that it really is. One of the things that is work for pennsylvania in a a bipartn way is to actually limit prescriptions come work with medical societies, medical schools to reduce the prescription of opioids to people. That really in short order helps reduce the amount of opioids that goes into the folks. People who die from Drug Overdoses, and there are thousand and pennsylvania every year, 80 of them, the gateway drug is a Prescription Drug. If we get the medical profession to work with us we can actually make big progress in reducing the ingestion of opioids. Governor do you see, i know you sign an executive order to try to get at the duration of the prescriptions that can be written for pain. You want to talk about your experience in arizona . Sure. Thats what we begin pick this is a real issue in arizona as well. We lost more than hundred Arizona State opioid abuse who died in the last 18 months. We had over 4500 overdoses and 453 babies that were born addicted to opioids. We also noticed that and that f our smaller counties, less than 200,000 people, we had four doctors who had prescribed over 6 million opioids in the last 18 months. Once we had that information we were ready to go above and beyond the executive order which happened the Previous Year which limited the amount of opioids that the government funded and paid for. So we wanted to do a special session but with our legislature and one of the first mondays of january, on a thursday of that, close that week we passed what was the most thorough and thoughtful and aggressive pieces of legislation that happen in the state of arizona at some time and we did it with unanimous vote, republican and democrat, house and senate. Limited first details on opioids. It also addressed people that had real chronic pain because we didnt want to pull the rug out from underneath any of them. We took away the opportunity for doctor shopping picks we try to look at both treatment, recovery, education and prevention in a very thorough piece but this idea, will have this population that is addictive and we will have to consider whoever we can avoid becoming addictive, so its a fiveday limit. The state of arizona, statistics show addiction skyrockets after the six day. Also some other hand over here. Governor bullock, you want to talk a little about the . Sure. Sort of ahead of the curve but i was running for attorney general 2008 in both narcotics officers and other places where i was going folks were saying opioids are becoming our largest problem. We deemed it back then the invisible epidemic. We took a number of steps, one of which was educating, recognizing the amount of youth taking it came from doctor a do. Had to be safety educating our folks, our medical community, doing greater education overall and our communities. We had to give doctors a tools they need so we start a Prescription Drug registry which we didnt have. Supply was a significant issue and what we found is most people when they get Prescription Drugs they tend to more than. We started take backs. The first takeback we got a glass pill bottle from 1952. Then we put permanent repositories in every single county. Then we did some stuff with Law Enforcement because in 2008 folks would get upset on other drugs but if they were large dealings of pills, nobody would pay any attention. As of today we have the lowest absolute death in the last decade, actually the last 15 years in montana. We decreased our Prescription Drug deaths by 45 since 2009, which was our peak, and reported nonpain relief use by 30 . So it does take an education and we still have to work on also the treatment parts, but its also on the one hand, where weve gotten much better hold on it, montana and we did a decade ago, found if you squeeze one side of the balloon we are seeing increases of significant all across our state. Let me follow up on that, made with some of the view because i know many states have found success in trying to limit the supply of these drugs. An argument has been made that this does push some of the use into the darkness. Thats been a criticism which some in the medical community have had. What are your experiences with that and how to address that unintended consequence . In arkansas we have growing over your challenge, over prescription, over subscribing of use and deaths here but methamphetamine is still our number one drug issue. I do think have to look at this comprehensively, and as the administration puts more money into education efforts, they should be broadbased, recognizing the fact that if we get control of the Opioid Crisis, theres going to be Something Else out there. I think the message has to be balanced and our enforcement efforts have to be balanced as well. If i might, let me follow up on what was talked about in terms of the drug takeback program. In partnership with the private sector is very important in this effort. I want to applaud walmart and sams club that as of january of this year are starting to put a patented powder substance that they are distributing with their opioid prescriptions, so if its an opioid scheduled to prescription, they have disposed rx that goes with that package that allows the consumer to be able to safely dispose of it and not keep it in the cabinet and killed is at takeback program. So its consumer friendly. I want to applaud them for doing that and