mr. cruz: mr. president, the american people have demanded for years that the federal government faithfully enforce our nation's immigration laws. americans are tired of seeing their laws flouted and their communities plagued by the horrible crime that typically accompanies illegal immigration. but for too long the pleas of the american people on this issue have gone unheeded here in washington. you see, when it comes to the problem of illegal immigration,

the political class and the business class, our nation's elites, are of one mind. they promise robust enforcement at some point in the future, but only on the condition that the american people accept a pathway to citizenship now for the millions of illegal immigrants who are already in this country. not wanting to be swindled, the american people wisely rejected this deal which the washington class calls -- quote -- "comprehensive immigration reform." of course the elites don't like this one bit. so instead they've taken matters into their own hands. they bend or ignore the law to make it more difficult for immigration enforcement officers to do their job. we've seen this repeatedly with the obama administration. president obama has illegally

granted amnesty to millions of illegal immigrants with no statutory authorization whatsoever. even though before his reelection, the president assured the american people that he couldn't do so without an act of congress. as president obama said when asked about could he grant amnesty, i am not an emperor. well, i agree with president obama. but yet, just a few months after saying he couldn't do this because he was not an emperor, apparently he discovered he was an emperor because he did precisely what he acknowledged he lacked the constitutional authority to do. and although the administration today claims to be focusing its resources on deporting illegal immigrants with criminal records, it has adopted a policy where many illegal immigrants that the administration deems to be low priority will not be

detained and deported but will be released back into our communities. remarkably in the year 2013 the obama administration released from detention roughly 36,000 convicted criminal aliens who were actually awaiting the outcome of deportation proceedings. these criminal aliens were responsible for 193 homicide convictions. they were responsible for 426 sexual assault convictions, 303 kidnapping convictions, 1,075 aggravated assault convictions and 16,070 drunk driving convictions. all of this was on top of the additional 68,000 illegal immigrants with criminal

convictions that the federal government encountered in 2013 but never took into custody for deportation. dwell on those numbers for a moment. in one year the obama administration releases over 104,000 criminal illegal aliens, people who have come into this country illegally who have additional criminal convictions. murderers, rapists, thieves, drunk drivers. one wonders what the administration says to the mother of the child lost to a murderer released by the obama administration because they will not enforce the laws. one wonders what the obama administration says to the child of the man killed by a drunk driver released by the obama

administration because they will not enforce our immigration laws. and while this administration's refusal to enforce the laws is bad enough, the scandalously poor enforcement of our immigration laws is made much, much worse by the lawless actions of the roughly 340 so-called sanctuary jurisdictions across the country. although these jurisdictions are more than happy, eager even, to take federal taxpayer dollars, they go out of their way to obstruct and impede federal immigration enforcement by adopting policies that prohibit their law enforcement officers from cooperating with federal officers. some of the jurisdictions even refuse to honor requests from the federal government to temporarily hold a criminal alien until federal officers can take custody of the individual.

not only are these sanctuary policies an affront to rule of law, they are extremely dangerous. according to a recent study by the center for immigration studies, between january 1 and september 30, 2014 -- just a nine-month period -- sanctuary jurisdiction released 9,295 alien offenders that the federal government was seeking to deport. that is roughly 1,000 offenders a month that sanctuary jurisdictions were releasing to the people. now, of those 9,295, 62% had prior criminal histories or other public safety issues. and amazingly, to underscore just how dangerous this is to the citizenry, 2,320 of those

criminal offenders were rearrested within the nine-month period for committing new crimes after they had already been released by the sanctuary jurisdiction. if that doesn't embody lawlessness, it's difficult to imagine what does. jurisdictions that are releasing over and over again criminal illegal aliens, many of them violent criminal illegal aliens, and exposing the citizens who live at home to additional public safety risk, to additional terrorist risk. this same study found that the federal government was unable to preapprehend the vast majority of the alien offenders released by the sanctuary jurisdictions. 69% as of last year.

even homeland security secretary jeh johnson has admitted that these sanctuary policies are -- quote -- "unacceptable." quote -- "it is counterproductive to public safety to have this level of resistance working with our immigration enforcement personnel." i'm thrilled to hear the secretary of homeland security say so out loud. i assume that means that the obama administration will be supporting the legislation before this body. after all, the secretary of homeland security says it's unacceptable. that it is countering productive to public safety and yet sadly the obama administration is not supporting the legislation before this body. indeed, it has taken the tragic and terrible death of kate steinle to galvanize action here in washington. kate died in the arms of her

father on a san francisco pier after being fatally shot by an illegal alien who had several felony convictions and had been deported from the united states multiple times. her death is heartbreaking. the senate judiciary committee, we had the opportunity to hear from kate steinle's family. the heartbreak is even more appalling because kate's killer had been released from custody and not turned over to the federal government to be deported because of san francisco's sanctuary policy. the city of san francisco is proudly a sanctuary city. they say to illegal immigrants across the country and across the world, come to san francisco. we will protect you from federal immigration laws. we, the elected democratic

leaders of this city, welcome illegal immigrants, including violent criminal illegal immigrants like the murderer who took kate steinle's life. these policies are inexcusable. they are a threat to the public safety of the american people, and they need to end. that's why i'm proud to be one of the original cosponsors of the stop sanctuary policies and protect americans act, which strips certain federal funds, especially community development block grants from jurisdictions that maintain these lawless policies. if these jurisdictions insist on making it more difficult to remove criminal aliens from our communities, then these federal dollars should go instead to jurisdictions that will actually cooperate with the federal government, that are willing to enforce the law rather than aid and abet the criminals.

