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epidemic in the local, state and federal levels. hosted by the brookings institution, this is 50 minutes. welcome, everyone, thanks for coming out on this rainy day, really appreciate it. i cover drugs and other issues. around the country. so with me, we have admiral brett girard, the assistant secretary of health at the department of health and human services. i'm going to ask some questions, we're going to get a robust conversation going. and open it up to all of you. i'm going to ask everyone on the panel to respond to this question. there's been a lot of policy

implemented around the opiod crisis. the number of overdose deaths are continuing to rise. what is being done is it sufficient? what must be done to stem this tide of overdose. admiral go ahead. >> good morning, and thank you very much for inviting me to be on the panel, and i look forward to open discussion. i always have trouble sitting down and speaking, but i'm going to do my best. now that i'm tethered on the microphone. as i've said many times, particularly opiod misuse crisis is the health challenge of our time. >> although we are doing as many things as we think that we can. there's always room to do more. our five point strategy has been well documented about improving pain control, data, access to

treatment, and improving research, and availability of revers reversal. what i want to say, though, in response to this question is the number of deaths and overdoses are far too many, and no one can declare victory, you need to look at the most recent data, the number of overdose deaths have increased. when you look at the data more recently. it does look like we are making an impact on the overall crisis. some of the things you would like to see happen that are happening, since january 2017, the amount of morphine milligrams prescriptions have gone down by 19%. the number of individuals receiving bupenorphine is up.

the data is from the national survey of drug use and health, shows that pain reliever misuse and pain reliever use disorder have both significantly decreased, between 25 and 2016 and 2017. the number of overdoses going to the emergency rooms between the third and fourth quarter of 2017 have declined for opiods almost 14%. if you look at the mortality curves, looking at the rolling 12 months, not just 2016 to 2017, the most recent 12 month periods, we're starting to hit a plateau and start to go down. what i'm not doing here is declaring victory, we have to redouble our efforts, and you saw three weeks ago, we had a major opiod push with $1.5 billion in grants. with the new surgeon general's documents, with new cdc money all going out. but what i don't want us to

believe is we're not making an impact. our efforts are starting to impact. i look forward to answering specific questions. >> thank you. >> so thank you very much for having us here today to talk about this important issue. i previously served in the obama add myth station in the white house office of national drug control policy for the entirety of the terms, the two terms, and in answer to the question of have we done enough, i think that i'm really pleased that -- this is one of the few areas in this country. and in congress where we have bipartisan agreement on what to do. and many of the things that we began in the obama administration, have continued. and actually been increased and expanded upon in this occurrence hhs, under the leadership of

many. that's a wonderful thing, i think we can all agree, we haven't done enough to address the issue in light of the fact that we're still seeing increased rates of overdose deaths, but also, we need to make sure we're looking at the issue of opiod use disorders, not just in the -- not just about opiods themselves, but about addiction, and if you look at the addiction epidemic, and all of the drugs that are involved in driving rates of substance use disorders in this country. that's really, i see the opiod epidemic, as the onramp to the broader discussion about the totality of substance use disorders? in that respect we have a long way to go, we really need to change our health care system, our treatment system, and our criminal justice system to recognize the disease of addiction. and recognize that it is a disease that can be prevented,

treated and from which people can recover. i think that if we -- certainly we haven't done enough yet on the opiod epidemic, we certainly haven't gone far enough to address the entirety of the diseases of addiction in this country. and i think also hr 6, which i think we're going to talk about today, which is a legislation that congress just passed in a bipartisan manner to address the opiod epidemic, that has a lot of good pieces of legislation in it, the other piece that i think are important is to look at the barriers, not necessarily a -- passing new laws, but looking at existing laws that stand in the way of treating the addiction as a public health issue. what are the legal barriers? what are the policy barriers, what are the regulatory barriers? those are some things i plan to be looking at in the future, in the next couple years, to explore how we can remove those barriers to address addiction as

the disease that it is. >> i think one of the challenges with an issue like this is, that it is so dynamic, and one of the benefits that we've seen from this administration, and as regina said, continuing on the work of the previous administration is a recognition that there needs to be coordination of strategy, data, coordination of a variety of means of communication. because ultimately, while federal policy makers are setting agendas, and federal policy makers are making recommendations, this is a local level issue. this is not just an issue that individuals in counties and municipalities are facing on the front lines, but they're facing it in different ways. what is creating problems, what is motivating opiod use disorders or overdose deaths in one state? may be very different than the underlying forces that are causing it in another state.

