Transcripts For CSPAN3 Washington Post Forum Explores Official Response To Opioid Epidemic 20170630

Response. Ill invite you all to sit down now. So joining me on stage pardon me just a moment while i adjust this. First off we have congresswoman diana deget of colorado. She is a senior democrat on the house energy and commerce committee, ranking democrat on the oversight investigation subcommittee. She cosponsored coauthored the 20th century cures act which put a billion dollars of new general funds into the Opioid Epidemic to combat it. She is the chief deputy whip of the Democratic House democratic caucus. Thank you very much, congresswoman. Senator ed markey is here, of massachusetts, democrat, and member of the Senate Commerce committee which has broad jurisdiction over private industry including the pharmaceutical industry. He has done numerous investigations and authored numerous pieces of legislation to address this crisis. Hes going to talk quite a bit about that. Last but not least, chairman greg walden is with us today, of oregon, republican of oregon. He is he has drawn attention to the Opioid Epidemic as its affected his district in Eastern Oregon. He has also plays a key role in overseeing the Health Sector of our economy. He played a key role in drafting the American Health care act, which is now going through the congressional process. Were going to give you an opportunity to talk about that legislation and the oversight that youve done on your committee. Thank you very much for being here. Let me start with senator markey. This is a question im going to throw to everybody on the panel today, but tell me how you first experienced this crisis as a crisis. When did you understand that this was something that needed your attention and what did you see in your state that compel you to act . It was in massachusetts, it was Martin Luther king day, january of 2014. I was standing in the back of the room getting ready to give my speech and i said to the police chief and the mayor in tanton, whats the Biggest Issue . Well, weve lost seven people to overdoses in just the last couple of weeks. And then i said to the chief, i said, well, whats the issue . And he said, well, theyre now lacing the heroin with fentanyl, and he explained to me about fentanyl. And i brought back the drug czar for the United States the next month, into tanton and the numbers are huge. In massachusetts, in 2016 we lost 2,000 people to Overdose Deaths, opioidrelated deaths. Were only 2 of americas population. If the whole country was dying at our rate, that would be 100,000 people in a year. That would be two vietnam wars every single year. Of those who died, in 2000 70 had fentanyl in their system, that would be 1,400 people last year. If you extrapolate it for the whole country, that would be 70,000 people dying from fentanylrelated overdoses in one year. That is now something that is going to hit the rest of the country slowly but surely. Wheaton, massachusetts is a prevalue of coming attractions. Only 30,000 people died from opioid overdoses in the whole country last year. Were three times worse than the national rate, but unless we put in place the prevention and treatment programs we are going to see this epidemic just explode even further. And from that moment in tanton when the police chief and the mayor told me about fentanyl it has just been a predictor of this catastrophe spreading inextraably, inevitably, across the country. What year was that, senator . January of 2014. So it was 14, 15, 16, were now halfway through 2017, and the numbers have skyrocketed since 2014 in massachusetts as they have across the country. If you pick up a copy of todays Washington Post theres a story in there with an amazing statistic that illustrates the scope of this issue. That in 2014 there were 1. 3 million emergency room visits or inpatient stays for opioidrelated issues in 2014. Thats a 99 jump for emergency room treatment compared to 2005. It is a remarkable statistics. By the way, that 2014 number, which is a great story in the Washington Post today, that number is much, much higher today. In massachusetts, and we were the second worst state on that list in the study that the post had today. We have a much worse problem today than we had in 2014. Chairman malden, let me ask you. You represent Eastern Oregon. It is a Rural Community, largely rural, some of the most beautiful country in america. So what is happening there . What have you seen . What was the moment that you realized there was something that needed to be done. Well, i had done a series of round tables a couple of years ago, and i always remember just a couple of examples. There was a woman in hemanston, oregon, rural Eastern Oregon who talked about her addiction to opioids. She is now a treatment counsellor, but trying to get off of it was almost impossible. She wanted to get on to soboxone that she wanted to get off. There was no physician to help her. So she would commute 5 1 2 hours each way to finally get trim to get off. In Southern Oregon i did a round table are Law Enforcement, addiction specialists, hospital people and family. And this fellow was sitting in the back. He wasnt actually part of the roundtable. But i called on him, said, what brings you here . He said, my son, my son was an athlete in high school and got injured and got prescribed opioids to deal with the pain. And tragically got hooked and went to the cheaper, more potent version of that, you would know it as heroin. He said he succumbed to that. He said my sister was a nurse, same sort of scenario. She got hooked on it. She would write her own prescriptions, forging the doctors prescription pad, got caught, moved on somewhere else, took it up again. The addiction overwhelm her and she too had died. Then you begin to talk to everybody else in your communities, how theyre affected and this addiction explosion thats been going on in oregon, were ninth in the country, fourth among women. But we predate that with the other scourge which was methamphetamine and the cooking and all of that, and oregon lead in this. We did work here in washington on it like were doing on opioids to get the precursor chemicals out. That still remains a big issue in Eastern Oregon. One of the leaders in trying to push back on this, dr. Chuck hoffman, is a friend of mine. He was quoted recently in a new series about how he was trained as a physician to prescribe opioids to relieve pain. They were never really trained in alternative pain relief practices. And now its just write the pills. So hes trying as a physician, leading an effort to turn this around. Were also seeing a dramatic increase, by the way, in 65 and older that are being treated as inpatients in hospitals because of this addiction. So it is affecting every age group. Finally, i would say there was a really troubling story as part of this series. The august observer ran about a physician who engages in the treatment, and one of his patients is a rancher who keeps preloaded syringes in the cab of his tractor so when hes out there he can just shoot up during the day, and theyre loaded with heroin. So, i mean, this is having unbelievable consequence across our country, and i think were altogether in trying to figure out strategies to reduce the illegal pills on the market and to you know, we passed legislation to reduce the prescription amounts that have to be given. I mean, theres a lot we can do. Congressman, let me ask you this. You represent a different kind of district. You represent a good part of denver and its suburbs. It is an urban and suburban district. So much of the reporting on this talked about this as a rural phenomenon in communities like in Eastern Oregon. Is that the whole picture or is that not the whole picture . Oh, no. I mean, this opioid problem pervades i think people focus on rural areas because they expect that drug and addiction issues will be urban issues, so theyre shocked when it is in rural oregon. But i remember, you were asking my colleagues when did you first when did this hit home. A couple of years ago i was at the book lovers ball, which is the annual fundraiser for the Denver Public library. And i was sitting next to the Denver Public librarian and i said, what are the issues youre facing here at the Denver Public library . And i thought she would Say Something like, you know, cybersecurity or access to books. She said, you know, we have people overdosing in the Library Every day, and we need to get our librarians maloxone so they can give it to people who have overdosed. At the Denver Public library. And so, and now there was just a story the other day in the denver post that they finally did get the librarians maloxone but they actually had a guy die in the main library last year. Theyve had a number of overdoses, and the librarians just open up their desks and run over. Imagine that. And i think what all three of us had recognized is this really does seem to have exploded on the scene. We heard stories about addiction for some years and about and cautions about overuse of opioids, but it really but these stories are just exploding. In our committee, the oversight and investigation subcommittee of energy and commerce, we did a whole series of hearings about a year or two ago on opioids, and it was amazing how many misconceptions there were about the extent and the nature of the problem and how much confusion there was about what you do about it. And so it is not always that you have hearings that really educate the members of congress, but i think we all learned a lot about what we need to be doing. And, of course, that was part of what informed the care bill last summer that we passed and then the funding that you mentioned that fred upton and i put in your our 21st century cures. Well talk about cures briefly. It was a remarkable bill not only for what was in it, but the fact that it came together at all at a time when the parties werent last year and still arent working together on a whole lot in a productive manner, but this was one area where republicans and democrats came together. You worked with fred upton, chairman waldens predecessor on energy and commerce, to make this happen. And talk specifically about the addiction part of that bill and how that got brought into this bill that was also about so much more, including, you know, pharmaceutical development and things like that. Well, i mean, this was a bill that we worked on for about three years, and it wasnt just me and fred. It was also greg and it was ed and his democrat and republican colleagues in the senate, so it was really an effort to focus primarily on research at the nih and the fda. But as the bill moved into its final stages, we realized that there were some funding issues in the Health Care Space where we could really get bipartisan, bicameral consensus. And, as i said, we had passed that care bill the year before that had a lot of really good administrative programs for opioid prevention and treatment, but it had no money. And that was one of the biggest criticisms everybody had at that time. And so when we did the hearst bill, we were able to say, lets really put some oomph here. Lets put a billion dollars in grants for state governments. Mr. Chairman, let me ask you this. Talk about the, pardon me for putting it in these terms, but it can be difficult for republicans, certainly House Republicans to spend money on republicans, to spend money on anything sometimes. But this issue is one where there was a wide agreement that something had to be done. Talk about what i get the feeling theres been among your republican colleagues in trying to come together. Yes, i would suggest too in the 21st century curist we did mandatory spending for nih because we believe in medical research, and really the big increases in nih go back to the days of gingrich who believed in research and doubling the nih. There was a pause and now were trying to ramp it back in a bigger direction. Clearly in dianas work and others really passionate about this. These issues dont pick parties when they show up on your doorstep. I think they help bring us all together in common cause. So the billion dollars, my state we just got 65 million in grants out of that. In pretty short order, i would argue the money got in there and now it is getting out on to the ground, into the field, hopefully into the hands of the professionals in our communities who know best what to do with it to address this issue. Pieces, to dianas point. There are good mechanical pieces, to dianas point. In terms of changing how many people a physician can treat with soboxone, my friend from herm anston who had to go out of state to get treatment, now they can treat more people, they can fill a prescription. That gets excess pills out of the market hopefully. These are all things i learned in the roundtables back home. And then getting the money in there. In the we put another 15 billion towards