it makes no sense to continue sending federal money to local governments that intentionally make it more difficult and costly for the federal government to do its job. but this bill doesn't just address sanctuary jurisdictions. it also addresses the problem of illegal immigrants who like kate steinle's killer, are deported but illegally reenter the country which is a felon knee. this class of illegal aliens has a special disregard and disdain for our nation's law, and too often these offenders also have serious rap sheets. in 2012, just over a quarter of the illegal aliens apprehended by border control had prior deportation orders. that's an astounding 99,420

illegal aliens. and of the illegal reentry owe offenders who are actually prosecuted in fiscal year 2014, that's just 16,556 offenders, but a fraction of those who committed a felony. the majority of those who were prosecuted had extensive or recent criminal histories, and many were dangerous criminals. but even though the majority of offenders had serious criminal records, the average prison sentence was just 17 months, down from an average of 22 months in 2008. in fact, more than a quarter of illegal reentry offenders received a sentence below the guidelines range because the government sponsored the low sentence. because we are failing to adequately deter illegal aliens

who have already been deported from illegally reentering the country, i introduced kate's law in the senate. and you'd like to thank senators vitter and grassley for working with me to incorporate kate's law, elements that have law into this bill. i also want to recognize and thank all of the original cosponsors who joined me in this bill, senators barrasso, cornyn, isakson, sullivan and toomey, and purdue. now, because of this bill, any illegal alien who illegally reenters the united states and has a prior aggravated felony conviction or two prior illegal reentry convictions will face a mandatory sentence of five years in prison. we must send the message that defiance of of our laws will no

longer be tolerated. whether it is by the sanctuary cities themselves or by the illegal reentry offenders that they harbor. the problem of illegal immigration in this country will never be solved until we demonstrate to the american people that we are serious about securing the border and enforcing our immigration laws, until we have a president willing to and in fact committed to actually enforcing the laws and securing the borders. this bill is just a small step, but at least it is a step in the right direction. and yet, mr. president, there will be two consequences from the vote this afternoon. the first, it will be an opportunity for our friends on the democratic side of the aisle to declare to the country on whose side they stand.

more than a few democratic senators when they are campaigning for reelection tell the voters they support securing the borders. more than a few democratic senators tell the voters, of course, we shouldn't be releasing criminal illegal aliens. more than a few democratic senators claim to have no responsibility for the 104,000 criminal illegal aliens released by the obama administration in the year 2013. these senators claim to have no responsibility for the murderer of kate steinle invited to san francisco by that city's sanctuary city policy. well, this vote today will be a moment of clarity. no democratic senator will be able to go and tell his or her constituents, i oppose sanctuary cities, i support securing the

borders, if they vote today in favor of sending federal taxpayer funds to subsidize the lawlessness of sanctuary cities. you know, when the senate judiciary committee heard testimony from families who had lost loved ones to violent criminal illegal aliens, one after the other after the other, children sexually abused and murders by violent illegal aliens, family members who've lost loved ones to drunk drivers, illegally in this country. at the time, i asked the senior obama administration official for immigration enforcement how she would look in the eyes of those family members and justify releasing murderers and rapists and drug drivers over and over and over again.

indeed, at that hearing, i asked the obama administration head of immigration enforcement, how many murderers did the obama administration release this week? her answer: i don't know. i asked her, how many rapists did the obama administration release this week? her answer: i don't know. how many drunk drivers? i don't know. none of us should be satisfied with that answer. with a president and an administration that refuses to enforce the laws that is willfully and repeatedly releasing violent criminal illegal aliens into our communities and endangering the lives of our families and our children. and for every democratic senator this vote today is a simple decision, with whom do you

stand? do you stand with the violent criminal illegal aliens who are being released over and over again because, mind you, a vote "no" is to say the next time, the next murderer like kate steinle's murderer comes in, we shouldn't have a mandatory five-year prison sentence, instead we should continue sanctuary cities that welcome and embrace them, until perhaps it is our family members that lose their lives. it is my hope that in this moment of clarity the democratic members of this body will decide that they stand with the american people and not with the violent criminal illegal aliens. and i.t. wort it's worth notinge way, the standard rhetorical device that so many democratic senators use to say that not all

illegal aiillegal immigrants are criminals. of course they are not. we are a nation of immigrants, of men and women fleeing oppression and coming to seek freedom. but this bill doesn't deal with all immigrants. it deals with one specific subset of immigrants: criminal illegal aliens. those who come to this country illegally and also have additional criminal convictions, whether homicide, whether sexual assault, whether kidnapping or battery or drunk driving. if it is the democrats' position for partisan reasons that they would rather stand with violent criminal illegal aliens, that is a sad testament on where one of the two major political parties in this country stands today. and i suspect the voters who

elected them would be more than a little surprised at how that jives with the rhetoric they use on the campaign trail. if, as many observers predict, democratic senators choose to value partisan loyalty to the obama white house over protecting the lives of the children who will be murdered by violent criminal illegal aliens in sanctuary cities if this body does not act, if they value partisan loyalty over that, and if they vote on a party-line vote, as many observers have predicted, that will provide a moment of clarity. but i will also suggest, it will underscore the need for republican leadership to bring this issue up again, not in the

context where democrats can blithely block it, obstructing any meaningful reforms to protect our safety, to security the border, to enforce the law, to stop violent criminal illegal aliens from threatening our safety but, rather, for republican leadership to bring it up in the context of a must-pass bill. to bring it up and attach it to legislation that will actually pass in law. i'm very glad we are voting on this this week. it is one of the few things in the last ten months we have voted on that actually responds to the concerns of the men and women who elected us. so i salute leadership for bringing up this vote, but if a party-line vote blocks it, then the next step is not simply to have a vote. the next step is to attach this legislation to must-pass legislation and to actually fix the problem.

