bipartisan task force to combat the heroin epidemic in the united states. bid of more than 50 members of congress republican in n democrats representing districts all around the nation. the investment does so many members have perspectives and ideas with the same enormous concern illustrates the reach of zero men into our communities. it is a national emergency to say the least we will have 10 americans died today at during the course of this roundtable. each was a brother, a son, a sister, daughter, a mother or father helpless in the grip of fear when addictions succumbing to the disease in my home state of new hampshire over 400 people died from a drug overdose in in 2015.

one added every 3,000 people in my home state it is transforming these productive members into desperate to attics and fatalities in the worst of cases. the risk of experimenting even ones can be deadly but with better treatment options we can help save many thousands of lives throughout our nation program will focus on the effective recovery treatments involving medication and psychotherapy to have 60 percent recovery rates requested which treatments work best and encourage their adoption in other states. joining us in that panel of experts is a deputy director of the national institute of drug abuse. , a medical officer from pharmacologic their peace

and substance abuse treatment in the associate director from addiction and treatment at johns hopkins it an associate professor with the development of psychiatry and behavioral science at the school of medicine. thanks for joining us to develop for word to hearing your perspective on this growing problem. there are other facets we introduce us stop abuse act to courtney law enforcement and public health agencies that federal-state local level. it creates a stronger program to monitor trafficking across state lines. over prescription in leads to large numbers of legitimate patience in cheaper street here when once the prescription runs out ready to crack down on the black market, a stop the abuse act includes treatment

and prevention grants with localities overwhelmed with addiction of opiate and heroin addiction. remus to everything we can to help those affected by hosting roundtable it gives members an opportunity to hear what we can do to combat this epidemic. of the forward to hearing from the up analyst of recovering addicts for right now i will turn it over to the co-chair of the bipartisan task force. seven faq congressmen for being with us today to republicans and democrat colleagues who have joined together in the bipartisan task force. the epidemic has grown to a historic proportions it medical providers are

struggling to keep up with the overdose interim the clinic and securing treatment first responders have taken on the burden to responding to a dangerous situation is when a call comes in and they're becoming more frequent. statistics show more americans are driving the in dash dying from drug overdose and a car crash in that sadly continues to grow. the number of drug deaths exceeded 400 far surpassing the current record set -- set at 324 is in these will continue to rise. we face a deadly combination the highest per capita addiction rate the second lowest treatment capacity.

last week i highlighted the tragic results as a result of lack of treatment options retelling the story of the house of the floor when he passed with 22 years old while incarcerated at dead did become available at a border full treatment center but the prison would not let her out meanwhile they offered a recovery services and when she was released to the bed was no longer available she died of an overdose, lacking treatment. when someone does get treatment it is not the end of the road. we have learned to that substance use disorders can said patients into relapse

in these methods need to be available all across the country. that the federal and state level we're working to develop the best practices for disorders they need to be guided by the latest research i look forward to working from the panel we need to know what works and what is now working so we can make the best decisions of the bipartisan task force. with best practices to share them across this country i was proud to introduce the stop the abuse act to bring together the federal agencies to coordinate a response working with a

pharmacist and experts in the field of the of mental health community paid advocacy groups to develop best practices for prescription medication and. the legislation will bolster its we are happy to have our colleagues who has an important bill for veterans. thank you for coming together those dingell bill both of the silver bullet but by a working together i am confident we can pass legislation to rich change the tide of the epidemic. i yield back. >> though i would like to introduce the first of three panelists.

providing scientific leadership in managing their research portfolio now like to recognize him for his presentation. >> representatives it is terrific to see such a great turnout for this issue that has devastated so many communities and the turnout is obvious and i applaud you for the bipartisan task force to address these in a pro-active way. i will go through these very quickly and leave them with you please let us know if there are any questions. themost important information is on the first slide to remind us the deaths associated with drugs

and abuse in general the pain killers of prescription or epo aids from the most recent data from 2014 into an thousand from heroin but even without surveillance data has of the cetus -- messy numbers look at how they are coated they are coded as a drug overdose but did not specify if it is related to prescription or heroin. there may be greater numbers than what is specified. the increasing rates are giving so many people a taste the parade has been exposed or the communities are they can be diverted and

taken automatically by so many people in what we have seen as a prescription and scallop the death goes up as well so there is a fourfold increase in the death associated with the painkillers like oxytocic road, hydrocodone warda overall all of these zero repute -- opioid pain in the first. that is the upstream driver of the heroin epidemic the deciding factor that is exposing sold ready to step by step forge that pathway into a problem the brain does not distinguish between different types of opium raids -- opioids very well so that heralded as a street drug has the very same impact as of seco don't or

hydrocodone some people cannot even distinguish the difference as they become more available with the eagles are related because said the availability and somebody communities. but then never people also has a corresponding increase is almost exponential it as an epidemiologist it concerns me because we like to see that curve coming down in three don't know where this curve will end. it is still on the upswing there are increases everywhere if i only show the south for the west it would be doubling the look at the midwest in the northeast with the four iran

and sixfold increase. despite all the age groups but non-hispanic whites we have seen the sharpest increases this is consistent with data on an injection in drug users from the northeast so they tend to to be under more equally male and female witches of novel change we think of this more common in males but that is not true with the injections and drug users. why do people with tuesday's? because they have the impact if they make you feel good it are rewarding it relaxing that is a basic principle it is the underlying feature that they are habit forming

but isn't for everybody some people take these pills and they find it unpleasant in some like it but they are the risk to do it again. i very pleased our secretary of health and human services has made this turkey in the tissues for laughs but after suez confirms she convened a small group to address this consistently. these are not the only things we're doing with the opioids epidemic better prevention approach, change how many are available by a focusing on prescribe for practices. saving lives immediately with greater access to lifesaving overdose treatment and finally medication and assisted their appeal as a proven

treatment for addiction and to reduce the of likelihood to increase that they will recover their lives for crowfoot is very briefly on the first to one of the issues we try to redress the there are guidelines that come from a variety of sources to be inconsistent, outdated or without conflicts of interest so as san alternative if -- for nine cancer non end of life care. when it comes to the overdose one of the of

pharmaceutical industries for the recent approval for the intranasal instead of the only approved for relationship being injection though there is a nasal spray if approved in november should be on the market shortly. getting to the main issue of medication there was a study a couple years ago that showed us as they increased the availability of methadone there was a drop of heroin so is it is a population base example to stabilize treatment access in a large population. i've 40 mentioned these substitutions and treatments

it works as another opioid. with a chemical is administered or take it it works by going into a receptor waikiki in a lock with morphine or heroin go into those receptors they produce a lot of activity downstream a blocking agent goes in there and does not turn so it fills the whole to keep other keys to get in the lock with no action. one like methadone 41 is a complete blocker we have the