this, addiction and other things. Thats certainly in there. It is not always about the money. It is about changing behaviors and finding best practices, that was part of the debate i heard, was better understanding the physician prescribing community, what they should do and shouldnt do. It kind of goes back to an original study that said, oh, theres no addictive nature to this, so feel free. If you go back, the foundation builtt i think on a false premise, that it was okay that these pills wouldnt be addictive. Right. So now we know 90 days is danger zone. Yeah. And so we need to do this education. Right. It turns out it wasnt even a study. It was a short letter in new england journal of medicine that the pharmaceutical industry used as an explanation for prescribing these drugs. Senator, let me ask you this. There continue to be bipartisan efforts to address this. Can you talk about what youre working on right now, the interdict act and other efforts in the oversight realm as well to take action . Well, im working with marco rubio on a bill to give customs and Border Patrol the technology they need in order to detect fentanyl and other substances at our border so that project veritas it comes in from mexico or from china that theyre able to do that. I actually said to Mitch Mcconnell two years ago that lexington, kentucky, lexington, massachusetts, it doesnt make any difference. We need a Surgeon Generals report on addiction. So what i suggested to him was the smoking report, the Surgeon Generals report in 1964 was a seminal moment. We need, you and i, we should ask the Surgeon General to do it and he completed it in one year, which laid out now the parameters of the problem and what needs to be done. So to that extent there is a lot of bipartisanship. I was able to pass legislation with rand paul on soboxone, on medicationassisted therapy. That became a part of the law as well. On the other hand, were having a big battle right now about funding in the Affordable Care act and whether or not the slashing of that funding is going to have a profound effect upon the ability for people to gain access to the treatment which they need, the centers for American Progress have concluded that 91 billion under the Affordable Care act would have been spent on Substance Use disorders over the next ten years. That money will not be there if the Affordable Care act is repealed. So were going to have a huge debate over whether or not, you know, this funding is going to be there because honestly, a vision without funding is a hallucination. You know, youve got to have the funding in order to provide these programs. This debate is now really escalating in the senate because we, the democrats are saying that this Opioid Epidemic, this Substance Use disorder epidemic is something that is going to get seriously shortchanged if the proposal as it is currently constructed becomes the law in our country. Well, let me throw it to chairman walden. As chairman of the energy and commerce committee, you know more than anybody else in the capital about what is in the American Health care act, which is the Republican Health care bill thats now moving through the process. Certainly, you know, that is not a bipartisan effort, as we all know. That this is the republican response to the Affordable Care act. Youve heard folks like senator markey and even some people in your own party on the senate side talk about the potentially difficult effects this bill could have on Addiction Treatment. Just give us some facts as you see them of what this bill would do and whats in that bill to help folks suffering from addiction. Sure. Yeah, thank you. First of all, you have to sort of bifurcate it because what we do know is the individual Insurance Market has a lot of problems on the exchanges. So you have a group of people we want to make sure have insurance or access to choices in insurance, affordable insurance, and right now state after state, county after county, were seeing more and more limited choices, some counties may have no choice. If you are in need of treatment and you cant get insurance, you have really no options or very few options. Were trying to fix that Insurance Market. This is difficult work to do, difficult in the house, difficult in the senate because were all we share a common goal of trying to make coverage available, make it affordable. On the other hand, on the medicaid side, we believe theres enough head room in there, about 90 billion thats there that we put in under a provision to allow increased deductibility of Health Insurance cost. It was really to move 90 billion to make it more flexible for the senate to make some changes. We put specifically 15 billion in for Addiction Treatment and some other related causes. In addition to the flexibility of the patients state Stability Fund which gives states great flexibility to use the money either to bolster their Insurance Markets and or use it for other purposes which could be addiction. So i think theres a lot there, and it is not always about the money. Remember, early on, i said in my state were seeing an up tick in people 65 and older, most likely on medicare, not medicaid. Thats a problem area that needs help. So what we have to do is get to the root cause. You have to get to the prescription issues. You have to get to the treatment issues i understand, but we think theres room there to do that. Councilman degette, i imagine you might have a different perspective . I agree, money is not always the panacea, but the problem is if people dont have insurance to pay for their treatment then they cant get the treatment no matter what funds you set up or whatever else. According to the Nonpartisan Congressional Budget Office under the house proposal 23 Million People will lose their insurance even after all of these funds were added at the 11th hour on the floor. And so when you have 23 Million People who are either on the Medicaid Expansion or are going to lose their insurance because theyre because their premium support is reduced or whatever it is, if they cant get access to Mental Health treatment programs because they dont have insurance then it doesnt do any good. Thats why many, many commentators in the Mental Health space say that the aaca would be very, very it would be a huge backwards step for opioid treatment because people just simply wouldnt be able to get access to those programs. Frankly, as much as i love my former energy and commerce colleague ed markey, i dont ever legislate in the hopes that the senate to say, well, you know, okay, this is a problem with this bill but i know it will be fixed over in the senate. I think we should get it right the first time. Im really concerned right now frankly that maybe exit talk about this, that Mitch Mcconnell is saying hes going to bring up some bill. Not only have the democrats not seen it, most of the republicans havent seen it either. We have no idea what that bill is going to do in terms of access to medicaid in the states or to premium support or anything else. You know, diana is right. The only thing more secret than this Republican Health care bill in the senate are Donald Trumps tax returns. We have no idea whats in it, the public has no idea whats in it, it is being put together in secret. We know it could have a profound impact on Substance Abuse disorder treatment. So the consequences for Public Health in our country are profound, and right now this is a process that has not allowed for any public input, any democratic bipartisan input, just the opposite of the way the cures act and care act were put together. Let me jump back in here. You have colleagues in the senate who have been very outspoken on the effect of this crisis on their states. Are you confident that theyre not going to vote for a bill that they think is going to harm their constituents in this way . Well, first of all, im not going to speak for any senator let alone senator portman. They can speak for themselves how theyre going to vote or anything else. I do know they care deeply about these issues. I do know that throughout the discussions in the house, i made a couple of presentations at the Senate Republican conference, so none of this was a secret within our world in terms of moving things back and forth. I mean, the legislative process taken between the house and the senate and understandings and flexibility, and im sure thats how we got to 21st century cures, how we got to care act, how we get to major legislation. Theres always give and taken between the senate. Reconciliation traditionally is a partisan process by both sides, used by both sides. As you know, when the Affordable Care act was first fully implemented, the final bill, we werent allowed a single amendment on the house floor because it couldnt be changed, because in my friends state, senator kennedy passed away, was replaced by scott brown. They couldnt allow a single word to be changed so we had no amendment capability and then they chased it with reconciliation to try to clear up the mess. Anf thats the law we have today, and it is crashing around the country when it comes to the individual Insurance Markets. You have five states that may be down to one on no options. Multiple counties. Premiums have not gone down 2,500 bucks, theyve gone up. And the cbo scores have consistently been wrong based on the principle they put or power they put on the individual mandate that is going to force people to buy insurance. Theyve been off twotoone in their estimates in 2016. In their estimates in 2017. I mean, they get it wrong. Theyve got a tough job, but their numbers are off. Were trying to rescue that market so people have access to affordable insurance. By the way, if youre not in a subsidized month. I know a woman the other month 600 a month in premium and 6,000 in deductible. You have a group of people suffering today so were trying to fix that market so people can get access to coverage. I will say, obviously, theres a partisan divide on this bill that we are not going to overcome today on this stage. I did want to, in the last few minutes here, ask about another part of this. We talked about the just from the industry perspective, the Public Health perspective, the oversight perspective. This was also a criminal issue, that people are breaking the law here. Senator markey, you talked about fentanyl and the very serious problem with that very potent opioid has created. We have a proposal on the table by senator grassley and senator feinstein to give federal prosecutors, the Justice Department more powers to take action in that regard. Have you had a chance to look at that legislation . Is that something that you are able to support or is there another way to go about it . Well, look it, we have to crack down on the really bad actors, that is the drug cartels coming in from mexico, what china is doing. We have to elevate this importation of fentanyl up to the same level as deeply as nonproliferation and copyright discussions. Thats the level, thats the terrorist threat on the american streets of america. Theres no two ways about it. Thats how the American People see it. But lets be honest, we owe an apology to an entire generation of africanamerican young men we incarcerated as part of the crack cocaine epidemic in the 1990s. Lets not think again we can incarcerate our way out of this problem. We can only provide treatment to get out of this problem, and while there might be some targeted Law Enforcement measures we can all come together to support. The overriding issue is providing the funding, the access to treatment and prevention for families in our country. Mr. Chairman, any what are you hearing from the Law Enforcement in your district . And what other tools do you think they need . Yes, there are some communication issues we need to carefully think through between Law Enforcement and the prescribing community. How do you manage patient privacy in that realm . You know, when Law Enforcement picks somebody up, what are they on, how do you treat them . Theres some communication issues there. And i think it really gets back to whos issuing the prescription in the first place. And are they getting the proper consultation and best practices. Because thats where it starts. We have this other issue. And i concur we have to deal with in terms of people who are hook. But we are now making some progress. Instead of issuing a 90day prescription it is 21. Fewer pills. And were investigating, will and i, hes investigating, will, the fentanyl issue. We are investigating the issue in West Virginia. How does a community with a few hundred people have a few hundred million pills going into it. We are doing a lot of that work as well. I commend the chinese for the steps they have taken. But obviously theres more to take to reduce access to fentanyl. Lets look at the postal service. Most of this stuff is coming in through the u. S. Postal service because they dont have the tools to