Ms. Satel welcome everyone to aei. My name is sally satel. I am a resident scholar here. As we know from reading the headlines, on a near daily basis, there is news of the fact that america has one big drug problem. And in fact, overdose from opiates Overdose Deaths come , from heroin and narcotic pills, are now the number one cause of accidental death in this country. So what can policy do about this . What can policymakers do about this . That is what we are here to discuss today. I am joined, very honored to be joined by very esteemed individuals. I think you know them all, but i will give a brief introduction. First, newt gingrich, former speaker of the u. S. House of representatives. Throughout his political life, he has worked to help foster a Health System that provides better care at lower costs. Patrick j. Kennedy, former representative of the state of rhode island for 16 years in the house of representatives. He took a lead role in 2008 legislation that established parity coverage for Mental Health and addiction problems, and he last year published a book called a common struggle, which is part autobiography and part blueprint for Mental Health and addiction reform. Mr. Van jones, former adviser for president obama, and went on to do many things, including establishing dream core, which is dedicated to among other things prison reform. In 2009, Time Magazine named you man of the year and named you one of the times most 100 influence of people. All three of them are Founding Member of a new group called advocates for opioid recovery. So i will be asking them questions about how policy can promote recovery, and afterwards will take questions from viewers , online and from you in the audience. But first, i want to begin with a little overview of the scope of the opiate problem. Ok. I see it there. Ok, great. I hope you can see this wall. Clearly, there has been a fourfold increase in the number of deaths from overdose from narcotics or heroin. Prescription narcotics or heroine. The line up with the red is prescription narcotics, and the purple triangles are from heroin. As far as the number of people who are addicted to heroin and pills, it is very hard to get good numbers. But the numbers you will read about are about 2. 5 Million People misusing narcotic pills , and im talking about vicodin, oxycontin, percocet and about , one Million People use heroin. That is higher than the numbers you will see from the cbc. As you can imagine, a lot of people are not amenable to the surveys. Just not accessible. Now another important part of , the slide is that 80 of the people who are now using heroin started with pills, started with painkillers. That wasnt sure the 1960s and 1970s, but it is true now. Who is that subset of people . These are the people who misused painkillers. There is a subset of folks who has gone on to use heroin. Not everyone who uses painkillers go on to use heroin. Among those who misuse it, the risk factors tend to be having a prior history of Substance Abuse and having a prior history or concurrent history of major depression or other psychological problems or alcohol problem. The next slide im going to go very quickly through this one it shows you the kind of medications, and aquatic painkiller medications opiate , painkiller medications, that have been subscribed for the end of 1996 to 2004. The pink are the oxycodone type medication, again, the most common being percocet. The green is hydrocodone, most known as by vicodin. Interestingly, the red on the bottom is oxycontin. So even though it has gone to play some role, at a lesser role after it was reformulated and became harder to crush in 2010, the actual amount of oxycontin prescribed is actually modest. The second point of the slide that is quite important is the fact that it is dipping off. Doctors are prescribing fewer pills now. That is because there is so much attention to this. Hopefully, better training and how to deal with pain, although we are just beginning that kind of reeducation. Also, prescription monitoring programs have kicked in. In 2010 and 2011, these till mills in l. A. The , dea crackdown on them heavily. In some places, especially ohio, even though prescribing is going down, the death rates from overdoses are not, and that is because people are moving on to other drugs and other painkillers. This im sure you are all , familiar with narcan. I just wanted to show that clearly. That is a godsend, it truly saves lives. It is an antidote. Rapid acting, it knocks the opioid molecule of the respiratory centers in the brain stem, and it is also available by prescription in all states. Your doctor can write a prescription and you can pick it up. About half of the states, you can get it without prescription. A large part of the opiate overdoses are due to fentanyl. Im sure you have heard of that. It is a very powerful drug. It has a perfectly fine use in anesthesiology and pain control. But when it is out there on the street, it is very dangerous. You can see from the relative potency, fentanyl is 100 times as potent as morphine, although most people dont abuse morphine. They abuse heroin, and they abuse percocet and vicodin, which are somewhere between as i mentioned, morphine and heroin in that slide in terms of potency. Anyway fentanyl is 50 times as , potent as heroin. Potent that should , not even be handled without gloves. Now there is a new drug called carsentinel which is 1000 times as potent as heroin. That can kill very efficiently. The fda is probably going to increase the dosage of narcan that is being administered in emergency situations to compensate. Were not going to get heavy into the medical weeds. Go back to the last slide . Why was carfentenil made . Ms. Satel its actually an elephant tranquilizer. Is it the potency or the size of it . Ms. Satel i think its just representative. Mr. Gingrich so to knockout an elephant, it is 1000 times more than a human. And theyre using it for humans . Ms. Satel a lot of the fentanyl is coming from china and mexico. Mr. Gingrich are they cheaper than heroin . Ms. Satel they are so much more potent. One can wonder if we somehow managed to suppress heroin availability, will fentanyl just replace it . Carry on with your uplifting presentation. Mr. Gingrich with methamphetamine, it spreads to because you can make it in the garage. How hard is it to manufacture these two . Ms. Satel it is hard, because it relies on precursors the dea controls very carefully. This is an something you can make at home in a lab. Mr. Gingrich that is a real relief. I hope all of you have learned something. I guarantee you the three of us just did. Ms. Satel so when there is an elephant in the room, you know what to do. [laughter] ms. Satel so these are the fda medications that are approved. The reason i want to go over them quickly is because this is what we are talking about getting more access to. The one you have heard the most about these days is buprenorphine. It is in the class of opioid replacement medication. It is a form of an opiate, definitely. It is not as dangerous an overdose, as a medication called methadone. Im sure youre familiar with it and i will talk about it in a it second. Can be prescribed by doctors, and that is a great advantage. You can go to the doctor like a regular patient, get a prescription, and go to your pharmacy and get it filled. Bupre norphine can be used in pill form or as an nasal spray. There is an implant