We are looking forward to a year of trying to make more progress on an issue that is of great concern to all of us. Just a recap of last year briefly. Last year the comprehensive addiction and recovery act was passed by the house and senate and passed into law. It provided with resources to address the opiod and heroin epidemic. We passed the act at the very end of the 114th congress. It added an additional 1 billion of funding to combat this epidemic. The house rolled out in the course of one week 18 bills last year that really became the foundation and much of the detail of what ultimately was passed into law. There is still a lot of work to be done. Last year over 52,000 americans died of a dress overdose, 52,000. 33,000 of them were opiod related deaths. Thats hundreds of people on any given day that are dying. This week is just beginning and we lost people already. First we educate members of congress and issue of affordable and effective treatment, Law Enforcement issues, etcetera. We serve to make sure that the funds that have been apropuated get spent wisely and local stake holders know how to apply and access those funds. These drugs have potency greater than heroin. They are using chemical components from china and elsewhere. They are being produced an aan and distributed here at home. It includes Law Enforcement, border trafficking issues including the flow of from china. The Public Health and treatment concerns that uniquely present. It couldnt be a more urgent topic for this task force to start with. I want to thank our four witnesses. She is the director of National Institute of drug abuse. Dr. Corey waller is the Committee Chairman society of addiction medicine, a new jersey native i want to thank for being here. Dr. Josh rising is from the knew charitable trusts. Lisa marsh of center of technology and Behavioral Health. Thank you for being here. We are eager to learn from you. Before us we have dozens of years of incredible experience on synthetics. It is a drug that has swept the state of New Hampshire. We have gone from number three in deaths per thousand population to number two. There are a lot of things New Hampshire likes to be first in the nation for. This is not one of them. I wanted to mention that when my former colleague and i started the Task Force Last year we knew that New Hampshire was a hot spot for dangerous opiate use. Often the user does not realize the drug they are intending to use has been contaminated with fent fental. They are much more powerful and we need to know what we are dealing with so that we can come forward with policies to help Law Enforcement to help get people into treatment which is something well be working on. It requires medically assisted it could have sweeping implications. I know from people when they to get treatment have difficulty accessing treatment for many reasons. We are looking forward from witnesses and i appreciate the work we do and we want to work with you to make sure we are doing everything we can to give you our Community Stake holders what they need to help people get well and become productive citizens of our community. Thank you very much. Well ask if each of you will make opening remarks and well hold questions until all four of you have spoken. And i want to first thank the task force for taking a leadership role that is in urgent need of resolution. I want to thank you for the opportunity to testify. It is an agency that is involved in doing research and generating knowledge that can help us address problems like the current epidemic we have that has lead to synthetic opiods. It is devastatidevastating. Those that are becoming addictive. The numbers speak for themselves. In 2015 there were more than 2 million americans that suffer from opiod use disorder most of these cases we really dont know because many of the new synthetic opiods cannot be with the current method. So when someone die and they dont necessarily know whats in there it wont be necessarily reported as synthetic opiod. Some populations have been and we have to recognize one of the issues is how it is inflicted by the epidemic. I think some of the numbers in the areas. They are abused because they target the opiod receptors. We have networks involved with pain, which is why these medications can be extremely effective and can be life saving under those conditions. We also have receptors and we also have them in areas involved with regulation of breathing and thats why they can inhibit those. What makes not all of the opiods the same, some of them are more p potent than others. We have vicodin. It is estimated to be between 50 and 100 times more potent. The new synthetic drugs that we are hearing about is estimated by some to be 50,000 or 100,000 more potent. You can absorb through rest pir ration. These are extremely dangerous drugs and they also pose an enormous challenge as it relates to diversion. Bringing heroin from other sources requires a much greater volume of drug that if youre breathing phentanyl. So from the perspective it is also a nightmare. One of them is the enormous number of people in the United States that suffer from pain conditions. Physicians started to rely on the use of opiods for treatment of those pain conditions. At the same time there was a market. It resulted in a massive ov over prescription. So these all of these combined to generate the massive increase in prescription which facilitated its die versiversio later in heroin because it became harder to get access on medication on people who become addicted. They transfer to heroin or other synthetic drugs. We need to recognize at least for heroin 80 of those heroin abusers started taking prescription opiods. If we want to address the issue of heroin we need to address the prevention and treatment of those and we have to prevent them during the transition. We have those that are prescribed opiods. Thats a group