Transcripts For CSPAN2 State Officials And Physicians Testify On Economic Impact Of Opioid... 20170612

Not that im aware of. Then why are you not answering . Its inappropriate. What you feel is an relevant. Changes to the doddfrank a act. And today, today we released a report titled was the cop on the beat . This is regarding the cfpb wholly inadequate role investigating the wells fargo fraudulent account scandal. We have received numerous records from both wells fargo and occ and others that indicate the cfpb was asleep at the wheel. Cspan programs are available at cspan. Org, on our homepage and by searching the media library. The joint Economic Committee examines the Economic Impact of opioid addiction and other forms of drug abuse. This is about one hour 40 minutes. Good morning and welcome. I want to welcome especially our Ranking Member senator heinrich and our vice chairman senator lee, as well as the other members of this committee, who have joined me in expressing the importance of holding a hearing on the threatening increase in opioid abuse. Drug abuse has become rampant in america and may be the worst the country has experienced. Ease of it is devastating families and degrading communities, and undermining parts of the economy. For several states and districts represented by members of this committee, the problem is acute. As figure 1 indicates, the crisis has a regional character. My hometown of columbus, ohio is part of the crisis epicenter east of the mississippi. Figure 2 shows the 2015 Drug Overdose death rates by state, which ranged from 40 per 100,00. In West Virginia to six per 100,000 in nebraska. The states represented by members of this committee among the ten highest rates, are highlighted in red, including my home state of ohio, which ranks third. Drugs markets, both legal and illegal, can be analyzed from the demand and the supply side. O the exact reasons for the extent of drug abuse are not clear at this point. With respect to demand, a changing perception of pain as a Health Problem in the 1980s by the World Health Organization in particular laid the ground for more intensive treatment. The labor market and the economy can have a major impact on demand, although not necessarily in ways one might expect. Some Research Shows less Substance Abuse when unemployment increases, for instance. And, while prolonged downturns in labor market and economicic conditions are associated with social, behavioral, and Health Problems, they do not necessarily affect all groups ir the same way or to the same all of society is vulnerable to the Opioid Epidemic, but it is compounding the economic distress that certain parts of the country and segments of the population already have been experiencing. Some areas of high unemployment tend to have higher rates of Substance Abuse. The economic innovation group, a representative of which testified at our last hearing,. The decline of Economic Opportunity causes and consequences, developed an economic distress index consisting of several economic indicators, a national map ofndx which is shown alongside the map of Overdose Deaths in figure 3. The darker the red, the worse the distress. Striking correlations are visible. Ar but it is also apparent from figure 3 that some economically distressed areas are notly distr experiencing high overdose death rates. From the supply side, theply particular locations where new, potent drugs initially happened to become most readily available, and the path ofic Geographic Market expansion they took, track a visible trail of destruction in figures 1 and 3. Without question, new developments in the sourcing, cost of production, potency, and retail delivery have moved the supply of both legal and illegal addictive drugs substantially to the right. And newly effective pain medication oxycontin, introduced in the mid1990s had initially unacknowledged addictive qualities and was overprescribed. Socalled black tar heroin, mora powerful and less expensive than other kinds, expanded its market share just as oxycontin was reduced in potency. The Prescription Drug explosion started in the appalachian part of ohio and spread to parts of kentucky and West Virginia. Stad black tar heroin entered theip southwest and spread westward but eventually also eastward, crossing the mississippi in 1998. T illegally distributed variations and counterfeit forms of Prescription Drugs like fentanyl can be poisonous and kill a person even in small doses, some by mere contact with the skin. Us we now face pure poisons masked as narcotics that are shippedmee across our borders. Senator portman and i have introduced the stop act, which aims to stop dangerous synthetic drugs from being shipped through our own postal service, keeping them out of the hands of drug traffickers in the united. States. But it would be a mistake to blame these drugs entirely for the rise in mortality that some groups and regions are suffering. There are other causes apparently emanating fromm longterm changes in the composition of the economy and of skill requirements. Determining cause and effect is obviously critical to reaching the right conclusions. Feedback effects often complicate causality and make as clear understanding of major causes difficult. For example, does a bad economy lead to drug abuse or does drug abuse to a bad economy byng. Lowering productivity, labor force participation, and social cohesion . We will hear perspectives that run in both directions today. We will hear about the economic decline of certain groupss leading to despair and selfdestructive behavior, of damage drug abuse causes individual lives, families, and communities in all segments of society, and of developments in the production and marketing of addictive drugs, which have made them more dangerous, affordable, and available. E. I look forward to mosti lo to our distinguished experts and i will now hear from Ranking Member heinrich. Thank you, chairman tiberi, and thank you to our panel for being here today. Addiction to heroin and prescription opioid pain relievers is a Public Health toy epidemic that is devastating families and communities across the country. T every day 91 americans die froms an opioid overdose. Ery overprescription is partially responsible for the epidemic. Since 1999, the amount ofse. Prescription opioids sold in the u. S. Nearly quadrupled and so t too has the number of Overdose Deaths from opioids. The economic costs of addiction are enormous, totaling more than 80 billion in 2013 from increased health care costs, higher rates of incarceration, and lost productivity. New mexicans know too well the devastation heroin andeased he prescription opioids can wreak. For years, without adequate treatment resources, communities in new mexico have suffered through some of the highest o rates of opioid and heroinea addiction and Overdose Deaths in the nation. E suffe Rio Arriba County has a Drug Overdose death rate of 81 per 100,000, five times the national rate. Im reminded of josh from espanola, who i met at a round table i hosted in Rio Arriba County last spring. At 14 years old, josh became addicted to prescription opioids. Over time he moved to heroin. Bc he stole from family and friends to maintain his growing addiction. Josh spent time in jail where he went through the pains of withdrawal. He even attempted suicide but in his gun didnt go off. Now in his 20s, josh has turned his life around because he finally got access to treatment and services. For millions of americans, proven Substance Use treatment is available because of Behavioral Health parity laws, and two, the Medicaid Program. E in new mexico, medicaid, called centennial care, is at the forefront of our fight againstnd the opioid crisis, accounting for 30 of lifesaving medicationassisted treatmenttfr payments for opioid and heroin addictions. Of at exactly the Time Congress ass should be giving states morend tools to fight this epidemic, House Republicans passed a bill that would repeal Medicaid Expansion, artificially cap the thatram, and shift the burden about who and what to cut onto states. Program more than a Million People who have been able to secure treatment for Substance Abuse would lose their coverage. Repealing Medicaid Expansion would cut about 4. 5 billion from treatment for Mental Health and Substance Abuse. Sion we cant fight a Public Health crisis with grant dollars alone. Grant dollars run out. Block grants lose their buying power over time. And private investment dollars, which are critical in this fight, wont come without certainty that the foundation is funded. Unfortunately, i wont be able to stay to hear your important testimony because of a hearing in the intelligence committee. Rt but i will be leaving you in thu very capable hands of my colleague, senator hassan. New hampshire loses at least one person every day to a Drug Overdose. As governor, senator hassan usea every tool at her disposal to fight the epidemic, including turning to the flexibility of the Medicaid Program to gain ground in her states fight. I will let her to tell you more, but i leave you with this, when a Community Faces a Public Health crisis, its not long before a state turns to the Medicaid Program to stem the tide. Thank you, senator hassan. I will turn over the rest of my time to you and thank you, chairman, for holding this critical hearing. Well, thank you, mr. Chairman and Ranking Member heinrich, and or witnesses today. Thank you for being as well. As i travel across my home state of New Hampshire, i hear from countless families and those on the front lines about how the heroin fentanyl and appeared crisis has devastated Community Across our state. And i know that many of our colleagues have heard of the i kacts interstates as well. Im proud that during my time as governor republicans and democrats in New Hampshire put our differences aside and cameha together to pass and reauthoriz our states bipartisan Medicaid Expansion plan. Medicaid expansion is providing quality, Affordable Health coverage to more than 50,000 granite staters including coverage for Behavioral Health and Substance Use disorder treatment. Experts at said it is the number one tool we have to fight this crisis. We should be coming together here just as we did in my home state, to support those on the front lines and help those who are struggling with addiction. And while members of both parties and the administration have discussed the severity of this crisis, we need these words to be matched by action. What we cannot do, however, is in Medicaid Expansion and Institute Deep and irresponsible cuts to the traditional medicaie program. Onal this crisis is a Public Health and Law Enforcement issue. But its also an economic one. A i believe the investment in helping people recover are a far better use of our dollars than the longterm cost of addiction. Both in terms of state