year. i recently introduced h.r. 225, the firearms safety act which would close the loopholes which prevents the consumer products safety commission from creating rules regarding the safety of firearms. if the consumer product safety commission can regulate teddy bears and car seats, it should firearms. they will save thousands of lives. senseless gun violence and it is unacceptable in the united states of america that gun violence is the leading cause of digit for people under 24. it's time for us to come together to end the gun violence that is taking the generation of young americans. how many and just who has to die before we take action. i urge my colleagues to attend a funeral to feel and see the hurt. our standing of moments of violence. let's take action and save lives. i yield back. mr. jeffries: i thank the distinguished gentlelady from illinois. one of the reasons we believe that members of congress need to act is that state laws are inconsistent from one jurisdictioto the other. in new york, we experience gun violence in certain communities at unprecedented levels, notwithstanding the fact that we have significant and rebus gun violence and prevention measures in new york. the overwhelming majority of guns used to commit crimes in brooklyn come from the neighboring states of pennsylvania, as well as up the up the i-95 corridor. chicago has been experiencing unprecedented levels of gun violence. linois has pretty robust gun violence prevention laws on the books. guns have ority of comes from wisconsin. los south central angeles, the situation has gotten better. california has good prevention laws. the overwhelming majority of guns used to commit crimes in east l.a. comes from the neighboring state of arizona. that's why we need congress to act to deal with what is a national problem. it is my privilege to yield to my good friend and colleague, my sister from the neighboring congressional district to mine who has been a forceful advocate on behalf of the communities she represents in brooklyn, let me yield to the distinguished gentlelady from the 9th congressional district of new york, representative clarke. ms. clarke: let me thank you my brother from the neighboring district in brooklyn, new york, mr. jeffries, along side my ister from ohio, ms. joyce beatey for their leadership, in our congressional black caucus special order hour discussing gun violence and gun safety measures. let me also commend the onorable, robin kelly of illinois, for her leadership until doing the work she is doing with our braintrust but being a forceful advocate for thend to gun violence not only for her district in chicago, illinois, but for all communities across this nation. gun violence in the united states has reached epic proportions in the 21 century, the death, the trauma, the devastation, that we are witnessing, can no longer be tolerated. madam speaker, the congress must act now. over the past decade, more than 100,000 people have been killed s a result of gun violence and millions more have been maimed by reckless and unlawful discharging of firearms. i applaud president obama for taking his executive action to address gun violence. these actions will save lives. the president's actions will strengthen lifesaving background checks, improve mental health services. we have all that we need in the united states to observe the second amendment right of americans, but at the same time, take our nation into the 21st century with responsible gun ownership that leaves little room for the illegal gun activity that we see taking place in terms of gun trafficking, in terms of the use of deadly arms in the hands of those who are unlicensed to hold them. as it relates to background checks, the proposal focuses on new background check requirements that will enhance he effectiveness of the system and greater education enforcement efforts of existing laws at the state level. specifically, it will direct the bureau of alcohol, tobacco and flows iffs that any business that engages in the sale of guns to obtain a federal license and conduct back grouped checks and calls increased funding for the hiring of will investigators to help enforce back grouped checks and requires the a.t.f. to issue a rule for back grouped checks of those who purchase them through a trust, corporation and encourages a greater communication between federal, state authorities on criminal history information. what could be wrong with that? that is within the boundary of our laws, within our constitutional rights and makes our nation safer. you know, i come to this floor today as one who considers herself to be a victim of gun violence and we need to confront this right aa because of many in our community it is not only those who have been physically harmed by gun violence, but those who have been traumatized by being a wilt to gun violence. i had the unfortunate privilege, if you will, of being in the city counsel chambers of the new york city city council when my colleague, the honorable davis was gunned down before all of his colleagues, workplace domestic terrorism and that incident has been with me from that day forward. to this day, i can in a moment's notice, recall the trauma of that day, what it meant to see my colleague's life taken from him, hear the gunplay that took place in the new york city counsel chambers. and i'm not alone. there are millions of americans who are witnesses to gun violence who may have been maimed in gun violence and did not necessarily die as a result of it, but whose lives have been changed dramatically. we shouldn't have another generation of americans to can speak to the unspeakable horror of what it is to be either directed impactly in the loss of a loved one or the families who have to recount the times when they had to be at the hospital to be with someone who is trying to recover from being gunned down. t is our obligation, it is our responsibility, as lawmakers of this nation to get this right for future generations. i applaud president obama for doing what he could do within the parameters of his authority. it is now time for the united states house of representatives to do our job. with that, i yield back to you, mr. jeffries. mr. jeffries: i thank my good friend and colleague for the very powerful presentation and for pointing out the sensibility of supporting all of the president's efforts but particularly as it relates to the a.t.f. which is the federal agency charged with enforcing our gun laws. the bare minimum that we can do to make sure that the a.t.f. has the manpower and row sewerses necessary to prevent the illegal trafficking of guns like brownsville and other neighborhoods in a congresswoman clarke represents. you are supporting the merchants f death who rely on underforce ment of a.t.f. in order to flood communities like chicago and south central chicago and many other neighborhoods in newark, new jersey, with illegal weapons. and with that, let me yield to my good friend and colleague, representative kelly and payne. we thank them for leading the c.b.c. special order hour. i yield to the the gentleman rom from new jersey. mr. payne: let me thank the gentleman from new york who passed the baton to representative kelly and myself in 2015 and rounded the corner and put it back in his capable hands along with our classmate, the honorable gentlelady from the great state of ohio, joyce beatey, who is demonstrating day in and day out why she was such a great leader in the ohio legislature and has brought those talents to bear on the entire nation. madam speaker, these are very serious times, and i want to start out by commending the president of the united states, in the t obama, fr to face of insurmountable odds, to not be hampered in wanting to do something with this terrible, terrible scurge that we suffer from in this nation. gun violence impacts many different communities in this others.some more than but it impacts us all. so i was proud to see the president step up and step in rd and not be hampered doing something. if the obstructionists on the other side of the aisle want to continue in that manner, then let them be, but he is going to do something. and so i want to commend my colleagues in the congressional black caucus in uniting with the president in this great effort. we understand in our communities what this means. we are trying to articulate it to the american people. we understand it. we live it, we feel it, we see it. the president's executive actions or gun control are steps in the right direction, but it is the responsibility of congress tore pass gun reform and that makes our communities safer. i have joined, along with representative kelley, who mentioned her two pieces of legislation and after sandy hook, several years ago, i proposed a piece of legislation that are did not really see the light of day. but as the president has not given up on this effort, i will not either. . . i have a piece of legislation called the safer neighborhoods gun buyback act. it would keep guns out of the hands of the wrong people by creating a federal voluntary gun buyback program. under my bill, state and local governments as well as gun dealers would distribute smart prepaid debit cards to gun owners in exchange for their firearms. my bill incentivizes gun owners to voluntaryly get guns off the streets. this will make communities safer for our children, families and our businesses. common sense proposals like mine are critical to ending our nation's epidemic of gun violence. this epidemic impacts every community in america including in my district. last year, in the city of newark, shootings increased 19% from 2014. nd homicides rose by 8%. in 2015, there were at least 76 gun deaths in my district. one third of all of the gun deaths in new jersey last year happened in my district. gun violence has had a disproportionate impact within the african-american community and other urban areas. that is clear when you look at hat's happening in my district throughout other african-american communities in new jersey as opposed to other african-american communities in new jersey. we need a federal approach to gun violence because it is a problem across state lines. case in point, new jersey is a net importer of crime guns. in other words, more illegal weapons confiscated by law enforcement came from out of the state than were purchased within the state. reducing gun violence is vital to the safety and security of american communities. my colleagues on the republican side of the aisle should drop politics and pandering, they should instead join with democrats in supporting the president and his commonsense reforms and like my gun buyback program to address gun tragedies in all communities. let me just say, madam speaker, no one wants to take guns away from anyone. we understand the laws and liberties that have made this nation great. but if we don't do something in reference to gun control, then it's shame on us. with that, madam speaker, i yield back. mr. jeffries: i thank the distinguished gentleman from new jersey, let me now yield the balance of our time to a dynamic new member of the house, representative stacey plaskett. ms. plaskett: i rise today in support of our president's actions toward making our community safer by ensuring guns are less likely to end up in the hands of those who shouldn't have them. i want to thank my colleagues, cookman jeffries and congresswoman beatty, for bringing this hour here in congress and i'm thankful for the congressional black caucus' special order hour for taking time to educate the american people of the importance of our president's actions. while this congress and in particular our republican colleagues have hemmed and dithered and engaged in political inertia and at the end failed to act in this matter, suspected terrorists are free to legally purchase combat-style weapons, american cities and other areas of this country are besieged by gun crimes, and thousands of lives are cut short. according to the american academy of pediatrics, guns cost twice as many deaths in young people as -- cause twice as many deaths in young people as cancers, five times as many as heart disease, yet we afford no funding for research and empirical data collection while at the same time we spend hundreds of millions researching mitigating the effects of those other mall days. every day this congress fails to act, more american families mourn. more american lives are cut short. many in their prime. and more american cities continue to mount homicide and shooting statistic. even in america's paradise mitigating circumstance home district of the united states virgin islands, this is so. in 2015, there were 40 homicides in the u.s. virgin islands. on a per capita basis that homicide rate has more than doubled out of the city -- is more than double that of the city of chicago. gun violence in cities like chicago, los angeles and other places, along with the united states virgin islands, sadly, are a near daily occurrence. and while we pause for moments of silence after mass shootings like the ones in newtown or san bernardino, the thousands of victims of mass shootings that play out kayly in cities like new york city and the u.s. vir-in islands go largely unnoticed and unrecognized. we want to bring those things to the people's voice right now. let people be aware of what's happening and while the president's actions will undoubtedly save lives we know the communities like our own are many -- like our many minority communities across this country, there needs to be more comprehensive actions to address the issues at the root of gun violence so i want to ask that this congress act on these things, this congress has in its power the ability to save thousands of lives, let us not allow the nearly daily occurrence of mass shootings to become the new norm. we must act to pass comprehensive gun legislation in this congress this year. thank you so much and i yield back the balance of my time. mr. jeffries: thank you, madam chair, i yield back. the speaker pro tempore: under the speaker's announced policy of january 6, 2015, the chair recognizes the gentleman from texas, mr. gohmert, for half the time remaining before 10:00 p.m. mr. gohmert: thank you, madam speaker. thank you, madam speaker. we've now learned that the administration is releasing, or mohammed al amran al-shamrani, a citizen of saudi arabia. he was transfered to saudi arabia on january 11, 2016. apparently "the new york times" d gotten hold of documents regarding, and this is from an october, 2008, recommendation for the continued detention under department of defense controlled for guantanamo detainee and then gives the long mber but it's moment abdul raman al-shamrat. you read what reports to be secret, i don't know how "the you ork times" got it, but eal over in his file that this on october etainee, -- well, 14 october, 2007, stated, quote, when i get out of here, i will go to iraq and afghanistan and kill as many americans as i can. then i will