you know, mr. president, leadership loves to speak of what they call governing. and in washington governing is always set at least an octave lower. governing. well, when it comes to stopping sanctuary cities and protecting our safety, we need some governing. we need to actually fix the problem rather than a show vote. so my first entreaty is to our democratic friends across the aisle, regardless of air' arease we different on partisan politics, this should be an easy vote. do you stand with the men and women of your state or do you stand with violent criminal illegal aliens? we will find out in just a couple of hours. but my second entreaty is to republican leadership that if democrats are partisans first rather than protecting the men and women they represent, that it is up to republican leadership to attach this to a must-pass bill, to actually pass it into law and solve the

problem, not to talk about it but to do it. it is my hope that's what all of us do together. i yield the floor. mr. menendez: mr. president? the presiding officer: the senator from new jersey. mr. menendez: i rise today to speak out against a bill that is misguiding, a bill that stands against everything that america represents, a bill that suggests this it will protect americans when in fact it will protect americans less. now, from our founding, our principles have been guided by core values of equality and fairness, freedom and politics. and in turn we have honored the many, many ways that immigrants have contributed to this country since its inception. yet the other side of the aisle

is once again engaged in a stubborn, relentless and shameful assault against immigrants. as a son of immigrants myself, i.t. hard not to take -- it's hard not to take offense at the anti-immigrant rhetoric we're hearing from their presidential candidates. it is unacceptable, deplorable and should be renounced by every american. we are witnessing the most ove overtly xeno februaryic campaign in modern u.s. history. we've hit a new low with the extraordinarily hateful rhetoric that diminishes immigrants' contributions to american history and particularly demonizes the latino community by labeling mexican immigrants as rapists and criminals. the republican leading in the polls actually launched his presidential candidacy by attacking immigrants saying, "they're bringing drugs, they're bringing crime, they're rapists."

please! please, spare me. senseless and false. yet some of my senate colleagues have decided to jump on the fearmongering bandwagon seeking to blindly send millions of hardworking, law-abiding immigrant families as criminals and rapists. that's really why we are here today because that anti-immigrant rhetoric has made its way to the senate floor, courtesy of donald trump, and some republicans eager to capitalize on this rhetoric for their own political gain. this is nothing more than an offensive anti-immigrant bill, another effort to demonize those who risked everything for a better life for themselves and their children, those who left with no choice but to flee persecution and violence or else face a certain death. that's what we are debating here today. those are the individuals this legislation seeks to brand as criminal. this bill does nothing more than

instigate fear and divide our nation. now, supporters of this bill may say that it is in response to tragedy like what happened in san francisco and what happened in san francisco was a tragedy. but such tragedies will not be prevented by this legislation, but real immigration reform. i'm happy to have that real debate, an honest and compassionate debate, a debate the country deserves. but that's not what's happening in this bill. the title of the bill asserts that it will protect americans. well, to be clear, this bill will not protect americans because it second-guesses decisions made by local law enforcement around the country about how to best police their own communities and ensure public safety. what's worse, this bill mandates local law enforcement to take on federal immigration enforcement duties by threatening to strip away funding from as many as 300

local jurisdictions from programs like the community development block grant, community oriented policing services, state criminal aliens assistance program, programs that directly help our towns and communities. the cdbg program grows local economies, improves the quality of life for families. it has assisted hundreds of millions of people with low and moderate income, stabilized neighborhoods, provided affordable housing, improved the safety and quality of life of american citizens. the cops on the beat grant funds salaries and benefits for police officers who serve us every day by keeping our communities safe. and they deserve better than being dragged into partisan politics. now, my colleague from louisiana seeks to strip funding from localities that undertake the balancing of public safety consideration and refuse to act as immigration and customs enforcement agents, but this bill goes even further than

that. the bill doesn't contend with taking discretion away from local communities. it takes it away from the judicial branch. it adds new mandatory minimums when as a nation we're trying to move away from that approach. the new mandatory minimum sentences would have a crippling financial impact with no evidence that they would actually deter future violations of the law. they could cost american taxpayers hundreds of millions of dollars. and i think that deserves a serious, thoughtful debate in the judiciary committee with expert testimony on whether this really makes us safer or we're throwing away hard-earned taxpayer dollars. but we don't even get that debate because this bill was fast tracked as a republican priority and it didn't even go through the regular committee process. the united states senate cannot nurture an environment that demonizes and dehealth and humas

latinos. senate republicans are saying it is okay to withhold funding to promote their agenda, it is okay to cut cop funding, a one size fits all approach that pun nishes state and local law enforcement agencies that engage in community practices doesn't make sense. local communities and local law enforcement are better judges than congress of what keeps their communities safe. police need cooperation from the community to do their jobs. that's why over the past several years hundreds of localities across our nation, with the support of some of the toughest police chiefs and sheriffs, have limited their involvement in federal immigration enforcement out of concerns for community safety and violations of fourth amendment. they need witnesses and victims

to be able to come forward without fear of recrimination because of their immigrant status. and fear of deep portation should never be a barrier to reporting crime or seeking help from the police. this fear undermines trust between law enforcement and the communities they protect and creates a chilling effect. these policies were put in place because local jurisdictions don't want to do isis job for them. effective policing cannot be achieved by forcing an unwanted role upon the police by threat of sanctions or withholding assistance, especially at a time when law enforcement agencies are strengthening police-community relations. furthermore, why do my republican colleagues believe they know better than the local towns and citizens who live this day in and day out? they talk endlessly about decentralizing government, giving the power back to local communities. but not this time. it's no wonder that this bill is

