The dea said that heroin is currently available in larger by aities, that it is used large number of people, and that it is causing the increasing number of Overdose Deaths in his expert . Mr. Milione yes, sir. Representative hice i want to focus on where this is coming from. Mr. Milione, let me start with you. Fromr test a meeting your testimony, it sounds to me like the da is going to focus less on the mexicobased organizations that are trafficking heroin and focusing thaton the street gangs are distributing heroin. We are never going to go away from our core mission of working up the chain. The link point that bridges the violent distribution sales domestically and also the cartels that are flooding the country with the heroin. It is absolutely not one or the other. It is a conference of approach. There atative hice is greater emphasis on the dissolution side of things . Mr. Milione i wouldnt say it is a greater emphasis. It is a shift of focus or we can do everything we can to get the violent dissolution sales. Under control. Representative hice is it fair to say that our interdiction efforts with the cartels have failed or at least not been as cisco as we had hoped . Mr. Milione i wouldnt characterize it as a failure. Interdiction is one part of it. We are focused on going after the actual individuals who are selling the powder, who are pushing it, the for structure, the corrupting influence, the money. it soundsive hice to me you are saying the evidences will be on the dissolution side of things. Mr. Milione i dont believe i said it would the just on the dissolution side there will be emphasis on the description side and also on the supplysider. Representative hice i shook my head all of this because we have been on this war on drugs forever. And its getting worse. We are not making any headway on this. You mentioned a while ago that we have a great relationship with the mexican government. And that relationship the reality is heroin is coming over the border now than it ever has. What good is a great relationship if we are not addressing the problem . At some point, this thing is getting worse and worse and worse. And we are throwing more and more money to it all the time. Frankly, it doesnt appear to me as though anything is happening that would problem go to the point of what you said a while ago, that we are addressing this aggressively. Mr. Milione sme who has served for 20 years and seen sacrifices of the men and women of the da in dangerous it it of the dea in dangerous situations, we are dealing with a difficult and cockpit of problem. We are working to reduce demand, but we are also going after the organizations. Investigations of highly dangerous, sophisticated cartels operating i am not ine hice any way belittling the agents in the field. But to try to give a picture that we are aggressively dealing with the problem went, in reality, it is getting worse and worse, it is putting forth a false image. You can disagree all you want. The fact is that problem is getting worse. You yourself has admitted that. Mr. Milione i dont disagree that it is a difficult problem and that there are parts that are getting worse. But i am not painting a picture that is and that is inaccurate when i say that we are doing everything we can at acumen to sacrifice. Representative hice how many people have been arrested in the Rolling Thunder program . Mr. Milione i cannot say you how many have been arrested. I will have to get back to with any specific statistics. Representative hice mr. Chairman, thank you. I see my time has expired. Mica the gentleman from california. iresentative the soldier would like to ask a couple of questions on the opiate side. Came to meuent who and made me aware of her personal situation where her son was going to school at the university of arizona and drove to los angeles with some other students who actually go to a doctor in los angeles and then overdosed. This doctor was recently convicted, multiple convicted convictions in los angeles. Constituent who drove to a baskinrobbins on afternoon and one of his skins desk is gives was killed right in front of him when a woman who had been abusing opiates and was dropped him across. One of the things that we were able to do in california was update our prescription Monitoring Systems. My question is really around Electronic Health records, where i would talk to doctors and they would say that electronic else records are right around the corner. Dr. Shopping will be a thing of the past. We talked with the attorney general in california. That process is in effect now and we are just weeding to see how effective that is. Arer. Botticelli and we just waiting to see how effective that is. So mr. Botticelli, it seems to me, it would be fairly efficient for the federal government to provide the infrastructure for a nationwide electronic Monitoring Systems so the department of justice in all 50 states would have red flags so they would see if a doctor, like the doctor in los angeles, is abusing his or her privileges or, if a client is dr. Shopping. Botticelli to your point, we are seeing a tremendous amount of success. We actually looked at when we started, we had only 20 states drugeffective prescription monitoring programs. And now we have 49 states to do that. We thought it was more prudent because we had some a states that already had an existing program to really look at state level. Point, what we are turned to focus on next is interstate data sharing so that states can talk to one of the desktop to one another and operability with Electronic Health records. In the to be responsive version of workload and how do we get timely information to them by supporting that. We have been working with hhs and others. This is an important priority for governors as well. We have talked with the National Governors association in terms of what states can do. This is one of the more effective tools we have seen. The we also need physicians to use them. So part of this is, you know, i get come i think we are very interested in states that have passed not only mandatory education, but, like massachusetts just did, checking the Prescription