in between agent somewhere in between the two it turns lovelock -- the block but the door of the open is part way. a blocking agent is a to wall it is in a long acting form and were taken successfully they don't get high. also been taking successfully if they make to -- might step up they do not have that intoxication that is the key of the averting experience. that is the short version we will go into this in more detail but we'll talk about new approaches as we focus on extended relief medication ted we are

pleased to have partnered with the release of the zero long acting opioids in addition also a vaccine to keep the drug out of the brain. what of the issues people will take these medications but my patience has to make the decision every day if they want to take medication and stay cleaned in a sober or not or go back to relapse. sometimes it is the conscious decision but it needs to be made every day with the injectable form they may not need to make that quite as often so this is the implantable device that only needs to be implanted once every six

months that the is the only have to make the decision about once every six months rather than every day or more than that. is they have success they're more likely to be compliant to produce greater abstinence that is a hopeful possibility this was submitted in september and is under expedited review some expected answer is that has met the threshold to gauge used within the next couple of months. the next area is promising vaccine development. they go from the blood system across the capillaries into the brain but vaccines attached to create a protein binder and

keep them in the circulatory system that is the theory there is quite a bit of clinical research with animals kill humans this might be effective but we have a ways to go before there will be able to be administered on a regular basis so the job is to support but we can do today and always will we can do tomorrow even better. class is implementation. we have had these many years we have had the oral medication 30 years and as the injectable the last couple the not very many people are treated even with specialty carew we are

pleased to see increasing subscriptions every year pleased to try novel trials a group at yale university said she was seen the same people over and over with an overdose or problems related to their harem issue in said maybe we can start them on the emergency department they're not taking the advice down the hall so we act as a primary care physician is there were much more likely to be in treatment and less likely to use drugs with they were re-evaluated a few weeks later. just one topnotch center the we think it is very promising and we're working on testing this and other centers to see if it can be rolled out to the emergency departments that want.

>> i was saddened by the story of representative custer of the patients who'd died shortly after being released because they cannot get into treatment this speaks to the importance to link our criminal justice and public out by represent the treatment eric i have had people dropout readily in the prison said settings they have recidivism with criminal activity but sometimes working together like the drug court model or that extensive work, we can do a better job whether the close supervision, of the treatment providers it even opportunities and incentives to turn their lives around

these models have been shown to work on 20 years we don't see that in wide use so this is an area where we do research. even medications can be used a wonderful study coming out to offenders who were about to be released from long-term incarceration who all had a history of addiction in the past this was not withdraw all but they refer them to methadone actively made dash referral to ring gauge them after they were released or starting them a few weeks before release those started prior to release set up by -- a better outcome with less criminal activity in and thus drug use for the first two months after release of this speaks to

being practical normally when they get out a little bit about treatment treadway there are other motivations. that to be very important. thanks for your attention though i will turn it over to linda. >> i will have the congressmen make the introduction. >> now currently serving at the medical officer for the division of pharmacological company's potion in board certified with additional credentials thinks for being with us. >> it is my pleasure.

before i get down to the business i want to take a moment things for supporting a new round of grants to high quality medication it has funds to dedicate to overdose prevention and thinks to the budget he worked so hard to pass also setting aside this block of time to gather more information about treatment options. i cannot begin to fathom the number of people to the you are faced with a and demand your attention. i came away from defers -- from the first upheld borrow without urgent need for betty out of the box what could be applied to help your community right now. so i will try hb concrete in

this presentation or repeat too much of what has already been presented. the other thing is i spent 10 years as upper scriber before coming to government five years in my solo practice in five years as medical director of the opiate treatment program in pittsburgh to maintain my private practice. . .

a lot of what i talk about today on that. sothat. so just a word about the pictures i'm showing you. when dad asked everyone i saw is is that you give me the permission to take a picture for me to use teaching medical students about bias and disparity in healthcare. this is far less than half the people i saw on that day of the people who gave me permission to remove the children and adults who were not able to consent. there are some people here was treating for addiction. in my private practice you can't tell one from the other. people said my waiting room and waited their turn between the kid with the ear infection and the old lady there to refill or high blood pressure medicine. he would have been surprised sometimes. subsequently i saw some of

the same people in my treatment program. the mill you was such that i saw different behavior, and i was often challenged. now you see what they are really like because they are in the clinic and in behavior is a little more street. why do you think this is what they are really like? what there really like is how they behaved in my office when they were being treated with respect and seen a pleasant place where they get the care that was individualized to them as human beings. not that thatbeings. not that we did not do our damnedest to do that for people. and i will go into that more little bit here. so to kind of reiterate, as far as your brand is concerned and opiate is no. while the problem may have its origins and prescription opioid overprescribing and being exposed to opiates to

start with, once that horse is out of the barn opiate use disorder is opiate use disorder.disorder. you may have different strategies to apply on the prevention and, but the treatment and looks pretty much the same. now, in addition to the different inherent qualities or characteristics of an opiate, how intense it is, how quickly it affects you, the individual person brings risk factors to bear, the biology, genetics, and social situation. unfortunately this is why we see worsening in the onus when the social burden of their disease increases. when they are functioning highly and getting their opiates either by misleading a prescriber about what it is they needed for or maybe getting pills from a friend and they keep the social

front intact, the consequences are usually less. now, unfortunately an opiate is just as deadly whether your social façade is intact as when it is not. if your existence is more marginal, housingmarginal, housing unstable, personal safety at risk, have been subject to trauma as a result of the risks you have exposed yourself to as a result of your addiction, then it does snowball. there is a cumulative risk. so while the brain and the opiate are kind of synergize and in whatever way we as a society have some role in how harmful the illnesses based upon how we define what we expect from people.

moving on from that point i want to talk about the essential ingredient not consider the treatment for addiction, it is the antidote to opioid poisoning. it has the shocking ability to take somebody and bring that person back to alert talking to you, not always very happy to see you, but alive again. it is astonishing the effect of the drug. it is absolutely essential to any successful treatment of people have access to the antidote to opioid poisoning when they needed. that means making the locks on available to people who are in detention are incarceration, people leaving detox or rehab

because they are going out in the fresh baby state, extremely vulnerable to exposure to opiate and it is important that people likely to be on the scene of an overdose weather friends and family or possibly other drug users have blocks of. one of the things that i did as part of my practice as a physician was to write prescriptions at the community overdose prevention program. supported developing a training that was offered in the jails where we were not at that time able to offer in the locks on for some programs around the country are doing a training and putting it in your personal effects so that when you leave jail or prison you have it with you when you walk out the door. there are all sorts of innovations going around around the country that will result in lives saved instead of lives lost.

