his is an hour and 15 minutes. >> good afternoon. good afternoon. could i ask everybody to take a eat? thank you very much. good afternoon. want to welcome you all here today to talk about one of the most important issues that affects every state in the country, every community in the country, every neighborhood in the country. that's the opioid epidemic that runs across this wonderful country of ours. i'm charlie baker the governor of massachusetts and vice chair of the health and human services committee. i am especially pleased today to be joined by governor roy cooper from north carolina who i serve with on the president's commission on opioid addiction. where is our host, governor gina raimondo. is she here? she's late to her own party. ok. gina will also be joining us up here later along with roy as long as our distinguished speakers to talk about this opioid epidemic, which obviously is a pertinent and relevant issue for all of us. the opioid epidemic is now claiming the lives of an estimated of 90 americans a day. in massachusetts, we had about 2,000 deaths in 2016. that's more than five deaths per day, more than all the deaths associated with automobile accidents and gunshots combined. there was a 22% increase in opioid related e.m.s. transports between 2015 and 2016. the first quarter of 2017 the number of opioid prescriptions dispensed in massachusetts declined by 23% compared to the same period in 2015. by 13% compared with the first three months of 2016. that's for a number of reasons. but among them in massachusetts you can't graduate from medical school or dental school or pharmacy school unless you take and pass a course in opioid therpy and pain management and you can't continue to be a prescriber back to get relicensed without taking a course and passing it in opioid therpy and pain management. we also dramatically upgraded and simplified our prescription monitoring program and at this point prescribers made more than 2 million searches of the new program. it has had a tremendous impact on prescriber behavior. we've also doubled state pending on treatment and recovery for those dealing with this issue here in the commonwealth of mass. more than 800 medical, dental, nursing and physician assistant students have undergone the training which is a core competency requirement and housands of narcan kids -- kits administered to first responders and family members. many other states have initiatives regarding this and governor cooper and i had a chance as part of the national commission to talk to many governors involved in this issue to get a sense about what practices are working and what practices aren't and how we can take those and incorporate them into our own strategies at the state level or into some of the national reforms and recommendations. we'll continue to lean on the n.g.a. as an avenue for discussion and problem solving as we deal with the issue going forward. in february, 2016, the governors expressed their frustration that despite many of our efforts to innovate and change the trajectory of this crisis change really wasn't coming quickly enough. we specifically identified a series of prescribing practice issues and opportunities deal with that and other issues associated with what i would call the front door of all this. as a result we pass'd resolution that directed the n.g.a. to unite governors around strategies, changing prescriber behavior, to prevent opioid abuse and overdose. since then we've partnered with a number of leading organizations doing research and providing guidance in this field including the national academy of medicine to better understand the clinician's role in reversing the epidemic. with that i am very happy to be joined today by dr. michael mcginnis the leonard d. shaffer executive officer at the national academy of medicine who will discuss the forthcoming release of a paper focused specifically on opioid prescribing practices. dr. mcginnis? [applause] dr. mcginnis: thank you, governor baker. thanks to each of the governors here and throughout the nation who have provided such important leadership in drawing attention to the terrible epidemic that we see throughout the country. the importance of this epidemic really cannot be over stated. there are the numbers. the fact that there are 3 in this country today that are sfruffering opioid use disorder. that is, they're addicted. the fact that there are unprecedented increases in the rate of addiction to opioids that we've seen in the last several years. that are contributing to unacceptable and tragic deaths throughout the nation. last year an estimated 59,000 deaths due to a drug overdose, about two-thirds of which were related to opioids. that is an unprecedented high for drug use overdose and deaths. it's also higher than the peak levels for hiv infection deaths and for automobile fatality deaths. it's higher than either of those at their peak level. in addition to the numbers, ere are the realities that each one of those numbers imprisons several souls. not just the souls of those affected directly by the addition but their families, her loved ones, communities, health care workers throughout the nation. this is an epidemic that when you think about etcetera dimensions in terms of the combination of numbers, lethality, rate, reach, the opioid epidemic is the fastest growing serious and far-reaching epidemic threat to americans across the board. so it requires the kind of leadership that you folks are providing, and the national academy of medicine is honored to be a part of the work that you have under way. we're committed to doing everything we can in support of your efforts. our special publication targeting every one of the some 5 million kleyn ignaczaks throughout -- clinicians throughout the nation has been developed in direct support of the n.g.a. resolution on opioid prescribing. you have a short description of that publication marshaling clinician leadership to counter the opioid epidemic at your tables. there are, in effect, three key messages in this publication. first is prioritize nonopioid strategies for chronic pain management. second, follow the five basic axy oms of responsible opioid prescribing. third, promote policies that facilitate action on the evidence. on the first, prioritize nonopioid strategies for chronic pain management. it's very clear that many patients who have cancer or are at the end of their lives require opioids for treatment. but when it comes to treating the chronic pain conditions that are also suffered by millions of americans, there are alternatives, which are generally effective in engaging hose problems. it is very important that we prioritize those effective alternatives in engaging chronic pain conditions. second, the five basic axioms. first, understand and tailor treatment to your patient. understanding what individual circumstances are for every patient is the watch word of health care in general, but it's especially the watch word in