student cam 2018 video documentary competition is right around the corner. it's january 18th. we're asking students to choose a provision of the u.s. constitution and create a video illustrating why it's important to you. students across the country are in the final stretch, and sharing their experience with us through twitter. these students participated in a student cam film festival. this group wrapped up an interview on climate change. and this student learning a lot and having fun while editing. our competition is open to all middle school and high school students, grades 6 through 12. $100,000 will be awarded in cash prizes. and the grand prize of $5,000 will go to the student or team with the best overall entry. for more information, go to our website, studentcam.org. >> next, the author of dreamland, the true tale of america's opiate epidemic, testified before the labor and

pensions committee. this is part of a series of hearings the committee is holding on the epidemic. >> senate committee on health, education, labor, and pensions will please come to order. today, we turn our attention again to the opioid crisis. the nation's number one public health challenge. our witness today is sam quinones, the author of dreamland, a true tale of america's opiate epidemic. senator murray and i will each have an opening statement, then i'll introduce the witness. then we'll hear from mr. quinones, and then senators will each have five minutes of questions. since he's our only witness, i have suggested to him if he wants to take a little more than five minutes to say whatever he has to say, we would welcome that.

but there will be plenty of conversation back and forth with members of the committee. member quinones, it is unusual to have a single witness at our hearings. but this is an unusual topic, one you quote washington state research professor gary franklin as calling the worst manmade epidemic in history. the challenge this crisis presents has captured the attention of every member of this committee. your research and writing has been acclaimed for their depth and breadth, so this is what we call a bipartisan hearing. most of ours are. one in which democrats and republicans have agreed on the topic, on its importance, and on the witness. it is my hope that we will restrain our habit of lecturing one another about health insurance and focus today on the topic, which is the opioid crisis. this epidemic kills more americans every day than car accidents. and each of our states, we're reminded of that almost every day. yesterday, i dropped by a meeting at the tennessee

governor's residence in nashville. the heads of all our state institutions involved in training doctors were planning how to discourage the overprescription of opioids. the governor told me that in our state of 6.6 million people, there were 7.6 million opioid prescriptions written in 20 sane. and that even though the state has reduced the amounts of opioids prescribed, that the number of overdose deaths is up because of the abuse of fentanyl, a synthetic opioid. rather than spend more time establishing the crisis, i want to focus today on what we can do about it. here are two things i'm hoping to learn from you. first, when 100 million americans live with pain, 25 million of them with chronic or severe pain, why is it not a good idea to continue to find the so-called holy grail of medicine, a nonaddictive pain medicine? second, if stronger communities

are the ultimate solution to this crisis, as you often suggest in your book, what can a central government in washington do that actually helps? now, my first question, you have a chapter in your book called searching for the holy grail, finding a nonaddictive pain medicine. i have actually read your book. i think there are a number of others here who have and have brought it with them. this search for the holy grail began, you say, 75 years ago, with a committee on problems with drug dependence. that was the goal, as you describe it, quote, couldn't the best scientists find a way of extracting the pain killing attributes from the morphine molecule while discarding its miserable addictiveness, unquote. this effort to find a better way to treat pain, you say, led to a revolution in attitudes towards pain treatment. first using opiates to relieve pain for dying patients and then for patients with chronic pain,

and then abetted by a multiple of helpers from mexican gangs to pain clinics, overprescribing dedoctors and enterprising drug companies spiraling into the addictions and consequences we find today. at least twice before this congress, dr. francis collins, the head of the national institutes of health, has predicted that the holy grail that was first sought 75 years ago is now within reach. last month, he said perhaps within five years. with our encouragement, dr. collins has organized nih researchers in partnership with private companies to speed up the process and the food and drug administration commissioner, dr. scott gottlieb is on board to fast track the effort within the bounds of safety and efficacy. but i read at least some of your book to say that this holy grail may never be found. you even quote some scientists who say it should not be found. so i hope you'll tell us what you think about this. should we not continue to try to find nonaddictive pain medicine

to relieve suffering without addiction? is that not the obvious antidote to opioid epidemic? the second area i would hope to learn from you about is what we can do from washington, d.c. we have tried in important ways to address the ravages of this crisis, which we have all experienced in our states. in 2016, congress passed the comprehensive addiction and recovery act, c.a.r.a., and the 21st century cures act, that gives states and communities, those on the front lines, the tools and resources they need to combat this crisis. for example, in c.a.r.a., provision by senators warren and capito is included that made it clear pharmacies can only fill part of certain prescriptions like oxycodone, that way a mom filling her son's prescription after his wisdom tooth surgery could ask for three days worth of pills instead of the 30 days he was prescribed. in addition to encouraging the

development of a nonaddictive pain medicine, cures included more than $1 billion in state grants. we're considering additional funding for treatment and to discover alternative pain medicines. we have held hearings on wellness, lifestyle changes, which you mention in your book, such as exercising, eating healthier, that help people lead healthier lives, and what incentives would help people make those lifestyle changes. but you and i apparently have at least one thing in common, i'm a skeptic of washington's capacity to solve problems that are essentially problems of communities, families, and lifestyle. you say that the opioid crisis is a problem of society. that when we lose our sense of community, we become easy prey for quick external solutions for complex problems like opioids. in your words, quote, i believe more strongly than ever that the antidote to heroin is community. make sure people in your neighborhood do things together.

break down those barriers that keep people isolated, unquote. in my own experience in public life, including time as governor, i have been increasingly convinced of the problem solving ability of communities with good jobs, good schools, strong families, where everyone seems to be interested in the wellbeing of everybody else. whenever i have tried as governor or senator to solve a problem in the end, it's boiled down to creating an environment in which communities could themselves fix problems, not sending in single shot solutions from a distance. for example, after spending years on state reforms and education as governor, i ended up traveling the state to create 143rd better schools community task forces because i believe the communities who wanted good schools could have them. and those who did not would not. i held the same views as we fixed no child left behind in 2015, when we restored more decisions to classroom teachers,

school boards, and states. so exactly what does congress do from washington, d.c. about this opioid crisis? this committee has jurisdiction over a significant amount of what you have written about in "dreamland" but not the spending of money. that belongs in the appropriations committee. we're eager to hear your testimony and to hear your solutions. senator murray. >> thank you very much, mr. chairman. i'm glad to be continuing our discussion on this really important issue. i know our witness today has been following the opioid crisis and its growth into the full-blown epidemic families and communities across the country are facing today. thank you for joining us. i also want to welcome your wife and daughter, whom i assume are sitting right behind you there. i'm glad they were able to be here with you today. i look forward to hearing your perspective on how we can better help our communities fight this crisis and support all of those who have been impacted. and i really appreciate the investigative work that you have done to help shed light on this

challenge, of course, and i'm sure you would agree, the rise of this epidemic is broader in scope that any one book can tell. there are people from every background and every corner of the country who have stories about the harm that this has done and they are parents who have lost children to an overdose, children who have lost parents to an overdose, veterans in chronic pain who are struggling with addiction, doctors treating babies born addicted to opioids and a lot more. i have heard these hardbreaking stories first-hand traveling around my home state of washington and meeting with doctors and families in communities fighting this disease. i was visiting a local hospital in long view, a rural community in my state, and the staff there told me almost 1 out of every 2 babies born there have mothers who struggle with substance abuse. that was astonishing and heartbreaking. it's unfortunately not the only evidence of this epidemic. since 2000, nearly 10,000 people

in washington state alone have died of opioid overdose. and this isn't just happening in long view. it's happening in local hospitals across the nation. we are losing 91 people every day to opioid overdose, and when i say this epidemic affects everyone, i don't just mean the individuals facing opioid addiction. there are other victims as well. this epidemic hurts families. it leaves children struggling to cope with the impact of their parents' addictions, it leaves many of them in foster homes. it leaves parents who are shattered with the heartbreak of their child's illness and leaves many struggling with the financial cost of opioid misuse and treatment recovery as well. and this epidemic hurts our communities as a whole. it takes up resources of public hospitals and law enforcement. it takes workers out of our local economy. it takes a toll on the morale of small towns and big cities alike with each new tragedy, and we're behind the curve on fighting this epidemic. one of the stories that stood out to me in your book was about

a state employee from washington department of labor and industries. a woman named jamie may. jamie was a pharmacist charged with overseeing the cases of workers who were receiving prescription drugs for injuries. after six months, she noticed that some of these workers were dying from the same pain killers that they had been prescribed. the paper she published in 2005 about the uptick in high strength opioid prescriptions and deaths was one of the first papers in the country to document the impact of the crisis that we're now facing today. but she published her paper over a decade ago, which just shows we have been fighting this battle far too long and we have to do more. now, i'm glad that we have taken some necessary steps. in 2016, congress passed the 21st century cures act, which included nearly a billion dollars of funding for states to address the opioid crisis through prevention and treatment and recovery efforts. and the comprehensive addiction and recovery act, which supports

specific outreach for veterans and pregnant and postpartum women. it expanded access to treatments and much more, but there is a lot more to do. along with many of my colleagues, i hope we can move more funding in the upcoming budget or appropriations agreement. first responders, state and local officials, treatment professionals and families have made it clear, continued federal funding is key to addressing this crisis. and unfortunately, we have heard a lot of talk from the administration on this, but we have yet to see the president take the kind of serious action that this emergency demands and that he promised families on the campaign trail. the white house's own council of economic advisers released a report estimating the economic cost of the opioid crisis to be over $500 billion just for 2015. addressing a problem this big will take an enormous investment of time and energy and focus and robust funding.

