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We are looking forward to a year of trying to make more progress on an issue that is of great concern to all of us. Just a recap of last year briefly. Last year the comprehensive addiction and recovery act was passed by the house and senate and passed into law. It provided with resources to address the opiod and heroin epidemic. We passed the act at the very end of the 114th congress. It added an additional 1 billion of funding to combat this epidemic. The house rolled out in the course of one week 18 bills last year that really became the foundation and much of the detail of what ultimately was passed into law. There is still a lot of work to be done. Last year over 52,000 americans died of a dress overdose, 52,000. 33,000 of them were opiod related deaths. Thats hundreds of people on any given day that are dying. This week is just beginning and we lost people already. First we educate members of congress and issue of affordable and effective treatment, Law Enforcement issues, etcetera. We serve to make sure that the funds that have been apropuated get spent wisely and local stake holders know how to apply and access those funds. These drugs have potency greater than heroin. They are using chemical components from china and elsewhere. They are being produced an aan and distributed here at home. It includes Law Enforcement, border trafficking issues including the flow of from china. The Public Health and treatment concerns that uniquely present. It couldnt be a more urgent topic for this task force to start with. I want to thank our four witnesses. She is the director of National Institute of drug abuse. Dr. Corey waller is the Committee Chairman society of addiction medicine, a new jersey native i want to thank for being here. Dr. Josh rising is from the knew charitable trusts. Lisa marsh of center of technology and Behavioral Health. Thank you for being here. We are eager to learn from you. Before us we have dozens of years of incredible experience on synthetics. It 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 New Hampshire likes to be first in the nation for. This is not one of them. I wanted to mention that when my former colleague and i started the Task Force Last year we knew that New Hampshire was a hot spot for dangerous opiate use. Often the user does not realize the drug they are intending to use has been contaminated with fent fental. They are much more powerful and we need to know what we are dealing with so that we can come forward with policies to help Law Enforcement to help get people into treatment which is something well be working on. It requires medically assisted it could have sweeping implications. I know from people when they to get treatment have difficulty accessing treatment for many reasons. We are looking forward from witnesses and i appreciate the work we do and we want to work with you to make sure we are doing everything we can to give you our Community Stake holders what they need to help people get well and become productive citizens of our community. Thank you very much. Well ask if each of you will make opening remarks and well hold questions until all four of you have spoken. And i want to first thank the task force for taking a leadership role that is in urgent need of resolution. I want to thank you for the opportunity to testify. It is an agency that is involved in doing research and generating knowledge that can help us address problems like the current epidemic we have that has lead to synthetic opiods. It is devastatidevastating. Those that are becoming addictive. The numbers speak for themselves. In 2015 there were more than 2 million americans that suffer from opiod use disorder most of these cases we really dont know because many of the new synthetic opiods cannot be with the current method. So when someone die and they dont necessarily know whats in there it wont be necessarily reported as synthetic opiod. Some populations have been and we have to recognize one of the issues is how it is inflicted by the epidemic. I think some of the numbers in the areas. They are abused because they target the opiod receptors. We have networks involved with pain, which is why these medications can be extremely effective and can be life saving under those conditions. We also have receptors and we also have them in areas involved with regulation of breathing and thats why they can inhibit those. What makes not all of the opiods the same, some of them are more p potent than others. We have vicodin. It is estimated to be between 50 and 100 times more potent. The new synthetic drugs that we are hearing about is estimated by some to be 50,000 or 100,000 more potent. You can absorb through rest pir ration. These are extremely dangerous drugs and they also pose an enormous challenge as it relates to diversion. Bringing heroin from other sources requires a much greater volume of drug that if youre breathing phentanyl. So from the perspective it is also a nightmare. One of them is the enormous number of people in the United States that suffer from pain conditions. Physicians started to rely on the use of opiods for treatment of those pain conditions. At the same time there was a market. It resulted in a massive ov over prescription. So these all of these combined to generate the massive increase in prescription which facilitated its die versiversio later in heroin because it became harder to get access on medication on people who become addicted. They transfer to heroin or other synthetic drugs. We need to recognize at least for heroin 80 of those heroin abusers started taking prescription opiods. If we want to address the issue of heroin we need to address the prevention and treatment of those and we have to prevent them during the transition. We have those that are prescribed opiods. Thats a group of patients that require a slightly distinct interventi intervention. So what do we do as it relates . One of them is the most important intervention that can reduce prevention. As it relates to research what are most effective in actually averting people from becoming dependent of prescription opiods . What factors relates to the ability and the other is of course treatment. In treatment we have to address the issue of number one, to first of all, we can always i always like to think about science in two ways. We solve problems right now. People are dying. We cannot afford to wait. We do science so we can solve it in a transformative way. I think it is how do we implement very effective in interfering with relapse and very effective. They are not being used. Less than 40 of individuals being treated for app opiod use disorder do not receive these. Why . One is lack of sufficient infrastructure to accommodate. It would improve your incomes and outcomes with relapse at three months by close to 80 . Implementing are working to make up a difference, taking advantage of the criminal justice system. We have shown if you use extended release you can actually prevent their drug use and prevent overdoses. We have strategies that will maximize resources. The other element that is very important to recognize, and i wanted to end up with this is the urgency of developing the management of pain using medications that are much less dangerous. Theres a whole space. At the end of the day the only way well be able to do it is to Work Together. So because of all of these i want you to find the opportunity for being here with you today. Thank you very much. Thank you. I really appreciate the opportunity to come and speak about this. It is something i have had to deal with in patients as well as in research. I have this reality of try to go teach you guys everything about the pharmacy and therapeutics aspects in seven minutes. We are all going to be physiologists shortly. Here we go. I want to make sure we settle on some terminology. I think one of those is potency. We need to know