look at that again. if you believe we need additional legislative tools for you, to look at it, review it, give us recommendations as to how you think it could be best shaped to protect consumer and address this issue. do you believe that it would be helpful if you did have legislation? >> absolutely. in particular in the data security area, currently we don't have fining authority. we have advocated for data security legislation that would give us the authority to seek civil penalties against companies that don't maintain reasonable data security practices. >> i would appreciate if you review what we had proposed. obviously it has to be updated. i'll do everything in my power to see if i can get senator levin to get engaged as well. he's pretty important in some areas, not others, but some. >> i'm not a tough sell in this area, i want you to know. >> thank you. >> i'm glad you made reference to the question about whether we need additional strong federal policy.

your written testimony says that the commission continues to reiterate its longstanding bipartisan call for enactment of a strong federal data security and breach notification law. is that still the position of the commissioner? >> absolutely. >> mr. mass mastria, do you want to comment? very taken a look at the possible legislation, for instance, that senator mccain made reference to? >> i am generally familiar with it but as a self-regulatory body, we do not weigh in on the legislation. we leave that to our founding trade associations to do that. >> are you done? >> i'm going to try to finish, if not, i'll be right back.

>> mr. mastria, the association has -- requires its members to publish the names of parties that do data collection for -- on or for their website. it's a link to their privacy disclosures. is that correct? you -- do you require that of your members? >> we do require notice and transparency. >> do you require your members to publish the names of the parties that do data collection on their website? publish on their website? >> no, we do require disclosure via a website. >> a website, okay. >> do they identify on that website which of the parties are not members of your association? >> so if you go to our choice

tool, all of those -- all of those folks participate with the daa either directly or indirectly. so all 115 or 117 that are on there certainly are affiliated with us. >> not necessarily members. >> we're not a membership organization. they have to certify they abide by our standard. >> everybody on that website that's listed is affiliated. >> yes. >> okay. there's a provision in there as i understand it, you have a website called aboutads.info and they can visit with a few clicks and see a list of every participating company tracking their browser, is that correct? >> it is a list of all participants affiliated with the daa, as you characterize, that do work to be intermediaries in the advertising space.

>> they can opt out of receiving advertisements. >> there's an opt out button that effectively occupan opts o everybody. >> the opting out as i understand it prevents consumers from receiving targeted ads based on existing cookies, is that correct? >> it is based on cookie technology, yes. >> no, does it prevent consumers from receiving -- >> yes. >> targeted ads? >> yes. >> now, when you opt out with one of the participating companies, the companies, still however, is it not correct, have the ability to collect future data about you as you travel the internet? >> so the -- >> is that a yes? >> so in some cases yes. but there are prohibitions against the collection of certain data for interspace advertising. >> that's generally true, is it not? >> yes. >> i'm talking about in terms of what is allowed for collection for intraspaced advertising. they can continue to collect future information?

>> yes, i can only speak to what our program covers. >> your program does not prohibit the collection of future information, is that correct? >> it does prohibit the collection of future information for interspaced advertising but not necessarily if there's something else going on. >> in other words, if you opt out, those companies can no longer collect information for interest based advertising for you? >> that's right. >> now, do they have to delete the data that they've already collected on you? >> based on the opt out -- the retention policy that we have is tied to, they are allowed to keep it as long as there's a business need -- >> that means they are allowed to keep it. >> until there is no longer a business need. >> obviously. >> but they are not required to

eliminate the data they've already collected. >> that's correct. >> but they cannot use it for interspaced ads. >> now, this as i understand it, if a consumer clears out all of the cookies on his internet, then because this is a cookie based opt out, that unless a interest based advertiser technology sees that cookie on the person's -- on the person's computer, they can then send an interspaced ad, is that correct? am i stating it correctly? >> yeah, so the clearing of cookies is an issue. and in 2012 we enabled a suite of browser plug-ins which solved that issue. it effectively -- >> if you eliminate all cookies

nonetheless, the opt out will still function. >> that's right. >> all right. so the consumer does not have to continually worry about opting out. once they have opted out, that will continue to be effective. >> using the browser plug-ins effectively creates a hardened cookie the way we sort of jargonly talk about it, yes. >> that's helpful, thank you. >> have you considered an opt-in approach instead of an opt-out approach? >> so, senator, there are certain categories of data for which our codes actually do require opt-in. >> how about the interest based ads? about interest based ads, they work on, as described earlier, there may be an audience that's more interested in outdoor furniture versus --

>> i understand that. have you considered an opt-in approach for interest based ads? >> no, the opt-out model seems to work, especially when putting consumers in control. the opt in -- >> how about asking consumers, would you prefer an opt in or opt out model? >> we don't ask those questions, we do ask consumers -- >> but your members, your associates, ask a whole lot of questions. >> i'm sorry, who? >> the people associated with your association, your people who you say are not members, they are associated with you. they ask a lot of questions. >> i'm not familiar with those but i can tell you -- >> any reason why you can't ask consumers whether or not they prefer an opt-in or opt-out approach to interest based ads? why your members could not do that? >> i think that the reality is that we give consumers an ability to opt out for data that is generally anonymous. for other categories of data, take, for instance, health or

financial, there are opt-in procedures -- >> i'm not talking about the other kind of data. i'm talking about the kind of data that is now -- there's only an opt out provision. any reason why that kind of data could not be subject to a choice? we either want to opt in or opt out. why couldn't consumers be given that choice is my question? >> it's based on a choice. >> the choice is opt out of everything or opt out of individual approaches to you. >> i'm saying why not give the consumer an opportunity to either opt in, or what they currently have, which is to opt out, period, or opt out specifically. >> consumers can, as you noted earlier, decide to clear cookies and reset the opt-outs but that's not the program we run. >> i know that. >> you're not going to answer my question, i guess. >> i apologize, senator -- as i

said earlier -- >> you don't think the question is clear? >> no, we don't take a position on policy. we simply run the program as it's effectuated. >> don't you have a code? >> yes, we have actually three. >> why not part of the code make it part of the code to give consumers that option? >> we do -- >> no, the option i've just described. >> that's not part of the code. the code -- >> why not change the code to give people that option? give people more choices. everyone says we want to give consumers choices, i'm adding an important choice so you're not bombarded and you're not put in the position to go try to understand what the privacy policy of 100 -- none of which privacy policies are even comprehensible they are so technical. we're not going to put you in position, you can opt out on everything. we're giving you that option. you can opt out individually on those advertising companies if you can figure out their advertising policy.

why not give them a opt-in option to opt-in on the type of interest -- special interest advertising that you might be interested in? >> why not give them that option? >> senator, the reality is that we don't force people to go look at privacy policies. one of the key benefits of the -- >> why not urge members to give people that option in their policy? that's all i'm saying. >> that's not part of the program. >> thank you. miss mithal, for the record, would you give us any suggestions relative to the local authority which you would like in addition to commenting on the legislation that senator mccain made reference to, would you give us any record -- soliciting recommendations from you as to any legislation that you would recommend to promote greater privacy, greater choice on the -- in terms of the internet and advertising on the

internet? would you do that? >> sure, senator. i would say that first and foremost, a federal -- >> i don't mean right now, for the record. >> okay, yes. >> i've got to go vote. i think i probably missed the first vote already. >> thank you both. it's been a useful hearing. we appreciate it. thanks for coming. we'll stand adjourned. here is a look at our prime time lineup on c-span3 american history tv with a look at u.s. foreign policy. we'll examine america's response to totalitarianism, al qaeda, and the rwandan genocide. it gets under way at 8:00 p.m. eastern. tonight on c-span, a special program on the use of consumer

drones from taking your picture, mapping construction sites, cleaning outsides of high-rise beings, all things drones are being used for these days. here is a look. this weekend three -- following, one of these things where the drone follows you. you're biking, skiing, running, whatever, and the drone just says 30 feet back and 30 feet up and keeps the camera focused on you and gets that perfect cinematic hollywood feel. on one level exactly what the youtube generation wants. it's incredibly complex artificial intelligence, using gps, image recognition, spotting you and creatively trying to figure out what the right angle is, looking at the sun, the shadows. this is all stuff that's science

fiction a few years ago. this is the droid you're looking for. it's just this weekend, a project was launched. one raised $1.5 million in a day all based on our platform i hasten to add. that was just today. tomorrow this mapping function we're talking about, what doing, this notion of construction. construction is arguably the number two industry in the world, agriculture is the number one. so this $300 can do, one-button mapper. goes around, takes piblgts around a construction site, takes pictures, gets sent to a cloud on a desk and creates this 3d model. again, that 3d model gets snapped to the cad model the engineering company is already doing. happens every day automated fashion, thanks to recharging

now you're the client, what's going on on the construction site. you can drive to the construction site or watch on the cloud, your building, snapped onto the cad model you approved, watch it going up, digitized, perfectly aligned. there's no bs. you've got ground troops or air troops, if you will. that's $300 copy. just imagine what's going to happen in the next five years. >> that a portion of tonight's program on turm drones, 8:00 p.m., 5:00 p.m. again on c-span. senate caucus on international narcotics control looked into heroin and prescription drug abuse recently. witnesses include national white house drug policy national director. also testifying deputy assistant administrator of the dea,

national substitute of drug abuse and phoenix house. this hearing is an hour and 45 minutes. come to order. i'd like to welcome our distinguished witnesses. they will be introduced shortly. recently the media has chronicled a resurgence of heroin abuse in the united states, more heroin moved into the country. according to a 2012 national survey 666,000 americans reported using heroin during the previous year. that number has steadily grown over the past several years. so this begs the question, why

