Withstood the issues of traduce and going through the a Opioid Crisis the key to remember is in the midst of this crisis and in the midst of the burgeoning number of individuals who are dying as a direct result of using opioid this still represents a comparative drop in the bucket with 50,000 lives lost last year due to opioid is a small number however compare that to the 80,000 lives lost due to the alcohol and 500,000 lives lost due to cigarettes the leading cause of death people with addictive dizzies of recovery is a smokingrelated illness so the major issue is tobacco the second most significant remains alcohol. The Media Attention to the Opioid Crisis is waterfall to abri attention to addictive disease but remember there are 3747 per day crashing and the media is focused on a car crash. We need every chance we get were also paying attention to the 747 full of people and we dont just look at the car crash. Coming back to the 50,000 lives lost due to opioid lets figure out where that comes from so we have a panel today we all have about 10 minutes i will take as little time as possible but i want to set the stage the Opioid Crisis rose out of a perfect storm that three things went wrong. First, doctors for many years were reluctant to prescribe because they didnt want to see people get addicted but they were told by a large to the pharmaceutical industry these are the long acting opiates that work well to treat patients with pain. Never mind the fact there is no literature to indicate opioid provide adequate treatment. They dont work there is no literature that says that they do. But the initial reaction is that makes me feel better. So when people feel that way they come back and ask for more and the doctor says it is working. If they are turned down the patient is dissatisfied that is part to of the perfect storm. At the same time, we have physicians and medical facilities being told the way they would do well over be certified to get a gold star is to make sure that patients were satisfied. The patient said that 30 worked well i want dirty war 80 tell the patient now you already had a one month supply is the patient satisfied . No. So they would leave a black mark instead of a gold star so we ended up with thousands of individuals taking opiates for a condition of which opioid are not indicated. We need to stop that. Doctors were reeducated programs giving out opioid like m ms were closed down so what happened to all of those individuals that were taking opiates every day who could no longer get them from their family physician and . They went to the street. When they went to the street what they found was part three of the perfect storm that the United States turned from importing marijuana to exporting marijuana because apparently we grow good marijuana. Because of at handed it is increasingly accepted we at an abundance of the plant we send hours across the border the department of justice pointed out these folks who sold us the marijuana need other centers of profit and so to accomplish that they send us cheap heroin that the exact time our patience could no longer obtain prescription narcotics from that will meld they would go to now they go to the streets with cheap pure heroin or you even get fentanyl if you dont die. These were the three steps the broadest to the point where were at now. As we have been educating his community and have seen a drop some of the ec that equal if not greater increase in the use of street opioid like heroin. Leer not even close to stopping this crisis i dont think we will be at that point and tell the country recognizes Addictive Diseases is Addictive Diseases independent of drugs if it encourages the use of chemistry that is killing tens of thousands of people and in that context say we still love deducted addictive drugs. The of the Deputy Director and dr. Clark and the oxford house our reach greater . And that Clinical Psychology professor and afford to hear from the panel today i apologize they only have 10 minutes to cram in that information. [applause] it is a pleasure to be here i have been a fan of oxford house for many years. And we had a new opera house back in the 90s. Cannot desk criminate and to be a little bit of an expert in the of field and i was so pleased that day succeeded that is my personal connection and i saw them and that is one of the themes we have this fantasy those treatment problems is a wonderful beginning to turn the of life around is a longterm process taking months or years to Reenter Society for those memories beginning to fade to be minimized for social activities for work and family the way they occupied mental that is why it plays such a key role in recovery. How we need to Pay Attention to the process to address the underlying issue. Which is addiction in so many people. Our job is to bring science to the Health Problems so how can that bring the solution . We certainly now plays a role of this destructive power of the opioids. We have noticed that is part of the reason it generated that addiction is somebody elses issue. So death is the number one reason but it is also infectious disease. It is complete the driven so now makes it harder to snort. So then they injected it regularly and has a half life. 4 of the community was eventually infected by hiv. Not just of a high risk group, but the entire community. It was quite astounding. We have deaths, infections, to add further its not just opiates, its a combination of opiates with other sedatives. We know whats killing people is not just the harrowing, phenolic Prescription Drugs, the combination was sedative agents. Its medical combination so some of my colleagues are helping to feel this by supplying both the opiates and the sedatives that help causes. Also leo nadel absence syndrome. Babies that are exposed in your notin utero during pregnancy art high risk. I visited charleston, West Virginia with hospitals, one in ten babies, that means every day they were seen babies who are suffering from opiate withdrawal