so they are updating our toolkit to reflect the new product that has been approved for intranasal which should be publicly available later this month. a piece of work that we are proud of. another take-home point for you, detoxification is not treatment. detoxification is necessary to break the cycle of dependence, tolerance, and withdrawal. it is not always necessary to begin treatment. you have to be detoxified. you have to be detoxified to start motor axon, and if you are choosing to be detoxified because that is what is best for you than being offered most tracks on should be considered an important follow one step, standard. for that person who is not seeking and opioid agonist. so detoxification is better thought of as the medical management of opiate

withdrawal. it doesn't change the risk factors for the course of the disease. even if that is followed by rehab stay. moving right along medication is not a treatment by itself. it will control the disease much the way your high pressure medicine will, but it will not change the course of the disease itself. just like if you're diagnosed with high blood pressure your doctors telling you you have to lose some weight. there is a ton of behavior change that comes with the most chronic illness, and

high blood pressure is so common. some of us are being treated for now. i think what we would want is to be treated with the medication that will be most effective for us and given the opportunity to in the education necessary to change our lifestyles. unfortunately socially and culturally the way we elected medication is kind of a treatment, frames the treatment of last resort. if you have gone the rehab and it hasn't worked and you have done it you are just going to have to go on medication. that is not how we look at your blood pressure. this put you on medication so you don't have a stroke and damage your kidneys play is some of this weight off and i had a control your stress. unless the f -- the attitude we need to have. get on it to get your ducks

in a row. i still have my little wooden ducks. are your ducks in a row yet? so the medication, i medication, i won't go into a lot of these except to talk about the difficulty that we in the people we interact with can have getting oura heads around the idea of giving and opiate to an opiate addict. it is intuitive, not where you would expect to be going. that as dr. comptondoctor compton was laying out, if you get on the right dose -- like take methadone, a methadone, a full agonist. the more you take a more effective has. if you get on the right dose it controls are withdrawal so you can stay engaged in treatment and function, function, but it

also builds of the receptors and keep some sort of on an even keel so that you are not constantly being driven to use but also your receptors are full. there is no place for them to go, no receptor for them to bind to the reward you for that.that. so your more likely to be able to go that didn't pan out and move on with your recovery instead of the old paths out of the tub. even more free and is a little different because it is not just about the dose and the right range, saturating the receptors. it is a little bit bad. people morphine has this process of binding so tightly that nothing else can compete. that momentyou no might be able to come up with most of what people take on the street is not going to be

able to budget. thebudget. the beauty is when it is bound to the receptor it doesn't fully stimulate the receptor. my receptors are not so busy. i don't need as many. and that isand that is where it is able to reduce tolerance over time and that is just a cool pharmacology aspect of the drug. if you're really geeky you will enjoy that aspect. now,now, the antagonist of course gets on the receptor, buys it, makes it impossible for any of the effect. it gets trickyit gets tricky because you have to be completely free of opiates. if that blocker goes into your body and riffs all the opiates often receptors in blocks them up you will wish you were dead.

so the process of getting on it as a couple of steps. how your going to keep them safe and get them from my want treatment .-dot treatment, the pathways a little different. hopefully i have not confused anything. this is the clinic i was medical director of. there is something inherent about methadone that requires of the administered in an ugly dilapidated building. that's how we have decided it needs to be done. broken glass block the medical director's not an

exaggeration. something about how we view if you went and found your neighborhood methadone clinic it will look different. certainly not where you want your kid are your nephew. we have 1400 of these programs the united states, mostly providing only methadone. they are subject to regulation, given a controlled substance to a drug user is a somewhat high-risk undertaking. so it merits some careful attention.

unfortunately some states have chosen to prohibit the opening of further opiate treatment programs. other communities have decided that they have to have special zoning which is a big parta big part of how you end up in the building. so if you want to find out everything they have but how to open a note to p comeau what goes into it, how they are regulated by how they get accredited, what you have to do to operate and opiate treatment program, we have our website here in the resources for your providers in the program staff. >> i saw the same patients here. on the 3rd floor the lights are on. this is where you might really rather go if you

needed treatment for opiate use, probably where you would rather your friends or family went. your standard doctors office i spent about five years are doing primary care and treating people nor free. i did use oral no caps on. i did not adopt the use of the injectable because for me the costs outweigh. it was just more than i could do, butbut i did have people who came out controlled setting for the treatment or incarceration to whether they ended up later is irrelevant but wanted the option of being blocked and feeling a little bit like -- having a little bit of your thumb on the scale of choosing not to use , and reused -- one of the patients is now a drug and alcohol counselor for my parent institution and

father of a one -year-old doing exceptionally well. other important thing, since it is not a controlled substance they can be prescribed by any health care professional. advanced practice nurse, physician assistant. it does not does not need to be provided in the context of a program. ultimatelyultimately the person would be better off receiving additional services. here are a couple of resources for you. again, medication assisted discusses all forms of inmates he including abstracts on, and then we have a publication that is solely devoted to it that you might find useful. now, we recommend the form that is combined with locks on the primarily what is used except if a person is pregnant and then we recommend only the people

nor free product which has few interactions with hiv or hepatitis c drugs which can be used in pregnancy does not require detoxification and is available in generic form. now, methadone does have a fair number of drug to drug interactions. you have to have a little more nuanced management. the peoplebeeping offering provider at this point in time has to be a physician, so your advanced practice nurse npa may be able to provide support that cannot prescribe it. the limitations that we work under now are you can treat 30 patients in your 1st year, 100 of time thereafter it is widely covered. we recommend providers who approach us about concerns about not being able to meet the need for treatment in the community, we recommend they become and opiate

treatment program because they can then treat as many people as the stable license and forth and can treat them with you pinoy friend. it does not have to be methadone. so we do try to encourage people to take that option if they are feeling unduly restricted by the current patient limit. i will skip going into a lot of detail but.out we have separate resources about how your physician providers and committee can become waivered and now theyhow they can learn what they need to know about how to do it command i will tell you in closing that i treated -- i work really hard to try to convince my colleagues when i was in practice they should be doing this as well and heard all the time, i don't have any of those people in my practice and i said, well,i said, well, i just took two of your patients from your primary care practice who changed to me because they needed treatment.

