this morning to the committee on oversight government reform, and to a hearing which is entitled america's heroin and opioid abuse epidemic. i would like t to welcome our ranking member, mr. cummings, and all the members, and our witnesses this morning to this hearing. and called the hearing to order. without objection a chair is authorized to declare a recess at any time. the order of business this morning will be as follows. we will begin airing with opening statements from myself, the ranking member, other members are welcome to submit opening statements. and with mr. cummings support we will leave the record open for -- how many days? five days, legislative days, for

additional comments or statements. without objection, so ordered. and when we complete the opening statements we will turn to our panel of witnesses. we have five distinguished witnesses today, three at the federal level, one at the state and one of the local level for our hearing. we will swear those witnesses in and then we will hear their testimony, and then we will proceed with questions. so that will be the order of business that we will follow. so again, welcomecome and i will start with my opening statement. unfortunately, the united states is experiencing a historic epidemic of drug overdose deaths. today, drug overdose, overdoses are the leading cause of accidental death in the united states.

in 2014, i don't have the 2015 figures yet, but in 2014, listen to this, 47,055 deaths caused by drug overdose. that means that this hearing lasts for two hours. 10 people will die in the next two hours in the united states from drug overdose death. more americans -- this is a little chart showing the increase since 1999. remember, i chaired criminal justice drug policy oversight subcommittee from 98-99, and we thought we had an epidemic back in 99 with 16,000. and i can show you some of the headlines from my local newspapers where we have people dying in a, many people dying over a weekend. unfortunately, that's what we

are seeing again in my community and across the united states. unfortunately, more americans have died from drug related overdoses in one year than all that were killed in the lengthy korean war. if the current trend continues, the annual death rate could climb beyond those killed in vietnam over that multi-year struggle, in one year. the carafe from the "washington post" illustrates -- grabbed -- disturbing rise in drug overdoses between 1999-2014. of the 47,000, more than 10,000 americans died of heroin related overdoses. air when use is increasing at a faster rate -- you want to talk about a war on women and war on our young people. the heroin deaths are killing

our women twice the rate of men come and 109% more with our youth. unfortunately, we've seen, according to the centers for disease control and prevention, that begin with heroin use among, deaths among our youth between 18-25 in the past decade have soared. and again, lead the deadly statistics. across all demographics the rate of heroin related overdoses deaths has increased 286%. while the exact cause of this epidemic is up for debate, many experts believe the use of other drugs is also a driving factor.

addiction to other drugs such as prescription painkillers and marijuana potentially open the door to an epidemic now destroying families and communities. those addicted to other drugs turned to heroin to get a similar high because it's cheaper and more readily available. mexican drug cartels have established heroin trafficking routes here in the united states and coming across our borders. now we see increase supplies in recent years. had a chance to talk with my police chiefs and law enforcement folks in the district, dea folks, and we are seeing an incredible supply and will have some questions about where that is specifically coming from. we know a lot of it is coming across the mexican border. impact unfortunately is still in

communities across the nation. just a few weeks ago i met with, again, all of the local officials and we have one of my local officials who we will hear from in a few minutes, teresa jacobs. our county mayor in orange county who's been forced to deal with the heroin epidemic in central florida and her county. and orange county alone, you hear more about this, we had 475 related heroin bookings in 2013. by the end of 2015, last year we had 840. the majority of those arrested were between the age of 18-44. the obama administration, unfortunately i believe has been sending mixed signals about the use of substances such as marijuana, which is one of the gateway drugs.

talk to anyone who's been counseling, treatment, rehabilitation, and you'll find out that marijuana is a gateway drug, and many of the heroin users start their and work their way up the chain of deadly drugs. according to daschle institute on drug abuse, now listen to this, more high school seniors are now using marijuana than cigarettes. a policy that has been adopted, unfortunately has consequences, the just say no drug policy which was championed by the late first lady nancy reagan has turned into a just say okay policy, and now we're seeing the consequences. while improving treatment is a key, enforcement is and must remain an essential part of combating heroin epidemics. when i talk to the police chief

and i saw the numbers in our locale, i said, well, looks like you've been able to keep the lid on some of those, although it is now at epidemic proportions. they told me, mr. mica, he said, this is only because we have now and don't that can bring these people back -- antidotes. the only reason we're not seeing double or triple the deaths is because our law enforcement and our first responders can bring these people back, if they can get to them in time. not only illegal immigrants afloat over the mexican border but also illegal drugs. we know that's the main source with the supply of heroin, cocaine and marijuana and a host of other deadly narcotics. stopping deadly direction entering the united states is a federal responsibility.

and we would've from some of those officials engaged in that were. new statistics show federal drug prosecutions unfortunately are down 6% in the last year, 2015. this comes after 14% drop since the beginning of the obama administration, so-called smart on crime initiative. our front-line law enforcement officers come if we're going to save more of these kids and others who are overdosing, they should be equipped with the resources to prevent and save them from overdose death, not just our emergency medical officers. the ems people get their usual after the first responders and it may be too late so this is something else we have learned from our local task force and law enforcement officials. one of the police chiefs in my district informed me that just

within the last month or so, we had one student who had to be revived from overdosing three times in one week. that's astounding. what's astounding is he still alive and were able to catch a bat. speaker ryan announced addressing disparate epidemic as a priority, and the senate has acted on some legislation. i believe that this is absolutely critical that this whole drug situation, including the heroin epidemic, become a priority for this congress. and i look forward hearing from our witnesses today as we examine how to protect our communities from this fast growing and skyrocketing national epidemic. i am now pleased to yield to a ranking member, mr. cummings. mr. cummings was my ranking member, we, together, led the effort from 98-2000.

i remember going into baltimore with him and conducting hearings there when the people were dying on the streets in huge numbers. but mr. cummings, we are back, unfortunately backsliding and here we are today. out he did a great job going to say people in his community, and he is now the ranking member of our full committee. mr. cummings. >> thank you very much, mr. chairman. i want to thank you for holding a hearing on america's heroin and opioid epidemic. i want to take a moment before i start to extend our prayers to the people of brussels, belgiu belgium,. >> and i would join you. and i would ask everyone for just a moment of silence, if we could. >> thank you, mr. cummings.

>> thank you, mr.chairman. today's hearing is about a national public health emergency, and we need to treat it like one. people are dying in baltimore, orlando, salt lake city, manchester, in cities all across our nation. we can no longer ignore this public health emergency. congress needs to put its money where its mouth is and actually help, help our state-funded treatment programs to stop this epidemic in its tracks. drug treatment facilities without adequate funding are like firemen trying to put out a raging inferno without enough water. last week leader pelosi sent a letter to speaker ryan to schedule a vote on $600 billion in emergency funding to help

states address this epidemic before this recess week. our colleague from connecticut has already introduced this bill in the house and senator shaheen has been pressing the legislation in the senate. congress did not leave town until we take emergency action to increase funding to help states combat this epidemic. we must also fully fund president obama's budget request for $1.1 billion in 2017. this crisis will not end in a day. it will take our sustained commitment, and every one of us owes it to our constituents to make that a priority. they want us to take action, and they want us to take action now. let me tell you why federal

funding is so important. in my hometown of baltimore, i've witnessed with my own eyes in my own neighborhood the destruction drug addiction in flex on our communities. the first time i ever heard of a drug overdose death was 55 years ago from heroin. 55 years ago. i didn't understand it then. a young man in our neighborhood who we looked up to who turned to heroin. i can remember being so confused as to what this is all about. so i have seen vibrant neighborhoods and hard-working families and communities destroyed. in baltimore where many of the victims were poor and black, this went on for decades. our nation treated this issue like a war rather than a public

health emergency. we've incarcerated generations rather than giving them the treatment they need. now things are changing. between 2006-2013, the number of first time there when users nearly doubled. about 90% of these first time users worldwide. -- were white. this has become a runaway train barreling through every family and every community in its path. it has no respect for barriers. it is now responsible for the deaths of 78 americans every single day. every single day. why is this happening? in part as a result of doctors over prescribing pain medication, drug companies urging them on so that they can make massive profits.