budgets, but also in ensuring that individuals are healthy enough to contribute to our economy. I am pleased were having this today, very grateful to the chair for calling it, but we need to continue to hold hearings on how proposals made here in washington would affecto our ability to stem and ultimately reverse the tide of this epidemic. This is an issue that arises above partisanship, and this is the work that we need to be doing. An because the lives of our people in our states depend on it. Im going to continue to work with my colleagues on solutions while stand firm against any policy that will pull us backwards. In and with that i thank you and ii look forward to hearing from our witnesses. Thank you. Let me introduce our first witness. Thad frank is a market moores professor of Health Economics at the department of Health Care Policy at harvard d University Medical school. He has held several positions at the health and human services, most recently assistant secretary for planning and evaluation vicki served as an editor for the journal of Health Economics and his recipient of awards from the southern o economic association, the american Public Health association and others picky as authoring, he is coauthor of the book better but not well. Dr. Frank, you recognize for five minutes. Turn on the microphone. Good morning, chairman tiberi and senator hassan. Thank you for allowing me to produce me in this discussion that is plaguing our nation. Just over 33,000 people died in 2015 from opioid overdoses. In the time i have with you today i want to focus on the gap between the need for treatment i and the receipt of care. In 2015 it was an estimated 2. 66 Million People with an opioid use disorder in the country. The illness in custody in the low income population. That is, 51 of people with an opioid use disorder, or ou d, incomes below 200 of the federal poverty line. Only 26 of the people received treatment for that disorder. That being said, 1. 9 7 Million People Million People in need oe care did not get it. This is tragic because treatments work. Medicationassisted treatment has been shown to be the most effective treatment for oud. They are a combination of pharmaceuticals, psychotherapy or counseling and drug testing to monitor treatment adherence. National survey data show that over half the people that did not get treatment because they either couldnt afford it or there were no providers available. Other reasons for not giving care were not being ready to stop using substances, stigma, as the denial of the problem. D policy tools are most amenable for addressing the affordabilitt and availability recently i will focus on three areas that are helping to make the achievementl gap smaller. Medicaid, private insurance and federal grants. Medicaid covers about 34 offedl people with an oud. Recent policy changes in medicaid have bolstered medicaids impact. The combination of the mental Health Parity of addiction equity ac at the requires comparable coverage for Mental Health and Substance Abuse disorders with medical surgical care, the Medicaid Expansion and essential Health Benefits that includes Substance Abuse treatment all have driven medicaid to a growing role. Together these provisions have resulted in large increases in the use of medicationassisted treatment. Th a number of states have beenea using medicaid as a central para of the attack on the Opioid Epidemic. The state of i recently reported substantial increases in access to care with disorder and inpord Ohio Medicaid now pays for nearly half of all the people in orphan prescriptions in the state which is one of the key drugs and medicationassisted treatment. Let me turn to private insurance. Private insurance covers aboutut 42 of people with an opioid use disorder. Recent changes their have bolstered the building of private insurance to shrink the treatment gap. They are the parity act apply tr private insurance, essential Health Benefit provisions in the small group and individual market and availability ofsu subsidized Insurance Company a insurance policies for low income. Nsuran in 2011 a survey of individual market insurers revealed 34 of policies sold did not cover Substance Abuse disorders. Ie today that is no longer theubstn case. Finally, grants to states. The recently enacted 21st century cures act appropriated 1 billion over two years that was intended to focus on closing the treatment gap by expanded capacity and expanding direct treatment. Just under 500 million of that money has been recently allocated to the states. Let me take a moment to put the cures money into context using the state of kentuckys experience. Kentucky is receiving a grant of about 10. 5 million under cures. That buys about 1900 full year treatment with medicationassisted treatment. Currently medicaid pays for 4200 person years of treatment in kentucky, and threequarters ofu that is for the expansion population. That means if medicaid cuts offf the magnitude proposed occur, the cures funds would likely not be used to expand capacity in treatment but would instead backfill for medicaid losses and would not even be able to cover twothirds of those. I not touch on availability. Since policy changes that i described have begun, theres been a surge of new private money into this sector. Theyrthere been 170 private eqy deals between 20122015, some as large as 100 million. These private investments are aimed at scaling upmillio evidencebased practices and Investment Community acknowledges it is directly linked to the flow of new funds both on the private and the public side. So the last ten years have set a platform for closing the treatment gap. The evidence suggests were starting to see important expansions in both capacity and treatment that will pay dividends in the future. Turning back now doesnt make either economic sense and likely lead to tragic consequence. Thank you. Thanthank you, dr. Frank, for your testimony. Our next witness, lisa sacco hat been an analyst and crying policy with the Congressional Research Service Since 2011. This past five years she specialized in published reports of domestic Drug Enforcement and synthetic drugs i from Prescription Drug abuse and various other drug and policy issue. Prior to work at crs she received her doctorate in otherr criminology and criminal justice of the university at albany. Hold several Dublin Research positions and taught College Courses on drugs and crime. Dr. Sacco, welcome. You are recognized for five minutes. Chairman tiberi, senator hassan and distinguished members of the committee my name is lisa sacco and i both crying policy analyst. Thank you for inviting me to speak with you. My test when will focus on the scope of the splat opioids in iv the United States. I will begin by stating three points from my written testimony that i will expand upon today. First, hair one, fentanyl and called control Prescription Drugs been ranked as a significant drug threats to the United States. While the report availability of control Prescription Drugs has declined over the last several years, the report availability of heroin and alyssa fentanyl has increased. Ra the availability of these drugs is a contributor factor to rising consumption. The accounts of what by regionf of the United States. Third, while the federal government has generally t concentrated on reducing theer supply of illicit drugs, federal drug control funding for supplyc reductions remained slap onto a flat loughlin or demand reduction has increased. While opioids have a long history in the years, this testimony focuses on the last several decades, as the market has shifted a great deal. In the 1990s availability of prescription opioids increased as legitimate production from lawful use increased sharply. This continued into the early 2000s as users obtain Prescription Drugs through doctor shopping, pill mills, the internet and to family and friends. The federal government the state and local government undertook a range of approaches to reduce the unlawful Prescription Drug supply including diversion control through Prescription Drug monitoring programs, the crackdown on pill mills, the increase relatio regulation of t pharmacies in 2008, the reefll formation of oxycontin 2010 and the rescheduling of hydrocodone in 2014. Some experts have highlighted the connection between the crackdown on the unlawful supply of Prescription Drugs and setsts with verizon heroin supply and abuse. Heroin is a cheaper alternative to Prescription Drugs and is often more accessible to some were seeking an opioid high. Su while most users of Prescription Drugs will not go on to heroin, accessibility and price are central factors cited by drug treatment patients in the decision to turn to heroin. The trajectory for heroin supply over the last seven decades is much different compared to prescription opioids, but the stories other supply are connected. Om in the late 1990s and early 2000s, white powder heroin dominate the market east of the0 Mississippi River and cheaper black tar and brown heroin produced in mexico dominate the market west of the mississippi. Price and pretty buried by region. In 2 million both of heroin seized was in south america while smaller was from mexico. In recent years the supply source has changed. Although less so years heroin prices have declined while purity, the purity of mexican heroin has increased. Over 90 90 of heroin seized isy from mexico, and a much smaller portion is in south america. Mexican traffickers dominate the views heroin market because of their proximity to the u. S. , their established transportation and distribution infrastructure and the ability to satisfy you a settlement demand. Increases in mexican heroin production have entered a reliable supply of low cost heroin even as demand for these drugs is increased. Mexican traffickers have increased their production of white powder heroin and ma maybe targeting those abuse prescription opioids. Compounding the current opioid problem is writes a nonpharmaceutical fentanyl onge the black market. He that no is often mixed with or sold as heroin and it is 50 to 100 times more potent. Nonpharmaceutical fentanyl largely come from china to support a cheaper than the cost of heroin. Increased potency of the compound sexually dangerous and Law Enforcement expect the fentanyl market will continue to expand in the future as new fentanyl products attractt additional users. The threat posed has increased since 2007 at the threat varies by region. In 2016 approximate 45 16 approximate 45 of Law Enforcement agencies respondeded to the National Survey reported heroin as the greatest threat it the event in contrast 8 of responders for heroin as a greatest threat in 20,072,007. Reports of heroin as the greatest that are concentrated in the northeast, midwest and midatlantic regions. Opioids are the main cause of i Drug Overdose deaths. A mid reports indicate that increases in Overdose Deaths are most likely driven by fentanyl and heroin. The increasing available of heroin and other opioids largely but not entirely corresponds to the increase in Drug Overdose deaths around the country. New hampshire ranks second in the country in Drug Overdose deaths and the report a highavailability of heroin in the area. New mexico and utah ranked eighth and ninth but only 4. 