Transcripts For CSPAN3 Health Care Advocates Testify On Synt

Taske bipartisan heroin force for the 115th congress. , want to thank my cochair annie custer. We are proud of the work that we have done. I think we are proud this is the most rigorously Bipartisan Group in the u. S. House of representatives and we are looking forward to a year of joined a make more progress on an issue that is of great concern to all of us. Just a recap of last year briefly. Year, the comprehensive addiction and recovery act was passed by the house and the senate and passed into law. And it provided stakeholders resources to combat the heroine epidemic. We passed an act at the end of 100 14th congress that added an additional 100 billion of to combat this epidemic. In both of these were college in no small measure because of the bipartisan work done by this task force. Out in theolled 18 bills thatweek really became the foundation and much of the detail of what was ultimately passed into law. There is still a lot of work to be done. Americans over 52,000 died of a drug overdues. 33,000 of them were opioid related deaths. Thats hundreds of people on any given day that are dying. Know some of them i think everyone knows people affected by this epidemic. County in new jersey, we are losing someone to a Drug Overdose every 33 hours. This week is just beginning and we have lost people already. The task force has an ongoing role. We educate congress and staff regarding essential topics in this space. Issues of affordable and effective treatments todays topic is of special importance. Synthetic opioids. Drugs like fentanyl, pink have driven depths. Enormousgs have potency. Many times greater than heroin. They are being produced and the united within states using chemical components from china and elsewhere, but they are being produced and distributed right here at home. Theres a host of issues to discuss in this area, including Law Enforcement, border trafficking issues, the flow of fentanyl from china, which we will address in a future roundtable. Today, we are looking at an overview of the Science Behind these drugs and the public and treatment concerns they uniquely represent. It could not be a more urgent topic for this task force to start with. I want to thank our four nora volkowday, dr. From the National Institutes of corey waller, dr. Rising, and dr. Lisa marsh. Thank you all for being here. We are eager to learn from you. With that, i want to turn this over to my cochair, representative kuster. Rep. Kuster thank you. We particularly want to thank our guest from New Hampshire. Before us, we have dozens of years of incredible experience on synthetics like fentanyl. Fentanyl is a drug that has swept the state of New Hampshire. We have gone from number three in deaths per thousand population to number two. There are a lot of things that New Hampshire likes to be first in the nation for, that this is not one of them. My former colleague mr. Denton started the Task Force Last year. We knew New Hampshire was a hotspot for opioid use, but what we did know was the nuances and the complexities of our crisis. Not only the availability of heroin and fentanyl is on the rise in New Hampshire, but this drug is very inexpensive and yet extremely dangerous. One of the issues i would love to ask you about as we go forward is our Law Enforcement officials have concerns about even responding because of the danger of fentanyl. Year for us on this issue. We became the second state in the nation. Its a gruesome statistic that is based on the proliferation of fentanyl. That this is a lethal combination, and often the user does not realize that the drug they are intending to use has been contaminated with fentanyl. That we in thel congress understand synthetic opioids. They are much more powerful. Arewe need to know what we dealing with so we can come forward with policies to help Law Enforcement and help give people into treatment, which is something we have been working on through the comprehensive addiction and recovery act in the 21stcentury cures act. I learned a little factoid today. Wholeece together this puzzle. Iday i spoke from someone spoke to someone from anthem who said nationally they have just maybe pronouncement they will no longer require advance approval of medically assisted treatment and that could have sweeping implications, because i know from friends and indeed that this is very challenging. Getle, when they want to treatment have difficulty accessing treatment for many reasons. Advanceto require that authorization for access is a big step. Im looking forward to hearing , and ir witnesses appreciate the work that you do and we want to work with you and the coming weeks and months to make sure were doing everything indeedto give you and our Community Stakeholders all the tools to help people get well and become productive citizens of our community. Thank you very much and i yield back. Rep. Macarthur im going to ask if each of you would make opening remarks in order and then we will hold questions until all four of you have spoken. Volkow, i would ask you to begin. yes, i would like to thank the task force. I would also like to thank you for the opportunity to testify. This is an agency involved in generatingrch and solutions that will help us address the Opioid Epidemic that has led to the abuse of heroin and synthetic opioids. The consequences are devastating. Its not just an enormous a its not and no just in a amount of people. Its contributing to the spread of diseases like hiv and also an syndromes. Other the numbers speak for themselves. There were more than 2 million americans that suffered from prescription opioid abuse disorder and 600,000 heroin. Fromople died in 2015 opioids, and that required more prescriptions,m 13,000, and really that incredible Staggering Number of 9580 from synthetic opioids. Becausey dont know many of them using synthetic withds cannot be assayed the current metals. When someone dies, they do not necessarily know what is in their. Thats not going to necessarily be reported. Some measures of been more effective than others. I think we have to recognize one of the issues we have been unprepared for, what proportion areas haveas, rural been affected by the prescription Opioid Epidemic. I think some of the numbers we are all worried about kentucky, virginia, the appellation area. Prescription opioids abuse . They are abused because they receptors. Opioid we have many in the brain and the body. We have opioid receptors in areas networked with pain. These medications can be extremely effective in the management of acute, severe pain and can be lifesaving in those conditions. Receptors inthese our brain centers, which is why they are so addictive and also involved in areas involved with the regulation of breathing, which is why they can inhibit those centers and result in an overdose death. Not all opioids are the same. Some are more potent than others. As we were discussing, we have Prescription Medication like vicodin and oxycontin that have ever levels of potency. Its estimated to be between 50 than00 times more potent heroin. We are hearing about, one is estimated to be 100 times more potent, and this is the concern First Responders may have because you can absorb sufficient through the skin to a depressionrate in respiration. Its an extremely, extremely dangerous drug and they also pose and a normas challenge. Bringing an enormous challenge. Heroin from mexico requires a greater volume of drug then fentanyl, where as you may require a very small vial. It is also a nightmare. Why are we here . I think we need to understand why we are here. I hope we learn from history. Startedan epidemic that and two phenomena were going on. One was the enormous number of people in the United States that suffer from pain conditions. The recognition that we dont have many treatments for pain. So physicians started to rely on the use of opioids for the treatment of this pain conditions. There was atime market that was taking advantage newhe industry to generate products that were increasingly more potent and they were underestimating the risk for addiction of these medications. It created a sense of overconfidence. Had a massive over prescription of medications that also responded to the thatents in 2000 physicians be required to screen and treat pain in their patients. So, all of these combine to generate a massive increase in the number of prescriptions diversionlitates the with all of the consequences. Then later, it translated into facilitating heroin because it became harder to access. Estriction medication they actually transferred to heroin or other synthetic drugs. Its important to recognize that. An issue of the epidemic of the heroin overdose that were now seeing. We need to recognize at least for heroin, we know the numbers. With taking start prescription opioids. If we want to address the issue of heroin, we need to address prescription opioids and we need. O prevent them these constraints, this situation, what is it that we are going to be doing . Well, we need to recognize the complexity of the issues. We have those individuals that are prescribed opioids because they have pain and they become addicted to their medication or overdose on their medication. That requires a slightly distinct type of intervention. The individual starts to want discussion opioids because they want to get high. Those are different. But both of those groups are at risk for addiction and risk for overdose. To the useas relates of science . What is the most important intervention we can do. What are the Prevention Strategies that are most effective in actually of hurting people from becoming dependent on prescription opioids or becoming addicted to heroin or synthetic opioids . At one end, of course, we have treatment. In treatment, we have to address the issue of number one we like to think about science in two ways. We use science to solve problems because people are dying. We cannot afford to wait. Look atcience so we can the future in a transformative way. We cannot wait for the future. We have to transform now. One of the big challenges is how do we implement the currently available medications. Ony are very effective preventing overdoses, very very effective. But they are not being used. 20 do not receive this medication. Why . There is a lot of sufficient infrastructure to accommodate. The issue is, how do we think about this . That is where science comes along. Initiate at the emergency room when someone comes with an overdose, your outcomes are much, much better. You can improve your outcomes by close to 80 . So, implementing will make a big difference. Thinking about the criminal justice system, we have shown with research that if you use extended release, you can actually prevent drug use and prevent the overdoses. Maximize the use of our resources. The other element that is very is thent to recognize urgency also of developing alternative treatments for the management of pain using medications that are much less dangerous. Day, while wethe do have interventions and a challenge to implement them, the only way we will be able to do it is by working together across agencies and disciplines. Of all of this, i want to thank you for giving me the opportunity to be with you today. Think you very much. Rep. Macarthur thank you. Dr. Waller . Dr. Waller thank you. I appreciate the opportunity to come and speak about this. This is something i have had to deal with as a clinician i would really as a clinician and i would really echo everything olkow has said. We are all going to be molecular or new or a shortly. Here we go. Want to make sure that we settle on terminology. Potency. Ne of them is we need to understand what we mean by that. Potency ultimately is