China t was legal to manufacture fentanyl up until early march. Fortunately our state department and others, you heard from omdc earlier helped to change that so we can get cooperation to reduce the flow t hasnt reduced yet but we have a ways to go. Fentanyl is 50 times more powerful than heroin. One gram is like 50 grams of heroin. It can be shipped in the mail. Shipped in commercial carriers. Fancy way of fedex, dhs, not Postal Service but other ways you ship packages across borders. It is shipped directly to the states or it is shipped to the canada and mexico. The wall street journal, you know theyre all about business, reminds us this is a business. The raw products cost about 1000 for fentanyl can be sold on the streets in the u. S. For about a million dollars. Thats pretty big profit margin and that motivates a lot of behavior. So i think as much as we can focus on the supply we better do something to help people in recovery so there is less of a demand for these products. I want to end by emphasizing that our department of health and Human Services in the federal government under dr. Prices leadership has laid out five main priorities. New approaches to pain. If a key driver was excess prescribing of opioids, cant we do a better job not using opioids to treat pain . Yes, we can. The second approach is improving prevention, treatment and recovery services. What can we do to focus on the addictive process itself and eliminating it. The third will be, can we save lives more readily providing naloxone, that is the antidote. I wonder how many recovery houses have naloxone in their facilities. I hope you all do. Not that the residents you all in recovery necessarily will have a problem but it might happen but you will know people that do. You will have friend that have an overdose, having this lifesaving medication readily available is a key part of saving livings so then people can make the gradual steps towards recovery. The fourth area is to improve our data. We talk about how many death west have in the u. S. From the overdose. My latest data is from 2015. Where are we . This is now september of 2017. Dont you think we could have numbers from 2016 by now . Dont you think we could no more about this . We would mike to speed up the process. Finally im pleased research is being supported. Im thrilled with the treatments we have. Im thrilled with the Recovery Support services we have. We need more of them. We need it know how timely meant them as efficiently and effectively as possible but frankly we need better treatments. Im kind of pleased with the medications we have treating heroin, fentanyl opioid disorders in general. We have medications that can be helpful. But they dont help everybody. Many, many people fail on the medication so cant we do a better job . I hope you are research into the basic mechanisms what explains these conditions and how we treat them better will lead us to transformations so we dont have to see some tens of thousands of people dying every year. Thanks very much. [applause] thank you, dr. Compton. Well move directly on to dr. Clark. [applause] thank you. Its a pleasure to be here again at the house. It has been a honk time, last year. So, i appreciate this audience and were going to be talking again later. So i dont have any slides but i have slide later. So both dr. Gitlow and dr. Compton addressed a host of issues associated with the epidemic that weve been discussing. So i would like to take a slightly different perspective. I want to point out there is an issue called the social determinants of health that gets forgotten. There is also an issue of how do we adequately treat pain. Dr. Compton made reference to that, but thats a large issue because indeed, it affects peoples desire to use opioids with. We brought in a whole host of people who were not previously using opioids. We have to keep in mind as dr. Compton points out and dr. Gitlow, we have 69 Million People that are binge drinkers. 65 Million People cigarette smokers. 22 people marijuana users. 4. 2 Million People who miss use pain relievers. Not the Largest Group of individuals. So dr. Gitlows point is welltaken. We have to deal with the fact that our society embraces use of psycho active substances. How it should be administered, what we should do, that is another matter. With regard to Prescription Drugs, we have, according to the Household Survey date from 2015, i agree with dr. Compton it is outdated data, ostensibly within the next two weeks we will hear 2016. 95 million past users of pain relievers but only 12. 8 past year admitted to misuse. We have to deal with the issue anybody here have any pain . Anybody here want to enjoy that pain . So unless youre into s and m [laughter] there are people, you know, psychiatrists, we meet all sorts of individual i dont want to dismiss their predilections and i had yo sin crow sis, if we dont deal with chronic pain, chronic, noncancer pain we wont deal with the issue. I know dr. Comptons institute, nih, has a working group trying to come up with nonpsychoactive substances that help treat pain, that resulting in strategies. The cdc has come up with guide lines to treat pain. The fact is we dont know how to treat nonchronic pain adequately. Take motrin. Motrin hurts you if you take too much. Take tylenol or acetaminophen. Acetaminophen hurts you if you take too much. Dont take opioids. The fact is i cant stand the things but im not a proponent of people suffering. In the discussion there is mistrust and distrust of consumers. Pill mills, though are responsible consumers. You show up, i got a pain in my pinky, they give all the pills in the world. That is not a responsible consumer. That is not a responsible prescriber. There are mistrust and diss trust as consumer. My fear we go from one end of the pendulum to the other end and single out the consumer as the bad guy. We have Prescription Drug monitoring programs. We have