7 of survey respondents in themexa southwest reported heroin as the greatest threat, 22. 6 reported High Availability of heroin. Oin this may be explained by number of factors including the lasalle the fentanyl. The federal government has construed on reducing the supply of illicit drugs. In recent years efforts reduce the demand has increased. Federal drug control dollars are to go towards addressing display time. Federal drug control funding for supply reductions remained flat over the last several years while funding for drug treatment and prevention has increased. Thank you. N thank you for your testimony. Its an honor to introduce my attorney general, mike dewine asserts that the states and in, as a member of United States house of representatives, your senator and not as ohios 50th attorney general. You are a tough ohio, ohios top drunk driving lesbian a leading proponent for highway safety. Hes advanced the use of dna evidence for victims of crime and worked tirelessly to fight the Opioid Epidemic in our state. Ive known mike for decades. Please you are able to come today to testify and give us your thoughts. You are recognized for five minutes. Chairman tiberi, senator hassan and members of the y committee thank you for inviting me today. The most visible sign of Opioid Epidemic in ohio of course is aa number of deaths we have. Last year the official total was eight per day. I think it was more than that. Today at least anecdotally it is clear that number is going up. The cost is so much, much more. Everything in ohio we have babies who are born who are addicted. We dont know what developmental cost for each of those childrens will be, what that will impact that particular child but we know many of them were in fact, be impacted. We do know what the cost is. The cost in the hospital, neonatal intensive care unit, average child there i think spends about 14 days. At a very tremendous cost. Our foster care system is bursting at the seams. Our children services. 50 of all the foster care children, children were in foster care are there because one or both parents are drug addicts. E. 70 of the infants in foster o care either because one or both parents are drug addicts. Our jails in ohio are overflowing. We have more women in our jails that weve ever had by far to date. Our jails in ohio, in our 88 counties are really detox centers, something they were not designed for at all. Nor can, all responders carryor narcan but as we moved on that, that is scraping and with allocated for that. But as with move from payments heroin to fentanyl to carfentanil, it takes more and more doses. Officer tell me the other day it took 12 different dosages to bring someone back to life. The big cost that we really, i think its much more difficult to determine, but its huge, absolutely huge, is the number of people who are in ohio who cannot pass a drug test and, therefore, cannot have a number of jobs. Cannot p you can never hire someone who cant pass a drug test to around machinery. Never hire someone to even be in charge of the local mcdonalds or the burger king. You cannot have someone to drive a truck. He the missed opportunities, the fact that these people are not living up to their godgiven potential with a tremendous impact it has on their own family, but also impact it has on the state of ohio is just absolutely huge. I do a quiz when i talk to employers and i say do your drug test . If they say, yes, i drug test. What percentage of people who come in here and you tell them there to take a drug test lead before they take the drug test . And then added at the frontage of people who come in for so arrogant or stupid or both that they take the test and failed it. The average when you put those two numbers together, almost everything time is 40 . Its not scientific. Its anecdotal but it tells us some of the great loss we have. What do we do about it . We start i think with the premise that most people who are addicted today to heroin, fentanyl, et cetera, started with pain meds. The first thing that we did is we took the licenses of over 100 doctors in the state of iowa. These are bad people, drug dealers. They needed to go away. But what remains is a lot of good doctors who are stillre influenced by a culture that we believe was caused by the Drug Companies purposely. To indicate that someone who has a long time chronic pain that is not terminal, that they are an appropriate candidate for pain medicine. These doctors still i think some believe that pain meds are appropriate for that circumstance. I think that is a problem. We are slowly changing the culture, mr. Chairman, and i think making improvement. Local communities must own the problem. There must be an admission that there is, in fact, a problem. What follows that should be an inventory. What are the assets we have, what are the challenges that we face . And that all the community has to go together. The business community, the Law Enforcement, the educators and the churches. One of the things weve emphasized is Faithbased Community needs to be involved. Another thing thats happened in ohio, mr. Chairman, is lawenforcement is doing something it never did beforeth and that is helping get people into treatment. Me its just amazing stories. Atment senator daschle a scathing, i gave him an increase in title. Sheriff clarke in lucas county does an amazing job. They go to the emergency room, they take people from the emergency room at the rate for treatment and to work with them and get them into treatment. R let me talk about two otherre things if i could, mr. Chairman, and i will conclude. I believe that we to move to a k12 every year talking about the kids in school about this y, problem. I think it should be repetitive, comprehensive and schoolbased. At msb ageappropriate. Youre not going to talk to kindergarten kids about heroin but you will talk to them abouta maybe the good choices and health. If you see a pill, dont pick that up. I was on reagans National Commission on drugfree schools. Every expert who came and said jeff to start in kindergarten, he had to do something every single year. We had a study commissioned that put this out. I would make this available to anyone whos watching this or any members of the committee. Its only 23 or 24 pages. We have mailed this to every superintendent in the state. Finally, mr. Chairman, i think in this country we need to do something, and i think it really needs to be on a national scale. We have to change the culture. E when i was a county prosecuting attorney in the 1970s, heroincoy was something that even people who were doing drugs, most people wouldnt touch heroin. Theres a psychological barrier there. That barrier is simply gone today and no longer exists. I think what we need as a media blitz, a social media blitz, on tv that is aimed at really two groups of people. One our kids and want our parents and adults. Get all the experts together. Im not an expert in this but put them together, put the best media people we can put together and lets try to change the culture because the iron is that as we have changed the culture in regard to tobacco, took a long time, weve gone the right direction. In regard to opiates weve got an obsolete the opposite direction. We can turn this around. Thank you, mr. Chairman. Thank you. Ol our last witness is professor angus deaton, senior scholar and professor of economics of International Affairs and there does at Princeton University Woodrow Wilson school. Hes also president , president ial provision economics at university of southern california, a member of the National Academy of sciences, the American Philosophical Society and i honorary fellow of the Royal Society of edinburgh. He was president of the America Economic association in 2009. 2009. In 2015 received a nobel prize in Economic Sciences in 2016 he. Was knighted by Prince William at buckingham palace. Thank you for joining us today, professor angus deaton curcumamo recognized for five minutes. Thank you, chairman, he very, senator hassan, and the other members of the committee for holding this hearing on economics and the opioid crisis. From legal and Illegal Drugs are contributing to almost unprecedented increase in overall mortality among middleaged white nonhispanics. A cinch of mortality decline came to a halt at the end of the 20th century, and mortality rates for this group were highee in 2015 that in 1998. Driven by these developments, Life Expectancy at birth, a key indicator of how well a society is doing, for white nonhispanics from 2013 to 2014 fell. And. And for the whole population of the United States from 20142015. Opioids are big part of this story. Supplies of opioids have stoked and maintain the epidemic. Selling heroin as profitable and illegal, selling Prescription Drugs as profitable and legal pharmaceutical companies have made billions of dollars of profits on prescription opioids. Opioids have legitimate if a limited role in treating pain but perhaps it wouldve been better had they never beenin approved. Physicians are far from infallible in detecting which patients are likely to become addicted, and once patients are addicted, treatment is difficuly and often unsuccessful. Lt my work has examined all. This is part of an epidemic of mortality, what we call depths of despair. These are suicides, deaths from alcoholic Liver Disease and accidental overdoses from legal and Illegal Drugs. The opioid deaths are the largest component in 2015 for white nonhispanic men and women aged 5054 without a College Degree who are much more seriously at risk than those with a College Degree. Depths of despair are around 11e per 100,000, of which 50 are accidental overdoses, 30 or suicides, and 30 are from alcoholic Liver Disease, cirrhosis. Theres recently been a turn up in mortality from Heart Disease after many years of decline. Obesity is at the cause come some these deaths might be depths of despair which would put a total levels approaching deaths from cancer or from Heart Disease, the two major killers in midlife. Figure one shows the mortality rate for nonwhite hispanics. The red line age 4554, together with mortality rates for selective comparison countries. The mortality rates in midlife and other countries continue to decline at the rates the prevailed in the United States the 41998. Americans are killing themselves by drinking, by accident overdosing, by overeating orcc more quickly and more straightforwardly, by