the president's third quarter paycheck is not going to cut it. our communities are crying out for serious solutions, so i'm eager to see this community continuing its bipartisan approach and to take substantive action to address this epidemic over the next few months. mr. chairman, i look forward to working with you to have all of our members bring their ideas forward so we can work on moving policies that help our families and communities. we have to do a lot more to fund prevention efforts and treatment programs and build on the gains we have made. this means immediately providing supplemental states need to implement evidence based tools to turn this epidemic around and make sure local stakeholders and partners, people on the ground who know what works best in their communities, have the resources and information they need to respond to this crisis. it also means going beyond prevention and treatment and recovery. we have to work to support not only the individuals facing addiction but the families and

communities who are suffering as well. i'm interested to hear your perspective on this today and how we do that, and i'm really grateful for you coming here today to testify before us, because if we're going to beat the scourge of this opioid addiction, we have to fund and enact solutions that are as comprehensive as this challenge. so thank you again very much for having this hearing. i look forward to working with you and all our members. >> thank you, senator murray. and thank you for working in this way to have such an important hearing. i'm pleased to welcome sam quinones and his family today. thank you for taking the time to be here. mr. quinones has 30 years experience as a journalist and author. he's written extensively on the opioid crisis and drug trafficking. he's the author of three acclaimed books. his most recent book "dreamland, a true tale of america's opioid epidemic" won an award for general nonfiction. early in his career,

mr. quinones was the recipient of the maria moors cabinet prize, the oldest award in journalism for his work covering latin america. he was also the recipient of a fellowship awarded to outstanding print journalists who pursue stories in the public interest. welcome again, mr. quinones. you'll have ten minutes to give you testimony and then senators are looking forward to having a conversation with you. >> there we go. clearly, i'm a rookie here. chairman alexander, senator murray, and honorable members of this committee, i would like to thank you for these hearings on our national epidemic of opiate addiction and for allowing me the honor of addressing you. i'm very happy to be here with my wife and daughter, who are part of producing "dreamland"

and without whom the book could have never been finished. this is the deadliest drug scourge we have known in this country, hitting areas of the country that have never seen this kind of drug problem. it's the first in modern america to be spread not by mafias, not by street dealers, but by doctors overprescribing pain pills, convinced they were doing right by their patients. urged on by the pharmaceutical industry, by the medical establishment, and indeed, urged on by us, by american health consumers who too often wanted a quick and easy end to pain. isis could not have dreamed of inciting the kind of torment and death that we have visited upon ourselves through this overuse of opiates. these drugs are a symbol for our era. for almost four decades, we have exulted the private sector, the individual, while we have ridiculed government as inefficient, incompetent, and

wasteful. we have mired wealthy business people regardless of whether the way they made their money produced anything of value for our country and our community. we wrought, i believe, a second gilded age. this epidemic of addiction to a class of drugs that thrives on isolation reflects all of that. this epidemic's costs have been born by the public sector, all its profits have been private. i believe the scourge is about issues far deeper than drug addiction. it's about the effects of this very cultural shift. it's also about isolation in areas rich and poor. about the hollowing out of small town america and the middle class, of the siloization of our society. and it's about a culture that acts as if buying stuff is the path to happiness. i believe we got into this

because we believe problems could be attacked in isolation with one magical silver bullet. a pill for all our pain. a jail cell for every addict. we exalted the private and mocked the public and the communal. and in so doing, we rid ourselves of things so essential to us that they have no price. we have been invaded by cheap junk as a result. we dug up dreamland pool and replaced it with a strip mall. did things like that across america for years now. heroin is what you get when you destroy dreamland. i believe isolation is heroin's natural habitat. i believe too this epidemic therefore is calling on us to reverse these decade of isolation and come together as americans. i believe more strongly than ever that the antidote to heroin is not naloxone. it's community.

people coming together and working in small and local ways toward solutions. no one saving the world alone. the good news, in fact, in all this i believe is there is no solution. there are many solutions. each small, each must be tinkered with, improved. some may be discarded. each must be funded fully and for a long time, but the good news too is none of them is sexy. none will do the trick alone. i believe that across america today, communities are finding these solutions. the more they band together, the more they leverage all of that talent and energy, bring in ptas, pastors, artists and athletes, recovering addicts and primary care docs, librarians and the chamber of commerce, the more cops and public health nurses go out for a beer, bridge that cultural chasm between

them, and i do believe as i said that this is happening in counties across america. it's my opinion and evidence shows the supply has ignited all this. we did not have this demand, this widespread addiction until we unleashed a large supply of powerful legal narcotics on the public for the last two decades. thus i believe it essentially that doctors reassess how and to who and what quantity they prescribe these drugs. that does not mean just cutting people off who are on high doses of these drugs and leaving them to fend for themselves. it does mean lobbying insurance companies to reimburse for pain strategies that do not involve narcotics. allowing doctors a wider array of pain strategies than simply pain pills. young docs meanwhile need more education in med school in both pain management and addiction treatment.

i have to say that i think it's delusional to spend time and money on yet another wall along the u.s./mexico border hoping that this will somehow staunch the supply of heroin and fentanyl. these drugs are coming in through areas with walls already. i believe a wall will in fact corrode the only thing that will truly help stop these drugs from flowing into our country. and that is a deep respectful but also forthright sometimes blunt, certainly honest relationship with mexico that will lead to it finally becoming the kind of neighbor and partner we can work with effectively, and in so doing, become the kind of neighbor that country needs of us. another wall, however, seems to me is just like heroin. it feels good for the moment, but it will leave us in a worse place in the long run. another silver bullet for a complicated adult problem.

sometimes solutions are about the mundane mechanics of governor. we should find, for example, new ways of funding coroner's offices around this country and expanding our national forensic pathologists which is dangerously dwindling. this epidemic spread because so many of those offices are so poorly funded. i believe we must expand treatment options in this country. one place to do this, ironically, crucially, i believe, is jail. consider how the country will be helped by transforming jail into a place of nurturing recovery. instead of a place of predation and tedium. then becomes an asset instead of a liability, and this is happening, particularly, i would note, in the state of kentucky. i would also like to add that all across america are families who are suffering due to the addiction of a loved one or the loss of that loved one. i believe they are a raw material to be marshalled,

harnessed in this fight. many now want to be involved, need to be involved. to help solve the lacerating wound that will last a lifetime. i believe you as senators can help this by recruiting them, recognizing them, giving them platforms from which to tell their stories. maybe it's because i'm a reporter, but i believe that through their stories, the awful stigma of addiction will be reduced. i'm happy to elaborate on any of this. before i do that, though, i want finally to urge you to view this as an opportunity. view this as an opportunity to revive those regions hammered by globalization and free trade. the roots of our national epidemic of narcotic addiction lie there, while the epidemic itself in turn stands in the way of their revival. many of these regions cannot revive until enough of their people can pass a drug test to fill new jobs. indeed, this is not only a story

of a drug addiction. it's a story of economic affliction. as politicians, i suspect your natural response to a crisis like this is to look about for things you can do quickly, to show constituents you're taking action, and i believe that is entirely understandable. i would caution, however, against believing in short-term responses. c.a.r.a. and the cures act make up a great start, and i thank you for them, but they are only a start. everything i have learned about this issue has taught me the importance of long-term community responses and commitment. i believe american history offers us two templates for action for which you might take guidance and inspiration. first is the marshal plan to rebuild europe after world war ii. second is our space program. each involve government and the private sector acting in concert over many years, bringing money,

brains, energy, and of course, long-term focus to bear. each achieved an unalloyed good for our country. those who were about doing things that seemed on first blush far beyond our own short-term self interests. the marshall plan was about building up ravaged regions to allow them to function independently while containing the viral spread of soviet communi communism. it let reborn countries to contribute to prosper in the world again. it might focus on rebuilding those regions that have been caught on dope and ravaged by economic devastation to contain the viral spread of addiction. through our space program, we were inspired as a people to spend years and dollars, all to achieve something no previous generation ever thought possible. we ended up far beyond the moon.

the spillover in economic benefit, increase in knowledge, and in simple human inspiration is beyond calculation. seems to me that we might profitably apply these examples, the marshall plan, and the space program, to regions of forgotten americans where this problem began. let's do it perhaps not because it is easy, but because jfk said, because it is hard. because that's what americans do. and have always done at their greatest. like our space program, i believe such an effort will have to last for years to be effective. focused far beyond the immediate goal of drug addiction and on the more profound problems of community destruction and the hollowing out of stretches of this country. i'm here today to urge you to see this not only as the catastrophe that it is but also as the gift that it can be. it offers an opportunity to

reinvest in areas that need it most. a chance to inspire us as americans again, to something great. it's an opportunity to bridge that political polar that so gnaws at our country. it's one of the few issues today that can do that. do not miss this opportunity. it does not come around often. this calling, i suspect, is the very reason many of you got into public service in the first place, and you're lucky, i think, to be here when it has again. you will be remembered for acting when acting was not easy to do. if you do, i believe your home towns will thank you. your counties will thank you. and we, your country men and women, will thank you long after you're gone. with that, i'm happy to talk about anything you guys want. >> we will begin now to have

