that is the part that bends some people's minds. i sit back, wait a mine, lidos working unmanned aerial vehicles. i this company -- let's get this together because i want to be domain agnostic. i want uuv, usv,uav swarming together. we want to understand is that technically feasible? the understanding is yes. how do we bring that together. i have three program managers. i have to work with him. a lot of this is not the science but business of the science. each of those projects that we have, have in stones experimentation and demonstrations and understanding how we bring that together takes day-to-day program management and leadership in the technological domain. thanks, shelley. . .

give us the latest that you can tell us. >> first of all we still continued to our shoulder full in directed energy. richardson's strategic focus to ensure that we can rapidly deliver next-generation capabilities to our warfighter has directed energy in that list. our technological maturity has come continues to move forward but we have moved into an engineering out of typing domain. the current 30-kilowatt capability that's out, for example, continues to be operational, operationally effective.

had we shut down adversarial things? no. but we are ready. the fact of the matter is that deterrence is as good as sometimes the actual use to understand how to operate that continuously feeds our sailors and our warfighters on concept of operations for our next step which is our solid-state laser technology maturation smp project. that may or may not be up there. my eyes are not as good as yours. the fact of the matter is that is on track and we are working specifically with the northrop grumman corporation as the lead with a portfolio second tier suppliers measured in about 20-30 businesses, the majority small businesses. and looking at, what are we looking at? energy density come energy storage and the ability to distract energy quickly. we are looking at high resolution and next-generation optics so that we can combine

these lasers. right now it brings six energy sources together and then shoot to the people who want to do is combine that energy together and then bring it through. you get a much lower degradation in power laws and a higher energy rages on the target. it's the power level of the size, spot and time on there. one of the things we are doing from an understanding what's good enough, right? for all those bombardier out there, we drop mark 82. we go to a thing called a joint munitions effectiveness manual to determine how much money for this type of target. there is no jmem energy for laser energy. how long does it take to put -- to cook a two-minute egg? depends, right? if you turn up the heat, less than two minutes. turned out the heat, it's more than two.

what does it take to engage different target sets. it depends because we are talking about a very dynamic environment, especially in the maritime domain to operate in the maritime domain and that is a very unforgiving and very nondeterministic environment to be using laser energy. so we are doing that science, that explanation come expectation. that's pretty exciting to tell you the truth because of we are really defining an interest in things we never knew before. we are also moving forward with prototyping laser elements that we plan to put at some of her worker centers to be able to do more expectation and demonstration. and then get those same types of capabilities out on our aircraft carriers, our destroyers and other ships as soon as possible. that's where we are right now. it's fullbore. we are moving forward. we've got good academic and

industry participation, and we are often running to the next generation of ultra short pulse lasers. some of the stuff they think star wars shields and things of that nature, we are working on that in the laboratories. that's years away but we've got to do we go about as well as the mature level seven stuff we have on the pod stuff. thanks. >> i think we will have one more question. how about the gentleman over here on the right side in the blue shirt? >> everybody is wearing a blue shirt. beside the swimming chemical our next week you mentioned another one in september. coodee thomas moore about that and when you expect to get to that three domain type of swarming a demo?

>> the locus of demo that is next week, really i think i've said all the details of that. the next steps on that is so now what? just because you can swarm a bunch of uavs, that school and they don't run into each other and you can break them off and separate and we combined them. and so we have our warfare development center tied to our hip of all of those. and doing tabletop, storyboard as well as technology innovation game type of activity. so locus will provide our warfighter the opportunity to see how that fits into the game plans and then we will continue to support as this transitions to a warfare center and potential programs of record. from a surface, we did one in the james river 2014-ish, and

that was the original algorithm since it knows been matured in locus. we have a follow-on to that which is more operationally aligned for a high-value unit with multiple swarming boats to set up a perimeter, break off at engage, come back, and all men on the loop and approved by the coast guard. there is a lot of preparation that you have to go do that. so that's going to be an exciting demonstration towards the end of september. our other program continues to move forward. will have a demonstration early next year, that takes one of our vehicles from san diego to san francisco, in the water, under the water in an open ocean navigation since and avoid demonstration.

i emphasize that because, ladies and gentlemen, since and avoid for unmanned vehicle doesn't matter if it's in the air or on the surface or underground is that insignificant the it's not through the. our service in which is passed the collision regulations for our surface warfare folks, so it can operate man on the loop but it just goes. if there's been scripted actors can maneuver, stop, and it doesn't all excel. it understands them it senses the invited. that algorithm set we are using the uav come into uavs to understand how you can deliver it a little more challenging undersea, but we understand that topography well enough but we are still, still expectation, very important to understand that. and then when will we bring you the coming usb and uav on together? that's not on a chart, right? we need to make sure we continue

to ensure those domains and get that out to prototyping, safer double in the next ran back to your so now, fleet exercises. we are actually going to be a part of the united kingdom's joint warrior 2016 here in september. they have first charter unmanned were element. we are bringing 10 u.s. department of navy technologies to demonstrate. i bring that up because we need to be leveraging off of exercises where we can. right now at rimpac we have roughly 40 experiments being executed across the board in turn 11. one of those fascinating is the nomad and am happy to talk to you about that afterwards. but a rotary unmanned system that can fly stationkeeping on a

moving vessel, it didn't what kind of it that you provide on that rotary nomad, you could actually provide increased self protection in the electromagnetic spectrum from cell to cell a lot of extra of its ongoing right now all the time. so to try to list all of them is almost, is cumbersome as that but it's important to understand, and i relate this to senior leadership, that we have a mechanism so we do know what's going on and you can have confidence that we're executing the science and technology, experimentation and demonstration. that's the most relevant anti-to our fleet capability apps. thank you very much. >> admiral, on behalf of csis and u.s. naval institute we thank you for coming out today and taking the time. you have a hugely important

portfolio, and i think we got some great insight here today about your vision for office. we appreciate it. also, csis at the naval institute want to thank our sponsors, lockheed martin in huntington eagles who have made this maritime security dialogue series possible. thank you very much. thank you, admiral. we appreciate it. [applause] [inaudible conversations] [inaudible conversations]

>> a quick reminder if you missed any of this discussion, you can see it again anytime in the c-span video library. go to c-span.org. we will be back here at csis this afternoon for look at russian and nato capabilities or underwater warfare. that would be live 1 p.m. eastern on c-span2. on our companion network c-span a joint news conference with president obama and mexican president nico. they will speak with reporters after that meeting. live coverage of the start at 11:45 p.m. eastern -- 11:45 a.m. eastern to about half hours from now. hillary clinton's campaign is expected to make an announcement today on her vice presidentpresident ial pick possibly before an afternoon event in tampa, florida, that may come through text message or an e-mail according to resort. the two candidates will likely campaign together in miami tomorrow. those wh who notably clinton dos

who notably clinton is pointed senator tim kaine of virginia. agriculture secretary tom vilsack another top contender, ma senator sherrod brown and cory booker of new jersey and labor secretary tom perez all have been seen as finalist. you can read more about this from that article in deal at the hill.com. also live with a presumptive democratic nominee to date in tampa, florida, pictures holding a rally at the florida state fairgrounds. live coverage starts at 4:30 p.m. is turn on c-span. spent every weekend booktv is 40 hours of nonfiction books and authors on c-span2. here's what's coming up on saturday.

>> and i think it's important for the american people to understand that there are nuances to these cases that not all terrorism cases are the same, that there's an entire spectrum of cases from those who are accused of wanting to plot and then with evidence like the subway bomber in new york to those who really just aspirational. >> and on sunday, >> go to booktv.org for the complete weekend schedule. >> opioids at prescription drug

abuse are topics at the annual summer meeting of the nation's governors in des moines, iowa. you will hear from officials on prevention efforts come increasing access to treatment and the rule of law enforcement in combating the growing epidemic. speakers include health and human services secretary sylvia burwell. this session led by massachusetts governor charlie parker your. >> but i couldn't everybody. i'm charlie baker, the government of the commonwealth of massachusetts on the nature of the nga's health and human services committee. i'm glad to be joined today by the committee's vice chairman and should governor maggie hassan as well as by governor bevin who sort of along with

governor shamblin, drop us all into this conversation in a big way at the meeting where back in february. i want to start first of all by saying how much i appreciate the fact that so many of our fellow governors signed onto the compact that we develop to deal with this issue. last count we had 46 governors who signed onto the compact represent about 250 million americans. certainly for us in massachusetts and a government of the folks around the table this is probably the single biggest public health issue you a dinner with. i know based on the conversations i've had with secretary burwell and others have big deal this is just across the country over all. i do want to point to the life clock up on the screen. so far issues and estimate of the number of individuals we've lost so far this year to an opioid overdose which is according to the latest cdc data and to increase every 20 minutes throughout the session to underscore the urgency with

which we must all work to find solutions and save lives on this issue. this is the leading cause of injury death in the united states and it affects every community across america. meany hereupon have their own stories. lord knows i've heard hundreds of my own or know somebody has been affected directly by this. i'm frankenstein if you were 20 people in rome in massachusetts i guarantee at least one of them have had direct experience with this dreaded disease. to highlight the far-reaching impact of the crisis we will take an anonymous poll of the audience and governors independence and i'm now want to turn the mic night overdue further, the director of nga's health division to walk us through. >> thank you very much. as you may have seen we are going to do a live poll during this session. everyone is invited, everyone in the audience, the governors as

we'll are invited to process big in order to join the pulled instructions are on the board, if you look up on the screen. you have to start by creating a text message on your phone to the number 2233. >> three. >> three, exactly. so 2233 22333. in the message line type nga 2016 and hit send your so let's get everyone one more moment to do this. in the number of line it is two to 333 and what you write is nga 2016. you should receive a text message back to let you know you have enrolled. okay. >> by the way, i don't have my phone with me i am a yes, and yes and yes for questions one and two and three. >> go ahead and let's put couple of live. -- put a poll up alive.

