your e-mails were in the state department system? who told you that? >> we learned that from the state department and their analysis of the e-mails that were already on the system, we were rtrying to help them close gaps they had. >> can you provide me with a name? when i asked the state department ten days ago what is the source of the figure, they shrugged their shoulders. >> you can look for the state.gov addresses and they pop up. >> and the inspector general report madam secretary, which you cannot arg-- found that les than 1% of state department e-mails, record e-mails were capture. so they give a number of less than 1% and you give a number of 90%. >> well, i don't know what you are referring to. i can only speak about my e-mails. my work related e-mails.

>> less talk about your work related e-mails. we asked for them last year and the state department gave us eig eight, if they had 90% of yours why did we get 8? >> i don't know, initially what you asked for, but i know they tried to be responsive. 90 to 95% of them were on state.gov, i understand that the committee broadened the scope of their request and in response, the tastate department has been trying to provide what you have requested and in the meantime, making all of the e-mails public. >> in the first request, you think there's only eight e-mails responsive to the request? >> i believe your first request was for benghazi and i believe the state department did a search and you expanded it to libya and weapons and a few other terms and i believe they conducted a diligent --

>> our jurisdiction is the same as it was. it has not grown. you say you turned over everything. i don't get a chance to watch you a lot on television, but when i see you interviewed, you make a point of saying i turned over everything. >> all my work related e-mails, yes. >> how do you know that? >> i know that because there was an exhaustive search done under the supervision of my attorneys and that is exactly the outcome. we turned over every work related e-mail, in fact, as somebody referred to earlier, we turned over too many. the state department and the national archives says there are 1246 out of the 30,000 plus that they have already determined did not need to be turned over. >> and you have a -- >> can i -- >> you have a good group of attorneys. which makes me wonder how they missed 15 of them. >> well if you are talking about mr. bloomenthal, i had some of

that he did not have and he had some that i did not have. and i was under no obligation to make any of his e-mails available unless i decided they were work related and the ones i decided were work related i forwarded them. >> is there any question that the 15 that james cole turned over to us were work related? they were work related. >> they were from a personal friend, not any official government official, and they were, i determined on the basis of looking at them, what was work related and what wasn't and some i did not have time to the read. >> chairman, regular order. mr. chairman -- >> are you saying that the 15 -- i will tell the gentle lady from california, that i'm going to take extra time just like everybody else has and we can either do it this round, or we can do it next round.

>> may i make a simple inquiry about how many more minutes the chairman plans? >> the fewer the interruptions, the quicker i can get done. >> okay, be mindful of the time. >> on the 15, did your lawyers find them and decide they were not work related or did they not find them? >> i don't know why he had e-mails i didn't and i don't know why i had e-mails he didn't. and all i can tell you, i turned over every work related e-mail in my possession. >> all right. i'm going to make two more observations and then, we are going to call it a night. the first i make, is when you speak to the public, you say, i turned over everything. that's for the most part a direct quote. when you talk to the public, you say i turned over everything. when you talk to the court, you say, while i do not know what information may be responsive, for purposes of this lawsuit, i

have directed that all my e-mails on clinton e-mail.com in my custody that were or potentially were federal records be provided to the department of state and information that i believe it was done. >> one is a shorthand. >> why not tell the court, i turned over everything. >> you know how lawyers are, they use more words perhaps than they need. >> trust me, i know that. and they charge you for every one of them. >> i'm well aware of that, mr. chairman and the clock is ticking. >> one more, one more and i will pay mr. kindle's fee for the last question. >> i don't think you want to do that. >> probably can't do it. you see my point, you are definitive when you talk to the american people, that you turned over everything. >> that's right. >> but those lawyerly fudge words when you are talking to court on information in belief and the reality is even tonight, you cannot tell us that you turned over everything, because

you didn't think you missed the 15. >> well, i didn't have them, i turned over everything i had. everything that i had has been turned over to the state department. >> that means you had somehow missed those 15. >> well -- >> last question on your system. mr. cummings said that your e-mail arrangement was of inappropriate. i think the president may have said it was a mistake. you have said that it was a mistake. my question to you, madam secretary, was it a mistake for the four years that you had that e-mail arrangement, was it a mistake for the almost two years that you kept the public record to yourself, or has it manifested itself as a mistake in the last six months? >> well, since i believed that all of my work related e-mails to.gov accounts were being captured and preserved, it was

of not until i was asked to help the state department to fill in what they saw as some record keeping gaps, not just with me, but with others, i did the best i could during those four years and thought that, everything that i was e-mailing, that was work related was of being preserved. >> if you can find a source for the 90 to 95%, i would be grateful for it and we would probably have fewer questions. if there's a source that you can provide that 90 to 95% were on the state department's system, then i will know that i need to ask the state department what took them so long? because i'm telling you, madam secretary, i got eight e-mails the first time i asked and now i have over 1500. there's some disconnect there. >> and well, mr. chairman, i think that is a fair question. and i'm not at the state department any longer, but i do want to defend them. they are under the most

extraordinary pressure to answer congressional inquiries, i saw a figure recently that foya requests have jumped something like 300%. they don't have the resources. they don't have the personnel. they take their responsibility of reading every single line -- >> on behalf of all of us, i want to thank you for your patience and your willingness to come and you have been willing to come in the past as i noted in my opening and we appreciate it, and with that, we will be adjourned. >> thank you.