or in another area of another state? and so one of the -- i would say biggest challenges, is there idea that there can be one size fits all strategies, that you can design something at the federal level that will help ohio, and will help alaska and arizona. the reality is, that the key to success, the pathway to success here, like in a lot of areas of policy, is to make sure federal policy makers assist local leaders, and assist local policy makers in addressing the opiod crisis. but that they get out of the way when they're causing too many problems. and we have a lot of policy at the federal level that is creating those types of complications. hr-6 tries to deal with a couple of them, and hopefully it ultimately will once the legislation is assigned. but there are a variety of ways that i think local leaders can continue to communicate with state officials and with federal

officials to say, this is where we need help. help in some cases means money, in a lot of cases it it mines money, in other cases they can say, here's what we need help with, and it is the freedom to do what we know will work. what we have seen has worked elsewhere or what we think might work. and whether that's working with a pilot grant program from hhs or whether it is just expanding what they have seen in other areas as helpful on their own with their own money, so long as federal officials and federal law allows them to do it. that creates this -- as i said, dynamic area of policy, that is extraordinarily difficult to tackle. one of the reasons why overdose rates are as high as they are, is because this is so complicated. because throwing money at it might help a little bit, but it's not going to solve the problem. because again, what is helping

in one state isn't going to help in another state. that creates a complexity that local level officials are aren't prepared for. they aren't able to deal with in a special way. it's that broader concern, opiod crisis is so widespread, individuals are naturally involved in it, this is not something localized to one or two or three states. because this is an issue that affects every public health official in the united states, every state legislature, everyone has some stake in this. while that's unfortunate, because it means tens of thousands of americans are dying of overdose deaths. hundreds of thousands of americans have opiod use or other substance use disorders, it does mean that you can shore up that kind of political support to create an area of

policy which is rare in our politics right now. that is where bipartisan support can be applied to tackle a massive national issue. >> since we're talking about the congressional bill now, what in it will make real change do you think. there's been criticism that a lot of it is tinkering around the edges. it's a political document. what concrete do you see that you will make real change on the ground in these states and in these places that are suffering on this. >> i agree with the criticism, this is a small bill relative to the size of the problem. this is an issue that i think a lot of members of congress can pat themselves on the back over, and go home to their constituents and say, especially in an election year, we're working to tackle the opiod crisis, but there are a couple -- there are a handful of real palpable benefits from this

legislation. one is an expansion of funding opportunities for pilot programs, but within states. whether the appropriations process ultimately funds these programs to the levels that are necessary, that remains to be seen. i think we have an experience this year, with an appropriations process, that has worked better than it has in quite some time, i think there's some optimism around that. but if those programs are funded, that's going to mean money in the hands of local governments to do what they need to do. to begin doing the research and data collection, and having those types of coordination efforts that can be meaningful. second, there are several provisions in the legislation that as i said, in my opening remarks, gets the federal government out of the way, or at least lessens their impact. so the caps on the number of patients that a doctor can treat using buprenorphine is a real

benefit. that means that people will be able to engage in this much will be able to use this in a way that they were third is the removal of limitations in terms of medicaid reimbursement for inpatient treatment for individuals with substance use disorders. this was something restricted for inpatient facilities--

facilities, creating the incentives that pushed individuals in two other avenues of treatment when inpatient treatment may have been best for them. is not universally best for everyone but that is the government getting out of the way and listening to local public health officials and physicians, and saying this is something that can help, so let's do what we can to make sure that outdated federal policy is not restricting our ability to serve those people most in need. >> you talked about additional money that you have allocated recently. was any of that reallocated because of public emergency? i'm hoping you can tuck up-- talk about that and what you are doing in the last couple of weeks. >> the additional funding that has been supplied in a bipartisan fashion is not a

result of the emergency declaration but the fact that this is a-- a public health emergency. i wanted to build on comments that one of the philosophies of the funding cycle at least currently is that we want to promote local activity. if we look at the state and opioid response in the $500 million before that it's great for states to use that money. we have really stood fast upon that with the caveat that it has to be evidence-based. we need to support those practices and to build on the discussion, addiction is a disease. it needs to be treated holistically and the evidence shows that medication assisted treatment with agonists but also antagonists combined with