come here and kill more americans. unquote. he also stated, quote, i love osama bin laden and mue la omar and if i get out of guantanamo, i will go back to fight americans and kill as many as i can, unquote. the detainee stated he hated all americans and will seek revenge if ever released from guantanamo. the detainee said if he is released, he would again participate in jihad against the enemies of muslims to include the united states. the detainee is proud of what he has done, what he is willing -- and he is willing to do anything to fight against enemies of muslims. detainee stated he decided to become more religious because of his dislike of the u.s. and its citizens. so, you know, for those who have been confused about the rules of warfare, ivilized there is nothing illegal, the stitutional, against geneva convention, for holding ople who are part of a group who are at war with your country ntil the group they're part of announces they're no longer at war with you. now, war was declared, as some of my muslim leader friends in the middle east and africa tell me, it's obvious to the rest of the world that radical islam declared war on the united states back in 1979, after president carter laid the foundation to allow what he to come inn of peace and take over ruling iran. his name was khomeini. and it was after that that our american embassy was attacked and over 50 people taken hostage, americans, and basically, we did nothing about it system of i know the president likes to say that that's -- that guantanamo is used as a recruiting tool but the fact is, oh, and basically if we get rid of guantanamo, then, you know that pretty much eliminates anger at america. the fact is that while president clinton was sending american military to protect muslims who ere being unfairly treated ere was not only attacks against americans, there was planning going on not only to attack the u.s.s. cole but to attack america. our facilities. our embassies. our buildings. and they were planning 9/11. there was -- there were no detainees at gauntaun moe. yet all of this plotting and planning and from my discussions with people in the middle east, when i've been over there with people who are from iran, iraq, syria, lebanon, when i've been in those countries, haven't been into syria, but have been right there at its border, but they all say the same thing. what they use to recruit is in 1979 we were attacked by rad cam islamists, we did nothing. under president carter. in 1983 we were attacked and around 300 marines were killed in beirut. congress under democratic control said we're getting our people out so president reagan ordered the evacuation from beirut. instead of fighting back, we ran home. i understand that reagan felt that was one of his big mistakes of his presidency. so the attacks have been ongoing. the world trade center attack in 1993. the attack on khobar towers. so many attacks under president clinton. he sent a lot of missiles, blew up some tents, seems like maybe there was an aspirin factory. but it was not guantanamo that as the driving force in all of those years, decades of war against the united states. didn't exist. and the elimination of guantanamo will not end the animosity and the desire of radical islamists to eliminate america from the map along with israel. and just to be clear, today, the gorge, zanne in a islamic state claim responsibility for baghdad mall attack. they are still at war. whether they're j.v. or not they're killing people. adam credo from the "freebie con" reports today, obama administration is stonewalling the investigation into 113 terrorists inside the united states. that's my friend ted cruz, senator cruz, senator sessions have disclosed monday they have been pressuring the obama administration for months to disclose the immigration histories of these foreign-born individuals implicated in terror plots. enator senators cruz and said quote, the american people are entitled on the history of terrorists seeking to harm them. we know we already knew 14 of the people that were brought over as refugees turned out to be terrorists, foreign terrorists, radical islamists but given legal entrance as refugees. we have a right to know how many of those 113 that have been arrested for terrorism, foreign-born, how many of them came in as refugees. these are all important. and then we see the story from yesterday by bennett, that almost half of california drivers' licenses went to illegal immigrants in 2015. wow. under the real idea act nobody should be able to use their drivers' licenses to get on airplanes to travel on interstate commerce or foreign travel. and then the story from philadelphia, january 8, absolutely tragic, man walks up shooting police, discussion today that there may be other people that were involved. and the gunman said he shot the philadelphia officer for the islamic state. the police have said that. however, despite the fact that this radical islamic terrorist has said he shot the police officer repeatedly in an ambush or allah and for the islamic state, headline from a story by dave boyer today, the obama administration is wondering whether the shooting of the philly cop was a terrorist act because they don't take the islamic terrorist who shot the and perhaps alla he is confused. he sounds like he knew what he was doing when he walked up and ambushed and trying to kill a philadelphia policeman. the story today of january 8 from jay sullivan in the "wall street journal," nuclear deal fuels iran's hardliners. as much as $100 billion in frozen revenues are expected to return to iran, which u.s. officials have said it could happen in a few weeks. madam speaker, mark my words, if that $100 billion to $150 billion is provided by this administration here in the united states of america to iran to its current islamic leaders who hate the united states, who have not signed the deal that president obama is so proud of and they have breached it repeatedly already. we know that money, some of that money will be used to finance e killing of americans and israelis. now, back when i was a judge, years and years ago, prosecutor, we would say, if you fund somebody who says they are going to use some of that money to fund hamas and hezbollah, which we know are terrorist organizations and we know they are terrorist organizations and the money is going to be provided to terrorist organizations, see, back when i was a prosecute and a judge, we would say, if you are knowingly providing money to someone who has already said is going to give it to terrorists that are going to kill people, it sounds like a case to be made for you , ng guilty, as they are certainly, it goes beyond the pale of gross negligence. but that's hypothetically speaking, i'm not a prosecutor or a judge or a chief justice anymore, but when is the sanity going to return when people say who they are your enemies and want death to america, continue to say death to america, continue to say we are going to provide more money once you give us that, we are going to fund more terrorism and it's already being reported -- it has already just the announcement that the money is coming, has stimulated more attacks on those who would .ope to be free in the iran it's tragic. just tragic. in any event, we are living in perilous times. many understand that there are radical islamists who are at war with us. it's time to recognize that. the release of a man who is said he wants to kill americans and will after he is released should be taken at his word. and i know there are some claim that he may not have said the things that are attributed to him by our own officers, our own personnel that were monitoring him, but needless to say, that is a real easy one. there is video somewhere unless it has been lost with some of the emails that were being pursued by congress, unless it has been lost with emails to try to avoid turning him over to congress, those videos can be consulted and we can know for sure whether this islamic radical that president obama has released from guantanamo guantanamo said the things that our people said he said. and i was hearing some of our friends eve comments about the gun laws. i know we all share the desire tore lessen and eliminate gun violence in america, the thousands of felony cases that came through my court caused me repeatedly -- to think back -- anybody who committed a crime with a gun, got it legally. outlaws don't get the guns legally. and the things that our president has proposed would not have stopped one of these mass murders that he now says spur him on to take action. i will encourage my friends, let's work to take action that will actually stop the mass murders that will actually stop he gun violence, but that will not occur by taking guns out of the hands of law-abiding citizens. and with that, i yield back. the speaker pro tempore: the gentleman yields back the balance of his time. under the speaker's announced policy of january 6, 2015, the chair recognizes, the gentleman from oregon, mr. blumenauer, until 10:00 p.m. mr. blumenauer: i appreciate the opportunity to come to the floor this evening to speak about an armed standoff that is taking place in my state of oregon. this is the ninth day of armed national of the wildlife refuge where we have reckless behavior on the part of out of state zealots who have taken over the federal resources. this is really hard to comprehend for a moment. as has been mentioned by numerous commentators, imagine what would happen if armed protestors who were of a different color or different religion occupied a different facility in chicago or washington, d.c., or philadelphia. we would not tolerate that behavior. we would watch people move in to remove in. and yet here, we are talking about the ninth day, with impunity these people have undertaken to exert their own vision for an amazing region. this high desert plateau in eastern oregon, a region of vast, high desert with key lakes and wetlands, that is the wildlife refuge that was created in 1908 by president teddy roosevelt. it was deemed important torl protect this critical highway and wildlife habitat. we found people slaughtering wildlife and taking the feathers to decorate women's hats. i understand that there are some people who have some frustrations about issues of management of med resources. i appreciate that. is is a large, vast country, 323 million people, and in much of the west, a significant portion of the land is owned, managed, and administered by the federal government on behalf of all 323 million of us. i have no doubt that occasionally there is frustration, from is a difference of philosophy. occasionally there are mistakes made. one of the problems we face, my republican friends in congress for years have refused to adequately these programs being able to take care of them appropriately and that leads to frustrations as well. i think it's important to note that contrary to the actions of these armed thugs, this land doesn't belong to them. doesn't belong to the 7,000 residents or even four million citizens of oregon. this land is in trust for 323 million americans. if we overrule these interests and get the federal government it's not equation, oing to revert to a few of the people in the region. the people who have first claim n this land are the piaout indians who resided on it for thousands of years before the federal government came in and crowded them out. this vast high desert area is worthy of protection, whether it is monument or willed deerness, many of the people of oregon, they agree that this is worthy of protection. i met with a number of those in central oregon. riends of the area, people who think this largest area in the lower 48 states of great environmental import is the largest unprotected area in the lower 48 states. now, there are, i listen to my friend from oregon hoe represents the area, congressman walden, express his concern and frustration. he talked about his challenges with the wilderness area and talked about his deep concern that the administration may consider a monument in the future for this area, monument status for hundreds of thousands of these acres. well, it's interesting to note, i was involved with that process, not as deeply as my friend, congressman walden, who i think can justly claim credit for having been the driving forcer protecting the wilderness area, but it never would have achieved wilderness status without the looming threat of a monument status. and i was pleased in a small way to help facilitate that forward and we are all better off as a result of the process that took place. i was rather surmised in the course of his extensive comments on the floor of the house a week ago that he, while talking about the cooperative effort and the value for the wilderness did not reference at all the process that has been taking place in the malhur ebay sin, where we have seen advocates for local ranching interests, we have environmentalists, people in the refuge management itself. all come together from 19 -- from 2010 to 2013. developing a vision to protect this area. having one of the largest water projects in the country over the next 15 years. a plan, a vision, a commitment, and it was done in a cooperative basis. you can review what's going on with the ongoing media coverage or with these armed, out of state thugs who have invaded the wildlife refuge with no hint of what has happened there to be able to build a consensus a vision, protect and enhance this area. the notion somehow that this government ought to get out of the way, turn this all over to the private sector, is a bit strained. first of all, it should be noted that about half the jobs in this little county of 7,000 people are themselves government jobs. many of them from the wildlife refuge. some of the best jobs in the region. they are -- they may not make much difference in portland or eugene or -- or eugene or seattle or washington, d.c. but in a region like this, having hundreds of family wage jobs with good benefits, pensions, it makes a huge difference. to the local economy. i am concerned that we're just passing over this expectation. that we have an opportunity here to be able to work with the affected people, moving it forward, protect this area. as opposed to folks who are threatening public employees, who've engaged on a personal basis, threatening people. we've had to shut down a number of government operations. it is sad. it is unfortunate. and it is wrong. it is -- we don't need outsiders coming in to oregon, or politician enabling or encouraging people to behave in this reckless, lawless fashion. we should, as a matter of fact, cut them off. there should be no electricity to the compound. they shouldn't be using the computers of public employees. we shouldn't have them ordering out for pizza or delivering food. i mean this is goofy. and it wouldn't happen in any other area if armed thugs took over a federal facility. i have great sympathy with my friend and colleague, peter defazio