that was unpersuasive. on the other thing was i don't want those people coming to my office. well, you already do because i just took two of them. so i cannot help but think my congressperson coming to me and my county medical society our state medical society or to me as the dr. and saying what we have a public health crisis but think of it as a cholera epidemic and do something. that's my pitch to you as an individual physician and i will send it back to you for further introductions. should have slides coming up. >> thank you very much. i would like to introduce our file. i would like to introduce doctor jessica pierce associate director of addiction treatment at john hopkins and associate

professor in the department of psychiatry and behavioral scientist at johns hopkins university school of medicine. doctor pierce has providedç direct patient care and supervise the psychosocial treatment of over 400 patients with opioid dependenceç. her treatment modelher treatment model has received awards from the joint commission and samsung. her treatment services research is designed to improve the uptake of and adherence to evidence -based treatment for opioid dependence. i would nowi would now like to recognize doctor pierce for her presentation. >> thank you for the opportunity to speak today. i am heartened by the great interest in the problem of opioid addiction and efforts to create solutions. i think it is a nice balance because i am actually not a prescriber. i will be talking about medication. i will be talking about the other aspect of treatment that were mentioned. i am a clinical psychologist.

and i am here on behalf of the american psychological association today to represent providers of treatment for opioid addiction and clinical researchers who work to improve opioid addiction. youyou have heard today about many effective treatments available and the need for more treatment, and i agree completely with those points.points. i want to add that we can actually improve treatment further. i want to review three ways that we could improve treatment, and i will give you examples of how. first, we can and should increase treatment enrollment. we can and should increase the amount of treatment services patients receive was there in the treatment program. third, we3rd, we can and should increase the use of evidence -based care, treatment that has shown to be effective for addiction and other problems related. talking about increasing enrollment, we have been

fortunate to work with the baltimore syringe exchange program since its inception in 1989, much of the research of which has focused on using contact to increase motivation for opioid addicted men and women. syringe exchange staff regularly encourage addicts to enroll in treatment, but that runs about 10 percent. we tested adding a brief motivational session to that referral and could triple the enrollment rate. we then added small incentives to the brief motivational session which included prepayment and that increase the rate by half. we were able to increase treatment enrollment from 10 pee exchanges to 50 percent with a short low-cost intervention without adding treatment.

pass as already been mentioned patients often drop out of treatment because treatment is hard, patients have to change a lot of their behavior, a lot of their environment, even the way that they think. the drop out of treatment. they really do want recovery. it does not mean they don't want to be drug-free. human beings just have a hard time making big changes. after all, it is only january 11 and how many americans have already broken their new year's resolutions? opioid addicts who dropout need to be able to return to treatment and return quickly in our work the motivational intervention on the right that a lot of dropouts back into treatment within three months, but we more than doubled up with the addition of an incentive. passing syringe exchange is getting most of them back into treatment, we can and should make that happen. once they get the treatment

they need to get the most out of this both the adaptive step was systematically varies the intensity and the amount of treatment based on objective indicators. and we tested it against the standard care treatment in our area which is one counseling session per month just as with treatment enrollment because you offer doesn't mean that patients needed. they develop 30 percent. with adaptive care we increase that by over 50 percent. scheduled for up to 36 counseling sessions per month. does that increase the amount of treatment? it does. you can see patients in standard care, 30 percent of

the urine drug tests were negative for all drugs. they boosted it even further. negative drug trust -- drug tests early in treatment with a structured treatment model applied uniformly. adaptive step care is the cost neutral intervention command the incentive has a favorable cost-benefit ratio. we can improve treatment outcome but increasing the amount of treatment received by the patient. i want toi want to mention the 3rd line that focuses on expanding the services available. opioid addiction. 25 percent of patients

having this disorder. he completed a small study we offer a gold standard treatment called prolonged exposure. allexposure. all participants were offered prolonged exposure in the clinic by providers that they knew. participants said that they wanted the treatment expected to attend the treatment. one group was offer the treatment and the other was offered a small incentive to attend the prolonged exposure session. the left graph shows how many each group attended. those simply offered the treatment attended with a median of one session all those offered the incentive and a treatment attended a meeting of nine out of ten. the order of magnitude improvement. inin the greater amount of treatment resulting greater outcome? yes. even a small study the proportion of patients with significant improvement more than doubled in the group who attended more sessions, not terribly surprising.

see more treatment get more benefit. we have expended follow-up study and review now which shows that we can offer evidence -based care and maximize the outcomes of that care with relatively little effort and some as both the treatment provider and a clinical researcher we have great treatments for opioid addiction and can make them better may increase opioid treatment enrollment and exposure to treatment services and offer more evidence -based care for addiction and related problems. we know how to improve treatment and we should. >> thank you very much. we are 1st going to yield to the gentle lady from indiana. >> thank you to my colleagues and thank you so much for being here. i appreciate it. i wanted to turn specifically to the number one bill that i dropped

which many on this podium appear will be a part of and i am interested -- i will direct this to the dr. dr. because we have an issue in this country with every single thing you are talking about, opiates, overprescribing and the like of suicide and accidental overdose, potential overdose of veterans. some of us up here sit on the committee and i am in the midwest and indiana and northern indiana. andy is on the east coast, but the unbelievable issues that have arisen now with the overprescribing of veterans drugs literally on the front lines looks like in our offices where we do casework my why veterans, my office of all ages, not just young veterans have experienced iraq and afghanistan but chronic now senior citizen aged the amount veterans facing a lot

of the same chronic problems coming in with boxes. they will have 2nd tropics, opiates, you name it in there in a variety of different kind of boxes and models, no problem whatsoever and come in often times with their spouse literally begging and crying for help and don't know what to do. i have a bill that we are filing to bring in more transparency and accountability into the va system itself which cannot at this point be controlled from within. our job becomes the issue of putting pieces together to start patrolling in association with the dea. what do we do to turn this off as quickly as we can so that there is giant flow stops coming out the doors because it has created a 3rd ring of drugs and the communities which are opiates and psychotropic drugs. kids have parties and the drugs show up.

the overdose drug is coming to the rescue. the best and brightest recruited to defend our country and this is what they have been given. have a bill that will be fast tracked that says if there is a state prescriptive database they have to go in so that another set of eyes can be looking and tracking immediately. my question is have any of you looked at or been involved in this issue of the gigantic increase in numbers due to so many of our veterans trapped in a system that really is not evidence -based but has been this way a long time and have been refusing to look at any kind of evidence -based model? heavyhave you come across the issue of this cross connection? >> two key issues that i hear. one is the excess prescribing opioids for many

painful conditions, and we have two intersecting problems. one is the issue around chronic pain in the 2nd is the overreliance on opioid to treat the pain. there are other approaches. those show promise and may do as good or better for many of the painful conditions for which clinicians ever gently reached for the prescription pad. integration, va records that are robust, have information from all the sources whether

it is the va or the indian health service or others that might be outside the traditional reporting mechanisms. it brings up the other idea, how we link them across state lines. it is a major issue lacking go 5 miles in them in three different jurisdictions with completely separate systems. ..