form that goes under your skin, and that lasts for six months. That is a great advantage for people who dont take medications regularly. Then there is the good old methadone, that has been around since the 1960s. I work in a methadone clinic. It is a great standby, but you have to get it in a clinic. Also finally, there is naltrexone. Whereas narcan quickly shoves an opiate molecule off the brain receptors, nlaltrexone is a blocker. It is sitting on the cell, and if an opiate molecule comes along it cannot bind. , if you were to get administered an opioid on top of it, it would have no effect. That is called naltrexone and has been around for at least two a few decades at least in the united states, before that in france. The pill is called revia and also comes as an ejection a monthly injection. Some jails in maryland have used that, and it has cut down on how many readmissions they have. They have injected inmates with medication with their permission , and it has worked to keep them drugfree. That is called the vivitrol. End of my presentation. Im going to ask some questions of these gentlemen, and then we going to have time for questions. Let me tell you how these questions are supposed to go. Ok. Then youead this and can ask these questions at any point although i will not get to them until we are finished and they appear on this device. It should all work, and if it doesnt, i will have to use live human beings. Ask you questions directly. So as i mentioned, i work in a gw, and inlinic near many ways, that is a Vantage Point from which i will ask most of these questions. I will start with newt may i call you newt . Mr. Gingrich yeah. May i call you joe . Ms. Satel yeah. You established opiate recovery in june. How did you come together . Mr. Gingrich it is an interesting story about how you can be bipartisan if you allow your interest in solutions, and patrick and i started back in 1999, 2000 period, we were very much into Electronic Health records. I remember the best single press conference we did, he and tim murphy, who is a republican who you know were hosting a press , conference and invited hillary to come. The amount of press who came to see hillary and me made just for the spectacle. It was a great event. We were working on those things. Since he was in congress, hes really taken a National Leadership role in Brain Science and in organizing an annual conference, and and invited me to speak. And so, theres a natural pattern there. Van and ime time, were doing crossfire. We were really coming down the road. Criminal Justice Reform in many ways overlaps with Mental Health and with addiction, because with the collapse of the mental hospital, the State Hospital systems, etc. , we often have jails in particular we may have , 40 of the inmates were really appropriately dealt with as Mental Health problems rather than as criminal problem. In most any case, you have a substantial number of inmates who have an addiction challenge. If youre going to get them back out into society, you have to have a strategy that deals with their addiction, otherwise you are simply putting them back on the streets somebody who is going to rapidly become a problem again. The three of us talked about it, that the place where you can have a in a society this this manys possible topics if youre going , to get attention for a general direction, you have to find something which is current and which people feel compelled with a sense of urgency. We have a general broad interest in Mental Health parity, i would describe it frankly as inclusion, the idea that your brain is actually part of your body, and that any Health Program that says heres your body, here is your brain is by definition wrong. That is a general thing we believe in. You are not going to get much coverage talking about that in general. But the tragedy of the addiction rates and the number of people dying from overdose involving opioids really in a number of places. In new hampshire, for example, it is the number one issue politically. It beats the economy, it beats terrorism. You name it. People are really frightened, because theyre seeing their children die, or they are saying seeing their brother or sister die. So we decided and there is a second part of this intersection one is to say here is a problem. The thing that drives you crazy is we have pretty solid evidence, and you may want to buys into it at some point because you are the technical expert up here, but we have pretty solid evidence that medication assisted recovery combined with cognitive retraining has a very high likelihood of succeeding, but it doesnt fit much of the medical professions tradition, and it doesnt fit many of the medical and state bureaucracies. And so, you have this moment in time where youre losing 47,000 people. You probably, in theory, could cut that by 45,000 lives a year if you had the right kind of sophisticated approach to this whole thing. And so, you see how many , times in your life can you find an issue where you might potentially affect half a Million People over a 10 or 12 year period . This is why we are talking about it, it attracts a level of attention that no one of us would get on our own. Ms. Satel right. Actually, that was one of my next questions. What can you do that other and other advocacy groups cannot . My other question was what are some of the agenda items . Mr. Jones first of all, i just wanted to say it is really good , to see this many people coming out. Many of us, we live in washington, d. C. , we deal with issues all the time. I think when you saw that graph, maybe just, let me back up here. The deaths, that is shocking. And those are not just little members up there. That is thousands and thousands of people who have died. Thats thousands and thousands andunerals, that is parents children. There is some external enemy that has figured out to kill this Many Americans a year, we wouldnt be able to have a room even this size. We would have a stadium full of people trying to figure out what are we going to do. So part of the reason i am here is because i have someone i was very close to who died and i did , not see it coming at all. I did not see the signs or the signals. I carry a lot of guilt about what could i have done . Luckily, i know newt well, and knew he was collaborating, so i was able to get myself added to the band. And happily so. What i will say is simply this. It turns out, this is completely unnecessary. It turns out that there are two strategies that could get this number way down. One is it is true people have to , change their minds. They have to have some willpower. They also, because of the way opioids work, have to change their brains back. This is a biological thing. Your brain is an organ, and once these doctors hand you these pills, this is about willpower, this is not about willpower this is not you are a bad person, you have organ damage. This is what the doctor gave you. The stigma and all of the theology and all the ideology that says this is addiction, suddenly we turn our brains off and dont look at evidence and dont look at facts and dont doctors help people. The people they have initially her. This can be changed. Hurt. This can be changed. This organization that we are a part of, we want go on the country and have meetings like this and create a situation where first of all, doctors stop overprescribing these opioids. If the doctor gives you something and you take it and