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We a a vy miarit thhun llf e idic w talked about. The number of opioid related deaths continue to rise. Over 33,000 this past year. To the risk of overdose the end of opioids can have other negative effects including an increased risk for cardiovascular events touches heart attacks, increased risk for acquiring hiv and hepatitis c from people using iv drugs. It was a drugs cost of the United States around 193 billion every year, largely related to lost productivity and interactions with the criminal system. We cant and shouldnt ignore the impact on children either. Many officials have made a direct connection between the rise of use of opioids and the rise of number of children in foster care. Addressing the Opioid Epidemic was not challenging enough, we now face the added difficulty of the high potency of fentanyl,oids carfentanyl, and the designer drug known as pink. The deaths from heroin and synthetic opioids last year rose 20 and 70 respectively. Any effort to reduce the use of synthetic opioids requires a comprehensive approach to pursue upstream solutions wherever possible. Most people with Substance Abuse disorder do not start out wanting to use these substances. Userout of five heroin started using prescriptive pain relievers prior to heroin. One approach is using narcan, which saves lives by reversing overdoses. But at its core, Substance Abuse disorder is a treatable, similar toease diabetes. Medication assisted treatments or m. A. T. Is the most effective therapy for Substance Abuse disorder, whether the verse and is dependent on heroin, fentanyl, any combination of these drugs. Result, the same treatment approaches will be effective, regardless of which opioids someone has used. The fda has approved three. Ifferent treatments the right medication and the right approach may vary for each individual patient. These drugs are taken by patients daily, monthly, or sometimes every six months in conjunction with behavioral therapy. Behavioral therapy can include individual or group counseling, cognitive behavioral therapy, and other interventions. Extensive research has really borne out the benefits and the efficacy of m. A. T. Of overdosehe risk and death, reduces the risk of overdose, and allows people to return to the workforce. Studies have shown every dollar of treatment returns at least seven dollars or more, according to conservative estimates. But only 10 of people with Substance Abuse disorder receive any type ofreceived therapy in 2015. Imagine if people with diabetes or high Blood Pressure received that amount of care. We know this is a Public Health crisis. What are the solutions . Magic bullets, but congress has taken actions already. Specifically, i would like to thank congress for, first of all, passage of the conference of Addiction Recovery act or cara. Cara advances new policies around prevention and treatment such as new and enhanced grant programming. Second, the recent appropriation of 500 million. Money is provided directly to states to strengthen prevention programming at the state and local level. We would like to recognize another opportunity for congress to spring to take action by appropriately additional 500 million for prevention and authorizedhat were in 21st century cures. There are Additional Solutions that will make a difference in addressing the opioid crisis. These three strategies include first of all, enhancing approaches that address prevention and Harm Reduction. Ensuring access to nonpharmacologic methods of treating pain, coupled with provider education and reducing unnecessary prescribing, Prescription Drug monitoring programs can help providers within a five patients at particular risk. Another important Harm Reduction practice is improving access to opioidoid reversal overdose reversal drug. We should have a system where people who want and need treatment can get it without coverage restrictions or delays. Coverage is a critical part of access. Around one third of individuals who felt the need for treatment for Substance Abuse disorder in 2015, but did not receive it cited a lakh of Insurance Coverage and inability to afford the cost as a reason. Optimizing access to existing programs, such as medicaid, is especially vital. 20 of adults on medicaid have a Substance Abuse disorder. Among people under treatment in new jersey, twice as many had medicaid as private insurance. We must also have integrated medical and Behavioral Health care. More providers willing to treat people with Substance Abuse disorder. Increased uptake of proven and effective models. An additional social services. And we need to reach people when they will be receptive to treatment, such as when they are in the emergency room due to an due to an overdose. Third, we need to reduce stigma around Substance Abuse disorders and treatment. Aware ofers must be the problem and evidencebased solutions to address the problem and a neck changes. Representatives kuster. R and kuster we look forward to working with you in your colleagues. Rep. Macarthur thank you. Dr. Marsh . Dr. Marsh thank you for including me in this bipartisan test force briefing today. Im pleased to have the opportunity to contribute as we importantthis very issue for nation. Im a medical professor at Dartmouth College in New Hampshire and i have had the research of conducting with a particular focus on opioid disorders for a couple decades. Today im going to tell you about a study we have the opportunity to conduct with the support of the National Institutes on drug abuse. New hampshire has had the secondhighest rate of opioid overdoses for capita and actually is number one for overdoses of fentanyl, fentanyl related deaths in the last couple of years, and an increase of almost extinct hundred percent in fentanyl related deaths in the last five years. This particular study was conducted under the National DrugEarly Warning system initiative, an agreement supportd by nida to factors giving rise to this crisis in New Hampshire. In a research at dartmouth and a resurgent dartmouth has and our research at dartmouth has networks to enable us to do this quickly. We did this in just three months. Witharted this project meetings with about 45 different stakeholders in the state, including prevention and treatment experts and the state opioid authority, medical examiners office, Health Providers across the state. The last three months, we did intensive interviews with 75 active fentanyl users, as well as 36 emergency medical ,ersonnel, fire, Police EmergencyFirst Responders, as well as physicians and other providers in Emergency Departments. And we just completed Data Collection for this study this past friday. We have seen a number of patterns in our preliminary results that really underscore a confluence of factors that seem to be giving rise to what we are observing in the state of New Hampshire. Users that we interviewed reported that fentanyl hit the market in New Hampshire in a substantial way a couple years ago, particularly