five-minute round of questions. i'll say to senators i'm going to try to stick to five minutes because we have lots of senators who want to ask questions. i'll be glad to stay for a second round of questions. senator paul. >> mr. cinones, thanks for coming. the book is great. when you write a book, you're not sure how many will read it and how much public policy effect. and i would say half or more of our committee have read your book. >> my mind is blown. >> it's having effect on the public policy. as i read the book, i was reminded when i was a kid, i used to visit my grandparents in pittsburgh, and there's a big pool like dreamland, and an amazing pool. 100 yards long with a slide in the center, and you see how the community was surrounding that pool and activities. as i read through the book, and we try to think what can we do better or change, the idea that big pharma lied and committed fraud is a part of the book and

a part of the problem. they were punished, but we need to make sure that people cannot lie and that it is fraud and it's punished, and it's preempted in some way. some of that could be federal, some could be state law. as a physician, i continue to become more and more alarmed that, you know, our profession is part of the problem. and we have tried to fix it. in kentucky, we have done a lot of things. we monitor, you can type into the computer patient's name, find out if they're seeking different doctors, have they gotten opioids somewhere else two days before. we have gotten rid of the bad doctors, the doctors you mention south of portsmouth, you know, mostly gone. the pill mills are no longer in kentucky, and yet, we have a county up in the mountains that has 21,000 people. last year, they had 2.8 million doses of hydrocodone and oxycodo oxycodone. this is after all the stuff. all the stuff, everybody knows it's a problem. everybody knows more people are dying than are dying from car accidents, and it's a horrible problem, and it was worst last

year in this county. they prescribed more. in and fact, since medicaid expansion, there's an 11% increase. we say let's have a plan, spend more money. we have to thing about how we spend it and what we do because we want more people to have health care. we expanded medicare. if you look at the expansion of medicaid and put that map overlying the united states, you have an overlay of the heroin problem and the opioid problem, and it's related to poverty and the expansion of health care. so in your book, you talk about, you can get for $3, you don't have to pay $200. you can pay $3 a month and you can get it and trade it and all of that that came. so we do have to figure out more rules on this. we have some new rules in kentucky on acute management. but i think the hard part is the chronic. if i'm your physician and you have been on it forever for low back pain, how do i get you off of it and how do i get you to keep coming to me or do you choose another doctor if i take you off of it? i guess that's the problem, and the question is, we all know the

knowledge. people have read your book, we know there's a problem out there. we have done some changes. and yet we still have this enormous prescription opioid problem. so what do you think we do beyond that? i agree with you, community, more local than federal is probably better and a local response, but we still, you know, how do we fix the medical aspect of this, how do we go a step beyond where we are? >> well, i mean, there's a lot -- that's a massive question, and i think there are smarter people than i who might also contribute to it. i think one of the reasons that you find a kind of correlation between heroin overdose and medicaid expansion is because more access to medical care means more access to pills. we still have not changed really the basic culture, and one of the reasons of doctors to prescribe pills as a solution. and so it seems to me that crucial in all this is that we get back to what we were doing

in the 1970s, and that is where insurance companies were reimbursing a wide array of strategies for pain. they have cut back significantly in many areas, i think. for a long time, i think it was all across the country, some insurance companies are stepping up more. but to me, it gets back to what the doctor has available to him or her in the appointment, at the point of contact with the patient. and you know, to me, that feels like a crucial step. every place i go to speak on this topic, and i run into doctors who tell me that they just don't have much in the way of other options to provide. >> i guess the hard part of this is, i live in a county where we have 4% unemployment and employers say we can't have enough workers who are drug-free

and have work ethic. there's not enough workers. and then i have counties where 30% of the people don't work and 30% is disabled. in my county, 4% is disabled. we all have big hearts, and people say let's help the disabled, the unemployed, and we give them stuff. perhaps when you become a permanent nonworker, we get you into a cycle where it's much more difficult. we have to figure out how to do it with a heart and a brain where we have work requirements and where you're only temporarily disabled until you're back in the workforce. it might involve money, but we have to be careful about how we do it such that we don't have perverse incentives. thank you. >> thank you, senator. mr. quinones, you can see the time clock we have on the senators. everybody will be very interested in having long conversations with you. so we're going to try to wrap each segment up in five minutes. then we'll keep going as long as we can. senator murray. >> thank you. thank you very much for your

very compelling testimony and thoughts. specifically here, i want to talk about the federal government. we play a very critical role in preventing and tracking and solving this epidemic. and in some areas have truly unmatched capacity and reach to be able to affect broad change. one example is the centers for disease control and prevention. they provide funding today to 45 states and washington, d.c. they support prescription drug monitoring programs. are invested in running a much needed public awareness campaign, and manage a critical national surveillance program. which is the only surveillance program to capture nonfatal overdoses as well as fatal overdoses and it uses some innovative ways to get timelier data. that public awareness program started under the obama administration back in 2016 to raise awareness of the opioid crisis, and is sending states to personalize and disseminate this

messaging. this administration has repeatedly requested cuts to cdc budget, so i wanted to ask you, you have mentioned in your writing that we need quality data collection and raising awareness in communities. can you share your thoughts on the necessity for continued robust funding for programs like that in cdc? >> yes. i would suggest that that is a good idea. i would also say that i think we need to greatly expand the amount of money we provide for research about addiction as well as pain management, pain treatment. all of this is part of all these many solutions. and when i talk about the federal government's role in all this, it is in no way to suggest that it has a dominant role or that i believe the important stuff is going on very often at the local level, and the role of

the federal government might well be to just simply facilitate, make easier their lives. i think cdc has a number of proposals and you know, programs that i think are extraordinarily effective. i would say that, you know, when i was doing this book, i found almost nobody who wanted to talk about this except for government workers. this was the first line of defense in this, when nobody really knew about this topic, when nobody really cared. when i thought i had bitten off an enormous contract to write a boog and put my family in jeopardy for a story nobody cared about, the people who really did care, who were working on this from the beginning, cops, coroners, cdc, dea, prosecutors, public health nurses, all of whom were earning a government salary. many of whom at the local level, of course, cdc is not that, but

i believe that the folks at cdc do remarkable stuff. in fact, i was a crime reporter. i am a crime reporter. did not write a word about health care until i wrote this book. and my overall feeling is one of awe for our public health folks, honestly. they have done amazing work in the face of almost rare thanks, let's put it that way. >> i also want to ask you, you have written about the importance of medicaid expansion to make sure patients get medication assisted treatment key to responding to part of this very complex crisis. in fact, medicaid expansion allowed about 1.6 million previously uninsured people with substance use disorder to get the health care and the treatment for health substance that they need to fix this. can you talk a little bit about the importance of medicaid in making sure individuals -- >> medicaid expansion provided drug treatment for people who did not have it. hundreds of thousands of people in different states.

it's extraordinarily important, i think. i think, i know people in different communities who have been enormously helped by this. i don't want to downplay, though, what senator paul was talking about, which is that you do have increases in overdose when that happens. and i think one reason for that, my hunch is, in too many communities, pills are still the only medical treatment. >> an important part of that is also the support, mental health support and everything else. >> of course. and when you get more access to health care, there are other things that come along with it. i think one thing that does come along with it is a reliance still to this day on these pills. we have dropped prescribing, but it's still at about 2006 levels and almost triple what it was in

the late 1990s. to me, that means that we probably still rely far too much on these. that said, of course, i do not understand the impulse to strip away medicaid expansion, particularly in areas where this problem is so intensely felt, and to me, it feels like this -- these are regions that desperately need the services that they have been provided through medicaid expansion. drug treatment being primary. >> thank you, senator murray. senator collins. >> thank you. first of all, let me thank you for writing such an important book. that offers possibilities of what has been discouraging to me is despite much greater public awareness and much more money

and much greater intentions that the problem does not seem to be getting much better. one possible community-based approach was described in the "morning sentinel" a paper in waterville, maine. it struck a chord with me because law enforcement officials in my state tell me that their jail intake rooms resemble hospital emergency rooms. so what some police departments in maine, including in waterville and scarborough and other areas are doing is they are telling addicts if they come in with their drugs and turn them in, that they will place them in treatment facilities. and this is the whole different approach for law enforcement to take. rather than locking people up,

helping them to get the help that they need. and it's also very community-based, as you have suggested in your book. in your experience, have you seen that type of program work better than the traditional approach? >> a couple of things i would say. first of all, in reference to your first point, senator collins, i think we need to keep in mind that we have been -- this problem has been festering for 20-plus years. 20-plus years. people come to me all the time, why isn't -- i'm like, it's been going on for 20 years. we have been at this for a year and a half or two years. i mean, it seems to me that as a culture, we need to learn patience. you know, and to not believe in silver bullett answers to mysterious problems like the mysteries of human pain. you know. there's a complicated thing. and so if we have not solved this problem in the last year and a half to two years, i would

say, well, yeah, of course not. we need to keep working at it. it's not -- you know, these things exist because they took -- it took a long time for these things to exist. now, with regret to law enforcement, i would say in general, some of the most innovative folks and innovative things i have seen come from law enforcement. you think not. you would think law enforcement would be holding on to the old ways of locking people up. no, i have been amazed to see the remarkably innovative ideas that come out of law enforcement. this is -- the one you mentioned is one that i mentioned in my written testimony is about the transformation of jail. i believe if we come out of this with a new kind of jail, a new way the jail is run, as you see in the state of kentucky, two dozen jails doing this. that would be an enormous advance. and what's more, jail would then be an asset again and not a liability. today, jail is a liability.