who felt if the federal government had acted with the lawbreakers in nevada years ago who refused to pay the heavily discounted grazing fees, a fraction of what they would pay if it were in private hands, and allowing this to go on unawait -- unabated, that they're encouraging this lawless, reckless behavior. i am pleased this evening that i am joined by my friend and colleague from california, congressman huffman who prior to coming to congress has had a long and distinguished career dealing with environmental protection, dealing with balancing these interests, solving problems, while we protect public interests. i would be pleased to yield to him for comments this evening. mr. huffman: i want to thank my friend from oregon for your leadership and advocacy, calling us together for this important discussion tonight. i want to thank you also for bringing up our great conservation hero teddy roosevelt, a republican president who i can't help but think is rolling in his grave over the fact that cornerstones of his legacy, the protection of public lands, the protection of wildlife, are under constant assault by too many of our friends across the aisle and for the last two weeks, by some very wrongheaded individuals who are heavily armed at a wildlife refuge in southern oregon. many americans who turned on their tv's last week, i think, were probably surprised to see that this heavily armed extremist group had taken over a national wildlife refuge, that they were threatening to kill anyone who stood in their way. they were led, of course, by amon bun di, the son of the infamous clivan bun dithat great philosopher who romanticizes slavery who refuses to pay legally required grazing fees and who organized his own armed insurrection in nevada a couple of years ago. americans were surprised to see that this group, which was part of a larger protest against federal authority and land regulations was so violent and so heavily armed and so extreme in their demands. i think so many americans are just surprised to find that people would be so violently opposed to our federal government's role in protecting public land and wildlife that they would do this kind of thing. but as a member of the house natural resources committee, i have to tell you, i'm disgusted by these reckless and dangerous and criminal actions but i'm not totally surprised. i'm not totally surprised. on any given week in the natural resources committee, you can hear the intellectual underpinnings of these dangerous, violence actions. you hear the divisive, over the top, anti-government rhetoric spewed by too many of our colleagues across the aisle, members of congress who may now be crit sidesing, ever so yently, the tactics of the gentleman in oregon, but out of the other side of their mouth they justify their actions by arguing that their anger and frustration with the government is justified and legitimate. that we should essential he sympathize with them rather than be outraged by their seditious, violence actions. i am amazed and grateful for the fact that our federal land management and law enforcement authorities have been so patient and so pass i and so deferential because after of their determination to try to bring this to a peaceful resolution. i admire and respect that. i know where they're coming from. but let's be clear about this. there has to be accountability for the occupiers. this armed group of thugs occupying a refuge in the state to my north can't be allowed to do this without consequences because many people you mentioned our colleague peter defazio, believe, correctly in my view that this wouldn't have happened had there been some consequences to the bundy ranch standoff two years ago. unfortunately, despite a very similar action, despite all of the same heavily armed threats and violence and the near avoidance of a tragedy that could have cost untold numbers of lives, there were no consequences. my understanding is that clivan bun distill owes well over $1 million in ranching fees to the federal government and he's still grazing his cattle without consequences. because there was no consequence, his son and the current gang occupying the refuge took the lesson that they could do it again and they'll do it again and again as long as we continue to give them a pass. is there has to be accountability. there has to be consequences for people that do this. there should also be accountable for politicians who tacitly fuel incidents lick this with their inflammatory and hyper bollic rhetoric that always casts environmental protection as an assault on individual rights and that falsely describes our national public lands as some type of threat to states and private property owners. it's not right. the truth is, in california and across the west, our public lands are a cornerstone of lots of local and state economies, including those in my district. i have huge tracts of federal public lands in the second congressional district of california from vast national parks and recreational areas to three different national forests to numerous national monuments and lots and lots of b.l.m. lands. for many of my constituents, federal lands help them put dinner on the table. help them pay their bills. 91% of western voters surveyed responded that they believe public lands are an essential part of their state's economy. we need to remember this. so i want to protect public lands. and i want to work cooperatively with the federal agencies that management them to iron out differences. our federal government isn't perfect. they make mistakes. sometimes they're in the the best neighbors. sometimes they aren't always as responsive and respectful to the communities and individuals that live nearby. and part of our job as members of congress who represent those communities is to try to make sure that the government, for its part is doing the right thing. is listening. is being a good neighbor. but i've seen it work time and time again. and the notion that the only way to resolve differences with federal land management agencies is to take up arms and threaten a violence insurrection is just absolute nonsense system of those are a few of my thoughts. i certainly could go on at length about some of the success stories i've seen in my district where communities have come together and actually collaborated with the federal government, not just as a neighbor but a partner, to do things, including things that brought jobs to those communities. i've seen it in trinity county with process called the trinity county collaborative where believe it or not, environmentalists are brorking -- are working together with folks in the forest products industry and with federal agencies and all sorts of other interests and they've agreed to cut thousands of acres of trees as part of a comps rehen -- comprehensive stewardship program. it's unique but it can work. it can work in other places. it almost worked in another part of southern oregon where we saw this historic coming together of farmers and fishermen an tribes and government agencies. the problem is, that collaboration depended on an act of congress to actually happen and sadly, you should current management, congress is where collaboration gos to die. is we were unable to do the right thing there. but it can be done. i want to thank the gentleman for his leadership in trying to interpose a little bit of sanity nto this debate. mr. blumenauer: i appreciate you joining me in this collaboration and what we need to do in the future. you're right, these are opportunities if done correctly, and you've had these experiences in california, where there are huge economic opportunities. there are 47 million bird watchers in this country. they spend somewhere in the neighborhood of $40 billion a ear. in the malhure wildlife refuge, almost 24,000 people made that long, long, long, long journey. i guarantee you they wouldn't have been sightseeing there but for the wildlife refuge. u referenced the clammoth, a lost opportunity if we're not on our toes. removing those four dams that have obstructed the flow of spawning salmon, prohibiting us from meeting our obligation to native americans, would create hundreds and hundreds of family wage jobs for years in northern california. it's just one more example of where congress is missing in action. where congress hasn't appropriately funded these agencies to be able to fully meet the opportunities. i have no small -- it's hard for me to express my wonderment that some people will come to the floor and somehow try and celebrate the hammond family, people who were convicted of arson and who have a record of having broken the law before. public records show behaviors that are not people you want for your neighbors. these folks do not have clean hands. and yet we have out of state, armed thugs taking over this facility to somehow talk about these convicted felons and undercut this process. i am hopeful that we can work together for people to focus on the opportunities, to have the administration step up, act responsibly, cut these people off, and remove them and to take action against other lawbreakers like we would in other areas of the country. i appreciate your joining me today to have a little bit of conversation here to try and round out the picture that is missing from the media. it's not probably going to get us on fox news but these are things that the american public needs to know because there is a path forward, there has been a regional consensus that's developed. there's a vision to protect the wildlife refuge and its economic activities and its future and it's one that we should support. thank you and i yield back. the speaker pro tempore: thank you. does the gentleman have a motion? -- mr. blumenauer: i move that the we recess until tomorrow morning. the speaker pro tempore: the question is on the motion to should happen tomorrow. and work begins on a measure related to coal mining activities near streams. lawmakers gather tomorrow morning to your the president deliver his final state of the union address. although the house live on c-span when members return tuesday. as president obama prepares for his state of the union address tuesday, he released this video on twitter. president obama: it is my last state of the union address. i can aching about the road we have traveled together. that's what makes america great, our capacity to change for the better. our ability to come together as one american family and pull ourselves closer to the america we believe in. sometimes butsee it is who we are. it is what i want to focus on in the state of the union address. >> c-span coverage starts at 8:00 p.m. eastern. looking back at the history and tradition of the president's annual message and what to expect in this year's address. at 9:00, our live coverage of president's speech followed by the response from south carolina governor nikki haley. and-span, c-span radio, www.c-span.org. we will re-air our state of the union coverage starting at 11:00 c-span2tern and live on after the speech, we hear from members of congress with their reaction to the president's address. coming up, the bipartisan task force to combat the hair on epidemic hold a hearing on addiction and treatment. with thet, a forum democratic presidential candidates. next comment that partisan congressional task force holds a addiction andoid treatment. witnesses included representatives from the national institute on drug abuse, john hopkins university, mental health administration. this is two hours. >> thank you for joining. the task force is made up of more than 50 members of congress representing districts all around our nation. the investment of so many members with different illustrates the reach of her win into our communities. if a national emergency to say the least. time this roundtable will take place, 10 americans will die of a drug overdose. each was a brother, son, sister, daughter, mother, father helpless in the group of heroin addiction who ultimately succumbed to the disease. in new hampshire, over 400 people died from a drug overdose in 2015. that is one out of every 3000 people in my home state. is transforming these productive members of society into desperate addicts -- caroline is transforming these productive members of society into desperate addicts. the risk of experimenting can be other treatment options, we can help save many thousands of lives throughout our nation. today's roundtable will focus on the effect of recovery treatments, some involving medication and psychotherapy resulting in almost 60% recovery rates. to get even more success, we must study which treatments work best and encourage their adoption in other states. joining us in that effort in our panel of experts, deputy director for the national , andtute on drug abuse medical officer for the division of pharmacological therapies and dr. jessica pierce, the associate director of addiction treatment at johns hopkins. i want to thank all of our participants for joining us today and i look for to hearing their perspectives on this growing problem. there are other facets to this problem. acttroduce the stop abuse to coordinate law enforcement and public health agencies at a federal, state, local level. strongercreate a program to monitor prescription pill trafficking. over prescription of legal opiate leads to large numbers of legitimate patients lead to street heroin. we need to crack down on the black market for legal opiate medication, including treatment and protection -- prevention grants. as members of congress, we must do everything we can to help those affected. by hosting roundtables and briefings, it gives members an opportunity to hear from experts to combatat we can do this. i want to thank all of you for joining. i look forward to hearing from the panelists about treatment options. i would like to turn this over to the cofounder of the bipartisan task force to combat the heroine epidemic. >> thank you. and thank you to all of you for being with us today, my colleagues who have joined together in the bipartisan task force to combat the heroine epidemic. grown tod epidemic has his stork proportions. medical providers are struggling to keep up with the flow of overdoses entering the clinic and to secure treatment. our law enforcement and first responders have taken on the burden of responding to more and more dangerous situations. becoming moree and more frequent. statistics show more americans are dying from drug overdoses than car crashes. in our home state of new hampshire, the opioid epidemic sadly continues to grow. debts --number of drug debts in the granite state exceeded 400, surpassing the record set last year. without quick action, these numbers will continue to rise. in new hampshire, we face a deadly combination. we had the nations highest per theta addiction rate in second lowest treatment capacity. last week, i highlighted the results that can result in a lack of treatment options in telling the story of the stepdaughter of a