opposed by law enforcement, including the fraternal order of police, the law enforcement immigration task force, the u.s. conference of mayors, immigrant and latino rights organization, faith groups, domestic violence groups, among others. this bill is not a real solution to our broken immigration system. bottom line is that we need comprehensive immigration reform. we passed bipartisan legislation in 20 p 13, but we haven't had a real discussion in congress for over two years. a recent poll found that 74% of americans overall said that undocumented immigrants should be given a pathway to stay legally. that includes 66% of republicans, 74% of independents, 80% of democrats who supported a pathway to legal status for undocumented immigrants. and that bipartisan support is not new. comprehensive immigration reform previously passed in the senate

brought millions of people out of the shadows who had to prove their identity, pass a criminal background check, pay taxes, provide an earned path to citizenship so i.c.e. could focus on the people who were l true public safety threats. the bill also increased penalties for repeat border crossers. it included $46 billion in new resources, including no fewer than 38,000 trained full-time active brother patrol agents deployed along the southern border. it increased the real g.d.p. of our country by more than 3% in 2023 and 5.4% in 2033, an increase of roughly $700 billion in the first ten years and $1.4 trillion in the second ten. it would have reduced the federal deficit by $197 billion over the next decade and by another $700 billion in the following. that's almost $1 trillion in is deficit spending reductions by

giving 11 million people a pathway to citizenship. that was a real solution. that's the type of reform we need. that in fact is the opportunity that existed. unfortunately the other body in the house of representatives did not even have a vote. and to the extent that americans are less safe, it is because of their inaction that we are less safe today. so, mr. president, tragedies should not be used to scapegoat immigrants. they should not be used to erode trust between law enforcement and our communities. we cannot let fear drive our policy making. so let us actively and collectively resist the demagoguery that threatens to shape american policy making for the worst. i believe a vote to proceed is a vote against the latino and immigrant communities of our country, and i hope that on a bipartisan basis we can rej

>> sunday night ate can rej 8:00 o'clock eastern and pacific on c-span q&a. >> aa house hearing on drug abuse, a panel of doctors and addiction experts talked about how to treat the problem and what federal resources are needed.

>> ladies and gentlemen, if you could take your seats, the subcommittee will come to order. we are reconvening this hearing. we had the 1st panel a couple of weeks ago, and this will be the 2nd panel. welcome back. examine legislative proposals we heard testimony from a panel of witnesses representing many different

government offices. today we will hear from a number of distinguished doctors on a panel today we have command i will introduce them in the order of . welcome. doctor chapman sledge, chief medical officer of cumberland heights,doctor robert corey waller, chair of the american society of addiction, medicines, legislative advocacy committee. welcome. then doctor kenneth katz, department of emergency medicine section of medical toxicology, lehigh valley health network. i do not see doctor alan anderson yet. so, thank you for coming. your written testimony will made a part of the record

and you will each have five minutes to summarize testimony. after opening statements we will do the questioning. so, you are recognized for five minutes. >> thank you, mr. chairman, ranking member, thank you for the opportunity to testify today. i come before you as both the founding dean of the indiana university of richard m fairbanks school of public health as well as the former state health officer of arkansas to discuss an important and far-reaching public health issue, heroin and prescription drug abuse epidemic and the deleterious effects which we are experiencing across the country and in my home state of indiana. addiction is a tragedy, not for the addicted person alone, but also for families, employers, and entire communities. the victim is often at the root of a myriad of health problems which harm all in

its path, even the most innocent among us. newborns who have been exposed to opioids in utero are often bought with a condition called neonatal absent syndrome. it mirrors the surgeon opioid use of the same time period. it's staggering. in my state of indiana alone the costs are estimated at over $7.3 billion annually. hospital charges for babies born with nas, over 1.5 billion nationally in 2013. opioid abuse is particularly pernicious because it is often a precursor to heroin use. nearly four out of five new heroin users tick nonmedical prescription pain medication before taking apparel and the end result of which is people are dying.

nationally heroin related deaths have escalated over 39 percent between 2012 and 2012 and 2013. and although mortality rates are up may states in the country, indiana is only four states with a rate of overdose death has put drupal. the public health crisis related to opioid abuse. scott county, population of less than 25,000 people had an unprecedented outbreak. to date the number of knew confirmed cases of new hiv cases for 2013 exceeds 130 people which is particularly alarming and has never had

more than five new cases annually. in addition, significant cuts and chronically underfunded public health infrastructure nationwide make communities more vulnerable and leave them without important public health services such as education and how to protect themselves against life-threatening diseases and access to controversial testing and treatment, among other important services like epidemiology and outbreak investigation capacity. this led the entire state in both drug overdose deaths and nonfatal emergency department visits due to opioid overdose. they are strikingly similar by virtue of their characteristics as well as the fragile public health capacity.

recently establishing an executive branch task force to focus state government agencies on the system issues surrounding substance abuse. in addition, our attorney general long-standing prescription drug task force has been focused on the coordination and oversight of indiana's prescription drug monitoring program, and the insight has been instrumental in developing legislative and policy level recommendations. lastly, i would like to acknowledge that they have provided primarily through the leadership of john daly has tirelessly lead and support of these efforts. additional national legislative efforts are needed.

