Transcripts For CSPAN3 State Officials And Physicians Testify On Economic Impact Of Opioid... 20170609

Global rise of antisemitism. Next a look at the Opioid Crisis and other forms of drug abuse and their effect on the economy. Witnesses included Ohio Attorney general mike dewine. This is about an hour and 40 minutes. Good morning and welcome. I want to welcome our Ranking Member and vice charmt and other members of the committee who join me in expressing the importance of holding a hearing on the threatening increase of drug abuse. Its become rampant in america and maybe the worst the country has ever experienced. Its devastating families, degrading communities, and undermining several parts of our economy. For several states and districts represented by members of this committee, the problem is acute, as the map displayed shows. The crisis has a regional character. My hometown of columbus, ohio is part of the crisis at the center east of the mississippi. Figure two shows the 2015 Drug Overdose rates by state, which range from 40 per 100,000 in west virginia, to 6 per 100,000 in nebraska. The states represented by the numbers of this committee are among the ten highest rates, including my home state of ohio which ranks third. Drug markets can be analyzed from the demand and supply side. The exact reasons or the extent of drug abuse are not clear at this point. With respect to man, ape a changing perception of pain laid the ground for more intense of treatment. Some Research Shows less Substance Abuse when unemployment increases and while the prolonged downturns in labor market are associated with social behavior and health problems, they do not necessarily affect all groups in the same way, or to the same degree. All of society is vulnerable to this epidemic. Its compounding the economic distress in 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 left hearing, the decline of Economic Opportunity causes and consequences, developed an Economic Stress Index consisting of several economic indicators. A national map, which is shown alongside the map of Overdose Deaths in the tv screens in figure three. The darker the red, the worse the distress. But its also apparent from figure three, that some economically distressed areas are not experiencing high overdose death rates. On the supply side, the particular locations where potent drugs happened to become readily available and the path of Geographic Market expansion. Without question, potency and retail delivery have moved the supply of legal and illegal addictive drugs substantially to the right. Newly effective pain medication oxycontin had initially unacknowledged addictive qualities and was overprescribed. Socalled black tar heroin, more powerful and less expensive, just as oxycontin was reduced in potency around the country. The prescription of drug expulsion started the Prescription Drug explosion started in the appalachian part of my state and spread to parts of kentucky and west virginia. Black tar heroin started in the southwest and spread east across the mississippi in 1998. Fentanyl can be poisonous and kill a person some by mere contact with the skin as attorney general dewine informed me earlier this year. We now face pure poisons massed as narcotics that are ships across our border. We introduced the stop act, which aims to stop dangerous drugs being shipped through our own postal service. Half the members of this committee have signed on as dose sponsors in a bipartisan way, and we should continue to build support for this important legislation. But i would it would be a mistake to blame these drugs entirely for the rise in mortality that some groups are suffering. There are other causes apparently emanating from longterm challenges in and the composition of the economy and skills requirements. Cause and effect is critical to reaching the right conclusions. Feedback often complicate causality and make a clear understanding of major causes that we are experiencing. For example, does a bad economy lead to drug abuse . We will hear about the economic decline of certain groups leading to despair and selfdestructive behavior. And developments of the production of marketing of addictive drug which have made them more dangerous, affordable, and available. I look forward to the statements of our witnesses. I will now yield to the Ranking Member who has another hearing. Thank you, chairman teas about berry and thanks so much for holding this incredibly important and timely hearing. Thanks to our panel for being here today. Addiction to both heroin and prescription opioid pain relievers is a Public Health epidemic that is devastating families and communities across our nation. Every day, 91 americans die from opioid overdose. Overprescription is partially responsible for this epidemic since 1999. The amount of prescription opioids sold in the u. S. Nearly quadrupled. And so too has the number of Overdose Deaths from opioids. The Economic Cost of that addiction are incredible. Totaling more than 80 billion from an increased health care cost, higher rates of incarceration and lost productivity. New mexicoians know all too well the devastation opioids can wreak. For years, communities in new mexico have suffered through some of the highest rates of opioid and heroin addiction and Overdose Deaths in the nation. Rio areba county has a Drug Overdose death rate of 81 per 100,000, five times the national rate. I am reminded of a young man named josh from espanola, who i met a a round table i hosted last year. At 14, josh became addicted to prescription opioids. Over time, he moved to heroin. He stole from his family and his friends to maintain his growing addiction. Josh spent time in jail, where he went through the pain of withdrawal. He even attempted suicide. 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 Behavior Health parity laws and the Medicaid Program. In new mexico, medicaid called centennial care is at the forefront of our fight against the Opioid Crisis, accounting for 30 of lifesaving medication assisted treatment, payment for opioid and heroin addictions. At exactly the time that congress should be giving states more tools to fight this epidemic. House republicans passed a bill that would repeal Medicaid Expansion, artificially cap the program and shift the burden about who and what to cut onto individual states. 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. We cannot fight a Public Health crisis with grant dollars alone. Grant dollars run out, block grants lose buying power over time and private investment dollars, which are critical in the fight, wont come without certainty that the foundation is funded. Unfortunately, i will not be able to stay here to hear the important testimony of our Witnesses Today because of a hearing you may have heard about in the intelligence committee. But i will be leaving you in the 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 used 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 tell ill let her 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 to our Witnesses Today, thank you for being here 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 Opioid Crisis has devastated communities across our state. I know that many of our colleagues have heard of the impacts in their states as well. Im proud that during my time as governor, republicans and democrats in New Hampshire put our differences aside and came together to pass and reauthorize or states bipartisan Medicaid Expansion plan. Medicaid expansion is providing quality, Affordable Health coverage, including coverage for Behavioral Health and Substance Use disorder treatment. Experts have 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 end Medicaid Expansion and Institute Deep and irresponsible cuts to the traditional Medicaid Program. This crisis is a Public Health and Law Enforcement issue. But its also an economic one. I believe the investments 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. Im pleased that were having this hearing today. Im very grateful to the chair for calling it, but we need to continue to hold hearings on how proposals made here in washington would affect our ability to stem and ultimately reverse the tide of this epidemic. This is an issue this rises above partisanship, and this is the work that we need to be doing, because the lives of our people in our states depend on it. Im going to continue to work with my colleagues on solutions while Standing Firm against any policy that will pull us backwards. With that, i thank you and i look forward to hearing from our witnesses. Thank you. Let me introduce our first witness, richard g. Frank, the professor of Health Economics at the department of Health Care Policy at Harvard University medical school. He has held several positions at the department of health and human services. Dr. Frank served as an editor for the journal of Health Economics. Hes the recipient of awards from the southern economic association, the american Public Health association and others. And he is coauthor of the book better but not well. Dr. Frank, you are recognized for five minutes. The microphone. Good morning, chairman te teaberry and senator hassan. Thank you for inviting me. 