your life falls apart, that is a bad sign. If you cant trust what a doctor hands you, that is bad. We want for the Insurance Companies to pay for and give the medicines that correct this. And we also want for the government to speed up these approvals, because there are a lot more drugs in the pipeline that could make a big difference. Lastly, we have the drug courts out there that have been doing a good job, but could be doing a better job. Opioidrecovery. Org and check that out. For me personally, a year ago, i was not thinking about this at all. It was not my radar screen at all. I did not think about addiction in any way except dont do drugs, and if you do drugs, get off of drugs, period. That was pretty straightforward in my view. My world got turned upside down like a lot of other peoples. Theres a lot more out there, and if we work together, we can do something about it. Ms. Satel patrick, i know your group commissioned a study on medicaid. Could you highlight some of the findings . Mr. Kennedy thank you. I appreciate this opportunity with good friends i greatly admire, and it is so impactful to hear speaker gingrich talk about how this needs to be treated like any other illness. It is so powerful when van jones talks about how you can think one thing one year and then have a totally different perspective after this is personally has personally affected you. The endgame here is we just want addiction treated like the disease that it is. That is the endgame. There are lots of things we can do today to help make that a reality so there arent as many people dying of overdose every year who are dying simply because of our neglect. Literally, it is taking time today to put in regulations. People are dying every day. Literally today, fda is sitting on the release of medication that can also augment what is available out there for people with opiate addiction. People are dying every 90 minutes. This is about a sense of urgency. And it is about the fact that as van said, if this were any other illness, they would be marching on washington right now and people would be throwing up their arms and sang what are you saying what are you doing about this . Instead, we get a bill passed and no funding. The regulations on implementation that are not forthcoming. We do not require Insurance Companies to disclose their medical management practices, which is the insidious way where they deny access to treatment for Mental Illness and addiction. So this is not about not knowing what to do. Youve got it. You could bury yourself in position papers, there are so many good ideas. It is about political will. And the reason we dont have political will is that we in our own lives are so ashamed of having these illnesses in our own personal lives or in our familys lives that we do not talk about. Guess what . If we cant talk about it in our own lives, how do we expect the government to talk about it for us . Unlike every other issue, there are not the advocates. Very rarely do you have someone puts their hand and say they are an opioid addict in recovery. Yes, addiction has affected my family, and it is an important issue to me and im going to vote on it, and im going to advocate for it. So, i am just so excited having worked in this for some time, to see the beginning of the advocacy part of this change, and, you know, being able to work with very public influence thought leaders like van and newt is a real honor for me. Ms. Satel thank you. Just a little mr. Gingrich we did a study of medicaid variation, which is amazing. It runs from, i think, it is 4 in mississippi to 68 in vermont, to give you a range. There are very wide ranges in how easy it is to get access, very wide ranges in what they will pay for. Almost no correlation of anybody stopping to say what is the outcome of that . This is a field i helped found a center for transmission welth transformation get involved in budgeting cycle is that dont have any kind of accumulation. You walk in and say we have a Medication Program that also has combined with it training so that people are both training their brain and at the same time they are reorganizing their brain medically. That costs x number of dollars. The legislature will say that we dont have that kind of money this year. So that person ends up maybe being a prisoner who doesnt fully recover, who ends up back in prison, so we pay 200 times as much money keeping them locked up as we would have paid. The prison money is over here and we have the prison money. The mental money is over here the Mental Health money is over here and we dont have the Mental Health money. We cannot figure out that doing the right interventions today we did a tv show today this morning and they had somebody on thereby remote from another town who 13 years ago had become a recovering addict. All of you this business know that you never recover, you are recovering. It is a lifetime journey. He talked about four times he d overdosed and four times , they brought him back. The fourth time, he finally got it. He went through the process, so he has now for 13 years held down a job, had a family, lived a full life as a citizen. How do you measure all of that . If you do it based on an annual budget, it is cheaper for them to die. Actually had a director of the budget tell me that that there is a real problem with People Living to long and it increases their costs. Too long and it increases their costs. And i said never ever go on television. What we discovered the study in this study every governor and every legislature should benchmark themselves against the medically appropriate standard, and ask themselves how many of their citizens are they willing to have die because they dont want to go to the appropriate modern system . The numbers on that are very striking. I may get them slightly wrong off the top of my head. But essentially, today, 80 of the people who want to be in recovery dont get treatment. Of the 20 who do get treatment, only 15 of the total population only 3 of the total population seeking treatment gets a medication based, sophisticated modern treatment. If i told you that about diabetes or cancer or about kidney disease, you would say that is outrageous, but because we have always had a lagging i think for very practical reasons worth thinking about for most of the last couple years, we have gained thousand more and more and more knowledge about every element of of the body except the brain. We have the capability now to watch living brains. Look at itould not because the brains we studied were dead. This model of theoretically trying to understand what might be happening in your head without really knowing. Now you have at the cuttingedge and sally knows about this these amazing breakthroughs, down to the level of study of synapses are doing which and neurons, its almost magic. It is understanding that the brain is integral the truth is, the brain is at the center, the center of who we are. For example depression is the , most common Single Health problem in america, and a surprising number of Health Problems are a direct function of depression. Now because we are only , beginning to enter the age of the brain, all of our Political Behavior and all of our bureaucratic behavior is still locked in an obsolete model that says i will spend anything to fix her cancer, but now this addiction problem you have, that is probably because you are a bad person, as opposed to, this addiction