we are grateful to rep. brooks and other members of the committee for shedding light on this serious problems of opioid abuse and heroin use which are becoming more pervasive with each passing day and it is clear that we need to effectively attack these problems from a system perspective to prevent further destruction of our public health. i applaud your efforts and ami'm grateful for your dedication and addressing this important public health issue. >> the chair thanks the gentleman and recognizes doctor sledge for five minutes and audible. >> make sure you press the button. >> thank you, mr. chair. i want to thank this committee for holding this important hearing on legislative solutions to combat the worsening drug crisis in our country. i am deeply concerned as to what i see happening with regard to the opioid epidemic. i am chief medical officer

of cumberland heights, a private not-for-profit medical treatment since. i previously served as medical director of treatment services at pine grove and have been practicing addiction medicine for over 26 years. i am certified by the american board of addiction medicine, fellow of the society and from 2005 to 2009 i represented mississippi alabama, florida, tennessee, and kentucky and served as secretary of the organization and said 2,011. cumberland heights is a 50 year tradition of treating addiction. we provide treatment to adult men and women as well as adolescents. we treat a fair number of patients with resources to self-pay and a fair number of patients. watershed moment came around 2006 a diagnosis of opioid

dependence which was knew to me. a diagnosis of opioid dependence. our most common diagnosis has been opioid dependence heroin addiction has become more and more prevalent as it becomes limited to less abusable prescriptions.

of 97 deaths from 2003, a staggering statistic that points to growing the abuse despite an array of measures to stem addiction more people died in 2014 from opioid overdose then by car accidents or gunshots. my expertise is based on direct patient care. almost all of our patients admitted to cumberland heights for opioid addiction have some experience with you pinoy from either by prescription or buying it off the streets over the years. you pinoy friend is sometimes used under the time come as designed, can be used intranasally or injected. motivations for illicit use include to get high as well as to treat withdrawal. some patients take it with a motivation to stop using

other opioids. a typical eighta typical 8-milligram dose cost $20 and middle tennessee when obtained illicitly and in east tennessee as much is $40 per 8-milligram dose. the street value supports my observation. in fact, it has been identified as the 3rd most diverted medication in the us. but in 2,008 the meeting of the american society of addiction medicine scientific conference in miami, i was asked by colleague if i used you pinoy friend to treat opioid dependence. i replied we utilized it to detox. he remarked he had never seen a patient recover without it, and i told him i had. he said, but you are not using intravenously. he appeared incredulous when i told him i recovered without. i cringe when an addiction medicine treatment provider

makes a recommendation based upon his or her personal experience and treatment and recovery. my experience indicates there are multiple paths recovery. no one-size-fits-all. we promote abstinence after detox, provide psychosocial treatment and use a long acting opioid as well as incorporation of spiritual. ongoing treatment. no one is claiming that detox from opioids alone will result in recovery. i thank you for the opportunity to speak. >> the chair thanks the gentleman and recognizes doctor waller for five minutes for your opening statement. in audible -- in audible. >> i'm grateful for you and the other leaders in addressing the opioid

addiction currently ravaging our country. i am the chair of the legislative action committee also known as a said. this testimony is offered on behalf of my organization. i am board certified in both addiction medicine and emergency medicine. the substance use disorder medical director and a regional communityregional community mental health organization based in grand rapids, michigan. my testimony will focus on the following three facts. a chronic disease of the brain at least a characteristic psychological and social manifestations, addiction can be successfully treated with a combination of medications and psychosocial intervention command we have published guidelines aa detailed best practices for the use of these medications. there are significant barriers to access to these

effective medications resulting in significant treatment gap in our country. stopping the treatment prematurely costs lives. we have reached epidemic levels in our country. these people need treatment now. methadone has been used in a highly regulated program.

substantial broad and conclusive evidence for the effectiveness of all three medications and methadone in particular. notably the literature is not new and there are a large scale rigorously conducted reviews of literature since the early '80s. all medications have been shown to reduce mortality. finally, we have a clear and comprehensive guideline for how to use medications effectively in the clinical care persons with addiction. however, despite the strong evidence-based use in the clinical guidance available very few are offered medication to help treat their disease. less than 30 percent off her

medications,offer medications, and less than half of eligible patients receive medications. indeed, a study published just last week found that 80 peh opioid addiction don't receive treatment. access barriers to methadone , limited geographic coverage, insurance coverage, and the requirement to receive methadone daily. intended to include access to treatment across geography by integrating it into the general medical setting. in recent months my practice has had to turn away patients due to the 100 patient limit100 patient limit for you pinoy friend which includes pregnant patients as well as children of friends and has resulted in at least two overdose deaths that we can track. if i am out of town or unavailable my assistants are unable to see patients

who needed urgent and take. that exists even if they are under the guidance of a physician who is board certified in addiction. it is important to note the entire purpose was to make addiction treatment available outside and otc. to reduce the stigma and patient burden associated. still, because diversion and quality of care remain legitimate concerns they have proposed a gradual and limited lifting of the data 2,000 limits. by coupling the limit treating large number of patients, wepatients, we feel we can expand access well ensuring are certain quality of care. alternative pain therapy options and early identification and treatment

of addiction. pain and addiction education should encourage throughout a person's career. community should have the resources to educate there's citizens about these issues and the outreach and surveillance resource necessary. thank you for the opportunity to present today we look forward to a continued collaboration on this and other issues. >> the chair thanks the gentleman. >> the drug epidemic confronting this nation has exploded in recent years due to the accessibility of cheaply made synthetic master produced drugs. i've witnessed how these compounds are led to violence, complications, and death. i spent countless hours where i came from patient suffering from the toxic effects of synthetic