i would like to get into the record an op-ed by emily that appeared in the "baltimore sun" on march 19. >> without objection, so ordered. >> i just want to read just a paragraph from this article. it says prescription opioids have been traditionally limited to cancer, pain and comfort measures. but in the mid '90s drug companies begin marketing these pills as a solution to a new platform, plethora of ailments. in their efforts to expand the market, producers understated and willfully ignored the powerfully addictive property of their drugs. the promotion of oxycontin by purdue pharma was the most aggressive marketing of is scheduled to drug ever undertaken a pharmaceutical company. the sackler family which owns

stanford connecticut-based purdue pharma achieved a place on forbes 2015 list of america's wealthiest families. the sackler's comp the richest newcomers on the list, are worth an estimated $14 billion. 14 billion. now, when on, so as she explains, the united states has only a 5% in this article, we have 5% of the world's population, but we consume 80% of the world's painkillers. tweet that. 5%, ladies and gentlemen, of the world's population, but 80% of the painkillers we consume.

so yes, i believe it was unconscionable that our nation ignored this issue for decades. but now republicans and democrats are starting to work together. and i thank god that this day is finally, and the stars are starting to align for meaningful change. we now have people like orrin hatch, chris christie, rob portman, kelly ayotte and mike pence realizing the gravity of this crisis and supporting more fun to help our cities and states. they are beginning to realize that this is not an urban issue, a rural issue, a black issue, a hispanic issue or a weight issue. this is an american issue that affects your sisters, your brothers, your sons and your daughters. there's something else we must do. we can no longer allow drug companies to keep ripping off taxpayers for life-saving medication.

the chairman mentioned just a moment ago the drug no luck so and it's life-saving -- the locks on. cities all around the country recognized the need to equip the first responders, police officers and public health officials with the locks one, drug that can reverse opioid overdose in a matter of minutes. but efforts have been directly undermined by corporate greed. as more first responders begin using this drug, the company that makes it began to increase its prices by staggering amounts. in a 2014, a 10 dose pack cost the baltimore city health department roughly $190. is what. today, it costs more than $400.

for a life-saving drug. despite repeated efforts by the home state of maryland, this company continues to overcharge for this drug. company also continues to obstruct oversight by refusing to produce all of the documents i requested last may about their massive price increases. mr. chairman, today's hearing is rightly focused on heroin and opioid epidemic. by to help the committee will return next to my request for documents as well as my request for rehearing with executives from amphastar. with that let me welcome our esteemed panel of what is today, and i thank you for being here. and particularly i would like to welcome leana wen, baltimore city health commissioner has done an outstanding job. she is a true national leader in developing and carrying out effective solutions to the opie

i'd price it we were very fortunate to have her head in our health efforts in baltimore. we are very pleased to have her here today. and with that, mr. chairman, i yield back. >> thank you mr. cummings. again we believe the record open for members who came in late for five legislative days if you would like to submit them at this point in the record. we don't want to again welcome our witnesses, and let me first introduce them and then we will swear you in. i am pleased to welcome the honorable michael botticelli, he is the director of office of national drug control policy at the white house. we have mr. lou milione, and he is a deputy assistant administrator for to version control at dea, the federal drug

enforcement administration at the department of justice. and then we have ms. kana enomoto, and she is the principal deputy administrator of the substance abuse and mental health services administration at the is department of health and human services. and then we have ms. leana wen come issues of health commissioner for baltimore city health department. and then i would like to also welcome my requested witness, the honorable teresa jacobs, mayor of orange county florida. some of your band before us before, some of you happen. we ask that you limit your statements to approximately five minutes. you see a little monitor. you can also request through the chair additional statements or information be added to the record.

so if you have a statement want to some right you are welcome to do. since this is an oversight and investigations panel of congress, i would like you to stand now and be sworn. please stand. raise your right hand. [witnesses were sworn in] >> all of the witnesses have answered in the affirmative. we will let the record reflect that. and then we will first turn to our own ondcp representative, the director of the office of national drug control policy from the white house your mr. botticelli, well, come and you are recognized. >> chairman mica, ranking member cummings, and members of the committee, thank you for the opportunity to appear here today to discuss the issues surrounding opioid drugs, including heroin and illicit to

know in the united states as those are federal response. during a state of the address president obama specifically mentioned addressing prescription drug and heroin are used as a priority an opportunity to work with congress in a bipartisan manner on this issue that transcends party, income level, gender, race, and geography. wheels up national drug control policy that reduces, produces special drug control strategy which is the administration's blueprint for reducing drug use and its consequences big using our role as according a federal drug control agencies, in 2011 administration released a plan to address the sharp rise in prescription opioid drug misuse that coincide with a search and opioid drug prescribing at the beginning of this century. as this crisis has evolved with an increase in heroin and fentanyl use an overdose death, the devastation continues to put forward new initiatives to deal with emerging issues. for example, in october the

administration announced a series of commitments it obtained from state local and private sector partners as well as federal agencies aimed at addressing this epidemic. opioids are having an unimaginable impact on public health and safety in communities across the united states. 57 people died each day for opioids in 2010, and i 2014 that figure was up to 78. the number of drug overdose deaths involving synthetic opioid other than methadone, including fentanyl come has more than doubled since 2012. these overdose rates are harrowing. however, we are making some progress. ..

has been rising while prices have remained low. the heroin crisis is compounded by the reemergence of center mall a powerful synthetic opioid that is sometimes added to increase its posted or used on its own. since it is more potent than heroine is used for overdose death. while prescription opioid misuse surpasses the transition for them on medical prescription brokers at a very low rate a recent review article concluded that the transition appears to be a part of the transition of addiction among those with frequent dependence rather than response to the reduction and availability of prescription medications at some have speculated. gradual medical education programs do not provide a comprehensive focus on the identification or treatment of

opioid disorders. the evaluation of health care claims found that a majority of the overdose victims would receive and opioid from a prescriber would receive a prescription again from a prescriber. in response last year president obama issued a memorandum requiring all federal agencies to provide the effective prescribing of opioid medications to staff who prescribed controlled substances as their duties. the centers for disease control issued recommendations for primary clinician care clinicians. the administration obtained commitments by more than 5,000 providers would complete the prescriber training in the next 20 years and the administration continues to work to make mandatory prescriber education part of the controlled substance

licensure. the administration focused on fn areas to reduce and prevent overdoses including the public overdose risk and interventions and increasing third-party and first responder access to the reversal medication and promoting good walls and connecting the victims and persons within overdose to treatment. yet there remains in the country a considerable gap that inhibits many victims of the epidemic from accessing the treatment they desperately need. therefore, the president's fy 2017 budget proposes $1 billion of new funding to support cooperative agreements with states to expand access to medication assisted treatment and to expand access to the treatment providers in the areas most in need of providers. just a few days ago the hhs secretary burwell announced $94 million in affordable care

act funding to health centers to expand the delivery of substance abuse services with a specific focus on medication treatment for opioid disorders and underserved populations. while we appreciate the congress to support the president's proposal underscores the need for additional funding to address this epidemic. to increase in address to use and availability, the national drug control strategy focuses on identifying, disrupting and dismantling the criminal organizations trafficking of opioid drugs working with the international community to address the cultivation of poppy in identifying the labs creating synthetic opioids. in addition last year ondsp created a group that is a disciplinary team of subject matter experts to lead federal efforts to reduce the supply of heroine and sentinel in the uniteunited states and we've alo committed 2.5 million a the high-intensity drug in the

trafficking area program's two develop a response strategy with law enforcement resources to address the threat across 15 states and the district of colombia. we've been actively engaged in the government of mexico on efforts to reduce the flow of heroine in the united states. we worked with other agency representatives and agreed to further collaboration the efforts to disrupt the protection. this bilateral cooperation will be mutually beneficial to both our countries. members of the committee we remain committed to working with our federal, state, tribal and private sector partners to reduce independent health and safety consequences of the non- medical prescription opioid, heroine use. thank you very much. >> we will recognize mr. milione

and the dea representative. >> thank you distinguished members of the committee. the dea views prescription opioid heroine abuse epidemic as a number one drug facing the country. i appreciate the opportunity to appear before you today and talk about what we are doing to address that threat. prescription opioids are walking users appear when stored to the threshold into the deadly embrace. mexican cartels are entrenched in communities through the country exploiting the opioid use epidemic and flooding the country with high purity, low-cost heroine. those cartels are forming a toxic business relation with distribution cells that are swinging that open in the communities. what's the end result? in one year almost 30,000 fellow americans died from a prescription opioid or heroin overdose. as everyone acknowledged, this is an unimaginable tragedy.