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 and the receipt of care. In 2015, there was an estimated 2. 66 Million People with an opioid use disorder in the country. The illness is concentrated in the low income population. That is 51 of people with an opioid use disorder or oud, have incomes below 200 of the federal poverty line. Only 26 of the people with an oud receive treatment for that disorder. That means that 1. 79 Million People who needed care did not get it. This is tragic because there are treatments that work. Medication assisted treatment has been shown to be the most effective treatment for ouds. They are combinations of pharmaceuticals, psychotherapy, or counselling, and drug testing to monitor treatment adherence. Now, National Survey data shows that over half the people that did not get treatment because they either couldnt afford it, or there were no providers available. R notetting care were, not being ready to stop using substances, stigma, and the denial of the problem. Now, policy tools are most amenable for addressing the affordable and availability reason. Ill focus on three areas that are helping to make the treatment gap smaller. Medicaid, privacy insurance, and federal grants. Medicaid covers about 34 of people with an oud. Recent policy changes to medication have bolstered medicaids impact preside. The act requires comparable coverage for Mental Health and Substance Abuse disorders, the Medicaid Expansion all have driven medicaid to a growing role. Together these provisions have resulted in large increases in the use of medication assisted treatment. A number of states have been using medicaid as a central part of their attack on the Opioid Epidemic. The state of ohio really reported substantial increases in access to care for people with opioid abuse disorder. In Ohio Medicaid pays for about half the drugs which are used in medical assisted treatment. Private insurance covers about 42 . Recent changes there have bolstered the ability of private insurance to shrink the treatment gap. They are the parity act applied to Health Insurance, the Central Health benefit provisions in the small group and individual market and the availability of subsidized insurance policies for low income. In 2011, a survey of individual market insurers revealed that 34 of policies sold did not cover Substance Use disorders. Today that is no longer the case. Finally, grants to state. The reasons they enacted the 21st century cures act appropriated 1 billion over two years that was intended to focus on closing the treatment gap by expanding kp expandi expanding capacity and direct treatment. Just under 500 million of that money has been recently allocated to the state. Let me take a moment to put that into context using the state of kentuckys experience. Kentucky is receiving a grant of about 10. 5 million under cures. That buys about 1,900 fullyear treatments with medicationassisted treatment. Currently medicaid pays for 4,200 in kentucky and threequarters of that is for the expansion population. That means, if medicaid cuts of the magnitude proposed occur, the funds would not be used to expand capacity and treatment, but would instead back fill for medicaid losses and wouldnt even be able to cover twothirds of those. I now touch on availability. Since policy changes that i described have begun, theres been a surge of new private money into this sector. There have been 170 private equity deals between 2012 and 2015, some as large as 100 million. These private investments are aimed at scaling up base practices and the Investment Community acknowledges its directly linked to the flow of new funds both on the private and public side. So the last ten years have set a platform for closing the treatment gap. Want eviden we are starting to see expansions in both capacity and treatment that will pay dividends in the future. Turning back now doesnt make economic sense and likely leads to tragic consequences. Thank you. Thank you, dr. Frank, for your testimony. Our next witness, lisa sakto has been an analyst and crime policy with the Congressional Research Service Since 2011. The past five years, shes specialized on reports in drugs, drug abuse and other various crime issues. She received her doctorate in criminology and criminal justice from the university at albany. Held several drug related positions and taught College Courses on drugs and crime. Distinguished measures of the committee. My name is lisa sacco. Thank you very much for inviting me to speak with you. My testimony will focus on the supply of opioids in the United States. I will begin with three points from my written testimony that i will expand upon today. First, heroin, fentanyl and controlled Prescription Drugs have been rang ranked as the largest threat to the United States. The availability of these drugs is a contributing factor to rising consumption. Second, the supply of opioids varies by regions of the United States. Third, while the federal government has generally concentrated on reducing the supply of illicit drug, federal drug control funding for supply production has remained flat, while funding for demand reduction has increased. This testimony focuses on the last several decades, as the market has shifted a great deal. In the 1990s, availability of prescription opioids increased and ensuing diversion from lawful use increased sharply. The federal government and state and local governments 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 increased regulation of internet pharmacies in 2008, the reformation of oxycontin in 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 the subsequent rise of heroin embarrass. Heroin is often more accessible. While most users of Prescription Drugs will not go on to use heroin, accessibility and price are factors cited by drug treatment patients. The trajectory for heroin supply is much different compared to prescription opioids, but the stories of their supply are connected. In the late 1990s and early 2000s, heroin dominated the market east of the mississippi river. And cheaper black tar heroin dominated west of the mississippi. Price and purity varied by region. In recent years, the supply source has changed. Over the last several years, heroin prices have declined, and purity has increased. Over 90 of heroin seized is from mexico, in a much smaller portion is from south america. Mexican traffickers dominate the u. S. Heroin market because of their proximity to the u. S. , their established transportation and distribution infrastructure, and their ability to satisfy u. S. Heroin demand. Increases in mexican heroin production have ensured a reliable supply even as demand has increased. Mexican traffickers have increased their production of white powder production and may be targeting those who use opioids. Compounding the problem is the rise of fentanyl on the black market. Its 50 to 100 times more potent than heroin. It largely comes from china and is reportedly cheaper than the cost of heroin. Law enforcement expect that the fentanyl market will continue to expand in the future as new products attract additional users. In 2016, 45 of Law Enforcement agencies that responded to the survey, reported heroin as the greatest threat in their area. In contrast, 8 of respondents reported it the greatest threat in 2007. The reports are in the northeast, midwest and mid atlantic region. Opioids are the main cause of Drug Overdose deaths. Reports indicate that increases in Overdose Deaths are most likely driven by fentanyl and heroin. The increase in available of heroin and other drugs corresponds to the increase in Drug Overdose deaths around the country. New hampshire ranks second in the country in Drug Overdose deaths and they have reported High Availability of heroin in the area. New mexico and utah rank eighth and ninth respectively. But only 4. 