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beatitude was, you know, let them do whatever they want as long as they are not coming into our neighborhoods. there are hard-working, wonderful family, kids, they want to be safe. they want to be in partnership with the police. just want to make sure that a

police officers properly trained so that just because a kid has a duty, they have, partly because they know the communities they don't assume that must be some of the should arrest or frisk. i can distinguish between kids the same way in their own neighborhood vacant established between kids are really causing trouble and kids were just being kids. so i think the moment this year but we've got to build on it, we've got to be systematic about it. a couple things that have been said that want to emphasize. electing data into something that's going to be very important in guiding us forward. and john was talking the federal, state and local cooperation. we don't really do a good job right now in collecting national data on a real-time basis. but we now have the tools and

technology to do it better. and the better our data the better we can target where israel crime going on, where are we seeing may be some problems in police committee interactions that we can catch ahead of time. it's transparent that the committee that has trust because they are saying, here's what's been happening. and so we are initiating both internally at the federal level but also reaching out to departments to figure how do we get a national database that is more effective. that's point number one. point number two, we have the outstanding chief who i had to visit, who i had a chance to visit. a great example of community policing and data driving down crime and regaining trust from the community. the chief here as sort of a war

room that has cameras on some of the hotspots around the city. but it's not considered big brother because they have set up software where the community can direct the cameras so they don't feel like they're being spied on from the outside but rather it is a tool to monitor what's happening. they are then sending that in and that she has trained, return his entire department. first thing they did when they brought in new recruits, they put them in the neighborhoods where they're going to be serving. they had to walk me before 24 hours, right? if they need to go to the restroom, they needed to get to know some people like that so they started beating local businesses, where the new dork hotshots and gang shootings related to drug. that she took some for for germany i think it was.

this is one of my favorite stories because it's more. it shows thinking. purchases to ice cream trucks has police officers try to ice cream trucks, partner with a drug dealing has been going on, give me a free ice cream on the police. suddenly families are out on the street and now it's creating a space in which it's a lot harder for you to just be dealing of drugs. and the chief talks but sometimes we know with a drug-free -- drug dealers are, instead of arrest them, just have an officer stand right next to them. [laughter] and talking to them and asking them why are you doing this? so the point is that the use of technology, the use of data combined with smart community policing really can have an impact. really can make a difference. but my hope coming out of all these efforts in, including the

legislation, is that we put an emphasis on what works. we are not blinded by ideology and we are not blinded by fear. all this talk i that's getting hyped about, the huge spike in violent crime, this is where to step back and say let's understand statistics. 2014 was a historic low in violent crime, so if there's a spike in some cities, that something went to take serious, pay attention to but that doesn't translate into this notion that a crime wave is coming. because it still lower this year than it was for every year between 1995-2013. it's just, it may be that lester was the anomaly. that's an example of us having to make sure that we are not being driven by fear or bias in

how we approach this problem. we are looking at facts and trying to figure what works and what doesn't. spin our timekeeper has just held up a card that says stop. actually she held it up about two-thirds the way last answer but i figured -- >> that's okay. this is my house. [laughter] [applause] i can go overtime generally. but maybe we can hear from the chief. >> i just think this is a tremendous opportunity for law enforcement and the justice system in america. with crisis comes opportunity. right now we do have a crisis of confidence. there's a tremendous opportunity for us to do better at putting out our message, about making sure people are treated fairly in making sure we are an effective law enforcement. this will be looked at in

history as a door that was opened, and hopefully we walk through together. >> i just want to go a comment the chief made, which is i'm amazed by the command of this area that the president has got among a million other things that he does. i would say, to go back to your first question, bill, what is success? in the end we have an opportunity. this is a moment in time and i think we're taking advantage of the collectively, to both reduce the rates of incarceration and make our communities safer by taking the savings and investing it, prevention and effective community oriented enforcement and in reentry programs. i think we can do that, it was the leadership of the president, the attorney general and all the people here both in congress active local and federal law enforcement, we are well down the road.

>> and because it's my house i'm going to take one last -- i want to drive down, drive home one point, that is the relationship between race and the criminal justice system. he does this is where sometimes politics intrudes pashtun because this is where sometimes politics intrudes. black lives matter is a social media movement that tried to jail around ferguson and there are other cases that came up. very rapidly it was posited as being in opposition to police, and sometimes like any of these relations some people pop off and say dumb things. and on the other hand, though it's targeting lifted up as these folks are opposed to police, opposed to cops, and all

lives matter. southern ocean osama same black lives matter was reversed racism are suggesting that other people's lives didn't matter, police officers lives didn't matter. whenever we get bogged down in that kind of discussion, we know where that goes. that's just down the old track. so let me just suggest this. i think everybody understands all lives matter. everybody wants strong, effective law enforcement. everybody wants the kids to be safe when they are walking to school your nobody wants to see police officers were doing their job fairly hurt. everybody understands it's a dangerous job. i think the reason that the organizers use the phrase black lives matter was not because they were suggesting nobody else's life better.