the degree on aich any chemical turns cell relative to another chemical in the same class. What that means his morphine is our marker. As our base. Ne it equals the same potency as one milligram of hydrocodone which is the number one prescribed pain medication in the United States. Tablet has five milligrams. Five milligrams of morphine equivalents in that one pill. If we were to look at that, we have to look at that is one of the pieces, but the other pieces, how fast does that get to the brain . How addictive is the substance . Does that get to the brain and release dopamine . How fast does it compare someone . Lipid solubility, how fast does it get to the brink, those of the two aspects of these drugs we have to think about if we want to compare and contrast each of those. When we talk about the relative potencies, i want to put the marker on that. If you take morphine of one milligram and i give you heroin, heroine is four to five times more potent. So if someone has a five ill,igrams hydrocodone p vicodin, if like taking five of those. If i give them sentinel in that same pill if i give them fentanyl in the same pill, its like taking a hundred of those. If we move to things like another of these synthetics we are finding out on the street, because we also use that in the hospital. I have used that many times for patients, thats a thousand of those pills. ,f we go up to car fentanyl thats a thousand of those pills shoved into a single tab. The difference between getting high and dying is the difference between one grain of sand and three grains of sand, you can see were the mistakes get made. This, one ofeive the synthetics, which is Something Else i hope we understand synthetic does not mean it is different. It just means we have made it synthetically as opposed to making it as a derivative of the the opium poppy is morphine and we can make coding from that. Time, synthetics are things we have made from science. Its a wonderful medication when used properly. I have use it regularly in my practice in my training as emergency medicine as vision, addiction physician, pain position. Very useful tool. Its very predictable. This is a medication where if i give you 100 micrograms, if i give you that, i know what is going to do, i know how long its going to last. Bone, iave a broken know in 28 to 35 minutes, you will need another dose. Very predictable. I can predict what it will do with other medications if we give them at the same time. Its really useful in that setting. If, however, you dont understand that extra few micrograms, the tiny hundreds of a milligram, when we start to go down, that little extra can make the difference between a patient that is comfortable, and one i have to put a tube in to breathe for. That little bit of difference is really important to understand. Carfenunderstand what entanyl, in the russian situation that the russian theater situation, they pumped gas. Rfentanyl and unfortunately they ended up killing those people because they got the dose wrong. Fully talk about danger, i worked with a swat team in michigan and the federal protective service in a number givesacities, if this aerosolized, it you can have multiple officers down. It can be the difference between i am getting high and im dead. This into other pieces, what we do when we find someone who has used it. Ow says, wer. Volk dont really know. If i test their urine for an overdose, we dont test it for fentanyl and carfentanyl. We dont test for it. We dont know. These patients require a reversal agent at a much higher rate. ,f someone overdoses on heroin i can get them. 4 milligrams of a small amount to wake them up, not put them in full withdrawal, allow them to breathe, and get them where we need to go. For someone who has overdosed on anyl, it can take 12 milligrams. We now have to go all the way up to 12 milligrams. An average ems truck carries eight total before they have to restock. So were looking at an incident where you can have ems there at the time and they can give you all of their medicine that they have in their stock and it may not be enough to reverse that agent at that time. The potency becomes really, really important when we start thinking about what this means for why people are dying from using this. Anyuse i dont know if of you have heard of blue light which is a website. Its a forum where drug users will have conversations back and forth. Its not like they are chemist i would kind of disagree. Look at they to right dosage by starting with 25 micrograms of moving up slowly to figure it out. But as they point out, the people using this, the batches they get, you can never predict what because and ration is. They are not buying it the way a laboratory would where it is standardized and filtered and set up. Because of the difference between 100,000 to one, if you have that extra grain of sand and you do not know what that is and youre trying to spike your heroin, what you end up doing is what we have seen a number of states in indiana and the northeast where we have had groups of people in small areas over two or three days die rapidly because of a bad batch of heroin got out and that was a chemical miscalculation. People ask why they use these drugs. I get asked, why in the world would you use something that will kill you . Theill move the fact that disease of addiction is defined very specifically based on behavior that follows a lakh of logic in his normal pathway as we would see it, and that is mainly because it literally shuts off the connection the tween the frontal lobe in the animal portion of the brain which is all about survival. They will not go through the pros cons list about what they will do next. Someone who does not know how they have mixed these drugs, that is a recipe for disaster. But now there are people who know we cannot test for these. If they are on an injectable that is in for three days, they know that they can use these on top of those. They can still get high and not be detected. So, this is a way in which they are also trying to overcome some of the efforts of treatment, and me as a treatment provider will have difficulty identifying theyve been on it. They may look in the urine, but these are not checked for. I guess the best way i can talk about it is really if somebody does not know they are one,g 100,000 pills in then that is a real risk for them and thats where this comes down as far as how put the synthetic drugs are. Thank you very much. Rep. Macarthur think you much. Dr. Rising . Thank you very much. Dr. Rising . Dr. Rising representatives ofarthur and kuster, members the task force, thank you for asking me to be here. It is a pleasure to be here with you and my distinguished fellow panelists. My name is josh rising. I work for the Bipartisan Group<\/a> in the u. S. House of representatives and we are looking forward to a year of joined a make more progress on an issue that is of great concern to all of us. Just a recap of last year briefly. Year, the comprehensive addiction and recovery act was passed by the house and the senate and passed into law. And it provided stakeholders resources to combat the heroine epidemic. We passed an act at the end of 100 14th congress that added an additional 100 billion of to combat this epidemic. In both of these were college in no small measure because of the bipartisan work done by this task force. Out in theolled 18 bills thatweek really became the foundation and much of the detail of what was ultimately passed into law. There is still a lot of work to be done. Americans over 52,000 died of a drug overdues. 33,000 of them were opioid related deaths. Thats hundreds of people on any given day that are dying. Know some of them i think everyone knows people affected by this epidemic. County in new jersey, we are losing someone to a Drug Overdose<\/a> every 33 hours. This week is just beginning and we have lost people already. The task force has an ongoing role. We educate congress and staff regarding essential topics in this space. Issues of affordable and effective treatments todays topic is of special importance. Synthetic opioids. Drugs like fentanyl, pink have driven depths. Enormousgs have potency. Many times greater than heroin. They are being produced and the united within states using chemical components from china and elsewhere, but they are being produced and distributed right here at home. Theres a host of issues to discuss in this area, including Law Enforcement<\/a>, border trafficking issues, the flow of fentanyl from china, which we will address in a future roundtable. Today, we are looking at an overview of the Science Behind<\/a> these drugs and the public and treatment concerns they uniquely represent. It could not be a more urgent topic for this task force to start with. I want to thank our four nora volkowday, dr. From the National Institutes<\/a> of corey waller, dr. Rising, and dr. Lisa marsh. Thank you all for being here. We are eager to learn from you. With that, i want to turn this over to my cochair, representative kuster. Rep. Kuster thank you. We particularly want to thank our guest from New Hampshire<\/a>. Before us, we have dozens of years of incredible experience on synthetics like fentanyl. Fentanyl is a drug that has swept the state of New Hampshire<\/a>. We have gone from number three in deaths per thousand population to number two. There are a lot of things that New Hampshire<\/a> likes to be first in the nation for, that this is not one of them. My former colleague mr. Denton started the Task Force Last<\/a> year. We knew New Hampshire<\/a> was a hotspot for opioid use, but what we did know was the nuances and the complexities of our crisis. Not only the availability of heroin and fentanyl is on the rise in New Hampshire<\/a>, but this drug is very inexpensive and yet extremely dangerous. One of the issues i would love to ask you about as we go forward is our Law Enforcement<\/a> officials have concerns about even responding because of the danger of fentanyl. Year for us on this issue. We became the second state in the nation. Its a gruesome statistic that is based on the proliferation of fentanyl. That this is a lethal combination, and often the user does not realize that the drug they are intending to use has been contaminated with fentanyl. That we in thel congress understand synthetic opioids. They are much more powerful. Arewe need to know what we dealing with so we can come forward with policies to help Law Enforcement<\/a> and help give people into treatment, which is something we have been working on through the comprehensive addiction and recovery act in the 21stcentury cures act. I learned a little factoid today. Wholeece together this puzzle. Iday i spoke from someone spoke to someone from anthem who said nationally they have just maybe pronouncement they will no longer require advance approval of medically assisted treatment and that could have sweeping implications, because i know from friends and indeed that this is very challenging. Getle, when they want to treatment have difficulty accessing treatment for many reasons. Advanceto require that authorization for access is a big step. Im looking forward to hearing , and ir witnesses appreciate the work that you do and we want to work with you and the coming weeks and months to make sure were doing everything indeedto give you and our Community Stakeholders<\/a> all the tools to help people get well and become productive citizens of our community. Thank you very much and i yield back. Rep. Macarthur im going to ask if each of you would make opening remarks in order and then we will hold questions until all four of you have spoken. Volkow, i would ask you to begin. yes, i would like to thank the task force. I would also like to thank you for the opportunity to