Taske bipartisan heroin force for the 115th congress. , want to thank my cochair annie custer. We are proud of the work that we have done. I think we are proud this is the most rigorously Bipartisan Group in the u. S. House of representatives and we are looking forward to a year of joined a make more progress on an issue that is of great concern to all of us. Just a recap of last year briefly. Year, the comprehensive addiction and recovery act was passed by the house and the senate and passed into law. And it provided stakeholders resources to combat the heroine epidemic. We passed an act at the end of 100 14th congress that added an additional 100 billion of to combat this epidemic. In both of these were college in no small measure because of the bipartisan work done by this task force. Out in theolled 18 bills thatweek really became the foundation and much of the detail of what was ultimately passed into law. There is still a lot of work to be done. Americans over 52,000 died of a drug overdues. 33,000 of them were opioid related deaths. Thats hundreds of people on any given day that are dying. Know some of them i think everyone knows people affected by this epidemic. County in new jersey, we are losing someone to a Drug Overdose every 33 hours. This week is just beginning and we have lost people already. The task force has an ongoing role. We educate congress and staff regarding essential topics in this space. Issues of affordable and effective treatments todays topic is of special importance. Synthetic opioids. Drugs like fentanyl, pink have driven depths. Enormousgs have potency. Many times greater than heroin. They are being produced and the united within states using chemical components from china and elsewhere, but they are being produced and distributed right here at home. Theres a host of issues to discuss in this area, including Law Enforcement, border trafficking issues, the flow of fentanyl from china, which we will address in a future roundtable. Today, we are looking at an overview of the Science Behind these drugs and the public and treatment concerns they uniquely represent. It could not be a more urgent topic for this task force to start with. I want to thank our four nora volkowday, dr. From the National Institutes of corey waller, dr. Rising, and dr. Lisa marsh. Thank you all for being here. We are eager to learn from you. With that, i want to turn this over to my cochair, representative kuster. Rep. Kuster thank you. We particularly want to thank our guest from New Hampshire. Before us, we have dozens of years of incredible experience on synthetics like fentanyl. Fentanyl 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 that New Hampshire likes to be first in the nation for, that this is not one of them. My former colleague mr. Denton started the Task Force Last year. We knew New Hampshire was a hotspot for opioid use, but what we did know was the nuances and the complexities of our crisis. Not only the availability of heroin and fentanyl is on the rise in New Hampshire, but this drug is very inexpensive and yet extremely dangerous. One of the issues i would love to ask you about as we go forward is our Law Enforcement officials have concerns about even responding because of the danger of fentanyl. Year for us on this issue. We became the second state in the nation. Its a gruesome statistic that is based on the proliferation of fentanyl. That this is a lethal combination, and often the user does not realize that the drug they are intending to use has been contaminated with fentanyl. That we in thel congress understand synthetic opioids. They are much more powerful. Arewe need to know what we dealing with so we can come forward with policies to help Law Enforcement and help give people into treatment, which is something we have been working on through the comprehensive addiction and recovery act in the 21stcentury cures act. I learned a little factoid today. Wholeece together this puzzle. Iday i spoke from someone spoke to someone from anthem who said nationally they have just maybe pronouncement they will no longer require advance approval of medically assisted treatment and that could have sweeping implications, because i know from friends and indeed that this is very challenging. Getle, when they want to treatment have difficulty accessing treatment for many reasons. Advanceto require that authorization for access is a big step. Im looking forward to hearing , and ir witnesses appreciate the work that you do and we want to work with you and the coming weeks and months to make sure were doing everything indeedto give you and our Community Stakeholders all the tools to help people get well and become productive citizens of our community. Thank you very much and i yield back. Rep. Macarthur im going to ask if each of you would make opening remarks in order and then we will hold questions until all four of you have spoken. Volkow, i would ask you to begin. yes, i would like to thank the task force. I would also like to thank you for the opportunity to testify. This is an agency involved in generatingrch and solutions that will help us address the Opioid Epidemic that has led to the abuse of heroin and synthetic opioids. The consequences are devastating. Its not just an enormous a its not and no just in a amount of people. Its contributing to the spread of diseases like hiv and also an syndromes. Other the numbers speak for themselves. There were more than 2 million americans that suffered from prescription opioid abuse disorder and 600,000 heroin. Fromople died in 2015 opioids, and that required more prescriptions,m 13,000, and really that incredible Staggering Number of 9580 from synthetic opioids. Becausey dont know many of them using synthetic withds cannot be assayed the current metals. When someone dies, they do not necessarily know what is in their. Thats not going to necessarily be reported. Some measures of been more effective than others. I think we have to recognize one of the issues we have been unprepared for, what proportion areas haveas, rural been affected by the prescription Opioid Epidemic. I think some of the numbers