dear friend of mine who passed away at just 22 years old. while incarcerated in craving treatment, a bed finally became available for amber at a wonderful treatment center. but the prison would not let her out to take that big and meanwhile -- that bed and the prison itself offered no recovery services and when she was released, the bed wasn't available. she died of a heroin overdose, lacking treatment, and without support. once someone does get treatment, it's not the end of the road. frank and i have learned as we've traveled around the state that substance abuse disorders can often send patients into relapse and it's vital that proven evidence-based treatment methods are available across the country. why our conversation today is so important. at the federal and state level, legislators are working to forlop the best practices treating substance use disorders. these decisions need to be guided by the latest research so those who seek treatment at the best chance for full recovery. i look forward to hearing from our panelists. we need to know what works and what is not working so that we can make the best decisions in this bipartisan task force. best best develop practices and share them across the country. i was proud to introduce the stop abuse act, a bipartisan bill to bring together our federal agencies to coordinate our response. we can work with physicians, dentists, subscribers, experts ,n pain research and addiction representatives from the addiction community, and develop best practices for pain management and prescription medication. legislation will bolster prescription drug monitoring program. jackie has an important bill for veterans on that regard. i thank you for coming together. no single bill will provide the silver bullet for this challenge but by working together, i am confident we can pass legislation that will start to change the tide of that epidemic. thank you. >> thank you. i would like to now introduce the first of three panelists, dr. wilson compton. dr. compton is providing valuable scientific leadership developing and managing the institute's research portfolio to improve our understanding of their results. i would like to recognize dr. compton. dr. compton: thank you very much. seeing such a great turnout for this issue that has devastated so many communities. this has been such a major impact in so many parts of our country. i applaud you for the task force to address these issues in a proactive way. i am glad i have my slides. through theseo very quickly but i will leave them with you and if there any questions, please let us know. the most important information is on this first slide. it reminds us of the tremendous number of deaths associated with drugs of abuse in general, the deathslers over 19,000 from 2014 and 10,000 deaths from heroine. i will point out that even the surveillance data has some messiness. how debtook at certificates are coded, there are a lot that are coded as drug overdose generally and don't specify whether it was related to prescription opioids or heroine. there may be a greater number of these. there --ve mentioned, it is the increasing rate of prescription that has given many people a taste for an opioid. their brain has been exposed to it or the communities are exposed to it in a way these pills can be misused and taken nonmedically. what we have seen is as the number of prescriptions go up, the numbers of deaths increase. there is a fourfold increase in deaths associated with these painkillers. that's drugs like oxycodone, hydrocodone. all of these narcotic opioid pain relievers. the reason i am starting with prescription opioids is that the upstream driver of this epidemic. that the deciding factor that has exposed so many people to opioids and lead them toward that pathway into a heroin problem. you bring it doesn't distinguish between different types of opioids very well. the brain sees them almost all as very similar. has the same impact on the brain as oxycodone or hydrocodone. in laboratory studies, people cannot distinguish the difference. rates of prescription drugs have become more available, we see an increase in heroin. because of the initial exposure to opioids and then the availability of heroin in so many communities around our country. misusingr of people opioids has sky rocketed and the heroine deaths have seen an increase. the next financial increase in the last few years and it certainly concerns me because we like to see a curve bending and eventually coming down and we don't know where this will end. it's still on the upswing. been increases everywhere. if i only showed you the south thought, we would have a doubling was a terrible scourge but look what is going on in the northeast. it is a sixfold increase in the number of deaths. it is in all the major ethnic, racial, age groups. young whites. it shows these new injection ,rug users tend to be younger equally male and female. that's a novel change. we think of most drug users being male but that's not true in these new users. that's another concern. why do people abuse these? they abuse them because they have an impact on the central circuitry. they make you feel good. a basic principle for much neuroscience are not going to go into detail but that's the underlying feature. these are habit-forming. not for everybody and that's a conundrum. some people take these drugs and they find it extraordinarily unpleasant but some really like it and there are at risk for doing it again. i am pleased our secretary of health and human services has made this one of her keynote issues. she convened a small group helpn the department to her address this in a proactive, consistent way. we have developed three priorities. these are not the only things we are doing but the three priorities relate to a prevention approach. many change how prescription opioid are available by focusing on prescriber practices. let's focus on saving lives immediately with greater access to life-saving overdose treatments. ,nd let's focus on treatment medication therapies and particularly as the proven treatment for opioid addiction theeduce -- to increase likelihood of people going on and recovering. thell focus briefly on first two. when it comes to prescribing this is, one of the issues we try to address relates to the opioidses for providing that pain clinicians use that come from a variety of sources. ine of them are outdated and conflict of interest. as an alternative, the cdc has been undertang the development of prescription guidelines and these -- when it comes to the overdose, we are pleased to be able to work with one of the pharmaceutical industries and for the recent approval of a formulation. the only fda approved formulation being an injection, there is a nasal spray. it was approved in november and it should be on the market shortly. to the main issue which has to do with medication. there was a's ready in baltimore a couple years ago that showed us as they increase the availability of methadone, they showed a stunning drop in heroin overdose deaths in that city. we see this as a population-based example of how you can save lives and increasing treatment access. methadone --ned i've already mentioned methadone, opioid substitution treatments. methadone works as another open your eight. -- opioid. let's take a quick lesson in the cellular chemistry. when a chemical is taken, it works by fitting into a receptor. think of it like a key going into a lock. methadone goes into the receptors, they go onto to the receptor and produce a lot of activity. that's kind of like you turn a lock and the tumblers move and the doors open. a blocking agent is like a dummy key. it goes in and doesn't turn. it fills the keyhole, keeps other keys from getting in, but doesn't produce any action. those are the easy ones. -- weone or opioids haven't and between agent that is somewhere between the two. it's a partial agonist. it turns the lock but the door doesn't open fully. that's a quick way to think of these different classes of medication. blocking agent is one of our in a that can be given long-acting form and when people take it successfully, they don't get high. they used heroin or other opioids. the same thing happens with methadone. when they are taking those successfully, they generally won't get any intoxication when they slip so they learn not to use them. that is the key to use these as a learning experience. that's the short version of the history and melinda will go into this with more detail. i will tell you what we're doing with new approaches focusing on extended-release medication. medications bit on and we are pleased to have partner with the release of a long-acting vivitrol. we have even developed vaccines as another way of keeping drugs out of the brain. one of our new medications is this long-acting. one of the issues as people will take these medications but there's an issue. my patient has to make a decision every day whether they want to stay in treatment and use their medication or they want to not do that and head back into a path towards relapse. sometimes as a conscious decision, sometimes not quite so but they need to make the decision every day. with a long-acting injectable form, they may not need to make that decision as often. you're interested in this idea , a longplantable device acting implant that only needs to be implanted once every six months. that means someone only has to make a decision about their life and turning things around about once in every six months rather than more than once a day. patients are more likely to be compliant when they take this. caprices greater abstinence. greateroduces abstinence. this was submitted to the fda in september and it's under an expedited review so we expect an answer about whether it's met the threshold and whether the data supports its actual use by clinicians within the next couple months. want to focus on a promising area of that scene development. the drugs have to get into the brain to have an impact. vaccines attached to those drugs so they create a protein binder to those drugs and they keep them in the capillaries. they keep them in our circulatory system and not the brain. that's the theory. there's a bit of preclinical research animal models. there is emerging human research to suggest this might be able to be effective. we had a way to go before we have that scenes that are useful. our job is to always be charting a path forward for what we can do tomorrow even better. the last challenge i will focus on is implementation. we have had these medications like methadone for about 50 years. naltrexone for 30 years. so what is going on? not very many people are treated. this is a major gap. we are pleased to see increasing prescriptions so more people are availing themselves. we have been pleased to try novel trials. ale noticedyield -- y they were seeing the same people over and over again coming in with an overdose or problems related to air when and other opioid issues. they said maybe we can start it here in the emergency department. they're not going to the clinic down the hall so why don't we act as their primary care physicians? they found they were more like you to be in treatment and less likely to be using drugs when they were reevaluated weeks later. this is just one center. we are not sure everyone else can do it as well. but we think that's promising and we are working now on testing this in a number of other senators -- centers. finally, i was saddened by the story representative custer related about a patient who died shortly after being released from prison. the importance of linking our criminal justice and public health efforts. i represent more of the public health and treatment area and i have issues with people dropping out of the treatment readily. sometimes working together through models like the drug activeodels, extensive work with probation and parole, we can do a better job using the best pieces of both whether that's the close supervision, the treatment the treatment providers provide and even , incentives for people to turn their lives around through modification. these models have been shown to work for 20 years but we don't see them in wide enough use. these efforts seem to be an area where we are doing research. i remind us that even medications can be used in this setting. tookdy out of baltimore offenders who were about to be released from long-term incarceration. to all had a history of heroin addiction in the past. this wasn't withdrawal. they referred them to methadone, actively referred them which means they actively made that referral and engage them in treatment after released where they started him on methadone a few weeks before release. those were methadone was started prior to release had a better outcome whether that related to less criminal activity as well as less drug use. this speaks to the importance of being practical and thinking through what happens. people get out of prison, they are not usually thinking about getting treatment right away. there are other motivations that are their first goal when they are released so starting treatment and setting them on the right foot could be very important. thank you very much for your attention. i'm going to turn it over to melinda. have theould just congresswoman make the introduction. >> thank you very much, dr. compton. the doctor who currently serves as a medical officer for the division of pharmacologic therapies at the substance abuse and mental health services administration. she's a physician board-certified in family medicine with additional credentials in addiction medicine. thank you for being with us. >> it's my pleasure. thank you for having me. before i get down to my presentation, i want to take a moment to thank you. sa is providing a new round of grants to help in assisted treatment and has funds to dedicate to overdose prevention thanks to the budget you worked so hard to pass. i want to thank you for setting aside the block of time to gather more information about treatment options for opioid abuse disorder. i cannot begin to fathom the number of equally critical issues you are faced with and that demand your attention. i came away from the first forum a few weeks ago really deeply impressed with the urgent need i felt from the members in attendance for ready come out-of-the-box direction for what could be applied to help your constituents. so, i'm going to try to really be concrete today in this presentation and not be too high too much of what dr. compton has already presented. the other thing i want to tell you about myself is that i spent 10 years as a prescriber before i came to government. five years in my solo private practice doing primary care medicine. as medicalears director of an opiate treatment program in pittsburgh. i maintained my private practice over that time. the single most therapeutic thing i did for anybody was provide respectful medical treatment. whether that included medication or just listening and advising and