are more people using heroin? and this is the senate caucus on international drug control. but the reason to control it is to keep it out of our country. and to do those things which prevent opiate use not to enable it. but one answer, according to the experts, may be the country's addiction and use of prescription pain medications. and here's why. a report released by the substance abuse and mental health services administration indicates that individuals who use prescription pain relievers for nonmedical purposes were 19 times more likely to use heroin in the past year than those who had not. that's an amazing thing to me. furthermore, 4 out of every 5 heroin abusers had abused prescription pain relievers in

the past. so pain relievers like oxycodone and hydrocodone affect the central nervous system in the same way as heroin. so the lesson here is that rather than thinking of two separate addictions, prescription pain medications and heroin, we should realize that we're facing a much larger opiate addiction epidemic that includes both. so the strategy to battle these drugs should have three parts. preventing drug abuse, treating addicts, and reducing the number of overdoses. but the first and most important strategy is to prevent drug abuse before it starts. and this means educating communities and youth about the dangers. now, some communities already do this through the federal drug-free communities program. in california, there's a program

called placer youth. and that program is contributed to a 50% reduction in prescription drug use among 11th graders between 2011 and 2013. so these programs, i believe, can work. it also means, though, recognizing that all stake holders share a responsibility that prescription opioids are prescribed and dispensed only, only for legitimate medical purposes. state-based prescription drug monitoring programs along with mandatory checks of electronic databases can help doctors and pharmacists identify drug abusers. since requiring mandatory checks, new york has seen 75% decrease in doctor shopping and significant reductions in pain reliever prescriptions.

takeback can help reduce opioid abuse because they get unused prescription pain medicines out of families' medicine cabinets where too many young adults first obtain these drugs so and heroin entering the united states from other countries must be addressed. the dea's signature program in 2012 determined that 90 wers of wholesale heroin seizures were able to be traced from mexico or south america. dea also reports mexican based drug cartel is expanding its market eastward and producing and selling heroin that is more pure. in other words, going from the brown to the white heroin. between 2008 and 2013, heroin seizures along the southwest border increased nearly four fold. from 559 kilograms to 2,196.

the second is successful -- the second key strategy in this fight is successful treatment, which often includes medication, assisted therapies, using drugs like methadone and i'm going to have trouble with this one -- bupanorphine. thank you, sirs. unfortunately, in 2012, 2.5 million people in our country were addicted to these opioids while only 351,000 received these methadone drugs to treat their addiction. that means the rest are not receiving treatment. finally, the third strategy is to address overdose deaths. in 2010, the latest year for which data is available, the

centers for disease control and prevention reported more than 19,500 unintentional opioid overdose deaths. now, there's steps that can be taken. there are drugs that immediately reverse these overdoses, and 18 states including california have taken actions to improve access to these drugs. i think we need to find a way to make these drugs more readily available to properly trained individuals, including first responders. i think we have an interesting hearing. i do want to point out if you look over at those charts, you

see the rate of opioid sales overdose, deaths and treatment between 1999 and in 2010. and this, here's the chart. the green is treatment admissions. the red are deaths, and the blue are sales. and as you can see, they are all going up in this country. so i think that's a good chart that really discusses what we're about. the other quick point is that heroin abuse increases as access to prescription painkillers decrease. now, that's a brand new thing for me, and that's what this other chart shows. so i would hope that some of you and your testimony would remark on this. and now i'd like to recognize the distinguished vice chairman. >> i'd like to defer to senator -- >> you certainly can. >> put on your microphone. >> i'd like to defer to senator mcconnell and thank him for his interest in this issue. and then -- >> and i thank you, as well, sir. thank you.

>> thank you, senator feinstein, senator grassley, for the opportunity to be here today to testify on the scourge of heroin abuse that is devastating as senator feinstein stated too many families and communities across america. and in particular, in particular in my home state of kentucky, thank you for your willingness to focus on this growing threat. i'd like to share with you the story of a wonderful vibrant community that i have the pleasure of representing here in the u.s. senate. it could be many places in america. but it happens to be in northern kentucky. in northern kentucky area of suburban cincinnati is the center of culture, arts in american history. it's the home to cincinnati kentucky international airport and gateway to the bluegrass state from the north. residents of the three counties up there, kent, boone and campbell, the area we refer to

as northern kentucky live in a time of great opportunity. they have the benefit of living in a major metropolitan area of more than 2 million people with all the livability and charm of a small town. they can take advantage of the cultural amenities like the cincinnati zoo and botanical gardens, newport on the levee, newport aquarium and kentucky speedway to name a few, or they can take in a cincinnati reds games or cincinnati bengals nfl game or the cincinnati art museum. and over 25,000 acres of park land give free rein to recreation on a temporate day. and yet this proud community is also settled with a terrible distinction with being the very epicenter, the very epicenter of heroin addiction in kentucky and in the nation.

many believe that the problem started because of prescription pain pill abuse, as senator feinstein was pointing out, kentucky has the third highest drug overdose mortality rate in our country. on the street, these pain pills are expensive, they can cost between $60 and $100 compared to a bag of heroin at just $10 a bag. so given the progress we've made in kentucky and fighting the illegal sale and use of prescription narcotics, it's no surprise that we've seen an uptick, as senator feinstein was pointing out, in heroin usage. once we understand the economics of it. a few months ago, i discussed the relationship between prescription painkiller abuse and growing heroin threat with leaders of federal agencies responsible for curbing these threats. and i'm going to continue to work with them as we all work together to fight this epidemic.

i want to highlight for the drug caucus hard but true facts about the extent of heroin abuse in northern kentucky. and i'd like to credit the northern kentucky chamber of commerce for the data. the fact that these numbers come from a chamber of commerce and not a law enforcement and public health agency demonstrates how pervasive, how pervasive the threat to the community is. these are the facts. in 2012, there was 61 heroin overdose deaths in the three counties referred to as northern kentucky. in fact, the number of overdose cases at the region's largest hospital increased by more than 75%. 75% in 2012. while the number of heroin overdose cases by just august of 2013 had already doubled the number in all of 2012. rates of acute hepatitis c infections in northern kentucky are double, double the statewide rate and 24 times the national rate.

24 times the national rate. public health officials attribute the region's high infection rate to the region's high level of heroin use. what's more, the northern kentucky health department has reported that for every one death, there's one new case of hepatitis c that incurs a lifetime cost of $64,500. the smallest among us are not spared from the scourge. sadly, newborn babies are born with drug withdrawal syndrome. each case is heartbreaking and not only costly in human terms but fiscally as well, incurring an average hospital cost of $ $14,257. law enforcement is on the front lines of this battle to protect kentucky families. according to the northern kentucky drug strike force, the number of court cases for heroin possession and trafficking has

increased by 500% from 2008 to 2012. in the three counties i mentioned, and is expected to double again in 2013. to put this in perspective, the three counties of northern kentucky area contained 60% of my state's heroin prosecutions in 2011 even though they are home to less than 10% of the state's population. let me adhere that it's fitting you are holding this hearing during national police week. when thousands of police officers from across the country visit the nation's capital. we owe these officers our profound thanks and gratitude for risking their lives to combat the drug problem. and the many ancillary violent and property crimes driven by the growing trend. clearly, the troubling facts i've just related show northern kentucky has a serious, serious heroin abuse problem. it's a major problem not for a few, but for the entire region. and while northern kentucky may

be ground zero in my state, the problem of heroin abuse is spreading like a cancer across the bluegrass state where we're losing close to 100 fellow kentuckians a month. a month to drug related deaths. we only have 4 million people in the whole state. this is more lives loss than fatal car crashes. this march, i held a 90-minute listening session in that area of our state to hear from those closest to the problem how federal resources could best be devoted to fixing it. as i've said in boone county, one of the three counties i referred to, there are great heroes in this tragic story such as the medical professionals who save lives, the business leaders who raise money for prevention and awareness efforts, the prosecutors and dedicated investigators who take drugs off the streets, and the recovered addicts themselves who find the courage to live despite their addiction. i heard from informed kentuckyians in the medical, public health and law

enforcement fields and in the business community. and in particular, i want to point out one brave young man patrick kenyan who had been ensnared by heroin and saw his friends use it and overdosed. it took repeated attempts for him to break his addiction. but he said proudly in the listening session, he was four years and ten months clean. i can't stress enough how helpful it was to hear about this issue from so many thoughtful perspectives. that's why i'm pleased you are holding this hearing today. let me just report briefly three take aways from the listening session i held several months ago. first is noted, it's clear that the increase in heroin addiction is tied to our fight against prescription drug abuse which is largely driven by the abuse of prescription painkillers. second, while kentucky is making progress with greater education and more aggressive prosecutions and enhanced regulatory authority at the state level, we

need a combination of both treatment and incarceration to be part of the solution. lastly, the heroin trade is no respecter of borders, which is why multijurisdictional and multiagency law enforcement efforts, such as in my state, the appalachian high intensity drug trafficking area are so crucial. in this area of finite federal resources, we must use these inner agency partnerships to the best extent to maximize our return from federal dollars we spend to combat the epidemic. my friend, executive director, never fails to remind his law enforcement partners that there's no limit to what we can accomplish when no one cares who gets the credit. the very same credo must also guide our efforts at the federal level. so senator feinstein, senator grassley, let me return to the picture i painted of a northern kentucky ripe with promise and

yet beset, beset by heroin abuse. thankfully, the ending to the story has yet to be written. that's why i'm here today to share with you the gravity of the heroin threat to my constituents and to pledge work with all the stake holders to save lives in kentucky from this terrible growing threat. with the efficient leveraging of federal resources and authorities using best practices learned from both the law enforcement and correction agencies as well as the medical and public health communities, we can and will eliminate the shadow of this terrible heroin addiction from robust communities all across america like northern kentucky. thank you very much. >> thank you very much, senator mcconnell. senator grassley, you haven't made your statement and then senator klobuchar would also like to make an opening statement. >> i think since you described the situation very well, i'm going to start out at the middle of my statement and refer to something that you and i learned about the existence of a database by doctors maintained by purdue pharmaceuticals.

