this decade can be seen in salary levels which have remained at their late 1990's level and which dampens incentives for domestic students to pursue stem degrees." did you know that? that actually i.t. graduates' salaries have stuck at 1990's lefts ls >>a9 the. >> in fact, and other fields to do better. if that is true, does that change of the use of this legislation gm does through the city is so proud of that the house passed? if that is true that i would prepared to ask somebody

to dispute it. then he goes on to say this and i agree with this line, talk about all stem graduates now if there were a talent shortage where are the market indicators like wage increases? d so mr. donahue and your friends at the chamber of commerce believe in the free market then why is it down if we have a shortage of workers? why aren't the wages going up? for another businessman that said recently there are 600,000 jobs in manufacturing going unfilled today the immigration bill king go along way to help uses fill these positions. great scott.

i have seen instances where thousands where people apply for just a h few jobs. as does he not have any interest first of all, that got our goals as a policymaker as united states of america is to say you have jobs? we havere to get people ready. k america is on welfare that needs to go to work. give us such a dance of people here first before you take away the ford workers to take away the limited number of jobs. 2000 through 2013 all net jobs went to him the grant pas workers.e can you imagine?tinu that is what the numbers show. 2 kith this bill were to pass the house they will continuens to accelerate 8.8 million

moreears working age americans entered the labor force. within those 13 years but he gets the jobs for american workers and the people actually fell 1.3 million. so that is why the dropout rate is so high but during that same period, period, 5.3 million immigrants got jobs. so really all the jobs created during this period of time mathematically speaking is it healthy? isn't that one reason why we have a hard time today? there are 50 million working age americans that are not working today.

wages are lower today than 1999. won it -- the median household income has dropped nearly $2,300 since 2009. the percentage of americans that are actually working is the lowest in 36 years. so i am glad to talk about this issue and immigration that we will talk about what is the interest of the american people. not your politics and ideology of special interest to what is good for america. what is good for america is to get more unemployed workers and wages going up rather than down. i'm not surprised you didn't

talk about workers and can wages did your remarks this morning when you do need people that oppose you and with your great deal that you drafted. it will not work. we will not be scared off or intimidated to hand over control of the immigration laws to a small group of special interest meeting in your office. baby promising -- may be promising. but i don't think there is anything wrong public policy wives to say we need to have all lawful system of immigration that we can be proud of. that is what the american people ask of us. and congress refuses to give over 30 years and i listen to the people and we can do it. i has been in law enforcement almost as long

as the senate. i know that this can be done but if the president doesn't want to enforce the law instead with the people who commit serious crimes and even those are not deported then we have a real deep problem. i think we can do better. rigo down the road of pushing and pushing just to pass a bill in the bill, do it fast we have to ram it through. this has been out there in the public for a long time. it has been in the sunshine and does the smell too good. the american people are not prepared to eat it than they shouldn't. think you to the senate for giving me a chance to express these concerns but

if we put american interest first we need to draft the immigration bill. know i yield the floor and a note the absence of a quorum.

>> the wonderful thing about the gulf coast it is under appreciated and that is good because if we were in new york or chicago those cities and places of course, york is the capital but here from texas to the florida panhandle there really is a a sensibility with a similar environment with palm trees and sandy soil and salt in the air the gulf of mexico nourishes and supplies with wonderful seafood with estuaries and rivers that are rich with tradition and culture. there have been books in and around all these things for hundreds of years. it is extraordinarily rich subject.

then along comes the oil spill in 2010 then we are center stage and people are beginning to look at the gulf coast and think what is it like there? we didn't know we had so much oil and gas from them so the nation was to and did to how important the gulf is. >> the hearing will come to order i will welcome the

distinguished witnesses introduced shortly. recently, the media has a resurgence of heroin abuse in the united states and more careful when moved into the country. according to a 2012 national survey, as 656,000 americans reported using heroin during the previous year. that number has steadily grown over the past several years. so this begs the question why are more people using heroin? and this is the senate caucus on international drug control but the reason we control which is to keep that out of our country and to do those things that prevent opiate used not to enable its. but one answer according to the experts is maybe the country addiction and use of

prescription pain medication and here is why. a report to released by the substance abuse and mental health services indicates individuals who use prescription pain relievers for nonmedical purposes were 19 times more likely to use heroin in the past year than those who had not. that is amazing. furthermore for out of every five heroin abusers had abused prescription pain relievers in the past. so paid relievers like oxycodone and hydrocodone affect the central nervous system in much the same way as heroin. the lesson is that rather than thinking of two separate addictions are prescription pain medications and heroin we should realize we face a much larger opiate addiction epidemic that includes both. so the strategy to battle

these drugs should have three parts, preventing drug abuse, and reducing the number of overdoses. but the first and most important strategy is to prevent drug abuse before it starts to educate the communities and use about the dangers. some communities already do this through the federal drug free communities program and there is a program that contributes to a 50% reduction of prescription drug use among 11th graders between 2011 and 2013. so these programs i believe can work. and also means recognizing all stakeholders share a responsibility that prescription and opioid are prescribed and dispensed

only for legitimate medical purposes. state based monitor programs can help doctors and pharmacists identified drug abusers. incidents requiring mandatory checks new york jazz scene as 75% decrease of doctor shopping and a significant reduction of paid reliever prescriptions. so the takeback programs would reduce opioid abuse because of prescription pain medication is but not both medicine cabinets were too many young adults first obtained the drugs. add heroin entering the united states from other countries also must be addressed. the d.a.'s signature program of 2012 determined 90% of

wholesale heroin seizures could be traced from mexico or south america. d.a. also reports the mexican base is expanding its market east to produce and sell heroin that is more pure calling from the ground. between 2008 and 2013 heroin seizures along the southwest border increased nearly fourfold up the 2,196 kilograms. the second key strategy is successful treatment that includes medication assisted therapies using drugs like methadone but unfortunately

in 2012 to .5 million people in our country were addicted to these opioid fall only methadone to treat addiction so that means the rest of not receiving treatment. finally, the third strategy is to reduce overdose deaths. in 2010 the latest year for which data is available the cdc reported more than 19,000 to 500 unintentional overdose death there are steps to be taken in drug said immediately reverse the overdose and 18 states including california have taken action to improve

access to these drugs. we need to find a way to make them more readily available to a minister individuals including first responders. we have an interesting hearing i want 2.0 you see the rate of opioid sales death and treatment from 1999 and 2010. the green is treatment admission and the red is death and as you can see they all go up in this country. that is a good chart that discusses what we are about to.