in the southern part of the state. This was also the time heroin became somewhat more inaccessible in the region. We see that fentanyl is often althoughh heroin, sometimes it is sold as a soul product. Often users do not know the composition of the product they consume. It was mucheported less expensive and much more potent, so it has a real economic advantage relative to heroin. Although we do have some users report they are accidentally getting fentanyl, we find that some are purposefully seeking out fentanyl as the preferred drug of choice. Users also report that given the potency, you do not have to carry as much on your person or you can take smaller quantities with you, so it easier to avoid detection. Also users report the high from fentanyl does not last as long as the high from heroin. More often,to use which may increase your chances of overdosing, but also increase your chances of infection from drug use. Everything one of the 75 users we interviewed reported having observed at least one in typically more than one overdose. We had one young woman who said in the past two months she obtained 20 to 25 overdoses, including her own mother, who died from an overdose, her brother, who overdosed 17 times in a matter of a month and is now incarcerated, and her own personal use of fentanyl persists. High availability of this highly potent drug in a context in which the access to prevention and treatment resources is limited. New hampshire has the Second Lowest treatment capacity in the nation. We know of the treatment offered, it does not always include evidencebased approaches, including medication assisted treatment. One example of that is New Hampshire has the lowest rate of medication available to it does not have any Needle Exchange programs. Users consistently cite the lakh of prevention resources in the state are perpetuating the opioid phenomena in in the state and some report driving to other states just get access to clean drug paraphernalia. Emergency personnel reported a opioid related diseases, and they say it is not unusual to see the same person come in two or three times the same day. They revive them, and they come back to the ed multiple times in the same day. One of the most compelling things we heard from ed personnel and First Responders is they feel like they have little to no options for linking these folks to care. Episode andhe acute there is the continual cycling of these folks in and out of the care facility. We also have many reports from medical personnel reporting spikes in significant medical applications from injections. For example, a cardiac surgeon recently contacted me and reported they have seen a dramatic spike in valve replacements from Infective Endocarditis heavily among young injection drug users, who often continue to inject after their openheart surgeries. He contacted me asking if someone could help 100 cardiac surgeons understand what addiction is and how can they link these people do care and not just perform this very costly and acute medical procedure. Fentanyl crisis in New Hampshire is occurring in a rural state, and what we hear from folks we interview is, one, they do not feel like there are a lot of other things to do, other opportunities, but we also reports a very tight social networks, which may lead to greater spread of use on long communities. I think together, these data really underscore messages we have heard on the panel here today, which is the importance of evidencebased such as the medical complications, the infection and exorbitant costs of the services. I think that these data also emphasizes the strong need for accessfective models for to integrated care approaches. This is a theme we have heard today, integrating approaches so we can coordinate efforts among Emergency Departments and First Responders and criminal justice systems. Emergency department providers and cardiac surgeons, they want linkages to services to get these patients help. The criminal justice systems want links to effective treatment resources to help prevent relapse and support recovery. It is clear from the discussion today that this is a time of considerable need and unprecedented opportunity for us to expand Implementation Research and really understand the best ways to engage this very Broad Network of stakeholders and systems in Effective Solutions to tackle this crisis we are experiencing as a nation. In closing, i would like to thank the many men and women who participated in this study and the tremendous insights they have provided. I would like to thank the American Psychological association for supporting my participation in this meeting and thank you again to the task force, the opportunity to participate in this briefing. Thank you. Thank you and thank all of you. In the interest of trying to give everyone up here a chance to ask questions, we are not running a clock. But i will ask each member and the four of you in your responses to try to be brief, so hopefully we can get to each person. I will yield my question time for now and ask representative mann if you would like to start. Grateful for your participation. I should really say, your commitment to this professionally and we are all in awe i think of the challenge that we face. I come to this with over 20 years as a prosecutor and that we saw the heroin issue and the cocaine, but that was the tip. Fentanyl is a new degree. One of the things i hear time and time again, and dr. Rising, i think you spoke to this a little bit, is when we confront the families who are looking at this issue, and they dont know where to go for help, and they are struggling with the sense of education. You spent your time talking about education and how to effectively do prevention or other kinds of things that might make a difference. And we are talking about the science here, the science, which can give people a better understanding. I am not sure whether you told me that this was a bridge to a solution, or whether it was simply a solution and treatment unto itself. Can you talk to me a little bit about what we should be doing in the community, who should be doing it, how we can connect people to better understand the science and have an impact on the issue . I would be happy to and thank you for the question. I am happy to see what thoughts my fellow panelists might have. I think we are to some degree, although the Opioid Epidemic is not particularly new, i think we are in the beginning stages of understanding the longterm treatment needs that are associated with the Opioid Epidemic and more research will be needed on that to understand the length of time for therapies in the right ways to be engaging different people in those therapies. I think the evidence does show that the best time to be engaging people who have Substance Use disorder is in the middle, of some degree, a crisis. That is when they are showing up in the emergency room. Something has happened to a family member. Something is really calling the question. There are a number of programs that