so the first question is just a test question. have you ever attended an nga summer meeting before? just text yes or no and the results are there for us. so looks like about half of the audience this new. it's great to see so many old friends and new friends. let's turn to the three key questions we want to ask of the obvious. the first question was, do you know anyone who struggle with opioid addiction? just text yes or no. all right. so what we see is one out of two people in this audience knows

somebody who has struggled with addiction. the next question. has anyone in your family, your direct family, been affected by the opioid addiction or overdose? so that's startling, almost one-third of the audience or a court of the audience who have someone in detroit them is been affected by opioid addiction. next question. has a friend or family member of yours died from an opioid related overdose? so that's a sobering moment

there, that within this audience one out of four of us actually know somebody who has passed away, almost a third of us has known some have passed away from opioid related overdose. that i think why we're having this discussion today. i would like to turn back over to governor baker. >> thank you very much, fred. those numbers don't price me. as you walk into the room this afternoon you may have noticed on the screen to the faces of individuals who are celebrate on operation unite hope wallpaper recognize them at all those who are rebuilding their lives without of addiction, treatment and recovery. this is the second time this year governors have gathered to discuss the opioid epidemic at our february meeting there was frustration there that will work for it but despite all of her efforts come innovate and change

the trajectory of this crisis, change isn't coming quickly enough. this is particularly to it comes to the inappropriate opioid prescribing practices that many people believe created this epidemic. but governors passed a resolution directing nga to that governors around strategies for changing prescriber behavior to prevent opioid abuse and overdose. governor hassan point out the many factors contribute to the opioid crisis in nga's response to the resolution should support states that taking a holistic approach to the problem. that charge we work with our fellow governors to inject to develop a compact to fight opioid addiction which is an unprecedented effort to court the state actions and response to the crisis. we believe by uniting the governors around a comprehensive set of strategies, a compact brings new momentum to efforts to rein in overprescribing combat stigma and ensure a pathway to recovery for those who need it. .com pakistan's a powerful signal to health care providers, drug manufacturers and others

whose participation in the partnership is critical to ending this public health crisis. i'm proud to report the compact was released this week and as i said previously it has the signatures of 46 governors representing 250 million americans. thank you, governor hassan for your partnership in leading this effort. thank you, governor bevin and how the show went in absentia. i want to thank all of our colleagues who signed the compact and continue our work to lead the nation in fighting this addiction. to further support governors and turning the tide on the epidemic the nga work with senior state officials and other national experts on a conference of roadmap to highlight evidence-based and promising strategies for combating opioid abuse. governors should have a copy before them. if you have questions about this tool please address them to credit during the discussion today or at any point after the session. before we move to the main part of the program on what to turn

on what to turn the floor over to governor hassan for her opening remarks an additional announcements. thank you. >> thank you, governor baker. it's been a real honor and privilege to work with you this year on the nga health and human services committee, as well as with our fellow new england governors to focus on this critical issue which is truly affecting not only both of our states, all of new england but i know all the states represented here, and the others that are not, throughout our country. in new hampshire and massachusetts we have been pushing for urgent action to combat the hair was an opioid crisis and help save lives. and i'm truly proud of the work we've been able to do with our fellow governors. our opioid compact reaffirms that governors from both parties are committed to working on a multipronged and coordinated approach in our individual states to combat this crisis.

we have worked together as a group to encourage additional federal action to support states, including much-needed emergency funding. as a group, governors has also been at the forefront of highlighting the importance of increasing medication-assisted treatment. i'm proud that just this week we approved funding in new hampshire to help recruit and contract with physician practices to develop or enhance their capacity to provide medication-assisted treatment. this afternoon i would like to take a moment to highlight a couple of other ways that the nga is supporting governors in our efforts to stem and reverse the tide of this truly horrible epidemic. as a governors know and we'll discuss more today, a growing number of overdoses are linked to heroin and illicit fentanyl, a powerful synthetic opioid that is often packaged and sold as heroin or counterfeit

prescription painkillers, and is, in fact, more lethal than heroin. earlier this year we took an important step to crack down on that note in new hampshire, bringing the penalty for the illegal sale and distribution in line with those for heroin. as part of our statewide comprehensive strategy that also focuses on prevention treatment and recovery. and today we're announcing a new technical assistance opportunity to the nga to help states prepare for and respond to the threat of heroin and illicit fentanyl as a component of their broader plans to address opioid abuse. during a six-month learning lab, the issue will work with up to seven states to share best practices and take a deep dive into successful state strategies for combating heroin and illicit fentanyl. participating states will learn and gain insights from other states and national experts

about using data to more effectively anticipate, detect and respond to the emergence of heroin and illicit fentanyl as part of a comprehensive and multipronged approach to combating this crisis. in your materials around the table you'll find a request for proposal for the learning lab. if you have questions, please direct them to fred during or after our discussion today. in addition to strengthen the role of health care providers in addressing the opioid epidemic, the nga is also pleased to announce a new partnership with the national academy of medicine, one of the nations most preeminent and authoritative voices on critical issues in health and medicine. and i know in a moment, not just want to check in with my chair, doctor mcginniss is prepared from national academies of medicine to discuss this with us but i wasn't sure, governor baker could want to go to

secretary burwell first? so doctor mcginniss can we would love to hear from you. i can against is a senior scholar at the national academies of medicine and doctor mcginniss, thank you and welcome. >> thank you, governor hassan. i'd like to underscore three self-evident points to i will be very brief but hopefully very clear. first on behalf of the national academies of medicine, thanks to you and governor baker to the nga coming to every governor in this room and in the nation who has given priority to the prevention, identification and treatment of the devastating consequences of opioid abuse, misuse and addiction. second, the issue is clearly personal. we saw the faces and the numbers. and i would imagine that there are not too many people in this room who, when they hear the

word of opioid addiction, don't have a personal face flashed before their minds i. but more than that, it clearly is a complex multifaceted societal challenge resenting conundrums for many stakeholders, for physician, the conundrum navigating between a professional and moral duties to relieve suffering and to do no harm. in the midst of uncertainties around individual variation and susceptibility of circumstances. for social and health policy. the problem that services are often organized around programs and not individuals. and for science in physiology addiction, how it varies from substance to substance and person-to-person. the nature and effectiveness of treatment ranging from like you to behavioral to social, and the critical interactions among each. the list goes on. and because it ultimately our

effectiveness is determined by local action, the centrality of the leadership that reside in the roadmap of the governors is critical as is the national support for the efforts that are reflected by secretary burwell's leadership. third, as the nation's formally chartered independent entity for advice and health and medicine, and national medicine is committed to helping in this work. two examples are important to underscore in the context of the session. first, to up the food and drug administration in its efforts to ensure that its regulatory policies to fight optimal guidepost and the boundaries. we have a study on the state of the science in effective pain management, opioid use and abuse as well as the approaches and

needs to balance individual effectiveness and public health consequences. secondly, to help physicians navigate the difficult challenges of their practices in the context of the uncertainties mentioned. we are partnering with the national governors association the steward of the development of the national academies of medicine white paper that will translate the findings of the study and other contributions into the practical clinician best practices that are needed. we anticipate being able to release it next year in rhode island, and look forward to that partnership and its fruits. so thank you again for your leadership, for the partnership and for the opportunity to be a to emphasize the priority for all of us. >> thank you very much, dr. mcginnis. we are truly grateful to you and all of our testing was to guess here today for your commitment in the fight against this