7 reported heroin as the greatest threat. This discrepancy may be explained by a number of factors, including fentanyl. Historically, the federal government has concentrated on reducing the supply of illicit drugs. In recent years, effort to reduce the demand for these drugs have increased. Drug control funding for supplier reduction has remained relatively flat over the last several years, while funding for drug treatment and prevention has increased. Thank you. Dr. Sacco, thank you for your testimony. Its an honor to introduce my attorney general, mike dewine, who has served as a state senator in ohio, as a u. S. Senator and now as ohios 50th attorney general. Ohios tough drunk driving law has been a leading proponent for highway safety. Hes advanced the use of dna evidence for victims of crime and worked tirelessly to fight the open yod epidemic in our state. Ive known mike for decades. Im pleased you were able to testify today to give us your thoughts. Youre recognized for five minutes. Members of the committee, thanks so much for inviting me today. The most visible sign of Opioid Epidemic in ohio is the number of deaths that we had. Last year, it was eight per day, i think it was more than that. Today, its clear that that number is going up. But the cost is so much more. Every day in ohio, we is have babies who are born who are addicted. We dont know what the developmental cost for each of those children will be, what that will impact efforts, but we know many of them will 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 there. At a very tremendous cost. Our foster care system is bursting at the seams. Our Children Services are. 50 of all the foster care children are there because one or both parents are drug addicts. 70 of the infants in foster care are there because one or both parents are drug addicts. Our jails are overflowing. We have more women in our prison system than weve ever had by far today. Our jails in ohio, in 88 counties are really detox centers, something that they were not really designed for at all. Narcan, all responders carry narcan. But as weve moved on that, that is a great thing, and weve advocated for that. But as we move from pain meds to heroin to fentanyl, it takes more and more doseages. I had an officer tell me the other day, it took 12 different doseages to bring someone back to life. But the number 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. You can never hire someone who cant pass a drug test to be around machinery, to even be in charge of the local mcdonalds or burger king. You cannot have someone to drive a truck. The missed opportunities, the fact that these people are not living up to their godgiven potential, with the tremendous impact it has on their own family, but also the impact it has on the state of ohio is just absolutely huge. I do a quiz when i talk to employers. I say, do you drug test . If they say yes, i say, what percentage of the people who come in here and you tell them they have to take a drug test leave before they have to take the test, and add to that, the people who come in here, who are arrogant or stupid or both, that take the test and fail it, the average almost every single time is 40 . Its not scientific, its anecdotal. But it tells us the great loss that 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, we took the licenses of over a hundred doctors in the state of ohio. These were bad people, drug dealers, they needed to go away. But what remains is a lot of good doctors who are still, frankly, influenced by a culture that we believe was caused by the Drug Companies purposely. To indicate that someone who has a longtime chronic pain that is not terminal, that theyre an appropriate candidate for pain meds. 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 that 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. O what are the assets that we have, what are the challenges that we face and then 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 that Faithbased Community needs to be involved. And the other thing thats happening in ohio, mr. Chairman, Law Enforcement is doing something it never did before, and thats helping getting people into treatment. Just amazing stories. Excuse me. I gave him an increase in title. Sheriff tharp in lucas county does an amazing job. They take people from the emergency room if theyre ready for treatment and they work with them and get them into treatment. Let me talk about two other things if i could, mr. Chairman and ill conclude. I believe that we need to move to a k through 12 every year, talking about the kids in school about this problem. I think it should be repetitive, comprehensive, and schoolbased, and it must be ageappropriate. Youre not going to talk to kindergarten kids about heroin. But maybe good choices and health. And if you see a pill, dont pick that up. I was on reagans National Commission on drugfree schools. Every expert who came in said, you have to start in kindergarten, you have to do something every single year. We had a Study Commission that put this out. I make this available to anyone who is watching this, or any members of the committee. Its only 23 or 24 pages. We 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. When i was a county prosecuting attorney in the 1970s, heroin 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 is a media blitz, a social media blitz, on tv, that is aimed at really two groups of people. One are kids. And one are 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. The irony is, as we have changed the culture in regard to tobacco took a long time weve gone the right direction. In regard to opiates, weve gone in absolutely the opposite direction. We can turn this around, thank you, mr. Tharchairman. Thank you. Our last witness is professor angus, who is professor of economics in princeton universitys Woodrow Wilson school. Also president ial professor of economics at the university of southern california. Hes a member of the national kack academies of sciences and an honorary fellow of the Royal Society of edinborough. He was president of the American Economic association in 2009. In 2015, he received a nobel prize in economic sciences. In 2016, he was knighted by Prince William at Buckingham Palace ceremony. Thank you for joining us today, professor sir angus stevedeeton. Youre recognized for five minutes. Thank you, members of the committee for holding this hearing on economics and the Opioid Crisis. Thus from legal and Illegal Drugs are contributing to an almost unprecedented increase in mortality among middle aged people. There was a halt at the end of the 20th century. And mortality rates for this mitd aged group were higher in 2015 than in 1998. Driven by these developments, Life Expectancy at birth, fell for white nonhispanics from 2013 to 2014. And for the whole population of the United States, from 2014 to 2015. Opioids are a big part of the story. Supplies of opioids have stoked and maintained the epidemic, selli selling heroin and profitable and illegal. Selling Prescription Drugs and profit ab profit profitable and legal. Opioids have a limited role in treating pain, but perhaps it would have been better had they never been approved. Physicians are far from infallible in detecting which patients are likely to become addicted. And once patients are addicted, treatment is difficult and often unsuccessful. My work has examined open yod deaths an epidemic of mortality, what we call deaths of despair, these are suicides, deaths from challengic 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 50 to 54 without a college degree, who are much more serial at risk than those with a college degree. Deaths of despair are around 110 per 100,000, of which 50 are accidental overdoses, 30 are suicides, and 30 are from alcoholic liver disease, cirrhosis. Theres recently been a turn up in martality from Heart Disease after many decreers have declined and if obesity is the cause, some of these deaths might be deaths of despair, which would put the total level with deaths from cancer or Heart Disease. Figure one shows the mortality rate for white nonhispanics, the red line together with mortality rates for selected comparison countries. The mortality rates in mid life in other countries continued to decline at the rates that prevailed in the United States before 1998. Americans