>> it will be easier to write a prescription for on opiate than to go through the process of actually doing the work. >> i appreciate and with that i yield back. >> just as a reminder to each member so we have enough time we will stick to the five-minute rule. i would like to recognize myself for five minutes. thank you were being here. i would like to start with dr. campopiano. you talked a little bit about the differences between the alternative prescriptions that are utilized whether it is

methodone, nordon, or the naltexrone. it appeared to me unless i misunderstood it is is the rational or reasoning based in law? it looked like there was a slide you had that there was a specific amount doctors are allowed to prescribe in a period of time. did i see that correctly? or a number of patients -- i think a limitations on the number of patients. >> i think you are referring to the law as it applies to narcan. it is limited to physicians at this time and a physician can treat up to 30 patients at any given time for the first year they are approved to prescribe the drug and then treat up to a 100 patients there after.

>> that the narrowing the ability for thepation to access the drug >> it is narowing in that program. -- narrowing -- he could be able to treat as many patients as he or she could be licensed by the state. >> and how is that physician treating what model makes sense for that patient? >> to the extent of choosing the right medication for someone

should be what drives what someone get. but because treatment programs where you think only get methodone or centers for the other drug one comes from a program or a physician's office. there is no one place to go and say assess me and give me the appropriate system. the system is chopped up because of the way the system is regulated. >> are you suggesting we modify those rules to allow one-roof treatment or management for a familiar diagnose.

>> who determines the length of treatment? who monitors for statistical purposes how long someone may be in a treatment facility? how long is long-term patient care? >> that is a really important question; how long should someone be treated for their opioid use disorder. we think some form of management and supervision should go on for a long time. this is based on how they are doing and functioning in the rest of their life to make those decisions >> as someone who was on long term for several years is that patient weened off the medicine? >> it is a one answer. if is a 17 year old who just

started six months ago you would not think about life time. but if it is someone who is 40 and been on it for 25 years it is a different case. >> are there other pharmaceuticals being considered to expand the treatment options? >> i highlighted two. one that is very much on the almost ready for release, we hope, in terms of the long acting nor phene and a vaccine might be a novel approach we can bring to existence in the years. >> some coming shortly and some other within the next year or two? >> i would not say year or two for vaccines. that is longer term. >> my time is about to expire so i will yield to congress woman kuster. >> thank you so much and thank you for your testimony. just briefly back to the question dr. campopiano.

what is the public policy behind the limit of 100 patients? we live in a very small state and there are not a lot of choices. we only have a handful of providers who are offering this treatment and it seems to be successful for the patients that can get it but most patients cannot. i am wondering what is the downside of congress eliminating the cap or raising the cap to 200 patients? >> well it is a complex question but an important and valid one. the quibbling is th-- the certa is that inadequately trained provider could just run a pill-mill type program and

resulting in medication available for misuse or accidental exposure for people that don't use opiates or children, for example. i think that was the rational behind the original limit. and maybe the idea was this should be integrated into primary care or general psyc psycheatric care. this is an alternative to the opiate treatment provided where that is generally the sole service and is a marker of why you are there. if you were able to go to your community mental health program or your regular doctors office and that person was seeing a

substantial handful of people you could blend in and not be subject to bias or stigma because of your addiction. that was the thinking that i think went into the law some years ago. and then after it had been in effect they did add the additional after you have been doing this for a year and you have experience you can go up to a hundred. but we know what is going on is there are groups of providers that are getting together and each of them with their hundred patient limit, and not necessarily doing a good job for patients, and causing this to be available for diversion into the community. >> thank you. i wanted to direct our attention to narcan because that is of wide use in new hampshire. you are right. it is a miracle. i have been on rides in a number of my communities with first responders and they describe the reaction to the administering of

narcan and the person coming back to life. the challenge that we are having is that narcan now has created unintended consequences. our state legislatures made it available to anyone. and the purpose being for family members or, you know, loved ones who know someone with an addiction. the challenge is that now our first responders are literally responding two or three four times and administering narcan to the same person. and i am wondering what the preferred protocol would be and how we can avoid the situation where it appears we have people using the narcan as a backup safety for a bigger high, if you will. >> do you want me to speak to that?

>> yes. or dr. campopiano. >> do you want ant opportunity to speak to this? -- an -- >> i think we both may have insight into this. one of the issues is we do need greater information and data on who the overdose patients are, how many times do we see them reoccur, and we have very little data that follows the patients. so the idea of it being over and over again is something we are hearing but we need to understand how often that happens. i liken it a little bit to if i had a patient with diabetes who had trouble with excess blood sugar or low blood sugar might call ems frequently and as a clinician i would say i need to consider what to do for the patient. and narcan is just a first step. it is not treatment. that is how you save someone's life and keep them from ending up in a medical examiner's office and allow us to have the

opportunity to intervene long term. the real question is linking them with a long-term treatment. >> thank you very much. i will yield back. >> thank you. yield five minutes to the gentlemen from main mr. poliquin. >> thank you. i represent north central and down east maine. i am also a parent. i raised my son from the time he was in diapers as a single parent and i love him. al of the parents across the country are scared to death about this issue. i don't know a family who hasn't been affected by drug abuse, alcoholism, or knows a family that has been.

can you tell me are individuals born with a tendency toward addiction or does that come through trauma and other things that folks might experience during life? >> short answer, yes. all of those things. >> all of thes things. >> there are risk factors that increase the risk for developing an addiction but not everybody has the risk factors. >> if one doctor experiments with opiate -- if someone, doctor -- are they on the path for permanently damaging their neurologic function? >> i will yield to someone about the neuro logical function but i will say once someone uses

narcotics the chance of developing an addiction increases but it is not a guarantee so it is important to intervene. the shorter the drug usage is the better the process. >> can you paint for us on the committee and the parents listening around the country is there a profile you could paint for us such that moms and dads and aunts and uncles and grandparents can look at these kids and say these young adults have more of a tendency to become addicted to drugs and alcohol or not? >> i don't want to say there is a profile. but a history of substance abuse order, whether it is alcohol which is the most common use of

substance disorder, can predispose generations. early exposure to things such as cigarettes can be a suggestion that an individual is acting on some biological or genetic impulse to alter one's state of mind. >> is there any that shows folks will have a higher likelihood? >> we have not unravelled the genetics issues. we know with tobacco certain genes that put you at a higher risk but we have not solved that when it comes to opioid