it's a place where you take people who once they have detoxed, want to see clearly the records of their own lives and want to change, and then we put them in a place that is tedious, predatory, ganged up, sexual stuff going on, all that kind of baloney. and twhat i have seen in certai jails, one in particular in kentucky, are remarkable change. one of nurturing, coming together. it's where you're working on your recovery from the moment you get up at 8:00 in the morning and make your bed military style to 11:00, whenever lights go out. that kind of change in jail would be enormous, and as i said in my testimony, i tried to highlight things that i thought would not just be beneficial to this problem but for the next drug problem as well. so we're not playing whack-a-mole with this stuff.

so i believe jail in fact is one of the great places of effervescence, you might say, when it comes to this epidemic and the way new ideas are being tried. it's in jail. and i have never been to maine, but it sounds like what you're highlighting is one of those. i do believe it's an essential part of this. if we come out with jail the way we always have used to run jail, then we will not really have advanced. the next problem will hit us and we'll wonder why we're not making greater advances. my feeling is, changing jail is the way it's happening, not just a revolutionary idea, you can find it in various examples around the country, and it's very invigorating to see. >> thank you. >> thank you, senator collins. senator casey. >> thank you, mr. chairman. mr. quinones, thank you for your testimony and for your work on these issues. >> my pleasure. >> i wanted to start with some of the realities that at least i

see in a state like pennsylvania. we have had last year, the last count, 2016, 4,624 overdose deaths. that's up 30%. >> sorry. >> up 37% from the prior year, 2015. in rural areas, higher. almost 10 percentage points higher by way of percentage. of an increase. and that's overdose deaths overall. obviously, a lot of that being driven by the opioid crisis, epidemic, really. >> mm-hmm. >> what i see, and i missed some of your testimony going back and forth between hearings. but what i see in pennsylvania is a tremendous resource gap. when we went across -- when i went across pennsylvania the last year, especially this past summer, we would have meetings with county officials, often in small rural counties, small town counties, where you have a kind

of an ad hoc group of people coming together. a mayor of a small town and the police chief and the coroner and the medical professionals, the treatment professionals. all around the table, meeting all the time. every week. because the dead bodies keep coming in. one county, a very small county said to us, maybe the most graphic metric was they didn't have enough places to put bodies. that's how -- that's how bad it was. it's everywhere. what i keep hearing from folks at the local level is we need more resources. we're getting our arms around this wrer we're dealing with it as a local community, but we need more resources. they need it for -- they certainly need it for community health workers, social workers, law enforcement obviously is bearing a lot of the burden. pathologists and otherwise. i guess the first question i would ask is what recommendations do you have for closing that resource gap, which i think is, even though the federal government has made some strides, as you note, with cures

and with c.a.r.a., what's your sense of the ways the federal government could provide more resources? >> well, speaking with people in the counties, this is one of the great places in america where this is taking place. counties are the level of government most effected, right? coroners, jails, libraries, public health, et cetera, courts. and so i have been struck, particularly in the last year, year and a half, to watch these very organic task forces or committees or what have you, whatever you call them, sprout up. and in county after county, in fact in pennsylvania, i know i was in licombing county, which is the home of little league world series. spoke with those folks at some length. yes, these folks are coming together in very healthy ways, seems to me. they're leveraging a lot. there's a whole bunch of people in that committee. there's recovering addicts,

primary care docs. a lot of different folks, speaking with the president there recently, she said one of the problems is we cannot -- we can find money for programming, for naloxone, whatever. we can't find money for the nuts and bolts that make it work like office space. that kind of stuff that is as essentially, if not as sexy as the other stuff. to me, i think that's where the federal government needs to step up, and i would say again, as i said in my testimony, that c.a.r.a. and the cures act, wonderful, thank you. but do not think that that -- we have been doing this for 20 years. overprescribing, creating addiction, unintentionally, for 20 years. one year, $1 billion, a lot of money in some sense, but in comparison to what the country needs, it's in every state in america. there's an unprecedented problem because it's in every state in america, all 50, coast to coast.

so this is -- what i'm suggesting is that the evidence shows there is a need for sustained -- i'm talking years worth, sustained investment in, i think, in i think, thinking in terms of, for example, this more mundane idea of how to let their job be easier, from the office space, telephones, that kind of thing. and again i could talk later if you'd like about the issue of coroners. but to me that's a crucial part of this as well. so i think i know it feels like a lot of money, a billion, it is a lot of money, but not compared to the breadth and depth and length of time this problem of this problem. it seems to me that this needs to go for sometime now. >> well, thank you for that. and i no he we are out of time. i actually introduced a bill to commit $45 billion over 10 years. so roughly $4.5 billion a year.

i borrowed the idea from the repeal of aca so i took what i thought was a good idea. we hope we can get support that is bipartisan. but we appreciate your commitment to these issues. >> thank you for having me. >> thank you, casey. mr. young. >> mr. quinones, thank you for being here today. thank you for writing this important book. and i appreciated your visit with us last week. i would like to discuss tour children, thousands children across my state are having their lives turned upside down because of this epidemic. not bauecause they are addicts r se but being removed from the home, their parents have become addicted. they are entering an already overwhelmed cost foster care system. you've identified in your book the need for more services for

families. can you elaborate on what specifically, what sort of either program needs there are for families or resources in your experience that might help mitigate this crisis? >> well, i think, honestly, as a reporter i would like to say best off talking to people who work in that field. i do think one of the areas that's been devastating as foster care though. my goodness, so much need now. if it weren't for grand pparent in america today, it would be just mind boggling to think what the need would be. seriously, some kids living with grandparents now because their mom's and dad's are gone or they are in prison or what have you. so my feeling, mr. quinones, very blunt and basic macro level that we need to look at at how

to fund more foster care. how to do foster care better is most likely another great question. but it's not one that i feel i can answer. >> your larger point about the solution, if you will, to this broader epidemic is hundreds, thousands of individual solutions. >> yes. >> and collectively many of them fall under the banner of community. >> absolutely. >> if we can persuade individuals that a fellow human being's plight, a fellow child's hard luck is actually their own plight, then we can more people to be foster parents to lobby on their behalf. so i think that's a good overall message that i've taken away from your book. we have already discussed jails. and in your book you have

highlighted some jails that offer rehabilitation services. and peculiarly, in those areas you have people putting them self into the criminal justice system just so they can get assistance or you have their relatives or friends doing so. and i'd like to sort of discuss a different sort of setting. i've visited with jails. i used to represent in the house of representatives austin, indiana. >> i've been there. >> you know that name. >> i do. >> because we have a huge hiv out break there on account of the intravenous use of opioid by the name of ork the name of opana. and many local sheriffs and communities like that around indiana, have a strong suspicion, because i've spoken with them, that nair inmates have either hiv or hep c or

something else they might test for, but they are on the horns of dilemma, because if they test these individuals they are legally on the hoo can to provide medical services to them. and in a place like say south county indiana, that would deplete their law enforcement budget for a year if many of them tested positive. look, i'm not asking you to be a magician here, but number one have you encountered this dilemma? and if yes, do you have any thoughts about how we may remedy it? >> i honestly, senator, have not. i don't doubt it exists. nothing surprises me about this topic, but i don't doubt it exists. you know, all i can say is that this seems to be the nature of this problem. that we are asking, well, in one

case foster care, but in another case you just mentioned jailers to be the, again, magicians, figure out this deep social problem, and that i don't think they have an answer for, you no he. they do not have an answer for, nor do they have the funding for. what they go about doing it, sometimes i'm a reporter, sometimes i have to say, i mean, i don't know. i honestly, sometimes it gets to that point where i'm overwhelmed by all the ways that this problem manifests itself. i do believe locally is the place where we find the solutions. but that you all have an absolute role in facilitating, making sure that they have the resources they need. because on the ground i have to

say the counties and the people in those counters are working hard and imaginatively. so had you going to them and finding out what they need to me seems to me the evidence would show the way we proceed on this. i don't believe that -- i do not believe most of these solutions mostly from washington d.c. chlgt i do believe the federal government has ha profound role in helping those solutions and facilitating those solutions. >> i agree. thank you. >> thank you, senator young. senator bennett. >> thank you mr. chairman. i appreciate you having this hearing. and sam, nice to see you again. thank you. >> you too, senator. >> one of the most compelling pieces of phon if fiction hinon read in a long time and very

depressing. >> thank you very much. >> the story you tell about something we haven't talked about is the heroin epidemic which rode on the prescription drug. >> right. >> my reaction reading it this was all happening in plain sight but somehow we missed it. and today 42,000 people a year are dying from this. the white house estimated this is costing the united states economy $504 billion a year. so a $1 billion is a lot of money but .2% what it's costing our economy. and the rural counties in my state is that lt sheriff tells you that 92% of the people he's admitting into his jail are testing positive for heroin. or that the jailers who opens up his jail and takes you to the back and opens the window and says, look, look, and you say what are you showing me t they

are women in my jail. i've never had women in my jail. and they have two jail cells full. and we are spending.2% on treatment targeted treatment. so i'm all, as a former local person, all about people in the local community. but they can't do it without resources. and in the rural counties that i go to, if anything, they have less access today to treatment than they did ten years ago. >> probably true. >> so it's tristriking we are moving in the wrong direction. if you want to comment on that. >> a lot to comment on. one of the problems is with our over prescribing of these pills, we in time created legions of addicts, and that in turn awakened the vast logistics potential of mexican drug trafficking culture, which i lived in mexico ten years and know fairly well.