terrible epidemic. and now i will turn back over to governor baker. >> thank you, governor hassan and thank you, doctor mcginniss. today's discussion will be broken up into two parts. first we are privileged to be joined by u.s. health and human services secretary silvio matthews burwell are following the remarks in a discussion with a governors year, will trigger a second panel of experts from washington state, the dea and vermont. i've had the pleasure of working with introducing secretary burwell more than once who's been a tremendous champion a partner to states and fight against open addiction. pictures also been terrific in managing all aspects and elements of hhs passport photo during her time in d.c. and only have a nga i want to wish you great success in whatever it is you choose to do next. we are very glad to have you here today. >> thank you. thank you, governor baker and governor hassan for your leadership in terms of the

committee and what we are focusing on today. it's a pleasure to be here as always. i've had the chance to see leadership across as a look around this table whether it's a document from my own home state or even recommendations on books to read, governor bevin, about the issue to the work we've seen. so across the board of the leadership that this aggregation in terms of the roadmap presents i have seen in individual states as well. hopefully you feel we all have heard your voices. these conversations we've been having since the first nga i attended right after i was confirmed in terms of the things that you all have been focused on and beat us to partner with, that's a lot of what we have spent our time on. about what i would do quickly is run through an update on some of the core elements of the strategy and progress we've made, it didn't touch on a few other things and then let's have a discussion.

i think you all often with our three-part evidence-based strategy. you all know me. i work in the threes. number one, the issue of making sure that we are having health providers have the tools and information they need. we put out the guideline and now we're taking a number of steps to make sure that guideline goes out. we recently have done a number of webinars to educate providers about how to government the guideline. in addition in the indian health service, we've announced that they'll be using pmp study of the first the agency to make sure that they will be required in terms of the prescribing both for prescribers and pharmacies that are part of the indian health service to make sure we are closing that gap. some of those gaps exist in your state. we've also heard some of the clinician to say that they were concerned that one of our cms surveys in the payments were causing, encouraging the prescription of opioid.

while we have not found evidence of it because of the way the money works, we went ahead and out of an abundance of caution have taken that question out in terms of the financing of the survey so that no one could even, weather was a monetary incentive or not, if people were thinking and believing that, we wanted to take the action. going to part two, that medication-assisted treatment which i know you all are working deeply on, we are as well. you may have heard last week we announced that for be performed mean we but i defy recognition that will increase the numbers that doctors who are prescribing as long as they meet certain conditions because want to make sure we do this in a safe way, that they're able to do. in terms of that expanding medication-assisted treatment as well as we are also today releasing two reports on ways to pregnant women and new mothers because that's a part of this with the medication-assisted

treatment. this is something you all have told us is one of the problems and so we go to reports coming out to help with the treatment insurance of pregnant women. and today we are actually announcing 9 million in grants from art which is our only part of hhs to focus on medication-assisted treatment. finally the other areas in a part of our three-part strategy is naloxone and making sure there's access to that. we are making sure we get access out. we've done some great making but additionally fda also has approved recently by narcan nasal spray. that will create an ability for non-experts to be able to applyy and use it for i know some of your states are leading in and ability to get that out. we also recently convened 18 rural communities about the issue of naloxone and narcan to find best practices so that we can ensure those more broadly with all of you. these are good steps but we know

there are critical areas where we need to know and do more. last week we announced 12 additional studies on the issues of pain and opioid use and abuse and addiction. so we are going to continue together with our colleagues at the man who are doing some work on these issues as well to work on it. we're going to keep working i think you are the one of the things we think is very important is the $1.1 billion we asked for. that's to get the point to you all. i think you all the 920 million of that is about moving money out. to the states sewall and get access to treatment. these would make sure folks in your states have access to treatment because that is a gap i think we consistently see. it would help us also develop more effective ways to make sure we're doing to treatment and recovery services. part of that money is for evaluation so you know we can work with you to know what is

working on the ground in your states. i think you all know a bill was passed in the senate this week. while we will sign the bill, you know, i think the real question is does that truly make a difference without the intent funding to get the medication-assisted treatment out? we've said consistently that the legislation includes important objectives but we are concerned that without funding, and so you will know, we are already planning for september when they come back because we want to continue that conversation. we think it's an important one that should that go into next year. if we watch the clock, in terms of the months that could happen before we get that. so we will be back at that when folks come back. the other thing in terms of access is medicaid. we are working with you all in a number of states to make sure medicaid is able to provide as much access to treatment as possible. and also while we are on

medicaid i will never fail to mention of those states who have not expanded, you know my door is always open. and will be for six months and four days. and lastly i just want to close on zika because i would be remiss if i were not with all of you. because while things surprise us and while many of you are not in the states, some of you are in the states that are the high risk of states, and certainly the governor of puerto rico understands this fully, i just want to a touch on a for a second there i want to thank you all for your partnership, each of your states participating inn putting together the plans and approaches and moving information. so many of you, even if you're not a risk of mosquitoes, you have a travelers and you know that because you're getting to cases in your states even if you're in places. so you know that's an important part. i think i've when those the severe risk of birth defects. we will start seeing those numbers. the numbers were updated yesterday the end of the united states we have 4200 cases of

zika. and in terms of that, in the continental u.s. that are almost 300 women who are pregnant who have tested positive for an indication of zika. so a very serious issue and we expect local transmission which already occurs in puerto rico, meaning the mosquito bites another person and passes it that way. we expect that may happen during the summer months here. we are working with a boy to make sure the plans are in place. at the same time we need to develop a vaccine and the need to develop better tests. when this happens and whoever has local transmission first, and the government knows it, a period of testing sometimes challenging in terms of how long it takes a people will be very anxious for interest. continue to work on that and mosquito control tools. in terms of what we can do to do that. we've already we will be awarding 109th of cdc in terms of the monies we've moved around. we stand ready to work with each

of your states and sent in an emergency response team if you need it let us know. we will be ready. i think it's important to mention the importance of the finest in the funding. without the supplemental during august we will have to slow the work toward a vaccine that is going to happen because we will run out of those funds during that period. it also inhibits our ability get a best practices approach to vector control in place as well as move forward on the diagnostics, and the research we need to do to understand more. quickly i will just close with the fact that this is my last time together with you all. whether in the health of space, whether it's protecting people from something in the medicine cabinet or a mosquito, it is something that we do together. just in these last next month, you all have my deep commitment that we're going to do everything we possibly can to work on the issue that we are discussing today. so that when we leave, we leave

both in the federal government and to you all the states the best and most progress we can make and passed from our success. so excited to continue to work with each of you on this and all the other issues that hhs has that we work together with you. thank you, governor. >> thank you very much madam secretary. [applause] questions, observations? i have one. the first indie a meeting i went to was a summit meeting. and he talked about i think it was 240 opioid prescriptions in the u.s. written in 2014 maybe. do you know what that number is for 15 speakers i don't think, the lack it is one of the big problems we have added a caufield in the states and we depend on your for it. i do think that our next numbers we will see some improvement in the number of prescriptions.

i don't think we finalize numbers but i think we will have some improvements in the numbers of prescriptions and i think you're starting to see that. some states data we're starting to see the. i don't think we have good enough aggregate data yet but i think we will see some. i think the real question also have two jobs ourselves with and i think kentucky and west virginia are tuesday to better see some of the prescribing numbers go down but i think we have to check ourselves of icing the number of overdoses going down? that's the real outcome that in a we are all interested in and i think we have to get the prescribing down but we've got to get the overdoses down as well. spent my follow-up just quickly would be come we talked a bit about this but we've also talked come is a something would work with you folks on with respect to fentanyl what you think is driving some of the deaths in some of the overdoses?

