Can hear host appreciate you joining us. Sounds like it is a busy practice for you. Well get one more view on the governments role. Barbara is in pennsylvania, on the others line. Guest good evening, caller good evening, i was in an accident, and i had five different doctors, and the last doctor just left me two months ago. Pain. N morphine for my and she is cutting me down, this new doctor, for two months, has and more i and more am in bed because i cannot walk. Host she has you down in terms of the amount of the prescription . Yes. R i have 27 days, and that is it. I had over 30. Now, i asked her to look up because in pennsylvania you have to show your license, even though the nurses know you, show you the license, and if you look my clipboard, you will see the day i take them up is always a weekend that have to two weeks later. Meds, butverdo my when i need a med, i needed. Host we want to remind you all on video we are showing you the program tonight is on www. Cspan. Org. To heroinll take you abuse summit held back in january, in a program that includes members of the National Institutes on drug abuse and Substance Abuse and the Mental Health services administration. The most Important Information reminds us of the deaths associated with drugs of abuse in general, the painkillers, restriction opioids, almost 19,000 t deaths in recent data from 2014. Data has some messiness in it. Deaths look at how certificates are coded. There are an awful lot that are coded as Drug Overdose generally, and dont specify whether it is in opioid or even heroin. It is prescription opioid or even heroin. There may be even greater numbers specified in the National Death data. Is the increasing rates of prescriptions that have given so many in this country a taste for an opioid. That means their brain has been exposed to it at some point. Or the communities are exposed in a way that these pills can be diverted and misused and taken nonmedically by so many around the west aruound the u. S. As the number of prescriptions go up, the number of deaths increase as well. A fourfold increase in the deaths associated with these we would painkillers. That strokes like oxycodone, hydrocodone, all of these narcotic opioid pain relievers. Witheason i am starting prescription opioids that is the upstream, driver of the recent heroin epidemic. That seems to be the deciding factor that exposed so many to opioids and let them towards that pathway into a heroin addiction. The brain does not distinguish between different types of opioids very well. The brain sees them almost all as not quite identical, but very similar. Heroin as a street drug, has pretty much the same impact on the brain as oxycodone or hydrocodone. In controlled laboratory studies, people cannot even distinguish when you give them one or the other. As those rates of prescription drugs become available, we seen a corresponding increase in heroin. We believe these are related in important ways because of the availability of heroin in so many communities. As youve already heard alluded to, the number of those misusing heroin has skyrocketed in the last five years. Overdose deaths have seen a corresponding increase. Its almost an exponential increase in the last few years. As an epidemiologist, it concerns me. We like to see a curve venting and eventually coming down. We dont know where this curve will end. Its still on the upswing. There have been increases everywhere. If i only showed you the south and west, we would have thought it doubly was a terrible scourge. But look what is going on in the midwest and northeast, somewhere between a four in sixfold increase in Overdose Deaths. All the different major ethnic, racial, and age groups. But particularly, nonhispanic whites of young and lh youing and no age seeing the sharpest young and middle age seeing the sharpest increases. It shows these new injection drug users tend to be younger, more equally male and female. That is a novel change. We think of most drug uses being more common in males than females. That is not so true in the new injection drug users. Thats another concern with the epidemic. Why do people abuse things . They abuse them because these drugs have an impact on the central reward circuitry. They make you feel good by rewarding and relaxing. That is a basic principle from much neuroscience, that i will go to in detail. That is the underlying feature here. These are habitforming, not for everybody. That is a conundrum here. Some people take these pills or drugs and find it extraordinarily unpleasant. But some really like it. And they are the ones at risk for doing it again and keeping on doing it. Im very pleased that our secretary of health and Human Services may do this one of her keynote issues. Shortly after she was confirmed and took office, she convened a small group within the department to help her address this in a proactive, consistent way. Weve developed three priorities. These are not the only things we are doing in opioid epidemic, but three priorities relate to prevention. Lets change how many prescription opioids are available by focusing on prescriber practices. Lets focus on saving lights immediately with the use of no locks on in greater numbers. Greater access to the lifesaving overdose treatment martin. Lets focus on treatment. Medicated assistant therapies as the proven treatment for opioid addiction to reduce the likelihood to increase the likelihood of those going on and recovering their lives. Im going to focus on the first two. When it comes to prescribing there are guidelines for prescribing opioids that plane that pain clinicians use. Those sources have been inconsistent. Some of them are outdated. Some are not without their conflict of interests. As an alternative, the cdc has undertook the development of prescription guidelines. We expect these to be released to assist in the proper prescribing of longterm opioids