of patients that require a slightly distinct interventi intervention. So what do we do as it relates . One of them is the most important intervention that can reduce prevention. As it relates to research what are most effective in actually averting people from becoming dependent of prescription opiods . What factors relates to the ability and the other is of course treatment. In treatment we have to address the issue of number one, to first of all, we can always i always like to think about science in two ways. We solve problems right now. People are dying. We cannot afford to wait. We do science so we can solve it in a transformative way. I think it is how do we implement very effective in interfering with relapse and very effective. They are not being used. Less than 40 of individuals being treated for app opiod use disorder do not receive these. Why . One is lack of sufficient infrastructure to accommodate. It would improve your incomes and outcomes with relapse at three months by close to 80 . Implementing are working to make up a difference, taking advantage of the criminal justice system. We have shown if you use extended release you can actually prevent their drug use and prevent overdoses. We have strategies that will maximize resources. The other element that is very important to recognize, and i wanted to end up with this is the urgency of developing the management of pain using medications that are much less dangerous. Theres a whole space. At the end of the day the only way well be able to do it is to Work Together. So because of all of these i want you to find the opportunity for being here with you today. Thank you very much. Thank you. I really appreciate the opportunity to come and speak about this. It is something i have had to deal with in patients as well as in research. I have this reality of try to go teach you guys everything about the pharmacy and therapeutics aspects in seven minutes. We are all going to be physiologists shortly. Here we go. I want to make sure we settle on some terminology. I think one of those is potency. We need to know what we mean by that. It is the degree to which any chemical turns on a cell relative to another chemical in the same class. What that means is that morphine is our marker. We use morphine as the base. One milligram of morphine equals about the same as 1 milligram of hydrocodone. About 5 milligram equivalence in that one pill. If we were to look at that we have to look at that as one of the pieces and the other is how fast does it get to the brain how addictive it is and how fast does it impair someone who takes it . How fast it gets to the brain are the two aspects of the drugs that have to be thought about if we are trying to compare and contrast each of those. I want to put the mark ordinary reason that. If you take morphine of 1 milligram heroin is four to five times more potent. If someone has 5 milligram hydrocodone pill it is like taking five of those if you put it in the same one. We go up by five thoon onon tha if we move to things like one of the synthetics we are finding out on the streets, because we use that in the hospital, thats a thousand of those pills. If we go up to carphentenyl it is a thousand shoved into a small single tab. The difference between getting high and dying is the difference between one grain of sand and 3 grains of sand. You can see where the mistakes get made. So when they receive it and they generally get this, which is one of the synthetics. It doesnt mean its different so we can make codeine from that. Heroin is a semi sen thetsynthe. It is a wonderful medication when used properly. I used it regularly. So it is a really useful tool but very predictable. It is a medication that if i give you 100 micrograms, if i give you that i know how long it is going to last. It is really useful in that setting. If you dont understand that extra few micrograms is a very small amount, when we start to go down in that that little extra would mean a patient who is comfortable and one that i have to put a tube in to breathe for. That little bit of difference, if you dont understand the chemistry of these is really important to understand. To underscore the reality of what it offers to us we do have experience with this and devastation we have they just got the dose wrong. And so this is something that we look at. I mean when you talk about danger, and i talked with Law Enforcement. I was the director for a s. W. A. T. Team in michigan and worked with protective service in a number of capacities, this is one that if you go in there you can have a number of officers down. It is a dangerous medication in the sense that it is so potent that a small amount of it could make a massive difference and the difference between im getting high and im dead. This moves us into this other piece. What do we do when we find someone that used it . We are not really able to know. If someone comes into the Emergency Department and i test their urine because they overdose we dont test it for all of these other deriveties. It is not just the ones that i mentioned. We dont test for it, so we dont know. These patients require reversal agents at a much higher rate. If someone overdoses on heroin i can give them. 4 milligrams, a small amount to wake them up, not put them into full withdraw, allow them to get where we need go. For someone who overdosed on the d deriveties it could take up to 23 12 milligrams. An average ems truck carries eight total before they have to restock. So we are looking at an incident where we can have ems there. They can give you all of their medicine and it may not be enough to reverse it at that time. I dont know if any of you ever heard of blue light. It is a forum drug users will have conversations back and forth. I would kind of disagree based on some i have read from this. They will actually try to the batch by starting with 25 micrograms and