>> i'm sure you all know better than i do that fentanyl is the problem on steroids. in terms of what it's doing to i think we think many of the tools we have in place are the correct tools but the question we're asking ourselves that i put together a working group at hhs gives you the tools be enhanced or change the specifics of fentanyl in terms of how it gets created and how it is being -- getting his. this is a place where the dialogue and this conversation is so important. if you are seeing things that are working in your states, please let us know because we are very specifically focused on the question right now. >> i would just add one of the things we did in new hampshire was update our criminal code to make the giving of illicit fentanyl on par with the giving of heroin. we also started to work with our public safety officials and public health in trying to develop articles for how you

investigate an overdose scene so you can actually prosecute somebody for causing the death through fentanyl. when medical personnel respond they rightly focus on saving the life of the person but that often means that criminal investigators don't have any evidence to work with effectively to try to prosecute. and while this is both a public health and safety problem and we need to go at the support of fentanyl and the production of it in a different way, it's worth talking to public safety and public health at first responder folks about how you can make sure it is clear to those dealing in illicit fentanyl that they will pay a price for doing so. >> one quick comment. it was a good question as the number of prescriptions goes down, will there be a subsequent decline in the number of overdoses? i would caution folks to realize

and has been out experienced to this point, not immediately or necessarily should it be assumed that the will be. ironically it almost exacerbates the problem a little bit. legal prescriptions go down. people are driven to feed the habit through other sources. there are no doctors prescribing like our heroin and yet there's more people using it as a result of the fact that arthur prescriptions. it isn't to say the should of the few prescriptions but there has become already the addiction. this is what has given rise to the and one and others have come and come the synthetics have crept their way into the marketplace. so i think we are actually at the front end and it's sobering and scary for everyone of us to realize that ethic america is at the front and of the number of overdoses gas that we are going to see for centric of time and that's why it's critical we start me take it in the bud. >> the other thing is the should

be some time lag we think the so thathat is some time lag in the prescription reduction and the catcher. we think there will be some but we think we have to quickly focus and that's what a medication-assisted treatment and the north can are important the only other thing i would see why we don't have governor scott here, florida interestingly, and governor baker and i were discussing, florida has seen more of terrible movement on the lines. what we're going to do is understand why that happened in florida and better understand that so a few things that happened in florida company to repeat other places, that we can share that with those of you who are making progress on the prescription reduction. >> i think the secretary has time for one more. governor hutchison? >> i want to thank bg you for your leadership on this governor baker and governor hassan. atlas. i did want to thank secretary

burwell not just for your attention to this matter but also your cooperation with the governors, your responsiveness every step of the way during your leadership. so wanted to recognize that and also i want to be nice because i still have some painting matters before you. [laughter] in regard to this issue, you know, in arkansas methamphetamine is still the number one drug challenge that we face. i wanted to decline but i don't want this to be number one. so we are trying to address this and i share the concern, we have another panel after this on soviet forces on which i'm very interested in because we have to address the demand side which will work as that which we are working on an alternative treatment courts in arkansas. we need to invest more in.

but it is ultimately a law for this site has to be a part of it as well. secretary burwell, all you will coordinate your efforts with the dea and with other law enforcement agencies? >> we are one of the announcements over the period, and i should have, i'm glad your basic of doing to take backs has been an important part of our dea partnership in terms of that work come as an important thing. this was feedback from the governors. you also told us it g8 engage. many of the steps were taken. -- va. takeback is an important part together thing with the dea is taking the lead is the issue of heroin itself and the illegal and illicit drugs that start and prescription drugs can do, when they're not used. so that's the place where they are focusing the most. our connection occurs through the office of the national drug policy coordinator at the white

house but also the chief of staff denis mcdonough has taken interest. we have been interested in this issue for a long time. so it actually has a person in his office t or to direct on the issue with a together and that's where we get our biggest connect with our colleagues at the dea. >> i cannot have the energy i want to thank you for your help and assistance. we wish you nothing but the very best. >> thank you. i will just close by saying acute end where i began when i came in july of 2014, one of the things that is always great about being with you all is actually i think on a day-to-day basis in terms of what you have to do and how you have to deliver in terms of being in the executive branch. it is a place where i am with people who hopefully you know i feel your pain and you feel

mind. so thank you all for all the partnership because with that at all the work on their consummate places as i look around this table that in your states we have made progress for the citizens of the state. that is an exciting thing for me another forward to doing more in the six months and a few days. thank you. [applause] >> i would just like to welcome our three other speakers up to the states. they will each speak for a couple of minutes. and by the way, one is going to talk a little bit about medical and prescriber education. when we talk about drug enforcement and the other will talk about what states experience with treatment. first is dr. gary franklin is one of the nation's foremost experts on opioid prescribing guidelines and educating clinicians on best practices for safe overprescribing.

dr. franklin is a research professor at the university of washington and medical director of the washington state department of labor. thank you for joining us. >> thank you very much governor baker, governor hassan, ladies and gentlemen. on gary franklin, ma medical director of the washington department of labor and industries in recent professor at the university of washington. most importantly i am the co-chair of the agency medical directors group represented all of the public agencies that purchase or regulate health care in washington. i had to work on issue a prescription opioid overdose for more than a decade. in fact, i reported the first deaths in 2005 from unintentional overdose prescribed opioids in a scientific journal. these were injured workers who had increased such as back pain, only to later die from prescribed opioids. by 2006 the public programs in washington already had over

10,000 citizens on doses greater than one to two milligrams a day, morphine equivalent to this one of the strongest risk factors for overdose and by 2008 this resulted in 580 deaths from the opioids, more than half in the medicaid program. in partnership with leading paying clinicians in washington develop the first opioid guidelines in the u.s. with a recommended dosing threshold in 2007. the principles of the guidelines were put into state regulation in 2010, the most recent addition of a guideline is highly consistent with the new cdc guidelines. these efforts have led to a 37% sustained decline in prescription opioid deaths in washington state. washington has also seen a reduction in high dose opioid prescribing in our medicaid population. to reverse this tragic man-made epidemic we must prevent our citizens from becoming addicted

or dying from and about prescribing. optimize the capacity to effectively treat pain and addiction with evidence-based alternatives to opioids and expanding access, and to implement the standard metrics to monitor progress and i'm going to focus on areas where washington has already had success as well as efforts currently underway or that are painting executive action. the first key to prevention is to repeal the overly permissive language passed in more than 20 states in the last 1990s, in the late 1990s which provided a safe haven for over prescribers. doing so in washington allowed us to take action. just yesterday against the most egregious prescriber end states history with more than 18 deaths. states need to adopt and operationalize the new cdc guidelines by setting a prescribing standards through the state licensing boards and

leveraging public insurance programs and the planned context of this effort will only be successful if the governors take action as governor tinsley did to make it collaboration highest level of state government across all the public programs in with leaders of the medical community. a second key to prevention is to protect our teenagers from potential abuse and the path to heroin addiction by limiting prescription to know more than three days or 10 tabs of short acting opioids for self-limited acute pain conditions such as dental extractions and sports injuries. their strong interest in washington sentiment such of them. this type of focused approach is easy to operationalize then limiting all acute prescribing with a wide range of exceptions. they key to improved treatment is to deliver regional, coordinated step care services aimed at improving pain and addiction treatment the this

includes delivery of effective services like cognitive behavioral therapy and exercise aimed at improving function overdose case management for patients with opioid disorder and much broader use of taliban services and multidisciplinary pain care. because both of these patients are managed in primary care settings, the lack of access to coordinate services is a severe threat to the integrity of our primary care safety net clinics. incorporating collaborative care services into the contracts would address this issue it is consistent with the governor call to integrate behavioral health with physical health and primary care by 2020. finally the development of a, our standard set of metrics will be critical to tracking state progress while reversing the epidemic and to the to identify effective strategies that this would provide guidance to public and private health plans to improve quality of these metrics

could also be used to provide useful feedback to out by prescribers comes over to the provide report card shown in this life. i applaud your app and the substantial work of the staff to date on the roadmap. thank you for the opportunity to visit washington's work in strategic direction. >> thank you dr. franklin. i must say, i just couldn't help but share the headline of your presentation with my copilot here, reversing the worst man-made epidemic in modern medical history. pretty strong words. >> that's the way it is. >> we will get the q&a after we give each of the presenters a chance to speak the second of this karen flowers will provide insight from dea on the growing threat of heroin and kind would associate special agent in charge of the chicago field division, ms. flowers lead dea's

efforts to crackdown on illegal drug activity in indiana, wisconsin, minnesota and north dakota. welcome. >> thank you. good afternoon. on behalf of the 9000 dea employs thank you for the opportunity to speak to you today. we are in the midst of a heroin and opioid epidemic that is at historic levels. this does not care who you are, the color of your skin, your age or where you live. and the way to push back is not a new tactic, but it needs to be looked at from a prescriptive, perspective of collaboration across all three pillars of our nation's drug control strategy. prevention, treatment, and enforcement are there is no surprise in the order of the panels today that mayors of the strategy biggest effort exerted on each pillar is a decisive factor in the outcome, at all three are of equal importance.

as you can see in this slide, deaths involving prescription drugs i had all of the drugs. heroin deaths more than tripled from 2010-2014. with over 10,000 americans dead. synthetic opioid deaths which include fentanyl also increased in 2013-2014. this map shows the rate of heroin drug poising deaths per 10,000 by state. you can see the deaths our country and the northeast, midwest as well as the pacific northwest and new mexico would dea has reported steady increases in heroin use. heroin and availability is increasing in most areas of the u.s. seizures have increased 254% since 2008, at the seizures size has doubled. heroin is everywhere. is easy to get.