have taken that approach. Theres one program in rhode e. D. , called angechor which connects people in the emergency room with ppeeer support counselors. They found a fantastic response rate. About 80 of people who they engage in the emergency room continue on with treatment, which is an extremely high rate. Clearly, the interventions need to happen at all points of care. Providers need to be equipped and they need to have data that will really help them understand which of their patients are most at risk and what might be effective strategies. Weve talked to about Emergency Rooms and ems providers. I think another challenge is that often local Public Health officials may not have some of the data they need to help get their arms around what is happening in their community. I do think there are opportunities to integrate some of the streams of data that might right now exist in desperate places. Description drug monitoring programs, insurers and payers might have information. E. D. s might have other information. Figuring out ways to integrate these sources and really kind of do that hot spot research in order to really understand what is happening right now is particularly important. Thank you. I will make this one quick follow up. Dr. Marsh, you talked about integrated services. Does that include what dr. Rising was talking about . Or is there some other characterization of integrated services . I think it includes what he was speaking about. And i was speaking about just how we have so many people trying to respond to the crisis, so many systems and stakeholders. We could have greater efficiency with coordinating care and providing this cycling through acute care, and linking criminal justice and Emergency Departments. Even our schools. You were speaking about the science. Would you answer, are there privacy issues . Hippa considerations . Those are considerations. But they are addressable considerations. I would like to say one more comment. How do we best understand the science . To unscore something the doctor said earlier is the importance of prevention and starting with our youth. We have had an opportunity to talk with many young people who have gotten involved with opioids and we found there are still many misconceptions about the risk of these substances and even distinct perceptions relative to other illicit drugs. Parents dont care as much if you are caught with pills or thinking they are not addictive because a physician described these. And then we see this trajectory we are talking about today that could lead to use, experimentation, and transition to heroin and synthetic opioids. As we think about science, there is a spectrum from prevention to recovery support. Its critical. I yield back. If i may, just one point on treatment because they do want to highlight it. In the treatment, we need to understand that addiction is a chronic disease and that changes in the brain produced by drugs, versus months or years after the person stops taking it. For treatment to be effective, they have to be focused on the chronic model of treatment, which actually leads to a letter patients, or practitioners, to say treatment do not work because the patient relapses. But it is a chronic disease and the concept of relapse is part of the condition itself. I think this is important to highlight, not to create false expectations. We dont cure. We treat. Its not like an antibiotic. You take the antibiotic and its gone. This has to be persistent treatment. Thank you. Representative kuster . Im going to yield to my colleague. Thank you. Sothank you and thank you much for pointing that out, how important it is. First of all, to my colleagues up here for continuing into next congress, keeping this in the forefront. 52,000 people a year die from the disease of addiction. That is more than all the that have killed americans in the last 20 years. We as a country spend over 600 billion a year defending our great nation. Have 52,000 people dying because we are not making the resources available. It is a disease of addiction that we just heard about. You dont get cured. There are two ways of ending this. One is when the coffin closes, or when you get treatment. Im glad we are here today to address the issue. I believe so many of our members know what is going on, but until you attend the funeral of a young man whose parents are looking down at their young son who just died of an overdose, thats when you start to understand the pain that goes on here. Of at went to a viewing young man, a friend of mine, who lost her son. He had been in and out of treatment and this time, he did not get saved. An issuey, fentanyl has and the narcan saves two, three, four, five doses, and it is still not doing it. My question goes first of all to dr. Volkow. The disease of addiction. We are talking about the synthetic heroin, but talk about the disease of addiction. Is there a difference, other than the outcomes and the way you die, alcohol, cocaine, and heroin . It is all the disease of addiction . The answer is yes. The way that all of these drugs specifically change, rewire centers in our brain in such a way that they strengthen certain responses and generate automatic behaviors that cannot be controlled by our front of cortex. Our frontal cortex. It is like when you touch a hot oven and you immediately remove it. Thats an automatic response. The way that the drugs do it is different, and some drugs do it more rapidly than others, like methamphetamine and heroin. As opposed to drugs like alcohol. But all result in this strengthening of these pathways, preferential pathways. And the best way that i can try to describe this to you, because its very difficult to understand why someone would keep on taking fentanyl when their mother already overdosed, is it generates that brain state equivalent to deprivation. It is the sense that it is sending the message that if you dont eat you are not going to survive. It puts your brain in a state of emergency where you will do anything in order to get the drug. Let me follow up. It is not a moral deficiency, the disease of addiction. No. That is very important because when you talk about addiction, somehow it is those people over there. Its not. Its the people everywhere. Dr. Rising, to follow up, in my hometown we have set up a program when a narcan save comes in, they have Automatic Access to treatment. And what the doctors are finding is, few if any, will take advantage of it coming out of an e. R. But they are finding sometime later, if you get them at that moment of clarity, it is. , youwe look at prevention talk about those on painkillers, how much time does the average medical student in his four year career of medical school spend on the disease of addiction . Sir, thank you for the question. One thing i would like to add to the previous question fielded is that i think all of those different types of addiction that you referenced all have very good evidencebased therapies available. I think regardless of what the addiction is, the