we are all worried about kentucky, virginia, the appellation area. Prescription opioids abuse . They are abused because they receptors. Opioid we have many in the brain and the body. We have opioid receptors in areas networked with pain. These medications can be extremely effective in the management of acute, severe pain and can be lifesaving in those conditions. Receptors inthese our brain centers, which is why they are so addictive and also involved in areas involved with the regulation of breathing, which is why they can inhibit those centers and result in an overdose death. Not all opioids are the same. Some are more potent than others. As we were discussing, we have Prescription Medication like vicodin and oxycontin that have ever levels of potency. Its estimated to be between 50 than00 times more potent heroin. We are hearing about, one is estimated to be 100 times more potent, and this is the concern First Responders may have because you can absorb sufficient through the skin to a depressionrate in respiration. Its an extremely, extremely dangerous drug and they also pose and a normas challenge. Bringing an enormous challenge. Heroin from mexico requires a greater volume of drug then fentanyl, where as you may require a very small vial. It is also a nightmare. Why are we here . I think we need to understand why we are here. I hope we learn from history. Startedan epidemic that and two phenomena were going on. One was the enormous number of people in the United States that suffer from pain conditions. The recognition that we dont have many treatments for pain. So physicians started to rely on the use of opioids for the treatment of this pain conditions. There was atime market that was taking advantage newhe industry to generate products that were increasingly more potent and they were underestimating the risk for addiction of these medications. It created a sense of overconfidence. Had a massive over prescription of medications that also responded to the thatents in 2000 physicians be required to screen and treat pain in their patients. So, all of these combine to generate a massive increase in the number of prescriptions diversionlitates the with all of the consequences. Then later, it translated into facilitating heroin because it became harder to access. Estriction medication they actually transferred to heroin or other synthetic drugs. Its important to recognize that. An issue of the epidemic of the heroin overdose that were now seeing. We need to recognize at least for heroin, we know the numbers. With taking start prescription opioids. If we want to address the issue of heroin, we need to address prescription opioids and we need. O prevent them these constraints, this situation, what is it that we are going to be doing . Well, we need to recognize the complexity of the issues. We have those individuals that are prescribed opioids because they have pain and they become addicted to their medication or overdose on their medication. That requires a slightly distinct type of intervention. The individual starts to want discussion opioids because they want to get high. Those are different. But both of those groups are at risk for addiction and risk for overdose. To the useas relates of science . What is the most important intervention we can do. What are the Prevention Strategies that are most effective in actually of hurting people from becoming dependent on prescription opioids or becoming addicted to heroin or synthetic opioids . At one end, of course, we have treatment. In treatment, we have to address the issue of number one we like to think about science in two ways. We use science to solve problems because people are dying. We cannot afford to wait. Look atcience so we can the future in a transformative way. We cannot wait for the future. We have to transform now. One of the big challenges is how do we implement the currently available medications. Ony are very effective preventing overdoses, very very effective. But they are not being used. 20 do not receive this medication. Why . There is a lot of sufficient infrastructure to accommodate. The issue is, how do we think about this . That is where science comes along. Initiate at the emergency room when someone comes with an overdose, your outcomes are much, much better. You can improve your outcomes by close to 80 . So, implementing will make a big difference. Thinking about the criminal justice system, we have shown with research that if you use extended release, you can actually prevent drug use and prevent the overdoses. Maximize the use of our resources. The other element that is very is thent to recognize urgency also of developing alternative treatments for the management of pain using medications that are much less dangerous. Day, while wethe do have interventions and a challenge to implement them, the only way we will be able to do it is by working together across agencies and disciplines. Of all of this, i want to thank you for giving me the opportunity to be with you today. Think you very much. Rep. Macarthur thank you. Dr. Waller . Dr. Waller thank you. I appreciate the opportunity to come and speak about this. This is something i have had to deal with as a clinician i would really as a clinician and i would really echo everything olkow has said. We are all going to be molecular or new or a shortly. Here we go. Want to make sure that we settle on terminology. Potency. Ne of them is we need to understand what we mean by that. Potency ultimately is the degree on aich any chemical turns cell relative to another chemical in the same class. What that means his morphine is our marker. As our base. Ne it equals the same potency as one milligram of hydrocodone which is the number one prescribed pain medication in the United States. Tablet has five milligrams. Five milligrams of morphine equivalents in that one pill. If we were to look at that, we have to look at that is one of the pieces, but the other pieces, how fast does that get to the brain . How addictive is the substance . Does that get to the brain and release dopamine . How fast does it compare someone . Lipid solubility, how fast