are killing themselves by drinking, by accidentally overdosing, by overeating or more quickly and more straightforwardly, by committing suicide. Deaths of despair have risen parallel for men and women. See figure two. Such deaths like all suicides are lower for women than for men. But the increases have marched in lock step. The key sdivtion here is not between men and women, but rather between these with and without a college degree. Deaths of despair cannot be explained by the economy. They were increasing before the Great Recession and continued to increase afterwards. We think of all of these deaths as suicide of a kind and suicides respond more to prolonged Economic Conditions and the associated social dysfunctions 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 in manufacturing, jobs that came with benefits and onthejob training, that could be expected to last and have brought regular increases in earnings and a road to middle class prosperity. Not so today. With fewer good jobs, there has been a decline in marriage rates. Though couples often cohabit and have children out of wed lock. Those cohabiting 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 quotes. Heavy drinking, overeating, social isolation, drugs, and suicide are plausible outcomes of these processes that have cumulatively undermined the meaning of life for white, working class people. Within this context, we tend to see the Opioid Epidemic as accelerants, as something thats poured fuel on the fire of something that was already very bad already. Thank you very much. Thank you all for your testimony today. Before i begin questions, just two notes in the spirit of bipartisanship, i allowed the democratic witness to go first. I hope that is noted as we move forward in continued bipartisanship on this panel and i allow the former member of this body and house, a few extra minutes out of professional courtesy. With that, mr. Attorney general, you hit on something in your testimony that i hear about something all the time in the southern counties of my district, urban, suburban, or small town, and thats the impact its having on the economy. Employers who are saying, i have three positions open and i cant find anybody to fill the position who can pass a drug test. From your perspective and all the work youve done in this area, whether its heroin or opioids or whatever type of drug abuse, where do you see in our state the problem being the worst, in terms of the Economic Conditions . Is it in places that have historically been left behind . Does geography not make a difference . Can you give us your thoughts on it . Mr. Chairman, i think if we analyze this, what is different 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 historically, you could trace the beginnings of this to southern ohio, appalachian counties 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 move to the heroin because at some point they cant get the pain med anymore and because heroin is so cheap. Move then to possible fentanyl. So if you go back ten years, you would see where the biggest problem would be in southern ohio with the pain med problem. Im not a soshologist, im not sure i can guess, but i dont have i great deal of expertise in this area at all. But it starts with that. But it is absolutely everywhere. And 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. Were 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. And for the last five years, every interview ive done on this, ive looked into the camera, if theres a tv camera and ive said, if youre watching this, you have an opioid problem. You have a drug problem in your community. So one followup, you mentioned this demand problem, and talking to kids as early as kindergarten. How about the supply problem . Is there any way to deal with that . You say you see it everywhere in our state in law enforceme, law seeing it everywhere. Any thoughts on the supply issue . Youre talking to somebody who is a county prosecuting attorney. What we do in the Attorney Generals Office is assist local Law Enforcement. We always look first to the Law Enforcement problem. What we did five years ago, created the Law Enforcement heroin group, unit, out of bci. I cant really talk in public about exactly what we do. But we will go in and help the local sheriff or the local prosecutor or the local police, once theyve already started their drug investigation. Well help them take it to a higher level and to get the bigger fish, the bigger drug dealers. That remains a central part of what we do. I talked to the attorney general of the United States about cooperation with information coming off the border. And that is 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 very good and close working relationship with them. So Law Enforcement is a key, component part. But were not going to arrest our way out of this problem. We have to deal with it wholistically, getting people into treatment, keeping them in treatment, and we have to do a much better job with prevention. Which is where i think is the most opportunity. If you look at this from the long run, where are we going to be in 10 years, 15 years, 20 years, start today in kindergarten and very few schools are doing this. Thank you. Professor deeton, you talked about the 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 shortrun problem. I think this is a deep problem to do with, you know, what people who dont have a University Degree are gonna do with their lives. And the world that they used to inhabit is a world thats broken. And i think the meaning the things that gave meaning to their 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, i deemphasize the opioids because that was my shtick here, but i think doing something about the opioids in some sense is the easy part of this. Though, god knows its hard enough and that we really have to do that, and 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. My time is expired. Miss hassan is recognized for five minutes. Thank you very much, mr. Chair, and thank you all for your testimony. Dr. Frank, medicaid has served as a life line for states hit hardest by the Opioid Epidemic. Experts have said its the number one tool we have in combatting this crisis. I certainly understand how critical it has been that the granite staters struggling 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 their residents, the per capita cap in the plan would result in massive cuts that would set limits on federal contributions regardless of the need for care and services. That will mean less buying power over time and will leave states with far fewer resources to provide services to their citizens. Could you address how a per capita cap approach to medicaid would impact the states ability to fight this epidemic and or future Health Emergencies . Sure, thank you for that question. The per capita cap essentially is set up so that it locks in 2016 per capita spending patterns, then inflates them forward at what the Congressional Budget Office predicts is about 3. 7 , which is the expected Consumer Price medical component. And so what that does is, it allows you to keep up with general inflation, based on the 2016 patterns of treatment. Now, as we know, mortality from opioids is growing at 15 a year. Hospital admissions, about 6 . Drug treatments for opioid addiction is growing at 10 to 12 a year. And so what happens is, when you have a per capita cap thats based on that 2016 pattern, and new things happen or old things grow faster, you start to fall behind very quickly. Thank you. Miss sacco, we know to your point that we need to attack the supply side of this epidemic, something that weve been working on in New Hampshire. And we know how Law Enforcement plays a Critical Role in cutting off the supply side of illegal opioids and other drugs into our communities. But in New Hampshire, our Law Enforcement officials will be the first to say, just as attorney general dewine just did, that we cant arrest our way out of this problem. I remember the colonel of my state police when i was a new governor calling me to testify in favor of Medicaid Expansion because we need it. We need to treat this as the Public Health crisis that is, and focus on addressing the demand side. Which means effective public he response that could be more cost efficient and effective. Oftentimes medication assisted treatment is less costly than simply incarcerating someone with a Substance Abuse disorder, not to mention