committing suicide. Ing depths of despair of reason in parallel for men and women. Such a deaths like all suicides are lower for women than for men, but the increases have marched in lockstep. They key distinction is not between men and women, but rather between those with and without a College Degree. Depths of despair cannot be explained by the economy. There were increasing for the Great Recession and continue to increase afterwards. T we think of all of these deaths as suicide of a kind and suicides respond more to prolonged Economic Conditions and the associate dysfunction and loss of meaning in the interconnected worlds of work and family life. Workers who entered the labor market before the early 70s, even without a College Degree, could find good jobs inge manufacturing, jobs again with the and onthejob training, that could be expected to last and have brought regular increases in earnings and a road to middleclass prosperity. Not so today. With you a good jobs there has been a decline in marriage rates, the couples often cohabit and their children out of wedlock. O those cohabitating relationships are less stable than marriages, so that many fathers do not live with or even know their children, and many children have lived with several fathers by their early teens, fathers in in court. Heavy drinking, overeating, social isolation, drugs and suicide are plausible outcomes of these processes that cumulatively undermine the meaning of life or White Working Class people. Within this context we tend to see the Opioid Epidemic as accelerants, and something thats poured fuel on the fire of something that was already very that already. F thank you very much. Thank you all for your testimony today. Before i begin, just to notes in the spirit of bipartisanship i allowed the democrat witness to go first. I hope that is noted as we move forward, continue bipartisanship on this panel. I allowed the former senator and former member of this body and house although a few extra minutes out of professional courtesy. With that, mr. Attorney general, you hit on something in your testimony that hear about all the time in the seven counties in my dizzy, urban, suburban,rn small town. Thats the impact. Employers are saying ive gotal three positions open and i cant find anybody to fill the position or who can pass a drugd test. From your perspective and all the work youve done in this area, whether its heroin or opioids are whatever type of drug abuse, where do you see in our state the problem being the worst in terms of economic p conditions . Is it in places that have historically been left behind . Does yardley not make a difference . And you give us your thoughts on it . Graphy mr. Chairman, i think if we analyze this, what is differentm about this drug problem that we have is how pervasive it is. It is absolutely everywhere. It is in our smallest communities. Its in our cities. Its in our most affluent suburbs. I think if you go back a historically, you could trace histbeginning of this to southern ohio, our appalachian counties come in regard to the pain med problem. We think that most of the addiction, although some people may start on heroin, most people become addicted to the pain meds and moved to the heroin becausep at some point they cant get the pain that anymore and because heroin is so cheap. They moved in from possibly defend no and carfentanil. If you go back ten years where you would see where the biggest problem would be is southernrn ohio with the pain med problem. Im not a sociologist. Im not sure i can guess but i dont have a great deal of expertise in this area at all. It starts with that, but it is absolutely everywhere. Part of the challenge i think always as you look at this problem, and i know that some states are at a different stage than we are. We are well down the path. What i would, you know, suggest is the biggest challenge you have is getting people to understand that this is a problem in their community. Their community. For the last five years every interview ive done on this, i looked into the camera if theres a tv camera, and i said if youre watching this, you have an opioid problem. You have a drug problem in your community. So one followup, you a mentioned the demand problem, and talking to give his early as kindergarten. How about the supply problem . O is there any way to do with thei you say you see before in our state. Any thoughts on the supply issue . Of course your talk to someone who is a county prosecuting attorney, and so, and what we do in the attorney General Office is assist local Law Enforcement. We always look first to Law Enforcement problem. What we did five years ago is weekly what we called Law Enforcement heroin group, you know, out of bci. I cant really talk in publicnf about exactly what we do, we will go in and help the local sheriff or the local prosecutore or the local police and once they start of the drug investigation, we will help them take it to eye level indicator the bigger fish in the bigger drug use. That remains a central part of what we do. I have talked to the attorney general. Of the United States, about cooperation with information coming off the border. Thats a work in progress. So that we get realtime information coming off the border. Back into ohio. So we do work with our federal partners and the fbi, Drug Enforcement administration and we have a close in good working, relationship with them. Law enforcement is a key component part, but we are not going to rest our way out of this problem. We have to deal with it were holistically, which is to do at better job with regard to treatment getting people into treatment and keeping them in treatment. O and we have to do a better job, a much better job with prevention, which were i think w is the most opportunity. If you look at this from the long run, where are we going to be in ten years, 15 just come in 20 years, started in kindergarten. Very few schools are doing thisn thank you. Professor deaton, you talked about the death and disparity, Economic Conditions that cause it. Are those Economic Conditions from your perspective getting worse, trending better, or is it geographically different . I think they have gotten somewhat better in the short run, but i dont think of this as being a short run problem. I think this is a deeper problem to do with, you know, what people who dont have a University Degree are going to do with their lives. And the world that fee used to inhabit is a world thats broken. And i think the meaning, the things that gave meaning to the lives, the steady jobs, are really not there anymore. And i am not particularly optimistic. I dont think its a good idea for everyone to go to college. I just think maybe things like apprenticeships may be a new way of thinking about that world of work really would help. I should say though that i deemphasize the opioids because that was my shtick here, but i think doing something about the opioids in some sense the easy part of this, though god knows its hard enough, and that we really have to do that. We really have to change this culture of doctors that believe that pain should be treated with heroin, essentially, which is something we never used to do. Thank you, professor appreciate that. Ms. Hassan is reckoned after five minutes. Take you very much mr. Kerry. Thank you all for your testimony. Dr. Frank, medicaid has served as a lifeline for states had yoen hit hardest by the Opioid Epidemic it and experts havek,ai said its the number one tool we have in combating this crisis. As a former governor i certainly understand how critical it is been in ensuring that grants to struggle with addiction have access to treatment and recovery services. So im obviously concerned that the republican bill that passed out of the house in april would fundamentally change the Medicaid Program as we know it. Instead of being a guaranteed benefit for states and the residence, the per capita cap in the plan would result in massive cuts that would set limits on federal contributions regardlesl of the need for care and services that will mean less buying power over time and belief states with far fewer resources to provide services to their citizens. Could you address out a percapita cap approach to medicaid would impact is difficult to fight this epidemic and or future Public Health emergencies . Share, thank you for that question. The percapita cap essentially is set up so that it locks in u 2016 per capita spending patterns and then inflates them forward at what Congressional Budget Office predicts is aboutm 3. 7 , which is the expected consumer pric price medical component. And so what that does is it allows you to keep up with the general inflation based on the 2016 patterns of treatment. Now as we know, mortality from opioids is growing at 15 a year. Hospital admissions at about 6 . Drug treatments for opioid addiction is growing at ten to 12 a a year. And so what happens is when you have a percapita cap that spacd on that 2016 pattern, and new things happen, or older things grow faster, you start to fall behind very quickly. Thank you. Dr. Sacco, we know to your point that we need to attack the supplyside of this epidemic am something we have been working on in New Hampshire. And we know how Law Enforcement plays a Critical Role in cutting off the supplyside of illegal opioids and other drugs into ouf communities. But in New Hampshire are Law Enforcement officials will beo the first to say, just asenforc attorney general mike dewine did, we cant arrest our way out of this pub. I remember the colonel of my state police when is a new governor calling the if i could testify in favor of Medicaid Expansion because we need. We need to treat this as a Public Health crisis that it is an focus on addressing the need demandside, which means having an effective Public Health response that could be more cost efficient and effective. Oftentimes medicaid, medicationassisted treatment is less costly than simply of incarcerating someone with a Substance Use disorder, not to mention being more effective at addressing the problem in reducing recidivism. Dr. Sacco, do you agree the opioid academic record both Public Health and Law Enforcement responses to address in the crisis or do you agree with the Law Enforcement officials in my state and the attorney general here that we can simply arrest our way out of the problem . Ou if you are seeking to address both the supply and demand, then yes, it would be a comprehensiv, approach. Law enforcement a strictly supply order, but yes, right now the response seems to be one that is comprehensive. Okay. Ow and would you agree that working on expanding prevention treatment and recovery programs including medicaid is important to helping address the entire crisis . Ams i crs does not take a position on the advisable of that, im sorry. Dr. Frank, proposals come out of