what we mean by that. It is the degree to which any chemical turns on a cell relative to another chemical in the same class. What that means is that morphine is our marker. We use morphine as the base. One milligram of morphine equals about the same as 1 milligram of hydrocodone. About 5 milligram equivalence in that one pill. If we were to look at that we have to look at that as one of the pieces and the other is how fast does it get to the brain how addictive it is and how fast does it impair someone who takes it . How fast it gets to the brain are the two aspects of the drugs that have to be thought about if we are trying to compare and contrast each of those. I want to put the mark ordinary reason that. If you take morphine of 1 milligram heroin is four to five times more potent. If someone has 5 milligram hydrocodone pill it is like taking five of those if you put it in the same one. We go up by five thoon onon tha if we move to things like one of the synthetics we are finding out on the streets, because we use that in the hospital, thats a thousand of those pills. If we go up to carphentenyl it is a thousand shoved into a small single tab. The difference between getting high and dying is the difference between one grain of sand and 3 grains of sand. You can see where the mistakes get made. So when they receive it and they generally get this, which is one of the synthetics. It doesnt mean its different so we can make codeine from that. Heroin is a semi sen thetsynthe. It is a wonderful medication when used properly. I used it regularly. So it is a really useful tool but very predictable. It is a medication that if i give you 100 micrograms, if i give you that i know how long it is going to last. It is really useful in that setting. If you dont understand that extra few micrograms is a very small amount, when we start to go down in that that little extra would mean a patient who is comfortable and one that i have to put a tube in to breathe for. That little bit of difference, if you dont understand the chemistry of these is really important to understand. To underscore the reality of what it offers to us we do have experience with this and devastation we have they just got the dose wrong. And so this is something that we look at. I mean when you talk about danger, and i talked with Law Enforcement. I was the director for a s. W. A. T. Team in michigan and worked with protective service in a number of capacities, this is one that if you go in there you can have a number of officers down. It is a dangerous medication in the sense that it is so potent that a small amount of it could make a massive difference and the difference between im getting high and im dead. This moves us into this other piece. What do we do when we find someone that used it . We are not really able to know. If someone comes into the Emergency Department and i test their urine because they overdose we dont test it for all of these other deriveties. It is not just the ones that i mentioned. We dont test for it, so we dont know. These patients require reversal agents at a much higher rate. If someone overdoses on heroin i can give them. 4 milligrams, a small amount to wake them up, not put them into full withdraw, allow them to get where we need go. For someone who overdosed on the d deriveties it could take up to 23 12 milligrams. An average ems truck carries eight total before they have to restock. So we are looking at an incident where we can have ems there. They can give you all of their medicine and it may not be enough to reverse it at that time. I dont know if any of you ever heard of blue light. It is a forum drug users will have conversations back and forth. I would kind of disagree based on some i have read from this. They will actually try to the batch by starting with 25 micrograms and moving up slowly in dosing to try to figure it out. The batch that they get you can never predict what the concentration is because they are not buying it the way that a laboratory would buy it. Because of this difference between 100,000 if you have that extra grain of sand and you dont know what it is and youre trying to spike your heroin then what you end up doing in indiana and northeast where we have had groups of people in small areas over two or three days dry rapidly. That bad batch was a chemical miscalculation. People will ask why they use these drugs. I get asked why would you use something that would kill you . Remove the fact that addiction is based on behavior that follows a lack of logic in the normal pathway as we would see it. It is because it shuts off the connection between the frontal lobe and portion of the brain for survival. They wont go through a pro con list of what they will do next. So when we have that when we have that set up with someone who doesnt know how theyve mickxed these drugs, thats a recipe for disaster. If they are on the long ive acting injectable, they know they can use these on top of those, still get high and not be detected. So this is a way in which theyre trying to overcome some of the efforts of treatment and me as a treatment provider will have difficulty identifying that theyve even been on it. They may look in their urine like they havent taken anything because these arent checked for. These are i guess the best way i can talk about it is really if somebody doesnt know that theyre taking 100,000 pills in one, then thats a real risk for them. Thats where this comes down as far as how potent these synthetic drugs are. Thank you for your time. Thank you. Dr. Ricing. Representatives, members of the Bipartisan Task force, thank you for inviting me to participate in todays discussion. Its a privilege to be here with you and my accomplished fellow panelists. My name is josh rising. I direct Health Care Programs at the Pugh Charitable trust. Our injeproject focuses on supporting policies that will reduce the inappropriate use of Prescription Drugs and expand access to evidence based treatments for people with Substance Use disorder. Im going to be focusing today on the second element, access to Effecti Effecti effective treatments. Weve all familiar with the epidemic as he talked about, the number of opioid related deaths continue to rise with 33,000 this past year. In addition toe the risks of overdose and death, chronic use of opioids have other negative Health Effects including an increased risk for heart attacks and increased risk of acquiring hiv and hepatitis c. Additionally elicit drugs cost the United States around 193 billion every year. Largely related to lost productivity and interactions with the criminal justice system. We cant and shouldnt ignore the impact on children either. Many state officials have recently made a direct connection between the rise in the use of opioids and the rise in the number of children in foster care. As if addressing the Opioid Epidemic was not challenging enough we now face opioids such as fentanyl and a designer drug known as pink. The use of these drugs has already had significant consequences. In the past year the number of deaths from heroin and synthetic opioids rose from 20 and 70 effectively. We need to take a comprehensive approach to prevention and treatment and pursue up streeam solutions wherever possible. Most people with Substance Use disorder do not start out using these substances. One study found out four out of five started using prescription pain relievers prior to using heroin. One critical part of a comprehensive approach is ensuring access no narcan which saves lives by reducing overdoses. Substance use disorder is a treatable chronic disease similar to hypertension or diabetes and the exact course of which may very for any particular person. Medicated a sichlted treatment or mas it the most effective for the disorder. Whether dependent on heroin, Prescription Drugs, fentanyl or any combination of these. All opioids respond to the same resept tors in the brain. The tame