being more effective at addressing the problem and reducing reacid sa recidivism. Do you agree we cant simply arrest our way out of the problem . If you are, senator hassan, if you are seeking to address both the supply and the demand, then yes, it would be a comprehensive approach. Law enforcement is a strictly supply order. But the yes, right now the response seems to be one that is comprehensive. Okay. And would you agree that working on expanding prevention and recovery programs is important to help address the entire crisis . We do not take a position on the advisability of that, im sorry. Okay. Dr. Frank, proposals coming out of the house would undermine the effectiveness of the aca. Cbo says that could increase out of pocket costs by thousands of dollars. Do you believe eliminating Substance Abuse treatment places a barrier to access to care for people struggling with Substance Abuse disorders . Absolutely. Weve seen in the states, for example, in medicaid and states where theres been dramatic decreases in the uninsured rate from private insurance, we see those are the states that have responded most strongly with medication assisted treatment in serving people with opioid use 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 this hearing on such an important issue that is having such a Significant Impact on communities across the country. This is certainly, as has been mentioned, a testimony problem that is everywhere. Unfortunately minnesota has not been able to escape the devastating effects, economic and otherwise, of opioid addiction and the Opioid Crisis. Just last month i spoke to a mother from maple grove, minnesota whose son bought an analog of fentanyl online, consumed it, and he decide. It goes without saying she was devastated by the loss of her son. But she was also devastated with the ease with which he was able to purchase opioids online. There is certainly a role for congress to play to ensure that opioids are not so easily accessible. Unfortunately minnesota was home to a much higher profile case last year, prince, one of the most successful pop artists of all time, passed away in chanhassen after taking fentanyl. My point is this is a problem that affects many different types of people, old and run, rich and poor, your neighbor down the street, as well as an international celebrity. And while it is important that we understand and address the physical and emotional effects of the Opioid Crisis on americans, there is also value in coming to grips with the economic toll it is taking on the country as well, which is why i appreciate having such a great panel of witnesses that are here with us today. Let me just start with a few questions. Mr. Dewine, synthetic opioid, fentanyl, is 100 times more potent than morphine. Carfentanil is similar but is 10,000 times as strong as morphine. It was developed fo for tranquilizing elephants and other large animals. The deaths have skyrocketed in ohio, and in 2015 there were 1155 fentanyl 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. You know, 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 police and every sheriff in the state, telling him and her and their officers, men and women of these deputies, dont field test drugs anymore, stop it, dont touch it. We had an experience in ohio within the last month or so where an officer overdosed literally because he was in the presence of this and somehow 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 its coming in. I know senator portman has been directly involved in that concern and the members of the house and senate have been. I think you see the drug dealers, theyre great marketers. Its amazing. This whole system is all about 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 in mexico. At some point they may sell it off to the local dealers. Then what kicks in is what i call a pizza delivery system. You pick up the phone, you call, theyll deliver it. You get it in a half hour or youll get it cheap. And theyll get you started. Im not a medical expert but im told the difference between an early stage heroin addict and a late stage heroin addict, it may grow to a 1,000 a day habit. Theyre always chafing a high. The reason you against to fentanyl is two things, its easier for the drug dealers to get and its cheaper for them and they can make more money on it, and number two, its a way to broadcast this is something different, this is a better high. The irony, the irony is that when we get a situation where five, six, seven people die in a weekend in some city in ohio, obviously because were on fentanyl or carfentanil, its a different potency or something is there, the demand appears to go up. So we worry, you know, we put the bulletin out, and local Law Enforcement says, look, be very, very careful. What we worry about is were 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 or the way you and i would be looking at today, not being addicts. Thank you, mr. Chairman. Thank you. Mr. Delaney is recognized for five minutes. Thank you, mr. Chairman. I want to thank you for holding this hearing on obviously a very important issue that affects all of our districts. As mr. Dewine said, this is in every community in the country. And the fact that youve assembled such a terrific group of witnesses, im grateful for that. In particular i want to thank mr. Dewine for what hes doing in holding the pharmaceutical industry accountable. Youll make them pay like other people will. And that wont solve the problem, but its the right thing to do, and it will send a message that were going to start thinking about these things differently. We believe in a capitalistic system in this country, i certainly do, but we want it to be just at some level. Efforts like youre doing will help make that happen. Its fairly obvious what needs to happen. The witnesses have eloquently covered it here today. Whether we have the conviction is another question. The steps mr. Dewine is taking are obviously incredibly important. Making sure we manage ourselves through the situation by having the Health Care System in place thats going to support the people afflicted by this, and i associate myself with the senator from New Hampshire and her eloquent comments about the importance of medicaid. Dr. Frank, your comments were very encouraging when you talked about how private investment sees this as effectively a very Large Business opportunity, and theyre putting a lot of money and resources against it. There will be a lot of innovation. The same forces of capitalism that caused the problem hopefully will be directed towards solving the problem. If were optimistic, perhaps we see a path out of the Opioid Crisis. Professor deaton, your comments were the most sobering in many ways. These deaths of despair are a manifestation of something going on in our society, something very broad and very significant, and vexing in terms of how we deal with it. You know, weve allowed globalization and technological innovation to occur, which have been extraordinarily positive for humankind but theyve been very negative for certain communities in particular who werent prepared for it, it happened too fast. And its been negative for pockets, really, in every community. And how we confront that, and the isolation, the lack of security that human beings have. You touched on it, theyre not getting married. 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. These people are frozen. They lack security. Theyre not engaging in society the way americans have historically engaged. The cost of doing nothing against this is obviously not nothing. 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 to jumpstart them and the citizens of these communities out of the conditions 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 delaney. I wish i knew the answer to that question. 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 substantial increase in American Manufacturing output. The jobs are not there anymore, because we dont need the labor to do that. I dont know. I mean, i think, you know, you saw the slides i showed. This is not happening in europe. 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. 