the house would undermine tha essential Health Benefits provision of the aca, that requires the coverage of Substance Use disorder services. Cbo says that could increase outofpocket costs by thousands of dollars. Do you believe a limiting Substance Use treatment places a greater access to care for people struggling with Substance Abuse disorders . Absolutely. Weve seen in the states, for example, that expanded medicaidi and in states where theres been dramatic decreases in the uninsured rate from private insurance, we see those of the states that have responded most strongly with medicationassisted treatment in serving people with opioid abuse disorders. Thank you very much. I see my time is up. The gentleman from minnesota is recognized for five minutes. Thank you, mr. Chairman for holding dishing on such an important issue that is havingso such a Significant Impact on hea communities across the country. This is certainly as the mentioned the testimony of problems that is everywhere. Unfortunately minnesota has not been able to escape the devastating effects, economiche. And otherwise, of opiate addiction and opiate crisis. Just last month i spoke to a mother from maple grove whose son bought an analog of fentanyl online, consumed it and he died it goes without saying that she was devastated by the loss of her son. She was also devastated by the ease with which he was able to purchase the opiate online. While it may not be within the scope of todays hearing or to mindy there is a role for congress to play to ensure that opiates are not so easily accessible. Unfortunately minnesota was found to much higher profile opiate case overdose case on april 21 of last year, prince, one of the most successful, pop artists of all time passed away in chan hassan after taking fentanyl. My point is that this is a problem that affects the different types of people, old and young, rich and poor, yourmy neighbor down the street as well as an international celebrity. Doile it is important we understand and address the physical and emotional effects of opiate crisis on americans,er theres also value in coming to grips with economic toll is taking on the country as well which is why appreciate havingn such a great panel of witnesses that here with us today. Let me just start with a few wie question. The synthetic opiate phenol is one of times more potent than morphine and carfentanil similar but it is 10,000 times as stron as morphine and was developed for tranquilizing elephants and other Large Mammals in just the. Past years sit in odessa skyrocketed. In ohio as you make an average l think for from 200 2007 from 201 added 2015 there were 1155 that no Overdose Deaths. Do you have insight into the reasons for this development in ohio in particular, or are there parallels or lessons that can be drawn for other states . Congressman paulsen, thank you for the question. Carfentanil is so dangerous, and fentanyl as well, but carfentanil certainly much more, that about a year ago we sent a bulletin out to every chief of m police and every share in thego state telling him and her ande e their officers, many women of these departments, dont field test drugs anymore. Stop it. Dont touch it. Ti we had an expert in ohio within the last month or so where an officer overdosed literally because he was in the presence of this and some of it got into his system. So it is highly dangerous. We believe a couple of things are happening we believe that the fentanyl is coming in primarily from china, although certainly some could be actually being made in ohio, but we think mostly it is coming in, i know senator portman has been directly involved in that concern and members of house and senate have been. I think you see the drug dealers, they are great marketers. I mean, its amazing. This whole system is all aboutam customer service, and its all about delivery. I mean, i tell people that if you look at heroin, mexican drug cartels have developed a perfect business model. They grow the poppies in mexico, ship it across our southern border into ohio. They control it down to the street level. At some point they may sell it off to the local dealers. Then what kicks in is what ier call a pizza delivery system. You pick up the phone, you call and they will delivery. You get in half an hour, get itchy. But they get you started, and im told, im not a medical expert but im told the ratio between earlystage heroin addict and maybe a late stage of an addict, do not taken to be a size 100 to one. What starts as a 10 a day habit may go to 100 to 1000 a day h. They are always chasing a high. And what the reason i think you get the fentanyl is t two thing. One, its easier for the drugay dealers to get, and is cheaper for them and they can make more money on it. And number two, its a way to fr broadcast that, this is something different, this is a better high. The ironing, the ironing is thad when we get a situation where five, six, seven people die in a weakened ironing insensate in ohio, obviously because we are on the fentanyl or onto carfentanil and its a different potency or something is a better, the demand appears to go up. And so we worry, we put thee, bulletin out and local long for this has look, be very, very careful. B what we worry about is we are just encouraging people to go seek a higher high. Its just, nothing makes sense about this. I think its clear, peoples brains are being altered. The person who is buying it is not looking at it rationally orr the way you and i would be looking at it today not being addicts. Thank you, mr. Chairman. Mr. Delaney is recognized for five minutes. Thank you, mr. Chairman. I want to thank you for holdingi this hearing unobvious every important issue that affects all of our districts. This is in every community in the country, and the fact you have a civil such a terrific group of witnesses im gratefulr for the period in a particular want to thank mr. Dewine for what he is doing in holding the pharmaceutical industry tha accountable. Peopll make them pay like other people will, and that will not solve the problem but its the right thing to do and it will send a message that we will start thinking about these differently. We believe in a capitalist system in this country. To i do but we wanted to be just at some level that efforts like what youre doing help make that happen. Its obvious what we need to do and the witnesses have covered it here today. Happen whether we have the commitment and conviction to do is a question, but the steps that mr. Dewine is taking are incredibly important, making sure we manage ourselves to the situation by having the healthtt care system in place thats going to support the people afflicted by this, and i saw fit myself with this candidate from New Hampshire and her eloquent, but imports of medicaid. And dr. Frank, your comers were very encouraging when you talk about how private investment is, sees this effectively a very Large Business opportunity and putting a lot of money and resourcess against it and will be a lot of innovation. The same forces of capitalism that calls the problem hopefully will be directed toward solving the problem, and so if we are pm optimistic perhaps we see a path out of the opioid crisis. But professor deaton, your comment with the most sobering this opioid situation was really kind of the perfect storm or the confluence of events almost like a match to fire based on that. So theyre not moving. Theres no mobility. Ik these people are frozen. They lack security. Theyre not engaging in society the way americans have historically engaged. And the cost of doing nothing against this is, obviously, not nothing. And so as an economist, how do you think about how we should approach this . Because it seems to me a transformative investment is required in these communities if were actually going toee jumpstart them and the citizens of these communities out of the condition that theyre in right now, which will obviously be very expensive. But how do you think about that in terms of not doing something thank you, representative dewine. I wish i knew the answer to that question. I dont i think globalization has been an issue. I think automation in some ways is more of a threat to many of those jobs. Theres not been much of a decline. In fact, in most industries, theres been a substantial increase in American Manufacturing output, but the jobs are not there anymore because we dont need the labor to do that. I dont know. T i mean, i think, you know, you saw this slides i showed. This is not happening in europe. Right. O and europe is facing the same challenges. Globalization is happening to europe. The pressure on jobs is the same in europe. And one of our research topics, i dont know the answer. Am i mean, my friends on the left tend to say europe has a much better social safety net than we do. One of the policies that people talk about is mothers, childrenc get state allowances on a regular basis which stops mothers having to shop around for men all the time yeah. And this sort of merry go round of marriage has slowed down. But theres a lot of dysfunctions and what is the cost to us if we dont solve this problem . Well, i think the opioid problem get solved putting aside the opioid problem, but the more structural problem that you identified. It depends on what the kind of i mean, do you actually think we can do something about this, and what is that something that we can do. And i certainly think we need to think through all possibilities and look at some of the thingsut that are happening in europe. The german apprenticeship system seems to really hold people together in a way that doesnt happen in this country, for instance. I know a lot of employers are upset about the labor force coming out of college or below is not trained for what they want and some sort of apprenticeship system may help that. But i really, i dont have any Surefire Solutions to solve this. Thank you, sir. I d gentleman is recognized for five minutes. Thank you, mr. Chairman. Have you ever had one of these evenings where you cant sleep, so youre up reading about and i read over all of here, and i want to find an elegant way to say this. Because being from arizona, a border state, we at leastin document a couple lost lives every single day in arizona. But in not talking some of the book from my friends on the left, id love to actually take a step backwards. Because theres things in the data i actually built some charts off dr. Franksst information, and in some ways i couldnt make parts of your argument work with the chart. You know, during time of Medicaid Expansion my numbers are going up still double digits, so is there any data sets . T if we were just to wipe our minds clean of our partisan angst and say give me something to look at that would help us do policy of is it an economic driver, is it the synthetics that are so small, theyre