purdue markets oxycontin, one of the most abused prescription opiates. the database allegedly contained information about doctors who engaged in reckless prescribing practices. during my investigation revealed many state medical boards as well as the center for medicare and medicaid services didn't know about this database. we encourage these organizations as well as dea to contact purdue about it. as a result, the information is now in the hands of authorities who could take action against irresponsible doctors. the purpose of this hearing is to learn more about what else is being done to combat this epidemic and what role congress can make. a multifacetted approach makes common sense. prevention effort through which doctors and the public are educated about the dangerousness of opioids and other addictive

drugs should be a part of that solution. this is why the mixed signals, the obama administration sends to young people about marijuana use are also damaging. young people and all those looking to climb up the ladder of opportunity in america don't need another pathway to addiction. but that is what i think that -- what the president has said provides by failing to enforce federal laws and dismiss marijuana use as just another bad habit. treatment for those who have become addicted is also a part of the solution, as well. a drug called moloxone has shown effectiveness in could you repeat countering the effects of heroin overdoses. of course, we can't arrest our way out of this crisis, but we can and must maintain the current law enforcement tools to go after those who are trafficking heroin into our nation and our communities.

unfortunately, sentencing reform bills that are now before congress does just the opposite. the proposed smarter sentencing act proposed out of the judiciary cuts the minimum sentencing for those who manufacture, import and distribute heroin and do that by cutting them in half. these are penalties for dealers, not for users. in the midst of an epidemic, my opinion, this makes no sense. federal prosecutors themselves wrote that the current system of penalties is a cornerstone of their ability to, quote, infiltrate and dismantle large scale drug trafficking organizations and to make violent armed career criminals to get them off the street, end of quote. i don't want to remove this cornerstone, at least of all at this particular time. thank the witnesses for being here and i'm going to put my entire statement in the record

in place of what i just said. >> please do, and thank you very much, mr. grassley. >> first, i'd like to thank you, senator feinstein and also senator grassley for holding this important hearing, for inviting me to participate. just yesterday afternoon, i was with president clinton at johns hopkins where the clinton health matters initiative held a very important forum on this very topic with the focus on prescription drug addiction and some discussion about heroin. i was on a panel with commissioner hamberg and the former representative patrick kennedy that followed president clinton's speech. and he is really taking this issue on, which i thought was a positive. and he has a lot of energy, as you know. i'd say -- i start with prescription drugs because when i look at the facts on heroin, the fact that while the vast majority of prescription drug users do not start to use heroin, something like 97% of them, in fact, 4 out of 5 heroin

users today started with prescription drugs. so i start with the demand issue with the prescription drugs and how we get to that. and i'd say, first of all, we have to do everything we can to reduce the supply. this means to me the drug takeback programs and getting them out of the hands of kids when it's the number two thing they're addicted to. senator cornyn and i passed a bill back in 2010. seems like quite a while ago, but still waiting on the rules that makes it easier and sets out some clear standards for how these drugs can be transported when they are put into takeback programs. we did that because there's certain police departments and long-term care facilities that still are not doing these programs. and they're concerned about liability. what the bill does, it makes it easier for pharmacies, which would be excellent if they voluntarily did this. i've done some events with pharmacies, if you can imagine, people bringing back their prescription drugs, getting them out of their medicine cabinets, bringing them back voluntarily

and doing it long-term care, you name it. so that is one thing. and if you think it's a small thing, how many tons do you think were collected just last april in one day in the united states of america prescription drugs? maybe you're thinking ten tons, 20, 390 tons of prescription drugs were collected and the day in april just this last month. and so that's what we're dealing with when we talk about the problem. second is drug courts, the more we can cut down the demand by getting people involved in drug courts and we're working on more funding for that because it's 3 out of 4 of the graduates never get in trouble again with the law. and then, the last thing i'd say on the supply side would be prescription drug monitoring. it's a patchwork system where the head of hazelton in minnesota isn't able to tell doctors when someone comes in

who he knows is doctor hopping to get different prescriptions of oxycontin. it's patchwork, not mandatory, not interoperable, won't go across state lines and there are funding issue as well. i think that would be a big thing. so then we get to the heroin. we have had a huge increase in heroin overdoses in minnesota in the first half of 2013, 91 people died in just hennepin and ramsey county in the twin city area. why? well, we've heard the heroin is more pure, it's coming up on more pure, it's coming up on 35w corridor, mostly out of mexico. 50% of the heroin in the u.s. is grown in mexico now, 60% is transported through mexico. because of that and other reasons, including sex trafficking, i led a trip down to mexico last month with senator senator hicamp and cindy mccain, the wife of senator john mccain. and we focused on two issues, sex trafficking and heroin. we met with the head of the

federal police in mexico, met with the attorney general. coming out of those meetings, i came back with this. i think the mexican authorities are more devoted than ever to do something about the violence and drugs in their country. they want to be part of this new economy in north america, they see getting rid of these drug problem and the violence is the key to that. they have gone after el chapo the head of their long time powerful drug cartel, but there's much more work to be done. this includes eradication of the new poppy fields that are pure white heroin, different than the black tar they used to be using in mexico. it includes strengthening their southern border where the heroin is coming up from countries south, not just our border but the southern border. and the third thing would be continuing coordination with u.s. law enforcement and the work that we have to do on the demand side back here. so i'm very excited you're doing this hearing as i heard the other senators talk about a major problem, but i think we have to be really smart in looking at what the answers are. and i'm looking forward to hearing from our witnesses. thank you. >> thank you very much, senator klobuchar.

let me introduce our witnesses today. and we'd ask each one of you to confine your remarks to five minutes. and if they're in writing, we'd like to have them for the record so that we can have a robust discussion. let me begin with the acting director of the office of national drug control policy. michael boticelli has been here before and we welcome him back. he's had more than two decades of supporting americans who have been affected by substance use disorders. prior to joining, he served as director of the bureau of substance services at the massachusetts department of public health. next, we welcome dr. nora vocal back to the caucus, the director of the national institute on drug abuse, which coincidentally

founded 40 years ago today. let me be the first to wish the institute a happy birthday. dr. volkow's work has been instrumental in demonstrate that drug addiction is a disease of the human brain. among her many accomplishments, she pioneered the use of brain imaging to investigate the toxic effects and addictive properties for drugs -- for drugs that are abused. next, we are pleased to have dr. wesley clark. he is a director of the center for substance abuse treatment within the substance abuse mental health services administration. as director, dr. clark leads the agency's nationwide effort to provide effective and accessible treatment for addiction disorders. he is a noted author and educator in the field of substance abuse, treatment and has received many awards for his service.

next, we have joseph ranuzizi, and we are pleased to welcome you, sir, back to the caucus. you're the deputy assistant administraor of the office of diversion control at the dea. as deputy assistant administrator, mr. ranazzizi is responsible for ensuring the more than 1.5 million dea registrants comply with the controlled substances act and it's implementing regulations. he was named as deputy assistant administrator in january of '06 and served with the dea for some 25 years from now. and last but certainly not least, we're pleased to have dr. andrew kalodny. the doctor is the chief medical officer of the phoenix house, one of our nation's leading nonprofit drug rehab organizations. he's an expert on our nation's

opioid addiction epidemic and he's a practicing psychiatrist in the field. he's helped develop and implement multiple effective substance abuse treatment programs in new york and is a past recipient of the daniel x. friedman congressional health policy award. so we welcome you all and perhaps we would begin with mr. boticelli and just go right down the line. hopefully with five minutes statements so that we can then have some time for questions. please proceed. >> chairman feinstein, senator klobuchar, co-chairman grassley, thank you for the opportunity to appear here today to discuss what is perhaps the most important public health issue facing the united states. namely, the abuse of opioid drugs, including prescription painkillers and heroin. i know that given recent media attention to overdose deaths, there's a heightened public interest in the threat of opioid

drug use. while this might be a new phenomena for many of our communities, some have been dealing with this issue for a very long time, and it's a matter of great concern for this administration. as we discussed, according to the centers for disease control and prevention, drug overdose deaths primarily driven by prescription opioids now surpass homicides and traffic crashes in the number of injury deaths in america. in 2010, the latest year of which we have nationwide data, approximately 100 americans died on average from overdose every single day. prescription annu analgesics we involved in almost 17,000 deaths that year and heroin was involved in another 3,000. more recent data posted by several indicated that deaths from heroin continued to increase. while heroin use remains relatively low in the united states as compared to other drugs, there has been a troubling increase in the number of people using heroin in recent years.

from 373,000 past year users in 2007 to 669,000 in 2012. it is clear that we can't arrest our way out of the drug problem. science has shown us that drug addiction is the disease of the brain, a disease that could be prevented, treated and from which one can recover. we know that substance abuse disorders, including those driven by opioids are a progressive disease. it's important to consider and understand that many people who develop a substance abuse disorder begin using at a very young age and often start with alcohol and tobacco. we know that as individuals' abuse becomes more frequent or chronic, that person is more inclined to purchase these drugs from dealers or obtain prescriptions from multiple doctors rather than simply getting them to friends and family for free or without asking. left untreated, this progression of an opioid use disorder may lead an individual to pursue lower cost and more potent alternatives, particularly

heroin. with these circumstances in mind, we release the obama administration's inaugural drug control strategy in 2010 in which we set out a wide array of actions to expand public health interventions and criminal justice reforms to reduce drug use and its consequences. that strategy noted opioid overdoses as a growing national crisis and set specific goals for reducing drug use, including heroin. three years ago, the administration released the first comprehensive action plan to combat the prescription drug use epidemic. the prescription drug abuse prevention plan strikes a balance between the need to prevent diversion and abuse and the need to ensure legitimate access to prescription pain medication. the plan expands on the national drug control strategy and brings together a variety of federal, state, local and tribal partners to support, one, the expansion of state-based prescription drug

monitoring programs. two, more convenient environmentally responsible disposal methods to remove expired or unneeded medication from the home. three, educating patients about opioid drugs and instructing health care providers in proper prescribing practices and treatment of substance use disorders. and four, reducing the prevalence of pill mills and doctor shopping through enforcement efforts. this work has been paralleled by efforts to address heroin trafficking and heroin use. the administration is also focusing on several key areas to reduce and prevent opioid overdoses, including educating the public about overdose risk and preventions and increasing access to noloxone, an emergency overdose reversal medication. because police are often the first on the scene of an overdose, the administration has strongly endorsed local law enforcement agencies to train and equip their personnel with this lifesaving drug.