dea understands we need a balanced holistic approach to this epidemic. we stand with our partners, including those here today and embrace the attention to treatment and education as critical to our success. however, enforcement must be a key component of the overall strategy. we need to investigate and bring to justice not those suffering from the opioid but those that are gaining a profit. our answer to this supply a reduced demand in our communities is the 360 strategy. there are three problems in the strategy. law enforcement, control and community outreach. my comments today focus on the office of controlled strategy that we would be happy to follow up with details of the operation rolling thunder, the heroine product of the 360 strategy that is focused on the distribution cells that are pushing sterling

and the communitiehere andin the mexican cartels that is killing so many americans. with 1.6 million registrants commit ebay version is uniquely positioned with enforcement education and engagement. the majority of the 1.6 million are law abiding citizens. these are practitioners, pharmacists, manufacturers, distributors working in our communities. we investigate a small percentage of those operating outside of the law, and get inflict considerable harm i on r country. for example, prescription is not a prescription for a legitimate purpose outside the course of professional practice, pharmacists are performing their corresponding response ability to make sure prescription is valid, manufacturers and distributors not upholding the obligation to prevent a version. how do we do that? with our tactical diversion squads, groups and federal state and local counterparts.

our tactical diversion parts are made up of an agent of intel analysts said we have 69 of them nationally and we will eight bringing the number up to seven within the next six to nine months. we are creating mobile squad to deploy where the need is giving a fluid enforcement capability. we have almost 700 investigators spread across the country in the groups, both the tactical squad and the divergent groups work with the u.s. attorney's office to bring criminal or civil charges against those registrants operating outside of the law. where appropriate they bring administrative actions to show cause or suspension orders revoking the registration. as i said earlier the enforcement in a strategy and educating them are just as critical. in the last two years the

diversion conducted more than 300 events providing education and guidance to the registrants and individual leaders. since 2011 with our partners at the association of the boards of pharmacy's we conducted more than 64 k. version conferences in 29 state 29 states and had te privilege of interacting with almost 10,000 pharmacy employees at the risk. we will continue engaging with our partners on important initiatives including expanding access to treatment, mandatory prescriber education and the safe and responsible disposal of unwanted prescription drugs. early in february the pharmacy announced they would place kiosks in 500 drugstores in 49 states and washington, d.c.. we see that as a positive step in the right direction. we look forward to to the day when those are commonplace

people can dispose of their unwanted or expired prescriptions frequently, safely and conveniently. the dea will continue the initiative with the events every six months starting this september, 2015 takeback from 5,202 collection sites we collected more than 370 tons of unwanted prescription drugs. the next takeback is april 30 about 5 weeks from now. for almost 20 years i had the privilege of working with the brave men and women of the dea along with federal, state, local counterparts investigating some of the most entrenched domestic organizations threatening the country. the current threat to the subject of the hearing is unlike anything i have ever seen. we will do whatever it takes to fight this epidemic. we will attack supply and work to reduce demand and do our best to empower communities. thank you for the opportunity to appear before you and i look forward to answering any

questions you may have. >> with the recognize ms ms. enomoto from the substance abuse mental health services at the department of health and human services. welcome and you are recognized. >> good morning ranking member cummings and members of the committee. i'm the principal deputy administrator and honored to hoo have been duplicated the duties and the authorities by the secretary burwell. many thanks to all of you for the leadership to raise awareness and catalyze action on the nation's opioid crisis. as you noted that this is a matter of life and death. i know prescription drugs, heroine and a list of fentanyl have devastating consequences in your districts and because they partner with leaders in your communities as they implement life-saving programs for individuals at risk for the opioid disorders for example the state of maryland and the city

of baltimore are addressing high rates of emergency room visits and utilizing peers to recruit patients into the treatment. in florida the prescription drug monitoring program interoperability grant helped get critical data to the front lines of the fight to prevent prescription drug abuse. in wyoming we have seen fantastic progress as the state has implemented our strategic prevention framework using data and science to focus their efforts. and in utah with their help is increasing access to family-based families and hurt residential treatment for pregnant and parenting women with substance abuse disorders. healthy babies are being born and progress is being made. while treatment is increasing overdose deaths have reached records not enough people are getting treatment and as a nation we will not stand the rising tide of the crisis if only two out of ten people with the disorder have access to the treatment they need. it wouldn't work for diabetes or

hiv and it will not work for addiction. we must join together to ensure every person with the disorder who seeks treatment finds an open door. towards this end they are proud to support the national drug control strategy and the secretary's opioid initiative. the secretary's initiative focuses on three high impact areas changing the prescription behavior can increasing access and expanding the use of medication treatment and recovery. it's simple, to prevent prescription opioid misuse we need to address the number of pills i and people's medicine cabinets. samhsa will encourage the use in order to chart a safer more effective course to the management of chronic pain. we know the majority of other prescriberotherprescriber certid well-trained professionals committed to their patient's health and we must give them the tools they need to develop safe

effective care. since 2007 they provided education to over 72,000 primary care physicians, dentists and other healthcare professionals. we also reach local communities and the grants that we administer together. these create environments that promote health and prevent drug use including prescription drugs heroin and illicit fentanyl. the second aim is increasing access. as you noted it can reduce the overdose but it only works if it's there when you need it for the prescribers and pharmacists one of the targeted strategies would promote a analgesics for patients with high risk of overdose. we also let them know there's block grant funds as well as to train and educate the usage soon

we will be issuing a funding announcements to purchase and equip and train first responders and we appreciate the strong support in this area. the third area is expanding the use of the treatment. research tells us that medication along with behavioral therapy and recovery support are important components of evidence treatment plan. as the director noted the budget requests $1 billion of mandatory funding which would focus on the continuum of prevention treatment recovery services expanding the use. there's $40 million of mandatory funding to evaluate the effectiveness of the treatment programs under different real-world situations.

on the discretionary side committee proposed to maintain and grow investments made by congress in 2015 and 2016 providing funding for 23 more states to expand capacity and we are preserving the safety net by maintaining increases to the substance abuse prevention treatment block grant. we also worked with the doj to clarify and enhance the connection between the criminal justice system. the criminal response in the nation's history this year we will prioritized treatment is less susceptible to diverse and technical assistance to make sure evidence-based practices are fully implemented. with all this new care who is there to provide it? we must ensure the substance abuse is sufficient to meet the growing demands and as such we are requesting 10 million for the prescribing authority demonstration to test the safety and effectiveness of expanding the prescribing to nurses and

physician assistants and the administration requested $20 million for our colleagues at the resources administration to grow the workforce in the national health service corps. finally they are proposing a new regulation to increase the patient limit for the physicians who have a waiver to prescribe. members of the committee, thank you for convening this hearing. thank you and we will now recognize doctor wen with the baltimore health departmen depad the health department. welcome. and you are recognized. >> thank you ranking members of the committee for calling this important hearing. i am here as an emergency physician who is treated hundreds of patients with opioid addiction. i have declared the epidemic to be a public health emergency.