managing people with chronic struggling are with issues that might compound their suss acceptibility to opioid adeggs -- their susceptiblety to opioid addiction. know your patients well. employ precautionary protocols. the highlights here are start with the lowest possible dose if you are prescribing opioids. start with the lowest possible dose and duration. and check the state prescription drug monitoring data base. very basic but under utilized by a substantial measure in this nation today. third, actively manage and monitor treatment. treatment merely begins with the prescription, and it's very important that when an opioid is used that there is an exit strategy in mind and in place, an agreed upon exit strategy with the patient from the very irst moment. fourth, know your team and your community resources. prepare for the likely probability that you will at some point encounter patients with opioid use disorders. and know where the community resources are. prepare your team for the probability that they will have to manage an opioid use disorder. and if those resources are not adily available, work hard with your community to try to develop alternative strategies. don't wait until the last minute. fifth, ensure access to substance abuse treatment. that's a logical corollary of the previous note. it is vital that especially in these days when our treatment resources are being overwhelmed that we work at every level to expand the availability of treatment and followup. and then the third point is the direct offshoot of this issue, promote policies that facilitate action on the evidence. just a couple quick notes on that count. because we in the national academy of medicine are committed to steadfast support for the related evidence based policy initiatives at the state and national level. e sort of policies that we heard from your colleagues in the governor's council of the bipartisan policy center called for in an announcement yesterday. on the regulatory front, we actually at noon today released a series of recommendations to the food and drug administration on strengthening the regulatory approval and monitoring policies of the food and drug administration. in order to ensure that when the fda reviews an opioid for approval, they're not just looking at the individual costs and benefits, but they're taking into account the societal costs and benefits. this is vitally important to provide air cover if you will or those policies at the clinician prescribing level. in addition, we are committed to working with you to ensure that every clinician is supporting the monitoring efforts that are embedded in the prescription drug monitoring programs that you have throughout your states. the treatment policy arena, we've mentioned briefly, is especially important that programs for medicaid, medication assisted treatment under medicaid are supported so that the treatment that's needed is available when necessary. the policies related to recovery support are also especially important. let me underscore this in my final comments. that is opioid abuse or opioid use disorder is a chronic disease. it's a chronic disease with different manifestations, but, in fact, it's not that much different in terms of etcetera need and management requirements than diabetes or hypertension or heart disease. you don't treat those conditions with a one-time interaction. there needs to be the ongoing recovery support that will help every patient to move into the productive -- back into the productive life they had before. thank you for your leadership. thank you for our partnership. we are honored to stand with you on behalf of our patients, our communities, our states, and our nation. thank you very much. [applause] governor baker: thank you, dr. mcginnis. that's a nice setup for the panel we're going to have here. at this time i'd like to invite richard baum, currently the acting director of the white house office of national drug control policy and has been one of the folks we -- i and governor cooper and governor christie and others have been working with on the national commission on opioid addiction. he's been part of the oncp for nearly 20 years in his tenure spanning four administrations. i'd also like to ask rhode island governor gina raimondo to come up and join this discussion as well as my seat mate on the national commission, governor cooper from north carolina. come on up. richard, come on up. [applause] >> thank you, governor baker, for that introduction. today in a couple minutes the thee governors that are taking decisive action against this problem will stand and we'll have a good conversation. but let me just share a few words about my perspective on the issue from the office of national drug control policy. as has already been said, this is the worst drug epidemic in american history. we've already talked about the numbers. 91 people per day. this crisis hurting communities and families from boston, hartford, charlotte, dayton, phoenix, just about everywhere in between. reducing the supply of heroine and fentanyl from abroad is critical. federal agencies are working to tighten border security and dismantle the trafficking organizations that are moving these deadly drugs into our country. in addition to reducing the supply, we have a great deal of work to do on a demand side. millions of americans have become dependent on opioids and need access to evidence based treatment, which means medication assisted treatment in most cases. there is also a need for the treatment system to change the way it operates to make ccessing care much easier. we also have to focus on recovery support, which sustains the investment and treatment and reduces relapse rates. clinical and successful recovery is making sure people have jobs. employers should give people in stable recovery a chance. they make great employees. we also have to do a much better job on prevention. our youth are not getting a clear and consistent message about the incredible risks posed to their health from illegal drugs. we intend to change this. the administration has already taken a number of critical steps on the opioid problem. in march the president established the opioid commission panel. in april h.s.s. released the first round from the 21st century cares act of funding sending 5 million out to states. another 500 million is coming your way next year. we run the high intensity drug trafficking areas program and the drug free communities d.f.c. program. these grant programs are fully funded and one or both operate in most states. at o.n.d.c.p. we want to partner closely with governors' offices. on staff we have some of the country's top experts in both demand reduction and supply reduction. we also have readily available the best research and data on the drug problem. so please think of us as a resource for you. this problem is too big and too complex for any one level government to solve on their own. the only way we'll turn this around is