coordination. obviously, medication was an important part and i will spend a lot of what i talked about today on that. one day, i asked everyone i saw it a would give me permission to take a picture. this is far less than half the people i saw that day. people waited their turn. nobody could -- when they were being treated with respect. when they were getting the care that individualized them as human beings. that in a little bit. reiterate, as far as your brain is concerned, an opiate is an opiate. problem we may have a to start with, once that horse opiateof the barn, and disorder is an opiate disorder. you may have different strategies on the prevention and that the treatment and looks pretty much the same for everybody. is, how quickly it affects you, the individual person brings risk factor to be. when they are functioning highly and getting their opiates either by misleading a prescriber or getting pills from a friend and they keep the social front in tact, the consequences are less. unfortunately, and opiate is just as deadly whether your social facade is intact or not. but if your existence is more marginal, if your personal safety is at risk, if you have as asubject to trauma result of your addiction, it does snowball. there is a cumulative risk. so, while the brain and the opiate are energizing in whatever way, we in society have ise role in how the illness based on how we define what we expect from people. criminalize their behavior or medicalized their behavior. i want to talk about the essential ingredient for recovery is that one be alive. the locks and is not medication assisted treatment. it is the antidote to opioid poisoning. has the shocking ability to take somebody who was completely without life, no air moving, and bring that person back to alert, talking to you. to seeays very happy you, but alive again. it is astonishing the effect of that drug. so, it is absolutely essential to any treatment that people have access to the antidote when they need it. available making it to people who are leaving detox or rehab because they are going out in a fresh baby state. they are extremely vulnerable to any exposure to opiates. that peopleant likely to be on the scene of an overdose, friends and emily or other users, have no locks and. -- what i used to do was write prescriptions for it at he prevention program and supported developing a training offered in at jails where we were not the time able to offer it. doing it as putting it in your personal effects so you haven't when you walk out the door. there are all sorts of innovations going around the country that will result on lives saved instead of lives lost. toolkite updating our for the intranasal version which latere available publicly this month as a piece of work we are proud of. another point for you, detoxification is not treatment. detoxification is necessary to dependence,cle of tolerance, and withdrawal. it is not always necessary to begin treatment. you do have to be detoxified to start it. if you are choosing to be detoxified because that is what is best for you, then being offered the drug should be an important step. it should be standard for that person who was not seeking the opioid. detoxification is better thought of as the medical management of opioid withdrawal. the risk ofchange disease or the factors for relapse over the course of the disease. it does increase the risk of fatal overdose should the person relapse. even if it is followed by a rehab stay. medication is not a treatment by itself. it will control the disease much the way your hide led pressure medicine will control your high blood pressure but it will not change the course of the disease itself. just like if you are diagnosed with high blood pressure and you have to lose weight, stop smoking, control stress. of behaviorhole ton change the cames with most chronic illness. high blood pressure so, and i am sure there is many of us here with it now. i'm sure what we would want would need to be treated with the medicine most effect it for us and to be given the opportunity and the education to change our lifestyle. lady, sociallya and culturally the way we have looked at medically assisted treatment is a treatment of last resort. if you have gone to detox and treatment however many times you want to pick, pick a number. then, well, gosh, you have to go on medication. youris not how we look at blood pressure. we say, let's go on this while we get weight off you and learn how to control stress. look athow we have to treatment. you have to be alive, you have to get your ducks in a row. i still have my wooden ducks, my pool toys, because i used to use that a lot. are your ducks in a row yet? dr. compton reviewed a lot or you and i won't go into detail except to talk about the difficulty that we can have in getting our heads around the idea of giving and opiate to an opiate addict. that is intuitive, it is not where you would expect to be going. but as dr. compton was laying out for you, if you get on the right dosage, take methadone. agonist, if a full you get on the right does it control short withdrawal so you can stay engaged in treatment and function, but it also fills up your receptors and it eats them on and make even key also you are not constantly being also your to use, but receptors are full so if you use something, there is no receptor for them to wind to to reboard you for that slip up. so you are more likely to move on with your recovery instead of the whole octopus out of the top of. morphine is different because it is not just getting the dose in the right to range and saturating the recep doors, it is a little bit that, but bupropion seen has this ability to bind to the receptor. most of the people who will take on the street will not budge that. the beauty of it is when it is bound to the receptor, it does not fully stimulate the receptor. the receptor is only working part time. your body says, i don't need as many and it starts to deregulate. that is when it starts to reduce tolerance over time. that is just kind of a cool pharmacology aspect of the drug if you are really geeky you will enjoy that aspect. now, the antagonist, of course, gets on the recep or, lines it, blocks it off, makes it impossible for any openly -- opioid affect to happen. because your system has to be cleansed of opiates in order for you to take that locker. because if that opiate goes into your body and ribs all the appearance of the receptors, you will wish you were dead. you might not die from your withdrawal, but you will wish you did. the process coming on it has a couple steps you have to go through. so it clinically and in terms of how you will interact with the patient, keep them safe, get them from they want treatment to on treatment, depends upon the medication you choose for them. hopefully i have not confused anything further. let's talk about methadone. this is the clinic i was in charge of. there is nothing inherent about methadone that requires it be administered in an ugly, dilapidated building. that is just how we decided it needs to be done. to their credit, they painted and they fixed the broken windows. you can see there is broken glass block. my office was in the shed. i used to say yes, i am the medical doctor. my office is in a tin shack on -- my office is in a tin shack on a cement slab. you find your neighborhood methadone clinic it will not look much different from this. there is the frank lloyd methadone architecture. brick, iron bars. not where you want to have to go every day or three days a week or certainly not where you want your kid or nephew to have to go. have 1400 of these programs in the united states mostly providing only methadone. they are subject to regulation conceptually and in reality, giving controlled substance to a drug user is a high risk undertaking so it airs special attention. havetunately, some states chosen to prohibit opening programs. some communities have decided they have to have special zoning which is how you end up in ugly buildings next to a car wash. find out,want to everything samsung has about opening one, how they are regulated, accredited, would you have to do and the to operate a program, we have a website here and we have a resource for your providers and program staff, to go into it a little bit. this is where my private practice was. i saw the same patience here. i moved up to the third floor where the lights are on. this is where you might rather go if you needed treat meant. this is where you would rather your friends or family went. this is your standard. or's office. i spent about five years there doing primary care. naltrexone.me oral me, as a private practitioner, it was more than i could do. but i did have some people who came out of a controlled environment. being blocked and feeling a attle bit like by having little bit of your thumb on the scale of choosing not to use, we used one of the patients who naltrexone is now a counselor and the father of a one-year-old and doing exceptionally well. another important thing about since it is not a controlled substance it can be prescribed by any health care professional. it does not need to be provided in the context of a program although ultimately the person would he better off receiving additional services. here is a couple resources for you. our training website discusses all forms including naltrexone. and we have a publication devoted to it that you might find useful. recommend the, we loxone.th na pregnant,erson is uprenorphine.mend b it does not require detoxification and is available in generic forms. hand,one, on the other when you have hepatitis or other things, it requires more for management but it is not that you cannot use it. the you pull morphine practitioner has to be -- bu bemorphine provider has to a physician. 130 patients the first air, 100 patients a year thereafter. aboutadvise physicians meeting the need in their community, we recommend they become an opiate treatment program because they can then treat as many people the state will relate them for. we do try to encourage people to take that option if they are feeling unduly restrict it by the current patient list. i will skip going into a whole lot of detail but point out we have separate resources on the samhsa website about how you can become wavered and learn what is needed to know about how to do it. i will tell you in closing that i treated, i worked really hard to try to convince my colleagues in practice they should be doing this as well. i heard all the time, well, i do not have any of those people in my this. and i said, well, i just took two of your patients from your primary care practice. they had to change to me as their pcp because they needed treatment. that was unpersuasive. the other thing was, i do not want those people coming to my office. i am like, well, you already do because i have two of them i just took and there are more. so, i cannot help but take, my congressperson coming to me at my medical society or to me as their dock there and saying, look, we have a public crisis, think of it as a cholera epidemic and do something. that is my little pitch to you as an individual physician and i will hand it act you for further introduction and you should have slides coming up in, i hope will stop >> thank you very much. i would like to introduce our final witness before we go to member questions. i would like to introduce dr. jessica pierce, from john hopkins bayview and associate professor at johns hopkins university school of medicine. directrce has provided patient care and supervise the psychosocial treatment of over 400 patients with opioid dependence. she has received awards from samhsa. the treatment services research is designed to improve the up take of and adherence to evidence-based treatment for opioid dependence. i would like to recognize dr. pierce for her hesitation. pierce: thank you very much for the opportunity to speak. i am heartened by the interest for the treatment and efforts to create solutions. i think it is a nice balance because i'm not able prescribe her. i am not want to talk about medication at all. i am going to talk about the other asked act of treat it. -- of treatment. i am a clinical psychologist and i am here on behalf of the american psychological association today to recommend treat men for opioid addiction and to recommend treatment. you have heard today about many affect if treatments and the means for more affect of treatment. i agree totally. i want to add we can improve treatments further. i will give you examples of how to do that from our research. first, we can and we should increase treatment and roman. should we can and we increase the amount of treatments patients receive in a treatment program. third, we can and we should increase the treatment of evidence-aced care, that is toatment research as shown be effective for addiction and other problems related to addiction. i am talking about increasing and enrollment. we have been fortunate to work with the baltimore exchange program. much of the research is focused on using contact with syringe exchange to increase motivation or opioid addicted men and women to enroll in treatment. regularly encourage addicts to enroll in treatment. at a slant, that runs 10% in that left graph. we tested adding brief, motivational sessions to that referral and tripled the and roman to rate. we then added a small incentive which included prepayment of the first week of treatment and that increased the rate by half again. we were able to increase fortment enrollment to 50% the short, low-cost intervention without adding any treatment cost. patients often drop out of treatment. that is because treatment is hard. patients have to change a lot of their behavior. a lot of their environment and to even the weight they think. and so, they dropout of treatment. they really do want recovery. it does not mean they want -- do not want to be drug-free. human eating's have a hard time making big changes. after all, it is only january 11, and how many americans have already broken their resolutions ? so, opioid addicts who dropout need to be able to return quickly. back intoropouts got treatment within three months, we more than that -- with the addiction and sentence. using an exchange to increase enrollment and getting dropouts back into treatment, we can make that happen and we should. once they get to treatment, they need to get the most out of it. this has been a second line of treatment research for us. treatment based on object to have indicators of treatment success and we tested the standard care treatment in our area, the baltimore region. just as with treatment enrollment, just because you offer treatment does not mean patients receive it. patients in standard care attendant about 30% of their counseling. pretty sparse. with adaptive step care we increased that by over 50% and took it even further with additional incentives. mind you, the adaptive care were scheduled for up to 36 sessions a month and were