treatment approaches will be effective regardless of which opioid someone has used. Mat combinesed uses fda has approved three different meds to treat the disorder, methadone, tracks own. The right med kaication 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. Behaviorial therapy can include individual or group koublicouns and other intervention. Research has borne out the benefits. It reduces the risk of overdose and death, reduces the amount of elicit drug use. And allows people to return to the works force. Studies have shown every dollar invested in treatment returns 7 or more according to estimates. We also know that access to treatment is inadequate. Only about 10 of people with Substance Use disorder received any type of therapy in 2015. Now imagine if only 10 of people with diabetes or high Blood Pressure received care. We know this is an incredible challenge. Its a medical and Public Health crisis. So what are the solutions . Well, theres no magic bullet. But congress has taken some actions already. Specifically i would like to thank congress for first of all passage of the comprehensive Addiction Recovery actor cara. Cara advanced new policies such as reducing prescriptions and new and enhanced grant programming. Second, the recent appropriation of 500 million. This money is provided directly to states to strengthen prevention treatment programming at the state and local level. We would like to recognize another opportunity for congress this spring to take action by appropriate iating the additional 500 million for prevention and treatment that were authorized. There are Additional Solutions 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. Ensuring access to nonfarm co logic methods of treating pain coupled with provider education can reduce unnecessary prescribing. Prescription drug monitoring programs can help providers identify patients who are at particular risk. Another important Harm Reduction practice is improving access to the overdose reversal drug. Our goal should be to have a system where people that 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 a Substance Use disorder in 2015 but did not receive it say a lack of Insurance Coverage and inability to afford the cost as a reason. Optimizing access in existing programs such as medicaid is especially vital since nearly 12 of the adults in medicaid have a Substance Use disorder. Among people admitted for treatment in new jersey, twice as many were on medicaid as had private insurance. But access to treatment includes more than just coverage. You must also have integrated medical and Behavioral Health care, more providers willing to treat people with Substance Abuse use disorder, increased uptake of proven and effective models, and additional social services. We also need to be sure we can reach people when they will be receptive to treatment such as when they are in the emergency room due to an overdose. Third, continuing to raise Public Awareness and disrupt the continued stigma around Substance Use disorders and treatment. Policymakers must be aware of the problem and the Evidence Based Solutions to address this problem and Work Together to enact needed changes. Thank you representatives for your actions in this area and to the entire Bipartisan Task force for holding this hearing today. We look forward to working with you and your colleagues to make progress in this important area. Thank you. Dr. Marsh. Yes. Thank you members of the task forfor including me in heroin briefing today. Im as we discuss this significant issue for our nation. I am a professor in the medical school at Dartmouth College in New Hampshire. Ive had the privilege of conducting Substance Use disorder for a couple of decades largely with the report of National Institute on drug abus at the National Institutes of health. Today im going to tell you about a study that we had the opportunity to conduct with support from nida, the National Institute on drug abus. As representative kuster pointed out, New Hampshire has had the second highest rate of opioid overdoses in the country per capita and actually is number one for fentanyl overdoses per capita in the country having experienced a doubling of fentanyl related deaths in the last couple of years and an increase of almost 1,600 in fentanyl related deaths in the last five years. So this particular study was conducted under the National Drug Early Warning System Initiative which is an operative agreement that was designed to evaluate factors thats giving rise to this crisis that we see in the state of New Hampshire. And our Research Group at dartmouth his networks and partnerships all over the state of New Hampshire through our northeast node of the nida which allowed us to do this study quickly. We did this in a period of three months. We start ted this project with meeting with about 45 different holders including treatment experts and the state Opioid Authority medical Examiners Office as well as Health Experts across the state. In the past three month, we did intensive interviews with 75 active fentanyl users as well as 36 emergency medical personnel in fire, police, emergency First Responders as well as physicians and other providers in Emergency Departments. We actually just completed Data Collection for the study this past past friday. Weve seen a number of our preliminary results that underscore a con flewens of factors that seem to be giving rise to what were observing in the state of New Hampshire. Users indicate fentanyl hit the market in New Hampshire a couple of years ago. This was also at a time when heroin became somewhat more inaccessible in the region. We see that fentanyl is often mixed with heroin, although sometimes its sold as a sole product and users report they dont often know what the composition is of the product they consume. We also see as was mentioned earlier that users report its much less expensive and much more potent and so it has a real economic advantage relative to heroin. And although we do have some users report that theyre accidently getting fentanyl, whether seeking heroin, we find that some were purposefully seeking fentanyl as a sole product as their transferred drug of choice. Users also report that given fe fentanyls po tennessee, yteycy person report that the high from fentanyl doesnt last as long as the high from heroin so you have to use more often to maintain a high which may increase your chances of overdosing. But also increase your chances of infection from injection drug use. Every single one of the 75 users that we interviewed reported having observed at least one and typically more than one overdoses. In fact, we had one young woman who said in the past two months she had seen 20 to 25 overdoses including her own morther, her brother who overdosed 17 times in the matter of months who is now incarcerated and her own use of fentanyl persists. So we have this High Availability of this highly potent drug occurring in a context where unfortunately access to prevention and treatment resources are limited. So New Hampshire has the Second Lowest treatment capacity in the nation. We know that of the treatment thats offered, it doesnt always include evidence based approaches including medication assisted treatment. So one example of that is that New Hampshire has the lowest rate of bup nor fine waivered physicians in the northeast and does not have any Needle Exchange programs. So users consistently cite that the lack of availability treatment and prevention resources in the state are perpetuating the opioid phenomenon in the state and are driving to other states to get access to clean drug paraphernalia. Emergency Department Personnel we talked to reported quote unquote a tiedal wave. They report its not unusual to see the same person come in two to three times. They revive them and they go back to the same batch they overdosed on come back to the ed in the same day. What we heard from First