for noncancer, not endoflife care. When it comes to the overdose, we are pleased on working with one of the pharmaceutical industries and with the fda for the recent approval of an intranasal. Instead of the only fda approved formulation being an injection, there is a nasal spray. As soon as it was approved in november, it should be on the market shortly. Lets get to the main issue, medications. There was a study in baltimore couple years ago that showed us that as they increased the availability of methadone, they showed a corresponding drop in heroin Overdose Deaths in the city. We see this as a populationbased example how you can save lives by increasing Treatment Access any large population. Ive already mentioned methadone. That is in opioid substitution treatment. Methadone is in opioid agonist. That is a fancy way of saying that it wont work as another opioid. What do we mean by that . Lets take a quick lesson in cellular chemistry. When a chemical is administered were taken, it works by fitting into a receptor. Think of it like a key going into iraq. Into a lock. When morphine or heroine agonists go, opioid into the brain, they go into the receptor and produce a lot of activity. Kind of like turning a lock, and the templars move and the door opens. And tumblers move and the door opens. Morphine is like a dummy key. If sills the keyhole it fills the keyhole, prevents other keys from getting in that locke. A full agonist like opioids we have and in between agent that is somewhere in between the two. Is a partial agonist. But therns the lock, door only opens partway. That is a quick way to think of these classes of medication. A blocking agent is one of our tools that can be given in a longacting form. When people take it successfully, they dont get high if they use heroin or other opioids. The same thing happens with methadone. When they take those successfully, and they might slip and use heroin or other drugs, they generally want get any high. Wont get any high. The key is a learning experience. That is a short version of what history is. Melinda will go into this in more detail. We have focused on extended relief medications. We focused event on medications and have been pleased to partner in the release of a longacting naltrexone. Weve finally been developing vaccines as another way of keeping drugs out of the brain. One of our new medications is a longacting beeper northing. People will take these medications, but there is an issue. My patient has to make a decision everyday whether they want to stay clean and sober, stay in treatment, take medication, or if they want to not do that and had back into a path towards relapse. Sometimes its a conscious decisions, sometimes not so much. They need to make that decision every day. With a long acting injectable form, they may not need to make that decision quite as often. In particular we are interested in this idea of an implantable device. A longacting implant that only needs to be implanted once every six months. Means someone only needs to make a decision about their life and turning things around about once every six months in some fundamental way, rather than every day. Patients are more likely to be compliant when they take this, certainly producing greater abstinence. That is one of the hopeful possibilities. This was submitted to the fda in september. Review,er an expedited so we expect an answer from the fda and whether the data supports its actual use by clinicians within the next couple months. The next area is promising vaccine development. For drugs to have an impact, they have to get into the brain. They go from the blood system, across the capillaries into the brain. Vaccines attached to those drugs, so they create a protein binder to those drugs. They keep them in the capillaries. They keep them in our circulatory system and not in the brain. That is the theory. There is quite a bit of Preclinical Research with animal models. There is now some emerging Human ResourceHuman Research that suggests this to be effective. But we have a ways to go before we have vaccines to be useful and administered on a regular basis. I remind you that our job is to support what we can do today and to always be charting a path forward tomorrow even better. Is last challenge implementation. Weve had these medications like methadone for about 50 years. Had naltrexone as an oral medication for 40 years and in injectable for the last couple years. What is going on . Not very many people are treated, even when you go to specialty care. This is a major gap for us. People are more veiling themselves of us. We have been pleased to try novel trials. A group at yellow university a group of Yale University noticed they were seeing the same people with either an overdose or problems related to heroine and other opioid issues. She said, maybe we can start them on it here in the emergency permit. Why dont we act as their primary care physician . They found they were much more likely to be in treatment. They were also less likely to be using drugs when they were reevaluated weeks later. This is just one center, a topnotch center. We dont think everyone else can do it as well. We think that is very promising and are working on testing this in a number of other centers. Butevery place should, those that see a lot of opioid addicts might want to do it. Saddened by the story representative custer relate about patient who died shortly after being released from prison because they cannot get into treatment. This speaks to the important of linking our kernel justice and Public Health effort. Our criminal justice and Public Health efforts. I have issues with high attrition. People drop out of this readily. With prison, they have recidivism and problems with mental activity and drug use. But working together like the drug court models, extensive work with probation and parole, we can do a better job using the