people wanting access. They want to put you on registries. They want access to your information. They want all they can get and your phone is doing half of that with your gps but they all want they can get from you. Vilifying the consumer is not a solution to this problem. We have people who are exploiting the vulnerable, the business misery. Dr. Compton made reference to indiana. It was a matter of opioids and benzodiazepine, but methaphetamines. I looked at jail in the community who was being arrested for what. That information was public. I looked at jail records. A bunch of folks arrested for methaphetamine. They were not injecting methaphetamine and smoked heroin . Anyone know how you do that . The combo . You inject the combo. When we focus on one substance alone as dr. Gitlow is pointing out, we ignore a larger issue. Social determinants of health. If they are being abused physically, if they are abused psychologically, if they have no solutions they tend to use whatever makes them feel better. We need solutions. And im going to turn to some of the themes that surface at oxford house because i see in oxford house some of the solutions. You may have seen from your materials over the years themes like accountability, responsibility, integrity, honesty, community, support, respect. These are themes that make for a good dr. Patient relationship, a Good Community relationship. We can deal with those things. Employers mindful and respectful of employees, not let me see if i can get the next 26 hours out of you. When you look at mine workers, look at the pain that they dont have cancer pain but hunched over for long years. They come out, all they have got is pain. Were surprised if they use opioids. How did that happen . Factory work, anybody work at a factory . I worked in a factory when i was college. I was one of those relief people. After eight hours my mind was numb. I was only doing it twice a week. I asked myself, could i do this every day of the week . Basically what they were interested in was the assembly line, not me. So, my point to you is oxford house offers some solutions. Wilson, there are some solutions. The solutions in the principles of oxford house, accountability and responsibility. The patient needs to be responsible. The patient needs to be accountable, but so does the doctor, so does the hospital, so does the drug company. The system needs to be accountable. Honesty, the doctors need it tell patients about them. [applause] they were giving out pills not alternative solutions. Alternative solutions costs 500, the pill is 5. What do you think the Insurance Company is going to do . Right. So im going to wind up with the notion of gratitude, because the principles of oxford house function well if our Larger Community adopts those principles. That way when someone is quote, backisliding, as dr. Compton points out you should have naloxone in your facilities because people crash and burn. This is not a perfect disease and the efforts are not always flawless but if you have a environment where people get support and people have opportunities and if they follow the basic tenets they have recovery on the horizon, then i think we can deal with chronic pain, if we have an Honest Society that recognizes that we put people in grueling environments, that they need relief, but they dont necessarily need to be drugged for relief. So your principles should be incorporated in the larger theme of what were going to do. There is not another pill necessarily. Not another big brother surveillance civil necessarily but a society that treats each other with respect and with dignity, that holds people to accountability and responsibility, and that diffuses to every participant in that society, then we have our solution. Thank you. [applause] dr. Major. [applause] good morning. How are you all doing . I got some bad news for you. I have a power point. [laughter] might take a second or two to put it up there on the screen. I dont have a prompter. I will look over here i think when i present. Lets see. Im john major, with harry s. Truman college, part of the city colleges of chicago. I dont have a prompter. I dont have my glasses. I will be looking at my notes, so bear with me. What constitutes a crisis number of things come to mind, what are the prevalence rates . I would like to go into detail on statistics and data discussed from dr. Carr and dr. Compton. This comes from smsa has on the website from the National Survey on drug use and health. This is data that was presented about one year ago today, reflecting 2015 data. I got a bunch of slides. Im not going to be terribly technical. So if you bear with me i will try to get through this as quick as i can. In terms of prevalence rates there is a lot of drug use going on and it is very comprehensive report from the survey that crassfied psychotherapeutic drugs into four categories. Were talking about Prescription Drugs that are painkillers, known as analgesics, things that make us not feel the pain. We have tranquilizers or things that calm us down, we know stimulants are, things that put a people to our step, adderall, ritalin, and sedatives to help us go to sleep. If you look at the chart there, it is surprising. Almost 45 of people in the United States are estimated for using these drugs. You might be thinking, oh, my gosh, this is an epidemic . Maybe they dont use the drugs like some of the people in attendance today. They throw away drugs or give them back to the pharmacy after done or take them as prescribed. The situation here is misuse of Prescription Drugs. The numbers are much smaller but still very significant. At least 7 of folks in the United States are estimated for misusing your Prescription Drugs. You see on the chart those frequently misused Prescription Drug in that category of psychotherapeutic drugs, pain relievers or analgesics. It doesnt get any bert. When you look at people using other drugs, alcohol included, tobacco, stimulants, folks who use heroin have a High Frequency of misusing Prescription Drugs. Can you guess which of the four categories they tend to misuse more . Painkillers, right. Analgesics, about the same rate. So there is a lost drug use going on. And in terms of meeting diagnostic criteria for a opioid use disorder, you see the bar charts there, very top it is alcohol. Like dr. Gitlow said, we have a big problem with smoking and drinking. But today were talking about opioids. If you look down, you see a little sliver,. 