medical profession does have resources it can bring to bear. And i think your point is a great one, in terms of first making sure that those points of contact, be they in an emergency room or another place, are not a onetime kind of contact, where we reached out and it did not work at that time. Efforts to engage people into treatment need to be ongoing to make sure that that touch point occurs when an individual is ready. I havent seen the stats recently as to how much time. I think it is slightly more than when i was a medical student. How much time did you spend . It was not a lot of time. When you look at the scope of the disease in the United States currently, i think there is a broad need to look both at schools, continuing medical education, and other ways to engage the profession and this going forward. Nobody likes to tell the doctors what to do, but i think we can give them a good clue of what is going on. Speak it outted to of it. One as an emergency medicine doctor who works this the state in which he represents. We looked at we called 111 medical schools out of the 163 and we found on average, there was less than one hour dedicated and addiction. Can you repeat that . After calling 111 medical schools, we found the average of didactic training was less than one hour. As a boardcertified emergency medicine physician who trained at a good program in philadelphia, i did not add to that in that training. My board certification in addiction came very far after my training in emergency medicine, which goes to the reason that when patients go to the Emergency Department, they leave not wanting help because they dont know how to give it. When you are in withdrawal and you say, here is a phone number, good luck, it does not work. The 30 day mortality rate for someone who shows up to the Emergency Department status post overdose is actually higher than that of someone who shows up and we miss a heart attack. Yet, if somebody comes in with chest pain we admit them to the hospital, they get an echocardiogram, they get a stress test and they see a card cardiologist. We call them with three nursing calls within the next 30 days. What happens to the addict who shows up to the Emergency Department who feel like they are dying in withdrawal. They get booted out with a phone number. We have to be honest about the actual treatment taking place in the Emergency Department and it is not patient centered and compassionate. And this happens all the medicine. In primary care, less than 10 of primary care doctors screen for addiction on a regular basis, yet greater than 75 write prescriptions for opioids. 75 ready prescription for opioids on a regular basis . Have a dea and prescribe opioids on a regular basis. Yet less than 10 routinely screen for addiction. S. Is no better for obgyn we can help that mom and get these babies out safely and back with the mom. There are a lot of things we can functionally do right now that we are not doing. I want to yield back my time, but i did make the suggestion, that would be a great topic, medical education in general. Thank you, and i yield back. Thank you. Representative schneider . Thank you. And i want to thank both of you for calling this hearing. The witnesses, thank you for being here, for sharing your expertise, sharing your experience for what is a growing problem and we are seeing it throughout the country. I will emphasize its not just rural. We are seeing it in the cities. In suburban districts like mine. And it gets worse year after year. You emphasized the numbers and the investment. Dr. Volkow he talked a bit in your remarks, clearly, the best way to fix the problem is to keep it from happening. Prevention is the best way to address this problem at the front end. Other programs that are considered most effective and more broadly, what are the barriers to getting those programs that are effective more in use and more prevalent . We have a significant number of researchers to develop prevention efforts for drug use in general. And what that research has shown us is that the strongest evidence comes from prevention programs that are initiated early on, in children and adolescents, and those that engage the family, school, and community. These prescription Opioid Epidemic and the associated heroin and fentanyl add a different wrinkle because we are seeing people who have never been exposed to drugs becoming addicted in their 30s, 40s, and 50s. The issue of prevention there requires something that was mentioned before, the importance of providing education for physicians on the proper prescriptions of opioid medications because we have gone from basically what, 50 million prescriptions a year of opioids to 250 million prescriptions since 2000. But we did not train physicians. And there was in turn, a big propaganda to actually educate physicians that these prescription opioids were safe and were not addictive if you have pain, which is incorrect. An important component of prevention right now is provide better education on the proper precipitation, on the proper use of prescription you know its on the one hand of prescription use on the one as was discussed before, they get one hour of education. If a physician doesnt know to recognize that their patient who they are giving a prescription opioid is addicted. They are not understanding withdrawal and physical dependness. Not to say what to do if that patient is becoming addicted. Even though it doesnt sound high technology, training and education is probably one of the most important prevention efforts we can do right now. Theut if i can, barriers, and that is using that as an example, training one hour over the course of four years in medical education, what are the barriers to getting more training . Whether it is at the Foundation Middle school level or continuing education over the course of a career. Why it is not happening more . It is not happening because what you get our complaints from the medical schools, they already have a very loaded curriculum and they cannot incorporate more classes. One of our strategies have been to negotiate with the organizations that generate the exams to get your medical the grap degree to put questions on Substance Use disorders. And that will motivate the medical schools to do it. So working with these organizations to put these questions, as well as on specialty treatment problems. Sorry to take your time. I know we are limited on time. Other thoughts, comments from the rest of the panel . There is push back from the Major Medical societies on mandated education. Thats pretty well documented in your offices on a regular basis. So, i think just continuing to push forward for at least a minimum standard mandated knowledge base. If you can document that you got it in medical school, great. If you cant, you need to get it at some other time if you want a dea license. Dr. Marsh. Two comments. As dr. Volkow indicated there are a number of effective drug treatment programs. I think there is also a need for Additional Research with