rather what they were suggesting was there is a specific problem that is happening in the african-american community that is not happening in other communities. and that is a legitimate issue that we've got to address. i forget which french writer said there was a law that was passed that really was equal because both rich and poor were forbidden from stealing loaves of bread and sleeping under the bridge. well, so here's, that's not a good definition. this situation, there is a specific concern as to whether african-americans are sometimes not triggered in particular jurisdictions fairly are subject to excessive force more frequently. i think it's important for those who are concerned about that to

back it up with data, not anecdotes, but not paint with a broad brush, to understand the overwhelming majority of law enforcement is doing the right thing, it wants to do the right thing, to recognize that police officers have a really tough job and we sent them into really tough neighborhoods that sometimes are really dangerous, if it had to make split-second decisions. and so we shouldn't be too sanctimonious about situations that sometimes can be ambiguous. but having said all that, we as a society, particularly given our history, have to take this seriously. one of the ways of avoiding the politics of this and losing the moment is everybody stepping back for a second and understanding that the

african-american committee is not just making this up. and it's not just something being politicized. it's real and there's a history behind it and we have to take it seriously. and it's incumbent than of activists to also take seriously, it's a tough job the police have. that's one of the things the post-ferguson task force did. we have activists who were marching in ferguson with police chiefs and law enforcement sitting down and figuring this stuff out. interest assuming good faith in other people, going to the issue of people being cynical i think is important. i've really gotten much accomplished a semi-the worst in other people. usually it works better if i assume the best. i just wanted to make that point. all right. >> thank you. i guess i'm your as represented of the cynical profession.

but i just would like to see there are a few issues i feel less cynical about. i share the worry you have, short attention span and i guess it's on us in the news media in part to make sure that doesn't happen. >> well, thank you for hosting this. thank you for everybody in attendance and for the chiefs for the good work you are doing. [applause] spitting let's start moving over here. [applause] spewing ladies and gentlemen, please remain in your seats until the president has left the room.

>> there was no credible actionable threat known against our compound. >> our hearing without commercials in its entirety on c-span. >> next to my testimony from doctors and addiction specialist before house energy and commerce subcommittee on the nation's drug abuse epidemic. members are considering federal resources needed to combat the

problem. this is about one hour 15 minutes. >> ladies and gentlemen, if you can take your seats, the subcommittee will come to mortar -- come to order. we had the first panel a week ago, couple weeks ago, and this will be the second panel. so welcome back. for those of you just joining us today, today is the second day of our hearing to examine legislative proposals to combat our nation's drug abuse crisis. on the first day of the hearing which took place on october 8, we heard testimony from a panel of federal witnesses representing dea, hhs and the executive office of the president. today we'll hear from a number of distinguished doctors with a

wide variety of expertise. hot stab panel today we have, and i'll introduce them in the order of their presenting their testimony. first adopter paul halverson, dean come indian universities fairbanks school of public health, welcome. secondly, doctor sledge, chief medical officer of criminal heights. third, dr. robert corey waller, chair of the american society of addiction, medicine, legislative advocacy. welcome. then dr. kenneth katz, department of emergency medicine section of medical toxicology, lehigh valley of network. welcome. and i don't see doctor anderson yet, president of the american orthopedic society for sports medicine. so thank you for coming. your written testimony will be made a part of the record to you each have five minutes to summarize your testimony.

and after opening statements we will do the question. so you're recognized for five minutes for your summary. >> thank you, mr. chairman. chairman pitts, ranking member green, thank you for the opportunity to testify today. i comforted as both founding dean of the indian university of richard m. fairbank school of public health as well as the former state health officer of arkansas to discuss a very important and far-reaching public health issue, the heroin of prescription drug abuse epidemic, and the deleterious effects which were experiencing across the country in a mild state of indiana. we know addiction is a tragedy, not for the addicted person alone, but also for families, employers and entire communities. addiction is often at the root of myriad social, mental, public health problem. it harms all in his path, even

the most innocent among us. newborns have been exposed to opioids in utero are often born with a condition called neonatal abstinence centered american left taking the number of affected babies is five times higher me a ring the surgeon opioid use of the same time period. the financial cost of drug addiction for health care criminal justice and education are staggering. in my state of india alone the costs are estimated at over $723 billion annually. hospital charges for babies born with nas, over 1.5 billion nationally in 2013. opioid abusers particularly pernicious because it's often a precursor to hear wendy used to samhsa that nearly four out of five new heroin users to nonmedical restriction pain medication before taking he her. the end result, people are dying. cdc knows 44 people died each

day in our country from an overdose of pain medication. nationally harewood related deaths have escalated over 39% between 2012-2013. although mortality rates are up in many states in the country, indiana is one of only four states where the rate of overdose death has quadrupled in 14 years. indiana made the national news this past spring with this public health crisis related to opioid abuse. scott county, a population of less than 25,000 people, had an unprecedented outbreak of hiv related to needle used. to date the number of new confirmed cases of hiv for 2015 exceeds 180. this number is particularly alarming since the entire southeastern region of india has never had more than five new cases annually prior to this year. in addition significant cuts in