adequately screen it out. We have some of this on our own hands here that we have to do more work on. We will be investigating all of those through the oversight committee. Congresswoman, i will give you the last word. I will just end on a collegial note here, is that what both of my colleagues it is really true. We need so much more coordination. Understanding of the problem. Coordination with the whole system. The prescription system. The Law Enforcement system. We didnt have that before. We also need to have a medical understanding of how these opioids work and what the best treatment is. In colorado, we have a consortium that has formed. I just met with them the other day. And theyre looking at these whole li holistic approach. How do we work on controlling how these opioids are prescribed. How do we prevent people and educate doctors and patients. And then how do we work at it from the Law Enforcement perspective. And how do we help people who have become addicted. I think more and more people realize that whole liftic approach is really the approach thats going to work. And in congress, what we need to figure out is both how to get the funding for that and also how to get the programs that work. I want to end real quick. Yes. I think its really important. We also should not overreact. These drugs are very important in Pain Management when administrated appropriately. And so we have to understand there are a lot of people managing pain effectively with opioids. We have to make sure we dont overreact and hurt them along the way by accident. So its a balance. Okay. Thank you very much. Congresswoman diana degette, senator markey. Thank you, all. Well have more panels for you very shortly. Youll be in very good hand it is. My colleague wendy bernstein. Thank you very much. [ applause ] thanks a lot, thanks a lot. Morning, everybody. Morning. Thanks very much for coming. Im lenny bernstein, the health and medicine reporter here at the post. Joining me on stage to talk about this Public Health crisis from a medical perspective and how doctors and Health Care Providers are responding to the opoid epidemic in america, we have dr. Andrew, the codirector of the opoid research. At brandeis university. Dr. Lena wen, Health Commissioner for the city of baltimore. More fortunately for us, these are two of the most farsided thinkers on this subject. They have been talking about this for many years. The doctor was sounding the alarms about irresponsible opoid prescribing before many of us were listening. Dr. Wen was taking these steps before many cities were responding to this crisis. Andrew, it seems that when we throw the full weight of our Public Health resources at other epidemics, hiv, drunk driving, car accidents, that we much more quickly were able to bend the curve on fatalities. Here we are 17 years into the opoid crisis. If the latest stat is correct. The numbers are just continuing to escalate. And escalate rather sharply. Whats different here . Why havent we why havent we been able to solve this . Thats a good question. I think one of the main reasons that we have failed to respond appropriately to the open idea crisis is that it was misframed. And intentionally so. So, you know, certainly by 2000, 2001, there were reports coming from appalachia and new england about oxycontin overdoses and addiction. And it was clear we were having a problem with opoioidsopioids. From the beginning of the crisis, the way the issue was framed, particularly by pain organizations that were getting funding from opoid manufacturers, the way the issue was framed for policymakers was as if all of the bad things that were hearing about, all of the open idea harms policymakers were told were limited to socalled drug abusers. And that millions of patients were being helped by the increase in prescribing. And so policymakers were told that, you know, your challenge is to try and do something about this drug abuse problem without making the chronic pain problem worse. Millions of americans are suffering from chronic pain. And if you were to promote any kind of intervention that would result in reduced prescribing, youll be punishing the pain patients for the bad behavior of the drug abusers. So youve got to balance these two competing problems. The reality is that we dont have these two distinct groups. And opoids are not safe and effective treatments for the vast majority of people suffering with chronic pain. Millions of patients with pain have become opoid addicted. Thousands of patients have lost their lives. And so the opoid crisis is not an issue of drug abuse. Its not an abeca abuse crisis. It ug suggests the problems drus good and theyre seaccidentally killing themselves, and maybe its making the pills that are hard to crush. Its not an the reason were seeing heroin and fentanyl in nonurban areas and children winding up in the foster care system, outbreaks of injection related Infectious Diseases is because weve had an increase in the number of americans suffering from opioid addiction, and if were going to bring the epidemic under control, we have to stop creating new cases of addiction through more cautious prescribing and see that millions have access to effective treatment. Very briefly, you and i have both spoken to dozens and dozens of people. Many of them older folks who swear they couldnt get through the day without their open yoids. It might be a small dose. It may never have increased the dose, but they say im in this wheelchair without these opioids. There are about 10 million to 12 million americans who have been put on longterm opioids. When you write a story about opioids, youll sometimes see in the comments section people writing in saying im not an addict, and youre punishing me or calling me an addict. I shouldnt lose access. Youve got many of these people who may truly believe the opioids are helping them. But if theyre on daily longterm opioids, theyre probably not being helped. What they may experience as relief when they take an opioid is probably relief of withdrawal pain rather than relief of an underlying pain problem. If youre taking opioids every day, around the clock, like an extended relief opioid that you take at morning and night, and youre doing it for months and years, its unlikely that youre still getting pain relief from the drug if youre on opioids chronically. Youll need higher and higher doses, and as the doses get higher, peoples functioning begins to decline, and we know that opioids can even make pain worse. Its a phenomenon. I wouldnt say we should never give opioids to people with chronic pain, but the way they might be affected for people who suffer from chronic pain is if theyre used intermittently. On a bad bay. Around the clock opiods are not helping these patients. And millions of americans are now stuck on opioids. I think we should really be thinking of that population as victims of our era of aggressive prescribing. We need a compassionate response. We dont want their primary care doctors to just fire them. For some of those patients we probably see them turn to heroin if they cant get opioids. Understood. The truth is we know what works in the battle against opioid addiction. The science is there. The policy is there. Could you tell us what works and why we still have an epidemic if we know those things . Thats right. And this is why all of our discussions today are so frustrating. There are a lot of diseases out there for which we dont have a cure. We dont have a treatment. We dont have prevention, and we really struggle with those, and we need more research, and yes, we need more research when it comes to opioids, but we actually know what works, and to your question earlier about why has this been so different from any other Public Health crisis, theres one word. Stigma. There are myths and disconceptions around the disease of addiction thats more different from other illnesses. I hear in baltimore you mentioned that wed been putting out our anecdote medication. I wrote a ban klanket prescript to all of our residents. Because everyone should be able to save a life. And yet, i hear people all the time say, well, why give this medication to people . Isnt that just going to make them use more drugs . Would you ever say to someone who is dieing from a peanut allergy, im sorry. Im not going to give you an epipen because it might make you eat more peanuts next time. We dont hear that. This drug is immediately life saving. Its nonaddictive. Its safe, and we have to save someones life today so get them into treatment tomorrow. Thats one thing that works and we dont have enough of it because of stigma. Theres also a huge stigma around treatment. We dont say to someone with diabetes, well, why are you still on insulin . Why cant you get off of your insulin and lifestyle changes, shouldnt that be enough, and yet, we make those assumptions about people with addiction before. Actually the science is clear that medications assisted treatment with methadone combined with social counseling are what works for the treatment of addiction. And for so long we have treated addiction as a moral failing, as a crime. Id go back to what i think our senator had as excellent points about a generation of people who we have to apologize to. In Baltimore City, ive had our residents at community forups come up to me and say i dont understand why suddenly the Opioid Epidemic is a Public Health crisis. Why is it an emergency when its been a state of emergency my entire life . Because it was poor minorities in inner cities who had this illness, and therefore, it was seen as a choice and moral failing. So if you end up in jail or dead, its your fault. Im glad were seeing it as a disease now, but we need to treat it as a disease and devote the resources that are necessary to fight it. And quickly, how many people what percentage of the people who need it get treatment . The Surgeon General support said that its about one in ten people. One in ten people with the disease of addiction are able to get the help that they need. Now, what other disease would we find that top acceptable . Would we find that acceptable with only one in ten people with cancer can get chemotherapy . Okay. One of the things that has changed in the last few years is that prescription opioids, the rate of overdose and addiction from those is going up much more slowly, but we have this explosive fentanyl heroin crisis. Doesnt that change the epidemic for us, and what do we do about that . I think its important to understand and interpret the data appropriately. What weve seen over the past couple of years is a leveling off and maybe a slight decline in Overdose Deaths involving prescription opioids. Starting in 2011 weve seen a soaring increase in Overdose Deaths and heroin involving heroin. And i think that many are misinterpreting that data. That whair thinking is that while weve seen this leveling in prescription opioids and prescription has gone up, that means the drug users are switching from the pills to heroin and that the painkiller problem has turned into a heroin problem. Thats not really correct. Its half correct, and that the vast majority of people who have started using heroin post 1995 were first addicted to prescription opioids. The switching part is correct, but the switching didnt begin in 2011. From the beginning of the prescription Opioid Crisis, young people who were becoming opioid addicted were switching to heroin. A young people who becomes opioid addicted through use of prescription opioids and the use begins, the addiction begins from either recreation or medical use or statement a combination. Brief medical exposure followed by social use. Once addicted, they have a hard time maintaining their visiting doctors. Its not that doctors and dentists dont like to give lots of people lots of pills, but doctors dont like to give healthy looking 25yearolds a large quantity on a monthly basis, so young people are addicted and have to maintain their supply. Youre not using because its fun. Youre using because you have to avoid feeling awful. Once addicted, they have to get their supply. Theyre expensive on the black market. If theyre where heroin is available, they switch because its cheaper, and whats happened steadily from the beginning of the prescription Opioid Crisis is weve seen heroin flood into more regions of the country where it wasnt previously available to meet the demand by young people who are opioid addicted. What starts happening in 2011 is that the heroin supply becomes more danger. Increasingly it has fentanyl in it or its being fentanyl being sold as heroin. Weve seen this sharp increase in deaths among young haeroin users but not a sudden switching. But whats also important is we have two populations that are opioid addicted. The Younger Group i just described but an older group as well. People in their 40s through 80s. The older group is developing it almost entirely through medical