addiction. there are ongoing studies to unravel this. >> dr. campopiano, you mentioned in your opening remarks some issues dealing with incentives. for those folks that you treat, who are in so desperate need of our help, what are some of the incentives to help them along the path to recovery? >> it is so highly individual. >> give us a few examples. >> well, for example, you would think that loosing everything would be an incentive, but it is not necessarily. you can lose jobs, you can louisiana your home, you can lose the trust of your friends and namly and still not be able to change your behavior -- family -- >> what i am looking for is the support these individuals need from their families and friends. it is so heart breaking and

destructive to our families in maine. give us some hope what these families, friends, and support groups can help these addicted individuals with when it comes to incentives. give us a few examples, please. >> the desire to be the parent or the son or daughter you set out to be at one point, the hope that that can be created for you within your family again, the knowledge that people are not going to give up on you or throw you away. >> there is so much, if i may miss chair, there is so much that has been discussed here today about post-detox meds that help folks get back on their lives. but what if somebody is non-compliant? how do you engage someone like

that such that you see there is an incentive for themselves to be compliant? how do you do? dr. peirce? >> i think families can do a lot to encourage individuals with opioid addiction. i think one thing they can do is insist patients go to treatment. they can refuse the give the support a family could give. we call that enabling. >> tough love? >> yeah. if you give money to someone who is addicted you are more likely to treat the addiction than the treatment. understanding the availability of treatment and insisting treatment is necessary and if they leave treatment and all of the love and care can go toward promoting help instead of promoting poor health. >> my time is up.

thank you very much. >> recognizing my colleague elizabeth from cunonnecticut an my colleague from maryland. >> thank you so much. i am going to yield 30 seconds to john. >> very quickly, i represent baltimore city. you alluded to it. it has been an important place for research and progress on this. i ask that you submit potentially in writing, if that is an opportunity we have, through the process here, i am very interested in this idea that we treat this as an epidemic. you alluded to the cholera epidemic. i would like to look at other epiwelco epidemics and how we responded and look at that. if you could submit that would

be wonderful. >> thank you very much. i want to thank you the three of you and i want to thank our cochairs of the task force and all of my colleagues. in connecticut we had over 300 deaths, a small state, in 2014 and my district has been the epicenter of that. i started working in 2009 on these issues with the abusive prescription drug. this is of grave concern. i couple questions i want to lay out and hopefully get as much response as i can on the record and follow-up. dr. compton, you and i talked a little bit before hand. can you talk about what we can do to right size opioid prepscription policies? i look at my kids who got 30 pills when they had wisdom teeth extracted which was the same mount when my brother and law had his hip shattered be got. that makes no sense and we need to right size prescriptions.

is there research being done on alternative pain management? are the drug companies doing research on less addictive, non-opioid or opioid but less addictive prescriptions we might be able to use for pain management? and for dr. peirce, if you can talk about how we can better dissiminate best practices. we talked about we know what works but it is fought being used everywhere. we up here want to get the information in the hands of your communities, our states, and the people we represent to save their lives and to be the parents they want to be, to be the children they want to be, to have a bright future. look forward to your responses. thank you so much very. >> as you mentioned, making sure

the number of pills prescribed is the number people need is a key ingredient in all care. having opioids leftover in the medicine cabinet can provide an incentive for diversion or misuse and addiction and abuse at that point. an opioid treats the pain and there are some people that can not tolerate ibrophen but it

should not be the first choice. we have very few studies to help guide that decision. so the boundary between when non-opioids should be used is not as clear cut as we would like it to be. the nih has a number of studies for alternative approaches. mindfulness training, physical therapy, other forms of non-medication treatment for chronic or acute pain. when we think of non-opioids this is a very large market. there is an awful lot of people with pain whether that is short-term or long-term pain. it is a lucrative market and there are a number of companies looking for new products in this area. that is just a quick version but i certainly agree with the idea

of right sizing prescriptions is key. i wish i had a clear answer for every clinical condition but why don't so we are working on making that better. >> speaking to the question of increasing evidence-based care from the policy side i think you can inform people of the evidence-base care that is available. you can expect it. you can bench mark treatment. you can say i need to see what your drug use rates are, i need to see how you treat your patients, and you can help to reduce stigma in seeking treatment. it is so difficult. part of the reason methodone clinics look like what you saw is people don't want them in their neighborhoods because people think they are terrible people. we need to increase that to increase treatment. >> i now yield five minutes to the gentlemen from pennsylvania mr. rothfus. >> i want to thank our co-chairs for organizing this task and doing all of the work on the

staff on putting this together. i thank the witnesses for coming in today to help educate us and the american people about what we are looking at here. a couple questions. dr. campopiano, you use the term idu, injection drug users. i want a point of clarification because from what i understand heroin is not -- it is injectible but snorting and smoking is going on as well. i am wondering if you educate me a little bit about what percent of heroin is being snorted versus smoked versus injected? >> i don't precisely know the percentage for each route. i will go back and see if i can find a specific answer to that. we know all of those routes are commonly used. it is typical an addict may

progress from the non-injection routes toward injection. injection of course is more efficient as a drug delivery system because it gets into your body quickly and more completely than when it is taken my mouth, snorted or smoked. all of those routes can be used, though. typically people start out with snorting or taking it my mouth is their first way of using almost all of these substances. >> when you talk about idu it is a drug that can be injected but is delivered through other uses? >> injection drug use means that specifically but typically people who use drugs by injection also use the other routes of administration. >> are you satisfied with the current prescription guidelines

for opioids? i was talking to a friend whose son had a shoulder surgery and they gave him a 45 day supply and the mother didn't think that was appropriate and asked for less. this is being looked at. can we expect changes in guidelines? >> first off, you have to remember guidelines are just that. they are not rules or regulations. they are advice to physicians or prescribers who will interpret them on their own observation. we see that opiates are overprescribed in many settings. finding ways to teach clinicians about smarter way to approach patients and get them down to the minimum that is needed rather than the maximum they may require. >> dr. campopiano, this quote "i

don't have any of those people in my practice" when you talk to your colleagues, i guess i am looking for protocols perhaps that might exist on the counselor side of things and informing physicians. under 42-cfr regulation, c confidential drug treatment papers are kept separate from the primary care physician. are there protocols in place where someone comes in for counseling and the counselor knows they should ask the patient whether they would like this to be community indicated to their pcp the >> there is two approaches to that situation. one is that particularlyhen you are prescribing

medication-assistance treatment the treatment provider has an obligation to coordinate care for the safety of that person who could be treated with drugs that would interact with the opiates or be dangerous with the opiates if they are prescribing methodone for the opiate use disorder the other treating physician should know. the treating physician or other prescriber who is treating the person's opiate use disorder does need to coordinate care. they must have the individuals agreement to do that. there is matching responsibility to ask about and identify substance use disorder.