make everybody aware that. Interesting. Governor, you want to get, talk more about the challenges of unintended consequences . Its important to understand and its been alluded to, 85, 86 of people of people addicted to opioids started that process on a prescription medication. Thats an important statistic to understand because once a person is addicted, they will seek a way to feed that addiction through whatever means available. It must day as as a prescriptin drug. It may move to what early on became heroin and black tar heroin, cheaper version, more readily available versions, now fentanyl and carfentanil which are becoming increasingly deadly. Its important to understand that while if you squeeze the blue and make it less available to figure addiction one way, a person who does have the addiction and was placed isnt going to let us start method as an alternative to not being able to get an opioid, you know. A methamphetamine. To that extent i think its important to understand theres no amount of money, no amountf edgecomb lamanna program, no amount of government ideas that will fix this epidemic at the bottom end of the funnel. It we dont close off the topping of the final, if we dont close it off, the numberf people fall into addiction, we are never going solve the problem. I speak just to kentucky for a moment. There are 1400 people overdose last year alone. This is not a good statistic. Its rising. The lethality of the drugs that are being used is higher than ever. 359 million opioid pills were prescribed last year in kentucky. We have 4. 4 million people. 79 tools for every man 79 tools for every man, woman and child. We are not in that much pain. I dont think any of the stick is. Other states have similar things. If you check you may find were not an outlier on this, unfortunately. The reality is this pic were not being serious enough about solving this problem. It isnt so the function of if we fix this or fix that. We really truly must get, and i applaud and what a comeback with quickly to the idea of m. A. T. , but weve got to get all the people at the table. We have to get the victims, victims i mean the family members who have lost someone. Again whether let that be determined. The reality is people who have lost someone to do a Drug Overdose have lost something irreplaceable. They need to be at the table. The people who reduce drug need to be at the table, people enforce the laws about how it is administered and what happens when you sent illegally. The people that are involved in the judiciary who sends people, all these folks with nobody pointed fingers at anybody need to sit down at the table at the same time. There is no wrong person in this instance. So my people to vilify a certain element of that equation. Whatever the element might be dependent on their perspective. But the reality is this is a big problem and it is truly epidemic and some have noted. A couple of things were done in kentucky, its now a three day limit on the initial prescription. Again as noted, cdc said addiction spikes after the fifth day, people who are likely to become addicted. Opioids, the affect of this, if you want to understand, read dreamland, its a great book. The pharmacodynamic effect is a given on the brain and other drugs. This is why were not able to get our arms around it. We also have to understand that coming back to the m. A. T. s quickly commercial of the things after, other drugs like speedy governor, let me just and will get to m. A. T. In a second. Chemical back to that . Was let me say one final thing as a relates to one thing were doing in kentucky. If you are not asking your Emergency Departments and hospitals to put into your Prescription Drug monitoring programs, which you probably have, i know people that are being brought in there for overdose, please do it. I think youll be amazed the fact that is not included. You are monitoring your doctors that are prescribing but youll be missing a tremendous amount of information if youre not asking Emergency Departments to load in the information about the people who come in and not just want to dive at the people who come in being treated for an overdose. Governor cooper, did you want to get in . Theres no question that the root of this problem is Prescription Drug overuse and misuse. And finally this country and the state to wake it up to that fact and now youre seeing prescription limits, youre seeing the Prescription Drug marketing monitoring program. You are saying more work interstate of us making sure that people dont overuse prescriptions. But it is driven people to streak heroin. It is driven people to fentanyl laced heroin. Street heroin. Although this is a good thing to cut down on the prescription overuse, because it is i think helping to prevent people from getting into the Substance Abuse disorder to start with, we still have a massive problem out there that isnt going to be cured by limiting Prescription Drugs. Thats why we have to to get into the treatment effort. Im heartened with the secretaries comments today about medicationassisted treatment. I know you be talking about that one thing we cannot forget is Health Insurance coverage. Over 50 of people who present to our Emergency Rooms in North Carolina have no coverage whatsoever. No medicaid, no medicare, no private insurance. We have to close this Health Insurance