22 states, plus the district of columbia, have implemented a law or developed a pilot program to allow the administration of this medication by a professional or layperson to reverse the effects to promote good samaritan laws, so that by by standing to an overdose will take appropriate action and help save lives. we are heartened that 17 states plus the district of columbia have now adopted good samaritan laws. while it is critical for us to save lives, we also need a comprehensive response to prevent overdose deaths. a smart public health approach requires us to catch the signs and symptoms of substance use earlier before it develops into a chronic disorder. we've been encouraging the use of screening and brief intervention to catch risky substantial abuse before it becomes an addiction. and, since only 11% of those who need substance abuse disorder treatment in 2010 actually received it, the administration is dramatically expanding access to treatment. the affordable care act and

federal parity law are extending access to substance abuse disorders and mental health benefits for an estimated 62 million americans helping to close the treatment gap and integrate substance abuse treatment into mainstream health care. this represents the largest expansion of treatment access in a generation and will help guide millions of americans into successful recovery. the standard of care for treating substance abuse disorder is driven by heroin or prescription ownership opioids. and an approach to treating addiction that utilizes behavioral therapy along with fda approved medications. either methadone or naltrexone. medication-assisted treatment already has helped thousands of people in long-term recovery. a prime goal of our office is to increase access to medication assisted treatment within existing treatment programs and through integration with primary care. there are some signs that these national efforts are working. the number of americans 12 and

older initiating the nonmedical use of prescription opioids in the past year has decreased significantly since 2009. additionally, according to the latest monitoring the future survey, in 2013 the rate of past year use of oxycontin and vicodin among high school seniors was at the lowest since 2002. and recent studies showed the implementation of the robust know lox yon distribution programs and the ax pension of medication assisted treatment programs can reduce overdose deaths and also be cost-effective. nonetheless, the reemergence of heroin use underscore the need for leadership at all levels of government. we will therefore continue to work with our federal, state, tribal and community partners to continue to reduce and prevent the health and safety consequences of prescription opioids and heroin. thank you. >> thank you. could you just tell me, you said that heroin use has doubled. that's in the last five years?

was that -- >> i believe since 2007. >> five years. >> i'm sorry. >> this is information from the most recent national survey on drug use and health, and it looked at people who used heroin in the past year, and that went from 373,000 past year users in 2007 to 669,000 in 2012. >> that's a very striking figure. five years. >> five years. >> very striking figure. thank you. dr. voldow, please. >> chairman and senator feinstein and senator grassley, i want to thank you for the opportunity to invite me to speak about the prescription opioid abuse in our country. opiate mathss are the most effective interventions we currently have for managing acute, severe pain. unfortunately, these drugs not

only inhibit pain centers but also activate brain reward regions which is why they are abused and why they are so addictive. so we face the unique challenge of preventing their abuse while safeguarding their value for managing severe pain which if untreated is terribly debilitating. it is estimated that 2.1 million americans are addicted to opioid painkillers, which reflects in part the widespread availability of these drugs. indeed, the number of yearly prescriptions for opioids more than doubled over the past 20 years from 76 million to 207 million prescriptions a year while at the same time in parallel there was a four fold increase in overdose deaths from these medications during that time period. painkillers like oxycontin and vicodin affect the brain

similarly to heroin. they can use euphoria which some intensify by taking stronger doses, snorting, or injecting them or combining them with alcohol which makes them more addictive and also much more dangerous because it increases the risk of respiratory depression which is the main cause of doet from open joud doses. recent trends also indicate a significant rise in heroin abuse in our country which currently affects more than 500,000 americans and is driven in part, basically the predominantly the new cases, by individuals switching from prescription opioids to heroin because it is cheaper and easier to access. what are we doing about the problem? it relates to three things. receive management and better management of pain, prevention of overdose deaths, and the treatment of opioid addiction.

how we treat pain better and how we protect those from becoming addicted and dieing from overdoses. we don't know enough about the risk of addiction among people that have chronic pain. so there's basic research on that area. but in parallel, we're developing medications to treat pain effectively that are not addictive. at the same time, we're funding research to develop ways of administering opioids that minimize the diversion and abuse. and finally, we're funding research for nonmedication strategies to help manage pain such as magnetic or electrical brain stimulation. what about preventing overdoses? we have a very effective medication that is actually quite safe, noloxone, that prevents that from overdoses. recently, the fda approved self-injecting noloxone.

nida is funding other user-friendly ways of administering na lockon. such as if the patient themselves can use it. also, since many of the overdoses occur when no one is around or the patient is asleep. nida is supporting the development of self-activated systems that initiate an emergency response when it's signaled that on overdose is occurring. finally research related to the treatment of opioid addiction. medication assisted therapies, methadone, naltrexone are all effective and they are effective in decreasing overdoses, but these medications are used in less than one-24ithird of patie who need them. we are working to overcome the barriers that interfere with their adoption and we are doing research for alternative treatments such as vac keecines against heroin addiction. we work closely with our partners, cin implementing

interventions towards preventing and treatment of this problem. i want to thank you again for organizing this meeting and for inviting us to participate. >> thank you very much, doctor. dr. clark? >> good afternoon, chairman feinstein and senator klobuchar and senator grassley. i want to thank you for inviting the substance abuse and mental health services administration to participate in this panel. i echo the comments of my cleggs regarding the importance of the topics of this hearing. i will focus on samhsa's programs and activities though we work with federal partners, states, tribes, and local communities. according to the national survey on drug use and health, which we conduct, 4.9 million people reported nonmedical use of pain relievers in the past month in 2012. 335,000 reported past month use

of heroin, a figure that has more than doubled in six years. in 2012, more than 1.89 million people reported initiating nonmedical use of pain relievers, and 156,000 reported initial use of heroin. one challenge in combating the misuse of pain relievers is educating the public in the dangers of sharing medication. according to the national survey, 54% of those who obtained pain relievers for nonmedical use in the past year received them from a friend or relative for free. another 14.9% either bought them or took them from a friend or relative. thus we have both a public health problem intertwined with the cultural problem. we have several programs focused on educating the public, including the not worth the risk even if it's legal campaign, which encourages parents to talk to their teens about preventing prescription drug abuse, our prevention of prescription abuse in the workplace effort, supports programs for employers, employees, and their families.

our partnership for success grant includes prescription drug abuse prevention as one of the capacity building in communities of high need. our referral to treatment program includes screening for illicit drugs, including heroin and other opioids. we've helped physicians maintain a balance between providing appropriate pain management and minimizing the risk of pain medication misuse. our screening brief intervention referral to treatment medical residency program includes modules for priges opioids for pain management and opioid misuse. over 6,000 medical residents and over 13, 700 nonresidents have been trained nationally. our physician clinical support system for medication assisted treatment training is available via live in person, live online and recorded modules accessible at any time. we fund the clinical support system for opioid therapies, a collaborative project led by the american academy of addiction in

psychiatry with six other leading medical societies. we will be funding a clinical support system on the appropriate use of opioids in the treatment of pain and opioid related addiction this fiscal year. at the end of april, in an article in the new england journal of medicine, describes the underutilization of vital medications and addiction treatment services and discusses ongoing efforts by major public health agencies to encourage their use. medication assisted treatment includes three strategies, therapy which uses methadone, partial which uses bup nor fen and antagonist therapy. we are responsible for overseeing the regulatory compliance of certified opioid treatment programs which use methadone and/or bup nor fen for the treatment of addiction and are being encouraged to use naltrexone. there are.