it's cheap, and the purity is a. these facts emerge with a large number of people addicted to prescription pain medicine are destroying families and taking lives. da is concerned by the increasing threat from fentanyl, a poet and dangers of opioid painkiller. anthan what is a powerful and deadly synthetic opioid which has high potential for abuse. .. fentanyl was discovered in a

black tar heroin form in california but it was fentanyl. much of the illegal fentanyl is produced in china and shipped through the mail system to criminals, trafficking organizations. because of its low dosage range, one kilogram purchased in china 3 to $5,000, can generate upwards conservatively 1.5 in dollars in revenue to the drug trafficker. this map shows large fenn that till seizures and fentanyl-related deaths in 2016. hate shaded are death and yellow stars are folks with seizures from fentanyl. in 2015 dea seized more fentanyl than any other year in our history. fentanyl can be absorbed through the skin or inhaled.

endangering our public safety personnel. on march 18th, 2015, dea issued a nationwide alert to law enforcement officials about the dangers of feign at that nil and fentanyl an a logs. they continue to make drugs like fentanyl illegal. recent spikes in overdose deaths dea emergency scheduled and made concealed fentanyl a illegal drug. we have two other fenn that till anna logs illegal. de-a agents stationed in beijing. david: china, working with the chinese government to top manufacture of synthetic opiods like fentanyl. to include six fentanyl substances. de-a strategically focused enforcement on cities and areas of the country where fenn that till usage is the highest and tar get street level suppliers, sources of supply in mexico and china.

to compliment this action. d-e-a is also pie lotting it is new 360 strategy in four cities which leverages commits federal state and local partnerships to address the problem on three different fronts, law enforcement, diversion control and community outreach. our enforcement activityies are directed at violent cartels and drug gangs responsible for feeding fentanyl in our communities. while also working with our community partners to reduce demand and educate our very vulnerable youth. this opioid heroin epidemic is deadly and touches every segment of society. no one is immune. we recognize prevention, treatment, enforcement have to work together to work against this epidemic. i'm going to go off script here with one comment.

yesterday in chicago we made a seizure of 5.5 pounds of one of the fentanyl anna logs dea emergency scheduled as illegal. along with.5 pounds was a pill press. rolls-royce, approximately $100,000 in cash. this is not a problem that i see going away anytime soon. and i think it is imperative that we educate our citizens of the dangers of prescription pill abuse and how that might lead us into more acceptable to use a pill with the name xanax which is actually fentanyl a friend might give you or find in medicine cabinet even in legitimate bottle when it is actually fenn that till. thank you for your time. [applause] >> thank you very much. to give us a sense how one state chased some of these issues, dr. harry chen, the vermont

health commissioner has been gracious enough to join us about the hub and spoke initiative which is leading the nation in many ways expanding access to high quality addiction treatment. >> thank you, governor. baker and governor hasan. faced with steep increases in the number of clients seeking addiction treatment for opioid addictions and increasing opioid overdoses and increasing criminal cases involving opioids , governor shumlin devoted entire state of the state address to. it was a lonely place to be out in front in early 2014. the actions he took immediately to add more funding for treatment resources to support legislative and regulatory changes in both health and criminal justice systems. vermont at same time adopt ad plan to address this public health crisis.

that is comprehensive including strategies, encompassing prevention, enforcement, intervention, treatment and recovery support. it is essential to recognize whatever we do in all of these spaces, to stem the tied of opioid problem it requires a coordinate the approach on the federal, state and community levels. so here we were, ready to invest money in treatment but at the same time our waiting lists were getting larger and larger. we just didn't have the capacity. so it was clear at that time we had to do something different. in doing something different really meant reforming our health care system. we developed an integrated approach to health care reform combining the health homes provision of the affordable care act to actually get 90% reimbursement for medicaid for eight quarters. we were able to leverage in our current payments and delivery

system reform called the blueprint for health using community health teams and advanced practice medical homes. this was a partnership between the health agency which was the substance abuse authority, and the medicaid agency which provided the outpatient treatment. importantly we had to measure our outcomes and our costs to know if we were making progress. from this came the care alliance for opioid addiction t was a regional approach for delivering medication assisted therapy to providers who suffered from opioid drug addiction. the care alliance was designed to coordinate addiction, treatment with medical care, counseling and support services using this infrastructure of the community health teams to effectively treat the whole person as they make that i way along the path to recovery. we know from the literature that medication assisted therapy works, an effective treatment

that involves prescribing medication, methadone, naltrexone in combination with counseling. this approach includes reduced drug use, better social functioning, better health, reduced criminal activity and reduced disease transmission and importantly reduced drug overoverdose. getting more details about the care alliance. the pieces include the hub which is regional opioid treatment center responsible for coordinating care and support services for patients who have the most complex addictions. those with ohio curing disorders they can be treated with methadone or bup morphine. there the are spokes which are medical home or primary care practice responsible for coordinating care and support services for patients with addictions m.o. have less complex medical.

they are treated with boo present nor mean in the spokes. how are we doing? in terms of health care costs we're worried about the black hole of substance abuse treatment in our budgets but overall the the health care costs for individuals treated with medication-assisted treatment did not increase in total. there was reduction in high cost emergency department and hospital utilization. more primary care and less specialty care. in terms of the important concept of social functioning employment, family life and quality of life, retention and treatment in the hub and spoke system resulted in a much improved outcomes and those who left prematurely, whether it be from leaving, moving, going into corrections at lower levels of improved functions.

other costs importantly must be considered the cost of corrections and social services of the we have plans to evaluate that but as you can imagine it is a pretty remarkable under taking. in terms of recommendation to the this group, treed addictions like any long term chronic disease. in chronic disease 20% of the people use 80% of the dollars. this is true of those with addiction. insure adequate capacity and system of care to support individuals and treatment of recovery. we have enough providers prescribing methadone or boo pen nor mean. important integration for ongoing patient support and integrated and holistic system while obviously the question, can you afford it? you answer is you can't afford not to do it. finally clear everyday reminders have to be part of the solution. with that we have two statewide campaigns, one is vermont's most dangerous leftovers. how to use and dispose of drugs

and second one is paradox. educating parents about their role talking with their children about drugs and alcohol. so thank you for the opportunity to share some of our experiences in the opiate crisis and addiction and overdose in vermont. i'm optimistic we're seeing light at the end of the tunnel but we have a lond way to go. >> thank you very much, dr. chen. [applause] >> thank you, karen flowers and dr. franklin as well. questions from the governors? >> thank you. and from the members of the panel. i just want to bring a little bit of touchy subject but not, just for discussion but to see if there is, any consideration of having from any of your states or the dea.

when i was state senator just from the fresh liquid brings to me some article and studies that he thought that i should consider i asked my staff to include one of those articles. all of us have it right now is an article by glen greenwald, professor. on drug addiction in portugal. this is very touchy subject i know. just to give you numbers, in

2001, people that died by heroin and opiates in portugal, where it was 281. in 2006, it was 133. they -- all drugs. just, i know, it is very touchy subject but i think it's a good article to take a look at. on page 18 there is a table that shows how the decline, number of dead people by consumption of illegal drugs. it is something that, i am, i haven't been able to put forward in puerto rico. i wish but i, just want to be serious consideration. i just want to know for you, you study these or what is your

opinion on these case studies that is happening with great success in portugal? nice softball to start of the conversation with. >> fire away with dr. franklin. >> i didn't have time to go through all how this started, if you don't understand how it all started in the late '90s you're not going to be able to reverse it. one of the things we recommended, most health care delivery is regulated at the state level through boards and commissions. the folks that wanted to make it more permissive to use opioids. we have language that no doctor shall be sanctioned for no matter how much opioids were. even if you egregious provider

or pill mill, it is very hard for our medical boards and commissions to take actions against that sort of stuff. so it is important to realize that it is the oversupply and overprescribing that has led to this and it was based on false teachings by some of our leaders and drug companies back in the nate 1990s. >> i'm looking forward to reading this report too. the main, the part i struggle with when people talk about decriminalizing this, we did. it is legal. the 240 prescriptions that secretary burwell were talking about, those were all legally prescribed, for the most part written in this country and part of the authorized approach to pain management that grew out of the reforms of the early 2,000s. i'm one of these people who thinks we're dealing with that right now. so it is very hard to for me to understand how that, sort of fits with this. but i'm looking forward to

reading it and seeing what it says. >> so the only thing i would add to that, there is no question this is a complex issue of addiction which is not all about pills although we know that doctors overprescribe in the 1990s, in hospitals encouraged them to do so because of satisfaction surveys and joint commission created pain -- at same time when essence when we use mat, to some extent you could say that is legalizings right? we are giving people opioids to make them stable, to make them healthier, to allow them to become productive members of society so they don't have to steal to get drugs or to risk the overdose related to the illicit drugs. >> governor. >> couple of different questions real quickly. just a quick question of the