Responders is they feel little to no option in linking these folks to care. They treat this acute episode and they see continual cycling of these folks in and out of that acute care facility. We also have many reports from medical personnel reporting spikes in significant medical complications from injection. For example, a cardiac surgeon recently contacted me and said that theyve seen this dramatic spike in valve replacements for infected endo carditis why drug users who continue to inject after surgeries. If someone could help cardiac surgeons understand what addiction is and how can they link these people to care and not just perform this very costly and acute medical procedure. Another important point i think that is fentanyl crisis in the state of New Hampshire is occurring in a rural state. What we hear from the folks we interview is that, woone, they feel like theres not a lot of other opportunities but also we hear reports of tight social networks. So i think together this data really underscore messaging weve heard on the pam here today which is the important of evidence based prevention and Treatment Options and also not just for the addiction but all of these medical Harms Associated with addiction such as the medical complications, the infection and the cost of the services in dealing with these issues. And i think that these data also emphasize the strong need for new effective models of implementing and scaling of access to integrated care approaches. This is a theme youve heard here today which is integrating approaches. Emergency department providers and cardiac surgeons, they want linkages to services to get these patients help. Criminal justice systems want to have links to effective treatment resources to help relapse and support people in their recovery. So i think its very clear from the discussion today this is a time of considerable need but its also a time of unprecedented opportunity for us to expand Implementation Research and really understand the best ways to engage this very Broad Network of steak holders and systems in creating novel and Effective Solutions to tackle this crisis. In closing id like to thank the many men and women who anticipated in the study and insights in whats happening. 50 id like to thank the American Psychological association for supporting my participation in this meeting. 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, were not running a clock, but i will ask each member and the four of you in your responses to try to be brief so that hopefully we can get to each person. Ill yield my question time for now and ask representative man if he would like to start. Thank the gentleman and i am very grateful for your participation, i should say your commitment to this professionally. We are all in awe i think of the challenge that we face. K i come to this with over 20 years as a prosecutor and saw heroin issue and cocaine. That was the tip. Fentanyl is a whole new degree and very, very challenging. One of the things that i hear time and time again, 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 theyre struggling with the sense of education. You spent your time talking about education and how to do prevention are other kinds of things that might make a difference. Were talking about the science here, the science which can give people a better understanding. Im not sure whether you told me that there was this is a bridge to a solution or whether it was simply, you know, a solution to 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 perhaps have an impact on the issue . Yeah. Sure. I would be happy to. Thank you for the question and im happy to see what thoughts my fellow panelists may have. I think we are to some degree, although the Opioid Epidemic is not particularly new, i think we are still in the beginning stages of understanding the longterm treatment needs that are associated with the Opioid Epidemic and more research will be needed to understand the length of time for therapies and the right ways to be engaging different people in those therapies. I think that evidence does show that the best time to be engaging people who have Substance Use disorder is in the middle of to some degree a crisis. Its when theyre showing up in the emergency room. Something has happened to a family member. Something is really calling the question. And so there are a number of programs that have taken that approach. Theres one program in rhode island called anchor e derks which connects people who are in the emergency room with peer 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 know 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 them about Emergency Rooms and ems providers. And then i think another challenge is that often local Public Health officials may not have some of the data they need to really help get their arms around whats happening in their community. So i do think there are some opportunities to integrate some of the streams of data that might right now exist in places, Prescription Drug monitoring programs, insurers and payers may have information, eds may have information. Figuring out ways to integrate the sources and do that hot spot research in order to understand whats happening right now is particularly important. Thank you. One quick followup. Dr. Marsh, you talked about integrated services. Does that include what dr. Rising was just talking about or is there some rother characterization of integrated services . I think it surely includes what he was speaking about. I was speaking about how we have so many people trying to respond to this crisis. We could have greater efficiency in our effort and coordinating care and preventing the cycling in and out of acute care episodes with the commitment to lic linking criminal justice and Emergency Departments. Even the schools you were asking to understand can you just answer are there privacy issues . Those are considerations, but i think theyre all addressable consideration, but this is an important issue. Id love to say one more comment. You were asking about how do we best understand the science. I think another area to underscore something he said earlier is the importance of prevention and starting with our youth. Weve had the opportunity to work with a number of young people who have gotten involved in using opioids and weve studied different models of interventions with kids. We find there are still many misconceptions about the risk of these substances. Even distinct perceptions relative to other sort of illicit drugs. Parents dont care as much if you get caught with pills or thinking theyre not addicted. Then we see this trajectory were talking about today that may lead to use, experimenttation. As we think about science and scaling up the science, that spectrum from prevention to Recovery Support is really critical. Thank you. If i may, just one point on treatment, because i 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 treatments to be effective, they have to be focused in that chronic model of treatment. Which actually leaves a lot of patients or practitioners to say treatments do not work because that patient relapses. Its a chronic disease. The concept of relapse is part of the disease condition itself. I think this is important to highlight. Not to create false expectations. We dont cure. We treat. Its ant like an abtie ntibioti im going to yield to my colleague. Thank you. Thank you so much for pointing that out. How important it is. But 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. Thats more than all of the terrorists have killed americans in the last 20 years. We as a country spend over 600 billion a year defending our great nation. Yet 52,000 people are diagnoyin because were not making the resources available. It is the disease of addiction that we just heard about. You dont get cured. Theres two ways of ending this. One is when the coffin closes or you get treatment. I am so glad were here to address the issue. I believe so many of our members know whats 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. I just went to a viewing of a young man, dear friend of mine, who lost her son. He had been in and out of treatment and this time he didnt get saved. Certainly fentanyl has an issue with the narcan, saves two, three, four, five doses and theyre still not doing it. The disease of addiction, were talking about today more along the lines of the synthetics, the heroin. Talk about the disease of addiction. Is there a difference other than the outcomes and the way you die, alcohol, cocaine, heroin . Its all a disease of addiction . The answer is yes. The way that all of these drugs specifically change, reward centers from our brain in such a way that they strain certain responses and generate automatic behaviors that cannot be controlled by our frontal cortex. Like when you touch an oven and its hot, you immediately remove. 