moving up slowly in dosing to try to figure it out. The batch that they get you can never predict what the concentration is because they are not buying it the way that a laboratory would buy it. Because of this difference between 100,000 if you have that extra grain of sand and you dont know what it is and youre trying to spike your heroin then what you end up doing in indiana and northeast where we have had groups of people in small areas over two or three days dry rapidly. That bad batch was a chemical miscalculation. People will ask why they use these drugs. I get asked why would you use something that would kill you . Remove the fact that addiction is based on behavior that follows a lack of logic in the normal pathway as we would see it. It is because it shuts off the connection between the frontal lobe and portion of the brain for survival. They wont go through a pro con list of what they will do next. So when we have that when we have that set up with someone who doesnt know how theyve mickxed these drugs, thats a recipe for disaster. If they are on the long ive acting injectable, they know they can use these on top of those, still get high and not be detected. So this is a way in which theyre trying to overcome some of the efforts of treatment and me as a treatment provider will have difficulty identifying that theyve even been on it. They may look in their urine like they havent taken anything because these arent checked for. These are i guess the best way i can talk about it is really if somebody doesnt know that theyre taking 100,000 pills in one, then thats a real risk for them. Thats where this comes down as far as how potent these synthetic drugs are. Thank you for your time. Thank you. Dr. Ricing. Representatives, members of the Bipartisan Task force, thank you for inviting me to participate in todays discussion. Its a privilege to be here with you and my accomplished fellow panelists. My name is josh rising. I direct Health Care Programs at the Pugh Charitable trust. Our injeproject focuses on supporting policies that will reduce the inappropriate use of Prescription Drugs and expand access to evidence based treatments for people with Substance Use disorder. Im going to be focusing today on the second element, access to Effecti Effecti effective treatments. Weve all familiar with the epidemic as he talked about, the number of opioid related deaths continue to rise with 33,000 this past year. In addition toe the risks of overdose and death, chronic use of opioids have other negative Health Effects including an increased risk for heart attacks and increased risk of acquiring hiv and hepatitis c. Additionally elicit drugs cost the United States around 193 billion every year. Largely related to lost productivity and interactions with the criminal justice system. We cant and shouldnt ignore the impact on children either. Many state officials have recently made a direct connection between the rise in the use of opioids and the rise in the number of children in foster care. As if addressing the Opioid Epidemic was not challenging enough we now face opioids such as fentanyl and a designer drug known as pink. The use of these drugs has already had significant consequences. In the past year the number of deaths from heroin and synthetic opioids rose from 20 and 70 effectively. We need to take a comprehensive approach to prevention and treatment and pursue up streeam solutions wherever possible. Most people with Substance Use disorder do not start out using these substances. One study found out four out of five started using prescription pain relievers prior to using heroin. One critical part of a comprehensive approach is ensuring access no narcan which saves lives by reducing overdoses. Substance use disorder is a treatable chronic disease similar to hypertension or diabetes and the exact course of which may very for any particular person. Medicated a sichlted treatment or mas it the most effective for the disorder. Whether dependent on heroin, Prescription Drugs, fentanyl or any combination of these. All opioids respond to the same resept tors in the brain. The tame treatment approaches will be effective regardless of which opioid someone has used. Mat combinesed uses fda has approved three different meds to treat the disorder, methadone, tracks own. The right med kaication 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. Behaviorial therapy can include individual or group koublicouns and other intervention. Research has borne out the benefits. It reduces the risk of overdose and death, reduces the amount of elicit drug use. And allows people to return to the works force. Studies have shown every dollar invested in treatment returns 7 or more according to estimates. We also know that access to treatment is inadequate. Only about 10 of people with Substance Use disorder received any type of therapy in 2015. Now imagine if only 10 of people with diabetes or high Blood Pressure received care. We know this is an incredible challenge. Its a medical and Public Health crisis. So what are the solutions . Well, theres no magic bullet. But congress has taken some actions already. Specifically i would like to thank congress for first of all passage of the comprehensive Addiction Recovery actor cara. Cara advanced new policies such as reducing prescriptions and new and enhanced grant programming. Second, the recent appropriation of 500 million. This money is provided directly to states to strengthen prevention treatment programming at the state and local level. We would like to recognize another opportunity for congress this spring to take action by appropriate iating the additional 500 million for prevention and treatment that were authorized. 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 nonfarm co logic methods of treating pain coupled with provider education can reduce unnecessary prescribing. Prescription drug mo