behavioral support, but we-- similarly, the technical assistance has been dramatically changed from a dc- centric technical assistance program to what samson has done -- samsa has done to decentralize that. there are contractors working at the local level to supply technical assistance as is needed. i fully agree that this type of local empowerment is a very important. the money that has gone out is to empower the community health centers. they are responsive to the local needs. there are about 70% of the health centers that have behavioral support along with typical physical-- types of typical physical services that they've already done but we have tried to push that down

to the local level to the degree that we can. i would say that the cdc is providing grants to localities to empower their data collection systems and very importantly, to link the electronic health records with prescription drug monitoring programs to create a uniform workflow. i want to build on the comments that we believe that this is a public health emergency. opioid use is only one aspect. methamphetamines are on the rise . the underlying psychosocial issues, suicidal thoughts, suicidal ideations. suicidal attempts on the rise. this is a more generalized problem within the society in which we believe addiction is an important symptom of that but one that we are tackling head on right now because of

the deaths and the overwhelming disruption for society. >> has any additional money been reallocated? >> what led to the public health declaration is what is driving funding by congress on allocation and efforts within hhs.>> you made an important point. cocaine use is up. if you go out and talk to people and local law enforcement they say they are having big issues with that. is public policy response to the opioid epidemic helping build an infrastructure in place to respond to these other emerging threats that are happening? >> the bulk of funding for states to deal with these comes through a grant that is

provided by samsa which has been funded for a number of years . that-- by samhsa which has been funded for a number of years. the grants are specifically tied in many cases-- they are specifically tied in many cases to the opioid issues. one thing in terms of methamphetamine use, i was speaking with someone from kentucky and many states are seeing increasing increased methamphetamine use rates. because it's mostly nickel-- liquid and that what we used to think about with trailer parks and people making it in their trailer, that's not what we are seeing. we see liquid meth coming through mexico and it is being injected. to the extent that the syringe exchange programs are being

taken into the country that have never had them before such as kentucky, they will be able to do outreach to individuals who are in check thing that they would not have been able to do during the last time we really faced an increase. cocaine, the challenges-- the great thing is that i want to commend hhs for the recent grants. they require that they be used for evidence-based treatment. that's very important. basically you are saying you may not like medications to treat opioid use disorders but the science leads us to the use of medication that is effective. if you want to use federal funds you need to provide evidence-based treatment which is critically important and will hopefully make a difference. in terms of cocaine, we don't have the same type of treatment for methamphetamine or cocaine.

we need to again focus on prevention, but the treatment will be different. the recovery supports will remain the same in terms of making sure people have stable housing, that they have employment opportunities. the continuum of care is the same but we do not have the same types of treatment available for what we are seeing as emerging drugs. >> i absolutely agree but i want to see that the point of the funding is to not just quote unquote solve opioids, but to create the philosophical , scientific, infrastructure to look at addiction and issues such as mental illness all across the board. that really includes, for example, enabling community health centers to have the type of providers to shift the workforce so that we have more

behavioral health providers, that we understand models of care that include not just an addiction psychiatrist which is important. but when you are talking about 2 million people you will never have enough addiction psychiatrist. we need to train primary care physicians, midwives, everybody , how to treat addiction as part of a team and all of the important components to that. including peer counselors and social workers. people who can work holistically and it is certainly our intent that what we are building will have broad applications across the spectrum of use disorders because this is not going away. if you look at our overall addiction problems you are on an exponential curve and that hasn't changed. the substances that are the

subject of any period changes are on an exponential curve that we have to fundamentally engage as the whole of society. >> people often say that in order to have an effective response you have to have a three-legged stool. so prevention treatment and enforcement. they are different initiatives that work together. how do you craft policy where each leg is equally balanced and you are able to really deal with those issues that are so important? >> i want to briefly, and i will turn it over to you in a second, but the drug control policy is supposed to do that. hr six did reauthorize that office. what our role was in the 7.5 years that i was there is to bring law enforcement together with public health. the first individual that we

have is a former police chief. he also really embraced public health approaches so he could go to law enforcement and say this is why carrying naloxone is an important part of community policing. also, he could speak to public health about wasn't-- what was important to law enforcement. it was communicating across many spectrums of opinions about law enforcement. the second person that we have was in recovery who came from a public health perspective. it can allow for that dialogue and by establishing a strategy of goals for the entirety of drug policy across the federal government and to set an