effective prevention of opioid use in particular because the complexion of this is different and there is a growing scientific literature that shows that risk factors particularly among young people may differ from risk factors for other substances of abuse. I think thats critical. In addition to the training and education initiatives we have spoken about, i think there are opportunities to think about more scaleable models that can build on that. Work force development and person delivered trainings alone might not meet a scale. There might be an opportunity to leverage technologies in other ways. Digital technologies, social media approaches, to take sciencebased prevention and promote more scalable widespread axis. Dr. Rising. One thing to add to what my fellow panelists have said and i think if you were to look at a number of providers who were out in the Community Already who might not be providing various treatments for Substance Use disorders, i think a major barrier is that this is a very challenging issue for providers to deal with in their office, especially if they feel there are not a lot of communitybased resources or Treatment Facilities to be able to engage people who need the treatment. If you are on your own, this is certainly a daunting field to enter or to feel like you can make a significant contribution. So, strengthening those Treatment Facilities and having providers feel like, yes, i can understand. I have some options when i identify somebody in my waiting room with a Substance Use disorder. That will go a long way in driving demand among active practitioners to become more engaged in Substance Use treatment. Thank you and thank you to the panel. I yield back. Representative frankel. Thank you and thank you to our chair into the panel. Im lois frankel. Im from florida, south florida. And we have somewhat of a unique situation which many of you may be aware of because now this puts and this is why i think its so important to have federal intervention because a lot of our addiction issues are coming by way of folks coming from, lets say New Hampshire. No slight to New Hampshire. I am just saying we have become the treatment, like a treatment capital of the country. While there are many good programs, there is also, i will tell you, thousands i am not exaggerating thousands of what they call sober homes and treatment programs that are not doing the right job. And to put this in further perspective, this is not today we have been talking about patients. Im not going to i think you y describe somel of these issues. Keep in mind that this is also affecting community resources. I will give you an example. Palm beach county, where i am from. It is about 1 million and a half people. We had 4000 calls that our firefighters had to answer to for drug overdoses, at about 1000 a clip. Start to add that up. We had a hearing i had a hearing a couple months ago and one of the issues that came up were the firefighters were being traumatized themselves because they were having to treat so much so many people who are dying. Think so, when we talk about trying to do something about this, it is not just for the patients and their thes, but all doctors, the paramedics, the communities that are having to grapple with this. My question is, and i am not sure if you can answer it, but where are these synthetic drugs coming from . Are they coming from outside the country . The understanding is that most of the fentanyl is actually being diverted from china and is actuallynyl that is produced in the United States for pharmaceutical purposes. It is generated in the black market. So, i had a conversation with my local folks, and and actually, that was one of the by one oft was raised the local officials who had been dealing with this. I want to bring this to the attention of the chair here. Could we start to put some pressure on china to try to stop the trafficking of the fentanyl . Two you know whether there has been any effort in that regard . Do you know whether there has been any effort in that regard . My understanding is there has been definitive efforts to try to engage china to minimize the production of these fentanyl from the black market, but im not the Agency Behind it. We can provide you the exact information. Mother my understanding but my understanding is, they are. Thiswould request that could be something i dont know whether the task force has looked into it, but if not, i would request that. Sure. I yield back. Do you have a question . Sure. Thank you very much. You have all been so informative and it is very helpful for our colleagues who are coming up this at different places in their educational process. But it occurs to me, and im going to move on a little bit from the fentanyl. But just to some of these bigger issues, years ago my mother had alzheimers disease. And so we did a deep dive in our family on alzheimers disease. One of the conclusions i had is that there is something in our society about Behavioral Health issues that americans assume that this is intentional. And what we learned as the alzheimers progressed is that indeed, the behavior was not intentional. And i feel like we are at a very similar place with Substance Use disorder in that we assume, and this story in particular, dr. Marsh, that you told is so stunning and striking, that a young woman who has watched her own mother overdosed and die, watched her brother overdosed 17 times and yet, those of us in the room and indeed, the medical providers at the emergency room somewhere in the back of our brains think, how is she acting that way . Why is she acting that way . Has beennk dr. Volkow very helpful to understand the science of the brain, that this is no longer intentional. Frontal lobe is not making the decision. There is a different place in her brain that is survival instinct based thats making a terrible decision. But i have to step back and say to the medical community at large, first do no harm, that the medical community, by receiving people in the e. R. Over and over and stabilizing the patient and sending them home to overdose in the parking thats not reasonable behavior either. It is not logical. It does not make any sense. For us to try to unravel, it has to do with the incentives. It has to do with the lack of coverage. Lets be candid and honest in this conversation. If they were paid the way they are with a heart attack to send the person upstairs to a room, to follow them carefully, to do home care and send someone home to make sure we check on them, we would have much greater rates of success. Hampshire, we are looking into where people fall through the cracks and bringing the hospitals and the Emergency Rooms together. I have been at my roundtables where the people in the Emergency Department are not having the conversation with the people on the fifth floor in the administration to have this conversation. So, now we are bringing everybody together. Now we are bringing the Insurance Companies to the table. The federal government is going to