coverage gap so that we could make sure people get access to treatment, and individuals react to treatment in different ways. Individuals respond positively to different kinds of treatment but we have to remember, healthcare coverage when were talking about this issue. As the feds look at this and estates look at this, weve got to remember that. I do want to get to treatment. I have one final question. Governor walker, you want to get here but let me put this question out. I dont know if you want to address this or something that the other governors have talked about. There has been some interest in using alternative pain medications that are not all. Base. Some of your states have been fairly aggressively looking at this. Do any of you want to talk, governor walker, im not sure if you are among those, but even if you want to talk about the potential there and what has been achieved so far in trying to provide alternatives that dont provide a path toward dangerous addiction for pain patients . Not what i was going to mention but i will just say what was effective for us, i issued a declaration of emergency and i got a twoyear, nineday legislature pass, every two weeks with a full Cabinet Meeting with one agenda, Opioid Crisis. Thats all we talk about, entire cabinet. We have invited the doctors into this, the medical committee into this problem because they have to be part of the solution. They are required to report how much they dispense on a much more frequent basis than the like to. That was not welcomed but the problem is not welcomed. They came in and are part of it. Nobody can be left out of this. This is one of the best things we do, as a compass was associating him to talk with this issue. Ive never had this topic discussed. Something out of from some of either doing something that were doing. Governor come you the first that started at. I wanted to beat you to get more out there. Its a matter of how to develop what someone does . Thank you very much for this payment. Look to is you. Theres a full room, a full table. We can all take something away that someone else is doing. Our goal is one and on this so thank you very much for this forum. Just along the lines of another quick take away. Like all the other governors what weve been focusing on, this is a whole of common approach. We pulled together doctors, nurses, pharmacists, dentists who are big part of this, get them all in liniment i would to save other any privatesector solutions because theres a lot of things we can do but looking to do right now today as a privatesector . Someone raise their hand and said we took a look at all these institutions are good Electronic Health records that were mandated. Our largest Healthcare Provider in the state said to look at the software, and when you went through that pain prescription, the first thing that came up was the narcotics. You had to page down by three pages in the software to get to the nonnarcotics and it had fixed dosages. Without any Government Intervention they flipped the order to the nonnarcotics at the top, reduced the size of initial prescription. And the next week for their prescriptions went down by 20 . Privatesector just doing that. I think thats a quick one for everybody here to change. The other thing i with her at the secretary, talked about the importance of having role models for recovery. Governor brown talked about the stigma. I just want to say we are very fortunate in north north dakota who had the first lady who courageously last year started talking her own path to recovery. She is a 16 years in recovery this week but threat someone like that, the outpouring of people have come forward to want to appear on the one in nine people seek treatment because theyre afraid of it. Many of the people, we just got done talking about my super fashions. If you have an issue like this, you would luger profession some of people lost interstate are no medical profession. They can no longer get the Prescription Drug because all the typing of the drug prescription database. They are the ones who end up overdosing because he didnt want anyone to know into profession that they had an addiction. We have to drop the shame and stigma and with got to be proactive. It will take courageous role models. There is hope. Recovery is possible in the break people can stand up and show us that need to be supported. Thank you. [applause] governor baker, did you wat to that applause by the way was for the first lady. Shes right here with us. [applause] so i would just do one about this alternative issue. We brought a whole bunch of people who know a lot about this topic in to talk with us, and people are doing a variety of things, but they are, theres not, i would argue so far anyway, i havent seen a system approach that is in place with the federal government can play a real role. But the point the governor made about the way this stuff is organized and some of the online tools from one of the things we found out because the ambulance folks came to us and they said that the preferred choice is an opioid, not tylenol or ibuprofen, for the ride when they pick people up. For the right to the hospital are part of the reason is because it works really fast. Some of his other stuff takes a little longer to take effect. There were also some financial and just organizational incentives to pursue the opioid we