testify. This is an agency involved in generatingrch and solutions that will help us address the Opioid Epidemic<\/a> that has led to the abuse of heroin and synthetic opioids. The consequences are devastating. Its not just an enormous a its not and no just in a amount of people. Its contributing to the spread of diseases like hiv and also an syndromes. Other the numbers speak for themselves. There were more than 2 million americans that suffered from prescription opioid abuse disorder and 600,000 heroin. Fromople died in 2015 opioids, and that required more prescriptions,m 13,000, and really that incredible Staggering Number<\/a> of 9580 from synthetic opioids. Becausey dont know many of them using synthetic withds cannot be assayed the current metals. When someone dies, they do not necessarily know what is in their. Thats not going to necessarily be reported. Some measures of been more effective than others. I think we have to recognize one of the issues we have been unprepared for, what proportion areas haveas, rural been affected by the prescription Opioid Epidemic<\/a>. I think some of the numbers we are all worried about kentucky, virginia, the appellation area. Prescription opioids abuse . They are abused because they receptors. Opioid we have many in the brain and the body. We have opioid receptors in areas networked with pain. These medications can be extremely effective in the management of acute, severe pain and can be lifesaving in those conditions. Receptors inthese our brain centers, which is why they are so addictive and also involved in areas involved with the regulation of breathing, which is why they can inhibit those centers and result in an overdose death. Not all opioids are the same. Some are more potent than others. As we were discussing, we have Prescription Medication<\/a> like vicodin and oxycontin that have ever levels of potency. Its estimated to be between 50 than00 times more potent heroin. We are hearing about, one is estimated to be 100 times more potent, and this is the concern First Responders<\/a> may have because you can absorb sufficient through the skin to a depressionrate in respiration. Its an extremely, extremely dangerous drug and they also pose and a normas challenge. Bringing an enormous challenge. Heroin from mexico requires a greater volume of drug then fentanyl, where as you may require a very small vial. It is also a nightmare. Why are we here . I think we need to understand why we are here. I hope we learn from history. Startedan epidemic that and two phenomena were going on. One was the enormous number of people in the United States<\/a> that suffer from pain conditions. The recognition that we dont have many treatments for pain. So physicians started to rely on the use of opioids for the treatment of this pain conditions. There was atime market that was taking advantage newhe industry to generate products that were increasingly more potent and they were underestimating the risk for addiction of these medications. It created a sense of overconfidence. Had a massive over prescription of medications that also responded to the thatents in 2000 physicians be required to screen and treat pain in their patients. So, all of these combine to generate a massive increase in the number of prescriptions diversionlitates the with all of the consequences. Then later, it translated into facilitating heroin because it became harder to access. Estriction medication they actually transferred to heroin or other synthetic drugs. Its important to recognize that. An issue of the epidemic of the heroin overdose that were now seeing. We need to recognize at least for heroin, we know the numbers. With taking start prescription opioids. If we want to address the issue of heroin, we need to address prescription opioids and we need. O prevent them these constraints, this situation, what is it that we are going to be doing . Well, we need to recognize the complexity of the issues. We have those individuals that are prescribed opioids because they have pain and they become addicted to their medication or overdose on their medication. That requires a slightly distinct type of intervention. The individual starts to want discussion opioids because they want to get high. Those are different. But both of those groups are at risk for addiction and risk for overdose. To the useas relates of science . What is the most important intervention we can do. What are the Prevention Strategies<\/a> that are most effective in actually of hurting people from becoming dependent on prescription opioids or becoming addicted to heroin or synthetic opioids . At one end, of course, we have treatment. In treatment, we have to address the issue of number one we like to think about science in two ways. We use science to solve problems because people are dying. We cannot afford to wait. Look atcience so we can the future in a transformative way. We cannot wait for the future. We have to transform now. One of the big challenges is how do we implement the currently available medications. Ony are very effective preventing overdoses, very very effective. But they are not being used. 20 do not receive this medication. Why . There is a lot of sufficient infrastructure to accommodate. The issue is, how do we think about this . That is where science comes along. Initiate at the emergency room when someone comes with an overdose, your outcomes are much, much better. You can improve your outcomes by close to 80 . So, implementing will make a big difference. Thinking about the criminal justice system, we have shown with research that if you use extended release, you can actually prevent drug use and prevent the overdoses. Maximize the use of our resources. The other element that is very is thent to recognize urgency also of developing alternative treatments for the management of pain using medications that are much less dangerous. Day, while wethe do have interventions and a challenge to implement them, the only way we will be able to do it is by working together across agencies and disciplines. Of all of this, i want to thank you for giving me the opportunity to be with you today. Think you very much. Rep. Macarthur thank you. Dr. Waller . Dr. Waller thank you. I appreciate the opportunity to come and speak about this. This is something i have had to deal with as a clinician i would really as a clinician and i would really echo everything olkow has said. We are all going to be molecular or new or a shortly. Here we go. Want to make sure that we settle on terminology. Potency. Ne of them is we need to understand what we mean by that. Potency ultimately is the degree on aich any chemical turns cell relative to another chemical in the same class. What that means his morphine is our marker. As our base. Ne it equals the same potency as one milligram of hydrocodone which is the number one prescribed pain medication in the United States<\/a>. Tablet has five milligrams. Five milligrams of morphine equivalents in that one pill. If we were to look at that, we have to look at that is one of the pieces, but the other pieces, how fast does that get to the brain . How addictive is the substance . Does that get to the brain and release dopamine . How fast does it compare someone . Lipid solubility, how fast does it get to the brink, those of the two aspects of these drugs we have to think about if we want to compare and contrast each of those. When we talk about the relative potencies, i want to put the marker on that. If you take morphine of one milligram and i give you heroin, heroine is four to five times more potent. So if someone has a five ill,igrams hydrocodone p vicodin, if like taking five of those. If i give them sentinel in that same pill if i give them fentanyl in the same pill, its like taking a hundred of those. If we move to things like another of these synthetics we are finding out on the street, because we also use that in the hospital. I have used that many times for patients, thats a thousand of those pills. ,f we go up to car fentanyl thats a thousand of those pills shoved into a single tab. The difference between getting high and dying is the difference between one grain of sand and three grains of sand, you can see were the mistakes get made. This, one ofeive the synthetics, which is Something Else<\/a> i hope we understand synthetic does not mean it is different. It just means we have made it synthetically as opposed to making it as a derivative of the the opium poppy is morphine and we can make coding from that. Time, synthetics are things we have made from science. Its a wonderful medication when used properly. I have use it regularly in my practice in my training as emergency medicine as vision, addiction physician, pain position. Very useful tool. Its very predictable. This is a medication where if i give you 100 micrograms, if i give you that, i know what is going to do, i know how long its going to last. Bone, iave a broken know in 28 to 35 minutes, you will need another dose. Very predictable. I can predict what it will do with other medications if we give them at the same time. Its really useful in that setting. If, however, you dont understand that extra few micrograms, the tiny hundreds of a milligram, when we start to go down, that little extra can make the difference between a patient that is comfortable, and one i have to put a tube in to breathe for. That little bit of difference is really important to understand. Carfenunderstand what entanyl, in the russian situation that the russian theater situation, they pumped gas. Rfentanyl and unfortunately they ended up killing those people because they got the dose wrong. Fully talk about danger, i worked with a swat team in michigan and the federal protective service in a number givesacities, if this aerosolized, it you can have multiple officers down. It can be the difference between i am getting high and im dead. This into other pieces, what we do when we find someone who has used it. Ow says, wer. Volk dont really know. If i test their urine for an overdose, we dont test it for fentanyl and carfentanyl. We dont test for it. We dont know. These patients require a reversal agent at a much higher rate. ,f someone overdoses on heroin i can get them. 4 milligrams of a small amount to wake them up, not put them in full withdrawal, allow them to breathe, and get them where we need to go. For someone who has overdosed on anyl, it can take 12 milligrams. We now have to go all the way up to 12 milligrams. An average ems truck carries eight total before they have to restock. So were looking at an incident where you can have ems there at the time and they can give you all of their medicine that they have in their stock and it may not be enough to reverse that agent at that time. The potency becomes really, really important when we start thinking about what this means for why people are dying from using this. Anyuse i dont know if of you have heard of blue light which is a website. Its a forum where drug users will have conversations back and forth. Its not like they are chemist i would kind of disagree. Look at they to right dosage by starting with 25 micrograms of moving up slowly to figure it out. But as they point out, the people using this, the batches they get, you can never predict what because and ration is. They are not buying it the way a laboratory would where it is standardized and filtered and set up. Because of the difference between 100,000 to one, if you have that extra grain of sand and you do not know what that is and youre trying to spike your heroin, what you end up doing is what we have seen a number of states in indiana and the northeast where we have had groups of people in small areas over two or three days die rapidly because of a bad batch of heroin got out and that was a