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 the strength strengthening of the pathways. The best way i can 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 puts your brain in a state of emergency where youll do anything to get the drug. Its needed for survival. Its not a moral defisciency. Somehow its those people over there. Its not. Its people everywhere. Dr. Rising, just to followup, in my hometown, weve set up a program when the narcan safe comes in, they have Automatic Access 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. When we look at prevention, you talk about those on pain killers. How much time does the average medical student in his fouryear career at medical Student Spend on the disease of addiction . Sir, thank you for the question. One thing i would like to add to the previous question that theo fielded is that i think all of those different types of de addiction that you evidenced all have resources available. I think your point is a great one in terms of first making sure that those points of contact, be they in the emergency room or another place, are not kind of a onetime contact. We reached out and it didnt work at that point in time. So efforts to engage people into treatment do need to be ongoing in order to make sure that that touch point occurs when an individual is ready. I vhavent seen the stats recently as to how much time. I think its probably slightly more than when i was a medical student. How much time did you spend . It was not a lot of time. Certainly when you look at the scope of the disease in the United States currently, certainly i think theres a broad need to look both at medical schools, but continuing medical education and other ways to engage the profession in this going forward. Nobody like to tell the doctors what to do, but i think we can give them a pretty good clue whats going on. Sir, i just want to reply. One is an emergency medicine doctor who works in the state in which you represent, i appreciate that and i appreciate the opportunity to talk about kind of there are a couple of realities we have to deal with. Ill tell you the exact number. We looked at we called 111 medical schools out of 163 and we found there was less than one hour dedicated to addictions. Would you repeat that. After calling 111 medical schools which is the vast majority of medical schools and ip kwi inquiring as to what they had for addiction training, we found the trajectory waverage was les hour. As a Board Certified emergency medicine physician that trained at a good program, i didnt add to that in that training. My board certification came after my training in emergency medicine which goes to the reason this when patients go to the Emergency Department that they leave not wanting help because they dont know how to give it. When youre in withdrawal and you say heres a phone number, good luck, it doesnt work. The 30 day mortality rate post overdose is higher than some that shows up and we miss a heart attack. If they come in with chest pain, we admit them to the hospital, they get a cardiologist, we send them home with followup, we call them with nursing phone calls after that. What happens to that patient that shows up to the Emergency Department status post overdose, that is in withdrawal, scared to death, feels like theyre diagnose, they get booted out with a phone number. We have to be honest about the actual treatment thats taking place in the Emergency Department. It is not patient centered compassionate addiction Knowledge Based treatment. And this happens all through medicine. Primary care, less than 10 of pre primary care doctors screen for addiction on a regular basis. Yet 75 write for opioids on a regular basis. Ob wait. 75 write a prescription for opioids on a regular basis . Yes. And do actively prescribe opioids on a regular basis yet less than 10 screen for addiction. No better for ob gyn that we can help that mom and get these babies out safely to a mom and back with them. So there are a lot of things we can functionally do right now that were not doing. I want to yield my time and make the suggestion that would be a great topic. Medical education in general. Thank you. I yield back. Representative schneider. Thank you. 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 were seeing it throughout the country. I will emphasize its not just rural. Were seeing it in the cities, in suburban districts like mine. It gets worse year after year. Dr. Vocal, you talked in your remarks, clearly the best way to fix a problem is to keep it from happening and prevention is the best way to address this problem at the front end. Are there programs that all of you are aware of 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 found a significant number of researchers to develop prevention efforts for drug use in general. What the research has shown us is that the strongest evidence comes from prevention programs that are initiated early on in children and adolescents and that engage the family, the school, and the community. Now, this prescription Opioid Epidemic and associated heroin and fentanyl add a different wrinkle because we are seeing people that had never been exposed to drugs becoming addicted in their 30s, 40s, 50s, sot iss so the issue of prevention requires something that was mentioned before. Education on the proper prescriptions of opioid medication. Because weve gone from basically 50 million prescriptions a year of opioids to 250 million prescriptions since 2000. But we didnt train physicians and there wasnt in turn a deep propaganda to actually educate physicians that these prescription opioids were safe and were not addicted if you have pain which is incorrect. So an important component of prevention right now is provide better education on the proper prescription on the property use of prescription opioids and also education on Substance Use disorders. Because as was discussed before, they get one hour if as much. A physician doesnt even know to recognize if their patient is becoming addicted. They dont know the difference in withdrawal and physical dependence from addiction. Not to say what to do even though it doesnt sound High Technology training and education is probably one of the most important prevention efforts we can do right now. If i can, the barriers, and using that as an example of training, you said one hour over the course of four years of medical education, what are the barriers to getting more training, whether it is at the Foundation Medical school level or continuing education over the koufrs course of a career . Why is it not happening more . Because what you get complaints from in the medical School System that 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 degree to put questions on Substance Use disorders and that will motivate medical schools to do it. So working with this organizations to put these questions as well as on specialty treatment programs. Sorry to take it. I know were limited on