decide medicare, medicaid, what are we going to cover . That is the conversation that we need to have. Instead of saying, that person deep in the throes of Substance Use disorder is not acting in a rational way, we turn the finger around and say, this person, whether it is a policymaker or an emergency room physician, or a Hospital Administrator or an insurance company, we are not making rational decisions because we act shocked that they show up again. And so, i really appreciate all of this perspective. And i hope with the folks tuned in on cspan, with our colleagues and staff in the room, that we can help to educate because we are so siloed. Every step of the way we are in a silo. We do our part with our widgets and medicine is no different. We have got to figure out a way to broaden that conversation. I thank you for your work and research because we need to have evidencebased information. Hank the rest of you for translating they were, the understanding you have into the society at large and back to the policymakers, so that we can make rational policy because we have already discovered on this task force irrational policy. We have already discovered we were rewarding physicians for pushing opiates into the community and then we are shocked that that did not work out well. So, to get to the question, i would like to follow up on this programs, oron and evidencebased research that we could do or should do, to give physicians an alternative. Pain is real. I have had surgery. I know pain israel. How do we help the physicians and why do we have such a gap between tylenol and full on opiates . Because now we know, i think one in 15 is the evidence we that willof patients be ending up with a chronic opiate use, but 99 of the patients getting surgery are getting opiate medication. If you all know, if anybody could weigh in and what could we be doing to help with alternative pain remedies, whether its different medication, and whether there is Evidence Based Research on other types of pain relief . Im going to be candid with you because i think that the issue that you are bringing up is one of utmost urgency. The reality that we dont have many alternatives for the management of severe or chronic pain. And there has been a big advance. The cdc recently last year had new guidelines in which they emphasize the need to actually limit and curtail that number of opioid doses that will be given to a patient. Ideally, not more than three days. So thats a very dramatic change in the way thats the new cdc guideline, ideally, not more than three days. Correct. And the other issue that they highlight is in the management of chronic pain, prescription opioids are not the panacea. You become tall and very rapidly, meaning you need higher and higher doses to relieve the same pain. That increases your risk of overdose and of addiction. And if they are not actually there are very few trials that have shown that they are effective in the management of chronic pain. Overall, the evidence is lacking. The cdc says, it is not that we are saying you should never use an opioid for chronic pain. But it should never be the first option. And it should only be used as part of alternative treatments for the management of pain. So, in a more integrated approach. You said it. Are we covering for those more integrated approach for the management of pain . Not necessarily. Its much more expensive. So, it is easier to prescribe an opioid. Changes,tructural structural issues that we need to change in order to also allow physicians to do the right thing. Yeah. And there are alternatives to the management of chronic pain. They are neither the panacea. Obviously as a Government Agency at the nih, we are investing resources in developing new medication for management of pain, as well as nonmedication all strategies. But an area that could help enormously is incentivizing the pharmaceutical industry to invest in this space. What happens is if you are selling billions and billions of 250 millionioids, prescriptions. What is your incentive to actually develop a new medication that is going to come compete with what you are already selling . Need tothere is a incentivize, just like we have done in other areas of medicine where there is an urge, like there is now, to develop new medications. We have done it for vaccines and rare diseases. There is the need to generate something that will incentivize pharmaceuticals to get into this space so we can provide for better treatments for patients dealing with chronic pain, which can be devastating. I will put in a plug for legislation that i introduced last cycle and will bring back again for consideration by the task force and by our colleagues in the congress for a pilot project. Fromwas mr. Kaufman colorado and myself coming out of the Veterans Affairs committee. It is in white river junction, vermont. A doctor named julie franklin, who was working with veterans with chronic pain. They were taking very high doses of opiates with no Mental Health. They had not dealt with ptsd or anything else. One gentleman i met was taking 160 pills a month for long periods of time. She took this group and had a clinic on alternative remedies. So, acupuncture, Mental Health therapy, physical therapy, wellness, mindfulness, yoga all these different things, and she was able to reduce the use of opiates for chronic pain 50 and had much better outcomes. People felt much better. They were much more active, much more able to participate in activities of daily life. Kaufman and i are trying to scale that up both but hopefully. , get evidencebased results that could then go out into the community. So, i will close, but if anybody has anything to add. Two quick things. One, back to the 111 medical schools. They only had 1. 2 hours of training in pain on average. Less than one hour for addiction and only 1. 2 hours on average for training on pain. So, they dont study either one. To try to onboard different modalities of treatment, to your point, the best literature for the treatment of chronic nonmalignant back pain, which is one of the most often seen complaints in a primary care office. The two things that have the most amount of literature behind them, randomized control, cochran level database stuff. The things we go to and say, we should apply this to everybody. They are yoga and mindfulness. The fact that we have this mountain of literature that shows that these are the things, yet physicians and p. A. s and a Nurse Practitioners are not trai ned in this. The first thing that they get is a prescription. That is problematic because that one hour i lived it in my family ath chronic pain and now, series of surgeries that a relative who has been on opioi tes since september 11, and now is challenged by dependency. And so, it is very, very frustrating. I cant tell you how siloed having gone out there and spent a week, if i could, personal privilege, being literally in the appointments with the surgeon who, fabulous surgeon wants nothing to do with this. Literally just came