From any of your states or dea. When our state senator just [inaudible] brings to me some articles is and studies that i, he thought that i should consider. I pay little attention to him until a couple of years later that i went to a conference he was giving to many people. And he explained x then i went back to those articles. I thank the nga staff and my taffe to be included one of those articles, and we all, all of us have it right now is an article by glenn greenwald, a yale professor on drug decriminalization in portugal. And this is a very touchy subject, i know. But just to give you numbers, in 2001 people that died by heroin is and opiate in portugal where it was, 281. In 2006 it was 133. They decriminalized all drugs. Just, i know its a very touchy subject, but i think its a good article to take a look at. On page 18 theres a table that shows how decline number of dead people by consumption of illegal drugs. Its something that i am, i havent been able to put forward in pert rio. Puerto rico. I wish. But i just want to be serious consideration. I just want to know from you, you study these, or whats your opinion on these case studies that is happening with Great Success in portugal . Thats a nice softball to start the conversation with. [laughter] fire away, dr. Franklin. I didnt have time to go through kind of how all this started. But if you dont understand how it all started in the late 90s, youre not going to be able to reverse it. And one of of the things we recommended, you know, most Health Care Delivery is regulated at the state level through boards of commissions. And the folks who wanted to make it more per permissive to use opioids, we had a language in our state that said no doctor shall be sanctioned for any amount of opioid written, and more than 20 states included language that was so permissive that even if you had an egregious provider or a pill milker its been very hard for our medical boards and commissions to take action against that sort of stuff. So its important to realize that its the oversupply and overprescribing that has led to this, and it was based on false teachings by some of our leaders and Drug Companies back in the late 1990s. Im actually looking forward to reading this report too. And the main, the part i struggle with on this when people talk about decriminalizing this is we did. It is legal. I mean, the 240 prescriptions that secretary burwell was talking about, those were all legallyprescribed, for the most part, written in this country. And part of the authorized approach to Pain Management that grew out of the reforms of early 2000s. And, i mean, im one of these people who thinks were dealing with that right now. So its very hard to me, for me to understand how that sort of fits with this. But im looking forward to reading it and seeing what it does. So the only thing id add to that is theres no question that this is a complex issue of addiction which is not all about pills, although we know that doctors overprescribed in the 1990s. And that, you know, hospitals encouraged them to do so because of satisfaction surveys and the joint commission created pain as the fifth vital sign. But at the same time, in essence, when we actually use m. A. T. , to some extent you could say thats legalizing, right . We are giving people opioids to make them stable, to make them healthier and to allow them to become productive members of society so they dont have to steal to actually, to get drugs or to risk the overdose related to the illicit drugs. [inaudible conversations] a couple of different questions real quickly. Just a quick question of the dea. What, if anything, can be done to stop that flow from china to mexico, the one that you cited . Is there, are there simple things that can be done to target like a laser on that channel for fentanyl in this instance . Yeah. So its a multilayered approach x we do have an office in beijing and in conjunction with the state department in our headquarters. And inner working groups in the d. C. Area in diplomatic relations with china and how we can augment or assist or educate them on the problems here and what these substances, the havoc theyre creating. I think that weve had a very successful relationship with the Chinese Government and their medical community in keeping that dialogue open. So im optimistic with their recent, you know, theyve basically criminalized over a hundred Chemical Substances because those were fentanyl analogs. Im on optimistic in the point t the dialogue is open, and they are sharing information with us. And as were seeing more and showing more examples of heres the chain of evidence that shows this came from this location in china, you know, what are you going to do about this, and i think thats something were going to continue to do and push forward with. Thank you. Another couple quick questions. Dr. Franklin, im curious your thoughts on bupremorphine, your thoughts on the effectiveness of it, and do you know if anybodys ever done a study as to the percentage of it . You mentioned that dr. Chen is one of the spokes. Has anybody ever studied the percentage of it thats prescribed thats actually used by the individual to whom it was prescribed versus that was sold on the street . Im sorry, i dont know the answer to that. Dr. Chen . But your thoughts on it as a drug. Codo you feel its an effective drug for treating opioid addiction . I believe it is an effective drug to treat opioid addiction, but we also need to take an approach. This is a special population that started out with prescription opioids, and our state guideline and our workers comp guideline are focusing on, first of all, trying to taper the drug in patients and having algorithms for primary care and pain clinics to taper along with the possibility of add youngtive medication by buy prenor teen. And if you can taper it 10 a week or Something Like that, we actually have no data a as to how often that could be done. So thatd be the first step. And if that fails either in primary care or in a specialty with addiction help, then we would probably allow