Drug monitoring , not only at first it but only a first dispensing, but every dispensing. And they are only as good as when people use them. Inresentative desaulnier early california, we have a lot of kaiser clients. Andou have a closed system there is still a problem. There is a financial aspect to this. For them, if they were able to use electronic records, both for the cost and for the efficient use of the system, but also to protect clients from being either overprescribed or clients taken advantage of the system. How far away are we from having a strong electronic Monitoring System that can do both . Seeing in some states great progress. In 2012, we had the opportunity to issue grants for the enhanced into Prescription Drug programs hrt offer operability with and interstate operability. And if those states, during the period of the grant, we had six of the nine states that were able to achieve that operability. Post a grant, we have two more states that are in line so they can start exchanging information very soon. A relatively small investment, partnering with cdd, with the national coordinator, we were able to get eight out of nine states to achieve that level of interoperability. thesentative desaulnier u. S. Has about 5 of the worlds population, but we use over 80 of the opiates. How much of this is the criminal aspect of this . Mr. Botticelli i would say very little. Again, i think this has been a concerted effort by the Pharmaceutical Company to look at falsely promoting those medications. We gave the cdc guidelines become so important of looking at not having opioid therapy as a firstline defense for chronic pain. When you do so with opioids, for some people who do need them, starting with the smallest, the lowest dosage and the smallest possible amount. You know, weelieve have made progress in many areas, but not enough progress in of lamenting safe opioid prescribing behavior. Chairman mica let me recognize mr. Carter from georgia. Carter thank you for being here. I have been in and out. I apologize. I had three Committee Meetings at the same time. I want to associate myself as a ball with all the comments that have been made about marijuana being a gateway drug and leading to drug abuse. I could not feel more adamantly about that. I just want to make sure everybody understands that. For those of you who dont know, i am a pharmacist, not practicing anymore. I have over 35 years of experience and a lot of experience with opioids as a dispenser. I am blessed that i have never taken any drugs and never had that im human. I have weaknesses, but thats not one of them and i feel very strongly about that. I will just are with you, mr. Milione. This is very uncomfortable. I would tell you that almost a year ago, a little over a year ago in fact, in cap a judge ruled against the actions of dea when you rated a compounding pharmacy. You completely shut down the pharmacy without real cause. Are you familiar with that situation . Mr. Milione im not. Needsentative carter you to be. This is not a shining example he want to point toward. This is an example where one of your supervisors conducted a raid and at the time had no experience in diversion investigation, hadnt written had not read the da handbook and had shut down the business, seized hundreds of thousands of dollars of medicine and rendered them useless, all because the dea misinterpreted and failed to follow their own laws. This is, as the judge said, per sponsors preposterous. I support that dea. I dont like anybody in health care who is not practicing by the best of standards. Weve got bad pharmacies out there. Weve got that pharmacists. Weve got bad doctors. R. Wen , you cant paint with a broad brush there are bad actors in every profession. But this kind of action is totally an acceptable. Especially when you have someone coming to your pharmacy bearing guns. That is unacceptable. I hope you will look at that. It is westchase pharmacy. I want to ask you, dr. Wen especially, you know, we talked about opioids being used as the entrylevel drug for pain control. One of the problems i see here, and mr. Bout, we were together before and mr. Botticelli, we worked together before. One of the problems i see is the fda taking products off of the market. Specifically, i want to talk ropoxin. R coxon p when they took it off, what did it do . It led people and opioids. That the only choice that doctors had. What do you do now . You had ibuprofen and acetaminophen. As a pharmacist, i can tell you. You try to give a patient something that is available without a prescription, you are not able to convince them that it is going to work. And i will tries hard as i can and i cant convince them of that. Thejust like the oxygen porpoxiden. Problems. T he had its im not trying to question that. What i am trying to point out is that we need more entrylevel dogs drugs, some bit drugs, something in between ibuprofen and acetaminophen and opioid. For doctorselines is very helpful. It needs to be enforced more. It needs to have some kind of teeth in it. Is mailorderm pharmacies sending these gigantic containers of opioids to the doorsteps of people, leaving them on the doorsteps for them to who knows whats going to happen to them. You get a 90day supply. They bring them to the drugstores all the time, joining containers giant containers of opioids. That needs to be suppressed, mr. Milione. The dea is to do something about that. That is ridiculous. The last thing. Listen,o talk about i am a big proponent of 21st century cures. I supported and i voted for it. It is dangerous and as to be looked at. You have the relationship between pharmacies in patients and doctors and patients. When you get into a locked in provision, it is difficult because you need pharmacists. We need pharmacists to participate in this and help us curb this problem. I have seen it ruined families. I have seen a real lives. I have seen it run careers. It is worse than can even be imagined at this point. I know ive gone over and i apologize. Chairman mica thank you. Mr. Connolly. Representative connolly thank you, mr. Chairman. Say, mr. Micah and i had a series of hearings