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, children get state allowances on a regular basis, which stops mothers having to shop around for men all the time and this sort of merrygoround of marriage has slowed down. In theres a lot of dysfunction going on. What is the cost to us if we dont solve this problem . I think the opioid problem will get solved. Putting aside the opioid problem. But the more structural problem you identified. It depends on what the counterfactual is, do you actually think we can do something about this and what is that something we can do. I certainly think we need to think through all possibilities and look at some things that are happening in europe. The germ 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 is not trained for what they want. Some sort of apprenticeship system may help that. I really i dont have any sure fire solution to solve this. Thank you. The gentleman from arizona is recognized for five minutes. Thank you, mr. Chairman. Have you ever had one of those evenings where you cant sleep so youre up reading about when i read over all of here, and i want to find an elegant way to say this, being from arizona, a border state, we at least document a couple of lost lives every single day in arizona. In not talking some of the book from my friends from the left, i would love to actually take a step backwards. Theres things in the data, i actually built some charts off dr. Franks information. And in some ways, i couldnt make parts of your argument work with the chart. You know, the time of Medicaid Expansion, my numbers are going up still double digits. Is there any data sets, 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 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, here is where were going to build our policy goal, please someone help me build what that policy is. I was going to go to dr. Sego. 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. At this point, this was only in march, this remains to be seen if this has an effect on whats coming over from china. I think i mentioned this increased production of heroin 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 i spoke 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 problem and theres a levels problem. On the levels problem, if you if we cut the number 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 the first things you would do, lets say we could wave a wand and elimination of description opioids. No, i think its more making sure 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. I think we need to sort of balance the two. And so far weve tipped the scale too far the other way. But and just from a, you know, junior standpoint, looking at what the chemical compounds were in the synthetics, its not that hard to make. The precursors. So im still not hearing a global professor. From an economists standpoint, whats my Global Solution . I wish i knew. Im more skeptical than dr. Frank is about treatment. I think, you know, somehow 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. 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. I think we need to be able to do that. The schools are a place, but the police are working on this. And its still true that not all that many people know about it. I think that 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. Im not sure if 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, along with senator hassan. Weve been working hard on these issues for many years. We passed our bill last year which of course 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. Thats things like getting the drugs out of the medicine cabinet, chaining doctor prescribing practices, doing something on stopping the huge amount of drugs out there that are legal that arent being used in the right way. The second is treatment, of course. And the third is 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 engage in fraudulent, deceptive marketing campaigns. It seems to me that the people responsible for marketing these drugs should pay for the human costs 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, im in a plane last week when i held a press conference that when i explain 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, the communities making the most progress were communities where it got so bad, they just got sick of it. It was usually a grassroots effort led by a mom, sometimes a dad, but usually a mom. And they just go and the try to transform the culture. Do you think a lawsuit, which i believe, like in the tobacco industry, the lawsuit got the information out there and it stopped people from doing bad things. Let me get to the center part of this, 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 late 90s, tried to change the culture. The culture historically had been for pain meds, that theyre used for acute pain. You can have your tooth taken out, you take it for a day, two 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 was they tried to convince doctors and did convince doctors that hey, it was just okay to use it for a third purpose. And that third purpose was for pain that goes on day after day after day but is not terminal. And they did it. And they were very successful in doing it. 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, several of you have said, its somewhere in the middle. Thank you. And we also have a bill with senator manchin that would put a p on some of these drugs and have, again, that go per mill i gran, have that go to treatment. Professor deaton, congratulations on your good work. Could you comment on what the attorney general has done here, which i think is commendable, and how sometimes lawsuits can change the economic situation. If companies are afraid of getting sued, that its not just public shaming, but actually out of their bottom line, that can make a difference in how they behave. Thank you, senator. Yes, i think it can make a difference. 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 is a time when that drug is killing large numbers of people. And i think, you know, we ought to make it clear this cannot be tolerated. I also agree with the attorney general that the local effort is where the culture will be need. But we dont need Pharma Companies trying to push doctors to prescribe addictive opioids for lower back pain. It just makes me cry, when you see all these rehab people and small town mayors and cops, theyre all trying to do the right thing, and 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 who has been a national leader, as you know, attorney general, on this issue, and talked to me in the last session of congress about introducing a bill, which i did, that youve been a leader on, the stop act. It deals with this issue of fentanyl coming in from china. Mr. Portman, youre recognized for five minutes. Thank you, chairman tiberi, and for taking the lead on the stop act. You have 123 sponsors, im sold. Thanks to crf for helping us with that legislation, and to mike dewine for his help, both as the top Law Enforcement official in 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, that this is ultimately going to be solved on 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 of the drugfree communities act, a law that helped spawn 200,000 community coalitions, local line the one i chaired in cincinnati, yet here we are, the worst drug crisis in our history, as bad as its been in the past. What weve learned today from this terrific panel of experts, also from some of our colleagues including congressman schweikert, is, mr. Chairman, the comprehensive approach 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. And senator klobuchar and i are cosponsors and authors of this stop act. Senator hassan is one of our original four cosponsors, by the way, and is here too. She also is one of the original klobuchar, me, white house, and others pushed this comprehensive roach and the comprehensive Addiction Recovery act, called comprehensive, but it includes a big component of education and prevention that has yet to be implemented, including a national earnest campaign on making this connection that attorney general dewine has made today between Prescription Drugs and heroin, fentanyl and other opioids. I think professor deaton is right, a lot of people dont make that connection because theyre not aware of the information. So when you go to a doctor and someone you trust prescribes Opioid Pain Medication and says heres 60 percocets, take this for the oral surgery you have. And there is a change in their brain which is a disease, which is called addiction. That is something we can do as part of this, and other aspects of the care legislation that need to be implemented. Ive urged the Obama Administration as im now urging the Trump Administration to implement these quickly. A couple of questions, one to senator dewine, again, as the chief Law Enforcement officer in our state, you know much better than i whats going on. But i just got an email yesterday from the coroner in could you Cuyahoga County who reported to me that he believes the deaths are fentanyl driven, in contrast to the horrible rate of overdoses and deaths last year of being more in the 20 to 30 range. Were now, even 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 im hearing back home, which is this notion to professor deatons point about who is being affected, that this is now being spread into the Africanamerican Community more with regard to these evil traffickers sprinkling fentanyl in cocaine and starting a whole nother series of addictions. If you could speak to that a little bit, i would appreciate it. Senator, thank you very much for the question. Thank you for the great work that youve done, youve been a great leader in this field. You know, i think theres a natural 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. He moves over to the heroin because its cheaper. 