and most traffickers don't want to trafrj heroin, viewed as disgusting drug and people are far more enamored with coke or meth. and they didn't want to traffic it too much until we begin to ex -- now of course their profit motivation is that radar is very high level and they want to get involved in that and it's exploded the numbers of people who are trafficking it i think from mexico and elsewhere. so that's one thing. as i said before, i believe that the community solutions, community is where it seems to me where i have seem people walking working hard and coming up with solutions appropriate to their counties and regions. i do not believe they can continue long-term without a whole lot of more help and sustained, as i said, long-term

focus, from the federal government. i believe a lot of folks are looking to the federal government. republican and democrat, right wing and left wing, in this fight for sustained help. not one off kind of idea. >> could you also say a word about -- you mentioned it very briefly earlier -- about the ways health insurance reimbursement create challenges for work at the local level? you were writing about the inability to get low cost social work, for example, reimbursed as opposed to pills? >> right. and initially in pain management for many years, pain management was to take one individual and design over a period of time in close connection to patient and doctor together, design a menu of strategies that would help

this one individual. so one individual, many, many strategies. marital counseling, diet, ac u p puncture, on and on, job therapy, physical therapy. as we began to believe that one pill, one kind of pill would or drug would be solution to all pain, insurance companies dropped a lot of that. and you couldn't really design the full pan a poe lee of strategies, because you were no longer getting reimbursed for a lot of that. to me that's fundamental in this whole problem. doctors need to be more educated but again after educated they need to have the tools. and doctors were told there is a pain epidemic and increasingly they were left with one tool. and big reason we got into this. so my belief strongly, and this comes from talking with lots of

doctors about their dilemmas, is that they need more solutions in that moment when they are meeting with the -- and some places are doing t by the way, va, hats off to them, they started us, leader into all this, now they have done a u-turn and i think you can get yoga acupuncture as well as opioid pain killers. not to say these drugs have no use. they are absolutely useful in certain windows. so i think we are seeing these kinds of changes. seems to me though that the reimbursement for different kinds of pain strategies is just like a fundamental part of this. >> thank you. >> thank you, senator bennett. senator murkowski. >> thank you, thank you for your leadership on this issue and really raising that level of

awareness. as you point out, this has been out there for a while. but i think my colleague just mentioned it's been growing in plain sight here. and thank you for acknowledging that there is no one silver bullet. i think you said it's a complicated, no silver bullet for a complicated adult problem. and yet we all know as has been mentioned it's not just an adult problem. our children are dying of overdoses. our children are suffering because the parents are checked out. i went to a senior center, sitting with a group of primarily senior ladies and said if i weren't here having lunch for you today, what would you be talking about? they looked around where we would find services for our grandkids because all of us are taking care of our grandkids because our kids are either in jail, have given up the kids, whatever. so this is truly a problem that consumes all ages, all

spectrums, all classes. i'm interested in your suggestion that we need to look at this from a very, very broad perspective and really strive high marshall plan, follow the same lines of the space program. >> yes. >> the problem that i see with that is we are still sophisticated, strangled by the stigma that is attached. it seems like it's just been recently that you will see in the obituaries that there is an acknowledgment that this young person or this individual died from an overdose. but we have buried it because there is a sense of, well, i failed as a parent if my child died as a drug overdose. so until you get beyond that stigma, i think there is still so many, well, those are the ones who just couldn't make it.

those are failures. >> sure. >> losers. which is a horrible, horrible thing to say. and i even hate to say it in front of a microphone, but there is that stigma that is out there. so how do we get people galvanized to help and to be inspired to do something as big as -- i agree with you -- this needs to be in order to make that difference? are we making head way in reducing this stigma? >> yes. great question, senator, thanks for asking. i mean, i think definitely we are. i can tell new 2013 i was writing this book, and i had had a conversation with my wife, i said, you know, we are going to write this book. going to put it out and fulfill the contract. but the truth is it's going to die when it comes out because nobody in this country cares about this problem. i could not find anybody to want to talk about it except for public health nurse hanau

cagesly nar cat icotics officer judge. and the reason is parents were embarrassed. this was a different kind of problem then existed in the past. people were mortified hat what had happened to their children. and you never ever saw an obituary told the truth. like the aides issue, people well he died of cancer. in this case it was well he died at a home at a heart attack at age 25. now, i believe what is helping to change that, i think similar to say the gay marriage issue which is a radical transformation in the last ten years, is getting to know people who are actually affected by that. that's where i believe -- i know you've heard a lot of you need to provide more funding, but i do believe you have a public profile role as senators. if you go to communities, find

those parents, talk to them, point out the programs, meet with those county groups that are sprouting up all over the country. it's amazing to see this. and lend your own high public profile to them. meet with parents and say, you know, thank you, tell us your story, recruit them. i think frequently there is a lot of folks who would go along and do that if they were asked. if they were pled with, please do this. and as i said in my testimony, maybe it's because i'm a reporter, but i believe in the enduring power of story, to change people's minds. we have as human beings from the prehistoric times to today always needed stories to help us understand. and the only people, and the reason this was not very well publicized was years ago, and hidden, was because the people

that could best tell the people didn't want to talk. now increasingly they want to talk. and it's so important to embrace them, to bring them out of the shadows. they want, many of them. some not yet but maybe some day soon. and with that my feeling is there is is a horrible stigma, exactly, as you say, and one of the main ways we defeat that is through stories. and i believe as public officials you all could have a magnificent role. whenever you go home, whenever you go to some public event that may deal with this, find those parents, bring them out, have them talk a little bit about their lives, recruit them, give them a phone call, you know, saying, hey, i heard this happened, we would love for you to tell your story. if you can't right now, fine, but just want them to know, we are here together. so many of them felt alone. they made horrible bad mistakes because they thought there was nobody else nearby, that they

were all alone in this. and i think defeating that isolation is part of the many, many solutions of things that have to be tried. >> great reminder to us, not just all resources but that we can have that role too. thank you, mr. chairman. >> thank you, senator murkowski. we have several that we want to stick to the five minutes. >> okay i'm sorry. >> senator murphy is next. >> thank you very much. if one of us were to go down to the senate floor and give a speech on loneliness we would worry it would come up looking silly. yet if you look at the map of the suicide epidemic in this country, the crisis is the worst where social isolation is the greatest. if you read pete ailes great book about the mental health crisis, he comes to the conclusion in the end very effective treatment program are the ones that build connectivity

between people. and you didn't title your book the great heroin epidemic, you tiled it "dreamland" and made it in your opening comment it's about connectedness. but the story of "dreamland" is a complicated one. private low cost community pool that closed in part because of factors that were outside of government's control. people had a lot more going on in their house. >> they had their own pools. they had more tv channels. kids have lots of reasons to stay inside. and yet you are sort of hint at being critical about the decision by the government to let that pool close because theoretic tli were other options. they could have spent some taxpayer money in order to keep it open. probably would have been criticized for throwing away money in a money losing effort. but pt result might have been that a community asset stayed open. so i guess let me sort of take you from where you left off in

your testimony. you focus your book on this question of building community. and we are really awkward when we try to address the ways in which government can build community antique loneliness because it sounds like something we are not supposed to do. and yet you know at the heart this is a critique that we should be thinking about those things. so just share with us your thoughts on how we can change maybe the way we spend money or public policy to try to build communities rather than tear them down. >> i think it's, best idea i can come up with is to consult those people who are already working on that. and i think all across the country that's happening. that's what's changing. another thing that's changed in answer to senator murkowski, that we have now on the ground lots and lots of people working on this in a variety of ways.

my feeling as a reporter is always to go there and ask them. but also understand that government has, it seems to me, an essential convening role, by providing the infrastructure that does bring people together. that includes stop signs and good roads by the way. that kind of thing. but also funding to provide, you know, the community centers and this kind of thing. and so i think you guys might talk more about that on the senate floor, honestly. it's not a conversation that we have enough in our country and you might be the ones to lead it. honestly, i think we would all be inspired if you did, seriously, my feeling anyway. i would be. so how do you do that? i mean, i'm a reporter. i'm not sure i know all the

ways. i do -- my impulse as a journal li ist is to go to those areas and talk to those areas and highlight them. as i was saying to senator murkowski, find the people working hard, find the community coalitions, the task forces and your presence at one of their meetings would be huge, huge. try that. try doing that. it's a great idea. i mean, try to be there with these folks and understand and see. will it be a pr event? probably. who cares. you want to highlight these are the folks working. and from that kind of -- that's how innovation works, right. you have factory floor, you have the factory worker, the supervisor, the computer software guy, accountant, all putting their brains together and finding little incremental ways for making the product better. and i think cities and towns

work the same way. no magic bullet or wand, just slow incremental work. >> i just raised the question because if we are going to spend a lot of money on this epidemic it's worth challenging us. >> most definitely. >> as well as paying for treatment. >> right. and i do believe in the overall -- somebody asked me what are some of the details? i don't have a clue. i'm just a guy, a reporter out there trying to understand this enormous country we have, and sometimes it's hard. >> thanks, mr. chairman. >> thank you, senator murphy. that's a pretty good description the way we feel. >> i bet you do. i don't blame you. >> i want to ask you about the holy grail, your chapter searching for the holy grail. what do you think about that? you don't pretend to be medical expert. but why is it not a good idea to

find nona tick tive pain medicine? >> you know, it's a strange thing. my friends from college would look askance when they hear me say this. but as i got into this story, i for the first time in my life began reading philosophy about how we create happiness as human beings. how we achieve happiness. what is happiness? because it seems like all these people all across the country are looking to this substance in one form or another of opiates to be happy at least for a few hours. and it seems to me, the philosophers i read talked about working hard towards something you are fulfilled by and excited by and loved to do, and a long the way comes a full fillment. >> but if i may interrupt. in your book you go through how first opiates was used to help people dying who were in

horrible pain. then it appeared that erroneously they not be addictive, so this whole revolutionary you describe it as making pain a vital sign came about, then it become addictive. but just because opiates turned out to be addictive is that a reason not to try to find other strategies or medicines that are not addictive? >> of course i would never stand in the way of people in pain. >> exactly. and i would never stand in the way of science. but i feel that in the long run, we are humans, and humans have never done well when they have it all. when they have all the pain treatment and none of the consequence. to me, this is it a hunch, i'm not saying i know. and if ten years from now science comes up with a pill that reduces all pain to

negligible amounts and does not addict anybody i would be thrilled. >> sounds like with your general approach, and i don't want to put words in your mouth, sounds like you would suggest that could be possible, that would be good if it were, but might only be one strategy for dealing with complications? >> i believe other strategies, given the fact we are humans and need friction and tension in our lives, to actually be productive and be happy, in fact, i believe that there are other things that need to happen in american culture. i believe as individuals when i was writing this book, i stopped drinking sodas. i believed i wanted to be the change that i wanted to see in the country, so i stopped eating food that i saw advertised on tv. i wanted to be -- i felt it was important to do things that would reduce my -- the chance that i would have of pain.