treatment. The older group when they become addicted is generally not turning to the black market. When they become addicted, they generally dont have a hard time finding doctors who will maintain them on a large quantity of opioids on a monthly basis, and up until pretty recently, we were seeing far more Overdose Deaths in the older group that gets pills more easily from doctors than we were seeing from the Younger Group thats been changing to heroin. In 2015 the last year for which we have the national data, it was about equal in terms of the number prescription opioid overdoses to the heroin overdoses. I think next year we will see the younger heroin more deaths in the younger heroin using groups because of meant nifenta. Baltimore has had a heroin problem for decades. Thats right. What are you seeing out there . Its getting worse. We have had the crack epidemic, heroin epidemic. We also have prescription pills. Thats a big issue in our cities as well, and also fentanyl. Were hearing about fentanyl today, but its many times stronger than heroin. And its now being mixed in with heroin, and people who are using it dont know it. And so if theyre using what they think is their usual amount, and now theres fentanyl in it, theyre overdosing and dying. The number of people in our zi overdosing from fentanyl has increased by 35 times in the last three years. Not 35 , 35 times in the last three years. It is a no doubt, its a Public Health emergency, but as with all Public Health emergencies, its complicated and there are at least two components. Theres the supply issue, and theres a demand issue. We heard about the supply issue and the need for Law Enforcement. Sure, thats one issue. But then were going to continue to have a problem unless we can address demand. Unless we can get people who have addictions into treatment, whether theyre addicted to heroin or prescription pills, they need treatment, and unless we can address that, were still going to see this crisis escalate. And now because of how deadly this drug is, its only going to get worse. What weve done in the city is first weve gotten narkan into the hands of everybody we can. Weve gotten the drug not only into the hands of First Responders like paramedics and First Responders but also every day people. Every day people have saved the lives of over 950 of their fellow residents in the last two years. We have a problem where were being priced out of the ability to save lives. We dont have the money to purchase enough narkan. Thats a problem. Is that why baltimore is running low . Youre running out of money to buy it . Thats correct. We dont have a shortage of narkna, but we dont have enough resources to be able to purchase it for everyone who needs it, so weve had to ration this life saving medication. And weve also been trying to increase treatment, but also dont have enough resources to do it. Is it because some people need multiple shots of narkan when they take meant nfentanyl . Its such a strong drug you do need multiple doses of narkan. We have reduced the regulatory barriers so everyone can carry it. No Everyone Wants to carry it. People are calling the Health Department saying im a faith leader. I run a neighborhood association. People are overdosing outside my door every day. I want to have this medication here. We dont have nearly enough to supply everyone at our city who can save a life to be able to do so. I want to get back to a point you made. Maybe ill start with lena on this. Youre both physicians. I thought back in 2015, toward the end of the year, when the cdc put out the guidelines for physicians, and then that was soon followed by work by the ama, one of the more conservative physicians organizations, they started to get the message out to doctors. You know, you dont need to give 30 pills when someone has a tooth pilled. You dont need to describe 60 when someone has a very minor surgical procedure. It seems to be universally agreed that physicians are going to have to step up in some regard and take responsibility for this epidemic. Are they . Are they changing their philosophies . Because everybody in this room has a friend who went home with a bottle of vicodin, 30 or 40 for a procedure that really didnt call for it. From my standpoint, the medical profession is changing, but slowly. But in the right direction. So when i was going through medical training, i didnt really learn about how addictive opioids were. We had big pharma around all the time, really misleading people about how important it is to address pain, and yes, its important to address pain, but becoming pain free actually shouldnt be our goal. If you fall down and you sprain your ankle, you bruise your knee, i dont know if thaw need to take opioids to take away that pain. Maybe living with the pain is okay, but we didnt learn about that. And now we are. We are learning about it. But physicians, too, are frustrated. We went into medicine to take away peoples suffering. We dont have a lot of tools when it comes to pain control. Were not really taught about physical therapy. Were not really taught about alternatives to opioids. Thats something we have to work on. The guidelines are helpful. And physicians in my city are beginning to use the guidelines and hold onto those guidelines to do better by their patients. But i would say one more thing which is that we continue to be frustrated every day in our practice. Im an emergency physician. In the e. R. , i have patients coming in who know that they need treatment. They will tell me they need treatment. Every nurse, every social worker, every physician that sees them knows they need treatment. They may have overdosed and now theyre seeking treatment, but i say im sorry, the next available treatment slot is in three weeks or two months. Again, what other disease would we find that to be acceptable . Do we ever say, sorry youve had a heart attack, if youre not dead in three months, come back and maybe we can get you to see someone then . Is that an insurance rebimersment issue . Its capacity, reimbursement and something thats to be worsened if we repeal the aca, but thats a different story. Theres more that needs to be done, but we physicians should be seen as partners in the process. We should push physicians, but they are trying to do the right thing as well. Andrew, are doctors getting the message . Im not so sure. The increase in opioid prescribing that would ultimately lead to this epidemic, it starts in 1996. From 1996 to around 2012, opioid prescribing was still increasing. The medical community was responding to a Multifaceted Campaign that misinformed us, led us to believe that the risk of addiction was very low and the compassionate way to treat pain was opioid. Since 2012 its plateaued and come down a little bit. It really hasnt come down very far. Were still massively overprescribing opioids in the United States. We want doctors to be able to weigh risks versus benefits better when prescribing opioids, but theyre not doing that very well, and i think one of the problems has really been the food and Drug Administration. I think that unfortunately, the food and Drug Administration is not properly enforcing the food, drug, and cosmetic act. If it were properly enforcing that law in 1996, the fda would have said you have extended release oxycodone. You can market that for use in hospices and send your sales reps to the hospices, but were not going to let you promote oxycontin for back pain or in Family Practice because the risks of using opioids for back pain outweigh the benefits. If they properly enforced the law, they would have done that, and i dont think wed have an epidemic today. By 2002, it was clear the prescribing took off at a rate far beyond what could be clinically needed. Fda is beginning to hear from members of Congress Whose constituents are overdosing. Theyre Holding Meetings and saying should we be changing the way in which we allow these drugs to be marketed . Should we be changing the way in which were approving these drugs . And they asked that at a meeting in 2002 and unfortunately the experts they called in to advise them were the same doctors who were leading the campaign to increase prescribing, and fda decided not to make any changes, and, in fact, they went in the opposite direction. Other pharmaceutical companies saw how well it was working for purdue. They wanted their extended released opioids on the market as well, and fda made it easier for new opioids to hit the market. Despite the fact, there was a problem, theres been a steady stream of new opioid approvals. Each time a new one hits the market, that company that brings the opioid to market has to recoop a considerable investment. The way they do it is with a campaign to increase prescribing. So at a time when the cdc and Health Officials across the country are urging the medical community to prescribe more cautiously, youve got new products hitting the market with campaigns to increase prescribing. Didnt they just ask one company to take an opioid off the market . Yes. Because its so being so widely abused . Yes. And the fda just asked a company to remove opana from the market, and hopefully this could signal fda is beginning the change the opioid pistoriuss. Its unclear whether that was based in a change in fda or had something to do with a battle between fda and endo over the naming. Theres quite a bit fda could do, and if they start taking the proper steps, it could be very helpful. We have about five minutes. Im going to give you each about half of that. Youre the drug czars. I mean you have all the power in the world to change this epidemic. Lena, whats your list of policies . Sounds amazing. First of all, i have to get used to this. First i would ensure that there is treatment on demand. Not treatment in three months but treatment at the time that people need and the right treatment. We shouldnt be telling people, well, theres only one thing available. You get methadone or counseling. We should give people the services they need. Ensuring treatment on demand. Second, i would support those on the front lines with the resources that they need. We in Baltimore City work closely with Law Enforcement, attorney offices with our nonprofit partners. We know what we need in the city. We have have state and federal partners, and as long as were able to get the resources, we know what works best in our communities. So support those on the front lines with getting the treatment that we need. The third is i would change the culture. Something that might take a little bit longer. But we need to change the culture by asking the difficult questions, including why is it that we have this mentality of a pill for every pain . Right . How can we change prescribing practices . Approval, but also the culture, the mentality that patients have, that we all have for a pill for every pain. And we need to ask the question, what pain is it that were treating . Because were not just treating physical pain. Were also treating deep trauma, deep disparities, Mental Health issues that may need to be addressed in another way. There needs to be a systemic and wholistic approach that can only come from us asking the hard questions and taking the difficult approach. When we see that, this is a solvable problem. We know what works. We just need the resources to get there. Okay. That was less than two and a half minutes. Im going to ask you a quick question, yes or no, before andrews list. Safe injection sites. Theyre against the federal law right now, but yes or no here in the United States . I would do it. Its a facility where people can come in and be monitored while they are using drugs. Theyll have a nurse who will take their blood pressure, their oxygen saturation while they are using drugs. This is a Harm Reduction approach similar its an extension of needle exchange. Theres one in vancouver. Its never lost anyone to an overdose. Thats right. And theres evidence saying its one approach to be taken to reduce the number of overdose stats. Since there is evidence for it, and because it is a Harm Reduction health approach, its something we would explore in Baltimore City if it were legal, because we dont really want to go to jail, and dont want all our federal funding to be pulled in order for us to do that. Thats a yes. So ill answer the safe injection, and then tell us how you would okay. I dont know that it will really help or hurt, so where it makes sense to have a safe injection facility is where you have an urban area, where there are homeless or people who are injecting drugs and they can go in and inject someplace where they can be monitored. Like baltimore. Yeah, but our Opioid Epidemic is disproportionately suburban in rural. We saw a fight in ithaca, new york over whether there should be a safe injection facility there. In urban or rural areas, i think its unlikely people will drive to town to inject in a facility. I think if they built it, nobody would come, and you have many areas where there are waiting lists for Addiction Treatment, and to get drugs that save lives and you got debates over whether or not to have a safe injection facility. I think there are interventions that would be more effective. Okay. Youre the drug czar for 82 seconds. There are many different policies. And i heard an economist talk about the problem recently. He said theres no magic bullet. We need a magic buck shot. What ill mention is the big picture strategies for controlling the problem. This is an addiction epidemic. And the way that we respond to this disease epidemic is similar to the way you orespond to othe epidemi epidemics. You have to prevent people from getting the disease, and see that people who suffer from the disease get effective treatment. To treat it, it boils down to much more cautious prescribing so we dont indirectly cause addiction by stocking homes. Theres a lot to be done on a state level and federal level produce more cautious prescribing, and for the millions who are addicted, you have to see they have access to effective treatment. When i say effective treatment, im not talking about counseling or rehabs or deto bes xes or ce injections. Im talking about treatment and methadone maintenance. We have to see its easier to Access Solutions than drugs. Were failing in every aspect of responding to this problem, but we also, if were going to respond appropriately, we need better surveillance of the problem. We need to know how Many Americans have opioid addiction. There was a report yesterday in the Washington Post that over 1 million americans have received a hospital treatment for opioid addiction, yet the national estimate of the number of people who are opioid addict second down 2. 