attending more than half of that. result in better outcomes? it does. in the right graph, you can see patients in standard care. step care increases the rate i over half again, listed even more with incentive. we were able to achieve 60% negative drug tests early in treatment with a structured treat the model applied uniformly. i want to point out that at adaptive step care is a cost-neutral intervention. difficult, but cost-neutral. increase treatment outcome simply by increasing the amount of treatment received by the patient. finally, a third line of research that focuses on expanding treatment available. post-traumatic stress disorder is one of the most common reoccurring stress disorders in opioid addiction, with about 35% of patients having me disorder. we offered a gold standard treatment for ptsd called prolonged disposer in the clinic by providers they knew. theyarticipants said wanted the treatment, all participants said they plan to attend. one was offered a small incentive to attend the sessions. the left graph shows how many sessions each group attended out of the schedule. though simply offered attended a meeting of one session, while those offered a incentive attended nine sessions. the greater amount of treatment result in a greater outcome? yes. study, a portion of patients who had small significant more than doubled in the group that attended more sessions. not terribly surprising, if you receive more treatment you get more benefits. the study shows we can offer evidence-based care and maximize the outcomes of that care with relatively little effort. as both a treatment provider and a clinical researcher, i am telling you we have great treatments for opioid addiction and we can make them better. andan increase enrollment exposure to treatment services and offer more evidence-race care for addiction and related problems. we know how to treat opioid addictions and we should. thank you. >> they keep very much, dr. pierce. we are first going to yield to the gentlelady from indiana. >> thank you to my colleagues were putting this together. i am going to direct this to dr. compton and dr. pierce because we have an issue in this country with every single thing you are talking about with opiates, overprescribing, and the like of suicide and accidental overdose, potential overdose, with veterans. some of us sit on the v.a. committee and i am in the andest in northern indiana andy is on the east coast, but the unbelievable issues that have arisen with the overprescribing of veterans drugs is the front line looks like i have veterans come in my office of all ages. butjust young veterans, senior citizen age be at facing a lot of the same chronic problems. they are coming in with boxes. and they will have psycho tropics, opiates, you name it in there in a friday of different taxes and bottles. times withn often their spouse literally begging and crying for help. they do not know what to do. my first question is, i have a -- a bille firing -- we are trying. together to start controlling this in association with the dea. what do we do to turn this fossett off as quickly as possible? now it has created a third ring country.in our those drugs to show up in living rooms and the overdose drug is coming to the rescue. withis what is happening veterans who were recruited to defend our country and they are coming home and this is what they are being given. i have a will going through that says if there is a state database, the v.a. database has to go in there so another set of eyes can be looking. my question is, have any of you look at or been involved in this issue of the gigantic increase in numbers due to so many of our veterans trapped in the system. the system has been this way a long time. and they have been refusing to look at other evidence. two key areas. one is the overprescribing of opioids for any conditions. we have two problems. one is the problem around chronic pain and how do we treat pain successfully. the second is the overreliance on opioids to treat that pain. there are other approaches. are we availing ourselves of non-opioid radical approaches that show promise and may do as good or better a job for many of the painful conditions for which clinicians have routinely reached for their prescription pad for a solution that does not work over the long haul. you brought up a very specific issue around the integration of the v.a. records into the prescription drug monitoring programs. certainly, making sure prescription monitoring programs are robust and have information from all the sources of opioids, whether it is the v.a. or the indian health service or whatever may be outside those traditional reporting mechanisms. it brings up the other idea, how do we link pdmp's across state lines. in this region, it is a major issue where i can five miles and i am in re-different errors diction with separate systems. -- i am in three different jurisdictions with three different systems. working on the interoperability, how to get the computer systems to talk to each other. when you aretors, looking at ptsd, do you look at evidence-based solutions? >> yes. rolleded exposure are out in the v.a. and preferential for other. i do know one of the problems people have and in the v.a. it is that the old guard sometimes do not want to go through the process of learning those their -- those therapies and they are difficult therapies to provide a yen to undergo. so it is easier to write a prescription for a benzodiazepine or an opiate and to go through the process of doing the work. >> i yield back my time. thank you chairman. chairman: just to remind, we are going to stick to the five-minute rule. i would like to recognize myself or five minutes. i would like to start with the doctor. you talked a little bit about the differences between the alternative prescriptions that are utilized whether it is or the others. it appeared to me that, unless i --understood, the rationale is it based in law? it looked like there was a slide you had where there was a specific amount doctors are allowed to prescribe in a certain time. did i not see that correctly? i think it was the number of patients? >> i think what you are referring to is the law as it pertains to prescribing. it is limited to physicians at this time. a physician can treat up to 30 patients at any given time for the first year they are approved to prescribe. then they can treat up to 100 patients at any given time thereafter. they have to request permission to do that. that negatively influencing the ability to prescribe? limits of ability to prescribe and that treatment setting. a physician who wanted to treat more patients could become registered as an opiate treatment program, which would require adhering to some different regulations. to treat as many patients as he or she could the licensed ride the state to do in that treatment model. >> how is the physician determining which treatment model makes sense for which patient? choosing extent that the right medication for a person should be what drives becauseebody gets, but we have opiate treatment programs that are the only place where you can get at the don't if that is what you need and opiate treatment programs in individual positions where you if that isther drug what you need, and then naltrexone which you can get at an addiction treatment somewhere or at a physician's office makes it difficult. there is no one place a patient can go to and say, assess me and give me the appropriate treatment because of the way the system is chopped up the cousin of the way the medications are regulated. tags is your suggestion that we modify those rules to allow under one roof treatment or management for a particular diagnosis? >> i do not know about modification, but the opiate treatment program modeled can provide all three of those if they choose to. encouragingy provision of treatment of all forms in the opiate treatment model is some ring that could currently happen. >> i don't know this is a question for you are done or compton, who determines the length of the treatment? who monitors for statistical purposes how long somebody may be in a treatment facility? how long is long-term patient care? >> that is an important question. how long should somebody be treated for their opioid disorder? some think it should go on for a very long time. does that mean an active, daily treatment for a very long time? probably not. based on howto be they are functioning in the rest of their life to make that decision. >> someone who is on long-term, several years, is that patient ever weaned off of the current medication they are utilizing? >> it needs to be individualized. if it is a 17-year-old that just aren't expensive though, you would probably not a devout lifetime. but of it is somebody who is 40 having your siphon old and has been on it for 20 years, a different case. what about expanding treatment options? >> yes. i highlighted two. one that is almost ready for release in terms of the long-acting and i also highlighted vaccines which might be a novel approach we could bring to your attention. >> one is coming to market shortly and others within the next year too? ask i would not even say your or two for vaccines. a smaller term. cracks my time is about to expire so i will yield 45 and it's too co-chair congresswoman custer. : brieflyoman custer back to the question of dr. comp publicll, what is the policy behind the limit of 100 patients? we live in a very small state and there are not a lot of choices. we only have a handful of providers who are offering. it seems to be successful for the patients you can get it, but most patients cannot. the wondering, what is downside of congress eliminating the cap or raising the cap to 200 patients? questionsay complex that it is an important and valid one. inadequatelys that trained or unscrupulous provider could run a pell-mell type one drughat provides instead of another. and, distribute large quantities without attention to how well people are doing or whether they are compliant, resulting in medication being available for misuse or accidental exposure or for people who do not use opiates or children, for example. that was the rationale behind the original limit and behind this should bet integrated into primary care or general psychiatric care and not necessarily be the sole focus or soul service provided. this offers an alternative to the opioid treatment model where that is generally the soul solece provided -- the service provided. so if you were able to go to your provider's office and that person was seeing a substantial hand all of people, you could blend in and not be subject to bias or stigma because of your addiction. that was the thinking that went into a law some years ago and after it had then in effect, they added the additional after you have been doing this for a year and got some mixed aaron's, you can go up to 100. we know there are some groups of providers getting together and not necessarily doing a good job someatients and causing drugs to be available for diversion into the community. >> i wanted to discuss a drug availablehed -- made in new hampshire. i have been on rides with first responders and a described the reaction to the administration and the person coming back to life. the challenge we are having is created aand now has unintended consequences. our state legislators made it available to anyone. the purpose being for family members or loved ones who know someone with an addiction. now ourlenge is that first responders are literally responding three or four times administering it to the same person. i am wondering what the preferred protocol would be and how we can avoid the situation we have appears that some people using the narcan forally as a backup safety a bigger high, if you will. >> do you want me to spank to that? >> i think we most might have some insights. intoed greater information who the overdose patients are, what happens to them after, how often we see this occurred. very little data follows those patients. the idea that they use it over and over again is something we are hearing, but we need to understand how that happens. i liken it is to if i had a , i mightith diabetes call ems frequently and as a clinician i would see it as a sign of what it might need to do for that patient. thateaks to the fact narcan is just a first step. keep them from ending up in a medical examiner's office and allow us to have an opportunity to intervene more long-term. how do we connect them with the other treatments? >> i yield act. i yield five minutes to the gentleman from maine. >> i thank you all for being here. i represent northwestern, down east main and i also raise my son from the time he was in diapers as a single dad and i love him like don't tomorrow. all of us parents across the country are scared to death about this issue. i don't know a single family that has not been affected by drug abuse, or know someone who has been. it is frightening for me as a parent looking at this. or peirce, could you tell me to the best of your ability in all of the experience you have clinically, are individuals born with a tendency towards addiction, or does that come through trauma and other things people might experience during life? dr. peirce: yes, all of those things. factors thate risk increase risk for developing addiction, but not everybody has those risk is. someone, dr., experiments with opiates, are they on a path for manila lead damaging their neurological functions and over what timeframe does it happen? dr. peirce: i would have to yield to someone else about neurological functions, but once someone starts using opioids the chance they will develop a dependency increases but it is not a guarantee. it is important to intervene as quickly as possible. the shorter the drug-using career, the better the prognosis. >> thank you very much. you mentioned during your briefing to our committee several different factors in one's life. could you paint for us on the committee and for the fence around the country listening, is there a profile that to you such that the moms and dads in the answer and our goals in can look at their families and say these kids, the asian adults, these adults have more tendency to become addicted to drugs and alcohol or not? >> i do not want to say there is a profile but certainly a family profile of a disorders such as alcohol, which is still the most substance use disorder can predispose subsequent generations. early experimentation with things such as cigarette can be a suggestion that an individual may beand on some biological or genetic impulse to alter one's state of mind. beyond that, it is kind of -- it could happen to anybody. takenetic mapping a has place, maybe dr. compton you want to discuss it. it helps folks to make sure they know that they have a higher or lower tendency to have this problem in in life. compton: we have not unraveled the genetics of addictive disorders. the closest we have in the tobacco area is specific genes which may