through working together. so this opioid issue is not a new one. n.g.a. as you probably know in july of 2016 46 governors signed on to a compact to fight opioid addiction. the first time in more than a decade governors came together to call for action in three areas reducing the inappropriate opioid prescribing, changing the nation's understanding of opioids and addiction, and ensuring a pathway of recovery to individuals with addiction. since that compact was signed, governors across the country have redoubled their efforts to address the crisis. there is an overview of some of these actions on your chair and details about what states did s available. we've been part of that process and taken an active role. they have acted to end the crisis through legislation, partnerships, and talking publicly about the issue of addiction. governors cooper and baker are on the opioid committee. in rhode island they implemented innovative -- [stand by audio difficulty] >> yesterday there was a new executive order signed on this problem. today it is an honor to moderate this discussion of governors on the front lines in this critical work. we'll hear a little bit about the action. i'll move over to the chair and i'll ask, governor cooper, to start us off. we'd love to hear about what you are seeing and doing in north carolina. governor cooper: well, i've talked to too many law enforcement officers who are frustrated, too many emergency responders and medical oviders who are overwhelmed, employers who can't get employees who can pass a drug test, and i've talked to way too many moms and dads who have lost kids to overdose. we've heard the figure. 91 people per day in the united states dying as a result of this epidemic. four people a day in my state of north carolina. it has to stop. what we've done in north carolina is i've put forth just st month a comprehensive opioid action plan. we had over 200 people from all fields who came together to help us with this plan. when we attack the problem it's got to be comprehensive and it's got to be data based. i am sitting on the president's commission to fight opioid addiction with governor baker, governor christie. what we're doing is listening to you and your states. we know that many of you, all of you, really, are facing this problem, and you know that we've got to step forward as states. we move faster with the laboratories of democracies, we can do things quicker. what we want to try to do with this federal commission is tie a lot of us this together and help states. the first thing i've called for is treatment and the first thing we have to realize is we cannot have millions of americans lose their health coverage and still effectively attack this crisis. we can't significantly reduce medicaid funding and still be successful in fighting addiction. bout 25% of opioid addiction treatment and substance abuse treatment comes from medicaid coverage. so we're kidding ourselves if we don't think what's happening with health care in congress right now isn't affecting this issue. at the same time, there are other things that we can do to attack the problem. we've heard about the issue of over prescribing and making sure that prescription drugs are less available to people. we do have a comprehensive strategy on that in north carolina. already we're seeing reductions in prescriptions to people, but it's almost like squeezing a balloon. we've seen now an increase in heroine use. sometimes that's even cheaper. what is really deadly is when it is laced with synthetic fentanyl and other drugs that can cause death immediately. helping us to fight the drug kingpins and traffickers, and in china where a lot of this synthetic fentanyl is being made, we need help with that. but one thing we know at the addiction level, and law enforcement will tell you this -- we cannot arrest our way out of this problem. this never-ending cycle of people going to emergency room's -- rooms and being arrested and being put in jail and getting back out and overdosing -- that is not going to work. and what we have to do as part of our plan is widespread use of naloxone. we have to make sure that we have emergency intervention with these people who overdose. that is the time, as they are near-death, and recovering in the next 24 to 48 hours, we have to get to them and convince them that they need treatment. we have to have that treatment -- we have to have that treatment available. law-enforcement stands ready to divert these people who are addicted to substances and opioids to treatment. already we have comprehensive programs throughout north carolina where law enforcement is making sure that they are getting into treatment. we are a fan of medication assisted treatment. each individual is different. you have to have health-care providers deciding what is right for them. we even have some law enforcement agencies who are inviting people with problems to come in and they are promising not to arrest them, and to assist them into getting help. so these strategies are positive that we are implementing. they are comprehensive. there are probably 36 or 37 of them. we need to make sure that we share our data, particularly when we have our studies, to tell us what is working. we know this law enforcement diversion is working. there is a less significant -- a significantly less chance that people get rearrested once they are diverted into treatment. i look forward to hearing your ideas at this conference. make sure you let us know what is happening in your state. i know that governor baker and i and governor christie have had a number of calls with you to know what is happening. it is important that you attack it in a comprehensive way. we have to make sure that we fight this problem on every level, from law enforcement to treatment to prevention to education. i have had enough of it, and i know you have too. richard: governor baker, can we turn to you? you lead the hhs committee here. can you talk about that experience and where we want to go from there? gov. baker: i would want to say the following -- i'm looking this row of governors in front of us and i know that most everyone here has participated in those phone calls that governor cooper was talking about and is dealing with this issue in the wrong right, in the run state. -- in their own state. i can't emphasize enough how important it is that we handle the front end of this, which is the overprescribing of painkiller medication in the united states. we have 5% of the world's population, we consume 80% of the world's opioids. there are places all over the globe where people would never give someone an opioid prescription to deal with their particular problem, or if they did, they would give them one or two instead of 50 or 60. part of the reason why we made training in this mandatory for anybody graduating from nursing, dental, and pharmacy schools -- if you are a current prescriber you can't get relicensed until you pass a course in this, so