300,000 people receiving methadone maintenance. there are currently 26,000 physicianings with a waiver to prescribe -- >> can i stop you. 300,000 people receiving what did you say? >> methadone. >> methadone. and that's throughout the united states? >> that's throughout the united states. there are currently 26,000 fashions with a waiver to prescribe bup nor fen. of niece 7700 are authorized to prescribe 100 patients. we estimate there are 1.2 million people receiving bup nor fen. we also issued an advisory encouraging drug courts to utilize viv troll in their treatment programs. we estimate between 7,000 and 10,000 people are on viv troll and, unfortunately a low number because it's useful for alcohol dependence and opioid dependence. in august of 2013 we published the opioid overdose tool kit to educate individual, families, and first responders about steps to take to prevent and treat opioid overdose including the use of nal lox yon.

it restores breathing to a victim in the throes of opioid overdose. it can be a teachable moment to refer a person to the appropriate resources. we inform states and jurisdictions that the substance abuse bloc grant may be utilized to support overdose prevention education and training. in addition, we notify jurisdiction that is block grants other than their primary prevention set aside funds may be used to purchase the drug and the necessary materials to assemble overdose kits and cover the costs associated with the dissemination of such kits. we continue to focus on the mission of reducing the impact of substance abuse. we thank you and the members of this caucus for convening this important hearing and providing ution with the tuget to address this very critical issue. >> thank you very much. before mr. rannazzisi speaks i was just astonished at a statistic i just found, and this

is for the most recent take back day. nationally there were 6,000 collection sites. 390 tons of medication was picked up. that's 780,000-plus pounds. it's amazing. >> it's amazing in the fact that we brought all these federal, state and local law enforcement agencies together with community groups on one saturday for four hours to pick up that much. and it was a collaborative effort. 6,000 sites. all that are stocked with police officers, local, state, county officers, as well as community groups, pharmacists, whoever would like to come out and work with law enforcement. so it was truly a collaborative effort. a wonderful, wonderful day. >> thank you. please proceed. >> thank you. chairman feinstein, distinguished members, on behalf of dae dea and the men and women

of the dea, thank you for the opportunity discuss today the relationship between prescription opioids and heroin and how the dea is addressing this public health problem. first, let me say the present state of affairs is not a surprise. dea is concerned about the connection between rising prescription opioid diversion and abuse and rising heroin trafficking and abuse for several years. we believe increased heroin use is driven by many factors, including increase in misuse and abuse of precipitation opioids. the signs have been there for some time now. law enforcement agencies across the country have been reporting an increase in heroin use by teens and young adults who begin the cycle of abuse with prescription opioids. treatment providers report opioid addicted individuals switched to prescription opioids and heroin depending on price and availability. non-medical prescription opioid use particularly by teens and young adults can easily lead to heroin use. heroin traffickers know all of this and are relocating to where prescription drug abuse is on the rise.

to give you an example, young adults can get prescription opioids for free from the medicine cabinet or their friends. let's assume a teenager gets hydrocodo hydrocodone, a schedule three prescription opioid and also the most prescribed drug in the united states today from a family medicine cabinet for a friend. once that free source runs out, it can cost as little as $5 to $7 per tablet on the street, but then the teen will eventually need more opioid to get the same effect, so increase the dose or move to a stronger opioid. thus, the cycle begins. black market sales of prescription drugs are typically five to ten times their retail value. on the street, a schedule two prescription opioid can cost $40 to $80 a tablet depending on the relative strength of the drug. it makes it difficult to continue purchasing especially for teens and young adults who don't have a steady source of income. given the high cost to maintain the prescription drug abuse habit, the teenager turns to heroin at a street cost of generally $10 a bag. the teenager gets a high similar to the one he got when he abused

the prescription drugs. it's just that easy. any long-term solution must include actions to address prescription drug diversion and misuse while educating the public about the dangers of nonmedical use of pharmaceuticals. educating prescribers and pharmacists in treating those individuals who have moved from misuse to abuse and addiction. dea currently has 66 operational tactical diversion squads in 41 states, the dishths of columbia, and puerto rico. these groups capitalize on task force officers and dea agents, to conduct criminal investigations and diversion of pharmaceutical drugs. dea regulates more than 1.5 million registrants. dea diversion groups concentrate on the regulatory aspects of enforcing the controlled substances acts with increased compliance inspections. this oversight enabledd ea to proactively educate reg strants and ensure that de a registrants understand and comply with the law. the diversion groups have

brought their skills to bear on what was previously known as ground zero for prescription drug abuse. florida based internet pharmacies and pain clinics, as the pill mill threat is driven out of florida and moves to the north and northwest, dea will continue to target the threat with groups proven law enforcement skills, and diversion groups, regulatory expertise, and by educating registrants. dea and law enforcement partners have aggressively targeted both prescription drug diversion and heroin trafficking. from 2001 to 2012, there was a staggering increase in opioid pain medications. a 275% increase for oxycodone, 197% increase for hydrocodone, and a 334% increase for morphine. there's also been a significant increase -- >> >> would you repeat that once again? >> these are coming from our national forensic lab information data. from 2001 to 2012, we saw an increase of hydrocodone to the

extent of 197%. a 275% increase in analysis of oxycodone. >> of what does analysis mean? >> when a drug -- >> increase? >> when a drug is submitted for analysis, it's either seized pursuant to arrest, purchased undercover. what it shows is our cases are moving from the standard drug cases over to -- an increase in cases related to prescription drugs. these analyses occur across the country. if an undercover agent or undercover officer at local county sheriff's department makes a purchase undercover of oxycodone, he submits that for analysis. we get those reports. >> so what is it, tripled? is that the figure? >> 275% in an 11-year period. >> almost. so what do you deduce from that? >> i deduce we have a major prescription drug problem. >> yeah. >> it's just getting worse. heroin is just a symptom of

prescription drug problems. >> what you're also deducing is that the prescription drug is a gateway drug to heroin, because if it gets too expensive, then the young person turns to heroin, which is much cheaper. >> i would absolutely agree with that. >> yeah. >> there was an increase in our heroin cases from 2008 to 2012. about 35%. if the data for 2013 remains constant, the increase will be about 51% for 2013. we're still getting reports in. the increase in heroin abuse and trafficking is a symptom of our country's insatiable appetite for prescription opioids that can ultimately lead to abuse and addiction. it's a natural progression from the abuse of prescription opioids. there's a dangerous misperception that abusing prescription drugs is safer than abusing heroin, but the abuse of both opioids and heroin can lead to addiction and death.

preventing the availability of pharmaceutical controlled substances to nonmedical users, pharmacists, and the public about diversion trafficking and abuse are priorities at the dea. as such, we'll continue to work and cooperate with the federal, state and local officials, our law enforcement partners, professional organizations, and community groups to address this epidemic. thank you for your invitation to appear today and i look forward to any questions you may have. >> thank you very much. dr. kolodny? >> chairman feinstein, senator whitehouse, and senator klobuchar, thank you for the opportunity to discuss our nation's opioid epidemic. the increasing use of heroin in suburban and rural counties across the country is easily explained. if you speak with a new heroin user, they will tell you that they began using heroin after becoming addicted to opioid painkillers. this phenomenon is not new. people have been switching from painkillers to heroin since the

epidemic began 18 years ago. like heroin, opioid painkillers are made from opium, and the effects they produce in the brain are indistinguishable from heroin. what this means is that when we talk about opioid painkillers, we are essentially talking about heroin pills. that said, these are also important medications for end-of-life care and when used to treat pain on a short-term basis. but these noncontroversial uses, cancer care or short-term use for acute pain, account for a small portion of our overall consumption. the cdc has been perfectly clear about the cause of this crisis. the chart with the three lines rising behind you is a cdc chart. the rising green line representing opioid consumption, according to the cdc, is pulling up the red line, which

represents deaths, and the blue line which represents addiction. please keep in mind that the red line represents the loss of 125,000 lives. what this graph represents is a public health disaster of catastrophic proportion. according to the cdc, increased prescribing of opioids has led to parallel increases in addiction and overdose deaths. in other words, this epidemic was caused by the medical community. we didn't do this out of malicious intent. for most of us it was a desire to treat pain more compassionately that led to overprescribing. we were responding to a campaign that encouraged long-term use. the risks were minimized, especially the risk of addiction, and benefits were exaggerated. in fact, most patients with chronic pain on long-term opioids are not doing well. we are probably harming far more

chronic pain patients than we're helping when we put them on long-term opioids. to help bring this crisis under control, the cdc is calling for reduced prescribing, especially for chronic pain. unfortunately, the fda has not been listening to the cdc. fda continues to approve dangerous new opioids, even over the objection of its own scientific advisers. and fda continues to allow marketing of opioids for common problems like low back pain, where risks are likely to outweigh the benefits of use. with only 5% of the world's population, we now consume 84% of the world's oxycodone and 99% of the hydrocodone supply. on what basis is fda concluding that we need more opioids? to end this epidemic, the two

things we must accomplish are the same two things we would need to do for any disease epidemic. one, we must prevent people from developing the disease in the first place, and two, we must see that people who have the disease are able to access effective treatment. to prevent people from getting this disease in the first place, the medical community, including dentists, must prescribe more cautiously so that we don't directly addict our patients and so that we don't indirectly cause addiction by stocking medicine chests with a hazard. for the millions of americans now struggling with addiction, we have effective treatments that will allow them to lead fully productive lives. unfortunately, in communities hit hardest by the epidemic, treatment capacity does not come close to meeting demand. especially for buprenorphine treatment, where strict limits of who can prescribe and

patient caps prevent many from accessing a treatment that could save -- >> explain what you mean by patient caps. >> well, the law data of 2000, which is the law that makes prescribing possible out of offices, limits doctors to treating 30 patients in their first year. after they have a year of experience, they're limited to treating only 100 patients. whereas a doctor who wants to treat low back pain with oxycontin can prescribe to hundreds -- as many patients as they'd like, no limits. and buprenorphine i should as is a much safer medication than y oxycont oxycontin, much lower risk of overdose. if we don't rapidly expand access to treatment, the outlook is grim. overdose deaths will remain at historically high levels. heroin will continue flooding into our neighborhoods. and our families and communities will continue to suffer the tragic consequences.