perelman abuse increases as access to prescription painkillers decrease. that is a brand new thing for me and that is what this other chart shows so i hope some if you would remark on this. know i will recognize the distinguished vice chairman. >> i will defer to senator mcconnell to thank jim for his interest in this issue. >> and i thank you as well simic figure for the opportunity to be here today to testify with carol and abuse says devastating as this senator indicated to many families across america and in my home state of kentucky. thank you for your willingness to focus on this growing threat. i would like to share with

you a story of the of vibrant community have the pleasure to represent here in the senate. it could be many places in america but it happens to be northern kentucky. of suburban cincinnati is the center of culture are its and the home to roost of kentucky international airport and the gateway to the bluegrass state from the north. residence of the three counties that we refer to as northern kentucky with a time of great opportunity to of the benefit of living and the major metropolitan area with all the charm of this small town and take advantage of the cultural amenities like this to and the botanical gardens and newport aquarium and the kentucky speedway or a

cincinnati reds game or the art museum. over 25,000 acres of parkland and. northern kentucky offers all of that but yet this proud community has settled with the distinction to be the very epicenter of heroin addiction of kentucky and in the nation and. many believe the problem started because of prescription pain pill abuse as senator feinstein was pointing out as the third highest drug overdose mortality rates in our country. on the street these hills are expensive and cost between 60 and $100 compared to a bag of heroin that is

just $10 so given the of progress to fight the illegal sale of prescription narcotics those that have seen the uptick of heroin usage once we understand the economics. a few months ago i discussed the relationship between the herald and threat with federal agencies responsible for curbing these threats and i will continue to work with them as we work together to fight this epidemic. i will highlight some hard and true facts of heroin abuse and northern kentucky. of a bite to credit said chamber of commerce for the data. the fact become from the chamber of commerce demonstrates how pervasive the threat to the community. these are the facts in 2012

there were 61 hero when overdose deaths in the three counties referred to as northern kentucky. the overdose cases increased by more than 75% in 2012. while the heroin overdose cases had already doubled by 2012. rates of acute hepatitis c are double the statewide rate in 24 times the national rate. 24 times the national rate. public health officials attribute it to the high level of heroin use. what is more of the northern kentucky health department has reported that for everyone out there there is one new case of hepatitis c that has a lifetime cost of

$64,200,500. but said they knew more babies are born with drug withdrawals syndrome it is heartbreaking not only costly in human terms of fiscally as well encouraging -- tinkering hospital costs over $2,000 according to the northern kentucky strike force the number of court cases has increased by 520% in the three counties that i mentioned in it is expected to double again. to put into perspective the three counties contains 60 percent of pearwood prosecutions from 2011 although they are less than 10 percent of the population. it is fitting you hold the

story national police week with thousands of police officers visit the nation's capital. we owe these officers our profound thanks and gratitude and the violent property crimes driven by the growing trend. clearly is shows northern kentucky has a serious problem it is a major problem for the entire region. although it may be ground zero in my state but it is spreading like a cancer across the bluegrass state we're losing close to 100 residents per month to drug-related deaths. we only have 4 million people in this state. this is more lives lost and a car crash. this march i held a listening session to hear from those how we could fix

it. of one of the county's i referred to there were great heroes such as the medical professionals the business leaders to raise money for awareness efforts sam of prosecutors and investigators taking drugs off the streets and those who found the courage to live despite their addiction. i heard from presidents from the business community and law enforcement and i want 2.0 one brave young man who was inspired by heroin and saw his friend use its and overdose it took repeated attempts to break his addiction but he said proudly in a listening session he was four years 10 months clean. i cannot stress how whole flow was to hear about this issue from so many thoughtful perspective is

that is why i am pleased he were holding this hearing today. so i will list three takeaways the first it is clear the increase of care with addiction tied to our fight against prescription drug abuse which is largely driven from prescription painkillers. second, while kentucky makes progress with greater education and more aggressive prosecution with enhanced regulatory authority we need a culmination of treatment and incarceration to be a part of the solution. also why multi law-enforcement efforts such as the appellation high a trafficking area is so crucial finite federal resources to use the interagency partnerships to

maximize our returns for federal dollars to combat the epidemic. the executive director never fails to remind his partners there is no limit to what we can accomplish if nobody cares to gets the credit. so i will return to the picture that i painted that is preset by carolyn abuse. thankfully the end is yet to be written that is why i will share the gravity of the threat to my constituents and pledged to work with all the stakeholders from the terrible growing threat with the leveraging of resources using best practices from law enforcement and corrections agencies as well as a public health communities we will eliminate the shadow of this epidemic from a robust

community all across america like northern kentucky. thank you very much. >> senator grassley you make your statement then senator colbert charpoy like spandex and she describes the situation very well i will start off in the middle of my statement and referred to what we learned about the existence of the database by doctors maintained by perdue pharmaceuticals from oxycontin one of the most abused prescriptions the database for those doctors that had reckless prescribing practices. many state medical boards as well as a center for medicare/medicaid services did not know about this database securities organizations to contact

perdue for those authorities to take action against irresponsible doctors but what else is being done to combat this epidemic what will congress would make if it is common sense? sir which doctors are educated and from the dangerous opioid and other addictive drugs to be a part of that solution. so what the obama administration sends is also a damaging. young people in those looking to climb up the ladder to not need another pathway to addiction but that is what is what the president said provides

failing to enforce federal laws as a bad habit. treatment for those who have become addicted is part of the solution as well. another drug have shown effectiveness to countering the effects of heroin overdose and law enforcement will have a critical role to play of course, we cannot arrest our way out of the crisis but we must maintain the current tools for those are trafficking heroin into our nation and communities but unfortunately with the reform bills that are now before congress does just the opposite to propose the smarter sentencing act has mandatory minimum sentences that distribute heroin and it do that by cutting them in half. these are penalties for dealers, not users in the

midst of an epidemic in my opinion it makes no sense. federal prosecutors right that the current system of penalties is the cornerstone to iñ4s/z'2!ñ and dismantle the organization's to make career criminals off the streets. i don't want to remove the cornerstone at this particular time. thank you to the witnesses for being here and i will put my entire statement in the record. >> please do. >> thank-you and die with like to think the senators to invite me to participate. just yesterday afternoon i was with president clinton at johns hopkins where the hope matters initiative held a very important forum on

this very topic with focus on prescription drug addiction and discussion about parallel amazon a panel with commissioner gary berg and of former representative patrick kennedy following the speech and he is taking this issue on and he has a lot of energy. i start with prescription drugs because if i look at the fact of care when one of the past majority a prescription drug users to not start with carol when. for out of five heroin users today's start with prescription drugs. they start with the demand issue of how we get to that and first of all, requests to do whatever we can to reduce the supply which is the drug takeback program to get them a lot of the hands of kids.