many of the people who have been writing those prescriptions for so many years, when they are confronted, they say it was something that was never part of the curriculum. when you are writing, as the u.s. did, 240 million opioid prescriptions and you have the substance abuse and mental health administration saying 4 of every 5 people that are addicted to heroin started on prescription pain meds, it is pretty clear where the problem came from. if you look at the data in the last 15 years in the growth of the opioid epidemic, prescribing was the top line, overdoses is the second line, and death from heroin is the third line. over the period of time, it is clear where this came from. one of the things i hope we get out of this national commission we are participating in is a much more aggressive stance as a country to the way we handle with and deal with prescription pain meds. i agree completely with all of the words that were in dr. mcginnis' commentary about how important it is to focus on the exit strategy from the start. for people dealing with chronic illnesses and terminal disease -- that is different from what actually goes on the ground in most places around this country. the second part, i would say, is that the treatment and recovery piece has tremendous potential, but at the same time a significant way to go. one of the things we heard quite a bit of when we held public hearings in washington was that -- and this is another place where the national government can play a big role -- we have not treated the study and research on addiction with quite the same focus or quite the same rigor that we treat the study of cardiovascular disease or certain kinds of cancers, or other mechanisms and illnesses and cures and therapies that of a lot of the nih work. one thing i think will be critically important to the whole medical assisted treatment movement is much better data around what works and why. i mean, one of the things that has always bothered me about this, when you talk to folks in the treatment business, they refer to themselves as suboxone providers or methadone providers or twelve-step folks. now, in most other forms of medicine, the way it works is somebody has a toolbox and based on best practice standards, historical experience and tons of bodies of evidence, this person is probably best suited with this approach to dealing with their addiction. that is not the way we currently do this, in many cases, in this country. another place where i think the federal government, states, and folks in the research community can play a big role is trying to help us all get smarter about which treatments are most likely to be successful with certain kinds of folks dealing with certain circumstances, situations, and symptoms. the final thing i will say is one of the things i appreciated about the nga conversation is -- on this was everyone was open. there wasn't anyone that felt like this is something they could sit back and do nothing about. when i look at our own data in massachusetts, i see modest progress on both prescriptions, overdose, and deaths. ok? but it is modest. i have never seen anything with the kind of negative trajectory that this issue has, and it is really going to take persistence and determination over a long period of time of working how -- the front-end associated with how people become addicted in the first place, the area associated with intervention, treatment and recovery, and what tools and what capabilities and what approaches to treatment are going to work best for certain people and collected did -- collected and incorporated into ongoing development of best practices going forward, and investment on the part of state governments and federal governments to see our way through, but the thing we have to do is recognize we did not get her overnight. this is 15 years of bad behavior by a whole bunch of deeper -- people in the clinical community. i say that as a health care guy. the likelihood that we will get out of it is pretty small. -- get out of it overnight is pretty small. it is important that everyone stay with it for a long period of time and not make it an issue that we only pay attention to for a few years and then move onto something else. because this will require continued vigilance, continued inquiry, continued investment, and a real big change in the way we handle this stuff. 80% of the world's opioid prescriptions, 5% of the world's population. if you walk away with nothing else today, i hope you walk away with that. that has to change. richard: you have been leading efforts in your state to solve this problem. what would you share with your fellow governors about what is working and what you would recommend based on your own experience? gov. raimondo: thank you, and welcome to rhode island for those of you here. we are happy to have you and excited for a great weekend. so, i think i probably speak for all my fellow governors in saying that this issue is something that we work the hardest on four, unfortunately, very marginal improvement, as charlie just said. i have done to executive orders on this -- two executive orders on this. i have worked with some of the best minds in the country. we are seeing some progress. i am happy to say that our opioid prescriptions in rhode island are down 25% in the past five years. some of the biggest dips in america. and still, 1200 people have died in rhode island in the past five years. a state of one million people. so i agree completely that we have to do more and we have to stay at it and commit ourselves to the long run. the other day i was doing a business tour in a town nearby. the event had nothing to do with opioids. it was a commerce event focused on business development. i was talking to the owner of a thriving and successful business. he is a well-off guy in a well-off suburb. in the end, he pulled me aside and said, governor, keep plugging away at the opioid issue. i asked if he had someone affected by it. he said, my son was in high school, he had straight a's, he was a baseball star. he got a scholarship to go to college, he started with shoulder pain. and he said, if only i knew what i know now. he started with four motrin at a time. 6 motrin at a time, then vicodin. he has been in and out of prison for years, in and out of rehab a couple times, and he and his dad were at a gas station, he was in the bathroom for a long time, his son was nearly unconscious on the ground and he had to revive him. that is what we are dealing with here. this is a successful businessman, and this is in his life. it happens to me all the time. i know it happens to you guys all the time. this issue is almost like no other we are dealing with because it is so pervasive, yet still relatively not well understood by the average person. i can say the average rhode islandere, -- rhode and it requires an unprecedented , level of collaboration in order to fix it. i have put together a task force. i think that is vital. one of