know but you at higher risk of tobacco addiction but we have not solved that when it comes to opioid addiction despite a great amount of effort. dr. comp leon oh, you mentioned in your opening some issues dealing with incentives. in those folks you'd to her such desperate need of our help, what are some of the incentives to help them along the path to recovery? dr. campopiano: you would think losing everything would be an incentive. , necessarily. you can lose your home, lose the trust of your friends and family and still not be able to change your behavior. >> what i am looking for is the support these people need from their family and friends. the fourd distract families throughout the country. the fourso distract the families throughout the country. give us some examples, please. campopiano: desire to be the son or daughter you set out to be at one point in life. they hope that can be created for you within your family again. people arege that not going to give up on you or throw you away. that hasere is so much been discussed here today about ingost-detox med that's help folks get back. compliant,one is on how do you engage them said they see there is an incentive for themselves to be compliant. how do you do that? dr. peirce? dr. peirce: i think families can do that. because i think one of the things they can do as they can insist the patient's goat to treatment. they cannot refuse to give a support a family would give. we call that enabling. tough love. if you give money to someone who has an active addiction you are more likely to see the addiction than treatment. so, and understanding about the availability of treatment, the insistence that treatment is necessary and as someone lives they need to return, and continued monitoring. in the context of all that love and care, it can go toward promoting health and set of promoting estrangement and poor health. >> thank you. >> thank you, i recognize my colleague from connecticut and john sarbanes from delaware. -- maryland. excuse me. >> thank you so much. i am going to yield 30 seconds. >> thank you for it yielding. very quickly, i represent baltimore city. you have alluded to it many times and it has obviously been an important is for research and progress. i recommend you submit in , im interested in this idea that we treat this as an epidemic. you alluded to a cholera epidemic, i would the curious to conclusions with other epidemics. if you could submit that that would be wonderful. a your back my time. -- i yield back my time. everyone.to thank in connecticut we have seen a germanic increase. we have had over 300 deaths and hasn my district and it been the epicenter. i started these issues as a state representative. we have seen an explosive increase and it is a grave concern. a couple of questions i want to lay out. talkedpton, yulia and i before hand. can you talk about what we can fiction lessees. i look at my kids who got when they had was some teeth extracted, the same amount when my brother-in-law had his hip shattered, he got will stop a need some ability to write-size prescriptions. is there research being done on management?in is there research being done on dig ofdid if -- less, a non-opioid or less a dig if -- less addictive -- opoiods? we know what we're doing, we know what works, but it is not being used everywhere. we want to get this in the hands of our communities, our states, and the people the represent. to be the parents and they want to be. to have a brave future. i look forward to your responses. >> as you mentioned, figuring out how to make sure the number of pills prescribed is the number people really need is a key ingredient in all medical care. it is particularly true of having them left in our medicine cabinets can create a pathway to their use. you raised a number of questions. there are medical conditions for which there is vertically declared evidence that opioids is generally not used. removal responds well to ibuprofen. it may produce a reduction in the inflammation which is part of the in. as opposed to opioid, which only takes away the pain. it should not pay the first choice in that setting. in many health conditions, we have a very few studies to help guide the decision. so the boundary is not nearly as clear-cut as we would like it to be. you asked about alternative gain management. the nih has a number of studies looking at alternate approaches. cognitive therapy. mindfulness training. as a cold therapy. -- physical therapy. when we think of non-opioids, this is a very large market. there are an awful lot people of pain, short-term or long-term. very lucrative pharmaceutical market. companies looking for new products in this market. but i do agree with you that the -sizing theht prescription in is key. to the question on how we can increase .vidence-based care you can inform people of the evidence-taste care. you can benchmark treatment. you can see, i need to see how you treat your license. -- patience. you can decrease stigma. treatmente reasons buildings look like they do is because a lot of april do not want -- people do not want them in their neighborhoods. >> i yield five minutes to the gentleman from pennsylvania. our co-chairshank for organizing this task force. i think the witnesses for coming in today to help educate us and the american people about what we are looking at here. termompton, used the injection drug users. i wanted a clarification here. heroin is notr, necessarily an injectable. it is injectable, but there's smoking goingand on. i wonder if you can educate me a little bit about what sent a fair one out there is being snorted versus smoked versus inject did -- injected? >> i will go back and see if i can find a specific answer. routes are commonly used. it is typical and addict may rest from the non-injection routes towards injection. objection is more efficient as a drug delivery system. it gets into your body are and more completely than when it is taken by mouth or snorted or smoked. it all of those of them administration can be used. withally, people start out snorting or taking it by mouth. >> been in your field, when you talk about idu you are talking about a drug that can be an jet did but also can be -- injected also by these other methods as well? dr. compton: typically, people who use drugs by injection also use the other routes of administration. >> are you satisfied with the current prescription guidelines for opioids? -- ave anecdotes dr. compton: i was talking to someone the other day, their son had shoulder surgery and they gave him a 45 day supply. the mother did not think that was appropriate and she asked for less. dr. compton: it you have to remember guidelines are just that. not rules or regulations. guidelines for interpretation they will then use for their own situation. i agree with you that we see opioids are over five in very many settings. -- rather than the maximum that they may require. i don't have any of those people in my practice. when you talk your colleagues. i guess i'm looking for some protocols perhaps that might exist within the counselor side of things. informing physicians. regulation,ivacy confidentiality of drug and alcohol abuse records from -- are required to be kept private from primary care physicians. this can lead to a situation with primary care physicians not knowing what is going on. are there protocols in place for example or somebody comes in for counseling and the counselor knows that they should ask the patient whether they would like this to be communicated to the door -- their pcp? >> there are two approaches to that situation. the cookie tray with drugs that would interact with the opiates or be dangerous. if they are prescribing methadone or the other for treating the disorder, the other physician should know. the treating -- the physician or other prescriber treating the person's opiate use disorder does need to coordinate care. they must have the individual's agreement to do that. there is a matching responsibility on the part of urgent care and emergency rims and primary care doctors. to ask about and identify substance use disorder. the protocol for that is to treatment referred to that others have advocated for. >> you mentioned 1400 certified programs. as these programs are certified, is there any effectiveness requirement that has to be demonstrated? how do we measure the effectiveness of any one of these 1400 programs? >> regulations do not specifically require that we ask about outcomes. developing ag into process that would tie certification and recertification to patient outcomes. the regulations were put in place at a time when the technological infrastructure and the understanding of what the outcomes could be was limited. >> is their consistency among certified programs looking at the medical side, the counseling side, which expect to go to any one of these 1400 certified programs in the country and see the same model? >> i would. >> shia shaking her head. >> i would at the basis of it. because, these programs are accredited by private nonprofit organizations. in addition to being certified by the federal government. my place to not have the staff to visit every individual program, they are required to be accredited by a nonprofit organization every three years. >> my time is expired. thank you. >> i like to recognize my colleague representative from new jersey. >> thank you. i appreciate the chairs putting this together because what we are talking about today is a disease of addiction. complex. long-term. certainly not one-size-fits-all. this, one of our former colleagues, patrick kennedy, we have to complement diseaset bringing the of addiction out of the closet so we can have this discussion. heroine and the opiate epidemic originally was thought to be an urban issue. it was them, we do not have to worry about it. it is in the suburbs. all the kids with great families are now in a very difficult situation. creating havoc for families. new jersey, we did the mobile methadone clinic. we do video exchange. we were one of 11 states to do the narc and have over 1000 saves already. with the nasal. as they were debating, i was in the state legislature, are we enabling them? what are you doing, you're making it easier he. there tried to save lives. they have that moment of clarity, maybe one time or five times. you want to make sure that they have that opportunity. i want to bring all of this back because treatments and jails, we are splinting plenty of money. spending it on jails instead of treatment for the nonviolent offenders. what i want to ask you, and i have not heard it yet, this is a lifelong issue. it does not go away like a broken arm. what do you consider a recovery? six months? six years? 60 years? on that hearing any of that discussion of what we are considering a victory. would you comment on that? you pick some interesting work looking at when you can say somebody has a pretty high likelihood of remaining abstinent for future years. a very nice long-term study out of chicago and illinois done by chris scott and mike dennis. they followed persons administered to the public treatment system. they followed them for 10 years. they found that after about so, ofears or abstinence, that the chances of remaining clean and sober for the next year are markedly increase. that tells you that it has to be quite a number of years for the accumulation of stability and their life to say that someone will likely be in recovery long-term. even then, i cannot give you a guarantee. >> that is exactly the point i want to make. there are no guarantees. if i could comments, i think recovery is function. the ability to function at your pre-drug use levels are close to it. as a member of society. as employed person. as a parent. as a responsible adult child. able to take care of your older parents. to fulfill those social roles. by thenot be defined illness of addiction. his recovery. and how long it takes and what shape it takes is their individual. what resources somebody needs to get there is going to depend on how far they got from their previous level of social function. whether or not they have a criminal record now. and whether or not they are closed from seeking employment in certain fields or fields in which they trained originally. but being able to be an employed , house, dignified person who can to fill your roles and your family i think our what makes recovery. >> would you consider that for the rest of their lives? >> i think from the point of view of a physician, yes. it is like if you're a cancer once, i will consider you to be at high risk for relapse. we may say you have five years into your care, but i will keep a close eye on you. that is the medical thinking that i would apply. >> thank you. >> one of the things i want to say is that is important to recognize that whatever recovery is for a given person, people can live well in recovery. they can live a long, happy fulfilled life in recovery. the fact that we have such a stigma associated with a history of opioid or other drug addiction, and which recovery makes that a problem, someone needs to be able to say, i'm in recovery and things are going great. and have the access to, i'm in recovery and things are starting to feel if they are slipping, what i need to do to get better? how can i get back on track? the importance is thinking about themselves as a person with living well in recovery. it out of the closet, that is what this hearing is doing. i yelled back. thank you. >> i now recognize the gentlelady from virginia. for five minutes. >> thank you. i went to my colleagues for this important hearing. share a concern about this growing epidemic. northernct is in virginia and it starts right around the cia and stretches all the way out to the west virginia border and we first started see this problem out in winchester and the western part of the district about his living east and we are seeing it throughout -- several taskforces are working on this. one of the things that has been really the most difficult thing -- so many things, i can't say what is most difficult. one of the things that was truly heartbreaking that we have seen in the in our hospitals neonatal unit, seeing babies born addicted. they are very difficult treatments. things to get those babies ok. when they have that situation. there was a little bit of a mention of how to treat somebody was pregnant if you can get them , what are some of the best practices? several pieces of legislation in that area to look at. best practices in what we can do both for the mother as well as for the baby. if any of you might have some thoughts on that. >> there are two key issues to me. one is, what can we do to prevent that? had the minimize exposure to opioids for those that are taking the medically or extra medically? and get pregnant women into treatment when it is identified. is toher issue is, improve the treatment for the newborn. the second is, not to think that it ends right there. because there may be long-term issues