5 million. Its an underestimate. Its well over 5 million that are addicted. We need to be able to measure the estimate how many new cases there are. So we now whether our efforts are working. We need much better Public Health surveillance. Thank you very much. Thats about all the time we have. Doctors, thank you so much for joining us. We look forward to speaking with you more in the future. Thank you. We want to introduce our sponsor segment and bring to the stage joe berger, Vice President and general manager for health and consumer, and also the deputy for the institute of drug ace bus. We heard a lot of statistics this morning about the opioid problem. I live in ohio. We have the unfortunate honor of leading the nation in this problem. In fact, i was driving to the airport yesterday and heard the most recent statistics on central ohio. Its mostly urban and suburbans. The opioid deaths are on track to reach 500 this year. We continue to be faced with this problem. Now the question is what can we do about it . Today im joined by dr. Wilson compton to discuss evidencebased treatment strategies to reduce the number of people developing addiction problems and to treat those who become addicted. Thank you for joining me. Im glad to be here. What are some of the biggest areas of progress weve made in stemming the tide of opioid addiction . Were making some progress. I think you just reminded us even as were making progress in areas, the in your opinion of deaths continue to increase. That has every Public Health official and every policy maker concerned. How can we do a better job of addressing this Public Health crisis. We see improvements in two areas. One, the overall number of prescriptions written for opioids has begun to decline. It levelled off starting in about 2012 and weve seen a reduction in the physicians electric willingness. We need to do a better job. Not level off but decrease the number of prescriptions significantly. The second hopeful sign is weve seen a terrific improvement in the Recreational Use of the medications by teenagers. About 15 years ago, we saw about 10 of 12 graders were misusing a prescription opioids to get high. They were using the prescriptions recreationally. That number has dropped to under 4 . Thats a terrific improvement. And this is the future of the field. These are the people who will go onto misuse in their early 20s and develop the series problems that end up with the addictions and deaths were seeing now. I think thats very hope of. Id love to dig into that more, but weve heard this morning about medication assisted treatment a lot. Id like to talk a little bit about what that is, maybe for our audience who arent as familiar with it as some. I think its a great question. What is medication assisted treatment . Basically it means using a Prescription Medication to combat the disease of addiction. Were very lucky in this field of opioid use disorder. Opioid addiction. We have three fda approved medications. Weve had methadone to treat people who are addicted to opioids. We added another drug a few years ago, and weve had neltrexone. More recently we had a long acting version of it. Thats a blocking agent. These come in two different classes. Two are medications that substitute for open yoitds and allow people when dosed properly to enter recovery and get back their functions and save their lives. Terxone blocks how opioids work in our brains. Its a blocking agent, and now it can last as long as a month with a single injection. Are you seeing trends . Are some of these becoming more popular . Are some of them being used less . Whats happening in that area with these three different treatments . Of course wed like to see these medications be available to every patient that needs them everywhere in the country on demand. Thats actually our goal, and thats the goal of all the Public Health system, to increase the availability so if you or a loved one has a problem with addiction and you go to your physician or show up in a emergency room, they can get you treatment on demand. Unfortunately, thats not the case. We have seen increases in both methadone availability. These have to be in specialized methadone treatment programs. Weve seen increases in prescribing of drugs. We needed changes in the rules. We see an improvement in the number of people they treat. We also see increases in the availability of the longacting injection. We spite that, there are tremendous barriers in many parts of the country and a lack of educated clinicians to take care of patients that need this care. Whats keeping what are some of the policy issues . Whats keeping us from getting it more broadly available to patients who do need it . The fundamental issue is the stigma around addiction. Weve spent too long of thinking of it as a failure of decision making. Youre making bad choices, quit doing it. If it were that simple, all the patients would have quit long ago. They suffer tremendous harms and yet, because of the compulsive behavioral origins, they keep engaging in the behavior. Thats why we need effective medications that can combat it. I think forums like this that help educate the public and others about the medical nature of this disease can really make a big difference. So, we both live in the research world. Lets talk a little bit about some of the research you think that needs to be done in this area. And maybe talk a little bit about some of the research that youre doing at nida to help us understand the problem better and address the problem. Im proud of the work were conducting at the National Institute of health and the national newt on drug abuse to address this drug akries. I put the research in two main buckets. One is we have treatments that have effects. We have treatments that are useful. We have prevention approaches that can provide communities and families and the tools they need to raise healthy children and keep them from moving into the addiction sphere. So why are we implementing these widely . Thats sort of the key Research Question . What can we do to improve the access and availability of the current treatments . Now, as much as i like our current treatments and im thrilled we have ways to prevent the treatments, theyre not as effective or as good as i would like. I would like something that was perfectly effective. I would like something as bad as ampicillin for an ear infection. You get the medication and youre better. Thats not the base with Addiction Treatments. They work. They help people, but only a minority of the people that start them. People stop the treatment. This is a longterm condition. These are some of the issues where i think research can provide tools that can be the solutions to these longterm problems if we invest in research successfully. Weve talked a little bit this morning about the how this is a bigger rural problem than maybe an urban problem. What are the some of the ways that maybe we can help that Rural Community access some of these treatments more effectively . Its probably weve heard its much easier maybe to put this in an urban setting, but what about the rural settings . Its not just limited to addiction. We struggle to get health care to rural populations across a range of issues. If you need a card yoiologist a you live outside an urban area, its hard to get those doctors. Theres some of the parts that dont have access to general or family medicine. What can we do to use telehealth or parttime practices that may come into these locations . What can we do to get physician assistants . Other forms of care that are part of helping people enter recovery in all the regions that need them . Can we use the internet to provide care Long Distance . Some of that has been shown to be possible. Research can help as can the new funding that weve seen with the 21st cinentury cares act. You got a little bit ahead of me there. What Public Health policies that have been implemented at federal state or Community Levels even do you see having a positive impact other than maybe the cures act . Well, there are multiple policies and practices that need to be implemented. What can we do to change the vabl availability of medications to treatment . Some states have regulations that require to fail nonmedication treatment before you can even start medications. That seems counterintuitive. As a physician, i want my patients to have access to the effective medications when they have a problem and not have to fail another ineffective approach before they can take what might help them. Thats one example of policies that can change. When it comes to the provision of noloxon, theres a prescription written so everyone in the city of baltimore can gain access to this lifesaving med dags medication. Thats not universal. What can we do to make sure this immediate nonaddictive medication is universally and easily accessible when people have an overdose in those libraries weve been hearing about which is a remarkable story or in other places where people may experience this death. Thank you very much for joining me this morning. Thank you to our audience for coming today and to the Washington Post for focusing on such an important Public Health issue. I encourage you after the speakers are done to talk to our subject Matter Experts who are outside. And now its time to turn it back over to the Washington Post for the next discussion. Thank you. Thank you very much. Welcome back again. Today in this segment we have anne prichette. She is the Vice President at pharma, the association that represents large foorm suit cal manufacturers, and were going to talk about their role in the epidemic, and what might be done about it. And i think im supposed to remind you that if you would like to tweet us questions, we can take them off here and request. So lets start with the premise that this country has more opioids than it may need for legitimate pain control. Why is that . What is the manufacturing companys role in that, and why are we seeing that and the contribution to the ep dem snick. I would say the cdc has said there are enough prescription opioids being supplied so every person in america has a 30day supply. In terms of the sources of the problem, there are a number of different factors that have contributed to the situation were in now. There are inappropriate opportunities to identify inappropriate prescribing. There have been lack of clinical guidelines to inform physicians prescribing, and weve seen changes in that space, particularly with cdc releasing information. Theres insufficient use of Prescription Drug monitoring programs. These allow you to identify doctor shoppers and inappropriate prescribing behavior, and yet only 22 of 49 states require that physicians access those databases. So we need to do more in terms of using the resources we have. We have seen that the dea this past year reduced the corda which was taking away a cushion in terms of opioid. Theres a connect in that dea said there was a cushion and they reduced the amount of lowered the cord us for manufacturers, but at the same time, we have a gao report saying when you look at drug shortages, the vast majority are for pain medications. There is a