the things that is a little frustrating, and i'm sure the governors can relate to this -- this is an issue that requires law enforcement on a state, federal, and local level to be on the same page. teachers, principals, coaches, and superintendents, same page. doctors, dentists, orthodontists, hospitals, same page. it's an unbelievable level of coordination, and no one really feels like it is their problem to solve. which means it is our problem to solve. it is exactly where a governor needs to step in and convene and push this forward. we have done similar to what has been said and had success. we have a prevention campaign we are about to kick off. we have done a medical assistant -- medical assisted treatment using our medicaid money for that, particularly in our prison system. a little bit controversial, very effective. previously folks who had been werecerated, estimates cold turkey was what happened. it makes people much more likely to die of an overdose when they get out. we are having luck with medical assisted treatment in prisons and other settings. we have had great success with a peer recovery coach model. if you are not familiar with that, i would recommend learning about it, using medicaid. the human interaction with a peer recovery coach who is almost always a former user themselves, can have a great relevant experience to share with the patient. that is something that has worked well. another thing that is working well is, we have set up what we call centers of excellence. these are health care centers, either at a hospital or community health care clinic, which are designated opioid centers of excellence. it is a place -- our general mantra is "all roads lead to treatment." this is a chronic disease, let's get everybody into treatment. centers of excellence are places where they have expertise in all kinds of medical assisted treatment, and the point is anyone with an addiction disorder can walk into one of these clinics and see a professional who are expert at the whole range of medical assisted treatment. i want to give a shout out and thank you to cvs. cvs is headquartered in rhode island and just today, announced a quarter of a million dollar investment in a center of excellence in northern rhode island town struggling with this issue. again, i just come back to where i began. this is an everybody issue -- corporations, government, law enforcement, everybody. it is a crisis. we are losing people every day. we are seeing some progress and i am eager to share that and learn from you. we have got to stay at it because too many of our friends and neighbors are dying every day. richard: thank you. i will ask governor baker one more question, but we can open up the conversation to governors in the front row. don't be shy. if there is something you want to add. no problem. governor baker, i was going to ask you about the shifting role of police. i know in your state, there is the angel program where police diversion has become a major initiative. do you think the role of law enforcement in the midst of this opioid epidemic has to change or should be changing? gov. baker: i think law enforcement knew about this first. i mean, they were the ones that discovered more and more people that were overdosing, that they were called to revive and deal with. i would it that in many states, that ing mine, -- i bet many states, including mine, first responders administer more narcan than even the folks in the er's. i think their interest and support for alternatives that lead to treatment, or treatment as part of the criminal justice system or drug courts or a whole bunch of other initiatives that have come about as a result of this epidemic, that was led by -- much of that was led by an advocated for folks in law enforcement. more than anybody else, they saw the terrible carnage that was going on in their communities before anybody else. they were the ones who got the call, more often than not, when somebody overdosed. i don't think it is so much that they need to change. i think they have been ahead of a lot of the rest of us on this one, and will continue to play a leading role. they are, in fact, huge players and huge advocates of diversion because they don't think we can arrest our way out of this either. richard: governor cooper, as you look forward, you have been grappling with this problem. what is coming over the horizon? what you want to accomplish over the next year or two as we try to turn around this progress -- process? >> i think education and awareness are going to be big. when you think about this problem of prescription drug over prescription, one of the byproducts is the fact that a lot of kids, most of them get -- where they get their medicine is from their own parents, from their grandparents, from their neighbors house. that is an epidemic in and of itself. awareness by parents in particular, and people in their household, that these drugs are very powerful. i think where you have the mistake is that people think that because a pill in and of itself is legal, that it is safe when, in fact, a prescription drug can be more deadly than a street drug. the awareness of that, that getting people to lock these drugs up. our prescription cutbacks are going to help this problem, but i think overall, education and awareness and making sure the public is behind you as you make this change -- they are beginning to see it just because there are not many people who don't know someone who has been affected by this, whether through a death, whether through employment. so they are realizing there is a problem. education and prevention to help them help us prevent it is going to be important, vitally important. romano -- rernor aimando, one of the things i have learned from being here is how the state is using recovery coaches to reach people that may not be coming forward for treatment but need it. can you talk about how you are trying to reach people? >> yes, so as i have said, we have had some success with the peer recovery coach model. we have more work to do to extinguish the stigma, and there are -- it is extremely helpful to have a recovered user who is experienced as a peer recovery coach, to be available as part of somebody's recovery and we sell -- and so we have had success with that. as you say, often these organizations are based in the community and it is a comfortable place to approach and a peer recovery coach has a shared experience with someone who is suffering from addiction. i will say, one challenge we have encountered that we are trying to deal with is for folks -- especially for folks who are in a hospital or leaving an emergency room, they are still reluctant to accept a recovery coach. part of it is stigma. all kinds of reasons. what we have found is that when they can then see the recovery coach and it is a person who is just like them, the uptake in in using a recovery coaches -- coach is higher which tells me we have more work to do to reduce stigma and