said look, thats our regulation or we will change it, which we did. It made it possible for them to pursue alternatives and they did. The other thing both the public and private carriers in massachusetts has started to do is make physical therapy, acupuncture, a whole variety of massage, a whole variety of alternatives to managing pain available to people as alternatives to just a bottle of pills. I do think that has potential but i think its going to be one of those things its going to require a very Big Community to change the way they have behaved for a very long time to get there, and thats probably going to take a while. Because time is short lets get to treatment. I since people want to talk about that topic. It has been a challenge obviously to expand the availability of treatment. Theres a good news bad news story that there are clearly protocols that work and yet not enough people can get them. Who wants to go First Talking a little bit about how your take on that challenge and broaden the availability of treatment . Back in 2015, a previous administration, previous governor to me, peter shum one, came talked about this in a state of the state of dress about this pending crisis that we are facing. I was Lieutenant Governor at the time, opposite party, sitting to wonder whether this was the right approach. He was right. He got out ahead of this and we are a leader in vermont in this regard. We have the hub and spoke Program Design of california has taken up on that as well. Its been extremely, extremely useful to us. We expanded upon that after i took office, trying to provide more Treatment Centers through this hub and spoke model but it is essential, essential that we are able to the Treatment Facilities available. Because when someone decides they want treatment, you bettr have it ready for them. Even in our small state with a small population, we only had, we had 700 people in one county come with some have people on the waiting list to get into treatment, waiting for months. And we lose them at that point we been able to reduce that by opening up more Treatment Facilities, working with the private sector in order to do the prep weve opened up more Treatment Facilities so that we have no waiting list at this point in time in vermont. Now people are coming forward more. Thats something were going to have to continue to monitor to contingent opened up the centers. If youd like to hear more about that will be happy to share it with you. I testified in congress a couple of weeks ago. They were very receptive to what we are doing. We provided some areas what we think we could use some help in this regard. I know time is short but id love to hear some time from anyone who has any suggestions, because its a fourlegged stool, right . Prevention Treatment Recovery and enforcement but the prevention side and how are we to our kids . What what we doing on a National Level in order to Work Together in order to get to the kids to try to prevent this from ever happening . If we have any ideas in that regard, we are all ears. Governor snyder, did you wt to get a. Was yes. With respect to the access question. One of the things that gets to this issue but changing the culture, about helping people versus putting people in incarceration or something. We had a Small Community and our upper peninsula, start a program that weve now adopted for every state police post in the state about where you can go. Its called the angel program. You can walk in the Michigan State police post and theyre not going to arrest you. They will connect you to an angel to help teach you treatment. I think thats a major statement about changing the whole culture to show Law Enforcement can be a positive barter and alec Work Together and solve his these problems and we are encouraging other Law Enforcement agencies to offer the same thing. Many cases when theyre ready to go get treatment, they dont know where to turn. We are promoting this state why to get the message after going. You could walk in to a state police post and you get help. Clearly expanding access like you have done in vermont doesnt come free. It takes money. Who has found money to do that . And if you havent, how . Ill tell you what, this is one reason why things like and 1115 waiver matters. When you get an 1115 waiver, cms, it affords states more autonomy. We have long been barred from using medicaid dollars, for example, which a lot of these folks are covered by medicaid or have the potential to be. Weve been precluded from using these dollars for treatment. These are the kind of things that can be removed through this 1115 waiver, one of the things replied to do them one of the things weve done. Weve increased the number of bets by over 1000 . Just in last couple of years. That sounds impressive but when you start with two smaller smala number thats easy to get to. Let me touch on two things will get on this front. The money is there. We spend billions, trillions of dollars in healthcare. This is a health care problem. It really is. Thats also a People Health problem. We spend a lot of money there, too. Its a function of use. How do we connect people, the question is the people know to call . If they call their local facility and theyre told theres not a bed and it with six much, do they know with te backup is. We base of the together program. We havent won a