example for the state, is the goal of that office. >> i think this is an important issue around the issue of opioids. not just striking the balance in terms of the design of policy that striking the balance in terms of rhetoric around that policy. enforcement is going to be a critical part of this fight against the types of substances creating use disorders. particularly with opioids i think it is something that is challenging not just in terms of stories, but routes of entry into the united states which are not, despite some rhetoric, being smuggled across the us mexican border in the dark of night are actually coming through the mail system and other shipping methods as well. being able to combat that and having a more power,-- powerful conversation about the production of synthetics i

think is an important part of american foreign policy which is so often left out of this conversations or in tickets past, though terribly mismanaged against the fight of the inflow of drugs in the united states. having that strong enforcement side rather than domestic enforcement is an important signal to individuals dealing with the struggle of addiction. for too long addiction was treated as a public safety issue and not a public health issue. because of that, it just incentivizes individuals from getting help. the admiral. very eloquently explained the purpose of new and continued grant funding to reverse those prior perceptions of what addiction was. that is important and starts at

the local level, being able to convey that you are not a criminal, you are ill and dealing with a medical condition. that is a very important first step towards finding prevention and treatment strategies. layering on top of that, for a lot of people, they see addiction as someone else's issue and a disease that affects other people. in many ways the pervasiveness of use disorders has pulled the curtain back to show people that it can happen in anyone's living room. most families know or probably don't know that someone has an opioid use disorder. part of that broad rhetoric around treatment and prevention

is talking to groups non- traditionally thought of as individuals who are system able to use disorders including senior citizens, veterans, retired athletes, and enormous numbers of americans often forgotten in the conversation around substance use disorders. policy and efforts in this area have to begin to address and have to begin to embrace, to say you are patients as well and we are here to help you. your service in iraq entitles you to healthcare but also entitles you to be treated when it comes to substance use disorders in the same way that we treat anyone, with compassion, care, and extended care beyond the moment where you are having a crisis with an overdose. or the moment where you are making a certain decision about using a substance are not.

to have that continuing conversation whether it is through va or private physicians or whatever platform you are getting medical care from. to make sure those groups are being included as well.>> i want to make the comment as well , as the senior advisor for opioid policy part of my job is to build bridges to other agencies. i can say that the interaction between doj and others has grown tremendously even in the past few months. everybody understands we cannot arrest our way out of addiction. that being said i can't have 120 pounds of fentanyl coming in on a regular basis that's enough to kill 30 million people. our job would be easier if we could eliminate those supplies. on the second day of being

appointed acting director., i was in his office facilitated by the current acting director. just last week, emblematic of what we are trying to do, we organized a panel where the acting director who runs dea diversion control, the surgeon general and myself on the pain management interagency task force met with the american society of addiction medicine. the family practice people. the nurse midwives. 20 organizations of healthcare providers. they have an open discussion about how we need to work better as an entire community integrating that with public health. it was a tremendous dialogue

because we do need to bridge some divides. my parents were police officers. everybody in my family is a police officer. i understand that point of view in the public health point of view. we can work together and i think we are getting there very productively but it's going to take continued work in dialogue. those kinds of things have to have all-- have to happen at the local level as well though. people smuggling-- really they have prescribers, intentionally bad prescribers not just on the tales of a normal distribution. those are law enforcement issues as is the smuggling of these drugs or the mailing of these drugs primarily from china . >> i'm sure you all have questions so i would love to open it up to see who-- >> people aren't shy.

>> that's fantastic. >> hold tight. >> appear kind of questions. >> good morning distinguished panelists and good morning to this amazing and diverse audience that i have the pleasure of sharing one hour with. i am the founder of speak life. i don't profess to be a writer of policy but ime-- i am an advocate and a lobbyist for medicinal cannabis therapy. i stand before you-- oh, and i'm a mother of an-- an 11-year- old child who medicates with cannabis. i stand before you with the suggestion.

98 seconds of the second. the money that we invest into these politicians as far as going into the candidacy and the support given to these politicians, why don't we make big pharma great again? why don't we make it bigger-- great again by cherry picking the best growers, the best farmers, the best doctors who have in the treat-- been in treatment for 25 years and develop a think tank? the money you give these politicians create a think tank and from there, create an exit drug off of opioids. create an exit drug from this opioid crisis. intern you will gain respect from the community, from the world, and also let yourself,

you are taking accountability for creating this. i think it would be a positive movement and something you may want to consider. i know that cannabis is the most is a happy thing that they want to hear but i have an 11- year-old daughter who at one time had 60 seizures a day. now it's in a six-month-old child, and medicating on valium , diazepam. she has been a medicinal cannabis therapy patient for 3 years and is now 90% seizure free. those words may be a little muffled because i know that i'm the big elephant in the room. i'm speaking like there is efficacy in cannabis. there is efficacy and people

are being penalized, and others are being paid to stop the progress and. >> do you have a question about how we can help? >> it was a suggestion that this may be something you may want to create. consider. i think it will be an alternative to crafting public- - crafting public policy and something a lot of americans do wish for a. >> thank you very much. >> usually the best way to get something to not do something is to offer them a preferable alternative. humans developed a situation where they have to struggle really hard to survive just to collect food and avoid predators . that leads to a lot of boredom. boredom is a major driver towards drugs and other addictions. screen time, video games and such.