the senator corded and i passed a bill in 2010 we're still waiting that makes it easier from clear standards how they will be transported with it takeback program because certain police departments that are still not doing the program said they are concerned about liability. this makes it easier for farmers see if they voluntarily did this is you can imagine people are bringing back prescription drugs out of the medicine cabinets voluntarily to do is a long-term care and that is one thing. and how many tons were collected in just one day day, 390 tons were collected one day in april.

that is so we are dealing with. and drug courts to cut down the demand to get people involved and we're working on more funding for that three out of court graduates never get in trouble again. and with the supply-side would be prescription drug monitoring the patchwork system where one system cannot even tell doctors when they know that they are dr. hopping to a get oxycontin it is not mandatory or interoperable or across state lines and funding issues as well. then we get to their hair when we have a huge increase of heroin overdoses in the first half of 201391 people died and the twin cities

area because you have heard it is more peter coming up the corridor mostly out of mexico and 50% dues grown in mexico 60 percent transported through mexico because of that along with sex trafficking with cindy mccain and senator i campbell focused on sex trafficking in heroin and met with the federal police and the attorney general. i came back with that the mexican authorities are more devoted dad ever to do something about violence and want to be a part of this new economy bases this as the key to that. they go after the cartel but there is more work to be done from the ratification

it is different than the black tar and strengthening the southern border where it is coming up from countries south in the third is continuing coordination with law enforcement on the demand side. when excited you're doing this hearing and we have to be smart at the answers let me introduce the witnesses. >> please confine your remarks to five minutes it in writing we would like to have them for the record to have a robust discussion i will begin with michael botticelli who has been here before and we welcome him

back. the director has more than two decades of experience supporting american's affected by substance use disorders prior to joining the served as the director of substance services at the massachusetts department of public health. next dr. volkow back to the caucus and director of the national institute on drug abuse which coincidentally founded 40 years ago today so i will be the first to wish the institute's a happy birthday. her work is instrumental saying it is a disease of the human brain. she pioneered the use of brain imaging to investigate the toxic effects for drugs

that are of use. dr. clark is a director for substance abuse treatment as director he leaves the agency nationwide effort for effective and accessible treatment for addiction disorders a noted author and educated of substance abuse treatment and has received many awards for service. next we have mr. rannazzisi back to the caucus said deputy assistant administrator of the version control at the da. mr. rannazzisi is responsible to ensure that more than 1.5 million d.a. registrants comply with the controlled substances act

and its implementing regulations for code-named the deputy assistant administrator in january january 2006 and has been with the dea 25 years. we are pleased to have dr. dr. teeeighteen the chief medical officer of phoenix house one of the leading non-profit drug rehab for organizations it is an expert on opioid at addiction epidemic and a practicing psychiatrist to develop and implement substance abuse treatment programs in new york and a past recipient of the congressional health policy award. so perhaps we will begin of with director botticelli and

co write-down of mine. then be will have time for questions. please proceed. >> the key for the opportunity to appear today for what is the most public issue facing the united states including opioid including prescription painkillers in peril and. given the recent media attention and there is a heightened interest of opioid drug use. this may be a new phenomenon for many communities but some have been dealing with this issue for all long time and it is a matter of great concern. drug overdose death primarily driven by a opioids surpasses traffic crashes and in 2010 the

latest year for data approximately 100 americans died from an overdose every single day. analgesics were involved and heroin was involved more recent data said it continues to increase. weld carol lynn remained slow compared to other drugs there is a troubling increase of people using heroin and receivers up to 669,000 in 2012. it is clear we cannot arrest our way out. science has shown drug addiction is the disease of the brain that can be prevented and treated and can recover. minnows substance abuse disorders are a progressive disease and it is important to consider and understand

many people to develop this begin using other young age and as individuals become more chronic they're more inclined to purchase the drugs from dealers or from multiple doctors rather than simply going to friends and family. lift country did this progression may exceed an individual to pursue a lower-cost and more prudent alternatives like heroin. with these circumstances in mind we look at the inaugural drug control strategy that we set out a wide wray of action of criminal justice reforms to reduce and drug use and consequences that noted overdose as a growing national crisis to set

specific goals for reducing drug use including maryland. the administration released the first comprehensive action plan for the epidemic. the prevention plan strikes a balance between the need to prevent abuse and to ensure legitimate access to prescription pain medication and expands on the national drug control strategy to bring together federal-state local and tribal partners to support the expansion of states based programs and more environmental with bids to remove expired or unneeded medication and educating patients about opioid drones and instructing health care providers into reduce the prevalence of kill bills and doctor shopping this has been trying to redress

trafficking and use for also focusing on opioid overdose including educating the public with intervention and increasing access with the emergency overdose information the police are often the first on the scene the administration has strongly encouraged local law enforcement to train and equip personnel with the life-saving drug. 22 states plus the district of columbia has implemented a law or pilot program to allow the administration of this medication to reverse the effects of the opioid related overdose also was good samaritan laws of bystanders will take appropriate action to help save lives. their current 17 states has now adopted good samaritan laws.

it is critical to save lives we need a comprehensive response to prevent the death there requires to catch the signs and symptoms of there before it develops we have been encouraging the use to catch use before it is the addiction and. says only 11 percent receive treatment that receive did their demanding access to treatment. the affordable care act is extending access to substance use disorders and mental health benefits for an estimated 62 million americans to close the treatment gap into mainstream health care. this represents the largest expansion in a generation by millions of americans helped into successful recovery. the standard of care driven

by a narrow win or prescription opioid involves the use of medication and approach to tree shilling dash treating addiction was behavior therapy as long as approved medications either treatment has helped thousands of people of long-term recovery their prime goal is to increase access to within existing programs and integration with primary-care. sometimes the national efforts are working the number of americans initiating the nonmedical use of opioid has decreased significantly since 2009. additionally according to the latest monitoring in 2013 of rate of past year used of opioid with high-school seniors as at the lowest since 2002. the implementation of distribution programs in the

expansion of assisted programs could reduce overdose death to be cost-effective. nonetheless continuing challenges with the reemergence of farewell news underscores the need for an leadership all levels of government. we will continue to work with federal state and tribal community partners to continue to reduce and prevent the health and safety consequences. thank you. >> could you just tell me you said heroin use had doubled? in the last five years? >> this is information from the most recent survey that looked at people who use heroin in the past year. that was 373,000 in 2007 up 669,000 in 2012.