marijuana which ripped through eastern pennsylvania my name is doctor kenneth katz, and i am board certified an emergency medicine toxicology and thank you for allowing me to testify today. advocate for hr 8537. every community across the nation, synthetic drug toxicity or poisoning. important to remember the term describes substances that are primarily manufactured in clandestine i'm chinese laboratories and is designed to mimic the effects of stimulant, stimulant depressant, or hallucinogenic properties, nonorganic, chemically synthesized, unsafe recreational drugs. many substances are marketed

as innocuous products. because of their commercial availability many presume they must be safe. however, the public should not be fooled. there colorfully packaged but poison. they can contain a vast array of different chemicals of varying potencies. syntheticpotencies. synthetic marijuana may contain compounds two to 500 times more powerful than thc in many cases they only alter the compound and technically create a new compound allowing them to bypass regulations. it is not until these substances are ingested or inhaled. hypothermia, elevated blood pressure and pulse. seizures, coma, muscle breakdown, kidney injuries and ultimately death.

a particular concern is the availability and high use of synthetic marijuana whether the data exponentially. that number grew to more than 29,000 trailing new york, mississippi, and texas. currently all 50 states have banned some cannabinoids.

they would amend the analog acts of the substance can be treated if it is chemically similar is targeted at the manufacturers and distributors of synthetic drugs. the easy access and use of synthetic drugs not only places their health and

lives at risk but can have a profound impact upon my ability to care for patients. when users need emergency medical attention they are utilizing precious resources such as ambulances, emergency department beds, hospital personnel, and limited hospital dollars and is my opinion and that of the american college of emergency physicians that the critical issue must be addressed and supplemented by a national campaign to educate americans about the dangers of using synthetic drugs. thank you. >> the chair thanks the gentleman and now recognizes doctor anderson for five minutes for your summary. >> good afternoon. i am doctor alan anderson, orthopedic surgeon specializing in sports medicine. nonprofit organization made up of 3,400 orthopedic surgeons specializing in care of athletic injuries at every level of competition. ..

>> >> one immediate access to controlled substances. there are times during air

travel with the team physician is the only metic available one of documented players having seizures after a clash -- a concussion on the flight home and when substances are needed to save the athlete's life. in its teeming care to take a pain pill if they had a broken bone. as you watch your favorite team and saturday at least one athlete is significantly injured is a your constituents reverie state the team physician is there on this side to render aid this is severely restricted by current law. that prohibits away from the site registered with the dea

makes illegal for a team doctors to transport quantity of pain control this is problematic for those in need of men and women dash ability to maintain that supply if a player is seen -- injured. current law precludes from the same state or cross state lines to work around is problematic including pre-dispensing medication to 80 members of the football team to create a logistical nightmare. one would this is also a problem. in opposing positions can provide medication but they have to independently examine to treat their own

team to have malpractice concerns to prescribe medication also privacy concerns as they are preparing for of the competing team to enter the training room. this would address the concerns to allow the physician traveling with the team the ability to appropriately manage in a similar move will fashion with facilities and it does not diminish the need or requirement at the current level. records of controlled substances were subject to be inspected by the dea at anytime. there will be responsible for the control substances the entire time they are traveling with of transport is limited as 72 hours.

contact sports are more from military maneuvers. it is hard for me to believe in that cows to get better medical treatment better athletes and also benefit physicians who donate time and declared disaster areas. therefore we urge you to support the transportation next we can provide the highest level of care for injured athletes thank you for giving me the opportunity to testify. >> that includes the opening statements of the second panel. with a bite to submit the following documents.

the national association of convenience stores dr. cooper of the dallas cowboy is the fraternal order of police former special agents ama american college of emergency physicians center for lawful access of abuse deterrencdeterrenc e, american academy physician's assistants and national association of chain drug stores. i recognize myself for five minutes. and law you can respond here, do you agree that patients addicted to opioids should receive treatment based on individual clinical needs? >> cancer. >> absolutely.

>> yes. >> yes, sir. >> how would you revise hhs to take this one to expand the use of medication assisted therapy? >> since i am not a physician alike to defect one dash defer to my colleagues. >> betting that prescribing physician should be trained in all medication assisted there be with abstinence as an option. >> one. >> i'm in charge of the seven county area so we have been able to delineate those that started very early in life in their adolescence

and have a different breed disease when they actually separate us out as far as treatment works. >> generally it is not indicated because of the many other factors. 92% are those about insurance is a perilous journey with a high mortality rate it is absolutely the right treatment at the right time to make sure we allow for an expansion of use of these medications. >> so expand more on the differences of certain types of patients and treatment

settings the therapeutic options to be addressed sooner if they do address that utilization this is the first guidelines elected of three fda recommendations normally it is the of cohort of patients were that in general we have programs better different than the of their so to utilize that time line we have delineated to back that up is the way i would say. >> the overarching principle identified by the institute of medicine included patient self-determination in the opium trade pact brings

patient self-determination back to the equation. >> in your opinion, what are the most significant obstacles at the present time to prevent more individuals with obi '08 use disorders for receiving the most effective treatment? >> the one-size-fits-all treatment is very detrimental to addressing the epidemic to have an assessment with each individual patient with recommendations and referrals as a successful treatment. >> neither obstacles? direct to obtain the appropriate medication if we deem it is the right medication for them for cry treat all pregnant patients in the seven county area and i have to turn people away to areas that our less than optimal or try our best but