dea. what if anything can be done to stop that flow from china to mexico, the one you cited? are there simple things that can be done to target, like a laser on that channel for fentanyl in this instance? >> it's a multilayer approach and we do have an office in beijing in conjunction with the state department and our headquarters. in our working groups in the d.c. area, working on the issue with diplomatic relations in china and how we can augment or assist or educate them on the problems here and what these substances, the habit they're creating. i think we had very successful relationship with the chinese government and the medical community and keeping that dialogue open. so i'm optimistic with their recent, you know, they decriminalized over 100 chemical substances because those were fentanyl analogs. to get to that point the

dialogue is open and they are sharing information with us. as we're seeing more of it and we show them more examples, here is the chain of evidence that shows that it came from this chemical company in this location in china. what are you going to do about this? i think that's something we'll continue to do and push forward with. >> thank you. another couple quick questions. dr. franklin, your thoughts, i'm curious on your thoughts on buprenorphrine which is known asnal locks own, which is the brand name? your thoughts on effectiveness of it? has anybody done percentage of it? you mentioned dr. chen as one of the spokes. has anybody ever studied percentage that is prescribed actually used by the individual who it was prescribed versus that which is resold on the street? >> i'm sorry, i don't know the answer to that. dr. chen? >> your thoughts on it as a drug, do you think it is effective drug for treating opioid addiction?

>> i think it is an effective drug for treating opioid addiction but we need to take approach, this is special population that started out with prescription opioids and our state guidelines and our workers' comp guidelines focusing first of all, trying to taper the drug in patients and having algorithms for primary care and pain clinics to taper alongwith the possibility of adjunctive medication like buprenorphrine, and if that, if you taper 10% a week or something like that, we actually have no data how often that could be done. that would be the first step. if that fails, either in primary care or in a specialty, with addiction help, then we would probably allow medication-assisted treatment for opioid use disorder because some people think that's a brain disorder that will be there the rest of your life. so, but we really have no

empirical data to say, you could get half these people off, and we've had examples of injured workers who were on huge doses that got off within a fairly short time and did pretty well. we need more empirical data on that approach. >> if i could try to address your question, i think the, one point is that we know from the evidence that methadone works very well. we've been using it for decades. we also know that buprenorphrine does work in a very similar way in terms of the outcomes measured against the terms of criminal activity, in terms of health. your point about street use of buprenorphrine, is a good one. i think there are two issues to that. i actually spent a morning in a clinic prescribing buprenorphrine to people. as a pinch-hitter. i asked everyone of them how they started in? i asked everyone of them what things they went through. and a lot actually started with street buprenorphrine. this is really self-medication as much as anything.

some of them said, yeah, i got high a little bit in the beginning. but after that it was just about not withdrawing. so, if you have demand that's not meeting supply, then they're going to buy it on the street. i think there are ways to be more mindful how you regulate buprenorphrine prescriptions. we have to be careful, not getting into another set of pill mill situations. the pill mills are buprenorphrine, not opioid. strong best practices how you prescribe it in a system of care is very important. >> governor, one final question/comment, and it is something i would challenge us as governors to think about. what know what the number is but i think is significant portion, percentage of doctors educated every year in the united states are educated in our public universities. certainly some high percentage of them are. and i think one of the things as i looked at this, i'm hardly an

expert on it, one certainly affected kentucky significantly. communication is critical. part of the communication the points you're making as well as education, you've been calling people's attention to it for decade plus, i have talked to doctors who have had no real education whatsoever in pain management prescription. they really haven't. it is not a part of the protocol for them to become doctors. it is starting to potentially become part of it now. but i wonder if we could not collectively in the nga, working perhaps with you, dr. mcginnis and you and others that looked at this for a long period of time, come up with a, a course for lack of a better term, that would be standard, that every single doctor, start with our public universities that we have more control over, but ultimately that every doctor in america would have some basic level of training in understanding the pain management drugs more so than they now do.

and i wonder if we did not all put ourselves behind it, short of demand it, at some fundamental level, at least within our public university medical schools, that we might not be able to turn this, because i think we are now reaping what was sown many, many years ago. that some of you found earlier than others but a lot of this prescription problem came out of a lack of understanding and fun fun trust that was -- fundamental trust, placed in information that turned out not what we believed it to be. i don't even know if that's a question. it is just a thought. i was curious, dr. mcginnis, do you have any thoughts that is even feasible? >> just so you know one of the elements of the compact talks about educating prescribers. i know in massachusetts the medical schools, all four of them, including the public one, dental schools and nursing schools have all committed to a

opioid therapy curriculum which you grant graduate unless you take and pass. we also now as you go through your ceu process you have to incorporate opioid therapy as part of that. i know that happened in a number of other states. i look forward to what dr. mcbegin -- mcginnis around nga and prescription provider piece but i can't tell you how many clinicians have said to me when we got into pretty pointed conversations about this, you know, i really don't know as much about this as i probably should and most of the docs who write most of the prescriptions are not ortho pods and oncologists. they're family practice, primary care. this is a really big and really important issue in this conversation. i think the idea of getting everybody's state school, if you have a medical school into this process or a nursing school or

dental school, i think that is a really good idea. do you want to? >> just briefly, to underscore and endorse your observation i would imagine that the piece that we'll be doing in partnership with the nga will not only identify the kinds of guidelines for providers on the front line, but also what's necessary in the educational process to improve the circumstances. >> governor walker. >> thanks, governor baker. to governor bevin's point, i'm sure this is true, both those that have panelists here and other governors are represented, two things come to mind in your question. partnership and cooperation, charlie you alluded to it with the medical colleges we found same thing with our medical schools but going to speak with our state medical society,

realizing this is wasn't something we could do to them. we needed them to be invested and still needs to be that. it is not just changing their mind or the medical schools. it is changing our minds of patients. example i often give, you go to urgent care, my kids are in their 20s, but when i was younger them spending every other weekend in emergency room and or emergency care with lot of football parents with some injury along the way. every time you go into urgent care, what is the sign you see up there? the sign with different faces tell you what level of pain that you have. well that's instinctive. not they weren't trained. they actually were trained not just because of reimbursements and things of that nature just in general the patients said, doc, give me something, i'm in pain. and so the thing they were missing wasn't the lack of how to deal with the pain but how to deal with it effectively without going on path that we're on

today. so we have to get people to buy into that and it will take a comprehensive approach. at least we found in our state, i love the things that we heard from the panelists here today. we'll take that back and match it with the things we're already doing but, it's certainly something we can't, either in state or at the federal level just dictate to people and expect it is going to work unless we get them to have some buy-in with the medical schools, dental schools, our nurses and otherwise. it has to be a partnership. >> governor? >> i just want to make the following point. our state, connecticut, has been dealing with this issue, i've been governor six sessions and we passed comprehensive legislation on this issue, five of those years and thought we got ahead of the problem. and i am going to say this and some people certainly can have

the right to disagree. i think our discussion today is largely about where the problem was three years ago and we're coming up with a response for what we probably should have taken on three years ago at this rate. i think, what i would say is the lasting effect of the introduction of some of these opioids and now with the addition of easily-accessible fentanyl is the cost of heroin or its alternative is now so low, and will remain so low, we're seeing people becoming addicted not first of all, to a prescription but it has moved to a very rapid, becoming addicted to something you can buy in a dose in my state for as little as $3.50 to $10, and a product, if it is pure -- heroin without

fentanyl is up to 71% purity as opposed to 15 or 30% purity when we were all, many of us growing up in this room. so yes, we do have a prescription drug transference problem, i'm not denying this, but i think people have to understand how cheap this is, how quickly people become addicted to it, and then of course the added factor of fentanyl when introduced as a mixing agent or replacement for heroin when the person runs out of heroin to put in the packets is causing death. as i have said, in a four year period of time we've seen fenn that till in -- fentanyl in our toxicology reports go from 14 deaths we're predicting 170 deaths. doesn't mean they intentionally took fentanyl. they thought they were taking heroin with 8 percentage of fenn

fentanyl and died of combination n new haven, four weeks ago we had someone selling as heroin mixes were largely fentanyl. 3 people died immediately. 15 people in total lot of consciousness. and, some of those folks, this was, a relatively new product for their ingestion. final, point, we need to talk to high schoolers we can worry about knee replacements or dental surgery, this stuff is so ubiquitous, you don't need to be hooked to something else before you are hooked to this? >> well-said. we're about to run out of time and we want to thank dr. flowers and dr. chen and we look forward

to working with dr. mcginnis and you and your colleagues going forward. i do want to give vice-chair hasan a chance to offer some final thoughts here. >> thank you i join governor baker and others here thanking all the panelists. i think all the comments reflected where we are, what work we still have to do. but i was, the saturday, just day before easter hosting our easter egg hunt on the front lawn of our capitol, as happens i would expect to most of us, if not to all of us, people throughout the day came up to talk to me and often would talk about this very issue. a loved one they had lost, child's friend who just died of an overdose. another person, maybe a colleague they knew who had been rescued by narc can.