get back to the issue that this is a disease and treatment is necessary. >> can i just leverage off the education and stigma? i cannot tell you how many people -- i have been talking about this issue ever since i started running for governor in 2013. there are few people in massachusetts that don't know that i think this is important and that this is a space where we want to help. even with that, there is still a lot of people when i have a town , or forum or a town meeting i am just talking to people in a diner or something, will only speak to me about this issue one-on-one. they will not raise their hand when everybody is asking about tax policy or local aid, or education or whatever. they will they talk to me about it afterward and that is because despite the fact that people are working hard to help people develop a sense of comfort, a lot of people cannot and will not. i went to visit a -- there is a cope" inled "learn to massachusetts. it is for parents dealing with this issue. it was started by a woman who lost one of her children to overdose. she had no place to go and no one to talk to. she created this group and we now have them all over massachusetts. i have been to their gatherings and they are really raw and really informative and i am really glad i went to them. one night, this guy said, you know, i live in this town but the first time i went to one of these meetings, i went to one 30 miles away because i was afraid i might run into somebody that i knew hear from our town. awayid i went to 130 miles away and i ran into people from our town and then one of the other guys said that is really funny -- the same thing happened to me. and this was going to a meeting where you knew everybody who was there was somebody who is dealing with this. and you know, there is a great, sad moment in an hbo documentary on cape cod in massachusetts where they have a mom who is talking about her own child's addiction and she says, if my kid had cancer every day one of my neighbors would be over here with a casserole looking to help and she said, but because my kid is going through an opioid addiction which has a mortality rate -- in some cases, it's higher than a lot of forms of i cannot talk about it. and i think the more that we do collectively to make it ok for people to realize and recognize they are not alone on this stuff which will help them access resources. richard: i wonder if i can ask you to share with the group what you shared with me about how you are, in your state, trying to get more employers to hire people in recovery and trying to support people in recovery to sort of get their lives back by getting a job. >> sure. i think this is a great panel discussion and unfortunately, new hampshire is on ground zero like a lot of states are. is there arending so many folks out there that have gone through recovery in treatment and as someone who i you shared my former life -- we are up in the north country of new england where we didn't have a lot of all the resources that southern new hampshire did so we had to design our own systems where we were kind of training our hr staff and so employees would feel comfortable, as governor baker was talking about, to talk about us that they had an issue. knowing we could keep them employed. one thing that occurred to me when i became governor is you create a recovery-friendly employers. we are going out and looking to train hr staff. all the employers know what the tools and resources are that are available. for so many people, you go down to the diner and they say, he was addicted to fentanyl and i had to let him go. but that was bad for him and it was bad for the employer. because we have a work shortage. we are a recovery-friendly workforce. the employers get certified. it is encouraging folks to reenter the workforce in a way and with an employer that understands the issue. that is going to be supportive. that is the hardest thing coming out of recovery. not only from the family, as there is so much isolation with this, but when you go to work every day, you are in a place where people understand it. people are going to support you and they will know the resources available. they will be able to broaden that support experience, which doesn't take six months, but years and years, sometimes a lifetime. getting people into the workforce, we think it is a win-win because it is dealing shortages, as well as dealing with the whole community process of recovery. richard: anyone want to jump in on that issue? >> i feel like because i live in virginia, i ought to call on my home state governor if you want to add anything you see in virginia on the opioid problem. >> as you know, we have had a dramatic increase in the last year and a half, and my public secretary -- and my secretary of interested inis the western part of the state is 100% opiates. in the east, it is all hair when an fentanyl. -- heroine and fentanyl. i assume north carolina is similar. in the western part, it is co-country. we have very distinct problems. there are no borders. we have a compact put together of prescription monitoring. we are all reporting to one another. no dr. in virginia can prescribed opiates for more than 10 days. -- can now prescribe an opiate for more than 10 days. after that, you have to send into the state that you certified for health risk assessment and it cannot go on beyond another 30 days. we are really trying to crack down on the doctors in the state. there are too many opiates being prescribed. we have gotten very tough on it, put more money in the budget for drug courts. you cannot arrest your way out of this. putting someone in incarceration does nothing but cost your state a lot of money in the long run. but we have come up with very religious -- created legislation now and holding doctors responsible with real sanctions. you are going to lose your medical license in virginia if you are prescribing drugs incorrectly. we have already seen a dramatic increase and they have to report those into the state. but it limits how long you can prescribed them, what you can prescribed, and the accommodations of drugs -- combinations of drugs you can prescribed. we are working with jurisdictions on monitoring. richard: do you want to get in on that? he did what you are doing in your state or what the federal government can do to support your efforts? >> thank you. we were working together on the prescription monitoring and prescription part of the problem. we haven't heard a lot about heroine and fentanyl and carfentanyl. it evolved. the problem is constantly evolving. we went from heroin to fentanyl to carfentanyl. it is killing people the first time they are using it. this is an issue, i first ran for governor, i traveled around our state and i was shocked to hear from one part of the state to the other, people talking about, what is the number one problem in the region? people saying heroin. it was in small towns and communities. none of the government leaders