unfortunately that doesn't turn out very well. >> knu comment on the role of nurse practitioners and physician assistants to provide treatment? >> i am not a provider so i will defer. >> without the utilization of my position assistance my office does not run. we have the capability to see patients in volume because we have well-trained there's practitioners and physician assistants that work directly with board certified people in their specialties whether neurosurgeon or orthopedic surgeon or a specialist to couple them with behavioral therapist it works out really well we have great outcomes and it is of medical one model that has been adopted so to eliminate

this as a possibility for this disease does not make sense from a monetary or patient delivery standpoint. >> i a matter of time that talking about synthetic drugs were moving toward legalization is synthetic marijuana considered medical marijuana? are the advocates trying to include that? >> not that i am aware of those are two different things. >> yes completely synthetic. that is what i thought. to the chair recognizes the gentleman from -- filling in for mr. green's. >> will enter letter of consent from perdue pharmacy school that provides additional perspective on the issue to add certain synthetic drugs to the

schedule one csa and the implications for scientific research for cry appreciate the testimony. first, dr., the word epidemic is used a lot one to describe this and i myself do not appreciate by the cdc definition of the epidemic but we have gotten to that .1. epidemic is used in a vernacular something that is out of hand but if you talk about epidemic analogous to ebola or sars or mersa.

>> epidemic is used in large part because of the fact we don't see any easily controllable end that we experience the phenomenon whether a flu or an epidemic related to any disease where it is reaching beyond our ability to control. and to have a profound impact so under those definitions a certain way to cds epidemic the view since the idea is we have an idea how to address it but at the current point in time we have to reach the point where we can say is controlled. >> any other perspectives? >> the two components of the epidemic is susceptibility

them then to come into contact to have it spread we have seen exactly that pattern with care when it shows up in a computer when dash community the have susceptibility and restarted on opioids one or this is the first drug a touched an early high-school then they have access and a genetic risk negroes and just like the disease and kills more people in my state than anything else and they're all young and healthy compared to other diseases and defects a whole different population. >> so if you are the opioid addiction is our - - tea 31 dash czar what would be resource dependent

as well as those that are not as well as lifting the caps? >> of first up is a reeducation of a population of the disease of addiction is it chronic neurological disorder of - - disorder? >> so that tsa would is that? how do you get that word out? >> public message jean, i reprinting to treat it with an emotional context rather than science. >> that has to be first second is access to all treatment then build the structure with high fidelity and low risk. >> i uninterested i have a piece of legislation on this topic with the idea to

encourage approach when dash prescribing at the same time as the opioid. what their recent demonstration projects around to test the potential conflict as circumstances under which that would be inappropriate with a patient's bone abilities the likelihood of a potential overdose, can you speak to your perspective on? >> i appreciate that peace of legislation is very impractical i carry in my backpack it is ready because it is something we can do it is the anti-death serum to have this in a code prescribing way to make sure family and friends are trained as a different then

to have the automatic if regulator on the wall in a gym and should be publicly available for the we definitely support that i personally supported as well >> the biggest issue we need to dispel the myth as the antidote changes their behavior that has been found three research not to be true where we have found it to be legalized and made it available we have seen nothing but a decrease of mortality not an increase of utilization or the amount per person or her time it is not true when you refer somebody that is one more time they're not dead an opportunity to get them into treatment. >> that looks like a first setback. >> absolutely.

>> mr. guthrie five minutes for questions. >> when i saw leon the airplane and i appreciate working with the people a practice in your area that only the opioids but the emergency room physician i traveled with the auburn tigers and there is a licensing issue also about a physician licensed in alabama economic cannot travel with the team. one of my good friends were very aggressive on toxic content prescription drugs and plotted ways to manage drug abuse and it seemed to be very successful in many

physicians had to manage a very closely. we thought we were getting a handle on the supply then all the sudden heroine was a big component somebody told me yesterday it is easier to get heroin their prescription drugs in kentucky. so we have to attack the demand as well. if you practice in this area , are their capsule law practices can use? to think those current caps should be lifted? >> one the short answer is

yes. we have identified this medication is diverted to have patience i treat for abuse is show up and they treat them for that now that we have the abuse deterrent version that inadvertent utilization of snorting or interaction is significantly declined to the point we generally don't use the of mono drug by itself at all in my clinic. >> dc you to treat lower? >> i have a seven month waiting list because of the cap and i have no one else in my community of 1.3 million that has any space that is a specialist in this area. >> to both practice in this area? >> i don't practice in this

treatment but there is not a cap involved with its incorporation of medication insisted there be. i did think there needs to be day version protection and whatever measures are taken. >> earlier you talk about psychosocial should be added why is that important? for the record. [laughter] >> absolutely just prescribing medication will not affect a change in the course of this chronic disease it is a chronic brain disease with not only manifestations and they all have to be addressed or ongoing recovery.