poverty chronically underfunded public health infrastructure nationwide make communities more vulnerable and frequently leaves them without important public health services such as education i had to protect themselves against life-threatening diseases, and access to confidential hiv testing and treatment among other important services like epidemiology at outbreak investigation capacity. indiana's public health system is particularly vulnerable with our overall health ranking at 41 after funding of public health services at 47 out of the 50 states. between 2009-13, his small role county led the entire state in both drug overdose deaths and nonfederal emergency department visits to do opioid overdose. it's also important to point out to our numerous counties in indiana and throughout the country that are strikingly similar by virtue of their social and demographic characteristics as well as the fragile public health system

capacity that exists. we are grateful to colleagues and the cdc for existing our state health department under leadership of dr. adams as they responded to in support of local public health community leaders into governor pence the recent establishing an executive branch task force to focus state government agencies on this is to issue surrounding substance abuse. our attorney general's long-standing prescription drug task force has been focused on the coordination and oversight of indiana's prescription drug ongoing program and its insight has been instrumental in developing legislative and policy level recommendations. lastly i would like to acknowledge the support dr. richard m. fairbanks school of public health has provided eberly to the leadership of doctor d duby was and how this d and supported these efforts in our state. despite these efforts additional national legislative efforts are needed. we are grateful to

representative brooks and other members of the committee to shedding light on the serious problems of opa to be his and heroin just which are becoming more pervasive with each passing day. it is clear we need to effectively attack this problem with a system perspective to prevent further destruction of a public health i applaud your efforts and i'm grateful for your dedication and addressing this important public health issue. thank you, sir spent now recognize doctor sledge, five minutes, for your summary. make sure you press the button. >> thank you, mr. chairman. i want to thank this committee for holding this important hearing on legislation solutions to combat the worsening the crisis in our country. i am deeply concerned as to what i see happening in regards to the opioid epidemic in particular i'm grateful that this opportunity to share my thoughts and experience. i'm chief medical officer of cumberland heights, private not-for-profit treatment

addiction center in nashville, tennessee. i previously served as medical director of the treatment services at pine grove be able health in mississippi and i've e been practicing addiction medicine for over 26 years. i'm certified by the american board of addiction medicine, a fellow of american society of addiction medicine. from 2005-2000 represented mississippi, alabama, florida, tennessee and kentucky on the board of directors of asam and served on the board of directors until 20 love. cumberland heights is a figure tradition of creating addiction. we provide treatment to adult men and women as well as adolescents. most of our patients are working class and pensions depend but we could put their number with resources to self-pay in which we got their number dependent upon scholarships to provide their treatment. a watershed moment in my career came around 2006 on a saturday morning i was making the rounds on a detox unit with 25 it and

realized every single one of those patients had a diagnosis of opioid dependence and that was new to me. some of those patients at other diagnoses as well but every single one had a diagnosis of opioid dependence and affect every single one was depend upon prescription opioids. our most common diagnosis at compline heights of the figure emissions per year has been opioid dependence particularly can young adults. tennessee leads the nation in prescription for opioid per capita. and harewood addictions become more and more prevalent as access to prescription opioids becomes limited to less a beautiful formation as well as education. the local newspaper restaurant on the opioid epidemic last month to quote at least 1263 and is the -- tennesseans died last you for opioid abuse.

a staggering statistic that points to growing abuse despite an array of measures to stem addiction. more people died in 2014 from opioid overdose in tennessee than by car accidents or gunshots. my expertise is based in direct patient care. on expert in what may patients disclose to me face-to-face in my office. almost all of our patients admitted for treatment of opioid dependence have some experience with you been referring -- over the years i've been amazed at stories of the version entities among patients presenting to cumberland heights for treatment. it is sometimes used under the tongue as it is designed, can be used intranasal or even eject the motivations for illicit use include to get high as well as to treat withdrawal. some patients with the version entities take it with the motivation to stop using other

opioids. a typical patent middleman does cost $20 when obtained all the silly entities tennessee as much as $40. the street value supports my observation as to the level of the version and abuse. in fact it has been identified as the third most diverted medication in the u.s. by the dea. at a 2008 meeting of american society of addiction medicine's in the medical scientific conference in miami comes as by calling if i used it to treat opioid dependence. i replied realize to detox from opus. are marketed to patients recover without it i told him i had recovered from opioid dependence without morphing. he said but you were not using intravenously. he. and credulous that i told i had -- i cringe when an addiction medicine treatment provider makes a recommendation based on his or her personal experience

in treatment and recovery. that's not what i'm saying but my experience indicates that are multiple paths to recovery. there is no one size fits all. at compline us with what abstinence after detox. we provide psychosocial treatment and reuse of long acting opioid blocker as well as incorporation of spiritual basis of recovery through a 12 step rehabilitation. we have sent addiction is a chronic illness, i'm going to cover parts ongoing treatment. no one is claiming detox from opioids alone will result in recovery. i thank you for the opportunity to speak spin the chair thanks the gentleman and recognizes dr. waller for five minutes. >> thank you, mr. chairman and ranking member green -- [inaudible] into this important think i'm grateful to any elements of the subcommittee for your leadership in addressing the epidemic of

opioid addiction currently ravaging our country. my name is doctor cornwall and i'm chair of the american society of addiction medicine also known as asam. this test is offered on behalf of asam myself as a practicing addiction special position in the pacer unable to speak before this committee themselves. i am board-certified in both addiction medicine and emergency medicine. i'm the chief offenders into the spectrum health hospital system as well as substance use and mental health organization based in grand rapids, michigan. my testimony will focus on the following three facts. addiction is a chronic disease of the brain to which the characteristic psychological, biological and social manifestations. addiction involving overuse can be successfully treated with a combination of medications, and we have published guidelines that detailed best practices for the use of these medications. they are significant barriers to access.