at the time were talking about it. it was something we were being sort of quiet about. when i first became governor, i -- and this warning in 2015, the first thing i did was create an emergency tax force. they held hearings around our state in various regions. to get input. hundreds of people would show up. out of those hearings and that task force, we came up with 33 recommendations from education to treatment to prevention to intervention. did nothing to slow down the problem so we went further. we passed tougher laws on law enforcement. we doubled the number of treatment. nothing happened. the crisis kept evolving. heroine in the last 12 months killed 2000 people in maryland which is more than gun shooting and traffic accidents and a number of other diseases all added together. all the governors at this table have done incredible work. we have done almost everything they have done in every other state and it has not slowed things down. the problem continues to grow out of control. we became the first state to declare a state of emergency. some people may remember the riots in baltimore, we declared a state of emergency, sent in the national guard, this emergency is far better -- bigger. we didn't have a single death in the riots in baltimore. we have had 2000 in one year with these drugs. this problem is tearing apart families and communities. from one end of our country to the other. and i will just say that, in spite of of all of our efforts, we are not making much progress. we have got to find a way to get the federal, state, local, community -- all working in the same direction together with organizations and faith-based organizations right down to the families and we have got to hit it from every directions but -- with everything we've got. but this is one of the biggest crises to ever affect our country. not just the drug crisis. it is going to become a number one killer. i want to thank everybody for the great work they are doing. i want to thank the nga for putting this on. i just want to ratchet up the panic level a little higher to say this isn't just an important issue we are talking about. a real crisis and danger. >> governor walker? you have a comment to add? >> i do. i have to leave for a call, but i have to comment on this discussion. i look for action. i look for things to do. i do not need somebody to tell me how bad it is. everyone has said it, we have all said it i came here one year ago and i listen to governor baker talk about the legislation passed in massachusetts. i went back to alaska and said, find out what he did, make it a little better, and we did very we made it a little better and we passed it. i issued a declaration of disaster. it is a disaster. we have a meeting every week with our cabinet for this. what is being done? we passed legislation. kit -- narcan kits have gone out, we save lives as a result of that. i am all about prevention. putting up signs and messages in port of entry into alaska out a vote -- of seattle saying, come to alaska, if you are carrying drugs -- i will get in your luggage, i will get in your face. my attorney general tells me all the things i can't do. i had to stop inviting her to these meetings. i want to be very aggressive. [laughter] we are aggressive on it. it is a disaster. every disaster as a fire or flood over oil spill. be aggressive. talk about it. it is widespread. every spectrum of income, the sports injuries are just heartbreaking. so many in our juno treat like the disaster it is. it is a disaster. looking for somebody else to come help and do it, do it yourself. 1/3duce my salary by because of situations in alaska and i paid the money to purchase drug dogs. step up and do something. i even went as far to say that we don't have the red sox in alaska. we have done themes. give me those dogs in the off-season. they are not drug dogs. just have a bunch of them at the airport. the friendlier the better. scare the hell out of these people, but keep these drugs out of our state. we have a forfeiture clause. we have one now. out of dutch harbor, they had drugs. now we have their boat. pull every lever that's there. it is a disaster and the only way to get ahead of it is to be aggressive. don't study it. act on it. >> thanks, governor. this of course, is a very serious crisis and we do need a sense of urgency, but as you have been gathering, are there some things you are hopeful about it maybe end on a positive note? >> you know, certainly awareness is much greater today than it was even a year ago. and that's the key piece of the puzzle. as i said earlier, more than any other issue i tackle, this requires collaboration from some of the different groups. everybody has to think it's their problem to solve. i think that awareness is leading to a greater level of collaboration. we have seen pretty substantial drops in our description rate over the past couple years. last year we passed legislation similar to what it sounds like originated to limit the dosage on a first prescription of painkillers. they're just there to see the effect of that. so, the hopeful sign is that we are here. we are all talking about it, like the crisis and emergency that it is. and i said to my people, too, let's throw the kitchen sink at it. we are starting to see results. and the most important thing is that we not let up. we are starting to see a leveling off of death. still hundreds a year. it is a huge problem. under no circumstance will he ever let our foot off the pedal. the fentanyl problem is that of control. the enforcement challenges are enormous. the fact that you can put enough fentanyl in an envelope to kill more than one problem is an enforcement problem. i think we just have to ratchet up the urgency. the hopeful sign is everybody's focused on it. it does seem some of the interventions we are trying a starting to have positive impacts. >> thanks you governor and thank you, everybody, for a great discussion. >> thank you. and by the way. o on the fentanyl piece, one of the things we should try to do is find a way to make this about what is happening at the wholesale level and not just chasing the retailers. a lot of what we do in local and state law in forcing us to chase the folks at the distribution chain. i would love to find a way to work with our colleagues in washington to see if we can start chasing people higher up the food chain. i think that would make a difference. i very much appreciate all of the work all of you are doing. i completely share the frustration and a sense of urgency. but i also agree with governor armando. i do think there are things people can do to work here, but it does not happen overnight. with that, i do want to get back to the head of the foundation and before that, had one of the toughest jobs in government, serving as the head of the chair welfare and the city of new york for 10 years. i just thought it would be helpful for him to give us some thoughts on what this opioid epidemic has meant in child