medication is unit dimensional but the disease is multifaceted and all diseases must be addressed before recovery. >> also for the record record, aside from the chronic health impacts of another health or social impacts are associated in indian and? with the zero pureed use disorders? >> what we experienced with the overdose patience with intravenous drug use. parts to the issue people overdose were a number of reasons and frequently will

be affected by infections as well as other deep -- diseases not from the effect they tried to get good additionally there are other issues that are related to the community's overall health and the ability for the community to be resilient around this kind of diseases important to take consideration in part a general lack of understanding around drug abuse in particular and one of the questions as fast what would you to address community awareness? to understand the scientific basis we have to treat it in that manner and approach it from a scientific perspective there are a number of people who believe

they should quit that and stop it and recognize it is a disease also to make sure that access to treatment in our state and others. >> i am over my time. i appreciate your answer. >> my question, as you know, you have mentioned the treatment -- a treatment for opioid dependence and i of interested to hear about methadone could you describe how that is used to treat individuals with opiate dependence what about the substance abuse context? >> it is a full medication

that resembles medications like roxy koto and hydrocodone and morphine. patients traditionally you have a heroin addiction we have dated the state's utilizing this medication and a fully inclusive environment specifically to add these aspects significantly decreases the craving for a drug and by doing that allows them to continue to show love to have my eye treatment rate so 75 percent will have a treatment compared to 65% one the number has not been fully presented but. >> what i am trying to find out why it should not be

regulated like methadone. >> the regulations around methadone are significant for their primary care physician it is a minimum of $150,000 immediately with paperwork and accreditation to the joint commission, and then at that point there are specific issues we have to combine with the community mental health with the request for proposals, a hearing and almost mitigates the capability to deliver this medication at all. >> but what are the medical reasons to justify why it comes with different requirements and the leather to drugs? >> that is how it was started and very regulated since the '60s ended does

have a higher potential for abuse the higher overdose risk. those are much lower why it is scheduled three to be utilized in that way. >> one of the bills we are discussing today for prescriptions that prescribe this in their offices so how would this affect patients access or our ability to treat special populations? >> it would complete the they gave my ability immediately if you would get a from a national perspective we would shut down any exclusion or expansion of this with the amount of money it takes with the amount of regulation surrounding it so not just me pretty well

understood if that happened it would be catastrophic in the mortality rate would skyrocket. >> it is our ability to respond to the current crisis. >> unfortunately yes. >> patients already face barriers in one major barrier to access appears to be the social stigma around the medication although there is evidence those of the treatment believe it is replacing one addiction with another. are there really replacing one with another? >> the short answer is no good if we look at what we are trying to do the part of the brain injured the medication to regulate that

to have beneficial psychotherapies to stabilize that but we have found those who use this for the extended period of time insure that part of the brain permanently and require stabilization for a long time including a lifetime. we are able to read off a good number but it takes time and the data is clear it is 18 months into years before the parade will begin to heal -- the brain will begin to heal. . .

essentially on-the-job training during residency, and we have to address that moving forward. i had a conversation. i guess pres. obama will be commenting on this specific subject in west virginia tomorrow, and i we will be looking forward to his comments and not they are planning to do to help all of us address the situation. i also want to comment. it is important, especially 1st responders and law enforcement and probably family members of people who have these issues as well, maybe the people themselves have access with the appropriate training. i have used it myself many

times, primarily in intensive care units, but there are ramifications of using it. we need to make sure that everyone has the training. the other thing is, this goes across age groups. in 2013 the most commonly prescribed drug was the generic version of viking, not an antibiotic but a narcotic. so with that said, you know, i appreciate all of your comments and agree with the dr., doctor anderson, we need to address the situation going forward. can you expand in your experience.

>> sure. >> your microphone, touch the button on your microphone. we offer patients coming in very clearly with the course of treatment that we would recommend at the time of the assessment. a myriad of reference in the national area if they choose , but we use it typically to detox to get the patient opioid free. with a sufficient period of time which is difficult to achieve in an outpatient setting, but we can begin to use up your opioid antagonist or opioid blocker, if you will, and

administer that in an extended-release formulation that lasts for 30 days. >> it is interesting your comments about 2872 since i am one of the ones working on it, and thank you. we're still working through this trying to expand access to treatment. wewe have a process that would need to continually work on. we should consider money as part of a reason why did you are not to do things as a relates to drug treatment. i understand the practical aspects. i mean, what might you suggest? what would your suggestions be to expand access to outpatient treatment for these problems because clearly as you know, we have methadone, you been offering , and the locks and.

i keep confusing the two. >> trying to expand access. if you don't think we should make sure that everyone is able to offer all options for treatment medically, what should we do? >> i may have misspoken. all three should be available and i use all three on a regular basis. we use it all the time. those of us who have knowledge and board certification, you would not want a general surgeon doing cardiothoracic surgery just like we would want to help our colleagues in primary care by stabilizing and then

helping to maintain them over a period of time in that fashion. bolstering. >> thank you, and i yield back. >> thank you, mr. chairman for holding this hearing. we are very fortunate to have you and indiana has

unfortunately, one of the state'sstates leading the country and prescription opioid heroin drug abuse, quite a discussion that day we purchased 25 appreciated his participation. their intent to encourage medical and health professional schools that was four years ago we are still struggling with getting our medical schools and continuing medical education programs, embracing this concept. could you pleasecould you please discuss not only your efforts, but i would be curious on the panel, what

are we doing wrong? why can we not get med schools and continuing medical education and other health educators to focus on the prescribing practices. would you please start? this is not a new issue. it was set in 2011. what challenges, obstacles, what do we need to do to get up covers on board with this? >> we appreciate your interest specifically in this matter. i would say that the need is clear. it is my understanding, as we look -- we are constantly looking at curriculum which is an important issue. i have had conversations with our medical school dean about this issue, but i know that there are other issues

that are in competition for that time, but itime, but i think there is no question about the importance of this education. certainly as we look at issues around the importance of education and the subscribers around this issue, continuing education is not in dispute. it has been in implementation, particularly as it relates to reimbursement and the logistics around getting it in place. i do not think there is disagreement about the importance of education. >> i have been involved in higher education before coming to congress and understand that there is a lot of discussion and work that goes into providing curriculums. however, when our med schools are saying they get three to five hours possibly in med school, it is simply not enough, and at this point to come up with one set curriculum, in