these affect come to these effective medications result in a significant treatment gap in our country. this is without question a chronic neurobiological disorder that starts with a genetic risk. it's informed by the environment and to solidify by the culture surrounding it. not unlike diabetes or hypertension we can effectively manage the disease but stopping the treatment prematurely costs us lives. we are here to provide recommendation on how best to respond to the addiction. according to the cdc we have reached epidemic levels in our country. we've seen to date and heard the shocking statistics but what's not said or enough is 2.3 many people d who need treatment for opioid addiction have a chronic disease of the brain. while we need to prevent other americans from developing addiction, these 2.3 million people need treatment now. dark alley three medications or fda approved. methadone which have been used and how to regulate opioid

treatment programs since the 1960s, used since 2000 by position of complete special training in the offices and candidness by any license prescriber. all of these medications are proving to be clinically effective. that 2000 13b b. of the scientific which found substantial brought and conclusive evidence that if it does of all three medications eveafter methadone in particula. notably the lecture is not new. the art a large-scale rigorously contact us reviews since the early '80s. all fda medications have been shown to reduce mortality. finally quit a clear and comprehensive guideline for the use of these medications effectively in the clinical care of persons with addiction. despite the strong evidence-based use of these medications and the clinical guidance, very few alice will patients are offered medication to treat their disease to less than 30% of the treatment

programs offer medications and less than half of eligible patients receive medications. a study published just last week in the journal of the american medical association found 80% with opioid addiction don't receive treatment. the treatment that is integral to many factors, some are more complex than others. research has demonstrated access breast methadone including waiting lists for treatment, limited geographic coverage, limited insurance coverage and requirement that many receive methadone daily. dated 2000 was intend to expand access by integrating it into the general medical setting. in recent months my practice has had to turn away patients due to the weather patient limit, this includes a pregnant patient until the the children of my friends and as result in at least two overdose deaths that we contract. if i'm out of town or out of town or inevitable my assistants are unable to see patients who needed urgent intake due to

restriction on p.a.s and nurse practitioners. is important to note that the entire purpose of data must make addiction driven to the outside and traditional position offers both increase access to areas where it is maybe physically accessible to reduce the stigma and patient burden of social with visiting on a daily basis. still because the version quality of to remain legitimate concerns, asam was a grudge on the deadlifting of the dated 2000 limits. by coupling a lifting of the patient limit with increased training requirements and accountability for those physicians treating large numbers of patients we feel we can expand access while also ensuring a certain quality of care. distinguish strategy should be one part of a broader federal effort to ensure safe prescribing for pain, options and early identification and treatment of addiction.

pain and addiction education should be required curriculum and medical school. communities should have the resources to educate their citizens about these issues and the outreach and surveillance resource message better than the unique issues and needs. thank you again for the opportunity to present your today. asam and myself look for to continued collaboration on this and other addiction related issues spill now recognized dr. katz, five minutes for your summary. >> drug epidemic as it's whatever see us do the accessibility of cheaply made mass-produced deadly synthetic drugs. as a physician from other point is that these dangers compounds have led to violence, hospitalizations and deaths. in both the adult and pediatric intensive care units in pennsylvania there's been countless hours at the bedside care and for many patients suffering from the effects of synthetic marijuana which ripped through eastern pennsylvania

leaving in its with multiple patients in emergency department, hospitals and the fortune more of us. my name is dr. kenneth katz and i board-certified in emergency medicine, medical toxicology and dental medicine. thank you for allowing me to testify today. and to advocate for h.r. 8537. in every commute across the nation my colleagues at our trading more and more patients who have experienced synthetic drug toxicity or voicing. they are not organic synthesize, unsafe, recreational drugs that reduce cycle active our mind altering effects. many of these are marketed as an office products such as instance, plant fertilizer our

air freshener and then sold at gas station or online. mimi uses presume they must be sacred however the public should not be fooled. even though these products may be hiding in plain sight they are called to play catch -- they are colorfully packaged poison. taken in a vast array of different chemicals with varying policies. synthetic marijuana may contain compounds two to 500 times more powerful than thc. in many cases the manufactures only goal is to alter the compound to create a new compound related to circumvent legislative and regulatory bands. it's modification process poses increasing risk to users were unaware of the reaction. it is not until these substances are inhaled or ingested that symptoms can occur. hypothermia, elevated blood pressure and pulse, severe agitation, seizures,, muscle breakdown, kidney injury and ultimately death.