thank you. >> well, thank you very much. we've just been joined by senator udall of new mexico. candidly, as i listened, i am really struck -- you know, 30 years ago i was mayor of a big city and, we had our share, nothing like today. nothing like today. i think this testimony is amazing in terms of the tripling of heroin users, the enormous abuse of oxycontin and oxycodone and hydrocodone. the question is, you mentioned the fda just keeps on licensing regardless. i think that's something that i am going to look into. i have this question. i was the senate sponsor of the ryan haith act which went into effect in 2008 and that provided

that no controlled substance that's a prescription drug as determined under federal food, drug, and cosmetic act may be delired, drkted or dispensed by means of the internet without a valid prescription. and then it describes what it takes to do a valid prescription. i thought that would cut down on some of the use, which ryan haight, and his mother called me from san diego, was an 18-year-old who essentially overdosed on it and died, bought it over the internet. has that been controlled do you think by these -- by this restriction, that you have to have a prescription? >> well, evidence would -- maybe that was effective. because internet purchase of schedule two opioids doesn't seem to be a big problem right now. >> really? >> these opioids are coming from doctors who are prescribing them. >> wow. >> vicodin can be phoned in very easily, prescribed with multiple

refills because it's in the wrong schedule right now. but for other opioids, it does require a doctor's visit. >> well, let me -- i'm -- so we solved that problem. so now we have the problem of doctors overprescribing. what would you recommend? >> well, for doctors to prescribe more cautiously, they need accurate information about the risks and benefits of these medications. what caused this epidemic in the first place, but caused the prescribing to just take off, was a very well-funded campaign with quite a bit of misinformation. doctors were taught -- i was taught that you shouldn't worry about getting patients addicted, that the compassionate way to prescribe is aggressively. and there isn't that much being done to correct the record. >> anybody else on this point? mr. botticelli and then we'll go right down the line. >> i would absolutely agree that part of what we have to look at and all of our colleagues talked about the vast overprescribing

of prescription medication by physicians. that part of the efforts that the federal government has been doing in conjunction with nida and samhsa is providing online training courses for physicians to look at appropriate and safe opioid prescribing. we think there's more to be done in this area and we think promoting mandatory prescriber education as many states have done is really part of providing and ensuring that physicians are getting accurate information other than information that's been provided in terms of the pain prescribing patterns. you know, we keep pointing to the data and it's very, very clear that this is driven by well-meaning physicians in many cases who don't understand the lethality of these drugs, the addictive properties and are not trained in terms of looking at al tern tifers and how do we monitor people who might be developing an adishtion. >> anybody else on this? dr. volkow? go i ahead. >> in addition to the issue of

education which is crucial and that overall there is missing education on the screening and proper prescription and management of pain in medical schools and pharmacy schools, there's also what you're mentioning, improving the access and friendliness of the prescription monitoring programs so that physicians when faced with a patient can access that information not just in their states but in other states, and i think the third issue we need to address is the fact that we have also a serious problem of severe pain of -- numbers of people with severe pain and we do not have adequate treatments to address pain for patients. it's another reality we need to face. >> thank you. dr. clark. >> we also have with the advent of the affordable care act, we have an opportunity to offer alternatives to pain medication for the treatment of pain, and i think that's something we should also keep in mind, that historically one of the problems was that there were few alternatives to pain medication for pain management because physical therapy was not

available to a lot of people who suffered from pain depending on the community in which you live and other strategies could not be supported if the insurance companies chose not to support them. so pain medications themselves were actually relatively inexpensive despite some of the new formulations, and so with the aca having an opportunity to get nonprescription strategies to address pain becomes more available. >> thank you. dr. rannazzisi. >> just pre-ryan haight we had a massive problem with schedules 3s and 4s coming off the internet. we had one case -- well, average pharmacy in twik was dispensing about 66,000 hydrocodone tablets a year. that's not that much. in one case we had 34 internet facilitation sites, 34 brick and mortar pharmacies that dispensed over 98 million hydrocodone tablets. what ryan ha ight did was shut

that down, but what did we see overnight? these were not physicians, they were traffickers. they gave up their white coat for trafficking and money. what we saw is overnight they moved from internet trafficking to pain clinic trafficking. we went from four to seven clinics in broward county in 2006 to over 142 in 2010. that doesn't make any sense. >> so what the you're saying, that the pain clinic is part of the problem. >> the rogue pain clinic, true, the rogue pain clinic is definitely part of the problem. these are doctors that are not practicing medicine. these rogue clinics, these are doctors that are just dispensing due to patient directed -- >> i thought that had been abated in that i think in florida, a big one was shut down. is that right? >> we decreased the number in florida through a collaborative effort between law enforcement, federal, state, and local law enforcement. they just moved into georgia. now they're up in tennessee.

there's over 300 clinics operating in tennessee right now. georgia has over 1 -- almost 200 clinics operating right now. they're moving north and west, and these are just prescription pain mills. >> so what can we do? >> we need to get aggressive -- it's a two-prong approach. we need to aggressively attack these clinics and get them out of business as soon as possible, but the regulatory boards in the states need to take control. a lot of these clinics could have been shut down if the regulatory boards would have exercised their authority. some states don't give them enough authority. >> i'm way over my time. so senator grassley, thank you. >> my first question would be to mr. rannazzisi, and it comes from news reports that we've had about the countless deaths linked to a mixture of heroin

and the painkiller fentanyl. in philadelphia just this week it said at least 28 people have died from the mixture. so it gives you a chance to educate us and the public. take the opportunity to tell the public what dea knows about the dangers associated with the mixture and explain why drug dealers might mix and tell us what steps dea can take to locate its sources and arrest traffickers. >> well, first of all, a little bit about fentanyl. it's a synthetic opioid. it's totally synthetic. it's not manufactured from the plant. it's manufactured in a lab. we've seen this over the years, over the past 35 years we've seen clusters of deaths related to clandestinely produced fentanyl. what we see is most of the fentanyl is clandestinely produced. most recently in 2005 or 2006 we had a rash of fentanyl deaths that were related to a lab that we tracked back into mexico to

toluca, mexico, and working with the mexican authorities we closed that lab down. fentanyl rears its head pretty much every few years. now, this particular drug, it could be fentanyl or it could be an analog of fentanyl. it could be another analog that we're just not familiar with. but the reason they use it is because it's approximately -- fentanyl i think is approximately 100 times more potent than morphine on a standard dose. so what -- if they have bad heroin or heroin is not potent enough or if they don't have heroin, they will use the fentanyl and sell it as heroin. people don't realize how potent fentanyl is. people don't realize how difficult it is to cut fentanyl. it's measured in micrograms, so the fact is if you don't know how to cut it, people are going to be getting hot shots and die of overdoses. so it's very important that we find the labs.

we have specific clandestine lab groups as well as heroin groups out there looking for the source just like we did in toluca. once we find the source, we'll take care of it. >> dr. volkow, common sense tells us that efforts to prevent all kinds of addictive behavior should begin as early as possible in life. i'm concerned about the increase in use of marijuana among young people leading to other addictions. you are obviously an authority on drug abuse and addiction and you have been outspoken in your views about marijuana itself being addictive. are you concerned that marijuana use by young people elevates their risk for other addictions later in life such as abusing prescription painkillers or heroin and what does science tell us about this? >> well, epidemiological studies tell us that most people that are addicted to drugs started by consuming marijuana and many of them started also by consuming tobacco and alcohol.

so this leads to the concept of the gateway theory of addiction and what we know is exposure to marijuana-like substances in animals early on during the period of adolescence or even younger increases the sensitivity to the addictiveness of other drugs, and in studies of twins, they have also shown that when the twin that starts early before age 17 has a much greater risk -- starts the use of marijuana before the age of 17 has a much greater rick of becoming addicted to a wide variety of drugs than the co-twin that started after that period of time. those stories are important because they control for common genetic and environmental factors that are also very important drivers of using and experimenting with drugs. so the data does seem to suggest that use of marijuana during adolescence will have deleterious affects making that person more vulnerable to the addictiveness of other drugs including prescription opioids.

>> mr. botticelli, you referenced in your testimony about the administration's prescription drug prevention plan. that goes back to april 2011 and the plan focused on prescription opioids and one of its goals was to reduce deaths associated with the drugs. do you think the plan needs to be revised in light of alarming developments over the last three years? if so, how, or are the solutions to this epidemic a question of doing a better job of implementing it? >> i think it's twofold, sir. clearly we have to look at the emerging evidence. i think any strategy worth its salt has to acknowledge the changing times and really look at how our strategy continues to evolve to address those issues. as we've talked about today, the prescription drug abuse prevention plan clearly falls in

the area in terms of how we attack in a multifaceted way these issues. we will continue to update our strategy, to talk about the evolving heroin issue. we have been continually promoting the use of medication assisted treatment, expansion of access to treatment, particularly in primary care settings, and the more widespread use of overdose prevention tools. so we will clearly evolve our strategies to reflect the changing demographic and changing use patterns and also changing strategies we need to address it. >> i'll submit my last question in writing to volkow and clark. i appreciate your answer. >> thank you, senator. >> i'll yield the floor. >> we'll do early bird. senator klobuchar. >> thank you very much. i wab wanted to follow up. senator feinstein asked some good questions about the drug take-back program. and you know that i have the bill that senator cornyn and i passed four years ago to make it

easier to do drug takebacks, and she talked about the 390 tons, but our problem is we don't have the rules, and i have talked to director leonard i think three or four times. she's from minnesota, i like her a lot, i know you guys are working on this and i know we just got them back from omb which is a great thing but when do you think those rules will be done because we can't support these drug take back programs to the extent that we want if we don't have the rules from thed ea when it's taken four years. >> thank you, ma'am, for that question. and thank you for your support and your leadership on that bill. that was a very important bill for us. right now there is just -- there's one issue that we're trying to address. >> long-term care facilities. something like that. you don't have to tell me. i don't know what it is. >> there's one issue we're trying to address and we're trying to do it as expeditiously as possible. >> okay. >> the fact is omb has done their job, they vetted it through, it came back to us, we're trying to work out this one problem. >> i just know given what the