better number, 833 theres a a live person that will connect them to any open available bed in the commonwealth of kentucky. This is something that probably doesnt exist in your states. It didnt in others. We have a dont let them die. Com website. Back to your question, we have psa is, with greater some of her own but we now have a contest with doing in conjunction with one of the largest Media Television stations in the largest media market. We are paying thousands of dollars in prize money to teenagers to develop the ads. This is how were going to reach people. We have to be real about this problem. Teenagers clothing adds to reach other teens is how we reached the thousands of dollars and theyre their inability to get the broadcast with a sevenfigure media by mpi is anything we need to be doing across the lines. So were getting your the end of our time but we have a little bit of leeway. Assuming you dont want to run out to the reception so we can keep the conversation going if there are more governors who want to wait. Governor herbert, i see who are interested. Let me add my observation. As as a crisis in all of our sts and how regard to is debatable and probably blames to go around. As we with her own doctors, who weve asked why you prescribing, and and is we didnt know. The information was given to us is this is i think Tobacco Settlement because this information with fun at did the in fact, no, this . We required in utah to put warning labels on medication, said this is highly addictive. We also created a database. For example, i had kidney stones a few weeks ago, and when i finally got to my regular general practitioner doctor come he knew what the surgeon and what the doctor prescribed to me in the emergency room. He knew what my urologist at done in the medication had prescribed so that he did not overprescribed something in his own vain here to make sure that we are not, you know, you cant doctor shop. You cant say i have faith and he says you are because of percocet, we are not going to give you any more. So sharing of information with the database i think will help us a lot. Again, i think our doctors are learning. They are looking and being trained and been made aware, find an alternative to an opioid prescription. What physically the i guess is what youre talking about, no, what are the alternatives going to be. Governor ducey and i would talk about what happened with good old ibuprofen and tylenol . I think the doctors are probably led down the pathway that they are somewhat ignorant of. I think thats changing now. Again, i think we all have roles to play in helping the prevention site and certainly the things that have suggested on the treatment side are part and parcel of it for you for success to get us where we need to be. Governor hogan . I would just like to make one final comment. First of all, id like to think ngf gf or continue to focus on this important issue and what to thank governor baker and Governor Brown for their for the leadership on. I know everybody sitting at the stable is grappling with this at its number one, not just Health Crisis but the number one i think crisis were all going to be faced with. In maryland ive been focused on this problem for four years as i skip any for governor and everywhere i went, every small town i asked them what was the number one problem facing their community, and every single town from the inner city to the wealthy suburbs to the small towns said heroin an opioid was a number one problem. First thing i did after being sworn and was to set up an emergency heroin task force. We came up with tons of recommendations and we implement it all of them. We then became the first state in the nation to declare our real state of emergency. We stood up just like you would for a natural disaster. We put half 1 billion in our small state into this fight and weve done almost everything that everybody here has talked about, and with some great innovative governors that are working hard on this issue. We started to bend the curve down on prescription opioid abuse and overdoses. We are bending the curve down on heroin overdoses. But the one thing we havent talked much about, governor baker mentioned in his opening remarks, fentanyl and carfentanil, thats the coming way. We are behind the curve on the Prescription Drugs. Where behind the curve on heroin. We had nearly, arnold state, despite almost never send that money money had nearly 2000 Overdose Deaths last year. Thats more than firearms and traffic accidents added together. And in spite of us bringing down the other two facets of it, fentanyl use, no overdoses of 70 . This is coming in from china. Its 100 times more dangerous than anything else were talking about. Starting it up, where it began important, dressing the problem out there is important but weve got to go after this new coming wave which is much more dangerous. Thank you. Thank you, Governor Hogan. Governor baker, Governor Brown, can i give you that chairs prerogative to reflect a little bit on what youve heard and talk about going forward, kind of whats on the agenda . I guess specifically address or your fellow partner start here anymore, but he obviously talked about the Trump Administration commitment to this issue. What more do states need from the federal government to keep up progress . I want to thank Governor Hogan for any