unfortunate at the point it may be too late for either my emergency been in colleagues or even me as a medical toxicologist to say that while there's an increasing and expanding array of synthetic drugs be manufactured a particular concern is the availability and use of synthetic marijuana what i it'st the data from sensors drug abuse warning network, d. a's system or poison control centers. it is clear synthetic marijuana use has increased exponentially since it first appeared a few years ago. according to -- by 2012 the number grew to more than 29,000 an increase of more than 200%. in the first six months that are close to 20,000 synthetic marijuana drug reports. my home state of pennsylvania has been especially hit hard by the increased use of synthetic marijuana going on in new york, mississippi and texas. currently all 50 states have

banned some tabloid. many states have passed laws targeting an entire class of substances or use broadly which to describe the prohibited drugs. federal statutes must be updated to meet this challenge and restrained these dangers properties. in addition the bill would add more than 200 known synthetic drugs to schedule one. this legislation is targeted the manufactures and distributes of the synthetic drugs, not the end users. h.r. 3537 women the analog data so it only apply to the silken manufacture important is to be a drugs, not simple possession. the easy access to a thoughtless use of the synthetic drugs but those were unaware of it into stocks as it is not a place of

their health and lives at risk by can have a profound impact upon my ability to care for my patients. when users need emergency medical attention they're utilizing precious resources such as a tim lincecum emergency department heads, personnel and limited health care dollars. it is my opinion and that the american college of emergency physicians that this critical issue must be addressed and supplement by national campaign to educate americans about the dangers of using synthetic drugs. thank you. >> the chair thanks the gentleman and that recognizes doctor anderson, five minutes, for your summary. >> good afternoon. i am doctor alan anderson, orthopedic surgeon specializing in sports medicine become also the president of the american orthopedic society for sports medicine, a nonprofit made up of 3000 foreign orthopedic surgeons specializing in the care of athletic injuries at every level of competition. 80% of our members are team of

physicians and 6% of our members take care of my contact dilution sports where she's injury can occur. a team physician is unique responsibility and qualifications. he or she must a fundamental knowledge of ongoing emergency care and treatment of musculoskeletal injuries and medical conditions. today i will discuss the need for a team physician to be able to carry controlled substances when traveling with the team and the problems with current law. effect the workarounds are not practical and what h.r. 301 for the medical control substances transportation act, will enable team physician to buy the best quality medical care to our injured athletes. in emergency or disaster significant, it is critical that a physician having the access to controlled substances. to our times such a strength air travel or on a bus when the team physician is the only medical person available.

there are documented cases that players having seizures after concussions on a flight home. and in such situations controlled substances are needed to stop the seizure and perhaps see the athletes life. it is humane care to allow a player to take a pain pill if he or she has a broken bone, dislocated shoulder or torn aco. as you watch your favorite team on saturdays one or more athletes to significantly injured in almost everything. these players are your constituents from every state. the team physician is probably a member of aossm is there on the sideline to render aid and take responsibly for the athletes welding. this aid is considerably restricted by current law. the current law prohibits the transportation and storage of controlled substances away from the site of storage that is registered with the dea. this makes it illegal for team doctors to transport a limited

quantity of critical medications that are needed for pain control of emergency management the this is highly problematic for athletic team physicians who need the ability to maintain a limited supply of controlled substances if a player is injured in an away game. the current law also precludes substances from a transporter within the same state or across state lines. the current workarounds are problematic. the current options include pre-dispensing medications to every member of the team out to travel. that would be 80 members on a football team. this would create a logistical nightmare. delegating to the whole medical staff in state of entry, this is also a problem. the opposing team physician can provide medications but they have to independent examine the patient and their limited time due to demands to treat their own team. this would also create malpractice concerns for that

physician prescribing medication and not following that nation. there are also privacy concerns. and local physician is generally caring for the competing team. this would be unacceptable for the coaching staff to enter the training room. h.r. 301 forward address these concerns that it allows the physician who is traveling with the team the ability to appropriate managed the injury in a similar fashion to win their home facility it does not diminish the need for requirement for controlled substances to be monitored at the current level. records of controlled substances to dispense or maintain and subject to inspection by the dea at any time. 15 position will be responsible for the security of the controlled substances throughout the entire time for team will be traveling and the duration of transport is limited to 72 hours. military flight surgeons and rural, large animal veterans can

carry this medication. contact sports can be much more perilous than non-military maneuvers. it is hard for me to believe that horses and particularly cows could get better medical treatment that our athletes. this legislation would also benefit patients and physicians who donate their time and declared disaster areas in the state or other states. therefore, we urge you to support h.r. 3014, a medical controlled substances transportation act ago so we can provide the highest level of care for our injured athletes. thank you for giving me this opportunity to testify, and i'm happy to take questions. >> the chair thanks the gentleman. that concludes the opening statements of our second panel. i have a request i would like to submit the following documents for the record. statements from the college on problems of drug dependence, the national association of convenience stores, dr. cooper,

head team physician for the dallas cowboys, the fraternal order of the place, society of former special agent of the fbi, the american medical association, american college of emergency physicians, american association of orthopedic surgeons, center for lawful access of abuse and deterrence can the american academy of physicians assistants, at the national association of chain drug stores. without objection, so ordered. i will begin the questioning, recognize myself five minutes for the purpose. dr. halverson, and dr. sledge, while you can respond here, too. do you all agree that patients addicted to opioids should receive treatment based upon the individual clinical needs? dr. halverson? >> yes. >> absolutely. >> dr. waller? >> yes. >> how would you each advise hhs

to take this principle into account with considering how to responsibly implement secretary burwell's recent announcement to expand the use of medication assisted therapy? dr. halverson? >> since i'm not a physician i would like to defer to my colleagues here. >> all right. dr. sledge. >> i think that prescribing physician should be trained in all modalities of medication assisted therapy as well as other option, particularly psychosocial treatment with abstinence as an option. >> dr. waller? >> we've looked at this close in the area i'm in charge of a seven county area with patient and putting out how to treat that very. we been able to delineate two separate groups which have good data for. those that started very early in life and started earlier in their adolescence which have a different brain disease and start later in life.