chemical miscalculation. People ask why they use these drugs. I get asked, why in the world would you use something that will kill you . Theill move the fact that disease of addiction is defined very specifically based on behavior that follows a lakh of logic in his normal pathway as we would see it, and that is mainly because it literally shuts off the connection the tween the frontal lobe in the animal portion of the brain which is all about survival. They will not go through the pros cons list about what they will do next. Someone who does not know how they have mixed these drugs, that is a recipe for disaster. But now there are people who know we cannot test for these. If they are on an injectable that is in for three days, they know that they can use these on top of those. They can still get high and not be detected. So, this is a way in which they are also trying to overcome some of the efforts of treatment, and me as a treatment provider will have difficulty identifying theyve been on it. They may look in the urine, but these are not checked for. I guess the best way i can talk about it is really if somebody does not know they are one,g 100,000 pills in then that is a real risk for them and thats where this comes down as far as how put the synthetic drugs are. Thank you very much. Rep. Macarthur think you much. Dr. Rising . Thank you very much. Dr. Rising . Dr. Rising representatives ofarthur and kuster, members the task force, thank you for asking me to be here. It is a pleasure to be here with you and my distinguished fellow panelists. My name is josh rising. I work for the Pew Charitable<\/a> trust. Work focuses on supporting policies that will reduce the inappropriate use of Prescription Drug<\/a>s and expand access to evidencebased treatment for people with Substance Abuse<\/a> disorder. I will be focusing on that second element. We are all very familiar with the human toll of the epidemic w talked about. The number of opioid related deaths continue to rise. Over 33,000 this past year. To the risk of overdose the end of opioids can have other negative effects including an increased risk for cardiovascular events touches heart attacks, increased risk for acquiring hiv and hepatitis c from people using iv drugs. It was a drugs cost of the United States<\/a> around 193 billion every year, largely related to lost productivity and interactions with the criminal system. We cant and shouldnt ignore the impact on children either. Many officials have made a direct connection between the rise of use of opioids and the rise of number of children in foster care. Addressing the Opioid Epidemic<\/a> was not challenging enough, we now face the added difficulty of the high potency of fentanyl,oids carfentanyl, and the designer drug known as pink. The deaths from heroin and synthetic opioids last year rose 20 and 70 respectively. Any effort to reduce the use of synthetic opioids requires a comprehensive approach to pursue upstream solutions wherever possible. Most people with Substance Abuse<\/a> disorder do not start out wanting to use these substances. Userout of five heroin started using prescriptive pain relievers prior to heroin. One approach is using narcan, which saves lives by reversing overdoses. But at its core, Substance Abuse<\/a> disorder is a treatable, similar toease diabetes. Medication assisted treatments or m. A. T. Is the most effective therapy for Substance Abuse<\/a> disorder, whether the verse and is dependent on heroin, fentanyl, any combination of these drugs. Result, the same treatment approaches will be effective, regardless of which opioids someone has used. The fda has approved three. Ifferent treatments the right medication and the right approach may vary for each individual patient. These drugs are taken by patients daily, monthly, or sometimes every six months in conjunction with behavioral therapy. Behavioral therapy can include individual or group counseling, cognitive behavioral therapy, and other interventions. Extensive research has really borne out the benefits and the efficacy of m. A. T. Of overdosehe risk and death, reduces the risk of overdose, and allows people to return to the workforce. Studies have shown every dollar of treatment returns at least seven dollars or more, according to conservative estimates. But only 10 of people with Substance Abuse<\/a> disorder receive any type ofreceived therapy in 2015. Imagine if people with diabetes or high Blood Pressure<\/a> received that amount of care. We know this is a Public Health<\/a> crisis. What are the solutions . Magic bullets, but congress has taken actions already. Specifically, i would like to thank congress for, first of all, passage of the conference of Addiction Recovery<\/a> act or cara. Cara advances new policies around prevention and treatment such as new and enhanced grant programming. Second, the recent appropriation of 500 million. Money is provided directly to states to strengthen prevention programming at the state and local level. We would like to recognize another opportunity for congress to spring to take action by appropriately additional 500 million for prevention and authorizedhat were in 21st century cures. There are Additional Solutions<\/a> that will make a difference in addressing the opioid crisis. These three strategies include first of all, enhancing approaches that address prevention and Harm Reduction<\/a>. Ensuring access to nonpharmacologic methods of treating pain, coupled with provider education and reducing unnecessary prescribing, Prescription Drug<\/a> monitoring programs can help providers within a five patients at particular risk. Another important Harm Reduction<\/a> practice is improving access to opioidoid reversal overdose reversal drug. We should have a system where people who want and need treatment can get it without coverage restrictions or delays. Coverage is a critical part of access. Around one third of individuals who felt the need for treatment for Substance Abuse<\/a> disorder in 2015, but did not receive it cited a lakh of Insurance Coverage<\/a> and inability to afford the cost as a reason. Optimizing access to existing programs, such as medicaid, is especially vital. 20 of adults on medicaid have a Substance Abuse<\/a> disorder. Among people under treatment in new jersey, twice as many had medicaid as private insurance. We must also have integrated medical and Behavioral Health<\/a> care. More providers willing to treat people with Substance Abuse<\/a> disorder. Increased uptake of proven and effective models. An additional social services. And we need to reach people when they will be receptive to treatment, such as when they are in the emergency room due to an due to an overdose. Third, we need to reduce stigma around Substance Abuse<\/a> disorders and treatment. Aware ofers must be the problem and evidencebased solutions to address the problem and a neck changes. Representatives kuster. R and kuster we look forward to working with you in your colleagues. Rep. Macarthur thank you. Dr. Marsh . Dr. Marsh thank you for including me in this bipartisan test force briefing today. Im pleased to have the opportunity to contribute as we importantthis very issue for nation. Im a medical professor at Dartmouth College<\/a> in New Hampshire<\/a> and i have had the research of conducting with a particular focus on opioid disorders for a couple decades. Today im going to tell you about a study we have the opportunity to conduct with the support of the National Institutes<\/a> on drug abuse. New hampshire has had the secondhighest rate of opioid overdoses for capita and actually is number one for overdoses of fentanyl, fentanyl related deaths in the last couple of years, and an increase of almost extinct hundred percent in fentanyl related deaths in the last five years. This particular study was conducted under the National Drug<\/a> Early Warning<\/a> system initiative, an agreement supportd by nida to factors giving rise to this crisis in New Hampshire<\/a>. In a research at dartmouth and a resurgent dartmouth has and our research at dartmouth has networks to enable us to do this quickly. We did this in just three months. Witharted this project meetings with about 45 different stakeholders in the state, including prevention and treatment experts and the state opioid authority, medical examiners office, Health Providers<\/a> across the state. The last three months, we did intensive interviews with 75 active fentanyl users, as well as 36 emergency medical ,ersonnel, fire, Police Emergency<\/a> First Responders<\/a>, as well as physicians and other providers in Emergency Departments<\/a>. And we just completed Data Collection<\/a> for this study this past friday. We have seen a number of patterns in our preliminary results that really underscore a confluence of factors that seem to be giving rise to what we are observing in the state of New Hampshire<\/a>. Users that we interviewed reported that fentanyl hit the market in New Hampshire<\/a> in a substantial way a couple years ago, particularly in the southern part of the state. This was also the time heroin became somewhat more inaccessible in the region. We see that fentanyl is often althoughh heroin, sometimes it is sold as a soul product. Often users do not know the composition of the product they consume. It was mucheported less expensive and much more potent, so it has a real economic advantage relative to heroin. Although we do have some users report they are accidentally getting fentanyl, we find that some are purposefully seeking out fentanyl as the preferred drug of choice. Users also report that given the potency, you do not have to carry as much on your person or you can take smaller quantities with you, so it easier to avoid detection. Also users report the high from fentanyl does not last as long as the high from heroin. More often,to use which may increase your chances of overdosing, but also increase your chances of infection from drug use. Everything one of the 75 users we interviewed reported having observed at least one in typically more than one overdose. We had one young woman who said in the past two months she obtained 20 to 25 overdoses, including her own mother, who died from an overdose, her brother, who overdosed 17 times in a matter of a month and is now incarcerated, and her own personal use of fentanyl persists. High availability of this highly potent drug in a context in which the access to prevention and treatment resources is limited. New hampshire has the Second Lowest<\/a> treatment capacity in the nation. We know of the treatment offered, it does not always include evidencebased approaches, including medication assisted treatment. One example of that is New Hampshire<\/a> has the lowest rate of medication available to it does not have any Needle Exchange<\/a> programs. Users consistently cite the lakh of prevention resources in the state are perpetuating the opioid phenomena in in the state and some report driving to other states just get access to clean drug paraphernalia. Emergency personnel reported a opioid related diseases, and they say it is not unusual to see the same person come in two or three times the same day. They revive them, and they come back to the ed multiple times in the same day. One of the most compelling things we heard from ed personnel and First Responders<\/a> is they feel like they have little to no options for linking these folks to care. Episode andhe acute there is the continual cycling of these folks in and out of the care facility. We also have many reports from medical personnel reporting spikes in significant medical applications from injections. For example, a cardiac surgeon recently contacted me and reported they have seen a dramatic spike in valve replacements from Infective Endocarditis<\/a> heavily