this on a really high note. [laughing] i guess i would start by saying the following. I do think as i listen to the conversation around the table, its clear everybody is pulling this one as hard as he possibly can. On behalf of the people of the states. A lot of the things that we are all doing are the sorts of things that i believe over time, if we stay with it, can make a difference. That would be. And the one for me, which is Governor Scott talked about the fact the governor race this in 2015. Its now 2018. This is not an issue thats going to go away in 2019 or 20242021. We are going to have to stay on this. Weve added 1100 treatment beds. Were were going to be adding many more. This whole notion of recovery coaches creating a credentialing mark for them and getting certification so they can be the consultative allies and advocates on behalf of people who are battling this particular addiction when they come out of whatever their particular Treatment Program is is going to be incredibly important. We certified hundreds of sober homes in massachusetts which turned out to be a really interesting and effective tool to help people stay on the straight and narrow points they come out come help in these find an opportunity for work. Many of them have lost their job because of some other issues with respect to the damage that their addiction had done to the sort of life they had been living before they fell into this terrible place. I view this as a sort of think it would take our foot off the pedal were going to have a huge problem with respect to continuing to move the needle on it. I also believe that almost everything weve talked about here are things the federal government could do and could leverage in a big way. I would love to see secretary azar and of the members of the Trump Administration really become significant and series partners with the governors on all of the prevention and enforcement education treatment and recovery issues that we are all pursuing. I mean, they have tremendous capacity to support and help us in ways that go way beyond what we can do on our own. I think the fact he talked about putting money into studying medicationassisted treatment so that people can start to figure out what the best approaches are going to be for helping people, depending upon their presenting symptoms and circumstances. As i talked about in my remarks, this fentanyl issue, this is one where the feds and the states and local Law Enforcement folks are going to have to be aggressive about participating in it. Because it is changing the game with respect to almost everything we are all trying to do. They predict that no out, the drop in deaths is a dramatic. I think its a place where we all have to step up. Governor brown . Thank you. One of the things that unites us is a fact that all of us in some way or another, are lifesaving impacted by Substance Abuse. We all have family members, with all their friends and a lawyer i used to practice in the foster care system, i saw the devastation that Substance Abuse impacted on her children and our families. What im so proud to see is for everyone is doing really treating this as a public Health Crisis that it is, and really focus on education, prevention, recovery and treatment. I think my perspective its critically important on a broader scale that we remove the stigma for people to access treatment, not just in the substance and alcohol arena but also the Mental Health arena, that we make sure we are comprehensively addressing Behavioral Health and our health care systems. In of your question of the federal government, for me our population can we have about 95 of our adults covered with health care at this point in time. I think if you want to make sure that people are able to have access to Substance Abuse or alcohol treatment, they need to have access to healthcare. And so making sure that the federal government partners with us to provide healthcare for all of our citizens he is key to making sure we can get people into treatment and get them into recovery and provide the support and services that they need to lead healthy, productive lives. Thank you all for your hard work. I so appreciate learning from you and your innovative strategies, and look forward to working with you. Thank you so much. [applause] i do want to thank noam for spending time with us and bringing his expertise and his perspective to the conversation. Really. Really appreciate you being here. [applause] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] this week on the communicators. I thought the internet was borderless . Thats really interesting. It can be borderless but what weve seen is everything i think were willing to focus on right now is it turns out that its this meeting with i was quite a give voice to the voices and in many cases did, and power to the powerless can also be used by dictators, by terrorists, by dark political money to undermine democracy. And weve got to address that problem. From the state of the net Conference Held in washington, d. C. , will discuss impact of technology on democracy and voting. Watch to communicate is tonight at the eastern on cspan2. More nga coverage as ibm chair president and ceo Ginni Rometty talks but we force as an ovation at the session begins with governor Brian Sandoval and later a a discussion on Higher Education innovation