>> that is striking. five years. >> good afternoon. '01 to take you to invite me to address the problem a prescription and opioid use. those medications are the most interactive to managing acute addiction. unfortunately the only inhibit paying centers but activate the brain regions why they are so addictive. reface a unique challenge to prevent their abuse for managing severe pain which is terribly debilitating. 2.1 million americans

predicted to opioid painkillers the reflect the widespread ability of the drugs. the number of years the prescriptions for opioid more than doubled over the past 20 years from 76 million up to 207 million prescriptions well at the same time there was a fourfold increase of overdose death from the use medication during that time period. like the din and oxycontin effect similar to heroin that gives euphoria that they can intensify to take higher doses or inject which makes them much more addictive and more dangerous because they increase the risk of respiratory depression which is the main cause of death from opioid overdose. also trends indicate a

significant rise of heroin use in our country affects more than half a million americans and is driven in part to by individuals switching because it is cheaper and easier to access. so what are we doing about the problem? management of pain pain, prevention of the overdose death and the treatment of addiction. how do we treat pain better and those that suffered? we don't know enough about the addiction for those that have chronic pain but in parallel we are developing medications to treat pain effectively but at the same time to develop ways to a minister opioids and finally

with research for non medications strategies is with electrical brain stimulation. what about preventing overdose is? we have a very effective medication that helps to prevent death from overdose of the fda approved the self injected drug will facilitate if administered by medical personnel. also friendly ways such as the patient themselves can use it to. when no one is around when the patient is asleep with the development of the self activated systems that initiate the emergency response to show that the

overdose but then looking at the zero pureed addiction with those therapies are all effective with the overdose it is less than one-third of those that need them to overcome the barriers and parallel of research such as vaccines of perelman addiction. additionally we work closely with the partners to implement the intervention will of the treatment of this problem. think you again for organizing this meeting and for inviting us to participate. >> dr. clark? >> good afternoon chairman

feinstein. i'm sorry i have to leave that with the possibility to participate in the panel at the wing that colleagues focusing on activities to you with that surveyed 4.9 million reported use over 2,012,335,000 of a figure that has more than doubled and in 2012 more than 1.80 million people reported initiating paid relievers and money to 56,000 reported initial use of heroin. one challenge is educating the public on the dangers of sharing medication according to the national survey 54 percent of the loss

column nonmedical accused precede them from a friend or relative to either bought them or took them from a friend or relative. so we have problems intertwined with cultural programs. focusing on educating the public including the legal campaign which encourages parents to talk to their teenagers about drug abuse and prevention of prescription abuse and their families, a prescription of prevention with the capacity building activities. screening and prevention program including urine and other opioid. all programs to provide appropriate pain management and minimizing the risk of issues.

with the medical residency program includes opioid for pain management and misuse. 6,000 medical residents and 13,700 non-residents have been trained nationally. with clinical support systems so with of modules it begins the clinical support system of a collaborative project with six other beating other societies. we will find a clinical support system on the correct use of opioid and related addiction's this year. at the end of report article in the "new england journal of medicine" describes the underutilization of

medication in addiction treatment to discuss the ongoing efforts of major public health agencies to encourage their use that includes three strategies of their fee that includes methadone that also has injectable release it is responsible for overseeing their regulatory compliance that use is methadone or the other two and they are encouraged to use. we estimate there are 300,000 people reseeding methadone maintenance and 26,000 positions with a reefer. >> can i stop you? >> 300,000 people receiving what? >> methadone throughout the united states has. >> there are physicians that have a waiver of those 77

and o dash 7700 to 1.2 million received the drugs to utilize in the treatment program. between 7,000 and 10,000 or on a lower number because there also alcohol dependent and zero pureed dependent we publish the opioid tool kit to educate responders and committee members are up the steps to take to prevent and treat the overdose it effectively restores breathing to a victim of an overdose. back to be a teachable moment that gives the person to the appropriate resources. with the block grant primary prevention and set aside funds with the education and training and we know that block grants other than and up primary prevention set aside funds with the

necessary materials to cover the costs associated into continue to focus on reduce the impact of mental illness rethink guyot and the members of this caucus to convene this important hearing and they give for the important opportunity to address this issue. >> before mr. rannazzisi speaks at was astonished at the statistic i just found for the most recent national takeback day, 6,000 collection sites, 390 tons of medication was picked up. 780,000 pounds. that is amazing. >> it is amazing we have a federal state local law-enforcement agencies together with community

groups on one saturday for four hours a. it was a collaborative effort. 6,000 sites all that are stocked with police officers, a local state county federal officers as well as community groups and pharmacists who would work with law enforcement it was a truly collaborative effort >> please proceed. >> chairman and distinguished members on behalf of dea administrator thank you for the opportunity to discuss the relationship between prescription in opioid and carolyn and how d.a. addresses this problem. the present state of affairs is not a surprise. to be concerned about the connection between rising opioid abuse and heroin traffic for several years. the dea believes increased terror when news is driven by many factors including the increase of misuse and

abuse of prescription opioid. law enforcement agencies across the country are reporting an increase by eight teenagers and young adults beginning a cycle of prescriptions. those that teach golf individual switched to heroin depending on price and availability. nonmedical use by $0.18 at young adults can lead to heroin use traffickers' new this and are relocating to areas where prescription drug is on the rise. we know many teenagers and adults can get prescription opioid for free from the medicine cabinet but if they get oxycodone -- short hydrocodone it is the most prescribed drug in the united states today. . .