problem you have is a biological function of how your brain has been reorganized around a chemical interface. Perfect. Ms. Satel you are talking about differential treatment at the level of the hospital and clinic. It is true, even medicaid in its various obviously, by state there are duration limits on how long you could be treated, the dosage maximum, and preauthorization. So, this takes up so much physician time which is time they should be spending with patients. The good news, on that last front, good news on friday, the Big Insurance Company has now dropped its preauthorizations. This was under pressure from eric schneiderman, who is the attorney general of new york. So maybe there is a role for attorney general. Mr. Kennedy there is a huge role for attorney generals as consumers and Patient Advocates , we cannot get redress for the violations of the parity law, denials of care and the like. But if we join together, we can appeal these denials to the attorneys generals in the various states who are really Consumer Protection folks. They are protecting the contract law aspect of this. People are paying for insurance that are not getting the coverage that they are actually paying for. We feel this is going to be the most expeditious way to advance the implementation of the Mental Health parity. And addiction equity act. To this date, most think that we are going to get appeals one at a time. We all know the best someone can get is there care paid for, often when it is too late. A year or so later when all appeals finally you need to be a harvard phd jd to understand how to do these bureaucratic appeals, and the Insurance Industry knows it and are counting on that. We need to have a Public Movement that takes our grievances directly to the attorney general of each of these states and let the ag take on the Insurance Industry on our behalf as consumers. When you add up all these families i am seeing around the country, the speaker and van jones we are going to start a , consumer revolution in this country, and i hope the Insurance Industry knows what they are in for, because we are going to start taking these stories to them and require that they not only follow the law, but they take care of the people who are suffering from these brainrelated illnesses as they are required to by law. Ms. Satel van, for you. You mentioned drug court a while ago. Actually i worked at the d. C. , drug court a while ago. For those of you who were not familiar with the drug court, they kind of bring the medical and moral model together and in that these are for folks who have been arrested and put into a diversion type program. If you complete it, your record is expunged. So stick with it. What happens in a drug court is the participants go through a treatment program, and they also are monitored pretty heavily in that swift, certain, but not severe consequences are administered if someone misses an appointment with their counselor or does not show up for some appointment, or gives urine that is positive. But, as i said the consequences , are not severe. They may be one day of community , service. They do escalate with continued infractions. If there are continued infractions. That is behavior 101. You respond to some sort of event that you want to change behavior immediately. Mr. Gingrich by the way, sally, mr. Kennedy by the way, sally Airline Pilots and physicians , have recovery levels over a fiveyear. That is because they have accountability and a lot to lose. Ms. Satel but when i was doing it, that was the cocaine era, and there were no medications then. But now, with all of these medications, the drug courts and the criminal Justice Systems in general, we have clinics in bc. Every week, you go over the in d. C. Every week, you go over the patients and you say they are all in jail that happens a lot. In the d. C. Jail, they detox people. In virginia, they dont. Some jails even keep people on methadone, which is very constructive, because you lower your tolerance in jail and if you use again, that is a prescription for overdosing. I should be letting you speak. What is the potential for all of these medications that we mentioned earlier in the crystal Justice System . Know one of the , big myths about change is that change is about people learning new things, but honestly, most change happens when you unlearn the old things first. What is holding back a lot of this is an old way of looking at addiction, which we have touched on. The good old 12step model, the blue book, the idea that if you are addicted to something, it is because you have some moral failing and you need moral redemption. You have had a lapse of willpower and need to get your willpower together. You and a higher power working together can get you out of this. There is deep truth in that and people who can give testimony about the power of that approach. The challenge is, 50 years later, 60 years later, when you are not merely talking about alcohol but these very complex substances, it just turns out is passed. On the others that is about half. On the other side, until we get to the point where we see the biological side of it as shame free, stigmafree so that we , can act intelligently, we are going to continue to stumble. I remember back in the 1980s aids crisis,v the government, we knew that this was a medical emergency, millions of people affected, but there was a slowness to response. Public concerns were going up, up, up but there was a stigma , associated with hiv and aids that was rooted in homophobia primarily, but also just a lot fear and ignorance. And the lad time lag time killed millions of people. Finally, we said enough is enough and people of all races and genders, from both sides of the aisle, said that america has to do better. Pressure was applied and the fda and other and now hiv is , considered a chronic condition. There is medication available. There is certainly, nobody wants to have hiv, but it is nowhere near the way that it was. That is the pathway we have to unlearn a whole bunch of stuff in order to just treat this just like a disease. Treat hiv like a disease without all of the stigma. We are to have to have the same approach now. Addiction, your children, your grandchildren, are being thrown out into a world where people apparently are bringing elephant tranquilizers to parties. That is not the world i drop in, that is not the world you grew up in, but that is the world now. In that kind of a world and frankly, kids are going into your medicine cabinet and taking your leftover vicodin and Everything Else from your last dental surgery and taking that to parties, too. In that kind of a world where we brains andkids dubbing them into these students of chemicals and opiates that can really change their brains, we have got to have a different approach. You talk about the criminal Justice System. Theres similarly up until very , recently, it was if you do something bad you should go to , jail. If you break the rules, you should go to prison. A bad ideait is because what happens is so many people have gone to prison that the stigma of going to prison in some communities is not even there anymore. 