senator said about the importance of that 390 tons we could multiply that over if we could make it easier to have these drug take backs on a weekly basis or have them on a daily basis in pharmacies so people can bring them back. >> the problem with this bill in particular was this bill and these regulations touch on several different -- >> i know, transportation -- >> transportation, epa, even the military. so we have to be very cautious because we don't want them to go back and make serious corrections in their statutes. >> i understand, and then you also brought up when senator grassley was asking you about synthetic drugs, and thank you for bringing up that issue as well, which is contributing to these addictions. the fact that people can manufacture them from compounds. we, of course, senator grassley and senator schumer and i and senator feinstein was very hopeful in this, supported

moving on the synthetic drugs. she and i have two different bills that are both supporting each other's bills about synthetic drugs with analogs and things like that, and you think that would be helpful to make it easier to prove up these cases? >> i believe any help we could get at this moment in time is going to be beneficial. we have about 200 compounds we have identified that are outside the act, outside the control substances act. noncontrolled drugs representing every class of drug of abuse out there today, including pcp. >> okay. thank you so much for what you're doing, and mr. clark, i appreciated what you said about naloxone. the fda just approved it quicker than usual to be used in emergency situations and i know my state this month passed a bill allowing first responders to use it and i'm going to move on because i'm somewhat obsessed with this prescription drug monitoring issue but i wanted to thank you for raising it. it's a very important issue and

it was the number one thing that president clinton talked about yesterday in baltimore. so it's a very big deal. so thank you. prescription drug monitoring. this is this idea that as we're seeing all of this -- these clinics that shouldn't be prescribing and miss volkow, i had never heard those numbers. what did you say about the increase in the number of prescriptions, the number you used? >> more than double over 20 years. >> more than double. [ inaudible ] >> 7 million prescriptions per year between hydrocodone and oxycodone products. >> right. without that much change in our population. and so it's just no way that all these -- yeah, so senator whitehouse is saying i guess this many more people are in pain, and i think we know that's not the case, and i think what we know is going on is people are being prescribed these drugs that shouldn't be. so tell me some ideas you have and how you think this -- if this prescription drug monitoring where at least we can put a check on these. mr. botticelli could help both

of you. >> you said 290 tons -- >> that's the drug take back. >> what it tells us is why are we ending up with so many medications -- >> that's a very good question. >> that speaks for itself. >> it gets to the root of it. the take back is good. i want to get it done but i am not naive to think that's going to fix our problem. so it's going to help and it's going to get it out and help with kids especially that are grabbing it from their parents' medicine cabinet. what do you think we can do? >> we need to prescribe much, much better and we need to treat pain much, much better and among the things because we have the technology, the prescription monitoring program should work. if i can order from google and get things immediately, immediately, why can we not have a system like that that is interoperational that i can have information from one state to another? >> mr. botticelli, very quickly, and then mr. kolodny, because i'm out of time. >> these are two complementary strategies. clearly when people start misusing prescription drugs, they're using them from the medicine cabinet. getting them out of the medicine cabinet is the first strategy.

clearly as people progress to more chronic use, they turn to doctor shopping to be able to do this. a large part of the strategy is getting every state to have an operational and effective prescription drug monitoring program. we have 48 now that are operational. one that's in the process. and we have one state, unfortunately, that refuses to invest in a prescription drug monitoring program, and a big part of our work with samhsa and the office of national coordinator has been easier to use programs as well as interoperable programs. so a number of senators said that these programs need to communicate across state lines. so we now have 20 states that have interoperable prescription drug monitoring programs. >> i know senator udall has a bill on this, so he'll have some follow-up questions and maybe he can direct one to you. they're teasing me for going way beyond my time. >> oh, that's already. we've all been known to go beyond our time.

i'm a relaxed chair. senator whitehouse. >> welcome. this is a terrific panel, and i thank chairman feinstein and our ranking member, senator grassley, for pulling us together. this is a very, very important topic. 38 rhode islanders died of opioid overdoses in the first six weeks of this year. if you expand that to the population of the country and to a full year, that's 100,000 americans dead per year. it's really very serious, and some good steps have been taken. the state police, for instance, have just issued naloxone to all of their folks and recommended that local police departments as well as the emt first responders have it available. so i think we're responding in some good ways. one that worries me a little bit is something that's been raised a bunch here, and that's these prescription drug monitoring

programs. i fought for years with, mr. rannazzisi, your agency, dea, to try to get scheduled narcotics onto electronic prescribing, and after senator klobuchar, you will be glad to know it wasn't just you, years of bureaucratic battle, finally the regulations came out. i think that facilitates via electronic prescribing prescription drug monitoring. when you no longer have to go and ask for the paper scrips from individual doctors or from individual pharmacies, you can look at a database and you can see, wait a minute, this fellow is a podiatrist, why are they prescribing oxycodone. wait a minute, this person prescribed 500 capsules last month and now they're prescribing 5,000. wait a minute, this person has gone to five different doctors in five different pharmacies for the same prescription. what's going on? and it opens investigatory

doors. and yet years later it's now electronic prescribing for all this stuff, the prescription drug monitoring programs don't seem to have yet really come online as a proper investigative tool to give us the common sense information that we need to make these determinations. what are the best next steps that we should be pursuing to try to get this prescription drug monitoring program to a place where we're getting these warnings before we have to go and, you know, run up a fake pain clinic that sold 100,000 prescriptions. you know, you should be able to catch that a lot sooner if you're actually watching the data as it comes up. what are our best next steps? miss volkow, let me ask you first because you talked about this very well. >> well, i would say that we should put the resources that are necessary to make these systems the way they should be.

immediate information right away and access to data that is relevant. there's no reason technologically that we cannot do it. >> and privacy concerns? >> the privacy concerns are equivalent to those that you have in electronic medical records. >> the data is there anyway, we're just not accessing it in an intelligent fashion. >> correct. >> dr. clark. >> samhsa working with omc and with rhode island promulgated some pmp electronic health record integration and interoperability programs. we've got a small portfolio. we also worked with department of justice which has the primary focus, but we've been working with rhode island to improve access to data for health care providers by integrating the functions into electronic software used by hospital and physicians' office and integrated the functions in the pharmacy dispensing software of a pharmacy and sharing pdmp data with other states including two

geographically bordering state. this work has to be done in order to make this effective. with new technologies, you don't necessarily get greater efficiencies unless you iron out the bugs, so we're working with rhode island health department to address this so we can establish these models that we can share with -- >> i think mike fine, who is our director of health, is probably the best person in the country on this, and thank you, michael botticelli, for nodding your head and andrew kolodny is nodding. i'm glad rhode island gets some cheers. let me wrap up by thanking dr. kolodny for being here. phoenix house has got a very important role in rhode island and dr. kolodny has been very, very helpful and to urge that as we -- particularly as dea does the enforcement in this area, let's not throw the baby out with the bath water. let's do remember that these drugs have a purpose to alleviate human suffering, and my particular concern is that when you've got people who are

weak and not particularly good advocates for themselves, particularly elderly people, particularly in nursing homes, if they run into an episode of very, very severe pain and you've ratcheted it down so tight that you need to wake up a doctor at 2:00 in the morning to prescribe them their medication, in the real world they're going to suffer for hours until somebody can be found to come in. so i hope that you'll be balanced and thoughtful and precise in the way we go about pursuing this and not risk the beneficial effects of these drugs in the pursuit of eradicating their abuse. >> may i respond just briefly? i believe the clinics and the practitioners that we investigate and prosecute are not doing any type of medical care, and you would not want an elderly person, let alone a healthy person go to them. what we're seeing is drug

seekers go to them and they're just facilitating addiction. >> i don't defend the pain clinics for one second. that's a racket out there. but if you have a situation where you need a doctor to prescribe somebody at 2:00 in the morning in the nursing home and you have to wake somebody out of bed, that's a problem i think. a legitimate nursing home that's been there for years you need to think of differently than is pain mill that just got stood up six weeks ago. >> thank you, senator. senator udall. >> thank you, senator feinstein. good to be here with you. >> good to have you here. >> let me just thank you and senator grassley for focusing on a tremendously important issue. this testimony we've seen, this chart that i think was in your package, this astronomical growth is just astounding, and in light of senator klobuchar's discussion with me, i first want to turn to you, doctor, and ask you on the prescription drug

monitoring issue, i think you wanted to say something there, and so i hope that you have an opportunity to do that. >> i did. thank you for asking me. so most states as we've heard have prescription drug monitoring programs and we can invest in interstate data sharing, but, unfortunately, they're not being used. the pdmps may be one of the best tools we have in the country for bringing this crisis under control, and except for new york, kentucky, and tennessee, the three states that made it mandatory for doctors to use them, they're just not being used. so if there's some way that you can incentivize states to make it mandatory for their physicians to use them, i think that would be very helpful. >> use what? >> the prescription drug monitoring. >> well, we ought to do that. that's something we can do. >> and that's what you're saying we should do. we should make that mandatory. >> absolutely. >> yeah, yeah. right. >> unfunded mandate.

>> a worthwhile one though. a worthwhile one. let me -- and i had an opening statement, too, but madam chair -- >> you're free to do it. >> i'm going to ask to put that in the record and go on to questioning because i think such good issues have been raised here. last month, and this goes to dr. rannazzisi, last month, i don't think you are a doctor, but anyway, last month senator portman and i sent a letter signed by 14 of our colleagues to attorney general holder urging the department of justice to draw on the many evidence-based strategies that are being successfully employed in states to address heroin and opiate addiction, the opiate addiction epidemic. can you explain what efforts are under way to find solutions that are working in the states and then expand them nationwide?