i have no problem with research trying to find a pill that would be completely pain killing woutd any ha diction. i just have a skepticism that in the long run it would be -- that we would as humans would be able to handle it. that we behave very poorly. kings, dictators, hollywood producers apparently these days behave very poorly when they have no other friction in their lives, when nobody to, you know, no accountability. >> i mentioned earlier yesterday i dropped by the governor's residence and he had a meeting in all of the people in the universities in charge of training physicians with the goal of changing their attitudes toward prescribing of opiates. one of the health officials there said to me when i told him that i would be hearing from you today, said ask him about fentanyl and where it fits.

so in 50 seconds can you tell us about that. >> fentanyl is transformed the heroin market completely. it has democracyized it. used to be when heroin was in our country came from four, five mexican states. now it can come from nebraska, from canada, ohio. it has made heroin dealers more willing to kill people. used to be for years you got customers was by overdosing your clients. when someone overdosed, that was not a warning, that was an advertisement on the street, a lot of addicts ran to find that dope that just oded that person or killed him. but that was very expensive to do. in heroin trafficking, what you want to do is cut, you want to reduce, because it gets you more volume, so you get a kilo and cut it into two or three and sell that but it's weaker, less chance of oding people sochlt

what fentanyl has done has made it far more cheaper to od people therefore create buzz around your product. die b diabolical thing to describe, but that is the nature it seems to me of this world. also it has allowed many, many more people to get involved in this and by the dark web coming from mexico, but also being sold on the dark web very prevalently. and that has allowed a lot of people now to get involved in selling it that probably never would have before. >> thank you. senator hasten. >> thank you, mr. chair and ranking member murray for holding this hearing and thank you mr. quinones for being here and your work. just at the outset i would say some of the es themes you touched on community are also the themes that robert putman has touched on in his work with kids. >> absolutely. >> and i think your book and his together are really important.

i want to just start by lay tg a little bit of ground work. i was governor of new hampshire started in january of 2013. also working with medicaid expansion in august 2013. in 2013, we had 192 overdose deaths in new hampshire. in 2014, 326. we were on an upward trajectory even before medicaid expansion. and in fact one of the reasons we all came together to implement medicaid expansion is because we had a crisis in our behavioral health and drug overdose deaths in our state and we knew that medicaid expansion would get more treatment to people. and my own anecdotal sense that medicaid expansion did not in fact cause an increase in opioid deaths is reinforced by recent article in health affairs. so i want folks to have a sense of that. i think there may be a correlation here.

but to suggest that there is it a causation is very troubling to me. and i also think speaks to some of the stigma issues that you've talked about. i do also want to thank you you for your insistence that this is a problem that was decades in the making. it is going to be decades in the fixing. and it requires subtle approaches and an approaches that can evolve with the way this epidemic is evolving. to the chairman's point fentanyl in hur staour state has changed in the way law enforcement and treatment community addresses this. so i thank you you for your advocacy for that. i want to spend a little bit of time on one of the issues that i don't think we've touched on as much right now as it deserves in your book you chronicle the so-called porter and jik letter

which was 1980 letter to the journal of medicine which was completely misinterpreted and used by opioid makers to say their drugs are nona tick tive. it's astounding that one paragraph jotted down in 1980 helped fuel the horrible epidemic that we are seeing today. your book outlines how drug companies have played ha big role here and how some of them have misled providers and addictive nature about their products. can you give us a brief overview of the role that pharmaceutical agency in creating the miss con exceptions of the port ser and jif letter. >> brief. >> you have 1 minute 45 second. >> well, i think evidence shows it was pivotal and all this. it starts really with pain

specialists believing we were poorly treating pain. and we were. we were. this was a story of a lot of people doing what they thought was the wriright thing but too h that turned out badly. i don't believe they would have had the mega phone that they came to have were it not for a lot of the mo enamoney and funding and selective use of their information by pharmaceutical companies. i think their money and influence was what really changed the tide. then of course they were joined by certain institutions like the va fifth vital sign and all that kind of stuff. but i think they saw early on, and pursue was one of these, they tried the time release opioid ms cot continue, and it was mag tive drug, if they stuck

right there we would be applauding them. instead what they saw was the cancer patient was pretty small. and there was a much much larger one called chronic pain which is normal pain of americans, basically. and they got on board. this was also, by the way, an important part of all this is these years involved the industry went through a sales force arms race where every company was hiring more and more and more and more sales reps. and these were not the older sales reps more grounded in fact. it's my impression talking to doctors who knew these older fellows, mostly guys, they knew what they were doing and they were not such a hard saile. they were more informational. then you hire a bunch of good looking folks, reps went from 35,000 to 100,000 in five-year

period, all of that also was part of this story. and i have to say this though, this is a complicated tale, and i wanted to not blink at the complications. i believe also we as americans play a huge role in all this. our desire to have quick to not have pain, to not be accountable for aur wellness. >> i think that is fair. i'm out of time. i thank you for this. i won't have a time for second round of questions but i'll say that in my state the need for funding to support the grassroots efforts like our safe station programs and some of the things our law enforcement is doing and treatment is critical and i would look forward to talking more with you about that. thank you. >> thank you. senator cain. >> thank you, mr. chain, and thank you mr. quinones. i think "dreamland" and factory land are two best works of reporting i've read in the last 24 years. >> thank you. >> tremendous work. i want to ask two questions, if

i can get to two. the first one is we have had witnesses here mr. quinones, and i've asked the questions, frances collins, could we set a goal addiction freebie 2030. if you don't have a target to organize around we will be on the moon. >> that's probably true. >> we will rebuild these economies hand enable them to protect themselves from the spread of soviet. if you don't set the target, then you don't marshall your resources around meeting the target. so if you were to advise us about what the target would be, again i pose the question to these folks, could we set the target of addiction free by 2030, and they said yes that's doable if you define tt right way, it's doable within the current scientific knowledge and technological likely near term future. but if you were to give us a

target, what would you tell us to say? >> if i were to give you a target we would all be in trouble. i would say that a target is good, and my hunch as an american that that is something to strive towards. it's always good to have a deadline. always good to have a goal. what that year should be and whether or not humans can ever be addiction free is a debatable point in my opinion. i'm not sure that's possible. however, and as i said in some of my testimony, written and oral, to me this is apply story. i lived in mexico ten years. and mexicans, when i was in mexico, not having thought about it, i adopted all our american drug problems was driven. >> there is a lot of evidence. but the demand will keep producing street corners.

>> i agree. but the primer in all that is correct the thing that starts it, i bloo evelieve, is supply. and i came to believe that after living in mexico where i believe the demand because mexicans like to believe that it dissolves them of responsibility. it's really not our drug problem chlgt it's binational needs to be addressed as such, us anthem. but when i started doing this book, began to realize, that's exactly not what happened. that we had no real problem with this before this over prescribing of opioids. difference in this story is that the supply did not come from columbian dealers and mexican cartel guys. it came from doctors buying into sincere well meaning good well trained doctors buying into an idea that they could help their patients by massively prescribing these pills. and so the goal is a laudable

one. target. but to my way of thinking, there is a supply is an issue, and that means pills and heroin and fentanyl, and therefore to get there i believe requires that, you know, there is a reason why all those guys from vietnam came back addicted, so many of them, well, first of law no longer war torn vietnam, but in rural tennessee, there was no supply. so the more you separate the addict from the supply, the better chance that addict has of success. that's what they are finding in some parts of ohio. >> let me ask you a second question. i have a brother-in-law bright ho dwight holt man. >> wonderful guy. >> next gig ceo of a substance abuse and suicide prevention lines for life. twilight sa dwight says this, if there is a

social movement for recovering that would be the most powerful movement in the united states. because he's grappling with this issue of how do you get over the stigma, then democrats, republicans, red state, blue state, this recovering social movement would be massive and would help us meet whatever target we set. i'm curious what you think about that. >> again the more stories you tell and more people end up -- this is what happens to me on airplanes all the time. i'll start talking about the book i just wrote, what do you do for a living i'll tell them, they'll start looking around, well, my cousin is doing five years in prison, whatever. and i think the more those stories come out, the more we all know how many people around us have this issue in their lives, the more it becomes a way you don't have to lower your voice anymore. it becomes natural. well, you know, recovering from x, that's why i think it's very important for recovering addicts

to mention that a lot. just because it normalizes and makes us all understand this is something that's going on all around us. and it is amazing thing to have written a book like this, and then go on the road and have these encounters in airports and places like that. so i believe in the power of story, as i said. >> i'm over my time. but i really appreciate you being here today. thank you. >> it's my pleasure. >> thank you, senator cane. senator warren. >> mr. chairman and thank you mr. quinones for being here. thank you for your research on the rise in prescription opioid use. and i want to follow up on your point about supply. in your book you write about a hospital in columbus where a doctor in the adolescent department helping heroin addicts get detoxed talks about the kids he was seeing who started with prescription pain killers.