last year baltimore launched a three-pronged approach to fight this on the front lines. first, we have to save lives. that's why we are making the antidote available to every single president. in the er i'v er i've given it o patients that are about to die and have watched them reside within seconds. it should be part of everybody's medicine cabinet. in 2015, we trained 8,000 people in the city on how to use it including our police officers who within six months have saved 21 citizens. in october i issued a blanket prescription to all 620,000 residents. but saving a life without connecting to treatment. we believe treating addiction as a crime is not scientific,

inhumane and ineffective. so the city's criminal justice and public health teams partnered on drug treatment courts and on the pilot project where individuals caught with small amounts of drugs would be offered treatment instead of incarceration. the science is clear addiction recovery requires medication treatments, social support and wraparound services yet nationwide only 11% of patients with addiction get the treatment that they need. imagine if they could get chemotherapy if my patients come seeking addiction treatment and i told them they must wait weeks or months. i've had patients overdose and die while waiting because we failed to get them help when they asked. we started a 24/7 half line that includes immediate access to a counselor or social worker and a

direct connection to make an appointment. the phone line was started less than six months ago and already receives about a thousand calls per week including from police officers and family members asking for resources. we have evidence to show what works for the addictions that we are nowhere near getting everyone treated and we are still very limited especially when it comes to the wraparound services. take housing we estimate that there are 18,000 kernel ways for less than 1,000 recovery beds. they save the society money. we encourage the treatment as don't die.org also includes buses and billboard ads and targeted outreach and libraries

churches and bars. they can print my prescription while targeting education to the physicians and administrators said doctors want to do the same thing. why also alerting doctors to the emerging trends nationwide one in three overdoses involved those like valium and xanax yet they routinely prescribe this dangerous combination together. last month i led a petition with 440 other state and health officials to call for the warning is the strongest risk communication.

there's a lot baltimore ha of bs done to emerge as a model of recovering but when we need further support from congress including expanding funding for the on-demand treatment and wraparound services. directly funding local jurisdictions those of us on the front line with the highest need to removing regulatory barriers like the cat on the exclusion and regulating the price of moloch so in and funding the stigma reduction campaign. the epidemic is a national public of emergency meeting of addiction doesn't discriminate. so we look forward to answering your questions.

only representatives can do that. i'm pleased now to welcome and recognize. i recognize the mayor of orange county florida and some of you asked where that is. of course orlando is the principal city and we have the mayor that started a hearing task force when we were hit with this epidemic and she's also a company that they are not going to testify, please raise your hand, david siegel lost a daughter and to a drug overdose has turned to tragedy into a concerted public effort and care in sessions is the former city commissioner from my first city of winter park. so i welcome all the guests and recognize mayor jacobs.

to discuss the threat facing the country is the mayor of orange county allow me to share a few statistics but first i would like to ask that a statement from one of the constituents you just introduced be added to the record. he is president of the victorious voice foundation and is the father of the victorious people who died of a drug overdose at the young age of 18. >> without objection so ordered. >> many of you know orange county as the home of the 12 other municipalities. we have a population of 1.2 million people. last year we broke a national record for tourism entertaining more than 62 million visitors but many of you probably don't know that we also lost before lives to heroin overdoses and probably nobody will know that that is a 600% increase since

2011. four years ago like so many other counties across the country, we were inviting pill mills. we worked hard and adopted regulations at the local and state level and resources to break addiction and we were pretty successful. today the frontline has moved the battle is tougher than ever. too many prescription drug abusers found an inexpensive and often deadly alternative. despite the strong economy extraordinary quality of life, heroine has absolutely exploded. last year approximately 2,000 users moved through the county jails. many of these infects most of them were not in possession they were other related offenses resulting from the debilitating effect heroine use has.

tragically in 2015 we housed 100 expectant mothers addicted to opioids and heroine. quite frankly the county jail has become the treatment center of last resort for so many people. yet too many people still don't realize the severe threat that it poses not only to the lives of the addicts but to the fabric of the community. for the whole community we are fighting and we are fighting hard. last summer i convened a harrowing tastheharrowing task d the sheriff to cochair the effort. we have high ranking officials that served on the task force from the chief judge to the state attorney to the medical professionals from all over the hospitals for the superintendent and public schools for the representatives of the colleges. i commend the effort of the orange county sheriff's office in the orlando police department's end of a euro of

investigation because since we fully informed of the task force and the collaboration of the dedication they arrested more than 370 incidences. last week the task force completed its efforts and it made 37 recommendations similar to the comments that you heard from my colleagues here. we recommend increases for trafficking and we recommend the media and social media campaigns warning about the deadly nature of here in. heroine is a serial killer among our community and so few people realize it for that. coordinated efforts to reduce the efforts to moloch so i commanded the work of my colleague here doctor wen. as you've heard it is a life-saving drug that is used in severe overdose situations and also to look for new opportunities to fight addiction

by coupling detox with addiction treatment programs using a long-acting opioid antidote and in addition to moving forwardwith the implementation of the recommendations were working with partners at the national association of counties which has teamed up nationally with the league of cities. we are working with other organizations to implement best practices. we know there is no single solution there are some universal effective approaches. enforcement is absolutely critical to combating heroine use. keeping with what we learned he must be tireless in educating people that addiction is an illness that requires serious medical treatment. it needs to be more accessible without a prescription and available at a reasonable cost. and one final point i want you to know that in orange county the collaborative effort we are

committed to doing everything we can in the resources that we have. here is where we need your help. help stop the influx of drugs across the border. we need you to continue to expand your effort our efforts e deadly drugs before they enter the communities. law enforcement will do their part, but the federal government must do everything possible to keep this from our shores and communities. help us treat more addicts a wih the reasonable population of 2.5 million we have only 26 beds for the uninsured. get 2% of the overdoses in the community are among the uninsured and help us raise awareness so more people would choose not to try this deadly drug in the first place. to end the crisis and save lives we all need to be engaged. thank you for your attention to this critical issue and for your leadership and service to the

country. >> thank you for participating today. now we will turn to questions and i will lead off the scope of the problems that we are facing i don't think people are comprehending this from 16,000 when we chaired the criminal justice drugs subcommittee policy subcommittee of 16,000 to 40,000. we are approaching 50,000 in one year heroine is only 20% of th that. we hope to have the figures by the end of the year. >> by the end of the year. we can't get them until the end of the year.

>> part -- >> 47,000 i'm afraid it's going to be off the chart. that doesn't count. there are 35,000 half of those people have a substance when they are killing themselves. it used to be that the biggest killer of teens with automobile accidents and now it's drugs. >> we haven't even gotten into the firearms are the tool of the drug trade and they have illegal weapons they are using to commit robberies. we haven't killed this many in the wars. we will lose half a million and

a decade or more. every family has been affected and now it is just a slaughter out of control. now, we have lots of responsibilities and i'm all for treatment that's at the end of the process. they've already been addicted. we've got to stop this stuff at our borders. i sat with the police chief. we put in place i had to do that by legislation a number of years ago because they play political games with the creation of high intensity drug trafficking areas but we did years ago and here we are far beyond where we ever were then. this is out of the newspaper from just a few days ago.

they are bringing this deadly substance and it's not just heroine. mexico, you talked about this and i said not just illegals are coming across the border, but they are coming across with drugs. is that right? >> that's right. >> i saw the pattern. these are cartels. did you all see el chapo does like the major most sought after drug dealer and he went over the border like it's some kind of a holiday visit to the united states. somehow we have to get a handle.

we looked at the prosecution and the trafficking with the illegal weapons as down in the prosecution. i talked to some of my folks, they won't tell you this on the record and they are not going to see this but it'say this but ito make cases on these guys a lot of them are dropped on the traffickers. you are aware that we have again prosecution. you build a case and give them to the district, and i'm going to demand a meeting with my u.s. attorney in the central district and to see why are down. but they are down, did you know that? they are bringing a deadly substances iin deadlysubstancese trafficking pattern trying to find out some is coming through the u.s. mail.