welfare, which i'm sure is an issue that all of us know has hit our child welfare agencies hard. dr. bell? [applause] >> thank you, governor. thank you all for your leadership and i really want to say thank you for nga, as you have continued to push the leadership role of governments in this nation. i don't think there is any greater call for us today than to tackle this issue of addiction. i'm so thrilled, listening to your leadership and listening to the direction you have already chosen to go. and the ownership you have taken for this challenge that is facing our nation. because at casey family programs, the sister foundation, we believe that one of the greatest challenges facing this nation today is the erosion of hope in the lives of our citizens. and that many of the challenges we are facing are directly connected to the lack of hope some of our families are facing. i heard something here today that i think we all need to hold on to. these are people. these are our people. and they need to know that we care about them. i was in new york city during the 1980's when the crack epidemic hit. unfortunately, we tried to punis h people out of drug use. we didn't see what someone said here today, which is, this is a disease. recovery is possible. but treatment is necessary. the underlying point i heard here today is the are not just talking about individuals who are addicted to a substance. we're actually talking about sons and daughters and aunts and uncles and mothers and fathers and brothers and sisters. and for every addicted person that we will encounter, there's a family standing behind that addiction. there's a father who is afraid his son will die. there's a brother, who, as i had to do in 2010, has to go verbury his deceased brother. there is a community expect great things from these people, thinking they would be the leaders that will replace you, who have to come face-to-face with the fact that that might not be possible. i stand here today to applaud you for your leadership. i want to encourage you to keep reaching up because the federal government has to step in and support you. they want you to reach down. because from your seat, you need to engage the mayors and the local city leaders, who are responsible for these same citizens in those communities and get them also on board with what you are trying to get done because as was said from this panel, we cannot do this alone. we cannot do this form a single -- theent or from business sector cannot do it by themselves. the elected government section cannot do it by themselves. the not for profit sector cannot do it by themselves. we also need to engage philanthropy, who cannot do it by themselves. we can make grants but we can't grant our way out of this. we have got to come together as one group and the group has to include a fifth sector, the community that surrounds these people, who touch them everyday, who have changed their diapers. we have to engage in a way where we cannot rest until this is over and we cannot give up on a single soul, no matter how many times they relapse. but we need to understand that we can beat this. we have a history of winning, and this is no different. but we cannot give up. we cannot declare it done. we cannot say, we have fixed this neighborhood and therefore, we will use this money to go summer else. we have to rebuild from the ground up. i will give you two numbers. one is 25 minutes. borny 25 minutes a baby is in the u.s. who is suffering from withdrawals from opiate addiction. that means that during the time of this conversation, this very inspiring, very encouraging discussion, three babies have been born suffering from withdrawal from opiates. that means by the time we finish this three-day convening, 173 babies would have been born suffering from opioid withdrawal. dramatizing how serious this is, and how we cannot rest until we get all of the solutions working for us and that we can keep moving forward together, saving as many as we can, but understanding that the longer that we wait, the more casualties we will experience. and the second number i will give you is 1/3. that number is significant. in 1999, there were 567,000 children in foster care across the country. anily program started endeavor called building communities of hope, an effort to change what is going on in communities, so children of have to come into foster care when the families face challenges, but we can serve them at home. thereom 1999 until 2012, was a 30% reduction in the number of kids in foster care. it had gone from 567,000 children in foster care to about 390,000 children in foster care. from 2012 to today, that number has gone back up. we are almost at 400,000 children in foster care. it is heading in the wrong direction. children who spend their lives in foster care have some of the worst life outcomes than any of the children in this nation, including those who are chronically poor. we must see the faces of these babies. and i encourage you to reach out to your other colleagues. every governor should be in this room on this issue. we need to make sure the federal government is on this. philanthropy has been on this issue. we bring the resources that we have gotten from the late jim casey and we give them to your states. right now we work with everyone of your child welfare agents to make sure we are not leaving any of our children on the playing field. we can't leave them behind because they need to be leading this charge as we go forward. and the challenges for us to continue to remember that these are people. and that 1/3 number, 1/3 of all of the placements that are made, that were made in this last year come over 200,000 children coming into foster care, 1/3 of the reasons for all the cases had parental substance abuse as a reason for removal. this epidemic is not just dealing with adults. it is also dealing with our babies and i believe that working together, in one of the quotes of the late jim casey, committed people working together can do anything. and so, i was honored to be invited to say a few words today, but the one were to want to say to you is, we will work with you because this is a fight we have to win. failture is not an option. thank you for inviting me. thank you for your leadership. and thank you for what you're doing for our children. [applause] >> let me disclose by thanking -- let me just close by thanking all of you for being here with us today. i take great pride in the fact that so many of you are working this issue so hard. and my big message to all of you is stay with it because i do believe we are making progress, but it will be a long, hard slog. do you want to say anything, governor? this is your town, here. >> no, i just want to thank everyone. we have a great attendance by governors. that gives me hope that together we will solve this crisis across the country. thank you all for your leadership. [applause] >> thank you. >> in his weekly address, the president talks abth