for the family. they need attention. what are the support for the and since as a gross -- the infant as it grows and develops in that household? >> the important thing i think and sometimes challenging thing is that pregnant women with or do use disorder need to be on medication for treatment. at this point time, we do not have evidence for safety of use of the medication with pregnancy. we cannot recommend it. the others are demonstrated to be effective. what sometimes happens is that women are encouraged to seek treatment while they are pregnant and then encouraged to get off of medication after they had given birth. what happens is, they relapse. the because the baby is on outside of their body does not mean that that baby isn't any better shape to enter parental relapse than during the pregnancy. so, washing out that we do not have policies and procedures in place that make it more difficult for women who are parenting to receive medication assisted treatment, peering services for the infant and the parents, mother or father. medication that assisted treatment is delivered nhl friendly way. -- child friendly way. at coming difficult when we are cautious dispensing controlled substances for a person to ingest that our tendency is to not want children in the environment. but if the person is a parents, they need to be there and they need to be there safely. really and truly encouraging breast-feeding among opiate dependent women who are stable on medication assisted treatment. it can improve the bonding and the parenting of parent-child relationships. >> there is no problem there or the baby with the breastmilk? >> the medication is generally in the breastmilk to a tiny extents, and this may actually help mitigate the withdrawal for the infant. >> ok. >> the mom has to be stable. she cannot be using any other drugs. care has to be taken with whether she might be on medications for other medical conditions or psychiatric conditions when the decision to breast-feed is made. it should be encouraged in women who are stable and i medication assisted treatment. >> thank you. i yelled back. thank you for the work that you are doing. i appreciate you being your today. >> thank you caret i reckon is the gentleman from pennsylvania for five minutes. mr. castella. >> thank you. i want to thank congressman and congressman for sharing this very important task force and i can say from my experience, i used to be a county official, usually what i would read about as a relates to the heroin epidemic related to policymaking from the law enforcement side or the treatment and recovery side. what i would like to ask you for your feedback on, and i ask this with a constituent company in my district, who is in the process of r&d and product developments on what is termed abuse deterrent oxycodone products. ,hat you are suggestions renditions, observations are with respect to preventing certain instances of opioid abuse in the first instance by designing these drugs which many do have a medical value, but designing them in such a way to strip it advance euphoric effect so that we are not introducing to potentialnts abuse on the backend and because they never experienced the euphoric effect on the front ends and with that i would like to have it be open-ended for all three of you to comment as you find appropriate. >> certainly the development of abuse deterrent formulations is -- could be helpful in reducing oralrogression from administration to either take it by nose or injected drug. it will not necessarily eliminate the 40 hour the pleasure and the reinforcement that people get from a oral form. that is one of the shortcomings of most of the current technologies. i do think that means that we need to keep looking at painkillers that are effective, but do not produce at all, the intoxication. that is different from sibley making sure that it is not dissolvable and cannot be injected, it has to do with more fundamental nature of how our brains work. i will say from the clinical side that this is something that we deal with in the medication assisted treatment program. there are many treatments out there for pain, because a patient still have pain even though they are methadone. oruse a lot of non-opiate cap opiate receptor medications. helpful. they do not run the risk of abuse. limited,le have very acute pain, they may need opioids while i methadone. we then monitor that great closely. we coordinate with the prescribing provider and we followed the pdm p. there are lots of ways to manage that even for somebody who already has an addiction. i think the other piece and the technology is very exciting. i'm sure there will be a place for it. i think the other piece is that how providers are educated and prepared to help patients deal with pain. i am speaking more from the point of view of treating people with opiate use disorder who unfortunately had painful medical conditions, a broken bone, a cancer diagnosis. and they did not want to take additional opiate. they thought the compromise the recovery. finds very difficult to providers who were willing to work with people on what the role of pain was in their illness. other ways to cope with it. instead of just kind of throwing a prescription added. , who isy it felt to me supposed between their addiction at their pain, to help them deal with how to accommodate this problem in terms of how you function or how you live your life. fromcan you really expect say and ibuprofen or tylenol for pain relief? how can we make that work for you? >> when you spoke about technology been exciting or the potential to be exciting, could you expound upon that a little more. maybe i'm just a science geek, but i think that the idea that you could have a drug that should it fall into the wrong hands, not the abusable, is an exciting reality of where we are at with technology. it is a plus. it is probably not going to be the only solution. needs to be part of the solution. >> i am not a science geek, but i find it exciting, too. particularly when you read about the number of stories of those who have been caught up in this absolutely terrible circumstance. the abuse and the consequences of abuse. it would have never been there but for being injured or having pain in the first place. and having it be in a downward cycle. i share that with you. i look forward to learning more about the technology and hope that it will continue to progress in a way that will enable those opportunities so that we can avoid some of the abuse that does occur. i yield that, thank you. >> thank you. i would like to recommend the gentleman from maine. for five minutes. >> thank you. somee to further explore of the issues that we talked about a short time ago. if i may. we are all in the believe, i'm sure, that governments, one of the primary jobs of government is to show compassion for those who truly, truly need our help. let's say you have a terrific young adult that is doing well and is learning a trade in a community college, and is living at home and for some reason, somehow, gets wrapped up with maybe the wrong people. parents always seem to say that, right? or gets mixed up with opiates or alcohol or what have you, and now, the parents is in one mess. along with the child. how du not enable the child? let's say the child goes through treatment. of course, we all know that dealing with individuals that really need help, they have to recognize that they need help. then after that, make sure they go through process to get the help and then when they get out of the detox situation, make sure they have ongoing treatment, which is based on the discussion we had today. but what if this individual falls back? you're told us here today that the probability of that happening is quite high. let's say you are a guardian and you take your daughter or your son or the person responsible for helping out to lunch three times a week. just to make sure that they have something good in their belly to last them over and they show up at lunch or knocking on the car window clearly high. the of talked all about this treatment using drugs and so forth and so on. but, what about the support system? remember, this indidual may now be getting assistance for housing and food and clothing and may have a small cash allowance. that enables individual to have the freedom to purchase whatever he or she wants. how do you make sure those individuals continue to stay on the path of recovery so they do not slip back, and how does that support group that is so important for these individuals to fully recover so their productive and at the dignity of being on their own an independent, have you help them? with support group is available out there? had to help these people? had you not the support group to help these people? a well-known 12-step recovery movement. has helped more people than i think we can possibly know. that can't be over emphasized. it is fully compatible with medication assisted treatment, in principle, if the person should be medication in addition to recoveries of her from peers. that said, a more formal. cover support model has been demonstrated to be effective. we have somebody who has been there. you can call them up and say, this is what i did when that happened. that our think government programs that are designed to help these folks that we love so much that we want so badly to help, do you think that they are designed to make sure that the individuals have incentives to follow a path of healthy behavior? be aat question might little bit broad. i think so. >> the challenge that i think is that we collectively live in a society that does not really do that. if you have a program where for a few hours a day or a few hours a week you get support and encouragement and then you go around the world where people treat you -- >> let me give you an example. a privatepeople on practice basis. let's say one of your patients comes in that has been following a regiment of treatment. but comes in height. or mrs. an appointment or two. what is ingrained in our programs to the individual accountable to get the individual back on track? --i think that it confrontation of the behavior. as the treatment provider of health care provider, if you are unprepared to deal with it, you feel that it is easier and less scary to kind of ignore it or send them away and let them come back when they pulled himself together and pretend it never happens, you are doing a disservice. >> it seems like -- i'm guessing, and i know you want to hop in here if it's possible, it seems like we need a little bit more focus on the programs that we provide to help the providers make sure that they hold these folks accountable for healthy behavior. >> i agree with you and i think we have models. which are evidence-based approaches that show that you can enforce rules and a consistent way that is not punitive, but is expectable and predictable and is set limits on behaviors, but it does require monitoring for infractions of the rules, so you have to do a appropriate intermittent right testing to catch people. also, observing their behavior. these are models that are typically very well done by drug courts at times and by others that combine an opportunity for close monitoring and enforcement along with compassion and the services that people need. >> thank you very much. i appreciate it. thank you mr. chairman. >> thank you to the general information. i would like to yield two minutes to the chair of the task force. the gentlelady from new hampshire. >> thank you so much to everyone who participated and to my colleagues and were panel. topic andchallenging a challenging problem for communities all across the country. the rapid rise of heroine related deaths is truly staggering. i think that what we need to do is educate ourselves as legislators and educated communities so that people begin to understand the elements of prevention, treatment, and then lifelong recovery. the resources that i need in our community. this testimony has demonstrated the challenges that we face, treating patients who suffer from substance use disorders and also areas of promise. i think there is hope. static conversation with an adoption attorney for 25 years and one of my patients -- one of my clients may years ago had a truly remarkable and very challenging circumstance and i was able to be a part of her life at a time when she took control of her life. today and hasd me not only been a recovery for eight years, but she is opening a center for women. to be able to live in recovery and a safe space. and to get the resources and the support that they need. very and things and by many others of the people that i have met. people themselves up in recovery for a long time. and they're coming for to address the challenge. what we have learned is that the epidemic has struck across gender, racial, says economic lines, and i might say, partisan lines. it is not a partisan issue. it is our duty as representatives to take actions for the american people. i look for to working with my colleagues on the task force to combat the heroine of the gimmick. to introduce legislation build upon these ideas and to share ideas for best practices, how we can encourage more treatment with scientifically based, sound performance guidelines, and how we can deal with these issues around prescription medication at makingure that are prescription drug monitoring is robust. a bill that the congressman and i -- it includes a provision for interstate compliance with prescription drug monitoring we are a small state. we have learned from hospitals and physicians and treatment providers that people are shopping across state lines, if you will. we can work together and work with law enforcement and health care providers and start begin to been the curve. those were dramatic and staggering sites and i hope it will get a chance to get this up and share those with our constituents and with people across the country. so people understand the urgency, but they understand that there are steps we can take and we will be taking them in the next six months to really make a difference in people's lives. thank you for being with us. i yield back. >> thank you to the gentlelady from new hampshire. i would like to yield myself two minutes. i would like to thank dr. compton and the other dr. for taking time to inform ss members and those interested -- us as members and is interested. and the cochair of the bipartisan task force. my colleague from new hampshire. as well as members of the task force and 50 numbers of congress. this is clearly a growing concern across nation, more and more members are understanding that concern not just from what we are, she year in washington, but from there can issuance. i think we have learned a whole host of new ways that we can help the prescription side of this particular issue. as we continue to look at legislation and how we can help at a federal level to integrate what we ar

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