out right now and said, not our problem, you will have to deal with that after the surgeries. Meanwhile, the Treatment Professionals dont want anything to do with the surgery, saying you can die of the drugs, but you wont die of not getting the surgery. I am just like, ok, is there anyone in this process that can help us navigate how to get this accomplished so that this person who we love so much can get back to their life and be productive . And the stigma at every step of the way, the stigma is so great. Instead of, you know, wow, lets call it cancer. Lets give it a different name. We will try to help you with your problem. So, thank you for that moment of personal privilege, just to say that i really appreciate the work that you are doing. Well, thank you. I had a couple of questions. And i appreciate all of your testimony very much. Frankly, it raised more questions for me than answers, but it did answer a number of things. I found a number of things deeply disturbing, actually. I want to get my mind around how we can help to improve some of these areas. But i just want to clarify, dr. Volkow, you talked about the physiological changes to the brain that occur when somebody is using opioids. D,. I want to understand those better. I lost my mother from cancer. We all know that if somebody stops smoking, maybe they cant totally reverse the effects of years of smoking, but it gets better. There is improvement. We all know that if you cut off your hand, there is no improvement. You never have a hand again. Its done. I understood your comments to be more like the latter, that there are physiological changes that occur to the brain that are irreversible. And i wanted to ask you to unpack that a little bit more so that we understand what happens to the brain and over what period of time, and what can be returned to some normalcy over time and what cannot be . I am glad you are asking me that question because i did not imply they were irreversible. I implied they were long lasting. In fact, what the evidence show is that while it is frequent to see relapse in people that are addicted, the longer that they sustain the treatment, the scarcer, the more rare it does occur. For example, the best outcomes are reported one patients are on chronic treatment for five years, at which time, they lives where lead they can recover. That means that you can get back to your previous state. But there is a level of vulnerability, but the rain recovers. People recover from strokes. We do interventions to maximize the likelihood that you can strengthen those areas that have been damaged. The same thing we should be addressing for helping those people recover those systems that have been damaged by drugs. Yes, the brain can recover. The extent to which it can recover will depend on many things, how addicted you are, your age, when you started taking drugs. But the evidence shows that with proper treatment, people recover from addiction. Ok. Thank you for the clarification. I want to talk about education a little bit. And dr. Waller, you talked about one hour in four years for addiction education, 1. 2 hours in four years for pain management. I listened to a program a month or so ago. I forget the womans name, but she was the head of the Addiction Recovery center at stanford university. And she was speaking at length about pain management. And how the whole american view of pain and the need to manage it, eliminate it, has fed into the opioid crisis. And it really got me thinking and i was thinking of it today as well. We cant fix everything in congress. We dont tell medical societies how to teach students. We dont regulate that. And neither should we. There are we are not physicians for the most part. But there are times where theres a federal nexus with Health Care Issues and we do get a lever that we can use. And i guess my question, to you in particular but ill ask all of you, what are the federal levers . Where, to your knowledge, do we license at a federal level . Do we do things at the federal governmental level that might allow us to exert more pressure entities,rnmental with regard to how they train physicians . Thank you for the question. And thank you for really having the ongoing thoughts about this. It is a complicated problem and we are all dealing with it in different ways. The federal government has one place in which it holds a pinch point for every prescribing physician in the country, and that is at the dea license level. We are required to fill out paper workof and pay 350, but not have any additional training to our medical degree to write for medications. I think that is one of the levers that we really have to start looking at how we would phase in, a you need to earn that dea certificate. Whether it is at the medical school level, or for those on the outside, you have two years to complete a certain number hourstinuing medical specifically dedicated to the and schedule iii drugs. As big of ang issue as it is with benzodiazepines, the vast majority of heroin overdoses are in combination with a sedative hypnotic, which is in combination with a benzodiazepine or alcohol, or another sedative with it. Doesing it again in a silo not allow people to cross a valuate what they are doing. At the dea level, thinking long and hard about what you should have to know to earn that license, because we are talking about in medical school we talk about how we are full. On every test i have taken, there is always a question about a rarelled a crumb i german. It is a once in a career tumor. Its on every test i take. I think that could take a little less time in my education through this. Especially when the number one cause of injury related deaths in our countrys drug overdose. I had three lectures from the National Traffic safety board as an emergency medical residency on car accidents. I can tell you what an a pillar does, a b pillar does, and a c pillar does. I have had those educations, but car crashes kill fewer people when drug overdoses. Federally, you dont have to look far. They are controlled substances and they are controlled by the federal government, by a license i am privileged to have from the federal government so i can affect positively peoples lives. There are 100 different ways, but i think that is the biggest one that you have right now that is purely a federal lever. To any of the rest of you see any other . Hi, yes. A couple other thoughts to share. Certainly, i think it is important to improve provider education, as we have all talked about the deficiencies here today. However, also providing the education does not necessarily get to the end results we are looking for, ensuring that it is quality education and that providers then are able to act differently and provide Services Better as a result of that education. So, other tools that might be available to get at that root question of what we are trying to assess and encourage. One is the use of quality measures, which are used widely across health care, but really we dont have once that have taken root when it comes to the treatment of Substance Use disorders. So, there could be some opportunities to encourage the development of some quality measures in that space. And then there are other ways to look at the services and referral that places are able to provide as part of the ongoing relationships that both medicare and medicaid have with various health care facilities. I just have to say, with regard to quality measures, that is actually one of the inadvertent, unintended consequences that got us into this situation. I am glad you brought it up because we could use it to help get us out. But this is with regard to physicians were judged based upon the patient satisfaction. The federaly government was reimbursing based upon patient satisfaction. And so, i think, it does not take much to make the leap that surgeons had done a fabulous job with the surgery. They were not going to get paid less from somebody whining about the pain and they said, 30 filled, take 60. 