to address prescription drug aversion well educating the public. educating pharmacists and treating those individuals who have moved from misuse to abuse and addiction. dea currently has 66 tactical diversion squats

opioid pain medications. 275% increase for oxycodone 197% increase for hydrocodone

a heroin is just a symptom of a prescription drug problem. >> what you are also deducing is that the prescription drug is a gateway drug to heroin because if it gets too expensive then the young person turns to heroin which is much cheaper. >> i would absolutely a query with that. there was an increase in our heroin cases from 2008 to 2012 of 35%. if the data from 2013 remains

constant the increase will be about 51% for 2013 and we are still getting reports in. the increase in heroin abuse and trafficking as a symptom of our country's insatiable appetite or opioids and can lead to abuse and addiction. it's a natural progression from the abusive prescription opioids. there's a dangerous misperception that abusing prescription drugs is safer than abusing heroin but can lead to addiction and death. preventing the availability of controlled substances and educating practitioners pharmacist in the public about pharmacy diversion trafficking abuse and priorities at dea. as such we will continue to work with federal state and local officials law enforcement partners professional organizations and quincy group's to address this epidemic very thank you for the invitation to appear today i look forward to answering questions you have. >> thank you very much.

dr. kolodny. >> chairman feinstein's senator whitehouse and senator klobuchar thank you for the opportunity to disclose our nations opioid epidemic. the increasing use of heroin in suburban rural counties across the country is easily explained. if you speak with the new heroin user they will tell you that they began using heroin after becoming addicted to opioids painkillers. this phenomenon is not new. people have been switching from painkillers to heroin since the epidemic again 18 years ago. like heroin opioid painkillers are made from oak wood and the effects

the world's oxycodone and 99% of the hydrocodone supply. on what basis is a concluded that we need more opioids? to end this epidemic i think we must accomplish the same two things we must do for india disease epidemic. one, that we must prevent people from developing the disease in the first place and two we must see the people who have the disease are able to access effective treatment. to prevent people from getting the disease in the first place the medical community must prescribe more cautiously so we

don't addict their patients and indirectly cause addiction by stocking medicine chest. for the millions of americans who now struggle with

the question is you mentioned the fda just keeps on licensing regardless. i think that's something that i'm going to look into. i have this question. i was the senate sponsor of the ryan haight act which went into effect in 2008. and that provided that no controlled substance that's a prescription drug is determined under cosmetic act may be distributed or dispensed

viking in can be found in very easily come of prescribed with multiple refills because it's in the wrong schedule. for other opioids it does require a doctor's visit. >> well, let me -- so, we solve that problem. now we have the problem of doctors over prescribing. what would you recommend? >> well, for doctors to describe more cautiously they need accurate information about the risks and benefits of these -- medications, what caused the

prescribing to take off was a well funded campaign with quite a bit of misinformation. doctors were taught, i was taught that you should not worry about getting patients addicted. that is a compassionate way to prescribe is aggressively. there really is not that much being done to correct the record . >> anybody else on this point? >> i would absolutely agree, the vast over prescribing of prescription medication, part of the effort that the federal government has been doing in connection -- conjunction is providing online training courses for positions to really look get appropriate and save opioid prescribing. there is more to be done, and promoting mandatory prescribed education is really part of providing and ensuring that physicians and getting accurate information other than the information that has been provided in terms of the pain

prescribing patterns. you know, we keep pointing to the data. and it is very clear that this is driven by well-meaning positions in many cases you don't understand the lethality of these drugs, the addictive properties, and are not trained in terms of looking at alternatives and how we monitor people who might be developing an addiction. >> anybody else? [inaudible] and overall there is missing education on the screening and proper prescription and management, medical schools and pharmacy schools. also mentioning, improving access and friendliness of the prescription program. when faced with the patient they can access that information, not just in their state but in other states. and the issue that we really need to address is the fact that we have also a serious problem of severe pain, and we do not

have adequate treatments to address pain of patience. another reality that we need to face. >> dr. clark. >> we also have with the advent of the affordable care act, and i virginity to offer alternatives to pain medication for the treatment of pain. think that is something we should keep in mind. historically one of the problems was that there were fewer alternatives to pain medication for pain management because physical therapy was not available to a lot of people who suffer from pain, depending upon the community in which to live. other strategies could not be supported if the insurance companies chose not to support. so pain medications themselves are actually relatively inexpensive this by some of the new formulations. and so with the hca, having an opportunity to get nonprescription strategies to address pain becomes more available. >> thank you.

>> we had a massive problem with schedule three and four coming of the internet. we had one case where the average pharmacy in 2006 was dispensing about 66,000 hydrocodone tablets a year. that's not that much. in one year we had pharmacies' dispense over 98 million hydrocodone tablets. what ryan a did was shut that down. what do we see overnight? these were not physicians with traffickers. they gave up their white coat for trafficking and money. what we saw is overnight then move from internet trafficking to pain clinic trafficking. we went from four to seven clinics and brevard county in 2006 to over 142 in 2010. that doesn't make any sense. >> what you are saying is, the pain clinic as part of the

problem. >> there rogue paid 25 rogue pain clinic is definitely part of the problem. these are doctors that are not practicing medicine. these road clinics, doctors that are just dispensing. >> i thought that had been debated in, i think, florida big one was shut down. isn't that right? >> we treat -- decrease the number in florida through a collaborative effort between law enforcement, federal, local, and state law enforcement. the move to it georgia. now there up in tennessee. georgia has almost to wonder clinics operating right now. they're moving north and west. these are just prescription pain mills. we need to get aggressive. it's a two-pronged approach. we need to aggressively aggressively attack these clinics and get them out of businesses in as possible, but the regulatory boards in the states need to take control.

a lot of these clinics could of been shut down of the regulatory boards would have exercised their authority. some states don't give them enough authority. >> i am way over my time. senator, thank you. >> my first question would be to the zone. it comes from news reports that we have had about the countless deaths linked to a mixture of heroin and painkiller. in philadelphia just this week, at least 28 people have died from the mixture. of give you a chance to educate us in the public. take the opporunity to tell the public what they know about the dangers associated with the mixture and explain why drug dealers might makes and tell us what steps we can take to locate sources under arrest traffickers. >> first of all, fentanyl is a

synthetic opioid. it is totally synthetic. it is not manufactured in a planned by lab. we have seen this over the years, over the past 35 years we have seen clusters of deaths related to clandestinely produced fentanyl. will we see is most of the fentanyl is clandestinely were produced. in 2005 or 2006 we had a rash of fentanyl debts that were related to allow we tracked back into mexico, taluca, mexico. working with the mexican authorities we close that down. fentanyl rears its head pretty much every few years. this particular drug, it could be fentanyl or it could be an analog of fentanyl. it could be another and law do we are just not familiar with. the reason they use it is because it is approximately a hundred times more potent than morphine on a standard dose.