easy to the transport and ship, is it, you know, border, is it demographics of the aging of my society . If i were to try to build a number of charts and say heres my inflection, heres where were going to build our policy goal, please, someone help me build what that policy is. And i was going to go to dr. Sacco. You live in this, youve been doing this for years. You had some real interesting stuff in your writeup. Where would you take us if you were building the policy . I think some things have already started. As youre more than aware, i in china, as you know, most of the fentanyl is coming from china. China recently scheduled for fentanyl products. And at this point, this was only in march. This remains to be seen whether this has an effect on whats coming over from china. Theres i think i mentioned increased production of heroin f in mexico and declining production in south america. It may be worthwhile to take a look at reducing the poppies in mexico but my fear is thats not my Global Solution. Im just now chasing a substitution of product. Oh, no, im saying im speaking to the supply side today. Absolutely, you should speak to my colleagues about the demand. Dr. Frank, you have something to this. Yeah. In a sense youre asking, theres the sort of growth problems, theres the levels problem. On the levels problem, if we cut the number of opioid prescriptions in this country by 90 , we would still be the Largest Consumer of opioids in the world. So in that model, one of first things you would do is lets say we could wave a wand and the elimination of prescription opioids. No. I think its more making sured that all our providers are trained in the best possible practices. Because i dont think we can ignore the pain problem. We have a real pain problem in this country. Okay. Well so i think that we need to sort of balance the two. And so far weve tipped the scale too far the other way. But in just from a, you know, a junior standpoint, just looking at what the chemical compounds were in the synthetics, its not that hard to make. I mean, the precursors, so im still not hearing a global professor. From an economist standpoint, whats my Global Solution . I wish i knew. Im more skeptical than dr. Frank is about treatment. I think the, you know, somehowow we have to choke back the supply. I mean, its interesting to look back to 30 years ago, what happened with the crack epidemic which devastated a different set of communities. And i think is there a parallel we can learn from that . Well, i think the communities dealt with it, in the end, and it became sufficiently pervasive that the communities, you know, its what attorney general dewine was talking about. We can educate the communities to the point where this becomes completely intolerable. And i think we need to be able to do that. And the schools would be a place, but the police are working on this. E. And its still true that not all that many people know about it. R and i think doctors really have to be choked back. I do believe that there is a genuine pain epidemic in this country. I dont know how much of it was stoked by opioids, how much of it was stoked by the Pharma Companies, but i think theres Something Else there, and we have no idea how to treat that. Thank you, professor. Mr. Chairman, im genuinely grown to believe this is one of those we do everything from economic to information to restrictions to access to it may be theres not a magic bullet. It needs to be an armory. Thank you, mr. Chairman. Thank you. The gentlelady from minnesota is recognized for five minutes. Thank you very much. Thank you to all of you. I see senator portman is here and along with senator hasan, weve been working hard on these issues for many years. We passed our bill last year which, of course, et the framework out. Set the framework out. And i really look at this as three different things. One is trying to stop people from being addicted in the first place, and thats things like getting the drugs out of thee medicine cabinet, changing doctor prescribing practices and doing something on stopping the huge amount of drugs out there that are legal but arent being used in the right way. The second is treatment, of course. And the third is then going after the Illegal Drugs, and were going to see more use of that as we, hopefully, can reduce the number of legal drugs that are going out and getting people hooked. So along those lines, attorney general, i was really interested and happy to see that you brought that lawsuit against five opioid manufacturers alleging that the Drug Companies engaging in fraudulent, deceptive Marketing Campaigns about the risks and benefits of these opioids. I know there was a settlement in West Virginia and a similar case. The money, of course, goes into treatment, and it seems to me that the people responsible for marketing these drugs should pay for the human cost of what has happened here. So could you talk about what you can about that lawsuit and how you think it could be replicated across the country . Because all the education were doing isnt getting us the money we need for treatment, and its not stopping the bad guys from getting people hooked. And by that i dont mean Illegal Drugs. Senator, thank you for the question. You know, i made it plain last week when i held a press conference that when i explained what we were doing and why we were doing it, one thing i said to my ohio citizens is this is not a substitute for the hard work at the local level. I am convinced that the work has to be done at the local level. I started seeing five or six years ago when we were dealing primarily with the pain med problem that the communities that were making the most progress were communities wheree it had gotten so bad, they just got sick of it. And its usually a grassroots effort led by a mom. Sometimes a dad, but its usually a mom. And they just go and they try td transform the culture do you think a lawsuit, which i believe like in the fact industry the lawsuits actually got the information out there yes. And so it stopped people from doing bad things . Yeah. Let me get to the second part, senator. Thank you very much. We believe this lawsuit is a fair lawsuit. We believe that what the evidence will simply show is that the pharmaceutical companies beginning in the latew 90s tried to change the culture. The culture historically had been for pain meds that theyre used for acute pain. Youd have your tooth taken out, youd take it for a day, twowo days, three days. Or to use at the other end of life, at the end of life when you have someone who is terminally ill. What the pharmaceutical companies did is they tried to convince doctors and did convince doctors that, hey, it was okay to use for a third purpose. And that third purpose was for pain that goes on day after day after day but is not terminal. Pain management. And they did that. And they were very successful in doing it. In answer, in response to your question, one of the things i would like to see these companies do and they can do it tomorrow and start, lawsuit or no lawsuit is to spend some money to change the culture back to where the culture should be which is several of you have said is somewhere in the middle. Thank you. And we also have a bill withe senator manchin that would put a fee on some of these drugs and have, again, that go per milligram, have that go to treatment. And so i guess, professor deaton, congratulations on your good work. Could you comment on the attorney generals what hes done here which i think is commendable and how sometimes lawsuits can change the Economic Situation if companies are afraid of getting sued, thatsu its not just public shaming, but actually out of their bottom line that that that can make afr difference in how they behave . Thank you, senator. , yes, i think it can make a difference. I mean, i dont have the figures, but the l. A. Times reported that the family that owned oxycontin had made 51 billion from it by the middle of last year. This at a time where that truck is killing large numbers of people. D and i think, you know, we ought to make it clear that this cannot be tolerated. I also agree with the attorney general that the local effort is where the culture will be changed, but we dont need Pharma Companies trying to push doctors to prescribe addictive opioids for lower back papes. Right. It just makes me cry when you see all these these rehab people and small town mayors and cops trying to do the right thing x then these people are getting a different message either on tv or when they go into the doctors office, and it just has to change. Thank you. Thank you. Its an honor to introduce my senator whos been a national leader, as you know, attorney general, on this issue. Talked to me last session of congress about introducing a bill, which i did, that youve been a leader on, deals with the fentanyl issue coming in from china. For f thank you, mr. Tiberi, i think you have 123 cosponsors, im told, and thanks for crs for helping us with that situation and to mike dewine for his help from the state of ohio who cares a lot about the supply side and keeping this poison out of our communities, but also someone who gets it which this is ultimately going to be solved through a comprehensive approach focusing on the local community. I was in this room 20 years ago as a house member trying to get legislation through called the drugfree communities act which is now a law that has helped spawn over 2,000 community our whole purpose was local, and yet here we are. The worst drug crisis many our history by any measure. As bad as its been in the past. And i think what weve learned today from this terrific panel of experts and also from some of our colleagues including congressman schweikert is that, mr. Chairman, the comprehensive approach that youve been advocating is the only way. And it has to be at every angle, and it has to include much more aggressive prevention and education efforts. Senator klobuchar and i are cosponsors and authors of this stop act. Ed senator hasan is one of our original cosponsors, by the way, is here two. But she also is one of the original klobuchar, me, whitehouse and others pushed this comprehensive approach in the comprehensive addiction and recovery act. But it includes a big component of education and prevention as yet to be implemented including a National Awareness campaign oe making this connection that attorney general dewine hass made well today between Prescription Drugs and heroin, fentanyl and other opioids. And i think professor deatons right, a lot of people dont make that connection because theyre not aware of the information. So so when you go to a doctor and someone who you trust prescribes Opioid Pain Medication and says heres 60 percocets, take this for this oral surgery youve had, you trust that doctor, and you do that. And for some people there