time. Other thoughts . Comments from the rest of the panel . Well, theres pushback from the Major Medical societies on mandate the education. Thats pretty well documented in your offices on a regular basis. I think just continuing to push forward for at least a minimum standard mandated Knowledge Base and if you document that you got it in medical school, great. If you cant, then you need to get it some other time if you want a dea license. Two quick comments. As dr. Vocal indicated there are a number of effective drug abuse prevention programs and nida has supported a lot of that terrific science. Theres also needed Additional Research about prevention of opioid use in particular because the complexion of this is different and theres scientific literature that shows that risk factor particularly among young people may differ from risk far factors. In addition to some of the training initiatives and the Educational Initiatives weve spoken about i think the opportunities to think about more scaleable models that can build on that. Work force development and person deliver trainings alone may not need a scale. So digital technologies, mobile technologies, social media types of approaches, to take science based prevention interventions and promote more access to them. Dr. Rising. One thing to add to what my fellow panelists have said. If you were to look at a number of providers who are perhaps out in the Community Already who may not be providing various treatments for Substance Use disorders, i think one of the Major Barriers is thats have a very challenging issue for providers to deal with in their Office Especially if they feel like there are not a lot of Community Based resources or Treatment Facilities to be able to engage in people who need the treatment f. Youre all on your own this is a daunting field to enter or to feel like you can really make a significant contribution. So strengthening those Treatment Facilities and having providers feel like yes, i can understand, you know, i have some options when i identify somebody in my waiting room with a Substance Abuse use disorder certainly will go a long way in trying to drive some command among active prakt ti pra practitioners. Thank you tour chairs and to the panel. Im lois. I am from florida, south florida. We have somewhat of a unique situation which many of you may be aware of because, and this is why i think its so important to have federal intervention. A lot of our addiction issues are coming by way of folks coming from lets say New Hampshire. Im just saying that we have become the treatment like a treatment capital of the country. While there are some many good programs, theres also i will tell you thousands, im not exaggerating, thousands of what they call sober homes and treatment programs that are not doing the right job. And to put them in further perspective, today weve been talking about patients. And im not going to i think you very articulately described some of these issues. Keep in mind that this is also affecting community resources. Ill give you an example. Palm beach count where im from. About a million and a half people. We had 4,000 calls that our firefighters had to answer to for drug overdoses at about 1,000 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 many people who were dying. So i think so when we talk about trying to do something about this, its not just its not just for the patients and their families but to all, doctors, paramedics, the communities that are having to grapple with this. My question is, and im not sure 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 not fentanyl thats actually produced in the United States for medical purposes. So generated in the black market. So i had a conversation with my local folks and actually that was one of the issues that was raised by one of the local officials who had been dealing with this was asking us, and i want to bring this to the attention to our chair here, is could we start to put some pressure on china to try to stop the trafficking of the fentanyl . Do you know whether theres been any efforts in that regard in any way . My understanding is that there have been definitive efforts to try to actually engage china to minimize indeed the production of these fentanyl from the black market. Im not the Agency Behind it, so we cant provide you the exact information. But my understanding is that indeed they are. I would request maybe this could be something, i dont know whether the task force has looked into this, but if not, i would request that maybe we could do that. Sure. Thank you. I yield back. Thank you. Do you have a question . Sure. Thank you very much. Youve all been so informative and its very helpful for our colleagues who coming at this in 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 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 Behaviorial Health issues that americans assume that this is intentional and what we learned as the alzheimers progressed is that indeed the behavior was not intentional. I feel like were at a very similar place with Substance Use disorder in that we assume, and this story particular dr. Marsh that you told is so stunning and striking that a young woman who has watched her own mother overdose and die, watched her brother overdose 17 times, and yet those of us in the room and indeed the medical providers at the emergency room some were in the back of our brains think how is she acting that way . Why is she acting that way . I think dr. Vocal has been very helpful to understand the science of the brain that this is no longer intentional. Her frontal lobe is not making the decision. Theres 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 lot or to thats not reasonable behavior either. Its not logical. It doesnt make any sense. So 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. And so in New Hampshire we are looking into where people fall through the cracks. And bringing the hospitals and the Emergency Rooms together. Ive been at my round tables where the people in the Emergency Department are not having the conversation with the people on the fifth floor in the administration to have this conversation. So now were bringing everybody together. Now were bringing the Insurance Companies to the table. The federal government has got to decide medicare, medicaid, what are we going to cover. Thats the conversation that we need to have so that instead of saying that person deep in the throes of Substance Use disorder is not acting in a rational way, we turn the finger around and say this person, whether its a policymaker or Emergency Room Physician or Hospital Administrator or an insurance company, were 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, with our staff in the room, that we can help to educate because were so silent every step of the way. Were in a silo. We do our part and medicine is not different. Weve got to figure out a way to broaden that conversation. I thank you for your work in research because we need to have evidence based information. I think the rest of you for helping to translate literally the work, the understanding that you have into the society at large and back to the policymakers so that we can make rational policy. Because weve already discovered on this task force irrational policy. Weve already discovered that we were rewarding physicians for pushing opiates out into the community. And then were shocked that that didnt work out well. So to get to the question, id like to followup on this upstream notion and programs or Evidence Based Research that we could do or should do to give physicians an alternative. Pain is real. I had an emergency cesarean. Ive had surgery. I know pain is real. 