11 prison so many people. You look at prison, and it turns out a lot of people in their have Mental Health issues at addiction issues, so you have not solved the underlying issue you have just spent a lot of , money hurting people who are already hurt. My hope is Going Forward that the criminal Justice System can start being data driven, evidencebased, outcome oriented. I would love to see wardens get and i was talking to newt about this i would love to see wardens get paid based on how well the people in their custody do when they leave. See right now, you get paid , based on how many come in the front door and stay with you. And if 20 more come you get more , money. If they come in with their best friends, you get more money. That is a bad business model. I would rather wardens get paid based on people are there, i gave good care, i dont with Mental Health issues, they did i did well with Mental Health issues, they did well. Its the outcome oriented. We have to rethink these systems. We have the technology to do so, the Brain Science to do so we , have to have the political will to do so. Ms. Satel we can go back. I think this is kind of a challenging question. This scenario in some places takes place with the same person athat guy, maybe 10 times in threemonth period. A lot of sheriffs and a lot of one state senator from new york in particular is , so concerned about this, that he is thinking or perhaps has introduced legislation that would say pretty much if there is a consistent pattern of overdosing, someone has to step in. Because you mentioned someone overdosed four times. Well it could have been he never , got to four after three. Again, they are seeing, seven or eight or nine. What the stateso senator is considering, and i must say, as someone who has worked in all the criminal justice and treatment elements of this, there is something to this. He is thinking about arresting for possession, but diverting to drug courts, diverting to treat ment so that that is what these people get, not going to jail. It is a more paternalistic, aggressive strategy that one would not use with a regular, what we call medical disease. Kind ofthis seems reasonable or at least something to think about. I would like to know how you see it. Mr. Gingrich well, i got into a lot of trouble when i first became speaker. Ive been influenced by someone who had been a member of congress and secretary of labor, and she had been in new york city dealing with drug addiction and she had described a woman who was an addict, and her boyfriend was an addict, and her boyfriend had abused her threeyearold but the , threeyearold had been returned because the presumption was that the mother was the best place. And then the boyfriend got mad , one evening and killed her. The question is, what do you do when youre faced with this . And i said very unwisely that we might have to seriously look at taking children in those kinds of circumstances and putting them in orphanages. And of course the left went wants to said gingrich rip children away from their mothers. [laughter] mr. Gingrich that i forgot to go on the tnt and introduce boys down. What is said later was that we need prep schools for the poor. If you are rich and you send little sammy to the prep school, nobody thinks that is an abuse. But if you are a three or four or fiveyearold, in danger of your life, we dont have any good models any foster care system. Now we come to this example. I am deeply antiaddictive drug use, and i am deeply antiaddictive drug use because i believe in freedom. If you are an addict, you have given up your free will. So i start with a very strong bias. I dont have a great deal of sympathy for the civil libertarian argument that youre right to be saved 10 times in a your right to be saved 10 times in a row means that the rest of us have to pay for the ambulance to come once again to save you at the last possible second until the time we dont get there and you die. It does strike me that there has to be some ability to look at patterns of behavior and you could make a cautionary argument that, ok, you overdose once, that is a sign that you are truly stupid and we will give you a pass. But if you overdosed twice, at that point, you clearly are out of control of your life, and therefore, we have an obligation as a society to help you get back into control of your life so you can go back to being free. Now that is coercion. This is a very serious national and iue we have to have very cautious about it because am of some of the issues we have had with Homeless People. I mean there are a significant , number of Homeless People who are homeless because they want to be. Those of you who drive over by Union Station know that there is a homeless shelter, and for most of the year, if you drive by there youll see some are , between 10 and 30 people who are sleeping on the street outside the shelter. They go to the shelter to eat and then they go back outside , because they dont want to be in the shelter. They dont want to be controlled by anybody. Now, it makes you uncomfortable, but on the other hand, if you believe that as long as they are in control of their life and making a decision to be kind of goofy, i favor their freedom to be goofy. A person who shows up like this to bring, 3 2, 3, 4, five times, they have lost control of their life. This person has lost control of their life. This person is relying on society at large to save them. I think we owe them more in and this goes back to the point about the brain we have to do enough that they can stand up to their brain that is still addicted. It will go back and overdose again. I would favor states exploring again, i keep this at the state level, because we need experimentation, not some federal law that is totally out of touch with reality we need local communities to figure out when they could get people to return to society as a complete person capable of being free. That is my bias. Mr. Kennedy you know i see it , slightly differently in that i just dont have a good answer. I will say my bias. Mr. Jones my bias is that we should do what works, and if a coercive model does not work, if a coercive model is telling somebody that you are going to have to get clean right now on a government timetable because we are sick of you, if that does not work and makes things worse and drives people underground it makes people less blood to call less likely to call for help. We need to be attentive to that. But newt and i actually share some biases as well, and that i am 1000 against the use of addictive drugs. I grew up in a family in which all the men in my family are incredibly hard workers, but at least until me, hard workers, hard smokers, and hard drinkers. They wound up, all of them, with good lives, good middleclass lives my dad was a cop, in the military, and became an educator but also impacted by alcohol. And my father actually also died of lung cancer. I made the decision when i was young that i was not going to drink or smoke. I can say at 48 years old, i have never had a beer never had , a sip of alcohol. Im extremist in all regards. So for me, i look at any addictive behavior with some real horror, because i know my own family shows a very strong pattern of that. And so, i am not i live in california but i am not one prodrugs, drums our freedom, no, to me drugs or slavery. They are the opposite of freedom in every way. My life is bad but i like my drugs, why not you stick your your life . Fix your life . In that regard i think we are , similar. I just worry that if you get overly coercive, you have unintended consequences. Ms. Satel can i say the next question . Bout 10 have a minutes. My plan was to ask this one last question, which is another tough