when their board. Fortunately we have reasonable treatments and ways to help, but its an indication that natalie that baby might have difficulty but the family needs help. We been paying attention to babies but what can we do to mobs to help them get the recovery that you have found in c. Thats enough about the background, what are we trying to do about this . I would love to say that we have the solution. Unfortunately the data dont suggest that. It suggests a number of people dying of overdose increases. First the prescription pills, i would suggest as economic forces. We say illegal marketing practices by pharmaceutical as one example that engage in egregious practices to promote these products and then it meant so many millions of people were exposed in misusing them, then a number become addictive that have deadly outcomes. The other economics is for heroin. Heroin is remarkable product. Were seen new distribution routes. I mentioned i lived in st. Louis. When i was there and working in the addiction field in the 90s we didnt have much of a heroin problem, thats not true in the last 15 years. Because there are so many people taken the pill and misusing them, there is a recognition that theres an untapped market for a cheaper, regularly available opiate that could be sold on the street thats what heroin represents, so, snow in cities like st. Louis the date used to have a problem. Fat now has had two lives, we sought in an outbreak in the mid to thousands for theres another number of deaths in philadelphia, chicago and other areas all brought about by one site that manufactures that no illegally. When that was set close down, the outbreak pretty much disappeared, there are now tens of thousands of companies that manufacture fentanyl in china. It was illegal to manufacture fentanyl up until early march. Our state department and others have been helping to change that. So we get cooperation to reduce the flow. We have a ways to go. It is 50 times more important than heroin. One grand, tiny amount is like 50 grams of heroin. That means it can be shipped in the mail, it can be shipped in commercial carriers. Thats a fancy way of saying fedex, and other ways to ship packages across borders. Shipped directly to the states, canada and mexico, the wall street journal, theyre all about business reminded us this is a business. The raw products cost about 1000 of fentanyl can be sold on the streets for about 1 million. Thats a big profit margin. That motivates a lot of behavior. As much as we can focus on the supply we better do something to help people with recovery. I want to end by emphasizing our department of health and Human Services and the federal government under doctor prices leadership has laid out five main priorities. New approaches to pain. The key driver, can we do a better job to treat pain . Yes we can. The second approach will be improving prevention, treatment and recovery services. What can we do to focus on the reit process and eliminating it. Can we save lives more readily by providing the antidote . I wonder how many oxford houses has locked so in their facilities. I hope most of them do. Its not that their residents might have a problem, but youre going to know people that you. You will have friends that have an overdose. Having this medication available is a key part of saving lives so people can then make those gradual steps towards recovery. The fourth is to improve our data. We talked about how many deaths in the u. S. From the overdose, my latest data from 2015, we are now september 2017, 20 think we could have numbers from 2016 by now . We like to speed up the process. Im pleased to see that research is being supported. Im thrilled with the treatments we have in the Recovery Support services we have, we need more, we need to know how to implement them as efficiently and effectively as possible. Im kinda pleased with the medications we have for treating harry one and opiate use in general. But they dont help everybody. Many people fail who are on these medications. Can we do a better job . Thats what i hope our research and how we can treat them better will lead us to. Some transformations that we dont have to see so many tens of thousands of people dying every year. Thank you. [applause] thank you doctor, will move on to doctor clark. [applause] thank you, it is a pleasure to be here again. It has been a long time, last year. I appreciate this audience and will be talking again laters and i dont have slides perhaps lights later. Both the doctors addressed a host of issues associated with the epidemic that we have been discussing. I want to take a different perspective and point out there is an issue called the social determinants of health that gets forgotten. Also the issue of how do we adequately treat pain. And we made reference to that earlier. Thats a large issue, indeed it affects peoples desire to use opiates. We brought in a host of new individuals who previously were not using opiates. Keep in mind, we have 60. 9 Million People 55 my people who are cigarette smokers, 22 million who are marijuana users, 4. 3 million who misuse pain relievers. Not the largest of individuals. So Doctors Point was well taken, we have to deal with the fact that our society embraces this use. How it should be administered, what we should do, thats another matter. With regard to Prescription Drug, we have according to the data sensibly within the next two weeks we will hear 2016 data. There are 97. 5 million past year user a pain relievers but only 20. 2. 