most poignant thing a woman approached me holding a baby, introduced her heavily, introduced her baby. i asked how hold she was. she told me and i said he was very cute and glad she had brought him to the easter egg hunt. and she looked at me and said, you know actually this is not my son. this is my grandson. we lost my daughter to an overdose last month. his mother. i admired the bravery of that grandmother in coming to the easter egg hunt the month after she lost her daughter to an overdose. it reminded me of the urgency of this issue and we look at this life clock today, i think it is three more lives have been lost since we started this discussion this afternoon. i am reminded in that story of the bravery of all of the survivors and people in recovery

who have been willing to overcome the stigma which has been part of this problem. and i also admired her optimism in bringing her grandchild to the easter egg hunt, trying to make sure that that child will have the future we all want all of our children to v while there is much work to do. i have great confidence in the capacity of our people to do it and our states do too. so thank you. >> thank you, governor. [applause] thank you all for being with us today. very much appreciate it. look forward to everybody working on their compacts and chasing this one as hard as we can, thank you.

[inaudible conversations] >> coming up in just under half an hour we'll bring awe discussion on russian and nato capabilities for underwater warfare hosted by center for strategic and international studies. that starts at 1:00 p.m. eastern here on c-span2. coming up this afternoon, c-span will be live with the democratic presidential candidate hillary clinton. she hold as campaign rally in florida today at the florida state fairgrounds in tampa. we're hearing she could announce her pick for running mate today. we'll have that news and live coverage of her campaign rally starting at start 4:30 eastern c pan. you have a front row seat to every minute of the democratic national convention on c-span.org. watch live streams of the convention proceedings without commentary or commercials. use our videotaping tool to

create your own clips of convention moments and share them on social media. read twitter feeds from delegates and reporters in philadelphia. our special convention pages have everything you need to get the most of c-span's gavel-to-gavel coverage. go to c-span.org/national c-span.org/national/convention. they are for what you want on desktop, laptop, tablet and cell phone. our special convention pages and c pan.org are a public service of your cable or satellite provider. so if you're a c-span watcher, check it out on the web at c-span.org. >> we'll be live with the discussion on underwater warfare starting at 1:00 eastern. until then we bring you a discussion on campaign 2016 froo this morning's "washington journal." >> host: joining us from

atlanta, emory university, alan abramowitz, political parties everything related to election campaigns. professor, thanks for joining us this morning. >> guest: i'm glad to be with you. >> host: can i take you back tot last year, you wrote in a paper this sentence, i want to start with this, you said a growingg number of americans have been voting against opposing partyy rather than for their own party. can you talk, expand what caused you to write that? can you also apply it to what you're seeing this year? >> guest: sure. we were looking at data on attitudes towards the candidates and political parties going back over the lags -- last 60 years from surveys that have been dono every election year and what we noticed over the past couple decades that there was anwas an increasingly negative view of the opposing party and its leaders from both democrats and republicans have come to view

the opposing party and its leaders much more negatively than they did in the past. so while our feelings toward our own party have not become more positive, our feelings toward the opposing party have become increasingly negative and that has in turn led to actually stronger party loyalty and straight ticket voting becausean the other party is simply viewed as an ahn acceptable alternative. and certainly we're seeing that play out in this year's election. the, at the republicanan convention over the past few days we've seen speaker afterwo speaker focus very heavily on attacking the open -- opposing nominee, hillary clinton that has been perhaps the single unifying factor at the republican convention this year. their is divided in many other ways but there is agreement onhe the fact that they really dislike hillary clinton.

and i think we're going to see something similar at the democratic convention. i'm sure we'll see a lot of attacks on donald trump and on the republican party. not perhaps the same degree of division over the democratic nominee as there was here over the republican none knee but certainly we'll see a great deal of negative energy focused on the republican candidate and on republican party in general. >> host: professor, we hear a lot about this campaign when it comes specifically to the candidates about their negatives and both of them being high. how do those factor into the decision-making processes and officially with the democratic nomination coming up what does it mean for hillary clinton to have high negatives? >> guest: we have two nominees this year who have the highest negatives of any major party nominees in recent history. now, part of that has to do with the fact peculiar to these

individuals but a lot has to do general tendency in recent years of negative views of opposing party and its nominee. so what we see is that in fact. among supporting party, i love the party's nominee not as positive as the party we've seen in the past. but a very negative view of the opposing party's nominee. so republicans are not necessarily crazy about donald trump. there is division ono donald trump. for the most part they dislike hillary clinton. we saw that play out at the convention. on the democratic side of course there are many democrats who have reservations about hillary clinton. and we saw him struggle in the primaries to overcome bernie

sanders's challenge. but, at the convention what we're going to see is a sharp focus on donald trump and on the weaknesses of the republican party and its policies. and among democrats we see also a very, very negative view of trump. among supporters of each party there are many individuals who are less than enthusiastic about the party's nominee but who will vote for that nominee because they intensely dislike the other the other side and other party's nominee.mo >> host: our guest, alan abramowitz, emory university how they vote campaign 2016 ask him questions on the line.e. democrats, 202-748-800. our first call for you, sir, comes from texas. comanche, texas, republican lin

you're on with our guest. ask him a question or make a comment. >> caller: i would like to make a comment. good morning to you guys. pretty much the same on both sides. you got, you know, the republicans don't want hillary in there which is, that's a good thing and then some of them don't want mr. trump in there which i don't really understand except the fact that he has never really been really a politician and they don't really care for that. then you got it going the same way on the other side. the democrats are talking about how, you know, some of them are saying that hillary's just a great thing you know. which we all know is not true.ot they have also got some of them that are saying going to vote

republican. in my opinion i hear more people talking about not voting for hillary, voting for donald trump than i do hear going the other way. so i'm pretty sure that donald has this wrapped up and in the bag and you know, people know that when they listen to hillary clinton or any of clintons it will be a lie. >> host: mike thank you. let our guest respond. >> guest: he doesn't have it in the bag. in fact what polling indicates, we're probably headed toward a fairly close election and that hillary clinton probably has the advantage, if anything. the outcome is not certain byt any means, but in the polling leading up to the conventions, we saw that clinton had an average lead in national polls of about 3 or 4 points. and, she is leading in most of the swing states. so i think we're heading towards a competitive race and the

basically that reflects the fact that there is a very close division between supporters of the two parties in the americane electorate. with democrats slightly outnumbering republicans. and we're going to see probably very high degree of party unity in voting and a lot of straight ticket voting. that is what we've seen in other recent elections. i think that is what we're going to see in this election.n. and key to winning the election is going to be probably been turnout. which party is able to turn out core supporters in larger numbers. frankly there are very few swing voters left in this country. the voters up for grabs and persuadable are small minority. vast majority of voters have their minds made up. >> host: westfield, massachusetts, independent line. john, hello. >> caller: good morning.

what concerns me, gone by now.y democratic leadership wasde clearly against mr. sanders and for hillary and by their.s by the use of superdelegates, did a job on bernie. didn't have a chance. didn't help the media point out, the fact, most of those hillary's lead was uncommitted votes. also on the other hand republican leadership was not for trump yet they they couldn't stop him. whether democrats are more devious or how did that comegu about? >> host: professor, go ahead. >> guest: i don't think hillary clinton won democratic nomination because the democratic party leaders were

being devious or somehow manipulated the nomination process. she won it because she won a lot more votes in the democratic primaries. if you go back and look at polling she has been leading in the polls on democratic voters from the very beginning. it did get fairly close at one point. sanders certainly ran a strong campaign challenging her and won a number of states and large number of delegates but clinton maintained the lead throughout. and in the end she won far more votes in those democratic primaries and her lead in delegates reflects that. the superdelegates, mostly supported her from the beginning new her and her confidence in ability winning election. clinton won a lot more votes in the primaries and won majority of delegates selected in the primaries. >> host: because of senator sanders, what does history suggest about the people really committed to him, as far as

either staying home and not voting or voting for another candidate all together? >> guest: we can look what happened in 2008 with supporters of hillary clinton after barack obama clinched nomination. eventually a large majority came around to voting for obama. what we're seeing this year iss something similar.r. what the polling has shown us is that already, we're seeing large majority of sanders voters are favoring hillary clinton, supporting hillary clinton at this point. there is a minority that are still holding out. very few of them are supporting donald trump. so even though trump has made some gestures towards appealing to the disgruntled sanders voters, very unlikely very many sanders voters will end up voting for donald trump because they are on the completely opposite side of almost everyy major issue.