6, why are we talking about heroin . That is small number. That translates to 591,000 criteria. Diagnostic criteria for opioid use disorder by way of heroin. But what is even more alarming, three times the rate more for other opioids. That is the thing im really going to be focusing today. So there is all kinds of opioid use. We seem to focus a lot on heroin but a lot it going on with other prescription opioid use that is being misused. This bar chart Shows Mission of drug use, people might be initiating or starting with Prescription Drugs, most of them being analgesics or painkillers. There is a lot of accessibility, probably explains the prevalence of use of these drugs. I would like to introduce some data produced a couple years ago when one of the most respected addiction researchers gave testimony to the United States senate focusing on americas addiction to heroin and Prescription Drugs. She wented very compelling and very scary data. This chart chose the increase in Prescription Drugs have been assigned in the last 20 years or so and folks, that is in the millions. Now i dont have my glasses on. I cant see that far but i think 74 million prescriptions were assigned in 91. 20 years later, nearly tripled. See the green line corresponding to specific opioid drugs that were prescribed. So this is a very serious problem. This graph here seems a little complicated but it is pretty simple. From the. Of 2009 to 2011, a threeyear period, they showed trends of drug use across four, four opioids. I think one category is other opioids. Oxycontin, oxycodone and other hydrocodone and heroin. Percentage of people reported they used opioids to get high the past 30 days. If you go to the far left it is about 10 of people surveyed that yeah, i used heroin to get high in the last 30 days. Then it gets to be 50 of those folks or more reporting that theyre using Prescription Drugs. You see there are changes when you go from the left to the right. Were talking about trends of drug use. Dr. Volkow says, in her interpretation of the data, and i quote, the emergence of chemical tolerance toward prescribed opioids prescribed in smaller number of cases with difficulty of obtaining many of these medications legally may explain transition of use of heroin, which is cheaper and some communities easier to obtain than Prescription Drugs. That is the concern of a lot of researchers. Theyre getting ahold of Prescription Drugs. Theyre hard to come by because theyre expensive. Go into the communities to get the dope because it is cheaper. When i read this, something stuck out it me. First, look at this line. Chemical tolerance towards prescribed opioids. Have you ever once heard anybody talk about the chemical tolerance toward heroin . Other things that speak out to me. Things like perhaps in a smaller number of cases. In other words, dr. Volkow is very smart, she is a researcher that had to be very careful when we term data. We have to be cautious. We have to use conservative language but she makes a point that these things are leading to transition to abuse. I come across a couple studies where the data suggests that people are using Prescription Drugs, therefore, it leads them to using heroin. Then they typically overd, overdose. Now when i look at the numbers on this graph, it shows changes over time. In other words trends. But nowhere in this report that i came across did it make reference to these changes being significant and that is very important because in research when we talk about statistics when we find something that is significant that means that it is due to something other than chance. It is not a chance occurrence. Often times we make attribution, has to do with independent variable or whatever it is were looking at. At least when i look at this chart, this to me shows normal trends across time. There is no rhyme or reason for the changes of frequencies. Now i have highlighted and probably from where youre sitting it might be difficult to see, two sets of data points that kind ever suggest that support the notion of a switch from Prescription Drugs to heroin. If you look at the turquoiscolored graph toward the bottom you see from one time point there is a slight increase in heroin use. And that corresponds to the other lines above it. Decreases in opioids. And you see that in the second highlighted column to the right. The idea is, people are increasing their heroin use because theyre getting less access or theyre decreasing their use of Prescription Drugs. That is pretty interesting. Now, dr. Volkow also says, if you read this on the website, heroin abuse like prescription opioid abuse is dangerous both because of the drugs addictiveness and the highrisk of overdosing. That is great. She is saying Prescription Drug abuse and heroin abuse are both dangerous. Theyre both highly addictive. But then we read in the case of heroin now i include the emphasis on the slide, the danger is compounded by the lack of control over the purity of the drug injected and its possible contamination with other drugs. Thats true. We know in recent years theyre mixing the dope with fentanyl. People are dropping left and right. It is horrible. When i read this, lets say im a u. S. Senator, not so adept looking at research stuff, i want to walk away with the idea heroin is worse for you. The danger is even more. But what about the dangers of prescri