and he says it was all of them. that's how all of this had gotten started was through prescription pain killers. >> right. >> a story that is true i take it for far too many americans. according to the cdc people who are addicted to pain killers are 40 times more olympiclikely to addicted to her win, and many people misuse opioids take the pills start out with pills that were legally predescribed, whether to them or a friend or to a relative. i know you've written about your own personal experience with opioid prescriptions when your appendix was removed. do you mind saying a bit more about that experience? about how many pain killers, you can keep this short, how many pain killers were you were prescribed and how many you think were needed. >> sure. and i think my story is multiplied by millions every year for 20 years. i mean, i had an appendix rupture. >> bad thing. >> at work.

i was at the l.a. times not shift one night. and i didn't realize, went home, went to the hospital later, they said my appendix had ruptured. twenty two days in the hospital. perfect example of what to do and not to do in my case i think. each of the two days i was in the hospital, they gave me two vicodin, very good idea. because i'd just been cut open. very good idea. then when i left, they gave me a bottle of 60 vicodin and said take as needed. this was, again, ooh ima crime reporter, i've done work on gangs and stuff like that is correct i did not -- have never written about health care. i did not, plus i spent most of my last ten years in mexico not paying attention to this issue. i did not know what vicodin was. i thought it was a glorified aspirin because they told me, as i left, take as needed. and i'm like okay that sounds like aspirin to me. i don't like taking pills. so i took two of them. >> so two?

>> right. >> and you got 60. so 58 unused pills. >> 58 remained in my medicine cabinet until 4 years until i got in the middle of this project and i said i think i have this vicodin. and sure enough dug through there and found it and exposed of it. a couple of things. that is a perfect example of the supply that we have unleashed on this country. multiply my case by millions and millions of people, every year for 20 years, and you get to where we are. >> so there is actually some data on this. study in the journal of the american medical association that found between two thirds and 92% of patients who underwent various surgical procedures like you did report they end up with unused opioids afterwards. and just like you, a locality of the lot of these sit around in the medicine cabinet and fall into the wrong hands.

>> very easily. >> and as senator alexander noted earlier last time they let patients request only a day or two to be filled at the pharmacy. and if they are still in pain a few days later they can get a few more pills if that's what they want to do. i know it's not -- you talked about how complex this problem is. but i want to talk about that one little part. >> that's the kind of thing i'm taublgi talking about. many small solutions. one of them is to take that supply out of the medicine cabinets basically. and also i think to get doctors in the habit of questioning, i think it was routine, for years, and this country prescribed 60, 90 of these pills and get doctors out of that. think of the windfall, by the way, to pharmaceutical company, when a doctor in a white coat

prescribes you ten times more than the pills that you need. and you say, okay, sure. >> or in this case 30 times more. >> sometimes. and sometimes refills. so on. again, i get back to the basic dichotomy. story built on belief in a magic bullet solution. no. i think there is lots and lots of little things. what you are outlining sounds like to me one of those little things. >> good. and i just want to say on this, we got the law passed here, but that doesn't make it a reality. so we have sent letters to every governor in the country. a lot of the different medical organizations asking them to back us on the implementation of partial fill. and, also, here we are almost a year after the law has changed

and drug enforcement administration still has a definition of partial fill that is out of date, not in compliance. so just a couple of weeks ago senator cap a toe and i along with senator grassley and senator feinstein sent aler to the r letter to ask them to update these. big complex problem. we have done our part now we have to ask them to get in line. thank you. >> thank you. senator baldwin. >> thank you. i really appreciate you being here today. >> it's my plesh suasure. >> what an opportunity to have a conversation. so you chronicle this epidemic as having its roots two decades ago, at least. >> yes. >> and yet we find ourselves still scrambling and in some cases not gaining ground but losing ground. i want to share i represent

wisconsin and the new front of this battle appears to be fentanyl. >> it does indeed. >> and in a community like milwaukee county largest county in the state of wisconsin,fentanyl specifically was the cause of 170 deaths in 2017. combined with other opioid overdoses, there are about 420 in that county last year. >> i'm sorry. >> yeah. and it's just one example in the state of wisconsin. and at this point, you know, there is no sense that 2018 is going to be a turnaround year. despite the fact that milwaukee county has a committed heroin

task force. i want to dove tail on your conversation with the chairman about synthetics like fentanyl sort of changing this epidemic in some ways. do we need to be prepared for a next generation of synthetic opioid? and what is the federal role again in assisting communities? >> well, gosh, that's a huge question. i think, and i'm not sure i have all the answers to it. >> i have a couple more huge questions. >> there is nothing but huge questions on this topic ks, it seems to me. yeah, fentanyl has been remarkable in trance formative. it's like the third stage, starts with pills, then heroin, now we are onto fentanyl.

and car fentanyl which is rhinoceros painkiller. i do believe that -- it's blie belief, strongly having lived in mexico, that it is calling on us to understand the only way we are going to stop and have any kind of effect on fentanyl is working with mexico. not at odds with mexico. no way you can stop the smuggling of fentanyl. we, alone can stop the smuggling of fentanyl into the united states. because it is so small. sugar packet of fentanyl would kill everyone in this room and probably in this whole floor. so the whole thing seems counter productive having lived in the country for a long time is rhetoric that demonizes mexico. i'm not saying as a way of putting on rosy colored glasses

with respect to mexico. i know the depth of problems they have there. but nevertheless, i think in a person to person connection, which we never really have achieved as government to government, i don't think, from what i can see, that is how you advance. you no he, they just shut done, very interesting case in july, they shut down two major dark web places in july of last year. and they did it with you'a bunc people, classic example of how you make a dent in supply by working with these governments, global economy, only groups apparently that don't work together are governments. that was one example i thought was fascinating how you move forward. that to me those are the ways that you help local law enforcement. local, being in local law

enforcement today feels like you are standing in the ocean trying to keep back the tide when talking about this topic. >> i'm going to ask a question i don't think they'll be time for an answer, but maybe we can follow up. >> sure. >> i've held a lot of round tables with stakeholders from recovering addicts, family members who have lost loved ones, law enforcement, heat, et cetera, around the state. you talk so much about solving this through ending isolation and having stronger communities. i do find some significant variation between what i hear in urban centers in wisconsin and what i hear in rural areas. everything from the availability of resources to help people who want to get treatment for their abuse, even to what drugs are being taken and abused. >> yeah. >> and would love to hear your

thoughts. i'm not going to be able to stay for the second round, but perhaps in follow up, about how we strengthen communications in all of those different settings as they respond to sometimes unique and sometimes common challenges. >> okay. >> thank you, senator, senator baldwin. senator collins. >> thank you, mr. chairman. i want to explore further with you the link between economic affliction and drug addiction that you've referred to. many of the communities featured in your book, like ports smith, ohio, have been devastated by mail closures, for example. you've also said that heroin is what you get when you destroy "dreamland." you've said that isolation is heroin's natural habitat.

in the state of maine, the opioid crisis appears to have started decades ago in washington county which borders canada. and it economically disadvantaged county with very high rates of unemployment and a lot of isolated communities. it then spread everywhere in main including our most prosperous towns and cities. the portland press herald last summer ran a 10-part series on the opioid epidemic and it focused, one story, on the lobster industry, highlighting the hyphigh entry rate in that industry, and also the logistical challenges of securing treatment in rural

communities. >> great story. i read it. >> they'll be glad and impressed to know that. >> yeah. >> in your investigation, did you find that drug dealers tend to target communities that are economically devastated? are they more fertile grounds for addiction? >> i didn't notice that, i don't think drug dealers are deep sociologists. i think they are following the money. and the first place where this began, again, this began in areas economically devastated because pain treatment and resorting to doctors was part of how you navigate economic disaster. you get disability, as we were talking about earlier. i can't remember which senator asked about this. yeah, people who are trying to navigate, and they go get

workers' comp and ssi or whatever it happens to be to get the needed doctor. again, this seemed to be, as time went on, pills seemed to be something to resort to for economic sus sten nans. you could get pills and high on them but also sell them. and some of the big dealers were seniors, they were not young people at all, seniors who figured out gee all these kids will buy this stuff and i'll sell half, keep what i need, and sell the rest, you know, that kind of thing. i do believe, as you say, that this starts in areas of deep economic affliction. and, again, the areas that are viewed as kind of like the losers in the great free trade globalization gambit we've had over the last 30, 40 years perhaps. now, of course, though, some of the things that i began to

reliedr realize, what me made change, it switched to communities with wealthy centers with mansions, they have the problem. then gets into larger questions of we as americans how we view pain and what we want to, how quickly we want to easily we want to deal with it. >> i also want to follow up on your comment about the heroic role that's played by grandparents. >> yes. >> i held a hearing in the aging community to look at this issue. and of grandparents raising their grandkids due to the opioid crisis. and just as an important statistic, i'll te will tell yoy state between 2010 and 2015, the number of grandparents taking care of their grandchildren, and being solely responsible for