in the Previous Congress on u. S. Drug policy and it included marijuana. It forced me to examine some things that i knew are believed about our drug policy, with respect to marijuana. But what is disturbing to me, if there is a gateway drug to heroine, it is opiate Prescription Drug addiction. Far more than marijuana. This hearing is so timely. Its affecting every community we represent here in this body. A is not a rural phenomena or urban phenomenon or a suburban phenomenon. You, mr. Botticelli, how did we get to this point . I mean, i dont want any doctor to leave a patient pain. Serious pain. You know, its a terrible flexion. Its a terrible affliction. First do no harm. But how do we draw the line justen Pain Management and an unbelievable avalanche of prescriptions for opioids that has now led to an epidemic of it epidemic of addiction in america . With presumably the best of intentions originally. Mr. Botticelli when you look at the roots of this epidemic and the significant drivers, yes, there are other issues going on. It is really the overprescribing of this very addictive pain medication. Representative connolly but how did we get there . Doctors are not stupid people. Mr. Botticelli i think doctors were given a significant amount of misinformation from the pharmaceutical companies in the medication the medical field itself. The scientific evidence, there was this fullcourt press to basically educate physicians and saying that these medications were not very addictive. And at the same time, we had, which i think was a very noble and should be a noble goal, that we should do a better job at a treatment in the unit is its. There are a lot of people who. In the United States. There are a lot of people with significant pain and there is a fullcourt press to treat pain. The v. A. Mention that it is the fifth vital sign. But also talking with prescribers about how addictive these painkillers were. Physicians in the United States get very little training on appropriate prescribing. Veterinarians get more training on prescribing and physicians get no training on Substance Abuse issues. It is a mixture of a whole set of factors that relate drove up addiction and overdose in the United States. And of late, now we have it compounded by heroine. Availability. Representative connolly dr. Wen , what is treatment or the system to recognize summit he has a problem someone has a problem and we need to get them treatment . What is efficacious treatment in trying to turn this around early before they move on to heroine or something worse . it is said that medicine is an art and not really a science because pain is subjective. What is a 10 for you is not the same for somebody else. Tothat is why doctors need understand how to treat individual individual patients and that it is not just about medication. We have to do physical therapy and education. Sometimes pain is ok and we dont have to do everything with a pill. Some pdmps that are some are difficult to use. Representative connolly what is efficacious treatment . What do you recommend . Dr. Wen judicious use of pain medication representative connelly i get that. What about treatment . What is efficacious . What have we learned . We are policymakers up here. We want to solve the problem. We get that part. Point we have got to the where we have an addictive problem and we are trying to avoid prevent a person from going to the heroine part, what works . What works by way of intervention . Recognizing that addiction is a disease and therefore we have to get people into addiction treatment, which is psychosocial counseling and wraparound services. We know that the World Health Organization shows that, for one dollar invested in treatment, that saves 12 for society and that is something we should invest in. Representative connolly thank you. They were quite informative. Chairman mica the gentleman from wisconsin. Grossman ve grothman this isthma an opportunity to learn more about Prescription Drug abuse. It is a great, great summit and i encourage everyone to attend. I think the gentleman for yielding. I have a question. One of the things that bothers me is the legal prescription of opiates. Ive had two minor Health Things in my life in the last two years. Both times, the medical professionals willing to give like a months worth of opiates, for something that had no business under any circumstances prescribing opiates. I will start with mr. Botticelli. Someone is can chime in here. What can we do to stop in these basic things i dont want to embarrass the medical professionals i would say it was par for the course. We are not going to reimburse anythingaid, medicare, else the federal government is for these sort of problems, no matter how much pain you claim you had because people never used to have them even forld perhaps say cms, we are just not going to reimburse across the board or if we are ever going to reimburse, if i friend three days, not this month prescription stuff. I know we can give the medical professionals a lot of little room. We have seen in the past that they will use that little room. Mr. Botticelli youre right. There is room to work with cms and with private insurance as well. I also think we need to continue to focus on mandatory prescriber education. Governmentbig fan of mandates around that, but i do think, again, we really need to educate the medical profession about safe and effective over your prescribing. Representative grothman all you need is a Little Common sense. If we have that many people in the medical field lacking that kind of common sense, we have a bigger problem. Mr. Botticelli i dont think that its common sense. We have the medical profession given the lack of information about the Addictive Properties and a full 4 and a full court press. i cantative grothman believe the medical professionals need training on this. But ok, you say they need training. I want to cover and to the. Enalty thing, mr. Milione that theto me penalties for people who sell heroin is not as high as it should be. Or they are not going to prison as long as possible. One of the problems i have is that a lot of this is local stuff h