one, but follows along. And then, as one of you to just sum up. There is a lot of talk, and i certainly understand it, about you know reducing stigma. , sometimes i wonder, and others have wondered, in a way, how realistic that is. I am thinking of that photo that went viral last month in ohio, these two adults who were overdosed in their car with a fouryearold in the back and it was the grandson of the woman. The two adults were arrested for child endangering. You know, the way the debate has been set up as i watched it, and not as presented by you, but just by watching in general, is that we have brain disease on one side and moral failing on the other. No one wants to get on that team, the moral failings i, i dont want to. Failing side, i dont want to. When you say brain disease, what that conjures up in many peoples mind is that the behavior is completely involuntary, completely hence no , responsibility at all. People take responsibility all the time. Patients coming to our clinic all the time because the wife is going to leave them, because consequence just got so much. It is a little more complicated than just having epilepsy or multiple sclerosis where, if i put you in a drug court with some sanctions, if you dont keep this appointment, i am going to you would not respond. That is autonomous, it does not respond to consequences but , addiction can. I guess the way i would sum up that question is, is there a way to can social disapproval of addiction im not talking about individuals. I know everyone knows this is suffering and that my personal areas of the selfmedication for misery but the point being that social disapproval of addiction coexisting with compassion and greater access to treatment. That is my question. Mothers against drunk drivers has made great progress with stigmatizing drunk driving. Mr. Kennedy sally i think you , after how we frame this issue. We have not made the progress we would like to make racism anding bigotry and prejudice in this country, but with the 1964 Civil Rights Act 1965 Voting Rights , act and fair housing and employment, we had done our job to try to outlaw discrimination. So no matter what you think you , just cannot act in a discriminatory way. Wet is my view as to how do move this forward on making sure we get people treated. We are going to still be arguing, is this a moral failing or medical failing in another 10 or 15 years. I wish i could say i had greater faith that we overcome our biases and prejudices, and all of a sudden that would mean , Insurance Companies would pay and we would fund and treat is equally and integrate it with the rest of medicine. I dont think that is going to happen. I think we need to enforce the law, and i think we need that we need that and i think we need that moment of clarity that those of us who have been suffering from addiction and have had some chance to get some sobriety have faced. And as society, we need a moment of clarity. We have, you know 47,000 people , dying of overdose, we have 42,000 taking their own lives every year. This is a Public Health epidemic. It is like hello, where is our response . We are collectively stuck in a time warp, where we are not understanding that we can do something about this. To your frame, i think we get away from having these debates and get about actually enforcing the law. If we enforce the law, more people will get treatment. Mr. Jones i want to be clear about that because i dont think people are as smart as you want us to be. Just say one more time the law you want us to enforce and why that would make everything different. Mr. Kennedy the law i want to force is the Mental Health parity act that says the brain is part of the body. You treat illnesses of the brain the same as other illnesses. Inpatients, in network, outofnetwork, outpatient. At the primary care, secondary and tertiary levels of care. In other words, the whole spectrum. Today, we only treat addiction stagee for illness four illness. How do we address that gentleman who needed it four times . You wouldnt in the future let that person get that are because they would have grown up in a household where you would have known their parents had addiction, depression, anxiety. You would have known they had exposure to violence, deprivation, other causes of trauma, and you would know that they ran a higher risk so we can personalize medicine to them. The future is avoiding having to use the medicine because we are waiting too long. That is not the paradigm we should be thinking about. The paradigm is not how were going to have more advanced directives and source of treatment, although i know today, having been guarded to my there is a nearterm reality. Mind, we moved upstream into the problem as stage one illness or people who are at risk for the illness and then you wrap it around. To your point, you are risk for this and your family, you had no help from your medical system, intervening and same tell us about your Family History of our tolerance and addiction. You made in your personal we in the future need medical consulting to say, like cardiovascular disease and like cancer, what are you at risk of . Let me see what i can do to curb the chances of getting cancer or having addiction. If i have that on my medical record, he guess we should not be treating this as a separate from medical care, which is what we do is keep them all separate, we have a chance of changing the course of the illnesses to the benefit of our criminal Justice System, our health care system, the whole country we live in today. Ms. Satel ok. That is great. Thank you so much. [applause] ms. Satel no wonder i couldnt see they are on here. Ok. Here is a question. Until about 4 50 and it is about 4 30 now. Asks, when parents are able to get into treatment programs of their kids two thirds of them complete the program. Shouldnt such programs be prioritized . I would just answer that and say yes. Im sure you all agree. Those kinds of treatment programs are excellent. They are expensive. There are not enough of them. Insurance is complaining about all these rogue rehabilitation places that dry you out, send you out and you are relapsing in no time. Then put more evidencebased yourment programs in network, mr. Insurance program. Right now, my fellows can get access to treatment in your narrow network. You cannot complain about how we hangthese flybynight, your shingle out and say you are for recovery when all youre doing is collecting the insurance premium. Until you help us pay for what really works, you will be stuck paying for what doesnt work, which is the problem. Mr. Gingrich let me at an example of a Brilliant Program was createdhat under mary a cuomo. It was founded by former social workers. They contract with the state and they only get paid if the person that they help is still on the job six months later. You arent insurance contractor in this thing, you say, we will pay you a base rate but you do not get a bonus unless the person is still drugfree a year later. You build in a huge incentive. This worked brilliantly. It is still around and doing great job. They may be the best program at taking hardcore Unemployed People and moving them into jobs because everybody at America Works gets the bonus when they are at work six months later. Mr. Kennedy the problem there is that there is not any continuity. In patient,eone they refer, there is no connection to the outpatient, and we wonder why people fall through