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 more and more and more, and less and less heroin. It used to be it was sprinkled in with it. One of the things 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. So it slows that down. I go back to something i said a moment ago. I think it is a marketing technique. And these people are selling this stuff, theyre killing people. Theyre good marketers. 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 in fact be fentanyl. As far as it moving more into the Africanamerican Community, i dont have any data on that. But sure, it would appear that, anecdotally, it would appear its getting pushed out. And, you know, as i look at this problem from a maybe a big picture point of view, sometimes people ask me you know, mike, what keeps you awake at night as the attorney general. My quick answer is, the opioid problem. I think its a bigger problem. Its been alluded to by several people here today. The opioid 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. We have the problem with people not having the right skills. That does impact this sum. Not in every case. Were seeing a lot of middle class people, 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. 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, parents need to be saying to their kids, look, we want you to live up to your full potential. Make youre working with your hands but you go to college, or an Apprentice Program or Something Else where you can become a welder or you could become a machinist and make a good salary. I think all of these things are tied into each other. Part of our challenge in ohio and other states, i think, is to focus on kids who are grownup, because its easier to impact them its not that were not going to try to impact someone older, but the kids are growing up, make sure they have all the opportunities that are there, no matter where theyre born or what their income or who their dad is or who their mom is. I think to me thats part of our solution, as we look at the Pain Medicine problem. Thank you. My time has expired. Thank you, mr. Chairman, for your indulgence. I have some questions for you, professor deaton, for the recor record. Thank you, mr. Chairman. Thank you. The gentleman from virginia is recognized for five minutes. Thank you, mr. Chairman. I thank all of you very much for being here. Its fascinating that it at least looks like a triangle in terms of there is the supply problem as argued by general dewine and dr. Sacco. There is the economic dislocation, the hopelessness, from professor deaton, and the treatment side from dr. Frank. Dr. Frank, can you cite the 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 a little bit more than half. And then the other main reasons have to do with stigma in the 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 medication assisted treatment is really the most effective treatment we have, but only about a quarter of the people who get treatment get that. And so were undershooting our potential by a great deal. And thats what in a sense causes us to underachieve. Thanks. We have this obamacare reform replacement repeal bill in the senate right now. Senator cassidy says he wants to make hour it passes the jimmy kimmel test, which the house bill clearly didnt pass. Im hoping that based on all that were learning now, senator portman talked about this is the worst addiction crisis in the nations history, that whatever bill comes out of the Senate Passes the Opioid Epidemic test. Professor deaton, you said this really hasnt hit europe yet, that might just be a temporary reprieve. Can you explain why the fentanyl from china and others hasnt affected that population, at least yet . At least yet. I mean, thats for us i guess it used to be the 64,000 question, now its a 64 billion question. You can see some of us in the English Speaking 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. If you look at those countries just by themselves, you would be worried about it. But when you put it in the context of the u. S. , theres nothing happening there. Partly i think its because these Prescription Drugs are controlled much more carefully in europe. And theyre used in clinical acute settings and theyre not prescribed in the community yet. But i mean, theres concern they will sprayead out into the community. And i think the fentanyl think i dont know the, but the black tar heroin, for instance, is coming from mexico. They have very easy targets here. And maybe fentanyl will come to europe in the same way too. So i think the europeans ought to be worried. And the ought to be you know, they ought to make sure 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. I think part of it is the control. Thank you. Dr. Sacco, it looks like youve been studying this drug thing for many, many years, academicalacademic ly in crs. What do we learn from the crack epidemic thats relevant to fighting the Opioid Epidemic . Im sorry, what do we learn from the crack epidemic . Yes. Are there lessons from the crack epidemic that are relevant here . Im not sure i can offer an opinion on that today. Okay. Its a little bit outside the scope of what i prepared for. I would be happy to follow up for you. Is there anything specific to the crack epidemic . For example, we seem to have responded to the crack epidemic with lots of incarceration, we were pretty harsh about that. Theres been a movement, bipartisan, in criminal justice, away from criminalizing essentially nonviolent drug offenders or the harshness of it, perhaps not with the attorney general recently, but is that a solution here too . Umm or do we tilt to the treatment side . You know, i cant advise one way or the other. I can certainly tell you that drug offenses account for the majority of federal offences carrying a mandatory minimum. If thats what youre speaking to, mandatory minimums did come out of the era of the crack epidem epidemic. And there are different ways of looking at the efficacy of minimums from an economic standpoint. Research says 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. In other words, a oneyear sentence likely has the same deterrent effect as a tenyear sense. 