is, obviously, a change in their brain which is a disease which is called addiction. And that is something that wee can do as part of this. And there are other aspects of the legislation that need to be implemented, and ive urged the Obama Administration as im now urging the Trump Administration to quickly implement these things in the face of this crisis. A couple quick questions. Ma one to senator dewine and, again, as the chief Law Enforcement officer in our state, you know much better thaw i whats going on. But i just got an email yesterday from the coroner in the ca hogue georgia county ca Cuyahoga County and he reported that 43 people have died in cleveland in the couple of weeks since memorial day. He believes its fentanyldriven can. By the way, this is in contrast even to the horrible rate of overdoses and deaths last yearhe of being, you know, more in the 2030 range. Were now even in this year, in april it was under 40, now in two weeks over 40. So can you talk a little bit about whats happened in ohio and maybe specifically what imc hearing back home which is this notion, to professor deatons point, about whos being affected, that this is now being spread into the Africanamerican Community more with regard too these evil traffickers sprinkling fentanyl in cocaine and starting a whole othere series of addictions. If you could just speak to that a little bit, id appreciate it. Well, senator, thank you very much for the question. Ad thank you for the great work that youve done, youve been a real leader in this field. You know, i think there is a natural pro depression which starts generally progression which starts generally with a pain med. 35yearold, 40yearold blue collar male hurts his back, is prescribed pain meds, becomes addicted to it and everything goes downhill from that. Es he moves over to the heroin because its cheaper and its maybe more available. And then the other thing that you have as you point out going on is fentanyl now. And the fentanyl, were finding fentanyl a lot more now, more and more and more and less and less heroin. It used to be it was sprinkled in with it. One of the things that were seeing in our crime lab is that these cases are much more complex and take longer to do because instead of it being all heroin or all fentanyl, its all mixed up. Of and so it slows that down. But i go back to something i said a moment ago. I think it is a marketing technique. To and these people who are selling this stuff who are killing people, theyre good marketers, and theyre its all about service. And its all about getting the best high. And part of the marketing is, hey, weve got something new, and that something new may, inhi fact, be fentanyl. As far as it moving more into the Africanamerican Community, i dont have any data on that. E but, sure, it would appear thata thats anecdotally would appear that its getting pushed out. And, you know, as i look at inti this problem from a, maybe a big picture point of view, sometimes people will ask me, you know, mike, what keeps you awake at night as the attorney general. My quick answer is the opiate problem. I think its a bigger problem,ui and its been alluded to by several people here today. The opiate problem is a subset of a bigger problem. The bigger problem is that we have a large number of people in ohio and other states who are not living up for many reasons to their godgiven potential. And weve got a problem with people not having the right skills. And that does impact this some. Not in every case. I mean, were seeing a lot of middle class people who everything would appear to be going fine in their life. But theres something going on there that causes that person to become addicted. But a related problem is the fact that weve got ohioans and people, im sure, in other states who arent living up to their godgiven potential because theyre addicted or, and or usually, many times they dont have the education. They, as the professor said, they do not have the education. They do not have the set of tools to make it. And part of it is we do have to, i think, start saying to people and we have to start parents need to be saying, look, to their kids, we want you to live up to your full potential. Maybe youre working with your hands and you dont go to college, but maybe you go to its been said an Apprentice Program or Something Elsewhere you can become a welled, or you can become a welder or you can become a machinist and make a very good salary. So i think all of these things are tied into each other. And part of our challenge in ohio and other states, i think, is to focus on kids who are growing up, because its easier to impact them than it is its not that were not going to try to impact someone older, but the kids who are growing up and make sure that they have all the opportunities that are there no matter where theyre born and no matter what their income or who their dad is or who their mom is. And i think, to me, thats part of our solution as we look at the pain med problem. Thank you. My time has expired. Thank you, mr. Chairman, for your indulgence. I have some questions for you, professor deaton, for the record about the Economic Impact of what you described x. I think the notion of opioids being an accelerate rant to what you andc senator warner just talked about is, actually, an apt description. Thank you, mr. Chairman. Thank you. Gentleman from virginia is recognized for five minutes. Thank you, mr. Chairman. And thank all of you very much for being here. Its fascinating. It at least looks like a triangle in terms of theres the supply problem as argued by general dewine and g. Sack row dr. Sacco, theres the hopelessness from professor deaton and then the treatment side from dr. Frank. To dr. Frank, can you cite thehe reasons why those with an opioid use disorder would not seek treatment . Yeah. About a little over half dont seek treatment because either they cant afford it which is the biggest chunk or there are no providers available to them. And so thats, thats a little bit more than half. And then the other main reasons have to do with stigma in theit workplace, in the community. And also theres a lot of people who deny that they have a problem. If i could take one other second, i just want to kind of clarify the issue around treatment which is kin medicationassisted treatment is really the most effective treatment we have, but only about a quarter of the people who get treatment get that. W and so were undershooting our potential by a great deal. And thats what, in a sense, causes us to underachieve. Thanks. You know, we have the obamacare reform replacement appeal bill is in the senate right now. I think senator cassidy says he wants to make sure it passes the jimmy kimmel test which theto house bill clearly didnt pass. But im hoping that based on all were learning now, and senator portman talked about this is ths worst addiction crisis in the nations history. Whatever bill comes out of the senate, hopefully it passes the opioid test. Professor deaton, you said this hasnt hit europe yet, there might be a temporary reprieve. Can you explain why the fentanyl from china hasnt affected that population . At least yet . Ve i mean, thats for us, i guess, it used to be the 64,00t question, now the 64 billion question. You can see some of this in the englishspeaking countries of the world. You see some of it in canada. Theres a little bit in britain and in ireland and australia. Perhaps a little bit in denmark. And if you looked at those countries just by themselves, you would be worried about it. But when you put it in the context of the u. S. , theresnm nothing happening there. Partly i think its because the Prescription Drugs are controlled much more carefully in europe, and theyre used inrt clinical, acute settings, and theyre not prescribed in the community yet. But, i mean, theres a concern that they will spread out into the community, and i think the fentanyl thing i dont know, but the heroin, for instance, is coming from mexico, and they have very easy targets here. And maybe fentanyl will come to europe in the same way too. I think the europeans ought tot. Be worried, and they ought to be, you know, they ought to make sure that they dont get to where weve gotten to. And they want to be very careful about it. But we dont see the signs of this epidemic, and i think part of it is the control. Thank you. Do dr. Sacco, youve been, looks like, studying this drug thing for many, many years academically in crs. What did we learn from the crack epidemic thats relevant to fighting the Opioid Epidemic . Im sorry, did you say what did we learn from the crack epidemic . Ra yeah. Are there lessons from the crack epidemic that are relevant here . Im not sure i can offer an opinion on that today. Y. Okay. Its a little bit outside the scope of what i prepared for, but happy to follow up with you. I dont have anything specific to the crack epidemic for example, weve seen that weve responded, for example,th with lots of incarceration. We were pretty harsh about that. Theres been a movement, bipartisan, in the criminal justice away from, you know, criminalizing, essentially, nonviolent drug offenders or the harshness of it. Perhaps not with the attorney general recently. Is that a solution here too . Or do we tilt more to the treatment side . I, you know, i cant advise one way or the other. I can certainly tell you that drug offenses account for the majority of federal offenses carrying a mandatory minimum. The fact that youre speaking to mandatory minimums did come outa of that era of the crack s epidemic, and there are different ways of looking at the efficacy of mandatory minimums from an economic standpoint. Research says that lengthy mandatory minimums are not Cost Effective and that other factors, such as certainty of arrest and prosecution, have a greater deterrent effect than the severity of the punishment. So in other words, a oneyear sentence be likely has the same deterrenting effect as a tenyear sentence. On the other hand, incapacitation prevents an individual from committing harm to society for that set period of years. At the same time, it is not clear if that punishment reduces crime. Often lowlevel drug offenders are easily and quickly replaceable. T thank you very much. Mr. Chair, yield back. Thank you. De the gentlelady from virginia is recognized. Ea thank you, mr. Chairman. And thank the witnesses for being here today. Weve seen in my district and im in northern virginia, just cross over the bridge here we have had a rise in ms13 gangs as getting more involved now in trafficking of heroin and opioids. And so were seeing this convergence of, you know, very violent gang and then preying upon very young people, both trying to recruit younger people into the gangs, but then also getting them involved in these various things. What are you how can, you know, what kind of