medicationassisted treatment for opioid use disorder, because some people think thats a brain disorder thats going to be there the rest of your life. But we really have no Empirical Data to say you could get half these people off. And weve had examples of injured workers who were on huge doses that got off within a fairly short time and did pretty well. So we just need more Empirical Data on that approach. If i could try to address your question, i think one point is we know from the evidence that methadone works very well. And weve been using it for decades. We also know that bupremnorphine does work in terms of criminal activity, in terms of health. Your point about street uses is a good one. I think there are two issues to that. I actually spent a morning in a clinic prescribing it to people. I happened to have my as a pinch hitter. And i asked every one of them how they started. I asked every one of them what things they went through. And a lot of them started with street medicine. Some of them said, yeah, i got high a little bit in the beginning, but after that it was just about not withdrawing. And so if you have demand thats not meeting supply, then theyre going to buy it on the street. And i think there are ways to be more mindful about how you regulate the prescriptions. You have to be very careful were not just going to get into another set of pill mill situation. So i think strong regulation, strong best practices about how you prescribe anytime a system of care in a system of care is very important. And, governor, one final question comment, and its something i would challenge us as governors to think about. I dont know what the number is, but i would think a significant portion, percentage of the doctors that are, that are educated every year in the United States are educated in our public universities. Certainly, some High Percentage of them are. And i think one of the things as ive looked at this, and im hardly an expert, but one that has has affected kentucky significantly, communication is critical. Youve been calling peoples attention to this for a decade plus. Ive talked to doctors who have had no real education whatsoever in Pain Management prescription. They really havent. Its not a part of the protocol for them to become doctors. It is starting to potentially become part of it now. But i wonder if we could not collectively in the nga in some way working, perhaps, with you, dr. Mcginnis, with you and others who have looked at this for a long period of time, come up with a course, for lack of a better term, that would be standard that every single doctor start with our public universities that we have more control over. But, ultimately, that every doctor in america would have some basic level of training in understanding Pain Management drugs more so than they now do. And i wonder if we did not be all put ourselves behind it and sort of demand it, at some fundamental level at least within our Public University medical schools that we might not be able to turn this. But a i think we are because i think we are now reaping what was sewn many, many years ago sown many, many years ago. A lot of this prescription problem came out of a lack of understanding and a fundamental trust that was placed in information that has turned out to not be what we believed it to be. So i dont even know if thats a question, its just a thought [inaudible] dr. Mcginnis, if you have any thoughts as to whether thats even feasible. Just so you know, one of the elements of the compact talks about educating prescribers. And i know in massachusetts, the medical schools all four of them the dental schools and the Nursing Schools have all committed to a opioid therapy curriculum which you cant graduate unless you take and pass. And we also now statutorily require if youre going to be a prescriber every two years as you go through your ceu process, you have to incorporate therapy into that. And i know thats happened in a number of states. And i certainly look forward to what dr. Mcginnis and the team come up with for nga in this prescriber education piece. But i tell you, i cant tell you how many clinicians have said to me when weve got into pretty pointed conversations about this, you know, i really dont know as much about this as i probably should. And most of the docs who write most of the prescriptions are not otter pods orr no pods and oncologists. Theyre family practice, primary care. I mean, this is a really big and really important issue in this conversation. And i think the idea of getting everybodys state school if youve got a medical school or a Nursing School or a a dental school, i think thats a really good idea. Do you want to [inaudible] well, just briefly, to underscore and endorse your observation, i would imagine that the piece that well be doing in partnership with the nga will not only identify the kinds of guidelines for providers on the front line, but also whats necessary in the educational process to improve the circumstances. Jonah walker. Thankses, governor baker. Actually, man, on your point, governor bev vins point, and im sure this is true. A lot of the states, both those that have panelists here and other governors that are represented, two things come to mind on your question. Partnership and cooperation. And, charlie, you just alluded to this with your medical colleges. We found the same thing not only with our medical schools, but going to speak with our state medical society realizing this is something we couldnt do to them. We needed them to be invested, and there still needs to be, because t not just changing their mind as the medical schools, its changing their minds as patients. The example i often give you go to urgent care, and my kids are in their 20s, but i can remember spending about every other weekend in an emergency room or urgent care for some injury along the way. Every time you go into urgent care, whats that sign you see up there . Its the sign with the different paces that tell you what level of pain that you have. Well, thats instinctive. Its not they werent trained, its actually