those groups of patients separate u us out as forceout treatment worked either many patients in my clinic that are physicians, pilots and lawyers who i don't get any medication to because general it's not indicate and with one of outcomes without any assisted medication. microswitch on 92% of my patients which are medication or those without insurance i find it is a perilous journey to try to treat them without medicine at the data backs it up with higher mortality rate. dr. sledge and i are saying the same thing. it is absolutely right thing for the right patient at the right time and making sure we allow for an exchange of use of these medications to save lives in hands of those people who are trained best to use them. >> all right. you've touched on this but expand a little bit more on how should differences in certain types of patients and treatment settings and therapeutic options be addressed speak was currently

we have guidelines that address utilization of the medication but these are the first guidelines that look at all three of the fda approved medications and it does speak to the behavioral psychosocial therapies without medications are generally the medication treat has been done in a cohort of patients who do not represent the physician or a pilot or a lawyer, which in general we have programs within states have strengthened their different in the different programmatic treatment pathways. utilizing the guidelines we have delineated with the appropriate education to back that up would be the way that i would say. >> dr. sledge? >> an overarching principle identified by the institute of medicine for successful treatment included patient self-determination. and i think that h.r. 2872, the opioid addiction act brings patient self-determination act to the equation.

>> in your opinion, what are the most significant obstacles at the present time to prevent more individuals with opioid induced disorders from receiving the most effective treatments speak with i think that one size fits all treatment is very detrimental to addressing the opioid epidemic. i think there's an assessment of each individual patient with recommendation and referral based on their individual needs is essential for successful treatment. >> any other significant obstacles, dr. waller speak with the legal obstacles to obtain the appropriate medication for patients that we denounce the right medication such a specifically be been offering for my patients. i treat all my pregnant patients in that area and i'm out of space. i have to turn people away to areas that are either less than optimal offer them or tried our best with what we can do. unfortunate that doesn't turn out very well.

to each of you comment the role of nurse practitioners and physician assistants play in providing office-based opioid treatment? >> i cannot provide a treatments i would defer to dr. waller. >> dr. waller. >> without the utilization of by physician assistant from my office doesn't run. we have a jbuilder two seat patients can find because we have well-trained physician assistants and nurse practitioners to work directly with ward certified people and their other special is whether this is a neurosurgeon or orthopedic surgeon or an addiction specialist in this case an addiction specialty, cupping my physician assistants along with behavioral therapist with my patients, it works out really well a great outcomes in this sm office been adopted in a medical model of care and is standardized throughout medicine. to eliminate this as a possibility for this specific disease doesn't make sense of a

monetary standpoint for a patient delivery standpoint. >> i'm out of time but dr. katz, utah to synthetic drugs and with the movement towards legalization of medical erewhon. is synthetic marijuana consider medical marijuana? are the advocates of trying to include it in medical marijuana speak was not that i'm aware. i think we're talking two different things spent it is completely synthetic. that's what i thought. thank you at this time that you recognize that jump from ireland, mr. sarbanes, filling iin for ranking member bring. >> thank you, mr. chairman pic before ask the question i would ask unanimous consent to enter a letter from purdue university college of pharmacy, doctor nichols, which provides some additional perspective on this issue of adding certain synthetic drugs to the schedule one csa and implications of that

for scientific research. >> without objection, so ordered. >> thank you. i appreciate the test whatever the buddy. the first question i want to ask, maybe dr. halverson from your sort of public health perspective and dr. waller, but others as well. the word epidemic is getting used a lot to describe this. and i frankly myself didn't appreciate that by the cdc definition of epidemic and we've actually gotten to that. epidemic is kind of use and the vernacular to just describe something that is out of hand and serious, but if you're talking about epidemic where it could be analogous to sars epidemic or mercenary, whatever, that's a bit different scale and agree. if you could speak to that, any of you. >> epidemic is used in large

part because of the fact that we don't see and easily controllable and that we experience the phenomena, whatever it may be, an epidemic of flu or an epidemic or later to any disease where the disease is raging beyond our ability to control it. and the disease has the potential to profound impact. under those definitions we certainly have seen an epidemic of opioid abuse, of deaths. and the real is that we do have an idea of how to address the epidemic, at our current point in time we haven't reached the point where we can actually say it is controlled. >> any other perspectives? >> so the two components of an epidemic is susceptible to something invented able to come into contact with the something and have it spread.