and they really dislike trump. what the polls show us, sanders supporters dislike trump more than clinton voters dislike trump. i think it is very unlikely you will see much of a crossover vote from sanders to trump. the real question there is whether the sanders supporters s will turn out. especially the younger ones. younger voters tend not to turn out in large numbers anyway. many sanders supporters were under the age of 30. clinton needs a strong turnout from those younger sanders supporters. if they turn out they will vote for her. they are not going to vote for donald trump. >> host: gold beach, oregon, democrats line. hello. >> caller: sorry, it is early here. i've been listening to the program, professor is, i was a sanders supporter and i'm kind of disappointed he got out of the race. kind of looking forward to it but i'm seeing more of a

grassroots thing. like in both parties there is opposition to the party structure and the people feel as though their voices are not being recognized and i'm wondering what the professor thinks of that as there might be a change in results because hillary and, when they were both party insiders, running against each other with hillary and obama, it was a differenttobama, situation now? >> guest: i think supporters of the defeated candidate are always going to be disappointed in the results. as far as insider versus outsider. certainly on republican side, donald trump ran as an outsider, i think overcame the opposition of the republican party establishment.e i think many of them were quite shocked that he was able to doab that and to defeat this large group of much more experienced candidates. on the democratic side, on the other hand, i think the

difference is that democratice voters by and large are not as dissatisfied with their party. and with its leadership. in fact, one of the keys here is that democrats overwhelmingly approve of the job presidenter obama is doing. among democrats, almost 90% approve of obama's job performance and even among sanders voters, over 80% approve of obama. so, i think you don't have the same kind of discontent with the party leadership on the democratic side that you have on the republican side, where there is great deal of frustration i think with the ineffectivenessit of the republican leadership and its inability to deliver to promises they made to republican voters. unrealistic promises in my opinion. >> host: democratic line. you're on line with alan abramowitz. go ahead.ce

>> caller: i heard a lot of reference to poll showing unfavorable ratings on each candidate. i was wondering whether polls show unfavorability ratings fora trump among registered republicans and whether they are higher or lower than unfavorability ratings for clintons among registered democrats? >> guest: right. so fine when you look at views of the candidate among republicans and democrats is that republicans, generally have a favorable opinion of donald trump but there is a minority there, or at least there has been up until the convention who continue to have negative view of trump. so generally about 70% of the fact that republicans have positive view of donald trump. still 30% don't particularly care for him. keep in mind a majority of republicans in the primaries did not vote for donald trump. now that may change following the republican convention.

we'll have to see what the a polling shows. trump's ratings have been going up among republicans but not among democrats and not among independents. on the democratic side, we see that large majority of democrats actually have a favorable view of hillary clinton. they may have some reservations about her but most of them actually like her. they intensely dislike donald trump. so on both sides there is a generally positive view of the candidate from their own party and a very, very negative view of the candidate from the opposing party. >> host: so professor, we heard from an independent. how do they factor as far as how they look at candidates and who they will vote for? >> guest: well, that is a great question. there are a lot of people inat this country who call themselvea as independents or like to think of themselves as independents but what we find when we look a little more closely that the large majority of those independents lean toward one party or the other, and the attitudes of those who lean toward a party and behavior of

those who lean toward a party are actually very similar to the attitudes and behavior of those who openly identify with a party. so, independent democrats think and act very much like democrats. independent republicans think and act very much like republicans. when you take out the independent leaners, as we call them, you're left with relatively small group of pure independents, independents who have no partisan leaning. that groups makes up less than 10% of the electorate. one thing about them, they tend to be the least interested in politics and least likely to vote of any group. so really the electorate is a lot more partisan than ity appears if you just look at the responses to that first party identification question. not only do vast majority ofvo voters identify or lean toward a party but in recent elections

there is extremely high party loyalty in voting. 90% plus of democrats and republicans vote for their own party and they vote right down the line for their party's candidates for house, senate, and even down to the state legislative level. so we're seeing a very high degree of consistency in voting and high degree of consistency in election results. consistency between the presidential and the senate and house elections but also consistency over time. and so we're very likely to see that the alignment of states in the 2016 presidential elections is going to end up looking very similar to the alignment of states in the 2012 presidential election. we may very well end up with an election which no more than a handful of states actually switch sides between 2012 and 2016 or possibly even no more than one. o right now, in the state polling we're seeing indications that

the state of north carolina mayh be the only state that switches sides between 2012 and 2016. could very well go for clinton by a narrow margin although it is very, very close there. so we're going to see alignment very similar to the strongly democratic states will remain strongly democratic, strongly republican states for the most part will remain strongly republican.ng that reflects reality of a very, very partisan electorate. >> host: let's hear from john in pennsylvania, republican line. >> caller: yes. i'm registered republican and i am also a never trump person. i, it is not trump's policies that bother me. it is the man that bothers me. i, this is the only candidate that i have ever been familiar with, i knew trump from goingha through atlantic city. trump was the biggest casino owner at one time in atlantic city.

and he has been a disaster. three of his four casinos in atlantic casino was on the boardwalk. trump world's fair, trump plaza and trump taj mahal. and these casinos on the boardwalk was bus casinos. every government check written, social security check, retirement check or income taxco check, any check that was given out trump had his buses there to bring them people there to steal their money off of them. there was never any kind of fairness in the way them machines paid out down there. he is, trump is the only casino owner in atlantic city, maybe only casino owner in the worldnl to have his casino manager shot dead in his casino because ofs the cheating down there.

>> host: okay, call, think. person has strong opinions. >> guest: as far as looking at mr. trump and his business experience, how does that factor in people's decision making? i want to bring awe tweet. this is michael off of twitter. trump is not your father's gop candidate. he relates that to polling abou' support for mr. trump. boil that together as far as how people look at mr. trump and whether they decide to vote for him?il >> guest: i think business back ground and experience cuts both ways with trump. there are obviously people who tend to view him as successful businessman and see that as a positive. there are other people who kind of look at the negative side of the record, at the bankruptcies and at the history of sometimes perhaps refusing to pay people who work, did work for him. reports along those lines. people can interpret that either way and not surprisingly, what you find is that people tend to

interpret that information in line with part sanes dispositions. in other words, democrats will tend to look at the negative side and republicans will look at the positive side. it is very true that trump is very unusual republican. in fact, he really has no long history of affiliation with the republican party. he is only become involved in republican party politics quite recently. never run for elected office. never held elected office. so yes, he is very unusual, but i think it just reflects the strength of party loyalties in the united states today that despite that fact, despite the fact that majority of republicans in the primariesic voted for other candidates, and many of them at that time had rather negative opinions of mr. trump, that by now the large majority of republicans come around to supporting hill. when it comes down to a choice between donald trump and hillary clinton, i think you will see

the vast majority of republicans, despite any reservations that they might have about mr. trump himself, about his record, experience, some of the positions that he is has taken, they never will vote for trump. same is going to be true on the democratic side as well, i think reservations have not been quite as great there for the most part but certainly there are plenty of democrats who have concerns about hillary clinton. when it comes to a choice between hillary clinton and donald trump, i think you will see again that the vast majority of democrats are going to vote for hillary clinton. that is, for the most part the polls have been showing us thus far. >> host: from houston, texas, democrats line, ashley.n, you're up next. >> caller: good morning. i am a democrat, so naturally i'm going to probably vote for hillary because she's a democrat and i think a very qualified lady.

trump scares me to death. i worked in the houston trauma center here for 30 years. we had emergency medicine on one side and we had psychiatry on the other side. i personally don't think trump is stable. i think he's a complete far sy sift and can only think of himself. that is the definition after fares sift. -- narcissist. i think he is not qualified to be president. that is the way i feel. and i thank you. >> host: i think that is probably the way most democrats feel about mr. trump. i think some. concerns expressed by the caller are shared by very large percentage of -- >> we are going to leave this discussion of this morning's "washington journal to go live to the floor of the u.s. senate for a brief proforma session this morning.

the presiding officer: the senate will come to order. the clerk will read a communication to the senate. the clerk: washington, d.c., friday, july 22, 2016. to the senate: under the provisions of rule 1, paragraph 3, of the standing paragraph 3, of the standing >> washington dc july 22, 2016, to the senate under the provision of the standing rulese of the senate i hereby appoint the honorable mike crees oh, senator from the state of idaho to perform the duties of the chair. the >> under the previous order the senate stands adjourned untilti 10:00 a.m. on tuesday, july 26, 2016.