they were trained not just because of reimbursements and things of that nature, but just in general that patients said, doc, give me something, im in pain. And so the thing they were missing wasnt the lack of how to deal with that pain, it was how to deal with it effectively without going down the path that were on today. And so weve got to get people to buy boo that into that, and its going to take a comprehensive approach. At least we found in our state, and we, you know, i love the things we heard from the panelists here today. Were going to take that back and match it with the things were already doing. But its certainly something that we cant either in state or at the federal level just dictate to people and expect its going to work unless we get them to have some buyin when its medical schools, dental schools, our nurses and otherwise. Its got to be a partnership. Governor . I just want to make the following point. Our state, connecticut, has been dealing with this issue. Ive been governor for six sessions, and weve passed comprehensive legislation on this issue five of those years and thought we got ahead of the problem. And i, and im going to say this, and some people certainly can have the right to disagree. I think the discussion today is largely about where the problem was three years ago, and were coming up for response for what we probably should have taken on three years ago at this rate. I think what i would say is the lasting effect of the introduction of some of these opioids and now with the addition of easilyaccessible fentanyl is the cost of heroin or its alternative is now so low and will remain so low that were seeing people becoming addicted not, first of all, to a prescription, but its moved to a very rapid becoming a addicted to something you can buy in a dose in my state for as little as 3. 50 to 10. And a product, if its pure if its heroin without fentanyl, is up to 71 purity as opposed to 15 or 30 purity when we were all, many of us were growing up in this room. So, yes, we have we do have a Prescription Drug transfer problem. Im not denying this. But i think people have to understand how cheap this is, how quickly people become addicted to it. And then, of course, the added factor of fentanyl when introduced as a mixing agent or a replacement for heroin when the person runs out of heroin to put in the packets is causing death. As ive said, in a fouryear period of time weve seen dependent knoll in our taxology reports go from 14 deaths to this year were predicting 170 deaths. Doesnt mean the person intentionally took fentanyl. They took heroin or thought they were taking heroin. It had a percentage of fentanyl, and they ended up dying of the combination. Final thought, in new haven just four weeks ago we had, someone was selling as heroin mixes that were largely fentanyl. Three people died immediately, 15 people in total lost consciousness, and some of those folks this was a relatively new product more their ingestion. Final, final point. I think we need to be talking to our high schoolers, our junior high schoolers. We can all worry about people our age having knee replacements or dental surgery, but this stuff is so accessible, it is ubiquitous in our communities, and you dont need to get hooked to Something Else before you get hooked to this. Well said, governor. Were about to run out of time here, so i do want to take a minute to thank dr. Mcginnis and dr. Frank lin and agent flowers and dr. Chen for your presentations and your participation today. It was all very educational, and we look forward especially to working with dr. Mcginnis and with you and your colleagues Going Forward. I do want to give vice chair hassan a chance to offer some final thoughts here. Thank you. And i join governor baker and all of the governors here in thank our panelists. I guess ill leave with this thought, because i think all of the comments have reflected where we are, what work we still have to do. But i was the saturday, just the day before easter, i was hosting our Easter Egg Hunt on the front lawn of our capitol. And as happens, i would expect to most of us if not all of us, people throughout the day came up to talk to me and often would talk about in this very issue; a loved one they had lost, a childs friend who had just died of an overdose, another person, maybe a colleague they knew who had been rescued by narcan. But perhaps the most poignant thing for me was a woman who approached me holding a baby introduced herself, introduced her baby. I asked how old he was, and she told me, and i said he was very cute and glad she had brought him to the Easter Egg Hunt. And she looked at me and said, you know, this is actually not my son. Hes my grandson. We lost my daughter to an overdose last month. His mother. I admired the bravery of that grandmother in coming to the Easter Egg Hunt the month after she lost her daughter to an overdose. It reminded me of the urgency of this issue, and we look at this life clock today. I think its three more lives have been lost since we started this discussion this afternoon. I am reminded in that story of the bravery of all of the survivors and people in recovery who have been willing to overcome the stigma that has been part of this problem, and i also admired her optimism. Its good to see you. Good job. [inaudible conversations] because it occurs to me some of the governors in the room or staff could pilot programs for direct Foreign Investment starting with community college, and a set of students from alaska, texas or florida doing the same developing the same skills in their state even if there wasnt the panasonic facility there. We work in and around panasonic facilities, in california, on the east coast in particular but practically speaking, they are open to anyone looking for an entrylevel. The Resource Department takes the paperwork side, they follow up with people. It is a great operation. Because of the aggressive skills, a Television Company or Camera Company or Something Like that, 15 of our business is in those arenas, under the hood of the car, the airpla