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 that we received of patients are going to be ending up with a chronic opiate use but 99 of the patients getting surgery are getting opiate medication. So where are we if you all know, if anybody could weigh in and what could we be doing to help with alternative pain remedies, whether its different mekds and whether theres Evidence Based Research on other types of pain relief . Im going to be candid with you because i think that issue that youre bringing up is one of utmost urgency. The reality that we dont have many alternatives for the management of severe chronic pain. Theres been a big advance. The cdc last year had new guidelines in which they emphasized the need to actually limit and curtail that number of opioid doses that will be given to a patient. So ideally not more than three days. Thats a very dramatic change. Thats the new cdc guideline, not more than three days . Correct. The other issue they highlight is in the management of chronic pain, you became tolerant very rapidly which means you need higher and higher doses to relief the same pain and that increases your risk of overdose and addiction. There are very few trials have shown they are effective in the management of chronic pain. Overall the evidence is lacking. So the cdc is not 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 enat the greated approach for the management of pain . Not necessarily. Its much more expensive. Its easier to prescribe an opioid. We have structural issues we need to change to allow physicians to do the right thing. And there are alternatives to the management of chronic pain. They are not neither obviously a government agent at the nih were investing resources on developing new medications for management of pain as well as nonmedication strategies that can be useful. An area that could help enormously is the pharmaceutical industry investing. What happens is you have you are selling millions and billions actually, i would guess close to that, of pills, of opioids. 250 million prescriptions. Imagine multiply by the member of pills. What is your incentive to actually develop a medication thats going to compete with what youre already selling . So i think that there is also a need to incent where there is an urge to develop medications. Weve done it for vaccines and rare diseases. There is the need to generate something to get into the space so we can provide for better treatments for patients suffering from severe chronic pain which can be devastating. So ill just put in a plug for legislation that i introduc 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. This was mr. Kaufman from colorado and myself coming out of the Veterans Affairs committee and its in White River Junction vermont. A doctor named Julie Franklin whos working with veterans with chronic pain. They were taking very high doses of opiates with no Mental Health. They hadnt dealt with ptsd or anything else. And one gentleman i met taking 160 pills a month and for long periods of time and she took this group and had a clinic on alternative remedies, so acu puncture, Mental Health 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. So mr. Kaufman and i are trying to scale that up both within the v. A. , but hopefully get some evidence based results that could then go out into the community. So ill close. But if anybody has anything to add on that. Two quick things. One, back to the 111 medical schools that we, they only had 1. 2 hours of training in pain on average. Less than hour on addiction and only 1. 2 hours more mandated training. So they dont study either one. So to try to on board, you know, different mo tal its the treatment for chronic back pain which is one of the most often seen complaints, the two things that have the most amount of literature behind them randomize control, crock ran level database stuff, the things we go to that we should apply to everybody are yog ga and mindfulness. We have this mountain of literature that show these are the things, yet physicians and all of those that take care of patients are not trained in this. The first thing that they get is a prescription is really problematic because that one hour i lived it in my family and with chronic pain and now a series of surgeries that a relative whos been on opiates since the 11th of september and now is challenged by dependency. And so its very, very frustrating. I cant tell you how silo, having gone out there and spent a week if i could, personal privilege, being literally in the appointments with the surgeon who wants nothing to do with this. Literally just came right out and said not our problem. You will have to deal with this after the surgeries. Meanwhile the Treatment Professionals dont want anything to do with the surgery saying you can die of the drugs but you wont die from not getting the surgery. Im just like okay, is there anyone in this process that can help us navigate how to get this accomplished so that this person whoo 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, and well 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 youre doing. Thank you. I had a couple of questions. I preefrappreciate 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. Vocal, you talked about the physiological changes to the brain that occur when somebody is using opioids. 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. Theres improvement. We all know that if you cut off your hand, theres no improvement. You never had a hand again. Its done. I understood your comments to be more like the latter. That there are physiological changes that occur to the brain that are irreversible. 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 normal see over time and what cannot be. Im glad youre asking me that question because i didnt imply that they were irreverse vibl. I implied they were long lasting. What the evidence show system that while it is frequent to see relapse in people that are having it, the longer they sustain the treatment, the scarce or more rare the cure. For example, the best outcomes are reported when patients senior on chronic treatment for five years. At which time they actually can lead a very much life where they are recovered. That means that you can get back to your previous state. You may have a level of vulnerability, but uhoh oh the brain recovers. I mean, 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. So yes, the brain can recover the extent to which it will recover will depend on many things such as how addicted you are, your age at which you started taking drugs. The evidence shows that with proper treatment people recover from addiction. Thank you for that clarification. I also wanted to talk about education a little bit. Dr. Walla, youve 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 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 eliminated has fed into the opioid crisis. 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. Neither should we. There are were not physicians for the most part. But there are times where theres a federal nexus with Health Care Issues 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 a governmental federal governmental level that might allow us to exert more pressure on nongovernmental entities with regard to how they train physicians . Thank you for the question. Thank you for really having the ongoing thoughts about this. This is a complicated problem and were all have to deal with it in different ways. The federal government does have one place where ch it holes a pinch point for every prescribing physician and thats at the dea license level. We are required to fill out paperwork, pay 3 350, but not have any so we can then write for medications that were quite fafrpg frankly not trained in. 