complex as we heard from the prior speakers that we really need to get our hands around collectively. I think weve seen tremendous progress from the administration where the fda is announcing, saying theyre going to review what their role is in terms to have crisis that we have nih, as you may have heard from wilson on the Previous Panel that nih and nida are looking to develop a public, private partnership with industries to develop nonopioid analgesics. Thats alternatives arent addictive to further science and technology to allow us to explore other ways to appropriately treat pain. Before we get to those, when we read or unfortunately some of us see on the ground and others experience that 780 million opioids are sent into West Virginia over a fiveyear span, certainly the distributors who are bringing those there know that that is occurring. The retailers who are selling them in drugstores know that is occurring. Dont the manufacturers know as well . Shouldnt they intervene . I think that everyone in the supply chain has a role and responsibility to behave ethically and legally and to ensure that only as much medication as needed is being provided. And i think clearly theres a break in the supply chain that thats not occurring . What can we do about that . Under the law everyone is supposed to raise a regular flag. I think its collective. I dont engage directly on the supply chain issues, but what ive read from different entities is one of the challenges is that there is a lack of clarity from dea on what is a suspicious order, what each person, and what each actor in the supply chains role is, and that i think there does need to be more coordination the dea and the fda in terms of engaging in areas. Theres a collective responsibility, and i wish i had the Silver Bullet answer to that. But i think events like this that are bringing attention to the issues and that we have an administration that has stated that they are focussed on this. We have a congress that over the past couple of years as really come to the recognition that Prescription Drug abuse and addiction are bipartisan issues, not political issues. And that we really need to address them wholistically. We need events like to this to bring people together and talk act collectively identifying the appropriate solutions. In what fashion are the manufacturers engaging with the government . I would say in a a number of our companies have been engaging with nih in the discussions about Public Private partnerships in terms of developing medication alternatives, furthering abuse deterrent formulations. Weve been supporting the efforts of the fda is look at things like should there be mandatory education for prescribers for pain and addiction. Thats something we feel strongly about. Its not popular among some provider groups, but the fda requires as a Risk Mitigation stre strategy of extended release opioids that theres medical training for providers an how to appropriately prescribe opioids but only about they werent able to meet the goal of 80,000 prescribers taking the training over a twoyear period. We think its critically important theres a focus on unfortunately, while no one likes mandates, the reality is prescribers need better education about the treatment of pain and about addiction. Studies have found that medical schools only spend a hand full of hours on how to treat pain as well as how to treat addiction. Thats a huge gap in our system. And our view is very strongly that you should only that physicians need the education needed to determine when its appropriate to describe an opioid, when it isnt, and that when they are prescribing one, they are relying on clinical guidelines to inform at what dose and for how long, and whether there are alternatives. I would say one of the other areas where weve been engaged in is educating i would say one of the challenges in this area is that a lot of people think they have this misconception that because its a prescription medicine, its somehow safer than Something Like heroin. Thats not accurate. We all need to do a collectively better job of educating the public about the dangers in this space. And we need to discourage people from sharing their medications. Its disturbing when the National Household survey on drug use and house finds people obtain drugs from a Family Member or friend. We patients should take their medications ads directed. They need to safely secure their medicines and appropriately dispose of them, and sharing of medications is not appropriate. Lets talk about the pills. Abuse deterrent pills. Or other forms. Its been tried. It hasnt been hugely successful. Is it possible . Can you make the medications unusable by abusers . I would say before i came to pharma i was on the illegal drug side. We found those that want to do ill will are always one step ahead of the game. I want to correct something a lot of people think if its an abuse deterrent, that means it cant be abused at all. Thats not accurate. It means theres less potential of abuse. And there are a variety of forms of deterrents and the fda recognizes the science and technology continues to evolve in the space, and thats one of the reasons why the fda requires post Approval Research on the medications, so were continuing to collect real world evidence to assess how well the medications are working and their level of abuse deterrents this. Thats one of the areas the nih Public Private partnership is intended to focus on. How do we develop better i ai bus deterrent technologies. What can we what can we learn about biomarkers so we can more appropriately target medications . Because pain is not one size fits all. Addiction isnt one size fits all. Theres a lot more that needs to be done, by abuse deterrent formulations are one part of the tool kit. So they should be in the tool part. Theyre partly successful, even though, the folks are going to abuse always seem to find a way into them. Maybe you could tell folks what a nonopioid onanalgesic is, and the possibility for using opioids that kill pain but dont provide the euphoric effect. Ill give you a sense of whats in the pipeline. More about 40 abuse deterrents in the pipeline. About 40 different medications to treat addiction. Many of them are opioid reversal agents. People are looking for convenient delivery forms. And then one of the areas is n nonopioid analgesics. This is looking at alternative medications where they dont have the potential for addiction. There are about 30 drugs in that space and development. One of the Biggest Challenges is that when you look at the opioids that are on the market, about 96 of those are generic and none of them have an abuse deterrent formulations. Only about 2 is abuse formulations and the other 2 is branded opioids . Why wouldnt generics have an abuse deterrent . The fda just finalized their guidance in that area. I would say one of the challenges is theres a lot of scientific and regulatory uncertainty as youre developing them. The fda doesnt have a black and white as to heres the criteria to meet as being an abuse deterrent formulation. Thats one of the challenges. We also have a disconnect in terms of when you look at the commercial coverage policies for the products. So what you generally see is that the generics that you generally see that abuse deterrent formulations are tier three and four. In other words, youre failing first on Everything Else. And theres not kind of a calculation that from the insurer perspective that we need to be considering the possibility for abuse. The fda said its a key priority to approve it. Its only one tool in the tool kit, but important. I want to make sure i understand. 96 of the opioids that folks take routinely, daily, legally, do not have any kind of abuse deterrent . Correct. So if someone, if a kid takes one out of my medicine cabinet, theres nothing there that would keep him from crushing it and snorting it or cooking it up and injecting it . Correct. Thats one reason we think its so important to increase our prescriber medication, and we support mandatory education on an expanding basis. Were going to have new nonopioid analgesics coming into the market. But prescribers need to know the new developments in terms of what medicines are coming, what the risks of the new medications are. They need to know the current learnings about the treatment of pain, the potential for addiction. Weve seen over the past couple of years just recently the American College of physicians altered the clinical guidelines regarding the treatment of lower pain. And the cdc changed the guidelines on how to treat chronic pain. So we need to ensure that prescribers are up to date and thats important. I would say educating the public as someone who has had loved ones affected by Substance Abuse issues, when im meeting with a doctor, im meeting with a doctor on behalf of a Family Member, im comfortable saying is there a potential, an alternative . Whats the most appropriate treatment. I think we need to educate patients and care givers to ask questions of prescribers. Empower them to know medicines need to be taken appropriately. If they have questions, ask the prescriber so theyre being appropriately treated . If youre not able to ask the question, perhaps your loved one can ask them for you . Yes. And as one of those in the generation who increasingly youre taking care of your parents, the roles shift a little bit. Its important given that were seeing a higher prevalence of addiction among theres two issues. Nonmedical use of open yoitpeni those being treated for chronic pain thats being addicted. Theres increased focus on how to prevent addiction among those that may be taking a number of medications including pain medications over a longer period of time. I think of a nonopioid analgesic as acetaminophen. Thats not going to work for post Surgical Pain or the pain of cancer late stage, your end of life pain. So what are we talking about . Whats in development . So weve got about 40 different medications at various stages that hold promise. I would say that when we are talking about lets say breakthrough chancer pain, late stage, having seen my grandmother suffer from that, and fentanyl was the only thing that helped her manage that Breakthrough Cancer pain. We heard from the other panelists, fentanyl is being implicated in exacerbating the current crisis. And a former fbi director came out with a report that was bringing attention to the threat of counterfeit fentanyls. The dea hundreds of thousands of counterfeit fentanyl pills are coming to the u. S. Through mexico and canada. This is kpsexacerbating the opi epidemic, and fentanyl is exponentially more powerful than morphine. And so we have this challenge of needing to address the need to ensure legitimate, that patients with legitimate medical needs have access to medicines they need, but we need to increase the Law Enforcement efforts, including considering whether we need to increase penalties for those that are involved in criminal organizations bringing counterfeit fentanyl into the u. S. , and weve heard an elephant tranquilizer being mixed with illegalubstances. We need to ensure where opioids are appropriate, that physicians have the clinical guidelines to inform their prescribing. And opioids are a critical medication, and when used appropriately can be beneficial to patients, but we need to identify alternatives, including nonmedication alternatives, other therapies that are appropriate. Were getting close to the end. Two more questions. Were getting a number of questions on twitter about cannabis, and whether pharma might go into that area. I think the point is to get me to say canabanoid in front of these people. There are some medical cannabis products available. Weve looked at the pine line. I want to say its a half dozen products in the pipeline that are in that space. There are companies that are exploring medication uses under and it has both practical potential and affordability . I think i am not in a position to comment on that. That we need the science to tell us whether and what the potential is. Okay. Great. In the last session they did this. For the next minute and 44 secs, youre the drug czar having worked in the drug czars office. Thats right. Whats your list . Were giving you the power you need to solve the ep dem snick. For me this is a multifaceted problem. Among of my top five on the list its that we need to improve education for prescribers. That means mandated education. That means on an ongoing basis. As part of that continuing to educate the public to increase their awareness of opioids and when theyre appropriate and when theyre not. That, two, we need to mandate the use of Prescription Drug monitoring programs. Studies show when prescribers are using monitoring programs, it affects their prescribing, and that many of them say it has reduced the potential for misuse and abuse. Even if they dont catch doctor shoppers, it