their care soared by 24%. >> yeah. >> and it's because of the opioid epidemic. >> yes. and i think that's what's repeated almost every -- many states in this country. >> thank you for your good work. >> thank you, senator. >> thank you, senator collins. senator murray, do you have additional questions or comment? >> i just want to thank our witness for being here today. your name has been pronounced a lot of different ways. can you pronounce it? >> kinones. thank you for tolerating us. thank you for your excellent work and your thoughts. mr. chairman, i look forward to working with you and all of our committee members on this. >> thank you, senator in you are and. >> my pleasure. >> i think senator murkowski has a question and then we'll wrap up the hearing. >> thank you, mr. chairman. and thank you, truly, thank you. so many statistics that you have cited in your book, but one that

just really floored me was the reference to the volume, really, that those in the united states consume when it comes to narcotics. you state that we -- the united states consumes, at the time of the writing, 83% of the world's oxycodone and fully 99% of the world's hydrocodone. gram for gram, written in in 2012, people in the united states consume more narcotic medication than any other nation worldwide. okay. so people can become addicted. >> yes. >> whether you're a u.s. citizen or whether you're -- >> right. >> some place in south america, europe. what is it about this country

that has -- that has us at fully 99% of the world's hydrocodone, the vicodin and lortab? what is it that has happened here? >> you know, that's a terrific question and i -- one that began to hit me as i got into this book and realized that this was not really just a story about drug addiction, it is a story about who we have become as americans. >> the united states as drug addicts. >> exactly. two generations or so ago, 11 million people joined the army and the whole country participated in defeating the nazis and now we can't get our wisdom teeth out without getting massive doses of opiates, you know? i mean, i sought the answer to that -- why -- what is the common denominator between portsmouth, ohio, a rust belt town battered by almost every

economic force for the last 30 years and charlotte, north carolina, a very wealthy town. salt lake city. these towns have done very, very well. what is the overriding common denominator. it's not economics, obviously. you've got two very different economic situations. my way of feeling, it's a combination of isolation and also, frankly, maybe this is an essay on the dangers of prosperity. that too much stuff given too freely, people not expecting to -- kids being raised bubble wrapped against any kind of pain. fearing that whatever -- skinning their knees may do to kids when they're outside so keeping them indoors and all across the country we see this. >> was it interesting to you that the boys that -- those that were doing the deliveries did not -- they didn't use the stuff. >> no, they were addicted to something else. >> they were addicted to --

>> going home a king. >> to the resources that came back. >> giving away pants and what not. >> still, you look at that and you say what is it about americans that has pushed us in this direction. >> yes. >> in such an extreme direction. you have other countries that have the same issues that we have. they have economic decline. they have isolationism. >> that's true. >> they've got the same things that we have and yet we have turned to opioids to numb it all. >> and i think in part it's also what i was talking about at the beginning, which was there is this focus -- we have focused on the individual, exalted the individual, great ideals of the american experiment become twisted in our pursuit of an end to pain. self-reliance becomes isolation. accountability becomes tantrums whenever any political official or any cop or any doctor doesn't do exactly what we say.

it seems to me that these are things that are behind a lot of this. that we have maybe have had too much. we've become pampered in some sense. i don't -- i don't pretend it know it all. these are questions that fascinate me and i love to talk about them. i make no claim to know all the answers to these very important questions you're posing here. >> so this -- this statement was made back in 2012 in the journal of pain physician. would you assume that those numbers have continued to increase even or -- >> well, they have not dropped. >> relative to other countries. >> and part of it, i have to say this also. it bears noting. part of that is because a lot of countries don't use enough of these drugs. people die in horrible agony from cancer where they shouldn't be. there is a proper role for these drugs in human medicine. it's just the debate over what

that role is is a very, very important one. and up until now over the last 20, 25 years in this country, the proper role appeared to be, you know, a bottle in every medicine cabinet and that's where we got into trouble, it seems to me. >> thank you. thank you, mr. chairman. >> thank you so much. >> if i may just make a couple of quick observations about your testimony and then one about your space shot marshal plan idea. >> yes. >> listening to this, one thought i had was with your family here especially you should -- as i mentioned to you before, you should be glad you weren't nominated for something or some senator would have chased you under a table and accused you of killing your grandmother in the process. >> i'm aware of that. >> we have thoroughly benefitted from your testimony and it strikes me with your book and with your testimony that you may be helping to lead a revolution in a different direction than

the one you describe in your book. >> thank you. >> when people, as you say, of mostly well-meaning, but a whole variety of participants, some not so well-meaning, mexican drug dealers and enterprising pharmacists and doctors who thought they were doing the right things all caused an overappropriati overprescription and use of o n yits. it takes some awareness. i think your book is helping us do that. as i mentioned yesterday, if you have all the heads of universitys and institutes training in tennessee, one of the leading states for this problem, working together with the governor to change the way they teach doctors about what to do about opiates, you'll have many more prescriptions of three days worth instead of 60 as

needed. there are steps we can take and i congratulate you on that. on your testimony, you demonstrate some humility. you don't claim to know everything. we find around here that's a very useful at beauty because we don't know everything either. second, you're a wonderful storyteller. it reminds me of my late friend alex haley who wrote "roots." he said, may i make a suggestion? when you begin you would say may i tell you a story instead of making a speech and someone might actually listen to what you have to say. because of your story telling, people -- we're listening to what you have to say. and finally on the marshal plan and the space shot, i think senator murray and i murkowski worked together to fix no child left behind a couple of years ago. one thing no child left behind did in education is have as a goal that 100% of children would be proficient in reading and

math by the year 2014. and i remember when that was said i wasn't in the senate, and i thought, well, i guess that's all right. we say all people are created equal and samuel huntington, a professor at harvard, once wrote that most of our politics is about setting high goals for ourselves that we never reach and dealing with the consequences of not having reached them. that's sort of what we do as a country. and then i was thinking about -- but it created a lot of problems for us that we had to -- the consequences that were attached to that high goal did. on the marshal plan and the space shot, i think this may be more like the marshal plan. the space shot was a high goal, inspired everybody, but it was done from washington. it was a centrally organized single shot effort and when it succeeded we would reach the moon. the marshal plan actually was a request of european countries to come up with their own plan. it wasn't -- >> yes. >> or president trueman's plan.

it was shows countries came up with a plan. and we funded it. but then they implemented it and some succeeded more than others. >> yes. >> which is probably what will happen here. so some sort of high goal, but i think the more important and better example may be the marshal plan. >> you may be right. >> because each of the states are different and i like the fact that you talk about the parts of the country that are ravaged by globalization and online purchasing, all of this business that leaves main streets empty and people without things to do, but we have the problem that spreads to charlotte and nashville, too, and those aren't poor cities. it's a complex problem. you've helped us understand it. thank you for your leadership and we appreciate your family coming as well all the way from los angeles. the hearing record will remain. senator murray, do you have anything else? the hearing record will remain

open for ten days. members may submit additional information for the record within that time if they would like. our committee will meet again on thursday, january 11th, for an executive session on nominations. thank you for being here. the committee will stand adjourned. >> thank you. and we are standing by to take you shortly to indiana for indiana governor eric holcombe's annual state of the state address in indianapolis. as we wait for that to get underway, we'll bring you a portion of this mornings's "washington journal."

>> the remainder of the "washington journal" today. we're going to be talking with senators and congressmen on the house and senate budget committees about their budget priorities as we hear from viewers about your budget priorities. and we begin this morning with sheldon whitehouse, senator from rhode island, democrat. and, senator, as we're asking about these priorities, what are your priorities and how are they shaping your role here and your thoughts as this looming budget deadline is coming in about ten days? >> well, i think the overarching thing that we are looking for is some degree of parity, more or less, between nondefense and defense spending increases. with that, that enables the appropriators to go back and fix the individual accounts at those known levels. very keen to see the promised second chunk of opioid spending coming through. we have been promised that. around washington, sometimes promises aren't quite as strong as they are elsewhere in the

world. then there are the big issues that i think we want in a bipartisan fashion to resolve but could fall apart. we need to do the children health insurance program, we need to fund the community health center, reauthorize and fund the national flood program. disaster relief to the disaster-struck states, including the fire-struck states out west and solve the daca d.r.e.a.m.ers issue. so a lot stake in these notions. but i think there are republicans who want all of that to happen, so it's a question of trying to avoid errors. >> can you do all of that in one deal or do you think specific issues will have to be broken out separately and daca being one of them that there is some discussion about whether it might come a little bit later past this spending deal? >> i think it's important that the agreement be reached while the leverage is in place. if you leave something out as a stray then that enables the republicans never to bring it up again. we saw that with basically an

accounting error that the republicans made on renewable energy tax extenders. they admitted they made a mistake in the language. they promised they would fix it. here it is well over a year later and they haven't even bothered to try. our experience if you leave orphans out is that they get ignored. so it would have to -- you know, you could stage it, but you'd have to have an overall agreement for the whole staging of all of these issues. >> and how do you do that? what is the -- what is the mechanism for doing that? >> well, agreement between the leaders in the senate and the speaker and the leader in the house and a strong, clear signal from the president that he'll accept what congress works out. >> and i know one of the issues that you speak often about on the senate floor is this issue of climate change and how do you ensure the