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We a a vy miarit thhun llf e idic w talked about. The number of opioid related deaths continue to rise. Over 33,000 this past year. To the risk of overdose the end of opioids can have other negative effects including an increased risk for cardiovascular events touches heart attacks, increased risk for acquiring hiv and hepatitis c from people using iv drugs. It was a drugs cost of the United States around 193 billion every year, largely related to lost productivity and interactions with the criminal system. We cant and shouldnt ignore the impact on children either. Many officials have made a direct connection between the rise of use of opioids and the rise of number of children in foster care. Addressing the Opioid Epidemic was not challenging enough, we now face the added difficulty of the high potency of fentanyl,oids carfentanyl, and the designer drug known as pink. The deaths from heroin and synthetic opioids last year rose 20 and 70 respectively. Any effort to reduce the use of synthetic opioids requires a comprehensive approach to pursue upstream solutions wherever possible. Most people with Substance Abuse disorder do not start out wanting to use these substances. Userout of five heroin started using prescriptive pain relievers prior to heroin. One approach is using narcan, which saves lives by reversing overdoses. But at its core, Substance Abuse disorder is a treatable, similar toease diabetes. Medication assisted treatments or m. A. T. Is the most effective therapy for Substance Abuse disorder, whether the verse and is dependent on heroin, fentanyl, any combination of these drugs. Result, the same treatment approaches will be effective, regardless of which opioids someone has used. The fda has approved three. Ifferent treatments the right medication and the right approach may vary for each individual patient. These drugs are taken by patients daily, monthly, or sometimes every six months in conjunction with behavioral therapy. Behavioral therapy can include individual or group counseling, cognitive behavioral therapy, and other interventions. Extensive research has really borne out the benefits and the efficacy of m. A. T. Of overdosehe risk and death, reduces the risk of overdose, and allows people to return to the workforce. Studies have shown every dollar of treatment returns at least seven dollars or more, according to conservative estimates. But only 10 of people with Substance Abuse disorder receive any type ofreceived therapy in 2015. Imagine if people with diabetes or high Blood Pressure received that amount of care. We know this is a Public Health crisis. What are the solutions . Magic bullets, but congress has taken actions already. Specifically, i would like to thank congress for, first of all, passage of the conference of Addiction Recovery act or cara. Cara advances new policies around prevention and treatment such as new and enhanced grant programming. Second, the recent appropriation of 500 million. Money is provided directly to states to strengthen prevention programming at the state and local level. We would like to recognize another opportunity for congress to spring to take action by appropriately additional 500 million for prevention and authorizedhat were in 21st century cures. There are Additional Solutions that will make a difference in addressing the opioid crisis. These three strategies include first of all, enhancing approaches that address prevention and Harm Reduction. Ensuring access to nonpharmacologic methods of treating pain, coupled with provider education and reducing unnecessary prescribing, Prescription Drug monitoring programs can help providers within a five patients at particular risk. Another important Harm Reduction practice is improving access to opioidoid reversal overdose reversal drug. We should have a system where people who want and need treatment can get it without coverage restrictions or delays. Coverage is a critical part of access. Around one third of individuals who felt the need for treatment for Substance Abuse disorder in 2015, but did not receive it cited a lakh of Insurance Coverage and inability to afford the cost as a reason. Optimizing access to existing programs, such as medicaid, is especially vital. 20 of adults on medicaid have a Substance Abuse disorder. Among people under treatment in new jersey, twice as many had medicaid as private insurance. We must also have integrated medical and Behavioral Health care. More providers willing to treat people with Substance Abuse disorder. Increased uptake of proven and effective models. An additional social services. And we need to reach people when they will be receptive to treatment, such as when they are in the emergency room due to an due to an overdose. Third, we need to reduce stigma around Substance Abuse disorders and treatment. Aware ofers must be the problem and evidencebased solutions to address the problem and a neck changes. Representatives kuster. R and kuster we look forward to working with you in your colleagues. Rep. Macarthur thank you. Dr. Marsh . Dr. Marsh thank you for including me in this bipartisan test force briefing today. Im pleased to have the opportunity to contribute as we importantthis very issue for nation. Im a medical professor at Dartmouth College in New Hampshire and i have had the research of conducting with a particular focus on opioid disorders for a couple decades. Today im going to tell you about a study we have the opportunity to conduct with the support of the National Institutes on drug abuse. New hampshire has had the secondhighest rate of opioid overdoses for capita and actually is number one for overdoses of fentanyl, fentanyl related deaths in the last couple of years, and an increase of almost extinct hundred percent in fentanyl related deaths in the last five years. This particular study was conducted under the National DrugEarly Warning system initiative, an agreement supportd by nida to factors giving rise to this crisis in New Hampshire. In a research at dartmouth and a resurgent dartmouth has and our research at dartmouth has networks to enable us to do this quickly. We did this in just three months. Witharted this project meetings with about 45 different stakeholders in the state, including prevention and treatment experts and the state opioid authority, medical examiners office, Health Providers across the state. The last three months, we did intensive interviews with 75 active fentanyl users, as well as 36 emergency medical ,ersonnel, fire, Police EmergencyFirst Responders, as well as physicians and other providers in Emergency Departments. And we just completed Data Collection for this study this past friday. We have seen a number of patterns in our preliminary results that really underscore a confluence of factors that seem to be giving rise to what we are observing in the state of New Hampshire. Users that we interviewed reported that fentanyl hit the market in New Hampshire in a substantial way a couple years ago, particularly in the southern part of the state. This was also the time heroin became somewhat more inaccessible in the region. We see that fentanyl is often althoughh heroin, sometimes it is sold as a soul product. Often users do not know the composition of the product they consume. It was mucheported less expensive and much more potent, so it has a real economic advantage relative to heroin. Although we do have some users report they are accidentally getting fentanyl, we find that some are purposefully seeking out fentanyl as the preferred drug of choice. Users also report that given the potency, you do not have to carry as much on your person or you can take smaller quantities with you, so it easier to avoid detection. Also users report the high from fentanyl does not last as long as the high from heroin. More often,to use which may increase your chances of overdosing, but also increase your chances of infection from drug use. Everything one of the 75 users we interviewed reported having observed at least one in typically more than one overdose. We had one young woman who said in the past two months she obtained 20 to 25 overdoses, including her own mother, who died from an overdose, her brother, who overdosed 17 times