so if they have bad heroin or the heroine is not potent enough , or if they don't have verlaine there will use the fentanyl and sella the sarah went. people don't realize how potent it is. people don't realize how difficult it is. it is measured in micrograms. if you don't know how to cut it people will be getting hot shots and dive overdoses. it is very important that we find collapse. we have specific clandestine lab groups as well as airline groups out there looking for the source once we find it domestically or brought we will take care of. >> common sense tells us that efforts to prevent all kinds of addictive behavior should begin as early as possible on life. i'm concerned about the increase in use of marijuana, and young people leading to other addictions. you are obviously an authority on drug abuse and addiction that

have been outspoken in your views about marijuana itself being addictive. are you concerned the marijuana use by young people elevates the risk for other addictions later life such as abusing prescription painkillers or heroin? what does science tell us about this? >> well, the studies tell us that most people or addicted to drugs started by consuming marijuana, and many of them started by consuming tobacco and alcohol. these plates to the concept of the day -- gave way. will we know is exposure to marijuana-like substances and annals early on during adolescence or even younger increases the sensitivity to the addictiveness of other drugs. and in studies of twins they have also shown that when that when that starts early before age 17 has a much credit risk, use of marijuana before a 17, a

much greater risk of becoming a victim to a wide variety of drugs. those are important because they control for environmental factors that are important drivers of using and experimenting with drugs. the data does seem to suggest that the use of marijuana during adolescence will have of deleterious effect, these of the making that person more vulnerable to the addictiveness of other drugs including prescription a opioids. >> you referenced in your testimony about the administration's prescription drug prevention plan. that goes back set april, 2011. the plan focused on prescription opioids. one of its goals was to reduce deaths associated with the drugs. do you think the plan needs to be revised in light of alarming

developments of the last three years? if so how? or are the solutions of this epidemic a question of doing a better job of implementing it? >> i think it is to fold. clearly we have to look at the emerging evidence. any strategy worked it so as to ignores the changing times and really look at our strategy continues tow of to address those issues. as we talked about today, the prescription drug abuse prevention plan clearly falls in the area in terms of how we attack in a multifaceted way these issues. we will continue to update our strategy to talk about the evolving heroin issue. we have been continually promoting the use of medication- assisted treatment, expansion of access to treatment, particularly in primary care settings and the more widespread use of overdoes prevention tools. we will clearly ball our strategy to reflect the changing demographic and changing use patterns and also changing strategies that we need to

address the. >> also, my last question, i appreciate your answer. >> thank you, senator. early bird. >> thank you very much, senator. i wanted to follow, senator feinstein has some very good questions about the drug take back program. you know, i have a bill that senator corn and i past four years ago to make it easier to do drug takebacks. she talks about the 390 tons, but our problem is we don't have the rules. i talked to director leonard three-year four times. she's from minnesota. we like for a lot. and now we just got them back from omb. when do you think those rules will be done? we cannot support these drug take back programs to the extent that we wonder if we don't have the rules from the al qaeda when it has taken four years. >> thank you for that question.

right now there is one issue the fact is that the omb has done their job, vetted it, came back to us, trying to work. the importance of that. we could multiplier that over if we could make it easier to have these charts take back on a weekly basis of the month daily basis in pharmacies of people can bring them back. >> the problem with this bill in particular was, this bill and these regulations touch on several -- >> i know. transportation. >> epa, even the military. we have to be very cautious. we don't want the have them go

back and make serious corrections in their statutes. >> i understand. synthetic turns, thank you for bringing up that issue as well which is contributing to these addictions, the fact that people can manufacture them from compounds. we, of course, senator grassley and shimmer and i and senator feinstein are very helpful in moving on the synthetic drugs. we have two different bills that are supporting each other's bills about synthetic drugs with analogs and things like that. you would think that would be helpful to make it easier. >> i believe any help we could get at this moment time is going to be beneficial. we have about two wondered compounds we have identified that are outside the act amounts of the control, representing every class of drug or abuse out

there. >> okay. thank you so much for what you're doing. i appreciate what you said. as you know, the fda just approved it quicker than usual to be used in emergency situations. and now my said this month passed a bill allowing for responders to use it. i'm going to move on because of somewhat obsessed with his prescription drug mommsen to vichy. a one of the thank you for raising it. it was the number one thing that president clinton talked by yesterday. it's a very big deal. prescription drug laundering, the idea that as we are seeing all of these clinics that should not be prescribing and i had never heard those numbers. what did he say about the increase in the number of prescriptions? the number used? >> more than doubled. >> 7 million prescriptions per

year between hydrocodone. >> without that much change in our population. okay. there's just no way. senator white house is to say many more people and not paying. at think we know that's not the case. people are being prescribed these jurors that should not be. tell me some ideas you have and how you think that if this prescription drug monitoring or at least we can put a check on these. >> the take back is good. i am not leave.

>> we have that technology. why can we not have a system like palaces and to operational? >> very quickly. and i'm out of time. >> these are two very complementary strategies. and people start abusing prescription drugs they're getting them from the medicine cabinet. getting them out of the medicine cabinet is the first at. they often turn to be able to do this. so a large part of our prescription drug abuse strategy, operational and effective prescription drug monitoring program. we have 48 now better operational. one that is in the process, and one state that refuses to invest in a prescription. a big part of our work has been

easier to use programs as well as a interoperable programs. north senator said these programs need to communicate across state lines. nav 20 states that have and drop will prescription drug monitor programs. >> i know you want to answer, but i know senator udall has some questions about this. they're teasing me for going way beyond my time. >> you are going. >> welcome. this is a terrific panel. i think senator feinstein and senator grassley for pulling this together. thirty-eight rhode islanders died of opioid overdoses in the first six weeks of this year. if you expand that to the population of the country into a full year that's 100,000

americans dead per year. it's really very serious. it steps have been taken. local police departments as well as the first responders will have available. i think we are responding in some good ways. one of worries me a little bit is something that has been raised a bunch year. the prescription drug monitoring programs. i have fought for years with your agency, dea, to try to get schedule narcotics onto electronic prescribing. and after years of bureaucratic battle, finally the regulations came out. i think that facilitates electronic prescribing, prescription drug monitoring. you no longer have to go and ask