is anybody looking at alternatives? productive, useful things that people can be doing to create alternatives for people so they don't get bored and get into drugs and stuff like that? >> there are social determinants that go into ym individuals develop disorders. it's a combination of the environment as well as hereditary, heredity. it's really not one thing or one factor. there's a combination of factors. but i'm a lawyer, not a doctor so i will let the doctor-->> thanks. i agree with what was just sad. i will see that scientifically, there is data that the number one reason why people misuse

opioids is because of pain. 62.4% misuse them because of pain. in order for us to solve the opioid crisis or at least one aspect, we have to deal with pain and pain needs to be dealt with not as until but as a holistic multimodal option including physical fitness, physical therapy, non-opioid pain medications. other types of behavioral therapy is. -- behavioral therapy. i don't think that we have the magic answer of white 18-35- year-olds, despite our youth making tremendously positive choices across the spectrum, have an increased issue with substance abuse. part of it is our fault for overprescribing opioids and having them so available that if you are bored or having trouble sleeping, you pull them out of the cabinet. two weeks later if you are on a

high enough dose you are-- you have the disease of addiction and telling the person to stop is like telling the person to stop breathing. many social determinants. i do want to highlight pain as an issue. we cannot just say stop doing opioids. we have to provide an alternative solution. the pain management best practices task force has dod and va. the draft gaps and recommendations are posted on the web and there will be a report posted for all of your input within the next month.>> one piece of this has been trying to create a pain medication. can you talk a little bit about that and how that is coming from the government as well? >> formulations have been in existence for a little while and i know that there is $100

million that went to nih, some of which was to identify alternatives. one of the issues, however, is insurance coverage of alternatives for pain treatment. that is a big part of the challenge. >> i will be talking to 700 insurance companies today.>> what will you be saying to them? >> that in addition to assuring that we limit the inappropriate prescribing of opioids, we need to guarantee the appropriate prescription for particularly pain patients who have chronic, unrelenting pain such as cancer patients or patients with sickle cell disease which is one of my personal-- before this to treat addiction is a disease in a comprehensive and holistic way.

the data shows that for many chronic pain syndromes physical therapy, physical fitness, overall health is much better than chronic opioids. these alternatives need to be covered. in terms of nih, i want to mention that there is an exciting initiative that feeds into one of the crosscutting initiatives called the healing communities initiative. this is going to supply in the neighborhood of $100 million a year for five years to communities that are hard-hit to bring the federal government and all of our agencies together , department of labor, incomplete conjunction with local and state authorities to reduce overdose disorders and deaths by 40%. again, it is trying to empower community models in urban, suburban, and rural communities to understand what best practices are. a lot of that money goes to basic type of research.

can we have nonaddictive opioids? how do we treat with mat better? it's good but none of us are satisfied with the current results. a lot of the money is going to community models of how to provide holistic care and bring everyone together and spin that out community to community. >> we are at this point where we have a prescription issue that we have had. the heroine issue we've had, and now this crisis happening right now. are we fighting the current crisis or the one from 10 years ago? how do we do these together since they are specific things? >> one of the important parts that was mentioned before, we have a struggle with addiction but in any 5-10 year period, substances of most importance cycle in and out.

ideally they would cycle out and go away but that's not what the experience is. the crisis-- were the crisis with opioids has shined a light on is just how vulnerable the mental health and addiction infrastructure is and how ill- prepared we are because we have not built that up in a sufficient way in a variety of areas. i talk about different individuals who are nontraditional or at risk including veterans. one of the biggest struggle is in rural communities. if you are 75 minutes from a local treatment center what you think the likelihood of going to that treatment center for help is if you live in a city that is seven blocks away and you are unlikely to go to that treatment center? what is going to work in washington dc is not necessarily the same type of

infrastructure problem that exists in rural idaho even if it may be the same in both places? it might be worse in rural idaho and it's not opioid. it's a meth issue and a variety of substances. strengthening that infrastructure in ways that make up for a lot of lost time and is able to be designed in the right way is for but that population faces whether it's the substances that the population faces, the infrastructure, or the socioeconomic forces that can affect choices over substance abuse as well. the grant programs do a great job giving local level flexibility and recognizing there is a need for that. making up for what is really an embarrassing infrastructure in this company that cannot keep up.