effect are you seeing anything like that . Are you seeing that elsewhere or how thats going to impact the economy . You know, particularly when you get these young people thatik theyre getting into these gangs and its a whole lifestyle and thats how theyre making a living. Theyre not getting educated and will be even in a worse situation. Sorry, is that addressed to me or sure. Thatd be great. Yeah. Im not sure i can really answer that question. What i can say is that when we look in ohio, you know, our Violent Crime in our cities, a great extent of that is driven by gangs. And there is many times a connection between Drug Trafficking and the gangs. Betwn and i know weve been focusing on the lower income an how weve seen the rise there, but i know we have seen in my district we have, you know, very high, a lot of high income areas in this region, and were seeing it hitting everywhere. So i did want to make sure here today even though were it was focusing on that lack of opportunity, that this is, you know, were seeing this in every fommunity. And with every aspect. S and so what is the difference when youre seeing, say, collegeeducated kid who maybe just got addicted to these frome a sports injury and then just took it too far and then theyre in this lifestyle, what are you seeing the difference between, you know, somebody like that versus, you know, this expansion in the lower income area . Thank you professor, thank you. The, i think its income is not the best marker of this partly because africanamericans tend to be, there are a lot ofhe low income africanamericans. And until recently africanamericans have been largely exempt. From this epidemic. That does seem to be changing, and there is a tick up in the last two or three years in mortality of africanamericans from opioids. And that may be fentanyl, it may be spilling over into those communities. But low education has certainly been an issue. And what you say is true, that Higher Education people are suffering from this too. But nothing like to the same degree. Ha i mean, this huge explosion has been among people with only a high school or even some college, but with a b. A. Its much, much less. You certainly find people, for sure. Its everywhere. Ch, much but its throughout the community. I think also some of the standard protect i have forces from people protective forces from people have sort of broken down. One example i like to give is utah has always been a very healthy place compared with nevada and for sort of obvious reasons. S but utah has not at all been exempt to this epidemic. And thats because, you know, mormons tend not they dont drink, they dont smoke, they dont do things that are bad for your health. But when your doctor gives you pills, that is not something youre programmed to resist, and the church has not been very good at dealing with that. So so the education efforts and the comprehensive approach that senator portman and others were talking about and the attorney general was talking about really at that young age, kindergarten, and making sure education efforts really needs to go everywhere then. Stop the docs pushing this. Yeah. And let people know its dangerous. Yeah. Thank you, i yield back, mr. Chairman. Thank you. The gentleman from illinois is recognized for five minutes. P thank you, mr. Chairman, for this hearing today and for this subject matter. And i want to thank the witnesses for your valuable testimony here today. Ive seen the devastating effects of opioid abuse andes heroin deaths in my own district. I represent a district of 19 counties in central and westcentral illinois, very rural district, and did a series of town hall events related to this issue with all the stakeholders, and it continues to be a problem. Weve talked a little bit here i today about some of the analogies to this epidemic, and we talked a little bit about crack cocaine. I spent ten years as a state and federal prosecutor, and i think back to in illinois 20, 25 years ago we had a real problem with drunk driving. It was number one killer in illinois of young people. And so what happened . We had an aggressive Law Enforcement effort. We raised awareness. A lot of tragic deaths. But we also had mothers against drunk driving which played a significant role from an organic level, kind of what you talked about, attorney general dewine. W we also used technology,ic ignition interlock. So today we have some of lowest levels of drunk driving deaths anywhere in the country, and thats because of an effort. And it was a movement at the time to do that. S and i think about that analogy here today. The addiction is much different here, but were able to reduce that problem and solve that in a variety of ways. And i think you have to weve talked about this, holding everybody in the chain accountable. All the way new. And im not sure all the way through. Is and im not sure were doing enough of that right now, and weve touched on some of those things. Attorney general dewine and then, dr. Frank, you want to comment on that . Congressman, i totally agree with you. This comes at the local level, the state level. Certainly, the federal government can play a role, but ultimately i think it comes back to the individual community. And, you know, what we have seen in ohio in this area is the communities that have started to make some real progress, number one, admit they have a problem. Number two, theres a Citizens Group thats put together by a mom whos lost a son or lost a daughter, and they go out, and they just they change the culture. Now, you still have a problem, but they make, they make some progress. I saw it in my own career. I introduced a bill in the ohio legislature, a drunk driving bill, and people were laughing at it. This was back in the early, early 80s, and it was the mothers against drunk driving who, frankly, got it passed. Yep. And it just shows that, you know, its the example i think we can all use with people,g look, you can make a difference. You can change the culture. You can change what people are talking about by a very active Citizens Group either at the local level, the state level or the national level. Dr. Frank, i may, you know, people also remember when we talk about drunk driving about, you know, the tv commercials that talked about these tragic deaths and highlight of just how horrific some of these were. And im not sure that we had that level. And if we have, maybe theres some states or local areas that have, that we can use as a Success Model on that. Yeah. I do want to offer a ray of hope, because we havent had much here today. And that is one area that weve been really successful on is ina reducing the number of prescriptions on methadone fors pain. It used to be that they were 6 of the prescriptions in opioids and 30 of the deaths. And weve turned that around. And the way weve turned it around is, i think, by being very aggressive in training and educating of the physician community, making sure that our Prescription Drug monitoring programs really focus on that, and then cms, through the Medicaid Program and through medicare, took measures to issue guidance to states and to do edits in the Prescription Drug plans under part d. And together they really brought down those prescriptions. And and i think that, you know, in a sense is a reflection of the sort of multipronged approach. And i do think that offers us a it bit of hope here. Professor deaton, you touched a little bit on how we maybe hold doctors accountable and what we need to do. Is there and much of that oversight on doctors and physicians is done at the state level. Is there an example of a state that has done a pretty good job in terms of holding doctors accountable . Im afraid i dont have an answer to that. Weve done very little work on d the geographic aspects of this epidemic, so i cant answer that. Thank you. Okay, thank you. Thank you, mr. Chairman. Thank you. Really appreciate all four of you being here. What great testimony we were t able to hear today. Im going to allow the acting Ranking Member, the gentlelady from New Hampshire, to have some final comments as well. Thank you, mr. Chair. And thank you all on behalf of Ranking Member heinrich and myself for being here and for your testimony. And i just wanted to close with the thought of a particular constituent of mine who is now in recovery from heroin addiction. Because i think its important as weve had this discussion to remember that, ultimately, this addiction is a disease. It is caused by a Chemical Reaction in the brain. And it is because people like my constituent, ashley, who woke up one morning to find her husband having overdosed and died next to her. She went and got treatment. Under Medicaid Expansion, she has gotten well. And she now is working, and shes getting her Health Insurance through her private employer, shes off of Medicaid Expansion. And i think its really important that we also to acknowledge the comments weve had about the importance of community response. Thanks to people who have this disease who have stood up, who have identified themselves asy people suffering from addiction, have done the hard work of Getting Better and then have turned their efforts to the make sure that they help with the prevention and recovery effort that is we need to undertake. So im going to keep ashley in my thoughts today. Shes about 17 or 18 months inak sobriety now. She continues to get treatment for recovery. Hes going to be reunited with her 3yearold son soon. Me there is hope if we go at this with the alloftheabove approach. Thank you so much. Thank you, senator. Thank you again. There are stories like that that we all can share. S attorney general dewine has shared many with me as hes on the front lines. But i appreciate, and i think this entire panel, if you couldnt tell, appreciates the time you put into this testimony. You all complemented each other quite well. This is a battle that were going to continue to fight in a comprehensive way and appreciate the knowledge that you were able to share with us today, and we look forward to working with you in the future. The record will be open for five Business Days for any member that would like to submit questions to the four panelists for the record. And our hope is that youd respond as well. This hearing is adjourned. Thank you, mr. Chairman. [inaudible conversations] [inaudible conversations] today defense secretary james mattis and joint chiefs chair Joseph Dunford testify before the House Armed Services committee on the pentagons nearly 640 billion budget request. Well have that live at 7 p. M. Eastern here on cspan2. Tonight on the communicators i decided this was a column in championing average people who never wanted to be techies. And in challenging the companies, the industry to serve those people. The first of a twopart conversation with one of the nations bestknown technology