does it get to the brink, those of the two aspects of these drugs we have to think about if we want to compare and contrast each of those. When we talk about the relative potencies, i want to put the marker on that. If you take morphine of one milligram and i give you heroin, heroine is four to five times more potent. So if someone has a five ill,igrams hydrocodone p vicodin, if like taking five of those. If i give them sentinel in that same pill if i give them fentanyl in the same pill, its like taking a hundred of those. If we move to things like another of these synthetics we are finding out on the street, because we also use that in the hospital. I have used that many times for patients, thats a thousand of those pills. ,f we go up to car fentanyl thats a thousand of those pills shoved into a single tab. The difference between getting high and dying is the difference between one grain of sand and three grains of sand, you can see were the mistakes get made. This, one ofeive the synthetics, which is Something Else i hope we understand synthetic does not mean it is different. It just means we have made it synthetically as opposed to making it as a derivative of the the opium poppy is morphine and we can make coding from that. Time, synthetics are things we have made from science. Its a wonderful medication when used properly. I have use it regularly in my practice in my training as emergency medicine as vision, addiction physician, pain position. Very useful tool. Its very predictable. This is a medication where if i give you 100 micrograms, if i give you that, i know what is going to do, i know how long its going to last. Bone, iave a broken know in 28 to 35 minutes, you will need another dose. Very predictable. I can predict what it will do with other medications if we give them at the same time. Its really useful in that setting. If, however, you dont understand that extra few micrograms, the tiny hundreds of a milligram, when we start to go down, that little extra can make the difference between a patient that is comfortable, and one i have to put a tube in to breathe for. That little bit of difference is really important to understand. Carfenunderstand what entanyl, in the russian situation that the russian theater situation, they pumped gas. Rfentanyl and unfortunately they ended up killing those people because they got the dose wrong. Fully talk about danger, i worked with a swat team in michigan and the federal protective service in a number givesacities, if this aerosolized, it you can have multiple officers down. It can be the difference between i am getting high and im dead. This into other pieces, what we do when we find someone who has used it. Ow says, wer. Volk dont really know. If i test their urine for an overdose, we dont test it for fentanyl and carfentanyl. We dont test for it. We dont know. These patients require a reversal agent at a much higher rate. ,f someone overdoses on heroin i can get them. 4 milligrams of a small amount to wake them up, not put them in full withdrawal, allow them to breathe, and get them where we need to go. For someone who has overdosed on anyl, it can take 12 milligrams. We now have to go all the way up to 12 milligrams. An average ems truck carries eight total before they have to restock. So were looking at an incident where you can have ems there at the time and they can give you all of their medicine that they have in their stock and it may not be enough to reverse that agent at that time. The potency becomes really, really important when we start thinking about what this means for why people are dying from using this. Anyuse i dont know if of you have heard of blue light which is a website. Its a forum where drug users will have conversations back and forth. Its not like they are chemist i would kind of disagree. Look at they to right dosage by starting with 25 micrograms of moving up slowly to figure it out. But as they point out, the people using this, the batches they get, you can never predict what because and ration is. They are not buying it the way a laboratory would where it is standardized and filtered and set up. Because of the difference between 100,000 to one, if you have that extra grain of sand and you do not know what that is and youre trying to spike your heroin, what you end up doing is what we have seen a number of states in indiana and the northeast where we have had groups of people in small areas over two or three days die rapidly because of a bad batch of heroin got out and that was a chemical miscalculation. People ask why they use these drugs. I get asked, why in the world would you use something that will kill you . Theill move the fact that disease of addiction is defined very specifically based on behavior that follows a lakh of logic in his normal pathway as we would see it, and that is mainly because it literally shuts off the connection the tween the frontal lobe in the animal portion of the brain which is all about survival. They will not go through the pros cons list about what they will do next. Someone who does not know how they have mixed these drugs, that is a recipe for disaster. But now there are people who know we cannot test for these. If they are on an injectable that is in for three days, they know that they can use these on top of those. They can still get high and not be detected. So, this is a way in which they are also trying to overcome some of the efforts of treatment, and me as a treatment provider will have difficulty identifying theyve been on it. They may look in the urine, but these are not checked for. I guess the best way i can talk about it is really if somebody does not know they are one,g 100,000 pills in then that is a real risk for them and thats where this comes down as far as how put the synthetic drugs are. Thank you very much. Rep. Macarthur think you much. Dr. Rising . Thank you very much. Dr. Rising . Dr. Rising representatives ofarthur and kuster, members the task force, thank you for asking me to be here. It is a pleasure to be here with you and my distinguished fellow panelists. My name is josh rising. I work for the Pew Charitable t