best pieces of both. Whether thats a close provision that provision and parole can provide, the treatment that providers cna provide. Even incentives for people to turn their lives around through modification. These models have been shown to work for 20 years. We dont see them in white enough usage. These combined efforts seem to be an area where theere can be improvements. Even medications can be used in this setting. A study coming out of baltimore took vendors about to be released longterm with a history of heroin addiction. This was in withdrawal. Wasnt withdrawal. They are the referred them to methadone actively, which means they actively made that referral and tried to engage them in treatment after release. Or they started them on methadone a few weeks before release. Those where methadone was started prior to release had a better outcome, less criminal activity as well as less drug use. At least over the first few months after release. This speaks to the importance of being practical and thinking through what happens. When people get out of prison, they are not usually thinking about getting treatment. There are other motivations they are paying attention to as their first goal when they are released. Starting treatment on the right foot could be important. Thanks very much for your attention. I will turn it over to melinda from sampson. If i could have congresswoman custer make the introduction. Thank you very much doctor. Welcome the current medical officer for the office of pharmacologic studies at the Substance Abuse and Mental Health services administration. She is a position Board Certified in family medicine, with additional credentialing in addiction medicine. Thank you for being with us. Its my pleasure. Before i get down to the business of my presentation, i want to thank you. Sam is supporting a new round of grantssa to improve access to highquality medication assisted treatment. And funds to Overdose Prevention thanks to the budget you work hard to pass. Similarly, i want to thank you for setting aside the block of time to together more information about Treatment Options for opioid disorders. I cannot begin to fathom the number of equally Critical Issues you are faced with. We will go live to the Brookings Institute from the turkish president recep tayyip who will speak about thega challenges facing his country. News agency has said n explosion has gone off in a bus terminal in southeastern turkey. Ur people were killed. We understand there were a number of protesters outside this event. [captions Copyright National cable satellite corp. 2016] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] live pictures from the brookings institution. They are hosting remarks from the turkish president recep tayyip erdogan, who is expected to talk about some of the challenges his country is facing. He will address challenges they face. Also here in washington, president obama is part of a Nuclear Summit taking place at the Washington Convention center. He said more has to be done to rid the world of nuclear weapons. He is calling on russia to reduce its nuclear stop file. He said the u. S. Will continue to stand up to north korea. World leaders are meeting in a Nations Capital for the fourth Nuclear Summit the president has hosted. President of the republic of turkey, recep tayyip erdogan. Good afternoon, everybody. Welcome to brookings. Welcome to our forum. Our speaker and our guest of erdogan, is innt washington at the invitation of president obama to participate in the Nuclear Security summit. Dogan is kind enough to be with us because it is part of our tradition and mission to invite World Leaders to address the issues of the day. It is a particular pleasure that the first lady of turkey would be with us once again as she was back in 2013. These discussions are intended to be in the spirit of informing the Global Public and promoting stability of debate and respectful, constructive, and candid public discourse. We need as much of that as possible in the case of u. S. Turkey relations right now. Ankey has long been especially important american ally, critical to American Foreign and security policy. It has been an ally for 65 years. This is especially a difficult for turkey as it is for much of the world. Turkey faces internal and external challenges, which all of us, whatever our perspectives and concerns, hope will be resolved in a way that contributes to regional peace, strengthens bilateral ties between our two countries, and upholds the Democratic Values of the transatlantic community. We look forward to hearing from the president his perspective. Colleague will conduct a conversation with the president followed by an opportunity for him to take a few questions from our guests. President , thank you once again for being back at brookings. And now, erdogan directors of the brookings, i would like to greet you with respect. Celebrating its centennial this year. It is a pleasure for me to meet you once again in this very reputable think tank. I would like to start my words by reminding you of the fact that there has been a terrorist attack targeting our Security Forces. I denounce this. We have regrettably lost Seven Members of the Security Forces who have lost their lives, and we have 14 injured, officers i would like to convey my condolences to those who lost and those who were injured. I am very sorry about these attacks, but those attacks will never keep us from fighting terrorists. The terrorist organization shows its acts. To make sureined that terrorism is no longer an obstacle inonger an our country. Terrorists unfortunately keep attacking our country. We cannot tolerate this anymore. European countries and other countries, i hope they can see the true face of terrorists of these attacks. I am meeting with you to discuss the global problems and my opinions about the approach of of those challenges. Achieved human