among young injection drug users, who often continue to inject after their openheart surgeries. He contacted me asking if someone could help 100 cardiac surgeons understand what addiction is and how can they link these people do care and not just perform this very costly and acute medical procedure. Fentanyl crisis in New Hampshire<\/a> is occurring in a rural state, and what we hear from folks we interview is, one, they do not feel like there are a lot of other things to do, other opportunities, but we also reports a very tight social networks, which may lead to greater spread of use on long communities. I think together, these data really underscore messages we have heard on the panel here today, which is the importance of evidencebased such as the medical complications, the infection and exorbitant costs of the services. I think that these data also emphasizes the strong need for accessfective models for to integrated care approaches. This is a theme we have heard today, integrating approaches so we can coordinate efforts among Emergency Departments<\/a> and First Responders<\/a> and criminal justice systems. Emergency department providers and cardiac surgeons, they want linkages to services to get these patients help. The criminal justice systems want links to effective treatment resources to help prevent relapse and support recovery. It is clear from the discussion today that this is a time of considerable need and unprecedented opportunity for us to expand Implementation Research<\/a> and really understand the best ways to engage this very Broad Network<\/a> of stakeholders and systems in Effective Solutions<\/a> to tackle this crisis we are experiencing as a nation. In closing, i would like to thank the many men and women who participated in this study and the tremendous insights they have provided. I would like to thank the American Psychological<\/a> association for supporting my participation in this meeting and thank you again to the task force, the opportunity to participate in this briefing. Thank you. Thank you and thank all of you. In the interest of trying to give everyone up here a chance to ask questions, we are not running a clock. But i will ask each member and the four of you in your responses to try to be brief, so hopefully we can get to each person. I will yield my question time for now and ask representative mann if you would like to start. Grateful for your participation. I should really say, your commitment to this professionally and we are all in awe i think of the challenge that we face. I come to this with over 20 years as a prosecutor and that we saw the heroin issue and the cocaine, but that was the tip. Fentanyl is a new degree. One of the things i hear time and time again, and dr. Rising, i think you spoke to this a little bit, is when we confront the families who are looking at this issue, and they dont know where to go for help, and they are struggling with the sense of education. You spent your time talking about education and how to effectively do prevention or other kinds of things that might make a difference. And we are talking about the science here, the science, which can give people a better understanding. I am not sure whether you told me that this was a bridge to a solution, or whether it was simply a solution and treatment unto itself. Can you talk to me a little bit about what we should be doing in the community, who should be doing it, how we can connect people to better understand the science and have an impact on the issue . I would be happy to and thank you for the question. I am happy to see what thoughts my fellow panelists might have. I think we are to some degree, although the Opioid Epidemic<\/a> is not particularly new, i think we are in the beginning stages of understanding the longterm treatment needs that are associated with the Opioid Epidemic<\/a> and more research will be needed on that to understand the length of time for therapies in the right ways to be engaging different people in those therapies. I think the evidence does show that the best time to be engaging people who have Substance Use<\/a> disorder is in the middle, of some degree, a crisis. That is when they are showing up in the emergency room. Something has happened to a family member. Something is really calling the question. There are a number of programs that have taken that approach. Theres one program in rhode e. D. , called angechor which connects people in the emergency room with ppeeer support counselors. They found a fantastic response rate. About 80 of people who they engage in the emergency room continue on with treatment, which is an extremely high rate. Clearly, the interventions need to happen at all points of care. Providers need to be equipped and they need to have data that will really help them understand which of their patients are most at risk and what might be effective strategies. Weve talked to about Emergency Rooms<\/a> and ems providers. I think another challenge is that often local Public Health<\/a> officials may not have some of the data they need to help get their arms around what is happening in their community. I do think there are opportunities to integrate some of the streams of data that might right now exist in desperate places. Description drug monitoring programs, insurers and payers might have information. E. D. s might have other information. Figuring out ways to integrate these sources and really kind of do that hot spot research in order to really understand what is happening right now is particularly important. Thank you. I will make this one quick follow up. Dr. Marsh, you talked about integrated services. Does that include what dr. Rising was talking about . Or is there some other characterization of integrated services . I think it includes what he was speaking about. And i was speaking about just how we have so many people trying to respond to the crisis, so many systems and stakeholders. We could have greater efficiency with coordinating care and providing this cycling through acute care, and linking criminal justice and Emergency Departments<\/a>. Even our schools. You were speaking about the science. Would you answer, are there privacy issues . Hippa considerations . Those are considerations. But they are addressable considerations. I would like to say one more comment. How do we best understand the science . To unscore something the doctor said earlier is the importance of prevention and starting with our youth. We have had an opportunity to talk with many young people who have gotten involved with opioids and we found there are still many misconceptions about the risk of these substances and even distinct perceptions relative to other illicit drugs. Parents dont care as much if you are caught with pills or thinking they are not addictive because a physician described these. And then we see this trajectory we are talking about today that could lead to use, experimentation, and transition to heroin and synthetic opioids. As we think about science, there is a spectrum from prevention to recovery support. Its critical. I yield back. If i may, just one point on treatment because they do want to highlight it. In the treatment, we need to understand that addiction is a chronic disease and that changes in the brain produced by drugs, versus months or years after the person stops taking it. For treatment to be effective, they have to be focused on the chronic model of treatment, which actually leads to a letter patients, or practitioners, to say treatment do not work because the patient relapses. But it is a chronic disease and the concept of relapse is part of the condition itself. I think this is important to highlight, not to create false expectations. We dont cure. We treat. Its not like an antibiotic. You take the antibiotic and its gone. This has to be persistent treatment. Thank you. Representative kuster . Im going to yield to my colleague. Thank you. Sothank you and thank you much for pointing that out, how important it is. First of all, to my colleagues up here for continuing into next congress, keeping this in the forefront. 52,000 people a year die from the disease of addiction. That is more than all the that have killed americans in the last 20 years. We as a country spend over 600 billion a year defending our great nation. Have 52,000 people dying because we are not making the resources available. It is a disease of addiction that we just heard about. You dont get cured. There are two ways of ending this. One is when the coffin closes, or when you get treatment. Im glad we are here today to address the issue. I believe so many of our members know what is going on, but until you attend the funeral of a young man whose parents are looking down at their young son who just died of an overdose, thats when you start to understand the pain that goes on here. Of at went to a viewing young man, a friend of mine, who lost her son. He had been in and out of treatment and this time, he did not get saved. An issuey, fentanyl has and the narcan saves two, three, four, five doses, and it is still not doing it. My question goes first of all to dr. Volkow. The disease of addiction. We are talking about the synthetic heroin, but talk about the disease of addiction. Is there a difference, other than the outcomes and the way you die, alcohol, cocaine, and heroin . It is all the disease of addiction . The answer is yes. The way that all of these drugs specifically change, rewire centers in our brain in such a way that they strengthen certain responses and generate automatic behaviors that cannot be controlled by our front of cortex. Our frontal cortex. It is like when you touch a hot oven and you immediately remove it. Thats an automatic response. The way that the drugs do it is different, and some drugs do it more rapidly than others, like methamphetamine and heroin. As opposed to drugs like alcohol. But all result in this strengthening of these pathways, preferential pathways. And the best way that i can try to describe this to you, because its very difficult to understand why someone would keep on taking fentanyl when their mother already overdosed, is it generates that brain state equivalent to deprivation. It is the sense that it is sending the message that if you dont eat you are not going to survive. It puts your brain in a state of emergency where you will do anything in order to get the drug. Let me follow up. It is not a moral deficiency, the disease of addiction. No. That is very important because when you talk about addiction, somehow it is those people over there. Its not. Its the people everywhere. Dr. Rising, to follow up, in my hometown we have set up a program when a narcan save comes in, they have Automatic Access<\/a> to treatment. And what the doctors are finding is, few if any, will take advantage of it coming out of an e. R. But they are finding sometime later, if you get them at that moment of clarity, it is. , youwe look at prevention talk about those on painkillers, how much time does the average medical student in his four year career of medical school spend on the disease of addiction . Sir, thank you for the question. One thing i would like to add to the previous question fielded is that i think all of those different types of addiction that you referenced all have very good evidencebased therapies available. I think regardless of what the addiction is, the medical profession does have resources it can bring to bear. And i think your point is a great one, in terms of first making sure that those points of contact, be they in an emergency room or another place, are not a onetime kind of contact, where we reached out and it did not work at that time. Efforts to engage people into treatment need to be ongoing to make sure that that touch