for the paper script for individual doctors or from individual pharmacies. you can look at a data base nc, wait a minute, why are they prescribing hydrocodone? this person for from 500 capsules and now they are prescribing 5,000. this burst on the five different doctors in five different pharmacies for the same prescription. what's going on? it opens investigatory doors. yet years later, now elect are prescribed for all the stuff. the prescription drug monitoring program still seem to have yet really, alan -- on line as a proper investigative tool to give us the common-sense information that we need to make these determinations. what are the best next steps that we should be pursuing to try to get this prescription drug monitoring program to a place where we are getting these warnings before we have to go

and, you know, run up a fake pain clinic that sold 100,000 prescriptions? you should be able to catch saddle lot sooner if you're actually watching the data has comes up. what are our next best steps? let me ask you first because you talked about this while. >> well, i would say that we should put our resources necessary to make these the way should be. immediate information right away there is no reason technologically that we cannot do it. >> privacy concerns? >> privacy concerns are, if we run into the los. >> we are just not excessing it in an intelligent fashion. >> correct. >> of perry. dr. parker. >> working with the lindsay and ryland has promulgated, the

electronic health record integration and upper ability programs. a small portfolio. you're with the department of justice who has the lion's share of the primary focus. we have been working with your island to improve access to data for health care providers by any rating functions used and by integrating the functions and the pharmacy dispensing software of the pharmacy data that other states. is forecast to be done in order to make this effective with new technologies. you don't necessarily get. we are working with the ryland health department to address this so we can establish models. >> i think our director of health is for with the best person in the country honest. thank you for nodding your head. i am glad to here.

let me wrap up by thinking the doctor for being here. phoenix house as an important role in rhode island. very, very helpful. a want to raise that as we, particularly as the d.a. does the enforcement in this area, let's not throw the baby out with the battle -- bathwater. when you have people who are we can not particularly good advocates for themselves, elderly people, nursing homes, if they run into an abyss of a very, very severe pain and you have ratcheted down so tight they need to wake of a doctor to in the morning, in the real world there will suffer for hours until somebody can be found command. i hope they you will -- the balance and awful and precise in

the way we go about pursuing this and not risk the beneficial effects of these drugs in the pursuit of eradicating their views. >> may i respond just briefly? i believe that the clinics and the practitioners that we investigate and prosecute are not doing any type of medical care, and you would not want an elderly person, let alone help the person. will we are seeing is drug seekers go and facilitate addiction. >> i don't defend the pain clinics for one second. but if you have a situation where you need a doctor to prescribe some the at two in the morning, that's a problem. i think a legitimate national that has been there for years, he did think of it differently than a pain no. >> thank you, senator. >> thank you, senator. good to be here with you.

let me just thank you and the senator for focusing on a tremendously important issue. this testimony we have seen the charts that i think was in your package, this astronomical growth is just astounding. and in light of senator coverage our's discussion with me, i first want to turn to you and ask you on the prescription drug monitoring mission, you want to say something. >> thank you for asking me. so for friction for the long term program. ninety-one of the best tools we have for bringing this crisis under control and except for new york, kentucky, tennessee the state that made it mandatory for

doctors to use them just aren't being used. make it mandatory for physicians to use them. >> we ought to do that. that's something we can't do. >> that's what you're saying we should do, make that mandatory. >> absolutely. >> a worthwhile one. let me -- i had an opening statement as to put that in the record and go on to questioning. i think such good issues have been race here. last want -- and this goes to the doctrines deasy last year we

cents a letter urging the department of justice to draw on them any evidence based strategies that have been successfully employed in states to address her when an opiate addiction epidemic. can you explain what efforts are underway to find solutions that work in the states and then expand the nationwide? >> i think for starters the states take the lead in having prescription drug summit mile in four the risk of pharmacists, nurses, also for community leaders. basically leverage their community coalitions out there doing education. using that as a force multiplier get the word out to our schools. the states are doing a remarkable job, working together

with investigations related to planning clinics and practitioners. i think that this problem, and we don't work as a team, both state and federal, local investigators and regulatory boards, it's just going the wars . more collaboration with regulatory boards. this to address this problem. florida is the perfect example. i think the states and the federal government together and doing a fine job. the great thing about our system is having the states as laboratories. that, with some very good examples that we can spread nationwide. i have of very large native american population, 23 tribes in the mexico.

the raid of nonmedical use among american indian or alaskan native adolescence was almost twice the national rate. during fiscal year 2006 and 2009 the high intensity drug trafficking areas program provided a small amount of discretionary funding for native american programs to combat drug trafficking on tribal lands. is this something you would be willing to consider? >> we have been significantly concerned. we have actually been working with the indian health service to look at how they might increase capacity. we have great cooperation from the indian health services and making sure that all the performers are appropriately trained. we have weight scored nation boehner also working and will continue to were about how we

might look at discretionary dollars. >> thank you. that's the perfect, i think, collaboration between union health service to move this whole issue forward. >> appreciated. welcome. >> thank you for inviting me. thank you for your good work. massachusetts and programs that distribute a line in the community. the family and friends of an appeal of user. he's pro grams save thousands of lives. my understanding, or ever, members of the general public have expressed concern about being held liable for lawsuits to pay a master and receive

orders situations. have you also heard these concerns? >> i have. >> of we were to eliminate those liability concerns, the think we could increase radically the number of people ready, willing, and able to save the lives. >> people in response to an overdose, a strategy that we should continue to investigate. the life of a family member or a loved one because of legal liability. a recently introduced a bill called the opiate reduction act. it extends projections to people who step in to save the lives of a person who was overdosing by administering a drug like naloxone. we need a national good samaritan law so that people will step in.

how many lives do you think would be saved? >> we know one of the prime issues this failure to call one on one end emergency. clearly signaling to people that there should not be afraid to, no one is a significant enhancement and now we're going to reduce overdose death. >> a good samaritan. i think that's really something we can do to pass a law which does provide a good summer. it is not true that for opiate addicts in prison the treatment approach the works best as combining medication, therapies with community-based treatments. >> indeed. we have the best outcomes. when they leave the prison system to go into a community, initiated and sustained not just

in their ability to stay off drugs but also decreasing the number of overdoses. that transition poses the risk of dying from over dove's. thirteen of 17 full. >> currently very few medication assisted their programs in prisons. >> unfortunately that is correct. >> what do you think of the barriers to expansion in federal and state prisons? >> it does relate to a culture. we observed in many of the treatment programs. by use of appearances of their peace, medications. >> a life is saved from an overdose. people would crack addiction need to be linked to effective ongoing treatment.

instrumental in massachusetts waiting for access. do you believe this model can be used to expand access to these their peers across the country? >> i do. one of our challenges how we continue to expand access without building bricks and mortar. are federally qualified health centers are unique is situated in rural areas to look good doing that. we should increase by about 10,000 number of massachusetts residents who were able to get very effective comprehensive medication with the rest of the services that they needed. >> do you agree? the expansion of manic patient this is a therapy into primary care settings would be helpful,. >> one of the day is the least which could include qualified.

enough time so that the person carrying agent draft. the penal facility in the name of ribbons. if we can have injectable the minister prior to facilities we would have at least a month's time to engage. substance abuse treatment program for and appeared program that would be using ultrasound to help facilitate reentry. >> thank you.