affects the way they do their jobs. Yes. I think we need to look at the prescriber patterns and look at the flags for potential doctor shoppers. In that pdmp space, one of the things weve heard from physicians is you have to get through ten screens to get to the information you need. We need to improve the capacity to crack down on illicit welcomes that are illegally providing controlled substances in the u. S. , and we need as we heard earlier, to increase treatment capacity. And i would say one of the big positives is that while i heard a lot theres still a lot of stigma, having worked in this area for the majority of my career, i think weve made a lot of progress. Were all here having this conversation today. Thank you very much. Your term as drug czar as just ended perfectly on time. Id like to thank dr. Prichette first, and then im going to hand this over to my colleague mary jordan. Shell be interviewing former congressman patrick j. Kennedy. Wow. What a morning. Im mary jordan from the Washington Post. And i think you know who im with here, patrick kennedy. He was a congressman from rhode island, and now hes devoted his life to going around the world and our country and talking about addiction. And hes just joined the White House Commission thats trying to combat this epidemic. So were delighted to have him here. Thank you all in the room here at the Washington Post this morning, and we encourage those here an online to send in questions. Its hash tag post live. So patrick, this matters a lot personally to you. Weve heard a lot of statistics and sad ones this morning, but why dont we talk about what this does to people, and then you can start with your own personal story. Well, my late grandmother on my moms side died at the age of 61. Wasnt found for a week. Like most people with alcoholism, she pushed away. My mother, my aunt, her husband, and she was alone. And that same disease that she had passed itself to my mother who had very debilitating both depression and alcoholism which i grew up with, and my dad, of course, had all these luminaries of the day come over to our house, people who are household names, and my mom would shuffle through the house, clearly, incapacitated from her illness, and no one would look up, and no one would look at her, and no one would say anything to her. So as a young boy, i got the very clear message that these were not things that we should talk about. And i, like everyone else, was hoping and praying that my mom would go back go back into a ro lock the door so that she could spare us the embarrassment of being out amongst everyone in our house. I had friends come over to the house to play with me when i was little, and i was terrified my mom would come to the door if my friends mom would ring the doorbell. And no one talked about it. Now, my dad had a number of traumatic events that happened in his life. We didnt know what trauma was back then until 9 11 this idea of posttraumatic stress was not something in our gnombut my dad anyone suffering from posttraumatic stress, my dad would be the guy. He would be like a perfect portrait of someone suffering from posttraumatic stress from the assassinations of his two brothers, you mean . Yeah. And we had until after he died and there was all this stuff written about our house and how there were bullet proof vests in every closet and i didnt think anything of it. Someone asked me there were bullet proof vests in every closet . Like, yeah. Arent there in your house too . It was a normal. And until i was able to look back on all of it and understand what they were suffering from the thing i write about in my book is the common aspect of it is we dont talk about these issues. I myself ended up having multiple addictions. And suffering from Mental Illness as well underlying those addictions. And even though i was the sponsor of Mental Health parody and addiction equity act, the law that requires Insurance Companies to pay for treatment of Mental Illness and addiction the same way they would pay for any other Chronic Health condition, i myself still cannot wrap my head around the fact after i went to rehab that i still needed continuity of care, i still needed Chronic Care Management, just like i got for my asthma. I have very, very bad asthma, i have to see my primary care physician and pull monologist all the time. But somehow my insurers were paying for my inpatient at mayo clinic but werent paying for any followup. And these Insurance Companies know better. And then they complain to people like me who are trying to enforce the parody law that, well, theres all these fly by night rehabs down in florida that arent given evidence based treatments. Im like, you got me, im with you. Im not trying to protect them. In fact, id like to shut those places down because theres 90 relapse rate for people coming out of those places. Theres no outcome based metrics and Insurance Companies still have to pay for that. Thats not what we want. We want chronic care, continuity of care recovery living and Insurance Companies arent paying for that now. I jumped right into my policy speech no. But this is. Trying to get away from having to talk about this important issue. Well, first of all, thank you for sharing your story. I think that weve heard this morning about stigma and that this still exists. And somehow if its in your mind like its not in your body. And so do you feel like there is some Movement Forward on that . I think were in denial. I think our country is in deep, deep denial. If this were an infectious disease, wed be throwing hundreds of billions of dollars at it right now. We know what to do. We dont need anymore white house policy forums, we dont need Surgeon Generals reports, we dont need the Washington Post forums. We know what needs to do. Lets talk about what needs to be done. We need to understand its the whole person. The bottom line in all of this is that we need to align financial incentives to encourage prevention, which is the best treatment of all. To encourage Chronic Care Management and integration of the whole person, ie Mental Health and addiction needs to be treated along with all other physical health conditions. So thats got to be our concept. And we have to understand that social determinants make a big deal. Like if you grow up in a family like kaiser showed where your mother or father was alcoholic, in jail, lived in poverty, subject to violence, witness violence, you check those bars off your trajectory in terms of vulnerability and risk goes through the roof. So its not like we have to spend a lot of money on everybody. Weve got to spend the right amount of money on those with the highest risk. And spend it on prevention and chronic care. So now youre at the white house. You had your first meeting. And who showed up to that meeting . So first of all the commissions really impressive. I mean, governor christie, if anybody saw his video that went viral during the president ial about talking about addiction, Everybody Knows governor christie gets it. Okay, he gets it. And we have governor cooper, a democrat. We have ber tha madris, i wont tell her affiliation but she works out of harvard hospital you can guess her affiliation. Im obviously democracy. And you have baker from massachusetts whos not like considered a real hard core trump supporter, right . So the irony is youve got a commission that i think is very legitimate. But does trump himself care . Hes talked about this throughout the campaign. He said this was high, high, high on his issue and now we have to talk about what money is he putting up and especially with whats going on in health care right now and perhaps slashing in medicaid. You know, is the white house really ready to address that . Because youre one of the few people in there talking. Medicaid as i said my Opening Statement at the commission was the elephant in the room, and that was because without continuity of care, block grants i dont want block grants. Block grants only pay for nonevidence based treatment. You dont fight cancer with block grants. Its just we got is block grants whats going on in the secret gop negotiations . Theyre using block grants as a way of really doing what they dont want to vote on doing, and thats sharply cutting the amount of money that goes to treatment. So they say theyre giving the same amount, but theyre letting states to do the dirty work. Because states budgets are going to crowd out the funding and the money is going to be fungible so they use those dollars to fund other things because people with addiction and Mental Illness are the most unpopular of all constituencies, so theyre the easiest people to drop by the wayside. But i think heres the big thing for the president is if hes going to ask for an 18 cut for corporate taxes, i propose that the white house make an objective for our country at a minimum to reduce suicide rates and overdose rates by an equal percentage for the American People. Because if we dont put our mind to something, were never going to start bending the curve and applying ourselves to the goal at hand. So i think when you see suicide rates and overdose rates so high and all the scientists will tell you we can reduce those, we can reduce those quite dramatically, we know what to do to reduce those. But if were not making it a goal of this country to reduce those, were never going to get to where we need to go. So i would say maek the reduction in suicide and overdose the same as you make corporate taxes the reduction in corporate taxes. And two, if were going to repatriate of hundreds of billions of dollars of overseas corporate taxes and this is the biggest Public Health crisis of our times and it affects one in four americans, why not say that were going to spend one in four dollars in repatriated money and put it into this the biggest Public Health epidemic of our time. And lets build the infrastructure because youre hearing from everyone that we dont have the workforce out there, we dont have the availability out there, we dont have the telemedicine out there, lets build that out. What does that look like . What does the there is an epidemic and everyone knows it. Theres some encouraging things that theres bipartisanship in a town in a country that cant agree on anything, you are talking with Newt Gingrich on one of the panels youre on, right . Yes. And you are with Chris Christie and Donald Trumps brother had problems with this. This doesnt know any partisan boundaries. Okay. And people are talking. So what is the its money that we have to watch where if some of these programs are gutted there was someone this morning said 91 billion could be 91 billion for opiate within the aca. If the republican plan plans to substitute it with the 45 billion half of really basically what the aca provides to opiate treatment over ten years, half the dollars. At a time when this epidemic is getting worse, not better. But going back to the bipartisan aspect of this, speaker gingrich and i are pushing for a 10 billion brain bond which can be paid for by slowly reducing the costs that are incurred from brain illnesses because of increase in understanding and research of newer therapies. Thats the kind of marrying both conservative and liberal points of view because, again, coming back to the dollars, if we were to put the real price tag on this epidemic, we would be including the increase in Child Welfare costs. Wed be increasing police time, adjudication time, correction time, prison time, parole time. You know, the enormity of this crisis as it relates to a number of different budgets, but what cbo and gao have not done is theyve not quantified across many budgets what this epidemic is doing in terms of its cost to society. If you took the true honest zero based budgeting on the true cost, i think you could justify to republicans that its smart to have an entitlement where you can track efficacy and quality. Republicans should be about outcomes based metrics. We ought to be about, you know, ensuring we get our quote unquote moneys worth. And were not paying for what works today. And we should pair up with republicans and say, listen, you want to get accountability, we want to get more people covered, lets get together on this. So so far republicans and democrats are certainly talking about this. Theyre certainly saying on both sides this is a massive issue. They are like this when it comes to how much money to spend on it, right . At least through the federal government. Where in your discussions is there kind of hope that something in agreement, is it finally to get rid of the stigma . I notice people keep calling it a brain disease. And your hash tag is, right tell them what it is. 4brainhealth. And stop talking about it like its some moral problem as somebody earlier today said, right . I mean, where are you seeing agreement . Where are you seeing the road when youre active illness you do a lot of immoral things and thats why