the cracks. They are in the er and are revived in get no aftercare. Basically youre talking about incentives. When we talk about drugs we are talking about sanctions and negative consequences, but positive are extremely helpful. There is literature that is called on what is called contingency management. The better they do they get rewards or more freedom, they dont have to report as often. In some cases, Johns Hopkins had an Interesting Program where people who were unemployed, but the better they did, the more they allow them to work in the workshop. They had wonderful results. These are expensive programs. They can be hard to replicate in gardenvariety programs, but they can work very well. We use them in the methadone clinic. It is a strategy that is important. Here is a question from a Real Clear Health editor. Isnt there a risk for addiction itself . One mr. Gingrich the longterm goal would be to help the person initially be able to cope with the physiological effects of the brain having been rewired and then over time so through the process of cognitive change and eventually be weaned off. The Current System where we detox you and think you will be ok, is proven to be a guaranteed failure. I would like to live in a world where nobody was addicted and Nobody Needed this kind of help, but that world does not exist. The question is, can you find the medication support that enables you to then go through what may be a several year process. It may not be a six weeks or six month process. Ms. Satel the medication is stabilizing. You have to actively participate. That is why it is so hard for private practitioners to prescribe. They dont have that kind of backup. Mr. Kennedy the state of massachusetts adopted this mandatory coverage for twoweek detox. You will see death rates rise in massachusetts. In other words, the science is not guiding the policymaking. It is happening all over the country. At the height of this crisis, we are not following what the science tells us to do. We have another issue here of Global Warming and we dont appreciate it. Mr. Johnson for those of us who were just thrown into this world , we think, if we had more detox centers, people could go and get detox and then they could go and get phds and everything would be fine. You just need those couple of weeks. It turns out that is not true. In fact, people are at great risk. People are at very great risk. After a nor can shot, their brain has begun to heal a little bit and rewire a little bit, and yet, there they are back out there in the world and dont have aftercare or any other medicine that they can rely on. What tends to happen people too often is they go back and they say what was i relying on before and they take that same dosage that before got them high and that same dosage now gets them dead. Detox turns out to be a rgue. Gboard into the mo we are not paying attention to the science. We have these theologies around 12 steps, but it turns out in a lot of these things, there is a 13th step. That is getting some medical support. This question is from alex. Do you have any policies solutions you can offer to state legislators looking to respond . We have toh appreciate the Multiplier Effect this has on when someone is ill s mr. Kennedy and it has been a reduction of their disability. I think what we saw in miamidade with the judge that reengineered the system to in the devise stable housing, peer support, medication assisted treatment. Recidivism has plummeted. And the county has more money. And people are doing better. It is like the trifecta. What do we do . We dont have that model easily replicable because no one is going around the country saying, here is the stepbystep changed. O get this the aei of think p for producing a road these state legislators. We need that roadmap and it needs to be available so they know what to do in order to make a difference in this issue. As an argument for optimism, you actually do see a wave going across the country of criminal Justice Reform that is having a positive impact. People who are not violent criminals or a danger to society are being reintegrated back into society. A lot of it has been places you would not expect. Georgia has been a leader, texas, south carolina, mississippi. A lot of places stopped and said, what were doing is crazy and it is breaking up communities by taking people who were not violent and turning them into criminals and taking them out of the community. The result has been encouraging. In that sense, if you can have a wave of examples like you just gave, you might well find a lot of state legislatures in the next few years who are prepared to do those kinds of changes in medicaid in particular that could be very powerful. Ms. Satel somehow i think ive run out of russians on that. Run out of questions on that. Please stand up. The v. A. . With does someone have a microphone . Sorry about that. This is a huge problem among veterans, suicide is related to homelessness. Veterans can also show us the way to cure the problem. Is, i want tong ask a question. You talk a lot about the hyper moralistic attitude about addiction. But there is a significant percentage of the population that does not feel that way and feels very differently about this. There is no communication. Like so many other things in our society. I think this is an issue. This is an issue that we need the kind of dialogue somehow between those who feel as you do , that this is a medical problem with medical solutions. Who still feel it is a moral issue. I dont agree with anything you said. I think veterans are probably one of the centers of concern because of the combination of different impacts on their lives and because were worrying about the suicide and addiction rate. At the same time, i am not quite sure how one has a dialogue. The point we were in terms of addiction, and i would be happy to have a debate about this whotime, we have somebody was just pointed out who is in their 10th recovery from overdose. I am fairly comfortable saying thats bad. Maybe there is some really somebody who wants to say that morally exclusive experience and we shouldnt prejudge it. There is a difference between addictive drugs that take control of your life. There are certain things you take that rewire your brain. It is not like you are Walking Around saying you will make this choice, your brain is telling you that the choice has been made because you have been rewired and you have a genuine , desperate hunger. My version of being free does not mean being free except for your brain. I do think we need to have a national dialogue. , ias going to go back thought pattern did a beautiful job of saying it. Im very prepared to be very hostile to the idea of becoming addicted while at the same time being very sympathetic and open to a person who is trying to deal with their addiction. I want to encourage some buddy who is addicted to feel they can have at and say they problem. But at the same time, i want discourage my grandchildren from thinking it is an acceptable gamble to see whether or not they would become addicts. I think that would be a horrible thing to happen. That is my bias. Mr. Johnson this is some of the hardest stuff. What is the right mix of carrots and sticks . What i most appreciate about your interventions, patrick, is to try to help us think about it afresh. As a parent, as a grandparent, i dont think any of us are ever going to be convinced that being