>> a few medications available to treat addiction. i'm concerned that we will find treatments the completely eliminate drug use and they keep us from finding treatments that will reduce the harms dissociative much acute months. the conservation of stability, difficulty holding a job. what do you think is needed to further the development? >> welcome it is unfortunately a paradoxical situation. we have a disease. tremendous impact in terms of mobility immortality. scientists have identified potential targets that would be beneficial for the treatment. we do not have input from the pharmaceutical community that institute of medicine. one of the recommendations is

helping incentivize the pharmaceutical industry in order for them to invest in the development of medication. but the targets are there. chronic. went further because have ways to incentivize. they have not been implemented. >> if i may just ask one final question. all of the prescription opiate painkillers prescribed in the world, 90 percent of the, 4% of the population. prescription opiate painkillers. >> what does that tell us? >> i think that the numbers speak for themselves. i don't think we can argue that we have much more severe chronic

pain. the numbers of china's something very clear. we are over prescribing, while at the same time it does not negate that we're not necessarily properly treating patients to suffer from chronic pain. >> i think each of them for their tremendous service. a good samaritan law. thousands of people's lives will be saved give them the help they need. we know that most people would just thank god. firefighters, police across the country will be willing to russia and apply treatment problem.

we don't have either right now. this process going to continue as delayed. >> three things done to me. what proportion of proportion is the po no? >> i think we always say 99 plus % of the practitioners or purge curve and the doctors. a great job doing what they do. this small percentage of doctors that have crossed the line are truly hurting a lot of the people. i can't give you a percentage because i just don't know. what i do know, if you have our road pain clinic in your

community you're going to see over the centuries. we're going to see general problems with any of the type of an open-air drug activity, and it is open-air drug activity. >> we talked about medical education. should this be done through the state medical associations? any opinion on that? >> sure. if i could quickly answer. it is important to recognize, we have to close down for a very large number of the overdose. in terms of the overall strategy for which rolling, the people who go to panels are usually either addicted, already addicted as were dr. simi well

up more problem or dentists to give a teenager's 30 bills. if we want to end this to give one are two bills instead of 30, if you want doctors to recognize that these are not good treatments, unfortunately the bulk of this is not teaching doctors. the cdc is put out the educational programs like that. he follows rules when he closed monitor. on this treatment, but it does not turn in the something that save the education is to be that

these are not good treatments for most people with chronic pain. >> okay. do you think we should mandate the state to mandate that medical programs essentially mandate physician's license to use toward monitoring programs. >> just by absolutely do. used foam layer of very few doctors -- a doctor thinks they know what that and it looks like the down. >> thank you very much. it was a very good hearing. we have some very good notes. thank you very much. it's appreciated. the hearing is adjourned.

>> national security adviser susan rice says she does not see any new information coming out of the house select committee, the attacks that killed four americans and benghazi, libya. it's a little of what she said. >> since you brought up benghazi , come on. the republicans have, as you know, created a special committee in the house representatives to look what happened before and during the attack on the consulate when the

ambassador and three others were killed. what more is there that the administration has done are said that we are not aware of? >> dahlia final. i mean, honestly. the administration has produced a might think, 25,000 pages of documents support, contributed. we have had an accountability review board. very distinguished group. house and senate committees have pronounced thomas repeatedly. so it is hard to imagine what further will come of yet another

committee. what we can do and what we must do with congress to increase security of our embassies and facilities around the world. we have a budget request. these necessary in the of ministration judgment got time to upgrade and provide the kind of security that our facilities need. let's focus on that. what is lost in all of this discussion about shows and talking points is that we lost forever americans on that day. and their families and those of us who work with them and to a degree. the last thing we need is to lose anymore. looking round the world, yemen, kenya, somalia, and the number of places where american diplomats, american servicemen and women who are doing all we ask them to do, being on the

front lines of our foreign policy, they deserve the support and protection that we can best provide. >> to you out think it's legitimate that the chairman said to look at among other things whether the administration should of done more to make that conflict safe, to make the ambassador safe? >> absolutely, which is what we have done. that's why we had accountability review board and their implementing the recommendations of the accountability review board and are seeking the resources we need not only to a deal with what transpired in libya but the risks that our personnel may face in various other parts of the world. the security and safety of american personnel is absolutely the top priority of the president, of the administration, and ought to be of congress. to the extent we're focusing on that, i think we all agree that's where the focus ought to be. >> in a few moments to look at

what the regulators will need to enforce regulations under the dodd-frank financial lot. in an hour-and-a-half senate debate on immigration reform. after that, we will be aired hearing on heroin a prescription drug abuse. a couple of live events to tell you about tomorrow morning. veterans affairs secretary eric chan said he will testify on veterans' health care and reports of lengthy delays in patient care at a hospital in arizona. that situation has prompted a congressional subpoena, and some veterans groups are calling for the secretary to resign. that is on c-span at 10:00 a.m. eastern. also at ten on c-span three the senate foreign relations subcommittee on africa will review u.s. policy regarding the nigerian government response to the kidnapping of more than 200 school rules. >> c-span newest book sundays at

8:00, a collection of interviews this of the nation's top story tellers. >> i can't say what the moment was because i have been living in all my life. my parents migrated from the south to washington d.c. my mother from georgia, my father from southern virginia. washington is where they met, mary, and then at me. without the great migration of would not be here. so i have lived with them all my life. i grew up with people from north carolina, south carolina, georgia all around me. i was surrounded by the language, the music, the ambitions of the people who migrated from the south, of competition about his child would go with school, catholic school, schools across the park. has been with me all this time. >> one of 41 unique voices from 25 years in book notes and q&a