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 low level drug offenders are easily and quickly replaceable. Thank you very much. Mr. Chair, i yield back. The gentlelady from virginia is recognized. Thank you, mr. Chairman, and i thank the witnesses for being here today. Weve seen in my district, and im in northern virginia, crossing over the bridge here, weve had a rise in ms13 gangs as getting more involved now in trafficking of heroin and opioids. And so were seeing this convergence of very violent gangs and preying upon very young people, both trying to recruit younger people into gangs and also getting them involved in these various things. How can you know, what kind of effect are you seeing anything like that, are you seeing that elsewhere, how thats going to impact the economy . What we see, particularly when you get these young people, theyre getting into these gangs and its a whole lifestyle, and thats how theyre making a living. Theyre not getting educated, and it will be even a worse situation. Sorry. Is that addressed to me . Sure. Im not sure i can really answer that question. What i can say is when we look at ohio, 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. And i know weve been focusing on the lower income and how weve seen the rise there. I know we have seen in my district, we have very high a lot of high income areas in this region. And were seeing it hitting everywhere. I did want to make sure here today, even though it was focusing on that lack of opportunity, that this is we are seeing this in every community, and with every aspect. So what is the difference, when youre seeing, say, a College Educated kid who got addicted from sports injury and took it too far, in this lifestyle . What are you seeing in the difference between somebody like that and this expansion in someone from a lower income area . Thank you, senator. Income is not the best marker of this, partly because africanamericans tend to be there are a lot of low income africanamericans. And until recently, africanamericans have been largely exempt from this epidemic. That does seem to be changing. And there is a tickup in the last two or three years in the mortality of prinafricanameric from opioids. Low education has certainly been an issue. What you say is true, Higher Education people are suffering from this too but nothing like to the same degree. 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. But its throughout the community. I think also some of the standard protective forces from people have sort of broken down. I mean, one example i like to give is, utah has always been a very healthy place compared with nevada, and for sort of obvious reasons. But utah has not at all been exempt from this epidemic. And thats because, you know, mormons tend 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 the education efforts, the comprehensive approach that senator portman and others are talking about, the attorney general is talking about, really at that young age, kindergarten, making sure education efforts really needs to go everywhere. Stop the docs pushing this so people know its dangerous. Thank you. I yield back, mr. Chairman. Thank you. The gentleman from illinois is recognized for five minutes. I thank you, mr. Chairman, for this hearing today, and for this subject matter. I want to thank the witnesses for your valuable testimony here today. I have seen the devastating effects of opioid abuse and heroin deaths in my own district. I represent a district of 19 counties and central and west central illinois, very rural district. I 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 today about some of the analyzing analogies to this epidemic. I spent ten years as a state and federal prosecutor. In illinois 20 years ago we had a real problem with drunk driving, it was the number one killer in illinois of young people. 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 like what you talked about, attorney general dewine. We also used technology, mission interlock. Today we have some of the lowest levels of drunk driving deaths anywhere in the country. Thats because of an effort. It was a movement at the time to do that. 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 through. And im not sure were doing enough of that right now. Weve touched on some of those things. Attorney general dewine and then dr. Frank, do you want to comment on that . Congressman, i totally agree with you. This comes at the local level. It comes at 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, the communities have started to make some real progress. Number one, admit you have a problem, number two, a Citizens Group started by a mom who lost a son or daughter, and they go out and change the culture. You still have a problem, but they make some progress. I saw it in my own career. I introduced a bill in the ohio legislature, a drunk driving people, people were laughing at it. This was back in the early 80s. It was mothers against drug driving who frankly got it passed. It just shows, its the example we all can use with people, 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 or the state level or the national level. Dr. Frank, people also remember when we talk about drunk driving, about, you know, the tv commercials that talked about these tragic deaths and highlight how horrific some of these were. Im not sure we have that level, and if we have, maybe theres some states or local areas 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 in reducing the number of predictions on methadone for 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 the physician community, making sure that our Prescription Drug Monitoring Program is really focused 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. I think in a sense that is a reflection of the sort of multipronged approach. And i do think that that offers us a bit of hope here. Professor deaton, you touched a little bit on how we maybe hold doctors accountable and what we need to do. And much of that oversight of doctors and physicians is done at the state level. Is there an example of a state that has done a good job at holding doctors accountable . Im afraid i dont have an answer to that. Weve done very little work on the geographic aspects of this epidemic. So i cant answer that. Thank you. Thank you, mr. Chairman. Thank you. I really appreciate all four of you being here. What great testimony we were able to hear today. Im going to allow the acting ranked 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. A constituent of mine who is now recovering from heroin addiction, 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, went and got treatment under Medicaid Expansion, that 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, thank the people who have this disease who have stood up, who have identified themselves as people suffering from addiction, have done the hard work of getting better, and then have turned their efforts to make sure that they help with the prevention Recovery Efforts that we need to undertake. Im going to keep ashley in my thoughts today. Shes about 17 or 18 months in sobriety now. She continues to get treatment for recovery. Shes going to be reunited with her 3yearold son soon. There is hope if we go at this with the all of the above approach. Thank you so much. Thank you, senator. Thank you again. There are stories like that that we all can share, attorney general dewine has shared many with me as hes on the front lines. 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. I 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. Our hope is that you would respond as well. This hearing is adjourned. Thank you, mr. Chairman. [ indiscernible conversation ] this sunday, q a is in hyde park, new york, at the franklin d. Roosevelt president ial library and museum, where we go inside for a rare look at fdrs personal office and collection of artifacts, with the museums director. This library opened in june of 1941. He was still president of the United States. So this became essentially the northern oval office. Fdr had an incredibly inqu kwis inquisitive mind. Every book in here was selected by fdr to be in this room. This room is almost identical to the way it was on the day that fdr died. Nothing has changed. Watch q a from the franklin d. Roosevelt president ial library and museum in hyde park, new york, sunday night at 8 00 eastern on cspan. Sunday night on after words, new America President and ceo ann marie slaughter examines global networking in the digital age in her book, the chessboard the web strategies of connection in a networked world. Shes interviewed by a former white house chief of staff in the Obama Administration. What would strike me was that we knew there was a world of states and state reps. Today, if you think about north korea or iran or sometimes china or russia, that world of state to state relations is still very, very important. And i think of it as the chessboard world, because its the world of how do we essentially beat our adversaries. And we think about a move and we try to anticipate a move theyre going to make. That world is there, and its very important. But equally important is what i call the world of the web. That world of criminal networks, including terrorists, but also arms traffickers and drug traffickers. The world of business, which increasingly big Network Supply chains, global corporations, and the world of nongovernmental organizations. I think of all those actors as web actors, as increasingly important actors. But we dont have strategies for how to bring them together. Watch afterwords, sunday night