>> can you talk a little bit about that?>> telemedicine is very important across the board in many aspects of the system. we provided a clarification based on some of those interpretations in that you can deliver by telemedicine and i think that's a very important as long as you have a dea registered provider. we are very hopeful about that. i think part of the registration said for reimbursement you don't need to be in a rural area. you can be reimbursed for that. coming from texas there are a dozen or so countries that don't have a healthcare provider. it's a very big country and we are going to need to use technology to our advantage. not only the providers that build the model systems, the

ancillary providers to make sure that care is distributed, and we focus on behavioral health which is critically important. smoking, alcohol use, and obesity, there are huge components to all of these. what we are building has long- lasting benefits but we need to build staff in a resilient fashion. here and there, samhsa grants won't go very far unless it is geared toward building and incentivizing what we need. >> substances go in and out of vogue but the one constant is alcohol. i think we cannot forget the number of people in the country with alcohol disorders. that has to be something when focusing on treatment and addiction.

>> thank you for being here with us today. i was wondering if you could talk about the root of the double standard in terms of how our country responded to the crack cocaine crisis in the 80s and 90s and the crisis we are facing today. today is mostly white opioid addicts and considered public-- part of a public health issue whereas crack cocaine addicts who happen to be african- american and-- in underserved communities were faced with a full-blown war on drugs. i was wondering if you could talk about what you could say is at the root of that double standard and clears our own perceptions. >> i think the answer is obvious. the root and the manner in which racism affects public policy in the united states and

frankly elsewhere in the world, is profound. it is hard to defend the differences in enforcement and laws around punishment particularly in the 1980s other than a racialized basis for that. there are also positives coming out of the opioid crisis. if it is affecting groups of people who raise awareness then the awareness is going to be more than if it were in underserved or communities of colors. -- communities of color. that is unfair, but there are individuals in this country who face-- were people of color and face those disorders or others and i would hope that if the bleaching of the substance use

disorders in this country means that it raises awareness and builds a better substance use infrastructure, it helps with treatment and prevention. that will be spread around and hopefully that is the case. there are a lot of areas of public policy that have dark histories. and mental health and addiction services are toward the top of that list. i think there are a lot of really competent professionals and a lot of well-intentioned individuals in our government and congress who are not only thinking seriously about racial divisions in the way that they can access treatment and prevention programs, but also how we can learn from our past mistakes. hopefully the future health is

brighter than what is a pretty dark past. >> thank you for your leadership . i'm from the alliance of community health plans and clinical leaders are very much invested in addressing the opioid epidemic. there has been a concern about challenges and sharing health information. from just trying to coordinate care, you want to have as much information as possible including understanding the history of addiction. there is a standard which is a bar higher than hipaa which makes it very difficult to have information be coordinated.

curious about your per spec is on that discussion. if you see some of that relaxing given some of the state of emergency, what can groups do to try to help and frankly, to share that information more freely? >> a lot of congressional intention, samhsa has done -- what they have done is put out clarifying information because there is a lot of misinformation. i'm sure congress will take it up again. they did not remove it entirely in this legislative session. but, it will come up because there are a lot of people who want to share that information. the most important thing is to listen to those-- listen to both sides on the issue. those who are opposed are very

opposed because if we think that the stigma is gone and it's just another disease, we are kidding ourselves. there's a lot of stigma attached and doctors who don't want to treat those patients. that is something that if a change is made, we have to have the realization that the stigma is alive and well. removing that in its entirety, it could have an impact on individuals that have addiction but they will discuss that a lot. i'm sure it will come up because there is a lot of dividers that want that information. >> it is 11 o'clock so i think we are done with this unfortunately. thank you all for coming. i really appreciate it. think you to everyone on the

panel for sharing the thoughts, so good discussion.

cyber security analyst and reporter on voting machines and election security. >> the department of homeland security has been working with states and counties to scan systems for vulnerabilities. that is only focused on the internet facing systems like the website that posts the result, or the website that stores the database. they are not looking at