>> as these programs are certified are there any effe effectiveness requirement that has to be demonstrated? how do we measure the effectiveness of any one of these 1400 programs? >> the understands of the outcome is limited. >> is there a consistency among the certified program looking at the medical side, the counseling side, would you expect to go to any one of these 1400 certified programs in the country scheand the same model? >> i would. >> dr. peirce is shaking her

head. >> i would at the bases of it because these programs are accred accredited by private-non-profit organizations in addition to being certified by the federal government. we at samsung don't have the staff to go visit every program they are required to be accre t accredited by non-profit organizations every three years. >> thank you. and i would like to recognize my colleague representative norcross from new jersey. >> i appreciate the chair putting this together. we are talking about the disease of addiction. it is complex, long-term, and not one-size-fits-all. when we look at this, a former colleague patrick kennedy, compliment him for bringing the

d d disease out of the closet. the heroin and opiate epidemic was thought to be a urban issue but now it is in the suburbs and families are in a difficult situation and it is creating havoc for families. new jersey, we did the mobile methodone clinic. we did the needle exchange. are we enabling them? >> we are trying to save your lives and had that moment in clarity. maybe it is one time. maybe it is five times.

what do you consider recovery? six months? six years? 60 years. i am not hearing the discussion on what is considered a win. >> there has been interesting work looking at when can you say someone has a likelihood of someone staying clean for year.

even then i cannot give you a guarantee. >> if you can function at the pre-drug abuse level or as close to it as a parent, a responsible adult child able to take care of your older parents to fulfill those social roles and newt be defined by the illness. how long it takes and what shape

is takes is very individual. what resources someone needs to get there is going to depend on how far they got from their previous level of social function, whether or not they have a criminal record or whether or not they are closed from there and being able to be a housed person who can fulfill your roles in your family are what makes them recovered. >> would you consider them at-risk for the rest of their lives? >> i think coming from the point of view of a physician, yeah. it is like if you had cancer once, i will consider you a high relapse. i might say it is five years and you are cleared but i will keep a close eye on you.

>> thank you. dr. peirce? >> i want to say it is important to recognize whatever recovery is for a given person people can live well in recovery. someone needs to say i am in recovery and say i am doing great. or say i am in recovery and things are starting to feel like they are slipping. how can i get better? the importance is thinking about themselves as a person who is living well in recovery. >> and bringing it out of the closet and that is what this hearing is doing. i yield back. >> i recognize the gentle lady

ms. com stalk. >> my district is in northern virginia and stretches out to the border. and now it is moving east and we are seeing it throughout with several task forces we are working on this. one of the things that have been the most difficult things, so many of the things, i cannot say what is most difficult but one truly heart breaking thing is out in our hospitals and in the neonatal unit seeing babies born addicted and the very difficult treatments and things to get those babies okay when they have that situation. i know there is a little bit of mention of how to treat somebody

who is pregnant. if you can, what are the best practices? we have pieces of legislation to look at best practices for that. >> there are two key issues. one is how do we prevent that exposure to opioids and get pregnant women into the treatment when it is identified. but the other issue is to improve the treatment for the newborns. but then the second is not to think that it ends right there because there may be long-term issues for the family that need attention. so what are the supports for the infant as it grows and develops

in that household? those are the long-term issues that need to be attended to as well. >> i think the important think and sometimes challenging thing is that pregnant women with opiate use disorder need to be on medication assisted treatment. at this point in time we don't have evidence for safety with the use of naltexrone so we cannot recommend it but methadone is safe. women are encouraged to seek treatment when they are pregnant and get off the treatment after giving birth and what happens is they relapse. and just because the baby is on the outside of their body doesn't mean that baby is in better shape to endure parental relapse than during the

pregnancy. so watching out so we have policies in place to make it easier for pregnant women to receive treatment, services for the treatment and the parent, mother and father, and making sure that medication-assisted treatment is delivered in a child-friendly way which is hard because we are cautious when prescribing something to ingest we typically don't want children involved. really and truly encouraging breast feeding among opiate dependent women who are stable on treatment can improve the bonding and parent-child relationship. >> there is no problem there for the baby with the breast milk? >> well the medication is

generally in the breast milk to a tiny extent and this may actually help mitigate the with drawl for the infant. but the mom has to be stable. she can not be using any other drugs and care has to be taken with whether she might be on medications for other medical conditions when the decision to breast feed is made. >> i recognize mr. costello. >> thank you. i can say from my experience i used to be a county official usually what i would read about as it relates to the heroin

epidemic related to policy making from the law enforcement side or the treatment and recovery side and what i would like to ask you for your feedback on and i ask this with a constiuent in my development who is working on abuse deterrent oxycotin project. and what are your observations with respect to preventing certain instances of opioid abuse in the first instance by designing these drugs, which many do have a medical value, but designed them in such a way to strip it of its euphoric

affect so we are not introducing certain patients to potential abuse on the back end because they never experienced the euphoric affect on the front end. i would like to have it be open ended for all three of you to comment as you find appropriate. >> the development of abuse deterrent formatiulation could helpful but it will not eliminate the reinforcement people get from the oral form. that is one of the shortcomings of most of the current technologies. i think we need to keep looking at pain killers that are effective but don't produce at all the intoxication or reward.

that is different from making sure it is dissolvable and can't be injected. it has to do with how our brains work. >> i will say from the clinical side this is something we deal with in the medication assistance treatment program. there are many treatments out there for pain. our patients still have pain even though they are on methadone. we use a lot of non-opiate receptor medications that are more helpful and do not run the risk of abuse when people have very limited acute pain they might need opioids even on methadone. we coordinate that closely with the prescriber. there are lots of ways to manage that even for someone who has an

addiction already. >> i think the other piece, and the technology is very exciting, and i am sure there will be a place for it. i think the other piece is that how providers are educated and people are a broken bone for example didn't want additional opiates thinking it would compromise their recovery. it was hard finding providers to work with what the role of the pain was and other ways of coping with it instead of throwing a prescription at it.