then they transfer it in the united states like it's sending some kind of a gift package is that correct? >> they intend on getting the package on time you've got to get them there on time so we've got to look at every avenue they are using the border. i was in mexico years ago i don't know if you came with me on that. you do a signature of heroine and cocaine, can't you come and you looked at this stuff coming across. where is it coming from? fifteen years ago it was all columbia but primarily i forget what was coming out of mexico but it was like amateur hour and now they become the pros and

they are dumping this stuff in the community. by the time we get treatment it is way too late and it's kind of sad. i am all for having that with the first responders but i told you the story one police chief told me three times in one week a student had to revive him to change the prescription drugs in the cabinet so people are reviving their surviving kids and family. we have done a good job, put the chart up. the drugs at the top and here we have actually brought that down a little bit. we've been effective on cracking down on the prescription drugs but look what happened to come is being replaced by a cheaper

and more available. they told me coming and you can verify this they said the price is down. when is the price down the supply is all over the place. so it's not just baltimore or washington, d.c. or orange county. it's new hampshire come its kentucky come if every state in the united states that we are seeing this. i get a little hot trod over this but our job is protecting the citizens of the united states, the national defense resolve what happened with our streets an into schools and families. again, they killed today 40 people. they killed 50,000 people into the latest statistics we have that are more than a year old and i know no tough enforcement

works. i worked with mayor giuliani a stothey stopped aloft with zero tolerance. i just announced the new federal policy just say okay instead of just say no. it doesn't have to start with the director with families and communities. >> i would agree part of the strategy is to focus on primary prevention. we know that by delaying when people use alcohol and marijuana and tobacco be substantially increased the fact that they are going to have a life free of -- >> and were you aware high school seniors now argues marijuana more than cigarettes? is a great commentary on the success in combating this. i would like to yield now to mr. clay. >> thank you mr. chair. thank you and the ranking member for your comments on the heroine

and opioid epidemic. i want to commend you for the groundbreaking work that you'vee doing in baltimore. you're not just talking the talk when it comes to ending the stigma you are walking the walk when it comes to expanding access to treatment for your residence. in your testimony, you discussed your efforts to provide treatment on a basis for baltimore residents and i would imagine that assuring someone can access treatment as soon as they present themselves as willing to do so is a powerful tool making sure they begin treatment. then we will save hundreds or thousands as a result.

the barriers is the medicaid imd exclusion which prohibits medicaid from paying for the hospital inpatient residential treatment into the sympathy of 16 or more. unfortunately the exclusion means if you are on medicaid, you are treated like a second-class citizen unable to access what may be the appropriate care for the substance abuse disorder. for the residents, you are responsible. do you agree they should have access to the appropriate care they need whether or not they are on medicaid? >> i agree and thank you for acknowledging that it is a disease. if a patient came with a heart

attack we would never say wait three weeks and maybe if there s some available we will get you in then. the same should apply the exclusion isn't based on evidence. we desperately need a residential substance abuse disorder treatment and removing it on a federal level would allow us to increase the ability to treat all of our patients regardless of their insurance status. >> and that would be equal footing with everyone else so that we don't seem to be discriminating based on the level of care. >> and it would increase more providers who we desperately need at this time and the capacity is just one in ten nationwide. >> let me thank you for appearing here today. every city and county should have a health commissioner raising the alarm as forcefully and effectively as doctor wen is

and hopefully orange county has got and congress will finally heed the call and do something about the opioid effort because it seems as though we as a country have come together to decide this is a national emergency. let me thank you for being here and what you have done to raise the level of awareness in your community. you testified about the work that samhsa does. can you describe that work in additional detail you testified in the $1 billion of the

mandatory funding samhsa proposes 920 million over two years to support cooperative agreements in the states to expand access to treatment for all opioid use disorders why is it important that samhsa receive these funds are >> they need far exceeds the capacity of the system today and we believe every person that has the disorder and seeks treatment, 24 hour access to treatment should be the standard of care for everyone. with the proposal for $920 million to be confused across the two years we think that would supercharge the capacity of the states and communities in the greatest need so they would have an open door because as we know the window can be small for some people. and we need to take advantage of

that opportunity when they come knocking. >> thank you mr. chairman and i yield back. >> thank you for your comments this is certainly affecting everyone in my community. i was touring a brand in the hospital and was taken back to the conference room to meet with the leadership of the hospital and ask them what is their most significant challenge and they told me babies being born addicted to opioids. out of all of the regulations out of all of the funding issues that they would have come it wouldn't have thought that the biggest challenge was babies addicted to opioids. mr. botticelli, thank you for all of your efforts. i appreciate your leadership and i think that you are doing a

great job and i appreciate your advice to congress how we might be able to formulate our to do list. i would like to put up a few slides that come from your fiscal year 2017 budget justification the first one being approximately needed to access treatment for the abuse disorder. candice come from your congressional budget justification? when we hold these hearings we don't do them justice for increased community awareness we do this for the congressional to-do lists but also for an agency to do list so that's why i'm turning to your budget justification we know that 1 million americans need but do not access treatment.

the next slide for example more than 80% of state prisoners and federal prisoners and 82% of jail inmates meet the criteria for having either a mental health or substance abuse issue staggering numbers. 72% federal and 80% of jail inmates are mental or substance abuse issues. next slide studies show the budget justification. the individuals involved in the criminal justice system who are in the need of the substance abuse treatment receive it as part of their justice system supervision. ms. enomoto come after i left the hospital i began trying to find out where our resources and how can we find the resources to provide treatment in our criminal justice system and the

community i introduced people who were struggling to try to provide treatment for those who are incarcerated and then i was introduced to a prohibition in your agencies funding. we have people that present themselves in the criminal justice system with this problem and we have an understanding that without treatment, they won't be able to transition and we will as the chairman said once again be providing assistance to them or see them in the criminal justice system. and yet in your funding there is an exclusion that prevents the communities from using the dollars that they receive from you to actually address that for people that are incarcerated and

to the comments in medicare and medicaid there are also similar exclusions that prevent people who are entitled to receive their treatment from receiving the treatment. i have a bill, hr 4076 that would eliminate those restrictions that would say this is the funding that's already there although i am for increasing the funding this is the funds that are already there that would allow the people to receive it. your agency by rule could eliminate the restriction. >> i think the issue that you pointed out is so important to the communities all across the country. we know that people in the jails and prison are overrepresented with disorders and getting them out is absolutely important for

the nation. at the same time we strongly support approaches and we've made significant investments -- stomach before i lose my time, can you please tell me why your agency will not waive the requirement to allow the funding to be utilized for those who need it the most? >> i want to make sure i get an accurate answer to that so i would be happy to follow up further for the record. >> i appreciate your hard work and i know you ar they know youo assist us so i would encourage you to cosponsor because it would help the agency had the momentum to the prohibition. we now recognize the ranking member. i want to thank you for being here. at the beginning of today's hearing we put into the record and op-ed for the "baltimore sun" and the effects of the

overprescription that is entitled. the author explains one reason we are seeing such a huge increase in the heroine overdoses because of legal prescription painkillers of being overprescribed. she says can and i quote once a patient is hoped, he or she often turns to street drugs which can be easier and less expensive to acquire. i think everybody else has said that this morning. i want to be clear i'm not trying to blame the doctors they have a very difficult job. one reason we are seeing an uptick in the heroine overdose is because of the abuse of the code beneath the opioids. they had a startling statistic that says, and i quote, with only 5% of the worlds reputation

who are consuming over 80% of the world's painkillers, the op-ed explains drug companies are actively promoting this problem come and i quote, the assistance that it is traditionally limited to the comfort measures but in the mi mid-90s the companies began marketing the pills to a new plethora in their efforts to expand the market the producers understated and woefully ignored the properties of their drugs. that sounds like drug companies are almost drug pushers. they cite several examples where it says this and i quote the promotion of oxycontin by a perdue farmer was a marketing of the scheduled drug undertaken by

pharmaceutical companies. doctor wen, this is big business. how in the world do we combat this effort by drug companies? when they are making billy. thank you for asking that question. i appreciate you saying that. doctors want to do the right thing to. they are going to say that it's bad that w but we have a culturf access because of the aggressive marketing of the drug companies, we have this expectation that there should be pills prescribed for every pain. this is what we have to change them as we have to make sure the doctors get the tools and resources they need including the prescription drug monitoring programs and guidelines that can help into prescribing but we

also need the resources when we are in the er to connect the patient's treatment because otherwise we feel frustrated during the patient's need care but we can't deliver it. >> is that also to include using painkillers that are not so addictive or not addictive at all? spinnaker guidelines include three things. first is the necessity of the co- prescribing with any opioids because somebody could die from this survey should get that as well. second is to be careful about the opioid medications knowing they are not first line medications they should only be prescribed for severe pain and third is the danger of also killing the residence. >> so it goes on to explain why the drug companies are doing this as no surpris is no surprit