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. In one fashion or another. Whether thats at the medical school level or for those that are on the outside you have now two years to complete a certain number of continuing medical education hours specifically dedicated to the schedule ii substances that are causing the vast majority of these problems, schedule ii and schedule iii. The Biggest Issue that i find is you cant drill down just on one of the controlled substances, though, because were finding as big of an issue with benzodiazepines and its smolderring in the back but the vast majority of heroin doses are in combination with a hypnotic. Thats with Something Like valium or xanax or alcohol with it. Teaching again in a silo doesnt allow people to cross evaluate what theyre 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 schools how we have were full. On every test ive taken, theres always a question about a thing called a one of the rarest tumors. Its on every test i take. All the way through. Even into my specialty training theres something about it. I think maybe that could take a little less time in my education through this. Especially when the number one cause of injury related death in our country is drug overdose. And so i had three lectures from the National Traffic safety board on car objections. I can tell what an a pillar does and b pillar because because when we look at pictures from ems, i can tell you what that is. To your point federally, you dont have to look far. There are controlled substances. They are controlled by the federal government. By a license that i am privileged to be able to have from the federal government so i can effect positive change in peoples lives and not kill them. Thats where i would focus. There are a hundred different ways, but i think that is the biggest one that you have right now that is purely a federal lever. Do any of the rest of you see any other . Yes. A couple other thoughts to share. One is that certainly i think it is important to improve provider education as i think weve all talked about the deficiencies here today. However, also providing the education doesnt necessarily get to kind of those end results were really looking for. Ensuring that its quality education and that providers then are able to act differently and provide Services Better as a result of that education. So other tools that may be available to get at more of kind of that root question of what were trying to assess and encourage. One is certainly the use of quality measures which are used widely across health care but really we dont have ones that have really taken root when it comes to the treatment of Substance Use disorders. So there could be some opportunities to look or to encourage the development of some quality measures in that space. And then senior certainly maybe other ways to look at the services and referrals that theyre able to provide as part of the ongoing relationships that both medicare and medicaid have with various medicare facilities. I just have to say with regard to quality measures, thats actually one of the inadvertent unintended consequences that got us into this situation. So im glad you brought it up because we could use to help get us out. This is with regard to physicians were judged based upon the patient satisfaction. And we literally, the federal government was reimbursing based upon the patients satisfaction and so i think, you know, it doesnt take much to make the leap that surgeons have done a fabulous job with the surgery. They werent going to get paid less from somebody whining about the pain. They said 30 pills, take 60. Wait, let me give you 90. I think that got us into this. So again, a piece of legislation, this one is the custard mooney bill so physicians will not feel pressured into increasing the medication for post surgery pain medication and in fact another bill that was included in cara we did partial fill because many, many, many patients, if not the vast majority, are going to be fine, i didnt know about the cdc three days. But five pills, six pills gets you through the weekend. Use ice. Keep your leg elevated. By monday youll be feeling much more comfortable rather than snis sending every single patient home with 30 pills. I just wanted to add to your response about federal levers. I wanted to add two more. One is related to research. The second is related to scaling up the application of science to Service Delivery models. The first one with regard to research, i think weve discussed here today that there are a number of effective prevention interventions. A number of medication assisted treatments. But theres a tremendous opportunity to scale up their yooutlization, so understanding how do we create systems that promote the max mal i think i really critical. As we talked about before, we have this unprecedented moment in time where we have this large amount of resources that have been allocated to expanding Service Capacity across the whole nation through the cara act and we have half a billion dollars slotted for that. We have a tremendous opportunity to ensure that what we know works best from the science is actually whats incent viezed, what the states encouraged to adopt and also have a scientific model wrapped around. If were going to invest this kind of resources into this implementation strategy, how do we know it works and how can we come up with metrics to know what the impact of that investment is. I think those are really key as well. The research and link aj of the research too. Im going to make another point. I think it be we do have treatment for the disorders, and in three classes only. How many do we have for hiv . How many for hepatitis c . Is that sufficient . No, it is not sufficient. They are extremely useful but many patients do not necessarily respond to. That highlighting the need of research that can lead us to alternative treatments is like we are dealing with a virus. What do we do . We develop vaccines. We develop medications. And we do it urgently. We have not that done that for addiction. The amount of investment that goes into the space of development of medications has been extremely restrictive. Yes, im very grateful for the medications that we have been able to develop thanks to the government. But i also recognize that it is important that we continue to strive for alternative treatment so that the parents have the greatest chance of survival. It is a very, very serious disease. It kills people and devastates families. And we should treat with t with the priority that we treat other conditions. And hopefully do no harm and have fewer people headed into that. It just breaks my heart. Four out of five people suffering from Substance Use disorder started down that path from a Prescription Medication from their physician. I cant think of anything else like that in our society, in our Health Care Delivery models. So thank you. We are going to have subsequent hearings. The next hearing will be hearing from some people that have implemented models in New Hampshire, safe station. You might be familiar with it of trying to help people get the help that they need. Weve got some very promises 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 wanted to thank you all of you. Its been helpful. As we consider future hearings, i think what youve given us today will help us. Our object is really to shine a bright light on this issue, to educate our colleagues and bring order out of a lot of Different Directions congress can go and introduce legislation at their own with their own counsel, but we want to try to make our efforts in Congress Deal with whats in front of us. What we did last year was helpful but its not enough. We want to get the best advice that we can. If you have further things that you want to suggest to us, i invite you to reach out to our offices and let us know and youll do a Great Service to the American People as you do it. As was mention ded, we do have another hearing schedules february 28th 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 or this round table is at anne end. We appreciate you being here. Were adjourned. Giving her 40 address. She calls her more invest ment and education and transportation

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