point occurs when an individual is ready. I havent seen the stats recently as to how much time. I think it is slightly more than when i was a medical student. How much time did you spend . It was not a lot of time. When you look at the scope of the disease in the United States<\/a> currently, i think there is a broad need to look both at schools, continuing medical education, and other ways to engage the profession and this going forward. Nobody likes to tell the doctors what to do, but i think we can give them a good clue of what is going on. Speak it outted to of it. One as an emergency medicine doctor who works this the state in which he represents. We looked at we called 111 medical schools out of the 163 and we found on average, there was less than one hour dedicated and addiction. Can you repeat that . After calling 111 medical schools, we found the average of didactic training was less than one hour. As a boardcertified emergency medicine physician who trained at a good program in philadelphia, i did not add to that in that training. My board certification in addiction came very far after my training in emergency medicine, which goes to the reason that when patients go to the Emergency Department<\/a>, they leave not wanting help because they dont know how to give it. When you are in withdrawal and you say, here is a phone number, good luck, it does not work. The 30 day mortality rate for someone who shows up to the Emergency Department<\/a> status post overdose is actually higher than that of someone who shows up and we miss a heart attack. Yet, if somebody comes in with chest pain we admit them to the hospital, they get an echocardiogram, they get a stress test and they see a card cardiologist. We call them with three nursing calls within the next 30 days. What happens to the addict who shows up to the Emergency Department<\/a> who feel like they are dying in withdrawal. They get booted out with a phone number. We have to be honest about the actual treatment taking place in the Emergency Department<\/a> and it is not patient centered and compassionate. And this happens all the medicine. In primary care, less than 10 of primary care doctors screen for addiction on a regular basis, yet greater than 75 write prescriptions for opioids. 75 ready prescription for opioids on a regular basis . Have a dea and prescribe opioids on a regular basis. Yet less than 10 routinely screen for addiction. S. Is no better for obgyn we can help that mom and get these babies out safely and back with the mom. There are a lot of things we can functionally do right now that we are not doing. I want to yield back my time, but i did make the suggestion, that would be a great topic, medical education in general. Thank you, and i yield back. Thank you. Representative schneider . Thank you. And i want to thank both of you for calling this hearing. The witnesses, thank you for being here, for sharing your expertise, sharing your experience for what is a growing problem and we are seeing it throughout the country. I will emphasize its not just rural. We are seeing it in the cities. In suburban districts like mine. And it gets worse year after year. You emphasized the numbers and the investment. Dr. Volkow he talked a bit in your remarks, clearly, the best way to fix the problem is to keep it from happening. Prevention is the best way to address this problem at the front end. Other programs that are considered most effective and more broadly, what are the barriers to getting those programs that are effective more in use and more prevalent . We have a significant number of researchers to develop prevention efforts for drug use in general. And what that research has shown us is that the strongest evidence comes from prevention programs that are initiated early on, in children and adolescents, and those that engage the family, school, and community. These prescription Opioid Epidemic<\/a> and the associated heroin and fentanyl add a different wrinkle because we are seeing people who have never been exposed to drugs becoming addicted in their 30s, 40s, and 50s. The issue of prevention there requires something that was mentioned before, the importance of providing education for physicians on the proper prescriptions of opioid medications because we have gone from basically what, 50 million prescriptions a year of opioids to 250 million prescriptions since 2000. But we did not train physicians. And there was in turn, a big propaganda to actually educate physicians that these prescription opioids were safe and were not addictive if you have pain, which is incorrect. An important component of prevention right now is provide better education on the proper precipitation, on the proper use of prescription you know its on the one hand of prescription use on the one as was discussed before, they get one hour of education. If a physician doesnt know to recognize that their patient who they are giving a prescription opioid is addicted. They are not understanding withdrawal and physical dependness. Not to say what to do if that patient is becoming addicted. Even though it doesnt sound high technology, training and education is probably one of the most important prevention efforts we can do right now. Theut if i can, barriers, and that is using that as an example, training one hour over the course of four years in medical education, what are the barriers to getting more training . Whether it is at the Foundation Middle<\/a> school level or continuing education over the course of a career. Why it is not happening more . It is not happening because what you get our complaints from the medical schools, they already have a very loaded curriculum and they cannot incorporate more classes. One of our strategies have been to negotiate with the organizations that generate the exams to get your medical the grap degree to put questions on Substance Use<\/a> disorders. And that will motivate the medical schools to do it. So working with these organizations to put these questions, as well as on specialty treatment problems. Sorry to take your time. I know we are limited on time. Other thoughts, comments from the rest of the panel . There is push back from the Major Medical<\/a> societies on mandated education. Thats pretty well documented in your offices on a regular basis. So, i think just continuing to push forward for at least a minimum standard mandated knowledge base. If you can document that you got it in medical school, great. If you cant, you need to get it at some other time if you want a dea license. Dr. Marsh. Two comments. As dr. Volkow indicated there are a number of effective drug treatment programs. I think there is also a need for Additional Research<\/a> with effective prevention of opioid use in particular because the complexion of this is different and there is a growing scientific literature that shows that risk factors particularly among young people may differ from risk factors for other substances of abuse. I think thats critical. In addition to the training and education initiatives we have spoken about, i think there are opportunities to think about more scaleable models that can build on that. Work force development and person delivered trainings alone might not meet a scale. There might be an opportunity to leverage technologies in other ways. Digital technologies, social media approaches, to take sciencebased prevention and promote more scalable widespread axis. Dr. Rising. One thing to add to what my fellow panelists have said and i think if you were to look at a number of providers who were out in the Community Already<\/a> who might not be providing various treatments for Substance Use<\/a> disorders, i think a major barrier is that this is a very challenging issue for providers to deal with in their office, especially if they feel there are not a lot of communitybased resources or Treatment Facilities<\/a> to be able to engage people who need the treatment. If you are on your own, this is certainly a daunting field to enter or to feel like you can make a significant contribution. So, strengthening those Treatment Facilities<\/a> and having providers feel like, yes, i can understand. I have some options when i identify somebody in my waiting room with a Substance Use<\/a> disorder. That will go a long way in driving demand among active practitioners to become more engaged in Substance Use<\/a> treatment. Thank you and thank you to the panel. I yield back. Representative frankel. Thank you and thank you to our chair into the panel. Im lois frankel. Im from florida, south florida. And we have somewhat of a unique situation which many of you may be aware of because now this puts and this is why i think its so important to have federal intervention because a lot of our addiction issues are coming by way of folks coming from, lets say New Hampshire<\/a>. No slight to New Hampshire<\/a>. I am just saying we have become the treatment, like a treatment capital of the country. While there are many good programs, there is also, i will tell you, thousands i am not exaggerating thousands of what they call sober homes and treatment programs that are not doing the right job. And to put this in further perspective, this is not today we have been talking about patients. Im not going to i think you y describe somel of these issues. Keep in mind that this is also affecting community resources. I will give you an example. Palm beach county, where i am from. It is about 1 million and a half people. We had 4000 calls that our firefighters had to answer to for Drug Overdose<\/a>s, at about 1000 a clip. Start to add that up. We had a hearing i had a hearing a couple months ago and one of the issues that came up were the firefighters were being traumatized themselves because they were having to treat so much so many people who are dying. Think so, when we talk about trying to do something about this, it is not just for the patients and their thes, but all doctors, the paramedics, the communities that are having to grapple with this. My question is, and i am not sure if you can answer it, but where are these synthetic drugs coming from . Are they coming from outside the country . The understanding is that most of the fentanyl is actually being diverted from china and is actuallynyl that is produced in the United States<\/a> for pharmaceutical purposes. It is generated in the black market. So, i had a conversation with my local folks, and and actually, that was one of the by one oft was raised the local officials who had been dealing with this. I want to bring this to the attention of the chair here. Could we start to put some pressure on china to try to stop the trafficking of the fentanyl . Two you know whether there has been any effort in that regard . Do you know whether there has been any effort in that regard . My understanding is there has been definitive efforts to try to engage china to minimize the production of these fentanyl from the black market, but im not the Agency Behind<\/a> it. We can provide you the exact information. Mother my understanding but my understanding is, they are. Thiswould request that could be something i dont know whether the task force has looked into it, but if not, i would request that. Sure. I yield back. Do you have a question . Sure. Thank you very much. You have all been so informative and it is very helpful for our colleagues who are coming up this at different places in their educational process. But it occurs to me, and im going to move on a little bit from the fentanyl. But just to some of these bigger issues, years ago my mother had alzheimers disease. And so we did a deep dive in our family on alzheimers disease. One of the conclusions i had is that there is something in our society about Behavioral Health<\/a> issues that americans assume