profit. it says the achieved a place on the list of america's wealthiest families adding the newcomers to the list with an estimated $14 billion. that is appalling and i call that blood money because people are dying big-time. i want to go back to something ms. enomoto. these aren't you concerned with even more money being requested in the treatment to deal with this problem because there are so many more the money would be spread so thin that it wouldn't

have the kind of impact that you are hoping for. >> i think we have to have a comprehensive response to this. first and foremost we need to bring into prescribing behavior in the united states. dissenters for disease control l the amount that followed the guidance that the doctor put out because that is where we note is the significant driver to the problem but we also know that despite all of our efforts, we still have too many people overdosing because they can't access the treatment programs ps when the need for treatment programs and this is why you think the president has put forth a significant proposal to expand the treatment capacity in the united states. i hear this wherever i go. i just did a town hall forum in toledo ohio where i asked the sheriff one single thing the government should be doing to address the opioid epidemic and he didn't say we need more

police officers. he said we need more treatment capacity because we are arresting too many people that haven't been able to access treatment, so we look at how many need treatment and try to adjust the proposal to focus on making sure that as many people as possible have access to treatment when they needed it. >> one last question doctor wen, what happened. in other words, this wasn't a problem before, not as much of a problem but then something happened and can you talk about what happened? the numbers to chairman cited, and i realize people are moving from the opioids but what happened with regards to get so many people and then to move to heroine? spinnaker was aggressive marketing by the drug companies so that the pain scale is something that is asked of every patient all the time in the

course of their hospital stays but the goal shouldn't be getting too pain-free. doctors are put in a hard place to satisfy those requirements when all of that was done for the drug companies benefit. >> so the doctors have a hard time. they say i'm at a nine. is that the kind of thing that happened? spirit doctors feel they have to get the patient's pain to zero that includes the narcotic painkillers in order to do so.

>> i would agree we set up an expectation whereby they are the first line of defense around pain therapies and what we are trying to do is particularly for people with chronic pain that are not the first line of defense to really substantially reduce the pain that we have to focus on others and the evidence seems to be pretty strong people that have chronic pain don't have significantly better functioning when they are on the opioids and we need to be thinking about things like exercise and diet and cognitive behavioral therapy and to be a piectherapies particularly for people with chronic pain. >> did mr. kerner asked a critical question when he talked about the treatment in prison is that right? what stops you from providing treatment is that what he was

asking? >> thank you. >> i think mr. turner said it is in their control and he is a bill to remedy that. let me recognize mr. walker now. your recognized. >> thank you, mr.chairman. appreciate it is doing. appreciate the panel of witnesses being here today. mr. botticelli can you talk to us earlier about treatment. i think you mentioned the one thing the federal government could do. treatment is good and we need more of it but that's what active after the problem already exists. is that fair to say? so let's start from the very basis. i married into the medical

community. my rights on and wife writes prescription. when the things i've seen as a minister for two decades is the introduction of marijuana or going for the statistic did already that more high school seniors now do we than cigarette. you discussed i believe the legalization of marijuana during a 60 minutes profile if i remember correctly. deeply this could lead to future drug use among the youth? >> i do everything the evidence is pretty clear that when you're talking particularly about early drug use by youth, particularly i'll call tobacco and marijuana, but that increases the probability that people are going to have more significant problems later in life. and that episode i talked about the fact that i and the federal government did not support legalization of marijuana because i do believe that when you look at the date in terms of the high levels of marijuana use the web among youth in the country and particularly would have an industry that is quite

honestly targeting our youth with things like funny cartoon characters and edibles, that we are in for more significant problems into united states. >> part of our pop-culture now speak i hear we are replicating what has happened in the past. >> do we have to worry that legalizing marijuana could lead to more drug use in the future, for people in general? >> we have been tracking data the past 40 years, and what it has shown is that when you proceed using drugs and particularly marijuana as less risky we often seem increase in drug use. not only have we had very high and historically high levels of marijuana use among youth come we're also seeing historically low levels of perception of risk oriskof marijuana use sketches e question can go to bill quick. i don't want use all my time. does anybody disagree with the findings, just a record, as it would agree this marijuana usage

is the potential of a greater problem? just for the record i'm seeing everybody seems except dr. wen. you have a different opinion speak with is one country. another is a prescription drug prices. 80% who use heroin first of using pain prescription. >> drew. >> sometimes the first introduction is the purchasing of marijuana. is that fair to speak with you so come also to misusing other prescriptions. >> i want to come today. i want to make sure we're not paying that doctors at the bad guys here today. -- inking. in counseling some of the people of gaza some of this come as good as people that are they've learned to become a master manipulators as far as going into the doctor's offices, emergency rooms. mr. cummings talked about the different pain level, russia. there's scoring systems by customer satisfaction index is

the hospitals that we about. dr. wen companies that churches and? >> most doctors are before the madrid a doctor trying to do the right thing. most patients are just trying to get the care that they want. unfortunately, patient's expectation that they have to be painfully. if i fall down and bruised my knee i will have something. ditty opioids is not the right answer. >> i love what you say, i paying for every bill. we've got to go away from that culture. we have seen a plateau to go it's never prescription pain, continue to do better. i think people like in the community, i think of richard and jennifer in central north carolina. they had a son who had no drugs into had no drugs into system except one thing. he deployed if a book into my before. via taken one prescription pain though from his grandmother's medicine cabinet and to kill the. they have taken that message throughout, two teachers in berlin to north t to live as thy traveled together parts of the state to bring more awareness of

what they can do. of legacy that his platoon and we do continue to stand do continue to stand top of that. i am overwhelmingly alarmed at this fight and the like to see this 2050 numbers as soon as those are available up where we are going with that is something we have to continue to more and with the i yield back the balance of my time. thank you, mr. chairman. >> thank the gentleman. let the recognize that gentlelady from new york, ms. maloney. >> i think the chairman and ranking member and all of the panelists for focusing on this really crisis and health care in our country. and it's encouraging to hear your testimony and efforts that are taking place in the city, state and federal governments across our country. but we and congress needs that money where our mouth is, in the short term i urge my colleagues to approve a 600 million in emergency funding which the professionals are asking for to

combat this epidemic. from what i'm hearing from dr. wen and others is if we hit the treatment level window becoming addicted to painkillers, if you hit it and it doesn't get to the other level of the opium. so i think if we could find it that would be important. the senate recently acted on this crisis. they passed the comprehensive addiction and recovery act of 2016 to help prevent and treat the opioid addiction. but it does not provide any funding. so what good is a program that doesn't provide any funding? does this program help people suffering in your city or your area? >> obviously congresswoman, funding is a necessary component of any program that we offer.

if i could add just one thing because we talked a lot about treatment, and we've mention that that is on the tail end. that's reactive. this country came together. it galvanized around tobacco use and get profoundly changed the way our youth look at that. if this country would come together, if the congress come if the state and local level, it would come together around the campaign of awareness about how very serious heroin use is, opioid addiction, drug painkillers, all of those things, i think we could make a bigger impact at that level. and stem the tide of this. >> i think that's an important point but that whole debacle effort, a lot of it stemmed access. it stemmed access to tobacco. they made it more difficult to have access to tobacco. i know the cdc just came out with some guidelines that

basically says don't prescribe this would easily. you should have a higher threshold for it, as dr. wen said when you fall down, you hurt yourself, you proved yourself. you are not always completely confused have pain sometimes and just a lower the expectation that can have anything if you have an operation, you will have pain. it's better t to have pain and become addicted to heroin or something worse. maybe some concrete guidelines on access to it, that maybe the scientific community should define what pain level should have access to opioids, and that it should not be something that everyone should expect to be pain-free the whole time they're in a hospital. i mean, how would you react to that, dr. wen, to having guidelines that really stemmed access to very severe he dashed

in severe pain levels? because what we are doing for someone to be accountable for a week we are doing them into addicts. this is a national health crisis. this is got to stop, and i would say to my colleagues on the other side of the aisle and on my side of the aisle, we should not leave until we vote that 600 billion that's needed for the program. what good is a program if you don't find it was it makes it sound like are doing something when we are not really doing something. what they need is the treatment in the field. but i would like to ask dr. wen, what do you think about reversing it? not just education but giving doctors help in knowing what threshold of pain would be necessary before this dangerous addictive drug is allowed? >> thank you for the excellent point. i agree with you that doctors to further guidance and tools in order to make the best decision possible for the patients.

and having guidance would also be useful because we don't want to punish doctors who are doing the right thing. and curly when reimbursement is tied to get thank you, doctor are getting the patients to become pain-free that becomes very difficult for the doctor to practice properly. i also want to cautious there are appropriate uses for opioid medications, for cancer pain, surgeries. so don't want to eliminate that altogether. >> but direct guidelines. would be the want one to do that? the cdc? regulated the guidelines that they just came forward with? >> i have and the guidelines we agree with and help it would go further in requiring that co-prescribing of naloxone and helping us put for the warnings including boxed warnings on opioids which are the fda's highest risk recommendation to alert both patients and doctors.