enslaved to addiction is a good outcome. That is something i will fight to keep my children safe from. Ofthe same time, coming out the society we have lived in that is so judgmental and so lacking in empathy, as you pointed out, there is some real learning that we have to do. We are missing something. There is some new place we have to arrive at where we want people to live full lives and we are willing to fight for that, and at the same time we causaligning the right factors in genetics and medicine. We cannot escape it. This will get bigger and bigger. We are being dragged into a different conversation. I cant tell you how much i appreciate both of you. Years of1520 bipartisan cooperation on this. This is the one issue that when you guys had your primary as last time, and i saw your protege john kasich with tears in his eyes going around in new hampshire. And it wasnt from the point of view of anything but hurt and concern and a desire to help people, i said that opens all whole different door to bipartisan cooperation. Ofeel good about the opening his being created, but i dont feel strong yet in all of the concepts and the right way to get there. Mr. Kennedy you pointed out veterans. Four times more likely to die of opiate overdose. Big challenges here. But they are not only dealing with the v. A. And trying to access care. Most of them get their health care through their employersponsored health care. We need to make sure that the parity is out there for our patriots, because if they encounter their own networks through their employer and cannot get treatment for their signature wounds of war, ptsd, thats on all of us. After the phoenix v. A. Started theerans weight we carry, and they monitor v. A. s around the country and how long it took for them to get their disability claims adjusted. We need to do the same for private insurance. We are partnering to get civilian soldiers to report when they cannot get access to their etna, united, cigna insurance. So that we can tell the Insurance Industry, you are not just denying the runofthemill person, you are denying those who served our country. That should get their attention. There is a certain moral hazard to the Insurance Company continuing to deny treatment and the way they would not do for any other illness. I appreciate you bringing that up and thank you for all you have done for our nation. Ms. Satel we have to end now. I apologize. I wanted to thank all of you, your comments about bipartisan is him are a great note to end on. [applause] tomorrow, a discussion on how a partnership between the Treasury Department and the president s emergency plan for aid relief could support foreign ministries in the fight against hiveights. At 10 30ave that lives a. M. Eastern on cspan. Results challenges in wisconsin, michigan and pennsylvania in the future of the Democratic Party were among the topics discussed on the sunday news shows today. We have collins from kellyanne conway, Bernie Sanders and tim nancywho is challenging losey is House Democratic leader. Why in the world cant the democrats accept the election results. All they did was ask people like if we wouldrump accept the election results. Why did mr. Trump say he would keep us in suspense, and now you have Hillary Clinton who on Election Night called donald trump to congratulate him and concede the election to him . I was right there. I did not hear him say, she conceded, that in less 2. 5 from now jill stein decides she should issue a recount in wisconsin. Jill stein got 33,000 votes in wisconsin, mr. Trump got 33 million e. It is not a serious effort to change the election results. The question to democrats is, why are you doing this . What does president obama think of this . He has eight weeks left to finish out his term. I think it is quite small of jill stein and Hillary Clintons council and perhaps her to interfere with president obamas legacy. President obama and president elect trump speak regularly. It is high time the hillary and herself orders and her supporters did the same. Democrats must focus on the realities of where we are. Are they wrong to do this recount and question the results . I trust youers know it was initiated by the green party. But Hillary Clinton has joined in. Senator sanders of course they have. It is a legal right, is not a big deal. Anil think anybody is it will have profound changes. Has got toight now be doing everything we can to address the real issues facing the working families of this country. What will change in the Democratic Party and is a time for the clintons to move on . Well have tos make this personal. Linton hasc served this country for 35 years. I think the real issue facing thatemocratic party is they are not in a good place. It is not just the white house. Im trying to revitalize a Democratic Party, bring in the end people and working people, the come less dependent on big money. Campaign contributors have tried to help, but they cannot be the dominant force. We have to open the doors. We have to go through 50 states in this country. Weve got to figure out how to have the robust economic message. These people left us in droves. Without a good message that connects deeply with them, issues that they talk about an care about, they are never going to come back. We need a leader who can go into those congressional districts and be able to pull voters back and energize the voters we need to show up at the polls. Maybe you are trying to build your profile, but you dont have a chance of beating nancy pelosi. She says two thirds of the caucasus signed up to vote. That is notve ryan the numbers we have feared i think we have a shot to win. People have been home with their families over thanksgiving and people are saying, look, this has been a change election, we want change. There are a lot of members of congress who are not understanding we need to make a change. We cannot keep running the same place. Winners win and we need to put leaders in place will give us an opportunity to win the house act. We have the smallest number in our caucus since 19. 9. We have to do something differently. Monday night on the communicator. I hope it will come with a requirement for some kind of framework for putting data in a central repository people can have access to it, where can be searched not only on an item by item basis but a scale basis. We run through 2. 5 million songs and were going to get more every day. Onpandora general counsel the music industry, copyright laws, ticket Price Inflation and the competition between humans and bots. He is interviewed by the Technology Reporter for politico. Bots buy tickets, but what they do is they keep other fans out of the market. What were finding is that some fans really want to go see a concert, and they can match the buttons on their computer all day long, but you cannot beat a bot. Theyre not able to get tickets in their first run at the list price. They are left with only the opportunity of buying those tickets on the secondary market after the bots have passed them to promoters who raise the prices. Communicators on cspan two. Q a with Edward Larson on his book. Then, theresa may takes pressure questions from the house of commons. This week on q a, professor Edward J Larson discusses his new book, George Washington, nationalist. Edward j larson, author of George Washington, nationalist George Washington was here today and could see the full run of this campaign, no matter who th