people are looked down upon. And thats why those of us whove been blessed to be in recovery talk about this as a threefold illness, a physical allergy, a mental obsession and a spirituality because if were acting against and hurting other people, were hurting our own chances of living in recovery, because we all are subject to guilt. We all have consciences. And i think that we need to have the active participation of t the community. I was just with reverend and kay warren, fabulous people, purpose driven life theyve lost their son to these illnesses. And most churches have no way of talking about these things. I was asked by my Catholic Church to speak about these issues. I was denied communion by my bishop in rhode island for not having the right kind of set of catholic, you know, checklist. And yet now im getting messages from the bishop that im doing great work and that my parish priest thinks im great and im there on sundays. Im just saying to you that the point is like i dont know what the point is, but i just had to say that. But i think one point there is that times are changing. Everyone is touched by this. And people are getting it more. And at least that is a step forward. Well, i just get approached everywhere. I often say when i came back from rehab after crashing my car in the capitol and everybody knew i was addict alcoholic, no one else in Congress Knows who we are. But because i was in the newspapers all the time. So when i got to the floor, you would be amazed at how many of my colleagues grab me to pull me off the floor of the house to tell me their own stories because they didnt know amongst all my other colleagues which one of us was in recovery or struggling with a Mental Illness or addiction. And so it was a real, you know, eye opener for me that, you know, in this room theres a number of us whove been suffering. Theres a number of us whove already gotten our 12step meeting in for the day. And theres many of us who also understand as i do that it took both medication assisted treatment and 12 step ri coveco for me to have the longest period of stability and sobriety in my life. So its not as if its one or the other, but the whole advocacy communitys at each others throats because the 12step folks think m. A. T. Is an abomination, all the Scientists Say yeah but all the evidence says m. A. T. , medication assisted treatment, is what is called for with this opiate crisis. And we have scant application of them across the country and twothirds of the Rehabilitation Centers dont even practice m. A. T. And yet were paying for them. And theyre in violation of all the American Society for addiction medicine, and, i mean, if were not offering m. A. T. For an opiate addiction, youre not providing what the scientists tell you works. You know, ive got to ask you because your father devoted his whole life practically to health care. And when we see whats going on now, what do you think he would think about the gop plan and ripping up obamacare now . And then were going to talk about what that means for addiction. Well, my dad you know, just believed that, you know, he watched my brother teddy in the early 70s get treated for cancer. And he was standing in the same childrens ward as all these other parents who are hoping their own kids could get the treatment who had to discontinue the treatment because they didnt have the financial wherewithal. And i found out later on in my life how many families came up to me and said your father paid for all of our kids treatment after my brother was released. Because it was something that he couldnt abide by the fact that he simply had the money could pay to save his sons life but the other parents cannot save their childrens lives, he just said theres something moral ly wrong about that. And so this wasnt a policy. This was a principle. And i think he would just say, you know, how can we and, you know, we could go all into the economics that it doesnt actually make sense to cut people off because we know they come back through the doors sicker and more costly. And we all end up paying for it as a surcharge on our insurance for those of us who are fortunate enough to have private insurance. But its an inefficient way to treat people through these ers. The better way is to cover them and do the prevention that i spoke about earlier. But taking all that aside, its just about treating others as you would want your own loved one to be treated. And then when it comes to addiction since you know what youve been through and how hard it is, what is a good Prevention Program look like . Well, theres evidence you know, Wilson Compton could tell you. Theres terrific resiliency coping mechanism, problem solving skills that can be brought into education. I mean, keep in mind we focus on numerousy and literacy with our children but we do not focus on emotional strength, resiliency, problem solving skills, the very things that theyre going to need in order to be successful. So our Education System really isnt purely designed to produce the most capable, you know, effective and capable students. So i would say that we have to do social emotional learning. Its got to be in every class in america. And this isnt soft science. Theres a lot of data out there showing it reduces the dropout. It actually improves scores in some of the worst most violent sections of neighborhoods in this country where theyve tested, you know, mindfulness and other things, coping mechanisms, they find the kids score scores go up dramatically because theyre flight or fight mode which is whats going on in the brain if they come to school and theres gunshots and their mother or fathers inkpas at a timed fr incapacitated from drugs or in jail, we need to prepare them. Were getting a few questions on twitter a lot of questions on twitter, but several of them about marijuana. What do you think about marijuana as places around the country now are legalizing it . I just dont want it targeting kids. And when you look at the products that are being produced by the new big tobacco, its gummy bears with, you know, red, white and blue gummy bears. Its like elixirs. I dont know if you know what elixirs are gummy bears with marijuana in them . Thc. Im not talking about the smoked kind. Thats benign. Im talking about the kind you put in your ecigarette. We all see folks with their ecigarettes around here, a dab of this high thc concentrate. But its mostly the edibles. Yeah, theres all kinds of edibles. And you think theyre more addictive . Well, first of all i think we have already seen the dramatic increase in use amongst teenagers. At the same time that the use of tobacco is going down thanks to great Public Health efforts. I mean, imagine this country weve done all this work reducing tobacco use bless you. And now, now were like, oh, this is no problem. And, again, its the targeting of kids. So i think we should have an impartial panel of medical experts just reviewing the products that are on being sold out there and putting a stop to those products that clearly have a higher penetration amongst kids. We do not we should all be in agreement that kids should not be using this stuff. Because it effects their developing brains, because it puts them at risk for all kinds of other addictions including opiate addiction. And it affects their Mental Health dramatically. And if more people use, and if theres a certain percentage that have a predisposition to having Mental Illness or addiction, that percentage goes up if the Larger Population of those using goes up. So we just have to be very conscious as a nation what were walking into as a nation with the quote unquote legalization. But i think its the commercialization is the problem. And theres no way Public Health is going to be able to keep pace, dollar for dollar, with the enormity of the budgets that the big marijuana corporate folks are going to have to market this stuff in all kinds of ways that i think is going to jeopardize all our best prevention efforts. You know, theres one thing we can do, but if we got big marijuana just flooding with different ads that its medical and all the rest, if its medical then let it go through the usual medical process. Dont be selling something out of your, you know, basement, oh, its medical. Dont know whats in it. No way of telling you how it might be spiked. Dont have any sense of whether it gives you the relief that its supposed to give you, but its medical. How many kids you have four kids now . Four kids. And three under the age of 4 or something . You have a lot of little ones, right . Yes. So thinking about thats why im fixated on gummy bears. Okay. And im not kidding. Kids pick this stuff up, put it in their mouths. And its happening. But as we look to all our kids, and its tough now. It seems to me its tougher now to be a kid than it ever was. Theres more stuff on the market, theres more everything. What would you do to fix one thing across the country to make it better and easier for kids today when it comes to addiction . Well, i think look at the whole family. If your parents are in crisis, your kids are going to be in crisis. We cant think of this as separate issues. My first bill signed into law was called the foundations for learning act. It never got voted on in subcommittee, full committee or even on the floor of the house but somehow became federal law, had nothing to do with the fact my dad was chairman of the Conference Committee on education. So he air dropped it in. And basically it said that, you know, if parents need support, support the parents because youre going to end up helping the kid dramatically if the parent can get the support they need. If the parents a wreck, i dont care what you do for the kid, the kids going to have a tough time. We have to understand this opiate crisis. Last thing ill say is there is a secondary effect to this opiate crisis, and thats all the kids now whove grown up with these Family Members whove suffered and died as a result of this crisis. And let me finally say, suicide is not been talked about much at this forum, but you cannot divorce the suicide rate from the opiate overdose rate. And both of them are way under reported because a quarter of all corners in this country are elected. And theres no standardization for medical examiners, if you can believe it, in this country. So everything you saw if it werent carrie fisher, we would have thought she died of sleep apnea. She had the extraordinary circumstance of being an uber, uber celebrity so we found out Everything Else thats going on. We have no clue what the true suicide rate overdose rate is here in this country. And, you know, not to be too startling, but as i said from the beginning were in denial in this country if we think we can micromanage this a little here, and put a little block grant for opiates over here, god bless senator portman for pushing for that, but this is along the margins. We are moving chairs on the titanic is our current approach to this issue. We need to fundamentally come to a different approach to how to deal with Mental Illness and addiction and stress management and Mental Health in this country. Unless we celebrate it, support it, the whole health care system, encourage it, pay for it, reimburse for it, all these other costs are going to be playing whackamole. Diabetes is going to go up, cardiovascular disease going up, hypertension go up, suicide continue to go up, we have to make this a National Priority if we expect to do anything to help change the nature of this illness and actually make a dent in the future suicide and overdose rates. [ applause ] well, i couldnt think of a better way to wrap up an amazing morning. Thank you for being so frank and honest. And i think a lot of people here are delighted that youre on the White House Commission. And i guess theyll be hearing over there that their rearranging chairs on the titanic or the country is, the focus on family, the focus on stopping denial. Im very grateful and on behalf of the Washington Post and the Washington Post live, thank you all for listening here in the audience and those online. And were going to be putting up clips from today at washingtonpostlive. Com, and more comments about this whole amazing morning. Thank you, and thank you, patrick kennedy. [ applause ] cspan, where history unfolds daily. In 1979, cspan was created as a Public Service by americas Cable Television companies, and is brought to you today by your cable or satellite provider. And we have more from politico this morning. President trump who has previously said he would prefer obamacare be repealed and replaced at the same time reversed course this morning suggesting instead that the process of undoing the Health Care Law could be broken up. Quote, if republican senators are unable to pass what theyre working on now, they should immediately repeal and then replace at a later date, President Trump wrote on twitter this morning. Anotherng