>> my time is up your thank you. >> let me see, we have mr. buck of colorado. you are recognized. >> thank you, mr. chairman. mr. milione, i have a few questions for you. in 1970 congress enacted the poison prevention packaging active address aspirin overdose cases with children. and as part of that, i tamper resistant container was developed for that purpose. we are now dealing with a situation where there are a huge number of young people who get these opioids from their parents medicine cabinet. and i have become, have been made aware of a product that i'm holding right here which cost less than 1 dollar. it would increase the cost of

the prescription less than 1 dollar. and it is, it has a combination on it. it would require the parents to open that. if a child that didn't have the combination tragedy into something like this it would be evidence to the parent that this was opened by someone that did not have the combination. has dea's look into packaging like this? >> congressman, as a father of three we support anything that would serve tha the purpose ande are aware of that company and that device speak you're probably aware that the company come from the great state of colorado. >> i almost said that. >> thank you. >> we were happy to listen to them about the technology. we would support that and the takeback kiosk to get drugs out of the medicine cabinet. that's a critical part of our overall strategy but any technology that would prevent those dangers of drugs getting a defense of children or anyone we would support.

>> and what needs to be done? do we need a law for that? i'm not a big proponent of the administrative regulations, believe me but can you require that dangerous drugs be dispensed in packaging like this? >> we can require the regulations cover that, the disposal. as far as requiring how it assistance i don't we begin. i can take it back and look at it. we've got to navigate somewhat carefully because if this technology were made widely available that would be great but we hav had to come from a private entity. it wouldn't something we could mandate necessarily. >> would you need an act of congress to require, obviously we're not going to name a company or a particular technology but we would certainly require opioids to be dispensed in some kind of safe computing. would that be something that would help you in furthering this goal? >> it would certainly help

prevent it from getting in defense of like essential to do something we would be happy to talk to you about an about and p visit was on the pending legislation. >> i would appreciate that very much. and mr. botticelli, wow, the federal government dispenses the drugs through the va and other agencies. again, would it require an act of congress or could the federal government for purposes of dispensing drugs to federal employees or veterans use packaging like this without a federal law from congress? >> i don't know that. similarly i think we have to go back and look at what kind of forward 40 -- 40 would have or if the federal government needs the additional authority to do that. i will say that part of what we've been trying to do at the federal level is ensure that every federal prescriber at least have some lov level of mandatory education as it

relates to those. but in terms of maintaining a package, i don't know if i either have the authority or we would need additional authority to be able to do that. i can look into it. >> if you can work with the office on that i would very much appreciate that and look forward to working with u2 tries to develop this area. i thank the chairman and i yield back. >> i thank the gentleman. will recognize now mr. lynch, gentleman from massachusetts. >> thank you, mr. chairman. i do want to associate myself with words of the chairmen and ranking them ranking member earlier on, on this issue. i think there's much we can do on the treatment side, but up front there's also the opportunity to reduce the number of people that require treatment. i think we really have to double our efforts in that regard. michael botticelli, good to see again. mike, those who don't know, headed of our efforts in massachusetts for quite a few years. done great work. and i want to thank mr. milione

for the dea's hell. my district has been overrun so you've been kind enough to assign dea officers and agents up in my area what with our locally so we really appreciate the help. in the individual state doesn't impact on the border but you do. so that's been an enormous help for us in trying to interdict some of the heroin pipeline that's been coming up into the boston area. i had the honor of cofounding the cushing house in boston for boys and girls, it's actually an adolescent treatment is only because our kids are coming in so young with addictions to the opioids and heroin. we've got basically 24 beds for boys, 20 for growth but the promise i've got a line out of the door. it's happening over and over and over again. i do want to say just as a sideline, as i talk to our young

people, and we put thousands of kids through this home, and it's a long-term rehab facility. and while i don't know if mary wanted is a gateway drug to heroin, but every single kid that ideally with who is on opioids and on heroin started with marijuana. so everything is a perfect match, 100% of every kid i am dealing with for heroin and for opioids, which i ask of them what did you start out with? they all say marijuana. maybe this is susceptibility there is something i'm not sure. it's not anecdotal. it's more than that. is empirical, over thousands of kids but it points in the direction. i think it deserves a cautionary note insurance of some of his marijuana legalization. i think we are buying ourselves a huge problem. one thing i want to talk about and get your opinion, we haven't talked about the power of these opioids.

allocated a couple of examples. young woman in my district had a tooth problem. she had an extraction. they gave her a very large description of oxycontin. she consumed that, went back and complained. falsely she tells me know, continued to spain. got another prescription and went back in and complete another tooth was hurting which was not so she's yanking her teeth out of her head just so she can get prescriptions of oxycontin. that is unbelievable. i talked to some of the doctors in the boston area and becoming a chemical changes in the brain, it overrides, the oxycontin and hydrocodone actually overrides the endorphin creation in the brain. so it's more powerful than the endorphins that the brain can produce on its own. so that's what, when they come off that, when they need that, that's why they're going for more oxycontin or heroin because

it's the only thing that can scratch that itch. we've got to think about this. these drug coverage are creating customers for life. customers for life. another young father in my district, a shoulder pain, same deal. given too much oxycontin prescription. two or three scripts later, bam, now he is buying it on the street. a good dad, good family, just totally fell into that trap. so we've got to figure out, i think it's a huge commercial advantage for some of his company to produce a product that creates a customer for life. we've got to think about what we are doing in that regard. that's a huge commercial advantage, and i think governor baker in the mass. legislature just cannot answer is going to prescribe this to you can only get so many pills. we will not let you refill them. it's also part of our drug monitoring peace that we are doing along those lines as well.

right is anything on the front end, mike, that we could be doing to stop the number of people? once they get in there, we are having terrible, terrible terrible problem. we've got a lot of recidivism, a lot of relapse, a lot of money worst thing for rehab and we need to do that. i'm not discounting that but on the front end to stop these kids a big trap and other unsuspecting patients from being trapped in this cycle. is anything else we can do up front to stop that from happening? >> i think you for the question because i think it's important. we talked to the cdc just for these guidelines but they are only guidelines. i agree that i think the vast majority of physicians and dentist are well-meaning. part of what massachusetts has done, 16 other states, there is legislation in congress. we would love to work on mandatory prescriber education. this is not about bad doctors but they got a lot of misinformation largely from drug

companies that these are not addictive medications and that we continue to have them out. i don't think in the oven epidemic it's unreasonable to ask the prescriber to take a minimal amount of education as it relates to say and effective opioid prescribing. if you look at the overdoses that we have seen, there's a direct correlation between the amount of prescriptions we are giving out an overdose death. it's been going on for 10 years. i think the medical command has or will do but that's a good starting point. >> what about liability? liability for drug companies at the docks to push this stuff out there. these people are getting addicted like that. >> i agree and that the legal action against purdue pharmaceutical for precisely that reason. that they have to multiply not only in terms of making sure there will reading the letter of the law in terms of market but encouraging other areas. we do need to work with the dea and others to go after outlined prescribers who are wanting we

ignoring the law. but you're right and we need prescriber education, good prescription drug marketing programs so physicians can actively people who might be going from doctor to doctor to do that. to your point if we really could reduce the magnitude of the problem we've got to scale back on the prescribing. identify people are starting to develop problems. >> i yield back. >> mr. lynch, i went into one of our drug programs in my community, talk to every kid i could, they are all useful in the treatment program, every kid told me the same thing. he started with marijuana and then they go on to all the rest of it. we have a very serious situation in this country. mr. walberg is next, gentleman from michigan. >> thank you, mr. chairman.