that this is intentional. And what we learned as the alzheimers progressed is that indeed, the behavior was not intentional. And i feel like we are at a very similar place with Substance Use<\/a> disorder in that we assume, and this story in particular, dr. Marsh, that you told is so stunning and striking, that a young woman who has watched her own mother overdosed and die, watched her brother overdosed 17 times and yet, those of us in the room and indeed, the medical providers at the emergency room somewhere in the back of our brains think, how is she acting that way . Why is she acting that way . Has beennk dr. Volkow very helpful to understand the science of the brain, that this is no longer intentional. Frontal lobe is not making the decision. There is a different place in her brain that is survival instinct based thats making a terrible decision. But i have to step back and say to the medical community at large, first do no harm, that the medical community, by receiving people in the e. R. Over and over and stabilizing the patient and sending them home to overdose in the parking thats not reasonable behavior either. It is not logical. It does not make any sense. For us to try to unravel, it has to do with the incentives. It has to do with the lack of coverage. Lets be candid and honest in this conversation. If they were paid the way they are with a heart attack to send the person upstairs to a room, to follow them carefully, to do home care and send someone home to make sure we check on them, we would have much greater rates of success. Hampshire, we are looking into where people fall through the cracks and bringing the hospitals and the Emergency Rooms<\/a> together. I have been at my roundtables where the people in the Emergency Department<\/a> are not having the conversation with the people on the fifth floor in the administration to have this conversation. So, now we are bringing everybody together. Now we are bringing the Insurance Companies<\/a> to the table. The federal government is going to decide medicare, medicaid, what are we going to cover . That is the conversation that we need to have. Instead of saying, that person deep in the throes of Substance Use<\/a> disorder is not acting in a rational way, we turn the finger around and say, this person, whether it is a policymaker or an emergency room physician, or a Hospital Administrator<\/a> or an insurance company, we are not making rational decisions because we act shocked that they show up again. And so, i really appreciate all of this perspective. And i hope with the folks tuned in on cspan, with our colleagues and staff in the room, that we can help to educate because we are so siloed. Every step of the way we are in a silo. We do our part with our widgets and medicine is no different. We have got to figure out a way to broaden that conversation. I thank you for your work and research because we need to have evidencebased information. Hank the rest of you for translating they were, the understanding you have into the society at large and back to the policymakers, so that we can make rational policy because we have already discovered on this task force irrational policy. We have already discovered we were rewarding physicians for pushing opiates into the community and then we are shocked that that did not work out well. So, to get to the question, i would like to follow up on this programs, oron and evidencebased research that we could do or should do, to give physicians an alternative. Pain is real. I have had surgery. I know pain israel. How do we help the physicians and why do we have such a gap between tylenol and full on opiates . Because now we know, i think one in 15 is the evidence we that willof patients be ending up with a chronic opiate use, but 99 of the patients getting surgery are getting opiate medication. If you all know, if anybody could weigh in and what could we be doing to help with alternative pain remedies, whether its different medication, and whether there is Evidence Based Research<\/a> on other types of pain relief . Im going to be candid with you because i think that the issue that you are bringing up is one of utmost urgency. The reality that we dont have many alternatives for the management of severe or chronic pain. And there has been a big advance. The cdc recently last year had new guidelines in which they emphasize the need to actually limit and curtail that number of opioid doses that will be given to a patient. Ideally, not more than three days. So thats a very dramatic change in the way thats the new cdc guideline, ideally, not more than three days. Correct. And the other issue that they highlight is in the management of chronic pain, prescription opioids are not the panacea. You become tall and very rapidly, meaning you need higher and higher doses to relieve the same pain. That increases your risk of overdose and of addiction. And if they are not actually there are very few trials that have shown that they are effective in the management of chronic pain. Overall, the evidence is lacking. The cdc says, it is not that we are saying you should never use an opioid for chronic pain. But it should never be the first option. And it should only be used as part of alternative treatments for the management of pain. So, in a more integrated approach. You said it. Are we covering for those more integrated approach for the management of pain . Not necessarily. Its much more expensive. So, it is easier to prescribe an opioid. Changes,tructural structural issues that we need to change in order to also allow physicians to do the right thing. Yeah. And there are alternatives to the management of chronic pain. They are neither the panacea. Obviously as a Government Agency<\/a> at the nih, we are investing resources in developing new medication for management of pain, as well as nonmedication all strategies. But an area that could help enormously is incentivizing the pharmaceutical industry to invest in this space. What happens is if you are selling billions and billions of 250 millionioids, prescriptions. What is your incentive to actually develop a new medication that is going to come compete with what you are already selling . Need tothere is a incentivize, just like we have done in other areas of medicine where there is an urge, like there is now, to develop new medications. We have done it for vaccines and rare diseases. There is the need to generate something that will incentivize pharmaceuticals to get into this space so we can provide for better treatments for patients dealing with chronic pain, which can be devastating. I will put in a plug for legislation that i introduced last cycle and will bring back again for consideration by the task force and by our colleagues in the congress for a pilot project. Fromwas mr. Kaufman colorado and myself coming out of the Veterans Affairs<\/a> committee. It is in white river junction, vermont. A doctor named julie franklin, who was working with veterans with chronic pain. They were taking very high doses of opiates with no Mental Health<\/a>. They had not dealt with ptsd or anything else. One gentleman i met was taking 160 pills a month for long periods of time. She took this group and had a clinic on alternative remedies. So, acupuncture, Mental Health<\/a> therapy, physical therapy, wellness, mindfulness, yoga all these different things, and she was able to reduce the use of opiates for chronic pain 50 and had much better outcomes. People felt much better. They were much more active, much more able to participate in activities of daily life. Kaufman and i are trying to scale that up both but hopefully. , get evidencebased results that could then go out into the community. So, i will close, but if anybody has anything to add. Two quick things. One, back to the 111 medical schools. They only had 1. 2 hours of training in pain on average. Less than one hour for addiction and only 1. 2 hours on average for training on pain. So, they dont study either one. To try to onboard different modalities of treatment, to your point, the best literature for the treatment of chronic nonmalignant back pain, which is one of the most often seen complaints in a primary care office. The two things that have the most amount of literature behind them, randomized control, cochran level database stuff. The things we go to and say, we should apply this to everybody. They are yoga and mindfulness. The fact that we have this mountain of literature that shows that these are the things, yet physicians and p. A. s and a Nurse Practitioners<\/a> are not trai ned in this. The first thing that they get is a prescription. That is problematic because that one hour i lived it in my family ath chronic pain and now, series of surgeries that a relative who has been on opioi tes since september 11, and now is challenged by dependency. And so, it is very, very frustrating. I cant tell you how siloed having gone out there and spent a week, if i could, personal privilege, being literally in the appointments with the surgeon who, fabulous surgeon wants nothing to do with this. Literally just came out right now and said, not our problem, you will have to deal with that after the surgeries. Meanwhile, the Treatment Professionals<\/a> dont want anything to do with the surgery, saying you can die of the drugs, but you wont die of not getting the surgery. I am just like, ok, is there anyone in this process that can help us navigate how to get this accomplished so that this person who we love so much can get back to their life and be productive . And the stigma at every step of the way, the stigma is so great. Instead of, you know, wow, lets call it cancer. Lets give it a different name. We will try to help you with your problem. So, thank you for that moment of personal privilege, just to say that i really appreciate the work that you are doing. Well, thank you. I had a couple of questions. And i appreciate all of your testimony very much. Frankly, it raised more questions for me than answers, but it did answer a number of things. I found a number of things deeply disturbing, actually. I want to get my mind around how we can help to improve some of these areas. But i just want to clarify, dr. Volkow, you talked about the physiological changes to the brain that occur when somebody is using opioids. D,. I want to understand those better. I lost my mother from cancer. We all know that if somebody stops smoking, maybe they cant totally reverse the effects of years of smoking, but it gets better. There is improvement. We all know that if you cut off your hand, there is no im test test test. Test test. Occur to the brain that are irreversible. And i wanted to ask you to unpack that a little bit more so that we understand what happens to the brain and over what period of time, and what can be returned to some normalcy over time and what cannot be . I am glad you are asking me that question because i did not imply they were irreversible. I implied they were long lasting. In fact, what the evidence show is that while it is frequent to see relapse in people that are addicted, the longer that they sustain the treatment, the scarcer, the more rare it does occur. For example, the best outcomes are reported one patients are on chronic treatment for five years, at which time, they lives where lead they can recover. That means that you can get back to your previous state. But there is a level of vulnerability, but the rain recovers. People recover from strokes. We do interventions to maximize the likelihood that you can strengthen those areas that have been damaged. The same thing we should be addressing for helping those people recover those systems that have been damaged by drugs. Yes, the brain can recover. The extent to which it can recover will depend on many things, how addicted you are, your age, when you started taking drugs. But the evidence shows that with proper treatment, people recover from addiction. Ok. Thank you for the clarification. I want to talk about education a little bit. And dr. Waller, you talked about one hour in four years for addiction education, 1. 