>> when you spoke about the technology being exciting or the potential for the technology to be exciting can you espound upon that more? >> maybe i am just a science geek but i think the idea that you could have a drug that should it fall into the wrong hands would not be abusable is an exciting reality of where we are at with technology. it is a plus. it probably is not going to be the only solution that needs to be part of the solution >> i am not a science geek. but i find it exciting, too,

particularly when you read about the number of stories of those who have been caught up in this absolutely terrible circumstance; the abuse and consequen consequences of abuse and would have never been there but for being injured, having pain in the first place, and having it be in a downward cycle there. i share that with you and i look forward to learning more about the technology and hope, i think we all hope, that we will continue to progress in a way that will enable those opportunities so we can avoid some of the abuse that does occur. i yield back. thank you. >> i thank the gentlemen. i would like to recognize the gentlemen from maine. >> i would like to further explore some of the issues we talked about a short time ago if i may. we are all in the belief, i am sure, that government -- one of the primary jobs of government

is to show compassion for those who truly need our help. let's say you have a terrific young adult that is doing well and is learning a trade in a community college and is living at home and for some reason somehow gets wrapped up with the wrong people, parents tend to say that, right? the wrong people or mixed up with opiates or alcohol or what have you. and now the parent is in one heck of a mess along with the child. what do you do? how do you not enable that child? let's say the child goes through treatment. we know that dealing with individuals that need help they first have to recognize they need help, right? after that make sure they go through a process to get the help and when they get out of a

detox situation make sure they have ongoing treatment based on this discussion in this area. what if this individual falls back and you told us here today the probability of that happening today is quite high. let's say you are a garden and you take your daughter -- guardian -- or son or the person you are supposed to help and you take them out to lunch three times a week to make sure they have something good in their belly. and they show up at lunch clearly high. we have talked about the treatment using drugs and so forth and so on but what about the support system? this individual may now get assi assistance for housing, clothing and a small cash aall -- a all w

allowance and you do you make sure they stay on the path to recovery so they don't slip back? and how does that support group, that is so important for the individuals to recover so they are productive and have the d dignity of being on their own, how do you help them? what support group, dr. campopiano, is available out there? how do you help these people? how do you help the support group to help these people? >> well there is the well known 12-step recovery movement that has helped more people than i think we can possibly know. that can't be over emphasized and it is fully compatible with m medication assistance treatment. a more formal peer recovery support model has been

demonstrated to be effective. we have somebody who has been there. and you can call them up and say this is what i did when that happened. >> do you think government programs designed to help these folks we love so much and want to help so badly do you think they are designed to make sure that the individuals have incentives to follow a path of healthy behavior? >> that question might be a little bit broad but i think so. >> good. >> the challenge i think is that we collectively live in a society that tudoesn't really d that. if we have a program for a new hours a day or week you get encouragement and go out in the

wor world, you treat people, folks on a private-practice bases. let's say one of your patients comes in and has been following a regimen of treatment but comes in high. or missess an appointment or two. what is engrained in our programs to hold that individual accountable to get them back on track? >> i think that it is honest confrontation of behavior. as the treatment provider or the health care provider and you are unprepared to deal with it, feel it is less scary to ignore it, or send them away and let them

come back when they are sober and pretend it didn't happen you are doing a disservice. >> it seems like we need a little bit more focus on the programs we provide to help the providers make sure they hold these folks accountable for healthy behavior. >> i agree with you. i think we have models like dr. peirce focusing on the step care model which are evidence base approaches that so you can enforce rules in a consistent way that is not punitive but is expectable and predictable and sets limits on behaviors. it requires monitoring for infractions of the rules so appropriate drug testing and observing behavior. these models are well done by drug courts and others that combine an opportunity for close monitoring and enforcement along

with the compassion and services that people need. >> thank you very much. i appreciate it. >> thank the gentlemen from maine. i mind like to yield two minutes to the chair of the task force to the gentle lady from new hampshire. >> thank you to everyone participating, from colleagues to the panel. this is a challenging topic around the country. the rise of heroin-related deaths is staggering. we need to educate ourselves as legislatures and educate the communities so people begin to understand the elements of prevention, treatment, and then life-long recovery. and the resources that are needed in our communities. this testimony is demonstrating the challenges that we face, treating patients who suffer from substance abuse disorders

but also areas of promise. i think there is hope. i was an adoption attorney for 25 years and one of my clients many many years ago had a truly remarkable and very challenging circumstance and i was able to be a part of her life at a time when she took control of her life. but she called me today, she not only web in recover for eight years but she is opening a center -- has been -- for women to be able to live in recovery in a safe space and get the resources and support they need. i am very buoyed by that story and many others of the people i have met; people themselves who have been in recovery for a long time and are now coming to the floor to address the challenge.

the epidemic struck across gender, race, socio economic lines and partisan lines. i look forward to working with my colleagues on the task force to combat the heroin epidemic, to introduce legislation and build upon the ideas for best practice and how we can encourage more treatment with scientifically-based, sound performance guidelines, how we can deal with these issues around prescription medication, and making sure our prescription drug monitoring is robust, the stop abuse act includes a provision for interstate compliance with prescription drug monitoring because we are in a small state surrounded by there other new englang lenengl

and have learned from hospitals and physicians that people are shopping across state lines if you will. on a number of fronts we can work together and work with law enforcement with health care providers and start to bend the curve as you said dr. compton. those were dramatic slides and i hope we get a chance to get them up and share with the voters and folks across the country so people understand the urgency and understand the steps we can take within the next six months to make a difference in their lives. >> thank you. i would like to yield myself two minutes as well. first, i would like to thank dr. campopiano, dr. compton, and dr. peirce for taking the time to inform us as members and interested in the epidemic.

i would like to thank the cochair of the task force, congresswoman kuster, as well as had members of the taskforce. -- task force. more and more members are thankfully understanding the concern, not just from what we are accomplishing here in washington, but from their voters as well. i think we learned a whole host of new ways we can help the prescription side of this particular issue. as we continue to look at legislation, and how we can help at the federal level to integrate what we trying to do with the stop abuse act, we may call on you for that challenge. one of the key components i see is eliminating the stigma. i have a family member who has a mental illness and the stigma

associated with a mental illness is just as bad as substance abuse. it is something we have to continue to inform and make people aware this is a disease and something we can attack and help. i also, in a hope this year we can pass the stop abuse act. there are several components of the act that i think would dramatically and immediately help those who are looking for a way to assist themselves or their family members in a way out of the deep dive they are in. we also do have to inform those in our districts and around the nation of how persuasive this epidemic is. if you think about whether it is from a national perspective or new hampshire perspective, heroin abuse into the united states has reached unprecedented levels increasing 61% over the last decade. when you see an increase that quickly you would consider that a national epidemic.

new hampshire alone we have doubled from 2004-2013 the number of state-based inpatient individuals to 1500. we have had thousands of overdoses just in the last year and 400 deaths related to drug abuse and drug overdose. i am interested, and i know chair kuster is also interested, in not just solving this crisis but anticipating and planning for the next one so we can be as proactive in saving as many lives as we can. i thank you for the time you have given us today. we will be announcing the next hearing in the coming week and look forward to working with each and everyone one of you in combating this heroin epidemic. our time has expired for the afternoon. thank you for being here. we are now closed.

called attention to what they see as red flags in the low numbers of assaults reported. from the national press club this is just over an hour.