we have seen exactly that out of with heroin. if it shows up those people are susceptible from a genetic predisposition and of our then start on opioid or in the case of many areas commuting people who this is the first drug to touch in some cases and early high school, internet access and genetic risk, it grossed just like a disease that would look at the outbreak which is covered the map and vessel bursting. it kills more people in my state to anything else and it's all people that are young and healthy as compared of the diseases that affect the hold of the population. >> let's say tomorrow you were appointed the opioid addiction czar the same when we had an ebola start -- >> i accept. >> and you could take whatever steps you thought were necessary. describe what the first two were things would be, both ones that would require additional resources, which the resource dependent as well once it may not be resource dependent, like

lifting some of the caps on the number of patients that can be treated and so forth. what would your steps the specs speak was the first it would be a reeducation of the population about what the disease of addiction is. this is a chronic neurobiological disorder that has more data about the brain disease aspect in any other mental health disease in his we've ever looked at. >> so is that psa? what is that? >> this is a surgeon general's report. this is public messaging, this is rebranding of the disease that has been maligned and we've been treating this with an emotional context rather than a sign context for years. that has to be the first place. second pieces access to all treatment and a third place is to build a structure around the statements so that deliver with high fidelity and low risk. >> okay thank you. i'm interested because i think piece of legislation on this topic of this idea of encouraging co-prescribing of

naloxone at the type of position is prescribing certain kind of opioid. and they would be some demonstration projects around this to test the potential of this and to look at particular circumstances under which that would be appropriate, the kind of patient, their particular vulnerabilities and the likelihood of a potential overdose, et cetera. can you just speak to your perspective on whether that would be a useful step? >> first, i appreciate that piece of legislation. it is very impactful. i carry naloxone in my backpack. it is sitting behind me in a ready injectable pemphigus is something we can do. it is an anti-death syndrome. said of this available in a co-prescribing would become immersed into patients alike it to make sure they're trained in the utilization of this is no different than having an automatic disable it on a wall in a gym. this is something that should be

publicly available and this is a great step towards that. we support that. i personally support this as well as asam as well. i think the biggest issue with this, we need to make sure and dispelled the myth of some of adding an antidote changes patient's behavior to use more and more often. that is been found through search -- the research not be to get into areas where the loudest to be legalized and given to police officers and community members and made it available to patients, we have seen nothing but a decrease in mortality. we've not seen an increase in utilization, in an amount of utilization per person per time to use. that is just not true. when you reverse somebody that it's one more time they are not dead and where the opportunity to get them into treatment. >> so you had to bring all the measures to bear and use it as a first step back. thank you very much. i yield back. >> the chair thanks the gentleman and now recognizes mr. guthrie. >> thank you very much.

first as a comment to dr. anderson. i know you got up early. oslo on the airplane coming out of nashville this morning. i'm also working with come notch or position the people who practice in your area, not just for opioids that you're talking about able to carry but also a friend of mine is an emergency room physician so we traveled to kentucky last thursday night with the auburn tigers to watch over the water plant our beloved wildcats. has a licensing issue back and forth about a physician licensed in alabama doesn't traveled to the team a kentucky. we need to fix that as well. second thing, a lot of my good friends back in the legislature in kentucky, former colleagues of mine, were very aggressive on oxycontin prescription drugs and put forth a prescription drug come ways to manage prescription drug abuse. and it seemed to be very successful with it. some of the physicians were really having to manage it very

closely. we thought we were getting a big candle on the support of the problem. all of a sudden heroin became a big component in kentucky. it became can somebody tell me, i had lunch yesterday with one of our drug task force leaders and he said it's easy to get hair women now than prescription drugs i in kentucky. i'm in a legal prescription drugs. we have to attack the demand for it as well. one of the questions i have, those of you practice in this area, dr. halverson, censure not an empty, but anyone who like to add to, i know there are caps on what taxes changes for buprenorphine. the question is do you think the current caps should be lifted? if not why? if so, how? so any of you who practice in this area. >> i can address it initially. the short answer is yes, but safely. we've identified that this

medication is a diverted and in some cases abused. i have patients that i treat for buprenorphine peace. they show up undertaken for the. .com have the abuse deterrent versions, the inadvertent utilization of it through snorting or injecting it is individually declined to the point where we generally don't use the mono drug, for buprenorphine by itself at all in my clinic spent do the caps put a limit on you? >> i have a seven month waiting list and it is purely waiting on slots because of the cat. i have no one else in my community of 1.3 million people that has any space on their cap that is a specialist in this area. >> dr. sledge, do you have the same issues? >> again i don't practice on this space come at their server is not a cap involved with extended release of medication

insisted therapy. again with the issue of the version attribute i think there needs to be the version protection in whatever measures are taken to increase spent dr. sledge come in your, chautauqua psychosocial should be added, again treated like people with attachment why is that important? >> why is that important? absolutely, just prescribing the medication is i going to affect much of a change in the course of this chronic disease. it's a chronic brain disease that affects not only with a biological manifestations but psychiatric, psychological, spiritual and social meditations and all of those areas have to be addressed for ongoing recovery. i think that medication is

unidimensional when it is used alone. it addresses the biological meditations of the disease but the disease is multifaceted and all of those areas must be addressed for recovery. >> if anyone wants to add to the. also visit for the record. a lot of us understand this but aside from the chronic health impacts of addiction and death from overdose what other public health or social impacts are associated? ..