2 hours in four years for pain management. I listened to a program a month or so ago. I forget the womans name, but she was the head of the Addiction Recovery<\/a> center at stanford university. And she was speaking at length about pain management. And how the whole american view of pain and the need to manage it, eliminate it, has fed into the opioid crisis. And it really got me thinking and i was thinking of it today as well. We cant fix everything in congress. We dont tell medical societies how to teach students. We dont regulate that. And neither should we. There are we are not physicians for the most part. But there are times where theres a federal nexus with Health Care Issues<\/a> and we do get a lever that we can use. And i guess my question, to you in particular but ill ask all of you, what are the federal levers . Where, to your knowledge, do we license at a federal level . Do we do things at the federal governmental level that might allow us to exert more pressure entities,rnmental with regard to how they train physicians . Thank you for the question. And thank you for really having the ongoing thoughts about this. It is a complicated problem and we are all dealing with it in different ways. The federal government has one place in which it holds a pinch point for every prescribing physician in the country, and that is at the dea license level. We are required to fill out paper workof and pay 350, but not have any additional training to our medical degree to write for medications. I think that is one of the levers that we really have to start looking at how we would phase in, a you need to earn that dea certificate. Whether it is at the medical school level, or for those on the outside, you have two years to complete a certain number hourstinuing medical specifically dedicated to the and schedule iii drugs. As big of ang issue as it is with benzodiazepines, the vast majority of heroin overdoses are in combination with a sedative hypnotic, which is in combination with a benzodiazepine or alcohol, or another sedative with it. Doesing it again in a silo not allow people to cross a valuate what they are doing. At the dea level, thinking long and hard about what you should have to know to earn that license, because we are talking about in medical school we talk about how we are full. On every test i have taken, there is always a question about a rarelled a crumb i german. It is a once in a career tumor. Its on every test i take. I think that could take a little less time in my education through this. Especially when the number one cause of injury related deaths in our countrys Drug Overdose<\/a>. I had three lectures from the National Traffic<\/a> safety board as an emergency medical residency on car accidents. I can tell you what an a pillar does, a b pillar does, and a c pillar does. I have had those educations, but car crashes kill fewer people when Drug Overdose<\/a>s. Federally, you dont have to look far. They are controlled substances and they are controlled by the federal government, by a license i am privileged to have from the federal government so i can affect positively peoples lives. There are 100 different ways, but i think that is the biggest one that you have right now that is purely a federal lever. To any of the rest of you see any other . Hi, yes. A couple other thoughts to share. Certainly, i think it is important to improve provider education, as we have all talked about the deficiencies here today. However, also providing the education does not necessarily get to the end results we are looking for, ensuring that it is quality education and that providers then are able to act differently and provide Services Better<\/a> as a result of that education. So, other tools that might be available to get at that root question of what we are trying to assess and encourage. One is the use of quality measures, which are used widely across health care, but really we dont have once that have taken root when it comes to the treatment of Substance Use<\/a> disorders. So, there could be some opportunities to encourage the development of some quality measures in that space. And then there are other ways to look at the services and referral that places are able to provide as part of the ongoing relationships that both medicare and medicaid have with various health care facilities. I just have to say, with regard to quality measures, that is actually one of the inadvertent, unintended consequences that got us into this situation. I am glad you brought it up because we could use it to help get us out. But this is with regard to physicians were judged based upon the patient satisfaction. The federaly government was reimbursing based upon patient satisfaction. And so, i think, it does not take much to make the leap that surgeons had done a fabulous job with the surgery. They were not going to get paid less from somebody whining about the pain and they said, 30 filled, take 60. 60. 0 pills, wait, take let me give you 90. And i think that got us into this. Again, a piece of legislation, this is one we will be bringing back to make that change, so that physicians will not be pressured into, or feel pressured, into increasing the medication for post surgery pain medication. That wasanother bill included, we did partial fill because many, many, many patients, if not the vast majority, are going to be fine i did not know about the cdc three days but you know, five pills, six pills, gets you through the weekend. And by monday you are going to be feeling much more comfortable, rather than sending every patient home with 30 pills. I wanted to add in response to your question about federal levers, i wanted to add two. One is related to research and the second is relatedto scaling up the application of science to Service Delivery<\/a> models. The first one with regards to research, i think we have discussed today that there are a number of effective prevention models. There is a tremendous opportunity to scale up their utilization in realworld places of care. So, and understanding, how do we create systems that promote the create systems that promote the maximally captions Copyright National<\/a> cable satellite corp. 2008 is where we have this large amount of resources have been allocated to expanding Service Capacity<\/a> across the whole nation through the care act and we have a half Million Dollar<\/a> this is year slotted for that. It seems like a tremendous opportunity as we embark upon this as a nation to ensure that what we know works best from the science is actually whats incentivized, what the states are encouraged to adopt and also to have a scientific model wrapped around evaluating that. If were going to invest in this kind of resources into this National Implementation<\/a> strategy for expanding Service Delivery<\/a>, how do we know it works . How do we know the impact of that investment . So i think those are key as well. The research and linkage of research to Service Delivery<\/a>. Im going to make another point because i think it behooves us recognizing how devastating addiction is to know yes we do have medications for that treatment of opioid use disorders, methadone, a lana th zone. Thats three. They are useful but not many patients necessary will i respond to that. Highlighting the need of research that can lead us to alternative treatments is like we are dealing with a psychovirus. What do we do . We develop vaccines. What do we do . We develop medications to address it and we do it urgently. We have not done that for addiction and the amount of investment that goes into the space of development of medications has been restrictive. And yes im grateful for the medications we have been able to develop thanks to the government but i recognize it is important that we continue to strive for alternative treatments so the patients have the greatest chance of survival. That lack zone. Naloxone. Addiction the a serious disease. We should treat it with the the priority that we treat other conditions. And hopefully do no harm and have fewer people headed into that. It breaks my heart. Four out of five people suffering from Substance Use<\/a> disorder started down that path from a Prescription Medication<\/a> from their physician. I didnt think of anything else like that in our society, in our Health Care Delivery<\/a> models. So thank you. I want to say we are going to have subsequent hearings that the next hearing will be hearing from some people that have implemented models in New Hampshire<\/a>, safe station you might be familiar with it of trying to help people get the help that they need. We have very promising results coming but we could also consider a hearing on ways that we can move forward to adapt adopt the models that youre talking about. I want to thank all of you. Its been helpful. Youve given us a lot to think about. As we consider future hearings, what youve given us today will help us. Our object is really to shine a bright light on this issue, to educate our colleagues, to bring order out of a lot of Different Directions<\/a> congress can go and members introduced their own legislation at their own with their own counsel but we want to try to make our efforts in congress comprehensively deal with whats in front of us. What we did last year was helpful but its not enough so i want to thank you for helping us in that. I want to invite you, if you have further thoughts, doctor, you mentioned there might be a hundred levers. Careful what you ask for. We want to get the best advice that we can and if you have further things you want to suggest to us, reach out to our offices and let us know and youll do a Great Service<\/a> to the American People<\/a> as you do it. As was mentioned, we have another hearing scheduled february 28 at 4 00 p. M. Representative custer will chair that hearing and we will hear from families that have been affected by the crisis and that will be difficult but well be able to explore with them just how that progressed in their lives. So i thank you. This hearing, this round table the at an end. We appreciate you being here and were adjourned. Thank you. Were live with the Governmental Affairs<\/a> subcommittee at 10 00 a. M. Eastern on cspan 3. Sunday night on after wards, melissa fleming, chief spokesperson for the United Nations<\/a> high commissioner for refugees recounts a young syrian womans to europe in her book a hope more powerful than the sea, one refugees incredible story of love, loss and survival. Shes interviewed by the president of refugees international. How did things develop to the point they felt they had to leave . Well, this is 2011 and the arab spring is happening all around them and theyre turning on the televisions, all kinds of average families in syria are living under an oppressive regime but they have homes, they have livelihoods, they have health care, theyre going to school, just going about their day to day life. This family in particular was not politically active. It wasnt theyre caught up in this excitement about actually the other countries around us are changing, maybe things could change here and demonstrations are starting in the streets and doah, who is then 16 years old, is inspired to see whats happening and she witnesses Peaceful Protesters<\/a> are shot at. Sunday night at 9 00 eastern on after words. Next, wyoming governor matthew mea matthew mead delivers the state of the state address. 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