8 admitted to misuse. We have to deal with the issue, anybody here have pain . Anybody here want to enjoy that pain . So, there are people, psychiatrist you made all sorts of individuals i dont want to dismiss her idiosyncrasies but if we dont deal with it issue of managing chronic pain then we are not going to deal with this issue. I know the institute has a working group trying to come up with non psychoactive substance that will help treat pain and i know the cdc has come up with guidelines to treat pain. The fact is, we dont know how to treat chronic noncancer pain adequately. People say take motrin. Motrin hurts if you take too much of it. They say take tylenol or acetaminophen. While acetaminophen hurts if you take too much of it. So im not a proponent of the opiates, i cant stand the things, but the fact is, im also not a proponent of people suffering. There seems to be a mistrust and distrust of consumers. The pills work for responsible consumers, you show up and say i have a pain and they give you all the pills in the world. Thats not a responsible consumer or prescriber. Theres mistrust and distrust in but my fears if we go from one end of the pendulum to the other and single out the consumer is the bad guy. We have Prescription Drug monitoring programs and people want access, they want to pitch on registry they want access to information, they want all of they can get from you. So there vilifying the consumers is not a solution. We have people who are exploiting the vulnerable, doctor made reference to indiana and it was a matter of opiates in a matter of also matter methamphetamines. Looked at the jail records of who is being arrested for what. , bunch of folks were being arrested for methamphetamines. They were inches snorting and injecting the heroine, anybody know about the way you do that, the, you inject the combo. The fact is, when we start focusing on one substance alone as doctor was pointing out, we ignore the larger issue. If people are being abused physically or psychologically if they have no solutions, then they tend to use whatever makes them feel better. We need solutions. I see an arthur how some of the solutions, you may have seen from your materials things like accountability, responsibility, integrity, honesty, community, support, respect, these are things that make for good dr. Patient relationship. Employers are mindful and respectful of employees, not let me see if i can get the next 26 hours out of you. You look at mineworkers, they dont have cancer pain, but there hunched over for years they come out all the have is pain. And there were surprised that they use opiates. Has anybody ever worked in factory . I do when i was in college. After eight hours my my9 my mind was non. I asked, can i do this every day of the week they said theyre interested in the assembly line, not me. So my points use, we need to offer some solutions. Solutions in the principles, the patient needs to be responsible and accountable. So does the doctor, the hospital, the drug company, the system needs to be accountable. Honestly, the dr. Needs to tell the patients about them. [applause] if you need physical therapy, you should really get physical therapy because i was another problem, there given out pills instead of alternative solutions. Will it cost a hundred dollars the pill plus 5, what you think the Insurance Company is going to do. So i wind up with the notion of gratitude because the principles function well if our Larger Community adopts those, that way when someone is backsliding initially the locks on in your facility because people do crash and burn. Its not a perfect disease. And the efforts are not always flawless. But, if you have an environment where peoples support, opportunities and people know that if they follow they have recovery on the horizon, then, i think we can deal with chronic pain if we havent on a society that recognize that we put people in building environments and they need relief but not necessarily drugged, so your principles should inc. The larger thing morgan and do is not another pill necessarily, not another big brother Surveillance System but a society that treats each other with respect and dignity and holds people to accountability and responsibility than we have our solution. [applause] good morning. Have some bad news, i have a powerpoint. I dont have a prompter so be looking over here i present. Im with Harry S Truman college of chicago. Osha had my glasses, going to be squinting and looking at my notes. Please bear with me. When i think about what constituted a crisis thing about the prevalence rate and i have to go into more detail on the statistics or data discussed, this comes they have some data on the National Survey of drug use and health, data that was presented about one year ago today reflecting 2015 data. I have slides, i will be terribly technical theres a lot of drug use going on. Its for a comprehensive report to classify psychotherapeutic drugs into four categories. Prescription drugs that are paying killers known as an ugl angela takes. And the sedatives typically use to help us go to sleep. If you look at the chart, and surprising, almost 45 people in the United States are estimated for using these, and you might be thinking this is an epidemic, maybe they dont use on as some of them in attendance, they throw them away or they take a mess prescribed. The issue here is misuse of Prescription Drugs. Only 7 of folks in the United States are estimated for misusing their Prescription Drugs. Those frequently misused, pain relievers. It doesnt get better. When you look at people who use other drugs, alcohol included, tobacco, stimulants, folks who use heroin have a High Frequency of misusing Prescription Drugs. Which of the four categories do they tend to misuse more . Painkillers. At about the same right. Theres a lot of drug use going on the terms of meeting criteria for an opiate use disorder in the very top is alcohol they were talking about opiates, you can see its like. 6, that translates to about 591,000 people meeting diagnostic criteria by the way of heroin but whats more alarming, three times the rate more for other opiates. Thats what im gonna be focusing today. Theres all kinds of opiate use, we focus a lot on heroine, but a lot is going on with other things thats been misuse. This shows initiation of drug use. People might be starting with Prescription Drugs must be painkillers. So that probably explains the use of these drugs. One introduced d