>> i think for starters, the states have taken a lead in having prescription drug summits not only for the prescribers, pharmacists, nurses, but also for community leaders. the states have basically leveraged their community coalitions and had the community coalitions out there doing education, using that as a force multiplier we get the word out to our schools. i think the states are doing a remarkable job. we're working together with these -- in investigations related to rogue pain clinics and rogue practitioners. i think that this problem if we don't work as a team, both state and federal and local investigators and regulatory boards, it's just going to get worse, and we are. we have more collaboration with regulatory boards and state and local task forces now than ever before. just to address this problem. florida is a perfect example.

so i think the states and the federal government together are doing a fine job addressing the problem. >> well, the great thing about our system is having the states as laboratories and as you said, they have come up with some very good examples that i think we can spread nationwide. dr. botticelli, drug abuse -- i have a very large native american population, 23 tribes in new mexico, and drug abuse in indian country is a significant problem. according to a samhsa survey, the rate of nonmedical use of prescription drugs among american indian or alaska native adolescents was almost twice the national rate. during fiscal years 2006 and 2009, the high intensity drug trafficking areas program provided a small amount of discretionary funding for a native american program to combat drug trafficking on tribal lands.

is this something you'd be willing to consider as director? >> sure. we've been significantly concerned in terms of substance use and particularly this issue on tribal lands. we've been working with the indian health service to look at how they might increase capacity around maetiedication assisted treatment. we've gotten great cooperation from the indian health services in making sure all their prescribers are appropriately trained on safe prescribing. so we've got great coordination with that, but we're also working and we will continue to work about how we might look at discretionary dollars to focus on that population. >> thank you very much. and that's a perfect, i think, collaboration between the indian health service and you to move this whole issue forward. thank you very much, madam chair. >> thank you very much, senator. appreciate it. senator markey, welcome. thank you, madam chair. thank you for inviting me. i very much appreciate it. dr. botticelli, thank you for your good work in massachusetts. thank you for your good work for

the country, and as you know, we've been a pioneer in massachusetts in programs that distribute naloxone widely in the community to those who are likely to observe an overdose such as the family and friends of an opiate user. these programs save thousands of lives. my understanding, however, is that some physicians, first responders, community volunteers, members of the general public have expressed concern about being held liable for lawsuits if they administer ma lox yon naloxone in emergency overdoze situations. have you also heard these concerns? >> i have. >> if we were to eliminate those liability concerns, do you think we could increase dramatically the number of people who are ready, willing, and able to save the lives of people who overdose? >> i do. i think guaranteeing some level of immunity for people who respond to an overdose is a strategy we should continue to investigate.

>> and i agree with you. i don't think anyone should be afraid to save the life of a family member or a loved one because of legal liability. and i recently introduced a bill called the opioid overdose reduction act. it's a really simple solution to it extends protections to people who step in to save the lives of a person who is overdosing by administering a drug like nalozone and that we need a national good samaritan law so the people will step in. how many lives do you think would be saved if we had such a law? >> we know one of the prime issues why people overdose and die is failure to call 911 in an emergency, and clearly, signaling to people that they shouldn't be afraid to call 911 is a significant advancement in how we're going to reduce overdose deaths. >> so a good samaritan law would really help here. >> absolutely. >> do you all agree with that? >> yes. >> yes. and i think that's really something we can do, to pass a

law which does provide that good samaritan protection. dr. volkow, isn't it true that for opiate addicts in prison, the treatment approach that works best is combining medication assisted therapies with community-based treatment at re-entry? >> indeed, we have the best outcomes on prisoners that when they leave the prison system to go into the community were initiated either on methadone or buprenorphine and are sustained on that not just in their ability to stay off drugs but also in decreasing the number of overdoses because that transition from prison into the community increases the risk of dying from overdose something like 13 or 17 fold. >> so there are currently very few medication assisted therapy programs in our prisons. >> unfortunately, that is correct. >> what do you think are the barriers to the expansion of medication assisted therapies in federal and state prisons?

>> i think that it does relate to a culture that we observe in many of the treatment programs that rejects the use of opioid assisted therapies is because of the belief that you're changing one drug for another when, in fact, we know they are very different. and they are beneficial and cost saving. >> mr. botticelli, after a life is saved from an overdose, by naloxone, people with chronic addiction need to be linked into effective on going treatment for their conditions. i understand that you were instrumental in massachusetts in helping to increase access to medication assisted treatment programs within community health centers. do you believe this model, the massachusetts model, can be used to expand access to these therapies across the country? >> i do. you know, one of our challenges is how do we continue to expand access without building bricks and mortar, and our federally qualified health centers are uniquely situated to look at doing that. we found by giving minimal

assistance to health centers we could increase by about 10,000 the number of massachusetts residents who were able to get very effective comprehensive medication assisted treatment with the rest of the services that they needed. >> dr. clark, do you agree that expansion of medication assisted therapies into primary care settings such as community health centers would be helpful? >> one of the things we sup pord ported and the use of transition from criminal justice system back to the community using medications naloxone buying the addict and community enough time that the person can reengage in follow-up treatment. what often happens is the person uses shortly after being discharged from the penal facility and then overdose, so if we could have naloxone

administered prior to discharge from those facilities, we would have at least a month time to engage in federally qualified community health center or substance abuse treatment system or an opioide treatment facility into the community. >> thank you. may i continue? >> go ahead. >> please, thank you, madame chair. dr. volkow, i'm kind of surprised at how remarkable it is that we have so few medications available to treat addiction. i'm concerned that our desire to find treatments that eliminate drug use may keep us from finding therapies and reduce the harms of drug use, like incarceration, difficulty holding a job. what do you think is needed to further the development of treatments that reduce drug use or related harms?

>> well, it is unfortunately a pair dpair dox call situation. it's morbidity and mortality. the science has identified several potential targets that if developed could be beneficial for the treatment and just we do not have the interest from the pharmaceutical industry in developing medications for serious or reasons delaying by the institute of medicine. and one of the recommendations is how to incentivize the pharmaceutical industry to invest in the development of medications. the targets are there. and you have a condition that actually is chronic so one of the arguments that they would not be able to recover their investment is not even correct. and i institute of medicine identify ways that they could -- the government could incentivize institutions a without costing a

single dollar to the government. >> if i may ask one final question. of all of the prescription painkillers prescribed in the world, 90% prescribed in the united states, 4% of the population of the world has 90% of the prescription opiade painkillers. what does that tell us about the united states, our society in. >> i think that you -- the numbers speak for themselves. i don't think that we can argue that we have much more severe chronic pain than other countries. i think the numbers are telling us something very clear. we are overprescribing while at the same time it does not negate we're not necessarily properly treating patients that suffer with chronic pain. >> yeah. i thank each of them for their tremendous service but at the end of the day there's one thing to do and that's pass a good samaritan law. i think thousand of people's lives would be saved immediately across the country because

people would not be afraid to inject someone or give them the help they need for fear they would be sued if something went awry and most people would just thank -- thank god that the fear is gone. i think firefighters across the country, policemen across the country, more willing just to rush in and just apply because if you do it in a timely fashion, you save the life. then deal afterwards with what happens to the person. do you have a bed for them? do you have the treatment for them? at least you have kept them alive. then we have a responsibility. we don't have either right now and until we put both in place and i think this problem will continue to escalate. thank you, madame chair. >> thank you, senator. just in conclusion, three things that jump to me. and of course, that's the pill mill that exists. what proportion of the problem is the pill mill?

>> i think we always say that 99% -- 99 plus percent o. practitioners prescribing, the doctors and -- are doing a great job doing what they do but that very small percentage of doctors that have crossed the line are truly hurting a lot of people. i can't give you a percentage because i just don't know what that number is but what i do know is if you have a rogue pain clinic in your community, you're going to see overdose increase. you're going to see, you know, the general problems that you get with any other type of open air drug activity and it is open air drug activity. >> now, we talked about medical education programs proceeding. should this be done through the ama? done through the state medical associations? any opinion on that? doctor? >> yeah. sure. if i could just quickly answer about pill mills.

>> sure. >> it is important to recognize i think, of course, we have to close down pill mills. they account for a very large amount of the overdose deaths but this terms of overall strategy for controlling this problem, the people who go to pill mills are usually either they're addicted, already addicted or drug dealers or could be a little bit of both. so that you could shut down all of the pill mills and it won't get at the problem of creating new people with cases of addiction. that's where doctors who mean well are more of a problem or dentists who give a teenager 30 pills when they needed one or two. so, and a kind of takes us to the question that you're asking about medical education. if we want dentists to give one or two pills instead of 30, if we want doctors to recognize that these are not good treatments for headache and low back pain, they need very good information on this. unfortunately, the bulk of the education on this topic right now is not teaching doctors that

using these medicines long term is a bad idea. the cdc put out educational programs like that but it's a minority of what's out there. the bulk of the education is really telling doctors that if you follow certain rules when you prescribe, it will all turn out rosy in the end. check a urine, that's somehow the patient won't wind up addicted. close monitoring is a prudent thing to do for the people who are on this treatment. but it doesn't turn it into something that's safe. these strategies don't prevent addiction. so really, the education needs to be that these are not good treatments for most people with chronic pain. >> okay. do you think we should mandate the states to mandate that medical programs -- essentially, to mandate physicians license to use drug monitoring programs? >> yes, i absolutely do.