60. 0 pills, wait, take let me give you 90. And i think that got us into this. Again, a piece of legislation, this is one we will be bringing back to make that change, so that physicians will not be pressured into, or feel pressured, into increasing the medication for post surgery pain medication. That wasanother bill included, we did partial fill because many, many, many patients, if not the vast majority, are going to be fine i did not know about the cdc three days but you know, five pills, six pills, gets you through the weekend. And by monday you are going to be feeling much more comfortable, rather than sending every patient home with 30 pills. I wanted to add in response to your question about federal levers, i wanted to add two. One is related to research and the second is relatedto scaling up the application of science to Service Delivery models. The first one with regards to research, i think we have discussed today that there are a number of effective prevention models. There is a tremendous opportunity to scale up their utilization in realworld places of care. So, and understanding, how do we create systems that promote the maximally impactful models and promote Widespread Adoption and sustainability of these models i think is really critical. Before, wed about had this unprecedented moment in time where we have this large amount of resources that have been allocated to expanding Service Capacity across the entire nation through the care act. And we have half 1 billion this year slotted for that and it seems like a tremendous opportunity as we embark upon this as a nation to ensure that what we know works best from the science is actually what is incentivized, what the states are encouraged to adopt. And also, to have a scientific model wrapped around evaluating that. If we are going to invest into strategy for expanding the Service Delivery model, how do we know that it works . And how do we know what the impact of the investment is . I think those are key, the research and the linkage of the research to Service Delivery. Im going to make another point because i also think it behooves us recognizing how devastating addiction is. Yes, we have medication for opioid drug disorders. Look at how many medications we have for hiv. How many we have for hepatitis c. How many antidepressants do we have . Is that sufficient . No, it is not sufficient. They are extremely useful, but there are many patients that do not respond to that. Highlighting the need of research that can lead us to alternative treatments. It is like we are dealing with the zika virus. What do we do with the development of vaccines in developing medications to fight it. We do that urgently. We have not done that for addiction. The amount of investment that goes into the space of developmental medication has been externally restricted. Yes, im grateful for the medications we have been able to develop thanks to the government, but i also recognize that it is important that we continue to strive for alternative treatments, so that the patients have the greatest chance of survival. Addiction is a very serious disease and it kills people. We should treat it with the priority that we treat other conditions. Andnd hopefully, do no harm have the fewer people headed into that. It just breaks my heart. Four out of five people suffering from Substance Use disorder started down that path from a Prescription Medication from their physician. I cant think of anything else like that in our society, in our Health Care Delivery model. Well, thank you. I just wanted to say we are going to have subsequent hearings. When we hearing will be will be hearing from some people that have implemented models in New Hampshire, the safe station. You might be familiar with it. We have some promising results coming, but you we could also consider a hearing on ways that we can move forward to adopt the models that you are talking about. Yeah. All of you. Thank it has been helpful and you have given us a lot to think about. As we consider future hearings, i think what you have given us today will help us. Our object is really to shine a bright light on this issue, to educate our callings, to try to bring some order out of a lot of Different Directions that congress can go and members of cores, introduced their legislation with their own council. We want to try to make our efforts in congress comprehensively deal with what is in front of us. What we did last year was helpful, but it is not enough. I want to thank you for helping us in that. I want to invite you, if you have a further thoughts, dr. Waller, you mentioned there might be 100 levers. Be careful what you ask for. But seriously, we want to get the best advice that we can. And if you have further things you want to suggest, i invite you to reach out to our offices and let us know and you will do a Great Service to the American People as you do it. As mentioned, we do have another hearing scheduled. 4 00 p. M. 8 at representative kuster will chair that hearing. We will hear from families that have been affected by the crisis. Nd that will be difficult we will be able to explore just how that progressed in their lives. I thank you. This hearing, this roundtable is at an end. I appreciate you being here and we are adjourned. In the afternoon, a look at the ongoing conflict between russia and ukraine and russias relationship with the west we will hear from Richard Armitage and connecticut senator chris murphy. Live coverage at 3 00 p. M. Eastern. Coming up up, the conversation on the state of the Opioid Epidemic and Health States and communities are responding. Hey keep on our state faces a crisis that is more urgent to new jerseys families than any other issue we could confront, a crisis that is destroying families, ripping the very fabric of our state apart. It is the crisis of drug addiction. Governor Chris Christie of new jersey from his state of the stated address, where he dedicated 53 minutes to his hour plus speech to the Opioid Epidemic. 40 americans dying every day from opioid