apologized for been out but rosie the river showed up at the capitol and i wanted to say hi from my district. interesting issue because it does affect all of us. my district in south central michigan have tremendous challenges and appreciate the efforts that all of you have shown toward this issue. mr. milione, how long has the dea been aware of the increased prevalence of that in all drugs? how are you responding to this problem specifically? >> thank you for the question. we have been aware of that no going back a number of years and we've seen its increasing use and sits on the country. what we're doing what we're doing basically what we do with all a criminal investigation. we look to target the worst of the worst criminal trafficking or positions, identify, and i think, captured and convicted. were trying to educate our state and locals about the risks associated with fentanyl.

it's a multipronged approach. it's something are concerned about. we are concerned about the unsuspecting users that are being exposed to when it is combined with heroin or when it is put into an exact replicate of an opioid bill. >> are those special force the challenges you have, or are there others beyond that? >> there's a whole panoply of different challenges. that's one of them. it also poses a risk to my law enforcement brothers and sisters that encounter increasingly fentanyl on enforcement operation. as you know it can be inhaled, absorbed through skin with tragic consequences. it is a major problem for us, for users, for the country and also for law enforcement. >> what has the dea learned about the source of fentanyl when it appears in cairo in? >> to primary sources. the majority of it is coming up from mexico with precursors an

actual fentanyl shipped from china, mexico and then across the southwest border all across the country particularly up in the northeast. but directly from china. those are the two primary threats. >> it's my editing that mexico has been a primary source. is that true? >> that is a true. >> how are you working to decrease his trafficking? any additional effort that you can talk about in regards to what's coming across the border? >> we have a great relationship, it's not our largest office in mexico but with great relationship with counterparts. we continue to work with them on those trafficking organizations. the cartels by the most powerful cartel delegate it's got a tremendous dish dish network spread across the country. they're capitalizing on the epidemic. they're flooding the country with heroin but also flooded it with fentanyl. we will discontinue an aggressive approach from the law for this site and do what we do with our counterparts every day.

>> mr. botticelli, what efforts is the u.s. engaging in to work with governments where heroin is produced to cut off the supply? and thensecondly, does this involve identify plants in countries like mexico which may be a trafficking bonanza of heroin and fentanyl in the united states, and what are the biggest barriers to stopping that? >> we looked at this issue, particularly heroin and fentanyl. having an aggressive approach that reduces the particularly import to do that. i was just in mexico a few weeks ago meeting with the attorney general and high level folks in the government calling for enhanced action particularly as relates to heroin. looking at enhanced eradication efforts, looking to go after both heroin and fentanyl labs that we continue to support

mutual collaboration are going after the organizations that deal with the. we have also been working with the dea at a high intensity drug trafficking areas domestically to look at reducing an act of those organizations that are trafficking heroin and fentanyl domestically. it's important for us to have this holistic approach and to focus on a robust law-enforcement response to reduce the availability of heroin and fentanyl. we have to really look at how we work with our customs and border protection to decrease the detection of both heroin and fentanyl and i think to mr. milione's point, we have to look at our international work with china that often produces these precursor chemicals as relates to fentanyl production. we were just pleased that china just moved to schedule over 130 new substances, including one of the precursors. it really is important for us to work with our international partners, particularly china,

mexico inward with our domestic law enforcement folks. >> thank you. i yield back. >> thank the gentleman. the gentleman from pennsylvania, mr. cartwright, recognized. >> thank you, acting chairman mica. advocate all the witnesses, today. i listen to all of your testimony and it's well taken. i come from pennsylvania. pennsylvania, hospitalization for overdoses due to pain medication increased 225% from 2000-2014. drug overdose deaths in pennsylvania increased by 12.9% between 2013-2014. compared to a 6.5 are sent increase nationally in the same time period. it's a huge problem in pennsylvania, and director botticelli, you mentioned attending a down-home earlier this year i did a total in my

district in a rural place. typically we get between 30-40 people out for routine town halls protect us when we had over 100 people come out, and nobody was smiling. every family is touched by this crisis, by this epidemic. the question is what can be done to combat it? in pennsylvania there is a company, right made using nanotechnology and is following the fda directive to use the lowest effective dose nsaids for chronic pain. it's an african-american owned company which is growing by the month providing not only jobs in pennsylvania but also a logical solution to our national opioid epidemic. i also believe that our legislative solutions to help address the issue, like h.r.

953, a comprehensive addiction and recovery act. now, this is introduced in the house by representative sensenbrenner of wisconsin. in the senate the same bill was introduced by senator whitehouse of rhode island. that bill passed the senate, and in the house i am a cosponsor of 953. it is a bill that would adjust existing authorizations and programs to provide a series of resources and incentives to help health care providers, law enforcement officials, states and local governments expand drug treatment and prevention and recovery efforts. and through funding towards those efforts. i wish to urge republican leadership to move h.r. 953 through the house floor to a vote. it is a concrete step we can take in the right direction.

now, my colleague, mr. lynch, talked about new england and new england area has been referred to as quote the cradle of heroin epidemic by the "new york times," and i see you nodding your head, mr. milione. .. 63.4% of new england law enforcement agencies reported heroine as their greatest drug threat and just like we-- last week the governor signed legislation making massachusetts the first state to pass a statewide limit on first-time opioid prescriptions are. q. question is with the rising number of opioid deaths come a what steps has dea taken to collaborate with the state local law enforcement agencies to

reduce opioid overdoses-- overdoses and deaths? >> under the leadership of our special agent we have a great relationship with the us attorney's office and they have brought together the different elements, state, federal, health community to identify where the hot spots are in to do community outreach and enforcement on the groups trafficking. >> okay. and director director botticelli, how are the government working to improve combating the opioid epidemic? >> i think there are never ways we are doing that. looking at funding opportunities to provide states with the opportunity to create innovative strategies. one of the things our office does is look at how we promote innovative things happening at the state level, so whether it's law enforcement looking to get people into treatment or things

like triage programs. part of what the federal government responses is injuried state and local have resources they need to continue to implement programs that address these issues. the secretary in pennsylvania has demonstrated strong leadership in the terms of what's happening here. i talk with the secretary about every date and looking at what more the federal government can do, but i think the largest function we have is making sure states of locals get the resources they need to develop and show leadership on this issue. >> amen to that and i yield back, mr. chair. >> recognize the gentleman from georgia. >> thank you, mr. chairman kirk the cdc in georgia has a report that georgia has seen a 10% increase in overdose death and i'm sure you have seen that in the last couple years. to me this is especially alarming just by the fact that

high school students are using painkiller medication at alarming rates, which makes them 40 times more vulnerable to use heroine. the dea said heroine is currently available in larger quantities, that it's used by a larger number of the people and it's causing an increasing number of overdose deaths. is that correct? >> yes, sir. >> i went to focus on where this stuff is coming from. so, mr. milione, let me start with you. from your testimony regarding that dea 360 strategy that you referred to, it sounds like the dea is going to focus less on the mexico -based organizations trafficking heroin and focusing more on the street gangs distributing heroin.

is that a correct assessment? >> congressman, it's not. it's more nuanced than that. we will never go away with our core mission of working up the chain of the cartel in mexico. the bridges pilot distribution affecting the communities in the cartel flooding the country with a heroine, so did absolutely is not one of the other. it's a comprehensive approach. >> is there a greater emphasis though on the distribution side of things now? >> i would not say greater emphasis. it's a shift of focus so we can do everything we can to get the violent distribution cells under control and get communities back to communities. >> is it fair to say from your assessment that are interdiction efforts with the cartel has failed or at least not been as successful as we had hoped to? >> i would not characterize it as failure. interdiction is one part of it, but we are focused on going after that actual individuals selling the powder that are pushing itth